HIV/AIDS and other infectious diseases among correctional inmates: transmission, burden, and an appropriate response

Discrimination and psychological distress among recently released male prisoners

Though theoretical perspectives suggest experiences of stigma and discrimination after release may be one pathway through which incarceration leads to poor mental health, little research considers the relationship between discrimination and mental health among former inmates. In this article, data from a sample of men recently released from prison to Oakland or San Francisco, California (N = 172), are used to consider how criminal record discrimination and racial/ethnic discrimination are independently and cumulatively associated with psychological distress. Results indicate that (a) the frequency of criminal record discrimination and racial/ethnic discrimination are similar; (b) both forms of discrimination are independently, negatively associated with psychological distress; and (c) the level of racial/ethnic discrimination does not alter the association between criminal record discrimination and psychological distress. The results highlight that criminal record discrimination is an important social stressor with negative implications for the mental health of previously incarcerated individuals.

Policies and practices in the delivery of HIV services in correctional agencies and facilities: results from a multisite survey

HIV risk is disproportionately high among incarcerated individuals. Corrections agencies have been slow to implement evidence-based guidelines and interventions for HIV prevention, testing, and treatment. The emerging field of implementation science focuses on organizational interventions to facilitate adoption and implementation of evidence-based practices. A survey of correctional agency partners from the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) revealed that HIV policies and practices in prevention, detection, and medical care varied widely, with some corrections agencies and facilities closely matching national guidelines and/or implementing evidence-based interventions. Others, principally attributed to limited resources, had numerous gaps in delivery of best HIV service practices. A brief overview is provided of a new CJ-DATS cooperative research protocol, informed by the survey findings, to test an organization-level intervention to reduce HIV service delivery gaps in corrections.

Initiation of buprenorphine during incarceration and retention in treatment upon release

We report here on a feasibility study of initiating buprenorphine/naloxone prior to release from incarceration and linking participants to community treatment providers upon release. The study consisted of a small number of Rhode Island (RI) prisoners (N = 44) diagnosed with opioid dependence. The study design is a single arm, open-label pilot study with a 6-month follow up interview conducted in the community. However, a natural experiment arose during the study comparing pre-release initiation of buprenorphone/naloxone to initiation post-release. Time to post-release prescriber appointment (mean days) for initiation of treatment outside Rhode Island Department of Corrections (RIDOC) versus inside RIDOC was 8.8 and 3.9, respectively (p = .1). Median post release treatment duration (weeks) for outside RIDOC versus inside RIDOC was 9 and 24, respectively (p = .007). We conclude that initiating buprenorphine/naloxone prior to release from incarceration may increase engagement and retention in community-based treatment.

Psychopathological Dimensions in Substance Abusers with and without HIV/AIDS and Healthy Matched Group

BACKGROUND

Inattention to symptoms of mental disorders and substance abuse in patients with HIV/AIDS and other at-risk groups, may lead to irreversible damages. The purpose of this study was to compare the psychopathological dimensions in substance abusers with and without HIV/AIDS and healthy matched groups.

METHODS

In a cross-sectional and analytical study, selected samples (by available, consecutive, and objective methods) were 43 HIV-positive substance abusers, 49 HIV negative substance abusers under methadone maintenance therapy (MMT) in the counseling clinic of Behavioral Diseases and Addiction Abandonment, and 45 ordinary individuals. All of them were evaluated by matched confounding variables via Symptom Checklist-90-Revised (SCL-90-R).

FINDINGS

Results indicated a significant difference between these groups in the Global Severity Index (GSI), Positive Symptom Distress Index (PSDI), and Positive Symptom Total (PST) (P < 0.001). Two by two the comparison of the three groups from psychopathological dimensions revealed that substance abusers with HIV/AIDS persistently suffer more mental problems in all dimensions compared with healthy individuals (P < 0.05). In addition, in comparison with HIV negative substance abusers, they also suffer more mental problems in other dimensions, including somatization, interpersonal sensitivity, depression, anxiety, phobia, and psychoticism (P < 0.05). Yet, the difference in paranoid ideation, hostility, and obsessive-compulsive cases was insignificant. Two by two, the comparison between healthy individuals and substance abusers without HIV/AIDS showed higher levels of depression and psychoticism in substance abusers (P < 0.05), but no difference in other dimensions.

CONCLUSION

Comorbidity of substance abuse and HIV diagnosis intensify mental disorder symptoms. Moreover, lack of prevention and implementation of appropriate psychological and psychiatric interventions after substance abuse and HIV lead to extended establishment of mental disorder symptoms.

Prevalence and trends of non-medical opioid and other drug use histories among federal correctional inmates in methadone maintenance treatment in Canada

BACKGROUND

The prevalence of illicit drug use among correctional populations is high, and associated with high levels of drug related morbidity risks and harms. The purpose of this study was to examine temporal and regional patterns of illicit drug use among a sample of Canadian federal correctional inmates participating in correctional methadone maintenance treatment (MMT).

METHODS

Socio-demographic and drug use data collected from 1272 male federal offenders admitted to Correctional Service Canada's (CSC) MMT program between 2003 and 2008 were examined. Univariate analyses were conducted on inmates' key demographic and correctional characteristics, pre-MMT opioid use and other problematic drug use, and opioid and injecting use while incarcerated. Bivariate associations on drug use measures across regions and over time were computed.

RESULTS

Prevalence of heroin use decreased, and prevalence of prescription opioid (PO) use increased over the study period. Significant regional differences existed for PO use, specifically for morphine/hydromorphone and oxycodone use. The majority used opioids and injected while incarcerated, with overall downward trends over time and regional variations. Approximately half the sample indicated a history of lifetime non-opioid problematic drug use, most commonly cocaine (72%) for which substantial regional differences were found.

CONCLUSIONS

Pre-MMT opioid and other problematic non-opioid drug use in the sample was high. Temporal and regional patterns of drug use observed may reflect developments in the general population, e.g. increasing PO misuse. The observed drug use patterns underscore the need for targeted drug specific prevention/treatment measures in correctional environments beyond existing interventions.

A randomized trial of methadone initiation prior to release from incarceration

Individuals who use heroin and illicit opioids are at high risk for infection with human immunodeficiency virus (HIV) and other blood-borne pathogens, as well as incarceration. The purpose of the randomized trial reported here is to compare outcomes between participants who initiated methadone maintenance treatment (MMT) prior to release from incarceration, with those who were referred to treatment at the time of release. Participants who initiated MMT prior to release were significantly more likely to enter treatment postrelease (P < .001) and for participants who did enter treatment, those who received MMT prerelease did so within fewer days (P = .03). They also reported less heroin use (P = .008), other opiate use (P = .09), and injection drug use (P = .06) at 6 months. Initiating MMT in the weeks prior to release from incarceration is a feasible and effective way to improve MMT access postrelease and to decrease relapse to opioid use.

Prevalence and correlates of HCV, HVB, and HIV infection among prison inmates and staff, Hungary

The aim of this national, multicenter, cross-sectional study was to assess the prevalence of hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency viruses (HIV) among prisoners, and to identify related risk behaviors including injection drug use. Overall, 4,894 inmates from 20 prisons were enrolled. To have a comparison group, prison staff were also asked to take part. Altogether, 1,553 of the 4,894 inmates from seven prisons completed a questionnaire on risk behaviors. According to the survey, 1.5%, 4.9%, and 0.04% of the prisoners were tested positive for HBsAg, anti-HCV and anti-HIV, respectively. These prevalence data are among the lowest reported from prisons worldwide, although comparable to the Central European data. The prevalence of HBV, HCV, and HIV in the Hungarian prison staff was low (0.38%, 0.47%, and 0%, respectively). The rate of HCV infection was significantly higher among inmates who have ever injected drugs (22.5%) than among inmates who reported they had never injected drugs (1.1%). This first prevalence study of illegal drug injection-related viral infections among Hungarian prisoners points out that ever injecting drugs is the main reason for HCV infection among inmates. The opportunity to reach drug users infected with HCV for treatment underlines the importance of screening programs for blood-borne viruses in prisons.

Health disparities and the criminal justice system: an agenda for further research and action

Although racial and ethnic minorities are more likely to be involved with the criminal justice system than whites in the U.S.A., critical scientific gaps exist in our understanding of the relationship between the criminal justice system and the persistence of racial/ethnic health disparities. Individuals engaged with the criminal justice system are at risk for poor health outcomes. Furthermore, criminal justice involvement may have direct or indirect effects on health and health care. Racial/ethnic health disparities may be exacerbated or mitigated at several stages of the criminal justice system. Understanding and addressing the health of individuals involved in the criminal justice system is one component of a comprehensive strategy to reduce population health disparities and improve the health of our urban communities.

HIV-related research in correctional populations: now is the time

The incarcerated population has increased to unprecedented levels following the 1970 US declaration of war on illicit drug use. A substantial proportion of people with or at risk for HIV infection, including those with substance use and mental health disorders, have become incarcerated. The overlapping epidemics of incarceration and HIV present a need for academic medical centers to collaborate with the criminal justice system to improve the health of incarcerated populations. With coordinated collaboration and new programmatic initiatives it is possible to reduce HIV-associated risk behaviors and the likelihood of acquisition and transmission of HIV. Centers for AIDS Research (CFAR), funded by the National Institutes of Health, have proactively responded to this need through Collaboration on HIV in Corrections (CHIC) to improve the diagnosis, treatment, linkage to care, and prevention of HIV. This collaboration serves as a model for aligning academic expertise with criminal justice to confront this challenge to individual and public health. This is especially relevant given recent evidence of the effectiveness of antiretroviral therapy in reducing HIV transmission.

Public health and the epidemic of incarceration

An unprecedented number of Americans have been incarcerated in the past generation. In addition, arrests are concentrated in low-income, predominantly nonwhite communities where people are more likely to be medically underserved. As a result, rates of physical and mental illnesses are far higher among prison and jail inmates than among the general public. We review the health profiles of the incarcerated; health care in correctional facilities; and incarceration's repercussions for public health in the communities to which inmates return upon release. The review concludes with recommendations that public health and medical practitioners capitalize on the public health opportunities provided by correctional settings to reach medically underserved communities, while simultaneously advocating for fundamental system change to reduce unnecessary incarceration.

The use of prisoners as sources of organs--an ethically dubious practice

The movement to try to close the ever-widening gap between demand and supply of organs has recently arrived at the prison gate. While there is enthusiasm for using executed prisoners as sources of organs, there are both practical barriers and moral concerns that make it unlikely that proposals to use prisoners will or should gain traction. Prisoners are generally not healthy enough to be a safe source of organs, execution makes the procurement of viable organs difficult, and organ donation post-execution ties the medical profession too closely to the act of execution.

Injection risk behaviors among rural drug users: implications for HIV prevention

OBJECTIVE

The purpose of this study was to examine injection drug use (IDU) among a cohort of felony probationers from rural Appalachian Kentucky.

METHODS

An interviewer-administered questionnaire given to 800 rural felony probationers ascertained data regarding demographics, drug use, criminal behavior, psychological distress, and HIV-risk behaviors.

RESULTS

The sample was primarily white (95.1%) and male (66.5%) and the median age was 32.3 years (interquartile range: 25.2, 40.5). There were no cases of HIV in the sample. Of the 800 rural probationers, 179 (22.4%) reported lifetime IDU. Receptive syringe sharing (RSS) and distributive syringe sharing (DSS) were reported by 34.5% and 97.1% of the IDUs, respectively. Independent correlates of risky injection behaviors included cocaine injection (adjusted odds ratio (AOR): 14.9, 95% confidence interval (CI): 8.0, 27.7) and prescription opioid injection (AOR: 14.7, 95% CI: 7.7, 28.1).

DISCUSSION

Although HIV was not prevalent, data suggest that the rural felony probationers in this sample were engaging in risky injection practices that could facilitate transmission of HIV. This is especially problematic since those involved in the criminal justice system may be more likely to be exposed to HIV. Therefore, prevention aimed at reducing HIV-risk behaviors among rural, criminally involved individuals is warranted.

Results of a pilot study of pre-release STD testing and inmates' risk behaviors in an Ohio prison

This study presents the results of a pilot study of mandatory pre-release testing for sexually transmitted disease (STD) and a behavioral risk survey for male inmates at an Ohio prison. Approximately 4-6 weeks prior to scheduled release, inmates took part in a mandatory blood test and optional genital swab and physical examination to test for STDs. At the time of testing, a voluntary behavioral and knowledge survey was administered to inmates. Pre-release testing identified 53 new cases of STDs among the 916 inmates (5.5%) scheduled for release during the pilot study period. Trichomoniasis and hepatitis C were the most common infections identified through pre-release testing. Nearly all inmates participated in the required blood test. Participation rates for the other testing methods averaged less than 45%. Inmates reported engaging in various risky behaviors during incarceration such as having sex (12.1%), tattooing (36.5%), and drug use (19.5%). Pre-release testing identified several new cases of STDs not identified through existing intake and for-cause testing procedures. Substantial useful information about the prevalence of STD risk behaviors can be obtained through a pre-release survey.

Dose-response effect of incarceration events on nonadherence to HIV antiretroviral therapy among injection drug users

BACKGROUND

Although some studies have identified impressive clinical gains for incarcerated HIV-seropositive injection drug users (IDUs) undergoing antiretroviral therapy (ART), the effect of incarceration on adherence to ART remains undetermined.

METHODS

We used data from a long-term community-recruited cohort of HIV-seropositive IDUs, including comprehensive ART dispensation records, in a setting where HIV care is free. We estimated the relationship between the cumulative burden of incarceration, measured longitudinally, and the odds of < 95% adherence to ART, with use of multivariate modeling.

RESULTS

From 1996 through 2008, 490 IDUs were recruited and contributed 2220 person-years of follow-up; 271 participants (55.3%) experienced an incarceration episode, with the number of incarcerations totaling 1156. In a multivariate model, incarceration had a strong dose-dependent effect on the likelihood of nonadherence to ART: 1-2 incarceration events (adjusted odds ratio [AOR], 1.49; 95% confidence interval [95% CI], 1.03-2.05), 3-5 events (AOR, 2.48; 95% CI, 1.62-3.65), and > 5 events (AOR, 3.11; 95% CI, 1.86-4.95).

CONCLUSIONS

Among HIV-seropositive IDUs receiving ART, an increasing burden of incarceration was associated with poorer adherence in a dose-dependent fashion. Our findings support improved adherence support for HIV-seropositive IDUs experiencing incarceration.

Behind the Bars of Paradise: HIV and Substance Use among Incarcerated Populations in Puerto Rico

For those who are incarcerated in jails and prisons, the correctional setting represents a unique context for health care access and utilization. In Puerto Rico, over 16 000 persons pass each year through a correctional facility, approximately 6.9% of the incarcerated population present HIV infection, and 73.8% and 27.1% evidence a previous history of drug and alcohol use, respectively. In addition, HIV-infected populations have comorbidity with other diseases that are associated with substance use. Several approaches have been considered to prevent, treat, and provide a continuum of care for HIV and substance disorders among incarcerated populations. Nearly 30 years of legally regulated practices for correctional health care have produced recommendations for addressing the needs of those with HIV and substance disorders within the correctional facilities in Puerto Rico. These recommendations include making prevention services available, building capacity among health care providers, and understanding the cultural and political contexts.

The health of prisoners

More than 10 million people are incarcerated worldwide; this number has increased by about a million in the past decade. Mental disorders and infectious diseases are more common in prisoners than in the general population. High rates of suicide within prison and increased mortality from all causes on release have been documented in many countries. The contribution of prisons to illness is unknown, although shortcomings in treatment and aftercare provision contribute to adverse outcomes. Research has highlighted that women, prisoners aged 55 years and older, and juveniles present with higher rates of many disorders than do other prisoners. The contribution of initiatives to improve the health of prisoners by reducing the burden of infectious and chronic diseases, suicide, other causes of premature mortality and violence, and counteracting the cycle of reoffending should be further examined.

Understanding the health needs of incarcerated men living with HIV/AIDS: a primary health care approach

Nearly 20% of American men with HIV/AIDS pass through a correctional facility each year. As these men pass through the criminal justice system, discontinuation of health care access and nonadherence to prescribed treatments often occur. Men who are not engaged in health care during and after incarceration are at risk for treatment interruption and disease progression. Correctional facilities are therefore important sites for secondary prevention of HIV/AIDS. Unprecedented scientific attention and resources are currently directed at detecting and treating HIV in the criminal justice system. To support these efforts to increase health care access, we must have a better understanding of the cultural and situational factors that structure opportunities for secondary prevention during incarceration and during the transition from correctional facilities back into the community. This article presents a timely review of the literature on the health needs of incarcerated men living with HIV/AIDS. The author uses the primary health care framework to describe the movement of HIV-positive men through the criminal justice system as a series of strategic opportunities to initiate and establish a process of care. The author concludes that although we understand many of the challenges of providing care to men who become incarcerated, and have evidence of effective health-promoting services, we are only beginning to understand how to make health care services accessible and acceptable to HIV-positive male inmates, and we have not yet used some proven HIV prevention tools.

Characterizing medical providers for jail inmates in New York State

OBJECTIVES

People who are incarcerated exhibit high rates of disease, but data evaluating the delivery of medical services to inmates are sparse, particularly for jail settings. We sought to characterize the primary medical care providers for county jail inmates in New York State.

METHODS

From 2007 through 2009, we collected data on types of medical care providers for jail inmates in all New York State counties. We obtained data from state monitoring programs and e-mail questionnaires sent to county departments of health.

RESULTS

In counties outside New York City (n = 57), jail medical care was delivered by local providers in 40 counties (70%), correctional medical corporations in 8 counties (14%), and public providers in 9 counties (16%). In New York City, 90% of inmates received medical care from a correctional medical corporation. Larger, urban jails, with a greater proportion of Black and Hispanic inmates, tended to use public hospitals or correctional medical corporations as health care vendors.

CONCLUSIONS

Jail medical services in New York State were heterogeneous and decentralized, provided mostly by local physician practices and correctional medical corporations. There was limited state oversight and coordination of county jail medical care.

HIV in the epicenter of the epicenter: HIV and drug use among criminal justice populations in New York City, 1980-2007

During the 1990s, some of the highest rates of HIV infection in the United States were found among inmates in the New York City jail and prisons systems. This article traces the history of drug use and HIV infection among populations incarcerated in New York City jails and New York State prisons between 1980 and 2007. It describes and analyzes the policies and programs that were initiated to respond to these epidemics and assesses the lessons learned from almost three decades of experience with HIV among populations in New York's correctional facilities.

HIV and hepatitis B and C incidence rates in US correctional populations and high risk groups: a systematic review and meta-analysis

BACKGROUND

High Human Immunodeficiency Virus (HIV) prevalence and high risk behaviors have been well documented within United States (US) correctional systems. However, uncertainty remains regarding the extent to which placing people in prison or jail increases their risk of HIV infection, and regarding which inmate populations experience an increased incidence of HIV. Describing these dynamics more clearly is essential to understanding how inmates and former detainees may be a source for further spread of HIV to the general US population.

METHODS

The authors conducted a systematic review and meta-analysis of studies describing HIV incidence in US correctional facility residents and, for comparison, in high risk groups for HIV infection, such as non-incarcerated intravenous drug users (IVDU) and men who have sex with men (MSM) in the US. HIV incidence rates were further compared with Hepatitis B and Hepatitis C Virus rates in these same populations.

RESULTS

Thirty-six predominantly prospective cohort studies were included. Across all infection outcomes, continuously incarcerated inmates and treatment recruited IVDU showed the lowest incidence, while MSM and street recruited IVDU showed the highest. HIV incidence was highest among inmates released and re-incarcerated. Possible sources of heterogeneity identified among HIV studies were risk population and race.

CONCLUSIONS

Although important literature gaps were found, current evidence suggests that policies and interventions for HIV prevention in correctional populations should prioritize curtailing risk of infection during the post-release period. Future research should evaluate HIV incidence rates in inmate populations, accounting for proportion of high risk sub-groups.

Opportunities to diagnose, treat, and prevent HIV in the criminal justice system

Persons involved with the criminal justice system are at risk for HIV and other transmissible diseases due to substance use and related risk behaviors. Incarceration provides a public health opportunity to test for HIV, viral hepatitis, and other sexually transmitted infections, provide treatment such as highly active antiretroviral therapy, and link infected persons to longitudinal comprehensive HIV care upon their release for such comorbidities as addiction and mental illness. Delivering health interventions inside prisons and jails can be challenging, yet the challenges pale in comparison to the benefits of interventions for inmates and their communities. This article reviews the current state of delivering HIV testing, prevention, treatment, and transition services to incarcerated populations in the United States. It concludes with summary recommendations for research and practice to improve the health of inmates and their communities.

The effect of incarceration on urban fathers' health

This study examines the effects of incarceration on the health of urban fathers. Using the Fragile Families and Child Well-Being Study, which surveys parents in 20 large U.S. cities across the country, the relationship between fathers' incarceration patterns and health status was examined while controlling for poor preexisting health and individual impulsivity. Findings indicate that fathers who have previously been incarcerated at some time are markedly more likely to rely on medications for physical or mental health problems, whereas recently incarcerated repeat offenders have reduced odds of being in poor health relative to those who have never been to prison. Improvements in health among recently incarcerated repeat offenders relative to those who have not been incarcerated may be related to prison health care and the overall disadvantaged circumstances of these fathers.

Treatment of medical, psychiatric, and substance-use comorbidities in people infected with HIV who use drugs

HIV-infected drug users have increased age-matched morbidity and mortality compared with HIV-infected people who do not use drugs. Substance-use disorders negatively affect the health of HIV-infected drug users, who also have frequent medical and psychiatric comorbidities that complicate HIV treatment and prevention. Evidence-based treatments are available for the management of substance-use disorders, mental illness, HIV and other infectious complications such as viral hepatitis and tuberculosis, and many non-HIV-associated comorbidities. Tuberculosis co-infection in HIV-infected drug users, including disease caused by drug-resistant strains, is acquired and transmitted as a consequence of inadequate prescription of antiretroviral therapy, poor adherence, and repeated interfaces with congregate settings such as prisons. Medication-assisted therapies provide the strongest evidence for HIV treatment and prevention efforts, yet are often not available where they are needed most. Antiretroviral therapy, when prescribed and adherence is at an optimum, improves health-related outcomes for HIV infection and many of its comorbidities, including tuberculosis, viral hepatitis, and renal and cardiovascular disease. Simultaneous clinical management of multiple comorbidities in HIV-infected drug users might result in complex pharmacokinetic drug interactions that must be adequately addressed. Moreover, interventions to improve adherence to treatment, including integration of health services delivery, are needed. Multifaceted, interdisciplinary approaches are urgently needed to achieve parity in health outcomes in HIV-infected drug users.

HIV treatment in US prisons

Arguably one of the most marginalized populations in our society, prisoners bear a disproportionate burden of infectious diseases, particularly HIV. In addition, groups known to be at an inordinately higher risk of HIV, including minorities, the addicted, the mentally ill and the impoverished are overrepresented among incarcerated populations. This concentration of HIV among groups that have been historically difficult to reach, with limited intersections with healthcare, provides an opportunity for testing, diagnosis, treatment, linkage to care and prevention. Providing HIV care within correctional facilities poses unique challenges. Barriers to confidentiality, access to medication and prior records, and lack of comprehensive discharge planning can serve as obstacles to providing optimal care. This article discusses the public health implications and importance of providing HIV care to prisoners, and also discusses the practicalities of working within an environment that poses particular barriers to care.

Seroepidemiology of viral hepatitis, HIV and herpes simplex type 2 in the household population aged 21-64 years in Puerto Rico

BACKGROUND

Viral hepatitis and sexually transmitted infections (STIs) are key public health problems that pose an enormous risk for disease transmission in the general population. This study estimated, for the first time, prevalence estimates of serologic markers of HCV, HBV, HAV, HIV and HSV-2 in the adult population of Puerto Rico and assessed variations across sociodemographic and behavioral characteristics.

METHODS

A seroepidemiologic survey was employed using a stratified cluster probability sample of households in Puerto Rico. Participants completed a face-to-face interview, a self-administered questionnaire using an ACASI system, and provided blood specimens for antibody testing. Prevalence estimates of viral hepatitis, HIV and HSV-2 were estimated using a logistic regression model weighting for the probability of participation in each household block and the inverse of the probability of selection according to geographic strata, households' blocks, and sex distribution.

RESULTS

A total of 1,654 adults participated in the study. Seroprevalence estimates for HCV (2.3%, 95% CI: 1.3%-4.2%), HBV (3.1%, 95% CI: 2.0%-4.7%), and HSV-2 (22.3%, 95% CI: 18.5%-26.7%) in Puerto Rico are roughly in agreement with estimates obtained in the US population; however, HAV (41.3%, 95% CI: 36.9%-45.8%) and HIV (1.1%, 95% CI: 0.5%-2.3%) seroprevalence estimates in Puerto Rico were higher. The proportion of individuals that were unaware of their serostatus was as follows: 80% for HCV, 98.3% for HBV, 96.4% for HAV, 36.4% for HIV, and 97.8% for HSV-2. Post-stratification estimates of seroprevalence varied significantly by demographic and risk related characteristics.

CONCLUSION

This data underscore the disproportionate impact of some viral infections across selected population subgroups in Puerto Rico. A concerted island-wide effort is needed to strengthen viral hepatitis and STIs prevention and control strategies, support surveillance to monitor chronic infections, and ensure appropriate counseling, testing, and medical management of infected persons. Integration of HCV, HBV, and HSV-2 counseling into HIV existing prevention services and outreach through social networks might represent a valuable approach to reach high-risk individuals.

Viral hepatitis B, C and HIV infection in Croatian prisons

Incarcerated persons comprise about 0.4% of the Croatian population, of whom 25-30% misuse drugs. We attempted to determine the structure of the prison population, prevalence of HBV, HCV, HIV markers, co-infections with HBV, HCV and HIV and acute HBV, HCV and HIV infection. In total, 25.9% of prisoners were positive for some markers for viral hepatitis (HBV 11.3%, HCV 8.3%, HBV/HCV 6.3%). Prevalence of HBV infection in intravenous drug users (IDUs) was 26.2% (highly promiscuous group 20.4%, individuals with psychiatric diseases and personality disorders 16.0%). HCV infection in IDUs was 52.0% and 4.9% in the highly promiscuous group. HBV/HCV co-infection was registered in 34.9% of prisoners positive for HBV markers (203/582). Acute HBV infection was detected in 0.5%, and HCV in 1.2%. Only 0.15% (5/3348) of prisoners were anti-HIV positive. It appears that individuals with psychiatric diseases and personality disorders could be an additional risk population for these viral infections.

New opportunities for the management and therapy of hepatitis C in correctional settings

Hepatitis C in prison populations is now a major public health problem, and large numbers of correctional facilities have no comprehensive management program, often because of formidable projected costs and tightening budget constraints. The North Dakota Department of Corrections and Rehabilitation has operated a management and therapy program since 2002 using consensus interferon and ribavirin with 45% cost savings. The program has provided excellent sustained viral responses: 54.2% for genotype 1 hepatitis C, 75% for genotypes 2 and 3, and 63.6% overall.

Methadone and buprenorphine prescribing and referral practices in US prison systems: results from a nationwide survey

BACKGROUND

More than 50% of incarcerated individuals have a history of substance use, and over 200,000 individuals with heroin addiction pass through American correctional facilities annually. Opiate replacement therapy (ORT) with methadone or buprenorphine is an effective treatment for opiate dependence and can reduce drug-related disease and recidivism for inmates. Provision of ORT is nevertheless a frequently neglected intervention in the correctional setting.

OBJECTIVE AND METHODS

We surveyed the 50 state; Washington, District of Columbia (DC); and Federal Department of Corrections' medical directors or their equivalents about their facilities' ORT prescribing policies and referral programs for inmates leaving prison.

RESULTS

We received responses from 51 of 52 prison systems nationwide. Twenty-eight prison systems (55%) offer methadone to inmates in some situations. Methadone use varies widely across states: over 50% of correctional facilities that offer methadone do so exclusively for pregnant women or for chronic pain management. Seven states' prison systems (14%) offer buprenorphine to some inmates. The most common reason cited for not offering ORT was that facilities "prefer drug-free detoxification over providing methadone or buprenorphine." Twenty-three states' prison systems (45%) provide referrals for some inmates to methadone maintenance programs after release, which increased from 8% in 2003; 15 states' prison systems (29%) provide some referrals to community buprenorphine providers.

CONCLUSION

Despite demonstrated social, medical, and economic benefits of providing ORT to inmates during incarceration and linkage to ORT upon release, many prison systems nationwide still do not offer pharmacological treatment for opiate addiction or referrals for ORT upon release.

The impact of antiretroviral therapy in a cohort of HIV infected patients going in and out of the San Francisco county jail

Background

Jails are an important venue of HIV care and a place for identification, treatment and referral for care. HIV infected inmates in the San Francisco County jail are offered antiretroviral treatment (ART), which many take only while in jail. We evaluated the effect of ART administration in a cohort of jail inmates going in and out of jail over a nine year period.

Methodology/Principal Findings

In this retrospective study, we examined inmates with HIV going in and out of jail. Inmates were categorized by patterns of ART use: continuous ART - ART both in and out of jail, intermittent ART - ART only in jail; never on ART - eligible by national guidelines, but refused ART. CD4 and HIV viral load (VL) were compared over time in these groups. Over a 9 year period, 512 inmates were studied: 388 (76%) on intermittent ART, 79 (15%) on continuous ART and 45(9%) never-on ART. In a linear mixed model analysis, inmates on intermittent ART were 1.43; 95%CI (1.03, 1.99) times and those never on ART were 2.89; 95%CI (1.71, 4.87) times more likely to have higher VL than inmates on continuous ART. Furthermore, Inmates on intermittent ART and never-on ART lost 1.60; 95%CI (1.06, 2.13) and 1.97; 95%CI (0.96, 3.00) more CD4 cells per month, respectively, compared to continuously treated inmates. The continuous ART inmates gained 0.67CD4 cells/month.

Conclusions/Significance

Continuous ART therapy in jail inmate's benefits CD4 cell counts and control of VL especially compared to those who never took ART. Although jail inmates on intermittent ART were more likely to lose CD4 cells and experience higher VL over time than those on continuous ART, CD4 cell loss was slower in these inmates as compared to inmates never on ART. Further studies are needed to evaluate whether or not intermittent ART provides some benefit in outcome if continuous ART is not possible or likely.

Using arrest charge to screen for undiagnosed HIV infection among new arrestees: a study in Los Angeles County

Despite high documented HIV prevalence, few jail systems offer universal HIV screening, nor is this always feasible. The authors evaluated undiagnosed HIV infection and HIV risk history by arrest charge among 1,322 new arrestees to examine whether specific charges may help prioritize jail-based screening. Undiagnosed HIV prevalence was 2.7% and 1.0% among males and females, with 32% and 45% reporting recent STD diagnoses or high-risk behaviors for HIV. HIV risk history distinguished HIV-infected males but not females. Males with parole violation, sex, or theft charges had high undiagnosed HIV infection rates relative to other males. A weaker trend was observed for females with parole violation, drug, or violent charges. These charges represented 30% and 66% of males and females studied and 56% and 100% of their undiagnosed HIV infections, respectively. Using arrest charge to target screening may efficiently increase HIV diagnosis in jail inmates where universal HIV screening is not possible.

Sexually transmitted diseases and incarceration

PURPOSE OF REVIEW

To summarize recent literature on the prevalence and burden of sexually transmitted diseases (STDs) - focusing on syphilis, chlamydia, and gonorrhea - among adult correctional inmates and detained juveniles. The review is largely limited to US settings.

RECENT FINDINGS

The prevalence is higher and the consequences of STDs are generally more severe for incarcerated women than men. Chlamydia and gonorrhea may be more prevalent among confined juveniles than among incarcerated adults, whereas syphilis is probably more prevalent among adults. The opportunity exists to provide effective STD prevention, screening, and treatment to seriously affected and underserved correctional populations, thus benefiting patients and their partners as well as the larger public health. Substantial research shows how screening might be targeted to be most cost-effective. Few correctional systems, however, have implemented the STD screening and treatment programs needed to take full advantage of this public health opportunity. Moreover, few systems have adopted condom provision for inmates, in the face of clear evidence that high-risk sexual activity occurs in correctional settings.

SUMMARY

The clinical tools are available to improve STD prevention, screening, and treatment in correctional facilities. However, more research and advocacy is needed to convince decision makers of the importance of committing the necessary resources and adopting the policies needed to close the gap between opportunity and reality in correctional STD programs.

Early initiation of antiretroviral therapy results in decreased morbidity and mortality among patients with TB and HIV

Introduction

The overlapping drug toxicity profiles, drug-drug interactions and complications of management of both HIV and tuberculosis (TB) in patients with advanced HIV have not been fully delineated.

Methods

We conducted a retrospective chart review of the outcomes of tuberculosis treatment among 69 HIV-infected patients with TB, who were hospitalized in Masih Daneshvari Hospital in Tehran, Iran between 2002 and 2006, and who received standard category 1 (CAT-1) regimens. Group I (N = 47) included those treated from 2002 to 2005 with highly active antiretroviral therapy (HAART) initiated after eight weeks of TB treatment for those whose CD4 count was <200 cells/mm³. Group II (N = 22) included TB patients treated from 2005 to 2006, with HAART initiated after two weeks of TB treatment if their CD4 count was <100 cells/mm³ and eight weeks after initiation of TB treatment for those whose CD4 count was between 101 and 200 cells/mm³.

Results

There were no differences between Groups I and II with regard to: adverse drug reactions [four (8.5%) versus two (9%), p = ns]; IRIS [six (12.7%) versus three (10.7%), p = ns]; and new opportunistic infections [eight (17.0%) versus two (9.1%), p = ns]. Death, however, occurred more frequently in Group I than in Group II [13 (27.7%) versus (4.5%), p = 0.03], where HAART was initiated earlier. Injection of drugs was the most common route of HIV transmission in both groups (72.3% in Group I and 77.3% in Group II).

Conclusion

This manuscript shows that in a retrospective review of HIV/TB patients hospitalized in Tehran, improved survival was associated with earlier initiation of antiretroviral therapy in HIV/TB patients with CD4 counts of below 100 cells/mm³.

Gender-specific correlates of incarceration among marginally housed individuals in San Francisco

OBJECTIVES

We assessed how different patterns of housing instability affect incarceration and whether correlates of incarceration are gender specific.

METHODS

We used multivariate logistic regression to assess associations between patterns of housing instability and recent jail stays among a reproducible sample of 1175 marginally housed adults in San Francisco, California.

RESULTS

Over the previous year, 71% of men and 21% of women in the sample reported jail stays. Among women, long-term single-room occupancy hotel stays ( > 90 days) were protective for incarceration. Stays in the street were associated with incarceration among both genders, but among men, short-term (i.e., <or= 90 days) street stays were associated with the highest odds of incarceration, and among women, long-term street stays were most correlated with incarceration. Sex trade increased the odds of incarceration among men only; recent drug use was associated with incarceration among both genders.

CONCLUSIONS

Correlates of incarceration differed by gender, and patterns of housing instability differentially affected incarceration for men and women. Policies to improve housing options and drug treatment for the urban poor are critical to breaking the cycle of incarceration and homelessness and improving health outcomes.

HIV transmission in a state prison system, 1988-2005

INTRODUCTION

HIV prevalence among state prison inmates in the United States is more than five times higher than among nonincarcerated persons, but HIV transmission within U.S. prisons is sparsely documented. We investigated 88 HIV seroconversions reported from 1988-2005 among male Georgia prison inmates.

METHODS

We analyzed medical and administrative data to describe seroconverters' HIV testing histories and performed a case-crossover analysis of their risks before and after HIV diagnosis. We sequenced the gag, env, and pol genes of seroconverters' HIV strains to identify genetically-related HIV transmission clusters and antiretroviral resistance. We combined risk, genetic, and administrative data to describe prison HIV transmission networks.

RESULTS

Forty-one (47%) seroconverters were diagnosed with HIV from July 2003-June 2005 when voluntary annual testing was offered. Seroconverters were less likely to report sex (OR [odds ratio] = 0.02, 95% CI [confidence interval]: 0-0.10) and tattooing (OR = 0.03, 95% CI: <0.01-0.20) in prison after their HIV diagnosis than before. Of 67 seroconverters' specimens tested, 33 (49%) fell into one of 10 genetically-related clusters; of these, 25 (76%) reported sex in prison before their HIV diagnosis. The HIV strains of 8 (61%) of 13 antiretroviral-naïve and 21 (40%) of 52 antiretroviral-treated seroconverters were antiretroviral-resistant.

DISCUSSION

Half of all HIV seroconversions were identified when routine voluntary testing was offered, and seroconverters reduced their risks following their diagnosis. Most genetically-related seroconverters reported sex in prison, suggesting HIV transmission through sexual networks. Resistance testing before initiating antiretroviral therapy is important for newly-diagnosed inmates.

Viral hepatitis in incarcerated adults: a medical and public health concern

Viral hepatitis is a common problem in the incarcerated population. It causes significant morbidity and mortality, and incarcerated inmates receive their health care almost exclusively from corrections-based health systems. The seroprevalence of hepatitis B and C infections is increased in this population, and a number of risk factors for viral hepatitis are particularly common and infer higher risk among inmates, including injection drug use (IDU), high-risk sexual activity, and tattoos. IDU, in particular, has been identified as an important and common risk factor for viral hepatitis in inmates, and variable rates of IDU among inmates have been found to be the most important cause of the marked variability of seroprevalence rates for exposure to hepatitis C virus. A number of risk reduction and management strategies have been identified that can decrease transmission to other inmates. Prison-based hepatitis A and hepatitis B vaccination programs, needle exchange programs, methadone maintenance programs, risk education programs, and hepatitis C virus antiviral programs, for example, have been shown to be safe and effective risk reduction and management strategies. Preliminary studies have shown that these strategies are underutilized in the United States. Reasons for this phenomenon are multifactorial, involving financial as well as ethical and political considerations. Additional funding, research, and formal consideration / discussion of the complex issues involving viral hepatitis in the US incarcerated population are clearly important for the sake of inmates and the community at large. In this article, the published medical literature regarding this important topic is reviewed.

Prison health and public health responses at a regional prison in Western Australia

OBJECTIVE

To describe the health of inmates in a Western Australian regional prison and evaluate the coverage of public health interventions.

DESIGN

Cross-sectional audit of all paper-based and electronic medical notes of inmates at one regional prison in Western Australia.

SETTING

A mixed medium-security prison in regional Western Australia.

PARTICIPANTS

185 prisoners, 170 men and 15 women.

MAIN RESULTS

The prisoners were mainly young (70% < 35 years of age) and Indigenous (84%). Fifty two percent of prisoners had at least one chronic health condition. There was a significantly higher prevalence of diabetes to that found in the general Indigenous population (15% vs 6% p=0.001), and a significantly lower prevalence hepatitis C (4.5%) compared with both national (29-61%) and State (20%) data. Screening for sexually transmitted infections and blood borne viruses within the first month of incarceration was achieved for 43% of inmates. Vaccination coverage for influenza (36%) and pneumococcal disease (12%) was low.

CONCLUSION

This study makes visible the burden of disease and reach of public health interventions within a largely Indigenous regional prisoner population. Our study demonstrates that the additional risks associated with being Indigenous remain in a regional Australian prison but also shows that interventions can be delivered equitably to Indigenous and non-Indigenous inmates.

IMPLICATIONS

Ongoing monitoring of prisoner health is critical to take advantage of opportunities to improve public health interventions with timely STI and BBV screening and increased vaccinations rates.

Estimating the prevalence of injection drug use among black and white adults in large U.S. metropolitan areas over time (1992--2002): estimation methods and prevalence trends

No adequate data exist on patterns of injection drug use (IDU) prevalence over time within racial/ethnic groups in U.S. geographic areas. The absence of such prevalence data limits our understanding of the causes and consequences of IDU and hampers planning efforts for IDU-related interventions. Here, we (1) describe a method of estimating IDU prevalence among non-Hispanic Black and non-Hispanic White adult residents of 95 large U.S. metropolitan statistical areas (MSAs) annually over an 11-year period (1992--2002); (2) validate the resulting prevalence estimates; and (3) document temporal trends in these prevalence estimates. IDU prevalence estimates for Black adults were calculated in several steps: we (1) created estimates of the proportion of injectors who were Black in each MSA and year by analyzing databases documenting injectors' encounters with the healthcare system; (2) multiplied the resulting proportions by previously calculated estimates of the total number of injectors in each MSA and year (Brady et al., 2008); (3) divided the result by the number of Black adults living in each MSA each year; and (4) validated the resulting estimates by correlating them cross-sectionally with theoretically related constructs (Black- and White-specific prevalences of drug-related mortality and of mortality from hepatitis C). We used parallel methods to estimate and validate White IDU prevalence. We analyzed trends in the resulting racial/ethnic-specific IDU prevalence estimates using measures of central tendency and hierarchical linear models (HLM). Black IDU prevalence declined from a median of 279 injectors per 10,000 adults in 1992 to 156 injectors per 10,000 adults in 2002. IDU prevalence for White adults remained relatively flat over time (median values ranged between 86 and 97 injectors per 10,000 adults). HLM analyses described similar trends and suggest that declines in Black IDU prevalence decelerated over time. Both sets of IDU estimates correlated cross-sectionally adequately with validators, suggesting that they have acceptable convergent validity (range for Black IDU prevalence validation: 0.27 < r < 0.61; range for White IDU prevalence: 0.38 < r < 0.80). These data give insight, for the first time, into IDU prevalence trends among Black adults and White adults in large U.S. MSAs. The decline seen here for Black adults may partially explain recent reductions in newly reported cases of IDU-related HIV evident in surveillance data on this population. Declining Black IDU prevalence may have been produced by (1) high AIDS-related mortality rates among Black injectors in the 1990s, rates lowered by the advent of HAART; (2) reduced IDU incidence among Black drug users; and/or (3) MSA-level social processes (e.g., diminishing residential segregation). The stability of IDU prevalence among White adults between 1992 and 2002 may be a function of lower AIDS-related mortality rates in this population; relative stability (and perhaps increases in some MSAs) in initiating IDU among White drug users; and social processes. Future research should investigate the extent to which these racial/ethnic-specific IDU prevalence trends (1) explain, and are explained by, recent trends in IDU-related health outcomes, and (2) are determined by MSA-level social processes.

Highly active antiretroviral therapy use and HIV transmission risk behaviors among individuals who are HIV infected and were recently released from jail

We evaluated highly active anti-retroviral therapy (HAART) use and risk behaviors among 177 inmates who were HIV infected and were released and reincarcerated in San Francisco, Calif, jails over a 12-month period. During the month preceding reincarceration, HIV transmission risk behaviors were common among respondents, and 59% of those with a history of antiretroviral use were not taking HAART. HAART discontinuation was independently associated with homelessness, marijuana use, injection drug use, and not receiving community medical care. Postrelease interventions for inmates who are HIV infected are needed.

Incarceration, African Americans and HIV: advancing a research agenda

Incarceration is a crisis among African Americans, and the prevalence of HIV/AIDS in incarcerated men and women is 3-5 times that of the general population. We explore the potential implications of the widespread incarceration of African Americans on HIV risk and HIV outcomes in: 1) the current and formerly incarcerated, 2) their sexual partners, and 3) the communities impacted by incarceration. We set forth a research agenda for understanding and ameliorating the negative impacts incarceration and conclude that the African-American population's ability to successfully address the HIV/AIDS epidemic requires a coordinated and evidence-based response to the challenge of effectively preventing, managing and treating HIV in populations affected by incarceration.

Research needed to more effectively combat HIV among African-American men who have sex with men

It is estimated that nearly half of all African-American men who have sex with men (AAMSM) living in major U.S. cities are already infected with HIV. Without a substantial and committed investment in research in HIV prevention among AAMSM and subsequent evidence-based policies and community programs, it is unlikely that we will ever be able to curtail the HIV epidemic among African Americans in general, regardless of gender, age or sexual orientation. In this paper, we briefly review what is known and what research questions remain in order to curtail the epidemic among AAMSM. Finally, we provide recommendations for future research that include the: 1) development of a national cohort of young AAMSM to prospectively study biological, behavioral, social and contextual factors that place AAMSM at risk for infection with HIV and other STDs; 2) adapting existing interventions in HIV prevention to the unique characteristics of AAMSM and evaluating their effectiveness; 3) evaluating factors such as intracommunity and familial discrimination against AAMSM that may lead to lack of disclosure; and 4) enhancing our understanding of how cultural and social factors can be used in a positive and self-affirming way to strengthen HIV prevention and care for AAMSM.

Increased HIV risk associated with criminal justice involvement among men on methadone

This paper examines the relationship between HIV risk and criminal justice involvement among a random sample of 356 men enrolled in methadone maintenance treatment programs in New York City. Bivariate and logistic regression analyses were performed to estimate the associations between measures of criminal justice involvement and participant HIV risk, controlling for socio-demographic variables. A lifetime history of incarceration was significantly associated with being HIV positive (Adjusted OR=5.08). Recent arrest was associated with unprotected vaginal sex and having multiple female sexual partners. Sex trading was associated with both arrest and incarceration, and the strongest association was found between selling sex and recent incarceration (Adjusted OR=5.69). Results suggest that recent criminal justice involvement among men with substance abuse histories is associated with increased HIV risk behaviors. Findings underscore the need for targeted HIV prevention efforts for men on methadone with a recent history of arrest or incarceration.

Does state certification or licensure influence outpatient substance abuse treatment program practices?

In the United States, state governments legally authorize outpatient substance abuse treatment programs. In some states, programs are certified or accredited (ideal standards). Other states license programs (minimal standards). Additionally, some states authorize programs through "deemed status", which is afforded to programs attaining accreditation from a national accrediting body. Primary legal research and the National Survey of Substance Abuse Treatment Services' (N-SSATS) data were used to examine the relationships between state authorization type (certification/accreditation vs licensure with and without deemed status) and outpatient treatment program practices. Programs in certification/accreditation (vs licensure) states had significantly higher odds of offering wrap-around and continuing care/after care services associated with better long-term treatment outcome. Programs in states that allowed for certification/accreditation with deemed status had significantly lower odds of infectious disease testing, but higher odds of providing group and family counseling. Results suggest that state authorization type may impact services offered by outpatient treatment programs.

A longitudinal study of the prevalence, development, and persistence of HIV/sexually transmitted infection risk behaviors in delinquent youth: implications for health care in the community

OBJECTIVES

Our goal was to examine the prevalence, development, and persistence of drug and sex risk behaviors that place delinquent youth at risk for HIV and other sexually transmitted infections.

METHODS

At the baseline interview, HIV/sexually transmitted infection drug and sex risk behaviors were assessed in a stratified random sample of 800 juvenile detainees aged 10 to 18 years. Participants were reinterviewed approximately 3 years later. The final sample in these analyses (n = 724) included 316 females and 408 males; there were 393 African American participants, 198 Hispanic participants, 131 non-Hispanic white participants, and 2 participants who self-identified their race as "other."

RESULTS

More than 60% of youth had engaged in > or = 10 risk behaviors at their baseline interview, and nearly two thirds of them persisted in > or = 10 risk behaviors at follow-up. Among youth living in the community, many behaviors were more prevalent at follow-up than at baseline. Among incarcerated youth, the opposite pattern prevailed. Compared with females, males had higher prevalence rates of many HIV/sexually transmitted infection risk behaviors and were more likely to persist in some behaviors and develop new ones. Yet, injection risk behaviors were more prevalent among females than males and were also more likely to develop and persist. Overall, there were few racial and ethnic differences in patterns of HIV/sexually transmitted infection risk behaviors; most involved the initiation and persistence of substance use among non-Hispanic whites and Hispanics.

CONCLUSIONS

Because detained youth have a median stay of only 2 weeks, HIV/sexually transmitted infection risk behaviors in delinquent youth are a community public health problem, not just a problem for the juvenile justice system. Improving the coordination among systems that provide HIV/sexually transmitted infection interventions to youth--primary care, education, mental health, and juvenile justice--can reduce the prevalence of risk behaviors and substantially reduce the spread of HIV/sexually transmitted infection in young people.

A longitudinal study of the prevalence, development, and persistence of HIV/sexually transmitted infection risk behaviors in delinquent youth: implications for health care in the community

OBJECTIVES

Our goal was to examine the prevalence, development, and persistence of drug and sex risk behaviors that place delinquent youth at risk for HIV and other sexually transmitted infections.

METHODS

At the baseline interview, HIV/sexually transmitted infection drug and sex risk behaviors were assessed in a stratified random sample of 800 juvenile detainees aged 10 to 18 years. Participants were reinterviewed approximately 3 years later. The final sample in these analyses (n = 724) included 316 females and 408 males; there were 393 African American participants, 198 Hispanic participants, 131 non-Hispanic white participants, and 2 participants who self-identified their race as "other."

RESULTS

More than 60% of youth had engaged in > or = 10 risk behaviors at their baseline interview, and nearly two thirds of them persisted in > or = 10 risk behaviors at follow-up. Among youth living in the community, many behaviors were more prevalent at follow-up than at baseline. Among incarcerated youth, the opposite pattern prevailed. Compared with females, males had higher prevalence rates of many HIV/sexually transmitted infection risk behaviors and were more likely to persist in some behaviors and develop new ones. Yet, injection risk behaviors were more prevalent among females than males and were also more likely to develop and persist. Overall, there were few racial and ethnic differences in patterns of HIV/sexually transmitted infection risk behaviors; most involved the initiation and persistence of substance use among non-Hispanic whites and Hispanics.

CONCLUSIONS

Because detained youth have a median stay of only 2 weeks, HIV/sexually transmitted infection risk behaviors in delinquent youth are a community public health problem, not just a problem for the juvenile justice system. Improving the coordination among systems that provide HIV/sexually transmitted infection interventions to youth--primary care, education, mental health, and juvenile justice--can reduce the prevalence of risk behaviors and substantially reduce the spread of HIV/sexually transmitted infection in young people.

Health Research Behind Bars: A Brief Guide to Research in Jails and Prisons

While most people make staying out of jail and prison a priority, a growing number of researchers are eager to get into correctional facilities in order to study the criminal justice system, the causes and consequences of incarceration, and the role of corrections in our society. For health researchers and their collaborators, the audience for this chapter, correctional facilities offer several unique advantages: a population at high risk of many health problems including infectious and chronic diseases, substance abuse, and mental health problems; social and physical environments that can enhance or impede well-being; a setting that is a focal point for the class, racial/ethnic, and gender differences that divide the United States; a site where health and mental health services and prevention programs are offered and can be evaluated; a controlled environment for administration of treatments such as directly observed therapy for tuberculosis; and a stopping point in the cycle of incarceration and reentry that so profoundly affects community well-being.