Everyone knows that HIV is American prisons is a huge problem, but we don’t hear much about it. There are several reasons for that. For one, prisons are unpleasant places, and for the most part, we don’t want to think about what goes on there. For another, many people figure that whatever happens to prisoners is their problem; some even assume that whatever happens to inmates is part of their well-deserved punishment. Perhaps homophobia is a factor, too. For some, it may be unpleasant for them to think about one of the modes of transmission of HIV/AIDS. Not that any mode is particularly nice to think about.
It is important to recognize that HIV is transmitted is different ways. Sexual activity is the most obvious, both homosexual and heterosexual. It may be tempting to assume that all sexual activity in prisons is homosexual, but that is not the case. Probably most is, but we need to be careful about making assumptions here. Intravenous or subcutaneous drug injection is another mode of transmission. Think you can’t get drugs or needles in prison? Tattooing is a problem, too. Sex, drugs, and tattooing are all prohibited, but enforcement is impossible in all but the most secure facilities.
Now, The New England Journal of Medicine has published an free-access article on the subject. It is accompanied by an audio interview with Theodore Hammett, a policy expert. (I notice that NEJM finally got around to calling their recorded interviews “podcasts.”) As I’ve mentioned before, the NEJM makes their articles open-access only if they think they contribute to public consideration of important pubic health or policy matters.
Sex, Drugs, Prisons, and HIV
Susan Okie, M.D.
NEJM 356:105-108, January 11, 2007
One recent morning at a medium-security compound at Rhode Island’s state prison, Mr. M, a middle-aged black inmate, described some of the high-risk behavior he has witnessed while serving time. “I’ve seen it all,” he said, smiling and rolling his eyes. “We have a lot of risky sexual activities. . . . Almost every second or minute, somebody’s sneaking and doing something.” Some participants are homosexual, he added; others are “curious, bisexual, bored, lonely, and . . . experimenting.” As in all U.S. prisons, sex is illegal at the facility; as in nearly all, condoms are prohibited. Some inmates try to take precautions, fashioning makeshift condoms from latex gloves or sandwich bags. Most, however, “are so frustrated that they are not thinking of the consequences except for later,” said Mr. M.
Drugs, and sometimes needles and syringes, find their way inside the walls. “I’ve seen the lifers that just don’t care,” Mr. M said. “They share needles and don’t take a minute to rinse them.” In the 1990s, he said, “needles were coming in by the handful,” but prison officials have since stopped that traffic, and inmates who take illicit drugs usually snort or swallow them. Tattooing, although also prohibited, has been popular at times. “A lot of people I’ve known caught hepatitis from tattooing,” Mr. M said. “They use staples, a nail . . . anything with a point.”
That is a nice description of the reality. Dr. Okie goes on to point out that the prison Mr. M was in, has one of the better HIV prevention programs among American prisons. But the important point is this: According to WHO and UN AIDS standards, the American programs are substandard. The reason goes back to the controversy over harm reduction strategies. Many other countries supply prisoners with condoms and even needles.
Such strategies have proven effective in other countries. Yet very few correctional institutions provide condoms, and none has a needle exchange program. Methadone maintenance programs are rare. These substandard practices persist, even though the prison population is at a record high. That, and a high percentage of inmates have drug, alcohol, or mental health problems.
One thing the article does nicely, is to provide statistics to keep things in perspective. It turns out that the rate of HIV serocoversion (reflecting the rate of newly-acquired infections) is low in prisons: 0.63% in one study. But given the large number of persons we lock up, even that seemingly low number translates into a large absolute number of new cases.
Presumably, the current Administration is not interested in doing anything about this, since nothing has been done. Well, that’s an exaggeration. Something is done: routine screening for infection. And there is some treatment. But very little for prevention. Given the cost of the treatment, one might think that prevention would be a high priority. And even among those who think that HIV infection is “just desserts” for inmates, it is important to recognize that any increase in the rate of infection presents a risk for the rest of the population.