Recently, the Department of Justice became embroiled in controversy when it threatened to file a lawsuit against South Carolina's prison systems which segregates HIV positive prisoners from the rest of the general prison population.
Prison officials argue that inmates are tested for HIV, and if found to be positive, then they receive "exceptional" care and counseling and live in a physically different part of the prison from other prisoners. Prison officials argue that HIV infection rates are practically non-existent because of this segregation. These same officials also say that if they are forced to send HIV positive inmates into the general prison population, spread out over a larger area, that they will no longer test for HIV or offered HIV specialist care as doing so for a large geographical area would be cost prohibitive.
Prisoners who tested positive feel that they face discrimination, and because of their housing assignments in HIV positive only housing facility, their relatives all learned that they were HIV positive based on where they were sent in the prison system. Normally HIV testing is done with a great amount of privacy, and information about a person's status is kept confidential.
I decided to dig deeper and try to figure out just how many men are contracting HIV in prison. Many people believe, perhaps without scientific evidence, that the severe localized HIV/AIDS epidemic in african Americans is due in large part to black men who contract HIV in prison. Certainly anything to break the back of the epidemic in this population would do a lot of good.
An article in the New England Journal of Medicine referenced one study conducted in a southern state that found that 0.65% of inmates contracted HIV while in prison. This doesn't sound like a very big percentage, though more research is needed to inform policy makers. However, the are a very large number of men in prison in the United States, approximately 2.5 million. If 0.65% of these men will get HIV in prison in a given year, then that number is approximately 16,250 new HIV cases each year. That is a big number considering that about 56,000 people are infected with HIV each year in the United States, according to the CDC. A study completed in Maryland found a 0.41% infection rate per prison year, comparable to a 0.65% yearly infection rate.
If my "back of the envelope calculations are correct" then perhaps a little less than one in three new HIV infections in the United States is due to prison inmates being infected while incarcerated. It is intuitive that this could be happening in prisons to some extent as the prevalence of HIV infection in the nation's prison may as high as 2.0%, five times higher than that in the general population.
However, not everybody agrees that the transmission of HIV in prisons is high. A study conducted between 1988 and 2005 in the Georgia prison system found only 88 cases of HIV transmission over this time period. However, while initial testing of prisoners was mandatory, later HIV testing was not, meaning that many cases of HIV infection during incarceration could have been missed, at least that is how I viewed the study. Experts appear to agree that more research needs to be done on this important issue.
In addition, inmates in the Rhode Island prison system receive free HIV testing, and about 1/3 of the state's new HIV positive patients are identified in this manner. This is good for these people as it means earlier medical care which will extend their lives, and it makes them aware that they could pass the virus on to others. As prisoners are literally a captive audience, it would appear to be ethical to mandate confidential HIV testing and counseling at this time.
This is a difficult question to answer, at least in my mind.
One thing is clear, if HIV/AIDS patients are physically separated from those without the virus, then the transmission of HIV will be reduced. In a way prison is like a microcosm of events occurring in the developing world. Some prisoners are forced, or coerced, into having sex with other prisoners, so too are women in the developing world coerced to have sex with HIV positive partners. This environment of sexual coercion is blamed, in part, for the rapid spread of HIV in the developing world. In addition, condoms and clean needles are not made available in prison, similar to the situation in many resource poor countries of the world. If one prisoner is raped by another in prison, and contracts HIV, then is the prison system responsible for this infection knowing that it could have been prevented? Possibly.
In the general population outside of prison walls was screened for HIV, and if HIV positive people were locked up in their own specially segregated city then this would be clear discrimination. However, the courts have ruled that prisoners forfeit much of their rights upon entering prison, and this is partly why mandatory HIV testing is made possible. However, even prisoners have the right to keep their confidential medical information confidential. Ideally, prisoners who tested positive for HIV would be isolated in a perfectly anonymous and fair manner away from the general prison population. This, of course, may be practically impossible.
While at first it sounded like a prudent idea to separate HIV positive prisoners from the general population in the name of preventing a deadly disease, does the same logic apply to the United States, or the world as a whole? Recently, the Obama administration lifted travel restrictions on travelers who are HIV positive into the United States, this seems like a no-brainer. And the Department of Justice appears to be extending this logic to the segregation of prison populations as well.
The Department of Justice's decision may be based upon a new view of HIV/AIDS which some people may erroneously believe is just another chronic medical condition. Many people have, and will die from AIDS in the United States, and the medications used to treat HIV have powerful side effects. In addition, just because an HIV positive person doesn't develop full blown AIDS doesn't mean that he or she won't develop an HIV associated cancer or other condition. After having seen several patients die from AIDS after developing resistant strains due to poor adherence to their medication regime, I wonder if anybody can fairly weigh the limited civil rights of prisoners versus the needless deaths.
Written by Mark Riegel, MD
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