Prisoners in the U.S. are much more likely to be living with HIV and hepatitis C virus (HCV) than the general public. Though this may not be surprising, there is a widespread false belief that most inmates living with HIV and HCV were infected while in prison. Most inmates living with HIV or HCV, however, were infected before they started serving their current term in prison.
There are limited data on HIV infection in prison settings. The most complete set of data comes from a 2006 study by the Georgia Department of Corrections, which found that the majority of inmates with HIV had been infected before being incarcerated. From July 1988 to February 2005, all Georgia prisoners were required to be tested for HIV when entering prison. Of all the Georgia prisoners who tested HIV-positive during that time, 90% were already living with HIV when they entered prison. Only 88 inmates tested negative when they entered prison and later tested positive. This study covered only Georgia prisons, but it is the most thorough study of its kind in the country and could suggest how the epidemic exists in other prison systems as well.
A 2008 Washington Post article offers an explanation for this trend. The article points out the fact that communities of color with high incarceration rates, usually in inner cities, are the most affected by HIV of any communities in the U.S. Prisons play a very large role in the spread of HIV, but in more hidden ways. When members of a community are constantly being taken to and returned from prison, their partners are more likely to have other relationships. As people in this community have multiple sexual partners at the same time, sexually transmitted infections like HIV spread very quickly.
These communities also tend to have limited access to health care, so members might be less likely to know their own status or how to protect themselves from HIV and HCV. In fact, prison is often the first place these individuals will have access to health care, or the first time they will be tested. Members of these communities make up a large percentage of people in prisons, so the rates of HIV in prisons are likely to be much higher as a result.
HCV rates are also significantly higher in prisons and jails than among the general public. According to the CDC, one in three prisoners is living with HCV. In 2005, 39% of people with HCV in the U.S. had a history of serving time in prison or jail, and a 2000 study found that 79% of all state prisons (which house 94% of inmates in the U.S.) offered HCV testing at some point during a prisoner's stay. But while prisons may sometimes be a good place to get tested, they rarely offer inmates the treatment they need. Between July 1, 1999, and June 30, 2000, only 7% to 27% of inmates who tested positive for HCV were being treated. The majority of HCV-positive prisoners weren't receiving treatment for reasons such as substance use, length of stay, and mental illness.
Many inmates have other health concerns that need more immediate attention, so medical staff prioritize those conditions over the HCV infection. Some medical staff aren't well trained to treat HCV, or don't want to start treatment on someone with a short sentence. Since standards of care vary between prisons, it's often difficult to maintain treatment when a prisoner is moved. Treatment is complex and sometimes painful, and only works about half the time.
But the most common reason given for the lack of HCV treatment in prisons is its cost. Treatment costs almost $10,000 per inmate per year, and many prisons and jails claim they don't have those resources. Some inmates file lawsuits against the prisons that deny them care, but many die during the fight, and a recent Montana Supreme Court decision ruled in favor of the prison system. Despite the fact that prisons have some of the highest rates of HCV infections, they have some of the worst care standards.
Data show that, much like HIV, the majority of HCV infections happened before serving time in jail or prison. A 2002 CDC report estimated that 72 to 86% of injection drug users are infected with HCV. Since the vast majority of HCV infections are due to injection drug use, an untreated person is very likely to pass the virus on to a partner or another user. After being released from prison, many untreated users will continue to inject, often sharing needles and likely infecting others with HCV. As HCV cycles through communities of injection drug users, many of whom are arrested and imprisoned, the infection rates in prisons remain high. And the longer inmates are denied proper HCV treatment, the worse the epidemic gets.
HIV and HCV transmission does occur in prisons and jails, but it happens less often than most think. Sexual activity occurs in prisons between inmates, between inmates and staff, and during conjugal visits. Sex can be consensual or by sexual assault. There is little supervision during most prison activities, so it can happen often. Condoms and other preventive barriers are often not available to inmates, so the risk of HIV and HCV transmission during sexual activity is high. Injection drug use also continues within the prison system, and since there are usually no syringe exchange programs in U.S. prisons, most inmates end up sharing needles.
For most injection drug users in prisons and jails, however, the risk of infection was present long before their imprisonment. Many users have very little access to health care or HIV and HCV testing in their home communities. Many have been unknowingly living with an infection for quite some time. Drug treatment programs are also severely lacking in communities with high rates of injection drug use, and partners of drug users are often subject to the same risks of infection through sexual contact.
The high rates of HIV and HCV infection in prisons seem to be a result of who gets sentenced. Out of the 1.7 million people in prisons and jails in 2000, 1.4 million were imprisoned due to possession or sale of narcotics, crimes to support their addiction, or offenses in which drug use was a factor. In that same year, 24% of inmates in state prisons and 14% in federal prisons had a history of injection drug use, while 340,000 state inmates and 170,000 federal inmates had shared needles at some time. If such a high proportion of people in prison have a history of drug use, and specifically injection drug use, prisons are bound to have higher rates of HIV and HCV infection than the general population.
State and federal prisons should be concerned with protecting inmates from HIV and HCV infection, but they also need to address the stigma and homophobia that inmates are faced with. For inmates who enter prison already living with one of these viruses, confidentiality is of utmost importance. When HIV-positive inmates receive HIV meds, they should never have to wait in a separate line from their peers, which puts them at risk of ridicule, isolation, and severe emotional and physical abuse. Similarly, prison officials should be well trained in the need for confidentiality and sensitivity toward HIV- and HCVpositive inmates. They should also be sensitive to the needs of lesbian, gay, bisexual, and transgender inmates since HIV stigma is still linked with this community. HIV stigma and homophobia only serve to push sexual activity and drug use further underground, putting inmates at greater risk of being infected or infecting others.
In addition, prisons should increase education about HIV and HCV prevention and care. For prisoners who have never received adequate health care and comprehensive sexual education, the prison could be a turning point in their lives. If prisons use this unique opportunity to reach out to inmates, they could keep inmates healthier long after they leave the facility. This information could then serve to lower infection rates when prisoners return to their communities.
Passing out condoms and clean syringes could also have a positive impact on communities affected by high incarceration and injection drug use rates. The more people who leave prison HIV- and HCV-negative, and the more people living with an infection who leave prison healthier and more knowledgeable, the healthier their communities will be.
These communities could also see a dramatic drop in the spread of HIV and HCV if incarceration becomes less common. The "stop-and-frisk" policies that target people in these communities are often driven by racism, homophobia, and transphobia, and create unstable and unsafe environments for the most vulnerable populations.
Lastly, the instability in some communities that is driven by incarceration and fuels the spread of HIV and HCV is made even worse by high rates of recidivism (going back to jail or prison). The constant cycling in and out of prison leaves a community devastated. But this could be prevented with the proper resources. Research shows that if prisons educate inmates and assist them in finding employment, they are much less likely to return to prison. If real opportunities were provided on a large scale, communities could begin to see much lower prison rates and, as a result, HIV and HCV infections. When communities are educated, the virus is less likely to spread.
By addressing the health and prevention needs of prisoners and their communities, prisons can help end the cycles of HIV and HCV infection.
Elizabeth Lovinger is a Policy Associate at GMHC.