system is thus highly associated with ethnicity and social class. Only a handful of correctional
facilities in the United States have instituted some type of therapeutic community treatment
who are in treatment for HIV find it impossible to remain on their medication schedules after
being arrested because their medications are often confiscated for days at a time.
The population in prisons and jails tripled between 1987 and 1997. Overcrowding and
understaffing are common in prison facilities and can increase inmates' risk of contracting HIV.
In 1992, HIV/AIDS cases for people in State and Federal prisons reached 195 per 100,000
compared with 18 per 100,000 for the general U.S. population.
Risky behaviors that lead to HIV infection are not eliminated when a person is imprisoned but
may actually increase in frequency and availability. This occurs for several reasons. First, drug
offenses count for the single largest number of Federal and State crimes for which people are
arrested and incarcerated. In 1996, 79 percent of State inmates reported at least one use of illicit
drugs during their lifetime. Therefore, high rates of HIV infection are not surprising in a
population so closely characterized by heavy substance abuse involvement. In addition, many
people enter jail or prison already infected with HIV. A 1993 study of 46 correctional facilities
found people entering these facilities had an average infection rate of 1.7 percent. In some
facilities, however, rates for women were as high as 21 percent and 15 percent for men. Among
injection drug users, rates ranged from less than 1 percent to 43 percent.
Injection drug users face particular risk in prison settings as clean syringes are all but impossible
to secure. Although syringes are not officially available, they can be acquired through illicit
prison markets at exorbitant prices ($34 in one Canadian facility) or through risky exchange of
syringes for unprotected sex. Syringes are typically not new or sterile. As a result, injection drug
users have as their only recourse used or shared syringes, which increases their chances of HIV
infection. Tattooing is also common practice among prisoners and is another source of HIV
infection. To date, there have been at least two documented cases of HIV/AIDS related to
tattooing with unsterile needles in a correctional facility.
Only six prison systems in the United States distribute condoms: Mississippi, New York City,
Philadelphia, San Francisco, Vermont, and the District of Columbia. Distribution strategies range
from receipt of a single condom per medical visit to receipt of multiple condoms during
HIV/AIDS education workshops. Furthermore, condom distribution programs send mixed
messages because sexual activity in some facilities is illegal and a punishable offense. In other
facilities, correctional medical and social service staff may advocate condom availability while
administration and security officers oppose it.
Sixteen prison systems mandate HIV testing, and although 77 percent make testing available to
inmates on request, few inmates request it for several reasons. First, confidentiality of results is
not guaranteed. Second, mandatory testing may result in the segregation of those who test
positive from those who test negative or who do not test. Third, prisoners do not wish to
acknowledge activities that could subject them to further sanctions. Fourth, confidentiality on
