Important note: Information in this article was accurate in June 1999. The state of the art may have changed since the publication date.
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The low number of women in prisons (6.4% of the prison population and 10.8% of the jail population) obscures the disproportionate impact of HIV infection on incarcerated women. In fact, prevalence of HIV infection among women is roughly two times higher than the rate among incarcerated men, and it's 35 times higher than the rate of HIV infection in non-incarcerated women 1.
Nationally in 1996, 3.5% of women inmates were known to be HIV-infected, compared to 2.3% of men 2. The prevalence of HIV infection among incarcerated women is even higher in geographical regions where HIV infection is more concentrated; for example, in Northeastern United States prisons, 13% of women inmates were known to be HIV-infected compared to 7.2% of men 2. Furthermore, while the number of incarcerated HIV-infected men has stabilized, the number of incarcerated HIV-infected women is still increasing. From 1991 to 1996, the number of HIV-infected women prison inmates increased an alarming 63% (1,159 in 1991 to approximately 1,897 in 1999), while the number of HIV infected men inmates only changed from 6,150 to approximately 6,155 in the same time frame 2.
In some institutions, as many as one in four of the women in the institution are HIV infected. The diagnosis and management of HIV and AIDS characterizes the practice of correctional health care in those institutions. As a result, correctional institutions for women that have the highest HIV prevalence rates have been trendsetters in three realms: standardizing correctional HIV care (MCI Framingham, MA and York Correctional Institute in Niantic, CT) 3, modeling peer education (Bedford Hills Correctional Institute, Bedford Hills, NY) 4, and evaluating discharge planning programs (Adult Correctional Institute, RI) 5.
The crimes for which women are incarcerated--most often drug use and drug-related crimes--are usually associated with a risk of HIV exposure. Indeed, the more often a woman is arrested for a criminal activity, such as sex work or drug use, the more likely she is to have been infected with HIV, and the more likely she is to accumulate real "prison time". Thus, there's a tendency for HIV prevalence to be higher among women serving prison sentences than among women who are awaiting trial and/or serving jail time 2.
Drug offenses. Drug use is linked to HIV risk. Nearly one in three women state prison inmates were serving time for drug offense in 1991, compared to one in five men 6. In many cases, sentencing for non-drug offenses like larceny (to support a drug habit) may obscure the link between incarceration and HIV risk behaviors 6.
Sex trade and sexually transmitted disease. In some circumstances, sex work contributes to HIV risk. Many incarcerated women have traded sex for drugs or money, regardless of whether they were arrested or charged with prostitution 7. These women may have engaged in sexual activity with multiple high-risk partners (such as intravenous drug users). Additionally, there is a high prevalence of sexually transmitted diseases (STDs) among incarcerated women 8, which may physiologically increase women's risk of HIV infection 9.
Sexual abuse. Histories of sexual abuse put incarcerated women at increased risk of HIV infection 10, 11. Browne and colleagues and a number of other researchers found a high rate of histories of sexual abuse among incarcerated women. In Browne’s study 59% of a diverse sample of women incarcerated in a large state maximum-security prison had experienced childhood sexual molestation 12. Childhood sexual abuse has a particularly profound effect on potential HIV exposure. Stevens and colleagues, working at the Massachusetts Correctional Institution at Framingham, discovered that women who informed researchers of a history of childhood sexual abuse were 4.5 times more likely to have participated in three HIV risk behaviors (sex work, drug use, and non-condom use) and 2.8 times more likely to be HIV infected than women who did not report this history 10.
Preliminary new data regarding gender differences in HIV-1 viral load is currently available. Several studies have indicated that women may have lower viral load than men with similar T-cell values 16, 17, and that women may progress to AIDS faster than men with similar viral load 17. Other studies have not shown this. In addition, viral load may be lower in individuals of color compared to whites 16. These differences have led some authors to consider that recommendations for treatment be re-evaluated for women. It is important to determine whether the response to treatment differs in women compared to men, and in people of color compared to whites, prior to developing new treatment recommendations that are gender or race specific.
The management of HIV infection among women differs quite dramatically from the management of HIV infection among men in two clinical areas: gynecology and obstetrics. Management of HIV infection in the pregnant woman will be covered in detail in a separate newsletter and is also briefly addressed in the faxed "Ask the Expert" section this month (see p.6).
HIV-infected incarcerated women have high rates of cervical cytologic abnormalities, sexually transmitted diseases and certain gynecologic infections. A 1995 study by Stevens and colleagues of 88 women incarcerated in a Massachusetts prison found that 68% of a sample of HIV-infected women had had at least one recent gynecological infection. Candida and trichomonas infections were the most common diagnoses 10. A recent national survey of all women incarcerated in city and county jails showed rates of syphilis, chlamydia and gonorrhea of 35%, 27%, and 8%, respectively 8. Because many incarcerated women have a history of sexual trauma, it is important to screen for gynecologic infections, but the practitioner's approach to gynecologic exam must be careful and sensitive (see Spotlight p.5).
Gynecological care in the correctional setting presents health care providers with a critically important context for assessing and enhancing the health of a population largely inexperienced with primary care, and for curbing HIV transmission. Providers have an opportunity to:
The correctional HIV provider should be aware of the association between HIV, human papilloma virus, and abnormal cervical cytology. The management of abnormal Pap smears in the correctional setting may need to be more vigilant as this population of women has had limited medical care prior to incarceration and may also have little access after release (see Heppigram p.7) Therefore, a more proactive approach may be necessary for HIV-infected women prisoners compared to women in community settings who otherwise engage in routine primary care.
Women infected with HIV have higher rates of human papilloma virus (HPV) expression in cervical secretions and a higher prevalence of cervical cytologic abnormalities than do HIV uninfected women 21. A recent study by Conley and colleagues demonstrated that the incidence of HPV-associated vulvovaginal lesions was 16 times greater in HIV-infected women compared to HIV-uninfected women 22. In addition, immunosuppression has been associated with increased pathological consequences of (HPV) infection, including invasive cervical cancer 21.
After two normal Pap semars during the first year, clinical guidelines for screening for cervical cytologic abnormalities, as outlined by the CDC, include performing Pap smears annually for all HIV-infected women. Some clinicians perform Pap smears more frequently (on a six-month basis) if the CD4 count is less than 400/mm3. These clinical guidelines may need to be modified as indicated for individual patients. For example, a provider may decide not to perform Pap smears at the recommended frequency for a woman who has had prior negative Pap smears and whose HIV disease is in a very advanced stage with opportunistic processes which confer a poor overall clinical prognosis.
There are conflicting reports about the accuracy of the Pap smear as a screening tool for cervical cytologic abnormalities in HIV-infected women, with some reports supporting its efficacy 23 and other reports suggesting it is insufficient as a diagnostic tool 24. In response to the latter concern, Goodman and colleagues performed a prospective study in a correctional institution and urban gynecology clinic in Massachusetts. The study compared Pap test results with the findings of colposcopy and directed biopsy. Goodman found that Pap tests returned a false negative result for 37% of the 102 HIV-infected women enrolled in the study, compared to 21.4% among the 82 HIV-uninfected women 24. These authors advised that women with significantly abnormal cervical cytology have yearly colposcopies to eliminate the risk of cervical cancer. These findings however, do not reflect current ACOG recommendations that currently support Pap smear screening alone, with colposcopy reserved when cytologic abnormalities are detected.
In providing gynecologic care, it is common to prescribe estrogens, progestin, and combinations of both for various conditions, in particular, for symptoms of estrogen depletion caused by natural, surgical, or premature menopause. When HIV infection is present, attention must be given to potential interactions between exogenous hormones and HIV drug therapies. Of particular concern are interactions with medications that are metabolized in the liver, including certain antibiotics, diphenylhydantoin, barbiturates, bronchodilating agents, corticosteroids and protease inhibitors. Another general concern is the effect of exogenous hormones on individual immune function. Differences in male and female immune response are mediated by sex hormones (in particular estrogens, progesterone, and testosterone) 25. Therefore, although testosterone replacement therapy has become an accepted treatment for hypogonadism and wasting in HIV-infected men 26, providers should exercise caution when administering less-studied female hormone replacement therapy to HIV-infected women.
HIV disproportionately affects incarcerated women. This has resulted in an increased need for comprehensive services for HIV-infected women prsoners. Correctional management of HIV-infected women must take into account the reasons for incarcerated women's acute vulnerability to HIV; these may include drug use, histories of physical and sexual abuse, and poverty. By testing for HIV infection and screening for gynecologic infections among incarcerated women, correctional health care providers can play a critical role in public health strategies for treating and reducing the spread of infectious diseases.
Correctional management of HIV can also be viewed as an opportunity to create a network of interconnected services that address the needs of incarcerated HIV infected women. These services might include physical and sexual abuse recovery programs, drug treatment, and mental health services provided in conjunction with routine clinical management of HIV infection.
Overall, incarceration provides a critical opportunity for the education, diagnosis, and medical care of HIV-infected women and high-risk HIV seronegative women; as well as a public health opportunity to reduce the spread of HIV infection.
1.Gilliard D. Washington, D.C.: U.S. Department of Justice. Bureau of Justice Statistics Bulletin NCJ-173414. March 1999.
2.Maruschak, L. Washington, D.C.: U.S. Department of Justice. Bureau of Justice Statistics Bulletin NCJ-164260. August 1997.
3. De Groot AS, Leibel SR, Zierler S. J Corr Health Care Fall 1998;5(2).
4. Morrill AC, Mastroieni E, Leibel SR. J Corr Health Care Fall 1998;5(2).
5. Mitty JA, Holmes L, Spaulding A, Flanigan T, Page J. J Corr Health Care Fall 1998;5(2).
6. Snell TL, Morton DC. Washington, D.C.: U.S. Department of Justice. Bureau of Justice Statistics Special Report. March 1994.
7. Schilling RF, El-Bassel N, Lvanoff A, Gilbert L, Su K, Safyer SM. Public Health Rep 1994;109(4), 539-547.
8. MMWR June 5, 1998;47(21): 429-31
9. Heverkos HW, Quinn TC. "The third wave: HIV infection among heterosexuals in the United States and Europe." Int J STD AIDS 1995 Jul-Aug;6(4):227-32.
10. Stevens J, Zierler S, Cram V, Dean D, Mayer KH, De Groot AS. J Women's Health 1995;4(5), 1-7.
11. Stevens J, Zierler S, Dean D, Goodman AK, Chalfen B, De Groot AS. J Corr Health Care 1995;2(2), 137-149.
12. Browne A, Miller B, Maguin E. Prevalence and severity of lifetime physical and sexual victimization among incarcerated women. In press, International J Law Psychiatry: Special Issue: Current Issues in Law and Psychiatry July 1999.
13. Cuccinelli D, De Groot AS. In Goldstein N, Manlowe J (Eds.) The gender politics of HIV in women, perspectives on the pandemic in the United States. New York, NY: NYU Press. 1994.
14. Richie BE, Johnson C. "Abuse histories among newly incarcerated women in a New York City jail." J Am Med Womens Assoc 1996 May-Jul;51(3):111-4, 117.
15. Mostashari F, Riley E, Selwyn PA, Altice FL. "Acceptance and adherence with antiretroviral therapy among HIV-infected women in a correctional facility." J Acquir Immune Defic Syndr Hum Retrovirol 1998 Aug 1;18(4):341-8
16. Anastos K, Gange SJ, Lau B, Melnick S, Detels R, Giorgi J, Kovacs A, Cohen M, Margolick JB, Landesman S, Munoz A, Phair J, Rinaldo C, Young M, Greenblatt R. "Gender Specific Differences in Quantitative HIV-1 RNA levels" 6th Conference on Retroviruses and Opportunistic Infections, Chicago, January, 1999. Abstract 274.
17. Farzedegan H, Hoover DR, Astemborski J, Lyles CM, Margolick JB, Markham RB, Quinn TC, Vlahov D. "Sex differences in HIV-1 viral load and progression to AIDS." Lancet 1998 Nov 7;352(9139):1510-4
18. Roberts SJ, Reardon KM, Rosenfield S. "Childhood sexual abuse: surveying its impact on primary care." AWHONN Lifelines 1999 Feb-Mar;3(1):39-45.
19. Dole, P. "Centering: reducing rape trauma syndrome anxiety during a gynecologic examination." J Psychosoc Nurs Ment Health Serv 1996 Oct;34(10):32-7.
20. Golding, JM, Wilsnack, SC, Learman, LA. "Prevalence of sexual assault history among women with common gynecologic symptoms." Am J Obstet Gynecol 1998 Oct;179(4):1013-9.
21. Sun XW, Kuhn L, Ellerbrock TV, Chiasson MA, Bush TJ, Wright TC. "Human papillomavirus infection in women infected with the human immunodeficiency virus." N Engl J Med 1997 Nov 6;337(19):1343-9.
22. Conley LJ, Ellerbrock TV, Bush TJ, Chiasson MA, Wright TC. "Incidence of HPV-Associated Vulvovaginal Lesions in HIV-Infected and Uninfected Women" 6th Conference on Retroviruses and Opportunistic Infections, Chicago, 1999. Absract 462.
23. Boardman LA, Peipert JF, Cooper AS, Cu-Uvin S, Flanigan T, Raphael S. "Cytologic-histologic discrepancy in human immunodeficiency virus-positive women referred to a colposcopy clinic." Obstet Gynecol 1994 Dec;84(6):1016-20.
24. Goodman AK, Abstract presented at the Annual Meeting of the Society of Gynecologic Oncology, San Francisco, CA, 1999.
25. Sthoeger ZM, Chioranzzi N, Lahita RG. "Regulation of the immune response by sex hormones. I. In vitro effects of estradiol and testosterone on pokeweed mitogen-induced human B cell differentiation." J Immunol 1988 Jul 1;141(1):91-8.
26. Denenberg R. AIDS Clin Care 1993;5:69-72.
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