At-risk diseases
HIV/AIDS
At least 17% of people living with HIV/AIDS have been incarcerated at some point in their life. The rate of contracting HIV is ten to one hundred times higher inside the prison system than outside. The incarcerated population is more likely to contract the disease because they are exposed to more high-risk behaviors within the correctional system. In a Louisiana prison study, 242 inmates (72.8% of male inmates) had participated in sexual encounters with other men, and did not always have access to proper protection. Additionally, research has demonstrated that infection rates via injection are much higher among those who have previously served prison terms. Research suggests that elevated rates of infection are a result of increased prison sentencing for drug-related offences and theHepatitis C
While the majority of HCV infections occur outside of prison, the disease is still widespread within the prison system as a result of drug injection. According to one Rhode Island prison study, HCV infection was found in 23.1% of the male prison population. HCV prevention proved to be more challenging than HIV prevention because inmates partake in high-risk behaviors such as "front loading" and sharing spoons to prepare drugs likeCOVID-19
Differences in funding for sexually transmitted diseases treatment
In 2002, the ''Public Health Reports'' released a study entitled "Comparing Quality of Care for Sexually Transmitted Diseases in Specialized and General Clinics", explaining the quality of care provided in public STD clinics and general medical clinics when treating patients with STDs. In October 1995, the County of Los Angeles Department of Health Services faced a budget deficit that led to the decision of restructuring their outpatient care system. The result of this restructuring led to the following: 17 LA County STD clinics and 3 of general medical clinics were also closed down. This then resulted in the shift of "balance of STD services in favor of general medical clinics." Reduced funding greatly therefore affecting the quality of patient care. Six clinics were studied from March 1, 1996, to June 30, 1996, with the data of patients recorded during each visit. Thirty-two process of care quality indicators were determined that listed patient expectations during visitation. Data showed that the public STD clinics demonstrated a greater adherence than general medical clinics for every 14 out of the 32 patient care quality indicators. As a result, both the general medical clinics and STD clinics suffered from the budget deficit of 1995. Separate studies assessed the practicality and cost-efficiency of vaccinating all adults treated at STD clinics in a span of a year. Two scenarios were compared, assuming a national program offering the Hepatitis B vaccine to two million clients in order to create a decision model. The first scenario lacked the Hepatitis B vaccination while the second followed a Hepatitis B vaccination. The stages of the HBV virus were followed in a Markov Model of Natural History. These are the stages that clients can potentially experience if they opted out of vaccination. Those that chose to be part of a routine vaccination would undergo a three-part vaccination stage within a year. The total medical cost for those who contracted the HBV virus is as follows: $1,587 million for societal costs; $346 million in medical costs; and $1,241 million in productivity losses. The projected cost for a national vaccination program that is to serve more than a million clients is "$138 million including $95 million for vaccine and administration, $30.5 million for staff training and supervision, and $12.2 million for protocol development and vaccination record-keeping. In North Carolina, the state Department of Health and Human Services Division of Epidemiology works with the AIDS Drug Assistance Program to help pay for HIV medication for incarcerated persons in county jails (state and federal prisons are not eligible). In order to qualify, county detention centers must complete an application for funds that includes the jail health budget to show need. Additionally, Duke University and UNC-Memorial Hospitals have collaborated with one jail's HCV positive inmates for further follow-up testing and care.Policies within the United States
ThePreventive measures
Shortcomings and limitations
Approaches to preventing the spread of diseases such as HIV and HCV in prisons include not only internal changes within correctional facilities, but also increased external community support. Between 2.7 million and 3.9 million Americans live with a chronic hepatitis C, but less than 20% receive treatment for the condition. Many medically underserved patients, who are appropriate candidates for antiviral treatment, do not receive treatment for a variety of reasons, including limited or no insurance coverage and the high cost of antiviral therapy. Such access barriers are compounded by the fact that HCV is particularly prevalent in populations struggling with substance abuse problems, poverty, homelessness, mental illness, low literacy, and language issues, thereby subjecting them to mass incarceration. A study conducted at a Florida State prison concluded that the continual persistence of HIV infections and deaths related to such infections are due to unequal distribution of health care resources to inmates. Such statistics coupled with an increasing rate of incarceration only amplify the issue of HIV/HCV prevention in prisons, with the number of inmates increasing but healthcare policies remaining stagnant. While the World Health Organization has endorsed certain preventive practices, only Vermont and Mississippi State Prisons and Los Angeles, San Francisco, New York, Philadelphia, and Washington County Jails have provided condoms to inmates. Others have argued against providing condoms because officials feel it condones sexual activity, which is illegal within the prison system. Imprisonment as a response to US drug use has created a ''de facto'' policy of jailing more HIV-infected individuals. High-risk behavior that persists within prisons poses harm to inmates and the greater community alike, but US courts have chosen to remain silent. Separating infected individuals from the rest of the prison population has been seen as ineffective because not all infected individuals have been properly tested. That, therefore, promotes high-risk actions because there is a perceived lack of infected population.Possible solutions
Universal screening methods have proven very effective in certain circumstances. For example, screening among blood donors has all but eliminated transmission of HIV through blood transfusions. Another example is the reduction of perinatal transmission with the introduction of routine screening for pregnant women. The benefits of introducing a routine screening program include: * Increasing diagnosis of new cases of HIV infection; * Preserving staff resources by streamlining the process; * Reducing stigma associated with testing * Potentially diagnosing HIV infection earlier for the inmate in the course of disease; and * Improving access to HIV clinical care, medication and prevention services. In 1996, the CDC revised its recommendations to incorporate diagnostic HIV testing and opt-out HIV screening as a part of routine clinical care in all health-care settings while also preserving the patient's option to decline HIV testing. The recommendations are intended for all health-care settings including hospital emergency departments, urgent-care clinics, inpatient services, STD clinics or other venues offering clinical STD services, tuberculosis clinics, substance abuse treatment clinics, other public health clinics, community clinics, correctional health-care facilities, and primary care settings. (The guidelines address HIV testing in health-care settings only; they do not change existing guidelines concerning targeted testing of persons at high risk for HIV who seek HIV testing in nonclinical settings such as community-based organizations, outreach settings, or mobile vans.) The new CDC guidelines state "in all health-care settings, screening for HIV infection should be performed routinely for all patients aged 13–64 years. Health-care providers should initiate screening unless prevalence of undiagnosed HIV infection in their patients has been documented to be <0.1%. In the absence of existing data for HIV prevalence, health-care providers should initiate voluntary HIV screening until they establish that the diagnostic yield is <1 per 1,000 patients screened, at which point such screening is no longer warranted." Additional recommendations for juveniles that are incarcerated in adult jails include the following: * Know that incarcerated adolescents may be unaware of their rights concerning medical care, privacy, and confidentiality; therefore, it is especially important that adolescents be informed of their rights and that these rights are respected. * Follow state or local laws that require parental consent or notification for HIV testing and/or HIV-related health-care services for minors. If required, obtain consent for testing and/or health-care services from the adolescent's parent or legal guardian prior to providing that service. Consent can be obtained directly from an emancipated minor as defined by state law. * Inform adolescents that the medical information, including HIV test results, will not be disclosed without their consent, except as required by law. * Inform adolescents that, as with all inmates, their HIV status will not adversely affect their medical care during incarceration or their legal rights. Procedures for offering support to the inmate who receives a diagnosis of HIV should be in place to assure they can manage the infection. Privacy in a correctional setting is difficult, but the inmate should be assured that his medical information is confidential. The following are CDC recommended procedures for inmate support: * Provide education to patients about HIV infection, AIDS-related symptoms, and the significance of any laboratory testing done. * Inmates diagnosed with HIV infection may require short-term mental health support. * Inmates with mental health conditions may require increased monitoring and intervention for these conditions. * Inmates may be reluctant to access or possess HIV educational materials due to concerns about disclosing their HIV infection. Strategies to provide HIV education and counseling for HIV-infected inmates can include HIV educational sessions and support groups. * Facilities should have HIV medical information and periodicals available in prison libraries and medical clinics. * Facilities should have chronic disease management programs for HIV-infected inmates. * Facilities should have a discharge-planning program for HIV-infected inmates. Linking inmates to HIV care services when they are quickly released back to the community from a local jail can be difficult. Often they can be more concerned with finding a place to live or finding money to pay their legal fees. But upon giving an inmate a diagnosis of HIV, steps should be taken immediately to ensure that an appointment has been made with a provider, that contact information for a health department or community-based organization case manager is available to help them navigate the healthcare system. Several studies indicate that follow-up care for HIV positive women may correlate with a reduction in recidivism. Correctional facilities should have the following CDC recommended procedures and resources in place for inmates being discharged from custody: * Provide a list of available agencies that provide HIV case management for released inmates. * Provide contact information for local AIDS service organizations and the local health department. * Assist inmates with making appointments with case manager before release from custody. If possible, arrange for the inmate to meet the case manager before release. * Complete applications for other services following release in conjunction with the inmate. * Provide medications if the inmate has started therapy.Alternative approaches
The high rate of turnover in local jails as opposed to prisons may make it difficult to implement a routine testing program at intake or on a scheduled basis. In cases where testing all incoming inmates is not possible, there are alternative approaches that can be used individually or in combination with other approaches. One alternative approach could include risk-based criteria screening. The CDC recommends that jails routinely offer HIV testing to inmates who fall under one or more of the following criteria: * Injection drug use (IDU); * Men who have sex with men (MSM); * Sex with an IDU, MSM, or HIV-infected partner; * Multiple sexual partners; * Exchange of sex for money, drugs, or other goods; and * Diagnosis of another sexually transmitted disease. The limitation with this screening approach is that risks are self-reported by the inmate. One study suggested that up to 42% of inmates diagnosed with HIV reported no risk factors. A second alternative approach is clinical screening based on HCV, HBV or STD infection. The presence of any of these diseases increases the likelihood of acquiring or transmitting HIV disease. Clinical criteria for screening include: * Pregnancy; * A diagnosis or history of sexually or parenterally transmitted infections (e.g., HBV or HCV, syphilis, genital herpes, gonorrhea, chlamydia, trichomonas infection); * ''Mycobacterium tuberculosis'' (MTB) infection or active TB; * Track marks indicative of illicit drug injection; * Signs or symptoms suggestive of HIV infection or acute retroviral syndrome. A third alternative approach for screening in the jail setting is based on demographics such as zip code of residence, age, gender and race or ethnicity. When using this approach, providers in correctional settings should with their state or local health department to determine the demographics of HIV for their population. Criteria examples for demographic screening could include: * Residence in low-income areas/zip codes; * Residence in known high-HIV prevalence areas/zip codes; * Female sex; * Age 25–44 years; and * Transgender identity (male to female). There is also some evidence that screening based on type of arrest could indicate higher rates of HIV infection. For example, a study by the Department of Justice found that HIV infection is more often associated with property and drug-related crimes. Because there is a high-volume turnover rate of inmates in the jail system, some inmates who are tested for HIV, HCV or other STDs may have been released before receiving their results. Correctional facilities should assure that all cases of newly diagnosed infectious diseases are reported to the state or local health department for assistance with notification of results, counseling, partner services and linkage to care. The CDC advocates a syndemic approach to intervene in the transmission of HIV, HCV and other STDs. This approach includes "combining services to minimize missed opportunities" to detect disease. This approach calls for a collaborative effort between agencies to address high incarceration rates and other social justice issues such as poverty. Possible HCV prevention techniques have included vaccinations,Post-treatment for HCV
Treatment after being released from prison can be difficult because individuals must locate facilities that can provide them treatment while considering their social status, limited knowledge, and access to these resources. Hepatitis C has been one of the most widespread blood-borne infection to date within the United States. From 2005 to 2006, the state of New York began implementing the Hepatitis C Continuity Program, offering free HCV treatment for inmates even after release from its state prisons. The program encompassed 70 prisons and 21 health-care facilities. This program was put together by the collaborative efforts of New York State Department of Correctional Services, New York State Department of Health, New York State Division of Parole, New York City Health and Hospitals Corporation, and other community-based health care providers. Together, these organizations addressed the immediate need for medication upon release from prison. Inmates were given proper medication provided they possessCDC definitions
* Diagnostic testing: Performing an HIV test for persons with clinical signs or symptoms consistent with HIV infection. * HIV-prevention counseling: An interactive process of assessing risk, recognizing specific behaviors that increase the risk for acquiring or transmitting HIV, and developing a plan to take specific steps to reduce risks. * Informed consent: A process of communication between patient and provider through which an informed patient can choose whether to undergo HIV testing or decline to do so. Elements of informed consent typically include providing oral or written information regarding HIV, the risks and benefits of testing, the implications of HIV test results, how test results will be communicated, and the opportunity to ask questions. * Inmate: A person incarcerated in a local jail, state prison, federal prison, or a private facility under contract to federal, state, or local authorities. * Jail: A confinement facility usually administered by a local law enforcement agency that is intended for adults, but sometimes holds juveniles, for confinement before and after adjudication. Such facilities include jails and city or county correctional centers; special jail facilities, such as medical treatment or release centers; halfway houses; work farms; and temporary holding or lockup facilities that are part of the jail's combined function. Inmates sentenced to jail facilities usually have a sentence of 1 year or less. Alaska, Connecticut, Delaware, Hawaii, Rhode Island, and Vermont operate integrated systems, which combine prisons and jails. * Opt-out screening: Performing HIV screening after notifying the patient that 1) the test will be performed and 2) the patient may elect to decline or defer testing. Assent is inferred unless the patient declines testing. * Prison: A long-term confinement facility, run by a state or the federal government, that typically holds felons and offenders with sentences of more than 1 year. However, sentence length may vary by state. Alaska, Connecticut, Delaware, Hawaii, Rhode Island, and Vermont operate integrated systems, which combine prisons and jails. * Screening: Performing an HIV test for all persons in a defined population without regard to the individual's characteristics. * Targeted testing: Performing an HIV test for subpopulations of persons at higher risk, typically defined on the basis of behavior, clinical, or demographic characteristics.See also
* Criminal transmission of HIV in the United States * Organ donation in the United States prison population * Healthcare in American women's prisons * Prison–industrial complex *References
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