Since the beginning of the HIV/AIDS epidemic, the disease has struck incarcerated
populations extraordinarily hard. The "War on Drugs" has produced a prison population
overwhelmingly dependent on illicit drugs. The confluence of drug use and national
drug arrest policies has made HIV infection rampant in the nation's prisons and jails.
According to the Department of Justice, almost 1.9 million people were incarcerated
in America as of June 1999. That's one out of every 147 residents behind bars. Rates
of incarceration disproportionately affect men of color. An estimated 11% of Black
males and 4% of Hispanic males in their twenties and early thirties are incarcerated,
compared to 1.5% of white males of the same age. Nationally, at the end of 1997, 2.1% of
male prisoners and 3.5% of female prisoners were known to be HIV positive. The rate of
confirmed AIDS was 5½ times higher in the prisons than in the general population. A
study of infectious diseases among people passing through correctional facilities in 1996
found that 17% of all prison and jail releasees were HIV positive.
HIV antibody testing policies vary among correctional jurisdictions, with only
18 states testing all inmates either at admission or while in prison. Most correctional
systems rely on voluntary testing, testing based on clinical indications, or prisoner
involvement in accidents. This makes tracking the actual rate of infection difficult. Stigmatization, the potential threat of violence, poor HIV education, and lack of confidentiality cause many prisoners to avoid voluntary testing even when they know that they
are at risk for infection. If a prisoner knows that he's HIV positive before entering prison
and does not need HIV specific medical care during the course of the sentence, he can
escape identification as HIV positive. Anecdotal evidence leads many people to believe
that the actual rate of HIV infection is much higher than that reported by the Department of Justice.
By definition, the common condition of imprisonment is that there is very little choice in
every aspect of life. This is also true for medical care, where prison authorities have a financial interest in limiting choice (much as HMO's do in the free world, but with even greater restrictions). The ability to make the most basic decisions about HIV antibody testing, HIV status disclosure, prevention education, or medical treatment are often denied to prisoners. In 1976, the Supreme Court found that prisoners are the only class of citizen guaranteed "the right to adequate medical care" (Estelle v. Gamble
). The courts define adequate care as meeting community standards. However, the Estelle
decision did not allow for inspection and enforcement of those standards. Litigation has become the routine
means of improving medical care and general prison conditions. Without successful litigation,
medical care is defined entirely by the prison and rarely reflects community standards.
|"Doctors drawn to prison practice often have little or no first-hand experience treating HIV in their communities"|
The spectrum of prison health care is as widely varied as in the "free world." It is impossible to generalize about conditions across one state, much less across the entire country. A select few prisons provide care equal to or even better than that available on the outside. However, the great majority do not even approach that level and quality of care. Some provide conditions seen only in developing countries. A recent report by the Correctional Association of New York looked at services provided by twenty-two correctional facilities in the New York State system. The report found "uneven clinical management, a vagueness among staff physicians about critical HIV/AIDS issues, wide variations in HIV testing, support services and education, and an absence of prevention measures."
Common Obstacles To HIV Treatment in Correctional Settings:
Prisons are not health care facilities
In correctional terms, the job of prisons is the "Care, Custody and Control" of prisoners. Most
often, control comes first. This mandate directly conflicts with proper medical care. Prisons are most concerned with security, limiting prisoner movement and keeping tight control on when
and where prisoners are in specified locations. Security concerns take precedence over any
other matters within the prison confines.
Lack of HIV-specific medical expertise
|Prisons are often in rural locales with few or no HIV patients in the area. Doctors drawn to prison practice often have little or no first-hand experience treating HIV in their communities. This limited knowledge of HIV/AIDS is dangerous considering that studies have shown a direct correlation between practitioners' HIV experience and positive patient outcome. Some prisons, hard-pressed to hire medical staff, utilize any available medical personnel. Infectious disease specialists are rare in prisons, where state budgets demand that resources be stretched.
The report by the Correctional Association of New York testified to the lack of board-certified or board-eligible physicians. Prisons have been known to hire practitioners with suspended licenses or with licenses from foreign countries. Unsubstantiated stories abound of veterinarians practicing medicine within the walls. Whether true or not, the persistence of such tales reflects the low regard in which prison medical staff is held by those they are treating. Similarly, non-medical staff in prison have little experience dealing with HIV. Administrators, counselors, security personnel, and chaplains are prone to treat HIV and AIDS as a problem of "others" -- those from the city, people of color, drug users, homosexuals -- and not something that requires an investment in educational, medical or staff resources.
The Latino Commission on AIDS in New York City estimates that 10% of prisoners in New York State are Spanish-language dominant. Other states with large immigrant populations such as California, Texas and Florida also see high numbers of Spanish speakers. With most prisons located in rural areas far from the large cities, it is very difficult to find bilingual medical or non-medical staff who can communicate complex medical concepts. In the absence of bilingual staff, inmates who do not speak English often must rely on bilingual inmates as translators. In doing so, they jeopardize their confidentiality.
Stigmatization and lack of confidentiality
Inmates have been attacked and killed for being perceived as gay and/or HIV positive in prison.
HIV is still largely considered a 'gay disease' inside. If an inmate becomes too interested in
treatment or education, he or she may be labeled as gay, adversely impacting health, housing, and life.
Many jurisdictions segregate HIV-positive inmates. Inmates often refuse to test or begin treatment if they know they will be separated from existing inmate friends and support systems. Some prisons transfer HIV-positive inmates to special units far from family and visitors. Despite the possibility of better medical care, a segregated inmate may lose the ability to hold a job, be considered for educational or work release, or to have contact visits with family and relatives. In this instance, disclosure can lead to a longer sentence.
Two ways of dispensing medication are used in prison settings: keep-on-person (KOP) and directly-observed-therapy (DOT). With KOP, inmates are issued a day's or week's worth of medications to keep in their cells and take at the appropriate times. The prison schedule may not allow for appropriate meals or fluids being available, or medications may be stolen for re-sale to other inmates. DOT means that the inmates must be released from their housing to stand in a pill line. Someone watches them take the medications and insures that they've been swallowed. Lockdowns or other circumstances sometimes make it impossible for inmates to go to the pill line. DOT often means the inmate surrenders all chances of confidentiality. Other
inmates see him routinely appear at a window and take "those big pink horse pills." To make matters worse, medication delivery often breaks down when inmates are transferred from one facility to another or taken to court. Medical records are routinely lost in the process, requiring the inmate to be re-tested and all medications suspended until the new results are received.
|"Access to the most basic prevention measures -- condoms, clean needles and syringes -- remains nonexistent in most correctional systems."|
|Lack of education & prevention|
|Until very recently, there was little prevention or treatment education available. Many within the correctional system (inmate and officer alike) were woefully ignorant of the most basic information. Since 1996, a number of national conferences and professional organizations, such as the National Commission on Correctional Health Care and the Correctional HIV Consortium, have
promoted educational opportunities which have begun to improve the quality of all medical
services in correctional settings. Ninety-four percent of state/federal prison systems reported
to the Department of Justice that they had instructor-led HIV education programs, and 41%
reported peer-led education. These figures are misleading. Advocates report that prison systems
often advertise brief, one-time orientation sessions as HIV education programs.
In prison, HIV is primarily transmitted through unprotected sex or injection drug use with shared needles. Access to the most basic prevention measures -- condoms, clean needles and syringes -- remains nonexistent in most correctional systems.
Where good prevention education programs exist, infection rates inside are reduced. Testing and treatment inceptions rise. Treatment outcomes and quality of life improve significantly. The Pastoral Care Service and AIDS Education Programs at the California Medical Facility, The COCOA Project in Washington State, the ACE (AIDS Counseling & Education) Program at Bedford Hills Correctional Facility in New York and pilot programs in Texas, Florida, and within the Federal Bureau of Prisons are good examples of such programs.
The numerous obstacles discussed above lead to increased stress levels, more rapid disease progression, shorter life expectancy and a depressed quality of life. In this population, where HIV/AIDS and other infectious diseases such as hepatitis C are growing at alarming rates, only a radical shift in public opinion and public policy will result in the changes necessary to bring about meaningful improvements in education, testing, and access to treatment.
Michael F. Haggerty, M.P.H. is the former Executive Director of the Correctional HIV Consortium. He is currently the Senior Partner of Correctional Medical Consultants in San Diego, California.
Steven Nesselroth is the AIDS in Prison Director of the Osborne Association in New York City.