"The degree of civilization in a society can be judged by entering its prisons."
-- Fyodor Dostoevsky
There is a public health emergency in New York State prisons. Infection rates of HIV and hepatitis C virus (HCV) are 8 to 10 times higher in prison than in the general community. Women are disproportionately affected by both diseases. The most recent NYS Department of Health (DOH) blinded seroprevalence studies found HIV infection present in 5% of men and 14% of women. HCV infection rates are 14% for men and 23% for women. The NYS Department of Correctional Services (DOCS) estimates that there are approximately 10,000 prisoners with HCV -- but this is very likely an underestimate. Published studies of prisoners in the correctional systems of California, Texas and Maryland have found that 30-40% of prisoners test positive for HCV. Since NYS DOCS currently houses about 65,000 prisoners, this indicates a probability of under-reporting.
There are 70 prisons in New York State, and the health care provided at each facility is subject to oversight only by DOCS, with no effective review by any outside agency. Whether a prisoner receives adequate care is dependent upon whether he or she is lucky enough to be at a facility where the generally understaffed and often poorly trained medical personnel are both able and interested in providing services to the many sick prisoners under their charge. While prisoners are entitled to adequate healthcare under the Eighth Amendment to the United States Constitution, the reality is that they often do not receive it. In 1992, DOH performed a limited audit of DOCS healthcare at 12 prisons and found significant deficiencies in care. No follow-up to that review has occurred despite the assertions in a 1994 Memorandum of Understanding between DOH and DOCS that DOH would perform additional review of DOCS healthcare at the original 12 facilities and at other state prisons.
According to the Legislative Action Coalition on Prison Health and the NYS Assembly, most common deficiencies found in NYS prisons are: a) failure to provide inmates education about, and voluntary testing for, chronic diseases including HIV, HCV, etc.; b) the failure to have sufficient numbers of adequately trained health professionals who have the expertise to care for prisoners with chronic diseases; c) the failure to have access to specialists to treat these patients; d) the failure to prescribe needed therapy for patients with chronic diseases; e) the failure to have a chronic disease program to monitor and treat state inmates with these illnesses; f) the failure to have an adequate quality assurance program in DOCS to monitor the care being provided; and g) a failure to ensure continuity of care as patients are transferred from one prison to another or are released to the community.
Advocates agree that one of the major problems with health care in NYS prisons is a lack of uniformity of treatment and the overall substandard delivery of health care. Current bills in the NYS legislature, A. 3586 (Gottfried) and S. 2819 (Duane), would amend the definition of "hospital" in Article 28 of the Public Health Law to include correctional health facilities. This would give the DOH oversight of all local and state health correctional facilities. It would ensure that all prisoners receive a uniform standard of care consistent with community standards as is required by the DOH in all other state health facilities.
Another bill, A. 3544 (Gottfried), would require the Department of Health (DOH) to review the policies and practices concerning HIV and HCV care at state prisons and local jails annually. But some advocates have concerns regarding this legislation, and are not convinced that the outcome of DOH AIDS Institute reviews and recommendations will be sufficient to bring about the level of change required for serious improvement of healthcare for prisoners. Some question if one state agency will report negatively on another to the same governor.
People in prison need help and support in many areas. For example, while there are an estimated 10,000 Spanish-language-dominant speakers in NYS prisons, there are few Spanish-speaking health care providers within DOCS. Spanish-speaking prisoners must seek the help of a bilingual prisoner to translate their needs to a prison health care provider. In the process their privacy and confidentiality are breached, there are omissions of information, and a potential for misdiagnosis exists. Although prisoners try to help one another, they are not trained in medical terminology and it is difficult for them to provide accurate translations.
Advocates are also pressing for harm reduction techniques to be taught to prisoners, including safer sex and safer injecting drug use. Not everyone coming out of prison will remain drug free. In fact, there are prisoners who are released from prison with drug habits. In some prisons there is easy access to illegal drugs but a scarcity of syringes, leading to many prisoners sharing the same syringe. In addition, condoms are desperately needed to help stop the spread of HIV/HCV and sexually transmitted diseases. Sex occurs in prison on a daily basis, whether it is consensual, coerced, bartered, or involuntary. There is prostitution and there are same-sex marriages in prison. Sexual activity is not limited to prisoners -- correctional staff also engage in unsafe sex with inmates. Another bill in the NYS legislature, A.3720 (Gottfried) and S.3048 (Duane), would require every correctional facility to implement STD/HIV education and prevention programs, including the distribution of condoms and latex barriers.
New York State continues to have the distinction of leading the nation in the number of prisoners with HIV and the number of prisoners in 24-hour lockdown cells. New York uses disciplinary confinement at a rate four times higher than any other prison system. Prisoners can be confined to these Special Housing Units (SHUs) for prolonged periods of time -- months, or even years. During this time, they have no access to prison programs, are allowed limited family visitation, and can shower only three times a week, inside their cells. Many prisoners sentenced to SHUs have a prior history of mental illness, and those who don't often develop mental illness as a result of the isolation and oppressive conditions within the SHUs. Ironically, there is limited or no access to mental health professionals while they are confined in these units.
Each year, about 25,000 prisoners are released from New York State prisons, and most of them return to the most underserved and impoverished communities of New York City. All too often their health care and medical needs were neglected while incarcerated. There are scores of squandered opportunities by prison officials and their contracted healthcare providers to educate prisoners about HIV/HCV, to provide testing, and to address their healthcare needs. The impact of inadequate, indifferent and neglectful health care delivery to prisoners is absorbed by the communities and the families that they return to. Many prisoners are released without adequate discharge planning, receive insufficient information about their health status, and often find that their parole officer has not received the training necessary to understand the connection between HIV, HCV, and substance abuse.
Transitional housing programs are also often lacking. People with HIV coming out of prison should never be released to shelters, but they may choose to go to one rather than spend one more day in prison. When they do find a transitional housing program, it may not offer the appropriate infrastructure, such as substance abuse prevention services, medical care, and the other supportive services that are needed for a successful transition.
In New York State, the Legislative Action Coalition on Prison Health (LACPH) is working to organize public forums, educate people about health care in prisons, and mobilize the community to support or oppose legislative bills that have an impact on the health of prisoners with HIV/HCV. LACPH is comprised of advocates and formerly incarcerated persons, and has the endorsement and support of over 50 community-based organizations, AIDS service organizations, activist groups, legal professionals, medical institutions, and policy groups. If you would like to join or need additional information, please contact Michele Bonan at firstname.lastname@example.org or call (212) 367-1045.
Nationally, the AIDS Treatment Activist Coalition (ATAC) Access to Healthcare for the Incarcerated Working Group is designed to empower an HIV/HCV population that is the most marginalized in our nation. ATAC is working towards developing national prison healthcare standards and seeks to work in unity with prisoners' activists across the United States to effect change. The mission of the Access to Healthcare for the Incarcerated Working Group is to improve the care provided to prisoners who are infected with HIV and/or hepatitis C virus and to enhance the prevention of these diseases through education, advocacy and building resources. If you would like to join or need additional information, please contact Christina Hurst at email@example.com or call (602) 364-3662.
Challenging the situation faced by people with HIV and HCV in our prisons requires consciousness and concerted actions from all members of our society. If we are to advance as a nation, we must ensure that all people have adequate opportunities to become self-sufficient and productive members of our society. We must demand that all people have decent and affordable housing and that all people are treated with respect and dignity.
Romeo Sánchez is a formerly incarcerated person living with HCV and is a long-term advocate for prisoners with HIV/HCV and affected communities. He is Deputy Director of the New York City AIDS Housing Network.