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Correctional Health Care Issues For Substance Abusing Offenders

—Kim Marie Thorburn, M.D., President, American Correctional Health Services Association, and Corrections Health Care Director, Hawaii Department of Public Safety

During the decade of the 1980s, the incarceration rate tripled. By the end of 1991, there were 310 people per 100,000 U.S. residents in State and Federal prisons. This dramatic increase is mostly due to the increase in drug-law convictions, many of which are accompanied by long mandatory prison sentences. The influx of offenders with substance abuse problems—a population vulnerable to HIV/AIDS and other infectious diseases because of their high-risk behaviors—has had a tremendous impact on the delivery of health services in jails and prisons.

Traditionally, people in prison were young and had few chronic health problems. The advent of AIDS, along with the influx of offenders who have substance abuse problems, has changed that. AIDS disproportionately strikes younger inmates, particularly injecting drug users. With AIDS has come the resurgence of tuberculosis (TB), including outbreaks of TB strains resistant to drugs.

The overcrowding of our prisons and jails has set up the ideal environment for spreading infectious diseases. There needs to be public awareness about the health impact of the current national drug control strategy, because these health concerns do not stay behind prison walls. Inmates do come back from prison—each year, approximately 540,000 inmates return to their communities from our Federal and State correctional institutions.

The need for public health partnerships

We all recognize the need to provide adequate health services for correctional inmates for public health, humane, and legal reasons. Health correction services achieved marked improvements during the 1970s. Those gains are now threatened by the dramatic influx of pretrial and convicted drug users that occurred during the 1980s.

The sheer numbers alone strain current resources, especially as public belt-tightening does not permit staff increases or equipment purchases. Health care facilities in jails and prisons grow more cramped and inadequate.

This national health problem should be a shared responsibility. It requires coordinated planning and initiatives by States and communities, as well as shared resources. It is time for correctional health care to be recognized as an integral part of the public health sector. Both State and local health departments need to join with correctional health professionals to control the spread of infectious disease within corrections and to the public.

The role of drug treatment

Because the behavior of substance abusers puts them at such high risk for HIV/AIDS and certain other infectious diseases, the partnership of the drug treatment community with corrections is immensely important. Drug treatment facilities can play a major role in screening offenders, as well as all other substance abusers, for infectious diseases.

Both corrections and drug treatment facilities are in a key position to prevent disease through education, to screen for and provide supervised, long-term treatment for TB and other diseases, and to help manage the long-term medical followup of those with HIV/AIDS and other chronic illnesses.

The need to restructure correctional health care

The changes that are needed for adequate delivery of health care in prisons and jails require coordination among correctional health professionals, public health agencies, and community resources as never before. Today, correctional health services are faced with caring for people who have HIV infection, tuberculosis, and other chronic infections, as well as diseases that are more prevalent in aging populations, such as hypertension, ischemic heart disease, and emphysema. There is also a growing demand for intensive prenatal services in jails and prisons.

Sick call—the health care system still used in most institutions—is no longer an appropriate delivery system. This model was designed for an earlier corrections population, when most incarcerated people were young, male, and healthy, with needs arising mainly from trauma or self-limiting illnesses.

Longer prison sentences mean that the incarcerated population is aging and more inmates need care for chronic illnesses. Correctional health services must reorganize to deliver:

• Prospective care, including screening for early detection of chronic illnesses, which is not a major component of sick-call systems
• Adequate followup of inmates who have chronic illnesses even as they move among institutions and into the community
• Supplementary services, such as demands for special diets and other programmatic needs for inmates with chronic illnesses

The challenge of HIV infection among offenders

The prevalence of HIV infection among correctional inmates is at least 14 times higher than the general population. The higher incidence in corrections is due to the overrepresentation of persons with histories of high-risk behavior, especially injecting drug use.

All prison systems have been impacted by the HIV epidemic. The prevalence rate varies greatly among correctional systems, reflecting the rate in injecting drug users in the community. The challenge of managing HIV infection in the correctional environment reaches beyond health services. Correctional systems have to struggle with many different issues, including:

• Mandatory HIV testing
• Sharing or protecting information about HIV-infected prisoners
• Housing
• Terminal care
• Early-intervention treatment
• Prisoner access to investigational drug trials
• HIV prevention education, including condom distribution
• Staff fears and education

Some issues are being resolved through litigation, but there is no standard recipe for HIV management in incarcerated populations.

Dealing with the problems of HIV infection and AIDS carry tremendous cost implications for the correctional health system. The lifetime cost of caring for one person with AIDS is estimated at more than $85,000, or $32,000 annually. For an asymptomatic HIV-infected person, annual cost of care is more than $5,000.

The box illustrates the cost impact of HIV/AIDS on one correctional health system.

Multidrug-Resistant TB

The incidence of TB in prisons is at least three times higher than in the general population. The incidence is also high at drug treatment centers, because drug users and carriers of HIV are most at risk. The incidence of TB in persons with AIDS is almost 500 times that of the general population.

It was a prison epidemic that alerted the public health community to the growing problem of multidrug-resistant tuberculosis (TB). In New York State, infected prisoners were hospitalized and the infection spread into the community. Overcrowded institutions, often with a high proportion of immune-suppressed people, are fertile ground for the spread of TB. To prevent transmission among the incarcerated population and into the community, correctional institutions must now scramble to institute systems that will identify and control TB infection and cases.

New York State recently instituted mandatory TB screening for all inmates and correctional staff. The Centers for Disease Control and Prevention (CDC) promotes a testing protocol for TB that costs about $1 per patient. The National Institute of Corrections estimates that the cost of treating one tubercular patient in a correctional setting ranges from $56,000 to $90,000.

Both correctional facilities and drug treatment centers are effective in providing onsite TB screening and preventive therapy, according to a CDC report in March 1993. In a CDC demonstration project with 25 State and city health departments, correctional facilities were successful in getting 94 percent of persons to complete the full 6- to 12-month course of preventive therapy. Drug treatment centers achieved a 66 percent completion rate. CDC recommends that priorities be:

1. To identify and effectively treat persons with active TB and their contacts
2. To screen for latent TB infection and provide preventive therapy to infected high-risk persons

The study found that approximately 25 percent of the Federal and State correctional inmates, and more than 13 percent of drug treatment center patients, had latent TB infection. All of the active TB cases and nearly 1/2 of the TB suspects identified in the project with known HIV status were HIV-seropositive.

Funding for such testing and preventive therapy is a big question. Funding for corrections has lagged far behind the explosive growth in the prisoner population. In some States, per capita medical expenditures have been reduced at a time when medical problems are escalating.

Medical issues for female inmates

The increasing percentage of women behind bars also affects the delivery of health services. Drug sentencing has had a major impact on the number of women coming into correctional institutions. While women still only represent 5.8 percent of the incarcerated population, their rates are increasing faster than male prisoners. A larger proportion of women are incarcerated for drug convictions (1 out of 3 women compared to 1 out of 13 prisoners overall). Women need gynecologic services and are at risk for cervical cancer and sexually transmitted diseases.

Many women are pregnant when they enter prison and their pregnancies often need intensive management due to high risks, such as drug use during early stages.

Women also have special needs for care based on their family histories. An estimated 41 percent of women in prison report having suffered previous physical or sexual abuse in their lives. For about 1 in 4 women, the abuse occurred before age 18. Since women still represent a small proportion of incarcerated people, their extensive health needs are often difficult to meet in systems that are planned for male-dominated programs.

For HIV-seropositive women, specific services are lacking. Incarcerated women have a higher rate of HIV infection than men do. A Massachusetts study of 400 inmates who volunteered to be tested found that 35 percent of the women were HIV-seropositive, compared to 13 percent of the men.

Future medical costs

The magnitude of inmate health problems is only expected to increase. The National Commission on AIDS estimated that under the present policy of mandatory sentencing for drug offenders, the percentage of drug offenders in Federal prisons will rise by 1995 from 47 to 70 percent.

The changing health demographics of prison populations have greatly impacted correctional budgets. The average yearly cost of health care for a correctional inmate more than doubled between 1982 and 1989—from $906 to $1848.

A 1989 survey of prison health care budgets indicated that health care represents an average of 9.5 percent of overall prison budgets, ranging from 5.1 to 18.9 percent. In 1989, the cost of health care for inmates incarcerated in the Nation's prisons was about $25 million. Costs of inmate health care can be expected to increase further.

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