Segregated prison units not always best for care
Segregated prison units not always best for care
Good relations with public health crucial
Several states segregate prisoners by HIV status. Detractors of the practice abound, principally because it increases the risk of TB outbreaks. Even so, states that enforce segregation say there are substantial benefits.
In Mississippi, Alabama, and South Carolina, men and women housed in the HIV units are subjected to what critics call "wholesale" segregation, meaning the prisoners spend both days and nights living apart from the general prison population, according to Jackie Walker, HIV project officer of the American Civil Liberty Union’s Washington, DC-based Prison Project.
In Florida, California, and Texas, inmates on HIV housing units have separate housing but still have access to programs — such as literacy or substance-abuse treatment — offered to other prisoners.
Everyone concedes that the practice of separating HIV-infected inmates has its pluses and minuses, but at least one expert says the minuses often prevail when it comes to health care.
Administrators like HIV units for three reasons, says Walker. First, they say, the units prevent transmission of HIV. In Alabama, for example, prison officials say that since setting up the prison system’s HIV-only units, instances of HIV transmission in prisons have ceased, Walker says. Administrators also like the units because they save money by letting prisons concentrate HIV expertise and resources in one place.
More controversial is the third advantage advocates claim: that segregated HIV-infected prisoners wind up getting much better health care.
At least one expert disagrees. "If all you do is segregate, and you don’t set up centers of expertise to go with them, then you wind up with substandard care in a segregated setting," says Anne DeGroot, MD, assistant professor of medicine at Brown University in Providence, RI.
The problem, DeGroot adds, is that in less-populous states, separating HIV-infected prisoners doesn’t always result in the number of people needed to purchase high-quality, on-site care. The substandard care that results often takes the form of what she terms "fax medicine." In that scenario, a nurse does an intake history or listens to an inmate’s complaints and then simply faxes or phones the information to a doctor who may be in another county. Without ever seeing the patient, the doctor faxes a reply.
Even advocates don’t deny that the biggest danger of setting up HIV-only units is the way they set the stage for TB outbreaks, because HIV makes it 10 to 30 times more likely that someone latently infected with TB will develop active disease. "Trying to educate people to the risks is a never-ending task," she says. "You’re constantly working to maintain expertise and keep the level of suspicion high. Even then, sometimes we screw up."
Outbreak results in tighter intake protocol
If the decision is made to set up an HIV-only unit, DeGroot and others say certain rules must be followed scrupulously. Most important is that the public health department and the prison unit maintain a close working relationship.
"You need to work hand in glove with corrections, and you have to have very, very close cooperation, and that relationship needs to start well before you set up the unit," explains Carol Pozsik, RN, MPH, head of TB control in South Carolina.
Pozsik knows firsthand what happens when that isn’t the case. Despite a long history of strong communication and good relations between TB controllers and prison health care staff, in 1998 a newly appointed state head of corrections decided to create HIV-only units. An outbreak that occurred might have been prevented with only minor changes in protocol, like the regular symptom screenings that now take place, says Pozsik
DeGroot adds that even when inmates who need prophylaxis are reluctant, every effort should be made to talk them into it.
It should go without saying that care for HIV-infected inmates should be expert and delivered on site, not by fax or by phone.
Post-outbreak policies at Broad River Men’s Correctional Institute in Columbia, SC, call for much tighter intake protocols as well, adds Pozsik. Now as before, inmates are tested for HIV as soon as they arrive, and infected inmates are placed in isolation for long and thorough work-up, she says. Staff and inmates alike are regularly skin-tested. Plus, the level of suspicion for TB is kept high.
DeGroot agrees that making sure medical expertise is available on site is a good first step. But unless prisoners trust the health care providers, competency alone may not be enough to prevent trouble, she adds. Lack of trust means prisoners will be reluctant to report symptoms, something they may already be reluctant to do because it generally results in their being placed in respiratory isolation.
"Prisoners don’t have many possessions," DeGroot points out. "When someone’s put into isolation, whatever stuff they do have — their mini-TV, the pictures of their wife and kids — all of that gets put into storage. When they get out, they get their stuff, but usually some of it’s missing. So [getting someone placed into] isolation is always a big struggle."
Lack of program access boosting recidivism
In South Carolina and 17 other states, HIV testing for prisoners is mandatory. In states where it’s voluntary, prisons that practice "wholesale" segregation (by preventing inmates from taking part in regular programs) risk discouraging prisoners from getting tested for HIV, notes the ACLU’s Walker. "If they’re serving a short term and the test is voluntary, they’ll often decide to wait until they get out rather than risk being put into the HIV-only unit," she says.
Denying prisoners access to programs also increases recidivism, Walker says. "They go in illiterate and with drug-abuse problems, and they come out the same way. That means they’re much more likely to wind up back in the same place," she says.
HIV specialists who advocate for good health care and strive for a trusting relationship with inmates often find they’re at odds with correctional staff, adds DeGroot. "The guards have a word for it: They call you a "con coddler." I try to explain that if the prisoner doesn’t come to us with that cough, that means he just stays in his cell [and spreads disease]."
DeGroot also cites the widespread conviction among guards and administrators that prisoners who are infected with HIV have "gotten what they deserve." In one jail where there was no discharge planning for HIV- and TB-infected inmates, DeGroot says a local sheriff once told her, "I don’t care what happens to them once they hit the door, just so long as they don’t come back here." DeGroot says she tried to explain that "people don’t stay in prison forever. They’re members of a community to which they eventually return. So what you’re doing is returning to the community people with partially-treated HIV and partially-treated TB. If I lived in one of these communities," adds DeGroot, "I’d be very, very upset."
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