Thursday, September 11, 2008

The Presence of HIV/AIDS in Prison Populations

Welcome to The AIDS Pandemic, a podcast hosted by Dr. David Wessner from the Department of Biology at Davidson College. I'm Ali Cundari.

U.S. prison populations are at a record high today, with barely enough room to house incarcerated individuals. Due to the close proximity and high-risk behaviors of inmates, as well as a lack of intervention from authorities, the transmission of HIV in prisons is a major problem today. A combination of both pre-existing and new infections plague prison populations, making them one of UNAIDS’ four major at-risk groups for HIV/AIDS.

In 2005, 1.8% of all state inmates and 1.0% of all federal prison inmates in the U.S. were believed to be HIV positive, leading to a total of 22,480 infected individuals behind bars. These percentages are disproportionate to the rest of the general population, making HIV/AIDS about four times as common among inmates than the population at large. Around 25% of all HIV infected people have spent time in a correctional facility, and these HIV infections are often accompanied and exacerbated by high rates of hepatitis and tuberculosis.

There are several means of transmission regarding the spread of HIV/AIDS in prisons, both primary and secondary. Injection drug use is one major cause of transmission, as sharing of dirty needles and syringes (estimated to be greater than 70%) is a common practice. Sharing items such as razors and toothbrushes contributes to the spread of other germs. Along with injection drug use there is tattooing and body piercing, a widespread activity among many inmates. Typically, it is performed through multiple skin-punctures and without sterile instruments, causing the inmates to resort to recycled, make-shift tools such as staples, paper clips, and plastic ink tubes from ballpoint pens. Finally, various sexual activities and rape directly contribute towards the problem. It is difficult to obtain accurate statistics regarding this area, due to fear and embarrassment, but consensual and non-consensual sex are both quite prevalent among prisoners. Boredom, identity issues, and the desire to assert dominance all contribute towards sexual activity. Types of sexual activities include consensual same-sex activity, sex between prisoners and staff, conjugal visits, and rape or other forms of sexual violence. Rape is a particularly complex problem, often brutal and gang related, and the violent nature of it makes recipients more prone to vaginal or anal tears, and thus increases the chances of HIV transmission.

Also contributing to the spread of HIV/AIDS, and co-infection with other STI’s, is the absence of condoms or clean needles. Additionally, a lack of information is a major problem, with many inmates being forced to live in a state of silence and fear, and a third major confounding factor is the lack of people getting tested. Currently, very few inmates get tested due to the large stigma surrounding it and fear of ridicule or violence if their test results confidentiality were to be violated. Additionally, the prison lifestyle and rapid turnover of inmates makes consistently adhering to ARV therapy difficult. Thus, the major hesitations to reform in U.S. prisons come from a lack of political will, security concerns, and false assumptions that such programs will encourage injection drug use and sexually risky behavior. Also, many opponents believe there is a lack of resources and technology to meet the overwhelming need in prisons.

In recognizing these problems, many ideas have been proposed for prevention and change. The main goal would be to develop a multi-pronged approach to enhance detection, prevention, and the reduction of sexual violence. Next, condoms, clean needles and syringes, and bleach kits must be distributed. Many advocates of reform also believe post-exposure prophylaxis (PEP) should be made available to victims of sexual encounters. Additionally, health education and support programs, and the strong encouragement to get tested would both serve to be useful. Finally, once diagnosed, HIV positive individuals must be able to receive consistent drug treatment.

Many model prisons show promising results in their quest to enact some of these changes, including the Hampden Country, MA, Correctional Center and Brown University’s Rhode Island Prison. Further lessons can be learned from countries like England who successfully prevented problems by targeting injection drug users early on in the epidemic, and Cuba, who was able to keep HIV under control through superb penitentiary health and clean conditions.

Overall, change is a daunting challenge due to the rapid turnover of inmates and the large sense of stigma and secrecy within prison walls. In order for change to be effective, it must occur on multiple levels. Officials can no longer turn a blind eye to this problem. Prisoners are ethically entitled to the same safety, health care, treatment, and support as the rest of society. Reforming the current state of correctional facilities would not only help these facilities run smoother, but according to the UNAIDS and WHO Framework, good prison health would equate to good public health. The vast majority of all incarcerated individuals will eventually return to society, bringing with them any known and unknown diseases they may have acquired in prison. If officials can bridge these barriers, they can indeed have a lasting impact on the spread of HIV/AIDS in the U.S. as a whole.

Thanks for listening. Until next time, this is Ali Cundari.

For more information:
• J├╝rgens, Ralf. “Interventions to Address HIV in Prisons – Prevention of Sexual Transmission.” World Health Organization. . 2007.
• Kanter, Elizabeth. “HIV Transmission and Prevention in Prisons.” HIV InSite Knowledge Base Chapter. . April, 2006.
• Lines, Rick, et al. “HIV/AIDS Prevention, Care, Treatment, and Support in Prison Settings.” WHO & UNAIDS Framework for an Effective National Response. . 2006.
• Maruschak, Laura. “HIV in Prisons, 2005.” Bureau of Justice Statistics Bulletin. . September, 2007.
• Polonsky, S., et al. “HIV Prevention in Prisons and Jails: Obstacles and Opportunities.” Public Health Rep. 109(5): 615–625. . September-October, 1994.
• “Prisons.” Joint United Nations Programme on HIV/AIDS. .

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