People with HIV have a high rate of ending up behind bars, but even though the diagnosis is not entirely uncommon among people in county jails, it’s hard to know the kind of care these patients receive while they’re detained due to a lack of research.
A recent study from researchers at the University of North Carolina at Chapel Hill attempted to glimpse through the curtain at what HIV treatment looks like for people living with HIV who cycled through 21 out of the state’s 95 jails.
The researchers interviewed 23 people, who reported more than 300 jail incarcerations across North Carolina in the time since they had been diagnosed with HIV.
What they found is indicative of medical care across jails in the state: that care varies depending on the jail.
North Carolina’s state prison system reports to the Department of Public Safety leadership in Raleigh, so there is some level of standardization across facilities.
But even though jails are required under state law to “be operated so as to protect the health and welfare of prisoners and provide for their humane treatment,” they are run by individual sheriffs and funded by county budgets, so both standards and quality of care may differ from county to county.
The disparities in treatment across jails are not unexpected; other forms of treatment also vary from county to county. For example, North Carolina Health News has previously written about the uneven distribution of medication-assisted treatment (MAT) in jails for people with substance use disorder.
Access to HIV medication
As many as one in seven people with HIV pass through the justice system each year, a function of the socioeconomic and racial disparities characteristic of the spread of HIV in the country today.
Incarcerated people are more likely to be poor, more likely to have a substance use disorder or mental illness, and to have less access to health care, circumstances shared by many of the people currently at the highest risk for acquiring HIV.
Most research on HIV in carceral settings, however, has been in prison settings, so it’s hard to know what kind of treatment they’re getting – especially in county jails.
While there is no known cure for HIV, people living with HIV can take antiretroviral medications which reduce an individual’s viral load to make it completely undetectable, and effectively prevent transmission of the disease through sexual activity, according to the Centers for Disease Control and Prevention.
“These medications help keep people with HIV healthy and they prevent the sexual transmission of the virus to others,” said David Rosen, one of the researchers who contributed to the study. “So there is both an individual benefit and a public health benefit to ensuring that people with HIV have access to these medications.”
Most of the study’s recipients were able to access medication while in jail, but some participants reported that there were periods during their incarceration where they did not get their medication. The delays could have to do with anything from administrative delays to jails declining to provide medication because they didn’t want to foot the bill.
“There are a variety of barriers for HIV treatment in jail,” Rosen said, “Stigma, low levels of health care and custody staffing and resources, and policies that delay treatment.”
Since individual counties often have to foot the bills for medical expenses, for some small counties, every penny counts.
About half of jail stays are two days, Rosen said, and “there seems to be little biologic consequence to missing a day or two and then restarting [HIV medication].”
However, Rosen said due to the large number of people with HIV who do become incarcerated, society misses a chance to help people with HIV by not providing adequate treatment.
There are non-medical barriers to accessing HIV treatment as well. People with HIV who have been incarcerated report handling two kinds of stigma — for being incarcerated and for having HIV.
Most participants in the study said they kept their HIV status private from both jail staff and other incarcerated people for fear of being treated differently. Then, when they had returned to the community, some participants explained that they were treated differently by their doctors on the outside for ending up in jail.
“Stigma associated with incarceration is an important health care issue and one that is deserving of a lot more attention,” Rosen said.
There are also “collateral consequences” to incarceration that can impact access to health care resources as well, Rosen said. It is difficult for formerly incarcerated people to find employment and housing, even when they have reentered society.
Policies such as Medicaid suspension for people incarcerated in local jails doesn’t help either. When a person is incarcerated in jail, their Medicaid must be suspended under state law. However, it could take more than a month to get back onto the program, advocates previously told North Carolina Health News.
As the North Carolina General Assembly continues to hold hearings on expanding Medicaid in the state, advocates have argued that Medicaid expansion could be vital to the health of formerly incarcerated people.
Rosen argued that Medicaid should be used to pay for incarcerated people’s health.
He also notes that many formerly incarcerated people are not eligible for insurance, even though incarcerated people tend to be sicker than the general population, with higher rates of diseases such as HIV, diabetes or hepatitis C.
Rosen wants to expand the conversation about health in jails outside of a legal obligation as well as alternatives to incarceration and getting people the help they need with community-based care.
“Jail health care seems to be primarily designed to provide just enough services to protect the jails against liability,” Rosen said. “Rescinding the inmate [Medicaid] exclusion policy could be an important step in changing that paradigm and providing more robust services.”