What Is the Role of Prisons in HIV, Hepatitis, STD and TB Prevention?
What is the impact of infectious disease and incarceration?
Incarcerated people are our neighbors. Jail and prison populations have doubled in the US in the past ten years. Overcrowding and understaffing are legion in correctional systems. Inmates are admitted and released frequently, making them active participants in the community. As more people pass in and out of jail and prison, so too do problems and infectious diseases associated with incarceration, like HIV, tuberculosis (TB), hepatitis B and C (Hepatitis C Virus) and sexually transmitted diseases (STDs).
Rates of many diseases are higher for the incarcerated than for the total US population. Among the incarcerated, rates of HIV are 8-10 times higher, rates of hepatitis C are 9-10 times higher and rates of TB are 4-17 times higher than rates for the general public. This underscore the need for prevention and treatment for the incarcerated.
Are prisoners at risk for disease?
Yes. Most inmates with infectious diseases come to jail or prison already infected. There is some evidence that infection also occurs during incarceration, especially with TB, which is transmitted in close quarters, and Hepatitis C Virus which is fairly easily transmitted.
Injection drug use, other illicit drug use, unprotected sex and tattooing are all risk behaviors that may occur during incarceration. A report of estimated risk behaviors among males in a California prison showed tattooing to be the most prevalent risk-related activity. High rates of unprotected sex and injecting drug use (IDU) were also reported.
The main reason for incarceration for Federal prisoners is drug offenses, increasing from 58% of the total prison population in 1991 to 63% in 1997. Drug use also increased, from 60% of Federal inmates in 1991 reporting using illicit drugs at some time, to 73% in 1997. In addition, drug offenders are now more likely to be incarcerated and for longer amounts of time: the average sentence increased from 47 to 80 months between 1980 and 1994. It is not surprising that high rates of HIV and Hepatitis C Virus infection occur in this population.
The cycle of incarceration is a way of life for many prisoners who have been in and out of the criminal system since adolescence. During incarceration, all activities are scheduled and behavior is strictly regulated. This atmosphere doesn't help inmates learn how to be responsible for their own behaviors, which is critical in disease prevention. Also, many underlying problems that led to incarceration, such as histories of violence, sexual abuse, addiction or mental disability, are associated with increased risk for infectious diseases.
Why prisons and jails?
The incarcerated are the only population in the US that has a constitutional right to health care. Many inmates have little or no access to health care outside of correctional systems and unfortunately may only have these health care needs addressed while in prison or jail. There are many opportunities for preventing, testing for and treating infectious diseases while inmates are incarcerated.
Prisons and jails would seem to be an ideal venue for drug treatment and education. There are more IDUs in correctional facilities in the US than in drug treatment centers, hospitals, or social service agencies. In 1997, only 13% of all State prisoners and 15% of all Federal prisoners who used drugs regularly had received drug treatment since admission. Drug treatment has declined since 1991, when 34% and 31% of State and Federal prisoners were in treatment. Lack of outreach and program information to prison staff may have contributed to limited implementation.
Screening for STDs or hepatitis in jail or prison systems in the US is spotty, even though inmates are disproportionately affected by these diseases. Prisons and jails may be reluctant to offer voluntary HIV testing because they know that if a prisoner tests positive, he or she must have access to costly medications. Testing for TB is more prevalent, with 92% of prison systems and 51% of jail systems screening all incoming inmates for TB.
What are obstacles to prevention?
Laws governing prison conduct can be barriers to disease prevention. Sexual activity (including consentual sex, rape, gang rape and survival sex), drug use and tattooing are illegal in prisons and jails; nevertheless, these activities occur. The vast majority of correctional facilities prohibit condom possession or distribution. All facilities prohibit possession of needles and syringes. Therefore, inmates who engage in risky sexual and drug use activities have no means to protect themselves from disease.
Prisoners often want to celebrate their release by engaging in activities that were not allowed while incarcerated. Often these activities pose high risk for infectious diseases. A study of Latino inmates in a California prison found that 51% reported having sex in the first 12 hours after release. Inmates also indicated the desire for "pure" sex (without condoms). In addition, 11% reported injecting drugs in the first day after release.
What is being done?
At the only prison facility in the state of Rhode Island, a comprehensive program addresses prisoners' needs while incarcerated as well as after their release. The program involves routine HIV testing for all entering inmates. For HIV+ prisoners, it includes comprehensive HIV care including antiretroviral medications, gynecological screening and substance abuse counseling. Discharge planning links ex-inmates to community-based services. After discharge, 83% of HIV+ women follow-up with medical care, and 68% make contact with a community-based drug treatment program.
The Hampden County Correctional Center in Massachusetts has developed a community-based health care delivery system that links inmates with education and health care while incarcerated and following their release. Physicians from inmates' local neighborhood health care center come to the jail to provide treatment and see the same clients after release. Case managers follow HIV+ inmates with discharge plans, and a full-time nurse works with seriously or chronically ill inmates. This system has proven cost effective, has led to a lower rate of re-incarceration and has increased the number of released inmates receiving medical care.
Centerforce Health Programs Division works with prison staff and inmates to provide comprehensive HIV, hepatitis and STD prevention and education at two California state prisons. Trained inmate peer educators deliver orientations for all incoming prisoners and, along with Centerforce staff, provide secondary prevention and education for HIV+ inmates. They also offer prevention case management for all pre-release inmates. Centerforce organizes health promotion fairs for all pre-release inmates to meet with community service providers. Men who received pre-release education were significantly more likely to use a condom the first time they had sex after release.
What still needs to be done?
Effective prevention for inmates requires collaboration between inmates, corrections staff, public health and community-based service organizations. This requires hard work, as these institutions often harbor distrust of each other and may have different missions. Involving inmates or former inmates as peer educators is essential for education and advocacy. Educational, social, psychological and medical services need to collaborate as well, because many inmates are triply diagnosed with infectious diseases, substance abuse and mental illness.
Prevention efforts need to begin the minute inmates enter the facility and continue post release. Discharge planning can help ensure better care for inmates once they have rejoined the community. Also, ongoing training and education for prison staff is key for ensuring that programs are consistent and sustainable within institutions.
Substance abuse treatment-both within prisons and jails and in the community after release-is critically important. Laws that prevent inmates' access to condoms and clean needles must also be challenged. Voluntary screening and testing for HIV, STDs, TB and hepatitis should be available, and all inmates who test positive, including IDUs, must have access to comprehensive treatment for HIV, Hepatitis C Virus and other infections.
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AIDS Education Project
ACLU National Prison Project
1875 Connecticut Avenue NW, Suite 410
Washington, DC 20009
phone: (202) 234-4830
fax: (202) 234-4890
AIDS in Prison Project
135 East 15th Street
New York, NY 10003
phone: (212) 673-6633
fax: (212) 780-9878
HIV in Prison Committee
California Prison Focus
940 l6th Street, #307
San Francisco, CA 94103
phone/fax: (510) 6651935
PREPARED BY BARRY ZACK MPH*, TIMOTHY FLANIGAN MD**, PAMELA DECARLO***
*CENTERFORCE, **BROWN UNIVERSITY, ***CAPS
August 2000. Fact Sheet #13ER
Reproduction of this text is encouraged; however, copies may not be sold, and the Center for AIDS Prevention Studies at the University of California San Franciso should be cited as the source of this information. For additional copies of this and other HIV Prevention Fact Sheets, please call the National Prevention Information Network at 800/458-5231. Comments and questions about this Fact Sheet may be e-mailed to FactsSheetM@psg.ucsf.edu. © August 2000, University of California