Providing HIV Services to People Who Are Incarcerated

The Maricopa Jail Project was implemented by five jails and leveraged the expansion of services under Policy Clarification Notice 18-02: The Use of Ryan White HIV/AIDS Program (RWHAP) Funds for Core Medical Services and Support Services for People Living with HIV Who Are Incarcerated and Justice Involved (PCN 18-02). To improve HIV care access for incarcerated people, Maricopa hired a nurse practitioner to manage service access and case manage across the jail system. The goals were to decrease the wait time between incarceration and/or diagnosis to the start of treatment, and to better support clients to reach viral suppression. The initiative was successful in increasing the number of clients who were virally suppressed.

Maricopa County, AZ

Emerging Intervention
Clinical service delivery model
Viral suppression
Treat
People who are incarcerated; People with HIV
RWHAP Part A
Correctional system
Need Addressed

Prior to the intervention, people with HIV had to wait for once-a-month HIV clinic days hosted by the jail system’s provider, meaning they may have to wait up to a month to receive services. This caused an extreme delay in access to HIV care and medications, and significant wait times on clinic days.  

Core Elements
Access to RWHAP services while incarcerated

PCN 18-02 allows RWHAP funds to be used for core medical services and support services for people who are incarcerated. Maricopa County leveraged this increased scope to hire a full-time nurse practitioner to manage HIV care across the jail system. The nurse practitioner follows people with HIV throughout their jail stay and helps with client education and access to HIV medications, in addition to working with Correctional Health Services to coordinate other needed care.

Enhanced linkage for previously diagnosed clients

Health assessments are completed for individual comings into the jail system within one to two business days. People with HIV will often wait to disclose their status until the assessment (rather than at intake). When they do disclose, the nurse practitioner is notified through a flag in the electronic health record (EHR) for follow-up, and medications can be started same day. Linkage to care times were expedited with addition of HIV medical services and case management (from 28 days to two days).

Increased HIV testing

During health assessments in the first week of entering the jail system, individuals undergo opt-out HIV testing. If a positive test result is found, the public health lab notifies the client and Correctional Health Services of the results, and the nurse practitioner is notified. The same day of the confirmation (if possible), the nurse practitioner begins assessment, education, medical care, and encourages the clients to start treatment. Clients who test positive but refuse treatment are rescheduled for regular visits with the nurse practitioner to continue education and encourage linkage to care. Clients who test negative receive health education and risk reduction counseling.

Enhanced relationships with other RWHAP providers

Through the RWHAP Part A system of care, the Maricopa County Jail System created relationships with other RWHAP providers to request and receive medical records more quickly (e.g., client medication(s), lab data), which contributed to faster initiation of treatment.   

Outcomes

The Maricopa County Jail System served 103 clients in 2020.

Category Information
Evaluation data As part of the evaluation, Maricopa County used client demographic and medical data from 2018–2020. Data are managed in CAREWare.
Measures Percentage of clients who reached viral suppression.
Results In 2020, 75% of clients were virally suppressed, compared to only 55% in 2018.

“And if they [test] negative, then I talk about PrEP. I talk about risk factors. I talk about every single thing that I can talk about with them to a level that they open up to me more than they do a whole lot of other people. And I think that continuity over the years works, too, because they know me and they can trust me. And if they don't trust me, I keep coming back until they decide to trust me and then we start plan of care.”

Planning & Implementation
  • Before the intervention the Maricopa County Jail System had a single provider who also ran infirmaries. Due to a busy schedule, the provider was only able to provide HIV care in a clinic once a month, making it difficult for clients to access care in an appropriate time frame. The nurse practitioner had previously been working in the jail system as a case manager and was familiar with the structure and the need for HIV services. The need for enhanced services and the PCN 18-02 guidelines were presented to the Medical Director of the Maricopa County Jail System, which were implemented immediately.
  • This intervention relies on one full time equivalent (1.0 FTE) nurse practitioner to provide HIV care in the jail system. RWHAP funds may also be used to pay for medications; in fact, RWHAP partnered with the Maricopa County Jail System to access 340B pricing in its pharmacies through this program.
  • Infrastructure for this intervention is provided by the Maricopa County Sheriff’s Office and the RWHAP Part A office. The RWHAP Part A manages a centralized eligibility office that oversees access to RWHAP services throughout the jurisdiction. This has made communication with other Part A subrecipients easier and also helps with linkage to care after release.
  • Working with people who are incarcerated requires sensitivity, and staff must be especially cautious regarding disclosure of HIV status in this environment. Health staff should treat people as “clients” rather than “inmates.”   
Sustainability
  • This intervention produced a high level of cost savings, particularly in medication costs, for jails that participated in it. Appropriately leveraging RWHAP as a supplement to the existing structure greatly increased access to care without incurring substantial costs beyond staffing.
  • Services provided under this intervention may only be used for HIV care. Other health services are provided by Correctional Health Services staff, meaning that RWHAP may not pay for primary medical care. 
Lessons Learned
  • Clients are at high risk for falling out of care when they are released from jail. Relationships with RWHAP providers in the community through centralized eligibility made pre-release discharge planning and data sharing less burdensome. Maricopa County is working on a Jumpstart program to further assist with linkage to care after release.
  • In addition to regularly seeing clients, the nurse practitioner will also run a list of HIV medication fills to identify clients who are HIV positive but had not been flagged in the EHR for follow-up with case management. This is done on Mondays and Thursdays in case a Friday appointment needs to be scheduled.   
Contact the Innovator
Maricopa Jail Project
Cynthia Quinn, NP
Project Medical Case Manager

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