The failure of many AIDS-infected inmates to continue treatment beyond prison walls poses a new public health challenge.
New York took a major step this fall to provide care for HIV-positive inmates — and a victory for prisoners' rights activists — with legislation giving the state Department of Health an official oversight role in the HIV/AIDS and hepatitis care provided in prison. But it underlined a problem that concerns public health experts and criminologists: what happens to HIV-infected prisoners when they return home?
The failure of many of those inmates to continue treatment after they leave prison is “both a public health and a public safety issue,” Prof. Roberto Hugh Potter, director of research at the University of Central Florida's Department of Criminal Justice and Legal Studies, told The Crime Report. According to Potter, when former prisoners return to dangerous behaviors such as drug use and unprotected sex, it is more likely they will transmit the virus in potentially new and drug-resistant strains.
No one can be forced to continue HIV treatment after he or she leaves the prison system?unless it's a condition of parole, Potter said. “The state has no more control over you, and that extends to health issues. It's up to that individual.”
The scale of the problem is still unknown, but the substantial population of HIV-positive inmates across the country raises concerns about what happens to them beyond prison walls. In 2006, the latest year for which figures were available, 1.6 percent of male inmates and 2.4 percent of female inmates in state and federal prisons were known to be HIV-positive or have AIDS, according to the Department of Justice. While that number represents a decline from the previous year, the overall rate of estimated AIDS cases among the prison population in 2006 (0.46 percent) was more than twice the rate in the country's general population (0.17 percent).
A Texas study conducted by doctors and researchers, released in February, found that about 80 percent of the state's HIV-positive former inmates did not fill a prescription for their medication within 30 days of release. This number goes down to 70 percent after 60 days, but that still means only about 30 percent of former inmates had continued treatment within two months of their release.
More Data Needed
Similar post-release treatment data is not available in other states with high numbers of HIV-positive prison populations. In 2006, the combined HIV-positive prison populations of New York, Florida, and Texas accounted for nearly half of all known HIV/AIDS-infected persons in U.S. state prisons. New York alone has the largest number of male HIV-positive inmates (3,650), representing about six percent of the state's male incarcerated population; and it reports the second largest number?after Florida–of female HIV-positive inmates (350), a staggering 12.2 percent of female prisoners in New York prisons.
What makes the situation particularly ironic is that, as New York's recent move demonstrates, care for HIV-positive patients inside prison walls has become a priority. Despite the high numbers of infected inmates, prison HIV care “is very decent and very effective,” said Dr. David A. Wohl, an infectious disease expert and associate professor of medicine at the University of North Carolina at Chapel Hill. “Overall, people do very well in prison.”
Many prisons try to prepare for an HIV-positive prisoner's release with programs that arrange for doctor visits and access to medication on the outside. The best programs, Wohl said, have a low caseload number and can provide individual attention. While some programs, like one in Rhode Island, are admired nationally, the quality of services varies across the country.
Considering that roughly 95 percent of incarcerated prisoners are eventually released, according to the American Correctional Association, both the quality and the consistency of treatment for ex-felons should be a high priority, according to experts. Halting treatment, as well as reverting to dangerous behaviors such as drug use and unprotected sex, diminishes the benefits inmates received while they were under direct prison supervision, Wohl said. “Many people fall through the cracks when they get out of prison,” he said. “That's a perfect storm for (HIV/AIDS) transmission.”
One key worry is the impact of recividism: since various HIV strains are mixing and mutating, people who go in and out of prison (and therefore on and off treatment), are increasing their chances of succumbing to the virus, warned Florida's Roberto Potter. “There's a point when you're likely to become treatment-resistant,” he said.
Prison officials seem aware of the problem. New York State's continuity of care programs focus on educating prisoners about their treatment and aftercare options, as well as the risks of unprotected sexual behavior, before their release. The continuity of care programs, which are voluntary, are provided on a case-by-case basis and typically begin between three and six months prior to release, said Erik Kriss, a spokesman for the state Department of Correctional Services.
In 50 of the state's 68 correctional facilities, inmates are trained to educate fellow prisoners about HIV, Kriss said. Inmates can receive guidance from peer educators in different settings, including informal interactions and more formal training sessions. When release is imminent, prisoners are connected with community organizations that help them plan for their continued HIV care. Appointments are arranged for inmates to visit a clinic or doctor upon release, and each inmate leaves prison with a 30-day supply of medications and additional prescriptions.
Although several other states have employed a variety of programs to help former inmates continue HIV care, experts say more needs to be done. Continuity of care programs are “incredibly important,” said Florida's Potter, adding, “there's certainly a promise there.”
But, added Potter, the programs might not be as effective as they could be. Researchers don't yet know enough about how well community groups and clinics follow through with the former inmates they're tasked with aiding or how well those former prisoners follow through with their care. One measure suggested by Potter is making HIV/AIDS care and education available before a prisoner starts serving time-and possibly widening it to include those on probation.
“From my perspective, the real issue is earlier intervention,” he said, “and not waiting until people progress all the way to prison.”
Christina Hernandez is a freelance writer and editor based in the Philadelphia area. Her work is available at www.christina-hernandez.com.
Photo by Dennis S. Hurd via Flickr.