Title: 1996-1997 Update: HIV/AIDS, STDs, and TB in Correctional
Facilities.
Series: Issues and Practices
Author(s): Theodore M. Hammett, Patricia Harmon, and Laura M.
Maruschak
Published: July 1999
Subject(s): HIV/AIDS in correctional facilities, inmate education programs, inmate health care,
jails and jail inmates, and HIV/AIDS
131 pages
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U.S. Department of Justice
Office of Justice Programs
National Institute of Justice

Issues and Practices

1996-1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

National Institute of Justice
Centers for Disease Control and Prevention
Bureau of Justice Statistics

HEALTH AND JUSTICE

-------------------------------

U.S. Department of Justice
Office of Justice Programs
810 Seventh Street N.W.
Washington, DC 20531

Janet Reno
Attorney General

Raymond C. Fisher
Associate Attorney General

Laurie Robinson
Assistant Attorney General

Noel Brennan
Deputy Assistant Attorney General

Jeremy Travis
Director, National Institute of Justice

Office of Justice Programs
World Wide Web Site 
http://www.ojp.usdoj.gov

National Institute of Justice
World Wide Web Site
http://www.ojp.usdoj.gov/nij

-------------------------------

U.S. Department of Justice
Office of Justice Programs
National Institute of Justice 

1996-1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

by 
Theodore M. Hammett, Ph.D. 
Patricia Harmon 
Abt Associates Inc.
and 
Laura M. Maruschak
Bureau of Justice Statistics

July 1999
NCJ 176344

-------------------------------

Issues and Practices in Criminal Justice is a publication series of the
National Institute of Justice. Each report presents the program options and
management issues in a topic area, based on a review of research and
evaluation findings, operational experience, and expert opinion on the
subject. The intent is to provide information to make informed choices in
planning, implementing, and improving programs and practice in criminal 
justice.

-------------------------------

National Institute of Justice

Jeremy Travis
Director

Cheryl Crawford
Program Monitor

National Center for HIV, STD, and TB Prevention Centers for Disease
Control and Prevention

Helene D. Gayle, M.D., M.P.H.
Director

Bureau of Justice Statistics

Jan M. Chaiken, Ph.D.
Director

-------------------------------

Prepared for the National Institute of Justice, U.S. Department of Justice
by Abt Associates Inc., under contract No. OJP-94-C-007. Points of view
or opinions stated in this document are those of the authors and do not
necessarily represent the official position or policies of the U.S.
Department of Justice.

The National Institute of Justice is a component of the Office of Justice
Programs, which also includes the Bureau of Justice Assistance, the
Bureau of Justice Statistics, the Office of Juvenile Justice and Delinquency
Prevention, and the Office for Victims of Crime.

-------------------------------

Foreword

HIV/AIDS, sexually transmitted diseases, and tuberculosis, as well as a
range of other health problems disproportionately found among inmates
and ex-offenders, pose serious challenges for corrections administrators,
health service providers, and public health officials. These problems also
present opportunities to intervene with effective prevention and treatment,
thereby benefiting inmates and those close to them as well as the larger
community.

To meet these challenges corrections and public health agencies must
work closely together with community-based organizations. 

The findings presented in this 1996-1997 Update report suggest that there
have been substantial improvements in many aspects of the policy
response to HIV/AIDS, STDs, and TB in correctional facilities. Much
work is still needed in comprehensive prevention programs, discharge
planning, community linkages, and continuity of treatment. The study also
shows increasing collaboration among correctional, public health, and
community-based agencies, but far more is needed.  

The three agencies that have sponsored and conducted the research
presented in this Update--the National Institute of Justice (NIJ), the
Centers for Disease Control and Prevention (CDC), and the Bureau of
Justice Statistics (BJS)--are committed to collaboration in research on
HIV/AIDS, STDs, and TB in correctional facilities and to collection and
dissemination of information that will foster comprehensive and
cooperative responses in policy and practice. This Update, for the first
time, combines in one volume the latest statistics on the extent of HIV
infection and AIDS among inmates from BJS surveys with the findings on
policy and practice from the ongoing series of national surveys sponsored
by NIJ and CDC.

We hope that the expanding collaboration in research and dissemination
represented by this report presages further increases in operational
collaborations for the development and implementation of model
HIV/AIDS, STD, and TB prevention and treatment programs in
correctional settings.

Jeremy Travis
Director 
National Institute of Justice

Helene D. Gayle, M.D., M.P.H.
Director
National Center for HIV, STD, and TB Prevention Centers for Disease
Control and Prevention

Jan M. Chaiken, Ph.D.
Director
Bureau of Justice Statistics 

Acknowledgments

It is a pleasure to acknowledge the many people who have been
instrumental in the preparation of this 1996-1997 Update report. At Abt
Associates, Tricia Harmon carried out all of the analyses of the survey
with great skill and thoroughness, David Deal managed the ninth NIJ/CDC
survey of correctional systems, Michael Gross reviewed and commented
upon earlier drafts of Abt's chapters, Mary Ellen Perry and Kim Kolosiej
provided expert word processing services, and Wendy Sanderson did the
camera-ready production.

At the Bureau of Justice Statistics, the statistical agency of the U.S.
Department of Justice, Allen J. Beck supervised the preparation of chapter
1 of the report. Christopher J. Mumola and Lauren E. Glaze provided
statistical review. Tom Hester and Yvonne Boston edited the chapter. Data
collection and processing for the National Prisoner Statistics Program
were carried out by Tammy Anderson under the supervision of Gertrude
Odom and Kathleen Creighton, Demographic Surveys Division, U.S.
Bureau of the Census.

Cheri Crawford was the National Institute of Justice project monitor for
Abt's portion of the project, participating in site visits and providing useful
comments and support throughout the preparation of the report. Lori de
Ravello and Mark Lobato of the Centers for Disease Control and
Prevention provided useful comments on the draft report. Juarlyn Gaiter of
CDC participated in several site visits and provided very helpful input.
John Miles was the CDC project monitor, participated in a number of the
site visits, and has been a steadfast supporter of interventions for the
prevention and treatment of infectious diseases and other health problems
among correctional inmates.

Finally, we acknowledge the valuable contributions of many staff
members in the agencies that participated in the site visits for this project:
California Department of Corrections, Centerforce and Center for AIDS
Prevention Studies at the University of California, San Francisco;
Louisiana Department of Corrections and Office of Public Health; New
York City Department of Corrections and Department of Health; San
Francisco County Sheriff's Department and Forensic AIDS Project, San
Francisco Department of Public Health; Los Angeles County Juvenile
Court Health Services and JWCH Institute; and Massachusetts Department
of Youth Services.

Theodore M. Hammett, Ph.D.
Abt Associates Inc.

Laura M. Maruschak
Bureau of Justice Statistics

Table of Contents

Foreword 

Acknowledgments

Executive Summary
--HIV/AIDS: Burden of Disease Among Inmates
--Sexually Transmitted Diseases and Hepatitis: Burden of Disease Among
Inmates
--HIV and STD Education and Behavioral Interventions
--HIV Transmission and Risk Factors, Precautionary and Preventive
Measures
--Counseling and Testing, Confidentiality, and Disclosure
--Housing and Correctional Management
--Medical Treatment and a Continuum of Care
--Tuberculosis (TB)
--Legal and Legislative Issues

Introduction
--HIV/AIDS in the U.S. Population
--The 1996-1997 Update: Contents and Sources
--Endnotes

Chapter 1: HIV in Prisons and Jails, 1996
--Key Findings
--Trends in HIV Infection in U.S. Prisons
--Confirmed AIDS Cases in U.S. Prisons
--Comparison to the U.S. Resident Population
--HIV Infection of Male and Female State Prison Inmates
--AIDS-Related Deaths in State Prisons
--HIV-Prevalence Rates and Testing Policies
--HIV/AIDS Reported in Personal Interviews
--HIV-Positive Prison Inmates, by Offense and Prior Drug Use
--HIV Infection of Local Jail Inmates
--HIV Test Results for Local Jail Inmates, by Inmate Characteristic
--Percent HIV Positive Among Jail Inmates, by Offense and Prior Drug
Use
--Methodology

Chapter 2: Sexually Transmitted Diseases and Hepatitis: Burden of 
Disease Among Inmates
--Key Findings
--STDs Among Inmates
--Hepatitis Among Inmates
--Conclusion
--Endnotes

Chapter 3: HIV and STD Education and Behavioral Interventions
--Key Findings
--Types of HIV/STD Education and Prevention Programs Provided
--The Importance of Comprehensive HIV/STD Education and Prevention
Programs
--Instructor-Led Education and Educational Materials
--Peer-Based Programs
--Conclusion
--Endnotes

Chapter 4: HIV Transmission and Risk Factors, Precautionary and
Preventive Measures
--Key Findings
--HIV Transmission and Risk Behaviors in Correctional Facilities
--Rape and Coerced Sexual Activity
--"Universal Precautions" Versus Correctional Officers' "Right to Know"
--Condom Availability
--Bleach Availability
--Needle and Syringe Exchange
--Methadone Maintenance
--Reduction of Risk Associated With Tattooing
--Conclusion
--Endnotes

Chapter 5: Counseling and Testing, Confidentiality and Disclosure
--Key Findings
--HIV-Antibody Testing Policies
--Confidentiality and Notification of HIV Test Results
--Conclusion
--Endnotes

Chapter 6: Housing and Correctional Management
--Key Findings
--Housing Policies for Inmates With HIV Disease
--Work Assignments and Other Programming
--Conjugal Visits
--Compassionate Release and Medical Furlough
--Conclusion
--Endnote

Chapter 7: Medical Treatment and a Continuum of Care
--Key Findings
--Medical Treatment for HIV/AIDS
--Guidelines for Antiretroviral Therapy
--Selection and Initiation of Antiretroviral Therapy
--The Patient-Clinician Relationship
--A Continuum of Care for Inmates
--Screening and Identification of Medical and Psychosocial Problems
--Case Management
--Psychosocial Support Services
--Hospice Care
--Substance Abuse Treatment
--Discharge Planning
--Continuity of Care and Community Linkages
--Conclusion
--Endnotes

Chapter 8: Tuberculosis
--Key Findings
--Tuberculosis Disease and Infection
--The Role of Policy Change
--Screening
--Containment
--Discharge Planning
--Education
--Conclusion
--Endnotes

Chapter 9: Legal and Legislative Issues
--Key Findings
--Confidentiality
--Segregation of HIV-Infected Inmates
--Access to Programs
--Alleged Exposure to HIV
--Medical Treatment
--Early Release
--Tuberculosis Issues
--Legislative Developments
--Conclusion
--Endnotes

List of Tables [Please see graphic file to view tables.]

Table 1: Estimated incidence of AIDS-Opportunistic Illnesses (AIDS-Ols)
and AIDS-related deaths, 1995-96-United States

Table 2: Inmates in custody of State or Federal prison authorities and
known to be positive for the human immunodeficiency virus, 1994-96

Table 3: Inmates in custody of State or Federal prison authorities, by type
of HIV infection or confirmed AIDS, year-end 1996

Table 4: State prison inmates known to be positive for the human
immunodeficiency virus, by sex, year-end 1996

Table 5: Number of inmate deaths in State prisons, by cause, 1994-96

Table 6: AIDS-related deaths of sentenced prisoners under State
jurisdiction, 1996

Table 7: Inmates ever tested or tested since admission for the human
immunodeficiency virus and test results

Table 8: Inmates ever tested for the human immunodeficiency virus and
results, by selected characteristics

Table 9: Inmates ever tested for the human immunodeficiency virus and
results, by offense and prior drug use 

Table 10: Standard error estimates for the 1996 Survey of Inmates in Local
Jails and the 1997 Surveys of State and Federal Correctional Facilities

Table 11: Results of mandatory and routine inmate syphilis screening,
1997

Table 12: Results of mandatory and routine gonorrhea screening, 1997

Table 13: Results of mandatory and routine chlamydia screening, 1997

Table 14: HIV/STD education and prevention programs for inmates,
1992-97

Table 15: HIV/STD education and prevention programs in adult
correctional facilities, 1995-97

Table 16: HIV/STD education and prevention programs for inmates, 1997
results of the validation study (VS)

Table 17: Topics covered in HIV/STD education for inmates, 1997

Table 18: Topics covered in HIV/STD education for inmates, 1997 results
of the validation study (VS)

Table 19: Providers of HIV/STD education and prevention services, 1997

Table 20: Availability of condoms and bleach, 1997

Table 21: Testing policies for antibodies to the human immunodeficiency
virus, by jurisdiction, 1995

Table 22: Summary of HIV-antibody testing policies

Table 23: Mutually exclusive categorization of HIV-antibody testing
policies for incoming inmates, 1997

Table 24: HIV-antibody testing policies, 1997: Results of the validation
study (VS)

Table 25: Pregnancy testing for female inmates, 1997

Table 26: HIV-antibody testing for pregnant female inmates, 1997

Table 27: Policies regarding notification of inmates' HIV-antibody test
results, 1997

Table 28: Notification of HIV-antibody test results, 1997: Results of the
validation study (VS)

Table 29: Mandatory and routine testing of incoming inmates for STDs,
1997

Table 30: Decline of segregation policies in State/Federal systems (n = 51)
1985-97

Table 31: State/Federal prison systems' housing policies for inmates with
AIDS and asymptomatic HIV infection, 1994 and 1997

Table 32: City/county jail systems' housing policies for inmates with
AIDS and asymptomatic HIV infection, 1994 and 1997

Table 33: Housing of inmates with asymptomatic HIV infection and
AIDS: Results of the validation study (VS)

Table 34: Compassionate release and medical furlough, 1997

Table 35: Inmates receiving compassionate release and medical furlough,
1996

Table 36: The availability of HIV therapies and monitoring, 1997

Table 37: The availability of HIV therapies and monitoring: Results of the
validation study (VS)

Table 38: Psychosocial and supportive services for inmates with
HIV/AIDS, 1997

Table 39: Discharge planning services, 1997

Table 40: Active TB disease among inmates, 1997

Table 41: TB infection among inmates, 1997

Table 42: Screening inmates for TB, 1997

List of Figures [Please see graphic file to view figure.]

Figure 1: Tuberculosis Cases and Rates Among New York State Inmates
(Exclusive of New York City), 1986-97

Executive Summary

At midyear 1998, more than 1.8 million people were in prisons and jails in
the United States, and 6 million were under some form of criminal justice
supervision. Inmates have disproportionately high rates of infectious
disease, substance abuse, high-risk sexual activity, and other health
problems. Thousands of former correctional inmates return to the
community each month.  Because prisoners are part of the community and
because correctional health and public health are increasingly intertwined,
health care and disease prevention in correctional facilities should be
based on the collaborative efforts of correctional, public health, and
community-based health care and social service organizations.

This 1996-1997 Update reports on the extent of HIV/AIDS, STDs, and TB
among correctional inmates and on the policies and practices being
implemented to prevent and control these diseases in correctional settings.
In this report, statistics on the prevalence of HIV infection and AIDS in
correctional populations are derived primarily from surveys conducted by
the Bureau of Justice Statistics (BJS) in 1996 and 1997. Findings
regarding policies and practices and legal and legislative issues are based
primarily on the ninth national survey of HIV/AIDS, STDs, and TB in
correctional facilities, sponsored by the National Institute of Justice (NIJ)
and the Centers for Disease Control and Prevention (CDC) and conducted
between December 1996 and August 1997.

Findings on HIV-testing policies presented in chapter 5 of this report are
from BJS' 1996 National Prisoner Statistics and the 1997 NIJ/CDC survey.
Statistics on other policies are based primarily on the NIJ/CDC ninth
national survey and associated site visits. Although the report focuses on
adult correctional systems, several examples of HIV prevention programs
in chapter 3 were drawn from site visits to juvenile facilities. Key findings
presented in this report are summarized below.

HIV/AIDS: Burden of Disease Among Inmates

o The overall prevalence of HIV infection and AIDS among inmates has
been quite stable since 1991, but some systems have experienced declines
in HIV seroprevalence.

o There have been some declines in AIDS deaths among inmates since
1995.

o Nevertheless, HIV infection and AIDS continue to be far more prevalent
among inmates than in the total U.S. population.

o The Northeast region has the largest number and percentage of inmates
with HIV infection and AIDS.

o The prevalence of HIV and AIDS is higher among Hispanic and black
inmates than among white inmates.

o The prevalence of HIV and AIDS is higher among female inmates than
among male ones.

Sexually Transmitted Diseases and Hepatitis: Burden of Disease Among
Inmates

o Available data on STDs and hepatitis B and C among inmates are very
incomplete, reflecting the relative rarity of routine screening for these
conditions in correctional facilities.

o However, behavioral profiles and anecdotal evidence suggest that
inmates are disproportionately affected by STDs and hepatitis.

HIV and STD Education and Behavioral Interventions

o HIV and STD education programs are becoming more widespread in
correctional facilities.

o However, few correctional systems have implemented comprehensive
and intensive HIV prevention programs in all of their facilities.

o Peer-based education and prevention programs offer important
advantages, such as cost-effectiveness, credibility, flexibility, and benefits
to peers themselves.

o Although few HIV/STD prevention programs in correctional settings
have been rigorously evaluated, anecdotal evidence suggests that programs
can be successful in reaching this extremely high-risk population with
practical risk-reduction messages.

HIV Transmission and Risk Factors, Precautionary and Preventive
Measures

o High-risk behaviors for HIV transmission-sex, drug use, sharing of
injection materials, and tattooing-occur in correctional facilities.

o HIV transmission among correctional inmates has been shown to occur.

o Comprehensive and intensive education and prevention programs
represent the best response to these facts, although the precise content of
such programs is controversial.

o Rape and coerced sexual activity also occur in correctional facilities but
require a different response, one based on inmate classification, housing,
and supervision.

o The implementation of "universal precautions" represents the heart of a
correctional infection-control program and the first line of defense against
the occupational transmission of HIV.

o Condom distribution and other harm-reduction strategies have not been
widely adopted in American correctional systems.

o Experience with harm reduction in correctional facilities in Europe and
elsewhere may warrant the attention of U.S. correctional administrators. 

Counseling and Testing, Confidentiality, and Disclosure

o Most correctional systems provide HIV antibody testing, although
testing policies differ widely.

o Seventeen State correctional systems and the Federal Bureau of Prisons
had policies for mandatory HIV-antibody testing of inmates at intake
and/or release.

o Few correctional systems have mandatory or routine pregnancy testing
of female inmates.

o Ongoing assessment of HIV-antibody and pregnancy-testing policies is
warranted in light of changing community standards for treatment of
HIV/AIDS.

o Very few correctional systems have policies for notification of
correctional officers regarding inmates' HIV status.

o Few correctional systems routinely screen inmates for STDs.

Housing and Correctional Management

o Only a small number of correctional systems segregate inmates with
HIV disease, and the number of systems with segregation policies has
declined sharply since the late 1980s.

o Some correctional systems still limit the work assignments for which
inmates with HIV are eligible.

o Few correctional systems permit conjugal visits for any inmates, and
even fewer allow such visits for inmates with HIV.

o Policies for the early or compassionate release of inmates with terminal
illness, including end-stage AIDS, are quite common, but relatively few
inmates are actually being released under such policies. 

Medical Treatment and a Continuum of Care

o Protease inhibitors and combination therapies have brought dramatic
improvements in the medical condition and survival of people with HIV,
at least over the relatively short term that has been available for study to
date.

o The new therapeutic combinations pose challenges for patient adherence,
and failure to adhere consistently to the regimens may have serious public
health consequences if drug-resistant strains are transmitted to others.

o New drugs and reduced dosing currently under study offer hope of more
"patient-friendly regimens."

o Clinicians must work closely with patients to make the best therapeutic
decisions.

o A continuum of services including early identification, timely and
effective treatment, case management, discharge planning, and community
linkages will make for optimal clinical and psychosocial outcomes for
inmates with HIV disease.

o Continuity of care and bridging to community services also contribute to
positive patient outcomes.

o Existing program models have not been rigorously evaluated but
probably warrant replication based on anecdotal evidence. 

Tuberculosis (TB)

o In recent years the incidence of TB has declined both in the overall U.S.
population and among correctional inmates, although it remains much
higher among inmates.

o Most State/Federal prison systems appear to be following CDC
guidelines regarding TB screening, isolation and treatment, and preventive
therapy, whereas adherence is lower among city/county jail systems.

o Better collection and reporting of screening data would help to document
the burden of TB infection and disease among inmates.

o Improvements are also needed in the use of directly observed therapy, as
well as in postrelease adherence to treatment for TB disease and TB
infection.

Legal and Legislative Issues

o The U.S. Supreme Court has ruled that HIV and HIV-related
discrimination are covered under the Americans With Disabilities Act.

o There were few other major legal developments affecting HIV/AIDS in
correctional facilities during the period covered by this Update report,
although courts generally continued to uphold correctional systems' policy
responses to HIV/AIDS.

o Some State legislatures have attempted to expand the requirements for
HIV antibody testing of inmates and disclosure of inmates' HIV status, but 
these efforts generally have been unsuccessful.

Introduction

In 1996 the Joint United Nations Programme on HIV/AIDS (UNAIDS)
cogently summarized the importance of health care and disease prevention
in correctional facilities: "Prisoners are the community. They come from
the community, they return to it. Protection of prisoners is protection of
our communities."[1] In the United States, the case is made particularly
compelling by the following facts: the continuing surge in incarceration,
with more than 1.8 million people in prisons and jails and 6 million under
some form of criminal justice supervision at midyear 1998; the continuing
disproportionate rates of infectious disease, substance abuse, high-risk
sexual activity, and other health problems among correctional inmates;
and the return of thousands of former correctional inmates to the
community each month. The 1996 UNAIDS statement also declared that
"failure to provide [prisoners] the basic measures, such as information,
education, and the means of [HIV] prevention available on the outside,
violates [their] rights to health, security of person, and equality before the
law." Because prisoners are part of the community and because
correctional health and public health are increasingly intertwined, health
care and disease prevention in correctional facilities should be based on
the collaborative efforts of correctional, public health, and
community-based health care and social service organizations. A public
health model of correctional health care is needed. Such an approach is
particularly urgent given the recent dramatic advances in antiretroviral
therapy and the attendant importance of continuity of treatment, adherence
to regimens, and minimizing the potential for development of drug
resistance.

HIV/AIDS in the U.S. Population

As context for the main contents of this Update, it is important to
understand the overall trends and patterns of HIV disease in the U.S.
population. 

Between 1995 and 1996, the HIV/AIDS epidemic in the United States
appeared to be lessening in intensity, at least in some sectors of the
population. However, the face of the epidemic continued to change, with
increasing concentration among the poor and people of color, the
populations from which the majority of inmates are drawn.

Table 1, adapted from CDC's Morbidity and Mortality Weekly Report,
reveals the dramatic changes in the epidemic that occurred between 1995
and 1996. Calendar year 1996 was the first year in which the incidence of
AIDS-opportunistic illnesses (AIDS-OIs) actually declined in the United
States.[2] AIDS-OIs is a measure designed to adjust for the 1993 change
in the AIDS case definition, thus permitting valid comparisons in
incidence over that time. It is calculated from the sum of cases reported
with an AIDS-OI and cases with estimated dates of diagnosis of an
AIDS-OI that were reported based only on the immunologic criteria added
in the 1993 revised case definition. (In this report, the AIDS-OI measure is
used only with regard to the total U.S. population and not with regard to
the situation in correctional facilities.)

Although the incidence of AIDS-OIs continues to be high--an estimated
56,730 cases were reported in 1996--incidence declined in all geographic
regions of the country, all 5-year age groups, and many other sectors of the
population (table 1). Incidence declined between 1995 and 1996 among
men (by 8 percent), non-Hispanic whites (by 13 percent), men who have
sex with men (by 11 percent), and injection drug users (by 5 percent).
Moreover, although HIV/AIDS remains a leading cause of death among
Americans between 25 and 44 years of age, AIDS deaths actually declined
for the first time between 1995 and 1996. The decline was substantial--23
percent. It was largest in the last three quarters of 1996 and affected all
geographic regions, racial and ethnic groups, and exposure categories. 

These temporal declines in AIDS-OI incidence are attributable to
reductions in rates of new infection--due in turn to prevention efforts--a
slowing in progression from infection to active disease, and AIDS-OI
diagnosis. Reductions in the number of deaths are based on increased
survival with AIDS-OIs, in turn the result of newly available antiretroviral
therapies and prophylaxis for OIs.[3] Increased survival and the relatively
stable incidence of new HIV infections, however, have resulted in an
increased prevalence of AIDS in the population: from 1995 to 1996 the
number of people living with AIDS in the United States increased by 11
percent, from 211,000 to 235,000. This increasing AIDS prevalence
indicates the need for more resources and services to treat and care for
those who are ill. 

The incidence of AIDS-OIs did not decline among all segments of the
U.S. population between 1995 and 1996. It remained stable among
non-Hispanic blacks, and actually increased among women (by 2 percent)
and persons who were infected through heterosexual contact (by 8
percent). In the United States, heterosexually transmitted HIV infection
results primarily from sexual relations with drug users.

An examination of trends in the proportional distribution of new AIDS-OI
cases across racial/ethnic groups, genders, and exposure categories
reinforces the conclusions that the epidemic is becoming increasingly
concentrated among people of color and that women are increasingly
affected. Between 1992 and 1996, the proportion of new cases of AIDS
that occurred among non-Hispanic whites declined from 48 percent to 38
percent, whereas it remained stable among Hispanics (18 percent to 19
percent), and increased from 33 percent to 41 percent among non-Hispanic
blacks. Indeed, for the first time in 1996, the number of new cases of
AIDS among blacks exceeded the number among whites. The proportion
of new AIDS cases among women also increased from 14 percent in 1992
to 20 percent in 1996.[4]

The 1996-1997 Update: Contents and Sources

This Update reports on the extent of HIV/AIDS, STDs, and TB among
correctional inmates and on the policies and practices being implemented
to prevent and control these diseases in correctional settings. Statistics on
the prevalence of HIV infection and AIDS in correctional populations
presented in this report are primarily from the Bureau of Justice Statistics
(BJS) 1997 Survey of State and Federal Correctional Facilities, 1996
National Prisoner Statistics, and 1996 Survey of Inmates in Local Jails.
Statistics on the prevalence of STDs and TB among correctional inmates
come primarily from the ninth national survey of HIV/AIDS, STDs, and
TB in correctional facilities, sponsored by the National Institute of Justice
(NIJ) and the Centers for Disease Control and Prevention conducted
between December 1996 and August 1997 and the CDC's TB surveillance
system. 

Findings on HIV-testing policies presented in chapter 5 of this report are
from BJS' 1996 National Prisoner Statistics and the 1997 NIJ/CDC survey.
Statistics and discussion in all other chapters on policies and practices, as
well as the chapter on legal and legislative issues, are based primarily on
the NIJ/CDC ninth national survey.

As in all of the previous national surveys in this series, responses were
received from all 50 State departments of correction and the Federal
Bureau of Prisons. The sample selection for the city/county jail systems
was modified in 1996-97 to target the 50 largest city/county jail systems
by average daily inmate population. Responses were received from 41 of
these, or 82 percent. Again in 1996-97, a validation survey was conducted.
An abbreviated version of the questionnaire was sent to 50 individual
facilities in 15 State correctional systems and the Federal Bureau of
Prisons. The objective of the validation study was to compare responses
on key policy issues from individual facilities and the central offices of
their departments of corrections.

The survey was supplemented by site visits to the States of California and
Louisiana and to New York City and San Francisco to observe HIV
prevention programs and discharge planning/transitional programs. Site
visits were also conducted to observe HIV/STD prevention programs in
the juvenile systems of Massachusetts and Los Angeles County,
California. 

Although the report focuses on adult correctional systems, several
examples of HIV prevention programs in chapter 3 were drawn from site
visits to juvenile facilities.

How widespread are comprehensive and collaborative approaches to
correctional and community health services? In general, the results of the
1997 NIJ/CDC survey suggest that HIV/AIDS education and prevention
programs are on the increase in prisons and jails but, as was also
demonstrated by the previous survey and by an extensive review of the
literature, still fail to take full advantage of this important public health
opportunity.[5] A separate report based on the 1997 survey shows that
public health-corrections collaborations are increasingly common but still
rarely rise to the level of a comprehensive public health model.[6]

Endnotes

1. "HIV/AIDS in Prisons," Statement by the Joint United Nations
Programme on HIV/AIDS (UNAIDS), April 1996.

2. Centers for Disease Control and Prevention, "Update: Trends in AIDS
Incidence--United States, 1996," Morbidity and Mortality Weekly Report
46 (September 19, 1997): 861-867.

3. F.J. Palella, Jr., et al., "Declining Morbidity and Mortality Among
Patients With Advanced HIV Infection," New England Journal of
Medicine 338 (March 26, 1998): 853-860.

4. Centers for Disease Control and Prevention, "Update: Trends in AIDS
Incidence, Deaths, and Prevalence--United States, 1996." Morbidity and
Mortality Weekly Report 46 (February 28, 1997): 165-173.

5. T.M. Hammett and R. Widom, "HIV/AIDS Education and Prevention
Programs for Adults in Prisons and Jails and Juveniles in Confinement
Facilities--United States, 1994," Morbidity and Mortality Weekly Report
45 (April 5, 1996): 268-271; T.M. Hammett, R. Widom, and S. Kerr,
"HIV Prevention in Prisons and Juvenile Facilities: A Missed 'Public
Health Opportunity,' " oral abstract We.D.351, presented at the 11th
International Conference on AIDS, Vancouver, Canada, July 10, 1996;
and T.M. Hammett, J.L. Gaiter, and C. Crawford, "Reaching Seriously
At-Risk Populations: Health Interventions in Criminal Justice Settings," 
Health Education and Behavior 25 (February 1998): 99-120.

6. T.M. Hammett, Public Health/Corrections Collaborations: Prevention
and Treatment of HIV/AIDS, STDs, and TB, Research in Brief,
Washington, DC: U.S. Department of Justice, National Institute of Justice,
1998 (NCJ 169590).

-------------------------------

Chapter 1

HIV in Prisons and Jails, 1996

Laura M. Maruschak--Bureau of Justice Statistics

At Year-end 1996, 2.3 percent of all State and Federal prison inmates were
known to be infected with the human immunodeficiency virus (HIV). A
total of 24,881 prison inmates were HIV positive (947 Federal and 23,934
State). HIV-positive inmates made up 1.0 percent of Federal prison
inmates and 2.4 percent of State prison inmates. Of those known to be
HIV positive in all U.S. prisons, 5,874 were confirmed AIDS cases, while
the remaining 17,656 either showed symptoms of HIV infection or were
asymptomatic.

In 1996, there were a total of 907 AIDS-related deaths in State prisons,
down from 1,010 in 1995. For every 100,000 State prison inmates in 1996,
90 died of AIDS-related causes. Between 1991 and 1996, about 1 in 3
State prison inmate deaths were attributed to AIDS-related causes.

Data based on personal interviews from the 1997 Survey of Inmates in
State Correctional Facilities show that 75 percent of State inmates were
ever tested for HIV. Of those who were ever  tested and reported results,
2.2 percent were HIV positive--2.2 percent of males and 3.4 percent of
females. As reported level of involvement in prior drug use increased, so
did the percent of HIV-positive inmates--2.3 percent of those who said
they had ever used drugs, 2.7 percent of those who used drugs in the
month before the current offense, 4.6 percent of those who injected drugs,
and 7.7 percent of those who ever shared a needle were HIV positive.

Data on HIV/AIDS in jails have been collected in the 1993 Census of Jails
and the 1996 Survey of Inmates in Local Jails. According to the 1993
Census of Jails, 1.8 percent of local jail inmates were known to be HIV
positive. The larger the size of the jail jurisdiction, the greater the
percentage of inmates with HIV/AIDS. 

Based on personal interviews conducted from October 1995 through
March 1996 in the Survey of Inmates in Local Jails, almost 6 in 10
inmates reported ever being tested for HIV. Of those who were tested and
reported results, 2.2 percent reported being HIV positive. Among female
inmates, 2.4 percent said they were HIV positive; among male inmates,
2.1 percent. An estimated 2.3 percent of tested jail inmates who said they
had ever used drugs were HIV positive, as were 2.9 percent who used
drugs in the month before arrest, 4.0 percent who used a needle to inject 
drugs, and 6.3 percent who ever shared needles. 

Trends in HIV Infection in U.S. Prisons

At Year-end 1996, 24,881 inmates in State and Federal prisons were
known to be infected with the human immunodeficiency virus (HIV), up
from 24,256 at Year-end 1995 (table 2). In State prisons, 23,934 inmates
were known to be HIV positive, and in Federal prisons, 947 inmates were
HIV positive. Although the number of HIV cases increased after 1991, the
percent of the total custody population with HIV remained relatively
stable. Between 1991 and 1996 the number of HIV-positive inmates grew
at about the same rate as the overall prison population (both increased by
about 42 percent).

HIV-positive inmates comprised 2.3 percent of the State prison population
in 1991 and 2.4 percent in 1996. In Federal prisons, HIV-positive inmates
comprised 1.0 percent in 1996, unchanged from 1991.

HIV-infected inmates were concentrated in a small number of States. New
York and Florida housed the largest number of  HIV-positive inmates
(9,500 and 2,152, respectively). In 1996, these two States housed nearly
half of all HIV-infected inmates in State prisons. 

More than half of the State prison inmates known to be HIV positive were
found in the Northeast. Within the Northeast, 7.5 percent of the prison
population were HIV positive, followed by 2.0 percent in the South, 1.1
percent in the Midwest, and 0.8 percent in the West. New York had the
highest percentage of inmates known to be HIV positive (13.6 percent),
followed by Connecticut (4.6 percent), and Rhode Island (3.9 percent). 
These three States had the highest percentage of HIV-positive inmates
after 1994.

Of the 48 States that reported information on the number of HIV-positive
inmates in 1996, each reported having at least one. Eight States (Alaska,
Maine, Montana, North Dakota, South Dakota, Vermont, West Virginia,
and Wyoming) reported 10 or fewer cases of HIV-positive inmates in their
prisons. Eleven States reported that fewer than 0.5 percent of their inmate
population were HIV positive. Between 1995 and 1996 the largest growth
of HIV-positive inmates was reported in Virginia--383 in 1996, up from
134 in 1995. Other notable increases during 1996 were reported in
Michigan (up 149) and Maryland (up 108).

Confirmed AIDS Cases in U.S. Prisons

At the end of 1996, 5,874 inmates in U.S. prisons had confirmed AIDS:
5,521 were State inmates and 353 were Federal inmates (table 3). Of the
remaining HIV-positive inmates, 1,959 showed symptoms of AIDS
(symptomatic), while 15,697 were HIV positive but showed no symptoms
of AIDS (asymptomatic).

Confirmed AIDS cases made up 0.5 percent of all inmates in State and
Federal prisons. Of those inmates known to be HIV positive, nearly a
quarter had confirmed AIDS.

During 1996 the number of confirmed AIDS cases increased by 748.
Overall, after 1991 the number of confirmed AIDS cases increased by
4,165--an average annual increase of 28.3 percent. The number of inmates
with lesser or no symptoms of HIV infection actually decreased in 1996,
and the number was below the numbers reported in every year from 1992
to 1995. 

The States with the largest number of confirmed AIDS cases were New
York (1,208), Florida (873), Texas (499), and California (429). Combined,
these States made up 55 percent of all confirmed AIDS cases in State
prisons. Eighteen States reported having fewer than 10 confirmed AIDS
cases in their prisons.

The highest percentage of the State prison population having confirmed
AIDS was in New York (1.7 percent), followed by Connecticut (1.6
percent), Massachusetts (1.5 percent), Florida (1.4 percent), and Maryland
(1.3 percent). In 17 States confirmed AIDS cases comprised 0.1 percent or
fewer of State inmates.

Comparison to the U.S. Resident Population

At the end of 1996, the rate of confirmed AIDS in State and Federal
prisons was six times higher than in the total U.S. population. About 54 in
10,000 prison inmates had confirmed AIDS, compared to 9 in 10,000
persons in the U.S. population. 

In every year from 1991 to 1996, the rate of confirmed AIDS was higher
among prison inmates than in the general population. In 1992 the rate of
AIDS was 11 times higher for prisoners than the general population. In
1993, following a revision of the HIV classification system and an
expansion of the case definition for AIDS, the rate of confirmed AIDS
increased 12 times among prisoners and doubled in the general population.
After the adoption of these new measures, the incidence of AIDS grew
somewhat faster in the general population.  At Year-end 1996 the rate of
confirmed AIDS was six times higher in prisons than in the general
population.

HIV Infection of Male and Female State Prison Inmates

At Year-end 1996 there were 21,799 male inmates and 2,135 female
inmates known to be HIV positive (table 4). Overall, 2.3 percent of male
inmates and 3.5 percent of all female inmates were known to be HIV
positive. The rate of HIV infection in females was higher than male
infection rates in all regions except the West and in most States.

Between 1995 and 1996 the number of infected female inmates decreased
2.2 percent from 2,182 to 2,135; the number of infected male inmates
increased 5.4 percent from 20,690 in 1995 to 21,799 in 1996. Overall,
among State prisoners, the number of males infected with HIV increased
35 percent, and the number of females infected increased 84 percent
between 1991 and 1996.

States in the Northeast reported the largest number of HIV-positive male
and female inmates (10,985 and 1,105, respectively). In eight States, more
than 5 percent of all female inmates were known to be HIV positive. In
two States over 10 percent of all female inmates were known to be HIV
positive--New York (20.5 percent) and Rhode Island (11.7 percent). New
York (13.2 percent) was the only State in which more than 10 percent of
all male inmates were HIV positive. 

Among all States, New York reported the largest number of male and
female HIV-positive inmates (8,736 and 764, respectively). The second
largest number of HIV-positive male inmates were in Florida (1,929),
followed by Texas (1,645). The second largest number of HIV-positive
female inmates were in Texas (231), followed by Florida (223). Seven
States reported no female HIV-positive inmates, and every State reported
at least one male HIV-positive inmate. 

AIDS-Related Deaths in State Prisons

The number of State inmates who died of Pneumocystis carinii
pneumonia, Kaposi's sarcoma, or other AIDS-related diseases decreased
from 1,010 in 1995 to 907 in 1996 (table 5). These AIDS deaths accounted
for 29 percent of all deaths among State prisoners, down from 34 percent
in 1995. Beginning in 1991 AIDS-related causes were the second leading
cause of death in State prisons, behind natural causes other than AIDS.  

In 1996, for every 100,000 inmates, 90 died from AIDS-related causes.
Between 1991 and 1995, the number of AIDS-related deaths in State
prisons increased 94 percent; however, in 1996 the number decreased 10
percent from 1995. With the introduction of protease inhibitors and
combination antiretroviral therapies, there was appreciable improvement
in the effectiveness of HIV/AIDS care.

The rate of death because of AIDS is about three times higher in the prison
population than in the total U.S. population age 15-54. Between 1991 and
1996, about 1 in every 3 prisoner deaths were attributable to AIDS-related
causes, compared to about 1 in 10 deaths in the general population.

AIDS-related deaths accounted for more than half of all inmate deaths in
Connecticut (65 percent), New York (55 percent), New Jersey (52
percent), and Florida (50 percent) (table 6). Seventeen States reported
having no AIDS-related deaths, and five States reported one AIDS-related
death.

HIV Prevalence Rates and Testing Policies

Data on HIV prevalence rates are reported in the National Prisoners
Statistics series (NPS) by prison officials. The quality of the information
reported varied by the testing policies that a particular State implemented.
Testing policies ranged from testing all inmates to testing only upon
inmate request. Although 19 States tested either all inmates in custody
or a random selection, and 27 test targeted groups (high-risk individuals or
upon indication or incidence), 5 tested solely upon inmate request. Official
data represent the minimum number of individuals known to be HIV
positive within a prison facility.

Blinded or "unlinked" studies have been conducted as another means of
determining the HIV prevalence in State prisons. These studies are blinded
in that the identity of the inmate is not linked to the result of the HIV test.
An inmate's blood that has been drawn during a routine physical
examination upon entering a facility is tested for HIV. The sample is sent
to a lab with no information regarding the inmate. 

Blinded studies may not accurately account for the prevalence rate of HIV
in prisons. Often these studies are conducted in only a few facilities, and
are snapshots, examined over one period solely on admission cohorts.
Because of this, blinded studies are limited in that they may not be
generalized to the overall prison population. Discrepancies are apparent
between HIV prevalence rates reported in official records and those
produced from blinded studies. 

Data from a blinded study conducted in Massachusetts in 1995 suggest
that 6.8 percent of incoming inmates are HIV positive, while official data
from 1995 indicate 3.9 percent of all inmates in custody were HIV
positive. Similarly, data from blinded studies conducted in Maryland
(1991), California (1994), Illinois (1991), and New Jersey (1991) suggest
that official data underestimate the HIV prevalence rate. 

Official data from New York in 1994 and 1995, however, revealed higher
HIV prevalence rates than data from a 1994-1995 blinded study. The
blinded study showed that 10 percent of all incoming inmates were HIV
positive, while official data showed that of all inmates in custody, 12.4
percent in 1994 and 13.9 percent in 1995 were HIV positive. Similarly,
National Prisoner Statistics (NPS) data from Arkansas (1992) and
Washington (1991) suggest a higher prevalence rate among inmates than
data from blinded studies (0.9 percent compared to 0.6 percent, and 0.5
percent compared to 0.2 percent).

HIV/AIDS Reported in Personal Interviews

Additional information on the prevalence of HIV/AIDS may also be 
obtained through personal interviews of prisoners. Though some inmates
may be reluctant to report that they are HIV positive and others may not
know, surveys provide a means to track HIV infection among demographic
and "high-risk" groups not identified in official records or blinded studies.

The 1997 Surveys of State and Federal Correctional Facilities asked
inmates if they had ever been tested, if they had been tested since
admission, and whether they were HIV positive. Similar questions were
asked in the 1996 Survey of Inmates in Local Jails. (See Methodology for
further detail.)

In 1997, 17,674 (1.7 percent) State prison inmates and 428 (0.5 percent)
Federal prison inmates were known to be HIV positive (table 7). Of those
inmates who reported being tested since admission to State prison, or to
Federal prison, 2.6 percent and 0.7 percent, respectively, reported being
HIV positive.

Among State prisoners, female inmates (3.4 percent) were more likely
than male inmates (2.2 percent) to be HIV positive (table 8). Black
non-Hispanic inmates (2.8 percent) were twice as likely as white
non-Hispanic inmates (1.4 percent) to report being HIV positive. 

Among male inmates, blacks (2.7 percent) were nearly twice as likely as
whites to be HIV positive. The rates of HIV infection among female
inmates were not significantly different among whites (2.3 percent), blacks
(3.9 percent), and Hispanics (4.2 percent).

In Federal prisons 0.6 percent of males and of females reported HIV
infection. Non-Hispanic white inmates reported the lowest HIV-positive
rates (0.3 percent). In both State and Federal prisons, inmates age 17 to 24
reported the lowest rate of being HIV positive (0.5 percent and 0.1
percent, respectively). In State prisons, inmates age 35 to 44 reported the
highest HIV-positive rate (3.1 percent). Those State inmates in each age
category over 24 were more likely to be HIV positive than those who were
24 or younger. In Federal prisons, inmates age 45 or older reported the
highest rate of HIV infection (1.2 percent).
 
HIV-Positive Prison Inmates, by Offense and Prior Drug Use

Those inmates being held on a drug offense in State prisons reported the
highest HIV positive rate (2.9 percent) (table 9). Of property offenders, 2.4
percent reported being HIV positive. Violent and public-order offenders
reported slightly lower rates (1.9 percent each). Among Federal prison
inmates, 1.0 percent of violent offenders, property offenders, and
public-order offenders reported being HIV positive as did 0.4 percent of
drug offenders.

The percentage of State and Federal prison inmates reporting that they
were HIV positive varied by level of prior drug use. By type of drug use
practice, the following percentages of State prison inmates reported being
HIV positive: never using drugs, 1.7 percent HIV positive; ever used
drugs, 2.3 percent; used drugs in the month before their current offense,
2.7 percent; used a needle to inject drugs, 4.6 percent; and shared a needle,
7.7 percent HIV positive. Like State inmates, Federal inmates who used a
needle and shared a needle had a higher rate of HIV infection than those
inmates who reported ever using drugs or using drugs in the month before
their current offense (1.3 percent and 2.1 percent compared to 0.7 percent
and 0.3 percent). Unlike State inmates, Federal inmates using drugs in
the month prior to their current offense reported a lower rate of HIV
infection (0.3 percent) than inmates who reported ever using drugs (0.7
percent).

HIV Infection of Local Jail Inmates

At midyear 1993, when the last national census of local jails was
conducted, 1.8 percent of the inmates were known to be HIV positive.
Among jails reporting data, a total of 6,711 inmates were HIV positive,
and 1,888 had confirmed AIDS. The infection rate was highest in the
largest jail jurisdictions. Almost 3 percent of the inmates in the Nation's
largest jurisdictions were reported HIV positive. Among the remaining
jurisdictions, the larger the size, the greater the percentage of inmates with
HIV/AIDS. In jurisdictions with 500 or more inmates, 1.6 percent of the
inmates were infected; in jurisdictions with 250 to 499 inmates, 1.2
percent; and in jurisdictions holding fewer than 250 inmates, 1 percent or
less.

HIV Test Results for Local Jail Inmates, by Inmate Characteristic

Detailed data, based on interviews of a national sample of inmates in local
jails, are available from the 1996 Survey of Inmates in Local Jails.
Conducted between October 1995 and March 1996, the survey provides
national estimates of the number of jail inmates tested for HIV/AIDS and
the percent HIV positive.

In 1996, 6,289 local jail inmates (1.2 percent of all inmates) were known
to be HIV positive (table 7). An estimated 57 percent of all respondents in
the survey said they had ever been tested for HIV. Of those who had been
tested for HIV, 2.2 percent said they were HIV positive. Since admission,
about 18 percent of inmates had been tested for HIV, and 3.9 percent
reported HIV positive results. 

Among jail inmates, 2.1 percent of males and 2.4 percent of females said
they were HIV positive (table 8). An estimated 2.6 percent of black
inmates, compared to 1.4 percent of white inmates, said they tested HIV
positive. Among male inmates, blacks (2.5 percent) were nearly twice as
likely as whites (1.3 percent) to report being HIV positive. Hispanic males
had the highest HIV-positive rate (3.5 percent). Among female inmates,
although the percentage who reported they were HIV positive was higher
among blacks (3.2 percent) than whites (2.1 percent) and Hispanics (1.3
percent,) the differences were not statistically significant.

Inmates age 24 or younger had the lowest HIV-positive rates (0.7 percent),
while those 35 to 44 had the highest rates (3.8 percent). Inmates 25-34 and
45 or older fell in the middle (2.1 percent and 3.0 percent, respectively).
Inmates who had completed high school were as likely as those who had
not completed high school to say they tested HIV positive (2.3 percent). 

Percent HIV Positive among Jail Inmates, by Offense and Prior Drug Use

Among jail inmates who said they had been tested for HIV/AIDS, those
held for drug offenses were the most likely to be HIV positive (3.3
percent) (table 9). Drug offenders were twice as likely as violent offenders
(1.5 percent) to report that they tested positive for HIV. Property and
public-order offenders reported somewhat lower rates--2.2 percent and 1.7
percent, respectively.

The percent of jail inmates reporting that they were HIV positive varied by
level of prior drug use. An estimated 2.3 percent of inmates who had ever
used drugs, 2.9 percent of inmates who used drugs in the month before
their current offense, 4.0 percent of inmates who said they had used
needles to inject drugs, and 6.3 percent of those who had shared a
needle with someone else reported being HIV positive.

Methodology

National Prisoner Statistics

The National Prisoner Statistics series (NPS) includes an annual Year-end
count of prisoners by jurisdiction, sex, race, Hispanic origin, and
admissions and releases during the year. The series consists of yearly
reports to the Bureau of Justice Statistics from the departments of
corrections of the 50 States and the District of Columbia and from the
Federal Bureau of Prisons.

Since 1991 respondents have been asked to indicate their policies for
testing for HIV and to provide the number of HIV-infected inmates in their
custody on the last day of the calendar year.

Surveys of Inmates in State and Federal Correctional Facilities, 1997

The 1997 Surveys of Inmates in State and Federal Correctional Facilities
were conducted for the Bureau of Justice Statistics by the U.S. Bureau of
the Census. The Federal Bureau of Prisons cosponsored the Survey of
Inmates in Federal Correctional Facilities. Personal interviews were
conducted from June 1997 through October 1997. Information was
collected about individual characteristics of prison inmates, current and
prior offenses and sentences, criminal histories, characteristics of the
current offense, family background, prior drug and alcohol use and
treatment, and conditions of confinement. 

The sample for the Federal inmates survey was selected from a universe of
135 Federal prisons holding sentenced inmates. For State inmates the
sample came from 1,453 State prisons counted in the 1995 Census of State
Correctional Facilities performed on June 30, 1995, with prisons opening
between the census and June 30, 1996, added. The overall response rate in
the State survey was 92.5 percent. Similar surveys of State prison inmates
were conducted in 1974, 1979, 1986, and 1991. The first survey of Federal
inmates was done in 1991.

Census of Jails, 1993 

The 1993 Census of Jails included all locally administered confinement
facilities (3,287) that held inmates beyond arraignment and were staffed
by municipal or county employees. The census also included 17 jails that
were privately operated under contract for local governments.

Excluded from the census were temporary holding facilities, such as drunk
tanks and police lockups, that do not hold persons after being formally
charged in court (usually with in 72 hours of arrest). Also excluded were
State-operated facilities in Alaska, Connecticut, Delaware, Hawaii, Rhode
Island, and Vermont, which have combined jail-prison systems.

Survey of Inmates in Local Jails, 1996

The 1996 Survey of Inmates in Local Jails was conducted for BJS by the
U.S. Bureau of the Census. Through personal interviews conducted from
October 1995 through March 1996, data were collected on individual
characteristics of jail inmates, current offenses, sentences and time served,
criminal histories, jail activities, conditions and programs, prior drug and
alcohol use and treatment, and health care services provided while in jail. 
The sample for the 1996 survey was selected from a universe of 3,328 jails
that were enumerated from the 1993 Census of Jails. The total
nonresponse was 13.7 percent. Similar surveys of jail inmates were
conducted in 1972, 1978, 1983, and 1989.

Accuracy of the Survey Estimates

The accuracy of the estimates from the 1996 Survey of Inmates in Local
Jails and the 1997 Surveys of Inmates in State and Federal Correctional
Facilities depends on two types of error: sampling and nonsampling.
Sampling error is variation that may occur by chance because a sample
rather than a complete enumeration of the population was conducted.
Nonsampling error can be attributed to many sources, such as
nonresponse, differences in the interpretation of questions among inmates,
recall difficulties, and processing errors. In any survey the full extent of
the nonsampling error is never known.

The sampling error, as measured by an estimated standard error, varies by
the size of the estimate and the size of the base population. Estimates for
the percentage of inmates ever tested for HIV and the percentage who
tested HIV positive have been calculated (see table 10). These standard
errors may be used to construct confidence intervals around percentages.
For example, the 95-percent confidence interval around the percentage of
males in local jails who were HIV positive is approximately 2.1 percent
plus or minus 1.96 times 0.33 percent (or 1.5 percent to 2.7 percent).

These standard errors may also be used to test the statistical significance of
the difference between two sample estimates by pooling the standard
errors of the estimates (that is, by taking the square root of the sum of the
squared standard errors for each sample estimate). All comparisons
discussed in this report were statistically significant at the 95-percent
confidence level.

AIDS in the U.S. Resident Population

The number of persons with confirmed AIDS in the U.S. general
population (age 13 and over) was derived from the Centers for Disease
Control and Prevention (CDC), HIV/AIDS Surveillance Report, Year-end
editions 1991-1996. For each year the number of active AIDS cases in the
United States was calculated by subtracting the number of cumulative
AIDS deaths for people age 15 and older at Year-end from the cumulative
number of total AIDS cases for people age 13 and older at Year-end as
listed in the HIV/AIDS Surveillance Report.

The data for the U.S. general population, excluding persons under age 13,
from 1991 to 1996 were taken from the U.S. Population Estimates, by
Age, Sex, Race, and Hispanic Origin: 1990 to 1995, PPL-41, and the
update for 1996.

The rate of confirmed AIDS cases in the U.S. resident population was
calculated by dividing the annual totals for individuals with AIDS by the
population estimates for the U.S. resident population of individuals 13 and
older.

The classification system for HIV infection and the case definition for
AIDS were expanded in 1993. This expansion improved estimates of the
number and the characteristics of persons with HIV disease, but
complicated interpretation of AIDS trends. The increase in reported AIDS
cases in 1993 was largely the consequence of the added surveillance
criteria. (See CDC, Morbidity and Mortality Weekly Report, Vol. 43, No.
45, November 18,1994.)

AIDS-Related Deaths in the United States

The number of AIDS-related deaths for persons age 15-54 was derived
from the CDC, HIV/AIDS Surveillance Report, Year-end editions. Deaths
in the U.S. population for persons age 15-54 were taken from the CDC,
Monthly Vital Statistics Report, Vol. 42, No. 2(S); Vol. 43, No. 12; Vol.
43, No. 6(S); Vol. 45, No. 3(S); and Vol. 45, No. 11(S).

AIDS-related deaths as a percentage of all deaths in the U.S. population
were calculated by dividing the national estimate of AIDS deaths of
persons age 15-54 by the national mortality estimates of persons age 15-54
in a given year. 

HIV Prevalence Rates from Blinded Studies 

Data from blinded studies on HIV prevalence rates in Massachusetts,
Maryland, California, and New York were gathered from several sources:

B. Werner et al., "Drop in HIV Seroprevalence among Men and Women
Entering Massachusetts Prisons," Abstract No. 115, presented at the Third
Conference on Retroviruses and Opportunistic Infections, Washington,
D.C., January 28-February 1, 1996.

C. Behrendt et al., "Voluntary Testing for HIV in a Prison Population with
a High Prevalence of HIV." American Journal of Epidemiology, 139
(1994) pp. 918-26.

J. Ruiz and J. Mikanda, Seroprevalence of HIV, Hepatitis B, Hepatitis C,
and Risk Behaviors among Inmates Entering the California Correctional
System (Sacramento: California Department of Health Services, Office of
AIDS, HIV/AIDS Epidemiology Branch, March 1996). 

J. Mikl et al., "Trends in HIV Infection Rates among New York
State Prison Inmates, 1987-1997," Poster abstract Number 23516,
presented at the 12th World Congress on AIDS, Geneva, June 30,
1997.

-------------------------------

Chapter 2

Sexually Transmitted Diseases and Hepatitis: Burden of Disease Among
Inmates

Theodore M. Hammett and Patricia Harmon-Abt Associates Inc. 

Key Findings

o Available data on STDs and hepatitis B and C among inmates are very
incomplete, reflecting the relative rarity of routine screening for these
conditions in correctional facilities.

o However, behavioral profiles and anecdotal evidence suggest that
inmates are disproportionately affected by STDs and hepatitis.

STDs Among Inmates

According to the 1997 NIJ/CDC survey, 88 percent of State/Federal prison
systems and 41 percent of city/county jail systems have policies for
mandatory or routine syphilis screening of incoming inmates (table 11).
However, 64 percent of State/Federal systems and 29 percent of
city/county systems with mandatory or routine syphilis screening did not
report or were unable to report the results of such screening on the survey.
Of those systems that did report, most had syphilis positivity rates of less
than 5 percent (table 11), but these are very incomplete data. Even fewer
correctional systems have mandatory or routine screening for gonorrhea or
chlamydia, and the few systems reporting results had positivity rates of
less than 5 percent for incoming inmates (tables 12-13). Indeed, the most
striking point about these survey findings is the rarity of screening and the
paucity of screening data. Since gonorrhea is likely to be symptomatic
among men, however, it is probable that most cases will be detected
without mass screening programs. 

Most available behavioral profiles of correctional inmates suggest that
they are at high risk for, and disproportionately infected with, STDs.
Anecdotal reports confirm this--for example, 24 percent of all of Chicago's
incident syphilis cases in 1996 were diagnosed in Cook County Jail, and
13 percent of Florida's syphilis morbidity was identified in correctional
facilities (site visit interviews, Chicago and Florida, March-April 1997).
Better estimates of the burden of STD morbidity among inmates may help
support increased resources for STD prevention and treatment programs in
correctional facilities.

Hepatitis Among Inmates

Hepatitis B vaccine is increasingly available to correctional inmates and
staff, and thus this infection, which is transmitted by the same routes as
HIV, can and should be brought under better control in correctional
facilities. The Occupational Safety and Health Administration (OSHA)
requires that correctional staff who have direct contact with inmates be
offered hepatitis B vaccination.

By contrast, there is not yet a vaccine or proven effective treatment for
hepatitis C, and this disease is an increasingly serious problem, particularly
among injection-drug users (IDUs) and persons infected with HIV.[1]  In a
1994 blinded study, 41 percent of incoming California inmates (39 percent
of men and 55 percent of women) were antibody positive for hepatitis C
virus (HCV). In the same study, 61 percent of HIV-seropositive men and
85 percent of HIV-seropositive women were also HCV positive.[2] A
study of female entrants to the Connecticut prison system found adjusted
odds ratios for HCV infection of 10 and 7, respectively, among
HIV-positive women and IDU women. More than 70 percent of IDU
women in the study were HCV positive, and 36 percent of sexual partners
of IDUs were HCV positive.[3] A voluntary study of 192 inmates at a
medium-security facility in Springhill, Nova Scotia, found that 28 percent
were HCV positive, but the rates were sharply higher among IDUs (52
percent) than among non-IDUs (3 percent).[4]  A pilot study of 108
incoming male and female inmates at the Hampden County,
Massachusetts, Correctional Center (Springfield area) in 1998 found that
22 percent were infected with HCV.[5]

Conclusion

Although available data are very incomplete, it appears that rates of STDs
and hepatitis B and C are higher among inmates than in the overall
population. Hepatitis C positivity rates are particularly high among
HIV-positive inmates and those with histories of injection-drug use. More
widespread implementation of hepatitis B immunization and screening for
hepatitis C in correctional facilities seem warranted.

Endnotes

1. Centers for Disease Control and Prevention, "The Epidemiology of
Viral Hepatitis in the United States," Morbidity and Mortality Weekly
Report 43 (1994): 437-455.

2. J.D. Ruiz and J. Mikanda, Seroprevalence of HIV, Hepatitis B,
Hepatitis C and Risk Behaviors Among Inmates Entering the California
Correctional System, Sacramento: California Department of Health
Services, Office of AIDS, HIV/AIDS Epidemiology Branch (March
1996): 1, 9, 12.

3. K.P. Fennie et al., "Hepatitis C Virus Seroprevalence and Seroincidence
in a Cohort of HIV+ and HIV- Female Inmates," poster abstract no.
Tu.C.2655, presented at the 11th International Conference on AIDS,
Vancouver, July 9, 1996.

4. L.Y. Lior et al., "A Look Behind Closed Doors: Injection and Sexual
Risk Behaviour and HIV, HBV and HCV Inside a Canadian Prison,"
poster abstract no. 23528, presented at the 12th World AIDS Conference,
Geneva, June 30, 1998. 

5. Thomas Conklin, Hampden County Correctional Center, unpublished
data.

-------------------------------

Chapter 3

HIV and STD Education and Behavioral Interventions

Theodore M. Hammett and Patricia Harmon-Abt Associates Inc. 

Key Findings

o HIV and STD prevention programs are becoming more widespread in
correctional facilities.

o However, few correctional systems have implemented comprehensive
and intensive HIV prevention programs in all of their facilities.

o Peer-based education and prevention programs offer important
advantages, including cost-effectiveness, credibility, flexibility, and
benefits to peers themselves.

o Although few HIV/STD prevention programs in correctional settings
have been rigorously evaluated, anecdotal evidence suggests that they can
be successful in reaching this extremely high-risk population with
practical risk-reduction messages.

Periods of incarceration offer important opportunities to provide HIV and
STD education and behavioral intervention programs for populations that
are at extremely high risk. Taking advantage of these opportunities,
moreover, stands to benefit not only inmates themselves but also the
health of the communities to which the vast majority of inmates return. A
wide range of HIV and STD prevention programs have been offered in
correctional facilities, but most have been and continue to be basic
education rather than more intensive behavioral interventions. In any case,
very few education and prevention programs in correctional facilities have
been subjected to a rigorous evaluation that includes conducting
interviews with former inmates in the community.[1]

Data from the 1997 NIJ/CDC survey presented in this chapter show that
HIV/STD education and prevention programs are becoming more
widespread in correctional facilities. Nevertheless, the important public
health opportunity to provide comprehensive HIV prevention programs for
correctional inmates has by no means been fully utilized.

Types of HIV/STD Education and Prevention Programs Provided

Table 14 summarizes the types of HIV/STD education and prevention
programs that correctional systems provided to inmates in at least one of
their facilities, according to the 1992, 1994, and 1997 NIJ/CDC surveys.
This shows that the percentage of State and Federal systems offering
instructor-led education rebounded to 94 percent in 1997 after dropping to
75 percent in 1994. The percentage of city/county systems providing
instructor-led education also increased in 1997 to 73 percent. 

Peer-led programs are in place in an increasing percentage of State/Federal
systems, but still in fewer than half. Only 7 percent of city/county jail
systems have peer programs, in part because inmates' short jail stays make
it more difficult to institute such programs. 

In the 1997 NIJ/CDC survey, the category "multisession prevention
counseling" was added to gauge the extent to which correctional systems
are moving beyond simple education and toward more intensive programs
designed to help inmates make and sustain the difficult behavioral changes
needed to reduce their risks of acquiring or transmitting HIV and STDs.
Almost 60 percent of State/Federal systems and 41 percent of city/county
jail systems reported offering such programs. Pre- and posttest HIV
counseling is offered in virtually all prison and jail systems, almost all
systems provide written materials on HIV and STDs, and large majorities
of systems employ audiovisuals.

The above figures reflect only the percentages of systems that reported
providing these types of education and prevention programs in at least one
of their facilities. The percentages of facilities (as opposed to systems) that
provide the same types of education and prevention programs (table 15)
are, in most cases, substantially lower. For example, less than two-thirds
of facilities provide instructor-led education, about one-third provide
multisession prevention counseling, and only 13 percent of State/Federal
prisons and 3 percent of city/county jails offer peer-led programs. Pre- and
posttest counseling was offered in the vast majority of facilities. 

The validation study, in which reported policies in individual facilities
were compared with those reported by systems' central offices, revealed a
fairly general agreement regarding education and prevention programs but
a few discrepancies as well (table 16). In particular, in systems that
reported providing multisession prevention counseling in all of their
facilities, only 59 percent of the facilities actually offered such programs.

The Importance of Comprehensive HIV/STD Education and Prevention
Programs

Comprehensive HIV/STD education and prevention programs should be
provided for correctional inmates, given the prevalence of high-risk
behaviors among them, the opportunity for interventions afforded during
periods of incarceration, and the potential public health benefits of such
programs. Given the existing knowledge of prevention and of the
particular circumstances and needs of the correctional setting, a
comprehensive program may reasonably be said to include instructor-led
education, peer-led programs, pre- and posttest counseling, and
multisession prevention counseling. The results of the 1997 NIJ/CDC
survey reveal that only 10 percent of State/Federal prison systems and 5
percent of city/county jail systems offer comprehensive programs meeting
this definition in all of their facilities. Clearly, then, there remains much
room for improvement in the depth and coverage of HIV/STD education
and prevention programs in correctional facilities. A promising approach
in this realm is occurring in Massachusetts, where the Department of
Public Health is funding comprehensive HIV/AIDS programs in the
State's county jails. To be eligible for this funding, the counties must
propose a program including HIV/AIDS prevention and education for
inmates and staff, HIV counseling and testing, HIV primary care and case
management, and aftercare/transitional planning. The HIV/AIDS
prevention and education component must include "most or all" of the
following elements: 

o Orientation.

o Peer education.

o Community-based prevention and education. 

o Individual prevention and education, on request.

o Written and audiovisual materials.

o Prevention and education in prerelease, day reporting, and pretrial
populations.

o Gender-specific programs at facilities housing women.

o Expansion of HIV curriculums to cover other communicable diseases.

o Programs and materials available in Spanish and English.

In addition, each county program must commit to funding 50 percent of a
full-time HIV/AIDS coordinator for the jail, with the State funding the
other 50 percent.[2]

Instructor-Led Education and Educational Materials

Seventy-one percent of State/Federal prison systems and 5 percent of
city/county jail systems reported that HIV/STD education was mandatory
for all incoming inmates; 20 percent of State/Federal but no city/county
systems reported mandatory HIV/STD education at release. Fifty-one
percent of State/Federal systems and 44 percent of city/county systems
reported voluntary HIV/STD education at release. The Illinois
Departments of Corrections and Public Health jointly planned a prerelease
HIV education and referral program being presented by existing prerelease
counselors and inmate peer educators who were specially trained to
provide these services in prerelease centers. 

The smaller percentages of city/county systems with mandatory education
programs no doubt relate to the shorter lengths of stay and more rapid
turnover of inmates in jails as compared with those in prisons. 

The validation study revealed some discrepancies regarding whether
educational sessions were mandatory. Substantial percentages of facilities
in systems with "mandatory" HIV/STD education at intake or release
reported that these sessions were not in fact mandatory for all inmates
(table16).  

Table 17 shows the topics covered in HIV/STD education programs,
according to the 1997 NIJ/CDC survey results. Basic information on the
diseases and the meaning of test results tend to be covered in almost all
systems' education programs. However, topics pertinent to behavioral-risk
reduction--including safer sex practices, negotiating safer sex, safer
injection practices, and triggers for behavioral relapse--are less commonly
included. These are the types of topics that are likely to be intensively
covered in multisession prevention programs.

Similarly, validation study results indicate that discrepancies between
central office and facility responses are most frequent on topics relating to
behavioral-risk reduction (see table 18). This may be because these topics
are more controversial. The left side of table 18 shows the extent of
agreement in systems reporting that the listed topic is covered in their
education programs. For example, in seven systems reporting that
negotiation skills for safer sex were included in their education, fewer than
half (45 percent) of facilities reported that this topic was in fact covered.
Conversely, in eight systems reporting that this topic was not covered in
HIV/STD education, half of the facilities reported that it was included.
Thus, some individual facilities are going beyond the educational topics
ostensibly prescribed by their central offices. 

Table 19 shows the categories of providers of HIV/STD education and
prevention programs in correctional systems. Very few systems are using
security staff to conduct HIV/AIDS education, whereas the involvement of
public health departments, AIDS service organizations, and other 
community-based organizations is widespread. This indicates an
increasing willingness on the part of correctional systems to permit outside
organizations to offer programs in their facilities. 

Accessibility and understandability of educational programs and materials
are critical to their effectiveness with inmates. In this regard, issues of
language, literacy, and cultural competence are pertinent. Thirty-nine
percent of State/Federal prison systems and 49 percent of city/county jail
systems report offering HIV/STD educational sessions in Spanish. These
percentages remain virtually unchanged from the 1994 survey (39 percent
and 41 percent, respectively). Fifty-five percent of State/Federal systems
and 66 percent of city/county systems reported having HIV/STD
educational materials for Latinos. Forty-one percent of State/Federal
systems and 58 percent of city/county systems said they had materials
especially for African-Americans, and 84 percent and 70 percent,
respectively, reported having materials especially for women. Similar
percentages were reported in 1994. More attention should probably be
paid to the development and distribution of culturally appropriate
HIV/STD educational materials. The mean grade level of HIV/STD
materials used by reporting correctional systems was 6.4 (SD = 1.8),
which seems appropriate. 

Three examples of instructor-led HIV/STD education and prevention
programs observed as part of site visits conducted for the NIJ/CDC survey
are presented in the following text boxes.

Peer-Based Programs

Inmate peer-based programs have four key advantages: credibility, range
of services, cost-effectiveness, and benefits to peer educators themselves.
Peer educators probably have more inherent credibility with inmates than
representatives of "the system." They speak the language of inmates and
have had similar life experiences. To be effective, however, it is important
and challenging for peer educators to avoid being seen as allies of or
spokespersons for the system, particularly in programs in which
correctional officials play evident roles in their selection. 

Peers can offer a range of services, including orientation ("AIDS 101");
individual and group risk-reduction counseling; and informal interaction
with inmates in the yard, during programs, and at other times and places
apart from structured meetings and presentations. Peer educators often go
on to work with inmates with HIV disease, explaining drug regimens and
improving adherence, serving as "buddies" and offering other supportive
services, and providing hospice care for terminally ill patients. Elizabeth
Mastroieni, Coordinator of AIDS Counseling and Education (ACE) at
New York's Bedford Hills women's facility, one of the first and best
established HIV peer inmate programs, described some of ACE's tangible
and intangible benefits.

I witness miracles here every day. I see women. . . sharing their
commissary and sharing their experiences. I witness women volunteering
their time to nurse women back to health, to educate them about their
health and cry with them about the experience of loss. I have been filled
by the bittersweet memorial services where a woman's life is celebrated as
her memory fills the room and enlivens the spirit.

For three years I have witnessed the energy of brainstorming, creating,
planning, and physically walking to raise money for children they do not
know but care for because of their emotions as wife, mother, lover, aunt,
sister, and friend . . . .

There is laughter. There is community. There is a sense that I can do for
others and they can and want to do for me. There is support. . . . There are
many miracles here at Bedford.[5]

Peer programs can be highly cost effective. Peers can provide formal and
informal services almost around the clock. They are often available when
regular staff are not. The only substantial costs of peer programs are likely
to be for training the peers. It is advantageous to have regular inmate work
slots designated for peer educators (as at the Albion women's facility in
New York State and at several California prisons), but inmate wages are
very low and in many systems are negligible, so this should not represent a
large expense, particularly in comparison with the cost of other models of
delivering education and prevention programs. The Oklahoma Department
of Health developed a peer program for women inmates in that State for
$4,000 in outside grant funds.[6]

Finally, inmate peer educators commonly report tremendous improvements
in self-esteem, knowledge, and commitment to the community based on
their experiences in these programs. Many go on to paid positions in HIV
prevention following their release from prison. Kathy McGrath became a
peer educator at Massachusetts Correctional Institution-Framingham and
now works as an HIV educator for Great Brook Valley Health Center in
Worcester. McGrath reported that "becoming a peer educator was the start
of my life" after years of drug addiction and repeated incarceration.
Moreover, she stated, "There are so many women like me who have
everything it takes inside, but no outlet for it."[7] Miguel Cruz was the first
HIV peer educator at Hampden County (Massachusetts) Correctional
Center and is employed as an HIV outreach worker at Holyoke Health
Center. Cruz spent 18 years of his life as a heroin addict and dealer.
According to a coworker:

Miguel is a man at peace with himself, and he is enjoying what life has to
offer him for the first time in two decades-going to the movies, playing
sports, doing a job he loves and doing it well, owning a car and nice
clothes. These are the rewards of a new life and he is not about to give that
up. His old friends from the street, he says, were at first skeptical just
waiting for him to do that first bag. This hasn't happened and that
skepticism is being replaced with unmistakable respect and admiration.
Miguel, their old compatriot, who was every bit one of them, now has
turned his life around and is back to the same old streets, trying to help his
buddies in any way he can to do the same. . . .

Miguel's 18-year training program for his present job gives him the ability
to accomplish things on the street that I, for example, simply never could.
His mere presence on the street, as living proof to all his old neighbors that
the evil power of addiction can be beaten, has more life-changing potential
than 10 doctors trying to patch these people up and to keep them alive. . . .
Miguel is not a doctor, but he is a healer. [8]

Although HIV/AIDS peer programs are finding increasing acceptance
among correctional administrators, there may still be resistance.
Opposition is most often based on suspicion of initiatives that seek to
"empower" inmates. Some administrators may view any empowerment of
inmates as an ultimate threat to discipline and order in their facility. At
one Federal facility, a new warden discontinued HIV/AIDS orientation
presented by peer educators because he considered this an "inappropriate"
role for inmates. 

Inmates themselves may have to address and overcome stigma that may
result from their involvement. It may be assumed, for example, that
anyone volunteering to be an HIV peer educator must be HIV infected. 

Inmate peer programs are easiest to implement in prison systems in which
inmates stay long enough to have a stable group of educators. However,
peer programs have been successfully established in jail systems as well.
In jails, peer educators are generally drawn from sentenced inmates. As of
the end of 1995, nine county jails in Massachusetts had established HIV
peer education programs with funding from the State's Department of
Public Health (DPH).[9] All of the Massachusetts county jails were
expected to implement peer education in 1998 as part of comprehensive
HIV/AIDS programs funded by DPH.[10]

Factors in successful peer-based programs include the following:

o Working closely with correctional officials in planning the program. To
address common objections and overcome resistance, a written proposal
should be submitted describing the program and its benefits.

o Involving outside organizations, such as public health agencies or AIDS
service organizations, in leading or otherwise key roles to demonstrate the
program's independence from the correctional system and thereby to build
credibility with the inmates.

o Carefully screening peer educator candidates for motivation, sincerity,
commitment, and absence of emotional problems and inappropriate
personal "agendas." Candidates' length of time left to serve should be
sufficient to allow them to contribute significantly to the program before
they are released.

o Ensuring that peer educators reflect the linguistic, racial, and cultural
profile of the inmate population.

o Giving peer educators specific goals and incentives, such as academic
credit, prison job slots, or "good time."

o Developing a peer-driven curriculum rather than one that is driven
primarily by the goals of the correctional system.

o Being sensitive to the stigma still associated with HIV/AIDS in many
correctional facilities that may adversely affect the recruitment of peers
and attendance at programs.

o Providing counseling and support for peer educators as necessary.[11]

The advantages of peer programs and the factors facilitating the success of
such programs are well illustrated by case studies of programs in the adult
correctional systems of Louisiana and California and the Los Angeles 
County juvenile system, observed during site visits for the survey. 

Louisiana

Between 1992 and 1997, under the leadership of the late William
Crawford, HIV/AIDS Services Education and Training Coordinator at the
Louisiana Office of Public Health, peer education and counseling
programs were established at six Louisiana State prisons--Angola,
Avoyelles, Dixon, Hunt, and Washington (men's facilities), and the
Louisiana Correctional Institution for Women, St. Gabriel. More than 150
inmates were trained as peer educators/counselors. In addition, about 400
correctional staff in health services, mental health, and security received
2-day training sessions on HIV/AIDS and STDs.

The inmate peer educators/counselors provided HIV/AIDS and STD
orientation sessions to all inmates at intake and prerelease. They also
offered one-on-one counseling for inmates considering HIV antibody
testing and others with concerns about HIV/AIDS and STDs, provided
educational sessions to inmate clubs and organizations, gave support to
inmates living with HIV or AIDS and those with loved ones living with
HIV or AIDS outside, and acted as liaisons for inmates hospitalized with
HIV disease.

In their educational presentations and individual prevention counseling,
the peers were permitted to discuss practical risk reduction--for example,
condom use and cleaning procedures for drug-injection material-in frank
and open terms, but they were not permitted to distribute condoms or
bleach. In informal conversations, however, inmates from several prisons
stated that condoms and bleach were fairly readily available--condoms "on
the walk" (in the exercise yard) in exchange for cigarettes, and bleach
from dorm-cleaning crews. 

Crawford emphasized the importance to the success of the peer programs
of gaining and keeping the trust and support of the correctional system and
its staff. It is necessary to understand and be sensitive to the "gargantuan"
task that prison administrators face and to accept the ground rules the
correctional system sets for a peer program. Within these ground rules,
Crawford stated, much can be accomplished. However, it is
counterproductive to "press an agenda" for condom distribution or other
controversial measures. Instead, it is better to reach agreement on what can
and cannot be done. Crawford noted that "you can get a lot more with a
smile than with a frown." 

To succeed, the program needs the full support of the administration at
central office and facility levels. An advocate within the system is critical
to overcoming the suspicion that inevitably greets suggestions for
establishing inmate peer programs and to obtaining initial agreement.
Once agreement is reached on scope and ground rules of the program,
peers' specific responsibilities can be negotiated. 

Inmate peer educators/counselors in Louisiana were recruited and selected
by nominations from other peers and from the mental health and health
services staff of the facility. Inmates interested in being peer
educators/counselors could also apply. The existing peers did the initial
screening and recommended 12-15 inmates. At Avoyelles, the mental
health director and peer program coordinator made final selections based
on conviction offense, sentence, prison disciplinary record, and any
handicaps. A critical criterion for selection was the inmate's agreement to
be a role model in terms of personal behavior. In particular, this meant that
the inmate would have to commit himself or herself to abstaining from all
sexual activity and drug use in prison. Final selections of peers had to be
approved by the facility's warden.

State Public Health Office staff conducted the training for the peer
educators/counselors. The class consisted of a minimum of 12 inmates.
Three or four classes were trained at each participating facility each year
to ensure continuity and effective performance of responsibilities. As part
of the training, each trainee was required to prepare and deliver an
orientation presentation chosen from a list of possible topics distributed to
the class. At Avoyelles, one inmate asked to prepare a presentation on a
topic of his own choice that was not on the list. This involved conducting
and presenting the results of a survey of inmates on risk behaviors for HIV
and levels of perceived risk. Peer programs at the Louisiana State
Penitentiary at Angola and the Avoyelles Correctional Center are
described in the text boxes on the following pages.  

A major issue for the Louisiana peer educators was overcoming
stigmatization and stereotyping by other inmates. One of the peers
reported that his attendance at the training caused him to be "diagnosed
with AIDS by my peers." Another peer educator described this as a
"powerful learning experience" regarding attitudes toward people with
HIV/AIDS that "could have been taught no other way."  However, the
peers were quite successful in winning the trust and support of the inmate
population. Almost 50 inmates attended the first session offered by the
peer educator who reported being initially stigmatized. He stated that there
is much concern about HIV/AIDS among inmates, even though many will
not speak openly about it. 

A primary objective of any education/prevention program is to bring about
positive change in the attitudes and behaviors of the target population.
However, with efforts such as the Louisiana inmate peer
education/counseling program, extremely important benefits can be
achieved among peer educators themselves. They develop positive focus
and purpose in their lives, become empowered, and perceive their own
ability to influence others in ways they never believed they could do. The
presentations by Louisiana peer educators during the site visit
demonstrated the poise, confidence, and commitment the program has
helped these inmates to develop. Andrew Joseph, an Angola inmate, has
changed his attitudes regarding HIV/AIDS dramatically. In 1987, Joseph
wrote in The Angolite, the inmate magazine, that he wanted nothing to do
with inmates with AIDS. Within a few years, Joseph had become a leader
of the peer education/counseling program at the prison and was master of
ceremonies at the 1996 HIV/AIDS education conference.

Greg Lehtonen, a peer educator at Avoyelles, wrote about the way his
HIV-positive status and his involvement in the peer program had changed
his life:

My attitude is much different now. My life here in prison isn't about being
tough and playing games. I find myself caring much more about others,
and my mind is on more serious matters . . . I constantly pray and hope
that I will see my family again, whom I have not seen in so many years,
due to my lifestyle! I always knew that I was a good person inside, and I
want my family to see and know that side of me-instead of remembering
the monster who did all those bad things. I used to not care about dying.
Now I want to live and let people see the good Greg!

Two former ACT counselors from Avoyelles are now working for AIDS
service organizations in the community. Other peer educators currently in
prison are also interested in continuing this work when they are released.
Many of them have shown an ability to overcome stigmatization and
hostility and to become effective educators, counselors, and supporters of
positive change among inmates. 

California

The Public Health Section of the California Department of Corrections'
Health Services Division is working closely with facility administrators
and the custody and health services staff to implement standardized HIV
peer education programs at all State prisons.[12] The Public Health
Section is preparing a video on the peer programs in several State prisons.
When completed, this video will be used for educational purposes as well
as to help recruit new peer educators. The peer programs at San Quentin,
Frontera, and Vacaville are described below.  

California State Prison, San Quentin

The average daily population of San Quentin is 5,500 to 6,000 men. About
60 percent of the population of this medium-security facility are reception
center inmates who are processed within 45 days and sent off to their
assigned facilities in the system. The rest of the inmates are "endorsed" to
San Quentin. Between 1986 and 1997, the California Department of
Corrections and the Marin (County) AIDS Project (MAP) collaborated on
HIV education and prevention programs at San Quentin. In 1997 MAP's
role was assumed by Centerforce, another community-based service
organization. Since 1991, the Center for AIDS Prevention Studies (CAPS)
at the University of California, San Francisco, has been conducting
collaborative evaluations with the staff of the San Quentin programs. The
programs have evolved over the years with input from peer educators and
strong support across the prison administration, from the warden and
upper management to correctional counselors and officers.

The inmate peer education program is the centerpiece of San Quentin's
HIV prevention initiatives. It began in 1986 with prerelease sessions
facilitated by program staff and has since expanded to include
comprehensive peer education training. Peers may facilitate most
educational interventions, including new inmate orientation and other
health-related services. San Quentin has five paid HIV peer educator
prison work positions. The average tenure as a peer educator is 6 months,
although many educators have served substantially longer.

Peer educators receive 5 days of comprehensive training. Centerforce staff
and community experts present 2 of these training courses per year to
25-30 inmates. Graduates receive certificates as peer educators. The
graduates receive an additional day of special training to present
orientations, one of the key duties of the peer educators. The goals of this
training are to create a pool of inmate peer educators, to introduce
participants to public speaking techniques, to increase their awareness of
the relationship between substance use and high-risk behaviors, to increase
multicultural awareness, and to provide a broad perspective on the impact
of HIV/AIDS on U.S. society and worldwide. Besides the usual attention
to the basics of HIV/AIDS, antibody testing, and the related issues of
STDs and TB, the training includes sessions on the real meaning of
HIV/AIDS statistics, family issues, racial/ethnic diversity, gay sensitivity,
and grief and loss. All participants also prepare and deliver timed talks to
practice public speaking techniques. These talks are critiqued by the
instructors and the class. Some classes have made videotaped public
service announcements that have been broadcast on the prison's
closed-circuit television station.

Peer educators observed during a site visit to San Quentin appeared to be
highly dedicated and committed to their work. One of them noted that a
year earlier he could not have imagined doing this work, but now he was
committed to "giving something back" and felt very rewarded for the
effort. Another peer educator said he originally signed up thinking that it
would be an easy "kick back" job. Quickly, however, he realized that it
was an intense, demanding job and accepted the challenge. Prison is the
"perfect place" to do HIV education and prevention with this population,
one of the peers noted, because the inmates are off drugs and have "clear
heads." 

The program staff have to play a difficult balancing act to gain and keep
the trust of both the inmates and the prison administration. If they are seen
with inmates too much, they run the risk of having the officers and
administration suspect them of joining "the enemy." Conversely, if they
work too closely with the administration, they may cause suspicion among
the inmates. The programs tend to emphasize "harm reduction" over strict
abstinence, in part because this helps to overcome the resistance of the
inmates, who otherwise might feel that "we're just telling them what to
do." By succeeding in maintaining this balance, the program staff are able
to educate both the inmates and the administration. They report that
officers often ask them questions about HIV.

The peer educators are a diverse group, including African- Americans,
Latinos, and whites, and gay and straight inmates with various drug and
alcohol histories. Most of the peer educators are HIV positive, but about
half of a recent group of trainees were HIV negative. Peer educators
appear to be very supportive of one another. Several said they hoped to
continue doing this work in the community after their release. One had
already written to several community-based organizations (CBOs) asking
about possible employment. 

Orientation sessions. Inmate peer educators present required HIV
orientation sessions for approximately 18,000 new inmates at San Quentin
each year. This program was mandated in 1991 after focus groups with
soon-to-be-released inmates suggested the need for more HIV information
and education. The orientation is mandatory, but only about 75 percent
actually receive it. Scheduling and other logistical problems preclude
providing orientation to all incoming inmates. 

The orientation is presented by teams of peer educators to groups of about
20 inmates in a classroom dedicated to this purpose. The session seeks to
"put a face on the epidemic" and to increase inmates' awareness of their
own risky behavior by having an HIV-positive peer educator present his
own story. Subsequently, the following topics are covered in the
orientation: the difference between HIV infection and AIDS; the four body
fluids that can transmit the virus; modes of transmission; safer sex issues;
the role of substance use in high-risk behavior; and HIV-antibody testing.
Ample time is allowed for questions and answers. The peers attempt to
dispel myths about HIV, including the apparently persistent belief that
HIV cannot be acquired heterosexually, and to encourage HIV-antibody
testing. Another strategy is to focus on the inmate's desire to protect his
family from HIV as a way of resisting peer pressure to engage in high-risk
behavior. The ultimate objective of the orientation and additional
education that peers provide is to induce inmates to reduce their own risky
behaviors. 

In addition to making the presentations, the peer educators prepare
paperwork for inmates interested in HIV testing (substantial numbers of
inmates take advantage of voluntary HIV testing, but the precise rates are
in dispute), document attendance, distribute and collect evaluations, and
maintain the classroom. Bilingual educators are available to meet the
needs of monolingual Spanish-speaking inmates. The peers also
participate in training sessions for new educators. 

Centerforce staff provide ongoing supervision, education, and other
support to the peer educators, spending approximately 10 hours per week
on site for these purposes. There is a weekly supervision meeting
involving the peer educators, Centerforce staff, a prison counselor, and/or
program sponsor.

CAPS and Centerforce conducted a collaborative study of the orientation
component. In a randomized design, a total of 2,295 incoming inmates
were assigned to orientation by an inmate peer educator, to orientation by
a professional educator, or no intervention. All participants completed a
survey of knowledge and behavioral intentions. The two intervention
groups had similar outcomes, both outperforming the no-intervention
group in intention to use condoms and seek HIV-antibody testing. The
intervention groups also had significantly higher self-perceptions of HIV
risk than the no-intervention group. The inmate participants
overwhelmingly favored HIV-positive peer educators over other providers
of the intervention.[13]

HIV intervention. Centerforce staff team up with one of the inmate peer
educators to present HIV education sessions to various groups and in
various settings in the prison, including prerelease classes (a 2-hour
session during the voluntary 3-week prerelease program), English as a
second language (ESL) classes, vocational classes, and others. The
objectives of these sessions are to present the "personal side" of
HIV/AIDS, to raise inmates' self-perceptions of risk, and to increase
general knowledge of HIV, testing issues, and resources available in the
community following release. 

Prerelease "booster" intervention. A prerelease booster invention is
presented on a voluntary basis to inmates 7-14 days prior to release. As
part of a research study, prerelease inmates who agreed to participate were
randomized to an intervention or no-intervention group. All participants
received an extensive baseline survey of knowledge, attitudes, and
behaviors, conducted one-on-one by a staff interviewer. The intervention
group also participated in a 30-minute one-on-one prevention booster
session with an HIV-positive peer educator. This session was specifically
designed to encourage risk reduction through condom use, avoidance of
substance use, and safer substance use strategies. Participants also
received referrals to community- based services. The no-intervention
group received only written materials and referrals. Inmates being released
from San Quentin received an HIV prevention brochure designed and
written by the peer educators that contains practical risk-reduction
suggestions described in frank language with drawings. Between 1 and 4
weeks after release, 43 percent of participants completed a telephone
followup survey regarding risk education and risk behaviors. Intervention
group participants were significantly more likely than comparison group
members to report condom use in their first postrelease sexual encounter
and were less likely to report using drugs or sharing needles in their first
weeks after release.[14]

Centerforce and CAPS are also completing a 3-year project for
HIV-infected inmates, funded by the universitywide AIDS Research
Program at the University of California. This program includes a
comprehensive 2-week "prerelease" education intervention with a focus on
staying healthy and accessing community service providers upon release
from custody. A unique aspect of this program is a resource fair of service
providers from counties to which the inmate participants are being
released. This allows the inmate and the community service provider to
make face-to-face contact and a personal connection prior to release.

Peer educator support. HIV-positive peer educators provide support to
other inmates who are newly diagnosed with HIV. This counseling
includes discussion of the meaning of HIV infection, circumstances of the
inmate's learning his status, his current physical and psychological state,
disclosure of status, sexual risk reduction, and policies for housing and
treating inmates with HIV. The initial session lasts 20-30 minutes;
followup sessions are offered. Inmate peer educators spend 2 hours per
week doing this counseling. Centerforce staff provide support and
educational backup for the peers.

HIV education for female visitors. Centerforce and CAPS are developing
and evaluating a peer HIV education program for women visiting male
inmates at San Quentin. Formative data reveal that female visitors are in
need of HIV education, support, and community referrals. Inmate peer
educators are planning and conducting group discussion sessions with
women visitors in the visitor center. CAPS will evaluate the intervention
in terms of utilization of community resources and self-reported
behavioral change.

Two other peer programs in California State adult correctional facilities
are described in the following text boxes.

Programs in Los Angeles County Juvenile System

Los Angeles County has the largest number of confined and probationary
youths of any juvenile system in the United States. About 27,000 enter the
system annually, and the average daily population of confined and
probationary youths (that is, those involved in school or other programs at
a juvenile facility) is about 4,000. Two peer-based HIV prevention
programs for youths in the Los Angeles County juvenile system, the AIDS
Video Project and the Peer HIV Education Project, are discussed below.

AIDS Video Project. The AIDS Video Project (AVP) provides youths on
probation with interactive and culturally appropriate HIV and STD
education. The AVP seeks to increase participants' knowledge and
application of HIV risk-reduction practices through classroom education
and training to become peer educators. The video production component is
the final stage in an educational process designed to teach as well as
involve students, inducing them to "open up" about their risk factors and
the behavioral changes needed to reduce their risks for HIV and other
STDs.

To be certified as a peer educator, a student must successfully complete an
eight-session educational program. More than 80 youths undergo this
training each year. Once certified, the peer educators work in teams to
create an HIV prevention video that can be shown as part of educational
sessions that the peer educators help to present in their own and other
juvenile facilities. The AVP has created about six videos each year since
its inception in 1989 and reached about 600 youths with HIV and STD
education.

At the conclusion of these education sessions, the attendees receive an
information packet and, if the facility permits it, condoms. The
information packet includes a resource guide developed by AVP, which
lists testing/counseling, family planning, and related services at little or no
cost within a 5- to 10-mile radius of each community education center.

Peer educator training. The peer educator training consists of eight 2-hour
sessions offered primarily in the community school facilities attended by
youths on probation who are living at home. The former AVP coordinator
noted that this is best, since "there's nothing like when they're actually . . .
able to have sex . . . [and] do drugs as opposed to when they were locked
up. . . . That's when they're really struggling with issues like why it's so
hard a subject to talk about, or did they use condoms this weekend."

The training sessions are presented by the AVP coordinator and a health
educator assistant. They follow an established curriculum that includes
exercises focusing on making decisions, clarifying values, enhancing
self-esteem, and exploring practical methods of HIV and STD risk
reduction. Extensive use is made of games and interactive exercises to
gain and hold students' attention. One session includes a presentation by
an HIV-positive speaker.

In the session attended during a site visit for this study, the educators used
several methods to involve the students. They passed around a "question
box" into which students could place any questions they wanted answered,
and the educators tried to answer all of them. The educators used cartoon
depictions of techniques for cleaning drug-injection equipment,
demonstrated proper condom use and factors for selecting condoms, and
employed a game (the "condom relay") to enable students to practice
proper condom use. The educators also provided good, understandable
discussions of the natural history of HIV disease and the differences
between confidential and anonymous testing.

Video production. As with the peer educator training, most of the video
production takes place at community schools that the youths attend while
living at home. The videos are the results of the collaborative efforts of the
students, the educators, and an independent filmmaker. Only 3 days are
allocated to the production of each video, from concept development to
final product. Thus, things must move quickly. The first day is spent
deciding on the concept and the story. The students develop the story, and
the filmmaker helps them storyboard the elements of their story, cutting
sections that do not fit or are impossible to shoot. All filming must be
done in the facility, so sets and props are limited- "You notice a lot of
'beds' that look like desks." The filming of the 5- to 8-minute videos must
be done in two 5-hour days of work. Shooting scripts are not used because
of the students' low literacy levels, so each scene must be done as a
rehearsed improvisation. The students all double as actors and crew
members, getting an opportunity to learn about filmmaking as well as
acting and the substantive issues involved in the story. Scenes are shot
numerous times from different angles. Once shooting is completed, the
students decide on music to be included and the filmmaker edits the video.

The filmmaker generally notes significant changes over the 3-day
production period. The students often begin by being "kind of aloof" but
become increasingly involved with and committed to the project. Their
level of involvement is sparked by employing a monitor that allows the
students to see simultaneously what is being filmed.

Completed AVP videos have used a variety of genres, including comedy,
musical, and drama. In "Captain Condom," a "condom-adorned" superhero
appears magically in a couple's living room to provide advice on safer sex.
"Class reunion" explores the reaction of a class to the news that a member
has died of AIDS. "Lunatic Rap" features a female rap duo performing
"HIV is in the 'Hood.'"

Once the video is completed, the peer educators present it to the other
students in the school as part of an HIV education session. The former
AVP coordinator states that this is "the best day on the planet." The
students are proud of their achievement, and the other students generally
respond favorably and with respect. The day ends with AVP giving a party
for the video makers.

Evaluation. AVP attempts to follow up with all peer educators at 3 and 6
months following their completion of the program. Tracking the
population is difficult, so followup rates are fairly low. Of 61 peers trained
in fiscal year 1994, 17 (28 percent) provided followup interviews. Low
followup may indicate biased selection, so conclusions based on these
samples may overstate positive outcomes. In any event, more than
three-quarters (76 percent) of the 1994 peer educators who provided
followup interviews reported an increase in HIV risk-reduction behaviors--
condom use and/or cleaning of injection material. Among 662 confined
and probationary youth exposed to AVP education sessions, the average
pre- to postknowledge gain was 23 percent.

Recent data reveal an average pre- to postknowledge gain of more than 90
percent among the youths being trained as peer educators. Followup at 3
and 6 months revealed that more than 80 percent reported an increase in at
least one risk-reduction behavior.

It is also important to recognize the intangible and immeasurable positive
outcomes of AVP. The former coordinator notes that it is important to give
these kids, many of whom are "set up to fail," a place where they can
succeed at something. "And if you have kids who feel that they're
succeeding, it will be easier for them to use a condom."

Peer HIV Education Project. The Peer HIV Education Project (PHEP) was
operated by JWCH Institute and supported by the Los Angeles County
Health Department using funds from the CDC Health Education and Risk
Reduction Cooperative Agreement. The PHEP presented mandatory
HIV/STD education sessions in county juvenile facilities, including
community education centers, juvenile halls, and camps. 

PHEP began operations in October 1995 using teams composed of a peer
educator and an adult professional. The PHEP curriculum consisted of
4-hour sessions and included numerous games and interactive exercises.

An evening PHEP session at Camp Routh was observed as part of the site
visit for this study. This was a condensation of the four-session curriculum
into one 2-hour session, and it seemed to work quite well. The adult
educator and the two peer educators involved in this session worked very
well together, trading off sections of the presentation quite smoothly. All
seemed comfortable with the subject matter and seemed able to establish
rapport with the students. The peer educators spoke effectively from their
own experiences with HIV risk behavior and used humor and
understandable slang terms very well.

A particularly effective part of the session was an outside speaker's
disclosure of his HIV-positive status in the midst of his presentation. He
was not identified at the outset as an HIV-positive person but rather
"sprung" his disclosure in the course of a discussion of heterosexual risk.
Once he had disclosed his status, he said, "It pisses me off that so many of
you think [based on your responses to the pretest] that you can't get HIV
through sex with a woman." The speaker went on to challenge the notion
that one can't deal with being HIV positive. It is admittedly very hard in
some ways, he said, but it can also be rewarding and fulfilling to help
others protect themselves against HIV. He acknowledged that he does not
have sex very much anymore because he is scrupulous to disclose his
status, and most women do not want anything to do with him once they
know he is HIV positive.

The session also included the "Virus Z" game, in which handshakes
among the group are used to demonstrate how a network of transmission
can develop very quickly. The educators demonstrated proper condom use
and involved students in this demonstration as well. In the course of the
demonstration, the educators discussed common condom substitutes and
cautioned against the use of microwavable plastic wrap because it has
microscopic holes. Female condoms and dental dams were discussed and
shown to the group. Another useful item of advice included in the
presentation was to avoid oral sex within 4 hours of brushing teeth.
Toothbrushing can cause small cuts in the mouth, thus providing a
possible avenue of transmission. Finally, the educators passed around
graphic photographs of STD conditions, and these seemed to have a strong
impact on the youths.

Evaluation forms submitted at the end of this and other PHEP sessions
observed during the site visit revealed overwhelmingly positive participant
responses, particularly regarding the approach taken by the educators and
the rapport they were able to develop with the participants. The following
are some examples of these comments:

o I think Tricia and Kay are good speakers and make good games that are
fun and let you learn at the same time. They're cool too, and respected us.

o I thought the speakers knew how to talk to us. I felt really comfortable
with them.

o I thought I knew a lot about HIV/AIDS, but I guess not. And now I'm
more interested in learning about my health!!!

o I really learned a lot and changed my mind about getting an HIV test. I
was scared, but now I'm going to take the test.

o I would like to thank you all for taking the time for us. I'm glad you
didn't take advantage of us being inmates. Thank you for treating us like
real people. 

o I think the class is very helpful. The teachers are great. They get down to
the point. That's how it should be done.

o I feel this is important because it is something we all have to learn about,
because it's not a fairy tale.

Conclusion

The 1997 NIJ/CDC survey reveals that HIV/AIDS and STD education
programs are becoming more widespread in correctional facilities but that
most facilities still do not provide a comprehensive program of HIV
prevention. In particular, more intensive interventions such as multisession
prevention counseling and peer-based programs should be expanded.
Peer-based programs offer distinct advantages of credibility,
cost-effectiveness, and benefit to the peer educators themselves. Although
systematic evaluation of peer programs has been limited, there are strong
indications from many programs, including those described in this chapter,
that peer-based programs can be effective in reaching inmates with
practical information on HIV and STD prevention. 

Endnotes

1. See the extensive literature review in T.M. Hammett, J.L. Gaiter, and C.
Crawford, "Reaching Seriously At-Risk Populations: Health Interventions
in Criminal Justice Settings," Health Education and Behavior 25 (February
1998): 99-120; and in R. Braithwaite, T. Hammett, and R. Mayberry,
Prisons and AIDS: A Public Health Challenge, San Francisco:
Jossey-Bass, 1996. 

2. Massachusetts Department of Public Health, AIDS Bureau, "Request
for Applications: Massachusetts County Sheriff's Department HIV/AIDS
Program," March 6, 1998. For more information on this program, contact
Tim Gagnon, Massachusetts Department of Public Health, AIDS Bureau,
250 Washington Street, 3rd floor, Boston, MA 02108-4619 (telephone:
617-624-5300).

3. Further information on the Forensic AIDS Project's programs in the San
Francisco jails may be obtained from Anne Stillwell, Director, 798
Brannan Street, San Francisco, CA 94103 (telephone: 415-863-8237).

4. Further information on the Corrections AIDS Prevention Program in
New York City may be obtained from the New York City Department of
Health, Bureau of HIV Prevention, Office of Corrections AIDS
Prevention, Beverly McDonald, Director, 253 Broadway, Room 602, New
York, NY 10007 (telephone: 212-676-2900).

5. "AIDS Counseling and Education" (program description), n.d. For more
information about ACE, contact Elizabeth Mastroieni, Coordinator,
Bedford Hills Correctional Facility, Bedford Hills, NY 10507.

6. "Tips for Starting a Peer Education Program for Inmates," AIDS Policy
and Law (April 18, 1997): 8-9.

7. K. McGrath, presentation at panel on peer education,   "HIV Treatment
Update for Prisons and Jails," Cambridge, MA, March 13, 1998.

8. P. Loescher, untitled story of his 2 days on the streets of Holyoke with
Miguel Cruz, distributed at the panel on peer education, "HIV Treatment
Update for Prisons and Jails," Cambridge, MA, March 13, 1998.

9. Massachusetts Sheriffs' Association, HIV/AIDS in the Massachusetts
County Correctional System, 1995, Massachusetts Sheriffs' Association
Task Force Report, 1997.

10. Massachusetts Department of Public Health, AIDS Bureau, "Request
for Applications: Massachusetts County Sheriff's Department HIV/AIDS
Program," March 6, 1998.

11. This list is based in part on "Tips for Starting a Peer Education
Program." See note 6.

12. For further information on peer programs in California prisons, contact
Public Health Section, Health Care Services Division, California
Department of Corrections, 770 L Street, Sacramento, CA 95814
(telephone: 916-327-1214). 

13. O. Grinstead, B. Faigeles, and B. Zack, "The Effectiveness of Peer
HIV Education for Male Inmates Entering State Prison," Journal of Health
Education 28 (November-December 1997, Supplement): S-31-S-37.  

14. O. Grinstead, B. Zack, B. Faigeles, N. Grossman, L. Blea, "Peer Led
Pre-Release Intervention Increases Condom Use Among Male Prison
Inmates" (draft under review, 1998).

-------------------------------

Forensic AIDS Project, San Francisco Department of Public Health

Forensic AIDS Project (FAP) staff offer "risk reduction groups" in all San
Francisco jail facilities.[3] About 15-20 sessions are held each week
according to a master schedule, ensuring that all facilities are covered.
These group meetings are voluntary, normal attendance is between 10 and
20 inmates (with as many as 60 participants at sessions in structured
program settings such as substance abuse treatment programs), and the
sessions last 1 to 2 hours, depending on the facility's schedule and
flexibility and the cooperativeness of custody staff.

Deputies vary widely in their degree of cooperativeness, FAP staff report.
Some are extremely helpful and supportive, and others appear to go out of
their way to obstruct FAP's efforts. For example, one deputy confiscated a
dildo used for a condom demonstration.

Topics covered in these sessions include general health; nutrition; practical
risk-reduction strategies (condom use and cleaning of injection material);
information on HIV/AIDS, STDs, and TB; HIV testing; and early
intervention. The session format includes a lecture, a discussion, videos,
and guest speakers. The educators also use games with prizes to involve
the inmates in the sessions. Condom distribution occurs in the context of
regular risk-reduction groups. The risk-reduction groups originally were
planned with the assumption that each inmate would attend one session.
However, with varying lengths of stay, the same inmates may attend
multiple sessions, so educators vary their plans to avoid duplicating
material.

Different educators have different approaches and concerns. For example,
one educator reported that she does not do condom demonstrations in
all-male classes because she feels it would undermine her authority.
Therefore, she asks a male inmate to do the demonstration in these classes.
In an effort to achieve greater consistency across educators, FAP has
developed standard lesson plans for the sessions, synthesizing the ideas,
strategies, and games/exercises used by the different educators. 

FAP offers enhanced counseling to inmates who are identified as high risk
by self-report or staff observation. This is multiple-session individual
counseling designed to help inmates adopt and maintain risk-reducing
behaviors. Special counseling is provided on the importance of partner
notification. When possible, FAP facilitates postrelease counseling with
partners.

-------------------------------

Corrections AIDS Prevention Program, New York City Department of
Health

The Corrections AIDS Prevention Program (CAPP) at the Rikers Island
jail complex is operated by the Division of Special Populations of the New
York City Department of Health, with funding from the Centers for
Disease Control and Prevention.[4] In collaboration with the Department
of Corrections, CAPP has established "an aggressive approach . . . to
HIV/AIDS prevention education," which includes HIV/STD orientation
for incoming inmates and ongoing prevention groups. Condoms are also
made available to inmates.

Orientation sessions on HIV/AIDS and STDs are mandatory for all
incoming inmates at Rikers Island. CAPP educators present basic
information on transmission and prevention, as well as on counseling and
testing, and ways to access additional information and assistance. During a
site visit for the NIJ/CDC survey, an orientation session with about 60
men at the C-76 men's facility was observed. The educator presented
HIV/AIDS and STD risks in a direct, simple, and explicit manner. She
spoke very directly about the risks of anal intercourse and the prevalence
of this behavior in jail. 

Ongoing prevention groups are held in several Rikers Island facilities. A
health educator conducts a series of meetings with inmates who have
longer sentences or are in drug-treatment programs. These meetings
provide opportunities to build rapport and to explore topics in greater
depth than can be done in an orientation session.

During a group meeting with about 15 men in a drug-treatment unit of the
C-73 men's facility, the educator engaged the men directly by asking
questions. She effectively prevented anyone from getting distracted or
losing attention by involving them in the discussion. She did a condom
demonstration, discussed issues of sexual risk and the role of drug use in
sexual risk, openly asked the men to consider what "your women are doing
while you're in jail," and discussed the precautions they should take when
they rejoin their women on the outside. The educator asked the inmates
about the definitions of man and boy, emphasizing that a real man takes
real responsibility for himself and his loved ones. She also asked how
many of the inmates "always" use condoms; most raised their hand, but
one said "A lot of people are lying here." The educator spent a good deal
of time on STDs. She passed around enlarged color photographs of the
conditions that can result from various STDs. The inmates seemed quite
affected by these photographs.

-------------------------------

Massachusetts Department of Youth Services

In 1989 the Massachusetts Department of Youth Services (DYS) and the
Massachusetts Department of Public Health (DPH) entered into an
interagency agreement to provide an HIV/AIDS prevention program with
CDC funding for two full-time bilingual (Spanish) and bicultural
health/AIDS educators. One educator covers the Boston area and North
and South Shore suburbs, and the other covers the rest of the State from
her base in Worcester. An important program component is a small group
of well-trained HIV-positive speakers who participate in varying formats,
including youth-controlled question-and-answer sessions and presentation
of personal stories with questions during and at the conclusion of each
session.

The educators primarily provide HIV and STD prevention education to
youths in DYS facilities and programs, group care, assessment programs,
day reporting centers, shelter care programs, secure detention programs,
and secure treatment programs. In addition, the educators train DYS
frontline child care and casework staff so that they understand and support,
rather than contradict or undermine, the education and prevention
messages presented to the youths. Although increased knowledge has
helped reduce concern about occupational HIV infection, educators still
emphasize the importance of universal precautions in their staff education.

Two full-time educators alone cannot reach the entire DYS population on
a regular basis or conduct the intensive interventions probably needed to
produce significant behavioral changes. Possible methods of increasing
coverage of HIV/AIDS and STD issues include hiring additional
educators, increasing staff training and "weaving" these topics into the
overall activities and programs of the various facilities, and using
community-based resources as well as print and audiovisual materials.

The DYS education sessions primarily emphasize teaching the basic facts
about HIV and STDs in a comprehensible and engaging manner. For
example, in a session observed at St. Mary's/Cornerstones, DYS educator
Eduardo Tautiva effectively used games and understandable images to
present complicated HIV facts, including a game demonstrating the
potentially quick transmission of HIV among people with interconnected
sexual relations and extended Pac-Man imagery showing the action of
HIV in infecting cells and multiplying infected cells.

The DYS educators also work to dispel myths and misinformation by
eliciting the youths' active involvement in the discussions and then
answering their questions with care and respect. In the session we
observed, Tautiva demonstrated that he was at ease with the youths and
the subject matter, which in turn helped participants feel more
comfortable, safe, and open about sharing experiences and expressing
concerns. The ability to connect and to establish trust and rapport with a
youthful audience is essential in developing a two-way process in which
DYS staff both learn from youths and teach them. It is always important to
be sensitive to the youths' mental and emotional state, their level of
literacy and cultural identification, and their mingled senses of
invulnerability and fear.

The DYS educators try to show program participants that they can succeed
in learning something and that they can change their lives, if given clear
goals and objectives and a realistic definition of success. The educators
focus on practical risk-reduction strategies, such as condom use and proper
cleaning of drug-injection material. However, since relatively few of the
DYS youths are injection-drug users, the greater emphasis is properly
placed on how use of marijuana, alcohol, and other drugs can lead to poor
decisionmaking and high-risk sexual activity. While DYS does not object
to frank and open discussion of risk-reduction strategies, condoms are not
distributed for use within facilities; youths being released or going out on
passes are given condoms.

An HIV-positive speaker observed at Connolly Secure Treatment gave an
extremely powerful presentation that strongly affected her audience. She
hopes that the story of her life can at least "plant the seed" in kids' minds
that things can be different, that a better life is possible. The speaker says
that she is "living proof" that things can change for the better, even if one
is HIV infected. 

-------------------------------

Peer Program at Angola

The first facility in Louisiana to establish an inmate HIV/STD peer
education and counseling program was the Louisiana State Penitentiary,
Angola, an extremely large (approximately 5,000 inmates)
maximum-security prison. The peer program at Angola was established in
September 1993, when William Crawford trained 42 inmates. Four of
these inmates became Angola's first HIV/AIDS Peer Education Team.

Between 1993 and 1996, peer educators provided HIV/AIDS and STD
education sessions to more than 1,200 incoming inmates at Angola. Peer
Education Team members divided the topics included in the orientation:
technical information on HIV/AIDS and STDs; strategies for surviving
prison "games" and avoiding high-risk behaviors and situations;
overcoming myths about HIV/AIDS; and modeling hope with a view to
engendering it in others. The inmate peer educators counseled new
inmates to get involved in positive activities such as educational and
self-improvement programs. The peers also provided informal one-on-one
counseling to inmates. Several members of the Peer Education Team were
enrolled in a Baptist seminary through Angola and were authorized to
provide pastoral counseling to inmates with HIV disease. The peer
educators also provided education and training to orderlies and members
of numerous prison organizations, including the CPR T.E.A.M., Drama
Club, Latin American Cultural Brotherhood, and Amateur Boxing
Association. The CPR T.E.A.M. presented HIV/AIDS education sessions
at various locations throughout the sprawling prison, the Camp D Social
Orientation Club conducted classes in the Camp D area, and the Angola
Jaycees offered HIV/AIDS awareness sessions in the main prison.
Members of the Latin American Cultural Brotherhood were trained as peer
educators and offered HIV/AIDS education and counseling services in
Spanish. They distributed Spanish-language fliers on HIV and STDs and
presented a series of three weekly HIV/STD seminars on Friday evenings.
More than 400 inmates signed up for the first series. 

Several other features of the Angola program are noteworthy. First, with
the collaboration and cosponsorship of the prison administration, the State
Office of Public Health-AIDS Services Program, and the Delta Region
AIDS Education and Training Center, the peer program presented three
annual HIV/AIDS education conferences at Angola. The conference held
in November 1996 attracted more than 400 health professionals, educators,
correctional staff, and others from Louisiana, Arkansas, Mississippi, and
Texas. The attendees were eligible for continuing education credits and
heard a variety of presentations on HIV/STD peer education and
counseling and related subjects. 

A second feature of the Angola program is the work of the Drama Club.
This group travels to other prisons and settings in the State to present its
dramas and skits on HIV/AIDS, STDs, and other themes. These are
written, produced, and acted entirely by the inmates. 

Third, the Angola Peer Education Team established mechanisms for
networking with peer programs in other prisons and jails. It published a
newsletter to share information across the programs. The peer educators
also attended and spoke at conferences and meetings of organizations
throughout the State as well as at juvenile confinement facilities.

-------------------------------

AIDS Counseling and Trust--Avoyelles Correctional Center

The Avoyelles Correctional Center is a medium-security men's facility
with about 1,475 inmates. The AIDS Counseling and Trust (ACT)
program was established at Avoyelles in 1994 with the training of 12 peer
educators/counselors. At the time of our visit, a total of 60 had been
trained, and 40 peer educators were active in the program. According to
Shirley Washington, ACT Coordinator, the basis of the program is the
belief that the best person to provide education and counseling to inmates
is "one of their own." 

ACT member Bobby Weatherton designed and wrote a brochure entitled
Johnny's Home from Prison, and . . . He Has AIDS. This brochure tells the
story of a man who has engaged in homosexual intercourse while in prison
but does not know that he is HIV infected. Unwittingly, he infects his
female lover soon after he is released. The brochure describes the "hidden"
culture of homosexuality in prison in which men who play the dominant
role in homosexual relations (that is the insertive partners in anal
intercourse) often do not consider themselves homosexual or do not
believe that they can become infected. Only the receptive partner is at risk
of infection, many of these "straight men" believe. On the back of the
brochure is a piece of advice to the potential sexual partners of men
coming out of prison: "Do not assume a man is disease free because he has
been in prison. Do not rely on his denial of risky behavior. DEMAND
THAT HE BE TESTED!!" The brochure is printed and distributed by the
Louisiana Office of Public Health's HIV/AIDS Services unit. 

The ACT educators at Avoyelles were responsible for providing
orientation sessions on HIV/AIDS and STDs for all new inmates. They
used a video produced by inmates in a New Mexico State prison and
followed this with an extensive question-and-answer session. During a
"staged" question-and-answer session observed at a site visit to Avoyelles,
ACT peers presented explicit information on practical risk-reduction
measures.

ACT also provided HIV/STD prevention sessions for all inmates 30 days
prior to their release. Inmates were referred to community-based providers.
The ACT peer counselors prepared nine regional directories listing all
types of health care and mental health services, substance abuse programs,
benefit programs, and housing and employment services, with addresses
and telephone numbers. Each inmate being released was provided with a
copy of the directory for the region to which he or she was being released.
The ACT peers also went through the directory with all inmates before
they were released to make sure they understood what was available to
them. Released inmates were also provided with "health care packages"
that included condoms and bleach kits.

Individual counseling was available on request through the mental health
department or informally in the prison yard and housing units at
Avoyelles. One-on-one counseling was provided in a private room with no
correctional officers or other staff present and was kept strictly
confidential. The following issues were commonly addressed in individual
counseling: Should you get tested? What do the results mean, and how
would you deal with them? What should you do/not do if you are positive?
What should you do/not do if you are negative? 

Other ACT activities included educational sessions for sports clubs,
self-help and religious groups, and other organizations at the prison;
periodic Friday evening videos on HIV/AIDS and STDs; a drama group,
patterned after the Angola Drama Club, presenting skits on HIV/AIDS
written and performed by inmates (during the visit, the group presented an
excellent skit on using knowledge and understanding to combat the
stigmatization of and discrimination against persons with HIV and AIDS);
a weekly support group consisting of about 15 inmates with HIV disease
that encouraged inmates to "live healthy with HIV" and dealt with
medications, side effects, and a range of psychosocial issues; and a Street
Outreach Program in which members made presentations and provided
services at parish jails, where inmate turnover is too rapid to permit
effective peer programs. 

-------------------------------

California Institution for Women, Frontera 

The California Institution for Women (CIW), Frontera, is one of five State
prisons for women in California. The average daily population of the
facility is about 1,600, of whom 38 were known to be HIV positive at the
time of the site visit. New diagnoses of HIV disease average one per
month. About 125 women per month receive voluntary HIV testing, a
considerable increase from the period before establishment of the peer
program.

CIW's HIV peer education program, started in 1994 by a public health
nurse working at the facility, is staffed by 24 volunteer peer educators and
2 who receive "good time" credit ("day for day") for their work.

Peer program volunteers are carefully screened, and the inmates selected
must be free of disciplinary action, highly motivated, able to communicate
effectively, and capable of building rapport and trust with other inmates
and staff. HIV-positive candidates and those with some previous
knowledge of HIV/AIDS are preferred. Each applicant must obtain a
recommendation from her correctional counselor, undergo an interview,
and write a paragraph explaining why she wants to be in the program.
Facility captains must approve all applicants before final selection to
guard against women who may want to use the program to advance an
independent "agenda." Selected applicants receive weekly training for 3
months provided by HIV Women's Voices, a community-based Orange
County organization.

The CIW peer educators present classes for the general inmate population,
substance abuse treatment programs, mental health groups, new intakes at
the reception center, prerelease inmates, and inmates slated to attend
forestry camps. During a site visit to CIW, four peer educators who were
observed conducting a session for the general inmate population
effectively spoke the inmates' language and established good rapport.
Several had loved ones with HIV/AIDS; at least one was HIV positive.
Each briefly told her own story; explained why she wanted to be a peer
educator; and described how doing something positive for others made her
feel better about herself. In their presentations, the peer educators
repeatedly stressed personal responsibility and personal control--"you have
the future in your hands" and "knowledge is power."

One educator effectively described the complex process of HIV infection
and replication of infected cells by drawing Pac-Man-like figures on the
board. Educators also used humor: in introducing an explicit discussion of
sexual risk behaviors, one said, "They call me Dr. Ruth." This created a
light atmosphere and encouraged the inmates to open up with their own
stories and concerns.

Educators used games to engage participants in a discussion of risky
behaviors. In "red light/green light," the class discussed a long list of very
specific behaviors, and for each one decided whether the behavior posed
no risk, low risk, or high risk of transmitting or acquiring HIV. Along with
descriptions of proper condom use, proper cleaning of injection material,
and introduction of the female condom, inmates discussed risk-reduction
strategies for particular situations. The discussion also provided
opportunities to address misconceptions. For example, when several
inmates said that they considered it very risky to hug someone with HIV,
one of the HIV-positive educators immediately hugged them, and the rest
of the class reinforced the point that this posed no risk because it involved
no exchange of body fluid. The discussion also addressed risks specific to
prison life. For example, the educators cautioned that the common prison
practice of using guitar strings for tattooing is particularly risky because
the grooves in the strings can catch and hold blood.

The peer educators at CIW also conduct weekly pretest counseling classes.
These classes take place under staff supervision to ensure consistency. The
pretest classes generally have 25-30 inmates in attendance and last 1 to
11/2 hours. Individual posttest counseling is provided by health services
staff, not by peer educators.

-------------------------------

California Medical Facility, Vacaville

The California Medical Facility (CMF) in Vacaville is the major medical
and mental health treatment facility for the male inmates of the California
Department of Corrections. The average daily population is about 3,200.
The facility includes Unit 4, a segregated housing unit for inmates with
HIV disease. Inmates in Unit 4 are eligible to participate in programming
with the general population.

CMF has 10 paid HIV peer educators. Inmates apply to be peer educators
and undergo a screening process. Jan Burrow, the program coordinator,
trains the peer educators. Two peer educators are certified pre- and posttest
counselors, although they do not perform this counseling in the prison. 

The peer educators orient all new inmates and see about 800 inmates per
month in group settings. They also provide informal education and
counseling in housing units, the exercise yard, and program areas. The
peer education program publishes a magazine, PEP Talk, whose
contributors are inmates. All articles are in English and Spanish. A recent
issue included articles on protease inhibitors, viral load monitoring, and
the importance of forgiving one's self and others. The peer education
program's "mission" and "oath" are printed on the back of each issue.
These stress the spiritual and nurturing foundation of the work. 

The peer educators offer a monthly schedule of hour-long educational
sessions in housing units (including Unit 4), work sites, and program areas
in the facility and in the prerelease center. Inmates must sign up to attend
these sessions. In the minimum-security part of the facility, the peer
educators offer a 5-week program with weekly meetings. 

The educators employ a "stages of change" approach in some of the
sessions, attempting to induce inmates to contemplate and then initiate
changes in risk-reduction behavior. They discuss real-life situations-for
example, exploring the relationship between substance use and high-risk
sex. They use all media and a variety of strategies, including posters,
audiovisual materials, stories, and games.

With support from the program coordinators, the peer educators are free to
discuss practical risk-reduction strategies in their sessions with inmates.
Although the peers always stress that sex in prison is against the rules and
that regulations prohibit the distribution of condoms in the facility,
relevant preventive methods are discussed. The peers used to be very
explicit in suggesting alternatives to condoms-for example, the fingers of
latex gloves-until the Department of Corrections (DOC) required a less
specific message-for example, "use something latex; use your
imagination." Moreover, if inmates ask about specific alternatives such as
latex glove fingers, the peers answer the questions directly and honestly.
For example, if an inmate asks about plastic wrap as an alternative to a
condom, the peer educator will respond that "it's better than nothing." The
educators also can make specific risk-reduction recommendations in the
context of "what you should do when you return to the community," but
this approach still provides suggestions that can be implemented inside the
facility.

In their group meetings with HIV-infected inmates, the peer educators
spend substantial time discussing the new medications and urging inmates
to seek early intervention. Their theme is "knowledge is power." Educators
also stress the importance of good nutrition and health habits, spiritual
development, and avoidance of reinfection.

-------------------------------

Chapter 4

HIV Transmission and Risk Factors, Precautionary and Preventive 
Measures

Theodore M. Hammett and Patricia Harmon--Abt Associates Inc. 

Key Findings

o High-risk behaviors for HIV transmission-sex, drug use, sharing of
injection materials, and tattooing-occur in correctional facilities.

o HIV transmission among correctional inmates has been shown to occur.

o Comprehensive and intensive education and prevention programs
represent the best response to these facts, although the precise content of
such programs is controversial.

o Rape and coerced sexual activity also occur in correctional facilities but
require a different response, one based on inmate classification, housing,
and supervision.

o Implementation of "universal precautions" represents the heart of a
correctional infection control program and the first line of defense against
the occupational transmission of HIV.

o Condom distribution and other harm-reduction strategies have not been
widely adopted in American correctional systems.

o Experience with harm reduction in correctional facilities in Europe and
elsewhere may warrant the attention of U.S. correctional administrators. 

There is evidence of high-risk behaviors and HIV transmission in
correctional facilities but also an ongoing debate as to what precautionary
and preventive measures against HIV should be implemented in these
settings. The principle of equivalent responses within and outside the walls
is challenged by demands from correctional officers' unions, the rules of
correctional facilities, and the perception that inmates should not and
cannot be treated like other people with relationship to HIV prevention.
This chapter discusses risk factors and HIV transmission in correctional
facilities and addresses some of the key issues in formulating a policy
response.

HIV Transmission and Risk Behaviors in Correctional Facilities

The possibility of HIV transmission among correctional inmates remains a
politically charged issue, although there have been few recent studies of
this. At this writing, it is possible that a study of HIV transmission in the
Texas prison system will be undertaken. The most recently published
study is from Florida and was based on voluntary HIV antibody testing of
inmates continuously incarcerated since before the appearance of HIV in
the United States. Although this study revealed apparent in-prison HIV
seroconversions, it presented a misleadingly high seroconversion rate by
using as a denominator only those inmates who consented to be tested
rather than all of the inmates eligible for the study on the basis of the
length of their incarceration. The study also failed to calculate annual
seroincidence rates based on total time of exposure (incarceration)
represented in the study population.[1] The Illinois Department of
Corrections replicated the Florida study, identifying 191 inmates
continuously incarcerated since 1977, of whom 140 (73 percent) had either
been previously tested for HIV antibodies in prison or consented to be
tested for this study. Only 1 of these inmates (0.7 percent) was HIV
seropositive.[2]

The important point, however, is that most studies have found evidence of
at least some HIV transmission among prisoners, albeit at low rates.
Further study is clearly warranted based on evidence of inmates' high-risk
behaviors for HIV transmission. Focus groups with former inmates in New
York State and New York City elicited reports of widespread sexual
activity and drug use within correctional facilities.[3] A survey of
Nebraska inmates revealed fairly high rates of participation in consensual
and forced sexual activity within the State's prisons.[4] An Australian
study demonstrated the existence of a network of needle sharing and
associated HIV infections in prison.[5] A small random survey of male
and female inmates in two Canadian Federal prisons revealed that 28
percent had injected drugs in prison and 64 percent of these reported
having shared needles. Thirty-three percent of the sample reported
receiving a tattoo in prison. Thirty-eight percent of the surveyed inmates
reported having engaged in sex in the correctional facility.[6]

Rape and Coerced Sexual Activity  

The issues of rape and HIV transmission are separate and thus require
separate and distinct responses. The primary means of addressing HIV
transmission ought to be comprehensive programs of HIV education and
prevention, whereas rape and other forms of sexual victimization must be
addressed by better programs of detection and enforcement. By no means
do all prison rapes result in HIV transmission, just as, conversely, by no
means are all HIV transmissions in prison attributable to rape. The danger
in treating the two issues as if they were interchangeable is that other
important aspects of HIV prevention and rape prevention may be ignored
or given insufficient attention. 

It is nevertheless clear that rape and coercive sex are serious and possibly
widespread problems in correctional facilities. Dramatic accounts of
sexual slavery such as contained in Stephen "Donny" Donaldson's "Punk's
Song"[7] and the testimony of former Illinois inmate Michael Blucker in
his lawsuit against the correctional system[8] indicate the potential horrors
of prison life for those who are vulnerable. Such accounts and other
evidence strongly suggest the need for better strategies to prevent sexual
and other forms of victimization of prison inmates.

"Universal Precautions" Versus Correctional Officers' "Right to Know"

Very few correctional systems have policies for routinely notifying
correctional officers of inmates' HIV status. However, many systems do
have policies regarding notification if a possible transmission incident
occurs. Some of these policies are based on legal or regulatory
requirements. The advent of postexposure prophylaxis for HIV infection in
health care settings is also pertinent to correctional facilities.

Some correctional officers' unions and some individual officers continue
to assert their "right to know" the names of all known HIV-seropositive
inmates, claiming that such knowledge will enable them to take special
precautions when dealing with these inmates. There are several problems
with this approach. First, no testing policy can identify all HIV-infected
individuals because of ongoing seroconversions and individuals testing
negative while in the "window period" of infection. Indeed, there is
evidence that a person may be most infectious while in the acute stage of
infection but may still be HIV-antibody negative.[9] A mandatory and
universal testing and notification policy may lull officers into a false sense
of security, leading them to think that they know who all the HIV-infected
inmates are. Second, even if it were possible to identify all HIV-infected
inmates, officers might not be able to remember all of them. This would be
a particular problem in systems with large numbers of HIV-infected
inmates.

These problems seem to point to the wisdom of the alternative:
maintaining confidentiality but systematically practicing "universal
precautions." The principle of universal precautions, promulgated by the
CDC in the mid-1980s and given full legal force by the Occupational
Safety and Health Administration in 1991, means that one should treat all
persons as if they are HIV infected, avoiding unprotected contact with
body fluids that are considered potentially infective, especially blood and
semen. Universal precautions are not necessary for contact with saliva,
tears, sweat, vomitus, urine, or feces unless they contain visible blood.[10]
Many correctional systems have issued their own policies regarding
universal precautions, and administrators should ensure that all staff
receive training on these policies and that these policies are implemented
in everyday practice. Universal precautions are also important for
preventing hepatitis C transmission. Hepatitis C is prevalent but
commonly undiagnosed in the inmate population, and there is no vaccine
or reliable treatment for the severe morbidity that may result from the
infection.

It is important to note that written policies and procedures, no matter how
detailed, cannot teach correctional officers how to act in every situation.
Many incidents in prisons and jails require that officers and other staff
decide what to do very quickly. Training and knowledge are important and
helpful, but in specific situations staff must exercise their own discretion
and judgment.

Condom Availability

An important component of HIV/STD education is the presentation and
frank discussion of practical risk-reduction strategies. However, a major
challenge to effective HIV prevention in correctional facilities is that in
most prisons and jails the means to carry out practical risk-reduction
strategies are not officially available. Indeed, in the vast majority of
correctional facilities inmates are prohibited from possessing condoms.
Table 20 shows that only six correctional systems make condoms
available to inmates for use in their facilities. These are the same six
systems that have had this policy for a number of years: Vermont,
Mississippi, New York City, San Francisco, Philadelphia, and
Washington, D.C. No additional systems have made condoms available
since the early 1990s.  

In contrast to the U.S. situation, condoms are available in most
European[11] and Canadian prisons (although there have reportedly been
some problems with ready and discreet accessibility in some facilities in
Canada),[12] and pilot programs of condom distribution have been
undertaken in correctional facilities in New South Wales (Australia) and in
Western Australia. In announcing the expansion of the condom program in
New South Wales prisons, Minister for Corrective Services Bob Debus
said, "[T]his is a public health issue: only by providing condoms in our
gaols can we ensure they don't become breeding grounds for diseases
which will eventually be spread to the wider community."[13] In
launching a condom distribution trial at Western Australia's Wooroloo
Prison Farm, a Justice Ministry spokesman said, "[We]'re not condoning
sex in prisons, but we're not naive, we know it happens, and we're trying
to make sure there's some sort of way to stop the spread of sexually
transmitted diseases like hepatitis and AIDS."[14]

Bleach Availability

Research findings suggest that bleach may not be effective for HIV
disinfection unless it is used at full strength and in strict accordance with
recommended procedures. CDC's revised procedures call for repeating the
following sequence of steps three times: rinsing the needle and syringe
with clean water, then with full-strength bleach, then with clean water
again. The needle and syringe should be shaken for 30 seconds during
each rinse. Bleach disinfection is considered a much less desirable
risk-reduction method than using a new needle and syringe for each
injection.[15]

As shown in table 20, 20 percent of correctional systems responding to the
1997 NIJ/CDC survey make bleach available to inmates within facilities
"for any purpose." The survey question was phrased this way because few
if any correctional systems would be likely to report that they make bleach
available specifically for cleaning injection equipment. However, if bleach
is available to inmates for cleaning or other legitimate purposes, it is quite
possible that it will be available in practice for cleaning injection
equipment. 

Officially sanctioned distribution of bleach for cleaning injection
equipment is more widespread in correctional systems outside the United
States. Half of the 20 European systems responding to a 1997 survey had
such policies.[16] A successful pilot bleach kit distribution program at a
Canadian Federal prison in New Brunswick led to the expansion of the
program to all Federal facilities. An inmate survey at the New Brunswick
facility found overwhelming support (99 percent) for bleach kit
distribution, and 63 percent of staff also felt that making bleach available
to inmates as a preventive measure is "important."[17] In a survey of
inmates in six Ontario provincial prisons, 52 percent of respondents
expressed positive feelings about the distribution of bleach in their
facilities.[18]

Needle and Syringe Exchange

Possession of needles and syringes in prisons and jails in the United States
is a violation of law and/or of correctional regulations. However,
needle/syringe exchange programs have been successfully implemented in
Swiss prisons since 1992. Eight Swiss prisons have needle exchange
programs. Evaluation of the program in the Hindelbank women's facility
in Switzerland found that contrary to some predictions, drug consumption
did not increase, and needle sharing declined markedly. Also, there were
no reports of needles being used as weapons. There were no incident cases
of HIV or hepatitis B infection among program participants. The program
was well received by inmates and staff.[19] In October 1997 the Swiss
Federal Office of Justice adopted an official statement that needle
distribution in prisons was legal and that prison administrators had a duty
to implement such programs in the context of an overall HIV prevention
strategy. The issuance of this statement has led to discussion of
prison-based needle exchange in at least seven Swiss cantons and its
adoption in all four major correctional facilities in the canton of Berne.[20]

Based on the experience of the Swiss facilities, needle/syringe exchange
programs have been initiated in three prisons in Germany and one prison
in Spain. An official at the Hamburg (Germany) prison stated: 

[S]taff are members of the public as well. They started seeing that what
was done outside is to the benefit of all drug users and the public, and
started questioning . . . whether it would not be possible and beneficial to
extend harm-reduction measures to prisons.[21]

A recent study in Australia found that needle/syringe exchange was
feasible in prisons and recommended initiation of a pilot exchange
program if the following conditions were met: (1) prison-based drug
treatment was available; (2) security and health staff were thoroughly
trained in the program; (3) the method of needle/syringe distribution was
chosen jointly by inmates and security and health staff; (4) distribution
was on a strict one-for-one exchange basis; and (5) changes in risk of
infection to staff, inmates, and visitors resulting from the program were
assessed. At this writing, the pilot needle/syringe exchange program has
not been implemented in Australia.[22] Seventy percent of inmates
surveyed in Ontario expressed negative feelings about needle distribution
in prisons.[23]

Methadone Maintenance

Methadone maintenance is offered in correctional facilities in only five
countries.[24] However, methadone maintenance may be an effective
strategy for reducing needle use and potentially reducing HIV and
hepatitis transmission in prisons. A study of former New South Wales
(Australia) inmates with histories of injection-drug use found that
individuals receiving methadone maintenance in the 3 months preceding
their incarceration and those receiving methadone maintenance at a dose
of at least 60 mg during incarceration reported significantly fewer
injections per week in prison than those who had not received methadone
maintenance.[25] 

Reduction of Risk Associated With Tattooing

Tattooing is extremely common in correctional facilities. If unsterile
equipment is used, it can be as risky for the acquisition of HIV and
hepatitis B or C as other forms of needle use. The correctional department
of New South Wales (Australia) has published an informative booklet on
risks and risk reduction for prison tattooing.[26] Indeed, one of the key
points made in the booklet is that prison tattooing is inherently unsafe and
should therefore be avoided in favor of visiting a professional tattoo artist
following release. An experienced prison tattooist is quoted as saying: "I
learnt very early in my sentence that there is ABSOLUTELY NO WAY a
tattoo can be performed hygienically or safely in prison." Importantly, the
booklet notes, "[T]att guns made in gaol are virtually impossible to
sterilise." The booklet lists precautions for inmates who still wish to be
tattooed in prison. These include the following: 

o Make sure your tattooist wears gloves.

o Wash and shave the area to be tattooed.

o Make sure the gun is cleaned in bleach.

o Replace cotton each time the gun is used.

o Cover the gun with latex.

o Take care of your new tattoo; apply antiseptic and keep it out of the sun. 

Conclusion

There is evidence of high-risk behaviors for HIV and STD transmission in
correctional facilities, as well as of actual transmission of HIV infection
among inmates. Rape and sexual victimization are also known to occur in
prisons and jails, but these problems require a policy response independent
from the problem of HIV and STD transmission. The practice of universal
precautions remains the first line of defense against the occupational
transmission of HIV and hepatitis B and C in correctional settings.
Postexposure prophylaxis for HIV should also be considered.
Harm-reduction approaches to prevention, such as making condoms,
bleach, and sterile injection equipment available, have not been widely
adopted in U.S. correctional facilities, although they are finding increasing
acceptance elsewhere.  There have been no additions since the early 1990s
to the short list of correctional systems making condoms available to
inmates. Correctional administrators should continue to consider the
experience of other countries in implementing harm-reduction strategies.

Endnotes

1. R.C. Mutter et al., "Evidence of Intraprison Spread of HIV Infection,"
Archives of Internal Medicine 154 (1994): 793-795.

2. J. Coe and H.I. Shuman, "Comparison of HIV Seroprevalence Rates
Among Long Term Incarcerated Inmates in Florida and Illinois"
(unpublished paper).

3. N. Mahon, "New York Inmates' HIV Risk Behaviors: The Implications
for Prevention Policy and Programs," American Journal of Public Health
86 (1996): 1211-1215.

4. C. Struckman-Johnson et al., "Sexual Coercion Reported by Men and
Women in Prison," Journal of Sex Research 33 (1996): 67-76.

5. K.A. Dolan et al., "A Network of HIV Infection Among Australian
Inmates," poster abstract no. We.D.3655, presented at the 11th
International Conference on AIDS, Vancouver, July 10, 1996.

6. L. Calzavara et al., Understanding HIV-Related Risk Behavior in
Prison: the Inmates' Perspective, Toronto: University of Toronto, Faculty
of Medicine, HIV Social, Behavioral and Epidemiological Studies Unit,
1997.

7. D. Tucker, A Punk's Song: View From the Inside, AMS Press, 1981.

8. "From Thief to Cellblock Sex Slave: A Convict's Testimony," New
York Times (Week in Review section), October 19, 1997, p. 7.

9. M. Piatak, Jr., M. Saag, L.C. Yang et al., "High Levels of HIV-1 in
Plasma During All Stages of Infection Determined by Competitive PCR,"
Science 259 (1993): 1749-1754; D.V. Havlir and D.D. Richman, "Viral
Dynamics of HIV: Implications for Drug Development and Therapeutic
Strategies," Annals of Internal Medicine 124 (1996): 984-994; J.A.
Jacquez, S.J. Koopman, C.P. Simon, and I.M. Longini, Jr., "Role of the
Primary Infection in Epidemics of HIV Infection in Gay Cohorts," Journal
of Acquired Immune Deficiency Syndrome 7 (1994): 1169-1184.

10. Centers for Disease Control and Prevention, "Perspectives in Disease
Prevention and Health Promotion Update: Universal Precautions for
Prevention of Transmission of Human Immunodeficiency Virus, Hepatitis
B Virus, and Other Bloodborne Pathogens in Health-Care Settings,"
Morbidity and Mortality Weekly Report 37 (June 24, 1988): 377-382; and
"Occupational Exposure to Bloodborne Pathogens," 29 Code of Federal
Regulations 1910.1030, December 6, 1991. 

11. J-D Laporte, "Joint WHO/UNAIDS European Seminar on HIV/AIDS,
Sexually Transmitted Diseases and Tuberculosis in Prisons: Results of a
Survey in European Prisons," Geneva, Switzerland, Multifaculty
Programme on Humanitarian Action and Institute of Legal Medicine,
Geneva University, December 1997. 

12. R. Jurgens, HIV/AIDS in Prisons: Final Report, Montreal: Canadian
HIV/AIDS Legal Network and Canadian AIDS Society, September 1996:
19-20.

13. New South Wales Minister for Corrective Services, "Media Release:
Protecting the Community," Sydney, Australia, January 8, 1997.

14. "Condom Trial Begins in Prison," Australian Associated Press,
January 19, 1998.

15. "New Recommendations for Disinfecting Injection Equipment,"
Medical Alert (October/November 1993),

16. Laporte, "Joint WHO/UNAIDS European Seminar." 

17. Jurgens, HIV/AIDS in Prisons, 8-13.

18. L. Calzavara et al., "Inmates' Opinions on Bleach and Needle
Distribution in Correctional Centres in Ontario, Canada," poster abstract
no. 43400, presented at the 12th World AIDS Conference, Geneva, July 2,
1998. 

19. J. Nelles and A. Fuhrer, Drug and HIV Prevention at the Hindelbank
Penitentiary: Abridged Report of the Evaluation Results, Bern,
Switzerland: Swiss Office of Public Health, 1995.

20. D. Zeegers Paget, "Needle Distribution in the Swiss Prison Setting: A
Breakthrough?" poster abstract no. 43403, presented at the 12th World
AIDS Conference, Geneva, July 2, 1998.

21. Jurgens, HIV/AIDS in Prisons, 63-65.

22. S. Rutter et al., Is Syringe Exchange Feasible in a Prison Setting? An
Exploration of the Issues, Sydney, Australia: National Drug and Alcohol
Research Center, technical report no. 25, 1995.

23. Calzavara et al., "Inmates' Opinions."

24. K. Dolan and A. Wodak, "An International Review of Methadone
Provision in Prisons," Addiction Research 4 (1996): 85-97.

25. K. Dolan, W. Hall, and A. Wodak, "Methadone Maintenance Reduces
Injecting in Prison" (letter), British Medical Journal 312 (May 4, 1996):
1162.

26. New South Wales Department of Corrective Services, HIV and Health
Promotion Unit, Gaol Ink, Sydney, Australia, n.d.

-------------------------------

Chapter 5

Counseling and Testing, Confidentiality and Disclosure

Theodore M. Hammett and Patricia Harmon-Abt Associates Inc. 
Laura Maruschak-Bureau of Justice Statistics 

Key Findings

o Most correctional systems provide HIV-antibody testing, although
testing policies differ widely.

o In 1997, 17 State correctional systems and the Federal Bureau of Prisons
had policies for the mandatory HIV-antibody testing of inmates at intake
and/or release.

o Few correctional systems have mandatory or routine pregnancy testing
for female inmates.

o Ongoing assessment of HIV-antibody and pregnancy-testing policies is
warranted in light of changing community standards for the treatment of
HIV/AIDS.

o Very few correctional systems have policies for the notification of
correctional officers regarding inmates' HIV status.

o Few correctional systems routinely screen inmates for STDs.

Policies for HIV counseling and testing have become more and more
important as early intervention with antiretroviral therapy has produced
increasingly promising results. After the HIV antibody test became
available in 1985, debate about testing in correctional facilities focused on
whether it could or should be used in conjunction with housing
segregation to prevent transmission among inmates. During that period,
there was no therapeutic reason for the early identification of HIV
infection, since there was nothing to offer patients.

Beginning with the advent of zidovudine (AZT) treatment in the early
1990s, the terms of the debate began to change. Subsequently, with the
availability of protease inhibitors and combination antiretroviral therapy in
1996, the value of early identification and intervention increased
dramatically. The Bureau of Justice Statistics (BJS) surveys revealed that
79 percent of State inmates in 1997 and 60 percent of local jail inmates in
1995-96 had been tested for HIV antibodies.

HIV-Antibody Testing Policies 

The most recent data on correctional HIV-antibody testing policies come
from BJS' 1996 National Prisoner Statistics and from the Ninth National
Survey of HIV/AIDS, STDs, and TB in Correctional Facilities sponsored
by NIJ and CDC. The BJS survey results offer an overall view of
HIV-testing policies in the correctional systems of the States, Federal
Government, and the District of Columbia, and the NIJ/CDC survey
results yield a mutually exclusive categorization of testing policies for
incoming inmates in State/Federal and city/county systems.

Overall HIV-Antibody Testing Policies in State, Federal, and D.C.
Systems 

Forty-nine States, the District of Columbia, and the Federal Bureau of
Prisons test inmates based on certain criteria (see table 21, summarized in
table 22). Only one State, Delaware, did not report whether it tested its
inmates for HIV. Most jurisdictions (42 out of 51) test inmates if they
have HIV-related symptoms or if the inmates request a test. Twenty-four
States test inmates after involvement in an incident, and 14 States test
inmates who belong to specific "high-risk" groups.

Sixteen States test all inmates who enter their facilities. Three of these
States (Alabama, Missouri, and Nevada) and the Federal Bureau of Prisons
also test inmates upon leaving the facility. Two States (Nevada and Rhode
Island) reported testing inmates not only upon entering but also while in
custody. 

States also test inmates selectively, based on the special circumstances of
an inmate. Forty States test for HIV upon inmate request; 38 test if the
inmate exhibits HIV-related symptoms; 24 test after involvement in an
incident; and 14 test inmates who belong to specific "high-risk groups."
Only four States (Maine, Massachusetts, Wisconsin, and New Mexico)
and the District of Columbia test solely upon inmate request. The Federal
Bureau of Prisons, Florida, and New York randomly test their inmates for
HIV.

HIV-Antibody Testing Policies for Incoming Inmates 

Table 23 presents a mutually exclusive categorization of HIV-antibody
testing policies for incoming correctional inmates, according to the 1997
NIJ/CDC survey. 

Mandatory and Routine Testing

Between the 1990 and the 1997 surveys, there was no change in the list of
16 State prison systems that conducted mandatory testing of all incoming
inmates. (However, since the 1997 survey was completed, South Carolina
initiated mandatory HIV-antibody testing of incoming inmates, raising the
total number to 17.) As in previous surveys, no city/county jail systems
reported mandatory testing at intake. The correctional systems with
mandatory testing generally have low HIV seroprevalence among their
inmates.

Some clinicians are calling for the mandatory HIV testing of correctional
inmates because they believe that incarceration provides a critical
opportunity for therapeutic interventions with an extremely high-risk and
previously underserved population. These clinicians typically argue that
no policy of mandatory testing should be implemented unless the
correctional system is fully committed to offering community standard of
treatment to all HIV-infected people. In this context, they believe that the
clinician's ethical imperative to offer treatment overrides the patient's right
to decide whether to be tested. 

As shown in table 23, two correctional systems have moved to "routine"
testing, an intermediate point between mandatory and voluntary testing, in
which patients are informed that they will be tested unless they
specifically refuse. More recently, the Texas State system has also decided
to adopt routine testing.[1]

Offered and On-Request Testing    

Most correctional systems continue to rely on voluntary testing to identify
inmates who might benefit from therapeutic intervention. Table 23 shows
that two-thirds of State/Federal systems and 80 percent of city/county
systems have policies for offering HIV testing or providing testing on
request. Dividing "voluntary" testing into these two policy choices in the
1997 NIJ/CDC survey was intended to distinguish between (1) systems in
which staff enthusiastically offer or recommend testing to those who seem
to be at risk based on a health history and assessment, and (2) systems in
which inmates are not tested unless they request it. In other words, the
distinction is between an active and a passive approach to testing. Table 23
indicates that correctional systems with voluntary testing are fairly evenly
divided between these two approaches. The results of the validation study
(table 24) reveal more discrepancies between central office and facility
responses regarding offered and on-request testing than regarding
mandatory testing, indicating possible confusion between these categories
either in complying with policy or responding to the survey. 

Most studies show that HIV seropositivity rates from voluntary testing in
correctional settings are lower than seroprevalence rates found in blinded
studies of samples of inmates representative of the entire incoming inmate
population. In Maryland, for example, 2.5 percent of inmates receiving
voluntary testing in 1991 were HIV-seropositive, as opposed to 8.5
percent of incoming inmates in a blinded study.[2]  The major reasons
adduced for voluntary testing programs understating the true HIV
seroprevalence among Maryland inmates are that many truly at-risk
inmates do not believe that they are at risk for HIV, and that inmates are in
denial about their risk status and, for this and other reasons, avoid being
tested.[3]  In California, 0.8 percent of voluntarily tested inmates were
HIV seropositive in 1994, while seroprevalence in a blinded study of
incoming inmates the same year was 2.5 percent.[4]

There are several possible explanations for the lower HIV-seropositivity
rates commonly found among voluntarily tested inmates as compared with
those from blinded studies (presented in chapter 1).  One is that many
HIV-positive inmates may already know their status. In the context of
"voluntary" testing programs, a critical question is how testing is presented
to inmates and whether inmates trust that the system will maintain their
confidentiality and provide them needed services if they accept testing.[5]
In Massachusetts a program that encourages voluntary testing and offers
state-of-the-art medical treatment for HIV diseases has generated a sixfold
increase in requests for testing.[6] However, HIV-infected inmates may
not have this level of trust. Of course, there are other possible explanations
for inmates declining to be tested, including fear of discrimination and
mistreatment, facing the consequences of being HIV positive, and
psychological denial. All of these issues should be addressed in
educational and counseling sessions.[7]

Occasions on which testing can be offered include intake medical
screening, HIV/AIDS orientation sessions, and other education and
prevention sessions. Individual risk assessments and pretest counseling
sessions provide other opportunities to offer and recommend testing. Staff
of the Forensic AIDS Project (FAP) of the San Francisco Department of
Public Health conduct risk-assessment counseling with inmates in all jails.
This involves individual counseling on HIV risk behaviors and behavioral
risk reduction. Disclosure counseling, or post-test counseling, is provided
to all tested inmates upon receipt of their results. In this counseling, FAP
staff focus on the importance of risk reduction regardless of whether the
inmate is positive or negative. Staff attempt to help inmates acquire and
develop the skills needed to practice risk reduction when they return to the
community. HIV-positive inmates are referred to FAP's Early Intervention
Team for in-jail services and development of a treatment plan. All inmates
are given materials on HIV prevention and referred to community-based
resources. 

In New York State both anonymous and confidential testing are offered to
inmates through the AIDS Institute of the State health department. Inmates
who receive anonymous testing also have the option of converting to
confidential status so they can receive services. Anonymous testing
programs may be affected by the increasing movement to the mandatory
reporting of HIV infection.

Testing of Pregnant Women 

Because of the findings of the AIDS Clinical Trials Group (ACTG) 076
trial that AZT treatment during pregnancy and delivery reduces the
chances of perinatal HIV transmission by two-thirds--from the previous
25-30 percent to 8-10 percent[8]--early identification and treatment of
pregnant HIV-infected women has become a major focus of testing policy.
Public Health Service (PHS) guidelines issued in 1995 call for the routine
counseling and voluntary testing of pregnant women as early as possible in
their pregnancies.[9] At this writing, the Institute of Medicine is engaged
in a study mandated by the Ryan White Care Act Amendments of 1996
designed to evaluate State efforts to reduce perinatal HIV transmission,
including efforts to increase the availability and acceptance of HIV testing
in many settings, such as correctional facilities.

There are obviously two steps in identifying pregnant HIV-infected
women. The first is to identify pregnant women and the second is to
determine which are HIV infected. Thus, policies for both pregnancy
testing and HIV testing are pertinent. Table 25 shows that less than half of
correctional systems provide routine pregnancy testing of incoming female
inmates, and the vast majority offer pregnancy testing on request. A
summary of HIV-testing policies for pregnant women, shown in table 26,
reveals that mandatory testing is the most common policy in State/Federal
prison systems (39 percent), and offered testing is most common in
city/county jail systems (51 percent). 

The lists of State/Federal prison systems with routine pregnancy testing of
incoming women and those with mandatory or routine HIV testing of
incoming pregnant women are quite different. Thirteen States and the
Federal Bureau of Prisons (FBOP) (27 percent of the total of 51) have both
policies (of these 14, 13 States do mandatory screening of all inmates at
intake; the FBOP does mandatory screening of all inmates at release).
Nine systems (18 percent) have routine pregnancy testing but some form
of voluntary HIV testing (all of these States do all HIV testing on a
voluntary or on-request basis). Fourteen systems (27 percent) have
mandatory or routine HIV testing of all incoming pregnant inmates but not
routine pregnancy testing (7 of these 14 States have mandatory HIV
testing of all incoming inmates). This leaves 14 State systems (27 percent)
that have neither policy and rely on voluntary/on-request testing for both
pregnancy and HIV testing. 

Overall, therefore, most systems have the same policy for HIV testing of
pregnant females that they have for HIV testing of all inmates. Only seven
State systems and the FBOP have mandatory or routine HIV testing of
incoming pregnant women but voluntary/on-request HIV testing for other
new inmates. Those with voluntary testing conform with the PHS
guidelines recommending that HIV testing of pregnant women remain
voluntary.[10] However, the NIJ/CDC survey data do not reveal whether
pregnant inmates in systems with voluntary HIV testing are being
routinely counseled regarding testing, which PHS also recommends.

Confidentiality and Notification of HIV Test Results 

Confidentiality is an extremely important ingredient in--some would say
prerequisite for--effective HIV diagnosis and treatment programs. As
noted earlier, people may be discouraged from coming forward for
voluntary HIV antibody testing, and thereby perhaps fail to receive timely
therapeutic intervention, if they fear unauthorized disclosure of their HIV
status and attendant discrimination or mistreatment. This may be a
particularly challenging problem in correctional facilities, where
confidentiality is more difficult to maintain and the consequences of
breached confidentiality are more severe. However, it is possible to
preserve confidentiality in a correctional setting, and many correctional
systems are quite successful in doing so.  Most of the blatant, systemic
violations of confidentiality common in the earlier days of the epidemic--
such as obvious flagging of medical records and posting or allowing free
access to lists of HIV-infected inmates--have been eliminated. In an era of
triple combination antiretroviral therapies, the most serious threat to
confidentiality is the need for patients on these therapies to "keep on
person" or swallow at a "pill line" large numbers of capsules that the
inmate grapevine easily identifies as HIV medications. A health care
provider in the Colorado prison system commented on other continuing
challenges of maintaining confidentiality of inmates' HIV status and other
medical information:

During transport of inmates, the medical charts are given to the
transporting correctional officers in a container that they are not supposed
to open. If security requests medical information (e.g., concern for safety
of an inmate during a forced cell entry) we are supposed to tell them only
if there is or is not a problem that they should be aware of, but not
necessarily the actual disease/reason for concern. The system works fairly
well but it depends greatly on the individual provider. Similarly, security
information is relatively inaccessible to [health care] providers. In reality,
the barrier is somewhat porous to information flow in both directions.[11]

In general, it is far preferable for policies to specify clearly, by category of
individual, who is to receive notification of inmates' HIV status and under
what specific circumstances. Policies providing for disclosure to persons
with a "need to know" should be avoided because the definition of such
persons is almost sure to be a matter of dispute. The Clinical Director for
the Vermont Department of Corrections commented that such "need to
know" policies leave "far too much room for subtle and not-so-subtle
pressure to be exerted on clinical staff by custody supervisors and officers
whose perception of risk is generally much higher than it actually is."[12]

Some States have laws or regulations requiring HIV testing and the
notification of results following incidents involving the possible
occupational transmission of HIV to correctional officers, law
enforcement officers, emergency medical technicians, and other
emergency response or health care-specified workers. In fact, California
has a law on the books, resulting from a referendum, that requires
notification to correctional officers of all HIV-seropositive inmates under
their supervision. The Forensic Services staff of the San Francisco
Department of Public Health reached a compromise with the correctional
officers' union, however, in which an incident-based testing and
notification policy was substituted for the mandated blanket notification.
In Rhode Island, similarly, a compromise for an incident-based policy was
reached with the correctional officers' union that has periodically called for
disclosure of the HIV status of all inmates.

Table 27 summarizes correctional systems' policies regarding the
disclosure of inmates' HIV-antibody-test results. Predictably, disclosure to
the inmate and the inmate's attending health care provider is virtually
universal, followed by notification to a public health department. In recent
months there has been considerable advocacy for and discussion of
expanded reporting to public health departments. Although at the time of
the survey HIV infection was reportable in only 29 States, 46
State/Federal correctional systems claimed to be reporting HIV infections
to public health departments.

Only 12 percent of State/Federal systems and 7 percent of city/county
systems reported official policies of notifying correctional officers of
inmates' HIV test results. Fewer than half reported notification to
correctional management at the central-office or institutional levels or to
parole agencies. Finally, policies for notification to victims of sexual or
physical assault and sexual or needle-sharing partners are also relatively
uncommon. Laws in some States require HIV testing of persons convicted
of (or, in some jurisdictions, persons charged with) sexual assault and
notification to victims of the results. 

Validation study results (table 28) indicate facilities' relatively high but not
complete compliance with central office policy to notify correctional
management and correctional officers but poor compliance with policies to
notify victims and sexual or needle-sharing partners. Central office
prohibitions against notification of particular categories of persons are in
general more often consistently followed by facilities. In particular, 34
facilities in 14 systems were 100 percent in agreement with the central
office policies not to notify correctional officers of inmates' HIV status.

STD Screening in Correctional Facilities 

Correctional inmates are disproportionately infected with and at high risk
for other sexually transmitted diseases. Therefore, as with HIV/AIDS,
correctional facilities are promising settings for the diagnosis and
treatment of STDs. Jail-based programs of rapid syphilis screening and
treatment funded by CDC have shown promising results.[13] Indeed, it is
possible that aggressive correctional STD screening and treatment
programs could help reduce community-wide STD morbidity.[14]

Table 29 suggests an unrealized opportunity to initiate more aggressive
STD screening and treatment in correctional facilities. Almost all
State/Federal prison systems have mandatory or routine syphilis screening
for incoming inmates, but coverage is much poorer for gonorrhea and
chlamydia. In city/county systems, mandatory or routine STD screening is
a relatively rare exception. A separate CDC survey of jails in 1997 also
found that few facilities conducted routine STD screening, and those that
had such policies tested fewer than half of the inmates. Few jails followed
CDC's STD screening and treatment guidelines.[15]

Conclusion 

Most correctional systems in the United States continue to provide
HIV-antibody testing on a voluntary basis for all categories of inmates,
including pregnant women. Discussion of mandatory testing is now driven
more by the potential for early medical intervention than by the belief that
primary prevention can be achieved. 

Confidentiality of HIV status remains an extremely important issue in
correctional facilities, as inmates may be discouraged from accepting
voluntary testing if they fear the unauthorized disclosure of their results
and the associated discrimination or mistreatment. However, correctional
systems appear to be improving their performance in the protection of
inmates' confidentiality.

Although the treatment implications of STD testing are relatively simple
and straightforward, they are much more complex for HIV/AIDS. As
described in chapter 7, the new HIV/AIDS regimens are challenging and
complex and often have significant side effects. Thus, ongoing evaluation
of policies for testing and early detection in light of factors likely to affect
decisions to initiate antiretroviral therapy is extremely important.

Endnotes 

1. "Texas Revises Inmate Testing and Prevention Policies," AIDS Policy
& Law 13 (March 20, 1998): 2.

2. P.M. Brien and A.J. Beck, HIV in Prisons 1994, Washington, DC: U.S.
Department of Justice, Bureau of Justice Statistics, March 1996 (NCJ
158020), Table 1; C. Behrendt et al., "Voluntary Testing for HIV in a
Prison Population with a High Prevalence of HIV," American Journal of
Epidemiology 139 (1994): 918-926.

3. Behrendt et al., "Voluntary Testing for HIV in a Prison Population with
High Prevalence of HIV."

4. Brien and Beck, HIV in Prisons 1994, Table 1; J. D. Ruiz and J.
Mikanda, Seroprevalence of HIV, Hepatitis B, Hepatitis C, and Risk
Behaviors Among Inmates Entering the California Correctional System,
Sacramento: California Department of Health Services, Office of AIDS,
HIV/AIDS Epidemiology Branch, March 1996: 1, 8.

5. A. DeGroot, T. Hammett, and R. Scheib, "Barriers to Care of
HIV-Infected Inmates: A Public Health Concern," AIDS Reader
(May/June 1996): 78-87.

6. A. Epstein, "Massachusetts HIV-1 Program," letter, Lancet 351 (May 9,
1998): 1439.

7. C. Behrendt et al., "Voluntary Testing for HIV in a Prison Population
With a High Prevalence of HIV," 918-926.

8. E.M. Connor, R.S. Sperling, and R. Gelber et al., "Reduction of
Maternal-Infant Transmission of HIV-1 With Zidovudine Treatment,"
New England Journal of Medicine 331 (1994): 1173-1180; Centers for
Disease Control and Prevention, "Recommendations of the U.S. Public
Health Service Task Force on the Use of Zidovudine to Reduce Perinatal
Transmission of HIV," Morbidity and Mortality Weekly Report 43, no.
RR-11 (August 5, 1994): 1-20. 

9. Centers for Disease Control and Prevention, "U.S. Public Health
Service Recommendations for HIV Counseling and Voluntary Testing for
Pregnant Women," Morbidity and Mortality Weekly Report 44, no. RR-7
(July 7, 1995): 1-15.

10. Ibid. 

11. J. Bloor, as posted on the Center for Integration of Health Sciences and
Criminal Justice list server, March 20, 1998.

12. T. Powell, Clinical Director, Vermont Department of Corrections, as
posted on the Center for Integration of Health Sciences and Criminal
Justice list server, March 7, 1997.

13. Centers for Disease Control and Prevention, "Syphilis Screening
Among Women Arrestees at the Cook County Jail-Chicago, 1996,"
Morbidity and Mortality Weekly Report 47 (June 5, 1998): 432-433.

14. D. Cohen, R. Scribner, J. Clark, and D. Cory, "The Potential Role of
Custody Facilities in Controlling Sexually Transmitted Diseases,"
American Journal of Public Health 82 (1992): 552-556; S. Blank et al.,
"New Approaches to Syphilis Control: Finding Opportunities for Syphilis
Treatment and Congenital Syphilis Prevention in a Women's Correctional
Setting," Sexually Transmitted Diseases 24 (1997): 218-226. 

15. Centers for Disease Control and Prevention, "Assessment of Sexually
Transmitted Disease Services in City and County Jails-United States,
1997," Morbidity and Mortality Weekly Report 47 (June 5, 1998):
429-431.

-------------------------------

Chapter 6

Housing and Correctional Management

Theodore M. Hammett and Patricia Harmon--Abt Associates Inc. 

Key Findings

o Only a small number of correctional systems segregate inmates with
HIV disease, and the number of systems with segregation policies has
declined sharply since the late 1980s.

o Some correctional systems still limit the work assignments for which
inmates with HIV are eligible.

o Few correctional systems permit conjugal visits for any inmates, and
even fewer allow such visits for inmates with HIV.

o Policies for the early or compassionate release of inmates with terminal
illness, including end-stage AIDS, are quite common, but relatively few
inmates are being released under such policies.

This chapter presents findings from the 1997 NIJ/CDC survey regarding
housing policies for inmates with HIV disease, as well as work
assignments, conjugal visits, and early release programs. In chapter 7, case
management, discharge planning, and continuity of care are discussed.

Housing Policies for Inmates With HIV Disease

Correctional housing policies for inmates with HIV disease have changed
dramatically since the beginning of the epidemic, with the continuing
eclipse of segregation. The changes were particularly pronounced during
the period 1985-92. Table 30 shows that by 1997 only three State prison
systems had policies for segregating all inmates with confirmed AIDS--
Alabama, Mississippi, and California--down from four in 1994. In
Alabama and Mississippi, the only two State prison systems that
segregated all known HIV-infected inmates, from the asymptomatic
through those with confirmed AIDS, the segregation is complete. Inmates
known to have HIV infection and AIDS are totally separated from the rest
of the inmate population residentially and programmatically. Since
Alabama and Mississippi have mandatory HIV-antibody testing of all
incoming inmates, these States probably identify and segregate a large
percentage of HIV-infected inmates. 

In most correctional facilities in California, inmates with AIDS live
separately, but the majority of these inmates go out into the general
population for work assignments, educational and vocational programs,
and other activities. Several California facilities do house inmates with
AIDS in the general population. In all California facilities, inmates with
asymptomatic HIV infection and symptomatic HIV disease short of an
AIDS diagnosis are housed in the general population.

In 1998 the South Carolina State correctional system initiated policies of
mandatory HIV-antibody testing and assignment of inmates with HIV to
one maximum-security facility regardless of their security classifications.
However, inmates with HIV disease are not segregated in this facility.
These changes were prompted primarily by a desire to identify inmates
with HIV in a timely manner so that they could be offered early-treatment
intervention. 

Tables 31 and 32 compare prison and jail systems' housing policies for
inmates with AIDS and asymptomatic HIV infection in 1994 and 1997.
The main change in State/Federal prison systems was the increase in the
number of systems with policies providing for general-population housing
with no restrictions. These increases came primarily at the expense of
policies for the case-by-case determination of housing for inmates with
confirmed AIDS and of policies for general-population housing with
restrictions for asymptomatic HIV-infected inmates. Among city/county
jail systems, the number and percentage of systems with policies for
general-population housing without restrictions of inmates with
asymptomatic HIV infection and AIDS increased from 1994 to 1997,
whereas the number of systems making housing decisions on a
case-by-case basis declined by similar amounts. The major policy shift
between 1994 and 1997 reversed the trend noted between 1992 and 1994
from general-population housing policies to case-by-case determination.

Table 33 represents the results of the validation study regarding the
housing of asymptomatic HIV-infected inmates and inmates with AIDS.
Agreement is generally higher for the blanket policies under which all
inmates in the category are either housed in the general population or
segregated. Case-by-case policies are inherently more ambiguous in that
they may operationally shade over into blanket policies. The converse is
also true, which may explain why the agreement rate in systems with
central office policies for general-population housing of inmates with
AIDS was quite low (29 percent). The divergent facilities all reported
case-by-case housing assignment.

Work Assignments and Other Programming

The predominance, noted above, of policies for the unrestricted housing of
inmates with HIV disease offers such inmates access to all work
assignments and other programming. However, the eligibility of
HIV-infected inmates for some program and work assignments remains
controversial. In particular, some correctional systems continue to exclude
HIV-infected inmates from food service jobs. One State correctional
system spokesperson gave the following justification for this policy: "It's
simply a health and safety issue. . . . Because people may get cut working
in food service, we consider it prudent and responsible to eliminate the
possibility, however slight, of exposing a great number of other people to
the AIDS virus."

When informed of the CDC's position that there is no scientific basis for
the exclusion policy, the correctional spokesperson said that "it's more a
matter of perception than a health issue. It was a political concession made
to the legislature some years back."[1] These statements exemplify an
important problem. In fact, HIV/AIDS is a health issue, and policy
decisions should be based on accurate health information rather than on
"perception" or "political concession." Indeed, as in the case of the
exclusion of HIV-infected inmates from food service work, policies
without basis in accurate health information may encourage erroneous and
dangerous perceptions that HIV may be transmitted through casual
contact. Such policies may also undermine the credibility of education
regarding the true means of HIV transmission. It is very important that
policies and educational messages be consistent.

Conjugal Visits

The number of State/Federal prison systems permitting conjugal visits
dropped from eight in 1994 to six (12 percent) in 1997. Of the six systems
permitting conjugal visits, five allow HIV-infected inmates to have such
visits. All six systems permitting conjugal visits make condoms available
to inmates participating in these visits.

Compassionate Release and Medical Furlough

With the dramatic advances in treatment for people with HIV/AIDS,
inmate AIDS deaths have declined in many correctional systems. Thus,
there are generally fewer inmates with terminal AIDS who might qualify
for early release or furlough programs. 

Nevertheless, inmates continue to die from a variety of diseases, so
policies making it possible for them to die at home or somewhere other
than prison remain important. Table 34 shows that almost two-thirds (65
percent) of State/Federal prison systems and almost half (44 percent) of
city/county jail systems permit early/compassionate release based on
either specific written policies or simply practice. Fewer systems, about
one-third (37 percent) of State/Federal prison systems and less than
one-fifth (17 percent) of city/county jail systems, permit medical furlough.
Table 35 reveals that 12 State/Federal systems granted early/compassionate
release to a total of 143 inmates during 1996, and 8 State/Federal systems
medically furloughed a total of 30 inmates. Fifteen city/county jail systems
granted early release to a total of 171 inmates, and 3 jail systems
furloughed a total of only 10 inmates in 1996. 

Conclusion

Policies of segregating inmates with HIV and AIDS continued their
decline among U.S. correctional systems in 1997, although the most
dramatic reductions occurred between 1985 and 1992. The unrestricted
housing of inmates with HIV disease generally means that inmates have
full access to work assignments and other programs offered in the facility.
However, some systems exclude inmates with HIV from food service
work assignments, which is problematic in that it may lead to the
erroneous belief that HIV can be transmitted through food.

Few correctional systems permit conjugal visits for any inmates, and even
fewer permit such visits for inmates with HIV/AIDS. Most systems have
some form of compassionate release or medical furlough program on the
books, but in fact relatively few inmates with HIV/AIDS have been
released under such programs. One reason for this may be the improved
medical condition and increasing survival of patients receiving the new
combination antiretroviral therapies.

Endnote

1. D. Cauchon, "AIDS in Prison: Locked Up and Locked Out," USA
Today, March 31, 1995, 6A.

-------------------------------

Chapter 7

Medical Treatment and a Continuum of Care

Theodore M. Hammett and Patricia Harmon--Abt Associates Inc.

Key Findings

o Protease inhibitors and combination therapies have brought dramatic
improvements in the medical condition and survival of people living with
HIV, at least over the relatively short term that has been available for
study to date.

o The new therapeutic combinations pose challenges for patient adherence,
and failure to adhere consistently to the regimens may have serious public
health consequences if drug-resistant strains are transmitted to others.

o New drugs and reduced dosing currently under study offer hope of more
"patient-friendly" regimens.

o Clinicians must work closely with patients to make the best therapeutic
decision.

o A continuum of services including early identification, timely and
effective treatment, case management, discharge planning, and community
linkages will make for optimal clinical and psychosocial outcomes for
inmates with HIV disease.

o Continuity of care and bridging to community services also contribute to
positive patient outcomes.

o Existing program models have not been rigorously evaluated yet
probably warrant replication based on anecdotal evidence.  

Inmate populations are disproportionately affected by a range of health
problems, including HIV/AIDS, STDs, TB, other infectious and chronic
diseases, high-risk sexual behavior, and substance abuse. Despite their
high levels of need, however, most inmates have been seriously
underserved in terms of medical care, drug treatment, and psychosocial
services when they arrived at correctional facilities. Many have never had
regular primary health care or dental care. In Connecticut 64 percent of
about 200 HIV-infected inmates reported that they were first offered
antiretroviral therapy in prison.[1]

Female inmates may have particularly serious health and psychosocial
problems: higher rates of substance abuse than male inmates, almost
universal histories of sexual and emotional abuse, high rates of
homelessness and other housing problems, and serious child custody and
family issues.

Although alcohol and drug use does occur in correctional facilities,
inmates are much more likely to be substance free while incarcerated than
when they were in the community. In general, there are fewer distractions
in prison than on the street. Therefore, periods of incarceration, however
brief, offer extremely important opportunities to treat many serious
conditions, to introduce inmates to primary care, and to provide a wide
range of health interventions.

This chapter discusses the availability of new antiretroviral drugs and
combination therapies in correctional settings as well as the complex
issues crucial to the selection and maintenance of regimens. It also
discusses an ideal continuum of services for inmates, from screening and
identifying health problems to discharge planning and community
linkages.

Medical Treatment for HIV/AIDS

Since 1996 the treatment of HIV/AIDS has been revolutionized by the
introduction of protease inhibitors and combination antiretroviral therapy.
However, the average cost of the new drugs is $12,000 per patient per
year. The Government's AIDS Drug Assistance Program (ADAP) is
generally not available to pay for the treatment of State inmates, but in
some States, such as Massachusetts, it may cover county inmates. 

The new HIV therapies appear to offer the possibility of long-term delay
in HIV disease progression, the long-term reduction of HIV viral loads to
undetectable levels, and consequent prolonged survival with HIV
disease.[2] There have already been reductions in the numbers of AIDS
deaths, both in the total U.S. population and in some prison systems,
attributable initially to AZT monotherapy and two-drug combinations and
even more markedly in the last 2 years following the introduction of
protease inhibitors and triple combination therapy. A recent study found
that the increased intensity of antiretroviral therapy produced increased
reductions in morbidity and mortality.[3]

These new drugs and combination therapies, as well as AZT therapy for
pregnant women, are widely available in correctional systems (table 36).
Viral load monitoring, which is critical to the ongoing assessment of
treatment effectiveness and adjustment of regimens, is not as widely
available in correctional systems (80 percent of State/Federal systems and
59 percent of city/county systems).

Table 37 presents the results of the validation study regarding the
availability of HIV-related therapies and monitoring methods. Rates of
agreement regarding the availability of protease inhibitors, combination
therapy, bactrim, and CD4 and viral load monitoring are very high. At the
same time, in the one system whose central office reported that protease
inhibitors and combination therapy were not available, the one facility in
the validation study reported that these therapies were in fact available
there. 

Although survey results show the wide availability of therapies, interviews
with staff and prisoner advocates in several major correctional systems
indicate that a combination of factors--including high medication costs;
inmate reluctance to seek testing and treatment based on denial, fear,
and/or mistrust; and uneven clinical competence and lack of uniform
treatment standards--may limit the availability of appropriate HIV
treatment regimens to inmates.[4]

Clinical trials offer another mechanism for expanded inmate access to new
HIV therapies. A study conducted in 1995 found that 9 of 32 correctional
systems surveyed had procedures in place for inmate participation in trials,
and 19 others prohibited inmate participation in clinical research.[5] More
recently, according to the 1997 NIJ/CDC survey, 242 inmates in 7 State
systems were enrolled in trials of anti-HIV medications.

Guidelines for Antiretroviral Therapy

Leading HIV clinicians identify the following key objectives of
antiretroviral therapy:

o To achieve maximum durable suppression of HIV viral replication.

o To preserve optimal immune function.

o To delay development of drug resistance.

o To maximize patient adherence by selecting a tolerable and
understandable regimen.

o To maximize future treatment options in the event of failure.[6]

Two complementary sets of guidelines for HIV antiretroviral therapy have
been issued.[7] These provide principles and algorithms for selecting
regimens that apply to all persons, including pregnant women. These
guidelines strongly recommend aggressive combinations of two
nucleoside reverse transcriptase inhibitors (NRTIs) with a potent protease
inhibitor or, as a generally less desirable alternative, one non-nucleoside
reverse transcriptase inhibitor (NNRTI) with two NRTIs. Combination
therapies for pregnant women must include AZT.[8] Combinations of two
NRTIs and all monotherapies are strongly discouraged. The baseline
measurement and ongoing monitoring of HIV viral load and CD4 counts
at specified intervals are essential. The combination of these two measures
provides the best assessment of disease progression and treatment
effectiveness. The state of the art in HIV treatment continues to evolve.
New drugs and new combinations, including "protease sparing" regimens,
as well as reduced dosing schedules for existing drugs are also being
evaluated. Promising results on some of these fronts were presented at the
12th World AIDS Conference in Geneva in July 1998. The hope is that
effective but more "patient-friendly" therapies will be widely available
soon.

New guidelines have also been issued for the prevention of opportunistic
infections in persons with HIV disease.[9] Johns Hopkins University
conveniently summarized the guidelines for antiretroviral therapy and
prevention of opportunistic infections in The Hopkins HIV Report.[10]

The most dramatic benefit from the new therapies has been demonstrated
most clearly in patients with advanced disease, whereas the risk-benefit
ratio for initiating antiretroviral therapy in the early stages of HIV disease
remains uncertain. Uncertainty about very early intervention is based on
the relatively slow progression of untreated HIV infection, the possibly
time-limited efficacy of the new therapies, the evolving knowledge of side
effects, the potentially increased problems of adherence in patients who
are entirely asymptomatic, possible adverse drug interactions, and
potential drug resistance and consequent limits on future treatment
options.[11] Nevertheless, as already discussed in chapter 4 with regard to
pregnant women, it is important to consider policies for HIV counseling
and testing--and particularly how aggressively to recommend testing to
patients who appear to be at high risk--in the context of developing
knowledge about the timing and efficacy of treatment.

Finally, the emergence of postexposure prophylaxis (PEP) for HIV
infection poses interesting challenges and possibilities for correctional
clinicians and administrators. The strategy of administering a course of
antiretroviral drugs immediately after parenteral or cutaneous exposure to
HIV-containing body fluids is already a routinely recommended practice
in health care systems.[12] PEP is currently under study in five U.S. cities
in nonoccupational contexts. In the correctional setting, such exposure
could occur through consensual or forced sexual intercourse, sharing of
drug-injection or tattooing equipment, or fights among inmates or between
inmates and staff. Given the prohibited nature of some of the activities that
might prompt an initiation of PEP, the administrative issues are probably
even more challenging than the clinical issues.   

Rapid expansion and frequent change in the best practice with regard to
HIV interventions require that clinicians keep constantly abreast of new
developments and that the appropriateness of correctional policies for the
clinical management of HIV disease undergo continuous evaluation. Some
of the complex and challenging issues in delivering HIV care are
discussed below.  

Selection and Initiation of Antiretroviral Therapy

In selecting an antiretroviral regimen, it is critical to "get it right the first
time" because failure of the first regimen can lead to cross-resistance to
other drugs of the same class, which in turn limits future treatment
options. In addition to proper combinations of drugs for maximum
biological efficacy, patient characteristics and environmental factors must
be considered because adherence to regimens is essential to treatment
success with triple combination therapies. These complex decisions
require knowing the patient, taking and considering his or her history and
prior treatment, understanding and considering possible side effects and
drug interactions, and considering patient characteristics and
environmental factors that may affect adherence to a treatment regimen.

Beyond patient-specific costs and the consequences of treatment failure,
the emergence of drug-resistant strains of HIV, which may be transmitted
to others, threatens the larger public health. Thus, complex and
challenging ethical issues surround the very decision to initiate
antiretroviral therapy.[13] These issues may be particularly difficult with
regard to the populations likely to be in correctional facilities--people with
serious substance abuse problems and highly chaotic and stressful lives. A
clinician's fundamental ethical obligation is to do what is best for the
patient. Doing what is best for the patient in terms of treating HIV disease
involves selecting the best treatment regimen from at least three different
perspectives: (1) what will work best biologically; (2) what will be most
tolerable to the patient; and (3) what will gain maximum patient
adherence. Because these perspectives, considered separately, will not
always lead to the same treatment decision, they must be weighed together
in the overall decision regarding a treatment. 

One of the most important ways to prevent the development of drug
resistance is to have the patient adhere to the prescribed regimen.
Interruption of any one of the medications in a regimen for more than a
few days is likely to present problems and, indeed, may be worse than
discontinuing the entire regimen.  

Even substantial adherence may be difficult to achieve among correctional
populations. However, many of the antiretroviral regimens are
complicated and challenging for even the most highly organized and
motivated patients, in terms of dosing schedule, number of pills to be
taken, and other requirements (for example, with or without food), as well
as possible side effects.  There may also be the problem of the continued
availability of a regimen in the community, which could lead to potentially
dangerous forced changes in drug combinations. Thus, in some cases, and
particularly in jail settings from which most inmates are released very
quickly, clinicians may reluctantly conclude that it would be more harmful
for the patient and for the community to initiate antiretroviral therapy only
to have the patient fail to adhere to the regimen or be unable to maintain
access to the drugs, perhaps develop serious drug resistance, and transmit
drug-resistant HIV to others. New and more "patient-friendly" regimens
may help to address these adherence issues.

The Patient-Clinician Relationship

An open, trusting relationship between clinician and patient is essential to
making the best decisions regarding HIV/AIDS treatment (that is, if at all
possible, "getting it right the first time") and to maximizing the likelihood
that adherence to the selected regimen will be high both during
incarceration and, even more important, following the inmate's return to
the community. The necessary clinician-patient relationship cannot
develop from a single, short interview. Indeed, the optimum model of care
provides for initially intensive consultation and regular subsequent
contact, and for a continuity of providers both during incarceration and
from the correctional facility to the community. As described later in this
chapter, some correctional systems have been able to implement such
models of care. 

Female inmates may need even more intensive interaction with clinicians
and even more complete continuity of care. Research advancing a
"relational model" of women's psychology suggests that women attach
more importance to personal relationships in making key life decisions
than do men. At the same time, the "other-directedness" commonly
observed among women may mean that they resist giving precedence to
caring for themselves,[14] and so they might have difficulty adhering to
complicated and demanding treatment regimens without substantial
support. Clinicians' experience with HIV-infected female inmates
confirms these observations and indicates that treating women with
HIV/AIDS poses challenges for correctional health care but offers
opportunities for successful clinical and psychosocial outcomes in the
hands of committed providers and administrators.[15]

Ideally, the clinician and the patient work together to decide on the best
treatment strategy, exploring and considering all relevant clinical and
behavioral factors as well as logistical issues posed by the correctional
setting such as the inmate's work, program, and meal schedule. The
provider should present the options in terms of regimens and methods of
administration available in the facility--for example, the "keep on person"
versus "attending a pill line" approach and making sure that the patient
understands potential threats to confidentiality and the stigmatization
associated with these methods. 

To win the trust of the inmate, the provider should also tell the whole truth
regarding the proposed regimen--dosing schedule and number of pills to
be taken at each time, as well as possible side effects--and make sure that
the patient understands this information. For example, if the patient has
not been clearly informed about the number of pills to be taken, he or she
may be surprised at the number and may be suspicious of being given a
dangerous overdose. Such concerns may be common in the correctional
setting, where inmate mistrust of the "system" and suspicions regarding
medications may be pervasive. 

The clinician should emphasize the importance of the patient's adherence
to the regimen and the likely serious consequences of nonadherence. It is
important to bear in mind that one of the few areas over which inmates
may exert control is whether or not to take medications. They may
therefore have psychological impulses to resist adherence. To address
these and other potential issues, the patient's "buy-in" to the treatment
must be obtained and specific adherence goals clearly set.

A Continuum of Care for Inmates

An integrated continuum of care with continuity of providers is the best
model for addressing the multiplicity of medical and psychosocial
problems of inmates both within correctional facilities and following their
return to the community. Such models are more and more commonly
being implemented for inmates with HIV and AIDS. However, they are
also needed for inmates with chronic diseases and other serious medical
problems, those with substance abuse problems, and those who are
medically healthy but behaviorally at risk for HIV/AIDS and STDs. In
short, almost all inmates could benefit from such services. Moreover,
comprehensive and integrated services may result in downstream savings
in costs of treatment and reincarceration if they offer timely and effective
interventions and help to reduce recidivism.

The key components of this continuum of care include the following: 

o Screening and identification of medical and psychosocial problems.

o Case management.

o Psychosocial support services.

o Hospice care.

o Substance abuse treatment.

o Discharge planning.

o Continuity of care and community linkages.

Examples of programs in prison and jail settings that incorporate all or
some of these components are presented below.

Screening and Identification of Medical and Psychosocial Problems

The important relationship between HIV- and STD-testing policies and
timely and effective treatment has already been discussed. However,
testing is only part of an overall strategy for identifying inmates' physical
and mental health problems. A comprehensive medical and psychosocial
screening should be provided to all inmates as part of the intake process.
At the Hampden County (Massachusetts) Correctional Center, all new
inmates receive comprehensive screening within 10 days of their arrival.
This includes screening for infectious diseases, chronic noninfectious
diseases, and high-risk behavior such as substance use, high-risk sexual
practices, and violence. Women are screened for pregnancy as well as
reproductive and gynecologic health needs. Registered nurses conduct
daily triage in all Hampden County housing units. The nurses work closely
with security staff on the units to ensure inmates' access to care. The
procedure enables all inmates with a need for medical care to be seen
quickly while also avoiding congestion of the system with unnecessary
visits, as often occurs in a traditional "sick-call" model.

Case Management

For care to be coordinated and consistently delivered as prescribed,
someone should be in charge of the overall treatment plan. In many
correctional settings, case managers play this role, which involves
coordination, monitoring, and patient advocacy. Case managers are
employed primarily for inmates with HIV/AIDS and other serious medical
problems, but a case management model can be used for prevention as
well as treatment. 

In response to recommendations from its AIDS Task Force, the
Massachusetts Department of Corrections directed its health services
contractor to add infectious disease case managers to its staff. Regional
case managers work with all Massachusetts inmates with HIV/AIDS and
other infectious diseases. In Hampden County, case managers who are
dually based at the correctional center and the community health centers
work with all inmates with HIV/AIDS and those with serious mental
health problems.

At the Central California Women's Facility in Chowchilla, the Henry J.
Kaiser Family Foundation and the California Endowment funded a
demonstration case management program for female inmates with
HIV/AIDS.[16] This is presented as a social rather than a medical model
of case management in which a full-time AIDS case manager is trained to
identify and advocate for the holistic care of inmates' medical, mental
health, and social problems. The case manager also conducts discharge
planning with inmates and works to link them with services in the
communities to which they will be released. However, this is not, strictly
speaking, a continuity of care model, since the community-based service
providers do not work with the inmates in the facility prior to their release.
For most inmates, the distances from the facility to their home
communities make such continuity infeasible. However, even without
continuity of care, the Chowchilla case management program has helped
to reduce recidivism among women with AIDS being released from the
facility. In the project's first 21 months, 114 HIV-seropositive inmates
were paroled from Chowchilla, of whom only 19 percent returned to
prison during this study period. The recidivism rate among HIV-infected
women prior to the program's initiation had been 76 percent.[17]

Psychosocial Support Services

Inmates with HIV/AIDS and other serious medical problems generally
need psychosocial support to cope with their illness as well as medical
care to address their clinical conditions. Psychosocial services may be
offered in a variety of ways. Table 38 shows that about two-thirds of
prison and jail systems offer support groups led by AIDS service
organizations. Less frequently offered are support groups led by
correctional staff or by inmate peer leaders. At Avoyelles Correctional
Center in Louisiana, the peer-based AIDS Counseling and Trust program
offers support groups for inmates with AIDS. Individual peer support to
inmates with HIV/AIDS is also provided in some facilities. At Stateville
Correctional Center in Illinois, a peer educator lives in the infirmary,
where he provides support and medical advocacy for inmates with
HIV/AIDS. At San Quentin prison in California, HIV-infected peer
educators provide counseling support to other inmates who have recently
been diagnosed with HIV disease. The counseling includes discussion of
the meaning of HIV infection, circumstances of the inmate's learning of
his or her status, his or her current physical and psychological state,
disclosure of status, sexual risk reduction, and the correctional system's
policies for housing and treating inmates with HIV/AIDS.

Hospice Care

With the advent of effective new HIV/AIDS therapies and the resulting
decline of AIDS deaths in at least some prison systems, there may be
fewer terminal patients appropriate for hospice care. However, these
services will still be needed in some cases. 

Several prison systems have established hospice programs within
correctional facilities. Many of these use inmate volunteers in key
care-giving roles. Some also use community-based organizations to
provide services.[18]

The first prison hospice in the Nation is at the Federal Bureau of Prisons'
Medical Center in Springfield, Missouri. This was established through the
cooperation of the security and health care staff, with training provided by
community-based organizations, and with heavy reliance on inmate
volunteers. The hospice team at Springfield includes a chaplain and two
nurse managers. There are two 20-bed wards, one for patients with cancer
and the other for AIDS patients. The inmate volunteers receive 30 hours of
initial training in counseling and supportive services and subsequently
participate in twice-monthly training sessions. The inmates often become
surrogate family members to the patients and are commonly with them at
their deaths.[19]

In January 1997 a hospice was opened at the Stiles Unit of the Texas
Department of Criminal Justice in Beaumont as a result of legislation
sponsored by State Senator Michael Moncrief. Moncrief stated that
inmates "have a right to die with dignity." The Stiles hospice is "designed
to do inside what a hospice does outside the walls," that is, to provide care
based on dying patients' spiritual, psychological, and medical needs.
Thirty-five trained inmates work in the hospice, keeping the patients
company, reading to them, and writing letters for them. One inmate
hospice volunteer explained the importance of his work as follows: "[A]
lot of them [the patients] don't have nobody. They are human. Everybody
has downfalls."[20] 

Substance Abuse Treatment

Most inmates with HIV/AIDS also have drug or alcohol problems. Indeed,
according to a recent report from the Center on Addiction and Substance
Abuse (CASA) at Columbia University, almost 80 percent of the more
than 1.7 million people incarcerated in U.S. prisons and jails are seriously
involved with drugs and alcohol. In short, as the CASA report bluntly
states, "[S]ubstance abuse and crime are joined at the hip in America."[21]

Despite exploding numbers of incarcerated people, largely the result of
more aggressive drug enforcement beginning in the early 1980s, and
despite the unprecedented opportunity to provide substance abuse
treatment in correctional facilities, treatment within the walls has become
less available in the last few years in terms of treatment slots per inmate.
According to the CASA report, the number of inmates in need of treatment
increased from 688,000 to 840,000 between 1993 and 1996, but the
number of inmates in treatment remained level at about 150,000.
Moreover, much of this treatment was short term and inadequate to
address most inmates' deep-seated problems. Long-term counseling and
residential treatment, such as therapeutic community-model programs,
remain quite rare in correctional facilities. Even where they exist, they can
accommodate only a small fraction of those who might benefit from
them.[22]

Some evaluations of prison-based drug treatment programs have shown
positive results, but these studies have often suffered from methodological
problems such as lack of control or comparison groups and flawed
measurement of outcomes.[23] Despite these technical problems with the
evaluation of programs, it is clear that treatment does work for some
people in some settings and that inmates and correctional facilities offer
treatment opportunities too important to miss. Substance abuse treatment
is one of the types of health interventions in correctional facilities that may
result in downstream savings in the costs of incarceration by helping to
reduce recidivism rates. Economic benefit would also accrue in the form
of income to newly productive and employed citizens. The CASA report
estimates the cost of a year of a comprehensive program of in-prison drug
treatment, aftercare, and vocational training at $6,500 per person, whereas
the first-year benefits would be $68,800 per successful inmate, using
conservative assumptions. Thus, even if only 10 percent of inmates in
treatment were successful in staying sober and employed in the year
following their release, the total cost of inmate drug treatment would be
more than repaid. Successful treatment of 10 percent of the estimated 1.2
million inmates who are substance abusers would bring more than $8.2
billion in total economic benefit in the first year following their release.
This is more than $456 million in excess of the total treatment, training,
and aftercare costs for all substance-abusing inmates.[24]

Discharge Planning

Whether they have HIV disease or other serious medical conditions or not,
all inmates can benefit from assistance in making the difficult transition
from a correctional facility to the community. Those with health problems
need particular types of assistance and linkages to community-based
services, but the others will almost certainly need help with housing,
benefits, drug treatment, job training and placement, and child custody and
family issues. Community corrections agencies should be brought into
integrated aftercare programs, perhaps helping to ensure that ex-offenders
with HIV/AIDS obtain their medications and adhere to their regimens and
providing HIV/STD prevention and risk-reduction counseling to their
at-risk clients. 

Table 39 summarizes the discharge planning services provided for inmates
with HIV disease, according to the 1997 NIJ/CDC survey. Ninety-two
percent of State/Federal systems and 76 percent of city/county systems
reportedly provide some discharge planning for inmates with HIV disease.
Specific types of clinical and psychosocial services covered in discharge
planning include enrollment in Medicaid and related benefit programs,
monitoring of CD4 counts and HIV viral load, access to HIV medications,
drug treatment, HIV counseling, other psychosocial support, and STD
services. 

Inmates in most State/Federal systems and in some city/county systems
are given referrals for most of these services. As part of an 11-session
health promotion series for HIV-positive inmates about to be released
from San Quentin prison in California, participants are encouraged and
helped to link up with services in the communities to which they will
return. At Avoyelles Correctional Center in Louisiana, peer educators
from AIDS Counseling and Trust conduct sessions for all inmates 30 days
prior to their release. At these sessions, the inmates are given one of nine
regional directories providing contact information for all types of health
care and mental health services, substance abuse programs, benefit
programs, and housing and employment services. The peer educators go
through the directory with all of the inmates to make sure that they
understand the services available to them.

As shown in table 39, fewer systems actually make appointments for
inmates to receive these services in the community. Although good
referrals are important, the frequent absence of appointments and
additional support and assistance in making contact with and keeping
appointments for services means that many released inmates never make
contact and never receive the services they need. Instead, many quickly
relapse to substance use and crime, often returning yet again to jail or
prison. 

Improved discharge planning, stronger community linkages, and
continuity of care between the correctional facility and the community will
help offenders negotiate the treacherous postrelease period more
successfully and give them a better chance to make significant positive
changes in their lives, obtain the services they need, reduce their risks of
acquiring or transmitting HIV and STDs, and avoid returning to crime and
incarceration. In designing programs, it is essential to bear constantly in
mind that issues of HIV/AIDS prevention and treatment may be only one
in a long list of serious problems faced by ex-offenders being released to
the community. The immediate problems of housing, food, employment,
and substance abuse treatment are likely to be more pressing. Thus,
programs must place HIV services in their appropriate context and seek to
help participants address their immediate survival needs and other ongoing
psychosocial problems. 

Several programs that offer comprehensive services bridging from
correctional facilities to the community are described below. There are
exemplary programs in both State prisons and county jails. A serious
challenge to the successful development of true continuity of service from
correctional facility to community is the great distance that often separates
an inmate's facility from his or her home community. This is especially
true in large State systems, where prisons are often in rural areas far from
the cities that are home to most inmates. A possible strategy for solving
this problem is to consider transferring soon-to-be-released inmates to
State or even county facilities closer to home for the last few months
before their release so that they can be linked directly and personally with
service providers in their communities.

Continuity of Care and Community Linkages

Rhode Island program. The first program to provide true continuity of
medical care for people with HIV/AIDS between the correctional facility
and the community was established in Rhode Island in the late 1980s. The
program was initiated by Brown University, Miriam Hospital, the Rhode
Island Department of Corrections, and the Rhode Island Department of
Health. Infectious disease physicians from Brown and the Miriam Hospital
provide care for inmates with HIV/AIDS in the correctional facility and
continue caring for them after their release. The program has been
expanded to include about 40 community-based organizations and service
providers, with comprehensive discharge planning and linkages to
community services.[25] The program is now available to both
HIV-positive inmates and high-risk but HIV-negative inmates. Initial
results reveal reduced recidivism rates among released females who are
associated with participation in the program.[26] Dr. Timothy Flanigan of
Miriam Hospital pointed to one of the key factors in the success of the
Rhode Island program: the providers who will be working with the
individuals in the community come into the prison and work with them
there first. Dr. Flanigan emphasized that simply "giving an inmate a phone
number and a piece of paper doesn't work. The inmate needs to see and
meet the person he or she will be working with in the community." This
dramatically increases the likelihood of follow-through after release.
Indeed, the Rhode Island program has produced sharp increases in
adherence to medical regimens and "show rates" for appointments with
service providers.[27]

Hampden County (Massachusetts) Correctional Center (HCCC). HCCC,
in partnership with community health centers, has developed and
implemented a public health model of correctional health care that
incorporates the following key components: 

o Early detection and effective treatment.

o Education and prevention.

o Case management and discharge planning.

o Continuity of care from HCCC to the community.[28]

The model is also based on an integration of care both vertically
(providing a comprehensive, holistic range of services) and horizontally
(providing a seamless continuity of care from the facility to the
community). To date the model has been implemented at a very reasonable
cost of about $6 per inmate day within a health services budget
representing only 9 percent of the entire facility's.[29]

Based on ZIP Code of residence, patients with HIV/AIDS and other
serious medical and mental health conditions are assigned to four dually
based health teams who work in the correctional center and in four
community health centers. Eighty percent of the inmates come from the
catchment areas of these four community health centers, and, on an
average day, 1.5 percent of the populations of these catchment areas are
incarcerated at HCCC. 

Case management and discharge planning are currently provided by dually
based case managers for all inmates with HIV/AIDS and serious mental
health issues. A discharge planning nurse at HCCC provides similar
services for inmates with chronic diseases. Discharge planning helps to
ensure continuity of care and community linkages with appropriate health
providers. In 1997, more than 70 percent of persons with HIV/AIDS
released from HCCC kept their first appointments at their assigned
community health center. Releasees are also linked with community-based
agencies that can address issues of family reintegration, housing,
employment training and readiness, and benefit programs. All of these
linkages have contributed to lower recidivism rates among people with
HIV/AIDS released from HCCC with a linkage to Brightwood Health
Center (46 percent over one year) versus the overall population of HCCC
releasees (72 percent). This is not a perfect comparison for evaluation
purposes but it may be suggestive of the program's efficacy. Additional
evaluation of this and similar programs is needed.

Continuity of care between the facility and the community for patients
with HIV/AIDS, chronic diseases, and other serious conditions is a
hallmark of the model. This horizontal integration of care is strongly
fostered by discharge planning and by the well-developed partnerships
among the correctional center, the community health centers, and other
community-based providers. The HCCC's partnerships with the
community health centers have helped to promote an integration of
community-based health services in Greater Springfield.

The Hampden County program serves a compact metropolitan area with a
population of about 500,000 in which distances are short enough to make
real continuity of care possible. Because 80 percent of the metropolitan
areas in the United States have populations in this range--between 100,000
and 1 million--the Hampden County model should be replicable in many
other places. Indeed, the Massachusetts Department of Public Health
intends to fund similarly constituted comprehensive HIV/AIDS care
programs in all of the State's county facilities.[30]

ETHICS Unit. In New York City, the Nation's largest metropolitan area,
the ETHICS Unit provides discharge planning and comprehensive
transitional services for inmates with HIV disease being released from
Rikers Island and New York State prisons.[31] The ETHICS Unit is a
program of the Fortune Society, an organization founded by ex-offenders
in 1977 to help ex-offenders make better transitions to the community, and
is funded as a Special Program of National Significance by the U.S.
Health Resources and Services Administration, with additional funding
from the New York City Department of Health.

Currently, five caseworkers and six peer counselors work in the ETHICS
Unit. Most of them are ex-offenders and/or recovering addicts. One
caseworker does all of the outreach and discharge planning at Rikers
Island and the State prisons as well as the remaining casework staff work
with clients in the community following their release from prison or jail.
The individual caseworkers have developed specialties and extensive
contacts in housing, hospital care, substance abuse treatment, and benefits
eligibility. 

The peer counselors assist with outreach, meet new clients when they are
released, and escort them to appointments with service providers. The peer
counselors also provide informal counseling in the office where clients
often come to receive support or just "hang out." 

The ETHICS Unit has an open-door policy. Clients are always welcome in
the office. They can take advantage of the educational, vocational, and
other programs available at the Fortune Society. 

The ETHICS Unit establishes relationships with its clients on a voluntary
basis. The program does not accept "mandates" from probation or parole
and will not provide information on its clients to these authorities except
general reports on attendance, and then only if the staff member feels
comfortable with the particular parole or probation officer. The program
does not divulge information on drug use.

ETHICS Unit staff recruit clients through regular outreach visits to Rikers
Island and to various New York State prisons. The site visit conducted for
this study included observation of an outreach session in a Rikers Island
unit housing and treating inmates with HIV disease. Because the session
clearly and powerfully illustrates the challenges posed and the
opportunities offered by these types of programs, it is worth describing it
in some detail.

The first priority when ETHICS begins to work with an ex-offender is to
help him or her achieve basic stability. This often means meeting clients at
the jail, prison, or bus terminal to help them get through the first hours,
when the temptation to relapse is particularly severe. The caseworkers find
the person a place to stay and, if appropriate, help arrange medical care.
Goals, objectives, and a treatment plan are worked out with the client. The
caseworkers try to act as role models--demonstrating that it is possible to
change one's life for the better--and to provide a positive and positively
structured social network, but they avoid setting unreasonably high
expectations. "We don't try to move too fast," a caseworker reported. They
focus on getting the client stabilized and housed and then move on to
employment issues.

ETHICS staff report that housing and medical care are the most critical
and difficult-to-arrange services for their clients, many of whom are
homeless when they are released. Ironically, the task is simpler if the client
has AIDS. These clients qualify for a number of housing, treatment, and
medication programs. However, those who are asymptomatic or have
symptomatic non-AIDS are much more difficult to place. Dually or triply
diagnosed individuals are also very hard to place. These categories of
clients are more likely to end up in single residence occupancy (SRO)
apartments or in the shelter system, where the temptations to return to drug
use and crime are virtually irresistible. The old coping skills (getting high)
are harder to avoid in the horrendous conditions of the shelters, and many
of the SROs are essentially shooting galleries with around-the-clock drug
activity. Even in the face of these challenges, the ETHICS staff are
persistent. As noted, the caseworkers have developed specialties and
identified many little-known referral resources. 

Although no formal evaluation of the program has been done, the ETHICS
Unit director reports that hundreds of clients have succeeded in turning
their lives around with the help of the program. Many clients go on to
become peer counselors, and some become paid staff members of the
program.

A group of ETHICS clients expressed uniformly positive feelings about
the program during the site visit conducted for this study. One client
remarked that the ETHICS Unit had helped her to come to terms with, and
accept, her HIV disease. "I'm not so afraid of it," she said, "there's no more
blaming. I look at what I did to put myself in this situation and move on
from there." 

Many of the clients feel that the program is their home and the staff is their
family. This feeling was clearly reflected in an emotional "Celebration of
Life" that was held during a site visit conducted for this study. This
celebration honored 16 clients who had "completed" the program to the
extent that they are drug free, have stable housing, and are following their
treatment plans. The clients told their stories: they are people who
seemingly had no hope but who have been able to achieve remarkable
transformations in their lives with the help of the ETHICS Unit. They have
gotten sober and stayed sober, developed a positive social network, found
inspirational role models, found stable housing, acquired job skills, and are
firmly committed to finding regular employment. Many of the clients had
found a spiritual basis for their lives and the changes they had achieved.
They spoke openly of how their religious faith, as well as the support of
ETHICS, had seen them through the hard times to lives of brighter
possibility. Clients and staff expressed great affection for one another;
strong and lasting bonds had clearly developed. This is where the clients
come for support and encouragement, and they receive it in full measure.
The celebration also honored several people from community-based
organizations and the community at large who had supported and assisted
ETHICS clients. 

The decision to include a client in the "Celebration of Life" is made jointly
by the client and his or her caseworker. This milestone can be reached
after 6 months to 2 years of enrollment in the program. The unit resists
referring to the "Celebration of Life" as a "graduation" because this would
imply completion and separation when it is but part of an ongoing process
and clients are encouraged to stay in touch and stay involved in the
program after the ceremony. 

Health-Link. Another program in New York City, Health-Link, works
with women and adolescents who are being released from Rikers Island to
the South Bronx or Central Harlem and who have substance abuse
problems and are at risk for HIV/AIDS.[33] People with HIV disease are
also eligible. Health-Link provides educational and community-based
supportive services to help women and adolescents make better transitions
to the community. The program has been operated by the Hunter College
Center on AIDS, Drugs, and Community Health since 1992, with funding
from the Robert Wood Johnson Foundation (RWJF). In phase 3 of
Health-Link, which began in 1997, the Fortune Society is providing all
case management services in jail and in the community. The Health-Link
staff includes 10 full-time equivalent case managers, 1 casework
supervisor, and 1 casework coordinator. 

Health-Link offers a structured and comprehensive program beginning
with empowerment groups for women and adolescents at Rikers Island,
linkages with a large network of community-based services in the South
Bronx and Central Harlem, and case management with continuity of
care-that is, the same case manager who works with the individual in jail
continues to work with the individual in the community. The network of
community-based providers, assembled in a Community Coordinating
Council (CCC) that also includes the Department of Corrections (DOC),
offers a comprehensive array of services designed to help ex-offenders
make successful transitions to the community. These include educational,
vocational, employment, housing, substance abuse treatment, HIV/AIDS
prevention, and health care services. It is a holistic approach, in which
clients are encouraged to analyze critically their life experiences and make
their own decisions about where they want to go with their lives and how
they can get there. A rigorous evaluation of Health-Link employing a
randomized design is being carried out.

The program maintains a careful balance between emphasizing individual
responsibility and its philosophy of providing comprehensive social
support. All clients are required to work with their case manager to
develop a discharge plan (including commitment to a primary community
placement) and to sign a contract to abide by it. Case management services
are provided for 1 year following discharge. In most instances clients are
escorted to their community placement. They are expected to meet with
their case managers several times a week during the first 10 weeks
following discharge. The number of meetings tapers off subsequently,
depending on caseloads and client needs. 

The relationship between Health-Link and its clients is voluntary; that is,
participation in the program is not a formal alternative to incarceration or
condition of probation or parole. However, Health-Link staff realized that
they could not treat the relationship with clients as if the criminal justice
nexus did not exist. Therefore, Health-Link staff do work with their clients
and serve as advocates with the probation and parole authorities.

Health-Link clients are recruited through empowerment groups at the
women's and adolescent facilities at Rikers Island. Case managers lead the
groups in teams of two; those recruited to the case management
component will be assigned to one of these case managers but will also
know another person to contact if the primary case manager is not
available. 

To be eligible for enrollment in the Health-Link case management
program, an inmate must have less than 1 year to serve before his or her
release. Adult women must have attended three empowerment group
meetings; because of generally shorter lengths of stay, adolescents must
attend two group meetings to be eligible for case management. All clients
must sign a discharge plan contract. They must also agree to receive
services in the South Bronx or Central Harlem neighborhoods, although
they need not live in these neighborhoods. Many of the program's clients
were homeless when they were sent to jail.

An extremely important facet of the Health-Link program is the
mobilization of community-based providers to meet the needs of
ex-offenders as they return to the community. The CCC of Health-Link
now comprises an array of about 40 organizations in the South Bronx and
Central Harlem. The CCC meets each month, with the meeting place
rotating among organizations so that participants can take a closer look at
the settings and services of member organizations. Each meeting is chaired
by a representative of the host organization. 

There are various relations between Health-Link and CBOs. One
important facet is that Health-Link helps build the capacity of CBOs to
serve ex-offenders by raising the organizations' level of knowledge and
sensitivity regarding the needs of ex-offenders. For example, ex-offenders
may consider highly structured and regimented drug-treatment programs
to be too much like jail, so programs may need to be a bit more flexible
and nonregimented, bearing in mind that ex-offenders tend to do best in
fairly structured situations. Health-Link also advocates for more attention
to the particular needs of women in substance abuse treatment programs--
for example, for child care services.

The DOC is also represented on the CCC of Health-Link. This
involvement offers good opportunities to establish and strengthen lines of
communication and coordination between CBOs and the DOC, as well as
for the CBOs and the DOC to "educate" each other about their respective
needs, roles, and concerns. As a result of their involvement in the CCC,
more CBOs have been able to provide services in, and receive referrals
from, Rikers Island.

The planned enrollment for Health-Link in phase 3 is 92 women and 92
adolescents in the first year and 115 in each group in the second year. This
is, of course, far short of the need for such services. Indeed, discharge
planning at Rikers Island and other New York City facilities is currently
very much a "hit or miss" proposition. In part because of rapid turnover
and short lengths of stay, many inmates receive no discharge planning--
they are simply turned loose to fend for themselves. Many of them are
homeless and have substance abuse and/or mental health problems. With
these problems, and with no transitional help, they are almost guaranteed
to return to jail. Health-Link wants to make discharge planning an integral
part of services for all inmates, arguing that this is likely to be very
cost-effective in terms of reduced recidivism. The New York City DOC
has established a committee to work toward the "institutionalization" of
discharge planning.

As previously discussed, inmates who are not infected with HIV but are
behaviorally at high risk of becoming infected are probably as much in
need of discharge planning, transitional assistance, and continuity of
service from jail or prison to the community as are those with HIV
disease. However, there are still relatively few programs available to the
high-risk uninfected. The Rhode Island program and Health-Link, already
described, are open to the uninfected. Two programs in Massachusetts
county jails specifically target this group. 

Search Out Another Road (SOAR). SOAR, a "reintegration program" of
the South Shore AIDS Project in Brockton, Massachusetts, works with
inmates about to be released from the Plymouth, Barnstable, and Bristol
County jails.[34] The SOAR reintegration counselor leads an eight-session
course encouraging participants to reflect upon their lives and to focus on
realistic behavioral changes. Following release, participants meet with the
same counselor once a month for at least 6 months to assess issues of
work, addiction, and risk reduction. The SOAR program works to place
releasees in residential drug treatment or intensive outpatient treatment.

After-Incarceration Support Systems (AISS). AISS, in Hampden County,
Massachusetts, provides transitional assistance to inmates without serious
medical problems.[35] A resource room has been established at the
correctional center where inmates may view and explore a range of
materials and computer databases. These cover resources and referrals in
education, job training, job readiness, health services, housing, substance
abuse prevention and treatment, family counseling, stress reduction,
violence prevention, and leisure activities. Counseling is available for
participants before they are released, and support groups are offered in the
community for participants who have been released. 

Conclusion

New drugs and combination therapies have brought dramatic
improvements to HIV/AIDS care but also pose challenges for
implementation, which may be especially difficult for correctional inmate
populations. However, new and more "patient-friendly" regimens offer the
hope of addressing these challenges. In any event, clinicians must work
closely with patients to make decisions regarding treatment regimens that
consider efficacy as well as maximum likely adherence, particularly
following release from incarceration. Nonadherence may mean not only
treatment failure for the patient but also danger for the larger public health
in terms of the development and transmission of drug-resistant strains of
HIV.

Inmates with HIV, STDs, and other medical and psychosocial problems
will benefit from a continuum of care that includes early detection,
effective treatment, case management, psychosocial services, hospice care
when appropriate, substance abuse treatment, discharge planning, and
linkage to community-based services. Continuity of care and bridging to
the community are particularly important for the maintenance of
adherence to HIV/AIDS treatment regimens. This chapter has described
extremely promising approaches to providing this continuum and
continuity of care, including programs in Rhode Island; Hampden County,
Massachusetts; New York City; and California. Although there is a need
for a more systematic evaluation of these programs and approaches,
preliminary data indicate that they may be cost-effective in terms of
promoting positive transitions to the community, reducing recidivism, and
producing downstream savings in costs of treatment and reincarceration.
The available evidence suggests that these program approaches deserve
widespread replication. 

Endnotes

1. F.L. Altice, F. Mostashari, A.S. Thompson, and G.H. Friedland,
"Perceptions, Acceptance and Adherence to Antiretrovirals Among
Prisoners," presented at the 4th Conference on Retroviruses and
Opportunistic Infections, Washington, DC, 1997.

2. S.G. Deeks et al., "HIV-1 Protease Inhibitors: A Review for Clinicians,"
Journal of the American Medical Association 277 (1997): 145-153.

3. F.J. Palella, Jr., et al., "Declining Morbidity and Mortality Among
Patients With Advanced HIV Infection," New England Journal of
Medicine (March 26, 1998): 853-860.

4. M. Purdy, "As AIDS Increases Behind Bars, Costs Dim Promise of
New Drugs," New York Times, May 26, 1997, A1, A12.

5. A. Collins, D. Baumgartner, and K. Henry, "Prisoners' Access to
Experimental HIV Therapies," Minnesota Medicine 78 (November 1995):
45-48.

6. V. Stone, "HHS Guidelines: The Role of Caregivers, Patients, and
Corrections," presentation to the HIV Treatment Update for Prisons and
Jails panel, sponsored by Brown University, Cambridge, MA, March 13,
1998. 

7. U.S. Department of Health and Human Services, National Institutes of
Health, Report of the Panel To Define Principles of Therapy of HIV
Infection, Rockville, MD: U.S. Department of Health and Human
Services, 1997; U.S. Department of Health and Human Services and the
Henry J. Kaiser Family Foundation, Guidelines for the Use of
Antiretroviral Agents in HIV-Infected Adults and Adolescents, Rockville,
MD: U.S. Department of Health and Human Services, 1997.

8. U.S. Public Health Service, "U.S. Public Health Service
Recommendations for Use of Antiretroviral Drugs During Pregnancy for
Maternal Health and Reduction of Perinatal Transmission of HIV-1 in the
U.S.: Request for Comment," September 1997.

9. U.S. Public Health Service and Infectious Disease Society of America,
"Guidelines for the Prevention of Opportunistic Infections in Persons
Infected with HIV,"  Morbidity and Mortality Weekly Report 46 RR-12,
(November 4, 1997): 1-46.

10. Panel on Clinical Practices for Treatment of HIV Infection,
"Department of Health and Human Services Guidelines on Use of
Antiretroviral Agents in HIV-Infected Adults," The Hopkins HIV Report 9
(Supplement, December 1997): 1-7.

11. B. Hirschel and P. Francioli, "Progress and Problems in the Fight
Against AIDS" (editorial), New England Journal of Medicine 338 (March
26, 1998): 906-908. 

12. M.H. Katz and J.L. Gerberding, "Postexposure Treatment of People
Exposed to HIV through Sexual Contact or Injection-Drug Use," New
England Journal of Medicine 336 (April 10, 1997): 1097-1100; and J.L.
Gerberding, "Prophylaxis for Occupational Exposure to HIV," Annals of
Internal Medicine 125 (September 15, 1996): 497-501. 

13. R. Bayer and J. Stryker, "Ethical Challenges Posed by Clinical
Progress in AIDS" (commentary), American Journal of Public Health 87
(1997): 1599-1602.

14. J.B. Miller, Toward a New Psychology of Women, Boston: Beacon
Press, 1986.

15. A. DeGroot, E. Hight, A.K. Goodman, and C. Stevenson, "Special
Issues for HIV-Infected Incarcerated Women," paper presented to the
panel HIV Treatment Update for Prisons and Jails, sponsored by Brown
University, Cambridge, MA, March 14, 1998. 

16. For information on the program at Chowchilla, contact Mary C.
Wallace, Executive Director, Central San Joaquin Valley HIV Care
Foundation, 2491 W. Shaw Avenue, Suite 110, Fresno, CA 93711
(telephone: 209-243-0580).

17. M.C. Wallace, "Women in Prison: AIDS Case Management," thesis
prepared for the Credentials Committee in partial fulfillment of the
requirements for Fellow status in the American College of Health Care
Executives, February 20, 1998.

18. R.A. Kiel, "Caring for Terminally Ill Inmates: On-Site Hospice Care
or Compassionate Release?" CorrectCare (June-July 1995): 5, 13-14.

19. E. Craig, "A Visit to the Hospice Program at the U.S. Medical Center
for Federal Prisoners," Fanfare 9 (Fall 1995): 18-19.

20. B. Rodriguez, "Some, However, Will Never Go Home"  (third part of a
five-part series on HIV/AIDS in prisons), San Antonio Express-News,
September 16, 1997, 1A, 6A.

21. National Center on Addiction and Substance Abuse (CASA) at
Columbia University, Behind Bars: Substance Abuse and America's
Prison Population, New York: CASA, January 1998: 27.

22. Ibid., 114-115.

23. T. Hammett, J. Gaiter, and C. Crawford, "Reaching Seriously At-Risk
Populations: Health Interventions in Criminal Justice Settings," Health
Education & Behavior 25 (February 1998): 111.

24. CASA, Behind Bars, 163-165.

25. P.S. Dixon, T.P. Flanigan et al., "HIV Infection in Prisoners: Meeting
the Health Care Challenge," American Journal of Medicine 95 (1993):
629-635.

26. J.Y. Kim et al., "Successful Community Follow-up and Reduced
Recidivism in HIV-Positive Women Prisoners," Journal of Correctional
Health Care 4 (1997): 5-17.

27. T.P. Flanigan, presentation to HIV Treatment Update for Prisons and
Jails panel, sponsored by Brown University, Cambridge, MA, March 13,
1998.

28. A.A. Skolnick, "Look Behind Bars for Key to Control of STDs,"
Journal of the American Medical Association 279 (January 14, 1998):
97-99; T.J. Conklin, T. Lincoln, and T.P. Flanigan, "A Public Health
Model To Connect Correctional Health Care With Communities,"
American Journal of Public Health (accepted for publication).

29. For more information on the Hampden County program, contact
Thomas Conklin, M.D., Director of Health Services, Hampden County
Correctional Center, 627 Randall Road, Ludlow, MA 01056 (telephone:
413-547-8000, ext. 2344).

30. Massachusetts Department of Public Health, AIDS Bureau, "Request
for Applications: Massachusetts County Sheriff's Department HIV/AIDS
Program," March 6, 1998.

31. For more information on the ETHICS Unit, contact JoAnne Page,
Esq., Executive Director, The Fortune Society, 39 West 19th Street, New
York, NY 10011 (telephone: 212-206-7070).

32. The description is from T. Hammett, "Lessons From a Day at Rikers
Island," unpublished article, April 1997.

33. For more information about Health-Link, contact Dr. Nicholas
Freudenberg, Director, Hunter College Center on AIDS, Drugs, and
Community Health, 425 East 25th Street, New York, NY 10010
(telephone: 212-481-4363).

34. For more information on SOAR, contact South Shore AIDS Project,
Inc., P.O. Box 2259, Brockton, MA 02405.

35. For more information about AISS, contact Jen Sordi, Manager,
Hampden County Correctional Center, 627 Randall Road, Ludlow, MA
01056 (telephone: 413-547-8000, ext. 2446). 

-------------------------------

An ETHICS Outreach Session at Rikers Island 

William Whitaker, a 41-year-old African American,[32] grew up in "the
system," entering the Spofford Youth Center at age 12, "graduating" to
Rikers Island at 16, and then doing stretches for felonies in several
facilities "upstate." After he was released from prison 6 years ago, he
decided to change his life so that he would never be sent back. He got
sober and has stayed sober. Referred to the Fortune Society by his parole
officer, Whitaker started as a client and then volunteered for several years
before becoming a caseworker. He is driven to offer others the gift of new
life he received through his own efforts and with the support of the
Fortune Society. Whitaker describes looking down from the DOC bus on
the way to Rikers and fixing his eyes on the driver of a car, wishing he
was on that journey rather than on his way to jail. Now, Whitaker says, the
people on the bus to Rikers are looking down at him, and he wants to help
as many as he can to get off that seemingly endless bus trip and onto the
journey to a new life. 

Nanci Ryan, a 35-year-old white woman, grew up in a family where it was
"funny" to get a 6-year-old child drunk, and it was evidence of "love"
when her parents beat each other up. She began drinking early and turned
to increasingly serious drug use, prostitution, and crime. Ryan also passed
through the juvenile system, was a frequent inmate at Rikers, and served
time at Taconic and Bedford Hills State prisons. She has three felony
convictions and is HIV positive. Ryan, too, made it to the Fortune Society
as a client, got sober and stable, and became a peer counselor for the
ETHICS Unit. Ryan displays the same intensity of purpose as Whitaker. 

Whitaker and Ryan work as a team, doing outreach for the Fortune
Society's ETHICS Unit at Rikers and at State prisons. Their session in
Ward 4 of North Infirmary Command began slowly. The patients, prodded
to attend, paid slight attention when Whitaker began his presentation as
the TV blared in the corner. Whitaker turned down the TV and told his
story: "Look at me," he said. "I've been here . . . I know what it's like . . . I
got through it . . . I'm sober . . . I have a job and a place to live . . . I'm here
to tell you about a program that will help you if you make the commitment
to change. . . . Call me . . . I'll stay with you; I won't let you fall. . . . It can
happen. . . .There is hope. . . . I'm living proof." A few inmates started to
pay attention. Whitaker encouraged the inmates to participate in a short
intake interview and to begin thinking about what they'll do when they get
out. "We can help you make a discharge plan and help you live up to it. . .
.The decision is yours."

One inmate spoke up: "This is all b---t . . . I'm in here for something I
didn't do. . . . The police planted a bag of dust on me." Once a con, there's
no hope of getting out of it, he said. He slouched in his chair, angry and
brooding. "Wait a minute," Whitaker said, "I want to talk to you," and he
walked toward him. Then he presented the essence of his message: "Sure,
the system is bad, but you can't do anything to change it; you can only
make the decision to change your own life and I can help you once you do
that. . . It's up to you. . . There will always be a bed for you here at Rikers
Island. Do you want to find yourself a better bed outside this place?" The
inmate began grudgingly to listen. Whitaker talked privately with him for
a while; the inmate agreed to call him-"Sure I will," he said. (Later, I
asked Whitaker whether he thought the inmate would really call him.
"Maybe," he said. "I know he was listening; I'll keep working on him.")
"Can a person with felony convictions get a job?" another inmate asked.
"Yes," replied Whitaker, "I have felonies and I have a job." 

Nanci Ryan also told her story in language the inmates could understand.
"I thought I was hopeless . . . I thought it was God's plan for me to be a
junkie." With tears in her eyes, Ryan talked about the friends she made in
prison and on the street who have died of AIDS or drug addiction or
gunshot wounds because they weren't able to make the choice for their
own lives or make it in time. She also talked of those, like herself, who
had made that choice and were trying to maintain it day by day. Her
passion for the cause was clear, particularly when she told the inmates that
by staying in the cycle of drugs, crime, and incarceration, they were only
fulfilling, and helping to perpetuate, society's expectations for them. "Why
not prove society wrong?. . . You can do it. . . We're here to help you."
About half of the inmates who attended the outreach session that day
completed the intake interview for Fortune's ETHICS Unit. It is only a
first step.

-------------------------------

Chapter 8

Tuberculosis

Theodore M. Hammett and Patricia Harmon--Abt Associates Inc. 

Key Findings

o In recent years there have been declines in the incidence of TB disease
both in the overall U.S. population and among correctional inmates,
although its incidence remains much higher among inmates.

o Most State/Federal prison systems appear to be following CDC
guidelines regarding TB screening, isolation and treatment, and preventive
therapy, whereas city/county jail systems are less adherent to CDC
guidelines.

o However, better collection and reporting of screening data would help to
document the burden of TB infection and disease among inmates.

o Improvements are also needed in the use of directly observed therapy
and directly observed treatment of tuberculous infection, as well as in
postrelease adherence to TB treatment and preventive therapy. 

This chapter summarizes available statistics on tuberculosis (TB) disease
and infection among inmates and describes correctional policies regarding
the screening of inmates and staff, management of suspected and
confirmed TB disease, preventive therapy, discharge planning, and
education.

Tuberculosis Disease and Infection

Concurrent with the rapid increase of the HIV epidemic and facilitated by
the prior dismantling of tuberculosis control programs and increased
immigration from areas of high TB prevalence, there was a resurgence of
TB disease in the United States in the late 1980s and early 1990s.
However, CDC surveillance data reveal that the incidence of TB disease
has dropped off again in recent years as control measures have been
rapidly reinstituted.[1]

The incidence of TB disease among inmates has followed a similar pattern
since the late 1980s but with much higher rates than in the total
population. Since 1993, the CDC case report form for TB disease has
included a question as to whether the person was a resident of a
correctional facility at the time of diagnosis. This enables CDC to provide
fairly complete surveillance statistics on TB disease in correctional
facilities. The numbers of new cases among correctional inmates declined
from 1,065 in 1994 to 729 in 1997, the latest year for which data are
available. In 1997, inmate cases represented 3.7 percent of the total in the
U.S. population.[2]

New TB cases and incidence rates among inmates in New York State,
where a serious outbreak of multidrug-resistant TB occurred in 1991, also
declined from 1991 through 1997, as shown in Figure 1. A new and
aggressive policy for screening inmates and staff, initiating and
completing preventive therapy, and managing cases of TB disease was
probably responsible in large measure for this decline. However, the
incidence of TB disease among New York State inmates in 1997, about 30
cases per 100,000, was still much higher than the 13 per 100,000 found in
the total population of the State.[3]

Data on new cases of TB disease among inmates from the NIJ/CDC
surveys in 1994 and 1997 are remarkably similar to the statistics reported
by CDC--768 cases under treatment in 1997 and 919 cases in 1994.
However, reporting to the NIJ/CDC survey on TB disease was very
incomplete, with almost one-third of State/Federal systems and 12 percent
of city/county systems in the survey not providing this information (table
40). This indicates that CDC surveillance data may undercount the actual
incidence of TB disease among inmates. The correctional systems
participating in the 1997 NIJ/CDC survey also reported 64 cases of
drug-resistant TB among inmates.

Data on TB infection reported to the 1997 NIJ/CDC survey, indicated by a
positive result on a purified protein derivative (PPD) skin test, were also
incomplete, as shown in table 41. More than half of the State/Federal
systems and more than a third of city/county systems failed to report
numbers of PPD-positive inmates. Among those reporting, six systems
had PPD positivity rates of 10 percent or higher among inmates over the
preceding 12 months. Altogether, 24 State/Federal systems and 25
city/county systems reported more than 45,000 positive PPDs in the 12
months prior to the survey.

Correctional employees may be at risk of contracting TB infection and TB
disease, depending on the control measures in place. One correctional
officer died during the multidrug-resistant TB outbreak in New York
State, and correctional staff and unions in many jurisdictions have been
active in demanding more aggressive control measures. According to CDC
surveillance data, approximately 18 correctional staff were diagnosed with
TB disease during 1997, although it is not known how many of these cases
resulted from occupational exposure.[4] Among New York State
correctional staff, occupational exposure to TB reached a peak in 1992 and
has declined since. 

In 1992, one-third of all 466 PPD skin-test conversions identified among
New York State prison employees were attributed to occupational
exposure. Higher odds ratios for PPD conversion related to occupational
exposure were found in the prisons with known inmate TB cases and in
the categories of correctional employees likely to be in direct contact with
inmates.[5]

The Role of Policy Change

Although tuberculosis is an airborne infection, its transmission can be well
controlled through aggressive implementation of screening and disease
management policies. The declining incidence of TB in New York prisons
since the 1991 outbreak is clearly related to the institution of mandatory
intake and subsequent annual PPD screening of inmates and staff, as well
as universal directly observed therapy for TB disease and treatment of TB
infection and strict isolation of persons with known or suspected infectious
TB. The New York State policy represents a good model for the control
and management of TB in the correctional setting.[6]

In 1996, CDC issued revised guidelines for the prevention and control of
TB in correctional facilities.[7] These guidelines focus on three critical
areas of activity: (1) screening--identifying persons with TB infection and
TB disease; (2) containment--preventing transmission of TB and providing
adequate treatment to patients with TB disease and latent TB infection;
and (3) assessment--monitoring and evaluating screening and containment
efforts. Screening for TB symptoms is the first line of defense, which
CDC recommends be done as soon as possible after intake for inmates in
all types of correctional facilities. Anyone with symptoms of TB disease
should be immediately isolated, evaluated, and treated as appropriate.
Inmates in long-term correctional facilities should be mandatorily screened
for TB infection (using the PPD skin test) at intake and on an annual basis
thereafter. Those with positive PPDs and those with or at risk for HIV
infection, regardless of the PPD result, should receive a chest radiograph
and medical evaluation. Inmates who fall into various risk categories for
TB disease listed in the CDC guidelines should be considered for
treatment of tuberculous infection.

The CDC guidelines call for TB symptom screening of inmates in
short-term facilities as soon as possible following entry. However, CDC
acknowledges that PPD screening may be infeasible in short-term facilities
because most inmates are released before a PPD can be read. Larger
facilities serving populations at high risk for TB should consider minifilm
x-ray screening of all incoming inmates for TB disease. The
cost-effectiveness of minifilm screening depends on the rates of TB
infection in the population being screened. In short-term facilities serving
populations generally at low risk for TB, further screening beyond initial
symptom screening should depend on an ongoing assessment of the risk
level of the population and the potential for exposure within the facility.

CDC also recommends mandatory PPD screening of correctional
employees at hiring and at annual intervals thereafter.

CDC's recommended strategies for containment include immediate
isolation in negative-pressure rooms of all persons with suspected or
confirmed TB disease. If active TB is confirmed, isolation should continue
until the patient is receiving effective treatment, improving clinically, and
has three consecutive negative sputum smears collected on different days.
The recommended initial treatment for TB disease in most patients is four
drugs: isoniazid (INH), rifampin (RMP), pyrazinamide (PZA), and either
ethambutol (EMB) or streptomycin (SM). 

CDC recommends evaluating all PPD-positive individuals and
HIV-seropositive but PPD-negative persons for treatment of tuberculous
infection with INH. Individuals with various risk factors for TB disease
should be treated for latent infection. Treatment of latent infection should
be a 6- to 12- month course of INH. Both treatment for TB disease and
treatment of TB infection should be directly observed for all patients.

Screening

Table 42 summarizes screening policies for TB disease and TB infection
reported to the 1997 NIJ/CDC survey. This shows that almost
three-fourths of systems are following the CDC recommendation
regarding screening for TB disease. More than 90 percent of State/Federal
systems have mandatory PPD screening for inmates at intake and annually
thereafter. These systems include primarily long-term facilities and thus
conform with CDC recommendations. The validation study revealed that
in 15 State/Federal systems with policies for mandatory PPD screening of
incoming inmates, 97 percent of facilities reported this policy as well. 

Only about half of city/county jail systems, which operate primarily
short-term facilities, require PPD screening of inmates at intake. Ten
percent of city/county jail systems reported screening for TB disease by
minifilm x ray.

The vast majority of correctional systems reported screening employees
for TB infection. Ninety percent of State/Federal systems and 97 percent
of city/county systems reported mandatory PPD screening of all new
employees, and 79 percent of State/Federal systems and 76 percent of
city/county systems reported mandatory screening of staff at specified
intervals during their employment.

Containment 

Critical components of a strategy to contain TB are the isolation of
patients with suspected or confirmed TB disease, proper treatment of TB
disease, and treatment of TB infection. The vast majority of systems-98
percent of State/Federal systems and 85 percent of city/county
systems-reported isolating inmates with suspected or confirmed TB
disease in negative pressure rooms. Eighty-four percent of State/Federal
systems and 74 percent of city/county systems reported policies for the
duration of isolation that conformed to the CDC guideline of three
consecutive negative sputum smears, although the other details of these
policies often differed from the precise CDC recommendations.

Seventy-one percent of State/Federal systems and 67 percent of
city/county systems reported conformity with CDC's recommendation of a
four-drug initial therapy for TB disease. The validation study found that in
13 systems whose central office policy calls for the recommended
four-drug initial regimen, 76 percent of the 29 facilities reported the same
policy. Most systems reported a treatment duration of at least 6 months.
Eighty-three percent of State/Federal systems and 65 percent of
city/county systems reported at least 6 months of treatment for
HIV-negative patients with TB disease, and 85 percent and 76 percent,
respectively, reported at least 6 months of treatment for HIV-seropositive
patients.

Completion of the course of therapy is important to prevent relapse,
continued transmission, and development of drug resistance. Directly
observed therapy and postrelease followup are critical factors in regimen
adherence and completion. Ninety-eight percent of State/Federal systems
and 95 percent of city/county systems reported employing directly
observed therapy for all inmates under treatment for TB disease. In 15
systems with this policy, the validation study revealed agreement from 94
percent of the 35 responding facilities. Although it may be difficult to
maintain adherence following release, outreach and followup programs in
the community can achieve positive results. In New York City, for
example, initiation of an expanded outreach program that included
incentives for patients under treatment for TB disease who were released
from Rikers Island helped to produce a dramatic increase in appearance
rates for followup appointments in the community, from less than 20
percent to 92 percent.[8]

Eighty percent of State/Federal systems and 87 percent of city/county
systems reported providing INH treatment to all PPD-positive inmates less
than 35 years of age. This policy appears to diverge from the CDC
recommendation that patients in this age group be started on treatment if
they are considered likely to be able to complete 6 months on the regimen.
Ninety percent of systems reported providing at least 6 months' treatment
of TB infection to HIV-seronegative patients, the CDC guideline, and a
smaller percentage--71 percent of State/Federal systems and 56 percent of
city/county systems-adhered to the CDC recommendation of 12 months'
treatment for HIV-infected patients. Directly observed treatment of TB
infection was the reported policy for all patients in 90 percent of
State/Federal systems and 85 percent of city/county systems. 

Studies of inmate adherence to treatment of TB infection have shown
mixed results. In a Texas program under which inmates received education
and were asked to sign written agreements to adhere to treatment appeared
to increase adherence rates.[9] A study of 262 persons released from
KingCounty Jail in Seattle while on treatment for TB infection revealed
that 40 percent could not be contacted, another 40 percent had enrolled in
a community-based directly observed treatment program, and 20 percent
had selected self-supervised therapy. Sixty percent of those who selected
directly observed treatment completed the course of treatment, as opposed
to 29 percent of those who selected self-supervised therapy. In sum, only
30 percent of the starting sample of releasees completed treatment of TB
infection.[10] Clearly, more effective strategies for helping patients to
complete treatment are needed. A San Francisco study also found low
rates of postrelease adherence--only 3 percent of 93 eligible patients
appeared at the public health department's TB clinic for followup within 1
month of release. Nevertheless, the authors concluded that jails represent
important settings for TB screening and recommended more intensive
efforts to improve postrelease adherence to the treatment of TB infection,
given the potential effects of nonadherence on the incidence of TB
disease.[11] A short-course preventive therapy regimen--2 months on a
combination of rifampin and pyrazinamide--is under study. A reduction
from 6 months to 2 months of therapy, if shown to be effective, would be
likely to improve adherence.[12]

Discharge Planning

Appropriate discharge planning for inmates receiving treatment for TB
disease or TB infection may improve postrelease adherence. Results of the
1997 NIJ/CDC survey reveal that discharge planning for inmates with TB
disease and TB infection, as for those with HIV/AIDS, almost always
involves referrals to the public health department (100 percent of
State/Federal systems and 97 percent of city/county systems), but much
less frequently includes making specific appointments for releasees with
community-based providers (35 percent of State/Federal systems and 21
percent of city/county systems). At the same time, the vast majority of
systems (92 percent of State/Federal systems and 87 percent of city/county
systems) report the names of persons with TB being released from their
facilities to public health departments along with locator information.
Thus, health departments may be able to locate and follow up with patients
in the community after their release.

Education

Educational programs may also help improve adherence, as well as
reinforce other aspects of TB-control policies and procedures. A survey of
TB knowledge among inmates and staff in Texas State correctional
facilities found common misconceptions about means of transmission, the
difference between TB infection and TB disease, and methods for the
prevention and treatment of TB. The study concluded that educational
programs sensitive to literacy levels and cultural differences in the target
population should be provided to inmates and staff in the facilities of the
Texas Department of Criminal Justice (TDCJ).[13] Consequently, TDCJ
instituted a TB module as part of its regular inmate education curriculum.
The program includes pre- and posttests of knowledge and viewing and
discussion of a video produced by TDCJ called "What You Don't Know
About Tuberculosis Can Kill You." A TB study guide prepared by the
Windham School District for TDCJ includes a range of other activities and
suggestions for weaving discussion of TB-related topics into other school
subjects such as language arts, mathematics, social studies, and
health/science.[14]

Conclusion

The incidence of TB disease has declined in recent years both in the total
U.S. population and among correctional inmates, but TB incidence rates
remain much higher among inmates than in the total population. Policies
such as those recommended by CDC in its revised guidelines and
implemented by the New York State Department of Correctional Services
can help reduce further the incidence of TB in correctional settings. Most
State and Federal prison systems are following key CDC recommendations
regarding the screening of inmates and staff and the isolation and treatment
of persons with TB disease and TB infection. Substantial improvement is
needed in city/county jail systems. In general, directly observed therapy
should be more widely implemented. Continuing problems with adherence
to regimens for the treatment of TB disease and TB infection following
release to the community may be amenable to improvement by better
education, discharge planning, linkages with health departments and
community-based providers, incentives to appear for followup
appointments (for example, food coupons and bus tokens), and shorter
courses of therapy. 

Endnotes

1. Centers for Disease Control and Prevention, Reported Tuberculosis in
the United States, 1996, Atlanta (July 1997), table 1: 5.

2. Ibid., table 12, 19; Centers for Disease Control and Prevention,
Reported Tuberculosis in the United States, 1994, Atlanta (July 1995),
table 12: 19; Centers for Disease Control and Prevention, Reported
Tuberculosis in the United States, 1997, Atlanta (July 1998), table 14: 25. 

3. Centers for Disease Control and Prevention, Reported Tuberculosis in
the United States, 1997, table 6: 15.

4. Ibid., table 23, 34.

5. K. Steenland, A.J. Levine, K. Sieber, P. Schulte, and D. Aziz,
"Incidence of Tuberculosis Infection Among New York State Prison
Employees," American Journal of Public Health 87 (December 1997):
2012-2014.

6. New York State Department of Correctional Services, Division of
Health Services, Health Services Policy Manual, policy no. 1.18,
"Tuberculosis," May 20, 1996.

7. Centers for Disease Control and Prevention, "Prevention and Control of
Tuberculosis in Correctional Facilities: Recommendations of the Advisory
Council for the Elimination of Tuberculosis," Morbidity and Mortality
Weekly Report 45, RR-8 (June 7, 1996): 1-27.

8. T.R. Frieden, P.I. Fujiwara, R.M. Washko, and M.A. Hamburg,
"Tuberculosis in New York City: Turning the Tide," New England Journal
of Medicine 333 (1995): 229-233. 

9. G.L. Woods et al., "Tuberculosis Education: Developing Effective
Programs for Incarcerated Individuals," presentation at the 21st National
Conference on Correctional Health Care, San Antonio, TX, November 11,
1997.

10. C.M. Nolan, L. Roll, S.V. Goldberg, and A.M. Elarth, "Directly
Observed Isoniazid Preventive Therapy for Released Jail Inmates,"
American Journal of Respiratory Critical Care Medicine 155 (1997):
583-586.

11. J.P. Tulsky, M.C. White, C. Dawson, T.M. Hoynes, J. Goldenson, and
G. Schechter, "Screening for Tuberculosis in Jail and Clinic Followup
After Release," American Journal of Public Health 88 (1998): 223-226.

12. M. Lobato, Division of Tuberculosis Elimination, Centers for Disease
Control and Prevention, personal communication, September 29, 1998.

13. G. L. Woods, S. L. Harris, and D. Solomon, "Tuberculosis Knowledge
and Beliefs Among Prison Inmates and Lay Employees," Journal of
Correctional Health Care 4 (1997): 1-9.

14. Margaret Smith, Tuberculosis: A Study Guide, Huntsville, TX: 
Windham School District, 1997.

-------------------------------

Chapter 9

Legal and Legislative Issues

Theodore M. Hammett--Abt Associates Inc. 

Key Findings

o The U.S. Supreme Court has ruled that HIV and HIV-related
discrimination are covered under the Americans With Disabilities Act.

o There were few other major legal developments affecting HIV/AIDS in
correctional facilities during the period covered by this Update report,
although courts generally continued to uphold correctional systems' policy
responses to HIV/AIDS.

o Some State legislatures have attempted to expand the requirements for
the HIV-antibody testing of inmates and disclosure of inmates' HIV status,
but these efforts have been generally unsuccessful.

This chapter summarizes legal developments pertinent to HIV/AIDS,
STD, and TB policies in correctional facilities. Main legal topics include
confidentiality of medical information, segregation, access to programs
and work assignments, alleged exposure to HIV, treatment, early release,
and TB issues.[1] Recent legislative activity, which focused on HIV
testing and disclosure of test results, is also summarized.

Confidentiality

As discussed in chapter 5, very few correctional systems have official
policies for disclosing inmates' HIV status to correctional officers or other
correctional officials. As part of a settlement in Shumate v. Wilson, the
California Department of Corrections agreed to end practices by which
inmates with HIV were identified to unauthorized persons in two women's
prisons.[2] By and large, however, courts have limited inmates' rights of
privacy and confidentiality regarding medical information such as HIV
status. Indeed, in Anderson v. Romero, the U.S. Court of Appeals for the
Seventh Circuit ruled that prisoners have no constitutional protection
against the unauthorized disclosure of their medical information, even if
such disclosure is motivated by spite. An HIV-infected Illinois prisoner
sued a warden and correctional officer for revealing his HIV status, and
the U.S. District Court held that the inmate might have a legitimate
right-of-privacy case. However, on appeal, the Circuit Court ruled that
prison officials have wide discretion regarding the disclosure of medical
information about inmates. In his opinion, Judge Richard Posner wrote:
"We cannot find any appellate holding that prisoners have a constitutional
right to the confidentiality of their medical records." The court also held
that this inmate's right to privacy must be subordinate to other inmates'
rights to be free from exposure to HIV; the protection of other inmates was
alleged to have been the objective of the disclosure.[3]

Segregation of HIV-Infected Inmates

Only two State correctional systems, those in Alabama and Mississippi,
segregate asymptomatic HIV-infected inmates. The Alabama policy of
segregation and exclusion of HIV-infected inmates from programs and
activities has been the target of a lengthy lawsuit, originally filed in 1987
as Harris v. Thigpen. In November 1997, a divided three-judge panel of
the U.S. Court of Appeals for the Eleventh Circuit overturned the District
Court's 1995 ruling that HIV-infected prisoners in Alabama could be
excluded from programs on the basis that HIV transmission is possible in
such program settings. The case, now captioned Onishea v. Hopper, was
remanded for retrial and the original judge was ordered removed.
Subsequently, however, in January 1998, the Eleventh Circuit Court
vacated the panel's ruling and ordered that the case be reheard en banc,
that is, before the full Circuit Court.[4]

At the same time, courts continued their usual pattern of upholding
correctional policies whether they require segregation or integration of
HIV-infected inmates. In Robbins v. Clarke, the Eighth Circuit Court
upheld a ruling by the U.S. District Court for Nebraska that housing
HIV-infected inmates in the general prison population does not constitute
"cruel and unusual punishment" of uninfected inmates.[5] In a more recent
Iowa case, Massick v. North Central Correctional Facility, the Eighth
Circuit Court upheld the District Court's dismissal of an inmate's claim
that prison officials acted with "deliberate indifference," the constitutional
standard of cruel and unusual punishment regarding health issues, by
knowingly housing him in a double cell with an HIV-infected inmate who
had open wounds. The dismissal was based on acceptance of the
defendant's assertion of qualified immunity, the superseding of which
would have required the plaintiff to prove that prison officials knowingly
placed him at substantial risk of serious harm and failed to abate that risk.
The District Court held that this had not been established, and the Eighth
Circuit Court agreed.[6] Implicit in this opinion is the principle that
correctional officials may house HIV-infected and HIV-uninfected inmates
in the same cells. 

Access to Programs

The issue of access to programs is closely related to the issue of
segregation, as in the Alabama case. Indeed, the Eleventh Circuit Court's
decision in Onishea v. Hopper may be influenced by the U.S. Supreme
Court's important rulings in Bragdon v. Abbott and Pennsylvania
Department of Corrections v. Yeskey. In Bragdon, the Court held that
HIV-related discrimination in the provision of health care services is
prohibited under the Americans With Disabilities Act (ADA) unless an
alleged transmission risk used to deny service could be assessed on the
basis of objective, scientific information.[7] In the Yeskey case, the Court
ruled that the ADA applies to correctional inmates. Previously, the Third, 
Seventh, Ninth, and Eleventh Circuit Courts had held that prisoners are
covered by the ADA, whereas the Tenth Circuit Court has issued an
ambiguous opinion on the subject, and the Fourth Circuit Court has ruled
against prisoners' rights under the ADA. The Yeskey case did not allege
discrimination against an inmate with HIV disease, but rather claimed that
a hypertensive inmate was improperly excluded from a boot camp
program.[8] Pennsylvania, joined by 36 other States, argued that a ruling
for Yeskey would undermine its ability to manage prisons efficiently and
establish programs with restrictive eligibility criteria. Attorneys for
Yeskey countered that the ADA requires only "reasonable
accommodation" of disabled persons and that Congress intended the Act
to cover everyone.[9]  The Supreme Court announced its decision in June
1998. In his majority, Justice Antonin Scalia wrote that the ADA
"unmistakably includes State prisons and prisoners within its
coverage."[10]

Two other Pennsylvania cases addressed correctional systems' ability to
exclude inmates with HIV from certain work assignments. As part of a
settlement in Austin et al. v. Pennsylvania Department of Corrections, a
class action civil rights suit challenging a range of conditions of
confinement, the department agreed not to discriminate against inmates
with HIV in making work assignments unless performance of the job
could involve a direct threat to the health of others.[11] No definition of
such direct threat to health was provided. However, the Austin settlement
was cited by the same court in rejecting the claims of two Pennsylvania
inmates that the department's failure to screen food handlers for HIV
antibodies in effect threatened the plaintiffs with infection. The court held
that under the Austin settlement the correctional department was not
permitted to exclude inmates from these work assignments on the basis of
HIV status.[12]

Alleged Exposure to HIV

There have been several cases in which inmates alleged that they were
infected with HIV through a rape in a correctional facility. None has yet
resulted in a verdict against a correctional department or its employees.
The most recent, and perhaps most highly publicized, of these cases was
Blucker v. Washington, in which a former Illinois inmate claimed that he
was repeatedly raped and consequently infected with HIV, and that prison
staff knew that the rapes were occurring but did nothing to protect him.
The suit named 15 individual defendants, but not the Illinois Department
of Corrections. Prior to trial, the court dismissed the cases against eight of
the defendants. In September 1997 a Federal jury refused to assess
damages against five of the remaining defendants but could not reach
verdicts on the other two. A new trial was held as to the last two
defendants, and in January 1998 a jury found no liability on their part.[13]
The defendants' main line of argument was that Blucker's sexual relations
with other inmates had been consensual. Blucker's acquisition of HIV
while incarcerated was not in dispute. 

In Arkansas the Court of Appeals for the Eighth Circuit ordered a new trial
in the case of an inmate who claimed to have been infected with HIV
through a prison rape after the warden failed to protect him from his
cellmate. A U.S. District Court judge had initially found no basis in the
inmate's allegation that the warden's failure to change his housing
assignment represented "deliberate indifference." The Circuit Court
determined, on the contrary, that the warden had disregarded direct
evidence that the plaintiff was at risk of being sexually assaulted by his
cellmate.[14]

A Federal District judge dismissed a New York inmate's suit against
prison officials for failing to protect him from an HIV-infected inmate
who threw feces and semen at him. The court held that the plaintiff
produced no evidence that the prison officials deliberately denied him
protection from his assailant.[15] However, the conviction of a Georgia
inmate with HIV for reckless endangerment by attempting to bite a
correctional officer was upheld. The inmate's attending physician testified
that it was "very strongly possible" that HIV could be transmitted though a
bite.[16]

Medical Treatment

Several important cases involving the medical treatment of inmates with
HIV/AIDS were recently decided. In settling Shumate v. Wilson, the
California Department of Corrections agreed to provide inmates at two
women's prisons with care for HIV/AIDS, cancer, heart disease, and other
serious illnesses that meets or exceeds community standards. Under the
terms of the settlement, four medical experts are monitoring the provision
of care for 16 months.[17]

In Franklin v. District of Columbia, a Federal District judge held that the
correctional department's failure to provide interpreters for
Spanish-speaking prisoners in health care and other situations was
unconstitutional. She specifically cited the department's inability to
provide adequate HIV counseling and care, diagnosis and treatment of
illness, and mental health services for Latino inmates. "It is difficult to
conceive of an example of [a] medical care system that can be more
deliberately indifferent than one in which illnesses are diagnosed and
medication is prescribed based upon the patient pointing to a region of his
or her body and saying the Spanish word for pain, 'dolor.' . . . For medical
care to be adequate, a doctor and patient must be able to understand each
other."[18]

In another case the Court of Appeals for the Ninth Circuit refused to grant
a sentence reduction to a Federal inmate with AIDS who claimed that he
needed to receive experimental medications available only through trials
being conducted in the community. The court did not rule directly on the
inmate's right to receive such experimental medications if he could not
tolerate the FDA-approved drugs available in the prison, but relied on the
"sparse" evidence presented by the plaintiff regarding the seriousness of
his medical condition and the urgency of his need for the medication.[19]

Early Release

In Jerrell v. State of New York, a U.S. District judge ruled against an
inmate with AIDS who claimed to have been unconstitutionally denied
early release. Jerrell argued that the State's tightening of the eligibility
criteria for early release, thereby excluding him because he was sentenced
as a "persistent, violent felony offender," represented a statute not
rationally related to a government interest and unduly burdensome to him
as an HIV-infected person. Jerrell claimed that he should be eligible for
early release because of his terminal medical condition and his exemplary
prison record. The court disagreed, holding that the State's tightening of
the eligibility criteria for release was rationally related to the State's
interest in protecting its citizens. Therefore, the court held, Jerrell's
constitutional rights had not been abridged in the application of these
eligibility criteria to him.[20]

Tuberculosis Issues

A fairly well-developed line of judicial opinion holds that correctional
systems are empowered to take aggressive measures, including the
mandatory PPD screening of inmates, to control tuberculosis in prisons
and jails. Indeed, courts have held correctional systems liable for failing to
implement such measures, thereby placing inmates at risk of acquiring
TB.[21] The most recent major case involving correctional TB policy is
Cunningham v. Coughlin, a New York action in which inmates exposed to
TB sought an end to double bunking in dormitory settings. This case is
still pending.[22]

Legislative Developments

The area of most common legislative activity regarding HIV/AIDS in
correctional facilities has been, and continues to be, testing and disclosure
policy. Many States have legislation mandating HIV testing and disclosure
of test results in certain circumstances, such as being convicted of or
charged with a sex offense or a drug offense, assaulting another inmate or
correctional staff member, or otherwise exposing another person to blood
or body fluids. The specific provisions of these laws vary widely regarding
when and how testing is to be performed and disclosure of results
effectuated.

Recent legislative developments in this area include the passage of
separate laws in Oklahoma requiring the HIV-antibody testing of persons
charged with sex offenses and inmates who hurl or expel body fluids at
officers or other inmates.[23] Colorado Governor Roy Romer vetoed
legislation that would have required the HIV testing of persons charged
with sex crimes involving penetration and forced public health agencies to
divulge whether an HIV-positive defendant had previously been notified
of a positive test result. The intent of the law was to enable prosecutors to
charge individuals who had been given a positive test result in the past
with the felony of committing a sex act with prior knowledge of being
HIV infected. In his veto message, Romer argued that using confidential
public health surveillance information for this purpose might discourage
people from seeking confidential HIV testing.[24]

The New York State Assembly took no action on a bill passed by the
Senate that would have made an inmate who throws feces, urine, blood, or
semen on a correctional officer guilty of a felony. A California law
shortened the time and streamlined the process by which inmates can
appeal an order to be tested for HIV antibodies following incidents in
which others were exposed to their body fluids. Legislatures in California
and Arizona voted down proposals requiring the mandatory HIV screening
of inmates. The governors of Washington and Rhode Island vetoed bills
that would have given correctional officers access to the names of
HIV-positive inmates. California Governor Pete Wilson vetoed a bill that
would have permitted the release of terminally ill inmates expected to die
within 6 months and required correctional officials to consider the costs of
such inmates' continued incarceration in making release decisions. Finally,
a new Florida law requires all persons convicted of drug offenses to
participate in an HIV awareness program.[25]

Conclusion

The period under review in this Update has produced few major
developments in case law or legislation regarding HIV/AIDS or TB in
correctional facilities. Courts generally have continued to permit
correctional systems broad discretion in devising the policies they think
necessary and appropriate and have been loath to interfere with this
policy-making function. Some legislators have sought radical expansions
of existing HIV-testing and disclosure policies but generally have been
unsuccessful in enacting such laws.

Endnotes

1. A convenient summary of recent litigation is found in AIDS in
Correctional Facilities: Critical Issues and Cases, Horsham, PA: LRP
Publications, 1997.

2. "California Agrees To Settle Inmates' HIV Privacy Claims," AIDS
Policy and Law (September 19, 1997): 9.

3. Anderson v. Romero, 7th Cir., no. 94-1251, decided December 15,
1995.

4. Onishea v. Hopper, 11th Cir., no. 96-6213, State's petition for rehearing
en banc granted January 23, 1998; "Two Major Prison Cases Poised for
Court Review," AIDS Policy and Law (February 20, 1998): 1, 8.

5. Robbins v. Clarke, 8th Cir., no. 90-2431, decided October 8, 1991.

6. Massick v. North Central Correctional Facility, 8th Cir., no. 96-3980NI,
opinion dated February 13, 1998; "Prison Not Liable for Putting Bleeding
Inmate With HIV in Shared Cell," AIDS Policy and Law (March 6, 1998):
14.

7. Bragdon v. Abbott, U.S. Sup. Ct., no. 97-156.

8. Pennsylvania Department of Corrections v. Yeskey, U.S. no. 97-634,
petition for certiorari granted January 23, 1998; "Two Major Prison Cases
Poised for Court Review." See note 4 above.

9. C. Mondies, "High Court Examines Whether Disability Law Applies to
Inmates," Philadelphia Inquirer (April 29, 1998), A3.

10. Pennsylvania Department of Corrections v. Yeskey, U.S. no. 96-6213,
decided June 15, 1998; AIDS Policy and Law (June 26, 1998).

11. Austin et al. v. Pennsylvania Department of Corrections, __F.
Supp.,___(E.D. PA., January 17, 1995), 1995 WL 65458.

12. Martin v. Vaughn, D.C E. PA., no. CA 92-3828, decided May 30,
1995; "Inmates Lose Bid To Screen Food Handlers for HIV Infection,"
AIDS Policy and Law (September 22, 1995): 7.

13. Blucker v. Washington, ND, IL, no. 95C50110, jury verdicts dated
August 29, 1997, and January 23, 1998; "Illinois Begins Testing Inmates
for HIV Following Rape Trial," AIDS Policy and Law (September 19,
1997): 1, 8-9; "Jurors Disbelieve Inmate's Claim That Rape Reports Were
Ignored," AIDS Policy and Law (February 20, 1998): 3. 

14. "Arkansas Warden Faces Retrial on Inmate's HIV Rape Allegation,"
AIDS Policy and Law (August 7, 1998): 9-10.

15. Whitfield v. Scully, SD, NY, no. 94-CIV-3290 (DC), decided
December 6, 1996.

16. Burk v. Georgia, GA Ct. App., 2d Div., no. A96A2310, decided
November 13, 1996.

17. "California Agrees To Settle Inmates' HIV Privacy Claims," AIDS
Policy and Law (September 19, 1997): 9.

18. Franklin v. District of Columbia, D. DC, no. CA 94-0511(JHG),
decided April 16, 1997.

19. U.S. v. Borkowski, 9th Cir., nos. 95-10480, 95-10481, decided
September 16, 1996; "Court Rejects Inmate's Request for Access to Drug
Trials," AIDS Policy and Law (November 1, 1996): 5. 

20. Jerrell v. State of New York; E.D. NY, no. CV-94-3036-CPS, decided
January 19, 1996; "HIV-Positive Prison Inmate Loses Bid for Early
Release," AIDS Policy and Law (April 19, 1996): 7.

21. For a review of policy and related case law, see L.O. Gostin, "The
Resurgent Tuberculosis Epidemic in the Era of AIDS: Reflections on
Public Health, Law, and Society," Maryland Law Review 54 (1995):
1-131, esp. 50-67.

22. Cunningham et al. v. Coughlin et al.; E.D.NY, 92-CV-0579; "News on
the TB Case," PWA Support 7 (Spring 1995): 2. 

23. "State Legislation: Oklahoma Adopts Testing Laws for Inmates, Rape
Suspects," AIDS Policy and Law (May 15, 1998): 12-13.

24. "Governor Vetoes Bill That Would Test Sex Offenders for HIV,"
AIDS Policy and Law (June 26, 1998): 11.

25. These developments are summarized in "HIV/AIDS and the States:
Looking Back at 1996," AIDS Policy and Law (bonus report, January
1997): 3.

-------------------------------

About the National Institute of Justice 

The National Institute of Justice (NIJ), a component of the Office of
Justice Programs, is the research agency of the U.S. Department of Justice.
Created by the Omnibus Crime Control and Safe Streets Act of 1968, as
amended, NIJ is authorized to support research, evaluation, and
demonstration programs, development of technology, and both national
and international information dissemination. Specific mandates of the Act
direct NIJ to: 

o Sponsor special projects, and research and development programs, that
will improve and strengthen the criminal justice system and reduce or
prevent crime. 

o Conduct national demonstration projects that employ innovative or
promising approaches for improving criminal justice. 

o Develop new technologies to fight crime and improve criminal justice. 

o Evaluate the effectiveness of criminal justice programs and identify
programs that promise to be successful if continued or repeated. 

o Recommend actions that can be taken by Federal, State, and local
governments as well as by private organizations to improve criminal
justice. 

o Carry out research on criminal behavior. 

o Develop new methods of crime prevention and reduction of crime and
delinquency. 

In recent years, NIJ has greatly expanded its initiatives, the result of the
Violent Crime Control and Law Enforcement Act of 1994 (the Crime
Act), partnerships with other Federal agencies and private foundations,
advances in technology, and a new international focus. Some examples of
these new initiatives: 

o New research and evaluation are exploring key issues in community
policing, violence against women, sentencing reforms, and specialized
courts such as drug courts. 

o Dual-use technologies are being developed to support national defense
and local law enforcement needs. 

o The causes, treatment, and prevention of violence against women and
violence within the family are being investigated in cooperation with
several agencies of the U.S. Department of Health and Human Services. 

o NIJ's links with the international community are being strengthened
through membership in the United Nations network of criminological
institutes; participation in developing the U.N. Criminal Justice
Information Network; initiation of UNOJUST (U.N. Online Justice
Clearinghouse), which electronically links the institutes to the U.N.
network; and establishment of an NIJ International Center. 

o The NIJ-administered criminal justice information clearinghouse, the
world's largest, has improved its online capability. 

o The Institute's Drug Use Forecasting (DUF) program has been expanded
and enhanced. Renamed ADAM (Arrestee Drug Abuse Monitoring), the
program will increase the number of drug-testing sites, and its role as a
"platform" for studying drug-related crime will grow. 

o NIJ's new Crime Mapping Research Center will provide training in
computer mapping technology, collect and archive geocoded crime data,
and develop analytic software. 

o The Institute's program of intramural research has been expanded and
enhanced. 

The Institute Director, who is appointed by the President and confirmed by
the Senate, establishes the Institute's objectives, guided by the priorities of
the Office of Justice Programs, the Department of Justice, and the needs of
the criminal justice field. The Institute actively solicits the views of
criminal justice professionals and researchers in the continuing search for
answers that inform public policymaking in crime and justice.