The Role of Jails in Engaging PLWHA in Care: From Jail to Community

HIV testing in jails has provided public health officials with the opportunity to not only identify new cases of HIV but to also reestablish contact with previously diagnosed individuals, many of whom never entered care following diagnosis or entered care but then dropped out. The presence of inmates throughout the HIV/AIDS continuum of care suggests that jails can play a strategic role in engaging persons living with HIV and AIDS in care. In order to be successful in structuring HIV/AIDS programs in jails, health care and correctional officials will be well-served to: (1) understand the HIV/AIDS continuum of care from the standpoint of engagement interventions that promote participation; (2) be aware of jail, community, and prison interventions that promote engagement in care; (3) anticipate and plan for the unique barriers jails provide in implementing engagement interventions; and, (4) be creative in designing engagement interventions suitable for both newly and previously diagnosed individuals.     

Gender Differences in Baseline Health,Needs at Release,and Predictors of Care Engagement Among HIV-Positive Clients Leaving Jail

Women represent a significant and growing segment of jail detainees and persons living with HIV. This paper examines gender differences in health status, care and social service needs, and care engagement among jail releasees with HIV. Data are from 1,270 participants in the HRSA-funded Enhancing Linkages to HIV Primary Care and Social Services multisite demonstration project (EnhanceLink). Compared to men, more women reported homelessness, reduced adherence to prescribed ART, worse health, more severe substance use disorders, and more chronic health conditions. Men and women generally reported different needs post-release. As the number of expressed needs increased, women were more likely to drop out of care. Our findings suggest that effective and gender-specific strategies are required to identify needs, link services between jails and communities, and sustain retention of women with HIV in programs after release from criminal justice settings.     

A package of primary health care services for comprehensive family-centred HIV/AIDS care and treatment programs in low-income settings

Particularly in resource-limited settings, HIV/AIDS is a family concern. Separate services for children and adults may make accessing care more difficult for families than services where family members can be cared for together. Implicit in comprehensive, family-centred approaches to care are the broader notions of longitudinal primary care and linkages to other services, including those based in communities. As highly-active antiretroviral therapy becomes more available, and the direct burden of HIV-associated morbidity diminishes, HIV-infected individuals require primary care that goes beyond exclusive management of HIV and related conditions, including preventive services and the management of common medical issues. The prevention of tuberculosis, diarrhoea, and, in endemic regions, malaria; the addressing of debilitating depression; cervical screening; and the management of chronic cardiovascular disease and its risk factors are all of benefit to patients accessing HIV/AIDS care. Packaging such services is an effective means both of standardizing care within a program and of ensuring patients receives a full roster of available interventions. As family-centred care models develop in resource-limited settings, the availability of evidence-based service packages such as presented here will help program designers prioritize available human and materiel resources toward those interventions that improve patients' global health and well being.     

Brief interventions for alcohol problems: a review

Relatively brief interventions have consistently been found to be effective in reducing alcohol consumption or achieving treatment referral of problem drinkers. To date, the literature includes at least a dozen randomized trials of brief referral or retention procedures, and 32 controlled studies of brief interventions targeting drinking behavior, enrolling over 6000 problem drinkers in both health care and treatment settings across 14 nations. These studies indicate that brief interventions are more effective than no counseling, and often as effective as more extensive treatment. The outcome literature is reviewed, and common motivational elements of effective brief interventions are described. There is encouraging evidence that the course of harmful alcohol use can be effectively altered by well-designed intervention strategies which are feasible within relatively brief-contact contexts such as primary health care settings and employee assistance programs. Implications for future research and practice are considered.     

Jails,HIV Testing,and Linkage to Care Services: An Overview of the EnhanceLink Initiative

Over 9 million persons in the United States (US) are admitted each year to jails. HIV prevalence among detainees is higher than the general population, which creates a public health need for linking HIV-infected detainees to services during jail and after release. The EnhanceLink initiative was funded as demonstration projects in 10 communities at 20 separate jails across the US. Grantees implemented and evaluated innovative models of HIV testing in jails and linkage of HIV-infected individuals to community services post release. In this paper, we describe services delivered with the EnhanceLink initiative. During 877,119 admission events, 210,267 inmates agreed to HIV testing and 822 new diagnoses of HIV were made. The majority of persons served with transitional services were previously diagnosed before the current incarceration. Cumulatively, 9,837 HIV+ persons were offered linkage and transitional services and 8,056 (82 %) accepted the offer. EnhanceLink demonstrated the feasibility of HIV testing in jail settings and provision of linkage services to enhance continuity of HIV care post-release.     

The Challenges of Assessing Fidelity to Physician-Driven HIV Prevention Interventions: Lessons Learned Implementing Partnership for Health in a Los Angeles HIV Clinic

Documenting fidelity to HIV prevention interventions is critical to ensure consistency in intervention implementation and necessary for measuring intervention exposure and, ultimately, outcomes. Significant variation from prescribed protocols or inconsistent implementation can jeopardize the integrity of evaluation research and render outcomes uninterpretable. There is increasing support for HIV prevention models targeting seropositive individuals designed to be delivered by physicians during clinic visits. Assessing fidelity to physician-delivered interventions that occur during clinical exams present unique challenges. This paper presents findings from various data sources designed to track intervention fidelity and exposure to the Partnership for Health intervention, a physician-delivered HIV prevention intervention implemented in an urban community HIV clinic. We present findings from chart abstraction data, patient surveys and exit interviews, and provider qualitative interviews. Lessons learned and recommendations for maximizing the accuracy and validity of fidelity assessment in future evaluations of HIV prevention interventions in primary care settings are considered.     

Hepatitis C virus infection in United States correctional institutions

In the United States, over 6 million people are under correctional supervision and over 2 million are in custody and receiving health care. Prisoners are overrepresented by individuals with high risk for hepatitis C virus (HCV) infection, including injection drug users, the sexual partners of injection drug users, and people living with HIV or AIDS and mental illness. As such, it is estimated that approximately 30% of all prisoners are infected with HCV. Despite this high prevalence, little has been done to implement effective therapy for treating this potentially curable infection in this setting. Correctional settings, with their structured environment and managed care approach, are ideal settings to screen, evaluate, and provide treatment and promote risk reduction interventions that will contribute to society’s improved public health.     

The HIV care continuum: no partial credit given

Despite significant scale-up of HIV care and treatment across the world, overall effectiveness of HIV programs is severely undermined by attrition of patients across the HIV care continuum, both in resource-rich and resource-limited settings. The care continuum has four essential steps: linkage from testing to enrollment in care, determination of antiretroviral therapy (ART) eligibility, ART initiation, and adherence to medications to achieve viral suppression. In order to substantially improve health outcomes for the individual and potentially for prevention of transmission to others, each of the steps of the entire care continuum must be achieved. This will require the adoption of interventions that address the multiplicity of barriers and social contexts faced by individuals and populations across each step, a reconceptualization of services to maximize engagement in care, and ambitious evaluation of program performance using all-or-none measurement.     

What is the relevance of mental health to HIV/AIDS care and treatment programs in developing countries? A systematic review

The expansion of AIDS treatment initiatives in resource-poor settings provides an opportunity for integrating mental health care into these programs. This systematic review of the literature on HIV and mental illness in developing countries examines the mental health risk factors for HIV, mental health consequences of HIV, psychosocial interventions of relevance for HIV-infected and affected populations, and highlights the relevance of these data for HIV care and treatment programs. We reviewed seven studies that measured the prevalence of HIV infection among clinic and hospital-based populations of people with mental illness or assessed sexual risk behavior in these populations; 30 studies that described the mental health consequences of HIV infection; and two reports of psychosocial interventions. The review demonstrates the need for methodologically sound studies of mental health throughout the course of HIV, including factors that support good mental health, and interventions that employ identified variables (e.g. coping, family support) for efficacy in reducing symptoms of mental illness. Promising intervention findings should encourage investigators to begin to study the implementation of these interventions in HIV service settings.     

Linkages to care for newly diagnosed individuals who test HIV positive in nonprimary care settings

Linkage services are an increasingly important component of the continuum of care for people living with HIV, particularly for individuals diagnosed in nonprimary care settings who are less likely than those identified in primary care settings to have a usual source of care. This study examines successful models used by hospital emergency departments, health department outpatient clinics, and other nonprimary care providers for testing, linking, and engaging newly diagnosed HIV-positive racial and ethnic minorities into medical care. Based on studies of five mature linkage-to-care (LTC) programs implemented in geographically and institutionally diverse settings, we identify five key characteristics that make them viable. Effective linkage programs are low cost, intensive, time limited, unique, and flexible. We also identify four core components of successful LTC protocols: directly employed linkage workers, active referral to medical care, person-centered linkage case management, and cultural and linguistic concordance. Finally, we develop a set of operational strategies to help providers address barriers at all levels of the health care system to help promote the effective linkage of newly diagnosed patients to care. We organize the strategies around four key areas: adherence to LTC protocols, selection of linkage workers, execution of linkage programs, and sustainability of linkage programs. The findings presented in this study provide a practical and operational guide for developing and implementing policies and procedures for linking newly diagnosed individuals who test HIV positive in nonprimary care settings into ongoing care for HIV infection.     

Linkage to HIV Care for Jail Detainees: Findings From Detention to the First 30 Days After Release

Of people living with HIV in the US, ~16 % or over 150,000 individuals passed through a correctional facility in 2006. Given the enormous impact of HIV within incarcerated populations, facilitating continuity of care from jails to the community is particularly important in reducing morbidity and mortality for releasees. Grantees participating in the Enhancing Linkages to HIV Primary Care in Jail Settings Initiative developed models for identifying HIV-positive detainees during incarceration and linking them to care following release. In this sample of 1,021 HIV-infected releasees, 79 % received clinical services and 74 % received additional community services within 30 days post-release. Our analysis found several significant factors associated with linkage including: receipt of HIV or medication education in jail, having a completed discharge plan at release, staff awareness of clients’ release date, and stable housing on the 30th day post-release. In addition, a subset of participants who had both jail and community viral load assessments showed a statistically significant increase in suppressed viral load. EnhanceLink data suggest that jails may be effective settings to engage individuals in care.     

Screening and treatment of sexually transmitted diseases: an important strategy for reducing the risk of HIV transmission

The role of sexually transmitted diseases (STDs) in the spread of human immunodeficiency virus (HIV) infection is reviewed. The rationale for and approach to reducing STD prevalence in high-risk communities are presented. Given the asymptomatic nature of these infections and problems associated with delivering curative therapy, effective interventions will require the use of diagnostic tests for screening and the use of single-dose therapies in appropriate settings: Treatment of individuals with STDs will likely reduce individual risk, while reduction of STD prevalence in high-risk communities may curtail the epidemic spread of HIV.     

Effects Of HIV stigma reduction interventions in diasporic communities: insights from the CHAMP study

Racialized diasporic communities in Canada experience disproportionate burden of HIV infection. Their increased vulnerabilities are associated with interlocking challenges, including barriers in accessing resources, migration and settlement stress, and systemic exclusion. Further, people living with HIV (PLHIV) in these diasporic communities face stigma and discrimination in both mainstream Canadian society as well as their own ethno-racial communities. HIV stigma negatively impacts all aspects of HIV care, from testing to disclosure to treatment and ongoing care. In response to these challenges, a Toronto based community organization developed and implemented the CHAMP project to engage people living with HIV/AIDS (PLHIV) and leaders from different service sectors from the African/Caribbean, Asian and Latino communities to explore challenges and strategies to reduce HIV stigma and build community resilience. The study engaged 66 PLHIV and ethno-racial leaders from faith, media and social justice sectors in two stigma-reduction training programs: Acceptance Commitment Therapy Training (ACT) and Social Justice Capacity Building (SJCB). Data collection included pre-and post- intervention surveys, focus groups and monthly activity logs. Participants were followed for a year and data on changes in the participants’ attitudes and behaviors as well as their actual engagement in HIV prevention, PLHIV support and stigma reduction activities were collected. CHAMP results showed that the interventions were effective in reducing HIV stigma and increasing participants’ readiness to take action towards positive social change. Participants’ activity logs over a period of 9 months after completing the training showed they had engaged in 1090 championship activities to advocate for HIV related health equity and social justice issues affecting racialized and newcomer PLHIV and communities.     

“In this thing I have everything I need”: perceived acceptability of a brief alcohol-focused intervention for people living with HIV

Although hazardous/harmful alcohol use impacts response to HIV treatment, there have been few attempts to deliver alcohol-reduction interventions within South African HIV treatment services. As a first step towards implementing alcohol-focused interventions in these settings, we explored patients’ views of the acceptability of a brief motivational interviewing and problem-solving intervention. In-depth interviews were conducted with 11 patients recruited from three HIV treatment sites in Tshwane, South Africa, who had completed the intervention. Participants noted that the intervention was acceptable and appropriate. As a result of the intervention, participants reported less use of alcohol as a coping mechanism. They described greater use of problem-focused and emotional coping strategies for dealing with mutable and immutable problems, respectively. Their only recommendation for improving the intervention was the addition of booster sessions. Findings suggest that this intervention is acceptable to patients receiving HIV treatment and is perceived to be helpful for reducing their use of alcohol.     

TB and HIV integration: obstacles and possible solutions to implementation in South Africa

Objectives To identify key obstacles to operational integration of TB and HIV services and to suggest strategies to promote integration in the prevention, treatment and care of patients with TB and HIV. Methods This is a health systems research case study of operational integration of TB and HIV in South Africa. Peer‐reviewed and grey literature together with the experiences of the authors were used to identify key obstacles to integration in service implementation practices and community‐level care. Relevant legislation, policies and guidelines were analysed to determine whether they facilitated or undermined the integration of TB and HIV services. Results Obstacles to integration exist at contextual and epidemiological levels as well as at intervention design and implementation levels. Importantly, integration at an operational level is undermined by fundamentally different principles underpinning the design of TB and HIV programmes and national policies and legislation which mitigate against integration. Conclusion South Africa has an opportunity to effect changes that will facilitate TB/HIV integration and improve care for all those infected with TB, HIV or both conditions. An analytic approach necessary to understand the obstacles to and ensure effective strategies facilitating integration is required. This needs to be followed by mobilisation of clinical and health systems expertise, health infrastructure, commitment and experience in creative and appropriate ways for the variety of health care settings.     

Challenges to the success of HIV and tuberculosis care and treatment in the public health sector in South Africa

The escalating human immunodeficiency virus (HIV) and tuberculosis (TB) epidemics have had a significant impact on public health services in resource-limited settings. The province of KwaZulu-Natal in South Africa is estimated to have one of the greatest TB/HIV coinfection burdens on the African continent, coupled with historically low TB treatment success rates. In May 2004, the South African government began providing antiretroviral therapy (ART) for HIV-infected individuals within the public sector. As in many counties, this HIV treatment program was established in parallel with an existing TB treatment service. In 2005, the Integration of TB in Education and Care for HIV/AIDS (iTEACH) Program was launched in KwaZulu-Natal at Edendale Hospital. The goal of iTEACH was to identify barriers to effective treatment and develop support interventions to enable rapid expansion of access to ART and improve ART and TB treatment outcomes within the district served by this facility. In the present article, we discuss challenges to the delivery of TB and HIV care by these separate treatment programs, as well as opportunities to improve both TB treatment and ART outcomes through lessons learned during ART scale-up in the context of the HIV and TB coepidemics.     

Can we control tuberculosis in high HIV prevalence settings?

The overlap between the epidemiology of HIV and tuberculosis and consequent rapid rise in numbers of patients with tuberculosis in many African countries has put a huge burden on health systems. The stigma of HIV has increased the existing stigma surrounding tuberculosis. There are three mechanisms by which we may reduce the number of cases of tuberculosis in a community: reducing transmission of tuberculosis, reducing reactivation of latent tuberculosis infection and reducing HIV transmission. Reinforcing the existing health service to find more cases, active case-finding in communities or enhanced case-finding in specific groups will reduce transmission of tuberculosis. However, health services that find it difficult to find cases efficiently will also find it difficult to support patients throughout treatment to achieve a cure. Partnership with traditional healers, community-based organizations and private practitioners could reduce this burden. Reactivation of tuberculosis among people living with HIV can be reduced by tuberculosis preventive therapy or by antiretroviral therapy. Programmes that identify people living with HIV can also implement enhanced tuberculosis case-finding increasing the benefits of the programme. However, the impact of widespread use of antiretroviral therapy may be to increase the number of people in a community who are mildly immunocompromised and the incidence of tuberculosis at a community level might rise. Any strategy that successfully reduces HIV transmission will benefit tuberculosis control, since around a third of all HIV-positive individuals will develop tuberculosis before they die. To control tuberculosis in high HIV prevalence settings, we must strengthen health systems to include not only expansion of the DOTS strategy but also full-blooded implementation of voluntary counselling and testing, enhanced and active tuberculosis case-finding, preventive therapy and better care for people living with HIV including antiretroviral therapy. The approach needed to control tuberculosis needs also to be integrated into broader development and poverty reduction goals.     

Provider perspectives on evidence-based HIV prevention interventions: barriers and facilitators to implementation

Since the beginning of the HIV/AIDS epidemic, community-based organizations (CBOs) have been key players in combating this disease through grassroots prevention programs and close ties to at-risk populations. Increasingly, both funding agencies and public health institutions require that CBOs implement evidence-based HIV prevention interventions, most of which are researcher developed. However, after completing training for these evidence-based interventions (EBIs), agencies may either abandon plans to implement them or significantly modify the intervention. Based on 22 semistructured interviews with HIV prevention service providers, this article explores the barriers and facilitators to dissemination and implementation of EBIs included in the Centers for Disease Control and Prevention's (CDC) Diffusion of Effective Behavioral Interventions (DEBI) program. Results suggest that there is a tension between the need to implement interventions with fidelity and the lack of guidance on how to adapt the interventions for their constituencies and organizational contexts. Findings suggest the need for HIV prevention intervention development and dissemination that integrate community partners in all phases of research and dissemination.     

The evolving role of HIV counseling and testing in resource-limited settings: HIV prevention and linkage to expanding HIV care access

The role of voluntary counseling and testing (VCT) of HIV in resource-limited settings has recently broadened from primarily that of a prevention intervention to its identification as the key entry point into expanding access to life-saving antiretroviral therapy, additional HIV-specific medical care, and other support services. To fulfill this expanded mandate, calls for routine counseling and testing in diverse health care settings, in addition to other innovative approaches to traditional VCT, are emerging. The efficacy and cost effectiveness of traditional facility-based VCT with respect to risk-behavior reduction of HIV have been demonstrated rigorously in resource-limited settings. Additional research is needed urgently to evaluate the feasibility, acceptability, and effectiveness of streamlined counseling and testing interventions that seek to reach as many individuals as possible to meet dual prevention and treatment goals.     

Factors influencing attitudes within AIDS service organizations toward the use of research-based HIV prevention interventions.

Although the efficacy of small-group, risk reduction interventions based on cognitive behavioral principles has been widely documented in HIV behavioral research literature, little is known about how AIDS service organizations (ASOs) view these research-based models. From a nationwide sample of 77 ASOs, this study assessed factors influencing attitudes of prevention program directors and frontline staff toward research-based interventions. Characteristics of individual respondents as well as organizational characteristics of the ASO itself were used to predict perceived benefits of adopting this type of intervention, perceived efficacy (confidence) in the ASO's ability to implement it, and perceived barriers to adoption. Findings revealed uniformly positive perceptions of benefits among respondents from ASOs of different sizes and organizational experiences, although directors held more favorable evaluations than frontline staff. Respondents from ASOs that were larger, had previously delivered group or workshop interventions, or had received outside technical assistance in the past expressed more confidence in the ability of their ASO to implement the intervention. On the other hand, older and more highly education individuals had less confidence in their organization's ability to implement the model. Resource constraints (money, staff, and time) were the most common barriers cited by the respondents. Overall, higher organizational role and longer tenure at an ASO were associated with the perception of more barriers to adopting science-based interventions. Respondents from ASOs with a history of receiving technical assistance reported fewer perceived barriers. The successful dissemination of HIV prevention models from the research arena to the service arena will require mechanisms to provide appropriate funding and technical assistance, particularly to smaller organizations. Mindful of the resource constraints faced by ASOs, researchers can facilitate this process by attempting to develop interventions that are less resource- and time-consuming than current models.