U.S. Department of Justice

Office of Justice Programs

National Institute of Justice

DEPARTMENT OF JUSTICE

OFF ICE OF JUSTICE PROGRAMS

BJA NI J OJJDP BJS OVC

continued...

R e s e a r c h i n B r i e f

National Institute of Justice

Centers for Disease Control and Prevention

July 1998

Public Health/Corrections

Collaborations: Prevention and

Treatment of HIV/AIDS, STDs, and TB

by Theodore M. Hammett, Ph.D.

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:

• According to NIJ/CDC survey responses, virtually all correctional systems

have at least some collaboration with

public health agencies.

• 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.

• Most existing collaborations involve

public health departments providing

funds, staff, or direct services in correctional facilities.

• Programs in Rhode Island and New

York State exemplify more comprehensive collaborations.

• Key factors in successful collaborations include:

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

Partners in Research on

Correctional Health Care
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R e s e a r c h i n B r i e f

Issues and Findings continued...

– 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:

• Public health agency collection and

dissemination of data on the burden of

infectious disease in inmate populations.

• Including correctional representation

on all HIV Prevention Planning Groups.

• Public health agency initiation or expansion of funding for services and staff

in correctional facilities.

• 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.

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

Survey and Site Visit Methodologies

he 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:

• States

– Florida.

– Illinois.

– Missouri.

T • 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.

– New York.

– Rhode Island.

– Washington.
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R e s e a r c h i n B r i e f

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:

• Administration and infrastructure.

• Policy development.

• 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 deExhibit 1: Collaboration Between Correctional Systems and Public Health Departments, 1997

Percentage of Systems Reporting Collaborations

HIV/AIDS STDs TB

State/Federal City/County State/Federal City/County State/Federal City/County

Prison Systems Jail Systems Prison Systems Jail Systems Prison Systems Jail Systems

Areas of Collaboration (N=51) (N=41) (N=51) (N=41) (N=51) (N=41)

Educational Programs 78 63 67 53 75 49

Other Prevention Programs 69 59 55 39 61 41

Testing/Screening 73 68 69 73 71 71

Case Reporting 90 66 92 59 92 85

Counseling 78 61 53 46 47 37

Partner Notification 75 44 78 59 78 54

Outbreak Investigation 51 37 61 44 82 73

Treatment/Prophylaxis 65 59 65 63 80 85

Discharge Planning 84 71 65 54 84 83

Staff Training 82 68 73 59 82 76

Source: 1997 NIJ/CDC Survey
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hode Island has developed a stateof-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 proRhode Island’s Model of Collaboration R viders 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 caseassignment 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 HIVinfected 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.
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R e s e a r c h i n B r i e f

Exhibit 2: Rhode Island AIDS Services After Prison (ASAP) Organizational Chart

Department of

Health

Department of

Corrections

Miriam Hospital/

Brown University

Office of Communicable

Diseases

Health Care Services

Medical Director

Office of

AIDS/STDs/TB

 AIDS Team (ASAP)

Supervisor

Immunologic Center

Physicians and Fellows

Partner

Notification

Testing/

Counseling

Discharge

Planning Peer Education

Community Affiliates

AIDS Service

Providers

Medical Services Drug Treatment

Programs

Case Management Housing Services State/Federal Agencies

• Support Groups

• Counseling

• Hotline

• Referral Services

• Spiritual Support

• Hospital-Based Clinics

• Health Centers

• HIV Centers

• Clinical Trials

• Methadone

• 12-Step

• Residential

• Outpatient

• Mental Health

• Hospice

• AIDS Housing

• Shelters

• Domestic Abuse 

Shelters

• U.S. Department of

Veterans Affairs

• R.I. Department of Employment

and Training

• Social Security Administration

• R.I. AIDS Medication Program
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R e s e a r c h i n B r i e f

velopment, 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:

• Data and events demonstrating a

need for collaboration.

• Organizational, legislative, and

regulatory provisions.

• Appropriate attitudes and

philosophies.

• Program funding and operations.

• 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
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R e s e a r c h i n B r i e f

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 agencies

coordinate 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:

• Strong commitment.

• Willingness to open facilities to

outside agencies.

• 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.
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R e s e a r c h i n B r i e f

New York State’s Model of Collaboration C ollaborations 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 casebased 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.

continued...
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R e s e a r c h i n B r i e f

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.

continued...

New York State’s Model of Collaboration

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.
10

R e s e a r c h i n B r i e f

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:

• Health department funding of programs in corrections.

• Presence of health department staff

and programs in correctional facilities.

• Presence of a liaison person.

• Formal agreements for collaborations.

• Staff characteristics.

• 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
11

R e s e a r c h i n B r i e f

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 depart-
12

R e s e a r c h i n B r i e f

ment 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:

• Correctional representation on HIV

Prevention Planning Groups.

• Health and correctional department

service on other joint committees.

• Regular meetings at leadership and

operational levels.

• 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,
13

R e s e a r c h i n B r i e f

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
14

R e s e a r c h i n B r i e f

Policy Implications T his 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:

• Behavioral prevention programs.

• Inmate peer-based programs.

• 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:

• 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.

• 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.

• 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.

• 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:

• Include specific roles and requirements for

health departments and correctional agencies for

collaborative efforts in appropriate legislation and

regulations.

• Formalize collaborative relationships between

health departments and correctional agencies in

memorandums of understanding or other written agreements.

• 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:

• Establish a commitment by health departments and correctional agencies to the principle

that public health is part of public safety.

• Recognize that correctional facilities are

part of the community. Additionally, virtually

all inmates return to the community.

• Open correctional facilities to outside organizations that can provide valuable resources and

expertise to address health issues.

• 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.

• 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:

• Locate health department programs and

staff in correctional facilities.

• Establish single, regularly accessible liaisons for collaboration at the central office

and facility levels.

• 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:

• Develop and implement better systems for

accessing and exchanging important clinical

and inmate-locator information at all jurisdictional levels.

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

• Hold regular joint staff meetings at the central office and facility levels.
15

R e s e a r c h i n B r i e f

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 AtRisk 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. BuryRaymond. “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.
16

R e s e a r c h i n B r i e f

Appendix: Summary of Collaborative 

DOH = Department of Health DOC = Department of Correction DOCS = Department of Correctional Services MDR = Multidrug Resistant

Health

Department

Responsibility

Disease

Surveillance

Database

Support

Inspections and

Assessments

Quality

Assurance Staff Training

Linkage

Sites Development

Administration and Infrastructure

Rhode Island

New York

Washington

Florida

Missouri

Illinois

Houston

(Harris

County),

Texas

Memphis

(Shelby

County),

Tennessee

Rochester

(Monroe

County),

New York

San

Francisco,

California

Chicago

(Cook

County),

Illinois

DOC medical staff report HIV,

STDs, TB, and all other

reportable infectious diseases

to DOH.

DOH collaborates on blinded

HIV-seroprevalence studies

and improved AIDS-case

counting. DOH funded demonstration TB screening projects

at DOCS intake facilities; 10

regional PHRs perform

surveillance, case tracking,

and contact investigations.

DOH collaborates on blinded

HIV-seroprevalence studies.

DOH documents STD morbidity in adult and juvenile

facilities.

DOH-funded staff prepares TB

case reports on inmates.

DOC provides HIV-screening

reports to DOH. DOH

conducts surveillance for HIV,

STDs, and TB.

DOH collaborates with DOC

on blinded HIVseroprevalence studies.

DOH provides HIV/AIDS, STD,

and TB surveillance and

disease tracking.

DOH provides onsite STD

surveillance.

DOH provides

computer equipment. DOC

provides database.

DOH access to

DOCS database

on inmate movements facilitates

TB tracking and

delivery of HIV-test

results.

DOH provides

DOC staff with

access to TB

treatment and

prevention therapy

databases.

DOH access to DOC

database on inmate

movements and

locations facilitates

TB tracking.

DOH staff have

access to jail

computer and

provide access to

city syphilis

registry.

DOC medical director

contacts DOH TB

coordinator in cases of

active/suspect TB in

discharged population.

DOH assisted with

investigation of

MDR-TB outbreak in

prisons. DOH assessed

air handling in DOCS

facilities and consults

on specifications for

negative-pressure

rooms.

DOH surveyed HIV/

AIDS, STD, and TB

services in prisons.

DOH inspects prisons

each year and helps

justify requests for

resources.

DOH-funded staff

monitor TB treatment

logs in prisons.

DOH surveyed HIV/

AIDS, STD, and TB

services in jails.

DOH reviews treatment of all cases.

DOH and DOCS

collaborates on

HIV/AIDS case

review. DOH monitors

treatment of TB cases

in DOCS facilities.

DOH reviews treatment of active TB

cases.

Collaborative TB

case-review

conferences are held

regularly.

DOH teams monitor

HIV and STD testing

and treatment in State

prisons. TB casereview meetings are

held monthly. DOH

participates in review of

DOC health services

contractor.

DOH reviews STD

morbidity reports to

assess treatment.

DOH ensures appropriate STD treatment

and participates in

infectious disease

quality-assurance

meetings.

DOC attends DOH HIV

Advisory Committee. DOC is

part of HIV Prevention

Planning Group.

Routine meetings are held

between DOH and DOCS.

DOCS participates in

statewide meetings with

contractors serving correctional facilities.

Quarterly meetings are held

with DOC and DOH staff.

Governors Council on AIDS

provides linkage among many

agencies, including DOC and

DOH. Quarterly TB coordination meetings are held. DOC

participates in HIV Prevention

Planning Group.

DOH funds women’s jail

committee. DOH serves

with jail staff on Jail Health

Advisory Committee.

DOH launched and coordinated Bay-area TB

control group, bringing

together public health and

correction staff.

DOH provides TB training

and technical assistance for

staff of DOCS. DOH trains

DOCS staff in HIV/AIDS

transmission, prevention,

workplace practices, and

universal precautions.

DOH reserves slots for DOC

staff at annual STD clinical

updates. DOH trains DOC

staff on HIV counseling and

testing.

DOH holds annual health

update conferences, including training in HIV counseling

and testing. DOC and DOH

jointly sponsor TB workshops.

DOH provides training to

probation and parole staff in

HIV risk assessment and

community linkages.

DOH trains DOC staff in TB

and STD interviewing and

counseling techniques.

DOH assists in providing

and coordinating STD

training to jail clinicians.

DOH trains clinicians at jail

and juvenile detention

center.

DOH TB control staff trained

jail staff in placing and

reading PPDs.

DOH provides TB training at

correctional officer’s academy

and STD training to jail

clinicians.

DOH is responsible

for health services

in jails.

DOH is responsible

for health and

mental health

services in jails.

Cermak Health

Services, a unit of

county government,

provides all jail

health services.
17

R e s e a r c h i n B r i e f

Legislation and

Policy

Clinical

Protocols

Education/Prevention

Programs

Testing, Screening, and

Followup Treatment

Discharge

Planning and

Transitional Services

Laboratory

Services

Policy Development Service Delivery

Efforts Identified During Site Visits

DOH and DOC collaborated

on DOC’s HIV/AIDS policy.

DOH and DOC jointly

drafted legislation on HIV

testing in response to

incidents and disclosure of

HIV status.

DOH helped draft and

review DOC infection control

manual. DOH reviews other

policies. DOH helped draft

legislation on disclosure of

HIV status.

DOC coordinates all HIV/

AIDS, STD, and TB policy

guidelines with DOH.

DOH and DOC collaborated

on point-scoring assessment

of TB isolation, developed

guidelines for TB screening

and treatment, and

compromised on condom

distribution at release.

Health officer mandated

universal PPD screening in jails.

DOH and sheriff’s department compromised on HIV

testing and disclosure policy.

DOH and DOC medical

director collaborated to

initiate universal pregnancy

screening at jail intake.

DOH (with CDC funding) funds prison

prevention staff, who offer HIV orientation

and multisession programs and coordinate inmate peer program.

$3 million per year for HIV/AIDS services

were provided to prisons, juvenile

facilities, and parolees for peer-led

programs. DOCS funds regional teams

from AIDS Institute to present HIV

educational programs.

DOH distributes STD prevention literature

to State prisons. DOH funds a CBO to

provide HIV prevention work in prisons.

DOH funds peer-based HIV/AIDS

prevention program at Lawtey Correctional Facility. Program is being expanded

to other facilities.

DOH provides training for inmate HIV/AIDS

peer educators in two DOC facilities.

DOH funds HIV/AIDS education programs

at prerelease centers. DOH funds and

provides training for peer HIV/AIDS

prevention program in most facilities. DOH

trained 100 peers, and peers made 17,000

contacts with inmates in 1996.

CDC funds VCRs and TVs to show HIV

prevention videos in city jail.

DOH/jail team offers HIV/STD educational

services at county jails.

DOH provides jail inmates with education

in TB preventive therapy.

DOH’s Forensic AIDS Project (FAP) offers

HIV education and prevention programs

and distributes condoms in jails.

Chicago DOH provides $340,000 per year

for HIV prevention programs, which funded

7 of 10 HIV educators in county jail.

DOH funds HIV pretest and posttest

counseling and partner notification in

prisons. DOH provides TB outreach

and followup for persons released from

jail and prison.

AIDS Institute regional teams and

funded contractors provide HIV

counseling and testing. DOH (with

CDC funding) supports STAT syphilis

screening and treatment programs in

selected county jails. DOH and DOCS

developed and implemented mandatory TB screening for inmates and

staff.

DOH provides HIV/STD partner

notification services in prisons. DOH

provides special STD screening in two

county juvenile detention centers. DOH

offers chlamydia screening at women’s

prison.

State/county DOHs provide STD

screening, followup, and partner

notification in many State prisons,

county jails, and juvenile facilities.

DOH-funded staff do TB followup.

DOH funds HIV/STD/TB screening and

partner notification services in prisons.

Three regional DOH teams conduct

followup interviews with syphilispositive inmates. DOH assists with TB

screening and followup in prisons.

DOH funds peer-based HIV prerelease

programs.

DOH staff conducts STD contact

investigations.

County DOH offers HIV counseling and

testing. City DOH provides inmate

followup for HIV/AIDS and STD

treatment, and referral. City DOH

provides partner notification to outside

contacts. City DOH/jail team provides

limited syphilis and HIV testing in

several facilities. City DOH performs

contact investigation on all active TB

cases in jail.

DOH/jail teams provide HIV counseling, testing and partner notification in

jails. DOH/jail teams provide STD

screening, followup interviews, partner

notification, and evaluation of PPDpositive TB tests.

DOH teams provide HIV counseling

and testing, and STD testing and

followup in jail and juvenile facilities.

DOH TB staff follow up on PPD

positives in jail and community.

FAP provides HIV counseling and

testing. DOH screens for STDs in jail,

follows up in the community, and

performs TB screening and followup.

DOH funds STD screening staff at jail

(with CDC funding). DOH provides

STAT (immediate) syphilis screening

and treatment for women in jail. DOH

follows up in community and provides

PPD results.

DOH and DOC

jointly fund

treatment, which

helps ensure

continuity of care.

Academic medical

center involved.

DOH funded a

demonstration of

directly observed

preventive therapy

for TB at DOCS

intake facilities.

DOH reps perform

TB case management at DOCS

facilities.

County DOH

follows up on TB

treatment of

released

inmates.

Joint project with

DOC/Parole

Department

provides incentives to refill TB

prevention

medication

prescriptions.

City DOH/jail

team provides

some medications for STD

treatment in jail.

County provides

directly observed

therapy for jail

releasees with

TB.

FAP provides

medical and

psychological

services for

inmates with HIV/

AIDS.

DOH provides

directly observed therapy

to jail releasees

with TB.

DOH and DOC jointly fund

discharge planning and

community linkage. DOC

medical director contacts

DOH TB coordinator in

cases of active/suspect TB

in discharged population.

AIDS Institute supports

Prisoners Hotline and

transitional services for

inmates with HIV/AIDS. DOH’s

TB bureau promotes collaborative planning between DOCS

and Parole Department, links

releasees and community

providers, and monitors

treatment in community.

DOC coordinates with DOH

on discharge planning and

continuing care for inmates

with HIV/AIDS and TB.

DOH hired discharge

planner to work in jail.

FAP provides discharge

planning and community

linkages for inmates with

HIV. Jail staff and DOH TB

control staff coordinate

discharge planning and

followup of patients with

active TB.

State lab

performs

confirmatory

HIV testing.

DOH lab

processes HIV

and STD tests

for DOCS

inmates.

DOH provides

some HIV and

STD testing for

State prisons.

DOH provides

STD testing for

many county

jails.

State public

health lab

provides all

STD testing for

State prisons.

State DOH lab

provides

confirmatory

syphilis testing.

DOH and

DOCS jointly

develop HIV/

AIDS treatment protocols and TB

control policy.

Governors

Council on

AIDS reviews

HIV/AIDS

treatment

protocols for

inmates.

CBO = Community-Based Organization
18

R e s e a r c h i n B r i e f

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.

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.

NCJ 169590

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.

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