Date: Fri, 5 Apr 1996 10:14:46 +0500
From: "Flynn Mclean" <Flynn_Mclean_at_NAC__PO@smtpinet.aspensys.com>
Subject: MMWR 04/05/96

MORBIDITY AND MORTALITY WEEKLY REPORT
******************************************
Centers for Disease Control and Prevention
April 5, 1996
Vol. 45, No. 13

*  HIV/AIDS Education and Prevention Programs For Adults
   in Prisons and Jails and Juveniles in Confinement 
   Facilities --- United States, 1994
*  Notices to Readers


HIV/AIDS Education and Prevention Programs For Adults in Prisons
and Jails and Juveniles in Confinement Facilities -- United States,
1994
     By the end of 1994, at least 4588 adult inmates of U.S.
prisons and jails had died as a result of acquired immunodeficiency
syndrome (AIDS), and during 1994, at least 5279 adult inmates with
AIDS were incarcerated in prisons and jails (1). Periodically
conducted national surveys instituted in 1985 (2) and sponsored by
the U.S. Department of Justice's National Institute of Justice
(NIJ) and CDC have documented the prevalence of human
immunodeficiency virus (HIV)/AIDS and the incidence of sexually
transmitted diseases (STDs) among adult inmates and confined
juveniles*. In addition, these surveys have enabled an assessment
of HIV/AIDS education and prevention programs in prisons and jails
for adults and confinement facilities for juveniles. This report
presents findings from the eighth survey, conducted in 1994, which
indicate the need to increase HIV/AIDS education and prevention
services among adult inmates and confined juveniles.
     In the 1994 NIJ/CDC survey, questionnaires were sent to and
responses received from the Federal Bureau of Prisons, all 50 state
prison systems for adults, city/county jail systems with adult
inmate populations among the largest in the country (29 [81%] of
36)**, state systems for juveniles (41 [82%] of 50), and
city/county systems with the largest populations of confined
juveniles (32 [64%] of 50)***. Most questionnaires were completed
by health services staff, but some portions were completed by other
administrators. Although most systems for adults and juveniles
include a number of individual facilities, systems were asked to
provide single answers covering all of their facilities. However,
for some questions, systems were asked to report the number of
their facilities providing certain types of programs. Rates of AIDS
and gonorrhea among the U.S. population were based on data reported
by state health departments to CDC.
Prisons and Jails for Adults
     Prison and jail systems for adults participating in the 1994
survey reported 5279 cases of AIDS among current inmates,
representing 5.2 AIDS cases per 1000 adult inmates--a rate almost
six times that of the total U.S. adult (aged greater than or equal
to 18 years) population (0.9 cases per 1000 population) (CDC,
unpublished data, 1995). Based on mandatory testing of all incoming
inmates or blinded studies, reported HIV seroprevalence rates of
inmates ranged from less than 1% to 22%; 12 state systems reported
rates greater than 2% (1).
     HIV/AIDS education included interactive programs (e.g.,
peer-led programs and instructor-led sessions such as lectures,
discussions, or question-and-answer periods) and passive programs
(e.g., use of videotapes, other audio-visual materials, or written
materials). Based on reports from all 51 state and federal systems,
the percentage of systems providing instructor-led HIV/AIDS
education in at least one of their facilities decreased from 96% in
1990 to 75% in 1994 (1). In 1994, of the 1207 state and federal
facilities, 582 (48%) were providing instructor-led HIV/AIDS
education programs, 90 (7%) were operating peer-led programs, 865
(72%) were using audio-visual materials, and 1068 (88%) were using
written materials. Of the 80 federal, state, and city/ county adult
systems participating in the 1994 survey, 30 (59%) responded to a
specific question that they would like to receive public health
department assistance with their HIV/AIDS education programs.
     Two state prison systems (Vermont and Mississippi) and four
city/county jail systems (New York City; Philadelphia; San
Francisco; and Washington, DC) reported making condoms available to
inmates in their facilities. Of the 80 prison and jail systems
participating in the 1994 survey, one city/county jail system
reported making bleach available to inmates (1).
Confinement Facilities for Juveniles
     As of December 1994, the 41 state and city/county systems for
juveniles participating in the 1994 survey reported a cumulative
total of 60 cases of AIDS and four cases of AIDS among currently
confined juveniles. The HIV seroprevalence among confined juveniles
in six state systems and one county system was less than 1% (3).
However, compared with the total U.S. population of equivalent age,
the incidence rates for gonorrhea, a marker of high-risk sexual
activity associated with HIV transmission, were 152 times and 42
times higher among confined juvenile females and males,
respectively (4). Twenty-six state systems reported a mean of 137
gonorrhea cases**** per 1000 confined females during the 12 months
preceding completion of the 1994 survey, compared with 0.9 cases
per 1000 total U.S. females aged 15-19 years during 1994.
Twenty-one state systems reported a mean of 25 gonorrhea cases per
1000 confined males during the 12 months preceding completion of
the 1994 survey, compared with 0.6 cases per 1000 total U.S. males
aged 15-19 years during 1994 (3,4).
     Of 456 confinement facilities in the 40 state systems
responding to the question, 31 (7%) were operating peer-led
HIV/AIDS education, 258 (57%) were providing instructor-led
education, 246 (54%) were using audio-visual materials, and 270
(59%) were using written materials. Of the 73 state and city/county
systems for juveniles participating in the survey, 40 (55%)
responded to the question that they would like to receive public
health department assistance with their HIV/AIDS education
programs. One county system (Alameda County, California) reported
making condoms available to juveniles confined in its facilities
(3).
Reported by: TM Hammett, PhD, R Widom, Abt Associates Inc,
Cambridge, Massachusetts. National Institute of Justice, Office of
Justice Programs, US Dept of Justice. Behavioral Intervention
Research Br, Div of HIV/AIDS Prevention, National Center for HIV,
STD, and TB Prevention (proposed), CDC.
Editorial Note: The findings in this report underscore the need to
take advantage of important missed opportunities to provide
HIV/AIDS prevention programs in prisons and jails for adults and in
confinement facilities for juveniles (5). These facilities are
important settings for HIV/AIDS education and prevention efforts
because of 1) high prevalences in their populations of HIV-infected
persons and persons with risk factors for HIV infection (6); 2)
demonstrated occurrence of and continuing high potential for HIV
transmission in these facilities through sexual activity and
sharing of drug-injection equipment (7,8); 3) eventual release of
almost all adult inmates and confined juveniles to the community;
4) high rates of re-incarceration and re-confinement (9); and 5)
feasibility of providing HIV/AIDS education and prevention programs
in these facilities. Despite the established HIV/AIDS epidemic
among adult inmates and high STD rates among confined juveniles,
many facilities have not provided interactive HIV/AIDS education
programs. In facilities for juveniles, HIV/AIDS education often is
presented as a curriculum unit of the school program, which many
juveniles may not receive because of their short lengths of stay.
Peer-led programs are provided in even fewer facilities for adults
and juveniles, although such programs may be more credible and
effective than those provided by educators affiliated with the
correctional system for adults or the system for juveniles (1).
     Findings from the NIJ/CDC surveys presented in this report are
subject to at least one limitation. Because the surveys did not
include all city/county jail systems and because of possible
underreporting by participating systems, the numbers of cumulative
AIDS deaths and AIDS cases among current adult inmates reported in
the survey probably were underestimated.
     To assist in reducing the transmission of HIV in the United
States, comprehensive and credible programs of interactive
education, counseling, testing, partner notification, and practical
risk-reduction techniques (e.g., safer sex and safer drug
injection) should be implemented for adult inmates in prisons and
jails and for juveniles in confinement facilities. In addition,
because many adult inmates and confined juveniles have established
patterns of high-risk behavior for HIV/AIDS, ongoing programs of
support and counseling are needed to assist them in initiating and
sustaining positive behavior change. Although counseling, testing,
and partner-notification programs have been implemented in some
correctional facilities for adults (10), few systems for adults or
juveniles make available the means to practice risk reduction
(e.g., condoms or bleach). Interviews with correctional
administrators indicate that condom and bleach distribution have
been rejected because such policies are believed to condone and
encourage behavior prohibited to inmates. Public health agencies at
all levels should collaborate with correctional systems for adults,
justice systems for juveniles, and community-based organizations to
strengthen HIV/AIDS education and prevention programs in facilities
for adults and juveniles. Collaborative efforts could be used to
formulate strategies for HIV/AIDS prevention and to implement
comprehensive HIV/AIDS education and prevention programs. Finally,
the needs of adult inmates and confined juveniles should be
included in the community HIV/AIDS prevention planning process.
References
1. Hammett TM, Widom R, Epstein J, Gross M, Sifre S, Enos T. 1994
Update: HIV/AIDS and STDs in correctional facilities. Washington,
DC: US Department of Justice, Office of Justice Programs, National
Institute of Justice/US Department of Health and Human Services,
Public Health Service, CDC, December 1995.
2. CDC. Acquired immunodeficiency syndrome in correctional
facilities: a report of the National Institute of Justice and the
American Correctional Association. MMWR 1986;35:195-9.
3. Widom R, Hammett TM. Research in brief: HIV/AIDS and STDs in
juvenile facilities. Washington, DC: US Department of Justice,
Office of Justice Programs, National Institute of Justice, April
1996.
4. CDC. Sexually transmitted disease surveillance, 1994. Atlanta,
Georgia: US Department of Health and Human Services, Public Health
Service, CDC, September 1995.
5. Glaser JB, Greifinger RB. Correctional health care: a public
health opportunity. Ann Intern Med 1993;118:139-45.
6. Bureau of Justice Statistics. Correctional populations in the
United States, 1991. Washington, DC: US Department of Justice,
Office of Justice Programs, Bureau of Justice Statistics, 1993;
publication no. NCJ-142729.
7. Mutter RC, Grimes RM, Labarthe D. Evidence of intraprison spread
of HIV infection. Arch Intern Med 1994;154:793-5.
8. Mahon N. High risk behavior for HIV transmission in New York
state prisons and city jails. Am J Public Health 1996 (in press).
9. Bureau of Justice Statistics. Correctional populations in the
United States, 1993. Washington, DC: US Department of Justice,
Office of Justice Programs, Bureau of Justice Statistics, 1995;
publication no. NCJ-156241.
10. CDC. Notification of syringe-sharing and sex partners of
HIV-infected persons--Pennsylvania, 1993-1994. MMWR 1995;44:202-4.

* In most states, offenders aged less than 18 years are handled by
the juvenile justice system and confined in juvenile facilities;
those aged less than 18 years are prosecuted in adult courts and
incarcerated in prisons and jails. However, the cutoff age varies
by state and even within some states on a case-by-case basis.
** The sample of 36 city/county jail systems for adults was
selected to represent systems with large inmate populations and to
provide geographic diversity. All 36 systems were among the 50
largest in the United States in inmate population in 1994. The
Washington, D.C., system was considered a city/county system.
*** The 50 city/county systems for juveniles selected for the
survey included the largest confined populations in 1994 based on
information provided by the Office of Juvenile Justice and
Delinquency Prevention, Office of Justice Programs, U.S. Department
of Justice.
**** The NIJ/CDC questionnaire sought numbers of gonorrhea cases
presumptively diagnosed and numbers of cases confirmed by
laboratory findings during the preceding 12 months. Incidence rates
for the 26 state juvenile systems providing the requested data were
calculated based on the total of these two categories of cases. The
reported means represent a simple average of the incidence rates in
these 26 systems.


Notice to Readers
International Course in Applied Epidemiology
     CDC and Emory University will cosponsor a course designed to
provide international health professionals with basic epidemiology 
skills. This "International Course in Applied Epidemiology" is
conducted in English and will be held at CDC during October 7-November 1, 
1996. It emphasizes the practical application of
epidemiology to public health problems and comprises lectures, 
workshops, classroom exercises (including actual epidemiologic 
problems), discussions, and an on-site community survey. Topics 
covered include descriptive epidemiology and biostatistics, 
analytic epidemiology, epidemic investigations, public health 
surveillance, surveys and sampling, computers and Epi Info 
software, and discussions of selected prevalent diseases. There is 
a tuition charge.
     Applications must be received by June 1, 1996. Additional
information and applications are available from PSB, Rollins School 
of Public Health, Emory University, 7th Floor, 1518 Clifton Road, 
N.E., Atlanta, GA 30322; telephone (404) 727-3485 or (404) 
727-0199; fax (404) 727-4590; e-mail address ogostan@sph.emory.edu.
     
     
Notice to Readers
Introduction to Public Health Surveillance
     CDC and Emory University will cosponsor a new course to
provide public health professionals with the ability to design, 
implement, maintain, and evaluate effective public health 
surveillance programs. "Introduction to Public Health Surveillance" 
will be held in Atlanta during June 3-7, 1996. Topics include 
overview and history of public health surveillance systems; 
planning considerations; sources and collection of data; analysis, 
interpretation, and communication of data; surveillance systems 
technology; program evaluation; ethics and legalities; state, 
regional, and local concerns; issues in developing countries; and 
future considerations. Surveillance problems will be presented and 
discussed, and the use of the computer in public health 
surveillance will be demonstrated. There is a tuition charge.
     Additional information and applications are available from
PSB, Rollins School of Public Health, Emory University, 7th Floor, 
1518 Clifton Road, N.E., Atlanta, GA 30322; telephone (404) 
727-3485 or (404) 727-0199; fax (404) 727-4590; e-mail address 
ogostan@sph.emory.edu.
     
     
Notice to Readers
Satellite Videoconference on Epidemiology and Prevention of 
Vaccine-Preventable Diseases
     Epidemiology and Prevention of Vaccine-Preventable Diseases,
a live satellite videoconference, will be broadcast to sites 
nationwide from noon until 3:30 p.m. eastern daylight time on May 
31 and June 7, 14, and 21 over the Public Health Training Network. 
Cosponsors are CDC, the Association of Schools of Public Health; 
The University of North Carolina at Chapel Hill School of Public 
Health; and the North Carolina Department of Environment, Health, 
and Natural Resources.
     The four-module interactive videoconference will provide
up-to-date information on vaccine-preventable diseases, vaccine 
management and safety, and standard vaccination practices. 
Toll-free telephone lines will be available for participants to ask 
questions about related topics. Physicians, nurses, physicians' 
assistants, nurse practitioners, and their colleagues who work in 
immunization, communicable disease, and infection-control programs 
will benefit. Continuing Medical Education credits, Continuing 
Education Units, and Nursing Contact Hours will be given to 
participants who complete the course. There is a fee for materials.
     Information about materials is available from the National
Technical Information Service (NTIS), telephone (800) 232-1824 
(order number PB96-780531LTE). Registration information is 
available from state immunization coordinators; from CDC, telephone 
(404) 639-8225, e-mail jmg1@nip1.em.cdc.gov; or from the World-Wide 
Web site (which includes state immunization coordinator contact 
information), http://www.sph.unc.edu/oce/course_list.html.