Up to 25% of HIV-positive individuals in the US will be incarcerated at some point

Many US prison officials think that inmates who contract HIV whilst incarcerated due to unsafe sex, injecting drug use, or tattooing have received their “just desserts”, according to an article in the January 11^th edition of the New England Journal of Medicine. The article highlights how US prisons are acting as “reservoirs” of HIV infection, and that as many as 25% of HIV-infected individuals may be imprisoned at some point.

All US prison systems fall short of international guidelines for the reduction of HIV transmission in prisons, writes Dr Susan Okie.

Very few US prisons meet WHO/UNAIDS standards by providing prisoners with the means to clean needles or condoms. In their absence, inmates are having unprotected sex and are sharing used, uncleaned injecting equipment.

Prohibitions on providing condoms, needles or bleach is justified by the prison authorities by reference to laws prohibiting sex in prisons, or by highlighting fears that providing safer-injecting equipment would be seen as a condoning drug use. However, Dr Okie quotes research from Germany, Spain and Switzerland that found that none of the individuals provided with safer injecting equipment was infected with HIV or hepatitis B or C, and that providing needles did not lead to an increase in injecting or drug use.

HIV is a very real concern for the US prison authorities. An estimated 2% of the US prison population is HIV-positive – a prevalence four times greater than that of the general American population. The exact prevalence of HIV in prisons varies from state to state: in New York 7% of inmates are infected with HIV, compared to less than 1% in California.

HIV -positive individuals have a high probability of being imprisoned at some time. Dr Okie quotes research that suggests that a quarter of people with HIV will spend some time in prison, as will 33% of individuals with hepatitis C, and 40% of those with active tuberculosis.

Although pressure is being put on US prison systems at federal, state and local level to implement international guidelines on HIV prevention, this has met with significant resistance. Dr Okie writes: “many US prison officials contend that providing needles or condoms would send mixed messages.” She quotes Rhode Island prison guard, Gerald Ducharme, who believes that by proving condoms “you’re saying sex, whether consensual or not, is OK.”

Dr Okie contrasts European and US attitudes to HIV prevention in prisons. “Whereas European prison officials tend to be more pragmatic, many US officials adopt a ‘just desserts’ philosophy, viewing infections as the consequences of breaking prison rules.”

There are limited data about the actual incidence of HIV infections in prisons: one study found that 88 prisoners were infected with HIV in Georgia state prisons in the 17 years before 2005, and another study has suggested an incidence of 1%. This might seem low, but Dr Okie writes, given the large prison population in the US (currently 2.2 million) “you do start thinking about large numbers of people contracting HIV.”

African Americans comprise 40% of the US prison population and a report from the National Minority AIDS Council highlights how prisons are acting as reservoirs of HIV infection for this population and calls for routine, voluntary HIV testing in prisons, for condoms to be made available to incarcerated individuals, and for HIV prevention, mental health, and substance abuse support to be provided to those released from prison.

Some prisons are trying to address HIV. Dr Okie draws attention to Rhode Island Prison which has a medical programme to identify and treat people with HIV. In addition HIV prevention education is provided along with referrals to HIV and drug support agencies on release.

But at the moment, Rhode Island seems to be the exception. Even should HIV prevention be address there is also an issue with antiretroviral therapy. “Drugs for treating HIV-infected prisoners are not covered by federal programs, and prison budgets often contain inadequate funding for health services”, writes Dr Okie.