The New York Times - September 7, 2004
Brent Staples

The hyperbole and exaggeration surrounding the "down low" has taken the public health debate in a counterproductive direction. It has spread paranoia and pushed a much-needed discussion about bisexual behavior further underground. Moreover, it has kept the country from focusing on the long-neglected connection between H.I.V. and the prison system, where infection rates are high and unprotected sex among male inmates is far more common than prison officials care to admit. Men who have sex with men in prison pose an enormous threat to women when they return to the outside world and heterosexual behavior.

In any given year, 35 percent of the people with tuberculosis, nearly a third of those with hepatitis C and 17 percent of the people with AIDS pass through jails and prisons. Faced with budget crises, many correctional facilities back away from testing inmates, fearing they will be required to pay for expensive treatments.

Condoms are banned or simply unavailable in more than 95 percent of the nation's prisons. The corrections system processes nearly 12 million people a year. It is especially vulnerable to AIDS and other blood-borne diseases that spread easily through risky, unprotected sex acts.

Congress was forced to confront the issue in legislation after a series of reports suggested that prisoner-against-prisoner rape, often accompanied by horrific violence, was commonplace. Concern over the problem led to the federal Prison Rape Elimination Act of 2003, a groundbreaking law that requires the Justice Department to collect data on prisoner-against-prisoner rape and act to prevent it.

Research on sex in prison is limited. But a much-cited study of California prisoners in the 1980's found that 65 percent of them participated in sex acts behind bars. The data, though sketchy, suggests that men who regard themselves as heterosexuals are more likely to have sex with other men the longer they remain in jail. Starved for intimacy, many inmates apparently enter relationships that they would never have considered in the world outside.

In an article published two years ago in The Prison Journal by Christopher Krebs of the Research Triangle Institute, inmates reported that 44 percent of the people they knew participated in sex acts in prison.

The Krebs study disputes the standard hypothesis that sex acts behind bars mainly involve men who were already active homosexuals. Indeed, fewer than one-third of the people mentioned in the study seem to fit that category, which suggests that about 70 percent experienced their first same-sex encounters only after landing behind bars. The infections these men pick up in prison cycle back into the community once they are released.

The prison data cries out for an AIDS-prevention strategy that would encompass all of the nation's jails and prisons. At a minimum, the program would give inmates free and open access to condoms. The American prison system is now dominated by the dangerous notion that distributing condoms would encourage prisoners to break the rules by having sex. As a result, condoms are unavailable in an overwhelming majority of jails and prisons.

Prison authorities have resisted condom distribution despite intense criticism from public health officials, who have pointed out time and again that condoms are freely distributed in prisons in many countries, including Canada.

The Canadian model is commendable in that it applies clear, specific rules throughout the prison system and leaves little to the judgment of local prison officials. The directive requires that condoms be made "easily and discreetly available" in gyms, libraries, schools, laundry rooms and other areas where inmates can get them without having to interact with guards. The point is to ensure that inmates do not bypass condoms out of fear or embarrassment.

The connection between the prison experience and the spread of AIDS outside prison is especially clear in poor communities, where a great many men spend time behind bars at some point in their lives. But with millions of people regularly exposed to H.I.V. in the prison system, the entire country has both a moral and a medical obligation to confront the sexual realities of prison life.

Until then, lives will be lost and prison-borne diseases will continue to spread from the corrections system into the community at large.
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