In this Chapter
Jails concentrate marginalized individuals with a range of social and health problems into one place.1,5 Prior to coming jail, many individuals may have received no health care or such services have been fragmented. This may be due to co-occurring health conditions or problems that interfere with access (e.g., substance abuse, mental illness), and due to structural inequalities, including poverty, unstable housing, limited educational attainment, and un- or underemployment.15,16 Vulnerable populations are less equipped to address health issues when faced with competing needs related to survival, such as food and shelter.17 In these communities, health disparities may lead to risky behaviors, which in turn contribute to HIV infection acquisition and to crime leading to arrest.18,19
Behaviors and vulnerabilities that increase risk for HIV are often associated with incarceration, such as substance abuse and high-risk sexual practices, including commercial sex work. Incarcerated persons also have high rates of sexually transmitted infections (STIs), including HIV as well as viral hepatitis, tuberculosis (TB), mental illness, substance abuse, and histories of physical, sexual, and emotional abuse.19,5 The intersection between HIV, homelessness, and incarceration is also well documented; in fact, individuals with mental illness are most likely to be homeless prior to and after incarceration.20
Jails represent a chance to test, diagnose, and treat high-risk populations. It can offer marginalized people an opportunity for contact with the healthcare system5,20 collaboration between public health agencies, community-based organizations, and jails has implications for public health and safety efforts. Working together, linkages promote continuity of care for a highly vulnerable population.21,22
A jail intervention, like Enhance Link, includes engagement, testing, and linkage coordination, all of which need to occur quickly because jail stays are often brief and the uncertainty around discharge dates presents a shorter window of opportunity to reach people.3 Medical screenings, however, are a part of the intake process and offer an opportunity to implement such interventions, as do booking and intake.19,20
Did You Know?
The idea that jails and prisons are "breeding grounds" for HIV transmission has been perpetuated over the years but is largely unfounded
Source: Hammett TM. HIV/AIDS and other infectious diseases among correctional inmates: transmission, burden, and an appropriate response. Am J Public Health. 2006;96:974–78
Without linkage interventions, barriers to care that existed prior to jail admission remain upon release. For example, many individuals released from jail are uninsured even if they’re eligible for Medicaid or Medicare. Their benefits may have been “turned off” when incarcerated and they may not know how to turn them back on. This barrier is difficult to navigate for many people and impedes access to medication and HIV primary care, both of which are paramount to addressing the HIV epidemic.17
The EnhanceLink project proved that this work could not only be done within this short window, but could be done successfully and cost-effectively.23 EnhanceLink grantees achieved a successful linkage rate of at least 60 percent.17
A successful jail intervention can decrease expensive emergency room visits, decrease transmission of HIV, reduce recidivism, and improve quality of life for individuals and, ultimately, for communities.17 Jail linkage programs offer the linkage and engagement services called for in the Affordable Care Act. If the United States is to achieve the vision of an AIDS-free generation and offer the access to care called for in the NHAS, then the millions of people who cycle through jails each year must be included. (To read more about the NHAS, visit HIV.gov.)
The CDC strongly recommends jail-based HIV testing.10 Routine HIV screening in jails is also consistent with the NHAS.10 Nonetheless, many HIV-positive jail inmates are unaware of their HIV status or are out of care. The majority of detainees pass through jail and never move on to prison but, rather, return to the communities they left.13,20 The transition period from incarceration back to the community is known to be a time of particular vulnerability, as well as high risk for cessation of antiretroviral therapy (ART), further underscoring the need for transitional and linkage services.10 Without assistance people leaving jails tend to return to the same conditions they were living in before they were incarcerated. This increases their risk for recidivism. If they are not linked to HIV primary care, they will contribute to higher community viral loads, leading to poor individual outcomes and increased HIV transmission.
Rapid HIV testing technology is ideal for jail settings, since results can be delivered to inmates so that they are aware of their serostatus. Identification of HIV alone is associated with a three- to fourfold reduction in sexual risk behaviors.10,24,25 Identification of HIV-positive individuals provides health departments with the opportunity to notify partners and provide them with testing and referral services, too, all of which support prevention efforts.20
Access to, and provision of HIV testing in jails is inconsistent, underscoring that more can be done to increase rates of HIV testing for those incarcerated in jails. (To review CDC testing recommendations in correctional settings, see https://www.cdc.gov/correctionalhealth/rec-guide.html, and to visit the AIDS Education and Training Centers (AETCs), National Clinician Consultation Center site to review State HIV testing laws.
Overall, HIV interventions help reduce transmission in the community by increasing awareness of HIV. They offer risk reduction counseling and information about the benefits of ART and the importance of adherence. They also link HIV-positive people to primary care providers and to ART.8 As such, health departments, local health care providers, and community-based organizations have a vested interest in the provision of HIV testing, treatment, and linkage to care and treatment in jails and upon inmate release. It is useful for health care and correctional staff to view jails as part of the continuum of care rather than independently, since this approach may help encourage strategic and retention-in-care planning.26
The CDC also recommends using “combinations of scientifically proven, cost effective, and scalable”27 prevention interventions. Given that case management for HIV-infected persons has been shown to increase engagement and retention in care and EnhanceLink proved to be cost-effective (see the following chapter), this jail linkage work should be considered for replication.23