Anne C. Spaulding

Prisoner Survival Inside and Outside of the Institution: Implications for Health-Care Planning

The life expectancy of persons cycling through the prison system is unknown. The authors sought to determine the 15.5-year survival of 23,510 persons imprisoned in the state of Georgia on June 30, 1991. After linking prison and mortality records, they calculated standardized mortality ratios (SMRs). The cohort experienced 2,650 deaths during follow-up, which were 799 more than expected (SMR = 1.43, 95% confidence interval (CI): 1.38, 1.49). Mortality during incarceration was low (SMR = 0.85, 95% CI: 0.77, 0.94), while postrelease mortality was high (SMR = 1.54, 95% CI: 1.48, 1.61). SMRs varied by race, with black men exhibiting lower relative mortality than white men. Black men were the only demographic subgroup to experience significantly lower mortality while incarcerated (SMR = 0.66, 95% CI: 0.58, 0.76), while white men experienced elevated mortality while incarcerated (SMR = 1.28, 95% CI: 1.10, 1.48). Four causes of death (homicide, transportation, accidental poisoning, and suicide) accounted for 74% of the decreased mortality during incarceration, while 6 causes (human immunodeficiency virus infection, cancer, cirrhosis, homicide, transportation, and accidental poisoning) accounted for 62% of the excess mortality following release. Adjustment for compassionate releases eliminated the protective effect of incarceration on mortality. These results suggest that the low mortality inside prisons can be explained by the rarity of deaths unlikely to occur in the context of incarceration and compassionate releases of moribund patients.

Public Health Implications for Adequate Transitional Care for HIV-Infected Prisoners: Five Essential Components

In the United States, 10 million inmates are released every year, and human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) prevalence is several-fold greater in criminal justice populations than in the community. Few effective linkage-to-the-community programs are currently available for prisoners infected with HIV. As a result, combination antiretroviral therapy (cART) is seldom continued after release, and virological and immunological outcomes worsen. Poor HIV treatment outcomes result from a myriad of obstacles that released prisoners face upon reentering the community, including homelessness, lack of medical insurance, relapse to drug and alcohol use, and mental illness. This article will focus on 5 distinct factors that contribute significantly to treatment outcomes for released prisoners infected with HIV and have profound individual and public health implications: (1) adaptation of case management services to facilitate linkage to care; (2) continuity of cART; (3) treatment of substance use disorders; (4) continuity of mental illness treatment; and (5) reducing HIV-associated risk-taking behaviors as part of secondary prevention.

A framework for management of hepatitis C in prisons.

Inmates with chronic hepatitis C virus (HCV) infection present a major challenge to prison health systems. In the United States, prisons house approximately 1.4 million adults serving sentences that range from 1 year to life (1). State prisoners serve an average of 30 months, and the average annual population turnover is 33% (2, 3). Sixteen percent to 41% of inmates are positive for antibody to HCV (anti-HCV), and 12% to 31% have chronic infection (4). The primary source of HCV infection in the United States is illegal injection drug use; drug offenders make up 20% of state and 55% of federal prison populations (5). Although 95% to 99% of prison inmates are eventually released to the community (6, 7), sentences have increased substantially over the past decade (3). Because of longer periods of incarceration, prison health care systems must provide care for chronic medical conditions, including liver disease. Prison health care officials are faced with the question of whether a chronic disease like hepatitis C, which is usually asymptomatic but is responsible for much of the liver disease previously attributed to alcohol abuse (8), is a health condition that merits identification, medical evaluation, and possible treatment. Prison systems are unlikely to benefit directly from proactive identification of inmates with HCV infection or from treatment of patients whose disease may take years to become symptomatic. In the United States, direct medical expenditures related to chronic hepatitis C are predicted to amount to

Adherence to HIV Treatment and Care Among Previously Homeless Jail Detainees

10.7 billion from 2010 to 2019 (9). Prison health care budgets could bear a large share of this cost because of the disproportionate number of incarcerated persons with HCV infection. However, current guidelines for identification, counseling, medical evaluation, management, and treatment of persons with chronic hepatitis C specifically recommend offering these services to incarcerated persons (4, 10). To gain insight into the challenges of identifying HCV infection and managing hepatitis C in prisoners, a meeting, funded by the Centers for Disease Control and Prevention and the National Institutes of Health, was held in January 2003. Forty-three state prison systems sent their medical director, a prison administrator, or both to the conference. Experts in prison and public health, hepatology, and infectious diseases (Appendix) gave presentations. The information and viewpoints shared at this meeting were intended to guide development of hepatitis C testing and treatment policies at state departments of corrections. Background The high proportion of incarcerated persons with HCV infection or risk factors for infection makes correctional facilities logical venues to implement hepatitis C prevention and medical management programs. The vast majority of incarcerated persons in the United States are short-term detainees. Although time does not permit these individuals to begin hepatitis C treatment before discharge, all inmates can still greatly benefit from hepatitis C education and appropriate referral for testing and, if infected, for disease evaluation in the community. If incarceration extends to months, diagnostic evaluations can begin. Prisons house inmates for longer sentences. This paper will focus on the long-term occupants of prisons. Many prison systems have established programs to prevent and manage other infectious diseases, such as tuberculosis, HIV/AIDS, and sexually transmitted diseases. Prevention of hepatitis C could feasibly be integrated into such programs (4, 11), which could reduce the incidence of new HCV infections and prevent transmission to others from already infected persons (primary prevention), identify and treat asymptomatic persons with infection to reduce chronic liver disease (secondary prevention), and reduce disability among persons with disease (tertiary prevention) (12). Substance abuse treatment and risk reduction counseling provided within prisons to prevent injection drug use can have effects on primary prevention in and outside the prison system. For inmates found to be infected with HCV, prevention services, such as substance abuse treatment and education about risk and harm reduction, could also reduce transmission of HCV to others. Secondary prevention for inmates with HCV infection begins with a medical evaluation to determine the extent of chronic liver disease, to determine the presence of comorbid conditions (for example, HIV infection and substance abuse), to assess the need for antiviral therapy with or without substance abuse (drug and alcohol) treatment, and to provide immunization against hepatitis A and hepatitis B, as needed. Natural History and Medical Management of Hepatitis C Most persons, including prisoners, with chronic HCV infection are asymptomatic, although 70% to 85% have histologic evidence of active liver disease, including inflammation, fibrosis, or cirrhosis (13, 14). It is not easy to determine which persons with chronic hepatitis C have infection that will progress to symptomatic liver disease and death. However, several factors speed disease progression, including male sex, becoming infected after 40 years of age, alcohol abuse, and co-infection with other viruses, such as hepatitis B virus and HIV (13). The efficacy of hepatitis C antiviral treatment has improved substantially over the past decade. Combination therapy with pegylated interferon and ribavirin achieves an overall sustained virologic response (SVR) of 50% to 60% (15). Although long-term data are not available for the effectiveness of antiviral therapy in decreasing hepatitis Crelated death, intermediate-term data indicate that persons with SVR have improved liver histologic characteristics and diminished liver disease (16, 17). Many correctional systems have developed evidence-based protocols for identification, medical evaluation, and antiviral treatment of inmates with HCV infection. Although these protocols vary in their inclusion criteria, they provide a framework for identifying and managing HCV-infected inmates. The use of protocols minimizes interprovider variability in therapeutic decision making, and their guiding principles permit the flexibility required to tailor treatment and medical management to patient needs (18). Preliminary data indicate that with good adherence to treatment regimens, SVR rates for prison patients treated with combination therapy are comparable to those observed in noninmate patients at similar stages of disease (19-22). However, therapy in prisons can be frequently interrupted (22). Also, in contrast to reports of lower SVR rates among black patients receiving the same therapeutic regimen as white patients in nonprisoner populations, the authors of one small prison study observed that SVR rates were similar among white and black patients with genotype 1 infection treated with interferon and ribavirin under direct observation of correctional nurses (23). The costs of hepatitis C medical management, including liver biopsy, transportation for specialty care, and medication, vary among correctional systems. Although some systems have negotiated lower prices for antiviral drugs and pay as little as 40% of the retail cost for peginterferon and ribavirin combination therapy (Peterson C, PharmD, Georgia Correctional HealthCare. Personal communication, 8 September 2004), the cost of hepatitis C treatment is still substantial in all systems. Treating eligible patients could represent a 15% to 60% increase in the average state correctional system medical budget (4, 24). Challenges to Management of Hepatitis C in Prisons Experts participating in this meeting did not reach consensus about all the issues discussed. However, data and discussion led to the identification of 5 areas in which generalizations could be made about optimal approaches to hepatitis C prevention, identification, and treatment. Participants proposed that consensus in the following areas would support a rational framework for the management of hepatitis C for infected prison inmates. Testing for HCV Infection in Prisons Would Identify Many Infected Americans Of all persons infected with HCV, approximately 29% to 43% pass through a correctional system each year (25). It is currently recommended that incarcerated persons with risk factors for HCV infection be screened (4). Although 49 states have at least 1 prison that tests inmates, only 10 states offer routine testing in all facilities. Of 1584 state prison facilities, 4% offer risk-factorbased HCV testing to incoming inmates and 5% offer testing to inmates already in custody (26). Routine HCV testing for all inmates is less common than routine HIV testing, which was performed for inmates at entrance in 19 state prison systems in 2000 (27). Although court rulings have granted prisoners access to health care, correctional systems are not obligated to seek potential medical problems (28, 29). Medical conditions identified for screening have been selected for the following reasons: 1) They are amenable to treatment; 2) they interfere with activities of daily living; 3) they could progress without treatment during the duration of incarceration; or 4) they pose a risk for infection transmission. Although hepatitis C can be easily identified by testing, it has not been considered a correctional health priority because it does not meet these criteria. Recommended screening strategies maximize identification of individuals infected with HCV while avoiding the cost of universal testing (4). In Wisconsin, 91% of anti-HCVpositive inmates were identified through testing the 27% of the population with a history of injection drug use, serologic evidence or a history of hepatitis B virus infection, or elevated alanine aminotransferase (ALT) levels (30, 31). Risk-based screening programs in the Federal Bureau of Prisons and Washington State prisons identified 6% and 15% of their populations, respectively, as anti-HCVpositive. However, the

Strategies to enhance linkages between care for HIV/AIDS in jail and community settings

HIV-infected persons entering the criminal justice system (CJS) often experience suboptimal healthcare system engagement and social instability, including homelessness. We evaluated surveys from a multisite study of 743 HIV-infected jail detainees prescribed or eligible for antiretroviral therapy (ART) to understand correlates of healthcare engagement prior to incarceration, focusing on differences by housing status. Dependent variables of healthcare engagement were: (1) having an HIV provider, (2) taking ART, and (3) being adherent (≥95% of prescribed doses) to ART during the week before incarceration. Homeless subjects, compared to their housed counterparts, were significantly less likely to be engaged in healthcare using any measure. Despite Ryan White funding availability, insurance coverage remains insufficient among those entering jails, and having health insurance was the most significant factor correlated with having an HIV provider and taking ART. Individuals interfacing with the CJS, especially those unstably housed, need innovative interventions to facilitate healthcare access and retention.

Hepatitis C Seroprevalence among Prison Inmates since 2001: Still High but Declining:

Abstract The policies of mass incarceration and the expansion of the criminal justice system in the USA over the last 40 years have weighed heavily on individuals and communities impacted by drug use and HIV disease. Though less than ideal, jails provide a unique opportunity to diagnose, treat and implement effective interventions. The role of jails in HIV detection, treatment, and continuity of care, however, has yet to be systematically examined. This paper reviews the service strategies and contexts for 10 demonstration sites funded to develop innovative methods for providing care and treatment to HIV-infected individuals in jail settings who are returning to their communities. The sites have implemented varied intervention strategies; each set in unique policy and service system contexts. Collaboration among agencies and between systems to implement these interventions is viewed as particularly challenging undertakings. We anticipate the sites will collectively serve 700–1000 individuals across the duration of the initiative. In this paper, we review the service contexts and strategies developed by the 10 sites. The individual and multi-site evaluations aim to provide new data on testing, treatment, and community linkages from jails that will further develop our knowledge base on effective intervention strategies in these settings.

HIV among persons incarcerated in the USA: a review of evolving concepts in testing, treatment, and linkage to community care.

Objectives. Although the hepatitis C epidemic in the United States disproportionately affects correctional populations, the last national estimates of seroprevalence and disease burden among these populations are more than a decade old. We investigated routine hepatitis C surveillance conducted in state prison systems and updated previous estimates. Methods. We surveyed all U.S. state correctional departments to determine which state prison systems had performed routine hepatitis C screening since 2001. Using seroprevalence data for these prison systems, we estimated the national hepatitis C seroprevalence among prisoners in 2006 and the share of the epidemic borne by correctional populations. Results. Of at least 12 states performing routine testing from 2001 to 2012, seroprevalences of hepatitis C ranged from 9.6% to 41.1%. All but one state with multiple measurements demonstrated declining seroprevalence. We estimated the national state prisoner seroprevalence at 17.4% in 2006. Based on the estimated total U.S. correctional population size, we projected that 1,857,629 people with hepatitis C antibody were incarcerated that year. We estimated that correctional populations represented 28.5%–32.8% of the total U.S. hepatitis C cases in 2006, down from 39% in 2003. Conclusions. Our results provide an important updated estimate of hepatitis C seroprevalence and suggest that correctional populations bear a declining but still sizable share of the epidemic. Correctional facilities remain important sites for hepatitis C case finding and therapy implementation. These results may also assist future studies in projecting the societal costs and benefits of providing new treatment options in prison systems.

Predictors of Reincarceration and Disease Progression Among Released HIV-Infected Inmates

Purpose of review People who are incarcerated have a disproportionately high risk of HIV infection. They also tend to have risk factors associated with underutilization of antiretroviral therapy (ART) such as substance abuse, mental illness, and poor access to care. In this review, we describe how incarceration is a marker of vulnerability for suboptimal HIV care, and also how criminal justice settings may be leveraged as a platform for promoting testing, linkage, and retention in HIV care for a high-risk, marginalized population. Recent findings In both prisons and jails, routine, opt-out HIV testing strategies are more appropriate for screening correctional populations than traditional, risk-based strategies. Rapid HIV testing is feasible and acceptable in busy, urban jail settings. Although ART is successfully administered in many prison settings, release to the community is strongly associated with inconsistent access to medications and other structural factors leading to loss of viral suppression. Summary Collaborations among HIV clinicians, criminal justice personnel, and public health practitioners represent an important strategy for turning the tide on the HIV epidemic. Success will depend upon scaled-up efforts to seek individuals with undiagnosed infection and bring those who are out-of-care into long-term treatment.

Prevalence and incidence of HIV among incarcerated and reincarcerated women in Rhode Island.

We conducted a retrospective cohort study to determine the 3-year reincarceration rate of all HIV-infected inmates (n = 1917) released from the Texas prison system between January 2004 and March 2006. We also analyzed postrelease changes in HIV clinical status in the subgroup of inmates who were subsequently reincarcerated and had either CD4 lymphocyte counts (n = 119) or plasma HIV RNA levels (n = 122) recorded in their electronic medical record at both release and reincarceration. Multivariable analyses were performed to assess predictors of reincarceration and clinical changes in HIV status. Only 20% of all HIV-infected inmates were reincarcerated within 3 years of release. Female inmates (hazard ratio [HR] 0.63; 95% confidence interval [CI], 0.47, 0.84) and inmates taking antiretroviral therapy at the time of release (HR 0.31; 95% CI, 0.25, 0.39) were at decreased risk of reincarceration. African Americans (HR 1.58; 95% CI, 1.22, 2.05), inmates with a major psychiatric disorder (HR 1.82; 95% CI, 1.41, 2.34), and inmates released on parole (HR 2.86; 95% CI, 2.31, 3.55) were at increased risk of reincarceration. A subgroup of reincarcerated inmates had a mean decrease in CD4 cell count of 79.4 lymphocytes per microliter (p < 0.0003) and a mean increase in viral load of 1.5 log(10) copies per milliliter (p < 0.0001) in the period between release and reincarceration. Our findings, although substantially limited by selection bias, highlight the importance of developing discharge planning programs to improve linkage to community-based HIV care and reduce recidivism among released HIV-infected inmates.

Patterns of Homelessness and Implications for HIV Health After Release from Jail

This study explores recent temporal trends in HIV prevalence among women entering prison and the incidence and associated risk factors among women reincarcerated in Rhode Island. Results from mandatory HIV testing from 1992 to 1996 for all incarcerated women were examined. In addition, a case control study was conducted on all seroconverters from 1989 to 1997. In all, 5836 HIV tests were performed on incarceration in 3146 women, 105 of whom tested positive (prevalence, 3.3%). Between 1992 and 1996, the annual prevalence of HIV among all women known to be HIV-positive was stable (p = .12). Age >25 years, nonwhite race, and prior incarceration were associated with seropositivity. Of 1081 initially seronegative women who were retested on reincarceration, 12 seroconverted during 1885 person-years (PY) of follow-up (incidence, 0.6/100 PY). Self-reported injection drug use (IDU; odds ratio [OR], 3.7; 95% confidence interval [CI], 1.3-10.1) was significantly associated with seroconversion, but sexual risk was not (OR, 1.1; 95% CI, 0.4-3.5). Incarceration serves as an opportunity for initiation of treatment and linkage to community services for a population that is at high risk for HIV infection.