Clinton Rejects Needle-Exchange Programs: Should We Provide Bleach & Condoms to Prisoners?

By Ronald L. Scott

The Clinton administration has recently rejected federal support for needle-exchange programs to help prevent the spread of AIDS. Yet drug use is the second most common risk factor for HIV infection in the United States, surpassed only by unprotected sex between men. After Clinton’s rejection of federally funded needle-exchange programs for AIDS prevention outside of prisons, are we ready to provide bleach and condoms to prisoners?

Studies have confirmed that existing prison education and prevention programs are not effectively halting the spread of AIDS in prison. It may be time to reevaluate AIDS prevention programs in prisons, specifically to consider making condoms and bleach freely available to prisoners. Powerful moral, economic, legal and public health arguments can be made in favor of this approach, including: (1) preventing AIDS in prison is the moral responsibility of the prison system; (2) preventing AIDS will reduce the costs of treating AIDS in prison; (3) failing to prevent HIV infection may violate the Eighth Amendment’s prohibition against cruel and unusual punishment; and (4) prisoners are eventually released from confinement and present a public health threat. Essentially, the arguments against condom and bleach distribution are that we should not encourage sex and illegal drug use in prison and that both needles and condoms present security risks in a prison setting.

In the total population, intravenous (IV) drug use is the second most common risk factor for HIV infection in the United States. By the end of 1992, about 30 percent of all AIDS cases reported to the Centers for Disease Control and Prevention (CDC) were associated with IV drug use. Within prisons, IV drug use is the dominant means of HIV exposure in the offender population. The transmission of HIV occurs when infected drug users inject heroin, cocaine, amphetamines or other drugs into a vein, under the skin, or into a muscle. To clear traces of the drug from the syringe, the user draws his or her blood back into the syringe and reinjects it into a vein. The "works" may then be shared with another drug user who repeats the procedure, mixing the blood of the two users. This process provides a highly efficient mode of HIV transmission. However, the virus is quite fragile outside the blood system and can easily be killed with dilute bleach or other disinfectants. Thus, it is quite simple and inexpensive to sterilize the "works."

A report by the CDC published May 1, 1996 in the Journal of the American Medical Association surveyed HIV/AIDS education and prevention programs for adults in prisons and jails and juveniles in confinement facilities within the United States in 1994. By the end of 1994, 4,588 adult inmates had died of AIDS, and during 1994, 5,279 adult inmates with AIDS were incarcerated. Only the San Francisco and Dallas (county) jail systems have been widely reported as officially making bleach available for cleaning drug-injection equipment. As early as 1991, the National Commission on AIDS issued a report on HIV/AIDS in United States correctional facilities, recommending that inmates be provided access to comprehensive HIV education and prevention programs. Prison officials faced with the question of whether it is better to acknowledge the existence of illegal behavior or to withhold life-saving preventative measures should perhaps look at the issue more from a public health perspective. Although more expensive than education programs alone, the effectiveness of condoms and bleach, compared with preventative education which only focuses on abstinence from sex and drugs, should easily outweigh any minor incremental costs.

The argument for bleach and condom availability is a narrow one. It is not suggested that either sexual activity or drug use should be encouraged or condoned. Prison officials should redouble efforts to prevent drugs and needles from entering correctional institutions, and drug treatment programs should continue to strongly discourage drug use. Nevertheless, life-saving health promotion activities should not be ignored because of the unsavory circumstances surrounding the transmission of disease. Correctional institutions have an unfortunate history of providing for inmate’s health care needs only after a court has ordered them to do so.

04/24/98