Harm Reduction Strategies: Condoms in Prison.

From the National Commission on Correctional Health Care:
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Prevention in Practice: Access to Condoms in California
By Mary Sylla, JD, MPH

Providing inmates with access to condoms is controversial. To some it seems hypocritical—why would we give inmates condoms when it’s illegal to have sex in jail and prison?—and to others it seems like common sense, unless we pretend to ignore the fact that some sexual activity takes place in jails and prisons. There are clearly pros and cons and unusual challenges to adopting a harm reduction strategy in a law-and-order environment.

On Oct. 15, 2007, California Gov. Arnold Schwarzenegger vetoed the latest “prison condom bill” to hit his desk. But this time he directed the California Department of Corrections and Rehabilitation to determine the “risk and viability of such a program” by establishing a pilot program.

What follows is a review of the inmate condom access programs in two jails—one in Los Angeles and one in San Francisco—administered by the Center for Health Justice, a community-based nonprofit organization focused on HIV and incarceration, and ongoing research on those programs.

Condom Access: Pros and Cons
There are serious concerns about providing inmates with condoms. Introducing anything new into the security environment provides an additional potential tool for conducting illegal activities, including secreting contraband and assaulting staff with bodily fluids or excrement (called “gassing” in California).

Furthermore, in a rule-based environment it can be considered hypocritical to tell inmates it’s illegal to engage in sexual activity and then provide the means to “safely” engage in that activity. From this viewpoint it sends the wrong message. Condoms also could be used by assailants to prevent evidence of sexual assault from remaining.

But there are also reasons why provision of condoms to inmates might be a good idea. Even though it is illegal to have sex in jail or prison, that rule cannot be perfectly enforced in the many overcrowded and understaffed institutions in this country.

Both scientific evidence and popular media point to the fact that sexual activity takes place behind bars. Last year the CDC published in the Morbidity and Mortality Weekly Report a study that documented seroconversion during incarceration. Those who became HIV-infected were 8 to 10 times as likely as likely to report engaging in male-to-male sexual activity while in prison than those who did not.

The prevalence of known HIV among prisoners is extremely high, 5 to 7 times that of the general population. The very behaviors that put people at risk for HIV infection—injection drug use and sex work—are also behaviors that can lead to incarceration. In the United States, approximately one in four persons with HIV infection passes through a jail or prison each year, and many of those do not know they are infected. Therefore, a considerable number of HIV-infected inmates may unwittingly transmit their infection to others.

Where Are Condoms Provided?
Condoms are provided to inmates in county jails in Los Angeles, San Francisco, Washington, D.C., Philadelphia and New York, and in the state prisons in Vermont and Mississippi. The manner in which condoms are made available varies widely, and most reach only a small subset of the inmate population.

In Los Angeles, the Center for Health Justice distributes free condoms to a segregated gay male population only, one condom per week per inmate, a limit imposed by the Los Angeles Sheriff’s Department.

San Francisco’s Forensic AIDS Project (part of the Department of Public Health) distributes condoms upon request through its public health nurses in one-on-one health counseling sessions, one per person, per request, and upon release. Earlier this year the Center for Health Justice in San Francisco installed a condom dispensing machine—a vending machine set to require no payment—in a gym to which 800 inmates have access. About 70 condoms per week are taken from the machine.

In Washington, D.C., inmates in the D.C. jail system have access to free condoms during health education classes, voluntary HIV pretest or posttest counseling, or upon request to members of the health care staff. The jail’s health educator and staff of a community-based AIDS service provider distribute about 200 condoms to inmates each month.

In Philadelphia, inmates can get condoms from the medical services department or through the commissary.

Two Pilot Programs in California

The Los Angeles County Jail Model
The Los Angeles condom access program was the result of a unique set of circumstances: A new custody chief—who had just been promoted from medical services—approached the Center for Health Justice about the possibility of designing a program that could provide gay male inmates in dormitory-style housing units with access to condoms without involving custody staff or time.

The program today exists as it did when implemented: Once a week a health educator from the Center for Health Justice goes into each dorm, provides a brief, interactive HIV education session, explains the rules of the program (including that sex is still illegal in jail under California law and that the condoms are not to leave the dorm or they will be considered contraband) and hands one condom to each inmate who lines up to receive one.

Although the average has changed over time, the Center for Health Justice currently distributes about 120 condoms per week to the 300+ inmates in this unit.

To evaluate this program, 101 of the approximately 300 inmates who live in the unit for segregated gay males were asked a series of questions through a computer-assisted self-interview program. Although the formal data analysis has not been completed, interesting statistics compiled so far include that 93% of respondents were aware of the condom program and 82% had received at least one condom from the program. Fifty-three percent of respondents reported anal sex during the past 30 days—but despite access to condoms, 75% of those individuals said it was unprotected. The three top reasons for not using condoms were (1) my partner and I are both HIV negative (or positive), (2) I ran out of condoms and (3) I don’t like the way condoms feel.

Information was gathered about other methods of condom access: 66% preferred the current method of distribution; other methods of distribution cited were medical (41%), vending (10%) or canteen (8%).

Charles R. Drew University’s Nina Harawa, PhD, MPH, and the Center for Health Justice (with funding from the Institute for Community Health Research, itself funded by the California HIV/AIDS Research Program) are evaluating the pilot program to determine whether it is reducing sexual risk activity. The results of this evaluation will be finalized and published during the coming year, but they support the assertion that some risk-reduction is achieved in this population through access to condoms.

The San Francisco County Jail Model
In San Francisco, the Center for AIDS Prevention Studies and Olga Grinstead, PhD, MPH, are conducting research on a novel way to provide inmates with access to condoms that has been successful in other countries.

As mentioned above, in San Francisco, inmates have had access to condoms since 1987 through the Forensic AIDS Project. In the fall of 2006, the Center for Health Justice, Dr. Grinstead and the Forensic AIDS Project approached the sheriff of San Francisco about installing a condom dispensing machine, in part because of reports from Forensic AIDS Project staff that the demographic characteristics of the health educator seemed to influence whether a inmate being counseled took a condom. The Center for Health Justice sought to evaluate a method of providing access to condoms that is more anonymous as well as less staff-intensive.

The dispensing machine program and its pilot feasibility are being conducted by the Center for Health Justice in collaboration with the Forensic AIDS Project. The machine was installed in April 2007 in a gym to which 800 inmates have access every week for their three hours of recreation. Sheriff Michael Hennessey himself, to provide a large number of inmates with access to the machine, suggested the precise location.

Before the machine was installed, brief written surveys were conducted with inmates to elicit baseline information about their HIV status, knowledge of the existing condom program and risk behavior. Interviews were conducted with sheriff’s department staff to assess attitudes about condom access for inmates and to determine potential security concerns. Center for Health Justice staff also made presentations to all deputy staff and inmates affected by the program before the machine was installed. The same written survey and similar interviews were conducted after the machine was operational for four months.

The machine itself is a low-profile, tamper-resistant unit, designed to withstand break-in attempts. It dispenses condoms in a cellophane-wrapped paper box. Inside the box the condoms are enclosed in another cellophane wrapper. The “Condom Machine Rules” posted next to the machine indicate that condoms are to be removed from the box and carried only in the clear wrapper, with the condom inside visible.

During the study period the Center for Health Justice has successfully installed, stocked and maintained the condom machine. Data analyses of the pre- and post-surveys and interviews are currently underway. Preliminary data analyses indicate that inmate self-report of sexual activity did not increase during the study period. In addition, the custody staff have reported no increase in reported sexual activity or any other security problems related to increased condom access.

We have encountered few operational problems, the most notable falling on the staff restocking the machine: The machine was difficult to open and close for restocking and sometimes jammed. A new model of machine has been purchased to address these problems.

Condoms Coming Soon to a Facility Near You?
While controversial, there is a trend toward increased inmate access to condoms. The CDC now recommends that prison systems with existing condom distribution programs evaluate those programs, and those without such programs consider the feasibility of implementing them.

Gov. Schwarzenegger’s “friendly” veto of legislation requiring inmate access to condoms may result in a pilot project across the state. At the federal level, California Rep. Barbara Lee’s JUSTICE Act of 2007 (H.R. 178), modeled on the California bill, requires federal prisoners to have access to condoms. Even where legislation is not pending, jails and prisons are considering the issue.

Regardless, programs that involve corrections cannot be successful without the support of the administration of corrections systems. The best circumstances for risk reduction involve input at the development stage, and any success these programs have is a credit to the professionalism of the corrections staff in the facilities where they exist.

— About the author: Mary Sylla, JD, MPH, is the director of policy and advocacy at the Center for Health Justice, based in West Hollywood and Larkspur, CA; http://healthjustice.net. This article is a written version of a presentation given at the National Conference on Correctional Health Care in Nashville on Oct. 17, 2007. It is a slightly abridged version of an article that appeared in the October-November issue of IDCR.

[This article first appeared in the Fall 2007 issue of CorrectCare.]