How did HIV and our criminal justice system become so well acquainted? The answer involves Darwinian evolution, 1980s era AIDS activists, the science of viral transmission, and Richard Nixon -- a confluence of seemingly unrelated events, crossed with the laws of unintended consequences, that led the virus that infected Rock Hudson to now be concentrated among those who find themselves doing time.
Here in the U.S. during the infancy of the HIV epidemic, it was the bathhouses and bars that urban gay men favored where the virus was to be found. Within a few years, thousands of infected gay men died and an anguished community responded with a strong push for safer, less risky sex.
HIV then found an opportunity among injection drug users and heterosexuals living in poverty -- people who were no strangers to the U.S. criminal justice system. Before long places like the Bronx and central Philadelphia had rates of HIV that rivaled those found in some African countries. Cut to our nation's prisons and jails.
The U.S. is a superpower when it comes to locking people up. We have 5% of the world's population but 25% of its prisoners.1 We incarcerate more people per capita than any nation on the planet -- about 2.5 million -- and have another five million under parole or other form of supervision in their communities.2 This massive incarceration has been brought to us by the "war on drugs." Launched in the early 1970s by President Nixon, the campaign to stamp out drug use through arrest and imprisonment led to a stratospheric increase in the number of people, especially people of color, sent to prisons and jails. Further swelling our correctional facilities were the Sentencing Reform Act of 1984, curtailing alternative sentencing, the "three strikes" laws of the 1990s, and harsher sentencing guidelines for crack cocaine than for powdered coke.
The number of people incarcerated each year has started to level out, and the population that is incarcerated has declined -- a consequence of an aging population, fairer sentencing laws, and a move away from conditional release, such as parole, that can make re-incarceration more likely. Still, one in 32 Americans is involved in the criminal justice system in one way or another.1
The U.S. has 5% of the world's population but 25% of its prisoners. We incarcerate more people per capita than any nation -- a total of 2.5 million.
According to government estimates there are about 22,000 people with HIV in prison, but the prevalence rates vary considerably (0.2% in Montana and 5.8% in New York).2 The number of HIV-positive inmates in jails, where people are housed before conviction and transfer to prison, is a mystery, but if the prevalence is close to that seen in prison, we are talking about another 11,000 HIV-positive detainees.
With the entrenchment of HIV in our correctional populations, there has been considerable thought given to the ways in which incarceration facilitates the spread of HIV. It is a common perception that HIV is spread within correctional settings, as predatory and consensual sex is known to occur in prisons and jails, places where condoms are contraband.
While there are clearly documented cases of HIV transmission in correctional settings, most data point to the lion's share of the HIV-positive individuals in prisons and jails having acquired the virus while free. Testing of inmates entering prison and jails finds high rates of infection, as described above -- likely reflecting the incarceration of those with or at high risk of HIV rather than the locking up of uninfected people who are then placed in a high-risk environment. One study that actually tested inmates in Rhode Island both on prison entry and then again on release found no cases of HIV acquisition during incarceration.4
On the other hand, an attention-grabbing report a few years ago did describe the detection of a number of inmates who tested HIV-negative when entering the state prison in Georgia and then were found to be HIV-positive during their incarceration.5 This demonstrates that transmission during incarceration does occur, but we remain unsure how often, and whether this is mostly sexual or via tattooing and needle sharing. In almost all states, condoms are not permitted in prisons and jails. Similarly, clean needles, bleach, and safe tattooing equipment are typically unavailable. Data from Canada and Europe suggest that such interventions, proven effective in other settings, can be implemented safely in prisons. However, there has been little interest in uptake of these measures in the U.S. This reflects a longstanding philosophical tension between the mores of the correctional culture in the U.S. and public health's reliance on evidence-based prevention methods.
Of even greater importance than the spread of HIV within prisons and jails are the broader socially disruptive effects of incarceration. The impact of imprisonment extends well beyond the individual placed in a cell and reaches his relationships and his community. Stable, protective, intimate partnerships are disrupted, if not ended, especially with prolonged incarceration.6,7 This can lead the partner left in the community vulnerable to infection via new relationships formed in the absence of the incarcerated partner. In communities where HIV and other sexually transmitted infections are more endemic, this can greatly increase the risk of infection.
As the vast majority of prisoners are released, those returning to their communities may now face an even greater risk of HIV transmission. For the HIV-negative former inmate, reconnecting with a partner who had sex with other partners during the incarceration, or who finds new partners post-release can result in exposure to HIV. The risk behavior of HIV-negative released men is well described and demonstrates that the potential for acquisition of HIV after, rather than during, incarceration is real.8 Much less is known about the behavior of HIV-positive men and women after prison release. Work conducted in North Carolina suggests that re-engagement in sex after release is a slow process, but that, as is the case with HIV-positive people in general, some do practice behaviors that can risk transmission of the virus.9
The collateral damage of incarceration extends even beyond the partner pair to the community at large, where the effects of the absence of a significant proportion of men alters the social landscape. Most directly, the gender ratio (number of men compared to the number of women) is shifted, influencing gender power (including negotiation regarding monogamy and condom use), and partner parity (social status, economic status, and HIV risk). Communities are further harmed by the loss of working age men and women, leaving a vacuum that saps vitality and stability. Therefore, incarceration has toxic societal effects that can promote the circumstances in which HIV thrives.
HIV mortality rates in prisons have plummeted, miroring survival trends seen in the free world, attributed to partnerships with academic centers and health departments.
Additionally, there is a sense among providers of HIV care in corrections that inmates may do better than free-world peers in terms of health outcomes due to structural factors that can lead to access to better nutrition, opportunities to exercise, limited or no access to substances of abuse, and close monitoring of adherence to medication and laboratory values.
The situation in jails may not always be so rosy. Unlike prison systems, which are run by the Federal or state governments, counties, municipalities, and towns fund jails. Unless they are one of the mega-jails like those in Chicago and Los Angeles, budgets are typically small and there are usually few or no staff with HIV expertise. The chaos of jails, where stays can be as short as a few hours or as long as months to even years, further challenges HIV care. Those entering jail without their medications can expect a lapse in dosing. With an average stay of a couple of days, there is also limited time to provide screening, treatment, and linkage to community care.
In the cascade of HIV care that extends from finding those who are infected to establishing care, retaining patients in care, and suppressing viral load long term, each point in this spectrum is an opportunity for those in corrections. As described above, screening for HIV is common in correctional settings and quality care is provided, especially in prisons and larger jails. The weakest link of this chain has been maintenance of the benefits of that care following release. It is ironic that incarcerated people living with HIV fare better, in terms of metrics of physical health (weight, viral load, and CD4 cell count), than those living with the virus in the communities from which they came. With release, much of the available data paints a bleak picture of unfilled ART prescriptions, missed medical appointments, and a return to behaviors that often lead to a return to a jail or prison.11 Much work has gone into identifying transitioning strategies that are effective at maintaining HIV care and service post-release. The model of HIV transition programming was pioneered in Rhode Island and involves pre- and post-release intensive case management.12 Other states have adapted this approach with reported success. One trial conducted in North Carolina found that among 89 HIV-positive inmates, those randomized to a case management program, modeled on the Rhode Island program, that spanned the periods before and after release had no more success in making doctor appointments post-release than those assigned to routine discharge planning by the prison. In all, about half of the former inmates in both study arms saw a medical provider within a month of release, at which time their prison-provided HIV medications would run out.13
Innovative approaches to linkage to care are being explored and the National Institutes of Health (NIH) and others have been funding efforts to test these in order to identify evidence-based models that can be implemented. Failure to link those under correctional supervision to ongoing HIV care would bode poorly for the broader effort to increase the proportion of all HIV-positive people with undetectable viral loads from its current 28%.
Incarceration is one of a number of forces that have shaped the domestic HIV epidemic. The massive imprisonment of the members of populations that bear a disproportionate burden of HIV has significantly perpetuated the spread of the virus and it is unlikely we will see an overhaul of the legal system any time soon. The sentencing laws that feed a gluttonous criminal justice system with inmates are likely to remain, as will policing policies that lead to the arrest of people of color and those living in poverty. Few people under correctional supervision will receive the substance abuse and mental health care they need. So, behind the walls of our correctional facilities, the virus will remain.
David Alain Wohl, M.D., is an Associate Professor of Infectious Diseases and Co-Director of the AIDS Clinical Trials Unit at the University of North Carolina. Metabolic complications associated with HIV infection and the nexus between HIV and incarceration are his major areas of research interest. His e-mail address is firstname.lastname@example.org.
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