In the Big House
Major media coverage of the Centers for Disease Control and Prevention's National HIV Prevention Conference last August put the spotlight again on the grim reality of HIV in American prisons. The latest Bureau of Justice statistics reveal that nearly 7 million people are incarcerated in the United States. The HIV rate in prisons and jails is eight to 10 times greater than in the outside population: AIDS accounts for almost one-third of all prison deaths. In 1997 it was estimated that 19 percent of people with HIV in the United States have spent some time in prison.

African-American women, incarcerated faster than any other group, also have the highest HIV infection rate among women, both in and out of prison. Women make up a greater percentage of the HIV-positive prison population than men do, an overlooked issue. Yet prisons continue to be built at an alarming rate, although not fast enough to alleviate the miserable conditions of prison overcrowding. In California all federal prisons operate at more than 200 percent capacity.

Most alarmingly, comprehensive HIV/AIDS prevention and education programs exist in only 10 percent of state and federal prisons and 5 percent of jails. Nineteen years into the epidemic and still only two state prison systems -- in Vermont and Mississippi -- and four jails -- in New York City, San Francisco, Philadelphia, and Washington, D.C.-provide condoms. As a rule, prisons forbid sexual activity, and no additional systems have made condoms available since the early '90s. Latex dental dams, meanwhile, are not available to women. Bleach, used to disinfect syringes, is strictly forbidden in a majority of prisons, and prisoners who use it are severely punished. Those caught with even clean syringes often face criminal charges in the courts.

HIV is not the only epidemic: hepatitis C has replaced HIV as the fastest spreading disease behind the walls. The latest statistics show that nearly one-third of all people infected with hepatitis C in this country have passed through the correctional system. National estimates of hepatitis C in prison are 17 to 19 percent, but surveys of individual systems show up to 40 percent infection rates. Yet little is being done to treat or to educate prisoners about Hepatitis C.

When it comes to HIV treatment, the picture is equally bleak. Most prison systems say that they make triple-combination therapy available to prisoners with HIV. But a national survey of jails and prisons conducted by Ted Hammett, Ph.D., of Abt Associates Inc., a Cambridge-based research firm, shows that a combination of factors, including high medication costs, denial and fear of HIV by inmates, mistrust, uneven clinical competence, and lack of uniform treatment standards may limit the availability of appropriate HIV treatment regimens. Across the country, prisons take various approaches to address the HIV crisis within their walls. In the following pages, we've looked at a model program, the pros and cons of segregation, the trend toward privatization of prison health care, and the state of HIV prison activism. We've also profiled four advocates on the inside and outside who are role models pushing for better care and support for the thousands of people with HIV who remain behind bars.

-The EDITORS

Photograph by Andrew Lichtenstein/Sygma