Strategies to reduce HIV risk behavior in HIV primary care clinics: brief provider messages and specialist intervention.

Reducing HIV transmission is a critical goal worldwide, prompting new strategies to slow the spread of the virus. This paper describes the theoretical underpinnings of the Comprehensive Harm Reduction Protocol (CHRP) and the process of its implementation in one large urban HIV clinic and two smaller rural primary care clinics. Patients enrolled in CHRP complete the Risk Diagnostic Questionnaire (RDQ), self-reporting HIV transmission risk behavior at most clinic visits. Clinicians review RDQs to trigger dialogue using motivational interviewing and the stages of health behavior change to reduce high-risk behaviors (drug use, alcohol use, or high-risk sexual behavior). In the ongoing evaluation study, CHRP patients receive two provider-only visits before being randomized to continue with provider brief prevention messages only or to receive additional intensive counseling with a risk-reduction specialist following the provider visit. If outcome data support one or both interventions, CHRP could be a useful model for widespread adoption. Observations from the implementation of this protocol are presented in order to facilitate the adoption of this protocol in interested clinics. Later, results of the evaluation of the implementation of the protocol may have value in developing prevention policy in HIV treatment clinics.

An approach to develop effective health care decision making for women in prison.

BACKGROUND: Decision making about medical treatment, advance care planning and end-of-life care often is limited or influenced by a patient's capacity to read or comprehend crucial information. Ineffective communication between patient and physician, and the complex nature of serious illness and dying also affect these decisions. America's incarcerated have virtually no autonomy in decision making, especially with regard to medical care and treatment. For the nearly 100,000 incarcerated women in the United States, medical issues differ significantly from those of male prisoners. Many women enter prison with chronic illnesses or are diagnosed with such illnesses while in prison. In addition, America's prison population reflects our country's unsolved literacy problems with almost two thirds of aging inmates lacking basic literacy skills. Maintaining a balance between the Eighth Amendment rights of prisoners and their status as wards of the state is a concern for inmates and for those responsible for their care. OBJECTIVE: The purpose of this study was to identify informational barriers to people making medical care and treatment decisions, particularly those with low literacy. Findings were used to in the development of a tool to assist patients to initiate discussion and become active participants in their own care. DESIGN: Female inmates of diverse ethnicity and literacy levels were recruited through self-selection from the Central California Women's Facility near Sacramento to participate in focus group discussions. The focus groups were guided by a set of research questions and were facilitated by the first author to identify informational barriers to medical care needs. SETTING: The female prison setting was identified as an appropriate setting for the development of a new approach to stimulate effective decision making by introducing basic information on medical care and treatment, advance care planning, and end-of-life care. A total of 113 inmates participated in 16 focus group, each 2 hours in length. RESULTS: Findings were used to develop a handbook to assist low literacy populations in general, and female inmates in particular, to obtain appropriate medical care and treatment and to make advance care decisions regarding the end of life. CONCLUSION: Those who face chronic, potentially life-limiting illness cannot make meaningful decisions regarding medical care and treatment without having a basic foundation of health information. Acquiring knowledge and improving communication skills reduce stress and vulnerability, assuring individuals of some control over decision making.

Hospice care for the incarcerated in the United States: an introduction.

Prison populations throughout the Unites States are growing; the 1990s saw an average 6.5% per year increase. Average inmate age is increasing, as are both the number and rate of inmate deaths. Aging inmates experience health concerns typical of the general, free, aging population. Inmates have higher incidence of health complications associated with various circumstances, risk behaviors, and associated medical conditions. These circumstances include prison violence, incarceration-related constraints on exercise, and diet. Inmates are more likely to have a history of alcohol abuse, substance abuse or addiction and sex industry work. Risk-behavior conditions include human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), hepatitis B and C, liver disease, tuberculosis, endocarditis, and cardiomyopathy. Hospice is increasingly the preferred response to the health and care needs of terminally ill inmates. Implementing hospice behind bars has some unique challenges in addition to those inherent in hospice work. This series will provide an in-depth look at four hospice programs for inmates in the United States.

Prison hospice and pastoral care services in California.

Hospice at the California Medical Facility (CMF) Vacaville dates back to the mid-1980s, when the acquired immune deficiency syndrome (AIDS) epidemic began to be felt throughout California's Department of Corrections. Vacaville has served for decades as the principal location for delivering health services to California's incarcerated men. Informal hospice-like services were inspired by Elisabeth Kubler-Ross and through inmate and community calls for more humane care for dying inmates. By 1990, efforts to formally establish a hospice were under way. In 1996, a 17-bed, state-licensed hospice began caring for dying inmates. An interdisciplinary team plans and delivers the care, meeting weekly to admit and review patients. The Pastoral Care Services (PCS) inmate volunteer program, with more than 50 trained participants, provides care and comfort to dying patients in hospice and to ill patients on the general medicine service. PCS volunteers perform many duties, including sitting vigil with actively dying inmates. Inmates enrolling in hospice have to forgo further curative therapy, consent to the program in writing, and have a 6-month or less survival prognosis; patients are not required to have a do-not-resuscitate (DNR) order, but are encouraged to consider one. Training for physicians, staff and PCS volunteers is provided by the University of California, Davis faculty of the West Coast Center for Palliative Education. Bereavement services are provided for PCS volunteers, other inmate "family" and staff. Family and friends of the deceased in the free community are followed by phone, mail, and primarily through referral to resources in their local area.