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Case 3: Discussion

Overview of the United States Correctional System

The United States correctional system is comprised of local jails, state prisons, federal prisons, as well as work release programs, probation offices, and systems for community supervision[1]. Jails mainly house accused persons awaiting trial or transfer, as well as some offenders who have sentences of less than one year. In contrast, prisons house convicted offenders serving longer sentences. Whether the offense committed involves federal versus state law determines the type of prison to which an inmate is sent. When convicted offenders leave prison, they continue in the correctional system on parole until completion of their sentence. Similarly, persons leaving jail are often supervised on probation. The overall incarceration rate in the United States has increased significantly since 1980 (Figure 1), partially as a result of the crackdown on illegal drug use[2,3]. According to the National Institute of Justice, by midyear 2004, the United States had more than 2 million persons housed in correctional facilities (Figure 2)[3] and had an incarceration rate that exceeded all other countries (Figure 3)[3,4].

Epidemiology of HIV in the Correctional Setting

It is estimated that about one fourth of all people living with HIV in the United States pass through a correctional facility annually[5]. Therefore, not surprisingly, all 50 states have housed offenders with HIV infection within their correctional systems, although most HIV-infected inmates have been concentrated in the northeastern and southern states (Figure 4 and Figure 5)[6,7]. Epidemiologic surveys indicate that the prevalence of HIV infection is approximately 2% among inmates in correctional facilities, a substantially higher HIV prevalence than in the general United States population[6]. This higher HIV prevalence can partially be explained by the high percentage of inmates with a history of injection drug use (IDU), which is often also associated with high-risk sexual behaviors[2,8]. In a 1994-1996 survey, 61% of inmates with AIDS reported IDU compared with only 27% of all persons with AIDS[9]. This presumably also accounts for the high hepatitis C virus (HCV) co-infection rate of 65% among incarcerated, HIV-infected persons[7]. In contrast with the general population, incarcerated women are more likely to be HIV-infected than men, with a prevalence of 2.8% compared with 1.9% among males[6]. This presumably results from female inmates having relatively high rates of IDU, promiscuity, prostitution, and exchange of sex for drugs--all factors that increase the risk for acquiring HIV[10]. Given the disproportionately high HIV prevalence among individuals who become incarcerated, all inmates should be offered HIV testing at entry to a correctional facility, regardless of the criminal charge[7,11]. Although rape, consensual sex, tattooing, and IDU are thought to frequently occur within the correctional setting, available data suggest that most incarcerated HIV-infected persons have acquired their HIV prior to entering prison[5,12,13]. Intra-prison transmission of HIV has been associated with male-male sex, black race, receipt of tattoo in prison, and low body mass index upon entry to prison[13].

Antiretroviral Therapy in the Correctional Setting

Entry into the correctional system may be the first time a prisoner has accessed healthcare. Those individuals known to be infected who have previously sought HIV care in the community often have lower rates of viral suppression with highly active antiretroviral therapy (HAART)[14,15]. Correctional facilities have an opportunity to optimize care for HIV-infected persons who otherwise may be difficult to reach in the community setting[16]. Among inmates known to be HIV-infected, nearly 75% begin antiretroviral treatment while incarcerated[17]. Methods of medication delivery vary among facilities. Some data support the effectiveness of directly observed therapy (DOT) in the prison setting, with high rates of documented virologic suppression[18,19]. In an intention-to-treat analysis, 85% (95% CI, 76-91) of HIV-infected patients receiving DOT achieved an HIV RNA level below 400 copies/mL by week 24[18]. It remains unclear whether the high success rates result exclusively from DOT or whether other prison factors, such as the decreased use of illicit drugs and greater access to mental health treatment, play a major role[7]. Other observational studies have found no significant difference in adherence between offenders receiving DOT and those allowed a month supply of medications to "keep on person" (the term for self-administered therapy in the correctional system)[20]. The "keep on person" strategy avoids the need to wait in line to receive DOT, a process that may deter some inmates from initiating or continuing HAART therapy (because of the inconvenience and the potential loss in confidentiality)[7,21].

Barriers for Success with Antiretroviral Therapy

Many of the barriers to successful results with antiretroviral therapy within prison are similar to those outside the correctional system. These include medication side effects, lack of trust in the medical provider, difficulty taking medication, absence of social support (especially from outside the prison), and depression[16,21]. In the prison setting, however, other unique barriers exist, such as frequent transfers between facilities, or particular assignments within the facility that can interfere with continuity of care or result in treatment interruptions[21]. In addition, HIV-infected persons in the correctional system also have higher rates of drug dependency and mental illness compared with persons in the community, further compromising adherence to medical therapy[7]. Despite these additional barriers, patients in prison taking HAART often achieve rates of undetectable virus at rates comparable to if not better than those found in community clinic settings. Moreover, when appropriate medical care is made available, HIV-infected inmates attain a comparable clinical benefit as seen in HIV-infected persons in the community[22].

Maintaining Confidentiality in the Correctional Setting

Maintaining confidentiality within the correctional system can often be difficult, which may cause an offender to conceal a known diagnosis of HIV upon prison entry. Some state correctional systems attempt to segregate known HIV-infected inmates, mainly to facilitate adequate healthcare by centralizing educational efforts and access to expert HIV care[19]. This strategy, however, can compromise confidentiality, since other inmates can infer a diagnosis of HIV based on a fellow inmate's cell location alone. Similarly, a prisoner's cellmate or correctional officer can discover the HIV-infected inmate's self-administered medications and thus expose a diagnosis of HIV. In addition, medical information often gets discussed in the presence of correctional officers, even though they are not medical personnel. Patient visits and medical information are confidential and should not be overheard by (or released to) a correctional officer, unless mandatory by law or felt necessary for safety reasons. For medical appointments outside of the correctional facility, the medical care provider should communicate all medically related information directly with either the offender or with the medical providers at the correctional facility.

Transition from the Correctional Setting to the Community

The transition from a correctional facility to the community is a critical event for HIV-infected inmates. Thus, discharge planning for an HIV-infected inmate should include a scheduled medical appointment in an appropriate community clinic that can provide HIV care upon release. Linking to a healthcare provider in the community prior to discharge, especially through a face-to-face meeting, improves follow-up rates[7]. In addition, a comprehensive prison discharge planning program that addresses drug treatment, mental health referral, housing, job placement, and social support will enhance the likelihood of success in transitioning to the community, as well as to maximize the chance of maintaining any health advances achieved within the correctional system[22,23,24,25]. Moreover, it is important that inmates on antiretroviral therapy receive an adequate supply of medication until their out-patient appointment.

Unfortunately, soon after release within the general community HIV-infected inmates have a high rate of unsafe sex practices, particularly with their regular partners[26,27]. Several studies have shown that women have an increased risk of acquiring HIV when they have sex with a male partner recently released from prison[28]. Increasingly, experts recognize that correctional health care should emphasize the importance of prevention[16]. Accordingly, correctional facilities should develop better primary and secondary risk-reduction programs to prevent an inmate from both acquiring and transmitting HIV upon release[7,27]. A great need exists for better community-release programs for HIV-infected incarcerated persons in conjunction with better community-based primary and secondary HIV prevention strategies.

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    Figure 1. Incarceration Rate of Sentenced Inmates under State and Federal
      Jurisdiction in United States, 1980-2004

    Source: Correctional Populations in the United States, 1997 and Prisoners in 2004. U.S. Department of Justice—Office of Justice Programs Bureau of Justice Statistics.

    Figure 1
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    Figure 2. Adult Correctional Populations, 1980-2004

    Source: Correctional Populations in the United States, 1997 and Prisoners in 2004. U.S. Department of Justice—Office of Justice Programs Bureau of Justice Statistics.

    Figure 2
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    Figure 3. Nations with Highest Incarceration Rates

    Source: International Centre for Prison Studies. Incarceration data were collected on varying dates and are based on available data from 2005.

    Figure 3
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    Figure 4. Prevalence of Known HIV-infection in United States Correctional Facilities, by State, 2003

    This graph is based on data from 2001-2003.
    Adapted and updated from Spaulding A, Stephenson B, Macalino G, Ruby W, Clarke JG, Flanigan TP. Human immunodeficiency virus in correctional facilities: a review. Clin Infect Dis. 2002;35:305-12.

    Figure 4
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    Figure 5. Prevalence of HIV Infection Among Inmates by Region of United
      States, 2003

    From: Maruschak LM. Bureau of Justice Statistics Bulletin: HIV in prisons, 2003. Document NCJ 210344.

    Figure 5