HIV Transmission Among Male Inmates in a State Prison System --- Georgia, 1992-2005

Editorial Note

This report indicates that HIV transmission among inmates in Georgia's prison system was associated with male-male sex and tattooing and highlights the need for more effective HIV prevention among inmates. Sex among inmates occurs,^[4] and laws or policies prohibiting sex among inmates have been difficult to implement or enforce. However, GDC might consider certain HIV prevention options (e.g., education, testing, and prevention counseling) proven to be effective for nonincarcerated populations; some of those prevention measures are being used in correctional settings within and outside the United States.^[4]

CDC recommends that HIV education, testing, and prevention counseling be made available to populations at increased behavioral or clinical risk for HIV infection, including inmates in correctional facilities .^[5,6] HIV prevention education in state prisons should address male-male sex, tattooing, and injection drug use that occurs during incarceration and risk behaviors that occur after release. Case studies of inmate-led HIV prevention interventions suggest that these interventions might engender more inmate trust of and cooperation with intervention staff ^[4] HIV education might also benefit correctional facility staff.

CDC recommends that HIV screening be provided upon entry into prison and before release and that voluntary HIV testing be offered periodically during incarceration. This investigation demonstrates that annual voluntary testing is useful; 41 (47%) of 88 HIV seroconverters were identified during the 2 years in which annual testing was offered. Prison HIV testing programs allow inmates to learn their HIV status and, if not infected, to learn protective behaviors to reduce their HIV infection risks.^[7] Inmates who test HIV positive should receive antiretroviral treatment and care in addition to prevention counseling to protect future sex partners; before release, they should receive discharge planning and linkages to care in the community. GDC provides treatment and care for HIV-infected inmates, provides a 30-day supply of antiretroviral drugs on release and, in 12 of 73 facilities, undertakes enhanced HIV discharge planning, which includes individualized case management, housing placement, substance abuse and mental health treatment referrals, enrollment in benefit programs, and referrals for assistance with employment and other social services.

Approximately 15% of inmates reported using improvised barrier protection methods during sex, and 38% recommended making condoms available in prisons. Providing condoms to sexually active persons is an integral part of HIV prevention interventions outside prisons. However, in most prison and jail settings, condoms are considered contraband.^[4] Condoms are provided to some inmates in state prisons in Mississippi and Vermont and jails in Los Angeles, New York, Philadelphia, San Francisco, and the District of Columbia.^[4] A recent survey in a large jail in a U.S. city reported that condom distribution was acceptable to most inmates and correctional officers.^[8] Departments of corrections with existing condom distribution programs should evaluate those programs to determine their effectiveness; departments of corrections without condom distribution programs should assess relevant state laws, policies, and circumstances to determine the feasibility and benefits and risks of implementing such programs.

Although no case of HIV transmission via tattooing has been documented, the procedure carries a theoretical risk for transmission if nonsterile equipment is used. In this investigation, receipt of a tattoo was associated with HIV seroconversion. Further investigation is required to explore commonalities in time frames, tattoo artists, or equipment among HIV-infected inmates who reported tattooing as their only risk behavior and to determine whether the association between tattooing and HIV seroconversion identified in this investigation is causal.

Black race was significantly associated with HIV seroconversion, although no differences in risk behaviors were identified among racial groups. HIV disproportionately affects blacks in the general population, and 86% of males who were already infected with HIV when they entered GDC facilities were black. Black-only sex or tattooing networks might exist in prisons, given that 63% of all male inmates and 86% of HIV-infected men in GDC facilities are black. If so, then black race might be a marker in the analysis for the choice of sex or tattooing partners within these networks. Having a BMI of ≤25.4 kg/m² also was significantly associated with HIV seroconversion, but the implications of this finding for HIV transmission and prevention are unclear. Although BMI was explored in the analysis as a physical characteristic associated with HIV seroconversion, insufficient data are available to determine whether a statistically significant association existed between lower BMI and reported rape.

The findings in this report are subject to at least three limitations. First, risk behaviors might differ between seroconverters identified through voluntary HIV testing and those refusing voluntary HIV testing, limiting representativeness. Second, recall bias might have affected the reporting of HIV risk behaviors. Finally, although ACASI interviews were conducted to provide privacy and reduce social desirability bias, inmates might have inaccurately reported HIV risk behaviors because sex between inmates, sex with correctional staff, injection drug use, and tattooing are illegal or forbidden by policy in this prison system.

In response to this investigation, GDC is evaluating options to modify existing HIV prevention education and house HIV-infected inmates in a limited number of facilities. Three state prison systems (Alabama, Mississippi, and South Carolina) house HIV-infected inmates in separate facilities to provide focused medical care. At least three other state prison systems (California, Florida, and Texas) house some HIV-infected inmates with advanced disease or those requesting separate housing in "centers of excellence" for medical care; HIV-negative and HIV-infected inmates mix for education, vocational training, religious, and other prison programs. However, separate housing of HIV-infected inmates is limited in that it 1) does not reduce the spread of other sexually transmitted, opportunistic, and bloodborne infections, 2) might increase the risk for tuberculosis outbreaks,^[9] 3) raises concerns about disclosure of inmates' HIV status and access to prison programs, and 4) does not prevent transmission by inmates who are unaware that they are infected or by HIV-infected corrections staff. No data are available on the effectiveness of separate housing for HIV-infected inmates as an HIV prevention strategy.

Although this investigation was conducted in a single state prison system, incarcerated populations in other correctional settings are at risk for HIV infection, both while in prison and after release into the community. Corrections officials, in partnership with public health officials, should assess the adequacy of existing programs and services for incarcerated populations and develop strategies to reduce HIV infection, both in prisons and in the community. This recommendation is consistent with one recently issued by the Presidential Advisory Council on HIV/AIDS, which called for improved HIV prevention in U.S. prisons, jails, and correctional facilities.^[10]

Morbidity and Mortality Weekly Report. 2006;55(15):421-426. © 2006 Centers for Disease Control and Prevention (CDC)

Cite this: HIV Transmission Among Male Inmates in a State Prison System --- Georgia, 1992-2005 - Medscape - Apr 01, 2006.