Incarceration and HIVCathy Elliott-Olufs, M.A.Laura McTighe, MTS

Correctional facilities are critical settings for the efficient delivery of prevention and treatment

interventions for infectious diseases. Such interventions stand to benefit not only inmates, their families, and partners, but also the public

health of the communities to which inmates return.

—T. M. HammettAmerican Journal of Public Health

Mission Statement

The Center for Health Justice empowers people affected by incarceration and HIV to make healthier choices and advocates for the elimination of disparities between prisoner health and public health. To achieve our mission, we advocate for HIV+ prisoners and provide HIV/AIDS, STD and Hepatitis education and treatment information to prisoners in California and throughout the United States.

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CHJ Services Areas

Policy and Advocacy

Re-Entry Support

In-Custody EducationServices

Community Outreach HIV Classes Medical ReferralsLegislative Involvement Individual Counseling Housing ReferralsPrevention Advocacy Hepatitis C Education Job CounselingHealth Advocacy STD Education Skills-BuildingPublic Awareness Inmate Hotline Clothing VouchersCondom Access Women’s Programs Risk-Reduction SupportCustody Staff Training Pre-Release Planning Hygiene KitsConsulting Treatment Education Educational Referrals Public Speaking Linkage to Care Moral Support

Mission Statement

The Institute for Community Justice is a Philadelphia-based national initiative committed to locally-rooted, national work to reduce not only the number of people in prison living with HIV, but also the lasting effects of mass imprisonment on communities most affected. By centering the wisdom and experiences of formerly imprisoned community leaders, we work to amplify existing efforts to build safe and vibrant communities, push for needed policy change, and realize our vision for community-led transformative justice.

Our Core Projects

•Reentry Organizing Center – a community center dedicated to helping people navigate the hurdles of self care, recidivism prevention, and political engagement.•TEACH Inside/TEACH Outside – an empowerment-based educational program on the intake housing units of the Philadelphia jails and in the community•Support Center for Prison Advocacy – a city-wide, neighborhood-based prison reentry resource center without walls in North, South and West Philly•Prison Health News – the nation’s only health newsletter written by and for people who are in prison

Overview of United States Correctional System

At end of year 2008

• The total number of inmates held in federal or state adult correctional authorities was 1,570,861—a 2.8% increase over 2005 year-end total1

– The prison population grew at a faster rate than the previous five years

• The total number of inmates held in local jails was 766,010—a 2.5% increase over 20051

• 1 in every 133 US residents was in prison or jail1

• Overall, the United States incarcerated 2,258,983 people—a 2.9% increase over the 2005 year-end total—and the most in the world2

1US Dept of Justice, Bureau of Justice Statistics. Prisoners in 2006. NCJ publication 219416. http://www.ojp.usdoj.gov/bjs/pub/pdf/p06.pdf. Published December 2007. Accessed Jan 9, 2008.2National Council on Crime and Delinquency. US Rates of Incarceration: A Global Perspective (FOCUS). http://www.nccd-crc.org/nccd/pubs/2006nov_factsheet_incarceration.pdf. Published November 2006. Accessed Jan 9, 2008.

0

400,000

800,000

1,200,000

1,600,000

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

Jails Prisons

US Incarcerated Population

US Dept of Justice, Bureau of Justice Statistics. Prisoners in 2006. NCJ publication 219416. http://www.ojp.usdoj.gov/bjs/pub/pdf/p06.pdf. Published December 2007. Accessed Jan 9, 2008.

Jail

• Short-term facility

• Usually operated by a city, county, or local government

• Holds arrestees awaiting trial or sentencing and inmates convicted and sentenced to less than 1 year

• Approximately 50% of arrestees are released within 48 hours1

• Public health interventions (eg, screening, testing, counseling, making referrals) must happen QUICKLY or not at all

• Most jails do very little screening—usually only for tuberculosis, sometimes for sexually transmitted diseases (STDs), sometimes for pregnancy and HIV

• Mean expected time of jail stay is 9 months2

1CDC. MMWR 1998;47:429-31.2US Dept of Justice, Bureau of Justice Statistics. Profile of Jail Inmates, 2002. NCJ publication 201932. http://www.ojp.usdoj.gov/bjs/pub/pdf/pji02.pdf. Published July 2004. Accessed Jan 15, 2008.Adapted from: de Ravello L; CDC. Prisons and drug abuse: challenges to HIV perinatal prevention efforts. http://www.cdc.gov/hiv/topics/perinatal/resources/meetings/2002/pdf/ps_prison.pdf. Published Feb. 13, 2002. Accessed Jan 9, 2008.

Prison

• Longer-term facility

• Usually operated by the state or federal government

• Greater opportunity to implement long-term public health interventions with follow-up

• Very comprehensive medical intake process, but the level and quality of ongoing medical care varies

Adapted from: de Ravello L; CDC. Prisons and drug abuse: challenges to HIV perinatal prevention efforts. http://www.cdc.gov/hiv/topics/perinatal/resources/meetings/2002/pdf/ps_prison.pdf. Published Feb. 13, 2002. Accessed Jan 9, 2008.

Top 10 HIV Seroprevalence Rates Among Incarcerated

StateOverall % HIV

Seroprevalence RateFemale

Seroprevalence RateMale

Seroprevalence Rate

NY 7.0% 14.1 6.7

FL 3.9% 5.7 3.8

MD 3.0% 6.9 2.8

MS 2.7% 2.5 2.7

CT 2.6% 4.0 2.5

LA 2.5% 3.2 2.5

NJ 2.3% 6.8 2.1

SC 2.2% 2.5 2.2

GA 2.1% 3.2 2.1

MA 2.1% 3.3 2.0

US Dept of Justice, Bureau of Justice Statistics. HIV in Prisons, 2005; Appendix Tables 1 and 2. NCJ publication 218915. http://www.ojp.gov/bjs/pub/pdf/hivp05.pdf. Published Sept. 2007. Accessed Jan 9, 2008.

US HIV-Positive Prison Population—2008

• 16.9% of all PLWHA in the US were in a correctional facility at some point (2006).

• On December 31, 2008, a reported 20,449 state prisoners and 1,538

federal prisoners were HIV positive or had confirmed AIDS

• 1 in 5 Black and Hispanic males released from corrections facility in US are HIV-positive.

• The percentage of female inmates with HIV/AIDS decreased slightly from 2.1 percent to 1.9 percent.

1. US Dept of Justice, Bureau of Justice Statistics. HIV in Prisons, 2008; 2. 1Maruschak LM et.al. US Department of Justice, Bureau of Justice Statistics, Bulletin, April 2008.3. Spaulding AC et.al. PLoS One, 2009

HIV Transmission in Correctional Settings

• The majority of HIV-positive people are infected before they enter prison1

• HIV risk behaviors often continue inside the institution and include injecting drug use, tattooing, body piercing, and consensual, nonconsensual, and survival sexual activities2

• The scarcity of sterile drug paraphernalia leads to needle sharing in prison3

• Needle sharing among soon-to-be released prisoners is high4

• Among IDUs in New Mexico, 37.6% of those with tattoos received them in jail or prison5

– Tattoos received in prison were associated with increased risk for HBV and HCV

1. CDC. MMWR. 2006;55(15):421-426.2. Hammett TM. Am J Pub Health. 2006;96(6):974-978.3. Davies R. Lancet. 2004:364:317-318.4. Stephens TT et al. Am J Health Stud. 2005.5. Samuel MC et al. Epidemiol Infect. 2001;127:475-484.

Incarceration is a Social Driver of HIV/AIDS

“We must remember… that incarceration itself—not just inadequate prevention and care behind bars—contributes substantially to the global burden of HIV, particularly among drug users and sex workers.

In fact, we would argue that the single most important strategy single most important strategy in controlling HIV in prison is to

stem the rate of incarceration itselfstem the rate of incarceration itself.”1

1Duncan Smith-Rohrberg Maru, Sanjay Basu, & Frederick L Altice. (2007) "HIV control efforts should directly address incarceration.” The Lancet Infectious Diseases: Vol. 7 No. 9.

Understanding Community-Level Vulnerability

Relationship

Instability

Fractured Communitie

s

Loss of Caregivers

Financial

Instability

Broken Family Ties

Lack of Jobs

Lack of Social

Services

Fractured Communiti

es Arrest – Jail/Prison –

ReentryNeed for Services and Support

From Vulnerability to Community Health

Relationship

Stability

Community Community WholenessWholeness

Family Suppor

t

Financial

Stability Family Reintegr

ation

Ready Employm

ent

Access to Social

Services

Community Community WholenessWholenessArrest – Jail/Prison –

ReentryComprehensive Care and

Support

Working at the Intersection of HIV and Incarceration

• Testing

• Prevention

• Treatment and Care

• Treatment and Prevention Education

• Reentry Support

• Structural Interventions

Mandatory HIV Testing Policies by State

No testing required

On entry

On release

On entry and in custody

On entry and on release

In custody and on release

On entry, in custody, and on release

All states test upon inmate requestexcept NH, IA, AL, KY, UT, and NV

US Dept of Justice, Bureau of Justice Statistics. HIV in Prisons, 2005; Appendix, Table 5. NCJ publication 218915. http://www.ojp.usdoj.gov/bjs/pub/pdf/p05.pdf. Published Sept. 2007. Accessed Jan 9, 2008.

Not reported

Condom in Prison Programs Nationwide

• County Jails

Los Angeles, San Francisco, Philadelphia, Washington, D.C. and New York

• State Prisons

California, Mississippi and Vermont

CHJ’s Condom Distribution

Los Angeles County Jail• Operated without incident for 7 years

• Distributed over 30,000 condoms

• Approximately 200-250 condoms per week

– Limited to K-6G Unit (ie. gay unit)

– One condom per week per inmate (now expanded)

– In conjunction with brief educational session

• Several small evaluations have been conducted.

• Findings indicate that condoms are being used and ongoing research is underway to determine whether high-risk sexual activity is reduced by access to condoms

San Francisco County Jail• Collaboration with Forensic AIDS Project

Program

• Since 1987

• Previously in one-on-one in health educator sessions

• Now offered via a condom dispensing machine in the gym (free)

Solano State Prison• Pilot program implemented Aug/Sep. 2008

• Under order from the Governor of California to determine feasibility of prisoner access to condoms

• Center for Health Justice selected to implement a condom machine and educational program

• Evaluation underway

HIV Treatment and Care in Prison

HIV-infected inmates are more likely to be HIV-infected inmates are more likely to be offered antiretroviral therapy in prisonoffered antiretroviral therapy in prison

Prisoners offered ART in prison (only)

64%ART offered in another setting

36%

Altice F et al. J Acquir Immune Defic Syndr. 2001;28:47-58.Study data collected from the Connecticut Department of Corrections (DOC)

Only 3% of HIV+ prisoners are on ART

at time of incarceration

HIV and Hepatitis Prevention and Treatment Education Train-the-Trainer Program for State Prison Settings

TEACH Outside (people living with HIV coming out of jail/prison)

TEACH Inside/TEACH Outside (all people passing through the Philly jails)

Reentry Support Programs

Who in the room??

In Communities:Sentencing reformCommunitypolicingPrison budget reinvestmentYouth empowerment

In Jail/Prison:Harm reduction programs Treatment education and advocacyGood time earned time

At Reentry:Civic participationCommunity-led mentoringJob creation and retentionHousing expansion

25Thinking About Structural Interventions

Research Advocacy Directions

• Lack of connection among those of us doing this work

• Lack of dissemination of programs we know work

• Lack of programming to reach jail-based populations and those on parole

• Lack of research on incarceration as a social driver of HIV in the US

• Lack of models for effective structural interventions

Thank You!