Survival Experience - HIV Transmission and Prevention in Prisons

AIDS deaths among prisoners have become less frequent. However, in the 1980s, the time from AIDS diagnosis until death was shortened to 42% (in 1986) and then 66% (in 1988) as long as that of matched New York City unincarcerated persons with AIDS. The survival time for female inmates in the state of New York was much worse than that for male inmates.(17) In addition, HIV-infected inmates with a first case of Pneumocystis jiroveci pneumonia (PCP) had a 22% mortality rate, compared with an 8% rate among patients with HIV and PCP in the community at large in 1989.(18) A remarkable statistic from New York in 1988 was that >25% diagnoses of AIDS, as defined by the U.S. Centers for Disease Control and Prevention (CDC), in prison settings were first made at autopsy.(19) In 1997, AIDS diagnoses of inmates in the state of New York were still often established only at autopsy, delaying statistical monitoring by at least 8 months, pending autopsy completion. Some diagnoses of tuberculosis (TB) in inmates were made only at autopsy. Although New York held one third of all prisoners in the United States known to be HIV positive, a 2001 report showed that the number of AIDS deaths in 1999 among prisoners in that state was 26, down from an annual peak of 258 in 1994, and the lowest it had been in 16 years. In 2003, when New York still reported the nation's highest HIV seroprevalence among its prisoners, the highest death rates from AIDS-related causes were reported in Delaware, Maryland, and Florida.(3) The availability of antiretroviral drugs for prisoners, increasing number of specialists in HIV care among prison medical staffs, and the lower rate of HIV seroprevalence among inmates are all believed to be factors contributing to the reduced frequency of AIDS-related deaths among prisoners.

A report from Spain describes a parallel improvement in case identification and survival. A review of the delay between time of discovery of HIV seropositivity and diagnosis of AIDS revealed that, in 1984, 100% of prisoners' HIV infections were diagnosed in the same month as AIDS, whereas in 2000 only 4% of HIV and AIDS diagnoses were made within a month of each other.(20)

HIV Transmission in Prisons
Numerous activities known to occur among prisoners pose a risk for HIV infection. Several studies have identified transmission of HIV in prison, based on serial serotesting for HIV antibody, some identifying seroconversion in inmates after more than 5 years of continuous incarceration.(21-24) Molecular analysis of 14 HIV-positive inmates in Glenochil Prison in Scotland in 1993 found sequencing similarities and clinical histories in 13 of the 14, indicating that transmission had occurred at the institution.(25)

Data gathered in the Georgia State Prisons from mandatory testing of all inmates at intake followed by inmate requested tests, or annual voluntary HIV serotesting which was offered between 2003-2005, identified 88 prisoners who seroconverted between 1992-2005 after one or more negative tests. Investigators analyzed data collected from cases and control subjects through computer assisted self interviews. Characteristics associated with prisoners' HIV seroconversion were male-male sex in prison, tattooing in prison, age >26 at interview, >5 years served of current prison sentence, black race, and a body mass index <25.4kg/m2 on entry into prison. This CDC report includes a wealth of information about the prisoners, reported risk activities, precautions practiced, and knowledge about and suggestions for prevention of transmission of HIV in prison.(26)