# Presentation: 460877

## Collateral Damage : Incarceration, HIV and Vulnerable Communities

**Andrew H. Kaplan, MD**
**David A. Wohl, M.D.**
**UNC Prison Working Group**
**UNC School of Medicine**

## Overview

**Setting**
**Spread of HIV Within Prison**
**Medical Treatment in Prison**
**HIV Testing in Prison**
**Jails**

## Acknowledgements

**Ada Adimora**
**Michael Bowling**
**Joanne Earp**
**Cathie Fogel**
**Carol Golin**
**Lisa Hightow**
**Maria Khan**
**Tasseli McKay**
**David Rosen**
**Anna Scheyett**
**Vic Schoenbach**
**Becky Stephenson**
**Sharon Weir**
**Kate Whetton**
- David Wohl

## Funding/Support

**NIMH - Chris Gordon, Andrew Forsyth, David Stoff and Dianne Rausch**
**NIDA - Elizabeth Lambert**

## Two Epidemics 

**African-Americans in the U.S. are acquiring HIV at rates that are several-fold higher than among whites.**
**60% of the prison population are racial or ethnic minorities.**
**An estimated 12.6% of all African-American men between 25 and 29 are in prison or jail.**
**The prevalence of HIV among inmates is 8 - 10 fold higher than among the general population.**

## Impact of Incarceration :Society

**Diversion of resources**
**3 million children have a parent in prison**
**Morally corrosive effect of the prison-industrial complex**

## Impact of Incarceration : National

**2 million people incarcerated at any one time in US - about a 300% increase since 1980**
**600,000 people released  every year**
**10,000,000 people pass through the jail system every year**
**Twenty percent of the HIV-infected people in the US pass through the correctional system every year**
**If current trends continue, 5% of the population can expect to spend at least one night in jail during their lifetime**

## Impact of Incarceration : Community

**Gender ratios - African American men (13%) of US population account for about 60% of prison inmates.**
**One-third of AA men between the ages of 20 and 29 are under correctional supervision**
**Normalization of incarceration and effect on normative community values of sex, violence and drug use**

## HIV+ men and women are more likely to have partners who have been incarcerated

- In a study of 244 African-American men and women with and without HIV infection in North Carolina:
**HIV+ men were 6x more likely to have had a sexual partner who had been incarcerated in previous year than HIV- men**
**HIV+ women were 4x more likely to have had a sexual partner who had been incarcerated in previous year than HIV- women**
**Eighty-one percent of HIV+ women reported that one of their last 3 sex partners had been incarcerated.   **
**Further, 24% of HIV+ women and 65% of HIV+ men had themselves been incarcerated during the past 10 years.**** **
- (Adimora A, et al, JAIDS 2003)

## Impact of Incarceration : Individual

**Employment prospects**
**Benefit eligibility**
**Disrupted social/family networks**
**Brutalizing experience**
**HIV transmission within prison**

## Who is getting incarcerated?

## Variability in Reporting

| Source | Type  | Prevalence |
| --- | --- | --- |
| BJS, 1997 | Physical/sexual abuse ever
Rape, prior to incarceration | 40-57%
21-37% |
| Fogel & Belyea,    
                   1999

                   2001 | Past partner violence
Repeated physical abuse by 
     partner/someone important
Forced sex by partner
Feared partner
Physical violence in year prior to 
     incarceration | 90%
70%

49%
25%
70% |
| Harris et al., 2003 | Physical/sexual abuse
Intimate partner abuse
Forced sex
Feared partner | 65%
33.9%
16%
17.5% |
| Bedard et al., 2003 | Physical/sexual abuse | 3-4 times national rate |

**Variability in Reporting**

**Notes:**
BRIEFLY emphasize variability in reporting, as well as different measures used
As within the general population, prevalence rates of violence/abuse also vary for incarcerated females. 
BJS = Bureau of Justice Statistics

## Violence against women

- 98 women hit in prior year, at an average of 32 times

**Notes:**
Prevalence and frequency of certain types of abuse
In relation to ‘host’, prevalence of certain types of abuse are shown here.  Quantitative findings about frequency of these types of violence/abuse augment the prevalence findings (click) (click).   Some qualitative findings also support the quantitative findings (click) (click) 

## Violence against women : Agent

**Notes:**
these convergent findings relate to ‘vector/agent’ (who committed the action, and how it was done)
Partners are common perpetrators in their lives
(click) (click) (click) (click)

## HIV Transmission Within Prison

**HIV Transmission Within Prison**

## Sexual Network

**Sexual**** ****Network**

## HIV Transmission Among Inmates in the Georgia State Prison (MMWR April 21, 2006 / 55(15);421-426)

**In 1988, the Georgia Department of Corrections (GDC) initiated mandatory HIV testing of inmates upon entry into prison and voluntary HIV testing of inmates on request or if clinically indicated.**
**From 1988-2005, 88 male inmates had a negative HIV test on entry and a subsequent confirmed positive HIV test result during incarceration.**
**GDC house 44,990 male inmates; median age is 34 years (range: 15--88 years) and 63% are black.**
**A total of 856 (1.9%) were known to be HIV infected, of whom 732 (86%) were black.**

## HIV Transmission Among Inmates in the Georgia State Prison (MMWR April 21, 2006 / 55(15);421-426)

**Among 54 inmates reporting male-male sex while in prison, 39 (72%) reported no male-male sex during the 6 months before incarceration.**
**Among these, 72% reported consensual sex and 89% reported sex with other inmates. **
**Of 43 inmates who reported any consensual sex, 30% reported using condoms or other improvised barrier methods (e.g., rubber gloves or plastic wrap). Of 14 inmates who reported exchange sex, three reported using improvised barrier methods but not condoms.**
**No barrier methods were used during rape.**

## Slide 19

## Medical Treatment in Prison

## Pregnancy Outcomes are Better for Incarcerated Women

## Viral Load Increases Among HIV+ Recidivists

**HIV-1 RNA (copies/ml)**

- Stephenson B, Wohl D et al 13th World AIDS Conf, Durban. 2000

## HIV Testing in Prison

**Only 19 state prison systems enforce mandatory HIV testing**
**In 31 states, HIV testing is voluntary**

## Special circumstances: Jails

**Only 25% of county jails tested more than one person for HIV/month.**
**In 75% of jails, the health screening form was administered in a common area, typically to a group of inmates.**
**Corrections officers administered the screening forms in 93% of the jails and dispensed medication in 81% of the jails.**
**Virtually all of the medical staff and officers agreed with the statement “If  an inmate is taking medications in jail, other inmates will know about it.”**