Other Important Opportunities for HIV Prevention

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The focus of this chapter is on educational and behavioral interventions as a method of HIV prevention. Other opportunities are presented below. Each one of these options is a documented form of HIV prevention.

Counseling and Testing

Counseling and testing has been shown to be an effective prevention strategy (Kamb et al., 1998). The intent of testing is to become aware of one's HIV status (taking the "window period" into account). The purpose of the counseling component of HIV testing is to reinforce positive health behaviors, with an emphasis on risk reduction. These risk reduction messages are equally important among those who test positive as among those who test negative. In addition, among those who test positive, information about the options available needs to be provided.

In the correctional setting, both the pre- and posttesting counseling are critical components of HIV prevention. Pretesting counseling is critical in the correctional setting as the setting in which it takes place requires additional attention; before one voluntarily consents to be tested for HIV in a correctional setting, the provider should incorporate "setting" into the consent process. For example, if one tests positive, one may be housed in a different location or transferred to a different institution; if one tests positive, one may have access to treatment opportunities and support both during incarceration and on release.

Condom Distribution and/or Availability

It is well documented that with consistent and proper condom use, HIV transmission can be prevented (National Institutes of Health 2001; Hearst, 2004; Holmes & Weaver, 2004). There have been legislative efforts to pass condom availability programs for correctional settings and many in the public and correctional health communities have advocated for such distribution programs. However, currently, few such programs are available.

The WHO and UNAIDS have recommended for more than a decade that condoms be made available to prisoners. As of February 2007, condoms are banned or unavailable in over 90% of U.S. prisons and jails. Currently, the state prisons in Mississippi and Vermont make condoms available, as do county jails in New York City, Philadelphia, Washington, D.C., San Francisco, and Los Angeles. Of those correctional institutions where a condom availability program exists (in both the United States and elsewhere), there have been no security or custody issue that resulted in closing the program (Dolan & Wodak, 2003).

Studies in Europe have documented the increasing acceptability of condom availability in the correctional setting (these state-sponsored programs increased from 53% in 1989 to 81% in 1997; Nerenberg, 2002). The United

States is one of the few industrialized countries that do not make condoms available to the correctional population (Canadian HIV/AIDS Legal Network, 2005). Human Rights Watch reports that these jurisdictions have distributed condoms for years without violence or other incidents that might compromise security, demonstrating that denying condoms to prisoners cannot be justified on public safety grounds.

Access to Clean Injection Equipment

Though there are no sanctioned in-prison/jail syringe exchange programs in the United States, it is well documented that (1) injection drug use occurs in the correctional setting, (2) sterile IDU paraphernalia is extremely difficult to obtain, and (3) as with sexual activity, the risk is greater on the inside as a result of higher prevalence.

An evaluation of programs in Switzerland, Spain, and Germany that provide sterile needles and syringes found "no increase in drug use, a dramatic decrease in needle sharing, no new cases of infection of HIV or Hep B or C, and no reported instances of needles being used as weapons" (Dolan & Wodak, 2003; Okie, 2007).

If a safe syringe/needle exchange program is not legal or feasible, both the World Health Organization and the U.S. Centers for Disease Control and Prevention are on record as stating that other measures should be made available to prevent further transmission. WHO states that the provision of other cleaning techniques (e.g., bleach) should be used "where there is implacable opposition to NSP (Needle Syringe Programs)." The Centers for Disease Control and Prevention states that bleach should be made available "where no other safer options are available." The WHO and UNAIDS also recommend that drug-dependence treatment and methadone maintenance programs be offered in prisons if they are provided in the community, and that needle-exchange programs be considered (Okie, 2007).

HIV Treatment as Prevention

Treatment of STDs can be a method of HIV prevention (Fleming & Wasserheit, 1999). By suppressing viral load, HIV treatment is also a clinical form of HIV prevention (Porco et al., 2004). Physicians and other medical staff also can play a direct or indirect role in prevention with their patients. If time/resources do not allow for this, correctional medical staff can advocate for others to take on this responsibility.

Treatment of Substance Use (Misuse, Abuse, and Addiction)

Through the documentation of the strong relationship between substance use and sexual risk behavior, and the high percentage of substance use of those in the criminal justice system (Bureau of Justice Statistics, 1997), substance abuse treatment is HIV prevention (and very few correctional systems provide substance abuse treatment) (Rich et al., 2001; Fiscella et al., 2004; World Health Organization, 2005; Okie, 2007).

Though there is ample evidence of the history of drug use and need for drug and alcohol treatment inside our prisons and jails, very few treatment programs exist and many of those do not have the capacity to treat all who voluntarily sign up. There are more substance abusers in our prisons and jails than in alcohol/drug treatment programs in the community. An estimated 42% of state prisoners have the comorbidity of substance dependence and mental health problem (Human Rights Watch, 2006).

Mental Health Treatment

A 2006 Bureau of Justice Statistics report documented the quadrupling of the number of mentally ill prisoners in the past 6 years. Rates of mental health disorders among state prisoners are five times higher than the community rates (Bureau of Justice Statistics, 2006); rates among female prisoners were even greater. Prisoners with mental health disorders are significantly more likely to have been physically and sexually abused, to have had family members with substance abuse problems, and to have a family member with an incarceration history.

There is evidence that a large percentage of those who engage in substance use are "self-medicating" a mental health disorder. This feeds the cycle of mental health disorder to substance use to high-risk sexual behavior.

Prevention Outcomes Measures

Different educational HIV prevention efforts have measured their successes with different outcomes. Though the bottom line outcome is not getting infected, there are a myriad of other outcomes that indirectly impact HIV incidence. Outcomes that should be considered for evaluation of programs include condom use and use of sterile injection equipment both inside and after release. The next "level" of outcomes among those who are released include: decreased alcohol/drug use with sexual activity, and if available, use of needle exchange programs, substance abuse and mental health treatment. Finally, with many prisoners not "connected" with community services, working with community case managers (including parole/probation) to access services and stay out of the criminal justice system should be considered as outcome measures. For someone with HIV, success would also include access and utilization of community health services. A successful community reintegration would also include housing, employment, and education. Finally, social support systems (family and friends) can be the critical link between staying healthy or going back inside.

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