Prisons and jails, designed to confine and punish people (many of whom are poor and lack influential outside advocates), frequently fail to provide the level of health services required by patients with HIV. As with other chronic illnesses, HIV requires health services that are expensive in terms of staff effort and expertise, laboratory testing, and medication. Prisons often have escaped outside attention to serious failures of care. HIV has placed an enormous fiscal burden on prisons, which already are stressed financially. The cost of HIV care in the 21st century in prisons now is rivaled by the cost and controversies surrounding management of hepatitis C, which affects up to 40% of prison inmates, and by the cost of psychotropic agents for the large number of individuals with mental illness who are imprisoned in the United States.

Prisons increasingly are recognizing the need for consultation and treatment of HIV by medical specialists, and several states provide care in conjunction with outside university-based clinic systems. Participation by HIV specialists is by no means the rule, however.(46) Treatment with potent antiretroviral therapy is the standard of care for HIV and AIDS in prisons, as in the community at large. A survey of treatment regimens of the 3,563 prisoners supplied through Stadtlander Pharmacy’s Corrections Division in February 1999 found that 45% were receiving drug regimens recommended by 1998 U.S. Department of Health and Human Services guidelines. Seven percent were on regimens categorized as “alternative,” 28% “not generally recommended,” 8% “not recommended,” and 12% were reported as “unclassified.”(47)

Often, prison conditions undermine the consistent dosing schedules essential to the long-term effectiveness of antiretroviral therapy. Gaps in treatment occur due to transfers of inmates among correctional institutions. Confiscation of all medications from prisoners is also a common practice of prison staff in the course of searches for contraband. Court appearances, transfers among facilities, punitive detentions, and release from custody are all part of the prisoner’s life, and provisions must be made to continue therapy through these events without interruption.

In many prisons, antiretroviral therapy is administered under direct observation to prisoners. Observers have reported that adherence to antiretroviral therapy among prisoners apparently has been good. At Rikers Island in New York City, patients’ CD4 counts rose in a pattern almost identical to that found in clinical trials.(48) Among 170 prison patients in Wisconsin who self-administered medications, improvements in CD4 and viral measures were comparable with those found in community patients.(49) A 1996 survey of 205 HIV-infected prisoners eligible for potent antiretroviral therapy that found an acceptance rate of 80% and an adherence rate of 84% also found that adherence was 82% in those who received directly observed therapy, and 85% in those who self-administered medications.(50)

Every jurisdiction is responsible for providing health care to its prisoners. In 2006, no required guidelines or standards of care exist, although several organizations have developed voluntary health care standards for correctional facilities. The American Correctional Association, the American Public Health Association (APHA), and the National Commission on Correctional Health Care (NCCHC) have published standards for health care and HIV management in jails and prisons. The NCCHC also provides accreditation for subscribing institutions that meet its standards. The World Health Organization (WHO) published guidelines for management of HIV in prison 1987 and 1993,(51) and the APHA included guidelines in its book of standards in 1986, updated in 1996 and 2003.(52,53) Medical personnel, public health advisers, prison administrators, legislators, courts, and the electorate all have influenced policy development for management of HIV in prisons.

Among 19 countries in an international survey prepared for the WHO, the United States was 1 of 4 that did not have a national policy for HIV management in prison.(12) The National Commission on AIDS, in its March 1991 report, proposed that the U.S. Public Health Service develop guidelines for the prevention and treatment of HIV in all U.S. correctional facilities.(1)

In the fall of 1987, the WHO Special Programme on AIDS held a consultation on the prevention and control of HIV in prisons, and specialists from 26 nations attended. This group’s consensus statement recognized the risks of HIV transmission in prisons and recommended the following general approaches:

 
• Treatment of prisoners in a manner similar to the treatment of other members of the community
 
• Consideration of compassionate release for prisoners with AIDS
 
• Implementation of nondiscriminatory practices relating to HIV infection
 
• Provision of information on HIV to staff as well as prisoners
 
• Implementation of means to obtain informed consent and ensure confidentiality in the event of HIV antibody testing
 
• Devotion of additional human and financial resources to HIV management in prisons, but not at the expense of other health services and activities

A subsequent WHO conference held in Geneva in 1992 drafted more extensive and specific guidelines outlining applications of the principles above.(51)

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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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