Adopting Precautions Against HIV Infection Among Male Prisoners: A Behavioral And Policy Analysis

• Author: Randy Martin,Sherwood E. Zimmerman
• Published date: 01 December 1990
• Date: 01 December 1990
• DOI: http://doi.org/10.1177/088740349000400404
• Subject Matter: Articles

330
Adopting Precautions Against HIV Infection
Among Male Prisoners: A Behavioral And Policy
Analysis
Randy Martin
Indiana University of Pennsylvania
Sherwood E. Zimmerman
Indiana University of Pennsylvania
Abstract
This analysis examines the potential impact of prison-based AIDS educa-
tion programs by integrating data collected at a minimum-medium security
institution in the Pennsylvania State Department of Corrections into
Weinstein’s (1988) model for adopting precautionary behavior. Expectations
concerning the potential for behavior change are used to assess the viability
of changing HIV risk behavior through prison-based AIDS education
programs. We conclude that such behavior change is in fact possible, but
highly unlikely. Behavior change is inhibited by a series of constraints in
the prison environment that preclude the effective implementation of AIDS
prevention activities. In addition, a variety of factors create a lack of political
commitment to prison-based AIDS education efforts. As a result of these
impediments, the primary contribution of these programs to date has been
their prophylactic effect against staff and inmate litigation.
Introduction
When AIDS emerged as a major public health issue in the mid-1980s,
there was concern that prisons might become sink holes for this modem
pestilence. The fear generated by AIDS in correctional settings created a
variety of management problems as administrators scrambled to address in-
mate and staff uncertainties about their safety. Perhaps the most acute problem
at that time was the threat of inmate-on-inmate violence against those known,
or even perceived, to be HIV positive. One common response was to put
While the authors wish to thank the Pennsylvania Department of Corrections for their support
and assistance in this project, the conclusions expressed here represent the views of the
authors and do not necessarily reflect those of the Pennsylvania Department of Corrections.

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in place some type of basic AIDS awareness or education program (Hammett,
1989), in the hope of reducing inmate and staff fears through the dissemination
of knowledge. In addition to this immediate management goal, many respon-
sible correctional administrators also hoped that these programs would have
some impact on the general public health problem of AIDS. A final goal
was to address the need to have some prospective protection against inmate
lawsuits. While this final goal may not have been overtly articulated, it was
nonetheless a powerful impetus to the development of prison-based AIDS
education programs.
Generally speaking, prison-based AIDS education programs seem to have
provided reasonable insulation from adverse judgments stemming from inmate
initiated litigation (Coughlin, 1988; Hunt, Moini and McWhan, 1990). It
also appears that the dissemination of accurate information has dispelled
many unfounded and potentially destructive fears among inmates and staff,
which probably has improved the quality of the living and work environments
within the institutions. Unfortunately, data do not exist to allow for more
definitive conclusions about this point.
No rigorous empirical information concerning the behavioral impact of
prison-based AIDS education programs currently exists. This lack of infor-
mation has the unfortunate consequence of limiting their potential impact
on the general health problem posed by AIDS. Three factors appear to have
contributed to this information deficit. First, given the high levels of fear
and confusion that initially characterized the AIDS crisis in corrections,
programs were hastily developed and implemented in an attempt to &dquo;do
something.&dquo; Consequently, little thought was given to exactly what the
programs should be designed to do, and to what information and formats
would be the most functional.
The second factor reflects the current state of knowledge concerning in-
traprison HIV transmission rates. The epidemiological data indicate that the
seroconversion rates within prison populations have been consistently less
than 1/2 of one percent per prison year (Horsburgh et al., 1990; Brewer et
al., 1988; Kelley et al., 1986). These rates are much lower than originally
feared, which has led to a reduction in concerns that prisons will become
breeding grounds for AIDS. This reduced concern has resulted in a con-
comitant diminution of interest in assessing the effectiveness of AIDS
programs that are intended to modify high-risk behaviors within this popula-
tion. Given these findings, and recent medical advances in treating HIV
infected individuals, the central focus of AIDS as a problem in prison seems
to have shifted to the provision of effective treatment for symptomatic AIDS
patients.
A
third potential factor is the ambivalence of correctional administrators
about their appropriate role in impacting AIDS as a public health problem.
In light of burgeoning prison populations and shrinking per capita resources,
it is understandable that corrections administrators are chary about what

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legitimately and reasonably can be expected of them in terms of altering the
post-release behavior of inmates. Such confusion and caution is under-
standable with a health problem like AIDS, because one set of high- risk
behaviors (sexual activity) is not within the legitimate purview of the criminal
justice system, and the other set (intravenous drug use) has been resistant
to criminal justice intervention (see, Walker, 1989; Moore and Kleiman,
1989).
Despite the apparent decline in interest and the lack of clarity about the
role of prisons in altering post-release behavior, AIDS education is an area
that warrants attention. Such attention is justified on several grounds. First,
prisons house a relatively high concentration of persons exhibiting risk-related
factors (Hammett, 1988). It has been estimated, for example, that a sample
of 100 to 500 members of the general population would be needed to find
one person with a history of repeated IV drug use. By contrast, a sample
of 100 prisoners could be expected to generate 30 individuals with such a
history (Vlahov and Polk, 1988). Second, the data indicate that a substantial
fraction of incarcerated individuals are HIV positive. Celentano et al. (1990)
report in-prison HIV infection rates ranging from 0.3 percent in Iowa in
1986, to seven percent in Maryland each year from 1985 to 1987, to 17.4
percent in New York in 1988. Third, there is considerable evidence that
prisons provide a dense pool of high-risk individuals who are difficult to
reach in other settings (Chronis and Simpson, 1989). The bulk of this in-
carcerated pool is made up of intravenous drug users (IVDU’s) who are
often underrepresented in community-based studies, largely because the sam-
pling frames used in these studies are typically based on participant lists
from treatment programs. The available evidence suggests that, whereas the
majority of those in drug treatment programs have a history of prison con-
finement (80 percent) (Craig, 1980), many of the IVDU’s in prison (13-50
percent) do not have a history of prior drug abuse treatment (Barton 1980,
1982).
We
begin our analysis by examining the possibilities for fostering changes
in AIDS related risk behaviors through prison-based education and awareness
programs. While there is a dearth of data specifically and directly addressing
the behavioral impact of prison-based AIDS education programs (Zimmerman,
Martin and Vlahov, 1991), it is possible to conduct an indirect assessment,
using data collected at a minimum-medium security institution in the Pen-
nsylvania State Department of Corrections (PDC). The data were gathered
to assess inmates’ general knowledge and attitudes about AIDS and their
individual perceptions about the risk of HIV infection. While these data do
not include any direct measures of behavior change, nor intent to alter behavior,
they provide some insights into the likelihood of such change when interpreted
within the framework of a model developed by Weinstein (1988). This model
is designed to explain the processes involved when individuals adopt precau-
tionary behavior to avoid hazards. The expectations concerning the potential

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for behavior change gleaned from this analysis are used as a springboard
for discussing the viability of changing HIV risk behavior as a goal of prison-
based AIDS education programs. The analysis then moves to the issues of
implementation and to policy considerations relating to the appropriate pur-
poses to be served by such programs.
The Model
Neil D. Weinstein’s (1988) model of the &dquo;precaution adoption process&dquo;
provides the framework for this analysis. The central question addressed by
precaution adoption theories is &dquo;When will people act to protect themselves
from harm?&dquo; (Weinstein, 1988: 355). There are a variety of precaution adop-
tion models, all of which provide some insight into why and how people
decide to avoid hazards (see Maddux and Rogers, 1983; Rogers, 1975, 1983;
Rogers and Mewbom, 1976). Of these, Weinstein’s model seems the most
applicable for our analysis of prison-based AIDS education programs.
Weinstein incorporates aspects from expectancy-value, utility, and other
precaution adoption theories, but includes factors that have traditionally not
been addressed (egs. costs and benefits over time, cues to action, competing
life demands, and differences between actual decision behavior and rational
ideals).
Weinstein (1988) characterizes the decision to adopt precautions as a
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