State-of-the-Art Review: The Intersection of Infectious Diseases and Carceral Medicine

Abstract

Mass incarceration is a national epidemic; all clinicians will encounter persons currently incarcerated or with a history of criminal-legal involvement. Infections are highly prevalent in these populations. This review will support clinicians to provide evidence-based infectious diseases treatment with explicit recognition of the interpersonal and structural intricacies in carceral care. Following a criminal-legal system primer, clinicians will have a finer understanding of the psychosocial complexities involved in building provider–patient relationships with those impacted by this system. By recognizing that care delivery can be subject to a potential conflict of interest in supporting both the health interests of persons incarcerated while respecting the unique carceral institution regulations in place to protect carceral staff, clinicians will navigate the concept of “dual loyalty.” With this, in conjunction with supporting patient autonomy in treatment decisions and providing infection-prevention counseling and treatment, clinicians can create a therapeutic patient alliance and reduce health disparities.

Graphical Abstract

The United States incarcerates more people than any country in the world [1]. As of 2022, nearly 2 million individuals are incarcerated in prisons and jails in the United States and it is estimated that 9 million individuals will cycle through jails at least once each year [2]. People who are incarcerated are at increased risk of illness and death [3]. In particular, death and disease related to infections are common [4].

As a result of racism, ethnically and racially minoritized populations comprise the majority of those within the carceral system. Black individuals are over 5 times more likely to be incarcerated than their White counterparts, while the likelihood for Hispanics is more than 3 times compared with White individuals [5, 6]. In addition, LGBTQIA (lesbian, gay, bisexual, transgender, queer, intersex, and asexual) individuals [7], individuals with disabilities [8, 9], Indigenous people [2], and those with mental health conditions [10] are also disproportionally affected by mass incarceration. People with a history of incarceration or who are currently incarcerated face distinct barriers to health. This includes, although is not limited to, prior psychological trauma, including from incarceration, disconnection from community and support systems, ongoing legal challenges, restrictions due to community custody (ie, probation, parole), and a criminal record limiting housing, educational, and employment opportunities.

Infectious diseases (ID) clinicians need to be prepared to care for people who have active, or a history of, criminal-legal involvement. We now refer to this population as “criminal-legal system (CLS) involved.” Given the prevalence of incarceration, even those who do not practice in jails or prisons will encounter patients with CLS involvement in outpatient and hospital settings. Human immunodeficiency virus (HIV), hepatitis C virus (HCV), and tuberculosis remain prevalent infections encountered within this population; however, these individuals remain at high risk to be most affected by epidemics and pandemics. The coronavirus disease 2019 (COVID-19) pandemic demonstrated many of the challenges in public health preparedness in carceral settings. Jails and prisons had a higher number of outbreaks compared with the public, along with mortality rates estimated to be 2 to 3 times higher than in the general population [11]. The large number of individuals processing through jails, exposed to coronavirus, and then returning to the community highlighted the porous nature of carceral facilities [12]. Over 95% of individuals incarcerated return to their community eventually; thus, jails and prisons often present a concentrated at-risk population that can benefit from targeted interventions.

Delivering ID-related clinical care for this population requires not only clinical knowledge but also an awareness of the potential conflict of interest known as “dual loyalty,” and a sensitivity to the psychological trauma experienced by people exposed to incarceration. To effectively serve CLS-involved individuals in any setting, healthcare clinicians must grasp the complexities of the intersection of health and justice. Following a brief primer on carceral health, we highlight core themes in carceral medicine, its intersection with the field of ID, and the potential for improved care of CLS-impacted individuals through a public health lens.

Carceral Health: Describing the Spectrum of Incarceration

Caring for individuals with CLS involvement is not limited to providing healthcare for those currently in jail or prison. Incarceration is a single point in the spectrum of the CLS, a spectrum where individuals are exposed to police, courts, parole officers, and other systems of carceral control [13]. Common terminology (defined in Table 1) can help clinicians understand the legal context of a patient who is in custody or impacted by the CLS [14-18]. Awareness of these intricacies can also facilitate use of the most appropriate language. As with other areas of medicine, language matters, and there is a broad shift to using person-first language. Terms like “prisoner,” “offender,” or “inmate” are not person-first. A person is not their crime nor defined by their carceral status, and continued use of labeling language may be further stigmatizing to an already highly stigmatized population. “Incarcerated individuals” or “individuals impacted by the criminal-legal system” do not define the person by their incarceration status [19]. Finally, the term “carceral” is a more appropriate term than “corrections.” This shift in terminology highlights how the CLS often spends less energy in rehabilitation or “corrections” since the integration of these terms in the 1970s [20]. In discussing carceral healthcare, this term provides a neutral label that still recognizes the specific needs of this population who, at some point in their life, were involved with the CLS (ie, during probation, while formerly or actively incarcerated in a jail or prison, or now released and possibly on parole).

Table 1.

Common Terminology Used Within the Criminal-Legal System

Terminology	Definition
Corrections	The conglomerate responsible for the retribution, rehabilitation, and supervision of criminal offenders through the system of incarceration, probation, and parole. The term “carceral” is now used more frequently given its consistency with the action of incarceration and to highlight how our criminal-legal system often spends less energy in rehabilitation or “corrections.”
Jail	Institution confining individuals either awaiting trial for an accused crime (and thus legally innocent) or those convicted and sentenced for a low-level crime (defined as misdemeanor or felony with less than 1 year sentence). Jails are usually managed at the city or county level.
Prison	A state or federal institution confining individuals convicted of felonies often with greater than 1-year sentences.
Parole	The conditional release of an individual prior to completion of their sentence under supervision of a parole officer. Factors such as good behavior are reviewed by a parole board which may grant early release. Violations of any condition of early release can result in return to prison.
Probation	A court-imposed criminal sentence that, subject to stated conditions and restrictions, releases someone who has been convicted of a crime into the community rather than confining them to jail or prison.

Data from references 14-18. These terms are necessary to understand the unique needs of this patient population.

Constitutional Right to Healthcare

To appropriately grasp the public health issues currently at play, a brief review of the relevant legislation is important. The 1976 US Supreme Court decision Estelle v Gamble is an important shift in the way healthcare is provided to CLS-involved populations. The Supreme Court clarified that withholding “community-standard” healthcare was “cruel and unusual punishment” and thus prohibited by the Eighth Amendment to the US Constitution [19]. Although this was a step in recognizing a dire need for improvement in carceral healthcare, there are several reasons why this standard has been challenging to attain in practice. Items such as providing hepatitis C treatment in carceral settings were not clearly defined. In addition, should an incarcerated person bring a claim to the judicial system, they needed to prove not only poor or negligent care but “deliberate indifference.” This ruling (Estelle v Gamble) was then significantly weakened 20 years later by the Prison Litigation Reform Act passed by US Congress in 1996 [20]. This act, among other things, required exhaustion of administrative remedies before incarcerated individuals could bring cases against carceral health providers to court, while also having to pay for all administrative fees. This placed additional barriers on the CLS involved when self-advocating for community standard healthcare all while clear standards for what defined that quality of care remained lacking. With lack of implementation of widely used accreditation bodies, and very little accountability in the system, it continues to remain challenging to consistently evaluate the quality, quantity, or cost of carceral healthcare [21].

Models of Care in Jails and Prisons

There are multiple models for care delivery within carceral facilities, determined at a governmental level. Terminology frequently used to address these delivery systems includes direct, contracted, private, or university and then hybrid models, relating to who is contracted to provide care and where that care happens [22]. Outside of these care models, some, generally small, facilities send patients offsite to local clinics or hospitals for all care. However, regardless of the care delivery model, patients will have a variable level of access to urgent care, primary or chronic healthcare services, and subspecialty services, often depending on the priorities, resources, and staffing of the facility where they are incarcerated. While many large jails are in urban centers, prisons, on the other hand, tend to be located rurally [23], which can further limit access to adequate healthcare staffing, subspecialty services, and emergency care. Physicians caring for patients who are incarcerated can contact their local facilities to understand their model of care delivery and what services they offer.

CLINICAL VIGNETTES

We use 3 hypothetical patient cases to illustrate several challenges commonly encountered in medical practice across various CLS settings and provide guidance on how to provide state-of-the-art ID care to these involved patients.

Case 1—The Challenges of Community Re-entry

Ms. Marquez is a 26-year-old transgender woman who presents to care after testing positive for HCV on nursing intake. She has a positive HCV antibody with a viral load of 2 000 000 copies per milliliter of blood. Screening for sexually transmitted infections is negative, including HIV. She reports unprotected anal receptive and insertive intercourse while incarcerated. You take this opportunity to discuss HCV treatment and HIV pre-exposure prophylaxis (PrEP); she has interest in both. She is being released in the next month and will “deal with it then.” She tells you she is not sure where she will be living but knows she is being mandated to stay at a recovery group-living setting, which will require serial drug and alcohol testing and meetings with a case manager. Ms. Marquez is worried about trying to balance her recovery while adjusting to a new housing situation and looking for a job. She tells you she needs to prioritize access to gender-affirming care. She is concerned about finding the time and money to attend additional medical appointments, especially if they are outside of where she will be receiving her gender-affirming care.

Core Themes

Screening for Infectious Diseases

The Centers for Disease Control and Prevention (CDC) recommends broad access to infectious disease screening in jails and prisons [24]; HIV and HCV screening should be offered at intake. The recommended form of offering testing is through opt-out questioning [25]. For example, “We will perform HIV and HCV testing unless you do not want it” is a method of opt-out, in comparison to “Do you want to be HIV and HCV tested?” which is opt-in. Although opt-out testing is an evidence-based method of increasing HIV testing [25], there are some ethical questions about whether someone who is incarcerated sincerely understands that they can “opt-out” [26] and whether staff as well understand what “opt-out” means [27]. HIV testing requires a level of trust and confidentiality that is not always provided in carceral settings. Moreover, logistical barriers exist for basic screening, particularly in jail settings where the length of incarceration can be a few days or fewer, and phlebotomy may not be readily available. Despite these potential barriers, HIV screening should be offered to everyone transitioning within carceral settings.

Hepatitis C

The overlap of criminalization of drug use disorder, barriers to harm-reduction tools, and decreased treatment rates in people with opioid use disorder (OUD) has led to high rates of HCV in carceral populations [28]. The original hepatitis C treatments, including interferon, were generally not offered to people in prison, and those incarcerated with hepatitis C died of liver disease at alarming rates [29, 30]. The introduction of highly effective and well-tolerated oral direct-acting antiviral treatments has revolutionized HCV treatment in the community and in some carceral settings, but full expansion into jails and prisons has been delayed [31, 32]. The cost of treatment continues to be a barrier, with a subsequent downstream effect of disincentivized screening efforts [33-35]. Screening for, and treatment of, HCV in jails and prisons is recommended by the CDC and remains a key pillar to HCV eradication. Similarly, the National Commission on Correctional Health Care recommends all individuals entering carceral facilities should be screened for HCV using “opt-out” questioning and offered direct-acting antivirals for treatment if positive [36]. Recent programs have shown effective implementation of this [37-39]. In our case, there are various approaches to effectively treating Ms. Marquez’s HCV infection. Although she is soon being released, this should not be a barrier to initiating curative therapy if she is interested in treatment and appropriate transition of care can be established.

Implementation of HIV PrEP in Carceral Settings

While HIV screening and treatment have received considerable attention in jails and prisons [40], there has been less focus on HIV prevention. People being released from jail or prison may be at increased risk of HIV in the period immediately after release due to condomless sex and return to injection drug use [41]. In a study of justice-involved women in Connecticut, one-third had increased HIV vulnerability and might benefit from oral or injectable PrEP [42]. There are many barriers, however, to initiating HIV PrEP prior to release from jail or prison [43], and most carceral facilities do not currently offer it or assess for HIV risk. Disclosing HIV status and behavioral vulnerabilities that increase HIV risk may be particularly stigmatized in jails and prisons [44]. Recent studies have shown that people who are CLS-involved may have little awareness of PrEP [45, 46] or little trust in carceral health services [47], reducing PrEP uptake. Finally, and perhaps most important, people being released from jail and prison have many competing priorities, and engaging in preventive healthcare may not be a priority [48]. Many states have applied for waivers (Section 1115 waivers) from the Centers for Medicare and Medicaid Services to extend Medicaid coverage into the 30 to 90 days prior to release from incarceration [49]. This increased funding prior to release may provide opportunities for greater use of long-acting injectable PrEP, which may be more acceptable to people being released from prison or jail than daily oral PrEP [50], and coordination of post-release care. In line with CDC PrEP guidelines [51], patients do not need to disclose their risk factors and should be prescribed PrEP simply because they ask for it. Given the stigma associated with HIV, and associated risk factors for acquisition, that may still exist within this population, this strategy may be particularly important in the carceral setting.

Case 2—Hospital Care for Incarcerated Individuals and Discharge Planning

Mr. Jones is a 42-year-old cisgender man with a history of OUD on methadone and prior thoracic spine injury with internal fixation who is currently incarcerated at a state prison. He initially presented to the emergency department (ED) in custody, after sustaining a fall while working out. A week later he developed a fever and worsening back pain and was transferred to the ED, where he was examined in shackles while accompanied by 2 officers. Magnetic resonance imaging of the spine revealed a thoracic paravertebral abscess and he underwent operative washout. His spinal hardware was not removed. Cultures obtained intraoperatively grow methicillin-sensitive (and rifampinsensitive) Staphylococcus aureus (MSSA). He was transitioned to intravenous (IV) cefazolin and the ID consult team recommended starting oral rifampin in conjunction with 6 weeks of IV antibiotic therapy via a peripherally indwelling central catheter line with appropriate weekly lab monitoring.

The patient is approaching hospital discharge when the clinical team discovered that he would need to be transferred to a maximum-security isolated unit for the duration of his treatment course given discharge with an indwelling line. The hospital pharmacist also expresses concern about rifampin reducing the efficacy of his methadone.

Core Themes

Building a Therapeutic Alliance

Clinicians working in the hospital setting who care for patients who are in custody of the police, jails, or prisons are likely to encounter carceral (correctional) officers. Maintaining a patient–clinician relationship can be difficult with officer presence, shackles, and uncertainty about what information can be disclosed. Shackles serve as a physical reminder of the patient’s status as an incarcerated person. Shackles may exacerbate underlying implicit biases among clinicians, prompt fear for safety, and create physical barriers to physical examinations or care delivery [52].

Officer presence may create challenges in obtaining accurate information necessary for appropriate diagnosis and treatment, which may be a barrier to the therapeutic relationship. Officers may provide collateral information in efforts to be helpful. However, carceral officers may supply information from a biased perspective or from their own assumptions that is not medically necessary. This added input, which can be unintentionally stigmatizing or derogatory, may hinder creating a comfortable environment, impeding the development of a therapeutic relationship between the patient and clinician.

It can also be hard to navigate the power dynamic with correctional officers present during clinical encounters. They are often following directives and may not be able to change protocol. There are multiple experience-based recommendations to consider in an effort to strengthen the patient–clinician therapeutic alliance. First, while the presence of custody officers is often mandatory whenever an incarcerated person is out of the jail or prison, many policies only require that officers be able to see the patient, not be directly adjacent to them. Clinicians can ask officers to step away but remain within eyesight or speak in a quiet tone to protect confidentiality. If an officer remains at bedside, clinicians can also ask the officers not to participate in the interview and emphasize that they want to ensure the patient is able to respond directly. Incarcerated individuals receiving care in a clinic or hospital setting still maintain rights to privacy as dictated by the Health Insurance Portability and Accountability Act (HIPAA) [53]. However, under HIPAA, Protected Health Information (PHI) can only be disclosed to correctional officers “when needed to provide health care to the individual; for the health and safety of the individual, other people who are incarcerated, officers or employees of or others at a correctional institution or responsible for the transporting or transferring people who are incarcerated; or for the administration and maintenance of the safety, security, and good order of the correctional facility, including law enforcement on the premises of the facility” [45 CFR 164.512(k)(5)] [53]. As in every other healthcare setting, every attempt should be made to maintain strict patient confidentiality.

Second, clinicians can request shackles be removed when medically necessary [54]. This may be to complete a physical examination, participate in physical therapy, or to create a therapeutic relationship. There are times when facility policy may require approval from custody leadership or where substantial security concerns may lead to officers to not approve requests for shackle removal. However, simply asking for removal of shackles can be a way to foster a therapeutic alliance with the patient. The American Public Health Association recently called for greater de-shackling of patients in healthcare settings [55], and 1 hospital recently developed and published a quality-improvement protocol to decrease unnecessary use of shackling patients [56].

Shared Decision Making and Antibiotic Selection

The standard of care should not change because a patient is incarcerated. However, as with all patients, shared decision making is essential, which involves considering how recommended treatments can impact the day-to-day life of a patient who will return to incarceration. In this case, the patient’s treatment plan involved IV antibiotics (cefazolin) and the use of oral rifampin.

Some carceral facilities can provide IV antibiotics and antibiotic monitoring on-site and some directly employ ID physicians, but this is not universal. In many cases, IV antibiotics may only be available in infirmary units, which can have decreased autonomy relative to standard jail or prison housing. Many facilities, particularly small jails, however, do not have the capacity to offer IV antibiotics and would require the patient to remain admitted in the hospital for the duration of their treatment course. If a patient who is incarcerated requires IV antibiotics, it is imperative to communicate with the prison or jail to understand not only what services they have available on-site but also where the patient would be placed and any additional restrictions of that setting. Clinicians should also discuss with the patient how receiving those services on-site (ie, prolonged stay in an infirmary unit or transfer to a different prison or continued hospitalization) could affect their overall well-being. Understanding these contextual factors can help ID clinicians guide shared-decision-making discussions and support patient autonomy and treatment adherence.

The ID team recommended that Mr. Jones receive IV antibiotics for 6 weeks of therapy for his MSSA spinal infection. Data from studies released within the last decade have consistently demonstrated noninferiority of oral antimicrobial therapy in many clinical scenarios. For example, several key studies such as the Partial Oral Treatment of Endocarditis (POET) [57], Staphylococcus aureus bacteremia antibiotic treatment options (SABATO) [58], and Oral versus Intravenous Antibiotics for Bone and Joint Infection (OVIVA) [59] trials show multiple standard-of-care treatment options in cases of infectious endocarditis, bacteremia, and bone infections. The ability to treat with oral antibiotics rather than intravenously in the appropriate clinical context may have substantial benefits for incarcerated patients.

In this patient’s case, the ID clinician should inquire what the impications of IV antibiotics are for the patient and then talk with the patient about the risks and benefits of different treatment options, including a full 6-week course of IV antibiotics or a transition to oral therapy after a shorter course of IV anti-staphylococcal antibiotics, with or without adjunctive rifampin, and the risks of incomplete eradication and recurrence given the retained hardware.

Opportunities to Support Autonomy

People who are incarcerated have limited autonomy and giving them as much choice as possible in their healthcare is paramount. Just like community-dwelling people, they can make decisions about healthcare engagement, including declining care. If, for instance, Mr. Jones would have to remain in the hospital and shackled to his bed to receive IV antibiotics for a prolonged period, this may negatively impact his quality of life. For example, he may risk missing an important court date while admitted and may prefer to switch to oral antibiotics sooner and return to prison. Similarly, if Mr. Jones were able to receive IV antibiotics within the prison system, this may nevertheless necessitate transfer to a different prison with more medical services, away from friends and belongings, which give him a sense of stability and meaning during incarceration. Accordingly, he may prefer oral antibiotics that allow him to return to his prior location. Having shared-decision-making conversations and supporting patients to make their own decisions about treatment options can further strengthen the clinician–patient therapeutic alliance.

The Intersection of ID and Substance Use in the Carceral Setting

In this case, the patient was continued on methadone in the carceral facility for his OUD. This is currently uncommon. Fewer than half of carceral facilities offer medications for opioid use disorder (MOUD) [60]. However, in the United States, with the rising influx of synthetic opioids, the prevalence of OUD continues to increase in certain populations [61]. Recent court rulings have supported the right to MOUD while incarcerated with protection by the Americans with Disabilities Act [62]. Considering these changes, many jails and prison systems may expand their MOUD programs soon. Thus, the need for evaluation of drug–drug interactions with medications commonly used for patients with OUD, such as methadone or buprenorphine, will be more common. Returning to our patient, Mr. Jones, decisions on the usage of rifampin in the setting of treatment of OUD should involve a multidisciplinary approach involving both clinical pharmacists and, ideally, carceral facility clinicians, to ensure risk associated with possible drug–drug interaction is mitigated. First, a review of the literature finds continued debate about the utility of any rifamycin (including the drugs rifabutin and rifampin) on outcomes for MSSA infection both with and without retained hardware [63-65]. Moreover, the interaction with MOUD can risk clinical opioid withdrawal and the use of rifampin and most rifamycins can interact with MOUD and risk clinical opioid withdarwal [66 , 67]. Thus, the decision to augment treatment with one of these agents should be made with this patient through shared decision making, discussing both the potential benefits of and limited data related to the additional antibiotic, along with the interactions with his methadone. There may be limited options for methadone dose changes within the facility, and withdrawal during incarceration may compound an already challenging situation for patients.

Case 3—Treatment of Infections in Carceral Settings

Ms. Smith is a 58-year-old cisgender woman with type 2 diabetes on insulin, primary hypertension, hyperlipidemia, obesity, and prior tobacco use disorder who presents with tooth pain. Her exam is notable for tachycardia and hypertension. She has a cracked molar with peri-gingival inflammation. After reviewing her allergies, she is prescribed oral amoxicillin for her tooth infection and a request is placed for her to see the dentist who comes to the prison weekly. You also take this time to ask her about her diabetes. Like several prison protocols prohibiting people from having needles, insulin is directly administered, or individuals are observed while self-administering insulin. Ms. Smith reports that, because of the long lines for medication administration and fears about hypoglycemia, she has been going without her insulin for much of the past few weeks. She was seen by a clinician 2 weeks prior for hyperglycemia and her nightly basal insulin was increased. Since the increase, she reports trouble waking up in the morning and breaking out in sweats in the middle of night. She has not gone back for nightly insulin since. Her point-of-care glucose check is 352 mg/dL. You talk to the covering internist about your concerns related to Ms. Smith’s diabetes and they decrease her basal insulin and prescribe a nightly snack for her.

Core Themes

Risk of Infection Among Chronic Medical Conditions in the Carceral Setting

People who are incarcerated may face a disproportionate burden of chronic disease. Cardiovascular disease, for instance, is a leading cause of death after release from prison [68, 69], and incarceration is associated with worse cardiovascular outcomes [70, 71]. This may be, in part, due to barriers to management of chronic disease that contribute to cardiovascular risk, such as diabetes, during and after incarceration alongside the chronic stress of incarceration. Diabetes care in carceral facilities differs dramatically from community settings. Patients cannot adjust their doses in real-time, have limited control over their diet, and may not have knowledge of what exactly they will be served for a meal when obtaining their prandial dose. Should they become hypoglycemic, they may not have ready access to snacks. In 2024, the American Diabetes Association released a statement on diabetes care for people who are incarcerated [72]. This statement underscores that diabetes management in jails and prisons should align with national guidelines [73]. It also recognizes, however, that carceral facilities face barriers to the implementation of guideline-directed diabetes care, including policies that do not allow incarcerated people to use needles themselves, limited medication availability or budgets, restrictions on available food, and frequent transfers of individuals between facilities or in and out of incarceration.

Clinicians treating common infections should be aware of the increased risk of chronic comorbidity presence and its potential intersection with the management and treatment of infectious diseases. Our patient, Ms. Smith, is seeking medical care for an odontogenic infection; appropriate antibiotics and prompt dental intervention are standard of care. In this case, however, the ID clinician seeing the patient noted that her labile glucose control was likely contributing to her infection and recognized the barriers she was facing to appropriately manage her diabetes, placing her at risk of persistent hyperglycemia. Communication between the ID clinician and the prison’s internist allowed for prompt adjustment to her insulin regimen and a nightly snack to be prescribed and arranged for her. In many carceral settings, additional or different foods (ie snacks, mechanical soft diets such as purees) or medical equipment require a special order from a clinician at the carceral facility. For example, if an incarcerated patient is being discharged from the hospital with new durable medical equipment or specific dietary needs, clinicians should contact the carceral facility and note these needs very clearly in a discharge summary to ensure that carceral providers can write for and accommodate the appropriate orders.

ADDITIONAL CONSIDERATIONS

Dual Loyalty

In addition to the core themes identified, all clinicians caring for patients who are incarcerated will navigate “dual loyalty.” This phrase refers to the loyalty a healthcare provider has to protect patient well-being while also protecting the carceral officials, maintain public safety, and following the rules of the carceral institution [74]. Providers may feel caught between the limitations of the carceral institution and providing what would be optimal care for the patient. This can affect the therapeutic relationship. Requesting that a patient be unshackled for an exam or providing consistent opportunities for shared decision making throughout the treatment course can further strengthen this critical patient relationship, even if there are limitations of the carceral setting that the ID provider cannot change. Recognizing this tension in clinical care can be helpful in navigating it.

One example of dual loyalty is discussing antibiotic follow-up with a patient. Outpatient parenteral antibiotics therapy (colloquially known as OPAT) requires close follow-up, often in an ID clinic offsite from the prison or jail. Incarcerated patients are often not allowed to know the date or time of their follow-up appointments. This is in an effort to prevent possible ambush or escape attempts of people who are incarcerated during the offsite trips, when there are far fewer officers and security features than within a jail or prison. While it is standard of care to discuss follow-up plans with patients, providing too much logistical detail could lead to an incarcerated patient’s appointment being cancelled, which could ultimately worsen outcomes.

Given that patients with CLS involvement face a myriad of barriers to care access both during and after incarceration, it is beneficial to the patient that providers take an “internist first” approach to each clinical encounter. These patients may particularly benefit from receiving the entirety of their care from a single provider. Consider Case 3: this patient’s uncontrolled diabetes may worsen their ID outcomes, and a clinician should be empowered to do what is within their scope of practice to evaluate, screen, and assist in the management of these chronic medical conditions. Similarly, in Case 1, those incarcerated have limited access to gender-affirming care [75], which, upon release, may be their priority to obtain. Thus, working with the patient to have PrEP managed through their gender-affirming care provider, rather than through an ID clinic, may allow the patient to have greater access to PrEP.

Public Health, Medicine, and Reimagining the CLS

De-carceration as public policy has also been discussed as a public health intervention. In 2021, the American Public Health Association called for “moving toward the abolition of carceral systems and building in their stead just and equitable structures that advance the public’s health” [76]. Infectious diseases clinicians, in their role as public health champions, may also have a role as advocates. Consider what it could look like to reimagine the CLS: a public health–oriented system that would prioritize both rehabilitation and the upstream causes of crime, such as poverty, social marginalization, mental health conditions, substance use, and systemic racism. Criminal-legal reform is a public health issue and an area where ID clinicians can also use their voices and societal position to call for change at the institutional, local, state, and federal levels.

Opportunities for Advancement

Recent literature recognizes the delay in implementing evidence-based practices within jails and prisons [77]. Clinician scientists have a role to play in innovating various implementation strategies of evidence-based care within carceral settings. Carceral settings warrant targeted implementation research, given how they differ from a community-based care setting. From implementation of prevention practices related to the diagnosis and treatment of transmissible infectious diseases to antimicrobial stewardship [78] within carceral healthcare systems, there are numerous opportunities to advance the healthcare provided within the carceral space and address an escalating public health crisis.

Fostering ID Clinician Involvement in Carceral Facilities

There is a shortage of healthcare providers in jails and prisons. All authors of this review have practiced in carceral facilities and can attest that these institutions, and the circumstances they produce, can be among the most challenging environments to work in but are also the most rewarding. Practicing high-quality medicine in jails and prisons provides opportunities to help people who may be most in need of evidence-based care and to see first-hand some of the most important individual and public health challenges that the United States faces. Historically, ID clinicians have been known for their leadership among the medical field in navigating public health crises and being a pioneer for change in how healthcare is delivered to marginalized populations [79]. Providing care for patients both during and after incarceration aligns with that mission.

CONCLUSIONS

Infectious diseases clinicians can play a vital role in mitigating health disparities by providing patient-centered care and advocating for improved healthcare standards within the CLS. By having a foundation in understanding the complicacies of the carceral system and the unique risks of and inequities affecting those along the spectrum of CLS involvement, ID clinicians can best serve this population and prevent, diagnose, and treat infectious diseases, and connect to appropriate care after release.