HIV Services for Inmates/Releasees

The Journal for Correctional Health Care recently published a study, "Challenges and Strategies of Frontline Staff Providing HIV Services for Inmates and Releasees," which addresses the difficulty of providing service linkages for this highly vulnerable population. This survey focused on Community-Based Organizations (CBOs) primarily, using focus groups to assess barriers to service for HIV-positive inmates and releasees. Healthcare was certainly discussed as a priority; however, interestingly, the primary concern they had was regarding housing, rather than HIV-focused services:

"...the most challenging service to secure was housing. Others included medical care, mental health and substance abuse treatment, and employment. Staff reported a general lack of available services for their clients."

The authors worked closely with CBOs, including social workers and advocates inside and outside correctional facilities. This study is unique in that it suggests that while "ecological frameworks of social work place the client at the center (Green, 2008), this analysis considers the staff as central because of their critical role in transitioning clients from correctional facilities to communities." The study proposes that population-based interventions directed at staff; these approaches are frequently supported by public health research. The intense stress experienced by staff working to advocate for this population resulted in high rates of mental illness and resignation, and disapproval or exhaustion with the clients.

Through my work with the Prison Visiting Project of The Correctional Association of New York, I have visited and inspected a variety of middle- and maximum-security prisons throughout the state. Part of my role included discussion with staff clinicians and inspection of medical facilities. My first-hand knowledge is limited to one state, but it is clear that, as the previous article suggested, a population-based intervention to support staff and increase their resources would improve healthcare and the reentry process.

On a visit to Bare Hill Correctional Facility, according to our report, "the medical staff estimated that it takes a couple of months to see a physician, even for important matters, and that it can take as long as four months for a routine appointment.  The inmate population confirmed these unacceptable delays." Staff were open to discussing the limitations they faced to provide proper care to their patients and deserve greater funding and access to resources.

Some facilities seem to be less concerned about the state of healthcare at their facilities, but this may be due to burn-out or even defensiveness at being confronted by The Correctional Association, which many correctional staff view as threatening or not understanding. However, disturbing healthcare situations behind bars remain prelevant in New York State; at Five Points Correctional Facility, "only 31 clients were identified as HIV-positive, representing 2.2% of the prison population." With only 31 known HIV-infected inmates, representing 2.2% of its prison population, Five Points has a smaller HIV population than many prisons and has identified only about one-third of the number of inmates at the prison who may be infected with HIV based upon the estimate that 6% of the state prison population is HIV-infected.  We are also concerned that only 13 HIV-infected patients were receiving treatment (see the report). This number was shockingly low considering there were seven patients with full-blown AIDS in residence and "three patients found in the most recent HIV Continuous Quality Improvement audit [an internal audit] to be unstable."

Further support for the lack of resources for HIV-positive clients, who are often not identified or treated for the disease while incarcerated or following reentry was revealed: "We have data on specialty care services used by each prison for Fiscal Year 2006-07 indicating that Five Points had only four appointments with an infectious disease (ID) specialist during that year...  [because of this] the prison may have increased their use of ID specialists recently, but we are concerned about whether the prison is aggressively evaluating its patients for HIV treatment and promptly referring patients whose therapy is not fully effective to an ID specialist for evaluation and potential changes in treatment."

Regarding reentry, the reentry plans developed for inmates within New York State prisons are generally included as part of a program called Phase III. Usually clients are assigned to this program, which ranges from 3-12 weeks in prisons I visited, during the final 4 months of their incarceration. However, due to parole hearings, they are often not in the program at an appropriate time. The articulated goal is to help the clients secure a safe passage back to society; this includes benefits, housing, employment, healthcare, and so forth. However (as with substance abuse treatment and other protocol) there exists absolutely no uniformity among programs in different facilities and staff do not receive formal training. Additionally, much of the provided information was hopelessly out of date, with many resources listed having been shuttered, and at some programs inmates had no access to outside resources at all. This points to the difficulties of both staff and patients in securing successful reentry.

Our visit to Bare Hill Correctional Facility highlights this issue. As stated in our report, "inmates expressed desire for a broadened Phase III program.  Through conversations, letters, and surveys, inmates requested parenting programs, more attention on re-entry programs, networking with community organizations and family reunification programs." This sentiment has been expressed numerous times by inmates and their loved ones, yet little is being done within the prison system to rectify the situation. This directly results in many of the challenges faced by CBOs once the formerly incarcerated attempt to reintegrate and avoid recidivism.

For information on healthcare in New York State prisons, please see this report by The Correctional Association. Although accurate statistics are virtually impossible to gather from correctional facilities (The Correctional Association is the only private entity in the state with legislative authority, established in 1844, to visit prisons and report findings to policy makers and the public), the organization does an excellent job summarizing the difficulties and problems inherent to the justice system and suggestions for improvement. Additionally, the Urban Justice Center released a report entitled "Jails and Prisons: Hospitals of Last Resort" that discusses barriers to mental treatment, among other relevant topics, behind bars.

This issue can be discussed indefinitely, but public health should conduct more studies to provide evidence-based programmatic and policy suggestions. Public health practitioners can assist frontline workers by arguing for novel intervention design and raising awareness about these important issues.