AIDS, Prison, and Preventative Medicine:

Society's Debt to its Debtors

Daniel Swarr

The word "prison" conjures up thoughts of a dark and deviant subculture, living in a chaotic and destructive environment out of the sight and mind of mainstream America. Hollywood has skewed our views of prisoners, painting them as a seemingly irreparable subclass of humans that are only further downgraded and downtrodden by prison lives filled with violence and rape. Certainly the life of a prisoner is tough, and violence is inevitably present in prison systems where gangs frequently play a prominent role in social organization (Conover 2000). However, misconceptions regarding prisons are numerous, and such misconceptions play an important role in how the AIDS problem in prisons is viewed.

For example, one of the most vivid, if not widespread misconceptions surrounding prisons are the stories of forced sexual activity and gang rapes—a view likely to lead an outsider to suspect that little can be done to prevent transmission of HIV among prisoners. In reality, this aspect of prison has been overdramatized and overemphasized, perhaps as a deliberate effort to amplify the purported deterring effect that the threat of a prison sentence has on crime. In fact, Ted Conover reports in his first-hand account of the infamous Sing-Sing, one of New York's most troubled maximum security prisons, that while "prison rape still occurs in New York and elsewhere," by far the most common type of prison sex, "after the autoerotic, is certainly consensual." He goes on to say, "I would even guess that, at least at Sing, sex between officers and inmates is presently more common than forcible sex between inmates" (Conover 2000). Such an example is a prime reason why prison officials, politicians and the general public alike need to focus not on the stereotypes of prison behavior, official codes of conduct, and expected or even legal behaviors, but rather what is actually occurring behind prison walls—illegal or legal, for better or for worse.

If rape isn't as widespread in prisons as the average moviegoer might be willing to believe—at the very least, it certainly isn't an everyday occurrence—and prisoners are not allowed to have sex or use drugs, then can one expect to see lower incidences of AIDS in prisons? NO! As Conover's statement indicates, much of what goes on in prison isn't "supposed" to take place. Prisoners have sex with each other—most often consensually, but in some instances forcibly—and even with guards; they take drugs, both injecting and non-injecting; they get tattoos; they participate in fights that often involve the shedding of blood. None of these activities are permitted, but every one of them occurs in most, if not all, of America's prisons—probably on a daily basis. More important, it has been pointed out by numerous researchers that "prisons house disproportionate numbers of individuals with histories of high-risk behavior, most notably drug abuse" (Martin 1995). In other words, many of the prisoners infected with HIV did not catch it in prison, but instead caught it "at home." In fact, AIDS is the second leading cause of death in prisons nationwide, second only to the more broad and nonspecific category of "natural causes" (Gilliard 1996). To compare prison AIDS rates to those found beyond the bars, consider that the per capita rate of AIDS in the United States is 27 per 100,000 persons, compared to a rate of 485 per 100,000 in prisons—this is nearly eighteen times as high (Cotton-Oldenburg 1997)! At a time in which violent crime is on the decrease, while the prison system rapidly expands due to the "war on drugs" (Conover 2000), it is inevitable that prison populations will "increasingly comprise members of groups at risk for HIV infection, such as minorities, the young, and drug users" (Robbles 1993).

Simply stated, American prisons currently house a large number of young, high-risk minorities that continue to engage in such risky behaviors while in prison, and will invariably continue to do so once they are released—thanks to the effectiveness, or lack thereof, of current preventative programs. One might be surprised to learn that most states do in fact provide AIDS education in some form to their inmates and have been doing so for many years (Martin 1993). In addition, it has been pointed out by a number of social scientists that inmates generally have a high knowledge of general HIV/AIDS subject matter—a knowledge-base among prisoners that dates back to early nineties (Zimmerman 1991, Hogan 1994). So, what is the problem? If inmates are so informed, why is there such a high rate of HIV among this population? The massive failure of current HIV/AIDS education and prevention programs are due to a variety of causes, which can be grouped into three major categories: failure to provide prisoners with the necessary resources to protect and/or help themselves; failure to provide appropriate and/or racially, culturally, and gender-specific education to prisoners; and finally, failure to provide prisoners with opportunities to learn and practice implementing skills that they may actively use to protect themselves from HIV, both inside and outside the prison.

If rates of HIV infection among prisoners are an indication of program success, then clearly most programs today are failures. Many individuals, however, particularly politicians and the general public as a whole, are at the very least indifferent to the problem. Most, either implicitly or even explicitly, have dismissed the issue under a guise of hopelessness. However, the disregard for the well-being of prisoners pushes much deeper into the sociological framework of our nation. Below the veils of hopelessness and cries of the inevitability of HIV/AIDS rates among prison population stems a more sinister psychology. In its shadow dismissals of the problem as "too difficult" become mere euphemisms; there is an underlying and often unspoken belief, at least on some level, that prisoners deserve it. Similar claims were initially voiced towards homosexuals, often quite vocally, at the beginning of the U.S. AIDS epidemic. Unlike homosexuals, however, prisoners have been legitimately accused of a crime or crimes. For this reason, prisoners are all the more easily ignored—most easily dismiss the cries of pain and suffering of a convicted murderer and rapist.

It would be a mistake, therefore, not to consider the benefits of HIV/AIDS prevention programs in America's prisons before discussing such objectives further—for if in fact the cause is hopeless, or pointless, then perhaps the current funds spent on AIDS education in prisons could be redirected to a more deserving cause. However, such a tragic fiscal mistake would indicate tremendous lack of foresight and social ingenuity on our part. Prisoners represent a particularly high-risk group of individuals that are more likely to be from poor, minority communities than otherwise and will probably be returning there once their term is up. Prison therefore represents a unique manner by which the benefits of HIV/AIDS prevention programs can be infused into communities otherwise extremely difficult to help. Prison disease prevention programs extend beyond the rights of prisoners (which should in itself be enough to stimulate action) into the domain of general public health. Prison populations are not static; instead, their barred cells are in a continual dynamic interaction with the communities that lie beyond their cold and concealing walls. If we, as a society, care at all about public health, particularly the health of America's poorer citizens, successful HIV/AIDS prevention programs in prisons must be implemented to take advantage of the relatively captive audience of otherwise unreachable individuals, while they are confined to a controlled prison setting (Keeton 1998).

First, current HIV prevention programs for prisons today need to improve their teaching methodologies. The high levels of general knowledge of HIV/AIDS among prisoners, in light of the high incidence of this same disease within this same population, strongly suggests that alternative measures must be taken to provide prisoners with "real risk reduction skills, especially as they relate to injection drug use," and to negotiating sexual encounters—two areas in which prisoners are generally weak (Martin 1995). The fact that merely providing information to prisoners does not induce social change, particularly surrounding issues such as drugs and sex, should not come as a surprise in light of a variety of supporting evidence from social psychologists.

Hammett and Daugherty have suggested that "simply providing information about HIV disease usually does not induce people to alter their risk behaviors" (Hammett 1990). This statement is supported with empirical data, which documents a lack of strong associations between information, attitudes, and commitment to actual behavioral modification (Miller 1990). Instead, prisoners must be directly provided with a way to protect themselves. One way this could be accomplished is through explicit discussions related to sexual contact and drug use, particularly within the context of prison life. However, the largest benefit to prisoners would be obtained from instruction in specific skills; such lessons might include demonstrations on how to use condoms and lubricants, how to clean a syringe or a tattoo needle, and how to obtain clean resources for participation in such activities.

Various studies of prisoners indicate that, in addition to hands-on skills, there are a few gaps in prisoners' otherwise sound general knowledge of HIV; unfortunately these knowledge gaps are in areas that can cause particular problems in a prison setting. It has been observed that prisoners tend to be uninformed about unlikely transmission routes of the virus; for example, the average prisoner would probably not know that donating blood, or contracting the virus outside the context of the human body (via mosquito bites or toilet seats) constitute extremely low risk activities (Keeton 1998). Such lack of information, or even misinformation, tends to breed fear and anxiety among prisoners, "emotions that are particularly problematic in the correctional setting" (Keeton 1998). In addition, due to the exclusion of more touchy subjects from some curriculums, such as the topic of oral sex in the Florida prison curriculum, other critical knowledge deficiencies exist (Keeton 1998). Therefore, in addition to providing hands-on preventive experiences and knowledge that can be actively applied, successful prison HIV/AIDS prevention programs in the future must address the current weaknesses left by existing programs, such as a lack of knowledge about lower risk routes of transmission and "touchier" topics, such as oral sex, that are often avoided.

The method of implementation of a given program is at least as important as its content. Many existing courses are led by prison staff, which according to current psychological evidence provides an immediate stumbling point. The literature indicates that social groups play a key role in risk-taking and risk-reduction decisions. Therefore, in order to modify such behavior, the proposed behaviors must be made consistent with group values and the fact that "influence is more likely when the message comes from a member of one's own group" (Fisher 1988). In addition, the student's perception of the information's source is a critical factor in determining what effect the message will have on that particular individual's behavior (Cooper 1984). This results directly from the psychological tendency to believe that people who are similar to us are more trustworthy (Simons 1970). Hence, it is crucial that HIV/AIDS education programs in prison settings actively involve peer-led discussion.

The HIV prevention program at San Quentin State Prison in California is touted as a model by the Center for AIDS Prevention Studies of the University of California at San Francisco (Centerforce 1999). This program, which has been in operation since 1986, is based upon the instruction of 40 prisoners per year through an intensive 5-day training course covering the basics of HIV and AIDS, substance abuse and STDs (as they relate to HIV/AIDS), sexuality as it relates to HIV, and basic public speaking skills and hands-on teaching experience, as well as diversity and gay sensitivity issues. These 40 prisoners are awarded a peer-counseling certificate after completing this training session and then go on lead mandatory HIV/AIDS education classes for incoming prisoners—classes that are conducted in both English and Spanish. The program is designed to "personalize" the disease, through detailed, nonfiction accounts surrounding the illness. Not only does the course provide the inmates with information regarding modes of transmission and the effects of alcohol and drug use on the spread of HIV, it also discusses techniques that may be used to practice safer sex and safer injection drug use. The fact that these prevention measures may be used to reduce the spread of other diseases, such as tuberculosis and a variety of STDs, is also emphasized.

This program is clearly implemented with a sound understanding of how such instruction must be delivered if it is to be successful. First, interested prisoners are selected from the general prison population to be trained as peer counselors. While the information provided by Centerforce does not describe how this selection occurs, it is important to point out that those inmates who seem to be role models to the other prisoners—perhaps even the gang leaders of the prison if their interests could be solicited—would be the most desirable individuals to seek for such a position. Next, these trained peer counselors are allowed to teach interactive classes emphasizing knowledge and skills useful to the inmates. Again, Centerforce provides information only on what is taught and does not provide detailed information on how it is taught; however, one would envision the most successful future HIV/AIDS education programs as having not only lectures discussing preventative techniques, but also demonstrations of these techniques. For example, the peer counselor would demonstrate how a condom is properly used, or how drug paraphernalia can be safely cleaned. Taking this idea a step further, a practicum could even be added to the course; that is, inmates would have the opportunity to clean drug paraphernalia and/or experiment with proper condom use (on a banana or anatomically correct model) under the careful and corrective guidance of the peer instructor. Such a method of instruction would provide students with the optimal chance not only to obtain knowledge that one day might save their own lives or the lives of their family, but also to acquire the skills that are necessary to make the life-saving power of this knowledge become a reality.

Another important aspect of the Centerforce program that needs to be addressed is its apparent concern for social, cultural and gender diversity. Currently, the average prison education program is characterized by lack of such sensitivity, which has profound implications on the success, or more accurately, the failure of such programs. It is pointed out that such "deficiencies render most AIDS education programs for inmates largely ineffective at producing the behavioral changes necessary to stop the spread of HIV disease" (Martin 1995). In addition, "a disproportionate number of incarcerated offenders are minority group members, and the majority of these offenders are either Black or Hispanic" (Glillard 1996); and of the prisoners infected with the HIV virus, minority group members are disproportionately represented (Burris 1992). Hence, to ignore the concerns of minorities within the context of HIV/AIDS education is to completely overlook one of the most important target groups.

The sensitivity level of preventative programs may be improved by a variety of means, including actively involving minorities in the design of course materials and syllabi, and including minority-led lessons directed at a particular group. To address such social and cultural issues, the communication barriers between the various groups involved must first be overcome. Most obviously, this means making instruction available in the prisoners' native languages; more subtly, it means that every aspect of a course directed at minorities needs to be either directly "approved" or even actually constructed by a representative sample of that particular group. A related issue is that many prisoners exhibit diverse educational backgrounds and intellectual capabilities. For example, the average prisoner's reading level is somewhere between the 3rd and 6th grade level (Hammett 1991), but at the same time most current HIV/AIDS education programs are based on written reading material produced by the correctional facilities' personnel (Hogan 1994). Such programs are bound to fail, unless the use of repetition and varying methodologies are implemented (Hogan 1994). It has even been suggested that an almost exclusive use of audiovisual aids is the most appropriate means by which prisoners should be instructed on HIV/AIDS (Keeton 1998). Essentially, failing to take the measure of such needs, both cultural and intellectual, will almost guarantee the failure of future prison preventative health programs in reaching the people who need help the most.

Similarly, distinct measures must be taken to successfully reach the female prison population. Accomplishing such a task is paramount in the fight against AIDS—particularly within the context of the American penal system, in which the rate of HIV infection among female prison inmates now exceeds that of men in nearly every large correctional jurisdiction of the United States (Ross 1998). For example, 20% of women prison entrants in New York State are HIV-positive, in contrast to a 9.2% rate for men (New York State Department of Health 1992). Studies of prison HIV/AIDS educational programs indicate that the vast majority of programs are "totally insensitive" to the needs not only of minorities, but also of women (Martin 1995). This weakness must be addressed by creating programs tailored specifically to the needs of female audiences. A successful program must discuss issues of female empowerment, and even more appropriately, involve active participation and practice of the techniques discussed in class by the participations. Such practical experience could be provided through activities such as role-playing. However, issues that are central to HIV/AIDS education for women, such as empowerment, completely contradict traditional penological views, and thus are likely to be extremely difficult, if not impossible, to implement. The instructor must also understand that students might not have complete control in a relationship, and so must be alternative and appropriate means of protection—for example, "just say no" might not be a valid solution. In addition, issues surrounding prenatal and postnatal transmission of HIV also need to be discussed, since many inmates may consider having children after or even during the course of their sentence.

Lastly, prison preventative health programs need to provide a unique program directed not at the prison inmates themselves, but rather at their female visitors. At least one example of such an education program already exists; it is a separate branch of the previously mentioned Centerforce program at San Quentin Prison. The purpose of this program is to hire and train women who visit the prison as peer counselors, who then conduct peer-led HIV education workshops for other women visitors. Such educational intervention begins before the conjugal visit is initiated and is followed up with post-visit intervention and periodic surveys (Centerforce 1999). This type of program begins to extend the reach of HIV education beyond the prison walls and into the communities from which the prisoners originally came—it extends the reach of our educational capabilities beyond male prisoners into their otherwise guarded and poor minority communities.

Educational programs are certainly one of the most crucial components of any preventative medical plan; however, if prisoners, current or former, find themselves without the necessary resources to protect themselves, it is likely that they will simply shrug off their newly acquired skills and lapse back into their old, unsafe behaviors. However politically unacceptable it may seem, it is critical that prison administrators overcome such difficulties and provide prisoners with the resources they need to protect themselves from disease.

For example, the taboos associated with condom distribution are further complicated within the prison system, in part because any such program could be viewed by some as resulting in one of the most undesirable things in the world of corrections—a loss of control over prisoners. To officials, such an act amounts to accepting the fact that they are unable to completely stop prisoners from participating in illicit activities. As inevitable and expected as such a loss of control might be, it is foreseeable that administrators and politicians alike will fight to the death before admitting such defeat.

However, the rewards that such programs would reap are tantalizing. Providing free condom dispensers in locations of the prison to which prisoners would have easy access but could still retain some privacy, would give these individuals the opportunity to actually implement the knowledge they acquired as part of the prison's AIDS education program. In addition, encouraging the social acceptance of condoms within the confines of a prison is likely to increase usage among ex-prisoners in the outside community. Again, it seems that programs offered within the confines of a prison have a strong potential to affect otherwise hard-to-reach communities.

An even more controversial, yet potentially effective resource distribution program has actually been implemented in Switzerland. In an effort to reduce drug-related needle-sharing and the consequent spreading of AIDS, six automatic dispensers for the exchange of syringes were placed in Hindelbank, a Swiss prison for women. The dispensers, which are freely accessible to inmates but are hidden from general view, provide clean needles only in exchange for a used syringe; the first exchange is by means of a dummy syringe given to each prisoner when they enter the prison (Nelles 1998). Such a program raises a host of issues, such as fears that inmates will use contaminated syringes as weapons, and that the distribution of needles might increase drug use.

However, the results of the Hindelbank project demonstrate such fears are likely unfounded. In the first year of the program, 5335 syringes were distributed without any operational or security problems. In addition, there was no evidence that there was any increase in drug consumption, and most importantly, the sharing of needles among inmates virtually disappeared (Nelles 1998). The results of the project at Hindelbank have encouraged the flowering of similar programs in various parts of Europe, which also seem to possess a high degree of success. It is critical to mention that drug use in these countries is illegal just as it is in the United States. Therefore, America should find itself with little reason to not support such programs, even though it will inevitably fail to do so, in light of the strong political opposition that exists towards these forms of preventative medicine. Such political ignorance both on this issue and other related issues surrounding the AIDS epidemic, has provided and will continue to provide a major stumbling block in the battle against HIV in America.

The AIDS epidemic has hit this country with discriminating force, not because the virus has any predisposition to one race or economic class over another, but because a variety of minority groups have found themselves engaging in behaviors that have placed them at high risk for contracting HIV. In particular, the poor minority communities that are frequently found in inner cities not only represent a high HIV risk group, but also are composed of individuals that are statistically more likely to end up in prison. Therefore, we as a society must make an extra effort to reach those behind bars, a task our nation has consistently and expectedly failed. Just as America falls down in helping the politically weak and poor with their many problems, we as a nation have backed away from any comprehensive preventative medical plan for prisoners. Admittedly, this is due in part to the fact that such groups are politically weak. However, reasons for our country's neglect towards these downtrodden individuals is more closely tied to the overwhelming indifference toward the poor, and in the case of prisoners, the belief among some that the prisoners deserve what they get. Such attitudes drastically weaken our ability as a national and a global community to battle the AIDS epidemic. Even worse, however, is the filth with which we as a society have painted ourselves. Our treatment of this subclass of American society is a dishonor that we can ignore for the present, but it is not one that we can ignore forever; and once ingrained into our past, this dishonor will never be lost from our nation's soul.

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