Unintended Consequences Of Incarceration: Concurrency In The Community

 

The criminal justice system removes individuals away from the community, friends, family, and intimate partners. Once sexual or injection drug partners are separated, new partners may be introduced into the relationship; partners left in the community may engage in sexual intercourse and injection drug use with new partners. When the number of sexual or drug injection partners are increased, the risk of becoming infected with HIV and other sexually transmitted diseases increases. While incarcerated, inmates may engage in sexual activities with new partners, either by choice or coercion. Injection and tattooing equipment may be shared with other inmates. Due to the large number of incarcerated black males, black women are disproportionately represented in the community. This increases the opportunity for men in the community to have relationships with multiple women and decreases the number of potential long-term male partners for women (Pouget et al. 2010). Men and women in the community and those in correctional facilities are placed at a higher risk becoming infected with HIV.

Among recently incarcerated males, high-risk sex partnerships are likely to be reported. A study of men, aged 15–44 years old, found that incarceration may impact sexual behavior between both users and nonusers of illicit drugs. Multiple and concurrent partnerships were strongly associated with recently incarcerated men; however, the introduction of illicit drugs heightened risk behaviors with multiple or concurrent partners. Drugs enable individuals to engage in risky sexual intercourse and further drug use without sound judgment (Khan et al. 2009). The correctional system has a significant impact on those incarcerated and those left behind in the community.
Linkage To Medical Care After Release
After being released from a correctional facility, individuals need to be integrated back into the community. Former inmates may encounter a host of social and medical challenges upon release. In a population with an exceedingly high number of substance abusers and individuals suffering from mental illness, relapse to addiction and untreated medical illness is common upon release, respectively. Though there is a particularly high prevalence of mental illness in the correctional system, including 60% in state prisons, 45 % in federal prisons, and 64 % in jails, only 25 % of inmates with psychiatric conditions received medications. Mental conditions left untreated can lead to a low adherence to antiretroviral therapy and reentry into a correctional facility (Rich et al. 2011). In states with a high rates of opiate abuse, drug overdose has been noted as a leading cause of death in the immediate post-release period (Binswanger et al. 2007). Homelessness and poverty often burden releases. It is possible for some inmates to lose Medicaid benefits during their sentence, resulting in an average interruption of 3 months in insurance coverage while the individual reapplies (Wakeman et al. 2009). Individuals convicted of drug-related charges are banned from receiving food stamps or federal assistance under the Welfare Reform Act and can be denied public housing under the Anti-Drug Abuse Act of 1988 (Pogorzelski et al. 2005). Antiretroviral therapy in correctional facilities has been successful in a few states; however, the improvements in an inmate’s health observed during incarceration may quickly diminish if adequate care and treatment is not continued (Rich et al. 2011). Medical services offered during incarceration may be the individual’s first link to primary healthcare and HIV/AIDS care. It is common for incarcerated persons to return to poor communities with little or inadequate access to HIV medical care. As there are a considerable number of obstacles presenting themselves, adhering to HIV treatments may not be a high priority for many releasees while trying to gain stability in the community. Release from a correctional facility has been associated with poor HIV treatment adherence: only 5.4 % of released HIV-positive inmates filled their antiretroviral prescriptions within 10 days, 17.7 % after 30 days, and 30.0 % after 60 days (Baillargeon et al. 2009). Poor adherence can lead to disease progression and emergence of drug–resistant viral HIV strains. Therefore, prerelease discharge planning, case management, and linkage to care are crucial to ensure that former inmates initiate and continue HIV/AIDS care and treatment. Non-adherence to HIV treatment upon release from a correctional facility may also be linked to inadequate discharge planning (Culbert 2011).

Prerelease discharge planning allows inmates to develop a plan to access medical care and treatment while incarcerated to reduce the burdens faced by inmates upon reentry into the community. Many agree that discharge planning is a legally and ethically mandated standard of care for those in the criminal justice system. During discharge planning, inmates can be provided with (a) a list of medical providers in the community, (b) an appointment with a community care provider, (c) education about the importance of adherence to medications, (d) transfer of medical records, (e) assistance with insurance applications, and (f) linkage to HIV case management services. Upon release, former inmates should be provided with an adequate supply of medication to avoid interruption in treatment until the initial appointment in the community (Centers for Disease Control and Prevention 2009).

HIV case management services have the ability to assist with discharge planning to link recent releases to healthcare and other resources in the community; case managers provide a link between former inmates and healthcare facilities to make access to healthcare easier. Inmates who participate in adequate discharge planning may be more likely to sustain their health and avoid reentry into correctional facilities (Culbert 2011). Although case managers can be beneficial to recent releasees, there are shortcomings that come with using just case management programs to ensure that adherence to HIV treatment and non-detectable viral loads are continued upon release, and that linkage to medical services is established. Discharge planning and HIV case management should not only involve linkage to HIV medical services and treatment, but also to organizations that can alleviate social burdens upon release as well such as health insurance, housing, and substance abuse treatment to reduce the number of burdens that releasees face. In the face of social burdens, HIV-positive releasees may disregard adherence to medication.

To create an effective discharge planning program, a considerable amount of money and faceto-face time is required in addition to the development and continuance of partnerships within the communities in which former inmates reside upon release. However, budget cuts and transfer of correctional healthcare services into the private sector have reduced partnerships with community-based organizations (Culbert 2011). Although there are challenges and resources may be limited in some facilities, an effort can be made to increase adequate discharge planning and case management programs in the correctional system.

Starting in 2006, the Rollins School of Public Health at Emory University and Abt Associates, Inc. coordinated the evaluation of the Enhancing Linkages to HIV Primary Care and Services in Jail Settings Initiative (EnhanceLink). This initiative successfully provided HIV testing in 20 US jails, resulting in 822 new diagnoses out of 212,464 inmates who agreed to HIV testing. Services were provided to not only address linkage to medical care but also to social needs upon release such as mental health and substance abuse treatment and linkage to housing. Transitional services were accepted by 82 % of HIV-positive persons in the program offered services (Spaulding et al. in press-a). At 6 months follow-up, 26 % of releasees had suppression of their HIV viral load (Spaulding et al. in press-b). In a jail setting, HIV testing and linkage to care after release are feasible. With adequate program planning, successful testing and transitional programs can be implemented in jails and prisons throughout the United States.
Conclusion
The prevalence of HIV is high in the correctional population, but HIV disease needs to be understood in context. Men and women entering the correctional system are also disproportionately affected by low socioeconomic status, violence, mental illness, substance abuse, chronic disease, and infectious disease. With a large proportion of HIV-positive individuals passing through the correctional system, these facilities have the opportunity to play an instrumental role in the diagnosis and clinical care of HIV/AIDS patients. Known HIV-positive persons would be able to receive HIV medication and avoid interruption of therapy. Undiagnosed HIV-positive persons could learn of their HIV status and begin treatment; access to HIV testing may be suboptimal after release. Treatment of HIV with antiretroviral therapy is needed to lower viral loads and restore the immune system, allowing HIV-infected persons to live a healthier life. Correctional facilities are settings where HIV-positive persons might control their HIV for the first time.

Furthermore, due to the poorer health status and higher incarceration rates of people of color, the criminal justice system has the opportunity to significantly decrease health disparities. If HIV medical services are not provided to the incarcerated and released population, poor health outcomes could continue to devastate communities plagued by poverty and high crime rates. The incarcerated have a right to adequate medical care. Many individuals transitioning through a correctional facility do not have access to adequate healthcare, prior to receiving healthcare in a correctional facility. An effort has to be made to develop more partnerships between the correctional system and the community-based organizations.

Medical care in the criminal justice system provides medical and public health professionals the opportunity to work with a vulnerable and underserved population. In order to continue to have a supply of providers sensitive to the needs of inmate patients, medical schools and residency programs should consider providing mentored training opportunities in correctional facilities. The correctional setting provides opportunities in a challenging environment to reach a large underserved population, while developing skills in areas such as working with patients with cooccurring medical conditions and dealing with a high turnover rate of patients. There are many practice and research opportunities available in correctional facilities to address and aid in the needs of the incarcerated. The criminal justice system has the capacity to be a wonderful training ground for future health professionals.

Correctional healthcare, if administered well, can have a positive impact on the lives of HIV-positive inmates. There is an opportunity to enhance HIV medical care in correctional facilities. Correctional healthcare can mitigate the disparities among a poor, underserved population. Improved HIV educational programs, HIV testing, and linkage to care is needed to ensure that better health outcomes are observed in the incarcerated population and after release to the community. Failing to address health disparities is an additional punishment.

Bibliography:

 	
Altice F, Sylla L et al (2010) Jail: time for testing, institute a jail-based HIV testing program. Yale University School of Medicine, New Haven