HOW SERIOUS IS HIV IN JAILS AND PRISONS?
It is estimated that 11 million people around the world are incarcerated at any given time. Since 2000, the proportion of incarcerated people assigned male at birth (AMAB) has grown by 18% and the proportion of incarcerated people assigned female at birth (AFAB) has increased by 50%. It is estimated that around 3.8% of the global prison population has HIV. Prevalence differs greatly between regions, with the proportion of incarcerated people with HIV greater than 10% in 20 low-income and middle-income countries.
The rate of HIV among incarcerated people is 5-7 times that of the general population. HIV rates are highest among Black/African American incarcerated people. A systematic evidence review from 2018 found recent incarceration is associated with an 81% increase in HIV risk.
The regions where incarcerated people are most affected by HIV are East and Southern Africa and West and Central Africa, both of which have high HIV prevalence in the general population, and Eastern Europe, Western Europe, and Central Asia, reflecting the over-representation of people who inject drugs (PWID) in prison. Read more about HIV among PWID.
In the U.S., more than 2 million people are incarcerated in federal, state, and local correctional facilities on any given day. In 2010, there were 20,093 incarcerated people with HIV in state and federal prisons. Epidemiologic surveys indicate the prevalence of HIV in 2015 was approximately 1.3% among incarcerated people, which is markedly higher than the 0.3-0.4% HIV prevalence in the general U.S. population.
WHY ARE INCARCERATED PEOPLE PARTICULARLY AT RISK FOR HIV?
Prisons are a high-risk environment for HIV transmission due to drug use and needle sharing, tattooing with homemade and unsterile equipment, high-risk sex, and rape. Overcrowding, stress, malnutrition, drug use, and violence weaken the immune system, making people with HIV more susceptible to getting sick.
Men aged 19-35 years old make up the vast majority of people in jails and prisons globally and many are there due to drug offenses. Young men who use drugs are already at higher risk of HIV infection before entering prison.
HIV prevention programs and antiretroviral therapy (ART) are rarely accessible to incarcerated people. In many parts of the world, prison conditions are poor and incarcerated people with HIV barely receive the most basic healthcare. The following factors contribute to the global burden of HIV among incarcerated people:
Injection drug use: The use of contaminated injection drug equipment is one of the primary routes of HIV transmission in jails and prisons. Where there are high numbers of incarcerated PWID, there is a higher risk of HIV transmission.
Inside jails and prisons it is difficult to obtain clean injection equipment. Possessing a needle is often a punishable offense and therefore many incarcerated people share equipment that has not been sterilized between uses.
Sexual violence, unsafe sex, and other high-risk behaviors: The prevalence of sexual activity in jails and prisons is largely unknown and thought to be significantly under reported due to denial, fear of stigma and homophobia, and the criminalization of same sex conduct. What is known is that incarceration disrupts stable partnerships and incarcerated people may form new and sometimes coercive sexual partnerships with multiple other people.
While some sex in jails and prisons is consensual, rape and sexual abuse is used to exercise dominance over others. Globally, it is estimated that 4-5% of incarcerated people experience sexual violence and 1-2% are raped.
Unavailability of condoms Globally, 58 countries (30%) provide condoms in prisons. However, even in countries where condoms are available, access is problematic. Data is also limited; the majority of countries that provide condoms do not report on coverage levels. For example in the U.S., federal law states that condoms should be provided in prisons but many states don’t follow the law. As a result, condom coverage is thought to be low, with only a few areas, including Los Angeles, New York, and Philadelphia, providing condoms.
Even when condoms are available they are not necessarily used. Additionally, incarcerated people often have to make an appointment in order to get condoms, which can have an impact on their right to confidentiality about their sexuality or HIV status. When this is the case, uptake is generally low.
Tattooing: Tattooing is commonplace among incarcerated people. This is particularly true in Latin America where it is estimated that around 45% of people in prison get tattoos. In Asia and the Pacific around 21% of prisoners have undergone tattooing and around 15% in North America and Europe have tattoos.
Tattoos are generally done without new or sterilized tattooing equipment. The process usually involves multiple skin punctures with recycled, sharpened, and altered implements including staples, paperclips, and plastic ink tubes found inside ballpoint pens. Some people use metal points connected to a battery or another electrical source, which increases the number of skin punctures, elevating the risk of HIV transmission.
Punitive laws and overcrowding: Punitive laws lead to the incarceration of people with HIV and other key populations (such as sex workers, PWID, transgender people, and men who have sex with men). These groups are disproportionately represented in prisons worldwide as a result.
National laws and criminal justice policies lead to high incarceration levels and overcrowding. Prison overcrowding is a systemic problem in more than half of countries globally: in 117 countries prison occupancy is more than 100% of capacity, in 47 it is more than 150%, and in 20 it is above 200%. Overcrowding increases incarcerated people’s likelihood of acquiring HIV and other infectious diseases.
HEALTHCARE IN JAILS AND PRISONS
Medical care in jails and prisons depends on the local facility. In general, incarcerated people do not receive healthcare that meets public health standards. Each year, many Americans with chronic diseases are incarcerated. This includes:
- 25% of Americans with HIV
- 33% of Americans with hepatitis C virus (HCV)
- 40% of Americans with active tuberculosis (TB)
In the U.S., incarcerated people have a constitutional right to healthcare that meets community standards. The Supreme Court case Estelle v. Gamble established this right. Failure to provide care that meets these guidelines might be considered cruel and unusual punishment. However, incarcerated people may need to advocate for their own care. They should understand their illness and make sure they get appropriate care in jail or prison.
PREVENTING HIV INFECTION AMONG INCARCERATED PEOPLE
Despite the high risk of HIV transmission among incarcerated people, HIV prevention and treatment programs are often limited in jails and prisons. Those that do exist also rarely link to national HIV prevention programs.
Reduce the global prison population
The first step to addressing HIV among the global prison population is to reduce the number of people in jails and prisons by rethinking detention for substance use, sex work, and other non-violent offenses. Many people with substance use disorders have been incarcerated as a result of profoundly misguided and harmful approaches to treatable conditions. Mass incarceration has destroyed millions of individual lives, had lasting negative effects on families and communities, and, in many areas, increased infection rates of HIV, HCV, and TB. Efforts to provide alternatives to incarceration for people who use drugs need to be intensified. Similarly, punitive laws regarding sex work and LGBTQ identities must be abolished.
Jails and prisons are important settings to test people for HIV, especially given that many people in the criminal justice system may be hard to reach with routine community-based testing and incarcerated people have a higher HIV prevalence than the general population. Evidence shows that if HIV testing and counseling is made readily available on entry to prison and throughout incarceration, uptake increases. This is especially true if counseling and testing are part of a comprehensive treatment and care program.
In the U.S., approximately 22% of people with HIV are unaware they have HIV upon entry into jail or prison. Not all jails and prisons offer HIV testing. Although CDC recommended in 2006 that correctional facilities perform routine opt-out HIV testing, HIV testing policies in jails and prisons vary from state to state. About 15 states perform mandatory HIV testing at entry (testing all inmates without need for consent) and 17 states provide opt-out HIV testing (testing is performed unless the incarcerated person declines).
Testing positive in a jail or prison may cause problems based on the rules of the facility. Incarcerated people with HIV have almost no privacy regarding their HIV status. They may be housed separately from others who do not have HIV and they may be blocked from some work assignments.
Compulsory or mandatory testing (that requires all prisoners to have an HIV test) is used in some jails and prisons as a means of identifying those who have HIV. This exists despite the World Health Organization (WHO), the European Centre for Disease Prevention and Control (ECDC), and Centers for Disease Control and Prevention (CDC) all opposing mandatory HIV testing on ethical grounds. Research suggests that mandatory testing and segregation of prisoners with HIV breaches human rights and is costly and inefficient.
HIV information, education, and communication
Incarcerated people and prison staff need to be educated about HIV/AIDS and how to prevent HIV transmission, with special attention to the likely risks of HIV transmission within jails and prisons.
Even in high-income countries, HIV programs for incarcerated people are not impacting levels of new infections. Sessions that include topics beyond HIV, such as employment and housing concerns, and peer-based interventions have been shown to have high success in changing risk behaviors, yet very few prisons have these type of programs
High levels of illiteracy among incarcerated people can also complicate HIV programs. For example, 70% of incarcerated people in the U.S. read at fourth grade level. As a result, incarcerated people often cannot understand the HIV prevention information they are given. This emphasizes the importance of tailoring programs to meet incarcerated people’s specific needs or they will be ineffective.
Encouraging condom use
Condoms are highly effective in preventing a person from getting or transmitting HIV infection if used the right way every time during sex. Condoms should be made available to incarcerated people to prevent sexual transmission of HIV.
Harm reduction services
A lack of harm reduction services such as sterile drug injection equipment leads to needle sharing in prison. Syringe service programs (SSPs) and opioid replacement therapy (ORT) should be available in jails and prisons. This has been shown to reduce injection drug use and needle sharing by up to 75%, thereby reducing the risk of HIV. However, prison-based harm reduction continues to be extremely susceptible to budget cuts and changes in political environments. Globally, harm reduction services in jails and prisons tend to be either absent or plagued by restrictions and inconsistency.
ANTIRETROVIRAL THERAPY (ART) AMONG INCARCERATED PEOPLE
Basic principles of HIV antiretroviral therapy (ART) are the same inside or outside of jails and prisons. The goals of antiretroviral therapy (ART) are the same:
- Reduce viral load as much as possible for as long as possible (with the ultimate goal of viral suppression)
- Restore or preserve the immune system
- Improve quality of life
- Reduce sickness and death due to HIV
HIV treatment in jails and prisons is influenced by many factors, including:
- Prior treatment history
- Current viral load level and CD4 cell count
- Resistance to medications
- Other health issues, such as injection drug use, mental health problems, liver disease, and diabetes
- Personal preferences
- Length of prison term
- Medication timing relative to their activities, food requirements, and refrigeration
Provision of ART for prisoners varies greatly between countries. For example, in South Africa in 2016, 97% of incarcerated people with HIV were on ART. By contrast, in Russia just 5% of incarcerated people with HIV were on ART. To increase treatment adherence in prisons, confidentiality must be guaranteed and positive relationships with prison health staff are essential.
Incarcerated people can improve their chances of getting good HIV health care if they bring information with them. This includes:
- What antiretroviral medications (ARVs) they are currently taking or have taken in the past
- Current CD4 cell counts and viral load
- History of opportunistic infections (OIs) they have had (these may require monitoring or preventive medication)
- Details on any serious side effects they have had from ART
Even when an incarcerated person provides good information, there can be a delay in getting HIV medications. Incarcerated people cannot bring their own medications with them. This delay or interruption in treatment increases the risk of resistance.
WHAT HAPPENS WHEN INCARCERATED PEOPLE WITH HIV ARE RELEASED?
An incarcerated person’s health is a critical factor in how well they make the transition to life in their community. Getting a referral to an HIV/AIDS services agency is very important. Recently incarcerated people may need help finding housing, employment, and support services. If you are an incarcerated person who is getting ready to be released, consider visiting the library or asking a friend or family member to send you the address of a local HIV/AIDS service organization. They may be able to help you get set up with some referrals before your release.
THE BOTTOM LINE
The rate of HIV among incarcerated people is 5-7 times that of the general population. HIV rates are highest among Black/African American incarcerated people. Prisons are a high-risk environment for HIV transmission due to drug use and needle sharing, tattooing with homemade and unsterile equipment, high-risk sex, and rape. Overcrowding, stress, malnutrition, drug use, and violence weaken the immune system, making people with HIV more susceptible to getting sick.
In the U.S., prisoners have a constitutional right to healthcare that meets community standards. However, incarcerated people may need to advocate for their own care. They should understand their illness and make sure they get appropriate care in jail or prison.
Despite the high risk of HIV transmission among incarcerated people, HIV prevention and treatment programs are often limited in jails and prisons. Incarcerated people need access to HIV testing and counseling, tailored information about prevention and risk-reduction behaviors, freely available condoms, and access to harm reduction services.
Avert: Prisoners, HIV and AIDS
WHO: People in prisons and other closed settings
National HIV Curriculum: HIV and Corrections
The BodyPro: HIV Among Incarcerated Populations in the United States
Reviewed May 2021Print PDF