Oct.1, 1996

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"Prison walls effectively restrain criminals, but not the AIDS virus," says Ronald L. Braithwaite, Ph.D., of the Rollins School of Public Health, Emory University, in his new book Prisons and AIDS (Jossey-Bass Inc. Publishers, San Francisco, 1996).

Along with co-authors Theodore M. Hammett, Ph.D., and Robert M. Mayberry, Ph.D., Dr. Braithwaite quantifies and comments on the pervasiveness of HIV infection and AIDS among inmates in United States correctional facilities. The book is based largely on research funded by the U.S. Centers for Disease Control and Prevention and the National Institute of Justice, U.S. Department of Justice.

The picture the authors paint is at first glance bleak; AIDS incidence is much higher in the prison population than in the U.S. population as a whole. But as public health practitioners, the authors see the advantages in targeting prevention and education messages to this high-risk group.

"Administrators, health, and mental health workers in prisons and jails have a unique opportunity to assist inmates -- who are literally a 'captive audience' and thus at least logistically easier to reach than similar at-risk populations in the community -- with health care, prevention, education, and substance abuse treatment," the authors say. "Better HIV/AIDS, TB (tuberculosis), and STDs (sexually transmitted diseases) prevention programs and medical care in prisons and jails will also benefit the larger society, since the vast majority of inmates return to the community."

Dr. Braithwaite is associate professor of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University. Dr. Hammett is a vice president at Abt Associates Inc., a policy research firm headquartered in Cambridge, Mass. Dr. Mayberry is director of the Morehouse Medical Treatment Effectiveness Center and is an associate clinical professor in the Department of Community Health and Preventive Medicine, Morehouse School of Medicine.

The excerpts below illustrate some of the complicated realities and avenues of possible relief outlined by the authors in Prisons and AIDS:

  • "In 1991, 4,000 of New York State's 8,000 inmates who were HIV positive were released. Additionally, because of overcrowding with prisons the 'revolving door' phenomenon is common, where inmates appear to be rotated in and out of the correctional system."

  • AIDS INCIDENCE: "AIDS incidence rates are significantly higher among correctional inmates than in the total population. The annual AIDS incidence rate in the total U.S. population in 1994 was 31 cases per 100,000 population... In state/federal systems in 1994, the aggregate AIDS incidence rate... was 518 cases per 100,000....The aggregate incidence rate for reporting city/county jail systems was 706 cases per 100,000 inmates in 1994..."

  • AIDS INCIDENCE: "AIDS incidence rates are significantly higher among correctional inmates than in the total population. The annual AIDS incidence rate in the total U.S. population in 1994 was 31 cases per 100,000 population... In state/federal systems in 1994, the aggregate AIDS incidence rate... was 518 cases per 100,000....The aggregate incidence rate for reporting city/county jail systems was 706 cases per 100,000 inmates in 1994..."

  • TOTAL AIDS CASES: "A cumulative total of 11,565 AIDS cases had been reported among inmates in U.S. federal, state, and larger city/county correctional systems as of November 1992... Based on this minimum estimate, at least 4.6 percent of the U.S. cases of AIDS through 1993 occurred among inmates."

  • TOTAL AIDS DEATHS: "... 4,588 inmates in the reporting correctional systems had died of HIV/AIDS as of December 1994... the figure represents 2 percent of the cumulative total HIV/AIDS deaths reported in the U.S. through June 1994 (240,323)."

  • CURRENT AIDS CASES - ADULTS: "In 1994, 47 states and federal prison systems reported 4,827 current cases, an increase of 59 percent over the 1992-1993 survey."

  • CHARACTERISTICS OF INMATES WITH HIV/AIDS: "...racial/ethnic breakdowns of AIDS cases in responding state/federal systems as 43 percent black, 38 percent white and 13 percent Hispanic. This compares with the distribution among total cumulative AIDS cases in the U.S. population of 50 percent white, 32 percent black and 17 percent Hispanic... data from other sources indicate that injection drug use is probably the most common exposure category in inmate AIDS cases."

  • MINORITY INMATES: "The picture of AIDS in correctional facilities is even grimmer for ethnic minorities... African-Americans have been described as the 'second wave' of the AIDS epidemic. They make up 12 percent of the nation's population but 28 percent of the nation's AIDS patients... The institutionalized racism that contributes to the increase of the AIDS epidemic among ethnic minorities in correctional facilities is most clearly reflected when the criminal justice system's view of illicit drugs is considered. The national control strategy stresses incarceration as a method to control the supply of illicit drugs and treat drug abuse. The strategy is failing. The system is failing to incarcerate across color lines (differential sentencing), and those who are incarcerated are not receiving adequate treatment."

  • JUVENILE INMATES: "For the first time in 1994, the NIJ/CDC survey covered juvenile systems. A cumulative total of 60 juveniles with AIDS was reported (50 boys and 10 girls, 54 in state and 6 in county systems). Although rates of HIV disease are not currently very high among adolescents, other sexually transmitted diseases are more prevalent, which indicates that adolescents are at risk for HIV infection, and that more HIV among adolescents in the future is likely."

  • WOMEN INMATES: "... incarceration rates are rising faster among women than men, and women in prisons and jails 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 (for example, exchanging sex for drugs and/or money) have placed many women at elevated risk for HIV/AIDS... The Massachusetts study (of 87 women recruited through the infectious disease clinic at Massachusetts Correctional Institution, Framingham; 70 percent of whom were HIV seropositive), found that injection drug use, commercial sex work, a history of childhood sexual abuse, and a history of genital or anal warts were all predictive of HIV seropositivity. Perhaps the most important finding of this study is the strong association between sexual abuse and risk-taking behaviors related to HIV. These findings indicate the importance of incorporating counseling for survivors of sexual abuse in HIV prevention programs for women."

  • MALE INMATES: "The vast majority of inmate AIDS deaths and current AIDS cases continue to occur among men. Ninety-six percent of cumulative AIDS deaths and 91 percent of current inmate AIDS cases in 1994 were among males..."

  • HIV TRANSMISSION IN PRISONS: "HIV transmission among correctional inmates remains a matter of serious concern. Indisputably, sex, injection drug use, and tattooing are occurring in prisons and jails regardless of prohibitions against all these activities. Condoms are not officially available to inmates in most correctional systems. In the absence of condoms, inmates may use and reuse such expedients as fingers cut from latex surgical gloves... Rape and other forms of nonconsensual sex are particularly serious issues demanding serious responses from correctional systems, independently of the issue of HIV transmission... Research from Britain suggests that injection drug use is less common in prisons than on the outside but considerably more risky, because the very shortage of needles that reduces prevalence of use also increases sharing... When needles are not available, pieces of pens and light bulbs are sometimes used by inmates to inject drugs.... Tattooing is a common practice in prisons and jails. Given the shortage of sterile needles, it is often done with guitar strings and other expedient materials.

  • "...75 percent of adult inmates believe that HIV is transmissible by casual contact... one study indicated that 91 percent of inmates believe AIDS is curable..."

  • CURRENT AIDS EDUCATION AND PREVENTION EFFORTS: AIDS prevention training geared toward parolees with histories of injection drug use; training included learning skills, self-help, community therapeutics and job training...prison-based drug abuse treatment... in-jail voluntary AIDS education curriculum among inner-city adolescents... promotion of abstinence as means of AIDS prevention in youth... peer drug and alcohol prevention programs for youth offenders... condom and dental dam distribution... bleach availability... HIV posttest counseling... pregnancy testing for juveniles... post-release methadone maintenance treatment..."

  • "...The public at large will be protected to the highest degree possible in a system where public health and corrections coordinate their activities toward reducing HIV infection... Historically, the public health profession has been based on social justice. Today, public health professionals must rise to the challenge of advocating for improving inmates' health for the sake of the inmates and all of society. From a public health perspective, the availability of clean needles, condoms, and bleach within correctional institutions would reduce the risk of HIV transmission in those settings. From the correctional point of view, items usable to prevent the spread of AIDS are potential weapons for inmates or could be used to smuggle contraband..."

  • "Building more prisons is certainly not the answer to combating AIDS within correctional facilities. On the contrary, less money invested in prisons would allow for society to invest in combating social factors... that contribute to high-risk behavior in relation to HIV/AIDS. As a society, we need to confront the issues... that are plaguing the disproportionate number of ethnic minorities in correctional facilities. When we meet this challenge as a society, we will see a decline in AIDS cases in and out of correctional facilities."

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