Patients with HIV disease or AIDS are commonly seen in the prison population. However, there is much variability in prevalence between states, regions of the country, and even countries. In 1993, rates of HIV seropositivity in prisons ranged from 0.6% (Oregon and
Wisconsin) to 17% (New York).¹ In a study of inmates serving a sentence at the Adult Correctional Institution (ACI) in Rhode Island, 4% of men and 12% of women were HIV-seropositive.¹ In fact, in 1990, 40% of all the newly identified cases of HIV infection in the entire state of Rhode Island were diagnosed at the ACI. In the Florida prison system there have been significant problems with HIV infection. From 1987 to 1992, AIDS was the leading cause of death in Florida prisons.⁵ In 1992, of all the inmates in the Florida prison system who died, 52.3% died of conditions secondary to AIDS. This was four times as many as died from either cardiovascular causes or cancer.⁵ At the end of 1994, the rate of confirmed AIDS cases was seven times higher in the state and federal prison systems than in the general population. Up to one quarter of those people with HIV infection in the United States pass through a U.S. correctional facility each year. In a study of female inmates in Quebec, 6.9% of all female inmates were seropositive for the HIV antibody.⁶ Female inmates who were injection drug users (IDUs) (13.0%) or prostitutes (12.9%) had increased rates of HIV seropositivity as well. However, other available information is quite variable, depending on the country and population studied. It is difficult to compare the data that are available secondary to the different methodologies and samples used.

Considering that over 22 million people pass in and out of correctional institutions each year,⁴ public health experts are focusing on the HIV situation in this population. People who are incarcerated form a new community that is ethically entitled to appropriate medical care. The majority of individuals in this population are only temporarily removed from their respective communities.⁷ Thus, improving the HIV health care and educational programs available in prisons is of the utmost importance.¹

As noted previously, for some inmates, incarceration can often be a rare opportunity for those participating in high-risk behaviors to have access to quality health care.² It may also be the only time that they are exposed to specialized HIV medical care along with HIV education and prevention information.¹ Incarceration is also felt to be a time when inmates can come to terms with imprisonment and acknowledge that the behaviors that led to the incarceration may also have placed them at risk for HIV infection.² For many inmates, incarceration is an opportune time for intervention, because they may be most amenable at this point to reception of HIV prevention information and the institution of the HIV treatment.

Although common sense would suggest that the prison system is an ideal venue to diagnose HIV infection, begin treatment, and educate inmates about prevention, there are still many barriers to this course of action. To begin, many prisons are hesitant to embrace the HIV prevention message that they feel directly contradicts prison policies.³ They express the rationale that it is unnecessary to provide clean syringes and condoms when sex between prisoners and drug abuse are prohibited in prison. At this time, only a small number of U.S. prisons have policies allowing prisoners access to HIV risk-reduction tools.⁴

Limited financial resources are problematic to attempts to stem the epidemic of HIV infection in prisons. Many departments of corrections are facing budget cuts, which means that lower priority activities (such as HIV education programs) are often eliminated.³ Also, many prisons have a set pharmaceutical budget to provide medications to all prisoners. With the high cost of retroviral agents, many prisons have begun to administer these agents under direct observation to ensure that the doses are actually taken.² Although this may seem a good way to ensure compliance, it may deter many inmates from taking medications because they fear they will be labeled as HIV-positive because they are waiting in long lines to take medications under direct observation.² Inmates often do not trust correctional facility staff and may refuse to participate in HIV treatments because they feel that their confidentiality may be breeched. The high prevalence of the mental illness in prisons also has been a barrier
in the attempts to control HIV infection in prisons, because these patients may pose challenges regarding compliance with HIV treatments.² Another major barrier to HIV infection education efforts is that there is often a lack of explicit information about specific preventive behaviors.⁷

The educational materials and activities used to target those at risk cannot be “one size fits all.” No standardized format of AIDS education is likely to meet the needs of all high-risk groups.⁷ There needs to be an understanding of the diverse beliefs and backgrounds of the inmates, along with their appreciation and perceptions about HIV disease. It has been noted that the behavioral interventions should be “gender specific, developmentally appropriate, and culturally competent.”⁷ Prevention education requires that the educators have an understanding of the specific risk behaviors in their treatment population and the “contexts and conditions that sustain them.”⁷ For example, for many African-American inmates, same-sex sexual encounters are felt to be situational in nature and do not mean that they are gay or bisexual. Therefore these inmates may not respond to HIV educational programming that targets bisexual or gay men.³ Therefore different educational programming may be necessary in this and other populations.

Finally, another barrier to controlling the HIV epidemic in prisons is the different mission of each of the parties involved. The department of corrections is dedicated to the security and custody of the inmates, whereas the public health system is most interested in disease prevention.³ For the prison system, above all else, maintaining a secure environment is the most important job, even if this means having some apathy toward inmate health and well-being.³ Although this attitude may be more cost effective for the prison system, it is very likely that there will be higher public health expenditures in the long term, after inmates are released back into their community if their care has been less than optimal.⁷

There are many different ideas regarding the control of HIV infection in the prison population. Some infectious disease specialists recommend that inmates with HIV disease be clustered together to allow for the coordination of educational efforts and to concentrate the provision of expert HIV medical care.² From a logistical standpoint, inmates should be easier to reach with education and prevention information because they have fewer demands on their time than when they were in the community.³ When incarcerated they also may be evaluating their life choices and therefore be more amenable to listening to the HIV educational message. HIV educational activities should address inmate concerns by increasing their awareness of the illness, especially in the context of avoiding postrelease high-risk behaviors.³ These educational activities should include a general AIDS education program for both the inmates and the correctional officers.¹ This education should also stress the importance of disease prevention and risk avoidance. Incarceration is also a time when the inmate is supposedly encountering fewer situations of risk, so there is the opportunity to stop further spread of the virus.³ It is also helpful that the inmate has access to comprehensive medical care.³ Inmates thus have an opportunity to have medical problems addressed and treated so that their HIV status can be managed in the best manner possible. For example, in a patient with viral hepatitis and HIV, the hepatitis may need to be treated with antivirals before the patient may begin highly active antiretroviral therapy (HAART).² In female patients with HIV, it is imperative that pregnancy be detected promptly so antiretroviral therapy can be initiated to avoid vertical transmission of the virus.²

In the past, the concern had been that the prison system is a reservoir of HIV infection, and that once released the inmates would spread the infection into the general population. This view is felt to be unsupported based on the evidence currently available. Although intra-prison spread is a concern, extra-prison spread is more of a concern because high-risk behaviors are
more common in the community than in prison.² Therefore the risk for HIV transmission increases rather than decreases when an inmate is released from prison. HIV risk-reduction programs are important because they teach inmates how to maintain safe behaviors so they can avoid acquiring HIV infection upon release from prison.² Prevention work with inmates gives public health workers the chance to address prevention in the larger community outside of prisons. This can be done through the education of family members, friends, and contacts.⁷ Careful discharge planning is of the utmost importance if the inmate is going to maintain the health care gains made while incarcerated. In fact, a face-to-face meeting between the inmate and the community health care provider while the inmate is still incarcerated improves follow-up rates.² Prerelease counseling is a final important opportunity to reinforce in those inmates about to be released ways to reduce the risk of acquiring HIV upon returning home to high- risk environments.⁷ The most effective HIV infection and AIDS prevention program is one that links correctional facilities, public health agencies, and community organizations in an attempt to design a network of support and prevention services.⁷