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.'"