Author's note: The article below is based on information provided by employees of U.S. corrections systems, and the content of the written interview was approved -- and in some cases amended -- by the Washington State Department of Corrections.
Statistics show that the risk of death from drug overdose in people involved in the criminal justice system is greatest within the first two weeks of their return to the community, Lara Strick, M.D., M.S., of the Washington State Department of Corrections, said in her presentation at the Association of Nurses in AIDS Care conference in Portland, Oregon. People lose their tolerance for a drug after getting little or none while in prison, but they often celebrate their return to the community and are released to an environment that triggers their substance use -- or they intentionally overdose, she explained.
A program in her state links people who leave prison to treatment in the community. For opioid use disorder (OUD), the goal is a community appointment within 24 to 48 hours of release, explained Tami Kampbell of the same corrections authority. For people living with HIV (PLWH), that timeframe is 30 days, but most see a provider within one to two weeks of leaving prison.
Meeting these targets is complicated by the fact that release dates are often not definite. A conference call two weeks before an anticipated release provides a "warm" hand-off to community care. The call includes the person who will leave prison, both prison and community providers, and a navigator. For PLWH, an HIV re-entry planner tracks shifting release dates and reschedules appointments as necessary. Those living with HIV are given a 30-day supply of HIV medications when they leave prison. People with OUD are given naloxone (Narcan) kits and instructions on their use. Naloxone can quickly reverse an overdose if a bystander administers it before medical help arrives.
Community clinic policies also help to get people into care quickly. "In Washington, many clinics treating OUD have developed low-barrier policies to allow people in the community, as well as people releasing from a correctional facility, to start on medication on a same-day basis," the state's Department of Corrections noted. For PLWH, the Seattle Ryan White program features a walk-in clinic. "One of the eligibility criteria to be seen in the walk-in clinic is a recent release from jail or [a] state correctional facility, to help ensure patients are seen soon after release," Strick wrote.
In Camden, New Jersey, clinic walk-in hours also facilitate linkage to care, as do the substance use treatment, behavioral health, and psychiatric services provided on site. The program is located within 2.5 blocks of Camden County Jail, explained Elizabeth Fletcher, D.N.P., AAHIVS, lead author of a study that enrolled 85 PLWH at the facility, 72 of whom have transitioned into the community. Seventy-four percent of those released have been linked to care, and 69% of those in care have achieved viral suppression. Two transitional care coordinators follow up on missed appointments to get people back into care.
In Washington state, re-entry planning includes community peers who help find those who did not show up for their appointments. Detailed locator information assembled prior to release and a printed list of appointments and contact information, which is given to the person leaving prison, help to prevent loss to follow-up. "Our agency also maintains a release of information for us to be able to talk to other community agencies with whom the patient is likely to have contact to help ensure they engage in care," Strick noted.
Strick is the only HIV care provider for the entire Washington state prison system. As of Sept. 30, 2019, the system housed an average of 19,225 people. However, the Washington state prison system's HIV prevalence rate is 0.6%, making for a manageable number of patients, she noted. Strick also works at the Seattle Ryan White clinic. In 2017, 219 of the 445 HIV diagnoses in Washington were in King County, where Seattle is located . Thus, many of her patients from prison continue to see her once they return to the community.
That continuity helps to keep people in care, as does the state's housing assistance program. "To my knowledge, since our medical housing program began, no one living with HIV has been release[d] from a Washington correctional facility to a status of homelessness or an encampment," Strick wrote. People on community supervision and without a stable address are provided with three months of housing assistance. That period can be extended for those with medical issues, such as HIV.
The jury is still out on the success of the OUD linkage to care program, the Department of Corrections acknowledged: "The agency is in the process of collecting data regarding the clinical outcomes of the program." Data are also sparse because research among people in prison is strictly limited -- for good reason, noted Strick.