Title: Public Health/Corrections Collaborations: Prevention and Treatment
of HIV/AIDS, STDs, and TB.
Series: Research in Brief
Author: Theodore M. Hammett, Ph.D.
Published: July 1998
Subject: Inmate health care, HIV/AIDS in correctional facilities
29 pages
67,000 bytes

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U.S. Department of Justice
Office of Justice Programs
National Institute of Justice

National Institute of Justice
Centers for Disease Control and Prevention
Research in Brief
July 1998

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Issues and Findings

Discussed in this brief: The extent and nature of public health/corrections
collaborations in the prevention and treatment of HIV/AIDS, STDs, and
TB, based on responses to the 1997 NIJ/CDC national survey of
correctional systems and site visits to six States and five city/county
jurisdictions.

Key issues: Correctional populations have higher rates of HIV/AIDS,
STDs, TB, and more risk factors for these diseases than the general
population. Virtually all inmates return to the community, where they may
place themselves and others in danger by engaging in high-risk behaviors.
Collaborations between public health and correctional agencies may help
fill gaps in programs for the prevention and treatment of HIV/AIDS,
STDs, and TB, thereby benefiting an at-risk and underserved population
as well as overall public health.

Key findings:
o According to NIJ/CDC survey responses, virtually all correctional
systems have at least some collaboration with public health agencies.

o Site visits identified numerous collaborations in disease surveillance,
testing and screening, followup, education and prevention programs, staff
training, treatment services, and legislation and policy development, but
found fewer collaborations in discharge planning and transitional services
for people being released.

o Most existing collaborations involve public health departments
providing funds, staff, or direct services in correctional facilities.

o Programs in Rhode Island and New York State exemplify more
comprehensive collaborations.

o Key factors in successful collaborations include:

-- Availability of data on disease burden or dramatic events such as
outbreaks demonstrating the need for collaborations.

-- Organizational, legislative, or regulatory provisions such as health
department responsibility for provision of health services in correctional
facilities; or legislation or regulations requiring oversight mechanisms,
screening, or disease reporting.

-- Attitudes and philosophies such as commitment to collaboration at
agency and facility levels; correctional agency willingness to open its
facilities to outside organizations; and mutual sensitivity to concerns,
priorities, and perspectives of corrections and public health personnel.

-- Health department funding of programs in correctional facilities and
operational features such as the presence of health department personnel
in correctional facilities, liaison staff in correctional and public health
agencies, formal agreements for collaboration (such as MOUs), and
long-standing interagency relationships.

-- Communication and information exchange such as correctional
representation on HIV Prevention Planning Groups, service on joint
committees, regularly held meetings at leadership and operational levels,
and the exchange of important information about patients.

Recommendations: The key recommendations of the NIJ/CDC study
involve implementing the following four key facilitators of collaboration:

o Public health agency collection and dissemination of data on the burden
of infectious disease in inmate populations.

o Including correctional representation on all HIV Prevention Planning
Groups.

o Public health agency initiation or expansion of funding for services and
staff in correctional facilities.

o Public health and correctional agency recognition of the importance and
potential benefits of interventions in correctional settings to the health of
the larger community.

Target audience: Correctional administrators, public health agency
administrators, correctional health services staff, public health agency
staff, and legislators and other policymakers concerned with public health
and criminal justice.

-------------------------------

Public Health/Corrections Collaborations: Prevention and Treatment of
HIV/AIDS, STDs, and TB

by Theodore M. Hammett, Ph.D.

The missions of public health departments and correctional agencies are
highly complementary: Correctional facilities and inmate populations are
part of the larger community, and public health is integral to public safety.
Public health and correctional agencies are increasingly working together
to improve the health of inmates and, at the same time, the health of the
larger community.

More than 1.75 million people are incarcerated in the prisons and jails of
the United States--close to 1 percent of the Nation's population.[1]
Inmates suffer disproportionately from infectious diseases, substance
abuse, and a constellation of socioeconomic problems. In particular,
human immunodeficiency virus/acquired immunodeficiency syndrome
(HIV/AIDS), sexually transmitted diseases (STDs) (such as syphilis,
gonorrhea, and chlamydia), and tuberculosis (TB) are far more prevalent
among incarcerated persons than the general U.S. population. 

Figures from a 1994 survey cosponsored by the National Institute of
Justice (NIJ) and the Centers for Disease Control and Prevention (CDC)
(the NIJ/CDC survey) reveal that AIDS is almost six times more prevalent
among inmates than in the total U.S. population.[2] State and Federal
inmates accounted for about 3 percent of the HIV-infected people in the
country in 1995.[3] Incidence rates of gonorrhea in 1994 were 152 times
higher among confined juvenile girls and 42 times higher among confined
juvenile boys than among girls and boys of equivalent ages in the total
population.[4] Comparisons are more difficult to make regarding TB, but
the numbers in themselves are telling. Based on 1994 data from 31 State
prison systems, the purified protein derivative (PPD) skin-test positivity
rate (which indicates TB infection) among inmates was almost 14 percent,
while 25 prison systems reported that more than 5,600 inmates converted
from negative to positive PPDs in the 2 years prior to the NIJ/CDC
survey.[5] In addition, risk factors for these infections are much higher in
incarcerated populations than in the population at large.

Adult inmates and confined juveniles represent a large, highly at-risk
population that could benefit greatly from health interventions. Such
interventions could also greatly benefit overall public health.[6,7] Many
correctional systems have responded to this need and opportunity by
instituting a variety of these interventions. However, the 1997 NIJ/CDC
survey results reveal that numerous gaps remain. Less than two-thirds (61
percent) of State and Federal correctional facilities were providing
instructor-led HIV/AIDS sessions, and only 13 percent were providing
peer-led programs.[8] Other areas of insufficient services include
discharge planning and continuity of medical services from correctional
facilities to the community. Overall, more coordination is needed between
services in these two domains.

Collaborations between public health and correctional agencies represent
a potential means of filling these and other gaps in health-related services
for inmates. Public health departments may have the funds, staff,
expertise, and other resources to help prisons, jails, and juvenile facilities
address the serious health needs of their inmates and thereby advance the
cause of public health in their communities.

Consistent with their overall public safety and security missions, prisons
and jails can create opportunities for interventions with underserved
populations who are at high risk for HIV/AIDS, STDs, and TB.
Correctional administrators can provide access to these populations and
otherwise facilitate interventions by including language requiring early
disease detection and treatment in their health protocols. Such language
may be particularly important where health services are being provided
through contracts with private organizations.

The study described in this report examined the extent and nature of
public health/corrections collaborations in the prevention and treatment of
HIV/AIDS, STDs, and TB. A description of the methodologies used for
the survey and the site visits is found in "Survey and Site Visit
Methodologies."

As expected, the study revealed that State health departments collaborated
primarily with State correctional agencies, while city and county health
departments worked primarily with county jails. However, there were
numerous interactions between State health departments and county jails.
In addition, collaborations between State correctional systems and county
jails were very important, but sometimes inadequate, particularly in the
area of information exchange.

The study occasionally touched on collaborations between corrections and
other entities such as community-based organizations (CBOs) and
academic medical centers. Indeed, a range of potential collaborators could
be identified for future program development and research efforts.

This report first summarizes collaborations reported to the 1997 NIJ/CDC
survey and those identified during site visits for this study. Two brief case
studies are then presented, followed by a discussion of the factors
important in successful collaboration. The report concludes with policy
implications for improving and expanding collaborations.

Diversity of collaborative efforts

Collaborations between public health and correctional agencies
encompass a wide variety of activities in the prevention and treatment of
HIV/AIDS, STDs, and TB (see exhibit 1). Responses to the 1997
NIJ/CDC survey of correctional systems show that collaborative efforts
are common and wide ranging. Virtually all State and Federal prison
systems (98 percent) and city/county jail systems (90 percent) reported
some collaboration with a public health department in the surveillance,
prevention, and treatment of HIV/AIDS, STDs, or TB.

The appendix (pages 16 and 17) summarizes the diverse collaborative
efforts identified during the site visits to 11 jurisdictions within the
following broad headings:

o Administration and infrastructure.

o Policy development.

o Service delivery.

Many collaborations exist in disease surveillance, staff training,
legislation and policy development, education/prevention programs,
testing/screening/followup, and treatment services, as shown in the
appendix. However, there are relatively fewer collaborations in quality
assurance, clinical protocol development, discharge planning/transitional
services, and laboratory services. Most of the collaborations identified in
this study involve public health departments providing funding, staffing,
and services to correctional departments. In order to succeed, such
arrangements require interaction and cooperation between public health
and correctional agencies as well as access to inmate populations.
However, some collaborations go well beyond health departments
providing services in prisons and jails. See "Rhode Island's Model of
Collaboration" and "New York State's Model of Collaboration" for brief
case studies of two such collaborations.

The following factors are common to successful collaborations between
public health and correctional agencies:

o Data and events demonstrating a need for collaboration.

o Organizational, legislative, and regulatory provisions.

o Appropriate attitudes and philosophies.

o Program funding and operations.

o Communication and information exchange.

Data and events demonstrating a need for collaboration

Successful public health/corrections collaborations are much easier to
develop and sustain when data documenting the burden of disease in the
inmate population are readily available. Some might suggest that such
data are a prerequisite for successful collaborations. Public health
departments could be more proactive in disease surveillance among
corrections populations. Better surveillance might produce a whole series
of positive effects: more resources for correctional health programs, better
services, a safer and healthier environment for inmates and staff, less
disease returned to the community, and ultimately improved public health.

In Rhode Island, for example, the health and correctional departments
demonstrated that 42 percent of all new HIV infections in the State were
identified in correctional facilities. This convinced the State's HIV
Prevention Planning Group to endorse substantial continued funding of
collaborative HIV programs in prisons. Until these data were available,
the planning group had expressed skepticism about the value and
importance of prison-based programs. In Florida, data showing that 13
percent of the State's syphilis morbidity was identified in correctional
facilities served as an important impetus for collaborative STD screening
programs. In Washington, the State health department documents and
publishes periodic reports on STD morbidity in adult and juvenile
facilities, which helps justify the department's continued involvement in
STD screening and followup programs in these facilities. 

Because of low success in locating people released from Cook County Jail
before syphilis treatment could be given, a rapid screening and treatment
program for women in the jail was initiated. As a result, the percentage of
Chicago's total syphilis morbidity identified at Cook County Jail increased
from 17 percent in 1995 to 24 percent in 1996. The rapid screening and
treatment program is a collaborative effort of CDC, the Chicago
Department of Health, and the Cook County Jail.

Without hard data on the incidence and prevalence of HIV/AIDS, STDs,
and TB, it is much more difficult to interest correctional and health
departments in collaborating on interventions. It is also more difficult to
justify requests for funding and other resources if the scope of the problem
is unknown or undemonstrated. In some jurisdictions visited for this
study, for example, jail medical services and public health department
staff have no clear picture of morbidity among the inmates. The lack of
this information is, in their view, a major stumbling block to more
effective and better supported collaboration.

Dramatic events may call attention to the need for collaboration. For
example, concern raised by the 1991 outbreak of multidrug-resistant TB
in New York State and by other local outbreaks was mentioned in a
number of jurisdictions as a factor promoting collaboration between
public health and corrections. The New York outbreak prompted the
formation of a city/county TB task force in Chicago.

In New York State, health department involvement in TB interventions
that helped to protect correctional staff smoothed the way for other
collaborations on HIV/AIDS and STDs. Staff in several jurisdictions
identified collaborations in TB prevention, with their strong employee
protection focus, as the "foot in the door" for other collaborative efforts.

Organizational, legislative, and regulatory provisions

In San Francisco and Memphis the health department is responsible for
providing health services in the correctional facilities. Such arrangements
require interaction and may help foster fuller collaboration. In San
Francisco, for example, the director of forensic services, the health
department unit responsible for jail health services, sits on several
committees with sheriff's department staff and, in turn, involves custody
staff in health services committees. Nurses also meet regularly with
custody captains to address issues in health services delivery.

Another important factor promoting collaboration is legislative and
regulatory provisions. Strong State legislation in New York called for
establishment of an interagency AIDS task force, which required that the
commissioners of the State health and correctional departments and other
agenciescoordinate efforts in criminal justice settings. California law
requiring notification to health departments of all TB cases was a spur to
collaborations with correctional systems in the development of reporting
procedures. Also in California, the legislatively created State Board of
Corrections has the power to regulate local and county jails. The board's
regulations require that each jail has a communicable disease control plan
jointly created by jail officials and the local health officer. A Texas law
enacted in 1993 requires all jails with 100 or more beds to submit TB
control plans to the local health department.

The Memphis-Shelby County health officer used the powers granted him
under Tennessee law to mandate PPD screening for TB in jails. Indeed,
the jail director also favored PPD screening but asked the health director
to require it in order to provide stronger justification and gain the
cooperation of jail staff. A 1988 Washington State law provides for
court-ordered HIV testing of inmates involved in potential transmission
incidents, as well as convicted injection drug users, sex offenders, and sex
workers. The correctional and juvenile agencies sought and obtained the
involvement of the State health department in providing this mandated
testing and reporting its results.

Attitudes and philosophies

Three important attitudes and philosophies of key actors in public health
and corrections systems appear to facilitate successful collaboration:

o Strong commitment.

o Willingness to open facilities to outside agencies.

o Sensitivity to the concerns of both corrections and public health.

At the level of agency and facility leadership, there must be a strong
commitment to collaborative approaches. This may involve a realization
and declaration that infectious diseases among inmates represent both a
correctional and a public health problem. As the county jail director in
Memphis emphasized, public health is a part of the public safety that
correctional facilities exist to protect. The Florida Department of
Corrections' assistant secretary for health services stated that "the health
problems of our inmates are public health problems because inmates go
back to the community." In Illinois, the director of the correctional
department endorsed an inmate peer education program sponsored by the
health department and wrote to all facility superintendents encouraging
their cooperation.

Correctional officials' commitment to collaborative approaches generally
leads to their willingness to open their facilities to outside organizations.
This is not always easy for correctional administrators to do, in view of
their primary concern with security. They may also be wary of outsiders,
based on their perceptions or experiences that outsiders' main purpose is
to find and expose fault in correctional facilities. Even when central office
leaders in a correctional system direct that there be open collaboration,
individual superintendents may still attempt to prevent it in their facilities.

Numerous superintendents, however, are open to the involvement of
outside agencies. Some, like the warden of Rhode Island's women's
facility, see such involvement as essential. She welcomes outside medical
providers, community-based organizations, student interns, and others to
her facility. She believes that prisons are part of the community and that
there should not be "impenetrable walls" between them. Moreover, she
believes that outside providers are helpful to inmates in making transitions
back to the community.

If correctional and public health agencies are to work together
successfully, they must have sensitivity to each other's concerns. It is
important, for example, that public health staff understand that security is,
and always will be, the first priority of correctional systems. Public health
activities must be accommodated within the overall correctional structure
and procedures. As a public health investigator from the Houston health
department's TB section commented, one must "ease in," work with
security staff, abide by their rules, and try to build one-on-one
relationships. Taking this approach, this public health investigator was
accepted as "one of them [the deputies]" and enjoys their full cooperation.
Similarly, the San Francisco health department's TB control staff person
working in the jails has achieved good cooperation from custody staff by
"requesting rather than demanding" assistance. In Washington State, the
correctional department credited health department staff with being
extremely collegial, focusing on finding solutions rather than finding
fault.

Showing a willingness to compromise on policy issues is another way to
demonstrate mutual concern and sensitivity. For example, the director of
forensic services in the San Francisco health department compromised
with the sheriff's department on the implementation of a State referendum
on disclosure of inmates' HIV status to correctional officers. The
compromise carefully restricted recipients of the information and provided
for coding of the information to minimize the possibility of unauthorized
disclosure.

Counterproductive factors. While the factors elucidated above can help
facilitate successful collaborations, it is important to realize that there are
real differences between the philosophies, perspectives, and priorities of
public health and correctional agencies that can make collaboration
difficult if they are not sensitively handled. For example, the medical staff
in the jail may align with security staff rather than with public health staff.
In Rochester/Monroe County, New York, health department staff reported
that when they first began providing services in the jail, there seemed to
be a "clash of cultures" between them and jail health staff. Since that time,
however, a mutual respect for the different perspectives and challenges of
each organization has led to collaborative and collegial relations. In
Rochester, important improvements were made after a public health nurse
spent time in the jail observing the work of her counterpart on the jail
health staff. Through this experience, the public health nurse gained an
appreciation of the danger, stress, and other challenges of working in the
jail and developed great respect for the jail health staff. 

The focus of the jail health staff is on emergency medicine and providing
needed care within the context of maintaining safety and security. Public
health activities and objectives such as disease tracking and followup are
not as high a priority for jail health staff. By contrast, the health
department staff who work in the jail place their highest priority on
proactive public health activities such as screening, disease tracking,
followup, and research. Nevertheless, the Rochester experience
demonstrates that through mutual understanding, common ground can be
discovered and effective collaborations achieved.

To be successful in the correctional environment, health department staff
need to be able to work within the system and the rules. They cannot be
confrontational and demand cooperation and then expect to succeed.
According to the assistant health director in the Rochester health
department, staff should beware of becoming inmate advocates and
denouncing the system. Rather, they should focus on advancing the
overall public health.

The director of medical services at the county jail in Houston described
the differing perspectives by using the metaphor of a spoked wheel. To
health services and public health staff, everything revolves around
providing patient care and addressing health issues. To correctional staff,
in contrast, health issues represent only one spoke of the wheel.

Lack of mutual respect and sensitivity can undermine collaborations. For
example, health services and public health staff should not dismiss or
ignore the concerns of correctional staff regarding occupational exposure
to HIV and other diseases. As long as these concerns are based on actual
risk of transmission, they should be addressed with respect and
seriousness. Correctional officers' unions are often in the forefront on
issues of occupational risk. These unions may oppose inmate peer
education programs or other programs that involve ex-offenders entering
jail facilities. A willingness to take these concerns seriously and to be
open to compromise on them is essential. In New York State, a
compromise was reached that allowed ex-offenders to present educational
sessions for inmates but not for correctional staff.

Collaborations also suffer if public health staff devalue the skills and
expertise of correctional medical staff and other correctional staff. In
several jurisdictions, correctional health care staff reported being treated
with disrespect by health department personnel. At one facility, the health
services staff employed by the correctional department resent what they
view as an inappropriate supervisory and oversight approach taken by
State health department staff who come into the prison. In other words,
the correctional health services staff want acknowledgment of and respect
for their expertise--instead of concern that they will not perform properly
unless closely supervised. The nurse administrator at this facility declared
that "until you treat people as equals, you can't collaborate; you can only
dictate." At the central office level in this jurisdiction, key health services
staff expressed concern about language suggesting similar suspicious
assumptions that was included in proposed terms of a memorandum of
understanding between the departments of health and corrections.

Health services staff of several other State correctional systems reported
county health department personnel, stigmatizing them as inferior
practitioners who could not find jobs elsewhere, demanding cooperation,
and refusing to work within correctional rules and regulations.

Conversely, obstructionism and lack of cooperation by correctional staff
can undermine collaborative efforts. For example, security staff may
hinder inmates' access to health services. In one jurisdiction, it was
reported that the correctional officers who prepared the sick-call lists
sometimes allegedly denied access to inmates needing services.
Gate-clearance problems sometimes also allegedly have made it difficult
for health department staff to provide services efficiently.

Program funding and operations

The following funding and operational factors were found to facilitate
collaboration:

o Health department funding of programs in corrections.

o Presence of health department staff and programs in correctional
facilities.

o Presence of a liaison person.

o Formal agreements for collaborations.

o Staff characteristics.

o Longstanding relationships.

Funding by health department. Funding is almost always a facilitating
factor in collaborations. The director of medical services at the county jail
in Houston said that collaboration could be based on the health
department's ability and willingness to fill and pay for gaps in services
and expertise. In Rhode Island, the health department provided much of
the initial funding for the collaborative HIV/AIDS programs in the
correctional facilities, but the Department of Corrections was
subsequently able to institutionalize the program and bring some of the
costs into its budget.

In contrast, perhaps the most pervasive barriers to collaborative efforts are
inadequate funding and resource constraints. Even the most powerful
arguments for public health interventions, no matter how well grounded in
data, may be denied adequate support in the current political climate
emphasizing the punitive over the rehabilitative functions of corrections.
Most of the collaborative programs observed in this study were working
under serious constraints on funds, staff, and space. In one jurisdiction
visited, the public health department suggested that jail health staff
resisted more aggressive screening for HIV and STDs because sufficient
funds were not available to treat all the patients who might be diagnosed.

Physical plant and staffing. One jurisdiction reported that no infrastructure
or space was available in the city jail to expand disease screening and
offer other health services in which the health department might
collaborate. In addition, staffing shortages at this same city facility would
prompt resistance to escorting inmates to health services even if such
health services were available. A jail director interviewed for the study
acknowledged that the staff and facilities were inadequate to support more
proactive health services.

Public health staff working in several other correctional facilities reported
frequent problems with the callout and escort of inmates to attend medical
services. These problems were attributed to a combination of staff
shortages and obstructionism or lack of interest on the part of security
staff.

Presence of public health programs. The physical presence of public
health programs and staff in correctional facilities has promoted--in many
cases, necessitated--collaboration. As described earlier, jail teams and
staff from public health departments regularly work in the correctional
facilities of the jurisdictions visited for this report, performing a variety of
functions including screening, surveillance, education and training,
contact investigation and partner elicitation, and followup.

Liaison. A liaison at the central office or facility level often makes
collaboration easier to manage and sustain. In New York State, each
facility has designated a single liaison for State health department
programs--usually the nurse administrator or deputy superintendent for
programs. This individual arranges gate clearances, sets up appointments,
and ensures inmate access to services. In Illinois, the department of
corrections' public health coordinator serves as the liaison for all health
department programs and helps the programs gain acceptance at the
facility level. A similar correctional liaison to the State health department
in Florida has proven to be very useful.

Formal agreements. Embodying collaborations in formal agreements has
been helpful in several jurisdictions. Memorandums of understanding
(MOUs) and similar instruments help to institutionalize collaborative
efforts, making them less dependent on personal relationships. Rhode
Island's broad-based HIV/AIDS collaborations involving the health and
correctional departments, an academic medical center, and numerous
CBOs are formalized in written agreements. 

From 1990 to 1996, the New York State Department of Health had an
MOU with the Parole Division to provide transitional services for
HIV-infected inmates. Because the covered services were rolled into other
contracts awarded in 1997, the MOU was not renewed. An MOU with the
Division for Youth covering education, counseling, and testing services is
still in place. 

In Washington State, MOUs between the health and correctional
departments and the juvenile agency specify roles and responsibilities
regarding court-ordered HIV testing. 

Other documents can also formalize collaborative efforts. For example,
the strategic plan of the Florida department of corrections requires
collaboration with the health department and other community resources.

Staff characteristics. In several visited jurisdictions it appeared that certain
staff characteristics make collaborations easier to forge and maintain. For
example, in Houston, both the director of medical services in the county
jail and the supervisor of the health department's jail team mentioned that
having a security background was useful for jail health services staff. The
health department's jail team supervisor worked in corrections and
criminal justice before assuming his current role and noted that this
background helped him both negotiate the jail system and win quicker
acceptance from security staff. The director of medical services in
Houston worked for many years in security before taking his present
position. He believes that when the director of medical services is a
sheriff's department employee rather than an employee of another agency
or a contracted organization, he or she has more leverage and authority to
advance public health objectives in the jail setting.

In both New York State and Illinois, the key liaison to the health
department in the correctional department previously worked for the
health department. This background helped the liaison not only to
understand and commit to a public health approach but also to develop
working relationships with health department staff more easily.

Relationships. Finally, longstanding relationships and the passage of time
often are required to perfect collaboration. In Washington State, for
example, the health and correctional departments were at one time part of
the same State agency, so they have a long history of working together. In
Rhode Island, the collaborative HIV/AIDS program was developed and
refined over a period of 10 years.

Communication and information exchange

Opportunities to discuss issues and exchange information are important to
developing and sustaining collaborations. The study identified four factors
that improve communication and information exchange:

o Correctional representation on HIV Prevention Planning Groups.

o Health and correctional department service on other joint committees.

o Regular meetings at leadership and operational levels.

o Exchange of important patient information.

Representation on planning groups. Correctional representation on HIV
Prevention Planning Groups is the most important factor in this category.
These groups are mandated by CDC in all States and cities receiving CDC
HIV prevention funds. The Prevention Planning Groups often have
substantial influence on the allocation of HIV prevention funding. 

In Rhode Island, a correctional staffer is a member of the State's
Prevention Planning Group. In San Francisco, a representative of the
health department's Forensic AIDS Project, which provides HIV
prevention programs in the jails, serves in the HIV Prevention Planning
Group. 

In Chicago/Cook County, a representative of the city health department's
STD program (who was an advocate for correctional needs) serves in the
HIV Prevention Planning Group. This representative presented jail data to
the planning group and successfully lobbied for allocation of resources to
the jail, resulting in the hiring of two additional staff for the jail's STD
program. 

There also can be valuable teaching opportunities on these planning
groups. The Florida Department of Corrections' infection control
coordinator is a member of the statewide Prevention Planning Group,
where she believes her most important function has been to educate the
other members about the correctional environment and the needs of
inmate populations.

On the other hand, the absence of correctional representation on HIV
Prevention Planning Groups, which is the case in most of the jurisdictions
visited for this study, almost inevitably means that programs in
correctional facilities receive insufficient attention and support. In turn, a
critical impetus for collaborative programs will be missing.

Joint committees. Service on other standing committees provides
opportunities to develop and enhance collaborations. In Illinois and New
York, the public health and correctional departments are both represented
on State interagency AIDS task forces, while in Missouri, Washington,
and New York, both departments serve on Governors' advisory councils
on AIDS. New York's advisory council has a subcommittee on criminal
justice that includes representatives of State corrections, health, and parole
agencies. In Missouri, the health department's medical director serves on
the department of correction's (DOC's) review committee for its health
services contract. 

The Florida DOC's medical director serves on the State TB Control
Coalition and the department of health's (DOH's) medical director for HIV
sits on the correctional department's medical ethics panel. A task force
comprising staff from the jail, corrections center, and health department
was convened in Memphis to address TB screening in jails. It has been
proposed to keep this group in existence to provide a forum for discussion
of other health issues in the jails and correctional center. In Rochester, a
Jail Health Advisory Committee has brought together high-level managers
at the jail and in the health department to address issues of common
concern.

Regularly held meetings. In addition to serving together on standing
committees, it is important for public health and correctional staff to
conduct regularly held meetings at both leadership and operational levels.
In Florida, there are quarterly coordination meetings of DOC and DOH
staff on TB issues, as well as regularly scheduled collaborative TB
case-review conferences. TB case-review meetings are also held in
Missouri on a monthly basis. These meetings have identified errors, one
involving a case in which treatment was wrongly terminated.

In contrast, a barrier to collaboration may have been the absence or
infrequency of meetings at central office and facility levels. In one
jurisdiction, the lack of meetings between the heads and high-level
management of relevant departments has led to a somewhat fragmented
approach to the provision of public health interventions in the jails. The
jurisdiction's approach has been characterized by overlapping functions,
poor communication, and turf disputes.

Sharing information. Access to and exchange of information about
individual patients is often critical to the success of collaborative efforts.
This is particularly true when correctional or health department staff
provide followup on test results or partner notification or continue patients
on medications following their transfer or release. (Inmates may be
transferred frequently from housing unit to housing unit within a facility
as well as between different facilities. Inmates may also be released on
short notice.)

In many of the visited jurisdictions, procedures have been developed to
transfer medical records and provide interagency access to important
clinical or locator information. In New York State, for example, health
department staff have access to portions of the department of correctional
services (DOCS) inmate information system so they can track transferred
inmates within the system and ensure that HIV and PPD results and
medication status are provided to the new facility. In Illinois, the health
department was able to track and respond appropriately to a TB outbreak
in the correctional system because their staff had access to the DOC
database on inmate movements and transfers. The work of Missouri health
department staff who conduct followup interviews in the prisons and elicit
information about sexual partners is facilitated by access to the
correctional department's HIV and syphilis case logs and to inmates'
automated medical records. Similarly, Chicago health department staff
who conduct STD screening and treatment in Cook County jail depend on
the jail's database for the locations and court dates of inmates and on the
Chicago health department registry for their treatment histories. 

Under a grant from the Corrections Program Office, U.S. Department of
Justice, Florida's prison and jail leadership is developing a partnership in
TB control with the primary objectives of coordination of services and
exchange of information as inmates move from county jails to State
prisons.

Correctional department access to health department databases can also be
very useful. In Washington State, when the DOC wishes to determine the
status of inmates being transferred or released, it can check health
department databases on patients receiving medications for TB and
patients receiving preventive therapy. 

On the other hand, problems with the availability and exchange of
information have impeded collaboration and undermined inmate health
care. In many instances, vital medical records, including test results and
medication status of transferred or released inmates, were never sent to the
new health care provider or sent only after long delays. HIV antibody tests
and PPD skin tests have had to be readministered because there was no
record of previous testing. At one juvenile detention facility, the county
health department was responsible for HIV counseling and testing but did
not furnish test results to the facility's medical director. Inmates receiving
combination antiretroviral therapy for HIV may arrive at a new facility
without written records of the specific regimen, and the new facility may
be unable to obtain records from the previous facility within a reasonable
period. Therefore, medications may need to be restarted.

Suggestions on how public health departments and correctional agencies
can work together to expand and enhance health services for inmates are
offered under "Policy Implications."

Conclusions

Collaborative efforts should be expanded to include organizations beyond
public health and adult correctional agencies and to involve a broader
range of criminal justice populations and organizations that offer needed
services and linkages. Other types of organizations to include in
comprehensive collaborations are probation and parole agencies, juvenile
systems and facilities, community-based organizations, AIDS service
organizations, substance abuse treatment programs, academic medical
centers and universities, and other service providers.

Clearly, State and local government agencies and service providers in the
affected communities bear the primary responsibility for development of
collaborations. However, Federal agencies such as CDC and NIJ may be
able to support expanded and enhanced collaborations in some ways.
These include funding demonstration projects (such as CDC's enhanced
STD screening and treatment efforts) and sponsoring conferences and
forums that offer opportunities for staff of correctional and public health
departments and other pertinent organizations to meet and discuss
collaborations.

The development and distribution by appropriate government agencies of
guidelines for the prevention of HIV/AIDS and STDs in correctional
settings might be helpful in fostering collaborations between public health
and correctional agencies. Guidelines such as those developed by CDC for
controlling TB in correctional facilities could provide a framework for
discussion of the benefits of appropriate prevention, control, and treatment
procedures.

In sum, correctional facilities are important points to access high-risk,
underserved populations and offer opportunities to reach these
populations with important health interventions. As the examples included
in this report demonstrate, collaborative efforts can be successful in
improving the health of inmates and benefiting overall public health as
well.

Notes

1. Gilliard, D.K., and A.J. Beck, Bulletin: Prison and Jail Inmates at
Midyear 1997, Washington, D.C.: U.S. Department of Justice, Bureau of
Justice Statistics, January 1998, NCJ 167247. 

2. Centers for Disease Control and Prevention, "HIV/AIDS Education and
Prevention Programs for Adults in Prisons and Jails and Juveniles in
Confinement Facilities--United States, 1994," Morbidity and Mortality
Weekly Report 45 (April 5, 1996):268-271.

3. Maruschak, L., HIV in Prisons and Jails 1995, Washington, D.C.: U.S.
Department of Justice, Bureau of Justice Statistics, August 1997.

4. Centers for Disease and Control and Prevention, "HIV/AIDS Education
and Prevention Programs."

5. Wilcock, K., T.M. Hammett, R. Widom, and J. Epstein. Tuberculosis in
Correctional Facilities 1994-1995, Research in Brief, Washington, D.C.:
U.S. Department of Justice, National Institute of Justice, July 1996. 

6. Glaser, J.B., and R.B. Greifinger, "Correctional Health Care: A Public
Health Opportunity," Annals of Internal Medicine 118 (January 15,
1993):139-145.

7. Hammett, T.M., J.L. Gaiter, and C. Crawford, "Reaching Seriously
At-Risk Populations: Health Interventions in Criminal Justice Settings,"
Health Education and Behavior 25 (February 1998):99-120.

8. Hammett, T.M., and P. Harmon. 1997 Update: HIV/AIDS, STDs, and
TB in Correctional Facilities, Issues and Practices, Washington, D.C.:
U.S. Department of Justice, National Institute of Justice and U.S.
Department of Health and Human Services, Centers for Disease Control
and Prevention, forthcoming.

9. Dixon, P.S., T.P. Flanigan, B.A. DeBuono, J.J. Laurie, M.L. DeCiantis,
J. Hoy, M. Stein, H.D. Scott, and C.C.J. Carpenter, "HIV Infection in
Prisoners: Meeting the Health Care Challenge," American Journal of
Medicine 95 (December 1993):629-35.

10. Flanigan, T.P., K. Vigilante, J. Burzynski, G. Bubley, J. Kim, S. Cu
Uvin, L. Normandy, M. Snead, A. De Groot, M.L. De Ciantis, and B. De
Buono, "Medical Care of HIV-Infected Prisoners: The Rhode Island
Experience," AIDS Clinical Research and Care: Meeting the Challenges
of an Epidemic in Flux, Public Responsibility in Medicine and Research
Conference Proceedings, October 1992.

11. Flanigan, T.P., J.Y. Kim, S. Zierler, J. Rich, K. Vigilante, D.
Bury-Raymond. "A Prison Release Program for HIV-Positive Women:
Linking Them to Health Services and Community Follow-Up" (letter).
American Journal of Public Health 86 (December 1996):887.

-------------------------------

Survey and Site Visit Methodologies

The ninth national NIJ/CDC survey of HIV/AIDS, STDs, and TB in
correctional facilities was conducted in 1996 and 1997. Responses were
received from all 50 State departments of correction, 41 of the largest
city/county jail systems, and the Federal Bureau of Prisons. Following
that, the survey was validated using an abbreviated version of the
questionnaire with 50 individual facilities in 15 State correctional systems
and the Federal Bureau of Prisons. The objective of the validation was to
compare responses on key policy issues from individual facilities with
responses from the central offices of their State departments of
corrections.

As a followup to the national NIJ/CDC survey, a series of 11 site visits
also was conducted in 1997 to determine the extent and nature of public
health/corrections collaborations in the prevention and treatment of
HIV/AIDS, STDs, and TB. 

Site visits were made to the following 6 States and 5 city/county-level
jurisdictions by teams from Abt Associates, the Centers for Disease
Control and Prevention, and the National Institute of Justice:

o States

-- Florida.

-- Illinois.

-- Missouri.

o Cities and Counties

-- San Francisco, California.

-- Chicago (Cook County), Illinois.

-- Rochester (Monroe County), New York.

-- Memphis (Shelby County), Tennessee.

-- Houston (Harris County), Texas.

The sites were chosen based on telephone interviews with more than 20
jurisdictions that had been identified by CDC and Abt Associates. The
final site selections were made with a view toward geographic diversity
and having an even mix of State and city/county jurisdictions.

The 2-day visits included interviews with correctional and public health
staff as well as visits to correctional and juvenile confinement facilities.
Key public health staff in HIV/AIDS, STDs, and TB and correctional
health services staff and others in the correctional systems who were
involved in collaborations with public health departments were
interviewed. The study team visited the major jail facility in each
city/county and one or two facilities in each State.

-------------------------------

Rhode Island's Model of Collaboration

Rhode Island has developed a state-of-the-art model of collaboration
involving the State Department of Health, the State Department of
Corrections, an academic medical center (Miriam Hospital, affiliated with
Brown University), and approximately 40 community-based organizations
and service agencies. The organizational chart of Rhode Island's AIDS
Services After Prison (ASAP) program, a centerpiece of the State's
collaborative efforts, is displayed in exhibit 2.

Meetings and interactions between all of the organizational partners in the
Rhode Island collaboration take place regularly. The partners also work
together on disease surveillance, policies, legislative proposals, and union
issues in the facilities. There is a demonstrable commitment to working
together. In the words of the administrator of the Rhode Island health
department's office of HIV/STDs, there is no sense of "our problem versus
your problem."

The Department of Health provided much of the initial funding for
staffing the program. However, over time, the program has been
institutionalized and the Department of Corrections has picked up an
increasing share of personnel costs, funding two public health educator
positions from its regular budget.

In 1986 collaboration between the Rhode Island health and correctional
departments led to the development of one of the first correctional AIDS
policies in the United States. Early on, treatment and supportive services
for inmates with HIV and continuity of care between providers in prison
and in the community were important goals of this collaboration.[9]
Subsequently, pretest and posttest counseling, discharge planning,
transitional services, and community linkages for HIV-infected inmates
and at-risk HIV-negative inmates were added. 

The legislatively mandated implementation of HIV-antibody testing for
incoming inmates in 1989 and the expansion of TB and STD screening in
Rhode Island correctional facilities provided data that made a compelling
case for health programming. The correctional department completes
surveillance reports on HIV, STDs, and TB and provides those reports to
the health department. The correctional department also notifies the health
department's TB unit when a person with active or suspected TB or on TB
prophylaxis is being released so continuity of care can be arranged.

Postrelease services for inmates with HIV infection or at risk for HIV
infection include medical treatment, housing, substance abuse treatment,
job development, psychosocial support, and long-term case
management.[10] Evaluation results reveal reduced recidivism rates
among female inmates who participated in these programs.[11]
Compliance with postrelease medical and other appointments for services
increased dramatically as well. 

Program staff participate in a weekly case-assignment meeting to discuss
community linkages and placements for inmates nearing release. Four key
community-based organizations that specialize in the following
populations and services participate in these meetings: 1) mentoring for
employable women; 2) services for cocaine- and/or alcohol-involved
persons; 3) services for long-term sex workers and/or injection drug users;
and 4) services for HIV-infected persons.

A disease investigation specialist, whose position is funded by the
Department of Health and who is based at the correctional facility, notifies
inmates' sexual partners and performs outreach, primarily HIV. The
specialist also locates HIV-positive individuals who have been released to
the community before receiving their test results and links them to
services at Miriam Hospital or a comparable provider of HIV services.

The CDC funding of two additional public health educator positions in the
Department of Corrections has increased the overall program's emphasis
on prevention. These educators orient incoming inmates on infectious
diseases, provide multisession prevention programs for current inmates
and educational sessions for staff, and coordinate inmate peer education
programs.

Health department staff have met with the correctional officers' union to
address issues surrounding disclosure of inmates' HIV status. The union
favored disclosure to all correctional officers, but a compromise was
achieved whereby disclosure may occur only in the case of potential
transmission incidents, which are the primary concern of the union.

-------------------------------

New York State's Model of Collaboration

Collaborations between the New York State Department of Health (DOH)
and the Department of Correctional Services (DOCS) on HIV/AIDS and
TB involve almost constant interaction between the two agencies at both
central office and facility levels. Collaborations on STDs have been
primarily between DOH and county jails because DOH staff believe that
the key opportunity for STD intervention is at the jail level and is
essentially lost once inmates move on to DOCS facilities.

Beginnings of collaboration. The AIDS Institute of the New York State
DOH and DOCS began their collaboration in 1987. The institute's
Criminal Justice Initiative (CJI) involves a comprehensive array of
HIV/AIDS services in DOCS facilities, such as HIV counseling and
testing, education (including peer education programs provided by
ex-offenders and current inmates), and supportive and transitional services
for inmates living with HIV disease. 

Facility-level cooperation. Institute staff emphasize that their involvement
has been and remains dependent on the cooperation of individual
facilities' superintendents, which, with the substantial assistance of DOCS
central office staff, they have been quite successful in winning and
maintaining. 

State-level cooperation. The DOH Bureau of HIV/AIDS Epidemiology
(AIDS Epi) and DOCS have collaborated on HIV/AIDS surveillance. The
AIDS Institute and DOCS have also collaborated on the development of
medical protocols and a quality review of HIV medical services. A
memorandum of understanding between DOCS and the AIDS Institute for
ongoing case-based quality review of HIV medical services was under
development at the time of the site visit. 

In 1989 the AIDS Institute and DOCS initiated a joint project in which
DOCS funded positions in the institute to form regional teams to provide
HIV counseling and testing for inmates and educational programs for
inmates and correctional staff. This project was closely coordinated by the
central offices of both agencies, and DOCS reviewed and approved the
educational curriculums. Funding was also provided for AIDS Counseling
and Education (ACE), a peer-based prevention and support program at the
Bedford Hills women's facility. In 1992, the Women's Prison Initiative
was established by the AIDS Institute to replicate the ACE peer education
model at the other women's facilities and to provide a comprehensive
continuum of care for HIV-infected females. Services provided at Albion,
Taconic, and Bedford Hills correctional facilities include peer training,
peer-delivered education on HIV/AIDS prevention and risk reduction,
HIV counseling and testing, supportive services for HIV-infected inmates,
and discharge planning and case management for inmates with HIV
disease.

The AIDS in Prison Hotline project, funded by the AIDS Institute and
operated by the Osborne Association in New York City, provides
counseling, education, support, and referrals to community-based services
for inmates. Inmate collect calls are encouraged. 

CBOs brought in. In 1993 the regional teams serving DOCS facilities
were expanded to include community-based organizations (CBOs).
DOCS, CDC, the AIDS Institute, and other sources provide about $3
million per year for CJI activities. Most DOCS facilities now receive
services through the AIDS Institute's CJI.

AIDS Institute staff reported that relations between the regional teams, the
CBOs, and DOCS central office and facility staff are generally good.
Although only about 25 percent of the funding for CJI activities comes
from DOCS, interdepartmental communication and collaboration at the
central office level are essential. At the facility level, the regional teams
and CBOs are often accepted as part of the facility's staff. Initial and
ongoing meetings on AIDS Institute programs at the facility level help
ensure mutual understanding of roles and expectations and address
emerging issues. Correctional officers' union representatives and inmate
liaisons are included in these meetings.

HIV-seroprevalence studies. In the late 1980s, AIDS Epi began
collaborating with DOCS on a series of blinded studies of HIV
seropositivity among incoming inmates at the reception centers--
Downstate and Ulster for men, and Bedford Hills for women. When it
became clear that HIV seropositivity rates among inmates accepting
voluntary testing were substantially lower than rates found in the blinded
studies, the AIDS Institute and DOCS collaborated on a pilot study at
Ulster to investigate these discrepancies. The 1994 study revealed that
many inmates did not accept voluntary testing because they denied or
underestimated the seriousness of their risk factors. Prior knowledge of
HIV status was not a major reason for inmates to decline voluntary
testing.

AIDS reporting extended. AIDS surveillance for DOCS inmates was
essentially passive until 1996; inmate cases were not reported to DOH by
DOCS. Only inmates admitted to a hospital for an AIDS-related illness
were reported. In 1996, however, DOCS began providing DOH with an
electronic database of case reports for all inmates known to have AIDS.
This facilitated cross-checking case registries and helped increase the
accuracy of case counts.

Success in TB control. Since 1988, the New York State DOH Bureau of
TB Control and DOCS have had extensive and, according to DOH staff,
"exemplary" collaborations in screening, treatment, case management,
surveillance, outbreak investigation, discharge planning, education and
training of staff and inmates, and technical assistance to staff. TB cases in
DOCS have declined steadily since reaching a peak in 1993. No TB
outbreaks have occurred in DOCS facilities since 1993.

In 1988 and 1993, the New York State DOH's Bureau of Occupational
Health assessed air-handling systems in DOCS facilities to better control
TB. Training in environmental infection control measures and monitoring
of negative pressure rooms was also given. DOH staff worked closely
with DOCS and CDC staff to investigate and respond to a 1991 outbreak
of multidrug-resistant TB. This included development and implementation
of mandatory annual inmate and staff screening, education and training,
and other measures to prevent recurrent outbreaks of TB.

HIV-related TB project. From 1991 to 1995, DOH collaborated with
DOCS on the HIV-Related TB Project (HRTP). This established a
demonstration screening and directly observed preventive therapy
program at DOCS intake facilities. DOH conducted TB surveillance at
DOCS facilities, and DOCS carried out all screening and treatment of
inmates.

Two public health representatives (PHRs) from the DOH Bureau of TB
Control are based at a DOCS reception center, where they are well
integrated with health service staff. Another eight PHRs collectively visit
each prison every 2 weeks to identify and report new suspected cases of
TB and monitor treatment. In general, the PHRs work closely with the
DOCS infection control nurses at the prisons on TB control, screening,
and treatment issues. DOH staff conduct all surveillance and case tracking
and consult on contact investigations and case management in DOCS
facilities. PHRs report possible AIDS cases they identify to the AIDS Epi
staff at DOH. The process of completing clinical records is automated so
the appropriate PHR can be notified and receive case records immediately
when an inmate is transferred to a facility in a different part of the State.
Regular meetings and interactions between DOH and DOCS staff are
devoted to surveillance, including reconciliation of case counts and other
matters. DOH's TB nurse coordinator meets every 2 weeks with the
DOCS director of communicable disease control who supervises the
infection control nurses in the prisons. DOH's TB Bureau works with
DOCS and the parole department on discharge planning for inmates with
TB, as well as on community linkages and monitoring of adherence to
treatment regimens following release.

STD control in county jails. As mentioned, collaborations on STD
services have largely occurred between the State health department and
county jails. In a demonstration project funded by CDC at the Nassau
County jail, DOH staff provided rapid syphilis screening at intake and
treatment of inmates with positive tests and no record of prior treatment.
This intervention had a significant and positive effect on syphilis
morbidity in the overall community. The STD control division of DOH is
working on similar programs with jails in Monroe, Westchester, and
Chautauqua counties, as well as in New York City.

-------------------------------

Policy Implications

This study identified many effective and promising public
health/corrections collaborations to address problems of HIV/AIDS,
STDs, and TB in correctional facilities, as well as gaps, shortfalls, and
weaknesses in collaborative efforts. In general, the study found that
inmate services and collaborations in the following areas could benefit
from expansion and enhancement:

o Behavioral prevention programs.

o Inmate peer-based programs.

o Discharge planning and transitional services, including continuity of
care, adherence to medication regimens, and social services to ease the
transition to the community.

The study also found that most current collaborations involve public
health departments providing or funding services in correctional facilities.
This is, to be sure, an important aspect of collaboration that requires
granting access to the facility as well as some interchange and discussion
between public health and correctional agencies. But several actions are
required to achieve comprehensive relationships:

o Collecting and disseminating data by public health departments to
demonstrate the disease burden in correctional and criminal justice
populations. Without these data, it may be very difficult to convince
decisionmakers of the need for more resources and expanded
collaborations.

o Including correctional representatives on HIV Prevention Planning
Groups. Such representation can help to ensure that correctional and
criminal justice settings receive their fair share of attention and that their
unmet resource needs receive appropriate priority.

o Initiating or expanding funding by public health departments of services
and staff in correctional facilities and other criminal justice settings. Such
funding support can be the first step in the development of full
collaborations.

o Recognizing the importance of interventions in correctional settings to
the health of the larger community. In particular, the importance of
screening, early detection, and early treatment can be understood and
reflected in program priorities.

Additional steps to consider 

Additional, more specific steps may be taken to help ensure successful
collaboration:

Improving the context for collaboration. Use administrative, legislative,
and regulatory powers to require collaborations:

o Include specific roles and requirements for health departments and
correctional agencies for collaborative efforts in appropriate legislation
and regulations.

o Formalize collaborative relationships between health departments and
correctional agencies in memorandums of understanding or other written
agreements.

o Establish and use the legal powers of health directors to require disease
screening and other interventions as appropriate and ethical.

Building collaborative attitudes. Promote the following attitudes and
philosophies that facilitate collaboration:

o Establish a commitment by health departments and correctional
agencies to the principle that public health is part of public safety.

o Recognize that correctional facilities are part of the community.
Additionally, virtually all inmates return to the community.

o Open correctional facilities to outside organizations that can provide
valuable resources and expertise to address health issues.

o Build mutual respect for each others' missions, priorities, concerns, and
capabilities. For example, address the legitimate concerns of correctional
employees regarding occupational exposure to HIV, STDs, TB, and other
diseases.

o Be willing to compromise and work within the reasonable rules and
constraints of the correctional facility in order to achieve larger public
health goals.

Operationalizing collaboration. Establish the following operational
features to foster collaboration:

o Locate health department programs and staff in correctional facilities.

o Establish single, regularly accessible liaisons for collaboration at the
central office and facility levels.

o Resolve logistical issues by, for example, providing trouble-free gate
clearance for health department program staff and expediting callout and
escorts for inmates attending health programs.

Improving communication. Improve communication and information
exchange among all staff members in the following ways:

o Develop and implement better systems for accessing and exchanging
important clinical and inmate-locator information at all jurisdictional
levels.

o Establish joint health department/correctional committees at the
leadership and operational levels.

o Hold regular joint staff meetings at the central office and facility levels.

-------------------------------

Theodore M. Hammett, Ph.D., a Vice President at Abt Associates Inc.,
was the principal investigator for this study. The project was supported by
contract OJP-94-C-007 awarded to Abt Associates Inc. by the National
Institute of Justice.

-------------------------------

Findings and conclusions of the research reported here are those of the
author and do not necessarily reflect the official position or policies of the
U.S. Department of Justice.

-------------------------------

The National Institute of Justice is a component of the Office of Justice
Programs, which also includes the Bureau of Justice Assistance, the
Bureau of Justice Statistics, the Office of Juvenile Justice and
Delinquency Prevention, and the Office for Victims of Crime.

-------------------------------

NCJ 169590

-------------------------------

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