Important note: Information in this article was accurate in December 1999. The state of the art may have changed since the publication date. | The online version of HEPP News displays the main article only, to view the entire newsletter download the following PDF:
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Correctional health care providers manage the care of a large number of individuals with communicable diseases in the U.S. A major portion of the nation’s Hepatitis B&C, HIV, STD and TB infected patients pass through prison and jail doors (see Heppigram). Moreover, many of these individuals also have other co-morbid conditions such as psychiatric illnesses, substance abuse and chronic medical conditions that thwart an integrated care approach for these patients in community settings.
Within correctional populations, moreover, women and people of color are much more heavily affected than men and Caucasian inmates. For instance, in most geographical areas, the prevalence of HIV among women prisoners is twice that found among male prisoners. Similar to findings in community-derived studies, people of color are disproportionately affected by all communicable diseases, however this phenomenon is magnified within our correctional system.
The disproportionately high burden of disease in correctional institutions identifies an extremely important opportunity to intervene aggressively with prevention and treatment programs. Such interventions promise to benefit not only inmates themselves and their partners and families, but also the broader public health. Contrary to popular perception, correctional facilities are a part of the community. The vast majority of inmates return to our streets and neighborhoods --more than 8 million are released from jails and prisons per year -- where they may either continue to place themselves and others at risk for infectious disease, or help to halt the linked epidemics of disease in the poor, under-served communities which are home to most of them.
The nation's correctional systems, public health departments, and community based providers have not yet exploited this important public health opportunity, except in a minority of instances. While there have been improvements in recent years and many correctional administrators appear to be taking an increasingly enlightened view of health services and disease prevention, there remains considerable room for improvement. Results of a series of national surveys of HIV/AIDS, STDs, and TB in correctional facilities elucidate the key areas of need.1 Progress and remaining needs in several key areas are summarized below.
The vast majority of correctional inmates have substance abuse problems. Successful treatment and achievement of permanent sobriety normally require multiple and prolonged treatment episodes. Periods of incarceration offer important opportunities to provide substance abuse treatment and thereby increase ex-offenders' chances of resisting relapse and avoiding recidivism.
Nevertheless, statistics from the Center on Addiction and Substance Abuse (CASA) at Columbia University reveal a serious and growing gap between the number of inmates needing drug treatment and those receiving treatment. In 1996, CASA estimated, there were 840,000 inmates in need of treatment but only 150,000 (18%) in treatment in correctional facilities.2 Current drug treatment programs are rarely offered to individuals in jails or who are serving short sentences.
The 1996-1997 CDC/NIJ survey was conducted just as the new antiretroviral therapies were becoming widely available. The survey included only a limited number of questions about HIV treatment. The next round of the survey will examine treatment in greater detail. The responses to these questions indicate that the vast majority of state/federal and city/county correctional systems made protease inhibitors (90%, 93%) and combination therapy (90%, 90%) available to inmates. However, these results do not demonstrate that these therapies were provided to all inmates who should have been receiving them on an uninterrupted basis. Indeed, there is anecdotal evidence to suggest that there may be substantial problems with continuously available medications in at least some correctional facilities. Nor do the survey results demonstrate that inmates were being prescribed the most appropriate combination therapies. A recent study by Stadtlanders Pharmacy, which provides pharmacy services to many correctional systems, found that 52% of about 3,500 inmates whose pharmacy records were examined were receiving either "preferred" (45%) or "alternative" (7%) combinations based on currently accepted federal guidelines and more than one third were receiving either "not generally recommended' (28%) or "not recommended" (8%) regimens.3 There is clearly room for improvement in compliance with the DHHS Guidelines in treating HIV-infected inmates.
As of 1997, about two-thirds of correctional facilities in the U.S. were providing instructor-led HIV/AIDS education, the most basic ingredient of an education and prevention program. Moreover, while most HIV education programs covered basic information on the disease, far fewer included practical risk reduction information, such as strategies for negotiating safer sex and methods of safer injection. Only about a third were providing more intensive multi-session HIV prevention counseling programs, the type of program probably needed to help inmates initiate and sustain the difficult behavioral changes required to reduce their risks of acquiring or transmitting HIV and other infectious diseases. Finally, only 13% of prisons and 3% of jails were offering peer-based programs in which inmates provide education and prevention services to other inmates. This represents an extremely under utilized but promising and potentially very cost-effective method of providing these services.
One definition of a "comprehensive" HIV/AIDS education and prevention program is that all of the following are provided in all of a correctional system's facilities: instructor-led education; HIV pre- and post-test counseling; peer-led programs; and multi-session prevention counseling. By this definition, only 10% of state and federal prison systems and only 5% of the 50 largest jail systems in the U.S. had a comprehensive program in 1997.
Beyond this, some may consider a "comprehensive" program to include provision of the means necessary to effectuate HIV risk reduction. Perhaps the most commonly advocated such policy is making condoms available to inmates. However, political considerations have made it extremely difficult for correctional administrators to permit condom distribution even though it is hard to deny that inmates engage in sexual activity within correctional facilities. As a consequence, only two state prison systems (Vermont and Mississippi) and four city/county jail systems (District of Columbia, New York City, Philadelphia, and San Francisco) make condoms available to inmates. This number has not changed since about 1990.
All inmates need more and better services to help them make successful transitions to the community, resist relapse to substance use, and avoid a return to high-risk behavior and criminal activity. This is especially true for inmates with HIV disease, who might benefit from a range of services including continuity of health care, stable housing, drug treatment, assistance gaining eligibility for benefits, and job training and placement services. Results of the 1996-1997 CDC/NIJ survey show that 92% of state/federal prison systems and 76% of the largest city/county jail systems were providing at least some discharge planning for inmates with HIV and AIDS. However, further analysis of the survey data reveals that while large percentages of systems were making referrals for HIV medications (82% of state/federal systems and 66% of city/county systems), drug treatment (75% and 63%), and for Medicaid and related benefits (78%, 56%), much smaller percentages were actually making appointments for inmates to receive these services in the community (31% of state/federal systems and 27% of city/county systems for HIV medications, 22% and 24% for drug treatment, and 35% and 29% for benefits). Making a referral can involve simply giving an individual a list of agencies where they might apply for services with no further assistance in actually accessing the services. Making an appointment for a soon-to-be-released inmate with a specific service provider by no means guarantees that the person will show up and receive the services, but it represents an additional step in the process. Geography can be a significant obstacle to achieving a successful transition. Exemplary programs in small geographic locations in Rhode Island4 and Hampden County, Massachusetts5 successfully provide continuity of services by having local clinicians provide care both within and outside of the correctional facility. Successful models in moderate-sized geographic areas, such as in Connecticut,6 have adopted a transitional case management model to overcome problems associated with geography. Such programs are beginning to demonstrate salutary effects on clinical outcomes as well as on recidivism rates of inmates participating in them.
Correctional systems cannot be expected to take full responsibility for addressing the serious public health problem or exploiting the important public health opportunity represented by the related epidemics of infectious diseases in correctional facilities. Public health departments, community-based organizations such as AIDS service organizations and community-based substance abuse treatment agencies, and other community-based providers have critical roles to play as well. There is increasing collaboration among these entities, but there remain far more opportunities and needs for working together. There are differences in philosophy and priority among these organizations, to be sure, but there are also growing examples of overcoming the barriers and forging successful collaborations to provide needed services to inmates and releasees as well as to benefit the public health and serve the interests of society at large.7
1.The most recent report is Hammett TM, Maruschak L, Harmon P. 1996-1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities (Washington, July 1999) NCJ 176344.pdf
2.National Center on Addiction and Substance Abuse. Behind Bars: Substance Abuse and America's Prison Population (New York, 1998), p. 11
3. Gajewski-Verbanac l, Lewis SM, Chrisman C, Rihn T, Hartman T, Vanscoy GJ. Retrospective analysis of antiretroviral treatment to guidelines in a national correctional base. Abstract #600. Abstracts of the 39th Interscience Conference on Antimicrobial Agents and Chemotherapy, San Francisco, September 26-29, 1999.
4. Vigilante KC, Flynn MM, Affleck PC, Stunkle JC, Merriman NA, Flanigan TP, Mitty JA, Rich JD. "Reduction in recidivism of incarcerated women through primary care, peer counseling, and discharge planning.", J Womens Health. 1999 Apr;8(3):409-15.
5.Conklin TJ, Lincoln T, Flanigan TP. "A public health model to connect correctional health care with communities.", Am J Public Health. 1998 Aug;88(8):1249-50.
6.Altice FL, Khoshnood K. Transitional Case Management as a Strategy for Linking HIV-Infected Prisoners to Community Health and Social Services (Project TLC). [monograph]. Connecticut Department of Public Health, 1997
7.Hammett TM. Public health/corrections collaborations: prevention and treatment of HIV/AIDS, STDs, and TB (Washington: National Institute of Justice and Centers for Disease Control and Prevention, July 1998). 169590.pdf
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©1997,1998,1999,2000. The recently formed HIV Education Prison Project (HEPP) is a medical education program that targets a growing population, inmates in correctional facilities, that has been underserved in HIV care. It is part of the Brown University AIDS Program. Permission to use and reproduce portions of this newsletter is hereby granted provided that author and publication are fully credited and both copyright and permission notice appear with reprinted material. Inquiries may be directed to heppnews@brown.edu. Website: HIV Education Prison Project.
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