As of mid-2004 there were 2.1 million people incarcerated in jails and prisons in the United States.¹ At the end of 2002, the latest year for available data, 3.0% of all female inmates and 1.9% of all male inmates were infected with human immunodeficiency virus (HIV).² The number of known HIV-positive inmates totaled just below 24,000 nationally. The national HIV infection rate in jails and prisons is six times higher than that among the general population.³ About a quarter of all people living with HIV disease or acquired immunodeficiency syndrome (AIDS) in the United States have been incarcerated at one time.⁴ The incidence of HIV infection in jails and prisons closely follows the pattern of injection drug use by region. A study of prison AIDS cases compared to total U.S. AIDS cases found that 61% of prison cases had injection drug use histories compared to only 27% of national cases.⁵ As a result, New York State accounted for more than a fifth of all inmates (5,000) known to be HIV-positive. The most common HIV risk behaviors reported before incarceration for female inmates were crack cocaine use and the resulting sex exchange for drugs, intravenous drug use, and sex with intravenous drug users.⁶ For male inmates, HIV risk behaviors before incarceration included intravenous drug use, high-risk sex associated with the use of alcohol and other noninjection drugs, and homosexual behavior.⁷ Drug use and sexual activity continue following incarceration, but inmates have less chance to procure clean needles or barrier protective methods to prevent HIV transmission. Inmates reported using improvised devices, such as stolen surgical gloves to serve as condoms or purloined plastic wrap in place of dental dams.⁸ Nonconsensual sex with inmates and coerced sex with corrections officers further contribute to the problem.

The prevalence of psychiatric disorders among incarcerated persons is also greatly elevated. The most common psychiatric disorder among inmates is personality disorder, with the antisocial type being by far the most common. This is of little surprise, because criminal behavior is one of the diagnostic criteria of this disorder. However, highly elevated rates of serious mental illness have also been reported.⁹ Serious mental illness is a term used to describe
people with diagnoses of schizophrenia and other psychotic disorders, as well as bipolar disorder and major depression. Published reports put the rate of serious mental illness in city and county jails at between 6% and 15% and in state prisons at between 10% and 15%.¹⁰

It is not news that prisons have replaced mental hospitals as the repository of people with severe mental illness. A report on the National Institute of Corrections’website cites estimates that over 250,000 people with mental illness are currently incarcerated in the nation’s jails and prisons and that an additional 500,000 are being supervised on probation. Contrast those statistics with the fact that in 1959 over 550,000 persons with mental illness resided in state mental hospitals, whereas today that number is less than 60,000. The situation has commanded so much attention that Human Rights Watch, an independent, nongovernmental not-for-profit agency, issued a 215-page report on the problem, and the New York Times has run front page stories on the issue.

Also well established are the elevated rates of HIV infection among people with mental illness. Rates of HIV infection among the mentally ill have been reported to range from 4% to almost 23%, depending on the subgroup of the population studied.¹¹ Little is known about the number of HIV-positive mentally ill individuals in correctional facilities in this country and the treatment that they receive. This chapter examines the reasons that so many people with mental illness are in jails and prisons, looks at the implications of having so many mentally ill persons incarcerated, considers the impact of HIV-positive mentally ill detainees, and discusses the integration of mental health and medical treatment within the prison system for the HIV-infected mentally ill.

How did so many people with serious mental illness end up in correctional institutions? First and foremost, it began with the widespread deinstitutionalization of the mentally ill. The deinstitutionalization of people in state psychiatric facilities that began in the 1950s was a result of many converging factors.

Drastic change in psychiatric treatment occurred with the introduction of psychotropic medications in the mid-1950s. Before the introduction of these medicines, treatment consisted of talk therapy, various forms of “cures” and “shock” treatments and psychosurgery, mostly to little effect. The administration of these medications allowed many institutionalized mentally ill people to be discharged from state hospitals. The first of these drugs introduced to the market was chlorpromazine. Within the first year after its introduction in 1954, the drug was being administered to more than 2 million patients in the United States.¹² During the following decade, so many patients were administered chlorpromazine that it became known as the “drug that emptied the state metal hospitals.”¹³ The problem with discharging mentally ill patients on antipsychotic medication is that many are frequently discharged into unstable environments, are unlikely to continue treatment without support, and may discontinue treatment because the drugs have negative side effects.¹⁴

This period also saw tremendous changes in civil commitment law. Riding the wave of change that had begun in the civil rights movement in the 1960s, the first major change in civil commitment procedures established the criteria of dangerousness as necessary to involuntary confine an individual.¹⁵ Thus, although based on a civil libertarian idea of preventing unnecessary detention, the ruling took the idea of commitment from a therapeutic concept to one that is protective of society. Those found to represent less than an imminent threat were to be treated in the least restrictive environment.

Also at this time, conditions for institutionalized individuals at their most abhorrent condition began to receive media attention. Perhaps the greatest example of the mistreatment of
the mentally ill was the 1967 film Titicut Follies by Frederick Wiseman. This documentary exposed abject neglect and outright abuse by staff of the inmates at the Massachusetts Correctional Institution for the Criminally Insane at Bridgewater. What is so glaring about the film is the utter lack of concern by the staff for having their actions filmed. In a review of the film in the New Republic, the psychiatrist Robert Coles¹⁶ stated “After a showing of Titicut Follies the mind does not dwell on the hospital’s ancient and even laughable physical plant, or its pitiable social atmosphere. What sticks, what really hurts is the sight of human life made cheap and betrayed.” The uproar following such exposés further fueled support for the deinstitutionalization of the mentally ill. Also occurring at this time was the antipsychiatry movement, most closely associated with Thomas Szasz and R. D. Laing. These psychiatrists believed mental illness to be a myth and viewed psychosis to be a reactive response to a bad situation. Many of their criticisms sprang from inhumane treatment of the mentally ill and damaging effects of long-term institutionalization, which lent more fuel to the fire to begin to empty the asylums. Also, reported abuses of psychiatry in the Soviet Union and the misuse of psychotropic drugs by the U.S. Central Intelligence Agency helped to bolster this movement.