Incarceration and HIV Cathy Elliott-Olufs, M.A. Laura McTighe, MTS

Correctional facilities are critical settings for the efficient delivery of prevention and treatment interventions for infectious diseases. Such interventions stand to benefit not only inmates, their families, and partners, but also the public health of the communities to which inmates return. —T. M. Hammett American Journal of Public Health

Mission Statement The Center for Health Justice empowers people affected by incarceration and HIV to make healthier choices and advocates for the elimination of disparities between prisoner health and public health. To achieve our mission, we advocate for HIV+ prisoners and provide HIV/AIDS, STD and Hepatitis education and treatment information to prisoners in California and throughout the United States.

Mission Statement The Institute for Community Justice is a Philadelphia-based national initiative committed to locally-rooted, national work to reduce not only the number of people in prison living with HIV, but also the lasting effects of mass imprisonment on communities most affected. By centering the wisdom and experiences of formerly imprisoned community leaders, we work to amplify existing efforts to build safe and vibrant communities, push for needed policy change, and realize our vision for community-led transformative justice.

Our Core Projects Reentry Organizing Center – a community center dedicated to helping people navigate the hurdles of self care, recidivism prevention, and political engagement. TEACH Inside/TEACH Outside – an empowerment- based educational program on the intake housing units of the Philadelphia jails and in the community Support Center for Prison Advocacy – a city-wide, neighborhood-based prison reentry resource center without walls in North, South and West Philly Prison Health News – the nation’s only health newsletter written by and for people who are in prison

Overview of United States Correctional System At end of year 2008 The total number of inmates held in federal or state adult correctional authorities was 1,570,861—a 2.8% increase over 2005 year-end total 1 –The prison population grew at a faster rate than the previous five years The total number of inmates held in local jails was 766,010—a 2.5% increase over in every 133 US residents was in prison or jail 1 Overall, the United States incarcerated 2,258,983 people—a 2.9% increase over the 2005 year-end total—and the most in the world 2 1 US Dept of Justice, Bureau of Justice Statistics. Prisoners in NCJ publication Published December Accessed Jan 9, National Council on Crime and Delinquency. US Rates of Incarceration: A Global Perspective (FOCUS). crc.org/nccd/pubs/2006nov_factsheet_incarceration.pdf. Published November Accessed Jan 9, crc.org/nccd/pubs/2006nov_factsheet_incarceration.pdf

US Incarcerated Population US Dept of Justice, Bureau of Justice Statistics. Prisoners in NCJ publication Published December Accessed Jan 9,

Jail Short-term facility Usually operated by a city, county, or local government Holds arrestees awaiting trial or sentencing and inmates convicted and sentenced to less than 1 year Approximately 50% of arrestees are released within 48 hours 1 Public health interventions (eg, screening, testing, counseling, making referrals) must happen QUICKLY or not at all Most jails do very little screening—usually only for tuberculosis, sometimes for sexually transmitted diseases (STDs), sometimes for pregnancy and HIV Mean expected time of jail stay is 9 months 2 1 CDC. MMWR 1998;47: US Dept of Justice, Bureau of Justice Statistics. Profile of Jail Inmates, NCJ publication Published July Accessed Jan 15, Adapted from: de Ravello L; CDC. Prisons and drug abuse: challenges to HIV perinatal prevention efforts. Published Feb. 13, Accessed Jan 9, 2008.

Prison Longer-term facility Usually operated by the state or federal government Greater opportunity to implement long-term public health interventions with follow-up Very comprehensive medical intake process, but the level and quality of ongoing medical care varies Adapted from: de Ravello L; CDC. Prisons and drug abuse: challenges to HIV perinatal prevention efforts. Published Feb. 13, Accessed Jan 9, 2008.

Top 10 HIV Seroprevalence Rates Among Incarcerated State Overall % HIV Seroprevalence Rate Female Seroprevalence Rate Male Seroprevalence Rate NY7.0% FL3.9% MD3.0% MS2.7% CT2.6% LA2.5% NJ2.3% SC2.2% GA2.1% MA2.1% US Dept of Justice, Bureau of Justice Statistics. HIV in Prisons, 2005; Appendix Tables 1 and 2. NCJ publication Published Sept Accessed Jan 9,

US HIV-Positive Prison Population— % of all PLWHA in the US were in a correctional facility at some point (2006). On December 31, 2008, a reported 20,449 state prisoners and 1,538 federal prisoners were HIV positive or had confirmed AIDS 1 in 5 Black and Hispanic males released from corrections facility in US are HIV-positive. The percentage of female inmates with HIV/AIDS decreased slightly from 2.1 percent to 1.9 percent. 1. US Dept of Justice, Bureau of Justice Statistics. HIV in Prisons, 2008; 2. 1Maruschak LM et.al. US Department of Justice, Bureau of Justice Statistics, Bulletin, April Spaulding AC et.al. PLoS One, 2009

HIV Transmission in Correctional Settings The majority of HIV-positive people are infected before they enter prison 1 HIV risk behaviors often continue inside the institution and include injecting drug use, tattooing, body piercing, and consensual, nonconsensual, and survival sexual activities 2 The scarcity of sterile drug paraphernalia leads to needle sharing in prison 3 Needle sharing among soon-to-be released prisoners is high 4 Among IDUs in New Mexico, 37.6% of those with tattoos received them in jail or prison 5 –Tattoos received in prison were associated with increased risk for HBV and HCV 1. CDC. MMWR. 2006;55(15): Hammett TM. Am J Pub Health. 2006;96(6): Davies R. Lancet. 2004:364: Stephens TT et al. Am J Health Stud Samuel MC et al. Epidemiol Infect. 2001;127:

Incarceration is a Social Driver of HIV/AIDS “We must remember… that incarceration itself —not just inadequate prevention and care behind bars— contributes substantially to the global burden of HIV, particularly among drug users and sex workers. In fact, we would argue that the single most important strategy stem the rate of incarceration itself single most important strategy in controlling HIV in prison is to stem the rate of incarceration itself.” 1 1 Duncan Smith-Rohrberg Maru, Sanjay Basu, & Frederick L Altice. (2007) "HIV control efforts should directly address incarceration.” The Lancet Infectious Diseases: Vol. 7 No. 9.

Understanding Community-Level Vulnerability Relationshi p Instability Fractured Communities Loss of Caregivers Financia l Instabilit y Broken Family Ties Lack of Jobs Lack of Social Services Fractured Communities Arrest – Jail/Prison – Reentry Need for Services and Support

From Vulnerability to Community Health Relationshi p Stability CommunityWholeness Family Support Financial Stability Family Reintegrati on Ready Employme nt Access to Social Services CommunityWholeness Arrest – Jail/Prison – Reentry Comprehensive Care and Support

Working at the Intersection of HIV and Incarceration Testing Prevention Treatment and Care Treatment and Prevention Education Reentry Support Structural Interventions

Mandatory HIV Testing Policies by State No testing required On entry On release On entry and in custody On entry and on release In custody and on release On entry, in custody, and on release All states test upon inmate request except NH, IA, AL, KY, UT, and NV US Dept of Justice, Bureau of Justice Statistics. HIV in Prisons, 2005; Appendix, Table 5. NCJ publication Published Sept Accessed Jan 9, Not reported

Condom in Prison Programs Nationwide County Jails Los Angeles, San Francisco, Philadelphia, Washington, D.C. and New York State Prisons California, Mississippi and Vermont

CHJ’s Condom Distribution Los Angeles County Jail Operated without incident for 7 years Distributed over 30,000 condoms Approximately condoms per week –Limited to K-6G Unit (ie. gay unit) –One condom per week per inmate (now expanded) –In conjunction with brief educational session Several small evaluations have been conducted. Findings indicate that condoms are being used and ongoing research is underway to determine whether high-risk sexual activity is reduced by access to condoms San Francisco County Jail Collaboration with Forensic AIDS Project Program Since 1987 Previously in one-on-one in health educator sessions Now offered via a condom dispensing machine in the gym (free) Solano State Prison Pilot program implemented Aug/Sep Under order from the Governor of California to determine feasibility of prisoner access to condoms Center for Health Justice selected to implement a condom machine and educational program Evaluation underway

HIV Treatment and Care in Prison HIV-infected inmates are more likely to be offered antiretroviral therapy in prison Prisoners offered ART in prison (only) 64% ART offered in another setting 36% Altice F et al. J Acquir Immune Defic Syndr. 2001;28: Study data collected from the Connecticut Department of Corrections (DOC) Only 3% of HIV+ prisoners are on ART at time of incarceration

HIV and Hepatitis Prevention and Treatment Education Train-the-Trainer Program for State Prison Settings

TEACH Outside (people living with HIV coming out of jail/prison) TEACH Inside/TEACH Outside (all people passing through the Philly jails)

Reentry Support Programs Who in the room??

In Communities:  Sentencing reform  Community policing  Prison budget reinvestment  Youth empowerment In Jail/Prison:  Harm reduction programs  Treatment education and advocacy  Good time earned time At Reentry:  Civic participation  Community-led mentoring  Job creation and retention  Housing expansion 25 Thinking About Structural Interventions

Research Advocacy Directions Lack of connection among those of us doing this work Lack of dissemination of programs we know work Lack of programming to reach jail-based populations and those on parole Lack of research on incarceration as a social driver of HIV in the US Lack of models for effective structural interventions

Thank You! Cathy Elliott-Olufs Center for Health Justice Cell: Web: Laura McTighe Institute for Community Justice Phone: x Web: