HIV Infection behind Bars

Each year, 8 million individuals pass through correctional systems in the United States [1]. The average daily census of incarcerated individuals in the United States recently reached 2 million, giving the United States the dubious distinction of incarcerating more people per capita than any other country in the world [2]. This growth has been fueled over the past 20 years in large part by the “war on drugs,” which emphasizes policies of law enforcement, prosecution, and punishment [3]. During the period of 1980–1995, the incarcerated population increased by 239%, and drug-related convictions accounted for 30%–60% of this increase in jailed and imprisoned people [4]. As a result of the increased proportion of inmates convicted for drug-related offenses, the demographic and epidemiologic characteristics of the incarcerated population are significantly different today from what they were 2 decades ago. Consistent with the nature of the crimes for which they were convicted, incarcerated individuals have a high prevalence of drug addiction, mental illness, and infectious diseases, including HIV infection [1]. Eighty percent of inmates report a history of drug use, and one-quarter report a history of injection drug use [2]. Behaviors related to drug use, such as trading or selling sex for drugs, can contribute to the spread of infectious diseases in the community. In 1999, the AIDS rate in prisons was 5 times that of the general population [5], and, currently, an estimated one-fourth of all HIV-infected individuals in the United States pass through the corrections system each year [1]. The disproportionately high burden of disease found among the incarcerated population presents both a challenge to correctional health systems and a tremendous public health opportunity. Prisons and jails are key points of contact with millions of individuals at high risk of HIV infection who are largely out of the reach of the medical system in the community [6]. For many inmates, incarceration may be the first time they have access to health services. Many inmates are offered HIV testing for the first time while incarcerated [7], and three-quarters of inmates with HIV infection initiate treatment while incarcerated [8]. Incarceration settings present an effective venue to engage these hard-to-reach and high-risk individuals in critical health services, including the diagnosis, treatment, and prevention of HIV infection. Addressing the HIV epidemic behind bars begins with identifying infected individuals. Most inmates acquire HIV infection while in the community [9]; thus, intake into the corrections system presents an opportunity for identification. In Rhode Island, where routine HIV testing has been in place in the corrections system since 1989, one-third of all newly diagnosed cases of HIV infection in the state have been diagnosed within the correctional system [10]. When testing is conducted as part of a comprehensive treatment program, it is widely accepted by the prison population [11]. However, attention must be paid to stigma and the negative consequences of testing: inmates will not agree to participate in testing if they face discrimination or abuse. Earlier identification of HIV-infected inmates leads to earlier medical attention and allows for time to engage individuals in important secondary prevention measures, such as partner notification, education, harm reduction, and/or referral for substance abuse treatment. Testing creates an opportunity to provide important health information to inmates during posttest counseling. The coupling of testing with education increases the effectiveness of counseling regardless of test result [12]. Thus, HIV testing in prisons and jails achieves both primary and secondary prevention objectives. The advent of combination antiretroviral therapy has significantly decreased mortality due to HIV infection/AIDS in the community setting [13]; there has been a parallel decrease in the mortality rate among incarcerated individuals. Between 1995 and 1999, the rate of mortality associated with AIDS in state prisons decreased by >75% as a result of the use of antiretroviral therapy [5]. Despite the logistical difficulties of administering complex medical regimens in prison, inmates demonstrate acceptable levels of adherence to treatment [14]. Because of the scale of the HIV epidemic behind bars, some prison health systems have been reluctant to institute routine screening for HIV because of the financial implications of providing antiretroviral medications. However, HIV care for inmates is not only medically and ethically appropriate and constitutionally mandated/protected [15], it is also more cost-effective than inadequate treatment [16]. In this issue of Clinical Infectious Diseases, Springer et al. [17] document the effectiveness of antiretroviral treatment among HIV-infected prisoners. The authors use demographic, pharmacy, and laboratory data from the Connecticut prison system to document, in a retrospective cohort study, that an increase in CD4 lymphocyte count and decrease in virus load occurred during incarceration in prisoners treated with antiretroviral therapy for >6 months: 59% of prisoners achieved undetectable virus loads at the end of their term of incarceration. This study adds to the evidence that, when provided with care and access to medications, prisoners respond well to antiretroviral treatment. Springer et al. [17] also analyzed data from individuals who were reincarcerated and found that those individuals had a log increase in virus load and a mean decrease in CD4 lymphocyte count of 80 lymphocytes/μL. Reincarceration may be associated with relapse to substance abuse, discontinuation of therapy, and, possibly, uncontrolled mental illness. This subgroup likely represents a subset of ex-offenders who relapsed to drug use and crime, leading to reincarceration. That the gains in health status made during the term of incarceration were lost among reincarcerated persons underscores the need for linkage to aftercare services for people with HIV infection upon release. Ex-offenders face multiple challenges upon release to the community, including addiction, mental illness, homelessness, joblessness, poverty, and violence. For ex-offenders with HIV infection, these challenges can present significant barriers to continuing medical care. Given that the majority of individuals who pass through correctional systems return to their communities [18], careful discharge planning and linkage to community care are important elements to maintaining and building on the health advances made while incarcerated. Discharge planning and community aftercare services should include mental illness triage and referral, substance abuse assessment and treatment, appointments for HIV care and other medical care, and referral for assistance with housing, nutrition, entitlements, job placement, and other services to assist with social stabilization. Model linkage programs in Rhode Island [19], Massachusetts [20], and New York [21] demonstrate that discharge planning increases the likelihood that ex-offenders will be successfully linked to medical care in the community. Not only does discharge planning and linkage to community aftercare maintain continuity of medical care, it also facilitates ongoing secondary prevention efforts and may reduce recidivism [22]. Because of the tremendous increase in the number of incarcerated individuals at high risk of acquiring HIV infection and other infectious diseases, the setting of incarceration should be a significant focus of efforts to address the HIV epidemic [23]. Routine testing of inmates can serve to identify infected individuals, provide them with effective care while incarcerated, and serve primary and secondary prevention goals [24]. Resources to implement routine testing are needed, and testing may be increasingly accessible with the availability of rapid HIV tests. Testing must be tied to the provision of comprehensive HIV care, as has been done in Connecticut. This will both help individuals with HIV and help to stem the epidemic.