As of year-end 2014, one in 36 adults in the U.S. was "under some form of correctional supervision," according to the U.S. Department of Justice. This number includes people on parole or probation, as well as those in federal prisons and local jails. The vast majority of those incarcerated (85%) are held in jails, said Barry Zack, M.P.H. of The Bridging Group in a recent webinar sponsored by the National Center for Innovation in HIV Care. HIV testing and treatment policies in these local facilities vary widely among states. Jail terms are usually relatively short, so there is a high turnover of inmates who may have access to HIV care only in a correctional institution. Without discharge planning that not only includes HIV treatment, but also addresses "life's competing priorities" -- such as lack of housing -- former inmates may not continue antiretroviral treatment, possibly resulting in the development of drug resistance or transmission of the virus, Zack explained.
Zack highlighted several different models for ensuring continuity of care both inside and outside correctional institutions. The California Transitional Case Management Program conducts psychosocial needs assessments, develops individual care plans and provides referrals to community resources. Transitional Care Coordination at New York City's Rikers Island screens inmates for eligibility for benefits, provides seven-days worth of medication plus a prescription upon release and arranges for appointments/transportation to facilitate continued care outside jail. Hampden County in Massachusetts uses community health clinics to provide in-jail medical services and links inmates to providers based on their zip code to provide a seamless transition from care on the inside to care on the outside.
Project Start+ is "a short-term, multi-session program that works one-on-one with individuals," said Zack, a principal consultant to the project. Meetings with clients start two months before their release and continue for three months after inmates have returned to the community. The program includes an immediate release checklist to plan for the first 24-48 hours after release -- housing, transportation, ID card, parole appointments, etc. -- in addition to HIV care. The checklist includes a "Plan B" in case any component of the initial plan does not work out. Some community medical clinics keep weekly slots open for recently released inmates to ensure immediate access to HIV care.
Zack stressed the importance of housing for released inmates, saying "Housing is prevention. Housing is treatment. Housing works." However, special attention must be paid to the conditions of parole or probation to ensure that geographic restrictions do not conflict with clinic or housing arrangements. In addition, treatment needs for other issues, such as mental health or substance use, must also be addressed, he noted.