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The

NEW ENGLA ND JOURNAL

of

MEDICINE

Perspective
january 11, 2007

Sex, Drugs, Prisons, and HIV
Susan Okie, M.D.

O

ne recent morning at a medium-security compound at Rhode Island’s state prison, Mr. M,
a middle-aged black inmate, described some of the
high-risk behavior he has witnessed while serving

time. “I’ve seen it all,” he said,
smiling and rolling his eyes. “We
have a lot of risky sexual activities. . . . Almost every second
or minute, somebody’s sneaking
and doing something.” Some participants are homosexual, he added; others are “curious, bisexual,
bored, lonely, and . . . experimenting.” As in all U.S. prisons,
sex is illegal at the facility; as in
nearly all, condoms are prohibited.
Some inmates try to take precautions, fashioning makeshift condoms from latex gloves or sandwich bags. Most, however, “are so
frustrated that they are not thinking of the consequences except for
later,” said Mr. M.
Drugs, and sometimes needles

and syringes, find their way inside
the walls. “I’ve seen the lifers that
just don’t care,” Mr. M said. “They
share needles and don’t take a
minute to rinse them.” In the
1990s, he said, “needles were coming in by the handful,” but prison officials have since stopped
that traffic, and inmates who take
illicit drugs usually snort or swallow them. Tattooing, although
also prohibited, has been popular at times. “A lot of people I’ve
known caught hepatitis from tattooing,” Mr. M said. “They use
staples, a nail . . . anything with
a point.”
Mr. M had just undergone a
checkup performed by Dr. Josiah
D. Rich, a professor of medicine

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at Brown University Medical School,
who provides him with medical
care as part of a long-standing
arrangement between Brown and
the Adult Correctional Institute
in Cranston. Two years ago, Mr.
M was hospitalized with pneumonia and meningitis. “I was
scared and in denial,” he said.
Now, thanks to treatment with
antiretroviral drugs, “I’m doing
great, and I feel good,” he reported. “I am HIV-positive and still
healthy and still look fabulous.”
U.S. public health experts consider the Rhode Island prison’s
human immunodeficiency virus
(HIV) counseling and testing practices, medical care, and prerelease
services to be among the best in
the country. Yet according to international guidelines for reducing the risk of HIV transmission
inside prisons, all U.S. prison systems fall short. Recognizing that
sex occurs in prison despite pro-

january 11, 2007

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105

PE R S PE C T IV E

Sex, Drugs, Prisons, and HIV

hibitions, the World Health Organization (WHO) and the Joint
United Nations Program on HIV/
AIDS (UNAIDS) have recommended for more than a decade that
condoms be made available to
prisoners. They also recommend
that prisoners have access to
bleach for cleaning injecting equipment, that drug-dependence treatment and methadone maintenance
programs be offered in prisons if
they are provided in the community, and that needle-exchange programs be considered.
Prisons in several Western European countries and in Australia,
Canada, Kyrgyzstan, Belarus, Moldova, Indonesia, and Iran have
adopted some or all of these approaches to “harm reduction,”
with largely favorable results. For
example, programs providing
sterile needles and syringes have
been established in some 50 prisons in eight countries; evaluations of such programs in Switzerland, Spain, and Germany
found no increase in drug use, a
dramatic decrease in needle sharing, no new cases of infection
with HIV or hepatitis B or C, and
no reported instances of needles
being used as weapons.1 Nevertheless, in the United States, condoms are currently provided on a
limited basis in only two state
prison systems (Vermont and Mississippi) and five county jail systems (New York, Philadelphia, San
Francisco, Los Angeles, and Washington, DC). Methadone maintenance programs are rarer still,
and no U.S. prison has piloted a
needle-exchange program.
The U.S. prison population has
reached record numbers — at
the end of 2005, more than 2.2
million American adults were incarcerated, according to the Justice Department. And drug-related

106

offenses are a major reason for
the population growth, accounting for 49% of the increase between 1995 and 2003. Moreover,
in 2005, more than half of all inmates had a mental health prob-

lem, and doctors who treat prisoners say that many have used
illicit drugs as self-medication for
untreated mental disorders.
In the United States in 2004
(see table), 1.8% of prison inmates
were HIV-positive, more than four
times the estimated rate in the
general population; the rate of
confirmed AIDS cases is also
substantially higher (see graph).2
Some behaviors that increase the
risk of contracting HIV and other
bloodborne or sexually transmit-

ted infections can also lead to
incarceration, and the burden of
infectious diseases in prisons is
high. It has been estimated that
each year, about 25% of all HIVinfected persons in the United
States spend time in a correctional facility, as do 33% of persons with hepatitis C virus (HCV)
infection and 40% of those with
active tuberculosis.3
Critics in the public health community have been urging U.S. prison officials to do more to prevent
HIV transmission, to improve diagnosis and treatment in prisons,
and to expand programs for reducing high-risk behavior after
release. The debate over such preventive strategies as providing condoms and needles reflects philosophical differences, as well as
uncertainty about the frequency
of HIV transmission inside prisons. The UNAIDS and WHO recommendations assume that sexual activity and injection of drugs by
inmates cannot be entirely eliminated and aim to protect both
prisoners and the public from
HIV, HCV, and other diseases.
But many U.S. prison officials
contend that providing needles
or condoms would send a mixed
message. By distributing condoms,
“you’re saying sex, whether con-

HIV–AIDS among Prison Inmates at the End of 2004.*
Jurisdictions with the Most
Prisoners Living with HIV–AIDS

No. of Inmates Living
with HIV–AIDS

Prevalence
of HIV–AIDS

New York

4500

7.0

Florida

3250

3.9

Texas

2405

1.7

Federal system

1680

1.1

California

1212

0.7

Georgia

1109

2.2

%

* Data are from Maruschak.2

n engl j med 356;2

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january 11, 2007

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No. of Cases of AIDS per 10,000

PE R S PE C TI V E

Sex, Drugs, Prisons, and HIV

60

Prisoners

40

20
General population
0

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Rates of Confirmed AIDS Cases in the General Population and among State and
Federal Prisoners, 1993–2004.
Data are from Maruschak.2

sensual or not, is OK,” said Lieutenant Gerald Ducharme, a guard
at the Rhode Island prison. “It’s
a detriment to what we’re trying
to enforce.” U.S. prison populations have higher rates of mental illness and violence than their
European counterparts, which,
some researchers argue, might
make providing needles more dangerous. And some believe that
whereas European prison officials
tend to be pragmatic, many U.S.
officials adopt a “just deserts” philosophy, viewing infections as the
consequences of breaking prison
rules.
Studies involving state-prison
inmates suggest that the frequency of HIV transmission is low but
not negligible. For example, between 1988 — when the Georgia
Department of Corrections began mandatory HIV testing of all
inmates on entry to prison and
voluntary testing thereafter — and
2005, HIV seroconversion occurred
in 88 male inmates in Georgia
state prisons. HIV transmission
in prison was associated with men
having sex with other men or receiving a tattoo.4 In another study

in a southeastern state, Christopher Krebs of RTI International
documented that 33 of 5265 male
prison inmates (0.63%) contracted HIV while in prison.5 But Krebs
points out that “when you have
a large prison population, as our
country does . . . you do start
thinking about large numbers of
people contracting HIV.”
Studies of high-risk behavior
in prisons yield widely varying frequency estimates: for example, estimates of the proportion of male
inmates who have sex with other
men range from 2 to 65%, and
estimates of the proportion who
are sexually assaulted range from
0 to 40%.5 Such variations may reflect differences in research methods, inmate populations, and prison conditions that affect privacy
and opportunity. Researchers emphasize that classifying prison sex
as either consensual or forced is
often overly simplistic: an inmate
may provide sexual favors to another in return for protection or
for other reasons. Better information on sexual transmission of
HIV in prisons may eventually become available as a result of the

n engl j med 356;2

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Prison Rape Elimination Act of
2003, which requires the Justice
Department to collect statistics on
prison rape and to provide funds
for educating prison staff and
inmates about the subject.
Theodore M. Hammett of the
Domestic Health, Health Policy,
and Clinical Research Division of
Abt Associates, a Massachusettsbased policy research and consulting firm, acknowledged that
for political reasons U.S. prisons
are unlikely to accept needleexchange programs, but he said
adoption of other HIV-prevention
measures is long overdue. “Condoms ought to be widely available in prisons,” he said. “From
a public health standpoint, I think
there’s little question that that
should be done. Methadone, also
— all kinds of drug [abuse] treatment should be much more widely
available in correctional settings.”
Methadone maintenance programs
for inmates have been established
in a few jails and prisons, including those in New York City, Albuquerque, and San Juan, Puerto
Rico. Brown University’s Rich is
currently conducting a randomized, controlled trial at the Rhode
Island facility, sponsored by the
National Institutes of Health, to
determine whether starting methadone maintenance in heroinaddicted inmates a month before
their release will lead to better
health outcomes and reduced recidivism, as compared with providing either usual care or referral
to community methadone programs at the time of release.
At the Rhode Island prison,
the medical program focuses on
identifying HIV-infected inmates,
treating them, teaching them how
to avoid transmitting the virus,
addressing drug dependence, and
when they’re released, referring

january 11, 2007

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107

PE R S PE C T IV E

Sex, Drugs, Prisons, and HIV

them to a program that arranges
for HIV care and other assistance,
including methadone maintenance
treatment if needed. The prison
offers routine HIV testing, and
90% of inmates accept it. One
third of the state’s HIV cases have
been diagnosed at the prison.
“These people are a target population and a captive one,” noted
Rich. “We should use this time”
for health care and prevention.
Nationally, 73% of state inmates
and 77% of federal inmates surveyed in 2004 said they had been
tested for HIV in prison. State
policies vary, with 20 states reportedly testing all inmates and the
rest offering tests for high-risk
groups, at inmates’ request, or in
specific situations. Researchers
said inmate acceptance rates also
vary widely, depending on how
the test is presented. Drugs for
treating HIV-infected prisoners
are not covered by federal programs, and prison budgets often
contain inadequate funding for

health services. “You can see how,
in some cases, there could be a
disincentive for really pushing
testing,” Hammett said.
Critics of U.S. penal policies
contend that incarceration has
exacerbated the HIV epidemic
among blacks, who are disproportionately represented in the
prison population, accounting for
40% of inmates. A new report
by the National Minority AIDS
Council calls for routine, voluntary HIV testing in prisons and
on release, making condoms available, and expanding reentry programs that address HIV prevention, substance abuse, mental
health, and housing needs as prisoners return to the community.
“Any reservoir of infection that
is as large as a prison would warrant, by simple public health logic,
that we do our best . . . to reduce the risk of transmission”
both inside and outside the walls,
said Robert E. Fullilove of Columbia University’s Mailman School of

Public Health, who wrote the report. “The issue has never been,
Do we understand what has to
happen to reduce the risks? . . .
It’s always been, Do we have the
political will necessary to put
what we know is effective into
operation?”
An interview with Theodore Hammett can be
heard at www.nejm.org.
Dr. Okie is a contributing editor of the Journal.
1. Dolan K, Rutter S, Wodak AD. Prisonbased syringe exchange programmes: a review of international research and development. Addiction 2003;98:153-8.
2. Maruschak LM. HIV in prisons, 2004.
Washington, DC: Bureau of Justice Statistics,
November 2006.
3. Hammett TM, Harmon MP, Rhodes W.
The burden of infectious disease among inmates of and releasees from US correctional
facilities, 1997. Am J Public Health 2002;92:
1789-94.
4. HIV transmission among male inmates in
a state prison system — Georgia, 1992–2005.
MMWR Morb Mortal Wkly Rep 2006;55:4216.
5. Krebs CP. Inmate factors associated with
HIV transmission in prison. Criminology Public Policy 2006;5:113-36.
Copyright © 2007 Massachusetts Medical Society.

Concurrent Sentences — Dialysis in the State Penitentiary
Eric M. Gibney, M.D.

I

was driving the last desolate
stretch of road to the state penitentiary, headed to visit patients
undergoing dialysis. I was well
outside my comfort zone of the
university transplantation clinic, and I was tense. The prison
loomed large in my imagination,
a caricature of every forbidding,
barbed-wire-and-cinderblock
jailhouse I had seen in the movies. Along the road, a sign marked
the boundary of the Great Dismal
Swamp.
I called ahead to Ms. Tuttle,

108

the nurse who would meet me
at the gate. “Tuttle,” she answered
the phone. The others would identify themselves similarly — a curt
surname only. Prison culture had
seeped into everyone; the nurses
had started to sound much like
the guards and the inmates.
In the parking lot, I shed all
the badges of my profession —
the cell phone, the pager, even
the stethoscope — and stashed
them in my glove compartment.
The prison was more sterile and
less frightening than I had imag-

n engl j med 356;2

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ined. Tuttle found me, and after
being marched through a metal
detector, I climbed into a golf cart
with her for the ride over to Building G, where 15 prisoners had
been on dialysis since 4 a.m. The
next shift started at 9, and I was
scheduled to meet my patients.
I had been to a prison ward before, as a medicine resident visiting sick inmates on the 19th floor
of Bellevue Hospital in New York.
I remembered the prison doctor
there, Rip Hafer, whose giant
stature and booming voice had

january 11, 2007

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