The correctional response to HIV and other infectious diseases has improved over time. During the early years of the HIV epidemic, correctional systems were far more likely to impose mandatory HIV testing of inmates and to segregate inmates who had HIV.38 Currently, about 18 state prison systems, but no large city/county jail systems, make testing of inmates mandatory, and only 2 state systems still segregate inmates who have HIV.39 Before the advent of effective antiretroviral treatment, mandatory HIV testing and segregation were adopted primarily to prevent HIV transmission, although there were serious shortcomings in this regard, including the harmful effects of stigma, discrimination, and mistreatment.

Today, mandatory testing is usually justified as a means of identifying inmates who need HIV treatment. This is the basis of a routine testing policy in Rhode Island, where few inmates refuse the testing.40 Braithwaite and Arriola argued for mandatory HIV testing as a way of overcoming racist withholding of medical care from inmate populations dominated by Blacks and Hispanics.41 Nevertheless, the ethical problems and potential detriments of mandatory testing seem to outweigh the advantages. As articulated in the World Health Organization (WHO) guidelines and elsewhere, correctional practices should reflect as much as possible those followed in the general community.42,43 People in the general community are not subjected to mandatory testing, and inmates should have the right to make their own informed choices. Creating a distinction on the basis of being incarcerated further stigmatizes inmates and undermines the important principle that correctional facilities are in fact part of the general community.

Within correctional facilities, the best policy is to offer and make readily available voluntary counseling and testing, with assurances that the results will remain confidential. Additionally, voluntary counseling and testing should be “marketed” to encourage people who have risk factors to take advantage of the service. However, uptake of voluntary counseling and testing may be a challenge because of concerns about confidentiality and discrimination44 and administrative and staffing problems.45
All testing and diagnostic programs for HIV, hepatitis, and STDs should result in appropriate treatment.36,46–49 State-of-the-art treatment for inmates is available in some US jurisdictions and in some other countries. However, despite the progress that has occurred, there is substantial room for improvement. In 2005, the New York Times documented very serious abuses in facilities where the for-profit organization Prison Health Services had contracts.50 This finding has renewed calls for correctional health services to be placed under the control of public health departments. Many factors beyond fiscal resources and the moral commitment of correctional departments (or lack thereof) influence treatment, including the quality and training of staff and restrictions on activities imposed by the correctional environment itself.

Theodore M. Hammett, PhD
Theodore M. Hammett is with Abt Associates Inc, Cambridge, Mass.
Requests for reprints should be sent to Theodore M. Hammett, PhD, Abt Associates Inc, 55 Wheeler St, Cambridge, MA 02138–1168 (email: ted_hammett@abtassoc.com).
Accepted July 21, 2005.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1470637/