Infectious diseases within American correctional settings are a concern within the public health sector. The corrections population is susceptible to infectious diseases through exposure to blood and other bodily fluids, drug injection, poor health care, prison overcrowding, demographics, security issues, lack of community support for rehabilitation programs, and high-risk behaviors. The spread of infectious diseases, such as HIV and other sexually transmitted infections, hepatitis C (HCV), hepatitis B (HBV), and tuberculosis, result largely from needle-sharing, drug use, and consensual and non-consensual sex among prisoners. HIV and hepatitis C need specific attention because of the specific public health concerns and issues they raise.
The implementation of HIV and STI screening programs in the correctional setting is an important approach to reducing the annual number of new HIV infections in the United States. The correctional system in America is a patchwork of a wide variety of settings such as state and federal prisons, local jails, and juvenile detention centers and they include the legal constraints of state laws. One process for HIV testing would be unlikely or even impossible in all correctional settings.
There is an inherent difference in the jail versus the prison setting that merits infectious disease testing at the jail level. Jails are largely used to hold offenders who have been charged but not convicted of a crime. Local jails admitted an estimated 11.7 million persons during the 12-month period ending June 30, 2013. The average weekly turnover rate was 60.2 percent. Implementing HIV, HCV and other STI screening programs at the jail level is an effective way to detect disease before an infected individual is released back to the community and is able to transmit disease.
At-risk diseases
HIV/AIDS
At least 17% of people living with HIV/AIDS have been incarcerated at some point in their life. The rate of contracting HIV is ten to one hundred times higher inside the prison system than outside. The incarcerated population is more likely to contract the disease because they are exposed to more high-risk behaviors within the correctional system. In a Louisiana prison study, 242 inmates (72.8% of male inmates) had participated in sexual encounters with other men, and did not always have access to proper protection. Additionally, research has demonstrated that infection rates via injection are much higher among those who have previously served prison terms. Research suggests that elevated rates of infection are a result of increased prison sentencing for drug-related offences and the war on drugs. Since prisons generally divide the individuals by gender, the populations experience different environments; incarcerated females in the United States tend to have higher rates of infection.
According to the U.S. Department of Justice's Bureau of Justice Statistics, at the end of 2010 among all of the U.S. inmates with HIV/AIDS 18,337 of them were male and 1,756 were female. Research suggests young men of color disproportionately represent U.S. inmates and these individuals may be at such a risk of contracting HIV due to high-risk behavior prior to entering the penitentiary system. Furthermore, research also shows that AIDS is the single largest cause of death among African American men between ages 25 through 44 years, mainly due to drug-related transmission of the virus. As of September 2013, condoms for prisoners are only available in the US state of Vermont (on September 17, 2013, the California Senate approved a bill for condom distribution inside the state's prisons, but the bill was not yet law at the time of approval).
A 2004 survey of inmates at state prisons and local jails revealed a self-reported HIV positive rate of 1.9% and 2.5% respectively. Sixty-nine percent of state inmates reported being tested since admission to the system while only 18.5% of those in the jail reported being tested. This suggests that expanded jail testing could increase the number of previously unidentified cases of HIV. In prisons, where inmates are incarcerated for more than a year, testing should take place at the medical evaluation. In jails, where a majority of inmates bail out between 72 hours and seven days, routine testing should ideally take place at the intake evaluation. This may not be possible if the inmate is under the influence of drugs or alcohol or is otherwise mentally unstable. While medical evaluations typically occur within 10 days of detention, some inmates may have been released and thus will not get tested.
Hepatitis C
While the majority of HCV infections occur outside of prison, the infection is still widespread within the prison system as a result of drug injection. According to one Rhode Island prison study, HCV infection was found in 23.1% of the male prison population. HCV prevention proved to be more challenging than HIV prevention because inmates partake in high-risk behaviors such as "front loading" and sharing spoons to prepare drugs like cocaine. The prevalence of these infections within prisons is a concern because they pose a potential public health risk. When prisoners are released, they may continue the same behaviors, thereby increasing the chances of the infection spreading to outside communities. The Western Journal of Medicine estimates the prevalence and predictors of HCV infection among inmates of California by conducting a system wide survey. Findings concluded that HCV infection appears most common in men and women entering prison, displaying prevalence of anti-HCV positive highest among white males and Latina women.
Limited testing for hepatitis C virus (HCV) in three North Carolina jails have shown a prevalence rate of approximately 7% for HCV. The primary barrier is the cost of additional tests needed beyond a screening test. However, some hematologists believe a screening test should be done regardless of ability to pay for follow-up care as a means of changing behavior (for example, refraining from alcohol or not sharing needles). Studies have shown that knowledge of disease status can change behavior with HIV infection. It is estimated that 80% of people with HIV who inject drugs also have hepatitis C virus. HIV co-infection more than triples the risk for liver disease, liver failure, and liver-related death from HCV.
Tuberculosis
The incidence of tuberculosis in the United States prison system is also significantly higher than rates in the general public. It is estimated that prisoners in the United States are four times as likely as individuals outside of the carceral setting. This is worth noting because although the prevalence of tuberculosis is higher among incarcerated populations, this is not a population that is actively targeted by TB prevention programs. According to a comprehensive review of the 2002 to 2013 Tuberculosis Surveillance System, rates remain high- particularly in the male prisoner population, "Among 5579 persons incarcerated at the time of their tuberculosis diagnosis, 2520 (45%) were US-born and 495 (9%) were female. Median estimated annual tuberculosis incidence rates were 29 cases per 100 000 local jail inmates, 8 per 100 000 state prisoners, and 25 per 100 000 federal prisoners." These rates of infection are significant, as if TB is not properly managed it can have lasting side effects including: permanent lung damage, infection of the bones, spine, brain and spinal cord. Proper attention and care must be provided to this vulnerable population to prevent morbidity and mortality in the United States inmate population.
COVID-19
Differences in funding for sexually transmitted infections treatment
In 2002, the Public Health Reports released a study entitled "Comparing Quality of Care for Sexually Transmitted Diseases in Specialized and General Clinics", explaining the quality of care provided in public STI clinics and general medical clinics when treating patients with STIs. In October 1995, the County of Los Angeles Department of Health Services faced a budget deficit that led to the decision of restructuring their outpatient care system. The result of this restructuring led to the following: 17 LA County STI clinics and 3 of general medical clinics were also closed down. This then resulted in the shift of "balance of STD services in favor of general medical clinics." Reduced funding greatly therefore affecting the quality of patient care. Six clinics were studied from March 1, 1996, to June 30, 1996, with the data of patients recorded during each visit. Thirty-two process of care quality indicators were determined that listed patient expectations during visitation. Data showed that the public STI clinics demonstrated a greater adherence than general medical clinics for every 14 out of the 32 patient care quality indicators. As a result, both the general medical clinics and STI clinics suffered from the budget deficit of 1995.
Separate studies assessed the practicality and cost-efficiency of vaccinating all adults treated at STI clinics in a span of a year. Two scenarios were compared, assuming a national program offering the Hepatitis B vaccine to two million clients in order to create a decision model. The first scenario lacked the Hepatitis B vaccination while the second followed a Hepatitis B vaccination. The stages of the HBV virus were followed in a Markov Model of Natural History. These are the stages that clients can potentially experience if they opted out of vaccination. Those that chose to be part of a routine vaccination would undergo a three-part vaccination stage within a year. The total medical cost for those who contracted the HBV virus is as follows: $1,587 million for societal costs; $346 million in medical costs; and $1,241 million in productivity losses. The projected cost for a national vaccination program that is to serve more than a million clients is "$138 million including $95 million for vaccine and administration, $30.5 million for staff training and supervision, and $12.2 million for protocol development and vaccination record-keeping.
In North Carolina, the state Department of Health and Human Services Division of Epidemiology works with the AIDS Drug Assistance Program to help pay for HIV medication for incarcerated persons in county jails (state and federal prisons are not eligible). In order to qualify, county detention centers must complete an application for funds that includes the jail health budget to show need. Additionally, Duke University and UNC-Memorial Hospitals have collaborated with one jail's HCV positive inmates for further follow-up testing and care.
Policies within the United States
The World Health Organization released guidelines to counteract the spread of HIV in prisons during the 1980s. They stated prisons should apply policies that reduce sexual violence, enhance detection, prosecute offenders, and increase evaluation of activities done to prevent disease from spreading in prisons. Within the United States there have been many important policies and programs to eliminate the spread of disease and expand the healthcare system within prisons.
There are two renowned federal cases that established prisoners' rights to healthcare and paved the way for disease prevention. In Estelle v. Gamble, the court case ruled that healthcare within prisons are a constitutional right. Prior to this court case, prison systems deliberately denied prisoners much treatment, delaying access to physicians, or failing to help prisoners seek any medical judgment. This court case created measures to reduce the spread of diseases and also provided inmates with medical attention. In Wayne County Jail Inmates v. Lucas, courts mandated that prisoners have the right to access drug detoxification and treatment for drug dependency. This has helped many inmates quarantine the disease by preventing the sharing of needles.