Prison's hidden cost

Inmates can take home AIDS risk

By Margaret Newkirk and David Knox
Akron Beacon Journal staff writers
Sun, Mar. 17, 2002

For more than a decade, the state pumped millions into educating Ohioans how to avoid the AIDS virus, HIV.

Use condoms.

Don't share needles.

Clean them if you do.

All that time, a dangerous gap in Ohio's public health policy may have been costing state taxpayers millions more in Medicaid money -- and costing some Ohioans, particularly black Ohioans, their lives.

And while Ohio officials touted AIDS-prevention tools, they forbid their use in state prisons, where the population exploded in the 1990s, and where a lopsided number of inmates were male and black.

And in that time, the rates of HIV infection and of AIDS among Ohio's black population soared.

No one knows -- and no one is trying to learn -- how much the virus is spreading in state prisons.

A growing number of public health advocates say it's time to change that. They look at the numbers describing the AIDS epidemic among Ohio blacks -- particularly black women -- and see the shadow of prison walls.

Prison officials deny it flatly. They say there's no relation between the numbers of black men coming out of Ohio's prisons each year and the growth of the AIDS epidemic among poor, black Ohioans.

To say otherwise would be ``extremely disingenuous, misleading and inaccurate,'' said Reginald Wilkinson, director of the Ohio Department of Rehabilitation and Correction.

He said prisoners bring the AIDS virus into the system because they do the things that spread it when they're outside prison walls.

``We're talking criminals here,'' Wilkinson said, stressing that many inmates used intravenous drugs before entering prison.

``You have it 180 degrees the other way.''

Is HIV spreading in prison?

``No, not in Ohio prisons,'' Wilkinson said.

He paused.

``It very well could be, but we have no information at all that any inmate gave it to another inmate.''

He's right. They don't.

Ohio tests inmates on their way into prison, but says it costs too much to do it again on their way out.

Each test costs $10.25.

Meanwhile, the neighborhoods that Ohio prison inmates return to have become the most infected in the state.

Black Ohioans are now six times as likely to have the AIDS virus as white Ohioans.

The virus is 11 times as common among black women in Ohio as among white women.

Many are dying, of both genders and both races.

More are living, chained to the costly regimen of AIDS drugs that is now a dreary daily requirement of surviving the disease -- at tremendous public cost.

Odds vary widely by race

Open a pack of playing cards: 52 regular cards and two jokers.

Shuffle the deck.

Pick a card.

The chance of drawing a joker is pretty small: 1 in 27, or less than 4 percent.

Those are the odds that a young white man, chosen at random, spent time behind Ohio prison bars in the past decade.

Now imagine a pack of cards with 13 jokers and only 41 regular cards, increasing the chance of drawing a joker to about 1 in 4, or about 25 percent.

Those are the odds that a young black man in Ohio has been in prison at some point since 1990.

As the AIDS virus moved deeper into the ranks of black women in the 1990s, about 42,500 young black men filed out of Ohio's prison system at least once, with another 13,500 still inside.

Young white men went to prison, too, in roughly equal numbers, in the 1990s.

But the impact on their larger communities doesn't come close.

Apply the laws of chance, and a sexually active young black woman in Ohio dating young black men would have to date about four to hook up with one who has been in prison.

A sexually active young white woman would have to date 27 white men to do the same.

Risk higher in prison

There is no question that the risk of getting the AIDS virus in prison is higher than on the outside, both because of its concentration among incoming prisoners and prison policy.

Nine in every 1,000 male inmates in Ohio are known to be infected, compared with about 2 in every 1,000 Ohio men overall, according to an Akron Beacon Journal analysis of prison and Ohio Health Department data.

The prevention tools recommended by health officials -- condoms, clean needles or bleach for needle disinfection -- are considered contraband in prison.

How virulent are prisons?

Ask the Red Cross. Years ago, it stopped accepting blood donations from anyone who has been held in a correctional facility -- a prison, jail, detention center, or halfway house -- for more than 72 consecutive hours in the previous year. The reason: The agency considers them ``high risk environments for HIV and hepatitis,'' a spokeswoman said.

Read the restriction carefully.

Significantly, the Red Cross allows former inmates to give blood again a year after their release, when a blood test would reveal any virus picked up in prison.

The restriction contradicts the argument that the AIDS virus is only carried into -- and not transmitted inside -- prisons.

In the past decade, 1,544 male inmates tested positive for the virus on their way into prison. Almost 70 percent were black.

Nobody knows how many men came out with the virus in those years.

Infected by ex-inmate

LaVon Jones is among the increasing number of Ohio black women carrying the AIDS virus.

The 44-year-old Akron grandmother of 12 hauled herself to the doctor two years ago: Her weight was dropping. Her head and legs were aching and she was dragging through too many days bone tired.

She learned she had the virus and knew immediately where she had gotten it.

She got it from Tito, her boyfriend.

Tito got it in prison.

She said she knows Tito got it in prison because he'd been tested: He didn't have it when he went in, she said.

Jones is sure she isn't alone in contracting the disease from someone who got it in prison.

``Yes, they're connected,'' she said, nodding so deeply her head nearly grazed a coffee table, her voice rising to a near shout.

``Yes, yes, YES. I'd say 65 percent of the black women who have the disease contracted it from men who have been in prison.''

Jones has no proof.

But she said she knows what goes on in prisons.

That's because she asks a lot of questions, of both women and former inmates: ``A lot of them men, they have to have someone to trust,'' she said.

There's no doubt in her mind.

``I think the governors should be held accountable for this,'' she said. ``The people with HIV go straight into the (general prison) population. Those men in there have lovers in there.''

And needles.

And makeshift tattoo guns.

The case for examining the role of prisons rests partly on a belief that behaviors that spread the AIDS virus are common there.

Men in prison are more likely to have unprotected sex with other men, more likely to share needles if they use them, and more likely to get tattooed with equipment that isn't clean.

Where the numbers lead

But the argument for looking at prisons as an incubator for AIDS rests first with the number of women such as LaVon Jones who have the virus and got it from sex with a man.

Those numbers beg for an explanation, because they show a difference in the behavior of the virus.

Among white Americans, HIV spread largely among gay men, after the staunchly promiscuous, late-1970s gay culture on the two coasts gave it a disastrous head start.

By the end of 2000, nearly 450,000 Americans died.

Among blacks, the epidemic got its start among intravenous drug users, spread more slowly, and was spread heterosexually far more than among whites.

An estimated 75 percent of black Ohio women diagnosed with HIV in the last two years of the 1990s got it through heterosexual sex, according to the state health department.

The men who gave it to them more than likely had not gotten it from another woman: AIDS doesn't spread well that way, a fact AIDS activists and prevention experts don't discuss much.

Chances are, most of those men got the virus in one of the ways that most easily spread not only HIV but also hepatitis B and C.

The first is dirty needles. The second is anal sex.

Health officials don't talk about what behaviors spread HIV most easily because they don't want anyone getting complacent.

``If I say male-to-female sex is a lot more efficient (at spreading HIV) than female-to-male sex, it allows the males to say this is her problem,'' said Ralph DiClementi, an Emory University professor who studies at-risk teens.

But it's health advocates' knowledge about how the virus spreads most easily that has them eyeing prisons with suspicion. In tiptoeing language, they say they're looking at the high numbers of men who got the virus through sex with men -- called MSM by AIDS clinicians -- and at the high numbers of black women who got it from men, and connecting the dots.

``There's a general feeling, especially among health officials, that the high amount of MSM/heterosexual transmission in that community is due to the African-Americans who are in prisons,'' said Kenneth Cook, an AIDS prevention specialist with the Columbus Health Department.

Tom Kuhns, the Toledo Health Department's expert, agrees. ``The case that it's spreading in prisons is that in African-American females -- their highest exposure to the virus is heterosexual sex.''

The Akron Health Department's Chris Partis also agrees: ``The suspicion would be that a fair amount of the HIV that's going into the minority population is getting there from prison.''

The Canton Health Department's Tom Wingert doesn't tiptoe. The prison system ``needs to be taken to task for this.''

Living `on the down low'

Last summer, the Centers for Disease Control and Prevention released an explosive study that implicitly acknowledged black men's behavior as a major cause of the spread of the AIDS virus among black women.

The study talked about secret bisexuality among black men -- men living ``on the down low,'' as the slang has it.

The study examined more than 8,000 HIV-positive men and found that an abnormally high percentage of the black men who had sex with both men and women considered themselves heterosexual. They don't tell the women of having sex with other men, in part because the taboos against homosexuality in the black community are so strong.

The study didn't go further than that. Left unexamined was the possibility of a link between the ``down low'' phenomenon and the extraordinary percentage of young black men who have been locked up without women.

Sex is illegal in prison, just as is shooting drugs or giving and getting tattoos. But all those things happen, according to former inmates, researchers and prison officials themselves.

Ohio's Wilkinson said both sex and tattooing happen in state prisons, but that their prevalence is exaggerated. Ohio punishes both harshly, but sex in particular is ``very difficult to monitor,'' he said.

Interviews with several former inmates paint a picture of a culture that spreads HIV and similar diseases. The only question -- and it has no answer -- is how much.

The ex-inmates are black. They were chosen because of the disproportionate number of black men in prison and the impact of that on black women.

The former inmates who agreed to be quoted asked that their last names not be published, to protect their privacy and their parole status.

They said tattooing and sex are the most common risky behaviors in prison. Both can land an inmate in solitary confinement.

Many inmates come into prison with tattoos. Others get them, or improve upon them, inside. Some get tattoos to flaunt gang symbols for self-protection, or just to look tough.

Sharpened paper clips and the needles from sewing kits make a tattoo tool, and the ink comes from ballpoint pens. A motor, removed from electronic equipment such as a Walkman, makes a crude vibrating tattoo gun.

An inmate has no way of knowing whether the inmate tattooed ahead of him is infected, and no way of getting the needle disinfected even if he knows that's the case.

Strict AIDS-confidentiality laws mean prisons never reveal who tests positive, and inmates don't tend to tell. ``I don't discuss that with no one,'' said Randy, a former inmate from Cleveland who came into prison with the virus. ``They'd look at you in a different way.''

Former inmate's views

Steve is a 45-year-old local man who spent eight years in the Marion Correctional Institution in the 1990s.

He had sex in Marion three days after he walked through the gates. He has sex almost exclusively with men on the outside, too, he said.

In his years in prison, Steve played the role of wife to three men consecutively.

But he was propositioned often.

In the prison barter economy of sex, cigarettes and beatings, ``I could have had a whole lockbox full of cigarettes.''

In Steve's opinion, sex is common in prison. He bases that on his first prison sex partner, a member of a religious group that harshly rejects homosexuality. ``If a black Muslim is doing it, that means a lot of people were doing it,'' Steve said.

Many men who are not gay have sex in prison, Steve said. At least one of his long-term prison partners slept with women when he wasn't locked up, he said.

Steve remembers when condoms were available briefly at Marion -- albeit through larceny. The prison had an outside contract to package them and the inmates assigned to that job helped themselves.

Steve turned to the prison kitchen. He stole Saran Wrap and used it instead.

He was diagnosed as HIV-positive in his seventh year in prison. Caught having sex, he and another man had to shell out $15 of their $19-per-month prison pay to get tested -- a prison rule.

It's impossible to tell how common Steve's prison experience was. Prison rules-infraction boards document only how many inmates get caught: From 1999 to 2001, 120 inmates were charged with ``obscene or seductive behavior'' at the minimum-security Pickaway prison, for instance.

But inmate after inmate repeated the kinds of tales Steve told. Straight men with gay men. Sex traded for cigarettes or money. Gay men becoming wives or property.

Inmates say it's possible to avoid sex if you're careful. ``Way back in the olden days, maybe it was coerced sex,'' said David, a 38-year-old who spent time in Pickaway for one of Ohio's most common felonies: possession of crack cocaine.

Like Steve, David said that normally straight men have sex with other men in prison. ``That's all you got,'' he said.

There are enough flamboyantly gay men in prison -- ``men who wear their shirts tied up, or have that Kool Aid lipstick,'' as David put it -- to satisfy most of the demand.

David is HIV-positive, and, like Randy, hid that from the other inmates while in prison.

He didn't have sex there. He avoided it by keeping a low profile and acting masculine. He also had something other than sex -- canned meat and cereal swiped from the kitchen -- to trade.

Like Steve, he described prison sex as commerce. ``Suppose you came in new, and you had something I wanted. Maybe you've got a better lawyer than me, and I want access to that lawyer. So I strike a deal. I rent you my `herm.' A jailhouse sweetheart is called a `herm.' ''

Vermont offers condoms

Tom Powell, medical director for Vermont's prison system, said the inmates' portrayal of prison life is accurate.

Powell is one of the few prison officials in the country who speaks frankly about sex in prison, because Vermont is one of only two states that distributes condoms in an effort to prevent the spread of disease.

Said Powell: ``It's very opportunistic behavior. Men have sex with men in prison because men are what's available.''

``Then they get out and go back to their wives and girlfriends outside.''

``If they've picked up a virus in jail, they're going to strew it around the community.

``Most prison administrators would prefer that this issue not be talked about. You just pretend the whole thing is not there.

``It drives public health people wild.''

Ask public health people why no one monitors the disease spreading in prison, and they answer in a near chorus: Prison officials don't want to know.

They say that's why only two state prison systems -- Missouri's and Nevada's -- test inmates on both ends of their prison terms. That's also why prison officials seldom lend a hand to researchers, they say.

``The problem you know about is a lot more expensive than the problem you don't know about,'' said the University of Louisville's Richard Tewksbury, one of the nation's top prison researchers.

The legal liability alone could be staggering.

``Everybody pretty much knows what goes on in prisons,'' said the Akron Health Department's Partis. ``But the prisons can't do anything about it because that would be admitting that a lot of this stuff goes on.''

Responses face hurdles

Even if prison officials decided to tackle the spread of the disease tomorrow, they'd face hurdles, some of them practical, most political.

Civil libertarians, the CDC and the nation's AIDS lobby despise mandatory testing of any kind. They say it violates prisoner rights, medical ethics and a bedrock principle of AIDS prevention -- that testing should be encouraged, not forced.

Opposition to segregating infected inmates is even fiercer. Medical people say segregating inmates who carry HIV would create virtual petri dishes for diseases such as tuberculosis, which preys on AIDS victims.

Prison people, meanwhile, say such segregation removes a curb on sex and rape: fear of infection. ``By separating individuals by supposed HIV status, this final disincentive to engage in this criminal activity would be lost,'' an Illinois prison director said in a 1994 letter.

Prisons could increase oversight. But that's not likely in Ohio, which shed 1,000 employees last year, and is poised to lose more.

Prisons could provide bleach to clean needles, as jails in Houston and San Francisco do.

But Wilkinson said bleach, in the hands of a prisoner, would be a potent weapon.

Prisons could provide condoms. That's what former inmates suggest. That's also what nearly every country in the western world has been doing for years, and what the World Health Organization of the United Nations urges.

In this country, two states and a handful of jails allow condoms. They're available in Vermont, Mississippi, Philadelphia, New York City, Washington D.C., San Francisco and, just recently, Los Angeles -- where the sheriff announced the shift in a terse public statement. Sex is still illegal in the jail, but ``communicable diseases must be controlled, that's all,'' the statement said.

The institutions that allow condoms can't document that they control HIV -- since no data exist -- but they have seen no evidence that condoms lead to increased sex.

Arguments against allowing condoms include the possibility that they could be used to smuggle drugs or as a weapon -- a suggestion that Vermont's Powell calls ``dopey.''

Condoms also pose political problems. Inmates in Philadelphia have been allowed to pick up condoms at the infirmary three times a day since the late 1980s. But the condoms are donated, heading off gripes about a public subsidy of homosexuality.

A spokeswoman for Mississippi's prison system is emphatic: The state doesn't ``provide'' condoms, she said; it ``allows'' them. Prisoners can buy them at the commissary. No public money -- repeat, no public money -- is involved.

Ohio official's stance

``Public health systems have an obligation, and that's to prevent illness by identifying high populations and targeting them,'' said Vermont's Powell. ``I can't imagine a better place to practice public health than prisons. You've got at-risk people, with unhealthy behavior and multiple partners. Why in God's name wouldn't you do this?''

So, will Ohio?

``Absolutely not,'' said Wilkinson, the state prison director. ``And it will never happen. To me, it would condone the possibility of inmates having sex.''

Ohio also has no plans to let the state health department handle AIDS prevention in prison, as Vermont does.

``We're running a corrections department, and we don't need interference from a third party in terms of how to operate a corrections system,'' Wilkinson said.

He said Vermont, with liberal politics and small prison population, isn't comparable to Ohio.

For Ohio taxpayers, meanwhile, the costs of AIDS are mounting.

In one year, the state shelled out $1.6 million for AIDS drugs in prisons; $7 million to teach the public how to avoid AIDS; $14.6 million for social services to the infected poor, and $42.5 million to pay for AIDS drugs and treatment, home health care and nursing home beds -- which can cost as much as $2,300 per victim per month.

Steve gets some of that money. The inmate who tried to protect himself by stealing Saran Wrap from the prison kitchen takes 28 pills daily -- 14 in the morning, 14 in the afternoon.

The public pays for those.

The public also pays his rent and buys his food.

Steve would like to work, but he's a felon. It's hard to find work, and he's banned by law from the nursing home job he's trained to do.

The last of his prison lovers lingered for a while, after both men got out: ``There are feelings you can't push aside.''

In the end, though, they drifted apart.

The other man isn't like Steve. ``He's got a girlfriend. He's got two or three kids.''