The burden of infectious disease among inmates of and releasees from US correctional facilities, 1997

Impact of new therapeutics for hepatitis C virus infection in incarcerated populations

Inmate populations bear a disproportionate share of the burden of hepatitis C virus (HCV) infection. With more than 90% of prisoners released back to their communities within a few years of sentencing, incarceration can be viewed as an opportunity to provide HCV screening and therapeutic interventions to benefit the individual, reduce the costs of HCV management to the health care system from a societal perspective, and improve overall public health. Although optimal medical management of HCV within prison settings would increase the current cost of correctional health care, it could decrease transmission within the community, reduce overall disease burden, and lower the future societal health care costs associated with end-stage liver disease. Nonetheless, most prison systems treat only a small fraction of infected inmates. Current and emerging therapeutic agents will cure HCV infection in the vast majority of patients. Mathematical modeling also shows that expanded HCV screening and treatment are cost-effective from the societal perspective. In this article, we will describe appropriate treatment regimens, propose strategies to lessen the burden of these costly HCV therapies on correctional health care systems, and address the challenges of expanded HCV screening in correctional settings.

The dose-response of time served in prison on mortality: New York State, 1989-2003

OBJECTIVES

I investigated the differential impact of the dose-response of length of stay on postprison mortality among parolees.

METHODS

Using 1989-2003 New York State parole administrative data from the Bureau of Justice Statistics on state correctional facilities, I employed multinomial logistic regression analyses and formal demographic techniques that used the life table of the populations to deduce changes in life expectancy.

RESULTS

Each additional year in prison produced a 15.6% increase in the odds of death for parolees, which translated to a 2-year decline in life expectancy for each year served in prison. The risk was highest upon release from prison and declined over time. The time to recovery, or the lowest risk level, was approximately two thirds of the time served in prison.

CONCLUSIONS

Incarceration reduces life span. Future research should investigate the pathways to this higher mortality and the possibilities of recovery.

Factors mediating HIV risk among female sex workers in Europe: a systematic review and ecological analysis

OBJECTIVES

We reviewed the epidemiology of HIV and selected sexually transmitted infections (STIs) among female sex workers (FSWs) in WHO-defined Europe. There were three objectives: (1) to assess the prevalence of HIV and STIs (chlamydia, syphilis and gonorrhoea); (2) to describe structural and individual-level risk factors associated with prevalence and (3) to examine the relationship between structural-level factors and national estimates of HIV prevalence among FSWs.

DESIGN

A systematic search of published and unpublished literature measuring HIV/STIs and risk factors among FSWs, identified through electronic databases published since 2005. 'Best' estimates of HIV prevalence were calculated from the systematic review to provide national level estimates of HIV. Associations between HIV prevalence and selected structural-level indicators were assessed using linear regression models.

STUDIES REVIEWED

Of the 1993 papers identified in the search, 73 peer-reviewed and grey literature documents were identified as meeting our criteria of which 63 papers provided unique estimates of HIV and STI prevalence and nine reported multivariate risk factors for HIV/STI among FSWs.

RESULTS

HIV in Europe remains low among FSWs who do not inject drugs (<1%), but STIs are high, particularly syphilis in the East and gonorrhoea. FSWs experience high levels of violence and structural risk factors associated with HIV, including lack of access to services and working on the street. Linear regression models showed HIV among FSWs to link with injecting drug use and imprisonment.

CONCLUSIONS

Findings show that HIV prevention interventions should be nested inside strategies that address the social welfare of sex workers, highlighting in turn the need to target the social determinants of health and inequality, including regarding access to services, experience of violence and migration. Future epidemiological and intervention studies of HIV among vulnerable populations need to better systematically delineate how microenvironmental and macroenvironmental factors combine to increase or reduce HIV/STI risk.

Epidemiological characteristics of HIV-infected women with and without a history of criminal justice involvement in South Carolina

The circumstances that lead to incarceration may potentiate the HIV/AIDS epidemic and this has become an emerging public health concern. In the United States and in most jurisdictions, HIV prevalence in the correctional setting is higher among female inmates than male inmates. This dichotomy is not fully understood and few studies have focused on women in the South. Using data from the South Carolina (SC) electronic HIV/AID Reporting System, the SC Law Enforcement Criminal History database, and a public access website of the SC Department of Corrections, the authors describe the epidemiological characteristics and correctional history of a population of HIV-infected women in SC diagnosed between January 1, 1996, and December 31, 2005.

Risky relationships: targeting HIV prevention for women offenders

HIV is a health issue for women offenders who are at particularly high risk. Women's prisons can be opportune settings for HIV prevention interventions. How women perceive partner relationships could be central to targeting HIV interventions. Consequently, this study examines changes in women offenders' risky relationships. Baseline and follow-up data are presented from 344 women offenders. Intent-to-treat analysis is used as well as analysis of covariance to control for baseline values. Findings indicate that women released to the community from prison who were randomized into the prevention intervention were significantly more likely to report changes in five of seven risky relationship thinking myths. Findings suggest that a relationship theory-based prevention intervention for reducing HIV risk could be promising for women offenders reentering the community after prison. Additional research is suggested.

HIV/STI Risk Behavior of Drug Court Participants

Drug abusing offenders have high rates of HIV and other sexually transmitted infections (STI). To date, the HIV/STI prevention needs of offenders in drug court programs have been ignored. This multi-method study employed interviews to assess drug court professionals' perceptions of the need for an HIV risk reduction intervention to be integrated into the services provided to drug court participants. Then, surveys were completed by 235 drug court participants to assess whether their sexual risk behaviors affirmed the need for such an intervention. The survey also assessed demographic characteristics, drug use prior to program entry, HIV knowledge, and condom attitudes. The relationship between duration in the drug court program and sexual risk behavior was also examined. Implications for the development and delivery of HIV risk reduction interventions within drug court programs are discussed.

Opioid agonist maintenance for probationers: patient-level predictors of treatment retention, drug use, and crime

This study examined outcomes and their predictors among 181 probationers enrolling in opioid agonist maintenance with methadone or levo-alpha-acetylmethadol (LAAM). Participants were interviewed at treatment entry and 2-, 6-, and 12-month follow-ups. Treatment retention and frequency of heroin use, cocaine use, and income-generating criminal activity were examined using survival and longitudinal analyses. Participants reported marked reductions in drug use and crime relative to treatment entry. A number of patient characteristics associated with various outcomes were identified. The findings support engaging probationers in treatment and highlight patient factors that might influence outcomes.

Preventing HIV in U.S. women and girls: a call for social action

Successes in HIV prevention efforts in the U.S. have resulted in drastic reductions in the number of new infections in the U.S. among white gay men and injection drug users, a stabilization in overall annual rates of new HIV infections, and near eradication of mother-to child transmission of HIV. Despite this remarkable progress, the proportion of AIDS cases in women has slowly, quietly, and steadily increased from 7% in 1985 to 25% in 2008. The fact the prevention efforts have not reduced HIV spread among women suggests that targeting the individual behaviors of women to prevent HIV acquisition is not a sufficiently effective public health strategy. Interventions that more broadly address the needs of women and their families, and address the contextual factors in which HIV risk occurs are more likely to lead to measurable and sustainable progress. Over the past 30 years, we have seen the U.S. HIV epidemic in women become similar to patterns of HIV risk among women in the developing world. In 2009, 85% of women who acquired HIV became infected through sex with a man and the majority (83%) of them were non-white women. Efforts to understand these immense disparities and create gender-responsive strategies must be a priority within our National HIV/AIDS Strategy.

Risks of drug-related death, suicide, and homicide during the immediate post-release period among people released from New York City jails, 2001-2005

The authors assessed the risks of drug-related death, suicide, and homicide after release from New York City jails in 155,272 people who were incarcerated anytime from 2001 through 2005 and examined whether the mortality rate was associated with homelessness. Using jail records matched with death and single-adult homeless registries in New York City, they calculated standardized mortality ratios (SMRs) and relative risks. After adjustment for age, sex, race, and neighborhood, the risks of drug-related death and homicide in formerly incarcerated persons were 2 times higher than those of New York City residents who had not been incarcerated in New York City jails during the study period. These relative risks were greatly elevated during the first 2 weeks after release (for drug-related causes, SMR = 8.0, 95% confidence interval (CI): 5.2, 11.8; for homicide, SMR = 5.1, 95% CI: 3.2, 7.8). Formerly incarcerated people with histories of homelessness had higher rates of drug-related death (RR = 3.4, 95% CI: 2.1, 5.5) and suicide (RR = 2.1, 95% CI: 1.2, 3.4) than did persons without such histories. For individuals who died of drug-related causes, longer jail stays were associated with a shorter time until death after release. These results suggest that jail- and community-based interventions are needed to reduce the excess mortality risk among formerly incarcerated people.

Newly identified HIV infections in correctional facilities, United States, 2007

We used Centers for Disease Control and Prevention HIV Counseling and Testing System data from 2007 to determine the percentage and characteristics of persons newly identified as HIV-positive in US correctional facilities. The newly identified HIV positivity was 0.7%, and 30% of detainees newly identified with HIV were categorized as having low-risk heterosexual contact or no acknowledged risk. Correctional facilities should provide detainees with routine opt-out HIV testing, unless the prevalence of previously undiagnosed HIV infection has been documented to be less than 0.1%.

Incarceration, high-risk sexual partnerships and sexually transmitted infections in an urban population

OBJECTIVES

The authors examined the associations between personal and partner incarceration, high-risk sexual partnerships and biologically confirmed sexually transmitted infection (STI) in a US urban population.

METHODS

Data from a probability survey of young adults 15-35 years of age in Baltimore, Maryland, USA, were analysed to assess the prevalence of personal and partner incarceration and its association with several measures of high-risk sexual partnerships including multiple partners, partner concurrency and current STI.

RESULTS

A history of incarceration was common (24.1% among men and 11.3% among women). Among women with an incarcerated partner in the past year (15.3%), the risk of current STI was significantly increased (adjusted prevalence ratio=2.3, 95% CI 1.5 to 3.5). Multiple partners (5+) in the past year and partner concurrency were disproportionately high among men and women who had been incarcerated or who had sexual partner(s) or who had recently been incarcerated. These associations remained robust independent of personal socio-demographic factors and illicit drug use.

CONCLUSIONS

Incarceration may contribute to STI risk by influencing engagement in high-risk behaviours and by influencing contact with partners who engage in risky behaviours and who hence have elevated risk of infection.

Prevalence and correlates of HCV, HVB, and HIV infection among prison inmates and staff, Hungary

The aim of this national, multicenter, cross-sectional study was to assess the prevalence of hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency viruses (HIV) among prisoners, and to identify related risk behaviors including injection drug use. Overall, 4,894 inmates from 20 prisons were enrolled. To have a comparison group, prison staff were also asked to take part. Altogether, 1,553 of the 4,894 inmates from seven prisons completed a questionnaire on risk behaviors. According to the survey, 1.5%, 4.9%, and 0.04% of the prisoners were tested positive for HBsAg, anti-HCV and anti-HIV, respectively. These prevalence data are among the lowest reported from prisons worldwide, although comparable to the Central European data. The prevalence of HBV, HCV, and HIV in the Hungarian prison staff was low (0.38%, 0.47%, and 0%, respectively). The rate of HCV infection was significantly higher among inmates who have ever injected drugs (22.5%) than among inmates who reported they had never injected drugs (1.1%). This first prevalence study of illegal drug injection-related viral infections among Hungarian prisoners points out that ever injecting drugs is the main reason for HCV infection among inmates. The opportunity to reach drug users infected with HCV for treatment underlines the importance of screening programs for blood-borne viruses in prisons.

HIV-related research in correctional populations: now is the time

The incarcerated population has increased to unprecedented levels following the 1970 US declaration of war on illicit drug use. A substantial proportion of people with or at risk for HIV infection, including those with substance use and mental health disorders, have become incarcerated. The overlapping epidemics of incarceration and HIV present a need for academic medical centers to collaborate with the criminal justice system to improve the health of incarcerated populations. With coordinated collaboration and new programmatic initiatives it is possible to reduce HIV-associated risk behaviors and the likelihood of acquisition and transmission of HIV. Centers for AIDS Research (CFAR), funded by the National Institutes of Health, have proactively responded to this need through Collaboration on HIV in Corrections (CHIC) to improve the diagnosis, treatment, linkage to care, and prevention of HIV. This collaboration serves as a model for aligning academic expertise with criminal justice to confront this challenge to individual and public health. This is especially relevant given recent evidence of the effectiveness of antiretroviral therapy in reducing HIV transmission.

The Prevalence of HIV Risk Behaviors among Felony Drug Court Participants

15 HIV RISK BEHAVIORS IN DRUG COURT

A small percentage of participants in a large metropolitan felony Drug Court engaged in high-risk injection drug use, but a large percentage engaged in high-risk sexual behaviors.

16 HIV RISK FACTORS IN DRUG COURT

HIV risk behaviors were associated with being male, African-American, and younger.

17 GEOGRAPHIC RISK FOR HIV

A large proportion of Drug Court participants resided in areas of the city with a high prevalence of persons living with HIV/AIDS, thus heightening the probability of exposure to the virus.

Incarceration predicts virologic failure for HIV-infected injection drug users receiving antiretroviral therapy

BACKGROUND

Incarceration may lead to interruptions in antiretroviral therapy (ART) for persons receiving treatment for human immunodeficiency virus (HIV) infection. We assessed whether incarceration and subsequent release were associated with virologic failure for injection drug users (IDUs) who were previously successfully treated with ART.

METHODS

ALIVE is a prospective, community-based cohort study of IDUs in Baltimore, Maryland. IDUs receiving ART during 1998-2009 who successfully achieved an HIV RNA level below the limit of detection (<400 copies/mL) were followed up for development of virologic failure at the subsequent semiannual study visit. Logistic regression with generalized estimating equations was used to assess whether incarceration was independently associated with virologic failure.

RESULTS

Of 437 HIV-infected IDUs who achieved undetectable HIV RNA for at least one study visit, 69% were male, 95% were African-American, and 40% reported at least one incarceration during follow-up. Virologic failure occurred at 26.3% of visits after a median of 6 months since achieving undetectable HIV RNA. In multivariate analysis accounting for demographic characteristics, drug use, and HIV disease stage, brief incarceration was strongly associated with virologic failure (adjusted odds ratio, 7.7; 95% confidence interval, 3.0-19.7), although incarceration lasting >30 days was not (odds ratio, 1.4; 95% confidence interval, .8-2.6).

CONCLUSIONS

Among IDUs achieving viral suppression while receiving ART, virologic failure occurred with high frequency and was strongly associated with brief incarceration. Efforts should be made to ensure continuity of care both during and after incarceration to improve treatment outcomes and prevent viral resistance in this vulnerable population.

Incorporating geospatial capacity within clinical data systems to address social determinants of health

Linking electronic health record (EHR) systems with community information systems (CIS) holds great promise for addressing inequities in social determinants of health (SDH). While EHRs are rich in location-specific data that allow us to uncover geographic inequities in health outcomes, CIS are rich in data that allow us to describe community-level characteristics relating to health. When meaningfully integrated, these data systems enable clinicians, researchers, and public health professionals to actively address the social etiologies of health disparities.This article describes a process for exploring SDH by geocoding and integrating EHR data with a comprehensive CIS covering a large metropolitan area. Because the systems were initially designed for different purposes and had different teams of experts involved in their development, integrating them presents challenges that require multidisciplinary expertise in informatics, geography, public health, and medicine. We identify these challenges and the means of addressing them and discuss the significance of the project as a model for similar projects.

All-cause, liver-related, and non-liver-related mortality among HCV-infected individuals in the general US population

BACKGROUND

Liver-related mortality among those infected with hepatitis C virus (HCV) has been described, but little is known about non-liver-related mortality. Our objective was to determine HCV-associated all-cause, liver-, and non-liver-related mortality in the general US population.

METHODS

A prospective cohort study of 9378 nationally representative adults aged 17-59 years was performed utilizing the Third National Health and Nutrition Examination Survey (NHANES III) Linked Mortality File that was made publicly available in 2010. HCV status was assessed from 1988 to 1994, with mortality follow-up of the same individuals through 2006.

RESULTS

There were 614 deaths over a median follow-up of 14.8 years. After adjusting for all covariate risk factors, HCV chronic infection had a 2.37 times higher all-cause mortality rate ratio [MRR] (95% CI: 1.28-4.38; P = .008), a 26.46 times higher liver-related MRR (95% CI: 8.00-87.48; P < .001), and 1.79 times higher non-liver-related MRR (95% CI: .77-4.19; P = .18), compared with being HCV-negative. This represents an estimated 2.46 million US adults aged 17-59 years with chronic HCV infection who had an estimated 31,163 deaths from all causes per year, of which 57.8% (95% CI: 21.9%-77.2%) were attributable to HCV. Among those, there was an estimated 9569 liver-related deaths per year, of which 96.2% (95% CI: 87.5-98.9%) were attributable to HCV. Non-liver-related deaths were not significantly associated with HCV status.

CONCLUSIONS

Chronic HCV all-cause mortality is more than twice that of HCV-negative individuals. This suggests that those with chronic HCV infection are at a higher risk of death even after accounting for liver-related morbidity and should be closely monitored.

Education, empowerment and community based structural reinforcement: an HIV prevention response to mass incarceration and removal

In the context of US urban jails, incarceration is often seen as an opportune intervention point for prevention interventions in public health. For the detained individual, it is an opportunity to reflect on individual choices and the potential for changes in one's life course. For population focused public health professionals, jail detention facilities represent a concentration of health risks, and an opportunity to have an impact on a significant portion of those at risk for HIV and other health concerns. This paper presents an innovative education and empowerment model that bridges across jail walls, beginning on the inside, and continuing on the outside of jail where individuals continue to be challenged and supported toward positive health and social choices. The intervention also seeks to foment community activism in the communities to which jail detainees return, thus aiming to have a structural impact. This paper examines both the intervention model and the challenges of examining the effectiveness claims for the intervention at multiple levels.

Toward a gender-responsive restorative correctional health care model

Infectious and chronic diseases are disproportionately greater among detained women than among women in the population at large. The overall punitive, male-based, one-size-fits-all approach to health care and the variant overall health care standards across correctional systems call for a new model of correctional health care. The assumptions, constructs, strategies, and future research implications of the restorative health care model are described.

Implementing opt-out programs at Los Angeles county jail: a gateway to novel research and interventions

Routine opt-out screening and vaccination programs are effective methods for improving public health in correctional populations. Jail-based rapid testing for HIV, hepatitis B and C, tuberculosis, syphilis, gonorrhea, and chlamydia can improve urban health by increasing diagnosis and linkage to care for infectious diseases. In addition, jail-based vaccination programs would significantly benefit community health and lower costs associated with tertiary level care. The paucity of ethical and rigorous scientific research among incarcerated populations excludes these marginalized members of society from potential advancements in correctional medicine and public health. Routine opt-out testing programs would not only benefit the health of the correctional population but also serve as platforms for future research. Trials measuring the efficacy of new rapid tests, screening methods, novel vaccine delivery systems, or accelerated vaccine regimens would be greatly beneficial.

Strategies to enhance linkages between care for HIV/AIDS in jail and community settings

The policies of mass incarceration and the expansion of the criminal justice system in the USA over the last 40 years have weighed heavily on individuals and communities impacted by drug use and HIV disease. Though less than ideal, jails provide a unique opportunity to diagnose, treat and implement effective interventions. The role of jails in HIV detection, treatment, and continuity of care, however, has yet to be systematically examined. This paper reviews the service strategies and contexts for 10 demonstration sites funded to develop innovative methods for providing care and treatment to HIV-infected individuals in jail settings who are returning to their communities. The sites have implemented varied intervention strategies; each set in unique policy and service system contexts. Collaboration among agencies and between systems to implement these interventions is viewed as particularly challenging undertakings. We anticipate the sites will collectively serve 700-1000 individuals across the duration of the initiative. In this paper, we review the service contexts and strategies developed by the 10 sites. The individual and multi-site evaluations aim to provide new data on testing, treatment, and community linkages from jails that will further develop our knowledge base on effective intervention strategies in these settings.

Testing for HIV, sexually transmitted infections, and viral hepatitis in jails: still a missed opportunity for public health and HIV prevention

Jails provide an underutilized public health opportunity for screening for HIV, sexually transmitted infections (STIs), and viral hepatitis, and for such other infectious diseases as tuberculosis. Incarcerated individuals are more likely to be men, poor, persons of color, and at high risk for HIV. The vast majority of jails in the United States do not screen routinely for HIV or STIs, thereby missing an opportunity for HIV and STI diagnosis, treatment, and prevention. Nesting HIV testing within STI testing and treatment in conjunction with testing and treatment for other infectious diseases, as appropriate based on community prevalence, provides a public health opportunity and will enhance HIV prevention. HIV testing and linkage to care, both within corrections and in the community, comprise an important component of the "seek and treat" strategy to further prevent HIV infection. Jail-based screening of infectious diseases, especially for HIV and STIs, in conjunction with treatment and linkage to community care has thus far been a neglected component of HIV prevention among high-risk communities.

Behind the Bars of Paradise: HIV and Substance Use among Incarcerated Populations in Puerto Rico

For those who are incarcerated in jails and prisons, the correctional setting represents a unique context for health care access and utilization. In Puerto Rico, over 16 000 persons pass each year through a correctional facility, approximately 6.9% of the incarcerated population present HIV infection, and 73.8% and 27.1% evidence a previous history of drug and alcohol use, respectively. In addition, HIV-infected populations have comorbidity with other diseases that are associated with substance use. Several approaches have been considered to prevent, treat, and provide a continuum of care for HIV and substance disorders among incarcerated populations. Nearly 30 years of legally regulated practices for correctional health care have produced recommendations for addressing the needs of those with HIV and substance disorders within the correctional facilities in Puerto Rico. These recommendations include making prevention services available, building capacity among health care providers, and understanding the cultural and political contexts.

Impact of prison status on HIV-related risk behaviors

Baseline data were collected to evaluate the effectiveness of interventions on completion of the hepatitis A and B vaccine series among 664 sheltered and street-based homeless adults who were: (a) homeless; (b) recently (<1 year) discharged from prison; (c) discharged 1 year or more; and (d) never incarcerated. Group differences at baseline were assessed for socio–demographic characteristics, drug and alcohol use, sexual activity, mental health and public assistance. More than one-third of homeless persons (38%) reported prison time and 16% of the sample had been recently discharged from prison. Almost half of persons who were discharged from prison at least 1 year ago reported daily use of drugs and alcohol over the past 6 months compared to about 1 in 5 among those who were recently released from prison. As risk for HCV and HIV co-infection continues among homeless ex-offenders, HIV/HCV prevention efforts are needed for this population.

The roles of law, client race and program visibility in shaping police interference with the operation of US syringe exchange programs

AIMS

To determine the comparative levels of and associations between policing interference and characteristics of US syringe exchange programs (SEPs).

DESIGN

Cross-sectional.

SETTING

A national survey of US SEPs.

PARTICIPANTS

A total of 111 program managers (representing 59% of all US SEPs).

MEASUREMENTS

Program manager self-report.

FINDINGS

With overall interference profiles ranging from systematic to totally interference-free, 43% of respondents reported at least monthly client harassment, 31% at least monthly unauthorized confiscation of clients' syringes, 12% at least monthly client arrest en route to or from SEP and 26% uninvited police appearances at program sites at least every 6 months. In multivariate modeling, legal status of SEP, jurisdiction's syringe regulation environment and affiliation with health department were not associated with frequency of police interference. Programs serving predominantly injection drug users (IDUs) of color were 3.56 times more likely to report frequent client arrest en route to or from SEP and 3.92 times more likely to report unauthorized syringe confiscation. Those serving more than three sites were 3.96 times more likely to report client harassment, while stationary operation was protective against uninvited police appearances. The majority (56%) reported not documenting adverse police events; those who did were 2.92 times more likely to report unauthorized syringe confiscation from clients.

CONCLUSIONS

Findings highlight limitations of the impact of legal reforms on aligning police activities with SEP operations. Systematic adverse event surveillance and evidence-based structural interventions are needed to maximize the benefits of public health prevention targeting IDUs and other criminalized populations. SEPs that report no adverse events may represent programs already working in harmony with law enforcement agencies, a priority highlighted in US Centers for Disease Control's new SEP guidelines. The significance of mechanisms translating criminal justice disparities into health disparities is discussed.

Incarceration, sex with an STI- or HIV-infected partner, and infection with an STI or HIV in Bushwick, Brooklyn, NY: a social network perspective

OBJECTIVES

We examined the link between incarceration and sexually transmitted infection (STI), including HIV, from a social network perspective.

METHODS

We used data collected during a social network study conducted in Brooklyn, NY (n = 343), to measure associations between incarceration and infection with herpes simplex virus-2, chlamydia, gonorrhea, and syphilis or HIV and sex with an infected partner, adjusting for characteristics of respondents and their sex partners.

RESULTS

Infection with an STI or HIV was associated with incarceration of less than 1 year (adjusted prevalence ratio [PR] = 1.33; 95% confidence interval [CI] = 1.01, 1.76) and 1 year or longer (adjusted PR = 1.37; 95% CI = 1.08, 1.74). Sex in the past 3 months with an infected partner was associated with sex in the past 3 months with 1 partner (adjusted PR = 1.42; 95% CI = 1.12, 1.79) and with 2 or more partners (adjusted PR = 1.85; 95% CI = 1.43, 2.38) who had ever been incarcerated.

CONCLUSIONS

The results highlight the need for STI and HIV treatment and prevention for current and former prisoners and provide preliminary evidence to suggest that incarceration may influence STI and HIV, possibly because incarceration increases the risk of sex with infected partners.

Risk factors for homelessness and sex trade among incarcerated women: A Structural equation model

Incarcerated women are among the most vulnerable and perhaps the least studied populations in the US. Significant proportions of female inmates are substance users, and many living in unstable housing conditions or being homeless. Female inmates are often at high risk of engaging in sex exchange for drugs or housing needs. While a disproportionate number of incarcerated women have experienced childhood household adversities and maltreatments, the effects of these childhood experiences on psychosocial and behavioral outcomes of this population in later life. We apply a life course perspective to examine these pathways in a sample of incarcerated women in Cook County, Illinois. Findings demonstrated lasting, but differential, effects of household adversities and childhood abuse on subsequent life risks and opportunities among these women.

An Empirical Ethics Agenda for Psychiatric Research Involving Prisoners

In the past 30 years, the incarcerated population in the United States has more than quadrupled to 2.3 million adults. With an alarmingly high prevalence of mental illness, substance use, and other serious health conditions compounding their curtailed autonomy, prisoners constitute perhaps the nation's most disadvantaged group. Scientifically rigorous research involving prisoners holds the potential to inform and enlighten correctional policy and to improve their treatment. At the same time, prisoner research presents significant ethical challenges to investigators and institutional review boards (IRBs) alike, by subjecting participants to conditions that potentially undermine the validity of their informed consent. In 2006, the Institute of Medicine Committee on Ethical Considerations for Revisions to the Department of Health and Human Services (DHHS) Regulations for Protection of Prisoners Involved in Research recommended both further protections and a more permissive approach to research review that would allow inmates greater access to potentially beneficial research. These recommendations have sparked renewed debate about the ethical trade-offs inherent to prisoner research. In this article, the authors review the major justifications for research with prisoner subjects and the associated ethical concerns, and argue that the field of empirical ethics has much to offer to the debate. They then propose a framework for prioritizing future empirical ethics inquiry on this understudied topic.

HIV, alcohol dependence, and the criminal justice system: a review and call for evidence-based treatment for released prisoners

BACKGROUND

People with both HIV and alcohol use disorders (AUDs) are disproportionately concentrated within the U.S. criminal justice system; approximately one-quarter of all people with HIV cycle through the system each year. HIV-infected prisoners with AUDs face many obstacles as they transition back to the community. Specifically, although they have impressive HIV treatment outcomes during the period of incarceration while they are free from alcohol; upon [corrected] release, however, they face inordinate challenges including relapse to alcohol use resulting in significant morbidity and mortality.

OBJECTIVE

To review the existing literature regarding the relationship of HIV and treatment for AUDs within the criminal justice system in an effort to determine "best practices" that might effectively result in improved treatment of HIV and AUDs for released prisoners.

METHODS

PubMed, PsychInfo and Medline were queried for articles published in English from 1990 to 2009. Selected references from primary articles were also examined.

RESULTS

Randomized controlled trials affirm the role of pharmacotherapy using naltrexone (NTX) as the therapeutic option conferring the best treatment outcome for AUDs in community settings. Absent from these trials were inclusion of released prisoners or HIV-infected individuals. Relapse to alcohol abuse among HIV-infected prisoners is associated with reduced retention in care, poor adherence to antiretroviral therapy with consequential poor HIV treatment outcomes and higher levels of HIV risk behaviors.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Untreated alcohol dependence, particularly for released HIV-infected prisoners, has negative consequences both for the individual and society and requires a concentrated effort and rethinking of our existing approaches for this vulnerable population.

Drug arrests and injection drug deterrence

OBJECTIVES

We tested the hypothesis that higher rates of previous hard drug-related arrests predict lower rates of injection drug use.

METHODS

We analyzed drug-related arrest data from the Federal Bureau of Investigation's Uniform Crime Reporting Program for 93 large US metropolitan statistical areas in 1992 to 2002 to predict previously published annual estimates of the number of injection drug users (IDUs) per 10,000 population.

RESULTS

In linear mixed-effects regression, hard drug-related arrest rates were positively associated (parameter = +1.59; SE = 0.57) with the population rate of IDUs in 1992 and were not associated with change in the IDU rate over time (parameter = -0.15; SE = 0.39).

CONCLUSIONS

Deterrence-based approaches to reducing drug use seem not to reduce IDU prevalence. Alternative approaches such as harm reduction, which prevents HIV transmission and increases referrals to treatment, may be a better foundation for policy.

Physicians in US Prisons in the Era of Mass Incarceration

The United States leads the world in creating prisoners, incarcerating one in 100 adults and housing 25% of the world's prisoners. Since the 1976, the US Supreme Court ruling that mandated health care for inmates, doctors have been an integral part of the correctional system. Yet conditions within corrections are not infrequently in direct conflict with optimal patient care, particularly for those suffering from mental illness and addiction. In addition to providing and working to improve clinical care for prisoners, physicians have an opportunity and an obligation to advocate for reform in the system of corrections when it conflicts with patient well-being.

Challenges of a hidden epidemic: HIV prevention among women in the United States

HIV/AIDS trends in the United States depict a concentrated epidemic with hot spots that vary by location, poverty, race/ethnicity, and transmission mode. HIV/AIDS is a leading cause of death among US women of color; two-thirds of new infections among women occur in black women, despite the fact that black women account for just 14% of the US female population. The gravity of the HIV epidemic among US women is often not appreciated by those at risk and by the broader scientific community. We summarize the current epidemiology of HIV/AIDS among US women and discuss clinical, research, and public health intervention components that must be brought together in a cohesive plan to reduce new HIV infections in US women. Only by accelerating research and programmatic efforts will the hidden epidemic of HIV among US women emerge into the light and come under control.

Human rights and HIV prevention, treatment, and care for people who inject drugs: key principles and research needs

Efforts to provide HIV prevention, treatment, and care to injecting drug users (IDU) are shaped by tensions between approaches that regard IDU as criminals and those regarding drug-dependent individuals as patients deserving treatment and human rights. Advocates for IDU health and human rights find common cause in urging greater attention to legal frameworks, the effects of police abuses, and the need for protections for particularly vulnerable populations including women and those in state custody. Arbitrary detention of drug users, and conditions of pretrial detention, offer examples of how HIV prevention and treatment are adversely impacted by human rights abuse. National commitments to universal access to prevention and treatment for injecting drug users, and the recognition that users of illicit substances do not forfeit their entitlement to health services or human dignity, offer a clear point of convergence for advocates for health and rights, and suggest directions for reform to increase availability of sterile injection equipment, opiate substitution treatment, and antiretroviral therapy. For IDU, protection of rights has particular urgency if universal access to HIV prevention and treatment is to become an achievable reality.

The effect of incarceration on urban fathers' health

This study examines the effects of incarceration on the health of urban fathers. Using the Fragile Families and Child Well-Being Study, which surveys parents in 20 large U.S. cities across the country, the relationship between fathers' incarceration patterns and health status was examined while controlling for poor preexisting health and individual impulsivity. Findings indicate that fathers who have previously been incarcerated at some time are markedly more likely to rely on medications for physical or mental health problems, whereas recently incarcerated repeat offenders have reduced odds of being in poor health relative to those who have never been to prison. Improvements in health among recently incarcerated repeat offenders relative to those who have not been incarcerated may be related to prison health care and the overall disadvantaged circumstances of these fathers.

Risk factors for infection and colonization with community-associated methicillin-resistant Staphylococcus aureus in the Los Angeles County jail: a case-control study

BACKGROUND

Community-associated methicillin-resistant Staphylococcus aureus (MRSA) infections and outbreaks occur in correctional facilities, such as jails and prisons. Spread of these infections can be extremely difficult to control. Development of effective prevention protocols requires an understanding of MRSA risk factors in incarcerated persons.

METHODS

We performed a case-control study investigating behavioral risk factors associated with MRSA infection and colonization. Case patients were male inmates with confirmed MRSA infection. Control subjects were male inmates without skin infection. Case patients and control subjects completed questionnaires and underwent collection of nasal swab samples for culture for MRSA. Microbiologic analysis was performed to characterize recovered MRSA isolates.

RESULTS

We enrolled 60 case patients and 102 control subjects. Of the case patients, 21 (35%) had MRSA nasal colonization, compared with 11 control subjects (11%) (P .001). Among MRSA isolates tested, 100% were the USA300 strain type. Factors associated with MRSA skin infection included MRSA nares colonization, lower educational level, lack of knowledge about "Staph" infections, lower rate of showering in jail, recent skin infection, sharing soap with other inmates, and less preincarceration contact with the health care system. Risk factors associated with MRSA colonization included antibiotic use in the previous year and lower rate of showering.

CONCLUSIONS

We identified several risks for MRSA infection in male inmates, many of which reflected preincarceration factors, such as previous skin infection and lower educational level. Some mutable factors, such as showering frequency, knowledge about Staph, and soap sharing, may be targets for intervention to prevent infection in this vulnerable population.

Characteristics of Prison Hospice Programs in the United States

Hospice programs have emerged over the last 40 years as both an effective and humane practice for responding to terminal illnesses in the free society. More recently, hospice has diffused throughout state, federal, and municipal correctional systems. Thus, we sought via a mailed survey of the 69 known prison hospice programs in the United States (response rate of 62%) to determine how prison hospice programs were similar or dissimilar to hospices in the free society. Our findings suggest that prison hospices have a more stringent screening process for volunteers and require more volunteer training prior to interacting with a hospice patient. Prison hospice programs tend to follow both the National Prison Hospice Association and the GRACE Project guidelines.

Sex and condom use in a large jail unit for men who have sex with men (MSM) and male-to-female transgenders

Few data are available on factors contributing to sexual activity and condom use in custody settings, particularly among self-identified sexual minority prisoners. To address this gap, we undertook a study of sexual behavior and condom use of 101 randomly-selected men who have sex with men (MSM) and male-to-female transgender inmates in a segregated Los Angeles jail unit that has weekly condom access. Most survey participants (53%) reported anal sex during custody. Although 65% of these reported using condoms, 75% also reported having sex without condoms. Qualitative interviews (n=17) indicate a wide range of reasons for participating in protected and unprotected sex during custody, the use of cues within the custody environment to assess potential partners' HIV status, and support for increased condom availability. Findings also indicate that high-risk sex occurs frequently in this unit and that condom distribution likely prevents a substantial amount of related HIV/STD risk.

Is incarceration a contributor to health disparities? Access to care of formerly incarcerated adults

Despite the disproportionate prevalence of incarceration in communities of color, few studies have examined its contribution to health disparities. We examined whether a lifetime history of incarceration is associated with recent access to medical and dental care. We performed a secondary data analysis of the 2007 Los Angeles County Health Survey, a population-based random-digit-dialing telephone survey of county households. Any history of incarceration in a prison/jail/detention center as an adult was assessed for a random subsample. Bivariate and multivariate logistic regression analyses examined whether incarceration history was associated with access to care, controlling for other characteristics. Ten percent of our study population reported a history of incarceration. While persons with an incarceration history were similar to their peers with regard to health and insurance status, their access to medical and dental care was worse. Incarceration history was independently associated with disparities in access to care. Interventions to improve the health of communities affected by high rates of incarceration could include efforts that enable access to care for formerly incarcerated adults.

Improved HIV and substance abuse treatment outcomes for released HIV-infected prisoners: the impact of buprenorphine treatment

HIV-infected prisoners fare poorly after release. Though rarely available, opioid agonist therapy (OAT) may be one way to improve HIV and substance abuse treatment outcomes after release. Of the 69 HIV-infected prisoners enrolled in a randomized controlled trial of directly administered antiretroviral therapy, 48 (70%) met DSM-IV criteria for opioid dependence. Of these, 30 (62.5%) selected OAT, either as methadone (N = 7, 14.5%) or buprenorphine/naloxone (BPN/NLX; N = 23, 48.0%). Twelve-week HIV and substance abuse treatment outcomes are reported as a sub-study for those selecting BPN/NLX. Retention was high: 21 (91%) completed BPN/NLX induction and 17 (74%) remained on BPN/NLX after 12 weeks. Compared with baseline, the proportion with a non-detectable viral load (61% vs 63% log(10) copies/mL) and mean CD4 count (367 vs 344 cells/mL) was unchanged at 12 weeks. Opiate-negative urine testing remained 83% for the 21 who completed induction. Using means from 10-point Likert scales, opioid craving was reduced from 6.0 to 1.8 within 3 days of BPN/NLX induction and satisfaction remained high at 9.5 throughout the 12 weeks. Adverse events were few and mild. BPN/NLX therapy was acceptable, safe and effective for both HIV and opioid treatment outcomes among released HIV-infected prisoners. Future randomized controlled trials are needed to affirm its benefit in this highly vulnerable population.

HIV treatment in US prisons

Arguably one of the most marginalized populations in our society, prisoners bear a disproportionate burden of infectious diseases, particularly HIV. In addition, groups known to be at an inordinately higher risk of HIV, including minorities, the addicted, the mentally ill and the impoverished are overrepresented among incarcerated populations. This concentration of HIV among groups that have been historically difficult to reach, with limited intersections with healthcare, provides an opportunity for testing, diagnosis, treatment, linkage to care and prevention. Providing HIV care within correctional facilities poses unique challenges. Barriers to confidentiality, access to medication and prior records, and lack of comprehensive discharge planning can serve as obstacles to providing optimal care. This article discusses the public health implications and importance of providing HIV care to prisoners, and also discusses the practicalities of working within an environment that poses particular barriers to care.

Sources of heterogeneity in hepatitis B virus (HBV) seroprevalence estimates from U.S. adult incarcerated populations: A systematic review and meta-regression analysis

HBV seroprevalence estimates from U.S. incarcerated populations are relatively high. However, the usefulness of these estimates for guiding HBV-related correctional healthcare policy is limited by wide variation in estimates across studies and little understanding of the sources of this variation. The authors systematically reviewed studies indexed from 1975-2005, meeting pre-specified criteria and reporting HBV seroprevalence estimates from U.S. adult incarcerated populations. Using meta-regression techniques, the authors investigated report type, geographical region, serum collection year, facility type, serum source, sampling procedures, sample characteristics, and measurement procedures as potential study-level sources of heterogeneity in prevalence estimates for common HBV seromarkers. In bivariable meta-regression analyses, mean age ≥31 years was strongly associated with increased HBsAg prevalence (POR=2.6), and serum collection year before 1991 was strongly associated with increased prevalence of any positive marker (POR=2.0). Other moderate-to-strong associations were observed, but these were considered less certain because of small numbers of observations, influence of single studies, or potential confounding. Potential sources of heterogeneity should be considered when comparing HBV seroprevalence estimates in adult U.S. incarcerated populations and when developing HBV screening and vaccination protocols in correctional settings.

Predictors of reincarceration and disease progression among released HIV-infected inmates

We conducted a retrospective cohort study to determine the 3-year reincarceration rate of all HIV-infected inmates (n = 1917) released from the Texas prison system between January 2004 and March 2006. We also analyzed postrelease changes in HIV clinical status in the subgroup of inmates who were subsequently reincarcerated and had either CD4 lymphocyte counts (n = 119) or plasma HIV RNA levels (n = 122) recorded in their electronic medical record at both release and reincarceration. Multivariable analyses were performed to assess predictors of reincarceration and clinical changes in HIV status. Only 20% of all HIV-infected inmates were reincarcerated within 3 years of release. Female inmates (hazard ratio [HR] 0.63; 95% confidence interval [CI], 0.47, 0.84) and inmates taking antiretroviral therapy at the time of release (HR 0.31; 95% CI, 0.25, 0.39) were at decreased risk of reincarceration. African Americans (HR 1.58; 95% CI, 1.22, 2.05), inmates with a major psychiatric disorder (HR 1.82; 95% CI, 1.41, 2.34), and inmates released on parole (HR 2.86; 95% CI, 2.31, 3.55) were at increased risk of reincarceration. A subgroup of reincarcerated inmates had a mean decrease in CD4 cell count of 79.4 lymphocytes per microliter (p < 0.0003) and a mean increase in viral load of 1.5 log(10) copies per milliliter (p < 0.0001) in the period between release and reincarceration. Our findings, although substantially limited by selection bias, highlight the importance of developing discharge planning programs to improve linkage to community-based HIV care and reduce recidivism among released HIV-infected inmates.

Fulfilling the mission of academic medicine: training residents in the health needs of prisoners

The single mission of academic medicine is the pursuit of health for all. This mandate serves as a reminder to focus care on vulnerable and underserved populations. The 12 million Americans who cycle through correctional facilities each year are arguably among the most vulnerable populations in this country; predominantly black, with a high burden of disease and many barriers to care after release. Medical training programs should provide exposure to the health needs of prisoners. Residents could establish care with inmates prior to release and arrange follow-up in the community. This addition to training would not only provide care to this underserved group, but also would train residents in the myriad problems prisoners face, and foster social responsibility.

HIV-infected prison inmates: depression and implications for release back to communities

High rates of both HIV and depression are seen in prison populations; depression has been linked to disease progression in HIV, risky behaviors, and medication non-adherence. Despite this, few studies have examined HIV-infected inmates with depression. We therefore conducted an exploratory study of a sample of HIV-infected inmates in North Carolina prisons (N = 101) to determine what proportion of this sample screened positive for depression and whether depression was associated with different pre-incarceration characteristics or post-release needs. A high proportion of HIV infected inmates (44.5%) screened positive for depression. Depressed inmates were significantly more likely have low coping self-efficacy scores (180 vs. 214), to report having had resource needs (OR = 2.91) prior to incarceration and to anticipate needing income (OR = 2.81), housing (OR = 4.07), transportation (OR = 9.15), and assistance with adherence (OR = 8.67) post-release. We conclude by discussion the implications of our findings for prison based care and effective prison release planning for HIV infected inmates.