Separate but equal?
Weighing the pros and cons of quarantine
By Emily Bass

While Shaw had the good fortune to be white, educated, and represented by a private attorney, he was still convicted of his crime in Mississippi, one of 16 states that require mandatory HIV testing for all incoming prisoners, and one of two states (Alabama is the other) that segregate all HIV-positive prisoners in a single facility separate from the general population. Arch-conservative pundit William F. Buckley Jr. first proposed this all-out quarantine model during the rampant AIDS hysteria of the early 1980s, justifying it on the grounds that segregation would reduce the rate of seroconversion (see box). The number of such programs has fallen dramatically since 1985, when 16 percent of all state and federal correctional facilities segregated prisoners with HIV, and 75 percent segregated those with AIDS. Today those figures are 4 percent and 6 percent, respectively.

Although the programs in Mississippi and Alabama may seem like relics from a different era, segregation also has a new face that's very '90s. Around the country, segregated programs like Vacaville in California and the Stiles facility in Beaumont, Texas, are being applauded for providing state-of-the-art care to prisoners at their special HIV units. Prison officials at these programs, which have also cropped up in Florida and South Carolina, offer a kinder, gentler, for-your-own-good rationale for separating HIV-positive prisoners. The idea is that grouping HIV-positive prisoners into a single facility isn't just the best way to treat them well-it's the only way. And while segregation has never looked so friendly, not everyone is smiling. Take a look below the surface, and it's clear that separate-but-equal still leaves much to be desired.

When Robert Shaw wrote to his mother in the summer of 1998, he had landed in Unit 28 at Mississippi State Prison in Parchman, a remote, sun-scorched delta town. Shaw joined roughly 220 other men who had tested positive for HIV at the start of their sentences. Life at Parchman was a rude awakening for treatment-savvy Shaw. He soon learned that it didn't matter what medications he was on before he was incarcerated. Every prisoner at Parchman had to earn the right to be placed on protease inhibitors by first adhering to a six-month course of two-drug nonprotease-inhibitor therapy-a near-guaranteed recipe for resistant virus, since dual-therapy combos allow the virus to go on copying itself, coming up with new genetic variants that may not respond to treatment.

At Parchman, Shaw met patients like Robert Hannah, who waited six months before receiving antivirals. This type of medical neglect is the standard of care at Parchman, say patients. Prisoners must submit written requests for medical care to a nurse who reviews them and decides whether they should be passed on to staff doctors. In most cases, there is no face-to-face contact with the medical staff. When one of Shaw's fellow prisoners complained of shortness of breath (a possible symptom of tuberculosis or pneumonia) and chest pain, he was not seen by a doctor and did not receive a chest X-ray. Instead, he was offered ibuprofen and Maalox.

Abysmal medical care is only one of the problems facing HIV-positive prisoners in Mississippi. The men do not have access to any of the work-release or continuing education programs available to their counterparts in the general population. The same goes for the men and women in the facilities at Limestone and Tutweiler in Alabama. They cannot hold jobs to earn money to buy snacks and hygiene items at the canteen, much less reduce their sentences by participating in ball-busting boot-camp style programs available to many first-time offenders. "These are all the kinds of things that mean the difference between life and being warehoused," says Margaret Winter, associate director of the ACLU's National Prison Project and lead counsel in the case of Davis v. Hopper, a long-running suit against the Alabama corrections systems that may reach the Supreme Court this year.

Today the ACLU is locked in a battle to become court-appointed counsel for a class action suit against Mississippi corrections. A court-ordered review of medical records by Robert Cohen, M.D., an attending physician at St. Vincents AIDS Center in New York, concluded, "The medical treatment is appalling. In every aspect, these men are denied minimal medical care, and they are forced to endure tremendous pain and suffering as a result." It's a fight for timely, adequate health care that could mean life or death to many if not all of the prisoners. "My son did something that put him there," says Carla Shaw, in the strained voice of someone who has learned to speak reasonably about the unthinkable. "He wasn't sentenced to death. The way it's going, that's what this is."

Miles away at the Stiles Unit in Beaumont, Texas, HIV-positive prisoners are segregated for a different reason-to better manage their disease. "The goal is to make Stiles a center of excellence," explains Mike Kelley, M.D., director of preventive medicine at the Texas Department of Criminal Justice Health Services Division. It's a lofty goal shared by Joseph Bick, M.D., whose HIV unit at Vacaville in California is touted as one of the best in the country.

Neither California nor Texas has mandatory testing and neither seeks to funnel all the HIV-positive prisoners into a single facility. Instead, prisoners are housed throughout the system until their T-cells fall below 500 or they develop HIV-related symptoms that require special treatment. Then, according to need, they are transferred to one of these cutting-edge clinics. Unlike many state prison systems, California and Texas have clearly formulated standards of care for HIV treatment that adhere closely to the U.S. Public Health Services guidelines. In Texas, prisoners have access to almost the entire formulary of anti-HIV meds, as well as the rare opportunity to participate in clinical trials. The Texas program model also calls for nutritional and adherence counseling, and includes a hospice for those dying of AIDS.

For some prisoners, this set-up seems to work. Michael Garza recently served the last six months of a five-year prison term at Stiles. When he arrived, he was put on d4T, 3TC, and Viracept, given antidiarrheal meds (to help manage one of Viracept's most common side effects), and had a note placed in his records indicating that he needed additional snacks to help boost his caloric intake and make it easier to take the meds. "I had viral load and CD4 T-cell tests done every two to three months," says Garza, who was released in August with a ten-day supply of medication. "They were doing a good job."

Other reports from the Stiles Unit are less positive. Prisoners complain of not receiving meds during lockdown, long waits, and arduous bus-and-ferry treks to see doctors at the University of Texas Medical Branch (UTMB) in Galveston, a top-notch facility that provides medical care to prisoners throughout eastern Texas. Some say that medical orders don't always make it back to the clinic and that cost-cutting combos are prescribed at the expense of prisoners' health. "One of my prisoners wrote me saying that his care amounted to 'random acts of kindness,'" says Margaret Bee, project director for a prison outreach program at BEAT AIDS in San Antonio.

And advocates have another problem with the Stiles model: In the prison world, one "center of excellence" cannot make up for hundreds of prisons with substandard medical care. In California, Texas, and other states, many prisoners are also bound to be to be left out in the cold, either because they don't end up at one of the special units or because these units are simply too overloaded when they get there. "Probably our biggest problem is the number of HIV-positive people in the state," says Mike Kelley. "They might all fit at Stiles, but you couldn't run a prison with that many sick people." Texas has recently started transferring HIV-positive prisoners to other facilities that, like the Stiles Unit in Beaumont, are within a few hours of UTMB.

With HIV-positive prisoners spreading out, a natural question arises: Why not improve health care everywhere? "Every single physician out there should have an excellent continuing medical education in TB, HIV, and hepatitis," says Michael Haggerty, a public health expert and former executive director of the Correctional HIV Consortium. "There's absolutely no reason why a prison doctor in rural Wisconsin shouldn't be able to do what a prison doc from Aaron Diamond AIDS Research Center [David Ho's cutting-edge New York research facility] could do." Texas' Kelley agrees but says it's also impossible. "You can't provide uniformity of care and expertise throughout the state, especially since so many units are located in rural areas."

Experts also warn that a quarantine model sidesteps the need for educating prisoners about HIV, and the controversial issue of providing them with condoms, bleach, and water, that can stop transmission, and that it may actually pave the way for even more infections. Since the widely used HIV tests only detect antibodies after a person has been infected for six months, it's virtually impossible to determine for certain whether or not a newly infected prisoner is positive at the start of his or her sentence. So prisoners in the general population may breath a sigh of relief and continue risky activities with a false sense of security.

Despite these caveats, calls for segregation are becoming more popular among public officials. This time, they bolster their arguments with the fact that early treatment saves lives. As the debate wears on, prison advocates, corrections departments, and state legislatures will continue to grapple with the thorny issues of mandatory testing and confidentiality raised by any model that seeks to identify and segregate HIV-positive prisoners.

In the meantime, Margaret Winter of the ACLU emphasizes that legal action is "necessary but not sufficient" for taking segregated programs to task. "We can work our hearts out litigating and literally not have the time to do the large-scale [community] organizing we need to do," she says, pointing out that public outcry is crucial, whether it comes from the press, families, or community groups. "Just to have somebody watching makes a huge difference. They get away with it because they can."

Photographs by Andrew Lichtenstein/Sygma