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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

  



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.