Down Under: Working with what you've got.

And the Australians, again. I think we have a lot to learn from them. This is from the Hepatitis Australia website, http://www.hepedu.org.au/  which is designed specifically with health care professionals in mind.

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Considerations for working with people in custodial settings

Set realistic goals in education about safe injecting practices

While people in custodial settings are in principle entitled to the same level of health care and information as the general community, in practice they are unable to adequately protect their own health due to the current constraints of the prison environment. Research indicates that the prevalence of injecting drug use in custodial settings is very high. In the general community around one percent of people inject, while in custody approximately 25% of inmates continue to inject in extremely hazardous circumstances. Prison inmates have limited access to the means of preventing hepatitis C transmission. Needle and Syringe Programs (NSPs) have not been implemented in any Australian prison. Other harm reduction measures such as peer based drug education and bleach provision are available in some jurisdictions but not all. Therefore, it is unrealistic for educators to provide detailed instruction to inmates on safe injecting practices when there are limited provisions to ensure inmates have the opportunity to implement safe practice.

Due to the fact that safe injecting practices are nearly impossible to achieve in custodial settings, alternative methods of administration should be explored such as smoking, snorting, swallowing or shafting (rectal administration). However, another deterrent to effective harm reduction strategies is the discrepancy in the type of sanctions imposed for injected as opposed to non-injected illicit drug use in custodial settings. It has been suggested that the efficacy in detecting cannabis as opposed to heroin may cause some inmates to switch to injecting routes of drug administration. 

There are some provisions to encourage safe injecting in custodial settings such as the provision of bleach and instructions about washing syringes with soapy water.

Inmates with hepatitis C also need to be provided with information on the risks associated with unsafe injecting practices and the potential for re-infection with different hepatitis C genotypes.

Evidence suggests that people with hepatitis C who are exposed to potential infectious blood can be infected with more than one genotype at a time, which can impact on the natural history of disease progression and treatment efficacy.

Considering the barriers in custodial settings, it is important that inmates are provided with information on safe injecting in the context of access to NSPs in the post release setting.

Set realistic goals in education about health maintenance

Educators need to be aware of the relevance and applicability of information provided to inmates on health maintenance activities, for example, healthy diet, exercise and managing stress. Inmates will have limited control over the food they eat and therefore, need to be provided with information that allows them to make healthy choices from the available food. Discussions about regular exercise and stress management need to be adapted to the context of custodial settings and could provide inmates with useful and tangible health maintenance advice. For example, developing an exercise program that accounts for limited space such as the inmate’s cell or at the gym could be useful.

Education programs need to be tailored to the custodial setting and take into account the resources that are available to inmates. However, people living in custodial settings still need to be equipped with relevant health maintenance information for their return into the community.

Provide practical advice about infection control principles

Tattooing and body piercing pose a particular problem in custodial settings where these procedures are often performed by untrained operators without access to sterile equipment. In addition, other potential sources of blood to blood contact include using blunt hair clippers, sharing razors injury, self harm, fighting and physical and sexual assaults. Spread of hepatitis C through sexual transmission in the context of sexual assault where blood and skin trauma both occur is a possibility.

Education programs which include practical information about the principles of infection control and all the potential sources of hepatitis C transmission could provide inmates with the ability to reduce the risk associated with blood to blood contact in custodial settings. 

People who work in custodial settings may not be interested in learning about hepatitis C beyond worksafe issues. Occupational health and safety is the responsibility of the employee’s organisation, however, hepatitis C educators may be contracted to provide specific training about hepatitis C transmission and prevention and infection control. 

Acknowledge structural barriers that may prevent access to specialist health care

Structural barriers may prevent or inhibit inmates from accessing health care including hepatitis C treatment and related specialists services such as testing and monitoring. Availability of antiviral therapy for hepatitis C is variable between the states and territories and between custodial settings in the same jurisdiction. The number of inmates treated in all Australian jurisdictions remains low. Hepatitis C treatment availability is restricted by limited correctional health budgets because the costs of hepatitis C treatment must be carried by State and Territory governments. It is also a policy issue that requires concerted lobbying to improve access to treatment for inmates.

Testing for hepatitis C using PCR technology is also limited for inmates due to financial restrictions, therefore, confirmation of a hepatitis C diagnosis may not be possible in custodial settings. Therefore, educators must consider these barriers when providing inmates with information on accessing hepatitis C treatment. At the same time, it is vital that educators provide inmates with information and guidance on accessing hepatitis C services post release from prison.

While it is important to acknowledge the structural barriers, it is vital that educators advocate for inmates to have access to health care including hepatitis C treatment, hepatitis A and B vaccination and monitoring tests such as PCR and liver function tests whilst incarcerated.

Provide adequate information for release from custodial settings

Although it is important to consider the barriers to hepatitis C education in custodial settings and to focus providing relevant information in the context of inmates’ limited access to resources and supports, it is equally as important to provide inmates with information on all aspects of hepatitis C including access to specialist treatment services, NSPs and information and support services for their release into the community. Developing specific education programs that target inmates due for release is one method of ensuring the information is provided to those that need it.

Overcoming hepatitis C education fatigue among inmates

Some inmates may experience hepatitis C education fatigue or overload, believing that they have “heard it all before” and believe they are well informed about hepatitis C. Acknowledging that some inmates are informed about hepatitis C is crucial to avoid fuelling the fatigue and subsequently turning them away from the safety message. At the same time using creative and interactive education strategies such as games, videos and knowledge quiz activities could make learning about hepatitis C more interesting.

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National Centre in HIV Epidemiology and Clinical Research. (2006). Hepatitis C Virus Projections Working Group: Estimates and projections of the Hepatitis C virus epidemic in Australia 2006.
Ibid.

Hellard, M., Crofts, N. and Hocking, J. for the Burnet Institute: Epidemiology & Social Research Unit. (2004). Hepatitis C virus among inmates in Victorian correctional facilities: report of the prevalence of hepatitis C virus and the risk behaviours associated with the transmission of hepatitis C virus in Victorian correctional facilities.

Hellard, M., Hocking, J.S. and Crofts, N. (2004), ‘The prevalence and risk behaviours associated with the transmission of hepatitis C virus in Australian correctional facilities’, Epidemiology and Infection 132, pp. 409-415.

Anti-Discrimination Board of New South Wales (ADBNSW). C-Change - Report of the enquiry into hepatitis C related discrimination. 2001; Sydney: Anti-Discrimination Board of New South Wales.
Dolan, K. (2000). The epidemiology of hepatitis C in prison populations. In: Commonwealth Department of Health and Aged Care (Ed.), Hepatitis C: Informing Australia's National Response, 61-94. Canberra: Commonwealth of Australia.

Bowden, S., McCaw, R., White, P.A., Crofts, N. & Aitken, C.K. (2005). Detection of multiple hepatitis C virus genotypes in a cohort of injecting drug users. Journal of Viral Hepatitis; 12(3): 322-324.

Releasing our Elders; Health Care Reform and Prisoners.

From the list-serve/newsletter of www.curenational.org (Citizens United for the Rehabilitation of Errants)

-------New Vera Report Shows Difference between Geriatric Release Policy and Practice-------

Harsh sentencing policies have made correctional facilities throughout the United States home to a growing number of older adults. Yet most states with provisions for releasing older prisoners rarely use them, despite the relatively low risk eligible inmates would pose to public safety and the opportunity for potential cost savings.

“It’s About Time: Aging Prisoners, Increasing Costs, and Geriatric Release” examines statutes related to geriatric release in 15 states and the District of Columbia, identifies factors that help explain the discrepancy, and offers recommendations for those who would address it.

“The upshot is that there’s a difference between what states would like to do—save money by releasing older prisoners—and what actually happens,” says the report’s author, Tina Chiu. “If states want the result of geriatric release policies to be consistent with that objective, they should review the release process to address potential and existing obstacles.”

The Vera Institute of Justice is an independent nonprofit organization that combines expertise in research, demonstration projects, and technical assistance to help leaders in government and civil society improve the systems people rely on for justice and safety.

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Thirteen million people are incarcerated in jails annually.

Three and a half million of this 13 million are incarcerated more than once during the year.

 The Patient Protection and Affordable Care Act and the Health Care and Education Affordability Reconciliation Act (together referred to as "the health reform law" expands health insurance coverage by expanding Medicaid, the federal-state health insurance program for low income people, to cover everyone under 133 percent of the federal poverty level (FPL). For uninsured individuals above 133 FPL the bill sets up state-based "health insurance exchanges" or regulated insurance marketplaces where individuals and small businesses can compare and purchase private health insurance policies. (They will function something like websites like Travelocity or Orbitz, but for health insurance.) Lower income individuals will be eligible for tax subsidies to buy insurance on the exchanges.

The health reform law does not change the current inmate exclusion for Medicaid and other federal health programs. Convicted inmates are also ineligible for insurance from the exchanges. However, pre-conviction inmates remain eligible and they also remain subject to the individual mandate to carry health insurance.

Regardless of the insurance arrangements covering prisoners, jails will still have a legal obligation based on the /Gamble /decision by the Supreme Court to provide medical care for all prisoners regardless of conviction status. How this obligation will be satisfied or impacted by the health reform legislation has not been addressed.

 There are two additional references to the criminal justice system in the health care bill. First, "conviction for a relevant crime of patient or resident abuse" disqualifies a person from being hired
as a health care worker, and second, the Federal Bureau of Prisons is specifically included in the Interagency Working Group on Health Care quality.

The Legal Action Center reports that the final health care bill incorporates many key elements on addiction and mental health services, as follows:

Includes substance use disorder and mental health (SUD/MH) services as required benefits in the basic benefit package for individual and small business health plans;

Requires that all plans in the health insurance exchange comply with the Wellstone/Domenici Parity Act in providing SUD/MH benefits in the same way as all other covered medical and surgical benefits;

Expands Medicaid eligibility for all Americans up to 133 percent of the federal poverty level and require newly eligible parents and childless adults receive coverage that includes SUD/MH services provided at parity;

Includes SUD and MH prevention strategies and efforts in the bill's chronic disease initiatives;

Includes the capacity of the mental and behavioral health workforce as high-priority topics in the bill's National Workforce Strategy section; and

Includes insurance reforms and consumer protections critical for individuals seeking or in recovery, including prohibiting insurers from denying coverage to people with pre-existing conditions, charging higher premiums based on health status, and placing annual or lifetime caps on insurance coverage.