Changing the Course of the HIV Prevention, Engagement and Care Cascade for Current and Former Prisoners

Key Information on HIV in Prison

• People who are in contact with the correctional system have higher rates of HIV than the general population. HIV rates are higher among incarcerated women than men, and highest among Indigenous women.
• The most significant risk factor for HIV (and hepatitis C) for current and former prisoners is injection drug use.
• Prisoners with HIV who receive effective, consistent treatment can achieve good health outcomes.
• Within prisons, treatment interruptions are common. Some are due to structural barriers, and some are caused by prisoners’ decisions to discontinue treatment, often because of concerns about confidentiality and stigma.
• The time immediately after release from prison is critical for the health of people with HIV. It is essential that they be linked to care and other support services in the community. The key gaps for people with HIV who move from prison to the community are mental health services and stable housing.

“One of the challenges we have in the clinic is folks who come to see us after incarceration… have significant and complex mental health challenges, as well as, often, an addiction challenge and HIV care might not be at the top of their personal priority [list].” – Dr. Wendy Wobeser

The Federal Prison System

In Canada, individuals sentenced to two years or more in prison are sent to a federal institution, managed by Correctional Service Canada (CSC). Statistics presented by Jonathan Smith show that, in 2013-14, 22,969 inmates moved through the federal corrections system, with an average of 15,215 people incarcerated on any given day. Of these inmates, 4.1% were women, 22.8% were Indigenous, and 80% were serving a sentence of two to five years.

According to data from the International Centre for Prison Studies, referenced in November, 2014, Canada ranks #129 in terms of its national incarceration rate. The United States ranks #2.

CSC offers voluntary screening for HIV, hepatitis C, STIs, tuberculosis and MSRA bacteria on admission and during incarceration. Federal prisons offer health promotion and education programs, and engage in harm reduction by providing condoms, dental dams and bleach to prisoners. Prisons also provide opiate substitution therapy (previously known as Methadone Maintenance Therapy or MMT).

Preliminary CSC data shows that over 80% of inmates are tested for HIV and hepatitis C on admission. 2.4 of every 100,000 HIV tests, and 31.2 of every 100,000 hepatitis C tests return a positive result, with women more likely to test positive in either case. Each year, the percentage of federal prisoners with HIV varies between 1.5-2%; as of 2012, the percentage of prisoners with hepatitis C was 18.5%.

2007 Study of Inmates in Federal Prisons

In 2007, 3,370 inmates from across Canada completed a questionnaire on drug use, risky sexual behaviors, tattooing and piercing practices, health education programs, harm reduction programs and testing and treatment of infectious diseases.

Results of this survey, presented by Jennie Thompson, show that drug and sex-related risk behavior generally decrease when people enter prison, but that men who use injection drugs are more likely to share injection equipment while incarcerated.

The majority of inmates don’t engage in risk behavior while incarcerated, but among those who do, men are more likely to use injection drugs, and women are more likely to engage in sexual risk behaviors.

The majority of inmates are aware that CSC provides condoms, dental dams and lubricant to reduce STI transmission. Among those who had tried to access these resources, the barriers they reported most often were broken or empty dispensers, damaged supplies, and having to ask staff. Women are more likely to access these resources than men.

Among inmates who are sexually active, 68% of women and 45% of men have tried to access condoms; 57% of women and 21% of men have tried to access dental dams; and 58% of women and 38% of men have tried to access lubricant.

Of those who tried to access these services, 29% of women and 34% of men encountered access problems with condoms; 20% of women and 50% of men encountered access problems with dental dams; and 20% of women and 37% of men encountered access problems with lubricant.

The majority of inmates are also aware that bleach is available. The barriers most commonly reported when accessing bleach were broken/empty dispensers, diluted supplies, and having to ask staff

At the time of the survey, 7% of inmates were in the Methadone Maintenance Treatment Program. Of those who tried and failed to join, 53% had failed to meet the program criteria. 60% of program participants did not report any opiate use.

The majority of inmates who reported testing positive for HIV had also seen a doctor and started treatment; unfortunately, a majority also reported treatment interruption for at least one day, often due to operational issues.

Only one third of inmates who reported testing positive for hepatitis C had started medication. The top reasons for not taking medication were: they were told they were ineligible; they felt fine; they were on a waiting list; and they’d heard it makes you sick. Half of the people taking medication for hepatitis C reported that it worked.

The Provincial Prison System

The Ontario Ministry of Community Safety and Correctional Services (MCSCS) operates 26 adult facilities in the province, housing an average of 8,262 inmates each day. Statistics presented by Ruth Dixon show that 60% of provincial inmates are on remand, awaiting trial, sentencing or the commencement of a custodial disposition. The average time inmates serve on a provincial sentence is 78 days (median 35 days); average time served on remand is 40 days (median 7 days).

The average age of provincial inmates is 33.7 years. 71% of inmates are diagnosed with substance abuse disorders, 7.13% are on Methadone Maintenance, and less than 1% are on suboxone.

17.6% of provincial inmates have hepatitis C, and 2-4% are HIV positive and receiving Highly Active Antiretroviral Therapy (HAART).

Challenges in providing care to provincial inmates include staff recruitment and retention; staffing levels and workload; the risk that day to day decisions are based on operational needs rather than clinical considerations; paper-based medical records, which are harder to transfer; professional role ambiguity (e.g., pharmacy functions performed by nurses); and oversight challenges (i.e., the fact that performance assessments are completed by non-clinical supervisors).

Further Resources

• Inside & Out Conference Backgrounder
• Correctional Service Canada Research Publications: Health and Mental Health

Dr. David Wohl was unable to attend the conference, because he was en route to join an infectious disease team providing care to Ebola patients in West Africa. Instead, he pre-recorded his keynote address, and joined the conference by phone to answer questions from the audience.

During his presentation, Dr. Wohl explained that people living with HIV who are incarcerated in the United States have a high prevalence of substance use and mental health issues. While most get good care during incarceration, many do not maintain HIV therapy after release.

“I would posit that… we have dual epidemics of incarceration and HIV.”

Demographics

In the United States, incarcerated people, including those living with HIV, are disproportionately non-white. Statistics presented during the keynote address show that, of white men aged 18 and older, one in 106 are incarcerated, whereas one in 15 black men over the age of 18, and one in 9 black men aged 20-34 are incarcerated.

14% of all people living with HIV in the United States are incarcerated, as are 33% of people with hepatitis C. Prevalence of HIV in prison is three times greater than in the general population, and prevalence of AIDS is four times greater.

High Incarceration and HIV Rates among African-American Men

Data show that African-American men living in the United States are disproportionately affected by HIV. HPTN 061, a study of African-American men at risk for HIV, involved 1,553 participants, 174 of whom had a prior HIV diagnosis, and 1,168 of whom tested negative for HIV at baseline.

Notably, 60% of participants in this study had a history of incarceration, including 80% of those who identified as trans, 74% of those who identified as straight or heterosexual, and 70% of those who had experienced childhood violence.

HIV Screening Study (NIMH)

A screening study in North Carolina showed that opt-out testing policies result in higher voluntary testing rates as compared to opt-in systems. Over 90% of people were tested for HIV in opt-out systems, compared to just under 60% in opt-in systems.

Over 90% of people who tested positive for HIV under either the opt-in or opt-out system were already known to be living with HIV, meaning that many people who tested positive for HIV had been diagnosed before entering prison.

Accessing HIV Medication after Prison Release

Most people living with HIV in prison have an undetectable viral load, but studies have shown that patients leaving prison don’t always fill their prescriptions. Citing research published in the Journal of the American Medical Association, Dr. Wohl explained that, in Texas, prisoners living with HIV are released with a prescription that can be filled for free within ten days. Only 5% of patients go to a pharmacy within the ten-day window, and only 30% go within 60 days of release.

imPACT Intervention

The North Carolina Department of Public Safety and the Texas Department of Criminal Justice are working together to study an intervention for maintaining HIV care after people leave prison.

In this intervention, inmates have two face-to-face sessions with a counsellor and discharge planner prior to release, and determine which clinic their records will be sent to. Inmates are issued a cell phone on the day of release, on which they receive text messages reminding them to take their medication, and six follow-up calls from the same counsellor, over a three-month period.

380 participants were enrolled in the study, which was ongoing at the time of Dr. Wohl’s presentation. Preliminary results showed that 89% of participants had had at least one clinical visit within six weeks of release, but that 33% had missed taking their antiretroviral medication at least once in the past two weeks.

Final Thoughts

Dr. Wohl explained that the challenge facing people who provide care to current and former inmates is to address the entire continuum of care, including incarceration, release and the problem of reincarceration. This involves addressing questions of diagnoses, treatment, linkage to care and services, community resources, poverty, discrimination, sentencing laws and policy.

Further Resources

• Accessing Antiretroviral Therapy Following Release from Prison
• CDC: HIV Incidence Statistics and Fact Sheets
• HPTN 061 Study

Former inmate and human rights activist TJ Parsell joined the conference to talk about his personal experience in US prison, and his project, developed in partnership with the New York State Department of Justice, to create sexual safety orientation videos for incoming prisoners.

Now an MFA student at New York University, Parsell was sentenced for robbery at the age of 17 and sent to an adult institution where he was assaulted by older inmates. While making a short film based on his memoir, he returned to the same prison, and shot in the same cell he’d been in as an inmate. Recalling that experience, he said, “It was a very cathartic, empowering moment because this place didn’t destroy me – and now I get to bring a lens in here and illuminate for the world what we’re doing with our young people in prison.”

The former president of Stop Prisoner Rape, Parsell also testified before congress to support the creation of the Prison Rape Elimination Act (PREA), the first federal legislation in the United States to address rape in prison. He considers his work as an activist and filmmaker to be a continuation of the therapy he’s had to process his experience.

The inmate orientation videos he wrote and produced for New York State involved conducting focus groups with inmates, in which he shared his own story, and encouraged them to do the same. “The more we listened,” he said, “the more they talked. Our experience was that they had a lot to tell us, and they were eager to tell and, once they got the vision of what we were trying to do, they were completely engaged.”

“It’s easy to think about prisoners in the abstract but, if you can put a human face on it, and you can humanize it, then I think there’s the opportunity to change hearts and minds.”

Workshop: Sexual Safety Prisoner Orientation Videos

Conference attendees had the opportunity to participate in a workshop following Parsell’s presentation, focused on the prisoner orientation videos he produced.

The men’s video emphasizes that prison culture and sexual violence have changed over the years – it’s now more common to see subtle manipulation and grooming rather than violent crimes. The video encourages incoming inmates to observe the behavior of others, and to remember that trust has to be earned. Inmates appearing in the video stress the importance of reporting threats of violence to prison staff.

The women’s video emphasizes social manipulation that inmates engage in, including gift-giving with hidden agendas, and the family dynamic in women’s prisons that may leave women feeling obligated to engage in sexual behaviors. Parsell pointed out that the problem of staff sexual misconduct is a greater challenge for female inmates.

Community Presentations

Parsell was eager to share his message with current inmates while in Canada, and conference organizers were able to arrange presentations at Collin’s Bay and Bath Institutions.

Further Resources

• TJ Parsell’s Website
• Just Detention International (Formerly Stop Prisoner Rape)
• National Institute of Corrections: PREA

“Work, I think, has to go on to normalize HIV infection so that it’s not stigmatizing… making HIV just a normal everyday infection… We still have to address that in terms of education.” – Jonathan Smith

In their discussion of challenges and opportunities in prison health care, presenters and panelists agreed that trust between staff – especially health care staff – and inmates was key to ensuring successful treatment outcomes.

Two recurring concerns were the challenges posed by security issues, and limitations on the types of medications and harm reduction services available.

In an interview with OHTN staff, Dr. Wendy Wobeser also explained that, in terms of research studies done within correctional settings, there can be barriers related to consent. “I think if we were better prepared in terms of our understanding of what an ethical study in prison actually looks like,” she said, “we could gain more traction.”

Accessing HIV Treatment in Federal and Provincial Correctional Facilities in Ontario: A Phenomenological Study

Elspeth McTavish, a fourth-year medical student at Queen’s University, presented the results of a qualitative study into the lived-experience of inmates receiving HIV treatment. The study involved in-depth interviews with 10 HIV-positive men who had been incarcerated in both provincial and federal institutions.

Among the themes identified in these interviews were decreased access to health services inside the prison (as compared to within the community), and decreased access to HIV medication during lockdown or transfers between provincial facilities.

Institutional policies like random urine testing also led people to use harder drugs, such as heroine, because these drugs would clear their systems faster than cannabis.

Inmates identified a lack of confidentiality as a barrier to accessing HIV treatment. They expressed concerns that medication spot checks would disclose their HIV status, and that they could not speak freely with health care providers when guards were present. In some cases, just being seen with the infectious disease nurse could also disclose someone’s status.

All participants reported that they had to advocate for themselves to get health care. For some, this included saving a portion of their HIV medication to ensure they would have access to it during transfer.

McTavish concluded by suggesting three ways to improve health care for HIV-positive inmates, based on the study results:

• Prison-specific nurse and physician HIV specialists
• Increased education around stigma and issues of confidentiality
• Increased recognition of how institutional policies, including security needs, shape health care delivery in prison.

Dr. Lori Kiefer presented the results of a pilot study on Rapid HIV Testing conducted in partnership between the Ministry of Community Safety and Correctional Services, the Ministry of Health and Long-Term Care, Halton Public Health, and the Ontario HIV Treatment Network.

The study was conducted at Maplehurst Correctional Centre, over a six-month period from October to March, 2012. During this time, inmates could submit a health care request to see representatives from Public Health, receive counselling on testing options, get tested, and receive post-test counselling. After testing, inmates had the opportunity to fill out a voluntary 25-question survey about the experience.

Test sessions were not noted in inmate charts, and no record was kept in the prison health system – they were instead documented by Halton Region.

Results from the study show that word of mouth was the most important factor in helping people decide to get tested. The top three reasons reported for getting the test were:

• Wanting an HIV test (31%)
• The chance to get a rapid HIV test (27%)
• And that the test was done by Halton rather than the prison (13%).

98% of survey respondents were completely satisfied with the testing and counselling experience.

The post-test survey also included the open-ended question “How could we improve HIV testing and counselling in jails?”

Out of 112 respondents, 51 said that testing was fine the way it was. 16 advocated for more promotion; 14 asked for better access; 5 asked for more education and information; 3 mentioned characteristics of the testers (e.g., female nurses, representatives from the health department); 8 asked for mandatory testing; and one mentioned segregating people with HIV. In general, comments pushed for the normalization of testing.

Dr. Kiefer noted that the HIV testing rate effectively doubled during the pilot study, indicating the desire for better access to testing.

Further Resources

• CATIE: Pilot to Offer Anonymous, Rapid Point-of-Care HIV Testing in Prisons
• CATIE: Resources on Rapid Point-of-Care HIV Testing

According to statistics from Correctional Service Canada, as of 2014, Indigenous people comprised 22.8% of the total incarcerated population in Canada, though they comprised just 4% of Canada’s total population.

As part of her presentation on providing care to Indigenous prisoners, Meagan Fumerton explained that Indigenous inmates enter prison with higher risk and needs ratings, more health problems and more mental health issues than non-Indigenous prisoners. Indigenous inmates also tend to be younger, and more of them have a history of substance abuse, physical abuse, parental neglect, foster care and poverty. They’re also uniquely affected by the impact of residential schools and the impact of intergenerational trauma.

Fumerton reviewed some of the programs available for Indigenous inmates, including Basic Healing, a four-week intensive program intended to empower inmates and place them on a healing path, while introducing them to the other Aboriginal programming available. Other programs include Aboriginal Substance Abuse, In Search of Your Warrior (a violence prevention program), and Aboriginal Family Violence. Each of these programs is available at either moderate or high intensity, and women-specific programs are an option as well.

Fumerton also spoke about igniting a sense of identity, and creating a spiritual link for Indigenous inmates through her work in the Aboriginal Peer Education and Counseling (APEC) program. She emphasized the importance of looking at historical factors, including colonization and the devaluation of women’s roles, as well as the legacy of residential schools, to help inmates understand the effect that intergenerational trauma continues to have.

Outreach to Indigenous Inmates

During the conference, OHTN staff were able to interview two outreach workers from the Ontario Aboriginal HIV/AIDS Strategy (OAHAS) – Wanda Whitebird, an Elder on the OHTN’s Indigenous Research Steering Committee, and Melissa Maracle, the Kingston Regional Support Outreach Worker for OAHAS.

Whitebird spoke candidly about the difficulties she’s faced in trying to bring a harm reduction message to federal prisons, and about her desire for a justice system more reflective of racial equality. “Before I die,” she said, “I really want to see a fairness and a justice system that’s fair to everybody. Because, 75% of the increase in the prison population in the last 10 years is minorities.”

Melissa Maracle noted that she has been able to bring condoms and medicines into prison with two weeks prior approval, but agreed that she would like to see a prison system where inmates are treated with more respect. “If [inmates] want help, it should be available for them to receive,” she said. “They’re no different than we are, here. I feel that everybody makes mistakes throughout their life, and we all need to be given a second chance.”

“Sometimes, for our men and women coming in at intake, that’s their first discussion of or introduction to their culture, because they’ve been displaced at some point in their lives. … By the end of the course, hopefully they’re sitting up a little taller and they’re proud of their identity and who they are.” – Meagan Fumerton

Indigenous Sharing Circle

Inside and Out was pleased to welcome Elder Gerard Sagassige, who facilitated a sharing circle for attendees on the second day of the conference.

Sharing circles are traditional, respectful ways for people to learn from one another, share challenges and success stories and gain strength through participating in a group. The sanctity of the circle requires that the specifics of what is shared within the circle not be discussed outside that space, except with the explicit consent of participants.

The Inside & Out sharing circle included both Indigenous and non-Indigenous participants, who shared their concerns related to incarceration and HIV. Key themes in the discussion included the way that trauma impacts life choices, placing individuals in situations that make them more vulnerable to HIV and other infections. This included misusing substances like drugs to escape the pain of violence and abuse, as well as the ongoing effects of residential school.

Group members also shared their experience of healing and their paths toward wholeness. They highlighted strength of and connection to culture as a way to begin healing, and identified culture as a factor that led to resiliency. It was noted that there should be some mechanism in the community to nurture resiliency and to address trauma and its effects.

Participants reported that the circle was a powerful experience, leaving them with a renewed sense of connection and purpose.

Further Resources

• Correctional Service Canada: Facts and Figures on Aboriginal Corrections
• The First Nations and Inuit Health Branch Strategic Plan: A Shared Path to Improved Health
• Ontario Aboriginal HIV/AIDS Strategy (OAHAS)
• Heartsong: Exploring Emotional Suppression and Disconnection in Aboriginal Canada

Leslie Lofton joined the conference to discuss end of life care provided by the hospice program at Louisiana State Penitentiary. In Louisiana, inmates may be sentenced to life without parole, meaning they will age and die in prison – the hospice program allows inmate volunteers to care for fellow prisoners during the final stages of life.

In an interview with OHTN staff, Lofton explained that she hadn’t been looking for a job when she was invited to work at the penitentiary, but that something told her to say yes, and, since then, she’s never looked back. One of the things she likes most about her job is being able to connect with prisoners’ loved ones and reassure them, if possible.

The hospice program is partly supported through the money raised by raffling and selling quilts sewn by hospice volunteers. One quilt was recently auctioned off to kickstart funding for a hospice program at another institution.

The program itself is offered as an alternative to the prison’s palliative care services, and requires patients to sign a Do Not Resuscitate (DNR) order. The focus is on making them as comfortable as possible in their final days, rather than extending their lives.

When asked if she would change anything about the prison system, Lofton said, “The sentencing… Identifying the people who have changed and can be productive citizens outside of the facility.”

“I will take an inmate with me… if I have to go far down the walk, and that’s who I trust to take care of me. And he knows I trust him to take care of me. And they trust me.”

Community Presentations

During her stay in Kingston, Lofton also visited the offices of HIV/AIDS Regional Services (HARS) and gave a presentation to community agencies.

Further Resources

• Angola Museum
• National Institute of Corrections: Hospice and Palliative Care
• The hospice program is also the subject of the Oprah Winfrey Network documentary Serving Life

The conference featured presentations on harm reduction services available both in Canada and internationally. Most harm reduction programs are at least partly designed to decrease the risk that inmates who are addicted to injection drugs will share injection equipment (which increases their risk of transmitting HIV and hepatitis C), during and after their time in prison.

Correctional Service Canada’s Opiate Substitution Therapy Program

Shanna Farrell MacDonald outlined CSC’s Opiate Substitution Therapy program, available since December of 1997, and previously known as Methadone Maintenance Therapy (MMT). As of December 2008, Suboxone has been available in place of Methadone.

MacDonald explained that MMT is associated with:

• reduced recidivism rates
• lower rates of post-release mortality
• reductions in injecting risk behavior
• reduced HCV infection
• reduced drug use in prison and involvement in prison drug trade
• less time in voluntary segregation
• and fewer serious drug-related institutional charges.

In a study that included 2,065 male and 209 female inmates on MMT as well as 36,073 other male and 1,879 other female inmates, 74% of inmates who used injection drugs reported sharing needles prior to incarceration. Prior to involvement with MMT, 65% of men and 35% of women had used opiates in prison – of those who used opiates, 81% of men and 62% of women had used needles; of those who used needles, 88% of men and 86% of women had shared needles; and, of those who had shared needles, 79% of men and 90% of women had cleaned the needles with bleach.

Inmates enrolled in MMT showed a decrease in positive testing for opioid use, a longer duration in education and employment programs, an increase in program completion, and a decrease in the proportion of them who had institutional disciplinary charges or placements in segregation.

Post-release follow-up with inmates revealed that women involved in MMT who continued after release were less likely to return to custody at 6 months and one year. Men who continued with MMT after release were 36% less likely to return to custody than those who had never enrolled in MMT and had similarly severe substance use issues.

MacDonald closed by acknowledging that CSC faces a changing clientele over time, and that there are regional variations that need to be taken into account, including the overall prevalence of injection drug use, and resources in the community. As injection drug use has a high comorbidity with mental health issues, other substance use issues and trauma, these issues need to be addressed in conjunction with any opiate substitution program.

Harm Reduction Programs in Moldovian Correctional Institutions

Although she was unable to join the conference in person, former Lieutenant Colonel Svetlana Doltu pre-recorded a presentation in Russian, which was translated by OHTN staff for the conference. Conference attendees with questions for Doltu were able to engage in a follow-up Q&A session by teleconference on December 16, 2014.

In her presentation, Doltu explained that the Moldovian penitentiary system is an integral part of the country’s National HIV/STI Prevention and Control Program, enacted in 2005.

As of 2013, there were 114 people living with HIV in the Moldovian prison system (2% of the total prison population), and over 300 people with various forms of hepatitis.

Employing the National HIV/STI Prevention and Control Program in prisons involved a three-step process including:

1. Information, education and communication to staff and inmates
2. HIV/HCV testing and counselling (compulsory testing was discontinued in 2007 and replaced with voluntary testing in 2008; rapid testing became available in 2012 through the support of non-profit partners)
3. Treatment, care and support, including diagnostic testing for tuberculosis and STIs, and substitution treatment for injection drug users.

The total number of substitution treatment patients is 320, though Doltu explained that some prisoners must be withdrawn from treatment before release, as they may not be able to continue in their communities. Other disadvantages of substitution treatment include that prisoners who don’t participate in the black market for drugs are pushed down the prison hierarchy, and that program guidelines exclude prisoners who inject substances other than opioids from participating. The prisons also experience high turnover in medical staff.

In addition to rapid HIV testing for prisoners, non-profit partners provide addiction counselling, a social reintegration program, treatment adherence training for prisoners receiving HIV treatment, pre-release planning and transitional case management.

Needle Exchange in Moldovian Prisons

In addition to substitution therapy, Moldovian prisons offer an anonymous needle exchange program, available at 13 institutions at the time of Doltu’s presentation, with two more institutions scheduled to offer the program in 2015. So far, a total of over 80,000 needles have been distributed.

The program is carried out by peer volunteers, with each institution offering 1-4 needle exchange sites in the dorms where volunteers live. These sites also distribute alcohol swabs, antiseptic and anti-inflammatory and IEC materials. 30,000 condoms are also distributed each year, through needle exchange sites, peer volunteers and medical staff.

Doltu explained that the needle exchange program is cost effective and acts as a bridge to substance use treatment programs. Since the program’s inception, there have been no reported incidents of inappropriate use of needles, and the program has led to less harmful drug use, decreased risk that staff will be punctured by used needles and increased partnership between community and prison health services.

Challenges of maintaining the needle exchange program include the need for continuous information to inmates and staff, as well as ongoing training for staff.

Further Resources

• Correctional Service Canada: Post-release Outcomes of Methadone Maintenance Treatment Program (MMTP) Participants
• Dr. Hino Stover presentation on Drug Use in European Prisons (PowerPoint)

Statistics presented by Ruth Dixon show that 23.4% of inmates in the provincial prison system are admitted with a mental health alert. 17.8% have severe or persistent mental illness, and over 40% have mild to moderate depression.

The Centre for Addiction and Mental Health and the Ministry of Community Safety and Correctional Services have developed a Forensic Early Intervention Service (FEIS) at the Toronto South Detention Centre to enhance timely access to forensic services. Inmates will be screened for mental illness by nursing staff on admission and those who screen positive for a mental illness that may impair their capacity to participate at trial, or may make a defense of Not Criminally Responsible available to them, will be referred to the service. They will then be assessed by an inter-professional team member (usually a mental health nurse) and a psychiatrist, before engaging with a multidisciplinary team for treatment planning, delivery and handover.

The Ministry anticipates that this will reduce the number of people requiring fitness to stand trial assessments and improve court efficiency through fewer delays and enhanced clinical coordination. The Forensic Early Intervention Service will also result in:

• Fewer treatment orders and keep fit orders
• More efficient forensic assessments
• Lower MCSCS costs
• Improved safety for inmates and correctional officers
• Improved demand management for the forensic system
• Improved re-engagement with community support agencies
• And improved ability to advocate for inpatient treatment of inmates requiring transfer from prisons to hospitals.

Dixon also noted that the South West Detention Centre, opened in 2014, features a 16-bed Direct Supervision mental health unit for male inmates, and a four-bed female mental health unit, in addition to an eight-bed male infirmary unit and a two-bed female infirmary unit.

St. Lawrence Valley Correctional and Treatment Centre

Dr. Colin Cameron and Brian Patterson joined the conference to discuss the St. Lawrence Valley Correctional and Treatment Centre, a hybrid mental health and correctional centre opened in Brockville, Ontario in October, 2003.

A partnership between the Ministry of Community Safety and Correctional Services and the Royal Ottawa Healthcare Group, St. Lawrence Valley is mandated to provide mental health centre-standard services to seriously ill inmates serving a provincial sentence. Its population consists of the most vulnerable male inmates drawn from Ontario’s 26 correctional facilities.

80% of staff at St. Lawrence Valley are health care professionals, and 20% of staff work in corrections. At the time of Dr. Cameron and Patterson’s presentation, 35.1% of current inmates had a “moderate” number of symptoms of severe mental illness.

St. Lawrence Valley consists of four self-contained treatment units, with 25 single bedrooms each – 37 designated for maximum security, and 63 for medium security. Each unit has a medical observation/seclusion room, and two units have negative pressure rooms. Each unit also has a maximum security “diamond” that includes four bedrooms and a dayroom for specialized needs, but the facility’s focus is on integration rather than seclusion.

“Progress is being made, and I think we have to realize it’s made incrementally, and we have to communicate that, too.” – Colin Cameron

Admission to St. Lawrence Valley is based on a triage procedure. The mental health needs of residents may involve psychotic disorders, major mood disorders or anxiety disorders. Issues with alcohol or substance use, intellectual or developmental disabilities, and personality disorders may also be present. Normally, inmates must be at risk of serious harm or impairment, or demonstrate severely limited capacity to function in one or more major life activities. Prisoners on remand or immigration holds may be admitted on a case-by-case basis.

St. Lawrence Valley offers its residents psycho-educational and mental health groups, as well as anti-criminal groups, including (among others):

• Medication and symptom management
• Nutrition
• Self-Esteem
• Meditation and mindfulness
• Controlling Anger and Learning to Manage it (CALM)
• Skills, Techniques, Options and Plans (STOP)
• And Dialectical Behaviour Therapy (DBT).

A sentence of four to six months is optimal for participation in group treatment, as residents are typically transferred to institutions in their home communities one to two weeks before release. Social workers are assigned to each resident on admission and take the lead on discharge planning.

In 2012-13, St. Lawrence Valley had an occupancy rate of 98.97% with 267 admissions, 266 discharges, and an average stay of 133 days per resident.

On admission, 93% of residents had at least two Axis I mental health diagnoses; 74% had at least three diagnoses, and 48% had four. 65% of residents had an Axis II diagnosis. In terms of the most responsible diagnosis for each resident (the most significant condition that warrants a resident’s stay in the hospital):

• In 27% of cases, issues with alcohol dependence or substance use were most responsible
• In 25% of cases, psychotic disorders were most responsible
• In 15% of cases, mood disorders were most responsible
• In 9% of cases, anxiety disorders were most responsible
• In 9% of cases, personality disorders were most responsible
• In 7% of cases, sexual disorders were most responsible

15-20% of residents also had an intellectual disability.

Statistics presented by Dr. Cameron showed that residents generally improved during their stay at St. Lawrence Valley. They scored higher on the Global Assessment of Functioning by their time of release – that is, they moved from the “serious” range to the “moderate” range. On the Severity of Illness Scale, more residents were “mildly mentally ill” or “borderline mentally ill” on release and fewer were “moderately” or “severely” mentally ill. The majority also showed an improvement as measured by the Clinical Global Improvement Scale.

Dr. Cameron and Patterson emphasized that the success of St. Lawrence Valley depends on the strong partnership and cooperation between health care and corrections staff, which has provided a unique opportunity for intervention to improve mental health in the long term.

Further Resources

• Ministry of Community Safety and Correctional Services: Mental Health Strategy for Corrections in Canada
• The Government of Ontario: Enhancing Public Safety Through Mental Health Services for Inmates

In their discussion of challenges in discharge planning and transitions, panelists and presenters agreed that pre-release planning, getting a family doctor and finding suitable housing for inmates was of paramount importance.

Several speakers noted that inmates may be released to a different community with less than 48 hours notice, making it difficult to arrange appointments and accommodations in advance. Many family doctors are also reluctant to take on patients newly released from prison, or to prescribe pain medication to them. With many half-way houses at capacity, it’s also a challenge to find somewhere for newly-released inmates to live, and shelters pose their own challenges to people living with HIV who want to hide their status.

One recurring theme was the need for more coordination between correctional institutions, parole boards and the community to set inmates up for success upon their release.

Services in the South East Local Health Integration Network (LHIN)

Cynthia Martineau provided an overview of health services and initiatives in the south east region of Ontario (including Kingston/Belleville). She noted that, in developing an integrated health services plan, the LHIN has heard concerns about are transitions in care, addictions and mental health from the community.

The South East LHIN is currently undergoing an Addictions and Mental Health redesign, which involves engaging with clinicians and patients to streamline services so that the continuum of care is less fractured and easier to navigate.

Martineau noted that the South East Health Line, an index of health services in the region, is now available as an ap as well as a website, and is actively monitored and updated with information. The Ministry of Health and Long-Term Care has also funded addiction supportive housing in the region, under the Housing First model. Thirty-two units geared toward people with addictions are available, and the region has plans to introduce another 36 units for people with mental health issues, based on a similar model.

Another new initiative from the Ministry is Health Links, designed to build more coordinated access to health care in the region, and geared toward people with complex comorbid conditions. Martineau explained that people with repeated visits to the emergency room are often there for complex reasons involving the social determinants of health and that Heath Links helps primary care providers to look at patients through that lens.

“Housing is pivotal; it’s a vital issue. If you don’t have somewhere to go that’s safe and stable, then nothing else matters. You're not worried about your addiction, you’re not worried about anything else except where you can put your head down that night, and that’s a terrible way to live.” – Diane Smith-Merrill

Street Health: Services for Inmates Returning to Kingston

Tina Knorr joined the conference to give an overview of the services available at Street Health, and the challenges faced by its clients.

A harm reduction centre, Street Health has offered a needle exchange program since 1991, and methadone maintenance since 1995. It offers primary health care through physicians and nurse practitioners, counselling referrals, smoking cessation, acupuncture and treatment for hepatitis C.

The clinic provides workshops around infectious disease and harm reduction, and attends pre-release fairs at correctional institutions to inform inmates of the services available. It can also accept collect calls from prison to help inmates prepare for release and set up appointments. One of the clinic’s most popular services to inmates is help with ODSP applications and tax returns (which may involve filing returns for up to the past ten years).

Street Health representatives may also connect with inmates on their day of release and take them to appointments in the community.

Knorr emphasized that Street Health has a good working relationship with probation and parole, but noted that discharge planning is inconsistent between institutions. Clients sometimes arrive with no ID and no provincial health card, which slows the process of connecting them to care. Street Health also receives many requests from inmates returning to communities outside of Kingston, who want to connect with a similar service. Knorr said it would be helpful to have more information about services these clients could be referred to.

Knorr also noted that there are sometimes misunderstandings about which services and medications are available outside of prison, and the limits of what a nurse practitioner can provide. She said it would be best if patients’ medical records, as well as their psychology and psychiatry reports were transferred before release, as they’re needed for ODSP applications.

Further Resources

• Kingston Community Health Centres: Street Health
• South East Health Line
• Government of Ontario: Health Links
• Homelesshub.ca: Housing First

Katie Kramer joined the conference to talk about Project START, an STI risk-reduction program developed in the United States for prisoners transitioning back to the community.

Kramer explained that an estimated 14-25% of all people living with HIV the United States spend time in prison or jail, and that over 90% of people in a correctional facility will one day return to the community. She emphasized that correctional medical care and health programs represent an opportunity to improve community health.

Project START is a short-term individual level program, beginning two months before an inmate is released, and continuing three months post-release. It is designed to help bridge people between the services available inside correctional institutions and those in the community, and is based on a client-centered, strengths-based harm reduction framework. Its goal is to reduce HIV, STI, and hepatitis C risk behaviours, while addressing the other life issues that people face during transitions. Its conceptual model is based on cultural awareness – of the correctional facility, of incarcerated populations, and of the home community.

Inmates enrolled in Project START complete two one-on-one sessions before release where they discuss risk behaviours and develop plans for individual risk reduction and transitional needs. Post-release, they participate in four additional one-on-one sessions, where they revise their goals for risk reduction, problem-solve and access risk-reduction materials including condoms and lubricants. Counsellors also facilitate service referrals to the community.

Project START + is a new adaptation of Project START specifically targeted to people living with HIV. It places more focus on linkage to care after release from prison, as well as on medication use and adherence.

“I think, in criminal justice, we have two buckets: we have the victims and we have the offenders. I work a lot with victim rights groups to really appreciate that there are a lot of victims of our criminal justice system, and that we can’t just put folks into the two buckets. What we see, over and over, is that we have individuals who may have been victims their entire lives and then the moment they commit an offense… they automatically move from victim to offender, and that entire history of victimization no longer counts. … I think we have a lot to do, when we talk about criminal justice, about changing the conversation.”

Evidence on the Effectiveness of Project START

Project START is the only corrections-based behavioral intervention supported by the US Center for Disease Control (CDC) High Impact Prevention Initiative, and is recognized as an approved effective intervention by the Substance Abuse and Mental Health Services Administration (SAMSHA). It’s also the only CDC-funded intervention that was designed from the ground up with correctional populations in mind.

Project START was part of a nine-year study funded by the CDC, to compare its effectiveness to that of a single session intervention. 522 men aged 18-29, being released from eight state prisons, were enrolled in the study, and findings show that men involved in Project START were less likely to report unprotected anal or vaginal sex at six months post-release.

Workshop: Implementing Project START

Conference attendees had the opportunity to participate in a workshop after Kramer’s presentation and learn more about Project START. Kramer walked participants through the theoretical and logic models of the program, including strategies involved with prevention case management, motivational enhancement, decision making and harm reduction.

She emphasized that the uniqueness of the START model is that the intervention begins while the client is still inside prison and continues after he or she is released back into the community. Project START is the only known evidence-based intervention to provide structured short-term transitional case management to incarcerated individuals.

During the workshop, participants learned about eight core elements and four key characteristics of the model, and reviewed the content of each of the six mandatory sessions, focusing on the goals and outcomes of each one. They also spent time reviewing the pre-release check list, a tool that helps to minimize health risks and reduce the chance of re-incarceration.

Kramer also provided participants with a link to the full project implementation package on the CDC website.

Further Resources

• The Bridging Group: Project START
• CDC: Project START

Tamara Easto gave an overview of the Ministry of Community Safety and Correctional Services’ community reintegration pilot, which was still in progress at the time of her presentation.

Easto explained that each of the 26 provincial institutions handles discharge planning in a different way, partly due to differing population sizes, and that none of the institutions currently engage in discharge planning for inmates on remand (approximately 65% of the provincial prison population). After reviewing the literature on discharge planning, the Ministry has developed a framework for all facilities, based on the following premises:

1. Discharge planning begins on day one
2. Discharge planning support should be available to all inmates
3. Discharge planning must be available at all institutions regardless of size
4. Mandatory minimum requirements and discharge planning will be based on an inmate’s status.

The pilot program, which involves early release for qualified inmates, is focused on individuals with weekend, Friday, or holiday release dates, which may make it more difficult for them to access community supports and services in a timely way. As part of the pilot, eligible inmates are released on an earlier date, between Monday and Thursday, to facilitate access to resources.

Easto explained that, in the provincial system, superintendents and deputy superintendents only have the authority to release people up to 72 hours early, which gave the pilot program a three-day window for early release. Inmates with inappropriate behavior were excluded from the pilot, as were inmates with recent misconducts, outstanding charges or police holds, or high risk assessment scores.

Program and resource limitations also mean that inmates in the pilot program need to have a sentence of at least 12 days, in order for staff to process their paperwork. As Easto explained, in the provincial system, inmates are automatically released after serving two-thirds of their sentence, which can result in quick turnaround times.

All releases during the pilot will also comply with existing policy.

Easto noted that, at the time she left the project, in September 2014, 15% of eligible inmates were being released under the pilot program. She expressed her hope that, over time, that percentage will increase.

“Part of our mandate of this program was also to start changing the philosophy of who deserves to be released, and changing it to who should we be keeping in? Quite frankly, someone’s getting out in 72 hours, and isn’t it a better way of releasing them with some conditions, and resources, and access to the community than releasing them on Saturday at four o’clock with no food, no housing, and no community supports?”

Development of Discharge Planning Tools

Ruth Dixon explained that, as part of this project, a healthcare discharge planning tool was developed for provincial use. It includes a checklist with areas for recommendations and referrals, as well as documentation that plans have been discussed with inmates. Inmates also receive a copy of the plan.

Dixon noted that the discharge plan become part of an inmate’s property upon release, meaning that, if an inmate is released at court, he or she has to return to the prison in order to retrieve these records.