HIV/AIDS among Inmates of and Releasees from US
Correctional Facilities, 2006: Declining Share of Epidemic
but Persistent Public Health Opportunity
Anne C. Spaulding1*, Ryan M. Seals1, Matthew J. Page1, Amanda K. Brzozowski1, William Rhodes2,
Theodore M. Hammett3
1 Rollins School of Public Health of Emory University, Atlanta, Georgia, United States of America, 2 Abt Associates Incorporated, Cambridge, Massachusetts, United States
of America, 3 Abt Associates Incorporated, Hanoi, Vietnam

Abstract
Because certain groups at high risk for HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome)
come together in correctional facilities, seroprevalence was high early in the epidemic. The share of the HIV/AIDS epidemic
borne by inmates of and persons released from jails and prisons in the United States (US) in 1997 was estimated in a
previous paper. While the number of inmates and releasees has risen, their HIV seroprevalence rates have fallen. We sought
to determine if the share of HIV/AIDS borne by inmates and releasees in the US decreased between 1997 and 2006. We
created a new model of population flow in and out of correctional facilities to estimate the number of persons released in
1997 and 2006. In 1997, approximately one in five of all HIV-infected Americans was among the 7.3 million who left a
correctional facility that year. Nine years later, only one in seven (14%) of infected Americans was among the 9.1 million
leaving, a 29.3% decline in the share. For black and Hispanic males, two demographic groups with heightened incarceration
rates, recently released inmates comprise roughly one in five of those groups’ total HIV-infected persons, a figure similar to
the proportion borne by the correctional population as a whole in 1997. Decreasing HIV seroprevalence among those
admitted to jails and prisons, prolonged survival and aging of the US population with HIV/AIDS beyond the crime-prone
years, and success with discharge planning programs targeting HIV-infected prisoners could explain the declining
concentration of the epidemic among correctional populations. Meanwhile, the number of persons with HIV/AIDS leaving
correctional facilities remains virtually identical. Jails and prisons continue to be potent targets for public health
interventions. The fluid nature of incarcerated populations ensures that effective interventions will be felt not only in
correctional facilities but also in communities to which releasees return.
Citation: Spaulding AC, Seals RM, Page MJ, Brzozowski AK, Rhodes W, et al. (2009) HIV/AIDS among Inmates of and Releasees from US Correctional Facilities,
2006: Declining Share of Epidemic but Persistent Public Health Opportunity. PLoS ONE 4(11): e7558. doi:10.1371/journal.pone.0007558
Editor: Anastasia P. Litvintseva, Duke University Medical Center, United States of America
Received July 6, 2009; Accepted September 17, 2009; Published November 11, 2009
Copyright: ß 2009 Spaulding et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: Partial support by the Emory Center for AIDS Research (P30 AI050409). The funders had no role in study design, data collection and analysis, decision to
publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: ASpauld@emory.edu

community. Using the correctional setting as a venue for
diagnosing HIV disease could benefit those passing through CFs
as well as those living in the communities to which they return [2].
Primary and secondary prevention to reduce the high proportion
of HIV/AIDS borne by incarcerated persons could help reduce its
overall prevalence in the US.
Are CFs still important targets for public health interventions? If
the criminal justice population represents a smaller share of the US
HIV epidemic, intervening in the CFs may have a smaller impact
on the US population as a whole and may be less cost effective than
in 1997. If the number of inmates infected is still high, and if there
are individuals in the correctional population who have poor access
to healthcare when at liberty, CFs may remain important settings
for public health interventions. Development of public health
interventions that can capitalize on even brief access to incarcerated
individuals may provide additional justification for public health
agencies to work among persons passing through CFs.
A number of trends in the past nine years influence the answer
to these questions. While HIV seroprevalence among people in
CFs has declined from 2.1% in 1997 [3] to 1.7% in 2006 [4], the

Introduction
An earlier paper [1] estimated the share of selected infectious
diseases, including HIV/AIDS (human immunodeficiency virus/
acquired immunodeficiency syndrome), borne by persons who
spent at least part of the year in correctional facilities (CFs) in the
United States (US) in 1997. That paper examined the percentage
of individuals with a particular disease in the total US population
who passed through a US CF in 1997. Multiplying prevalence by
estimates of the size of the populations that moved through CFs
yielded projections that, among all persons in the US with HIV/
AIDS, between 20% and 26% had been incarcerated for at least
part of that calendar year [1]. The results were widely
disseminated; as of September 2009, according to www.Scholar.
Google.com, the paper has been cited 242 times. The findings
communicated the challenges presented by the disproportionately
high levels of infectious diseases in correctional settings. Furthermore, they demonstrated the importance of improving the health
of the community by treating jail and prison inmates, since
virtually all of those incarcerated eventually return to the
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releases in 2006 were taken from publications of the BJS and the
National Corrections Reporting Program (NCRP, website at
http://www.icpsr.umich.edu/NACJD/ncrp). Estimates of the size
composition of the stock population were taken from data
collected at mid-year (June 30) 2006. To estimate the total
number of jail admissions, we took data from the 2006 Annual
Survey of Jails (available on the NCRP website) and used the
method of Sabol and Minton [16] to derive a figure for total
admissions.
Other than an estimate published in one previous paper [1], we
are aware of no nationally representative data on re-arrest rates in
jail detainees published in the peer-reviewed literature. For this
paper, the estimate of the number of unique persons represented
by total jail admissions in a year was derived from several sources
of information: two smaller jails in jurisdictions with combination
jails and prisons; data from the 1989 BJS Census of Jails; a
previously published estimate by two of our authors (WR, TMH)
based on data from the Drug Use Forecasting System [1]; and
communication with four very large jail systems, collectively
representing 2.5% of all admissions nationwide, that have inmate
data reporting systems able to provide information on how many
unique persons were represented in the pool of all admissions for a
given year (see Table S1). An important caveat is that the various
sources provide counts of slightly different, but closely linked
events—arrest, booking, admission into a jail cell. The mean value
of the number of entrances into the pre-trial division of the
criminal justice system per individual in each data set was used as
our estimate of admissions per individual, because the data from
several sources provided similar estimates. Dividing the number of
total jail admissions in a year by the average number of jail
admissions per individual provides us with an estimate of the
number of individuals admitted to jail in a given year.
In order to determine the number of releases from jails in a 1-y
period, we first calculated the net yearly growth of the jail system.
The difference in average daily US jail population between 2005
and 2006 represents the balance between admissions and releases.
The residual number of persons indicates the number of persons
by which the jail population grew. By subtracting the amount by
which the population grew from the total number of admitted
individuals, we can estimate the number of unique releasees.
While jail admissions require an estimate based on national data
and recidivism rates, prison records allowed us to perform a more
complete enumeration of the number of individuals admitted and
released in a year. In the current paper, we wanted to account for
the growing number of persons admitted to state prison who are
same-year recidivists, predominantly parole violators. In 2006,
17% of the state parolee population returned to incarceration [17].
This phenomenon is not as pronounced in the Federal Bureau of
Prisons, where only 7% (8,521 of 128,774 parolees, or those on
supervised release) returned to federal custody during the same
year [17]. In the earlier paper, the number of prison releases was
considered a reasonable estimate of the number of different people
released from prisons because the average length of stay was
greater than one year. Therefore, the estimate did not reflect the
number of prisoners released on parole who returned to prison
within a year ([i] in Figure S1) [1]. Information on the frequency
of prison releasees who were readmitted and had more than one
release in a single year were taken from NCRP. Because 2003 data
were the latest available as of the preparation of this paper, we
compared state-by-state data from 2002 and 2003 to assess
stability and judge the suitability of extrapolation to 2006.
Records on all prison admissions from the 34 states reporting to
NCRP were reviewed (according to date of birth, race, and state of
imprisonment) to identify how many represented unique persons

number of inmates behind bars at midyear 2006 was 130% of the
that in 1997 (an increase from 1,725,842 to 2,245,189 persons)
[5,6]. At the same time, the way in which HIV affects the
correctional population has changed. Highly active antiretroviral
therapy (HAART) has markedly improved treatment for HIV,
resulting in prolonged survival among both infected inmates and
those previously incarcerated [7]. Rapid diagnostic algorithms for
HIV [8–11] and brief behavioral interventions for prevention and
management of HIV [12–14] have proven effective. Given these
trends and their important policy implications, our objective was
to recalculate the share of HIV/AIDS borne by correctional
populations in the US.
We developed new estimates of the size of the population
flowing through CFs in one year and the number of releasees that
same year. Our estimation methodology accounts for the fact that,
because so many individuals pass through more than once, neither
the reported number of CF intakes nor of releasees represents
unique persons passing though a facility. Using these estimates of
the number of persons ever incarcerated during a year and the
number of releasees, we developed estimates for the proportion of
HIV borne by the respective populations.

Methods
For this update, we estimated the share of HIV/AIDS in
incarcerated persons during 2006. Using data from the Bureau of
Justice Statistics (BJS), we estimated the percentage of inmates
afflicted with HIV/AIDS and applied these percentages to the
number of persons passing through CFs in 2006. Dividing this
period prevalence by the number of infected persons nationwide
provided estimates of the proportion of the US epidemic of HIV/
AIDS borne by inmates and releasees.
We used a period prevalence rather than point prevalence
because a 1-d snapshot of the incarcerated population fails to
describe adequately how many different people enter and exit CFs
during any given year. Jails and, to a lesser extent, prisons are
characterized by flux [15]. For example, the Atlanta City
Detention Center turns over its population rapidly, with a mean
length of stay of just 22.5 h (Sgt. Rafael Bryant, personal
communication, December 30, 2008). Prison inmates have a
mean length of stay of 3 y [15].
Figure S1 displays the relationships and movements between
locations within the correctional system, with the upper half
representing custody and the lower half representing freedom. A
hypothetical inmate may commit a crime, be arrested, be booked
into a jail, and enter a cell pre-adjudication (a), go to court, and be
sentenced and transferred to prison (e). For most individuals, this
would take place within one year. Our methodology strove to
account for this course of events and would count this individual as
one person admitted to the correctional system. If the individual
were eventually released on parole (k) and went on to recidivate
within one year, she or he would be represented by the dotted line
(i). If an individual was released from jail, either on bond or after
charges were dropped, and was subsequently re-incarcerated in
the same year on new charges, she or he would begin the travel
through the criminal justice system at point (a) again. Our
methodology counted this individual as just one person involved in
the criminal justice system in the given year. Any recidivism after
one year would make her or him a unique admittee in the next
year.

Number of Correctional Facility Inmates and Releasees
Data on the size of the stock population (those in cells and not
moving in or out during a given year), total admissions, and total
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to 3-y entry period, one can assign an estimate of the HIV
prevalence to the block and thus derive an HIV prevalence
estimate for the stock population as a whole (methodology
published in BJS bulletin [20] and L.N. Wright, personal
communication, July 30, 2008).
The earlier paper estimated that the true range of HIV was
between 1 and 1.5 times the BJS estimate [1]. For the present
paper, we took the BJS estimates as given since no evidence has
recently emerged that these estimates substantially deviate from
true values. Rates for HIV prevalence by race and sex were taken
from the 2004 State Inmate Survey. The inclusion criteria for
falling into the category of ‘‘other,’’ a category which comprises
those not fitting into three major race/ethnicity categories, either
because of multiple races, membership in another racial group, or
non-response, was not uniform and so minimum and maximum
values based on extremes of possible classification schemes were
estimated.
HIV in total population. In late 2008, the CDC released
data for 2006 on HIV/AIDS prevalence by race and ethnicity in
33 states with name-based reporting, based on new methodology
[21]. Data on AIDS prevalence is collected in all states and
reported to the CDC [22]. We used these CDC data for estimates
of AIDS prevalence in the total population.

and how many prisoners were admitted multiple times. To
extrapolate the figures for the remaining 16 states not included in
NCRP data, we calculated the overall percentage of BJS-reported
admissions comprising unique persons. We removed data from the
single state with a proportion of unique releasees more than two
standard deviations below the mean (California, with abnormally
high recidivism) and from the one state with a proportion of
unique releasees more than two standard deviations above the
mean (North Carolina, with abnormally low recidivism) and
recalculated the mean ratio of unique persons admitted relative to
total number of admissions. We next examined the trend of state
prison admission data from 2000 to 2006 as reported by BJS to
yield a year-to-year growth factor that would allow us to extend
2003 data to 2006. BJS statistics on admissions to Federal prisons
were added to yield the number of unique admittees to prisons
nationwide. We used the same approach to derive unique releasees
from prisons nationwide.
To estimate the total number of releasees in the community, we
accounted for people who were released from jail into prison. Data
from the State Court Processing Statistics of large urban counties
(available on the NCRP website) provided an estimate of the
proportion of individuals sentenced to prison who were detained
pretrial. This group of individuals released from jail directly to
prison was subtracted from the total number of jail releasees to
obtain the number released to the community.
In order to compare our 2006 estimates to the 1997 estimates,
we recalculated the 1997 prison release estimates using the new
approach. Because a complete enumeration of unique jail releasees
does not exist for 1997, we retained the earlier estimate of jail
releasees.

Sensitivity Analysis
We performed a bidirectional sensitivity analysis to assess the
stability of our estimate of the proportion of HIV/AIDS borne by
those released from CFs in 2006. To assess the extreme upper limit
of our estimate, we assumed that all jail and prison admissions and
releases reported by the BJS were, in fact, unique persons (inflating
the numerator) and employed the lower bound of the CDC
estimate for HIV/AIDS in the US (deflating the denominator). To
obtain a lower limit, we assumed that the average jail inmate was
incarcerated 1.5 times, and employed our point estimate for
unique prison releases and the upper bound of the CDC estimate
for HIV/AIDS in the US. We estimated how many fewer HIVinfected persons would be in the cohort of releasees if this higher
return rate were used and assessed whether or not the number of
releasees would decline by the same number of persons as did the
number of admittees. To estimate the difference in the likely
number of HIV-infected persons in this release cohort, we
multiplied the HIV seroprevalence of jail detainees by the number
of persons by which the release cohort declined.

Determining Sex and Race/Ethnicity Proportions
We sought to describe the composition of incarcerated
populations going in and out of CFs by race/ethnicity and sex.
The total number of persons ever inside a CF and the total
number of releasees is mostly influenced by the flow of persons
through jails [1]. We weighted the cohort by sex and race/
ethnicity proportionally to the demographics of its constituent
parts. We relied on self-reports of sex and race/ethnicity in recent
inmate surveys to derive demographic data. For prisoner race and
ethnicity demographics, we used a published 2004 survey of state
inmates [18]. For similar demographics for jail detainees, we used
results from the BJS 2002 Survey of Jail Inmates available on the
NCRP website. In both surveys, the term ‘‘whites’’ and ‘‘blacks’’
stood for non-Hispanic whites and blacks, respectively; ‘‘Hispanic’’
referred to those of Hispanic ethnicity regardless of race.

Results
Static or ‘‘Stock’’ Population, June 30, 2006
Estimates for the ‘‘stock’’ population, the number of persons
behind bars on June 30, 2006, are from the BJS, which estimated
that 1,479,179 persons were incarcerated in prison that day.
Adding to this the 766,010 jail inmates as of mid-year 2006, a total
of 2,245,189 adults were incarcerated in the US on June 30, 2006
[5].

Methods for Deriving HIV/AIDS Data
Data derived from BJS
2002 Survey of Jail Inmates were used to estimate overall HIV
prevalence among jail detainees who had been tested for HIV
[19]. Additional information was taken from CDC data on
HIV prevalence among untested jail detainees [10].
BJS produces annual estimates of the number of HIV/AIDS
cases in prisons based on reports from state and federal prison
systems. Testing practices vary widely between states, with some
systems testing all incoming inmates, some testing all outgoing
inmates, others conducting routine seroprevalence surveys, and
still others with little or no routine testing. The state with the
highest prevalence of HIV, New York, uses an innovative
methodology for estimating stock population prevalence; blinded
seroprevalence surveillance has been conducted on a sample of
sequential admissions every 2–3 y since 1988. Examining the
percentage of the current population that entered during each 2HIV in jail and prison populations.

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Number of Individuals Passing through Correctional
Facilities, 2006
From the 2006 Annual Survey of Jails data, using the method of
Sabol and Minton [16], we calculated that there were 12.8 million
admissions to jails in 2006. Data from the sources listed in Table
S1 gave a mean value for the number of incarcerations per
individual of 1.4. Dividing the total number of admissions by the
number of jailings per individual yields 9 million unique persons
admitted to jails in 2006 ([a+d] in Figure S1). The number of
releasees was found by taking the difference between the mid-year
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releasees used in the initial paper, we obtained a revised estimate
of 6.93 million jail releasees. NCRP data on prison releases in
1997 yielded an estimate of 368,263 unique releasees from state
and federal prisons. Thus, the revised estimate of unique releasees
from jails and prisons in 1997 is 7.30 million. This revised estimate
for the denominator changes estimates of the epidemic borne by
the correctional population only moderately (Table S6).

US jail population in 2006 (766,010) and 2005 (747,529). From
mid-year 2005 to mid-year 2006, the jail population grew by
18,481, meaning there were that many fewer releases than
admissions. Therefore, 8,981,519 unique persons were released
from jail to the community or prison in the year preceding June
30, 2006 ([b+c+e+g+h] in Figure S1).
Records from 2003 NCRP data on all prison admissions from
34 states showed that 354,120 unique persons were admitted in
these 34 states. This figure represents 71.95% of the number of
prison admissions reported by BJS (for concordant states, when
outliers California and North Carolina are ignored; see Methods).
According to BJS, in 2003 there were 96,416 prison admissions in
the 16 states not covered by NCRP. Reducing the total number of
admissions by the same factor (71.95%) yielded 69,376 unique
admittees. Added to the states already covered by NCRP, we
arrived at 423,496 unique admittees to state prison in 2003.
Comparison of 2002 and 2003 admission data from NCRP
showed very little variation between years, leading us to conclude
that the data were stable enough for short-term extrapolation. In
order to extrapolate to 2006, we examined the trend of state prison
admission data between 2000 and 2006 as reported by BJS. Yearto-year changes varied by factors ranging from 1.0157 to 1.0346
(average 1.0259). We used this average growth rate to project a
2006 estimate from our 2003 estimate to arrive at 457,261 unique
admittees to state prisons in 2006. Adding the 57,495 admissions
to federal prisons to this figure yields an estimate of 514,756
unique admissions to all US prisons in 2006.
Of the 514,756 unique admissions, 70.84% (364,653) of
individuals sentenced to prison were detained pretrial ([e] in
Figure S1). The difference in these two figures (150,103
individuals) was admitted directly from the street. The number
of jail detainees released to the community should therefore be
364,653 less than the number of total jail releasees, or 8,616,866
individuals ([b+c+g+h] in Figure S1).
The same methodology was applied to estimate 414,731 unique
releasees from state prison in 2003. To extrapolate to 2006, we
examined the trend of state prison release data between 2000 and
2006 as reported by BJS. With the exception of the year 2002,
which saw a 1% drop in releases, year-to-year growth varied by
factors ranging from 1.0219 to 1.0398 (average 1.0270). Applying
this growth rate to the 2003 estimate from NCRP data yielded
449,240 unique releasees from state prisons in 2006. Adding to this
the 47,920 federal releasees, there were 497,160 unique prison
releasees ([j+k] in Figure S1).
To derive the number of people in a CF at any point in 2006,
we added the number of unique jail admissions, the number of
prison admissions from the street, and the stock prison population
at the beginning of 2006 (the 1,525,924 persons in prisons the last
day of 2005). This calculation yielded 10,676,027 individuals.
In order to calculate the number of persons released to the
community, we summed the unique jail and prison releasees to
yield 9,114,026 individuals (Tables S2 and S3).
To examine the sex and race/ethnicity composition of those
ever in and those released from CFs, we weighted the population
by the sex and race/ethnicity makeup of the constituent parts. For
the total number of persons who were ever in a CF in 2006, about
85% were jail inmates. Releasees were composed of about 95% jail
detainees and 5% prisoners. Estimates of the correctional
population broken down by sex and race/ethnicity are shown in
Tables S4 and S5.
For comparative purposes, we recalculated our 1997 estimates
of releasees downward from 7.8 million, using the same correction
coefficients. We arrived at 384,009 unique persons admitted to
state and federal prisons in 1997. Applied to the 7.2 million jail
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HIV/AIDS: Period Prevalence among Inmates and
Proportion of the US Epidemic
Based on the varying testing practices among prison systems, the
BJS, in HIV in Prisons, 2006, reported prison HIV/AIDS
prevalence of 1.7% and an AIDS prevalence of 0.5% [4]. Because
some of these states do not routinely test for HIV, this estimate
may be inaccurate, but the bias could be in either a positive or
negative direction.
In a nationally representative survey of jail inmates’ medical
problems conducted in 2002, 1.3% of jail detainees reported
themselves to be HIV positive [24]. Of those surveyed however,
37.1% had never been tested [19,23]. MacGowan has shown that
approximately 0.8% of all jail inmates with unknown HIV status
are positive [10]. If 0.8% of the 37.1% of untested inmates are also
positive, it raises the overall jail HIV prevalence estimate to 1.6%,
which is almost as high as the estimate for prisons. As a previous
paper noted, jail and prison populations have similarities in
demographics related to HIV risk.[1] We applied an HIV
prevalence of 1.7% to both jail and prison populations.
Tables S7 and S8 show the estimated number of persons
infected, by race and sex. The HIV prevalence data by race and
sex, from the 2004 Survey of State Inmates (available on the NCRP
website), were multiplied by the number of persons in the
demographic category to give estimated crude estimates of the
number of persons infected, which are shown in Tables S7 and S8.
If none of the HIV-infected men ever in a CF classified as ‘‘other’’
were black, then 73,466 black men would be infected; if all of the
HIV-infected male prisoners classified as ‘‘other’’ were black, then
92,591 of black men would be infected. Possible ranges for the
numbers in other demographic groups among those ever in a CF
are shown in Table S7.
The revised CDC methodology estimated that 1,106,400
persons were living with HIV (range: 1,056,400–1,156,400) in
the US (50 states and the District of Columbia) in 2006 [21]. Based
on our estimates of 10,642,946 persons ever in a CF in 2006 and a
prevalence of 1.7%, 16.9% of all Americans with HIV/AIDS were
in a CF at some point in 2006. If none of the HIV-infected male
prisoners classified as ‘‘other’’ were black, then 22.1% of black
men living with HIV in the US would pass through a CF in 2006;
if all of the HIV-infected male prisoners classified as ‘‘other’’ were
black, then 27.9% of black men living with HIV would pass
through a US facility in the same year. Possible ranges for the
percentages for other demographic groups are shown in Table S7.
The CDC estimate for the number of persons living with AIDS
in the 50 states and the District of Columbia in 2006 was 447,720
[22]. If the prevalence of AIDS in correctional populations is
0.5%, then 11.9% of all individuals with AIDS were in a CF at
some point in 2006.
Table S8 shows similar calculations for the proportion of the
HIV epidemic borne by the 9,114,026 releasees from CFs in 2006.
Of all Americans with HIV/AIDS, 154,938 (14.0%) were released
from a CF that year. This represents a 29.3% decline from 1997
(Table S9). The proportion of the US black male HIV epidemic
represented by black men released from CFs in 2006 is likely
between 18.7% and 23.7% (Table S8). Of all Americans with
AIDS, 45,570 (10.2%) were released from a CF at some point that
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year (Table S8). This represents a 31.1% decline from 1997 (Table
S9).

from a jail to a prison and the number of releasees who would
return to the same type of facility in the space of 1 y. The
sensitivity analysis shows that even with faulty estimates, the
general trend is probably accurate. We emphasize the unlikelihood
of all jail and prison releasees representing unique persons. A
second limitation is that our recidivism data were based on rates of
return to the same institution. The assumption that recidivists
would be reincarcerated in the identical jurisdiction is not farfetched, given that many releasees would be on probation or
parole, which often stipulates residency in the same jurisdiction.
Third, HIV/AIDS prevalence in prisons and jails was largely
derived from self-reported data, and an estimate of the prevalence
in untested individuals was applied. We believe this would bias our
estimate of inmates with HIV/AIDS slightly downwards, if at all.
Because certain groups at high risk for HIV/AIDS come
together in correctional facilities, seroprevalence was high early in
the epidemic; 16.2% of men and 25.1% of women tested for HIV
in 1989 at the New York City jail on Rikers Island were found to
be HIV-positive [29]. The decline in HIV prevalence among
correctional populations has been offset by the growing number of
inmates. Although the proportional share of HIV/AIDS borne by
those passing through CFs has declined since 1997, the total
number of HIV infected persons who are in this flow has remained
steady at roughly 150,000 individuals, an estimate that is only
marginally perturbed by an assumption that each detainee is
incarcerated 1.5 rather than 1.4 times per year.
As the HIV epidemic has matured, the share borne by releasees
has decreased, but the total number of persons with HIV released
from CFs is unchanged. This steady size of the target population
leads us to conclude that CFs still represent a rich focus for public
health interventions. Interventions in CFs may have the greatest
impact on the HIV epidemic among minority men, given the
disproportionate incarceration rates in the US criminal justice
system. The proportion of minorities diagnosed with HIV late in
the course of disease, less than 12 mo before a diagnosis of AIDS,
continues to lag behind whites [30], so reaching minority
populations is a public health priority. Jail and prison inmates
represent a captive, and still very important, audience for HIV
testing, counseling, and prevention messages. After diagnosis,
enabling HIV-infected releasees to link to community care is of
utmost importance. Because virtually all persons entering CFs
return to the community, effective interventions benefit not only
CF populations but also the communities to which releasees
return.

Sensitivity Analysis
We assessed the stability of our estimate of the proportion of
HIV/AIDS borne by releasees from CFs. Treating all 12.8 million
jail releasees and 713,473 prison releasees reported by the BJS as
unique persons and using the lower bound of the CDC estimate of
HIV/AIDS prevalence in the US, the proportion of HIV/AIDS
borne by releasees is 20.6%, which is lower than the midpoint of
our revised estimate for 1997 and near the lower limit of the 1997
range. Given the uncertainty of the earlier estimate, we can
conclude that even if our estimates of unique releasees were grossly
inaccurate, the proportion would not have shifted substantially
from 1997 levels. To calculate a lower bound, we assumed that the
average number of incarcerations per jail inmate was 1.5 (the
highest return rate found in sources of data for Table S1). Using
this return rate yielded an estimated proportion of HIV/AIDS
borne by releases from CFs of 12.7%. The range of the estimate
was therefore 12.7% to 20.6%.
If 12.8 million jail admissions in 2006 represented individuals
who each were incarcerated 1.5 times rather than 1.4 times per
year, approximately 500,000 fewer persons were admitted to jail.
This adjustment would not change the number of persons who
were released from jail to go to prison or who were released from
prison; therefore, the absolute number of releasees would decline
by 500,000. Assuming an HIV prevalence of 1.7%, this
adjustment would mean that 8,500 fewer HIV-infected persons
(4.5% fewer than previously estimated) were released from
correctional facilities in 2006.

Discussion
We suggest four factors that could explain the diminishing
proportion of HIV/AIDS borne by the populations moving
through CFs; these four factors could contribute either alone or in
combination. First, with increased life expectancy for persons with
HIV with the advent of better therapeutics, infected persons are
aging out of the crime-prone years, generally considered to be
between the ages of 15 and 24. Second, while a person may have
been infected in his or her crime-prone years, with HAART,
prison AIDS mortality has fallen [20], and that person is more
likely to survive incarceration, be released, and stay out. Third, the
past decade has seen a decline in the number and proportion of
HIV/AIDS cases among injection drug users [21,22], probably
due to interventions to reduce the harm associated with parenteral
drug use.
Finally, considerable effort has been made by prison systems,
and some jails, to enhance discharge planning for HIV-infected
persons [24]. The effects of these programs are difficult to assess. A
controlled but non-randomized trial has been conducted in North
Carolina [25,26]. Preliminary results show a non-significant trend
in the efficacy of discharge planning, but final results have yet to be
published as of submission of this manuscript. Observational
studies seem to show that those CFs with adequate discharge
planning do better than those without [27]. A program in Rhode
Island compared the recidivism of HIV-infected women to
historical controls and found a significant difference in return
rates [28]. Enhanced discharge planning of HIV-infected inmates
beyond that usually received by prisoners may be contributing to
lower recidivism rates in the HIV-infected population in Rhode
Island.
One limitation of this study was the need to make numerous
assumptions about the proportion of persons who would move
PLoS ONE | www.plosone.org

Supporting Information
Populations Flowing through Correctional Facilities
Found at: doi:10.1371/journal.pone.0007558.s001 (1.61 MB TIF)

Figure S1

Table S1 Number of Individuals Represented in Total Admissions.
Found at: doi:10.1371/journal.pone.0007558.s002 (0.04 MB
DOC)
Table S2 Unique Persons Ever in a Correctional Facility during
2006.
Found at: doi:10.1371/journal.pone.0007558.s003 (0.03 MB
DOC)
Table S3 Releasees from All Correctional Facilities in 2006.
Found at: doi:10.1371/journal.pone.0007558.s004 (0.03 MB
DOC)
Table S4 Sex and Race/Ethnicity Stratification of Unique

Persons Ever in a Correctional Facility during 2006.
5

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HIV/AIDS in Inmates/Releasees

Table S9 Decline in Share of HIV and AIDS Borne by
Releasees without a Substantial Change in Numbers Affected.
Found at: doi:10.1371/journal.pone.0007558.s010 (0.03 MB
DOC)

Found at: doi:10.1371/journal.pone.0007558.s005 (0.03 MB
DOC)
Table S5 Sex and Race/Ethnicity Stratification of Releasees
from All Correctional Facilities in 2006.
Found at: doi:10.1371/journal.pone.0007558.s006 (0.03 MB
DOC)

Acknowledgments
The authors are grateful for the help of Robert O’Reilly, Inter-University
Consortium for Political and Social Researchliaison for Emory University,
and Judith Simmons, Graphic Design Services, Emory University. We also
wish to thank William J. Sabol, Laura M. Maruschak, and Allen J. Beck of
the Bureau of Justice Statistics. The views expressed in this paper do not
necessarily reflect the views of the US Department of Justice or its Bureau
of Justice Statistics.

Table S6 Revised 1997 Estimate of Share of HIV/AIDS among

Correctional Facility Releasees.
Found at: doi:10.1371/journal.pone.0007558.s007 (0.03 MB
DOC)
Table S7 HIV/AIDS among Populations Ever in a Correctional

Facility (CF) during 2006.
Found at: doi:10.1371/journal.pone.0007558.s008 (0.04 MB
DOC)

Author Contributions
Conceived and designed the experiments: ACS. Performed the experiments: RMS. Analyzed the data: ACS RMS MJP AKB WR TMH. Wrote
the paper: ACS RMS MJP AKB TMH.

Table S8 HIV/AIDS among Releasees from Correctional
Facilities in 2006
Found at: doi:10.1371/journal.pone.0007558.s009 (0.03 MB
DOC)

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