Low transmission rate among Georgia inmates
Low transmission rate among Georgia inmates
Tattooing could be mode of transmission
Public health officials have relied on sparse data about HIV transmission in prisons, even while knowing that HIV infection rates among prisoners typically are higher than in the general population.
So the CDC studied HIV transmission among male inmates in the Georgia prison system with the goal of learning enough to make recommendations, says Patrick Sullivan, DVM, PhD, chief of the behavioral and clinical surveillance branch of the CDC.
The state of Georgia invited the CDC to conduct an epidemiological investigation as a way to understand the factors associated with HIV infection and to make recommendations for preventing transmission, Sullivan says.
Investigators reviewed data showing that from July, 1988, to February, 2005, 88 male inmates had both a negative HIV test when they entered prison and a positive HIV test while they were incarcerated.1
"We wanted to shed light on the subject and have a snapshot of the specific circumstances of 88 men who became infected in a prison system," Sullivan says. "The study fills in some gaps and challenges a popular misconception about prison."
A control group of inmates had a negative HIV result on their most recent HIV tested during 1997 and 2005.1
Inmates who participated in the study were given audio, computer-assisted self-interviews and no personally identifying information was collected. The interview asked about risk behaviors, including sex, drug use, and tattooing during the six months before incarceration and during the incarceration period.1
The investigation had some interesting findings, including the possibility that some inmates were infected with HIV while receiving tattoos while in prison.1
"We're going back to the inmates who reported tattooing and doing an in-person interview because our experience is that sometimes you need repeated contact in interviews to build a relationship before you can ascertain all of the risk factors," Sullivan says.
"We want to be scientific about observing whether this is a mode of transmission," Sullivan explains. "We'll ask them who did their tattoo and what kind of equipment was used, and whether they saw someone else get a tattoo right after them."
It would be unusual to find that tattooing is indeed a mode of transmission for HIV, but in prisons where there is no access to sterile needles for tattooing it would make the possibility more likely, Sullivan adds.
Through DNA analysis and viral "fingerprinting," investigators will determine whether there is a relationship between the viruses of men who reported tattooing as their only risk factor and those who reported sex as a risk factor, as well, Sullivan says.
"The goal is to reach the best conclusion about whether this relationship is causal," he says.
One common belief that was punctured by the study is the idea that most sex is non-consensual, Sullivan says.
Most of the men who had sex in prison characterized it as consensual, and rape was the least reported among the types of sexual encounters, Sullivan says.
Among the men who were infected with HIV while in prison, 29% reported no sexual encounters, 46% reported consensual sex only, 16% reported sex in exchange for food, drugs, or cigarettes, and 9% reported having been victims of rape.1
The study also shows that most of the inmates who are HIV positive had entered the prison system while infected, Sullivan says.
The Georgia Department of Corrections had 44,990 male inmates in 73 facilities in October, 2005, and 856 of these inmates were known to be HIV-positive. Of these 856 inmates, 780 had been infected before incarceration and 732 were black.1
"In October, 2005, when we looked at the whole group of infected inmates in the state prison system, we saw that 91% came into the prison system with HIV, and 9% of all HIV-infected individuals had acquired it in prison," Sullivan says. "That doesn't minimize the importance of prisons in the HIV epidemic because we know from other sources of data that the prevalence of HIV among inmates is four times what it is in the general population."
What the study does show is that the prison population is a population of men who engage in high-risk behaviors within their communities, and they have some risk of acquiring HIV while in prison, Sullivan says.
This population is a hard one to reach while they're in the community, and 97% of them will return to their communities, so providing HIV prevention services to them while they're in prison is critical, Sullivan adds.
"We'd like to think those released back into the community will go back with the knowledge, tools, and skills to protect themselves, their partners, and the community," he says.
The study's final analysis found four things associated with being infected with HIV among inmates, and these included male-to-male sex and having received a tattoo while in prison, Sullivan says.
"Both were independently associated with being HIV infected," he says. "The other factors were demographics, including being black and having a [lower] body mass index (BMI) which was in the lowest quartile of inmates we talked to."
The demographic factors aren't related to risk biologically, but probably are markers for other aspects of behavior or HIV prevalence, Sullivan notes. (See table of HIV-positive inmate demographics.) For instance, HIV prevalence is higher among African American men than it is among Caucasian men, so although the percentage of black men who said they had engaged in male-to-male sex was similar to the percentage of white men who said the same, the black men may have encountered more partners at risk for having HIV infection, Sullivan says.
"One hypothesis is if there are race-specific sexual or injecting networks in the prison, then that would suggest the black inmates were preferentially picking partners of a higher prevalence pool," he explains.
Another hypothesis, which is about the BMI findings, is that men of slight build are more likely to be receptive partners when anal intercourse occurs, Sullivan says.
"Because the number of reported rape incidences was low, we weren't able to statistically say that men of slighter build were more likely to be rape victims," he says. "We're still in the process of looking at data to see whether they were more likely to be receptive partners in consensual sexual relationships."
Other characteristics associated with HIV seroconversion in prison were being older than 26 years at the time of interview and having served five years or more of the current sentence.1
Reference:
- HIV transmission among male inmates in a state prison system—Georgia, 1992-2005. MMWR Morb Mortal Wkly Rep. 2006;55(15):421-426.
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