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Jails in unique position to ID high-risk population
Cook County in Illinois serves as model
Ten million people pass through the United States correctional system each year, and 2 million of these people are incarcerated, while a large proportion of the remaining 8 million spend at least a little time behind bars.
Since studies have shown that people in the correctional system are at greater risk for HIV than the general population, it makes good public health policy to provide prevention, testing, and counseling services to people in jails and prisons, says James B. McAuley, MD, MPH, director of pediatric infectious diseases and associate professor of pediatrics and internal medicine at Rush-Presbyterian-St. Luke’s Medical Center in Chicago. McAuley also was the medical director of Cook County Jail until September 2003.
A blinded study of the HIV rate among people incarcerated in the Cook County jail, located in Chicago, found that 2.5% of the 2,500 people tested for HIV had the virus, he says.
While that rate is lower than the HIV infection rate of New York prisons, it still is five times the HIV prevalence rate of the Chicago area, McAuley adds.
"What’s fascinating is that the vast majority of people in jail will go back into the community, and these often are individuals who don’t have easy access to health care," he explains. "The vast majority are poor and disenfranchised; 85% are male, and poor men between the ages of 17 and 40 do not typically have health insurance because most public health insurance is geared toward women and children."
The opportunity to intervene with this at-risk population often is a brief one because the median length of stay in the Cook County Jail is nine days, McAuley says. "Why do HIV care and prevention in jail? That’s because that’s where the patients are."
Also, people who are incarcerated are going to bring their illnesses and problems back into the community once they are released from jail, he says. "These are people who don’t have insurance and will ultimately end up in Cook County health care, and they’ll come in sicker and need more care, and it will end up costing you more to care for them than if you started to treat them in jail."
While money spent on HIV testing, prevention, and care services for prisoners is not a popular cause politically, it makes good sense from a public health perspective because the work that’s done in the jails will benefit the entire community, McAuley explains.
"It’s really a matter of going where you might get the most impact for your dollar, but the problem is that in corrections, it’s a hard sell," he says. "There’s no political lobby; it’s a disenfranchised population, and getting resources is more difficult than it is for the gay community or other communities."
Through a grant from the Centers of Disease Control and Prevention (CDC) of Atlanta, the Cook County correctional system has developed an HIV prevention and testing program that has succeeded in identifying about 60% of the inmates who are HIV-infected, McAuley says.
About 40,000 of the 100,000 people who passed through the Cook County jail system agreed to participate in the voluntary HIV education system, and about 10,000 of these people agreed to be tested for the virus, he points out.
"The rest of the people passed through the system far too quickly for us to engage them in any meaningful way," McAuley says.
Although the testing rate is low, the blind HIV prevalence study indicated that the people who chose to be tested were among those at greatest risk for infection, so the program appeared to identify more than half of the people who were HIV-positive, McAuley adds.
Once an inmate is identified as HIV-positive, the care portion of the program begins. It works this way:
• Get HIV-infected inmates into care as soon as possible.
"We engage them as quickly as possible into care," he says.
Clinicians conduct a history, physical, and viral load testing, and the patient is evaluated by an HIV specialist.
"Depending on the person’s disease status, we make a decision about treatment," McAuley says.
Cook County has an antiretroviral formulary for inmates, but most inmates are incarcerated too briefly to receive the treatment. Then there is the state of Illinois’ rule that prohibits people who are incarcerated from receiving AIDS Drug Assistance Program (ADAP) drugs, he adds.
"Say someone has HIV, and they come to the jail and are there six days and then leave," McAuley says. "Is it the jail’s responsibility to give them the medication as they leave, or is it the public sector’s responsibility?"
This why it’s important for a corrections system HIV program to include a transition strategy and team, he stresses.
• Provide team that helps with transition to community.
"When they are ready for discharge we offer them the same disease specialist team at a place called the Core Center, that is the Cook County Bureau of Health Services, a public medicine provider for Cook County’s uninsured poor," McAuley says. "Core is one of the largest HIV providers in the country with a patient census of [more than] 3,000."
Of those eligible to follow-up with Core, about 60% attend their follow-up visit, he says.
After a few visits, the Core team may turn the patient over to another team or clinic for care, but the goal is to provide consistency in HIV treatment during the transition period, McAuley says.
"Our goal is to give them, during transition, a sense of belonging to an individual provider and then to the Core Center in general," he explains. "That’s the theory behind it, and we think it’s been reasonably successful at this point."
• Offer case management:
There are two case managers who work within the jail to provide intakes, and there are four case managers who work with patients when they’ve left the jail.
"The case manager’s main goal is to try to get the patients on ADAP, but if that’s unsuccessful while they’re in jail, then they can do that when they’re at Core," McAuley points out.
Also, case managers can provide patients with HIV-prevention education, job training, and housing assistance.
The Cook County jail does not provide condoms to inmates, so clients receive only educational services while incarcerated, but once they are discharged, they may receive harm reduction services and condoms, he says.
Although the CDC grant soon will expire, McAuley says he is optimistic that the county will continue the jail prevention program.
"The Cook County Bureau of Health Services under Ruth M. Rothstein has really been unusually committed to both the health care of the underserved, but also supportive of health care in corrections," he says. "Mrs. Rothstein and others have really understood that if we’re interested in the health care of the citizens of Chicago, then we have to focus at some level on the population in jails."