amfAR, The Foundation for AIDS Research

Putting HIV on Lockdown

HIV Testing and Prevention Behind Bars

By Winnie McCroy 


April 20, 2009—In the U.S., HIV prevalence in correctional facilities is three times higher than in the general population. With America incarcerating one in 100 adults—more than any other country—HIV in prisons is a national crisis. And since 90 percent of prisoners are released back into the community, this problem impacts people in jail and in the community.


Prisoner seated 

Prisoner advocates agree that it is time to tackle the problem aggressively, but a close look at HIV behind bars reveals the complexity of that task. An effective campaign would start with HIV testing upon intake but it would also need to provide clinical care during incarceration, plus prevention and harm reduction measures in prisons, including condom distribution and syringe exchange.

“I think testing is a good idea—with the caveat that in order to have an impact, we need to link testing to clinical care and prevention,” said Lara Strick, M.D., an infectious disease physician for the Washington State Department of Corrections.

Currently, 21 state prison systems test inmates for HIV at admission, while in custody, or upon release, according to the 2006 Bureau of Justice Statistics. Nearly all states and federal prisons provide HIV testing upon request and test symptomatic inmates.

Evidence has shown that knowledge of HIV status leads to an overall reduction in HIV risk behaviors and affords earlier access to care, treatment, and prevention services. In correctional facilities, opt-out HIV testing is becoming the norm, in which inmates are informed that an HIV test will be done unless they decline. This leads to higher rates of testing and reduces the stigma around testing by normalizing it.

Some elected officials are now taking measures to control the HIV epidemic among prison populations in their states. In Tennessee, State Rep. Brenda Gilmore has proposed legislation that requires HIV tests for inmates before they are released into the community. Gilmore described this plan as part of a multifaceted approach to curb the spread of AIDS in the African-American population. Although African Americans comprise only 13 percent of the population in Tennessee, they represent approximately 35.4 percent of inmates, and 64 percent of new HIV cases.

“In jail, the context of freedom, liberty, and consent takes on a different meaning.” 

But some prison advocates find this legislation discriminatory and ineffective, calling instead for informed HIV testing upon entry to prison, accompanied by treatment.

“There is no data to support the perception that men go into prison uninfected, get infected inside, then come out and infect women. This increases the stigma around inmates and scapegoats them,” said Barry Zack, CEO of corrections and health for the Bridging Group, a correctional consulting firm. Still, he would support this type of legislation provided it increased funding for treatment during incarceration and upon release.

Although Zack agreed that knowledge of HIV status is very important, he also spoke of the problems that result from testing positive in prison—among them discrimination, relocation to another facility, being confined to designated HIV units, and losing prison work privileges that can qualify inmates for early release.

“In jail, the context of freedom, liberty, and consent takes on a different meaning,” noted Zack. “In my opinion, it is unethical to institute routine testing without the individual understanding the ramifications of what the test results are.”

Prevention is the Key

In addition to testing, more can be done to prevent the spread of HIV among prisoners. Advocates insist that condoms be provided during conjugal visits; many also urge that they be provided among general prison populations. Only four jail systems, in New York City, Philadelphia, San Francisco, and Washington, and two prison systems, Vermont and Mississippi, make condoms available to some of their inmates.

Most U.S. correctional facilities do not distribute condoms due to security concerns or because of fears that condom distribution suggests that sex is permitted. “There have been no reported events of condoms being used as any type of weapon,” said Ralf Jürgens, director of the Canadian HIV/AIDS Legal Network, in a 2002 article. Condoms have been available in Canadian federal prisons since 1992. Jürgens said that while sex in prison is still an institutional offense, fighting the spread of HIV is more important than upholding morality, especially since sex in prisons is occurring with or without condoms. After 10 years distributing condoms, the “issues [surrounding condom distribution in corrections] have become non-issues,” said Jürgens. 

“I think both sides have points,” said Dr. Strick. “But sex in prison is not always consensual; it can be coercive. Does that mean we shouldn’t give access to protection?”

For those inmates who have tested positive, advocates demand that they be linked with appropriate and confidential treatment services, both during incarceration and upon release. “This is a population of people who are not necessarily medically savvy. It tends to be a low-educated population that may not have ever accessed care prior to prison,” said Dr. Strick.

Without prevention and treatment, the high rates of HIV transmission in prisons will continue. Additional work needs to be done to address the multiple barriers to care facing inmates, from instituting harm reduction measures in correctional facilities to providing inmate services upon release. It is imperative that these strategies take a realistic look at life behind bars. 

“Drug use and sex both occur in prisons, regardless of what we want to happen,” said Dr. Strick. “I would personally support condoms in prisons, and I think custody could bring in a third party to distribute them. And education is always good. We can argue that not everyone is using condoms correctly, but it is still better than no one having them. It is still making a difference.”

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