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Amfar Issue Brief-hiv in Correctional Settings March 2008

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The Foundation
for AIDS Research

Issue Brief No. 5
March 2008

issue brief
“The degree of
civilization in a society
can be judged by
entering its prisons.”
– Fyodor Dostoyevsky


he U.S. correctional system is
facing critical challenges as
the number of incarcerated
people continues to grow. At
the end of 2006, there were
nearly 2.26 million inmates in
state, federal, and local correctional facilities, a rate of 751 inmates per 100,000 U.S.
residents.1 This is a record high for the
U.S. and is the highest incarceration rate
in the world.2 For the first time, more than
one in every 100 adults in America is now
confined in a jail or prison.3 Such high
rates of incarceration have far-reaching
implications for the health and well-being
of families, communities, and society at
large. The increasing size of the incarcerated population also has serious cost implications for the healthcare infrastructure, particularly since the cost of medical
care in the U.S. is now more than seven
times higher than it was in 1980.4
HIV/AIDS has a disproportionate impact
on incarcerated populations in the U.S.,
with prevalence among prisoners more
than three times higher than the general
U.S. population (see Figure 1).5 The presence of HIV-infected persons and those at
high risk of infection in the correctional
system is a critical challenge to both the
correctional health system and the public
health community. This challenge offers
unique opportunities to reach these high-

HIV in Correctional Settings:
Implications for Prevention
and Treatment Policy
risk individuals and engage them in HIV
prevention, treatment, and care.

The Link Between
Correctional Facilities
and Communities
In 2005, more than 7 million people in the
U.S. were under some form of correctional
supervision, either in institutional correctional facilities (prisons or jails) or in the
community (e.g., on probation or parole).6
Approximately 3.2 percent of the U.S.
population—or one in every 32 adults—
were incarcerated, under probation, or
on parole at the end of 2005.6 Approximately seven percent of all inmates
were women.7 Communities of color are
disproportionately represented in the U.S.
correctional system. Approximately 60
percent of inmates in state and federal
prisons with sentences of longer than one
year are African-American or Latino.7 In
addition to their over-representation in the
correctional system, men and women of
color are disproportionately affected by
HIV/AIDS (see Figure 2). Although African
Americans represent only 13 percent of
the total U.S. population, they account for
more HIV and AIDS cases and more HIVrelated deaths8 than any other racial or
ethnic group. Latinos, the fastest growing
racial or ethnic group in the U.S., are not

far behind. They account for 14 percent
of the total U.S. population, but have the
second highest HIV prevalence in the nation after African Americans. Women of
color are particularly hard hit by the
epidemic. They not only represent the
majority of American women currently
living with HIV, but also account for the
majority of new HIV infections and
existing AIDS cases among women.8
The disproportionate impact of HIV in
communities of color and in correctional
facilities is exacerbated by a lack of
access to adequate health and social
services for inmates while incarcerated
and upon their return to the community.
Since more than 90 percent of inmates are
eventually released into the community,9
the health profile of returning inmates
imposes specific demands on already
overburdened community services.
Many former inmates do not have the
resources to access services that are
not part of post-release planning, such
as addiction and mental health treatment,
psychological support,10 reproductive
healthcare, education and job training,
and stable housing.11-15
Inmates’ risky behaviors before and during
incarceration also have a significant
effect on their partners’ health. Incarcerated men report engaging in behaviors

Figure 1

Prevalence of HIV/AIDS in State and Federal Prisons and in the U.S. Population in 2005


In correctional settings
In U.S. population






the primary partner is released. Similarly,
individuals who are released from
correctional facilities may want to
maintain friendships that were made
while incarcerated and, therefore, introduce new members into an existing social
or sexual network. The presence of
concurrent sexual networks has been
found to contribute to elevated rates of
HIV infection in communities already affected by high STI rates and other social
and health issues.19 Alcohol and drugs are
often a part of the context in which risky
sexual practices occur and, in one study
of men just released from prison, were
associated with risky sexual behavior
at one week and at six months after
release.20 In addition to sharing drug
injection paraphernalia, other risks include
engaging in sexual acts to obtain drugs
or providing a partner with drugs as a
way to obtain sex.


HIV in Correctional Settings

% with HIV/AIDS

% with Confirmed AIDS

a) HIV/AIDS (State and Federal Prisons): Maruschak LM. HIV in Prisons, 2005. Department of Justice. Bureau of Justice
Statistics, NCJ 218915. September 2007. Available at: b) HIV/AIDS (U.S.
Population): CDC. HIV/AIDS Surveillence Report: Cases of HIV Infection and AIDS in the United States and Dependent Areas,
2005. Volume 17, Revised June 2007. Available at

that elevate their risk for HIV and other
sexually transmitted infections (STIs) both
before incarceration and after release.16
These behaviors include injection drug
use, needle sharing, and unprotected
sex with multiple high-risk partners.17
Since approximately 50 percent of men
who have been incarcerated or have
passed through the correctional system
consider themselves to be in committed
heterosexual relationships and intend to
return to their partners upon release from
custody,16 as many as 6.5 million women
each year will experience the risk of
having a partner who has been incarcerated.16 Given the disproportionate number
of low-income men of color in correctional
settings, low-income African-American
and Latina women are more likely to have
intimate sexual or needle-sharing
relationships with recently imprisoned


men.16 Sexual risk behavior is not limited
to those who are HIV negative; one study
found that men with HIV who were
released from prison had unprotected
sexual intercourse within an average of
six days of their release, and 31 percent
of these men believed it was likely they
would infect their primary sexual partner.18
It should be noted that inmates are not the
only ones who engage in risk behaviors.
The destructive impact of incarceration
on existing partnerships, families, and
communities may also facilitate new and
varied sexual and social connections that
further increase risk of HIV transmission
for inmates returning to their communities.
For example, individuals whose primary
partners are incarcerated for long periods
of time may develop other sexual relationships, which may continue even after

The first report of AIDS in correctional
facilities was published in the early
1980s.21,22 Currently, all U.S. state correctional facilities have reported inmates with
HIV infection, and it is estimated that up
to one-fourth of the people living with
HIV in the U.S. pass through a correctional
facility each year.23
Although the number of known HIV-positive inmates has been steadily decreasing
since 1999, the overall rate of confirmed
AIDS cases among the prison population
(0.4 percent) at the end of 2005 was close
to three times the rate in the general U.S.
population (0.15 percent).5 Data from federal prisons show that in 2004, HIV
infection rates were highest among
African-American female inmates (2.6
percent); in both federal and state prisons,
females were more likely than males to
be HIV positive, and African Americans
and Latinos were more likely than whites
to be HIV positive.24 State and federal
corrections data from 2005 indicate that
African-American inmates accounted
for two-thirds of the AIDS-related deaths
while in custody; moreover, they were
nearly 2.5 times more likely than whites

and almost five times more likely than
Latinos to die from AIDS.5
In addition to higher rates of HIV infection
and AIDS, correctional populations also
have higher rates of co-morbid conditions
that facilitate HIV transmission, such as
STIs, substance use, mental health problems, and other infectious diseases
such as tuberculosis and hepatitis.
Drug-dependent inmates are also more
likely than other inmates to report experiences of sexual abuse, housing instability,
unemployment, parental substance use,
and parental incarceration. One in seven
drug-dependent inmates in state prisons
reported being homeless in the year before incarceration, which contributes to
a lack of access to healthcare.25

Sexual Behavior
Many individuals are already infected with
STIs and other diseases (e.g., hepatitis C)
by the time they arrive at a correctional
facility. Due in part to participation in sex
work, women may be at greater risk of entering prison with STIs.26 Researchers also
demonstrated that risky sexual behaviors
associated with STI and HIV transmission
can occur during incarceration27,28 via
sexual relations (both consensual and
coerced) among inmates as well as
between inmates and prison officials
(e.g., correctional officers).20 Condom
availability is rare except in a few state
prisons and county jails. However, even
when condoms are available, they are
rarely used during consensual sex. In
one study, only 30 percent of prisoners
reported using condoms or improvised

barrier methods during consensual sex; no
barrier methods were used during rape.29
Although some of the sexual activity
occurring in prisons may be consensual,
the very context of life in correctional
facilities is such that true consent may
be illusory. Sexual activity may occur as
a means of survival (e.g., obtaining goods
or protection) or as a result of coercion. It
is estimated that 20 percent of male
inmates and 25 percent of female inmates
face sexual assaults behind bars.30,31
While any inmate can become a victim
of sexual assault, certain inmates are particularly vulnerable. Nonviolent, first-time
offenders are more likely to be victimized,
as are gay and transgender detainees and
youth held in adult facilities.32 Immigrants
are also vulnerable to sexual assault in

Figure 2

Disproportionate Impact of AIDS and Incarceration on Minorities, 2005

Proportion of total U.S. AIDS cases, 2005
Proportion of correctional facility population
Proportion of total U.S. population















% White, Non-Latino

% Black, Non-Latino

% Latino

% Other

a) Ethnicity in Corrections: Harrison PM, Beck AJ. Prisoners in 2005. Department of Justice, Bureau of Justice Statistics Bulletin, NCJ215092, November 2006, Revised January 2007. Available at: b) Ethnicity in AIDS Cases and U.S. Population: CDC HIV/AIDS Surveillance by Race/Ethnicity (through 2005), Powerpoint slides revised
June 28 2007. Available at:–ethnicity/index.htm.


prisons, due in part to fear of deportation,
and limited literacy and language skills.32
Such assaults on immigrant prisoners
might be prevented by increased monitoring of U.S. Immigration and Customs
Enforcement (ICE) detention centers
by immigrant advocacy organizations.

Sexual violence in
prisons and jails
is drastically
While legal protections exist to protect
inmates from guard brutality and violence
inflicted by other prisoners, sexual
violence in prisons and jails is drastically
underreported due to the illicit nature of
the activity and the stigma associated
with rape and same-sex behavior.33
Inmates’ unwillingness to report their
victimization contributes to the failure
of prison authorities to react appropriately
and to investigate complaints of sexual
violence. This limits authorities’ ability
to prosecute perpetrators or to provide
victims with appropriate access to care,
including HIV testing, counseling, and
post-exposure prophylaxis.33
Unsterile Injection Equipment
Tattooing is a common practice in
correctional settings and is associated
with group membership and desire for
personal expression. The use of unsterile,
makeshift tattooing equipment (including
guitar strings, pins, needles, etc.) is a risk
factor for transmission of HIV, hepatitis,
and other parenterally transmissible
infections.34 Not surprisingly, these
makeshift instruments are difficult to
sterilize reliably,35 thus facilitating the
spread of blood-borne infections.
Possession and use of illicit substances
are forbidden in correctional facilities, but
research has found that such substance
use prohibitions may be circumvented
through the cooperation of correctional
personnel.20,36 Due to a lack of new
and sterile injection equipment, a large
proportion of incarcerated drug users

who are using injection drugs share
needles or are unable to clean them
Mental Health Issues
Mental health issues also contribute to
HIV risk behavior. Data from 2005 show
that 56 percent of state prisoners, 45
percent of federal prisoners, and 64
percent of jail inmates had been clinically
diagnosed with mental illness exclusive of
substance use or dependence.38 Women
were more likely than men to be diagnosed
with mental health problems, as were
white inmates and those 24 years of age
or younger. Compared to other inmates,
those with mental health needs were more
likely to report having lived in foster homes
or institutions while growing up, histories
of physical or sexual abuse, family members with histories of substance use and
incarceration, and low rates of employment.38 Approximately three-fourths of the
state prisoners and jail inmates who had
mental health diagnoses also met criteria
for substance use or dependence, and
more than a third of inmates with mental
health diagnoses reported having used
drugs at the time of their offense.38
Further, mentally ill inmates are much
more likely to suffer physical abuse while
incarcerated, earn disciplinary sanctions
for breaking prison rules, and to accrue
further criminal punishment that lasts
throughout their incarceration.39 The
use of isolation as a form of discipline
can exacerbate mental illness and prompt
acts of self-harm.40

Improving HIV Services for
Incarcerated Populations
The period of incarceration provides a
unique window of opportunity to reach
both uninfected and HIV-positive inmates
with targeted education about and
services for HIV prevention, treatment,
and care. This position is supported by
domestic41,42 as well as international43,44
authorities on HIV prevention.
A fundamental starting point for HIV
prevention in any setting is knowledge

of one’s HIV status. The Centers for
Disease Control and Prevention (CDC)
has recommended that correctional
institutions routinely offer HIV testing as
a component of standard medical evaluation for inmates.41,45 While policies for
HIV testing vary by jurisdiction and by
type of correctional facility,46 fewer than
half of the state prison systems and few
jails routinely provide HIV testing on
entry.46 For many inmates in correctional
facilities that offer or mandate HIV testing,
incarceration represents the first real
contact with a healthcare system,47 and
may be the first time they have been
offered HIV testing.48,49
Of the institutions that do currently provide
HIV testing to inmates, some take the “no
news is good news” approach to diagnostic testing and, thus, do not inform or counsel individuals with negative HIV and STI
test results.49,50 This lack of follow-up for
uninfected persons represents an important missed opportunity for prevention
counseling that has serious implications.
Receiving negative test results can create
a critical “teachable moment” for inmates
to receive sexual and drug use-related risk
reduction education, acquire accurate
prevention and care information, and reinforce risk reduction practices. Furthermore, because some inmates who test
negative for HIV may actually be in the
early stages of infection (before HIV antibodies have developed), it is critical to
provide education about the importance
of repeat testing.
A major problem with standard HIV testing
is the waiting period of two weeks or
longer for blood samples to be analyzed
and the results returned to the inmate.
This issue is particularly relevant for
correctional facilities that house inmates
for shorter periods of time (such as jails)
or that function as transfer facilities for
inmates being relocated. In such facilities,
waiting two weeks for a test result translates into missed opportunities for inmates
to learn their serostatus and receive appropriate counseling and referrals to care.
Rapid testing assays that allow the immediate provision of results may be a more viable option in these types of settings.51,52

Aside from the logistical issues, it is
important to note that inmates themselves
may have valid concerns about getting an
HIV test while incarcerated. In addition
to the stigma associated with HIV/AIDS,
inmates may also be concerned that medical confidentiality will not be maintained.
Moreover, inmates may be concerned
that testing positive will result in housing
segregation, ostracism by or violence from
other inmates, and decreased access to
medical care and support services.
Despite these issues, offering repeat
voluntary counseling and testing within
correctional settings can be an important
entry point to HIV-related prevention and
care services for at-risk and infected
inmates.50 Because inmates may be
psychologically impaired due to substance
use or trauma, care must be taken to
ensure that they are ready to receive
HIV test results and counseling.

To maximize the
uptake of HIV testing, correctional
facilities should
keep inmates’
medical information
strictly confidential.
Recognizing the benefits of routine testing
in correctional institutions, leading public
health organizations such as the CDC41
and the National Commission on Correctional Health Care53 agree that all HIV
tests must be conducted with the inmate’s
consent and that inmates should have
the right to opt out of testing. Unfortunately, this agreement is not present in
all correctional institutions: in 2003, 19
state prisons and the Federal Bureau of
Prisons had mandatory HIV screening

policies for their incoming inmates.54
While many prisoners are intellectually
capable of giving informed consent, the
context of being incarcerated and the
omnipresent potential for coercion in
correctional settings call into question
the degree to which inmates are truly
able to give free and informed consent.
Routine HIV testing procedures must
be undertaken in a fashion that allows
inmates to be told of and to exercise
their right to refuse testing and other
medical care.
Extreme care must be taken to ensure
that refusal of testing does not result in
adverse consequences or punishment.
For example, a study of a pilot program
implementing routine HIV testing in District
of Columbia jails obtained reports from
inmates stating that those refusing HIV
testing were placed on “medical hold,”
that is, confined in a single cell until
they complied.55 Fortunately, this practice
was discontinued as a result of strong
negative responses from the local community and the uncertain legal standing of
this procedure. Nonetheless, reports
such as these imply that routine or
“automatic” testing is hardly voluntary
given the consequences of refusal.
To maximize the uptake of HIV testing,
correctional facilities should keep inmates’
medical information strictly confidential,
and provide linkages and access to
specialty care and support services.
Correctional care providers in Rhode
Island have reported that ensuring these
important components of care has resulted in the vast majority of inmates—
both positive and negative—accepting
HIV testing services.56
Peer Education and Other Prevention
Services for Inmates
Because incarcerated populations are
ethnically, culturally, and educationally
diverse, HIV prevention and other health
education programs must be designed in
a way that effectively reaches diverse
populations and addresses special needs.
While education about HIV/AIDS preven-

tion and care can and should be delivered
by correctional health staff or outside
service contractors, research shows that
prevention education programs delivered
by peer educators are highly effective in
establishing the trust and rapport that are
needed to discuss sensitive topics related
to sexual practices, substance use, and
HIV/AIDS.57 Because peer educators are
often inmates or former inmates, they are
more attuned to the realities of life both in
the correctional facility and post-release
and, thus, may be more successful in
providing support and teaching the skills
necessary to address the complicated
situations that put inmates at risk.58
Moreover, peer educators may be able
to motivate inmates more effectively to
access HIV-related services. For example,
one study found that 44 percent of inmates
requested HIV testing after participating
in a peer-led program, despite the fact that
HIV testing in that facility was not anonymous and individuals diagnosed with HIV
or AIDS were housed separately.59
Harm Reduction and Risks Related to
Sexual Behavior and Substance Use
Although sexual and substance use behaviors are not permitted in incarcerated
settings, the reality is that such behaviors
do occur. Therefore, efforts to reduce the
risk of infection from these behaviors
would benefit both the incarcerated persons and the communities to which they
return. Indeed, researchers and advocates
have expressed the need for more harm
reduction programs in prisons and jails.60
While the use of harm reduction strategies
such as condoms and access to sterile injection equipment in correctional facilities
is endorsed by the World Health Organization,61 the vast majority of U.S. prisons and
jails specifically prohibit the distribution
and possession of these items.50 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,
D.C.∗).24 Contrary to critics’ arguments,

* In Washington, D.C., only the public jail has limited condom distribution. The privately run correctional treatment facility bans condoms.


few inmates have used condoms as
weapons or to smuggle contraband into
correctional facilities11,62 and there is no
evidence that sexual activity within correctional facilities has increased as an
outcome of condom distribution.62,63 In
fact, in those correctional institutions (both
in the U.S. and elsewhere) where a condom availability program exists, there have
been no security or custody issues that resulted in the closure of the program.64
With regard to substance use, harm reduction measures are relatively new to
correctional systems and are often perceived as a threat to their security regulations and traditional abstinence-oriented
drug policy.65 Currently, no correctional facilities in the U.S. provide sterile injection
equipment to inmates. However, harm reduction programs related to injection drug
use have been established in more than 50
prisons in eight European countries. Evaluations of such programs in Switzerland,
Spain, and Germany found no increase in
drug use, dramatic decreases in needle
sharing, no new cases of HIV infection or
hepatitis, and no reported instances of
needles being used as weapons.64,65
Addressing Addiction and Mental
Health Issues
Over the past several decades, the number
of drug-involved offenders incarcerated in
state and federal penitentiaries has increased substantially as a result of more
stringent drug-related laws.65 These laws,
coupled with the inadequate availability of
community-based substance use programs, have exacerbated the negative impact of the nation’s drug problem on
families and communities without addressing the medical and socioeconomic roots
of addiction.
Incarceration can provide a unique opportunity to treat inmates with addiction and
mental health diagnoses. However, such
programs are limited in correctional settings. Estimates from 2004 indicate that,
although 53 percent of state and 45.5
percent of federal inmates met diagnostic
criteria for drug dependence, only 14.8
percent of state and 17.4 percent of
federal inmates received professional

addiction treatment.25 Although such
treatment programs can be costly,
research has shown that investing in
addiction treatment for inmates is costeffective66,67 and can result in substantial
reductions in post-release criminal
activity, relapse, and recidivism.67,68
Addressing Stigma and Discrimination
Stigmatization of HIV/AIDS remains prevalent in correctional institutions. Individuals
who enter with or test positive for HIV
may face discrimination and threats from
correctional officers and other inmates
and can be segregated or denied prison
jobs, activities, and visiting privileges.55
Some correctional authorities may believe
that HIV-positive prisoners need to be isolated for their own safety. Others argue
that segregating inmates with HIV is undesirable because it labels them unnecessarily, makes them more vulnerable to
assault and discrimination, and may result
in disparate treatment and diminished access to services and desirable housing
conditions. In some cases, HIV-negative
inmates may pressure correctional authorities to house HIV-positive inmates separately. The resulting false sense of security
may lead to an increase in high-risk behaviors among a population that incorrectly assumes itself free of HIV
infection.16 As a step toward reinforcing
HIV prevention education and minimizing
misinformation and stigma, both inmates
and correctional staff need comprehensive HIV/AIDS education, including information about the importance of repeat
HIV testing for those practicing high-risk
Treatment and Care for HIV-Positive
The implementation of routine testing policies in correctional facilities has important
implications for the correctional system’s
identification and case management of
HIV-positive inmates.70 Privacy and confidentiality concerns are significant barriers
to HIV testing and care-seeking in correctional settings. Given the unique living conditions (and, in many cases, overcrowding)
in correctional facilities, maintaining confidentiality of personal and/or medical information can be extremely difficult. While

confidentiality may be breached by other
inmates, other breaches of confidentiality
may be due to inappropriate behaviors by
correctional staff or procedures associated with accessing prison healthcare,71
by attending pill call or standing in the
medication dispensing line,56 or simply
from having to fill out forms requesting
medical attention and the reasons for
needing to see a clinician.72

Effective HIV
treatment in
prisons has led
to a 75 percent
reduction in AIDSrelated mortality.
All inmates in correctional systems have a
constitutional right to medical care, including HIV care. Given that about 75 percent
of HIV-positive inmates initiate treatment
while incarcerated,73 the opportunities for
successful viral suppression and overall
management of HIV disease can be improved through increased adherence to
a well-designed care system. Indeed,
effective HIV treatment in prisons has led
to a 75 percent reduction in AIDS-related
mortality, a decline mirroring that of nonincarcerated populations.74,75
Some have alleged that HIV care and support in the correctional setting lags behind
the standards in the community due to
cost concerns, lack of adequately trained
care providers, and stigmatization of
HIV/AIDS.69 Privatization of correctional
healthcare has imposed further constraints on HIV care delivery.76 The increased prevalence of HIV in correctional
populations indicates the need for greater
attention to HIV/AIDS prevention, case
management and care in correctional facilities,77 as well as attention to treating
the co-morbid conditions (e.g., hepatitis,
TB, addiction) that could negatively affect
therapeutic outcomes.

One factor contributing to inadequate
healthcare for inmates is the lack of
coordination and programming within
correctional institutions, and between
correctional institutions and healthcare
providers in the community. Correctional
medical providers are not routinely given
access to information about the HIV status
of individuals under their care.50 Certain
aspects of incarceration—such as “lock
down” periods, punitive detentions, court
appearances, and transfers between
facilities—also undermine consistent
dosing schedules essential to the longterm effectiveness of antiretroviral and
other medications. Additionally, some state
correctional facilities require inmates to
provide “co-payments” for medical services;53,72 inmates who cannot pay may
be reluctant to seek those services for
fear of being rejected.
Correctional administrators in the U.S.
are increasingly concerned about the
escalating costs of healthcare for “special
needs” inmates, such as drug users and
those with HIV.78 In some cases, correctional staff with no specialized training in
HIV, drug or alcohol addiction, or mental
illness are the ones obligated to provide
care. For example, in 2000, two-thirds of
all inmates receiving psychotherapy or
medications were in facilities that did not
specialize in providing mental health services.79 Medical providers have reported
missed opportunities for linkages with the
public health systems in the community
after offenders are released.50 In some
cases, the lack of coordination is due to
confidentiality-related policies pertaining
to the sharing of patient information
across different agencies.12 In other
cases, poor coordination is due to inadequate staffing levels and insufficient
resources for discharge planning.12
Correctional health and public health
authorities should work together to develop cost-effective mechanisms by which
HIV-positive and other “special needs”
inmates can receive appropriate and
consistent treatment and care, both while
they are incarcerated and upon release.

Discharge Planning and Other
Programs Following Release
from Incarceration
Each year, close to 700,000 prisoners are
released from state and federal prisons.80
Post-release or discharge planning for
this population is critical in ensuring
continuity of HIV prevention, treatment,
and care through linkages and access
to necessary medical and psychosocial
support services.12 Even in optimal cases,
when inmates receive the care they need
during their period of incarceration, the
benefits achieved by this treatment are
only sustainable if these same services
are available and accessible to the inmates when they return to their communities.14 Discharge planning activities
include providing inmates with information
about outside resources, prescribing medications at release in sufficient quantity,
scheduling and accompanying inmates
to appointments with care providers, and
assisting with applying for medical and
financial assistance.

Offenders with
admitted to seeking
re-arrest to access
medical services
in prisons.
Recent data pertaining to the health of exoffenders underscore the importance of
appropriate post-release planning and
linkages to care.81 A study of more than
30,000 newly released prison inmates
found that, compared to the general population, former inmates’ risk of death was
nearly 13 times higher during their first two
weeks out of prison. Over the entire study
period of 3.5 years, the adjusted death rate
was 3.5 times higher than that of the general population, and the rates for every
major cause of death (e.g., drug overdose,
liver disease, suicide) were higher. To a
large extent, death rates reflected the fact

that the inmate population was poor and
uneducated, and over 70 percent of the
sample had been diagnosed with drug or
alcohol dependence. Without appropriate
pre-release planning or other similar support, newly released inmates may not be
able to access lifesaving services such as
addiction treatment, medical care, and
transitional housing.81
For HIV-positive inmates, one of the greatest impediments to continuity of care is
being released from a correctional facility
without knowing their HIV status or what
their treatment options are.70 A study examining the response to antiretroviral
treatment in the correctional setting indicated that, when provided with adequate
clinical care, inmates have clinical improvements that are comparable to those
found in the community.82 Without appropriate discharge planning, the benefits of
antiretroviral treatment that may have
been achieved during incarceration may
be lost after returning to the community.82
Moreover, applying for federal and state
medical assistance can take several
months, leaving qualified ex-offenders
without access to necessary healthcare
and financial support in the critical period
after release.13 Offenders with HIV/AIDS
have admitted to seeking re-arrest to access medical services in prisons, which
highlights the crucial need for such services for released offenders.14
Continuity in HIV treatment and care
for ex-inmates is also hampered by lack
of access to health insurance. Many exoffenders do not have private sources of
healthcare coverage and must rely on
public programs, free clinics, and emergency rooms to receive medical attention.83 Moreover, gaining access to public
health insurance can be equally difficult.
Although federal regulations do not require termination of inmates’ Medicaid
eligibility upon incarceration, a 1999
survey found that all 50 states had policies
terminating inmates’ Medicaid coverage
upon incarceration.84 For those with
terminated Medicaid benefits, the process
of re-establishing eligibility can take
anywhere from 14 to 45 days (and sometimes longer), depending on the state.85

The Center for Medicaid and State
Operations has encouraged states to
suspend rather than terminate inmates’
Medicaid benefits during the period of
incarceration to ensure that benefits are
restored to eligible individuals immediately
upon release.86 Making reinstatement
to Medicaid eligibility a fundamental
component of discharge planning would
contribute to successful re-entry85 and
would ensure that ex-offenders have
access to essential healthcare services.83

Discharge planning
programs focusing
on HIV prevention
have been found to
have significant,
positive effects on
sexual risk behavior.
Despite these barriers, some correctional
systems have tried to reduce the likelihood
of ex-offenders falling through the cracks
when trying to access care by establishing
partnerships with community health
providers. These independent efforts
enable correctional health facilities to
have medical staff who also work in
the community, common medical records
systems, and well-developed referral
and outreach protocols.87 Federal funds
received under the Ryan White CARE Act
(RWCA), as established in Title XXVI of
the Public Health Service Act, allow
community-based organizations to provide
short-term traditional support services,
such as linkages to primary care, to
HIV-positive inmates prior to release
and as part of effective discharge planning.88 It is important to note that RWCA
funds can be used only where no other
services exist, or where these services
are not the responsibility of the correctional system.88
Some correctional facilities have also
tried to address the limitations of the

current system by establishing enhanced
discharge planning for inmates. Compared
to standard processes, enhanced discharge planning incorporates planning
for a variety of inmates’ needs, such as
healthcare, mental health treatment,
treatment of addiction, housing, and
employment. Existing discharge planning
programs focusing on HIV prevention have
been found to have significant, positive
effects on sexual risk behavior,89,90 while
programs focusing on the needs of HIVpositive inmates have been successful in
retaining a very challenging population in
care and addressing their needs for both
HIV medical care and addiction treatment
without providing any of these services
directly.91 Addressing these important
prevention and healthcare needs in
advance of release from incarceration
could greatly enhance successful
transition to the community.
Removing Social Policy Barriers to
Successful Re-Entry
Providing access to adequate health
and social services to ex-offenders upon
release would address the current gaps
in continuity of care for those in need of
HIV services. However, the provision of
healthcare alone is insufficient to address
the complex social and economic issues
that contribute to the high prevalence of
HIV among corrections populations and
minorities. Current policies that make it
difficult for ex-offenders to find adequate
housing and employment, and to gain
access to public assistance, only serve
to exacerbate the impact of HIV in these
populations, particularly low-income
communities of color.
For example, in most states, individuals
are released from correctional facilities
without the documentation necessary to
obtain a state-issued identification card,
and many states do not accept prison
documentation as valid proof of identity.92
Without some sort of government identification, ex-inmates are unable to complete
the application processes for a variety
of essential medical and health services,
such as obtaining Social Security benefits,
public or private healthcare coverage,
and other public assistance. In addition,

proof of identity is often a necessary
requirement for completing job applications, and is absolutely required to cash
paychecks or open bank accounts. The
simple act of ensuring that all inmates
have the appropriate identification documentation upon release may greatly enhance their ability to make a successful
transition back to the community.
Lack of identification is not the only
barrier to getting a job for former inmates.
In fact, very few ex-offenders have jobs
waiting for them when they return to
their communities and the majority of
others face significant barriers to
getting employment due to lack of job
skills, lack of education, and employers’
unwillingness to hire individuals with
criminal records.93 Although most
corrections facilities offer some type
of educational program or vocational
training for inmates, there are only a
limited number of program slots.94,95
This lack of slots is unfortunate given
that the existing data indicate that such
programs are associated with improved
outcomes, including reduced criminal
recidivism.96,97 Even when such programs
are available, however, HIV-positive
inmates may not be granted access
to them. The Alabama Department of
Corrections, for instance, bars HIVpositive state prisoners from participating
in community-based programs such as
work release.98 However, a recent change
in the Department of Corrections’ policies
now allows HIV-positive prisoners to participate in transitional programs involving
education and vocational training.99
Ensuring that ex-offenders and their
families have sufficient social and
economic support may help prevent
them from participating in illegal activities
as a means of support, or engaging in
behaviors such as drug use that increase
their risk for HIV. In order to support
themselves and their families, many
ex-offenders turn to public assistance.
However, obtaining such support can be
problematic. The Personal Responsibility
and Work Opportunity Reconciliation Act
of 1996 (which instituted the Temporary
Assistance for Needy Families [TANF]

Act; P.L. 104-193) stipulates that persons
convicted of a state or federal felony drug
conviction are subject to a lifetime ban
on eligibility for food stamps and other
benefits. While this policy has a direct effect on individual inmates’ ability to rebuild
their own lives, it also has a substantial
impact on inmates’ ability to support their
children and families. Because formerly
incarcerated men have diminished earning
capacity (as much as 40 percent less)
over the course of their lifetimes, they are
unable to provide as much support to the
families with whom they live.100 Hence, a
vicious cycle is perpetuated: the communities from which inmates come are places
with very few economic resources, and inmates returning to these communities are
unable to contribute to the economic stability of the community due to diminished
earning potential. The result is diminished
family health and well-being, as well as
weakened family stability.101
Furthermore, because of the demographic
profile of incarcerated persons with felony
drug convictions, this policy has a disproportionate impact on African-American
and Latina women, as well as AfricanAmerican men—populations already experiencing significant social and health
disparities, including greater risk of HIV infection.93 Revising this policy to reinstate
eligibility for benefits to those with felony
drug convictions—for example, after some
prescribed period of time and after proof
of rehabilitation—could have a positive
impact on ex-offenders and their families,
who are trying to re-establish stable lives
in their communities.
Lack of employment, income, and access
to public assistance all contribute to housing instability for ex-offenders and their
families. Given the links between housing
instability and health outcomes (such as
HIV risk, mental illness, and addiction),
ensuring resources for and linkages to
stable housing for newly released individuals is another critical step to successful
re-entry. Research has shown that inability to secure stable housing and employment after release from prison may lead
drug-involved ex-offenders back to drug
dealing and to risks associated with this

lifestyle, including risky sexual behaviors.60,102,103
Federal legislation (such as the Department of Housing and Urban Development’s
Housing Opportunity Program Extension
Act of 1996) restricts or, in some cases, denies access to public housing for many exoffenders, particularly those convicted of
drug-related offenses.93,95 While some exoffenders may try to find housing with family members or friends, such efforts may
not always be successful. If family members or friends reside in public housing,
accepting an ex-offender into their home
may jeopardize their own residential stability due to the exclusion policies applicable to federally subsidized housing.

For inmates with
HIV, access to stable
housing can be the
critical factor in maintaining HIV treatment
While the lack of affordable housing is a
problem for the general population, making
efforts to link newly released inmates with
affordable, stable housing has been shown
to reduce rates of recidivism.104,105 For
those inmates with HIV or at risk of infection, access to stable housing can be the
critical factor in maintaining HIV treatment
adherence and risk reduction behaviors,
increasing access to medical services,
and improving health outcomes.106-108
Incorporating efforts to secure stable
housing as a part of effective discharge
planning for soon-to-be-released inmates
could help to reduce recidivism and
ensure that any health-related gains
achieved during incarceration are not
reversed once individuals are back in
their communities.

As a result of poverty, addiction, and other
forms of health and social disenfranchisement in their home communities, inmates
in correctional facilities have a uniquely
high prevalence of communicable disease,
including HIV/AIDS.109 In some ways, this
is not surprising given that, in almost every
corner of the world, HIV strikes the communities that are the least economically
and politically empowered.110 The disparities observed in America’s correctional
system reflect some of the problems seen
in its healthcare system. A strong commitment from all sectors of society is needed
to reduce social and economic disparities
in both systems in order to enhance the
health and well-being of all Americans,
regardless of race or ethnicity.
While it may seem that the goals of the
public health and corrections communities
are worlds apart, the reality is that both
strive to improve the conditions in society
that enhance public safety and contribute
to overall quality of life. Given the multidimensional impact of HIV/AIDS on individuals and families, the public health and
corrections/criminal justice communities
should work more collaboratively to address the socioeconomic disparities and
environmental factors that put individuals
at risk for both HIV infection and incarceration. Prison health is public health.111 In
order to alleviate the devastating impact of
HIV/AIDS on communities that are already
disproportionately affected by the epidemic, it is imperative to address the individual, social, and environmental factors
that predispose members of these communities to both HIV risk and risk of incarceration. It is equally imperative that we take
full advantage of the window of opportunity provided by incarceration to give inmates access to the healthcare and social
services that could facilitate reductions in
morbidity and mortality, successful reentry, and decreased recidivism. Doing so
would not only benefit the health of incarcerated persons, but also their families
and communities.


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amfAR is extremely grateful to Barry Zack (formerly of Centerforce) for his general guidance
about HIV prevention in correctional settings, and to the following individuals for their helpful
comments on an earlier version of this document:
Philip Fornaci, D.C. Prisoners’ Project of the Washington Lawyers’ Committee for Civil Rights
and Urban Affairs • Peter Gamache, M.B.A., M.L.A., M.P.H. (R.N.), University of South Florida •
Deborah M. Golden, Esq., D.C. Prisoners’ Project of the Washington Lawyers’ Committee for
Civil Rights and Urban Affairs • Adisa Griffin, Prison Initiative Manager, National Minority AIDS
Council • Olga Grinstead, Ph.D., University of California, San Francisco • Kathleen Morrow,
Ph.D., Brown University • Josiah Rich, M.D., M.P.H., Brown University • Jackie Walker, ACLU
National Prison Project • Milton Zelermeyer, The Legal Aid Society, Prisoners’ Rights Project

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