A group of researchers from the Centers for Disease Control and Prevention (CDC) set out to compare the racial identity, sexual identity and sexual practices of MSM who considered themselves "on the down low" (DL) with those MSM who did not. Drawing on a convenience sample of men (n=455) from12 northeastern cities, the study found that 20% of participants self-identified as DL; that is they were both aware of the term and considered it descriptive of their own situation. Overall, blacks (41%) and Hispanics (17%) were more likely than whites (4%) to self identify as DL. In regard to sexual identity, participants who did not identify as gay were more likely to describe themselves as DL. Behaviorally, DL-identified MSM were less likely to have had seven or more male sex partners in the prior 30 days, but were more likely to have had a female partner and participated in unprotected vaginal sex. High rates (68%) of both DL and non-DL men had taken part in unprotected anal sex in the last thirty days, but self-identified DL individuals were more likely to have done so with partners of unknown serostatus. Additionally, the DL-identified group was less likely to have ever been tested for HIV. While the investigators concede the limitations of the study, due largely to convenience sample eligibility and varying definitions of the term DL, they also recognize that the results highlight the need for public health programs to adopt and expand risk reduction strategies among this population.

In this study, investigators in Texas reported select results on Project Wall Talk, a community-based, peer-led HIV prevention and education program implemented in thirty six Texas State Prisons. The data demonstrates significant improvement in HIV knowledge among both the peer-educators (N=257) and students (N=2,506) following enrollment in the program. Importantly, the training was able to erase differences in HIV-related knowledge across categories of prior education and race/ethnicity from baseline to follow-up, a period of nine months. Peer-educators, who received 40 hours of intensive training prior to conducting education sessions with other inmates, reported higher levels of HIV testing. Similarly, more students indicated plans to take an HIV test following receipt of peer-led education, even though fewer students reported knowing their current serostatus. At five prison facilities where Program Wall Talk was implemented, the number of HIV tests was approximately double that of five, matched comparison units in both the 12 and 18 month follow-up periods. Additionally, the authors suggest that the diffusion of the knowledge may spread well beyond the classroom and even outside the prison, with teachable moments reaching as high as 84,000 opportunities per year. While the study data is limited by an attrition bias, which may have positively selected the more able peer-educators (43.6% of baseline sample), the authors strongly assert that peer-education training represents an effective means of improving both HIV knowledge and peer education skills.

While the majority of research regarding HIV prevention and transmission in prisons has occurred in high-income countries, in this review article, published in the Lancet Infectious Diseases, Dolan et al provide a summary of imprisonment rates, HIV prevalence, and injection drug use (IDU) in 152 low and middle-income countries. Using data from a variety of governmental and non-governmental sources, the authors found that HIV in prisons was a significant problem, especially in areas where IDU is common, such as Eastern Europe, Central Asia, and Latin America. Overall, the prevalence of HIV was greater than 10% in prisons in 18 countries, including seven in sub-Saharan Africa and at least one country in all the regions of the world except South Asia. Of the eight countries reporting HIV prevalence among IDU prisoners, seven reported HIV prevalence among this group at levels greater than 10%. Unfortunately, data collection proved to be a challenge, as researchers faced poor record keeping, language barriers, and official reluctance to release documentation. For many countries, the lack of data, especially in regard to the relationships between HIV prevalence and IDU, made the contribution of HIV in prison settings difficult to determine. In closing, the authors suggest that further data collection is urgently needed to inform future HIV prevention strategies in these countries.

An accompanying editorial makes the point that richer countries also have HIV levels among prisoners above those seen in their general populations. The U.S., France, Netherlands, Spain and Portugal all have reported HIV prevalences among prisoners substantially above their national rates. In Spain, 24% of inmates were HIV-infected in 1996; however, the prevalence was cut in half to by 2003 following the introduction of harm reduction programs.