of Infectious Disease Among Inmates of and Releasees From US
Correctional Facilities, 1997
Theodore M. Hammett, PhD, Mary Patricia Harmon, AB and William
Theodore M. Hammett, Mary Patricia Harmon, and William Rhodes
are with Abt Associates Inc, Cambridge, Mass. Mary Patricia
Harmon is also with the Harvard Graduate School of Education,
Correspondence: Requests for reprints should be sent to Theodore
M. Hammett, Abt Associates Inc, 55 Wheeler Street, Cambridge, MA
02138 (e-mail: email@example.com ).
Objectives. This study
developed national estimates of the burden of selected
infectious diseases among correctional inmates and releasees
Methods. Data from surveys, surveillance, and other reports were
synthesized to develop these estimates.
Results. During 1997, 20% to 26% of all people living with HIV
in the United States, 29% to 43% of all those infected with the
hepatitis C virus, and 40% of all those who had tuberculosis
disease in that year passed through a correctional facility.
Conclusions. Correctional facilities are critical settings for
the efficient delivery of prevention and treatment interventions
for infectious diseases. Such interventions stand to benefit not
only inmates, their families, and partners, but also the public
health of the communities to which inmates return.
Although some figures have been published,1–3 comprehensive
statistics demonstrating the burden of infectious disease among
inmates have been lacking. An important "public health
opportunity" in prisons and jails has been identified by some
authors.4–7 This opportunity has yet to be fully exploited for
various reasons, including a lack of statistics as well as the
fact that prisoners are generally marginalized, despised, and
politically impotent. Political leaders and the public have not
recognized the importance of correctional settings for health
interventions. Prevention and treatment programs are extremely
uneven in quality and quantity and, in some respects,
This article presents national estimates for 1997 of inmates and
releasees with HIV infection (non-AIDS) and AIDS, hepatitis C
virus (HCV) infection, and tuberculosis (TB) disease and the
proportions of the total burden of these conditions found among
people who passed through US correctional facilities in that
year. We selected these conditions for this study because they
offered the best data for developing national estimates, and we
chose 1997 because it was the most recent year for which data
were available. The presentation of these estimates is intended
to help make a case for expanded and improved prevention and
treatment interventions in prisons and jails.9
In this study we developed national estimates of the prevalence
of selected infectious diseases among prison and jail inmates
during 1997, then applied these percentages to the number of
persons incarcerated on June 30, 1997, to estimate the number of
inmates with each condition. Next, we applied the prevalence
percentages for inmates to the total number of people released
from correctional facilities during 1997 to yield an estimate of
the number of releasees with each condition. Finally, we
calculated the percentages of the total number of people with
these conditions in the United States found among correctional
releasees in 1997. Below, we describe the methods used to
develop each of the components used in these national estimates.
Number of Correctional Facility Inmates and Releasees
The 1997 figures on state and federal prison populations and
city and county jail populations come from surveys conducted by
the Bureau of Justice Statistics (BJS). We used BJS midyear 1997
prison and jail inmate statistics as well as data on all 1997
prison releases10,11 The BJS figure on prison releases—528
848—represents a reasonable estimate of the number of different
people released from prisons, because average length of stay in
prison systems is about 2 years.
It was also necessary to estimate the number of unique
individuals released from jails during 1997. This estimate was
based on a statistical model of the frequency of arrests. The
only data available for such a model came from a special 1995
addendum to the Drug Use Forecasting (DUF) survey conducted by
the National Institute of Justice (NIJ). The DUF survey,
administered in 6 sites, provided data about recent arrests for
a sample of arrestees who were weekly or more frequent heroin
and cocaine users. Given that a negative binomial process
generates arrests, this sample averaged about 0.38 arrests per
year at liberty. (Ongoing analysis of data from 37 different
cities suggests that an average of 0.38 arrests per year is
broadly representative of this group of drug users nationally.)
This figure implies that N/1.38 unique individuals among a total
of N weekly drug users are arrested during a year. In a steady
state, the number of arrests will roughly equal the number of
jail releases. The most recent BJS estimate of jail releases is
10 million in the year 1993.12 By this logic, 10 million total
releases represents 7.2 million (10/1.38) different individuals
released from jail in 1993. Admittedly, among the universe of
arrestees, regular drug users tend to be arrested more
frequently, but the use of an overstated arrest frequency would,
if anything, yield an underestimate of different releasees and
thus an underestimate of the number of releasees with a given
infectious disease. In short, the use of the data on arrest
frequency among drug users results in more conservative
estimates of the burden of disease among releasees.
Data Sources and Estimation of AIDS and HIV Infection (Non-AIDS)
AIDS. The BJS conducts surveys that gather statistics on the
numbers of inmates with AIDS and with HIV infection. We used
these data to calculate the number of inmates with HIV who have
not yet progressed to AIDS. We used the 1997 year-end BJS
prevalence percentage (0.5%) for state/federal prison inmates
with AIDS.3 Four states did not report to the 1997 BJS survey:
for Maine and Virginia, the figures reported to BJS for 1996
were used, and for Delaware and Indiana, the average of the
figures submitted by the other states in the region was
employed. The BJS prevalence estimate for state/federal prison
inmates with AIDS was applied to city/county jail inmates. This
approach seems reasonable, given the similarities in these
populations. According to BJS statistics,11,13 these populations
are quite similar in terms of demographics: sex (jails: 90%
males; state prisons: 94%), race/ethnicity (jails: White, 37%;
Black, 41%, and Latino, 19%; state prisons: 33%, 47%, and 17%,
respectively), and age distribution (jails: aged 18 years or
younger, 18%; 25–34 years, 37%; 35–44 years, 24%; and 45 years
or older, 9%; state prisons: 20%, 38%, 29%, and 13%,
respectively). These populations also are similar in most
offense categories for which inmates are incarcerated—property
offenses (27%, 22%) and drug offenses (22%, 21%) in jails and in
state prisons, respectively—although the percentage of inmates
incarcerated for violent offenses is substantially higher in
state prisons (47%) than in jails (26%). Most jail inmates (73%)
and prison inmates (75%) have prior criminal records. Most
members of both populations have histories of drug use (82% in
jails, 83% in state prisons), and most inmates (64% in jails,
70% in state prisons) report using drugs "regularly."
Statistics on the number of persons living with AIDS in the
United States in 1997 were obtained from Centers for Disease
Control and Prevention (CDC) surveillance reports.
HIV Infection (Non-AIDS. The data on the numbers of inmates with
HIV infection (non-AIDS), based on BJS statistics, have a major
limitation: they are compiled from state/federal prison systems
with differing HIV testing policies. Only 16 state correctional
systems and no major jail systems in the United States had
mandatory HIV testing of new inmates in 1997. The majority of
state prison and city or county jail systems had voluntary or
on-request HIV testing, the aggregate results of which almost
certainly underestimate true HIV seroprevalence, because some
portion of HIV-infected inmates will not accept voluntary
testing.8 Because of this potential underestimation, we
developed a range of point prevalence rates for HIV infection
(non-AIDS). The lower bound (1.45%) was based directly on BJS
unadjusted survey data on the number of inmates with HIV
infection (non-AIDS) in 1997.3 The upper bound was obtained by
adjusting upward by 50% (or by a specific adjustment factor, if
available, for several state prison systems) the HIV
seropositivity rates reported to BJS. Adjustment factors were
based on comparisons between seropositivity rates found in
voluntary testing and in blinded seroprevalence studies. In
Maryland14,15 and California,16,17 for example, HIV
seropositivity in blinded studies was 2 to 3 times that in
voluntary testing. The size of the discrepancy depends on the
degree of encouragement by prison systems of voluntary testing
and on inmates’ receptivity to testing. Some HIVinfected inmates
may have difficulty accepting their status or fear
discrimination, mistreatment, or breach of confidentiality.
These circumstances vary across and even within systems.
For the 4 states that did not report 1997 seropositivity
statistics to BJS, the BJS seropositivity rate for the state’s
region (Delaware, Indiana) or the state’s 1996 reported data
(Maine, Virginia) were adjusted upward by 50%.
Upward adjustments were applied to the federal prison system and
to all but 4 of the states with voluntary testing. The 4
voluntary-testing states whose BJS figures were not adjusted
were New York18 and Connecticut,19,20 where seropositivity rates
reported to BJS were very close to those found in blinded
seroprevalence studies, and Oregon and Wisconsin, where
independent comparisons showed that seropositivity in voluntary
testing was very similar to seroprevalence in blinded intake
studies.21,22 All of these calculations resulted in a national
upper bound of 2.03%. The estimated range (1.45%–2.03%) was then
applied to the national total of state/federal inmates.
Because no major jail systems in the United States had mandatory
HIV testing and no breakdowns of AIDS and HIV (non-AIDS) cases
among jail inmates were available, we applied the prevalence
range for prisons to city and county jails. This choice seems
justifiable on the basis of the population similarities
We also compared the HIV prevalence range for city and county
jails with an estimate obtained by a different method.
Tabulations of data for the year 2000 from 32 counties
participating in the NIJ’s Arrestee Drug Abuse Monitoring
Program indicate that a simple average of 8% of arrestees had
injected drugs during the year before their booking. An analysis
of DUF data from 20 counties showed that injection rates were
falling by about 0.003 per year, so we assumed that 8.8% of
arrestees injected drugs during 1997. This 8.8% was multiplied
by the estimated national HIV seroprevalence among injection
drug users, based on data from 96 US metropolitan areas (14%).23
(A similar estimate of HIV seroprevalence among injection drug
users, 12.7%, comes from 1992–1993 data from 16 US metropolitan
areas.24) This calculation yielded an estimated HIV prevalence
of 1.2% among jail inmates, similar to the lower-bound estimate
based on BJS data (1.45%).
The number of persons in the total US population living with HIV
(non-AIDS) was obtained by subtracting the number living with
AIDS (from surveillance data) from a national estimate of 750
000 persons living with HIV infection. The 750 000 figure was
based on 3 published estimates: 650 000–900 000 in 1992,25 630
000–897 000 in 1993,26 and 800 000–900 000 in 1998.27
Data Sources and Estimation Methods for HCV
No national surveillance and no systematically collected
national data are available on hepatitis among inmates. However,
an indirect method of estimating HCV prevalence among inmates
exists. According to the CDC, between 72% and 86% of injection
drug users are infected with HCV28 and an estimated 24% of state
prison inmates have histories of injection drug use.29
Multiplying these 2 figures yields an estimated HCV prevalence
among inmates of 17% to 21%, assuming that sharing of drug
injection equipment is the primary risk factor for HCV among
inmates. However, this estimate may be conservative given the
prevalences of 30% to 41% found in system-specific studies in
California,17 Connecticut,30 Rhode Island,31 Washington,32 and
Therefore, we used an inmate HCV prevalence range of 17% to 25%
for this study, increasing the high end of the range from the
indirect method (17%–21%) by 4% to account for the higher
prevalences found in the system-specific studies. However, it is
also important to recognize that most of these system-specific
studies were conducted where HCV prevalence might be expected to
be higher than nationally because of generally higher rates of
injection drug use among inmates. An estimate of the total
number of people in the United States with HCV infection was
obtained from a population-based serologic survey.34
Data Sources and Estimation Methods for TB Disease
The primary source for prevalence estimates of TB disease among
inmates was the ninth National Survey of HIV/AIDS, Sexually
Transmitted Diseases (STDs), and TB in Correctional Facilities,
conducted by Abt Associates Inc for the CDC and the NIJ in
1996–1997. The survey sought data on the number of inmates under
treatment for active TB disease at the time the survey was
completed, yielding a point prevalence estimate.
Separate weighted average prevalence estimates were calculated
for prison and jail inmates based on data from 32 state/federal
prison systems and 35 city/county jail systems.
The prevalence of TB disease in the total US population in 1997
was estimated using data from the CDC’s TB registry reports and
TB surveillance reports. The TB registry reports, which provided
data on numbers of prevalent cases of TB disease, were
discontinued after 1994. For the years since 1994, only
incidence data on TB disease are available. Therefore, ratios of
prevalence to incidence for 1992, 1993, and 1994 were
calculated. The prevalence of TB disease during a given year was
taken to be the sum of cases at the start of the year and cases
added during the year. The incidence figure was taken from the
CDC’s TB surveillance reports.35 The average
prevalence-to-incidence ratio for these 3 years (.627) was
applied to the 1997 incidence figure of 19 85135 to obtain an
estimated prevalence of TB disease in that year of 31 660.
AIDS and HIV Infection (non-AIDS)
National point prevalence estimates of inmates with confirmed
AIDS and period prevalence estimates of releasees with confirmed
AIDS in 1997 are presented in Table 1, broken down by prison and
jail systems but combined for men and women. On June 30, 1997,
more than 6300 state/federal prison inmates and more than 2800
jail inmates had AIDS.
TABLE 1— —National Estimates of Inmates and
Releasees With AIDS, 1997
AIDS, %, 1997b
1 218 256
7 246 337e
1 785 335
7 775 185
District of Columbia.
from Gilliard and Beck.10
from Bureau of Justice Statistics (BJS).11
estimate of 10 000 000 jail releasees divided by
1.38. See text ("Methods") for discussion.
Also, there were more than
2600 state/federal prison releasees and more than 36 000 jail
releasees with AIDS in 1997. Thus, almost 16% of the estimated
total of 247 000 persons living with AIDS in the United States
in 199736 passed through a correctional facility that year
TABLE 3— —Estimated Burden of Infectious
Disease Among Inmates and Releasees: United States, 1997
Prevalence Among Inmates, %
No. of Inmates
Releasees With Condition
Total in US
Population With Condition
Condition as % of Total in US Population With
25 881–36 310
. . .
. . .
35 093–45 522
1 321 781-1
4 500 000c
HCV = hepatitis C virus.
from Centers for Disease Control and Prevention
based on prevalence estimate in McQuillan.34
from CDC data.35
After applying our point prevalence range of 1.45% to 2.03%,
there were between 17 000 and 25 000 state/federal prison
inmates and between 8000 and 11 000 city/county jail inmates
with HIV infection (non-AIDS) on June 30, 1997 (Table 2). Given
the same prevalence range, between 112 000 and 157 000 people
with HIV infection (non-AIDS) were released from US prisons and
jails in 1997. This estimate suggests that between 22% and 31%
of the approximately 503 000 people living with HIV infection
(non-AIDS) in the United States in 1997 passed through a
correctional facility that year (Table 3. Altogether, between
150 000 and 200 000 people with HIV infection passed through a
US correctional facility in 1997, or between 20% and 26% of all
people living with HIV in the nation that year (Table 3).
TABLE 2— —Inmates and Releasees With HIV
Infection (Non-AIDS); United States, 1997
HIV (Non-AIDS), Range
HIV (Non-AIDS), Range
HIV (non-AIDS), Range
1 218 256
17 658–24 798
6 984–10 560
7 246 377
1 785 335
25 881–36 310
7 775 185
District of Columbia.
Table 3 presents national period prevalence estimates indicating
that 17% to 25% of inmates and releasees were infected with HCV
in 1997—303 000 to 446 000 inmates and 1.3 to 1.9 million
releasees respectively. These estimates combine prison and jail
systems. The estimate of 1.3 to 1.9 million releasees with HCV
suggests that 29% to 43% of people with HCV infection in the
United States passed through a correctional facility in 1997.
Table 3 presents point prevalence estimates of state/federal
prison inmates (0.04%) and city/county jail inmates (0.17%)
undergoing treatment for TB disease as of June 30, 1997—more
than 1400 inmates. Applying the estimated prevalences among
inmates to releasees indicates that more than 200 people who had
active TB disease during 1997 were released from state/federal
prisons in that year, whereas more than 12 000 people who had TB
disease during 1997 were released from city/county jails that
year. This application, in turn, suggests that almost 40% of the
31 000 persons who had TB disease in the United States in 1997
passed through a correctional facility that year.
Estimates of the numbers of inmates and releasees with selected
infectious diseases and the percentages of the total burden of
these diseases among persons passing through US correctional
facilities are extremely high. These high estimates are driven
principally by the large number of people being released from
correctional facilities and especially from jails—jail releasees
are estimated to number more than 7.2 million annually.
The estimates presented here are subject to several general and
disease-specific limitations. Because they are based on
incomplete data, the findings should be considered rough
estimates of the burden of these infectious diseases in
correctional populations. It is impossible to develop precise
statistics, because a lack of systematic surveillance has
resulted in few observations on which prevalence estimates could
be based. Indeed, the lack of such data is strong evidence that
surveillance must be undertaken or enhanced for this critical
population and that surveillance data must be used to shape
The estimates are based primarily on data from state and federal
prison systems. The application of the prison prevalence
estimates to jail populations may be questioned, although some
comparisons were presented which suggested that this is a
The prevalence estimates for AIDS and HIV infection are combined
for males and females because most of the statistics on which
the estimates are based do not provide breakdowns by sex.
However, numerous system-specific studies have shown HIV
seroprevalence to be higher among female than among male
inmates.37 The BJS 1997 survey3 discussed previously found that,
across all state and federal prison systems reporting HIV test
results, 3.4% of female inmates were HIV-positive, and 2.2% of
Prevalence statistics for inmates by race and ethnicity are
generally lacking, so it was not possible to develop estimates
of disease burden by racial and ethnic group. However, the
disproportionate incarceration rates experienced by African
Americans and Latinos and the already disproportionate burden of
the diseases under study among the same groups combine to
produce a situation in which the vast majority of inmates and
releasees with these infectious diseases are African American or
Latino. In New York State correctional facilities, 48% of
inmates diagnosed with AIDS in 1997 were Black and 45% were
Hispanic, compared with the proportions of these groups in the
total population of the state of 18% and 14%, respectively.38,39
The study also relied on data reported by correctional systems
that may not be based on standard case definitions and may be
otherwise inaccurate or incomplete.
There are several limitations of the estimates of correctional
populations on which the disease burden estimates are based. The
methodology for estimating the number of unique jail releasees
depended on data regarding frequency of arrests among regular
drug users in 6 sites during a single year. Although these
estimates seem reasonable based on other available evidence,
they are unlikely to be a perfectly accurate representation of
the rates among all arrestees nationally. Still, the actual
arrest rates would have to be much higher to have a material
effect on the conclusions of this study, which is unlikely to be
The estimates may reflect some double counting between prison
and jail populations. However, these duplications should not be
great because prison terms are typically longer than 1 year;
therefore, few people would be released from a jail and a prison
during the same year.
Because the estimates for releasees are based on total numbers
of persons released during a full year (period prevalence), an
especially high figure for jails, they are much higher than the
estimates for inmates which are based on the correctional
population on a given day (point prevalence). Statistics on
total numbers of individuals incarcerated during a full year are
There are also several disease-specific limitations to consider.
First, the estimates presented here are for 1997, when highly
active antiretroviral therapy for HIV was only beginning to be
introduced. Thus, in subsequent years, the numbers of inmates
with AIDS diagnoses may have declined, as occurred in the total
population, but this decline would probably have been
counterbalanced by an increase in the number of persons living
with HIV infection (non-AIDS). A second limitation is that the
estimated range of inmate HCV prevalence presented here
(17%–25%) is lower than prevalences found in virtually all
studies of specific correctional systems, so these estimates may
be at the low end. Third, although the estimates of TB disease
are based on incomplete data, an independent check suggests that
these data are reasonably accurate. According to CDC
surveillance data, 728 TB cases were diagnosed among
correctional inmates in 199735; this figure is quite close to
the figure of 768 inmates reported in the 1996–1997 NIJ/CDC
survey to be undergoing treatment for active TB disease.
However, the overall incidence of TB disease in the United
States has declined since 1997. Finally, the estimate of
releasees with TB disease was calculated by applying a point
prevalence rate for inmates (i.e., the percentage of inmates
under treatment for TB disease on a given day in 1997) to the
total number of releasees during the full year of 1997. This
does not mean that all of these releasees had TB disease at the
time of their release from prison or jail. In fact, most of them
probably did not have TB disease at the time of their release,
because if properly treated, TB disease typically lasts only a
short time. Nevertheless, the estimate indicates the congruence
between populations likely to be incarcerated and those likely
to have TB disease.
The estimates summarized in Table 3 demonstrate that the burden
of infectious disease among correctional inmates and people
being released from US correctional facilities is strikingly
heavy. A disproportionate share of the burden of AIDS, HIV
infection (non-AIDS), HCV infection, and TB disease is found
among people who pass through correctional facilities. During
1997, about 3% of the US population spent time in a correctional
facility. By contrast, between 16% and 43% of the burden of
these infectious diseases was found in this relatively small
segment of the population. The qualifications noted above, even
if they all suggested some downward revision of the estimates,
would not substantially change the estimates or the conclusions
to be drawn from them.
The policy implications of these findings are clear.
Correctional facilities are critical settings in which to
provide interventions for the prevention and treatment of
infectious diseases. Moreover, rates of many other health
problems among inmates are also high. A recent report to
Congress demonstrates that correctional populations are heavily
burdened by STDs, current or chronic hepatitis B infection,
chronic diseases, and mental illness.40
As noted, the bulk of infectious disease in correctional
populations is found among persons passing through city and
county jails. Because of the generally short lengths of stay of
jail inmates—many of whom are being detained prior to trial as
opposed to serving sentences and are often released after only a
few hours in custody—and the rapid turnover of jail populations,
mounting effective interventions in jails is particularly
challenging. However, it can be done. The public health model of
correctional health care developed at the Hampden County,
Massachusetts, Correctional Center gives evidence that a jail
can provide high-quality prevention, diagnostic, and treatment
services to a large and fluid inmate population.41 Correctional
interventions of this kind stand to benefit not only inmates
themselves and their families and partners, but also the public
health of the communities to which the vast majority of inmates
This research was supported by the National Commission on
Correctional Health Care (NCCHC), the National Institute of
Justice, and the Centers for Disease Control and Prevention
(CDC). This article represents an updated and condensed version
of a background paper prepared for the NCCHC and submitted as
part of a 2002 report to Congress.40 The Bureau of Justice
Statistics of the US Department of Justice collected much of the
data on which the estimates and prevalences presented here are
based. The authors are grateful to the following for their
comments on the draft and various versions of the article:
members of the Expert Panel on Communicable Diseases, Health
Needs of Soon to be Released Inmates Project, NCCHC; Robert
Greifinger MD, former Project Director, Health Needs of Soon to
be Released Inmates Project, NCCHC; John Miles, MPA, and Karina
Krane Rapposelli, MPH, Office of the Director, National Center
for HIV, STD, and TB Prevention, CDC; Mark Lobato, MD, Division
of TB Elimination, CDC; Patrick Coleman, PhD, Hepatitis Branch,
Division of Viral and Rickettsial Diseases, National Center for
Infectious Diseases, CDC; and Allen Beck, Bureau of Justice
Statistics, US Department of Justice.
Human Participant Protection
No protocol approval was needed for this study.
T. M. Hammett was principal investigator of the study and lead
author of the paper; M P. Harmon conducted most of the data
analyses; and W. Rhodes contributed important analytic concepts
and designed and carried out several specific analyses.
Accepted for publication January 18, 2002.
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