http://www.hivcorrections.org/archives/sept01/

Bridging the Communicable Disease Gap: Identifying, Treating and Counseling High-risk Inmates
Marthali Nicodemus*,  HEPP News Staff Writer, Acting Executive Director of the GAIA Vaccine Foundation 
Joseph Paris, Ph.D., M.D.**,  CCHP Georgia Dept. of Corrections

Recent outbreaks of communicable diseases in correctional settings have underscored the importance of identifying communicable diseases, educating inmates and staff, and treating where appropriate. In June 2001, an outbreak of HBV was reported in a state correctional facility in Georgia (1). In November 2000, the CDC reported an outbreak of TB in a state correctional facility in South Carolina (2). Concurrent syphilis outbreaks were identified in three Alabama men's state prisons in 1999 (3). These events all point to an important gap between awareness of infection (diagnosis) and medical intervention in correctional settings. This article describes the communicable disease gap in correctional settings, and addresses means of bridging that gap.

The Need to Know
Lack of information about an inmate's diagnosis of HBV, TB, STD, and/or HIV may be due to the inmate's failure to provide this information, unwillingness to be screened or inability to access screening for these diseases, or the failure of routine hepatitis, TB, STD and HIV screening protocols to detect communicable disease. Denial, fear of illness and concern about confidentiality are major deterrents for inmates. Concern about the cost of treatment may also contribute to delays in diagnosis. Furthermore, current guidelines for treating the disease may advise delaying treatment until medically necessary, diminishing the patient's and providers' sense of urgency about obtaining a diagnosis. While some individuals may not need active treatment under existing HIV and Hepatitis C Virus guidelines, they are still likely to benefit from education about their medical condition and the risk of transmission to their families and communities after release from incarceration. Furthermore, as illustrated by outbreaks of communicable diseases in correctional settings, inmates who have communicable diseases sometimes continue to participate in risky activities while incarcerated. Diagnosis and appropriate medical intervention may reduce the risk of communicable disease transmission to other inmates and correctional staff.

Beneficial Strategies
HIV: The benefits of diagnosing and treating are multiple. Routine recommendations for HIV testing by primary health care providers has been shown to improve the incidence of requested testing, the identification of infected individuals and earlier diagnosis of infection, leading to earlier entry into care (17). Inmates who are eligible for treatment may experience fewer opportunistic infections (18), fewer hospitalizations (19) and may be less likely to transmit HIV if still participating in HIV risk behavior (20).

Hepatitis C Virus: Hepatitis C Virus treatment guidelines for correctional facilities will be published by the CDC in late 2001 or early 2002. Because of the prevalence of Hepatitis C Virus infection among inmates and the lack of official treatment protocols guiding Hepatitis C Virus treatment in corrections, emphasis has shifted to identifying infected individuals and providing education about means of limiting further spread of Hepatitis C Virus. As Dr. Robert Greifinger, MD, recently said: "It's almost distracting to talk about treatment. The much larger issue is prevention (21). "It is hoped that education about Hepatitis C Virus may help motivate Hepatitis C Virus-infected individuals to take precautions against transmitting Hepatitis C Virus in communities to which they return, and to seek appropriate Hepatitis C Virus treatment in the community if it they are unable to participate in Hepatitis C Virus treatment while incarcerated.

HBV: The CDC has recommended that all adults at risk of HBV infection be vaccinated (inmates and staff in correctional institutions are included in the high-risk category) (22). Again, limiting vaccination to higher-risk inmates (those with a history of IDU, for example) would lower costs (23).

STDs: Jail intake represents an important opportunity for STD screening. However, the rapid turnover of inmates can limit the efficacy of STD diagnosis and treatment. A number of rapid tests for STD infections have been developed (24). In Chicago, these methods for rapid STD diagnosis and treatment led to the identification of most of the city's STD cases and successful treatment before release (25,26).

Education, Education, Education
Education is not only arguably the most effective way to achieve prevention of transmission, it is also one of the cheapest. A study by the CDC published this year found that HIV prevention programs in prison that included testing and counseling not only saved society a lot of money (while prevention programs can seem expensive, treatment after infection costs a lot more), it reduced the risk of infection for uninfected inmates by 20%, and transmission from infected inmates by 25% (30). Another study in San Francisco found that prerelease risk reduction counseling reduced sex- and drug-related risk behavior of inmates after release, and improved the use of community resources (31). Peer-led education has been convincingly demonstrated to be the most effective form of education for inmates.

Treatment and education programs may need to be gender-specific, since female prison populations often have different disease dynamics than their male counterparts. For instance, about 10% of women who enter jails in the US are pregnant. The prevention of mother-to-child HIV transmission is a particularly important intervention for correctional facilities. Infants of mothers with acute (and chronic active) HBV infection are also at risk of contracting the disease.

Because of the complex relationship between various communicable diseases, and the high prevalence of infection among prison populations, effective management programs have to be coordinated efforts that screen for various risk-associated behaviors and medical conditions. Prison and jail-based programs, in the context of overall public health interventions, are extremely effective for the following reasons: they have the potential of identifying and reaching a high number of those infected with communicable diseases and those at risk of infection, and they effectively bring treatment and prevention strategies directly to a population that is at highest risk in a setting that may be more conducive to learning than educational programs located "on the street (32,33)." Communicable diseases impact more than the correctional population, as inmates  eventually return to their communities. Will correctional facilities act as incubators or educators? That is the question of the new millennium.

At the NIH conference two significant statements were made: that Hepatitis C Virus is now an epidemic in the US, and it is curable in many cases. The consensus panel also expanded its recommendations to treat Hepatitis C Virus in populations that had previously not been considered eligible (HIV-infected patients and former or active drug addicts). Dosing schedules for the drugs described in the consensus statement are available in the March 2002 issue of HEPP News (www.hivcorrections.org). The panel also reinforced the need to identify infected patients, educate them about their disease, and initiate treatment in those most likely to respond. Studies are currently underway to better understand the impact and treatment of HIV and Hepatitis C Virus co-infection. Clinicians working in correctional settings will continue to be on the front line of this epidemic for the foreseeable future.