HIV Prevention and Education in State Prison Systems

Abstract

The prevalence rate of HIV infection in jails and prisons is approximately 5 times the rate in the U. S. general population. The authors surveyed state prison officials to assess HIV testing and HIV prevention policies—specifically voluntary testing, group HIV prevention counseling, and peer education—in the 50 states and to determine whether those policies are associated with the characteristics of the state and its prison population.

Keywords

HIV/AIDS HIV prevention HIV testing peer education prisons

Introduction

The prevalence rate of HIV infection in jails and prisons in the United States has declined recently but is still approximately 5 times the rate in the general population (Maruschak, 2012). Elevated HIV prevalence in jails and prisons is likely due mainly to preincarceration behavior rather than sexual or drug-related transmission within the institution (Hammett, 2006). The same factors that place individuals at risk for incarceration, especially substance use, also place them at risk for HIV infection (Harawa & Adimora, 2008). Cycles of repeated incarceration further raise the high underlying HIV risk in this population by dissolving stable sexual relationships (Adimora & Schoenbach, 2005) and increasing casual sexual relationships on release (Abiona, Adefuye, Balogun, & Sloan, 2009). Elevated rates of incarceration may in turn drive elevated community HIV and sexually transmitted infection (STI) rates among African Americans (Iguchi, Bell, Ramchand, & Fain, 2005; Johnson & Raphael, 2006). While the share of the population living with HIV/AIDS that passes through U.S. correctional facilities each year has recently declined, an estimated 150,000 individuals living with the virus are incarcerated every year (Spaulding et al., 2009). For these reasons, jails and prisons are critically important sites for HIV prevention efforts.

This article reviews the literature on promising HIV prevention programs in prison and reports on results of a survey among state prison officials of the HIV prevention policies in their state prison systems. Evidence-based HIV risk reduction programs in prisons and jails with community follow-up range from a brief DVD-based intervention (Inciardi et al., 2007) to one-on-one risk counseling (Project START; Grinstead et al., 2008; Wolitski, 2006). Other programs focus on certain subpopulations such as adolescent males leaving jail (REAL Men; Freudenberg et al., 2010) and injection drug users (Project ARRIVE; Barreras & Drucker, 2009; Wexler, Magura, Beardsley, & Josepher, 1994). Peer education involves training group members to effect change in knowledge, attitudes, beliefs, and behaviors among members of the same group. As a behavior-change strategy, peer education is based on both individual cognitive and group empowerment and collective action theories (Freire, 2000; Population Council, 2000). Peer education may also generate demands for other services such as STIs management and HIV counseling and testing. Peer education is regarded by some as an inexpensive intervention strategy because it often relies on volunteers. Yet the costs of implementing high-quality peer education can be high due to the need to train, supervise, and equip peer educators with resource material (Population Council, 2000). Ideally, the training of peer educators, as well as their support and supervision, should be ongoing and include initial and ongoing evaluation of competencies. In addition, the peer educators themselves should be involved in the design or adaptation of the training curriculum and support materials to ensure the relevance of the training and ownership of the program.

Peer-led HIV prevention programs in prisons have typically included (1) basic information about HIV and transmission, such as the American Red Cross curriculum; (2) information on HIV testing, such as in California’s “Reach One, Teach One” curriculum; and (3) information on preventing HIV through safe sex and (in some cases) safe injection drug use practices. Peer-led prevention programs will be most effective if they are targeted at behaviors in the community, where most inmates with HIV are infected, rather than at behaviors in prison (Hammett, 2006). Research has shown that peer-based HIV education programs that link returning prisoners to follow-up services in the community can reduce HIV risk behavior; two such programs are Project START (Grinstead et al., 2008) and Project Bridge (Zaller et al., 2008).

Models such as the Self-Help in Eliminating Life-Threatening Diseases (SHIELD) (Latkin, Sherman, & Knowlton, 2003), the Risk Avoidance Project (Weeks et al., 2009), and the ongoing Indigenous Peer Leader model in Chicago (Wiebel, 1993) have been designed for out-of-treatment drug users in the community. Participants are trained to be peer educators and are taught strategies to reduce HIV risk, as well as communication skills to convey these strategies to their social networks. Ultimately, peer educators are trained to be HIV prevention leaders within their social networks and communities. These models have been shown to reduce both unprotected sex and risky injection drug use behaviors, both among the network members and, significantly, among the peer educators themselves (Latkin et al., 2003; Weeks et al., 2009). It is as yet unknown whether training in peer outreach can be adapted for jails or prisons. In these settings, peer educators cannot immediately practice their skills with active drug users in their networks. On the other hand, they may be at a reflective and/or vulnerable moment where they are more likely to agree to commit to a peer educator role than if they were in the community.

Inmate peer educators can create a natural environment of trust and respect for the health education topic in question. However, peers may not always be the most influential people to promote behavior change on certain topics. Perceived credibility of peers must be considered when designing programs (Population Council, 2000) as well as status and power within the informal inmate hierarchy of the peers who volunteer or are selected. A survey of inmates and probationers/parolees revealed a high basic level of HIV knowledge (Belenko, Shedlin, & Chaple, 2005). The survey did not test skills such as condom use and safe injection practices. Many prisoners surveyed endorsed statements such as that the government’s HIV information cannot be trusted and that HIV is a man-made disease. In the absence of trust in the sources of information, education and skills training may be insufficient to change behavior. This suggests that peer-led education may be more effective than provider-led education (Collica, 2007). State correctional systems differ, both state to state and regionally, in their HIV prevention policies. The HIV epidemic also differs regionally, with Northeastern states continuing to have the highest prevalence rates although new cases have been increasing in the South (Reif, Whetten, & Wilson, 2011). We sought to understand how these regional differences as well as other state prison system characteristics may impact HIV prevention programs in prison through a survey of state prison officials.

Method

A questionnaire was developed that sought information about the state prison system’s annual budget, number of employees, inmate demographic information, methods adopted for harm reduction such as condom distribution, HIV testing, HIV and health education, peer-led education, and other HIV/AIDS prevention strategies. Three members of the Illinois Correctional Taskforce, a volunteer group of clinical and public health professionals and correctional administrators, reviewed the survey instrument for content validity and appropriateness and offered suggestions for revision.

Contact information for each state correctional system was obtained from its website, and questionnaires were mailed to the office of the director of departments of corrections in all 50 states. In general, the director’s office forwarded the questionnaire to the medical director or director of programs to be completed and returned by mail. Forty-three states completed the questionnaire. The states that did not complete the survey were Florida, Illinois, Maine, New Mexico, North Dakota, West Virginia, and Wyoming, comprising 8.8% of the prison population. Data were augmented by a 2010 report on HIV in prisons (Maruschak, 2012).

Data Analysis

Summary statistics were calculated for characteristics of the 43 state systems that responded to our survey. For data analysis purposes, the states were divided into four regions—Northeast, Midwest, South, and West—consistent with the Bureau of Justice Statistics classification, and summary statistics for the states within each region were calculated. Bivariate statistics were used to test for significant differences between the Northeastern states and other regions. We then used bivariate and multivariate statistics to model relationships between state prison system characteristics, including HIV prevalence, and provision of prevention services. Since size of state prison systems, HIV prevalence rates, correctional budgets, and inmates per correctional staff member are not normally distributed, we transformed these variables with a natural logarithm transformation for multivariate analysis.

Results

General characteristics of the 43 state prison systems responding to our survey, as well as their HIV testing and education policies, are presented in Table 1. Regional differences are presented in Table 2. Significant regional differences were seen in provision of voluntary testing and group-level HIV prevention counseling, with Northeastern states more likely to provide these services. According to data from the Maruschak (2012) report, HIV prevalence rates in state prisons in 2007 were highest in the New York, Louisiana, and Maryland. Although many factors can account for the differing rates of prison HIV prevalence across the states, injection drug use is more likely to be a factor in the high prison HIV prevalence in Maryland and New York than in Southern states (Reif et al., 2011).

Table 1.

General Characteristics and HIV Testing and Education Policies of 43 State Prison Systems.

State	HIV Rate per Hundred Inmates^a	Individual Counseling	Group Counseling	Peer Education	Support Groups for HIV+ Inmates	Voluntary HIV Testing	Inmates per Employee	Expenditures per Inmate
Northeast
Connecticut	1.7	Yes	Yes	No	Yes	Yes	2.7	42,500
Delaware	1.1	Yes	Yes	Yes	Yes	Yes	2.5	7,100
Maryland	3.2	Yes	Yes	No	No	Yes	3.8	37,300
Massachusetts	1.8	Yes	Yes	Yes	No	Yes	2.3	46,900
New Hampshire	0.5	Yes	No	No	Yes	No	2.8	38,700
New Jersey	1.9	Yes	Yes	No	No	Yes	2.8	38,500
New York	5.5	Yes	Yes	Yes	Yes	Yes	2.0	50,200
Pennsylvania	1.5	Yes	Yes	Yes	Yes	Yes	3.2	32,000
Rhode Island	1.5	Yes	Yes	No	Yes	No	2.6	53,500
Vermont	0.2	Yes	Yes	No	No	Yes	2.1	60,600
South
Alabama	1.0	Yes	Yes	Yes	No	No	2.6	22,300
Georgia	1.9	Yes	Yes	No	Yes	Yes	3.7	17,100
Kentucky	0.7	Yes	No	No	Yes	No	3.4	28,500
Louisiana	3.5	Yes	Yes	Yes	Yes	Yes	2.6	14,700
Mississippi	2.3	Yes	Yes	No	No	No	7.5	15,300
North Carolina	1.8	Yes	No	No	No	No	2.1	24,200
South Carolina	1.8	Yes	Yes	Yes	Yes	No	4.3	13,900
Tennessee	1.5	Yes	No	No	No	No	3.8	35,800
Texas	1.7	Yes	Yes	Yes	Yes	No	5.2	18,900
Virginia	1.0	Yes	Yes	No		Yes	2.5	30,300
Midwest
Arkansas	0.9	Yes	Yes	No	Yes	No	3.6	18,500
Indiana	0.0	Yes	No	No	Yes	No	4.1	1,300
Iowa	0.4	Yes	Yes	Yes	No	No	2.8	42,000
Kansas	0.4	Yes	Yes	Yes	Yes	Yes	2.8	29,000
Michigan	0.5	Yes	Yes	No	Yes	No	3.0	42,200
Minnesota	0.5	Yes	No	Yes	No	Yes	2.2	51,200
Missouri	0.9	Yes	Yes	Yes	Yes	No	7.1	13,600
Nebraska	0.4	Yes	Yes	No	Yes	No	1.9	38,500
Ohio	0.8	No	No	No	No	No	3.8	35,300
Oklahoma	0.9	Yes	Yes	Yes	No	No	5.3	19,900
South Dakota	0.3	Yes	No	No	No	Yes	5.2	14,600
Wisconsin	0.6	Yes	No	No	No	Yes	2.0	56,700
West
Alaska	N/A	Yes	Yes	No	No	Yes	4.1	45,800
Arizona	0.5	Yes	No	Yes	No	Yes	4.3	24,100
California	0.7	Yes	Yes	Yes	Yes	No	2.5	58,300
Colorado	1.0	Yes	No	No	Yes	No	3.7	32,400
Hawaii	0.5	No	No	No	No	Yes	1.9	20,800
Idaho	0.4	Yes	No	No	No	No	4.6	26,900
Montana	0.4	Yes	No	No	No	No	1.9	58,600
Nevada	1.1	Yes	Yes	No	Yes	No	3.4	24,900
Oregon	0.5	Yes	Yes	Yes	Yes	Yes	2.8	13,100
Utah	0.6	Yes	No	No	Yes	No	2.8	34,000
Washington	0.4	Yes	No	No	No	No	2.1	48,600

^a Source. Maruschak (2009).

Table 2.

Characteristics of State Prison Systems by Region.

Region	HIV Rate per 1,000 Inmates	Expenditures per Inmate^a	Inmates per Employee	Offers Voluntary HIV Testing^a	Offers Peer Education	Offers Group-Level HIV Prevention^a
Northeast (n = 10)	21.6	US$40,774	2.7	80% (n = 8)	40% (n = 4)	90% (n = 9)
South (n = 10)	13.5	US$22,154	3.8	30% (n = 3)	40% (n = 4)	70% (n = 7)
Midwest (n = 12)	6.8	US$30,381	3.6	40% (n = 4)	40% (n = 5)	60% (n = 7)
West (n = 11)	5.3	US$35,279	3.1	40% (n = 4)	30% (n = 3)	40% (n = 4)

^aDifference between Northeast and other regions is significant at p < .05.

Harm Reduction

Only two states, California and Vermont, reported providing condoms to state prisoners. Vermont has provided condoms to prisoners on request since 1987. In California, at the time of the survey, condoms were being dispensed in a pilot program at California State Prison, Solano (Estrella, 2010). It should be noted that the city jails of New York, San Francisco, Los Angeles, Washington, DC, and Philadelphia also permit distribution and that “the American Public Health Association, the United Nations Joint Program on HIV/AIDS and the World Health Organization have all endorsed the effectiveness of condom distribution programs in correctional facilities” (Housingworks.org, 2011). No state reported providing clean syringes or injection drug equipment. Our own research in Illinois prisons found that 3.8% of women and 7.4% of men reported having injected drugs in prison (Abiona et al., 2009).

Voluntary HIV Testing

Voluntary as opposed to mandatory HIV testing is a best practice in community settings (Centers for Disease Control and Prevention, 2009; Levine & Bayer, 1989). Nineteen of the 43 states that responded to our survey stated that all HIV testing was voluntary in their state prison systems. Eighty percent of Northeastern states, versus 33% of other states, provided voluntary testing only (χ² = 6.78, p < .02).

HIV Prevention Counseling

All but two state prison systems stated that they provide HIV prevention counseling to inmates, usually one-on-one counseling in conjunction with testing. States that reported that they did not provide any HIV counseling were Hawaii and Ohio. In addition, all states but Hawaii reported that they provide some form of HIV education. However, only 63% of the states provide group HIV prevention interventions. Northeastern states were again more likely to provide group counseling than other states (90% of states vs. 54%, p < .04).

Peer Education

In our survey, 16 of the 43 state systems (37%) reported that they provide inmate-led education on HIV prevention. Comparing our findings with a survey conducted in 2005 (Collica, 2007), three states that indicated they had peer education in 2005 did not on our more recent survey (Arkansas, New Jersey, and Vermont). Seven states had instituted peer education since the 2005 survey: Arizona, California, Michigan, Minnesota, Missouri, Oregon, and South Carolina. There were no significant regional differences. Peer education was not used as a substitute for professional counseling since, as noted, 41 of the 43 states provided some form of professional counseling. States that provided peer counseling were larger in terms of overall number of inmates (t = 2.24, p < .03) but did not have significantly higher expenditures per inmate or HIV prevalence rates.

Support Groups for HIV Positive Inmates

Approximately half (52%) of state prison systems that responded provide support groups for HIV-infected inmates. A policy of providing these support groups tended to be associated with higher HIV infection rates and numbers of HIV-positive inmates in these states, but the effect was not significant. All 43 states reported that they provide antiretroviral treatment to inmates with HIV/AIDS.

Multivariate Analysis

To further explore the relationship of state characteristics to HIV testing and prevention policies, we constructed logistic regression models, with the dependent variables of voluntary versus mandatory HIV testing, as well as group and peer HIV prevention education. Independent variables included in the models were region (Northeastern vs. other regions), size of state prison systems, HIV prevalence rates, and correctional budgets. The results are shown in Table 3. Northeastern states were significantly more likely to provide voluntary HIV testing than states in other regions, after controlling for size of prison system, HIV prevalence rates, and correctional expenditures. Multivariate analysis also showed that peer education programs were associated with larger prison systems after controlling for region, expenditures, and HIV prevalence.

Table 3.

Logistic Regression of Association of State Characteristics With HIV Prevention Policies.^a

State Characteristics	Voluntary Testing			Peer Education			Group Counseling
State Characteristics	β	SE	p	β	SE	p	β	SE	p
Northeast region	3.49	1.39	.01	−1.96	1.31	n.s.	−1.89	1.70	n.s.
HIV prevalence rate^b	−1.78	1.76	n.s.	2.42	1.80	n.s.	−0.09	1.93	n.s.
Number of inmates^b	1.02	1.13	n.s.	−3.06	1.32	.02	−2.09	1.31	n.s.
Expenditures per inmate^b	−1.45	0.96	n.s.	2.07	0.99	.04	1.91	1.09	n.s.

Note. n = 41 states. SE = standard error; n.s. = not significant.

^aIndiana and Alaska are excluded from the analysis because HIV prevalence was not available. ^bNatural log transformation of variable.

Discussion

Given the much higher rate of HIV as well as other infectious diseases in prisons compared to the general population, state prison systems have responded with a number of initiatives. We conducted a survey to examine the current extent of peer-led HIV prevention and other HIV prevention programs in state prisons in the United States and found that HIV prevention policies were associated with state prison system characteristics. The survey results described here shed light on HIV prevention activities and initiatives across the country and within specific regions. All state prison systems conduct HIV testing. It is noteworthy that prison systems that conducted only voluntary testing tended to have higher HIV rates than prisons that conducted mandatory testing, but this relationship most likely reflects statewide policies on testing (for the free as well as incarcerated population) rather than any cause–effect relationship. Nearly all states provide some form of one-on-one HIV counseling, and most conduct group HIV education sessions. Group-level interventions may be more effective because they engage group processes that reinforce norms and intentions to change (Wohlfeiler & Ellen, 2007). So far, few state prison systems have followed the lead of some large urban jails by providing condoms, and no state provides clean injection equipment for prisoners. Our results also showed that in the 4 years since a 2005 survey, states have adopted peer HIV education programs. Adoption of these programs was more common among larger prison systems.

Substance abuse treatment is itself a form of HIV prevention because of the association between use of substances and unsafe sex (Shoptaw, Reback, Frosch, & Rawson, 1998) and because substance abuse treatment reduces sharing of injection drug equipment (Metzger & Navaline, 2003). In multiple studies, substance abuse treatment in jails and prisons has been shown to reduce criminal behavior and criminal justice involvement (Ettner et al., 2006; Kelly, Finney, & Moos, 2005) as well as sexual risk behavior after release (Cao, Marsh, & Shin, 2008). Longer lengths of treatment are positively associated with reductions in risk (Lubelczyk, Friedmann, Lemon, Stein, & Gerstein, 2002). Although many jail and prison substance abuse treatment programs incorporate HIV prevention programming, the HIV prevention component is rarely evaluated on its own nor do evaluations assess outcomes after release (Bryan, Robbins, Ruiz, & O’Neill, 2006). Thus, future research should explore whether and how HIV prevention is integrated into substance abuse treatment in state prison systems.

Limitations of the study include the incomplete response rate for the surveys and limits on requesting busy administrators to fill out lengthy, in-depth surveys. It should be noted that Florida, which did not respond to our survey, has one of the highest rates of HIV prevalence in state prisons (3.4%; Maruschak, 2012). Since all data are aggregated at the level of the state, conclusions about individuals or individual prisons cannot be inferred. For instance, we do not know the extent of HIV prevention services among the prisons, or within prisons, in each state in our survey. It would be particularly erroneous to infer that voluntary as opposed to mandatory testing somehow causes higher HIV rates, given other data about the reasons for high HIV prevalence in the Northeast.

Conclusion

In recent years, the recognition has grown that elevated incarceration rates, substance use, and HIV rates are syndemic—intertwining and mutually reinforcing epidemics (Singer, 2000). The syndemic perspective implies that these epidemics must be addressed together. While prevention materials such as condoms are needed within jails and prisons and are inadequately provided (Hammett, 2006; Seal et al., 2008), ultimately HIV prevalence may best be reduced in the prison system by interrupting the cycle of incarceration through substance abuse treatment.

Peer-led HIV education in prisons is not necessarily lower cost than education by professionals since peers need training, supervision, and support (Population Council, 2000). Thus, it is encouraging that a number of prison systems have recently adopted it. It is to be hoped that the other 32 states consider this form of HIV prevention programming as an addition to their current HIV testing and prevention counseling programs. An important area of future research will be to determine the cost savings and cost-effectiveness of peer education programs (National Commission on Correctional Health Care, 2008). Finally, future research should be conducted to determine whether peer outreach models that have been shown to reduce drug use and risky sexual behavior in the community can be successfully adapted to jail and prison.

Footnotes

Declaration of Conflicting Interests

The authors disclosed the following potential conflict of interest with respect to the authorship and/or publication of this article: Author Adefuye is employed at Abbvie, Inc. For information about JCHC’s disclosure policy, please see the Self-Study Exam.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the African American HIV/AIDS Response Act of the Illinois State Legislature [410 ILCS 303].

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