Brief: Addressing HIV and STDs Among Prisoners

Inmates in state prisons and jails have higher rates of HIV and STIs than the general population.  Inmates are usually infected prior to incarceration, but due to lack of access to health care and other factors they are often first diagnosed by correctional health services.  To stop the spread of infections in communities when inmates are released, state and local corrections, public health and community-based programs are collaborating to help inmates get tested and access  treatment for HIV and other STIs—both before and after release.

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Inmates in state prisons and jails have higher rates of HIV and sexually transmitted infections than the general population. Incarceration is often the first time inmates are diagnosed with infections of which they were unaware. Treating the infections protects others in communities when inmates are released.

Incarcerated adults reflect the communities from which they come. They often have not had access to medical care outside of correctional facilities, and are more likely to be drug offenders, homeless or mentally ill. Their lives more likely include drug and alcohol abuse, lack of education, a history of physical abuse, unemployment and participation in unsafe sex practices. African-Americans and Hispanics have higher rates of incarceration compared to whites; African-American men are incarcerated 6.6 times as often as white men, according to the Bureau of Justice Statistics.

HIV and sexually transmitted infections disproportionately affect African Americans and Hispanics. HIV/AIDS is transmitted through unprotected sex or by sharing syringes or other injection equipment for drugs or tattooing, and most likely occurs before or after incarceration. In fact, HIV/AIDS affects federal and state inmates at nearly 2.5 times the rate of the general U.S. population, and 20,000 state prisoners had HIV or confirmed AIDS in 2008, according to the Bureau of Justice Statistics. (See table.)

Other sexually transmitted infections, such as gonorrhea and chlamydia, also occur more often among people entering corrections facilities than among the general population. These treatable infections can make people more susceptible to HIV infection if exposed, and can lead to infertility in women. Gonorrhea and chlamydia infections usually have no symptoms, so they often are diagnosed only after routine testing. According to the Centers for Disease Control and Prevention, screening inmates for these infections at intake provides an opportunity to treat them and prevent complications, as well as reduce transmission to families and communities when inmates are released.

Correctional Health and Community Health
To stop the spread of infections in communities, state and local corrections, public health and community organization programs are helping inmates get tested and access treatment for HIV and other sexually transmitted infections.

Programs focus on testing, continuing treatment and prevention education to reduce health disparities, prevent further transmission of infections, and improve the health of inmates, corrections facility staff, inmates’ partners, family members and communities. More than 20 percent of state and federal inmates were never tested for HIV or didn’t receive their test results, the Bureau of Justice Statistics reports. In jails, more than 80 percent of inmates were never tested for HIV. 

Not all states require inmates to be offered testing during prison intake, and inmates can opt out of screenings. When prisoners are tested in private rooms as part of other routine medical care and results are disclosed privately, they are more likely to consent to testing. At a time when some public health and correctional health resources are limited, experts suggest the testing of inmates be prioritized for:

  • Inmates from communities with high levels of sexually transmitted infections and HIV/AIDS;
  • Jails with the largest inmate populations; and
  • Inmates in younger age groups, who are most at risk.

New York Health Department Oversees Correctional Health Services
New York Assembly Bill A903 and companion Senate Bill 3842 (2009) seek to improve medical care in prisons and jails by requiring the state health department to oversee correctional medical services in prisons and jails. The Department of Correctional Services benefits from the health department’s expertise and assures high quality medical care for all HIV/AIDS- and hepatitis  C-infected inmates through a facility review and inspection process.  The bill authorizes reviews of similar services in local correctional facilities to begin in two years. The financial costs of the program were offset by the expected savings from initiating early treatment and decreasing the incidence of HIV and other sexually transmitted infections among the inmates. The average cost of  caring for a person with early HIV disease is approximately $14,000 a year, while the cost of caring for a person with advanced HIV disease is approximately $34,000 per year.

Community support for the New York bill focused on the disproportionate impact of HIV and  hepatitis C infection in black and Latino communities, and the need to address the epidemics both during and after incarceration. If inmates start treatment and education while they are incarcerated, inmates likely will continue treatment after release, encourage family and friends to seek testing and care, and avoid passing infections on to loved ones or seeking costly emergency services. Also, since women in New York’s prisons are twice as likely to have HIV as men in prison and 80 times more likely than the general population, strong support existed for making quality medical care available to all female inmates.

Illinois Communities, Public Health and Correctional Health Join Forces
An estimated 85 percent of those incarcerated in Illinois return to the greater Chicago area,  followed by the greater East St. Louis and Springfield areas. Because of that, the Illinois Department of Public Health funds six local health departments to test inmates for HIV in county jails, and a program in all 39 state prisons which trains peer educators on HIV prevention. The department also supports a statewide case management network available for all low-income  people with HIV, including inmates after release. The HIV Care Connect network of regional providers provides comprehensive medical and case management services across the state. As Illinois Department of Corrections discharge planners learn the release date of an HIV positive inmate, they can contact any of the HIV Care Connect Regional programs, which serves as a clearinghouse where each inmate is matched to a case manager and medical provider for health care.

The AIDS Foundation of Chicago, one of the partners in that network, provides case management for HIV positive former inmates, as well as substance abuse treatment, and housing and family support services. It also conducts cross-training of AIDS service providers and Illinois Department of Corrections staff to test and initiate treatment for inmates when needed. It is also applying recent Urban Institute research demonstrating that strong family relationships can diminish recidivism and families are the primary source of housing after release. Inmates and their families are supported through educational programs to encourage successful re-entry of inmates.

Chicago’s health department will begin offering routine HIV and sexually transmitted infection testing to men with and without symptoms in the Cook County Jail later this year when new medical facilities open. Using current technology, test results will be available within 24 hours and medical treatment can be initiated before the detainee is released back to the community.

Helping inmates obtain continuous medical treatment for their infections after release remains challenging for corrections and public health officials, as well as community support organizations. Former inmates may face delays in obtaining proof of identification, residence or enrollment in  Medicaid or Medicare, or they may return to custody before medical coverage can be established. Finally, former inmates who began treatment of HIV infection while in prison may not have their  medical records, making it difficult to continue their previous treatment.

To help small community  organizations, the Illinois legislature authorized the Quality of Life Endowment Fund in 2007  through a special Illinois Lottery Game fund to support HIV/AIDS prevention, education and  treatment services. The “Red Ribbon Bonus Bucks” program generated $1.4 million to be awarded later this year to 11 community agency applicants serving the highest risk individuals, including the formerly incarcerated. Organizations that provide HIV prevention interventions or re-entry support services for HIV positive persons are eligible to apply, and half the awards will go to small organizations with budgets less than $300,000.

Wisconsin Seeks Additional Medicaid Funding to Support Services
Wisconsin enacted Senate Bill 647 in 2010, authorizing the Department of Health Services to apply for additional federal Medicaid funding to support expanded case management services and improve outcomes for all patients with HIV, including former inmates. Through a patient-centered medical home model, more intensive case management will arrange and follow each patient’s  compliance with prescribed medications, primary and specialist medical visits, inpatient medical care, dental and mental health care and other needs such as housing assistance. The additional funds will support nonprofit and public agencies providing services to persons with HIV or at risk of contracting HIV.

This publication was supported by Cooperative Agreement 1H25PS00138-02 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention.