HIV Transmission Among Male Inmates in a State Prison System --- Georgia, 1992-2005

Morbidity and Mortality Weekly Report. 2006;55(15):421-426. 

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The estimated prevalence of human immunodeficiency virus (HIV) infection is nearly five times higher for incarcerated populations (2.0%)[1] than for the general U.S. population (0.43%).[2] In 1988, the Georgia Department of Corrections (GDC) initiated mandatory HIV testing of inmates upon entry into prison and voluntary HIV testing of inmates on request or if clinically indicated. GDC offered voluntary HIV testing to inmates annually during July 2003–June 2005 and currently offers testing to inmates on request. During July 1988–February 2005, a total of 88 male inmates were known to have had both a negative HIV test result upon entry into prison and a subsequent confirmed positive HIV test result (i.e., seroconversion) during incarceration. Of these 88 inmates, 37 (42%) have had more than one negative HIV test result before their HIV diagnosis. In October 2004, GDC and the Georgia Division of Public Health invited CDC to assist with an epidemiologic investigation of HIV risk behaviors and transmission patterns among male inmates within GDC facilities and to make HIV prevention recommendations for the prison population. This report describes the results of that investigation, which identified the following characteristics as associated with HIV seroconversion in prison: male-male sex in prison, tattooing in prison, older age (i.e., age of >26 years at date of interview), having served ≥5 years of the current sentence, black race, and having a body mass index (BMI) of ≤ 25.4 kg/m2 on entry into prison. Findings from the investigation demonstrated that risk behaviors such as male-male sex and tattooing were associated with HIV transmission among inmates, highlighting the need for HIV prevention programs for this population.

To describe the state's male inmate population and the 88 inmates known to have become HIV positive while in prison (i.e., seroconverters), investigators analyzed summary demographic data for all inmates and prison-movement and HIV-testing histories of seroconverters, all of which had been routinely collected for GDC administrative purposes. The HIV-testing and prison-movement histories of seroconverters were also analyzed to identify the facility in which HIV transmission occurred, defined as one in which a seroconverter had a negative HIV test followed by a subsequent positive HIV test confirmed by Western blot while incarcerated in the same facility.

To identify demographic characteristics and behavioral risk factors associated with HIV seroconversion, both an unmatched and a matched case-control study were conducted. Male inmates aged ≥18 years were eligible to participate in both studies. Case inmates had documented HIV seroconversion during the incarceration period. Control inmates had a negative result on their most recent HIV test (during 1997–2005) and had their HIV-negative status confirmed by repeat HIV testing on enrollment in the investigation. For the unmatched study, control inmates were randomly selected from a list of eligible inmates in the seven prisons in which the largest proportion of seroconverters were believed to have become infected with HIV. For the matched case-control study, to compare inmates with the same duration of exposure to risk for HIV transmission, control inmates were selected from the 31 prisons currently housing the case inmates and matched by sentence length (±2 years) and time already served (±2 years). After giving written, informed consent, inmates completed audio computer-assisted self-interviews (ACASI). No personally identifying information was collected in these interviews. To determine how behavioral risks for HIV infection changed during incarceration, the interview asked about sex, drug use, and tattooing behaviors during the 6 months before incarceration and during the incarceration period. Questions were also asked about knowledge regarding HIV transmission. Exact multivariate logistic regression was used to analyze unmatched data, and exact multivariate conditional logistic regression was used to analyze matched-pair data. After ACASI, investigators asked open-ended questions about strategies to reduce HIV transmission among inmates.

In October 2005, GDC housed 44,990 male inmates in 73 facilities; median age was 34 years (range: 15–88 years). A total of 28,350 (63%) were black, 16,364 (36%) were white, 50 were American Indian (0.1%), and 47 (0.1%) were Asian; race was not reported for 179 (0.4%). A total of 856 (1.9%) were known to be HIV infected, of whom 780 (91%) were infected before incarceration, and 732 (86%) were black.* During July 1988–February 2005 (the month in which the last seroconverter included in the investigation was identified), 88 male inmates had both a negative HIV test result upon entry into prison and a subsequent HIV seroconversion during incarceration. Of these 88 inmates, the median age at time of HIV diagnosis was 32 years (range: 21–58 years). Fifty-nine (67%) were black, and 29 (33%) were white. Diagnoses were made during September 1992–June 2003 for 47 (53%) inmates and during July 2003–February 2005 for 41 (47%). For 26 (30%) of the 88 seroconverters, the facility in which HIV transmission occurred was identified; for 34 (39%) seroconverters, the facility in which transmission occurred was narrowed to two. Of the 88 seroconverters, 11 were released from prison and two died before the start of the case-control study. Of the remaining 75 inmates, 68 (91%) were enrolled in both the unmatched and matched case-control studies as case inmates. Sixty-five (87%) unmatched control inmates and 70 (79%) matched control inmates who were eligible agreed to participate.

In multivariate analysis of the unmatched study, variables significantly associated with HIV seroconversion were male-male sex in prison, older age, having served ≥5 years of the current sentence, and having a BMI of ≤25.4 kg/m2 on entry into prison.

Univariate analysis of matched case-control study data identified multiple demographic characteristics and risk behaviors as significantly associated with HIV seroconversion ( Table 1 ). However, in the final multivariate logistic regression model, only four covariates were significantly associated with HIV seroconversion during incarceration: male-male sex in prison, receipt of a tattoo in prison, BMI of ≤25.4 kg/m2 on entry into prison, and black race ( Table 2 ).

Among 54 inmates (45 case and nine control) reporting male-male sex while in prison, 35 (78%) of 45 case inmates and four (44%) of nine control inmates reported no male-male sex during the 6 months immediately before incarceration. Among 54 inmates (case and control) who reported any male-male sex during incarceration, 39 (72%) reported consensual sex and 48 (89%) reported sex with other inmates. Exchange sex (e.g., for money, food, or cigarettes) and rape were also reported. Of 43 inmates (34 case and nine control) who reported any consensual sex, 13 (30%) reported using condoms or other improvised barrier methods (e.g., rubber gloves or plastic wrap). Of 14 (12 case and two control) inmates who reported any exchange sex, three (21%) reported using improvised barrier methods but not condoms; no barrier methods were used during rape. Of 59 inmates (48 case and 11 control) who reported having sex in prison, 36 (75%) case inmates and six (55%) control inmates reported intent to tell sex partners outside prison about unprotected sex in prison.

Of 68 inmates who reported receiving a tattoo in prison, 59 (87%) used clean tattooing equipment for at least one tattoo, 52 (76%) used bleach to clean tattooing equipment, two (3%) used tattooing equipment that was not cleaned, and seven (10%) did not know whether tattooing equipment was cleaned before they received at least one tattoo. Most inmates correctly identified that HIV can be transmitted through unprotected sex (88%), needle sharing (83%), and infected blood (78%). In 181 responses to open-ended questions about how to reduce HIV transmission in prison, inmates suggested that condoms be made available in prison (38%), that inmates receive HIV education (22%), and that inmates practice safe tattooing (13%).

Reported By: J Taussig, MPH, Georgia Dept of Corrections and Georgia Dept of Human Resources, Div of Public Health; RL Shouse, MD, Georgia Dept of Human Resources, Div of Public Health. M LaMarre, MN; L Fitzpatrick, MD, P McElroy, PhD, CB Borkowf, PhD, R MacGowan, MPH, AD Margolis, MPH, D Stratford, PhD, E McLellan-Lemal, MA, K Robbins, W Heneine, PhD, A Greenberg, MD, P Sullivan, PhD, Div of HIV/AIDS Prevention, National Center for HIV, Hepatitis, STD and TB Prevention; Z Henderson, MD, K Jafa, MBBS, EIS officers, CDC.

* Black persons are disproportionately affected by HIV/AIDS. Although blacks represent 12% of the U.S. population, an estimated 43% of all persons living with AIDS in the United States are black.[3] In Georgia, an estimated 76% of new AIDS cases reported in 2004 were among blacks (additional information is available at http://dhr.georgia.gov/DHR/DHR_FactSheets/AIDS%20in%20Georgia%20Jan%2006%20rev.pdf).

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