If tens of thousands of inmates are released from state prison over the next two years, they'll bring their HIV, hepatitis C and tuberculosis infections with them back to their communities.

The state prison system's health care delivery is so bad, it was deemed unconstitutional by federal judges, who could find no other fix than to order the reduction of the prison population. But because of cuts to already-slim services for ex-cons, there's no guarantee that the sickest parolees will be much better off on the outside.

"It's almost set for failure to just release people with no resources," said Jessica Flintoft, a policy director for re-entry in San Francisco.

When so many other adults and children have trouble seeing their doctor or getting their medications, there are few tears for the formerly incarcerated. But ignoring parolee health can have serious consequences on public health.

"We want to prevent them from spreading disease to anyone else," said Marianne Gallagher, supervisor of the Neil A. Christie Living Center, which provides services to people with HIV and AIDS in San Jose, including the formerly incarcerated.

"It's not a popular population. But they are probably the most vulnerable."

Former prisoners face more obstacles to health care than the typical uninsured. Many are homeless and can't find jobs because of their records. Many are angry at the system and view doctors on the same plane as their jailers. So health care, even for those with serious diseases like HIV, is far more difficult to access, and rarely a priority.

"In a paradoxical way, they do much better in jail than they do at home," said Dr. Dean Winslow of the PACE clinic in San Jose. "Because they're not actively doing drugs, they're eating three meals a day and they're usually under less stress in jail than on the outside."

HIV is one of the most common diseases among incarcerated populations. A 2000 study found that almost a quarter of all people living with HIV or AIDS in the United States were released from a correctional facility within the year.

If ex-cons don't see a doctor quickly, and miss even a few doses of their medications, their disease can develop drug resistance.

"People are not controlling the virus in their own system, then they're passing on viruses that are already resistant to other people," said Dena Dickinson, health center manager at the PACE clinic.

Skipping medication also causes viral loads to spike. This makes it easier to transmit the infection, and makes patients more susceptible to other contagious viruses - like swine flu - that can then spread through the community.

The PACE clinic currently serves about 1,100 patients. Dickinson estimates about 20 percent of them spent time in jail or prison within the last couple of years.

The clinic is waiting to hear how many inmates will be released under the court order and when before developing a plan to serve them.

In the meantime, the clinic is one of several San Jose programs trying to better help HIV-positive inmates transitioning in and out of county jails and state prison.

PACE doctors and pharmacists visit inmates at San Jose's county jails monthly to help familiarize them with clinic staff so they'll be more likely to make an appointment when they're released.

Case managers from PACE and the LINKS program at the Living Center help inmates find housing and work. Sometimes they meet with men on the day they're released and accompany them to appointments so they don't drop off the radar.

Doctors and advocates have asked the county to release HIV-positive people with a week or month's supply of medication and during the daytime, when they can more easily access social services.

But many people still slip through the cracks. Funding at the jails has been cut like all other county programs, and there's simply not enough staff to monitor release orders on a daily basis.

"We have four or five positions that are vacant," said Dr. Alex Chyorny, medical director for the county jails.

And there is no staff to do routine HIV screening when inmates are admitted to the jail.

Testing is done only if a patient requests it or a doctor recommends it. Several hundred people with HIV pass through the system each year, Chyorny estimates, but he sees only a third of them. A third don't know they're infected, and another third know they're HIV-positive but don't want to tell anyone.

That leaves clinics like PACE to treat more advanced illness, and has public hospitals footing the bill for months-long stays.

"Unfortunately, people still tend to wait until they're sick. By that time, it's AIDS defined and it's a lot harder to bring them back to baseline," Dickinson said.

"If people get into care early, it optimizes their health and it also contains the cost."