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HIV/AIDS Education and Prevention Programs For Adults in Prisons and Jails and Juveniles in Confinement Facilities -- United States, 1994

By the end of 1994, at least 4588 adult inmates of U.S. prisons and jails had died as a result of acquired immunodeficiency syndrome (AIDS), and during 1994, at least 5279 adult inmates with AIDS were incarcerated in prisons and jails (1). Periodically conducted national surveys instituted in 1985 (2) and sponsored by the U.S. Department of Justice's National Institute of Justice (NIJ) and CDC have documented the prevalence of human immunodeficiency virus (HIV)/AIDS and the incidence of sexually transmitted diseases (STDs) among adult inmates and confined juveniles *. In addition, these surveys have enabled an assessment of HIV/AIDS education and prevention programs in prisons and jails for adults and confinement facilities for juveniles. This report presents findings from the eighth survey, conducted in 1994, which indicate the need to increase HIV/AIDS education and prevention services among adult inmates and confined juveniles.

In the 1994 NIJ/CDC survey, questionnaires were sent to and responses received from the Federal Bureau of Prisons, all 50 state prison systems for adults, city/county jail systems with adult inmate populations among the largest in the country (29 {81%} of 36) **, state systems for juveniles (41 {82%} of 50), and city/county systems with the largest populations of confined juveniles (32 {64%} of 50) ***. Most questionnaires were completed by health services staff, but some portions were completed by other administrators. Although most systems for adults and juveniles include a number of individual facilities, systems were asked to provide single answers covering all of their facilities. However, for some questions, systems were asked to report the number of their facilities providing certain types of programs. Rates of AIDS and gonorrhea among the U.S. population were based on data reported by state health departments to CDC. Prisons and Jails for Adults

Prison and jail systems for adults participating in the 1994 survey reported 5279 cases of AIDS among current inmates, representing 5.2 AIDS cases per 1000 adult inmates -- a rate almost six times that of the total U.S. adult (aged greater than or equal to 18 years) population (0.9 cases per 1000 population) (CDC, unpublished data, 1995). Based on mandatory testing of all incoming inmates or blinded studies, reported HIV seroprevalence rates of inmates ranged from less than 1% to 22%; 12 state systems reported rates greater than 2% (1).

HIV/AIDS education included interactive programs (e.g., peer-led programs and instructor-led sessions such as lectures, discussions, or question-and-answer periods) and passive programs (e.g., use of videotapes, other audio-visual materials, or written materials). Based on reports from all 51 state and federal systems, the percentage of systems providing instructor-led HIV/AIDS education in at least one of their facilities decreased from 96% in 1990 to 75% in 1994 (1). In 1994, of the 1207 state and federal facilities, 582 (48%) were providing instructor-led HIV/AIDS education programs, 90 (7%) were operating peer-led programs, 865 (72%) were using audio-visual materials, and 1068 (88%) were using written materials. Of the 80 federal, state, and city/county adult systems participating in the 1994 survey, 30 (59%) responded to a specific question that they would like to receive public health department assistance with their HIV/AIDS education programs.

Two state prison systems (Vermont and Mississippi) and four city/county jail systems (New York City; Philadelphia; San Francisco; and Washington, DC) reported making condoms available to inmates in their facilities. Of the 80 prison and jail systems participating in the 1994 survey, one city/county jail system reported making bleach available to inmates (1). Confinement Facilities for Juveniles

As of December 1994, the 41 state and city/county systems for juveniles participating in the 1994 survey reported a cumulative total of 60 cases of AIDS and four cases of AIDS among currently confined juveniles. The HIV seroprevalence among confined juveniles in six state systems and one county system was less than 1% (3). However, compared with the total U.S. population of equivalent age, the incidence rates for gonorrhea, a marker of high-risk sexual activity associated with HIV transmission, were 152 times and 42 times higher among confined juvenile females and males, respectively (4). Twenty-six state systems reported a mean of 137 gonorrhea cases **** per 1000 confined females during the 12 months preceding completion of the 1994 survey, compared with 0.9 cases per 1000 total U.S. females aged 15-19 years during 1994. Twenty-one state systems reported a mean of 25 gonorrhea cases per 1000 confined males during the 12 months preceding completion of the 1994 survey, compared with 0.6 cases per 1000 total U.S. males aged 15-19 years during 1994 (3,4).

Of 456 confinement facilities in the 40 state systems responding to the question, 31 (7%) were operating peer-led HIV/AIDS education, 258 (57%) were providing instructor-led education, 246 (54%) were using audio-visual materials, and 270 (59%) were using written materials. Of the 73 state and city/county systems for juveniles participating in the survey, 40 (55%) responded to the question that they would like to receive public health department assistance with their HIV/AIDS education programs. One county system (Alameda County, California) reported making condoms available to juveniles confined in its facilities (3).

Reported by: TM Hammett, PhD, R Widom, Abt Associates Inc, Cambridge, Massachusetts. National Institute of Justice, Office of Justice Programs, US Dept of Justice. Behavioral Intervention Research Br, Div of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention (proposed), CDC.

Editorial Note

Editorial Note: The findings in this report underscore the need to take advantage of important missed opportunities to provide HIV/AIDS prevention programs in prisons and jails for adults and in confinement facilities for juveniles (5). These facilities are important settings for HIV/AIDS education and prevention efforts because of 1) high prevalences in their populations of HIV-infected persons and persons with risk factors for HIV infection (6); 2) demonstrated occurrence of and continuing high potential for HIV transmission in these facilities through sexual activity and sharing of drug-injection equipment (7,8); 3) eventual release of almost all adult inmates and confined juveniles to the community; 4) high rates of re-incarceration and re-confinement (9); and 5) feasibility of providing HIV/AIDS education and prevention programs in these facilities. Despite the established HIV/AIDS epidemic among adult inmates and high STD rates among confined juveniles, many facilities have not provided interactive HIV/AIDS education programs. In facilities for juveniles, HIV/AIDS education often is presented as a curriculum unit of the school program, which many juveniles may not receive because of their short lengths of stay. Peer-led programs are provided in even fewer facilities for adults and juveniles, although such programs may be more credible and effective than those provided by educators affiliated with the correctional system for adults or the system for juveniles (1).

Findings from the NIJ/CDC surveys presented in this report are subject to at least one limitation. Because the surveys did not include all city/county jail systems and because of possible underreporting by participating systems, the numbers of cumulative AIDS deaths and AIDS cases among current adult inmates reported in the survey probably were underestimated.

To assist in reducing the transmission of HIV in the United States, comprehensive and credible programs of interactive education, counseling, testing, partner notification, and practical risk-reduction techniques (e.g., safer sex and safer drug injection) should be implemented for adult inmates in prisons and jails and for juveniles in confinement facilities. In addition, because many adult inmates and confined juveniles have established patterns of high-risk behavior for HIV/AIDS, ongoing programs of support and counseling are needed to assist them in initiating and sustaining positive behavior change. Although counseling, testing, and partner-notification programs have been implemented in some correctional facilities for adults (10), few systems for adults or juveniles make available the means to practice risk reduction (e.g., condoms or bleach). Interviews with correctional administrators indicate that condom and bleach distribution have been rejected because such policies are believed to condone and encourage behavior prohibited to inmates. Public health agencies at all levels should collaborate with correctional systems for adults, justice systems for juveniles, and community-based organizations to strengthen HIV/AIDS education and prevention programs in facilities for adults and juveniles. Collaborative efforts could be used to formulate strategies for HIV/AIDS prevention and to implement comprehensive HIV/AIDS education and prevention programs. Finally, the needs of adult inmates and confined juveniles should be included in the community HIV/AIDS prevention planning process.

References

  1. Hammett TM, Widom R, Epstein J, Gross M, Sifre S, Enos T. 1994 Update: HIV/AIDS and STDs in correctional facilities. Washington, DC: US Department of Justice, Office of Justice Programs, National Institute of Justice/US Department of Health and Human Services, Public Health Service, CDC, December 1995.

  2. CDC. Acquired immunodeficiency syndrome in correctional facilities: a report of the National Institute of Justice and the American Correctional Association. MMWR 1986;35:195-9.

  3. Widom R, Hammett TM. Research in brief: HIV/AIDS and STDs in juvenile facilities. Washington, DC: US Department of Justice, Office of Justice Programs, National Institute of Justice, April 1996.

  4. CDC. Sexually transmitted disease surveillance, 1994. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, September 1995.

  5. Glaser JB, Greifinger RB. Correctional health care: a public health opportunity. Ann Intern Med 1993;118:139-45.

  6. Bureau of Justice Statistics. Correctional populations in the United States, 1991. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 1993; publication no. NCJ-142729.

  7. Mutter RC, Grimes RM, Labarthe D. Evidence of intraprison spread of HIV infection. Arch Intern Med 1994;154:793-5.

  8. Mahon N. High risk behavior for HIV transmission in New York state prisons and city jails. Am J Public Health 1996 (in press).

  9. Bureau of Justice Statistics. Correctional populations in the United States, 1993. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 1995; publication no. NCJ-156241.

  10. CDC. Notification of syringe-sharing and sex partners of HIV-infected persons -- Pennsylvania, 1993-1994. MMWR 1995;44:202-4.

* In most states, offenders aged less than 18 years are handled by the juvenile justice system and confined in juvenile facilities; those aged less than 18 years are prosecuted in adult courts and incarcerated in prisons and jails. However, the cutoff age varies by state and even within some states on a case-by-case basis. 

** The sample of 36 city/county jail systems for adults was selected to represent systems with large inmate populations and to provide geographic diversity. All 36 systems were among the 50 largest in the United States in inmate population in 1994. The Washington, D.C., system was considered a city/county system. 

*** The 50 city/county systems for juveniles selected for the survey included the largest confined populations in 1994 based on information provided by the Office of Juvenile Justice and Delinquency Prevention, Office of Justice Programs, U.S. Department of Justice. 

**** The NIJ/CDC questionnaire sought numbers of gonorrhea cases presumptively diagnosed and numbers of cases confirmed by laboratory findings during the preceding 12 months. Incidence rates for the 26 state juvenile systems providing the requested data were calculated based on the total of these two categories of cases. The reported means represent a simple average of the incidence rates in these 26 systems.




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