Clinical care of adults during incarceration

INTRODUCTION — 

Health care in the criminal legal system, which includes local, state, and federal jails and prisons, should be available and provided at the same standard as health care in the nonincarcerated population. The provision of medical care in jails and prisons has been strongly informed in the United States by the legal case of Estelle v. Gamble, 1976 [1,2]. In this case, the Supreme Court deemed that deliberate indifference to serious illness or injury in a prisoner can be considered cruel and unusual punishment, in violation of the Eighth Amendment of the Constitution. Cases following this ruling have upheld three basic rights: the right to access to care, the right to care that has been ordered by a health professional, and the right to a professional medical judgment.

The provision of medical services in jails and prisons (also called "correctional medicine") provides an opportunity to promote public health [3]. Unfortunately, health care data sets intended to be nationally representative in the United States frequently exclude individuals who are incarcerated; as a result, health information from these settings is not complete [4].

Specific medical conditions, such as coronavirus disease 2019 (COVID-19) and tuberculosis, are of critical concern due to the increased risks for transmission of infection due to congregate living conditions [5-7]. The design of jails, prisons, and correctional health services may unintentionally facilitate the transmission of disease [8]. Jails and prisons often lack space for isolating people with communicable diseases, and overcrowding is a risk factor for communicable diseases. Infection control may be adversely impacted by limited access to showers and drinking water, a limited supply of clean clothes, little access to soap and personal hygiene products, and prohibitions against bleach and condoms [7]. People in jails and prisons may be expected to wash their own laundry by hand, rather than use institutional laundry services, and this may be insufficient to disinfect clothing. Additionally, kitchen workers and barbers may have inadequate training in infection control.

This topic addresses health issues of particular relevance to the adult incarcerated population. Issues related to the care of children of incarcerated parents and caregivers are discussed separately. (See "Developmental and behavioral implications for children of incarcerated parents".)

DEFINITIONS — 

In the United States, jails are generally local or county institutions, detaining individuals awaiting trial and sentencing as well as some who have been sentenced to short prison terms or who are being transferred between facilities. Persons detained in jails generally have short stays, although jails may also house individuals when prisons are overcrowded.

Prisons in the United States generally house persons who have been sentenced to longer terms, including life sentences. State and federal prisons house individuals who have been convicted of a crime and sentenced either by a state or the federal government, respectively. People who have violated the terms of their parole or probation generally go directly to prisons, although this varies by state. A few states, and some other countries, including England and Wales, have combined jail and prison facilities that include individuals awaiting trial or sentencing and those serving sentences.

Individuals on parole (sometimes called community supervision) have been released from prison but are still under the supervision of the criminal legal system and may return to prison for violation of their parole terms. Probation refers to the supervision of individuals as an alternative to incarceration.

Solitary confinement may be referred to by different terms (eg, isolation, maximum security, restrictive housing) in prisons, jails, and juvenile facilities. It implies that an individual has limited "meaningful" contact with other people [9].

HEALTH SERVICES IN PRISONS AND JAILS — 

Health service availability and delivery in jails and prisons vary by country and region. There is wide variation in the size of jails and prisons, and facilities are often in rural locations and geographically isolated.

An international systematic review identified inconsistent reporting of health care expenditures in prisons, with spending estimated from USD $34 (Sri Lanka) to $6714 (United Kingdom) per person in prison annually [10]. In 2015, prison medical spending was estimated at approximately $8.1 billion in the United States with substantial variation by state; annual spending per incarcerated person ranged from just over $2000 per person in Louisiana to nearly $20,000 in California [11]. Spending on medications for chronic medical and mental health conditions in jails and prisons is lower than would be expected for the nonincarcerated population with a similar disease prevalence [12]. Some individuals have not had adequate access to health care prior to their incarceration and have medical needs at the time of booking and intake. Furthermore, community resources to care for their needs after release may be lacking or difficult to procure [13]. Thus, clinicians face the complex task of addressing barriers to meeting the health needs of their patients while striving for quality goals. Groups have sought to identify appropriate quality and patient safety indicators for care in jail/prison settings [14,15] and apply quality improvement and patient safety principles to health care in such settings [16].

Health services in jails and prisons are provided in a variety of ways. Counties, territories, states, or the federal government may hire their own health providers and administer their own health care. In the United States, health care may be managed using for-profit contractors, or local public health departments may provide care to those detained in jails. One observational study identified lower mortality rates in publicly operated prisons compared with privatized prisons [17]. In Australia, health services are provided by the Department of Health in some areas and by the Department of Justice or Corrections in others [18]. Telemedicine can address the lack of availability of specialty services in some rural areas or in a geographically large state, such as Michigan [19]. The COVID-19 pandemic accelerated efforts to improve access to telemedicine and mobile electronic health records in the United Kingdom [20].

In the United States, patients may face disruptions in insurance coverage during incarceration [21-23]. The Medicaid Reentry Section 1115 Demonstration Opportunity may provide new avenues for states to fund prerelease mental and health care services [24]. Sometimes, patients are charged copayments to access health services [25-27]. The National Commission on Correctional Health Care has issued a position statement opposing the use of fees for medical care that restrict access to care [26].

DEMOGRAPHICS — 

Globally, there are approximately 11 million people in jail and prison facilities, although the number may be greater given some underreporting of people on pretrial detention [28]. In the United States at year-end in 2021, 5.4 million people were under supervision (eg, in jail, in prison, on probation, or on parole), representing 2.1 percent of the adult population [29]. While the number of people in prison in the United States tripled between 1987 and 2007 [30], the population has declined since 2009 [29]. Prior to the COVID-19 pandemic, there were approximately 10.3 million jail admissions and 577,000 prison admissions per year [31,32]. In the United States, Black and Hispanic individuals are disproportionately incarcerated (figure 1) [32].

Estimates from 2024 suggest that over 7 percent of individuals in United States federal prisons are in special housing units or administrative maximum units [33]. For jails, the estimates of the number of individuals held in restrictive housing were approximately 6 percent, based on a 2019 survey [34].

GUIDELINES — 

Special challenges are posed by delivering health care in jails and prisons while maintaining security and safety for health care personnel and patients and adhering to appropriate ethical standards. Several organizations have created guidelines and standards for the delivery of health care in jails and prisons. For instance, the World Health Organization (WHO) Regional Office for Europe issues guidance on a wide range of issues related to the provision of health care for persons who are incarcerated, including mental health, drug treatment, tuberculosis (TB), and solitary confinement [35,36]. In the United States, the National Commission on Correctional Health Care (NCCHC) has published a number of health care guidelines and standards for compliance with acceptable health care in jail and prison facilities [37,38]. NCCHC has also issued a position statement on the use of solitary confinement [9].

In addition, the Centers for Disease Control and Prevention and the WHO have published guidelines for the prevention and control of infectious diseases including TB and COVID-19 in correctional facilities [39-42] (see 'Tuberculosis' below and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Society guideline links'). The United States Preventive Services Task Force has also issued guidelines on screening for latent TB infection relevant to adults who have a history of incarceration [43].

Medical services in jails and prisons are voluntarily accredited. Both the NCCHC and the American Correctional Association offer accreditation. (See 'Society guideline links' below.)

INITIAL SCREENING AND ASSESSMENT — 

Upon entrance to a jail or prison from the community, individuals should be screened for transmissible diseases, acute and chronic medical and psychiatric problems, optical and dental needs, potential drug and alcohol withdrawal, injuries, conditions that may have an immediate flare or require uninterrupted medical treatment (eg, treatment for cancer or tuberculosis [TB]), continuing medication therapy, suicide risk, and pregnancy. In addition, during periods of active community spread of infectious disease (eg, such as during the COVID-19 pandemic), those entering jails or prisons from the community or transferring in from other facilities should be carefully screened for the presence of infection [41]. The following conditions should be considered for screening.

Drug and alcohol withdrawal — Based on 2019 national data from the Bureau of Justice Statistics, 4.8 percent of individuals entering local jails were treated for opioid withdrawal [44]. Approximately 64 percent of all individuals sentenced to prison reported drug use in the month prior to their arrest [45]. In addition, almost half of individuals met the criteria for substance use disorder prior to admission, with 40 percent having a drug use disorder and 21 percent having an alcohol use disorder (AUD). Among admissions to jails screened (64.2 percent), 14.5 percent met criteria for opioid use disorder [44].

In a systematic review of international studies on substance use disorders at entrance into prison, estimates of AUDs (abuse/dependence) were 17 to 30 percent for males and 10 to 24 percent for females; estimates of substance use disorders were 10 to 48 percent for males and 30 to 60 percent for females [46].

The high rates of drug and alcohol use, and potentially life-threatening complications from unrecognized withdrawal, make initial screening for alcohol, benzodiazepine, and barbiturate withdrawal crucial. Ongoing monitoring for use and withdrawal syndromes may be necessary, since alcohol and drug use may occur in jails and prisons [47]. Appropriate and effective treatment of withdrawal may decrease drug use and syringe-sharing during incarceration and improve the ability of people in jails and prisons to make informed legal decisions [48].

The management of withdrawal syndromes is discussed elsewhere. (See "Management of moderate and severe alcohol withdrawal syndromes" and "Opioid withdrawal in adults in the emergency setting" and "Benzodiazepine withdrawal".)

Injuries — Injuries from both accidents and violence are common during incarceration [49]. They are often related to altercations that led detainees to jail, skirmishes with police officers, sports in jail or prison, deliberate self-harm, attempted suicide, and conflicts with other individuals in jails and prisons. A study of people in Texas prisons demonstrated that 2.9 percent were treated for fractures during a one-year period [50]. Injuries were the most common cause of evaluation at a local Scottish emergency department close to a prison: 22 percent of injuries were due to deliberate self-harm, 18 percent due to injury resulting from violence, and 15 percent due to sports injury [51].

Continuity of care for chronic conditions — Many chronic medical problems require uninterrupted medication, even during short periods of incarceration. Inquiry into the possibility of these conditions, as well as inquiry into medications used, is essential at reception into jail. An evaluation by a health professional or a complete health assessment is often recommended within a 7- to 14-day time window from admission to the jail/prison [35]; this delay should not result in interruption of maintenance medications. Medication changes in regimens at entry into prison can have untoward effects on the mental health of individuals with mental health disorders [52].

Uninterrupted medication is crucial for many medical conditions, including human immunodeficiency virus (HIV) therapy, TB, psychotic conditions, asthma, seizure disorders, coronary artery disease, diabetes mellitus, deep venous thrombosis, arrhythmias, and rheumatologic conditions. Brief lapses in therapy can have significant untoward effects, such as diabetic ketoacidosis or the evolution of resistance for HIV therapy.

Obtaining an accurate list of medications and dosing from the patient's community provider should be a priority, especially if any doubt is present about dosing. This is particularly important for opioid pain medications, which can be the source of friction between patients and clinicians; providers may fear that opioid pain medications will be misused, while patients fear inadequate pain relief.

Prevention of suicide and self-harm — In many countries, self-harm and suicide are common concerns in prisons and jails [53,54]. In 2018, more suicide deaths were reported in United States prisons than in any prior year on record, and the Bureau of Justice Statistics reported that the suicide mortality rate in prisons was slightly higher than in the general population [55]. In an international study comparing suicide rates between the incarcerated versus nonincarcerated population, the risk of suicide for incarcerated males was three times greater and for incarcerated females nine times greater than in the nonincarcerated male and female populations, respectively [54].

Self-harm includes intentional self-poisoning or self-injury, regardless of underlying motive or suicidal intent. A study in United Kingdom prisons found that self-harm (mostly of low lethality) was reported for 5 to 6 percent of incarcerated males and 20 to 24 percent of females [53]. Among males, suicide rates for those who self-harmed were approximately four times the rates for those who did not self-harm; in females, rates of suicide were approximately 1.5-fold for those who self-harmed compared with those who did not.

A number of risk factors have been identified for self-harm and suicide while incarcerated [56,57]. In an international systematic review, risk factors associated with an increased risk of suicide in prison included male sex, being married, suicidal ideation, psychiatric diagnoses, living in a single-cell accommodation, no social visits, serving a life sentence, remand status (pretrial detention), and having a violent offense [58]. Additional risk factors for self-harm include prior self-harm, borderline personality disorder, solitary confinement, disciplinary infractions, and physical or sexual victimization [57]. (See "Suicidal ideation and behavior in adults".)

Several suicide screening instruments exist for jails and prisons [59]. Recommended suicide prevention practices include the presence of explicit prevention policies that have been reviewed by medical or mental health professionals, baseline and annual staff training, screening, and psychologic autopsies after completed suicides [56]. Additional recommendations include identifying individuals with prior suicidal behavior and treating psychiatric disorders.

One factor that seems to predict success in suicide prevention is not leaving at-risk incarcerated people alone [60]. The least restrictive environment possible should be used, and the use of administrative segregation in a punitive manner should be avoided [56,61]. However, segregation with observation is common practice for those screened and found to be at suicidal risk, typically due to constraints related to limited resources.

Pregnancy testing — Individuals at risk for pregnancy should be tested if new medications are initiated at intake, if radiographs are required, or if they may be likely to undergo opiate withdrawal. People who might be pregnant or who are concerned that they are pregnant should also be tested.

All pregnant patients should be referred to appropriate prenatal services. (See 'Pregnancy' below.)

Infectious diseases

Chlamydia, gonorrhea, syphilis, and Trichomonas vaginalis — Risk factors for sexually transmitted infections, including trading sex for money, are common among people in jails and prisons [62]. Rates of infections with chlamydia, gonococcus, syphilis, and Trichomonas vaginalis are high in jails [63-65]. As examples:

●In a study in a Los Angeles jail from 2002 to 2012 (n = 76,207), among females who agreed to be tested, 11 percent were positive for chlamydia and 3 percent for gonorrhea [66]. Forty-three percent of females testing positive for gonorrhea were also positive for chlamydia. By comparison, overall rates among females in the United States in 2008 were 0.6 percent for chlamydia and 0.1 percent for gonorrhea [67]. Among male detainees, 6.2 percent at an Illinois jail had chlamydia or gonorrhea [68].

●In Brazil, from 2011 to 2014, the prevalence of syphilis among incarcerated pregnant people was estimated at 8.7 percent, with an estimated 68 percent mother-to-child transmission [69].

●In a Los Angeles jail, between 2006 and 2009, among females who agreed to be tested, 1.4 percent were positive for syphilis [66]. Syphilis seroprevalence rates are higher among older adult detainees than adolescents [66].

●T. vaginalis infections were identified in 8.5 percent of a sample of female in United States federal prisons [70].

●Among individuals entering Australian prisons in 2014, there were three sexually transmitted infections per 100 people [18].

Local incarceration rates have been also associated with county rates of chlamydia and gonorrhea [71]. Screening for sexually transmitted infections in jails may reduce community rates of these infections following detainee release [72]. Nonetheless, active case finding is not universally performed, but systematic reviews suggest active case finding is warranted given high detection rates [65,73].

The Centers for Disease Control and Prevention (CDC) recommends the following sexually transmitted infection screening upon entry into the facility: chlamydia, gonorrhea, and T. vaginalis screening for females ≤35 years and chlamydia and gonorrhea screening for males <30 years [74]. The United States Preventive Services Task Force (USPSTF) also recommends screening for chlamydial infection in sexually active females <25 years old as well as in older females at increased risk of infection [75,76]. While these USPSTF guidelines are not specific to jails and prisons, they are broadly applicable in these settings.

The CDC also states that universal screening for syphilis in carceral settings should be based on local and institutional prevalence [74].

Testing and treatment of sexually transmitted infections are reviewed elsewhere:

●(See "Screening for sexually transmitted infections".)

●(See "Treatment of Chlamydia trachomatis infection in adults and adolescents".)

●(See "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents".)

●(See "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents".)

●(See "Trichomoniasis: Clinical manifestations and diagnosis".)

Tuberculosis — The incarcerated population has a high risk of latent TB infection [65,77], and incarcerated adults are at higher risk for active TB than the general population [78,79]. In the United States, 2.3 percent of all identified active TB cases in 2021 were in incarcerated individuals [80]. Contributing factors are a higher-than-average risk of HIV, history of drug use, and lack of housing.

Rates of active TB are also high in incarcerated populations globally. For example, the rate was 2.1 percent among those screened in four facilities in South Africa [81] and 0.8 percent among nine prisons in Ethiopia [79]. In a systematic review including prison populations in the European Union/European Economic Area, the prevalence of active TB varied from 0.12 to 0.3 percent [65].

Jail and prison facilities provide environments that may promote person-to-person TB transmission due to communal living, poor ventilation, and overcrowding [82]. Possible secondary transmission of TB to visitors [83] and facility employees [84] has been reported.

CDC guidelines for the prevention and control of TB in correctional facilities advise specific inquiry about the possibility of TB during the initial medical screening and prior to integration with the general population in the facility [39]. A systematic screening tool should be administered by trained staff to ascertain any prior history of TB or symptoms of active TB, including prolonged cough, hemoptysis, or chest pain. Individuals with symptoms should be placed in an airborne infection isolation room and evaluated for TB (chest radiograph, Mantoux tuberculin skin test or interferon-gamma release assay blood test, and sputum examination if indicated). (See "Tuberculosis transmission and control in health care settings", section on 'Components of Tuberculosis infection control' and "Diagnosis of pulmonary tuberculosis in adults", section on 'General diagnostic approach'.)

The USPSTF recommends screening adults in correctional facilities for latent TB infection [43]. The CDC recommends a yearly assessment of each correctional environment for the risk of TB transmission and classifies the facility into minimal risk or nonminimal risk TB categories based on specific criteria. Facility risk assessment can help determine the implementation of further TB screening within a given facility. Screening with chest radiographs, the Mantoux tuberculin skin test, or an interferon-gamma release assay blood test is generally recommended in nonminimal risk facilities and among people at high risk for TB in minimal-risk facilities. Latent TB should be treated in correctional facilities, with attention to the likelihood of completion of TB treatment prior to release.

People in jails and prisons and employees with symptoms of active TB should be identified quickly and reported to local health departments. Persons with possible TB should be isolated in airborne infection isolation rooms, if available at the correctional facility, or transferred to a facility with appropriate isolation rooms. Persons with suspected or confirmed active TB should be treated with directly observed therapy [39]. (See "Tuberculosis transmission and control in health care settings", section on 'Components of Tuberculosis infection control' and "Adherence to tuberculosis treatment".)

The diagnosis and management of TB and latent TB infection are discussed in detail separately. (See "Treatment of tuberculosis infection (latent tuberculosis) in nonpregnant adults with HIV infection" and "Treatment of tuberculosis infection (latent tuberculosis) in nonpregnant adults without HIV infection" and "Treatment of drug-susceptible pulmonary tuberculosis in nonpregnant adults without HIV infection" and "Diagnosis of pulmonary tuberculosis in adults" and "Tuberculosis infection (latent tuberculosis) in adults: Approach to diagnosis (screening)".)

Testing for HIV — HIV prevalence estimates in jails and prisons are highly variable, ranging from 0.3 to 26.6 percent [65]. (See 'HIV prevalence, prevention, and treatment' below.)

HIV screening policies differ by correctional system, ranging from mandatory screening upon intake or release, to voluntary testing in response to patient request or clinical indication [65]. In the United States, the CDC recommends an "opt-out" policy for HIV screening in correctional health care settings (ie, the individual should be informed that HIV screening will be performed unless specifically declined) [74,85]. In one state prison system, the rate of HIV screening increased with sequential changes over time in testing policy as follows: 5 percent for testing on request; 72 percent for opt-in; 90 percent for opt-out [86]. The CDC also recommends that patients at high risk for HIV infection be screened for HIV infection at least annually. A more general discussion of HIV screening is presented elsewhere. (See "Screening and diagnostic testing for HIV infection in adults".)

Based upon the CDC definition of high risk (people who inject drugs, persons who exchange sex for money or drugs, men who have sex with men, sex partners of individuals with HIV infection, and individuals who have had more than one sex partner or whose partners have had more than one sex partner since their last HIV test), many individuals in correctional facilities are high risk and therefore should be considered for annual HIV testing. Furthermore, since people in correctional facilities may be hesitant to report high-risk behavior in prison (ie, needle sharing, sexual contact, or rape), testing on demand is also offered in many settings.

It is paramount that plans be explicitly made at the time of testing to provide HIV test results to inmates who may be released before the results are available. Results from Rhode Island suggest that HIV testing within 24 hours of admission to a correctional facility resulted in greater identification of previously unknown cases of HIV than delayed testing at seven days [87]. The role of rapid HIV testing in corrections is growing [88,89]. The necessity for confirmatory testing of positive rapid tests should be emphasized to patients, and confidentiality of results is all-important in the correctional setting.

Hepatitis B — In Australia, 18 percent of people entering prison tested positive for hepatitis B core antibody [18]. In the European Union/European Economic Area, active case finding for hepatitis B virus (HBV) yielded positive results in 0.6 to 13 percent across included studies [65]. The CDC recommends screening for persons incarcerated in a jail, prison, or other detention setting (table 1) [90]. The USPSTF does not specifically recommend HBV screening of incarcerated persons, although it does recommend screening in populations with a prevalence of HBsAg ≥2 percent, such as populations who have injected drugs [91,92]. (See "Hepatitis B virus: Screening and diagnosis in adults", section on 'Approach to screening and testing'.)

The CDC recommends that all incarcerated adults who do not have proof of prior vaccination or serologic evidence of immunity be vaccinated against HBV, including pregnant individuals (table 2) [93]. Immunization records should be transferred to the individual's medical provider in the community upon release.

Hepatitis C — The prevalence of chronic hepatitis C in United States jails has been estimated as ranging from 12 to 35 percent [94], and most people are unaware of their infection [95]. In Australia, 31 percent of people entering prisons tested positive for hepatitis C antibody [18]. Based on modeled data from 2014, an estimated 15 percent of incarcerated people worldwide had hepatitis C virus (HCV) [96].

Prevention of HCV in jails and prisons is appropriate [97]. Efforts should be made to identify individuals with HCV infection and educate them about HCV. CDC guidelines recommend an assessment of risk factors for hepatitis C at entry and at medical evaluations, and testing of individuals with risk factors for hepatitis C [94]. However, screening only those reporting risk may miss a significant number of people with HCV: in one report from the Rhode Island Department of Corrections, 66 percent of males who tested positive for HCV did not report injection drug use [98]. (See "Screening and diagnosis of chronic hepatitis C virus infection", section on 'Limitations of risk-based screening'.)

A rapid fingerstick test is available to screen for HCV. Some have argued for opt-out routine testing for HCV for jail entrants, recognizing that treatment for confirmed positive tests would require counseling and coordination with outside medical services on release from jail [95]. This strategy might identify half a million new cases of hepatitis C in the first year of implementation.

COVID-19 — COVID-19 is highly infectious and easily transmissible in institutional settings such as jails and prisons. Upon entrance into a facility (from the community or another facility), incarcerated persons should be screened for active infection according to guidelines issued by the CDC and the World Health Organization [41,42]. In addition, staff [99] and visitors should be screened for symptoms. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Society guideline links'.)

CDC guidelines and the National Commission on Correctional Health Care position statement suggest that people who are incarcerated and staff should be offered and prioritized for COVID-19 vaccination [100,101]. (See "COVID-19: Vaccines".)

MANAGEMENT FOR SPECIFIC CONDITIONS AND POPULATIONS — 

The high prevalence of chronic conditions and opportunities for prevention among the incarcerated requires an approach that incorporates routine scheduled follow-up visits and chronic disease management clinics. One review from Switzerland suggests targeting four high-risk conditions for preventive measures among the incarcerated population: tuberculosis, HIV, hepatitis, and sexually transmitted infections [102]. Management of chronic disease has the potential to not only improve health for the individual but also to decrease costs of care for complications and off-site transport and treatment.

Asthma — In the United States, the prevalence of asthma in state and federal prisons is approximately 15 percent [103], in contrast to 10 percent in the general population [104]. In Australia, 31 percent of females and 22 percent of males entering prison reported a history of asthma [18].

Potential barriers to quality asthma care in the correctional setting include lack of timely access to urgent care and restrictions on patients carrying their own medications [105]. Efforts should be made to minimize these barriers.

The clinical management of asthma is discussed separately. (See "An overview of asthma management in children and adults".)

Diabetes mellitus — The prevalence of diabetes mellitus is approximately 9 percent in United States prisons and 4 percent among people in Australian prisons [18,50,103].

Managing diabetes mellitus poses special challenges for people in jails and prisons. Restrictions on the use of injecting equipment and blood glucose monitoring limit patient autonomy, an important component of diabetes self-care [106]. Self-management of diabetes (self-testing and administration of insulin) should be encouraged within the limits of individual facility policies. Other problems include the timing and type of food, limited exercise, and delays in accessing medical care. Efforts should be made to assess facility resources for diabetes management and transfer people with diabetes to facilities with 24-hour nursing care and better dietary resources, when appropriate.

The American Diabetes Association has issued guidelines for diabetes care in correctional settings [107]. Patients with risk factors for diabetes should be screened, and pregnant individuals should be assessed for gestational diabetes. A team approach to diabetes management and self-management education are emphasized. Correctional staff should be trained to recognize and treat hypo- and hyperglycemia.

The Federal Bureau of Prisons offers clinical guidance for the treatment of diabetes in federal prisons. For example, they address contingency plans if a lockdown or other emergency occurs after insulin is administered and before eating [108].

Fundamentally, the standard of care should be the same as that for the general population, accommodating additional precautions that may be necessary due to security constraints in the correctional setting. (See "Overview of general medical care in nonpregnant adults with diabetes mellitus" and "General principles of insulin therapy in diabetes mellitus".)

Seizure disorders — Seizure disorders are more common in the incarcerated population than in the general United States population. Prevalence among people in Texas prisons was 1.9 percent [50] compared with 0.5 percent in the general population [109]. A higher prevalence of substance use disorders and a history of head trauma may contribute to the higher rate of seizures among people in correctional facilities.

Details of the management of first seizures, epilepsy, and alcohol withdrawal seizures are found elsewhere. (See "Evaluation and management of the first seizure in adults" and "Overview of the management of epilepsy in adults" and "Management of moderate and severe alcohol withdrawal syndromes".)

Infectious diseases — Correctional facilities have the potential for easy transmission of infectious diseases due to the higher prevalence of certain infections among incarcerated persons, congregate living conditions, and typically limited access to personal hygiene supplies.

Influenza and COVID-19 — The prevention and management of highly infectious viral respiratory diseases such as influenza and COVID-19 present unique challenges in correctional facilities.

●COVID-19 – COVID-19 is easily transmissible in institutional settings [6,110]. The disease spreads readily in a crowded institutional setting, affecting incarcerated persons and correctional staff alike.

Between March 1 and June 20, 2020, the case positivity rate in United States jails was 11.4 percent, with just over 23,000 positive COVID-19 tests. By June, 2020, there were over 42,000 COVID-19 cases and 510 deaths among all incarcerated United States adults, with a case rate and adjusted death rate higher than among the general United States population (5.5 and 3 times higher, respectively) [111].

As single-cell occupancy was associated with reduced prison COVID-19 incidence, decarceration and vaccination were employed as infection control strategies [112-117]. Decarceration involves the implementation of policies to lower the number of people held in a facility by reducing admissions and/or releasing individuals prior to their planned release date. An analysis of United States data suggested that county jail decarceration by 80 percent could reduce COVID-19 daily growth rates by 2 percent. To put these findings in context, prison visitation bans have been associated with a 1.2 percent reduction in case growth rates; statewide mask policies, a 2.5 percent reduction; and stay-at-home policies, a 0.8 percent reduction [118]. Nine percent of people in jails received expedited release due to the COVID-19 pandemic [119].

COVID-19 vaccination should be widely administered to correctional populations (including incarcerated persons as well as correctional facility staff) as an essential component of a COVID-19 infection control strategy [115,116,120,121].

If an individual with COVID-19 is released from a correctional institution to recover in the community, the facility should arrange for an appropriate discharge plan for medical isolation, social support, and information on available medical follow-up during recovery [40,122] (see "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Infection prevention in the home setting'). Facilities that have provided vaccination should also ensure people have their vaccine documentation prior to release [100].

The Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) issued interim guidelines to manage COVID-19 in jails and prisons while preserving human rights [40,41], and the WHO has developed a checklist to help facilities respond to COVID-19 [123]. The WHO has also developed a brief on vaccination in jails and prisons [124].

●Influenza – Seasonal influenza vaccination should be made widely available to people incarcerated in jails and prisons as well as staff to prevent and mitigate outbreaks [100,125].

HIV prevalence, prevention, and treatment — Globally, there is a high burden of HIV among the incarcerated population. In a model using 2014 data, it was estimated that 3.8 percent of persons in prisons worldwide had HIV [96], with the prevalence of HIV infection estimated at greater than 10 percent in some countries' prison systems [126]. Based upon data reported by correctional authorities to the United States Bureau of Justice Statistics in 2020, approximately 1.2 percent of people in United States prisons report a history of HIV/acquired immunodeficiency syndrome (AIDS) [127].

The incarcerated population is at excess risk for HIV infection compared with the nonincarcerated population due to multiple risk factors including injection drug use, a history of work in the sex industry, or trading sex for drugs [128].

Attention to infectious disease prevention and HIV treatment in correctional settings is crucial in order to minimize the risk of transmission among residents and correctional staff, since transmission of HIV (as well as hepatitis B and C virus [HBV, HCV]) may occur in jails and prisons [129]. Among those who seroconverted while incarcerated, the following risk factors were identified: male-to-male sex, receiving a tattoo while incarcerated, serving a period of incarceration for five or more years, and being from a Black population [130].

Incarcerated persons may not have access to condoms or clean injection equipment, which can foster HIV transmission. Estimates of sexual assault in prison range from 0 to 40 percent [131], and nonconsensual sexual activity prevents incarcerated persons from protecting themselves against infection. Needle and syringe exchange programs in correctional settings have been piloted internationally [132], and condoms could be made available in jails and prisons. It is also imperative that HIV education be provided and made easily accessible [133,134].

Guidelines are available to assist in the use of antiretroviral therapy (ART) in HIV-infected adults, in pregnant individuals, and for the prevention and management of opportunistic infections. These guidelines can be accessed at the United States Department of Health and Human Services website. Correctional facilities should consider the use of HIV experts to manage HIV care. Telemedicine may facilitate access to expert guidance.

A few points regarding the management of HIV in the correctional setting warrant emphasis:

●Coinfection with hepatitis B and/or hepatitis C is common among incarcerated individuals with HIV; screening for hepatitis B and C in people with HIV is important [94,135].

●For patients already on ART, uninterrupted treatment is essential to prevent the evolution of viral resistance to medications. Patients should continue on the same medication they were taking in the community. Home medication regimens should be provided immediately upon intake into jail or prison, and they should be provided without interruption in dose or schedule.

●For people with HIV not on ART at the time of incarceration, appropriate prophylaxis against opportunistic infections should be provided for patients with low CD4 counts, and ART should be offered to those for whom ART is indicated according to current guidelines. (See "Overview of prevention of opportunistic infections in patients with HIV" and "Overview of antiretroviral agents used to treat HIV" and "When to initiate antiretroviral therapy in persons with HIV".)

Establishing HIV care upon release from prison or jail is challenging, but interventions such as case-management strategies, increasing access to health insurance and prescription benefits, and improved HIV care during incarceration can all improve post-release retention in HIV care.

●In a randomized trial of 356 males and transgender females with HIV released from Los Angeles County Jail, a novel peer-navigation intervention was compared with traditional case management [136]. The percentage of individuals maintaining viral suppression over 12 months following release declined from 52 to 30 percent with traditional case management, while it remained unchanged at 49 percent among those participating in the peer navigation intervention.

●In Connecticut, among formerly incarcerated individuals with HIV, retention in post-release HIV care and sustained viral suppression were associated with early post-release care, receipt of ART while incarcerated, health insurance, and an increased number of transitional case-management visits [137].

Upon release, health care providers and discharge planners should ensure that people with HIV have an adequate supply of medications to last until they can follow up with a community provider. Transfer of the prison medical record to the community provider should be facilitated to ensure that information about the patient's history of HIV treatment is available.

Viral hepatitis (hepatitis A, B, and C) — Incarcerated individuals may have active hepatitis B or C infection upon intake into a correctional facility, or a new infection with hepatitis A virus (HAV), HBV, and/or HCV may occur while incarcerated. The epidemiology and management of viral hepatitis in the incarcerated population is discussed below.

●Hepatitis A – HAV is transmitted by fecal-oral route via household contact, sexual contact, drug use, or contaminated food. The age-adjusted prevalence of HAV in correctional populations is reported to be similar to the prevalence in the general population [138], but outbreaks have been reported, corresponding to HAV epidemics among injection drug users in the community [135].

HAV vaccination should be provided to correctional populations at risk for HAV, including men who have sex with men, people who use drugs, and those at high risk from severe adverse outcomes if infected (ie, those with chronic liver disease) [138]. Given the high prevalence of substance use disorder among people in correctional facilities, these recommendations are likely to apply to many individuals. Vaccination should be administered as soon as possible after incarceration, and a system to track completion of the series should be established. Individuals should be encouraged to complete the series at release from prison, and immunization records should be transferred to the community medical provider upon release [138].

Administration of a combination hepatitis A/B vaccine with an accelerated schedule may be an option for the high-risk incarcerated population. As an example, in a Los Angeles county jail, this immunization program was successfully implemented for men who have sex with men [139]. (See "Hepatitis B virus immunization in adults", section on 'Combination vaccines'.)

People with signs of acute hepatitis should be tested for viral hepatitis. If HAV is identified, close contacts (ie, cell mates, sexual contacts) should be treated with immune globulin for postexposure prophylaxis, and health authorities should be notified [138]. (See "Hepatitis A virus infection in adults: Epidemiology, clinical manifestations, and diagnosis" and "Hepatitis A virus infection: Treatment and prevention".)

●Hepatitis B – HBV infection (either active infection or evidence of previous infection) is common among people in jails and prisons [140]. In the United States, up to 11 percent of incarcerated individuals were positive for HBsAg (active infection) and up to 43 percent were positive for HBcAb (past or current infection) in one study [141]. Globally, the percentage of the incarcerated population with active HBV infection ranges from 0.15 percent (Mexico) to 26 percent (Ghana) [91,142]. In 2014, the worldwide prevalence of chronic HBV among people in prisons was approximately 5 percent [96].

Individuals are also at risk for acquiring HBV infection during incarceration. In one outbreak of acute HBV infection in a state prison, the identified mechanism of transmission was men having sex with males in the affected dormitory [143]. Over 900 men at the facility were at risk for acquiring HBV infection, with greater than 50 percent reporting at least one risk factor, including having sex with males, sharing a razor, or receiving a tattoo during incarceration.

Postexposure prophylaxis should be available for incarcerated persons who have had a potential exposure to HBV. Chronic HBV infection should be treated according to standard practice and the latest treatment guidelines. (See "Hepatitis B virus immunization in adults" and "Hepatitis B virus: Overview of management".)

●Hepatitis C – HCV infection is common among individuals in jails and prisons. Reported HCV infection rates among the incarcerated have varied from 3.4 percent in Lebanon [144] to 5 percent in France [144] and greater than 20 percent in the United States [98,138,145,146]. Estimates suggest that 9.8 percent of people in United States correctional facilities report a history of hepatitis C, but many may not be aware of their serologic status [103].

People with signs or symptoms of liver disease should be tested for HCV, and people with known HCV should have further evaluation to determine the extent of liver disease and eligibility for treatment. Hepatitis A and B vaccination should be provided to those individuals with HCV who have not already been vaccinated or are not immune or infected. Education regarding factors that may contribute to worsening liver disease, such as alcohol intake, is recommended [138].

Costs of treatment for HCV infection can be a concern given correctional budget constraints, although treatment is feasible in the correctional setting [147], and one analysis found that treatment in the prison population could be cost-saving [148]. While the Federal Bureau of Prisons has guidance on HCV management in incarcerated persons [149], there are legal challenges aimed to broaden access to appropriate antiviral therapy [150].

Further information regarding therapy for HCV is presented elsewhere. (See "Overview of the management of chronic hepatitis C virus infection".)

Methicillin-resistant Staphylococcus aureus — Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of skin and soft tissue infections in many correctional systems [151,152]. In most United States correctional facilities where it has been studied, the prevalence of MRSA is higher than in the general population [153]. Risk factors for MRSA in correctional settings include the proportion of people housed with drug offenses, history of antimicrobial use, comorbidities, crowding, and inadequate hygiene [154-156].

MRSA transmission has been documented in several correctional systems [151,157,158]. Strict attention to hygiene, including wide access to soap, high-temperature laundering and drying of clothing, and timely access to medical care, may prevent the spread of MRSA infections. The CDC also recommends skin screening at intake, skin monitoring, culturing lesions, and using appropriate antibiotic therapy for MRSA [151]. The Federal Bureau of Prisons has issued guidelines on the management of MRSA in federal prisons [159]. In a Georgia detention center, implementation of measures to improve screening for skin disease and improve personal hygiene, wound care, and proper use of antimicrobial therapy decreased the incidence of MRSA [160].

Sickle cell disease — Sickle cell disease is more prevalent in people whose ancestors come from regions where malaria is endemic, including sub-Saharan Africa and the Middle East. Optimal care requires daily medications and timely access to urgent or emergency care, including opioid-based medications for vaso-occlusive pain episodes . Though studies are limited, in one review, seven deaths while incarcerated were attributable to a lack of care escalation in patients with complications related to sickle cell disease [161]. The clinical management of sickle cell disease is discussed separately. (See "Overview of preventive/outpatient care in sickle cell disease" and "Acute vaso-occlusive pain management in sickle cell disease".)

Tobacco use — Nicotine use disorders are highly prevalent among residents and staff in jails and prisons. More than 14 million people who smoke pass through correctional facilities each year [162,163]. Most states in the United States have implemented smoking bans in prisons (indoor, outdoor, or both) [164,165], but prison smoking bans may not be as common in other countries. In observational studies, smoking bans are associated with improved prison indoor air quality, decreased mortality from smoking-related causes (cardiovascular and pulmonary deaths), and, for bans in place longer than nine years, decreased mortality from tobacco-related cancers [164,166]. Some facilities allow the use of electronic cigarettes, and others ban them due to health concerns [167,168]. (See "Vaping and e-cigarettes".)

Resumption of tobacco use after release from prison is common, with self-reported abstinence of only 3.1 percent at six months among individuals with chronic health conditions released from a tobacco-free jail in the community [169]. Smoking cessation programs could have a lasting impact on the health of the incarcerated population. Clinicians should discuss smoking and smoking cessation with their patients. A prison-based multimodal smoking cessation intervention has been found to be feasible in New South Wales [170]. (See "Benefits and consequences of smoking cessation" and "Overview of smoking cessation management in adults".)

Opioid use disorder — The majority of individuals with an opioid use disorder or who use heroin report a history of criminal legal involvement at some point over their lifetime [171]. Among those with opioid use disorder, the risk of criminal legal system involvement within the prior year is almost seven times higher than among those without opioid use disorder. For those with heroin use disorder in particular, the risk is almost 15 times higher.

Ideally, opioid use disorder in incarcerated adults should be managed in the same way as in the nonincarcerated population. This includes:

●Management of acute opioid intoxication (see "Acute opioid intoxication in adults")

●Management of acute withdrawal symptoms (see "Opioid withdrawal in adults in the emergency setting")

●Initiation or continuation of medication for opioid use disorder (MOUD), both during incarceration and following release (see "Opioid use disorder: Pharmacologic management")

Individuals should have access to treatment for opioid use disorder during incarceration [172]. The WHO recommends that incarcerated individuals should have access to the same treatment options as those available to them in the community, including all forms of MOUD, such as methadone, buprenorphine, and naltrexone [173]. The American Society of Addiction Medicine (ASAM) specifically recommends continuing treatment that was begun prior to incarceration [174]. (See "Opioid use disorder: Pharmacologic management", section on 'Methadone: Opioid agonist' and "Opioid use disorder: Pharmacologic management", section on 'Naltrexone: Opioid antagonist' and "Opioid use disorder: Pharmacologic management", section on 'Buprenorphine: Opioid partial agonist'.)

Appropriate treatment of opioid use disorder in those involved with the criminal justice system has been shown to increase post-release treatment, decrease recidivism, decrease transmission of HIV and hepatitis C infection, improve public safety, and reduce post-release overdoses and deaths [175-178]. Starting or continuing an individual's maintenance MOUD during incarceration has also been shown to increase the probability of participating in post-release treatment [179,180]. In a randomized trial of people with opioid use disorder who declined buprenorphine or methadone at release, treatment with long-acting injectable naltrexone reduced relapse rates at four weeks. [181].

It is important to arrange for transitional care in anticipation of release, as drug cues in the environment can trigger renewed craving and resumed drug use, increasing the possibility of overdose and death. Among people formerly incarcerated in Washington state prisons between 1999 and 2009, overdose was the leading cause of death post-release, with opioids involved in 15 percent of those deaths [182]. In England, receiving MOUD in prison has been shown to reduce the number of post-release drug-related and all-cause deaths [183]. In a retrospective cohort analysis, participation in a Rhode Island statewide correctional system comprehensive MOUD program (patients were maintained on MOUD while incarcerated and then referred to programs to continue treatment after release) was associated with a 61 percent reduction in post-release overdose deaths [176].

Naloxone should be available in prisons and jails to prevent in-facility deaths [174]. In addition, the risk of overdose death is highest in the weeks following release from the correctional setting, and some correctional systems have begun to prescribe naloxone to individuals at risk for overdose after release from prison [184]. One-quarter of United States jails surveyed in 2019 reported providing naloxone at release to people with opioid use disorder [44]. In 2011, Scotland implemented a program to provide education and naloxone to people at risk for an opioid overdose prior to their release from prison. This program was associated with a significant reduction in post-release death from opioids in the first month after prison release [185]. These results suggest that providing overdose risk reduction education and prescribing naloxone to people at risk for overdose is an effective strategy to reduce the risk of opioid overdose after release; this strategy is now recommended by ASAM [174].

Unfortunately, many people with opioid use disorders do not receive treatment either while incarcerated or after release [44,186-188]. "Forced withdrawal" has been demonstrated to be harmful, causing suffering and increasing the risk of overdose death [180]; updated guidelines for treatment of opioid use disorder in correctional facilities recommend against forced withdrawal [174].

Barriers to receiving appropriate care include punitive attitudes, cost of treatment, concerns over medication diversion, and federal regulations that limit methadone prescribing to licensed opioid treatment programs [172,189]. The National Commission on Correctional Health Care has the authority to accredit opioid treatment programs in jails and prisons. Several organizations have published guidance or policy statements regarding managing MOUD in jails and relating to other justice-involved populations [174,190,191].

Other drug and alcohol use disorders — In a 2012 review of drug treatment programs for criminal justice populations, there was evidence to support the effectiveness of cognitive behavioral therapy, contingency management, therapeutic communities, and drug courts, in addition to the use of medications [192].

For criminal justice involved patients with alcohol use disorder (AUD), evidence supporting the benefit of naltrexone treatment is mixed, and treatment rates are low. As an example, in a trial of people with AUD in prisons, extended-release naltrexone started prior to release from prison only showed benefit for the younger subgroup (ages 20 to 29), with reduction in time to heavy drinking and reduction in alcohol use, but no benefit for the overall group [193]. Among US Veterans Health Administration patients with AUD, overall rates of treatment with naltrexone are low, although higher among those with criminal justice involvement than among those without (8 percent with a prison history and 11 percent with a jail/court history versus 5 percent with no criminal justice involvement) [194].

Psychiatric disorders — Globally, psychiatric disorders, particularly schizophrenia and bipolar disorder, are far more prevalent among incarcerated individuals than the general population [27,195,196]. Among those incarcerated in United States prisons, 41 percent have a history of a mental health condition, while the prevalence of serious psychologic illness is estimated at 13 percent [197]. Suicide was the leading cause of death in jail inmates in the United States in 2014 [198].

The management of psychiatric disorders in prisons and jails often requires specialty input from forensic psychiatrists who specialize in mental health in the context of the criminal legal system. Management of psychiatric conditions in prison should continue into solitary confinement settings such as "Supermax" facilities [199].

Of crucial importance is ensuring the continuity of mental health care after release from incarceration. In a cohort study of released prisoners in Sweden, rates of violent reoffending were lower during periods when people received psychotropic medications (antipsychotics, psychostimulants, and/or drugs to treat substance use disorder) compared with periods when they were not medicated (hazard ratio [HR] 0.58, 95% CI 0.39-0.88) [200].

Sexual violence — Sexual violence (including staff-on-inmate and inmate-on-inmate) experienced during incarceration is common. Estimates of sexual assault in prison range from 0 to 40 percent and vary based upon reporting approaches [201,202].

Healthcare providers should report abuse, counsel victims, treat injuries, arrange for follow-up, and gather forensic evidence when seeing a sexual assault victim either on or off site [203]. Facilities should develop protocols for appropriate management of abuse. Methods to prevent sexual violence among the incarcerated deserve further study.

Pregnancy — In the United States, adult and adolescent females are the fastest-growing population in prisons and jails, and management of the pregnant incarcerated individual presents special challenges [204]. Prenatal care for incarcerated people is discussed in detail separately. (See "Prenatal care: Incarcerated females".)

Special needs to be considered for pregnant people in jail or prison include levels of work activity, housing issues (lower bunk bed), nutritional needs, vitamin supplementation, drug and alcohol treatment, smoking cessation, screening for infections, and mental health issues. The use of shackles for pregnant people has been barred in several states and in federal facilities except in extreme situations, due to concerns of safety related to balance issues, as well as postural needs during labor and delivery. Maternal and fetal outcomes for incarcerated compared with nonincarcerated females in similar populations, are generally improved, with higher birth weights and lower rates of stillbirth [205].

Postpartum issues relate to difficulties with breastfeeding and the lack of nursery facilities in most prisons leading to need for newborn foster care. Providing reproductive planning services prior to release is an important issue, since unplanned conception within 90 days of leaving jail is common and females who choose not to become pregnant are more likely to initiate contraception when provided in the prison than when offered free in the community [206].

Cancer — Cancer diagnoses are increased among the incarcerated compared with the general population [207]. In one population, the most prevalent cancers were lung cancer, non-Hodgkin lymphoma (NHL), and cancers of the oral cavity and pharynx [207]. Cervical cancer was the most common cancer in females. In addition to increased prevalence, median survival for lung, hepatic, and NHL cancer was lower in the incarcerated population, compared with an age-matched population (21 versus 54 months).

Cancer was the leading cause of death among deaths occurring in United States prisons in 2018 [55], with lung cancer the leading cause of cancer death both during incarceration and after release [208]. Correctional health care workers should provide smoking cessation counseling, monitor for early signs and symptoms of lung cancer in current and former smokers, and offer lung cancer screening according to guidelines as in the general population. (See "Overview of smoking cessation management in adults" and "Clinical manifestations of lung cancer" and "Screening for lung cancer".)

Other cancer screening for inmates in long-term facilities should be performed according to guidelines for screening in the general population (see "Overview of preventive care in adults", section on 'Cancer screening'). Cancer screening in short-term facilities may be an opportunity to provide preventive services to a population with a higher risk for cervical cancer and lower colon cancer screening rates than the general population [209].

Geriatric populations — An increasing concern is management of the health needs of older people in prisons, a growing population in the criminal justice system [210,211]. Prisons are generally not prepared to address the aging prisoner with medical comorbidities, functional impairment, or cognitive impairments, or to provide palliative care services when needed. Designated facilities that meet the special needs of older incarcerated individuals identified with functional impairments or geriatric syndromes may be one way to manage this problem, in conjunction with evaluation of the older adults in prisons for functional and cognitive limitations. (See "Geriatric health maintenance", section on 'Functional assessment and geriatric evaluation'.)

ROUTINE HEALTH CARE MAINTENANCE — 

Incarceration presents an opportunity to provide preventive services to a high-risk population who may otherwise have poor access to care. Routine health care maintenance, as would be offered to patients in the community, is indicated for the incarcerated, including age-appropriate cancer screening and vaccinations [209]. Additionally, incarceration offers an opportunity to address lifestyle issues for a vulnerable population. In a systematic review of noncommunicable diseases among people in prisons in 15 countries, female prisoners in the United States and Australia had a greater likelihood of obesity compared with the general population, salt intake was more than twice the recommended levels for prisoners in nine studies, and levels of physical activity for prisoners varied by country [212].

Incarceration itself has been associated with an increased risk for hypertension and left ventricular hypertrophy, after adjustment for other risk factors [213]. This underscores the need to provide health care screening to incarcerated persons, a population more likely to be medically underserved upon release. Additionally, incarcerated females are at high risk for sexually transmitted infections and unplanned pregnancy, and attention to reproductive health needs in this population could benefit the individuals as well as their community outside the prison [214]. (See "Overview of preventive care in adults".)

SPECIFIC ETHICAL ISSUES — 

Ethical concerns arise frequently in any medical practice, but there can be particular challenges in providing care to the incarcerated patient. Health care professionals have obligations to their patients but may report to and be supervised by jail and prison administrators and security staff rather than public health or health care systems. This raises potential issues with "dual loyalty," which may be addressed through training, oversight, and integration of correctional health services with public health services [215]. Caring for incarcerated individuals who are hospitalized and lack decisional capacity involves the potential that autonomy and privacy are violated, with prison staff involvement in decision-making [216]. Specific ethical issues addressed here are pain management, hunger strikes, and solitary confinement. Issues and challenges surrounding the care of terminally ill individuals in jails and prisons are reviewed in detail separately. (See "Palliative care for incarcerated adults".)

Pain management — Pain management can be complex in the correctional setting. Providers fear prescription drug misuse and diversion in the setting of poor patient credibility and a history of substance use disorder in the correctional setting [217]. Patients may have difficulty trusting providers and fear inadequate pain control.

Institutional factors, including security protocols and formulation restrictions, often present barriers to adequate pain management for people in prisons and jails [217].

For new entrants into the correctional facility, communication with outside providers who prescribe chronic pain medications to patients in the community is paramount. In addition, follow-up medical visits to assess the adequacy of pain relief with prescribed therapy may be helpful in building trust between provider and patient.

Hunger strikes — Complex practical and ethical concerns complicate the medical management in jails and prisons. A hunger strike, in which a patient who has the capacity to understand the potential medical impact of food refusal and who is not suicidal refuses food for a specific reason, is one example. The medical management of patients on hunger strike should include psychiatric consultation, a medical history and evaluation, assessment of motives for food refusal and the possibility of coercion, and the prisoner's understanding of the risks and benefits of the food refusal [218]. The person on hunger strike should finalize an advanced directive, to be followed in the event of their becoming incompetent, to express wishes.

Clinician assessment is often initiated after 72 hours of food refusal. In prison, people on hunger strike may accept water, salt, sugar, and vitamin B1. Some may accept liquid nutritional supplements. Refusal of both food and water is unusual, because a rapid death would not allow negotiation to meet demands.

Weight loss of approximately 18 percent of initial weight can result in serious medical problems; loss of more than 30 percent is life-threatening [218]. Force-feeding a malnourished individual can result in refeeding syndrome, characterized by electrolyte abnormalities including hypophosphatemia, fluid retention, and hyperglycemia.

The World Medical Association Declaration of Malta states that forced feeding is unethical [219]. The 8th Amendment to the Constitution in the United States prohibits cruel and unusual punishment and has been variably interpreted to permit forced feeding in certain situations, often involving the court system. Clinicians in correctional environments may need to balance divergent ethical principles such as respecting the sanctity of life and respect for individual autonomy. Guidance on such issues has been provided by thoughtful articles in the literature [218,220,221]. Position statements from the World Medical Association [222] and other medical associations are also available to guide clinicians. Generally, states have been successful when they have argued that their responsibility to preserve life outweighs the individuals' right to starve themselves.

Solitary confinement — Among other recommendations, the National Commission on Correctional Health Care recommends that the use of solitary confinement be limited to 15 or less consecutive days and avoided in juveniles, individuals with mental disorders, and pregnant individuals. They further recommend that health staff should not be involved in making determinations of fitness for solitary confinement [9].

HIGH MORTALITY RATES IMMEDIATELY FOLLOWING RELEASE — 

There is a high risk of death in the immediate period following release from jail or prison, with the greatest risk of death from drug overdose [175,208,223-225]. As examples:

●In the state of Washington, the adjusted risk of death in the first two weeks following prison release was substantially higher than that of other state residents (RR 12.7, 95% CI 9.2-17.4) [208]. Drug overdose was the most common cause of death. Death rates remained elevated compared with the general population over the subsequent two years.

●In New York City, the risk of drug-related death in the first two weeks following release from incarceration was eight times the death rate of nonincarcerated individuals adjusted for age, sex, race, and neighborhood [224].

●In the state of Minnesota, the rate of overdose death was 15.5 times greater following release from jail and 28.3 times greater following release from prison when compared with the general population, with opioids as the leading cause of overdose [225].

BARRIERS TO CARE AFTER RELEASE — 

Barriers to care following release from incarceration, including poverty, lack of housing, lack of health insurance, and medical practice discrimination, can interfere with the establishment of routine medical care post-release. Referrals to medical providers and assistance in establishing medical care in the community should be facilitated whenever possible.

Communication between medical providers both inside and outside of correctional facilities, and between different correctional facilities, is critical to prevent disruptions in medical care with potential negative health consequences.

Despite a high rate of medical and psychiatric illness, many individuals do not receive timely medical care post-incarceration. While 80 percent of released individuals have chronic medical, psychiatric, or substance use disorders, only 15 to 25 percent had a clinician visit (other than to an emergency department) within the first year after release [226]. In a study of Medicare beneficiaries released from correctional facilities, rates of hospitalization within one week to three months post-release were twice the rates for matched controls.

It may be difficult for recently released inmates to obtain appointments with medical providers in the community. As an example, Canadian researchers posing as new patients telephoned for appointments at family practitioner offices, with some callers self-identifying as having been recently released from incarceration [227]. Those identifying as former prisoners were less likely to be offered an appointment than those not identifying as such (43 versus 84 percent).

Employing a cooperative program of dually based medical providers who work in both corrections and in community clinics can improve continuity and access to care [228].

Lack of housing following prison release should also be addressed, since temporary shelters are used by 6 to 11 percent of people after release and housing instability increases the risk for medical illness and mortality [229]. Appropriate discharge planning for people leaving prisons is indicated, including referral to community drug treatment programs and housing services [230].

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Health care of criminal justice-involved populations".)

SUMMARY AND RECOMMENDATIONS

●Principles of health care in jails and prisons – Health care in jails and prisons should be delivered based upon the best evidence for effective care as it is in the general population. (See 'Introduction' above.)

●Health screenings upon correctional facility intake – Screening upon entry into a jail or prison facility should include assessment for potential drug and alcohol withdrawal, injuries, conditions that may have an immediate flare or require continuing medication therapy, suicide risk, transmissible diseases, and pregnancy. (See 'Initial screening and assessment' above.)

●Screening for infectious diseases – Particular attention should be paid to screening for COVID-19, HIV infection, viral hepatitis, chlamydia, gonorrhea, Trichomonas vaginalis, syphilis, and tuberculosis. Some of these infections are more prevalent among persons who are incarcerated than in the general population, and all can be transmitted within facilities if not identified and appropriately managed. (See 'Infectious diseases' above.)

●Chronic disease management – Chronic disease management should not be compromised due to incarceration. Maintenance medications for underlying conditions should be continued without interruption. (See 'Management for specific conditions and populations' above.)

●Opportunity for preventive and health care maintenance services – Incarceration presents an opportunity to provide preventive services to a population who may otherwise have poor access to care. Routine health care maintenance, as would be offered to patients in the community, is also appropriate during incarceration, including age-appropriate cancer screening and vaccinations. (See 'Routine health care maintenance' above.)

●Post-release risks and barriers to care – There is a high risk of death in the immediate period following release from jail or prison, with the greatest risk of death from drug overdose. Management of opioid use disorder with medication (continued or initiated during incarceration) with plans made for transition of care to the community is one strategy to mitigate this risk.

Barriers to care following release from incarceration, including limited income, lack of housing, lack of health insurance, and medical practice discrimination, can interfere with the establishment of routine medical care post-release. Appropriate discharge planning upon prison discharge is indicated, including referrals to housing services, community drug treatment programs, and medical providers. (See 'High mortality rates immediately following release' above and 'Opioid use disorder' above and 'Barriers to care after release' above.)