The rate of HIV among prisoners is 5-7 times higher than among the general population.
It is estimated that approximately 150,000 HIV-infected persons (14% of all Americans with HIV) pass through correctional facilities each year.
Why this disparity?
For a large segment of the prison population, the conditions and behaviors that led to an HIV infection are exactly those that led to their incarceration (e.g. injection drug users, sex workers, victims of domestic abuse, those with mental illness, and those living in poverty). Another segment of inmates are infected with HIV during their sentence, via unprotected sex and needle sharing.
Mass Incarceration in the U.S.
As of 2017, there are more than 2.3 million people confined by the American criminal justice system, spread out among state prisons, federal prisons, juvenile correctional facilities, and local jails. Of this number, almost half a million are locked up because of a drug offense. Nonviolent drug convictions play a significant role at the federal level, and are less prevalent at the state and local level. However, most states continue to arrest people for drug possession, which destabilizes individual lives, families and communities subject to over-policing, and results in criminal records, reduced employment opportunities, stigmatization, and the possibility of longer sentences for future offenses.
Women in the Criminal Justice System
There are more than one million women behind bars in the United States. Since 1985, the number of women in the criminal justice system has increased at nearly double the rate of men, making women the fasting growing segment of the incarcerated population. Like the incarcerated population at large, women of color are overrepresented in the criminal justice system, with black women representing 13% of the general female population in the United States, and 30% of all incarcerated women. Additionally, Hispanic women represent only 11% of the general female population but make up around 16% of incarcerated women.
Among those in jail, African American women are more than twice as likely to be diagnosed with HIV than are white or Hispanic/Latino women. Drug use and HIV infection are more prevalent among women in prison than among men in prison, due mainly to the circumstances and behaviors that affect women in particular. For example, injection drug users and sex workers are overrepresented in the correctional system. Because women constitute a relatively small fraction of the prison population, they are often surrounded by facilities, programs, and services that have been tailored for men, even though their needs are often very different. Responding to the particular needs of incarcerated women involves developing alternatives to imprisonment to reduce overcrowding, the prevention of sexual violence, and expanding health services to match those of the community.
The Prison Process
Unjust and Discriminatory Incarceration
The United States contains five percent of
the world’s population, yet it holds twenty-
one percent of its inmates. The emphasis on
a “tough on crime” attitude that became
popular in political rhetoric throughout the
1980s and 1990s led to an unbelievable
increase in the number of people behind
bars. In 2010, America’s prisons housed more
than 2.2 million people, an increase of about
1.9 million when compared to the late 1970s.
However, since 1990, violent and property
crime rates have steadily decreased, yet the
prison population continues to increase
The “war on drugs” plays a significant role in
this phenomenon, and is not only largely
responsible for the increase in incarceration rates, but also for the racial disparities that are a product of the current criminal justice system. Men and women of color are disproportionately represented in the corrections system, as African Americans and Hispanics make up around 32% of the U.S. population and 56% of the prison population. African Americans, who are especially harmed by the current system, are imprisoned at more than 5 times the rate of whites.
Conditions Within Prisons
Upon release, prisoners face stigma and marginalization, which serves only to further deepen health disparities, as they are unable or become unwilling to access health and social support services. Many prisoners return home to sexual and needle-sharing partners, meaning that the risk of transmitting disease is high following release, making the issue of HIV within prisons a community problem.
Post-release planning should include support and education that encourages the reduction of risky sexual and injection drug-related behaviors, and ensures that HIV medication regimens are adhered to in the long-term.
USA High Rights of Icarceration
More than 1% of all adults in the United States are currently in a jail or prison. This mass incarceration, particularly of African American men, fosters conditions that facilitate the spread of HIV in communities where both HIV and incarceration are endemic. Recognition of the role of mass incarceration in the perpetuation of the HIV epidemic is essential to development of effective HIV prevention policies.
The United States is home to 5% of the global population but accounts for 25% of the world's prisoners. Per capita, the United States incarcerates more of its own people than any other nation, with 1 in 99 adults currently behind bars, in either a jail or a prison; an additional 4 million people are supervised under parole or probation. The consequences of this large-scale incarceration, beyond the considerable financial cost to taxpayers, are multiple and not always obvious. The policies that have led to mass incarceration have affected minorities and those living in poverty the most, and this unevenness in the application of the law has perpetuated economic and other disparities, as ex-offenders struggle to find work, housing, and stable medical care. In addition, the incarceration of a sizable proportion of the community causes societal disruptions that foster the spread of infectious diseases, including HIV.
This commentary describes how the coincident epidemics of incarceration and HIV infection have led to a concentration of HIV in US prisons and jails, which facilitates the spread of HIV infection in communities where both incarceration and HIV are prevalent.
This shift toward a more punitive and less rehabilitative approach to public safety not only led to large-scale imprisonment but also disproportionately affected racial and ethnic minorities and people living in poverty. The United States currently incarcerates a greater proportion of its black population than did South Africa during the Apartheid era. States with the highest rates of incarceration are found in the Southern region of the United States.
At the same time that incarceration rates were increasing in the United States, so too was the incidence of HIV infection. Initially confined to populations of men who have sex with men in large cities on the East and West coasts, HIV infection quickly entered into and spread among networks of injecting drug users and those using crack cocaine. Consequently, the policies that were established to arrest and imprison those involved in the use and trafficking of illicit substances inadvertently targeted for incarceration those with an elevated risk of HIV and viral hepatitis infections, including substance users, many of whom suffer from mental illness.
At present, the national prevalence of HIV infection in state and federal prisons is estimated at 1.5%—approximately 5-fold greater than the rate in the general US population—but rates vary greatly by state. In a study performed by our group at the University of North Carolina (UNC) at Chapel Hill, excess blood specimens that remained after routine medical screening of over 23,000 adult men and women entering the North Carolina prison system in 2008–2009 were anonymously tested for HIV antibodies. Overall, 1.45% of inmates entering the prison system during this period tested HIV seropositive; this rate is many times greater than the state's HIV prevalence rate but on par with the average for prisons nationally.
The flip side of the concentration of HIV infection in our nation's correctional facilities is the high prevalence of imprisonment among persons living with HIV. According to one study, an estimated 14% of all persons living with HIV infection in the United States, and 20% of African American HIV-infected individuals, pass through a jail or prison each year (as do one-third of all those identified with chronic hepatitis C virus infection).
Prisons and HIV
It is estimated that 3.8% of the global prison population is living with HIV. This rate of HIV among prisoners is 5 to 7 times that of the general population. HIV rates are highest among black prisoners.The correctional setting is often the first place incarcerated men and women are diagnosed with HIV and provided treatment. Inmates in jails and prisons across the United States, generally, do not receive health care that meets public health standards. In some facilities, prisoners with HIV have no confidentiality or privacy regarding their HIV status. They may be segregated and housed separately from other inmates, and may be blocked from some recreational activities and work assignments.
For many inmates, the behaviors and circumstances that contributed to their HIV infection are those that led to their incarceration (e.g., drug use, sex work, domestic abuse, mental illness, poverty). For others, infection with HIV occurred during incarceration via sex or sharing needles. Response to the critical need for health care interventions and prevention efforts in correctional facilities have a direct impact on the health of the communities to which prisoners return.
All graphics by Jaclyn Saik