|
Introduction
Prisoners are at exceptional risk for infection with HIV because of the
association of injection drug use with incarceration. Women prisoners who
have practiced prostitution, which frequently is associated with injection
drug use and contact with HIV-infected sex partners, are at additional risk
for HIV infection. This chapter reviews the following issues involved with
HIV infection in prisoners: epidemiology, prevalence, and transmission; the
growing coincidence of tuberculosis and hepatitis C; institutional issues,
including prison policies and practices, confidentiality, informed consent,
and medical research; the extensive involvement of the legal system in the
area of HIV in prisoners; and the role of educational programs in prevention
efforts.
HIV Transmission in Prisons
Numerous activities known to occur among prisoners pose a risk for HIV
infection. Several studies have identified transmission of HIV in prison,
based on serial serotesting for HIV antibody, some identifying
seroconversion in inmates after more than 5 years of continuous
incarceration. Molecular analysis of 14 HIV-positive inmates in Glenochil
Prison in Scotland in 1993 found sequencing similarities and clinical
histories in 13 of the 14, indicating that transmission had occurred at the
institution.
Data gathered in the Georgia State Prisons from mandatory testing of all
inmates at intake followed by inmate requested tests, or annual voluntary
HIV serotesting which was offered between 2003-2005, identified 88 prisoners
who seroconverted between 1992-2005 after one or more negative tests.
Investigators analyzed data collected from cases and control subjects
through computer assisted self interviews. Characteristics associated with
prisoners' HIV seroconversion were male-male sex in prison, tattooing in
prison, age >26 at interview, >5 years served of current prison sentence,
black race, and a body mass index <25.4kg/m2 on entry into prison. This CDC
report includes a wealth of information about the prisoners, reported risk
activities, precautions practiced, and knowledge about and suggestions for
prevention of transmission of HIV in prison.
No confirmed cases of HIV infection among prison staff in the United States
have been attributed to contact with inmates. There is a report from
Australia of seroconversion of an officer who was injected by an
HIV-infected inmate with a syringe full of the inmate's blood.
Sexual activity among male inmates is not uncommon in prisons and jails. A
Federal Bureau of Prisons study in 1982 reported that 30% of federal prison
inmates engaged in homosexual activity while incarcerated. In a 1984 study
of Tennessee inmates, 17% reported homosexual activity in prison. Former
prisoners surveyed in New York reported use of makeshift devices for safer
sex, such as fingers of latex gloves, when condoms were not available.
The frequency of homosexual rape in jails and prisons is extremely difficult
to estimate. The victim who reports rape in prison faces a probability of
further suffering and worse injury. The Federal Bureau of Prisons study
reported that 9-20% of federal inmates, especially new or homosexual
inmates, were victims of rape. The text of the Prison Rape Reduction Act
of 2002 states that the best expert estimate of the percentage of
individuals who are sexually attacked at least 1 time during their
incarceration is a national median of 13.6%. (The act establishes standards
for identifying, investigating, and eliminating prison rape in the United
States.)
Other incidents of interpersonal violence (including fights involving
lacerations, bites, and bleeding in 2 or more participants) present some
risks for HIV transmission. Housing more than 1 inmate per cell, common now
in crowded institutions, is a major contributing factor to incidents of
violence and sexual assault.
British investigators interviewed 452 released prisoners about activities
before, during, and after prison stays and found that persons engaged in
fewer incidents of HIV risk behavior in prison, but that activities in
prison were associated with increased risk. Those who reported engaging in
penetrative sex while in prison also reported doing so with greater
frequency outside, although they used condoms only outside. Reported sharing
of syringes increased during imprisonment, as did less effective methods of
syringe cleaning. In another report from the United Kingdom, IDUs who were
former prisoners reported a high prevalence of injection and sexual risk
behaviors while in prison; 33 of 50 had injected drugs, and 5 of 50 had
engaged in sex with 2 to 16 men.
Although imprisoned IDUs do not use drugs with the frequency that they can
when they are not incarcerated, they share injection equipment more and
sterilize it less because of scarce resources. A handmade syringe may be
fashioned from (among other things) parts of pens and light bulbs. Prisoners
also may share toothbrushes and shaving equipment in facilities where they
are not issued, where inmates are unable to purchase their own, or where
infection control precautions are not practiced adequately.
Tattooing is a widespread activity in prisons and usually is performed
without fresh or sterile instruments. It involves multiple skin punctures
with recycled, sharpened, and altered implements such as staples, paper
clips, and the plastic ink tubes from ballpoint pens. Prison wisdom holds
that tattooing that causes blood to flow results in the best quality image
and is least likely to become infected. Homemade pigment is delivered
intradermally (at a sharp angle) rather than through direct puncture. Metal
points connected to a battery or other electrical source are capable of
producing vibration, increasing the number of skin punctures exponentially,
thereby creating a better tattoo, but also increasing the risk of HIV
transmission. Body piercing is becoming more popular in prison, as in the
outside community, and clean instruments for this practice similarly are
unavailable.
Prevention
Means of prevention of HIV transmission, and their use in prisons, always
have provoked controversy and implementation of divergent policies. Prisons
historically have approached prevention of HIV either by quarantine and
segregation or by education. Other specific preventive practices include
dispensing of condoms, bleach and clean injecting equipment, and methadone
maintenance treatment.
Bleach
Safer injecting practice information (including providing bleach for
cleaning syringes)is included in the education and counseling programs of
many correctional systems in Europe, whereas correctional systems in the
United States do not systematically provide bleach. Half of 20 European
countries' prison systems surveyed provided disinfectant for injection
materials in 1998.
Confidentiality
Confidentiality of medical information in the prison setting is virtually
impossible to maintain. Where quarantines exist, confidentiality cannot.
Persons other than medical staff members may handle medical records, and
medical personnel may not be meticulous about protecting privacy. Once
information is released in a prison, it travels rapidly. Many people in the
prison setting believe they have a particular need to know who in the
institution is infected with HIV. It has been argued that prisoners have a
greater need for privacy than those outside because they live in a closed
community where violence is common.
Medical Treatment of HIV-Infected Prisoners
Prisons and jails, designed to confine and punish people (many of whom are
poor and lack influential outside advocates), frequently fail to provide the
level of health services required by patients with HIV. As with other
chronic illnesses, HIV requires health services that are expensive in terms
of staff effort and expertise, laboratory testing, and medication. Prisons
often have escaped outside attention to serious failures of care. HIV has
placed an enormous fiscal burden on prisons, which already are stressed
financially. The cost of HIV care in the 21st century in prisons now is
rivaled by the cost and controversies surrounding management of hepatitis C,
which affects up to 40% of prison inmates, and by the cost of psychotropic
agents for the large number of individuals with mental illness who are
imprisoned in the United States.
|
