Over the last three decades, the number of inmates in State and Federal prisons in the United States has skyrocketed: from less than 200,000 in 1970 to 1,254,600 by 1999.  Local jails house another 606,000 people, and in addition to those who are incarcerated, 5 million people are either on probation or parole. Thus, the United States has one of the highest rates of incarceration in the world: 682 inmates per 100,000 citizens, second only to Russia's rate of 685.¹

The dramatic increase in the number of incarcerated people has, in part, been fueled by the American "war on drugs."  In 1984, 29 percent of the population in Federal prisons were drug offenders. From 1984 to 1998, the Federal incarcerated population more than tripled and, in 1998, nearly 60 percent were drug offenders.²

The incarcerated population is primarily male—94 percent in 1999—and the majority are people of color: African American (48 percent) and Latino (19 percent).  Incarcerated people often come from poor backgrounds, and tend to be less educated than the general population: in 1991, 32 percent of jail inmates who had been free for at least one year prior to their arrest had annual incomes of under $5,000; 65 percent of State prison inmates had not completed high school.¹

There is a "revolving door" into incarceration in the United States, with thousands of inmates rotating in and out of jails and prisons each year.  Although recent data on recidivism are not available, a study estimated that of the 108,580 persons released from prisons in 11 States in 1983, 62.5 percent were rearrested for a felony or serious misdemeanor within 3 years, 46.8 percent were recon-victed, and 41.4 percent returned to prison or jail.³

Incarcerated populations suffer from myriad diseases and health problems. In particular, tuberculosis, HIV/AIDS, and other sexually transmitted diseases such as syphilis, gonorrhea, hepatitis, and chlamydia are far more prevalent among incarcerated persons than the general U.S. population.4  Many of today's inmates are involved with drugs; some reports estimate that two-thirds of those entering State and Federal penitentiaries have histories of substance abuse.⁵

Providing adequate health care to the incarcerated population is rife with challenges. Despite the fact that inmates are the only Americans with a guaranteed right to health care, there is a long history of inadequate and substandard care for this population. 

While correctional institutions are obligated to provide health care to inmates, security and detainment remain their foremost concerns. The concern for security can be at odds with the provision of health care, leaving those with complex care needs especially vulnerable. In addition, public opinion may not be sympathetic to this population: skeptics decry providing "free" health care to a criminal population when health care for many Americans is costly and out of reach. 

Incarcerated People with HIV

According to the "1996-1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities," 2.3 percent of all State and Federal prison inmates were infected with HIV, or 24,881 people (947 Federal and 23,934 State) at year-end 1996.  Recent estimates indicate that the number is now 56,000.

In 1996, New York housed more than one-third of all inmates known to be HIV positive; Florida had the next largest number. More than one-half of the State prison inmates known to be HIV positive were found in the Northeast, where 7.5 percent of the prison population were HIV positive (2.0 percent were HIV positive in the South, 1.1 percent in the Midwest, and 0.8 percent in the West.)⁶

A 1999 study found that, of the 220,000 persons in the United States reported with AIDS from January 1994 through December 1996, 9,370—or 4 percent—were incarcerated at the time of diagnosis.  Compared with the overall population of PWAs at the time of the study, more of the incarcerated population were male (89 percent versus 81 percent), African American (58 percent versus 40 percent), and younger at the time of diagnosis (median age of 35 versus 37). Not surprisingly, more of the incarcerated persons contracted HIV through injection drug use than the general population—61 percent versus 27 percent, and more were men who had sex with men who inject drugs (9 percent versus 5 percent).⁷

Harm Reduction in Correctional Settings

The risk reduction education that would include recommendations on condom use during sex and the use of bleach to clean injection equipment is not generally being provided in the prison or jail setting.  The majority of U.S. correctional facilities prohibit condoms, and most are reluctant to provide bleach for the specific purpose of cleaning needles, although they are finding increasing acceptance in other places such as Europe and Canada.⁶

In terms of HIV testing, a 1999 survey conducted by the trade journal Corrections Compendium found that 20 of the responding U.S. systems test inmates at intake.  Thirty-six test if it is requested by the inmate, and 29 will test if requested by a physician.  Testing can also be done if court ordered or if the inmate is exposed to bodily fluids.  New Jersey, South Dakota, and Wisconsin will also test if requested by a physician, but only with the inmate's consent.  Mississippi, South Carolina, Nevada, and Texas segregate infected inmates; four other jurisdictions will do so if the inmate's behavior warrants such action.⁹

Within correctional systems, HIV/STD education and prevention programs are becoming increasingly common, including instructor-led education and, in some cases, peer-led programs. Evidence suggests that peer-education programs are particularly effective in reaching inmates with practical information on HIV and STD prevention; such programs are credible to inmates, as well as cost effective.⁶

Training
For a variety of reasons, prison health care providers have difficulty keeping abreast of the most current advances in HIV treatment.  Many lack the caseloads necessary for generating a wide base of experience.  Others are isolated from urban centers where HIV is most common, leaving them cut off from providers who are knowledgeable about complex HIV standards of care. Prison health care providers also often operate with scarce resources, so securing funds and time for participating in educational activities is difficult.⁷

HRSA's AIDS Education and Training Centers have also responded to the training needs of prison personnel through special initiatives. Telemedicine and the Internet, in particular, are improving access to up-to-date treatment information for these clinicians.

Costs
HIV/AIDS care in prisons is expensive: based on voluntary reporting through a 1998 survey, the San Francisco-based Correctional HIV Consortium estimates the average cost of housing and security for an AIDS-diagnosed Federal inmate to be nearly $106,000 a year, compared with $38,500 for the average inmate. (Because of huge variances, calculating accurate costs for State and local prison costs is not possible.) The Consortium estimates that an HIV-positive Federal inmate's housing and security costs are more than $80,000.

In the context of high treatment costs, some in the prison health care field express concern about the provision of prison health care services by outside vendors or contractors, who receive set amounts of funding to
provide services in a specific institution or locale. Contractors may regard early identification and treatment of persons with HIV infection as a financial liability, which may serve as a disincentive to identify and treat such inmates.¹⁰ 

Discharge Planning
Case management and discharge planning services are critical if inmates are to receive appropriate HIV care and treatment after release. Many will rely on providers funded through the CARE Act, and these providers must be prepared to meet the needs for a comprehensive array of services.  Discharged inmates with HIV need immediate access to health care services.  Prisoners are often released  with a short-term medication supply.  Other concerns are equally critical, including housing, employment, and substance abuse treatment.

HIV/AIDS among incarcerated people is a potential public health emergency, both within jail and prison walls, and in the communities to which inmates return.  In addition to adequate, humane health care for the entire inmate pop-ulation, specific challenges must be met in order to bring care that meets current standards to the HIV-infected population.  The treatment advances of the last several years are meaningless to those behind bars if they do not have access to—and the means to adhere to—complex regimens. HRSA's HIV/AIDS Bureau has identified and funded projects that are making a difference, but much more needs to be done.

1."Facts About Prisons and Prisoners," The Sentencing Project, April 2000, Washington, DC.
2."Federal Bureau of Prisons Quick Facts," www.bop.gov, April 2000.
3.Beck J, Shipley B. "Recidivism of Prisoners Released in 1983."  Bureau of Justice Statistics Special Report, April 1989, NCJ-116261.
4.Hammett TM. "Public Health/Corrections Collaborations:  Prevention and Treatment of HIV/AIDS, STDs, and TB." National  Institute of Justice and Centers for Disease Control, Prevention Research in Brief, July 1998.
5.Inciardi J. "HIV Risk Reduction and Service Delivery Strategies in Criminal Justice Settings." Journal of Substance Abuse Treatment, (13)5:421-428, 1996.
6.Hammett TM, Harmon P, Maruschak LM. "1996-1997 Update:  HIV/AIDS, STDs, and TB in Correctional Facilities," July 1999.
7.Dean-Gaitor HD, Fleming, PL. "Epidemiology of AIDS in incarcerated persons in the United States, 1994-1996. "AIDS, 1999, 13:2429-2435.
8.Mutter R, Grimes R, Labarthe D. "Evidence of Intraprison Spread of HIV Infection." Archives of Internal Medicine, 154:793-795, 1994.
9."Inmate Health Care-Part 2," Corrections Compendium, (24)11:12, 1999.
10.Frank L. "Prisons and Public Health: Emerging Issues in HIV Treatment Adherence." Journal of the Association of Nurses in AIDS Care, 6:10, November 1, 1999.

Through relationships with community partners, the Hampden County Correctional Center in Ludlow, MA, provides high-quality medical care to inmates, and assures continuing health care after inmates are released from jail. The results of their program hold great promise for replication by other correctional systems.

This facility has contracted for medical services with the four non-profit neighborhood health centers in greater Springfield. Each center provides physicians and case managers, who work both at their center and at the jail. When an inmate is diagnosed, he is matched with a physician and case manager at the health center nearest his home, in anticipation of his eventual release.

All inmates in this facility are seen by a medical professional and receive a physical exam and compre-hensive medical and diagnostic assessment. Eligible inmates without health insurance are enrolled in Medicaid, which is activated after their release.

This program follows the basic public health model of care: early detection, early treatment, prevention, education, and continuity of care.  The program has made a considerable difference in terms of health and quality-of-life—the vast majority of inmates keep medical appointments after being released, and the recividism  rate among the facility's inmates is much lower than the national average.  Although every corrections system has unique characteristics, the Hampden County Correctional Center model is instructional for other institutions that seek to develop partnerships based on a public health model.

Emory University School of Medicine:
HIV Training for Georgia's Correctional
Health Care Providers

Helping prison health care providers stay abreast of the most current advances in HIV treatment is a significant challenge. In Georgia, Emory University School of Medicine is helping to fill the training void, with promising results that can be replicated elsewhere.

From 1994-1999, Emory, home of the Southeast AIDS Education and Training Center, provided training to Georgia Department of Corrections personnel on a variety of topics related to HIV/AIDS. The training took place in two settings: large, off-site statewide HIV training workshops that covered a wide range of subject matter, open to any employee of the corrections department; and within eight prison sites, where interactive clinical teaching was provided by a preceptor.

The project's goals were:

1. Increase the capacity of correctional health providers to deliver appropriate, comprehensive care to inmates with HIV/AIDS through the provision of training and education;
    
2. Design two distinct models for correctional health worker training in order to compare their impact and outcome; and
    
3. Evaluate the effectiveness and replicability of different models of correctional HIV training and education.

In addition to the two training models, the HIV knowledge base among correctional providers was assessed, and an HIV curriculum for corrections was developed. Results have been disseminated to the professional community. The program has also focused on the need to educate caregivers about the particular problems inmates face as they transition back into their communities. 

The Fortune Society, ETHICS 3 Program

Even for those inmates who receive good care while in a jail or prison, continuity of care once they are released is a significant obstacle. The Empowerment Through HIV/AIDS Information, Community and Services (ETHICS) 3 program at The Fortune Society in New York City helps provide continuity of care for HIV-positive ex-offenders, and does so with a family model.

The Fortune Society serves incarcerated people and ex-offenders with a "holistic" approach, offering a wide range of health, support, and social services.  The majority of ETHICS 3 clients make initial contact with Fortune Society staff while they are still incarcerated, and are then linked with medical care and support services upon their release.

The program links clients and families with an integrated system of care that is sensitive and responsive to the needs of people with HIV/AIDS; health care providers  work closely with case managers, who help stabilize ex-offenders' lives.

Program staff have found that substance abuse figures prominently among many of their HIV-infected clients, making substance abuse treatment a high priority in their discharge plans. Without it, clients relapse, making it difficult for them to adhere to medication regimes.  In addition, homelessness, risk of relapse, transition from incarceration, and isolation are issues that staff must address as they help clients make the transition back to their communities.

The study focused on gaps in services faced by Federal inmates reentering the community. CARE Act funds cannot be used to provide services covered by other resources, but the study considered to what extent they can be used to provide transition services not available from other sources.  The study concentrated on Federal inmates with HIV disease entering a community-based halfway house setting, but findings are applicable to inmates released from State, county, and local prisons and jails.

The study revealed that corrections staff often assist HIV-positive individuals who are about to be discharged.  For example, a physician may make clinic appointments and establish community contacts for the inmate.  Some case managers and social workers assist inmates with linkages to medical and social services.  However, recently released inmates did not always enter the halfway house program with a 30-day supply of medications.  Moreover, halfway house staff were often unaware of the HIV status of residents.

Authors of the study made the following recommendations:

• Make release planning for inmates with HIV disease the primary responsibility of the unit management case manager with assistance from the medical staff.
• Adjust current Bureau of Prisons policy to allow for more than a 30-day supply of medications.
• Create appropriate linkages with the community, to begin during the release planning process. For example, CARE Act- funded programs in a community could link with release planners at Federal prisons.
• Allow inmates to apply for Medicare and Medicaid while in Federal custody.
• Create a community resource manual.
• Increase prevention education and training for both staff and inmates.
• Increase support for case managers at halfway houses.

More than 15,000 copies of the 400-page guide were given away during the Conference -- 8,000 on the first day.

Edited by Jean Anderson, M.D., Johns Hopkins School of Medicine, the book includes 14 chapters written by women care providers on a range of topics, including primary medical care and prevention, HIV and reproduction, gynecologic problems, psychiatric issues, substance abuse, adolescents, and palliative and end-of-life care. The guide also includes an extensive list of resources.

The Women's Guide is available online at www.hrsa.gov/hab.  Single copies may be ordered from the HRSA Information Center by calling 1-800-275-4772.

This is a preliminary edition, and the HIV/AIDS Bureau invites your comments.  Please send them to:

Downloadable Documents Available on the Web

HAB's Web site (www.hrsa.gov/hab) now has technical assistance documents for downloading. Items can be found under "Tools to Help CARE Act Programs-TA Publications." Among the additions: Needs Assessment Guide; Outcomes Evaluation TA Guide; PLWH Sourcebook; Title I, II, and III Manuals; Evaluation Monographs; and National TA Call Reports.

Reauthorization Update

The Senate and House of Representatives have passed separate bills to reauthorize the CARE Act.  In keeping with normal legislative procedures, the next step is to proceed to conference, which will be held after the August recess.  In the interim, House and Senate staff members are expected to begin to resolve differences between the two bills so that the conference may complete its work rapidly. 

After the conference has completed its work a final bill will be created.  The bill and the conference report will then be sent to both Houses and, after passage, to the President for signature.  It is unlikely that this process will be completed before mid-September. 

Generally, key stakeholders in both the House and the Senate have given their respective bills strong support.  However, certain provisions that are of concern are likely to be the focus of much discussion during the House-Senate conference.  The House bill includes languages on several issues not included in the Senate's, for example: partner notification, perinatal transmission, data and evaluation, and activities with the CDC.  Other provisions in the House bill expand representation of affected communities on planning bodies and favor using HIV surveillance data (not reported AIDS cases) as a basis for planning and funding.  Finally, the hold harmless provisions for Title I EMAs differ between the two bills and will need to be resolved. 

The bills are largely similar in the areas of planning, bringing people who are HIV-positive into care, services to women, quality management, and capacity building.

To order publications,
call: 1-888-ASK-HRSA

HRSA Care ACTION
is published by the HIV/AIDS Bureau,
Health Resources and Services Administration,
Department of Health and Human Services.
All information contained
herein is in the public domain.

Please forward comments, letters and questions to: