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OCTOBER & NOVEMBER 2007
Main Article:
Prevention in Practice: Prisoner Access to Condoms – the California Experience
Mary Sylla, JD, MPH Director of Policy & Advocacy Center for Health Justice West Hollywood and Larkspur, CA Disclosures: Nothing to Disclose Introduction Providing prisoners access to condoms is controversial. To some it seems hypocritical – why would we give prisoners condoms when it’s illegal to have sex in jail and prison – and to others it seems like common sense, unless we pretend to ignore the fact that some sexual activity takes place in jails and prison. There are clearly pros and cons and unusual challenges to adopting a harm reduction strategy in a law and order environment. On October 15, 2007, California Governor Arnold Schwarzenegger vetoed the latest “prison condom bill” to hit his desk. But this time he directed the California Department of Corrections and Rehabilitation to determine the “risk and viability of such a program” by establishing a pilot program. What follows is a review of the prisoner condom access programs in two correctional facilities – one in Los Angeles and one in San Francisco – administered by the Center for Health Justice, a community-based non-profit organization focused on HIV and incarceration, and on-going research on those programs. This article is a written version of a presentation given at the National Convention on Correctional Health Care in Nashville on October 17, 2007. Condom Access for Prisoners: Pros and Cons There are serious concerns about providing prisoners with condoms. Introducing anything new into the security environment provides prisoners with an additional potential tool for conducting illegal activities including secreting contraband and assaulting staff with bodily fluids or excrement (called “gassing” in California). Further, in a rule-based environment it can be considered hypocritical to tell prisoners it’s illegal to engage in sexual activity and then provide the means to “safely” engage in that activity. From this viewpoint it sends the wrong message, and could be used by assailants to prevent evidence of sexual assault from remaining. There are reasons why provision of condoms to prisoners might be a good idea. Even though it is illegal to have sex in jail or prison, that rule cannot be perfectly enforced in the many overcrowded and understaffed institutions in this country. Both scientific evidence and popular media point to the fact that sexual activity takes place behind bars. Last year the Centers for Disease Control and Prevention (CDC) published in the Morbidity and Mortality Reports (MMWR) a study that documented seroconversion during incarceration.1 Those who became HIV-infected were 8 to 10 times as likely to report engaging in male-to-male sexual activity while in prison than those who did not. The prevalence of known HIV among prisoners is extremely high: the rate of HIV infection among prisoners is 5 to 7 times that of the general population.2,3 The very behaviors that put people at risk for HIV infection – injection drug use and sex work – are also behaviors that can lead to incarceration. In the U.S., approximately one in four persons with HIV infection passes through a jail or prison each year – and many of those do not know they are infected.4 Therefore, a considerable number of HIV-infected prisoners may not know they are HIV-infected and as such unwittingly may transmit their infection to others. Where are condoms provided to inmates? Condoms are provided to prisoners in county jails in Los Angeles, San Francisco, Philadelphia, Washington, D.C. and New York and in the state prisons in Vermont and Mississippi. The manner in which condoms are made available varies widely among these facilities. In Los Angeles, the Center for Health Justice distributes free condoms to a segregated gay male population only, one condom per week per inmate, a limit imposed by the Los Angeles Sheriff’s Department. San Francisco’s Forensic AIDS Project (part of the Department of Public Health) distributes condoms upon request through its public health nurses in one-on-one health counseling sessions, one per person, per request, and upon release. Earlier this year the Center for Health Justice in San Francisco installed a condom dispensing machine – a vending machine set to require no payment – in a gym to which 800 prisoners have access. About 70 condoms per week are taken from the machine. In Washington, D.C., prisoners in the D.C. jail system have access to free condoms during health education classes, voluntary HIV pretest or posttest counseling, or upon request to members of the health care staff. The jail’s health educator and staff of a community-based AIDS service provider distribute about 200 condoms to prisoners each month. In Philadelphia, prisoners can get condoms from the medical services department or through the commissary. These methods of providing prisoners access to condoms vary, and most reach only a small subset of the prisoner population in the jail and prison systems in which they operate. Two pilot programs of condom distribution in California The Los Angeles County Jail Model The Los Angeles condom access program was the result of a unique set of circumstances: a new Custody Chief – who had just been promoted from Medical Services – approached the Center for Health Justice about the possibility of designing a program that could provide gay male prisoners in dormitory-style housing units access to condoms without involving custody staff or time. The program today exists as it did when implemented: once a week a health educator from the Center for Health Justice goes in to each dorm, provides a brief, interactive HIV education session, the rules of the program (including that sex is still illegal in jail under California law and that the condoms are not to leave the dorm or they will be considered contraband) and hands one condom to each prisoner who lines up to receive one. Although the average has changed over time, the Center for Health Justice currently distributes about 120 condoms per week to the 300+ prisoners in this unit. To evaluate this program, 101 of the approximately 300 prisoners who live in the unit for segregated gay males were asked a series of questions through a computer-assisted self-interview program. Although the formal data analysis has not been completed, interesting statistics compiled so far include that 93% of respondents were aware of the condom program and 82% had received at least one condom from the program. Fifty-three percent of respondents reported anal sex during the past 30 days – but despite access to condoms, 75% of those who reported anal sex during the past 30 days said it was unprotected. The three top reasons for not using condoms were: (1) my partner and I are both HIV negative (or positive); (2) I ran out of condoms; and (3) I don’t like the way condoms feel. Information was gathered about other methods of condom access: 66% preferred the current method of distribution; other methods of distribution that would be to others who indicated Medical (41%), Vending (10%), or Canteen (8%). The results of this evaluation will be finalized and published during the coming year, but support the assertion that some risk-reduction is achieved in this population through access to condoms. The San Francisco County Jail Model In San Francisco, the Center for AIDS Prevention Studies and Dr. Olga Grinstead are conducting research on a novel way to provide prisoners access to condoms that has been successful in other countries. As mentioned earlier, in San Francisco, prisoners have had access to condoms since 1987 through the Forensic AIDS Project’s health educators in one-on-one individual consultations. In the fall of 2006, the Center for Health Justice, Dr. Grinstead and theForensic AIDS Project approached the Sheriff of San Francisco about installing a condom dispensing machine, in part because of reports from Forensic AIDS Project staff that the demographic characteristics of the health educator seemed to influence whether a prisoner being counseled took a condom. The Center for Health Justice sought to evaluate a more anonymous method of providing prisoners access to condoms, as well as being less staff-intensive. The dispensing machine program and its pilot feasibility are being conducted by the Center for Health Justice in collaboration with the Forensic AIDS Project. The machine was installed in April 2007 in a gym to which 800 prisoners have access every week for their three hours of recreation. Sheriff Michael Hennessey himself, to provide a large number of prisoners access to it, suggested the precise location of the machine. Prior to installing the machine, brief written surveys were conducted with prisoners to elicit baseline information about their HIV status, knowledge of the existing condom program and risk behavior. Interviews were conducted with Sheriff’s Department staff to assess attitudes about condom access for prisoners and determine potential security concerns. Center for Health Justice staff also made presentations to all deputy staff and prisoners affected by the program before the machine was installed. The same written survey and similar interviews were conducted after the machine was operational for four months. The machine itself is a low-profile tamper-resistant unit, designed to withstand break-inattempts. The machine dispenses condoms in a cellophane wrapped paper box. Inside the box the condoms are enclosed in another cellophane wrapper. The “Condom Machine Rules” posted next to the machine indicate that condoms are to be removed from the box and carried only in the clear wrapper, with the condom inside visible. The Condom Machine Rules, in full, read:
During the study period the Center for Health Justice successfully installed, stocked and maintained the condom machine. Data analyses of the pre- and post-surveys and interviews are currently underway. Preliminary data analyses indicate that prisoner self-report of sexual activity did not increase during the study period; in addition the custody staff have reported no increase in reported sexual activity or any other security problems related to increased condom access. We have encountered few operational problems, the most notable falling on the staff restocking the machine: the machine was difficult to open and close for restocking and sometimes jammed. A new model of machine has been purchased to address these problems. Evaluations of these two pilot programs are currently being analyzed. In Los Angeles, Charles R. Drew University’s Dr. Nina Harawa and the Center for Health Justice (with funding from the California HIV/AIDS Research Program-funded Institute for Community Health Research) are evaluating the current Los Angeles County Sheriff’s Department program to determine whether the program is reducing sexual risk activity. Conclusions: Condoms coming soon to a facility near you? While controversial, there is a trend toward increased prisoner access to condoms. The CDC now recommends that prison systems with existing condom distribution programs evaluate those programs, and those without such programs consider the feasibility of implementing condom distribution programs. Governor Schwarzenegger’s “friendly” veto of legislation requiring prisoner access to condoms may result in a pilot project across the state. At the federal level, Representative Barbara Lee’s JUSTICE Act of 2007 (H.R. 178), modeled on the California bill, requires federal prisoners to have access to condoms. Even where legislation is not pending, jails and prisons are considering the issue. Regardless, programs that involve corrections cannot be successful without the support of the administration of corrections systems. The best circumstances for risk-reduction involve input at the development stage, and any success these programs have is a credit to the professionalism of the corrections staff in the facilities where they exist. References: 1.CDC. HIV Transmission Among Male Inmates in a State Prison System ---Georgia, 1992--2005. MMWR Morb Mortal Wkly Rep. 2006;55(15):421-26. 2.Maruschak, L. 2005. HIV in Prisons. 2003. U.S. Department of Justice, Bureau of Justice Statistics Bulletin. 3.Weinbaum CM, Sabin KM and Santibanez SS. 2005. Hepatitis B, hepatitis C, and HIV in correctional populations: a review of epidemiology and prevention. AIDS 19 3, S41-6. 4.Hammett TM, Harmon P and Maruschak LM.1999. 1996-1997 update: HIV/AIDS, STDs, and TB in correctional facilities. Washington, DC: National Institute of Justice. |
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