Executive Summary: State-of-the-Art Review: The Intersection of Infectious Diseases and Carceral Medicine

Over the past 5 decades, the United States has incarcerated a greater portion of its population than any other country in the world, ever. Politics and policy changes in the 1970s, such as the “war on drugs” and the deinstitutionalization of the mentally ill, led to massive increases in the number of people incarcerated, which has been referred to as a shift from “plantation to penitentiary.” Moreover, the term “criminal–legal system” is now preferred over the term “criminal justice system” to acknowledge the injustice of mass incarceration [1]. Mass incarceration has disproportionately affected populations including, but not limited to, Black persons, indigenous persons, persons of color, the LGBTQIA community, individuals with disabilities, and especially those with addiction and mental illness. Incarceration has exacerbated health disparities, particularly in infectious diseases (ID) and public health [2, 3]. The trauma of incarceration also has direct effects on health, including placing this population at higher risk for the acquisition and transmission of infectious diseases. Healthcare clinicians can both advocate to promote policies that reform mass incarceration and improve carceral conditions while concurrently continuing to provide high-quality care to those who are currently incarcerated or impacted by the criminal–legal system. Through clinical vignettes, we highlight common ID case-based scenarios. In the first case, a patient with hepatitis C virus presents with a sexually transmitted infection (STI). This provokes a discussion of the increased prevalence of STIs in criminal–legal involved patients and how to approach screening for infectious diseases, as well as a discussion of how preexposure prophylaxis can be implemented as patients transition back to their community. The second case is a hospitalized patient who is incarcerated with staphylococcal bacteremia and also receiving medication for opioid use disorder. We discuss the care of incarcerated patients in the hospital setting and recommend methods used to build a therapeutic alliance while working with corrections personnel. We highlight considerations for shared decision-making and formulating a long-term treatment plan with an incarcerated patient. The third case discusses how chronic medical conditions are managed in the carceral setting and how those may intersect with ID care and outcomes. We discuss the interplay of infectious diseases and chronic medical conditions in carceral healthcare and the role ID clinicians have in whole-person care for this population. Our review concludes with a discussion of how the ethical principle of dual loyalty, a unique triangle of potential conflict of interest within the carceral setting, applies to clinicians who provide healthcare to people who are incarcerated. This discussion describes areas where evidence is lacking within the carceral healthcare setting and what empowered ID clinicians can do to improve a system so integral to ensuring this population receives the high-quality care that everyone deserves. Acknowledgments. S. P. expresses their sincere appreciation and gratitude to the collaborative efforts of all authors, Drs Josiah Rich, Justin Berk, Helen Jack, and Alysse Wurcel. The medical expertise, dedication to carceral healthcare reform, and collegiality of these authors allowed for the construction of this state-of-the-art review. The collective efforts of this team are greatly valued. To the peer reviewers who took the time to meticulously examine the manuscript, your expertise and dedication to the integrity of academia are deeply appreciated. Financial support. J. B. reports funding from the National Institute on Drug Abuse (NIDA) (K23DA055695).