Interventions with incarcerated persons

This chapter reviews the experience to date with interventions in the incarcerated setting that have relevance to HIV prevention, and is predominantly focused upon the United States, which has the highest rates of incarceration in the world. Incarceration is a fundamentally flawed, extremely expensive and inefficient approach to major societal problems. With this massive warehousing of people, society is embarking on a vast social experiment that will likely have dramatic and unanticipated implications in the years to come, reaching far beyond the actual individuals being incarcerated. One of these unanticipated consequences has been a disproportionate number of imprisoned individuals with and at risk for HIV infection. The epidemic of incarceration provides a tremendous opportunity to implement HIV prevention measures in a population that is often marginalized by the US health-care system, and poses a high risk of proliferating HIV epidemic. Participation rates in a range of in-house drug-dependence programs by drug-dependent inmates in state (39 percent) and federal (45 percent) prisoners reached new highs in 2004. These inmates mostly reported taking part in self-help groups, peer counseling, and education programs. Inmates in US correctional facilities often have a constellation of risk factors for HIV infection in addition to histories of substance dependence and abuse. Jails and prisons have become a storehouse for individuals with mental illness. In addition to mental illness, inmates frequently have histories of homelessness, physical and sexual abuse, and unstable family environments. These risk factors are often interrelated. Maintaining inmates in care during incarceration, and (often more challenging) after release, may well have a dramatic impact on reducing further spread of HIV both during incarceration and after release.