Infectious diseases within American prisons

At least 17% of people living with HIV/AIDS have been incarcerated at some point in their life.[6] The rate of contracting HIV is ten to one hundred times higher inside the prison system than outside.[7] The incarcerated population is more likely to contract the disease because they are exposed to more high-risk behaviors within the correctional system. In a Louisiana prison study, 242 inmates (72.8% of male inmates) had participated in sexual encounters with other men, and did not always have access to proper protection.[6] Additionally, research has demonstrated that infection rates via injection are much higher among those who have previously served prison terms. Research suggests that elevated rates of infection are a result of increased prison sentencing for drug-related offences and the War on Drugs.[8][9] Since prisons generally divide the individuals by gender, the populations experience different environments; incarcerated females in the United States tend to have higher rates of infection.[7]

According to the U.S. Department of Justice's Bureau of Justice Statistics, at the end of 2010 among all of the U.S. inmates with HIV/AIDS 18,337 of them were male and 1,756 were female.[10] Research suggests young men of color disproportionately represent U.S. inmates and these individuals may be at such a risk of contracting HIV due to high-risk behavior prior to entering the penitentiary system. Furthermore, research also shows that AIDS is the single largest cause of death among African American men between ages 25 through 44 years, mainly due to drug-related transmission of the virus.[11] As of September 2013, condoms for prisoners are only available in the US state of Vermont (on September 17, 2013, the California Senate approved a bill for condom distribution inside the state's prisons, but the bill was not yet law at the time of approval).[12]

A 2004 survey of inmates at state prisons and local jails revealed a self-reported HIV positive rate of 1.9% and 2.5% respectively. Sixty-nine percent of state inmates reported being tested since admission to the system while only 18.5% of those in the jail reported being tested.[4] This suggests that expanded jail testing could increase the number of previously unidentified cases of HIV. In prisons, where inmates are incarcerated for more than a year, testing should take place at the medical evaluation. In jails, where a majority of inmates bail out between 72 hours and seven days, routine testing should ideally take place at the intake evaluation. This may not be possible if the inmate is under the influence of drugs or alcohol or is otherwise mentally unstable. While medical evaluations typically occur within 10 days of detention, some inmates may have been released and thus will not get tested.

While the majority of HCV infections occur outside of prison, the disease is still widespread within the prison system as a result of drug injection.[13] According to one Rhode Island prison study, HCV infection was found in 23.1% of the male prison population.[14] HCV prevention proved to be more challenging than HIV prevention because inmates partake in high-risk behaviors such as "front loading" and sharing spoons to prepare drugs like cocaine.[3] The prevalence of these diseases within prisons is a concern because they pose a potential public health risk. When prisoners are released, they may continue the same behaviors, thereby increasing the chances of the disease spreading to outside communities.[14] The Western Journal of Medicine estimates the prevalence and predictors of HCV infection among inmates of California by conducting a system wide survey.[15] Findings concluded that HCV infection appears most common in men and women entering prison, displaying prevalence of anti-HCV positive highest among white males and Latina women.

Limited testing for hepatitis C virus (HCV) in three North Carolina jails have shown a prevalence rate of approximately 7% for HCV. The primary barrier is the cost of additional tests needed beyond a screening test. However, some hematologists believe a screening test should be done regardless of ability to pay for follow-up care as a means of changing behavior (for example, refraining from alcohol or not sharing needles). Studies have shown that knowledge of disease status can change behavior with HIV infection.[16] It is estimated that 80% of people with HIV who inject drugs also have hepatitis C virus. HIV co-infection more than triples the risk for liver disease, liver failure, and liver-related death from HCV.

The incidence of tuberculosis in the United States prison system is also significantly higher than rates in the general public. It is estimated that prisoners in the United States are four times as likely as individuals outside of the carceral setting.[17] This is worth noting because although the prevalence of tuberculosis is higher among incarcerated populations, this is not a population that is actively targeted by TB prevention programs. According to a comprehensive review of the 2002 to 2013 Tuberculosis Surveillance System, rates remain high- particularly in the male prisoner population, "Among 5579 persons incarcerated at the time of their tuberculosis diagnosis, 2520 (45%) were US-born and 495 (9%) were female. Median estimated annual tuberculosis incidence rates were 29 cases per 100 000 local jail inmates, 8 per 100 000 state prisoners, and 25 per 100 000 federal prisoners."[18] These rates of infection are significant, as if TB is not properly managed it can have lasting side effects including: permanent lung damage, infection of the bones, spine, brain and spinal cord.[19] Proper attention and care must be provided to this vulnerable population to prevent morbidity and mortality in the United States inmate population.

Approaches to preventing the spread of diseases such as HIV and HCV in prisons include not only internal changes within correctional facilities, but also increased external community support. Between 2.7 million and 3.9 million Americans live with a chronic hepatitis C, but less than 20% receive treatment for the condition.[37][38] Many medically underserved patients, who are appropriate candidates for antiviral treatment, do not receive treatment for a variety of reasons, including limited or no insurance coverage and the high cost of antiviral therapy.[39][40] Such access barriers are compounded by the fact that HCV is particularly prevalent in populations struggling with substance abuse problems, poverty, homelessness, mental illness, low literacy, and language issues, thereby subjecting them to mass incarceration.[38][39][41][42] A study conducted at a Florida State prison concluded that the continual persistence of HIV infections and deaths related to such infections are due to unequal distribution of health care resources to inmates.[43] Such statistics coupled with an increasing rate of incarceration only amplify the issue of HIV/HCV prevention in prisons, with the number of inmates increasing but healthcare policies remaining stagnant.

While the World Health Organization has endorsed certain preventive practices, only Vermont and Mississippi State Prisons and Los Angeles, San Francisco, New York, Philadelphia, and Washington County Jails have provided condoms to inmates.[11] Others have argued against providing condoms because officials feel it condones sexual activity, which is illegal within the prison system.[9]

Imprisonment as a response to US drug use has created a de facto policy of jailing more HIV-infected individuals. High-risk behavior that persists within prisons poses harm to inmates and the greater community alike, but US courts have chosen to remain silent.[44] Separating infected individuals from the rest of the prison population has been seen as ineffective because not all infected individuals have been properly tested. That, therefore, promotes high-risk actions because there is a perceived lack of infected population.

Universal screening methods have proven very effective in certain circumstances. For example, screening among blood donors has all but eliminated transmission of HIV through blood transfusions.[45] Another example is the reduction of perinatal transmission with the introduction of routine screening for pregnant women.[46] The benefits of introducing a routine screening program include:

• Increasing diagnosis of new cases of HIV infection;
• Preserving staff resources by streamlining the process;
• Reducing stigma associated with testing
• Potentially diagnosing HIV infection earlier for the inmate in the course of disease; and
• Improving access to HIV clinical care, medication and prevention services.[4]

In 1996, the CDC revised its recommendations to incorporate diagnostic HIV testing and opt-out HIV screening as a part of routine clinical care in all health-care settings while also preserving the patient's option to decline HIV testing. The recommendations are intended for all health-care settings including hospital emergency departments, urgent-care clinics, inpatient services, STD clinics or other venues offering clinical STD services, tuberculosis clinics, substance abuse treatment clinics, other public health clinics, community clinics, correctional health-care facilities, and primary care settings. (The guidelines address HIV testing in health-care settings only; they do not change existing guidelines concerning targeted testing of persons at high risk for HIV who seek HIV testing in nonclinical settings such as community-based organizations, outreach settings, or mobile vans.)

The new CDC guidelines state "in all health-care settings, screening for HIV infection should be performed routinely for all patients aged 13–64 years. Health-care providers should initiate screening unless prevalence of undiagnosed HIV infection in their patients has been documented to be <0.1%. In the absence of existing data for HIV prevalence, health-care providers should initiate voluntary HIV screening until they establish that the diagnostic yield is <1 per 1,000 patients screened, at which point such screening is no longer warranted."[47]

Additional recommendations for juveniles that are incarcerated in adult jails include the following:

• Know that incarcerated adolescents may be unaware of their rights concerning medical care, privacy, and confidentiality; therefore, it is especially important that adolescents be informed of their rights and that these rights are respected.
• Follow state or local laws that require parental consent or notification for HIV testing and/or HIV-related health-care services for minors. If required, obtain consent for testing and/or health-care services from the adolescent's parent or legal guardian prior to providing that service. Consent can be obtained directly from an emancipated minor as defined by state law.
• Inform adolescents that the medical information, including HIV test results, will not be disclosed without their consent, except as required by law.
• Inform adolescents that, as with all inmates, their HIV status will not adversely affect their medical care during incarceration or their legal rights.[4]

Procedures for offering support to the inmate who receives a diagnosis of HIV should be in place to assure they can manage the infection. Privacy in a correctional setting is difficult, but the inmate should be assured that his medical information is confidential. The following are CDC recommended procedures for inmate support:

• Provide education to patients about HIV infection, AIDS-related symptoms, and the significance of any laboratory testing done.
• Inmates diagnosed with HIV infection may require short-term mental health support.
• Inmates with mental health conditions may require increased monitoring and intervention for these conditions.
• Inmates may be reluctant to access or possess HIV educational materials due to concerns about disclosing their HIV infection. Strategies to provide HIV education and counseling for HIV-infected inmates can include HIV educational sessions and support groups.
• Facilities should have HIV medical information and periodicals available in prison libraries and medical clinics.
• Facilities should have chronic disease management programs for HIV-infected inmates.
• Facilities should have a discharge-planning program for HIV-infected inmates.[4]

Linking inmates to HIV care services when they are quickly released back to the community from a local jail can be difficult. Often they can be more concerned with finding a place to live or finding money to pay their legal fees. But upon giving an inmate a diagnosis of HIV, steps should be taken immediately to ensure that an appointment has been made with a provider, that contact information for a health department or community-based organization case manager is available to help them navigate the healthcare system. Several studies indicate that follow-up care for HIV positive women may correlate with a reduction in recidivism.[48][49][50] Correctional facilities should have the following CDC recommended procedures and resources in place for inmates being discharged from custody:

• Provide a list of available agencies that provide HIV case management for released inmates.
• Provide contact information for local AIDS service organizations and the local health department.
• Assist inmates with making appointments with case manager before release from custody. If possible, arrange for the inmate to meet the case manager before release.
• Complete applications for other services following release in conjunction with the inmate.
• Provide medications if the inmate has started therapy.[4]

The high rate of turnover in local jails as opposed to prisons may make it difficult to implement a routine testing program at intake or on a scheduled basis. In cases where testing all incoming inmates is not possible, there are alternative approaches that can be used individually or in combination with other approaches. One alternative approach could include risk-based criteria screening. The CDC recommends that jails routinely offer HIV testing to inmates who fall under one or more of the following criteria:

• Injection drug use (IDU);
• Men who have sex with men (MSM);
• Sex with an IDU, MSM, or HIV-infected partner;
• Multiple sexual partners;
• Exchange of sex for money, drugs, or other goods; and
• Diagnosis of another sexually transmitted disease.[4]

The limitation with this screening approach is that risks are self-reported by the inmate. One study suggested that up to 42% of inmates diagnosed with HIV reported no risk factors.[51]

A second alternative approach is clinical screening based on HCV, HBV or STD infection. The presence of any of these diseases increases the likelihood of acquiring or transmitting HIV disease. Clinical criteria for screening include:

• Pregnancy;
• A diagnosis or history of sexually or parenterally transmitted infections (e.g., HBV or HCV, syphilis, genital herpes, gonorrhea, chlamydia, trichomonas infection);
• Mycobacterium tuberculosis (MTB) infection or active TB;
• Track marks indicative of illicit drug injection;
• Signs or symptoms suggestive of HIV infection or acute retroviral syndrome.[4]

A third alternative approach for screening in the jail setting is based on demographics such as zip code of residence, age, gender and race or ethnicity. When using this approach, providers in correctional settings should with their state or local health department to determine the demographics of HIV for their population. Criteria examples for demographic screening could include:

• Residence in low-income areas/zip codes;
• Residence in known high-HIV prevalence areas/zip codes;
• Female sex;
• Age 25–44 years; and
• Transgender identity (male to female).[4]

There is also some evidence that screening based on type of arrest could indicate higher rates of HIV infection. For example, a study by the Department of Justice found that HIV infection is more often associated with property and drug-related crimes.[52]

Because there is a high-volume turnover rate of inmates in the jail system, some inmates who are tested for HIV, HCV or other STDs may have been released before receiving their results. Correctional facilities should assure that all cases of newly diagnosed infectious diseases are reported to the state or local health department for assistance with notification of results, counseling, partner services and linkage to care. The CDC advocates a syndemic approach[53] to intervene in the transmission of HIV, HCV and other STDs. This approach includes "combining services to minimize missed opportunities" to detect disease. This approach calls for a collaborative effort between agencies to address high incarceration rates and other social justice issues such as poverty.

Possible HCV prevention techniques have included vaccinations, methadone treatments for drug addicts, access to sterile syringes and needles, use of proper cleaning materials for syringes and needles, lowering the prison population, improving healthcare within prisons, increased availability of condoms, psychological therapy or counseling, or educational classes on drug use and sexual behavior for both inmates and prison staff.[1][54][55] Some prisons already provide prevention techniques such as bleach tablets for cleaning, drug counseling, detoxification, and drug behavior management, but these techniques are not fully effective.

While vaccination programs are accepted, they are not widely implemented. Substance abuse programs are also rare, though HIV and HCV testing are widely available.[1] Because of the ineffectiveness of some preventive techniques, advocates push for alternative forms of rehabilitation for drug offenders to keep these potentially infected people outside of the prison system.[13] These techniques do not only apply to HIV and HCV prevention, but also address the various other diseases present within correctional facilities. Since prevention of any infectious diseases presents a major unsolved problem, public healthcare professionals advocate for a more inclusive and all-encompassing approach.[1]

Due to the high rate of HIV that exists within prisons and the carceral system, these sites are crucial in educating individuals for further infection. The National Commission on Correctional Health Care conducted a study evaluating current modes of handling HIV through prevention programs across the US. In particular, one of the researchers explored peer education in the forms of curriculum modeled after the American Red Cross and California's "Reach One, Teach One" program. By discussing methods in which infected individuals can be educated, the spread of infectious diseases can be reduced by an appreciable margin.[56]

Although there is near consensus in the literature about what needs to be done to reduce the incidence of sexual violence in prisons, to date, little if any research has been undertaken to assess which strategies are most effective. In addition to evaluating the various components of policies and programs to address sexual violence, prison systems have not allowed external, independent researchers to carry out, at regular intervals, a comprehensive review and analysis of the incidence of rape and other forms of sexual violence in their prisons. Additionally, victims of sexual assault in prison do not have access to post-exposure prophylaxis (PEP), which could reduce the risk for HIV transmission after exposure to HIV.[33]