While the reports must have been interesting, each should be read in the context of the site where they were performed. Rates of HIV infection, methods of HIV transmission and cultures differ and these differences and must be factored into any decision on public health interventions. Context influences the choice of any public health intervention. For example, in some parts of the world yellow fever vaccine is required of international travelers and in some parts of the world BCG vaccine is required for infants to prevent complications of tuberculosis. However, neither of these is recommended in the U.S. In some parts of the U.S. extensive mosquito control programs are used to prevent West Nile disease however these control programs are not needed or effective in other areas.

Programs vary among countries. In some countries condoms are readily available to inmates, in some countries methadone maintenance is provided to inmates, in some countries drug treatment on demand is available to inmates and in at least one country heroin is provided to addicted inmates. Each of these may be appropriate in some places and not in others. Rate of infection, rate of transmission, patterns of transmission and culture must be considered.

It is interesting to consider the debates that will occur when an effective vaccine against HIV becomes available. Will it be required for some groups, perhaps as a "no shots no school requirement?" How will those groups be defined? It does not seem likely that fundamentalist pastors will take kindly to a requirement that their ten-year-old children must be vaccinated against HIV.

As we in the U.S. consider which of the various interventions to prevent HIV transmission in prisons to recommend, we must not get too far ahead of our U.S. culture. If we do we are likely to discredit ourselves in the eyes of those to whom we have to look for support as we try to provide the full range of health care needed by our inmate patients. While we need to lead, moving too far or too fast will not be effective.

We do have an obligation to consider potentially effective interventions. We should recommend those that are targeted to the specific needs of our inmates, most of whom will return to our communities, and have a chance of being made operational within our culture. The decision on any specific program may not be self evident and will not be the same for all jurisdictions.

- Lester Wright, MD