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Availability of and Access to Medical Services Among HIV-Infected Inmates Incarcerated in North Carolina County Jails David L. Rosen, MSPH Carol E. Golin, MD Victor J. Schoenbach, PhD Becky L. Stephenson, MD David A. Wohl, MD Brett Gurkin, MD Andrew H. Kaplan, MD Abstract: This study assessed human immunodeficiency virus (HIV)-related services in county jails and staff perceptions of HIV-infected inmates and their care. A statewide telephone questionnaire was administered to detention officers and health care workers providing medical services in North Carolina jails. Eighty-five percent of participating facilities employed one or more on-site medical personnel, including physicians (51%), physician assistants (14%), and nurses (71%). Only 25% of jails tested more than one inmate for HIV per month. In 75% of jails, initial medical screening was performed in a common area. Officers administered medical screening forms at 93% of jails and distributed medications at 81%. Ninety-three percent of officers and 94% of medical staff agreed with this statement: “If an inmate is taking medications in jail, other inmates will know about it.” Overall, our data indicate that few North Carolina jail inmates are tested for HIV. Greater protection of confidentiality may improve screening and treatment of HIV-infected inmates. Key words: Access to health care, human immunodeficiency virus, jails, antiretroviral therapies, surveillance, patient discharge, HIV.

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hronic medical problems are common among newly incarcerated inmates.1 Recent data from the United States Bureau of Justice Statistics indicate that human immunodeficiency virus (HIV) infection in the United States is several times more prevalent in the incarcerated population than in the general population.2 This concentration of infected persons has given rise to numerous studies and reports examining HIV care in the context of state prison systems.2-11 This stands in marked

MR. ROSEN is a Graduate (PhD) student in the Department of Epidemiology, DR. GOLIN is Assistant Professor in the Department of Medicine and in the Department of Health Behavior and Health Education, DR. SCHOENBACH is Associate Professor in the Department of Epidemiology, DR. STEPHENSON is Associate Professor in the Department of Medicine, DR. WOHL is Assistant Professor in the Department of Medicine, DR. GURKIN is Resident in the Psychiatry of Epidemiology, and DR. KAPLAN is Associate Professor in the Department of Medicine at the University of North Carolina at Chapel Hill.

Journal of Health Care for the Poor and Underserved 15 (2004): 413–425.

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contrast, however, to the very limited published data available regarding the experience of HIV-infected inmates incarcerated in county jails. Although prisons and jails are both institutions of incarceration, they each pose very different health care challenges. In general, state prison systems are made up of an integrated group of facilities spread throughout a state that are run by the state government. State prisons are populated by inmates who are incarcerated for relatively prolonged periods in institutions that have health clinics that are often run by prison medical personnel and provide integrated medical care for inmates. Inmates in county jails, in contrast, tend to be incarcerated for short periods of time, often less than one week. In most states, each jail is administered independently by the county governments and, unlike the state prison systems, often lacks facilities dedicated to the delivery of health care. North Carolina is one of 44 states in the United States to maintain a state-operated prison system that is independent of county-operated jails.12 The North Carolina Department of Corrections (NC DOC) maintains an integrated system of health care, including four regional infectious disease clinics, serving the entire state prison system. In contrast, county jails in North Carolina have no system of integrated health care. Instead, each jail must rely on county funds and local resources for medical care. The North Carolina Department of Health and Human Services (NC DHHS) requires that each county jail provide inmates with “health screening” and “routine medical care,” but does not define how these requirements should be met.13,14 As a result, counties in North Carolina vary in their health care practices and resources.15 Data collected by the U.S. Department of Justice indicate that county-to-county variation in the level of health care services provided in jails is common in the other 43 states with county-operated jails.15 As in other U.S. jails, the 400,000 inmates incarcerated yearly in North Carolina’s county jails (also referred to as detention facilities) are either awaiting trial or serving short sentences (typically less than 1 year). National data collected in 1997 suggest that half of all jail inmates are released within 48 hours.16 Approximately 75% of North Carolina jail inmates are pretrial detainees; the remaining 25% are serving sentences.13 In 1999, a national survey indicated HIV prevalence rates of 1.7% among all jail inmates and 1.8% among the inmates incarcerated in North Carolina’s county jails.17 In the absence of mandatory testing, however, even these relatively high rates probably underrepresent the prevalence of HIV in incarcerated populations. Jails present an important opportunity to provide health care services to highrisk, underserved populations. However, health care in general and HIV care in particular may be hampered in jails by short inmate stays, limited resources, and the perceptions of jail staff concerning inmates’ medical needs. Given these potential obstacles, access to and availability of HIV-related health care services provided in county jails merit further research. This is the first statewide study designed to characterize medical services pertinent to HIV care in jail facilities. A clearer understanding of the obstacles to providing care in this setting is the first step toward developing programs that address the needs of these inmates. The results may be useful in directing jail policies to enhance health care services available to inmates and reduce the spread of HIV infection.

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Methods Study population. Each of North Carolina’s 100 counties maintains a detention facility, with the exception of five counties that share regional jails and two counties that both share a regional jail and maintain their own jail.14 For the purposes of this study, we use the definition of jail contained in the 1999 Census of Jails conducted by the U.S. Bureaus of Justice Statistics.15 Briefly, a jail is a locally owned facility that receives and/or holds individuals pending arraignment, trial, and sentencing; temporarily detains juveniles and mentally ill patients awaiting transfer to appropriate health facilities; holds individuals for the military, protective custody, contempt, and for the courts as witnesses; and transfers inmates to the federal or state prison systems.15 Jails may also house inmates from other facilities to alleviate overcrowding.15 Although several counties have satellite detention facilities, for the purpose of this study interviews were conducted with jail personnel employed at the main county jail, of which there are 98 in North Carolina. These detention facilities house pretrial detainees as well as those incarcerated as a result of contempt of court, public intoxication, or sentenced confinement (typically less than 1 year).14 In accordance with national reports,2,15,18 we refer to all of these individuals as inmates. From July 1, 2000 through July 30, 2001, we telephoned 97 of North Carolina’s 98 county jails to request an interview with the jail administrator. Jail administrators at 3 facilities refused to be interviewed, and 14 jail administrators were unavailable for interview despite multiple attempts. In 8 additional facilities, the jail administrator was unavailable for interview but allowed a member of his or her medical staff to be interviewed. To evaluate the compatibility of responses between jail administrators and medical personnel, we conducted interviews with medical personnel from a random sample of ~12% (9 of 72) of those facilities employing a jail administrator who had been interviewed. Our final study population consisted of 72 jail administrators and 17 medical personnel from 80 county jails. Responding facilities represented 83 counties, including 97% (34 of 35) of the counties in North Carolina containing a metropolitan area (as defined by the U.S. Census Bureau) and 75% (49/65) of North Carolina counties without a metropolitan area.19 The population residing in participating counties constituted 87% of the total population in North Carolina for 200020 and accounted for 94% of the cumulative HIV cases in North Carolina reported to the NC DHHS.21 In 2000, 88% of all jail admissions were within participating facilities.22 This study was approved by the Committee on the Protection of the Rights of Human Subjects, School of Medicine, University of North Carolina at Chapel Hill. Questionnaire development. To develop our survey instrument, we first reviewed the health services literature regarding HIV services available in low-occupancy county jails. Because there exist few published reports pertaining to medical services provided in jails, we conducted site visits to a small sample (6%) of jails located in North Carolina counties that varied widely by geography, per capita income, and population density. During these site visits, we conducted semi-structured qualitative interviews with jail administrators and nursing staff (when such staff existed) to identify issues relevant to HIV care in jail.

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Responses from these interviews in conjunction with themes identified in the existing literature as important to jail health care, were used to inform the first version of our instrument. Important themes included (1) the presence of medical staff in jails, (2) procedures for medical activities such as HIV testing and medication delivery, and (3) attitudes among jail administrators and medical staff regarding the provision of care for HIV-infected inmates. Questions regarding provider attitudes were adapted from other surveys of HIV services.23,24 The instrument was then tested for face validity, content, and wording by a panel of clinical researchers and social scientists including medical sociologists, health behaviorists, epidemiologists, and clinicians with extensive experience treating HIV-infected inmates. Appropriate revisions were made based on the panel’s suggestions. Members of the research staff were then trained to administer the instrument by telephone in a standardized manner. Following the completion of their training, staff piloted the questionnaire with a total of five jail administrators and nurses. Based on these pilot interviews, a small number of items were revised to facilitate the flow of the interview. Interviews. Fifteen-minute telephone interviews with jail personnel were conducted using a standardized questionnaire. Participants were asked about jail procedures pertaining to medical care as well as their own attitudes, assessed with Likert-type scales, regarding HIV-infected inmates.23,24 Questions about procedures focused on the availability and training of in-house medical staff, utilization of outside medical facilities, and the frequency of HIV testing. Participants were also asked about their view of the appropriateness of providing medical care in a detention setting, their attitudes toward HIV-infected inmates, and their estimate of the number of HIV-infected inmates incarcerated in their jail during the prior 6 months. Specifically, we asked jail personnel, “Over the last 6 months, how many inmates would you estimate have been HIV positive?” Thus, HIV prevalence estimates were based on participants’ perceptions rather than a systematic review of inmates’ medical records. Statistical analyses. Interview data were double-entered into a Microsoft Access database. Validation of data entry and data analysis were performed using SAS software, v. 8.1.25 Facility HIV prevalence was calculated based on personnel estimates of HIV-infected jail inmates over the 6 months prior to the interview, divided by average facility admissions over 6 months. Do Not Know responses are included in the denominators for the percentages in Table 1 because these responses may be indicative of barriers to care.

Results Medical personnel/facilities. Eighty-five percent of participating facilities employed one or more on-site medical personnel, including physicians (51%), physician assistants (14%), and nurses (71%) (Table 1). Thirty-five facilities (44%) employed both nurses and physicians; 9 facilities (11%) employed both nurses and physician assistants; 4 facilities (5%) employed nurses, physicians, and physician assistants; no facilities employed physicians and physician assistants without employing nurses. Among facilities employing on-site personnel, physicians, and nurses were present at the facility a median of 4.5 hours/week and 30 hours/week, respectively.

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Table 1. AVAILABILITY OF HIV-RELATED MEDICAL SERVICES IN 80 COUNTY JAILS IN NORTH CAROLINA, 2000-2001a Service

N (%)

Onsite medical personnelb Physician Physician assistant Nurse None

41 (51) 11 (14) 57 (71) 14 (18)

Co-payment required for non-emergent care Yes No Missing

57 (71) 19 (24) 4 (5)

Who distributes medicationsb Detention officer Nurse

65 (81) 23 (29)

Community sources of medical careb County health department Local hospital Private health clinics Other

55 (69) 77 (96) 45 (56) 12 (15)

Social/medical services referral for released HIV-infected inmatesb Health department 27 (34) Community physician 5 (6) AIDS service network 5 (6) Social worker 1 (1) Other 3 (4) No referral 25 (31) Do not know 23 (29) Location of initial medical screening questionnaireb Common processing area Private room Other Do not know

60 (75) 19 (24) 1 (1) 3 (4)

Administer initial medical screening questionnaireb Detention officer Nurse Do not know

74 (93) 8 (10) 1 (1)

Initial medical screening questionnaire specifically addresses HIV/AIDS Yes 22 (28) No 56 (70) Do not know 2 (3) (continued)

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Table 1. Continued. Service

N (%)

Location of HIV testing Jail Local health department Local clinic Hospital Do not know

18 (23) 39 (49) 4 (5) 11 (14) 13 (16)

a

Data for 80 facilities. Nurses were interviewed in 8 facilities in which jailers declined. Participants could respond with more than one answer, resulting in percentage totals exceeding 100%. b

Seventy-one percent of detention facilities required a copayment from inmates for non-emergent medical appointments. Medications were distributed by detention officers in 81% of facilities and by nurses in 29% of facilities (Table 1). Sixty-nine percent of facilities utilized the county health department as a resource for medical care, for services such as HIV, sexually transmitted diseases, and tuberculosis screening, as well as hospitals (96%), private clinics (56%), and other facilities (15%), such as mental health and dental facilities. Nineteen percent of the nurses providing care at detention facilities were employed through the county health department. Respondents at 34% of facilities reported that released HIV-positive inmates were referred to county health departments. In 31% of facilities, referrals were never made for HIV-positive inmates, and respondents at 29% of facilities were unsure whether a referral would be given (Table 1). Of the 37 facilities that reported incarcerating two or more HIV-infected inmates over the prior 6 months, 32% (12/ 37) reported no medical or social service referrals for released HIV-infected inmates. HIV screening and testing. In 75% of facilities, initial medical screening questionnaires were administered in a common processing area. Questionnaires were administered by jail administrators in 93% of facilities and by nurses in 10%. According to respondents, 70% of medical screening questionnaires did not include questions that specifically addressed HIV or acquired immunodeficiency syndrome (AIDS) (Table 1). HIV testing of jail inmates was performed at the detention facility (23%), county health department (49%), local clinics (5%), and local hospital (14%); 16% of jail personnel reported that they did not know where testing would be performed (Table 1). Twelve facilities reported that one or more inmates per month received an HIV test. In these facilities, the median number of inmates tested per month was two. Attitudes. Data on staff attitudes regarding medical care were obtained from 72 jail administrators and 17 medical personnel who provided medical services in county jails (Table 2). Sixty-three percent of detention personnel and 71% of medical

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Table 2. ATTITUDES CONCERNING HIV-RELATED CARE ENDORSED BY JAIL AND MEDICAL PERSONNEL WORKING IN NORTH CAROLINA COUNTY JAILS, 2000-2001* Attitude

Chief jailer (n= 72) N (%)

Medical personnel (n= 17) N (%)

If the financial and personnel resources are available, jails are an appropriate place to provide medical care.

45 (63)

12 (71)

Inmates commonly make requests to be seen by medical personnel when it is not necessary.

54 (75)

11 (65)

If HIV medications are not taken as prescribed, the HIV in one’s body may become resistant to the medications.

19 (26)†

11 (65)

4 (6)

1 (6)

In general, if an inmate is taking medications in jail, other inmates will know about it.

67 (93)

16 (94)

Housing HIV-infected inmates endangers the health of other inmates or jail staff.

33 (46)

0 (0)

In general, dispensing HIV medications in jails is more trouble than it is worth.

*Values are expressed as number of participants who endorsed each statement and percent of all responses including “Do not know.” †48 (66.7) responded “Do not know.”

personnel agreed that, “If the financial and personnel resources are available, jails are an appropriate place to provide medical care.” Seventy-five percent of jail administrators and 65% of medical personnel agreed that “inmates commonly make unnecessary requests to be seen by medical personnel.” Most jail administrators (67%) responded, “Do not know” to the statement, “If HIV medications are not taken as prescribed, the HIV in one’s body may become resistant to the medications.” Six percent of both jail administrators and medical staff agreed, “In general, dispensing HIV medications in jail is more trouble than it’s worth.” Ninety-three percent of jail administrators and all but one medical staff agreed that, “In general, if an inmate is taking medications in jail, other inmates will know about it.” Fortysix percent of jail administrators but no medical staff endorsed the statement, “Housing HIV-infected inmates endangers the health of other inmates or jail staff.”

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Jail personnel’s perceptions of HIV prevalence in North Carolina jails. We asked jail personnel to estimate the number of HIV-positive inmates incarcerated in their facilities over the previous 6 months. Personnel from 18 facilities responded, “Do not know”; in the remaining 62 facilities, estimates ranged from 0 to 160 (median: 2 or fewer inmates, 75th percentile: 5 or fewer inmates), with estimates from just 12 facilities accounting for 85% of identified HIV-infected inmates. The 6-month HIV facility prevalence across all facilities was 0.48%. We evaluated agreement between medical staff and jail administrators’ estimates of the number of HIV-infected inmates admitted during the previous 6 months by querying a random sample of 9 medical staff who were employed at facilities in which jail administrators had given interviews. At one facility, estimates were substantially different between the jailer (20) and the medical staff (1), and at another facility the jailer responded, “Do not know.” The exclusion of these observations yielded a moderately high correlation (r = 0.85, 95% confidence interval [CI] 0.27– 0.97) between estimates of jail administrators and staff working at the same facility; the coefficient of jailer estimates regressed on medical staff estimates was 0.65 (95% CI 0.20–1.10). For all of the facilities, including the outlier, the correlation coefficient declined to 0.29 (95% CI -0.52–0.82).

Discussion We present the first statewide survey of HIV care practices and attitudes in county jails. The rapid turnover of inmates, lack of an integrated system of health care, and financial pressures faced by individual counties all place unique pressures on the delivery of HIV care in jails compared with its delivery state prison systems. Overall, our data suggest that HIV-infected inmates incarcerated in county jails in this large southeastern state face a number of significant barriers to care. These barriers both limit HIV testing of inmates at risk and discourage inmates already on antiretroviral therapy from getting appropriate treatment while in jail. Many of the risk factors associated with incarceration are also associated with HIV infection, including use of illicit substances and commercial sex work.2,3,11,9,26-28 As a result, the need for medical services available in institutions of incarceration has grown in the era of HIV. Further, several studies demonstrate that these institutions have become an important avenue for inmates to receive health care.26,29,30 Jails and prisons represent an opportunity to test and counsel inmates who are at risk for HIV infection and to provide access to appropriate therapy for those who are HIV-infected. The importance of HIV-infected persons knowing their serostatus and receiving appropriate counseling and therapy has been highlighted recently in a national HIV control strategy.31 Access to non-emergent, high-level medical care may be constrained by the limited availability or absence of physicians. Although the availability of nurses was unexpectedly high, nurses seldom administered initial medical screening questionnaires or distributed medications. In accordance with North Carolina state law, all detention facilities administer a medical screening questionnaire to new inmates upon admission.14 In most facilities, this questionnaire is administered in a common processing area by a detention officer rather than by medical personnel. Of particular concern is the observation

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that a minority of medical screening questionnaires specifically addressed HIV/ AIDS (28%), referring instead to “contagious,” “infectious,” or “sexually transmittable” diseases. Some respondents whose questionnaires used these general terms erroneously believed that questions addressing HIV/AIDS were not permissible by law. Our data suggest that a number of characteristics of the policies prevalent in these county jails are likely to discourage inmates from revealing HIV infection or being tested for HIV. These include the lack of privacy in which these interviews are conducted, the stigmatizing nature of HIV, and the inherently antagonistic relationship between inmates and detention officers. In this setting, a reluctance to address HIV/AIDS specifically in the initial medical screening process may also limit the numbers of inmates who either reveal that they are HIV-infected or request testing. The lack of confidentiality in many facilities may also discourage inmates from receiving medications; 90% of participants agreed with the statement, “If an inmate is taking medications in jail, other inmates will know about it.” Furthermore, in 81% of facilities, detention officers distribute medications, frequently in view of other inmates. Therefore, HIV-infected inmates’ fears of being identified might discourage them from revealing their HIV status to jail staff. Because lapses in adherence may lead to the development of antiviral resistance, we queried jail personnel regarding their understanding of the consequences of nonadherence. When jail administrators were asked if improper adherence to HIV medications could lead to resistance, 67% responded that they did not know. When asked to estimate the number of HIV tests performed in a typical month, respondents from two thirds of facilities said that no tests were performed. As in most correctional facilities,2 respondents from many county facilities reported that HIV testing is a passive process, meaning that inmates must request testing, as opposed to being offered testing. The benefits of properly offering HIV testing for this high-risk group include the opportunity to link HIV-infected inmates to medical care both in jail and in the community,2,6,29 to initiate contact tracing, and to reduce secondary infection.32 These benefits may be offset by logistical barriers such as short incarceration periods and lack of jail health infrastructure, staffing, and space.13 Additionally, costs of testing and subsequent treatment for inmates identified as HIV positive may be overly burdensome to many detention facilities. Despite these barriers, HIV testing and client-centered counseling of jail inmates may prove effective in identifying relatively high proportions of HIV-infected individuals. When inmates who are known by jail staff to be HIV positive are released back into the community, one third of detention facilities make no referral linking inmates to resources that address medical or social needs. In correctional settings, the use of discharge planning for HIV-infected inmates has been associated with reductions in viral loads33 and decreased rates of recidivism.6 Vigilante and co-workers34 found that discharge planning targeting seronegative female prison inmates at high risk for HIV infection reduces recidivism and may reduce high-risk behavior. This study has some limitations, the most obvious of which is that we studied jails in only one state. Furthermore, at 17 facilities, all potential study participants

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refused to be interviewed or could not be contacted after several attempts; conditions at these facilities could be different from those at the 80 participating facilities. Study size constraints limited precision of estimates. Bias may have also occurred when identifying participants within facilities. At each facility we attempted to contact the person responsible for day-to-day operations of the jail. In facilities in which the jail administrator was unavailable or unwilling to respond to our questionnaire, we spoke to the supervising nurse. In nine facilities that were selected randomly, we spoke to both a detention officer and a nurse. Many questions addressed procedures such as medical screening and dispensing of medications that were relevant to the daily duties of both types of respondents. However, accuracy of response to some questions may be duty specific. For example, medical personnel may have more accurate estimates of the number of HIV-positive inmates who are incarcerated. Questions about the number of HIVpositive inmates incarcerated over a 6-month period and the number of HIV tests performed in a month are time sensitive and may be subject to recall bias. Further, our estimates of the number of HIV-infected inmates may be conservative because jail staff may be unaware of HIV-infected inmates who were jailed and released before the health questionnaire could be administered. Finally, these estimates are based on respondents’ impressions as opposed to recall of specific data. Even though our estimate of 6-month HIV prevalence (0.48%) was less than the 1-day prevalence (1.8%) reported in the 1999 Census of Jails17 and the 1-year HIV prevalence estimated from NC DOC data (1.9%),35 none of these estimates are based on comprehensive seroprevalence data. Thus far, little research has focused on access to medical services inside county detention facilities. This survey of North Carolina detention facilities examines several aspects of medical care pertinent to the identification and treatment of HIVinfected inmates. Our results suggest that much of the identified HIV burden within North Carolina county jails is concentrated in a limited number of detention facilities. This identified population may represent only a fraction of all HIV-infected individuals incarcerated in North Carolina county jails. Seroprevalence studies are necessary to better enumerate the HIV burden in county jails to direct medical resources appropriately. Use of rapid HIV tests in conjunction with active testing policies may improve inmate acceptability of HIV testing and may be well suited to this transient high-risk population.36 However, changes in facility policies, particularly those policies related to screening practices and medication distribution, which are commonly inadequate in protecting inmates’ confidentiality, are also essential for identification, treatment, and protection of HIV-infected inmates. In addition, referrals to case managers by jail staff could lead to greater continuity of care as HIV-infected inmates re-enter their communities. Such innovations could benefit both the health of HIV-infected inmates and the health of communities to which they return. It is important to note that many of the issues relevant to HIV infection may also be relevant to other chronic conditions.

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Acknowledgments This work was supported by NIH R01 DA13826-01 to AHK. Technical support was provided by The General Clinical Research Center at the University of North Carolina Hospitals and the University of North Carolina Center for AIDS Research (CFAR), an NIH funded program #9P30 AI 50410-04. The authors thank Nicole Kiziah, Clarence Potter, Paul Stewart, Margaret Wigfall, and Rachel Fischoff for their assistance with this project.

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