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http://www.hivcorrections.org/archives/dec99/intro.html
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.
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
Hepatitis B (HBV) -
Overlooked and Under-treated
The
prevalence of chronic HBV (HbSAg positive patients) may be
lower than Hepatitis C Virus infection in correctional settings, but it is
still a threat. In fact, HbSAg positivity rates (up to 47%)
are considerably higher than in non-incarcerated populations
(5%)(25).
• Vaccination
and Screening for HBV
Prisons
are an ideal setting for HBV vaccination, although only a few
facilities have adopted CDC guidelines recommending all
inmates and exposed personnel receive the HBCV vaccine. The
CDC has also recommended HbSAg screening for all pregnant
women, and vaccination is recommended for the household and
sexual contacts of HbSAg carriers (26). Correctional
facilities can obtain HBV vaccine for free for inmate patients
up until their 19th birthday under a federal program, Vaccines
for Children. Accessibility may differ in each state but
providers can check with local departments of health, which
may be willing to consider cost sharing for HBV vaccination
for older inmates, depending on the region’s incidence of
HBV infection. HBV vaccination has been adopted in some
correctional facilities due to the high rate of infection
among inmates returning to correctional facilities. In
Rhode Island, incidence of new HBV infection in recidivist
women has been demonstrated to be high: 12 per 100 person
years. This year, RI DOC began vaccinating inmates less than
19 years old (27). HBV vaccination is less effective in
patients who already have HIV infection, thus boosters or
higher doses may be needed (26).
• Treatment
Options for HBV
Interferon
at 5 million units subcutaneously for 16 weeks was the first
treatment for chronic HBV infection. New agents for HBV,
including lamivudine (3TC), adefovir (ADV) and famciclovir (Famvir)
are in the process of being evaluated. Each patient should be
evaluated for treatment and decisions about treatment should
be made on an individual basis.
• Treatment
of HBV in the Presence of HIV Co-infection
HIV may
lessen the liver damage in the HIV/HBV infected patient and
treatment could be less of an issue than with Hepatitis C Virus/HIV
co-infection. If, in the future, life expectancy for HIV
increases further, even moderate liver damage in HIV/HBV
co-infected patient may need to be addressed, especially if
HBV treatment improves. Whether sequential or combination
therapy is optimal is unclear. Any liver damage at all may be
important if it will compromise tolerance of anti-retroviral
therapy.
Contributors
include:
HEPP Staff
and Rob Lyerla, PhD, epidemiologist in the Hepatitis Branch,
National Center for Infectious Diseases, CDC.
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