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HIV Care in Correctional Settings
Guide for HIV/AIDS Clinical Care, HRSA HIV/AIDS Bureau
Caring for HIV-infected patients who are incarcerated is a complex and challenging task. For many of these patients, the prison health service provides their first opportunity for access to consistent health care. This chapter will discuss some of the issues relevant to the HIV-infected population in correctional settings.
It is important to note the distinction between "jail" and "prison" custodial settings. These terms are often used interchangeably, but doing so can create confusion for health care providers, as the services that an inmate receives while incarcerated may differ greatly according to the type of facility (NYSDOH, 2008).
Jails are locally operated, or managed, institutions that detain individuals who typically are serving short sentences of 1 year or less. They also hold individuals who are awaiting arraignment, trial, or sentencing, or those who have violated terms of their parole (Harrison and Beck, 2006). Because inmates who are detained in jail settings have shorter confinement terms, providers often face time constraints in establishing longer-term treatment plans for chronic conditions such as HIV/AIDS, and for substance use and mental health problems. Opportunities for inmate education also may be more limited. In addition, because jail inmates often are released within days, weeks, or months after initial confinement, establishing continuity of health care may be challenging for providers and administrators (Okie, 2007).
Prisons, in contrast, are operated by state governments or the Federal Bureau of Prisons. Prisons generally detain people who have been convicted of state or federal felonies and are sentenced to terms of longer than 1 year (Harrison and Beck, 2006). The nature of a person's crime, namely a state or federal offense, will dictate the type of prison in which he or she will be detained. The length of sentences for inmates in state or federal custody is longer than those for persons serving time in jail, and prison inmates typically have a firm release date in advance. As a result, HIV-infected inmates released from prison may be more likely to have treatment and discharge plans in place (NYSDOH, 2008).
Note that these characteristics may differ from prison to prison and jail to jail.
Inmates continue to be disproportionately affected by the epidemic, with the estimated overall rate of AIDS among prison inmates at more than 2.5 times the rate in the United States general population. In 2006, there were 21,980 HIV-infected inmates in prisons, according to the latest report from the Bureau of Justice Statistics, and there are many more in jails. With the advent of effective combination antiretroviral therapy (ART), AIDS-related mortality as a percent of total deaths in state prisons decreased significantly between 1995 and 2006, from 34.2% to 4.6% (Maruschak, 2006).
Often, behaviors that lead to incarceration also put inmates at high risk of becoming infected with HIV, hepatitis C virus (HCV), and other infectious pathogens. These risk factors may include unsafe substance use behaviors, such as sharing syringes and other injection equipment, and high-risk sexual practices, such as having multiple sex partners or unprotected sex. Many inmates also may have conditions that increase the risk of HIV transmission or acquisition, such as untreated sexually transmitted diseases (STDs).
The prevalences of chronic viral hepatitis and tuberculosis are much higher among incarcerated persons than among the general public. Depending on the prison system, 13% to 54% of inmates are infected with HCV (Cassidy, 2003). The incidence is 10 times higher among inmates than among non-inmates and is 33% higher among women than among men (Nerenberg et al., 2002). The Centers for Disease Control and Prevention (CDC) recommends that all incoming inmates be screened for HCV, and those who are infected should be evaluated for liver damage and the need for treatment (Cassidy, 2003). Chronic hepatitis B virus (HBV) infection and tuberculosis also are substantially more common among the incarcerated population than among the general public. The presence of any of these conditions should prompt HIV testing (Nicodemus and Paris, 2002).
Women account for almost 7% of the prison population in the United States (West and Sobol, 2009). The HIV epidemic in the United States increasingly affects women of color, and this trend is reflected in HIV rates among the incarcerated. In terms of total numbers, there are more males than females with HIV/AIDS in state and federal prisons nationally (19,809 and 2,135, respectively). However, the percentage of female inmates with known HIV infection in these settings is higher than that for incarcerated males (2.4% and 1.6 percent, respectively) (Maruschak, 2006).
In many cases, incarcerated women are low-income and have limited education and sporadic employment histories. Compared with men, they are less likely to be incarcerated for a violent crime, and more likely to be incarcerated for a drug or property offense. Women's property crimes often are the result of poverty and substance-use histories (National Institute of Corrections, 2003). Numerous studies have shown that the behaviors that lead to incarceration also put women at increased risk of HIV infection. Risk factors that are present in abundance among female inmates include the following:
Among all women entering a correctional facility, 10% are pregnant (De Groot and Cu Uvin, 2005). These women should be offered HIV testing, and HIV-infected pregnant women should be offered combination ART immediately to prevent perinatal HIV transmission. Many incarcerated women will receive their first gynecologic care in prison. Because the incidence of cervical cancer is higher among women with HIV, referrals for colposcopy should be made for any HIV-infected woman with an abnormal Papanicolaou test result.
The correctional facility is an ideal location for identifying individuals already infected with HIV, HCV, or HBV, and for education interventions that are geared to prevent infection among those at highest risk of these acquiring diseases. For many adults, the prison or jail setting is a rare potential point of contact with the health care system, making it an important avenue for HIV testing and linkage to care.
Inmates commonly are hesitant to be tested for HIV because they fear a positive diagnosis and because of the potential stigma involved. They often lack accurate information about HIV, including awareness of behaviors that may have put them at risk and knowledge of means for protecting themselves from becoming infected. Health care providers in correctional settings are in a key position to evaluate inmates for HIV risk factors, to offer HIV testing, and to educate and counsel this high-risk group about HIV.
HIV testing policies in correctional facilities vary from state to state and among local, state, and federal penal institutions. Depending on the setting, policies may require testing of inmates upon entry, upon release, or both, but more than 50% of state prison systems do not require HIV testing at any point. Some prisons may do HIV testing based on clinical indication or risk exposure during incarceration, and this may be voluntary or mandatory. Most prison systems do provide HIV testing for inmates who request it. See Table 1 for an overview of the circumstances under which inmates in state prisons were tested for HIV in 2006 (Maruschak, 2006).
In high-risk settings such as correctional facilities, routine, voluntary HIV testing has been shown to be cost-effective and clinically advantageous (Paltiel et al., 2005). The CDC supports universal opt-out HIV screening in prisons and jails and has produced the HIV Testing Implementation Guidance for Correctional Settings. This document serves as a guide for individual institutions in determining and establishing the most appropriate testing strategy for their settings, presents the components of such a testing program, and explains obstacles that may be encountered in the implementation process. It also provides information regarding the following:
Testing inmates for HIV prior to their release is a critical aspect not only of individuals' own health care needs but also of preventing transmission of HIV to others. Knowledge of their HIV status affects people's HIV risk behaviors: Studies have shown that, after learning they are infected with HIV, many persons take measures to reduce the risk of transmitting HIV to others.
Given the high HIV seroprevalence among inmates, the reentry of inmates into the community presents a danger of spreading HIV and other infectious diseases, and it is a public health concern. Thus, inmates need adequate HIV prevention counseling before release, both to protect themselves and to decrease the likelihood of infecting others in their communities with HIV (Gaiter and Doll, 1996). The World Health Organization (WHO) has stated: "All inmates and correctional staff and officers should be provided with education concerning transmission, prevention, treatment, and management of HIV infection. For inmates, this information should be provided at intake and updated regularly thereafter."
Risk-reduction counseling addresses specific ways the inmate can reduce the risk of becoming infected with HIV. If an inmate is already HIV infected, the goal of counseling is to reduce the risk of infecting others or becoming infected with a drug-resistant strain of HIV.
Education should focus on the use of latex barriers with all sexual activity. Condoms and dental dams are not available in most jails and prisons; nonetheless, the inmate should receive education regarding their proper use. The state prisons systems that provide condoms to inmates are those of Vermont and Mississippi. The larger metropolitan jails in New York City, such as Rikers Island, as well as those in Los Angeles, San Francisco, Philadelphia, and Washington, also provide condoms. Within the systems that allow condoms, inmates' ability to obtain them may be restricted (e.g., limited to one per week or available only via medical prescriptions or dispensing machines) (Sylla, 2007); see chapter Preventing HIV Transmission/Prevention with Positives.
No correctional system in the United States provides clean injection needles as a part of a prevention program (Sylla, 2007). However, inmates with a history of IDU should be educated about the risks of sharing needles and injection equipment, specifically the high risk of transmitting or acquiring HIV, HCV, and HBV. Inmates also should be counseled about the risks of sharing needles and other "sharps," such as those used for tattooing or body piercing. Substance abuse treatment should be provided when appropriate. Recovery from addiction often is a chronic process and relapses are common. In addition to substance abuse treatment, risk-reduction strategies should include planning for support after release from the correctional setting. For example, prior to release, inmates should be provided with information about needle exchange or clean needle access programs in their communities. These programs have proved to be quite effective in decreasing the rate of parenteral HIV transmission (CDC, 1999).
Furthermore, overdose prevention should be discussed with inmates leaving correctional systems. Using heroin after a period of abstinence, such as during incarceration, hospitalization, or drug treatment, is a major risk factor for overdose. Former inmates are at highest risk of overdose within the first 2 weeks after release (NYSDOH, 2008). Overdose risk is heightened when someone has a significant medical condition, such as HIV infection (Catania, 2007). The literature documents an increased number of correctional systems that consider including naloxone (Narcan) prescriptions in prerelease planning for inmates with a history of opiate addiction (Wakeman et al., 2009). Naloxone is a prescription medicine that reverses an overdose by blocking heroin (or other opioids) in the brain for 30-90 minutes (NYSDOH, 2008).
In correctional facilities, as in any setting, a consideration of HIV treatment must begin with educating the patient about the risks and benefits of treatment and the need to fully adhere to the entire regimen, and with an assessment of the patient's motivation to take ART (see chapter Antiretroviral Therapy).
Correctional facilities have two main methodologies for dispensing medications to those who are on ART. Each has advantages and disadvantages that can impact treatment adherence. These are directly observed therapy (DOT) and keep-on-person (KOP).
DOT is the system in which the inmate goes to the medical unit or pharmacy for all medication doses; dosing is observed by staff members. This system offers the advantage of more frequent interaction between the patient and the health care team, allowing for earlier identification of side effects and other issues. In general, patients have better medication adherence in this system, resulting in better control of HIV. For some inmates, however, the need for frequent visits to the medical unit or pharmacy may be a barrier to receiving proper treatment, particularly if they are housed at a distance from the medical unit. Another disadvantage of DOT is the potential loss of confidentiality, as many inmates feel that the frequency of dosing and the large number of pills they may take will reveal clues that they are HIV infected. In addition, this system puts inmates in a passive role in terms of medication treatment and does not foster self-sufficiency.
KOP is the system that allows inmates to keep their medications in their cells and take them independently. Monthly supplies are obtained at the medical unit or pharmacy. This system offers greater privacy and confidentiality regarding HIV status. It also allows inmates to develop self-sufficiency in managing medications, which may facilitate improved adherence upon release. However, as the KOP system involves less interaction with medical staff, problems with adherence can be more difficult to identify (Ruby, 2000). Problems with refills also can occur. For example, inmates usually must initiate the process for obtaining a refill. They may be told that a refill request was made too early or too late, which can result in delays in dispensing medications, and ultimately, treatment interruptions. In addition, many facilities do not have on-site pharmacies, but rely on local pharmacies, or a regional or central pharmacy in the state; this may further delay refills (NYSDOH, 2008).
In a study comparing DOT in HIV-infected inmates with KOP in nonincarcerated HIV-Infected patients receiving ART as part of a clinical trial, a higher percentage of DOT patients achieved undetectable viral loads compared with the KOP patients (85% vs. 50%) over a 48-week period (Fischl, 2001).
Adherence is one of the most important factors in determining the success or failure of ART. For the HIV-infected inmate starting ART, a number of issues can affect medication adherence. These include patient-related factors, factors related to systems of care (including the medication dispensing systems described above), and medication-related factors. The following are suggestions for supporting adherence to ART. (Also see chapter Adherence.)
It is estimated that 630,000 individuals are released from jails and prisons in the United States each year (Bonczar, 2003; Travis, 2005), and many of these individuals are HIV infected. Many will have difficulty managing even the most basic elements for successful reintegration into their communities. Inmates living with HIV face many challenges when reentering the community, such as finding stable housing, employment, adequate medication supply, follow-up medical care, and psychiatric and substance use treatment services (Hammett et al., 1997).
Ideally, the discharge process at the correctional facility will maximize the likelihood that the releasee will have continuous medical care. At the time of discharge from the correctional facility, all HIV-infected inmates should have a discharge plan that addresses the following:
As discussed, inmates in prisons generally serve longer sentences than do those incarcerated in jails, and they have a release date that is known in advance. Thus, HIV-Infected inmates in prisons may be more likely than HIV-infected inmates in jails to have treatment and discharge plans in place before their release. However, because the extent of discharge planning resources varies among correctional systems of care, it is important for care providers to discuss the scope of services their clients received while incarcerated to learn of any service gaps upon reentry to the community (NYSDOH, 2008).
The need to find housing often is the greatest challenge for an HIV-infected inmate leaving a correctional facility. In many correctional systems, inmates must document a physical address at which they intend to reside in order to be released. However, problems with housing availability, stability, and location can create significant stressors for an HIV-infected releasee and can compromise the likelihood that he or she will access HIV health care and adhere to an HIV medication regimen (NYSDOH, 2008).
HIV-infected individuals leaving correctional settings have a variety of experiences with ARV medication continuity. A short confinement period, for example, can prevent the development of a solid transitional plan. Jail inmates may be released without their medications and have no choice but to call or walk into community health centers or clinics for their medications and ongoing care. Being released from jail after business hours, such as on a Friday night, can result in treatment interruptions over the weekend (NYSDOH, 2008). Depending on the state system, HIV-infected inmates leaving prison are more likely than jail releasees to have a medication supply in hand when they reenter the community. For example, in the New York State Department of Correctional Services, inmates will leave prison with a 30-day supply of HIV medications as well as a prescription for another 30-day supply (NYSDOH, 2008).
For some individuals, interruptions in treatment occur during their time in jail or prison. For example, many inmates choose not to disclose their HIV infection while they are incarcerated. Particularly if the sentence is short, an inmate may feel it better not to mention HIV status and instead plan to resume taking medications upon release. Such treatment interruptions can result in adverse health outcomes (NYSDOH, 2008).
It is important that clinic staff and community-based organizations develop the capacity to work with clients in real time as they present for care in order to help them maintain continuity with their medications.
A number of HIV education resources for inmates and correctional health care providers are cited on the Albany Medical College website.
Table 1. HIV Testing in Prisons: Circumstances Under Which Prison Inmates Were Tested for HIV (by Jurisdiction)
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