Human Immunodeficiency Syndrome, commonly known as HIV, is a virus that causes Acquired Immunodeficiency Syndrome (AIDS), a condition that leads to a progressive immune system failure giving a chance to other opportunistic infections to thrive (WHO, 2005). The first case of AIDS was diagnosed in 1981 and the disease has since spread throughout the world to worrying proportions. The disease has killed over six hundred thousand Americans and cost the economy billions of dollars. About thirty million people have died worldwide and over thirty three million are infected. About four million people are receiving medication. It is a deadly disease and has become of a global concern. The disease is mainly transmitted through unprotected sex, although there are other modes of transmission like perinatal transmission and blood transmission. The disease has no cure, but there are ways one can protect himself or herself from being infected. Recently, there has been a high prevalence of the disease among the criminal justice personnel. This has called for the involved stakeholders to come up with measures to countercheck the situation.
HIV in Criminal Justice System
Everyone is entitled to quality healthcare irrespective of whether he is a criminal or criminal justice personnel. There should be a comprehensive policy for the diagnosis and treatment of all infected people without discriminations. Interruptions in treatment should be avoided at all costs.Incarcerated individuals and imprisoned criminals have more than 2.5 times of the rate of confirmed AIDS cases in America than the general population. This is mainly because they engage in high risk behavior like drug and alcohol abuse and unprotected sexual intercourses among others before imprisonment and detention. It is also shocking to find that they still continue these risky behaviors even in prison, although it is illegal. This group also has a higher rate of tuberculosis, Hepatitis C, and other Sexually Transmitted Diseases (STDs).
According to NIOSH (the National Institute for Occupational Safety and Health), HIV prevalence among correctional institutions is very high as the environment poses a very high risk of exposure to both inmates and prison officers (Costoyevsky, 2008). Some of the factors with the risk of exposure include:
- Unpredictable work settings in jails and prisons
- Prisons administration pays much attention to the security of these institutions at the expense of infections control
- Inmates can have a higher rate of blood borne diseases.
Prison officers and correctional healthcare care personnel can be stabbed or bitten during an inmate assault, splashed in the face with blood, or punctured with a used needle. Exposure to blood borne pathogens may happen in any of these situations. Condom availability in these correctional institutions is rare except in few state prisons and county jails. Even when they are there, they are rarely used during consensual sex. For example, in one study only thirty percent of prisoners reported using them or improvised barrier methods during sex and no barrier methods were used during rapes (Costoyevsky, 2008). Mainly, sexual activities occur as a means of survival, obtaining goods or protection or as a result of coercion. Although any victim can become a victim of a sexual assault, some groups are more vulnerable. The most vulnerable ones include but are not limited to nonviolent, first-time inmates, gays, and transgender detainees and the youth held in adult facilities. Immigrants are also exposed to the risk of sexual assault in jails due to the fear of deportation and limited literacy and language skills. These assaults can be minimized by increased monitoring by the U.S Immigration and Customs Enforcement (ICE) detention centers by immigrant advocacy organizations. Although there is a comprehensive legal protection of inmates against these inhumane acts inflicted upon them by other prisoners and guard brutality, violence in these correctional institutions is rarely reported due to the illicit nature of the activity and stigma associated with rape and same-sex behavior. Inmates are also unwilling to report to the relevant authorities. Hence, this makes authorities not react appropriately and investigate complaints of sexual violence. Subsequently, authorities fail to prosecute perpetrators or to provide victims with appropriate access to medical care including HIV testing, counseling, and post-exposure prophylaxis (WHO, 2005).
Another major contributor to the high HIV prevalence in U.S. jails and prisons is tattooing that is a common practice associated with group membership and desire for personal expression. The process mainly uses unsterile makeshift tattooing equipment, which includes guitar strings, pins, and needles among others. This exposes them to a very high risk of getting infected not only with HIV/AIDS, but also with other parenterally transmissible infections like hepatitis. These makeshift instruments are difficult to sterilize reliably. Thus, they facilitate the spread of blood-borne infections. It is interesting to find that the possession and use of tools is forbidden in jails and prisons, but they still find their way into these correctional institutions. The reason behind this may be the collusion between inmates and prison authorities. Due to the lack of new and sterile injection instruments, a significant number of incarcerated drug users using them often share needles and are unable to clean them adequately (WHO, 2007).
More than fifty percent of the combined state and federal prisoners suffer from mental health exclusive of substance abuse and dependence. Women are the most infected. Most inmates diagnosed with mental illness were found to have been brought up in foster homes or institutions, have histories of substance abuse, incarceration, and low rates of employment. These inmates are more likely to suffer from physical abuse while in jail, earn disciplinary sanctions for breaking prison rules and regulations and other punitive measures, which lasts throughout their incarceration period. The use of isolation as a form of discipline can trigger mental illnesses and prompt acts of self-harm (Groot, Anastos, & Stubblefield, 1999).
Improving HIV Services for Incarcerated Populations
The period of imprisonment provides a unique opportunity to reach both infected and HIV-positive inmates with targeted education about services for HIV prevention. The move is supported by both domestic and international authorities on HIV prevention. To start with, the HIV status of inmates must be known in order to determine the appropriate steps to be taken. The Centers for Disease Control and Prevention (CDC) has recommended that correctional institutions routinely offer testing as a component of standard medical evaluation for inmates. These policies vary with jurisdiction and by the type of a correctional facility. However, less than a half of state and federal jails and prisons routinely provide HIV testing on entry. Most inmates get the first real healthcare in these correctional facilities and most likely this is where they get treated for HIV for the first time. Most institutions that provide these testing facilities do not inform or counsel inmates found to be HIV – negative. This lack of follow up for uninfected people represents an important missed opportunity for the prevention counseling. This leads to serious implications. Negative results can motivate inmates to receive sexual and drug use related risk education, acquire accurate prevention and care information, and reinforce risk reduction practices (Costoyevsky, 2008). It is worth noting that those who have negative test results may be actually in the early stages of infection and it is important to provide them with education on the need for repeat testing.
It normally takes a standard time of two weeks after an inmate is tested for HIV for the blood samples to be analyzed and the results to be sent back to him or her. This issue is particularly challenging, especially for correctional facilities that house inmates for a shorter period of time or those which function as transfer facilities for inmates waiting to be relocated. This period may seem to be lengthy for inmates in terms of learning about their status and receiving appropriate counseling and referrals to care. The best solution is improving a system for it to provide results immediately. Inmates may also have valid concerns about getting HIV tests while incarcerated. This is because tests are associated with stigma and medical confidentiality of the results is not likely to be maintained. Also, inmates are concerned that negative testing will result in segregation, ostracism, or violence from other inmates and in the decreased access to medical care and support services (WHO, 2007).
Despite the above issues, offering a repeat voluntary counseling and testing within correctional facilities may play a crucial role in HIV-related prevention and care services for inmates at a risk and those infected with HIV. Extreme care should be taken to ensure that they are ready to receive HIV test results and counseling. This is because inmates may be psychologically impaired due to the substance use or trauma. There are many benefits accrued to routine HIV testing and counseling in correctional institutions. Leading public health organizations like CDC and National Commission on Correctional Services agree that these tests must be conducted with the consent of inmates. Unfortunately, this agreement is not present in all correctional institutions. For example, in 2003 nineteen state prisons and the Federal Bureau of Prisons had mandatory HIV screening for incoming inmates. While many prisoners are intellectually capable of giving informed free consent, the issue of being incarcerated and the likelihood of being coerced in correctional facilities undermine their ability to give a free consent. Reforms must be introduced on regular HIV testing to allow inmates to be told of and to exercise their right to refuse testing and other medical procedures. The refusal should however not lead to adverse consequences or punishment (Costoyevsky, 2008).
In order to fully maximize the number of inmates going for HIV testing, correctional facilities should keep inmates’ medical information strictly confidential and provide linkages and access to special care and support services. Correctional service providers in Rhode Island have reported that ensuring this has led to a big number of inmates being both positive and negative towards accepting HIV testing services (WHO, 2007). Inmates also come from diverse cultural, ethnic, religious, and educational dimensions. This calls for the HIV prevention and other health education programs to be designed in such a way they adequately address the diversity and special needs of these inmates. While education about the HIV/AIDS prevention and care should be provided by the correctional health staff or outside contractors, research shows that prevention educational programs carried out by peer educators are highly educational. They establish trust and rapport that are needed to discuss sensitive topics related to sexual practices, drug and substance abuse, and HIV/AIDS among others. These peer educators are often inmates and are therefore more versed with the realities of life in both correctional facilities and post release environment. They are therefore successful in providing support and teaching skills necessary to address complicated situations that put inmates at risk. Moreover, peer educators are able to motivate inmates more effectively to access HIV- related services. This has been evidenced by a study which has shown that forty four percent of inmates requested for HIV testing after participating in a peer-led program despite the fact that HIV testing in that facility was not anonymous and individuals diagnosed with it were housed separately (WHO, 2007).
Sexual behaviors and substance use are prohibited in correctional facilities. However, some inmates still engage in these illicit activities. Efforts to reduce the risk of infection arising from these behaviors would not only benefit inmates, but also communities to which they return. World Health Organization (WHO) advocates for harm reduction strategies such as distribution of free condoms and access to sterile injection equipment in correctional facilities. Most of the U.S prisons have however illegalized the possession and distribution of these items. Only two state prisons (Vermont and Mississippi) and five county jail systems (New York, Philadelphia, San Francisco, Washington D.C., and Los Angeles) provide condoms, but on a limited basis. Some people have argued that inmates may use these condoms as weapons to smuggle contrabandists to jails and prisons. However, contrary to this, condom availability in correctional facilities has not raised any security or custody issues. There is also no evidence of the increased sexual activity in these facilities as a result of condom distribution. Currently, there are no correctional facilities in the USA providing sterile injection equipment to inmates. This is because such measures could be perceived as a threat to their security regulations and traditional abstinence-oriented drug policy.
Stigmatization of HIV/AIDS is still high in U.S. correctional facilities. Inmates who are tested positive may face discrimination and threats from correctional officers and fellow inmates. They can be denied prison jobs, activities, and visiting privileges. Some officers strongly believe that HIV-positive prisoners need to be separated for their own safety. Others argue that segregating them is not justified as it labels them as outcasts and may in turn expose them to the assault and discrimination. This may result in the disparate treatment and limited access to services and desirable housing conditions. Sometimes HIV-negative inmates may pressure prison authorities to house HIV-positive inmates separately. The resulting false sense of security may increase a high risk behavior among the population that incorrectly believes and assumes itself to be HIV free. In order to reinforce the HIV prevention education and minimize misinformation and stigma, both inmates and correctional staff require comprehensive HIV/AIDS education. This includes information on the importance of HIV testing for those practicing high risk behaviors (Costoyevsky, 2008).
Treatment and Care for HIV-Positive Inmates
Routine testing of inmates is important in the correctional system’s identification and case management of HIV-positive inmates. It has been identified that privacy and confidentiality concerns are a significant barrier to HIV testing and care-seeking in correctional settings. Challenging living conditions and mostly overcrowding in these correctional facilities make it extremely difficult for the maintenance of confidentiality of the personal and medical information of an inmate. Confidentiality may be breached by fellow inmates. However, correctional staff may facilitate it by engaging in unethical behavior while accessing the inmates’ healthcare records. Also, by requesting inmates to fill in the reasons for seeing a clinician may interfere with confidentiality. All inmates have constitutional rights to medical care. Opportunities for successful viral suppression and overall HIV management can be improved through the increased adherence to a well-designed health care system. Effective HIV treatment in jails and prisons has led to more than seventy five percent reduction in mortality, which is higher than that of non-incarcerated populations. HIV care and support in correctional institutions lag behind financial constraints, inadequate trained care providers, and stigmatization of HIV/AIDS inmates among others. Privatization of the correctional healthcare has further constrained the delivery of HIV care. This has called for the need to pay greater attention to HIV/AIDS prevention, case management, and care in correctional facilities as well as treating secondary illnesses like tuberculosis that could negatively affect therapeutic outcomes. Inadequate coordination and programming within correctional institutions and between correctional institutions and community healthcare providers adversely affect treatment efforts. Lock down periods, punitive detentions, court appearances, and transfers between facilities undermine consistent dosing schedules (WHO, 2007). Additionally, prison health providers may ask for co-payments for medical services. This locks out many inmates who do not have money. Health care costs for inmates with special needs such as drug users and those with HIV are also escalating. There are also inadequately trained health officers to attend to these patients. To overcome these challenges, correctional health and public health authorities should work together to develop cost-effective mechanisms in order to ensure that HIV-positive inmates as well as others with special needs receive appropriate health care both while in prison and upon their release.
Incarceration authorities should be properly compensated for any losses or injuries arising while in the course of their official duties. A physician’ opinion that the disease is an occupational one would be required to prove a case for the benefits for a disease. Prompt payment should then be made and the staff should bear in mind that there are limitations of actions. They should consider consulting a qualified attorney for a proper advice. The staff should be adequately trained and equipped. They should also use universal precautions like placing a barrier, for instance, latex gloves, protective eyewear, or masks to minimize their contacts with the body fluids. Prison environment should be kept clean all the time. Prison staff should follow work procedures that have been developed by the management in consultations with the prison staff. They should wash their hands and identify any wounds or breaks on the skin. These should then be covered with a waterproof dressing. The staff should wear gloves and other protective gear all the time while dealing with inmates, particularly during searches. The staff can also embrace the culture of zero tolerance to drug use and sexual activities among inmates. While conducting searches, torches should be used to light dark areas to minimize injuries by sharp objects (WHO, 2007).