An opportunity not yet seized

Prevention and Treatment of HIV/AIDS and Other Infectious Diseases in Correctional Settings: An Opportunity Not Yet Seized

December, 1999
Theodore M. Hammett, Ph.D.
Abt Associates Inc.

Correctional health care providers manage the care of a large number of individuals with communicable diseases in the U.S. A major portion of the nation’s Hepatitis B&C, HIV, STD and TB infected patients pass through prison and jail doors (see Heppigram). Moreover, many of these individuals also have other co-morbid conditions such as psychiatric illnesses, substance abuse and chronic medical conditions that thwart an integrated care approach for these patients in community settings.

Within correctional populations, moreover, women and people of color are much more heavily affected than men and Caucasian inmates. For instance, in most geographical areas, the prevalence of HIV among women prisoners is twice that found among male prisoners. Similar to findings in community-derived studies, people of color are disproportionately affected by all communicable diseases, however this phenomenon is magnified within our correctional system.

The disproportionately high burden of disease in correctional institutions identifies an extremely important opportunity to intervene aggressively with prevention and treatment programs. Such interventions promise to benefit not only inmates themselves and their partners and families, but also the broader public health. Contrary to popular perception, correctional facilities are a part of the community. The vast majority of inmates return to our streets and neighborhoods --more than 8 million are released from jails and prisons per year -- where they may either continue to place themselves and others at risk for infectious disease, or help to halt the linked epidemics of disease in the poor, under-served communities which are home to most of them.

The nation's correctional systems, public health departments, and community based providers have not yet exploited this important public health opportunity, except in a minority of instances. While there have been improvements in recent years and many correctional administrators appear to be taking an increasingly enlightened view of health services and disease prevention, there remains considerable room for improvement. Results of a series of national surveys of HIV/AIDS, STDs, and TB in correctional facilities elucidate the key areas of need.1 Progress and remaining needs in several key areas are summarized below.

HIV/AIDS Education & Prevention
As of 1997, about two-thirds of correctional facilities in the U.S. were providing instructor-led HIV/AIDS education, the most basic ingredient of an education and prevention program. Moreover, while most HIV education programs covered basic information on the disease, far fewer included practical risk reduction information, such as strategies for negotiating safer sex and methods of safer injection. Only about a third were providing more intensive multi-session HIV prevention counseling programs, the type of program probably needed to help inmates initiate and sustain the difficult behavioral changes required to reduce their risks of acquiring or transmitting HIV and other infectious diseases. Finally, only 13% of prisons and 3% of jails were offering peer-based programs in which inmates provide education and prevention services to other inmates. This represents an extremely under utilized but promising and potentially very cost-effective method of providing these services.
One definition of a "comprehensive" HIV/AIDS education and prevention program is that all of the following are provided in all of a correctional system's facilities: instructor-led education; HIV pre- and post-test counseling; peer-led programs; and multi-session prevention counseling. By this definition, only 10% of state and federal prison systems and only 5% of the 50 largest jail systems in the U.S. had a comprehensive program in 1997.

Beyond this, some may consider a "comprehensive" program to include provision of the means necessary to effectuate HIV risk reduction. Perhaps the most commonly advocated such policy is making condoms available to inmates. However, political considerations have made it extremely difficult for correctional administrators to permit condom distribution even though it is hard to deny that inmates engage in sexual activity within correctional facilities. As a consequence, only two state prison systems (Vermont and Mississippi) and four city/county jail systems (District of Columbia, New York City, Philadelphia, and San Francisco) make condoms available to inmates. This number has not changed since about 1990.

Discharge Planning/Community Linkages
All inmates need more and better services to help them make successful transitions to the community, resist relapse to substance use, and avoid a return to high-risk behavior and criminal activity. This is especially true for inmates with HIV disease, who might benefit from a range of services including continuity of health care, stable housing, drug treatment, assistance gaining eligibility for benefits, and job training and placement services. Results of the 1996-1997 CDC/NIJ survey show that 92% of state/federal prison systems and 76% of the largest city/county jail systems were providing at least some discharge planning for inmates with HIV and AIDS. However, further analysis of the survey data reveals that while large percentages of systems were making referrals for HIV medications (82% of state/federal systems and 66% of city/county systems), drug treatment (75% and 63%), and for Medicaid and related benefits (78%, 56%), much smaller percentages were actually making appointments for inmates to receive these services in the community (31% of state/federal systems and 27% of city/county systems for HIV medications, 22% and 24% for drug treatment, and 35% and 29% for benefits). Making a referral can involve simply giving an individual a list of agencies where they might apply for services with no further assistance in actually accessing the services. Making an appointment for a soon-to-be-released inmate with a specific service provider by no means guarantees that the person will show up and receive the services, but it represents an additional step in the process. Geography can be a significant obstacle to achieving a successful transition. Exemplary programs in small geographic locations in Rhode Island4 and Hampden County, Massachusetts5 successfully provide continuity of services by having local clinicians provide care both within and outside of the correctional facility. Successful models in moderate-sized geographic areas, such as in Connecticut,6 have adopted a transitional case management model to overcome problems associated with geography. Such programs are beginning to demonstrate salutary effects on clinical outcomes as well as on recidivism rates of inmates participating in them.

Collaboration Needed
Correctional systems cannot be expected to take full responsibility for addressing the serious public health problem or exploiting the important public health opportunity represented by the related epidemics of infectious diseases in correctional facilities. Public health departments, community-based organizations such as AIDS service organizations and community-based substance abuse treatment agencies, and other community-based providers have critical roles to play as well. There is increasing collaboration among these entities, but there remain far more opportunities and needs for working together. There are differences in philosophy and priority among these organizations, to be sure, but there are also growing examples of overcoming the barriers and forging successful collaborations to provide needed services to inmates and releasees as well as to benefit the public health and serve the interests of society at large.7

• Treatment-Associated Side Effects

Interferon side-effects commonly include flu-like symptoms, irritability, and depression. Hematological abnormalities such as anemia are common. Severe adverse effects include severe depression, seizures, and generalized bacterial infections (<2% of patients receiving interferon) (11). Decreasing the dosage of interferon may be helpful; severe side-effects result in the discontinuation of treatment in 5 to 10% of patients. Paradoxical worsening of hepatitis may also occur, and is thought to be due to an autoimmune response. Treatment should be discontinued in patients who have rising serum ALT levels to greater than twice the baseline. Ribavirin can produce hemolytic anemia, which can be life threatening in patients with heart disease and cerebral vascular disease. Ribavirin is teratogenic, and therefore contraindicated in women who are considering becoming pregnant and their male partners. Sexually active women and men should use reliable birth control during treatment and for at least 6 months after completion of a ribavirin regime. A male prisoner leaving prison less than 6 months after treatment ends needs warning not to impregnate a female partner until risk of teratogenicity has passed.

• HIV and Hepatitis C Virus Co-infection

Co-infection with HIV further complicates Hepatitis C Virus treatment decisions. Now that HAART has improved the overall prognosis of HIV, viral hepatitis is destined to become an increasing cause of morbidity and mortality for many of our HIV and Hepatitis C Virus co-infected patients.

While co-infected patients can tolerate interferon therapy (17), few may respond and those who do may relapse (18, 19), although some practitioners believe the response rate for HIV and non-HIV infected patients may not differ (20). In some co-infected patients, CD4 T cell counts have been observed to plummet on interferon (21). In addition, previously asymptomatic patients with high CD4 counts who are started on interferon have developed opportunistic infections such as Pneumocystis carinnii pneumonia.

Interactions with anti-retroviral medications should be carefully considered prior to initiation of therapy. Ribavirin may block the action of zidovudine (AZT) and stavudine by inhibiting the phosphorylation of the antiretroviral drug. It does not seem to antagonize didanosine (ddI) and ribavirin/ddI combinations may even be synergistic (22). The interaction of ribavirin with all anti-retroviral drugs needs to be better defined, as few have had experience with combining these therapies.

Despite these caveats, there is emerging evidence that treating Hepatitis C Virus in HIV co-infected patients may prevent liver failure. Outcomes may improve further since the recent approval of ribavirin in combination with interferon as standard initial Hepatitis C Virus therapy. An AmFAR sponsored study of interferon with or without ribavirin therapy in HIV/Hepatitis C Virus co-infected patients has been on-going since 1998. Anemia, which causes treatment withdrawals in some Hepatitis C Virus-infected patients may be a significant problem when the combination is used in patients with HIV especially when HIV, is advanced or AZT is used. Thus, treatment of Hepatitis C Virus is now being carefully considered for selected HIV-infected incarcerated patients. The challenge for the correctional physician lies in determining whether treatment is appropriate for an individual patient.

• Timing and Cost Effectiveness

Hepatitis C Virus cure rates (sustained virologic response) with currently available regimens remain low, ranging between 15 to 50%, depending on the treatment (12, 13, 14). The cost of the medication can be as high as $12,000 per year per patient. Low cure rates and high cost have led to delays in the initiation of Hepatitis C Virus screening programs in correctional settings, even though screening for and treating Hepatitis C Virus has been shown to be cost-effective in some populations. For older patients, a 6 month-long treatment was on the scale of other interventions that the American public would accept. For young patients, 6 months of treatment maybe cost saving (23). The use of ribavirin for Hepatitis C Virus changes the picture-cost benefit analyses for combination therapy. Combination therapy is more expensive than interferon alfa alone, but because it has a higher success rate, it may be more cost-effective.

Careful selection criteria can further improve the cost-effectiveness of Hepatitis C Virus treatment in the correctional setting. My colleagues and I have previously shown that a policy of routinely treating appropriately screened Hepatitis C Virus patients with interferon treatment demands only 3% of correctional facility health care budgets (24). The following table shows the hepatitis treatment criteria at RI DOC with the addition of criteria that must be met before adding ribavirin to a regimen.

Many U.S. inmates may meet the criteria described above and receive treatment, however, the total number of Hepatitis C Virus infected inmates treated using these criteria will be much lower than the total number of inmates who have Hepatitis C Virus infection. One approach to limiting the impact of Hepatitis C Virus screening on correctional budgets might be to screen only those inmates who would qualify for Hepatitis C Virus treatment by
clinical criteria. Appropriately screening HIV patients for treatment may reduce Hepatitis C Virus treatment costs.

• Conclusion

High Hepatitis C Virus infection rates and new guidelines for treatment are forcing difficult decisions in correctional health facilities. In community settings, clinicians treat Hepatitis C Virus infected patients who meet treatment criteria with combination interferon/ribavirin therapy. Guidelines for the selection of patients for therapy in correctional settings should be developed, with the participation of regional public health officials. Cost-sharing between correctional facilities and public health is a subject that needs to be explored, particularly if 30% of all people with Hepatitis C Virus in the community cycle through correctional facilities. Treatment of these individuals to reduce Hepatitis C Virus morbidity and mortality will have broad implications for general public health.

Treatment of Hepatitis C Virus infection in HIV infected patients also bears careful consideration. As HAART therapy continues to prolong the lives of HIV infected people, providers need to place more importance on co-morbid conditions. More HIV patients may die from illnesses other than opportunistic infections. We recommend that all HIV infected patients receive screening for viral hepatitis antibodies (but screening does not need to take place during incarceration, especially if the stay is brief).

Correctional facilities with limited budgets are urged to develop
guidelines for prioritizing whom will receive Hepatitis C Virus therapy. We recommend that Hepatitis C Virus/HIV co-infected patients who have participated in substance abuse treatment, have an expected duration of incarceration that permit completion of therapy, have stable psychiatric or medical conditions, have elevated transaminases but normal hematological parameters, be considered for treatment of hepatitis C virus.