Peer-Based Programs

Inmate peer-based programs have four key advantages: credibility, range
of services, cost-effectiveness, and benefits to peer educators themselves.
Peer educators probably have more inherent credibility with inmates than
representatives of “the system.” They speak the language of inmates and
have had similar life experiences. To be effective, however, it is important
and challenging for peer educators to avoid being seen as allies of or
spokespersons for the system, particularly in programs in which
correctional officials play evident roles in their selection.
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nstructor-Led Education and Educational Materials

Seventy-one percent of State/Federal prison systems and 5 percent of
city/county jail systems reported that HIV/STD education was mandatory
for all incoming inmates; 20 percent of State/Federal but no city/county
systems reported mandatory HIV/STD education at release. Fifty-one
percent of State/Federal systems and 44 percent of city/county systems
reported voluntary HIV/STD education at release. The Illinois
Departments of Corrections and Public Health jointly planned a prerelease
HIV education and referral program being presented by existing prerelease
counselors and inmate peer educators who were specially trained to
provide these services in prerelease centers.
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The Importance of Comprehensive HIV/STD Education and Prevention
Programs

Comprehensive HIV/STD education and prevention programs should be
provided for correctional inmates, given the prevalence of high-risk
behaviors among them, the opportunity for interventions afforded during
periods of incarceration, and the potential public health benefits of such
programs. Given the existing knowledge of prevention and of the
particular circumstances and needs of the correctional setting, a
comprehensive program may reasonably be said to include instructor-led
education, peer-led programs, pre- and posttest counseling, and
multisession prevention counseling. The results of the 1997 NIJ/CDC
survey reveal that only 10 percent of State/Federal prison systems and 5
percent of city/county jail systems offer comprehensive programs meeting
this definition in all of their facilities. Clearly, then, there remains much
room for improvement in the depth and coverage of HIV/STD education
and prevention programs in correctional facilities. A promising approach
in this realm is occurring in Massachusetts, where the Department of
Public Health is funding comprehensive HIV/AIDS programs in the
State’s county jails. To be eligible for this funding, the counties must
propose a program including HIV/AIDS prevention and education for
inmates and staff, HIV counseling and testing, HIV primary care and case
management, and aftercare/transitional planning. The HIV/AIDS
prevention and education component must include “most or all” of the
following elements:
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Types of HIV/STD Education and Prevention Programs Provided

Table 14 summarizes the types of HIV/STD education and prevention
programs that correctional systems provided to inmates in at least one of
their facilities, according to the 1992, 1994, and 1997 NIJ/CDC surveys.
This shows that the percentage of State and Federal systems offering
instructor-led education rebounded to 94 percent in 1997 after dropping to
75 percent in 1994. The percentage of city/county systems providing
instructor-led education also increased in 1997 to 73 percent.
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HIV and STD Education and Behavioral Interventions

Theodore M. Hammett and Patricia Harmon-Abt Associates Inc.

o HIV and STD prevention programs are becoming more widespread in
correctional facilities.

o However, few correctional systems have implemented comprehensive
and intensive HIV prevention programs in all of their facilities.

o Peer-based education and prevention programs offer important
advantages, including cost-effectiveness, credibility, flexibility, and
benefits to peers themselves.
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Conclusion

Although available data are very incomplete, it appears that rates of STDs
and hepatitis B and C are higher among inmates than in the overall
population. Hepatitis C positivity rates are particularly high among
HIV-positive inmates and those with histories of injection-drug use. More
widespread implementation of hepatitis B immunization and screening for
hepatitis C in correctional facilities seem warranted.

Endnotes

1. Centers for Disease Control and Prevention, “The Epidemiology of
Viral Hepatitis in the United States,” Morbidity and Mortality Weekly
Report 43 (1994): 437-455.

2. J.D. Ruiz and J. Mikanda, Seroprevalence of HIV, Hepatitis B,
Hepatitis C and Risk Behaviors Among Inmates Entering the California
Correctional System, Sacramento: California Department of Health
Services, Office of AIDS, HIV/AIDS Epidemiology Branch (March
1996): 1, 9, 12.

3. K.P. Fennie et al., “Hepatitis C Virus Seroprevalence and Seroincidence
in a Cohort of HIV+ and HIV- Female Inmates,” poster abstract no.
Tu.C.2655, presented at the 11th International Conference on AIDS,
Vancouver, July 9, 1996.

4. L.Y. Lior et al., “A Look Behind Closed Doors: Injection and Sexual
Risk Behaviour and HIV, HBV and HCV Inside a Canadian Prison,”
poster abstract no. 23528, presented at the 12th World AIDS Conference,
Geneva, June 30, 1998.

5. Thomas Conklin, Hampden County Correctional Center, unpublished
data.

Hepatitis Among Inmates

Hepatitis B vaccine is increasingly available to correctional inmates and
staff, and thus this infection, which is transmitted by the same routes as
HIV, can and should be brought under better control in correctional
facilities. The Occupational Safety and Health Administration (OSHA)
requires that correctional staff who have direct contact with inmates be
offered hepatitis B vaccination.

By contrast, there is not yet a vaccine or proven effective treatment for
hepatitis C, and this disease is an increasingly serious problem, particularly
among injection-drug users (IDUs) and persons infected with HIV.[1]  In a
1994 blinded study, 41 percent of incoming California inmates (39 percent
of men and 55 percent of women) were antibody positive for hepatitis C
virus (HCV). In the same study, 61 percent of HIV-seropositive men and
85 percent of HIV-seropositive women were also HCV positive.[2] A
study of female entrants to the Connecticut prison system found adjusted
odds ratios for HCV infection of 10 and 7, respectively, among
HIV-positive women and IDU women. More than 70 percent of IDU
women in the study were HCV positive, and 36 percent of sexual partners
of IDUs were HCV positive.[3] A voluntary study of 192 inmates at a
medium-security facility in Springhill, Nova Scotia, found that 28 percent
were HCV positive, but the rates were sharply higher among IDUs (52
percent) than among non-IDUs (3 percent).[4]  A pilot study of 108
incoming male and female inmates at the Hampden County,
Massachusetts, Correctional Center (Springfield area) in 1998 found that
22 percent were infected with HCV.[5]

STDs Among Inmates

According to the 1997 NIJ/CDC survey, 88 percent of State/Federal prison
systems and 41 percent of city/county jail systems have policies for
mandatory or routine syphilis screening of incoming inmates (table 11).
However, 64 percent of State/Federal systems and 29 percent of
city/county systems with mandatory or routine syphilis screening did not
report or were unable to report the results of such screening on the survey.
Of those systems that did report, most had syphilis positivity rates of less
than 5 percent (table 11), but these are very incomplete data. Even fewer
correctional systems have mandatory or routine screening for gonorrhea or
chlamydia, and the few systems reporting results had positivity rates of
less than 5 percent for incoming inmates (tables 12-13). Indeed, the most
striking point about these survey findings is the rarity of screening and the
paucity of screening data. Since gonorrhea is likely to be symptomatic
among men, however, it is probable that most cases will be detected
without mass screening programs.
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Sexually Transmitted Diseases and Hepatitis: Burden of Disease Among
Inmates

Theodore M. Hammett and Patricia Harmon-Abt Associates Inc.

Key Findings

o Available data on STDs and hepatitis B and C among inmates are very
incomplete, reflecting the relative rarity of routine screening for these
conditions in correctional facilities.

o However, behavioral profiles and anecdotal evidence suggest that
inmates are disproportionately affected by STDs and hepatitis.

AIDS-Related Deaths in the United States

The number of AIDS-related deaths for persons age 15-54 was derived
from the CDC, HIV/AIDS Surveillance Report, Year-end editions. Deaths
in the U.S. population for persons age 15-54 were taken from the CDC,
Monthly Vital Statistics Report, Vol. 42, No. 2(S); Vol. 43, No. 12; Vol.
43, No. 6(S); Vol. 45, No. 3(S); and Vol. 45, No. 11(S).

AIDS-related deaths as a percentage of all deaths in the U.S. population
were calculated by dividing the national estimate of AIDS deaths of
persons age 15-54 by the national mortality estimates of persons age 15-54
in a given year.
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