For more than two decades, UNC’s infectious disease specialists have provided HIV care to incarcerated individuals across North Carolina’s prison system. Dr. Becky White is the director of UNC Infectious Diseases and HIV Services in the N.C. Department of Adult Corrections. Dr. Lina Rosengren-Hovee is the associate director.
In the following, Dr. White explains how HIV care has evolved since the early days of the HIV/AIDS epidemic. She is one of the leading physicians who described the association between the release of HIV-infected prisoners and the subsequent increase on their viral loads. This connection continues to have significant implications for HIV transmission and health outcomes for at-risk populations in the community, including released prisoners.
Funded by the National Institutes of Health, White is designing an intervention that will address HIV prevention needs during re-entry, partnering with the N.C. Formerly Incarcerated Transitions program–which led by UNC Family Medicine’s Dr. Evan Ashkin, and N.C. A&T State University’s Dr. Sharon Parker and Dr. Zahra Fazli Khalaf–in collaboration with the N.C. Department of Adult Correction and N.C. Community Health Center Association.
HIV Care Among N.C.’s Incarcerated Populations
White started working with North Carolina’s incarcerated populations as an infectious disease fellow in the 1990s, providing HIV care alongside Dr. David Wohl and other senior ID fellows, as well as UNC nurse practitioners. During this time, approximately one-third of North Carolina’s incarcerated population was HIV-infected.
Dr. Becky White began working with the NC prison system as an infectious disease fellow.
“I remember being struck by the severity of illness among the prison population, many of whom were suffering from advanced AIDS-related complications. Even at the beginning of the HIV epidemic, it was apparent that people who were in prison were disproportionately affected.”
As deaths began to peak, Dr. Myron Cohen, chief of infectious diseases at the time, established a formal contract with the N.C. Prison System. This put Dr. White on the road three to four days a week, driving to Central Prison, the Women’s Prison, and McCain Prison in Hoke County (now closed). She held HIV clinics, seeing patients with pneumocystis pneumonia, an AIDS-defining diagnosis. Then, just as she was starting her third year of fellowship, the prison’s only full-time physician left. While this created a prison crisis, it offered Dr. White the chance to become the attending physician, with a faculty appointment. She was soon leading HIV care in the state prison system, still working with Dr. Wohl, who provided mentorship, a physician assistant named Charles Mitchell, and a dedicated HIV-clinical trials pharmacist. Meanwhile, experienced prison nurses played a vital role across the prison system.
“The nurses were really an experienced army who had seen so many sick patients with AIDS,” said Dr. White. “They helped me navigate the complex prison system, which was just as crucial as the medical care itself.”
Since COVID-19, Dr. White continues to see many of her patients via telehealth.
White says it was these dedicated HIV-outreach nurses, embedded within each prison facility, that counseled new HIV-positive patients, ensured continuity of care for those transferred between prisons, and built trust between incarcerated individuals and the medical team.
COVID Brings Telehealth, Expanded Care
During the COVID-19 pandemic, HIV care for incarcerated populations transitioned to telehealth, and this included general infectious disease consultations.
“The needs of the prison expanded when the number of correctional officers decreased and could not drive patients to different places. In addition, It was a lot easier for them to have us see patients for infectious disease issues as well.”
Today, there are approximately 400 HIV-infected individuals in the N.C. prison system. Most are biologically suppressed, a significant achievement because people can live long and healthy lives with anti-retroviral treatment. However, during the reentry period, adhering to HIV medication and appointments remains challenging. Many can face homelessness and mental illness, returning to drug and alcohol use, and other behaviors that increase their risk of viral rebound and HIV transmission to others.
Listening to Her Patients
Through the years, Dr. White continued to learn, leading multiple studies on treatment adherence. One day she realized. She had dismissed the voice of the patient.
“I saw patients getting released who would ask me if they could come back to prison. I didn’t understand why anyone would want to do that. But what they were saying was they wanted to continue the HIV care when they were released.”
(Left) The NC Correctional Institution for Women is the state’s primary correctional facility for women, housing the largest offender population in the state, in southeast Raleigh. (Right) Central Prison is operated by the NC Department of Adult Correction and sits on 29 acres west of Downtown Raleigh.
Evidence shows a released individual is less likely to come back to prison if they are able to continue with health care. White realized an intervention program was needed that could be just as robust in the community as it was in the prison system. Without one, any progress made in the prison system would always be in jeopardy when an individual was released.
N.C. Formerly Incarcerated Transition Program (N.C. FIT)
Evan Ashkin, MD, professor of family medicine, founded N.C. FIT in 2017.
The solution could be an intervention integrated with the North Carolina Formerly Incarcerated Transition (NC FIT) program. Founded in 2017 by Evan Ashkin, MD, professor of family medicine, NC FIT focuses on comprehensive reentry planning for individuals with chronic diseases, mental illnesses, or substance use disorders, post-incarceration.
NC FIT employs formerly incarcerated people who are trained to become community health workers, funded by a combination of prison system contracts, county health departments, and grants. The program is an affiliate of the Transitions Clinic Network, a model that started in the Bay Area, San Francisco. Community Health Workers with lived experience of incarceration serve as patient navigators.
“Formerly incarcerated individuals in North Carolina face a high risk of suicide post release, and getting them into essential health services has been one of the major issues of re-entry,” said Ashkin.
To be eligible for FIT, one has to have a chronic medical problem, mental illness or substance use disorder, and be recently released, although the program has accepted people within two years of release.
“The FIT program hires people who are formerly incarcerated, and then trains them as community health workers, where they’re embedded in the primary care medical homes, which are mostly federally qualified health centers in our state,” said Ashkin.
These community health workers make a difference during this timeframe because they’re able to create rapport and trust, and because they have a lived experience of incarceration. And what makes the program even more effective is that they go to the appointments with the client/patient. They are advocates with the clinicians, and they are there to help interpret. Until now, the program has not focused on individuals infected or at risk for HIV.
Adding HIV Care and Prevention to N.C. FIT
Dr. White is introducing HIV prevention PrEP (pre-exposure prophylaxis for HIV) services for women in one of the eight counties where NC FIT is already working. In Guilford County, two community health workers will work with women who are about to be released, to establish re-entry plans. This will include accessing medical records and scheduling appointments before they’re released, with a plan to see them within a week after release to connect them with care.
Cure, Eradicate, Get Rid of It
Continuity of care must use an infectious disease paradigm throughout a person’s life cycle, during incarcerated and post incarceration, says White.
Dr. White is also passionate about teaching and training the next generation.
“With all of the resources we have, it is unacceptable that there are people who don’t have access to HIV treatment and prevention. We should not accept this.”
Reflecting on clinical accomplishments for the incarcerated, Dr. White recognizes how hard she and others (including patients) have worked to help individuals infected with HIV live longer.
“When I was a medical student and a resident, during the peak of AIDS related deaths in the U.S., I saw patients my own age get infection after infection with no end in sight. I think about those patients, especially the parents who never saw their children grow up. I used to hope and pray that these patients would find relief.”
“I went into infectious diseases because you can cure people, and that’s what I want to do. I don’t want to maintain. I want to cure, eradicate, get rid of disease. Eliminate suffering. We now have the tools from decades of publicly funded research and clinical trials. We must implement these tools to benefit the public.”
Dr. White is introducing HIV prevention PrEP (pre-exposure prophylaxis for HIV) services for women in one of the eight counties where NC FIT is already working. In Guilford County, two community health workers will work with women who are about to be released, to establish re-entry plans. This will include accessing medical records and scheduling appointments before they’re released, with a plan to see them within a week after release to connect them with care.