Download RSAT Training Tool - (RSAT) Training and Technical Assistance

RSAT Training Tool:
HIV Prevention and the
Treatment Needs of Offenders
at risk for or living with
HIV/AIDS
Niki Miller, M.S. CPS
Advocates for Human Potential
www.ahpnet.com
Cherie Hunter
Treatment Alternatives for Safer Communities
www.tasc-il.org
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Who Needs this Information?
A lack of information and training, specifically within the correctional
workforce, has been identified as a barrier to reducing the spread of HIV.
Mental Health
Counselors
Addiction Professionals
Case Managers
Volunteers
RSAT Staff
Administrators
Healthcare Staff
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Security Staff
Chaplains
Community Corrections
3
Purpose
Cross-disciplinary training curriculum designed
to increase knowledge of the relationship
between HIV infection and substance use; best
practices for integrated care in jail and prison
settings.
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Objectives

Increase knowledge of the benefits of testing and of
HIV screening and prevention procedures in
correctional settings.

Enable RSAT staffs to meet the treatment needs of
offenders with HIV/AIDS and help them modify highrisk behaviors.

Recognize cultural considerations and health
disparities among subgroups of at-risk offenders that
affect their re-entry planning needs.
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Why Learn about HIV/AIDS
Each year, 1 in 5 HIV+ individuals passes through a corrections
facility; the opportunity for reducing the spread of the disease
extends far beyond prison walls.

At least a quarter of the 1 million people infected with HIV in the
U.S. do not know it.

With early detection, new therapies can extend life and delay the
onset of AIDS related health problems, sometimes indefinitely.
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Module I:
Introduction to HIV/AIDS in
Correctional Treatment
Settings
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Module I: Topics
a)
b)
c)
d)
HIV/AIDS Basics
HIV/AIDS Issues in Custody
Priorities for RSAT Staff
Resources and Review
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Module I: Learning Objectives

Define HIV and symptoms of progression into AIDS.

Explain the ways HIV can and cannot be transmitted.

Discuss prevalence and risk factors for HIV/AIDS
among incarcerated populations.

List the advantages of HIV prevention, education and
testing for RSAT clients.
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Module I Pre-Test: True or False
1.
According to the CDC, the overall prevalence of HIV in US correctional
facilities is four to five times higher than in the general U.S. population.
2.
The risk of HIV infection is 12 times greater for people with substance use
disorders.
3.
There are clear guidelines and uniform standards for HIV testing in jails or
prisons.
4.
HIV only causes one type of AIDS. The cause for other types of AIDS is
unknown.
5.
If a HIV positive inmate spits on a staff member and saliva comes in
contact with, unbroken skin, it is not considered exposure. There is no
risk of HIV infection or need to take a protective dose of medication to
prevent transmission.
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Module I:HIV/AIDS Basics
Human Immunodeficiency Virus Type 1 (HIV-1)

HIV is the retrovirus isolated and recognized as the cause of AIDS. HIV
infection results in the virus inserting its own RNA into the host cell's DNA,
preventing the host cell from carrying out its natural functions and turning
it into an HIV factory.
Acquired Immunodeficiency Syndrome (AIDS)

AIDS progression means the virus has weakened the immune system,
resulting in severe health complications, opportunistic infections or AIDS
related cancers. AIDS is also defined by the degree of immunodeficiency in
an HIV-infected individual.
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Module I:HIV/AIDS Basics

Transmission of HIV
1.
2.
3.
4.
5.
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Modes of HIV infection
Sexual intercourse with an infected partner
Sharing a syringe or other equipment with someone who
is infected
Mother to child transmission during pregnancy, labor or
delivery, or through breastfeeding
Transfusion or organ transplant from an infected donor
Certain workplace exposures to contaminated body
products; needle sticks
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Module I: HIV/AIDS Basics

Fluids with sufficient HIV levels to result in
transmission are highlighted in red -in order of the
amount of the virus they contain.
1.
2.
3.
4.
5.
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blood
semen
vaginal secretions
breast milk
cerebrospinal fluid
6.
7.
8.
9.
10.
amniotic fluid
bronchial secretions
urine
tears
saliva
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Module I: HIV/AIDS Basics
Sexual Transmission
Types of high risk sexual contact include:
Male to male and heterosexual anal intercourse
 Receptive partner is at highest risk
 Vaginal intercourse; women are at twice the risk
compared to men
 Possible through oral sex when open sores are present

Exercise 1, pg. 9 -Mode of Transmission
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Module I: HIV Issues in Custody
How Prevalent is HIV/AIDS among Offenders?

Known full-blown AIDS cases-between 2.7 and 4.8 times
higher than general population

HIV infection among incarcerated people is estimated at more
than 5x the rate of the general population

Some studies have found rates up to 10-14 times higher

Florida, Texas and New York account for almost half of HIV+
inmates in state prisons

Up to 13% of female inmates in some facilities are HIV+
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Module I: Review
Module I: Research
•
Offenders with substance use problems are especially highrisk for HIV/AIDS.
•
HIV is the virus that causes AIDS. It is mainly transmitted
sexually and through blood products.
•
Current guidelines recommend HIV screening as a part of
routine healthcare.
•
Opt out testing means that everyone is offered screening and
consent is built into the consent form for medical treatment.
•
Advantages of screening include reducing the spread of HIV
and access to new effective treatments.
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Module I: Context and Background
HIV Screening and Detection
 Once individuals learn about their HIV infection, they
substantially reduce their high-risk sexual behaviors.
The transmission rate among those who do not know they are
infected is 3.5 times higher than for people who know.
 Public safety and public health improve when re-entering
offenders know their HIV status and what to do to prevent
the spread of HIV.
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Module I: HIV Issues in Custody
Module I: Research
Understanding all the New Guidelines:

New testing guidelines from the Centers for Disease Control (CDC) routine “opt-out” HIV screening for everyone- ages 13-64 years

CDC - screening guidelines for pregnant women, prenatal care and
prevention of mother-to-child transmission

The National Commission on Correctional Health Care - voluntary,
routine universal screening, informed consent and opt out rights

Center for Substance Abuse Treatment- best practice for SUD treatment
- rapid-testing/risk reduction counseling
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Module I: HIV Issues in Custody
Module I: Research
Stigma and Discriminatory Practices- high level in the general
population--even higher within prisons and jails. Inmates fear
violence from other inmates or staff and institutional discriminatory
practices. May results in HIV+ offenders:
• Denying HIV status
• Failing to disclose healthcare needs to medical staff
• Discontinuing medications
• Avoiding testing
• Avoiding mental health or substance abuse treatment
• Avoiding healthcare
Exercise 2, pg. 17 – Meet Joe
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
Module I: Legal Issues in HIV Testing pg. 20 in manual
Module I: Research
Familiarize staff with facility & state guidelines; align practices
accordingly…

HIV Testing laws for each state

State laws specific to testing prison & jail inmates

Federal BOP testing guidelines – mandated for high risk inmates

Public Health requirements for newly detected cases: informing
and notification

Use the National HIV/AIDS Consultation Center: info on state laws;
hotline for questions
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Module I:
Abstinence Violation at Release
Module I: Research
Majority are infected before entering correctional systems;
small numbers contract HIV in correctional facilities

Substance use - predictor of high risk sexual behavior at release

Studies show some offenders have unprotected sex and use IV
drugs within hours of release

Goal: modify post-release drug use and sex high risk behaviors
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Module I: Priorities for RSAT Staff
Module I: Research
Accurate information on preventing transmission

Evidence-based risk reduction interventions help modify sex and
drug use behaviors.
Convey the benefits of knowing their status

Today, HIV+ status is far from the death sentence it once was.
Emotional support

If clients must face a difficult diagnosis, better to do so while
they are in treatment and have support.
Effective substance use disorder interventions

Quality treatment and continuing care.
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Module I: Resources
Module I: Research
Resource page (pg. 20) in your manual can help locate:
•
•
A hotline number for questions
•
Testing recommendations and
clinical care guidelines for
correctional settings
Addiction treatment best practices
for clients with HIV/AIDS
•
Evidence-based HIV treatment and
prevention practices
•
Guidelines on HIV/AIDS and
pregnancy
•
Resources for re-entering offenders
with HIV/AIDS
•
•
Federal BOP guidelines on HIV/AIDS •
Fact sheets for clients and families •
•
Training and consultation resources
•
State laws, notification
requirements and procedures
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Advocacy and legal information
Exposure protocols for staff
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Module II:
HIV Issues in Addiction
Treatment
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Module II: Topics
a)
b)
c)
d)
HIV/AIDS and Substance Use
Best Practices
Importance of HIV Testing
Resources and Review
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Module II: Learning Objectives

Discuss reasons IV drug use, crack/cocaine,
methamphetamine heighten the risk of HIV infection.

Describe the links between drug and alcohol use and
unsafe sexual behaviors.

Identify best practices for addiction treatment and
HIV risk reduction interventions.

List the types of HIV tests and describe the elements
of pre-test and posttest counseling.
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Module II Pre-Test : True or False
1.
Only HIV rapid tests require a follow up confirmation test.
2.
Most RSAT clients who do not use IV drugs are at minimal risk for HIV
infection.
3.
If RSAT clients test negative for HIV upon intake, but have been recently
exposed to HIV, then they should be retested in 3-6 months.
4.
Even if some RSAT clients continue to use drugs, there are still ways they
can reduce their risk of HIV infection.
5.
Condom use, needle exchanges and opiate replacement therapy are all
examples of universal precautions.
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Module II: HIV/AIDS and Substance Use
Module I: Research
Health risk behaviors tend to occur together….

Substances increase the likelihood of unprotected sex or
multiple partners (especially alcohol).

Substance abuse multiplies the risk for HIV infection nearly 12
times (CSAT, 2000).

Alcohol and drug addiction result in health problems
(hepatitis, pancreatitis, other STI’s) that can increase HIV risk
and speed the progression of AIDS related diseases.
Four of every ten AIDS deaths are related to drug abuse
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Module II:
Hepatitis,
HIV
and
IV
Drug
Use
Module I: Research
HIV prevention can reduce related medical costs:

Hepatitis B virus (HBV); Hepatitis C virus (HCV) more
easily transmitted

Co-infection with HIV is common.

Rates of HCV are epidemic = 10 x the rate of the general
public; 33% higher for women offenders.
Exercise 4, pgs. 27-28 Risk Factors for Specific Substances
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Module II: HIV/AIDS and Substance Use
Module I: Research
At least 50% of HIV+ individuals have a mental health disorder.

Untreated mental health disorders contribute to high-risk behaviors

Mental health services should be available, especially for those just
learning of their HIV+ status

The need for MH assessment may be ongoing as health status
changes or AIDS related conditions progress

Mental health treatment improves HIV/AIDS outcomes; best to treat
mental health and substance abuse disorders before beginning HIV
treatments (when possible)
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Module II: Best Practices
Module I: Research
Best practices specific to HIV/AIDS in substance
treatment include:



Pre-test counseling
Information on the advantages
of testing
Rapid testing and referral to
treatment
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



Education
Risk assessment
Risk reduction counseling
Preventing the spread of the
infection for HIV+ clients
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Module II: Best Practices
Module I: Research
Diffusion of Effective Behavioral Interventions (DEBI)

DEBI is the CDC’s equivalent of an evidence-based practice.

The CDC funds 11 regional training centers that offer a
training, including on line courses.

A Compendium of risk reduction programs for various
populations is available at the CDC website

Compendium of effective behavioral interventions:
http://www.cdc.gov/hiv/topics/research/prs/compendium-evidencebased-interventions.htm

Regional training centers:
http://depts.washington.edu/nnptc/regional_centers/index.html
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Module II: The Importance of HIV Testing
Module I: Research
Who Should Be Tested?

Unless the population is documented as low risk, HIV testing
should be part of routine healthcare for:
•
•
•
•
All patients aged 13-64 years
All patients initiating treatment for tuberculosis (TB)
All patients seeking treatment for any sexually transmitted
infection (STI’s)
All pregnant women
In both correctional and substance use treatment settings,
where the population is at a higher that average risk, testing
should be part of routine intake health screenings.
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Module II: The Importance of HIV Testing
Module I: Research

Repeat testing, 3-6 months later, is recommended for:
•
High risk individuals– annual testing is recommended
•
Pregnant women at high-risk for infection; re-test in third trimester
•
Any person whose blood or body fluid is the source of an occupational
exposure to a health care provider or other staff
•
Any persons known or suspected to have engaged in drug use or
sexual activity while incarcerated
•
Any victim or suspected victim of a sexual assault (and any identified
assailants)
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Module II: Best Practices - Women
Module I: Research
All pregnant women and women of childbearing age should
receive counseling, testing and prevention education

Young women 13 to 29 represent 50% of new infections

Young women of color are particularly at high risk

Women who use IV drugs are at risk, but many more women
are infected by a partner that uses IV drugs

African American women now make up 66% of new HIV
infections in women; making AIDS the leading cause of
death among Black women 25-34 in the US.
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Module II: Best Practices - Women
Module I: Research
Women Offenders continued…
 Anti-retroviral treatments during pregnancy can almost
eliminate the risk of transmitting HIV to the infant

If women live in high-risk sexual conditions, "survival sex” is a
more accurate description than “engaging in high risk sexual
behavior.”

Educating women about the risk of HIV infection can only be
effective if they have the power to make a choice.

Safe housing and safety from intimate partner violence are
necessary in order to reduce risk of HIV for re-entering women.
Research with women and youth shows safety as a bigger
predictor of changes in high risk behaviors than education.
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Module II: HIV Testing
Module I: Research

General Components of pre and posttest education and risk
reduction counseling are:
•
Repeating drug and sex-related risk reduction messages at each
contact
•
Offering testing, information on reducing the risk of infection and
preventing transmission to others.
•
Enabling HIV+ persons to inform their drug and sex partners about
the risk of infection and the importance of testing.
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Module II:
Types of Tests
Module I: Research
All HIV testing requires a second confirmation test

Rapid testing - results within an hour-must be sent to lab for
confirmatory test

Rapid testing is often best approach for jails; also best practice in
addiction treatment

Conventional testing - ELISA ,looks at antibodies in serum

Confirmatory testing - usually a Western Blot test (labs automatically
perform confirmatory tests)
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Module II: HIV Testing
Module I: Research

Post Test Counseling for an HIV+ Client


•
•
If an offender receives notification that they are HIV positive
it is important to provide support, information and preserve
medical confidentiality
An RSAT client finding out for the first time that they
are HIV positive may need:
Short term mental health support;
mental health assessment
To be assessed and monitored for
suicide risk
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•
•
•
Information on exactly how to
interpret a positive test result
Follow-up medical care
Counseling on partner/contact
notification
39
Module II: What RSAT Clients should know about tests
Module I: Research
•
Knowing you have HIV infection can improve your prognosis with treatment.
•
Knowing you have HIV can help you take precautions to prevent passing it to others.
•
Refusing an HIV test will not affect the care you receive
•
Test results are confidential. However, in certain states (including California), if a
confirmatory test is positive, the law requires that the results be reported to the
health department.
•
A negative test means you do not have HIV infection; however, the test may not
show recent infection from an exposure within the past 3 months.
•
A negative test in patients recently exposed to HIV should prompt repeat screening
in 3-6 months.
•
If the test is positive, there are medications that help people live long, health lives.
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Module II: Review
Module I: Research

Best practices in substance treatment include HIV testing, risk reduction
and prevention education, referral and care coordination.

The relationship between various substances, blood borne HIV infection,
injection drug use and sexual transmission is complex.

Most people with HIV have mental health needs.

African Americans and young women are increasingly affected.
Approaches should be culturally responsive, considering safety, exposure
to violence, discrimination and access to care.

Testing for pregnant women and women of childbearing age is critical.

Confidentiality is essential; individual counseling is often warranted for
clients at high risk for HIV infection and for those who are HIV+.
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Module III:
Meeting the Needs of HIV+
RSAT Clients and Clients
Living with AIDS
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Module III: Topics
a)
HIV+ Individuals Entering Correctional Facilities
b)
People Diagnosed while in Custody
c)
Re-entry and Continuity of Care
d)
Resources and Review
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Module III: Learning Objectives

Explain RSAT staff’s role in supporting clients living with
HIV/AIDS as they enter correctional facilities and SUD
treatment.

List the types of support RSAT staff can provide to HIV+
clients learning of their status while in custody and to those
receiving medical treatment.

Describe key elements and resources for re-entry planning
and transitional care for RSAT clients living with HIV/AIDS.
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Module III Pre-Test: True or False
1.
HAART is the federally funded program that provides healthcare coverage to
people living with HIV/AIDS.
2.
Re-entering offenders are not eligible for housing resources for people living
with AIDS and Ryan White Care Act funded services.
3.
Most RSAT clients that do not use IV drugs are at minimal risk for HIV
infection.
4.
Prisons provide anti-retroviral medications to inmates living with AIDS.
5.
The success rate of anti-retroviral therapy for people with HIV/AIDS receiving
treatment in prison is significantly lower than the rate in the community.
6.
Successful medication treatments can reduce the amount of HIV virus in the
blood to point where it is undetectable.
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Module III:
Challenges of Diverse Care Needs
Module I: Research
Program staff is the offender’s source of addiction recovery
treatment and support. A team approach ensures staff function
within the scope of knowledge and training.
Case
Management
Addiction
Treatment
Medical Care
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Mental
Health
Treatment
CognitiveBehavioral
Treatment
HIV+
Inmate
Social Skills
Training
Housing
Re-Entry
Support
46
Module III:
Care Needs at Each Stage
Module I: Research
HIV+ offenders have many of the same treatment needs as
other RSAT clients: support for changing their behavior.
But, their circumstance may differ:
•
•
•
•
•
•
Offenders who do not disclose their HIV+ status
Offenders HIV+ with limited access to care
Offenders not yet at the point of needing treatment
Offenders for whom treatment is medically indicated
Offenders undergoing treatment in the community
Offenders with full blown AIDS
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Module III
Meeting the Needs of HIV+ Clients
Approaches & treatment needs of HIV+ clients differ at
each stage of disease and may include:

Anti-retroviral treatment adherence issues

Complicating medical conditions

Care transitions & re-entry planning for HIV+ offenders

Resources for community-based care & housing
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Module III: HIV+ Individuals Entering
Correctional
Facilities
Module
I: Research
Clients enter facilities knowing their status, but may not disclose that
they are HIV+, even to medical staff.
a)
•
RSAT Staff Approaches: Can benefit from individual counseling sessions that
review risk reduction principles; a clear discussion of confidentiality limits;
participation in HIV education groups; assurances and measures to protect
confidentiality and collaborative sessions with medical staff.
Clients know their status, but may have had limited access to care.
b)
•
Due to lack health coverage, or because they are from underserved communities
that experience disparities in access to care.
•
RSAT Staff Approaches: Can benefit from the above approaches, along with
periodic medical evaluations and routine care for HIV+ individuals; includes
Immunological Monitoring (T-cell counts and viral levels).
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Module III: HIV+ Individuals Entering
Correctional
Facilities
Module
I: Research
Clients may not have advanced to the point of needing treatment.
c)
RSAT clients may have been living with HIV for an extended period and may
be healthy and asymptomatic. Routine immunological monitoring, ongoing
medical evaluation is necessary while they are in custody.
•
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RSAT Staff Approaches: HIV education and risk reduction counseling as part
of a substance treatment plan. Documentation of HIV status; medical
records and lab results are critical for HIV+ inmates as they prepare for reentry.
50
Module III: HIV+ Individuals Entering
Correctional
Facilities
Module
I: Research
Clients may have been undergoing treatment in the community.
d)
For offenders undergoing treatment in the community for HIV/AIDS, the most
challenging issues when they enter a facility include documentation and
continuity of care.
•
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RSAT Staff Approaches: RSAT staff can help clients obtain medical records,
work with medical staff to re-establish or continue care and adherence to
medical regimes and to provide substance use disorder treatment and
recovery support.
51
Module III: HIV+ Individuals in Correctional
ModuleFacilities
I: Research
e)
Clients may be at the point that treatment is medically indicated.
RSAT staff is not responsible for the clinical care, but can learn about the
medical decisions that clients face.
RSAT Staff Approaches: RSAT staff can work with medical care providers as they
prepare clients for treatment and offer encouragement and support:
•
•
•
•
•
•
Establish readiness to start therapy
•
Provide education on medication dosing •
Review potential side effects
•
Support treatment of side effects
Utilize educational aids, including pictures
•
and calendars.
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Engage family and friends.
Help simplify regimens, dosing, and food
requirements.
Utilize a team approach among nurses,
pharmacists, and peer counselors.
Provide an accessible, trusted health care
team.
52
Module III: People Diagnosed with
HIV/AIDS
in Custody
ModuleWhile
I: Research
As time goes on, many more people may learn of their HIV status
while in custody. They will also have diverse needs.

Asymptomatic–
•

RSAT clients that learn of their HIV status but do not require treatment will need
routine medical care, vaccinations, treatment for other health conditions and
immunological monitoring. It is important to treat their substance use disorders
and other behavioral health issues to ensure they are prepared to adhere to and
benefit from medical treatment.
Candidates for Treatment–
•
Those with high viral loads and low T-cell counts may be considered for HAART.
Although it is best to treat substance use and mental health problems prior to
beginning HAART, that may not always be possible. They may need concurrent
treatment and support .
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Module III: People Diagnosed with
HIV/AIDS
in Custody
ModuleWhile
I: Research

Clients Receiving HAART—
•
Most facilities use one of two methods to dispense anti-retroviral meds
•
DOT is Directly Observed Therapy that involves nursing staff watching
the patient take their medication.
•
KOP- is a more flexible option. It stands for Keep On Person, which
means inmates can carry some of their medication with them, so they
can take it when they need to.
KOP may be a better option for clients in RSAT programs. Staff may need to
work with these clients in individual sessions to come up with a strategy for
maintaining confidentiality for those receiving HAART while in RSAT programs.
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Module III: Individuals with AIDS in
Correctional
Facilities
Module
I: Research
Clients may have advanced to full blown AIDS & may have
numerous health issues and complex treatment needs.
These clients may be very ill, requiring medical care that interferes with
program participation. They may also need mental health and addiction
recovery supports.
•
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RSAT Staff Approaches: Clients should not be excluded from programming
solely on the basis of their health status. Each individual’s wishes should
be respected along with the medical recommendations of the clinical care
team. End stage AIDS patients often require analgesic medications for
pain management. Substance treatment professionals can support the
care team by providing information on minimizing the potential for abuse.
55
Module III:
What is HAART?
Module I: Research
Highly Active Anti-retroviral Therapy.

Aggressive medication treatment, consisting of a
combination of at least three drugs.

Effective for offenders in facilities but, transitions in
and out of prisons and jails result in interruption

Interruption and low adherence is associated with poor
outcomes, including earlier death
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Module III: HAART
Module I: Research
HAART continued…

HAART can be as effective for offenders in correctional facilities
as it is for people receiving treatment in the community; but,
transitions in and out often result in interrupted treatment.

However! Research shows reasons for hope regarding treatment
of HIV/AIDS during incarceration.
•
•
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75% of HIV positive inmates undergoing treatment began receiving antiretroviral therapy after they were incarcerated.
59% inmates who received 6 months of HAART while in custody had
undetectable viral loads by the time they left prison
57
Module III: HAART
Module I: Research

HAART continued…

Interruptions or low adherence to HAART is associated with
poor outcomes, including earlier death, for people living with
HIV/AIDS.

Adherence is a problem among women, African Americans,
Native Americans and other diverse cultural sub-groups that
experience economic and health disparities.

It is also a problem for offenders transfering facilities or reentering.
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Module III:
Re-entry and Continuity of Care
Module I: Research

Long term substance treatment in facilities is significantly more
effective when followed up with community treatment

The same is true of HIV treatment

Connections to community care, resources and a support
system are critical needs

Re-entering HIV+ offenders best served by leaving with a 30
day supply of meds and an appointment
Exercise 5, pg. 51 HIV Related Counseling Needs
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Module Module
III: Re-entryI:and
Continuity of Care
Research
Ryan White CARE Act – Funds Many Services & Programs

Reauthorized in 2006
•

Housing Opportunities for People living With AIDS (HOPWA)
•

Increased resources directed toward outreach to incarcerated and reentering HIV+ individuals.
Housing support is available in some communities to re-entering offenders
as long as they meet the income eligibility guidelines.
AIDS Drug Assistance Program (ADAP)- Administered by the states
•
•
•
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Low income offenders returning to the community can receive HIV
medications through the program.
Most offenders who begin HAART in correctional facilities cannot or do not
continue with HIV drug therapies once they are released.
But, those that had help filing an ADAP application were more likely to have
their medications after release.
60
Module III: Re-entry and Continuity of Care
• Ryan White funded programs and AIDS Service Organizations work in each
community. Justice population are a priority; some offer education
workshops for inmates, work inside facilities on pre-release planning,
assisting inmates with Medicaid and Social Security applications.
• RSAT staff may be able to obtain a Ryan White funded medical case
managers for re-entering HIV+ clients.
• The first thing an offender will need in order to qualify for medical care,
through Ryan White funded programs, is documentation. The list of steps
in exercise 6 outlines some of what is needed.
• Links to state by state listings of Ryan White funded programs, housing
resources and AIDS Service Organizations are on pg. 58 of the manual.
Exercise 6, pgs. 53-55 Steps to Ensure Clients Can Qualify for Care
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61
Module III:
Re-entryI:and
Continuity of Care
Module
Research
Supporting HIV+ offenders is challenging, but RSAT staff do not have to go it
alone. Both internal and external care teams and partners can be utilized.

Make use of medical and nursing staff, psychiatric case management,
chaplain services and the connections that your internal team may have.

Exercise 7 on pg. 57 of the manual suggests listing contacts for agencies
that assist with re-entry planning. Check in with them on what they can
do for HIV+ clients. They may have specific funding and programs.
•
•
•
•
•
•
•
•
•
•
•
•
•
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Substance abuse treatment ____________________________________________
Temporary Assistance for Needy Families (TANF) __________________________
Job readiness and training______________________________________________
Child Welfare________________________________________________________
Housing assistance___________________________________________________
Mental health services_________________________________________________
Recovery/ AA/ Peer Support____________________________________________
Ministries, synagogues, mosques________________________________________
Domestic violence/ rape crisis ___________________________________________
Food pantry, clothing exchanges etc.______________________________________
Gyms, YMCA, recreational programs______________________________________
Medication resources__________________________________________________
Minority community organizations________________________________________
62
Module III: Review
Module I: Research





HIV+ RSAT clients may fall into a number of categories which
have varying care needs.
Care transitions and documentation are two important issues for
HIV+ clients within correctional systems.
RSAT HIV+ clients also have special counseling needs.
Re-entry planning for HIV+ offenders includes all aspects of
transition planning required by any RSAT client, connections to
Ryan White funded services and other programs for people
living with HIV/AIDS and medical services in the community.
There are many resources that RSAT staff can tap to increase the
correctional system’s capacity to serve inmates at-risk for or
living with HIV/AIDS.
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63
Module IV:
Case Histories and HIV/AIDS
Special Topics
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64
Module IV: Topics
c)
Cultural Competency and Health Literacy
HIV issues for Underserved Groups: Youth, Women,
African Americans and Others
Sex in Prison Settings and PREA Requirements
d)
Resources and Review
a)
b)
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Module IV: Learning Objectives

Discuss health literacy and cultural considerations in HIV
prevention and treatment.

Describe important issues affecting various sub groups of
offenders and strategies to engage diverse clients.

Define the Prison Rape Elimination Act and explain staff
reporting responsibilities.

Explain the influence of cultural dynamics (age, gender,
sexuality, race, ethnicity, and socioeconomic status) on HIV
care and treatment through the use of case studies.
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66
Module IV Pre-Test True or False
1.
Women have fewer side effects from anti-retroviral and a better response to
medication therapies for HIV/AIDS in comparison to men.
2.
Most African American women with HIV are infected through blood-born
transmission due to IV drug use.
3.
Latino men and women have a higher rate of HIV infection as compared to Whites.
4.
PREA Law protects inmates from sexual assault, but it does not protect staff from
sexual assault by inmates.
5.
Some peer-led prison HIV education programs delivered by inmates have been
shown to have a greater influence on reducing high risk behaviors than education
programs delivered by professionals.
6.
If an inmate reports a sexual assault to an RSAT staff member, but doesn’t want to
tell anyone else, staff must report it to the authority responsible for investigating
PREA incidents.
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67
Module IV: Cultural Competency
and Health
Literacy
Module
I: Research

Changes in drug control policies and sentencing have altered
the composition of the prison population.

In 1985, only 8.6% of inmates were in state prisons due to
drug offenses.

By 1995 there was a 478% increase in drug offenders.

Between 1985 and 1995, the correctional population
increased 78.5 %
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68
Module IV: Cultural Competency
and Health
Literacy
Module
I: Research

Researchers have found that the highest
concentrations of adult illiteracy are among prisoners.
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69
Module IV: Health Literacy
Module I: Research

Defining Health Literacy:

The ability to read, understand and act on health
information.

The U.S. Department of Health and Human Services states:
people need to be able obtain, process and understand
information and services in order to make informed health
decisions.

The example on the next slide demonstrates the various skills
required to understand critical health information.l
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70
Health Literacy: Exercise 8. pg. 63

Read the Instructions Below. Then check off the skills
required to follow them.
Take nothing by mouth from midnight the night before your procedure. Arrive at the office 15 minutes
before your scheduled appointment. The nurse will instruct you on how to obtain a clean catch urine
sample. Return your specimen to the front desk, with your name written on the label, prior to changing
into the gown provided. Once your procedure is complete you must remain in the waiting room for 2
hours and 45 minutes unless you have pre-arranged transportation home. Do not drive a car until the
next day. Be sure to wear the compression garment for 2 full weeks. Call the office immediately if
bruising or swelling occurs. You may take up to 2 Tylenol at a time every 4 hours with meals for no more
than 5 days .





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reading
writing
listening
speaking
math




grasping abstract concepts
conceptualizing knowledge
following multi-step directions
understanding consequences
71
Module IV: Health Literacy
Module I: Research

What Works:

Using simple language, short sentences, and defining technical
terms

Supplementing instruction with videos, models, and pictures

Asking open-ended questions

Organizing information so that the most important points stand
out and are repeated

Crafting materials that are responsive to the age, literacy level,
cultural, ethnic, and racial diversity of clients
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Module IV: Health Literacy
Module I: Research

RSAT staff can assist HIV+ clients with information,
questions and explanations.

Staff can check in on those receiving HAART to monitor
adherence and make sure clients understand dosage
schedules and the consequences of skipping doses .
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73
Module IV: Underserved Groups - Women
Module I: Research
HIV and Women

HIV+ women are at higher risk for mental disorders, violent
and sexual victimization, stigma and discrimination.

At least half of HIV+ women have one or more psychiatric
conditions-- rates of post‐traumatic stress disorder alone
range from 20%-60%

What Works: All women should be tested for HIV, especially
women of childbearing age or those who may be pregnant.
Use HIV risk reduction education and counseling curricula
developed specifically for women and for groups of racial and
ethnically diverse women.
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74
Module IV: Underserved Groups - Women
Module I: Research

Messages that bear repeating:
•
Repeatedly point out that women are at risk for HIV infection.
•
HIV is passed on to women more easily.
•
Women should protect themselves against HIV infection.
•
Birth control pills, diaphragms, or gels do NOT provide protection
against HIV.
•
Women should get tested for HIV.
•
Get to the gynecologist regularly.
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Module IV: HIV Issues: Underserved Groups:
Youth, Women,
Module
African
I: Research
Americans & Others

Treatment for Women:



5/6/2017
Women get more and different side effects than men when
they are treated for HIV/AIDS and have higher blood levels of
medications for longer periods.
Women are more likely than men to die of AIDS
Fewer women than men are getting HIV treatment. However,
when they are supported and treated with HAART, they can
respond and extend their lives at rates comparable to men’s.
76
Module IV: Underserved Groups - Youth
Module I: Research

HIV and Youth
•

Risk Factors and Barriers to Prevention for Youth




Young people in the United States are at high risk for HIV infection, especially
minority youth and young girls of color.
Risk Factors include: early age at sexual initiation; intercourse before age 13
Heterosexual transmission is the mode for new cases of HIV infection,
especially among minority girls.
Young men who have sex with men are at very high risk for HIV infection.
What Works: age-appropriate education that includes ways to talk with their
parents or other trusted adults about HIV/AIDS, ways to reduce or eliminate risk
factors, and how to talk with potential partners about risk factors. Skill rehearsal
and role plays.
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77
Module IV: Underserved Groups - African
Americans
Module
I: Research

African Americans and other underserved groups
•
•
•
Health disparities have a profound impact on outcomes for those
infected with HIV.
African Americans are under represented in research studies,
including AIDS research.
Distrust among significant sectors of the Black community
regarding HIV, behavioral health services and research.
What Works: Connect all HIV+ offenders with AIDS Service Organizations
and culturally specific community agencies. Include dealing with the
effects of discrimination, racism and disparities as central recovery
issues. Validate distrust and its basis in historical fact. Ask about trusted
networks and information sources and consider family as a resource.
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78
Module IV: HIV Issues: Underserved Groups - Latinos
Module I: Research

Latinos are diverse and sub-groups differ drastically


5/6/2017
A relatively young population, often experiences language
barriers that interfere with access to care, isolation from family
living outside the US, employment discrimination and other
stressors.
What Works: Approaches should account for stigma and for
community norms in Hispanic communities. Latino
organizations may offer appropriate educational groups;
curricula tailored to Latina women for HIV education are
available. The use of HIV peer educators in prisons and jails has
been evaluated, is considered extremely effective, and has been
embraced in states like Texas and Oklahoma.
79
Module IV:
Best Practices w/Underserved Groups
Module I: Research
Good
• Use of culturally specific risk reduction
interventions from the CDC
Better
• AIDS Service Organizations or culturally specific
community groups deliver these to offenders
Best
• Have these groups train Latino, African American,
females etc. to deliver peer-led groups
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Module IV:
Examples of Interventions for
w/Underserved
Groups
Module
I: Research
Project Start–Young men leaving prisons
Safer Sex Skills Building-Sexually active
women in drug treatment
Safe on the Outs–Juvenile detention
facilities
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Module IV: Sex in Prison Settings
and
Module
PREAI:Requirements
Research

2003- President Bush signed the Prison Rape
Elimination Act (PREA) into law

The provisions of the law classify prisoners as a protected vulnerable
population that cannot consent to sex due to their diminished status,
similar to the protections afforded to underage youth and children.

It protects inmates from other inmates, staff, visitors, volunteers and
contracted workers that come into facilities or have contact with
inmates at work release sites.
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82
Module IV: Sex in Prison Settings
and
Module
PREAI:Requirements
Research

PREA Law Requirements

5/6/2017
The National Institute of Corrections (NIC) is a resource for
information about PREA. Links to NIC PREA information and
to a two-hour online PREA e-Learning course, which can be
accessed at no charge, are listed on the resource page in the
manual (pg 78).
83
Module IV: Sex in Prison Settings
and
Module
PREAI:Requirements
Research

The Extent of Sex in Prison
• There is wide variation in the nature and extent of
consensual, coerced and forced sex in different facilities
• 5% = average rate of sexual assault in US prisons and jails
• 20% = average rate at the most problematic facilities

Legal Considerations and Inmate Rights and Protections
 PREA law provides a basis for action if inmate rights are
violated and assigns responsibility to correctional facilities for
taking steps to prevent and respond to violations.
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84
Module IV: Sex in Prison Settings
and
Module
PREAI:Requirements
Research

Inmates at Risk for Sexual Assault
•
PREA law requires screening inmates for vulnerability and
risk of victimization and for predatory and violent tendencies.
•
The highest risk group is sexual and gender non-conforming
inmates, including: gay, lesbian, bisexual, transgendered
men, women and youth.
•
Offenders with developmental disabilities, mental health
disorders, and women with histories of prostitution are also
high risk.
RSAT staff should be aware of the possibility of past or current
victimization among clients that belong to at-risk groups.
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85
Module IV: Sex in Prison Settings
and
Module
PREAI:Requirements
Research
What RSAT Staff Need to Know:

PREA policy in their facility, including reporting procedures:
• If an inmate makes staff aware of a sexual assault, staff must report it to
the responsible authority.

A forensic exam is performed at a hospital when a recent incident of sexual
assault is reported (with in the last 72-96 hrs.).

Inmate victims may fear retribution or have been threatened and feel it is not
safe to report an incident. They may, however, seek information about HIV
testing and exposures. They can get confidential services in the community.

Any RSAT client disclosing a past assault should be offered mental health
services. Be aware that such an experience can trigger the desire to use drugs
and alcohol.
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Module IV: Sex in Prison Settings
and
Module
PREAI:Requirements
Research

Sexual Risk Behaviors upon Release

All HIV education and risk reduction counseling should target
changing risk behaviors upon release.

Reduced risk behavior was more likely among re-entering
offenders with stable housing, jobs and community support.

Substance treatment can target risk behavior, educate clients
about HIV and addresses criminal thinking, values and associates.

Sound discharge planning, culturally responsive community
support, drug and alcohol aftercare and medical care are all
components of successful re-entry for RSAT clients at risk for and
living with HIV.
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Module IV: Review
Module I: Research

New cases of HIV infection are growing among African Americans, Latinos,
women and youth. Immigrants, Indigenous Americans and MSM are also
at high risk for HIV infection.

RSAT staff can help clients undergoing treatment by explaining materials
and checking in with those on medication regimes.

Women, especially young women of color, are at high risk. All women of
childbearing age should be tested. Sexual and violent victimization is
associated with HIV risk for women.

All RSAT staff should be familiar with PREA policy, sexual assault reporting
procedures in their facility and aware of clients at risk for sexual abuse.

Re-entry planning, documentation, linkages to community support, HIV
programs, recovery support and medical care are all necessary for HIV+
offenders.
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RSAT Technical Assistance and Training Center
HIV Manual : www.rsat-tta.com/Curricula
For more information on RSAT training and technical
assistance visit: www.rsat-tta.com/Home
Or email Jon Grand, RSAT TA Coordinator :
[email protected]
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