Will correctional facilities act as incubators or educators? That is the question of the new millennium.
The state of Texas operates 105 state correctional facilities, which is about one prison or state jail for every 2.4 counties. In 2001, almost 145,000 people were imprisoned in these facilities. Texas had the third highest incarceration rate per 100,000 residents of any state, behind Louisiana and Mississippi. Most Texas prisoners are African-American or Hispanic, and just under half have never completed high school. As a group they suffer from more substance abuse than the general population. And unsurprisingly, more of these prisoners also suffer from a variety of physical illnesses, from infectious diseases like tuberculosis to lifestyle and age-related illnesses such as hypertension, coronary disease, and diabetes.
HIV and Hepatitis C are two of the most alarming illnesses more prevalent in the prison population. Both are communicable, and despite new developments in understanding Hepatitis C, there are currently no vaccines or cures available for either disease. HIV, the virus that causes AIDS, has been a concern for prison officials nationwide since the 1980s. The first report of AIDS in a correctional facility was published in 1982, only one year after reports of opportunistic infections in gay men. Tracking within the Texas prison system began in 1990. By 1999, Texas had the third highest number of prisoners with known HIV infections, after New York and Florida. The current rate of HIV infection in Texas prisoners is at least 1.7 percent, ten times the rate in the general population. Hepatitis C became an object of attention in the mid 1990s, and has been tracked in the Texas prison system since that time. Left untreated, it causes chronic liver disease in just over half of those infected. Studies of Texas prisoners have estimated an infection rate of about 30 percent, compared to 2 percent in the general population. The number of Texas prisoners who test positive for Hepatitis C has doubled in the last two years.
The prison system is legally required to provide health care to these prisoners, which is an increasingly costly proposition. The system's managed health care budget in FY 2002 was $280.8 million. About $36 million of that was spent on pharmaceuticals, and 40.4 percent of the pharmaceutical budget ($14.7 million) was for HIV antiretroviral medications for about 1,600 of the 2,400 HIV positive prisoners. Treatment for Hepatitis C infections, while not quite as complicated as that for HIV, is long-term and expensive. Although only a fraction of the prison population had been tested for Hepatitis C by 2002, there were about 14,000 prisoners who had tested positive for this virus. Treatment of both illnesses requires specialized medical expertise, which can be difficult to attract and retain within limited budgets.
Providing health care in a prison system can also bring medical treatment for prisoners into conflict with the system's primary mission of incarceration. Both health care providers and corrections staff must factor in the safety and security risks that arise when prisoners receive medical care, ranging from minor uncertainty due to the interruption of daily routines to violence or escape attempts. Prisoners are limited in their choice of providers, and health care providers are limited in their ability to affect patients' diet, exercise, and other behaviors that play a role in health care.
Finally, every group involved in the prison health care system prisoners, their families, corrections officials and staff, health care providers, lawmakers, and advocates of all persuasions have expressed concern over the public health dimension of concentrating a group of people with high rates of communicable disease infections, then releasing them back to communities outside prison. Prisons have a unique ability to control the behavior and environment of their population, a tool not normally available to combat disease. They also have a captive audience for prevention education. However, the prison system is more restricted than many community education providers because of its security concerns and the criminalization of certain disease-transmitting behaviors in the prison setting.
This report examines the policy challenges faced by the Texas prison system in dealing with prisoners who have been infected by HIV and Hepatitis C. The Texas prison system, like many others, has often struggled to meet its responsibilities in providing health care. Chapter 2 of this report presents background information on its response to an evolving set of demands made by the courts, prisoners, and cost restrictions. This chapter also explains the scope of demands made by current HIV and Hepatitis C infections, including groups within the prison population who are particularly affected by these diseases.
Solutions devised to meet this demand must meet a variety of criteria imposed on the system. Chapter 3 outlines the criteria for evaluating policy decisions made by the prison system, from legal requirements and accreditation standards to ethical principles. Cost, and public willingness to bear cost, is also a major factor that limits the range of policy options.
The first major category of policy issues involves testing prisoners for HIV and Hepatitis C. Chapter 4 describes the state's decisions about testing, and the choice between segregation and mainstreaming for those prisoners who test positive is explored. The prison system must also then adopt policies that determine how infected prisoners will be treated.
Chapter 5 highlights three key policy and practice choices in treatment of HIV, AIDS, and Hepatitis C. Administration of HIV medications, prisoner participation in HIV drug trials, and treatment for Hepatitis C infections are reviewed.
The public health implications of HIV and Hepatitis C infections in the prison population have motivated the state to implement prevention education. Chapter 6 focuses on the messages and methods of these education efforts.
Public health and individual health intersect when prisoners are released back into their communities. Chapter 7 explains the planning process for prisoners with HIV and Hepatitis C who are released, and the options made available to them for continuity of health care services. This chapter also examines the Texas Medically Recommended Intensive Supervision program, a special parole system designed to save state dollars and provide certain terminally ill prisoners a gentler atmosphere in their final months.
Chapter 8 summarizes the recommendations made on what the state of Texas can do to improve conditions for its prisoners and the community at large, and concludes the report.