7
Overcoming Social Barriers

Although major accomplishments have been made in HIV prevention over the past 20 years, a number of unrealized opportunities to avert new infections still exist. These missed opportunities derive from underlying social and political barriers that have acted as constraints to the objective of preventing as many new infections as possible. Among the most pernicious of the social barriers are poverty, racism, gender inequality, AIDS-related stigma, and society’s reluctance to openly address sexuality. Other important barriers have been the lack of leadership by political and national leaders in galvanizing efforts to combat the epidemic, as well as misperceptions about HIV/AIDS among many people at risk for becoming infected. These barriers have had a profound effect on the course of the HIV epidemic by influencing risk behaviors and by promoting a social context in which HIV transmission is likely to occur. The barriers also have had a fundamental bearing on public policy decisions regarding funding, research, and treatment, and they have influenced decisions about which prevention programs are implemented, the mechanisms by which they occur, and the populations targeted.

The Committee believes that while these entrenched barriers cannot be easily overcome, they must nevertheless be explicitly acknowledged in HIV prevention efforts. The Committee also believes that specific policies and laws emanating from these social and political conditions and attitudes can and must be changed. In this chapter, we describe the barriers that influence the epidemic, and we identify four specific instances in



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No Time to Lose: Getting More from HIV Prevention 7 Overcoming Social Barriers Although major accomplishments have been made in HIV prevention over the past 20 years, a number of unrealized opportunities to avert new infections still exist. These missed opportunities derive from underlying social and political barriers that have acted as constraints to the objective of preventing as many new infections as possible. Among the most pernicious of the social barriers are poverty, racism, gender inequality, AIDS-related stigma, and society’s reluctance to openly address sexuality. Other important barriers have been the lack of leadership by political and national leaders in galvanizing efforts to combat the epidemic, as well as misperceptions about HIV/AIDS among many people at risk for becoming infected. These barriers have had a profound effect on the course of the HIV epidemic by influencing risk behaviors and by promoting a social context in which HIV transmission is likely to occur. The barriers also have had a fundamental bearing on public policy decisions regarding funding, research, and treatment, and they have influenced decisions about which prevention programs are implemented, the mechanisms by which they occur, and the populations targeted. The Committee believes that while these entrenched barriers cannot be easily overcome, they must nevertheless be explicitly acknowledged in HIV prevention efforts. The Committee also believes that specific policies and laws emanating from these social and political conditions and attitudes can and must be changed. In this chapter, we describe the barriers that influence the epidemic, and we identify four specific instances in

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No Time to Lose: Getting More from HIV Prevention which these conditions and attitudes have resulted in public policies that run counter to scientific knowledge about effective HIV prevention. SOCIAL BARRIERS Poverty, Racism, and Gender Inequality There is considerable evidence that social inequalities defined by income, race, ethnicity, and gender are key elements in the social contexts and environments that contribute to HIV infection risk. These contextual forces can act at the individual level, when life circumstances such as homelessness or drug use increase the likelihood of high-risk behaviors. The forces also can act at the societal level (Henderson, 1988). For example, economic inequalities between women and men can affect women’s perceptions of their ability to negotiate safe sex practices in a social relationship. Similarly, racism—both historically and in its contemporary forms—has resulted in assaults on the economic opportunities and the self-identity of racial and ethnic minorities, and has implications for Americans’ receptivity to HIV prevention efforts. Moreover, social inequalities create conditions that make it difficult for individuals and communities to even focus on the problem of HIV, since other problems may seem more immediate (e.g., housing, employment). Better understanding these societal forces is critical to achieving the objective of preventing as many new infections as possible. Increasingly, the metropolitan areas that are most severely affected by HIV/AIDS are also areas of social and political neglect. Individuals living in these disenfranchised environments have increased exposure to a variety of social and psychosocial factors (e.g., poverty, stress, disrupted family structures, insufficient social supports, and toxic environmental exposures) that have demonstrated associations with morbidity and mortality (Geronimus, 2000). Further, inadequate access to health care and lack of supportive, culturally appropriate social services allow co-occurring conditions—such as substance abuse, mental illness, tuberculosis, sexually transmitted diseases (STDs), and violence—to flourish, thus forming epidemiological clusters for a wide variety of concurrent health and social problems (NRC, 1993). Moreover, the higher prevalence of drug trade in impoverished neighborhoods increases the likelihood of exposure to and use of drugs, such as heroin, crack, and cocaine, that are linked to HIV risk (Zierler and Krieger, 1997). These findings are consistent with studies documenting the correlation between economic deprivation and overall AIDS incidence at the state level (Zierler et al., 2000) and in major metropolitan areas (Fordyce et al., 1998; Simon et al., 1995; Hu et al., 1994; Fife and Mode, 1992).

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No Time to Lose: Getting More from HIV Prevention Given that racial and ethnic minority groups are also over-represented among those with HIV/AIDS (see Appendix A; CDC, 2000a), the added burden of coping with societal racism further complicates the implementation of HIV prevention efforts, especially in urban communities. In many urban areas, a legacy of discriminatory social policies (e.g., racially biased mortgage practices, siting of public housing projects and transportation routes) has resulted in a concentration of racial and ethnic minorities in neighborhoods isolated from the social and health care infrastructures needed to preserve health (Cohen and Northridge, 2000; Gerominus, 2000). In addition, racism in the health care setting can pose a major barrier to engaging members of racial and ethnic minority groups in care and prevention efforts (Bayne-Smith, 1996). In one survey of racial and ethnic minorities, 98 percent of respondents reported experiencing some type of racial discrimination within the past year, and 55 percent reported discrimination by health care professionals (Landrine and Klonoff, 1997). Historical accounts of racism in the medical establishment (e.g., the Tuskegee Syphilis Study) have fostered a lack of trust in the modern health care system among some minority groups (Thomas and Quinn, 1991). For example, a recent survey found that 27 percent of African-American respondents believed that HIV/AIDS is a government conspiracy against their racial group (Klonoff and Landrine, 1999). The distrust and fear derived from racist experiences and historical traumas have serious implications for carrying out effective HIV prevention and treatment activities in minority communities. If prevention efforts are to succeed in reaching racial and ethnic minorities, then they must take into account the impact of racism and explicitly address these types of concerns in developing scientifically sound, ethnically appropriate, and culturally acceptable interventions (Thomas and Quinn, 1991). Over the past two decades, women have represented a steadily increasing proportion of AIDS cases (see Appendix A; CDC, 2000a). Because a substantial and increasing proportion of women are infected through heterosexual contact, HIV prevention strategies broadly targeted to women have stressed women’s negotiation skills in sexual decision making as a way to change male behavior, rather than targeting male behavior directly. This strategy assumes, however, that women have control in sexual decision making and that relations between the genders are equal, which is often not true (Campbell, 1995). In many cases, gender inequality and the consequences that can derive from it (e.g., domestic violence, fear of abandonment) contribute to a social environment in which a woman may be either unable or unwilling to negotiate consistent condom use or lower-risk sexual practices (Zierler and Krieger, 1997). In extreme instances, initiating discussions of condom use and risk reduction may lead to physical or sexual abuse (Lurie et al.,

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No Time to Lose: Getting More from HIV Prevention 1995). Gender inequality may be extreme for drug-addicted women and for those whose partners use drugs, as a large proportion of these women report histories of childhood or adult sexual abuse (Walker et al., 1992; Cohen et al., 2000). In fact, there is a growing body of evidence linking childhood or adolescent sexual abuse to behavioral sequelae that increase risk for HIV infection in adulthood (Zierler and Krieger, 1997). In addition, for some women, sexual risk behavior may be tied to practices (e.g., commercial sex work) that ensure economic survival for themselves and their families. For these reasons, it is essential to acknowledge that gender inequality affects many women and must be taken into account when creating prevention messages for women. The Sexual “Code of Silence” Society’s reluctance to openly confront issues regarding sexuality results in a number of untoward effects. This social inhibition impedes the development and implementation of effective sexual health and HIV/ STD education programs, and it stands in the way of communication between parents and children and between sex partners (IOM, 1997b). It perpetuates misperceptions about individual risk and ignorance about the consequences of sexual activities and may encourage high-risk sexual practices (Gerrard, 1982, 1987). It also impacts the level of counseling training given to health care providers to assess sexual histories, as well as providers’ comfort levels in conducting risk-behavior discussions with clients (ARHP and ANPRH, 1995; Risen, 1995; Makadon and Silin, 1995; Merrill et al., 1990). In addition, the “code of silence” has resulted in missed opportunities to use the mass media (e.g., television, radio, printed media, and the Internet) to encourage healthy sexual behaviors (IOM, 1997b; NRC, 1989). The media can be powerful allies in promoting knowledge about HIV and other STDs, and in fostering behavioral change that can reduce the chances of acquiring these diseases (STD Communication Roundtable, 1996). For example, while both children and adolescents are constantly exposed to—and particularly vulnerable to—explicit and implicit sexual messages in various media, the presence of prevention messages (e.g., use of condoms) in the media is practically nonexistent (Lowry and Shidler, 1993; Harris and Associates, 1988). Further, because many adolescents are not receiving accurate information regarding drugs, STDs, and healthy sexual behavior from their parents or other trusted adult sources, they often rely on the media as a primary source of information (STD Communication Roundtable, 1996). Given the impact of media on young people’s attitudes, as well as on consumer behavior, messages that consistently promote risk reduction could facilitate much-needed changes in social norms regarding sexual behaviors and drug-use practices.

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No Time to Lose: Getting More from HIV Prevention TEXT BOX 7.1 Recommendations from The Hidden Epidemic The Hidden Epidemic made two major recommendations in terms of developing a new social norm of sexual behavior as the basis for long-term prevention of STDs. These recommendations are: An independent, long-term national campaign should be established to: (a) serve as a catalyst for social change toward a new norm of healthy sexual behavior in the United States; (b) support and implement a long-term national initiative to increase knowledge and awareness of STDs and promote ways to prevent them; and (c) develop a standing committee to function as an expert resource and to develop guidelines and resources for incorporating messages regarding STDs and healthy sexual behaviors into all forms of mass media. Television, radio, print, music, and other mass media companies should accept advertisements and sponsor public service messages that promote condom use and other means of protecting against STDs and unintended pregnancy, including delaying sexual intercourse. In order to address the public’s reluctance to openly confront and discuss sexuality and sexual health, the Committee wishes to acknowledge and endorse recommendations from a prior Institute of Medicine report, The Hidden Epidemic, which aimed to catalyze social change by encouraging discussion of these issues and by promoting balanced mass media messages (IOM, 1997b). Specifically, the report called for a significant national campaign to foster social change that would lead to a new norm of healthy sexual behavior. This campaign would make extensive use of the media to promote comprehensive public health messages regarding STDs, HIV infection, sexual abuse, and unintended pregnancy (Text Box 7.1). The strategies set forth in The Hidden Epidemic recommendations, if they were implemented, would constitute significant steps toward changing social and cultural norms and beliefs about sex. Stigma of HIV/AIDS Since the beginning of the HIV/AIDS epidemic, people living with HIV or AIDS have been the targets of stigma and discrimination. Despite two decades of public education, prevention efforts, and passage of protective legislation, AIDS-related stigma continues to be a serious problem (Herek, 1999). AIDS stigma is manifested through discrimination and social ostracism directed against individuals with HIV or AIDS, against groups of people perceived to be likely to be infected, and against those

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No Time to Lose: Getting More from HIV Prevention individuals, groups, and communities with whom these individuals interact (Herek and Capitanio, 1998). AIDS stigma is closely linked to other existing social prejudices, including prejudice against homosexuals and drug users. The initial identification of HIV/AIDS among these marginalized groups has had a lasting impact on the way in which the disease is perceived by the American public. Throughout the 1980s, many people closely associated the AIDS epidemic with homosexual behavior and, although the epidemiology of HIV/AIDS has changed considerably, most heterosexual adults continue to associate AIDS with homosexuality or bisexuality (Herek and Capitanio, 1999). In a 1997 survey, 45 percent of respondents thought that a healthy man could get AIDS by having sex with another uninfected man (Herek and Capitanio, 1999). The public also assigns more blame to people who contract HIV/AIDS through behavior that is perceived as controllable (e.g., sex, sharing needles). In the same 1997 survey, 98 percent of respondents felt sympathy for a person who contracted AIDS through a blood transfusion, while only 58 percent felt sympathy for someone who has contracted the virus through homosexual contact (Herek and Capitanio, 1999). Similarly, AIDS-related stigma has combined with stigma of drug use to affect public policy about HIV prevention programs that target injection drug users (IDUs). For instance, there continues to be strong opposition to needle exchange programs, despite strong evidence of their efficacy (Herek et al., 1998). In the United States, a significant minority of the public has expressed consistently negative attitudes toward persons living with AIDS and has supported blatantly stigmatizing and punitive measures against them (Herek, 1999). Such actions have helped foster widespread public stigma toward those who are HIV-infected or even perceived to have AIDS, resulting in overt discriminatory practices (such as denial of housing or employment), violence, social prejudice, and moral judgments (Herek and Glunt, 1988; Herek and Capitanio, 1998). Fortunately, support for such measures has declined over time. A national survey conducted in 1991 found that 36 percent of the population supported quarantines for HIV-infected persons and 30 percent supported public disclosure of the names of infected persons; the same survey conducted in 1997 found that these percentages had dropped to 17 percent and 19 percent, respectively (Herek and Capitanio, 1998). Further, the 1997 survey indicated that the majority (77 percent) of respondents believed that people with AIDS are unfairly persecuted in our society (Herek and Capitanio, 1998). However, there are disturbing trends, too. Compared to 1991, more respondents agreed that people who acquired AIDS through sex or drug use got what they deserved (29 percent in 1997 versus 20 percent in 1991). Similarly, the proportion of the public that believes casual social contact

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No Time to Lose: Getting More from HIV Prevention might lead to HIV infection has increased somewhat (Herek and Capitanio, 1998). In 1991, 55 percent of respondents believed it was possible to contract AIDS from using the same drinking glass (compared with 48 percent in 1991), and 54 percent believed that AIDS might be transmitted through a cough or sneeze (compared to 45 percent in 1991). AIDS stigma has serious implications for carrying out effective prevention efforts. At-risk or HIV-infected individuals who fear stigmatization or being labeled as part of a stigmatized social group may be reluctant to admit risk behaviors, to seek or find relevance in prevention information, to obtain antibody testing, or to access health care services (Chesney and Smith, 1999; Herek, 1999). These factors can increase the likelihood of continuing risk behaviors, becoming infected, and transmitting the virus to others (Herek et al., 1998). Thus, while some progress has been made in reducing AIDS stigma, and while public support for discriminatory policies has diminished, AIDS stigma still persists and continues to undermine HIV prevention efforts. As a result, the Committee believes that the protection of human rights, privacy, and equity continues to be a significant concern, and that concurrent efforts at the federal, state, and local level to remove or at least lessen the impact of stigma and discrimination are necessary. In this belief, the Committee states its unflinching commitment to the protection of the rights of those living with HIV/AIDS and those at risk for HIV. Misperceptions In addition to the social conditions and attitudes that impede HIV prevention efforts, many people at risk for becoming infected have a variety of misperceptions about HIV/AIDS that hinder the effectiveness of prevention efforts. Several studies have shown that individuals often underestimate or misperceive their risk of acquiring HIV (Mays and Cochran, 1988; Schieman, 1998; Kaiser Family Foundation, 1999a) and STDs (IOM, 1997b), which can lead to an increase in risk behaviors. This misperception is driven, in large part, by the complexity of exposure to HIV: the uncertainty of exposure, the low probability of infection per encounter, the time interval between infection and clinical manifestation of HIV, and the emotional reaction to the severity of AIDS (Poppen and Reisen, 1997). Studies have shown that general knowledge about HIV does not necessarily predict practice of preventive behaviors (Mickler, 1993). Even when individuals are worried about contracting HIV, their perception of the likelihood of actually contracting HIV often is relatively low (Dolcini et al., 1996; Ford and Norris, 1993). Individuals who do not consider themselves to be in “high-risk groups” perceive themselves at low risk and thus engage in riskier behaviors (Dolcini et al., 1996; Mickler,

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No Time to Lose: Getting More from HIV Prevention 1993; Lewis et al., 1997). Another belief that influences individuals’ risk behavior is their misperception about HIV-infected people. For example, some individuals believe that anyone who “looks healthy” must not have AIDS, which may lead these individuals to be falsely confident in selecting partners (Ford and Norris, 1993). Finally, the stigma associated with HIV/AIDS can affect the perception of high-risk behavior. People who engage in high-risk activities believed to be behaviorally irresponsible, such as injecting drugs or having unprotected sex, may dissociate from their own behaviors and rationalize that they are not at risk for contracting HIV (Poppen and Reisen, 1997). The success of combination antiretroviral therapies, along with the emphasis on vaccine development, has also led some people to believe that they no longer need to take precautions against transmitting or acquiring HIV. For example, in a study of HIV-negative or untested persons at risk, 17 percent reported that they were less careful about sex and drug use, and 31 percent were less concerned about becoming infected, because of new treatments (Lehman et al., 2000). In addition, recent studies indicate that treatment advances may have contributed to a resurgence in high-risk behaviors, particularly unprotected sex, as demonstrated by the increased incidence of STDs in San Francisco (CDC, 1999a), Seattle (CDC, 1999b; Williams et al., 1999), Los Angeles, and Philadelphia (Marquis, 2000), particularly among men who have sex with men. Lack of Leadership Concerted efforts by politicians and national leaders to openly discuss HIV and engage the public in HIV prevention efforts can set the stage for a national-level mobilization against the epidemic. The Committee believes that such high-level political commitment is necessary for developing a coherent strategy for responding to the epidemic and for providing leadership and direction to other public and private partners, such as federal, state, and local government agencies, community-based organizations, advocacy organizations, researchers, health care providers, the media, and affected communities. While several studies have made recommendations to resolve the interagency1 and intraagency2 co- 1   The 1994 report to Philip Lee, then Assistant Secretary of Health, made strong recommendations aimed at resolving many of the coordination and leadership issues within the Department of Health and Human Services (DHHS, 1994). 2   The 1999 review of the CDC’s HIV/AIDS activities by the CDC Advisory Council on HIV Prevention identified opportunities for improved programmatic and budgetary coordination within the agency (CDC Advisory Committee, 1999).

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No Time to Lose: Getting More from HIV Prevention ordination and leadership problems at the federal level, the nation still lacks the federal leadership and integration of prevention activities necessary to effectively address the epidemic (CDC Advisory Committee, 1999; PACHA, 2000). Although there are difficulties in developing coordinated public and private-sector leadership for prevention, such leadership is not impossible. Studies in select developing and industrialized countries reveal the critical roles of consistent, visible political leadership and commitment, along with community mobilization, in slowing the epidemic. For example, in Uganda, a country ravaged by HIV/AIDS, government leaders openly acknowledged the epidemic and took active steps to prevent its spread by creating, in 1986, a National AIDS Control Programme. The program, which involves collaborations among community, government, and donor agencies, includes extensive prevention education campaigns to promote safer sexual behavior, STD prevention and treatment, condom distribution, HIV counseling and testing, and community mobilization to promote behavior change (UNAIDS, 1998; Abdool Karim et al., 1998). These efforts have contributed to high levels of awareness about HIV/ AIDS and declines in HIV incidence among some populations in Uganda (UNAIDS, 2000; UNAIDS, 1998). Political commitment and strong public health programs have also helped Thailand reduce HIV incidence among some of its populations (UNAIDS, 1998; Nelson et al., 1996), and they have helped Senegal maintain one of the lowest HIV incidence rates in Africa (UNAIDS, 1999). Among industrialized countries, government leaders in Australia and the Netherlands have worked with communities to develop policies that minimize the harm incurred by drug abuse and reduce stigmatization of drug users. These countries offer drug abuse treatment on demand; they also have rapidly expanded the availability of methadone maintenance, and they have successfully developed innovative methods for targeting drug users and slowing the HIV/AIDS epidemic among IDUs (Drucker et al., 1998). Perhaps the most impressive aspect of these successes is that, in some cases, such leadership has occurred in countries that have fewer educational, financial, biomedical, and social resources than does the United States. While there have been prevention successes in the United States as a result of community mobilization, these have generally occurred on a more localized scale and often in the absence of high-level political leadership. For example, community mobilization in the gay community in the early and mid-1980s led to significant changes in sexual behavior and declines in HIV incidence among MSMs in major urban epicenters such as New York and San Francisco (Katz, 1997). These efforts preceded the development of any official public education programs (NRC and IOM, 1993).

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No Time to Lose: Getting More from HIV Prevention UNREALIZED OPPORTUNITIES The Committee identified four specific instances in which the social and political barriers described above have led to public policies that run counter to the scientific evidence regarding the effectiveness of HIV prevention interventions. These instances involve access to drug abuse treatment, access to sterile drug injection equipment, comprehensive sex education and condom availability in schools, and HIV prevention in correctional settings. These examples fall into two categories: (1) those in which policies impede implementation of effective HIV prevention efforts, and (2) those in which policies encourage funding for programs with no evidence of effectiveness. We believe that continuing to support such policies will result in unnecessary new HIV infections, lives lost, and wasted expenditures. Access to Drug Abuse Treatment and Sterile Injection Equipment Injection drug use is a major factor in the spread of HIV in the United States, accounting for 22 percent of new AIDS cases in 1999 (CDC, 2000a). Although the primary route of transmission among IDUs is through sharing of contaminated injection equipment, sexual partners and children of IDUs are also at high risk for infection (NRC and IOM, 1995). Non-injection drug use (e.g., use of alcohol, methamphetamines, crack cocaine, inhalants) also increases the likelihood of HIV infection and transmission through increasing high-risk sexual behaviors (IOM, 1997b). Two of the most effective strategies for preventing HIV infection among IDUs include eliminating or reducing the frequency of drug use and associated risk behaviors through drug abuse treatment, and reducing the frequency of sharing injection equipment through expanded access to sterile injection equipment. However, legal, regulatory, and funding barriers prevent widespread implementation of these interventions. Access to Drug Abuse Treatment Drug abuse treatment can be provided in a variety of care settings (e.g., outpatient, residential, inpatient) using two primary types of interventions: pharmacotherapy or psychosocial/behavioral therapy. Pharmacotherapy, such as methadone maintenance treatment for opiate addiction, relies on medication to block the euphoria of the drug and the cravings and withdrawal symptoms associated with drug dependency. Psychosocial/behavioral therapies include skills training or a variety of counseling approaches. Some programs combine elements of the two approaches; for instance, many methadone maintenance programs also utilize some form of counseling or psychotherapy (GAO, 1998).

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No Time to Lose: Getting More from HIV Prevention Studies conducted over three decades have demonstrated the effectiveness of drug abuse treatment in reducing drug use (NIH, 1997a; GAO, 1998; OTA, 1990). Methadone maintenance has been the most rigorously studied treatment modality, and it has been shown to be the most effective approach for treating opiate addiction, particularly when combined with counseling, education, and other psychosocial support services (NIH, 1997b; GAO, 1998).3 Methadone maintenance also has been associated with other positive outcomes such as improved social functioning among those on maintenance and decreased crime rates (GAO, 1998; NIH, 1997b; IOM, 1995b). The recent nationwide Drug Abuse Treatment Outcome Study concluded that other common forms of drug abuse treatment (long-term residential, outpatient drug free, and short-term inpatient programs), in addition to methadone maintenance, are also effective in reducing drug use and in improving social functioning for a variety of drug-using populations4 (Hubbard et al., 1997). There is less agreement, however, about the most appropriate treatment approach and setting combinations for non-opiate drug abusing populations (GAO, 1998; IOM, 1990). In recent years, a number of studies have found that drug abuse treatment also reduces risk behaviors associated with HIV/AIDS. Methadone maintenance, which reduces injection and needle-related behaviors that place individuals at risk for HIV have shown particular success (Broome et al., 1999; Magura et al., 1998; Camacho et al., 1996; Longshore et al., 1993; Ball et al., 1988). For example, one study of opiate-addicted IDUs found a six-fold difference in HIV seroconversion rates between those in methadone treatment (seroconversion of 3.5 percent) and addicts who did not enter treatment (seroconversion rate of 22 percent) (Metzger et al., 1993). Drug abuse treatment reduces sex-related risk behaviors (Broome et al., 1999; Magura et al., 1998; Camacho et al., 1996), although this is not a traditional objective of drug treatment (Broome et al., 1999) and earlier findings have been inconsistent (Fisher and Fisher, 1992). Despite the effectiveness of treatment, many people who could benefit from treatment do not receive it. The Office of National Drug Control Policy estimates that, of the approximately 5 million individuals with 3   While many drug treatment programs include basic services such as HIV testing and counseling (D’Aunno et al., 1999), few programs offer other important medical and psychosocial services (Friedman et al., 2000). While large amounts of ancillary support services are not cost-effective, moderate amounts of support are better than minimal support levels (Kraft et al., 1997). The cost-effectiveness and proper targeting of ancillary services to improve HIV risk behavior are areas that warrant further research. 4   Cocaine was the most common drug of abuse in these settings, followed by alcohol (Hubbard et al., 1997).

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No Time to Lose: Getting More from HIV Prevention ported relatively few problems with use of condoms as weapons or for smuggling contraband (NIJ et al., 1999). In the 1997 survey of facilities, an official at the Mississippi State Prison in Parchman cited only one incident when a condom was used for smuggling (NIJ et al., 1999). In Vermont, officials report that after an initial period of controversy, condom distribution became routine and was no longer an issue. Vermont officials report few problems with the misuse of condoms, and they have observed no evidence that condom distribution has led to an increase in sexual activity or undesirable behavior (NIJ et al., 1999; Braithewaite et al., 1996). In a survey of over 400 correctional officers in Canada’s federal prison system, 82 percent reported that condom availability had created no problems in their facilities (NIJ et al., 1999). While some U.S. correctional facilities provide information about safer drug injection practices, no facilities distribute needles or injection equipment (Hammett et al., 1999; NIJ et al., 1999). Indeed, possession of needles and syringes is illegal in correctional settings (NIJ et al., 1999). Needle exchange programs have, however, been implemented in prison systems in other countries, with considerable success. Switzerland was the first country to introduce prison needle exchange programs, beginning in 1992. Evaluation of such a needle exchange program in the Hindelbank women’s facility found that the program did not increase drug consumption and significantly reduced the frequency of needle sharing. In addition, there were no reports of needles being used as weapons, and there were no new cases of HIV or hepatitis B reported among program participants. Based on the experience in Swiss facilities, needle exchange programs have been initiated in several prisons in Germany and in at least one prison in Spain. Plans to initiate a pilot needle exchange program in Australia have also been made (NIJ et al., 1999). Availability of bleach for cleaning injection equipment is also limited in U.S. prisons. Only one facility (San Francisco) has reported making bleach available expressly for cleaning injection equipment (NIJ and CDC, 1995). However, ten state or federal and eight city or county correctional systems report making bleach available to inmates for general purposes (Hammett et al., 1999; NIJ et al., 1999). Bleach is made more widely available in prisons in other countries. Over half of 20 European systems that responded to the 1997 NIJ/CDC survey reported having such policies. A successful pilot study of a bleach kit distribution program in Canada led to the expansion of this program in all Canadian federal facilities (NIJ et al., 1999). Therefore, the Committee recommends that: The Department of Health and Human Services should collaborate with the Department of Justice to develop guidelines

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No Time to Lose: Getting More from HIV Prevention to remove policy barriers that hinder the implementation of effective HIV prevention efforts in correctional settings. At a minimum, these guidelines should ensure that: discharge planning is enhanced so that individuals with HIV or who are at high risk for HIV (e.g., due to substance abuse or mental health issues) are linked with appropriate community-based prevention and treatment services; comprehensive HIV prevention education programs for incarcerated individuals and staff are implemented in all correctional settings; and drug treatment is available for inmates with drug abuse problems. While there is not yet definitive evidence that condom distribution in correctional facilities would reduce HIV transmission, in light of the absence of problems reported by facilities that have implemented such programs, the Committee recommends that condoms be made readily available to incarcerated individuals. The Committee recognizes that data on HIV sexual transmission in correctional facilities are lacking, as is evidence that condom availability reduces the incidence of sexually transmitted HIV in these settings. Nonetheless, the Committee concludes that providing condoms to inmates is prudent public health practice for the following reasons. First, condoms are clearly the best available means to reduce the risk of sexually transmitting or acquiring HIV among at-risk individuals having intercourse (Davis and Weller, 1999; Pinkerton and Abramson, 1997). Second, studies have documented higher rates of HIV/AIDS among inmates than in the general population (Hammett et al., 1999). Third, the risk of sexual transmission of HIV in correctional facilities is possible because there is evidence (cited in Braithwaite et al., 1996) indicating that sexual activity does occur in correctional settings despite prohibitions against these activities. Finally, correctional facilities in the United States and other countries that have implemented condom distribution programs have reported relatively few logistical or security problems as a result of such programs (NIJ et al., 1999). The Committee further reasons that providing condoms is a very inexpensive intervention. Based on this evidence, the Committee concludes that in the absence of this intervention, inmates are at increased risk of transmitting or acquiring HIV. The Committee is not making a recommendation at this time with regard to needle availability in correctional settings. The Committee rec-

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No Time to Lose: Getting More from HIV Prevention ognizes that lack of access to sterile injection equipment and/or bleach in correctional facilities may result in fewer averted infections, but we understand the concerns of the correctional system with regard to safety threats (both to corrections staff and other inmates) that could result from making these items available to inmates. However, in the absence of these measures, the Committee believes that HIV educational programs in correctional facilities should include information about safe injection practices and all inmates needing substance abuse treatment should receive such services upon request. REFERENCES Abdool Karim Q, Tarantola D, As Sy E, Moodie R. 1998. Government responses to HIV/ AIDS in Africa: what have we learnt? AIDS 11(Suppl B):S143–S149. American Academy of Pediatrics (AAP). 1995. Condom availability for youth [Web Page]. Located at: www.aap.org/policy/00654.html. Association of Maternal and Child Health Programs (AMCHP). 1999. Abstinence Education in the States—Implementation of the 1996 Abstinence Education Law. Washington, DC: AMCHP. Association of Reproductive Health, Association of Nurse Practitioners in Reproductive Health (ARHP and ANPRH). 1995. STD counseling and practices and needs survey. Silver Spring, MD: Schulman, Roca, and Bucuvalas, Inc. Ball JC, Lange WR, Myers CP, Friedman SR. 1988. Reducing the risk of AIDS through methadone maintenance treatment. Journal of Health and Social Behavior 29(3):214–226. Bayne–Smith M. (Ed.). 1996. Race, Gender, and Health. Sage Series on Race and Ethnic Relations, Vol. 15. Thousand Oaks, CA: Sage Publications. Beck A. 2000. Prison and jail inmates at midyear 1999. Bureau of Justice Statistics Bulletin. Washington, DC: U.S. Department of Justice, Office of Justice Programs. Blendon RJ and Young JT. 1998. The public and the war on illicit drugs. Journal of the American Medical Association 279(11):827–832. Braithewaite RL, Hammett TM, Mayberry RM. 1996. Prisons and AIDS: A Public Health Challenge. San Francisco: Jossey–Bass. Broome KM, Joe GW, Simpson DD. 1999. HIV risk reduction in outpatient drug abuse treatment: Individual and geographic differences. AIDS Education and Prevention 11(4):293–306. Bureau of Justice Statistics. 2000. U.S. correctional population reaches 6.3 million men and women represents 3.1 percent of the adults U.S. population (Press release). Washington, DC. Bureau of Labor Statistics. 1999. Employee Benefits in Medium and Large Private Establishments, 1997, Bulletin 2517. Washington, DC. Bureau of Labor Statistics. 1998. Employee Benefits in Medium and Large Private Establishments, 1995, Bulletin 2496. Washington, DC. Burris S, Lurie P, Abrahamson D, Rich JD. 2000. Physician prescribing of sterile injection equipment to prevent HIV infection: time for action. Annals of Internal Medicine 133(3):218–226. Camacho LM, Bartholomew NG, Joe GW, Cloud MA, Simpson DD. 1996. Gender, cocaine and during-treatment HIV risk reduction among injection opioid users in methadone maintenance. Drug and Alcohol Dependency 41(1):1–7.

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