Public Health, Spring 1997

An Epidemic Ignored In a new book, a public health researcher explores an aspect of the AIDS epidemic that is largely ignored, the problem of HIV behind prison bars.



The problem of HIV and AIDS in prison settings is a time bomb ready to go off.
- Ronald Braithwaite



by Amy Stone

In numbers far greater than among the general population of the United States, a largely invisible segment is contracting and dying of AIDS. This group is prison inmates, and according to a new book co-autho red by a Rollins School of Public Health professor, they are nearly six times as likely as the general population to have AIDS.

Undeniably, AIDS and HIV infections are growing problems among prison inmates. But why should the rest of the country care about inmates sequestered away from the general public? It is precisely that "out of sight, out of mind" attitude that causes Ron ald Braithwaite, an associate professor at the school, to be alarmed.

"The problem of HIV and AIDS in prison settings is a time bomb ready to go off," Braithwaite says. "Most inmates eventually get paroled from prison. If they don't learn how to manage their disease while they are incarcerated, they will continue to prac tice unsafe behaviors and infect others once they are released."

Additionally, the financial implications of a growing HIV-positive prison population are great. As more inmates become infected with HIV and develop AIDS, the expenses for their medication and health care can reach into the hundreds of thousands of dol lars in excess of the $30,000 average cost of housing an inmate for one year.

Braithwaite is one of the country's foremost scholars on the issue of AIDS and inmates. Along with co-authors Theodore M. Hammett, a vice president at Abt Associates, Inc., and Robert M. Mayberry, director of the Morehouse Medical Treatment Effectivene ss Center at Morehouse School of Medicine, he has written Prisons and AIDS: A Public Health Challenge, published in September 1996, by Jossey-Bass. The book is the first comprehensive overview of this critical subject and serves as a resource for policymakers, researchers, managers, and administrators of correctional institutions and community-based organizations. It is a tool to aid in the design and implementation of educational and prevention programs related to HIV and AIDS for correction al populations.

Working with prison populations



A psychologist by training, Braithwaite started his career working with prison populations. To receive his masters degree in correctional rehabilitation from Southern Illinois University, he did field work in two of the nation's toughest prisons : Marion and Menard, both in Illinois. And, for a doctoral degree in educational psychology from Michigan State University, he wrote a dissertation on a state prison in southern Michigan.

After completing his doctorate, Braithwaite shifted his focus to other communities in need of interventions. He directed a free clinic at Eastern Virginia Medical School, which used students from all medical disciplines to provide medical services to t he underserved. He then moved to the Morehouse School of Medicine's Health Promotion Resource Center, designed to engage low-income, inner city, and rural individuals in health promotion activities.

More recently, at the Rollins School of Public Health, Braithwaite has initiated two substantial, ongoing projects. Project MARTIN (Mentoring Adolescents through Risk Reduction, Training, Insulation, and Nurturing) is a community-based substance abuse prevention program targeted toward middle school students. Project HEAL (Health, Empowerment, and Leadership) is a partnership designed to bring academic, community, and local health departments together to develop health promotion and disease prevention programs. (See story in Public Health, Fall 1996.)

A few years ago, Braithwaite's career came full circle when he became involved in a CDC effort to assess, describe, and evaluate the health education of HIV programs in prisons. This research served as the basis for his book.

"We wrote the book because HIV is the No. 1 public health problem facing the nation," Braithwaite says. "We need to acknowledge that HIV in prison populations is an ignored epidemic and to design interventions to reach the prison population, helping th em change their risky behaviors. If we can do this, we stand a chance of making a contribution to overall efforts in HIV prevention."

Problems peculiar to prisons



HIV transmission in prison occurs the same way it does outside of prison: through shared needles, unsafe sex practices, and tattooing. However, managing those problems inside a prison requires a different perspective. Prevention measures used su ccessfully on the street - needle exchange programs, bleach kits to clean needles, and condom giveaways, for example - are not typically allowed in prison settings. Because needles are harder to obtain in prisons, they are used longer and shared more. The lack of condoms contributes to unsafe sex practices. Tattooing often is done with guitar strings and other substitute materials instead of needles. Sharing these materials, along with the ink and string to transmit the ink, raises the risk of HIV transmi ssion.

"One of the biggest problems in AIDS education in prisons is that condoms are considered contraband," says Braithwaite. "We can't continue to bury our heads in the sand on this issue and pretend sex does not occur in prison settings. We have a good exa mple with Canada, which implemented a clinic-based condom distribution method in its prisons. Switzerland and England also distribute condoms. Additionally six systems in the United States make condoms available. They should be used as a model for others. "

Some argue that condom distribution, bleach kits, and needle exchanges promote unsafe behaviors. Braithwaite counters that when the means to reduce risks are available, changes in unsafe sex and drug behaviors will occur, an argument backed by research .

Health aside, correctional officers believe that condoms may be used as weapons or to smuggle drugs, thereby compromising the security of the prison. This perspective underscores a larger issue, that the goals of correctional personnel often conflict w ith those of public health workers. Ideally, Braithwaite writes, those responsible for security as well as health should be involved in the formative stages of educational planning to insure the development of mutual goals.

Lessons learned

A Fact Sheet from Prison and AIDS

As of November 1992, a cumulative total of 11,565 AIDS cases had been reported among inmates in US federal, state, and larger city/county correctional systems.

Based on this estimate, at least 4.6% of AIDS cases in the United States through 1993 were among inmates.

Between 1990 and 1992, the rate of increase of AIDS in prison populations was 66%.

By 1994, in state/federal systems, the aggregate AIDS incidence rate was 518 cases per 100,000, up from 362 per 100,000 in 1992. In 1994, 47 state and federal prison systems reported 4,827 current cases of AIDS.

The number of prison deaths from AIDS is growing--from 325 in 1985 to 4,588 at the end of 1994. AIDS is the leading cause of death among inmates in many correctional facilities in the United States.

AIDS incidence rates are significantly higher among correctional inmates than in the total population, due to the high concentration in correctional populations of persons with risk factors for HIV.

The vast majority of inmate AIDS deaths and current AIDS cases occur among men, accounting for 96% of cumulative AIDS deaths and 91% of current inmate AIDS cases in 1994. However, because HIV infection rates are higher now in women, an increase in AID S cases among women can be expected.

Although rates of HIV infection are not high among adolescent inmates currently, rates of sexually transmitted diseases are high in this group, suggesting that these adolescents are at risk for HIV infection.


Braithwaite and his colleagues have found that some teaching methods work better than others in this specialized population. The most successful method of getting inmates to listen to health messages is to use peer educators or counselors - some one like themselves who understands their backgrounds and particular pressures. Peer counselors, whether matched to the inmate population by gender, race, ethnicity, or circumstances, have a much better chance of breaking through barriers that may exist b etween teachers and students. "When designing health programs for inmates, one has to consider the messenger as well as the message," Braithwaite says.

According to Braithwaite, educational programs also need to be repeated frequently. Even when a program is highly effective, the lessons are forgotten after six months, say the juvenile offenders Braithwaite interviewed.

These interviews revealed inmates' pessimism about the ability of HIV education to stop unsafe behaviors as well as the refusal of many inmates to be tested for HIV. "This group of people has a fear of finding out their HIV status," says Braithwaite. " They would rather assume they are uninfected than face the anxiety of the testing process. Additionally, they have a very real fear of discrimination if they are HIV positive."

Working with inmates can be frustrating, but prisons still represent an opportunity to "win souls," says Braithwaite. It is rare to have such a contained audience for health messages. While inmates with AIDS often may have been hard to reach in their p revious lives on the streets, their entry into the correctional system is an ideal time to try to change their behaviors.

Prisons and AIDS discusses formidable barriers to educating inmates about HIV and AIDS. Despite these barriers and the reluctance of Americans to dedicate tax dollars toward improving the health of this unseen population, Braithwaite maint ains that something must be done to slow the rising HIV infection rates in this group. "Society needs to be proactive now to control a rising epidemic. We need to invest in research and develop programs to reduce the transmission of HIV in prison settings ," he says. "These problems are not going to go away. They are going to get worse and they will eventually affect more than just people in prison."


Spring 1997 Issue | Our Modern Plague | A Prayer for AIDS | REAL Life Lessons
Putting a Price on Prevention | An Epidemic Ignored | It's MAGIC | Supporting Player
School Sampler | Alumni Sampler
WHSC | RSPH

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