Correctional systems provide health care for approximately 25% of all people with HIV in the United States. In 2002, the prevalence of AIDS in state and federal prisons was greater than three times that in the general U.S. population. The prevalence of HIV infection was 2% of state and 1.1% of federal prison inmates, and was higher in women, 3%, than in men, 1.9%. Although prisons in the northeast had the highest rate of HIV infection, 4.6%, Southern prisons had the highest number of HIV cases by geographical region. African-Americans had the highest prevalence of HIV reported in any racial group, 2.8%.
Although there is some evidence of intra-prison spread of the virus, most of the HIV among prisoners is thought to have been acquired outside of prison. The high prevalence of HIV in correctional facilities is mainly a consequence of the incarceration of substance abusers and at-risk minorities. In fact, correctional facilities are not only places where HIV-positive individuals are housed, but often where they are identified; prisons and jails may be the most important HIV testing sites in the U.S. In 1990 in Rhode Island, for example, over 40% of all newly diagnosed HIV-infected persons were first tested in a correctional setting.
The high-risk populations mentioned above, very often, are also those most likely to be underserved by the health care system. Indeed, the incarceration period may be the only time that they receive continuous access to health care.
While surveys and prison formularies support that antiretroviral therapy is widely available in correctional facilities, availability and access are not necessarily the same thing. Thus, the growing disparity of HIV for minorities and other marginalized populations in the United States is only further amplified within correctional facilities.
Although there have been no prospective evaluations of HIV outcomes among inmates of correctional facilities, available data suggest that the outcomes in facilities that provide expert HIV care and open access to HIV therapy can be equivalent to or better than non-incarcerated populations. However, a standard of comparison to non-incarcerated populations that overwhelmingly lack access to any primary health care may hide the pressing need to address inadequacies that exist in many correctional systems.
The number of AIDS-related state prison deaths has mirrored the trend for all people with HIV since the introduction of HAART, decreasing by 72% from 1995 to 1999. The only systematic evaluation of HAART outcomes in correctional facilities examined the virological and immunological outcomes of 1,866 men and women treated with HAART for at least six months while incarcerated. The study found that 59% of the inmates achieved viral loads below 400 by the end of their incarceration, which is comparable to HAART outcomes in community cohorts. This study demonstrates that incarceration itself has no adverse impact on clinical outcome when inmates are given adequate clinical care and provided an opportunity to access HAART. But the testimonials of many incarcerated individuals speak to the fact that such care and such access are not always the rule. Prisoners can face many obstacles to controlling HIV disease, including transfers from one prison to another, leading to a lack of continuity of care, and difficulty in continuing medication during and after such moves.
Because of the high proportion of people with HIV who are incarcerated, it is important to investigate the factors that determine their health outcomes. Traditionally, these populations were underserved by the health care systems in their communities and experienced significant health care disparities before they were incarcerated. North Carolina, for example, has a waiting list for its AIDS Drug Assistance Program (ADAP). The population on the waiting list is no different demographically than the population of newly diagnosed HIV/AIDS cases in the state, being primarily of minority race/ethnicity, poor, and, increasingly, from rural areas. The structured health care of correctional facilities, with its presumed equal access, could therefore benefit these underserved non-incarcerated populations, who likewise suffer from unequal access to quality health care.
But, at the same time, prison health care may impede successful HIV outcomes. Directly observed therapy (DOT) is but one example of prison health care practices that can seriously impede HIV care. DOT was started in prisons and jails mainly to monitor inmate adherence to psychotrophic and tuberculosis drugs. It was expanded to HIV medications because of the high costs of HAART and its unique resistance risks. Inmates who receive DOT must stand in line and wait to receive their medications, which a nurse or correctional officer dispenses and watches as they are taken. Many DOT programs in prisons are inflexible, involuntary, non-confidential, and non-individualized. The lack of confidentiality and long lines have been reported by many HIV-positive prisoners as barriers to taking medications. In one study involving directly observed therapy, HIV-infected individuals universally disliked the intervention. Given the stigma attached to HIV by both correctional facility staff and inmates, HIV cannot be treated like any other infection or disease.
It is unclear if DOT is an effective intervention for enhancing antiretroviral adherence in prisons. One study found DOT to be beneficial in a clinical trial of HAART: 95% of prisoners, who were on DOT, achieved viral loads below 400, compared to 75% of non-prisoners, who were not on DOT. But it remains unclear if the higher success rate was due to DOT or to the many other differences between those who are incarcerated and those who are not. Other observational studies in prisons have shown no difference in the adherence or viral loads of individuals on self-medications vs. DOT. DOT is also labor-intensive and costly for correctional facilities, most of which are chronically understaffed and over budget.
The history of health care within correctional systems in itself makes evaluation difficult. Until fairly recently, it was primarily correctional officers who attended to prisoners' health care needs. With the advent of the modern prison health care system, that responsibility was reassigned to nurses, physicians, and physician-extenders such as nurse practitioners. But understaffing is such a chronic problem that prisons and jails are listed as "underserved areas" by the federal government. Staff turnover is high -- especially among nurses -- resulting in poor continuity of care. Often, prisons are once again relying on correctional officers to perform the many tasks more appropriately the responsibility of nurses. Treatment of HIV disease requires constant updates, education, and a high degree of expertise, and the use of those whose main responsibility is custody and control -- and with whom prisoners not surprisingly tend to have adversarial relationships -- can present substantial barriers to the delivery of quality care.
While adherence to HAART for inmates can be challenging, the barriers are not unique to prisons and can be overcome -- given adequate access to expert care and open access to therapy. Issues such as confidentiality and the inflexibility of medication delivery are significant barriers to meaningful access, however, and thus may be greater determining factors for successful HIV outcomes than the mere presence of the latest medications. In addition, many opportunities for HIV testing and education around HIV prevention are missed in correctional institutions. The impact on inmates is great, and the impact on the communities these inmates are taken from and released into may be even greater.
The time has come to recognize the disparity of care that exists within the correctional system and to ensure that a consistent and equal standard of care is provided for all inmates with HIV, no matter the state or facility in which they are detained. The inadequacy of care that exists for people with HIV in the United States reflects a basic social injustice that must be addressed. The inadequacy of HIV care for many inmates may also pose a Constitutional rights issue.
Becky Stephenson is an assistant professor of medicine at University of North Carolina School of Medicine at Chapel Hill, and is co-director for HIV services for the North Carolina Department of Corrections state prisons system.
Peter Leone is an associate professor of medicine at University of North Carolina School of Medicine at Chapel Hill.
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