Introduction
Prisoners are at exceptional risk for infection with HIV because of the association of injection drug use with incarceration. Women prisoners who have practiced prostitution, which frequently is associated with injection drug use and contact with HIV-infected sex partners, are at additional risk for HIV infection. This chapter reviews the following issues involved with HIV infection in prisoners: epidemiology, prevalence, and transmission; the growing coincidence of tuberculosis and hepatitis C; institutional issues, including prison policies and practices, confidentiality, informed consent, and medical research; the extensive involvement of the legal system in the area of HIV in prisoners; and the role of educational programs in prevention efforts.

Epidemiology and Background
As of December 31, 2004, nearly 7 million people in the United States lived under the jurisdiction of the criminal justice system, and more than 2.2 million were in jail or prison. The United States imprisons its population at the highest known rate in the world, 724 per 100,000 persons in 2004. In 1998, 11.5 million people were released from jails and prisons into communities in the United States. These figures, which continue to increase, reflect the country’s adherence to a formidable social policy of imprisonment and raise the public health issue of the huge impact that prisoners’ health will have on the community at large. Prison populations have grown in recent decades primarily because incarceration has been the central tactic of the “war on drugs” in the United States. The millions of intermittently incarcerated people in America, many of whom are illicit drug users, have been among the most difficult people to reach with critical health information, management, and treatment. The National Commission on AIDS stated in its 1991 report: “By choosing mass imprisonment as the federal and state governments’ response to the use of drugs, we have created a de facto policy of incarcerating more and more individuals with HIV infection.” Fifty-seven percent of federal prisoners were incarcerated for drug-related offenses in 2001.(1,2-4)

The AIDS prevalence in 2003 was more than 3 times higher in state and federal prisons (0.51%) than in the general U.S. population (0.15%).(3) Between 20% and 26% of people living with HIV/AIDS in the United States have spent time in the correctional system.(5) No precise count of HIV cases in prisoners is available, as brief incarceration, particularly in jails, limited access to health care, and lack of universal screening hinder the identification and diagnosis of inmates with HIV infection. Also, arrestees may choose not to declare their HIV status.

In 2003, a U.S. National Institute of Justice survey of the 50 state prison systems and the federal prison system reported 5,944 current AIDS cases.(3) New York, Texas, and Florida accounted for nearly half of the confirmed AIDS cases within the 50 state prison systems.

HIV seroprevalence reported by the 50 state prison systems was 1.9%, and 1.1% in the federal prisons, in 2003.(3) Jails in the south and northeast accounted for 80% of known HIV-infected inmates. Greatest seroprevalence was found in jails in the largest jurisdictions: the District of Columbia (7.6%), New York (4.3%), and Massachusetts (4.0%).

The 2002 Survey of Inmates in Local Jails was conducted by asking inmates for their HIV testing history and status. From a pool of 3,365 jails previously surveyed in 1999, a sample of 465 jails was selected in 2002. A total of 6,982 inmates in 420 jails agreed to participate, and the percentage of HIV-positive males in the local jail population in 2002 was determined to be 0.8-1.6%.(4)

Female inmates, accounting for 5-10% of the prison population, have had a higher HIV antibody seroprevalence than male prisoners (2.8% compared with 1.9%, respectively, in 2003). This discrepancy exists in most state prison systems, and cumulatively in each of the 4 regions identified by the U.S. Department of Justice: Northeast, Midwest, South, and West. More than 10% of all female inmates were known to be HIV positive in 2 states: New York and Maryland (14.6% and 11.1%, respectively). In all states, <10% of male inmates were reported to be HIV positive. Only New York reported >5% seroprevalence among male prisoners (7.4%).(3)

HIV seroprevalence in U.S. prison inmates parallels the uneven geographic distribution of HIV in injection drug users (IDUs) and regional patterns of incarceration and case finding. A comparison of prison AIDS cases with total U.S. AIDS cases in 1994-96 found that 61% of prisoners had injected drugs, compared with 27% of total cases.(6) A report from the state of New York on changing HIV seropositivity identified a decreasing incidence of HIV in newly admitted inmates between 1998 and 2003. Increasingly, persons of African American or Hispanic race, those >30 years of age, and men who have sex with men (MSM) have approached IDUs as predictor groups for seropositivity.(7)

The disproportionate burden of HIV infection among racial minorities is more pronounced in prison than in the community at large. A comparison of prison and total AIDS deaths found that African Americans comprise more than two thirds of prison cases, compared with 39% of total cases. A 2001 report from Maryland of 888 AIDS cases identified in the state’s prisons noted that 91% were African American, compared with 75% statewide.(8)

Improved HIV identification and treatment in the late 1990s resulted in a precipitous drop in AIDS deaths among the incarcerated population as well as in the community at large. In 2003, a total of 268 state prisoners died of AIDS, down from 1,010 in 1995. The number 268 was determined by the use of 2 reporting systems, the National Prisoner Statistics and the additional Deaths in Custody Reporting Program, enacted in 2000. In 2001, the Bureau of Justice Statistics began collecting individualized details about deaths in state prisons, which corrected some previous underreporting of AIDS-related deaths. In 2002, the percentage of deaths due to AIDS in prisons was more than 2 times that of the U.S. general population.(3)

The state of New York has had the longest and the largest experience with HIV in its prison system, and the New York State Commission of Correction has published the most extensive reports on state prison cases of HIV infection beginning in the 1980s. As of the end of 2003, one fifth of all inmates in the United States known to be HIV infected were in New York prisons. New York had recorded 2,186 prison deaths from AIDS through September 1996. New York’s early experience with huge numbers of prisoners with HIV offered a view into the future for other prison systems.(9,10) By 2003, however, HIV seroprevalence among inmates entering state prisons in New York had declined 75% for males and 40% for females.

Other nations began reporting AIDS cases in prisons several years after the United States. However, the rate of increase in such cases has been steep. Countries with particularly high seroprevalence identified among prisoners include Brazil (15% in 2001 [0.6% for the general community]), Co^te d’Ivoire (27.5% in 2001 [10.8% for the general community]), South Africa (40% in 2003), Zambia (26.7%), Nigeria (9.0%), Honduras (6.8%), Russian Federation (3.1%), Netherlands (3.1%), France (4.1%), and Spain (16.4% in 2000).(11-16)

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Elizabeth Kantor, MD
University of California San Francisco

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Dr. Elizabeth Kantor MD practices geriatric medicine and internal medicine in San Francisco, California.

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REFERENCES

1. U.S. National Commission on AIDS. HIV Disease in Correctional Facilities. Washington: U.S. National Commission on AIDS; 1991.
2. Harrison P, Beck AJ. Prisoners in 2004. Washington: U.S. Department of Justice, Bureau of Justice Statistics; October 2005.
3. Maruschak L. HIV in Prisons, 2003. Washington: U.S. Department of Justice, Bureau of Justice Statistics; September 2005.
4. Maruschak L. HIV in Prisons and Jails, 2002. Washington: U.S. Department of Justice, Bureau of Justice Statistics; December 2004.
5. Hammett TM, Harmon P, Rhodes W. The Burden of Infectious Disease Among Inmates and Releasees from Correctional Facilities. In: The Health Status of Soon-to-Be-Released Inmates: A Report to Congress. Vol. 2. Chicago: National Commission on Correctional Health Care; March 2002.

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