On any given day in America, more than two million people are incarcerated in correctional facilities, whether they’re awaiting trial or serving time. People in correctional settings are five to seven times more likely to have HIV than the civilian population. The HIV crisis in jails and prisons is part of a far-reaching and complex health care crisis in the United States, one that wraps around the opioid epidemic, public health, and the very structure of the law in America.
HIV and AIDS in prisons disproportionately affect black men and women, just as they do on the outside. While the high infection rate in prisons may conjure up images of risky practices like injection drug use and unprotected sex on the inside, that’s not actually the reason why rate is so high. Most HIV+ prisoners enter the system with active infections—the actual transmission rate inside US jails and prisons is very low.
Instead, this is a function of how the law is structured. The same populations vulnerable to HIV infection—injection drug users and sex workers in particular—are also those who tend to be criminalized. The racial wealth gap also plays a big role in differential HIV infection rates outside prison walls, and unsurprisingly is amplified within them as well. In a sense, the justice system is self-selecting a high-risk population for incarceration.
Some aren’t even aware they have HIV, thanks to poor access to HIV testing and treatment on the outside. Once in prison, their access to care can vary considerably depending on where they’re incarcerated. Sylvia Stacy, a physician who has worked in correctional settings since 2014, notes that some challenges are unique to the prison system; for example, lockdowns and other security procedures can interfere with the timely delivery of medication. Jails and prisons across the US have also been called to task on failure to provide adequate care, as in New Orleans in 2016.
But the real problems begin when people leave, says Frederick Altice, a professor of medicine, epidemiology and public health at Yale University. Altice is one of the authors of a recent study in The Lancet HIV looking not simply at HIV in prisons, but what happens after people are released. Altice’s work focuses heavily on HIV in the prison system, and this study found that just 21 percent of subjects secured access to long term care within two weeks of release.
For people leaving the prison system after lengthy sentences, the adjustment period can be rocky—they may have lost friends, family, and connections. Newly released inmates are struggling to secure work, a place to live, and other needs in life. For those with HIV, whether diagnosed in prison or before, managing the virus can take a back seat. Patients, Altice says, are released into the community with a limited supply of medication, and “it would be really hard to manage your HIV in the setting of just surviving.”
He notes that providing transition services that start in jail or prison and extend to connecting inmates with resources on the outside can facilitate access to care. Such programs require attentiveness, though; transition programs are useless without services on the outside to help with the adjustment period, and failure to follow up on the part of case managers can allow people to fall through the cracks. This kind of care is critical for helping people manage their HIV, especially in the case of those with well-controlled infections and undetectable viral loads— because they have better health outcomes, and they can’t transmit the virus to others.
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HIV positive people who have just left the system face some other challenges, though, and one is directly linked with the looming opioid crisis. The current leading cause of death for prisoners within the first two weeks of release is overdose, often associated with injection drugs. This highlights the lack of access to addiction treatment in prison, which leads people to seek drugs when they leave, and potentially allows them to spread HIV to others through shared needles or risky sexual behavior.
“The biggest problem we have across this country,” Altice says, “is we have people with substance use disorders, and no treatment.” Outside, substance abuse treatment is hard to access for those who aren’t wealthy or well-insured. But on the inside, it’s even worse. Many jail and prison systems don’t provide even basic substance abuse care, and when people are released, they aren’t referred to services to help them manage addiction. In the chaos of reentry, HIV management tends to get neglected as people take up drug use again; and after weeks, months, or years of forced sobriety in prison, it’s easy to take a fatally high dose of drugs.
This goes both ways; as the opioid epidemic facilitates the spread of HIV, more HIV+ people are likely to be incarcerated, and they in turn will enter the revolving door when they’re released. Of the 1.2 million HIV+ Americans, roughly one in six goes through the penal system every year. Altice warns that though the United States has made tremendous progress on the HIV epidemic, opioids could reverse the downward trend in new infections, and this should be cause for concern.
As the specter of the HIV/AIDS epidemic has faded in a world where people can achieve excellent long-term outcomes on HIV medications, vulnerable populations sometimes fall by the wayside. As the situation with HIV in prison settings illustrates, though, this could come back to haunt us—because inadequate care and followup in the prison system will inevitably spill over into the civilian world.
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