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AIDS Knowledge Among Prisoners

A population behind bars can be forgotten, especially when AIDS education programs are being created. Yet prisoners are an identified high-risk group for AIDS and HIV due to unsafe sexual contact and the sharing of intravenous needles inside and outside prison. Inmates therefore require HIV education and prevention programming designed specially for their needs and delivered while they are still in institutions.

In 1991, the John Howard Society of Metropolitan Toronto undertook an initiative concerning HIV and AIDS education among offenders. This prison reform and advocacy agency conducted Canada's first assessment of AIDS education needs among the prison population. The study determined prisoners' level of knowledge and awareness concerning HIV and AIDS. ft also examined their opinions about education, prison exit kits, condom distribution, bleaching kits and needle exchanges in the community. The ultimate goal of this study was to collect information which would assist in the development of an AIDS education and prevention program specially tailored to the needs and preferences of the prison population.
Method of Study This study was conducted in cooperation with the Ontario Ministry of Correctional Services. A total of 100 adult male offenders from two provincial correctional facilities in Toronto were randomly selected and interviewed. Fifty-five men participated from the Metropolitan Toronto West Detention Centre (15% of the centre's adult male sentenced and remand population for the dates the interviews took place) and 45 men from Mimico Correctional Centre (17% of the centre's sentenced population for the dates the interviews took place).

Participants were approached individually, the purpose of the survey was explained and informed consent was obtained. They were assured anonymity and confidentiality, and were given the options to refuse to answer any uncomfortable questions and to end the interview at any time. Prisoners were not asked their name, institution number, nature of current offence or HIV serostatus. A survey-questionnaire was used to collect the data.

For those who agreed to participate, the questionnaire was administered individually in an interview style in a private room. Questions were read to participants and verbal answers were recorded directly on the questionnaire. Although a few questions were open-ended, most required a straightforward answer. The interviews each lasted about one hour. All participants completed the questionnaire (i.e., no inmate ended the interview prematurely).

The results of the study were significant, not only because they described the needs of an unresearched population, but also because they strongly substantiated the need for prisoner-specific HIV/AIDS education programming. Findings The typical inmate in this study was between the ages of 18 and 22, a repeat offender and born in Canada with an education level of Grade 9 to 11. The sample's age range was 18 to 54 years. While 21% of participants were first-time offenders, 65% were repeat offenders who had served provincial sentences only and 14% were repeat offenders who had served both provincial and federal sentences.

Sixty-one percent of the inmates studied were born in Canada, while 19% were from the West Indies/Caribbean - the high proportion of this ethnicity is typical of the Toronto region, but not of other or more remote provincial institutions in Ontario. Conversely, only 3% of the sample were native Canadian - this statistic is also attributable to the location of the study; the native population found in Northern Ontario correctional facilities is significantly higher than in Toronto facilities. Therefore, data were not compared along multicultural lines.

To assess the inmates' level of awareness and knowledge concerning HIV and AIDS, inmates were asked questions concerning definitions of AIDS-related terminology, HIV transmission and prevention, HIV testing and interpreting a negative (HIV-) result and general understanding of the etiology of the virus in relation to HIV illness and AIDS. These questions were asked throughout the interview and appeared in different sections of the questionnaire. The intent of this strategy was to gather information without creating a test environment. This strategy was also used to deter-mine what prisoners knew about HIV and AIDS, what they did not know and what misconceptions or myths they held. Misconceptions Overall, prisoners had a relatively high level of awareness and knowledge about HIV and AIDS. However, rather alarming misconceptions were identified among the inmates. For example, 56% believed that HIV could be contracted by donating blood, 46% considered tongue kissing to be a risk, as well as sharing food or a cup (28%), sneezing or coughing (28%) and mosquitoes (34%). Answers to these questions concerning HIV transmission showed a specific, and considerable, lack of knowledge. Clearly, certain means of contracting a virus specific to an airborne communicable disease were considered by some inmates as the same means for contracting the blood-borne/body fluid exchange communicable virus leading to AIDS.

Only 6% of the sample correctly gave the full term for the acronym AIDS, and only 3% for the acronym HIV. In total, 85% of the prisoners interviewed did not know the difference or the relation between HIV and AIDS. Although most were aware that a test for HIV exists (in fact, 44% have had themselves tested for the virus), very few had heard of anonymous HIV testing, nor could they define it.

Prisoners primarily believed that using condoms and knowing one's sexual partners were the keys to safer sex practices. Generally, public health messages concerning safer sex focus on condom use and knowing one's sexual partner; hence these same messages were reflected in the sample's knowledge.

Almost half the inmates understood a negative test result to signify that the person is conclusively not infected (HIV-free). Only about one third were aware of the need to retest following a negative test result for HIV. Sources of Information Prisoners were also questioned about what sources of information they used to learn about HIV and AIDS, whether they currently or in the past had received information on AIDS while in prison, if they were aware of AIDS information agencies and community groups in Toronto, whether they had gone to these agencies in the past and if they would in the future and where they would seek information on HIV and AIDS if they needed it.

A large proportion of prisoners identified the media as their only source of information. Thirty-two percent of participants said they received information from television, 22% identified the printed media and 4% the radio. Eighteen percent indicated they received information from pamphlets and posters at their physician's office. At the time of the interview, only 6% of the sample had received information about AIDS during their incarceration, while 21% had received information during previous incarcerations.

Overall, most prisoners had never heard of Toronto's many AIDS community agencies, or of other community groups which provide HIV/AIDS information or services. Also, most admitted that they would not go to such organizations because they did not actively seek such information. Inmates stated that should they require information, they would ask their family doctor for it rather than contact an AIDS organization. Prisoners gave rather phobic and naïve reasons for avoiding such organizations (e.g., afraid to contract HIV from members of the organizations, assumed that these are gay agencies and feared being perceived as homosexual). Educational and Prevention Programming All inmates agreed that education on HIV and AIDS prevention was important for all community members. The vast majority (92%) felt it would be useful to have education on this topic available in prison, and 87% supported the implementation of an HIV/AIDS education program. Inmates' perceptions concerning the educational needs of correctional staff were also investigated. All inmates interviewed agreed that correctional staff should receive training and education concerning HIV and AIDS.

When participants were asked their opinion concerning educational tools, video was the most popular medium chosen for educating the collective prison population, while written materials were a more popular choice for individual learning. Most inmates (58%) preferred a group format for receiving education on AIDS, while 32% preferred a one-on-one format with an AIDS educator. More inmates would attend an AIDS education program while in prison (if available) than in the community after release from prison.

Inmates were also asked their opinions about condom kits (containing one or two condoms with instructions and an AIDS pamphlet) and bleaching kits (containing bleach, water, instructions for cleaning injection needles, condoms and an AIDS pamphlet). Most supported the availability of condom kits in the community, two thirds supported bleaching kits and half supported a combined kit. Almost all inmates favoured the availability of a prison exit kit (condom with instructions and a pamphlet). In fact, three quarters said that they would use this kit if one were issued upon release from prison. Most prisoners were familiar with, and endorsed, the idea of a community based needle exchange program (receive one free sterilized syringe for every used syringe "traded"). Conclusion The John Howard Society's study has demonstrated that prisoners are in dire need of accurate and effective programming concerning HIV/AIDS education and prevention. Overall, prisoners gave strong evidence of supporting and desiring an AIDS education program in the prison system for both themselves and correctionai staff. They admitted they would not actively seek educational materials on HIV and AIDS outside prison, but would be receptive to obtaining such education while incarcerated, if it were offered. Also, they supported and encouraged the distribution of prison exit kits.

In January 1992, the needs assessment study was published in a report by the John Howard Society and included many recommendations.(1) One of these called for a comprehensive AIDS education program for prisoners and staff to be implemented in correctional facilities. The Society also recommended that a strategic and inclusive approach (education, tools required to practise safer sex and safer drug use) must be taken when designing such a program. Educational materials must be developed in consultation with external experts and community AIDS educators to ensure that the information is unbiased and accurate. The Society further recommended that to ensure effective endorsement of an AIDS strategy, management, correctional support staff, operations staff and medical staff should be included in its implementation.

The John Howard Society strongly believes that AIDS education programming should be a compulsory element in the prison environment, and that the prison population should be involved in the development of educational programming. Suggested tools include peer training (i.e., inmates trained to educate fellow inmates), a process which would facilitate a joint effort and, in turn, would nurture support and endorsement of the program and its importance.

(1)Copies of the report Prisoners and AIDS: An AIDS Education Needs Assessment are available from the National Clearinghouse on AIDS, 1565 Carling Avenue, Suite 400, Ottawa, Ontario K1Z 8R1; Telephone (613) 725-3769; Fax (613) 725-9826.
Get The Facts: Surviving in Prison and in the Community is Canada's first HIV/AIDS education book written for prisoners. It provides two components of information concerning HIV and AIDS - education and a resource directory of services and information available in the city of Toronto. It is a pocket book written at a Grade 7-to-8 level, using street language, and includes 19 illustrations. Get the Facts will be available for distribution in December 1992 and can be ordered from the John Howard Society of Metropolitan Toronto. The John Howard Society is completing a report on a knowledge-attitude-behaviour study concerning HIV/AIDS and prisoners. The report to this study will also be available for distribution in December 1992.