What is the impact of HIV and incarceration?
Incarcerated people are our neighbors. Jail and prison populations have doubled in the past ten years. Overcrowding and understaffing is legion in correctional systems. Inmates are admitted and released more frequently, making them active participants in the general population. As more people pass in and out of jail and prison, so too do problems and diseases associated with incarceration, like HIV.
In 1992, AIDS cases for people in State or federal prisons reached 195 for every 100,000, as compared to 18 for every 100,000 for the general population of the US.(1)
The incarcerated are the only population in the US that has a constitutional right to health care. High rates of AIDS and HIV infection underscore the need for health care.(2)
Are prisoners at risk for HIV?
Yes. Recent studies show that female inmates, inmates age 25 or younger, and African American and Hispanic inmates are at greatest risk for HIV infection.(3) Injection drug use, other illicit drug use, unprotected sex, and tattooing are all risk behaviors for HIV.
Drug offenses account for the single largest number of Federal crimes for which people are incarcerated.(3) In 1991, 79% of State prison inmates reported using illicit drugs at some time.(4) It is not surprising then, that high rates of HIV infection occur in this population. Injection drug users (IDUs) are at special risk, as clean needles are almost impossible to find both in and out of the prison system.
What are obstacles to prevention?
Many jail and prison officials do not wish to acknowledge that drug use and sexual activity is prevalent in their institutions. Prisoners also may not wish to acknowledge activities that could subject them to further sanctions.(5)
Prisons and jails would seem to be an ideal venue for drug treatment and education. There are more IDUs in correctional facilities in the US than in drug treatment centers, hospitals, or social services. However, in 1991 only 1% of federal inmates who had moderate to severe drug abuse problems had received appropriate treatment. Also, for inmates who did complete treatment, there were no aftercare services in place to help them remain drug-free.(6) Lack of outreach and program information to prison staff may have contributed to limited participation.
Only six prison systems in the US distribute condoms: Mississippi, New York City, NY, Philadelphia, PA, San Francisco, CA, Vermont, and the District of Columbia. Methods of distribution vary from receiving one condom per medical visit to receiving multiple condoms as part of HIV/AIDS education.(1) However, distribution programs often send a mixed message because sexual activity in some institutions is illegal and a punishable offense. Also, correctional medical staff may advocate condom availability while administration and security staff oppose it.
Currently, 16 state prison systems mandate HIV testing; 77% make HIV testing available to all inmates on request.(1) Testing HIV-positive while incarcerated could pose two problems: health care is often inadequate to treat HIV infection, and some prisoners fear discrimination or segregation if they are found to be positive.(7)
Why are HIV rates so high?
Most incarcerated people come into jail or prison already infected with HIV. A study of 46 correctional facilities found that people entering correctional facilities had a median infection rate of 1.7%. In some facilities, rates for women were as high as 20.6%, and for men 14.8%. For homosexual and bisexual men, rates ranged from 9.4% to 34.5%; for IDUs rates ranged from 0.6% to 43.1%. (8)
A study of Latino inmates in a California state prison found that 51% reported having sex in the first 12 hours after release. Inmates also indicated the desire for "pure" sex (without condoms) once they leave prison. In addition, 11% reported injecting drugs in the first day after release. (9)
What is being done?
State and local health departments provide HIV testing and counseling services in almost 430 correctional facilities in 42 states, the District of Columbia and Puerto Rico. However, health education and risk reduction programs are only provided in facilities in 20 states and the District of Columbia. (10)
At the only prison facility in the state of Rhode Island, a comprehensive program addresses needs of prisoners while incarcerated and follow-up after their release. The program involves HIV education in prison, HIV testing and counseling, medical care for HIV-infected prisoners, and pre-release counseling and post-release monitoring of HIV-infected individuals. Pre-release counseling included medical care, drug abuse, housing, and financial support needs of prisoners. One year after release, 73% of HIV-infected inmates were receiving follow-up medical care. (11)
A community follow-up intervention targeted incarcerated youth aged 13-19 in the District of Columbia. The program reinforced risk-reduction behaviors by providing adult mentoring, peer support, and access to health care services. (10)
Weekly HIV/AIDS education and support groups were set up for female inmates at a facility in New York City, NY. The groups were facilitated by a community-based organization, and focused on communicating with family members and close contacts about risk behaviors, locating medical care, and other HIV-related information. (10)
Men at a large state prison in California can take part in a comprehensive intervention program that includes: HIV-positive inmate peer education, pre-HIV test counseling, health promotion for HIV-positive inmates, pre-release educational booster session, discharge planning and community follow-up. The success of these programs involves ongoing support and input from inmates, guards and correctional officers, prison counselors, educators, administrators and the prison medical team. (12)
What still needs to be done?
Overcrowding, high turnover, and escalating rates of HIV and other diseases, combined with restricted rights of inmates, create a dangerous public health situation in correctional institutions in the US. Some claim that "the prison population needs access to means of reducing harm more than the general population does." (13)
The pandemic of HIV has paralleled the pandemic of incarceration. Correctional institutions could be an ideal setting for HIV education, prevention, and treatment since inmates are a captive audience. A comprehensive HIV prevention strategy uses many elements to protect as many people at risk for HIV as possible. In addition to education and treatment in prison or jail, discharge planning is essential to help inmates develop links with their community. Also, ongoing training and education for prison staff (guards, nurses, doctors) is key for ensuring that programs are consistent and sustainable within institutions. (14)
References:
Prepared by Pamela DeCarlo and Barry Zack
Reproduction of this text is encouraged; however, copies may not be sold. The Center for AIDS
Prevention Studies at the University of California San Franciso is the source of this
information. For additional copies of this and other HIV Prevention Fact Sheets, please call the
National AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may
be e-mailed to prevention_factsheets@quickmail.ucsf.edu. ©1996, University of California
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