Important note: Information in this article was accurate in August/September 2001. The state of the art may have changed since the publication date. | The online version of HEPP News displays the main article only, to view the entire newsletter download the following PDF:
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Recent outbreaks of communicable diseases in correctional settings have underscored the importance of identifying communicable diseases, educating inmates and staff, and treating where appropriate. In June 2001, an outbreak of HBV was reported in a state correctional facility in Georgia.1 In November 2000, the CDC reported an outbreak of TB in a state correctional facility in South Carolina.2 Concurrent syphilis outbreaks were identified in three Alabama men's state prisons in 1999.3 These events all point to an important gap between awareness of infection (diagnosis) and medical intervention in correctional settings. This article describes the communicable disease gap in correctional settings, and addresses means of bridging that gap.
Lack of information about an inmate's diagnosis of HBV, TB, STD, and/or HIV may be due to the inmate's failure to provide this information, unwillingness to be screened or inability to access screening for these diseases, or the failure of routine hepatitis, TB, STD and HIV screening protocols to detect communicable disease. Denial, fear of illness and concern about confidentiality are major deterrents for inmates. Concern about the cost of treatment may also contribute to delays in diagnosis. Furthermore, current guidelines for treating the disease may advise delaying treatment until medically necessary, diminishing the patient's and providers' sense of urgency about obtaining a diagnosis. While some individuals may not need active treatment under existing HIV and HCV guidelines, they are still likely to benefit from education about their medical condition and the risk of transmission to their families and communities after release from incarceration. Furthermore, as illustrated by outbreaks of communicable diseases in correctional settings, inmates who have communicable diseases sometimes continue to participate in risky activities while incarcerated. Diagnosis and appropriate medical intervention may reduce the risk of communicable disease transmission to other inmates and correctional staff.
According to the National Commission on Correctional Healthcare's "Health Status of Soon-to-be-Released Inmates" project, the diseases that are particularly prevalent in prisons are HBV, HCV, HIV, sexually transmitted diseases (STDs), including syphilis, chlamydia and gonorrhea, and airborne diseases such as TB (4,5,6). A summary of this report's findings is provided in the next four paragraphs.
HIV: 98,000 to 148,000 soon-to-be-released inmates were infected with HIV at the time the study was carried out (1998). This number represents 12% to 18% of the total infected population in the US. HIV infection is more prevalent among incarcerated women than incarcerated men, however the total number of infected women is small (due to lower overall numbers of incarcerated women). (See Figure 1 and Table 1.)
STDs: Syphilis infection is highly prevalent in correctional settings: in 1999 it was estimated that 558,000 inmates were infected with syphilis (RPR+) compared to 186,000 inmates infected with chlamydia and 77,500 inmates infected with gonorrhea. In a 1999 study in New York City it was found that although the rate of syphilis infection among the general population had reached a record low, prevalence among incarcerated women was 25%.7 These high numbers for STD infection are not reserved for adult inmates: a study recently conducted at two juvenile detention facilities in Texas found that 22.2% of female and 8.7% of male participants were infected with chlamydia.8
TB: Active tuberculosis disease (TB) was detected in 12,000 US inmates in 1999, which accounts for 35% of total cases of TB disease in the US. This TB case rate was more than 50 times that of non-incarcerated individuals.9 Active screening and appropriate medical intervention can have a dramatic effect on the incidence of TB in correctional settings, as demonstrated by the significant decline of TB cases, from 225/100,000 to 26/100,000, in the New York State Department of Corrections over the past decade.10 In other settings, factors such as failure to identify active TB and to adequately treat latent TB infection (LTBI) in inmate populations, difficulties obtaining previous TB treatment records and lack of continuity of care between institutions may contribute to ongoing outbreaks of TB such as the one recorded in Broad River, South Carolina, last year.
Hepatitis: In terms of sheer numbers, the two diseases that most disproportionately affect inmate populations are hepatitis B (HBV) and hepatitis C (HCV). In 1999 it was estimated that 155,000 inmates being released were infected with HBV. Up to 1.25 million inmates being released were estimated to be infected with HCV. (See Table 1.)
Very little information is available about the transmission of communicable diseases inside US prisons and jails. Studies performed outside of the United States have demonstrated that inmates participate in a number of high risk behaviors while incarcerated, including intravenous drug use (IDU), which is the risk behavior that contributes most to new HIV, HBV and HCV infections. In a study conducted in England, for instance, 58% of IDU inmates admitted to injecting drugs while incarcerated, and 73% of those injecting in prison shared needles.11 A study in Canada also found that the overwhelming risk association for HIV and HCV was IDU, either inside or outside prison.12 Two Australian studies have found proof of both HCV and HIV transmission occurring within prison walls. It was determined that IDU was the probable cause for inmates contracting HIV and HCV, while lacerations from barbers' shears and physical assault were the likely means of HCV infection in other cases.13,14 It is unknown, however, whether conditions in British, Canadian and Australian institutions compare to conditions in US facilities.
Other factors that may contribute to the transmission of blood-borne, sexually transmitted and airborne diseases in prisons and jails include overcrowding, poor or delayed access to healthcare and treatment, recidivism and frequent transfers from one prison to another.15 Some correctional institutions have a policy of segregating HIV+ prisoners from seronegative inmates. While this practice may have some benefits, including being able to manage HIV+ prisoners' healthcare more efficiently, it also concentrates individuals who are at higher risk of opportunistic infections and disease. In 1999/2000, for instance, the CDC determined that segregation and concentration of HIV+ inmates in one dormitory had contributed to the outbreak of TB in a state correctional facility in South Carolina (2).
Risky behaviors can be associated with infection by more than one communicable disease. For instance, acquiring an STD is linked to unprotected sexual contact, which should point to the associated risk of HIV infection. In the same way, it is highly probable that an inmate who is being treated for IDU has been exposed to unsafe sex (trading sex for drugs or money, for instance), meaning possible exposure not only to blood-borne viruses like HBV and HCV, but also to HIV and other STDs.
Identifying communicable disease "flags" that signal the need to institute a screening protocol is one way to reduce disease transmission and improve patient education. Every medical encounter can be viewed as an opportunity to pick up on these signals, allowing providers to intervene with appropriate medical intervention and/or education (see HEPPigram page 6).
If limited resources for communicable disease screening are available, histories of high risk behavior and some laboratory tests can be used to identify higher-risk individuals, and testing can be confined to those determined to have the most at-risk profile (see HEPPigram). Childhood sexual abuse and sex work have both been associated with high risk of HIV infection, for instance.16 Screening for these two "flags", along with other indicators, can decrease the number of potential HIV test candidates.
HIV: The benefits of diagnosing and treating are multiple. Routine recommendations for HIV testing by primary health care providers has been shown to improve the incidence of requested testing, the identification of infected individuals and earlier diagnosis of infection, leading to earlier entry into care.17 Inmates who are eligible for treatment may experience fewer opportunistic infections,18 fewer hospitalizations19 and may be less likely to transmit HIV if still participating in HIV risk behavior.20
HCV: HCV treatment guidelines for correctional facilities will be published by the CDC in late 2001 or early 2002. Because of the prevalence of HCV infection among inmates and the lack of official treatment protocols guiding HCV treatment in corrections, emphasis has shifted to identifying infected individuals and providing education about means of limiting further spread of HCV. As Dr. Robert Greifinger, MD, recently said: "It's almost distracting to talk about treatment. The much larger issue is prevention.21 "It is hoped that education about HCV may help motivate HCV-infected individuals to take precautions against transmitting HCV in communities to which they return, and to seek appropriate HCV treatment in the community if it they are unable to participate in HCV treatment while incarcerated.
HBV: The CDC has recommended that all adults at risk of HBV infection be vaccinated (inmates and staff in correctional institutions are included in the high-risk category).22 Again, limiting vaccination to higher-risk inmates (those with a history of IDU, for example) would lower costs.23
STDs: Jail intake represents an important opportunity for STD screening. However, the rapid turnover of inmates can limit the efficacy of STD diagnosis and treatment. A number of rapid tests for STD infections have been developed.24 In Chicago, these methods for rapid STD diagnosis and treatment led to the identification of most of the city's STD cases and successful treatment before release (25,26).
Currently, different prisons have different protocols on testing and treating communicable diseases. One example of a protocol addressing HCV comes from the Pennsylvania Department of Corrections.27 Inmates who are HCV positive or request an HCV test are also tested for HIV, if at high risk. Those who are HCV positive are educated about HAV and HBV vaccines, and those who have more than 12 months left on the minimum sentence and are not excluded from treatment for other medical reasons and are HIV negative are then offered HCV treatment. If the inmate accepts, the treatment proceeds. (See April 2001 HEPP News, available on line at http://www.HIVcorrections.org, for a full discussion of HCV treatment protocols). According to Dr. Fred Maue, MD, chief of clinical services in the Pennsylvania DOC, 10,135 inmates there have been tested as of May 31 2001, and 5,429 tested positive for HCV infection. Of those, 292 have completed treatment and 378 are receiving treatment. Of those not receiving treatment, 40% are still under evaluation, some were excluded because of medical, psychiatric, drug and alcohol abuse and sentencing reasons, and 20% refused treatment after having met the criteria for receiving it.28 Every inmate has received one-on-one education about HCV with a trained healthcare provider.
New protocols for treating latent TB infection were developed by the CDC and published in June, 2000. Updated protocols reflecting concerns about PZA/Rifampin toxicity (see Newsflash in this issue) and guidelines for appropriately identifying and treating latent TB infection in correctional settings can be obtained from the CDC Division of Tuberculosis Elimination, at www.cdc.gov/nchstp/tb/pubs/mmwrhtml/mmwr_ updates.htm.29 HIV treatment protocols are revised by a committee of experts every year: updated protocols available online at the Health Resources and Services Administration website, www.hab.hrsa.gov, and at the AIDS Education Global Information System website, www.aegis.org.
Education is not only arguably the most effective way to achieve prevention of transmission, it is also one of the cheapest. A study by the CDC published this year found that HIV prevention programs in prison that included testing and counseling not only saved society a lot of money (while prevention programs can seem expensive, treatment after infection costs a lot more), it reduced the risk of infection for uninfected inmates by 20%, and transmission from infected inmates by 25%.30 Another study in San Francisco found that prerelease risk reduction counseling reduced sex- and drug-related risk behavior of inmates after release, and improved the use of community resources.31 Peer-led education has been convincingly demonstrated to be the most effective form of education for inmates.
Treatment and education programs may need to be gender-specific, since female prison populations often have different disease dynamics than their male counterparts. For instance, about 10% of women who enter jails in the US are pregnant. The prevention of mother-to-child HIV transmission is a particularly important intervention for correctional facilities. Infants of mothers with acute (and chronic active) HBV infection are also at risk of contracting the disease.
Because of the complex relationship between various communicable diseases, and the high prevalence of infection among prison populations, effective management programs have to be coordinated efforts that screen for various risk-associated behaviors and medical conditions. Prison and jail-based programs, in the context of overall public health interventions, are extremely effective for the following reasons: they have the potential of identifying and reaching a high number of those infected with communicable diseases and those at risk of infection, and they effectively bring treatment and prevention strategies directly to a population that is at highest risk in a setting that may be more conducive to learning than educational programs located "on the street."32,33 Communicable diseases impact more than the correctional population, as inmates eventually return to their communities. Will correctional facilities act as incubators or educators? That is the question of the new millennium.
* Nothing to disclose
** Speaker’s Bureau: Merck & Co., Roche, and Schering-Plough
1. "Hepatitis B Outbreak in a State Correctional Facility, 2000", MMWR, June 29, 2001 / 50(25);529-532.
2. "Drug-Susceptible Tuberculosis Outbreak in a State Correctional Facility Housing HIV-Infected Inmates --- South Carolina, 1999--2000", MMWR, November 24, 2000 / 49(46);1041-1044.
3. Spaulding A, Lubelczyk RB, Flanigan T., "Can unsafe sex behind bars be barred?", Am J Public Health 2001 Aug;91(8):1176-7.
4. Greifinger R. Personal communication, December 1999.
5. Meeting of the expert panel on communicable disease, NCCHC-NIJ, “Health of soon-to-be-released- inmates” project. June 14-15, 1999, Chicago IL.
6. Margolis H. Hepatitis Branch NCID, CDC. Prevention and Control of Viral Hepatitis in the Community. CDC Consultants' Meeting, 2001.
7. Blank S, Sternberg M, Neylans LL, et al., "Incident syphilis among women with multiple admissions to jail in New York City", J Infect Dis 1999 Oct;180(4):1159-63.
8. Kelly PJ, Bair RM, Baillargeon J, et al., "Risk behaviors and the prevalence of Chlamydia in a juvenile detention facility", Clin Pediatr (Phila) 2000 Sep;39(9):521-7.
9. Centers for Disease Control and Prevention. "Tuberculosis Morbidity Among U.S.-Born and Foreign-Born Populations --- United States, 2000", MMWR February 8, 2002 / 51(05);101-4 See, also, http://www.cdc.gov/nchstp/tb.
10. Lester Wright, Editor’s Letter in HEPP News, March 2001.
11. Edwards A, Curtis S, Sherrard J., "Survey of risk behaviour and HIV prevalence in an English prison", Int J STD AIDS 1999 Jul;10(7):464-6.
12. Ford PM, Pearson M, Sankar-Mistry P, et al., "HIV, hepatitis C and risk behaviour in a Canadian medium-security federal penitentiary. Queen's University HIV Prison Study Group", QJM 2000 Feb;93(2):113-9.
13. Haber PS, Parsons SJ, Harper SE, et al., "Transmission of hepatitis C within Australian prisons", Med J Aust 1999 Jul 5;171(1):31-3.
14. Dolan KA, Wodak A., "HIV transmission in a prison system in an Australian State", Med J Aust 1999 Jul 5;171(1):14-7.
15. Valway SE, Richards SB, Kovacovich J, et al., "Outbreak of multi-drug-resistant tuberculosis in a New York State prison, 1991", Am J Epidemiol 1994 Jul 15;140(2):113-22.
16. Mullings JL, Marquart JW, Brewer VE., "Assessing the relationship between child sexual abuse and marginal living conditions on HIV/AIDS-related risk behavior among women prisoners", Child Abuse Negl 2000 May;24(5):677-88.
17. "Routinely Recommended HIV Testing at an Urban Urgent-Care Clinic --- Atlanta, Georgia, 2000", MMWR June 29, 2001 / 50(25);538-541.
18. Gallant JE, McAvinue SM, Moore RD, et al., "The impact of prophylaxis on outcome and resource utilization in Pneumocystis carinii pneumonia", Chest 1995 Apr;107(4):1018-23.
19. Moore R. Presented at the Brazil/Johns Hopkins University HIV/AIDS Conference October 20-22, 1999, Rio de Janeiro.
20. Cohen MS. 40th Interscience Conference on Antimicrobial Agents & Chemotherapy; Day 3 - September 19, 2000.
21. "Hepatitis C has higher incidence among inmates." Associated Press, September 5 2001.
22. "Hepatitis B Virus: A Comprehensive Strategy for Eliminating Transmission in the United States Through Universal Childhood Vaccination: Recommendations of the Immunization Practices Advisory Committee (ACIP)", MMWR, November 22, 1991 / 40(RR-13);1-19.
23. Skidmore S, Parry JV, Nottage P. "An investigation of the potential risk of an HAV outbreak in a prison population following the introduction of cases from a community outbreak", Commun Dis Public Health 2001 Jun;4(2):133-5.
24. Parece MS, Herrera GA, Voigt RF, et al., "STD testing policies and practices in U.S. city and county jails", Sex Transm Dis 1999 Sep;26(8):431-7.
25. Beltrami JF, Cohen DA, Hamrick JT, et al., "Rapid screening and treatment for sexually transmitted diseases in arrestees: a feasible control measure", Am J Public Health 1997 Sep;87(9):1423-6.
26. "Syphilis Screening Among Women Arrestees at the Cook County Jail -- Chicago, 1996", MMWR, June 05, 1998 / 47(21);432-433.
27. Maue, FR. Presentation at the CDC Consultant Meeting, March 3-7, 2001.
28. Maue, FR. Personal communication, September 2001.
29. "Targeted Tuberculin Testing and Treatment of Latent Tuberculosis Infection", MMWR, June 09, 2000 / 49(RR06);1-54.
30. Varghese B, Peterman TA., "Cost-effectiveness of HIV counseling and testing in US prisons", J Urban Health 2001 Jun;78(2):304-12.
31. Grinstead O, Zack B, Faigeles B. "Reducing postrelease risk behavior among HIV seropositive prison inmates: the health promotion program", AIDS Educ Prev 2001 Apr;13(2):109-19.
32. Kassira EN, Bauserman RL, Tomoyasu N, et al., "HIV and AIDS surveillance among inmates in Maryland prisons", J Urban Health 2001 Jun;78(2):256-63.
33. Wohl AR, Johnson D, Jordan W, et al., "High-risk behaviors during incarceration in African-American men treated for HIV at three Los Angeles public medical centers", J Acquir Immune Defic Syndr 2000 Aug 1;24(4):386-92.
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©1997,1998,1999,2000,2001. The recently formed HIV Education Prison Project (HEPP) is a medical education program that targets a growing population, inmates in correctional facilities, that has been underserved in HIV care. It is part of the Brown University AIDS Program. Permission to use and reproduce portions of this newsletter is hereby granted provided that author and publication are fully credited and both copyright and permission notice appear with reprinted material. Inquiries may be directed to heppnews@brown.edu. Website: HIV Education Prison Project.
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