Important note: Information in this article was accurate in April 2000. The state of the art may have changed since the publication date.
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Even though women are less likely to be incarcerated than men (one in 10 inmates in US prisons and jails is a woman), incarcerated women are three times more likely to be HIV infected than incarcerated men. The proportion of inmates with HIV (US prisons: 2.3% of men and 3.5% of women) is much higher than the proportion of HIV infected persons in the general population (US free population: 0.6% of men, 0.1% of women). This difference is amplified in the Northeast, where HIV prevalence among incarcerated men is 7% and 13% among incarcerated women.1
In addition, the number of HIV infected women in prison has risen steadily since 1980, due in part to the steady increase in the total number of women who are incarcerated (figure 2).2 The prevalence of HIV infection among incarcerated women rose 88% in 1995, while the rate among men rose 28% (figure 1).3
In most prison systems, the prevalence of HIV among women is two- to three-fold higher than in men. Numerous studies have shown that the same behaviors that lead to incarceration put women at increased risk for HIV infection.4,5,6,7 Links between drug use, sex work, victimization, poverty, race and HIV explain the prevalence of HIV infected women behind prison walls. Recent reports on the status of women inmates in the US have revealed the following:
Incarcerated women frequently report histories of sexual and physical abuse. As many as two in three incarcerated women (33-65%) report prior sexual abuse and as many as two in five (19-42%) report a history of childhood sexual abuse.14,15 More than 80% of women in prison have experienced significant and prolonged exposure to physical abuse by family members or intimates.16 In contrast, in studies of women who are not currently incarcerated, approximately one in seven women reported a history of forced sex, one in five women (20%) report a history of childhood sexual abuse, and about one in four (25%) women report a history of physical abuse. (Note that these studies of women in "free living" communities did not explore histories of incarceration, thus there may be some overlap between the populations). The impact of prolonged sexual and physical abuse prior to incarceration on incarcerated women's health care, mental health care, and risk behaviors is thought to be profound.17,18
Incarceration represents an opportunity for health care and mental health care that may reduce the long-term sequelae of physical and sexual abuse. Although unproven, it is likely that selected interventions (such as HIV education, sexual abuse recovery, mental health care) in the appropriate setting may also reduce HIV risk behavior among these high-risk women after release from prison. For those women that are already HIV infected, incarceration represents an opportunity to initiate a comprehensive HIV care plan and to build a framework for continuity of care that extends to the community to which she will return.
The life circumstances of this population, as described above, are a critical reminder that an HIV-infected incarcerated woman has many concerns that affect her ability and willingness to engage in the complex course of intervention that is characteristic of effective HIV treatment. An incarcerated woman's experiences and concerns are the framework within which a provider must construct her HIV management plan.
Especially in state prison systems, there may be elective or mandatory HIV testing at the beginning or the end of incarceration. Most systems allow elective testing when medically indicated at any time during incarceration as well. In prisons or jails where there is no mandatory testing, the issue of convincing female prisoners to be tested becomes very important. When approached in a sensitive manner, incarcerated women are often willing to be tested for HIV. Factors that can encourage women to be tested include the impact of HIV infection on their present or future children and concerns about having acquired HIV infection in the context of other sexually transmitted diseases. Many of these women may have been tested in the course of prior pregnancies and may therefore be familiar with the concepts and procedures related to performing the HIV test. However, younger women (who have had fewer arrests, fewer pregnancies, and may have had fewer opportunities for interacting with HIV testers and counselors) may be more resistant to testing.
Given the high prevalence of HIV infection and HIV risk behaviors among incarcerated women, it is extremely important to use every opportunity to discuss HIV testing and to promote safer lifestyles. The following clinical situations indicate HIV testing and HIV education:
The incarcerated woman's fear of stigmatization by her peers and by correctional staff has a markedly negative impact on testing programs in prisons and jails. The closed setting of correctional institutions makes confidentiality difficult to maintain (particularly if a clinic or care provider is identified as being associated with HIV). Peer education programs that reduce stigmatization and increase the general awareness of HIV (and the prevalence of infection among their peers) in the female prison or jail population appear to have a positive impact on a woman's willingness to be tested.20
Once the diagnosis of HIV is made, clinicians should discuss treatment with the patient. It is becoming increasingly important to spend a great deal of time educating patients prior to initiating therapy. Some correctional facilities for women schedule an initial discussion with the HIV physician specialist, followed by an additional one to two visits at two-week intervals prior to the initiation of therapy. Clinicians and patients should address timing of medication, special meal restrictions, and side effects prior to instituting therapy. The physician or nurse case manager should provide a written description, in the appropriate language, of the regimen, accompanied by pictures of the pills. For illiterate patients, instructions that include pictures of their pills accompanied by drawings of clocks (showing dosing times) are usually very helpful. The patient should be asked to recite the medication regimen from memory at each visit. Incarcerated women are usually ready partners, once treatment is initiated, and exhibit better adherence while incarcerated than has been reported among patients in the community.21
In 1998, 1,400 women gave birth within prisons, but the number of those who were HIV infected is unknown.22 The extent of prenatal screening for HIV infection performed in federal and state prisons is also unknown at this time. Transmission of HIV infection to the fetus has been all but eradicated in the US due to the success of pre-natal HIV testing programs in the community. However, leading pediatric HIV researchers have raised concern about reaching high risk women who seek care late in the course of pregnancy.23
The correctional setting provides a critical opportunity to reach a group of women who may not have accessed pre-natal testing in the community. Therefore, incarceration represents an opportunity to intervene, should maternal HIV infection be diagnosed, and an opportunity to teach women about the need for HIV testing and treatment during future pregnancies. According to standards set forth by Centers for Disease Control and Prevention,24 thorough and non-judgmental discussion of HIV testing and antiretroviral therapy is a required component of pre-natal care.
The high prevalence of HIV infection among incarcerated women has had a dramatic impact on the type of care provided in correctional health units and on the cost of providing that care. Health care budgets for women's correctional facilities can be two-fold higher than budgets for men's correctional facilities. Those institutions that provide care for women populations where HIV is highly prevalent rank among the most expensive health care programs in the country.25
Due to the recent increase in HIV patients within corrections, some institutions have developed flexible approaches to providing medications that address women inmates' needs. For example, women who are expected to be poor adherers can "graduate" to keeping their medications on person if they demonstrate adherence by attendance at the medline window. In some other institutions, a "strip pack" containing a one-day supply of medication is provided. This diminishes medline staffing needs while allowing for monitoring of medication and avoids the distribution of excess medication. (Release of strip packs is approved by a licensed doctor over the phone.)
Weekend admissions, dietary requirements and the timing of administration make adherence to and continuity of medications formidable tasks. One correctional facility for women recently addressed the problem of weekend admissions by making a three-day supply of medications available in "contingency" for use during weekends and extended holidays when less experienced M.D.s are covering the HIV infected patients.
Continuity of access to medication after release is addressed by providing a supply of medication at discharge that is sufficient, in theory, to cover the time period between release from incarceration and the first clinic visit post release. Some facilities provide a thirty-day supply of medication at discharge, recognizing how difficult it may be for women to locate a place to live, to reconnect with their families, and to attend to their medical needs after release from prison or jail. In fact, discharge planning programs have by now become a widely accepted component of correctional HIV management, helping incarcerated women make smoother transitions into the community and continue to access HIV medical and related services after incarceration. A number of innovative inmate release plans have been devised to ensure continuity of HIV care, such as the StadtRelease plan formulated for various prison systems by a national medication distributor, Stadtlanders. Other states, like Georgia, have created similar plans with the assistance of a number of ART drug manufacturers.
In recognition of the important role that HIV education plays in the reduction of HIV risk behaviors, many women's correctional facilities offer an array of HIV and safer sex education programs, peer led groups, drug treatment, counseling, and vocational training programs for their incarcerated female population. Bedford Hills in New York paved the way for future and existing models of HIV care by offering sexual and physical abuse recovery as a component of its program, AIDS Education and Counseling (ACE).
Programs that provide basic understanding of the virus, the disease, and build skills that diminish HIV risk are critically important in correctional settings. Programs that include these components have been published in detail.26 Providers and patients need to have the same points of reference if the patient is ever to understand concepts of bacteria and viruses.
Incarceration is also an excellent opportunity to discuss risk reduction practices.27
Correctional management of HIV can be viewed as a network of interconnected services that can address the various needs of an incarcerated woman infected with HIV. By testing for HIV infection and screening for gynecologic infections among incarcerated women, correctional health care providers can play a critical role in public health strategies for treating and reducing the spread of infectious diseases. By diagnosing HIV and instituting a plan for treatment, correctional facilities for women can play a critically important role in the reduction of morbidity and mortality among HIV infected women in high risk populations. By instituting comprehensive prenatal diagnosis and treatment protocols, correctional facilities can reduce vertical transmission. By diagnosing and treating sexually transmitted diseases, and using every sexually transmitted infection as an opportunity to teach about HIV, correctional facilities for women can reduce susceptibility to HIV and may also reduce horizontal transmission.
Overall, incarceration provides a critical opportunity for the education, diagnosis, and medical care of HIV-infected women and high-risk HIV seronegative women. Education and empowerment of these women who live with HIV and who are at risk of HIV, will help reduce their vulnerability. Above all, if we can address their HIV care and engage them as partners in an HIV management plan, it will not only benefit the women as individuals, but also the communities to which they may return.
* Speaker’s Bureau: Agouron Pharmaceuticals, Bristol-Myers Squibb, Dupont
1. Hammett TM, Harmon P, Maruschak LM. 1997 Update: HIV/AIDS, STDs and TB in correctional facilities. US DOJ, NIJ and U.S DHHS, CDC, July 1999. NCJ 176344. 
download the PDF version
2. GAO Report to Honorable Eleanor Holmes Norton, Women in Prison. December 1999. GAO/GGD-00-22 US General Accounting Office.
3. Maruschak L. HIV in Prisons 1997. November 1999. Bureau of Justice Statistics Bulletin. NCJ 178284.
4. Fogel, CI, Belyea, M, "The lives of incarcerated women: violence, substance abuse, and at risk for HIV." J Assoc Nurses AIDS Care 1999 Nov-Dec;10(6):66-74.
5. Stevens J, et al." Risks for HIV infection in incarcerated women." J Women's Health 1995; 4(5). 569-577.
6. Johnson JC, Burnett AF, Willet GD, Young MA, Doniger J." High frequency of latent and clinical human papillomavirus cervical infections in immunocompromised HIV-infected women." Obstet Gynecol 1992 Mar;79(3):321-7.
7. Zierler S, and Krieger N." Reframing Women's Risk: Social Inequalities and HIV Infection. Annual Review of Public Health." 1997; 18: 401-436.
8. GAO Report
9. GAO Report
10. Gilliard, Darrell K. (March 1999). Prison and jail inmates at midyear 1998. Washington, D.C.: U.S. Department of Justice. Bureau of Justice Statistics Bulletin, NCJ-173414
11. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 1998; 10(2): 17.
12. GAO Report
13. Browne A, A., Miller, B., Maguin, E. Prevalence and Severity of Lifetime Physical and Sexual Victimization Among Incarcerated Women. J Law and Psychiatry 1999 May-Aug; 22(3-4): 301-22.
14.Browne, et al
15.GAO Report
16.Browne A, et al.
17. Stevens J, Zierler S, Cram V, Dean D, Mayer KH, and De Groot AS. 1995a. Risks for HIV infection in incarcerated women. Journal of Women's Health, 4(5), 569-577.
18. Richie, B.E., & Johnson, C. (1996)." Abuse histories among newly incarcerated women in a New York City jail." Journal of the American Medical Women's Association, 1996 May-Jul;51(3):111-4, 117.
19. Poulin C., Alary, M, Bernier, F, Finguet J, Joly, JR." Prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae, and HIV infection among drug users attending an STD/HIV prevention and needle-exchange program in Quebec City, Canada." Sex Transm Dis 1999 Aug;26(7):410-20.
20. Members of the ACE Program at the Bedford Hills Correctional Facility. Breaking the Walls of Silence. New York, NY. The Overlook Press, 1998.
21. Mostashari, F., Riley, E., Selwyn, P.A., & Altice, F.L. " Antiretroviral use among HIV-infected female prisoners." J Acquir Immune Defic Syndr Hum Retrovirol 1998 Aug 1;18(4):341-8
22. GAO Report
23. Lindegren ML." Trends in perinatal transmission of HIV/AIDS in the United States." JAMA 1999 Aug11; 282(6):531-8.
24. U.S. Public Health Service Recommendations for Human Immunodeficiency Virus Counseling and Voluntary Testing for Pregnant Women. MMWR, July 07, 1995 / 44(RR-7);1-15.
25. New services provisions impact health care costs--inmate health care part I, survey summary. Corrections Compendium, October 1997: 5-19.
26. ACE Program
27. Gaiter J, Jürgens R, Mayer KH, Hollibaugh A. Harm reduction inside and out: controlling HIV in and our of correctional institutions. AIDS Reader. 2000 Jan; 10(1): 45-53.
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©1997,1998,1999,2000. The recently formed HIV Education Prison Project (HEPP) is a medical education program that targets a growing population, inmates in correctional facilities, that has been underserved in HIV care. It is part of the Brown University AIDS Program. Permission to use and reproduce portions of this newsletter is hereby granted provided that author and publication are fully credited and both copyright and permission notice appear with reprinted material. Inquiries may be directed to heppnews@brown.edu. Website: HIV Education Prison Project.
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