Florida Corrections Commission 1998 Annual Report

http://www.fcc.state.fl.us/

5.0. HIV/AIDS in Corrections

5.1. 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)

*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)

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

*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

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

2. 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

3. 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

4. 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

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:

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

Table 5-F

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