On both sides of the prison walls—prisoners and HIV

Transcription

Comment
“It is said that no-one truly knows a nation until one has
been inside its jails. A nation should not be judged by how
it treats its highest citizens, but its lowest ones.”
Nelson Mandela
Few would refute that the most neglected and vulnerable
of all populations in the global HIV/AIDS response are
people who are incarcerated. Today, The Lancet continues
its ongoing attention to HIV in marginalised populations
with a collection of reviews on HIV and related infections
in prisoners.1–6 Prison populations are at especially high risk
of HIV infections as a consequence of risk factors that are
in play both before incarceration and once in prison where
there are frequent opportunities for further transmission.
Consequently, prisoners experience high HIV disease
burdens. They have little or no access to HIV treatment,
prevention, and care, and due to their legal status they
are discriminated against by the criminal justice system,
which in turn perpetuates the high HIV transmission rates.
Globally, about 10·2 million men, women, and children
are in prisons, detention, or some form of government
custody at any given time.1 Annually, an estimated
30 million people pass through some form of detention.7
This Series describes the unique and complex nature
of an HIV epidemic in an understudied and underserved
population. No other general medical journal has
published such an extensive and in-depth global
report on HIV in prisoners. We also highlight the often
disparate HIV risks and health-care needs of incarcerated
men and women. By doing so, we hope to bring
widespread attention to prisoners as a key population in
the HIV pandemic.
A substantial global increase in the population of
prisoners and detainees during the HIV era is largely a result
of failed prohibitionist drug policies.8 This situation has
been especially true in the USA, eastern Europe, central
Asia, and southeast and east Asia where most prisoners
are detained for drug-related offences. Substance users
bear high burdens of HIV, hepatitis C, hepatitis B, and
tuberculosis, including multidrug-resistant tuberculosis,
and comorbidities such as substance use disorders and
mental illnesses. Indeed, as Kate Dolan and colleagues1
show, prison populations have a higher prevalence, and
in some contexts a higher incidence, of these infections
than in the general population. Furthermore, modelling
studies in this Series suggest incarceration of substance
users and people who inject drugs drives transmission
of HIV and tuberculosis within prisons and in their wider
communities.1,6 This finding is particularly relevant since
most prisoners are eventually released. Re-entry to the
community, linkage to care for persons newly released
from prison, and the interactions of prison-acquired
infections with community risks and vulnerabilities need to
be addressed as part of a wider public health effort.
Despite the complex challenges of providing health care
in a prison setting, the Series shows that quality clinical care
can be provided,2 and that prison harm-reduction and drug
treatment programmes can substantially reduce disease
transmission.3 Unfortunately, in many parts of the world
the reality for people deprived of their liberty is unjustly
harsh. Human rights violations, such as denial of access to
prevention and treatment, violence, and discrimination
are common in prisons.4 In addition, there is a flagrant
disregard of the right to an adequate standard of health
care, which is enshrined in international law.4
Africa, by far the region most affected by HIV globally,
has among the most marginalised of all incarcerated popu
lations as Lilanganee Telisinghe and colleagues5 show. Many
prisoners in Africa face years in detention without ever
being formally charged or tried for alleged offences. Pre-trial
detention is a high-risk environment for disease exposure
and for treatment interruptions for people on ongoing
HIV or tuberculosis treatment. There needs to be an urgent
reform of the criminal justice system and legislative reform
to eliminate this hugely damaging practice.
On the global stage, much is spoken of the gains in
HIV control, particularly in relation to the increasing
numbers of people who have access to treatment
and the reduction in AIDS-related deaths. Indeed, in
response, UNAIDS have embarked on an agenda to
accelerate efforts towards ending the AIDS epidemic
by 2030. But one only has to look at the reported
2·1 million new HIV cases in 2015 to know intensifying
more of the same will not be sufficient.9 The 2016
UN High Level Meeting on Ending AIDS in June was a
major setback for key populations because civil society
and harm-reduction groups were excluded from
participating. The language in the final resolution has
left many feeling that key populations are yet again
www.thelancet.com Published online July 14, 2016 http://dx.doi.org/10.1016/S0140-6736(16)30892-3
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On both sides of the prison walls—prisoners and HIV
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Comment
being marginalised in the HIV/AIDS response, and this
includes prisoners and detainees.10
As Archbishop Desmond Tutu’s message ”Don’t forget
the prisoner” reaffirms,11 we have a moral and human
imperative to provide treatment to prisoners since we
have limited their ability to access care except through
prison health. Only by fully including them and other
marginalised populations in the global HIV/AIDS response,
will the fast-track to accelerate the fight against HIV and to
end the AIDS epidemic by 2030 become a reality.
Pamela Das, Richard Horton
The Lancet, London EC2Y 5AS, UK
We thank Chris Beyrer for his extraordinary leadership, energy, and commitment to
making this Series possible as well as his colleagues Martin McKee, Josiah Rich,
Joseph Amon, Kate Dolan, and Adeeba Kamarulzaman, who ably supported his
leadership. We also thank the Center for Public Health and Human Rights at Johns
Hopkins Bloomberg School of Public Health and their funding of the work of this
Series, which included grants from the National Institute on Drug Abuse; The Bill &
Melinda Gates Foundation; the Open Society Foundations; the United Nations
Population Fund; the Johns Hopkins University Center for AIDS Research, a National
Institute of Health (NIH)-funded programme, 1 P30AI094189; and AIDS Fonds
Nederlands. The findings and conclusions contained within this Series are those of
the authors, and do not necessarily reflect positions or policies of the funders.
2
1
Dolan K, Wirtz AL, Moazen B, et al. Global burden of HIV, viral hepatitis, and
tuberculosis in prisoners and detainees. Lancet 2016; published online July 14.
http://dx.doi.org/10.1016/S0140-6736(16)30466-4.
2 Rich JD, Beckwith CG, Macmadu A, et al. Clinical care of incarcerated people
with HIV, viral hepatitis, or tuberculosis. Lancet 2016; published online July 14.
http://dx.doi.org/10.1016/S0140-6736(16)30379-8.
3 Kamarulzaman A, Reid SE, Schwitters A, et al. Prevention of transmission of HIV,
hepatitis B virus, hepatitis C virus, and tuberculosis in prisoners. Lancet 2016;
published online July 14. http://dx.doi.org/10.1016/S0140-6736(16)30769-3.
4 Rubenstein LS, Amon JJ, McLemore M, et al. HIV, prisoners, and human
rights. Lancet 2016; published online July 14. http://dx.doi.org/10.1016/
S0140-6736(16)30663-8.
5 Telisinghe L, Charalambous S, Topp SM, et al. HIV and tuberculosis in prisons
in sub-Saharan Africa. Lancet 2016; published online July 14. http://dx.doi.
org/10.1016/S0140-6736(16)30578-5.
6 Altice FL, Azbel L, Stone J, et al. The perfect storm: incarceration and the
high-risk environment perpetuating transmission of HIV, hepatitis C virus,
and tuberculosis in Eastern Europe and Central Asia. Lancet 2016; published
online July 14. http://dx.doi.org/10.1016/S0140-6736(16)30856-X7.
7 UNODC, ILO, UNDP, WHO, UNAIDS. HIV prevention, treatment and care in
prisons and other closed settings: a comprehensive package of interventions.
Vienna: United Nations Office on Drugs and Crime, 2013.
8 Csete J, Kamarulzaman A, Kazatchkine M, et al. Public health and
international drug policy. Lancet 2016; 387: 1427–80.
9 UNAIDS. Global AIDS update 2016. May 31, 2016. http://www.unaids.org/en/
resources/documents/2016/Global-AIDS-update-2016 (accessed June 21, 2016).
10 UN General Assembly. Political declaration on HIV and AIDS: on the fast-track
to accelerate the fight against HIV and to end the AIDS epidemic by 2030.
June 8, 2016. http://www.unaids.org/en/resources/documents/2016/2016political-declaration-HIV-AIDS (accessed June 21, 2016).
11 Beyrer C, Kamarulzaman A, McKee M, for the Lancet HIV in Prisoners Group.
Prisoners, prisons, and HIV: time for reform. Lancet 2016; published online
July 14. http://dx.doi.org/10.1016/S0140-6736(16)30829-7.
Comment
Prisoners, prisons, and HIV: time for reform
Prisoners and detainees worldwide have higher
burdens of HIV, viral hepatitis, and tuberculosis than
the communities from which they come. This disease
burden among prisoners has been recognised since the
early years of these inter-related pandemics.1 Yet the
health needs of prisoners receive little attention from
researchers or advocates working to improve responses
for these diseases, and scant funding for prevention
or treatment interventions. This Lancet Series on HIV
and related infections in prisoners1–6 shows that the
reasons for this neglect include the very factors that
make prisoners and detainees vulnerable to infection
and unable to get treatment: unjust and inappropriate
laws; underfunded and overcrowded prisons with large
numbers of individuals in lengthy pre-trial detention;
policing practices that lead to imprisonment with
compulsory drug detention centres that provide no
evidence-based treatment for substance use disorders
and inadequate health care; and discriminatory criminal
justice systems.1–7 The inter-related epidemics of HIV,
viral hepatitis, and tuberculosis in prisoners have been
seen as part of broader syndemics, which include mass
incarceration without needle and syringe programmes,
substance use, and mental disorders.
In the decades long, failed War on Drugs, people
who use drugs have been incarcerated in profoundly
misguided and harmful approaches to treatable
substance use disorders.8 Mass incarceration has
destroyed countless individual lives, had lasting
negative effects on prisoners’ families and communities,
and, in many settings, increased community rates of
HIV, tuberculosis, multidrug-resistant tuberculosis, and
hepatitis C virus (HCV).8 The threat of incarceration,
police harassment, and interference with access to HIV
and HCV prevention and treatment services has also had
an enormous impact on people who use drugs and other
marginalised populations, including sex workers, men
who have sex with men, and migrants and refugees. It is
past time for a rethink on the uses of incarceration, and
on ways of mitigating the effects mass incarceration has
had on the overlapping epidemics we all seek to control.
The need for a rethink is especially important because
of how the incarcerated population is changing.
Although most of the world’s 10·2 million estimated
prisoners and detainees are men, women and girls are
the fastest growing incarcerated population worldwide.9
The Institute for Criminal Policy Research reported
a 50% increase in the number of women and girls
incarcerated between 2000 and 2015 to about 700 000
worldwide, 205 000 (29%) of whom were in the USA
alone.9 The human, social, and financial costs of mass
incarceration in the USA are severe—most especially
among communities of colour. Among US women, HIV
burdens are also most concentrated among women and
girls of colour: in 2014 the rate of new HIV infections was
34·8 per 100 000 people in African American women
compared with 1·8 per 100 000 in white women.10
The first task in addressing HIV and related infectious
diseases among those incarcerated is to reduce the
numbers of people in prison and detention for substance
use, sex work, and other non-violent offences. This effort
will require policies that send fewer people to prison and
reduce the length of sentences. This change can happen
only if there is agreement on what prisons—and what
imprisonment—are for. Conventionally, incarceration
has had four possible goals: retribution (punishment);
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Panel: Don’t forget the prisoner
Everyone has a right to dignity when they need medical care. And everyone has a right to
compassionate medical treatment if they are suffering from diseases like HIV or
tuberculosis. And by everyone, I also mean our brothers and sisters behind bars. Our late,
beloved leader, President Nelson Mandela, contracted tuberculosis while he was a
prisoner on Robbin Island. Our country, indeed all of humanity, is so very fortunate that
Madiba survived to help lead us out of the darkness of Apartheid. But so many others in
prisons and jails, in detention or awaiting trial, are less fortunate. Imagine, if you can,
languishing with untreated HIV or tuberculosis, and lacking the freedom to do anything
about it. Fearing HIV exposure or acquiring tuberculosis, and being denied the basics of
prevention. Across Africa, our prisons and jails are overcrowded with men and women
who are at risk for HIV and tuberculosis, or who are already living with these treatable
infections—but who are being denied the care they so urgently need. We have left them
behind. This is unacceptable to God and it should be unacceptable to all of us. For when
we take away a man or a woman’s freedom, we must take on the responsibility to provide
for their wellbeing—with adequate food, decent sanitation, with the right to
representation, and to a timely trial—but also with prevention and treatment for these
deadly diseases.
God has not forgotten the prisoner, the detainee. No one is outside the circle of his love.
But we have forgotten, and we must do better. I urge all of you working on HIV and
tuberculosis to remember those among us who are not free. Keep them in your thoughts
and actions, build them into your budgets and plans. When you care for people suffering
from AIDS and tuberculosis without discrimination, especially for those forgotten by
others, you wipe a tear from God’s eye.
His Grace, Desmond M Tutu, Archbishop Emeritus of Cape Town
1
Comment
deterrence; incapacitation (stopping the prisoner from
reoffending while they are in prison); and rehabilitation
(reducing the risk that they will reoffend after release).11 The
evidence for each of these goals is much less clear than it is
often made out to be.
Legislators often cite public demand for retribution
to justify long prison terms with harsh regimes. Yet
research shows that they consistently overestimate
public demand for harsh treatment12 and for retribution
rather than rehabilitation.13
The evidence that prisons are a deterrent is complex
and subject to different interpretations.14 Durlauf
and Nagin15 provided a detailed methodological
review of the many weaknesses of previous research
on deterrence and concluded that what matters to
deter crime is the probability of being caught and
the certainty of punishment. Greater severity of
punishment, such as longer sentences, does not deter
those who might offend. Rather, deterrence is more
sensitive to effective policing through targeting of
resources and ensuring that responses are appropriate
to specific contexts. Prison terms and felony records
can initiate first-time offenders into cycles of poverty,
crime, and recidivism and, in many countries, there is
no attempt to rehabilitate prisoners.6,16 Gendreau and
colleagues’ comprehensive review17 found no evidence
that prison sentences reduced reoffending and, in some
comparisons, there was evidence that imprisonment
increased it. The authors concluded that the sole
justifications for prisons were incapacitation and
retribution, goals with which few citizens agree.17
The scarce evidence to support long periods of
incarceration raises the question of why, in some countries,
incarceration rates are so high, especially when other
countries manage to achieve low crime rates with much
lower rates of imprisonment. Several factors have a role.
First, in some countries, prisons act, in effect, as a surrogate
for mental health services. Second, in some countries
the numbers of incarcerated are swollen by many people
in detention awaiting trial.18 They are often detained in
facilities that are far worse than standard prisons.19 As
Lilanganee Telisinghe and colleagues5 point out in their
Series paper, pre-trial detention is also a particular challenge
for many African correctional systems, often in unsafe,
harsh conditions of overcrowding and undernutrition
without health services. Third, mass incarceration has been
increasingly used for offences related to substance use.
2
In any global review of mass incarceration, the USA
stands out. Presently, nearly one in every 100 Americans
is in jail, and in 2012 the USA accounted for 25% of the
world’s prisoners (and 29% of all female prisoners) but
only 5% of its population.20 A primary factor was the War
on Drugs, which systematically targeted people who use
drugs within minority communities, something reflected
in the composition of the prison population; in 2010,
African Americans were incarcerated six times more, and
Hispanics three times more, than non-Hispanic whites.21
There is an urgent need for reform on public health
and also on moral grounds (panel). 60 years ago, the
UN adopted the Standard Minimum Rules for the
Treatment of Prisoners. Although not binding, the rules
proved useful to prison administrators and monitoring
bodies. But they were also a product of another era, a
time when the human rights of prisoners were not widely
recognised and before the HIV/AIDS epidemic, the War on
Drugs, and the high prevalence of mental disorders among
prisoners. Bringing the rules up to date, however, was a
challenge, because many states were reluctant to subject
themselves to more stringent rules that could be used to
hold them to account. The new rules, entitled the Nelson
Mandela Rules, were finally adopted by the UN Commission
on Crime Prevention and Criminal Justice in May, 2015, and
approved by the UN General Assembly in December, 2015.22
The Nelson Mandela Rules provide benchmarks to
achieve meaningful reform in access to health care for
those detained. We can, and should, do better to reduce
both the numbers of those incarcerated and the length of
their sentences, and to improve prevention, treatment,
and post-release linkage to care for prison-associated
infectious diseases. Meeting community standards of
care in correctional settings, especially in low-income
and middle-income countries, will require political will,
financial investment, and support from medical and
humanitarian organisations across the globe, but it can
and must be done. Global control of HIV, viral hepatitis,
and tuberculosis will not be achieved without addressing
the unmet health needs of prisoners.
*Chris Beyrer, Adeeba Kamarulzaman, Martin McKee, for
the Lancet HIV in Prisoners Group
Center for Public Health and Human Rights, Johns Hopkins
Bloomberg School of Public Health, Baltimore, MD 21205, USA
(CB); University of Malaya, Kuala Lumpur, Malaysia (AK); and
London School of Hygiene & Tropical Medicine, London, UK (MM)
cbeyrer@jhu.edu
Comment
This Comment and the Lancet Series on HIV and related infections in prisoners
were supported by grants to the Center for Public Health and Human Rights at
Johns Hopkins Bloomberg School of Public Health from: the National Institute on
Drug Abuse; The Bill & Melinda Gates Foundation; the Open Society Foundations;
the United Nations Population Fund; and the Johns Hopkins University Center for
AIDS Research, a National Institute of Health (NIH)-funded programme,
1 P30AI094189; and AIDS Fonds Nederlands. The content is solely the
responsibility of the authors and does not necessarily represent the official views
of the NIH. The authors would like to thank His Grace, Archbishop Emeritus
Desmond M Tutu for his panel. The Lancet HIV and Prisoners Group includes:
Chris Beyrer, Joseph J Amon, Kate Dolan, Josiah Rich, Adeeba Kamarulzaman,
Leonard Rubenstein, Frederick L Altice, Lilanganee Telisinghe, Andrea L Wirtz,
Brian W Weir, Peter Vickerman, Michel Kazatchkine, and Martin McKee.
9
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15
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3
4
5
6
7
8
Dolan K, Wirtz AL, Moazen B, et al. Global burden of HIV, viral hepatitis, and
tuberculosis in prisoners and detainees. Lancet 2016; published online
Rich JD, Beckwith CG, Macmadu A, et al. Clinical care of incarcerated people
with HIV, viral hepatitis, or tuberculosis. Lancet 2016; published online
Kamarulzaman A, Reid SE, Schwitters A, et al. Prevention of transmission
of HIV, hepatitis B virus, hepatitis C virus, and tuberculosis in prisoners.
Lancet 2016; published online July 14. http://dx.doi.org/10.1016/S01406736(16)30769-3.
Rubenstein LS, Amon JJ, McLemore M, et al. HIV, prisoners, and human
rights. Lancet 2016; published online July 14. http://dx.doi.org/10.1016/
S0140-6736(16)30663-8.
Telisinghe L, Charalambous S, Topp SM, et al. HIV and tuberculosis in
prisons in sub-Saharan Africa. Lancet 2016; published online July 14.
http://dx.doi.org/10.1016/S0140-6736(16)30578-5.
Altice FL, Azbel L, Stone J, et al. The perfect storm: incarceration and the
high-risk environment perpetuating transmission of HIV, hepatitis C virus,
and tuberculosis in Eastern Europe and Central Asia. Lancet 2016; published
online July 14. http://dx.doi.org/10.1016/S0140-6736(16)30856-X.
Todrys KW, Amon JJ. Criminal justice reform as HIV and TB prevention in
African prisons. PLoS Med 2012; 9: e1001215.
Csete J, Kamarulzaman A, Kazatchkine M, et al. Public health and
international drug policy. Lancet 2016: 387: 1427–80.
10
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12
13
14
16
17
18
19
20
21
22
International Center for Prison Research. World female imprisonment list.
2015. http://wwwprisonstudiesorg/news/ (accessed June 9, 2016).
Centers for Disease Control and Prevention. National HIV surveillance
report. Atlanta, GA: Centers for Disease Control and Prevention, 2015.
Kifer M, Hemmens C, Stohr MK. The goals of corrections: perspectives from
the line. Crim Justice Rev 2003; 28: 47–69.
Applegate BK. Penal austerity: perceived utility, desert, and public attitudes
toward prison amenities. Am J Crim Justice 2001; 25: 253–68.
Applegate BK, Cullen FT, Fisher BS. Public support for correctional
treatment: the continuing appeal of the rehabilitative ideal. Prison J 1997;
77: 237–58.
McManus WS. Estimates of the deterrent effect of capital punishment:
the importance of the researcher’s prior beliefs. J Polit Econ 1985;
93: 417–25.
Durlauf SN, Nagin DS. The deterrent effect of imprisonment. Controlling
crime: strategies and tradeoffs. Chicago, IL: University of Chicago Press,
2010: 43–94.
Hammett TM, Donahue S, LeRoy L, et al. Transitions to care in the
community for prison releasees with HIV: a qualitative study of facilitators
and challenges in two states. J Urban Health 2015; 92: 650–66.
Gendreau P, Cullen FT, Goggin C. The effects of prison sentences on
recidivism. Ottawa, ON: Solicitor General Canada, 1999.
Walmsley R. Global incarceration and prison trends. Forum Crime Soc 2003;
3: 65–78.
Bobrik A, Danishevski K, Eroshina K, et al. Prison health in Russia: the larger
picture. J Public Health Policy 2005; 26: 30–59.
Travis J, Western B, Redburn S. The growth of incarceration in the United
States: exploring causes and consequences. Washington, DC: National
Academies Press, 2014.
Drake B. Incaceration gap widens between whites and blacks. FACTTANK:
News in the Numbers: Pew Research Center, 2013.
UN General Assembly. UN Standard Minimum Rules for the Treatment of
Prisoners (the Nelson Mandela Rules), 2015. New York: United Nations,
2015.
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Comment
African Americans, HIV, and mass incarceration
non-existent in US correctional facilities.8 Yet, many
prisoners engage in consensual sex, drug use, and
tattooing while in detention. Third, many prisons have
high rates of violence, including sexual assault.9 Fourth,
incarceration can limit or interrupt a person’s access
to health care. Effective HIV services that allow for
preventing, testing, and treating infection are often
absent.10 Individuals whose infections are detected and
treated while detained are likely to find their treatment
is interrupted upon release, or if they are re-detained.9
Most of these people quickly rebound with a high HIV
viral load during treatment interruptions, rendering
them infectious for sexual partners.9 With some 14% of
all Americans living with HIV cycling through the criminal
justice system each year, these common treatment
interruptions may play the most important role in the
markedly increased likelihood for African Americans
to encounter a sexual partner with HIV and who is not
virally suppressed.11
Since women represent less than 10% of the prison
population in the USA, the disproportionately high
incarceration rates for African American women do not
explain the sharp increase in HIV/AIDS rates among this
group. Instead, one influential study concluded that
the disparity in HIV/AIDS rates between black and white
populations is best explained by the hyperincarceration
of black men.12 The spike in HIV/AIDS rates among black
women seems to be due primarily to their increased risk of
having an infected partner. The CDC estimates that 87%
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The disproportionate rates of HIV infection among
African Americans are perplexing. In 2014, about 44% of
new HIV infections and 48% of AIDS diagnoses in the USA
were among African Americans, although they represent
just 12% of the overall population.1 The US Centers for
Disease Control and Prevention (CDC) reports, in 2016,
that the HIV incidence rate for black men is more than
six times that of white men, and more than twice that of
Hispanic men.2 The HIV incidence rate for black women is
20 times that of white women, and nearly five times that
of Hispanic women.2 Furthermore, African Americans
represent close to half of all patients with AIDS in the USA
who have died during this epidemic.2
HIV/AIDS prevention and treatment services in the
USA have largely focused on individuals with a history
of high-risk behaviours, such as injection drug use or
unprotected sex. Although white young adults who
engage in such high-risk behaviours are at increased
risk for HIV, young black adults without these usual risk
factors are nevertheless at higher than average risk for
HIV.3 One 2010 study showed that condom use was,
in fact, higher for black and Hispanic individuals than
for other racial groups.4 To explain the higher rates
of HIV/AIDS among African Americans, we need to
examine structural factors, such as access to health care
or disease prevalence within communities.
African Americans differ from other groups mainly
with regard to socioeconomic vulnerability—that is,
their probability of living in poverty, being homeless,
or spending time in a detention facility. A 2016 study
showed that, by 2011, the incarceration rate for black
men was six times that of white men and more than
twice that of Hispanic men.5 The incarceration rate for
black women was 2·5 times higher than the rate for white
women and roughly twice the rate of Hispanic women.5
Rates of incarceration and of HIV/AIDS have skyrocketed
for African Americans during the past three to four
decades. These two issues are linked for several reasons.
First, people at increased risk for HIV, such as injection
drug users and sex workers, often end up in prison due to
zero-tolerance policies in the USA for these activities.6,7
As a result, HIV prevalence is 3–5 times higher in prisons
and jails than in the general population.5,8 Second,
harm-reduction programmes—eg, provision of condoms
and clean needles to high-risk populations—are almost
1
Comment
of African American women with HIV become infected
through heterosexual sex, and only a small percentage
through injection drug use or other pathways.1
Incarceration rates have quadrupled in the USA in the
past several decades, and this has reduced the number
of men in black communities, and therefore the number
of available partners for heterosexual black women.
This fact, together with ongoing racial segregation,
contributes to the formation of insular sexual networks
with overlapping, concurrent partners.13,14 Moreover,
heterosexual African American women are more likely
to have sexual partners in high-risk groups, notably
men with a history of incarceration and, therefore,
men who have sex with men—a category that refers to
a person’s behaviour not someone’s sexual orientation.
Men who have sex with men include sexually active
men in single-sex settings, such as prisons, who do
not identify as gay or bisexual.15 Heterosexual African
American women have about twice the rate of HIV
infection compared with heterosexual African American
men (men who report no sexual activity with other
men), and this difference could be because of women’s
greater biological vulnerability14 and also because the
partners of heterosexual black men come from groups
with lower HIV risk.2 Importantly, the so-called down
low theory, which is often invoked to explain the high
rates of HIV/AIDS among African American women,
puts the spotlight on the wrong contributing factors.
This theory posits high numbers of secretive bisexuals in
African American communities and erroneously focuses
on a person’s sexual orientation rather than his history
of incarceration.16 It is a pernicious theory because it can
lead to inappropriate interventions and stigmatise a
sexual minority for the spread of HIV/AIDS.
To reduce HIV/AIDS rates among African Americans
we need to focus on structural factors, such as reducing
incarceration rates and improving access to health care.
For instance, all prisons and jails should initiate regular
opt-out HIV testing and increase prison counselling
and education programmes. Such practices generally
improve participation in testing, adherence to treatment,
and reduce risky behaviours. Also, correctional facilities
should develop harm-reduction strategies such as needleexchange and condom distribution programmes. Perhaps
most importantly, better linkages between community
and correctional health-care systems are essential to
reduce treatment interruptions in HIV treatment upon
2
detention, and after release, including assistance with
enrolling in health insurance programmes.17,18 Finally, we
need to evaluate the public health effects of adopting
zero-tolerance policies to deter recreational drug use,
adult sex work, and other non-violent offences, since
these policies may do more harm than good.
Laurie Shrage
Philosophy Department, Florida International University, Miami,
FL 33199, USA
lshrage@fiu.edu
I declare no competing interests. I thank Chris Beyrer for helpful suggestions on
this Comment, and the Edmond J Safra Center for Ethics at Harvard for supporting
my work on this topic.
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Centers for Disease Control and Prevention. HIV among African Americans.
2016. http://www.cdc.gov/hiv/group/racialethnic/africanamericans/
(accessed May 16, 2016).
Centers for Disease Control and Prevention. CDC fact sheet: HIV among
African Americans. 2016. http://www.cdc.gov/nchhstp/newsroom/docs/
factsheets/cdc-hiv-aa-508.pdf (accessed May 16, 2016).
Hallfors DD, Iritani BJ, Miller WC, Bauer DJ. Sexual and drug behavior
patterns and HIV and STD racial disparities: the need for new directions.
Am J Public Health 2007; 97: 125–32.
Reece M, Herbenick D, Schick V, Snaders SA, Dodge B, Forenberry JD.
Condom use rates in a national probability sample of males and females ages
14 to 94 in the United States. J Sex Med 2010; 7 (suppl 5): 266–76.
Tarver BA, Sewell J, Oussayef N. State laws governing HIV testing in
correctional settings. J Correct Health Care 2016; 22: 28–40.
Lanier MM, Zaitzow BH, Farrell CT. Epidemiological criminology:
contextualization of HIV/AIDS health care for female inmates.
J Correct Health Care 2015; 21: 152–63.
Blankenship KM, Smoyer AB, Bray SJ, Mattocks K. Black-white disparities in
HIV/AIDS: the role of drug policy and the corrections system.
J Health Care Poor Underserved 2005; 16 (4 suppl B): 140–56.
Lyons T, Osunkoya E, Anguh I, Adefuye A, Balogun J. HIV prevention and
education in state prison systems: an update. J Correct Health Care 2014;
20: 105–15.
Kantor E. HIV transmission and prevention in prisons. HIV InSite. April, 2006.
UCSF Center for HIV Information. http://hivinsite.ucsf.edu/
insite?page=kb-07-04-13 (accessed May 16, 2016).
Belenko S, Hiller M, Visher C, et al. Policies and practices in the delivery of HIV
services in correctional agencies and facilities: results from a multisite survey.
J Correct Health Care 2013; 19: 293–310.
Rich JD, Beckwith CG, Macmadu A, et al. Clinical care of incarcerated
people with HIV, viral hepatitis, or tuberculosis. Lancet 2016; published
online July 14. http://dx.doi.org/10.1016/S0140-6736(16)30379-8.
Johnson R, Raphael S. The effect of male incarceration dynamics on AIDS
infection rates among African-American women and men. J Law Econ 2009;
52: 251–93.
Pouget ER, Kershaw TS, Niccolai LM, Ickovics JR, Blankenship KM.
Associations of sex ratios and male incarceration rates with multiple
opposite-sex partners: potential social determinants of HIV/STI transmission.
Public Health Rep 2010; 125 (suppl 4): 70–80.
Higgins JA, Hoffman S, Dworkin SL. Rethinking gender, heterosexual men,
and women’s vulnerability to HIV/AIDS. Am J Public Health 2010;
100: 435–45.
Smith, Brenda V. Analyzing prison sex: reconciling self-expression with
safety. Human Rights Brief 2006; 13: 17–22.
Saleh LD, Operario D. Moving beyond “the down low”: a critical analysis of
terminology guiding HIV prevention efforts for African American men who
have secretive sex with men. Soc Sci Med 2009; 68: 390–95.
Solomon L, Montague BT, Beckwith CG, et al. Survey finds that many prisons
and jails have room to improve HIV testing and coordination of postrelease
treatment. Health Aff (Millwood) 2014; 33: 434–42.
Bechelli MJ, Caudy M, Gardner TM, et al. Case studies from three states:
breaking down silos between health care and criminal justice.
Health Aff (Millwood) 2014; 33: 474–81.
Perspectives
Click on to the website of Brown University’s Center for
Prisoner Health and Human Rights and you’re greeted
by a shocking nugget of information. “The nation’s three
largest psychiatric facilities”, it says, “are the New York, Los
Angeles and Chicago jails. More than half of the incarcerated
population has a mental health problem.” The Center’s
Co-Director is Josiah “Jody” Rich, Professor of Medicine and
Epidemiology at Brown University’s Warren Alpert Medical
School in Providence, Rhode Island. Co-founded in 2005 by
Rich and colleague Scott Allen to draw attention to the plight
of prisoners, the centre had humble origins. “We started it
with a website and some stationary—and some chewing
gum and a little piece of string”, Rich jokes. But he believes it’s
achieving the critical mass required to make an impact. “As
soon as you put that flag in the ground people start coming
out of the woodwork…It’s identified a lot of people within
the academic community who are doing things already.” Rich
speaks whereof he knows; since he joined Brown University’s
affiliated Miriam Hospital as an attending physician in
1994 he’s made countless visits to his local prison, tackling
problems of infectious disease, particularly HIV, and drug use.
Timothy Flanigan, Professor of Health Services, Policy and
Practice at Brown Medical School, has known and worked
with Rich for 20 years. “When Jody came here he started to
work in a weekly clinic for people in jail. He noted the high
rate of HIV among injecting drug users and also that they
were reusing needles. It was common for users to resharpen
their needles on the striking area of a matchbox. Needles were
being used 20 times or more because needle possession in the
state of Rhode Island was a felony that carried up to a 5-year
sentence. So he worked, one on one, with the law makers,
with the Department of Health to build a coalition, educating
and advocating to change the law. And sure enough, over a
few years, needle possession became a misdemeanour and
was eventually decriminalised.”
Rich’s efforts have had a real impact on prisoners’ health
says Michael Fine, Director until last year of the Rhode Island
Department of Health, and before that the Medical Program
Director of the Department of Corrections, who has worked
closely with Rich. “His work led to a substantial reduction in
the prevalence of HIV in Rhode Island. He brought screening
to the Department of Corrections. He cajoled, he pleaded, he
twisted, he turned, he did everything he could to encourage
a resistant correctional hierarchy to think about itself as a
centre point in the detection and treatment of HIV/AIDS.” It
took 20 years of hard work; but by looking for the people who
were blocking progress and either changing their minds or
finding a way around them Rich got there.
The struggle to change policy in respect of drug use proved
equally arduous. “When I got there”, Rich says, “if prisoners
came in on methadone, day one they’d get 50 mg, on day
two 40 mg and then 30, 20, 10 and then none. Anyone
who knows anything about methadone will tell you
that’s inhumane and ineffective.” Under his influence, the
authorities began to taper off the dose more gradually or even
continue it. As he noted last year in a Lancet Article, the more
liberal policy works: “Forced withdrawal from methadone on
incarceration reduced the likelihood of prisoners re-engaging
in methadone maintenance after their release.” Rich’s current
thinking on health in prisons is outlined in the Series paper
he has co-authored on the clinical care of incarcerated people
with HIV, viral hepatitis, or tuberculosis for The Lancet’s new
Series on HIV and related infections in prisoners.
Born into a family of scientists, Rich first studied chemistry
and then developmental biology. But his brother got hit
by a drunk driver and spent 2 months in hospital. “I spent a
lot of time there with him”, he recalls. “I just got exposed to
medicine, and intrigued by it.” He qualified at the University
of Massachusetts Medical School in 1987 before moving to
Atlanta for his internship and residency at Emory University.
During this time he spent 3 months in Bangladesh. “That
really opened my eyes to public health and infectious
diseases”, he says. Rich went on to do fellowships at Brigham
and Women’s Hospital in Boston, and at Harvard Medical
School, and became involved in the care of patients with
HIV. His interest in prisoners’ health dates back to his time at
Emory where he’d worked with them. The move to Miriam
Hospital was partly prompted by the possibility of being
able to extend this work in conjunction with Tim Flanigan.
Through making regular visits to his local prison, he began to
realise how profoundly the disease burden there differed from
that in the wider community—“kind of like going into another
world”. The more familiar he became with this disadvantaged
population, the more he felt there were ways in which their
health could be improved. While disliking incarceration, he
also sees it as a unique public health opportunity to engage
with people who are otherwise too often off the medical radar.
Fine sees Rich as motivated by his sense of justice. Flanigan
describes him as a happy warrior: “Jody’s relentlessly optimistic
and cheerful, always with a smile and with courtesy…And he
loves the drama of human nature. He’s famous for his stories,
just the events you come across in everyday life. Anything—
he’ll make a story of it.” Rich’s anecdotes enlivened my own
conversation with him—one concerned the time when he
came last among a group of candidates running as Mayor of
Charlestown, MA: an election he fought to publicise his antismoking views. His stories capture his audience. But when
Rich speaks up about prisoners his words help transform lives.
Photo Nola Rich
Profile
Josiah Rich: speaking up for the incarcerated
Published Online
July 14, 2016
S0140-6736(16)30901-1
See Online/Series
S0140-6736(16)30466-4,
S0140-6736(16)30379-8,
S0140-6736(16)30769-3,
S0140-6736(16)30663-8,
S0140-6736(16)30578-5, and
S0140-6736(16)30856-X
For the Center for Prisoner
Health and Human Rights see
http://www.prisonerhealth.org/
For Rich and colleagues’ 2015
Article see Lancet 2015;
386: 350–29
Geoff Watts
1

On both sides of the prison walls—prisoners and HIV

Transcription

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