US correctional facilities: Complex approach needed for HIV, HCV screening, treatment

Prisons, jails miss unique opportunities for diagnosis, management and treatment of infectious diseases.

According to the US Bureau of Justice Statistics, 20,449 state prisoners and 1,538 federal prisoners were HIV-positive during 2008 — five times the rate of the general population infected with HIV. Moreover, most recent data from the CDC indicates an almost 10-fold increased rate for hepatitis C virus among inmates compared with the general population.

Yet, opportunities for prevention, diagnosis and treatment are missed across most US correctional facilities, as only 24 states reported testing inmates for HIV at some point while in custody. Prisons house inmates for longer periods of time, allowing for significant opportunities to provide long-term medical care; however, the volume of individuals who pass through the jail system (often short-term) is high. Therefore, it is just as significant to screen for infectious diseases in the jail system.

Not only is jail-based screening for infectious diseases a neglected component of health care, but treatment and linkage to care once incarcerated individuals leave the system and are reintroduced to the community are also greatly underutilized.

For this article, Infectious Disease News contacted several experts working on this important health issue, who agree that better efforts are needed for the treatment and prevention of HIV, HCV and other infectious diseases in the US correctional setting.

According to Anne Spaulding, MD, of the department of epidemiology at Rollins School of Public Health and School of Medicine, Emory University, a sizable amount of the HIV epidemic in the US is composed of people who have an interaction with the criminal justice system. “One out of six people who have HIV in the US will go through jail or prison each year. With the epidemic of incarceration, we can use this time to allow people to access testing services,” she said.

“About 15% of all people with HIV and almost 25% of all people with HCV are cycled through the correctional setting,” Timothy P. Flanigan, MD, professor of medicine and director of the division of infectious diseases at Rhode Island and The Miriam Hospitals and Brown Medical School, said in an interview with Infectious Disease News. “During the past 5 years, there has been broad support for better medical treatment for HIV and other diseases in prisons. Yet, the challenges of working in jails are huge — [currently] the priority within jails is security, not health.”

But health could be a priority, according to Flanigan. The Rhode Island Department of Corrections prison and jail offers comprehensive HIV treatment for infected inmates and links them to community-based resources upon release. More than 70% of HIV-infected individuals in the program are linked with primary medical care at Miriam’s Immunology Center, he said.

High cost-benefit ratio

In a 2010 study published in the Journal of Acquired Immune Deficiency Syndrome, Flanigan and colleagues laid out the “blueprint” for an infectious disease screening and HIV prevention program within a jail system. As more individuals pass through jails before being transferred to prisons, “jail incarceration is a key opportunity to provide health interventions.…The intake process may be the best time to implement testing,” they wrote.

Data were pooled from two controlled studies that assessed routine HIV testing in a Connecticut jail. When HIV testing was offered within 24 hours of admission, both males and females were more likely to get tested. Although only one new HIV case was found during the study period, the researchers identified a significant number of previously infected individuals who were then reintroduced to HIV therapy.

“Diagnosing and treating infectious diseases such as HIV and STIs have a high cost-benefit ratio; screening and treating these infectious diseases will prevent spread in the community,” Flanigan and colleagues wrote. “Economic and logistical obstacles to testing in jails, stigma surrounding incarceration, and lack of political will need to be addressed for progress to be made in implementing HIV, STI, and HCV testing and care programs within jails.”

Joanne Csete, PhD, associate professor at the Mailman School of Public Health at Columbia University, said when people are placed in custody, correctional authorities should make routine offers of HIV testing. “There should be an offer of testing; people should have the chance to understand what they are being tested for and to ask questions.”

HIV and HCV coinfection

Managing individuals with HIV who are coinfected with HCV is another problem in the correctional setting.

“The HIV and HCV coinfection rate can be quite significant in a prison population that has a history of injection drug use,” David Cohn, MD, Infectious Disease News Editorial Board member, said in an interview. “The most important focus is that we don’t always know who is infected, but if you have active screening programs, you’ll know. Obviously, HIV care for people incarcerated is important, but I suspect that active HCV treatment is relatively uncommon.”

The recommended standard duration of HCV treatment is 48 weeks. However, many individuals are only incarcerated for a short period of time, not allowing for completion of HCV treatment and leading to interrupted care. Independent monitoring is recommended for HCV-infected inmates ineligible for treatment and identification and treatment guidelines for HCV are still evolving, particularly in the prison setting.

Flanigan said with HIV, proper diagnosis, evaluation and treatment, and linkage to care upon release are necessary. However, for HCV, a robust research agenda is needed to determine how best to test, treat and, ultimately, link incarcerated individuals to care once released.

“We need active collaboration to encourage screening, diagnosis and evaluation of treatments of infectious diseases that occur more commonly in disenfranchised communities within prisons and jails,” he said. “This is hard to do and requires time, patience and partnerships based upon mutual respect. It is extraordinarily important. If you are not going to diagnose, treat and control infectious diseases within jails and prisons, then there will be continued spread within the community.”

Nonadherence to treatment

Once HIV-positive convicts are identified, treatment would seem to be the next logical step, but there is an increasing burden of nonadherence to antiretroviral therapy among incarcerated HIV-infected injection drug users, according to Evan Wood, MD, PhD, of the British Columbia Center for Excellence in HIV/AIDS in Vancouver, and colleagues.

For this reason, Wood and colleagues set out to assess data on 490 HIV-seropositive injection drug users with access to free HIV care included in a long-term community-recruited study in Vancouver.

The researchers examined the association between the overall burden of incarceration and the rate for adherence to ART among participants who reported incarceration (n=271) at some point during the study period (between 1996 and 2008). Of 1,156 total incarceration episodes, 53.7% occurred in jails, 41.2% in prisons, 1.6% in federal penitentiaries, and 0.5% in youth detention facilities.

Overall, incarceration adversely affected adherence to ART. Specifically, participants with one or two incarcerations were almost twofold more likely to report nonadherence to ART compared with those with no history of incarceration (OR=1.91; 95% CI, 1.35-2.72). For participants with three to five incarceration episodes, the odds increased to 2.85 (95% CI, 1.87-4.33) and to 3.59 for those with five or more incarceration episodes (95% CI, 2.12-6.09).

Although the researchers said they could not link an association between imprisonment and nonadherence to ART, “the behaviors that lead to arrest, such as illicit drug-use, were a contributing cause of nonadherence.”

“Because the findings are from a long-running observational cohort linked to complete ART dispensation records in a setting of universal access to free HIV care, these results are not under the influence of the confounding effect of financial ability or biased by the limitations of self-reported adherence,” they wrote. “Our analysis considers the effect of incarceration in the course of HIV disease among community-recruited [injection drug users] and clearly indicates that increasing number of cycles of imprisonment, release and reincarceration are associated with poorer ART adherence in this population of [injection drug users].”

Need for prevention

HIV testing and linkage to care upon release is necessary, but not sufficient to prevent HIV. Csete said that redressing the absence of access to condoms in many prisons around the world should be an urgent HIV prevention priority.

During 2006, Governor Arnold Schwarzenegger of California vetoed Bill AB 1677, that would have enabled public health agencies to provide condoms to state prison inmates. The hope was to further control the spread of HIV/AIDS in communities outside of the correctional setting.

“Condoms are available in prisons in the District of Columbia, Vermont, and Philadelphia as well as in Canada, South Africa, most of the European Union, and parts of Latin America,” Former Assemblyman, Paul Koretz, (D-West Hollywood), said in a press release. “Among jail systems, New York City, Los Angeles, and San Francisco allow condoms for the incarcerated.”

Thus, the vast majority of US prisoners have no access to condoms, Csete said. “Condoms are not provided in many countries due to denial that same-gender sexual activity occurs in prison or because such activity is disallowed by law and officials do not want to encourage it by providing condoms.”

She said methadone therapy and sterile syringe programs should also be available for basic protection in view of convincing evidence of widespread drug injection in many prisons. “Methadone therapy for opiate dependence is available in only a few US prisons, [but it] is a life-saving service for some people living with addiction and is offered with excellent results in many prison systems around the world. A handful of US prisons, including Riker’s Island in New York City, offer methadone.”

Sterile syringe programs can be low cost, however one of the biggest hurdles is for prison staff to admit drug-abuse is occurring in the correctional setting, she said. “Health services for drug-users in this country have been handicapped by this idea that drug-use is a character flaw rather than a chronic relapsing disease.”

Successful programs

The Maryland Prevention Case Management program is one successful program implemented by the Maryland Department of Health and Mental Hygiene. The program aims to provide counseling and educational services to inmates and assist in adopting safer behaviors upon release to reduce the risk for HIV transmission to others in the community.

Researchers from the Department of Health and Mental Hygiene tested the program among 529 inmates within 6 months of release from incarceration across four prerelease units within the Division of Correction, Maryland Department of Public Safety, and local detention centers across 14 Maryland counties.

Surveys were conducted before and after initiation of the program that assessed differences in perceived HIV risk; condom use; reduced injection drug risk and other substance abuse risk; and behavioral intentions.

“After 4 years follow-up, significant changes were observed in self-reported condom attitudes, self-efficacy for condom use, self-efficacy for injection drug use risk, self-efficacy for other substance use risk, and intentions to practice safer sex upon release,” the researchers wrote.

Flanigan helped to develop the successful Rhode Island State Prison-based program and said it is critical to screen for HIV in all jail systems. Once individuals are identified as HIV-positive, it is just as important to link them to care after release. “Even if a program links just 50% of inmates to care upon release, this could have an enormous impact,” he said.

“We know that we can do rapid HIV tests in jails, we do it in Rhode Island and it’s widely accepted by inmates. We also know that incarceration is a time when individuals may be open to discussing what they can do to keep themselves uninfected. Although it may be difficult to provide a supportive setting for interventions in jail and prison, as they are at times chaotic, underfunded and have a high turnover rate, it’s all the more important to intervene.”

Spaulding is currently in the process of forming a center for the health of incarcerated individuals by establishing testing for HIV at Fulton County Jail in Georgia.

“We have introduced rapid testing for HIV to replace the conventional serum testing,” she said. “We are finding much greater acceptability of mucosal swabs as opposed to phlebotomy and that there’s a very high acceptance of offers for routine opt-out testing for HIV among all entrants coming into intake. The cooperative agreement allows Fulton County Jail to demonstrate how well it can screen for HIV, and it’s also allowing us to integrate the screening services for HIV with screening services for other infections, namely STIs.”

Reform needed

WHO recommends that prisoners have the right to receive health care without discrimination equivalent to care available in the outside community. Yet, there is no legal mandate that requires providing care to prisoners. Monitoring inmates with HIV or HCV upon release from jail or prison remains a challenge, and there is a need to establish systems for extended management of treatment.

“We need to have much stronger advocacy at the federal, state, county and city level,” Flanigan said. “The CDC has recognized that this is an issue and has provided guidelines that are helpful for the screening of HIV in prisons, but more could be done, and the CDC could challenge state and city departments of health to utilize their jails as key places for testing and screening within their communities.”

“Correctional systems basically have no excuses [on this issue] because we know what works, and the measures that work are in place in a number of countries,” Csete said. “As usual, it is a matter of political will and allocation of resources, which is of course not easy when we’re talking about people whom the general public are happy to have out of sight and out of mind. Policymakers are not always seeing that prison health is public health, most people who are in prisons will get out and for people to emerge from prison with HIV is going to be a burden down the road, any way you cut it.” – by Ashley DeNyse and Jennifer Henry

For more information:

• AIDS InfoNet. Fact Sheet No. 615. HIV in prisons and jails. Available at: www.aidsinfonet.org/fact_sheets/view/615. Accessed April 26, 2011.
• CDC. Drug use, HIV, and the criminal justice system. August 2001. Available at: www.cdc.gov/idu/facts/criminaljusticeFactsheet.pdf. Accessed April 26, 2011.
• Fazel S. Lancet. 2011;377:956-965.
• Federal Bureau of Prisons. Stepwise approach for the prevention and treatment of hepatitis C and cirrhosis. March 2011. Available at: www.bop.gov/news/PDFs/hepatitis_c.pdf. Accessed April 26, 2011.
• Flanigan TP. J Acquir Immune Defic Syndr. 2010;55(Suppl 2):S78-S83.
• Malek M. J Correct Health Care. 2011;17:69-76.
• Office of Justice Programs. HIV in prisons, 2007-08. Available at: bjs.ojp.usdoj.gov/index.cfm?ty=pbdetail&iid=1747. Accessed April 26, 2011.
• Schwarzenegger Terminates Condoms for Inmates Bill. Available at: www.beyondaids.org/articles/20061001.html
• Richardson DA. #404. Presented at: the National HIV Prevention Conference; Aug. 29-Sept. 1, 1999; Atlanta, Ga.
• Spaulding AC. Ann Intern Med. 2006;144:762-769.
• Spaulding AC. pLoS One. 2009 4(11); e7558.
• Tolou-Shams M.J Correct Health Care. 2011;doi:10.1177/1078345811401357.
• UNAIDS. WHO guidelines on HIV infection and AIDS in prison. September 1999. Available at: data.unaids.org/publications/IRC-pub01/jc277-who-guidel-prisons_en.pdf. Accessed April 26, 2011.

Disclosures: Drs. Baillergeon, Csete, Rich and Spaulding reported no relevant financial disclosures. Dr. Flannigan has no grants and no consultancies with the pharmaceutical industry, but he owns equity in the pharmaceutical companies that produce antiretroviral therapy.

How aggressive should correctional facilities be at screening inmates for HIV and/or HCV?

Based on WHO recommendations, correctional facilities should offer comparable care to that of the general community.

In the United States, some prisons have mandatory screening, but many have voluntary screening and it should be strongly encouraged. It’s important to screen this population at intake and at release, but not all prison systems do this.

WHO recommends delivery of health care in the prison system comparable to that of the general community, and therefore, we shouldn’t have mandatory required HIV screening for inmates, because it’s not required most places in the general community. Their view is that it should be made available, and be strongly encouraged for the purposes of offering treatment to this high-risk group.

So I would subscribe to that view. I think it should be universal and strongly encouraged. If it were mandatory, that means, if they refuse, then you have the right to take a blood sample against their will, and I think that’s a little extreme. But it should be very strongly encouraged so that there are more opportunities for care.

People who are incarcerated tend to be out of the reach of conventional community-based health care. These are people who were marginalized, somewhat hidden, and a lot of them don’t have access to health care.

For the majority of inmates who are HIV-infected, being incarcerated can represent their first opportunity to get tested for HIV, and, if they are positive, to be treated for HIV. So, it’s a rare and unique opportunity for this marginalized group of individuals to be screened, treated, educated, and ultimately link them to care in the community when they are released. Prison, for this group, can really represent a unique public health opportunity.

Jacques Baillergeon, PhD, associate professor of Preventive Medicine & Community Health at the University of Texas Medical Branch. Disclosure: Dr. Baillergeon reports no financial disclosures.

HIV testing is mandated in Rhode Island, and HCV is recommended.

Rhode Island is unique, because there is a single facility for the entire state, and in 1989, HIV testing was mandated for all sentence inmates. Because it’s both a prison and a jail, it was decided to test everyone, not knowing where people were going to end up. Our routine testing has picked up about one-third of all HIV in the state. The program is phenomenally successful in not only identifying people who are positive, but getting them treatment, getting linked up to care after release, getting their partners tested, and we’ve had a dramatic decrease in injection drug use and HIV throughout the state.

This is a public health opportunity; it is a way to address the epidemic. The fact that a third of people in the state with HIV were diagnosed in a correctional facility should be a huge wake-up call to any community interested in HIV. If you’re not addressing what’s going on with HIV in a correctional facility, you’re missing a big slice of the pie. And it helps a lot of people get diagnosed earlier in their disease. People that are getting sick and dying from HIV are predominately those who don’t know they have it. The long-term prison population allows us to be able to treat for HIV and prevent death for the most part.

For HCV, the CDC recommends those with risk factors should be screened. However, given that the prevalence of HCV in prison is approximately 30%, why should you limit your screening when one in three tests are going to be positive? If you are able to screen all prisoners, you will identify much more people than screening just those with risk factors. If we are able to screen all prisoners for HCV, provide opt-out testing, and provide comprehensive educational programs, we would have a huge impact.

Josiah Rich, MD, professor of Medicine and Community Health at Brown Medical School, co-founder and director of The Center for Prisoner Health and Human Rights. Disclosure: Dr. Rich reports no relevant financial disclosures.

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