Every year, roughly 641,000 people are released from federal and state prisons, and a whopping 10.6 million people cycle in and out of jails. Lots of research has shown that without health care and some support, the months just after release from custody are when people are most vulnerable to contracting HIV and other illnesses, or even dying. HealthHIV's SYNChronicity Conference in mid-April 2019 included a panel discussion on the current dilemma of health services for persons throughout the nation's prisons and jails and for those re-entering the general public.
Following the session, two of the presenters, Mandy Altman, M.P.A., CCHP, director of the National Hepatitis Corrections Network and Siddharth Raich, M.P.H., education and research director at the Center for Health Justice, spoke with TheBodyPro.
"HIV is still more prevalent in prison than it is within the general public, but hep C is something that is very much impacting correctional populations," Altman said.
Hepatitis C (HCV) and HIV hold greater disease burdens on the correctional community than within the general public. For instance, an estimated 20% of inmates have HCV, while among the general public, the rate is about 1%. The same applies for HIV: Almost 2% of the incarcerated population lives with HIV, whereas 0.34% of the general public is living with HIV.
Altman said HIV and hepatitis C testing in prisons could be more consistent due to the slower turnover rate than with people who are in city and county jails. Though "prison" and "jail" as terms in everyday language are often used interchangeably, they have different meanings and can be very different experiences. Typically, jails house people waiting for their verdicts or serving short sentences (usually less than a year). Prisons house people following a guilty verdict, typically for a felony conviction. Health services vary from jurisdiction to jurisdiction.
"It's different in every state," Altman said. "There are several states that are doing a good job, and Washington is one of them. It starts with testing. Some states don't do testing at all, because if they don't know someone has something, they can't be held accountable for curing or treating them. Prisons are not given enough money to treat everyone."
Altman is based in Washington state, which has opt-out testing. Each inmate is tested for HIV and HCV during intake, yet they have the right to refuse to be tested. Opt-out testing is recommended by the Federal Bureau of Prisons. Each state can decide what approach they want. Further, there are differences between jails and prisons -- as well as differences between health care at private prisons and those run by state corrections departments. And increasingly even in state-run facilities, the health care is managed by private companies.
"That's why even estimating how much hep C is in prison can be difficult, because here in Washington state, we know it's about 20% of men incarcerated have hep C antibody prevalence and about 25% of women, so slightly higher," said Altman. "There are some states like New Mexico who have as high as 50% prevalence of hep C," she said. "There is no exact number, because we don't test everyone. Not every state is the same."
Injection drug use is the most commonly cited cause for hepatitis C prevalence within corrections, but resources are not consistently made available to people who use drugs.
"The hep C rate varies based upon access to syringe exchanges and clean injection equipment, and even what kind of drugs [people] are using," Altman said. "All of that factors in to prevalence."
But health care in Los Angeles County jails may be even more challenging than that in a state like Washington -- it is the largest jail system in the United States and houses between 17,000 and 20,000 individuals across seven facilities. More than 57% are aged 18 to 34, and people in these jails are predominantly black and Latinx. About 25% of the inmate population have diagnosed mental health disorders. The Center for Health Justice (CHJ) in LA provides health education, trauma-informed care, and assistance to people re-entering their communities from the jail system.
"We have a re-entry center downstairs where clients can come in once they're released to get information about HIV, STIs [sexually transmitted infections], and get linked to testing," said Raich. "We realized there's a need for accurate information within LAC [Los Angeles County] settings to dispel myths. A lot of people on the inside don't have access to this sort of information. What we may have gained in school, health, or sex ed, they have never been exposed to."
Raich leads many of these education and research activities for CHJ, which conducted a training module with pre- and post-training assessments of participants' knowledge of HIV and STIs. Raich used the post assessments to evaluate the curriculum's acceptance. There was a 30% increase in awareness of coinfections of HIV and STIs, a 22% increase in awareness of unsafe sex while under the influence of drugs or alcohol, and an 18% increase in knowledge of antiretroviral treatments.
Raich is looking to further CHJ's research into their HIV/STI training program for people leaving jail.
"What we are figuring out is that we are able to educate them about their health, so that's a good thing," he said. "We're also able to get them tested. That's another good thing. And we're able to link them to curative care -- and that's great too, but now what's happening is that there's a step four about people staying in care, and we're starting to see a lot of people dropping out of care," he said.
Raich listed language barriers and literacy as obstacles in initiating the program. Materials had to be written in elementary school–level English and Spanish due to the limited education received by many formerly incarcerated people. In addition, mental health challenges and reading comprehension were considered in determining the pace of the curriculum. Refining this curriculum to serve this community will likely be an ongoing process.
"Prison health is public health," Altman added. "Over 90% of the prison population has a release date. You have a huge concentration of people affected that are in incarcerated settings. What's a better time to treat someone than when they don't have anywhere else to go and they have the opportunity to see a doctor every day?"
But upon release, people who have served time in prison or jail -- especially if they have HIV or hepatitis C -- face dual stigmas.
"What we as the general public can do is to not look down on them trying to better their lives," Raich said.