HIV Prevention in the U.S. Correctional System, 1991

During 1990, an estimated 4,350,000 adults -- 2.4% of the total U.S. adult population -- were under correctional supervision * in the United States, a 75% increase since 1983 (1). From 1983 through 1989, the number of juveniles (aged 10-17 years) in custody increased 25%, from 80,091 to 99,846 (U.S. Department of Justice, personal communication, 1992). By November 1990, 4519 cases of acquired immunodeficiency syndrome (AIDS) had been reported among inmates in federal and 45 state prisons, and 2466 cases had been reported by 25 city/county jail systems (U.S. Department of Justice, unpublished data, 1991); these totals include both cases of AIDS reported among persons before their incarceration as well as those reported by prison systems. This report characterizes efforts to prevent human immunodeficiency virus (HIV) transmission within correctional systems. **

HIV counseling and testing programs provide persons in correctional facilities with information about their HIV serostatus and identify persons who require medical treatment for asymptomatic HIV infection and other prevention services. State and local health departments provide HIV counseling and testing services in approximately 430 correctional facilities in 42 states, the District of Columbia, and Puerto Rico (Figure 1). These sites have reported the results of at least 65,724 HIV-antibody tests from January 1 through December 31, 1991. *** Most (67%) persons who have been counseled and tested in correctional facilities have identified themselves as injecting-drug users (IDUs).

Health education/risk-reduction programs in correctional facilities provide prevention messages, information materials, and risk-reduction counseling to persons whose behaviors (e.g., men who have sex with men, substance abusers (including IDUs), persons who exchange sex for money or drugs, or persons who are or were sex or needle-sharing partners of these persons) place them at risk for HIV infection. Health education/risk-reduction activities are provided in correctional facilities in 20 states and the District of Columbia (Figure 1) either by health departments or community-based organizations (CBOs); these activities are illustrated by programs in Massachusetts; the District of Columbia; Palm Beach County, Florida; and New York City.

• The Awaiting Trial Unit (ATU) sexually transmitted disease (STD) clinic at the Framingham Women's Correctional Facility in Massachusetts provides women with HIV counseling and testing; routine screening for syphilis, gonorrhea, chlamydia, and tuberculosis (TB); and referrals to a hospital for diagnostic and treatment services. An estimated 1400 women enter the ATU each year, with approximately 70 women in residence at any one time.

• The Office of AIDS Activities, District of Columbia Commission of Public Health, has designed a curriculum and implemented an HIV-prevention education program for incarcerated youth aged 13-19 years. A community follow-up program reinforces risk-reduction behaviors by providing adult mentoring, peer support, and access to health-care services.

• The Comprehensive AIDS Program (CAP) of Palm Beach County, Florida, provides HIV- and STD-prevention education to inmates in the correctional system. "Safety kits" distributed to inmates on release include condoms, AIDS brochures, information about needle hygiene for IDUs, and referrals to CAP for additional information.

• Life Force (a CBO), New York City, collaborates with the Bayview Correctional Facility in Manhattan to provide weekly HIV/AIDS education/support groups for female inmates. The groups focus on communication with family members and close contacts about risk behaviors, locating medical care, and other HIV-related information.

Reported by: C Ryan, MSW, Office of AIDS Activities, ME Levy, MD, District Epidemiologist, District of Columbia Commission of Public Health. J Jackson, AIDS Program, RS Hopkins, MD, State Epidemiologist, Florida Dept of Health and Rehabilitative Svcs. J Auerbach, MBA, AIDS Program, A DeMaria, Jr, MD, State Epidemiologist, Massachusetts Dept of Public Health. R Greifinger, MD, New York State Dept of Corrections; K Ong, MD, New York City Dept of Health; DL Morse, MD, State Epidemiologist, New York State Dept of Health. L Wood, AIDS Program, R Hutcheson, MD, State Epidemiologist, Tennessee Dept of Health. J Vergeront, MD, Wisconsin AIDS/HIV Program, JP Davis, MD, Communicable Disease Epidemiologist, Wisconsin Dept of Health and Social Svcs. Div of Sexually Transmitted Diseases and HIV Prevention, Office of the Deputy Director (HIV), National Center for Prevention Svcs; Program Development and Svcs Br, Div of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: A recent report indicated that among entrants to 10 selected U.S. jails and federal and state prisons, the HIV seroprevalence rate was 2.1%-7.6% for men and 2.7%-14.7% for women (2). The high seroprevalences, compared to seroprevalences among first-time blood donors (males, 0.04%; females, 0.02%) (3), underscore the need for providing primary and secondary HIV-prevention services to populations within the U.S. correctional system. To enhance their effectiveness, HIV-prevention programs for correctional institutions must provide adequate staff training and address issues of confidentiality.

In addition to high HIV seropositivity among prison entrants, HIV transmission occurs within prison settings (4), where a substantial proportion of inmates have histories of prior drug use (5,6). A report by the National Institute on Drug Abuse indicated that, based on a study during 1987-1989, approximately 83% of IDUs reported having been in jail or prison at some time (7). Because of the increased opportunities for transmission, the risk for HIV infection may be higher in prisons in which inmates serve longer terms or with large inmate populations (8).

The recent emergence of multidrug-resistant TB as an important opportunistic infection of HIV-infected persons (9) underscores the need for secondary HIV-prevention services in correctional facilities. Persons in correctional institutions are at increased risk for TB because of the high prevalences of HIV infection and latent TB, overcrowding, poor ventilation, and the frequent transfer of inmates within and between institutions (10).

Because of the risks for HIV infection among prisoners, state and local health departments are encouraged to identify opportunities to implement HIV-prevention activities in correctional facilities. Organizations receiving funding through the 1992 Cooperative Agreements for Minority and Other Community-Based HIV Prevention Projects are required to collaborate with local juvenile and adult criminal justice systems, correctional institutions, or parole programs providing HIV-prevention and education services. Additionally, applicants for fiscal year 1993 Cooperative Agreements for HIV Prevention (through state/local/territorial health departments) will be required to include in health education/risk-reduction programs persons in the correctional and criminal justice systems (including parole, probation, and transition programs) and to collaborate with correctional institutions and the correctional justice systems in developing program activities for these populations. Additional information on the 1993 program is available from state health departments.

References

1. Bureau of Justice Statistics. Probation and parole, 1990. Washington, DC: US Department of Justice, November 1991; document no. NCJ-133285. (Bureau of Justice Statistics bulletin).

2. Vlahov D, Brewer TF, Castro KG, et al. Prevalence of antibody to HIV-1 among entrants to U.S. correctional facilities. JAMA 1991;265:1129-32.

3. CDC. National HIV seroprevalence surveys -- summary of results: data from serosurveillance activities through 1989. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1990.

4. Castro KG, Shansky R, Scardino V, Narkunas J, Coe J, Hammett T. Evidence of HIV transmission in correctional facilities (Abstract). In: Program and abstracts of the Interscience Conference on Antimicrobial Agents and Chemotherapy. Washington, DC: American Society for Microbiology, 1991;142.

5. Decker MD, Vaughn WK, Brodie JS, Hutcheson RH, Schaffner W. Seroepidemiology of hepatitis B in Tennessee prisoners. J Infect Dis 1984;150:450-9.

6. Anda RF, Perlman SB, D'Alessio DJ, Davis JP, Dodson VN. Hepatitis B in Wisconsin male prisoners: considerations for serologic screening and vaccination. Am J Public Health 1985;75:1182-5.

7. CDC. Risk behaviors for HIV transmission among intravenous-drug users not in drug treatment -- United States, 1987-1989. MMWR 1990;39:273-6.

8. Valdiserri EV, Hartl AJ, Chambliss CA. Practices reported by incarcerated drug abusers to reduce risk of AIDS. Hosp Community Psychiatry 1988;39;966-72.

9. CDC. Nosocomial transmission of multidrug-resistant tuberculosis among HIV-infected persons -- Florida and New York, 1988-1991. MMWR 1991;40:585-91.

10. CDC. Prevention and control of tuberculosis in correctional institutions: recommendations of the Advisory Committee for the Elimination of Tuberculosis. MMWR 1989;38:313-20,325.

• Includes all persons aged greater than or equal to 18 years in jails and in federal and state institutions; under state parole supervision, whether released from prison by parole board decision or mandatory release, who had been sentenced to more than 1 year in prison; or who, as part of a state or local court order, were under the supervision of a probation agency. ** Single copies of this report will be available free until June 5, 1993, from the CDC National AIDS Clearinghouse, P.O. Box 6003, Rockville, MD 20849-6003; telephone (800) 458-5231. *** Because of reporting lags, the final data analysis will not be completed until late June 1992.

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