Care of HIV-infected inmates benefits public
Untreated former inmates pose risk to community
It’s in everybody’s best interest to ensure that HIV-infected drug users and offenders receive prevention education, treatment, and a continuum of care that follows them through their incarceration and back into the community, HIV experts and prison/jail officials say.
It’s very easy for criminal offenders to fall through the cracks when they are released, says John Miles, special assistant for corrections and substance abuse for the Centers for Disease Control and Prevention (CDC) in Atlanta. "One of the things we tend to forget is that inside a corrections institution there is a rigorous, controlled environment, and every movement of each day is controlled," Miles says. "So when an offender comes back to the community, that person oftentimes does not have the life skills to find an infectious disease doctor or to receive health care services."
Follow-up health care for HIV-infected inmates cannot be left entirely to the parole system because the number of inmates receiving parole is increasingly getting smaller, he says. "The preponderance of prisoners serve their time and then are out, and there is no parole."
Also, the necessary community-based support cannot be left entirely to the corrections system or community health organizations, Miles says; rather, all of those groups need to work together.
There are several good models for how correction systems can work with community health organizations to follow up on an HIV patient’s care after the person is released from prison or jail. Corrections systems in Rhode Island, New York, and Massachusetts serve as examples of how a successful continuum of care can be established for an incarcerated population, Miles says.
The Rhode Island prison system’s HIV care includes assistance from infectious disease specialists at Miriam Hospital, one of the Brown University hospitals in Providence. Because Rhode Island is so small, most of the state’s prisoners are located near Providence, which makes it easier for the state to provide a continuum of care to HIV-infected inmates. The same physicians may care for the inmate during and after his incarceration, explains Anne Spaulding, MD, medical director of the corrections department and an infectious disease physician at the Brown/Rhode Island Hospital division of infectious disease in Cranston, RI.
Rhode Island’s system has two nurses who provide assistance in treatment and discharge planning of HIV-infected prisoners. System staff include five physicians, mostly internists, and a nurse practitioner. When more specialized HIV care is necessary, the Miriam Hospital physicians are consulted, Spaulding says. "If someone has a problem with a failing HIV regimen, the Miriam doctors would be consulted. If someone has an earache, the patient would see an internist."
Post-incarceration care has a better chance of succeeding because the inmates already have met the doctors who will be continuing their care outside prison, Spaulding explains. "We try to give them an appointment when they leave," she adds.
Also, Rhode Island corrections officials assist inmates in applying for medication through the AIDS Drug Assistance Program (ADAP).
The New York corrections system works closely with the AIDS Institute in the state’s health department to contract with community-based organizations (CBOs) to provide services, including some testing and counseling, to incarcerated HIV patients. Those same organizations also help the prison system in transitional and discharge planning for HIV-infected inmates, says Lester Wright, MD, MPH, deputy commissioner and chief medical officer for Albany-based New York State Department of Correctional Services.
"Before someone with HIV leaves our system, they’re given a 30-day supply of medication, a prescription for medication, and they have an appointment set up with a provider on the outside," Wright says. "Does it always work? Of course not. Do the medications sometimes get sold? Of course."
The system does, however, walk inmates through the process, making it easy for them to continue their antiretroviral regimen upon release to the community, Wright adds. Also, the community-based organizations help inmates, before they leave the prison system, apply for medications through ADAP.
New York’s corrections system has 17 staff physicians who have received HIV certification and now treat HIV-infected inmates. However, because the New York corrections system has 70 prisons, many of which are in rural areas, some of the HIV care provided to inmates comes from HIV specialists who contract with the system.
Given the size of New York and the large number of HIV-infected inmates, the corrections system is doing the best it can to provide a continuum of care, Wright notes. "About 75% of the state’s inmates come from New York City, but at least that percentage of prisons are in the upstate of New York, which is why arrangements have to be made before they leave," he explains. "It often involves one upstate community-based organization talking with a CBO in New York City to try to arrange for care for a person who is being released."
New York’s corrections system also provides HIV prevention education to every inmate. The women’s prisons have a peer education program that was started by inmates who felt it was necessary to educate these women about HIV, Wright says.
The system also educates its staff about HIV through a continuing medical education program on HIV care in corrections. The program, which is broadcast by satellite, usually is held three times a year in collaboration with the Albany (NY) Medical Center. "It gets our staff up to speed and also is down-linked by many prison systems around the country," Wright adds.
Hampden program considered a model
Hampden County Correctional Center in Ludlow, MA, has a comprehensive continuum of care program for inmates, including those with HIV infection. Touted by Miles as one of the best public health models in the country, the Hampden County program has a discharge plan for every person who leaves jail.
The plan assesses the inmate’s needs from the perspective of health care, family reintegration, housing, home environment, child care, and other aspects, explains Tom Conklin, MD, director of health services for the correctional center. (See story on Hampden County’s program, p. 122.)
Conklin says he believes in research and outcomes studies; as a result, the county has been following inmates at one month and six months after release to determine whether they are continuing to receive adequate health care services.
"In correctional medicine, there has been a lot of anecdotal information and very little information based on research, facts, and figures, and that is changing," Conklin says. "If we’re able to get some good research going, it may help to change the chronic underfunding of all jails."
The county has received research funding from the CDC and the Soros Foundation in New York City. Also, the National Institute of Justice in Washington, DC, has provided funding for research firm Abt Associates Inc. of Cambridge, MA, to help the corrections center conduct an outcomes study.
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