HIV IN CORRECTIONS
John G. Bartlett, M.D. , Louis C. Tripoli, M.D. ,
Ellen S. Rappaport, MPH , William Ruby, D.O.
date: July 1, 2000
Testing Policies, Prevalence, Housing issues, Challenges, Recidivism,
HIV case management, Medications, Clinical trials
TESTING POLICIES IN CORRECTIONS
polices for HIV detections are highly variable between the federal,
state, and local (jail) jurisdictions. Eighteen state prison
systems mandate testing for HIV on entering the system, including
New Hampshire, Rhode Island, Iowa, Michigan, Missouri, Nebraska,
North Dakota, South Dakota, Alabama, Georgia, Mississippi, Oklahoma,
Colorado, Idaho, Nevada, South Carolina, Utah, and Wyoming.
Transmission of HIV in prison does occur, but accurate quantification
of transmission rates has never been undertaken aside from several
1: Summary of HIV serology testing policies
No. of Jurisdictions
Upon inmate request
Upon clinical indication
Upon involvement in incident
All incoming inmates
All inmates at time of release
All inmates in custody
Source: 1996 BJS
National Prisoner Statistics; totals updated to include
S. Carolina (Hammet M, et al. U.S. Dept. Justice, Office
of Justice Programs, Nat Inst. Justice 7/99 pg. 56)
Note: Detail adds to more than 52 because
a jurisdiction may have more than one testing policy.
-- Missouri, Alabama, Virginia, and Nevada -- also require inmate
testing upon release. The Federal prison system test inmates upon
release (but not on entry). Arkansas, Rhode Island, and Virginia
test all inmates in custody. New York tests inmates at random.
States also test selectively, according to circumstances. Forty
states test based upon inmate request, termed "voluntary testing."
There is an intermediate type of testing between mandatory and
voluntary -- termed "routine," in which testing is performed unless
the patient refuses. Two states have routine testing on entry.
No city or county jail system conducts mandatory testing.
all state prison systems make HIV antibody testing available,
but the circumstances under which testing occurs varies widely.
for pre-test and post-test counseling (Based on recommendations
of the NY State AIDS Institute 3/00 for testing of all persons)
history of HIV test counseling;
of AIDS and HIV-related complications;
of diagnosis and medical intervention;
- HIV transmission
and risk reduction behaviors;
discrimination resulting from disclosure of HIV test results
and legal protections against discrimination;
- for pregnant
women: benefits of diagnosis for preventing perinatal transmission
and for treatment of the newborn.
Consent for HIV Antibody Test
written informed consent, prior to ordering test, from patient
or person authorized to consent.
patient with a copy of the consent form or document containing
all pertinent information.
patients ability, to comprehend the nature and consequences
of HIV antibody testing. If the patients ability to understand
is temporarily impaired, defer testing.
test and procedures:
of the test;
of test results;
may be withdrawn any time.
protections of confidential HIV-related information and conditions
of authorized disclosure.
- A licensed
physician or other person authorized by law to order a laboratory
test must sign all orders for HIV antibody testing and certify
the receipt of informed consent.
reassurance and/or referrals for emotional support for patient
during the waiting period.
- Plan discussion
of test results and post-test counseling (allow sufficient time
for completion of confirmatory testing).
patients with a negative test result:
meaning of the test result;
that a negative test result does not imply immunity to future
personal risk reduction strategies.
patients with positive test result:
meaning of the test result;
availability of medical care including prophylaxis for opportunistic
infections and antiretroviral therapy;
pregnant patient discuss and recommend use of antiretroviral
agents, consistent with clinical practice guidelines, to reduce
risk of maternal-child transmission;
referral of partners and children for HIV testing;
counseling or refer to counseling:
coping with the emotional consequences of test result;
discrimination that disclosure of result could cause;
behavior change to prevent transmission of HIV infection;
or refer to needed medical support services.
patients with indeterminate test results:
provision of post-test counseling, including the test results and
any arrangements for partner/spousal notification.
meaning of test results;
availability of appropriate medical follow-up;
personal risk reduction strategies
OF HIV IN CORRECTIONS
rate for HIV antibody in prisons and jails is 2.1%, according
to the Department of Justice statistics (Maruschak LM: HIV in
Prisons, US Dept Justice, Bureau of Justice Stastistics, 12/9/99,
pg. 1). This prevalence has been roughly stable from 1991 to 1997.
In 1997, the prevalence rate was 1.0% in Federal prisons, 2.2%
in state prisons, and 3.4% in female inmates. (The true prevalence
is underestimated because a minority of systems tests all entrants.)
The Department of Justice listed the following jurisdictions with
HIV-seroprevalence greater than 3% in 1997: New York 10.8% (decreased
from 13.9% two years earlier), Connecticut 5.1%, Massachusetts
3.7%, Florida 3.6%, Maryland 3.5%, New Jersey 3.4%, and Rhode
Island 3.2% ( ibid pg. 2). The prevalence rate in the Northeast
region overall is 6.4%; the Midwest, 0.9%; the South, 2.0%; and
the West 0.8%. The overall prevalence in the Midwest and West
is very low (usually less than 1%), but some urban areas contribute
numbers similar to the Northeast (West J Med 1990;153:394).
Quite different seroprevalence are reported in the 1998 Corrections
Yearbook (The Corrections Yearbook 1998, Camp CG, pg.
38). The following systems reported rates above 3%: Delaware 10.1%.
Maryland 9.0%, Vermont 5.7%, Alabama 4.6%, South Carolina 4.2%,
New Jersey 3.6%, West Virginia 3.6%, California 3.3%, and Pennsylvania
3.1%. (These studies were done on selected samples, and the figures
do not represent the true prevalence rates because the samples
may have been on entrants and not all inmates). Nine states reported
ten or fewer HIV-positive inmates in their prisons: Alaska, Idaho,
Kansas, Montana, North Dakota, South Dakota, Vermont, West Virginia,
and Wyoming (Maruschak LM: HIV in Prisons, US Dept Justice, Bureau
of Statistics, 12/9/99, pg. 3).
Vlahov, et al. have shown significant variability of rates of
HIV seroprevalence among entrants to ten correctional institutions
ranging from 2.1% to 7.6% for men and 2.5% to 14.7% for women
(JAMA 1991;265:1129). Studies done in the last decade on
entrants into the Maryland state prison system showed higher rates
than current prevalence studies, but entry studies and prevalence
studies on inmates are not directly comparable. Data from April
to June 1985, 1986, and 1987 showed the crude prevalence of positive
HIV serology was 7.1, 7.7, and 7.0%, respectively (JAIDS
Based on Department of Justice survey statistics, the percentage
of males in local jails who were HIV positive is approximately
2.1% + 0.6 (or 1.5% ─ 2.7%) (Maruschak LM: Update
HIV/AIDS, STDs and TB in Correctional Facilities, US Dept Justice,
Office of Justice Programs, Nat Instit Justice, 7/99, pg. 16).
In general, the larger the size of the jail, the higher the percentage
with HIV infection. This survey does not include inmates who are
being detained for trial or sentencing.
large metropolitan areas, particularly in the Northeast, probably
have a very high prevalence rate of HIV-positivity, but data are
scarce. It is likely that estimates of the prevalence understate
the true number in jails. According to a study in New York City
the prevalence of HIV-1 positivity in entrants to the city jail
was 15% (375/2479) in 1992 and 10% (544/5414) in 1996. In 1992,
the prevalence in men was 12%, while that in women was 26%. By
1996, prevalence in men had declined to 7%, while that in women
was 20% (5th CROI, 2/98, Abst 142).
in Women: The Northeast has the highest proportion of
female inmates infected with HIV, at 12.7% prevalence in 1997
(Maruschak LM: HIV in Prisons 1997, US Dept Justice, Bureau of
Justice Statistics, 12/9/99, pg. 5). New York is the highest at
20.7%. Other states of high prevalence include: Connecticut, 13.1%,
Massachusetts 8.2%, New Jersey 5.5%, Rhode Island 6.1%, Florida
and 7.1%, Georgia and 4.2%, and Maryland 7.6%, and Nevada 4.9%.
While caring for with HIV infection in general is becoming a specialized
task, caring for female inmates with HIV disease requires further
of AIDS: From 1996 to 1997, the mortality rate from AIDS
declined from 0.54 deaths per 1,000 inmates to 0.27 presumably
due to improved treatment with HAART (The Corrections Yearbook
1998, Camp GM, pg. 35). The number of confirmed AIDS cases tripled
from 1991 to 1997 to a total of 6,184 individuals at the end of
1997 (Maruschak LM, HIV in Prisons 1997, US Dept Justice, Bureau
of Justice Statistics, 12/9/99, pg. 4 ). The overall percent of
the population with confirmed AIDS was reported at 0.55%. The
highest percentage of state prison population having confirmed
AIDS was in New York (1.9%), followed by Rhode Island (1.4%),
Connecticut (1.3%), Florida (1.3%), and Maryland (1.3%).
ISSUES FOR INMATES WITH HIV AND AIDS
of inmates with HIV infection from the general population is a
controversial issue that has undergone significant change. Some
jurisdictions segregate HIV-positive inmates for the purpose of
preventing transmission of HIV, while other systems cluster HIV-positive
or those with symptomatic HIV infection for purposes of treatment
and allocation of medical resources.
A 1985 review
of 51 state and federal prison systems showed eight systems had
segregation policies for HIV-infected inmates, and 38 (75 percent)
of systems had segregation policies for patients with AIDS. By
1997, the number of systems segregating HIV-infected inmates had
dropped to two -- Mississippi and Alabama -- and 3 systems segregated
inmates with AIDS: Alabama, Mississippi, and California (Hammett
MH 1996-97 Update: HIV/AIDS, STDs and TB in Correctional Facilities,
US Dept Justice, Nat Inst Justice, 7/99, pg. 63). In 1998, South
Carolina adopted the policy of mandatory HIV serology of all state
inmates with transfer of those with positive tests to a maximum
security prison in Columbia.
from the Justice Department publications is somewhat misleading,
because it gives the impression that Mississippi, South Carolina,
and Alabama are the only states that practice separation of HIV-positive
inmates from others, and California is the only one that separates
those with AIDS. In reality, there are many states that separate
inmates with HIV, and the reasons may be either medical or non-medical.
The Criminal Justice Institute lists the following jurisdictions
that segregate HIV-infected inmates in addition to those named
above: Arkansas, Delaware, Illinois, Maine, Montana, Nebraska,
Nevada, Ohio, Pennsylvania, Tennessee, and West Virginia (Corrections
Yearbook 1998, Camp CG, 1998, pg. 38). In California, the
housing of patients with AIDS is separate from the other inmates,
but the daily activities of these inmates are mixed with the general
population (AIDS Policy Law 1997;12:8).
It is important
to distinguish between "segregation" and "clustering"
or concentration of HIV cases. The key distinction is that with
clustering, most HIV-infected inmates live in general housing.
For the purposes of clarification, Dr. Larry Mendel proposes the
following categories (personal communication):
of all HIV infected inmates.
segregation based upon prior behavior (after appropriate hearing).
of HIV cases to selected sites especially for complicated cases
("Centers of Excellence").
to a medical facility to provide for advanced care needs, especially
daily living needs. Examples include New York Regional Medical
Units, California Medical Facility, and Corrections Medical
Center in Ohio .
for segregating HIV-positive inmates stated by Alabama in Harris
v. Thigpen is that integrating HIV-positive inmates into the
mainstream would pose a significant health risk to the other inmates.
The state Department of Corrections presented data that indicated
their policy reduced the rate of transmission. They indicated
an annual seroconversion rate of 0.0006%/year in Alabama, compared
to 0.19%/year in Nevada, 0.33%/year in Illinois, and 0.41%/year
in Maryland (AIDS Policy & Law 1997 November 28; 12 (21):
It is widely
assumed that the transmission rates of HIV within prison populations
are low and segregation does not materially affect transmission.
Three studies showed seroconversion rates of 1/200 to 1/604 person-years
in prisons with seroprevalence rates of 2 4%( 1.Horsburgh CR
Jr , Jarvis JQ , McArther T , Ignacio T , Stock P. Seroconversion
to Human Immunodeficiency Virus in Prison Inmates. American Journal
of Public Health 1990 February; 80 (2): 209-10.
K , Shansky R , Scardino V , Narkunas J , Coe J , Hammett T: HIV
transmission in correctional facilities. Centers for Disease Control,
Atlanta, GA, USA Int Conf AIDS 1991 Jun 16-21;7(1):314 (abstract
TF , Vlahov D , Taylor E , Hall D , Munoz A , Polk BF, Department
of Health Policy and Management, Johns Hopkins University: Transmission
of HIV-1 within a statewide prison system. AIDS 1988 Oct;2(5):363-7)
. The rate of transmission seems to correlate with the baseline
rate of infection, implying an exposure risk. Extrapolated to
the entire population of 2.1 million inmates in the United States,
1 to 2 infections per 600 inmates per year would mean 350 to 700
HIV infections occur in incarcerated individuals per year.
issue of transmission, theoretical advantages and disadvantages
for grouping of HIV-positive inmates include the following:
Aggregation helps patients with similar specialized care needs
to obtain uniformity of treatment and enhance access to expert
in a therapeutic community may enhance patient education through
peer counseling and support, and reduce stigmatization among
the inmate population.
on special needs may promote institutional flexibility such
as scheduling of meal times and medication administration to
coincide with particular requirements for antiretroviral medications.
Segregation of HIV-positive inmates has the following disadvantages:
may decrease HIV infected inmates' access to participation in
programs that are not available at the institutions where they
are problems associated with combining prisoners of varying
security levels in the same unit (Lines R: The case against
segregation in "specialized" care units. Prisoners With HIV/AIDS
Support Action Network, Toronto, Ontario, Canada. Can HIV AIDS
Policy Law 1997-98 Winter;3-4(4-1):30-5.).
with HIV may be separated from the proximity of family or support
outside of their home region, or they may decline to be tested
because of that concern. (Lines R: The case against segregation
in "specialized" care units. Prisoners With HIV/AIDS Support
Action Network, Toronto, Ontario, Canada. Can HIV AIDS Policy
Law 1997-98 Winter;3-4(4-1):30-5.)
may inadvertently give credence to unscientific beliefs about
may compromise confidentiality of HIV serostatus.
AND OPPORTUNITIES WITH TREATING HIV IN CORRECTIONS
HIV in a correctional environment can offer some distinct advantages
and many challenges. The most significant advantage is the ability
to offer therapy and to monitor patient adherence to treatment
recommendations. In some systems, inmates must take antiretrovirals
under the "directly observed therapy" (DOT) system,
while others practice "keep on person," called "KOP"
in prison parlance. The DOT method offers the unique opportunity
to judge more accurately whether a regimen is failing due to issues
of medication choice and not adherence. To date DOT for HIV therapy
has been successfully implemented almost exclusively in the correctional
system despite desirability of a much broader application.
of care: It is difficult to evaluate the quality of HIV
care in the correctional system. Possible advantages are that
patients in the correctional environment often have access to
health care resources that may not be readily accessible in the
general population; and there usually are no financial barriers
to obtaining care for chronic conditions such as HIV, though some
states and the Federal system have instituted co-payments for
some services. Inmates are rarely far from a medical resource,
as long as they are allowed to access the resource. Most inmates
would be Medicaid recipients or uninsured if not imprisoned; this
is the category of patients identified by the Institute of Medicine
report as having suboptimal care, a problem that is increasing
under managed care.
inmates have little choice regarding the health care providers
they see. Therefore, entities undertaking prison health care should
develop the educational and mentoring capabilities that are necessary
to be sure the providers are able to provide high quality HIV
care in the correctional environment. Several agencies exist that
offer accreditation for correctional health care units including
the National Commission for Correctional Health Care (NCCHC) and
the American Corrections Association (ACA). These entities have
their strengths and weaknesses, but they represent one way in
which the quality of correctional health care can be monitored.
It is equally important for health systems to have their own systems
to monitor the quality of the providers, their credentials, their
performance, the systems and processes in place to promote good
health care, and ultimately -- the health outcomes of the delivery
care: One of the greatest challenges facing prison health
care is the continuity of care following release. It is often
difficult for even highly-motivated inmates leaving prison to
access medical services or funding for medications. Even when
Medicaid funding is available, the inmate may have to wait 30
days to a year after release to become eligible. Ryan White Care
Act funds specifically target the inmate population and should
be contacted regarding medical care and support services. Many
of the pharmaceutical companies have made free medication available
for inmates leaving prison for some defined period until they
have sources of funding for their medications, but this availability
still does not address the issue of the assignment of providers
of care. Several innovative projects are underway to address these
issues, and a recent set of grants from the Department of Health
and Human Services have challenged corrections and public health
agencies to work together to solve these problems. A frustrating
but oft-repeated scenario is the inmate who receives state-of-the-art
care for his HIV while in prison, is released, and later presents
again to the prison with resistant virus from inconsistent medication
adherence post release due to incongruous medical care.
Many jail systems tend to interact with some people on an ongoing
basis. These individuals often do not have access to continuous
health care upon leaving the incarcerated setting, often due to
the inability to qualify for state health care funding, or, more
frequently, failure to access medical care due to an inability
to understand how to enter the system or apply for help. This
often arcane skill can represent a challenge even to educated
and highly-motivated persons. Well-meaning providers in the jail
setting often see it as their duty to initiate antiretroviral
therapy when an inmate has HIV infection, but then fail to consider
the consequences of this initiation once the patient leaves the
institution. Some communities have few or no providers willing
to take care of HIV infected former inmates, while in other communities
access is limited due to lack of communication between the jail
and the public health providers. It has now become increasingly
apparent that clinicians should avoid initiating antiretroviral
therapy that cannot be continued post release if this is anticipated
The question of who is responsible for the health care of the
patients remains a difficult issue in many jails, and there is
still a great deal of work to be done in coordinating care for
chronic offenders in jail systems. It is important to remember
that lengths of stay in jail system may average a few days to
weeks, and many offenders are not actually convicted of crimes
while they are in jail. This is an important issue because the
jail may serve as an excellent site for testing and counseling,
but the short stay with indefinite medical care follow-up may
make the initiation of antiretroviral therapy unrealistic or even
ill-advised. In 1997, the average length of incarceration of unsentenced
prisoners released from jails was 38.6 days; sentenced prisoners
stayed an average of 93.9 days, and the combined average stay
for all jail inmates was 47.3 days (The Corrections Yearbook
1998. Camp CG, Camp GM. Criminal Justice Institute, Inc.,
Middletown, CT, 1998; p.229.). Medium-sized jails have an average
length of incarceration of only 23 days (The Corrections Yearbook
1998. Camp CG, Camp GM. Criminal Justice Institute, Inc.,
Middletown, CT, 1998; p.228).
work and mental health issues: Programs that deal with
the psychological and social aspects of HIV disease (and other
chronic diseases) have been shown to reduce recidivism (Kim J.Y.
et al., "Successful Community Follow-up and Reduced Recidivism
in HIV-Positive Women Prisoners," Journal of Correctional
Health Care 4 (1997): 517). In general, recidivism correlates
with sub-optimal self care and increases the likelihood of poor
disease outcomes. HIV and other chronic infectious diseases like
Hepatitis C tend to be over-represented in persons who are likely
to be incarcerated multiple times. According to a survey by the
Criminal Justice Institute, jail systems often have programs for
intervening in drug abuse problems, including group counseling
in 81.7% of jails 82% of jails with 57% offering individual drug
counseling (The Corrections Yearbook 1998. Camp CG, Camp
GM. Criminal Justice Institute, Inc., Middletown, CT, 1998; p.254).
The reader should keep in mind, however, the possibility that
respondents to the survey that supplied these results may not
represent the true rate.
to reduce drug addiction and recidivism have been generally disappointing.
An exception is Delaware where a "therapeutic community"
(TC) model of substance abuse treatment and intervention with
treatment during and after incarceration demonstrated durable
reduction of recidivism in that state (Martin SA, Butzin CA, Saum
CA, Incardi JA, Three-year outcomes of therapeutic community treatment
for drug-involved offenders in Delaware: from prison to work release
to aftercare. The Prison Journal; 79(3) Sept. 1999 p.294-320).
This model also demonstrated how partnerships between public and
private entities can create synergy. Coupling HIV care with the
treatment of substance abuse seems to be a promising method of
encouraging and maintaining adherence, and it serves the interests
of the state as well as the patient. Another potentially useful
but controversial method of HIV intervention is to base medication
administration for HIV around a methadone-maintenance program.
MEDICAL EVALUATION: The following summarizes the basic elements
of HIV care that apply to virtually all adult patients with HIV
- HIV serology
with dates of positive and negative tests
- HIV related
history: CD4 counts, VL, HIV-associated complications
care: history of care and source, prior PPD, prior Paps, vaccinations:
Pneumovax, tetanus, influenza, HBV, HAV
- Past medical
history: cardiovascular risks (HAART candidates) obesity,
hypertension, smoking, family history, and blood lipids.
history: TB exposure/risk, prior chicken pox or shingles, STDs,
hepatitis A, B or C, gynecologic history, substance abuse
HIV meds and adherence; OTC drugs, alternative therapy
- ROS: constitutional
symptoms fever, night sweats, weight loss, fatigue; GI:
Anorexia, nausea, vomiting, diarrhea, abdominal pain; chest:
cough, dyspnea, chest pain; neuro: headaches, extremity
pain/parenthesis, mental status changes; miscellaneous:
rashes, insomnia, adenopathy, vision
Risk reduction, natural history of HIV, benefits of antiretroviral
therapy and OI prophylaxis, nutrition, smoking risk.
3 6 mo.
3 6 mo; repeat at therapeutic thresholds and for
3 4 mo.; baseline and at 1 month with new regimen
in asymptomatic patients who have nodocumented
test result plus no identified risk ornegative
VL without therapy
profile with liver and renal function tests
if initially negative when pt. becomes candidate
for toxoprophylaxis or has illness consistent with
PPD or chest symptoms
hx of + PPD; repeat annually in high risk patients
with negative prior tests; > 5 mm in duration is
x-ray → if neg. → PZA + Rif x 2 mo. or INH x 9
positive FTA confirmation; LP if positive plus
plus Chlamydia urine test in women
GC: Ceftriaxone, cefixime, or ciprofloxacin C.
trachomatis: Azithro or doxycycline
inmates confirm positives with RIBA or HCV RNA
level. If confirmed ALT
if negative vaccinate for HBVScreen
patients with HCV if negative for HAV
Vaccinate (Some vaccinate all HCV infected patients
without HAV screening.)
therapy PI or NNRTI
for HAART should have fasting triglycerides,
cholesterol, LDL, HDL and glucose at baseline; repeat
at 3 months and then at intervals dictated by initial
results and risk
and renal function q 3 6 mo.
q mo. optional
q 3 6 mo.
D4T, ddI, ddC
for peripheral neuropathy
gap, CPK, ALT, LDH, lactate level
LFT including bilirubin q mo.
> 200 recommendedCD4
< 200 optional
patients with negative anti-HBC
patients with chronic HCV plus susceptibility (negative anti-HAV)