Nicolas Overfield’s Avoidable Tragedy is a Symbolic Failure of Justice

By: Ranier Simons, ADAP Blog Guest Contributor

Access to timely, appropriate care is required for a high quality of life and optimal healthcare outcomes. Vulnerable populations face many challenges to proper care, especially people who are living with HIV (PLWH). Incarcerated PLWH endure compounded harm. The same people who are disproportionately represented in jails and prisons are also disproportionately represented by HIV. Recently reported in the media is the story of a young man, Nicholas Overfield, who lost his life because he was denied his HIV medication while in jail.[1]

Photo Source: Los Angeles Times | Overfield family

In February 2022, Nicholas Overfield was arrested and detained at El Dorado County Jail for failure to appear in court.[2] Upon his arrest, he informed the police that he was HIV positive and required his HIV medication daily to keep his HIV controlled.[2] His medication was present at this home, and his mother gave his medication to the police before they took him away.[2] On April 22, 2022, Nicholas’ mother visited him, and he was brought to her in a wheelchair because he was too weak to walk and was unable to speak.[2] The following day, his mother confronted a jail nurse demanding the medical care that he needed, and he subsequently ended up being rushed to the hospital that same night, requiring emergent care. After being hospitalized, he was placed into hospice care and died on June 21, 2022.[2]

Under the Eight Amendment of the U.S. Constitution, prisoners have a right to receive medical care, especially for serious medical issues, regardless of whether they are housed in a local, state, or federal jail or prison.[4] Mandisa Moore-O’Neal, Executive Director of the Center for HIV Law and Policy (CHLP), explains, “It is a fundamental duty to provide the necessary healthcare to those under your care and control, and yet jails and prisons across the country find so many ways to circumvent or all around avoid that duty.” 

It is well-documented that many inmates in jails and prisons receive substandard medical care.[3,5,6]. About 19% of inmates haven’t had a single health-related doctor visit since incarceration. The disjointed and weak infrastructure of incarceration health is especially life-threatening for people with chronic health conditions such as HIV. 

Photo Source: PBS News Hour

Incarcerated PLWH frequently have long delays in receiving medication, spotty administration of medication, or complete omission. This can result in drug resistance, which can make a person even sicker. In the case of Nicolas Overfield, because he was denied his medication, he progressed to AIDS.[2] His lack of proper care in jail also resulted in the failure of his body to fight off the encephalitis varicella-zoster virus that he contracted while incarcerated, which also contributed to his physical decline.[2]

Nicolas Overfield’s situation spotlights one of the contributing factors to poor prison healthcare, which is the outsourcing of prison healthcare to private contractors. Marcus J. Hopkins, founder & executive director of the Appalachian Learning Initiative (AAPLI), explains, “One of the biggest issues with carceral healthcare provision is that most of it occurs behind a wall of secrecy. As with most services, healthcare provision has been contracted out to private companies, such as Corizon and Wellcare, who use trade secrets laws—specifically the provisions that protect the negotiation of services and prices—to shield the exact services they provide.” 

This makes it hard to gather information since they are characteristically lax in reporting their data. A deep-diving Reuters study of over 500 jails revealed that from 2016-2018, jails relying on one of the five leading jail healthcare contractors had higher death rates than facilities where medical services are run by government agencies.[3] Often, some facilities, especially those in smaller jurisdictions with tighter budgets, will hire private contractors for ease of managing health services and to save money.[3]

Unfortunately, the means by which some private contractors save money is by denying care, such as not sending inmates to hospitals when care is needed. The contracts these private providers have sometimes do not have proper standards, staffing requirements, and protocols stipulating protocols for health monitoring and hospitalizations.[3] When inmates, especially those with chronic and mental health conditions, do not receive care, it is not only dangerous for their well-being but also the well-being of other inmates and staff. Inmates with documented mental health issues can be a danger to themselves and others when they are not effectively monitored and kept on their medications. Additionally, when inmates are not treated and screened for sexually transmitted diseases, diseases spread. Eventually, people in jails and prisons are released back into society. This is a danger to public health at large, releasing people with undocumented and uncontrolled diseases or ailments. 

Photo Source: The Lancet | Copyright © 2016 Sakhorn

The largest jail healthcare companies are Wellpath Holdings Inc., NaphCare Inc., Corizon, PrimeCare Medical Inc., and Armor Correctional Health Services Inc.[3] Wellpath is the company in charge of the jail where Nicolas Overfield was a pre-trial detainee. Not only is Wellpath private, but it is owned by a private equity firm, which would indicate that it has a targeted interest in saving money and making a profit.[3] Some private jail health contractors state that the levels of healthcare challenges of incarcerated populations are why they have higher death rates. However, studies have shown that when you control for the differences in the health of the overall population as compared to the general population, private prisons still have more deaths.[3]

Nicolas Overfield’s avoidable tragedy is a symbolic failure of justice. Ms. Moore-O’Neal expressed, “his incarceration sheds some light on the injustice that is our criminal legal system. The fact that he was even in jail because of a February 2022 arrest for failure to appear in court should have all of us appalled and ready to overhaul this entire system.” Many people like Nicolas Overfield sit in jails and suffer harm and neglect, sometimes fatally before they even make it to trial. Failure to provide constitutionally adequate medical care is not only a legal issue but a human rights issue.

[1] Kandel, J. (2024, January 19). ‘A shocking failure’: Inmate died after jail medical staff denied him HIV medication for months, lawsuit alleges. Retrieved from https://lawandcrime.com/lawsuit/a-shocking-failure-inmate-died-after-jail-medical-staff-denied-him-hiv-medication-for-months-lawsuit-alleges/

[2] Complaint for Damages OVERFIELD v. WELLPATH, et al. (2024, January 16). Retrieved from https://s3.documentcloud.org/documents/24369518/overfield-v-wellpath-complaint.pdf

[3] Szep, J., Parker, N., Eisler, P., Smith, G. (2020, October 26). Special Report: U.S. jails are outsourcing medical care — and the death toll is rising. Retrieved from https://www.reuters.com/article/idUSL1N2HG0MD/

[4] Estelle v. Gamble, 429 U.S. 97, 102 (1976).

[5] Levins, H. (2023, March 6). Reviewing The Flaws of U.S. Prisons and Jails’ Health Care System. Retrieved from https://ldi.upenn.edu/our-work/research-updates/the-flaws-of-u-s-prisons-and-jails-health-care-system/

[6] Wang, L. (2022, June). Chronic Punishment: The unmet health needs of people in state prisons. Retrieved from https://www.prisonpolicy.org/reports/chronicpunishment.html#insurance

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.

CANN Hosts 3rd Annual Community Roundtable on Correctional Hepatitis

By: Marcus J. Hopkins, Policy Consultant

Reprinted with Permission from the Community Access National Network (CANN)

On Wednesday, April 17th, the Community Access National Network (CANN) hosted its 3rdAnnual Community Roundtable on Viral Hepatitis in Correctional Settings at the Pharmaceutical Research and Manufacturers of America (PhRMA) headquarters in Washington, DC. Their panel included three presenters: yours truly, along with Wayne  Turner (Senior Attorney at the National Health Law Program), and Todd Schwartz (National Account Director at Gilead Sciences, Inc.). Each presented touched on some facet of the myriad issues faced by inmates living in state correctional facilities, as well as various research efforts, funding mechanisms, and opportunities for improvement.

I presented on viral hepatitis in Correctional Settings, during which I focused on CANN’s two-year research effort focusing on HIV, Hepatitis B (HBV), and Hepatitis C (HCV) testing protocols in state prisons, as well as the declining per inmate cost of HCV treatments, and the state of HCV-related Class-Action lawsuits winding their ways through various courts.

Since 2017, I have been reaching out to Department of Corrections (DOCs) in every state and the District of Columbia on behalf of both CANN and the ADAP Advocacy Association to determine what are the state protocols for testing: Is testing compulsory (required), upon request, or based upon clinical criteria, is it conducted during or after the intake process, can inmates refuse to be tested, and is testing offered using an Opt-In (“informed consent”) or an Opt-Out (“informed refusal”) model of delivery. This research represents only a handful of national efforts to identify state correctional testing protocols and to determine whether or not these protocols will help the U.S. towards reaching its established goals of reaching elimination of HIV and HCV (both by 2030).

As of March 2019, all but seven states either responded to inquiries or had the protocols publicly posted on their respective states’ DOC websites (only 14 states, including two that responded, publicly post their testing protocols). Our findings determined that, while most states (n=34) do a good job of making HIV testing compulsory, only 11 states require HBV testing, and only 22 require HCV testing (Hopkins, 2019).

What is concerning about these findings is that, in Arizona, Alaska, Florida, Kentucky, Maine, and Massachusetts – all areas of the country where Injection Drug Use (IDU) is high, HIV testing is performed only upon request.

For HBV, the testing landscape is, for lack of a better word, “bleak.” Despite having a commercially available vaccine for HBV since 1981 (and recombinant vaccines since 1986), only 50 million adults and 70 million babies in America have received at least one dose of the vaccine since 1982 – roughly 37% of the American population (Immunization Action Coalition, 2017). Because, HBV is transmissible via sexual contact, as well as by IDU, the vaccination recommendations are considerably broad, but because the disease was so rare, physicians in more rural parts of the nation never bothered to vaccinate many Americans. As a result, the U.S. is seeing an increase in new HBV infections in places where the virus was largely absent. With only 11 states requiring HBV testing in state prisons, inmates face a greater risk of encountering this entirely avoidable, yet incurable disease.

For HCV, as the rates of new infections continue to climb, in all ten of the states with the highest rates of new infections, testing is either not compulsory, or there are no protocol data made available.

You can find my report at the following link: Viral Hepatitis in Correctional Settings.

Wayne Turner, Senior Attorney at the National Health Law Program (NHLP), presented on the various ways state Medicaid programs can and cannot be utilized to help cover to cost of treating incarcerated individuals. He discussed the various intricacies of how the Medicaid program defines “inmate” and “incarceration,” as well as issues surrounding eligibility during and after incarceration, linkage to Medicaid during the reentry process, and how Medicaid is structured.

You can find Mr. Turner’s report at the following link: Medicaid, Incarcerated Persons, and Hepatitis C Treatment.

Todd Schwarz, National Account Director at Gilead Sciences, Inc., provided us with an overview of the corrections system, Gilead’s efforts to help with education, HIV and HCV resource location services, education efforts, and statistics related to new infections and prevalence rates within the state correctional healthcare systems.

You can find Mr. Schwartz’s presentation at the following link: Community Roundtable on Linkages to Care for Incarcerated Citizens Living with Hepatitis C – Gilead Focus on Hepatitis C in Corrections.

Contact CANN to learn more.

References:

• Hopkins, M.J. (2019, April 17). Viral Hepatitis in Correctional Settings. Washington, DC: Community Access National Network. Retrieved from: http://www.tiicann.org/urls/2019_CANN_Presentation_1_Hepatitis_Corrections_04-17-19_HOPKINS.pdf
• Immunization Action Coalition. (2017, December). Hepatitis B: Questions and Answers. St. Paul, MN: Immunization Action Coalition: Handouts: Vaccine Index: Hepatitis B. Retrieved from: http://www.immunize.org/catg.d/p4205.pdf
• Schwartz, T. (2019, April 17). Community Roundtable on Linkages to Care for Incarcerated Citizens Living with Hepatitis C – Gilead Focus on Hepatitis C in Corrections. Foster City, CA: Gilead Sciences, Inc. Retrieved from: http://www.tiicann.org/urls/2019_CANN_Presentation_3_Hepatitis_Corrections_04-17-19_SCHWARTZ.pdf
• Turner, W. (2019, April 17). Medicaid, incarcerated persons, and hepatitis C treatment. Washington, DC: National Health Law Program. Retrieved from: http://www.tiicann.org/urls/2019_CANN_Presentation_2_Hepatitis_Corrections_04-17-19_TURNER.pdf

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.

State Departments of Corrections Lack Focus on HIV Care for Former Inmates

By: Marcus J. Hopkins, Consultant, Community Access National Network (CANN)

It has been nearly 40 years since the HIV/AIDS epidemic began showing up across the United States, and after all this time, with the amazing level of resources and support available for those living with the disease, it became clear that there was little information publicly available concerning incarcerated populations. To that end, all 50 states’ and the District of Columbia’s respective Departments of Correction (DOCs) were contacted by the ADAP Advocacy Association and Community Access National Network (CANN) to inquire about their procedures for preparing inmates living with HIV for reentry into the general population. Not surprisingly, our research re-confirmed the disparities that exist in serving former inmates.

A few of the disparities are highlighted in the findings presented earlier this week in an infographic, which was made available by the ADAP Advocacy Association as part of its ongoing Correctional Health Project. The infographic can be downloaded from their website.

HIV is currently a disease that requires lifelong treatment that must be adhered to regularly in order to achieve and maintain Viral Suppression – when the Viral Load (the number of HIV virus cells active in the body) measures below 40 copies per milliliter (aka – Undetectable). With new data showing that Undetectable = Untransmittable, it is more important than ever for people living with HIV to have access to their medications in order to both stay healthy, and to prevent transmission of the disease to others. Former inmates deserve the same access to care and treatment as the general population, especially upon their discharge from prison.

We found that 31.3% of state DOCs fail to disclose the amount of meds inmates are provided upon release, making it difficult to track or accurately report the circumstances inmates face upon reentering the general population. In addition, 27.4% of states provide NO policy information on their reentry programs, whatsoever.

Rhode Island’s DOC has perhaps the most comprehensive HIV care program in the U.S. justice system, both during and post-incarceration. The state contracts with the state university to provide care throughout the inmate’s stay at state facilities and ensures that continuity of care continues by keeping inmates with their same providers after they leave (should they stay in the state). Additionally, inmates are provided with an excellent comprehensive reentry program that integrates the state’s Ryan White program and assists with the Medicaid application process. They also look into accessing HOPWA (Housing Opportunities for Persons With AIDS) to help provide housing if they are returning without a reliable home.

New Hampshire's DOC was unaware of the Ryan White Program. We were able to provide them information about the program and connect them with the state's Ryan White Director. NH is currently determining whether or not to incorporate Ryan White as part of their Reentry Program for inmates living with HIV/AIDS who do not qualify for Medicaid.

The latter story should be considered a success story for the Correctional Health Project – introducing state DOC’s to resources for reentering inmates living with HIV that can help them to maintain continuity of care between incarceration and reintegration into the general population is one of the primary goals. Additional resources will be made available on this project continues to unfold this year.


Read our related blogs on this topic:

• Improving Access to Care Among Formerly Incarcerated Populations with HIV/AIDS under the AIDS Drug Assistance Program (October 27, 2017)
• Linkages to Care During Post-Incarceration (July 5, 2017)

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.

Improving Access to Care Among Formerly Incarcerated Populations with HIV/AIDS under the AIDS Drug Assistance Program

By: Brandon M. Macsata, CEO, ADAP Advocacy Association & Marcus J. Hopkins, HIV/HCV Co-Infection Watch Project Director, Community Access National Network

The ADAP Advocacy Association announced earlier this month that it has launched a new project to improve access to care and treatment for correctional inmates living with HIV/AIDS who are transitioning back into community life. The project – “Improving Access to Care Among Formerly Incarcerated Populations with HIV/AIDS under the AIDS Drug Assistance Program (ADAP)” – aims to raise awareness about issues confronting formerly incarcerated populations living with HIV/AIDS (and/or Hepatitis C) who also access care and treatment (or whom could benefit from such care and treatment) under the AIDS Drug Assistance Program (ADAP), as well as provide useful resources and tools to the communities serving them.

The data on the number of formerly incarcerated populations infected with HIV/AIDS (and/or HCV), in many cases, simply isn’t available. In fact, most states’ epidemiology reports that did report HCV numbers didn’t account for incarcerated populations. What data is available is woefully out of date, using data four years or older. The data on HIV isn’t much better.

The Centers for Disease Control and Prevention (CDC) website, updated on March 14, 2017, cites numbers from 2010 – seven years prior to the most recent update.[1] The data cited is obtained from a 2012 report by the Bureau of Justice Statistics (BJS) – revised in March 2015 – that looked at HIV in prisons and jails from 2001-2010.[2] What used to be an annual report with yearly updates from 1993-2008, has apparently been shelved, over the past decade. Moreover, there doesn’t seem to be much in the way of a replacement from any government agency.

The BJS report indicated a few very important findings:

• In 2010, there were 20,093 inmates in state and federal prisons infected with HIV, representing 1.5% of the total incarcerated population. 3,913 of those inmates were living with an AIDS diagnosis.
• Of the total HIV-infected population, 91% were male. African-American (AA) men were 5 times as likely to be diagnosed than White men, and twice as likely as Hispanic/Latino men. AA women were more than twice as likely to be diagnosed with HIV than both White and Hispanic/Latino women.
• Rates of AIDS-related deaths among state and federal prisoners declined an average of 16% a year from 2001 to 2010, from 24 deaths/100,000 in 2001 to 5/100,000 in 2010.

Other than those numbers, there isn’t a lot of information that is readily available to the public, which is troubling for a number of reasons.
Among them:

1. HIV remains a deadly disease that, when left untreated and/or undiagnosed, can lead to numerous life-threatening complications and death; 
2. Incarceration settings are notorious for being hotbeds of transmission for a host of sexually transmitted diseases; and
3. This failure to present regular data updates may mean that prisons and jails are not complying with regulations requiring that all inmates be screened for HIV.

The CDC does, however, tout support for a number of community-based pilot projects, including Project START, Project Power, a partnership with Emory University (based in Atlanta) focused on juvenile AA girls aged 13-17, and a partnership with Morehouse Medical School to counsel AA male jail inmates about high-risk sexual behaviors and how to reduce them.  These programs are designed to help male and female inmates understand the risk associated with certain behaviors, as well as prevention strategies to be used both within and outside of incarceration settings.

One of the most frustrating aspects of conducting any research is the lack of information available to the public. Disease statistics are the foundation for making good policy at all levels of government, which means that, in order for citizens, legislators, and executives to craft data-driven, meaningful legislation and regulations, these data must be present. The data must be easily accessible, regularly updated (annually), and reliable.  At this point, that data is simply unavailable, which further leads to the need for greater awareness, and clearer guidelines on linkages to care.

What makes this approach vitally important is that access to care and treatment for HIV-infection (and/or HCV) is something that is sorely lacking in the areas that are hardest hit; not just HIV education, really – healthcare literacy in general is an issue. As such, there is a need to work on ways to get people to actually care about their health; help to identify the appropriate linkages to care; and engage in successful care and treatment strategies that will lead them to be Virally Suppressed. 

Available supports and services are going unused in too many ADAP jurisdictions, evidenced by data shared in the 2017 National ADAP Monitoring Project Annual Report (as seen in the charts below).[3] 

There exists a need to raise awareness among key stakeholders – among them, ADAP Directors, community service providers, and state/local advocacy organizations – about existing and emerging issues confronting formerly incarcerated populations. Furthermore, there is a need to model existing best practices to ADAP across the 50 states and territories in the United States. 

To that end, key elements of the project include:

1. Community Forum on Formerly Incarcerated Populations & Provider Friendly Care;

2. Animated Video on Formerly Incarcerated Populations & Linkages to Care;

3. Infographic on Ryan White/ADAP Serving Formerly Incarcerated Populations;

4. White Paper on Model Policy for Ryan White/ADAP Serving Formerly Incarcerated Populations; and

5. Twitter Chat on Ryan White/ADAP Serving Formerly Incarcerated Populations.

The project will execute all of the key elements between September 1, 2017 and March 31, 2018.

To learn more about the ADAP Advocacy Association's Correctional Health Project, please email info@adapadvocacyassociation.org.

__________
[1]  Centers for Disease Control and Prevention (CDC). (2017, March 14). HIV Among Incarcerated Populations. Atlanta, GA: United States Department of Health and Human Services: Centers for Disease Control and Prevention: National Center for HIV/AIDS, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis Prevention: Division of HIV/AIDS Prevention. Retrieved from: https://www.cdc.gov/hiv/group/correctional.html
[2] Bureau of Justice Statistics. (2012, September 13). HIV in Prisons, 2001-2010 (NCJ 238877). Washington, DC: United States Department of Justice: Office of Justice Programs: Bureau of Justice Statistics. Retrieved from: https://www.bjs.gov/content/pub/pdf/hivp10.pdf
[3] National Alliance of State & Territorial AIDS Directors (2017, May 18); 2017 National ADAP Monitoring Project Annual Report; p. 24. Retrieved from http://www.nastad.org/sites/default/files/2017-national-adap-monitoring-project-annual-report.pdf.