Victor Morales hasn't always been open about his HIV-positive status.
"In county [jail] and prison it wasn't easy, because of how they still visualize HIV, even though these days there's so many medications and so many pills, " he said.
When Morales went to jail this time, he said he told them he was HIV-positive. He was given his medications and received HIV treatment.
In April of 2011, Morales was charged with a DUI, and given a two-year probation. In the second year of his probation, he tested positive for marijuana and failed a breathalyzer. He was sent to Cook County Jail.
Morales is 39, gay and Mexican-American. He was diagnosed with HIV in 1997, in Atlanta. He said you can find a lot of work in Atlanta if you're bilingual. But eventually, he returned to Chicago, where he has family.
Morales is one of many HIV-positive people who have gone through jail or prison in the U.S.
"A lot of people are afraid to say they're positive," he said. "They'll just be cool until they get out. I've done that."
His story is not uncommon. It illustrates part of the reason for a recent change at Cook County Jail concerning treatment and care for people living with HIV.
Over the past three and a half years Cook County Department of Corrections (CCDOC) has been transitioning to an opt-out HIV/sexually transmitted infection testing system. Instead of having the right to ask to be tested for HIV, those detained in jail are told they will be tested and given the right to refuse.
Medical practitioners and AIDS advocates in Chicago had long wanted an opt-out system at the jail.
John Peller, vice president of policy for the AIDS Foundation of Chicago (AFC), has dedicated his career to being an advocate for HIV-positive people and getting them treatment. According to him, one in five people who are positive don't know they are.
Testing behind bars
Identifying HIV-positive people in jail means identifying some of the most at-risk people for contracting the virus, experts say.
So when Peller met newly appointed Cook County Commissioner Bridget Gainer in 2009 at a fundraiser, he told her about opt-out testing, about the one-in-five people who don't know their positive status, and he shared one more statistic that really struck Gainer.
"In national studies, over many, many years, it's a consistent metric that says when someone is informed of their HIV-positive status, they may not seek regular medical care, but 68% of the people change their behaviors to minimize the transmission to another person," Gainer recalled. "So in my mind, regardless of anything like budgets or healthcare, any of that stuff, that to me was the most compelling statistic."
Gainer set up a meeting that week with Peller to discuss the research.
Then, she met with jail officials and other members of the Cook County Board. What seemed like a simple rephrasing of a question, from "opt-in" to "opt-out," would require a whole new facility, she learned.
Approximately 200 to 350 people are processed at the jail every day.
Part of that intake involves a medical screening.
In the past, detainees were screened right next to one another, with very little privacy.
"People don't like to say that [they are HIV-positive] in front of others, especially when they're in a potentially very violent, all-male environment," Gainer said.
Now, those going through intake are given medical screenings in a larger room partitioned off with glass walls, where staff are able to ask questions with considerably more privacy.
Changing the facility was only the first step. Detainees are typically released within a short time period. For a testing facility to have an impact, the staff would have to get the results the next day.
According to Gainer, Cook County was able to fund the opt-out program by saving money in the State's Attorney officea coordinated effort with State's Attorney Chief of Staff Dan Kirk. Gainer said the creation of a separate unit that dealt with conflicts of interest saved the county more than a million dollars in private attorney's fees.
Cook County was also able to implement the system by using the John H. Stroger, Jr. Hospital of Cook County to conduct the lab work, which was less expensive than private-firm testing, and by switching to an electronic medical records system, which allowed for results from overnight testing to be shared with the county jail the next day.
In the new intake facility, those who consent to be tested have blood drawn, which is taken to Stroger. Overnight, a phlebotomist conducts what is called a Enzyme-linked immunosorbent assay (ELISA) test, which uses enzyme reactions to detect the presence of HIV antibodies. Since the test is not always accurate, for those that come back positive, a Western Blot test, which also uses enzymes to digest blood particulates so they can be detected, is conducted on those blood samples. Western Blot test results take a week to come back.
Anyone who initially tests positive (the results are not 100 percent accurate) is called into a specialized medical care clinic. They are informed of their preliminary result, and a rapid test is conducted to confirm their status.
For many reasons, someone who tests positive may not get results back. The grant-funded tester counselor, who reviews the positive cases the next morning, works Monday through Friday. So anyone processed over the weekend won't get his or her results back right away. Some are bonded out or released the same day they're arrested. A detainee may also be in court, or a unit may be in security lockdown.
The Chicago Department of Public Health (CDPH) has a unit that, among other things, works to locate those who tested positive but were released from the jail before they were notified.
HIV by the numbers
The gap between those who are HIV-positive (whether they know their status or not), and those who have been getting treatment long enough to have a suppressed viral load is significant.
Using the most recent CDPH data available, from 2010, AFC put together what's called a "treatment cascade" to illustrate this disparity.
In its 2013-2015 strategic plan, AFC shows that of the 35,093 people who are infected with HIV, 28,741 have actually been diagnosed, and 15,520 have accessed care. Only 9,303 have a suppressed viral load.
Peller has another statistic he likes to use to sum up this data: 50 percent of those with HIV aren't in medical care. Dealing with HIV in jails isn't just about identifying those who are positive; it's also about caring for them.
Those in Cook County Jail go one of two places. The first is to prison, under the control of the Illinois Department of Corrections (IDOC). The IDOC has recently begun implementing its own opt-out program, and people who are HIV-positive are getting specialized care via a telemedicine program through the University of Illinois.
Otherwise, those detained in CCDOC go back into the community, where concerns about putting a roof over their head, food on the table, and the struggles of daily life often trump specialized medical care needs.
"In a lot of ways, HIV is a symptom of a lot of the problems that low income, people of color face," Peller said.
One Wednesday afternoon, Dr. Chad Zawitz, a doctor at Cermak Health Services, which serves the jail, sees a patient in his own office.
The patient, an African-American man in his 50s, is living with HIV.
ZawitzDr. Z to many of his patients and coworkersconducts a routine physical, fills out the man's prescription and orders his lab work.
Zawitz is impressed, he says. It is the healthiest he has ever seen his patient.
The patient reports that he has been having a hard time. Zawitz asks him if there is anything he needs. The man needs a coat. Zawitz offers to bring his partner's old coat, which will be his size, next week when the man comes by to get the lab work results. Finally, Zawitz refers his patient to a case manager.
The last time Zawitz saw his patient was at the jail, before he was sentenced to prison. The man was released two weeks ago, and this is his first visit with a doctor on the outside since.
Every Wednesday afternoon at the Ruth M. Rothstein CORE Center, Zawitz treats people who have been incarcerated and are living with HIV. The clinic has a special staff consisting of medical practitioners, mental health specialists, case managers, substance abuse counselors, nutritionists and health educators.
In addition to running the clinic, he is also the Director of Infectious Diseases for Cermak Health Services in CCDOC. If an HIV-positive person is detained in the jail, or if someone tests positive at intake, Zawitz is the specialist they see.
For those who test positive within CCDOC, they're scheduled a priority visit at the Continuity of Care Clinic inside the jail. First he finds out if the individual has a doctor.
"If not, well you just met him. I'm your doctor," he said.
Zawitz does an extensive post-counsel by going over HIV/AIDS with his patient, doing a complete physical exam and medical history, and performing a series of baseline lab testsT-cell count, viral load, chemistry panels, liver function.
"We don't start HIV meds until we have the labs back, and until they have assessment of their readiness to adhere the medicine," he said. "We get a better assessment of their nonmedical needs, meaning, are they homeless, do they have access to a support network? You can imagine all the possible needs they have."
Because the jail is a transient place, Zawitz also looks at a patient's next court date and schedules them an appointment for his clinic outside the jail the following week.
The CORE Center clinic is also called the Continuity of Care Clinic.
Zawitz's Wednesday patient has been through the system multiple times. This time, he said he spent a year in prison for shoplifting a coat. At the clinic, the patient receives services that extend beyond getting a physical or a prescription filled.
"I have the easy job. Taking care of medical needs is relatively easy," Zawitz said. "It's all the other stuff that's really hard. "
The clinic houses case managers, mental health specialists, substance abuse counselors, nutritionists and health educators. To keep clients in care, this team tries to address the myriad problems those who've been incarcerated or detained face: addiction, homelessness, joblessnesspoverty, essentially.
In addition, those formerly incarcerated or taken into CCDOC custody who are HIV-positive have access to some social services outside the clinic.
Cynthia Tucker is the director of Prevention and Community Partnerships for the AFC. Since 2005 the Illinois Department of Health has funded a Corrections Case Management Program through the AFC, and Tucker is responsible for coordinating with five case managers who work closely with those getting out of both Cook County Jail and state prisons.
"The re-entry population has a group of really specific things that they need, so we try to cater to those things," Tucker said. "So we try to work with them on many facets."
Case managers are charged with figuring out what works best for each individual. She says sometimes that is food or a cell phone, anything that will help a person be more productive and transition back into the community.
People leaving prison can prepare a little, said Tucker, but the jail can be more challenging. It can be a revolving door, and individuals can be released quickly and easily fall through the cracks.
Since the transition to electronic medical records, the jail has been able to improve the level of healthcare it provides, officials say. It also hopes to address recidivism, and try to find out why people aren't getting treatment.
The opt-out testing program has been in effect for females at the jail since 2011.
Last year, Cook County announced the success of implementing opt-out for male inmates.
That testing, however, has yet to begin in full. When asked for a comment, Cermak Health Serviced said the program does exist, with all patients having testing for HIV available to them, though not through an opt-out program.
"Initially, when we were preparing to initiate the program, the Health and Hospital System opted to initiate the opt-out process with HIV as the test offered to patients in male intake," said Cermak in a statement. "The process is still proceeding. Female intake is currently offering the full opt-out program. We are planning of having the full opt-out process in the new building."
The new building refers to the construction of a new tower, which will house an intake facility.
Cermak Health Services commented neither on why the opt-out testing wasn't yet fully in place for male detainees, nor about where funding for male opt-out testing is currently going, if not towards testing, by the time this story published.
According to Zawitz, there's no reason why a detainee won't get their medication so long as they know what they take, who their doctor is, or what pharmacy they get it from. If a detainee doesn't have this information, it can take time before the staff is able to identify and verify an individual's medication regimen.
According to Zawitz, this same process is in effect for transgender individuals detained in the jail. If an individual has a prescription for HIV-medication as well as hormones by a licensed physician, the medication will be provided.
Room for improvement
Because sex is not allowed within the jail, neither are condoms, a major shortcoming in the eyes of advocates like Peller.
Peller cites a 2011 study, which showed that greater condom access in a California State Prison Facility did not increase self-reported sexual activity and posed no increased safety risk.
The Sheriff's office said in a statement that while they obviously encourage individuals to practice safe sex, they cannot ignore policies like the Prison Rape Elimination Act, which prohibits sex, and also poses safety and security concerns.
"Any access to condoms program would have to be developed in close consultation with our Federal Monitor under the Department of Justice Agreed Order, " the statement read.
Beyond Cook County
While some advocates praise HIV care at Cook County Jail, other parts of the state have a long way to go, say experts.
Arick Buckles is one example, advocates say. Buckles works as a housing specialist at HIV service agency Chicago House.
About two years ago, Buckles submitted to a background check for a job and discovered he had an outstanding warrant in Bureau County, Ill. He was detained and sent back to Bureau to face those charges.
"And that's where the nightmare began, actually," he said. "Upon entering that system, I'd informed the jailers that I was a person who was living with HIV, and I was in need of my life-saving medications, my HIV regimen."
Buckles alleges he never met with a physician. He was there for seven days, all the while his doctor, partner, and friends from Chicago House were calling the jail to get Buckles his HIV medication.
"My needs went unaddressed and ignored that entire seven days, and finally I was released and told to go home," he said. "They made me aware that they could not, I want to say that they could not afford the medications, and so they were going to release me."
After release, Buckles contacted John Knight, director of the LGBT and AIDS project for the American Civil Liberties Union of Illinois. The ACLU-IL filed suit in 2012 and amended their complaint to add the name of the privately contracted company that provides medical care for Bureau County Jail, Advanced Correctional Healthcare Inc. (ACH).
Knight said that ACH excludes payments of HIV medications in their contract with the jail.
"I will say that in general there's not much of a contest here," he said. "They know that Arick had HIV, they know that he didn't get his medications for a week. What we don't know is exactly why that happened."
Knight thinks the problem is a lack of state administration or review of the jails statewide, because the individual counties control them. The Illinois Department of Corrections (IDOC) does have a set of standards for jail, and Knight and the ACLU-IL asked for the IDOC to conduct a review to ensure these standards were being met.
According to the administrative code, jails are required to provide a competent medical authority to ensure prescription and administration of medications, as well as provide a doctor to attend to the medical and mental health of those detained in jail.
In a copy of the review, provided by the ACLU, the IDOC found no violations of the standard, which is what Knight finds most troubling.
"Our larger goal is to go to the Department of Correction or, if necessary, go to the legislature and do something about this," he said. "Because if this is not a violation of the standards, then there is a problem."
Knight says that ACH has been named as the defendant in a similar lawsuit in Oklahoma.
Transgender issues and HIV
But while navigating HIV issues behind bars is challenging, advocates say that transgender people face especially difficult hurdles.
Channyn Lynne Parker is trying to address that. Parker is a care coordinator for the TransLife Project at Chicago House.
"Male-to-females are more visible in the public eye ... so therefore that increased visibility usually leads to a lot of systemic oppression," Parker said. "You end up having discriminated housing, employment, medical care, and because of those things trans women of color end up having a fear of seeking help in all of those arenas."
Parker's job is to link these women to healthcare. She understands that medical care is the key to ending transmission of HIV. But the TransLife Project also addresses housing, employment and legal services for trans people.
Parker has recently begun a counseling program for trans women housed in Cook County Jail.
"Really what I'm trying to do is for the trans detainees to have some emotional support and to address the whole recidivism issue. We know that most of the trans detainees are not violent offenders. They are really there because they commit what I like to say are survival crimes," Parker said. "They get out and they're still vulnerable. They're still visible, they're still vulnerable, they still lack emotional support, they still lack trainings, life skills, and so the cycle just continues. And so I'm hoping that me going into the county is going to address some of those barriers and stop some of that recidivism."
The jail as healthcare provider
The jail now finds itself as a first provider for many who cannot afford or do not use the healthcare system.
"Unfortunately the economic downturn and resulting healthcare cuts have dramatically impacted the jail making it the provider of first resort for any number of health problems, HIV included," the Sheriff's office said in a statement.
"We are working to better identify those with medical and behavioral healthcare needs, including HIV, and developing better transitions to care in the community with the hope that people will continue to access that care rather than cycling through the jail for care."
Mariame Kaba is director of Project NIA, which works on eradicating youth incarceration here in Chicago. For Kaba, healthcare within the jails raises bigger concerns about where our society's priorities are. She said CCDOC is among the most utilized three providers of mental health services in the country.
"To me that's a travesty because it illustrates that jails are primary healthcare providers," she said. "That is not what they should be, that is never what they were intended to be."
"Why is it that we're willing and able to provide healthcare for people when they're locked up and we don't before they're part of the system?" Kaba asked.
Victor Morales, the HIV-positive man who was detained in Cook County, noted the lack options.
"Being an ex-offender, it's hard. We don't have a lot of the resources," Morales said.
He said the first thing he needed upon release was housing, that everything elsea job, medical carecame secondary.
He just moved into a place, after two months. It's a couple blocks from the lake, a studio with lots of sunlight, but a little bit smaller than he's used to, so he's adjusting. After getting his GED, he wants to go to Harold Washington and get a degree in social work.
Morales didn't take his medication regularly while in jail, before he was sentenced and sent to prison. He was part of a recovery program there called Gateway Foundation that deals specifically with substance abuse. In the past a nurse discreetly administered his medicine, but while in Gateway, he was given all his medicine and expected to take it himself. He was scared others would see all his pills, so he hid them and didn't take them.
Morales wants to see jail employees educated about HIV, undoing some of the stigma.