Prisons, jails often face uphill battle in dealing with HIV-infected inmates
Nation’s HIV epidemic partially fueled by inmates
About one in six AIDS patients has spent time in an American prison or jail. Many community clinics and providers treating HIV-infected patients have seen at least some patients who have been treated for HIV or have discovered their HIV status while incarcerated.
The United States’ correctional system has a greater HIV prevalence among its inmates than is found in the population as a whole.1 When these people are released back into the community without follow-up care, there is a high risk that their disease will progress to AIDS and they’ll continue to infect others. "Our major concern is that the population housed in correctional institutions come to the institutions with a lot of high-risk behaviors," says John Miles, special assistant for corrections and substance abuse at the Centers for Disease Control and Prevention (CDC) in Atlanta. "They have high-risk sexual activity, high-risk drug use, and 80% or more of inmates have a prior history of alcohol or substance abuse."
Prisoners sometimes become infected with HIV while they’re incarcerated, primarily due to injection drug use and possibly tattooing, Miles says. "If a drug user is inside an institution, he’ll make an injection rig out of whatever is available, and that oftentimes is passed around."
Incarcerated people with HIV are more likely than nonincarcerated people with HIV to have been infected via injection drug use before their arrest, according to CDC research. Of all incarcerated people with AIDS, 61% have injected drugs, compared with an injection drug rate of 27% among nonincarcerated people with AIDS.2 Female inmates with HIV have a higher injection drug use rate than male inmates. Also, HIV infection is more prevalent among female inmates than male inmates, and it’s more prevalent among black and Hispanic inmates than among white inmates.1
All of those factors have contributed to a big health and social problem, Miles says. "All of those social ills in communities are concentrated in corrections facilities."
When community health care providers ignore the problem of HIV-infected inmates, they are being shortsighted because nearly all of these inmates will be returning to the community, Miles adds.
Some states and counties have established comprehensive health care programs that routinely test, treat, and track HIV-infected inmates. Many others, however, discourage HIV testing and provide too little health care to HIV-infected patients while they’re incarcerated. Also, a lot of systems do not provide post-release support.
Only 16 state prison systems routinely test all inmates for HIV, according to the latest U.S. Department of Justice report on HIV in U.S. prisons.1 Another 27 states provide HIV testing to inmates in high-risk groups or when a need for one is demonstrated, and five states only provide HIV testing when the inmate specifically asks for one.1
Don’t ask, don’t provide’ policy ineffective
Inmates typically don’t know how to ask for an HIV test, and so the states that only provide tests upon request end up testing fewer than 5% of their inmates, says Tom Conklin, MD, director of health services at Hampden County Correctional Center in Ludlow, MA.
"We’ve come a long way in health care in jails and prisons, but we haven’t come far enough," Conklin adds. "The Supreme Court said inmates must receive medical care, but the court didn’t say who would pay for it, and funding is very low."
Albany-based New York State Department of Correctional Services has the largest HIV population in the United States, with about 10,000 HIV-infected inmates. Between 10% and 13% of the people incarcerated in New York are infected with HIV, compared with a national rate of less than 3%. AIDS also accounts for more than half of all deaths among New York inmates.1
The state provides voluntary HIV testing to about 25,000 inmates each year, says Lester Wright, MD, MPH, deputy commissioner and chief medical officer for the correctional services department.
A major expenditure
New York’s prison system provides HIV antiretroviral therapy when one of the state’s HIV and infectious disease specialists says it’s medically indicated, Wright says. "HIV is a major expenditure in my system," he adds. "I’ve got close to 3,000 people on HIV medications at this point."
The Rhode Island Department of Corrections has a policy of requiring an HIV test for all sentenced inmates. At commitment, inmates are routinely asked if they want an HIV test. More than 90% of the inmates sign a consent form and have the test done at the time of commitment, which is before sentencing for most offenders, says 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.
"We have 3% of our population at any given time who are HIV-positive, and about 1% of the people who enter the system are HIV-positive," she says.
Physicians treating Rhode Island prisoners decide when to place an HIV-infected patient on antiretroviral therapy based on standard guidelines, the patient’s desires, and their own clinical judgment, Spaulding says.
HIV treatment is one of the state corrections system’s biggest expenditures, costing just under $500,000 per year.
Some prison systems provide only the minimum level of care, a Band-Aid’ style of medicine, Conklin says. That approach means a prison’s health officials will conduct a cursory assessment of new inmates. The assessment goal is not to uncover every disease the inmates may have because each health problem costs the system money.
The justice department’s study shows that local jails are least likely to conduct HIV tests. While nearly 70% of inmates in federal prisons and nearly 60% of inmates in state prisons were tested, only 17.7% of inmates in local jails received HIV testing.
While local jails traditionally are thought to be holding cells until a person is tried and convicted or found innocent, they increasingly are serving as prisons for convicted criminals. In Massachusetts, for example, the major county facilities house pre-trial inmates as well as convicted inmates sentenced to fewer than three years in prison, Conklin explains.
The state places those convicted inmates there so first- and small-time offenders will not be sent to a state prison where they could be influenced by more dangerous criminals. Also, inmates in local jails might have a better chance at rehabilitation, Conklin says.
As part of its rehabilitation efforts, Hampden County Correctional Center strives to provide good medical care, Conklin says. The center’s health care program involves asking all inmates to take an HIV test and routinely screening for syphilis, liver function studies, urinalysis, and urine-based chlamydia screening.
"People come from the community and are with us and then back in the community, so the inside of the jail is a reflection of the outside," Conklin explains. "So we feel we have a responsibility to the community and a responsibility to public safety."
Not all prison systems have the same philosophy. About 10% of state, federal, and local correctional systems do not have HIV protease inhibitors or combination therapies available for inmates.1 Discharge planning services are available at 92% of state or federal prisons and 76% of local jails, but they mostly entail a referral to an outside clinic or doctor who treats HIV patients.
The percentage of inmates who actually make an appointment or have an appointment made for them is quite low. Less than a third of inmates in state and federal facilities and about 27% in local jail systems make appointments to receive HIV medications.
"There has to be a public health commitment to look at diseases in incarcerated populations," explains Hazel Dean-Gaitor, ScD, MPH, epidemiologist in the CDC’s Division of HIV/AIDS Prevention. "And once they get back into the community, we need to remain in contact with the released incarcerated population so that we can provide a public health service to that person and to the community."
The CDC is involved in a continuity-of-care demonstration project to address the complex concerns of HIV-positive inmates released into the community. Those projects will address links between corrections and the community, Dean-Gaitor says.
The winners
The groups that were awarded funding for the project include the California Department of Health Services, Georgia Department of Human Resources, Florida Department of Health, Health Research Inc. and the New York State Department of Health, Chicago Center for Health Systems Development, Massachusetts Department of Public Health, and the New Jersey Department of Health and Senior Services.
"The goal of the demonstration project is to improve access to care and prevention services involving HIV-infected persons while they are inmates and upon their release from jail or prison," Dean-Gaitor says. "In each project area, the health department and department of corrections are working collaboratively with one or more community-based organizations to provide services."
Some corrections systems have good programs that provide a continuum of care, and their efforts could become role models for other prison systems, Miles says. (See story on program examples at right.)
Many incarcerated people are nonviolent offenders who have the potential to return to the community and lead productive lives, he adds. "But if we don’t provide community-based support and infrastructure, they’ll have recidivism and return to prison."
References
1. Hammett TM, Harmon P, Maruschak LM. 1996-1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities. National Institute of Justice; 1999: http://www.ojp.usdoj.gov/nij/pubs-sum/176344.htm.
2. Dean-Gaitor HD, Fleming PL. Epidemiology of AIDS in incarcerated persons in the United States, 1994-1996. AIDS 1999; 13:2,429-2,435.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content