By Aakash Shah and James McGreevey
The contours of his expression relaxed. The wrinkles on his face grew less tense. “Doc, I didn’t even know that I had it until I got there, but I am so glad I found out,” Michael sighed. “I was one of the lucky ones who did.”
The “it” Michael was referring to was HIV, and the “there” he was referring to was prison. And he was indeed one of the “lucky ones” to be screened and treated behind the prison wall.
Studies reveal that the scourge of HIV in our prisons and jails is substantial. The prevalence of HIV for those in correctional facilities is approximately four times that of the general population. In states like New York—some of the highest rates in the nation—the prevalence in prisons is an order of magnitude greater than that of the general population.
In recent decades, so many of these infections have been caused by injection drug use by those caught in the throes of the opioid crisis. The result is that individuals with HIV who live behind prison walls are among those whose cases are the most medically complex. Many also suffer from concomitant hepatitis C infections. Recent data suggests that the prevalence of hepatitis C behind the wall ranges from 15-40 percent. Those with hepatitis C are five times more likely to have HIV than those who do not have hepatitis C, and nearly 65 percent of those with HIV also have hepatitis C.
The two infections—both spread through injection drug use— dovetail so closely that clinicians have labelled the combination a syndemic to underscore the circumstance of their overlapping. In our experience at New Jersey Reentry Corp, the two epidemics are all too often compounded as a result of addiction, anxiety, depression, and a number of other conditions.
Making matters worse, the inequities in our healthcare system are compounded by the inequities in our criminal justice system. Black men who are incarcerated are twice as likely to have HIV than their white counterparts. And trans women suffer from a strikingly high (and by some estimates, the highest) rate of HIV among those behind the wall.
Unlike Michael, far too many inmates have never been diagnosed with or treated for HIV. Nearly one out of every five incarcerated individuals with HIV do not know they are infected. Even among those who do know, less than 30 percent enter with viral loads that are undetectable, indicating that they are not being effectively treated. Even among those who do know and are effectively treated, studies indicate that less than 30 percent fill prescriptions for antiretrovirals (the medication to suppress HIV) within 60 days of release, and less than 30 percent are in treatment six months after release.
This can and must change. Prisons can take three simple steps to do exactly that. First, they must implement mandatory or, at a minimum, optional opt-out testing for HIV upon incarceration. At present, fifteen states mandate testing, seventeen offer opt-out testing, and the rest perform opt-in testing. Second, antiretroviral treatment must be made available to all those who test positive. This treatment can be delivered in a cost-effective manner by specialists who are available via telemedicine. Third, discharge planning from prison must include prescriptions for antiretrovirals for more than 30 days (individuals are rarely able to secure an appointment for a refill within such a short period), medical insurance cards (e.g. Medicaid cards), and information for follow-up appointments and wraparound services.
At New Jersey Reentry Corp, our team works hard to ensure that folks like Michael are not the exception but the rule. To end the scourge of HIV in our communities, policymakers must take the steps above to prove that they are doing the same.
Aakash Shah serves as the Medical Director of New Jersey Reentry Corp and is a practicing addiction and emergency room doctor.
James McGreevey serves as the Executive Director of New Jersey Reentry Corp and previously served as the governor of New Jersey.