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Providing Services to Inmates Living With HIV

August 2001

One state found that creating a system that took advantage of new therapies for HIV infection dramatically reduced the prison system's AIDS death rate. Many correctional facilities provide these therapies, but carrying out a comprehensive HIV treatment regimen for individual inmates may be difficult.

Correctional Facilities Have High Rates of HIV and AIDS

In 1999, 34,372 inmates in prisons and jails were HIV-positive and 9,723 had AIDS.

In 1999, 2.3 percent of state prison inmates, 0.9 percent of federal prison inmates, and 1.7 percent of jail inmates were infected with HIV. This rate of infection is 5-7 times higher than that of the general population. The AIDS rate is about 5 times that of the general population.

Although almost every state has at least one HIV-positive inmate, most of the HIV infections among inmates are concentrated in a small number of states. New York, Florida, and Texas house nearly half of all state prisons inmates who are living with HIV (in 1999, New York had 7,000 infected inmates, Florida had 2,633, and Texas had 2,520). These numbers reflect the relative prevalence of HIV among injection drug users (IDUs), the number of IDUs in those states, and the large number of injection and other drug users who are incarcerated.

Medical Treatment for Inmates With HIV/AIDS Reflects New Advances in Therapies

Since the mid-1990s, medical treatment for HIV/AIDS has been revolutionized by new therapies. These include protease inhibitors, combination antiretroviral therapies, and AZT and other anti-HIV medications for pregnant women. The new therapies offer the promise of long-term delay in HIV disease progression and long-term reduction of viral load, often to undetectable levels. This means longer survival with improved quality of life. These new drugs and therapeutic strategies are widely available in prisons and jails.

New York State has shown how the new therapies can help inmates.

During the early 1990s, about two-thirds of the deaths among New York State prison inmates were AIDS-related. Between 1990-1995, the annual rate averaged 36.4 per 10,000. Intense efforts to improve and standardize care in New York's 70 state prisons led to a dramatic decline in these rates: 26.3 per 10,000 inmates in 1996, 8.6 per 10,000 in 1997, and 6.1 per 10,000 in 1998.

To achieve this remarkable success, the New York corrections system made major changes in the medical care provided to inmates living with HIV. They:

Number of Deaths from AIDS in New York State Prisons 1995: 258 1996: 181 1997: 60 1998: 39

New therapies by themselves aren't enough.

Inmates with HIV disease often have other medical and psychosocial problems, including drug addiction and mental illness. As a result, a growing number of prisons and jails are incorporating new therapies into a continuum of care that is better able to deal with these complex cases.

This model includes:

Providing Care to Inmates With HIV Is Challenging

Achieving a balance between the facility's security concerns and the inmate's needs for privacy and high-quality care can be tricky.

Corrections' prime focus is maintaining secure facilities by maintaining control over the inmates. At the same time, inmates being treated for HIV want privacy and confidentiality. Both elements present difficulties. Escorting inmates to get medications, visit a doctor, or go to the infirmary is a security issue and may strain correctional staff resources. These same elements of care may make it difficult to keep the inmate's infection status confidential. If it becomes known, the inmate may be ostracized and harassed by staff or other inmates.

A prison or jail's strict work, program, and meal schedule also may make it hard for an inmate to adhere to the HIV treatment regimen. This is particularly true if the inmate is concerned about keeping his or her infection status confidential. Pharmacy monitoring systems need to be in place and working well to ensure that the inmate receives medications correctly.

Some correctional systems have implemented "keep-on-person" medication policies, in which inmates are allowed to keep a specified amount of medication with them so that they do not have to go to the pharmacy for each dose. In some settings, these policies help inmates maintain confidentiality, but in others they may pose more problems. Other issues must also be considered with "keep-on-person" policies. These include adherence to the treatment regimen (it is harder to monitor on a timely basis) and concerns about legal liability (will the facility be sued if a patient doesn't adhere to the regimen and develops clinical problems).

A final, and crucial, quality control issue is providing the means to keep corrections medical staff up to date with rapidly evolving best practices.

The complexity of HIV care and the nature of inmate patients also pose challenges.

Medication costs are high. Inmates may be reluctant to seek testing and treatment because of fear, denial, or mistrust. The competence of correctional medical staff may be uneven. HIV treatment practices may not be uniform. All of these factors can limit a system's ability to provide high-quality care to drug-using inmates infected with HIV.

Patient characteristics and environmental factors have to be carefully weighed before beginning therapy:

Another challenge is developing long-term, trusting relationships between inmate patients and clinicians. Providers must:

Innovative Programs and Strategies Are Addressing the Problem

Prisons and jails across the country are working to meet these challenges and improve the care they give HIV-infected inmates. Here are a few examples of innovative programs:

To Learn More About This Topic

Read the overview fact sheet in this series on drug users and the criminal justice system -- "Drug Users, HIV, and the Criminal Justice System." It provides basic background information, links to the other fact sheets in this series, and links to other useful information (both print and internet).

Check out these sources of information:

Centers for Disease Control and Prevention. Decrease in AIDS-related mortality in a state correctional system -- New York, 1995-1998. Morbidity and Mortality Weekly Report 1999;47(51/52):1115-1117.

Flanigan T.P., Rich J.D., Spaulding A. HIV care among incarcerated persons: a missed opportunity. AIDS 1999;13:2475-2476.

Hammett T.M., Harmon P., Maruschak L.M. 1996-1997 update: HIV/AIDS, STDs, and TB in correctional facilities. Issues and Practices in Criminal Justice. Washington (DC): U.S. Department of Justice, National Institute of Justice; July, 1999. NCJ 176344.

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