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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”


 
    

 

 

HIV/AIDS in Corrections

Florida Corrections Commission 1998 Annual Report

http://www.fcc.state.fl.us/fcc/reports/final98/c5aids.html

BACKGROUND:

The presence of HIV (Human Inmmuniodeficiency Virus) and AIDS (Acquired Immune Deficiency Syndrome) has had a profound effect on the cost of health care in the correctional setting. The prevalence of HIV/AIDS in prisons exceeds its prevalence in the general population. As the prison population increases and inmates are being incarcerated longer due to stricter sentencing guidelines, the costs of HIV/AIDS will continue to rise as inmates remain in prison through the later, more costly stages of the disease and new treatment protocols are developed. For the past several years, the Florida Department of Corrections (DC) has reported that expenditures for the treatment and testing of HIV/AIDS have far exceeded the appropriation.

This section examines the issue of HIV/AIDS in corrections and the DC's efforts in dealing with these diseases. The issues reviewed are: the treatment for HIV/AIDS; characteristics of inmates with HIV/AIDS; prevalence of HIV/AIDS in Florida's prisons; HIV testing; housing; correctional staff; release; HIV transmission in prison; prevention strategies; costs of testing for and treating HIV/AIDS; and practices in other correctional systems. (NOTE: Appendix 5.1, is a glossary of HIV/AIDS related terms found in this section and its appendices.)

5.1.1. Treatment of HIV/AIDS

HIV is transmitted when the blood, semen, vaginal fluid, or breast milk of an infected person gets into the body and bloodstream of another person. HIV infection goes through several stages: acute, chronic, and AIDS, the final stage. People do not die of AIDS, but rather from complications from the process of AIDS.1 Appendix 5.2 contains a full explanation of how HIV causes AIDS and the events in HIV infection.

Combination antiretroviral therapy is now the standard of care for people with HIV. The antiretroviral drugs fall into three categories: reverse transcriptase inhibitors (RTIs, also known as nucleoside analogs), protease inhibitors, and non-nucleoside reverse transcriptase inhibitors (NNRTIs). Recent studies show that three-drug combinations of these antiretroviral drugs are more effective in preventing disease progression and death than single- or two-drug therapies. The best combination of antiretroviral treatments to use is still uncertain and varies from patient to patient. Treatment regimens are complicated and costly. A typical HIV patient must take some twenty antiretroviral pills a day, some with meals, some without. They may also be taking prophylactic medications (medications taken to prevent other diseases or infections).2 When a patient is in a prison setting, taking the right medication at the right time can be difficult. HIV can become resistant to the effects of antiretroviral drugs, making strict adherence to treatment regimens essential. If a person is noncompliant with the treatment regimen, they may be considered unsuitable for treatment.3

When to begin treatment is still being debated. The viral load test, which measures the amount of HIV in the blood, along with the CD4 cell count test can help make that determination. (CD4+ cells normally orchestrate the body's immune responses and are HIV's preferrred target.) These tests also help to measure the effectiveness of antiretroviral drug therapy.4

Along with the combination antiretroviral therapy, persons infected with HIV also require prophylactic medications to prevent opportunistic infections; that is, infections that take advantage of compromised immune systems, some of which are not usually seen in humans. The most common opportunistic infections associated with HIV/AIDS include Pneumocystis carinii pneumonia, fungal infections of the mouth, throat, and intestines, and parasitic eye and brain infections.5 (See Appendix 5.3, Florida Department of Corrections' HIV/AIDS Care Plan, for the DC's treatment protocol for HIV and opportunistic infections.)

Although treatment for HIV/AIDS has improved over the years, there is no cure.

The AIDS Drug Assistance Program is a federal program that was established in October 1987 to provide drugs to individuals who otherwise could not afford them. Each state sets its own criteria for financial and medical eligibility and the drugs included in the program.6

In Florida, the AIDS Drug Assistance Program is managed by the Department of Health and funds are distributed to county health departments. To be eligible, a patient must have an income at or below 200 percent of the federal poverty level. Patients with incomes between 100-200 percent of federal poverty level are assessed for co-payments according to a sliding fee scale. Also, their CD4+ cell count must be less than 500, although this requirement can be waived. The drugs covered by the program are available through the Public Health Unit where the client enrolls.7 (Appendix 5.4 lists the drugs included in Florida's AIDS Drug Assistance Program.)

5.1.2. Inmate Characteristics

The high rates of HIV/AIDS infection in correctional institutions are related to behaviors reported by inmates that have been determined to be high-risk. Not only do inmates engage in more of these behaviors, they also engage in them more frequently than members of the general population.8

The number one risk factor for HIV/AIDS in the correctional setting is injection drug use prior to incarceration. According to one report, injection drug users were eight times more likely to test HIV-positive (HIV+) than a non-drug user entering prison in 1987.9

As one witness testified before the National Commission on Acquired Immune Deficiency Syndrome, "Because drug use increases one's risk of incarceration as well as of HIV infection, the inmate population often constitutes a distillate of the infection in the community."10

Other at-risk behaviors reported by inmates include: anal intercourse; tattooing; a history of multiple sexual partners; a history of multiple sexually transmitted diseases; poor physical and/or mental health; and risk-taking personality/behavior.11

Female inmates are more likely to be infected with HIV/AIDS than male inmates. This is in contrast to studies that show that males in other populations have a rate higher than that of females. Women in prison are more likely to be drug users than are male inmates. Economic dependency, injection drug use, crack use, and associated increases in unsafe sexual practices (e.g., exchanging sex for drugs and/or money) have placed women at elevated risk for HIV infection. A Massachusetts study found a strong association between sexual abuse and risk- taking behavior related to HIV. Incarceration rates are also rising faster among women than men.12

The median racial/ethnic breakdown of AIDS cases in state/federal systems in 1994 was: 43 percent black, 38 percent white, and 13 percent Hispanic. This compares with the distribution among the total cumulative AIDS cases in the U.S. population: 50 percent white, 32 percent black and 17 percent Hispanic. A 1991 study found: seroprevalence is greater for male inmates over 25 years of age and for female inmates under the age of 25; inmates imprisoned for drug and property offenses were more likely to be infected than violent offenders; and recidivists were more likely to be HIV+ than first-time admissions.13

5.1.3. Prevalence of HIV/AIDS in Florida's Prisons

In 1995 Florida ranked seventh nationally, along with Maryland, in HIV/AIDS cases as a percentage of total custody population (3.4 percent) according to a report by the National Institute of Justice, up from 2.4 percent in 1991 (ranking ninth). Nationally the average is 2.3 percent. In 1995 there were 1,971 male cases of HIV, or 3.3 percent of that population, and 222 female cases of HIV, or 6.1 percent of that population, in Florida's prisons. In 1995 Florida ranked second, behind New York, in the number of confirmed AIDS cases (692), which accounts for 31.6 percent of the total HIV cases, and 1.1 percent of the total inmate population.14

Tables 5-A through 5-D illustrate where Florida's prisoners rank nationally in terms of the prevalence of HIV/AIDS infection, by calendar year. (NOTE: Testing polices for HIV vary from state to state and may account for higher percentages of inmates diagnosed with HIV in some states.)

Table 5-A

Inmates known to be HIV+, CYs 1993-1995
(ranked by % of total population)

 

 

Total known to be positive

HIV/AIDS cases as % of
total custody population

1993

1994

1995

1993

1994

1995

U.S. Total

21,475

22,717

24,226

2.4

2.4

2.3

New York

8,000

8,295

9,500

12.4

12.4

13.9

Connecticut

886

940

755

6.6

6.6

5.1

Rhode Island*

89

113

126

3.4

3.8

4.4

Massachusetts

394

388

409

3.9

3.4

3.9

New Hampshire*

17

26

31

4.4

3.6

3.7

New Jersey

881

770

847

4.4

3.6

3.7

Maryland

769

774

724

3.8

3.7

3.4

Florida

1,780

1,986

2,193

3.4

3.5

3.4

*Tests all inmates for HIV
Source: "HIV in Prisons and Jails, 1995," Bureau of Justice Statistics, National Institute of Justice, August 1997

Table 5-B

Inmates known to be HIV+, CYs 1993-1995
(ranked by total number of cases)

 

Total known to be positive

HIV/AIDS cases as % of
total custody population

1993

1994

1995

1993

1994

1995

U.S. Total

21,475

22,717

24,226

2.4

2.4

2.3

New York

8,000

8,295

9,500

12.4

12.4

13.9

Florida

1,780

1,986

2,193

3.4

3.5

3.4

Texas

1,212

1,584

1,890

1.7

1.6

1.5

California

1,048

1,055

1,042

0.9

0.8

0.8

Source: "HIV in Prisons and Jails, 1995," Bureau of Justice Statistics, National Institute of Justice, August 1997

Table 5-C

Inmates Known to HIV Positive, By Gender - 1995

 

Male HIV Cases

Female HIV Cases

Number

% of Pop.

Number

% of Pop.

Total

20,690

2.3

2,182

4.0

New York

8,678

13.4

822

22.7

Rhode Island*

105

3.9

21

14.5

Connecticut

627

4.6

13

13.4

New Hampshire*

17

0.9

14

11.4

Massachusetts

340

3.5

69

10.5

New Jersey

748

3.4

99

9.8

Florida

1,971

3.3

222

6.1

*Tests all inmates for HIV
Source: "HIV in Prisons and Jails, 1995," Bureau of Justice Statistics, National Institute of Justice, August 1997

Table 5-D

Inmates with Confirmed AIDS - 1995

 

 

Confirmed AIDS Cases as a
percent of -

# of Confirmed AIDS Cases

Total HIV cases

Custody Population

U.S. Total

5,099

21.0%

0.5%

New York

1,182

12.4%

1.7%

Florida

692

31.6%

1.1%

Texas

495

26.2%

0.4%

California

385

36.9%

0.3%

New Jersey

343

40.5%

1.5%

Maryland

258

35.6%

1.2%

Source: "HIV in Prisons and Jails, 1995," Bureau of Justice Statistics, National Institute of Justice, August 1997

In 1995 Florida ranked second, behind New York, in inmate deaths due to AIDS. Between 1989 and 1997, AIDS deaths accounted for over half (50.6 percent) of all inmate deaths in Florida's prisons.

One national study indicates that inmates die more quickly from AIDS than those patients who are not incarcerated: in 1991, the median time from diagnosis to death is 159 days for prisoners as opposed to 318 days for all others.15

5.1.4. HIV Testing

There has been a great debate in the correctional community over the testing of inmates: mandatory versus voluntary. Both strategies have been adopted by a number of state correctional systems. This past year, South Carolina became the seventeenth state to test all inmates upon entrance into prison, the first to adopt this practice since 1990. Three states test all inmates in custody; three states and the federal government test upon release.16

Both mandatory and voluntary testing have been challenged in the courts. Those opposed to mandatory testing questioned whether the testing violated an inmate's right to privacy and subjected them to unlawful searches and seizures. The courts have consistently upheld the prison's right to mandatory testing. The courts have also denied the challenge that failure to perform mandatory testing violates an inmate's Eighth Amendment rights. It is important to note that no case involving the question of HIV/AIDS in the prison setting has reached the Supreme Court. The final word on what is required, or prohibited, of prison officials in this area has yet to be written.17

With the advances made in recent years in finding effective treatments for HIV, early detection and treatment can potentially reduce the number of opportunistic infections, and the attendant costs, and delay the diagnosis of AIDS and deaths due to the disease.

5.1.5. Housing

Another issue in the HIV/AIDS in prison debate is the segregation of infected inmates. If the decision is made to segregate, which inmates will be separated: only those with full blown AIDS, all those who are HIV+, or those somewhere in between those two conditions? Currently, only two states, Alabama and Mississippi, segregate all inmates who test positive for HIV. (These two states also test all inmates entering the system.) Most states segregate HIV/AIDS inmates on a case-by-case basis, based on medical and/or security or other needs.18

Segregation can have detrimental effects on inmates. Segregation labels the inmate, putting that individual at-risk for discrimination and disparate treatment. It often limits the inmate's access to work, educational and recreational programs, visitation, and religious services. Many isolated prisoners report severe depression, which exacerbates their medical condition. When New York State attempted segregation of all known HIV+ inmates, the court found that "automatic segregation to be wholly without public health merit, often giving rise to dangerous circumstances for the correctional community as a whole." Segregating inmates can give those left in the general population a false sense of security about their chances of becoming infected if they continue high-risk behaviors.19

5.1.6. Correctional Staff

In 1988, Congress passed the Health Omnibus Programs Extension Act (Public Law 100-607) which included in its provisions a charge to the Secretary of Health and Human Services and the Centers for Disease Control and Prevention to develop and disseminate guidelines to all public safety workers, including corrections officers, concerning the transmission of HIV. The Bureau of Justice Assistance AIDS Policy Project designed a training program. The program's goal was to "change the knowledge and attitudes of criminal justice policy makers about HIV disease and to impart the necessary skills to develop HIV-related policies within their respective agencies." These guidelines and programs were developed to assist corrections departments in educating their employees about the nature of HIV/AIDS. Early studies showed that many employees were misinformed about the transmission of HIV. That misinformation led to inordinate precautions being taken and discrimination against infected inmates.20

There has been much controversy concerning HIV/AIDS in the work place, including the issue of confidentiality versus the duty to warn and the right to know. Public health must be safeguarded, while at the same time protecting the patient's rights to privacy and nondiscrimination. The courts have frequently been called upon to decide these issues, more so than with past infectious diseases.21

These decisions must balance the need for disclosure against the harm done to both the individual's privacy and the public interest. Generally, because infection control precautions in the health care and correctional setting are both the standard of practice and highly effective, right to know claims are difficult to maintain. With the use of universal infection control precautions, the risk of HIV transmission is negligible.22

Employers, including health care and correctional facilities, have a duty to provide a reasonably safe workplace. The Occupational Safety and Health Administration's blood-borne pathogen safety standard (Chapter 29, Section 1910.1030, Code of Federal Regulations) has been challenged as too broad, but remains the primary safety standard. In Florida, employee claims involving occupational transmission, or fear of occupational transmission, are covered by workers' compensation statutes, which provide exclusive remedies for work-related claims against employers.23

To disclose an inmate's HIV status to unauthorized personnel may violate that person's constitutional right to privacy; not all prison employees are authorized to receive confidential information. Generally, legal experts agree that the dissemination of HIV test results should be limited to medical personnel and others who have a clear need to know.24

5.1.7. Release

The National Commission on AIDS recommends the streamlining of early release mechanisms to allow for the "compassionate release" of AIDS infected inmates when their release would not compromise public safety and adequate care is assured. The National Institute of Justice and the Centers for Disease Control and Prevention caution that the temptation might arise to release AIDS infected inmates early as a cost savings measure. Their report notes that this simply shifts the burden to another government program and often the inmate receives better care in prison than in the community.25

5.1.8. HIV Transmission in Prison

A great concern of many correctional professionals is the intraprison transmission of HIV. Several studies undertaken to date suggest that such transmission is rare, as low as an annual incidence rate of 0.3 percent, while another study found the rate to be as high as 21 percent. Despite such disparate findings, clearly the risk of infection does increase with higher HIV prevalence rates among inmates. Although sex, injection drug use, and tattooing are all prohibited activities, they continue to occur in prisons.26

Studies on sexual activity in prison, both consensual and nonconsensual, also vary widely in their findings, from as low as 1 percent to as high as 90 percent.27 Research suggests that injection drug use is less frequent in prisons than on the outside but considerably more risky because the shortage of needles leads to increased sharing. Also, inmates are not always aware that "sharing" includes containers, cookers, cotton, and needles that have been used by persons not present. When needles are not available, pieces of pens and light bulbs have been used by inmates to inject drugs. Tattooing is a common practice in prison, often done with whatever materials are readily available, such as guitar strings. In tattooing, sharing the needle or needle substitute, ink, and string used to transmit the ink may pose risks for HIV transmission.28

    

5.1.9. Prevention Strategies

Universal Precautions

In 1987 the Centers for Disease Control and Prevention recommended that universal precautions be consistently used for all persons regardless of their blood-borne infection status. Under universal precautions, blood and certain body fluids are considered potentially infectious for HIV, hepatitis B virus, and other blood-borne pathogens and measures should be taken to avoid exposure to these fluids. These measures include: use of protective barriers such as gloves, gowns, masks, and protective eyewear; preventing injuries when using needles, scalpels, and other sharp instruments or devices; and immediately and thoroughly washing hands and other skin surfaces that are contaminated with blood or body fluids. Universal precautions are now the standard in the workplace, including the correctional setting, and have been adopted by the Occupational Safety and Health Administration (29 CFR 1910.1030).29

HIV/AIDS Education

Prisons house high concentrations of inmates with histories of injection and other drug use, high-risk sexual practices, and other behaviors that may place them at increased risk for HIV infection and who are less likely to be reached by community-based AIDS education efforts. Also, inmate populations are "captive audiences" available for education and intervention programs for the length of their stays in correctional facilities. Most prisoners will return to the community; helping them to reduce their risk-taking behaviors benefits not only them, but also others they may encounter in the outside world.

Education is the most common HIV/AIDS prevention strategy employed by correctional systems. Researchers agree that information alone is insufficient to induce permanent changes in the often deeply ingrained or addictive behaviors that place people at risk for HIV infection. Instead, effective HIV prevention requires comprehensive approaches that "address the complex contexts in which high-risk behaviors occur and persist."30

In 1991, the National Commission on AIDS "offered a set of recommendations relating exclusively to corrections-based AIDS education,"31 including mandatory participation in an AIDS education program for all inmates upon entry into the system. (See Appendix 5.5, National Commission on AIDS Recommendations for AIDS Prevention Programs in Correctional Settings (1991).) These recommendations have been endorsed and expanded on by others. The components of effective programs found throughout the literature include:

  1. Programs should be tailored to the audience, by using the appropriate content, the appropriate presenter, and the appropriate language. The material and the communicator must be racially and culturally sensitive.

Generally, inmates distrust information provided by correctional staff, particularly on controversial topics such as HIV/AIDS. Messages regarding behavior change are more credible when they come from a member of one's own group and reflect their values. Peer-based programs offer a number of advantages. They can be implemented at little cost to the correctional system; peer educators may be more likely to speak in terms understandable to inmates; peer educators are available for informal counseling in various places in the prison compound, as well as conducting formal education, counseling, and support groups; and the educators can be available on a 24-hour basis.32

Inmates and staff have both raised issues of confidentiality in opposition to peer programs. Some are concerned that an inmate's HIV status may be revealed by the peer educators directly divulging the information, or indirectly by other inmates observing interactions between the peer educators and HIV+ inmates.33

  1. Programs should emphasize risk behaviors in discussing the prevention of HIV acquisition and transmission. The message should be one of behavior change/modification through risk reduction. The programs should recognize risk behaviors that occur within the facility and provide resources that enable inmates to reduce such risks.

Injection drug use represents the primary source of heterosexual transmission of HIV, and through pregnancy, the major route of transmission to infants. Because injection drugs are both illegal and addictive, educational programs that have worked addressing other addictions do not work with injection drug users. Behavior modification based solely on fear is not generally successful. It has been found that injection drug users are most influenced by programs that stress empowerment by taking charge of their lives. According to one team of researchers, if education and prevention efforts are to "address the nexus of injection drug use and HIV disease," they need to contain:

    1. explicit instruction/training in the cleaning of injection equipment and other reduction strategies;
    2. peer counseling relating to behavior change;
    3. strong links between education and prevention and other health and social services, such as drug abuse counseling programs; and
    4. the availability of risk reduction resources.34

The best method for achieving the necessary long-term behavior change is through drug abuse treatment programs. Demand for drug abuse counseling far outstrips available programs.

Also, education programs should include clearly stated techniques to identify, negotiate, and adopt appropriate precautions against sexual transmission of HIV disease, such as proper condom use and other safe sex practices.35

Researchers recommend that correctional systems should be willing to provide the necessary resources for risk reduction, such as condoms.36

  1. Female inmates have special HIV/AIDS education needs.

Women currently comprise the group with the fastest rate of increase in HIV infection. The dominant risk behaviors for women are injection drug use and heterosexual contact with an injection drug user. The percentage of women incarcerated for drug offenses is higher than among men. Also, women are more likely to share equipment than men. Non-injection drug use is also closely associated with HIV diagnosis in women. Programs for female inmates should discuss issues of empowerment (e.g., how to deal with male sex partners and/or violent relationships) and building self-esteem.37

  1. Programs should contain an evaluation component.38

Without an evaluation component of any educational program in place, it is hard to determine if the program is reaching the inmates that need to be tested, if the information being given is understood and learned, and if resources dedicated to HIV/AIDS education are being optimally used.

Other Strategies

The more controversial strategies for HIV prevention include the distribution of condoms and sterile injection equipment. These approaches are fraught with problems. Since sex and drugs are prohibited in the correctional setting, supplying condoms and sterile needles or bleach to inmates might convey the message that these behaviors are condoned. Sex and drugs are present in prisons, however, and failing to acknowledge the situation complicates a dangerous health care problem. Many health professionals advocate treating the conditions inside prison with the public health model and effectively dealing with HIV by distributing condoms. Correctional officials fear that allowing condoms would undermine security and adherence to regulation. Condoms could be used as weapons or to conceal drugs or other contraband.39

Currently six corrections systems within the United States (Mississippi and Vermont prison and the San Francisco, Philadelphia, New York City and Washington, D.C., jail systems) and the Canadian federal prison system make condoms available to inmates. Vermont, for example, makes condoms available while adhering to a prohibition on sex. San Francisco and Washington jail systems and the Canadian federal system also make dental dams available for women. Systems that do allow condom availability have not seen an increase in security violations as a result of their use. It is noteworthy that since the late 1980s when these policies were adopted, no system has reversed the policy of making condoms available to inmates.40

Bleach and needles are present in the prison environment for other uses. The inability to sterilize the equipment increases the risk of transmitting infection. While many correctional systems provide information on safer injection practices in their education and counseling, three systems -- San Francisco and Harris County (Houston) jail systems and the Canadian federal system -- provide bleach, but no system distributes needles. (A female facility in Switzerland has started a pilot needle exchange program.) Research has shown that bleach is only effective as a disinfectant when correct procedures are followed carefully. Therefore, bleach is only recommended "when no other safer options are available."41

5.1.10. Costs of Testing for and Treating HIV/AIDS

As indicated in Table 5-E, HIV/AIDS now accounts for 7.8 percent of the DC's Office of Health Services' (OHS) budget.

Table 5-E

Cost of HIV/AIDS as Percentage of Total of
Office of Health Services Budget
FY 1994-95 - FY 1997-98

 

OHS

HIV/AIDS

FY 94-95

Total Expenditures

$176,151,934

$8,127,836

% of Budget

100.0%

4.6%

FY 95-96

Total Expenditures

$194,406,876

$7,759,530

% of Budget

100.0%

4.0%

FY 96-97

Total Expenditures

$206,158,679

$10,774,183

% of Budget

100.0%

5.2%

FY 97-98

Total Expenditures

$220,402,224

$17,104,188

% of Budget

100.0%

7.8%

Source: Office of Health Services, Florida Department of Corrections

The OHS was asked to provide the costs of testing for and treating HIV/AIDS and an explanation of how those costs are estimated. The Commission received the following explanation:

 

OHS has tracked HIV/AIDS costs as a separate budget object over the past 5-6 years in order to establish yearly per diem baselines. These historical costs serve as the forecasting basis for the next year's estimated treatment costs. Once the basis is determined, the projected inmate admission population and corresponding extrapolation for the newly identified HIV/AIDS infected inmates is incorporated into the estimate. Improvement in treatment regimens are considered.42

 

According to the DC's Legislative Budget Requests (LBRs) for FY 1997-98 - FY 1999-00, to estimate the necessary funding for AIDS, the department multiplies the average daily population by the current prevalence rate of HIV/AIDS cases, then multiples the projected number of cases by the projected cost of treatment per case (the current cost per case X the average rate of increase in drug and medical care costs). (See Tables 5-F through 5-H.) The Legislative Budget Requests noted that

 

expenditures for the treatment of AIDS/HIV will continue to increase not only as the population increases but also as a result of stricter sentencing guidelines as inmates suffering from the disease are now remaining in the system through the sicker, more costly, stages of the illness. The new Centers for Disease Control and Prevention treatment guidelines requiring the use of protease inhibitors and viral load testing for HIV/AIDS cases will further increase costs.43

 

Table 5-F

Florida Department of Corrections Estimated Cost of HIV/AIDS Treatment
LBRs FY 1997-98 - FY 1999-00

LBR for

FY 1997-98

 

LBR for

FY 1998-99

1995-96 actual AIDS expenditure

$7,759,530

 

1996-97 actual AIDS expenditure

$10,101,406

1995-96 average cost per case

$2,663

 

1996-97 average cost per case

$4,727

X 3.6% increase

$2,858

 

X 2.9% increase

$5,005

1997-98 average daily population

69,913

 

1998-99 average daily population

67,193

X prevalence rate of HIV/AIDS

X4.6%

 

X prevalence rate of HIV/AIDS

X3.4%

1997-98 projected HIV/AIDS cases

3,216

 

1998-99 projected HIV/AIDS cases

2,285

X 1997-98 projected cost per case

X $2,858

 

X 1998-99 projected cost per case

X $5,005

1997-98 projected AIDS expenditures

$9,191,328

 

1998-99 projected AIDS expenditures

$11,436,425

less 1996-97 appropriation

-6,300,000

 

less 1997-98 appropriation

-6,300,000

1997-98 additional funding request

$2,891,328

 

1998-99 additional funding request

$5,136,425

 

 

 

 

 

LBR for

FY 1999-00

 

1997-98 projected HIV/AIDS expenditures

$17,200,000

1997-98 average cost per case

$9,052

X 2.9% increase

$9,585

1999-00 average daily population

66,941

X prevalence rate of HIV/AIDS

3.4%

1999-00 projected HIV/AIDS cases

2,276

X 1999-00 projected cost per case

$9,585

1999-00 projected AIDS expenditures

$21,815,460

less 1998-99 appropriation

-6,800,000

less projected cost avoidance at CFRC-South Unit

-1,000,000

1999-00 additional funding request

$14,015,460

Source: LBRs FY 1997-98 - FY 1999-00, Florida Department of Corrections

Table 5-G

Cost of HIV/AIDS Treatment

FY 1994-95 - FY 1999-00

 

FY 94-95

FY 95-96

FY 96-97

FY 97-98

FY 98-99

FY 99-00

Appropriation

$6.3 mil

$6.3 mil

$6.3 mil

$6.3 mil

$6.8 mil

 

Expenditures

$8.1 mil

$7.8 mil

$10.8 mil

$17.1 mil

$19 mil*

$21.8 mil**

Difference

-$1.8 mil

-$1.5 mil

-$4.5 mil

-$10.8 mil

-$12.2 mil

 

*Estimated costs as of September 29, 1998
**Estimated costs from DC's FY 1999-00 LBR
Source: Office of Health Services, Florida Department of Corrections

Table 5-H

Analysis of AIDS Expenditures
FY 1993-94 - FY 1997-98

 

FY 93-94

FY 94-95

FY 95-96

FY 96-97

FY 97-98

Expend.

%

Expend.

%

Expend.

%

Expend.

%

Expend.

%

Drugs

$2,696,390

36.1%

$3,321,896

40.9%

$4,210,019

54.3%

$7,167,309

66.5%

$11,877,366

69.4%

Comm. Hosp.

$2,733,801

36.6%

$2,404,163

29.6%

$1,634,681

21.1%

$1,614,215

15.0%

$2,311,378

13.5%

Anc. Svcs.

$823,641

11.0%

$958,455

11.8%

$946,582

12.2%

$1,178,142

10.9%

$2,058,996

12.0%

Comm. Phys.

$650,403

8.7%

$708,045

8.7%

$453,424

5.8%

$469,452

4.4%

$493,370

2.9%

Other

$555,158

7.4%

$735,277

9.0%

$514,824

6.6%

$345,065

3.2%

$363,078

2.1%

TOTAL

$7,459,393

100%

$8,127,836

100%

$7,759,530

100%

$10,774,183

100%

$17,104,188

100%

HIV Cases

1,254

 

1,319

 

1,171

 

1,173

 

1,101

 

AIDS Cases

453

 

618

 

747

 

730

 

693

 

TOTAL CASES

1,707

 

1,937

 

1,918

 

1,903

 

1,794

 

Cost Per Case

$4,370

 

$4,196

 

$4,046

 

$5,662

 

$9,534

 

Expenditures do not include treatment for inmates housed in private facilities.
Source: Office of Health Services, Florida Department of Corrections.

The expenditures listed in Tables 5-E through 5-H do not include estimates of the cost of medical staff or administrative costs.

Not all HIV infected inmates are suitable candidates for the antiretroviral therapy. The Commission asked how many inmates were actually receiving the therapy, but the OHS does not track that information.

According to the Correctional Medical Authority (CMA), the treatment protocols used by the DC do conform to the standard set by the Centers for Disease Control and Prevention. When asked by the Commission if the advances in treatment have resulted in any costs savings to the department because of reductions in hospitalizations and related infections associated with HIV/AIDS, the DC responded:

 

Because of the rapid increase in the number of HIV+/AIDS inmates and the corresponding dynamic growth of treatment protocols, the specific reduction in hospitalizations and opportunistic infections directly attributable to these new protocols has not been documented. HIV and AIDS data . . . show a decrease in the number of deaths associated with AIDS . . . . It appears that some of this decrease may be attributable to close management efforts on the part of OHS in minimizing unnecessary external, community hospital stays and the use, by OHS, of improving pharmaceutical therapy for HIV+/AIDS inmates. It is expected that continued improvement will be attainable through the growing use of the Central Florida Reception Center, South Unit, AIDS treatment facility.

 

In FY 1992-93, the DC formally began planning for the consolidation of the delivery of health services. Part of that plan involves consolidation by disease entity; that is, collocate the high cost, complex diseases such as HIV/AIDS, cancer, and cardiac illnesses. According to the Health Services Consolidation Plan (draft, January 7, 1998), consolidation will "build a level of expertise within the system, establish a cadre of contracted experts from outside the system," improve the quality of care, create an economy of scale, and "build a base of knowledge . . . which will reduce the need for excess diagnostic testing," specialty referrals, and hospitalization. Appendix 5.6 lists the institutions where inmates with HIV/AIDS have been consolidated. Of the 23 institutions listed, 4 of the 5 private prisons and 2 of the 4 institutions that contract their health services to private providers are included.

There are two policy analysis measures in the Performance-Based Program Budgeting Official Performance Ledger, Executive Office of the Governor (draft, October 1998), regarding HIV/AIDS:

  1. Annual costs of the three most expensive illnesses treated in prisons.
  2. Total number of inmates with the three most expensive illnesses treated in prisons.

HIV/AIDS is the most expensive illness treated in Florida's prisons. Table 5-I lists these policy analysis measures.

Table 5-I

HIV/AIDS Measures Included in Performance-Based Program Budgeting

 

 

 

FY 1997-98

FY 1998-99

Policy Analysis Measure

Baseline Standard

Baseline FY

Agency's Estimate

Agency's Estimate

Annual costs of the three most expensive illnesses treated in prisons:

 

 

 

 

 


HIV/AIDS

$10,774,183

1996-97

$13,278,782

 

 


Cardiac Illnesses

$1,448,178

1996-97

$4,812,944

 

 


Cancer

$2,908,803

1996-97

$3,093,424

 

Total number of inmates with the three most expensive illnesses treated in prisons:

 

 

 

 

 

HIV/AIDS

 

 

 

2,304 (853 AIDS)

 

Cardiac Illnesses

 

 

 

1,085

 


Cancer

 

 

 

835

Policy Analysis Measures: These measures are for use in program policy analysis and budget management. They are not intended to be used to evaluate agency performance in the budget process at this time.
Source: Adapted from Performance-Based Program Budgeting Official Performance Ledger (draft, October 1998), Executive Office of the Governor

5.1.11. Other Correctional Systems

Fourteen states or federal systems were surveyed by Commission staff regarding HIV/AIDS policies, practices, and costs. These correctional systems were chosen because they reported high HIV prevalence rates or because of uncommon practices. (Testing polices for HIV vary from state to state and may account for higher percentages of inmates diagnosed with HIV in some states.) Table 5-J lists the systems surveyed, prevalence rates, and testing and housing policies.

Table 5-J

HIV/AIDS Policies and Practices in Other States

State

1995 Percent of population

Testing

Housing

Male

Female

Alabama

1.1%

1.0%

Upon intake and release

Segregated

California

0.8%

0.9%

Voluntary, involvement in an incident

Specialized AIDS unit at Vacaville for later stages of disease. Otherwise, not segregated

Connecticut

4.6%

13.4%

Voluntary

Not segregated

Georgia

2.3%

4.0%

Upon intake, at inmate's request

Not segregated

Maryland

3.3%

5.5%

Voluntary, involvement in an incident

Not segregated

Massachusetts

3.5%

10.5%

Voluntary, random sample

Not segregated

Mississippi

1.4%

0.3%

Upon intake

Segregated

New Hampshire

0.9%

11.4%

Upon intake, at inmate's request

No segregation

New Jersey

3.4%

9.8%

Voluntary

Not segregated

New York

13.4%

22.7%

Voluntary, involvement in an incident, random sample

Not segregated

Texas

1.4%

3.0%

Voluntary

Not segregated

Vermont

0.0%

0.0%

Upon clinical indication

Not segregated

Federal

2.3%

4.0%

Upon release, voluntary, random sample

Not segregated

Canada

N/A

N/A

Voluntary

Not segregated

Source: "HIV in Prisons and Jails, 1995," Bureau of Justice Statistics, National Institute of Justice, August 1997

5.2. FINDINGS:

5.2.3. Prevalence of HIV/AIDS in Florida's Prisons

Inmates in Florida are tested for HIV at their request or if they have been involved in an incident where body fluids were exchanged.44

Because of the largely voluntary nature of HIV/AIDS testing in the state's prisons, many inmates are believed to pass through undiagnosed. In 1990, Johns Hopkins University published results of a Correctional Regional Infection Sentinel Surveillance Project study based on sampling done in 1988 and 1989. The purpose of the study was

 

to identify seroprevalence [the proportion of persons who are HIV+] of HIV-1 antibody among consecutive entrants to ten distinct correctional systems in the United States, and to characterize seroprevalence by gender, geography, racial/ethnic grouping, and facility type (i.e., jails versus prisons).45

 

The DC participated in this study. In 1996, the department conducted a follow-up seroprevalence study based on the methodology used in the Correctional Regional Infection Sentinel Surveillance Project study, with some modification.46

The results of the 1996 study indicate that the overall seroprevalence rate for inmates in Florida's prisons was 4.5 percent. The male inmate prevalence rate was 4.2 percent and the female inmate prevalence rate was 8.7 percent. Charts 5-A and 5-B show prevalence rates by gender and age.47

Chart 5-A

Intake and Seroprevalence Rates of
Male Inmates in Florida's Prisons - 1996
by Age

Source: "HIV Surveillance Study (Draft)," Office of Health Services, Florida Department of Corrections, February 7, 1997

Chart 5-B

Intake and Seroprevalence Rates of
Female Inmates in Florida's Prisons - 1996
by Age

Source: "HIV Surveillance Study (Draft)," Office of Health Services, Florida Department of Corrections, February 7, 1997

The study also looked at the race and seroprevalence of incoming inmates. Blacks, who made up 53 percent of the sample accounted for 76 percent of the positive results; Whites (45 percent of the sample) accounted for 21 percent of the positive results; and Other (2 percent of the sample) accounted for 3 percent of the positive results. (See Table 5-K.)48

Table 5-K

Intake and Seroprevalence Rates of
Inmates in Florida's Prisons - 1996
by Race and Gender

 

Total

Male

Female

Race

% of sample tested

% of positve results

% of sample tested

% of positve results

% of sample tested

% of positve results

Black

53%

76%

53%

78%

52%

60%

White

45%

21%

45%

19%

47%

40%

Other

2%

3%

3%

4%

1%

0%

Source: "HIV Surveillance Study (Draft)," Florida Department of Corrections Office of Health Services, February 7, 1997

The top three sentencing counties -- Broward, Dade, and Hillsborough -- provided 35 percent of the total intake and accounted for 51 percent of the positive results.49

The Office of Health Services began tracking HIV+ inmates in FY 1992-93, the same year they began to keep statistics on the incidence of AIDS. Tables 5-L and 5-M show the number of HIV and AIDS cases reported by the DC.

Table 5-L

Number of HIV Cases Reported by the Florida Department of Corrections
FY 1992-93 - FY 1997-98

 

 

Daily Average Population

HIV+ Incidence - for FY

# of Known HIV+ Inmates on June 30

Prevalence Rate Per Thousand

Total # of PositiveTests

% of Total # of HIV Tests

FY92-93

Total

49,681

996

6.9%

1,581

32

Female

2,510

140

13.8%

153

61

Male

47,171

856

6.3%

1,428

30

FY93-94

Total

55,097

617

4.3%

1,658

31

Female

2,820

200

15.1%

170

63

Male

52,277

417

3.2%

1,488

30

FY94-95

Total

60,902

804

5.3%

1,937

34

Female

2,703

139

11.5%

181

61

Male

58,199

665

4.8%

1,756

32

FY95-96

Total

63,756

722

4.7%

2,171

34

Female

3,534

103

7.4%

254

72

Male

60,222

619

4.4%

1,917

32

FY96-97

Total

63,766

709

N/A*

2,159

34

Female

3,437

91

N/A*

219

64

Male

60,329

618

N/A*

1,940

32

FY97-98

Total

65,058

889

N/A*

2,274

35

Female

3,372

181

N/A*

236

70

Male

61,686

708

N/A*

2,038

33

N/A - Not Available. The OHS did not track the number of tests performed during FYs 1996- 98.
Source: Office of Health Services, Florida Department of Corrections

Table 5-M

Number of AIDS Cases Reported by the Florida Department of Corrections
FY 1992-93 - FY 1997-98

 

 

Daily Average Population

# of Newly Diagnosed AIDS Cases for FY

# of AIDS Cases on June 30

Prevalence Rate Per Thousand

FY92-93*

Total

49,681

373

411

8

Female

2,510

44

26

10

Male

47,171

329

385

8

FY93-94

Total

55,097

412

530

10

Female

2,820

30

28

10

Male

52,277

382

502

10

FY94-95

Total

60,902

516

748

13

Female

2,703

71

67

23

Male

58,199

445

681

12

FY95-96

Total

63,756

529

833

13

Female

3,534

70

78

22

Male

60,222

459

755

12

FY96-97

Total

63,766

406

827

13

Female

3,437

59

65

19

Male

60,329

347

762

13

FY97-98

Total

65,058

358

745

12

Female

3,372

24

34

10

Male

61,686

334

711

12

*The criteria for the diagnosis of AIDS published by the Centers for Disease Control and Prevention was changed as of January 1, 1993. The DC adopted these criteria on that date. Source: Office of Health Services, Florida Department of Corrections

In the CMA's Report on the Health Care Delivery of the Florida Department of Corrections Fiscal Year 1996-97, they listed fourteen inmate deaths as problematic. Of these, five (noted at four institutions) were HIV/AIDS related.50 The problematic deaths were identified through the triennial institutional surveys conducted by the CMA. The CMA reviews the deaths that have occurred since their last survey, which may have been conducted as far back as 1994. (The OHS's procedures for identifying and treating HIV/AIDS have changed since that time.) On those surveys, CMA staff has access only to the medical record of the deceased inmate. The OHS response to the CMA's annual report did not question these findings.

According to the CMA, "the most common deficiencies identified during reviews of HIV/AIDS mortality records were poor assessments, delayed diagnosis, questionable treatment choices, and/or delayed referrals for a higher level of care." Follow up corrective action plan visits were made to each of the four institutions found to have HIV/AIDS related citations to determine if the problems had been corrected. One of the four was found to be adequately corrected (Century CI), two were considered "not corrected" (Broward CI and Marion CI), and the fourth institution had a high volume of deficiencies that were considered "systemic" and the mortality citation was not specifically reviewed (Everglades CI).51

The OHS has its own mortality review process which is described in Health Service Bulletin (HSB) 15.09.09 (October 27,1997). The mortality review process is divided into four categories:

  1. Targeted diagnoses - deaths due to AIDS, cancer, or cardiac disease.
  2. Minimal reviews - death was expected, other than targeted diagnoses.
  3. Standard reviews - death due to a critical event such as stroke or accident.
  4. Expedited reviews - death was unexpected due to such causes as suicide or medication errors.

Upon the death of an inmate, the institution must perform a mortality review within seven days, except in the cases of expedited reviews, which are done immediately. The institutional mortality review is sent to the Central Office and then to an outside physician reviewer. If problems are identified, a corrective action plan is developed at the regional office and forwarded to the institution for implementation. Appendix 5.7 illustrates the mortality review process for targeted cases. According to the OHS, the differences in their findings and those of the CMA are often the differences in opinion between one health care professional and another.

    

For the past year, the Quality Management Committee of the CMA, which meets quarterly, has reviewed approximately five mortality review files of problematic deaths that have occurred in the quarter prior to their meeting. This peer review process was put in place to ensure that the OHS's mortality review process is effective and that the CMA's review of mortalities are done as soon after the deaths as possible.

Chart 5-C tracks the total number of AIDS deaths in Florida's prisons compared to overall deaths, by calendar year, since 1987. While AIDS was once the leading cause of death in prison, the number of AIDS-related deaths has been declining since 1995. It is believed this due to the effectiveness of the new treatment protocols.

Chart 5-C

Total Deaths/AIDS Deaths in Florida's Prisons
CY 1987-1997

Source: Office of Health Services, Florida Department of Corrections

5.2.4. HIV Testing

HIV testing in Florida's prisons is done primarily on a voluntary basis. Section 945.35(3), Florida Statutes (1997), allows the department to begin a testing program on any inmate found to be engaged in the following high-risk behaviors:

  • sexual contact with any other person;
  • an altercation involving exposure to body fluids;
  • the use of intravenous drugs;
  • tattooing; or
  • any other activity medically known to transmit the virus.

It is the department's policy to encourage all inmates to be tested for HIV without incurring a co- payment for testing or pretest and posttest counseling. Inmates that test negative may request retesting in six months. All inmates scheduled for testing receive pretest and posttest counseling. All admissions to the reception centers are encouraged to be tested and testing information is provided during orientation at their permanent institution.52

The department uses the ELISA (Enzyme-Linked Immunosorbent Assay) antibody test for HIV. If the ELISA is positive, a Western blot test is done to confirm the diagnosis. An "indeterminate" or "slightly reactive" result should be repeated in three months; a second "indeterminate" result within six months is considered negative.53

The DC's health service bulletin on HIV policy notes that "manifestations of HIV are highly variable" and lists the symptoms that should alert health care workers to possible infection. (See Appendix 5.8, Symptoms of HIV.)54

Inmates considered to be at "high-risk" for HIV infection are urged to be tested. A refusal of this recommendation must be documented. The department considers an inmate to be at high- risk if any of the following factors are identified:

  • Men who have had sex with men.
  • History of multiple sex partners.
  • History of intravenous drug use or use of crack cocaine.
  • History of sexually transmitted diseases.
  • Those who received blood or blood products between 1978 and 1985.
  • Sexual or needle sharing contacts with any of the above groups.
  • History of Tuberculosis or recent Mantoux skin test conversion.
  • History of Hepatitis B or Hepatitis C positivity.
  • Laboratory tests that indicate the following:
    • Reduced white blood cell count
    • Reduced hemoglobin
    • Reduced platelets
    • Unexplained gamma globulin elevation
  • Persistent Herpes simplex or multi-dermatomal zoster (shingles) or zoster in a young person, even in one dermatome.
  • Pregnant inmates.
  • Inmates presenting with swollen lymph nodes and/or lymphadenopathy.
  • Female inmates presenting with recurrent candidial vaginitis.
  • Female inmates with cervical cancer or pre-cancerous lesions.
  • Inmates with recurrent bacterial pneumonias.
  • Recurrent or persistent diarrheas.
  • Kaposi's sarcoma.
  • Lymphoma.
  • Inmates who consider themselves "at-risk," or are just curious; or "just want to know" HIV status.55

Inmates who have less than 60 days remaining on their sentence are not generally tested. Each institution is responsible for testing its permanent inmates. Bulletin board notifications are available in English and Spanish and Creole, upon request. These bulletin board notifications name most of the first eight risk factors listed above and add involvement in prostitution. They do not include the sharing of injection drug use equipment as a risk factor and do not mention that the testing and counseling are free. (See Appendix 5.9, Department of Corrections, Office of Health Services, Notice to Inmates.)56

Testing after incidents where body fluids have been exchanged, such as altercations or needle sticks, will be performed immediately after the incident, unless the inmate is known to be HIV+, and repeated at six weeks, three months, and six months if the affected inmate remains negative.57

Chapter 10D-3.062, Florida Administrative Code, requires all newly positive HIV tests to be reported to the Florida Department of Health.58

Table 5-N

Number of HIV Tests Administered by the Florida Department of Corrections
FY 1992-93 - FY 1996-97

 

Daily Average Population

# of HIV Tests Administered YTD

# of Confirming HIV Tests Positive YTD (Western Blot)

Incidence Rate (% of tests done that have a positive result)

FY92-93

49,681

14,518

996

6.9

FY93-94

55,097

14,198

848

6.0

FY94-95

60,902

15,162

797

5.3

FY95-96

63,756

16,389

710

4.6

FY96-97

63,766

N/A

813

N/A

*N/A - Not Available. The OHS did not track the number of tests performed during FYs 1996-98.
Source: Office of Health Services, Florida Department of Corrections

On April 30, 1996, the DC issued a study, Estimated Costs of Mandatory Testing for HIV Seroprevalence. At that time, the department estimated the following:

 

The cost of testing one inmate for HIV, including staff time -

$16.98

 

The cost of confirming test and diagnostic testing for those who test positive, per inmate -

$626.34

 

Cost to test status population that have not tested voluntarily -

$834,533.00

 

The cost of confirming test and diagnostic testing for status population if 5.4 percent of the population tests positive -

$1,662,301.35

 

Annual cost of testing of all new admissions -

$427,896.00

 

The annual cost of confirming test and diagnostic testing for new admissions if 5.4 percent of the population tests positive -

$856,833.12

It should be noted that these estimates represent 1996 numbers. The protocol for diagnostic testing when an inmate tests HIV+, including the addition of the viral load test, has changed since 1996. The cost of the tests alone, exclusive of staff time, has risen 13.8 percent in the last two years. (See Appendix 5.10, Costs of Tests for the Screening and Treatment of HIV/AIDS.) Also, these estimates do not calculate the cost of treatment for all inmates newly identified through mandatory testing as being HIV+. However, using the 1996 numbers and adjusting for a 13.8 percent increase in testing costs, it would cost approximately $1,436,584 to test the status population and all new admissions for HIV the first year a mandatory testing policy is adopted.

5.2.5. Housing

Currently, inmates in Florida who test positive for HIV or who have AIDS are not housed separately. However, the Central Florida Reception Center-South Unit, a special needs facility, was opened in December 1997 to house terminally-ill, male AIDS patients. According to the DC's 1996-97 Annual Report,

 

through economies of scale, reduced hospitalization and security costs, it is expected to improve the quality of care for these inmates. The facility will include all special support functions for inmates with AIDS requiring special housing and health care support. Done in partnership with DC, Florida Hospital and the University of Miami, and Dr. Margaret Fischl [director of Miami's AIDS Clinical Trial Unit].59

 

 

The Central Florida Reception Center-South Unit is a 100-bed facility that was formally a work release center known as Cape Orlando. With 2,274 cases as of June 30, 1998, this unit holds approximately 4.4 percent of the known HIV+ inmates. Commission staff, along with Commissioner Alma Littles, M.D., toured the Central Florida Reception Center-South Unit on August 4, 1998. On the day of the site visit, the South Unit had a population of approximately 95 inmates.

Dr. Dianne Rechtine, Executive Medical Director for the Central Florida Reception Center, reported that the inmates respond very well to the treatment at the unit. She has not had any problem getting what she needs to treat the inmates to date. Dr. Rechtine reported that it cost the South Unit approximately $125,000 a month for medications alone.

Dr. Rechtine and her staff review inmates for eligibility before they are assigned to the South Unit. If it is believed that an inmate can benefit from the care available at the unit, he is eligible. All inmates at the unit are HIV+ and are assigned jobs, such as housekeeping, canteen, or disabled inmate assistants, while they are physically able to work.

There is a weight room equipped with donated supplies that can only be used when there is a certified wellness instructor present. A full-time wellness instructor is assigned to the unit. Also, there are two full-time mental health positions at the unit that coordinate two peer support groups and a grief program. Chaplaincy services are available to the inmates.

Some inmates from the South Unit may be eligible for work release. If an inmate has a history of substance abuse, the inmate must have been enrolled in a substance abuse program to be eligible for work release. Currently, there are no substance abuse or General Education Diploma (G.E.D.) programs available at the South Unit.

The University of Miami is now conducting Phase III clinical trials on inmates who meet the criteria and agree to participate.60 Approximately twenty inmates are participating in the clinical trials. The clinical trials are currently testing only antiretroviral drugs; no prophylactic medications are being studied. To be eligible for the program, inmates must be "naive"; that is, they must not have been previously treated with any other antiretroviral drugs.

5.2.6. Correctional Staff

Section 945.35(2), F.S. (1997), requires all staff in correctional facilities to complete an HIV/AIDS education program "with an emphasis on appropriate behavior and attitude change."

In Florida, HIV is considered a sexually transmitted disease with special confidentiality status. All cases of AIDS have been reported to the Department of Health since 1985; HIV cases are now reported as of July 1, 1997. Names of those infected with HIV/AIDS are reported to Department of Health using the Centers for Disease Control and Prevention's confidential reporting form.

Section 381.004(3)(f)(3), F.S. (1997), requires the Department of Health to "adopt a rule defining which persons have a need to know." These rules are contained in Chapter 64D-2.003, F.A.C. Generally, those that "need to know" are health care workers involved in the care and treatment of these patients. A court can order an offender to undergo an HIV test if there has been an exchange of bodily fluids (s.775.0877, F.S. [1997]). Test results are made available only to the offender, the victim or the victim's legal guardian, and the Department of Health. Pleadings pertaining to disclosure of test results are to use a pseudonym for the test subject and court proceedings as to disclosure of test results are to be conducted in the judge's chambers (s.381.004, F.S. [1997]).

Florida has had one occupational exposure to HIV case filed by a correctional officer (Elliot v. Dugger, 1991). Ultimately, the courts found that workers' compensation laws covered any claim arising from occupational exposure to HIV.61

5.2.7. Release

The release of inmates with HIV/AIDS is coordinated between the chief health officer and classification officer at their permanent institutions. A maximum 30-day supply of currently prescribed medications, sufficient to provide the inmate with treatment until treatment is received from a non-DC provider, will accompany the inmate along with a referral to an appropriate medical facility. The DC will try to arrange Social Security Insurance benefits for the inmate prior to release, if possible. Inmates will receive an HIV/AIDS Health Information Summary, to be completed for the inmate to help the inmate with follow-up care (see Appendix 5.11 for a copy of that form. ).62

All inmates who receive any medication(s) which is approved by the AIDS Drug Assistance Program will be referred to this program for follow-up care. With the inmate's consent, the DC will provide the Department of Health with the necessary information to establish the inmate's eligibility for the AIDS Drug Assistance Program and make an appointment at the health department in the county where the inmate will reside, if appropriate.63

Inmates with AIDS in Florida may receive conditional medical release under certain circumstances.64 As indicated in Table 5-O, almost half (45.8 percent) of all referrals to the conditional medical release program are for inmates with AIDS. The Florida Corrections Commission reviewed the conditional medical release program and did not recommend any changes in the program in regard to inmates diagnosed with AIDS. (See Section 3.0, Conditional Medical Release.)

Table 5-O

Conditional Medical Release Program - Cases Referred and Disposition
All Causes versus AIDS
CYs 1996-1998

 

CY 1996

CY 1997

CY 1998

All

AIDS

All

AIDS

All

AIDS

Referrals

86

43

56

24

13

4

Approvals

19

16

14

6

5

2

Denials

29

25

20

15

2

1

Deaths

38

2

22

3

3

0

Pending

N/A

N/A

N/A

N/A

3

1

As of May 15, 1998
Source: Office of Health Services, Florida Department of Corrections

5.2.8. HIV Transmission in Prison

In November 1997, the Gainesville Sun reviewed the disciplinary reports for 67 inmates in the Eighth Medical Examiner's District that died of AIDS before October 1, 1997, that year. The Eighth Medical Examiner's District includes the hospital at the North Florida Reception Center where most terminal AIDS patients are sent. The Sun review found that 19 (28%) of the inmates that died of AIDS were disciplined for consensual sexual activity. One inmate was disciplined for tattooing. Twenty-four of the inmates had served prison sentences of ten or more years, which is considered to be the normal incubation period, including eight from the group that had been disciplined for sexual activity. A total of 37 inmates (55%) belonged to either the sexual activity or long-term group. Another 24 inmates had narcotics violations in prison that could have included injection drug use.65

According to the article, the DC has not studied the correlation between disciplinary reports and HIV infections. At the request of the Commission, the department reported the number of disciplinary reports contained in the corrections data base associated with certain high-risk behaviors.

Table 5-P

Number of Disciplinary Reports of High-Risk Behaviors
CYs 1995-1997

 

 

 

 

Type of Disciplinary Report

1995

1996

1997

Assault-Sexual Battery

14

18

2

Sex Acts

605

610

621

Tattooing

526

481

410

Possession of narcotics, drug paraphernalia

1,117

1,020

765

Use of alcohol/drugs

3,329

2,736

2,172

Source: Bureau of Research and Data Analysis, Florida Department of Corrections

5.2.9. Prevention Strategies

HIV/AIDS Education

Section 945.35, F.S. (1997), requires the DC to establish a mandatory and continuing education program on HIV/AIDS for all inmates that is sensitive to cultural "and other relevant differences among inmates" and emphasizes behavior and attitude change. The programs are to be designed for the inmates while they are incarcerated and prior to their release and are to be updated as new medical information becomes available.

According to HSB 15.03.08, HIV/AIDS training will be provided to inmates at reception, transfer to a permanent institution (HIV 101-Basic and HIV 102-Testing Policy), and prior to release, with updates offered as needed. The provision of this education must be documented. The decision on what HIV/AIDS educational materials to purchase, including booklets and videos, is made at the institution level. There can be great variation in the quality and quantity of HIV/AIDS information that is available from institution to institution.

The basic HIV information course is given at orientation and could be a handout and/or a videotape. Generally, the videotape "HIV/AIDS 101," produced by the Florida Department of Health, is used. The tape does not specifically address the issues relating to HIV in the correctional setting, but does cover transmission, testing, and treatment. According to the OHS "there are no specific educational materials addressing AIDS for pre-release. Verbal instructions to the pre-release inmates were to include more HIV/STD [sexually transmitted disease] prevention and condom use."

The DC provided examples of educational materials to the Commission. Most booklets are at the sixth to eighth grade reading level. An increasing number of the booklets and videos use "Real Stories," inmates talking to inmates about their experience of having HIV/AIDS in prison, how they contracted the disease, and prevention strategies. Not all of the materials mention using condoms, explain about sharing injection drug use equipment other than needles, suggest getting drug treatment, or discuss safer sex practices.

Inmate Peer Educator Project

The DC reports an "Inmate Peer Educator Project" at Lawtey CI, Florida CI, and Dade CI. The Inmate Peer Education Project recognizes that prisoners are one of the highest risk groups for contracting HIV/AIDS and other sexually transmitted diseases. Through educating both inmates and correctional staff, the program hopes to reduce the incidences of these diseases for those not infected and help HIV+ persons develop a plan to maintain good health and prevent transmission.66

The Inmate Peer Educator projects are funded by a federal grant, through the Centers for Disease Control and Prevention, of $50,000 annually per program and are administered by the Bureau of HIV/AIDS, Florida Department of Health, with the DC as the "provider." The funds allow the DC to employ one Full-Time Equivalent Education and Training Specialist as the project coordinator and one Other Personnel Services Data Entry Operator, purchase office supplies and computer equipment, and cover other necessary expenses.

According to the Bureau of HIV/AIDS, inmates access the program either by volunteering or by referral. Prior to formal instruction, the project coordinator will interview inmates to ascertain their knowledge of HIV/AIDS and sexually transmitted diseases. A study package is issued and an inmate peer counselor is assigned to assist with the study process. Peer educators give educational presentations to inmates during the HIV/AIDS basic awareness course, inmate orientation, and pre-release sessions.

Upon entering the facility, inmates receive a thirty-minute basic HIV/AIDS orientation during which a survey is completed. Some inmates then choose to take the fifteen-hour basic awareness course. A subset of those completing this course go on to take the advanced or peer education course. Those inmates who have become peer educators are given credit for adding a "life betterment" course to their education. Inmate peer educators who have been released from prison can request assistance with placement in an HIV/AIDS prevention agency in their home community in order to continue working in the area of prevention. The project coordinator contacts the local HIV/AIDS program coordinator who assists with placement either as a volunteer or a paid employee.67

Each day, the project coordinators walk the compound, speaking with inmates, dispelling misinformation, and encouraging them to take the basic awareness course. As a result, an average of ten inmates are reached per day. This process helps reduce rumors and is referred to by inmates as "Rumor and Fact Control."

The contract requires the department to implement at least twenty courses during the contract year: a minimum of one inmate orientation or inmate pre-release module per month, a minimum of four staff training courses; a minimum of two HIV/AIDS basic awareness courses; and a minimum of two peer educator courses. The inmates trained as peer educators will assist with inmate orientation and pre-release presentations, under the direction of the project coordinator.

In order to evaluate the projects, the contract requires the project coordinator to distribute survey forms during orientation, prior to HIV/AIDS basic awareness course, and during the pre-release program and to maintain a database with the results. The project coordinator will also track the number of participants, demographics, reasons for non-completion, and the number of HIV voluntary testing referrals that were submitted as a result of the program participation. The peer counselors' educational presentations will be evaluated by the project coordinator and verbal feedback will be offered concerning strengths and areas to improve. Peer counselors can volunteer to participate in a follow-up study after release. Volunteers will be sent a survey every six months for two years after release. (An inmate cannot be excluded from the program for failure to volunteer for the follow-up study.)

The project is considered successful if 70 percent of the inmates participating in the basic HIV/AIDS awareness course demonstrate increased knowledge as indicated on the pretest and posttest surveys and the voluntary testing levels increase by at least 5 percent from the previous year.

The Inmate Peer Education Project began at Lawtey CI in August 1994. Between July 1, l997, and June 30, 1998, that program reported the following activities: 13 basic awareness courses were taught, reaching 137 inmates, 35 peer educators were trained; and 484 inmates were informed about the program during their orientation to the institution. Over 170 inmates were referred to the medical unit to be tested for HIV and 184 were counseled and tested by the project coordinators.

The Inmate Peer Education Projects at Dade CI and Florida CI began in December 1997. The Florida Department of Health has applied for a grant to extend the program to an additional female facility, Jefferson CI. Of these four institutions, only Lawtey CI is not considered an HIV/AIDS facility in the health care consolidation plan.

Other Strategies

In 1993, the Governor's Red Ribbon Panel on AIDS recommended that the prison system "make condoms available to slow the spread of HIV." The department has declined to adopt this policy and considers condoms contraband.68

5.2.10. Costs of Testing for and Treating HIV/AIDS

The Commission asked the DC for a complete listing of services and expenditures considered ancillary services or other costs. Table 5-Q lists those expenditures.

Table 5-Q

Ancillary Services and Other HIV/AIDS Costs
FY 1996-97 and FY 1997-98

Ancillary Services

FY 96-97

FY 97-98

Radiology

$165,981

$170,017

Clinical & Pathology

$835,244

$1,700,174

Ambulance services

$67,044

$73,513

Autopsies & Funerals

$98,019

$108,981

Other Services

$11,854

$6,311

Total

$1,178,142

$2,058,996

 

 

 

Other Costs

 

 

Eye exams

$22,935

$17,222

Prosthetics

$799

$6,291

Medical Instruments

-

$2,212

Dental Materials & Supplies

-

$5,686

Lab Supplies

$18,364

$22,230

Bandages, Gauze, Dressings

$3,128

$2,871

Dietary Supplements

$83,345

$71,134

Gloves

$27,434

$58,184

IV Materials & Supplies

$108,322

$124,250

Equipment Rental

$53,078

$32,686

Other Materials & Supplies

$27,650

$20,312

Subotal

$345,055

$363,078

TOTAL

$1,523,197

$2,422,074

Total HIV/AIDS Budget

$10,774,183

$17,104,188

% Other & Ancillary Services of Total AIDS budget

14.1%

14.2%

Source: Office of Health Services, Florida Department of Corrections

Together, ancillary services and other costs account for 14.2 percent of HIV/AIDS costs. According to the OHS, medical expenses not related to HIV/AIDS are not counted in those costs.

The Commission compared what the AIDS Drug Assistance Program pays for drugs it offers and what Medicaid pays for the same medications as an indication of what HIV/AIDS medications cost on the "outside" to what the DC pays for the same drugs (see Appendix 5.12, Cost Comparison Between HIV/AIDS Drugs Offered by AIDS Drug Assistance Program, Medicaid, and the DC.) Generally, the DC pays 24.7 percent more for HIV/AIDS drugs than the AIDS Drug Assistance Program but 6.6 percent less than Medicaid.

In June 1998, based on the cooperative agreement between the DC and the private vendors, the department agreed to reduce the number of HIV+ inmates it was sending to these facilities from the level at that time of approximately 13 percent of the total capacity of the institution to 3.4 percent of capacity. The private institutions will continue to be HIV/AIDS institutions, but have this limitation. Table 5-R shows the old capacity level and the new level based on the agreement.

Table 5-R

Previous and Current Levels of HIV+ Inmates
Assigned to Private Prisons

 

 

 

 

Institution

Capacity

13% of Capacity

3.4% of Capacity

Bay

750

98

26

Moore Haven

750

98

26

South Bay

1,318

171

45

Lake City

350

46

12

Total

3,168

413

109

Source: Office of Health Services, Florida Department of Corrections

The OHS has identified $37,000 in fixed capital outlay funds to build a viral load laboratory at the North Florida Reception Center. Currently, each viral load test costs the DC $43.40 when sent to the contracted lab, Lab Corps. In comparison, an ELISA (the initial test for identifying HIV) costs the department $5.50 when done at the North Florida Reception Center and $10.73 when done at Lab Corps. The department hopes to realize comparable savings when the viral load laboratory opens in late 1998.

In November 1996, the Office of Program Policy Analysis and Government Accountability reviewed the DC's inmate health services and cited possible cost-savings measures.69 While the report examined all health services, some of their analyses and recommendations are relevant to HIV/AIDS. The Office of Program Policy Analysis and Government Accountability recommended the continuation of the consolidation of health care and privatizing one region's health care services. The report considered the possibility of collecting a co-payment for prescription drugs, but concluded it would not be cost-effective nor in the department's best interest. (Currently inmates pay a $4 co-payment for each inmate-initiated, non-emergency medical, dental, or mental health care visit. Those co-payments are processed as an expenditure refund and are used to offset the total institutional health care expenditure.) They did not endorse increasing the use of conditional medical release based on public safety concerns. The report did find merit in increased monitoring of community treatment billing for overcharges and the implementation of additional preventive health care measures when programs are accompanied by a monitoring or evaluation plan to assess their cost-effectiveness.

5.2.11. Other Correctional Systems

Of the fourteen systems surveyed by Commission staff, eight had contracts with outside vendors to provide medical services to inmates systemwide, one state (New York) had specialty care contracts. Four of the eight systems contracted with a state university for the provision of medical care, another four contracted with one or more private providers, primarily Correctional Medical Services of St. Louis, Missouri. (Correctional Medical Services considers its costs related to HIV treatment proprietary knowledge and does not release that information.)

Most states do not track HIV/AIDS treatment as a separate budget category and could only give pharmacy costs or estimates of annual costs. Below is a summary of the survey.

Alabama - The segregation of HIV+ inmates is currently being challenged in federal court. Medical services are provided by Correctional Medical Services. The Alabama Department of Corrections estimates that it costs $4,800 per inmate per year for antiretroviral therapy.

California - The Correctional Medical Facility at Vacaville has a special HIV Center that includes a 472-bed wing and one floor of the prison hospital. Depending on their security level, inmates do have access to prison programs. California has appropriated $5.3 million for protease inhibitors for FY 1998-99.

Connecticut - Medical care is provided by the University of Connecticut. Connecticut spends approximately $12,000-$13,000 per inmate per year on HIV medications. Table 5-S shows the amount the state spends on HIV drugs in comparison to total drug purchases.

Table 5-S

Connecticut's HIV Drug Expenditures

 

FY95-96

FY96-97

FY97-98*

HIV+ Drugs

$1.0 mil

$2.9 mil

$3.0 mil

Total Drug Purchases

$4.3 mil

$6.4 mil

$5.7 mil

% of all drug purchases

24.4%

46.2%

53.0%

*through April 1998
Source: Connecticut Department of Corrections

Georgia - Medical care is provided by the Medical College of Georgia through an interagency agreement.

Maryland - The state has a statutory prohibition against involuntary testing, including blind serology studies. Medical care is privately provided by contract by region. Maryland has five correctional regions that contract with four different vendors. Because of the escalating costs of HIV/AIDS treatment due to new antiretroviral drug protocols, Maryland has taken protease inhibitors out of the contracted medical care and appropriated $2.5 million for FY 1998-99 for those drugs. The state spends approximately $11,000 per inmate per year for HIV/AIDS treatment.

Massachusetts - Medical care is contracted to Correctional Medical Services, a private provider.

Mississippi - Although segregated, inmates have access to all programs. Condoms are distributed through the canteen for $.25 each. Mississippi allows conjugal visits and does not want HIV being brought into the prison. The University of Mississippi is in the process of taking over medical care for the correctional system. As of July 1, 1998, Mississippi no longer has a medical release program.

New Hampshire - The state spends approximately $112,800 annually for HIV drugs. The state also has an active early release program for terminally ill inmates.

New Jersey - At one time, confirmed AIDS cases were clustered, but this practice was halted by a consent agreement (Roe v. Fauver, 1991). Health care is provided by Correctional Medical Services.

New York - It is estimated that the state spent $6 million on treatment for HIV/AIDS in FY 1995-96 and will spend between $25-$30 million for FY 1998-99, an increase of almost 400 percent. The state has about 7,500 HIV+ inmates, 3,000 of whom are receiving antiretroviral therapy. New York has specialty care contracts that are with three private vendors in four regions. Also, they are building regional medical units to treat sub-acute through hospice patients. These units will treat approximately 70,000 inmates. Three units are currently operational with the remaining two expected to be on-line by October 1998.

Texas - The Texas Department of Criminal Justice contracted with the Correctional Managed Health Care Advisory Committee to create and oversee the implementation of a managed health care delivery system within the department. The committee in turn contracts with the University of Texas Medical Branch at Galveston and Texas Tech University Health Sciences Center to provide the health care to inmates. Texas has a chronic care facility in Beaumont which is available to inmates with CD4+ cell counts of 200 or less. A new HIV/AIDS treatment policy was adopted in March 1998 to follow the Centers for Disease Control and Prevention guidelines. The Texas Department of Criminal Justice expects to begin blind serology studies this year to determine the prevalence of HIV/AIDS. Table 5-T shows the annual cost of antiretroviral drugs per inmate per year.

Table 5-T

Texas - HIV Antiretroviral Costs
Per Inmate Annually

 

 

 

 

 

 

Year

1994

1995

1996

1997

1998*

Annual Cost

$982

$1,267

$1,548

$4,661

$6,687

% Increase

N/A

29.0%

22.2%

201.1%

43.5%

*Projected based on first six months data
Source: Texas Department of Criminal Justice

Vermont - Since 1987, Vermont has made condoms available to inmates free through the infirmary. This was seen as the best public health practice. The Vermont correctional system, which includes jails, has approximately 1,300 inmates. It is estimated that there are currently 15- 25 HIV+ inmates, 5 with AIDS.

U.S. Bureau of Prisons - The Bureau of Prisons estimates that it currently has approximately 1,100 HIV+ inmates, 750 of whom are on antiretroviral therapy. The annual cost of treatment is approximately $10,000 per inmate. The Bureau of Prison's pharmacy cost for antiretroviral medications was approximately $1 million in 1995, $1.4 million in 1996, and $5.5 million in 1997. The federal system incarcerates approximately 110,000 offenders.

Correctional Services Canada - The Canadian federal prison system provides condoms, dental dams, lubricants, and bleach to inmates through dispensers located in the prisons. They also have approximately 50 inmates in a methadone maintenance treatment program. The correctional system is divided into five regions, comprised of two provinces; financial arrangements for medical care are made at the regional level. Standards of care are adopted at the provincial level. A peer education program is available in each institution. The Canadian federal prison system has approximately 14,000 inmates sentenced to two years or more and approximately 8,000 under supervised release.

5.3. RECOMMENDATIONS:

5.3.1. The Florida Legislature should provide the estimated $14 million deficit in the funding for treatment of HIV/AIDS in Florida's prisons for FY 1999-00.

5.3.2. The Department of Corrections should test all inmates for HIV at reception.

5.3.3. The Department of Corrections should provide substance abuse and G.E.D. classes at the Central Florida Reception Center-South Unit.

5.3.4. The Department of Corrections should dedicate an entire close custody facility to health care that includes all seriously ill inmates, not just HIV/AIDS patients, along the Central Florida Reception Center-South Unit model.

5.3.5. The Department of Corrections should continue its efforts to consolidate care for HIV/AIDS-infected inmates in a limited number of institutions where specially trained staff are located.

5.3.6. The Department of Corrections should refine its definitions of what is considered an HIV/AIDS cost, especially in the areas of ancillary services and other costs, and track those costs.

5.3.7. The Department of Corrections should increase the monitoring of community treatment billing to guard against overbilling.

5.3.8. The Department of Corrections should privatize the health care services for one region stipulating that the vendor guarantee a savings of ten percent over the Office of Health Service's annual costs.

5.3.9. The Department of Corrections should begin to track HIV/AIDS inmates by the following characteristics: race, length of sentence, sentence of conviction, and age.

5.3.10. The Department of Corrections should continue to track the number of HIV tests (ELISA and Western blot) that it performs in its Monthly Utilization Reports.

5.3.11. The Department of Corrections should track the number of HIV-positive inmates who are receiving the antiretroviral treatment.

5.3.12. The Department of Corrections should better track the implementation of Corrective Action Plans that are formulated as a result of a mortality review where problems have been identified.

5.3.13. All HIV/AIDS educational materials used by the Department of Corrections should include specific risk reduction instruction in the areas of injection drug use and safe sex practices.

5.3.14. The Department of Corrections should evaluate its HIV/AIDS education program to ensure that the funds dedicated to the program are being optimally used. Such an evaluation could include a knowledge test given before and after HIV/AIDS education classes and tracking any increase in the number of inmates testing voluntarily for HIV.

Lead Analyst: Robbie A. Bouplon

Notes for Section 5.0

1 AIDS info.com, http://www.aids-info.com/101.html. May 6, 1998.
2 "Easier-to-use AIDS drug gets FDA approval," Health, CNN Interactive, http://www.cnn.com/HEALTH/9809/18/aids.drug.ap/, September 21, 1998.
3 AIDS Treatment Data Network, Treatment Review Double Issue #26 & #27, November 1997, http://204.179.124.69/network/trs/2627.html, May 7, 1998.
4 Ibid.
5 Broward County Medical Examiner and Trauma Division, Health Guide for the Perplexed, HIV/AIDS, http://www.co.broward.fl.us/mei00224.htm, June 11, 1998.
6 The Access Project, AIDS Drug Assistance Programs, http://aidsinfonyc.org/network/access/index.html#adap, June 13, 1998.
7 The Access Project, AIDS Drug Assistance Programs, Florida, http://aidsinfonyc.org/network/access/states/fl/fl.html, June 13, 1998.
8 Louis A. Pagliaro and Ann M. Pagliaro, "Sentenced to death? HIV infection and AIDS in prisons - Current and future concerns," Canadian Journal of Criminology, 34 (April 1992): 204.
9 David Vlahov, "HIV-1 Infection In The Correctional Setting," Criminal Justice Policy Review, 4 (December 1990): 307.
10 National Commission on Acquired Immune Deficiency Syndrome, HIV Disease in Correctional Facilities, (March 1991), 15.
11 Pagliaro, 205.
12 Carolyn Behrendt, et. al., "HIV Infection and AIDS Among U.S. Prison Inmates," Journal of Crime and Justice, 15 (1992): 175; Richard J. Koehler, "HIV Infection, TB, and the Health Crisis in Corrections," Public Administration Review, 54 (January/February 1994): 32; Pagliaro, 205; Vlahov (1990), 307; David Vlahov, et. al., "Prevalence of Antibody to HIV-1 Among Entrants to US Correctional Facilities," Journal of the American Medical Association, 265 (March 6, 1991): 1131.
13 Theodore M. Hammett, et.al., 1994 Update: HIV/AIDS and STDs in Correctional Facilities, U.S. Department of Justice, Office of Justice Programs, National Institute of Justice, (December 1995), 14; Carolyn Wolf Harlow, HIV in U.S. Prisons and Jails, U.S. Department of Justice, Bureau of Justice Statistics Special Report, (September 1993), 2-5.
14 Laura Maruschak, HIV in Prisons and Jails, 1995, Bureau of Justice Statistics, U.S. Department of Justice, (August 1997), 2.
15Koehler, 34.
16 Maruschak, 7; National Commission, 21-22. The states that test all inmates entering prisons are: Alabama, Colorado, Georgia, Idaho, Iowa, Michigan, Mississippi, Missouri, Nebraska, Nevada, New Hampshire, North Dakota, Oklahoma, Rhode Island, South Carolina, Utah, and Wyoming. Rhode Island, Utah, and Wyoming test all inmates in custody; and Alabama, Missouri, and Nevada test inmates at release.
17 Barbara A. Belbot and Rolando V. Del Carmen, "AIDS in Prison: Legal Issues," Crime and Delinquency, 37 (January 1991): 138; Kenneth C. Haas, "Constitutional Challenges to the Compulsory HIV Testing of Prisoners and The Mandatory Segregation of HIV-Positive Prisoners," The Prison Journal, 73 (September/December 1993): 394-400, 417; Daniel L. Skoler and Richard L. Dargan, "AIDS in Prisons - Administrator Policies, Inmate Protests, and Reactions From the Federal Bench," Federal Probation, (June 1990): 30.
18 Hammett, 51; Pagliaro, 207.
19 National Commission, 22-24.
20 Mark Blumberg, "The Transmission of HIV: Exploring Some Misconceptions Related to Criminal Justice," Criminal Justice Policy Review, 4 (December 1990): 288-305; Anna T. Laszlo and Barbara E. Smith, "Evaluating Criminal Justice Training Addressing AIDS Policy," Crime and Delinquency, 37 (January 1991): 19-20; U.S. Department of Health and Human Services, Guidelines for Prevention of Transmission of Human immunodeficiency Virus and Hepatitis B Virus to Health-Care and Public-Safety Workers, (February 1989), 1.
21 Lawrence O. Gostin, JD and David W. Weber, JD, "HIV Infection and AIDS in the Public Health and Health Care Systems: The Role of Law and Litigation," JAMA, 279 (April 8, 1998), Journal of the American Medical Association, HIV/AIDS Information Center, Library, http//www.ama-assn.org/special/hiv/library/readroom/jama98/jlm71034.htm, May 21, 1998.
22 Ibid.
23 Lawrence O. Gostin, J.D., and David W. Weber, J.D., "The AIDS Litigation Project, Part I: HIV/AIDS in the courts in the 1990s," AIDS & Public Policy Journal, 13 (Spring 1998), Journal of the American Medical Association, HIV/AIDS Information Center, Library, http//www.ama- assn.org/special/hiv/library/readroom/other98/alp1.htm, May 21, 1998.
24 Lawrence O. Gostin, J.D., and David W. Weber, J.D., "The AIDS Litigation Project, Part II: HIV/AIDS in the courts in the 1990s," AIDS & Public Policy Journal, 13 (Summer 1998), Journal of the American Medical Association, HIV/AIDS Information Center, Library, http//www.ama-assn.org/special/hiv/library/readroom/other98/alp2.htm, May 21, 1998.
25 Hammett, 54-55; National Commission, 29.
26 Behrendt, 175; Hammett, 14-15; Robert Horsburgh, et al., "Seroconversion to Human Immunodeficiency Virus in Prison Inmates," American Journal of Public Health, 80 (February 1990): 209-210; Patrick W. Kelley, et. al., "Prevalence and Incidence of HTLV-III Infection in a Prison," Journal of the American Medical Association, 256 (October 24-31, 1986): 2198-2199.
27 Christine A. Saum, et. al., "Sex in Prison: Exploring the Myths and Realities," The Prison Journal, 75 (December 1995): 414; Cindy Struckman-Johnson, et. al., "Sexual Coercion Reported by Men and Women in Prison," The Journal of Sexual Research, 33 (1996): 67-68; Hammett, 14-15.
28 Hammett, 14-15.
29 Occupational Safety and Health Administration, U.S. Department of Labor, OSHA Regulations, (Standards - 29 CFR), Bloodborne pathogens - 1910.1030, http://www.osha- slc.gov/OshStd_data/1910_1030.html, July 14, 1998.
30 Hammett, 23. 31 Randy Martin, et. al., "A Content Assessment and Comparative Analysis of Prison-Based AIDS Education Programs for Inmates," The Prison Journal, 75 (March 1995): 9; National Commission, 16-21.
32 Martin, 11-12, 27; Hammett, 28, 30.
33 Hammett, 31.
34 Martin, 30.
35 Martin, 29.
36 Hammett, 24.
37 Martin, 12, 32-34.
38 Martin, 11.
39 Hammett, 37-39.
40 Behrendt, 180; Pagliaro, 208; Hammett, 38-39; Ralf Jurgens, "Developments in Criminal Law and Criminal Justice: Sentenced to Prison, Sentenced to Death? HIV and AIDS in Prisons," Rutgers University School of Law, Criminal Law Forum, (1994).
41 Hammett, 39.
42 Letter from Bill Thurber, Deputy Secretary, Florida Department of Corrections, to John D. Fuller, Executive Director, Florida Corrections Commission, dated April 14, 1998.
43 Florida Department of Corrections, Legislative Budget Request FY 1997-98, 215; Florida Department of Corrections, Legislative Budget Request FY 1998-99, 33.
44 Florida Department of Corrections, 1996-97 Annual Report, (November 1997), 61.
45 Florida Department of Corrections, Office of Health Services, HIV Surveillance Study (draft), (February 7, 1997): 2.
46 Ibid., 2-3.
47 Ibid., 5.
48 Ibid., 6.
49 Ibid., 7.
50 Correctional Medical Authority, Report on the Health Care Delivery of Florida Department of Corrections Fiscal Year 1996-97, (November 1997), 19-20.
51 Memo to Florida Corrections Commission from the Correctional Medical Authority, July 16, 1998.
52 Florida Department of Corrections, Office of Health Services, Health Service Bulletin No. 15.03.08, (March 5, 1997), 2-3.
53 Ibid., 5.
54 Ibid., 1.
55 Ibid., 3-4.
56 Ibid., 3.
57 Ibid., 4.
58 Florida Department of Corrections, Office of Health Services, Health Service Bulletin No. 15.09.02, (November 12, 1997), 1.
59 Department of Corrections, 1996-97 Annual Report, 61
60 Ibid.
61 Elliot v. Dugger, 579 So.2d 827 (Fla. App. 1 Dist. 1991).
62 HSB 15.03.08, 12; Florida Department of Corrections, Office of Health Services, Health Service Bulletin No. 15.03.29, (October 27, 1997), 1-3.
63 Florida Department of Corrections, Health Service Administrative Memorandum No. 97-4, (September 12, 1997), 1-3.
64 HSB 15.03.08, 10.
65 Doug Martin, "HIV spread in prisons, study shows," Gainesville Sun, (22 November 1997).
66 Florida Department of Health, Bureau of HIV/AIDS Early Intervention Section, "Department of Corrections Peer Education Program," (undated).
67 Ibid.
68 Doug Martin, "AIDS ravages prisons," Gainesville Sun, (11 November 1997).
69 Office of Program Policy Analysis and Governmental Accountability, Review of Inmate Health Services Within the Department of Corrections, Report No. 96-22, (November 27, 1996), 8, 11-12.