A Report and Officials Agree That Prisons Like CMC Don't Do Enough to Slow the Spread of HIV

BY STEVEN T. JONES

More than half of those living with acquired immune deficiency syndrome in San Luis Obispo County are behind bars, mostly in the California Men's Colony.

That may not seem alarming. After all, those men are not in the SLO County dating pool. But research shows that prisons are acting as incubators for the AIDS virus, one of the few places in American society where the 20-year-old epidemic is growing with virtually no efforts to curtail it.

And then, most inmates are set to be released into their communities to potentially spread their HIV.

And the prison AIDS numbers are artificially low. An even greater number than these 212 "institutional males" with full-blown AIDS are thought to be carrying the AIDS-causing human immunodeficiency virus and potentially passing it on to fellow inmates through sex (forced or consensual) or shared needles (for drugs or tattooing).

The true number of HIV-positive inmates isn't known because the tests are voluntary and confidential. Federal studies have found the number of HIV-positive inmates is roughly three times the number of AIDS cases in a given prison.

Prison system policies are not addressing the problem in a few key ways, as correctional considerations trump the concerns of public health officials.

Condoms and bleach are considered contraband; HIV testing is not mandatory; and HIV-positive inmates are placed in higher security units and banned from certain jobs, providing a disincentive for them to get tested.

And those are just the known factors, for although California Department of Corrections officials say "we do everything we can to prevent prison rape," anecdotal evidence suggests that may not be true in all cases (see accompanying story).

And problems with the system's handling of HIV cases are felt especially strongly here at CMC, which is one of seven prisons in the state designated to receive HIV-positive inmates.

"All over the prison system, they are sending people [with HIV] to San Luis Obispo," said Marsha Bollinger, AIDS program coordinator for the County Health Department, who works with many of these cases.

A new federal study concludes that more needs to be done to treat HIV-positive inmates and contain the spread of HIV in prisons, where infection rates remain high even as HIV infection rates among the general public hit new lows.

"Issues and Practices 1996-1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities," released in July by the U.S. Department of Justice and Centers for Disease Control and Prevention, outlines several areas of concern.

While the AIDS infection rates among the general population in the United States has dipped to nine people in 10,000, the rate is six times higher among the prison population (54 in 10,000).

The main reason for the difference is the tendency of inmates to engage in high-risk behaviors, like unprotected sex and intravenous drug use, both before they were incarcerated and after.

"There is evidence of high-risk behavior and HIV transmission in correctional facilities but also an ongoing debate as to what precautionary and preventive measures against HIV should be implemented in these settings," the report reads, singling out as a barrier to HIV prevention "the perception that inmates should not and cannot be treated like other people relative to HIV prevention."

Yet denying condoms to sexually active inmates or ways of sterilizing needles to drug-addicted inmates means allowing the spread of HIV if correctional administrators are unable to prevent these activities, as current evidence shows has been the case so far.

"Comprehensive and intensive education and prevention programs represent the best response to these facts, although the precise content of such programs is controversial," concludes the study.

Topping the list of controversial practices is the distribution of condoms, which occurs at just a half-dozen prison and jail systems in the United States–including San Francisco's jail–but is more common in European and Canadian prisons.

"Experience with harm reduction in correctional facilities in Europe and elsewhere may warrant the attention of U.S. correctional administrators," concludes the report.

But so far, the California Department of Corrections isn't considering a policy change because of concerns that condom distribution would be seen as condoning forbidden sexual activity, or that condoms could be used weapons or smuggling devices.

"Since sexual activity is illegal, that's the primary reason we don't allow condoms," said Terri Thornton, a spokesperson for the California Department of Corrections. "It is true that condoms would reduce the spread of AIDS, but that's where we stand."

U.S. correctional institutions have also been criticized by the international public health community. Two years ago, the Joint United Nations Programme on HIV/AIDS called the American approach a violation of the most basic human rights.

"Failure to provide [prisoners] the basic measures, such as information, education, and the means of [HIV] prevention available on the outside, violates [their] rights to health, security of person, and equality before the law," concludes the report.

According to the U.N. report, failure to proactively address the AIDS problem in prisons creates a public health danger to the society as a whole.

"Prisoners are the community. They come from the community, they return to it. Protection of prisoners is protection of our communities," it reads.

Bollinger supports the distribution of condoms in prison and anything else that can be done to control the spread of HIV.

"I believe it is a public health issue, but the prison doesn't," she said. "The system is not set up for public health; it is set up to keep them in prison. Everything else is secondary."

For years, Bollinger said, CMC has resisted instituting the most basic HIV education programs, and are just now of the verge of starting a peer education program for those in prison with HIV.

Also helping to expand the HIV education and prevention programs at CMC and other prisons is Centerforce, a Marin-based AIDS support program now using grant money to take systemwide the programs it started at San Quentin State Prison.

"Yes, it's an illegal behavior," Centerforce director Barry Zack said of sex, drug use, and tattooing in prison. "But it's happening, and you have to protect public health."

"It's a real strong stance that corrections takes in this state," said Terry Comer, a health counselor with the AIDS Support Network of San Luis Obispo County.

By not acknowledging sex happens in prisons where HIV infection rates are the highest, Comer said, the prison system is potentially accelerating the spread of HIV.

For each AIDS case doctors must fill out a reporting form, which includes a question asking the patients how they believe they contracted the disease. Those who don't indicate either unprotected homosexual sex or IV drug use–the two most common means of transmission–are interviewed by Bollinger and one of her staff.

"Most of them don't know how they got it," said Bollinger, noting that many inmates have several HIV risk factors. Compounding the problem is the silence that surrounds sex in prison.

"They are not likely to say they got it from having sex with men, because there is a stigma attached to that and a macho culture in the prisons." Bollinger said.

Still, in many cases Bollinger's intelligence-gathering is limited by the fact that many inmates not only don't know how they became infected, but also when.

"A lot of those folks coming into the penal system are infected when they come in, and they've just never been tested," Comer said. "Many may have been HIV-positive for 10 years."

So while prisons may not be the root cause of the HIV spread, health officials say incarceration presents a tremendous opportunity to influence the behavior of those infected with the virus to keep them from spreading it.

Zack points out that inmates are the only group of American citizens constitutionally entitled to medical care. So while in prison they can treat their HIV and take steps to slow its progression into AIDS. And they are a captive audience for educational efforts.

"There can't be enough education," Zack said.

Centerforce's program includes intensive counseling efforts in the weeks leading up to an HIV-positive inmate’s release from prison and efforts to get the individual involved in AIDS support networks on the outside as well as medical care and Social Security.

"You really need individuals to be able to plug into the systems, because those systems were not built with them in mind," Zack said.

Educational efforts are the one thing that prison officials, public health experts, and advocates for those with AIDS can all agree on, but it may be one of the only solutions where they all agree.

There are deep divisions over the issue of mandatory HIV testing in prisons, which raised questions about rights to privacy, cost, creating stigmas, and whether it presents a false sense of security.

Prison spokesperson Thornton said knowing the HIV status of inmates would make it easier to control the spread of the disease in prison.

"It's the people we don't know about who are HIV-positive that are the biggest risks," Thornton said. "If there was mandatory testing, we could begin treating them sooner."

Yet Zack doesn't support mandatory testing for HIV, saying it would create a false sense of safety because a negative test for HIV doesn't mean that person doesn't carry the virus.

Indeed, some studies have shown carriers are most infectious in the early stage of the infection, before they have developed the antibodies that trigger the HIV-positive diagnosis.

Plus, he worries about the stigma: "In prisons there really is no such thing as anonymous testing. Everyone knows everything."

Bollinger, like many of her public health peers, is supportive of changing HIV into a disease that is reported to public health officials, like AIDS, even though many advocates for those with AIDS oppose the reporting of HIV.

Assembly Bill 103, which would establish a statewide HIV reporting system by 2001, has cleared the Assembly and is now working its way through the Senate. A similar measure was passed by the Legislature last year, only to be vetoed by then-Gov. Pete Wilson.

"That will really change our job. We'll be out investigating HIV-positive cases," Bollinger said.

On the issue of condom distribution the main division is between public health officials and prison authorities, who fall back on the "sex is illegal" argument.

"We have regulations that it is illegal to have sex in prison, so we don't allow possession of condoms," said CMC spokeswoman Terri Knight.

Public health officials draw parallels to needle-exchange programs and distribution of condoms to children in public schools, all practices that to some seem to condone risky and illegal behavior, while others focus on the public health aspects.

"People do have sex in prison, and they do use drugs, and they do get tattoos," Zack said.

Condoms are also prohibited in San Luis Obispo County Jail, although county officials say sex, drug use, and other risky behavior are not as common in jail as they are in prison.

"We don't have those kinds of problems. It's a different type of mentality, because [inmates in jail] know they are in for less than a year," said Sheriff's Department spokesman Sgt. Sean Donahue, who worked at the jail for two years.

He said most inmates want to do good time and get out, not risk longer stays by breaking laws in jail. Jail supervision is also set up so inmates have little opportunity to commit a rape, for example, with patrols done at irregular intervals.

And in the jails, where most sentences are between a few weeks and a few months, sexual abstinence is more of an option, whereas prison inmates locked up for several years are more likely to have sex with each other.

"We don't have condoms in jail," Donahue said. "There would be no reason."