Finally, to focus only on what transpires within the prison walls as it relates to HIV is a mistake: such a perspective fails to capture the range of social impacts on prison staff, prisoners, and their families and friends. What transpires in prisons has a great deal to do with the social life of many inner-city neighborhoods, even if the prisons are located on rolling hillsides, hundreds of miles away. The correctional enterprise, through the parole system, remains involved in many prisoners' lives long after they leave the institution. For many offenders, moreover, prisons have revolving doors. HIV disease may also play a role in decisions about charging criminal defendants, determining the term of incarceration when sentencing prisoners, and deciding when to release prisoners to the community.

This chapter first presents a brief overview of the U.S. prison population and then examines the scope of HIV disease in prisons and its impact on prisoners and prison administration. Among the issues addressed are prison policies regarding HIV testing and screening, segregation of HIV-infected prisoners, prisoner access to routine health care and to experimental treatment, and policies regarding the transfer and release of prisoners with HIV disease.


Approximately 1 million individuals are currently confined in prisons and local jails in the United States (Associated Press, 1991; Mauer, 1991).2 The prison population has grown every day since 1974; recent growth is the largest since the federal government began keeping annual records in 1926 (Johnson, 1990). Of every 100,000 U.S. residents, 426 are incarcerated; among black men, the number is 3,109 per 100,000.3 Spending on federal and state prisoners in the United States approaches $25 billion annually (Malcolm, 1991). Since the beginning of the HIV epidemic (approximately 1980), the population in federal prisons and in prisons in the District of Columbia and 18 states has doubled; in California and New Jersey, two states particularly hard hit by the HIV/AIDS epidemic, the number of inmates tripled during the same period (National Commission on AIDS, 1991).

Most commentators have attributed the dramatic increase in the U.S. prison population to mandatory minimum sentences (commonly associated with drug and weapons offenses and sexual assaults and other violent crimes) and restrictive parole eligibility criteria. Langan (1991) holds that the most important factor has been higher imprisonment rates (prosecutors obtaining more felony convictions and judges meting out more prison sentences), which Langan says account for 51 percent of the increase in state prison populations from 1974 to 1986. By contrast, imprisonment for drug offenses accounts for only 8 percent of the increase (although the increase may be greater in recent years, and many property crimes are drug related).

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