Title: 1996-1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities. Series: Issues and Practices Author(s): Theodore M. Hammett, Patricia Harmon, and Laura M. Maruschak Published: July 1999 Subject(s): HIV/AIDS in correctional facilities, inmate education programs, inmate health care, jails and jail inmates, and HIV/AIDS 131 pages 311,000 bytes ------------------------------- This is an ASCII plain-text file. To view this document in its graphic format, download the Adobe Acrobat graphic file available from this Web site or order a print copy from NCJRS at 800-851-3420 (877-712-9279 for TTY users). ------------------------------- U.S. Department of Justice Office of Justice Programs National Institute of Justice Issues and Practices 1996-1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities National Institute of Justice Centers for Disease Control and Prevention Bureau of Justice Statistics HEALTH AND JUSTICE ------------------------------- U.S. Department of Justice Office of Justice Programs 810 Seventh Street N.W. Washington, DC 20531 Janet Reno Attorney General Raymond C. Fisher Associate Attorney General Laurie Robinson Assistant Attorney General Noel Brennan Deputy Assistant Attorney General Jeremy Travis Director, National Institute of Justice Office of Justice Programs World Wide Web Site http://www.ojp.usdoj.gov National Institute of Justice World Wide Web Site http://www.ojp.usdoj.gov/nij ------------------------------- U.S. Department of Justice Office of Justice Programs National Institute of Justice 1996-1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities by Theodore M. Hammett, Ph.D. Patricia Harmon Abt Associates Inc. and Laura M. Maruschak Bureau of Justice Statistics July 1999 NCJ 176344 ------------------------------- Issues and Practices in Criminal Justice is a publication series of the National Institute of Justice. Each report presents the program options and management issues in a topic area, based on a review of research and evaluation findings, operational experience, and expert opinion on the subject. The intent is to provide information to make informed choices in planning, implementing, and improving programs and practice in criminal justice. ------------------------------- National Institute of Justice Jeremy Travis Director Cheryl Crawford Program Monitor National Center for HIV, STD, and TB Prevention Centers for Disease Control and Prevention Helene D. Gayle, M.D., M.P.H. Director Bureau of Justice Statistics Jan M. Chaiken, Ph.D. Director ------------------------------- Prepared for the National Institute of Justice, U.S. Department of Justice by Abt Associates Inc., under contract No. OJP-94-C-007. Points of view or opinions stated in this document are those of the authors and do not necessarily represent the official position or policies of the U.S. Department of Justice. The National Institute of Justice is a component of the Office of Justice Programs, which also includes the Bureau of Justice Assistance, the Bureau of Justice Statistics, the Office of Juvenile Justice and Delinquency Prevention, and the Office for Victims of Crime. ------------------------------- Foreword HIV/AIDS, sexually transmitted diseases, and tuberculosis, as well as a range of other health problems disproportionately found among inmates and ex-offenders, pose serious challenges for corrections administrators, health service providers, and public health officials. These problems also present opportunities to intervene with effective prevention and treatment, thereby benefiting inmates and those close to them as well as the larger community. To meet these challenges corrections and public health agencies must work closely together with community-based organizations. The findings presented in this 1996-1997 Update report suggest that there have been substantial improvements in many aspects of the policy response to HIV/AIDS, STDs, and TB in correctional facilities. Much work is still needed in comprehensive prevention programs, discharge planning, community linkages, and continuity of treatment. The study also shows increasing collaboration among correctional, public health, and community-based agencies, but far more is needed. The three agencies that have sponsored and conducted the research presented in this Update--the National Institute of Justice (NIJ), the Centers for Disease Control and Prevention (CDC), and the Bureau of Justice Statistics (BJS)--are committed to collaboration in research on HIV/AIDS, STDs, and TB in correctional facilities and to collection and dissemination of information that will foster comprehensive and cooperative responses in policy and practice. This Update, for the first time, combines in one volume the latest statistics on the extent of HIV infection and AIDS among inmates from BJS surveys with the findings on policy and practice from the ongoing series of national surveys sponsored by NIJ and CDC. We hope that the expanding collaboration in research and dissemination represented by this report presages further increases in operational collaborations for the development and implementation of model HIV/AIDS, STD, and TB prevention and treatment programs in correctional settings. Jeremy Travis Director National Institute of Justice Helene D. Gayle, M.D., M.P.H. Director National Center for HIV, STD, and TB Prevention Centers for Disease Control and Prevention Jan M. Chaiken, Ph.D. Director Bureau of Justice Statistics Acknowledgments It is a pleasure to acknowledge the many people who have been instrumental in the preparation of this 1996-1997 Update report. At Abt Associates, Tricia Harmon carried out all of the analyses of the survey with great skill and thoroughness, David Deal managed the ninth NIJ/CDC survey of correctional systems, Michael Gross reviewed and commented upon earlier drafts of Abt's chapters, Mary Ellen Perry and Kim Kolosiej provided expert word processing services, and Wendy Sanderson did the camera-ready production. At the Bureau of Justice Statistics, the statistical agency of the U.S. Department of Justice, Allen J. Beck supervised the preparation of chapter 1 of the report. Christopher J. Mumola and Lauren E. Glaze provided statistical review. Tom Hester and Yvonne Boston edited the chapter. Data collection and processing for the National Prisoner Statistics Program were carried out by Tammy Anderson under the supervision of Gertrude Odom and Kathleen Creighton, Demographic Surveys Division, U.S. Bureau of the Census. Cheri Crawford was the National Institute of Justice project monitor for Abt's portion of the project, participating in site visits and providing useful comments and support throughout the preparation of the report. Lori de Ravello and Mark Lobato of the Centers for Disease Control and Prevention provided useful comments on the draft report. Juarlyn Gaiter of CDC participated in several site visits and provided very helpful input. John Miles was the CDC project monitor, participated in a number of the site visits, and has been a steadfast supporter of interventions for the prevention and treatment of infectious diseases and other health problems among correctional inmates. Finally, we acknowledge the valuable contributions of many staff members in the agencies that participated in the site visits for this project: California Department of Corrections, Centerforce and Center for AIDS Prevention Studies at the University of California, San Francisco; Louisiana Department of Corrections and Office of Public Health; New York City Department of Corrections and Department of Health; San Francisco County Sheriff's Department and Forensic AIDS Project, San Francisco Department of Public Health; Los Angeles County Juvenile Court Health Services and JWCH Institute; and Massachusetts Department of Youth Services. Theodore M. Hammett, Ph.D. Abt Associates Inc. Laura M. Maruschak Bureau of Justice Statistics Table of Contents Foreword Acknowledgments Executive Summary --HIV/AIDS: Burden of Disease Among Inmates --Sexually Transmitted Diseases and Hepatitis: Burden of Disease Among Inmates --HIV and STD Education and Behavioral Interventions --HIV Transmission and Risk Factors, Precautionary and Preventive Measures --Counseling and Testing, Confidentiality, and Disclosure --Housing and Correctional Management --Medical Treatment and a Continuum of Care --Tuberculosis (TB) --Legal and Legislative Issues Introduction --HIV/AIDS in the U.S. Population --The 1996-1997 Update: Contents and Sources --Endnotes Chapter 1: HIV in Prisons and Jails, 1996 --Key Findings --Trends in HIV Infection in U.S. Prisons --Confirmed AIDS Cases in U.S. Prisons --Comparison to the U.S. Resident Population --HIV Infection of Male and Female State Prison Inmates --AIDS-Related Deaths in State Prisons --HIV-Prevalence Rates and Testing Policies --HIV/AIDS Reported in Personal Interviews --HIV-Positive Prison Inmates, by Offense and Prior Drug Use --HIV Infection of Local Jail Inmates --HIV Test Results for Local Jail Inmates, by Inmate Characteristic --Percent HIV Positive Among Jail Inmates, by Offense and Prior Drug Use --Methodology Chapter 2: Sexually Transmitted Diseases and Hepatitis: Burden of Disease Among Inmates --Key Findings --STDs Among Inmates --Hepatitis Among Inmates --Conclusion --Endnotes Chapter 3: HIV and STD Education and Behavioral Interventions --Key Findings --Types of HIV/STD Education and Prevention Programs Provided --The Importance of Comprehensive HIV/STD Education and Prevention Programs --Instructor-Led Education and Educational Materials --Peer-Based Programs --Conclusion --Endnotes Chapter 4: HIV Transmission and Risk Factors, Precautionary and Preventive Measures --Key Findings --HIV Transmission and Risk Behaviors in Correctional Facilities --Rape and Coerced Sexual Activity --"Universal Precautions" Versus Correctional Officers' "Right to Know" --Condom Availability --Bleach Availability --Needle and Syringe Exchange --Methadone Maintenance --Reduction of Risk Associated With Tattooing --Conclusion --Endnotes Chapter 5: Counseling and Testing, Confidentiality and Disclosure --Key Findings --HIV-Antibody Testing Policies --Confidentiality and Notification of HIV Test Results --Conclusion --Endnotes Chapter 6: Housing and Correctional Management --Key Findings --Housing Policies for Inmates With HIV Disease --Work Assignments and Other Programming --Conjugal Visits --Compassionate Release and Medical Furlough --Conclusion --Endnote Chapter 7: Medical Treatment and a Continuum of Care --Key Findings --Medical Treatment for HIV/AIDS --Guidelines for Antiretroviral Therapy --Selection and Initiation of Antiretroviral Therapy --The Patient-Clinician Relationship --A Continuum of Care for Inmates --Screening and Identification of Medical and Psychosocial Problems --Case Management --Psychosocial Support Services --Hospice Care --Substance Abuse Treatment --Discharge Planning --Continuity of Care and Community Linkages --Conclusion --Endnotes Chapter 8: Tuberculosis --Key Findings --Tuberculosis Disease and Infection --The Role of Policy Change --Screening --Containment --Discharge Planning --Education --Conclusion --Endnotes Chapter 9: Legal and Legislative Issues --Key Findings --Confidentiality --Segregation of HIV-Infected Inmates --Access to Programs --Alleged Exposure to HIV --Medical Treatment --Early Release --Tuberculosis Issues --Legislative Developments --Conclusion --Endnotes List of Tables [Please see graphic file to view tables.] Table 1: Estimated incidence of AIDS-Opportunistic Illnesses (AIDS-Ols) and AIDS-related deaths, 1995-96-United States Table 2: Inmates in custody of State or Federal prison authorities and known to be positive for the human immunodeficiency virus, 1994-96 Table 3: Inmates in custody of State or Federal prison authorities, by type of HIV infection or confirmed AIDS, year-end 1996 Table 4: State prison inmates known to be positive for the human immunodeficiency virus, by sex, year-end 1996 Table 5: Number of inmate deaths in State prisons, by cause, 1994-96 Table 6: AIDS-related deaths of sentenced prisoners under State jurisdiction, 1996 Table 7: Inmates ever tested or tested since admission for the human immunodeficiency virus and test results Table 8: Inmates ever tested for the human immunodeficiency virus and results, by selected characteristics Table 9: Inmates ever tested for the human immunodeficiency virus and results, by offense and prior drug use Table 10: Standard error estimates for the 1996 Survey of Inmates in Local Jails and the 1997 Surveys of State and Federal Correctional Facilities Table 11: Results of mandatory and routine inmate syphilis screening, 1997 Table 12: Results of mandatory and routine gonorrhea screening, 1997 Table 13: Results of mandatory and routine chlamydia screening, 1997 Table 14: HIV/STD education and prevention programs for inmates, 1992-97 Table 15: HIV/STD education and prevention programs in adult correctional facilities, 1995-97 Table 16: HIV/STD education and prevention programs for inmates, 1997 results of the validation study (VS) Table 17: Topics covered in HIV/STD education for inmates, 1997 Table 18: Topics covered in HIV/STD education for inmates, 1997 results of the validation study (VS) Table 19: Providers of HIV/STD education and prevention services, 1997 Table 20: Availability of condoms and bleach, 1997 Table 21: Testing policies for antibodies to the human immunodeficiency virus, by jurisdiction, 1995 Table 22: Summary of HIV-antibody testing policies Table 23: Mutually exclusive categorization of HIV-antibody testing policies for incoming inmates, 1997 Table 24: HIV-antibody testing policies, 1997: Results of the validation study (VS) Table 25: Pregnancy testing for female inmates, 1997 Table 26: HIV-antibody testing for pregnant female inmates, 1997 Table 27: Policies regarding notification of inmates' HIV-antibody test results, 1997 Table 28: Notification of HIV-antibody test results, 1997: Results of the validation study (VS) Table 29: Mandatory and routine testing of incoming inmates for STDs, 1997 Table 30: Decline of segregation policies in State/Federal systems (n = 51) 1985-97 Table 31: State/Federal prison systems' housing policies for inmates with AIDS and asymptomatic HIV infection, 1994 and 1997 Table 32: City/county jail systems' housing policies for inmates with AIDS and asymptomatic HIV infection, 1994 and 1997 Table 33: Housing of inmates with asymptomatic HIV infection and AIDS: Results of the validation study (VS) Table 34: Compassionate release and medical furlough, 1997 Table 35: Inmates receiving compassionate release and medical furlough, 1996 Table 36: The availability of HIV therapies and monitoring, 1997 Table 37: The availability of HIV therapies and monitoring: Results of the validation study (VS) Table 38: Psychosocial and supportive services for inmates with HIV/AIDS, 1997 Table 39: Discharge planning services, 1997 Table 40: Active TB disease among inmates, 1997 Table 41: TB infection among inmates, 1997 Table 42: Screening inmates for TB, 1997 List of Figures [Please see graphic file to view figure.] Figure 1: Tuberculosis Cases and Rates Among New York State Inmates (Exclusive of New York City), 1986-97 Executive Summary At midyear 1998, more than 1.8 million people were in prisons and jails in the United States, and 6 million were under some form of criminal justice supervision. Inmates have disproportionately high rates of infectious disease, substance abuse, high-risk sexual activity, and other health problems. Thousands of former correctional inmates return to the community each month. Because prisoners are part of the community and because correctional health and public health are increasingly intertwined, health care and disease prevention in correctional facilities should be based on the collaborative efforts of correctional, public health, and community-based health care and social service organizations. This 1996-1997 Update reports on the extent of HIV/AIDS, STDs, and TB among correctional inmates and on the policies and practices being implemented to prevent and control these diseases in correctional settings. In this report, statistics on the prevalence of HIV infection and AIDS in correctional populations are derived primarily from surveys conducted by the Bureau of Justice Statistics (BJS) in 1996 and 1997. Findings regarding policies and practices and legal and legislative issues are based primarily on the ninth national survey of HIV/AIDS, STDs, and TB in correctional facilities, sponsored by the National Institute of Justice (NIJ) and the Centers for Disease Control and Prevention (CDC) and conducted between December 1996 and August 1997. Findings on HIV-testing policies presented in chapter 5 of this report are from BJS' 1996 National Prisoner Statistics and the 1997 NIJ/CDC survey. Statistics on other policies are based primarily on the NIJ/CDC ninth national survey and associated site visits. Although the report focuses on adult correctional systems, several examples of HIV prevention programs in chapter 3 were drawn from site visits to juvenile facilities. Key findings presented in this report are summarized below. HIV/AIDS: Burden of Disease Among Inmates o The overall prevalence of HIV infection and AIDS among inmates has been quite stable since 1991, but some systems have experienced declines in HIV seroprevalence. o There have been some declines in AIDS deaths among inmates since 1995. o Nevertheless, HIV infection and AIDS continue to be far more prevalent among inmates than in the total U.S. population. o The Northeast region has the largest number and percentage of inmates with HIV infection and AIDS. o The prevalence of HIV and AIDS is higher among Hispanic and black inmates than among white inmates. o The prevalence of HIV and AIDS is higher among female inmates than among male ones. Sexually Transmitted Diseases and Hepatitis: Burden of Disease Among Inmates o Available data on STDs and hepatitis B and C among inmates are very incomplete, reflecting the relative rarity of routine screening for these conditions in correctional facilities. o However, behavioral profiles and anecdotal evidence suggest that inmates are disproportionately affected by STDs and hepatitis. HIV and STD Education and Behavioral Interventions o HIV and STD education programs are becoming more widespread in correctional facilities. o However, few correctional systems have implemented comprehensive and intensive HIV prevention programs in all of their facilities. o Peer-based education and prevention programs offer important advantages, such as cost-effectiveness, credibility, flexibility, and benefits to peers themselves. o Although few HIV/STD prevention programs in correctional settings have been rigorously evaluated, anecdotal evidence suggests that programs can be successful in reaching this extremely high-risk population with practical risk-reduction messages. HIV Transmission and Risk Factors, Precautionary and Preventive Measures o High-risk behaviors for HIV transmission-sex, drug use, sharing of injection materials, and tattooing-occur in correctional facilities. o HIV transmission among correctional inmates has been shown to occur. o Comprehensive and intensive education and prevention programs represent the best response to these facts, although the precise content of such programs is controversial. o Rape and coerced sexual activity also occur in correctional facilities but require a different response, one based on inmate classification, housing, and supervision. o The implementation of "universal precautions" represents the heart of a correctional infection-control program and the first line of defense against the occupational transmission of HIV. o Condom distribution and other harm-reduction strategies have not been widely adopted in American correctional systems. o Experience with harm reduction in correctional facilities in Europe and elsewhere may warrant the attention of U.S. correctional administrators. Counseling and Testing, Confidentiality, and Disclosure o Most correctional systems provide HIV antibody testing, although testing policies differ widely. o Seventeen State correctional systems and the Federal Bureau of Prisons had policies for mandatory HIV-antibody testing of inmates at intake and/or release. o Few correctional systems have mandatory or routine pregnancy testing of female inmates. o Ongoing assessment of HIV-antibody and pregnancy-testing policies is warranted in light of changing community standards for treatment of HIV/AIDS. o Very few correctional systems have policies for notification of correctional officers regarding inmates' HIV status. o Few correctional systems routinely screen inmates for STDs. Housing and Correctional Management o Only a small number of correctional systems segregate inmates with HIV disease, and the number of systems with segregation policies has declined sharply since the late 1980s. o Some correctional systems still limit the work assignments for which inmates with HIV are eligible. o Few correctional systems permit conjugal visits for any inmates, and even fewer allow such visits for inmates with HIV. o Policies for the early or compassionate release of inmates with terminal illness, including end-stage AIDS, are quite common, but relatively few inmates are actually being released under such policies. Medical Treatment and a Continuum of Care o Protease inhibitors and combination therapies have brought dramatic improvements in the medical condition and survival of people with HIV, at least over the relatively short term that has been available for study to date. o The new therapeutic combinations pose challenges for patient adherence, and failure to adhere consistently to the regimens may have serious public health consequences if drug-resistant strains are transmitted to others. o New drugs and reduced dosing currently under study offer hope of more "patient-friendly regimens." o Clinicians must work closely with patients to make the best therapeutic decisions. o A continuum of services including early identification, timely and effective treatment, case management, discharge planning, and community linkages will make for optimal clinical and psychosocial outcomes for inmates with HIV disease. o Continuity of care and bridging to community services also contribute to positive patient outcomes. o Existing program models have not been rigorously evaluated but probably warrant replication based on anecdotal evidence. Tuberculosis (TB) o In recent years the incidence of TB has declined both in the overall U.S. population and among correctional inmates, although it remains much higher among inmates. o Most State/Federal prison systems appear to be following CDC guidelines regarding TB screening, isolation and treatment, and preventive therapy, whereas adherence is lower among city/county jail systems. o Better collection and reporting of screening data would help to document the burden of TB infection and disease among inmates. o Improvements are also needed in the use of directly observed therapy, as well as in postrelease adherence to treatment for TB disease and TB infection. Legal and Legislative Issues o The U.S. Supreme Court has ruled that HIV and HIV-related discrimination are covered under the Americans With Disabilities Act. o There were few other major legal developments affecting HIV/AIDS in correctional facilities during the period covered by this Update report, although courts generally continued to uphold correctional systems' policy responses to HIV/AIDS. o Some State legislatures have attempted to expand the requirements for HIV antibody testing of inmates and disclosure of inmates' HIV status, but these efforts generally have been unsuccessful. Introduction In 1996 the Joint United Nations Programme on HIV/AIDS (UNAIDS) cogently summarized the importance of health care and disease prevention in correctional facilities: "Prisoners are the community. They come from the community, they return to it. Protection of prisoners is protection of our communities."[1] In the United States, the case is made particularly compelling by the following facts: the continuing surge in incarceration, with more than 1.8 million people in prisons and jails and 6 million under some form of criminal justice supervision at midyear 1998; the continuing disproportionate rates of infectious disease, substance abuse, high-risk sexual activity, and other health problems among correctional inmates; and the return of thousands of former correctional inmates to the community each month. The 1996 UNAIDS statement also declared that "failure to provide [prisoners] the basic measures, such as information, education, and the means of [HIV] prevention available on the outside, violates [their] rights to health, security of person, and equality before the law." Because prisoners are part of the community and because correctional health and public health are increasingly intertwined, health care and disease prevention in correctional facilities should be based on the collaborative efforts of correctional, public health, and community-based health care and social service organizations. A public health model of correctional health care is needed. Such an approach is particularly urgent given the recent dramatic advances in antiretroviral therapy and the attendant importance of continuity of treatment, adherence to regimens, and minimizing the potential for development of drug resistance. HIV/AIDS in the U.S. Population As context for the main contents of this Update, it is important to understand the overall trends and patterns of HIV disease in the U.S. population. Between 1995 and 1996, the HIV/AIDS epidemic in the United States appeared to be lessening in intensity, at least in some sectors of the population. However, the face of the epidemic continued to change, with increasing concentration among the poor and people of color, the populations from which the majority of inmates are drawn. Table 1, adapted from CDC's Morbidity and Mortality Weekly Report, reveals the dramatic changes in the epidemic that occurred between 1995 and 1996. Calendar year 1996 was the first year in which the incidence of AIDS-opportunistic illnesses (AIDS-OIs) actually declined in the United States.[2] AIDS-OIs is a measure designed to adjust for the 1993 change in the AIDS case definition, thus permitting valid comparisons in incidence over that time. It is calculated from the sum of cases reported with an AIDS-OI and cases with estimated dates of diagnosis of an AIDS-OI that were reported based only on the immunologic criteria added in the 1993 revised case definition. (In this report, the AIDS-OI measure is used only with regard to the total U.S. population and not with regard to the situation in correctional facilities.) Although the incidence of AIDS-OIs continues to be high--an estimated 56,730 cases were reported in 1996--incidence declined in all geographic regions of the country, all 5-year age groups, and many other sectors of the population (table 1). Incidence declined between 1995 and 1996 among men (by 8 percent), non-Hispanic whites (by 13 percent), men who have sex with men (by 11 percent), and injection drug users (by 5 percent). Moreover, although HIV/AIDS remains a leading cause of death among Americans between 25 and 44 years of age, AIDS deaths actually declined for the first time between 1995 and 1996. The decline was substantial--23 percent. It was largest in the last three quarters of 1996 and affected all geographic regions, racial and ethnic groups, and exposure categories. These temporal declines in AIDS-OI incidence are attributable to reductions in rates of new infection--due in turn to prevention efforts--a slowing in progression from infection to active disease, and AIDS-OI diagnosis. Reductions in the number of deaths are based on increased survival with AIDS-OIs, in turn the result of newly available antiretroviral therapies and prophylaxis for OIs.[3] Increased survival and the relatively stable incidence of new HIV infections, however, have resulted in an increased prevalence of AIDS in the population: from 1995 to 1996 the number of people living with AIDS in the United States increased by 11 percent, from 211,000 to 235,000. This increasing AIDS prevalence indicates the need for more resources and services to treat and care for those who are ill. The incidence of AIDS-OIs did not decline among all segments of the U.S. population between 1995 and 1996. It remained stable among non-Hispanic blacks, and actually increased among women (by 2 percent) and persons who were infected through heterosexual contact (by 8 percent). In the United States, heterosexually transmitted HIV infection results primarily from sexual relations with drug users. An examination of trends in the proportional distribution of new AIDS-OI cases across racial/ethnic groups, genders, and exposure categories reinforces the conclusions that the epidemic is becoming increasingly concentrated among people of color and that women are increasingly affected. Between 1992 and 1996, the proportion of new cases of AIDS that occurred among non-Hispanic whites declined from 48 percent to 38 percent, whereas it remained stable among Hispanics (18 percent to 19 percent), and increased from 33 percent to 41 percent among non-Hispanic blacks. Indeed, for the first time in 1996, the number of new cases of AIDS among blacks exceeded the number among whites. The proportion of new AIDS cases among women also increased from 14 percent in 1992 to 20 percent in 1996.[4] The 1996-1997 Update: Contents and Sources This Update reports on the extent of HIV/AIDS, STDs, and TB among correctional inmates and on the policies and practices being implemented to prevent and control these diseases in correctional settings. Statistics on the prevalence of HIV infection and AIDS in correctional populations presented in this report are primarily from the Bureau of Justice Statistics (BJS) 1997 Survey of State and Federal Correctional Facilities, 1996 National Prisoner Statistics, and 1996 Survey of Inmates in Local Jails. Statistics on the prevalence of STDs and TB among correctional inmates come primarily from the ninth national survey of HIV/AIDS, STDs, and TB in correctional facilities, sponsored by the National Institute of Justice (NIJ) and the Centers for Disease Control and Prevention conducted between December 1996 and August 1997 and the CDC's TB surveillance system. Findings on HIV-testing policies presented in chapter 5 of this report are from BJS' 1996 National Prisoner Statistics and the 1997 NIJ/CDC survey. Statistics and discussion in all other chapters on policies and practices, as well as the chapter on legal and legislative issues, are based primarily on the NIJ/CDC ninth national survey. As in all of the previous national surveys in this series, responses were received from all 50 State departments of correction and the Federal Bureau of Prisons. The sample selection for the city/county jail systems was modified in 1996-97 to target the 50 largest city/county jail systems by average daily inmate population. Responses were received from 41 of these, or 82 percent. Again in 1996-97, a validation survey was conducted. An abbreviated version of the questionnaire was sent to 50 individual facilities in 15 State correctional systems and the Federal Bureau of Prisons. The objective of the validation study was to compare responses on key policy issues from individual facilities and the central offices of their departments of corrections. The survey was supplemented by site visits to the States of California and Louisiana and to New York City and San Francisco to observe HIV prevention programs and discharge planning/transitional programs. Site visits were also conducted to observe HIV/STD prevention programs in the juvenile systems of Massachusetts and Los Angeles County, California. Although the report focuses on adult correctional systems, several examples of HIV prevention programs in chapter 3 were drawn from site visits to juvenile facilities. How widespread are comprehensive and collaborative approaches to correctional and community health services? In general, the results of the 1997 NIJ/CDC survey suggest that HIV/AIDS education and prevention programs are on the increase in prisons and jails but, as was also demonstrated by the previous survey and by an extensive review of the literature, still fail to take full advantage of this important public health opportunity.[5] A separate report based on the 1997 survey shows that public health-corrections collaborations are increasingly common but still rarely rise to the level of a comprehensive public health model.[6] Endnotes 1. "HIV/AIDS in Prisons," Statement by the Joint United Nations Programme on HIV/AIDS (UNAIDS), April 1996. 2. Centers for Disease Control and Prevention, "Update: Trends in AIDS Incidence--United States, 1996," Morbidity and Mortality Weekly Report 46 (September 19, 1997): 861-867. 3. F.J. Palella, Jr., et al., "Declining Morbidity and Mortality Among Patients With Advanced HIV Infection," New England Journal of Medicine 338 (March 26, 1998): 853-860. 4. Centers for Disease Control and Prevention, "Update: Trends in AIDS Incidence, Deaths, and Prevalence--United States, 1996." Morbidity and Mortality Weekly Report 46 (February 28, 1997): 165-173. 5. T.M. Hammett and R. Widom, "HIV/AIDS Education and Prevention Programs for Adults in Prisons and Jails and Juveniles in Confinement Facilities--United States, 1994," Morbidity and Mortality Weekly Report 45 (April 5, 1996): 268-271; T.M. Hammett, R. Widom, and S. Kerr, "HIV Prevention in Prisons and Juvenile Facilities: A Missed 'Public Health Opportunity,' " oral abstract We.D.351, presented at the 11th International Conference on AIDS, Vancouver, Canada, July 10, 1996; and T.M. Hammett, J.L. Gaiter, and C. Crawford, "Reaching Seriously At-Risk Populations: Health Interventions in Criminal Justice Settings," Health Education and Behavior 25 (February 1998): 99-120. 6. T.M. Hammett, Public Health/Corrections Collaborations: Prevention and Treatment of HIV/AIDS, STDs, and TB, Research in Brief, Washington, DC: U.S. Department of Justice, National Institute of Justice, 1998 (NCJ 169590). ------------------------------- Chapter 1 HIV in Prisons and Jails, 1996 Laura M. Maruschak--Bureau of Justice Statistics At Year-end 1996, 2.3 percent of all State and Federal prison inmates were known to be infected with the human immunodeficiency virus (HIV). A total of 24,881 prison inmates were HIV positive (947 Federal and 23,934 State). HIV-positive inmates made up 1.0 percent of Federal prison inmates and 2.4 percent of State prison inmates. Of those known to be HIV positive in all U.S. prisons, 5,874 were confirmed AIDS cases, while the remaining 17,656 either showed symptoms of HIV infection or were asymptomatic. In 1996, there were a total of 907 AIDS-related deaths in State prisons, down from 1,010 in 1995. For every 100,000 State prison inmates in 1996, 90 died of AIDS-related causes. Between 1991 and 1996, about 1 in 3 State prison inmate deaths were attributed to AIDS-related causes. Data based on personal interviews from the 1997 Survey of Inmates in State Correctional Facilities show that 75 percent of State inmates were ever tested for HIV. Of those who were ever tested and reported results, 2.2 percent were HIV positive--2.2 percent of males and 3.4 percent of females. As reported level of involvement in prior drug use increased, so did the percent of HIV-positive inmates--2.3 percent of those who said they had ever used drugs, 2.7 percent of those who used drugs in the month before the current offense, 4.6 percent of those who injected drugs, and 7.7 percent of those who ever shared a needle were HIV positive. Data on HIV/AIDS in jails have been collected in the 1993 Census of Jails and the 1996 Survey of Inmates in Local Jails. According to the 1993 Census of Jails, 1.8 percent of local jail inmates were known to be HIV positive. The larger the size of the jail jurisdiction, the greater the percentage of inmates with HIV/AIDS. Based on personal interviews conducted from October 1995 through March 1996 in the Survey of Inmates in Local Jails, almost 6 in 10 inmates reported ever being tested for HIV. Of those who were tested and reported results, 2.2 percent reported being HIV positive. Among female inmates, 2.4 percent said they were HIV positive; among male inmates, 2.1 percent. An estimated 2.3 percent of tested jail inmates who said they had ever used drugs were HIV positive, as were 2.9 percent who used drugs in the month before arrest, 4.0 percent who used a needle to inject drugs, and 6.3 percent who ever shared needles. Trends in HIV Infection in U.S. Prisons At Year-end 1996, 24,881 inmates in State and Federal prisons were known to be infected with the human immunodeficiency virus (HIV), up from 24,256 at Year-end 1995 (table 2). In State prisons, 23,934 inmates were known to be HIV positive, and in Federal prisons, 947 inmates were HIV positive. Although the number of HIV cases increased after 1991, the percent of the total custody population with HIV remained relatively stable. Between 1991 and 1996 the number of HIV-positive inmates grew at about the same rate as the overall prison population (both increased by about 42 percent). HIV-positive inmates comprised 2.3 percent of the State prison population in 1991 and 2.4 percent in 1996. In Federal prisons, HIV-positive inmates comprised 1.0 percent in 1996, unchanged from 1991. HIV-infected inmates were concentrated in a small number of States. New York and Florida housed the largest number of HIV-positive inmates (9,500 and 2,152, respectively). In 1996, these two States housed nearly half of all HIV-infected inmates in State prisons. More than half of the State prison inmates known to be HIV positive were found in the Northeast. Within the Northeast, 7.5 percent of the prison population were HIV positive, followed by 2.0 percent in the South, 1.1 percent in the Midwest, and 0.8 percent in the West. New York had the highest percentage of inmates known to be HIV positive (13.6 percent), followed by Connecticut (4.6 percent), and Rhode Island (3.9 percent). These three States had the highest percentage of HIV-positive inmates after 1994. Of the 48 States that reported information on the number of HIV-positive inmates in 1996, each reported having at least one. Eight States (Alaska, Maine, Montana, North Dakota, South Dakota, Vermont, West Virginia, and Wyoming) reported 10 or fewer cases of HIV-positive inmates in their prisons. Eleven States reported that fewer than 0.5 percent of their inmate population were HIV positive. Between 1995 and 1996 the largest growth of HIV-positive inmates was reported in Virginia--383 in 1996, up from 134 in 1995. Other notable increases during 1996 were reported in Michigan (up 149) and Maryland (up 108). Confirmed AIDS Cases in U.S. Prisons At the end of 1996, 5,874 inmates in U.S. prisons had confirmed AIDS: 5,521 were State inmates and 353 were Federal inmates (table 3). Of the remaining HIV-positive inmates, 1,959 showed symptoms of AIDS (symptomatic), while 15,697 were HIV positive but showed no symptoms of AIDS (asymptomatic). Confirmed AIDS cases made up 0.5 percent of all inmates in State and Federal prisons. Of those inmates known to be HIV positive, nearly a quarter had confirmed AIDS. During 1996 the number of confirmed AIDS cases increased by 748. Overall, after 1991 the number of confirmed AIDS cases increased by 4,165--an average annual increase of 28.3 percent. The number of inmates with lesser or no symptoms of HIV infection actually decreased in 1996, and the number was below the numbers reported in every year from 1992 to 1995. The States with the largest number of confirmed AIDS cases were New York (1,208), Florida (873), Texas (499), and California (429). Combined, these States made up 55 percent of all confirmed AIDS cases in State prisons. Eighteen States reported having fewer than 10 confirmed AIDS cases in their prisons. The highest percentage of the State prison population having confirmed AIDS was in New York (1.7 percent), followed by Connecticut (1.6 percent), Massachusetts (1.5 percent), Florida (1.4 percent), and Maryland (1.3 percent). In 17 States confirmed AIDS cases comprised 0.1 percent or fewer of State inmates. Comparison to the U.S. Resident Population At the end of 1996, the rate of confirmed AIDS in State and Federal prisons was six times higher than in the total U.S. population. About 54 in 10,000 prison inmates had confirmed AIDS, compared to 9 in 10,000 persons in the U.S. population. In every year from 1991 to 1996, the rate of confirmed AIDS was higher among prison inmates than in the general population. In 1992 the rate of AIDS was 11 times higher for prisoners than the general population. In 1993, following a revision of the HIV classification system and an expansion of the case definition for AIDS, the rate of confirmed AIDS increased 12 times among prisoners and doubled in the general population. After the adoption of these new measures, the incidence of AIDS grew somewhat faster in the general population. At Year-end 1996 the rate of confirmed AIDS was six times higher in prisons than in the general population. HIV Infection of Male and Female State Prison Inmates At Year-end 1996 there were 21,799 male inmates and 2,135 female inmates known to be HIV positive (table 4). Overall, 2.3 percent of male inmates and 3.5 percent of all female inmates were known to be HIV positive. The rate of HIV infection in females was higher than male infection rates in all regions except the West and in most States. Between 1995 and 1996 the number of infected female inmates decreased 2.2 percent from 2,182 to 2,135; the number of infected male inmates increased 5.4 percent from 20,690 in 1995 to 21,799 in 1996. Overall, among State prisoners, the number of males infected with HIV increased 35 percent, and the number of females infected increased 84 percent between 1991 and 1996. States in the Northeast reported the largest number of HIV-positive male and female inmates (10,985 and 1,105, respectively). In eight States, more than 5 percent of all female inmates were known to be HIV positive. In two States over 10 percent of all female inmates were known to be HIV positive--New York (20.5 percent) and Rhode Island (11.7 percent). New York (13.2 percent) was the only State in which more than 10 percent of all male inmates were HIV positive. Among all States, New York reported the largest number of male and female HIV-positive inmates (8,736 and 764, respectively). The second largest number of HIV-positive male inmates were in Florida (1,929), followed by Texas (1,645). The second largest number of HIV-positive female inmates were in Texas (231), followed by Florida (223). Seven States reported no female HIV-positive inmates, and every State reported at least one male HIV-positive inmate. AIDS-Related Deaths in State Prisons The number of State inmates who died of Pneumocystis carinii pneumonia, Kaposi's sarcoma, or other AIDS-related diseases decreased from 1,010 in 1995 to 907 in 1996 (table 5). These AIDS deaths accounted for 29 percent of all deaths among State prisoners, down from 34 percent in 1995. Beginning in 1991 AIDS-related causes were the second leading cause of death in State prisons, behind natural causes other than AIDS. In 1996, for every 100,000 inmates, 90 died from AIDS-related causes. Between 1991 and 1995, the number of AIDS-related deaths in State prisons increased 94 percent; however, in 1996 the number decreased 10 percent from 1995. With the introduction of protease inhibitors and combination antiretroviral therapies, there was appreciable improvement in the effectiveness of HIV/AIDS care. The rate of death because of AIDS is about three times higher in the prison population than in the total U.S. population age 15-54. Between 1991 and 1996, about 1 in every 3 prisoner deaths were attributable to AIDS-related causes, compared to about 1 in 10 deaths in the general population. AIDS-related deaths accounted for more than half of all inmate deaths in Connecticut (65 percent), New York (55 percent), New Jersey (52 percent), and Florida (50 percent) (table 6). Seventeen States reported having no AIDS-related deaths, and five States reported one AIDS-related death. HIV Prevalence Rates and Testing Policies Data on HIV prevalence rates are reported in the National Prisoners Statistics series (NPS) by prison officials. The quality of the information reported varied by the testing policies that a particular State implemented. Testing policies ranged from testing all inmates to testing only upon inmate request. Although 19 States tested either all inmates in custody or a random selection, and 27 test targeted groups (high-risk individuals or upon indication or incidence), 5 tested solely upon inmate request. Official data represent the minimum number of individuals known to be HIV positive within a prison facility. Blinded or "unlinked" studies have been conducted as another means of determining the HIV prevalence in State prisons. These studies are blinded in that the identity of the inmate is not linked to the result of the HIV test. An inmate's blood that has been drawn during a routine physical examination upon entering a facility is tested for HIV. The sample is sent to a lab with no information regarding the inmate. Blinded studies may not accurately account for the prevalence rate of HIV in prisons. Often these studies are conducted in only a few facilities, and are snapshots, examined over one period solely on admission cohorts. Because of this, blinded studies are limited in that they may not be generalized to the overall prison population. Discrepancies are apparent between HIV prevalence rates reported in official records and those produced from blinded studies. Data from a blinded study conducted in Massachusetts in 1995 suggest that 6.8 percent of incoming inmates are HIV positive, while official data from 1995 indicate 3.9 percent of all inmates in custody were HIV positive. Similarly, data from blinded studies conducted in Maryland (1991), California (1994), Illinois (1991), and New Jersey (1991) suggest that official data underestimate the HIV prevalence rate. Official data from New York in 1994 and 1995, however, revealed higher HIV prevalence rates than data from a 1994-1995 blinded study. The blinded study showed that 10 percent of all incoming inmates were HIV positive, while official data showed that of all inmates in custody, 12.4 percent in 1994 and 13.9 percent in 1995 were HIV positive. Similarly, National Prisoner Statistics (NPS) data from Arkansas (1992) and Washington (1991) suggest a higher prevalence rate among inmates than data from blinded studies (0.9 percent compared to 0.6 percent, and 0.5 percent compared to 0.2 percent). HIV/AIDS Reported in Personal Interviews Additional information on the prevalence of HIV/AIDS may also be obtained through personal interviews of prisoners. Though some inmates may be reluctant to report that they are HIV positive and others may not know, surveys provide a means to track HIV infection among demographic and "high-risk" groups not identified in official records or blinded studies. The 1997 Surveys of State and Federal Correctional Facilities asked inmates if they had ever been tested, if they had been tested since admission, and whether they were HIV positive. Similar questions were asked in the 1996 Survey of Inmates in Local Jails. (See Methodology for further detail.) In 1997, 17,674 (1.7 percent) State prison inmates and 428 (0.5 percent) Federal prison inmates were known to be HIV positive (table 7). Of those inmates who reported being tested since admission to State prison, or to Federal prison, 2.6 percent and 0.7 percent, respectively, reported being HIV positive. Among State prisoners, female inmates (3.4 percent) were more likely than male inmates (2.2 percent) to be HIV positive (table 8). Black non-Hispanic inmates (2.8 percent) were twice as likely as white non-Hispanic inmates (1.4 percent) to report being HIV positive. Among male inmates, blacks (2.7 percent) were nearly twice as likely as whites to be HIV positive. The rates of HIV infection among female inmates were not significantly different among whites (2.3 percent), blacks (3.9 percent), and Hispanics (4.2 percent). In Federal prisons 0.6 percent of males and of females reported HIV infection. Non-Hispanic white inmates reported the lowest HIV-positive rates (0.3 percent). In both State and Federal prisons, inmates age 17 to 24 reported the lowest rate of being HIV positive (0.5 percent and 0.1 percent, respectively). In State prisons, inmates age 35 to 44 reported the highest HIV-positive rate (3.1 percent). Those State inmates in each age category over 24 were more likely to be HIV positive than those who were 24 or younger. In Federal prisons, inmates age 45 or older reported the highest rate of HIV infection (1.2 percent). HIV-Positive Prison Inmates, by Offense and Prior Drug Use Those inmates being held on a drug offense in State prisons reported the highest HIV positive rate (2.9 percent) (table 9). Of property offenders, 2.4 percent reported being HIV positive. Violent and public-order offenders reported slightly lower rates (1.9 percent each). Among Federal prison inmates, 1.0 percent of violent offenders, property offenders, and public-order offenders reported being HIV positive as did 0.4 percent of drug offenders. The percentage of State and Federal prison inmates reporting that they were HIV positive varied by level of prior drug use. By type of drug use practice, the following percentages of State prison inmates reported being HIV positive: never using drugs, 1.7 percent HIV positive; ever used drugs, 2.3 percent; used drugs in the month before their current offense, 2.7 percent; used a needle to inject drugs, 4.6 percent; and shared a needle, 7.7 percent HIV positive. Like State inmates, Federal inmates who used a needle and shared a needle had a higher rate of HIV infection than those inmates who reported ever using drugs or using drugs in the month before their current offense (1.3 percent and 2.1 percent compared to 0.7 percent and 0.3 percent). Unlike State inmates, Federal inmates using drugs in the month prior to their current offense reported a lower rate of HIV infection (0.3 percent) than inmates who reported ever using drugs (0.7 percent). HIV Infection of Local Jail Inmates At midyear 1993, when the last national census of local jails was conducted, 1.8 percent of the inmates were known to be HIV positive. Among jails reporting data, a total of 6,711 inmates were HIV positive, and 1,888 had confirmed AIDS. The infection rate was highest in the largest jail jurisdictions. Almost 3 percent of the inmates in the Nation's largest jurisdictions were reported HIV positive. Among the remaining jurisdictions, the larger the size, the greater the percentage of inmates with HIV/AIDS. In jurisdictions with 500 or more inmates, 1.6 percent of the inmates were infected; in jurisdictions with 250 to 499 inmates, 1.2 percent; and in jurisdictions holding fewer than 250 inmates, 1 percent or less. HIV Test Results for Local Jail Inmates, by Inmate Characteristic Detailed data, based on interviews of a national sample of inmates in local jails, are available from the 1996 Survey of Inmates in Local Jails. Conducted between October 1995 and March 1996, the survey provides national estimates of the number of jail inmates tested for HIV/AIDS and the percent HIV positive. In 1996, 6,289 local jail inmates (1.2 percent of all inmates) were known to be HIV positive (table 7). An estimated 57 percent of all respondents in the survey said they had ever been tested for HIV. Of those who had been tested for HIV, 2.2 percent said they were HIV positive. Since admission, about 18 percent of inmates had been tested for HIV, and 3.9 percent reported HIV positive results. Among jail inmates, 2.1 percent of males and 2.4 percent of females said they were HIV positive (table 8). An estimated 2.6 percent of black inmates, compared to 1.4 percent of white inmates, said they tested HIV positive. Among male inmates, blacks (2.5 percent) were nearly twice as likely as whites (1.3 percent) to report being HIV positive. Hispanic males had the highest HIV-positive rate (3.5 percent). Among female inmates, although the percentage who reported they were HIV positive was higher among blacks (3.2 percent) than whites (2.1 percent) and Hispanics (1.3 percent,) the differences were not statistically significant. Inmates age 24 or younger had the lowest HIV-positive rates (0.7 percent), while those 35 to 44 had the highest rates (3.8 percent). Inmates 25-34 and 45 or older fell in the middle (2.1 percent and 3.0 percent, respectively). Inmates who had completed high school were as likely as those who had not completed high school to say they tested HIV positive (2.3 percent). Percent HIV Positive among Jail Inmates, by Offense and Prior Drug Use Among jail inmates who said they had been tested for HIV/AIDS, those held for drug offenses were the most likely to be HIV positive (3.3 percent) (table 9). Drug offenders were twice as likely as violent offenders (1.5 percent) to report that they tested positive for HIV. Property and public-order offenders reported somewhat lower rates--2.2 percent and 1.7 percent, respectively. The percent of jail inmates reporting that they were HIV positive varied by level of prior drug use. An estimated 2.3 percent of inmates who had ever used drugs, 2.9 percent of inmates who used drugs in the month before their current offense, 4.0 percent of inmates who said they had used needles to inject drugs, and 6.3 percent of those who had shared a needle with someone else reported being HIV positive. Methodology National Prisoner Statistics The National Prisoner Statistics series (NPS) includes an annual Year-end count of prisoners by jurisdiction, sex, race, Hispanic origin, and admissions and releases during the year. The series consists of yearly reports to the Bureau of Justice Statistics from the departments of corrections of the 50 States and the District of Columbia and from the Federal Bureau of Prisons. Since 1991 respondents have been asked to indicate their policies for testing for HIV and to provide the number of HIV-infected inmates in their custody on the last day of the calendar year. Surveys of Inmates in State and Federal Correctional Facilities, 1997 The 1997 Surveys of Inmates in State and Federal Correctional Facilities were conducted for the Bureau of Justice Statistics by the U.S. Bureau of the Census. The Federal Bureau of Prisons cosponsored the Survey of Inmates in Federal Correctional Facilities. Personal interviews were conducted from June 1997 through October 1997. Information was collected about individual characteristics of prison inmates, current and prior offenses and sentences, criminal histories, characteristics of the current offense, family background, prior drug and alcohol use and treatment, and conditions of confinement. The sample for the Federal inmates survey was selected from a universe of 135 Federal prisons holding sentenced inmates. For State inmates the sample came from 1,453 State prisons counted in the 1995 Census of State Correctional Facilities performed on June 30, 1995, with prisons opening between the census and June 30, 1996, added. The overall response rate in the State survey was 92.5 percent. Similar surveys of State prison inmates were conducted in 1974, 1979, 1986, and 1991. The first survey of Federal inmates was done in 1991. Census of Jails, 1993 The 1993 Census of Jails included all locally administered confinement facilities (3,287) that held inmates beyond arraignment and were staffed by municipal or county employees. The census also included 17 jails that were privately operated under contract for local governments. Excluded from the census were temporary holding facilities, such as drunk tanks and police lockups, that do not hold persons after being formally charged in court (usually with in 72 hours of arrest). Also excluded were State-operated facilities in Alaska, Connecticut, Delaware, Hawaii, Rhode Island, and Vermont, which have combined jail-prison systems. Survey of Inmates in Local Jails, 1996 The 1996 Survey of Inmates in Local Jails was conducted for BJS by the U.S. Bureau of the Census. Through personal interviews conducted from October 1995 through March 1996, data were collected on individual characteristics of jail inmates, current offenses, sentences and time served, criminal histories, jail activities, conditions and programs, prior drug and alcohol use and treatment, and health care services provided while in jail. The sample for the 1996 survey was selected from a universe of 3,328 jails that were enumerated from the 1993 Census of Jails. The total nonresponse was 13.7 percent. Similar surveys of jail inmates were conducted in 1972, 1978, 1983, and 1989. Accuracy of the Survey Estimates The accuracy of the estimates from the 1996 Survey of Inmates in Local Jails and the 1997 Surveys of Inmates in State and Federal Correctional Facilities depends on two types of error: sampling and nonsampling. Sampling error is variation that may occur by chance because a sample rather than a complete enumeration of the population was conducted. Nonsampling error can be attributed to many sources, such as nonresponse, differences in the interpretation of questions among inmates, recall difficulties, and processing errors. In any survey the full extent of the nonsampling error is never known. The sampling error, as measured by an estimated standard error, varies by the size of the estimate and the size of the base population. Estimates for the percentage of inmates ever tested for HIV and the percentage who tested HIV positive have been calculated (see table 10). These standard errors may be used to construct confidence intervals around percentages. For example, the 95-percent confidence interval around the percentage of males in local jails who were HIV positive is approximately 2.1 percent plus or minus 1.96 times 0.33 percent (or 1.5 percent to 2.7 percent). These standard errors may also be used to test the statistical significance of the difference between two sample estimates by pooling the standard errors of the estimates (that is, by taking the square root of the sum of the squared standard errors for each sample estimate). All comparisons discussed in this report were statistically significant at the 95-percent confidence level. AIDS in the U.S. Resident Population The number of persons with confirmed AIDS in the U.S. general population (age 13 and over) was derived from the Centers for Disease Control and Prevention (CDC), HIV/AIDS Surveillance Report, Year-end editions 1991-1996. For each year the number of active AIDS cases in the United States was calculated by subtracting the number of cumulative AIDS deaths for people age 15 and older at Year-end from the cumulative number of total AIDS cases for people age 13 and older at Year-end as listed in the HIV/AIDS Surveillance Report. The data for the U.S. general population, excluding persons under age 13, from 1991 to 1996 were taken from the U.S. Population Estimates, by Age, Sex, Race, and Hispanic Origin: 1990 to 1995, PPL-41, and the update for 1996. The rate of confirmed AIDS cases in the U.S. resident population was calculated by dividing the annual totals for individuals with AIDS by the population estimates for the U.S. resident population of individuals 13 and older. The classification system for HIV infection and the case definition for AIDS were expanded in 1993. This expansion improved estimates of the number and the characteristics of persons with HIV disease, but complicated interpretation of AIDS trends. The increase in reported AIDS cases in 1993 was largely the consequence of the added surveillance criteria. (See CDC, Morbidity and Mortality Weekly Report, Vol. 43, No. 45, November 18,1994.) AIDS-Related Deaths in the United States The number of AIDS-related deaths for persons age 15-54 was derived from the CDC, HIV/AIDS Surveillance Report, Year-end editions. Deaths in the U.S. population for persons age 15-54 were taken from the CDC, Monthly Vital Statistics Report, Vol. 42, No. 2(S); Vol. 43, No. 12; Vol. 43, No. 6(S); Vol. 45, No. 3(S); and Vol. 45, No. 11(S). AIDS-related deaths as a percentage of all deaths in the U.S. population were calculated by dividing the national estimate of AIDS deaths of persons age 15-54 by the national mortality estimates of persons age 15-54 in a given year. HIV Prevalence Rates from Blinded Studies Data from blinded studies on HIV prevalence rates in Massachusetts, Maryland, California, and New York were gathered from several sources: B. Werner et al., "Drop in HIV Seroprevalence among Men and Women Entering Massachusetts Prisons," Abstract No. 115, presented at the Third Conference on Retroviruses and Opportunistic Infections, Washington, D.C., January 28-February 1, 1996. C. Behrendt et al., "Voluntary Testing for HIV in a Prison Population with a High Prevalence of HIV." American Journal of Epidemiology, 139 (1994) pp. 918-26. J. Ruiz and J. Mikanda, Seroprevalence of HIV, Hepatitis B, Hepatitis C, and Risk Behaviors among Inmates Entering the California Correctional System (Sacramento: California Department of Health Services, Office of AIDS, HIV/AIDS Epidemiology Branch, March 1996). J. Mikl et al., "Trends in HIV Infection Rates among New York State Prison Inmates, 1987-1997," Poster abstract Number 23516, presented at the 12th World Congress on AIDS, Geneva, June 30, 1997. ------------------------------- Chapter 2 Sexually Transmitted Diseases and Hepatitis: Burden of Disease Among Inmates Theodore M. Hammett and Patricia Harmon-Abt Associates Inc. Key Findings o Available data on STDs and hepatitis B and C among inmates are very incomplete, reflecting the relative rarity of routine screening for these conditions in correctional facilities. o However, behavioral profiles and anecdotal evidence suggest that inmates are disproportionately affected by STDs and hepatitis. STDs Among Inmates According to the 1997 NIJ/CDC survey, 88 percent of State/Federal prison systems and 41 percent of city/county jail systems have policies for mandatory or routine syphilis screening of incoming inmates (table 11). However, 64 percent of State/Federal systems and 29 percent of city/county systems with mandatory or routine syphilis screening did not report or were unable to report the results of such screening on the survey. Of those systems that did report, most had syphilis positivity rates of less than 5 percent (table 11), but these are very incomplete data. Even fewer correctional systems have mandatory or routine screening for gonorrhea or chlamydia, and the few systems reporting results had positivity rates of less than 5 percent for incoming inmates (tables 12-13). Indeed, the most striking point about these survey findings is the rarity of screening and the paucity of screening data. Since gonorrhea is likely to be symptomatic among men, however, it is probable that most cases will be detected without mass screening programs. Most available behavioral profiles of correctional inmates suggest that they are at high risk for, and disproportionately infected with, STDs. Anecdotal reports confirm this--for example, 24 percent of all of Chicago's incident syphilis cases in 1996 were diagnosed in Cook County Jail, and 13 percent of Florida's syphilis morbidity was identified in correctional facilities (site visit interviews, Chicago and Florida, March-April 1997). Better estimates of the burden of STD morbidity among inmates may help support increased resources for STD prevention and treatment programs in correctional facilities. Hepatitis Among Inmates Hepatitis B vaccine is increasingly available to correctional inmates and staff, and thus this infection, which is transmitted by the same routes as HIV, can and should be brought under better control in correctional facilities. The Occupational Safety and Health Administration (OSHA) requires that correctional staff who have direct contact with inmates be offered hepatitis B vaccination. By contrast, there is not yet a vaccine or proven effective treatment for hepatitis C, and this disease is an increasingly serious problem, particularly among injection-drug users (IDUs) and persons infected with HIV.[1] In a 1994 blinded study, 41 percent of incoming California inmates (39 percent of men and 55 percent of women) were antibody positive for hepatitis C virus (HCV). In the same study, 61 percent of HIV-seropositive men and 85 percent of HIV-seropositive women were also HCV positive.[2] A study of female entrants to the Connecticut prison system found adjusted odds ratios for HCV infection of 10 and 7, respectively, among HIV-positive women and IDU women. More than 70 percent of IDU women in the study were HCV positive, and 36 percent of sexual partners of IDUs were HCV positive.[3] A voluntary study of 192 inmates at a medium-security facility in Springhill, Nova Scotia, found that 28 percent were HCV positive, but the rates were sharply higher among IDUs (52 percent) than among non-IDUs (3 percent).[4] A pilot study of 108 incoming male and female inmates at the Hampden County, Massachusetts, Correctional Center (Springfield area) in 1998 found that 22 percent were infected with HCV.[5] Conclusion Although available data are very incomplete, it appears that rates of STDs and hepatitis B and C are higher among inmates than in the overall population. Hepatitis C positivity rates are particularly high among HIV-positive inmates and those with histories of injection-drug use. More widespread implementation of hepatitis B immunization and screening for hepatitis C in correctional facilities seem warranted. Endnotes 1. Centers for Disease Control and Prevention, "The Epidemiology of Viral Hepatitis in the United States," Morbidity and Mortality Weekly Report 43 (1994): 437-455. 2. J.D. Ruiz and J. Mikanda, Seroprevalence of HIV, Hepatitis B, Hepatitis C and Risk Behaviors Among Inmates Entering the California Correctional System, Sacramento: California Department of Health Services, Office of AIDS, HIV/AIDS Epidemiology Branch (March 1996): 1, 9, 12. 3. K.P. Fennie et al., "Hepatitis C Virus Seroprevalence and Seroincidence in a Cohort of HIV+ and HIV- Female Inmates," poster abstract no. Tu.C.2655, presented at the 11th International Conference on AIDS, Vancouver, July 9, 1996. 4. L.Y. Lior et al., "A Look Behind Closed Doors: Injection and Sexual Risk Behaviour and HIV, HBV and HCV Inside a Canadian Prison," poster abstract no. 23528, presented at the 12th World AIDS Conference, Geneva, June 30, 1998. 5. Thomas Conklin, Hampden County Correctional Center, unpublished data. ------------------------------- Chapter 3 HIV and STD Education and Behavioral Interventions Theodore M. Hammett and Patricia Harmon-Abt Associates Inc. Key Findings o HIV and STD prevention programs are becoming more widespread in correctional facilities. o However, few correctional systems have implemented comprehensive and intensive HIV prevention programs in all of their facilities. o Peer-based education and prevention programs offer important advantages, including cost-effectiveness, credibility, flexibility, and benefits to peers themselves. o Although few HIV/STD prevention programs in correctional settings have been rigorously evaluated, anecdotal evidence suggests that they can be successful in reaching this extremely high-risk population with practical risk-reduction messages. Periods of incarceration offer important opportunities to provide HIV and STD education and behavioral intervention programs for populations that are at extremely high risk. Taking advantage of these opportunities, moreover, stands to benefit not only inmates themselves but also the health of the communities to which the vast majority of inmates return. A wide range of HIV and STD prevention programs have been offered in correctional facilities, but most have been and continue to be basic education rather than more intensive behavioral interventions. In any case, very few education and prevention programs in correctional facilities have been subjected to a rigorous evaluation that includes conducting interviews with former inmates in the community.[1] Data from the 1997 NIJ/CDC survey presented in this chapter show that HIV/STD education and prevention programs are becoming more widespread in correctional facilities. Nevertheless, the important public health opportunity to provide comprehensive HIV prevention programs for correctional inmates has by no means been fully utilized. Types of HIV/STD Education and Prevention Programs Provided Table 14 summarizes the types of HIV/STD education and prevention programs that correctional systems provided to inmates in at least one of their facilities, according to the 1992, 1994, and 1997 NIJ/CDC surveys. This shows that the percentage of State and Federal systems offering instructor-led education rebounded to 94 percent in 1997 after dropping to 75 percent in 1994. The percentage of city/county systems providing instructor-led education also increased in 1997 to 73 percent. Peer-led programs are in place in an increasing percentage of State/Federal systems, but still in fewer than half. Only 7 percent of city/county jail systems have peer programs, in part because inmates' short jail stays make it more difficult to institute such programs. In the 1997 NIJ/CDC survey, the category "multisession prevention counseling" was added to gauge the extent to which correctional systems are moving beyond simple education and toward more intensive programs designed to help inmates make and sustain the difficult behavioral changes needed to reduce their risks of acquiring or transmitting HIV and STDs. Almost 60 percent of State/Federal systems and 41 percent of city/county jail systems reported offering such programs. Pre- and posttest HIV counseling is offered in virtually all prison and jail systems, almost all systems provide written materials on HIV and STDs, and large majorities of systems employ audiovisuals. The above figures reflect only the percentages of systems that reported providing these types of education and prevention programs in at least one of their facilities. The percentages of facilities (as opposed to systems) that provide the same types of education and prevention programs (table 15) are, in most cases, substantially lower. For example, less than two-thirds of facilities provide instructor-led education, about one-third provide multisession prevention counseling, and only 13 percent of State/Federal prisons and 3 percent of city/county jails offer peer-led programs. Pre- and posttest counseling was offered in the vast majority of facilities. The validation study, in which reported policies in individual facilities were compared with those reported by systems' central offices, revealed a fairly general agreement regarding education and prevention programs but a few discrepancies as well (table 16). In particular, in systems that reported providing multisession prevention counseling in all of their facilities, only 59 percent of the facilities actually offered such programs. The Importance of Comprehensive HIV/STD Education and Prevention Programs Comprehensive HIV/STD education and prevention programs should be provided for correctional inmates, given the prevalence of high-risk behaviors among them, the opportunity for interventions afforded during periods of incarceration, and the potential public health benefits of such programs. Given the existing knowledge of prevention and of the particular circumstances and needs of the correctional setting, a comprehensive program may reasonably be said to include instructor-led education, peer-led programs, pre- and posttest counseling, and multisession prevention counseling. The results of the 1997 NIJ/CDC survey reveal that only 10 percent of State/Federal prison systems and 5 percent of city/county jail systems offer comprehensive programs meeting this definition in all of their facilities. Clearly, then, there remains much room for improvement in the depth and coverage of HIV/STD education and prevention programs in correctional facilities. A promising approach in this realm is occurring in Massachusetts, where the Department of Public Health is funding comprehensive HIV/AIDS programs in the State's county jails. To be eligible for this funding, the counties must propose a program including HIV/AIDS prevention and education for inmates and staff, HIV counseling and testing, HIV primary care and case management, and aftercare/transitional planning. The HIV/AIDS prevention and education component must include "most or all" of the following elements: o Orientation. o Peer education. o Community-based prevention and education. o Individual prevention and education, on request. o Written and audiovisual materials. o Prevention and education in prerelease, day reporting, and pretrial populations. o Gender-specific programs at facilities housing women. o Expansion of HIV curriculums to cover other communicable diseases. o Programs and materials available in Spanish and English. In addition, each county program must commit to funding 50 percent of a full-time HIV/AIDS coordinator for the jail, with the State funding the other 50 percent.[2] Instructor-Led Education and Educational Materials Seventy-one percent of State/Federal prison systems and 5 percent of city/county jail systems reported that HIV/STD education was mandatory for all incoming inmates; 20 percent of State/Federal but no city/county systems reported mandatory HIV/STD education at release. Fifty-one percent of State/Federal systems and 44 percent of city/county systems reported voluntary HIV/STD education at release. The Illinois Departments of Corrections and Public Health jointly planned a prerelease HIV education and referral program being presented by existing prerelease counselors and inmate peer educators who were specially trained to provide these services in prerelease centers. The smaller percentages of city/county systems with mandatory education programs no doubt relate to the shorter lengths of stay and more rapid turnover of inmates in jails as compared with those in prisons. The validation study revealed some discrepancies regarding whether educational sessions were mandatory. Substantial percentages of facilities in systems with "mandatory" HIV/STD education at intake or release reported that these sessions were not in fact mandatory for all inmates (table16). Table 17 shows the topics covered in HIV/STD education programs, according to the 1997 NIJ/CDC survey results. Basic information on the diseases and the meaning of test results tend to be covered in almost all systems' education programs. However, topics pertinent to behavioral-risk reduction--including safer sex practices, negotiating safer sex, safer injection practices, and triggers for behavioral relapse--are less commonly included. These are the types of topics that are likely to be intensively covered in multisession prevention programs. Similarly, validation study results indicate that discrepancies between central office and facility responses are most frequent on topics relating to behavioral-risk reduction (see table 18). This may be because these topics are more controversial. The left side of table 18 shows the extent of agreement in systems reporting that the listed topic is covered in their education programs. For example, in seven systems reporting that negotiation skills for safer sex were included in their education, fewer than half (45 percent) of facilities reported that this topic was in fact covered. Conversely, in eight systems reporting that this topic was not covered in HIV/STD education, half of the facilities reported that it was included. Thus, some individual facilities are going beyond the educational topics ostensibly prescribed by their central offices. Table 19 shows the categories of providers of HIV/STD education and prevention programs in correctional systems. Very few systems are using security staff to conduct HIV/AIDS education, whereas the involvement of public health departments, AIDS service organizations, and other community-based organizations is widespread. This indicates an increasing willingness on the part of correctional systems to permit outside organizations to offer programs in their facilities. Accessibility and understandability of educational programs and materials are critical to their effectiveness with inmates. In this regard, issues of language, literacy, and cultural competence are pertinent. Thirty-nine percent of State/Federal prison systems and 49 percent of city/county jail systems report offering HIV/STD educational sessions in Spanish. These percentages remain virtually unchanged from the 1994 survey (39 percent and 41 percent, respectively). Fifty-five percent of State/Federal systems and 66 percent of city/county systems reported having HIV/STD educational materials for Latinos. Forty-one percent of State/Federal systems and 58 percent of city/county systems said they had materials especially for African-Americans, and 84 percent and 70 percent, respectively, reported having materials especially for women. Similar percentages were reported in 1994. More attention should probably be paid to the development and distribution of culturally appropriate HIV/STD educational materials. The mean grade level of HIV/STD materials used by reporting correctional systems was 6.4 (SD = 1.8), which seems appropriate. Three examples of instructor-led HIV/STD education and prevention programs observed as part of site visits conducted for the NIJ/CDC survey are presented in the following text boxes. Peer-Based Programs Inmate peer-based programs have four key advantages: credibility, range of services, cost-effectiveness, and benefits to peer educators themselves. Peer educators probably have more inherent credibility with inmates than representatives of "the system." They speak the language of inmates and have had similar life experiences. To be effective, however, it is important and challenging for peer educators to avoid being seen as allies of or spokespersons for the system, particularly in programs in which correctional officials play evident roles in their selection. Peers can offer a range of services, including orientation ("AIDS 101"); individual and group risk-reduction counseling; and informal interaction with inmates in the yard, during programs, and at other times and places apart from structured meetings and presentations. Peer educators often go on to work with inmates with HIV disease, explaining drug regimens and improving adherence, serving as "buddies" and offering other supportive services, and providing hospice care for terminally ill patients. Elizabeth Mastroieni, Coordinator of AIDS Counseling and Education (ACE) at New York's Bedford Hills women's facility, one of the first and best established HIV peer inmate programs, described some of ACE's tangible and intangible benefits. I witness miracles here every day. I see women. . . sharing their commissary and sharing their experiences. I witness women volunteering their time to nurse women back to health, to educate them about their health and cry with them about the experience of loss. I have been filled by the bittersweet memorial services where a woman's life is celebrated as her memory fills the room and enlivens the spirit. For three years I have witnessed the energy of brainstorming, creating, planning, and physically walking to raise money for children they do not know but care for because of their emotions as wife, mother, lover, aunt, sister, and friend . . . . There is laughter. There is community. There is a sense that I can do for others and they can and want to do for me. There is support. . . . There are many miracles here at Bedford.[5] Peer programs can be highly cost effective. Peers can provide formal and informal services almost around the clock. They are often available when regular staff are not. The only substantial costs of peer programs are likely to be for training the peers. It is advantageous to have regular inmate work slots designated for peer educators (as at the Albion women's facility in New York State and at several California prisons), but inmate wages are very low and in many systems are negligible, so this should not represent a large expense, particularly in comparison with the cost of other models of delivering education and prevention programs. The Oklahoma Department of Health developed a peer program for women inmates in that State for $4,000 in outside grant funds.[6] Finally, inmate peer educators commonly report tremendous improvements in self-esteem, knowledge, and commitment to the community based on their experiences in these programs. Many go on to paid positions in HIV prevention following their release from prison. Kathy McGrath became a peer educator at Massachusetts Correctional Institution-Framingham and now works as an HIV educator for Great Brook Valley Health Center in Worcester. McGrath reported that "becoming a peer educator was the start of my life" after years of drug addiction and repeated incarceration. Moreover, she stated, "There are so many women like me who have everything it takes inside, but no outlet for it."[7] Miguel Cruz was the first HIV peer educator at Hampden County (Massachusetts) Correctional Center and is employed as an HIV outreach worker at Holyoke Health Center. Cruz spent 18 years of his life as a heroin addict and dealer. According to a coworker: Miguel is a man at peace with himself, and he is enjoying what life has to offer him for the first time in two decades-going to the movies, playing sports, doing a job he loves and doing it well, owning a car and nice clothes. These are the rewards of a new life and he is not about to give that up. His old friends from the street, he says, were at first skeptical just waiting for him to do that first bag. This hasn't happened and that skepticism is being replaced with unmistakable respect and admiration. Miguel, their old compatriot, who was every bit one of them, now has turned his life around and is back to the same old streets, trying to help his buddies in any way he can to do the same. . . . Miguel's 18-year training program for his present job gives him the ability to accomplish things on the street that I, for example, simply never could. His mere presence on the street, as living proof to all his old neighbors that the evil power of addiction can be beaten, has more life-changing potential than 10 doctors trying to patch these people up and to keep them alive. . . . Miguel is not a doctor, but he is a healer. [8] Although HIV/AIDS peer programs are finding increasing acceptance among correctional administrators, there may still be resistance. Opposition is most often based on suspicion of initiatives that seek to "empower" inmates. Some administrators may view any empowerment of inmates as an ultimate threat to discipline and order in their facility. At one Federal facility, a new warden discontinued HIV/AIDS orientation presented by peer educators because he considered this an "inappropriate" role for inmates. Inmates themselves may have to address and overcome stigma that may result from their involvement. It may be assumed, for example, that anyone volunteering to be an HIV peer educator must be HIV infected. Inmate peer programs are easiest to implement in prison systems in which inmates stay long enough to have a stable group of educators. However, peer programs have been successfully established in jail systems as well. In jails, peer educators are generally drawn from sentenced inmates. As of the end of 1995, nine county jails in Massachusetts had established HIV peer education programs with funding from the State's Department of Public Health (DPH).[9] All of the Massachusetts county jails were expected to implement peer education in 1998 as part of comprehensive HIV/AIDS programs funded by DPH.[10] Factors in successful peer-based programs include the following: o Working closely with correctional officials in planning the program. To address common objections and overcome resistance, a written proposal should be submitted describing the program and its benefits. o Involving outside organizations, such as public health agencies or AIDS service organizations, in leading or otherwise key roles to demonstrate the program's independence from the correctional system and thereby to build credibility with the inmates. o Carefully screening peer educator candidates for motivation, sincerity, commitment, and absence of emotional problems and inappropriate personal "agendas." Candidates' length of time left to serve should be sufficient to allow them to contribute significantly to the program before they are released. o Ensuring that peer educators reflect the linguistic, racial, and cultural profile of the inmate population. o Giving peer educators specific goals and incentives, such as academic credit, prison job slots, or "good time." o Developing a peer-driven curriculum rather than one that is driven primarily by the goals of the correctional system. o Being sensitive to the stigma still associated with HIV/AIDS in many correctional facilities that may adversely affect the recruitment of peers and attendance at programs. o Providing counseling and support for peer educators as necessary.[11] The advantages of peer programs and the factors facilitating the success of such programs are well illustrated by case studies of programs in the adult correctional systems of Louisiana and California and the Los Angeles County juvenile system, observed during site visits for the survey. Louisiana Between 1992 and 1997, under the leadership of the late William Crawford, HIV/AIDS Services Education and Training Coordinator at the Louisiana Office of Public Health, peer education and counseling programs were established at six Louisiana State prisons--Angola, Avoyelles, Dixon, Hunt, and Washington (men's facilities), and the Louisiana Correctional Institution for Women, St. Gabriel. More than 150 inmates were trained as peer educators/counselors. In addition, about 400 correctional staff in health services, mental health, and security received 2-day training sessions on HIV/AIDS and STDs. The inmate peer educators/counselors provided HIV/AIDS and STD orientation sessions to all inmates at intake and prerelease. They also offered one-on-one counseling for inmates considering HIV antibody testing and others with concerns about HIV/AIDS and STDs, provided educational sessions to inmate clubs and organizations, gave support to inmates living with HIV or AIDS and those with loved ones living with HIV or AIDS outside, and acted as liaisons for inmates hospitalized with HIV disease. In their educational presentations and individual prevention counseling, the peers were permitted to discuss practical risk reduction--for example, condom use and cleaning procedures for drug-injection material-in frank and open terms, but they were not permitted to distribute condoms or bleach. In informal conversations, however, inmates from several prisons stated that condoms and bleach were fairly readily available--condoms "on the walk" (in the exercise yard) in exchange for cigarettes, and bleach from dorm-cleaning crews. Crawford emphasized the importance to the success of the peer programs of gaining and keeping the trust and support of the correctional system and its staff. It is necessary to understand and be sensitive to the "gargantuan" task that prison administrators face and to accept the ground rules the correctional system sets for a peer program. Within these ground rules, Crawford stated, much can be accomplished. However, it is counterproductive to "press an agenda" for condom distribution or other controversial measures. Instead, it is better to reach agreement on what can and cannot be done. Crawford noted that "you can get a lot more with a smile than with a frown." To succeed, the program needs the full support of the administration at central office and facility levels. An advocate within the system is critical to overcoming the suspicion that inevitably greets suggestions for establishing inmate peer programs and to obtaining initial agreement. Once agreement is reached on scope and ground rules of the program, peers' specific responsibilities can be negotiated. Inmate peer educators/counselors in Louisiana were recruited and selected by nominations from other peers and from the mental health and health services staff of the facility. Inmates interested in being peer educators/counselors could also apply. The existing peers did the initial screening and recommended 12-15 inmates. At Avoyelles, the mental health director and peer program coordinator made final selections based on conviction offense, sentence, prison disciplinary record, and any handicaps. A critical criterion for selection was the inmate's agreement to be a role model in terms of personal behavior. In particular, this meant that the inmate would have to commit himself or herself to abstaining from all sexual activity and drug use in prison. Final selections of peers had to be approved by the facility's warden. State Public Health Office staff conducted the training for the peer educators/counselors. The class consisted of a minimum of 12 inmates. Three or four classes were trained at each participating facility each year to ensure continuity and effective performance of responsibilities. As part of the training, each trainee was required to prepare and deliver an orientation presentation chosen from a list of possible topics distributed to the class. At Avoyelles, one inmate asked to prepare a presentation on a topic of his own choice that was not on the list. This involved conducting and presenting the results of a survey of inmates on risk behaviors for HIV and levels of perceived risk. Peer programs at the Louisiana State Penitentiary at Angola and the Avoyelles Correctional Center are described in the text boxes on the following pages. A major issue for the Louisiana peer educators was overcoming stigmatization and stereotyping by other inmates. One of the peers reported that his attendance at the training caused him to be "diagnosed with AIDS by my peers." Another peer educator described this as a "powerful learning experience" regarding attitudes toward people with HIV/AIDS that "could have been taught no other way." However, the peers were quite successful in winning the trust and support of the inmate population. Almost 50 inmates attended the first session offered by the peer educator who reported being initially stigmatized. He stated that there is much concern about HIV/AIDS among inmates, even though many will not speak openly about it. A primary objective of any education/prevention program is to bring about positive change in the attitudes and behaviors of the target population. However, with efforts such as the Louisiana inmate peer education/counseling program, extremely important benefits can be achieved among peer educators themselves. They develop positive focus and purpose in their lives, become empowered, and perceive their own ability to influence others in ways they never believed they could do. The presentations by Louisiana peer educators during the site visit demonstrated the poise, confidence, and commitment the program has helped these inmates to develop. Andrew Joseph, an Angola inmate, has changed his attitudes regarding HIV/AIDS dramatically. In 1987, Joseph wrote in The Angolite, the inmate magazine, that he wanted nothing to do with inmates with AIDS. Within a few years, Joseph had become a leader of the peer education/counseling program at the prison and was master of ceremonies at the 1996 HIV/AIDS education conference. Greg Lehtonen, a peer educator at Avoyelles, wrote about the way his HIV-positive status and his involvement in the peer program had changed his life: My attitude is much different now. My life here in prison isn't about being tough and playing games. I find myself caring much more about others, and my mind is on more serious matters . . . I constantly pray and hope that I will see my family again, whom I have not seen in so many years, due to my lifestyle! I always knew that I was a good person inside, and I want my family to see and know that side of me-instead of remembering the monster who did all those bad things. I used to not care about dying. Now I want to live and let people see the good Greg! Two former ACT counselors from Avoyelles are now working for AIDS service organizations in the community. Other peer educators currently in prison are also interested in continuing this work when they are released. Many of them have shown an ability to overcome stigmatization and hostility and to become effective educators, counselors, and supporters of positive change among inmates. California The Public Health Section of the California Department of Corrections' Health Services Division is working closely with facility administrators and the custody and health services staff to implement standardized HIV peer education programs at all State prisons.[12] The Public Health Section is preparing a video on the peer programs in several State prisons. When completed, this video will be used for educational purposes as well as to help recruit new peer educators. The peer programs at San Quentin, Frontera, and Vacaville are described below. California State Prison, San Quentin The average daily population of San Quentin is 5,500 to 6,000 men. About 60 percent of the population of this medium-security facility are reception center inmates who are processed within 45 days and sent off to their assigned facilities in the system. The rest of the inmates are "endorsed" to San Quentin. Between 1986 and 1997, the California Department of Corrections and the Marin (County) AIDS Project (MAP) collaborated on HIV education and prevention programs at San Quentin. In 1997 MAP's role was assumed by Centerforce, another community-based service organization. Since 1991, the Center for AIDS Prevention Studies (CAPS) at the University of California, San Francisco, has been conducting collaborative evaluations with the staff of the San Quentin programs. The programs have evolved over the years with input from peer educators and strong support across the prison administration, from the warden and upper management to correctional counselors and officers. The inmate peer education program is the centerpiece of San Quentin's HIV prevention initiatives. It began in 1986 with prerelease sessions facilitated by program staff and has since expanded to include comprehensive peer education training. Peers may facilitate most educational interventions, including new inmate orientation and other health-related services. San Quentin has five paid HIV peer educator prison work positions. The average tenure as a peer educator is 6 months, although many educators have served substantially longer. Peer educators receive 5 days of comprehensive training. Centerforce staff and community experts present 2 of these training courses per year to 25-30 inmates. Graduates receive certificates as peer educators. The graduates receive an additional day of special training to present orientations, one of the key duties of the peer educators. The goals of this training are to create a pool of inmate peer educators, to introduce participants to public speaking techniques, to increase their awareness of the relationship between substance use and high-risk behaviors, to increase multicultural awareness, and to provide a broad perspective on the impact of HIV/AIDS on U.S. society and worldwide. Besides the usual attention to the basics of HIV/AIDS, antibody testing, and the related issues of STDs and TB, the training includes sessions on the real meaning of HIV/AIDS statistics, family issues, racial/ethnic diversity, gay sensitivity, and grief and loss. All participants also prepare and deliver timed talks to practice public speaking techniques. These talks are critiqued by the instructors and the class. Some classes have made videotaped public service announcements that have been broadcast on the prison's closed-circuit television station. Peer educators observed during a site visit to San Quentin appeared to be highly dedicated and committed to their work. One of them noted that a year earlier he could not have imagined doing this work, but now he was committed to "giving something back" and felt very rewarded for the effort. Another peer educator said he originally signed up thinking that it would be an easy "kick back" job. Quickly, however, he realized that it was an intense, demanding job and accepted the challenge. Prison is the "perfect place" to do HIV education and prevention with this population, one of the peers noted, because the inmates are off drugs and have "clear heads." The program staff have to play a difficult balancing act to gain and keep the trust of both the inmates and the prison administration. If they are seen with inmates too much, they run the risk of having the officers and administration suspect them of joining "the enemy." Conversely, if they work too closely with the administration, they may cause suspicion among the inmates. The programs tend to emphasize "harm reduction" over strict abstinence, in part because this helps to overcome the resistance of the inmates, who otherwise might feel that "we're just telling them what to do." By succeeding in maintaining this balance, the program staff are able to educate both the inmates and the administration. They report that officers often ask them questions about HIV. The peer educators are a diverse group, including African- Americans, Latinos, and whites, and gay and straight inmates with various drug and alcohol histories. Most of the peer educators are HIV positive, but about half of a recent group of trainees were HIV negative. Peer educators appear to be very supportive of one another. Several said they hoped to continue doing this work in the community after their release. One had already written to several community-based organizations (CBOs) asking about possible employment. Orientation sessions. Inmate peer educators present required HIV orientation sessions for approximately 18,000 new inmates at San Quentin each year. This program was mandated in 1991 after focus groups with soon-to-be-released inmates suggested the need for more HIV information and education. The orientation is mandatory, but only about 75 percent actually receive it. Scheduling and other logistical problems preclude providing orientation to all incoming inmates. The orientation is presented by teams of peer educators to groups of about 20 inmates in a classroom dedicated to this purpose. The session seeks to "put a face on the epidemic" and to increase inmates' awareness of their own risky behavior by having an HIV-positive peer educator present his own story. Subsequently, the following topics are covered in the orientation: the difference between HIV infection and AIDS; the four body fluids that can transmit the virus; modes of transmission; safer sex issues; the role of substance use in high-risk behavior; and HIV-antibody testing. Ample time is allowed for questions and answers. The peers attempt to dispel myths about HIV, including the apparently persistent belief that HIV cannot be acquired heterosexually, and to encourage HIV-antibody testing. Another strategy is to focus on the inmate's desire to protect his family from HIV as a way of resisting peer pressure to engage in high-risk behavior. The ultimate objective of the orientation and additional education that peers provide is to induce inmates to reduce their own risky behaviors. In addition to making the presentations, the peer educators prepare paperwork for inmates interested in HIV testing (substantial numbers of inmates take advantage of voluntary HIV testing, but the precise rates are in dispute), document attendance, distribute and collect evaluations, and maintain the classroom. Bilingual educators are available to meet the needs of monolingual Spanish-speaking inmates. The peers also participate in training sessions for new educators. Centerforce staff provide ongoing supervision, education, and other support to the peer educators, spending approximately 10 hours per week on site for these purposes. There is a weekly supervision meeting involving the peer educators, Centerforce staff, a prison counselor, and/or program sponsor. CAPS and Centerforce conducted a collaborative study of the orientation component. In a randomized design, a total of 2,295 incoming inmates were assigned to orientation by an inmate peer educator, to orientation by a professional educator, or no intervention. All participants completed a survey of knowledge and behavioral intentions. The two intervention groups had similar outcomes, both outperforming the no-intervention group in intention to use condoms and seek HIV-antibody testing. The intervention groups also had significantly higher self-perceptions of HIV risk than the no-intervention group. The inmate participants overwhelmingly favored HIV-positive peer educators over other providers of the intervention.[13] HIV intervention. Centerforce staff team up with one of the inmate peer educators to present HIV education sessions to various groups and in various settings in the prison, including prerelease classes (a 2-hour session during the voluntary 3-week prerelease program), English as a second language (ESL) classes, vocational classes, and others. The objectives of these sessions are to present the "personal side" of HIV/AIDS, to raise inmates' self-perceptions of risk, and to increase general knowledge of HIV, testing issues, and resources available in the community following release. Prerelease "booster" intervention. A prerelease booster invention is presented on a voluntary basis to inmates 7-14 days prior to release. As part of a research study, prerelease inmates who agreed to participate were randomized to an intervention or no-intervention group. All participants received an extensive baseline survey of knowledge, attitudes, and behaviors, conducted one-on-one by a staff interviewer. The intervention group also participated in a 30-minute one-on-one prevention booster session with an HIV-positive peer educator. This session was specifically designed to encourage risk reduction through condom use, avoidance of substance use, and safer substance use strategies. Participants also received referrals to community- based services. The no-intervention group received only written materials and referrals. Inmates being released from San Quentin received an HIV prevention brochure designed and written by the peer educators that contains practical risk-reduction suggestions described in frank language with drawings. Between 1 and 4 weeks after release, 43 percent of participants completed a telephone followup survey regarding risk education and risk behaviors. Intervention group participants were significantly more likely than comparison group members to report condom use in their first postrelease sexual encounter and were less likely to report using drugs or sharing needles in their first weeks after release.[14] Centerforce and CAPS are also completing a 3-year project for HIV-infected inmates, funded by the universitywide AIDS Research Program at the University of California. This program includes a comprehensive 2-week "prerelease" education intervention with a focus on staying healthy and accessing community service providers upon release from custody. A unique aspect of this program is a resource fair of service providers from counties to which the inmate participants are being released. This allows the inmate and the community service provider to make face-to-face contact and a personal connection prior to release. Peer educator support. HIV-positive peer educators provide support to other inmates who are newly diagnosed with HIV. This counseling includes discussion of the meaning of HIV infection, circumstances of the inmate's learning his status, his current physical and psychological state, disclosure of status, sexual risk reduction, and policies for housing and treating inmates with HIV. The initial session lasts 20-30 minutes; followup sessions are offered. Inmate peer educators spend 2 hours per week doing this counseling. Centerforce staff provide support and educational backup for the peers. HIV education for female visitors. Centerforce and CAPS are developing and evaluating a peer HIV education program for women visiting male inmates at San Quentin. Formative data reveal that female visitors are in need of HIV education, support, and community referrals. Inmate peer educators are planning and conducting group discussion sessions with women visitors in the visitor center. CAPS will evaluate the intervention in terms of utilization of community resources and self-reported behavioral change. Two other peer programs in California State adult correctional facilities are described in the following text boxes. Programs in Los Angeles County Juvenile System Los Angeles County has the largest number of confined and probationary youths of any juvenile system in the United States. About 27,000 enter the system annually, and the average daily population of confined and probationary youths (that is, those involved in school or other programs at a juvenile facility) is about 4,000. Two peer-based HIV prevention programs for youths in the Los Angeles County juvenile system, the AIDS Video Project and the Peer HIV Education Project, are discussed below. AIDS Video Project. The AIDS Video Project (AVP) provides youths on probation with interactive and culturally appropriate HIV and STD education. The AVP seeks to increase participants' knowledge and application of HIV risk-reduction practices through classroom education and training to become peer educators. The video production component is the final stage in an educational process designed to teach as well as involve students, inducing them to "open up" about their risk factors and the behavioral changes needed to reduce their risks for HIV and other STDs. To be certified as a peer educator, a student must successfully complete an eight-session educational program. More than 80 youths undergo this training each year. Once certified, the peer educators work in teams to create an HIV prevention video that can be shown as part of educational sessions that the peer educators help to present in their own and other juvenile facilities. The AVP has created about six videos each year since its inception in 1989 and reached about 600 youths with HIV and STD education. At the conclusion of these education sessions, the attendees receive an information packet and, if the facility permits it, condoms. The information packet includes a resource guide developed by AVP, which lists testing/counseling, family planning, and related services at little or no cost within a 5- to 10-mile radius of each community education center. Peer educator training. The peer educator training consists of eight 2-hour sessions offered primarily in the community school facilities attended by youths on probation who are living at home. The former AVP coordinator noted that this is best, since "there's nothing like when they're actually . . . able to have sex . . . [and] do drugs as opposed to when they were locked up. . . . That's when they're really struggling with issues like why it's so hard a subject to talk about, or did they use condoms this weekend." The training sessions are presented by the AVP coordinator and a health educator assistant. They follow an established curriculum that includes exercises focusing on making decisions, clarifying values, enhancing self-esteem, and exploring practical methods of HIV and STD risk reduction. Extensive use is made of games and interactive exercises to gain and hold students' attention. One session includes a presentation by an HIV-positive speaker. In the session attended during a site visit for this study, the educators used several methods to involve the students. They passed around a "question box" into which students could place any questions they wanted answered, and the educators tried to answer all of them. The educators used cartoon depictions of techniques for cleaning drug-injection equipment, demonstrated proper condom use and factors for selecting condoms, and employed a game (the "condom relay") to enable students to practice proper condom use. The educators also provided good, understandable discussions of the natural history of HIV disease and the differences between confidential and anonymous testing. Video production. As with the peer educator training, most of the video production takes place at community schools that the youths attend while living at home. The videos are the results of the collaborative efforts of the students, the educators, and an independent filmmaker. Only 3 days are allocated to the production of each video, from concept development to final product. Thus, things must move quickly. The first day is spent deciding on the concept and the story. The students develop the story, and the filmmaker helps them storyboard the elements of their story, cutting sections that do not fit or are impossible to shoot. All filming must be done in the facility, so sets and props are limited- "You notice a lot of 'beds' that look like desks." The filming of the 5- to 8-minute videos must be done in two 5-hour days of work. Shooting scripts are not used because of the students' low literacy levels, so each scene must be done as a rehearsed improvisation. The students all double as actors and crew members, getting an opportunity to learn about filmmaking as well as acting and the substantive issues involved in the story. Scenes are shot numerous times from different angles. Once shooting is completed, the students decide on music to be included and the filmmaker edits the video. The filmmaker generally notes significant changes over the 3-day production period. The students often begin by being "kind of aloof" but become increasingly involved with and committed to the project. Their level of involvement is sparked by employing a monitor that allows the students to see simultaneously what is being filmed. Completed AVP videos have used a variety of genres, including comedy, musical, and drama. In "Captain Condom," a "condom-adorned" superhero appears magically in a couple's living room to provide advice on safer sex. "Class reunion" explores the reaction of a class to the news that a member has died of AIDS. "Lunatic Rap" features a female rap duo performing "HIV is in the 'Hood.'" Once the video is completed, the peer educators present it to the other students in the school as part of an HIV education session. The former AVP coordinator states that this is "the best day on the planet." The students are proud of their achievement, and the other students generally respond favorably and with respect. The day ends with AVP giving a party for the video makers. Evaluation. AVP attempts to follow up with all peer educators at 3 and 6 months following their completion of the program. Tracking the population is difficult, so followup rates are fairly low. Of 61 peers trained in fiscal year 1994, 17 (28 percent) provided followup interviews. Low followup may indicate biased selection, so conclusions based on these samples may overstate positive outcomes. In any event, more than three-quarters (76 percent) of the 1994 peer educators who provided followup interviews reported an increase in HIV risk-reduction behaviors-- condom use and/or cleaning of injection material. Among 662 confined and probationary youth exposed to AVP education sessions, the average pre- to postknowledge gain was 23 percent. Recent data reveal an average pre- to postknowledge gain of more than 90 percent among the youths being trained as peer educators. Followup at 3 and 6 months revealed that more than 80 percent reported an increase in at least one risk-reduction behavior. It is also important to recognize the intangible and immeasurable positive outcomes of AVP. The former coordinator notes that it is important to give these kids, many of whom are "set up to fail," a place where they can succeed at something. "And if you have kids who feel that they're succeeding, it will be easier for them to use a condom." Peer HIV Education Project. The Peer HIV Education Project (PHEP) was operated by JWCH Institute and supported by the Los Angeles County Health Department using funds from the CDC Health Education and Risk Reduction Cooperative Agreement. The PHEP presented mandatory HIV/STD education sessions in county juvenile facilities, including community education centers, juvenile halls, and camps. PHEP began operations in October 1995 using teams composed of a peer educator and an adult professional. The PHEP curriculum consisted of 4-hour sessions and included numerous games and interactive exercises. An evening PHEP session at Camp Routh was observed as part of the site visit for this study. This was a condensation of the four-session curriculum into one 2-hour session, and it seemed to work quite well. The adult educator and the two peer educators involved in this session worked very well together, trading off sections of the presentation quite smoothly. All seemed comfortable with the subject matter and seemed able to establish rapport with the students. The peer educators spoke effectively from their own experiences with HIV risk behavior and used humor and understandable slang terms very well. A particularly effective part of the session was an outside speaker's disclosure of his HIV-positive status in the midst of his presentation. He was not identified at the outset as an HIV-positive person but rather "sprung" his disclosure in the course of a discussion of heterosexual risk. Once he had disclosed his status, he said, "It pisses me off that so many of you think [based on your responses to the pretest] that you can't get HIV through sex with a woman." The speaker went on to challenge the notion that one can't deal with being HIV positive. It is admittedly very hard in some ways, he said, but it can also be rewarding and fulfilling to help others protect themselves against HIV. He acknowledged that he does not have sex very much anymore because he is scrupulous to disclose his status, and most women do not want anything to do with him once they know he is HIV positive. The session also included the "Virus Z" game, in which handshakes among the group are used to demonstrate how a network of transmission can develop very quickly. The educators demonstrated proper condom use and involved students in this demonstration as well. In the course of the demonstration, the educators discussed common condom substitutes and cautioned against the use of microwavable plastic wrap because it has microscopic holes. Female condoms and dental dams were discussed and shown to the group. Another useful item of advice included in the presentation was to avoid oral sex within 4 hours of brushing teeth. Toothbrushing can cause small cuts in the mouth, thus providing a possible avenue of transmission. Finally, the educators passed around graphic photographs of STD conditions, and these seemed to have a strong impact on the youths. Evaluation forms submitted at the end of this and other PHEP sessions observed during the site visit revealed overwhelmingly positive participant responses, particularly regarding the approach taken by the educators and the rapport they were able to develop with the participants. The following are some examples of these comments: o I think Tricia and Kay are good speakers and make good games that are fun and let you learn at the same time. They're cool too, and respected us. o I thought the speakers knew how to talk to us. I felt really comfortable with them. o I thought I knew a lot about HIV/AIDS, but I guess not. And now I'm more interested in learning about my health!!! o I really learned a lot and changed my mind about getting an HIV test. I was scared, but now I'm going to take the test. o I would like to thank you all for taking the time for us. I'm glad you didn't take advantage of us being inmates. Thank you for treating us like real people. o I think the class is very helpful. The teachers are great. They get down to the point. That's how it should be done. o I feel this is important because it is something we all have to learn about, because it's not a fairy tale. Conclusion The 1997 NIJ/CDC survey reveals that HIV/AIDS and STD education programs are becoming more widespread in correctional facilities but that most facilities still do not provide a comprehensive program of HIV prevention. In particular, more intensive interventions such as multisession prevention counseling and peer-based programs should be expanded. Peer-based programs offer distinct advantages of credibility, cost-effectiveness, and benefit to the peer educators themselves. Although systematic evaluation of peer programs has been limited, there are strong indications from many programs, including those described in this chapter, that peer-based programs can be effective in reaching inmates with practical information on HIV and STD prevention. Endnotes 1. See the extensive literature review in T.M. Hammett, J.L. Gaiter, and C. Crawford, "Reaching Seriously At-Risk Populations: Health Interventions in Criminal Justice Settings," Health Education and Behavior 25 (February 1998): 99-120; and in R. Braithwaite, T. Hammett, and R. Mayberry, Prisons and AIDS: A Public Health Challenge, San Francisco: Jossey-Bass, 1996. 2. Massachusetts Department of Public Health, AIDS Bureau, "Request for Applications: Massachusetts County Sheriff's Department HIV/AIDS Program," March 6, 1998. For more information on this program, contact Tim Gagnon, Massachusetts Department of Public Health, AIDS Bureau, 250 Washington Street, 3rd floor, Boston, MA 02108-4619 (telephone: 617-624-5300). 3. Further information on the Forensic AIDS Project's programs in the San Francisco jails may be obtained from Anne Stillwell, Director, 798 Brannan Street, San Francisco, CA 94103 (telephone: 415-863-8237). 4. Further information on the Corrections AIDS Prevention Program in New York City may be obtained from the New York City Department of Health, Bureau of HIV Prevention, Office of Corrections AIDS Prevention, Beverly McDonald, Director, 253 Broadway, Room 602, New York, NY 10007 (telephone: 212-676-2900). 5. "AIDS Counseling and Education" (program description), n.d. For more information about ACE, contact Elizabeth Mastroieni, Coordinator, Bedford Hills Correctional Facility, Bedford Hills, NY 10507. 6. "Tips for Starting a Peer Education Program for Inmates," AIDS Policy and Law (April 18, 1997): 8-9. 7. K. McGrath, presentation at panel on peer education, "HIV Treatment Update for Prisons and Jails," Cambridge, MA, March 13, 1998. 8. P. Loescher, untitled story of his 2 days on the streets of Holyoke with Miguel Cruz, distributed at the panel on peer education, "HIV Treatment Update for Prisons and Jails," Cambridge, MA, March 13, 1998. 9. Massachusetts Sheriffs' Association, HIV/AIDS in the Massachusetts County Correctional System, 1995, Massachusetts Sheriffs' Association Task Force Report, 1997. 10. Massachusetts Department of Public Health, AIDS Bureau, "Request for Applications: Massachusetts County Sheriff's Department HIV/AIDS Program," March 6, 1998. 11. This list is based in part on "Tips for Starting a Peer Education Program." See note 6. 12. For further information on peer programs in California prisons, contact Public Health Section, Health Care Services Division, California Department of Corrections, 770 L Street, Sacramento, CA 95814 (telephone: 916-327-1214). 13. O. Grinstead, B. Faigeles, and B. Zack, "The Effectiveness of Peer HIV Education for Male Inmates Entering State Prison," Journal of Health Education 28 (November-December 1997, Supplement): S-31-S-37. 14. O. Grinstead, B. Zack, B. Faigeles, N. Grossman, L. Blea, "Peer Led Pre-Release Intervention Increases Condom Use Among Male Prison Inmates" (draft under review, 1998). ------------------------------- Forensic AIDS Project, San Francisco Department of Public Health Forensic AIDS Project (FAP) staff offer "risk reduction groups" in all San Francisco jail facilities.[3] About 15-20 sessions are held each week according to a master schedule, ensuring that all facilities are covered. These group meetings are voluntary, normal attendance is between 10 and 20 inmates (with as many as 60 participants at sessions in structured program settings such as substance abuse treatment programs), and the sessions last 1 to 2 hours, depending on the facility's schedule and flexibility and the cooperativeness of custody staff. Deputies vary widely in their degree of cooperativeness, FAP staff report. Some are extremely helpful and supportive, and others appear to go out of their way to obstruct FAP's efforts. For example, one deputy confiscated a dildo used for a condom demonstration. Topics covered in these sessions include general health; nutrition; practical risk-reduction strategies (condom use and cleaning of injection material); information on HIV/AIDS, STDs, and TB; HIV testing; and early intervention. The session format includes a lecture, a discussion, videos, and guest speakers. The educators also use games with prizes to involve the inmates in the sessions. Condom distribution occurs in the context of regular risk-reduction groups. The risk-reduction groups originally were planned with the assumption that each inmate would attend one session. However, with varying lengths of stay, the same inmates may attend multiple sessions, so educators vary their plans to avoid duplicating material. Different educators have different approaches and concerns. For example, one educator reported that she does not do condom demonstrations in all-male classes because she feels it would undermine her authority. Therefore, she asks a male inmate to do the demonstration in these classes. In an effort to achieve greater consistency across educators, FAP has developed standard lesson plans for the sessions, synthesizing the ideas, strategies, and games/exercises used by the different educators. FAP offers enhanced counseling to inmates who are identified as high risk by self-report or staff observation. This is multiple-session individual counseling designed to help inmates adopt and maintain risk-reducing behaviors. Special counseling is provided on the importance of partner notification. When possible, FAP facilitates postrelease counseling with partners. ------------------------------- Corrections AIDS Prevention Program, New York City Department of Health The Corrections AIDS Prevention Program (CAPP) at the Rikers Island jail complex is operated by the Division of Special Populations of the New York City Department of Health, with funding from the Centers for Disease Control and Prevention.[4] In collaboration with the Department of Corrections, CAPP has established "an aggressive approach . . . to HIV/AIDS prevention education," which includes HIV/STD orientation for incoming inmates and ongoing prevention groups. Condoms are also made available to inmates. Orientation sessions on HIV/AIDS and STDs are mandatory for all incoming inmates at Rikers Island. CAPP educators present basic information on transmission and prevention, as well as on counseling and testing, and ways to access additional information and assistance. During a site visit for the NIJ/CDC survey, an orientation session with about 60 men at the C-76 men's facility was observed. The educator presented HIV/AIDS and STD risks in a direct, simple, and explicit manner. She spoke very directly about the risks of anal intercourse and the prevalence of this behavior in jail. Ongoing prevention groups are held in several Rikers Island facilities. A health educator conducts a series of meetings with inmates who have longer sentences or are in drug-treatment programs. These meetings provide opportunities to build rapport and to explore topics in greater depth than can be done in an orientation session. During a group meeting with about 15 men in a drug-treatment unit of the C-73 men's facility, the educator engaged the men directly by asking questions. She effectively prevented anyone from getting distracted or losing attention by involving them in the discussion. She did a condom demonstration, discussed issues of sexual risk and the role of drug use in sexual risk, openly asked the men to consider what "your women are doing while you're in jail," and discussed the precautions they should take when they rejoin their women on the outside. The educator asked the inmates about the definitions of man and boy, emphasizing that a real man takes real responsibility for himself and his loved ones. She also asked how many of the inmates "always" use condoms; most raised their hand, but one said "A lot of people are lying here." The educator spent a good deal of time on STDs. She passed around enlarged color photographs of the conditions that can result from various STDs. The inmates seemed quite affected by these photographs. ------------------------------- Massachusetts Department of Youth Services In 1989 the Massachusetts Department of Youth Services (DYS) and the Massachusetts Department of Public Health (DPH) entered into an interagency agreement to provide an HIV/AIDS prevention program with CDC funding for two full-time bilingual (Spanish) and bicultural health/AIDS educators. One educator covers the Boston area and North and South Shore suburbs, and the other covers the rest of the State from her base in Worcester. An important program component is a small group of well-trained HIV-positive speakers who participate in varying formats, including youth-controlled question-and-answer sessions and presentation of personal stories with questions during and at the conclusion of each session. The educators primarily provide HIV and STD prevention education to youths in DYS facilities and programs, group care, assessment programs, day reporting centers, shelter care programs, secure detention programs, and secure treatment programs. In addition, the educators train DYS frontline child care and casework staff so that they understand and support, rather than contradict or undermine, the education and prevention messages presented to the youths. Although increased knowledge has helped reduce concern about occup