HIV Transmission and Prevention in Prisons

Introduction

Prisoners are at exceptional risk for infection with HIV because of the association of injection drug use with incarceration. Women prisoners who have practiced prostitution, which frequently is associated with injection drug use and contact with HIV-infected sex partners, are at additional risk for HIV infection. This chapter reviews the following issues involved with HIV infection in prisoners: epidemiology, prevalence, and transmission; the growing coincidence of tuberculosis and hepatitis C; institutional issues, including prison policies and practices, confidentiality, informed consent, and medical research; the extensive involvement of the legal system in the area of HIV in prisoners; and the role of educational programs in prevention efforts.

Epidemiology and Background
As of December 31, 2004, nearly 7 million people in the United States lived under the jurisdiction of the criminal justice system, and more than 2.2 million were in jail or prison. The United States imprisons its population at the highest known rate in the world, 724 per 100,000 persons in 2004. In 1998, 11.5 million people were released from jails and prisons into communities in the United States. These figures, which continue to increase, reflect the country's adherence to a formidable social policy of imprisonment and raise the public health issue of the huge impact that prisoners' health will have on the community at large. Prison populations have grown in recent decades primarily because incarceration has been the central tactic of the "war on drugs" in the United States. The millions of intermittently incarcerated people in America, many of whom are illicit drug users, have been among the most difficult people to reach with critical health information, management, and treatment. The National Commission on AIDS stated in its 1991 report: "By choosing mass imprisonment as the federal and state governments' response to the use of drugs, we have created a de facto policy of incarcerating more and more individuals with HIV infection." Fifty-seven percent of federal prisoners were incarcerated for drug-related offenses in 2001.(1,2-4)

The AIDS prevalence in 2003 was more than 3 times higher in state and federal prisons (0.51%) than in the general U.S. population (0.15%).(3) Between 20% and 26% of people living with HIV/AIDS in the United States have spent time in the correctional system.(5) No precise count of HIV cases in prisoners is available, as brief incarceration, particularly in jails, limited access to health care, and lack of universal screening hinder the identification and diagnosis of inmates with HIV infection. Also, arrestees may choose not to declare their HIV status.

In 2003, a U.S. National Institute of Justice survey of the 50 state prison systems and the federal prison system reported 5,944 current AIDS cases.(3) New York, Texas, and Florida accounted for nearly half of the confirmed AIDS cases within the 50 state prison systems.