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Prisons
HIV Transmission and Prevention in Prisons
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Introduction
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Epidemiology and Background
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Survival Experience
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HIV Transmission in Prisons
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HIV and Hepatitis C
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HIV and Tuberculosis
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Medical Treatment of HIV-Infected Prisoners
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HIV Testing Policies
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Confidentiality
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Prevention
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transparent imageEducation
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transparent imageCondoms
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transparent imageSterile Syringes
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transparent imageBleach
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transparent imageMethadone Maintenance
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Discharge Planning
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AIDS Research
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Legal Issues in U.S. Prisons
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References
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Related Resources
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Introduction
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Prisoners are at exceptional risk for infection with HIV because of the association of injection drug use with incarceration. Women prisoners who have practiced prostitution, which frequently is associated with injection drug use and contact with HIV-infected sex partners, are at additional risk for HIV infection. This chapter reviews the following issues involved with HIV infection in prisoners: epidemiology, prevalence, and transmission; the growing coincidence of tuberculosis and hepatitis C; institutional issues, including prison policies and practices, confidentiality, informed consent, and medical research; the extensive involvement of the legal system in the area of HIV in prisoners; and the role of educational programs in prevention efforts.

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Epidemiology and Background
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As of December 31, 2004, nearly 7 million people in the United States lived under the jurisdiction of the criminal justice system, and more than 2.2 million were in jail or prison. The United States imprisons its population at the highest known rate in the world, 724 per 100,000 persons in 2004. In 1998, 11.5 million people were released from jails and prisons into communities in the United States. These figures, which continue to increase, reflect the country's adherence to a formidable social policy of imprisonment and raise the public health issue of the huge impact that prisoners' health will have on the community at large. Prison populations have grown in recent decades primarily because incarceration has been the central tactic of the "war on drugs" in the United States. The millions of intermittently incarcerated people in America, many of whom are illicit drug users, have been among the most difficult people to reach with critical health information, management, and treatment. The National Commission on AIDS stated in its 1991 report: "By choosing mass imprisonment as the federal and state governments' response to the use of drugs, we have created a de facto policy of incarcerating more and more individuals with HIV infection." Fifty-seven percent of federal prisoners were incarcerated for drug-related offenses in 2001.(1,2-4)

The AIDS prevalence in 2003 was more than 3 times higher in state and federal prisons (0.51%) than in the general U.S. population (0.15%).(3) Between 20% and 26% of people living with HIV/AIDS in the United States have spent time in the correctional system.(5) No precise count of HIV cases in prisoners is available, as brief incarceration, particularly in jails, limited access to health care, and lack of universal screening hinder the identification and diagnosis of inmates with HIV infection. Also, arrestees may choose not to declare their HIV status.

In 2003, a U.S. National Institute of Justice survey of the 50 state prison systems and the federal prison system reported 5,944 current AIDS cases.(3) New York, Texas, and Florida accounted for nearly half of the confirmed AIDS cases within the 50 state prison systems.

HIV seroprevalence reported by the 50 state prison systems was 1.9%, and 1.1% in the federal prisons, in 2003.(3) Jails in the south and northeast accounted for 80% of known HIV-infected inmates. Greatest seroprevalence was found in jails in the largest jurisdictions: the District of Columbia (7.6%), New York (4.3%), and Massachusetts (4.0%).

The 2002 Survey of Inmates in Local Jails was conducted by asking inmates for their HIV testing history and status. From a pool of 3,365 jails previously surveyed in 1999, a sample of 465 jails was selected in 2002. A total of 6,982 inmates in 420 jails agreed to participate, and the percentage of HIV-positive males in the local jail population in 2002 was determined to be 0.8-1.6%.(4)

Female inmates, accounting for 5-10% of the prison population, have had a higher HIV antibody seroprevalence than male prisoners (2.8% compared with 1.9%, respectively, in 2003). This discrepancy exists in most state prison systems, and cumulatively in each of the 4 regions identified by the U.S. Department of Justice: Northeast, Midwest, South, and West. More than 10% of all female inmates were known to be HIV positive in 2 states: New York and Maryland (14.6% and 11.1%, respectively). In all states, <10% of male inmates were reported to be HIV positive. Only New York reported >5% seroprevalence among male prisoners (7.4%).(3)

HIV seroprevalence in U.S. prison inmates parallels the uneven geographic distribution of HIV in injection drug users (IDUs) and regional patterns of incarceration and case finding. A comparison of prison AIDS cases with total U.S. AIDS cases in 1994-96 found that 61% of prisoners had injected drugs, compared with 27% of total cases.(6) A report from the state of New York on changing HIV seropositivity identified a decreasing incidence of HIV in newly admitted inmates between 1998 and 2003. Increasingly, persons of African American or Hispanic race, those >30 years of age, and men who have sex with men (MSM) have approached IDUs as predictor groups for seropositivity.(7)

The disproportionate burden of HIV infection among racial minorities is more pronounced in prison than in the community at large. A comparison of prison and total AIDS deaths found that African Americans comprise more than two thirds of prison cases, compared with 39% of total cases. A 2001 report from Maryland of 888 AIDS cases identified in the state's prisons noted that 91% were African American, compared with 75% statewide.(8)

Improved HIV identification and treatment in the late 1990s resulted in a precipitous drop in AIDS deaths among the incarcerated population as well as in the community at large. In 2003, a total of 268 state prisoners died of AIDS, down from 1,010 in 1995. The number 268 was determined by the use of 2 reporting systems, the National Prisoner Statistics and the additional Deaths in Custody Reporting Program, enacted in 2000. In 2001, the Bureau of Justice Statistics began collecting individualized details about deaths in state prisons, which corrected some previous underreporting of AIDS-related deaths. In 2002, the percentage of deaths due to AIDS in prisons was more than 2 times that of the U.S. general population.(3)

The state of New York has had the longest and the largest experience with HIV in its prison system, and the New York State Commission of Correction has published the most extensive reports on state prison cases of HIV infection beginning in the 1980s. As of the end of 2003, one fifth of all inmates in the United States known to be HIV infected were in New York prisons. New York had recorded 2,186 prison deaths from AIDS through September 1996. New York's early experience with huge numbers of prisoners with HIV offered a view into the future for other prison systems.(9,10) By 2003, however, HIV seroprevalence among inmates entering state prisons in New York had declined 75% for males and 40% for females.

Other nations began reporting AIDS cases in prisons several years after the United States. However, the rate of increase in such cases has been steep. Countries with particularly high seroprevalence identified among prisoners include Brazil (15% in 2001 [0.6% for the general community]), Côte d'Ivoire (27.5% in 2001 [10.8% for the general community]), South Africa (40% in 2003), Zambia (26.7%), Nigeria (9.0%), Honduras (6.8%), Russian Federation (3.1%), Netherlands (3.1%), France (4.1%), and Spain (16.4% in 2000).(11-16)

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Survival Experience
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AIDS deaths among prisoners have become less frequent. However, in the 1980s, the time from AIDS diagnosis until death was shortened to 42% (in 1986) and then 66% (in 1988) as long as that of matched New York City unincarcerated persons with AIDS. The survival time for female inmates in the state of New York was much worse than that for male inmates.(17) In addition, HIV-infected inmates with a first case of Pneumocystis jiroveci pneumonia (PCP) had a 22% mortality rate, compared with an 8% rate among patients with HIV and PCP in the community at large in 1989.(18) A remarkable statistic from New York in 1988 was that >25% diagnoses of AIDS, as defined by the U.S. Centers for Disease Control and Prevention (CDC), in prison settings were first made at autopsy.(19) In 1997, AIDS diagnoses of inmates in the state of New York were still often established only at autopsy, delaying statistical monitoring by at least 8 months, pending autopsy completion. Some diagnoses of tuberculosis (TB) in inmates were made only at autopsy. Although New York held one third of all prisoners in the United States known to be HIV positive, a 2001 report showed that the number of AIDS deaths in 1999 among prisoners in that state was 26, down from an annual peak of 258 in 1994, and the lowest it had been in 16 years. In 2003, when New York still reported the nation's highest HIV seroprevalence among its prisoners, the highest death rates from AIDS-related causes were reported in Delaware, Maryland, and Florida.(3) The availability of antiretroviral drugs for prisoners, increasing number of specialists in HIV care among prison medical staffs, and the lower rate of HIV seroprevalence among inmates are all believed to be factors contributing to the reduced frequency of AIDS-related deaths among prisoners.

A report from Spain describes a parallel improvement in case identification and survival. A review of the delay between time of discovery of HIV seropositivity and diagnosis of AIDS revealed that, in 1984, 100% of prisoners' HIV infections were diagnosed in the same month as AIDS, whereas in 2000 only 4% of HIV and AIDS diagnoses were made within a month of each other.(20)

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HIV Transmission in Prisons
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Numerous activities known to occur among prisoners pose a risk for HIV infection. Several studies have identified transmission of HIV in prison, based on serial serotesting for HIV antibody, some identifying seroconversion in inmates after more than 5 years of continuous incarceration.(21-24) Molecular analysis of 14 HIV-positive inmates in Glenochil Prison in Scotland in 1993 found sequencing similarities and clinical histories in 13 of the 14, indicating that transmission had occurred at the institution.(25)

Data gathered in the Georgia State Prisons from mandatory testing of all inmates at intake followed by inmate requested tests, or annual voluntary HIV serotesting which was offered between 2003-2005, identified 88 prisoners who seroconverted between 1992-2005 after one or more negative tests. Investigators analyzed data collected from cases and control subjects through computer assisted self interviews. Characteristics associated with prisoners' HIV seroconversion were male-male sex in prison, tattooing in prison, age >26 at interview, >5 years served of current prison sentence, black race, and a body mass index <25.4kg/m2 on entry into prison. This CDC report includes a wealth of information about the prisoners, reported risk activities, precautions practiced, and knowledge about and suggestions for prevention of transmission of HIV in prison.(26)

No confirmed cases of HIV infection among prison staff in the United States have been attributed to contact with inmates. There is a report from Australia of seroconversion of an officer who was injected by an HIV-infected inmate with a syringe full of the inmate's blood.(27)

Sexual activity among male inmates is not uncommon in prisons and jails. A Federal Bureau of Prisons study in 1982 reported that 30% of federal prison inmates engaged in homosexual activity while incarcerated.(28) In a 1984 study of Tennessee inmates, 17% reported homosexual activity in prison.(29) Former prisoners surveyed in New York reported use of makeshift devices for safer sex, such as fingers of latex gloves, when condoms were not available.(30)

The frequency of homosexual rape in jails and prisons is extremely difficult to estimate. The victim who reports rape in prison faces a probability of further suffering and worse injury. The Federal Bureau of Prisons study reported that 9-20% of federal inmates, especially new or homosexual inmates, were victims of rape.(28) The text of the Prison Rape Reduction Act of 2002 states that the best expert estimate of the percentage of individuals who are sexually attacked at least 1 time during their incarceration is a national median of 13.6%. (The act establishes standards for identifying, investigating, and eliminating prison rape in the United States.)

Other incidents of interpersonal violence (including fights involving lacerations, bites, and bleeding in 2 or more participants) present some risks for HIV transmission. Housing more than 1 inmate per cell, common now in crowded institutions, is a major contributing factor to incidents of violence and sexual assault.

British investigators interviewed 452 released prisoners about activities before, during, and after prison stays and found that persons engaged in fewer incidents of HIV risk behavior in prison, but that activities in prison were associated with increased risk. Those who reported engaging in penetrative sex while in prison also reported doing so with greater frequency outside, although they used condoms only outside. Reported sharing of syringes increased during imprisonment, as did less effective methods of syringe cleaning.(31) In another report from the United Kingdom, IDUs who were former prisoners reported a high prevalence of injection and sexual risk behaviors while in prison; 33 of 50 had injected drugs, and 5 of 50 had engaged in sex with 2 to 16 men.(32)

Although imprisoned IDUs do not use drugs with the frequency that they can when they are not incarcerated, they share injection equipment more and sterilize it less because of scarce resources. A handmade syringe may be fashioned from (among other things) parts of pens and light bulbs. Prisoners also may share toothbrushes and shaving equipment in facilities where they are not issued, where inmates are unable to purchase their own, or where infection control precautions are not practiced adequately.

Tattooing is a widespread activity in prisons and usually is performed without fresh or sterile instruments. It involves multiple skin punctures with recycled, sharpened, and altered implements such as staples, paper clips, and the plastic ink tubes from ballpoint pens. Prison wisdom holds that tattooing that causes blood to flow results in the best quality image and is least likely to become infected. Homemade pigment is delivered intradermally (at a sharp angle) rather than through direct puncture. Metal points connected to a battery or other electrical source are capable of producing vibration, increasing the number of skin punctures exponentially, thereby creating a better tattoo, but also increasing the risk of HIV transmission. Body piercing is becoming more popular in prison, as in the outside community, and clean instruments for this practice similarly are unavailable.

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HIV and Hepatitis C
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The prevalence of hepatitis C virus infection among prisoners approaches 40%, and far exceeds that of HIV in prison. Coinfection with the 2 viruses, which therefore is exceptionally common in prisoners, is associated with an accelerated course of hepatitis C disease, making treatment of both diseases particularly urgent in the correctional setting. Recognition of the existence and course of hepatitis C, and of its epidemic proportions in prison, has been relatively recent.(33,34)

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HIV and Tuberculosis
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TB has long been an infection of particular concern in the prison setting because of its higher incidence compared with that of the community at large and the ease and frequency of airborne transmission of TB bacilli in the crowded conditions commonly found in prisons.(35)

Reports described a 6-fold increase in the incidence of TB among inmates in the state of New York from 1976 to 1986, by which time more than 50% of inmates with TB also were infected with HIV.(36) A survey of TB cases in the United States between 1993 and 2003 found that 3.8% were reported from correctional systems, 3-4 times the rate reported outside prisons. This survey of 210,976 cases also found that 58.9% of prisoners completed treatment, compared with 73.2% of noninmates.(37)

The inconsistent treatment that often characterizes prisoners' medical care can permit the development of multidrug-resistant (MDR) strains of Mycobacterium tuberculosis--a medical calamity reported in the New York and California state prisons. In New York, 7 inmates and 1 immune-suppressed guard died with rapidly fatal, untreatable TB in 1991.(38) The clinical history of a California prison inmate treated for M tuberculosis and then MDR-TB over 3.5 years illustrates the full range of problems in prison medical care: poor record keeping at initial screening, delay in diagnosis of symptomatic disease, lack of isolation of the patient at the time of diagnosis, lack of supervision or observation of medication ingestion, lack of follow-up after completion of initial treatment, infirmary treatment in a setting with susceptible HIV patients, inadequate ventilation of patients' rooms, transfers among 3 different prisons, and inadequate screening and testing of prison staff and inmate contacts.(39) Illustrating the dangers of TB to HIV-infected prisoners, a 1999 CDC report described multiple tuberculin skin test (TST) conversions in 1995-96 among California prisoners, staff, and community contacts despite TB control practices. Two HIV-positive inmates--one with a documented negative TST, the other previously treated for positive TST, with M tuberculosis-negative sputum smears and cultures--proved to be infected with TB after initial placement in open prison HIV housing units. Similarly, during 1999-2000, 31 HIV-positive prison contacts of an inmate with unsuccessfully treated latent TB were diagnosed with TB in South Carolina. Rapid spread of TB can be a consequence of segregated housing for HIV-positive inmates.(40,41) TB outbreaks continue to evade infection control programs; reports have come from many correctional systems, including Alabama in 2003, Kansas in 2004, Florida in 2005, and Georgia in 2006.

In jails, many inmates are not incarcerated long enough to permit diagnosis or treatment. Clinical investigation for suggestive signs and symptoms is critical. To detect active pulmonary disease in the setting of rapid inmate turnover, the Los Angeles County Jail system features "mini chest films" at intake--single-view, low-dose screening radiographs--at much greater cost than the widely practiced skin test, but with immediate results. Although they will not detect all cases of TB, these radiographic images identify persons with communicable disease who require immediate treatment and isolation.(42)

In addition to intake screening for TB, subsequent routine follow-up and surveillance programs are essential for inmates and prison staff. The CDC published recommendations for prevention and control of TB in correctional institutions in 1989 and 1996. In December 2005, the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings published by the CDC included correctional facilities as health care settings.(43,44,45)

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Medical Treatment of HIV-Infected Prisoners
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Prisons and jails, designed to confine and punish people (many of whom are poor and lack influential outside advocates), frequently fail to provide the level of health services required by patients with HIV. As with other chronic illnesses, HIV requires health services that are expensive in terms of staff effort and expertise, laboratory testing, and medication. Prisons often have escaped outside attention to serious failures of care. HIV has placed an enormous fiscal burden on prisons, which already are stressed financially. The cost of HIV care in the 21st century in prisons now is rivaled by the cost and controversies surrounding management of hepatitis C, which affects up to 40% of prison inmates, and by the cost of psychotropic agents for the large number of individuals with mental illness who are imprisoned in the United States.

Prisons increasingly are recognizing the need for consultation and treatment of HIV by medical specialists, and several states provide care in conjunction with outside university-based clinic systems. Participation by HIV specialists is by no means the rule, however.(46) Treatment with potent antiretroviral therapy is the standard of care for HIV and AIDS in prisons, as in the community at large. A survey of treatment regimens of the 3,563 prisoners supplied through Stadtlander Pharmacy's Corrections Division in February 1999 found that 45% were receiving drug regimens recommended by 1998 U.S. Department of Health and Human Services guidelines. Seven percent were on regimens categorized as "alternative," 28% "not generally recommended," 8% "not recommended," and 12% were reported as "unclassified."(47)

Often, prison conditions undermine the consistent dosing schedules essential to the long-term effectiveness of antiretroviral therapy. Gaps in treatment occur due to transfers of inmates among correctional institutions. Confiscation of all medications from prisoners is also a common practice of prison staff in the course of searches for contraband. Court appearances, transfers among facilities, punitive detentions, and release from custody are all part of the prisoner's life, and provisions must be made to continue therapy through these events without interruption.

In many prisons, antiretroviral therapy is administered under direct observation to prisoners. Observers have reported that adherence to antiretroviral therapy among prisoners apparently has been good. At Rikers Island in New York City, patients' CD4 counts rose in a pattern almost identical to that found in clinical trials.(48) Among 170 prison patients in Wisconsin who self-administered medications, improvements in CD4 and viral measures were comparable with those found in community patients.(49) A 1996 survey of 205 HIV-infected prisoners eligible for potent antiretroviral therapy that found an acceptance rate of 80% and an adherence rate of 84% also found that adherence was 82% in those who received directly observed therapy, and 85% in those who self-administered medications.(50)

Every jurisdiction is responsible for providing health care to its prisoners. In 2006, no required guidelines or standards of care exist, although several organizations have developed voluntary health care standards for correctional facilities. The American Correctional Association, the American Public Health Association (APHA), and the National Commission on Correctional Health Care (NCCHC) have published standards for health care and HIV management in jails and prisons. The NCCHC also provides accreditation for subscribing institutions that meet its standards. The World Health Organization (WHO) published guidelines for management of HIV in prison 1987 and 1993,(51) and the APHA included guidelines in its book of standards in 1986, updated in 1996 and 2003.(52,53) Medical personnel, public health advisers, prison administrators, legislators, courts, and the electorate all have influenced policy development for management of HIV in prisons.

Among 19 countries in an international survey prepared for the WHO, the United States was 1 of 4 that did not have a national policy for HIV management in prison.(12) The National Commission on AIDS, in its March 1991 report, proposed that the U.S. Public Health Service develop guidelines for the prevention and treatment of HIV in all U.S. correctional facilities.(1)

In the fall of 1987, the WHO Special Programme on AIDS held a consultation on the prevention and control of HIV in prisons, and specialists from 26 nations attended. This group's consensus statement recognized the risks of HIV transmission in prisons and recommended the following general approaches:

  • Treatment of prisoners in a manner similar to the treatment of other members of the community

  • Consideration of compassionate release for prisoners with AIDS

  • Implementation of nondiscriminatory practices relating to HIV infection

  • Provision of information on HIV to staff as well as prisoners

  • Implementation of means to obtain informed consent and ensure confidentiality in the event of HIV antibody testing

  • Devotion of additional human and financial resources to HIV management in prisons, but not at the expense of other health services and activities

A subsequent WHO conference held in Geneva in 1992 drafted more extensive and specific guidelines outlining applications of the principles above.(51)

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HIV Testing Policies
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HIV in prisons raises a number of issues that do not exist for the general community; one of these is mandatory HIV antibody testing. The earliest public policy debates on HIV in prisons focused not on care and prevention but on whether to mandate testing. In 2003, 19 state prison systems and the Federal Bureau of Prisons had mandatory HIV screening policies for their incoming inmates.(54)

Prisoners cannot give true, free informed consent. In every area of life, inmates bargain for privileges, better conditions, and, ultimately, release. Where HIV testing is not mandatory, prisoners require more information than others to make informed decisions about taking the test. To give informed consent, prisoners must understand the institutional consequences of a positive HIV antibody test result, such as segregation and loss of access to activity programs, visitation, and jobs. Even this information may not permit prisoners to make a free choice about testing, as many prisons have policies of segregating prisoners who refuse testing with the policy that they can join the general population only after they have been "medically cleared."

HIV testing has benefited inmates in institutions that offer antiretroviral therapy and prophylaxis against opportunistic infections. Voluntary testing increasingly has become available to prisoners since early medical intervention has been offered. A review of HIV infections identified through voluntary counseling and testing programs for prisoners in 48 project areas in the United States between 1992 and 1998 found a steady increase in the use of testing services. There were 16,797 reactive tests (3.4%), 56% of which involved individuals who had been unaware of their serostatus at the time of testing.(55) Acceptance rates for seroprevalence testing by new inmates in Maryland and Wisconsin have been reported at 47-83%.(48) In 2003, 45 of 49 responding state prison systems and the federal prison system reported testing for HIV at inmates' request.(3)

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Confidentiality
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Confidentiality of medical information in the prison setting is virtually impossible to maintain. Where quarantines exist, confidentiality cannot. Persons other than medical staff members may handle medical records, and medical personnel may not be meticulous about protecting privacy. Once information is released in a prison, it travels rapidly. Many people in the prison setting believe they have a particular need to know who in the institution is infected with HIV. It has been argued that prisoners have a greater need for privacy than those outside because they live in a closed community where violence is common.

Prison policies vary in regard to disclosure of test results. Fear of disclosure and its consequences may discourage voluntary testing. Prison officials use HIV antibody test results to make decisions about housing and segregation, work assignments, and visiting privileges, among other matters. It has been common practice to bar inmates with HIV (or AIDS) from kitchen work. In some jurisdictions, results of HIV tests go directly to the prison staff. In 1988, California voters passed Proposition 96, an initiative authored by the sheriff of Los Angeles County requiring prison and jail physicians to give lists of known or suspected HIV-infected prisoners to custodial staff members. Such policies reflect the fear and misinformation prevalent in many prisons, and undermine the message and practice of universal precautions.

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Prevention
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Means of prevention of HIV transmission, and their use in prisons, always have provoked controversy and implementation of divergent policies. Prisons historically have approached prevention of HIV either by quarantine and segregation or by education. Other specific preventive practices include dispensing of condoms, bleach and clean injecting equipment, and methadone maintenance treatment.

By 2005, only the state of Alabama tested and placed all those identified as HIV positive in segregated housing. The trend over time has been away from segregation and toward case-by-case determination of housing placement.

Increasing staff-to-prisoner ratios, classifying and housing inmates carefully, decreasing overcrowding, and providing activities for inmates help to prevent transmission through nonconsensual risk behavior (eg, violence, including rape). Preventing violence is the ongoing responsibility of prison staff. Effective staffing and education help prevent consensual but risky behavior (eg, sharing contaminated needles, unsafe sex).

For the purpose of HIV infection control in most U.S. prisons, the educational message is that no risk activity is safe, and exposure to semen and bloody body fluids should be avoided.

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Education
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Prisoners represent a crucial and huge target population for HIV education programs; prisons concentrate persons at risk who are not easily reached in the community by such efforts. As many as 50% of U.S. prisoners are functionally illiterate, and many are not native English speakers; to be effective, educational programs must be modified to reach them. The generally available literature on HIV infection and AIDS either cannot be understood by most inmates or fails to address many of their particular needs.

Although the primary goal of HIV education in prisons is prevention, other critical objectives include promoting an understanding that engenders rational and humane treatment of affected inmates. Because of the dynamics of the correctional setting, information provided by people who are not prisoners, from general facts to specific medical advice, often is not trusted. Recommendations to begin antiretroviral therapy, for instance, have not been accepted as readily in prisons as in the general community. Therefore, HIV education in prisons must transmit information in a manner that addresses and bridges not only language, culture, and literacy gaps, but also the distrust of people on the other side of the bars. Individual counseling, peer counseling, support groups, and special programs for women, designed by and for prisoners, have been successful in a number of institutions and seem to be the best educational tools. Several gripping and effective videotapes have been made by and for prisoners.

Coupling educational programs with voluntary testing and counseling services has been effective in identifying individuals with previously unknown infection, promoting acceptance of and adherence to treatment interventions and postrelease follow-up, and reducing risk behavior in custody and after release.(55,56) An analysis of the cost effectiveness of HIV counseling and testing in U.S. prisons identified cost benefits from reduction of HIV transmission among otherwise unidentified and uninformed people.(57)

Accurate and adequate information for staff and inmates can reduce fears and ultimately affect institutional policies in ways that can alter prisoners' lives profoundly. All persons entering prison must be informed in clear, simple terms, and in their own language, about how to avoid transmission of HIV and other communicable diseases. Educational programs can reduce fears about HIV and its transmission among staff members and inmates.

A Quebec City study of staff members from probation agencies, halfway houses, and prisons found that prison officers were the group least informed about HIV transmission and prevention and expressed the most negative attitudes about HIV-infected people.(58) A Pennsylvania prison study reported that prisoners, staff, community groups, and legal authorities believe the "quality of life for HIV-positive inmates was most influenced by education of prison staff. Effective education for staff and inmates was live and interactive, targeted to the perceived risk of distrustful audiences, delivered by a trusted source, accurate, and aimed at reducing risk-perception."(59)

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Condoms
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Condom availability in prison is one of the many issues over which legal interests and public health interests conflict. Most prison administrators in the United States have not permitted the distribution of condoms to inmates. Statutes in many jurisdictions make sexual activity in prison a punishable crime. It is argued that condom distribution would condone and promote this behavior. Another objection to condoms in institutions is that they are considered contraband--a container for hiding drugs or other illegal things that inmates may swallow and later retrieve.

In the United States, condoms are available in state prisons in Vermont and Mississippi and in urban jail systems in New York City, Philadelphia, Los Angeles, San Francisco, and the District of Columbia. Condoms have been available in most European prisons for more than 10 years. Studies have found few incidents of improper condom use (eg, as a container for swallowed illegal drugs) and a high level of reported safer sex.

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Sterile Syringes
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The distribution of sterile syringes to inmates also has been discussed as a means of preventing HIV transmission but does not occur in any U.S. prison. A survey conducted in December 2000 identified 19 prison-based needle exchange programs in Europe.(60) Evaluations of these programs found decreased needle sharing and no newly identified cases of HIV, hepatitis B, or hepatitis C. The Swiss Hindelbank pilot project performed a 1-year study of the effects of a needle exchange program, observing that needles were not used as weapons and that fewer abscesses occurred among inmates.(61) As with condoms, syringes usually have been available through dispensing machines or prison health personnel.

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Bleach
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Safer injecting practice information (including providing bleach for cleaning syringes)is included in the education and counseling programs of many correctional systems in Europe, whereas correctional systems in the United States do not systematically provide bleach. Half of 20 European countries' prison systems surveyed provided disinfectant for injection materials in 1998.(62)

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Methadone Maintenance
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Although methadone maintenance treatment rarely is available to prisoners in the United States, it is offered to inmates in most Western European systems, some Eastern European systems, and Australia and Canada. Studies indicate reduced use of illicit injections among participants in these programs.(12,63)

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Discharge Planning
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As noted above, one quarter of HIV-positive people in the United States have spent time in the correctional system. Connecting released prisoners to community resources is a critical opportunity and responsibility for jails and prisons. Recognizing the potential for public health and educational interventions in prisons to reduce the disease's devastation in the larger community, prisons and jails gradually are making efforts to assure continuity of care and follow-up of AIDS patients after their release from custody. The transition for prisoners from custody to community often is chaotic and difficult, and health care concerns often take a lower priority than the search for jobs and housing, rebuilding personal relationships, and a myriad of other chores. Many policies exist on paper but not in practice. The planning that does occur ranges from giving inmates information about outside resources, to making appointments, to accompanying released inmates and assisting with enrollment for housing, health care, drug rehabilitation, financial benefits, HIV counseling, and psychosocial support. Several states provide case management services, establishing contact with prisoners and beginning to plan several months before scheduled release dates. A review of women who had participated in Rhode Island's intervention and discharge planning program found that their rate of return to prison was reduced by 26% a year after release, suggesting that these women had reduced the risk activities in the community that in the past had led to their incarceration.(64)

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AIDS Research
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The Nuremberg Code, developed after World War II as the result of hearings regarding Nazi treatment of prisoners, stated that "the voluntary consent of the human subject is absolutely essential" for medical research. Many countries subsequently outlawed all research on prisoners. The pharmaceutical industry regularly performed medical research involving prisoners in the United States until banned by federal prisons and several states in the 1970s. Prisoners who participated often lived in separate and superior housing units, ate better food, earned more money than was available for other prison work, and were offered hope of parole. No pharmaceutical agents were being used in clinical trials in the U.S. state prison systems in 2005.(65)

The issue of medical experimentation and research on prisoners arose in a new context in the 1980s and 1990s, as HIV and related conditions were treated in the community with experimental drugs that the Food and Drug Administration had not yet approved and that generally were not available to prisoners. There is a clear distinction between experimental drug treatments used primarily for the benefit of the imprisoned HIV-infected patients and those used to test the hypotheses of drug developers or others.(66) In 1994, 15 of the 51 state or federal systems surveyed reported offering experimental therapies to inmates with HIV disease.(67) A Connecticut prison survey of 101 eligible inmates in 1996 found that 50% were willing to participate in clinical trials within the prison, whereas 66% were willing to do so "outside."(68)

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Legal Issues in U.S. Prisons
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Prisoners have a constitutional right to health care that people "on the outside" do not have. Under the Eighth Amendment, prisoners are entitled to protection from "cruel and unusual" punishment, and to a "safe and humane environment." In an important U.S. Supreme Court decision, this right was further defined as prohibiting "deliberate indifference to serious medical need" (Estelle v Gamble, 429 US 97 [1976]). In 1991, the U.S. Supreme Court ruled that to show "deliberate indifference," plaintiffs must demonstrate that correctional officials actually intended to cause the alleged inadequate treatment (Wilson v Seiter, 111 SCt 2321 [1991]). This narrowed standard is much more difficult for prisoners to prove.(69)

Since the mid-1970s, prison health services have improved as civil rights advocates and attorneys advocating prisoners' rights have challenged conditions of confinement. Prisoners do not vote, and legislators generally have not granted resources for their health care. Litigation, or fear of it, has compelled state and local governments and prison administrations to provide a level of care closer to that available for the general community. Case law regarding HIV in prison has involved a wide range of issues and has contributed to policy development.

Historically, the U.S. courts have been reluctant to scrutinize or challenge prison and jail conditions, assuming that the complexities and peculiarities of those institutions were best dealt with by the prison authorities. Since the critical Estelle v Gamble decision, courts generally have continued to support existing institutional policies when these are challenged by prisoner plaintiffs. In the area of HIV management and care, courts also have tended to defer to prison managers, despite their lack of medical or public health credentials. Courts have upheld policies of segregation of HIV-seropositive persons as well as policies of no segregation. In 1990, for the first time, a court overturned one state's mandatory HIV testing policy for prisoners. The Ninth Circuit Court of Appeals declared that the state of Nevada failed to show that its policy "was reasonably related to legitimate penological interests." Several settlements modified strict policies of segregation of HIV-positive inmates by prisons, including those in Connecticut and California. In contrast, a federal court upheld mandatory testing and segregation in the Alabama state prison in 1990 and stated that prisoners who requested zidovudine treatment were not entitled to "state of the art" treatment, only reasonable care according to the community standard.(69,70) In January 2000, the U.S. Supreme Court refused to consider an appeal by Alabama inmates who challenged their segregation in that state's prisons. In 2006, the Limestone Correctional Facility in Alabama houses all that state's HIV-positive male prisoners, and a January 2004 court decision affecting these inmates allowed integration for work and educational programs. Two years later, only 2 or 3 inmates were participating in these programs. Other prison HIV issues that have been challenged in the courts include breaches of confidentiality, conspicuous special handling of HIV-positive inmates in court and other public places, inadequate medical and psychological care, HIV antibody testing without consent, lack of mandatory HIV testing, incorrect HIV diagnosis, and lack of HIV education. In addition, prisoners have been tried for aggravated assault, assault with a deadly weapon, and attempted murder for alleged biting, spitting, or spilling blood in altercations with guards. A Texas prisoner serving a 2-year term was sentenced to life in prison after being convicted of spitting at a prison guard.(71) In August 1997, a former inmate of the Illinois state prison system sued prison staff, claiming he was infected with HIV as a result of ongoing sexual abuse by prison gang members while his requests for help from staff were ignored. He had a documented seroconversion while in custody. His claim was disputed and ultimately was rejected after 2 trials (Blucker v Washington, 95c50110, U.S. District Court [ND Ill]).

Incarceration also has been used as a means of punishing and controlling persons who are believed to be knowingly infecting others. Many statutes have created criminal sanctions against HIV-infected people believed to be spreading the virus through irresponsible behavior.

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