LEAD: A RECENT proposal by the State Department of Corrections to make AIDS testing available to all state prisoners on a voluntary basis raises vexing medical, ethical and financial issues for prison and health care officials, experts say.
A RECENT proposal by the State Department of Corrections to make AIDS testing available to all state prisoners on a voluntary basis raises vexing medical, ethical and financial issues for prison and health care officials, experts say.
As treatment options like the drugs AZT and pentamidine become available for people with AIDS and AIDS-related complex, officials will soon be faced with deciding at what point in an inmate's illness he or she should be treated with the expensive and sometimes toxic medications.
Although inmate's rights advocates support the proposed change in policy, they caution that issues of confidentiality, possible segregation of infected prisoners and the possibility of false diagnoses will make an inmate's decision to request testing for acquired immune deficiency syndrome a difficult one.
The department's previous policy was to test inmates only when they showed symptoms of the disease, were on dialysis or were pregnant. The proposed program of voluntary testing was disclosed by John J. Rafferty, the Deputy Commissioner of the Department of Corrections, in a recent interview. Mr. Rafferty said the department "still has to come up with the mechanism" for the testing.
Although most experts agree that expanded AIDS testing is necessary and beneficial, some say it could be a double-edged sword for prisoners who test positive.
'Very Serious Discrimination'
"It becomes an added punishment," said Judy Greenspan, AIDS information coordinator for the American Civil Liberties Union National Prison Project, based in Washington. In the past, she said, "positive HIV test results have led to some very serious discrimination" against inmates and have affected inmates' applications for parole.
"It's looked upon in society as a condemnatory type of disease," she said.
The debate surrounding the testing and treatment of AIDS-infected inmates in the state's prison system has been a contentious one, with corrections officials pitted against inmate advocacy groups, constitutional rights organizations and even the department's own officers.
In New Jersey, for example, the Office of Inmate Advocacy, a division of the Department of the Public Advocate, has filed a class-action lawsuit against the Corrections Department, charging that it discriminates against inmates with AIDS.
"Once a prisoner has full-blown AIDS," said Catherine A. Hanssens, the assistant deputy public defender handling the case, "they are treated pretty much the way people on death row are."
Prisoners diagnosed with AIDS are prohibited from participating in work-release programs, religious services and education courses, Ms. Hanssens said, and are segregated by being placed in a "special medical unit."
"Basically," she said, "what goes on in that unit is the extent of their lives."
Mr. Rafferty disagrees. "There is no particular prison that you go to if you have AIDS," he said. The segregated unit referred to by Ms. Hanssens, he said, "is for prisoners with very, very advanced stages" of the disease. That unit is in St. Francis Medical Center in Trenton and contains beds for 12 patient inmates, Mr. Rafferty said.
Officials are now aware of 515 HIV-positive inmates, Mr. Rafferty said. There are 44 AIDS sufferers now in special medical units and 9 severely ill inmates in St. Francis Medical Center, he said. Two of the confirmed cases are women.
Prisoners who test HIV positive but who do not show AIDS symptoms, Mr. Rafferty said, are housed with other inmates in prisons throughout the state. If a prisoner is in the early stages of the disease, "there is no reason he can't function in the institution," he said. "We treat AIDS like any other medical illness." But that, Ms. Hanssens said, is the reason for another accusation in the lawsuit, which addresses an HIV-positive inmate's right to "timely access to medical care."
"Prior to the lawsuit," Ms. Hanssens said, "it was the policy of the Department of Corrections to give AZT only to the people they could fit into their segregated AIDS unit."
Benefits of the Drugs
AZT, which is manufactured by the Burroughs Wellcome Company of Research Triangle Park, N.C., and sold under the brand name Retrovir, has been shown to prolong the lives of AIDS patients and to reduce the isk and severity of infections associated with the disease. Another drug, pentamidine, manufactured by LyphoMed of Rosemont, Ill., appears to prevent AIDS-related pneumonia.
After the lawsuit was filed, Ms. Hanssens said, the Corrections Department changed its policy and made AZT more widely available. But, she said, it is not nearly as available as it should be. "Theoretically, AZT is available to prisoners in the general population," Ms. Hanssens said, "but there is evidence that prisoners are not being evaluated and treated early enough." The only way to insure early and adequate treatment, she said, is through voluntary testing.
Trial Date Not Set
The lawsuit, which was filed in Federal District Court in Newark, was certified last month as a class action. A Corrections Department motion to dismiss the suit was denied. A trial date has not yet been set.
Corrections officers have also recently called for AIDS testing of prisoners. But they would like to see the testing carried out regardless of a prisoner's wishes.
"We would like to see every inmate tested upon admission to the facility," said Bruce W. Sapp, a corrections officer in charge of transporting inmates to St. Francis Medical Center. "If a guy has a cut and he's bleeding," he said, "we don't know if he's being treated; we don't know what he did on the streets prior to being incarcerated."
He said that corrections officers who must deal closely with inmates should be advised if a prisoner tested HIV positive so that the officers could take whatever precautions they felt necessary. "We have families," he said. "We're not machines." Sam Love, president of the 4,500-member corrections officers' union, said the department was hesitant to test prisoners for basically one reason: "They are afraid of what they're going to find out," he said.
"You have a lot of homosexual activities that take place in the prisons and a lot of drug addicts," he said. There would be hysteria, he said, among the prison population if the true numbers of HIV-positive inmates became known.
Corrections officers have other reasons for wanting to know who is infected. "There have been several threats made to officers where inmates have said that they'll bite them," Mr. Love said. "They use it as a scare tactic. But if you have to move an inmate, you have to move him. You just hope that he doesn't bite you and hope that he doesn't have AIDS."
The officers' concerns, however, may be exaggerated, medical experts say.
"The odds of contracting the AIDS virus from a bite are extraordinarily unlikely," said Dr. Donald B. Louria, chairman of the department of preventive medicine and community health at the University of Medicine and Dentistry of New Jersey in Newark.
Nevertheless, Dr. Louria also advocates mandatory AIDS testing of all prisoners incarcerated for more than three months. The reasons, he said, are that detection of HIV-positive inmates will allow for proper counseling before a prisoner is released, and early detection will enable prison physicians to make more effective judgments about the administration of drugs like AZT.
"The data is still coming in," Dr. Louria said, "but it suggests that the best time to administer AZT is when the first symptoms appear or when the T-cell count falls clearly below normal levels." T-cells, which provide the body's primary defense against infectious disease, he said, are considered to reach abnormal levels when their count falls below 400. Counseling of infected prisoners is necessary, he said, because of the possibility that once released from prison, an infected individual might further spread the disease.
"You have people who are basically heterosexual," Dr. Louria said, "who change their sexual behavior patterns in prison." Those actions, he said, include homosexual activity without using condoms, thereby increasing the risk of transmitting the disease.
After those prisoners are released, perhaps unaware that they are infected, he said, "they then go out into the community and engage in heterosexual behavior."
"And if they are antisocial and angry, which is a good possibility, it is less likely that they are going to be checked or follow safe practices," he said. "The prison system is in essence subverting its own stated purpose. They are inadvertently sending people back into society who are more dangerous than they were when they went in."
Corrections officials agree that counseling inmates is necessary, and have taken steps toward making more professional guidance available to all prisoners.
Treatment of infected prisoners with such drugs as AZT, officials say, will be conducted upon the advice of a physician on a case-by-case basis.
Such treatment, however, could prove to be an expensive undertaking, experts say.
Currently, there is no consensus as to how many of the 20,000 prisoners in the system are infected with the deadly virus; estimates range from as low as 30 percent to as high as 80 percent, Ms. Hanssens said, although everyone at this point is "just guessing."
But with a full course of AZT therapy costing about $6,000 a year, the expense of administering treatment to even 30 percent of the prison population could be as high as $36 million a year, and that is in addition to the usual medical expenses associated with the disease.
Another consideration facing physicians and virus-positive patients is the apparent side effects of AZT in some cases.
"There are significant side effects associated with this therapy," said Kathy Bartlett, a spokeswoman for Burroughs Wellcome. Among the most significant, she said, are reduced red and white blood-cell counts, which can require dosage adjustments or discontinuation of therapy in some cases.
Regardless of the cost or potential side effects of the therapy, inmate advocates say, every HIV-positive prisoner has a right to make his or her own decision about treatment.
The proposal by the Corrections Department to provide voluntary testing, they say, goes a long way toward giving inmates at least some control over the treatment of their illness. But for any testing program to be truly effective, the department must be willing and able to insure confidentiality, inmate advocates say, even if that means keeping the results from corrections officers.
"Prisoners who test positive sometimes get more than they bargained for," Ms. Hanssens said. Infected inmates, she said, are perceived as outcasts by corrections officers and prisoners alike. "They can't even get a haircut," she said. "It goes from the profound to the absurd."
Prisoners who test negative, she said, are also at risk because they then develop a false sense of security.
"It's like Russian roulette," she said. "If you think that the gun you're holding to your head has an empty chamber, sometimes you pull the trigger."
But for people who have AIDS, Ms. Hanssens said, there is no more difficult place to be than prison. They are essentially alone at a time when companionship is desperately needed. Regardless of the length of prisoners' sentences, there is always a more intimidating specter haunting their dreams of freedom.
"AIDS," Ms. Hanssens said, "is the great equalizer."
AIDS In Prisons
ESTIMATES of the number of inmates who are HIV positive range from as low as 30 percent to as high as 80 percent. The reason for the wide range is that most state prisoners are never tested for the virus, either upon admission to the prison or upon release.
The incidence of acquired immune deficiency syndrome in prison is widely believed by inmate advocacy organizations to be much higher than that in the general population for several reasons.
AIDS is most readily transmitted by unprotected homosexual activity. According to the Centers for Disease Control in Atlanta, 74 percent of all AIDS infections are transmitted in this manner and 17 percent by the sharing of needles by intravenous drug users.
Unprotected homosexual activity in prison, although undocumented, is believed to be relatively common. Intravenous drug use in prison, while less prevalent than on the outside, is more insidious in the prison environment because of the relative scarcity of needles and the resultant likelihood that an infected needle might be shared often.
In Newark, as many as 50 to 60 percent of the intravenous drug users who seek treatment are HIV positive, said Marilyn Reilly, a spokeswoman for the State Department of Health.
Since a great proportion of inmates come from the state's larger cities, and since a large percentage of them are intravenous drug users, the incidence of AIDS in the prison population may be close to that of large cities, said Edward Martone, executive director of the American Civil Liberties Union of New Jersey in Newark. He is a member of the board of the New Jersey Association on Corrections, a nonprofit group that runs halfway houses for paroled prisoners.
"I wouldn't be surprised," he said, "if the incidence of HIV-positive inmates in the prison population is as high as 40 to 50 percent."
Judy Greenspan, AIDS information coordinator for the American Civil Liberties Union National Prison Project in Washington, said that 17 states now do mandatory HIV testing on incoming prisoners. The Federal system, she said, does testing 60 days before release. The American Civil Liberties Union supports HIV testing, Ms. Greenspan said, but only on a voluntary basis.
"The most enlightened health opinion in this country," she said, "is that everyone should act as if they're HIV positive."