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:
- made sure antiretroviral medications and medications for opportunistic infections were available throughout the system;
- established a work group in collaboration with the New York Department of Health to develop and regularly update HIV treatment guidelines so that they would be consistent with nationally recognized best practices;
- began quarterly live satellite videoteleconferences for prison medical care staff to provide training and continuing education about HIV treatment;
- developed new medical record flow sheets to monitor care given to HIV-infected inmates; and
- used the pharmacy system to monitor medications dispensed and identify cases of inappropriate care, and notified other members of the health care team for review and action.
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:
- screening to identify medical as well as psychosocial problems, such as infectious and chronic diseases, high-risk drug-use and sexual behaviors, mental illness, and violence; among women inmates, screening helps to identify pregnancy and reproductive problems;
- substance abuse treatment, including short- and long-term treatment and therapeutic community approaches;
- case management, in which one person coordinates and is responsible for the inmate's overall treatment plan;
- psychosocial services, such as one-on-one counseling or support groups led by peers or AIDS service organizations;
- hospice care for terminally ill inmates;
- discharge planning that helps inmates return successfully to their communities; and
- efforts to ensure continuity of care and community linkages, so that organizations provide services to the inmate and continue to work with that inmate after release.
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:
- will the inmate choose and be able to adhere to the regimen?
- will the inmate's drug addiction interfere?
- does the inmate have viral hepatitis or other infectious, mental illness, or chronic health conditions; if so, will this diminish the effectiveness of therapy?
Another challenge is developing long-term, trusting relationships between inmate patients and clinicians. Providers must:
- deal with inmate's mistrust of authority and unfamiliarity with health care providers and services (many inmates have had little or no previous contact with health care); and
- be clear and open about the reality of antiretroviral therapy and the consequences of missing doses, even for a few days.
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:
- Hampden County Correctional Center (HCCC)
This Massachusetts facility conducts comprehensive screening for all inmates. Within 10 days of arrival, each inmate is screened for infectious and chronic diseases, substance use, high-risk sexual behaviors, and violence. Every day, registered nurses check on the health and medical needs of inmates in each of the facility's housing units. They also work closely with security to make sure that inmates receive prompt medical and health care. HCCC has developed a unique public health model for corrections. This continuity-of-care program links four community clinics to the inmates at the jail by zip code. After release, the former inmate can then receive services from the same providers that he or she used inside the jail. The program is comprehensive and includes mental health care, substance abuse treatment, job skills training, and parenting classes. For more information, contact Karina Krane, (email@example.com), CDC/NCHSTP/OD/PSO, Corrections and Substance Abuse Unit, 1600 Clifton Road, NE, Mail Stop E-07, Atlanta, GA 30333, 404/639-8011.
- Empowerment Through HIV/AIDS Information, Community and Services (ETHICS)
The Fortune Society, a New York-based organization that provides support services for former inmates, established this program to offer risk reduction, treatment, counseling, case management, and support services for HIV-positive inmates. ETHICS counselors visit correctional facilities across the state to prepare discharge plans for inmates living with HIV who are nearing their release dates. For more information, visit www.fortunesociety.org.
- AIDS Counseling and Trust Program, Avoyelles Correctional Center
This peer-based Louisiana program provides group psychosocial support for inmates with HIV or AIDS. At California's San Quentin prison, peer educators living with HIV offer counseling support to other inmates recently diagnosed with HIV. This counseling covers a range of issues, including helping inmates determine whether to disclose their HIV status, medical and psychosocial needs, and the system's policies for housing and treating inmates with HIV/AIDS. For more information on Avoyelles, contact Shirley Washington, Director of Mental Health, Avoyelles Correctional Center, 1630 Prison Rd., Cotton Port, LA 71327, 318/876-2891. For more information on San Quentin, visit www.centerforce.org.
- Federal Bureau of Prisons' Medical Center Hospice, Springfield, Missouri
This hospice has one 20-bed ward for AIDS patients and a second 20-bed ward for cancer patients. Community-based organizations trained and worked closely with security and health care staff to establish the program. Inmate volunteers are heavily involved and receive substantial training in counseling and supportive services. The Stiles Unit of the Texas Department of Criminal Justice, Beaumont, Texas, established a hospice in 1997. Inmate volunteers are an essential component of this program as well. For more information about the Missouri hospice, contact MCFP Springfield, P.O. Box 4000, 1900 West Sunshine, Springfield, Missouri 65801-4000, 417/862-7041. For more information about the Stiles Unit, contact Dr. David Paar, University of Texas Medical Branch, Galveston, TX, 409/747-0243. For more information on other corrections-based hospice programs, visit www.graceprojects.org.
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. www.ncjrs.org/pdffiles1/176344.pdf.