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Two Epidemics: Incarceration and HIV

How the Criminal Justice System Has Played a Role in the HIV Epidemic

May/June 2012

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Care for HIV in Prisons and Jails


HIV mortality rates in prisons have plummeted, miroring survival trends seen in the free world, attributed to partnerships with academic centers and health departments.

The confluence of HIV and incarceration has forced jails and prisons to provide medical care and services to infected inmates. Prisons provide HIV therapy to inmates at no cost and monitor viral load and CD4 cell counts. All indicators suggest HIV care in prisons is good, with the majority of HIV-positive individuals behind bars achieving undetectable HIV viral loads.10 Further, rates of death due to HIV have plummeted in prisons over the past several years, mirroring the survival trends seen in the free world.2 Much of this success can be attributed to partnerships between corrections, academic centers, and departments of health, as well as the hiring of correctional health care providers with HIV expertise.

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


  1. The Pew Center on the States. One in 100: Behind Bars in America 2008. 2008.
  2. Maruschak, L.M. & R. Beavers. HIV in Prisons, 2007-08. NCJ 228307. Washington, D.C.: U.S. Department of Justice, Bureau of Justice Statistics, 2009.
  3. Spaulding AC, Seals RM, Page MJ, Brzozowski AK, Rhodes W, Hammett TM. HIV/AIDS among inmates of, and releasees from, US correctional facilities, 2006: declining share of epidemic but persistent public health opportunity. PLoS One 4(11): e7558. doi:10.1371/journal.pone.0007558.
  4. Macalino GE, Vlahov D, Sanford-Colby S, Patel S, Sabin K, Salas C, Rich JD. Prevalence and incidence of HIV, hepatitis B virus, and hepatitis C virus infections among males in Rhode Island prisons. Am J Public Health. 2004 Jul;94(7):1218-23.
  5. Jafa K, McElroy P, Fitzpatrick L, Borkowf CB, Macgowan R, Margolis A, Robbins K, Youngpairoj AS, Stratford D, Greenberg A, Taussig J, Shouse RL, Lamarre M, McLellan-Lemal E, Heneine W, Sullivan PS.HIV transmission in a state prison system, 1988-2005. PLoS One. 2009;4(5):e5416
  6. Khan MR, Behrend L, Adimora AA, Weir SS, White BL, Wohl DA. Dissolution of primary intimate relationships during incarceration and implications for post-release HIV transmission. J Urban Health. 2011; 88 (2):365-75.
  7. Khan MR, Behrend L, Adimora AA, Weir SS, Tisdale C, Wohl DA. Dissolution of primary intimate relationships during incarceration and associations with post-release STI/HIV risk behavior in a Southeastern city. 2011; Sex Transm Dis. 38 (1):43-7.
  8. Seal DW, Margolis AD, Sosman J, Kacanek D, Binson D; Project START Study Group. HIV and STD risk behavior among 18- to 25-year-old men released from U.S. prisons: provider perspectives. AIDS Behav. 2003 Jun;7(2):131-41.
  9. Stephenson BL, Wohl DA, McKaig R, Golin CE, Shain L, Adamian M, Emrick C, Strauss RP, Fogel C, Kaplan AH.Sexual behaviours of HIV-seropositive men and women following release from prison. Int J STD AIDS. 2006 Feb;17(2):103-8.
  10. Springer SA, Pesanti E, Hodges J, Macura T, Doros G, Altice FL. Effectiveness of antiretroviral therapy among HIV-infected prisoners: reincarceration and the lack of sustained benefit after release to the community. Clin Infect Dis. 2004 Jun 15;38(12):1754-60
  11. Baillargeon J, Giordano TP, Rich JD, Wu ZH, Wells K, Pollock BH, et al. Accessing antiretroviral therapy following release from prison. JAMA. 2009;301(8):848-57.
  12. Rich JD, Holmes L, Salas C, Macalino G, Davis D, Ryczek J, Flanigan T.Successful linkage of medical care and community services for HIV-positive offenders being released from prison. J Urban Health. 2001 Jun;78(2):279-89.
  13. Wohl DA, Scheyett A, Golin CE, White B, Matuszewski J, Bowling M, Smith P, Duffin F, Rosen D, Kaplan A, Earp J. Intensive Case Management Before and After Prison Release is No More Effective Than Comprehensive Pre-Release Discharge Planning in Linking HIV-Infected Prisoners to Care: A Randomized Trial. AIDS Behav. 2011 Feb;15(2):356-64

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This article was provided by Positively Aware. It is a part of the publication Positively Aware. Visit Positively Aware's website to find out more about the publication.
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