Jl048d pue uoneqoiqd ut SAIV ~ U.S. Department of Justice Office of Justice Programs National Institute of Justice National Institute of Justice EX TTX 111 Practices AIDS in Probation and Parole BERKELEY LIBRARY UNIVERSITY OF \ CALIFORNIA PUBLIC HEALTH LIBRARY About the National Institute of Justice The National Institute of Justice is a research branch of the U.S. Department of Justice. The Institute’s mission is to develop knowledge about crime, its causes and control. Priority is given to policy-relevant research that can yield approaches and information that State and local agencies can use in preventing and reducing crime. The decisions made by criminal justice practitioners and policymakers af- fect millions of citizens, and crime affects almost all our public institutions and the private sector as well. Targeting resources, assuring their effective allocation, and develop- ing new means of cooperation between the public and private sector are some of the emerging issues in law en- forcement and criminal justice that research can help illuminate. Carrying out the mandate assigned by Congress in the Justice Assistance Act of 1984, the National Institute of Justice: e Sponsors research and development to improve and strengthen the criminal justice system and related civil aspects, with a balanced program of basic and applied research. e Evaluates the effectiveness of justice improvement pro- grams and identifies programs that promise to be suc- cessful if continued or repeated. e Tests and demonstrates new and improved approaches to strengthen the justice system, and recommends actions that can be taken by Federal, State, and local governments and private organizations and individuals to achieve this goal. * Disseminates information from research, demonstrations, evaluations, and special programs to Federal, State, and local governments, and serves as an international clear- inghouse of justice information. e Trains criminal justice practitioners in research and evaluation findings, and assists practitioners and research- ers through fellowships and special seminars. Authority for administering the Institute and awarding grants, contracts, and cooperative agreements is vested in the NIJ Director. In establishing its research agenda, the Institute is guided by the priorities of the Attorney General and the needs of the criminal justice field. The Institute ac- tively solicits the views of police, courts, and corrections practitioners as well as the private sector to identify the most critical problems and to plan research that can help solve them. James K. Stewart Director U.S. Department of Justice National Institute of Justice Office of Communication and Research Utilization AIDS in Probation and Parole by Dana Eser Hunt, Ph.D. with assistance from Saira Moini and Susan McWhan June 1989 Issues and Practices in Criminal Justice is a publication series of the National Institute of Justice. Designed for the criminal justice professional, each Issues and Practices report presents the program options and management issues in a topic area, based on a review of research and evaluation findings, operational experience, and expert opinion on the subject. The intent is to provide criminal justice managers and administrators with the information to make informed choices in planning, implementing and improving programs and practice. Prepared for the National Institute of Justice, U.S. Department of Justice by Abt Associates Inc., under contract #0OJP-86-002. Points of view or opinions stated in this document are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Justice. Advisory Panel Wilbur Brown Rolando del Carmen Chief Probation Officer Professor, Criminal Justice Center Salem County Probation Sam Houston State University Department Huntsville, TX Salem, NJ Malcolm MacDonald Nancy Campbell Administrator, Community-Based Director of Community Services Corrections Department of Corrections Texas Adult Probation Commission Olympia, WA Austin, TX Program Monitor Cheryl Crawford National Institute of Justice Washington, DC The Assistant Attorney General, Office of Justice Programs, coordinates the activities of the following program Offices and Bureaus: National Institute of Justice, Bureau of Justice Statistics, Bureau of Justice Assistance, Office of Juvenile Justice and Delinquency Prevention, and Office for Victims of Crime. FOREWORD Acquired Immunodeficiency Syndrome, or AIDS, is one of the most urgent public health issues of our time. It is a deadly disease. The outlook for vaccines or cures is uncertain. And there are significant problems and costs associated with treatment. This public health issue has particular ramifications for the criminal justice system. Many offenders are or have been IV drug users and are thus at risk for contracting and transmitting the disease. To help minimize this risk, the National Institute of Justice has since 1985 conducted a series of studies to assist criminal justice agencies in developing sound and appropriate policies and procedures for dealing with AIDS and HIV infection. For community corrections services, AIDS presents unique problems. The dilemma is how to develop effective and equitable polices that serve the rights and needs of HIV-infected offenders, but also protect the larger community in which the offenders are supervised and address the concerns and safety of correctional staff. Community corrections administrators face tough decisions about disclosure of HIV status information, education and prevention, and costs of care and treatment —a task made more difficult by expanding caseloads and limited budgets. This report responds to the needs of community corrections agencies. It reviews up-to-date medical and legal information and offers guidelines and examples of policies and strategies for dealing with AIDS in probation and parole services. It represents not only the work of the authors, but also the cooperation and assistance of numerous professionals in the fields of community corrections and medicine. No single course of action is prescribed. Rather, the report discusses the range of AIDS policies and practices in operation across the country and examines the advantages and disadvantages of different approaches. In addition, the report presents the basic facts about AIDS —how it is transmitted, how it can be prevented, and its impact on probation and parole agencies. The National Institute of Justice hopes that community corrections professionals will find this information useful in developing education, training, and effective management programs to counteract the threat of AIDS. James K. Stewart Director National Institute of Justice Foreword iii ACKNOWLEDGEMENTS The report draws upon the considerable knowledge and experience of members of the project’s advisory board: Rolando del Carmen, Wilbur Brown, Malcolm Mac- Donald and Nancy Campbell. They influenced the development of the questionnaire and the selection of appropriate state contacts, and they reviewed the manuscript. Special thanks are extended to Malcolm MacDonald, who was called on many times for advice and information and always responded with patience and erudition, and to Cheryl Crawford and Virginia Baldau of the National Institute of Justice for their help and support. The staff of Abt Associates Law and Public Safety area also deserve a great deal of thanks for their help and support throughout this effort. Saira Moini provided invaluable help with questionnaire development and data management,and also prepared the section of education and training. Susan McWhan assisted in both the coding of questionnaires and the preparation of the section on legal issues. Joan Mullen provided many hours in reading and reviewing drafts of the document, and Ted Hammett served as a patient and knowledgeable source of information about AIDS in correctional institutions. Special thanks goes to Melissa Weissberg for many hours of editing the manuscript, and to Kristine Mattson and Laura Paspalas for their coordinating assistance. I would like to thank Andrew Blickenderfer, Catherine Viscovich, and Mary-Ellen Perry for their pre-production and preparation work, always done cheerfully and expertly. And finally, to Sioux Waks and Pearl Jusem who provided invaluable graphic and pro- duction skills. Most important, this work could not have been com- pleted without the cooperation of the hundreds of community corrections professionals who responded to both our questionnaire and the many follow-up phone calls. The expertise and enthusiasm in the field was an important part of the success of this enterprise. Acknowledgements Vv TABLE OF CONTENTS Page FOREWORD. .... «ci canis fins woe as 5 450 0 werm mw ws ions ode 53805 0 510580 800.5 $1908 5 8100 65105 was iii ACKNOWLEDGEMENTS... i ee ee ee ee ce ieee Vv LIST OF FIGURES. o-oo 5055 5 si mm ss son's wmv 5 6k SRE5E 5F 005 HE 7 00080 96 56 200 2 5 dre bh § ix INTRODUCTION: PURPOSE AND CONTENTS OF THE REPORT ..................... xi OAS Of tHE REIT 5 55 min 5 35 510 05 005 i cs i 5 91 4 0 30 5 0800 6 601 D040 0 30 9000 0100 5 00 B06 00 4 0 0 6 Jd 0 80 xi SOUICEE Of Tr OTTO ION. « 5:2 warm 950m 5550 500 0 5 0 0 0 3 ss 0» wn 5 30 nod 3 55 05 0 372 08 0 ow i 8 6 3 3 1 xi CHAPTER 1: THE CAUSES OF AIDS AND ITS TRANSMISSION. ................... 3 What Causes BIIDIST.. . «ois soc on mms 5% 56 05 3 abs 4g 00s a7 » or wioco seme co co fo 0505 555 S050 50 8 5) oh 006 097 0% 0 wig rd 3 Exposure, Seroconversion and Manifestation of AIDS Symptoms. ..............cooiiiiininn... 4 How is the AIDS Virus Transmitted?. .......... oii ieee ete en ene 6 Transmission through Inoculation with Blood or Blood Products. ................coovvininnn.. 6 Perinatal TRansmiSion. . ..oe ons RUT REEEEEE § aghg mpm vi me some wml ons SSR BLE HEU FE 10 Transmission through Sexual Contact. .............uiinitiinit erent eieetaenenenennnn 10 Common Misconceptions about Transmission. . o.oo. ut utter ie ieee nenenereenennn 11 Current Treatments and Vaccine Research. .......coauvssinsisininssssssssrarsarassasen sons 12 CHAPTER 2: EPIDEMIOLOGY OF AIDS... eee ee 15 ATDS In. The INE SUAS. » a0. 5 1505-6 56m 5: 5 10 450 1 5 5 ww 0 wh 5 5 10 hk 98 70 Bed W505 50 8.50 kl 3 8 1 185 9050 3 8 miles rw 0b 10 15 What Does This Have to Do With Probation and Parole?..................... cian... 16 AIDS in Community Supervision Populations. ..............coiuiiniiniiiniinenennennennnnn 18 Sources of Infection and Seroprevalence. ...............iiiiniiniiiin tiie 22 CHAPTER 3: HIV ANTIBODY TESTING. ...... ieee 23 The HIV Antibody Tests Currently in Use. .........iuiiiniiiit iti et iieieenenennns 23 Reliability: Aid VANAIUT, « vss ov min oes mes oma som oi 5 -w0 57000 000 W100 08 00 000 5 6105 010 5005.0 00m 50 0 co 000 040 24 NIJ SUnVEY Ress: « 55.00 0s colpmes Shr 5s 55 55 wis vi vm mms ws onds S50 WE REIS 0553 0 0% 5 03s ow 26 Issues TOVOIVEd. In TSENG. ov ois hio5 05 Bas BEEBE SSE 2 odipw sme wer sin wand iih FH wo GD BOSE S SA 26 HOW COStly 18 ToStIME. « «ott titi e ete eee tee ee tee tet e iain ie en ein en annannns 27 Summary and Recommendations Concerning Testing in Probation and Parole. ................. 27 CHAPTER 4: AIDS EDUCATION AND TRAINING IN COMMUNITY CORRECTIONS SERVICES ..... cov sosmbinisnibuhviamsas sss suers ws smmss vstmns dso es 29 Education For Probationers and Parolees. ......covivivmimimiivssarnsimsanimsans sions ns ss enss 29 Education/Traling, FOr Stall. occu sams osm nmmen ven sw momma omens is am saod somes sno 31 Staff Training on Advocacy, Referrals, and Resource Coordination. ...............ccoouiiunann.. 32 Role of Agency Management, Correctional Institutions, and Courts in Facilitating Education/ TURING soi ai nai 5 rw 000 508 00 0 0 5m 4 0 0 0 0.8 8500 0 00 0 3 03 5 8 4 ol 0 © nd 32 Frequent and Mandatory Mass AIDS Education for Probationers and Parolees................. 34 Policy Recommendations. . .........iuitii tiie tet e tet et ieee ite aaa 35 CHAPTER 5: CONFIDENTIALITY, LEGAL AND LABOR RELATIONS ISSUES. ....... Notification and Confidentiality... ......... i eee eee Overview of NIJ Survey Results. ..osuissivsonimsivivasssinssninssssussss nines nine wuss sess Range of Legal Options Regarding Who Receives Information. ............................... Notification of Other Criminal Justice Agencies, Public Health Departments. .................. Notification of Sexual Partners, Spouses, EmMplOYers. . «ovo wivsiuimmimssnins ens masons asus in Legal and Labor REIALIONS ISSUES: .viuiuvviimmimsnims Manni Bins mine Ss Sau pi Ri Gai mI Eh en basse Challenges to Parole ELgibility. . ..... oo Discrimination Against Probationers or Parolees with AIDS. ................................. Special Conditions Of SUDCIVISION. was cass issn womens ses shes sh sns so BiBsdsIEIeL HITE 18 EHS Challenges to Eligibility and/or Segregation in Residential Facilities. .......................... Challenges 10 HIV ANGDOAY ToSHIIIG. « vo vv vc vvmiunmins sms nsnsiinsmsnsssssoson es sss wsmeseses Confidentiality of Medical Information. ............ ieee Issues Raised by Staff: Community Corrections’ Liability and Concerns. ....................... Obligation 10: Perform DUES. cc cu suum snes sain vaesdmh eae ses o8 @sie ssn sins S08 08 STE0E DETTE 205 Policy RecommERAAtIONS. « « o.i5 5 im msn omits winmmivs siads nd Ges a E852 0Ea 8 E08 5 RaHE LEEBES HE dh io CHAPTER 6: GENERAL POLICY GUIDELINES ON AIDS FOR PROBATION AND PAROLE SERVICES... American Probation and Parole ASSOCIAtION. ............ uit Federal Division of Probation and the U.S. Parole Commission. ................oiiuiinuen.n.. Education and Training. . ....... iit eee eee ee Maen ance OF ReECOTCS:. us wm ww me vs moins om sis ows eo ss 6nd we ss Mans rR Sui ETI HIRO 02a State Level Efforts: NIJ Survey Results. .......... i eee ieee Specific Restrictions POLICIES. . o.oo. ieee Less Restrictive Policies. . . o.oo i i i tt tt tt te aa Elements of a Good AIDS Policy and Procedural Guide. ............vivivnvivinvininssvsviss CONCTUSTON . . «vim visi sins wows monn memos 3 003 0a 06 538k 080 ma 40 hn 8 ct APPENDIX A: Probation and Parole Divisions/Agencies Responding to NIJ Survey on AIDS ISBHIES. cvs rr vr EES EEE EE EEE SAE SAE AA EE SER PERE E EE APPENDIX B: Medical DefIlIONnS. ...o.covvvsimismins sins sosns sams sssssinsaeess esas ssn APPENDIX C: Iowa Department of Corrections AIDS Screening: Health History. .............. APPENDIX D: Examples of Training Materials and Policy Directives. ......................... APPENDIX E: Educational Brochures, Posters and Cards. ......... o.oo. APPENDIX F: Federal PoliCIeS. ...... coo ee APPENDIX G: Stale PolCIBS. .urusiusivimrsnsmenminsnnsmiinevemmnssasmaensasemimuingenis APPENDIX H: National Institute of Justice Policy Response Protocol for Law Enforcement PXZCINCTES vv cov vrs vi pg 8 590 810 60 E65 08 000 0 30 9.60 51 do a 0 5 9 0 35 3 LIST OF FIGURES Figure 1.1 Relationships Among Exposure, Infection, HIV Seropositivity, ARC, and AIDS. ..... Figure 1.2 Breakdown of AIDS Survival Rates in the U.S. by Year of Diagnosis. ............... Figure 1.3 Breakdown of Total AIDS Cases in the U.S. by Transmission Frequency............. Figure 2.1 Breakdown of Total AIDS Cases in the U.S. by Transmission Category and Sex. ...... Figure 2.2 Breakdown of Total AIDS Cases in U.S. by State of Residence. .................... Figure 2.3 Breakdown of AIDS Cases in the U.S. by Standard Metropolitan Statistical Area (SMSA) OF ReSIABICE « cons mo ams wn mise vms dhs host o sw ew opus ah SHS ES 06 5205 85% iso Figure 2.4 Breakdown of AIDS in the U.S. by Race/Ethnic Group and by Transmission CALBBOTY vc vn vim» vivre m ruiwmew sw rms 0B TES DREGE 00m vw pe ws or ymin £ poms 2 HE FEES LHR Figure 2.5 Breakdown of Total AIDS Cases in the U.S. by Age at Diagnosis and by Racial/ FUNG (OTOUD 0 4 500 5% 0.00% 200 wea 0 mms won 70 07 01 0 15 a rc J i 50 Figure 2.6 Distribution of Confirmed AIDS Cases Among Probationers and Parolees, by Tope Of AZENY, US. uv onvms cocms ame me 2 ase owe seme: orks 8 o mn Hae we 2 esis 2 ens Figure 2.7 Breakdown of Total AIDS Cases in Community Corrections by Region and Type OF AABBIICT i 56 505 518% 50 ose wm vt 0 wn 6 co 00 5 0 5085909 508 0 0 ww cm cow 0 0 0 4 Figure 3.1 Hypothetical HIV Antibody Screening In a Population of 500 With a 20% True Prevalence OF INTECUORN ui wus ms an inaiminsmmesio suims a0 0mm iiss m imams mi ew mi Figure 3.2 Hypothetical HIV Antibody Screening In a Population of 500 With a 1% True Prevalence of Infection. ............. iii eee Figure 4.1 Modes of AIDS Education and Training Presentation For Probationers, Parolees, ANA. AZENOY SAF 55 555.6 50a wom mmo wali. wid GHEEE GRRE 55 T5 # svmmren onion sion de 5 Figure 6.1 American Probation and Parole Association Position Statement on AIDS............ Introduction: PURPOSE AND CONTENTS OF THE REPORT Since it was identified nearly a decade ago, the deadly disease known as AIDS, or acquired immunodeficiency syndrome, has garnered unprecedented attention in the United States and around the world. Recognized first in this country among homosexual and bisexual men, the virus spread rapidly through the intravenous drug- using community through sexual activity and the sharing of injection equipment. With nearly 80,000 cases reported to date," it is estimated that more than 270,000 cases will have been diagnosed by 1991.’ While the media have occasionally reported on AIDS in prison populations, little attention has been devoted to the unique problems faced by HIV-infected persons leaving prison, or on probation or parole. Nor has at- tention focused on the special issues faced by their supervising agencies and line officers. In order to ad- dress the concerns of these two groups, the National Institute of Justice has sponsored this report. Goals of the Report The management of persons with HIV-related conditions is a complex matter for community corrections personnel. These cases raise a series of medical, logistical, ethical, legal, and safety-related questions. e How should both staff and clients be educated about AIDS? e What training should staff receive? e How can the risk of exposure to the disease or actual transmission of the virus be minimized? e How can unreasonable fears be minimized? e When, if at all, is it appropriate to test probationers and parolees for AIDS? e How should confidentiality be maintained if testing takes place? e What are the costs, financial and other, of education and of testing? e What are the legal parameters of supervision? There is no single answer to many of these questions. Different jurisdictions may choose different policies to address specific local conditions and priorities. To inform these decisions, this report draws on the most up-to-date information available, and includes both guidelines for developing individual policies and examples of policies already in place in certain jurisdictions. The early part of this report provides a brief but in- depth overview of the medical history and epidemiology of AIDS. The last several chapters provide specific guidelines for formulating testing policies, developing education and training programs, and dealing with confidentiality and related legal issues. Thus the areas covered in this report include: eo medical definition of AIDS, and how it is transmitted e epidemiology of AIDS: in the U.S., and in probation and parole populations e testing for AIDS, and the issues it raises e education and training e confidentiality, legal, and labor relations issues It is hoped that with the significant issues identified, and with pertinent information supplied about both general concerns and specific solutions, this report will help each agency to develop effective AIDS policies. Sources of Information This report is based on information from the follow- ing sources: e materials received from 68 probation agencies, of which 42 are administered through a central state agency and 26 are county or regional systems; e materials received from 47 parole agencies, of which 45 are central state agencies and two are county systems; e discussions with community corrections person- nel; and e an extensive review of pertinent literature. Information was requested from every state’s proba- tion and parole agencies. In states where probation or parole is administered by region or county, a sample of regional or county agencies was contacted. List of all the probation and parole agencies which responded are provided in Appendix A. Introduction xi Our primary interest was in determining numbers of AIDS cases under supervision in each agency, defini- tions currently used by agencies to identify AIDS or ARC, and any policies the agencies had formed or were forming in such areas as education, training, safety precautions, liability, and disclosure. Information was also requested on legal issues or cases encountered, and concerns about AIDS case management. The request made clear that no data obtained about the incidence of AIDS in corrections populations (numbers of current cases), would be reported according to state or jurisdiction. Instead, all report- ing of incidence figures is organized by region or area, rather than state or county. Any other information in this report containing state-based incidence data— whether in correctional facilities or in the general population — comes from other published sources. On the other hand, we did request permission to identify states or jurisdictions in connection with descriptions of any specific policies, procedures, or other useful information. Respondents could answer with permission, with qualified permission, or could request anonymity. In the last case the authors promised not to link any specific information to the state or jurisdiction anywhere in the document. In some cases, we clarified confusing or evocative responses with phone conversations. We also asked agencies to provide any written policy and any education and/or training materials they currently used, some of which are included in the Appendices. All questionnaires were coded and analyzed using the microcomputer versions of the Statistical Package for the Social Sciences (SPSS/PC). All data are current as of November 15, 1987 through March 1, 1988, the period during which the questionnaires were answered. In addition to the survey results, the project draws on the growing body of AIDS literature and related topics, in fields as varied as education, medicine, public health, and general-interest media. The author also drew on national data bases, as well as on the expertise of medical and legal experts and corrections personnel. NOTES 1. Centers for Disease Control, AIDS Weekly Surveillance Report November 14, 1988. 2. Institute of Medicine, National Academy of Sciences, Confron- ting AIDS: Directions for Public Health, Health Care, and Research (Washington, D.C., 1988), p. 57. xii AIDS IN PROBATION AND PAROLE AIDS IN PROBATION AND PAROLE Chapter 1: THE CAUSES OF AIDS AND ITS TRANSMISSION AIDS, or Acquired Immunodeficiency Syndrome, is a condition in which the immune system becomes so compromised that the individual is unable to fight off a host of infections. It was first identified in 1981 among previously healthy homosexual or bisexual men in New York and San Francisco, although it has been found in banked blood of IV drug users in New York donated as early as 1978." The first cases involved a rare form of bacterial pneumonia (Pneumocystis carinii pneumonia), or a type of skin cancer (Kaposi’s sar- coma), which had previously been seen only in a far less virulent form among elderly men of eastern Euro- pean or Mediterranean origins. In the absence of other causes, the appearance of these rare diseases pointed to an underlying problem with the immune system. Those affected were simply unable to fight off infec- tion naturally and, often after a series of illness episodes, died. In addition to these two diseases, iden- tified early in the epidemic, persons with AIDS may also suffer from a wide range of “opportunistic infec- tions.” These infections, often from common viral or bacterial sources, are not life-threatening in a healthy individual but become deadly in persons with serious- ly compromised immune systems. The diagnosis of AIDS involves the appearance of one of the known AIDS-related diseases and clinical evalua- tion of severe immune suppression unrelated to other factors (such as chemotherapy). The Centers for Disease Control’s guidelines for the diagnosis of AIDS can be found in Appendix B. Since AIDS was first recognized, New York City reports an unusually high incidence of fatalities from diseases such as bacterial endocarditis, non-pneumocystic pneumonia and tuber- culosis among intravenous drug users,” leading to speculation about the specific role of the AIDS virus in other diseases as well. As information develops, these or other diseases may be added to the CDC definition. There are a number of “indicator diseases” associated with AIDS. The anomalous presence of one or more of them helps to identify AIDS. For example, some diseases are often not seen in a given age group, such as Kaposi’s sarcoma or severe candidiasis (“thrush”). Others are not typically found in the organ affected, such as cytomegalovirus or tuberculosis in areas other than the lung. Some are even diseases not usually manifested in humans. The AIDS virus may also pro- duce encephalopathy or “AIDS dementia,” which involves increasing neurological problems, or a condi- tion known as HIV “wasting syndrome,” involving un- controlled weight loss and deterioration. The name “AIDS” is really an umbrella term, referring to a syndrome, or a group of diseases caused by a virus. Moreover, it actually refers to the end state of the ill- ness. Some persons infected with the virus may remain asymptomatic for many years, perhaps indefinitely. Others progress from infection to a condition known as AIDS-Related Complex (ARC), a milder condition characterized by weight loss, swollen lymph glands, continuous or intermittent diarrhea and fever, severe fatigue and tests indicating immune suppression. It is only recently, in fact, that scientists have argued that ARC should be considered an early form of AIDS, rather than a separate complex or condition. From ARC, patients usually progress to full-blown manifesta- tion of the disease. In the end state, the individual has marked laboratory indications of immune suppression and has developed one or more of the indicator diseases associated with the syndrome. However, AIDS does not always mean an orderly pro- gression to an end state, as the definition might imply. Persons may become infected and quickly develop the end stage of the illness. Others may never progress beyond ARC symptoms. What determines the rate or sequence of progression is the subject of current in- vestigation. It is believed, though, that AIDS is nearly always fatal. Of the 80,000 cases of AIDS diagnosed since June of 1981, 56 percent have died. In the early stages of the epidemic, life expectancy for a person diagnosed with AIDS was approximately two years. Due to the development of life-extending treatments, patients may live as long as five or more years after diagnosis.’ Expectancy nationwide also varies with a number of co-factors, which are discussed in the next section. What Causes AIDS? AIDS is caused by a virus generally known as the Human Immunodeficiency Virus (HIV), a human retrovirus which was discovered by scientists at the In- stitute Pasteur in Paris and further defined by Dr. Robert Gallo and his associates at the National In- stitutes of Health in 1983 and 1984. The virus infects certain white blood cells known as T-4 cells, rendering them incapable of combating infections. Once the virus The Causes of Aids and its Transmission 3 has entered a host cell, it may remain dormant for long periods of time. When stimulated into action, though, the virus reproduces rapidly, causing the depletion of T-4 cells that is the hallmark of AIDS diagnoses, and thus leaving the individual vulnerable to a number of opportunistic infections which would not normally harm a healthy person. It is not known definitely what stimulates the dormant virus into activity. However, it is believed that a number of “co-factors” influence one’s susceptibility to the development of AIDS once exposed: continued high- risk behaviors such as intravenous drug use, poor nutri- tion, alcohol and drug consumption, and continued unprotected sexual contact with infected persons; ad- ditional infections such as hepatitis B or cytomegalovirus; and genetic predisposition.’ Research continues on the co-factors involved with AIDS, but the exact role they play is as yet unknown. A factor such as heavy alcohol use, for example, may act as a catalyst for HIV action or may simply further suppress the immune system. Exposure, Seroconversion and Manifestation of AIDS Symptoms It is important to distinguish among the various stages of HIV-related illness and to understand their relation- ships to one another. Exposure to the virus, for exam- ple, does not guarantee infection, and infection does not necessarily cause symptoms to appear. Exposure means that the person has had high-risk con- tact with someone infected with the AIDS virus, which may have resulted in his or her own infection. The ratio of exposure to actual infection is not known. However, research with homosexuals and intravenous drug users indicates that those who engage in high-risk activities frequently and with multiple partners are the most like- ly to become infected. Tests are usually done in series, consisting of an “ELISA test,” which is repeated if positive, and a con- firmatory “Western Blot test.” These are discussed in Chapter 3. Figure 1.1 explains the relationships among exposure, infection, HIV seropositivity, ARC, and AIDS. The term “seropositivity” refers to a positive test result, indicating a person’s infection with the virus. All of the standard tests, it is crucial to note, detect antibodies to the virus in the blood of those infected, not the virus itself. Thus an infected individual is accurately referred to as “HIV antibody-positive,” or alternately, seropositive. Moreover, since seropositivity refers to in- fection, the progression from exposure to infection is known as “seroconversion.” As was discussed, sero- 4 AIDS IN PROBATION AND PAROLE positivity does not imply current or active illness. But it is generally agreed that seropositivity does indicate the ability to transmit the virus to others. One factor which may complicate the identification of a particular stage is the “window,” or period time bet- ween exposure and development of antibodies or subse- quent detectable infection. This window, or time to conversion, may not occur for as long as weeks or even months after exposure.’ Thus, an infected person may test negative because antibodies to the virus have not yet developed, but in this critical period, the individual would still be able to transmit the virus. For this reason, tests should be repeated up to six months after exposure to ensure the validity of the results. There is limited evidence as to the amount of the virus and/or the number of exposures required for infection to occur. There is also limited evidence as to the amount of the virus or the number of exposures required to transmit infection. It does appear that a large dose of tainted blood given intravenously, as occurs during a blood transfusion, poses an extremely high risk; small doses, as with an accidental needle stick, pose a fairly small one. On the other hand, repeated exposure even to small amounts of blood or other body fluid, as with intravenous drug use involving shared needles, ultimately will present a serious risk.’ There also appears to be a relationship between con- tinued exposure and development of the disease. In studies of HIV-infected intravenous drug users in New York, the best predictor of manifestation of the disease is continued intravenous use of drugs.” This may be related to continued assaults on the immune system, lessening its ability to combat the virus, or to the ac- cumulation of active virus in the system. The number of seropositive persons who will eventually manifest the disease is unknown. It is believed, however, based on data gathered by tracking infected persons, that the majority of those infected will eventually develop AIDS. The National Academy of Science estimates that 25-50 percent of HIV seropositives will develop AIDS within five to 10 years of infection and that 90 percent of seropositives will show some immune system deficiency within five years of seroconversion." One of the difficult aspects of AIDS for epidemiological study is the long incubation period of the disease, or the long time between infection and the appearance of symptoms. In most cases the incuba- tion period ranges from two and a half to five years, although there are reported cases of incubation as long as eight or 10 years.’ This long period of uncertainty presents some of the most difficult problems for managing infected persons and for estimating sero- Stage Exposure Infection Seropositivity ARC AIDS Figure 1.1 RELATIONSHIPS AMONG EXPOSURE, INFECTION, HIV SEROPOSITIVITY, ARC, AND AIDS Meaning Individual has contact with HIV in a way that makes transmission possible (e.g., sexual contact or needle-sharing activity). Individual is infected with HIV. Infection is assumed to be permanent. Individual has antibodies to HIV, meaning that infec- tion has occurred at some some time in the past. Antibody tests cannot pin- point date of infection. It usually takes 3-12 weeks from the time of infection for the antibodies to ap- pear, although lag-times significantly longer have been reported. Presence of a combination of conditions together giving evidence of sympto- matic infection with HIV, (Note: New CDC definition of AIDS incorporates many individuals previously classified as ARC patients). Illness characterized by one or more "indicator diseases" listed by CDC. Relationship to Previous Stage(s) Unknown, although multiple exposures probably in- crease the risk of infec- tion. CDC considers double ELISA test confirmed with a Western Blot to be an ac- curate indicator of infec- tion status; however, there continues to be concern about false posi- tives, particularly in populations with a low prevalence of infection National Academy of Sciences estimates that 90% of seropositive individuals show some immunodeficiency within 5 years. It is generally believed that at least one-half of seropositive individuals and individuals with ARC will develop AIDS. However, all estimates are uncertain due to the lengthy incubation period. Source: T.M. Hammett, Aids in Correctional Facilities: (Washington, D.C.: Issues and Options, Third Edition, National Institute of Justice, U.S. Department of Justice, 1988). The Causes of AIDS and its Transmission 5 prevalence, or prevalence of seropositivity in a given population. Persons who are infected may not know they are HIV-infected until symptoms of illness appear. Persons who are aware of their HIV antibody-positive status, but are otherwise healthy, may spend many anx- ious years anticipating and fearing the appearance of symptoms. While AIDS is believed to be universally fatal, survival time varies in length according to the particular illness manifested, and to genetic factors, the availability of treatment, and the general health of the patient. Figure 1.2 indicates the rates of survival by year of diagnosis. As this figure shows, fatality for cases diagnosed in 1981 is over 90 percent. Survival after the first year of diagnosis also varies considerably with the specific il- Iness contracted. Persons who develop Kaposi’s sar- coma seem to survive almost twice as long as those with Pneumocystis carinii pneumonia, though short-term survival with this disease is improving." Factors such as concurrent intravenous drug use also influence the length of survival. Intravenous drug users, for exam- ple, are more likely to contract Pneumocystis and/or opportunistic infections, are more likely to continue high-risk activity, and are more likely to have both poor nutrition and health care. How is the AIDS Virus Transmitted? While a great deal of media attention has been paid to AIDS, the question paramount in the public’s mind, “Can someone give it to me?,” is still not adequately understood by a great number of people. A survey con- ducted by the United States Public Health Service’s Weekly National Health Interview revealed that a number of people still think AIDS can be transmitted through sharing kitchen utensils, from public toilets or by donating blood." There are three known methods of transmission of the virus: sexual contact, inoculation with blood, and perinatal events. The latter term refers to pregnancy and childbirth, and may include breast-feeding. Empirical evidence from the CDC and other sources speaks strongly against the probability of transmission through body fluids other than blood, semen, vaginal secretions, and breast milk. In the 10 years of the AIDS epidemic, there have been no documented cases of transmission through any other sources. Moreover, studies of over 14,000 persons with AIDS have found no cases of transmission to family members through non-sexual casual contact. These findings hold true even in the case of children or infants with AIDS where daily contact with urine, tears and saliva is part of the care of the child.” 6 AIDS IN PROBATION AND PAROLE Since the epidemic began, epidemiologists have careful- ly tracked all cases, and the three known routes outlined have remained the only means of transmission iden- tified. With almost 75,000 cases of AIDS and many more ARC and seropositivity data, the consistency of these findings is extremely compelling. Except for a small number of cases lost to follow-up, all known cases of AIDS can be attributed to one of the three methods of transmission. Figure 1.3 summarizes the risk of infection through the various transmission modes. As the data indicate, transmission of HIV is difficult and does not occur through casual contact. Though it is a blood-borne disease like hepatitis B, HIV is far more difficult to transmit than hepatitis B,"” and precautions or clean-up procedures developed for hepatitis B are more than adequate for dealing with the AIDS virus. The following sections briefly describe the three known transmission modes: e transmission through inoculation with blood e transmission through sexual contact e perinatal transmission Transmission through Inoculation with Blood or Blood Products There are four instances in which contaminated or HIV-infected blood is inoculated into a non-infected person, making transmission of HIV possible: 1. injection of the blood of someone else during sharing of intravenous drug use equipment; 2. transmission during transfusion with con- taminated blood or blood products; 3. transmission through accidental needle- sticks with contaminated needles; and 4. transmission through an open wound or mucous membrane exposure. 1. Transmission through intravenous drug use Transmission which occurs during sharing of in- travenous drug use equipment is the most common method of transmission by inoculation. Eighteen per- cent of all AIDS cases in this country come from this source. In areas of high incidence of intravenous drug use, the numbers are even higher. For example, in New York and northern New Jersey, almost 50 percent of all AIDS cases are found among intravenous drug Figure 1.2 BREAKDOWN OF AIDS SURVIVAL RATES IN THE U.S. BY YEAR OF DIAGNOSIS NUMBER OF NUMBER OF CASE-FATALITY CASES KNOWN DEATHS RATE 1981 Jan-June 89 82 92% July-Dec 181 168 93% 1982 Jan-June 368 326 89% July-Dec 655 577 88% 1983 Jan-June 1238 1112 90% July-Dec 1608 1429 89% 1984 Jan-June 2501 2064 83¢ July-Dec 3258 2670 82% 1985 Jan-June 4536 3586 79% July-Dec 5846 4379 75% 1986 Jan-June 7361 4963 67% July-Dec 8675 4723 54% 1987 Jan-June 10306 4394 43% July-Dec 10534 3008 29% 1988 Jan-May 02 3620 542 15% TOTAL? 60852 34088 56% ! Reporting of deaths is incomplete. Table totals include 76 cases diagnosed prior to 1981. Of these 76 cases, 65 are known to have died. Source: CDC, AIDS Weekly Surveillance Report - United States, May 2, 1988. The Causes of AIDS and its Transmission 7 Figure 1.3 BREAKDOWN OF TOTAL AIDS CASES IN THE U.S. BY TRANSMISSION FREQUENCY TRANSMISS10N CATEGORIES’ Year Ending MAY 2, 1987 ADULTS/ADOLESCENTS Number (%) Homosexual /Bisexual Male 9949 ( 66.1) Intravenous (IV) Drug Abuser 2446 ( 16.3) Homosexual Male and IV Drug Abuser 1081 ( 7.2) Hemophi | ia/Coaqulation Disorder 166 ( 1.1) Heterosexual Cases’ 615 ( 4.1) Transfusion, Blood/Components 386 ( 2.6) Undetermined’ 402 (2.7) SUBTOTAL 15045 (100.0) cHILOREN® Hemophilia/Coagulation Disorder 14 ( 6.3) Parent with/at risk of AIDS’ 181 ( 80.8) Transfusion, Blood/Components 22 x 9.8) Undetermined 7 (3.1) SUBTOTAL 224 (100.0) TOTAL 15269 1 the category listed tirst, Year Ending CUMULATIVE CASES AND DEATHS MAY 2, 1988 SINCE JUNE 1981 Number (%) Number (%) Deaths (% Cases) 14990 ( 60.0) 37999 ( 63.4) 21010 ( 62.7) 5113 « 20.5) 11045 ( 18.4) 6203 (18.5) 1752 ( 7.0) 4438 ( 7.4) 2637 ( 2.9) 256 ( 1.0) 591 ( 1.0) 349 ( 1.0) 1072 ( 4.3) 2463 (4.1) 1320 ( 3.9) 752 ( 3.0) 1467 ( 2.4) 988 « 2.9) 1038 ( 4.2) 1894 (3.2) 1027 ( 3.10 24973 (100.0) 59897 (100.0) 33534 (100.0) 26 ( 5.9) 53 ¢ 5.9 32 ( 5.8) 329 ( 74.9) 735 ( 77.0) 422 (76.2) 63 ( 14.4) 13) ( 13.7) 79 (14.3) 21 (4.8) 3 ( 3.3 21 ( 3.8) 439 (100.0) 955 (100.0) 554 (100.0) 25412 60852 34088 Cases with more than one risk factor other than the combinations listed in the tables or footnotes are tabulated only in Includes 1460 persons (321 men, 1139 women) who have had heterosexual contact with a person with AIDS or at risk for AIDS and 1003 persons (780 men, 223 women) without other identified risks who were born in countries in which heterosexual transmission is believed to play a major role, although precise means of transmission have not yet been fully defined. Includes patients on whom risk information is incomplete (due to death, refusal to be interviewed, or loss to follow-up), patients still under investigation, men reported only to have had heterosexual contact with a prostitute, and interviewed patients for whom no specific risk was identified; also includes one health-care worker who seroconverted to HIV and developed AIDS after documented needlestick to blood. Includes all patients under 13 years of age at time of diagnosis. Epidemiologic data suggest transmission from an infected mother to her fetus or infant during the perinatal period. Source: CDC, AIDS Weekly Surveillance Report - United States, May 2, 1988. users. The cases in this region constitute almost 75 per- cent of the nation’s total IV drug-related AIDS 14 cases. The AIDS virus is spread among intravenous users through sharing the needles, syringes and heating elements (“cookers”) used in injection. Users tradi- tionally will draw their own blood up into the syringe to mix with the dissolved drug and re-inject it into their veins, in order to use all traces of the drug mixture. The next user will continue in the same way, but will inject any traces of blood remaining from the previous user, as well as his own blood with his drug injection. Since needles are only cleaned in the most perfunctory way — traditionally this means only blowing into the needle or manually clearing a clogged tip of the hypodermic with a wire —traces of the prior user’s blood remain in the equipment. When a needle is shared among many users, as is often the case, the possibility of HIV infection is multiplied again and 8 AIDS IN PROBATION AND PAROLE again. Sharing equipment is common. A study in San Fran- cisco indicates that 90 percent of addicts reported that they had shared needles with an average of 37 different people in the prior year,” and a New York/New Jersey study found that one-third of users reported sharing daily.'® Data from the Drug Use Forecasting System (DUF) indicates that almost half of all drug injectors arrested in Los Angeles report that they cur- rently share needles with one or more people; other cities report lower incidence of sharing, 20 to 25 per- cent. DUF, a program sponsored by the National In- Stitute of Justice, conducts voluntary and anonymous urine screening of male and female arrestees national- ly every three months. Differences found across the country may be attributable to changes in the behavior of addicts in response to AIDS, or to basic regional differences in the drug culture. Why do users share equipment? There are several reasons. First, initiation into drug use is often the oc- casion for sharing “works.” New IV users are unlikely to have their own injection equipment, as initiation is not generally a planned event. Consequently, they are most often “turned on” with friends who share their equipment with them. Second, sharing “works” with a “running partner,” a friend or a spouse, is a common feature of the drug- use world. Sharing is seen in this context as a social activity, a sign of trust and friendship as well as a con- venience. Only one party need carry the equipment when both go to buy and use drugs. And both parties may share the drugs purchased by pooling them into the same “cooker” and into the same syringe. Resear- chers have found that failure to share can be seen as a serious sign of mistrust or disloyalty among IV users and a serious breach of drug world etiquette." Sharing needles may also be a convenience if equip- ment is scarce. While only 12 states make possession of a hypodermic needle a punishable offense, they are in many cases the states in which IV drug use is very common. Addicts may share or rent “works” because they have no access to their own or because they do not wish to be caught with the equipment in their possession. This is the underlying motivation for the use of shooting galleries. Shooting galleries can vary from highly commercial operations, such as those found in New York City, to the more prevalent infor- mal renting of works done by other users in their apart- ments or in areas where drugs are bought. In a shooting gallery or similar place, a set or several sets of works are rented out to users so that they can use their drugs quickly and leave the area. For the obvious reasons, the spread of HIV has been linked to the use of shooting galleries or similar opera- tions. It is clear that the more one injects drugs, and consequently the more one is likely to rent, borrow, or share contaminated works, the more likely one is to become infected. 2. Transmission during transfusion HIV infection can also occur when contaminated blood or blood products such as plasma are administered to a patient. Since the blood supply has been screened for the presence of HIV since 1985, the number of cases from this source has been dramatically reduced. Only 3 percent of the total AIDS cases reported since 1981 have come from this source, and the majority of these cases stem from infection prior to 1985. The CDC estimates that only about 100 transfusion-associated infections will occur annually out of a total of 16 million units of blood transfused, and the National Academy of Sciences estimates that the risk of trans- fusion infection is less than 1 in 34,000 for those receiv- ing packed red blood cells." 3. Transmission through accidental needle sticks The fear of accidental puncture with a contaminated needle causes great concern among both health care workers and correctional personnel who worry that they may inadvertently come into contact with a needle used by an HIV antibody-positive individual through routine delivery of care, or during law enforcement pro- cedures such as pat-downs or searches. While at first glance the risk of infection through accidental punc- ture seems similar to that of needle sharing among IV users, there are important differences. First, in the case of IV drug use, blood is thoroughly mixed with drugs and possibly with contaminated blood before the in- jection. In the case of a needle stick, the infected traces of blood are not thoroughly blended with the second person’s blood and in most cases enter only under the skin rather than intravenously, reducing the likelihood of transmission. Second, IV drug users share con- taminated needles repeatedly, multiplying the risk of transmission, while the accidental needle stick is a solitary risk event. For these reasons, the number of transmissions from accidental needle sticks has been very small. In studies of 887 health care workers who have received needle sticks or puncture wounds from HIV-contaminated needles, only four have been infected as a result.” These data strongly suggest that, while not an impossi- ble event, infection from these sources is not common. 4. Transmission through an open wound or mucous membrane exposure Exposure through contact with certain contaminated mucosa (eyes, nose, mouth) is also of concern to those working closely with or caring for HIV-infected per- sons. Fortunately, transmission from this source is even less likely than transmission from accidental needlesticks. In CDC studies of health care workers who have had open wounds or mucous membrane ex- posure to infected patients, no cases of transmission have appeared. There are four instances reported in the literature, however, which have involved open wound or mucous membrane exposure to contaminated blood. In these cases, all four of whom were health care workers, the individuals became infected after direct contact between HIV-infected blood of a patient and their own broken skin or mucosa.” In the first in- stance, a health care worker with seriously chapped hands came into direct contact with the blood of an The Causes of AIDS and its Transmission 9 HIV-infected patient for 20 minutes. In the second case, an individual using a high-speed centrifuge spilled HI V- contaminated blood over ungloved hands and forearms. In the third case, a health care worker was splashed with infected blood in the face and mouth. In the last case, a laboratory researcher became infected after regular and extended contact with concentrated preparations of the virus. It is believed that in the course of the work, an incident of unprotected con- tact occurred between the preparations and the resear- cher’s broken skin or mucosa. It should be emphasized that these instances might all have been prevented had precautions been taken — gloves, masks, covering broken skin. In the many laboratory situations across the country where staff are working daily with HIV, often in highly concentrated forms, and in the many hospital settings in which in- fected patients are treated, there have not been addi- tional cases of transmission. This evidence strongly suggests that this fourth form of inoculation transmis- sion is uncommon and preventable with adequate precautions. Perinatal Transmission Perinatal transmission, apparently occurring during pregnancy or childbirth, is the most common cause of AIDS infection in infants and small children. These cases result from the mother’s HIV infection, often stemming from her intravenous drug use. Seventy-seven percent of the pediatric AIDS cases reported to the CDC are from perinatal events. In these cases, the virus is passed to the unborn child in utero, during childbirth, or through breast milk. The mechanism of perinatal transmission has not completely been identified, and the timing has not been pinpointed. But there appears to be a 40-50 percent chance that an HIV-infected mother will give birth to a child who will be HIV antibody-positive at birth.” There has only been one known case of confirmed transmission of the virus through breast milk.” In this case, the mother was in- fected by a blood transfusion after delivery, and the child became infected through nursing. About a third of children who test HIV antibody-positive at birth will also test negative months later; this happens because infants shed their mothers’ antibodies and form their own. Thus an infant may have tested positive because it retained some of its mother’s antibodies, but was not itself harboring the virus. When its own immune system begins to mature, and the mother’s antibodies naturally degrade and disappear, the infant will no longer test positive. Infants may change from positive to negative status as long as 15 months after birth; it is crucial therefore that they be re-tested until then, ac- cording to some clinicians.” 10 AIDS IN PROBATION AND PAROLE The majority of pediatric cases have come from New York City, New Jersey, and Florida — areas with high concentrations of IV drug users. Perinatal transmis- sion cases also come disproportionately from minori- ty populations, as these populations are over- represented among IV drug users. Eighty-five percent of the total cases of perinatal transmission occurred among blacks or Hispanics, a figure which represents 65 percent of all pediatric AIDS cases.” Transmission through Sexual Contact The AIDS virus can be transmitted through either homosexual or heterosexual contact. Activities that may produce small breaks in mucosa, such as anal in- tercourse, appear to be the most risky. However, vaginal intercourse is also a mode of male-to-female or female- to-male transmission. Unprotected homosexual activity remains the single largest risk behavior for transmission of the AIDS virus. Homosexual or bisexual males constitute 64 per- cent of the total number of AIDS cases reported. Hav- ing receptive anal intercourse as well as having many partners are both linked to increased chances of con- tracting infection.” Both factors increase the likelihood of contact with another infected male and the likelihood of producing small fissures in the anal mucosa. The extent of heterosexual transmission has been wide- ly discussed. While the proportion of total cases stem- ming from heterosexual transmission has remained constant at 4 percent, the number of heterosexual cases has increased more rapidly than the numbers in other categories. For example, in September 1984, only 25 cases of heterosexual transmission to women were reported to the New York City Health Department; just two years later that figure had multiplied more than five times. The number of AIDS cases among female IV drug users also increased dramatically during this time, to three and a half times the 1984 figure.” These data do not necessarily predict an explosion of AIDS into the non-1V drug-using population, but they do suggest increasing numbers of cases among those in regular sexual contact with IV users and/or bisexual men. The question of the efficiency of heterosexual transmis- sion is an important one. Most of the data on heterosexual transmission comes from studies of the sexual partners of intravenous drug users, prostitutes, or other persons with AIDS and from American military samples. Small studies of the sexual partners of persons with AIDS indicate that regular unprotected sexual activi- ty results in a high rate of infection in the partners. In a U.S. study of 24 seronegative partners of persons with AIDS, of the 10 pairs who used condoms over the 12-36 month study period, only one partner became infected. By comparison, of the 14 pairs who engaged in unprotected sexual activity, 12 partners (88%) became infected.”® Padian reports that the risk of heterosexual transmission from vaginal intercourse in- creases with frequency of contact, but seems to remain stable after a threshold of 10-20 exposures.” This is not true for anal intercourse in her sample. In this small sample, 88 percent of partners of persons with AIDS became infected, and 30 percent of persons who were seropositive but asymptomatic got the disease. Similar findings have been reported among sexual partners of IV drug users in New York. Since 60 to 75 percent of IV users are male, and approximately 95 percent are heterosexual, the number of non-IV drug-using sexual partners for this population is significant.” One study in particular found that nearly half the female part- ners of male IV users did not themselves use IV drugs.” Studies of American military recruits report that na- tionally, the ratio of male-to-female seropositivity is 2.7 to 1, but almost one-to-one in areas of highest population prevalence of seropositivity.”> Among this group were numerous married couples in which both parties were HIV antibody-positive. The areas where male-to-female ratios are almost equal are areas in which substantial portions of the cases involve IV drug use — highlighting again the strong link between heterosexual transmission and intravenous drug use. The largest subgroup of heterosexual transmission cases involves partners of IV users from the New York metropolitan area and South Florida. To date there is little evidence of major transmission in the “second wave”; for example, infection from IV user to non-drug- using partner to another non-drug-using sexual partner. For criminal justice agencies, the case of heterosexual transmission from prostitutes is a particularly impor- tant issue. In both European and U.S. studies of pro- stitutes, the percentage of seropositivity is high, due primarily to the large number of IV drug users in this group. In a New York study, for example, 42 percent of street prostitutes were IV drug users,” and in a New Jersey study, half of the IV drug-using prostitutes were seropositive.” There is some speculation that prostitutes may also be more susceptible to HIV in- fection, due to high rates of other sexually-transmitted diseases.” Prostitutes also come into contact with both IV drug users and persons who have multiple sex- ual partners. In the CDC multi-city study of pro- stitutes, 11 percent of the prostitutes who engaged in unprotected sex with customers tested positive for HIV, compared to none of the 22 who always used condoms for vaginal intercourse.’ Transmission from infected prostitutes appears to be surprisingly low, however. First, many prostitutes both here and abroad practice safer sex techniques in response to both AIDS and other sexually transmitted diseases.” In addition, the frequency of contact with an infected prostitute may be too low to produce ef- fective trarismission to any one customer. As a result, only a handful of reported cases involve transmission through heterosexual contact with a prostitute. It is important to note that single-contact heterosex- ual transrnission does occur, but it appears less likely than was first thought. Padian’s results, the prostitu- tion data, and the overall case distribution material all suggest that regular or repeated sexual contact with an infected individual is required for heterosexual transmission. It should be emphasized, however, that the possibility exists of single-contact transmission between heterosexuals. Common Misconceptions about Transmission It is critical for education and training programs to ad- dress some of the common misconceptions about AIDS transmission. Here, we will briefly review some of the most common areas of confusion. e Can I get infected from kissing, hugging, or sharing dishes, silverware, toothbrushes, razors, with a person with AIDS or who is seropositive? There is strong evidence that HIV infection does not occur from sharing household items, even those in- timate household items such as a toothbrush or razor. Seven separate studies totaling almost 500 family members of persons with AIDS in daily in- timate contact show no cases of infection which did not come from one of the known risk factors.” In some cases, toothbrushes, razors, toilets, and such intimate household items were routinely shared with the infected party. In addition, family members and health care workers often kiss or hug AIDS patients, and no cases of infection through this route have been reported. CDC does recommend avoidance of deep kissing, however, due to the possibility of small breaks in skin or sores which may contact mucosa and, although highly unlikely, result in transmission. Sirnilarly, though no cases exist, sharing razors and toothbrushes should be avoided as the possibility exists that small amounts of blood could be transferred. The Causes of AIDS and its Transmission 11 e Can I contract HIV on the job? What if 1 have to administer emergency first aid to a co-worker? There is absolutely no evidence to support fears of transmission in the normal course of job perfor- mance. Again, in a study of persons with several years of close personal contact in a residential school setting with hemophiliac children who were seropositive, no non-hemophiliac child'ren became infected.” There have been no cases of infection among law enforcement personnel, paramedics, or firemen as a result of giving moutlh-to-mouth resuscitation to an infected person. Haimmett also finds no cases of infection reported in correctional personnel through occupational contact in the three years of examination of AIDS in correctional set- tings.*’ As a general precaution, however, masks or resuscitation cups should be used in all’ cases of resuscitation to protect both parties from: this and numerous other contagious infections. e I have heard that the AIDS virus is in saliva. Can I get infected if an infected person bites me? HIV can be isolated in a number of body fluids — saliva, tears, urine —though the concentrations in these fluids is low and, in recent culture stuclies, very rarely viable.” It has been estimated, therefore, that it would take one quart of saliva or urine entering the bloodstream to produce infection.” Biting or spitting generally involves small amounts of saliva which, as has been discussed, poses no real threat. Biting which breaks the skin may bring saliva of an infected person in contact with the blood of the person bitten. But only if the person biting has an open sore or wound in his or her mouth can blood mix with the blood of the person bitten. Thus, given both the low frequency of the usually one-time event, and the unlikelihood of enough infected blood be- ing involved, it is not surprising that there have been no reported infections among persons who have been bitten by someone with AIDS. e Is there risk of transmission to staff" who conduct urine testing? Again, the concentration of the virus in HIV-infected urine is so small that transmission would require ex- posure to a much larger quantity of urine than is handled in routine testing. Moreover, good hygiene would indicate that staff should be wearing gloves to handle urine samples, to avoid any contact with the many other, far more readily transmittecl infec- tious agents found in human urine. 12 AIDS IN PROBATION AND PAROLE eo Should I allow an HIV positive probationer or parolee to work in a food-handling job? Much of the same evidence holds here. HIV antibody-positive individuals have undoubtedly been employed in food handling, and no cases of transmission have appeared as a result. Persons with AIDS have also prepared food as members of a fami- ly with no cases of infection resulting. Hypothetical- ly, an individual could bleed or spit into food preparations, which could be eaten by someone with a cut or sore in the mouth. Even in this unlikely scenario, any virus would almost certainly be killed by the stomach acids. Therefore, CDC specifically recommends against screening food service workers for HIV. e Since the AIDS virus is a blood-borne virus, can I get it from an insect that has bitten someone who is infected? Important evidence about insect transmission comes from areas where the virus is well-established, and prevalence of HIV infection is high. In studies of areas of Africa where large portions of the adult population are infected, and in Belle Glade, Florida, where there is an unusually high concentration of HIV infection, there is no evidence of infection out- side the known risk groups—IV drug users, homosexuals and their partners.” If insects transmitted the infection, one would expect children, the elderly, and all segments of the population to be affected. In addition, the insect must be able to replicate the virus in its own system before it could transmit it to humans; it has been found that mos- quitoes are unable to do this with the AIDS virus. Current Treatments and Vaccine Research A great deal of scientific attention has been focused on the AIDS virus. To date, no cure for the underly- ing immune suppression caused by the virus has been found. There are, however, a few treatments currently available which appear to prolong life and make the AIDS patient more comfortable. There are also more than 100 studies of 40 or more substances under study by the Food and Drug Administration for use in the treatment of AIDS." Treatments center around two types of drugs. Anti-viral agents attack or inhibit the growth of the virus; im- munomodulating agents work to boost or restore the immune system. As of this writing, only azidothymidine (AZT) is approved by the Food and Drug Administration specifically for treatment of AIDS or advanced ARC, although many more agents are under study. Other drugs, which are already ap- proved for other uses, may be included in AIDS treat- ment; an example is pentamidine, used to treat Pneumocystis carinii pneumonia (PCP). AZT is an anti-viral drug that attacks the replication cycle of the virus and has had considerable success in extending the life of persons with AIDS. While still an expensive therapy, the price of AZT has been reduced from about $10,000 to $7,500 per patient per year. It is also a drug approved for use only in seriously immune- compromised persons, those with T-4 cell counts below 200. In a healthy individual, the T-4 cell count ranges from 700 to 1,400; in a person with ARC or AIDS, the count can range from 50 to 200.” AZT, therefore, could not be used to retard the virus among asymp- tomatic seropositive persons or those in the very early stages of illness. Other drugs, like pentamine isethionate or Ampligen, are designed to stimulate the immune system (increase the number of T-4 cells), and inhibit the spread of the virus. Some treatments under study involve the com- bination of types of drugs. For example, researchers report encouraging results in the treatment of PCP us- ing pentamidine, an anti-cancer drug which interferes with the metabolism of the organism causing PCP, and a vitamin-like substance, called Trimextrate, which pro- tects normal cells from destruction.” In all of these therapies, the illness is retarded or thwarted somewhat, rather than cured. To date, no therapy has provided a cure or complete remission. Therefore, a great deal of effort is being made in the search for a vaccine. Scientists report that the AIDS virus presents a par- ticularly difficult vaccine problem in that “it hides in cells, it mutates rapidly, and it survives despite many immune responses that would normally rid the body of an invading virus”.”’ It appears, for example, that people infected with the live AIDS virus develop an- tibodies which, in the laboratory, inactivate the virus. These people, however, may still become sick and die, indicating that the kind of immune response which will protect a person from AIDS infection is unknown, and that vaccines, like those used in the development of the polio or measles immunizations, may not work. There are also no animal models appropriate for vaccine research. Chimps who can be infected successfully with the virus never develop the disease. The goal of the vaccine research is to find a vaccine that will produce a strong group-specific antibody that could protect against the diverse AIDS virus strains. Estimates as to the timetable for vaccine availability reflect these problems, and range from several years to decades. There are currently several AIDS vaccines in clinical trials. in humans. However, a recent article in Science concluded: “Scientists have known since they began to work on an AIDS vaccine that it would not be easy, but perhaps no one realized it would be so difficult”. * NOTES 1. D.C. DesJarlais and S.R. Friedman, “HIV Infection Among In- tiravenous Drug Users: Epidemiology and Risk Reduction,” AIDS 1987: 1:67-76. 2. Ibid. 3. A. Rankiet al., “Long Latency Precedes Overt Seroconversion in Sexually-Tran smitted HIV Infection,” Lancet, September 12, 1987: 2:589-93. 4. HILW. Haverkos, “Factors Associated with the Pathogenesis of AIDS,” Journal of Infectious Diseases, July 1987: 156:251-7. 5. J.S. Schwartz, P.E. Dans, and B.P. Kinosian, “Human Im- mwunodeficiency Wirus Test Evaluation, Performance and Use,” Journal of the Airnerican Medical Association 259 (May 6, 1988): 17:2574-79. 6. G.H. Friedland and R.S. Klein, “Transmission of the Human Immunodeficiency Virus,” New England Journal of Medicine, October 29, 19137: 317:1125-35. 7. DJC. DesJarlais and D. Hunt, “AIDS Bulletin: AIDS and In- travenous Drug Use” (Washington, D.C.: National Institute of Justice, U.S. Department of Justice, 1988). 8. Institute of Meclicine, National Academy of Sciences, Confron- ting: AIDS: Directions for Public Health, Health Care, and Research (Washington, D.C., 1986). 9. J.J. Goedert, presentation, “Heterosexual Spread of HIV In- fection and AIDS in the U.S.,” National Institute on Drug Abuse Technical Reviews, January 1988. 10. Rothenburg et al., “Survival with AIDS,” New England Jour- nal of Medicine, November 19, 1987: 317:1297-1302. 11. “AIDS Fears Persi st,” Medical World News, November 23, 1987: 39. 12. Friedland and Klein, op. cit. 13. Ibid. 14. Centers for Disease Control, “AIDS Weekly Surveillance Report — United Staites,” May 2, 1988 15. J. Watters, D. Iura and K. Tura. “AIDS Prevention Services to Intravenous Drug U sers throu gh the Mid-City Consortium to Combat AIDS: Adniinistrativie Report,” December 1980. 16. H. Ginsberg, J. French, J. Jack.son, et al., “Health Education and Knowledge Assessment of 14TLV-111 Disease Among In- travenous Drug Users,” Health Ea'ucation Quarterly 13 (Winter 1986): 4:373-82. 17. E. Wish, J. O'Neil, and V. Baldau, “Lost Opportunity to Com- bat AIDS: Drug Abusers in the Criminal Justice System,” presented at National Institute of Justice Drug Abuse Technical Review on AIDS and IV Drug Use, July 1988. 18. D.C. DesJarlais, S. Friedman, and D. ¢ 3trug, “AIDS Among In- travenous Drug Users: a Sociocultural I %erspective” in The Social Dimensions of AIDS, ed. D. Feldmar and T. Johnson (New York: Praeger Press, 1985). The Causes of AIDS and its ' Transmission 13 20. 21. 22. 23. 24. 25. 26. 27. 28. 20. 30. 3). 32. 33 34. 38. 36. 37. 38. 39. 40. 41. 14 Institute of Medicine, National Academy of Sciences, op. cit. Friedland and Klein, op. cit. Update: “HIV Infections in Health-care Workers Exposed to Blood or Infected Patients,” Morbidity and Mortality Weekly Report, May 22, 1987: 36:285- 88. G.B. Scott, M.A. Fischl, N. Klimas, M.A. Fletcher, G.M. Dickin- son, R.S. Levine, and W.P. Parks, “Mothers of Infants With the Acquired Immunodeficiency Syndrome,” JAM.A 1985a: 253:363. J.B. Ziegler, et al., “Post-natal Transmission of AIDS-A ssociated Retrovirus from Mother to Infant,” Laricet, 1985: 1:896-98. K. Speger, R.N., M.P.H, epidemiologist, Boston City Hospital, personal communication, September, 1'988. Centers for Disease Control, op. cit.. Haverkos, op. cit. Friedland and Klein, op. cit. M.A. Fischl, G.M. Dickinson, G.B. Scott, N. Klimas, M.A. Flet- cher, and W. Parks, “Evaluation of Heterosexual Partners, Children, and Household Contacts of Adults With AIDS,” JAMA 257:640-44. N. Padian, “Male to Female Transmission in San Francisco Heterosexual Spread of HIV Infection and AIDS in the U.S.,” NIDA Technical Review, January 1988. DesJarlais and Hunt, op. cit. D.C. DesJarlais, E. Wish, S.R. Friedman, R. Stoneburner, et al., “Intravenous Drug Use and H.etercisexual Trans, mission of Human Immunodeficiency Virus: Current Trends in NY.C.,” New York State Journal of Medicine 87 (1987): 283-85. “HTLV-111/LAV Antibody Prevalence in U.S. Military Recruit Applicants,” MMWR, July 4, 1986: :35:421-24. D.S. Burke et al., “HIV Infections among Civiliani Applicants for U.S. Military Service, October 19 85 to March 1986,” New England Journal of Medicine, July 16, 1987: 317:131-6. E. Wish and B. Johnson, “The Impa.ct of Substance Abuse on Criminal Careers,” in Criminal Care ers and Career Criminals, ed. A. Blumstein, J. Cohan, and C. Visher (Washington, D.C.: National Academy Press, 19836), 2:/52-58. H. Ginsberg, J. French, J. Jackson, et al., “Health Education and Knowledge Assessment of HT 'LV-III Disease Among In- travenous Drug Users,” Health Edu cation Quarterly 13 (Winter 1986) 4:373-82. Des Jarlais and Friedman, op. cit. MMWR, July 4, 1986, op. cit. DeslJarlais, Wish, Friediman, et al., op. cit. Friedland and Klein, op. cit. A. Bertheir et al., “Treansmissibility of HIV in Hemophiliac and Non-Hemophiliac Children Living in a Private School in France,” Lancet, September 13, 1986: 598-601. T.M. Hammett, AI DS in Correctional Facilities: Issues and Op- tions, Third Editic)n (Washington, D.C.: National Institute of Justice, U.S. Dep: artment of Justice, 1988). D.D. Ho et al., “ Letter: Infrequency of Isolation of HTLV-III Virus from Salive 1 in AIDS,” New England Journal of Medicine, December 19, 1985: 1606. AIDS IN P'ROBATION AND PAROLE 42. 43. 44. 45. 46. 47. 48. Alvin Novick, M.D., Yale University, presentation at National Institute on Sentencing Alternatives/National Institute of Cor- rections Workshop on AIDS — Policy and Treatment Dilemmas for Residential Community Corrections Programs, Newton, Mass., September 21, 1987. “AIDS in Western Palm Beach County, Florida,” MMWR, 1986: 35:609-12. G. McBride, “Impact of AIDS Drugs on Hospitals Unclear,” Modern Health Care, January, 1988: 40-41. M. Chase, “Researchers to Report Results of Study on Drug In- tended to Delay Onset of AIDS,” The Wall Street Journal, December 4, 1987: 42. “Extending AIDS Patients’ Lives,” Newsweek, November 2, 1987: 85. D. Barnes, “Obstacles to an AIDS Vaccine,” Science, May 1988, 719-21. Ibid, p. 721. Chapter 2: EPIDEMIOLOGY OF AIDS This chapter examines the epidemiology of AIDS, its incidence and prevalence. We first discuss the spread of the disease in the general population, and then we report on AIDS in parole and probation systems. For the general population we draw on data collected by the Centers for Disease Control, including numbers of cumulative and current cases of AIDS across the coun- try. For the prevalence information for parole and pro- bation populations, we rely on the data provided by 47 parole and 68 probation agencies. In addition, we will discuss briefly data from annual surveys of prisons and jails in the United States, conducted for the publication series AIDS in Correctional Facilities, a project also sponsored by the National Institute of Justice (NIJ). AIDS in the United States Each year the numbers of AIDS cases grows at an alarming rate. Just four years ago, only 4,000 cases had been reported to the CDC. By May of 1988, almost 60,000 cases had been reported; of this figure, more than 10,000 had been reported since January 1 (Figure 2.1). Almost 1,000 of the total cases are in children under the age of 13. The comment heard often early in the epidemic that the early cases were only the “tip of the iceberg” has proven, tragically to be accurate. Of the cases diagnosed as of this report, 56 percent have died. While AIDS has now been reported in all 50 states (Figure 2.2), the majority of cases are still concentrated in the Northeast and West. California, New York and Florida account for more than 50 percent of the cases; Texas and New Jersey add an additional 13 percent. Moreover, these five states together contribute 68 per- cent of the nation’s total pediatric cases. However, as Figure 2.2 indicates, though case numbers are small in some states, they may represent early stages or new areas of the infections. For example, of the 19 cases reported to date in Idaho, 15 were diagnosed in the last two years. Even within high-incidence states, cases are geographically concentrated in certain areas, areas with large numbers of intravenous drug users and an active homosexual population. Figure 2.3 shows those stan- dard metropolitan areas which have the largest number of AIDS cases reported and the progression of case ac- cumulation since 1985. The highest incidence area, New York City, has considerably more cases than any other city, though smaller cities such as Jersey City, New Jersey, contribute a disproportionate share of cases relative to their populations. This is due to the large intravenous drug user population of cities like Newark and Jersey City, suburbs to New York City and a short train ride to those areas of the Lower East Side of Manhattan where drugs are sold and used. In addition to the number of confirmed AIDS cases which these figures represent, the National Academy of Sciences estimates that there may be as many as 50,000-125,000 cases of AIDS-Related Complex (ARC) in the U.S. and as many as 1.5 million persons who are seropositive but currently asymptomatic.’ It is estimated that by 1991, 270,000 AIDS cases will have been diagnosed and more than 50,000 persons each year will die of AIDS.’ Most adult AIDS cases have been white (59%) and male (92%) and stem from transmission through homosexual activity (63%). (See Figure 2.1 and also 2.4, which shows the breakdown of AIDS cases by race/ethnic group and by transmission category.) However, minorities are overrepresented in comparison to their numbers in the general population, particularly in the intravenous drug use risk category. Of the IV drug use-related cases, 75 percent occur among blacks or Hispanics. These two groups make up less than 25 percent of the nation’s population. The majority of female AIDS cases are also related to IV drug use. Of the 5,776 female AIDS cases diagnosed to date, 51 per- cent are IV drug users. Figure 2.5 shows that 88 percent of AIDS cases have been diagnosed in persons 20-49 years old, with the majority of these occurring in the 30-40 age group. While relatively few cases (257) have been diagnosed in teenagers, it is important to interpret these data with caution. A brief look at the number of cases which ap- pear in the 20-29 age category shows that 2/ percent of all cases fall in this group. Given the long incuba- tion period of the virus, often spanning several years, it is likely that infection of a substantial portion of this group occurred in the teen years. Heterosexually transmitted cases represent 4 percent of the total cases reported (Figure 2.4). Male-to-female transmission is more common, due in part to the larger ratio of male IV drug users to female IV users in the country and to the homosexual and bisexual contact source of male infection. Consequently, heterosexual Epidemiology of AIDS 15 Figure 2.1 BREAKDOWN OF TOTAL AIDS CASES IN THE U.S. BY TRANSMISSION CATEGORY AND stx':2 MALES FEMALES TOTAL Since Jan | Cumulative Since Jan | Cumulative Since Jan | Cumulative ADULTS/ADOLESCENTS Number (%) Number (f£) Number (%) Number (%) Number (f) Number (%) Homosexual /Bisexual Male 5776 (63) 37999 (69) 57176 (56) 371999 (63) Intravenous (IV) Drug Abuser 1908 (21) 8607 (16) 583 (54) 2438 (51) 2491 (24) 11045 (18) Homosexual Male and IV Drug Abuser 672 (7) 4438 (8) 672 (7) 4438 (7) Hemophi | la/Coagulation Disorder 101 a) 568 (1) 5 (0) 23 (0) 106 (1) 591 ) Heterosexual Cases’ 180 (2) 1101 (2) 259 (24) 1362 (29) 439 (4) 2463 (4) Transfusion, Blood/Components 191 (2) 951 (2) 1S (1) 516 (11) 306 (3) 1467 (2) Undetermined? 403 (4) 1493 3) 108 (10) 401 (8) 511 (5) 1894 (3) SUBTOTAL (f of all cases] 9231 (90) 55157 (921 1070 (101 4740 (8) 10301 (1001 59897 (1001 CHILDREN? Hemophi | la/Coagulation Disorder 12 (1 51 (10) 2 (0) 12 (6) 53 (6) Parent with/at risk of Al0s® 77 (69) 369 (TM) 74 (85) 366 (84) 151 (76) 135 an Transtusion, Blood/Components 19 (17) 80 (15) 10 (11) 51 (12) 29 (15) 131 (14) Undetermined? 4 (4) 19 (4) 30) 17 (4) 7 36 (4) SUBTOTAL (f of all cases] 112 (56) 519 (54) 87 (44) 436 (46) 199 (100) 955 (100) TOTAL ($ of all cases] 9343 (89) 55676 (91) 1157 (11) S176 (9) 10500 (1001 60852711001 These data are provisional. 2 Cases with more than one risk factor other than the combinations listed in the tables or footnotes are tabulated only in the category listed first. 3 Includes 1460 persons (321 men, 1139 women) who have had heterosexual contact with a person with AIDS or at risk tor AIDS and 1003 persons (780 men, 223 women) without other identified risks who were born in countries in which heterosexual transmission is believed to play a major role although precise means of transmission have not yet been fully defined. 4 Includes patients on whom risk information is incomplete (due to death, refusal to be interviewed or loss to follow-up), patients still under investigation, men reported only to have had heterosexual contact with a prostitute, and interviewed patients for whom no specific risk was identified; also includes one health-care worker who seroconverted to HIV and developed AIDS atter documented needlestick to blood. 5 Includes all patients under 13 years of age at time of diagnosis. 6 tpidemiologic data suggest transmission from an intected mother fo her tetus or infant during the perinatal period. Includes 5901 patients who meet only the 1987 revised surveillance definition tor AIDS. Source: COC, AIDS Weekly Surveillance Report - United States, May 2, 1988. contact is more frequently a source of infection for women than for men. This is reflected in the fact that 29 percent of all female cases result from heterosexual contact, compared to only 2 percent of the total male cases reported (Figure 2.1). What Does This Have To Do With Probation and Parole? First, the age group at greatest risk for AIDS, those 20-39 years old, is also the age group in which the greatest number of criminal offenders cluster. Sixty- one percent of all persons arrested in the United States are between 20-39 years old.’ Second, the population of offenders has a high proportion of intravenous drug users. Recent data from the NIJ Drug Use Forecasting System indicates that between 5 and 25 percent of male 16 AIDS IN PROBATION AND PAROLE arrestees report ever injecting heroin, while 7 to 27 per- cent report ever injecting cocaine. These statistics are based on voluntary self-reports and should therefore be interpreted as minimum estimates of injection in ar- restees.’ Consequently, because age and substance abuse are predictors, we might expect that large numbers of persons entering the criminal justice system are at high risk for HIV. Not surprisingly, data from the 1987 edition of NIJ’s AIDS in Correctional Facilities indicate that many per- sons paroled after incarceration may be HIV-infected and/or have AIDS.’ In the facilities surveyed nation- wide, 1964 cumulative cases of AIDS were reported; of this number there were 295 current cases in the Federal system and 126 in the city or county systems. These figures represent an increase of 156 percent in the three years since the first NIJ survey of prisons and STATE OF RESIOEN New York California Florida Texas New Jersey Illinois Pennsylvania Georgia Massachusetts District of Columbia Maryland Puerto Rico Louisiana Washington Ohio Connecticut Virginia Colorado Michigan Missouri Arizona North Carolina Oregon Minnesota Indiana Tennessee Alabama South Carolina Oklahoma Hawaii Wisconsin Nevada Kentucky Kansas Rhode Island Mississippi Arkansas Utah New Mexico Delaware Towa Maine New Hampshire Nebraska West Virginia Alaska Vermont Idaho Montana virgin Islands Wyoming South Dakota North Dakota Guam Tryst T rritor TOTAL Figure 2.2 Breakdown of Total AIDS Cases in U.S. Year Ending Year Ending MAY 2, 1987 MAY 2, 1988 Number Percent Nymber Pgrcent 3934 ( 25.8) 5083 ( 20.0) 3327 { 21.8) 5204 ( 20.5) 1148 (7.5) 1848 (7.3) 1146 ( 7.5) 1863 ( 7.3) 864 ( 5.7) 1933 ( 7.6) A417 ( 2.7) 803 ( 13.2) 381 ( 2.5) 764 ( 3.0) 362 ( 2.4) 544 ( 2.1) 315 ( 2.1) 528 ( 2.1) 275 ( 1.8) 510 ( 2.0) 280 ( 1.8) 463 (1.8) 95 ( 0.6) 577 ( 2.3) 195 ( 1.3) 385 ( 1.5) 208 ( 1.4) 381 (1.5) 251 ( 1.6) 389 ( 1.5) 179 (1.2) 313 ( V.2) 169 ( 1.1) 297 ( 1.2) 178 ( 1.2) 2714 ( 1.1) 173 1) 211 ( .1) 126 ( 0.8) 303 ( 1.2) 79 ( 0.5) ns ( 1.2) 90 ( 0.6) 270 ( 1.) 80 ( 0.5) 193 ( 0.8) 98 ( 0.6) 134 ( 0.5) 78 ( 0.5) 151 ( 0.6) 59 ( 0.4) 196 ( 0.8) 65 ( 0.4) 179 ( 0.7) 65 ( 0.4) Mm (0.4) s6 ( 0.4) 119 ( 0.5) 69 ( 0.5) 96 ( 0.4) 63 ( 0.4) 95 ( 0.4) 52 ( 0.3) ns ( 0.5) 36 ( 0.2) 65 ( 0.3) 40 ( 0.3) 72 ( 0.3) 45 ( 0.3) 62 ( 0.2) 33 ( 0.2) 79 ( 0.3) 34 ( 0.2) 63 ( 0.2) 2s ( 0.2) §7 ( 0.2) 32 ( 0.2) 48 ( 0.2) 24 ( 0.2) 42 ( 0.2) 17 ( 0.1) 33 ( 0.1) 24 ( 0.2) 30 ( 0.1) 15 ( 0.1) 36 ( 0.1) 1s { 0.9) 34 ( 0.1) 14 ( 0.1) 17 ( 0.1) 10 ( 0.1) 15 ( 0.1) 8 ( 0.1) 14 ( 0.1) 5 ( 0.0) 0 ( 0.0) 4 ( 0.0) 0 ( 0.0) 3 ( 0.0) 9 ( 0.0) 4 ( 0.0) 2 ( 0.0) 2 ( 0.0) 4 ( 0.0) 2 ( 0.0) 3 ( 0.0) 15269 (100.0) 25412 (100.0) by State of Residence CUMULATIVE TOTAL SINCE JUNE 1981 Adylt/A Number Percent Nymber Paercant 15429 13035 4232 4081 3893 1655 1556 1250 1219 1140 1014 873 796 798 751 696 687 638 588 527 492 469 349 327 308 294 285 242 218 221 206 201 145 139 nN 128 19 114 103 90 72 n 61 62 44 42 28 17 18 15 L.... E 59897 ( 25.8) ( 21.8) 7.1) 6.8) 6.5) 2.8) 2.6) 2.1) 2.0) 1.9) 1.7) 1.5) 1.3) 1.3) 1.3) 1.2) 1.1) 1.1) 1.0) 0.9) 0.8) 0.8) 0.6) 0.5) 0.5) 0.5) 0.5) 0.4) 0.4) 0.4) 0.3) 0.3) 0.2) 0.2) 0.2) 0.2) 0.2) 0.2) 0.2) 0.2) 0.1) 0.1) 0.1) 0.1) 0.1) 0.1) 0.0) 0.0) 0.0) 0.0) 0.0) 0.0) 0.0) 0.0) PN NNN NONPOINT PPP PNP PP nN PNP PP PNP PN PN NPN NN ~~ (100.0) Children Total Number Percent 300 ( 31.4) 15729 ( 25.8) 7 { 1.4) 13106 ( 21.5) 113 (11.8) 4345 (7.1) 38 ( 4.0) 4119 ( 6.8) 128 ( 13.4) 4021 ( 6.6) 22 ( 2.3) 1677 ( 2.8) 22 ( 2.3) 1578 ( 2.6) 20. ( 2.0) 12718 £ 2.1) 22 ( 2.3) 1241 (2.0) 12 (1.3) 1152 (1.9) 2 ( 2.2) 103s ( 1.7) 3 ( 3.2) 904 ( 1.5) mn (1.2) 807 ( 1.3) 4 ( 0.4) 802 ( 1.3) 12 (1.3) 763 ( 1.3) 24 (2.5) 720 ( 1.2) 14 ( 1.5) 700 (1.2) 4 ( 0.4) 642 ( 1.1) 10 ( 1.0) 598 ( 1.0) 7 ( 0.7) 534 ( 0.9) 3 (0.3) 495 ( 0.8) 9 (0.9) 478 ( 0.8) 1 ( 0.1) 350 ( 0.6) 2 (.0.2) 329 ( 0.5) 3 ( 0.3) 311 ( 0.5) 5 ( 0.5) 299 ( 0.5) 8 ( 0.8) 293 ( 0.5) 5 ( 0.5) 247 ( 0.4) 6 ( 0.6) 224 (,0.4) 1 ( 0.1) 222 ( 0.4) 1 ( 0.1) 207 ( 0.3) 2 ( 0.2) 203 ( 0.3) 145 ( 0.2) 2 (0.2) 141 (0.2) 3 ( 0.3) 134 ( 0.2) 128 ( 0.2) ny ( 0.2) 3 (0.3) nr (0.2) 1 ( 0.1) 104 ( 0.2) 2 ( 0.2) 92 ( 0.2) 2 ( 0.2) 74 (0.1) 2 ( 0.2) 73 ( 0.1) 3 ( 0.3) 64 ( 0.1) 62 ( 0.1) 2 (0.2) S46 (0.1) a2 L 0.)) 28- ( 0.0) 2 ( 0.2) 19 ( 0.0) 18 ( 0.0) 1 ( 0.1) 16 ( 0.0) 9 ( 0.0) 8 ( 0.0) 6 ( 0.0) 4 ( 0.0) -— — 0.0) 955 (100.0) 60852 (100.0) Epidemiology of AIDS 17 Figure 2.3 BREAKDOWN OF AIDS CASES IN THE U.S. BY STANDARD METROPOLITAN STATISTICAL AREA (SMSA) OF RESIDENCE SMSA OF RESIDENCE POPULATION! BEFORE 1985 1985 1986 1987 19882 CUMULATIVE TOTAL New York, NY 9.12 3296 2619 3541 3921 815 14192 San Francisco, CA 3.25 1090 967 1414 1524 358 5353 Los Angeles, CA 7.48 808 880 1347 1538 194 4767 Houston, TX 2.91 293 340 618 690 ‘12 2013 Washington, DC 3.06 221 341 452 672 149 1835 Newark, NJ 1.97 268 267 411 680 100 1726 Miami, FL 1.63 an 293 410 428 44 1552 Chicago, IL 7.10 199 234 399 581 100 1513 Dallas, TX 2.97 17 178 336 550 59 1240 Philadelphia, PA 4.72 174 208 333 459 55 1229 Atlanta, GA 2.03 12 168 2N 334 52 937 Boston, MA 2.76 136 151 216 328 52 883 San Diego, CA 1.86 78 118 215 315 68 794 Ft. Lauderdale, FL 1.02 97 131 209 289 58 184 Jersey City, NJ 0.56 14 144 206 244 25 733 Nassau-Suffolk, NY 2.61 123 121 205 201 29 679 Seattle, WA 1.61 66 94 179 234 37 610 New Orleans, LA 1.19 70 97 154 215 22 555 Denver, CO 1.62 63 85 139 201 55 543 Baltimore, MD 2.17 59 81 139 218 39 536 REST OF U.S. 168.48 2213 2865 4845 7218 1237 18378 TOTAL 230.11 9974 10382 16036 20840 3620 60852 ! Population of SMSA's in millions as reported in the 1980 census. 2 Cases diagnosed in this calendar year and reported to COC as of date of this summary. Source: jails was conducted in 1985, and a 59 percent increase since last year. However, the rate of increase in the general population is even greater— 61 percent in the past year. Unlike cases in the general population, however, all of the AIDS cases in persons incarcerated must be dealt with by community supervision agen- cies upon release, and increases in these numbers repre- sent escalating problems for these agencies. AIDS in Community Supervision Populations Figure 2.6 represents the numbers of confirmed AIDS cases reported nationally in parole and probation agen- cies. There were a total of 161 cases in parole and 171 cases in probation reported. These figures represent a very conservative estimate of the number of cases in community supervision, however. Many of the agen- cies (28 parole and 46 probation) reported that they could give no numerical estimate, but it should not be assumed that this inability indicates that there were no 18 AIDS IN PROBATION AND PAROLE CDC, AIDS Weekly Surveillance Report - United States, May 2, 1988. cases in populations served by these agencies. These respondents reported that it was impossible to respond either because their areas have no mechanism for reporting cases to a central organization; or that con- fidentiality policies in their states require that they not report cases. Thus, the only true “no case” instances are those reported as “zero.” As might be predicted from the general population data, a few areas contribute the bulk of reported cases in community supervision. In the case of parole, one state with 125 cases represents 78 percent of all cases reported nationwide. In the case of probation, six pro- bation systems contributed 68 percent of the total cases reported. Figure 2.7 shows the distribution of cases nationwide, for those states which reported them in the survey. So few agencies were able to provide any information about cases of ARC in their jurisdictions that we are unable to report even an estimate of its prevalence. Agencies were also unable to provide data about the Figure 2.4 BREAKDOWN OF AIDS IN THE U.S. BY RACE/ETHNIC GROUP AND BY TRANSMISSION CATEGORY WHITE, BLACK, oTHER'/ NOT HISPANIC NOT HISPANIC HISPANIC UNKOWN TOTAL Cumulative Cumulative Cumulative Cumulative Cumulative ADULTS/ADOLESCENTS Number (%) Number (%) Number (%) Number (%) Number ~~ (%) Homosexua|/Blisexual Male 27996 (79) 5842 (38) 3788 (45) 373 (68) 37999 (63) Intravenous (IV) Drug Abuser 2134 (6) 5626 (37). 3228 (38). 57 (10) 11045 (18) Homosexual! Male and IV Drug Abuser 2735 (8) 1078 (7) 604 (7) 21 (4) 4438 (7) Hemophi | ia/Coagqulation Disorder 501 {n) 38 (0) 40 (0) 12 (2) 591 (1) Heterosexual! Cases? 435 (1) 1683 (11) 335 (4) 10 (2) 2463 (4) Transfusion, Blood Components 1092 (3) 226 on) 13 (1) 36 (7) 1467 (2) Undetermined’ 701 (2) 764 (5) 391 (5) 38 (7) 1894 (3) SUBTOTAL (% of all cases] 35594 (59) 15257 1251 8499 (14) 547 (1) 59897 (1001 CHILDREN? Hemophi | ia/Coagulation Disorder 40 (18) 6 on) 5 (2) 2 (20) $3 (6) Patient with/at risk of AIDS? 104 (47) 454 (88) 170 (81) 7 (70) 735 (17) Transfusion, Blood/Components 72 (32) 31 (6) 27 (13) (10) 131 (14) Undetermined” 13) 22 (4) 10) 36 (4) SUBTOTAL (% of all cases) 223 (23) 513 (54) 209 (22) 10 (1) 955 (1001 TOTAL (% of all cases] 35817 (591 15770 (26) 8708 (14) 557 [ni 608525 (1001 Includes patients whose race/ethnicity is Asian/Pacific Islander (353 persons) and American Indian/Alaskan Native (62 persons). 2 Includes 1460 persons (321 men, 1139 women) who have had heterosexual contact with a person with AIDS or at risk for AIDS and 1003 persons (780 men, 223 women) without other identified risks who were born in countries in which heterosexual transmission is believed to play a major role although precise means of transmission have not yet been fully det ined, Includes patients on whom risk information is incomplete (due to death, refusal to be interviewed or loss to follow-up), patients still under investigation, men reported only to have had heterosexual contact with a prostitute, and interviewed patients tor whom no specific risk was identified; also includes one health-care worker who seroconverted to HIV and developed AIDS after documented needlestick to blood. o Includes all patients under 13 years oft age at time of diagnosis. Epidemiologic data suggest transmission from an infected mother to her fetus or infant during the perinatal period. Includes 590! patients who meet only the 1987 revised surveillance definition for AIDS. 5 6 Source: CDC, AIDS Weekly Surveillance Report! - United States, May 2, 1988. Figure 2.5 BREAKDOWN OF TOTAL AIDS CASES IN THE U.S. BY AGE AT DIAGNOSIS AND BY RACIAL/ETHNIC GROUP WHITF BLACK, OTHER®/ NOT HISPANIC NOT HISPANIC HISPANIC UNKOWN TOTAL Cumulative Cumulative Cumulative Cumulative Cumulative AGE GROUP Number (9%) Number (%) Number (%) Number (%) Number (%) Under 5 151 (0) 460 (3) 185 (2) 8 (nn) 804 (1) 5-12 72 (0) 53 (0) 24 (0) 2 (0) 151 (0) 13 - 19 120 (0) 88 (1) 44 (1) 5 (on) 257 (0) 20 - 29 6772 (19) 3670 (23) 2018 (23) 100 (18) 12560 (21) 30 - 39 16294 (45) 7607 (48) 4093 (47) 237 (43) 28231 (46) 40 - 49 8100 (23) 27125 (17) 1687 (19) 138 (25) 12650 (21) Over 49 4308 (12) 1167 (7) 657 (8) 67 (12) 6199 (10) TOTAL [($ OF ALL CASES) 35817 (59) 15770 126) 8708 (14) 557 (nl 60852 (1001 3 Includes patients whose race/ethnicity is Asian/Pacific Islander (353 persons) and American Indian/Alaskan Native (62 persons). Epidemology of AIDS 19 Figure 2.6 DISTRIBUTION OF CONFIRMED AIDS CASES AMONG PROBATIONERS AND PAROLEES, BY TYPE OF AGENCY, U.S. PAROLE n g n 7 Number of AIDS Cases Systems Systems Cases Cases 0 13 25% 0 0% | 2 4 2 1 2 2 4 4 2 4 2 4 8 5 5 1 2 5 3 7 1 2 7 4 10 1 2 10 6 125 1 2 125 78 No Estimate 28 55 me —— TOTAL 51 100% 161 994° N = 55 4 = missing PROBAT | ON n 2 n 7 Number of AIDS Cases Systems Systems Cases Cases 0 11 14% 0 0% | 3 4 3 2 2 6 8 12 7 3 3 4 9 5 5 1 1 5 3 6 2 3 12 7 7 2 3 14 8 15 4 5 60 35 20 1 1 20 12 36 1 1 36 21 No Estimate 46 58 ini rn TOTAL 80 102° 171 100% N = 80 0 = missing Source: NIJ Survey of AIDS Issues for Probation and Parole 3Due to rounding 20 AIDS IN PROBATION AND PAROLE Figure 2.7 BREAKDOWN OF TOTAL AIDS CASES IN COMMUNITY CORRECTIONS BY REGION AND TYPE OF AGENCY (Federal Probation and Parole Excluded) NUMBER OF NUMBER OF STATES PERCENTAGE OF CASES REPORTING CASES TOTAL CASES PROBAT | ON New England? 6 1 4% Mid-Atlantic? 26 2 15 E.N. Central® 39 2 23 W.N. Centrald 0 0 0 S. Atlantic® 16 2 9 E.S. Centralf 0 0 0 W.S. Centrald 29 1 17 Mountain’! 8 2 5 Pacific! 47 3 28 TOTAL 171 13% 101% PAROLE New England? 0 0 0 Mid-Atlantic? 125 1 78 E.N. Central® 5 1 3 W.N. Centrald 4 1 3 S. Atlantic® 17 4 11 E.S. Centralf 0 0 0 W.S. Centrald 0 0 0 Mountain! 9 2 6 Pacific’ 1 J = TOTAL 161 10% 101%J Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut BNew York, New Jersey, Pennsylvania ohio, Indiana, Illinois, Michigan, Wisconsin Minnesota, lowa, Missouri, North Dakota, South Dakota, Nebraska, Kansas Delaware, Maryland, District of Columbia, Virginia, West Virginia, North Carolina, South Carolina, Georgia, Florida frentucky, Tennessee, Alabama, Mississippi JArkansas, Louisiana, Oklahoma, Texas PMontana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada "washington, Oregon, California, Alaska, Hawaii JDue to rounding *These figures represent the number of states reporting cases. 47 states provided data for parole and 48 states provided data for probation. *% Less than 1 percent. Source: NIJ Survey of AIDS Issues for Probation and Parole Epidemiology of AIDS 21 age, sex, ethnicity or mode of transmission of the AIDS cases reported. Sources of Infection and Seroprevalence In interviews with community supervision personnel, administrators overwhelmingly cite intravenous drug use as the major source of transmission of AIDS among their populations. This is consistent with the reports of transmission in the 1987 prison and jail survey in which correctional systems attributed two- thirds of their total cases and 92 percent of female cases to IV drug abuse.’ In areas of high incidence of IV drug abuse, the number of correctional AIDS cases at- tributable to IV drug use is much higher than the number of AIDS cases in the general population at- tributable to drug use. In New York State, for example, 96 percent of the correctional system AIDS cases are among IV drug users, while only 34 percent of the AIDS cases in the general New York State population are IV drug users.’ Since no jurisdictions currently conduct mass screen- ing of all parolees or probationers, estimates of the seroprevalence rates in these populations are not available. However, the 1987 edition of NI1J’s AIDS in Correctional Facilities estimates that, based on small or focused screening projects conducted in some states, from 0 to 2.6 percent of the prison and jail popula- tions are seropositive.” Tests of high-risk populations such as IV drug users or homosexuals show predict- ably higher rates of seroprevalence. However, because of the variety of results, the difference in test groups, and the small samples, it is difficult to predict the actual figures for seroprevalence in the correctional population. It has also been suggested that there may be increased numbers of AIDS cases in parole and probation due to high rates of transmission during incarceration. However, Hammett reports that currently available data suggest low rates of transmission within correctional facilities.” In 1985, Maryland conducted voluntary testing of a group of inmates who had been con- tinuously incarcerated for seven or more years. The testing indicated a very low rate of infection (1.5%) in this group. It was assumed that any infection at all was attributable to transmission in prison because they had been continuously incarcerated since before the virus appeared in force in the United States Data from the New York and Florida correctional systems also sug- gest that infection while in prison is relatively rare. New York reports only five infected inmates (2.3%) among those who had been continuously confined for seven years, and Florida reports only 2 percent of such in- mates infected. 22 AIDS IN PROBATION AND PAROLE In summary, the prevalence of AIDS in the communi- ty supervision population mirrors in many respects the prevalence and distribution of cases in the population in general. Cases are clustered in areas of the country where there are large numbers of intravenous drug users, active homosexual populations, and where the virus has been established in those populations for a number of years. A definitive number of cases in com- munity corrections is not available due primarily to the lack of a reporting system for corrections personnel. Most of the cases reported are felt to be related to IV drug use. It is important to note that practitioners as well as researchers are frustrated by the lack of information about the number of AIDS cases under community supervision. Many of the state parole and probation agencies reported that they would like to have summary data on the number of cases for purposes of plann- ing, management and policy development, but were unable to collect such data without central support and administration. They find themselves relying on anec- dotal information about the prevalence in their popula- tions and/or estimating from the general information provided by the CDC on AIDS cases in their areas. NOTES 1. Institute of Medicine, National Academy of Sciences, Confron- ting AIDS: Directions for Public Health, Health Care, and Research (Washington, D.C., 1986). 2. W.M. Morgan et al., “AIDS: Current and Future Trends,” Public Health Reports 1986: 101:459-65. Institute of Medicine, op. cit.: 69-70. 3. US. Department of Justice, Crime in the United States, Uniform Crime Reports, July 1987. 4. National Institute of Justice, Drug Use Forecasting System Report, April-June, 1988. 5. T.M. Hammett, AIDS in Correctional Facilities: Issues and Op- tions, Third Edition, (Washington, D.C.: National Institute of Justice, U.S. Department of Justice, 1988). 6. Ibid. 7. Ibid. 8. Ibid. 9. Ibid. Chapter 3: HIV ANTIBODY TESTING In this chapter we will discuss the increasingly impor- tant and controversial question of testing persons for the presence of HIV antibodies. The debate about testing must include such crucial elements as cost, reliability of results, and the possibility of maintain- ing confidentiality. In order to help administrators weigh these factors for decision making, we present information on the following: e the tests in current use, their reliability and validity e the current use of testing in parole and pro- bation services ¢ policy recommendations for HIV testing in parole and probation he HIV Antibody Tests Currently in se There are two types of tests available for determining HIV infection: viral culture tests and serological tests. Viral culture tests involve growing the virus from samples; unfortunately, even highly skilled technicians in favorable conditions cannot grow HIV from blood in 40 percent or more of samples known to be infected. This is thought to be due primarily to differing levels of infection activity in samples.’ Serological tests, by contrast, measure antibodies to a viral agent present in the bloodstream. There are cur- rently four serological tests available for identifying HIV infection: the enzyme-linked immunosorbant assay test (ELISA), the Western Blot immunopheresis test, the radioimmunoprecipitation test (RIP) and the cytoplasmic membrane immunofluorescence assay (IFA) test. The ELISA is the most commonly used test for HIV antibody screening because of its low cost, standardized procedures, reliability, and rapid turn- around of results.’ The most common sequence for HIV antibody testing begins with an ELISA test. If the result is positive, a second ELISA will be done for verification, and then the more labor-intensive Western Blot will serve as con- firmation. Positive results on all three tests is considered laboratory evidence of HIV infection. It is crucial to recognize that a positive result on this test series is not evidence that the subject has AIDS or will necessarily even develop AIDS. It merely shows the presence of antibodies to a core protein of the AIDS virus in the person’s system. This means that at some time the individual was exposed to the virus and his or her system responded by producing antibodies. Persons testing positive may progress to ARC or AIDS or may remain asymptomatic. As we discussed in Chapter 1, infection with the virus is a necessary but not a sufficient condition to predict the appearance of the full illness. It is not known what proportion of those who test positive will eventually manifest the disease; estimates range from 20 to 100 percent. As groups of HIV- infected individuals are studied over time, larger pro- portions are seen to develop AIDS; data suggest the great majority of those infected will manifest the disease. One San Francisco study of infected men show- ed that almost no AIDS cases appeared in the first two years after infection was discovered. But after eight and a half years, more than 40 percent had developed AIDS and a similar proportion had developed some symp- toms of infection.” Another study of 288 seropositive men found that 22 percent had developed AIDS after three years of observation.® Moreover, other data seem to show that the rate of pro- gression from HIV infection to full AIDS increases with age; the only exception ta this pattern are newborns, who have the highest progression rate of all. It is assumed that persons testing positive on the whole test series are infected with HIV and are therefore able to transmit the virus, even if they are not ill themselves. The ELISA test was developed in the mid-1980s for the screening of the nation’s blood supplies. The presence of HIV antibodies is signalled by a color reaction quantified through the use of a spectrophotometer. The higher the antibody level, the greater the optical density or color change. Therefore, there is no single “all or nothing” decision point, and testers must assign deter- mination points at which infection is indicated. Manufacturers of the test kit provide suggested density points, based on the color change occurring for definitively-known positive or negative samples (for example, in the test results of persons with full-blown AIDS). However, different ELISA kits can provide varying results, even when testers follow the same standard manufacturer-suggested procedures. The HIV Antibody Testing 23 Figure 3.1 HYPOTHETICAL HIV ANTIBODY SCREENING IN A POPULATION OF 500 WITH A 20% TRUE PREVALENCE OF INFECTION True Infection Status Antibody Test Results False Results as % of n % Negative Positive True Group Result Result a True Infected 100 20% 1 99 1% Groups b ? Uninfected 400 80% 396 4 1% Total 500 100% 397 103 d False Results as % 0.3%" 3.9 of all Test Results in Category 2 This reflects the test sensitivity of 99%. Y This reflects the test specificity of 99%. This is the percentage of all negative results which would be false. d This is the percentage of all positive results which would be false. varying results, it has been suggested, may be at- tributable to variations in the batches of antigen used. The Western Blot test, as we have noted, is used for confirmation after two positive ELISA results. For this test, inactivated virus is separated into component parts and “blotted” onto special paper. Complexes of viral protein and antibodies are seen as spots or bands in the final preparation.’ The Western blot test is not sold commercially as a kit, nor does it have standard- ized interpretive procedures. Consequently, the inter- pretation criteria and reliability of results can vary widely with the laboratory and the skill of technicians. Federal efforts are currently underway to examine and standardize laboratory HIV antibody testing. Reliability and Validity No medical test is 100 percent accurate. Tests vary in their accuracy, their reliability, and their consistency. Some mistakes are attributable to human errors, such as misreading or mislabeling, and others may be due to flaws in the test itself. But with a potential result as psychologically and emotionally devastating as HIV infection, it is critical to understand and try to minimize the errors associated with these tests. One way to assess the validity of a test is to see how accurately it identifies those known to be infected. A 24 AIDS IN PROBATION AND PAROLE “false negative” result occurs when a subject known to be infected tests negative. A “false positive,” converse- ly, occurs when a test indicates someone is positive, or has antibodies to the disease, when he or she is not real- ly infected. All tests have some rate of error; these can be mini- mized by good definitions, standardized procedures, and careful administration. The CDC estimates that the sensitivity and specificity of the two-ELISA sequence is 99 percent. This means that on average, the test will correctly identify 99 out of every 100 persons who are actually infected (its sensitivity) and that it will correctly identify 99 out of 100 persons who are actually uninfected (its specificity). However, this does not mean that only 1 percent of all the positive or negative results will be false. The percentage of false negative or positive results depends on the actual prevalence of infection in the population tested. For example, Figure 3.1 shows that if the actual prevalence of infection in a test population of 500 people is 20 percent (meaning 100 people are actually infected), and the accuracy of the test is 99 percent, then 1 percent of the truly uninfected people, or 4 people, will receive a false positive result. In addition, 1 percent of the truly infected people, or 1 person, will a Figure 3.2 HYPOTHETICAL HIV ANTIBODY SCREENING IN A POPULATION OF 500 WITH A 1% TRUE PREVALENCE OF INFECTION True Infection Status Antibody Test Results False Results as % of n %o Negative Positive True Group Result Result True Infected 5 1% 0.05 4.95 192 Groups b Uninfected 495 99% 490 5 1% Total 500 100% 490.05 9.95 False Results as % 0.01% 49.8% of all Test Results in Category This reflects the test sensitivity of 99%. Bris reflects the test specificity of 99%. This is the percentage of all negative results which would be false. d This is the percentage of all positive results which would be false. receive a false negative result. Thus 103 people in the group will test positively and four of them, or 3.9 per- cent of all positives, will be false. The figures are quite different in the case of a popula- tion in which the true prevalence of infection is very low — for example, if our same 500 people have a prevalence rate of 1 percent (Figure 3.2). In this case, the percentage of positive results which are false rises dramatically. Four cases in this group will be truly in- fected and four cases will be false positives, making the error rate for false positives 50 percent for this low- incidence sample. Another factor in the accuracy of HIV tests is the cutoff, or determination points, at which a blood sample is declared infected. Because the ELISA test was first developed to screen blood supplies, a process in which it was crucial to minimize false negative results (it being better to discard an actually uninfected unit than to transfuse someone with infected blood), the cutoff points were set quite low. But because the deter- mination points were set conservatively, false positive results are automatically increased. This is appropriate for screening the blood supply, but it is a serious pro- blem when false information is given to actually uninfected patients. And as we discussed, this is in- creasingly possible with low-incidence populations. The manufacturers of ELISA test kits reccommend set- ting the determination point differently for different runs of the test, taking into account the type of popula- tion. The cutoff point should be higher for low- incidence populations (to minimize false positives) and lower for high-incidence populations (to minimize false negatives). Unfortunately, the sophistication of test use varies widely; these adjustments are not always made. In addition, the Western Blot test is not standardized, is highly labor-intensive, and relies heavily on the interpretive ability of the laboratory technicians. This ability varies, making results even of this confirmatory test less than definitive. Even the loss of a fraction of a percentage of specificity due to interpretive differences or lack of quality control becomes critical in the production of false positives in populations where the true prevalence of the virus is low. For the example shown in Figure 3.2, adding even one- half of one percentage point of error to the results — making it only 98.5 percent accurate — due perhaps to laboratory reading error, would make the percentage of positive results that were false 75 percent. In reviewing the information on testing reliability and validity, it is important to remember the purpose of the test. Screening of low-risk populations, such as applicants for a marriage license, should have quite HIV Antibody Testing 25 different interpretive criteria than tests used in clinics treating sexually transmitted diseases or IV drug use, or as part of the clinical diagnosis of persons with symptoms of AIDS. To summarize, a single ELISA test or even two ELISA tests is not adequate for screening HIV, due primarily to variations in test application and an unacceptably high rate of false positives. Even the Western Blot con- firmatory test, designed to identify and eliminate false positives, is subject to human error in handling materials and, most important, in interpretation of results. It should also be pointed out that in order to be effec- tive with high-risk populations, the test sequence must be repeated periodically. CDC estimates that the average time from infection to conversion (appearing positive on a test) ranges from six weeks to as long as 14 months.” Therefore, a person who does not test positive but has engaged in high-risk behavior during the previous six-month period is not necessarily free of infection and should be retested. Persons who con- tinue to engage in high-risk behavior should also be tested periodically, as infection can occur at any time. NIJ Survey Results During the time of the NIJ survey, December 1987 through March 1988, none of the state probation agen- cies reported mass screening; only the Texas Division of Parole reported that it was mass screening all new parolees at that time. In 1987, the Federal Bureau of Prisons instituted a program of testing all parole- eligible inmates within 60 days of release. In this pro- gram, approximately 2-3 percent test HIV antibody-positive.® Six state parole or probation agencies currently con- duct limited testing. One tests high-risk groups, two test persons with clinical indications of illness, three test in response to a specific incident, and three others test at the individual’s request. Test information is available, however, to 40 percent of community cor- rections agencies, from a variety of sources. In one state, for example, results from any pre-trial testing which may have occurred are routinely available. Other sources of test results for parole officers include medical records (22%), court-ordered testing of high- risk groups (4%), and prior incarceration records (31%). All agencies who test report the results to the proba- tioner or parolee, and to his or her personal physician, as well as to the public health department. In only one state, the corrections agency is officially notified if a parolee tests positive. Only in one state is testing re- 26 AIDS IN PROBATION AND PAROLE quired of the parolee or probationer if he or she is in- volved in an incident in which HIV transmission may have occurred; other areas do not require testing in these cases but stated that they counsel or encourage the parolee, probationer, or officer involved to be tested. For those jurisdictions not requiring testing in such cases, the reasons may be related to state legal restrictions on requiring testing, the absence of a clear policy for such circumstances, or policy against such testing from the Department of Corrections. Only in Georgia is HIV testing used in considering eligibility for parole. Beginning in 1988, the Georgia State Board of Pardons and Paroles began screening all inmates upon release. The Board may refuse to grant parole to seropositive inmates who fail to meet special supervisory conditions. These conditions are discuss- ed in detail in Chapter 6. In Ohio, test results and/or illness may factor in the timing of parole and may in- fluence early release decisions or decisions to delay release while appropriate treatment or care facilities are arranged. The survey also asked agencies about their perceptions of the utility of testing. Of the agencies conducting testing, one reported that it found the test very useful, primarily to help target education and training pro- grams for those identified. Three reported that the pro- gram has made no real difference. Two others said that it has had a negative effect on agency operations, mainly by adding the burden of maintaining confiden- tiality to management’s responsibilities. The agencies which do not test are divided in their perceptions of the utility of testing. Half of the jurisdic- tions feel that testing would be useful, primarily for treatment counseling, staff safety and better supervi- sion. The other half question the value and costs of testing. Issues Involved in Testing The issue of HIV testing in community corrections — particularly mass screening — is extremely controversial. Testing can be done in several ways: mass screening at the initiation of parole or probation; testing of high- risk behavior groups (homosexuals, IV drug users, sex offenders); testing in response to incidents in which transmission may have occurred; voluntary testing; and anonymous testing as part of epidemiological or public health research. The debate surrounding testing of parole or probation service populations in many ways mirrors that regard- ing the general population. But community corrections supervisors are particularly vulnerable to potential liability for release of an infected person into the com- munity. In addition, they may be liable for the poten- tial leaking of confidential test information. For ex- ample, probationers or parolees may face stigmatiza- tion and discrimination if their HIV antibody-positive status is disclosed. Officers, on the other hand, may be liable to third parties as a result of non-disclosure of information. As these results suggest, the issue of testing parole and probation populations engenders considerable debate. Some practitioners feel that it is important to know the HIV status of persons under supervision for several purposes: to protect staff from possible transmission; to protect public safety, including the sexual partners of HIV-infected individuals or others in community facilities; and to prepare for managing the individual’s incipient illness. The advocates of targeted or mass- testing of groups such as IV drug users argue that seropositive individuals should be identified in order to focus educational and informational services. In ad- dition, testing proponents feel that staff need to know which persons under supervision are seropositive, in order to take special precautions in dealing with them and to help manage their transition back into marital and community life. Critics of testing argue that the transmission of HIV to staff is a moot issue, because the behavior necessary for effective transmission is unacceptable in the first place. In addition, opponents point out that testing, which is expensive, would have to be repeated periodically to insure that the infected persons were ac- tually identified. Without repeated testing, a false sense of security might develop for those not yet identified — encouraging community corrections officers to be more lax in standard search or cleanup procedures. Finally, the rate of false positives produced might present more difficulty for supervisors than would other proactive methods of identification of high-risk individuals, such as careful history-taking and medical examination. Ap- pendix C contains one such health examination pro- tocol used in Iowa correctional facilities. This exam pays particular attention to lifestyle indicators reported and physical indicators of HIV picked up in pharyngeal, anal, and lymph node examination. Mandatory screening programs may not be possible in many states under existing statutes. Laws in Califor- nia, Washington, D.C., New York, Wisconsin, and Massachusetts, for example, prohibit testing without the informed consent of the subject. Case law is con- tinually developing in this area and will be discussed in following chapters. In addition, the right to refuse testing may be legally viable, if it is argued that disclosure of results could have serious negative con- sequences for such things as insurance benefits, employment opportunities, or family relations. How Costly is Testing? The final question in the debate about testing is that of cost. The ELISA tests across the country as reported in NIJ’s AIDS in Correctional Facilities report range from $2 to $38 and average $13 per test.” The Western Blot test averages about $41 per test with a range of $2 to $99 reported. The Western Blot adds considerably to the cost of testing, particularly if a large number of persons tests positive on the ELISA sequence. However, laboratories may offer a low flat rate of under $10 for the total sequence, particularly if the positive rate on the ELISA is expected to be low. Clearly, screening a large number of parolees or pro- bationers could be quite expensive. If an agency has even 1000 persons under supervision and obtains a flat rate for the test sequence of $5 per test, the cost of one- time testing is $5000. That test would need to be repeated at three- or six-month intervals to insure both that new transmission had not occurred and that per- sons initially seronegative but infected had tested positive. Even a conservative test schedule of two times per year for the population of 1000 would produce substantial costs, which would have to be balanced against both the perceived benefits of testing, and also the opportunity costs. These include resources that could have been spent on education or counseling. Summary and Recommendations Con- cerning Testing in Probation and Parole Evaluation of whether and under what circumstances to test in community corrections involves questions we will summarize below. Each jurisdiction should weigh these questions carefully before deciding how to ad- dress this issue. e Who else is testing in community corrections and what is their experience? At the time of the NIJ survey, only one state and the Federal prison system were conducting mass screening of parolees. However, many others were currently conducting or planning to conduct selec- tive screening soon. Respondents usually described selective screening as one or more of the following: testing in response to an incident involving the potential for transmission, testing because the in- dividual is showing possible symptoms of AIDS, or voluntary testing. Those who report no testing and no desire for testing cite as their reasons both costs and fears of con- fidentiality problems. HIV Antibody Testing 27 e [Is it possible to maintain confidentiality in community corrections? Proponents argue that clients’ privacy can be assured by strict adherence to confidentiality procedures. Such procedures involve controlling all access to test information, maintaining separate files, and/or removing all mention of HIV tests from corrections records. Opponents of mass testing argue that it is impos- sible to maintain this information in a system in which multiple supervisors may have access to an individual’s file. Transfers to other areas or split- sentence cases, for example, add additional parties to the information chain. While an AIDS diagnosis may be part of someone’s file due to clinical symp- toms of the illness, they argue that adding the ad- ditional confidentiality burden of HIV test results is unwarranted. Can screening work with education pro- grams to increase cooperation of proba- tioners and parolees and better allocate resources? Proponents argue that educational resources would be more useful if targeted to those persons testing seropositive. In addition, persons identified as positive can take necessary steps to avoid transmit- ting the disease to others. Opponents argue that linking education programs to mass-screening results ignores the fact that many infected individuals may not yet test positive. Con- sequently, testing fails to identify the total HIV- infected population. More important, education programs must be widespread and widely available to control transmission. Finally, persons who are identified as HIV antibody-positive may not respond well to educational messages if they have been singl- ed out for attention. This group may feel less threatened if addressed as part of a larger, only potentially infected group. Is mass screening the only way to determine the extent of the AIDS problem in com- munity corrections? Proponents argue that mass screening is the only way to determine the scope of the problem and to make sound budgetary decisions based on this knowledge. Opponents argue that blind epidemiological tests on representative samples of probationers or parolees in each jurisdiction can provide the same informa- tion at a lower cost. 28 AIDS IN PROBATION AND PAROLE o Will mass testing improve the delivery of timely medical care to probationers and parolees? Proponents argue that early identification of seropositive individuals will help signal the need for special medical referrals or special residential placements of those infected. If treatments become available which slow the progress of the disease even for those with early-stage AIDS, then early identi- fication will be important. Opponents argue that the majority of seropositives are not ill and not in need of special medical care, especially since neither a cure nor an approved medication to slow early-stage AIDS is currently available. As symptoms of illness appear at varying times for seropositives, it is not possible to predict medical needs based only on HIV status. Finally, placing seropositives in special residences or giving them special treatment may be discriminatory and illegal in some states. NOTES 1. J.S. Schwartz, P.E. Dans and Bruce P. Kinosian, “Human Immunodeficiency Virus Test Evaluation, Performance and Use,” Journal of the American Medical Association, May 6, 1988: 259 (17): 2574-2579. 2. Ibid. 3. Institute of Medicine, National Academy of Sciences, Confronting AIDS Update 1988 (Washington, D.C.: National Academy Press, 1988), pp. 35-36. 4. Ibid., p. 36. 5. Ibid. 6. Michael J. Barry et al., “Screening for HIV Infection: Risks, Benefits, and the Burden of Proof,” Law, Medicine and Health Care, December 1986: 14:259-267. 7. Schwartz, op. cit. 8. Bulletin of the Federal Courts, December 1987. 9. T.M. Hammett, AIDS in Correctional Facilities: Issues and Options, Third Edition (Washington, D.C.: National Institute of Justice, U.S. Department of Justice, 1988). Chapter 4: AIDS EDUCATION AND TRAINING IN COMMUNITY CORRECTIONS SERVICES As in the general population, education and training are the cornerstone of any efforts to prevent the transmission of AIDS and to serve both infected pro- bationers and parolees and those who interact with them. Preventing transmission of the virus from pro- bationers and parolees to spouses, staff, or others, is of great concern to corrections agencies. Unfortunately, mass AIDS education is still rare among community corrections services. This is often because agencies fail to recognize each person as a potential HIV carrier. AIDS education for probationers and parolees often consists of post facto, case-by-case counseling, or refer- rals to community AIDS education or health organiza- tions. On the positive side, however, educating staff about AIDS is a growing practice, and even a priority, of many community corrections services. The agencies that do not provide AIDS-related educa- tion to staff and/or clients cite the following reasons: they have no known HIV seropositives or AIDS cases; their agencies and officers are overburdened; or the problem is too recent. While these reasons may seem compelling, many stronger arguments exist for man- dating AIDS education and training. This chapter describes examples of AIDS education and training ap- proaches used around the country, and proposes methods of dealing with the growing concerns of pro- bation and parole agencies. Education for Probationers and Parolees Though the majority of community corrections agen- cies provide no comprehensive AIDS education for clients, two-thirds expressed a need for such education. Figure 4.1 summarizes the modes of instruction reported by parole and probation services. Currently, community corrections services who supply clients with AIDS education in the form of brochures focus their efforts on those who request the material or those known to be members of high-risk groups. Proba- tioners or parolees usually pick up the materials in waiting areas or upon meeting their supervising officers at the community corrections office. Most of the brochures distributed have been developed by external organizations, such as national and local public health departments, or the state department of corrections. Topics most frequently covered by the educational materials include facts about HIV transmission, medical information about AIDS, and listings of rele- vant, accessible community resources. Several community corrections services employ writ- ten materials discussing safer sex practices, but only a few use brochures covering procedures for cleaning and disinfecting hypodermic needles and other equip- ment (“works”) of IV drug users. The probation divi- sion of Austin-Travis County, Texas, distributes wallet- size cards listing “Safer Sex Guidelines,” AIDS hotline phone numbers, and information on the current number of AIDS cases in Austin.’ California’s parole division hands out pamphlets, with concise messages that are appropriately targeted. Pamphlets include: “AIDS Kills Women and Babies,” which contains AIDS hotline and other phone numbers for those in and out of jail, and “Facts About AIDS and Drug Abuse.” The better pamphlets define any technical terms used, such as “condoms” and “syringes,” in popular jargon, e.g., “rubbers” and “works.” Some of these excellent, simple, and straightforward materials also contain street language for drug users. One brochure provides National Institute on Drug Abuse phone numbers for referral to drug treatment programs. Spanish-language versions of many brochures also exist, including a cleverly designed and very frank double-sided Spanish- English one, “Alcohol, Drugs & AIDS/Alcohol, Drogas y AIDS,” used by the probation division of Contra Costa County, California. Examples of some of these materials and information on obtaining them can be found in Appendix E. Live AIDS education, broadly defined as any instruc- tional mode beyond distribution of written materials, is almost nonexistent for probationers and parolees. In the handful of localities where live education is pro- vided, it takes the form of general information on HIV transmission or, in one case, on drug diversion pro- grams. Only a few of these community corrections services allot time during an information session for questions and answers. A handful of community cor- rections services employ videotapes; those who do not cite several reasons, usually a lack of available funds or no need perceived. Two community corrections services enlisted clients in program development by re- questing their suggestions and including them in an AIDS video. AIDS Education and Training in Community Corrections Services 29 Figure 4.1 MODES OF AIDS EDUCATION AND TRAINING PRESENTATION FOR PROBATIONERS, PAROLEES, AND AGENCY STAFF PROBATIONERS/PAROLEES Parole Agencies Probation Agencies N = 55 N = 80 Mode of Presentation n % n Z « Live Education 2/43% 4.7% 4/63 6% « Brochures 13/43 30 16/63 25 e Videotapes 2/40 5 5/62% 8 AGENCY STAFF Parole Agencies Probation Agencies N = 55 N = 80 Mode of Presentation n % n Z e Live Education 36/41% 887% 44/63% 70% « Brochures 29/40% 72.5 54/64 84 * Videotapes 25/40% 61 35/63 55 *Denominator represents number who answered question. Denominators differ due to differences in number of agencies reporting on each mode and to use of multiple modes. Source: NIJ Survey on AIDS Issues for Probation and Parole. 30 AIDS IN PROBATION AND PAROLE Agencies which create their own videos on AIDS, more tailored to IV drug users, for example, might supple- ment these with any of a number of general AIDS videos on the market. Two videotapes suggested for use with probationers and parolees are “AIDS: A Bad Way to Die,” produced by and for inmates but applicable to community corrections, and “Dying for Love,” a general audience video aimed at women’s concerns, such as transmitting the virus to one’s fetus.’ The Treatment Alternative to Street Crime (TASC) Pro- gram in Cook County, Illinois is developing an educa- tion/intervention strategy called “Brief Risk Interven- tion (BRI) which provides information to those iden- tified as possible high-risk clients.’ During a brief in- terview and intervention sequence, the officer identifies high-risk activities or health problems, outlines risk reduction strategies, and provides other relevant information. About one-fifth of community corrections services make some educational materials, such as general brochures or information sheets, available to families or sexual partners of probationers and parolees. A few agencies also make live education and/or videotapes available to them, although none regularly schedule programs. As with AIDS education for clients and of- ficers, providing third parties with such instruction can lessen the potential liability of an agency to those parties. Education/ Training For Staff As Figure 4.1 indicates, of the community corrections services offering AIDS education to staff, about half provide it in the form of brochures or other written materials, often distributed during training sessions or at staff meetings. Most of these materials are derived from or distributed with existing materials put out by public health organizations, commercial enterprises, other states, or federal agencies. The Massachusetts Parole Board distributes pamphlets to officers on topics ranging from precautionary measures to counseling parolees known to be HIV antibody-positive. These pamphlets include “AIDS and Your Job: Are There Risks?” and “If Your Test for the Antibody to the AIDS Virus is Positive.” The New York State Division of Probation has developed an exemplary notebook of information and supervision guidelines for parole officers and ad- ministrators.” Divided into 10 sections, the book covers general information about AIDS, a review of state policies, common questions and answers, and detailed directions for use of referral sources with specifics on how to help individuals apply for special services. Community corrections services who do not provide staff with brochures offer the following reasons: their materials are awaiting approval by management or a central agency; their materials are still being developed; or their agency uses educational methods other than written materials. Three-quarters of community corrections services pro- vide their staff with live training on AIDS, from lectures to classroom instruction and seminars. The most popular format consists of general information about AIDS presented in a lecture, brochures, and/or a videotape. Variations include holding one-time workshops or showing a videotape or slides followed by a question-and-answer period. A majority of com- munity corrections services allot some time for questions and answers, anywhere from 10 to 50 per- cent of session time. Approximately half of community corrections services employ videotapes in education programs for staff. Several services noted the unavailability of videotapes, especially ones geared to the concerns of community corrections. Although videotapes expressly tailored to community corrections are presently not available, videos for general correc- tional audiences abound. For example, Idaho shows videos, approximately 30 minutes long, such as “AIDS: A Bad Way to Die,” “AIDS: The Challenge for Cor- rections,” and “Information for Law Enforcement Officers.” Community corrections services across the country use different types of trainers for their live programs, the most common trainers being in-house staff, medical experts, and state or local health officials. The New Jersey Probation Services Training Unit has, with good results, used trainers from the state’s Department of Health to reduce staff fear and anxiety by providing up-to-date information on AIDS. A few services con- tract with outside consultants to provide AIDS train- ing. Kentucky’s Corrections Cabinet, which includes the Division of Probation and Parole, hires professional AIDS trainers to equip counselors with the knowledge and empathy required for counseling releasees." Missouri’s Department of Probation and Parole plans to give similar lessons designed to alleviate fear from the working relationship between officer and HIV- infected probationer or parolee.” About a third of community corrections services involved their own staff in the development of the agency’s AIDS education program. Staff contributions ranged from working within a task force on AIDS instruction to designing and carrying out the entire program. Only one or two jurisdictions involved a staff union in the development of their AIDS education. The length of these education and training sessions AIDS Education and Training in Community Corrections Services 31 ranges, depending on the mode and format, from 45 minutes to four hours. New York State’s Division of Probation and Correctional Alternatives employs local health agencies to present three hours of regional staff training on AIDS-related subjects. These include safer sex, and counseling techniques, including helping families deal with the disease or death of a relative. Education and training classes among community cor- rections services are usually given once a year, although a few agencies offer two or more sessions at intervals. Some community corrections services hold sessions at hiring or initial training of staff. Other jurisdictions determine session frequency and timing on the basis of need. Attendance at training sessions is mandatory in approximately one half of community corrections services. Staff Training on Advocacy, Referrals, and Resource Coordination The most successful community corrections’ AIDS education and training programs for staff present in- formation and techniques for advocacy, referrals, and resource coordination. Good programs also include units on resources available for AIDS counseling, testing, medical care and other services. Because pro- grams do and will vary from state to state, “program” in this context means anything from the dissemination of brochures to the live presentation of AIDS information. In dealing with AIDS, the principal task for communi- ty corrections is resource coordination: between staff and clients; institutional/court staff and field staff; staff and community organizations; and staff and government agencies. The best programs provide pro- bation and parole officers with articles on traditional and experimental counseling techniques and provide clients with tapes directing them to the appropriate ser- vices. Missouri’s Department of Probation and Parole is currently working on a manual that contains excerpts from Elisabeth Kubler-Ross’ writings on death and dy- ing and other researchers’ psychological analyses of HIV-infected IV drug users. In comprehensive pro- grams community corrections staff are trained to act as central switchboards, serving as generalists who refer clients to specialized resources such as HIV testing centers, drug treatment programs, Social Security (SSI) administrators, and hospices. Agency management can play a pivotal role by gathering information on services and local organizations and by facilitating staff con- tact with these other resources. The Maricopa County, Arizona community corrections service has established a relationship with the Arizona Stop AIDS Project (ASAP), a community program 32 AIDS IN PROBATION AND PAROLE offering people with AIDS (PWAs) assistance with applications to social services such as SSI and food stamps; referrals to doctors, lawyers, and priests; finan- cial assistance (through grants and loans) for rent and utilities; and emotional support through volunteers and support groups, for the PWA and the family. They also offer a housing/hospice program. Parolees and proba- tioners, particularly those who are IV drug users, often lack adequate social support systems or the motiva- tion and knowledge to seek out public support. As liaisons, community corrections staff take the initiative to explore available benefits appropriate for their clients. For example, those who are HIV seropositive or who have ARC but not full-blown AIDS may not automatically qualify for SSI and may need trained guidance in this area. San Mateo County, California, has developed a Bud- dies Program, which pairs PWAs (and also people with ARC) and their families with a trained resource and support volunteer. The Buddies Program exemplifies coordination at its best: San Mateo community cor- rections officers can refer clients with AIDS to Bud- dies. Buddies is a program of ELLIPSE (Peninsula AIDS Services Inc.) which works with the San Mateo County AIDS Project of the Department of Health Services. Not all locales may have an ASAP or a Buddies Pro- gram, but similar community resources exist in many areas. Where they exist only in neighboring vicinities, staff might help clients establish contact with nearby self-help organizations. Role of Agency Management, Correctional In- stitutions, and Courts in Facilitating Education/ Training Effective AIDS policies never sacrifice consistency for caution. Promulgating agency policies and procedures that incorporate extreme precautions contradicts the stated purpose of education programs, which is to dispel irrational fears. For example, education pro- grams for law enforcement officers continually em- phasize the point that transmission cannot occur through casual contact. Yet in some jurisdictions, law enforcement officers may be issued gloves — without specific guidelines for their use. Some law enforcement personnel have even requested the HIV antibody status of probationers or parolees with outstanding warrants, indicating that the officers believe special precautions should be taken in apprehending them. These inconsistencies illustrate the potentially dangerous belief that the only individuals with whom it is necessary to take precautions or who need counsel- ing are those known to be members of high-risk groups or those known to have ARC or AIDS. A probationer or parolee who is, unknown to the supervising officer, the sexual partner of an HIV-infected individual, carries the same minimal risk of viral transmission to staff as does the probationer or parolee openly suffer- ing from AIDS. The officer might be wary around the latter individual but would not know to take the same precautions, such as avoiding blood-to-blood contact, with the former individual. It bears repeating both in agency policy memoranda and in AIDS education pro- grams, that any client, or even any officer, may be a carrier of the virus and that certain high-risk behaviors, rather than high-risk groups, should be of primary con- cern. A few universal precautions should be the standard. No community corrections educational response to AIDS can be carried out without the commitment of agency management. Given the great investment of time and funds required for thorough AIDS education and training programs, management support is essen- tial. Consulting with legal counsel and notifying of- ficers about their jurisdiction’s particular health-status disclosure regulations and other relevant laws is clear- ly an important role for agency management. Agency heads can also act to relieve the enormous ten- sions brought on officers by the presence of HIV- infected persons in caseloads. Exemplary of such foresight, the New York State Division of Probation and Correctional Alternatives urges its local probation departments to establish informal support systems to help staff bear up to the stress of caseloads contain- ing many high-risk or HIV seropositive clients." New York’s policy directive on AIDS asks management to ensure that staff fears about HIV transmission do not drive staff to such extreme measures as replacing face-to-face contacts with phone contacts. It states that only in the case of a client too sick with AIDS to visit the office, or other circumstances deemed extenuating by the court, would phone contacts be an acceptable deviation from probation or parole conditions. Since New York State’s is a decentralized, county-based pro- bation system, this umbrella organization can only offer guidelines to local departments. However, these suggestions, although not binding, form a very helpful framework within which staff of local departments can make their decisions and judgments. Both the New York State Division of Parole and the Division of Probation and Correctional Alternatives have published excellent guidelines on AIDS, with topics ranging from informational resources (including a map of New York State AIDS Task Forces and a phone list of SSI Teleclaims offices) to a section of questions and answers specifically relating to com- munity corrections. The following are examples from New York State materials: Question: Does the Division have money to help parolees with AIDS with the cost of housing or other expenses? Answer: The Emergency Support Fund and Emergen- cy Housing Funds established in each area of- fice exist to assist parolees in need of hous- ing, transportation, and other assistance. Funds can be accessed in accordance with local area office procedures. Question: Is a probation officer prohibited from routinely questioning defendants and/or pro- bationers on their sexual preference, in- travenous drug use, and whether they have AIDS or are a carrier (seropositive)? Answer: While questioning is not barred, it is never- theless . . . highly sensitive in nature and therefore it is not recommended . . . . Should a defendant or probationer volunteer this in- formation, further questioning would not ap- pear inappropriate. If a probation officer has contact with [a member of] any of the high- risk categories, s/he should consider pro- viding information (i.e. brochure, hot line number, testing sites) and encourage such in- dividuals to seek counseling and testing." Kentucky’s Division of Probation and Parole also sends its staff members memoranda containing highly per- tinent AIDS-related questions and answers, such as: Question: Do we have a liability to notify employers/ family members when AIDS is detected in probationers or parolees? Answer: No such liability exists, and current legal opinion seems to point to the fact that we would be placing ourselves in a liable posi- tion with the client should we disclose the information." Many community corrections departments are capitalizing on the AIDS education programs in progress for inmates and pre-parolees at various cor- rectional institutions. Three community corrections services say that they require AIDS education as a AIDS Education and Training in Community Corrections Services 33 parole condition for parolees who are HIV-infected or have ARC or AIDS. Colorado’s Department of Cor- rections, like several other states, educates seropositive pre-parolees before their release into parole or com- munity placement. Georgia’s Board of Pardons and Paroles has established 10 special conditions of parole for those who are HIV antibody-positive, and has created an acknowledgment form which these in- dividuals must sign. The parole conditions consist of: pledges to refrain from “risky” behavior, such as tat- tooing and selling blood; permission to disclose HIV antibody-positive status to prospective co-residents; and proof, via oral or written exam, of thorough knowledge about the disease, precautions, and health management. Such an AIDS policy requires a close working relationship between institutional parole and field parole officers and an equally communicative relationship between field officers and collateral con- tacts. (For examples of the Georgia forms, see Appen- dix G.) Attempting to bring together probationers and/or parolees who may be scattered throughout the com- munity and may not be grouped in residential placements is difficult. However, there are ways to facilitate such group AIDS classes. For example, judges may as a condition of probation order probationers to attend special AIDS classes which community correc- tions services arrange through their chapters of the Red Cross, local AIDS Action Committees, or other groups. Some judges in Cincinnati, Ohio have already adopted this approach, by requiring as a sentencing condition that IV drug users and sex offenders participate in a special two-hour class on avoiding exposure to AIDS." Frequent and Mandatory Mass AIDS Educa- tion for Probationers and Parolees The epidemic nature of AIDS requires repeated and mandatory education for probationers and parolees. Up to now, most community corrections services have been working within their existing system of reporting and supervisory contacts to encourage known IV drug users to be tested for the virus or to urge individuals with apparent symptoms of ARC or AIDS to undergo a complete medical examination. This reactive ap- proach, which may be adequate for a jurisdiction with few HIV-infected individuals, will fail community cor- rections services as more IV drug users and other high- risk clients either become seropositive or develop ARC or AIDS. Besides not reaching the larger population of those who are potentially or presently (but unknown to the officer) HIV seropositive, these case-by-case ef- forts undoubtedly reach only a fraction of those with manifest ARC or AIDS. 34 AIDS IN PROBATION AND PAROLE Therefore, it is suggested that community corrections services supplement this form of AIDS education with a proactive approach: live training, or at least distribu- tion of written materials to all clients. Arranging classes for probationers and parolees is not a simple task, especially for those whose sentences do not include residential placements. But solutions can be found with proper planning, support, and coordination. Several of the community corrections services consider the AIDS education that parolees have had as inmates suf- ficient for their tenure as releasees. This policy ignores the necessity of repetition and the importance of tailor- ing education to specific audiences. A parolee’s behavior and concerns, like those of a probationer, are different from those of an inmate. Community correc- tions’ liability is likewise different from institutional liability. Therefore, past classes in prison will not suf- fice for parolees; random and occasional referrals to community organizations will not suffice for proba- tioners. AIDS requires a thoughtful and comprehen- sive educational effort. Unlike correctional facilities, which need to avoid alarmism in their AIDS education, community cor- rections services might do better to stimulate concern among clients. Parolees and probationers may lack the fear of HIV transmission which confinement inspires in inmates. Furthermore, those not incarcerated come into contact with many more members of society whom they could potentially infect or be infected by. It is for these reasons that agencies should convey the harsh realities of the high rate of HIV transmission and of a lingering AIDS death, especially among IV drug users. At the same time, community corrections services must strike a balance in their presentation to avoid discouraging those who might be HIV antibody- positive from being tested. For example, some California county probation departments, such as San Diego County, give clients bulletins or booklets describ- ing antibody testing at alternative test sites. These materials present the pros and cons of taking the test, discuss anonymity and confidentiality, talk about the interpretation of test results, and draw the distinction between testing positive for antibodies to HIV and actually having ARC or AIDS. The bulletins answer in clear and concise language such thorny questions as: Question: If there is no known cure for AIDS, why should I have the test? Answer: After learning all the facts, you may decide that you do not want the test. However, you may want to consider taking the test if you are in one of the high-risk groups discussed above. Results of the test along with ap- propriate education may help guide you in what precautions you should take to protect your health and the health of others." To summarize, the following are key elements of suc- cessful AIDS education and training programs, both for officers and for probationers and parolees: e education that is timely, regular, and mandatory; e programs backed by the commitment of agency management; e staff and client participation in initial and ongoing program development; e programs that employ live presentation, in- cluding a talk, question-and-answer period, videotape, and/or slide show, plus written materials, such as brochures or memoranda; e education that puts forth simple and straightforward messages targeted, in both content and language, to the appropriate audience —more technical for officers, more colloquial for clients; e programs that maintain credibility by us- ing knowledgeable and approachable presenters, peer trainers, and accurate materials prepared by national organizations; e for direct protection from agency liability, documentation of program attendance and/or receipt of written educational materials."® Strategic planning of a good AIDS education program requires time and money. Any measures instituted by an agency will ultimately be determined by available resources, but a variety of resources can be used, in- cluding outside agencies and local support groups. Policy Recommendations Although it is best to plan and institute educational programs on AIDS before the first case is encountered and before worries surface among clients or community corrections staff, it is never too late to begin. By mid-1988, many community corrections services will have encountered and dealt with at least a few HIV antibody-positive and some AIDS-afflicted clients. This chapter has discussed the key issues in AIDS education and training. The answers to the following questions summarize our recommendations: oe Whom should AIDS education and training programs address? AIDS education should be mandatory for all com- munity corrections staff and for all probationers and parolees. In addition, all staff should receive train- ing in how to manage AIDS patients in their caseload. Where possible, educational materials and programs should be made available to spouses or family members of HIV-infected clients who wish to participate. o What are the most effective education and training programs? Programs which are live, and use up-to-date infor- mation presented in a simple, easy-to-understand fashion are most effective, especially when they in- clude question-and-answer periods. Where possible, role-playing issues or situations reinforces the message. Peer training is also an effective use of available resources. e How often should such programs be given? Programs which are updated and repeated periodically have more potential for producing results than those given once or twice. For example, the distribution of generic materials at one point in supervision or training should not be expected to have lasting value. o Why should our agency train specifically for AIDS? AIDS has captured the fears of the population in a unique fashion. This fear has produced misinfor- mation about the disease and its transmission in all quarters, including criminal justice. To deal calmly and effectively with the clients coming through an agency, both the staff and the clients need to be well- informed and trained. Finally, preparedness is the best protection against liabilities related to supervi- sion of probationers and parolees. Agencies may, through documented education and training pro- grams, counter claims that training or information they provided inadequately protected staff or third parties. NOTES 1. “AIDS Services of Austin—Safer Sex Guidelines,” AIDS Services of Austin, March 1987. 2. “AIDS Kills Women and Babies,” San Francisco AIDS Foun- dation and San Francisco Department of Public Health Jail Medical Services. AIDS Education and Training in Community Corrections Services 35 10. 11. 12. 13. . “Facts About AIDS and Drug Abuse,” American Red Cross and the U.S. Public Health Service, October 1986. . “Alcohol, Drugs and AIDS/Alcohol, Drogas y AIDS,” San Fran- cisco AIDS Foundation and Department of Public Health, July 1986. . “AIDS: A Bad Way to Die” (videotape). Copies available without charge by sending a blank VHS cassette with self-addressed mailer to Charles Hernandez, Superintendent, Taconic Correc- tional Facility, 250 Harris Road, Bedford Hills, NY 10507, (914) 241-3010. “Dying for Love” (videotape, $40). Available from Lifetime Productions, Inc. (212) 719-7162. . “Brief Risk Intervention,” Cook County, Illinois. Draft. 1988. . “AIDS and Your Job: Are There Risks?” and “If Your Test for the Antibody to the AIDS Virus is Positive,” American Red Cross and the U.S. Public Health Service, October 1986. “Straight Talk About Sex and AIDS,” San Francisco AIDS Foundation and San Francisco Department of Public Health, 1987. “AIDS Kills Women and Babies.” . AIDS Policy Guidelines for Probation Departments and Alternative Programs, Division of Probation and Correctional Alternatives, Executive Department, State of New York. Notebook. . “AIDS: The Challenge for Corrections” (videotape). Developed by National Sheriffs Association (NSA); $25 to rent or $110-175 to purchase; available in Spanish or English. NSA, 1450 Duke St., Alexandria, VA 22314; (703) 836-7827. “Information for Law Enforcement Officers” (videotape). Available from San Francisco Police Department (415) 553-9777, or from AIDS Hotline (415) 864-4376, x2036. “AIDS Memorandum No. 1,” Commonwealth of Kentucky Corrections Cabinet, February 14, 1986. “Training Curricula,” State of Missouri Department of Corrections and Human Resources, March 1988. “AIDS Policy Guidelines for Probation Departments and Alternative Programs,” Division of Probation and Correctional Alternatives, Executive Department, State of New York, Albany, NY., 1987. . Ibid. . “AIDS Memorandum No. 1,” op. cit. . “Justice Policies,” State Capitals Newsletter (New Haven: Wakeman/ Walworth) August 17, 1987: 41:33. . “Questions and Answers About the HIV Blood Test,” County of San Diego Department of Health Services, April 1987. . T.M. Hammett, AIDS in Correctional Facilities: Issues and Options, Third Edit.on (Washington, D.C.: National Institute of Justice, U.S. Department of Justice, 1988). 36 AIDS IN PROBATION AND PAROLE Chapter 5: CONFIDENTIALITY, LEGAL, AND LABOR RELATIONS ISSUES This chapter is divided into three sections. The first examines the issue of notification and disclosure, that is, who receives or should receive information on the HIV status of individuals under community corrections supervision. The second discusses the growing case law on AIDS as it applies to probation and parole depart- ments. The concluding section provides summary guidelines for developing policies to protect confiden- tiality and minimize the liabilities of parole and pro- bation services. Notification and Confidentiality The need to form policies regarding disclosure of HIV antibody test results and notification of an AIDS or ARC diagnosis gives rise to some of the most pressing decisions that parole and probation services face. Com- munity corrections staff often argue that they have both a need and a legal right to know test results, because of the perceived health risks associated with not know- ing, the potential liabilities for failing to provide necessary services, and the failure to notify and thus prevent HIV infection of a third party. Seropositive in- dividuals conversely assert their right to privacy. While there have been no cases brought specifically against community correction agencies or officers, it is reasonable to assume that indiscriminate circulation of a client’s HIV status might entail a serious risk of liability. Decisions regarding confidentiality and disclosure may be governed by state law or policy standards. Califor- nia, for example, requires written authorization to release test results or other medical records. More often, however, there is room for discretion, and community corrections services face conflicting demands. Community corrections administrators may feel a need to know test results in order to make informed classification and programming decisions. Probationers or parolees suffering from AIDS or ARC often do have special needs in obtaining medical attention, employ- ment, housing, counseling, or other support services. In these cases, officers may have a legitimate need to know in order to secure the necessary services. Notifica- tion to public health departments, other agencies within community corrections (such as residential facilities), or third parties, such as spouses, sexual part- ners, employers, or family are all considered important in releasing clients into the community responsibly. Disclosures may also reduce the system’s legal liability should a probationer or parolee transmit HIV infec- tion to others. On the other hand, the most compelling reason for maintaining confidentiality is that persons known to have AIDS, ARC, or asymptomatic HIV infection may suffer discrimination in employment, housing, or in- surance coverage, as well as possible ostracism by the community, family, or friends. Again, there is also the danger of complacency or a false sense of security if it is assumed that all those infected have been iden- tified. By contrast, if “universal” blood and body fluid precautions are routinely followed, knowledge of an- tibody status will be unnecessary to protect staff from infection. Overview of NIJ Survey Results As preceding sections have reported, there are only a handful of community corrections systems that are cur- rently testing or planning to test clients for HIV an- tibodies. Only three agencies currently do any systematic testing of parolees and two others are con- sidering instituting testing. Five probation systems cur- rently test some probationers and five plan to begin selective testing programs in the future. As discussed in Chapter 3, however, most agencies do have access to test information from other sources. Thirty percent of the systems surveyed have access through prior in- carceration records and 21 percent have access through medical reports. Few community corrections systems have specific policies regarding the disclosure of HIV antibody test results. Only 21 percent of the probation agencies and 16 percent of the parole systems answered questions concerning disclosure of clients’ HIV antibody test results. Again, it must be emphasized that the lack of a response to this question cannot be assumed to in- dicate a lack of a policy. Survey results indicate that when this information is available, some parole or pro- bation officers, physicians, other medical staff, and departments of public health will be informed. Seven percent of the systems surveyed formally inform the officer and 5 percent formally notify the attending physician. Seven percent surveyed officially notify the department of public health, as is often required by law. Only one probation system and one parole system —both in Georgia —routinely disclose this in- Confidentiality, Legal, and Labor Relations Issues 37 formation to an individual’s spouse or family, and no systems report that they inform employers. Range of Legal Options Regarding Who Receives Information Sixteen states reported state laws governing notifica- tion. The laws vary widely in their restrictions on disclosure, from severely limited to more lenient. Many states, including California, Florida, Illinois, Massachusetts, Oregon, and Wisconsin, have very restrictive laws regarding disclosure of HIV antibody test results. Under California law, only the subject is entitled to the results of the test unless he or she pro- vides written authorization for their disclosure; writ- ten consent is also required for each subsequent disclosure. Without written consent, no one may iden- tify the subject or divulge the results of any test. Test results are not subject to disclosure under California’s employer “right-to-know” law and may not influence any decision regarding employment or insurability. In California, for example, blood banks and plasma centers submit monthly reports summarizing data con- cerning HIV antibody tests, but reference to the iden- tity of individual donors is prohibited. Under Wisconsin’s law, only the subject, the subject’s physician, laboratory personnel or other staff of health- care facilities, and the state epidemiologist can legally receive results of HIV antibody tests. A court order is required for all other disclosures. Therefore, in states such as California and Wisconsin, community correc- tions staff who are not health-care personnel have no right to obtain test results. Medical staff, in particular an individual’s attending physician, have an obvious need to know HIV antibody test results for diagnostic and treatment purposes. These individuals are in a crucial position for main- taining the confidentiality of this information within a correctional environment, as they may be the only persons legally authorized to obtain and disclose this information. If community corrections authorities are notified of a client’s HIV seropositivity, the informa- tion often comes from correctional medical staff where the individual has been incarcerated. Many community corrections services argue that both administrators and line officers need to know the results of HIV antibody tests in order to make classification and programming decisions and to pro- tect themselves and the community from infection. The argument that an officer might need to know the HIV antibody test results of an individual under supervi- sion rests on the need for that information in order to provide the necessary services: financial, housing, 38 AIDS IN PROBATION AND PAROLE legal, medical, or counseling. It is essential, however, that policies define carefully who needs to know what and why. Universal precautions with all clients are ade- quate for the protection of staff in their day-to-day duties so that officers not associated with a client have no real need to know his or her HIV antibody status. On the other hand, directly supervising officers con- cerned about provision of medical services or protec- tion of third parties may feel strongly that they need to know. Because community corrections systems have few and usually broad policies regarding disclosure of information on HIV infection, every effort should be made to formalize procedures as precisely as possible. Vagueness inevitably causes problems, and while it may help protect the agency from liability, it serves only to increase the potential liability of an officer. Moreover, policies should be both reasonable and en- forceable, as an officer may be liable for not enforc- ing agency guidelines. For example, a condition of supervision prohibiting the transmission of bodily fluids (through unprotected sex, donation of blood, etc.) may place an impossible responsibility on officers to monitor the most intimate behaviors of clients. Few community corrections services are aware of or could become aware of an individual’s HIV antibody status, barring self-disclosure or evidence of either clinical indications or high-risk behaviors. However, most systems require that pre-sentence reports include a description of the offender’s mental, psychiatric, and physical condition. In New York State, the investigating probation officer looks for possible signs of AIDS or ARC when compiling such reports. If a defendant states that he or she has AIDS or ARC or if this infor- mation is passed on to the officer by a third party, the source and circumstances of the disclosure are record- ed, along with an assessment of its reliability. If it is suspected that a defendant has AIDS or ARC, despite the absence of substantiation, guidelines suggest that the officer explain to the defendant why it is impor- tant that this information be communicated to the agency, although the officer must be careful not to deny the defendant his or her right to privacy.’ The New York state guidelines for probation departments are in- cluded in Appendix G. In the case of parole, if the offender has previously been incarcerated, the same prison systems notify the parole board of an individual’s HIV antibody status. Although only a few prison systems conduct mass screening, many test on a limited basis —when clinical- ly indicated, on request, or if inmates are believed to be at risk. A number of correctional systems, including Missouri, Maine, Iowa, and New York, routinely notify community corrections authorities of an individual’s HIV antibody status. This information is often included in the medical report, as are diagnoses of AIDS or ARC, to insure treatment or to secure other necessary services. New York State provides for a formal exchange of medical information. The Department of Corrections provides institutional parole staff with medical discharge summaries. These reports include a diagnosis of the parolee’s condition, a reference to living ar- rangements and employability where dictated by his or her current medical condition, an indication of whether the inmate has accepted his or her condition and is cooperating with treatment, and whether there is any need to develop or continue treatment. The Depart- ment of Corrections sends the Director of Parole a list of all inmates diagnosed with AIDS or ARC. In turn, senior parole officers receive a list of all those under parole supervision who have developed ARC or full- blown AIDS.’ The notification of the infected individual’s supervis- ing officer is based on the need to provide special services. It would be difficult to argue that all officers have a right to know when they are working with HIV- infected individuals based solely on a perceived health risk, since AIDS cannot be transmitted through normal officer-client interaction. As long as standard blood and body-fluid precautions are followed, the officer has little or no risk of infection. AIDS education and train- ing and documented precautionary policies can suc- cessfully alleviate unfounded fears of HIV infection on the part of staff who are not directly involved in providing services. Notification of Other Criminal Justice Agen- cies, Public Health Departments Opinions vary on the need to notify other criminal justice agencies. The study highlighted two concerns in particular. One is whether it is necessary to inform residential facilities of a client’s HIV antibody status. If these facilities segregate seropositives, disclosure could be required or strongly advised prior to place- ment. Alternatively, as is the case in Texas, parolees may be required to submit to an HIV antibody test prior to placement, and if they test positive, they may be refused placement. Jurisdictions with such policies de- fend them as efforts to protect a correctional institu- tion from potential liability should staff or other in- dividuals at the facility become infected. States that have special housing requirements include Wisconsin, Florida, Texas, Colorado, New Hampshire and Georgia. There is, of course, the potential liability from exclusion or special treatment of these clients inherent in this policy. Another consideration is whether or not community corrections services should inform local police or other law enforcement officers of HIV-infected individuals under their jurisdiction. Some services, including New York, Massachusetts (to a limited degree) and Iowa have made specific provisions for disclosure to local jurisdictions in the event that an individual violates probation or parole and a warrant is filed for his or her arrest.” In some jurisdictions, the specific diagnosis may not be revealed, but officers may be warned to “take normal precautions,” or they may be given vague disclosures regarding “infectious diseases” or “blood-borne diseases.” While technically these warnings maintain confidentiality, since they can apply to diseases other than AIDS, they may in actuality be thinly-veiled codes. Because following “universal precautions” for blood-borne diseases should protect the arresting officer from infection, there may be no real argument in support of such policies. Six percent of probation systems and 6 percent of responding parole systems routinely notify public health agencies when a client is known to be seropositive. Some states, including Colorado, Nevada, and Louisiana, have laws requiring notification of public health departments. Others, such as California, have laws requiring that summary, statistical informa- tion be reported without revealing a subject’s identity. Under the Colorado law, all positive HIV antibody tests must be reported to state and local public health agen- cies. The law is designed to alert public health authorities to the presence of potentially infectious in- dividuals and to ensure counseling about test results and preventive measures. However, in Colorado, this information is to be held in the strictest confidence and is not disclosed to insurers or employers without per- mission of the subject.’ Notification of Sexual Partners, Spouses, Employers Notification of sexual partners presents one of the most difficult problems for supervising officers. Many com- munity corrections administrators feel that they may have a moral responsibility to notify the spouse or sex- ual partner(s) of probationers or parolees with HIV- related conditions, when there is evidence that the in- dividual will not assume that responsibility. The real question is whether community corrections systems should take on a responsibility that is not required of institutions in the community at large, or whether they should rely on AIDS counseling and education to per- suade clients to reveal their status to partners. Some states require that an inmate give his or her writ- ten consent for disclosure to the spouse, in order to Confidentiality, Legal, and Labor Relations Issues 39 be eligible for parole. There are serious legal issues raised by such a policy, since mandated disclosure may contradict a constitutional right to privacy. Instead, in an effort to minimize the risk of liability, some agen- cies adopt written policies requiring the physician, health-care provider, or officer who may know of an individual’s HIV seropositivity to counsel him or her. These providers or officials would advise the individual of the responsibility to inform all sexual partners of his or her medical condition, to use safer-sex techniques and, if relevant, not to share needles and to disinfect them properly. In cases in which subjects refuse to inform their spouse or sexual partners of their HIV status, the Federal Division of Probation and the American Parole and Probation Association recommend that community corrections officers refer the matter to the public health authorities. However, if after consultation with public health authorities an officer determines a specific, medical risk to a third party, and the public health department is unable or unwilling to make such a disclosure, and state or local law does not prohibit such a disclosure, the officer should provide a “discrete and confidential warning.” Recent CDC guidelines similarly suggest that if an infected individual refuses to notify his or her sexual partners, the health-care professional should consider making a confidential disclosure. A recent law in California permits physicians to notify the spouses of HIV-infected persons. Community corrections systems should make sure that they are aware of state and local confidentiality laws before instituting policies govern- ing third-party disclosures. Such guidelines must be precise, avoiding vague wording that leaves decisions to the “discretion of the officer” or to examination on a “case-by-case” basis. Since AIDS cannot be transmitted casually, an employer cannot argue that a probationer or parolee poses a threat to the health and safety of others in the workplace. It is unlawful for an employer to discriminate against an employee who is HIV antibody- positive, unless that individual is incapable of perfor- ming the tasks required of the job. Therefore, there is no need for community corrections officers to disclose HIV status information to an employer. In fact, agen- cies may be held liable for defamation or invasion of privacy if the probationer or parolee is discriminated against in a work environment or refused employment as a result of the disclosure. Legal and Labor Relations Issues Currently, legal issues pertaining to the treatment of AIDS cases in probation and parole systems are 40 AIDS IN PROBATION AND PAROLE theoretical, as no cases have been filed. However, an examination of the rapidly growing case law on AIDS, in particular as it relates to AIDS in a correctional en- vironment, may clarify the legal issues and liabilities facing community corrections services. This section summarizes case law and legal and labor relations issues raised by probationers and parolees, and by staff. Issues Raised by Probationers and Parolees e Challenges to parole eligibility e Discrimination against those with HIV infection/AIDS e Special conditions for those with HIV infection/AIDS e Challenges to segregation in residential facilities e Challenges to HIV antibody testing e Confidentiality of medical information Issues Raised by Staff e Community corrections’ liability for third- party HIV infection e Testing in response to potential transmis- sion incidents e Labor relations issues e Obligation to perform duties Challenges to Parole Eligibility It has been argued that inmates with AIDS should re- main under the correctional system’s medical care, without parole or pre-release placement in halfway houses or community-based programs, in order to en- sure proper care, to minimize the risk of HIV transmis- sion, and to reduce potential liabilities faced by the system. The question is whether or not a parolee’s physical condition should alter sentences which were originally mandated by criminal acts and whether or not there are any legal implications associated with such a policy. Persons who are mentally ill and who pose a threat to society or to themselves may be legally removed from society at large and may be committed for extended periods of time. The case of a person with AIDS, however, is very different as the danger of transmis- sion rests largely on consensual acts rather than forci- ble victimizations. The violent sexual offender is, of course, the exception; he may require special efforts to ensure rehabilitation prior to release. When determin- ing an inmate’s eligibility for parole, it would seem reasonable to make an assessment of his or her medical condition as well as an assessment of the likelihood that he or she would engage in violent or other non- consensual acts by which the infection might be transmitted. However, it is unlikely that medical factors alone could legally warrant extending incarceration. Early release and executive clemency are being con- sidered by some states as the number of persons with AIDS in correctional facilities rises. No states currently report an early release policy for persons with AIDS, though all may use the discretionary early release pro- vision for illness. Although it may seem reasonable for an officer to recommend early discharge for a parolee dying of AIDS, such a recommendation, based solely on humanitarian reasons, may not be consistent with criteria established by law. Most states have laws dictating early discharge from community corrections services, depending on whether the individual has diligently complied with the conditions of the sentence, whether his or her release would jeopardize public safety (from criminal behavior, not from disease), and whether he or she is in need of continued guidance or other assistance as provided through community cor- rections services.” While early release of individuals with AIDS or ARC is not necessarily recommended except in special cir- cumstances, there may be legal grounds for establishing such special conditions for those with AIDS, ARC, or asymptomatic HIV infection. Community corrections services could be held liable if, as a result of supervi- sion, a client is subject to conditions that adversely affect health. In this regard, an individual’s medical condition might warrant changes or exceptions to supervision requirements. Persons with AIDS or ARC may experience periods of severe debility or illness, re- quiring hospitalization or periods of recuperation, during which time home visits may be the only reasonable method for making personal contacts. AIDS diagnosis alone is not necessary and sufficient to mandate reclassification, although a client’s health may factor into such decisions. Discrimination Against Probationers or Parolees with AIDS In October, 1988, the U.S. Department of Justice was asked to issue an opinion on the scope of the existing anti-discrimination provisions of the federal Rehabilitation Act of 1973. This act prohibits federally funded employers from discriminating against employees with handicaps, provided they are otherwise qualified to work. It was unclear, however, whether both persons ill with AIDS and asymptomatic HIV carriers were protected. The Justice Department’s opinion stated that the first group, those ill with the disease, were clearly protected according to the decision of the U.S. Supreme Court in School Board of Nassau County v. Arline (1987). The Court ruled that a contagious disease —in this case, tuberculosis —is a handicap protected by the Act. Notably, the court rejected arguments that fear of transmission was grounds for dismissal: “It would be unfair to allow an employer to seize upon the distinction between the effects of a disease on others and the effects of a disease on a patient and use that distinction to justify discriminatory treatment. [The...] basic purpose [of the Act is] to ensure that handicapped individuals are not denied jobs or other benefits because of the prejudiced attitudes or the ignorance of others.” The Justice Department opinion concurred with the Court and took the further position that even asymp- tomatic HIV-infected individuals should be protected. The Office of Legal Counsel, which prepared the opinion, said it was guided by information from the Surgeon General. He contends that even asymptomatic HIV-infected individuals are “physically impaired,” from a medical standpoint, and adds that the impair- ment of HIV infection cannot meaningfully be separated from clinical AIDS. Thus the Justice Department concludes that both those with full-blown AIDS and those asymptomatic but in- fected are included in the definition of handicapped for the purposes of the Act. The Department mentions further grounds for including the latter group: the Supreme Court concluded in Arline that “if a person is perceived by others as having a handicapping con- dition . . . that in itself could bring the person within the terms of the Act.” In conclusion, the opinion reiterated earlier statements that HIV-infected employees should be treated on a case-by-case basis. So long as they pose no “threat to the health or safety of others [and are not] unable to perform the job,” the Department feels employees should receive full federal anti-discrimination protection." In New York it is illegal to discriminate against a person with asymptomatic HIV infection, ARC, or AIDS. Last year in New York, the state Supreme Court ruled that AIDS is a disability and that individuals with AIDS, ARC, or asymptomatic HIV infection are pro- tected by the New York State Human Rights Law (Ex- ecutive Law Art. 15) which prohibits discrimination against persons who are disabled or who are perceived Confidentiality, Legal, and Labor Relations Issues 41 to be disabled. AIDS has been characterized as a han- dicap in several other cases as well." As the trend is towards treating AIDS, ARC, and HIV antibody positivity as protected handicaps, it would seem that community corrections services must afford those with AIDS all the rights and opportunities available to others, and in particular, that discrimina- tion in housing or employment would be unlawful. Special Conditions of Supervision In an effort to protect themselves from the threat of third-party liability, some agencies suggest imposing special conditions on HIV-infected individuals. Some advocate conditions which prohibit contact with bodily fluids of HIV-infected individuals. However, as we will discuss in Chapter 6, the United States Parole Com- mission and the Federal Division of Probation main- tain that to impose such a condition inappropriately extends the role of community corrections from the prevention of crime to the prevention of disease. Moreover, such a condition places the responsibility on officers to monitor the most intimate behaviors of their clients. As such it is perhaps an unenforceable condi- tion, which serves only to further the liability of com- munity corrections officers in the event of injured third parties. Only one state, Georgia, imposes such specific prohibitions as conditions of supervision. Some agencies, including Georgia and Tennessee, re- quire that infected clients disclose their status to spouses, prospective sex partners, or other persons in danger of being infected as a condition of parole or probation. A compelling argument against such a con- dition is that in many states, non-voluntary disclosure constitutes violation of state law. The Federal Division of Probation maintains that mandated disclosure as a condition of supervision by clients who have been exposed to HIV “is an unwarranted intrusion by criminal justice into the public health arena without any medical evidence that it would have any effect whatsoever on the AIDS epidemic.”” However, the Federal Parole Commission suggests disclosure to third parties at risk in states where it is permissible. Another condition of supervision used in some states is participation in AIDS education and training for probationers and parolees who are HIV-infected. As previously discussed, under most circumstances com- munity corrections authorities are not permitted to disclose an individual’s HIV antibody status to third parties. Thus, identifying persons for participation must be handled judiciously. It may be reasonable, for example, to establish a special condition requiring the successful participation of all clients in AIDS education, counseling, and treatment programs. 42 AIDS IN PROBATION AND PAROLE Alternatively, such participation could be required of persons with a history of IV drug use, or sexual of- fenses. Unlike other conditions, this one is rehabilitative and supportive in nature, a role with which communi- ty corrections authorities may be more comfortable. Challenges to Eligibility and/or Segregation in Residential Facilities Residential facilities and prisons face similar program- ming decisions when attempting to ensure the health and safety of staff and individuals under their super- vision. When dealing with HIV infection and AIDS in a secure environment, systems have a responsibility to protect staff and inmates from transmission. Those who are HIV seropositive must also be protected from threats and possible violence as a result of their anti- body status. A brief examination of the existing case law for correctional facilities may clarify potential suits faced by residential facilities. Many correctional facilities have chosen to segregate inmates with AIDS, ARC, or asymptomatic HIV in response to these concerns and, as a result, have faced suits filed by segregated inmates alleging that condi- tions of their confinement violate equal protection standards and/or constitute cruel and unusual punish- ment. Although several cases remain pending, the courts have upheld the discretion of correctional of- ficials to segregate HIV-infected inmates and to deny them access to programs and privileges, such as rehabilitation or work-release programs, in an effort to advance medical, safety, and security objectives. In the context of community corrections, one could en- vision residential facilities faced with suits filed by narolees challenging their segregation at these facilities or their exclusion from these programs as a result of their HIV antibody status. In Cordero v. Coughlin,” a group of segregated in- mates with AIDS sued the New York State Department of Correctional Services alleging cruel and unusual punishment, deliberate indifference to their serious medical needs, and deprivation of equal protection of the laws, claiming that the conditions of their confine- ment produced depression and decline in their medical condition. The plaintiffs also argued that even though they had no absolute right to such things as rehabilita- tion programs, exercise or visitation, they were nonetheless entitled to equal access to those programs. The court held that inmates have no constitutional right to freedom from segregation enforced to further a legitimate institutional objective, in this case preven- ting HIV transmission. Any equal protection claims were denied because the court did not consider inmates with AIDS to be “similarly situated” as other inmates in the institution, as required by the constitution. A similar suit was filed in an Oklahoma case, Powell v. Department of Corrections." In this case, an HIV antibody-positive but asymptomatic inmate alleged that he was segregated from the general prison popula- tion and denied access to worship services and exer- cise. Despite the different medical conditions of the plaintiffs, the court reached the same conclusion as in Cordero that the segregation policy sustained correc- tional objectives of protecting staff and inmates from HIV infection. In addition, the court asserted that in- mates have no constitutional right to be in the general population and that the inmate was not denied equal protection, as he had not been treated differently from other seropositive inmates, even though he was the only identified seropositive inmate in the prison system. In Marsh v. Alabama Department of Corrections,” an inmate alleged that he was unconstitutionally segregated and disqualified from work-release pro- grams as a result of his HIV seropositivity. Citing Cor- dero and Powell, the court ruled in favor of the Alabama correctional system. Case law is quite exten- sive in this area and follows the patterns of the cases described here.'® In light of these decisions, it seems reasonable to ex- pect that the courts would rule in favor of community corrections services, in the event that a parolee were to file suit alleging that he or she was unconstitutionally segregated or excluded from a residential facility as a result of his or her HIV antibody status. However, the expense of segregation and its ultimate utility in deal- ing with transmission may make such a policy untenable. Challenges to HIV Antibody Testing To date, there have been no suits challenging man- datory mass screening for antibodies to HIV, although such a suit might result if HIV status became a widespread criterion for determining eligibility for parole. There have been, however, several challenges to other antibody testing situations. In Connecticut an inmate tried to prevent blind epidemiological studies of the incidence of HIV in the correctional population in the case of Durham v. Commissioner of Correc- tions," but the case was dropped by the plaintiff. In an Oklahoma case, an inmate claimed that he was tested against his will," emphasizing the care which must be taken to define procedures carefully before conducting any kind of testing. Numerous suits have been filed by inmates and staff of correctional facilities seeking mandatory testing and segregation of seropositives in order to ensure protec- tion from HIV infection; these cases may have some relevance to the issue of screening for residential place- ment. The courts have upheld, thus far, correctional systems’ policies not to institute mass screening, and are likely to be consistent in cases involving residential facilities." Confidentiality of Medical Information As of yet, there have been no suits filed by clients or staff challenging the disclosure or the confidentiality of medical information regarding AIDS and HIV in- fection in a community corrections environment. As has been the case with inmates in correctional facilities, probationers or parolees may challenge the disclosure of information about their HIV status. As the risks of transmission associated with confinement are not present for community corrections services, a client may well be able to invoke his or her right to privacy and build a potentially strong case against the agency and/or the officer responsible for making an unauthorized disclosure. Additionally, a probationer or parolee could have grounds for claiming mistreatment, defamation or psychological hardship or damage as a result of the disclosure. Recent legislation suggests that an exception to such a ruling may be cases involving disclosure to spouses. For example, California has enacted laws per- mitting physicians to disclose a patient’s HIV antibody status to his or her spouse. Should an individual refuse to inform a spouse of his or her medical condition, an agency may well have firm legal grounds for making a confidential disclosure. On the other hand, there may be instances in which community corrections staff try to obtain lists of all seropositives within their system. Two such suits have been filed by staff of correctional facilities, one per- mitting and one limiting such disclosure. In Delaware, a group of inmates claiming to have had homosexual relations with an HIV-infected inmate volunteered to be tested with a guarantee of confidentiality. In response, officers filed a union grievance claiming that based on a provision of their contracts, they were entitled to know which inmates were “suspected of having any communicable disease.” The court ruled that the correctional system, abiding by the terms of the contract, must disclose the names of the seropositives.”’ In Nevada, however, correctional officers have made several attempts to gain access to similar lists. The state’s attorney general issued an opinion that disclosure was limited to those who “have a legitimate medical need to know in connection with the prevention and control of “AIDS.” Confidentiality, Legal, and Labor Relations Issues 43 Issues Raised by Staff: Community Correc- tions’ Liability and Concerns One of the most serious legal concerns for communi- ty corrections services is the threat of liability should staff, probationers or parolees, or members of the community become infected with HIV as a result of contact with an infected individual. A federal district court judge noted that, in the case of prisons, “prison officials might face a §1983 suit for failing to isolate a known AIDS patient or carrier, if the carrier infects another inmate who could show that such failure to isolate constituted grossly negligent or reckless conduct on the part of such officials.” Plaintiffs alleging HIV infection as a result of negligence face two serious problems. First, with the possible exception of blood transfusions and spouse infection, it is very difficult to link a particular incident to transmission. And secondly, as community correc- tions systems cannot be expected to monitor the most intimate acts of their clients or to enforce behavior changes, it would be difficult to establish that an agency or officer was negligent in allowing the incident to occur. To avoid potential liability, community corrections ser- vices should attempt to prevent high-risk behavior among clients through AIDS education and training, particularly for those at risk of infection, including homosexuals, drug users, and sex offenders. All clients who are known to have AIDS, ARC, or asymptomatic HIV infection should be counseled regarding their responsibility to inform sexual partners of their medical condition. And, as previously discussed, in the event that a client refuses to make such a disclosure, the agency should consider making a confidential disclosure in keeping with laws and/or policies of the jurisdiction. Residential facilities, like correctional facilities, may be held liable for damages resulting from homosexual rapes and other assaults.” However, correctional facilities have not been held liable for insuring the absolute safety of persons in their custody. In several cases, the courts have ruled that a facility can only be held liable for assaults it knew or should have known would occur.” Although no cases of this kind have been filed, com- munity corrections services may also be concerned with the liability involved should an employee be infected by a probationer or parolee under his or her supervi- sion. Systems are not mandated by law to insure the absolute safety of their employees, but are only held to a reasonable standard of care. An agency is not liable for injury incurred in the line of duty unless procedures 44 AIDS IN PROBATION AND PAROLE are violated or the department is found to be other- wise negligent. While worker’s compensation might well apply, negligence on the part of the agency would also have to be established in the case of HIV infection. Inadequate AIDS education and training or poor precautionary guidelines against HIV infection could be sufficient to establish such negligence. Training and procedures should be well-documented as protection against future lawsuits. The question of whether or not an individual may be compelled to be tested for HIV antibodies following an incident in which transmission may have occurred is complex. Some jurisdictions prohibit mandatory testing and it can be argued that forced testing violates a person’s Fourth Amendment protection from search and seizure. Some recent state-level legislation suggests, however, that persons involved in aggressive or negligent acts can be required to undergo testing. For example, judges may issue a court order requiring testing and disclosure in special cases. In Houston, Texas, court orders requiring testing have been issued to sex offenders.” In Florida, search warrants are issued for “examinations” of persons with sexually transmitted diseases, including AIDS.” Notably, at least two such cases have been decided in favor of the defendant. A Massachusetts trial judge ruled that an inmate who had allegedly scratched and spit on a guard could not be required to undergo HIV antibody testing based on a state law prohibiting forced testing and disclosure as well as on medical evidence against HIV transmission through saliva.”’ Similarly, a California court revoked a search warrant authoriz- ing HIV antibody testing of a defendant charged with biting a police officer, based on a state law prohibiting the disclosure of test results without the subject’s in- formed consent.” Staff of community corrections services express two major concerns regarding AIDS. The first is the possibility of HIV transmission in the course of their jobs, and the second is the threat of personal liability as a result of actions taken or not taken regarding clients with AIDS, ARC, or asymptomatic HIV infection. While survey results indicate that few community cor- rections staff have taken concerted action regarding HIV infection on the job, correctional facilities have had complaints, particularly by those working in special AIDS units, and have received demands for “hazardous duty” pay and/or reduced working hours. These fears —and demands —can only be addressed through AIDS education and training and through written policies which outline an agency’s response to incidents in which transmission may have occurred. In one case reported in the NIJ survey, staff refused to participate in urinalysis testing procedures due to fear of HIV transmission from probationers and parolees. An education and training program took place and the issue was settled. In another instance, staff took con- certed action to obtain training from the agency. In a third reported case, officers attempted to pressure the parole department to release HIV status of parolees under their supervision. No full legal action was pursued. A frightening prospect for staff is the possibility of a lawsuit filed against a community corrections officer. Should such a case be filed, 75 percent of probation and 77 percent of parole agencies surveyed report that they would provide defense for the officer who acted within the line of duty; a few others would provide defense in all circumstances. Some systems (44 percent of probation and 35 percent of parole) have liability insurance to cover officers who are sued. Forms of coverage include state indemnification statutes, com- prehensive general liability, or state insurance funds for risk management. In a limited number of jurisdictions, self-insurance is also available. In most cases an officer’s concerns can be alleviated through written policies which describe how agencies will respond to a lawsuit. Few agencies have state or local guidelines explaining potential criminal or civil liabilities. However, 44 percent of probation systems surveyed and 36 percent of the parole systems surveyed disseminate information to agency staff concerning general representation and damages. Obligation to Perform Duties Survey results indicate that only three probation systems and one parole system have faced potential work disruptions as a result of staff members who have refused to work with HIV-infected clients. In general, agencies have taken the position that fear of AIDS does not excuse employees from performing duties, as there is a very low risk of HIV infection associated with occupational activities. In response to the San Francisco Sheriff’s Department request for a legal opinion as to whether officers were required to render CPR to inmates known or suspected to be HIV- infected, the city attorney’s office asserted that deputies have an unequivocal responsibility to provide CPR whenever necessary, as failure to do so could make the city liable for any resulting injury and subject the employee to disciplinary action.” Pregnant staffers, however, are an exception to this rule. In California, for instance, no pregnant women may be assigned duties involving the supervision or care of persons with AIDS. This is because of the risk of ex- posure to cytomegalovirus (CMV), commonly found in persons with AIDS, which can cause birth defects. Precise and accurate AIDS education and training, coupled with policies calling for swift disciplinary action should an employee refuse to perform his or her duties out of fear of AIDS, can effectively allay most concerns and disruptions among community correc- tions staff. Legally, an employee cannot refuse work in other situations because of personal bias, such as work with a handicapped, female, or minority co- worker. Though not tested in the courts, the rulings may hold true for refusal to work with a co-worker or client with AIDS. Policy Recommendations In this chapter we have reviewed some of the legal issues involved in dealing with AIDS in community correc- tions. In the following sections, we summarize some of the key questions and answers. o What are the legal guidelines for disclosing the HIV status of someone under supervi- sion to third parties such as spouses, other family members, potential residential placements or employers? Each state has different laws regarding confidentiali- ty of HIV status information. Many states require mandatory reporting to Public Health Departments by medical personnel identifying the condition; this does not include reporting by or to community cor- rections services. Community supervision staff should seek legal verification of the confidentiality and disclosure statutes in their state before any disclosure or special placement is made. For example, in most states staff may not disapprove a client’s residence plan if he or she refuses to disclose HIV status to the person with whom he or she will be living. Such a disapproval could be seen as a viola- tion of the right to confidentiality. o Can staff refuse to supervise or work with HIV-infected persons? No. Refusal to work with AIDS-infected persons could be interpreted as discrimination if the infected individual is otherwise carrying out his or her obliga- tions, either job obligations or the requirement to report for supervision. Only in the case of a pregnant supervisory officer might this refusal be allowable. e What is the best protection against third- party suits in community corrections? Suits can be mounted against corrections staff on grounds such as inappropriate disclosure of HIV Confidentiality, Legal, and Labor Relations Issues 45 status, failure to disclose with resultant third-party injury, or damages due to inadequate medical management resulting in injury. Detailed disclosure guidelines for protection of confidentiality and documented training in those guidelines provide the best protection in these instances. Similarly, the problems of inadequate medical management can be alleviated by training of staff in AIDS informa- tion and referral systems available. Failure to disclose, while troubling to many supervisory staff, is a problem generally dealt with by restrictions of state and federal law. Can I require testing for an individual whom I suspect is HIV antibody-positive and who is involved in a transmission incident? This depends on your state’s laws. Some agencies currently can obtain a court order in cases of transmission incidents which can be used to force HIV antibody testing. Careful examination of the incident is urged prior to such action. For example, is it an incident in which a real risk exists, as in a rape, or a negligible or non-existent risk, as in a biting or spitting incident? It may be more prudent to have the victim tested for a six-month period than to avoid possible legal action from the offender. Can state residential placement facilities refuse to house HIV antibody-positive parolees? Again, depending on state law, this may be legally possible. Case law nationally has upheld segrega- tion of persons with AIDS in prisons and jails. A more cautious approach, however, argues that all individuals be treated as though seropositive since there is no way to determine the HIV status over time of the total population. Persons deemed acceptable at one point in time are possibly unacceptable (infected) at later points. These realities should be stressed to residential facilities, few of which have resources available for repeated testing of residents. NOTES L 46 AIDS Policy Guidelines for Probation Departments and Alter- natives Programs, State of New York Division of Probation and Correctional Alternatives, Albany, New York, 1987, p. 3. AIDS Information Guide, New York State Parole Operations, Albany, New York, April 1986, p. 11-3. Ibid., p. 111-11. Colorado: H.B. 1177, Chapter 208, 1987 Laws. AIDS IN PROBATION AND PAROLE 20. 21. 22. 23. D. Chamlee, Chief of the Federal Division of Probation, letter to Benjamin F. Baer, chief of the U.S. Parole Commission, September 29, 1987. . AIDS Policy Guidelines, Section 410.90 of the New York State Criminal Procedure Law; p. 16. . School Board of Nassau County v. Arline, 107 S. Ct. 1123 (1987). . DW. Kmiec, Office of Legal Counsel, U.S. Department of Justice, Memorandum, October 6, 1988. . School Board of Nassau County, op. cit. . Kmiec, op. cit. . Doe v. Charlotte Memorial Hospital, Complaint No. 04-84-3096 (August 5, 1986); Thomas v. Atacadero Unified School District, Civil No. 86-6609, U.S. Dist. Ct. (C.D. California, November 7, 1986); Shuttleworth v. Broward County, 639 F. Supp. 654 (S.D. Florida, 1986); American Federation of Government Employees Local 1812 v. U.S. Department of State, 25 Govt. Empl. Rel. Reptr. (BNA) 612 (U.S.D.C. D.C. No. 87-0121, April, 22, 1987). . Chamlee, op. cit. . 607 F Supp 9 (S.D.NY., 1984). . US.D.C., N.D. Oklahoma, Nos. 85-C-820-C and 85-C-816-B, dismissed February 20, 1986. . US.DC. -N.D. Alabama, No. CV-86-HM-5592-NE. Decided April 20, 1987. . Farmer v. Levine (US.D.C. -Maryland, 1985), No. HM-85-4284, 19. Magistrates Report dated May 28, 1986; Marioneaux v. Col- orado State Penitentiary, 465 F Supp. 1245 (1979); Johnson v. Fair (US.D.C. - D. Massachusetts, 1987). Civil Action NO. 87-0217 Mc; Williams v. Sumner 648 F. Supp. 510 (C.D. Nevada, 1986) Doe v. Coughlin 509 NYS 2d 209 (NY App. 1986). Buraff Publications, AIDS Policy and Law, December 2, 1987, 2:5. . Hartford District Court, Civil No. H-87-623. . Dunn v. White (U.S.D.C. - N.D. Oklahoma) No. 87-C-753-C. . For some examples see Wiedmon v. Rogers (U.S.DC., E.D., North Carolina), No. C-85-116-G; Maberry v. Martin (U.S.D.C., E.D., North Carolina), No. 86-341-CRT; Potter v. Wainwright (US.DC., Middle Dist. Florida), No. 85-1616-CIV-T15; Stalling v. Cave (2d Circuit, De Leon County); McCallum v. Staggers (5th Circuit, Lake County), No. 85-1338-CAOI; Bailey v. Wainwright (8th Cir- cuit, Baker County); Lloyd v. Wainwright (2d Circuit, De Leon County), No. 86-3144; Jarrett v. Faulkner, (US.D.C. S.D. In- diana), No. IP85-1569-C; Herring v. Keeney (U.S.D.C., Oregon), filed September 17, 1985, decided July 1987; Piatt v. Ricketts (US.D.C., Arizona), No. CIV-85-538-PHX); Foy v. Owens (US.D.C., E.D. - Pennsylvania, 1986), Civil Action No. 85-6909; Lareau v. Manson 651 F. 2d 96 (2d Cir. 1981); Bell v. Wolfish 441 U.S. 520 (1979); Estelle v. Gamble 429 U.S. 97 (1976). State Department of Correction v. Public Employees Council 82 (Del h. 1987), Civil Action No. 8462. AIDS Policy and Law, December 16, 1987; 2:5; Carson City Nevada Appeal, November 12, 1987, p. A-10. Judd v. Packard, (unreported opinion, U.S.C. D. -Maryland), Civil Action No. S 87-1514, September 24, 1987. Cites Withers v. Levine 625 F. 2d 158 (4th Cir.), cert denied, 449 U.S. 849 (1980). See Redmond v. Baxley 475 F. Supp. 1111 (U.S. D. C. E. Dist. Mich. 1979); Garrett v. United States 501 F. Supp. 337 (U.S.DC., N. Dist. Georgia 1980); Saunders v. Chatham County 728 F. 2d 1367 (11th Cir. 1982); Kemp v. Waldron 479 N.Y.S. 2d 440 (Sup. Ct. 1984); Thomas v. Booker 762 F. 2d 654 (8th Cir. 1985). 24. See Mosby v. Mabry 699 F. 2d 213 (8th Cir. 1982); O’Quinn v. Manuel 767 F. 2d 174 (5th Cir. 1985). . Manual of Policies and Procedures for Health Services, No. 3-39, October 1987, p. 6. . §796.08 Florida Statutes (Supplement 1986). See Aylesworth, G. and Knabe, R., “Warrant for Examination for Sexually Transmit- ted Diseases,” Florida Police Chief, December 1987, 13:63. . Dean v. Bowie, Suffolk Sup. Ct. (Massachusetts), Civil Action #87-4745. Barlow v. Superior Court 236 Cal Rptr. 134 (Cal. App. 4th Dist. 1987). “Deputy Sheriff’s Duty to Administer CPR,” City Attorney George Agnost to Sheriff Michael Hennessey, July 1, 1985. Confidentiality, Legal, and Labor Relations Issues 47 EN CO Chapter 6: GENERAL POLICY GUIDELINES ON AIDS FOR PROBATION AND PAROLE SERVICES The development of a policy response to AIDS in com- munity corrections requires the incorporation of infor- mation from all of the areas discussed in this volume. What constitutes an AIDS policy—in terms of both content and comprehensiveness — varies widely from state to state, and even within counties of the same state. For the federal parole and probation systems, AIDS policy is covered under the guidelines included in Appendix F. These guidelines, discussed below, follow CDC guidelines and recommendations and are meant to provide general guidance for federal parole and probation systems. Many states have begun to use the same process in developing policy — looking to the federal system or to public health sources for guidance and adopting general position statements on AIDS. Other AIDS policy packages are far more developed and specific. Some include comprehensive steps for disseminating information and making referrals, such as the New York State Parole Guidelines. Others, such as Georgia’s, provide specific conditions of parole and instructions for officers. This chapter reviews state and federal efforts in AIDS policy development for com- munity corrections and summarizes AIDS policy sug- gestions arising from this study. General AIDS policy statements and guidelines are addressed. Specific sug- gestions in the areas of education, legal issues, and testing can be found in each of the previous chapters. It should be emphasized that no single policy is ap- propriate for all jurisdictions. However, it is hoped that this document will aid in the development of a sound policy, tailored to the needs of each area. We begin with a discussion of three policy statements issued by three groups —the American Parole and Probation Associa- tion (APPA), the Federal Division of Probation, and the U.S. Parole Commission. American Probation and Parole Association At the August 1988 meeting of the APPA Board of Directors the “American Parole and Probation Position Statement on AIDS” (Figure 6.1) was adopted. This statement stresses the importance of local agency development of policies and/or procedures regarding AIDS training, precautionary measures, and confiden- tiality protection for use in community corrections settings. Written as a single-page, general statement, the APPA document recommends that all offenders receive AIDS information. In addition, it recommends special attention be given to IV drug abusers and others exhibiting high-risk behavior. It encourages informa- tion and presentation of testing options as part of an education effort both for staff and for probationers and parolees. With respect to disclosure of clients’ HIV status, the APPA suggests that inappropriate disclosure of an in- dividual’s status to any third party is a “violation of his/her right to privacy.” However, in cases in which individuals are continuing high-risk behaviors and en- dangering known third parties, correctional staff are urged to seek legal and supervisory assistance in deter- mining whether or not to disclose the clients’ HIV status. Finally, the policy emphasizes that probation and parole officers are never exposed to situations where transmission of the AIDS virus is likely in the routine daily performance of their duties and should not con- sider HIV-infected clients a threat to their own safety. In summary, the APPA statement emphasizes that: e AIDS education and training for all staff and clients is important and particularly critical in the case of drug-using offenders. ¢ Confidentiality procedures must be strict- ly followed and may be breached only after legal consultation and in the face of immi- nent threat to a third party. e Community corrections officers are not at risk of contracting the AIDS virus in car- rying out routine duties, if they follow stan- dard hygienic procedures. Federal Division of Probation and the U.S. Parole Commission Both the U.S. Parole Commission and the Federal Divi- sion of Probation have developed guidelines for the management and supervision of HIV antibody-positive probationers and parolees. Both sets of guidelines can be found in Appendix F. General Policy Guidelines on AIDS for Probation and Parole Services 49 Figure 6.1 AMERICAN PROBATION AND PAROLE ASSOCIATION POSITION STATEMENT ON AIDS Introduction Acquired Immune Deficiency Syndrome (AIDS) has emerged as a significant concern and challenge to correctional administrators. As the numbers of HIV positives, persons with ARC, and persons with AIDS continue to multiply, proba- tion and parole personnel must be aware of the implications of various actions and non-actions, confidentiality issues, and medical facts. Policies and procedures governing all facets of AIDS prevention and education must reflect best current medical and ethical practices. Discussion The American Probation and Parole Association supports the findings and recommendations of the National Institute of Justice in “AIDS and the Law Enforcement Officer” and “AIDS in Correctional Facilities.” While neither of these publications specifically addresses the unique issues faced by probation and parole officers, the detailed analysis assesses many of the major areas of concern expressed by staff. Education of all citizens about the dangers and means of transmission of the human immunodeficiency virus is a primary social objective. Offenders demonstrating high risk behaviors should be targeted for intensive educational efforts. Drug- abusers, in particular, should receive special attention and services. Other offenders should also be provided wath informa- tion about preventive measures and testing options. Disclosure of oftender medical information presents difficult ethical, legal and professional dilemmas. As a general rule, such information is confidential. When staff become aware that a specific offender is HIV-positive, disclosure to other parties without the subject's informed consent is a violation of his/her right to privacy. In special cases where there is evidence suggesting on-going high-risk behavior that might result in the infection of a third party. the right to privacy may be outweighed by a duty to warn possible victims. In such cases, staff should be encouraged to seck supervisory and legal assistance on a case by case basis. In the daily performance of their duties, probation and parole officers are rarely exposed to situations where viral transmission is possible. The only recognized means of contracting the AIDS virus is through blood to blood contact or seman to blood contact. Neither is likely to occur in the context of the probation/parole officer's job. Common hygienic procedures and recognition of high-risk behaviors and situations should be sufficient to prevent exposure. Officers may wish to carry rubber or surgical protective wear. The AIDS virus is not easily transmitted, and there is no evidence that professionals employed in law enforcement fields are at risk of contracting it, if standard procedures are followed. Position All jurisdictions should develop policies and procedures which stress regular training, utilizing the latest medical research; provision of appropriate safety and hygenic materials, equipment, and information; consideration of prevailing confidentiality statutes; and opportunities for staff to discuss issues of concern. Final adoption of this position statement will take place at the August 28, 1988 meeang of the APPA Board of Directors. For further informadon contact: Mr. Ben Jones, APPA, P.O. Box 11910, Lexington, KY 40579, (606) 252-2291. 50 AIDS IN PROBATION AND PAROLE A statement made during testimony by the U.S. Parole Commission Chairman, Benjamin F. Baer, summarizes the current position of his agency: [43 . . the Commission does not view itself, under its statute, as having the power to take action directed solely to protecting the public from the spread of AIDS, at least to the ex- tent that activity which would spread AIDS is not also criminal activity.” Guidelines for federal probation officers developed by the Judicial Conference Committee on Criminal Law and the Probation Administration for use by federal probation officers and pre-trial service officers outline recommended steps for managing persons who have been exposed to HIV or who have developed sympto- matic AIDS infection (see Appendix F). These guidelines suggest that an individual case plan be developed for the offender in cooperation with a resource person within the agency who is specially designated and trained for dealing with HIV infection. Education and Training Both federal policies stress the importance of AIDS education, counseling, and treatment in the offender’s re-entry into the community. However, federal policy for both probation and parole systems also stresses that the HIV infected offender should not be treated dif- ferently than others under supervision unless their medical condition requires special considerations. Similar to the APPA guidelines, both the federal parole and probation systems recommend that educational materials be made available to probationers. In addi- tion, they recommend that specially designated officers be trained in AIDS information and referrals and serve as an AIDS resource officer. This officer should be par- ticularly well versed in the state’s confidentiality laws. The Parole Commission also recommends AIDS in- formation/education for all parolees. In the case of parole, this programming in such programs could be made a condition of release for persons known to be infected or at risk. It can be argued that participation in such programming is both enforceable and in keep- ing with the mission of community corrections. Unlike monitoring private behaviors, monitoring actual par- ticipation in classes or treatment session could be ac- complished by correctional staff. Policy for disclosure to third parties. Federal probation. Disclosure of HIV status to sexual or drug partners remains with the individual supervised in the federal probation system, though supervisors are instructed to impress upon him or her the importance of self-disclosure and the possible criminal liabilities of non-disclosure to sexual/drug partners. As is true in states with strict disclosure regulations, the federal probation system requires informed, written consent of the supervisee before officers may disclose to fami- ly members, parents, or sexual/drug partners, if the supervisee refuses to disclose. The exception to this is, in those states which permit non-consensual disclosure to public health officials. Therefore, officers are instructed to disclose the HIV status of probationers only when informed written con- sent is obtained; in states which permit disclosure to public health officials, officers may disclose to this source, drawing on the ability of public health officials to further encourage the person to disclose his/her status to sexual/drug partners. The case of disclosure to criminal justice officials, residential placement facilities, halfway houses, and jails is somewhat different. Probation officers are in- structed to attempt to have the supervisee give his/her informed, written consent to release HIV status infor- mation to these sources. However, if he/she refuses to do so, they advise that this information be released to the U.S. Marshall when a warrant for violation of con- ditions of his/her release is issued and to the health care officials of a residential placement or jail facility when the person is put into its custody. Federal parole. The U.S. Parole Commission position states that it is appropriate to make a “discrete and con- fidential warning” to third parties in certain cases, after consultation with public health officials. In such cases, 1) the parolee is known to be infected; 2) a clear risk to a third party exists; 3) public health officials have been unsuccessful or unwilling to make a warning; and 4) state law does not prohibit such disclosure. Moreover, the Parole Commission recommends that if a violator warrant is issued for an HIV-infected in- dividual, the U.S. Marshal should be notified.” It is important to note that all staff are urged to gain per- mission from the parolee and, if permission is denied, only act within the individual state’s laws. Both Federal agencies recommend that supervisory of- ficers consult with public health authorities in their local areas to determine if disclosure to public health agencies is allowed under the laws of their state before any form of disclosure, even to those same public health officials. Both agencies also stress the need for con- fidential record keeping. Both supervisory staff are directed only to disclose to designated public health officials as allowed by state law; in addition, they are encouraged, if possible, to get written voluntary con- sent from the infected person to protect themselves ful- ly from problems related to unauthorized disclosure. General Policy Guidelines on AIDS for Probation and Parole Services 51 Maintenance of Records Federal probation. Information about a probationer’s HIV status may be unofficially disclosed or available to supervisors from a variety of sources — case records, third parties, etc. Before any further disclosure of this information, probation supervisors are instructed to get their written authorization of the probationer, in- cluding specific persons to whom the information can be released, i.e., sexual partners, medical services, drug treatment providers. In addition, they are instructed that all information related to the probationers HIV status should be kept in a separate section of his/her case record marked as confidential information. Pro- bation guidelines recommend that persons within the criminal justice agency who have this information should be limited to only those with direct supervisory responsibilities. This means that such information should not be included in pre-trial service or pre- sentence investigation reports unless it is related to the offense, such as in the case of sexual assault. However, courts may order complete disclosure of such infor- mation. In this case, the probation division recom- mends the officer provide it in confidence and with it state the defendant’s refusal to give consent for disclosure. Federal parole. The Federal Bureau of Prisons in- stituted testing of all inmates prior to release from federal prisons in June of 1987. Thus, the HIV status of new parolees may be known to federal parole of- ficers in some instances. It should be stressed that testing at release only gives the HIV status of the in- dividual at that time and cannot determine that he or she has not been exposed, nor predict that he or she will not, post-test, engage in risky behaviors and ac- quire the virus. However, protection of the confiden- tiality of test results is of paramount importance, and written procedures to insure that protection should be part of supervisor training. State level efforts: NIJ Survey Results Among the parole and probation agencies surveyed, few have written, formal policies regarding the manage- ment of clients with AIDS. For example, over 80 per- cent of the state or county parole systems report no formal AIDS policy. Many, however, are in the process of developing policies or statements and were interested in the existence of policies from other jurisdictions. Some areas report that their guidelines are developing piecemeal. For example, some states may distribute information on precautionary procedures to commu- nity corrections officers as part of education and train- ing or may copy state law on disclosure of HIV status information for distribution to officers, but do not 52 AIDS IN PROBATION AND PAROLE assemble the material into a policy statement or official set of guidelines. In states with county or regional ad- ministration systems, it is possible to find one county with detailed instructions for officers and a neighbor- ing one with no guidelines or even written educational materials available. Policies and guidelines vary considerably in terms of what they include. In some cases a policy covers everything from general education and training to disclosure procedures. In others, it is a brief statement or agreement of purpose. It is clear, however, that the policy decisions about AIDS in community corrections are interrelated. Education and training of staff, for example, is related directly to policies regarding precau- tions and legal issues about on-the-job infection. States in which there are large numbers of cases and/or large numbers of IV drug users are most concerned about placement, costs, and supervision of the AIDS-infected probationer or parolee. Areas in which there are only a handful of cases tend to focus on transmission into the community at large or educating staff and the com- munity to avoid undue fears. Specific restrictions policies Policies in which conditions of release or behaviors in the community are stipulated are the most specifically restrictive policies; that is, they limit the movement or behavior of the individual in some way because of his or her HIV status. The policy of the Georgia State Board of Pardons and Parole is an example of the restrictive approach. The Georgia policy has been in effect since 1986 and is being used as a model for con- sideration in many states. A copy of the Georgia policy and forms can be found in Appendix G. As of July 1988, Georgia Law requires that all inmates entering the prison system must be tested for the HIV antibody and by the year 1991, every inmate in the State correctional system will have been HIV tested. Prior to this time, testing was only conducted on inmates who exhibited symptoms of the disease or who requested to be tested. Also effective July 1988, Georgia Law authorizes the Georgia Board of Pardons and Paroles to order HIV testing of any inmate eligible for Parole. The Board has exercised this authority selectively for those whose medical profile or high-risk activities in- dicate a real possibly of infection. It is the Board’s policy not to discriminate against those who are HIV positive, therefore all eligible inmates are considered for parole. However, the Board does require that an HIV infected person demonstrate the following prior to release: e an awareness of the nature of HIV infec- tion and its modes of transmission; ® a sincere commitment to prevent transmis- sion to others; e a supervisory plan in accordance with the above goals; e a personal history indicating the feasibili- ty of these goals. The Board will not grant parole to HIV seropositive persons failing to meet these conditions, and it reserves the right to revoke parole if there is evidence of viola- tion of the conditions of release related to AIDS. HIV- infected inmates are interviewed prior to parole con- sideration to determine the level of risk they present to the community. The Board imposes several special conditions of release which it feels are "promotive of the well being of the HIV-infected individual, his family or co-residents and the general public.” These conditions, which the parolee must sign prior to release, include permission for the agency to disclose HIV status to the head of the household with whom he or she resides; proof of a level of knowledge about AIDS, agreement to undergo regular medical exams, promise not to engage in unsafe sexual activities or to donate blood, coopera- tion with public health officials, restraint of excessive use of alcohol and any use of illegal drugs, and restraint from tattooing. It is not required that the HIV-infected person disclose his or her status to an employer or pro- spective employer except in the instance where “the nature of the employment is such as to pose a real and immediate potential for injury to the person of the HIV-infected individual. Ordinarily, it will be deemed inappropriate for HIV-infected individuals to seek employment in a high-risk industrial position.” The parolee must also sign authorization for use of any medical information by “the State Board of Pardons and Paroles for all purposes necessary to confirm the health status of the undersigned (releasee), the employ- ment capabilities and status of the undersigned, and the compliance of the undersigned with the terms and conditions of the parole . . .”’ This authorization serves as written consent for disclosure to spouses or sexual partners should the parolee fail to or refuse to disclose. Disclosure of HIV status under Georgia’s policy is limited to the supervising officer, persons providing medical services to the parolee, and the head of the household in which the parolee resides. Officers are trained in the importance of confidentiality of records and specific guidelines have been established to pre- vent unauthorized disclosure. Under this policy, the Board of Parole is informed of any violation of these conditions and may “act to pro- mote the health of the general public,” which may in- clude revocation of parole. It is the duty of the super- vising officer to monitor closely, as well as possible, the behaviors of the parolee. During the first three months of 1988, 25 HIV-infected parolees were super- vised and, of that number, three paroles were revoked for violations covered in this policy.’ The Georgia Board of Pardons and Paroles is utiliz- ing a two prong approach to halting the transmission of the virus by persons on parole. On the one hand, the Special Conditions are designed to prohibit, under the threat of negative sanctions, illegal or unsafe activi- ties. Simultaneously, the Board is providing training to every field officer in the areas of supportive counsel- ing, treatment resources (alcohol, drug and medical), and education. The Board believes that combining its authority to pro- hibit dangerous activities with a humane, compas- sionate and educational treatment program is the most effective way to promote the welfare of the infected parolee and the citizenry of Georgia. Advocates of a restrictive system such as Georgia's argue that identification of releasees is essential for public safety and the safety of the releasee. By making AIDS knowledge and adherence to risk-reduction be- haviors conditions of parole, they believe the justice system is actively participating in reducing transmis- sion of AIDS. By identifying releasees who are sero- positive and handling them differently, they contend the system is providing potentially better medical surveillance of their illness. There is a great deal of debate in the correctional field about the use of restrictive policies such as this. Critics argue that, as the Federal Probation Division and the U.S. Parole Commission suggest, HIV infection is a public health issue and not the appropriate domain of the criminal justice system. In addition, they argue that HIV infection is not a static condition; repeated testing and monitoring are necessary if a policy is to have any impact on transmission of the virus. They also suggest that monitoring of private sexual behaviors of releasees is not only impossible but also an inappropriate in- vasion of their privacy. Finally, it has been suggested that the constitutionality of such a policy may be ques- tionable, in that a condition of release is linked to non- criminal behaviors, and similar prohibitions are not used in the case of other communicable diseases. Less Restrictive Policies The New York State Division of Parole began develop- ing policy and procedural guidelines early in the AIDS crisis. It has compiled some of the most detailed and sophisticated materials for use by correctional officers to date, some of which are appended to this document. General Policy Guidelines on AIDS for Probation and Parole Services 53 The New York State Division of Parole produces an “AIDS Information Guide” for correctional officers, which includes general information about AIDS, policy guidelines, service and resource information and ques- tions and answers about AIDS. In New York, there are no conditions of parole linked to HIV status. Persons whose HIV status is known have that information in- cluded in their medical discharge summaries where it may be considered by the parole board or judge. However, special treatment, such as less frequent reporting or elimination of appearances in court, are only deemed acceptable when the individual has AIDS or ARC and is seriously ill or incapacitated by the disease. Persons with AIDS may not automatically be reclassified for reduced reporting in New York State, but must go through reclassification for medical reasons, as would any other individual who is ill and unable to report. However, those with AIDS or ARC are not required to make an Arrival Report to their local office upon release, but may instead telephone in their report. Parole officers may not disclose AIDS diagnosis or HIV status without the written consent of the parolee. Officers are strongly advised to gain consent for release of information from the parolee even in medical or social service referrals. Similarly, in the New York State probation system, the probationer’s HIV status may appear in a medical evaluation portion of the pre- sentence investigation, but access to that information is limited to parties specified by law. Probation officers are asked to encourage vigorously that clients disclose their status to sexual partners. It is stressed, however, that without client consent, the officer may not disclose the information. There is no mandatory testing in New York State, nor is there routine testing for persons engaging in high- risk behaviors in either parole or probation services. For those probationers or parolees who are known to be positive (either from prior medical records, pre- sentence investigation reports, diagnosis of current illness, or from voluntary report of their status), New York State community corrections services provide a broad range of referral services. These services are listed in the guides developed for officers’ use. Probation Services of the Administrative Office of the Courts in New Jersey has formulated through its In- tensive Supervision Program a policy for dealing with HIV infection and AIDS in probationers. It includes specific protocols for dealing with those with AIDS or ARC, including recommendations for voluntary testing and the development of case-management plans. It ad- vises that face-to-face contact with the probationer is to be continued unless illness renders this impossible. Any modification of contact procedures must be made 54 AIDS IN PROBATION AND PAROLE formally. IV drug users with AIDS or ARC who con- tinue to use drugs (as evidenced in regular urine screens) are considered in violation of probation con- ditions to prevent transmission through needle sharing. New Jersey does not recommend general HIV screen- ing for probationers and parolees. Instead, it advises officers to urge HIV testing for persons exhibiting symptoms of illness or involved in high-risk behaviors. There are no special residential placements or condi- tions of release directly related to AIDS. It is also ad- vised that a general medical examination be conducted for these individuals. New Jersey also provides a guide to services in regions of the state for use by supervis- ing officers. Elements of a good AIDS Policy and Pro- cedural Guide Summarized below are the basic elements of a com- prehensive policy or set of guidelines for dealing with HIV infection and AIDS in community corrections. These elements may be incorporated into a simple statement to be used as a guide for programming. Alternatively, they may be presented in a more elaborate training manual or notebook format. Guidelines presented as frequently updated notebooks with separate sections on issues, questions and answers, and resource guides are the most complete. Key elements include: e Detailed statement of the confidentiality and disclosure laws of your state with specific questions and answers for practitioners; e Detailed written confidentiality procedures for all records containing HIV status infor- mation; e Program outlining mandatory education and training for staff and clients about AIDS, its transmission, and risk-reduction behaviors; e Detailed steps for officers to follow with a person whose positive HIV status is known to them, i.e., what to do about placements, reporting agendas; e Detailed list of resources and how to use them for persons with AIDS or HIV infection; e Statement about state’s policy and rationale for any HIV antibody testing, i.e., when it is deemed appropriate and legal, under what circumstances it should be suggested; e Universal precautionary measures; and e [egal and labor relations issues for employees with AIDS or HIV infection. CONCLUSION AIDS has presented society with a serious dilemma. While it is essential to be supportive and helpful to per- sons who have contracted this infection, the fatal nature of the illness can frighten the most humane and reasonable people. The difficulties society faces with this issue are even more acute in community correc- tions, where a disproportionate number of persons in need of supervision may be infected with the virus. The response to this crisis has been growing in com- munity corrections across the country. Many areas have begun with important education and training of staff to serve better the infected or ill probationer or parolee and the community. This is a critical first step in deal- ing with misinformation and fears surrounding this disease. In many of the materials received in the development of this document, and in many conver- sations with community corrections administrators, it was often repeated that a situation of fear and ap- prehension among staff and clients was noticeably reduced after the institution of an education program. In addition, some areas have developed invaluable resource guides to help supervisory staff in directing clients to appropriate medical and social services for dealing with AIDS. The most critical need is for detailed informational support and specific procedural guidelines for parole and probation officers on how to handle the day-to- day issues the AIDS-infected client presents. Some jurisdictions, such as New York, have done admirable jobs in this regard. Others need to follow this lead with material tailored to the statutes and conditions of their areas. While general statements of purpose —such as the protocol included in Appendix H —are important as guiding principles for agencies and officers to follow, the need for step-by-step guidelines and case manage- ment suggestions is critical. NOTES 1. “House Panel Hears Corrections, Parole Officials Discuss AIDS Policies for Prisoners, Parolees,” The Third Branch: Bulletin of the Federal Courts, December, 1987, 19 (12): 7-8. 2. Parole Commission Instructions to Probation Officers, U.S. Parole Commission, 1987. 3. “Policy for the Human Immunodeficiency Virus Infected”: Georgia. 4. Ibid. 5. “Special Conditions of Parole for HIV-Infected Parolees”: Georgia. 6. “New Georgia law to permit tests of would-be parolees,” AIDS Policy and the Law, April 20, 1988, Vol. 3 (1): 9-10. Conclusion 55 APPENDICES APPENDIX A Probation and Parole Divisions/Agencies Responding to NIJ Survey on AIDS Issues STATES WITH PROBATION DIVISIONS/AGENCIES RESPONDING TO NIJ SURVEY ON AIDS ISSUES Where counties are listed, these were the respondents; if only the state is listed, then the central agency responded. 1. ALABAMA 17. KENTUCKY 36. OKLAHOMA 2. ALASKA 18. LOUISIANA 37. OREGON 3. ARIZONA 19. MAINE Muzion Maricopa 20. MARYLAND 38. PENNSYLVANIA Pima Allegheny 4. ARKANSAS 21. MASSACHUSETTS par 5. CALIFORNIA 22. MICHIGAN Lackawanna Contra Costa 23. MINNESOTA Lehigh Fresno Lycoming Los Angeles 24. MISSISSIPP] Westmoreland Orange 25. MISSOURI 39. RHODE ISLAND py 26. MONTANA 40. TENNESSEE SE nme aww Sutter 42. UTAH 6. COLORADO 29. NEW HAMPSHIRE 43. VERMONT 7 CONNECTICUT 30. NEW JERSEY 44. VIRGINIA 8. DELAWARE 31. NEW MEXICO 45. WASHINGTON 9. FLORIDA 32. nw YORK 46. WEST VIRGINIA 10. GEORGIA Monroe 47. WISCONSIN 11. HAWAII Dow City 48. WYOMING 12. IDAHO Suffolk 13. ILLINOIS Westchester Cook 33. NORTH CAROLINA 14. INDIANA 34. NORTH DAKOTA 15. IOWA 35. OHIO 16. KANSAS Appendix A 61 STATES WITH PAROLE DIVISIONS/AGENCIES RESPONDING TO NIJ SURVEY ON AIDS ISSUES Where counties are listed, these were the respondents; if only the state is listed, then the central agency responded. 1. ALABAMA 18. MAINE 35. OREGON 2. ALASKA 19. MARYLAND Marion 3. ARIZONA 20. MASSACHUSETTS 36. PENNSYLVANIA 4. ARKANSAS 21. MICHIGAN 37. RHODE ISLAND 5. CALIFORNIA Wayne 38. SOUTH DAKOTA 6. COLORADO 22. MINNESOTA 39. TENNESSEE 7 CONNECTICUT 23. MISSISSIPPI 40. TEXAS 8. DELAWARE 24. MISSOURI 41. UTAH 5 FLORIDA 25. MONTANA 42. VERMONT 10. GEORGIA 26. NEBRASKA 43. VIRGINIA 71. TWAT 27. NEVADA 44. WASHINGTON 2. IDAHG 28. NEW HAMPSHIRE 45. WEST VIRGINIA 13. INDIANA 29. NEW MEXICO 46. WISCONSIN 14. IOWA 30. NEW YORK 47. WYOMING 15. KANGAS 31. NORTH CAROLINA 16. RENTUCKY 32. NORTH DAKOTA 17. LOUISIANA 33. OHIO 62 AIDS IN PROBATION AND PAROLE APPENDIX B Medical Definitions * Centers for Disease Control (CDC) Definition of AIDS e National Institutes of Health (NIH) Definition of ARC . ot - a M M w . - PB Reprinted by the U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES PUBLIC HEALTH SERVICE CENTERS FOR DISEASE CONTROL from MMWR SUPPLEMENT, August 14, 1987, Vol. 36, No. 1S, pp. 35—15S Vol. 36 / No. 1S MMWR 3s Revision of the CDC Surveillance Case Definition for Acquired Immunodeficiency Syndrome Reported by Council of State and Territorial Epidemiologists; AIDS Program, Center for Infectious Diseases, COC INTRODUCTION The following revised case definition for surveillance of acquired immunodefi- ciency syndrome (AIDS) was developed by CDC in collaboration with public health and clinical specialists. The Council of State and Territorial Epidemiologists (CSTE) has officially recommended adoption of the revised definition for national reporting of AIDS. The objectives of the revision are a) to track more effectively the severe disabling morbidity associated with infection with human immunodeficiency virus (HIV) (including HIV-1 and HIV-2); b) to simplify reporting of AIDS cases; c) to increase the sensitivity and specificity of the definition through greater diagnostic application of laboratory evidence for HIV infection; and d) to be consistent with current diagnostic practice, which in some cases includes presumptive, i.e., without confirm- atory laboratory evidence, diagnosis of AlDS-indicative diseases (e.g., Pneumocystis carinii pneumonia, Kaposi's sarcoma). The definition is organized into three sections that depend on the status of laboratory evidence of HIV infection (e.g., HIV antibody) (Figure 1). The major proposed changes apply to patients with laboratory evidence for HIV infection: a) inclusion of HIV encephalopathy, HIV wasting syndrome, and a broader range of specific AIDS-indicative diseases (Section |l.A); b) inclusion of AIDS patients whose indicator diseases are diagnosed presumptively (Section I1.B); and c) elimination of exclusions due to other causes of immunodeficiency (Section |.A). Application of the definition for children differs from that for adults in two ways. First, multiple or recurrent serious bacterial infections and lymphoid interstitial pneumonia/pulmonary lymphoid hyperplasia are accepted as indicative of AIDS among children but not among adults. Second, for children<15 months of age whose mothers are thought to have had HIV infection during the child's perinatal period, the laboratory criteria for HIV infection are more stringent, since the presence of HIV antibody in the child is, by itself, insufficient evidence for HIV infection because of the persistence of passively acquired maternal antibodies < 15 months after birth. The new definition is effective immediately. State and local health departments are requested to apply the new definition henceforth to patients reported to them. The initiation of the actual reporting of cases that meet the new definition is targeted for September 1, 1987, when modified computer software and report forms should be in place to accommodate the changes. CSTE has recommended retrospective applica- tion of the revised definition to patients already reported to health departments. The new definition follows: Appendix B 65 4s MMWR August 14, 1987 1987 REVISION OF CASE DEFINITION FOR AIDS FOR SURVEILLANCE PURPOSES For national reporting, a case of AIDS is defined as an illness characterized by one or more of the following “indicator” diseases, depending on the status of laboratory evidence of HIV infection, as shown below. I. Without Laboratory Evidence Regarding HIV Infection If laboratory tests for HIV were not performed or gave inconclusive results (See Appendix |) and the patient had no other cause of immunodeficiency listed in Section I.A below, then any disease listed in Section |.B indicates AIDS if it was diagnosed by a definitive method (See Appendix Il). A. Causes of immunodeficiency that disqualify diseases as indicators of AIDS in the absence of laboratory evidence for HIV infection 1. high-dose or long-term systemic corticosteroid therapy or other immuno- suppressive/cytotoxic therapy <3 months before the onset of the indicator disease any of the following diseases diagnosed <3 months after diagnosis of the indicator disease: Hodgkin's disease, non-Hodgkin's lymphoma (other than primary brain lymphoma), lymphocytic leukemia, multiple myeloma, any other cancer of lymphoreticular or histiocytic tissue, or angioimmu- noblastic lymphadenopathy a genetic (congenital) immunodeficiency syndrome or an acquired immu- nodeficiency syndrome atypical of HIV infection, such as one involving hypogammaglobulinemia B. Indicator diseases diagnosed definitively (See Appendix Il) 1. 2 3. 4 o oN 10. 11. 12. candidiasis of the esophagus, trachea, bronchi, or lungs cryptococcosis, extrapulmonary cryptosporidiosis with diarrhea persisting >1 month cytomegalovirus disease of an organ other than liver, spleen, or lymph nodes in a patient >1 month of age herpes simplex virus infection causing a mucocutaneous ulcer that per- sists longer than 1 month; or bronchitis, pneumonitis, or esophagitis for any duration affecting a patient >1 month of age Kaposi's sarcoma affecting a patient < 60 years of age lymphoma of the brain (primary) affecting a patient < 60 years of age lymphoid interstitial pneumonia and/or pulmonary lymphoid hyperplasia (LIP/PLH complex) affecting a child <13 years of age Mycobacterium avium complex or M. kansasii disease, disseminated (at a site other than or in addition to lungs, skin, or cervical or hilar lymph nodes) Pneumocystis carinii pneumonia progressive multifocal leukoencephalopathy toxoplasmosis of the brain affecting a patient >1 month of age Il. With Laboratory Evidence for HIV Infection Regardless of the presence of other causes of immunodeficiency (l.A), in the presence of laboratory evidence for HIV infection (See Appendix |), any disease listed above (1.B) or below (lI.A or I1.B) indicates a diagnosis of AIDS. 66 AIDS IN PROBATION AND PAROLE Vol. 36 / No. 1S MMWR 5S A. Indicator diseases diagnosed definitively (See Appendix Il) 1. bacterial infections, multiple or recurrent (any combination of at least two within a 2-year period), of the following types affecting a child < 13 years of age: septicemia, pneumonia, meningitis, bone or joint infection, or abscess of an internal organ or body cavity (excluding otitis media or superficial skin or mucosal abscesses), caused by Haemophilus, Streptococcus (including pneumococcus), or other pyogenic bacteria 2. coccidioidomycosis, disseminated (at a site other than or in addition to lungs or cervical or hilar lymph nodes) 3. HIV encephalopathy (also called "HIV dementia,” "AIDS dementia,” or "subacute encephalitis due to HIV") (See Appendix ll for description) 4. histoplasmosis, disseminated (at a site other than or in addition to lungs or cervical or hilar lymph nodes) 5. isosporiasis with diarrhea persisting >1 month 6. Kaposi's sarcoma at any age 7. lymphoma of the brain (primary) at any age 8. other non-Hodgkin's lymphoma of B-cell or unknown immunologic phe- notype and the following histologic types: a. small noncleaved lymphoma (either Burkitt or non-Burkitt type) (See Appendix IV for equivalent terms and numeric codes used in the International Classification of Diseases, Ninth Revision, Clinical Modification) b. immunoblastic sarcoma (equivalent to any of the following, although not necessarily all in combination: immunoblastic lymphoma, large- cell lymphoma, diffuse histiocytic lymphoma, diffuse undifferentiated lymphoma, or high-grade lymphoma) (See Appendix IV for equivalent terms and numeric codes used in the International Classification of Diseases, Ninth Revision, Clinical Modification) Note: Lymphomas are not included here if they are of T-cell immuno- logic phenotype or their histologic type is not described or is described as “lymphocytic,” “lymphoblastic,” “small cleaved,” or “plasmacytoid lym- phocytic” 9. any mycobacterial disease caused by mycobacteria other than M. tuber- culosis, disseminated (at a site other than or in addition to lungs, skin, or cervical or hilar lymph nodes) 10. disease caused by M. tuberculosis, extrapulmonary (involving at least one site outside the lungs, regardless of whether there is concurrent pulmo- nary involvement) 11. Salmonella (nontyphoid) septicemia, recurrent 12. HIV wasting syndrome (emaciation, "slim disease”) (See Appendix Il for description) Indicator diseases diagnosed presumptively (by a method other than those in Appendix Il) Note: Given the seriousness of diseases indicative of AIDS, it is generally important to diagnose them definitively, especially when therapy that would be used may have serious side effects or when definitive diagnosis is needed Appendix B67 6S MMWR August 14, 1987 for eligibility for antiretroviral therapy. Nonetheless, in some situations, a patient's condition will not permit the performance of definitive tests. In other situations, accepted clinical practice may be to diagnose presumptively based on the presence of characteristic clinical and laboratory abnormalities. Guide- lines for presumptive diagnoses are suggested in Appendix lll. candidiasis of the esophagus cytomegalovirus retinitis with loss of vision Kaposi's sarcoma lymphoid interstitial pneumonia and/or pulmonary lymphoid hyperplasia (LIP/PLH complex) affecting a child <13 years of age mycobacterial disease (acid-fast bacilli with species not identified by culture), disseminated (involving at least one site other than or in addition to lungs, skin, or cervical or hilar lymph nodes) 6. Pneumocystis carinii pneumonia 7. toxoplasmosis of the brain affecting a patient >1 month of age POND on Ill. With Laboratory Evidence Against HIV Infection With laboratory test results negative for HIV infection (See Appendix |), a diagnosis of AIDS for surveillance purposes is ruled out unless: A. all the other causes of immunodeficiency listed above in Section |.A are excluded; AND B. the patient has had either: 1. Pneumocystis carinii pneumonia diagnosed by a definitive method (See Appendix Il); OR 2. a. any of the other diseases indicative of AIDS listed above in Section |.B diagnosed by a definitive method (See Appendix Il); AND b. a T-helper/inducer (CD4) lymphocyte count <400/mm?. COMMENTARY The surveillance of severe disease associated with HIV infection remains an essential, though not the only, indicator of the course of the HIV epidemic. The number of AIDS cases and the relative distribution of cases by demographic, geographic, and behavioral risk variables are the oldest indices of the epidemic, which began in 1981 and for which data are available retrospectively back to 1978. The original surveillance case definition, based on then-available knowledge, pro- vided useful epidemiologic data on severe HIV disease (1). To ensure a reasonable predictive value for underlying immunodeficiency caused by what was then an unknown agent, the indicators of AIDS in the old case definition were restricted to particular opportunistic diseases diagnosed by reliable methods in patients without specific known causes of immunodeficiency. After HIV was discovered to be the cause of AIDS, however, and highly sensitive and specific HIV-antibody tests became available, the spectrum of manifestations of HIV infection became better defined, and classification systems for HIV infection were developed (2-5). It became apparent that some progressive, seriously disabling, and even fatal conditions (e.g., encephalop- athy, wasting syndrome) affecting a substantial number of HIV-infected patients were not subject to epidemiologic surveillance, as they were not included in the AIDS 68 AIDS IN PROBATION AND PAROLE Vol. 36 / No. 1S MMWR 78 case definition. For reporting purposes, the revision adds to the definition most of those severe non-infectious, non-cancerous HIV-associated conditions that are cate- gorized in the CDC clinical classification systems for HIV infection among adults and children (4,5). Another limitation of the old definition was that AIDS-indicative diseases are diagnosed presumptively (i.e., without confirmation by methods required by the old definition) in 10%-15% of patients diagnosed with such diseases; thus, an appreciable proportion of AIDS cases were missed for reporting purposes (6,7). This proportion may be increasing, which would compromise the old case definitions usefulness as atool for monitoring trends. The revised case definition permits the reporting of these clinically diagnosed cases as long as there is laboratory evidence of HIV infection. The effectiveness of the revision will depend on how extensively HIV-antibody tests are used. Approximately one third of AIDS patients in the United States have been from New York City and San Francisco, where, since 1985, < 7% have been reported with HIV-antibody test results, compared with > 60% in other areas. The impact of the revision on the reported numbers of AIDS cases will also depend on the proportion of AIDS patients in whom indicator diseases are diagnosed presumptively rather than definitively. The use of presumptive diagnostic criteria varies geograph- ically, being more common in certain rural areas and in urban areas with many indigent AIDS patients. To avoid confusion about what should be reported to health departments, the term "AIDS" should refer only to conditions meeting the surveillance definition. This definition is intended only to provide consistent statistical data for public health purposes. Clinicians will not rely on this definition alone to diagnose serious disease caused by HIV infection in individual patients because there may be additional information that would lead to a more accurate diagnosis. For example, patients who are not reportable under the definition because they have either a negative HIV- antibody test or, in the presence of HIV antibody, an opportunistic disease not listed in the definition as an indicator of AIDS nonetheless may be diagnosed as having serious HIV disease on consideration of other clinical or laboratory characteristics of HIV infection or a history of exposure to HIV. Conversely, the AIDS surveillance definition may rarely misclassify other patients as having serious HIV disease if they have no HIV-antibody test but have an AIDS-indicative disease with a background incidence unrelated to HIV infection, such as cryptococcal meningitis. The diagnostic criteria accepted by the AIDS surveillance case definition should not be interpreted as the standard of good medical practice. Presumptive diagnoses are accepted in the definition because not to count them would be to ignore substantial morbidity resulting from HIV infection. Likewise, the definition accepts a reactive screening test for HIV antibody without confirmation by a supplemental test because a repeatedly reactive screening test result, in combination with an indicator disease, is highly indicative of true HIV disease. For national surveillance purposes, the tiny proportion of possibly false-positive screening tests in persons with AIDS- indicative diseases is of little consequence. For the individual patient, however, a correct diagnosis is critically important. The use of supplemental tests is, therefore, strongly endorsed. An increase in the diagnostic use of HIV-antibody tests could improve both the quality of medical care and the function of the new case definition, as well as assist in providing counselling to prevent transmission of HIV. Appendix B69 8S MMWR August 14, 1987 FIGURE I. Flow diagram for revised CDC case definition of AIDS, September 1, 1987 (" Laboratory evidence of HIV infection (Appendix |) ) a Has any disease in Sections |.B or [LA been definitively diagnosed (Appendix II) ? Unknown or inconclusive Has any disease in Section 11.B been presumptively diagnosed (Appendix II) YES ? Are there other causes of immunodeficiency (Section L.A) ? Not a Case NG NO Not a Case Not a Case Has any disease in Section I.B been definitively diagnosed (Appendix II) ? NO YES Not a Case Not a Case 70 AIDS IN PROBATION AND PAROLE pneumonia been Negative Are there other causes of immunodeficiency Section |.A) Pneumocystis carinii definitively diagnosed (Appendix II) 2 NO Has any other disease in Section |.B been definitively diagnosed (Appendix Il) ? YES Is the T-helper lymphocyte count <400/mm3 ? YES Vol. 36 / No. 1S MMWR 9S References 1. World Health Organization. Acquired immunodeficiency syndrome (AIDS): WHO/CDC case definition for AIDS. WHO Wkly Epidemiol Rec 1986;61:69-72. 2. Haverkos HW, Gottlieb MS, Killen JY, Edelman R. Classification of HTLV-III/LAV-related diseases [Letter]. J Infect Dis 1985;152:1095. 3. Redfield RR, Wright DC, Tramont EC. The Walter Reed staging classification of HTLV-III infection. N Engl J Med 1986;314:131-2. 4. CDC. Classification system for human T-lymphotropic virus type lll/lymphadenopathy- associated virus infections. MMWR 1986;35:334-9. 5. CDC. Classification system for human immunodeficiency virus (HIV) infection in children under 13 years of age. MMWR 1987;36:225-30,235. 6. Hardy AM, Starcher ET, Morgan WM, et al. Review of death certificates to assess complete- ness of AIDS case reporting. Pub Hith Rep 1987;102(4):386-91. 7. Starcher ET, Biel JK, Rivera-Castano R, Day JM, Hopkins SG, Miller JW. The impact of presumptively diagnosed opportunistic infections and cancers on national reporting of AIDS [Abstract]. Washington, DC : lll International Conference on AIDS, June 1-5, 1987. Appendix B71 10S 1. MMWR August 14, 1987 APPENDIX | Laboratory Evidence For or Against HIV Infection For Infection: When a patient has disease consistent with AIDS: a. a serum specimen from a patient =15 months of age, or from a child <15 months of age whose mother is not thought to have had HIV infection during the child's perinatal period, that is repeatedly reactive for HIV antibody by a screening test (e.g., enzyme-linked immunosorbent assay [ELISA]), as long as subsequent HIV-antibody tests (e.g., Western blot, immunofluorescence as- say), if done, are positive; OR a serum specimen from a child < 15 months of age, whose mother is thought to have had HIV infection during the child's perinatal period, that is repeatedly reactive for HIV antibody by a screening test (e.g., ELISA), plus increased serum immunoglobulin levels and at least one of the following abnormal immunologic test results: reduced absolute lymphocyte count, depressed CD4 (T-helper) lymphocyte count, or decreased CD4/CD8 (helper/suppressor) ratio, as long as subsequent antibody tests (e.g., Western blot, immunofiuorescence assay), if done, are positive; OR a positive test for HIV serum antigen; OR a positive HIV culture confirmed by both reverse transcriptase detection and a specific HIV-antigen test or in situ hybridization using a nucleic acid probe; OR a positive result on any other highly specific test for HIV (e.g., nucleic acid probe of peripheral blood lymphocytes). 2. Against Infection: A nonreactive screening test for serum antibody to HIV (e.g., ELISA) without a reactive or positive result on any other test for HIV infection (e.g., antibody, antigen, culture), if done. 3. Inconclusive (Neither For nor Against Infection): a. a repeatedly reactive screening test for serum antibody to HIV (e.g., ELISA) followed by a negative or inconclusive supplemental test (e.g., Western blot, immunofluorescence assay) without a positive HIV culture or serum antigen test, if done; OR a serum specimen from a child < 15 months of age, whose mother is thought to have had HIV infection during the child's perinatal period, that is repeatedly reactive for HIV antibody by a screening test, even if positive by a supplemen- tal test, without additional evidence for immunodeficiency as described above (in 1.b) and without a positive HIV culture or serum antigen test, if done. 72 AIDS IN PROBATION AND PAROLE Vol. 36 / No. 1S MMWR 118 APPENDIX II Definitive Diagnostic Methods for Diseases Indicative of AIDS Diseases cryptosporidiosis cytomegalovirus isosporiasis Kaposi’s sarcoma lymphoma lymphoid pneumonia or hyperplasia Pneumocystis carinii pneumonia progressive multifocal leukoencephalopathy toxoplasmosis candidiasis coccidioidomycosis cryptococcosis herpes simplex virus histoplasmosis tuberculosis other mycobacteriosis salmonellosis other bacterial infection Nm Naat mm at Definitive Diagnostic Methods microscopy (histology or cytology). gross inspection by endoscopy or autopsy or by microscopy (histology or cytology) on a specimen obtained directly from the tissues affected (in- cluding scrapings from the mucosal surface), not from a culture. microscopy (histology or cytology), culture, or detection of antigen in a specimen obtained directly from the tissues affected or a fluid from those tissues. culture. Appendix B73 128 HIV encephalopathy* (dementia) HIV wasting syndrome* MMWR August 14, 1987 clinical findings of disabling cognitive and/or motor dysfunction interfering with occupation or activities of daily living, or loss of behavioral de- velopmental milestones affecting a child, progressing over weeks to months, in the absence of a concurrent illness or condition other than HIV infection that could explain the findings. Methods to rule out such concurrent illnesses and conditions must include cerebrospinal fluid exam- ination and either brain imaging (computed to- mography or magnetic resonance) or autopsy. findings of profound involuntary weight loss >10% of baseline body weight plus either chronic diarrhea (at least two loose stools per day for = 30 days) or chronic weakness and documented fever (for = 30 days, intermittent or constant) in the absence of a concurrent illness or condition other than HIV infection that could explain the findings (e.g., cancer, tuberculosis, cryptosporidi- osis, or other specific enteritis). *For HIV encephalopathy and HIV wasting syndrome, the methods of diagnosis described here are not truly definitive, but are sufficiently rigorous for surveillance purposes. 74 AIDS IN PROBATION AND PAROLE Vol. 36 / No. 1S MMWR 138 APPENDIX iI Suggested Guidelines for Presumptive Diagnosis Diseases candidiasis of esophagus cytomegalovirus retinitis mycobacteriosis Kaposi's sarcoma lymphoid interstitial pneumonia Pneumocystis carinii pneumonia of Diseases Indicative of AIDS Presumptive Diagnostic Criteria a. recent onset of retrosternal pain on swallowing; AND b. oral candidiasis diagnosed by the gross appearance of white patches or plaques on an erythematous base or by the microscopic appearance of fungal mycelial fila- ments in an uncultured specimen scraped from the oral mucosa. a characteristic appearance on serial ophthalmoscopic examinations (e.g., discrete patches of retinal whitening with distinct borders, spreading in a centrifugal manner, following blood vessels, progressing over several months, frequently associated with retinal vasculitis, hemorrhage, and necrosis). Resolution of active disease leaves retinal scarring and atrophy with retinal pigment epithelial mot- tling. microscopy of a specimen from stool or normally sterile body fluids or tissue from a site other than lungs, skin, or cervical or hilar lymph nodes, showing acid-fast bacilli of a species not identified by culture. a characteristic gross appearance of an erythematous or violaceous plaque-like lesion on skin or mucous membrane. (Note: Presumptive diagnosis of Kaposi's sarcoma should not be made by clinicians who have seen few cases of it.) bilateral reticulonodular interstitial pulmonary infiltrates present on chest X ray for =2 months with no pathogen identified and no response to antibiotic treatment. a. a history of dyspnea on exertion or nonproductive cough of recent onset (within the past 3 months); AND b. chest X-ray evidence of diffuse bilateral interstitial infil- trates or gallium scan evidence of diffuse bilateral pul- monary disease; AND c. arterial blood gas analysis showing an arterial pO, of <70 mm Hg or a low respiratory diffusing capacity (<80% of predicted values) or an increase in the alveolar-arterial oxygen tension gradient; AND d. no evidence of a bacterial pneumonia. Appendix B 75 14S MMWR August 14, 1987 toxoplasmosis a. recent onset of a focal neurologic abnormality consis- of the brain tent with intracranial disease or a reduced level of con- sciousness; AND b. brain imaging evidence of a lesion having a mass ef- fect (on computed tomography or nuclear magnetic resonance) or the radiographic appearance of which is enhanced by injection of contrast medium; AND c. serum antibody to toxoplasmosis or successful response to therapy for toxoplasmosis. 76 AIDS IN PROBATION AND PAROLE Vol. 36 / No. 1S MMWR 18S APPENDIX IV Equivalent Terms and International Classification of Disease (ICD) Codes for AIDS-Indicative Lymphomas The following terms and codes describe lymphomas indicative of AIDS in patients with antibody evidence for HIV infection (Section Il.A.8 of the AIDS case definition). Many of these terms are obsolete or equivalent to one another. ICD-9-CM (1978) Codes Terms 200.0 Reticulosarcoma lymphoma (malignant): histiocytic (diffuse) reticulum cell sarcoma: pleomorphic cell type or not otherwise specified 200.2 Burkitt's tumor or lymphoma malignant lymphoma, Burkitt's type ICD-0O (Oncologic Histologic Types 1976) Codes Terms 9600/3 Malignant lymphoma, undifferentiated cell type non-Burkitt's or not otherwise specified 9601/3 Malignant lymphoma, stem cell type stem cell lymphoma 9612/3 Malignant lymphoma, immunoblastic type immunoblastic sarcoma, immunoblastic lymphoma, or immunoblas- tic lymphosarcoma 9632/3 Malignant lymphoma, centroblastic type diffuse or not otherwise specified, or germinoblastic sarcoma: diffuse or not otherwise specified 9633/3 Malignant lymphoma, follicular center cell, non-cleaved diffuse or not otherwise specified 9640/3 Reticulosarcoma, not otherwise specified malignant lymphoma, histiocytic: diffuse or not otherwise specified reticulum cell sarcoma, not otherwise specified malignant lymphoma, reticulum cell type 9641/3 Reticulosarcoma, pleomorphic cell type malignant lymphoma, histiocytic, pleomorphic cell type reticulum cell sarcoma, pleomorphic cell type 9750/3 Burkitt's lymphoma or Burkitt's tumor malignant lymphoma, undifferentiated, Burkitt's type malignant lym- phoma, lymphoblastic, Burkitt's type Appendix B77 NIH's DEFINITION OF AIDS-RELATED COMPLEX At least 2 of the following clinical signs/symptoms lasting 3 or more months PLUS 2 or more of the following | laboratory abnormalities, occurring in a patient having no underlying infectious cause for ths symptoms and who is in a cohort at increased risk for developing AIDS. Clinical: 1. 4. 5. 6. Paver: >100°7, intermittent or continuous, for at least J months, in the absence of other identifiable causes. Weight Loss: 10ZX or 215 lbs. Lysphadenopethy: persistent for at least 3 months, involving >2 extra-inguinal node bearing areas. Diarrhea: intermittent or continuous, 23 months, in the absence of other identifiable causes. Fatigue, to the point of decreased physical or mental function. Night Sweats: {intermittent or continuous, 23 months, in the absence of other identifiable causes Laboratory: 1. 2. 3. 4. 3. 6. Depressed helper T-cells (22 standard deviations below mean). Depressed helper/suppressor ratio (22 standard deviations below mean). At least one of the following: leukopenia, thrombocytopenia, absolute lymphopenia or anemia. Elevated serum globulins. Depressed blastogenesis (poksweed and PHA). Abnormal skin tests (using Multi-Test or equivalent). 78 AIDS IN PROBATION AND PAROLE APPENDIX C Iowa Department of Corrections AIDS Screening: Health History OW Nw — 10. 11. 12. 13. DEPARTMENT OF CORRECTIONS Iowa Medical and Classification Center Health Services AIDS SCREENING: HEALTH HISTORY Inmate Nuaber 2. Admit Date Sex: Male Female 4, Birthdate Height 6. Weight 7. BP 8. PPD Ethnic Background: White American Indian Black Other Hispanic (i.e., Cuban, Puerto Rican, Mexican) USE OF IV DRUGS: History of IV drug use Yes No If Yes: a. Date of last usage b. Avg. frequency of use ¢. Duration of use (mos./yrs.) d. Shared needle usage Yes No USE OF OTHER DRUGS: Yes No If Yes: a. Circle types: 1 2 3 4% 5 6 7 8 9 10 11 12 13 14 15 b. Date of last usage c. Avg. frequency of use d. Duration of use (mos./yrs.) e. Poppers (Amyl Nitrate): Yes No USE OF ALCOHOL: Yes No If Yes: a. Date of last usage b. Avg. frequency of use c. Duration of use (mos./yrs.) SEXUAL HISTORY: a. Age of 1st sexual contact b. Number of different sexual contacts per week/month c. Approximate date of last contact d. Sexual preference: heterosexual; bisexual; homosexual e. If male bisexual or homosexual: Date of last homosexual activity Average frequency of homosexual activity (per wk./mo.) Duration of homosexual activity (mos./yrs.) Anal intercourse Yes No EWN —- « oe If Yes: Anal initiator Anal recipient Both S. Oral intercourse Yes No 6. Fist intercourse __ Yes No 7. Number of different partners per month f. Frequency of use of condoms: always; sometimes; never Appendix C 81 Dw 14, Have you been outside of Iowa since 19757? Yes No If Yes: a. List states b. When (year) c. Length of stay (mos./yrs.) d. If in prison, how long What states 15. HAVE YOU RECEIVED BLOOD/BLOOD PRODUCTS SINCE 1975? Yes No If Yes: a. When b. Kinds c. Arount 16. SYMPTOMS AND SIGNS OF AIDS: Yes No Onset a. Unexplained, persistent fatigue b. Unexplained fever, shaking, chills, or drenching night sweats lasting longer than several weeks c. Unexplained weight loss greater than 10 pounds d. Unexplained swollen glands lasting longer than two weeks e. Unexplained skin changes, especially purplish blotches or bumps, or bruises that do not disap- pear ———e r— ff. Persistent white spots or blemishes in the mouth g. Persistent diarrhea h. Persistent dry cough, not associated with URI 17. HISTORY OF HEPATITIS: Yes No If Yes: a. What type b. When Cc. Hospitalized or Outpatient 18. HISTORY OF STD: Yes No If Yes: a) Warts ; b) Herpes ; ¢) Gonorrhea ; d) Chlamydia e) Nonspecific vaginitis/urethritis ; f) Other 19. PREVIOUS TEST(S) FOR AIDS VIRUS: Yes No If Yes: a. Where b. Results 20. HIV ANTIBODY TEST: Date Drawn: Results 21. WBC mm3 Differential: % segs.; 4 bands; % eos. ; 4 basos.; $ lymphs.; ¢ monos.; % morph. Completed by Signature/Title Date Completed 12/18/86 82 AIDS IN PROBATION AND PAROLE APPENDIX D Examples of Training Materials and Policy Directives ® Maricopa County, Arizona Adult Probation Depart- ment Guidelines (Sections I and II) e State of New Jersey Administrative Office of the Courts, Probation Services (pp. 8-12) eo New York State Parole Operations (Section III, pp. 3-11) Appendix D 83 Maricopa County, Arizona Adult Probation Dept. COMMUNICABLE-CONTAGIQUS DISEASES {. 2 . So DUTIES, RESPONSIBILITIES AND LIABILITIES dl Su - < . Authorit—: Common Sense Purpose: To Establish A Policy Upon Which Decisions Can Be Reached By Staff In The Supervision, Treatment And Surveillance Of Probationers Known To Have Communicable, Contagious Diseases And/Or Be In Identifiable High-Risk Environments Por Said Diseases. This Policy Is Intended To Address The Pollowing Areas And Issues. I. Definitions II. Officer Responsibilities III. Duty to Supervise and Officer Liability IV. Client Privilege/Privacy vs Public Need-To-Know V. Duty To Inform Issues VI. Probationer Testing Procedures VII. Officer and Probationer Safety and Welfare. Introduction: With increasing frequency persons sentenced to probation are known, or may be diagnosed while under supervision, to have a communicable and contagious disease such as AIDS and hepatitis. In many instances it is appropriate, either because of statutory requirement, Court directive or care needs that a treatment regimen prevail, including urinalysis or Dbreath/intoxilyzer testing. Anyone under probation Appendix D 85 supervision with a confirmed diagnosis as actively contagious presents special needs: the statutory or Court directive must be complied with and a duty to supervise attaches to probation staff. This duty must be carried out in a safe and secure environment that protects staff, maintains the probatiomer's rights and serves and protects the public's welfare. This policy is intended to provide the procedures, safeguards and direction to effectively accomplish all these objectives. I. Definitions: Any disease or infectious condition that is actively contagious and transmittable, in deference to the mode of transmission. Diseases and afflications include, but are not limited to: AIDS (HLV IV Virus) Infectious Hepatitis ? ™ Rubella (German Measles) J 7 SD ~ ed A RE Viral Encephalitis sw TY B. Persons At High Risk (PAHR): Any person whose history includes illicit IV-drug usage or any person who has had, or does have, intimate social and/or sexual relationships with illicit IV-drug users, PWA's and/or persons -2 - 86 AIDS IN PROBATION AND PAROLE identified in populations of greater iacidonca of AIDS, .2patizlia or relatsd contagious diseases. Cc. EWA: Person(s) with AIDS. D. Qfficer: Any probation or surveillance officer of the department or any clerical staff, volunteer, intern or other person who may be delegated duties raolating to supervision or presentance activities iavolving potential contact with persons with communicable-contagious diseases. a J LEE IT. Officer Responsibilities: v { J Im, ¥ = ~ / 4 A. PSI: 1. If AQuring the course of the presentence investigation a person claims he or she has any active communicable disease; i.e., AIDS or hepatitis, fears he or she may be infected, lives wit: someone having such a disease or classifies as a high-ris: class offender, the officer shall inquire and request copies of any medical tests of certification of the disease. Requests for medical Release of Information for physicians. hospitals or agencies treating the person shall be mada. “3. Appendix D 87 2. In any case where a person admits or acknowledges that they have a communicable disease during the presentence investigation, the officer sBould. Letom the person the fact will be reported to the Court. This information, including whether it is verified by medical personnel or an unverified assertion should be cited in the presentence report in the Social History section. Furthermore in ALL such cases the officer should prepare a special Incident Report and request that support staff type in this incident on the blue chronie sheet of the case file. The incident should be as comprehensive as possible and list the treating physician, support group or other relevant information and reference any documentation in file. 3. If a person asserts he or she is contagious but demands privacy under a doctor-patient privilege, or if an officer assesses the person to fit the PAHR profile, said information should be included in a special Incident Report for the file via the blue chronie page. In these instances no reference shall be made in the PSI to the person's assertions or officer assessment. 7 4 . an lo Sy o ’ B. Field Supervision or IPS: ‘ 7 Te Wise LI i! >» 2 cy “J If a person is under supervision who has admitted or acknowledged having a communicable disease, all supervision plans and treatment decisions should take into account the factor: 88 AIDS IN PROBATION AND PAROLE Cc. If a person's disease and contagion have been medically certified, officers shall procure medical releases and coordinate all supervision planning, including residential status, employment and WOP/CSH placement with the treating physician and/or disease-specific support group that may be involved. If a person alleges or believes he or she may be actively contagious, officers shall attempt to make diagnostic referrals to appropriate medical professionals for verification and/or certification. Officers may utilize an implementation form to require probationers to submit to testing. Any person evaluated to be a PAHR shall be treated as if they are contagious and should be referred by the officer on a case-by-case basis to public health presentations or counseling/support groups. Further a person under supervision who remains in an environment of a PAHR may be periodically referred for medical testing at an officer's discretion. All activities relating to communicable-contagious diseases of any probationer in a., b., or c. shall be scrupulously documented in a probationer's case file. -5 = Appendix D 89 Robert D. Lipscher Administrative Director of the Courts Harvey M. Goldstein Assistant Director for Probation FINAL REPORT OF THE PROBATION COMMITTEE ON AIDS Administrative Office of the Courts Probation Services Justice Complex, CN-987 Trenton, NJ 08625 July 1987 90 AIDS IN PROBATION AND PAROLE probation Committee on AIDS 8 DISCUSSION The best available scientific information indicates that AIDS is transmitted through exchange of internal body fluids (blood and semen) in intimate sexual relations or activities engaged in by a small subgroup of IV drug users. These behaviors do not occur during the regular conduct of probation supervision. Since the risk of transmission at the work place is very low, few change in proba- tion policies are warranted. while there is no reason to make extraordinary modifications in procedures, any risk at all is a cause for concern given the fact that AIDS is almost always fatal. Probation administrators must take prudent action to develop policies consistent with the best scientific knowledge, agency priorities and social conscience. A prominent researcher has noted..."right now, our oply tools [for controlling AIDS] are education and behavior change." Probation's response to the challenge of AIDS must halance several competing interests, all compelling in their own right. The safety of staff must be protected by reducing the risk of exposure. The rights of the person with AIDS to services and to a degree of dignity must be protected. Persons with AIDS could easily become social outcasts. The rights of society to enforcement of court orders and protection through supervision cannot be forgotten. Because of the long incubation period for AIDS, infected persons are able to carry and transmit the virus without themselves showing symptoms. Those who have contracted the disease or carry the virus may remain quite able to continue behavior associated with transmis- sion for some time. If they still use intravenous drugs and proba- tion does not take appropriate steps to stop them, probation is not only remiss in its duty but indirectly contributes to the spread of the disease. In that regard, probation is obligated to work toward assuring the discontinuation of intravenous drugs use. Probation also has a role to educate persons under its supervision about AIDS and high risk behavior and to locate and make available the appropriate services for infected probationers. Historically, probation has located and provided services for those in much less severe need. The person with AIDS is an individual in the most desperate need. Probation has a moral obligation to respond. 5 Dr. Harold Jaffe of the Centers for Disease Control, addressing a NIC-sponsored meeting of correctional administrators, Novem- ber 6, 1985. Appendix D 91 probation Committee on AIDS 9 RECOMMENDED STRATEGY TO RESPOND TO AIDS probation's response to AIDS includes procedural changes and educa- tion. Modified supervision policies for infected probationers and training for staff are designed to achieve safety without sacrific- ing the integrity of supervision. Training Staff training will educate probation personnel about the disease and reduce the level of fear and anxiety which exists. In turn, probation staff will be able to provide accurate information to others, including probationers and «court personnel. The New Jersey Department of Health has been providing training about AIDS for some time and has maintained the most up to date information. In order to provide quality training in a timely fashion, the AOC Training Unit has utilized trainers from the Department of Health to conduct sessions for probation staff. The AOC Training Unit staff will maintain a liaison with staff of the Department of Health to monitor developments in this area, and provide additional training and/or information as it becomes appropriate. Verification and Medical Treatment A probation staff member may learn of AIDS infection from a probationer or other reliable source. Those with AIDS will probably be getting medical treatment. Therefore, the simplest and most reliable way of verifying an HIV infection is through the medical provider who informed the probationer of the infection, e.g., the doctor, clinic, the HIV antibody testing site, etc. The medical provider should be contacted in writing, either directly or by having the probationer hand-carry a written request for information, to verify an AIDS diagnosis or other stage of HIV infection. The provider should respond in writing on letterhead or prescription form. Because of the highly confidential nature of this information, the first step must be to have the probationer sign a specific records release author- ization, a copy of which would accompany any written communi- cation to the medical provider. (Having the probationer hand-carry such a request may expedite matters by allowing the provider to receive personal verification of permission to release the information.) If this process is unsuccessful, for whatever reason, and the HIV infection reported by the probationer or some other source is still suspected, then an HIV antibody test should be consid- ered as an alternative means to verify infection. The need for 92 AIDS IN PROBATION AND PAROLE probation Committee on AIDS 10 an HIV antibody test should be carefully discussed with the probationer. Information should be provided about the poten- tial for discriminatory use of test results should they become known, for example, in the insurance and housing markets. (New Jersey has no state law safeguarding against such discrimina- tion.) Then a referral should be made to either a state-funded counselling and testing site where confidentiality is strictly guarded, or to another medical provider mutually agreed upon, where confidentiality may or may not be securely preserved. (See Appendix C for a listing.) If a probationer is reluctant or refuses to submit to antibody testing, the probation staff should make every effort to convince the probationer of the need for testing for personal and public health reasons. Should these efforts fail to persuade the probationer, the case should be referred to the sentencing judge for action in obtaining cooperation. If probationers with HIV infection are not gettinc adequate medical treatment, probation staff should encourage them to do so and assist with referrals to appropriate facilities. (See Physicians' Referral List in Appendix C.) This is very impor- tant because life-threatening symptoms can develop very quick- ly. If the probationer's permission is given, medical personnel may be able to provide information to the probation staff which will assist in supervision. Confidentiality Persons with AIDS, ARC, or HIV infection rur a significant risk of becoming social outcasts. Probation staff should exercice caution in revealing information about infected persons. Normal restrictions apply, but the potentially damaging nature of this information requires careful exercise of discretion. Therefore, information on AIDS infection should be revealed only to those individuals who absolutely must know to effect successful supervision. Urine Monitoring Screening for drug use gains importance due to the high risk of transmission of the virus through sharing of needles. Proba- tion staff involved with urine monitoring should follow the procedures developed for use by the Centers for Disease Con- trol, as adopted by the state Intensive Supervision Program. (See Appendix D.) THESE PROCEDURES SHOULD BE FOLLOWED FOR ALL URINE SPECIMENS BECAUSE THEY ARE EFFECTIVE CONTROLS FOR ANY COMMUNICABLE DISEASE. (See also Appendix E.) Education With the overlap of one high risk AIDS group (IV drug users) and the probation population, educational materials should be readily available in the probation offices including informa- tional brochures and posters. Staff should be knowledgeable Appendix D 93 probation Committee on AIDS 11 am— about AIDS, but when they are unable to answer probationers’ specific questions, referral should be made to the New Jersey AIDS Hotline (1-800-624-2377) or other reliable sources listed in Appendix F. Supervision Policy Statement The probation departments and their employees shall provide supervision and services to all persons placed under their jurisdiction by the courts, despite a suspect- ed or confirmed diagnosis of AIDS or HIV infections. Probation supervision activities should not be eliminated in the face of AIDS, but some modifications may need to be incorporated into standard operating procedures on a case-by-case basis. Supervision Contacts Probation staff should continue to provide supervision to persons verified to be HIV infected. If an HIV infected person's medical condition would rule out or prevent benefiting from a face-to-face personal contact (e.gqg., probationer is bedridden or hospitalized due to secondary illness), collateral contacts should be an option. Testing A variety of questions remaining about HIV antibody testing lend themselves to resolution through policy promulgation by the courts. These issues include the following. ...Can the courts compel testing? ...1f so, should they? ...For whom? ...Where should testing be done? ...Who should pay for it? Probation officers and other appropriate judicial employees need to be trained about the advantages and disadvantages of testing. They should alsc be given the skills and sensitivity needed to counsel probationers on this subject and the knowl- edge of where to refer for testing and counseling. Although there is no known cure for AIDS, testing is still advisable for a number of reasons. If the individual to be tested does not have AIDS, the test can provide reassurances. The results are not foolproof, but they are accurate enough to relieve some of the fear and anxiety associated with the disease. On the other hand, if positive test results are found, certain medications may be beneficial while new ones could be discovered at any time. Also, modifications of certain behaviors may slow the progress of the disease or help 94 AIDS IN PROBATION AND PAROLE probation Committee on AIDS 12 to prevent the onset of opportunistic infections. Equally important, changes in habits or life styles could help signifi- cantly in limiting the spread of infection to others. (See Appendixes G and H.) The most reasonable stance to take on this issue seems to be an avoidance of wholesale testing in favor of a selective approach pased on individual case circumstances. One important criteri- on should be to conduct tests whenever an individual is put at risk by another person's actions. In such cases as rape or other type of assault where the possibility of infection is present, testing should be done on the perpetrator if at all possible and the results shared with the victim if that person wants to know them. If for any reason the perpetrator cannot be tested, then the victim should be counseled about the advisability of being tested. Appendix D 95 AIDS INFORMATION GUIDE a % \ J A ee RE Parole Operations April 1986 New York State Division of Parcie MARIO M. CUOMO RAMON J. RGPRIGUEZ Govemor Chairman 96 AIDS IN PROBATION AND PAROLE TABLE OF CONTENTS IntZoUcElON 4 4 4 » vo « & © = 5 = $v ¥ vw ® © 0 8 8 8 Hw ow wT Acknowledgements . . . +. « « 4 + tt ttt 0 4 ve ee we 4. . iii General Information About AIDS . . . . . +. + + « « « « « « « . . Section I Policies and Procedures . . . . . . . . +... «+ «+... . Section II Questions and Answers About ATDS . . . + « « «+ « « « « « « « « . Section III Service Needs of People With AIDS . . . . « « « « Section IV "Overview of Psychosocial Issues Concerning AIDS" "Dual Diagnosis: AIDS and Addiction” "Psychosocial Issues With AIDS and IV Drug Users" "Additional Strategies of Intervention" "Emotional Stages of the Dving Patient" "Legal Aspects of AIDS" Services and Informatior:. Resources . . . + « « « « « « « «. . . Section V NYS AIDS Task Forces Map NYS Regional AIDS Task Force Listings NYS DSS Regional Offices NYS DSS Local Social Services Districts Agency Contacts for Discrimination Camplaints Prisoners Legal Services Offices Parole Services Program Specialists/AIDS Liaisons . . . . . . . .Section VI Social Security Administration . . . . « « + « ¢« « + + + « « « « Section VII Prerelease Agreement Social Security District Office AIDS Liaisons Social Security Teleclaims Phone Numbers An Overview of SSD and SSI Medical Evidence Needed for Disability Claims for Persons with AIDS/ARC NYS Department of Health . . . . . . « « « « « « « « « « « « « « Section VIII AIDS Institute Newsletter DOH Memorandum: Confidential and Identifying Patient Information DOH Memorandum: Mandatory Reporting of AIDS Appendix D 97 Brticles About BIDS « « » « « » s « 5 = = » sa oa» & & » @ 9 5» « Section IX "Curbing the Fear of AIDS" "Lack of Transmission of HTLV-III/LAV Infection of Patients with AIDS or ARC with Oral Candidiasis" "Transmission of AIDS, The Case Against Casual Contagion" "Update: Evaluation of Human T-Lymphotropic Virus Type III/Lymphadenopathy - Associated Virus Infection in Health-Care Personnel - United States" "AIDS Poses No Dangers to Co-Workers in Office Settings" AIDS Update Part 2 DSAS, Special Bulletin 1-85: AIDS, October 3, 1985 "Dual Diagnosis: AIDS and Addiction" "The Epidemic of Acquired Immunodeficiency Syndrome (AIDS) and Suggestions for its Control in Drug Abusers" "The National Prison Project Gathers the Facts on AIDS in Prison" "AIDS in Prisons and Jails: Issues and Options" 98 AIDS IN PROBATION AND PAROLE SECTION III - QUESTIONS AND ANSWERS ABOUT AIDS 1. Q: According to the prison grapevine, we have an irmmate in population who has AIDS who has not been officially "diagnosed" as such by DOCS and added to their roster. Why aren't we being told and what should we do to find out? The prison grapevine cannot be relied on as being totally accurate, and with an issue as emotionally charged as this one, is likely to be greatly exaggerated. There have, however, been instances where an official diagnosis of AIDS only confirms that which has been suspected, but unofficial. There is no simple answer as to why this occurs. In part it is the result of less than perfect cammnication between DOCS and DOP; that situation- should be greatly improved with the now regular exchange of information between our agencies on these cases. In part, suspicions of inaccurate reporting stem fram the fact that people can only be diagnosed as having AIDS or ARC after a very specific set of medical circumstances have been satisfied——and great care must be taken not to misdiagnose, thereby leaving an individual permanently stigmatized by such an error. Finally, in same instances DOCS Health Services staff may not be aware of an immate's illness and therefore cannot treat or report it. In order to uncover medical problems requiring treatment, all new DOCS admissions receive a medical evaluation upon arrival in the correctional system. In addition, DOCS is required to provide periodic follow up medical exams on all inmates. If test results indicate abnormal findings, the immate is referred to a cammunity hospital for a camplete evaluation. All confirmed AIDS and ARC cases are placed in the facility infirmary or community hospital. DOCS facility Health Services staff are, by law, precluded from discussing a patient's medical diagnosis with anyone other than Health Services staff without the patient's permission. The Health Services Unit provides DOP with a list of all AIDS and ARC cases and medical summary information for purposes of discharge planning. This information provided to Parole should be treated with the utmost confidentiality as is required bv law, and should not be disclosed without the permission of the patient to anyone other than Division of Parole or DOCS Health Services staff. No immate identified as having a cammnicable disease, known to Health Services, remains in population untreated. Bear in mind, however, that irmates have the right to seek, or to refuse to seek, health care. Obviously DOCS lists of AIDS/ARC cases will not include inmates wham you suspect might be ill but who have not come forth for treatment. Questions about anv such cases should be directed to the facility Health Services Director or Nurse Administrator for clarification. Bear in mind, however, that DOCS cannot provide information on cases that have not been diagnosed. III -1 Appendix D 99 2. Q: I recently interviewed an inmate in population who looked pretty ill, and while he didn't say so directly, I got the feeling frcm his description that he may think he has early symptoms of AIDS. He hasn't elected to be seen by the Health Services Unit nor has he discussed this with any DOCS personnel. What should I do about this? A: In addition to counseling the inmate about the serious implications for himself and others with wham he has contact if he is in Zact ill, you should urge him to seek medical attention and assist him to do so in any ways that are appropriate. At a point, however, if the irmate fails to contact medical staff and you have reason to believe he is ill, you have an obligation to discuss the situation with the DOCS facility Health Services Physician or Nurse Administrator. Keep in mind, however, that medical treatment cannot be imposed by force, and the DOCS Health Services staff can only treat immates who cane forth for such treatment. 3. Q: I'm not a Parole Officer, but I'm still worried about having contact with inmates or parolees with AIDS. Can I get AIDS by being near them or processing paperwork on them? A: No. AIDS is not transmitted through the air, food or water, or by touching any object handled, touched or breathed on by a person with AIDS. There is no indication that AIDS is spread through any form of casual contact. AIDS cannot be transmitted by a routine office contact with inmates or parolees with AIDS. 4. Q: If I am working with an inmate or parolee with AIDS, will my family be in danger of getting infected? A: AIDS is not an easily transmissible disease and there is no evidence that it can be transmitted through air, water, food or casual ccntact. Since you are personally not at risk of getting AIDS as a result of the routine contact you have with an immate or parolee with the disease, your family suffers no risk of exposure or infection as a result. The largest study to date of AIDS patients and their families, undertaken by the Montefiore Center in New York City, has unearthed no evidence of transmission of the virus to household members who have shared household items and facilities and had close personal interaction with the patient. The study indicates that household contacts who are not sexual partners of, or born to, patients with AIDS are at minimal or no risk of infection with HTLV III. Copies of the Montefiore Study can be obtained by contacting the Pegional AIDS Liaison. III - 2 100 AIDS IN PROBATION AND PAROLE In preparation for a Pre-Board Summary, I will be interviewing an inmate who has AIDS and is in the prison infirmarv., How do I know what precautions to take? Just as you would for any inmate being treated for a communicable illness, consult the DOCS facility Nurse Administrator to determine what, if any, precautions are advised for DOCS staff and Parole Officers. (Note: For epidemiological and medical purposes, AIDS is not classified as a communicable disease.) Can I conduct my Pre-Board Summary interview with an immate with AIDS by telephone? There is no medical evidence to suggest that AIDS is transmitted through casual contact. In most instances these interviews can be safely conducted in a face-to-face contact; face-to-face interviews with these irmates shall be the expected standard. Where, however, facility medical staff recommend that face-to-face contact not take place, after consultation with the Senior Parole Officer, a telephone interview may be arranged. In all instances where deviation fram the face-to-face interview procedure occurs, an entrv shall be made in the immate's case record stating the basis on which such a decision was rendered. Written notice of all such actions shall be forwarded to the Area Supervisor with a copy to the Parole Services Program Specialist. Inmates with AIDS who are scheduled to appear before the Parole Board are often not ambulatory and may not be present at a given facilitv on their Board date. What can these immates expect with regard to Board action in their cases? An ambulatory inmate with AIDS who is in the facility infirmarv should appear before the Parole Board in the Parole Board roam if at all possible. A non-ambulatory immate with AIDS who is in the facility infirmary will, if necessary, be visited by the Parole Board members in the infirmary. Institutional Parole staff are responsible for coordinating with Correction staff to insure that appropriate arrangements for these interviews are made. An immate with AIDS who is in the cammunity hospital and is unable to appear or be seen at the facility infirmary will, if an initial applicant, be postponed for no more than two months or earlier to determine the arrangements necessary to accamplish the Parole Board appearance. Once a determination has been made, arrangements should be implemented without delay. In most instances this will include an assignment of a special panel of the Parole Board to conduct the parole interview at the community hospital. In the event an inmate with AIDS is scheduled to return to the correctional facility and the medical condition indicates no emergent need to provide an on-site community hospital visit, the irmate will be scheduled for the rext available Board at the facility of return. IIT=3 Appendix D 101 In reappearance cases where the immate is in a cammunity hospital, the Board will direct an immediate and expeditious investigation with regard to the inmate's medical condition. As a rule, this period of investigation by the institutional Parole Officer should not exceed two to three weeks and should result in a report to the Board concerning the seriousness of the disability and the likelihood of return to the institutional setting. Based upon a case-by-case decision following review of this report, the Board will make a determination relative to the urgency attached to an on-site community hospital Board appearance. Where return to the facility bv th=2 inmate can be anticipated, the inmate will be seen at the next Board panel visit at the facility. Otherwise, a special panel will be assigned to conduct the parole interview at the cammnity hospital. It is the responsibility of the Senior Parole Officer at the institution to insure that all necessary information and reports are prepared. for the Board in a timely and enhanced fashion in order to eliminate unnecessary delay in these cases. If there is a need to discuss plans for the Roard interview in advance, Parole staff should contact the Executive Secretarv to the Board of Parole to discuss the case. 8. Q: What should I do if an immate with AIDS or ARC is transferred from my institution to another prison? A: The Parole Transfer Summary prepared in these cases should be "flagged" in order to alert the receiving Parole Office that the case requires special attention, similar to the manner in which cases involving T.B. or extreme suicidal tendencies are identified. All available information concerning the immate's medical condition should be noted in the summary, as well as any immediate needs of the irmate which would have an impact on the receiving facili 2 LR JTO¥Vd ANV NOILVEOdd NI SdIV 0 :Queé es el AIDS (SIDA)? AIDS es el Sindrome de Immuno Deficiencia Adquinda. El virus llamado HIV produce el AIDS (SIDA). El AIDS ha causado la muerte en todos los grupos sociales, principalmente de estos grupos: Mujeres y hombres que han tenido relaciones sexuales con personas de estos grupos Hombres y mujeres que usan agujas para drogarse Homosexuales y bisexuales Gente que ha recibido sangre que contiene el virus del AIDS Ninos nacidos de padres que pertenecen a estos grupos ¢Coémo se contrae el AIDS? La sangre y el semen son portadores del virus del AIDS. El fluido vaginal también puede llevar el virus del AIDS. La sangre y el semen tienen que ir directamente de una persona infectada a otra. Al comparur agujas durante el uso de drogas, también contrae el virus. Una mujer embarazada puede transmitir el virus a su bebe por nacer. Tu no puedes contagiarte con el AIDS por: Los besos: Besos en la piel son seguros. El virus del AIDS puede estar en la saliva, pero no sabemos de alguien que haya contraido el AIDS por besos de boca a boca. Tocandose: Tu no puedes contagiarte con el AIDS tocando a una persona con AIDS o estando cerca de ella. Comer: Tu no puedes adquirir el AIDS comiendo con una persona con AIDS. Estornudando, usando vestidos o usando la cama de una persona con AIDS. :Cémo puedo saber si tengo el virus del AIDS? Tu puedes hacerte un examen de anticuerpo en que se muestre si eres portador del virus del AIDS. Algunas personas que tienen el virus, se enfermaran. Conversa con un doctor, una enfermera o anda a un centro de salud para averiguar mas sobre el examen. :Cémo puedo protegerme a mi mismo/a y a mi companero/a? No se puede decir que alguien tiene el AIDS, por su aspecto externo. Sigue las siguientes Instrucciones: Para sexo anal o vaginal: Usa siempre un condoén. Usa un condén y un espermicida. Los espermicidas matan el esperma en el semen. También matan el virus del AIDS en el semen. NO USE aceite vegetal, mineral ni vaselina con el condon. Estos danan facilmente el condén y lo rompen. Sique las instrucciones del paquete del condon. jAsegurate que el condén no se rompa! iNo uses el condén mas de una vez! Para sexo oral: No dejes que entre el semen de un hombre infectado en tu boca. El fluido vaginal de una mujer infectada puede transmitir el virus. La sangre del flujo menstural también puede portar el virus. El sexo oral con una mujer infectada es de mavor riesgo cuando ella esta con su periodo menstrual. TU PUEDES DETENER EL AIDS Sigue los consejos de este folleto. Usa siempre condones y no compartas agujas. J xipuaddy 121 Signs of AIDS: Swollen glands Dinnhea Night sweats ry cough Tied each day Fever Unexplained weight loss If you are worried about AIDS or feel sick, vou can get help: In Jail Contact the medical office or call Forensic AIDS Project: (115) 86:1-4589 Out of Jail Call the AIDS Hotline. In San Francisco: (415) 863-AIDS In Northern California: (toll-fice) 800-FOR-AIDS TDD (for deal people): (415) 864-6606 or call the Forensic AIDS Project: (-115) 861-4589 Partial funding for this brochure was provided by the San Francisco Department of Public Health and by the Calilornia Department of Health through the San Francisco Department of Public Health Consultation and editing: Fducation Programs Associates Hustations: Peggy Modine Design: Shelley Flarper Typography: Fa Raza Graphics Center This boc hine was prepened by the Forensic AIDS Project of the San Francisco Department of Public Health Fl Meshoal Services and produced by the San Francisco AIDS Foundanon SI AIDS San Francseo MIDS Foundation FOUNDATION TH Valencn Steet NGL Fonmnth Flow tS San Fomaiseo, CA 91107 7 , ca HT0YVd ANV NOILVEOYd NI SAIV TI You can get AIDS from sex or sharing needles. You can stop AIDS: Never share needles or works. Always use a rubber (condom) when you have sex. You can't tell who has AIDS by how they look. Someone can feel and look OK. © and sull give ATDS 10 vou il you have sex with them or shane needles with them. You can give AIDS to your unborn baby without knowing it. Get medical help right away if you are pregnant. You can’t get AIDS hom touching, food, sneezes, toilet seats, clothes or sheets. q xipuaddy Cl What's the Connection? rugs and alcohol are known to cause a D variety of health problems. Recent research has indicated that alcohol, as well as such street drugs as amphetamines (speed), marijuana, and nitrite inhalants (poppers), all damage the immune system, leaving the user open to infection and cancer. The reasons for the use of drugs and alcohol are as varied as the individuals who use them. Much of this drug use may have begun innocently but progressed to a point of harm, carrying with it many health risks Drugs and alcohol are believed by many researchers to be significant factors in increasing personal risk for AIDS: The cause of AIDS is a type of virus (called a retrovirus) which changes the structure of the cells it attacks. It may require the presence of an already damaged immune system before it can cause disease Alcohol and drugs interfere with many types of medical and alternative therapies for AIDS Alcohol and drugs alter the judgment of the user, who may become more prone to engage in activities which put people at high risk for AIDS Alcohol and drug abuse causes stress, including sleep problems, which harms immune functioning The AIDS crisis has brought about a grow- ing health awareness. For many people. this means re-evaluating their drug and alcohol use Alcohol Icohol abuse is one of the leading health problems in the United States. Exces- sive drinking causes disease in every part of the body. Alcohol abuse decreases white blood cell counts, causing the body to respond poorly to infection Alcoholic liver disease inhibits the body’s ability to form T-cells (white blood cells affected by AIDS) Chronic abusers of alcohol have fewer T- cells. Alcohol abuse is a co-factor in the develop- ment of many forms of cancer. Chronic abusers of alcohol tend to have poor nutritional intake, leading to a gener- alized state of poor health. Alcohol abuse interferes with the body's use of vitamins and minerals necessary to maintain a healthy immune system Amphetamines (Speed, Crank) mphetamine use can lead to numerous A health problems. Using contaminated needles is a known risk factor for con- tracting AIDS. There is also risk of injecting foreign bodies into the blood stream which may cause damage or infection Use of amphetamines in any form, whether injected or not, can damage many body sys- tems, including the immune svstem Liver damage from amphetamine use causes an overall suppression of the white blood cell count, diminishing response to infection Malnutrition due to appetite suppression deprives the body of essential vitamins and nutrients, causing a general decline in health Amphetamine euphoria may lead to behav- ior generally accepted as increasing risk for contracting AIDS Marijuana arijuana is a widely used drug, often believed to have few harmful effects However, recent research has indicated that it may lower the body's ability to fight infection. One study has shown a decrease in antibo- dies circulating in the blood stream of fre- quent users. Another study of frequent users has found abnormalities in T-cells function closely resembling those found in AIDS Impaired judgment may make the user more prone to engage in high risk sexual activities Nitrites (Poppers, Amyl) oppers were one of the first factors con- P sidered as a possible cause of AIDS due to their widespread use as a new sexual stimulant in the gay community. The role played by this drug in AIDS has yet to be understood ® Some researchers believe poppers may be a co-factor in the development of AIDS There is strong evidence that poppers lead to generalized suppression of the immune system Some research indicates that poppers may be a co-factor in the development of Kapo- SIS sarcoma Other Drugs esearch into the effects on the immune R system of drugs such as cocaine, heroin, Quaaludes, and manv others is not yet available. This does not mean that these drugs are safe. Problems may stem from direct bodily harm from the drug or from impaired judgment What To Do IFYOU .... ® Feel a loss of energy, ® Are under a great deal of stress, * Develop infections easily, * Eat poorly or have no appetite, or ® Fear that you might have AIDS AND YOU DRINK OR USE DRUGS, e Cut down or stop. ® Don't share needles. Learn to “get high” without drugs. Try to reduce stress. Techniques include meditation, exercise, hobbies, support groups, friendships. Eat well and get plenty of sleep. Follow “safe sex” guidelines. Know the signs and symptoms of AIDS. Get regular medical checkups. Seek professional help for drug and alco- hol problems. For more information about AIDS and sensitive health care referrals, call the San Francisco AIDS Foundation Hotline 333 Valencia Street, 4th Floor San Francisco, California 94103 (415) 863-AIDS or Northern California AIDS Hotline 1-800-FOR-AIDS Text by the Committee on Substance Abuse and AIDS, San Francisco, California Translation by Lucrecia Bermudez Production by San Francisco AIDS Foundation, and the Pacific Center AIDS Project Partial funding provided by San Francisco Department of Public Health and the California Department of Health Services through the San Francisco Department of Public Health © July 1986 HT10dVd ANV NOILVEOdd NI SAIV ¥TI CORTEREN TE PHL + ¢Cual Es La Relacion? F s sabido que el alcohol vy las dro- gas son la causa de una variedad de problemas de la salud Recientes estudios han indicado que el alcohol, al igual que otras drogas, como anfetaminas, marihuana e inhalantes de nitrito, todas danan el sistema inmuno- logico, dejando al que usa estas drogas propenso a infecciones y cancer Las razones para el uso de drogas vy alco- hol son tan variadas como los individuos que las usan. Mucho del uso de estas dro- gas puede que haya empezado inocente- mente, pero aumento a un punto de peli- gro, acarreando con ello muchos otros problemas de la salud Muchos investigadores creen que las dro- gas y el alcohol son factores significativos en el aumento del riesgo personal de con- traer AIDS ® La causa de AIDS es un tipo de virus (llamado retrovirus), el cual cambia la estructura de las células que ataca Puede que requiera la presencia de un sistema inmunoldgico ya dafiado, antes que una enfermedad pueda iniciarse El alcohol y las drogas interfieren con muchos tipos de terapia, médica y alter- nativa, en el tratamiento de AIDS El alcohol y las drogas alteran el juicio del que las usa, pudiendo asi com- prometerse a participar en actividades que signifiquen el exponerse al alto riesgo de contraer AIDS El abuso de alcohol y drogas causan alta tension, incluyendo problemas al dormir, los cuales afectan el funciona- miento inmunologico La crisis de AIDS ha producido un aumento de conciencia sobre la salud Para mucha gente esto significa la reeva- luacion de su uso de drogas y alcohol Alcohol | abuso del alcohol es uno de los F mas graves problemas en los EE UU. El tomar excesivamente causa enfermedades en todo el cuerpo ® El abuso del alcohol disminuye el numero de globulos blancos, causando una pobre respuesta a las infecciones . Enfermedades en el higado producidas por el alcohol. inhiben la habilidad del cuerpo para formar células T (globulos blancos afectados en AIDS) Los alcohdlicos cronicos tienen pocas células El abuso del alcohol es un co-factor en el desarrollo de muchas formas de cancer ® Los que abusan del alcohol tienden a tener una nutricion pobre, llegando a un estado generalizado de mala salud El abuso del alcohol interfiere con el uso que el cuerpo hace de vitaminas y minerales, nece- $arios para mantener un sistema inmunolo- gico saludable. Anfetaminas 1 uso de anfetaminas puede oca- F sionar nuevos problemas de salud. El uso de agujas contaminadas es un conocido factor de riesgo para contraer AIDS. Existe, ademas, el riesgo de invectar cuer- pos extranios en la corriente sanguinea, lo cual puede causar dao o infeccion. El uso de cual- quier forma de anfetaminas, sea invectada o no, puede dafar muchos sistemas del cuerpo, incluyendo el sistema inmunoldgico. El higado daiiado por el uso de anfetaminas causa una supresion total del numero de glo- “bulos blancos, disminuyendo la respuesta a la inteccion La malnutricion debida a la disminucion del apetito, priva al cuerpo de las vitaminas y nutrientes escenciales, ocasionando un declive en la salud en general La euforia de la anfetamina puede provocar un cambio de conducta, generalmente acep- tada como un incrementu del riesgo de con- traer AIDS Marihuana a marthuana es una droga amplia- | mente usada, v se cree que tiene pocos efectos dafinos. A pesar de ello, estudios recientes indican que la marihuana puede disminuir la habilidad del cuerpo para controntar una inteccion ® Un estudio ha mostrado una disminucion de los anticuerpos, que circulan en la corriente sanguinea de los consumidores de la droga Otro estudio de consumidores frecuentes, ha encontrado anormalidades en la funcion de células T, bastante parecidas a las encontra- das en AIDS El desvirtuado juicio puede hacer que el con- sumidor esté mas propenso a participar en actividades sexuales de alto riesgo. Nitritos os “poppers” fueron uno de los | primeros factores considerados como posible causa de AIDS, debido a su uso generalizado como estimulante sexual en la comunidad homosexual. El rol que esta droga juega en AIDS tiene aun que ser entendido. Algunos investigadores creen que los “poppers” pueden ser un co-factor en el desar- rollo de AIDS. Hay una fuerte evidencia que los “poppers” generan una supresion total del sistema inmunologico. Algunos estudios indican que los “poppers” pueden ser un co-factor en el desarrollo de sarcoma Kaposi Otras Drogas studios sobre los efectos, en el sis- F tema inmunoldgico, de ciertas dro- gas como cocaina, heroina, Qualudes vy otras muchas, no estan aun disponibles. Esto no significa que estas drogas no sean un peligro Hay problemas que pueden provenir directa- mente del cuerpo afectado por drogas o juicio desvirtuado. Lo Que Se Puede Hacer Si tu * Sientes la perdida de energia, ® Estas bajo una gran tension, * Desarrollas infecciones facilmente, * Comes muy poco 0 no tienes apetito, * Temes haber adquirido AIDS Y BEBES O CONSUMES DROGAS + Consume menos estas sustancias o deja de hacerlo. No uses agujas. Aprende a “elevarte” sin drogas. Trata de reducir la tension. Las técnicas incluyen meditacion, ejercicio, distraccion, grupo de apoyo y amistades. Come bien y duerme bastante. Sigue las guias para un “sexo seguro.” Conoce los signos y sintomas de AIDS. Ten chequeos médicos regulares. Busca ayuda profesional para los problemas de drogadiccion y alcoholismo. Para mayor informacion acerca de AIDS, llama a la Linea de Emergencia de la Fundacion AIDS en San Francisco. 333 Valencia Street, 4th Floor San Francisco, California 94103 (415) 863-AIDS en el Norte de California 1-800-FOR-AIDS libre de recargo Texto del comité de Abuso de Substancias/AIDS, San Francisco, California Traducido por Lucrecia Bermudez Producido por San Francisco AIDS Foundation Pacific Center AIDS Project Subvencido parcialmento por el Departamento de la Salud Publica de San Francisco y el Departamento de los Servicios de Salud de California por medio del Departamento de la Salud de San Francisco. © July 1986 Home Phone Day Phone APPLICATION FORM [f vou are interested in becoming a buddy or vou are a person with AIDS or ARC who is nterested in having a buddy, please fill out this form and mail it to ELLIPSE: Peninsula AIDS Services. 631 Woodside Road. Redwood City, CA 94061. (City) Street) I am interested in becoming a buddy. [ am interested in having a buddy. be q xipuaddy Name Address ya! San Mateo County AIDS Project Department of Health Services 225 W. 37th Avenue San Mateo, CA 94403 ELLIPSE 631 Woodside Road Redwood City, CA 94061 BLILIPSIY The Buddy Program is coordinated by Bill Glenn. Initial training, continued education and ongoing professional support are provided by the County of San Mateo. Buddies is a program of ELLIPSE: Peninsula AIDS Services Inc. For further information call: San Mateo County AIDS Project (415) 573-2588 or ELLIPSE: Peninsula AIDS Services (415) 366-AIDS AIDS PROJECT County of San Mateo Department of Health Services 225 W. 37th Avenue San Mateo, CA 91103 4T0¥Vd ANV NOILVEO¥d NI SAIV 971 CUDDIES RESPOND TO A NEED: AIDS is a community problem. The number of people affected by AIDS has been increasing dramatically in the last five years. It is projected that by 1991. there will be over 220.000 cases of \ IDS in the United States. San Mateo County is expected to share proportionately in this increase. In addition, for every person with AIDS there are