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The United States has witnessed a significant rise in the number of incarcerated men and women since the 1970s. In the more recent years of this “epidemic of incarceration,” the epidemic of the human immunodeficiency virus (HIV) has hit the correctional system especially hard (Spaulding et al. 2002). Many persons first learn of their HIV infection through jailor prison-based screening (de Voux et al. 2012). Among Americans living with HIV, about one in five are unaware of their HIV status (Centers for Disease Control and Prevention 2010; Centers for Disease Control and Prevention 2012). As the HIV prevalence among US prisoners is more than three times higher than that of the general population (Maruschak 2008), implementing more HIV testing in correctional facilities would provide an opportunity to identify new cases of HIV. Integrating HIV care into standard medical care in all healthcare venues “normalizes” the disease and may encourage persons with known HIV diagnoses to disclose their status. Additional programs are needed to link HIV-positive individuals to HIV treatment and other medical care, as well as to HIV/AIDS education, both in correctional facilities and upon release. The criminal justice system has the opportunity to not only promote public safety, but to lessen health disparities found in the populations passing in and out of correctional facilities.
Dual Epidemics: Incarceration And HIV
The United States has the highest incarceration rates in the world (International Centre for Prison Studies), accounting for approximately 2.3 million Americans serving time behind bars (Glaze 2010). In comparison to the general population, individuals in correctional facilities are more likely to be living with mental illness, tuberculosis, viral hepatitis, substance use disorders, and/or sexually transmitted diseases (STDs) (Rich et al. 2011). Incarcerated individuals are considerably more likely to be living with HIV disease at all stages, including late stage and symptomatic HIV [otherwise known as acquired immunodeficiency syndrome (AIDS)] compared to the general population; approximately 17 % of all Americans living with HIV pass through correctional facilities at least once in a given year (Spaulding et al. 2009).
Minorities are over-represented in both the correctional population and the HIV-positive population. Non-Hispanic Blacks and Latinos are represented disproportionately among those inmates held in prisons and jails. In addition to exceedingly high incarceration rates, Blacks and Latinos are disproportionately affected by HIV. Although Blacks represent only 14 % of the total US population, they account for 46 % of people living with HIV. Latinos represent 16 % of the total US population and account for 17 % of people living with HIV (Centers for Disease Control and Prevention 2012). HIV infection affects those incarcerated as well as the communities to which these people return.
HIV can be transmitted through sexual fluids or blood, placing individuals who participate in unprotected sex, particularly unprotected anal sex, or injection drug use at an increased risk of becoming infected with HIV in comparison to those who do not. When the HIV epidemic began in the United States, gay, primarily white, men were the first persons infected with the virus. As time went on, the epidemic spread to those who participated in injection drug use and unprotected heterosexual sexual intercourse. Additionally, HIV infections were identified among blood transfusion recipients and newborns with an HIV-positive mother. Many injection drug users lived in urban communities and were well acquainted with the criminal justice system. During the time of the HIV transition into a new population, the United States criminal justice system was ballooning, due to the declared “war on drugs” (Spaulding et al. 2002). Drugs users were incarcerated at rising rates, increasing the number of HIV-infected persons in correctional facilities.
Why Is Screening Necessary?
Most incarcerated men and women who are infected with HIV acquired their infection while in the community, before entering a correctional facility (Jurgens et al. 2009; Centers For Disease Control and Prevention 2009). High-risk behaviors such as unprotected sexual encounters and drug use and lifestyles linked with HIV are common among persons who subsequently enter a correctional facility (Braithwaite and Arriola 2003). Substance abuse besides injection drug use can lead to disinhibiting behavior which promotes high-risk behavior, making alcohol, cocaine, and methamphetamine abusers as vulnerable to HIV infection as injection drug users. Social factors epidemiologically associated with high HIV risk include poverty and homelessness (Braithwaite and Arriola 2003). HIV testing of asymptomatic persons has the ability to identify cases that may otherwise go undiagnosed and untreated. Since 18–20 % of Americans are unaware of their HIV status (Centers for Disease Control and Prevention 2010; Centers For Disease Control and Prevention 2012) and the incarcerated population are known to participate in high-risk behaviors associated with HIV infection, there may be a large number of undiagnosed HIV-positive individuals in correctional facilities.
After learning their status, HIV-positive persons tend to decrease unsafe sexual risk behavior and needle sharing; the prevalence of unprotected anal and vaginal intercourse can drop by more than 50 % after HIV diagnosis (Marks et al. 2005). The same phenomenon has been observed among inmates who tested HIV positive during incarceration; receipt of an HIV diagnosis is associated with lower rates of anal intercourse among male inmates (Jafa et al. 2009). HIV testing in correctional facilities, either during or after entry, not only benefits those incarcerated, but also those in the community as well. Partner Services conducted by the local health department (Altice et al. 2010) may be able to locate former sexual and injecting drug partners of incarcerated HIV-positive individuals, allowing those in the communities to seek testing; if positive, these individuals can obtain clinical care and HIV/AIDS education. This is an opportunity to decrease the transmission of HIV/AIDS and to increase HIV/ AIDS knowledge in the communities, extending the potential benefits of HIV testing in the correctional system.
The Center for Disease Control and Prevention (CDC) published the HIV Testing Implementation Guidance for Correctional Settings in 2009. The CDC recommends the adoption of a universal, routine, opt-out testing approach to improve HIV detection among the incarcerated population. This approach includes incorporating consent for HIV treatment into the general consent form for medical services within the institution, meaning that all inmates should be tested for HIV unless an inmate refuses to have the test completed. Studies of jail detainees newly diagnosed with HIV reveal that the majority had no risk for HIV acquisition other than heterosexual sexual relations (Macgowan et al. 2009). Thus, limiting HIV screening to those who report injection drug use or men who have sex with men is less effective in identifying HIV cases compared to universal testing. A large proportion of individuals moving through the correctional system may be offered screening and tested before being released into the community or transported to another facility undiagnosed. Inmates should be given information about HIV/AIDS before testing occurs, and the decision to test must be noncoercive (Centers For Disease Control and Prevention 2009). Medical staff should note when an inmate declines HIV testing because he or she may accept a repeat offer in a subsequent medical encounter. Reasons why inmates may refuse testing include fear of needles, conflict with another activity, lack of knowledge of risk behaviors, and/or an upcoming release date (Altice et al. 2010). Routine opt-out testing has the ability to standardize HIV testing in correctional facilities, reducing the stigma and fear associated with HIV testing. Universal opt-out testing may not be perceived as an option in some facilities when budgets are tight or where custody staff are unable to provide security services for a prolonged medical encounter at entry. Alternatives to the optimal approach of universal testing by nursing at entry include risk-based screening or screening during subsequent medical encounters. Risk-based screening constitutes offering HIV testing to inmates who have had high-risk characteristics (injection drug use, men who have sex with men, sex with an at-risk partner, transactional sex, multiple sex/drug partners, and STDs) within the last 12 months. These approaches allow correctional facilities to test those individuals that may be at the highest risk of HIV infections. However, as noted above, an important study showed that the most common risk factor for undiagnosed HIV among those entering a correctional facility is heterosexual sexual behavior (Macgowan et al. 2009). Thus, targeted testing will miss most infected persons.
Traditional testing consists of an HIV enzyme immunoassay (EIA). When traditional HIV testing is performed, the specimen is processed in an external laboratory; it can take several days for the result to be returned to the staff of the correctional facility. It is still a practical option for inmates with a longer length of stay such as those found in prisons. As of mid-2012, any positive HIV screening test is followed by a second confirmatory test using a Western blot assay (Centers for Disease Control and Prevention 2009). The algorithm for confirming positive tests may be changing in the near future.
In correctional facilities with rapid population turnover such as jails, new “rapid HIV tests” can offer several advantages. Most rapid tests have been approved to be used at the “point of care”; processing does not require sending the specimen to a laboratory. The median length of stay in many jails is 48 h or less (Spaulding et al. in press-a), which means half of the population may have left the facility before conventional HIV tests return. Training for conducting rapid, point-of-care tests is not extensive. With an oral swab or a finger stick for a rapid test, medical staff can complete the HIV tests in as little as 10–30 min (Altice et al. 2010). Medical staff are therefore able to quickly inform inmates of their HIV status shortly after the testing, rather than bringing the person back to the healthcare setting at a later time. Rapid testing offers the advantage of producing a preliminary result quickly; further testing can take place during the same visit, at the clinician’s discretion.
Some facilities do not have access to resources to offer opt-out testing and linkage to appropriate medical care. Partnerships with local health departments and/or community-based organizations can aid in carrying out HIV testing and counseling in correctional facilities where further resources are needed. Additionally, academic institutions have the capacity to assist with testing and clinical care. Professionals with expertise in various disciplines such epidemiology, sociology, and criminology can provide the criminal justice system with data collection and analytic skills to aid in the improvement of testing and clinical care (Rich et al. 2011).
Testing Permits Treatment and Prevention HIV in the incarcerated population is diagnosed at a younger age and earlier stage of disease than in the general population, factors leading to better HIV/AIDS health outcomes (Spaulding et al. 2002; de Voux et al. 2012). Prompt diagnosis after infection and treatment has the ability to save lives. HIV testing is crucial in the correctional system to identify HIV-positive cases or allow individuals to reveal their HIV-positive status, if previously diagnosed. Upon diagnosis, treatment options can be explored and safer behaviors can be implemented to slow disease progression and prevent transmission to others, leading to longer, healthier lives.
Once an HIV-positive status is known, the first step to treatment is HIV education to ensure that the inmate is aware of necessary lifestyle changes and the importance of adherence to treatment (U.S. Department of Health and Human Services 2011). Before initiating antiviral medications, untreated infected persons should have their virus tested to determine what drugs would be most likely to suppress it. This test of susceptibility should be reviewed with a healthcare provider experienced in treating HIV to determine the appropriate therapeutic regimen. In some cases, HIV-infected persons may need to be referred to an outside HIV specialist depending on the complexity of the inmate’s medical issues. Medical staff in some correctional facilities may lack HIV specialists or persons with adequate HIV experience and education on site; these facilities can develop links to HIV specialists in the community and contract with providers to provide the necessary consultative care (Centers for Disease Control and Prevention 2009). Those inmates who disclose their known HIV-positive status and have been prescribed antiretroviral medication should continue or resume treatments under the direction of a provider with HIV experience. Previous medical records should be consulted.
The two methods of administering HIV medications in facilities are directly observed therapy (DOT) and keep-on-person (KOP) therapy. The DOT system requires staff members to administer medications; patients are known to have better adherence using this system, but an inmate may fear the loss of confidentiality. Conversely, KOP therapy requires an inmate to be responsible for administering his/her own medication: the inmate is not monitored by the medical staff and adherence to medical treatment is often unknown. However, this method can aid in adherence of HIV treatment after release (U.S. Department of Health and Human Services 2011).
Since many inmates have co-occurring illnesses, the treatment of disease can become complex. Adherence to HIV medication is essential to decrease viral loads and increase CD4 lymphocyte (CD4+) counts. It is common for inmates, including HIV-positive inmates, to have multiple medical conditions such as substance abuse or mental health conditions. Inmates should receive treatment for co-occurring issues while receiving HIV medication to ensure that they are in a state of mind to understand how to properly take the medication and maintain a healthy lifestyle. Additionally, medical staff need to learn how to identify side effects to HIV treatment and schedule follow-up visits during the first weeks of therapy to monitor adherence and potential side effects (U.S. Department of Health and Human Services 2011).
Treatment: Specific Issues For Prisons
Correctional facilities have become a significant provider of HIV medical care and treatment due to the high number of HIV-infected persons transitioning through the criminal justice system. Additionally, HIV-positive persons incarcerated in prisons have sentences longer than a year unlike those in jails, providing adequate time to receive testing, results, and antiretroviral therapy. The introduction of highly active antiretroviral treatment (HAART) in correctional facilities has aided in the suppression of viral loads and increased CD4+ counts in HIV-infected inmates (Springer and Altice 2005). Sustaining HIV treatment allows HIV-infected individuals to achieve undetectable viral loads, which can greatly decrease the risk of HIV transmission to sexual or drug injection partners. An increased CD4+ count in an HIV-infected person allows preservation of the immune system to help the infected person avoid life-threatening medical conditions. Accordingly, AIDS-related deaths among all deaths in state prisons decreased from 34.2 % to 4.6 % between 1995 and 2006 (Maruschak 2008). This massive decrease in AIDS-related deaths mirrors the decrease of HIV-/AIDS-related deaths nationwide.
Incarceration can be an opportunity for prisoners to receive quality healthcare from medical staff; adherence to medical treatment may be facilitated in a controlled environment. When individuals in correctional facilities are provided with adequate care, health outcomes can be comparable to those in the community setting; however, due to the variation of healthcare services currently offered in correctional facilities, health outcomes vary from facility to facility. A study completed in Texas found that only one-third of HIV-infected inmates who were eligible to be treated based on the Department of Health and Human Services criteria for initiation of HAART were on HAART therapy (Baillargeon et al. 2000). While treatment of HIV infection in correctional facilities can be successful, inmates have the right to refuse treatment and not all inmates take advantage of the possible medical treatments for reasons such as adverse side effects or poor prognosis.
Diagnosis And Treatment Is Feasible In Jails
HIV testing and treatment rates in jails tend to be lower than those in prisons (Culbert 2011). However, due to the success rates observed in some prison settings, jails have the potential to produce successful declines in HIV complications. On a given day, 750,000 persons are incarcerated in jails, most only staying for a short period of time (Spaulding et al. 2009). Jails provide a setting to offer HIV testing and treatment, if necessary, to thousands of persons daily. Inmates may not have access to adequate healthcare in the community and may not pursue testing on their own. Without testing, undiagnosed HIV-positive individuals will continue to engage in risky behaviors and may transmit the virus while incarcerated and/or in the community.
Given the rapid turnover of inmates and chaotic environment of jails, traditional HIV testing was challenging, but rapid testing has made HIV testing feasible in jail settings. However, if a rapid test produces a positive result, results of confirmatory testing may take 1–10 days to arrive at a correctional facility. Some inmates may be released from jail by the time the test result returns. However, community-based organizations can aid correctional facilities in contacting former inmates regarding their HIV status and offer linkage to medical treatment, if needed. An oral fluid HIV test can offer an alternative to blood tests, especially for persons who fear needles; confirmatory results will arrive in 3–5 business days (Altice et al. 2010).
In 2003, the states of Florida, Louisiana, New York, and Wisconsin received funding from the CDC to conduct HIV testing in jails. These four programs successfully performed 33,211 tests and identified 269 new HIV cases. With the use of rapid HIV testing, 99.9 % inmates received their test results. These testing programs also demonstrated the feasibility of universal opt-out testing. Of those who received a reactive rapid HIV test, rates were particularly high among persons who did not report risk behaviors (3.1 %), including injection drug use, male-to-male sex, transactional sex, sexual assault, STDs, heterosexual behavior, or sex with an at-risk partner. Incarcerated men who did not report risk behaviors were more than four times likely to be diagnosed with HIV than incarcerated men who reported heterosexual behavior. Therefore, new cases may be missed if inmates were only offered testing based on risk behaviors. A total of 440 known and newly diagnosed HIV-positive inmates with a reactive rapid HIV test were referred to medical care, treatment, and prevention services (Macgowan et al. 2009), demonstrating that HIV testing and linkage to medical care and treatment is feasible in the fast pace environment of jails.
In a jail setting, inmates may be released soon after being diagnosed as HIV positive; therefore, inmates may not have the opportunity to receive a pretreatment evaluation and begin antiretroviral treatment in jail. Linkage to HIV medical care and treatment in the community is critical to ensure that these HIV-positive individuals begin treatment as soon as possible after release. For those individuals with a longer length of stay in jail, pretreatment evaluation can be completed and the appropriate antiretroviral treatment can begin. Many newly diagnosed HIV-positive inmates start HIV treatment while in a correctional facility, receiving HIV medical care for the first time. Additionally, inmates and former inmates may be able to resume HIV therapy previously interrupted in jail and through linkage to care after discharge. Considering the short length of stay for most jail inmates, the cost of treatment for those with a longer length of stay should be minimal (de Voux et al. 2012).
Trust And Confidentiality
Although HIV/AIDS diagnosis in the correctional system has its benefits, some inmates may delay or refuse HIV/AIDS-related services in correctional facilities for reasons such as mistrust of staff and/ or fear of discrimination from peers. Routine and opt-out testing has the capacity to reduce the stigma associated with HIV/AIDS. Inmates can be provided with literature on various health topics to deter others from learning about their medical conditions. In many facilities, HIV testing is provided only upon request. In a harsh environment such as a correctional facility, inmates may not feel comfortable requesting an HIV test. Inmates may feel more comfortable releasing medical information and completing care during medical assessments when the testing is common practice in correctional facilities (Centers for Disease Control and Prevention 2009).
HIV treatment in correctional facilities can lead to issues regarding confidentiality, as inmates have little privacy while incarcerated. It is important for facilities to create methods to guarantee inmates’ medical confidentiality during HIV treatment delivery. In a setting where HIV may be stigmatized and the risks of violent acts are high, inmates may not feel safe while disclosing and receiving medical care from the medical staff. To receive medications, inmates may have to be escorted to another area in the correctional facility. When HIV-positive inmates are segregated, adherence to medication may be reduced and confidentiality compromised. Methods as small as allowing the doors to be closed while medical staff are disclosing information to the inmates may decrease the amount of information overheard by other staff and inmates as well as gain the trust of the inmates. All medical records should be under lock and key with access to only select personnel. The trust between the staff and inmates is vital to encourage the treatment of HIV and persuade HIV-positive inmates to initiate and adhere to the recommended treatments during their sentence and when released back into the community (Centers for Disease Control and Prevention 2009; Wakeman and Rich 2010). Ultimately, the medical staff and the custody staff must work as a team to keep inmates being tested for HIV safe.
HIV Prevention Inside Correctional Facilities
More risk behaviors usually take place in the community than while incarcerated (Braithwaite and Arriola 2003); however, the risk behaviors and potential to transmit HIV and other infectious agents to others during incarceration should not be overlooked. A study completed in Georgia found new cases of HIV during incarceration among inmates who tested negative during entry HIV testing (Jafa et al. 2009). There is evidence that transmission of HIV occurs in correctional facilities; however, the frequency of its occurrence and method of transmission is not absolutely known. The incidence of HIV transmission may vary in different facilities.
Existing data and research provide evidence that high-risk behaviors associated with HIV, including sexual intercourse and injection drug use are present in correctional facilities, even though these activities may be banned. The World Health Organization and the Joint United Nations Programme on HIV/AIDS strongly recommend the use of harm reduction strategies in correctional facilities. Condom distribution in correctional facilities has the capacity to reduce HIV transmission during penetrative sexual intercourse. Additionally, distribution of clean needles and syringes or diluted bleach along with instructions for cleaning injection equipment has the ability to reduce HIV transmission during drug injection, tattooing, and skin piercing (The World Health Organization and The Joint United Nations Programme on HIV/AIDS 2006). Most US correctional facilities have resisted adopting HIV prevention policies and practices such as condom distribution, needle and syringe programs, and decontamination strategies for injection equipment to reduce the transmission of HIV, because adoption of the UN standards is perceived as condoning such behavior. Items such as condoms and needles are viewed as contraband in jails and prisons, and inmates are not allowed to possess them while incarcerated (Tucker et al. 2007; Jurgens et al. 2009). Condoms are available in state prisons in only two states, Vermont and Mississippi, and in jails in five large urban jails (New York City, Philadelphia, San Francisco, Los Angeles, and Washington D.C.) (Braithwaite and Arriola 2003). Controversy surrounds the issue of providing inmates with harm reduction strategies such as condoms and clean needles due to the conflict between risk behaviors and rules in correctional facilities. Many administrators of correctional facilities do not want to acknowledge that risk behaviors continue to take place in their facilities since rules have been established in an attempt to prevent such occurrences. Even though some correctional officials may be aware of the needs for HIV prevention and medical care among the incarcerated population and wish to provide these populations with harm reduction equipment and knowledge, limited resources and decreased funds may replace the health of inmates with custody and security issues on the list of priorities (Braithwaite and Arriola 2003; Tucker et al. 2007). To decrease the concern that some HIV prevention programs may contradict the rules and policies of the correctional system, it has been recommended that messages and education to reduce HIV transmission be presented in a way as it applies to HIV prevention once released from a correctional facility (Braithwaite and Arriola 2003). In this way, correctional officials would not have to deviate from the rules in their facilities, and inmates would have the opportunity to learn how to protect themselves and sexual and/or drug injection partners from HIV transmission.
Unintended Consequences Of Incarceration: Concurrency In The Community
The criminal justice system removes individuals away from the community, friends, family, and intimate partners. Once sexual or injection drug partners are separated, new partners may be introduced into the relationship; partners left in the community may engage in sexual intercourse and injection drug use with new partners. When the number of sexual or drug injection partners are increased, the risk of becoming infected with HIV and other sexually transmitted diseases increases. While incarcerated, inmates may engage in sexual activities with new partners, either by choice or coercion. Injection and tattooing equipment may be shared with other inmates. Due to the large number of incarcerated black males, black women are disproportionately represented in the community. This increases the opportunity for men in the community to have relationships with multiple women and decreases the number of potential long-term male partners for women (Pouget et al. 2010). Men and women in the community and those in correctional facilities are placed at a higher risk becoming infected with HIV.
Among recently incarcerated males, high-risk sex partnerships are likely to be reported. A study of men, aged 15–44 years old, found that incarceration may impact sexual behavior between both users and nonusers of illicit drugs. Multiple and concurrent partnerships were strongly associated with recently incarcerated men; however, the introduction of illicit drugs heightened risk behaviors with multiple or concurrent partners. Drugs enable individuals to engage in risky sexual intercourse and further drug use without sound judgment (Khan et al. 2009). The correctional system has a significant impact on those incarcerated and those left behind in the community.
Linkage To Medical Care After Release
After being released from a correctional facility, individuals need to be integrated back into the community. Former inmates may encounter a host of social and medical challenges upon release. In a population with an exceedingly high number of substance abusers and individuals suffering from mental illness, relapse to addiction and untreated medical illness is common upon release, respectively. Though there is a particularly high prevalence of mental illness in the correctional system, including 60% in state prisons, 45 % in federal prisons, and 64 % in jails, only 25 % of inmates with psychiatric conditions received medications. Mental conditions left untreated can lead to a low adherence to antiretroviral therapy and reentry into a correctional facility (Rich et al. 2011). In states with a high rates of opiate abuse, drug overdose has been noted as a leading cause of death in the immediate post-release period (Binswanger et al. 2007). Homelessness and poverty often burden releases. It is possible for some inmates to lose Medicaid benefits during their sentence, resulting in an average interruption of 3 months in insurance coverage while the individual reapplies (Wakeman et al. 2009). Individuals convicted of drug-related charges are banned from receiving food stamps or federal assistance under the Welfare Reform Act and can be denied public housing under the Anti-Drug Abuse Act of 1988 (Pogorzelski et al. 2005). Antiretroviral therapy in correctional facilities has been successful in a few states; however, the improvements in an inmate’s health observed during incarceration may quickly diminish if adequate care and treatment is not continued (Rich et al. 2011). Medical services offered during incarceration may be the individual’s first link to primary healthcare and HIV/AIDS care. It is common for incarcerated persons to return to poor communities with little or inadequate access to HIV medical care. As there are a considerable number of obstacles presenting themselves, adhering to HIV treatments may not be a high priority for many releasees while trying to gain stability in the community. Release from a correctional facility has been associated with poor HIV treatment adherence: only 5.4 % of released HIV-positive inmates filled their antiretroviral prescriptions within 10 days, 17.7 % after 30 days, and 30.0 % after 60 days (Baillargeon et al. 2009). Poor adherence can lead to disease progression and emergence of drug–resistant viral HIV strains. Therefore, prerelease discharge planning, case management, and linkage to care are crucial to ensure that former inmates initiate and continue HIV/AIDS care and treatment. Non-adherence to HIV treatment upon release from a correctional facility may also be linked to inadequate discharge planning (Culbert 2011).
Prerelease discharge planning allows inmates to develop a plan to access medical care and treatment while incarcerated to reduce the burdens faced by inmates upon reentry into the community. Many agree that discharge planning is a legally and ethically mandated standard of care for those in the criminal justice system. During discharge planning, inmates can be provided with (a) a list of medical providers in the community, (b) an appointment with a community care provider, (c) education about the importance of adherence to medications, (d) transfer of medical records, (e) assistance with insurance applications, and (f) linkage to HIV case management services. Upon release, former inmates should be provided with an adequate supply of medication to avoid interruption in treatment until the initial appointment in the community (Centers for Disease Control and Prevention 2009).
HIV case management services have the ability to assist with discharge planning to link recent releases to healthcare and other resources in the community; case managers provide a link between former inmates and healthcare facilities to make access to healthcare easier. Inmates who participate in adequate discharge planning may be more likely to sustain their health and avoid reentry into correctional facilities (Culbert 2011). Although case managers can be beneficial to recent releasees, there are shortcomings that come with using just case management programs to ensure that adherence to HIV treatment and non-detectable viral loads are continued upon release, and that linkage to medical services is established. Discharge planning and HIV case management should not only involve linkage to HIV medical services and treatment, but also to organizations that can alleviate social burdens upon release as well such as health insurance, housing, and substance abuse treatment to reduce the number of burdens that releasees face. In the face of social burdens, HIV-positive releasees may disregard adherence to medication.
To create an effective discharge planning program, a considerable amount of money and faceto-face time is required in addition to the development and continuance of partnerships within the communities in which former inmates reside upon release. However, budget cuts and transfer of correctional healthcare services into the private sector have reduced partnerships with community-based organizations (Culbert 2011). Although there are challenges and resources may be limited in some facilities, an effort can be made to increase adequate discharge planning and case management programs in the correctional system.
Starting in 2006, the Rollins School of Public Health at Emory University and Abt Associates, Inc. coordinated the evaluation of the Enhancing Linkages to HIV Primary Care and Services in Jail Settings Initiative (EnhanceLink). This initiative successfully provided HIV testing in 20 US jails, resulting in 822 new diagnoses out of 212,464 inmates who agreed to HIV testing. Services were provided to not only address linkage to medical care but also to social needs upon release such as mental health and substance abuse treatment and linkage to housing. Transitional services were accepted by 82 % of HIV-positive persons in the program offered services (Spaulding et al. in press-a). At 6 months follow-up, 26 % of releasees had suppression of their HIV viral load (Spaulding et al. in press-b). In a jail setting, HIV testing and linkage to care after release are feasible. With adequate program planning, successful testing and transitional programs can be implemented in jails and prisons throughout the United States.
The prevalence of HIV is high in the correctional population, but HIV disease needs to be understood in context. Men and women entering the correctional system are also disproportionately affected by low socioeconomic status, violence, mental illness, substance abuse, chronic disease, and infectious disease. With a large proportion of HIV-positive individuals passing through the correctional system, these facilities have the opportunity to play an instrumental role in the diagnosis and clinical care of HIV/AIDS patients. Known HIV-positive persons would be able to receive HIV medication and avoid interruption of therapy. Undiagnosed HIV-positive persons could learn of their HIV status and begin treatment; access to HIV testing may be suboptimal after release. Treatment of HIV with antiretroviral therapy is needed to lower viral loads and restore the immune system, allowing HIV-infected persons to live a healthier life. Correctional facilities are settings where HIV-positive persons might control their HIV for the first time.
Furthermore, due to the poorer health status and higher incarceration rates of people of color, the criminal justice system has the opportunity to significantly decrease health disparities. If HIV medical services are not provided to the incarcerated and released population, poor health outcomes could continue to devastate communities plagued by poverty and high crime rates. The incarcerated have a right to adequate medical care. Many individuals transitioning through a correctional facility do not have access to adequate healthcare, prior to receiving healthcare in a correctional facility. An effort has to be made to develop more partnerships between the correctional system and the community-based organizations.
Medical care in the criminal justice system provides medical and public health professionals the opportunity to work with a vulnerable and underserved population. In order to continue to have a supply of providers sensitive to the needs of inmate patients, medical schools and residency programs should consider providing mentored training opportunities in correctional facilities. The correctional setting provides opportunities in a challenging environment to reach a large underserved population, while developing skills in areas such as working with patients with cooccurring medical conditions and dealing with a high turnover rate of patients. There are many practice and research opportunities available in correctional facilities to address and aid in the needs of the incarcerated. The criminal justice system has the capacity to be a wonderful training ground for future health professionals.
Correctional healthcare, if administered well, can have a positive impact on the lives of HIV-positive inmates. There is an opportunity to enhance HIV medical care in correctional facilities. Correctional healthcare can mitigate the disparities among a poor, underserved population. Improved HIV educational programs, HIV testing, and linkage to care is needed to ensure that better health outcomes are observed in the incarcerated population and after release to the community. Failing to address health disparities is an additional punishment.
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