Sex, Drugs, Prisons, and HIV (NewEngJournMed)

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Volume 356:105-108 January 11, 2007 Number 2

Sex, Drugs, Prisons, and HIV

Susan Okie, M.D.

One recent morning at a medium-security compound at Rhode Island's state prison, Mr. M, a middle-aged black inmate, described some of the high-risk behavior he has witnessed while serving time. "I've seen it all," he said, smiling and rolling his eyes. "We have a lot of risky sexual activities. . . . Almost every second or minute, somebody's sneaking and doing something." Some participants are homosexual, he added; others are "curious, bisexual, bored, lonely, and . . . experimenting." As in all U.S. prisons, sex is illegal at the facility; as in nearly all, condoms are prohibited. Some inmates try to take precautions, fashioning makeshift condoms from latex gloves or sandwich bags. Most, however, "are so frustrated that they are not thinking of the consequences except for later," said Mr. M.

Drugs, and sometimes needles and syringes, find their way inside the walls. "I've seen the lifers that just don't care," Mr. M said. "They share needles and don't take a minute to rinse them." In the 1990s, he said, "needles were coming in by the handful," but prison officials have since stopped that traffic, and inmates who take illicit drugs usually snort or swallow them. Tattooing, although also prohibited, has been popular at times. "A lot of people I've known caught hepatitis from tattooing," Mr. M said. "They use staples, a nail . . . anything with a point."

Mr. M had just undergone a checkup performed by Dr. Josiah D. Rich, a professor of medicine at Brown University Medical School, who provides him with medical care as part of a long-standing arrangement between Brown and the Adult Correctional Institute in Cranston. Two years ago, Mr. M was hospitalized with pneumonia and meningitis. "I was scared and in denial," he said. Now, thanks to treatment with antiretroviral drugs, "I'm doing great, and I feel good," he reported. "I am HIV-positive and still healthy and still look fabulous."

U.S. public health experts consider the Rhode Island prison's human immunodeficiency virus (HIV) counseling and testing practices, medical care, and prerelease services to be among the best in the country. Yet according to international guidelines for reducing the risk of HIV transmission inside prisons, all U.S. prison systems fall short. Recognizing that sex occurs in prison despite prohibitions, the World Health Organization (WHO) and the Joint United Nations Program on HIV/AIDS (UNAIDS) have recommended for more than a decade that condoms be made available to prisoners. They also recommend that prisoners have access to bleach for cleaning injecting equipment, 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.

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Source Information

Dr. Okie is a contributing editor of the Journal.

An interview with Theodore Hammett can be heard at www.nejm.org.

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http://content.nejm.org/cgi/content/full/356/2/105?query=TOC