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Declining Concentration of HIV in Correctional Facilities, but 20 Percent of HIV-Infected People in the U.S. Have Been in a Correctional Facility

An Interview With Anne Spaulding, M.D., M.P.H., and Matthew Page, M.P.P.

February 11, 2009

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There's nothing like hearing the results of studies directly from those who actually conducted the research. In this interview, you'll meet two of these impressive HIV researchers and read their explanation of a study they presented at CROI 2009.

Anne Spaulding: I'm Dr. Anne Spaulding, and I'm from Rollins School of Public Health.

Matt Page: Matt Page, also from Rollins School of Public Health at Emory University.

Anne Spaulding: We're presenting a poster on how the share of the burden of HIV/AIDS has declined in U.S. correctional releasees, but the numbers have not.1

Could you please talk us through the poster?

Anne Spaulding: The thing that this poster highlights is that the portion of the HIV epidemic that is represented by the millions of people that go through jails and prisons is a smaller percentage of the overall U.S. epidemic than it was a decade ago.

In 1997, there was a paper that was written by Ted Hammett called "The Burden of Infectious Disease Among Inmates and Releasees From U.S. Correctional Facilities," and that was published in The American Journal of Public Health in 2002. That showed that over 20 percent of all of the people who were infected with HIV passed through either a jail or a prison.

The take-home message from that paper was, if you want to find people with HIV, especially folks who may not have good access to care, go to where people pass through, and that would be jails and prisons. That was a public health opportunity that was often missed.

Since that time, the prevalence of people who are admitted to jails and prisons has been going down. We did a recalculation of what portion of the epidemic is represented by the people who go in and out of jails and prisons, and we found that not only is the prevalence going down, but the portion of the epidemic has gone down.

What's important, though, to realize with that is that, at the same time, the sheer number of people who are HIV infected has remained almost unchanged.

So, our calculations were based on data from the Bureau of Justice Statistics in 2005. We have shown that about 150,000 individuals were released from jails and prisons in 1997. In 2005, about 150,000 individuals were released from jails and prisons. So there is no reason to stop looking in jails and prisons for public health opportunities for interventions -- to prevent HIV, to diagnose HIV that's already been transmitted, to start people on care and to have discharge planning so people will be released to care on the outside.

But what has happened in the past decade is that there are more people in the United States who are infected. We have gone from probably around 775,000 people in 1997 who were infected to over a million people. At the forefront of the epidemic now, new cases are occurring in women. New cases are occurring in populations that have a lower propensity to go through jails and prisons. So, just that the denominator has increased is probably what has led to having the share go down.

Could you explain what you mean when you say that the share has gone down but the numbers have stayed stable?

Anne Spaulding: Think of it as a fraction. On the bottom part of the fraction, in the denominator that number is the number of people in the U.S. who have HIV. On the top number is the number of people that go through jails and prisons; that's the numerator.

What has happened in the past decade is that the denominator has increased without a change in the numerator. That means that the part of the pie -- if you want to look at it as a graph -- that is represented by this population, is a smaller slice of a pie, but that the pie has gotten larger, as a whole. That means that the need has not changed.

People are not parts of a pie, and I'm not trying to imply that at all. But it just means that this is a smaller part of the whole epidemic. So, this is not good news.

Matt Page: To sum it up, the relative numbers have changed, have gone down, but the absolute numbers have not changed. It's still a large population for case finding and prevention.

What are the numbers, actually, currently? Is there some sort of approximate number of people who pass in and out of prisons in a yearly basis?

Anne Spaulding: I would say that number is probably around 150,000. The prevalence of HIV is 1.7 percent in jails and prisons. So that's a pretty high percentage of persons.

The majority of people going through jails and prisons are not HIV infected. Sometimes if people have watched too much TV, they think everyone in prisons and jails is HIV infected. By far, that is not the case.

But do we actually know the right numbers? Throughout the United States, are people getting in and out of jails and prisons tested for HIV? Do we actually know their status?

Anne Spaulding: There's not universal testing of everyone who goes through jails and prisons. I think prisons are probably in the right neighborhood of determining how many people are infected.

In jails, I think, it's much more of an open book. With the advent of rapid testing for HIV, we now have a technology to diagnose HIV at a pace that is the same as the pace of people going through jails and prisons. There was a paper that just came out this month, actually, with Robin McGowan as the first author, that is looking at the uptake of rapid testing in jails. He found that 0.8 percent -- so, 8 people out of 1,000 -- who went through jails were not only infected with HIV, but were infected and were previously undiagnosed. So it's very, very low-hanging fruit for public health to go and target for a place where people can be brought into the health care system when they have previously not had access.

Do you have an ethnic breakdown of the people who are HIV infected in prisons?

Anne Spaulding: I think the answer to the question of: Do we have an ethnic breakdown? Is, sort of. We have tried to do that analysis with some incomplete data. One of the problems is that when the Bureau of Justice Statistics gets information from the prisons and jails as to the racial and ethnic makeup of the populations, they will look at gender as a whole, so this percent are female, this percent are male -- and then, separately, they will say what percent are African-American -- well, they say black, white, or Hispanic. The characterization of the Hispanic -- whether or not Hispanic/black, Hispanic/white -- is not always spelled out. Then that's different from the self-declared racial identification.

But with all those caveats, looking at inmate surveys of people who consider themselves African American, and from surveys that were done earlier this decade, we probably have about 20 percent of the epidemic of HIV-infected African-American men pass through a prison or a jail in a given year, and are released from a prison or a jail. And over 19 percent is very similar to the percentage of people who -- the whole epidemic that went through jails and prisons back in 1997.

These numbers caused a lot of headlines years ago, that close to one out of five people were passing through a prison or a jail. The numbers are unchanged for African-American men.

What about a gender breakdown?

Anne Spaulding: The portion of the epidemic that is passing through jails and prisons; it's a very small portion of the epidemic in women in the United States. It is still a very large portion of the epidemic that is in men, and we have had more people who are infected among women. That's where we're having a lot of the new infections. So, still, a substantial portion of HIV among men, of all races, is still represented in the correctional population.

Are you hoping that policies will change, or things will change, particularly in this administration, regarding this population?

Anne Spaulding: Very much so. I think the opportunity that we have right now is to look at the jails and prisons as an opportunity to have people be offered HIV testing.

I think, especially in jails, where people are all presumed innocent, we don't want to force testing for HIV. But we should at least give people the opportunity to access that as part of routine health care.

The CDC [U.S. Centers for Disease Control and Prevention] has just come out with guidelines for testing within corrections, and this is a wonderful opportunity. Everyone in the United States who goes through a jail or prison has a right to have their health care not be disregarded. If this is part of the health care that people are having, this should be part of the health care in every setting, including the health care in jails and prisons.

I think the opportunity we have that's most important would be routine testing, routine offering, and routine screening for HIV, especially among the persons who go through jails. I think also we have an opportunity for linkage to care.

Right now, there's a study that's been funded by HRSA [Health Resources and Services Administration], looking at opportunities to link people who are going through HIV to care in the community upon release. I think that particular demonstration project will show best practices.

Thank you very much for taking the time to talk with me.

Anne Spaulding: Thank you.


  1. Spaulding A, Seals R, Page M, et al. HIV/AIDS borne by U.S. correctional releasees: share of burden declines, numbers don't. In: Program and abstracts of the 16th Conference on Retroviruses and Opportunistic Infections; February 8-11, 2009; Montréal, Canada. Abstract 1033.
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This article was provided by TheBodyPRO. It is a part of the publication The 16th Conference on Retroviruses and Opportunistic Infections.
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