Two Epidemics: Incarceration and HIV
How the Criminal Justice System Has Played a Role in the HIV Epidemic
Care for HIV in Prisons and Jails
Additionally, there is a sense among providers of HIV care in corrections that inmates may do better than free-world peers in terms of health outcomes due to structural factors that can lead to access to better nutrition, opportunities to exercise, limited or no access to substances of abuse, and close monitoring of adherence to medication and laboratory values.
The situation in jails may not always be so rosy. Unlike prison systems, which are run by the Federal or state governments, counties, municipalities, and towns fund jails. Unless they are one of the mega-jails like those in Chicago and Los Angeles, budgets are typically small and there are usually few or no staff with HIV expertise. The chaos of jails, where stays can be as short as a few hours or as long as months to even years, further challenges HIV care. Those entering jail without their medications can expect a lapse in dosing. With an average stay of a couple of days, there is also limited time to provide screening, treatment, and linkage to community care.
Transition to the Community
In the cascade of HIV care that extends from finding those who are infected to establishing care, retaining patients in care, and suppressing viral load long term, each point in this spectrum is an opportunity for those in corrections. As described above, screening for HIV is common in correctional settings and quality care is provided, especially in prisons and larger jails. The weakest link of this chain has been maintenance of the benefits of that care following release. It is ironic that incarcerated people living with HIV fare better, in terms of metrics of physical health (weight, viral load, and CD4 cell count), than those living with the virus in the communities from which they came. With release, much of the available data paints a bleak picture of unfilled ART prescriptions, missed medical appointments, and a return to behaviors that often lead to a return to a jail or prison.11 Much work has gone into identifying transitioning strategies that are effective at maintaining HIV care and service post-release. The model of HIV transition programming was pioneered in Rhode Island and involves pre- and post-release intensive case management.12 Other states have adapted this approach with reported success. One trial conducted in North Carolina found that among 89 HIV-positive inmates, those randomized to a case management program, modeled on the Rhode Island program, that spanned the periods before and after release had no more success in making doctor appointments post-release than those assigned to routine discharge planning by the prison. In all, about half of the former inmates in both study arms saw a medical provider within a month of release, at which time their prison-provided HIV medications would run out.13
Innovative approaches to linkage to care are being explored and the National Institutes of Health (NIH) and others have been funding efforts to test these in order to identify evidence-based models that can be implemented. Failure to link those under correctional supervision to ongoing HIV care would bode poorly for the broader effort to increase the proportion of all HIV-positive people with undetectable viral loads from its current 28%.
Incarceration is one of a number of forces that have shaped the domestic HIV epidemic. The massive imprisonment of the members of populations that bear a disproportionate burden of HIV has significantly perpetuated the spread of the virus and it is unlikely we will see an overhaul of the legal system any time soon. The sentencing laws that feed a gluttonous criminal justice system with inmates are likely to remain, as will policing policies that lead to the arrest of people of color and those living in poverty. Few people under correctional supervision will receive the substance abuse and mental health care they need. So, behind the walls of our correctional facilities, the virus will remain.
David Alain Wohl, M.D., is an Associate Professor of Infectious Diseases and Co-Director of the AIDS Clinical Trials Unit at the University of North Carolina. Metabolic complications associated with HIV infection and the nexus between HIV and incarceration are his major areas of research interest. His e-mail address is email@example.com.
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