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Treating Prisoners with HIV/AIDS: The Importance of Early Identification, Effective Treatment, and Community Follow-Up

The U.S. currently imprisons a larger proportion of its population than does any other country in the world. Drug-related crimes constitute the largest percentage of arrests, and most of these crimes involve possession rather than sales or manufacture. Given the large number of drug users incarcerated in the U.S., it is not surprising that HIV is more prevalent among prisoners than in the general population. This phenomenon presents both a prison health crisis and a public health challenge. Many inmates either are diagnosed with HIV or first receive medical care for HIV while incarcerated. By screening widely for HIV in prisons, educating and treating HIV-infected inmates, and implementing individualized follow-up care upon release, we can use incarceration as an opportunity for important public health interventions.

EPIDEMIOLOGY

"War on Addicts"

As of June 2001, more than 1.96 million people in the U.S. were incarcerated in state or federal prisons or local jails:¹ a 62% increase from 1990 to 2001, during which the proportion of sentenced inmates increased from 292 to 472 inmates per 100,000 residents.² This rise in incarceration rates can in part be explained by initiatives of the National Drug Control Strategy (NDCS), first announced in 1989. These federal initiatives of the "War on Drugs," which emphasize law enforcement, prosecution, and punishment, are intended to decrease the use of illegal substances.³

In the absence of adequate substance-abuse-treatment programs, however, these policies have increased the number of incarcerated drug abusers without addressing the root of the problem. From 1980 to 1999, drug-abuse arrests increased 3-fold, from 580,000 to more than 1.5 million, with more than 80% of these arrests for drug-possession violations.⁴ From 1980 to 1995, the number of people incarcerated increased by 239% (from 501,886 to 1,700,661), and drug-law violations accounted for 30%, 60%, and 41% of these total population increases in state prisons, federal prisons, and local jails, respectively.⁵ Of the estimated 840,000 inmates who could benefit from substance-abuse treatment, fewer than 150,000 receive it.⁵

HIV/AIDS in Prison

With the increased incarceration of substance abusers, including those who inject drugs and engage in other high-risk behaviors (e.g., commercial sex work), it is not surprising that HIV and other bloodborne infectious diseases, such as hepatitis B and C, are at higher concentrations in U.S. prisons than in the general population. In 1999, 25,757 inmates were known to be HIV positive, with the prevalence in state and federal prisons and local jails at 2.3%, 0.9%, and 1.7%, respectively.⁶ State prisons in the Northeast had the highest rates of HIV infection, with New York (9.7%), Washington, DC (7.8%), Rhode Island (6.9%), and Connecticut (6.0%) leading all other states.⁶ Higher rates of HIV infection in these states likely reflect the demographics of injection drug use in the U.S. Reliable data on HIV infection in prisons worldwide are not available, but the factors that lead to high HIV prevalence among prisoners in the U.S. (drug use, associated crime, prostitution, and high-risk sex) probably lead to higher rates of HIV infection among prisoners in many nations.

In one 1994 to 1996 study, researchers examined the characteristics of 220,000 AIDS cases and compared people diagnosed in prison (4% of the total) with those diagnosed in the community. The rate of injection drug use among incarcerated AIDS patients was more than twice that among AIDS patients in the community (61% vs. 27%; see Table 1).⁷ Data regarding race were striking: In the general population, 40% of AIDS cases were among blacks and 40% were among whites, whereas in prison, 58% of AIDS cases were among blacks and only 18% were among whites (see Table 1).⁷ In 1997, among male state-prison inmates throughout the U.S., blacks (2.7%) and Hispanics (2.5%) were nearly twice as likely as whites (1.4%) to be HIV positive.⁸

View this table: [in a new window]   Table 1: Adult or adolescent persons reported with AIDS for whom diagnosis was made in a correctional facility in the United States, 1994-1996

 

PRISON HEALTH AS PUBLIC HEALTH

The vast majority of prisoners eventually return to the community. In 2000, more than 600,000 inmates were released from state and federal correctional facilities.² In 1991 alone, 4,000 of New York's 8,000 HIV-positive inmates were released from prison.⁸ It is estimated that, in 1997, there were more than 35,000 HIV-infected prison and jail inmates nationwide on any given day and that more than 150,000 HIV-infected prisoners were released during that year.¹⁰ Incarceration presents both a challenge and a public health opportunity for the treatment of HIV. Such treatment can be achieved through collaboration between departments of health and departments of corrections in the following areas: 1) early identification of HIV-infected inmates through widespread screening in prisons and jails, 2) effective treatment during incarceration, and 3) close follow-up upon release from prison to maintain continuity of medical care. Table 2 illustrates levels of collaboration between correctional facilities and departments of health in the care of inmates with HIV/AIDS.¹¹

View this table: [in a new window]   Table 2: Percentage of Correctional Systems Reporting Collaborations with Public Health Departments as of 1997

 

HIV Screening

Although existing data on seroprevalence of HIV within prisons suggest that HIV is concentrated at much higher numbers in prisons than in the general population, these figures almost certainly underestimate the scope of the problem, because testing policies vary widely among facilities. A 1996 survey of local jails and a 1997 survey of state and federal prisons revealed that only 57.2% of jail inmates and 74.6% and 79.6% of state- and federal-prison inmates, respectively, had ever been tested for HIV.⁸ As of 1996, 16 state prison systems tested all inmates, 27 tested high-risk groups, 3 tested inmates randomly, and 5 tested by inmate request only.⁸ In states with mandatory HIV testing for prisoners, significant proportions of the HIV-positive individuals in the state have been diagnosed within the prison system. In Rhode Island, where HIV testing of all adults sentenced to the state prison has been mandatory since 1989, one-third of all new HIV cases in the state have been diagnosed within the prison.¹² The state prison is the single largest HIV-testing site within Rhode Island. Thus, to ignore the incarcerated population in addressing the HIV epidemic is to ignore a large portion of the infected population.

It is critical to identify HIV-positive inmates during incarceration, because this may be the only interaction that many of these individuals have with organized health care. In addition, there are several benefits of identifying HIV-infected inmates early in the course of the disease. On an individual level, early identification leads to early medical attention and decreased morbidity and mortality. Inmates can begin antiretroviral therapy and prophylactic medications before progressing to opportunistic infections and advanced AIDS. On a societal level, early identification allows other HIV-infected individuals to be identified sooner rather than later through contact tracing. Furthermore, identifying and educating HIV-infected individuals about high-risk behaviors can reduce the spread of HIV.

Little evidence exists on HIV transmission in prison, but tattooing, sex, and, less frequently, injection drug use do occur in correctional facilities. HIV screening and counseling can also minimize transmission within prisons and jails; however, to date, condoms are prohibited in most correctional facilities, and bleach is available under limited circumstances (but not for the purpose of, or in the quantities necessary for, sterilizing needles).⁹

Effective Treatment

In 1976, the U.S. Supreme Court affirmed an inmate's constitutional right to medical services, citing the Eighth Amendment's prohibition of cruel and unusual punishment.¹³ Inmates with HIV/AIDS are entitled to the same standard of care as is the general population. Most inmates who get tested receive pre- and post-test counseling and education, and most who are shown to be infected receive medical evaluations and medications, but the exact protocol varies from state to state. In addition to general guidelines for the treatment of HIV, clinical practice guidelines provided by the Federal Bureau of Prisons can assist prison medical personnel in the treatment of HIV-infected prisoners, with special attention to such issues as discharge planning and transition to the community.¹⁴

Two approaches to dispensing medication to imprisoned HIV patients have been used: "directly observed therapy" (DOT), in which medical personnel observe the patient taking each dose of medication, and "keep on person" (KOP), in which medications are dispensed to the patient to take on his or her own. In a study in Italy, in which these approaches were compared among matched inmates, significantly more DOT patients than KOP patients achieved undetectable viral loads (62.3% vs. 34%).¹⁵ In a study in Florida, Fischl and colleagues compared patients in clinical trials outside prison who self-administered their medications with patients in prison who received DOT: 75% of patients in the community achieved viral loads less than 400 copies/mL, compared with 95% of the prisoners.¹⁶ Such findings suggest that providing DOT to inmates significantly reduces viral load and should be considered whenever feasible.

With increasing proportions of inmates with chronic diseases such as HIV, health services occupy increasing proportions of state corrections budgets. Therefore, it is important to find cost-effective ways to provide inmates with the HIV treatment that they require.³ A handful of successful collaborations among departments of corrections, departments of health, and academic medical centers have been developed. These programs help distribute the cost and improve the delivery of care. In addition, not only do inmates have the benefit of medical expertise of HIV specialists from the community, but they also have the opportunity to continue medical care with the same providers when they are released.¹¹

COMMUNITY FOLLOW-UP

One of the goals in providing effective medical care to HIV-infected inmates is to maintain the success of therapy upon release from prison. Former inmates contend with multiple challenges, from addiction and mental illness to homelessness and poverty, many of which undoubtedly contributed to their incarceration in the first place. Without structure and support services, such as substance-abuse treatment, many former inmates find themselves back behind bars. Rearrests currently account for 35% of all prison admissions, up from 17% in 1980, and as many as two thirds of all parolees are rearrested within 3 years.¹⁷ For former inmates with HIV, the challenges of substance abuse, homelessness, mental illness, and joblessness can present major barriers to continuing medical care. Stephenson and colleagues showed that HIV-infected inmates who are released and then reincarcerated have significantly higher viral loads than those who remain in prison.¹⁸ Therefore, developing programs that emphasize transition to the community is vital to the effective treatment of HIV-infected inmates. Several such programs have been created, most notably in Rhode Island, Massachusetts, and New York.

Project Bridge in Rhode Island

Project Bridge, a collaboration between the Rhode Island Department of Corrections and Brown University-affiliated Miriam Hospital, was developed in 1996 to improve the continuity of medical care for HIV-infected inmates upon their release from prison. Funded through a Ryan White CARE Act Special Project of National Significance research grant, this program, offered to every HIV-infected inmate in the state prison, consists of a team of outreach workers, social workers, doctors, and nurses, who provide various services for 18 months following release from prison. Thirty to ninety days prior to release, a licensed social worker evaluates the inmate to assess his or her needs and develops a discharge plan. Upon release, an outreach worker helps the former inmate access appropriate services, meeting weekly for the first 3 months and then biweekly for the remaining 15 months. Because of high recidivism rates within the first 6 months of release, early contact after release is critical if transition programs are to be effective. Services include "mental illness triage and referral, substance abuse assessment and treatment, appointments for HIV and other medical conditions, and referral for assistance with housing, nutrition, entitlements, and community programs that address basic survival needs."¹⁹ While the social workers help these former inmates to achieve "social stabilization," the same physicians who cared for them in prison continue to follow them regularly in the community. Preliminary results from these projects demonstrate a 92% success rate in follow-up with medical appointments. Despite this success, substance-abuse relapse and reincarceration do occur. However, the program takes a "harm-reduction approach" that emphasizes the importance of substance-abuse-treatment plans without making medical care contingent upon abstinence.¹⁹

Hampden County Correctional Center in Massachusetts

Hampden County Correctional Center in Ludlow, Massachusetts, in collaboration with the state department of health and regional medical centers, also has developed a model program that provides effective health care to HIV-infected individuals during incarceration and after release. Upon prison admission, each inmate is screened for chronic and infectious diseases, substance abuse, high-risk sexual behaviors, and violence. The inmates then are sorted by zip code. Each inmate receives all of his or her medical care from 1 of 4 health teams that work both in the jail and at 1 of several community clinics. Upon release, former inmates continue to receive care from the same health care provider at the designated clinic. This program also offers inmates case management, discharge planning, mental health care, and substance-abuse treatment. In 1998, 80% of former Hampden County inmates were receiving medical care in the community.²⁰

ETHICS Unit in New York

ETHICS Unit provides discharge planning and transitional services for inmates released from New York state prisons and Riker's Island jail. Like Project Bridge, ETHICS Unit is funded as a Ryan White Special Project of National Significance, and, like the programs in Rhode Island and Massachusetts, ETHICS Unit enlists the aid of outreach workers to assist former inmates to "achieve basic stability" by securing housing, substance-abuse treatment, medical care, and benefits. ETHICS Unit is unique among these models, however, in that it is run by Fortune Society, an organization founded in 1977 by ex-offenders for ex-offenders. Established former inmates serve as outreach workers and role models as they help recently released inmates transition to the community. Although no formal evaluation of the program has been conducted, anecdotal evidence indicates that "hundreds of clients have succeeded in turning their lives around with the help of the program," and that many clients go on to become peer counselors themselves.⁸

These programs make sense not only for the health of inmates but also for the health of the entire society. There is evidence that such transition programs decrease recidivism, presumably because they facilitate more effective reintegration into the community. In Hampden County's program, the recidivism rate among the 152 known HIV-positive patients was 46%, versus 72% for the HIV-negative inmates.²¹ In a Rhode Island program developed specifically for female inmates, HIV-positive women had significantly lower recidivism rates compared with HIV-negative incarcerated controls at 6 months (12% vs. 27%) and at 12 months (17% vs. 39%).²² In addition to helping inmates maintain medical management of their HIV, effective transition programs ultimately could help many individuals end the cycle of addiction, crime, and incarceration.

CONCLUSION

Because of the explosion of prison and jail populations stemming from the War on Drugs, many HIV-positive individuals in the U.S. reside behind bars or cycle through correctional facilities. Despite existing data that reveal high HIV prevalence in the incarcerated setting, the true burden of HIV in prisons and jails has not been fully realized. Many inmates have never received adequate medical treatment prior to incarceration. Widespread HIV screening of inmates, as in Rhode Island, could help reveal the full scope of the HIV epidemic in this population. Counseling and education programs within prisons and jails could then aid in secondary prevention, and effective medical management could decrease AIDS-related morbidity and mortality. Finally, transition programs, like those in Rhode Island, Massachusetts, and New York, provide the critical link for inmates who are returning to the community. When executed effectively, these programs have the potential not only to improve continuity of medical treatment for HIV-infected individuals, but also to address long-standing addictions and thereby interrupt the cycle of crime and punishment that characterizes the lives of so many HIV-infected inmates.

— Catherine Crosland, Michael Poshkus, MD, and Josiah D. Rich, MD, MPH

Ms. Crosland is a fourth-year medical student at Harvard Medical School in Boston. Dr. Poshkus is an Infectious Diseases Fellow at Brown University School of Medicine in Providence. Dr. Rich is Associate Professor of Medicine and Community Health at Brown University School of Medicine and Attending Physician at The Miriam Hospital in Providence.

Published in AIDS Clinical Care August 1, 2002

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