U.S. Department of Justice

Federal Bureau of Prisons

 

Office of the Director Washington, DC 20534

Aeril 22, 1994

June E. Osborne, M.D.

Chairman

National Commission on AIDS
1730 K Street, N.W., Suite 815
Washington, D.C. 20006

Dear Dr. Osborne:

I support your important work on HIV issues both inside and
outside of correctional facilities and have read the National
Commission on AIDS report titled "HIV Disease in Correctional
Facilities" issued in March 1991.

While we disagree with your recommendations regarding condom
distribution, the elimination of mandatory testing, and the need
for written consent before releasing test results to any
employee, your other recommendations are sound. Unfortunately,

you do a general disservice to the correctional health care
community. There are undoubtedly some correctional agencies that
are not providing the level of education and care necessary to
combat this significant problem. However, I am disturbed that
the Commission took such a broad approach in the report. It
leaves an uninformed reader with the sense that little effort is

being made in HIV education and treatment, especially on the part
of the Bureau of Prisons.

As a Federal agency, the Bureau assumes the responsibility
of implementing programs that serve as models to the States. In
1988, the President's Commission on the HIV Epidemic recognized
the Bureau's program as exemplary. Your recent report
Significantly undermines the leadership efforts of the Bureau
of Prisons in the area of HIV and AIDS education and treatment.

I am especially dismayed and take exception to the report's
lack of differentiation among the correctional systems and the
general absence of information about the Bureau of Prisons.
Despite the fact that Dr. Kenneth P. Moritsugu, Medical Director
for the Bureau of Prisons, testified before the Commission and
provided his statement in writing to the Commission, his
testimony was not used or referenced in the report as was other
testimony. Only in the section on "Prevalence of AIDS and HIV
Infection" was the Bureau of Prisons highlighted and. our success
at preventing internal seroconversion noted.

 

 

 
Also, the report does not mention the numerous other State
and local correctional agencies with excellent HIV programs so
that they too might be given deserved credit. The report gives
the inaccurate impression that all or most correctional systems
are providing the same inadequate level of education, counseling,
and treatment.

The one major exception in our practices to the
recommendations in the report concerns the distribution of
condoms. While the report recommends that "condom distribution
Should be part of an overall health promotion and HIV prevention
effort in all correctional systems," the Bureau does not endorse
the distribution of condoms to inmates. The distribution of
condoms is a basic contradiction to our policy of prohibiting
sexual activity within our institutions. Issuing condoms would
transmit a mixed and confusing message to the inmate population.

Regarding other specific recommendations in the area of
Education and Prevention, the report states:

° Inmates and staff will remain at risk of HIV infection
until they are taught how to reduce or eliminate that
risk. Without specific education geared toward
correctional personnel they will continue to impede
their own and inmate's progress toward minimizing risk
behaviors.

Inmates receive AIDS education upon entering the Bureau
of Prisons and on a quarterly basis. Inmates who
receive testing receive special counseling. Our staff
receive HIV and AIDS education upon initial employment
and at a minimum of yearly thereafter in institutional
annual refresher training.

Former prisoners are re-entering their communities with
little or no added knowledge about HIV disease and how
to prevent it.

Inmates receive counseling and testing prior to release
from the Bureau of Prisons. Special counseling is
provided to HIV-positive inmates prior to release.

In the findings on Human Rights and Confidentiality, the
report states:

° Prisoners with HIV disease are often segregated from
the rest of the prison community despite the fact that
there is absolutely no legitimate public health basis
for the practice.

 
Inmates in the BOP are not segregated as a result of
their HIV status. HIV-infected inmates remain in the
general populations of our institutions unless their
medical care requires hospitalization.

Segregated inmates often lose access to religious
services, work programs, visitation rights, libraries,
including law libraries, educational and recreational
programs, and drug and alcohol treatment.

Because they are not segregated, inmates who are HIV-
infected have access to the full range of institutional
programming in the Bureau of Prisons.

Prisoners with HIV disease are being denied access to
early release programs.

Inmates with HIV infection have full access to early

release programs. Early release is considered on a
case by case basis.

In small prisons, isolation because of HIV positive
status can virtually become a sentence of solitary
confinement. In larger prisons, inmates with HIV
disease, whether from maximum or minimum security
facilities, are often grouped together
indiscriminately.

HIV-infected inmates are not segregated nor isolated
from the general prison population. HIV infection is
not considered in the placement of inmates in BOP
facilities unless hospitalization or the advanced care
of a medical referral center is needed.

Mandatory testing or screening should not be employed.

The Bureau utilizes mandatory testing in order to
develop and assess management strategies and the
allocation of human and financial resources.

Test results should never be made available to any
prison employee, even prison medical employees, without
the specific, written informed consent of the
prisoners.

Our HIV test results are made available to unit
managers and the U.S. Probation Office, prior to an
inmate's release, in order to assure proper placement
in the community and to insure access to medical
resources.

 
In correctional facilities where segregation is not
practiced, confidentiality is often violated due to the
lack of privacy when meeting with medical personnel and
during the distribution of medication.

The Bureau of Prisons is greatly concerned with the
maintenance of confidentiality. Medical examinations
and reviews are conducted in private settings.
Medications are administered as part of general
population medication without the use of special
medication procedures which could violate
confidentiality.

Inmates with AIDS are dying inside prisons and
hospitals without release, or the support of family,
friends or counselors despite the fact that they are
not a threat to society.

Inmates who are suffering from AIDS are considered for
early release as are other terminally-ill inmates. One
of our medical centers has developed a hospice program
to assist terminally-ill inmates. Inmates are
instrumental in the success of the program.

In the area of Health Care the Commission reported that:

° --einmates are often denied access to clinical research
programs...

Currently, all HIV-infected inmates in the Bureau of
Prisons are assessed on an individual basis for
inclusion in FDA approved clinical trials. A number of
federal inmates have participated in clinical trials or
extended access programs and have received appropriate
treatment and follow up.

Inmates living with HIV disease are often denied access
to specialists outside the correctional facility.

All HIV-infected inmates in the Bureau of Prisons have
access to specialists in the community as well as in
our medical centers.

T-cell counts, essential for monitoring the progression
of HIV disease, are often administered erratically, if
at all. Medications are not always available or
administered in a consistent manner.

All HIV-infected inmates are followed on a monthly
basis with T-cell determinations based upon Centers for
Disease Control guidelines. Treatments which are
clinically indicated are promptly provided to inmates.

 

 

 

 
Access to voluntary testing with appropriate counseling
is in very short supply. Prisoners are often tested
without their knowledge and consent and then informed
of their seropositive status with inaccurate
projections of life spans, treatments, etc.

Voluntary testing is actively encouraged in the Bureau.
Inmates and staff are always notified of the reason for
testing. Inmates receive standardized pre-test and
post-test counseling with special counseling being
provided for inmates with HIV positive test results.

We share the Commission's concern and interest on the
important public health issues of HIV infection. I offer the
Bureau's resources in these matters to assist the Commission with

subsequent inquiry and publications on HIV and AIDS in
correctional facilities.

Michael Quinlan
rector

cc: Members of the Commission