Several times each month, a white bus picks up newly released ex-inmates at New York’s Rikers Island jail complex and drives into Harlem, where helping hands await at a transition program run by a nonprofit called the Fortune Society.
These new arrivals face the myriad challenges confronting anyone leaving jail or prison - and a daunting additional one. They have HIV.
While infection and incarceration represent a double challenge, this can be a health-care opportunity, says JoAnne Page, the Fortune Society’s president. "You don’t want to see people locked up - but if you’re trying to reach people who are HIV-positive, that’s the place to be."
Each year, according to federal estimates, one out of seven Americans with HIV passes through a correctional facility. Thousands are released every year - transitioning to the uncertainties of the outside world from a regimented environment where, in most cases, HIV medication is provided without charge.
Even health professionals who believe the U.S. incarcerates excessively view imprisonment as a vital chance to offer HIV testing and connect HIV-positive people to health care. These experts worry about what happens post-release, when freedom can lead to disruption of the ex-inmates’ medication, worsening their own health and raising the risk they’ll infect others.
"In prison, they’re a captive audience," said Dr. Josiah Rich, a professor at Brown University’s medical school and co-director of the Center for Prisoner Health and Human Rights.
"But when they’re out, it can be hard to track them down," he said. "Often they’re stopping treatment at exactly the point they’re starting new sexual relationships. It’s the perfect storm - exactly what we don’t want from a public health standpoint."
Rich co-authored a 2010 study that examined 1,750 HIV-infected inmates released from Texas prisons. It found that only 28 percent enrolled in an HIV clinic within 90 days.
The study spurred efforts to ensure post-release continuity of care, and drew attention to agencies such as New York City’s health department, which had an ambitious transitional care program in place for HIV-positive people exiting jail. At the core of the program are individual discharge plans, addressing each ex-inmate’s need for housing, health care and other supports.
Alison Jordan, who oversees the program, said her team draws up about 2,500 discharge plans per year and helps link more than 70 percent of the released HIV-positive inmates to primary health care in their community.
Jordan has estimated the HIV prevalence rate in New York’s jail population at 5.2 percent - far higher than the 1.25 percent HIV rate in the nation’s prison system or the 0.4 percent rate for the general population.
The Fortune Society is among the city’s partners in confronting the challenges, sending its own staff into Rikers to help with the discharge planning and then offering services ranging from mental health counseling to residential accommodation.
Without such support, says Page, many newly released people become disconnected from care.
"They return to old neighborhoods and fall back into habits that perpetuate a cycle of health decline and self-destructive behaviors that often lead back to jail or prison," she said.
Clients who have benefited from the interventions are grateful.
"I thought I was damaged goods. Coming here to Fortune helped prove me wrong," said Melissa Carter, who was diagnosed with HIV in 1994, and was behind bars in 1997-2000 for arson and writing bad checks.
In the decade after her release, she stopped taking HIV medication - except during two pregnancies - and reverted to drug abuse. She lost custody of her children, and her health went downhill.
"I hit rock bottom," she said. "The doctor told me, ’If you don’t start taking meds, you’re not going to live to see the end of the year.’"
She lived at the Fortune Society’s Harlem facility for two years - becoming a go-getter who helped lead group meetings. Now she has reconnected with her children, is studying for an online degree, and recently married.
Comprehensive discharge-planning programs such as New York City’s are far from the norm. There remains uncertainty among health professionals and policymakers as to what approach is most cost-effective.
One study addressing the question involves 400 people being discharged from incarceration in Texas and North Carolina; one group goes through existing procedures, while others get more intensive follow-up, including reminders of medical appointments sent by text to cellphones they’re provided with.
"We’re working on motivation - how make getting care a higher priority for those who are released," said the study’s leader, Dr. David Wohl, a professor at the University of North Carolina’s medical school and co-director of HIV services for the state corrections department.
In general, Wohl said, America’s prisons do a decent job of improving HIV-positive inmates’ health as they take medication and - in most cases - are prevented from substance abuse.
"The problem is, they get out. That’s sometimes the most dangerous part," Wohl said. "There’s a lapse of medical care, re-engaging in drug use ... It’s just a shame, because in prison we saw how well they were doing."
Increasingly, corrections officials recognize the continuity-of-care problem, Wohl said, because of the high medical costs of dealing with HIV-positive repeat offenders who return to prison much sicker than when they left.
While HIV treatment can be a strain on state prison budgets, it can be far more problematic for local jail operations, Wohl said.
"One person with HIV can break a local jail’s budget," he said.
According to federal figures from 2010, there were just over 20,000 inmates in state and federal prisons with HIV or AIDS. Those numbers don’t encompass jails, where turnover is high.
With jails included, Dr. Anne Spaulding, an infectious disease expert at Emory University, estimates more than 100,000 people infected with HIV are being released from incarceration annually in the U.S. In most jurisdictions, she says, they could be provided with transitional case management services for less than $9,000 per person during the first year after release.
Though HIV medication is expensive, released ex-inmates often can obtain financial assistance, notably through the federal Ryan White HIV/AIDS Program that serves people lacking adequate health coverage of their own.
Josiah Rich, the Brown University doctor, says it’s crucial that policymakers understand the importance of HIV treatment for those in prisons and jails, and those just out.
"If we can treat enough people, the HIV epidemic will go away," he said. "To do that, we need to treat the most challenging cases. This is where we find them."