On both sides of the prison walls—prisoners and HIV
Transcription
On both sides of the prison walls—prisoners and HIV
Comment “It is said that no-one truly knows a nation until one has been inside its jails. A nation should not be judged by how it treats its highest citizens, but its lowest ones.” Nelson Mandela Few would refute that the most neglected and vulnerable of all populations in the global HIV/AIDS response are people who are incarcerated. Today, The Lancet continues its ongoing attention to HIV in marginalised populations with a collection of reviews on HIV and related infections in prisoners.1–6 Prison populations are at especially high risk of HIV infections as a consequence of risk factors that are in play both before incarceration and once in prison where there are frequent opportunities for further transmission. Consequently, prisoners experience high HIV disease burdens. They have little or no access to HIV treatment, prevention, and care, and due to their legal status they are discriminated against by the criminal justice system, which in turn perpetuates the high HIV transmission rates. Globally, about 10·2 million men, women, and children are in prisons, detention, or some form of government custody at any given time.1 Annually, an estimated 30 million people pass through some form of detention.7 This Series describes the unique and complex nature of an HIV epidemic in an understudied and underserved population. No other general medical journal has published such an extensive and in-depth global report on HIV in prisoners. We also highlight the often disparate HIV risks and health-care needs of incarcerated men and women. By doing so, we hope to bring widespread attention to prisoners as a key population in the HIV pandemic. A substantial global increase in the population of prisoners and detainees during the HIV era is largely a result of failed prohibitionist drug policies.8 This situation has been especially true in the USA, eastern Europe, central Asia, and southeast and east Asia where most prisoners are detained for drug-related offences. Substance users bear high burdens of HIV, hepatitis C, hepatitis B, and tuberculosis, including multidrug-resistant tuberculosis, and comorbidities such as substance use disorders and mental illnesses. Indeed, as Kate Dolan and colleagues1 show, prison populations have a higher prevalence, and in some contexts a higher incidence, of these infections than in the general population. Furthermore, modelling studies in this Series suggest incarceration of substance users and people who inject drugs drives transmission of HIV and tuberculosis within prisons and in their wider communities.1,6 This finding is particularly relevant since most prisoners are eventually released. Re-entry to the community, linkage to care for persons newly released from prison, and the interactions of prison-acquired infections with community risks and vulnerabilities need to be addressed as part of a wider public health effort. Despite the complex challenges of providing health care in a prison setting, the Series shows that quality clinical care can be provided,2 and that prison harm-reduction and drug treatment programmes can substantially reduce disease transmission.3 Unfortunately, in many parts of the world the reality for people deprived of their liberty is unjustly harsh. Human rights violations, such as denial of access to prevention and treatment, violence, and discrimination are common in prisons.4 In addition, there is a flagrant disregard of the right to an adequate standard of health care, which is enshrined in international law.4 Africa, by far the region most affected by HIV globally, has among the most marginalised of all incarcerated popu lations as Lilanganee Telisinghe and colleagues5 show. Many prisoners in Africa face years in detention without ever being formally charged or tried for alleged offences. Pre-trial detention is a high-risk environment for disease exposure and for treatment interruptions for people on ongoing HIV or tuberculosis treatment. There needs to be an urgent reform of the criminal justice system and legislative reform to eliminate this hugely damaging practice. On the global stage, much is spoken of the gains in HIV control, particularly in relation to the increasing numbers of people who have access to treatment and the reduction in AIDS-related deaths. Indeed, in response, UNAIDS have embarked on an agenda to accelerate efforts towards ending the AIDS epidemic by 2030. But one only has to look at the reported 2·1 million new HIV cases in 2015 to know intensifying more of the same will not be sufficient.9 The 2016 UN High Level Meeting on Ending AIDS in June was a major setback for key populations because civil society and harm-reduction groups were excluded from participating. The language in the final resolution has left many feeling that key populations are yet again www.thelancet.com Published online July 14, 2016 http://dx.doi.org/10.1016/S0140-6736(16)30892-3 Gary Calton/Panos Pictures On both sides of the prison walls—prisoners and HIV Published Online July 14, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)30892-3 See Online/Comment http://dx.doi.org/10.1016/ S0140-6736(16)30829-7 and http://dx.doi.org/10.1016/ S0140-6736(16)30830-3 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(16)30466-4, http://dx.doi.org/10.1016/ S0140-6736(16)30379-8, http://dx.doi.org/10.1016/ S0140-6736(16)30769-3, http://dx.doi.org/10.1016/ S0140-6736(16)30663-8, http://dx.doi.org/10.1016/ S0140-6736(16)30578-5, and http://dx.doi.org/10.1016/ S0140-6736(16)30856-X 1 Comment being marginalised in the HIV/AIDS response, and this includes prisoners and detainees.10 As Archbishop Desmond Tutu’s message ”Don’t forget the prisoner” reaffirms,11 we have a moral and human imperative to provide treatment to prisoners since we have limited their ability to access care except through prison health. Only by fully including them and other marginalised populations in the global HIV/AIDS response, will the fast-track to accelerate the fight against HIV and to end the AIDS epidemic by 2030 become a reality. Pamela Das, Richard Horton The Lancet, London EC2Y 5AS, UK We thank Chris Beyrer for his extraordinary leadership, energy, and commitment to making this Series possible as well as his colleagues Martin McKee, Josiah Rich, Joseph Amon, Kate Dolan, and Adeeba Kamarulzaman, who ably supported his leadership. We also thank the Center for Public Health and Human Rights at Johns Hopkins Bloomberg School of Public Health and their funding of the work of this Series, which included grants from the National Institute on Drug Abuse; The Bill & Melinda Gates Foundation; the Open Society Foundations; the United Nations Population Fund; the Johns Hopkins University Center for AIDS Research, a National Institute of Health (NIH)-funded programme, 1 P30AI094189; and AIDS Fonds Nederlands. The findings and conclusions contained within this Series are those of the authors, and do not necessarily reflect positions or policies of the funders. 2 1 Dolan K, Wirtz AL, Moazen B, et al. Global burden of HIV, viral hepatitis, and tuberculosis in prisoners and detainees. Lancet 2016; published online July 14. http://dx.doi.org/10.1016/S0140-6736(16)30466-4. 2 Rich JD, Beckwith CG, Macmadu A, et al. Clinical care of incarcerated people with HIV, viral hepatitis, or tuberculosis. Lancet 2016; published online July 14. http://dx.doi.org/10.1016/S0140-6736(16)30379-8. 3 Kamarulzaman A, Reid SE, Schwitters A, et al. Prevention of transmission of HIV, hepatitis B virus, hepatitis C virus, and tuberculosis in prisoners. Lancet 2016; published online July 14. http://dx.doi.org/10.1016/S0140-6736(16)30769-3. 4 Rubenstein LS, Amon JJ, McLemore M, et al. HIV, prisoners, and human rights. Lancet 2016; published online July 14. http://dx.doi.org/10.1016/ S0140-6736(16)30663-8. 5 Telisinghe L, Charalambous S, Topp SM, et al. HIV and tuberculosis in prisons in sub-Saharan Africa. Lancet 2016; published online July 14. http://dx.doi. org/10.1016/S0140-6736(16)30578-5. 6 Altice FL, Azbel L, Stone J, et al. The perfect storm: incarceration and the high-risk environment perpetuating transmission of HIV, hepatitis C virus, and tuberculosis in Eastern Europe and Central Asia. Lancet 2016; published online July 14. http://dx.doi.org/10.1016/S0140-6736(16)30856-X7. 7 UNODC, ILO, UNDP, WHO, UNAIDS. HIV prevention, treatment and care in prisons and other closed settings: a comprehensive package of interventions. Vienna: United Nations Office on Drugs and Crime, 2013. 8 Csete J, Kamarulzaman A, Kazatchkine M, et al. Public health and international drug policy. Lancet 2016; 387: 1427–80. 9 UNAIDS. Global AIDS update 2016. May 31, 2016. http://www.unaids.org/en/ resources/documents/2016/Global-AIDS-update-2016 (accessed June 21, 2016). 10 UN General Assembly. Political declaration on HIV and AIDS: on the fast-track to accelerate the fight against HIV and to end the AIDS epidemic by 2030. June 8, 2016. http://www.unaids.org/en/resources/documents/2016/2016political-declaration-HIV-AIDS (accessed June 21, 2016). 11 Beyrer C, Kamarulzaman A, McKee M, for the Lancet HIV in Prisoners Group. Prisoners, prisons, and HIV: time for reform. Lancet 2016; published online July 14. http://dx.doi.org/10.1016/S0140-6736(16)30829-7. www.thelancet.com Published online July 14, 2016 http://dx.doi.org/10.1016/S0140-6736(16)30892-3 Comment Prisoners, prisons, and HIV: time for reform Prisoners and detainees worldwide have higher burdens of HIV, viral hepatitis, and tuberculosis than the communities from which they come. This disease burden among prisoners has been recognised since the early years of these inter-related pandemics.1 Yet the health needs of prisoners receive little attention from researchers or advocates working to improve responses for these diseases, and scant funding for prevention or treatment interventions. This Lancet Series on HIV and related infections in prisoners1–6 shows that the reasons for this neglect include the very factors that make prisoners and detainees vulnerable to infection and unable to get treatment: unjust and inappropriate laws; underfunded and overcrowded prisons with large numbers of individuals in lengthy pre-trial detention; policing practices that lead to imprisonment with compulsory drug detention centres that provide no evidence-based treatment for substance use disorders and inadequate health care; and discriminatory criminal justice systems.1–7 The inter-related epidemics of HIV, viral hepatitis, and tuberculosis in prisoners have been seen as part of broader syndemics, which include mass incarceration without needle and syringe programmes, substance use, and mental disorders. In the decades long, failed War on Drugs, people who use drugs have been incarcerated in profoundly misguided and harmful approaches to treatable substance use disorders.8 Mass incarceration has destroyed countless individual lives, had lasting negative effects on prisoners’ families and communities, and, in many settings, increased community rates of HIV, tuberculosis, multidrug-resistant tuberculosis, and hepatitis C virus (HCV).8 The threat of incarceration, police harassment, and interference with access to HIV and HCV prevention and treatment services has also had an enormous impact on people who use drugs and other marginalised populations, including sex workers, men who have sex with men, and migrants and refugees. It is past time for a rethink on the uses of incarceration, and on ways of mitigating the effects mass incarceration has had on the overlapping epidemics we all seek to control. The need for a rethink is especially important because of how the incarcerated population is changing. Although most of the world’s 10·2 million estimated prisoners and detainees are men, women and girls are the fastest growing incarcerated population worldwide.9 The Institute for Criminal Policy Research reported a 50% increase in the number of women and girls incarcerated between 2000 and 2015 to about 700 000 worldwide, 205 000 (29%) of whom were in the USA alone.9 The human, social, and financial costs of mass incarceration in the USA are severe—most especially among communities of colour. Among US women, HIV burdens are also most concentrated among women and girls of colour: in 2014 the rate of new HIV infections was 34·8 per 100 000 people in African American women compared with 1·8 per 100 000 in white women.10 The first task in addressing HIV and related infectious diseases among those incarcerated is to reduce the numbers of people in prison and detention for substance use, sex work, and other non-violent offences. This effort will require policies that send fewer people to prison and reduce the length of sentences. This change can happen only if there is agreement on what prisons—and what imprisonment—are for. Conventionally, incarceration has had four possible goals: retribution (punishment); Published Online July 14, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)30829-7 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(16)30466-4, http://dx.doi.org/10.1016/ S0140-6736(16)30379-8, http://dx.doi.org/10.1016/ S0140-6736(16)30769-3, http://dx.doi.org/10.1016/ S0140-6736(16)30663-8, http://dx.doi.org/10.1016/ S0140-6736(16)30578-5, and http://dx.doi.org/10.1016/ S0140-6736(16)30856-X Panel: Don’t forget the prisoner Everyone has a right to dignity when they need medical care. And everyone has a right to compassionate medical treatment if they are suffering from diseases like HIV or tuberculosis. And by everyone, I also mean our brothers and sisters behind bars. Our late, beloved leader, President Nelson Mandela, contracted tuberculosis while he was a prisoner on Robbin Island. Our country, indeed all of humanity, is so very fortunate that Madiba survived to help lead us out of the darkness of Apartheid. But so many others in prisons and jails, in detention or awaiting trial, are less fortunate. Imagine, if you can, languishing with untreated HIV or tuberculosis, and lacking the freedom to do anything about it. Fearing HIV exposure or acquiring tuberculosis, and being denied the basics of prevention. Across Africa, our prisons and jails are overcrowded with men and women who are at risk for HIV and tuberculosis, or who are already living with these treatable infections—but who are being denied the care they so urgently need. We have left them behind. This is unacceptable to God and it should be unacceptable to all of us. For when we take away a man or a woman’s freedom, we must take on the responsibility to provide for their wellbeing—with adequate food, decent sanitation, with the right to representation, and to a timely trial—but also with prevention and treatment for these deadly diseases. God has not forgotten the prisoner, the detainee. No one is outside the circle of his love. But we have forgotten, and we must do better. I urge all of you working on HIV and tuberculosis to remember those among us who are not free. Keep them in your thoughts and actions, build them into your budgets and plans. When you care for people suffering from AIDS and tuberculosis without discrimination, especially for those forgotten by others, you wipe a tear from God’s eye. His Grace, Desmond M Tutu, Archbishop Emeritus of Cape Town www.thelancet.com Published online July 14, 2016 http://dx.doi.org/10.1016/S0140-6736(16)30829-7 1 Comment deterrence; incapacitation (stopping the prisoner from reoffending while they are in prison); and rehabilitation (reducing the risk that they will reoffend after release).11 The evidence for each of these goals is much less clear than it is often made out to be. Legislators often cite public demand for retribution to justify long prison terms with harsh regimes. Yet research shows that they consistently overestimate public demand for harsh treatment12 and for retribution rather than rehabilitation.13 The evidence that prisons are a deterrent is complex and subject to different interpretations.14 Durlauf and Nagin15 provided a detailed methodological review of the many weaknesses of previous research on deterrence and concluded that what matters to deter crime is the probability of being caught and the certainty of punishment. Greater severity of punishment, such as longer sentences, does not deter those who might offend. Rather, deterrence is more sensitive to effective policing through targeting of resources and ensuring that responses are appropriate to specific contexts. Prison terms and felony records can initiate first-time offenders into cycles of poverty, crime, and recidivism and, in many countries, there is no attempt to rehabilitate prisoners.6,16 Gendreau and colleagues’ comprehensive review17 found no evidence that prison sentences reduced reoffending and, in some comparisons, there was evidence that imprisonment increased it. The authors concluded that the sole justifications for prisons were incapacitation and retribution, goals with which few citizens agree.17 The scarce evidence to support long periods of incarceration raises the question of why, in some countries, incarceration rates are so high, especially when other countries manage to achieve low crime rates with much lower rates of imprisonment. Several factors have a role. First, in some countries, prisons act, in effect, as a surrogate for mental health services. Second, in some countries the numbers of incarcerated are swollen by many people in detention awaiting trial.18 They are often detained in facilities that are far worse than standard prisons.19 As Lilanganee Telisinghe and colleagues5 point out in their Series paper, pre-trial detention is also a particular challenge for many African correctional systems, often in unsafe, harsh conditions of overcrowding and undernutrition without health services. Third, mass incarceration has been increasingly used for offences related to substance use. 2 In any global review of mass incarceration, the USA stands out. Presently, nearly one in every 100 Americans is in jail, and in 2012 the USA accounted for 25% of the world’s prisoners (and 29% of all female prisoners) but only 5% of its population.20 A primary factor was the War on Drugs, which systematically targeted people who use drugs within minority communities, something reflected in the composition of the prison population; in 2010, African Americans were incarcerated six times more, and Hispanics three times more, than non-Hispanic whites.21 There is an urgent need for reform on public health and also on moral grounds (panel). 60 years ago, the UN adopted the Standard Minimum Rules for the Treatment of Prisoners. Although not binding, the rules proved useful to prison administrators and monitoring bodies. But they were also a product of another era, a time when the human rights of prisoners were not widely recognised and before the HIV/AIDS epidemic, the War on Drugs, and the high prevalence of mental disorders among prisoners. Bringing the rules up to date, however, was a challenge, because many states were reluctant to subject themselves to more stringent rules that could be used to hold them to account. The new rules, entitled the Nelson Mandela Rules, were finally adopted by the UN Commission on Crime Prevention and Criminal Justice in May, 2015, and approved by the UN General Assembly in December, 2015.22 The Nelson Mandela Rules provide benchmarks to achieve meaningful reform in access to health care for those detained. We can, and should, do better to reduce both the numbers of those incarcerated and the length of their sentences, and to improve prevention, treatment, and post-release linkage to care for prison-associated infectious diseases. Meeting community standards of care in correctional settings, especially in low-income and middle-income countries, will require political will, financial investment, and support from medical and humanitarian organisations across the globe, but it can and must be done. Global control of HIV, viral hepatitis, and tuberculosis will not be achieved without addressing the unmet health needs of prisoners. *Chris Beyrer, Adeeba Kamarulzaman, Martin McKee, for the Lancet HIV in Prisoners Group Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA (CB); University of Malaya, Kuala Lumpur, Malaysia (AK); and London School of Hygiene & Tropical Medicine, London, UK (MM) [email protected] www.thelancet.com Published online July 14, 2016 http://dx.doi.org/10.1016/S0140-6736(16)30829-7 Comment This Comment and the Lancet Series on HIV and related infections in prisoners were supported by grants to the Center for Public Health and Human Rights at Johns Hopkins Bloomberg School of Public Health from: the National Institute on Drug Abuse; The Bill & Melinda Gates Foundation; the Open Society Foundations; the United Nations Population Fund; and the Johns Hopkins University Center for AIDS Research, a National Institute of Health (NIH)-funded programme, 1 P30AI094189; and AIDS Fonds Nederlands. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The authors would like to thank His Grace, Archbishop Emeritus Desmond M Tutu for his panel. The Lancet HIV and Prisoners Group includes: Chris Beyrer, Joseph J Amon, Kate Dolan, Josiah Rich, Adeeba Kamarulzaman, Leonard Rubenstein, Frederick L Altice, Lilanganee Telisinghe, Andrea L Wirtz, Brian W Weir, Peter Vickerman, Michel Kazatchkine, and Martin McKee. 9 1 15 2 3 4 5 6 7 8 Dolan K, Wirtz AL, Moazen B, et al. Global burden of HIV, viral hepatitis, and tuberculosis in prisoners and detainees. Lancet 2016; published online July 14. http://dx.doi.org/10.1016/S0140-6736(16)30466-4. Rich JD, Beckwith CG, Macmadu A, et al. Clinical care of incarcerated people with HIV, viral hepatitis, or tuberculosis. Lancet 2016; published online July 14. http://dx.doi.org/10.1016/S0140-6736(16)30379-8. Kamarulzaman A, Reid SE, Schwitters A, et al. Prevention of transmission of HIV, hepatitis B virus, hepatitis C virus, and tuberculosis in prisoners. Lancet 2016; published online July 14. http://dx.doi.org/10.1016/S01406736(16)30769-3. Rubenstein LS, Amon JJ, McLemore M, et al. HIV, prisoners, and human rights. Lancet 2016; published online July 14. http://dx.doi.org/10.1016/ S0140-6736(16)30663-8. Telisinghe L, Charalambous S, Topp SM, et al. HIV and tuberculosis in prisons in sub-Saharan Africa. Lancet 2016; published online July 14. http://dx.doi.org/10.1016/S0140-6736(16)30578-5. Altice FL, Azbel L, Stone J, et al. The perfect storm: incarceration and the high-risk environment perpetuating transmission of HIV, hepatitis C virus, and tuberculosis in Eastern Europe and Central Asia. Lancet 2016; published online July 14. http://dx.doi.org/10.1016/S0140-6736(16)30856-X. Todrys KW, Amon JJ. Criminal justice reform as HIV and TB prevention in African prisons. PLoS Med 2012; 9: e1001215. Csete J, Kamarulzaman A, Kazatchkine M, et al. Public health and international drug policy. Lancet 2016: 387: 1427–80. 10 11 12 13 14 16 17 18 19 20 21 22 International Center for Prison Research. World female imprisonment list. 2015. http://wwwprisonstudiesorg/news/ (accessed June 9, 2016). Centers for Disease Control and Prevention. National HIV surveillance report. Atlanta, GA: Centers for Disease Control and Prevention, 2015. Kifer M, Hemmens C, Stohr MK. The goals of corrections: perspectives from the line. Crim Justice Rev 2003; 28: 47–69. Applegate BK. Penal austerity: perceived utility, desert, and public attitudes toward prison amenities. Am J Crim Justice 2001; 25: 253–68. Applegate BK, Cullen FT, Fisher BS. Public support for correctional treatment: the continuing appeal of the rehabilitative ideal. Prison J 1997; 77: 237–58. McManus WS. Estimates of the deterrent effect of capital punishment: the importance of the researcher’s prior beliefs. J Polit Econ 1985; 93: 417–25. Durlauf SN, Nagin DS. The deterrent effect of imprisonment. Controlling crime: strategies and tradeoffs. Chicago, IL: University of Chicago Press, 2010: 43–94. Hammett TM, Donahue S, LeRoy L, et al. Transitions to care in the community for prison releasees with HIV: a qualitative study of facilitators and challenges in two states. J Urban Health 2015; 92: 650–66. Gendreau P, Cullen FT, Goggin C. The effects of prison sentences on recidivism. Ottawa, ON: Solicitor General Canada, 1999. Walmsley R. Global incarceration and prison trends. Forum Crime Soc 2003; 3: 65–78. Bobrik A, Danishevski K, Eroshina K, et al. Prison health in Russia: the larger picture. J Public Health Policy 2005; 26: 30–59. Travis J, Western B, Redburn S. The growth of incarceration in the United States: exploring causes and consequences. Washington, DC: National Academies Press, 2014. Drake B. Incaceration gap widens between whites and blacks. FACTTANK: News in the Numbers: Pew Research Center, 2013. UN General Assembly. UN Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules), 2015. New York: United Nations, 2015. www.thelancet.com Published online July 14, 2016 http://dx.doi.org/10.1016/S0140-6736(16)30829-7 3 Comment African Americans, HIV, and mass incarceration non-existent in US correctional facilities.8 Yet, many prisoners engage in consensual sex, drug use, and tattooing while in detention. Third, many prisons have high rates of violence, including sexual assault.9 Fourth, incarceration can limit or interrupt a person’s access to health care. Effective HIV services that allow for preventing, testing, and treating infection are often absent.10 Individuals whose infections are detected and treated while detained are likely to find their treatment is interrupted upon release, or if they are re-detained.9 Most of these people quickly rebound with a high HIV viral load during treatment interruptions, rendering them infectious for sexual partners.9 With some 14% of all Americans living with HIV cycling through the criminal justice system each year, these common treatment interruptions may play the most important role in the markedly increased likelihood for African Americans to encounter a sexual partner with HIV and who is not virally suppressed.11 Since women represent less than 10% of the prison population in the USA, the disproportionately high incarceration rates for African American women do not explain the sharp increase in HIV/AIDS rates among this group. Instead, one influential study concluded that the disparity in HIV/AIDS rates between black and white populations is best explained by the hyperincarceration of black men.12 The spike in HIV/AIDS rates among black women seems to be due primarily to their increased risk of having an infected partner. The CDC estimates that 87% www.thelancet.com Published online July 14, 2016 http://dx.doi.org/10.1016/S0140-6736(16)30830-3 Published Online July 14, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)30830-3 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(16)30466-4, http://dx.doi.org/10.1016/ S0140-6736(16)30379-8, http://dx.doi.org/10.1016/ S0140-6736(16)30769-3, http://dx.doi.org/10.1016/ S0140-6736(16)30663-8, http://dx.doi.org/10.1016/ S0140-6736(16)30578-5, and http://dx.doi.org/10.1016/ S0140-6736(16)30856-X Lucy Nicholson/Reuters Pictures The disproportionate rates of HIV infection among African Americans are perplexing. In 2014, about 44% of new HIV infections and 48% of AIDS diagnoses in the USA were among African Americans, although they represent just 12% of the overall population.1 The US Centers for Disease Control and Prevention (CDC) reports, in 2016, that the HIV incidence rate for black men is more than six times that of white men, and more than twice that of Hispanic men.2 The HIV incidence rate for black women is 20 times that of white women, and nearly five times that of Hispanic women.2 Furthermore, African Americans represent close to half of all patients with AIDS in the USA who have died during this epidemic.2 HIV/AIDS prevention and treatment services in the USA have largely focused on individuals with a history of high-risk behaviours, such as injection drug use or unprotected sex. Although white young adults who engage in such high-risk behaviours are at increased risk for HIV, young black adults without these usual risk factors are nevertheless at higher than average risk for HIV.3 One 2010 study showed that condom use was, in fact, higher for black and Hispanic individuals than for other racial groups.4 To explain the higher rates of HIV/AIDS among African Americans, we need to examine structural factors, such as access to health care or disease prevalence within communities. African Americans differ from other groups mainly with regard to socioeconomic vulnerability—that is, their probability of living in poverty, being homeless, or spending time in a detention facility. A 2016 study showed that, by 2011, the incarceration rate for black men was six times that of white men and more than twice that of Hispanic men.5 The incarceration rate for black women was 2·5 times higher than the rate for white women and roughly twice the rate of Hispanic women.5 Rates of incarceration and of HIV/AIDS have skyrocketed for African Americans during the past three to four decades. These two issues are linked for several reasons. First, people at increased risk for HIV, such as injection drug users and sex workers, often end up in prison due to zero-tolerance policies in the USA for these activities.6,7 As a result, HIV prevalence is 3–5 times higher in prisons and jails than in the general population.5,8 Second, harm-reduction programmes—eg, provision of condoms and clean needles to high-risk populations—are almost 1 Comment of African American women with HIV become infected through heterosexual sex, and only a small percentage through injection drug use or other pathways.1 Incarceration rates have quadrupled in the USA in the past several decades, and this has reduced the number of men in black communities, and therefore the number of available partners for heterosexual black women. This fact, together with ongoing racial segregation, contributes to the formation of insular sexual networks with overlapping, concurrent partners.13,14 Moreover, heterosexual African American women are more likely to have sexual partners in high-risk groups, notably men with a history of incarceration and, therefore, men who have sex with men—a category that refers to a person’s behaviour not someone’s sexual orientation. Men who have sex with men include sexually active men in single-sex settings, such as prisons, who do not identify as gay or bisexual.15 Heterosexual African American women have about twice the rate of HIV infection compared with heterosexual African American men (men who report no sexual activity with other men), and this difference could be because of women’s greater biological vulnerability14 and also because the partners of heterosexual black men come from groups with lower HIV risk.2 Importantly, the so-called down low theory, which is often invoked to explain the high rates of HIV/AIDS among African American women, puts the spotlight on the wrong contributing factors. This theory posits high numbers of secretive bisexuals in African American communities and erroneously focuses on a person’s sexual orientation rather than his history of incarceration.16 It is a pernicious theory because it can lead to inappropriate interventions and stigmatise a sexual minority for the spread of HIV/AIDS. To reduce HIV/AIDS rates among African Americans we need to focus on structural factors, such as reducing incarceration rates and improving access to health care. For instance, all prisons and jails should initiate regular opt-out HIV testing and increase prison counselling and education programmes. Such practices generally improve participation in testing, adherence to treatment, and reduce risky behaviours. Also, correctional facilities should develop harm-reduction strategies such as needleexchange and condom distribution programmes. Perhaps most importantly, better linkages between community and correctional health-care systems are essential to reduce treatment interruptions in HIV treatment upon 2 detention, and after release, including assistance with enrolling in health insurance programmes.17,18 Finally, we need to evaluate the public health effects of adopting zero-tolerance policies to deter recreational drug use, adult sex work, and other non-violent offences, since these policies may do more harm than good. Laurie Shrage Philosophy Department, Florida International University, Miami, FL 33199, USA [email protected] I declare no competing interests. I thank Chris Beyrer for helpful suggestions on this Comment, and the Edmond J Safra Center for Ethics at Harvard for supporting my work on this topic. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Centers for Disease Control and Prevention. HIV among African Americans. 2016. http://www.cdc.gov/hiv/group/racialethnic/africanamericans/ (accessed May 16, 2016). Centers for Disease Control and Prevention. CDC fact sheet: HIV among African Americans. 2016. http://www.cdc.gov/nchhstp/newsroom/docs/ factsheets/cdc-hiv-aa-508.pdf (accessed May 16, 2016). Hallfors DD, Iritani BJ, Miller WC, Bauer DJ. Sexual and drug behavior patterns and HIV and STD racial disparities: the need for new directions. Am J Public Health 2007; 97: 125–32. Reece M, Herbenick D, Schick V, Snaders SA, Dodge B, Forenberry JD. Condom use rates in a national probability sample of males and females ages 14 to 94 in the United States. J Sex Med 2010; 7 (suppl 5): 266–76. Tarver BA, Sewell J, Oussayef N. State laws governing HIV testing in correctional settings. J Correct Health Care 2016; 22: 28–40. Lanier MM, Zaitzow BH, Farrell CT. Epidemiological criminology: contextualization of HIV/AIDS health care for female inmates. J Correct Health Care 2015; 21: 152–63. Blankenship KM, Smoyer AB, Bray SJ, Mattocks K. Black-white disparities in HIV/AIDS: the role of drug policy and the corrections system. J Health Care Poor Underserved 2005; 16 (4 suppl B): 140–56. Lyons T, Osunkoya E, Anguh I, Adefuye A, Balogun J. HIV prevention and education in state prison systems: an update. J Correct Health Care 2014; 20: 105–15. Kantor E. HIV transmission and prevention in prisons. HIV InSite. April, 2006. UCSF Center for HIV Information. http://hivinsite.ucsf.edu/ insite?page=kb-07-04-13 (accessed May 16, 2016). Belenko S, Hiller M, Visher C, et al. Policies and practices in the delivery of HIV services in correctional agencies and facilities: results from a multisite survey. J Correct Health Care 2013; 19: 293–310. Rich JD, Beckwith CG, Macmadu A, et al. Clinical care of incarcerated people with HIV, viral hepatitis, or tuberculosis. Lancet 2016; published online July 14. http://dx.doi.org/10.1016/S0140-6736(16)30379-8. Johnson R, Raphael S. 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Survey finds that many prisons and jails have room to improve HIV testing and coordination of postrelease treatment. Health Aff (Millwood) 2014; 33: 434–42. Bechelli MJ, Caudy M, Gardner TM, et al. Case studies from three states: breaking down silos between health care and criminal justice. Health Aff (Millwood) 2014; 33: 474–81. www.thelancet.com Published online July 14, 2016 http://dx.doi.org/10.1016/S0140-6736(16)30830-3 Perspectives Click on to the website of Brown University’s Center for Prisoner Health and Human Rights and you’re greeted by a shocking nugget of information. “The nation’s three largest psychiatric facilities”, it says, “are the New York, Los Angeles and Chicago jails. More than half of the incarcerated population has a mental health problem.” The Center’s Co-Director is Josiah “Jody” Rich, Professor of Medicine and Epidemiology at Brown University’s Warren Alpert Medical School in Providence, Rhode Island. Co-founded in 2005 by Rich and colleague Scott Allen to draw attention to the plight of prisoners, the centre had humble origins. “We started it with a website and some stationary—and some chewing gum and a little piece of string”, Rich jokes. But he believes it’s achieving the critical mass required to make an impact. “As soon as you put that flag in the ground people start coming out of the woodwork…It’s identified a lot of people within the academic community who are doing things already.” Rich speaks whereof he knows; since he joined Brown University’s affiliated Miriam Hospital as an attending physician in 1994 he’s made countless visits to his local prison, tackling problems of infectious disease, particularly HIV, and drug use. Timothy Flanigan, Professor of Health Services, Policy and Practice at Brown Medical School, has known and worked with Rich for 20 years. “When Jody came here he started to work in a weekly clinic for people in jail. He noted the high rate of HIV among injecting drug users and also that they were reusing needles. It was common for users to resharpen their needles on the striking area of a matchbox. Needles were being used 20 times or more because needle possession in the state of Rhode Island was a felony that carried up to a 5-year sentence. So he worked, one on one, with the law makers, with the Department of Health to build a coalition, educating and advocating to change the law. And sure enough, over a few years, needle possession became a misdemeanour and was eventually decriminalised.” Rich’s efforts have had a real impact on prisoners’ health says Michael Fine, Director until last year of the Rhode Island Department of Health, and before that the Medical Program Director of the Department of Corrections, who has worked closely with Rich. “His work led to a substantial reduction in the prevalence of HIV in Rhode Island. He brought screening to the Department of Corrections. He cajoled, he pleaded, he twisted, he turned, he did everything he could to encourage a resistant correctional hierarchy to think about itself as a centre point in the detection and treatment of HIV/AIDS.” It took 20 years of hard work; but by looking for the people who were blocking progress and either changing their minds or finding a way around them Rich got there. The struggle to change policy in respect of drug use proved equally arduous. “When I got there”, Rich says, “if prisoners came in on methadone, day one they’d get 50 mg, on day two 40 mg and then 30, 20, 10 and then none. Anyone who knows anything about methadone will tell you that’s inhumane and ineffective.” Under his influence, the authorities began to taper off the dose more gradually or even continue it. As he noted last year in a Lancet Article, the more liberal policy works: “Forced withdrawal from methadone on incarceration reduced the likelihood of prisoners re-engaging in methadone maintenance after their release.” Rich’s current thinking on health in prisons is outlined in the Series paper he has co-authored on the clinical care of incarcerated people with HIV, viral hepatitis, or tuberculosis for The Lancet’s new Series on HIV and related infections in prisoners. Born into a family of scientists, Rich first studied chemistry and then developmental biology. But his brother got hit by a drunk driver and spent 2 months in hospital. “I spent a lot of time there with him”, he recalls. “I just got exposed to medicine, and intrigued by it.” He qualified at the University of Massachusetts Medical School in 1987 before moving to Atlanta for his internship and residency at Emory University. During this time he spent 3 months in Bangladesh. “That really opened my eyes to public health and infectious diseases”, he says. Rich went on to do fellowships at Brigham and Women’s Hospital in Boston, and at Harvard Medical School, and became involved in the care of patients with HIV. His interest in prisoners’ health dates back to his time at Emory where he’d worked with them. The move to Miriam Hospital was partly prompted by the possibility of being able to extend this work in conjunction with Tim Flanigan. Through making regular visits to his local prison, he began to realise how profoundly the disease burden there differed from that in the wider community—“kind of like going into another world”. The more familiar he became with this disadvantaged population, the more he felt there were ways in which their health could be improved. While disliking incarceration, he also sees it as a unique public health opportunity to engage with people who are otherwise too often off the medical radar. Fine sees Rich as motivated by his sense of justice. Flanigan describes him as a happy warrior: “Jody’s relentlessly optimistic and cheerful, always with a smile and with courtesy…And he loves the drama of human nature. He’s famous for his stories, just the events you come across in everyday life. Anything— he’ll make a story of it.” Rich’s anecdotes enlivened my own conversation with him—one concerned the time when he came last among a group of candidates running as Mayor of Charlestown, MA: an election he fought to publicise his antismoking views. His stories capture his audience. But when Rich speaks up about prisoners his words help transform lives. Photo Nola Rich Profile Josiah Rich: speaking up for the incarcerated Published Online July 14, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)30901-1 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(16)30466-4, http://dx.doi.org/10.1016/ S0140-6736(16)30379-8, http://dx.doi.org/10.1016/ S0140-6736(16)30769-3, http://dx.doi.org/10.1016/ S0140-6736(16)30663-8, http://dx.doi.org/10.1016/ S0140-6736(16)30578-5, and http://dx.doi.org/10.1016/ S0140-6736(16)30856-X For the Center for Prisoner Health and Human Rights see http://www.prisonerhealth.org/ For Rich and colleagues’ 2015 Article see Lancet 2015; 386: 350–29 Geoff Watts www.thelancet.com Published online July 14, 2016 http://dx.doi.org/10.1016/S0140-6736(16)30901-1 1