One in Four

Reports of alarming rates of HIV among incarcerated Americans fall on deaf ears of those in power.
Left Field by Patricia Nell Warren

Between 20% and 26% of people living with HIV/AIDS in the United States have spent time in the correctional system.” That was the startling and little-noticed statement in a 2006 study by UC San Francisco professor Elizabeth Kantor, titled “HIV Transmission and Prevention in Prisons.” As her source, Kantor cited a 2002 report to Congress by the National Commission on Correctional Health Care. She pointed out that this figure is an estimate, saying: “No precise count of HIV cases in prisoners is available, as brief incarceration, particularly in jails, limited access to health care, and lack of universal screening hinder the identification and diagnosis of inmates with HIV infection. Also, arrestees may choose not to declare their HIV status.”

So—conservatively one in five, maybe one in four. If that provocative figure is accurate, it reveals a shocking and fundamental fact about the U.S. AIDS epidemic that has been kept quiet. The fact: U.S. prisons and jails, plus the prevailing policies on tough sentencing and social conditions behind bars, are a driving force in the spread of HIV. And who are these “one in four” people?

To get a hard statistic, a researcher would have to know the identity of each HIV-positive person, then backtrack to see if that individual had spent time behind bars. With sexual violence raging in our correctional system, even a few days behind bars (waiting to make bail, for example) can be long enough for an arrestee, adult or minor, to be raped and exposed to HIV infection. But in 2006, only eighty percent of the states were reporting name-based HIV diagnoses. So a name-based search for prison records of HIV-positives would necessarily be incomplete.

To look for human faces in this “one in four” figure, we have to step onto the shifting sands of estimates and extrapolations. According to the CDC in a 2008 Morbidity and Mortality Weekly Report, this was how 2006 HIV-positives divided into risk groups: “46.1% were black, 34.6% were white, 17.5% were Hispanic, 1.4% were Asian/Pacific Islander, and 0.4% were American Indian/Alaska Native. Males accounted for 74.8% of prevalent HIV cases. The greatest percentage of cases was attributed to male-to-male sexual contact, accounting for 48.1 percent overall (and 64.3 percent among men). High-risk heterosexual contact, defined as heterosexual contact with a person known to have, or to be at high risk for, HIV infection (e.g., an injection drug user) accounted for 27.6 percent of prevalent cases overall (12.6 percent of cases among men and 72.4 percent of cases among women). Injection drug use (IDU) accounted for 18.5 percent of total cases (15.9 percent of cases among men and 26.3 percent of cases among women). The remainder of cases were attributed to men who reported both male-to-male sexual contact and IDU (5.0 percent) or whose transmission category was classified as other (0.8 percent; including hemophilia, blood transfusion, perinatal exposure, and risk factors not reported or not identified).”

So CDC gives us a clue about some of these “ones in four.” The agency went on to add: “The HIV prevalence rate for black men…was six times the rate for white men…The rate for black women was greater than the rate for all other groups, except for black men.”

At the time that Elizabeth Kantor and the CDC made their announcements, African-American men were not only a large slice of the HIV-positive pie—they were seventy-five percent of the total population behind bars in the United States. Black inmates were a hard figure, not an estimate. By January 2006, there were more than 2,100,000 inmates in our prisons and jails. Then, as now, the U.S. incarcerates a higher percentage of its people than any other country—including China and other dictatorships out there. So surely black men are one of those four.

Black women, too, must have a presence in that “one in four,” along with injection drug-users, who are at high risk of HIV infection because of needle sharing. The CDC doesn’t mention transsexuals and intersex people, but they too have a high incarceration rate, thanks to social biases against them, and the fact that many of them are unemployed and turn to prostitution for a living.

CDC insisted that adult MSMs have the highest infection rate of all risk groups. Once behind bars, these HIV-positive MSMs may become targets of sexual violence if they are gay or bi and their orientation becomes known to other inmates. Or they may be the heterosexual inmates who adopt homosexual behaviors while behind bars, and infect other prisoners through consensual or violent nonconsensual sex.

LGBT youth loom large among those “ones in four.” Says Prison Law on-line: “LGBT youth make up 15 percent of the prison population…. ‘LGBT youth are more likely to be arrested than straight youth because they’re more likely to be pushed out of their homes,’ says Dr. [Marty] Beyer. And ‘family rejection is a direct pipeline to the juvenile justice system,’ says San Francisco State University researcher Caitlin Ryan of the Family Acceptance Project.” These LGBT youth are more likely to be black or Latino than white, because of problems they might have at home with conservative religious parents in these ethnic communities.

One thing that Kantor’s estimate can’t tell us is whether those “one in four” are seroconverting while in prison, or whether they were already positive when they got there. LGBT youth inmates are frequently victims of sexual violence—exposing them to HIV infection for the first time in their lives. In the adult category, some black men who may acquire their infections prior to first sentencing may have acquired HIV through down-low activities. But African-American commentator Keith Boykin questions whether “down low” is the major factor that it’s been made out to be. He points out that “we’re not talking about needle exchange programs…we’re not talking about condoms in prisons …we’re not talking about the…African Americans who don’t have health insurance. How do you encourage people to get tested for HIV if they don’t have insurance to treat HIV?”

Rev. Jesse Jackson is an African American who looked hard at the “one in four” factor. He calls male sex in prison “the epicenter” of the AIDS epidemic for black men. Todd Savage in AIDSInfoNY quotes Jackson as saying, “For two prisoners to be put together—one positive and one not—that is genocide and not observing [prisoners’] constitutional rights, especially if there are going to be instances of consensual or even forced sex.”

As I write this, national media are discussing whether President Obama will launch any prison reform. As an African American, he is acutely aware of the justice system’s sickening bias against black men, who experience the highest rate of arrest and unjust sentencing—even death sentences for men who are later proven innocent. There is also a screaming need for effective rehabilitation to replace punishment for problem youth. Way fewer nonviolent offenders should be incarcerated—and the ugly recent trend of jailing Americans for inability to pay small debts should be declared unconstitutional. The costs of this out-of-control penal system are among those bankrupting our nation.

Meanwhile, with our incarcerated population pushing 2.4 million today, the overcrowded jails and prisons are bursting with sexual and social tensions. Conditions that contribute to spread of HIV are still rampant. Prison authorities continue to deny condom use to prisoners, insisting that having sex there needs to remain illegal. They are moving slowly and reluctantly towards ending sexual violence, and providing testing of inmates, as well as separate wings and adequate treatment for those with HIV/AIDS. Which means that our penal system still sends that shadowy, unacknowledged one out of four to stand among Americans who live with HIV/AIDS.

Further reading:

• Elizabeth Kantor’s paper:

• Prison Law on LGBT youth:

Author of fiction bestsellers and provocative commentary, Patricia Nell Warren has her writings archived at Reach her by e-mail at [email protected]

Copyright © 2010 by Patricia Nell Warren. All rights reserved.

November 2010