Means of prevention of HIV transmission, and their use in prisons, always have provoked controversy and implementation of divergent policies. Prisons historically have approached prevention of HIV either by quarantine and segregation or by education. Other specific preventive practices include dispensing of condoms, bleach and clean injecting equipment, and methadone maintenance treatment.

By 2005, only the state of Alabama tested and placed all those identified as HIV positive in segregated housing. The trend over time has been away from segregation and toward case-by-case determination of housing placement.

Increasing staff-to-prisoner ratios, classifying and housing inmates carefully, decreasing overcrowding, and providing activities for inmates help to prevent transmission through nonconsensual risk behavior (eg, violence, including rape). Preventing violence is the ongoing responsibility of prison staff. Effective staffing and education help prevent consensual but risky behavior (eg, sharing contaminated needles, unsafe sex).

For the purpose of HIV infection control in most U.S. prisons, the educational message is that no risk activity is safe, and exposure to semen and bloody body fluids should be avoided.

Education
Prisoners represent a crucial and huge target population for HIV education programs; prisons concentrate persons at risk who are not easily reached in the community by such efforts. As many as 50% of U.S. prisoners are functionally illiterate, and many are not native English speakers; to be effective, educational programs must be modified to reach them. The generally available literature on HIV infection and AIDS either cannot be understood by most inmates or fails to address many of their particular needs.

Although the primary goal of HIV education in prisons is prevention, other critical objectives include promoting an understanding that engenders rational and humane treatment of affected inmates. Because of the dynamics of the correctional setting, information provided by people who are not prisoners, from general facts to specific medical advice, often is not trusted. Recommendations to begin antiretroviral therapy, for instance, have not been accepted as readily in prisons as in the general community. Therefore, HIV education in prisons must transmit information in a manner that addresses and bridges not only language, culture, and literacy gaps, but also the distrust of people on the other side of the bars. Individual counseling, peer counseling, support groups, and special programs for women, designed by and for prisoners, have been successful in a number of institutions and seem to be the best educational tools. Several gripping and effective videotapes have been made by and for prisoners.

Coupling educational programs with voluntary testing and counseling services has been effective in identifying individuals with previously unknown infection, promoting acceptance of and adherence to treatment interventions and postrelease follow-up, and reducing risk behavior in custody and after release.(55,56) An analysis of the cost effectiveness of HIV counseling and testing in U.S. prisons identified cost benefits from reduction of HIV transmission among otherwise unidentified and uninformed people.(57)

Accurate and adequate information for staff and inmates can reduce fears and ultimately affect institutional policies in ways that can alter prisoners’ lives profoundly. All persons entering prison must be informed in clear, simple terms, and in their own language, about how to avoid transmission of HIV and other communicable diseases. Educational programs can reduce fears about HIV and its transmission among staff members and inmates.

A Quebec City study of staff members from probation agencies, halfway houses, and prisons found that prison officers were the group least informed about HIV transmission and prevention and expressed the most negative attitudes about HIV-infected people.(58) A Pennsylvania prison study reported that prisoners, staff, community groups, and legal authorities believe the “quality of life for HIV-positive inmates was most influenced by education of prison staff. Effective education for staff and inmates was live and interactive, targeted to the perceived risk of distrustful audiences, delivered by a trusted source, accurate, and aimed at reducing risk-perception.”(59)

Condoms
Condom availability in prison is one of the many issues over which legal interests and public health interests conflict. Most prison administrators in the United States have not permitted the distribution of condoms to inmates. Statutes in many jurisdictions make sexual activity in prison a punishable crime. It is argued that condom distribution would condone and promote this behavior. Another objection to condoms in institutions is that they are considered contraband-a container for hiding drugs or other illegal things that inmates may swallow and later retrieve.

In the United States, condoms are available in state prisons in Vermont and Mississippi and in urban jail systems in New York City, Philadelphia, Los Angeles, San Francisco, and the District of Columbia. Condoms have been available in most European prisons for more than 10 years. Studies have found few incidents of improper condom use (eg, as a container for swallowed illegal drugs) and a high level of reported safer sex.