Living with Stigma: HIV Among Incarcerated People
This week we explore the intersection between the prison system, the needs of the incarcerated, and he collective health of the communities we live and work in. The concept of public health focuses largely on the prevention of disease and the cultivation of healthy behaviors. Public health is research-oriented and data-driven, working to save money through best practices and improve the quality of life. Public health also functions at the community-level, meriting work that advances healthy living outcomes for people in all backgrounds regardless of race, gender, or socio-economic status. It is also a catchall that accounts for environmental and social factors in the spreading of diseases. Whether you know it or not, most of us have a role to play in the health of our communities. Every time you get the annual influenza vaccine or participate in a bike-sharing program, you are making choices that impact collective health. Chief among those concerns of public health advocates is HIV/AIDS transmission and long-term disease maintenance. Since the HIV/AIDS virus was raised into national consciousness in the early 1980s, large multi-dimensional campaigns have worked to provide resources that aim to reduce infection rates, offer pathways to disease sustainability, and eliminate AIDS-related deaths. Improved forms of diagnosis and treatment, as well as anti-retroviral drugs have dramatically decreased transmissions since its genesis. From 2008 to 2014 alone, the number of new HIV infections dropped by about 18%. With even newer preventative drugs like the Pre-Exposure prophylaxis (PrEP) daily-use drug, we are now able to eliminate risk of transmission all together.
Of course, a discussion on advances in medicine must also incorporate the reality of financial barriers that exist for so many. Simply put, education and proper treatment are unevenly distributed, creating a hierarchy of resource allocation that ultimately drives disparities. These disparities are a large part of why rates of HIV and the number of those cases that go untreated are higher among people of color and the low-income poor. Unlike other diseases, once HIV is contracted it must be maintained through regular medical intervention to prevent an escalation into AIDS. Between regular doctor visits and astronomically high-cost drug prices, living with HIV is prohibitive. Gaps in service emerge especially when looking at another source of social disparity: incarceration. For those incarcerated in local, state, or federal jails and prisons, availability of care becomes a state enterprise and one the state is often ill prepared to manage. The combination of a tight budget drawn from ever-dwindling state coffers and the environmental context of prison and its convergence of already under-served populations means that prisons are often home to a disproportionately high number of existing and newly diagnosed cases. Because resources are severely stretched, there is great concern among advocates, medical personnel, and researchers about HIV among the incarcerated. It is time that policy makers share this passion and recognize why HIV prevention and maintenance should be a key component of any correctional operation. We must also pivot into a discussion on what HIV means for public health in jails and prisons, as well as the health of the wider community upon re-entry.
INCARCERATED WHILE POSITIVE
Prisons are unique spaces where the norms of everyday life are shaped by both tangible and abstract constraints. People incarcerated must learn to navigate a hostile environment that is designed to radically transform the individual and rob them of pleasantries commonplace in the outside world. This means renegotiating everything from inter-personal relationships to individual coping habits. Because of this, prisons are often seen as -risk environments where all sorts of diseases and personal choices can raise the chance for chronic medical conditions. This is true of conditions like tuberculosis and hepatitis B and C, with inmates having significantly higher rates of infection when compared to the public. This is compounded by other issues like hypertension and lifetime weight problems as well. Among the many medical concerns that people both enter with and are at risk of while incarcerated, HIV is among the biggest. HIV rates among the incarcerated are nearly twice the rate of the general population. Because it is so prevalent and the risk of infection is much higher, identification and care are crucial to containment. A revised 2016 Bureau of Justice Statistics report, however, shockingly details that unlike other forms of disease containment and management, most jurisdictions are ill prepared for HIV. Only 71% of those incarcerated had received an HIV screening during their tenure. Only about 1/3 of all corrections jurisdictions provide automatic testing upon entry, with the rest offering only opt-out/opt-in services or no service at all. Even when requested, many states do not offer HIV testing unless court-ordered or deemed to involve high-risk circumstance (e.g. risky sexual activity; the use of intravenous needles). These numbers are even worse when shifting to local facilities, where some studies have shown 68% of individuals receive no medical examination for HIV from entry to release. For those that do get seen, rates of regular medication use drop significantly among inmates due to inattention to active medical problems. These types of gaps in prison medical care are unacceptable and akin to a wholesome violation of human rights.
Louisiana sits at the meeting point of these two social concerns, with the state ranking third in new HIV diagnoses and holding the distinct title of “most incarcerated place on earth.”. Specific to the New Orleans area, more than 6,600 people were living with HIV, with a large majority of these people being men (75%) and African American (65%). Not surprisingly, the same causal factors that place people at risk of HIV are also influential in determining whether someone has contact with the criminal justice system. As a Human Rights Watch report notes, the racial disparities that so heavily permeate Louisiana are seen front-and-center at the nexus of HIV transmission and incarceration rates. State-wide, African Americans are 10x more likely to be diagnosed with HIV and 5x more likely to be incarcerated than other racial and ethnic groups. Because these two groups overlap so much, it becomes crucial that public health concerns operate with correctional outcomes in mind. As mentioned, for those in prison medical coverage becomes a major concern. But just like those outside of prison, cost becomes the single greatest barrier to treatment in prisons. The average treatment cost for HIV medication typically exceeds $50,000 per year, a cost that is passed onto the state. In reality, these costs cannot be absorbed by parish-run jail facilities and so fall to the side. This translates into an absence of testing, a lack of medical attention, and an inability to acquire antiretroviral drugs treatments. In Louisiana, reports have shown that only 5 of the 104 parish jails offer open regular HIV testing. For those facilities that do offer testing and drug coverage, like East Baton Rouge Correctional Center, covering the cost for over 50 HIV-positive inmates totals upwards of $100,000 per month, a figure that represents a majority of the total medication budget. Additional concerns like staff training costs and access in rural facilities further escalates existing disparities. The single biggest problem in all cases is both lack of initial access and continued access to treatment. The interruption of medical attention and appropriate medications means that conditions among those with HIV can deteriorate rapidly. The mountain of bureaucratic obstruction experienced in the correctional system and a poorly funded prison health system means that people do not get the proper testing needed, wait weeks for a doctor once tested, and weeks more to receive medication they have been prescribed. This is a major social crisis that must be addressed.
THE PROBLEM AND WHAT TO DO
Beyond the obvious issue of any disease epidemic, the duality of being incarcerated and living with HIV means big obstacles for those transitioning back into the community. While delivery of medical care is inconsistent across prison facilities, most will receive some type attention during their tenure. In truth, this attention is often better than what would have been received outside of prison. Many living with HIV will go on to experience setbacks through non-adherence to anti-retroviral drugs, thus progressing the disease following release from prison. Moreover, many will face already limited access to medical care and health insurance, reduced social benefits, and housing and employment instability upon.These factors impact all formerly incarcerated peoples, but the challenge is even greater among those with HIV/AIDS. Beyond the individual impact, the barriers to re-entry can also place the community at greater risk for the transmission of disease. Ensuring successful re-entry for those living with HIV means making integrated decisions about how to maximize both employment opportunities AND a sustainable health regiment.
There must be an effort to incorporate this aim into people who are incarcerated as well. Re-entry is an already challenging process without the additional burden of ongoing medical concerns. Extensive medical treatment and maintenance should be offered for those incarcerated people living with HIV/AIDS, but moreover, prevention efforts must include both a resource-rich educational platform and practical solutions like offering condoms and clean needles. Prisons might also look to emphasize integrated mental and emotional counseling, as well as programming that is linked in with monitoring of behaviors, like sexual activity and drug dependency. It is not only the responsibility of the state’s correctional department but the health department as well to ensure that inmates receive access to reliable and timely care. We MUST acknowledge that human rights standards exist and among them is the right to health care – provided by the state – while in detention. This axiom has been reflected by the UN Standard Minimum Rules for the Treatment of Prisoners, a declaration that holds the provision of quality health care services must be deliverable to all incarcerated people. There must also be a prioritization of care after prison. Formerly incarcerated people must be linked to care to avoid lapses and the subsequent increase in virality. Taken from the mission statement of Louisiana’s Department of Health Office of Public Health, efforts are designed around the protection and promotion of health and wellness of all individuals and communities in Louisiana. This is done through education, the promotion of healthy lifestyles, the prevention of disease and injury, the enforcement of environmental regulations, the sharing of information, and the assurance of preventative services to uninsured or underserved peoples. The Justice and Accountability Center of Louisiana believes in this vision of public health and looks to the health departments both in and outside Louisiana for new ways to provide integrated care that incorporates those detained and in state custody. Because JAC’s organizational work focuses on re-entry, we also look to other groups that prioritize the health of individuals and the community particularly regarding access to care for vulnerable populations. As the state continues to finalize the finer details of an operating budget and reduce spending, it would be sage for policy makers to learn how preventative and maintenance-oriented health care can be both financially and socially beneficial in and out of our prison communities.
 Maruschak, L. M., Berzofsky, M., & Unangst, J. (2016). Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-12.
Washington D.C.: Bureau of Justice Statistics. Retrieved from https://www.bjs.gov/content/pub/pdf/mpsfpji1112.pdf
 Springer SA, Pesanti E, Hodges J, Macura T, Doros G, Altice FL: Effectiveness of antiretroviral therapy among HIV-infected prisoners: reincarceration and the lack of sustained benefit after release to the community. Clin Infect Dis. 2004, 38: 1754-1760. 10.1086/421392.
 Stephens TBR, Robillard A, Colbert SJ: A Community-Based Approach to Eliminating Racial and Health Disparities Among Incarcerated Populations: The HIV Example for Inmates Returning to the Community. Health Promot Pract. 2002, 3: 255-263. 10.1177/152483990200300220.