What Happens to HIV+ Inmates in the SD County Jail System, Stays in the SD County Jail System: Challenges and Opportunities

AIDS CLINICAL ROUNDS
The UC San Diego AntiViral Research Center sponsors weekly
presentations by infectious disease clinicians, physicians and
researchers. The goal of these presentations is to provide the most
current research, clinical practices and trends in HIV, HBV, HCV, TB
and other infectious diseases of global significance.

The slides from the AIDS Clinical Rounds presentation that you are
about to view are intended for the educational purposes of our
audience. They may not be used for other purposes without the
presenter’s express permission.

What Happens to HIV+ Inmates
in the SD County Jail System
Stays in the SD County Jail
System (at least until the MD
becomes a snitch) - Challenges
and Opportunities

Daniel Lee, MD
Clinical Professor of Medicine
UCSD Medical Center – Owen Clinic
December 7, 2012

Outline
Difference between Jails and Prisons
Epidemiology of HIV in Corrections
Tour of the San Diego County Jail system
Challenges and Opportunities in SD Jails
– Intake visit
– Managing HIV
– HIV testing
– Discharge
– Retention into medical care

Differences between the Jail System
and Prison System
Jail Prison
Prior to sentencing After sentencing
– Awaiting trial or transfer – if convicted for a long time
– Inability to post bail Long-term sentence
– Detainees picked up on – Usually > 1 year* with mean
suspicion of committing a duration of 3 years
crime More extensive amenities
Short-term sentence – Exercise areas
– Usually < 1 year* with median – Common areas for eating and
duration of 48 hours socializing
Amenities – Church facilities
– Minimal or very limited – Educational facility

*To deal with overcrowding in the jails, AB109 mandated that the jails would now be responsible for
taking care of inmates who are incarcerated up to 3 years

Assembly Bill 109
Signed in 2011 by Governor Brown to reduce
the number of inmates in the state’s 33 prisons
by 5/24/13 as ordered by the Supreme Court
– Allows non-violent, non-serious, and non-sex
offenders to serve their sentence in county jails
instead of state prisons
– No inmates currently in state prison will be transferred
to county jails or will be released early
– All felons sent to state prison will continue to serve
their entire sentence in state prison
– All felons convicted of current or prior serious or
violent offenses, sex offenses, and sex offenses
against children will go to state prison
California Department of Corrections and Rehabilitation Fact Sheet, 7/15/11.

EPIDEMIOLOGY
OF HIV IN CORRECTIONS

Persons Subject to Correctional
Oversight, 2010
8 7.08
Estimated Number of People in United States Supervised by
Number of Individuals

7 Adult Correctional Systems, by Correctional Status
6
(Millions)

5 4.06
4
3
2 1.5
0.84 0.75
1
0
Total Population* Probation Parole Prison‡ Local Jails§

Community supervision Incarcerated†
Note: Estimates rounded to the nearest 100. Data may not be comparable to previously published BJS reports because of updates and changes in
Number of individuals released into the community annually : 2
reference dates. Community supervision, probation, parole, and prison custody counts are for December 31 within the reporting year; jail population counts
are for June 30. The 2007 and 2008 totals include population counts estimated by BJS because some states were unable to provide data. See Methodology.
*Estimates were adjusted to account for some offenders with multiple correctional statuses. Details may not sum to total. See Methodology.

Jails → 8,600,000
†Includes jail inmates and prisoners held in privately operated facilities.

‡Includes prisoners held in the custody of state or federal correctional facilities or privately operated facilities under state or federal authority. The custody

prison population is not comparable to the jurisdiction prison population. See the text box on page 2 for a discussion about the differences between the two
prison populations.
Prisons → 597,000
§Estimates were revised to include all inmates confined in local jails, including inmates under the age of 18 years who were tried or awaiting trial as an adult

and the number held as juveniles. Totals for 2000 and 2006 through 2010 are estimates based on the Annual Survey of Jails. See appendix table 4 for
standard errors. Total for 2005 is a complete enumeration based on the 2005 Census of Jail Inmates. See Methodology.
1. Glaze LE. Correctional Populations in the United States, 2010. Washington, DC: Bureau of Justice Statistics; December 15, 2011.
2. Springer SA, et al. CID. 2011;53:469-479.

HIV and AIDS: US Population vs.
Imprisoned Population
In the US, HIV is approximately 3 times more prevalent
and AIDS is 2.5 times more prevalent among
imprisoned people compared with the US population*

Total number of HIV-infected inmates
or inmates with confirmed AIDS
held in state or federal prisons
at year’s end in 2008:

21,987 (1.5% total population)*

*Data as of 12/31/2008 (most recent available)

CDC. HIV/AIDS surveillance report, 2009. Vol. 21. www.cdc.gov/hiv/surveillance/resources/reports/2009report. Accessed February 28, 2011.
*Maruschak LM, Beavers R. HIV in Prisons 2007-08. NCJ 228307. Revised 1/28/10.

Number of HIV Infections in
Incarcerated Populations by State*
9 states have >500 inmates with HIV infection†
Nine states have <20
inmates with HIV
infection: Alaska, Maine,
Montana, Nebraska, New
Hampshire, North Dakota,
South Dakota, Vermont,
and Wyoming

*Information not available for Indiana
† Data as of 12/31/2008 (most recent available); includes inmates of both state and federal prisons
Maruschak LM, Beavers R. HIV in Prisons 2007-08. NCJ 228307. Revised 1/28/10.

Rate of HIV Infection in
Incarcerated Populations by State*
11 states have higher-than-average rates
of HIV infection in imprisoned populations†

*Information not available for Indiana
† Data as of 12/31/2008 (most recent available); includes inmates of both state and federal prisons


HIV Infections by Incarceration,
Status, and Sex
In the US, most people infected with HIV are male.
The difference is more pronounced in the imprisoned population*

US Population Imprisoned Population
with HIV Infection with HIV Infection

*Data as of
12/31/2008
(most recent
available)


Rates of HIV Infection are Higher in
Incarcerated Women Compared to Men
Compared with the US population, rates of HIV infection are
10 times higher in women and 3 times higher in men who are incarcerated

In the US in 2008, 24%
of new HIV infections
were in women.

85% of these women
were infected through
heterosexual contact.

*Data as of 12/31/2008 (most recent available)


US and Imprisoned Populations
by Race/Ethnicity
People of color are also overrepresented
in the imprisoned population
US Population* Imprisoned Population†
(N=310,200,000) (N=1,548,700)

White

Hispanic/
Latino
Black/African
American
Other

No recent data exist on the racial/ethnic distribution of HIV infection among inmates in the US
*Projected data for 2010
†Estimated data as of 12/31/2009 (most recent available), including inmates of both state and federal prisons
Kaiser Family Foundation. Distribution of US population by race/ethnicity, 2010 and 2050. facts.kff.org/chart.aspx?ch=364. Accessed February 28, 2011.
US Department of Justice. Prisoners in 2009. bjs.ojp.usdoj.gov/content/pub/pdf/p09.pdf. Accessed February 22, 2011.

Leading Causes of Death
in Federal Prisons
Within federal prisons, AIDS is the third leading cause of death*

*Data from 2008 (most recent available), including federal agency-managed institutions only
†50% of accidental deaths were due to drug or alcohol intoxication

Rate of AIDS-Related Deaths
in State Prisons by Race/Ethnicity
Within the state prison system, people of color
are more likely to die from AIDS-related causes*

*Data from 2007 (most recent available)

Polling Question #1
If you were arrested, who do you want to
be your best friend?
1. “C/O”
2. “Doc”
3. “Cellie”
4. “Greenbander”

Polling Question #1
If you were arrested, who do you want to
be your best friend?
1. “C/O”
2. “Doc”
3. “Cellie”
4. “Greenbander”

The answer is probably 1, 2, or 3 (depending on
what you need)

San Diego County Jail System
San Diego Central Jail (SDCJ)

George Bailey Detention Facility (GBDF)

Vista Detention Facility (VDF)

Facility 8 Detention Facility (F8DF)

East Mesa Detention Facility (EMDF)

South Bay Detention Facility (SBDF)

Las Colinas Detention Facility (LCDF)

HIV Care at San Diego Jails
Jail medical care in San Diego is
currently provided by UCSD
Emergency Medicine Department
HIV specialty care is subcontracted
out to Owen Clinic
– All HIV+ inmates are sent to
SDCJ for HIV medical care
– Weekly HIV Clinic on Tuesday
PMs (direct patient care) at San
Diego Central Jail since 12/28/98
– Average of 10-15 inmates/week
(Range 5-20)

Jail Entry and Intake
Inmates are seen by physician for initial
medical intake visit
– Review of past medical history
– Medications for acute or chronic medical
conditions may be started
HAART may or may not be started
– Labs may be ordered if needed
HIV-specific labs may or may not be ordered
– Old records are ordered
– Referred to Tuesday PM clinic for HIV-specific
care

Tuesday 1PM HIV Clinic
Inmates are sent from outside jails and transferred early
in the AM to SDCJ
– Assessment of jail-related factors – may affect plan of action
When is the upcoming court date?
Likelihood of release?
Prison time or not?
– Review of HIV-related history/ARV history and old
records/UCSD records (EPIC)
– Consider restarting HAART
– Consider ordering HIV-specific labs
– Address other concerns
Diet
“Chronos”
– Transitional case manager assessment of inmate interest in
drug/EtOH rehabilitation programs

Factors to Consider When Starting
HAART in a Correctional Setting
Incarcerated patients face additional challenges with
antiretroviral therapy, including:
– Confidentiality
– Necessity of visiting medication lines on a regular basis
– Distribution methods: keep on person (KOP) or directly-observed
therapy (DOT)
– Availability of food and water may not correspond with conditions
needed for specific antiretroviral medications
– Detention in segregation or other area where medications are
not accessible
– Policies and procedures focused on security that may not allow
for needed flexibility

AIDS Education and Training Centers National Resource Center. Correctional Settings. http://www.aids-ed.org/aidsetc?page=cm-801_corrections. Accessed April 12, 2011.
Stephenson B, Leone P. HIV care in U.S. prisons: the potential and challenge. www.thebodypro.com/content/art14528.html. Accessed April 12, 2011.

Polling Question #2
In addition to starting HAART, let’s
assume you were also trying to “score”
pain medications, what is the most likely
diagnosis you should claim to have?
1. Back pain
2. Toothache
3. Neuropathy
4. Rib pain
5. None, just trade with someone who gets it
“legit”

Polling Question #2
In addition to starting HAART, let’s
assume you were also trying to “score”
pain medications, what is the most likely
diagnosis you should claim to have?
1. Back pain
2. Toothache
3. Neuropathy
4. Rib pain
5. None, just trade with someone who gets it
“legit”
The correct answer is Neuropathy

HIV Testing Is Underutilized
in the Corrections System
25
23 Many prison systems provide
testing on request or based on
20 clinical indication or risk factors
Only 2 states (Missouri and
States Testing, No.

15 Nevada) test at all 3 time
points
10
Not all states use opt-out
testing practices as
6 recommended by the Centers
5
5
for Disease Control and
Prevention (CDC)
0
Entering In Custody On Release
Custody

Dwyer M, et al; HIV/AIDS Bureau. HIV care in correctional settings. Guide for HIV/AIDS Clinical Care. Rockville, MD: Health Resources and Services
Administration; January 2011.

HIV Screening Is Cost Effective Even When
the Prevalence Is Substantially <1%
Cost-effectiveness of a One-time Screening Program
vs No Screening in the General Population1
Incremental Cost-Effectiveness

200,000
180,000
of Screening, $/QALY

160,000
140,000
120,000
100,000
80,000
Costs and benefits to partners excluded
60,000
40,000
Costs and benefits to partners included
20,000
0
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

Prevalence of Unidentified HIV, %
The prevalence of HIV in many incarcerated populations is >1%2
– CDC3: Patients aged 13-64 years should be screened for HIV in settings with
prevalence ≥0.1%
QALY, quality-adjusted life year.
1. Adapted from Sanders GD, et al. N Engl J Med. 2005;352:570-585. ®New England Journal of Medicine. 2. Beckwith C, et al; Centers for Disease Control and
Prevention. HIV Testing Implementation Guidance for Correctional Settings. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health
& Human Services: January 2009: 1-38. 3. Viall AH, et al; Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2011;60:805-810.

Testing Programs Can Bridge the Gap
from Custody to Community

Individuals unaware of their HIV-positive
status are 3.5 times more likely to transmit
the virus
Testing, upon intake, is especially important
for jail inmates due to typically shorter stays
Knowledge of HIV status lowers risk-taking
behaviors with others by 50%

Altice FL, et al. Jail: time for testing. www.enhancelink.org/sites/hivjailstudy/Training Manual ready to print.pdf. Accessed March 19, 2012.

HIV-Related Testing and Post-
Exposure Prophylaxis at SDCJ
HIV-related tests
– HIV antibody testing is not proactively offered at intake or at
discharge, but available upon request
– HIV rapid tests are not available
– HIV antibody tests consist of EIA with confirmatory CIA –
turnaround time ~ 2 wks
– All those tested for HIV are referred to Tuesday PM for review of
HIV test results
– CD4/VL (RNA PCR tests) – turnaround time ~2 wks
– HIV Genotype testing (Quest) – turnaround time ~2-4 wks
Post-exposure prophylaxis
– All inmates are started on LPV/RTV with TDF/FTC and single-
dose NVP x 28 days and HIV antibody testing sent

Polling Question #3
What is the most commonly “cheeked”
non-narcotic pain medication?
1. Ibuprofen
2. Tramadol
3. Gabapentin
4. Indocin

Polling Question #3
What is the most commonly “cheeked”
non-narcotic pain medication?
1. Ibuprofen
2. Tramadol
3. Gabapentin
4. Indocin

The correct answer is tramadol, but gabapentin
is a common as well

Jail Discharge at SDCJ
Inmates are discharged typically in late
evening/early morning by discharge MD
– Psych medications are given upon discharge
– A prescription for a 30-day supply of HIV
medications is given to the inmate or faxed to
Hillcrest Pharmacy (contract with Jail to
supply HIV medications) if written by the
discharge MD
– Other ancillary medications (ie. diabetes
medications, antihypertensives, or pain
medications) may or may not be written for
upon discharge

The Transition to the Community
Is an Especially Vulnerable Time
Many inmates received an HIV-positive
diagnosis while incarcerated
– 75% initiate ART while in custody, but many
discontinue therapy once released

≥90% of newly released inmates do not fill
ART prescriptions in time to avoid treatment
interruption
– >80% do not fill their prescriptions within 30
days of release
Baillargeon J, et al. JAMA. 2009;301:848-857.

The Hierarchy of Needs for the HIV-
infected Former Inmate
Risk behavior
HIV modification

Mental illness
management

Drug dependence management

Case management:
Shelter, food, employment, and safety

Springer SA, et al. CID. 2011;53:469-479.
Reproduced with permission of Oxford University Press in the format Journal via Copyright Clearance Center.

HIV+ Individuals Returning to the
Community Face Many Obstacles
HIV-positive South Florida Inmates
Require Assistance on Release1 Additional obstacles2
– Anti-Drug Abuse Act of 1988
80 May be denied public
70 67 housing if convicted of a
Released Inmates, %

60 crime
60
– Welfare Reform Act
50 45 Prohibited from receiving
40 food stamps or federal
30 assistance
30
– Reinstating Medicaid
20
coverage may be delayed
10 (average of 3 months)
0 Benefits affected by
Housing Case Obtaining Substance Use duration of incarceration
Management Medication Treatment
Assistance Required
1. Jordan AO, et al. Policy Brief — Enhancing linkages to HIV primary care and services in jail settings initiative: transitional care coordination — from
incarceration to the community. www.enhancelink.org/sites/hivjailstudy/Policy_brief_Transitional_Care_Coordination_Final_1.27.11.pdf. Accessed March 15,
2012. 2. Wakeman SE, et al. HIV treatment in US prisons. www.medscape.com/viewarticle/725477. Accessed March 1, 2012.

One Simple Method to Reduce
Treatment Interruptions
Assisting HIV-infected inmates in filling out AIDS
Drug Assistance Program (ADAP) forms (Texas)
– Inmates who did not receive assistance filling out
forms
5.4% filled prescriptions within 10 days after release
17.7% within the first 30 days
30% were still on therapy 60 days post-release
– Inmates who had assistance filling out forms
Twice as likely to fill their initial prescriptions within 30 days
33.6% were still on therapy 60 days post-release

Whitten L. http://m.drugabuse.gov/news-events/nida-notes/2011/03/hiv-treatment-interruption-pervasive-after-release-texas-prisons. Accessed
February 29, 2012.

The VIBE Health Study:
Interruptions in Antiretroviral
Therapy (ART) are Common
Following Release from Jail
Robin A. Pollini 1, Daniel Lee 2, Ken Saragosa 2, Tim Smith 3,
Josiah D. Rich 4, María Luisa Zúñiga 2

1) Pacific Institute for Research and Evaluation, Calverton,
Maryland, USA; 2) School of Medicine, University of
California San Diego (UCSD), San Diego, California, USA; 3)
Health and Human Services Agency, County of San Diego,
San Diego, California, USA; 4) Brown Medical School and
Miriam Hospital, Providence, Rhode Island, USA

Background
HIV prevalence in U.S. prisons and jails is four
times that of the general population1 and 1 in 7
HIV+ persons in the U.S. passes through a
criminal justice facility annually2
2009 JAMA study3 found that only 5% of HIV+
persons released from prison with a 10-day
supply of ART filled their prescription within 10
days, and only 18% filled the prescription within
30 days.

1. Maruschak 2009/10. http://bjs.ojp.usdoj.gov/content/pub/pdf/hivp08.pdf
2. Spaulding AC, et al. HIV/AIDS among inmates of and relesees from US correctional facilities, 2006: declining share
of epidemic but persistent public health opportunity. PLoS One. 2009;4(11):e7558.
3. Saldana, J. (2009). The coding manual for qualitative researchers. Los Angeles, CA: SAGE.

Study Objective

Our research team initiated the Viral
Inhibition through Better reEntry (VIBE)
Study to better understand:
– frequency and causes of post-release
interruptions in ART among HIV+ persons
leaving jail in San Diego County, California.

Methods
Setting: San Diego County operates 7 jail
facilities housing >5,000 inmates. HIV+
inmates treated by UCSD physicians; HIV+
inmates eligible for the County’s AIDS Case
Management Program
Recruitment: August 2010-October 2011
Eligibility: 1) 18+ years old 2) released from
SD county jail in the last 30 days 3)not
currently incarcerated 4) ever diagnosed with
HIV 5) received HIV care during their last
incarceration

Methods (con.)
Data Collection: Interviewer-administered
quantitative survey and a 1-hour qualitative
interview
Data analysis: descriptive statistics, regression
modeling to identify factors independently
associated with ART discontinuity; qualitative
interview summaries coded using descriptive
coding 3,4 to identify references to ART discontinuity
and its contributing factors
63 HIV+ recently-released individuals were
enrolled in the study

Results: ART Continuity After Jail
Release

Of the 38 participants on ART at the time
of release
23 (61%) missed at least one dose
immediately following their release
(average number of days = 4)

Days of missed ART doses
immediately after jail release (N=38)

Results (cont.): Survey results
Most commonly cited reason for missed
doses while in jail: need for HIV physician
to prescribe medications after
incarceration
Other reasons: unavailability of
participant’s full ART regimen, provision of
incorrect drugs or dosages, not wanting to
go to HIV clinic for fear of HIV+
identification

Survey results: Reasons for missing ART doses after jail release (N=23)
%
Didn’t have the medications 87
Couldn’t pay for the medications 26
Was using drugs or alcohol 9
Had medications but couldn’t get to them when needed 4

Top priority for participants who missed ART doses
immediately after release (N=23)
%
Get drug or alcohol treatment 35
Find housing 22
Get cash 17
Reunite with family, partner or friends 9
Take care of legal problems 4
Use drugs or alcohol 4
Get HIV care/medications 4
Get identification 4

Comparing those who missed doses
after jail release to those who did not:

Missing ART doses was significantly
associated with individuals who were
younger, who used transportation from
treatment facilities or used public
transportation, and reported post-release
methamphetamine use

Results: In-depth interviews
Barriers to post-release ART missed doses
included:
Expiration of MediCal and/or AIDS Drug
Assistance Program (ADAP) coverage
Logistical issues: medications not
delivered to drug treatment facility, lack of
transportation

Conclusions
A majority of VIBE Study participants
missed ART doses immediately following
jail release.
Factors such as discontinued medical
insurance played a role
Participants reported competing
priorities/demands: substance abuse
treatment, housing, cash, etc.

CQI Project at SDCJ
Identifying needs of SDCJ
– Many opportunities for improvements exist
– Needs identified by administration
Lack of HIV specialty care
– Driven by concern for lawsuits
– Disinterest by jail doctors to assume care of HIV inmates
– Needs identified by consultant/care provider
Improve HIV-related care at SDCJ
– HAART initiation, management
– Diagnose/manage HIV specific conditions including OIs
– Post-exposure prophylaxis and HIV post-test counseling

CQI Project at SDCJ
Planning and implementing interventions
(buy-in) to address needs
– Not too difficult as long as interventions were
“simple, cost-effective, and prevent lawsuits”
Simple = minimal disruption to nursing staff and
officers
Cost-effective = not costing too much extra or
breaking the budget
Prevent complaints/lawsuits (unstated) – likely true
though

Administrative Obstacles
Obstacle Intervention Outcome
Provide consultation and Continued improvement
1. Lack of HIV specialty care
direct HIV care of HIV care
No intervention yet. No change, but lead by
2. Disinterest of physicians
Consider more education example
3. Disinterest of nursing staff
4. Disinterest of officers
Some education provided Some improvement of
5. Disinterest of pharmacists
through direct interaction identification of errors
No restriction on use of
Perceived high costs of HIV Education of cost and
HAART, but less difficulty
6. drugs (use of generic risk/benefit of HAART and
w/obtaining resistance
drugs?)/resistance testing resistance testing
testing now

HIV Medical Care Obstacles
Obstacle Intervention Outcome
Delay in initiating/resuming Usually started within a
1. None, seen by intake MD
HAART few days, w/exceptions
Weekly review of all HIV Less medication errors,
2. HIV medication errors meds for all SDCJ but disincentive for jail
inmates staff to learn
Inmates may refuse to
3. None No change
come to clinic due to stigma
Discharge inmates with HIV Discussion with nurses Variable and dependent
4.
medications emphasizing importance on discharge RN & MD
Work with transitional Improved transition of
Inmates lost to followup on
case managers to place care back with their HIV
5. discharge, high recidivism
inmates in drug rehab primary care provider,
rates
programs/placement decreased recidivism
Implemented VIBE study Identified gaps in the
Transitional care upon
6. to look at transitional area of discharging
release from jail
care inmates with HIV meds

Number of Inmates

0
5
10
15
20
25
30
35
40
45
1/15/2008
2/15/2008
3/15/2008
4/15/2008
5/15/2008
6/15/2008
7/15/2008
8/15/2008
9/15/2008
10/15/2008
11/15/2008
12/15/2008
1/15/2009
2/15/2009
3/15/2009
4/15/2009
5/15/2009
6/15/2009
7/15/2009

Week
8/15/2009
9/15/2009
10/15/2009
11/15/2009
12/15/2009
1/15/2010
2/15/2010
3/15/2010
4/15/2010
5/15/2010
6/15/2010
7/15/2010
HIV+ Inmates in San Diego County Jails

8/15/2010
9/15/2010
10/15/2010
11/15/2010
VDF
FAC8
SDCJ

LCDF
GBDF

EMDF
Total #

Number of Errors

0
1
2
3
4

1.5
2.5
3.5
4.5

0.5
1/15/2008
2/15/2008
3/15/2008
4/15/2008
5/15/2008
6/15/2008
7/15/2008
8/15/2008
9/15/2008
10/15/2008
11/15/2008
12/15/2008
1/15/2009
2/15/2009
3/15/2009
4/15/2009
5/15/2009
6/15/2009
7/15/2009

Week
8/15/2009
9/15/2009
10/15/2009
11/15/2009
12/15/2009
1/15/2010
2/15/2010
3/15/2010
4/15/2010
5/15/2010
6/15/2010
7/15/2010
ARV Prescription Errors in San Diego County Jails

8/15/2010
9/15/2010
10/15/2010
11/15/2010
Errors

ARV Medication Errors
Total of 86 errors over 126 weeks of ARV review
– from 83 providers (37 unique providers)
– 3 providers with 2 different errors
Errors per week
– Mean = 0.68 errors/week
Range = 0-4 errors/week
Errors per provider
– Median = 1 error/week
– Range = 1-9 errors
– 16 providers with 2 or more errors

ARV Medication Errors
Type of Errors:

1 Less than 3 ARV drugs 30
2 Incorrect dose of ARV drug 37
3 Incorrect frequency of ARV drug 9
4 ARV interaction 1
5 MD error (ie. Zerit instead of Zestril) 5
6 Missing Ritonavir as a Booster PI 1
7 Missing PI with Ritonavir 1
8 Too many ARV agents 1
9 Written for same drug twice 1

Summary and Future Directions
Many opportunities exist for continued
improvement in the delivery of quality HIV care
in inmates at SDCJ
– Has been successful in some areas
– Require buy-in and support of administration and all
those involved in care
Future directions
– Continue multi-pronged CQI projects
– Continue providing education and developing rapport
and collaborations with those interested in HIV care

Acknowledgments
Colleagues who have shared Emergency Department
the burden of work at the jail Physicians
– Chris Mathews – Ted Chan
– Theo Katsivas
– Gary Vilke
– Alfredo Tiu
– Tyler Lonergan SDCJ Staff
Transitional Case Managers – Earl Goldstein
– Rafaela Jennings – Sue Smith
– Sonja Proctor – Terry Zakosky
– Amy Applebaum – Chris McClean
– Tim Smith SDCJ Pharmacy Staff
VIBE Study Staff – Jeffrey Crutchfield
– Robin Pollini – Ashley Clark
– Mari Zuniga – Ida Bleich
– Ken Saragosa
– Serena Ruiz

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