Issues and Practices

1996–1997 Update:

HIV/AIDS, STDs, and TB

in Correctional Facilities

U.S. Department of Justice

Office of Justice Programs

National Institute of Justice

DEPARTMENT OF JUSTICE

OFF ICE OF JUSTICE PROGRAMS

BJA NI J OJJDP BJS OVC

National Institute of Justice

Bureau of Justice Statistics

Centers for Disease Control and Prevention

HEALTH AND JUSTICE

APED TR MENT OF HEALTH & HUMAN SERVICES • USA
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

Noël Brennan

Deputy Assistant Attorney General

Jeremy Travis

Director, National Institute of Justice

Office of Justice Programs National Institute of Justice

World Wide Web Site World Wide Web Site

http://www.ojp.usdoj.gov 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

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.

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
Foreword iii

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 v

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

Page

Foreword ........................................................................................................................................................... iii

Acknowledgments ............................................................................................................................................ v

Executive Summary ........................................................................................................................................xiii

HIV/AIDS: Burden of Disease Among Inmates ......................................................................................xiii

Sexually Transmitted Diseases and Hepatitis: Burden of Disease Among Inmates.................................xiii

HIV and STD Education and Behavioral Interventions ............................................................................xiii

HIV Transmission and Risk Factors, Precautionary and Preventive Measures...................................... xiv

Counseling and Testing, Confidentiality, and Disclosure .......................................................................... xiv

Housing and Correctional Management ................................................................................................... xiv

Medical Treatment and a Continuum of Care ......................................................................................... xiv

Tuberculosis (TB) ..................................................................................................................................... xv

Legal and Legislative Issues ..................................................................................................................... xv

Introduction ....................................................................................................................................................... 1

HIV/AIDS in the U.S. Population .............................................................................................................. 1

The 1996–1997 Update: Contents and Sources .......................................................................................... 3

Endnotes ...................................................................................................................................................... 3

Chapter 1: HIV in Prisons and Jails, 1996 ................................................................................................... 5

Key Findings ............................................................................................................................................... 5

Trends in HIV Infection in U.S. Prisons..................................................................................................... 6

Confirmed AIDS Cases in U.S. Prisons ..................................................................................................... 9

Comparison to the U.S. Resident Population .............................................................................................. 9

HIV Infection of Male and Female State Prison Inmates ........................................................................ 10

AIDS-Related Deaths in State Prisons ..................................................................................................... 11

HIV-Prevalence Rates and Testing Policies ............................................................................................ 13

HIV/AIDS Reported in Personal Interviews ............................................................................................ 13

HIV-Positive Prison Inmates, by Offense and Prior Drug Use ............................................................... 15

HIV Infection of Local Jail Inmates ......................................................................................................... 16

HIV Test Results for Local Jail Inmates, by Inmate Characteristic......................................................... 16

Percent HIV Positive Among Jail Inmates, by Offense and Prior Drug Use .......................................... 16

Methodology .............................................................................................................................................. 17

vii
Page

Chapter 2: Sexually Transmitted Diseases and Hepatitis: Burden of Disease Among Inmates ...... 21

Key Findings ............................................................................................................................................. 21

STDs Among Inmates .............................................................................................................................. 21

Hepatitis Among Inmates ......................................................................................................................... 22

Conclusion ................................................................................................................................................. 22

Endnotes .................................................................................................................................................... 22

Chapter 3: HIV and STD Education and Behavioral Interventions ....................................................... 25

Key Findings ............................................................................................................................................. 25

Types of HIV/STD Education and Prevention Programs Provided ......................................................... 25

The Importance of Comprehensive HIV/STD Education and Prevention Programs ............................... 27

Instructor-Led Education and Educational Materials ................................................................................ 28

Peer-Based Programs ............................................................................................................................... 33

Conclusion ...............................................................................................................................................44

Endnotes...................................................................................................................................................45

Chapter 4: HIV Transmission and Risk Factors, Precautionary and Preventive Measures ............. 47

Key Findings ............................................................................................................................................. 47

HIV Transmission and Risk Behaviors in Correctional Facilities ............................................................. 47

Rape and Coerced Sexual Activity ........................................................................................................... 48

“Universal Precautions” Versus Correctional Officers’ “Right to Know” .............................................. 48

Condom Availability .................................................................................................................................. 49

Bleach Availability .................................................................................................................................... 49

Needle and Syringe Exchange ...............................................................................................................50

Methadone Maintenance ........................................................................................................................50

Reduction of Risk Associated With Tattooing .....................................................................................50

Conclusion ...............................................................................................................................................51

Endnotes...................................................................................................................................................51

Chapter 5: Counseling and Testing, Confidentiality and Disclosure ..................................................... 53

Key Findings ............................................................................................................................................. 53

HIV-Antibody Testing Policies ................................................................................................................. 53

Confidentiality and Notification of HIV Test Results ............................................................................... 58

Conclusion ................................................................................................................................................. 60

Endnotes .................................................................................................................................................... 60

Chapter 6: Housing and Correctional Management................................................................................. 63

Key Findings ............................................................................................................................................. 63

Housing Policies for Inmates With HIV Disease ..................................................................................... 63

Work Assignments and Other Programming ............................................................................................ 65

Conjugal Visits .......................................................................................................................................... 66

Compassionate Release and Medical Furlough ........................................................................................ 66

Conclusion ................................................................................................................................................. 66

Endnote ..................................................................................................................................................... 67

viii
Page

Chapter 7: Medical Treatment and a Continuum of Care ....................................................................... 69

Key Findings ............................................................................................................................................. 69

Medical Treatment for HIV/AIDS ........................................................................................................... 70

Guidelines for Antiretroviral Therapy ....................................................................................................... 71

Selection and Initiation of Antiretroviral Therapy ..................................................................................... 72

The Patient-Clinician Relationship ............................................................................................................ 72

A Continuum of Care for Inmates ............................................................................................................ 73

Screening and Identification of Medical and Psychosocial Problems ....................................................... 73

Case Management .................................................................................................................................... 74

Psychosocial Support Services.................................................................................................................. 74

Hospice Care ............................................................................................................................................ 74

Substance Abuse Treatment ..................................................................................................................... 75

Discharge Planning ................................................................................................................................... 76

Continuity of Care and Community Linkages ........................................................................................... 77

Conclusion ...............................................................................................................................................82

Endnotes...................................................................................................................................................82

Chapter 8: Tuberculosis ................................................................................................................................85

Key Findings ...........................................................................................................................................85

Tuberculosis Disease and Infection .......................................................................................................85

The Role of Policy Change ....................................................................................................................87

Screening .................................................................................................................................................88

Containment.............................................................................................................................................89

Discharge Planning .................................................................................................................................90

Education .................................................................................................................................................90

Conclusion ...............................................................................................................................................90

Endnotes...................................................................................................................................................90

Chapter 9: Legal and Legislative Issues .................................................................................................... 93

Key Findings ............................................................................................................................................. 93

Confidentiality ........................................................................................................................................... 93

Segregation of HIV-Infected Inmates ...................................................................................................... 93

Access to Programs .................................................................................................................................. 94

Alleged Exposure to HIV ......................................................................................................................... 94

Medical Treatment .................................................................................................................................... 95

Early Release ............................................................................................................................................ 95

Tuberculosis Issues ................................................................................................................................... 95

Legislative Developments ......................................................................................................................... 96

Conclusion ...............................................................................................................................................96

Endnotes...................................................................................................................................................96

ix
Page

List of Tables

Table 1: Estimated incidence of AIDS-Opportunistic Illnesses (AIDS-Ols) and

AIDS-related deaths, 1995–96—United States ............................................................................. 2

Table 2: Inmates in custody of State or Federal prison authorities and known to be positive

for the human immunodeficiency virus, 1994–96 ............................................................................... 7

Table 3: Inmates in custody of State or Federal prison authorities, by type of HIV infection

or confirmed AIDS, year-end 1996 .................................................................................................... 8

Table 4: State prison inmates known to be positive for the human immunodeficiency

virus, by sex, year-end 1996 ............................................................................................................. 10

Table 5: Number of inmate deaths in State prisons, by cause, 1994–96 ........................................................ 11

Table 6: AIDS-related deaths of sentenced prisoners under State jurisdiction, 1996 .................................... 12

Table 7: Inmates ever tested or tested since admission for the human immunodeficiency

virus and test results ......................................................................................................................... 14

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

by selected characteristics ............................................................................................................... 14

Table 9: Inmates ever tested for the human immunodeficiency virus and results,

by offense and prior drug use ........................................................................................................... 15

Table 10: Standard error estimates for the 1996 Survey of Inmates in Local Jails and the

1997 Surveys of State and Federal Correctional Facilities ............................................................... 18

Table 11: Results of mandatory and routine inmate syphilis screening, 1997................................................... 21

Table 12: Results of mandatory and routine gonorrhea screening, 1997 .......................................................... 22

Table 13: Results of mandatory and routine chlamydia screening, 1997 .......................................................... 22

Table 14: HIV/STD education and prevention programs for inmates, 1992–97 .............................................. 26

Table 15: HIV/STD education and prevention programs in adult correctional facilities, 1995–97 .................. 26

Table 16: HIV/STD education and prevention programs for inmates, 1997 results of the

validation study (VS) ........................................................................................................................ 27

Table 17: Topics covered in HIV/STD education for inmates, 1997 .........................................................28

x
Page

Table 18: Topics covered in HIV/STD education for inmates, 1997 results of the validation study (VS) ....... 29

Table 19: Providers of HIV/STD education and prevention services, 1997 .................................................... 29

Table 20: Availability of condoms and bleach, 1997 ..................................................................................49

Table 21: Testing policies for antibodies to the human immunodeficiency virus, by jurisdiction, 1995 ............. 55

Table 22: Summary of HIV-antibody testing policies....................................................................................... 56

Table 23: Mutually exclusive categorization of HIV-antibody testing policies

for incoming inmates, 1997 ............................................................................................................... 56

Table 24: HIV-antibody testing policies, 1997: Results of the validation study (VS) ....................................... 56

Table 25: Pregnancy testing for female inmates, 1997 .................................................................................... 57

Table 26: HIV-antibody testing for pregnant female inmates, 1997 ................................................................ 57

Table 27: Policies regarding notification of inmates’ HIV-antibody test results, 1997 ..................................... 59

Table 28: Notification of HIV-antibody test results, 1997:

Results of the validation study (VS) ................................................................................................. 59

Table 29: Mandatory and routine testing of incoming inmates for STDs, 1997 ............................................... 60

Table 30: Decline of segregation policies in State/Federal systems (n = 51) 1985–97 ............................63

Table 31: State/Federal prison systems’ housing policies for inmates with AIDS

and asymptomatic HIV infection, 1994 and 1997 ............................................................................ 64

Table 32: City/county jail systems’ housing policies for inmates with AIDS and

asymptomatic HIV infection, 1994 and 1997 ................................................................................... 65

Table 33: Housing of inmates with asymptomatic HIV infection and AIDS:

Results of the validation study (VS) ................................................................................................. 65

Table 34: Compassionate release and medical furlough, 1997 ......................................................................... 66

Table 35: Inmates receiving compassionate release and medical furlough, 1996 ............................................ 67

Table 36: The availability of HIV therapies and monitoring, 1997............................................................70

xi
Page

Table 37: The availability of HIV therapies and monitoring: Results of the validation study (VS) ........71

Table 38: Psychosocial and supportive services for inmates with HIV/AIDS, 1997 ....................................... 75

Table 39: Discharge planning services, 1997 ................................................................................................... 76

Table 40: Active TB disease among inmates, 1997 ......................................................................................... 87

Table 41: TB infection among inmates, 1997 ................................................................................................... 87

Table 42: Screening inmates for TB, 1997 ....................................................................................................... 88

List of Figures

Figure 1: Tuberculosis Cases and Rates Among New York State Inmates ...............................................86

(Exclusive of New York City), 1986–97

xii
Executive Summary xiii

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

• 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.

• There have been some declines in AIDS deaths among

inmates since 1995.

• Nevertheless, HIV infection and AIDS continue to be

far more prevalent among inmates than in the total U.S.

population.

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

• The prevalence of HIV and AIDS is higher among

Hispanic and black inmates than among white inmates.

• 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

• 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.

• However, behavioral profiles and anecdotal evidence

suggest that inmates are disproportionately affected by

STDs and hepatitis.

HIV and STD Education and

Behavioral Interventions

• HIV and STD education programs are becoming more

widespread in correctional facilities.

• However, few correctional systems have implemented

comprehensive and intensive HIV prevention programs

in all of their facilities.

• Peer-based education and prevention programs offer

important advantages, such as cost-effectiveness, credibility, flexibility, and benefits to peers themselves.
xiv 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

• 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

• High-risk behaviors for HIV transmission—sex, drug

use, sharing of injection materials, and tattooing—

occur in correctional facilities.

• HIV transmission among correctional inmates has been

shown to occur.

• Comprehensive and intensive education and prevention programs represent the best response to these facts,

although the precise content of such programs is controversial.

• Rape and coerced sexual activity also occur in correctional facilities but require a different response, one

based on inmate classification, housing, and supervision.

• 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.

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

• 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

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

• Seventeen State correctional systems and the Federal

Bureau of Prisons had policies for mandatory HIVantibody testing of inmates at intake and/or release.

• Few correctional systems have mandatory or routine

pregnancy testing of female inmates.

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

• Very few correctional systems have policies for notification of correctional officers regarding inmates’ HIV

status.

• Few correctional systems routinely screen inmates for

STDs.

Housing and Correctional

Management

• 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.

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

• Few correctional systems permit conjugal visits for any

inmates, and even fewer allow such visits for inmates

with HIV.

• 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

• 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.
Executive Summary xv

• 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.

• New drugs and reduced dosing currently under study

offer hope of more “patient-friendly regimens.”

• Clinicians must work closely with patients to make the

best therapeutic decisions.

• 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.

• Continuity of care and bridging to community services

also contribute to positive patient outcomes.

• Existing program models have not been rigorously

evaluated but probably warrant replication based on

anecdotal evidence.

Tuberculosis (TB)

• 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.

• 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.

• Better collection and reporting of screening data would

help to document the burden of TB infection and

disease among inmates.

• 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

• The U.S. Supreme Court has ruled that HIV and HIVrelated discrimination are covered under the Americans

With Disabilities Act.

• 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.

• 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 1

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, highrisk 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 AIDSOI 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 AIDSOIs, 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.
2 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

Table 1. Estimated incidence of AIDS-Opportunistic Illnesses (AIDS-Ols) and AIDSrelated deaths, 1995–96—United Statesa

 AIDS-OIsb Deathsb

% Change % Change

 1995 1996 From 1995 1996 From

Characteristics n n 1995 to 1996 n n 1995 to 1996

Sex

 Men 49,360 45,240 -8 42,000 31,440 -25

 Women 11,260 11,490 2 8,140 7,340 -10

Race/Ethnicityc

 White, non-Hispanic 24,370 21,130 -13 21,700 14,670 -32

 Black, non-Hispanic 24,090 24,030 0 18,840 16,460 -13

 Hispanic 11,410 10,800 -5 9,010 7,220 -20

Exposure Category

 MSMd 28,640 25,530 -11 24,880 17,310 -30

 MSM–IDUe 3,580 3,030 -15 3,310 2,490 -25

 Male–IDU 12,880 12,140 -6 10,790 8,970 -17

 Female–IDU 4,950 4,750 -4 3,830 3,440 -10

Heterosexual Contact

 Male 3,420 3,790 11 2,300 2,120 -8

 Female 5,900 6,320 7 3,980 3,640 -8

 Totalf 60,620 56,730 -6 50,140 38,780 -23

aEstimates are presented rounded to the nearest 10 because they do not represent exact counts of persons with AIDS-Ols but are estimates

that are approximately ± 3% of the true value.

bFigures are for people ≥ 13 years old.

cNumbers for races other than black and white were too small for meaningful analysis. Persons of Hispanic origin may be of any race. dMen who have sex with men.

eInjection-drug user.

f

Includes persons aged 13 years with hemophilia/coagulation disorders, transfusion recipients, or persons with other or no risks

reported.

Source: Centers for Disease Control and Prevention, “Update: Trends in AIDS Incidence—United States, 1996.” Morbidity and Mortality

Weekly Report 46 (September 19, 1997): 863.

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
Introduction 3

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
4 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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).
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.

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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. 

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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 yearend 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.

Source: BJS, National Prisoner Statistics.

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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).

 6 3;;8%3;;9 7RFCVG< *+81#+&5. 56&U. CPF 6$ KP %QTTGEVKQPCN (CEKNKVKGU
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--Not reported.

a

The custody population includes only those inmates housed in a jurisdiction's facilities. b

Totals exclude those inmates in jurisdictions that did not report data on HIV/AIDS. 

Counts may differ from previous reports. Percentages for all years are based

on year-end custody counts. 

Source: BJS, National Prisoner Statistics.

Wyoming 6 5 4 0.6 0.4 0.3

Washington 55 92 99 0.5 0.8 0.8

Utah 48 31 31 1.5 0.8 0.7

Oregon 24 29 39 0.3 0.4 0.5

New Mexico 19 24 11 0.5 0.6 0.2

Nevada 122 147 133 1.8 1.9 1.6

Montana 7 4 6 0.4 0.2 0.4

Idaho 20 11 17 0.8 0.4 0.5

Hawaii 14 12 23 0.5 0.4 0.7

Colorado 79 93 94 0.9 1.0 0.9

California 1,055 1,042 1,136 0.8 0.8 0.8

Arizona 143 140 205 0.7 0.7 0.9

Alaska -- 5 10 -- 0.2 0.3

West 1,592 1,635 1,808 0.8% 0.8% 0.8%

West Virginia 8 10 7 0.4 0.4 0.3

Virginia 285 134 383 1.4 0.6 1.5

Texas 1,584 1,890 1,876 1.6 1.5 1.4

Tennessee 89 120 131 0.7 0.9 1.0

South Carolina 434 380 422 2.5 2.0 2.1

Oklahoma 102 115 108 0.8 0.8 0.7

North Carolina 521 526 589 2.2 1.9 2.0

Mississippi 119 138 135 1.2 1.4 1.3

Maryland 774 724 832 3.7 3.4 3.8

Louisiana 285 314 347 1.8 1.8 2.0

Kentucky 44 41 55 0.5 0.4 0.5

Georgia 884 858 814 2.6 2.5 2.3

Florida 1,986 2,193 2,152 3.5 3.4 3.4

District of Columbia -- -- -- -- -- --

Delaware 34 122 -- 0.8 2.5 --

Arkansas 81 83 77 1.0 1.0 0.9

Alabama 210 222 234 1.1 1.1 1.1

South 7,440 7,870 8,162 2.0% 1.9% 1.9%

Wisconsin 65 72 91 0.6 0.6 0.7

South Dakota 2 3 4 0.1 0.2 0.2

Ohio 454 346 343 1.1 0.8 0.7

North Dakota 3 2 3 0.5 0.3 0.4

Nebraska 16 19 17 0.6 0.6 0.5

Missouri 146 173 190 0.8 0.9 0.9

Minnesota 35 46 24 0.8 1.0 0.5

Michigan 384 379 528 0.9 0.9 1.2

Kansas 20 24 16 0.3 0.3 0.2

Iowa 25 20 24 0.5 0.3 0.4

Indiana -- -- -- -- -- --

Illinois 600 583 634 1.6 1.5 1.6

Midwest 1,750 1,667 1,874 1.1% 0.9% 1.0%

Vermont 0 0 3 0 0 0.3

Rhode Island 113 126 125 3.8 4.4 3.9

Pennsylvania 461 590 652 1.6 1.8 1.9

New York 8,295 9,500 9,500 12.4 13.9 13.6

New Jersey 770 847 705 3.6 3.7 3.0

New Hampshire 26 31 18 1.3 1.5 0.9

Massachusetts 388 409 393 3.4 3.9 3.6

Maine 8 4 4 0.5 0.3 0.3

Connecticut 940 755 690 6.6 5.1 4.6

Northeast 11,001 12,262 12,090 7.4% 7.8% 7.5%

State 21,783 23,434 23,934 2.5 2.4 2.4

Federal 964 822 947 1.1 0.9 1.0

U.S. totalb 22,747 24,256 24,881 2.4% 2.3% 2.3%

Jurisdiction 1994 1995 1996 1994 1995 1996

HIV/AIDS cases as a percent of

total custody populationa Total known to be HIV positive

Table 2. Inmates in custody of State or Federal prison authorities and 

known to be positive for the human immunodeficiency virus, 1994-96
 8 3;;8%3;;9 7RFCVG< *+81#+&5. 56&U. CPF 6$ KP %QTTGEVKQPCN (CEKNKVKGU

 Note: Totals and percentages exclude inmates in jurisdictions that did not report data on type 

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 **Not calculated for 10 or fewer cases.

 --Not reported.

,Less than .05%. aGeorgia, Louisiana, and Missouri reported the total of HIV-positive cases but not the type of HIV. bIncludes all inmates who had tested positive for the HIV antibody but had no HIV-related symptoms. cIncludes inmates with symptoms of HIV infection but without a confirmed AIDS diagnosis.

 Source: BJS, National Prisoner Statistics.

Wyoming 4 4 0 0 ** 0

Washington 99 46 21 32 32.3 0.3

Utah 31 17 0 14 45.2 0.3

Oregon 39 23 12 4 10.3 ,

New Mexico 11 9 0 2 18.2 ,

Nevada 133 94 -- 39 29.3 0.5

Montana 6 2 0 4 ** 0.3

Idaho 17 13 0 4 23.5 0.1

Hawaii 23 17 4 2 8.7 0.1

Colorado 94 77 -- 17 18.1 0.2

California 1,136 585 122 429 37.8 0.3

Arizona 205 171 -- 34 16.6 0.2

Alaska 10 4 6 -- ** --

West 1,808 1,062 165 581 32.1% 0.3%

West Virginia 7 6 0 1 ** ,

Virginia 383 275 0 108 28.2 0.4

Texas 1,876 1,128 249 499 26.6 0.4

Tennessee 131 -- 94 37 28.2 0.3

South Carolina 422 309 -- 113 26.8 0.6

Oklahoma 108 99 -- 9 8.3 0.1

North Carolina 589 -- 390 199 33.8 0.7

Mississippi 135 111 -- 24 17.8 0.2

Maryland 832 521 37 274 32.9 1.3

Louisiana 347 -- -- -- -- --

Kentucky 55 36 13 6 10.9 0.1

Georgia 814 -- -- -- -- --

Florida 2,152 1,279 -- 873 40.6 1.4

District of Columbia -- -- -- -- -- --

Delaware -- -- -- -- -- --

Arkansas 77 20 37 20 26 0.2

Alabama 234 176 0 58 24.8 0.3

South 8,162 3,960 820 2,221 27.2% 0.5%

Wisconsin 91 43 30 18 19.8 0.1

South Dakota 4 0 0 4 ** 0.2

Ohio 343 279 -- 64 18.7 0.1

North Dakota 3 3 0 0 ** 0

Nebraska 17 9 4 4 23.5 0.1

Missouri 190 -- -- -- -- --

Minnesota 24 9 7 8 33.3 0.2

Michigan 528 255 -- 273 51.7 0.6

Kansas 16 9 -- 7 43.8 0.1

Iowa 24 16 -- 8 33.3 0.1

Indiana -- -- -- -- -- --

Illinois 634 394 42 198 31.2 0.5

Midwest 1,874 1,017 83 584 31.2% 0.3%

Vermont 3 3 0 0 ** 0

Rhode Island 125 56 29 40 32 1.2

Pennsylvania 652 318 112 222 34 0.6

New York 9,500 8,005 287 1,208 12.7 1.7

New Jersey 705 445 -- 260 36.9 1.1

New Hampshire 18 0 18 0 0 0

Massachusetts 393 79 148 166 42.2 1.5

Maine 4 4 0 0 ** 0

Connecticut 690 199 252 239 34.6 1.6

Northeast 12,090 9,109 846 2,135 17.7% 1.3%

State 23,934 15,148 1,914 5,521 23.1 0.6

Federal 947 549 45 353 37.3 0.4

U.S. total 24,881 15,697 1,959 5,874 23.6% 0.5%

Symptomatic Confirmed AIDS Total HIV cases Custody population c Asymptomaticb Totala Jurisdiction

Cases of HIV or confirmed AIDS Confirmed AIDS cases as a percent of &

Table 3. Inmates in custody of State or Federal prison authorities, by type of HIV infection 

or confirmed AIDS, year-end 1996
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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.

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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 1Î 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.

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Note: Care should be exercised when comparing the

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HIV classification system and expanded the surveillance

case definition for AIDS to include specific CD4+

T-lymphocyte criteria and three additional clinical conditions&pulmonary tuberculosis, recurrent pneumonia, and

invasive cervical cancer. This expansion resulted in a

substantial increase in the number of reported AIDS

cases during 1993. See Methodology, pp. 17-19.

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Note: The percent of the general population with confirmed

AIDS in each year may be overestimated due to delays in

death reports. Care should be exercised when comparing

percents over time, because of changes in the case definition

for AIDS. See Methodology, pp. 17-19.

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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.

 

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--Not reported.

Source: BJS, National Prisoner Statistics.

Wyoming 3 0.2 1 1.1

Washington 85 0.7 14 1.5

Utah 28 0.7 3 1.1

Oregon 35 0.4 4 0.7

New Mexico 10 0.2 1 0.3

Nevada 103 1.4 30 5.2

Montana 6 0.4 0 0

Idaho 15 0.5 2 0.9

Hawaii 23 0.8 0 0

Colorado 86 0.9 8 1.0

California 1,096 0.8 40 0.4

Arizona 200 1.0 5 0.3

Alaska 8 0.3 2 1.1

West 1,698 0.8% 110 0.7%

West Virginia 7 0.3 0 0

Virginia 355 1.5 28 2.1

Texas 1,645 1.3 231 2.3

Tennessee 129 1.0 2 0.5

South Carolina 398 2.1 24 2.1

Oklahoma 98 0.7 10 0.8

North Carolina 517 1.9 72 4.0

Mississippi 130 1.4 5 0.7

Maryland 763 3.7 69 6.6

Louisiana 329 1.9 18 2.3

Kentucky 52 0.5 3 0.6

Georgia 734 2.2 80 3.6

Florida 1,929 3.2 223 6.8

District of Columbia -- -- -- --

Delaware -- -- -- --

Arkansas 72 0.9 5 0.9

Alabama 217 1.1 17 1.3

South 7,375 1.8% 787 3.0%

Wisconsin 83 0.7 8 1.3

South Dakota 4 0.2 0 0

Ohio 317 0.7 26 0.9

North Dakota 2 0.3 1 1.8

Nebraska 17 0.6 0 0

Missouri 178 0.9 12 0.8

Minnesota 23 0.5 1 0.4

Michigan 498 1.2 30 1.6

Kansas 15 0.2 1 0.2

Iowa 21 0.4 3 0.6

Indiana -- -- -- --

Illinois 583 1.6 51 2.3

Midwest 1,741 1.0% 133 1.3%

Vermont 3 0.3 0 0

Rhode Island 100 3.3 25 11.7

Pennsylvania 605 1.8 47 3.2

New York 8,736 13.2 764 20.5

New Jersey 614 2.8 91 9.0

New Hampshire 15 0.8 3 2.1

Massachusetts 327 3.2 66 9.1

Maine 4 0.3 0 0

Connecticut 581 4.2 109 9.7

Northeast 10,985 7.2% 1,105 13.0%

Total 21,799 2.3% 2,135 3.5%

Percent of 

Number population

Percent of 

Jurisdiction Number population

Male HIV cases Female HIV cases

Table 4. State prison inmates known to be positive for the 

human immunodeficiency virus, by sex, year-end 1996

*In 1991 North Carolina, South Dakota, and the District 

of Columbia did not report data by gender. In 1995 Delaware,

Indiana, South Carolina, and the District of Columbia did not report

data by gender.

Source: BJS, National Prisoner Statistics.

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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. 

#+&5/4GNCVGF &GCVJU KP 5VCVG 2TKUQPU

The number of State inmates who died of Pneumocystis

carinii pneumonia, Kaposi’s sarcoma, or other AIDSrelated 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 AIDSrelated 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 AIDSrelated death.

 *+8 KP 2TKUQPU CPF ,CKNU. 3;;8 33

-- Not available.

* See Methodology, p. 18, for source of data.

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Note: In 1994 some States did not report complete data on cause of death. To calculate the rate of death, the 

number of inmates under State jurisdiction on June 30 of each year was used as an approximation of the average 

population exposed to the risk of death during the year. Inmates in States that did not report data on inmate deaths 

were excluded in 1994. All States reported data on inmate deaths in 1995 and 1996.

Source: BJS, National Prisoner Statistics.

Other/unspecified 244 27 204 20 166 16

By another person 68 7 86 9 65 6

Execution 30 3 56 6 45 4

Accident 33 4 48 5 43 4

Suicide 155 17 160 16 154 15

AIDS 955 104 1,010 100 907 90

1,393 152 1,569 156 1,715 170

Natural causes other

 than AIDS

 Total 2,878 314 3,133 311 3,095 308

Rate of death per

100,000 inmates

 

 Number

Rate of death per

 Number 100,000 inmates

Rate of death per

100,000 inmates

 

Cause of death Number

1994 1995 1996

Table 5. Number of inmate deaths in State prisons, by cause, 1994%96
 12 3;;8%3;;9 7RFCVG< *+81#+&5. 56&U. CPF 6$ KP %QTTGEVKQPCN (CEKNKVKGU

--Not reported.

**Not calculated for 10 or fewer deaths. 

 aBased on the number of inmates under State jurisdiction on June 30, 1996. bNational and regional totals exclude inmates in jurisdictions that did not report

 data on cause of death.

Source: BJS, National Prisoner Statistics.

Wyoming 8 612 0 0 **

Washington 33 289 9 79 27.3

Utah 7 214 1 31 **

Oregon 25 333 2 27 8.0

New Mexico 4 97 0 0 **

Nevada 35 467 8 107 22.9

Montana 5 264 0 0 **

Idaho 3 93 1 31 **

Hawaii 4 112 0 0 **

Colorado 22 205 0 0 0

California 253 192 49 37 19.4

Arizona 61 292 0 0 0

Alaska 3 93 0 0 **

West 463 220 70 33 15.1%

West Virginia 6 246 0 0 **

Virginia 84 308 31 114 36.9

Texas 377 297 122 96 32.4

Tennessee 60 402 8 54 13.3

South Carolina 76 390 27 139 35.5

Oklahoma 66 375 4 23 6.1

North Carolina 74 276 26 97 35.1

Mississippi 32 257 5 40 15.6

Maryland 48 224 16 75 33.3

Louisiana 86 346 20 81 23.3

Kentucky 30 251 1 8 3.3

Georgia 114 334 48 141 42.1

Florida 247 398 124 200 50.2

District of Columbia 29 277 -- -- --

Delaware 20 430 0 0 0

Arkansas 23 253 2 22 8.7

Alabama 89 443 13 65 14.6

South 1,461 327 447 109 30.6%

Wisconsin 14 132 4 38 28.6

South Dakota 4 220 0 0 **

Ohio 117 269 20 46 17.1

North Dakota 0 0 0 0 **

Nebraska 8 286 0 0 **

Missouri 37 195 0 0 0

Minnesota 10 210 1 21 **

Michigan 125 302 -- -- --

Kansas 20 289 2 29 10.0

Iowa 10 176 0 0 **

Indiana 39 248 2 13 5.1

Illinois 96 254 32 85 33.3

Midwest 480 252 61 41 12.7%

Vermont 0 0 0 0 **

Rhode Island 7 223 1 32 **

Pennsylvania 128 429 33 111 25.8

New York 330 482 182 266 55.2

New Jersey 142 554 74 289 52.1

New Hampshire 2 97 0 0 **

Massachusetts 30 262 7 61 23.3

Maine 3 206 0 0 **

Connecticut 49 327 32 213 65.3

Northeast 691 437 329 208 47.6%

Total 3,095 308 907 90 29.3%

As a percent of 

all deathsb

Rate per 100,000

inmatesa Total

Rate per 100,000

inmatesa Jurisdiction Total

AIDS-related deaths

Deaths from all causes 

in State prisons

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

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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.)

 *+8 KP 2TKUQPU CPF ,CKNU. 3;;8 35

Note: Categories are mutually exclusive; therefore total adds to 51.

Delaware did not report data on testing policies.

See chapter 5 for more detailed data on testing policies.

Source: BJS, National Prisoner Statistics.

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a

Data from Illinois, New Jersey, Arkansas, and Washington came from

the 1994 Update: HIV/AIDS and STDs in Correctional Facilities. Data

for Massachusetts, Maryland, California, and New York came from other

sources. (See Methodology, p. 19, for further detail.) b

The New York blinded study covered both 1994 and 1995. The NPS

rate for New York represents an average of the reporting years.

c

No women were tested in the blinded study.

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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 

 14 3;;8%3;;9 7RFCVG< *+81#+&5. 56&U. CPF 6$ KP %QTTGEVKQPCN (CEKNKVKGU

Note: Data are from the 1996 Survey of Inmates in Local Jails

and the 1997 Surveys of Inmates in State and Federal 

Correctional Facilities.

HIV positive 3.9 2.6 0.7

Tested since admission 17.7% 59.1% 69.7%

HIV positive 2.2 2.2 0.6

Ever tested 57.2% 74.6% 79.6%

HIV positive 1.2% 1.7% 0.5%

All inmates

 Federal 

 prisons

 State 

 prisons

 Local 

Characteristic jails

Percent of inmates

Table 7. Inmates ever tested or tested since 

admission for the human immunodeficiency 

virus and test results

Note: Data are from the 1996 Survey of Inmates in Local Jails and the 1997 Surveys of Inmates

in State and Federal Correctional Facilities. 

High school or more 122,597 2.3 254,975 2.4 37,237 0.5

GED 45,431 1.3 231,714 1.4 16,389 0.6

Less than high school 121,589 2.3% 302,437 2.7% 17,226 0.8%

Education

Never married 169,270 2.1 453,664 2.4 29,045 0.8

Separated 25,929 2.1 45,435 2.9 3,884 0

Widowed/divorced 48,695 3.0 161,468 2.0 16,331 0.4

Married 45,890 1.4% 128,834 1.7% 21,545 0.5%

Marital status

45 or older 21,455 3.0 92,168 2.7 16,884 1.2

35%44 70,776 3.8 232,835 3.1 22,228 0.4

25%34 116,532 2.1 310,161 2.3 26,262 0.5

17%24 81,228 0.7% 154,181 0.5% 5,528 0.1%

Age

Female 4,774 1.3 8,382 4.2 1,573 0

Male 40,985 3.5 115,344 2.4 16,892 0.7

Hispanic 45,759 3.2 123,725 2.5 18,466 0.7

Female 14,806 3.2 27,135 3.9 1,791 1.3

Male 110,453 2.5 357,736 2.7 26,387 0.8

Black non-Hispanic 125,259 2.6 384,870 2.8 28,178 0.8

Female 11,278 2.1 18,232 2.3 1,563 0.3

Male 98,745 1.3 239,687 1.4 19,565 0.3

White non-Hispanic 110,023 1.4% 257,919 1.4% 21,128 0.3%

Race/Hispanic origin

Female 31,972 2.4 55,800 3.4 5,179 0.6

Male 258,019 2.1% 734,327 2.2% 65,723 0.6%

Sex

All inmates 289,991 2.2% 790,128 2.2% 70,902 0.6%

Percent 

Number HIV positive

Percent 

Number HIV positive

Percent 

Characteristic Number HIV positive

Local jails State prisons Federal prisons

Inmates ever tested 

Table 8. Inmates ever tested for the human immunodeficiency virus and results, 

by selected characteristics
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).

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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).

 *+8 KP 2TKUQPU CPF ,CKNU. 3;;8 37

Note: Data are from the 1996 Survey of Inmates in Local Jails and the 1997 Surveys of Inmates

in State and Federal Correctional Facilities.

 Ever shared a 25,476 6.3 74,393 7.7 4,022 2.1

 needle

61,862 4.0 168,446 4.6 9,443 1.3

 Used needle to

 inject drugs

106,907 2.9 460,685 2.7 32,113 0.3

 In the month before

 offense

Ever 247,233 2.3 665,977 2.3 51,847 0.7

Never 42,242 1.6% 123,049 1.7% 18,917 0.3%

Prior drug use

Public-order 64,820 1.7 77,049 1.9 10,029 1.0

Drug 65,780 3.3 164,256 2.9 43,815 0.4

Property 79,936 2.2 178,601 2.4 4,660 1.0

Violent 72,846 1.5% 360,370 1.9% 10,681 1.0%

Current offense

Percent 

Number HIV positive

Percent 

Number HIV positive

Percent 

Characteristic Number HIV positive

Local jails State prisons Federal prisons

Inmates ever tested 

Table 9. Inmates ever tested for the human immunodeficiency virus and results, 

by offense and prior drug use
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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.

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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). 

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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.

 16 3;;8%3;;9 7RFCVG< *+81#+&5. 56&U. CPF 6$ KP %QTTGEVKQPCN (CEKNKVKGU

a

Based on the average daily population between July 1, 1992,

and June 30, 1993.

b

Excludes inmates in facilities that did not report data.

Source: HIV in Prisons and Jails, 1993.

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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 co-sponsored 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 Stateoperated 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).

 *+8 KP 2TKUQPU CPF ,CKNU. 3;;8 39
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. 

 18 3;;8%3;;9 7RFCVG< *+81#+&5. 56&U. CPF 6$ KP %QTTGEVKQPCN (CEKNKVKGU

 Shared a needle 1.71 1.09 1.41

 Used needle to inject drugs 0.85 0.57 0.73

 Used month before offense 0.58 0.27 0.19

 Ever used 0.33 0.21 0.23

 Never used 0.62% 0.41% 0.25%

Prior drug use

 Public-order 0.66 0.55 0.62

 Drug 0.79 0.46 0.19

 Property 0.52 0.40 0.91

 Violent 0.49% 0.25% 0.60%

Current Offense

 High school graduate or more 0.49 0.34 0.23

 GED 0.46 0.27 0.38

 Less than high school 0.47% 0.33% 0.42%

Education

 Never married 0.38 0.25 0.33

 Separated 0.97 0.88 0.00

 Widowed/divorced 0.88 0.39 0.31

 Married 0.58% 0.40% 0.30%

Marital Status

 45 or older 1.13 0.60 0.52

 35%44 0.85 0.40 0.26

 25%34 0.42 0.30 0.27

 Under 24 0.30% 0.20% 0.27%

Age

 Female 0.76 1.67 0.00

 Male 1.09 0.61 0.56

 Hispanic 0.98 0.58 0.52

 Female 0.74 0.72 1.15

 Male 0.53 0.38 0.51

 Black non-Hispanic 0.47 0.37 0.48

 Female 0.68 0.80 0.63

 Male 0.41 0.31 0.33

 White non-Hispanic 0.38% 0.29% 0.31%

Race/Hispanic origin

 Female 0.44 0.44 0.35

 Male 0.33% 0.20% 0.19%

Sex

Federal

prisons

State 

prisons

Local 

Characteristics jails

Table 10. Standard error estimates for the 1996 Survey 

of Inmates in Local Jails and the 1997 Surveys of State 

and Federal Correctional Facilities
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.

 *+8 KP 2TKUQPU CPF ,CKNU. 3;;8 3;
Sexually Transmitted Diseases and Hepatitis 21

Chapter 2

Sexually Transmitted Diseases

and Hepatitis:

Burden of Disease Among Inmates

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

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.

Key Findings

• 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.

• However, behavioral profiles and anecdotal evidence suggest that inmates are disproportionately affected by

STDs and hepatitis.

Table 11. Results of mandatory and routine

inmate syphilis screening, 1997

 State/Federal City/County

% Positive Prison Systems Prison Systems

 n % n %

<5 13 25 5 12

5–9.99 1 2 4 10

10–20 2 4 3 7

>20 0 — 0 —

Did not report 29 57 5 12

No mandatory or

 routine screening 6 12 24 59

 Total 51 100 41 100

Source: NIJ/CDC survey.
22 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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 HIVseropositive 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 mediumsecurity 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.

Table 12. Results of mandatory and routine

gonorrhea screening, 1997

 State/Federal City/County

% Positive Prison Systems Prison Systems

 n % n %

<5 3 6 2 5

≥5 0 — 0—

Did not report 11 22 1 2

No mandatory or

 routine screening 37 73 38 93

 Total 51 101* 41 100

*Due to rounding.

Source: NIJ/CDC survey.

Table 13. Results of mandatory and routine

chlamydia screening, 1997

 State/Federal City/County

% Positive Prison Systems Prison Systems

 n % n %

<5 5 4 1 2

≥5 0 — 0—

Did not report 5 16 1 2

No mandatory or

 routine screening 41 80 39 95

 Total 51 100 41 99*

*Due to rounding.

Source: NIJ/CDC survey.
Sexually Transmitted Diseases and Hepatitis 23

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.
HIV and STD Education and Behavioral Interventions 25

Chapter 3

HIV and STD Education and

Behavioral Interventions

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

Key Findings

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

• However, few correctional systems have implemented comprehensive and intensive HIV prevention

programs in all of their facilities.

• Peer-based education and prevention programs offer important advantages, including costeffectiveness, credibility, flexibility, and benefits to peers themselves.

• 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 instructorled 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.
26 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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. Preand 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.

Table 14. HIV/STD education and prevention programs for inmates, 1992–97

 Percentage of State/Federal Percentage of City/County

 Prison Systems Providing Jail Systems Providing

 in at Least One Facility in at Least One Facility

 1992 1994 1997 1992 1994 1997

Programs (n = 51) (n = 51) (n = 51) (n = 31) (n = 29) (n = 41)

Instructor-led education 86 75 94 58 62 73

Peer-led programs 33 35 41 10 7 7

Pre-/posttest counseling N/A N/A 96 N/A N/A 93

Multisession prevention counseling N/A N/A 59 N/A N/A 41

Audiovisual materials 96 88 84 90 66 78

Written materials 96 94 96 71 72 90

Source: NIJ/CDC surveys.

Table 15. HIV/STD education and

prevention programs in adult correctional

facilities, 1995–97

Percentage of Percentage of

 State/Federal City/County

 Facilities Providing Facilities Providing

 1994 1997 1997

Programs (n = 1,207) (n = 1,486) (n = 152)

Instructor-led

 education 48 61 66

Peer-led

 programs 7 13 3

Pre-/posttest

 counseling N/A 86 84

Multisession

 prevention

 counseling N/A 31 33

Source: NIJ/CDC surveys.
HIV and STD Education and Behavioral Interventions 27

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

Table 16. HIV/STD education and prevention programs for inmates, 1997 results of the

validation study (VS)

 Systems in VS Facilities From These Percentage in

Central Office Policy With This Policy Systems in VS Agreement

Instructor-led education in all facilities 7 20 75

Mandatory intake education 11 30 57

Mandatory prerelease education 7 25 60

Peer-led education in all facilities 1 1 100

Pre-/posttest counseling in all facilities 10 28 100

Multisession prevention counseling in

 all facilities 5 17 59

Videos/audiovisual materials in all facilities 11 29 76

Written materials in all facilities 12 31 97

Source: NIJ/CDC surveys.

care and case management, and aftercare/transitional planning. The HIV/AIDS prevention and education component

must include “most or all” of the following elements:

• Orientation.

• Peer education.

• Community-based prevention and education.

• Individual prevention and education, on request.

• Written and audiovisual materials.

• Prevention and education in prerelease, day reporting,

and pretrial populations.

• Gender-specific programs at facilities housing women.

• Expansion of HIV curriculums to cover other communicable diseases.

• 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
28 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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

Covered in Education Sessions

 U.S. State/Federal Prison Systems U.S. City/County Jail Systems

 (n = 51) (n = 41)

Topics No. of Systems % No. of Systems %

Basic HIV information 51 100 35 85

Basic STD information 46 90 32 78

Meaning of HIV test results 51 100 38 93

Meaning of STD test results 48 94 36 88

Safer sex practices 34 67 29 71

Negotiation skills for safer sex 21 41 19 46

Safer injection practices 23 45 20 49

Tattooing risks 42 82 22 54

Alcohol/drug risks 41 80 30 73

Self-perception of risk 30 59 27 66

Identifying barriers to behavioral change 28 55 23 56

Triggers for behavior relapse 29 57 22 54

Referral to other services 49 96 36 88

Planning for positive test 40 78 26 63

Source: NIJ/CDC survey.

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
HIV and STD Education and Behavioral Interventions 29

Table 18. Topics covered in HIV/STD education for inmates, 1997 results of the

validation study (VS)

Systems in

Systems in Facilities From VS That Do Facilities From

VS That These Systems % in Not Cover These Systems % in

Central Office Policy Cover Topic in VS Agreement Topics in VS Agreement

Basic HIV information 16 40 98 0 — —

Basic STD information 15 38 89 1 2 0

Meaning of HIV test results 16 40 95 0 — —

Meaning of STD test results 14 34 91 1 2 0

Safer sex practices 12 28 68 3 4 50

Negotiation skills for safer sex 7 20 45 8 16 50

Safer injection practices 9 23 35 6 12 67

Tattooing risks 13 32 78 2 4 25

Alcohol/drug risks 14 33 82 1 2 0

Self-perception of risk 11 28 68 4 8 38

Identifying barriers to

 behavioral change 10 23 56 5 12 67

Triggers for behavior relapse 9 22 45 6 14 71

Referral to other services 16 40 98 0 — —

Source: NIJ/CDC survey.

Table 19. Providers of HIV/STD education

and prevention services, 1997

Percentage of Percentage of

State/Federal City/County

Systems Using Systems Using

Categories Category Category

of Providers (n = 51) (n = 41)

Security staff 8 0

Correctional

 medical staff 100 71

Public health

 department 67 78

Community-

 based org./

 AIDS service org. 69 56

Inmate peer

 educators 41 7

Source: NIJ/CDC surveys.

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
30 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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 riskreduction 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.

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.
HIV and STD Education and Behavioral Interventions 31

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.
32 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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 youthcontrolled 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.
HIV and STD Education and Behavioral Interventions 33

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
34 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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:

• 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.

• 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.

• 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.

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

• Giving peer educators specific goals and incentives,

such as academic credit, prison job slots, or “good

time.”

• Developing a peer-driven curriculum rather than one

that is driven primarily by the goals of the correctional

system.

• 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.

• 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
HIV and STD Education and Behavioral Interventions 35

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
36 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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 selfimprovement 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.

Peer Program at Angola
HIV and STD Education and Behavioral Interventions 37

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.
38 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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
HIV and STD Education and Behavioral Interventions 39

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 AfricanAmericans, 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-bereleased 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
40 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

designed to encourage risk reduction through condom use,

avoidance of substance use, and safer substance use strategies. Participants also received referrals to communitybased 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 riskreduction 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 riskreduction 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.”
HIV and STD Education and Behavioral Interventions 41

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 Institution for Women, Frontera
42 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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.
HIV and STD Education and Behavioral Interventions 43

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 druginjection 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 riskreduction 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.
44 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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:

• 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.

• I thought the speakers knew how to talk to us. I felt

really comfortable with them.

• I thought I knew a lot about HIV/AIDS, but I guess not.

And now I’m more interested in learning about my

health!!!

• 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.

• 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.

• I think the class is very helpful. The teachers are great.

They get down to the point. That’s how it should be

done.

• 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.
HIV and STD Education and Behavioral Interventions 45

Endnotes

1. See the extensive literature review in T.M. Hammett,

J.L. Gaiter, and C. Crawford, “Reaching Seriously AtRisk 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).
HIV Transmission and Risk Factors, Precautionary and Preventive Measures 47

Chapter 4

HIV Transmission and Risk Factors,

Precautionary and Preventive Measures

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

Key Findings

• High-risk behaviors for HIV transmission—sex, drug use, sharing of injection materials, and tattooing—occur

in correctional facilities.

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

• Comprehensive and intensive education and prevention programs represent the best response to these

facts, although the precise content of such programs is controversial.

• Rape and coerced sexual activity also occur in correctional facilities but require a different response, one

based on inmate classification, housing, and supervision.

• 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.

• Condom distribution and other harm-reduction strategies have not been widely adopted in American

correctional systems.

• 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
48 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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 system8 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 precau-
HIV Transmission and Risk Factors, Precautionary and Preventive Measures 49

tions 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 European11 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.

Table 20. Availability of condoms and

bleach, 1997

 State/Federal City/County

Prison Systems Jail Systems

 (n = 51) (n = 41)

Policy n % n %

Make condoms

available for use

within facility 2 4 4 10

Make bleach

available for

any purpose 10 20 8 20

Source: NIJ/CDC survey.
50 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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:
HIV Transmission and Risk Factors, Precautionary and Preventive Measures 51

• Make sure your tattooist wears gloves.

• Wash and shave the area to be tattooed.

• Make sure the gun is cleaned in bleach.

• Replace cotton each time the gun is used.

• Cover the gun with latex.

• 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. Harmreduction 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.
52 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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.
Counseling and Testing, Confidentiality and Disclosure 53

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

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

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

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

• Ongoing assessment of HIV-antibody and pregnancy-testing policies is warranted in light of changing

community standards for the treatment of HIV/AIDS.

• Very few correctional systems have policies for the notification of correctional officers regarding inmates’ HIV

status.

• 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.
54 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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 HIVrelated symptoms or if the inmates request a test. Twentyfour 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 onrequest 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
Counseling and Testing, Confidentiality and Disclosure 55

Table 21. Testing policies for antibodies to the human immunodeficiency virus,

by jurisdiction, 1995

Jurisdiction Entering All Inmates High-Risk Inmate Clinical Involvement Random Other

In Custody Upon Group Request Indication in Incident Sample

Release

Federal System X X X X

Northeast

Connecticut X X X X

Maine X

Massachusetts X

New Hampshire X X X

New Jersey X X

New York X X X X X

Pennsylvania X X X

Rhode Island X X X X X

Vermont X

Midwest

Illinois X X X X

Indiana X X X

Iowa X

Kansas X X

Michigan X X X X

Minnesota X X X X

Missouri X X X X X

Nebraska X X X X X

North Dakota X

Ohio X X X X X

South Dakota X X

Wisconsin X

South

Alabama X X X

Arkansas X X X X

Delaware

Dist. of Columbia X

Florida X X X X X

Georgia X X X

Kentucky X X X

Louisiana X X X

Maryland X X X

Mississippi X X X X

North Carolina X X X X X

Oklahoma X X X

South Carolina X X X

Tennessee X X X X

Texas X X X X

Virginia X X

West Virginia X X

West

Alaska X X

Arizona X X X

California X

Colorado X X X X

Hawaii X X

Idaho X

Montana X X

Nevada X X X

New Mexico X

Oregon X X X

Utah X X

Washington X X X

Wyoming X

Source: BJS 1996 National Prisoner Statistics.
56 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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 HIVseropositivity 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 developTable 22. Summary of HIV-Antibody

Testing Policies

Testing Policy No. of Jurisdictions

Upon inmate request 40

Upon clinical indication 38

Upon involvement in incident 24

All incoming inmates 16

High-risk groups 14

All inmates at time of release 4

Random sample 3

All inmates in custody 2

Note: Detail adds to more than 52 because a jurisdiction may have

more than one testing policy.

Source: BJS 1996 National Prisoner Statistics.

Table 23. Mutually exclusive

categorization of HIV-antibody testing

policies for incoming inmates, 1997

 State/Federal City/County

Prison Systems Jail Systems

 (n = 51) (n = 41)

Policy n % n %

Mandatory 16 31 0 —

Routine 1 2 1 2

Offered 18 35 14 34

On request 16 31 19 46

No policy 0 — 7 17

 Total 51 99* 41 99*

*Due to rounding.

Source: NIJ/CDC survey.

Table 24. HIV-antibody testing policies,

1997: Results of the validation study (VS)

Facilities

Systems in VS in Percentage

Central Office in VS With These in

Testing Policy This Policy Systems Agreement

Mandatory* 6 11 100

Offered 8 23 35

On request 2 6 33

*Screening of all incoming inmates or all releases.

Source: NIJ/CDC surveys.
Counseling and Testing, Confidentiality and Disclosure 57

ment 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

percent8—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 HIVinfected 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

Table 26. HIV-antibody testing for

pregnant female inmates, 1997

 State/Federal City/County

Prison Systems Jail Systems

 (n = 51) (n = 41)

Policy n % n %

Mandatory 20 39 1 2

Routine 8 16 6 15

Offered 16 31 21 51

On request 7 14 9 22

No policy 0 — 4 10

 Total 51 100 41 100

Source: NIJ/CDC survey.

Table 25. Pregnancy testing for female

inmates, 1997

 State/Federal City/County

Prison Systems Jail Systems

 (n = 51) (n = 41)

Policy n % n %

Routine testing

 of all incoming

 women 23 45 12 29

On request 43 84 38 93

Clinical indications 51 100 39 95

Source: NIJ/CDC survey.
58 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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 carespecified 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,
Counseling and Testing, Confidentiality and Disclosure 59

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.

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

(VS)

Systems in Facilities Systems in Facilities

VS That From These % in VS That Do From These % in

Person or group Notify Systems in VS Agreement Not Notify Systems in VS Agreement

Inmate 16 40 100 0 — —

Attending health care provider 16 38 95 0 — —

Correctional management 8 14 43 8 25 64

 (central office)

Correctional management 7 14 50 9 25 80

 (institution)

Correctional officers 2 5 60 14 34 100

Public health department 14 35 83 2 4 50

Victims of sexual/physical

 assault by inmate 8 12 33 6 17 76

Spouse/sexual partner(s) 6 15 27 6 12 67

Needle-sharing partner(s) 6 15 27 6 12 83

Source: NIJ/CDC surveys.

Table 27. Policies regarding notification of inmates’ HIV-antibody test results, 1997

 State/Federal City/County

Prison Systems Jail Systems

 (n = 51) (n = 41)

Policy to Notify n % n %

Inmate 51 100 36 88

Attending health care provider 51 100 33 83

Correctional management (central office) 21 41 6 15

Correctional management (institution) 19 37 6 15

Correctional officers 6 12 3 7

Public health department 46 90 29 70

Victims of sexual/physical assault by inmate 24 47 10 24

Parole agency 15 29 0 —

Spouse/sexual partner(s) 16 31 6 15

Needle-sharing partner(s) 14 27 4 10

Source: NIJ/CDC survey.
60 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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 communitywide 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.

Table 29. Mandatory and routine testing

of incoming inmates for STDs, 1997

 State/Federal City/County

Prison Systems Jail Systems

 (n = 51) (n = 41)

Policy n % n %

Syphilis

 Mandatory 31 61 9 22

 Routine 14 27 8 20

Gonorrhea

 Mandatory 8 16 1 2

 Routine 6 12 2 25

Chlamydia

 Mandatory 4 8 1 2

 Routine 6 12 1 2

Source: NIJ/CDC survey.
Counseling and Testing, Confidentiality and Disclosure 61

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.
Housing and Correctional Management 63

Chapter 6

Housing and Correctional Management

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

Key Findings

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

• 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.

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

• Few correctional systems permit conjugal visits for any inmates, and even fewer allow such visits for inmates

with HIV.

• 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.

Table 30. Decline of segregation policies

in State/Federal systems (n = 51), 1985–97

 Systems With Segregation Policies for:

 HIV-Infected Inmates With

Inmates AIDS

 No. of No. of

 Year Systems % Systems %

1985 8 16 38 75

1986 8 16 30 59

1987 5 10 41 80

1988 6 12 20 39

1989 4 8 16 31

1990 4 8 9 18

1992–93 2 4 5 10

1994 2 4 4 8

1997 2 4 3 6

Source: NIJ/CDC surveys.
64 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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

Table 31. State/Federal prison systems’ housing policies for inmates with AIDS and

asymptomatic HIV infection, 1994 and 1997

 State/Federal Prison Systems

 AIDS Asymptomatic HIV

 1994 1997 1994 1997

Housing Policy n % n % n % n %

General population

 No restrictions 8 16 17 33 28 55 31 61

 With precautions 3 6 1 2 4 8 1 2

Permanently segregated 4 8 3 6 2 4 2 4

Case-by-case determination 36 71 30 59 17 33 17 33

 Total 51 101* 51 100 51 100 51 100

*Due to rounding.

Source: NIJ/CDC surveys.
Housing and Correctional Management 65

Table 33. Housing of inmates with asymptomatic HIV infection and AIDS: Results of the

validation study (VS)

 Systems in VS Facilities in VS Percentage in

Central Office Housing Policy With This Policy in These Systems Agreement

Asymptomatic HIV-infected

General population 8 19 79

Segregated 2 2 100

Case-by-case 6 16 25

AIDS

General population 3 7 29

Segregated 3 5 60

Case-by-case determination 10 24 58

Source: NIJ/CDC surveys.

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.

Table 32. City/county jail systems’ housing policies for inmates with AIDS and

asymptomatic HIV infection, 1994 and 1997

 City/County Jail Systems

 AIDS Asymptomatic HIV

 1994 1997 1994 1997

Housing Policy n % n % n % n %

General population

 No restrictions 1 3 10 24 14 48 32 78

 With precautions 0 — 1 2 2 7 0 —

Permanently segregated 0 — 2 5 0 — 2 5

Case-by-case determination 28 97 28 68 13 45 7 17

 Total 29 100 41 99* 29 100 41 100

*Due to rounding.

Source: NIJ/CDC surveys.
66 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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

Table 34. Compassionate release and

medical furlough, 1997

 State/Federal City/County

Prison Systems Jail Systems

 (n = 51) (n = 41)

Policy n % n %

Early/compassionate

 release 33 65 18 44

Medical furlough 19 37 7 17

Source: NIJ/CDC survey.
Housing and Correctional Management 67

improved medical condition and increasing survival of

patients receiving the new combination antiretroviral therapies.

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

 State/Federal Prison Systems City/County Jail Systems

 No. of No. No. of No.

Systems Released Systems Released

Compassionate Release

 Released no inmates 14 0 1 0

 Released some inmates 12 143 15 171

 Missing/don’t know 7 — 2 —

 Don’t permit compassionate release 18 0 23 0

 Total 51 143 41 171

Medical Furlough

 Furloughed no inmates 8 0 1 0

 Furloughed some inmates 8 30 3 10

 Missing/don’t know 3 — 3 —

 Don’t permit medical furlough 32 0 34 0

 Total 51 30 41 10

Source: NIJ/CDC survey.

Endnote

1. D. Cauchon, “AIDS in Prison: Locked Up and Locked

Out,” USA Today, March 31, 1995, 6A.
Medical Treatment and a Continuum of Care 69

Chapter 7

Medical Treatment and a

Continuum of Care

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

Key Findings

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,

• 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.

• 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.

• New drugs and reduced dosing currently under study offer hope of more “patient-friendly” regimens.

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

• 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.

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

• Existing program models have not been rigorously evaluated yet probably warrant replication based on

anecdotal evidence.
70 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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 longterm 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.

Table 36. The availability of HIV therapies

and monitoring, 1997

 State/Federal City/County

Prison Systems Jail Systems

 (n = 51) (n = 41)

Policy n % n %

Protease inhibitors 46 90 38 93

Combination therapy 46 90 37 90

 (protease inhibitors

 with antiretrovirals)

Bactrim 50 98 41 100

 (prophylaxis

 for PCP)

AZT for pregnant

 women 47 92 38 93

CD4 monitoring 51 100 38 93

Viral load monitoring 41 80 24 59

Source: NIJ/CDC survey.
Medical Treatment and a Continuum of Care 71

Guidelines for Antiretroviral Therapy

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

• To achieve maximum durable suppression of HIV viral

replication.

• To preserve optimal immune function.

• To delay development of drug resistance.

• To maximize patient adherence by selecting a tolerable

and understandable regimen.

• 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 possibiliTable 37. The availability of HIV therapies and monitoring: Results of the validation study

(VS)

 Systems in VS Facilities in VS Percentage in

Central Office Policy With This Policy in These Systems Agreement

Protease inhibitors 15 37 84

Combination therapy 15 38 87

(protease inhibitors with antiretrovirals)

Bactrim 16 39 92

(prophylaxis for PCP)

CD4 monitoring 16 39 95

Viral load monitoring 14 34 82

Source: NIJ/CDC surveys.
72 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

ties for correctional clinicians and administrators. The

strategy of administering a course of antiretroviral drugs

immediately after parenteral or cutaneous exposure to HIVcontaining 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 druginjection 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.
Medical Treatment and a Continuum of Care 73

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:

• 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.

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)
74 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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, highrisk 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
Medical Treatment and a Continuum of Care 75

was established through the cooperation of the security and

health care staff, with training provided by communitybased 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

Table 38. Psychosocial and supportive

services for inmates with HIV/AIDS, 1997

 State/Federal City/County

Prison Systems Jail Systems

 (n = 51) (n = 41)

Policy n % n %

Peer support groups 17 33 2 5

Support groups led 32 63 13 32

 by correctional

 staff

Support groups led 34 67 25 61

 by outside AIDS

 organizations

Source: NIJ/CDC survey.
76 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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 exoffenders 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 HIVpositive 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.

Table 39. Discharge planning services, 1997

Percentage of State/Federal Percentage of City/County

Prison Systems Providing Jail Systems Providing

Services (n = 51) (n = 41)

Discharge planning 92 76

 for HIV+ inmates

Referral Appointment Referral Appointment

Made Made Made Made

Medicaid/related benefits 78 35 56 29

CD4 monitoring 71 24 54 17

Viral load monitoring 61 22 46 20

HIV medications 82 31 66 27

Substance abuse treatment 75 22 63 24

HIV counseling 73 27 61 32

Psychosocial support 73 24 54 27

STD prevention and

 treatment 65 22 46 17

Source: NIJ/CDC survey.
Medical Treatment and a Continuum of Care 77

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:

• Early detection and effective treatment.

• Education and prevention.

• Case management and discharge planning.

• 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
78 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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 exoffenders 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 exoffender 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.
Medical Treatment and a Continuum of Care 79

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.
80 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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 communitybased 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, HealthLink, 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 fulltime 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
Medical Treatment and a Continuum of Care 81

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,
82 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

there are still relatively few programs available to the highrisk uninfected. The Rhode Island program and HealthLink, 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:
Medical Treatment and a Continuum of Care 83

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.
84 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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).
Tuberculosis 85

Chapter 8

Tuberculosis

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

Key Findings

• 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.

• 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.

• However, better collection and reporting of screening data would help to document the burden of TB infection

and disease among inmates.

• 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
86 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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

1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

0

20

40

60

80

100

120

0

50

100

150

200

Year

Number Rate

Num ber Rat e 

Source: New York State Department of Health, Bureau of Tuberculosis Control:

Tuberculosis in New York State, 1997 Annual Statistical Report.

Figure 1. Tuberculosis Cases and Rates Among New York State Inmates

(Exclusive of New York City), 1986-97

Rate per 100,000 Inmates

Number of Cases
Tuberculosis 87

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

Table 40. Active TB disease among inmates, 1997

State/Federal Prison Systems City/County Jail Systems

(n = 51) (n = 41)

 No. of No. of No. of No. of

Inmates Under Treatment Systems % Cases Systems % Cases

0 12 24 — 13 32 —

1–10 15 29 52 17 41 51

11–50 5 10 94 4 10 117

51–100 1 2 74 2 51 33

>100 2 4 247 0 — —

Did not report 16 31 — 5 12 —

 Total 51 100 467 41 100 301

Drug-resistant TB cases 35 29

(7%) (10%)

Source: NIJ/CDC surveys.

Table 41. TB infection among inmates, 1997

State/Federal Prison Systems City/County Jail Systems

(n = 51) (n = 41)

 No. of No. of No. of No. of

Percentage With Positive PPD Systems % Cases Systems % Cases

<5 20 39 6,512 9 22 6,117

5–9.99 3 6 7,200 11 27 8,162

10–20 1 2 1,283 5 12 16,165

>20 0 — — 0 — —

Did not report 27 53 — 16 39 —

 Total 51 100 15,033 41 100 30,539

Source: NIJ/CDC surveys.
88 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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.

Table 42. Screening inmates for TB, 1997

 State/Federal City/County

Prison Systems Jail Systems

 (n = 51) (n = 41)

Screening Policy n % n %

All incoming inmates

 screened for TB

 disease 37 73 30 73

All incoming inmates

 screened for TB

 infection (mandatory) 46 92 21 51

All inmates screened

 at regular intervals

 for TB infection

 (mandatory) 43 91 17 41

Source: NIJ/CDC survey.
Tuberculosis 89

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 King

County 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 selfsupervised therapy. Sixty percent of those who selected

directly observed treatment completed the course of treatment, as opposed to 29 percent of those who selected selfsupervised 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
90 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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 Elimi-
Tuberculosis 91

nation 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.
Legal and Legislative Issues 93

Chapter 9

Legal and Legislative Issues

Theodore M. Hammett—Abt Associates Inc.

Key Findings

• The U.S. Supreme Court has ruled that HIV and HIV-related discrimination are covered under the Americans

With Disabilities Act.

• 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.

• 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 HIVinfected 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-ofprivacy 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 HIVinfected 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
94 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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 HIVrelated 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
Legal and Legislative Issues 95

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 HIVinfected 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
96 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities

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 HIVantibody 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 HIVpositive 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 policymaking 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.
Legal and Legislative Issues 97

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:

● Sponsor special projects, and research and development programs, that will improve and strengthen the

criminal justice system and reduce or prevent crime.

● Conduct national demonstration projects that employ innovative or promising approaches for improving

criminal justice.

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

● Evaluate the effectiveness of criminal justice programs and identify programs that promise to be successful if

continued or repeated.

● Recommend actions that can be taken by Federal, State, and local governments as well as by private organizations

to improve criminal justice.

● Carry out research on criminal behavior.

● 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:

● New research and evaluation are exploring key issues in community policing, violence against women, sentencing

reforms, and specialized courts such as drug courts.

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

● 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.

● 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.

● The NIJ-administered criminal justice information clearinghouse, the world’s largest, has improved its

online capability.

● 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.

● NIJ’s new Crime Mapping Research Center will provide training in computer mapping technology, collect and

archive geocoded crime data, and develop analytic software.

● 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.