Important note: Information in this article was accurate in July 2000. The state of the art may have changed since the publication date. | The online version of HEPP News displays the main article only, to view the entire newsletter download the following PDF:
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Delegates from resource-rich nations attending the 13th International AIDS Conference in Durban, South Africa last month confronted the unfathomable suffering HIV is causing in South Africa and other developing nations. However, as desperate as the situation is in many of the world's poorest nations, it is in prisons where HIV reigns.
Reflecting the unique role prisons and jails play in the HIV pandemic, an entire conference symposium, entitled 'HIV Behind Bars', was convened. Oral and poster presentations at this symposium provided a glimpse of life behind prison walls - from rural sub-Saharan African jails to Latin American penitentiaries, and painted a fuller picture of HIV in the nation with the greatest per capita prison population, the US.
Presentations at Durban reinforced Dr. Jonathan Mann's observations that the most vulnerable members of the population of any country are at the highest risk for contracting HIV/AIDS1. Regardless of the country, prisons and jails concentrate HIV-infected and at-risk individuals. Data regarding the prevalence of HIV/AIDS in prisons in countries outside North America and Europe have been scarce, however, reports at the conference provided some new HIV prevalence information. The methods used for collecting HIV prevalence data from correctional facilities differed widely. Some studies relied on voluntary reporting (to surveyors or to prison health care officials) which may significantly underestimate the number of inmates who have HIV infection by at least 25%2. Anonymous sero-surveys are far more accurate than voluntary reporting3.
Studies of the prevalence of HIV in African prisons show rates ranging from 2.7% in a cross sectional serostudy in Senegal4 to 27% in Zambia as determined by a voluntary questionnaire and ELISA testing of 1,596 inmates8. In the Côte D'Ivoire, a random sample of 500 inmates in one facility demonstrated a prevalence rate of HIV infection of 28%, double that of the general population4.
These high HIV prevalence rates are not surprising, given the impact that HIV has had on this region of the world. In sub-Saharan Africa approximately 24.5 million people are living with HIV infection - over two thirds of the world's burden of HIV. Over 11.5 million Africans have died of AIDS, representing 83 percent of the total HIV-related deaths worldwide. In several African countries, the rate of HIV infection among adults aged 15 to 49 exceeds 20%5 and life expectancies have plummeted to turn of the century figures.
Eighteen percent (7 million) of the global population of HIV-infection individuals live in South and Southeast Asia. Limited information regarding HIV prevalence rates in Asian correctional settings is available (see Table 1). This is unfortunate given that the Asian/Pacific region had the second highest rate of new infections in 1998, second only to Sub-Saharan Africa, and that this region is predicted to be the next epicenter of HIV infection5.
HIV infection rates have doubled over the past year in many sub-populations of Latin America. On the Caribbean coast of Latin America, the prevalence rate exceeds 16% among adults in their 20s5. According to the UNAIDS report, heterosexual transmission is rapidly spreading the disease throughout the region. A 1999 report from Brazilian correctional facilities describes an HIV prevalence of 16% among 631 inmates who agreed to voluntary testing6. A cross-sectional study of 693 inmates from three Brazilian prisons revealed an HIV prevalence rate of 14%, with a range of 11% (in one minimum-security facility) to 22% (in one maximum security facility)7.
European countries report a wide range of prevalence rates, ranging from 0.19% in anonymous survey of 544 inmates in Athens, Greece8 to 11% of inmates who volunteered for an anonymous survey in Southeastern France9 and 47% among a selected group of 639 injection drug using prisoners incarcerated in Léon, Spain10. In comparison, the nationwide average prevalence rate in the U.S. is low, 2.3% overall. In the Northeastern U.S., however, anonymous serosurveys have revealed HIV infection rates ranging from 7 to 26% depending on the location of the correctional facility (rates are highest in New York City, New York State, and New Jersey)11.
Distribution of HIV prevalence by gender is reversed in correctional settings. In U.S. prisons, incarcerated women are twice as likely as men to have AIDS11, in contrast to the general US population where men are almost four times as likely to have AIDS than women (See HEPP News, April 2000)12. Several papers presented at the conference from Brazil indicate women in that country also exhibit higher rates of HIV infection than men (7.2% versus 4.8%)(13, 14, 7). Likewise, a study from India found a high rate of 9.5% HIV prevalence among women inmates, compared to 1.7% among men. Ghante Nagaraj and colleagues attribute the high rate of HIV among incarcerated women to the fact that most are commercial sex workers, a very high-risk occupation15. Likewise in the U.S., women are more likely to be incarcerated for sex and drug crimes known to be associated with increased risk for HIV infection.
Obtaining data regarding in prison drug use is challenging, but critical to our understanding of the risk of HIV transmission inside prisons. In several reports, investigators presented evidence that injection drug use does occur in correctional settings and is associated with HIV infection. Outside the US, intraprison spread is an important concern. Greek researchers found that 55% of IDUs use drugs in prisons, and over half (57.8%) used injection drugs. Ninety percent of those injecting in prison shared needles, and these researchers suggested that IDUs inject less but share needles more frequently when incarcerated8.
Very few correctional facilities allow the distribution of sterile injection equipment. Switzerland, Spain, and Germany, however, have had successful pilot programs and some facilities have since adopted programs that allow clean injection equipment to be available. Inmates and staff in these facilities have reported that they feel safer, needle stick injuries have declined significantly, and there was no increase in drug consumption16. In Durban, C. Menoyo presented similar findings from a 22-month needle exchange pilot study in the prison of Bilbao, Spain17. Prison officials, guards and inmates all expressed satisfaction. No custody or safety incidents related to the program occurred.
Condom availability continues to be a highly controversial topic in most correctional settings. According to the Canadian HIV/AIDS Legal Network, all facilities in Canada and New South Wales, Australia, and some facilities in Europe allow condom distribution within correctional settings. Condom availability is rare in facilities in the United States.
In 1996, South Africa ended segregation of HIV-infected prisoners and established a policy allowing the distribution of condoms. However, according to a report presented at the International AIDS Conference by Teboho Kekana of the AIDS Law Project in South Africa, policy and practice are very far apart. Only 3 facilities actively distribute condoms18.
A recent World Health Organization (WHO) report found that 23 of 52 countries surveyed allowed condom distribution in their correctional systems. Significantly, no system that has adopted a policy of making condoms available in prisons has reversed the policy, and the number of systems that make condoms available has continued to grow every year19. According to the WHO, "condoms should be made available to inmates throughout their period of detention and prior to any form of leave or release"20.
In most countries, prisons are recognized as key intervention sites to prevent the advance of HIV. Reports on access to testing, medications, and trained providers in correctional settings are limited. Many experts and corrections-related institutions, however, have written recommendations for HIV interventions in correctional settings.21 In 1993, The World Health Organization established broadly applicable recommendations for the management of HIV infected inmates (20, see Table 2 for a summary).
In the United States, the National Commission on Correctional Health Care (NCCHC) promotes voluntary testing of prisoners and recommends the involvement of prisoners in the development and delivery of HIV/AIDS educational programs.22 Most authors emphasize the importance of educating staff as well as inmates about HIV risk and the needs of HIV infected people. The success of anonymous testing in one study was attributed to the high level of HIV education in the general prison population.2
Even when effective HIV care is administered in a prison setting, the gains made may be lost following release, as was highlighted in a presentation by Stephenson and colleagues.23 In this retrospective study of state prison inmates in North Carolina, HIV-infected inmates receiving potent HIV therapies who were released and subsequently reincarcerated were compared to matched HIV-infected controls who remained in prison. Released prisoners experienced significant increases in HIV viral loads, while those remaining in prison actually saw a modest decline in HIV levels during the study period. Clearly, these data demonstrate that correctional facilities indeed provide an opportunity for HIV care initiation but that community resources must pick up where jails and prisons leave off.
Durban has focused the world's attention on the plight of the developing nations engulfed by HIV. In many ways prisons and jails represent the best and worst of the pandemic both in developing and developed nations. Great strides have been made in many countries to address HIV and AIDS in prisons and jails. Programs enabling the distribution of condoms and sterile injection equipment in some European and Australian facilities show promise for preventing the spread of HIV. Some U.S prisons and jails have developed strong programs for HIV testing and treatment, and many facilities conduct seroprevalence studies concerning HIV risk behaviors. However, despite these successes, the failure to implement comprehensive national programs (even in the U.S) combined with the lack of resources from non-western countries indicate that the global community needs even more focus on HIV/AIDS in prisons.
Prisons were identified years ago as key intervention sites for identifying and treating persons with HIV/AIDS. In 1987, prison medicine researcher T.W. Harding wrote: "Prison medical services will be tested by the AIDS epidemic. Prisons are not created to promote health. Nevertheless, the AIDS epidemic demonstrates forcibly how important prison health policy is for the community as a whole" (24). How nations meet the challenge of providing care and preventive services in their correctional systems remains to be seen, but thanks to Durban, the world is now watching.
*Speaker’s Bureau: Abbott Laboratories, Glaxo Wellcome and Merck & Co.
**Speaker’s Bureau: Agouron Pharmaceuticals, Bristol-Myers Squibb, DuPont, Glaxo Wellcome, Merck, Roche.
1. AIDS in the world II : global dimensions, social roots, and responses / the Global AIDS Policy Coalition. Ed Mann JM and DJM Tarantola. New York : Oxford University Press, 1996.
2. Bird AG, Gore SM, Jollife SW, Burns SM. Anonymous HIV surveillance in Saughton Prison, Edinburgh, AIDS 1992 Jul;6(7):725-33.
3. Simooya, O. XIII International AIDS Conference, July 2000, Durban, South Africa. MoPeC2336.
4. Togbe T. Determinants of HIV transmission in incarcerated populations in Africa. The Cote d'Ivoire experience, International Conference on AIDS, 1998; 12: 1180 (Abstract 60986).
5. Report on the global HIV/AIDS epidemic. June 2000. Available at www.unaids.org.
6. Osti NM. Human immunodeficiency virus seroprevalence among inmates of the penitentiary complex of the region of campinas, state of Sao Paulo, Brazil, Mem Inst Oswaldo Cruz 1999 Jul-Aug;94(4):479-83.
7. Carvalho ML. International Conference on AIDS, 1998; 12: 454-5 (Abstract 12563).
8. Malliori M, Sypsa V, Psichogiou M et al. A survey of bloodborne viruses and associated risk behaviours in Greek prisons, Addiction 1998 Feb;93(2):243-51.
9. Rotily M, Galiner-Pujol A, Obadia Y et al. HIV testing, HIV infection and associated risk factors among inmates in south-eastern French prisons, AIDS 1994 Sep;8(9):1341-4.
10.. Martín V, Cayla JA, Morís ML et al. Predictive factors of HIV-infection in injecting drug users upon incarceration, Eur J Epidemiol 1998 Jun;14(4):327-31.
11.. Hammett TM, Harmon P, and Maruschak LM. 1996-1997 Update: HIV/AIDS, STDs and TB in Correctional Facilities. US Department of Justice, July 1999. NCJ 176344.
12.. Dean-Gaitor HD, Fleming PL. Epidemiology of AIDS in incarcerated persons in the United States, 1994-1996, AIDS 1999 Dec 3;13(17):2429-35.
13.. Bauer, PG, et. al. Injecting drug use and HIV and HCV infections in the prison system of Rio de Janeiro, Brazil, XIII International AIDS Conference, July 2000, Durban, South Africa. Abstract TuPeD3674.
14.. Gomes , JDS et. al. Prevalence of HIV, hepatitis B and other sexually transmitted diseases (STDs) in Gate Prisons of Rio de Janeiro- Brazil in the last four year (1996–1999), XIII International AIDS Conference, July 2000, Durban, South Africa. Abstract TuPeD3690
15.. Ghante Nagaraj, S. HIV seroprevalance and prevelant attitudes amongst the prisoners: A case study in Mysore, Karnataka state India, XIII International AIDS Conference, July 2000, Durban, South Africa. Abstract MoPeC2333.
16.. Fact sheet: HIV/AIDS in Prisons. Prevention: Sterile Needles. Canadian HIV/AIDS Legal Network. Available at: http://www.aidslaw.ca/Maincontent/issues/prisons/e-info-pa6.htm.
17.. Menoyo, C. Needle exchange programme (NEP) in the prison of Bilbao 2 experience years: 1997-1999, XIII International AIDS Conference, July 2000, Durban, South Africa. Abstract TuOrD322.
18.. Kekana, T. An overview HIV/AIDS management policies in South African prisons: the imperative to turn policy into practice, XIII International AIDS Conference, July 2000, Durban, South Africa. Abstract MoPpD1039.
19.. Fact Sheet: HIV/AIDS in Prisons. Prevention: Condoms. Canadian HIV/AIDS Legal Network. Available at: http://www.aidslaw.ca/Maincontent/issues/prisons/e-info-pa4.htm.
20.. World Health Organization. WHO guidelines on HIV infection and AIDS in prisons. Global Program on AIDS, Geneva. 1993 March. WHO/GPA/DIR/93.3.
21.. De Groot SA, Leibel SR, Zierler S. A standard of care for incarcerated women: Northeastern United States' experiences. J Correctional Health Care 1998; 5(2): 139-175.
22.. National Commission on Correctional Health Care. Management of HIV in Correctional Facilities. Chicago, IL. 2000. www.ncchc.org.
23.. Stephenson, B. Release from prison is associated with increased HIV RNA at time of re-incarceration, XIII International AIDS Conference, July 2000, Durban, South Africa. Abstract TuOrD323.
24.. Harding TW. AIDS in prison, Lancet 1987 Nov 28;2(8570):1260-3.
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