INTRODUCTION

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Published in Monograph No 79, February 2003

HIV/Aids in Prison, Problems, Policies and Potential

KC Goyer

The reality in South Africa is that one need not spend a night in jail to be at risk for HIV infection. The people who are more likely to be incarcerated are also those who are more likely to be HIV positive. The socio-economic factors which significantly contribute to the prevalence of HIV positive within a specific population are very similar to those which lead to criminal activity and incarceration. Poverty is a defining characteristic of both prisoner and HIV positive populations alike. In South Africa, HIV “flourishes most in areas that are burdened by unemployment, homelessness, welfare dependency, prostitution, crime, a high school drop-out rate, and social unrest.”²

The impact of joblessness, illiteracy and a general environment of lawlessness, all commonly considered contributing factors towards criminal behaviour, has also been studied as a factor in HIV infection. The poor are more likely to become migrant labourers or commercial sex workers as a survival strategy. HIV prevalence has also been tied to levels of social cohesion, or the amount of unifying bonds between members of a community, usually supplied by civil society. Areas which struggle with violence, high rates of crime and substance abuse, substandard housing, and overcrowded, unsanitary living conditions are also likely to be plagued by unemployment, domestic abuse, dysfunctional relationships, and a lack of security or stability. Furthermore, the uneducated and illiterate are less likely to be reached by HIV education programmes, and have lower levels of HIV/AIDS knowledge and awareness. Finally, people in marginalised communities are less likely to have access to health care, and thus more likely to suffer from untreated sexually transmitted infections (STIs), which increases the probability of HIV transmission.³

In addition to similar behaviour patterns and social environments, age, race, and gender are significant predictors of HIV infection rates. Young people are at high risk for HIV infection.⁴ Because people between the ages of 18 to 35 are less likely to be in monogamous relationships and have a wider sexual network, they are more likely to contract HIV as well as other sexually transmitted infections (STIs). Furthermore, the presence of STIs in one or both partners increases the risk of HIV transmission not only because the presence of sores allows the virus to enter the skin, but also because untreated STIs can increase the viral load in genital fluids.⁵

In South Africa, the HIV infection rate is highest among the black population: seropositivity is ten times more common in black South Africans than in any other racial category.⁶ Projected HIV prevalence for black men peaks with the 25 to 29 age group with an estimated 38.89% infected with HIV by 2002.⁷ This infection rate is considerably greater—and growing faster—than infection rates in the population as a whole, making young black men a particularly high risk group.⁸ Nationally, 76% of prisoners in South Africa are black men between the ages of 18 to 35, with the most significant portion between the ages of 25 and 35.⁹ The people who are sent to prison are primarily young, black men from marginalized communities with HIV prevalance and low access to health care. All of these characteristics combine to make the prison population at high risk for HIV infection prior to their incarceration.

High risk behaviour prior to incarceration

Marginalized groups are disproportionately represented in the prison population as well as amongst the population of people living with HIV/AIDS. In addition to environmental factors, however, there are several aspects of pre-incarceration behaviour which places prisoners at high risk for HIV infection. High risk behaviour for contracting HIV includes unprotected sex, particularly with multiple partners, commercial sex work, or sex which takes place in exchange for drugs. Drug use is also high risk behaviour, in that the influence of drugs usually leads to other risk taking behaviour including high risk sex as well as sharing needles for intravenous drug use. The potential that this type of pre-incarceration risk-taking will continue after incarceration also exists, in the absence of effective intervention programmes and policies.

In the United States, one in five of all people living with HIV/AIDS pass through a correctional facility each year.¹⁰ In a study of prisoners about to be released, 79% reported unprotected sex with their regular partner prior to incarceration. This number rose to 81% with casual, or non-regular, partners. All pre-release prisoners reported drug use, specifically crack/cocaine in the year prior to incarceration.¹¹ A separate study found that 17% of women and 15% of men had sex with ten or more partners during the 12 months prior to incarceration.¹² This study also found that among men, a history of homelessness (OR=2.8) and selling drugs as a primary income source (OR=4.4) were associated with having ten or more sex partners prior to incarceration. Among the women, receiving money for sex was associated with having ten or more sex partners (OR=25.6).¹³

A recent study in Brazil found that 27% of sexually active prisoners have never used a condom, 67% did not use a condom in the six months prior to incarceration, 43% never used a condom with casual partners, and 41% reported that condom use “interferes in the sexual intercourse”.¹⁴ Even though 84% knew the primary means of transmission of HIV, and 60% perceived themselves to be at high risk for HIV infection, 42% did not use any protection during sexual activities.¹⁵ The estimated HIV prevalence rate in Brazilian prisons is between 13% and 17%.¹⁶

A study conducted at a prison in St. Petersburg, Russia, found that 40% of subjects reported multiple sexual partners in the 12 months prior to incarceration, and of these, 61% never used a condom. Fifty eight percent of subjects reported IV drug use in the 12 months prior to incarceration, and of these, 22% shared a syringe. Amongst reported injection drug users, 46% were HIV positive. The HIV prevalence rate overall was 34%, and 35% of HIV positive prisoners knew their HIV status prior to entering prison. About one third of participants in the study had been previously incarcerated.¹⁷

Given the high burden of HIV in Russian prisons, a pilot HIV/AIDS prevention program has been implemented by Medecins Sans Frontieres (MSF) with the Russian Ministry of Justice. The three-year program includes health promotion publications; training prison officers, health workers and prisoners; bleach and condom distribution; peer education; pre- and post- HIV test counselling; and research. MSF and Russian counterparts are supporting the intervention based on their belief that, “targeting a high prevalence (and very likely high risk) population inside prison makes it possible to prevent the spread of HIV beyond prison walls as well.”¹⁸

High risk behaviour during incarceration

The prevailing types of high risk behaviour for transmission of HIV in the prison environment are contaminated needles and/or other cutting instruments, and high risk sexual activity. The most common forms of transmission in a prison are usually similar to those outside of prison. In countries where intravenous (IV) drug use is endemic, the resultant needle sharing tends to be the principal means of HIV infection. In areas where HIV is primarily transmitted through high risk sex, the same is likely to be true of transmission in the prisons. However, similarities between transmission inside and outside prison will not be exact as there are several aspects of the prison environment which create unique situations and unique risks in any country.

Contaminated needles

Many industrialised nations face a serious problem with intravenous (IV) drug use and the resultant needle sharing. The probability of transmission from shared injection drug equipment is extremely high, second only to receiving a contaminated blood transfusion amongst non-sexual means of transmission. Sentencing practices for drug-related offenses can lead to an extremely high incarceration rate amongst drug users and addicts, particularly in countries where drug policy emphasises criminalisation over rehabilitation. In the United States, there are more IV drug users in American correctional institutions than in drug treatment centres.¹⁹ While in prison, addicts will find ways to continue their habit, but are less likely to obtain clean syringes or disinfectants and thus needle sharing is a widespread practice. The result is that IV drug use is the leading cause of HIV infection in US correctional institutions.²⁰

One of the first studies on HIV in prison in Canada was conducted in a medium security prison for women in Montreal. The researchers found that injection drug use was reported by 50%, and of those who used IV drugs, needle sharing was reported by 84%.²¹ The study concluded that, “Nonsterile injection drug use practices and unprotected sexual activity with an injection drug user were found to be the strongest risk factors for HIV infection.”²²

The Correctional Service of Canada (CSC) has reported that HIV prevalence in prison has increased an average of 27% per year since 1990.²³ Ralf Jürgens, executive director of the Canadian HIV/AIDS Legal Network, claims that needle sharing for injection drugs is the primary reason for the increase in HIV infection in Canadian prisons. Similarly, CSC spokeswoman Michele Pilon-Santilli attributed the high infection rates to the fact that approximately 70% of inmates have drug-related problems prior to incarceration.²⁴

At Glenochill prison for men in central Scotland, 14 of the 350 (4%) prisoners were found to be HIV positive. A phylogenetic analysis of the viral sequences showed that 13 of the 14 HIV positive prisoners had been infected from a common source. The conclusion from the molecular evidence was that these 13 men were infected while incarcerated, most likely as a result of needle sharing for IV drug use.²⁵

The continued use of IV drugs in prison is a pervasive problem in many prison systems. The first study on HIV conducted by HM Prison Service in England and Wales found that 41% of men, 25% of women, and 20% of juveniles who were IV drug users prior to entering prison were able to continue using IV drugs while in prison.²⁶ In a separate study undertaken in England, researchers also found high rates of drug use inside prison. Of 50 men and women studied by one physician, “47 ex-prisoners had taken at least one illegal drug in prison and of these 33 had done so by injection. Twenty six had shared injecting equipment.”²⁷ Another survey in England found that 75% of respondents who admitted to using IV drugs while in prison also reported sharing needles and syringes with others. One ex-prisoner explains, “I was lending my needle to 20 prisoners and I’m HIV. They knew I was HIV.”²⁸

At Featherstone jail in Wolverhampton, England, drug use is so rampant that prisoners who were not users prior to incarceration are becoming addicts by the time they leave the prison. Drug problems were also cited as a cause for increasing violence in the prison, with the result that many inmates were compelled to carry knives to protect themselves. According to a report by Sir David Ramsbotham, Chief Inspector of Prisons at the time, “Many prisoners felt that people came to prisons without a drug problem, but turned to drugs to cope. They then left prison with a heroin habit and inevitably came back to prison for a drug-related crime.”²⁹

Attempts to curb drug use in prison have included random drug testing, but the effects have in some ways become counter-productive. In order to avoid getting caught by a random drug test, prisoners who formerly preferred cannabis, which is detectable for up to a month after use, began switching to heroin, which is out of the system in a few days.³⁰ Heroin is a popular IV drug, while cannabis is normally smoked, and heroin is much more addictive. Therefore, heroin leads to considerably higher risk behaviour for the transmission of HIV.

In countries and regions which do not experience a great deal of heroin or other IV drug use outside of prison, IV drugs will also not be common inside prison. However, the use of contaminated, or unsterilised, needles is not limited to IV drug use. An integral part of the prison sub-culture is the incidence of rudimentary tattooing by inmates on other prisoners.³¹ Most jurisdictions will specifially prohibit tattooing, which leads to the use of smuggled, and usually unsterilised, needles or other cutting instruments.

One of the many health and safety hazards associated with this is the transmission of HIV. The risk of transmission is higher if a tool is used to puncture the skin, is contaminated with HIV positive blood, and is then immediately used on another prisoner. Less likely means for transmitting HIV include sharing razor blades or use of sharp implements in prison violence or self-mutilation. Owing to the relatively secure nature of the prison, needles as well as other cutting instruments are in short supply and are thus more likely to be shared. The risk for HIV transmission from use of contaminated cutting instruments will depend on the amount of blood involved and the time elapsed between uses, as well as the viral load of the infected person and certain biological attributes of the non-infected person.³²

High risk sex

In the context of determining HIV transmission, the difference between sexual activity in prison and in the general population is significant. Three aspects of sexual activity inside the prison make it a higher risk for transmission: anal intercourse, rape and sexually transmitted infections (STIs). Anal intercourse and rape often result in tearing, thus, there is a higher risk of HIV transmission.³³ In addition, a common characteristic of a prisoner’s background is a history of STIs. The risk for transmission and acquisition of HIV is greater among individuals with an STI.³⁴

The probability of transmission of HIV from anal intercourse is much higher for the receptive partner than for the insertive partner. This is because the acceptance of semen into the rectum allows for prolonged contact with mucous membranes. Amongst sexual means of transmission, unprotected receptive anal intercourse carries the highest probability of infection, at 0.5% to 3%. In comparison, the probability of infection for a man participating in unprotected vaginal intercourse with an HIV positive woman is .033% to 0.1%.³⁵ Comparisons of transmission probabilities between various sexual behaviours have sometimes yielded conflicting results, yet one maxim remains true throughout the research to date: “It is clear that unprotected anal intercourse has the highest potential for transmitting the virus.”³⁶

The extent of sexual activity in prisons is difficult to determine because studies must rely on self-reporting, which is distorted by embarrassment or fear of reprisal. Sex is prohibited in most prison systems, leading inmates to deny their involvement in sexual activity. Sex in prison usually takes place in situations of violence or intimidation, thus both perpetrators and victims are disinclined to discuss its occurrence. Finally, sex in prison usually takes the form of homosexual intercourse which carries persistent social stigma. However, perpetrators of homosexual intercourse in the prison environment usually consider themselves to be heterosexual. Consensual homosexual intercourse is not tolerated by the prison sub-culture, which also contributes to the under-reporting of sexual activity in the prison environment.³⁷

Numerous studies have sought to gain information on sexual activity in prison. In Britain, a survey of 453 ex-prisoners found that 10% admitted to participating in unprotected anal penetrative intercourse.³⁸ In a survey of 50 recently released former prisoners in England, four reported having anal sex whilst in custody, with between four and 16 partners.³⁹ The Prison Reform Trust, a policy research NGO based in the UK, has estimated that up to 30% of prisoners become involved in homosexual activity. This estimate is supported by information obtained in a survey conducted by the National Association of Probation Officers, which concluded that “sexual relationships were not unusual between prisoners.”⁴⁰

Prisoner participation in homosexual activity is usually not related to a person’s sexual orientation outside of the prison, but is rather a product of the circumstances within a prison environment. The need for sexual fulfilment is only one part of the prison sexuality dynamic. Sex in the prison environment, particularly in the form of rape, is more often about power and asserting control over another human being than about sexual fulfilment.⁴¹ One study in the United States found that 55% of self-designated heterosexuals reported sexual activity in prison. The same study determined that while 14% of prisoners reported that they were sexually assaulted, 19% had regular sexual partners.⁴²

Prison officials, as well as prisoners themselves, are reluctant to discuss the nature and extent of sexual activity in prison because it indicates a lack of control and/or weak management. With only official statistics and self-reporting to rely on, it is generally assumed that the actual incidence of sex and rape is much higher than the limited information available suggests. In a study of the Philadelphia jail system, interviews with 3,304 prisoners found that more than 2,000 sexual assaults had taken place within 26 months. Although 60,000 men passed through the system in that same time frame, only 96 assaults were reported, 64 were included in prison records, 40 resulted in disciplinary action, and 26 were reported to the police for prosecution.⁴³

In 1999, a study of HIV/AIDS in Malawi prisons was conducted for Penal Reform International at the Zomba central prison complex. The study found that most prisoners and prison officers acknowledged that homosexual intercourse was the most likely form of transmission of HIV in prison and that this activity was common. Respondents estimated that 10% to 60% of prisoners participate in homosexual activity at least once and about one third of these have habitual sex with other prisoners.⁴⁴ The impact of overcrowding was recognised by most respondents, in that most homosexual activity was reported to take place where up to 43 prisoners are kept in one cell. Some prisoners explained that a shortage of blankets would lead to prisoners sharing blankets and that sex would also occur in these situations.

Homosexual activity is referred to as an “unnatural offence” in the Malawi Penal Code and carries a prison sentence of 14 years, therefore it is understandable that homosexual activity inside the prison will be under-reported. Prisoners and wardens explained that only a small portion of prisoners who participate in homosexual activity inside the prison are homosexuals outside of prison, while the rest engage in homosexual activity only because of their situation inside the prison.⁴⁵ Those who consistently serve as the receptive partner are often described as “very needy” as the excerpt below explains:

They are usually recently detained, either juveniles or young adults, who have no blanket, soap, plates or food. They have no relatives from the outside to help them and care of them, they are in physical need and confused by their recent detention and they turn to somebody to care for them. The ones they usually turn to are those who have outside supplies. The relationship between them was described as similar to that between a poor prostitute and a rich client.⁴⁶

Prisoners most likely be the insertive partner were those who worked in the kitchen because they are in a position to offer food as a medium of exchange.⁴⁷

Inquiries about homosexual rape in the Zomba study obtained mixed responses. Juveniles reported that they had, “heard of fellow juveniles having been raped” and some adults reported they had heard of it on occasion but not frequently. Other adults, however, said rape was fairly common but that authorities could be bribed to keep quiet.⁴⁸ The most alarming finding of the study was that prison officials are actively involved in prostitution rings involving juvenile offenders who are “rented” to adult prisoners:

An adult prisoner approaches a prison officer, gives him some money and asks him to get him a boy. You know some prisoners are rich compared to the guards. The guard then smuggles a juvenile into the adult blocks when they are out of the juvenile wing. Once they are there they can be hidden for months, and the man who paid for them rents them out to other prisoners ‘for short time’, using other prisoners to get him customers.⁴⁹

The prostitution rings are in part assisted by the inadequate segregation of juveniles from adult offenders. The adult prisoners come into contact with juveniles in the kitchen, the library, work details and the clinic and it is through this contact that prisoners are able to either abduct, lure, or ‘put in an order’ for juveniles. At the main gate, prisoners bribe officers to allow a juvenile into the adult facility, sometimes for as little as 30 US cents. One prisoner explains the plight of these juveniles:

There are 22 of us in our cell, and two of my cell mates have juveniles as ‘wives’. They got them by bribing the POs [Prison Officers] at the main gate. These juveniles agreed to have sex with these men because they had no clothes and no blanket, and they were hungry. One day these boys started to cry and refused to have sex. The man took away their blankets and after spending a night in the cold they agreed to allow the men to have sex with them again. We try to tell these boys that they will die of AIDS, but what can these boys do?⁵⁰

Researchers point out that while segregation of juveniles from adults and better supervision would help protect them, the involvement of prison officers makes their abuse more difficult to prevent. Better conditions, or closer proximity to family members or other community ties could also help as the study explains that “the root causes of juveniles prostituting themselves to adult prisoners are the physical needs to food and shelter, and the need for protection.”⁵¹

As well as the likelihood of HIV transmission, the incidence of HIV infection and AIDS related deaths in prisons in Malawi paint an equally depressing picture. AIDS is the leading cause of death in prison in Malawi, consistent with international data. In 1997, 25% of prisoners attended to by health services at Zomba central prison were HIV positive. During the first six months of 1998, just under half of prisoners treated by the health staff tested positive for HIV. The most common illnesses treated in the prison clinic were malaria, pulmonary TB, scabies, and diarrhoea.⁵²

Tuberculosis (TB)

In many countries, TB has become the most recurring disease contracted in conjunction with HIV, resulting in the pattern that where TB is high, HIV is high.⁵³ In the United States, prisons have become an incubator for TB due to overcrowding and poor ventilation.⁵⁴ The most common form of tuberculosis is pulmonary, meaning that the illness infects the lungs. Symptoms usually include coughing, resulting in the dispersion of infected sputum. Inhalation of airborne droplets of infected sputum is the most common means of contracting TB. Thus, contagiousness of TB can be compounded by areas which involve a great deal of people crowded into a small poorly ventilated space.⁵⁵

Many adults can be TB carriers but will not develop any symptoms until their immune system is compromised, such as by infection with HIV. An asymptomatic TB carrier infected with HIV thus becomes actively contagious, contributing to increased TB infection in the rest of the population.⁵⁶ In this way, HIV causes an increase in the spread of TB, and other infectious diseases, to other HIV-negative people. It is estimated that in sub-Saharan Africa, “one out of every four TB deaths among HIV-negative people would not have occurred in the absence of the HIV epidemic”.⁵⁷

The rate of TB infection in Russia more than doubled between 1991 and 1997. Of the more than 100,000 new cases reported each year, one third are found in prison. It is estimated that an additional 30,000 cases each year are undetected.⁵⁸ An Amnesty International report found that:

Conditions in penitentiaries and pre-trial detention centres continued to amount to cruel, inhuman or degrading treatment. The Procurator General expressed concern at serious overcrowding and revealed that some 2,000 people had died of tuberculosis in prison in 1996, a death rate of ten times the rate in the general population.⁵⁹

In 2001, the Russian prison system—the second largest in the world—experienced a “10-40 fold increase in new cases of HIV infection.”⁶⁰ HIV infection is increasing in Russian prisons, and the presence of TB is compounding the problem. One study conducted in St Petersburg found that the number of new HIV/AIDS cases more than quadrupled from 1998 to 1999 and that one in four of these cases was in prison.⁶¹ The morbidity rate for HIV outside the prison was 62 per 100,000 while inside prison the morbidity rate was 510 per 100,000.⁶²

Hepatitis C (HCV)

In US prisons, most prisoners infected with HIV are co-infected with Hepatitis C (HCV). This is difficult to detect, however, because HIV infection can result in the body not being able to produce the antibodies which show up in preliminary HCV testing. HCV is a degenerative liver disease and is chronic in 85% of the people who contract it. It is transmitted only through blood-to-blood contact, and can lead to serious secondary illnesses, disabilities, liver failure, and death. In some patients, severe symptoms do not occur for 20 or 30 years.

According to the Centre for Disease Control (CDC) in the United States, Hepatitis C is the most common blood-borne infectious disease in the country with 2% of the population infected, excluding the homeless and the incarcerated. In the prison population, however, infection rates are as high as 60%. Many patients, both inside and outside of prison, are misdiagnosed or HCV is simply not detected due to co-infection with HIV. HCV is the most common reason for liver transplantation, but with proper diagnosis, treatment, and lifestyle changes the need for a transplant can be avoided entirely.⁶³

HIV/AIDS prevalence in prisons

Studies of HIV infection in US prisons have found that seroprevalence is anywhere from five to ten times higher than the general population.⁶⁴ In addition, the number of new AIDS cases in prison is 20 times that of the population at large.⁶⁵ One of the few studies to determine custodial seroconversion was conducted by the Center for Disease Control (CDC) on a sample of male prisoners in Illinois. Out of 2,390 prisoners who tested negative at intake, there were seven confirmed seroconversions after one year’s incarceration.⁶⁶ This translates into an annual transmission rate of 0.33%.

In Canada, a comprehensive study of over 12,000 people entering Ontario prisons was conducted in 1993. The results found HIV infection rates of approximately 1.0% for adult men and 1.2% for adult women. While these infection rates may seem low, they are more than ten times that of the Canadian population. The findings in this, as well as other less extensive studies, have reiterated the same conclusions: rates of HIV-infection amongst inmates are much higher than in the general population. One explanation offered is that this higher prevalence is related to two factors, “the proportion of prisoners who injected drugs prior to imprisonment, and the rate of HIV infection among injection drug users in the community.”⁶⁷

A number of studies have noted higher prevalence rates amongst women prisoners. HIV prevalence amongst female prisoners in England and Wales is 13 times that of the general population, compared to a combined prevalence for both male and female prisoners which is four times that of the general population.⁶⁸ Studies in the US have found that HIV infection rates are higher among women prisoners because female prisoners are more likely to have histories of injection drug use.⁶⁹ A case study conducted at the Mysore Jail in Karnataka, India—a state with one of the highest prevalence rates in India—found that the seroprevalence rate was highest amongst female inmates, at 9.5%, and was 25% amongst inmates who were also commercial sex workers.⁷⁰