Jail is not the same as prison. It's a distinction that Alysse Gail Wurcel, M.D., M.S., wishes more people understood, because there are dramatic differences in the way incarcerated people receive medical care.
As bleak as health outcomes can be in the nation's prisons, people with infectious diseases are often worse off in the nation's local jails.
"When you see that the ACLU won some [lawsuit] for hepatitis C treatments in prisons, that does not mean anything for jails," said Wurcel, attending physician and assistant professor at Tufts University School of Medicine.
Wurcel presented her perspective on screening and treatment in jail at the IDWeek conference on Oct. 2 in Washington, D.C. The following day, she and her colleagues presented a poster about the current state of hepatitis C (HCV) care in Massachusetts jails.
About 11 million people pass through the nation's jails every year, making jails an important opportunity to screen for infections that disproportionately affect incarcerated people.
But according to Wurcel's research in Massachusetts jails, less than half (46%) of nursing intake forms offered HIV testing, and only 15% of forms offered HCV testing.
Testing rates are low in jails because -- unlike prisons -- jails tend to be more transient holding centers, making it less likely that jails will invest in a patient's long-term health. Also unlike prisons, they are managed locally, subject to the political leanings of regional sheriffs.
Meanwhile, jails are used to temporarily house Immigration and Customs Enforcement detainees, and if any may happen to have a condition like measles, mumps, or tuberculosis, language services and other supports may not be available in jails. This increases the likelihood of illness and even death for immigrants being detained in city and county jails.
There are many health disparities to tackle in jail, but Wurcel says that bolstering HIV and HCV testing upon intake would make a big difference.
"The lowest-hanging fruit is that during nursing intake, people be asked if they would want HIV/hep C testing, because that's the only mandated [health care] interaction," she said.
Beyond that, Wurcel believes it's important to ask people in jail multiple times, and at each medical encounter, if they would like to be tested -- preferably using opt-out testing language.
According to Wurcel's unpublished survey of 21 people jailed in Massachusetts, less than 10% who went through the nursing intake remembered being asked about HIV/HCV testing.
Even when jails ask their inmates if they would like to get tested, Wurcel has mounting evidence that those requests are often not carried out.
"A lot of my research is saying that when they say yes [to testing], it doesn't get done," said Wurcel, who is working on a still-unpublished paper that will include more than 8,000 participants.
When Wurcel started working in jails in Massachusetts, she quickly recognized that all the medical training in the world didn't prepare her for the political realities of working within the correctional system.
As she gained experience, she believed that many of the corrections officers' concerns were valid. For example, jail officials are reluctant to give buprenorphine to people with opioid withdrawal -- not out of cruelty, but because buprenorphine is used as currency within the jailhouse walls.
At IDWeek 2019, she presented a poster that summarized key stakeholder concerns about HCV care in prison. Those stakeholders included patients, providers, payers, policy makers, product makers, and researchers.
Through qualitative interviews, Wurcel and her colleagues learned that HCV care in jail was not a priority because HCV is not an acute illness. Jail administrative staff were also put off by the cost of treatment and the stigma against people who inject drugs. Still, she noted that jails present a good opportunity to screen for HCV, and many people in jail are interested in accessing HCV care.
"I think it's very easy as an infectious diseases doctor to say, 'You need to treat everybody for hep C,'" she said. But the reality is very different. For Wurcel, the best thing providers working in jail can do is advocate for opt-out HIV/HCV screenings.
Beyond that, she said, "we need criminal legal reform, because I'm not sure there is a lot of justice involved."