HIV Care in Correctional Settings

Background

Caring for HIV-infected patients who are incarcerated is a complex and challenging task. For many of these patients, the prison health service provides their first opportunity for access to consistent health care. This chapter will discuss some of the issues relevant to the HIV-infected population in correctional settings.

Jail vs. Prison Settings

It is important to note the distinction between "jail" and "prison" custodial settings. These terms are often used interchangeably, but doing so can create confusion for health care providers, as the services that an inmate receives while incarcerated may differ greatly according to the type of facility (NYSDOH, 2008).

Jails are locally operated, or managed, institutions that detain individuals who typically are serving short sentences of 1 year or less. They also hold individuals who are awaiting arraignment, trial, or sentencing, or those who have violated terms of their parole (Harrison and Beck, 2006). Because inmates who are detained in jail settings have shorter confinement terms, providers often face time constraints in establishing longer-term treatment plans for chronic conditions such as HIV/AIDS, and for substance use and mental health problems. Opportunities for inmate education also may be more limited. In addition, because jail inmates often are released within days, weeks, or months after initial confinement, establishing continuity of health care may be challenging for providers and administrators (Okie, 2007).

Prisons, in contrast, are operated by state governments or the Federal Bureau of Prisons. Prisons generally detain people who have been convicted of state or federal felonies and are sentenced to terms of longer than 1 year (Harrison and Beck, 2006). The nature of a person's crime, namely a state or federal offense, will dictate the type of prison in which he or she will be detained. The length of sentences for inmates in state or federal custody is longer than those for persons serving time in jail, and prison inmates typically have a firm release date in advance. As a result, HIV-infected inmates released from prison may be more likely to have treatment and discharge plans in place (NYSDOH, 2008).

Note that these characteristics may differ from prison to prison and jail to jail.

Epidemiology

Inmates continue to be disproportionately affected by the epidemic, with the estimated overall rate of AIDS among prison inmates at more than 2.5 times the rate in the United States general population. In 2006, there were 21,980 HIV-infected inmates in federal or state prisons, according to a report from the Bureau of Justice Statistics, and there are many more in jails. With the advent of effective combination antiretroviral therapy (ART), AIDS-related mortality as a percent of total deaths in state prisons decreased significantly between 1995 and 2006, from 34.2% to 4.6% (Maruschak, 2006).

Inmates who have drug- or sex-related illegal behaviors that lead to incarceration often are at high risk of becoming infected with HIV, hepatitis C virus (HCV), and other pathogens through these behaviors. Their risk factors may include unsafe substance use behaviors, such as sharing syringes and other injection equipment, and high-risk sexual practices, such as having multiple sex partners or unprotected sex. Many inmates also may have conditions that increase the risk of HIV transmission or acquisition, such as untreated sexually transmitted diseases (STDs).

The prevalences of chronic viral hepatitis and tuberculosis are much higher among incarcerated persons than among the general public. Depending on the prison system, 13% to 54% of inmates are infected with HCV (Cassidy, 2003). The incidence is 10 times higher among inmates than among non-inmates and is 33% higher among women than among men (Nerenberg et al., 2002). The Centers for Disease Control and Prevention (CDC) recommends that all incoming inmates be screened for HCV, and those who are infected should be evaluated for liver damage and the need for treatment (Cassidy, 2003). Chronic hepatitis B virus (HBV) infection and tuberculosis also are substantially more common among the incarcerated population than among the general public. The presence of any of these conditions should prompt HIV testing (Nicodemus and Paris, 2002).

Incarcerated Women

Women account for almost 7% of the prison population in the United States (West and Sobol, 2009). The HIV epidemic in the United States increasingly affects women of color, and this trend is reflected in HIV rates among the incarcerated. In terms of total numbers, there are more males than females with HIV/AIDS in state and federal prisons nationally (19,809 and 2,135, respectively). However, the percentage of female inmates with known HIV infection in these settings is higher than that for incarcerated males (2.4% and 1.6 percent, respectively) (Maruschak, 2006).

In many cases, incarcerated women are low-income and have limited education and sporadic employment histories. Compared with men, they are less likely to be incarcerated for a violent crime, and more likely to be incarcerated for a drug or property offense. Women's property crimes often are the result of poverty and substance-use histories (National Institute of Corrections, 2003). Numerous studies have shown that the behaviors that lead to incarceration also put women at increased risk of HIV infection. Risk factors that are present in abundance among female inmates include the following (Hammett and Drachman-Jones, 2006):

  • History of childhood sexual abuse and neglect
  • History of sex work, with increased frequency of forced, unprotected sex
  • High rates of STDs
  • High rates of mental illness
  • History of injection drug use (IDU) or sex partners with IDU history
  • Poverty

Among all women entering a correctional facility, 10% are pregnant (De Groot and Cu Uvin, 2005). These women should be offered HIV testing, and HIV-infected pregnant women should be offered combination ART immediately to prevent perinatal HIV transmission. Many incarcerated women will receive their first gynecologic care in prison. Because the incidence of cervical cancer is higher among women with HIV, referrals for colposcopy should be made for any HIV-infected woman with an abnormal Papanicolaou test result.

Testing and Prevention

The correctional facility is an ideal location for identifying individuals already infected with HIV, HCV, or HBV, and for education interventions that are geared to prevent infection among those at highest risk of these acquiring diseases. For many adults, the prison or jail setting is a rare potential point of contact with the health care system, making it an important avenue for HIV testing and linkage to care. It also may be an effective setting in which to initiate and maintain individuals on ART.

Inmates commonly are hesitant to be tested for HIV because they fear a positive diagnosis and because of the potential stigma involved. They often lack accurate information about HIV, including awareness of behaviors that may have put them at risk and knowledge of means for protecting themselves from becoming infected. Health care providers in correctional settings are in a key position to evaluate inmates for HIV risk factors, to offer HIV testing, and to educate and counsel this high-risk group about HIV.

HIV testing policies in correctional facilities vary from state to state and among local, state, and federal penal institutions. Depending on the setting, policies may require testing of inmates upon entry, upon release, or both, but as of 2010 more than 50% of state prison systems did not require HIV testing at any point. Some prisons may do HIV testing based on clinical indication or risk exposure during incarceration, and this may be voluntary or mandatory. Most prison systems do provide HIV testing for inmates who request it. See Table 1 for an overview of the circumstances under which inmates in state prisons were tested for HIV in 2006 (Maruschak, 2006).

In high-risk settings such as correctional facilities, routine, voluntary HIV testing has been shown to be cost-effective and clinically advantageous (Paltiel et al., 2005). The CDC supports universal opt-out HIV screening in prisons and jails and has produced the HIV Testing Implementation Guidance for Correctional Settings . This document serves as a guide for individual institutions in determining and establishing the most appropriate testing strategy for their settings, presents the components of such a testing program, and explains obstacles that may be encountered in the implementation process. It also provides information regarding the following:

  • Background statistics on HIV in correctional facilities
  • Inmate privacy and confidentiality
  • Opt-out HIV screening in correctional medical clinics
  • HIV testing procedures
  • HIV case reporting

Testing inmates for HIV prior to their release is a critical aspect not only of individuals' own health care needs but also of preventing transmission of HIV to others. Knowledge of their HIV status affects people's HIV risk behaviors: Studies have shown that, after learning they are infected with HIV, many persons take measures to reduce the risk of transmitting HIV to others.

Risk-Reduction Education

Given the high HIV seroprevalence among inmates, the reentry of inmates into the community presents a danger of spreading HIV and other infectious diseases, and it is a public health concern. Thus, inmates need adequate HIV prevention counseling before release, both to protect themselves and to decrease the likelihood of infecting others in their communities with HIV (Gaiter and Doll, 1996). The World Health Organization (WHO) has stated: "All inmates and correctional staff and officers should be provided with education concerning transmission, prevention, treatment, and management of HIV infection. For inmates, this information should be provided at intake and updated regularly thereafter."

Risk-reduction counseling addresses specific ways the inmate can reduce the risk of becoming infected with HIV. If an inmate is already HIV infected, the goal of counseling is to reduce the risk of infecting others or becoming infected with a drug-resistant strain of HIV.

Education should include information about the efficacy of ART in decreasing risk of HIV transmission. In addition, it should focus on the use of latex barriers with all sexual activity. Condoms and dental dams are not available in most jails and prisons; nonetheless, the inmate should receive education regarding their proper use. The state prisons systems that provide condoms to inmates are those of Vermont and Mississippi. The larger metropolitan jails in New York City, such as Rikers Island, as well as those in Los Angeles, San Francisco, Philadelphia, and Washington, also provide condoms. Within the systems that allow condoms, inmates' ability to obtain them may be restricted (e.g., limited to one per week or available only via medical prescriptions or dispensing machines) (Sylla, 2007); see chapter Preventing HIV Transmission/Prevention with Positives.

No correctional system in the United States provides clean injection needles as a part of a prevention program (Sylla, 2007). However, inmates with a history of IDU should be educated about the risks of sharing needles and injection equipment, specifically the high risk of transmitting or acquiring HIV, HCV, and HBV. Inmates also should be counseled about the risks of sharing needles and other "sharps," such as those used for tattooing or body piercing. Substance abuse treatment should be provided when appropriate. Recovery from addiction often is a chronic process and relapses are common. In addition to substance abuse treatment, risk-reduction strategies should include planning for support after release from the correctional setting. For example, prior to release, inmates should be provided with information about syringe exchange or clean needle access programs in their communities. These programs have proved to be quite effective in decreasing the rate of parenteral HIV transmission (CDC, 1999).

Furthermore, overdose prevention should be discussed with inmates leaving correctional systems. Using heroin after a period of abstinence, such as during incarceration, hospitalization, or drug treatment, is a major risk factor for overdose. Former inmates are at highest risk of overdose within the first 2 weeks after release (NYSDOH, 2008). Overdose risk is heightened when someone has a significant medical condition, such as HIV infection (Catania, 2007). The literature documents an increased number of correctional systems that consider including naloxone (Narcan) prescriptions in prerelease planning for inmates with a history of opiate addiction (Wakeman et al., 2009). Naloxone is a prescription medicine that reverses an overdose by blocking heroin (or other opioids) in the brain for 30-90 minutes (NYSDOH, 2008).

Antiretroviral Therapy in Correctional Facilities

In correctional facilities, as in any setting, a consideration of HIV treatment must begin with educating the patient about the benefits and risks of treatment and the need to fully adhere to the entire regimen, and with an assessment of the patient's motivation to take ART (see chapter Antiretroviral Therapy).

Correctional facilities have two main methodologies for dispensing medications to those who are on ART. Each has advantages and disadvantages that can impact treatment adherence. These are directly observed therapy (DOT) and keep-on-person (KOP).

Directly Observed Therapy

DOT is the system in which the inmate goes to the medical unit or pharmacy for all medication doses; dosing is observed by staff members. This system offers the advantage of more frequent interaction between the patient and the health care team, allowing for earlier identification of side effects and other issues. In general, patients have better medication adherence in this system, resulting in better control of HIV. For some inmates, however, the need for frequent visits to the medical unit or pharmacy may be a barrier to receiving proper treatment, particularly if they are housed at a distance from the medical unit. Another disadvantage of DOT is the potential loss of confidentiality, as many inmates feel that the frequency of dosing and the large number of pills they may take will reveal clues that they are HIV infected. In addition, this system puts inmates in a passive role in terms of medication treatment and does not foster self-sufficiency.

Keep-on-Person

KOP is the system that allows inmates to keep their medications in their cells and take them independently. Monthly supplies are obtained at the medical unit or pharmacy. This system offers greater privacy and confidentiality regarding HIV status. It also allows inmates to develop self-sufficiency in managing medications, which may facilitate improved adherence upon release. However, as the KOP system involves less interaction with medical staff, problems with adherence can be more difficult to identify (Ruby, 2000). Problems with refills also can occur. For example, inmates usually must initiate the process for obtaining a refill. They may be told that a refill request was made too early or too late, which can result in delays in dispensing medications, and ultimately, treatment interruptions. In addition, many facilities do not have on-site pharmacies, but rely on local pharmacies, or a regional or central pharmacy in the state; this may further delay refills (NYSDOH, 2008).

In a study comparing DOT in HIV-infected inmates with KOP in nonincarcerated HIV-Infected patients receiving ART as part of a clinical trial, a higher percentage of DOT patients achieved undetectable viral loads compared with the KOP patients (85% vs. 50%) over a 48-week period (Fischl, 2001).

Adherence

Adherence is one of the most important factors in determining the success or failure of ART. For the HIV-infected inmate starting ART, a number of issues can affect medication adherence. These include patient-related factors, factors related to systems of care (including the medication dispensing systems described above), and medication-related factors. The following are suggestions for supporting adherence to ART. (Also see chapter Adherence.)

Patient-Related Factors

  • Correct misconceptions about HIV and ART that are common among inmates and could affect adherence adversely. Inmates should be educated about the disease process and the role of the medications, along with the benefits and risks of taking ART.
  • Use teaching tools that are appropriate in terms of language and reading level. Illiteracy and low-level reading ability are common among inmates. Diagrams and videos may be more effective than reading-intensive material in some cases. Basic HIV education prior to initiation of ART should include the following topics:
  • How the medications work
  • Potential benefits in terms of personal health and reducing transmission risk
  • Consequences of nonadherence
  • Names and dosages of all medications
  • Potential side effects and strategies for managing them
  • Encourage participation in peer support groups. These can be effective ways to foster self-esteem, empower inmates to come to terms with a positive diagnosis, allay fears and correct misconceptions about HIV disease, and aid adherence. Upon release, telephone hotlines may be available to provide follow-up support and linkages to community services. To the extent possible, family and friends should be included in the education process.
  • Provide alcohol and substance abuse treatment before, or while, initiating ART. Without appropriate treatment during incarceration, linkages to supports, and follow-up treatment upon discharge, inmates are more likely to resume high-risk behaviors that may interfere with adherence to ART. In 2004, nearly one third of inmates in state facilities and one fourth of inmates in the federal system committed their offenses under the influence of drugs (Mumola and Karberg, 2006).
  • Use mental health consultation to identify inmates with psychiatric needs. Treatment for underlying mental health disorders should precede or take place concurrently with the initiation of ART to ensure successful adherence. Depression and other psychiatric illnesses are more prevalent among inmates than among the general population (James and Glaze, 2006).

Factors Related to Systems of Care

  • Educate the facility's security staff about the importance of timely medication dosing, and communicate with other facilities in advance of a transfer; this can eliminate or reduce the frequency of missed doses.
  • Schedule frequent follow-up medical visits in the early weeks after ART is initiated; these can make the difference in whether or not patients "stay the course."
  • Consult with an HIV specialist, if possible. If a facility's medical provider lacks experience in treating patients with HIV, the results may be undertreatment of side effects or errors in prescribing medications. Because caring for HIV-infected patients is complicated, HIV specialists can provide assurance that patients are receiving proper care. Of particular concern are patients whose current ART regimens are failing, those who are declining clinically, and those who are coinfected with other diseases such as tuberculosis, HCV, and HBV.

Medication-Related Factors

  • Aggressively monitor and treat side effects. The most common barrier to proper adherence to ART is side effects from the medications. Inmates should be educated in advance about potential adverse events and urged to observe and report them. In the first weeks after starting a new ART regimen, patients should be assessed frequently for side effects. For treating gastrointestinal toxicities, antiemetics and antidiarrheals should be available on an as-needed basis. As with all patients on ART, inmates should have appropriate laboratory monitoring.
  • Be aware of food requirements. Various food requirements must be considered carefully when administering ART. That can be especially challenging in the correctional environment, particularly in facilities that do not allow inmates to self-administer medications. Make arrangements with prison authorities to provide food when inmates are taking medications that require administration with food.
  • Avoid complex regimens and regimens with large pill burdens, if possible. Simple regimens with fewer pills appear to help improve adherence.
  • Avoid drug-drug interactions. Some antiretroviral medications have clinically significant interactions with other drugs (e.g., methadone, oral contraceptives, cardiac medications, antacids). These interactions may cause failure of either the antiretroviral drug or the other medication, or they may cause additional toxicity. Consult an HIV specialist or pharmacist for information on drug interactions.
  • Question patients about medication adherence at each appointment.
  • ART regimens need to fit into each patient's schedule and lifestyle. This becomes a bigger issue when an inmate is close to release. Education about HIV management, including ART adherence, should begin well before the inmate is discharged back to the community.

Transition to Community Care

It is estimated that 630,000 individuals are released from jails and prisons in the United States each year (Bonczar, 2003; Travis, 2005), and many of these individuals are HIV infected. Many will have difficulty managing even the most basic elements for successful reintegration into their communities. Inmates living with HIV face many challenges when reentering the community, such as finding stable housing, employment, adequate medication supply, follow-up medical care, and psychiatric and substance use treatment services (Hammett et al., 1997).

Ideally, the discharge process at the correctional facility will maximize the likelihood that the person being released will have continuous medical care. At the time of discharge from the correctional facility, all HIV-infected inmates should have a discharge plan that addresses the following:

  • Housing
  • Health insurance
  • 30-day supply of HIV medications
  • Follow-up appointments for medical care and, if necessary, psychiatric and substance abuse care

As discussed, inmates in prisons generally serve longer sentences than do those incarcerated in jails, and they have a release date that is known in advance. Thus, HIV-infected inmates in prisons may be more likely than HIV-infected inmates in jails to have treatment and discharge plans in place before their release. However, because the extent of discharge planning resources varies among correctional systems of care, it is important for care providers to discuss the scope of services their clients received while incarcerated to learn of any service gaps upon reentry to the community (NYSDOH, 2008).

The need to find housing often is the greatest challenge for an HIV-infected inmate leaving a correctional facility. In many correctional systems, inmates must document a physical address at which they intend to reside in order to be released. However, problems with housing availability, stability, and location can create significant stressors for an HIV-infected person being released and can compromise the likelihood that he or she will access HIV health care and adhere to an HIV medication regimen (NYSDOH, 2008).

Medication Continuity Issues

HIV-infected individuals leaving correctional settings have a variety of experiences with ARV medication continuity. A short confinement period, for example, can prevent the development of a solid transition plan. Jail inmates may be released without their medications and have no choice but to call or walk into community health centers or clinics for their medications and ongoing care. Being released from jail after business hours, such as on a Friday night, can result in treatment interruptions over the weekend (NYSDOH, 2008). Depending on the state system, HIV-infected inmates leaving prison are more likely than jail releasees to have a medication supply in hand when they reenter the community. For example, in the New York State Department of Correctional Services, inmates will leave prison with a 30-day supply of HIV medications as well as a prescription for another 30-day supply (NYSDOH, 2008).

For some individuals, interruptions in treatment occur during their time in jail or prison. For example, many inmates choose not to disclose their HIV infection while they are incarcerated. Particularly if the sentence is short, an inmate may feel it better not to mention HIV status and instead plan to resume taking medications upon release. Such treatment interruptions can result in adverse health outcomes (NYSDOH, 2008).

It is important that clinic staff and community-based organizations develop the capacity to work with clients in real time as they present for care in order to help them maintain continuity with their medications.

Strategies for Supporting Inmates upon Release

  • A clear way to support clients is to intervene immediately and directly upon their release, such as by meeting them as they step off a bus or exit a facility.
  • Engage clients by:
  • Hearing their stories; listening to concerns, wishes, history, perceptions, feelings, and so forth
  • Asking open-ended questions, affirming strengths, listening reflectively, and summarizing discussions and plans
  • Understanding their backgrounds, goals, and motivations (understand "where they are coming from")
  • Avoiding getting caught up in issues about the crimes they committed
  • Identifying perceived needs by asking how services can be beneficial to them
  • Acting honestly by providing a full disclosure of one's role as a provider (e.g., what you can or cannot do)
  • Provide material assistance by giving clients something tangible such as a meal ticket, condoms, bleach kit, or hygiene kit.
  • Provide information and referrals to short-term and survival services for clients to help improve their immediate situation.
  • If possible, accompany clients to support them in obtaining short-term and survival services such as health care, food, shelter, and clothing.
  • Respond to emergency situations.
  • Support clients in meeting parole or probation requirements to avoid reincarceration. Based on their individual histories, anticipate circumstances that may result in them breaking parole. For example, if a client confides that he or she has anxiety regarding meeting the parole officer, initiate and practice role plays to better prepare the client for this encounter.
  • Be culturally competent.
  • Link to services (e.g., medical care, mental health, substance use, domestic violence).
  • Diversify clinic staffing, and use a multidisciplinary approach, including peer support.
  • Think outside the box! (NYSDOH, 2008)

A number of HIV education resources for inmates and correctional health care providers are cited on the Albany Medical College website at www.amc.edu/Patient/services/HIV/index.cfm (go to the section on correctional education).

References

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  • Cassidy W. Hepatitis C Infection in Prisons. Accessed December 1, 2013.
  • Catania H. Drug Dependence Treatment in Prison and upon Release. Presented at the 18th International Conference to Reduce Drug-Related Harm (Satellite on HIV/AIDS in Prison Settings); May 13, 2007; Warsaw.
  • Centers for Disease Control and Prevention. Drug Use, HIV, and the Criminal Justice System. Accessed December 1, 2013.
  • Centers for Disease Control and Prevention. HIV Testing Implementation Guidance for Correctional Settings. January 2009. Accessed December 1, 2013.
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  • Fischl M, Castro J, Monroid R, et al. Impact of directly observed therapy on long-term outcomes in HIV clinical trials. In: Program and abstracts of the 8th Conference on Retroviruses and Opportunistic Infections; February 4-8, 2001; Chicago, IL. Abstract 528.
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  • Maruschak L. HIV in Prisons, 2006. Bureau of Justice Statistics Bulletin . Washington: U.S. Department of Justice, Office of Justice Programs; revised April 2008. Publication NCJ 222179.
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  • Nerenberg R, Wong M, DeGroot A. HCV in corrections: Front line or backwater? HEPP News. Vol 5 (4); 2002.
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Table 1. HIV Testing in Prisons: Circumstances Under Which Prison Inmates Were Tested for HIV (by Jurisdiction)
 All Inmates 
JurisdictionEnteringIn CustodyUpon ReleaseRandomHigh-riskInmate requestCourt orderClinical indicationInvolvement in incidentOther

Adapted from Maruschak L. HIV in Prisons, 2006. Bureau of Justice Statistics Bulletin. Washington: U.S. Department of Justice, Office of Justice Programs; revised April 2008. Publication NCJ 222179.

Federal    XXXXX 
Northeast
Connecticut    XXXXX 
Maine     XXX  
Massachusetts     X  X 
New HampshireX     XX  
New Jersey     XXXX 
New York   XXXXXX 
Pennsylvania     XXXX 
Rhode IslandX    XXXX 
Vermont     X XX 
Midwest
Illinois    XXXXXX
IndianaX   XXXXX 
IowaXX   XXXX 
Kansas    XXXXXX
MichiganX    XX X 
MinnesotaX    XXXX 
MissouriXXX X XXX 
NebraskaX    XXXX 
North DakotaXX   XXXX 
OhioX    XXXX 
South Dakota     XXXXX
Wisconsin    XXXXX 
South
AlabamaX XX XXXXX
ArkansasX XXXXXXXX
Delaware     XXXX 
Florida  X  XXXX 
GeorgiaX    XX X 
Kentucky    X  XX 
Louisiana     XXXX 
Maryland    XXXXXX
MississippiX   XXXXX 
North Carolina     XXX X
OklahomaX    XXXXX
South CarolinaX    XXXXX
Tennessee    XXXXX 
TexasX X XXXXX 
Virginia     XXXXX
West Virginia     X    
West
Alaska    XX XX 
Arizona    XXXX  
California     XXXX 
ColoradoX    XXXX 
Hawaii     X XX 
IdahoXX  XXXXX 
Montana     XXXX 
NevadaXXX  XXXX 
New Mexico     X X  
Oregon     XX   
UtahX   X  XX 
WashingtonX   XXXXX 
WyomingX    X X