Basic Healthcare Eludes HIV+ Prisoners

By Karin McKie
Contributor

When HIV-positive prisoner Albert Knox was led out of his Alabama prison cell last year, "the guards would always say 'dead man walking' loud enough for the other prisoners to hear."

At the time, Knox was living in one of the two remaining states that still segregated HIV-infected inmates from the general prison population. After officials found out he had eaten lunch in the regular commissary, they put him in solitary confinement and locked down the whole facility. "They were trying to find my particular spoon and plate," Knox wrote. "I'm not sure why, since you can't transmit HIV this way. It wasn't right to be punished just because we have a disease."

As if this weren't enough, in an act reminiscent of the yellow Star of David Jews wore in Nazi-controlled Europe, Alabama's Department of Corrections forced Knox and 260 other HIV-positive prisoners to wear white armbands at all times. By publically identifying their status, these men were forced into involuntary disclosure. That only reinforced their pariah status.

The Alabama Department of Corrections represents only the most extreme example of how little progress has been made in the treatment of HIV-positive inmates.

Despite all the niceties about rehabilitation and debt to society prisons remain shrouded in secrecy, fortressed warehouses for people whose lives are of little concern beyond family members and a handful of advocacy organizations like the Fortune Society. The United States leads the world in the number of people behind bars, and where 1 in 100 people is incarcerated.

Prisoners with HIV should be of concern to all of us because simple human decency demands it. There's a practical reason as well: Most infected prisoners will eventually be discharged back into the public.

More than 2 million Americans are in prison and an estimated 1 in 7 of those living with HIV will pass through a correctional facility. Contrary to the image projected by popular entertainment, Dr. David Alain Wohl of the Division of Infectious Diseases at the University of North Carolina at Chapel Hill told EDGE that "very few people contract HIV in prison. This debunks the TV-spun notion of incarceration being a breeding ground for HIV."

A Forgotten Population

Even so, prisoners are nearly two-and-a-half times more likely to have HIV than the general population. The vast majority of these prisoners are members of America's permanent underclass who became infected from injecting drugs or unprotected intercourse. Ironically, many of them only become aware of their serostatus in prison, which at least provides them with an HIV test.

It's also the first time they have had to consistent health care, according to "HIV Care in Correctional Settings," a report from the federal Health Resources and Services Administration's HIV/AIDS Bureau (HAB). "The correctional facility is an ideal location for identifying infected individuals," according to the HAB report. "This setting is a rare potential point of contact with the health care system, making it an important avenue for HIV testing and linkage to care."

The Eighth Amendment to the U.S. Constitution's famous "cruel and unusual punishment" clause and the Americans with Disabilities Act are supposed to mandate detection and proper treatment. Both, however, are obeyed mostly in the breach when it comes to prisoners. Thanks to severely limited funding, only about half of the prisons in the United States even provide HIV tests, let alone adequate healthcare.

Only this year did the State of Alabama finally end its 25-year fight with the ACLU and stop segregating HIV-positive prisoners. After Alabama changed its policy, South Carolina became the last state to abolish HIV-positive segregation in its prison system.

Alabama "publically stigmatized them," complained the ACLU's Margaret Winter, which effectively excluded them "from a host of rehabilitative services, jobs and vocational training opportunities, plus mental health, substance abuse and educational programs."

Tools to Keep Healthy on the Outside

If fellow prisoners remain ignorant about HIV transmission, their guards usually aren't much better informed. "We were considered contagious not only by inmates, but by staff too," Dana Harvey, another Alabama prisoner, told USA Today. Harvey was one of the 1.7 percent of women prisoners in the United States with HIV - a higher percentage than their male counterparts (1.4 percent).

The HAB reports a perfect storm in many of their lives that made HIV infection all but inevitable. Many of them were abused or neglected as children. They may be suffering from mental illness. With little education, little chance of finding a job and, having never been given the most basic life lessons, having even more difficulty keeping one, it's hardly surprising that many turn to prostitution, where they continually confront tricks who refuse to use a condom. Even the ones not in "the life" may well have had husbands or boyfriends along the way who were junkies.

Kimberly Collica-Cox, a professor of criminal justice at Berkeley College in Woodland Park, N.J., has worked with female prisoners at Sing Sing and Taconic Correctional Facility, both in New York State. At Taconic, a woman-only prison, inmates were highly appreciative of Collica-Cox's efforts to educate them about living with HIV, avoiding other sexually transmitted diseases; as well as showing those who were not infected how to remain that way once they faced the pressures of life outside.

"These programs weren't just about education; they were about redirection," Collica-Cox told EDGE. "Disciplinary infractions went down as self-esteem and confidence went way up." Many of the women in their turn became peer educators and continued their work at HIV organizations when they returned to their communities.

Short-term prisoners present a different set of obstacles and goals. Because of their short sentences, they have to get a quick course in how to navigate the health system as well as basic information about what HIV infection means and what to do about it.

Michelle Milberger, a prison medical case manager at the Philadelphia Linkage Program, that counsels these inmates shortly before release and sets up meetings with its counselors weekly afterward. Considering what they face on the outside - navigating the public health system; addiction; homelessness; mental health issues; meetings with probation, parole officers and social workers; dealing with family matters - it's a lot to learn in a monthly meeting.

As important as such programs are, helping HV-positive inmates while they're in lock-up and after they are released feel comfortable using condoms or syringes - and ensuring that they have access to them - is just as, if not more, important. "Providing condoms and clean syringes to sexually active persons is an integral part of HIV prevention outside prisons," according to the CDC. "But most US prisons and jails specifically prohibit the distribution and possession of these items."

The biggest outrage concerning prisoners and HIV is that everyone knows prisoners have sex, but giving prisoners condoms would be acknowledging it. Like drugs, sex is officially forbidden for the incarcerated.

When it comes to sex, the popular image of prison as a place of sexual conquest and submission might be melodramatic, but it's a lot more honest than the official version. Denying the reality only perpetuates the conditions for HIV infection.

Condoms & Syringes: Necessities, Not Indulgences

Prisoner-rights groups like the Canadian HIV/AIDS Legal Network work to remedy the situation. Its co-director of research and advocacy, Sandra Ka Hon Chu, believes that prisons need "to promote the human rights of prisoners to have access to HIV prevention, treatment, care and support services equivalent to those available in the community." That includes access to drugs like methadone that wean addicts off their junk and harm-reduction education. "Prison health is public health," Chu told a recent Toronto conference.

The United Nations has also taken up the cause. Its Office on Drugs and Crime's 2010 HIV in Prisons: Situation and Needs Assessment Toolkit provides a blueprint for governments to implement long-needed programs to prevent and treat HIV infection. In the United States, however, it appears to be business as usual, if the expected fate of Calif. U.S. Rep. Maxine Waters' "Stop AIDS in Prison Act" is any indication.

Reintroduced earlier this year, the proposed comprehensive HIV testing and counseling initiative has a slim-to-none chance of getting out of committee, and less than that even it ever managed to reach the floor of the GOP-controlled House.

Fiscal hawks might blanch at the extra funding needed for widespread HIV testing, but HAB noted that routine, voluntary HIV testing has been shown in fact to be cost-effective and clinically advantageous. Not only that, it would help prevent prisoner-to-prisoner infection.

Desegregating poz prisoners gives them a chance to work which means money for them - and the prison system. "I would have loved to be able to work as a cook so I could have saved some money to help me land on my feet when I got out of prison," said Knox. "Instead, I couldn't make any money. The prison loses out too, since they get part of the pay when prisoners are allowed to work."

Prisoners are literally not only a captive audience; they're hungry to learn. Yet despite the success of HIV education programs, Collica-Cox noted that too many prison systems still refuse to implement them. As a consequence, incarcerated infection rates remain alarming.

Many prisoners are ready, willing and able to be trained as peer counselors. Training them to help others like themselves gives them "high levels of self-esteem and strengthened social bonds," said Collica-Cox. "Teaching about transmission increased levels of institutional and post-release success, and served as a life transition that altered the criminal trajectory."

In Anna Isabella Thackery Ritchie's words, "If you give a man a fish, he is hungry again in an hour. If you teach him to catch a fish, you do him a good turn." Give people a condom or clean syringe, they will soon need another. But if you teach them how to prevent the spread of HIV, you do them a good turn.

This story is part of our special report: "HIV Minority Report". Want to read more? Here's the full list.