Epidemiologic Notes and Reports Acquired Immunodeficiency Syndrome in Correctional Facilities: A Report of the National Institute of Justice and the American Correctional Association

Recently, the National Institute of Justice (NIJ) of the U.S. Department of Justice, and the American Correctional Association (ACA) jointly sponsored the development of a report on the incidence of acquired immunodeficiency syndrome (AIDS) in correctional facilities, the issues and options facing correctional administrators in formulating policy responses to the problem, and the rationales advanced for various policy choices (1). The report was based, in part, on a questionnaire mailed to all 50 state correctional departments, the Federal Bureau of Prisons, and 37 large city and county jail systems. Following are key findings of the report.

1. Responses were received from mid-November 1985 through early January 1986 from all 50 of the state correctional departments, the Federal Bureau of Prisons, and 33 of the 37 large city and county jail systems that had been asked to participate. A cumulative total of 766 AIDS cases meeting the CDC surveillance definition were recognized among inmates in these responding correctional systems; 24 state prison systems and the Federal Bureau of Prisons reported 455 cases, and 20 large city and county jail systems reported 311 cases.* Of the 766 AIDS patients, 322 (42%) died while in the custody of the correctional systems; 265 (35%) were released from custody; and 179 (23%) remained in custody. The remaining 26 (52%) state systems and 13 (39%) local systems responding to the questionnaire had no reported cases. Among state and federal systems, 80% of the systems accounted for only 5% of the total AIDS cases, while 4% of the systems contributed 72% of the cases. Among responding city and county systems, 69% accounted for only 5% of the total AIDS cases, while 6% accounted for 77% of the cases (Table 4).

2. Respondents reported eight AIDS cases among current or former correctional staff. Seven of the eight had known risk factors for AIDS; investigation of the eighth case is not complete. None of these staff members reported involvement in an incident with an inmate in which transmission of human T-lymphotropic virus type III/lymphadenopathy associated virus (HTLV-III/LAV), the AIDS virus, might have occurred.

3. The geographic distribution of total AIDS cases among inmates is highly skewed. Over 70% of total AIDS cases in state prison systems and city and county jail systems has occurred in the mid-Atlantic region, with all of the other regions of the United States contributing much smaller percentages (Table 5).

4. In jurisdictions with large numbers of AIDS cases among inmates, the majority appears to have occurred among persons with histories of intravenous (IV) drug abuse. For example, 95% of cases in the New York state correctional system had such a history (2).

5. Responding correctional systems agreed on the importance of providing education on AIDS to staff and inmates. Ninety-three percent currently provide or are developing AIDS training or educational materials for staff; 83% currently provide or are developing such programs or materials for inmates. Responding jurisdictions in which educational programs had been in effect long enough to offer assessments of their impact reported that such programs have been effective in reducing the fears of staff (85% of jurisdictions) and inmates (79%). Timely and effective education efforts have prevented threatened job actions by correctional staff unions and generally forestalled hysteria over AIDS within the institutions of several correctional systems.

6. Six state prison systems and seven of the responding city or county jail systems are now screening or are planning to screen all inmates, all new inmates, or all inmates belonging to at least one high-risk group for antibody to HTLV-III/LAV (Table 6). Most of the other responding jurisdictions use the test on a more limited basis. This includes testing in support of diagnoses of AIDS or AIDS-related complex (ARC); testing in response to incidents in which HTLV-III/LAV might have been transmitted; testing on inmate request; and testing for epidemiologic studies of the prevalence of seropositivity and/or seroconversion within correctional facilities (Table 6).

7. The majority of responding jurisdictions (67% of state/federal systems and 70% of the city/county systems) either has in place or has in the developmental stage policies and procedures for the correctional management of inmates with AIDS, ARC, and asymptomatic HTLV-III/LAV infection. While housing policies for these inmate categories vary considerably across jurisdictions (Table 7), the four systems with almost 75% of the AIDS cases (New York state, New York City, New Jersey, and Florida) follow the same combination of policies: (1) medical segregation of all inmates with confirmed AIDS, but no segregation of inmates with ARC or asymptomatic HTLV-III/LAV infection;(2) clinical evaluation and ongoing monitoring (without testing for HTLV-III/LAV antibody) of inmates in risk groups; and (3) intensive and continuous education programs on AIDS for both staff and inmates. None of these four systems screen inmates for antibody to HTLV-III/LAV.

Reported by TM Hammett, PhD, Abt Associates, Inc, Cambridge, Massachusetts; National Institute of Justice, US Dept of Justice, Washington, DC; American Correctional Association, College Park, Maryland; AIDS Program, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note:The NIJ/ACA report illustrates both the scope of the AIDS problem in correctional facilities and the diversity of the responses such facilities are taking.

The apparent lack of reported AIDS cases among correctional staff as a result of contact with inmates is consistent with previous findings that the risk of HTLV-III/LAV transmission in occupational settings is extremely low and does not appear to result from casual contact. Correctional staff should follow published guidelines for preventing transmission of HTLV-III/LAV infection in the workplace (3).

Since IV drug abuse is an important predisposing factor to both incarceration and HTLV-III/LAV infection, it is not surprising to find AIDS cases in inmate populations. It is also not surprising that a high proportion of cases among inmates has been reported from correctional facilities in New York and New Jersey, since those two states have reported 62% of all U.S. AIDS cases associated with histories of IV drug abuse. In addition, the proportion of IV drug abusers with HTLV-III/LAV antibody is reported to be higher in New York City and northern New Jersey than in other parts of the country (4).

Incarceration is not, in itself, associated with a risk of HTLV-III/LAV transmission. The risk of transmission in inmate populations depends on the prevalence of infection among persons who have been incarcerated and the frequency with which such persons might participate in IV drug abuse, with sharing of needles, or in sexual contact with other inmates. However, data to quantify this risk have been quite limited.

Thus far, the only study of HTLV-III/LAV transmission among inmates was conducted by the Maryland Division of Corrections (5). In that study, conducted from April through July 1985, serologic testing for HTLV-III/LAV antibody was offered at one facility to all 360 inmates who had been incarcerated 7 years or longer. Of the 137 inmates who participated, two (1%), both of whom had been incarcerated for 9 years, were seropositive by both enzyme immunoassay and Western blot methods. Because testing was done in a way to preserve anonymity, additional information about the seropositive inmates was not available. The possible effects of selection bias in this study are also unknown.

Additional data are available from correctional facilities on the incidence of infection with hepatitis B virus (HBV), which has routes of transmission generally similar to those of HTLV-III/LAV. In two recent studies of inmates incarcerated for 1 year, annual seroconversion rates to HBV ranged from 0.8% to 1.3% (6,7).

It is clear from the NIJ/ACA report that many correctional systems have given high priority to AIDS education programs and that such programs are the basis for AIDS-prevention activities in these systems. At present, most correctional systems are performing serologic tests for HTLV-III/LAV antibody on a limited basis. More extensive use of the tests, such as testing all inmates, all new inmates, or all inmates known to belong to risk groups, would undoubtedly identify additional seropositive persons, who might then

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