AIDS deaths among prisoners have become less frequent. However, in the 1980s, the time from AIDS diagnosis until death was shortened to 42% (in 1986) and then 66% (in 1988) as long as that of matched New York City unincarcerated persons with AIDS. The survival time for female inmates in the state of New York was much worse than that for male inmates.(17) In addition, HIV-infected inmates with a first case of Pneumocystis jiroveci pneumonia (PCP) had a 22% mortality rate, compared with an 8% rate among patients with HIV and PCP in the community at large in 1989.(18) A remarkable statistic from New York in 1988 was that >25% diagnoses of AIDS, as defined by the U.S. Centers for Disease Control and Prevention (CDC), in prison settings were first made at autopsy.(19) In 1997, AIDS diagnoses of inmates in the state of New York were still often established only at autopsy, delaying statistical monitoring by at least 8 months, pending autopsy completion. Some diagnoses of tuberculosis (TB) in inmates were made only at autopsy. Although New York held one third of all prisoners in the United States known to be HIV positive, a 2001 report showed that the number of AIDS deaths in 1999 among prisoners in that state was 26, down from an annual peak of 258 in 1994, and the lowest it had been in 16 years. In 2003, when New York still reported the nation’s highest HIV seroprevalence among its prisoners, the highest death rates from AIDS-related causes were reported in Delaware, Maryland, and Florida.(3) The availability of antiretroviral drugs for prisoners, increasing number of specialists in HIV care among prison medical staffs, and the lower rate of HIV seroprevalence among inmates are all believed to be factors contributing to the reduced frequency of AIDS-related deaths among prisoners.

A report from Spain describes a parallel improvement in case identification and survival. A review of the delay between time of discovery of HIV seropositivity and diagnosis of AIDS revealed that, in 1984, 100% of prisoners’ HIV infections were diagnosed in the same month as AIDS, whereas in 2000 only 4% of HIV and AIDS diagnoses were made within a month of each other.(20)

HIV Transmission in Prisons
Numerous activities known to occur among prisoners pose a risk for HIV infection. Several studies have identified transmission of HIV in prison, based on serial serotesting for HIV antibody, some identifying seroconversion in inmates after more than 5 years of continuous incarceration.(21-24) Molecular analysis of 14 HIV-positive inmates in Glenochil Prison in Scotland in 1993 found sequencing similarities and clinical histories in 13 of the 14, indicating that transmission had occurred at the institution.(25)

Data gathered in the Georgia State Prisons from mandatory testing of all inmates at intake followed by inmate requested tests, or annual voluntary HIV serotesting which was offered between 2003-2005, identified 88 prisoners who seroconverted between 1992-2005 after one or more negative tests. Investigators analyzed data collected from cases and control subjects through computer assisted self interviews. Characteristics associated with prisoners’ HIV seroconversion were male-male sex in prison, tattooing in prison, age >26 at interview, >5 years served of current prison sentence, black race, and a body mass index <25.4kg/m2 on entry into prison. This CDC report includes a wealth of information about the prisoners, reported risk activities, precautions practiced, and knowledge about and suggestions for prevention of transmission of HIV in prison.(26)

No confirmed cases of HIV infection among prison staff in the United States have been attributed to contact with inmates. There is a report from Australia of seroconversion of an officer who was injected by an HIV-infected inmate with a syringe full of the inmate’s blood.(27)

Sexual activity among male inmates is not uncommon in prisons and jails. A Federal Bureau of Prisons study in 1982 reported that 30% of federal prison inmates engaged in homosexual activity while incarcerated.(28) In a 1984 study of Tennessee inmates, 17% reported homosexual activity in prison.(29) Former prisoners surveyed in New York reported use of makeshift devices for safer sex, such as fingers of latex gloves, when condoms were not available.(30)

The frequency of homosexual rape in jails and prisons is extremely difficult to estimate. The victim who reports rape in prison faces a probability of further suffering and worse injury. The Federal Bureau of Prisons study reported that 9-20% of federal inmates, especially new or homosexual inmates, were victims of rape.(28) The text of the Prison Rape Reduction Act of 2002 states that the best expert estimate of the percentage of individuals who are sexually attacked at least 1 time during their incarceration is a national median of 13.6%. (The act establishes standards for identifying, investigating, and eliminating prison rape in the United States.)

Other incidents of interpersonal violence (including fights involving lacerations, bites, and bleeding in 2 or more participants) present some risks for HIV transmission. Housing more than 1 inmate per cell, common now in crowded institutions, is a major contributing factor to incidents of violence and sexual assault.

British investigators interviewed 452 released prisoners about activities before, during, and after prison stays and found that persons engaged in fewer incidents of HIV risk behavior in prison, but that activities in prison were associated with increased risk. Those who reported engaging in penetrative sex while in prison also reported doing so with greater frequency outside, although they used condoms only outside. Reported sharing of syringes increased during imprisonment, as did less effective methods of syringe cleaning.(31) In another report from the United Kingdom, IDUs who were former prisoners reported a high prevalence of injection and sexual risk behaviors while in prison; 33 of 50 had injected drugs, and 5 of 50 had engaged in sex with 2 to 16 men.(32)

Although imprisoned IDUs do not use drugs with the frequency that they can when they are not incarcerated, they share injection equipment more and sterilize it less because of scarce resources. A handmade syringe may be fashioned from (among other things) parts of pens and light bulbs. Prisoners also may share toothbrushes and shaving equipment in facilities where they are not issued, where inmates are unable to purchase their own, or where infection control precautions are not practiced adequately.

Tattooing is a widespread activity in prisons and usually is performed without fresh or sterile instruments. It involves multiple skin punctures with recycled, sharpened, and altered implements such as staples, paper clips, and the plastic ink tubes from ballpoint pens. Prison wisdom holds that tattooing that causes blood to flow results in the best quality image and is least likely to become infected. Homemade pigment is delivered intradermally (at a sharp angle) rather than through direct puncture. Metal points connected to a battery or other electrical source are capable of producing vibration, increasing the number of skin punctures exponentially, thereby creating a better tattoo, but also increasing the risk of HIV transmission. Body piercing is becoming more popular in prison, as in the outside community, and clean instruments for this practice similarly are unavailable.

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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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