Administrative Management of HIV in Correctional Institutions
The National Commission’s policy on the Administrative Management of HIV in Correctional Institutions does not address the medical management of HIV-positive inmates or correctional staff. The Commission’s Board of Directors endorses the concept that the medical management of HIV-positive inmates and correctional staff should parallel that offered to individuals in the noncorrectional community. Such information is available from the U.S. Department of Health and Human Services through its AIDSinfo service, available on the Web at http://AIDSinfo.nih.gov.
In The Health Status of Soon-to-Be-Released Inmates report (NCCHC, 2002) it was estimated that the prevalence of HIV infection among state and local prison populations is approximately five times that of the general public. As many as 17% of all HIV-positive people in the United States are processed through the criminal justice system each year. As a result, prisons and jails have an opportunity to impact on HIV care and public health.
NCCHC believes that correctional administrators have an important role in the management of HIV care. The quality of life for seropositive inmates is greatly affected by administrative decisions on screening and detection, housing, programs, access to quality medical treatment, mental health support, and funding. The public health of our communities also is influenced by administrative decisions regarding discharge planning, education of HIV-positive inmates, and ongoing prevention services.
The management of HIV is very complicated, and administrative decisions can affect patient outcomes at every stage of the disease. As a result, finding administrative solutions to HIV-related issues requires collaboration and coordination between custody and health staff. For example, since the HIV-positive inmate must take multiple medications on varying schedules, custody and health staff must develop a supportive medication administrative system. This position statement provides guidance to resolve administrative issues by suggesting common ground for the overarching goals and objectives of an HIV service delivery system.
HIV Screening and Detection
Advances in the diagnosis and treatment of HIV have made early detection of the HIV seropositive individual obligatory. All clinicians should include HIV testing, when indicated, as part of routine medical care. The HIV testing should be offered on a voluntary basis, as with any other screening or diagnostic test. Anyone with clinical indication of HIV disease and anyone who has engaged in high-risk behaviors should be encouraged to test for HIV. However, HIV testing should not be performed without specific informed consent from the patient.
To decrease the incidence of perinatal HIV transmission, NCCHC promotes the recommendation that all pregnant women be tested for HIV disease. Thus, correctional administrators should make HIV education to women a priority, encouraging them to be tested for HIV if they are pregnant.
Decisions on housing HIV-positive inmates should be based on what is appropriate for their age, gender, and custody class. NCCHC opposes routine segregated housing for HIV-positive inmates. HIV-positive inmates, like any other inmate, may require a higher level of care that may not be available at all institutions. This is a clinical judgment, based upon the acuity of care required for the patient. Patients with HIV infection may require isolation if, for example, they have pulmonary tuberculosis. HIV patients should not be medically isolated solely because of their HIV status.
HIV-positive inmates and those with AIDS who otherwise meet eligibility criteria for special correctional programs (e.g., education, work, parole, or medical reprieve) should be given the same consideration as other inmates.
Access to Quality Medical Treatment
The community standard for HIV care is to have access to HIV specialists who are knowledgeable of newer and sophisticated treatment. It is the correctional administrator’s responsibility to assure continuity of care through organizing and structuring health care services. Various quality improvement studies can be performed to ensure that HIV-infected patients are receiving quality services. The administrator can improve the system by conducting quality improvement process studies such as timeliness of referrals made and kept, patient adherence to antiretroviral therapy, and the number of patients seen in the HIV chronic disease clinic. The correctional administrator’s role in assuring continuity of care, one of the most challenging factors to HIV care in jails and prisons, cannot be overstated. Improved patient outcomes is directly related to the administration’s ability to monitor and enhance the management of its HIV program.
All medications approved for HIV antiviral therapy and prophylaxis should be on the formulary of the facility. All intake facilities should have a system to assure continuity of HIV medications.
Successful HIV therapy requires that there be no interruption in antiviral medications. Correctional medical programs can assure this necessary continuity by establishing mechanisms to enhance the continuous availability of HIV treatment to infected patients.
Intake facilities should maintain adequate supplies of all approved HIV antiviral medications, as well as drugs used for PCP, MAC, and CMV treatment and prophylaxis, so that newly admitted inmates will be able to continue with their treatments without interruption. Prisons and jails should establish automatic renewal systems for these medications to prevent predictable interruptions in care.
Mental Health Support
As many as one in three persons with HIV suffer from depression. There also is a high incidence of anxiety disorders among people with HIV. If left untreated, depression can increase the risk for suicide. Correctional administrators need to ensure that sufficient mental health services are available to inmates with HIV.
In addition, mental health services can be useful in HIV prevention efforts. It is well-documented that high-risk behaviors contribute to the spread of HIV, and many of these behaviors are associated with loneliness, depression, low self-esteem, sexual compulsivity, sexual abuse, marginalization, lack of power, and oppression. Consequently, mental health specialists should be involved in HIV prevention programs.
The Ryan White CARE Act is a significant source of federal funding for people living with HIV/AIDS in the United States. The Act requires Congressional reauthorization every five years; it was last reauthorized in 2000. Ryan White promotes linkages between medical entry points (jails and prisons, for example) that may care for newly diagnosed HIV-positive people with HIV testing, referral, and outreach. Correctional administrators are encouraged to explore and understand the Ryan White CARE Act in their jurisdictions.
Education of HIV-positive Inmates
Clinical outcomes are greatly improved when the patient is informed and motivated. Correctional administrators can foster successful HIV care and services by ensuring that effective education of HIV-positive inmates takes place. HIV/AIDS information should be specifically designed to take into account the common characteristics or lifestyles that put inmates at risk for noncompliance with HIV treatment. Furthermore, appropriate staffing levels should be maintained to ensure provision of education and support of the HIV-positive patient’s continuity of care.
Ongoing Prevention Services
Successful strategies to prevent HIV exposure include peer education, discharge planning, transitional case management, and harm reduction techniques.
It has been shown that trained inmate peer educators can effectively provide HIV education and orientation sessions within the inmate population. Health staff and peer educators should use educational materials that are written in the diverse languages found in prisons and jails. The HIV educational materials should be written for low reading levels and for a lower socioeconomic group. Correctional administrators can provide support to the training and maintenance of peer educators.
Discharge planning is an important service that jails and prisons can provide. HIV-positive inmates need to receive prevention, education, and treatment that continues when they are released. However, it can be difficult for HIV-positive individuals to find health care services outside the correctional environment. HIV-positive patients receiving highly active antiretroviral therapy (HAART) and those with low T-cell counts (CD4) need to have continuity of care upon discharge from jail or prison. HIV-positive inmates should be given sufficient supplies of their medications to assure that they will not run out. Depending upon community availability of HIV follow-up care, this should be at least 14 days, and preferably 30 days, of medication. HIV-positive inmates should receive instruction on the importance of taking antiretroviral agents continuously and the dangers of stopping and starting medications indiscriminately. Administrators should work with various agencies to provide HIV services to inmates and ensure postrelease HIV care.
Correctional administrators can assist in the adequate staffing, training, and development of transitional case management programs. Case managers may conduct adherence checks of medications, follow up with patients for not keeping clinic appointments, and provide specialized counseling or referral as needed.
Harm reduction techniques (such as condom distribution, needle exchange, counseling, and availability of bleach tablets) have been used in a few U.S. jails and prisons with some degree of success (May and Williams, 2002). While NCCHC clearly does not condone illegal activity by inmates, the public health strategy to reduce the risk of contagion is our primary concern. NCCHC recommends that correctional administrators implement harm reduction strategies.
One of the most difficult tasks facing correctional staff is to maintain confidentiality of medical information, such as tests, diagnoses, and treatments. Correctional administrators can contribute to medical confidentiality by creating a supportive environment that reminds staff to exercise caution and diligence in maintaining confidentiality. Correctional administrators should ensure that custody staff receive regular training to not discuss observed or overheard medical care. They need to reinforce health staff training by insisting that inmate medical care is not discussed within earshot of other inmates or officers. Administrators also can foster an environment for confidentiality by ensuring that medical records are secured at all times.
Correctional administrators should provide infection control training for staff. Correctional administrators should ensure implementation and enforcement of universal precautions policies, such as sterilizing equipment for each patient, preventing exposure during surgical procedures, and wearing masks and gowns when appropriate. Combining universal precautions with implementation of harm reduction strategies is the most effective way to address the infection control issues of HIV within correctional facilities.
Adopted by the National Commission on Correctional Health Care Board of Directors
November 8, 1987
Revised: October 9, 2005
May, J. P., & Williams, E. L., Jr. (2002). Acceptability of condom availability in a U.S. jail. AIDS Education and Prevention, 14(5), 85-91.
National Commission on Correctional Health Care. (2002). The Health Status of Soon-to-Be-Released Inmates, Volume 1. Chicago, IL: Author.