More than 2.2 million persons are currently incarcerated in US prisons and jails.1 Prisoners retain fundamental rights to health and health care, and prisoners and prisons are part of the larger community. Thus, the management of infectious disease in prison is both an issue of human rights and a matter of public health.
Incarcerated individuals bear a disproportionate burden of infectious diseases, including Hepatitis B virus (HBV), Hepatitis C virus (HCV), and HIV/AIDS. Although inmates comprise 0.8 percent of the US population, it is estimated that 12-15 percent of Americans with chronic HBV infection, 39 percent of those with chronic HCV infection, and 20-26 percent of those with HIV infection pass through a US correctional facility each year.2 The HIV prevalence in state and federal prisons is more than 3 times higher than in the general population.3 The prevalence of HCV among prisoners approaches 40 percent. Co-infection is also a concern: although data is scarce, a significant number of HIV-positive inmates are also infected with HCV.4
Although the majority of inmates infected with HBV, HCV and HIV acquired the infection outside of prison, the transmission of infectious disease in prison is increasingly well documented.5 Targeted interventions to reduce the risk of HIV transmission in prison, such as the provision of condoms, methadone maintenance treatment, and supplying bleach to clean needles and syringes, have proven highly effective in preventing HIV transmission in prisons, just as they have been when implemented outside. Often referred to as harm reduction, these approaches have been endorsed by the World Health Organization, the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the UN Office of Drugs and Crime (UNODC) as an integral part of HIV prevention strategies, including in prison.6 Government failure to ensure access to harm reduction services puts inmates at unnecessarily increased risk of infection.
Regardless of institutional regulations, sexual activity, both consensual and coerced, is common in prisons and jails.7 Sex among inmates has been documented extensively not only in academic studies and by human rights organizations, including Human Rights Watch, but by correctional systems themselves in the form of individual grievances and disciplinary actions against inmates engaging in prohibited behavior.8 Recent federal legislation found that an estimated 13 percent of US prisoners had been sexually assaulted in prison and called for research into its prevalence and patterns.9 Home-made tattoos and body piercings also contribute to a risk of transmission.10
1 US Department of Justice, Bureau of Justice Statistics Corrections Report, 2005.
2 C. Weinbaum et al, Hepatitis B, Hepatitis C, and HIV in Correctional Populations: a Review of Epidemiology and Prevention, AIDS, vol. 19 ( 3) (October 2005), p. 41.
3 51 of every 10,000 inmates is HIV positive, compared to 15 of every 10,000 non-incarcerated persons. National Minority AIDS Council, African Americans, Health Disparities and HIV/AIDS: 2006 Report, p.8.
4 A. Spaulding et al, A Framework for Management of Hepatitis C in Prisons, 144 Annals of Internal Medicine, vol. 144 (10) (May 2006) p. 763; S. Allen et al, Hepatitis C Among Offenders- Correctional Challenge and Public Health Opportunity, Fed. Probation, vol. 67 (22), (Sept. 2003), p. 22.
5 See, e.g. CDC Morbidity and Mortality Weekly Report (MMWR), HIV Transmission among Male Inmates in a State Prison System- Georgia 1992-2005, April 21, 2006, vol.55, no. MM15, p. 421. For a review of HBV, HCV and HIV transmission studies for both international and US prisons, see R. Jurgens, HIV/AIDS and HCV in Prisons: A Select Annotated Bibliography, International Journal of Prisoner Health, vol. 2 ( 2) (June 2006), p. 131. For a review of the US literature in this area see T. Hammett, HIV/AIDS and Other Infectious Diseases Among Correctional Inmates: Transmission, Burden and an Appropriate Response, American Journal of Public Health , vol. 96 (6) (June 2006), p. 974.
6 See, e.g. United Nations Office on Drugs and Crime, HIV/AIDS Prevention, Care, Treatment and Support in Prison Settings: A Framework for an Effective National Response (New York: United Nations, 2006); World Health Organization, UNAIDS, United Nations Office on Drugs and Crime, Evidence for Action on HIV/AIDS and Injection Drug Users. Policy Brief: Reduction of HIV Transmission in Prisons, WHO/HIV/2004.05 (2004).
7 Krebs, CP, High Risk HIV Transmission Behavior in Prison and the Prison Subculture, Prison Journal vol. 82 (2002), p. 19.
8 See, e.g., Krebs, CP et al, Intraprison Transmission: An Assessment of Whether it Occurs, How It Occurs, and Who Is at Risk, AIDS Education and Prevention (Supp. B) vol. 14 (2002) p. 53.; A. Spaulding, et al, Can Unsafe Sex Behind Bars Be Barred? American Journal of Public Health vol. 91(8) (2001) p. 1176; N. Mahon, New York Inmates HIV Risk Behaviors: the Implications for Prevention Policy and Programs, American Journal of Public Health vol. 86 (1996) p. 1211; Human Rights Watch, No Escape: Male Rape in US Prisons, April 2001.
9 Prison Rape Elimination Act, 2003, P-L 108-79, 108th Congress.
10 CDC MMWR, Hepatitis B Outbreak in a State Correctional Facility, 2000 June 29, 2001, vol. 50, no. MM25, p. 529.