Bloodborne Pathogens in Rhode Island: Is the Greatest Threat Inside or Out?

What is the risk of contracting a bloodborne disease while serving a prison term? At the Adult Correctional Institute (ACI) of Rhode Island, this question may be first in the minds of any of the 15,000 people who pass through ACI intake every year.

Two studies conducted by Grace Macalino, Ph.D., and her colleagues in the Brown University Department of Community Health may show that the real threat lies on the "outside" rather than in prison. This makes prisons and jails an essential intervention site for disease prevention in the "free" community.

The investigators have been conducting a blind sero-survey of all sentenced inmates entering the ACI during the last three years. Blood is drawn at intake by ACI for mandatory testing for HIV. For the first part of the study, half of the excess sera samples from testing are sent to off-site laboratories to blind-test for Hepatitis B and C (HBC and HCV), as well as Human T-Lymphotropic Virus (HTLV I/II). The other half of the sera samples (linked with demographic data) is reserved for incidence measurement. This part requires new blood samples from inmates who have continuously been at the ACI for a minimum of 11 months. At 11 months, inmates provide consent and are pre-counseled before being tested. Outreach workers return within a month to counsel and disclose results of the tests.

In the second study, Macalino and colleagues are measuring prevalence of the same bloodborne pathogens among recidivist men. The design is similar to an earlier study conducted with women inmates at ACI (Rich, J.D.; Macalino, G.E.; Dickinson, B.; Flanigan, T.; "CDC HIV Prevention Conference: Community Incidence and Intake Prevalence in a Population of Incarcerated Women," Atlanta, Ga., 1999). It estimates the "community" incidence of the tested infections by comparing the results of serial samples obtained at intake. Since inmates are often in the correctional system for short periods of time, Macalino attributes this incidence (i.e., negative on an earlier intake and positive on a later intake) to transmission in the community.

Preliminary results from 675 participants at intake found prevalence rates of 1.3 percent HIV, 19.8 percent HBV, 24.7 percent HCV and 1.2 percent HTLV I/II. Preliminary analysis found no seroconversion to reveal infection with HIV, HCV or HTLV I/II. Two cases of conversion to HBC infection were found. Data kept on injection drug use (IDU) among study participants found the highest rate of IDU among those patients with HIV (66.7 percent). For those with HBV, IDU was 38 percent; for HTLV I/II, 50 percent; and for HCV, 46 percent.

In the previous recidivist study, 2.4 percent of women at the ACI returned from the community infected with HIV. The numbers are much higher for hepatitis: 34 percent had HBV, and 36 percent had HCV. Nine women (2.2 percent) had HTLV I/II. Because of these results, colleagues of Macalino recently received a grant to evaluate the feasibility of hepatitis B vaccines in prison.

Macalino anticipates that transmission rates within the prison will be much less than on the outside. Any positive results will indicate to the ACI administration that education and prevention should be an essential component of their staff training and inmate health-education programs.

In an interview for the article, Macalino expressed appreciation for the ACI Medical Director Anne Spaulding who has recently stated that it is "better to know than not to know" the transmission rates within prison. Macalino said "My frustration is that you hope that you're going to make changes [but it is not a guarantee]. This is a high risk-population -- a hidden population. They are not going to be in most studies or accessing care, and there is a chronic history of feeling overlooked and mutual distrust." Yet, Macalino is optimistic that research is possible with corrections, provided that researchers establish open communication and awareness among all interested and involved staff and inmates.

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