What is the role of prisons and jails in HIV prevention?
Is prevention in prisons and jails important?
Absolutely. The US has the highest incarceration rate in the world, and the numbers keep growing.1 In 2007, the US had over 2.4 million people in state, federal and local correctional facilities.2 For the first time, more than 1 in every 100 adults in the US is confined in a jail or prison.1
Persons in prison and jail have higher rates of many diseases and health problems than the general population.3 HIV rates among incarcerated persons are 2 ½ times higher than in the general population. In any given year, about 25% of all HIV+ persons in the US pass through a correctional facility.4 Persons in prison and jail also have higher rates of STIs, tuberculosis and viral hepatitis, as well as substance abuse and mental illness.5
These high infection rates in prisons and jails in the US reflect the fact that the majority of persons who are incarcerated come from impoverished and disenfranchised communities with limited access to prevention, screening and treatment services.6 These are the same neighborhoods with high rates of HIV, STIs and other infectious diseases.
Criminal justice and public health systems can work together to provide comprehensive prevention and treatment inside and outside facilities. Incarceration presents a window of opportunity for primary prevention, screening, treatment and establishing comprehensive, pro-active transitional linkages for persons approaching release and follow-up.
What is the HIV connection between prisons, jails and the community?
At least 95% of persons in prison are released into the community at some point.7 The impact of incarceration and disease is not limited to the men and women being locked up, but extends to their families, partners and communities.
There is a mistaken belief that men and women acquire HIV inside, when in fact, the vast majority of HIV+ persons in prison and jail enter the criminal justice system HIV+.8,9
Persons with a history of mental illness, trauma or physical and sexual abuse, who do not have access to mental health services, may self-medicate with substance use. This combination puts them at increased risk for behaviors that may both lead to HIV and land them in jail or prison. Rates of mental health diagnoses for persons in jail and prison are 45-65%, while rates of substance abuse are as high as 75%.10
How does incarceration impact HIV risk?
Persons in prison and jail may engage in risk behaviors before, during and after incarceration. However, behavior during incarceration may be riskier for those who do not have access to condoms, clean syringes and other prevention tools. Sexual activity (both consensual and coerced), substance use, injecting and tattooing can all put individuals at risk for HIV/STIs and viral hepatitis.11 In one study of incarcerated young men, 50% had used substances and 17% had consensual sex with men or women while confined.12
Release from correctional settings and re-entry into the community can be a stressful time and often carries higher risks than being incarcerated. Persons released from prison and jail may celebrate their release with HIV risk-related behaviors such as drinking, drug use and sex. Persons released with few resources often return to the same precarious environments where they were arrested. A study of persons formerly incarcerated in Washington found a high risk of drug overdose within the first two weeks of release.13
There is a misperception that incarcerated men are responsible for increasing rates of HIV/STIs. Imprisonment does affect HIV/STI rates in the community, but not from men getting infected on the inside and bringing it out to their female sexual partners once they are released. Instead, incarceration decreases the number of men in the community, which disrupts stable partnerships, changes the male-to-female ratio and promotes higher-risk concurrent, or overlapping, partnerships.14
What can be done inside?
Across the US, many HIV prevention agencies and public health departments are working with the criminal justice system to improve the health of persons who are incarcerated and their communities. Agencies can provide: peer-based prevention programs, including prevention with positives; harm reduction programs; quality health care; treatment for HIV/STIs; treatment for substance abuse and mental illness; links to community services pre-release; help with community reintegration post-release.10,15
Counseling, testing and treatment for HIV/STI/hepatitis/TB. Incarceration can be an opportunity for screening and treating a group of individuals with high risk behaviors. This should include comprehensive pre-test counseling with a consent process describing the implications of testing positive or negative, as these can have consequences within correctional facilities, such as limiting housing and work assignments, and restricting visiting privileges. It should also include providing treatment for those who test positive and prevention education to those who test positive and negative.
Mental health treatment. Persons in prison and jail have high rates of mental illness. Conditions in correctional settings such as overcrowding, violence and isolation have negative effects on mental health. Prisons and jails can help by providing assessment and effective treatment. Persons with mental illness who have committed minor offenses should be diverted to mental health services before or instead of prison or jail.16
Comprehensive substance abuse treatment. While many jails and prisons in the US offer detoxification, professional and peer counseling, self-help groups and drug and alcohol education, very few offer methadone maintenance. The capacity of effective substance abuse treatment programs falls far short of the need. The KEEP program, based in New York, NY, provides jail-based methadone treatment and dedicated treatment slots to released individuals in the community.17
What are transitional interventions?
Effective transitional interventions ensure that prevention and treatment services provided on the inside are continued on the outside. Many communities will have an increasing role in transitional planning with enactment of the Second Chance Act.18
Project START is the only intervention for incarcerated populations in the CDC’s Compendium of Evidence-Based Interventions. Project START is a client-centered, 6-session HIV, STI and hepatitis risk reduction intervention for persons being released from a correctional setting. Based in harm reduction, it uses a prevention case management model and motivational enhancement to encourage risk reduction. The first two sessions are pre-release and the last four are post-release. All sessions include facilitated referrals for housing, employment, substance abuse and mental health treatment, legal issues, and avoiding reincarceration. Research demonstrated that Project START was effective in reducing unprotected sex among young men after their release from prison.19
Project Bridge in Providence, RI, provides intensive case management for HIV+ persons being released from state prison. Enrollees receive 18 months of case management by a social worker and an outreach worker. Participants meet weekly for 12 weeks, then once a month, at a minimum. Project Bridge is effective in helping HIV+ persons obtain and maintain much needed post-release services. Research showed that despite high levels of addiction (97%) and mental illness (34%), participants received post-release medical care (95%), secured housing (46%), linked to mental health care (71%) and linked to addiction services (51%).20
What are next steps?
Effectively addressing HIV in prisons, jails and communities requires both effective prevention strategies (such as peer education, access to condoms, HIV counseling and testing) and effective structural and medical strategies. Some of the proven effective strategies and policies that can help reduce HIV/STIs in prisons and jails include: harm reduction programs (providing clean syringes);21 substance abuse treatment;17 mental health treatment;16 STI/HIV treatment;5 transitional discharge planning;19,20 housing;5 alternatives to incarceration;15 and sentencing and parole reform.1
Collaboration between the criminal justice system (prison, jail, parole and probation) and the community public health system (social services, medical/health clinics, treatment programs, etc.) is essential, and there are several effective models. Building partnerships can help tackle public health issues while understanding the challenges of public safety and custody priorities. If we truly want to decrease rates of HIV, STIs and hepatitis in our communities, we have to work together to create a seamless continuum that will improve prevention, care and treatment both inside prisons and jails as well as in disproportionately affected communities.
1. PEW Center on the States. One in 31: The long reach of American corrections. March 2009.
2. West HC, Sabol WJ. Prisoners in 2007. Bureau of Justice Statistics Bulletin. 2008.
3. Maruschak L. HIV in Prisons, 2006. Bureau of Justice Statistics Bulletin. 2008.
4. Hammett TM, Harmon MP, Rhodes W. The burden of infectious disease among inmates of and releasees from US correctional facilities, 1997. American Journal of Public Health. 2002 ;92:1789-1794.
5. The Foundation for AIDS Research. HIV in correctional settings: implications for prevention and treatment policy. Issue Brief No 5, March 2008.
6. Golembeski C, Fullilove R. Criminal (in)justice in the city and its associated health consequences. American Journal of Public Health. 2005;95:1701–1706.
7. Hughes T, James Wilson D. Reentry trends in the United States. Bureau of Justice Statistics.
8. Vlahov D, Putnam S. From corrections to communities as an HIV priority. Journal of Urban Health. 2006;83:339-348.
9. Zack B, Kramer K. HIV prevention education in correctional settings. Project UNSHACKLE discussion paper. May 2008.
10. James DJ, Glaze LE. Mental health problems of prison and jail inmates. Bureau of Justice Statistics Special Report. September 2006.
11. HIV transmission among male inmates in a state prison system – Georgia, 1992-2005. Morbity and Mortality Weekly Report. 2006;55:421-426.
12. Seal DW, Margolis AD, Morrow KM, et al. Substance use and sexual behavior during incarceration among 18- to 29-year old men: prevalence and correlates.AIDS and Behavior. 2008;12:27-40.
13. Binswanger IA, Stern MF, Deyo RA, et al. Release from prison—a high risk of death for former inmates. New England Journal of Medicine. 2007;356:157-165.
14. Aral SO, Adimora AA, Fenton KA. Understanding and responding to disparities in HIV and other sexually transmitted infections in African Americans. Lancet. 2008;372:337-340.
15. Freudenberg N. Jails, prisons, and the health of urban populations: a review of the impact of the correctional system on community health. Journal of Urban Health. 2001;78:214-235.
16. World Health Organization. Mental health and prisons. 2005.
17. Tomasino V, Swanson AJ, Nolan J, et al. The Key Extended Entry Program (KEEP): A methadone treatment program for opiate-dependent inmates. The Mount Sinai Journal of Medicine. 2001;68:14-20.
18. Second Chance Act.
19. Wolitski RJ, The Project START study group. Relative efficacy of a multi-session sexual risk-reduction intervention for young men released from prison in 4 states. American Journal of Public Health. 2006;96:1845-1861.
20. Zaller ND, Holmes L, Dyl AC, et al. Linkage to treatment and supportive services among HIV-positive ex-offenders in Project Bridge. Journal of Health Care for the Poor and Underserved. 2008;19:522-531.
21. Jürgens R, Ball A, Verster A. Interventions to reduce HIV transmission related to injecting drug use in prison. Lancet Infectious Diseases. 2009;9:57-66.
Prepared by Barry Zack MPH and Katie Kramer MSW/MPH, The Bridging Group LLC
March 2009. Fact Sheet #13R
Special thanks to the following reviewers of this Fact Sheet: Tim Flanigan, Nick Freudenberg, Robert Fullilove, Robert Greifinger, Ted Hammett, Bob Hogg, Ralf Jürgens, Beth Justiniano, James Learned, Robin MacGowan, Alex Margolis, Dan O’Connell, Anthony Papa, Robin Pollini, Hugh Potter, Cristine Rodriguez, David Seal, Dan Wohlfeiler, Jeanne Woodford.
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