"The prison, above all others, should be the most human of institutions."

-- Eugene V. Debs, Walls and Bars, 1927

Prisons and jails contain perhaps the highest concentrations of persons infected with HIV and those at greatest risk of acquiring HIV by injection drug use and sexual contact. According to a report by the US Bureau of Justice Statistics, the rate of confirmed AIDS cases is more than six times higher in state and federal prisons than in the general population. About 2.3 percent of all persons incarcerated in the US in 1995 were HIV-seropositive, and about 0.51 percent had confirmed AIDS.

It is not difficult to recognize that HIV interventions implemented in correctional settings are among those with the greatest potential to have a substantial impact on the epidemic. The incarcerated population, like the HIV-infected population, is overrepresented by minority groups and characterized by high rates of poverty, overcrowding, injection drug use, high risk sexual activity, and poor access to preventive and primary healthcare. Incarceration provides a remarkable public health opportunity for screening, counseling, and treating a "captive" audience at high risk of HIV infection and transmission, most of whom will eventually be released and return to their communities.

The diagnosis, management, and prevention of HIV infection in jail and prison settings were among the topics discussed at the 21st National Conference on Correctional Health Care, held November 10-12, 1997, in San Antonio, Texas. The conference was sponsored by the National Commission on Correctional Health Care, a non-profit organization that provides a broad range of educational, certification, and accreditation programs and establishes standards for health services in jails, prisons, and juvenile detention and confinement facilities.

Barriers within walls

Many strategies have been employed in correctional settings in response to the growing problem of HIV infection among prison inmates.^(1,2) Some of these strategies have been implemented for the purpose of lowering the risk of HIV transmission among inmates, while others have been structured to provide HIV education, prevention, and treatment services to inmates prior to and following release. The most common HIV intervention strategies employed in correctional settings include HIV serologic testing, segregating of HIV-infected inmates from the general prison population, establishing special healthcare units for HIV-positive inmates, and providing HIV counseling and risk reduction services. Other more controversial measures include the provision of condoms, bleach, and sterile injection equipment to inmates, and compassionate release for the terminally ill.

Barriers to the provision of HIV treatments and services to incarcerated persons were reviewed by Frederick Altice, MD, Yale University HIV in Prisons Program. According to Altice, HIV-positive persons in correctional facilities are subject to the multiple obstacles of stigmatization, segregation, restricted formularies, and reliance on "sick call" systems that typically fail to recognize HIV-related complications or provide adequate diagnosis, referral, and follow-up services.

Low rates of treatment acceptance and compliance among HIV-infected prison inmates are common myths, Altice said. "Over 80 percent of prisoners with HIV disease will accept therapy offered in an appropriate setting, and 85 percent of those will adhere to therapy," he stated. This rate of compliance, he noted, is higher than that typically seen in controlled clinical trials. Factors associated with medication adherence in correctional facilities include the health status and beliefs of the prisoner, medication dosing and side effects, and the availability and stability of healthcare services, Altice said. Trust in the healthcare provider outweighs trust in the medication as a determinant of treatment acceptance and adherence, he noted, and those who begin antiretroviral therapy while incarcerated are likely to continue such treatment following release.

Maintaining confidentiality is one of the best ways to maximize acceptance of HIV testing and treatment by jail and prison inmates, Altice said. Official breach of confidentiality is uncommon in the correctional setting, Altice said, but information "leaks" are common and prisoners are quick to develop mistrust of health services and correctional staff as well as fellow inmates. The majority of prison and jail systems have policies against notifying correctional staff, other than medical staff, of inmates' HIV status, and policies permitting disclosure to nonmedical personnel usually limit this practice to institutional management staff. Despite official policies, confidentiality of HIV-related information is difficult to maintain in the correctional setting, and many correctional officers and inmates gain access to medical records and contend they are entitled to know who is HIV-seropositive.

Many HIV-infected persons receive their first introduction to antiretroviral therapy while incarcerated, Altice said, and the correctional setting provides a unique opportunity to initiate effective antiretroviral therapy and provide interventions designed to maximize treatment adherence. Targets for interventions designed to improve the efficacy of antiretroviral therapy in jails and prisons include education of inmates, formulary committees, and administrative and correctional staff; and the development of treatment strategies specifically adapted to the unique aspects and limitations of life in the correctional setting. Common reasons for nonadherence in the correctional setting include complex medication schedules, inadequate patient education, and fear of stigmatization, Altice said.

HIV-infected persons released from correctional institutions typically encounter difficulties obtaining medical care and social services upon release into the community, Altice said. In a study by Warren et al, 40 HIV-infected inmates were interviewed following their release from a New York City jail.⁽³⁾ Of the 40 former inmates, 25 (62 percent) had not received a medical appointment for follow-up care at the time of their release. Only eight (27 percent) of the 32 individuals who received zidovudine (ZDV) while incarcerated obtained ZDV following release, and only one (8 percent) of those who received isoniazid prophylaxis in jail received isoniazid prophylaxis upon release.

Corrections in Canada

Perhaps the most comprehensive analysis of the issues raised by HIV/AIDS in prisons has been undertaken by the Canadian Expert Committee on AIDS in Prisons (CECAP). CECAP was a multidisciplinary task force established in June 1992 to assist the Canadian government in promoting and protecting the health of inmates and staff and preventing the transmission of HIV and other infectious agents in federal correctional facilities.

During its 18 months of existence, CECAP visited federal correctional institutions throughout Canada, interviewed prison authorities, staff, and inmates about issues raised by HIV/AIDS and drug use in the prison environment, and reviewed Canadian and international policies regarding HIV/AIDS and drug use in prison. Preliminary conclusions of the CECAP were released in June 1993 to stimulate discussion and give those interested in the issues raised by HIV/AIDS and drug use in prison an opportunity to comment on the CECAP's findings and proposals.

According to Ralf Jurgens of the Canadian HIV/AIDS Legal Network, the 16-month period following the release of CECAP's preliminary report was marked by a 40 percent increase in the number of known cases of HIV/AIDS in Canadian federal prisons, an increase in the number of prisoners living with symptomatic HIV infection, increased evidence of high-risk behaviors and HIV transmission in prisons, and reports of hepatitis C seroprevalence rates of 28 percent to 40 percent in Canadian prisons.

The prevalence of and risk factors for HIV infection among inmates of a provincial prison in Canada were documented by Dufour et al.⁽⁴⁾ Inmates incarcerated at the Quebec Detention Centre were asked to provide saliva samples and participate in an anonymous survey regarding HIV infection. The participation rate was 95 percent. The prevalence of HIV infection was 2 percent in the overall population, 9 percent among inmates who were injection drug users (IDUs), and 14 percent among IDUs who admitted previous needle-sharing. All of the HIV-positive inmates were IDUs.

The final report issued by CECAP examines the full range of medical, educational, institutional, legal, and social concerns raised by HIV/AIDS and drug use in Canadian prisons. The report takes a strong public health approach to the problem of HIV/AIDS in prisons and contains 88 recommendations designed to protect the health of prison inmates and staff. The CECAP's recommendations are summarized in Table 1 and are consistent with those issued in 1993 by the World Health Organization for the treatment and prevention of HIV infection in prisons.

The CECAP concluded that making sterile injection equipment available in prisons "will be inevitable," particularly because of doubts that have arisen in regard to the efficacy of bleach in destroying HIV. The CECAP expressed concern that, in prisons, the scarcity of drug-injection equipment almost guarantees that inmates who persist in drug-taking behavior will share their equipment. The CECAP acknowledged that sterile injection equipment should not be made available immediately but recommended that research be undertaken to identify ways to reduce the risk of HIV transmission in prison and that the research include one or more projects that would expedite making sterile injection equipment available in federal correctional institutions.

The CECAP also recommended that full-strength household bleach be made available to inmates in federal correctional institutions as a disinfectant. The CECAP suggested that small quantities of bleach and instructions on how to clean needles most effectively be included in a "health kit" given to every inmate on entry into the institution and offered to every inmate on exit from the institution, and that the bleach be made available to the inmates in a manner similar to that for condoms, dental dams, and lubricant. The CECAP reported that bleach is made available to inmates in many prison systems throughout the world, and that there are no reported incidences of negative consequences of making bleach available.

The Correctional Service of Canada (CSC) has accepted many of the recommendations of the CECAP, Jurgens said, including those to strengthen its policy of maintaining the confidentiality of inmates with HIV/AIDS, improve educational programs on HIV/AIDS and drug use for staff and inmates, permit inmates to engage professional tattooing services at their own expense, provide condoms, dental dams, and water-based lubricant through a variety of distribution channels, recommend the release of inmates with life-threatening illnesses including AIDS earlier in the course of their disease, and provide inmates with healthcare comparable to that available in the community. However, the CSC has been criticized for rejecting other critical CECAP recommendations including those to remove prohibitions against consensual sexual activity between inmates, provide methadone maintenance programs, and pilot-test needle exchange programs in prisons. Since more prisoners may be at risk of HIV infection by needle-sharing than by tattooing or sexual activity, the response of CSC to CECAP's recommendations may be more politically correct than practical.

National survey

Findings from the 9th National Survey of HIV/AIDS, STDs, and TB in Correctional Facilities were presented by Theodore Hammett, PhD, Abt Associates, Cambridge, Massachusetts. According to Hammett, the American Correctional Association (ACA) and the National Institute of Justice (NIJ) began a series of surveys in 1985 in response to inquiries from regional correctional agencies regarding the scope of the problem of HIV/AIDS in prison inmates and the need for HIV treatment and prevention policies. The current report is based on surveys sponsored by the NIJ and Centers for Disease Control and Prevention and supplemented by Bureau of Justice statistics on HIV in prisons and jails. The survey provides an overview of national patterns of policy and practice and includes documentation of HIV/AIDS education and behavioral interventions, antibody testing, confidentiality and disclosure, housing practices, compassionate release, medical services, and psychosocial and supportive services. Data on the current prevalence of HIV/AIDS among state and federal prison inmates are summarized in Table 2. "These figures are probably underestimates because they are based on information from systems with different testing policies," Hammett said. "Larger correctional systems typically do not have mandatory testing policies and probably fail to identify a large number of HIV-positive inmates."

Only about 10 percent of state and federal prison systems and 5 percent of city and county jail systems surveyed in 1996 provided comprehensive HIV/AIDS education and prevention programs, Hammett said. Comprehensive programs were defined as those providing instructor-led counseling, peer-led programs, pre- and post-test counseling, and multi-session prevention counseling. Topics covered in HIV/AIDS education programs for inmates include basic HIV and STD information, meaning of HIV and STD assay results, safe sex and injection practices, behavioral change and relapse triggers, and referral to psychosocial and other services.

The proportion of state and federal prison systems providing instructor-led education increased from 48 percent to 61 percent between 1994 and 1996, Hammett said, and 66 percent of city and county jail systems provided these services in 1996. Despite the improvement, coverage among individual facilities remains weak. Few prison systems offer comprehensive HIV/AIDS prevention programs in all of their facilities, Hammett said, and very few of these programs have been rigorously evaluated.

Rates of bleach and condom availability in US prisons remain discouragingly low. Only 4 percent of state/federal prison systems and 10 percent of city/county jail systems make condoms available for use within the facility, Hammett said, and 20 percent of prison systems in both categories make bleach available for any purpose. Bleach is available for general cleaning purposes in many correctional systems, Hammett noted, and some inmates may have de facto access to bleach for needle cleaning even in the absence of policies explicitly permitting this practice.

The survey found that current HIV antibody testing policies for incoming inmates vary widely among correctional systems. HIV antibody testing is mandatory in 31 percent and offered in 35 percent of state/federal prison systems upon incarceration, Hammett said. Among city/ county jails, 34 percent offer HIV antibody testing upon incarceration and 46 percent provide such testing upon request. Inmates and attending healthcare providers are notified of HIV antibody test results in 100 percent of the state/federal prison systems surveyed, whereas 88 percent and 83 percent of inmates and healthcare providers in city/county jail systems, respectively, are notified of HIV antibody test results. Correctional management personnel are notified of inmate HIV antibody test results in 37 percent and 15 percent of state/federal and city/county prison systems, respectively, and correctional officers are notified in 12 percent and 7 percent, respectively.

The availability of peer support groups is 33 percent in state/federal prison systems and 5 percent in city/county jail systems, Hammett said. Support groups led by correctional staff are available in 63 percent of state/federal prison systems and 32 percent of city/county jail systems, and support groups led by outside HIV/AIDS organizations are available in 67 percent and 61 percent of these institutions, respectively.

Housing and segregation policies for inmates with HIV/AIDS in state and federal prison systems have changed dramatically over the past 10 years, Hammett said. The proportion of state/federal prison systems with segregation policies for HIV-positive inmates decreased from 16 percent in 1985 to 4 percent in 1996, and the proportion with segregation policies for inmates with symptomatic AIDS decreased from 75 percent to 6 percent during this same period. Currently, Hammett said, 33 percent of state/federal prison systems have policies of no segregation or housing restrictions for inmates with symptomatic AIDS, and 61 percent have similar policies for inmates with asymptomatic HIV infection.

Most correctional systems offer some discharge planning services, Hammett said, but most do not make appointments for released inmates to obtain services in the community. Overall, 78 percent of state/federal prison systems provide referrals for Medicaid and related benefits, 71 percent for CD4+ cell monitoring, 61 percent for viral load monitoring, and 73 percent for HIV counseling; the proportions of city/county jail systems providing these services are consistently lower in each service category.

Compassionate release

Compassionate release, also known as medical parole, provides a means for early release of inmates with terminal illnesses. Policies regarding compassionate release have been established in 59 percent of state/federal prison systems and 32 percent of city/county jail systems, Hammett said, and medical furlough programs were available in 37 percent and 10 percent of state/federal and city/county jail systems, respectively.

Compassionate release of terminally ill inmates is more a political than medical issue, said Judy Greenspan, director of Catholic Charities' HIV/AIDS in Prison Project, a statewide advocacy project for prisoners with HIV/AIDS based in San Francisco, California. According to Greenspan, the policy of early release of inmates who are terminally ill is appropriate from both fiscal and humane standpoints. "Unless we develop effective systems for releasing these prisoners back into the community, correctional systems will be faced with healthcare costs spiraling out of control," she said.

Despite legislative setbacks, the issue of compassionate release for prisoners with AIDS and other terminal illnesses is on the agenda of many individuals, organizations, and advocacy groups, Greenspan said. A compassionate release bill signed into law by California Governor Pete Wilson in October 1997 streamlines procedures for releasing terminally ill inmates, sets strict time limits for the California Department of Corrections to process requests, and establishes procedures by which the families of terminally ill inmates can help initiate the compassionate release process. Similar bills are under consideration by other state legislatures, Greenspan said.

One of the major obstacles to an effective compassionate release program is the identification of hospices, skilled nursing facilities, and other institutions willing to accept inmates who are terminally ill, Greenspan said. "Hopefully we are approaching a time in which terminally ill prisoners are not vilified and we can begin to move away from punishment and address the societal problems that put people in prison in the first place," Greenspan said.

Model program

A period of incarceration may be the only time that many IDUs have the opportunity to participate in HIV education and healthcare programs, said Timothy Flanigan, MD, Brown University, Rhode Island. More IDUs are currently in correctional facilities than in drug treatment programs, Flanigan said, and a high proportion of inmate IDUs do not receive appropriate health or HIV-related services prior to incarceration.

"The role of corrections in the HIV epidemic is only beginning to be realized," Flanigan said. "What puts people at risk for incarceration and what puts people at risk for HIV are by and large the same."

Flanigan described a comprehensive program initiated by the Rhode Island Department of Health in cooperation with the Brown University AIDS Program designed to provide multifactorial healthcare for HIV-infected inmates. The activities of the program include HIV education, testing, and pre- and post-test counseling, medical management of HIV-infected inmates, along with pre-release counseling and post-release healthcare follow-up of HIV-positive inmates.

The roots of the program extend to 1988, Flanigan said, when the state of Rhode Island passed a comprehensive HIV/AIDS law mandating that all prison inmates be tested for HIV infection on admission, during incarceration, and prior to release, that all prison inmates must be provided with HIV/AIDS education and pre- and post-test counseling, and that inmates with HIV infection be provided reasonable medical treatment. The Rhode Island Department of Health soon thereafter established a comprehensive program for the education, counseling, and medical management of HIV-infected inmates at the Adult Correctional Institute (ACI), the only prison facility in Rhode Island, and the program included the establishment of the multidisciplinary AIDS Education and Management Program.

The Rhode Island Department of Corrections began routine HIV testing of inmates in 1989, Flanigan said, and HIV testing is voluntary for persons awaiting trial and mandatory for those convicted. The issue of voluntary vs. mandatory HIV testing of prison inmates is controversial. In a study of Maryland prison inmates, voluntary testing was accepted by only 47 percent of newly incarcerated persons, and refusers of voluntary testing were almost twice as likely to test HIV-seropositive as were accepters.⁽⁵⁾ Voluntary HIV testing may be less successful than mandatory testing in identifying HIV-seropositive inmates, but mandatory testing can be construed as unethical and discriminatory if such testing is not imposed on the general population.

In the year following the implementation of the HIV testing policy, 3.0 percent of the inmates tested at ACI were HIV-seropositive, including 2.5 percent of the men and 7.6 percent of the women tested. About 35 percent of men and 29 percent of women currently diagnosed with HIV in Rhode Island are diagnosed at the ACI, Flanigan said. The higher HIV seroprevalence among female inmates at ACI is consistent with other reports that HIV seroprevalence is greater among incarcerated women than incarcerated men, Flanigan noted, and the trend probably reflects the fact that a greater proportion of women than men are incarcerated for drug-related offenses.

All inmates at ACI who are found to be HIV-positive are referred to the HIV Management Team for evaluation and counseling, Flanigan said, and any seropositive inmate may request evaluation by the team at any time. Asymptomatic HIV-seropositive inmates are scheduled for periodic medical evaluations at intervals no greater than every six months, and those with advanced HIV disease are evaluated more frequently.

The HIV Management Team includes an attending physician, an infectious disease fellow, and a registered nurse who serves as the on-site coordinator, Flanigan said. The team uses the same medical facilities as the ACI prison staff but operates as a special consultative service. During its first 24 months of operation, the HIV Management Team provided health services to 24 percent of known persons with HIV/AIDS in the state of Rhode Island, Flanigan said. Upon release, HIV-positive inmates are referred to community-based sources of medical and support services. Most released inmates with HIV infection are subsequently followed by physicians affiliated with Brown University, Flanigan said, and compliance with follow-up is generally high.

The need for follow-up of HIV-seropositive women on release from prison is particularly high, Flanigan said. Incarcerated HIV-positive women frequently lack medical and gynecological care, substance abuse treatment, and psychosocial support upon release, Flanigan said, and women who fail to receive these services may be at higher risk of recidivism.

The Rhode Island DOC and Brown University have developed a cooperative program designed to provide linkage to community-based follow-up services for HIV-seropositive women upon release from prison, Flanigan said. Every HIV-positive woman receives individual counseling on medical care, substance abuse treatment, and family support at three to six months prior to release, and participants are followed up three to six months after release.

The program has had a significant effect on recidivism among HIV-positive women who are released from prison, Flanigan said. HIV-seropositive women who participated in the prison release program during the first year had recidivism rates of 12 percent and 17 percent at six and 12 months, respectively, whereas HIV-seropositive women released during the year prior to the availability of the program had recidivism rates of 27 percent and 39 percent at six and 12 months, respectively.

Costs of treatment

The availability of combination antiretroviral therapy, viral load monitoring, and other standard elements of HIV/AIDS treatment in correctional institutions is generally high, but access of inmates to experimental therapies and clinical trials is largely limited (Table 3). The participation of inmates in clinical studies raises a host of legal, ethical, and practical issues, not the least of which is the potential for coercion among those who are socially, economically, and otherwise disadvantaged.

The development and implementation of policies regarding the participation of inmates in clinical research is a combined effort of the US Department of Health and Human Services and the Department of Corrections (DOC). To assess the variables associated with policies regarding access by inmates to HIV-related clinical studies and experimental therapies, Collins et al conducted a telephone survey of DOC medical directors from 32 states.⁽⁷⁾ States with high HIV/AIDS incidence rates, large numbers of HIV-related deaths in prisons, and high concentrations of minorities in the correctional system were more likely to allow prisoners to enroll in clinical studies and receive experimental medications. Participation of a prison representative on the board reviewing a clinical trial was identified as an important factor in allowing inmate participation. The constant evolution of newer anti-HIV therapies poses a formidable problem to correctional healthcare systems charged with the responsibility of maintaining high standards of care for inmates while operating within fiscal budgets, said Joseph Paris, MD, PhD, Medical Director, Georgia Department of Corrections. The costs of treating and monitoring HIV-infected inmates have soared during the past few years, Paris said, and variability in inmate acceptance of newer therapies further compounds the difficulty of developing accurate healthcare budget projections.

Psychotropic medications and HIV medications including protease inhibitors account for 28 percent and 30 percent, respectively, of Georgia DOC's drug expenditures, Paris said. HIV-infected inmates comprise about 2.4 percent of the Georgia correctional population, he said, and these inmates consume about 10 percent of DOC's correctional healthcare resources. The annual medication costs of an inmate on triple combination therapy including a protease inhibitor in Georgia is about $10,620, Paris noted, whereas mean annual inmate healthcare costs are about $2570. Healthcare costs currently account for about 17 percent of Georgia DOC's total operating budget. Paris said that the Georgia DOC currently bases inmate eligibility for HIV treatments on a combination of CD4+ cell counts, viral load, and clinical status. In contrast, Medicaid definitions of eligibility for certain HIV drugs are based on CD4+ cell counts alone. This discrepancy makes comparisons between correctional and noncorrectional healthcare systems difficult to make, Paris said, because the same patient may be eligible for anti-HIV therapy under one system but not the other.

A useful mechanism developed to control increasing HIV drug expenditures by the Georgia DOC is the pretherapy checklist, Paris said. The pretherapy checklist is similar to preapproval mechanisms employed in managed care settings and consists of a series of data fields that must be completed to ensure procurement of the medication. The data fields include details of indications for prescribing protease inhibitors based on CD4+ cell counts and viral load, contraindications and medication interactions, and a listing of the primary objectives of patient counseling and education. The checklist is forwarded to the institution's pharmacy for approval and medication dispensing, and borderline or doubtful cases are reviewed by the state medical director.

The Georgia DOC also instituted a statewide policy mandating an education session for HIV-positive inmates prior to initiating protease inhibitor therapy and daily trips to the health unit with partially used medication blister packs for more education and compliance checking, Paris said. Inmates felt to be compliant have their education and compliance sessions reduced to weekly visits, and inmates refusing education are assigned to directly-observed single-dose therapy or assumed noncompliant and withdrawn from medication until additional education has taken place.

Paris said that rapid advances in anti-HIV treatment will mean longer survival for HIV-infected inmates, and that society will continue to bear the ever-increasing costs of providing healthcare for inmates with HIV infection. "Correctional physicians and administrator will have to plead their cases, hat in hands, as the relentless pace of medical progress continues to improve, but not cure, the correctional HIV patient," Paris said.

Clearly, prisons and jails have a moral and legal responsibility to prevent the spread of HIV and other infectious diseases among inmates and to staff and to the public, and to provide a level of care for inmates living with HIV comparable to that available in the community. Whether HIV testing should be mandatory or voluntary, whether housing should be integrated or segregated by HIV serostatus, and whether condoms, bleach, and clean needles should be made available to inmates are questions hotly debated by administrative and scientific groups. Clean needles usable to prevent the spread of HIV infection in correctional settings may be viewed as simple and effective interventions by some and as contraband by others. Much can be done to address the issues raised by HIV/AIDS in correctional institutions, but the implementation of effective HIV/AIDS treatment and prevention strategies in these settings stands threatened by the often competing ideologies of public health and correctional officials. The inmate population and the public at large are best served by a system in which the coordinated efforts of public health and correctional systems are directed toward the development of policies and programs with the greatest likelihood of preventing the spread of HIV among inmates while providing the highest levels of care to those already infected. In a society in which incarceration is characterized by increased risk of HIV transmission and increased rates of disease progression in those already infected, who are the true criminals?

David S. MacDougall is a medical writer in New Jersey. E-mail: dsmac@earthlink.net

References

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3. Warren N, Bellin E, Zoloth S, Safyer S. Human immunodeficiency virus infection care is unavailable to inmates on release from jail. Arch Fam Med 1994;3:894-898.

4. Dufour A, Alary M, Poulin C, et al. Prevalence and risk behaviors for HIV infection among inmates of a provincial prison in Quebec City. AIDS 1996;10:1009-1015.

5. Behrendt C, Kendig N, Dambita C, et al. Voluntary testing for human immunodeficiency virus in a prison population with a high prevalence of HIV. Am J Epidem 1994;139:918-926.

6. Potler C, Sharp VL, Remick S. Prisoners' access to HIV experimental trials: legal, ethical, and practical considerations. JAIDS 1994;7:1086-1094.

7. Collins A, Baumgartner D, Henry K. US prisoners' access to experimental HIV therapies. Minn Med 1995;78:45-48.

©1998, Medical Publications Corporation