The prevalence of hepatitis C virus infection among prisoners approaches 40%, and far exceeds that of HIV in prison. Coinfection with the 2 viruses, which therefore is exceptionally common in prisoners, is associated with an accelerated course of hepatitis C disease, making treatment of both diseases particularly urgent in the correctional setting. Recognition of the existence and course of hepatitis C, and of its epidemic proportions in prison, has been relatively recent.(33,34)

HIV and Tuberculosis
TB has long been an infection of particular concern in the prison setting because of its higher incidence compared with that of the community at large and the ease and frequency of airborne transmission of TB bacilli in the crowded conditions commonly found in prisons.(35)

Reports described a 6-fold increase in the incidence of TB among inmates in the state of New York from 1976 to 1986, by which time more than 50% of inmates with TB also were infected with HIV.(36) A survey of TB cases in the United States between 1993 and 2003 found that 3.8% were reported from correctional systems, 3-4 times the rate reported outside prisons. This survey of 210,976 cases also found that 58.9% of prisoners completed treatment, compared with 73.2% of noninmates.(37)

The inconsistent treatment that often characterizes prisoners’ medical care can permit the development of multidrug-resistant (MDR) strains of Mycobacterium tuberculosis-a medical calamity reported in the New York and California state prisons. In New York, 7 inmates and 1 immune-suppressed guard died with rapidly fatal, untreatable TB in 1991.(38) The clinical history of a California prison inmate treated for M tuberculosis and then MDR-TB over 3.5 years illustrates the full range of problems in prison medical care: poor record keeping at initial screening, delay in diagnosis of symptomatic disease, lack of isolation of the patient at the time of diagnosis, lack of supervision or observation of medication ingestion, lack of follow-up after completion of initial treatment, infirmary treatment in a setting with susceptible HIV patients, inadequate ventilation of patients’ rooms, transfers among 3 different prisons, and inadequate screening and testing of prison staff and inmate contacts.(39) Illustrating the dangers of TB to HIV-infected prisoners, a 1999 CDC report described multiple tuberculin skin test (TST) conversions in 1995-96 among California prisoners, staff, and community contacts despite TB control practices. Two HIV-positive inmates-one with a documented negative TST, the other previously treated for positive TST, with M tuberculosis-negative sputum smears and cultures-proved to be infected with TB after initial placement in open prison HIV housing units. Similarly, during 1999-2000, 31 HIV-positive prison contacts of an inmate with unsuccessfully treated latent TB were diagnosed with TB in South Carolina. Rapid spread of TB can be a consequence of segregated housing for HIV-positive inmates.(40,41) TB outbreaks continue to evade infection control programs; reports have come from many correctional systems, including Alabama in 2003, Kansas in 2004, Florida in 2005, and Georgia in 2006.

In jails, many inmates are not incarcerated long enough to permit diagnosis or treatment. Clinical investigation for suggestive signs and symptoms is critical. To detect active pulmonary disease in the setting of rapid inmate turnover, the Los Angeles County Jail system features “mini chest films” at intake-single-view, low-dose screening radiographs-at much greater cost than the widely practiced skin test, but with immediate results. Although they will not detect all cases of TB, these radiographic images identify persons with communicable disease who require immediate treatment and isolation.(42)

In addition to intake screening for TB, subsequent routine follow-up and surveillance programs are essential for inmates and prison staff. The CDC published recommendations for prevention and control of TB in correctional institutions in 1989 and 1996. In December 2005, the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings published by the CDC included correctional facilities as health care settings.(43,44,45)

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Elizabeth Kantor, MD
University of California San Francisco

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Dr. Elizabeth Kantor MD practices geriatric medicine and internal medicine in San Francisco, California.

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REFERENCES

1. U.S. National Commission on AIDS. HIV Disease in Correctional Facilities. Washington: U.S. National Commission on AIDS; 1991.
2. Harrison P, Beck AJ. Prisoners in 2004. Washington: U.S. Department of Justice, Bureau of Justice Statistics; October 2005.
3. Maruschak L. HIV in Prisons, 2003. Washington: U.S. Department of Justice, Bureau of Justice Statistics; September 2005.
4. Maruschak L. HIV in Prisons and Jails, 2002. Washington: U.S. Department of Justice, Bureau of Justice Statistics; December 2004.
5. Hammett TM, Harmon P, Rhodes W. The Burden of Infectious Disease Among Inmates and Releasees from Correctional Facilities. In: The Health Status of Soon-to-Be-Released Inmates: A Report to Congress. Vol. 2. Chicago: National Commission on Correctional Health Care; March 2002.

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