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HIV in the Texas Department of Criminal Justice (TDCJ) Inmate Population
1. Jonathon Poe, MSSW Program Specialist V TB/HIV/STD Epidemiology and Surveillance Texas Department of State Health Services HIV in the Texas Department of Criminal Justice (TDCJ) Inmate Population
11. HIV Testing, Reporting and Prevention in TDCJ TDCJ HIV/AIDS Coordinator Positive Western Blot Lab Report DSHS Central Office Loc./Reg. HD Unit Galveston HD
This is a map showing the locations of the 113 TDCJ units. As you can see, the units are spread out across Texas, though they are more concentrated in Southeast Texas. This wide dispersal can make HIV surveillance challenging, though TDCJ has a good reporting system in place, which I’ll talk about shortly. Texas has the 2 nd largest prison system in the US behind California. If TDCJ were a city, it would be a bit larger than Brownsville.
This slide shows the proportions of age groups for the TDCJ and Texas populations. The TDCJ population has a greater proportion of the <enter> 20-29, 30-39 and 40-49 year age groups than the general Texas population. The proportion of the TDCJ population that is in the <enter> youngest and oldest age groups is smaller than in the general Texas population.
These graphs show the breakdown of TDCJ and Texas populations by race/ethnicity. The largest difference between the two populations is the proportion of TDCJ inmates that are black <enter> as compared to the general Texas population. 38% of the offenders in TDCJ are black compared to only 11% of the general population that are black. The proportions of TDCJ inmates that are White, Hispanic or Other, which includes Native American, Asian and Pacific Islanders are less than in the general population.
The TDCJ population is largely male. Females only make up 8% of the TDCJ population, as opposed to 50% of the general population in Texas.
Testing is mandatory for all people entering into a TDCJ facility. From what I understand, what TDCJ calls “mandatory” is actually opt-out testing at intake, though few offenders opt out of testing. Before release, inmates are tested again, and this time the testing is actually mandatory. The test at release is done with enough time before the inmate is released that any positive inmates will be informed of their diagnosis and referred for care after release. Inmates are allowed to voluntarily test twice per year. They can also be tested if there was a possible exposure, such as contact with blood.
In terms of prevention, all newly diagnosed inmates are giving post-test counseling. There are also education programs given for the inmates, which includes peer educators, inmates educating other inmates. TDCJ provides drug rehab, which is important to the TDCJ population when considering the dominate mode of transmission for the TDCJ population diagnosed w/HIV, which we’ll look at shortly. The only common prevention measure not undertaken in TDCJ facilities is condom distribution, which is banned. There is also no access to clean needles.
On most of the next few slides, we’re going to compare the diagnosis rates for two populations: the first population consists of those people whose residence at time of initial HIV diagnosis was TDCJ, including concurrent diagnoses. The second population is everyone not living in a TDCJ facility at time of initial HIV diagnosis. This analysis does not include people under the age of 14, since TDCJ does not include offenders this young. As you’re looking at rates for TDCJ, something to keep in mind as a data limitation is that the total TDCJ population, or the denominator used to calculate the rates come from the TDCJ Statistical Report. This report counts the number of people on hand on August 31 of the year of the report. The TDCJ population is extremely transient, people are always coming and going, so if the TDCJ census were to take place on October 31 instead of August 31, the rates could look different, especially for some of the smaller demographic groups.
This chart shows the number of diagnosis for TDCJ from 2000-2008. For the last four years, there have been around 275 diagnoses in TDCJ each year. There were 265 diagnoses in 2008. The number of diagnoses in TDCJ has basically been stable over the nine years listed on this chart.
This chart compares the HIV diagnosis rates per 100,000 population for 2005-2008. The light green bars are the rates for TDCJ and the dark green bars are the rates for Texas as a whole. The diagnosis rate for TDCJ is around 9 times higher than in the rest of Texas. The rate has been steady at TDCJ except for 2008 which saw a drop.
This slide puts the number of diagnoses in TDCJ in perspective with geographic locals in Texas. If TDCJ were its own county, it would have had the fourth highest number of diagnoses in 2008, higher than Tarrant and Travis Counties.
This chart shows the diagnosis rate per 100,000 population for people diagnosed in TDCJ compared with people not diagnosed in TDCJ in 2008. The light green bars are the TDCJ diagnosis rate and the dark green bars are the diagnosis rates for those not diagnosed in TDCJ. The TDCJ diagnosis rates are higher in all age groups than the non-TDCJ rates in all age categories. The rates also peak at different categories for the two groups. The diagnosis rate for those diagnosed in TDCJ peaks at the 40-49 year age group, whereas the diagnosis rates for those not diagnosed in TDCJ peaks at the 20-29 year age group. Despite seeing some patterns in the rates, the median ages between those diagnosed in prison and those not diagnosed in prison aren’t that different. The median age for those diagnosed in TDCJ is 35 while the median age for those not diagnosed in TDCJ is 34.
This chart shows the diagnosis rate by race/ethnicity. The light green bars are the diagnosis rates for people diagnosed in TDCJ, the dark green bars are the rates for those not diagnosed in TDCJ. As in the general population, there is a disparity between the black diagnosis rates compared to the diagnosis rates of the other race/ethnicity groups in TDCJ, with 125 diagnoses per 100,000 population among whites in TDCJ versus 256 diagnoses per 100,000 population for blacks in TDCJ. It is interesting to note however, that the rate disparity in TDCJ isn’t as great as in the general population. In the general population the diagnosis rate among blacks is a bit more than five times higher than in whites, but for the TDCJ population, the diagnosis rate among blacks is only two times higher than among whites. Something else to keep in mind about these data is that there was only 1 diagnosis in TDCJ among the “other” race category, but the denominator was so small, the one diagnosis amounted to a high rate for this group.
This slide shows the diagnosis rates by sex. The rate was much higher in TDCJ than among the rest of Texas, with 165 diagnoses per 100,000 population for men in TDCJ vs. 25 diagnoses per 100,000 population for men in the rest of Texas, and 394 diagnoses per 100,000 population for women in TDCJ vs. 8 diagnoses per 100,000 population for women in the rest of Texas. Female Rates 2005 324.4592 2006 338.4514 2007 307.8971 2008 394.1759
The next few slides will compare proportions rather than rates. The TDCJ denominators for these categories are so small, especially for women, the rates are too volatile to tell us much. This slide shows the proportion of diagnoses for females by age group between those diagnosed in TDCJ and those not diagnosed in TDCJ. The proportion of those women diagnosed in TDCJ in the 20-29 year age group <enter> is higher than in the population not diagnosed in TDCJ (44% vs 28%) as well as those in the <enter> 40-49 year age group (32% vs. 22%). The proportion of women diagnosed in TDCJ in the <enter> 30-39 year age group is smaller (12%) than those not diagnosed in TDCJ (29%).
This slide shows the proportion of diagnoses for males by age group between those diagnosed in TDCJ and those not diagnosed in TDCJ. The proportion men diagnosed in TDCJ in the <enter> 30-39 and 40-49 age groups are higher (31% and 32%) than the proportion of men not diagnosed in TDCJ for those age groups (22% and 18%).
This slide shows the proportion of diagnoses for females by race/ethnicity between those diagnosed in TDCJ and those not diagnosed in TDCJ. The proportion of women diagnosed in TDCJ who are white (30%) is higher than the proportion of women who are white and who was not diagnosed in TDCJ (18%). Conversely, the proportion of women diagnosed in TDCJ who are black is smaller than the proportion of the same group in those not diagnosed in TDCJ (52% vs. 60%)
This slide shows the proportion of diagnoses for males by race/ethnicity between those diagnosed in TDCJ and those not diagnosed in TDCJ. The proportion of black men diagnosed in TDCJ is higher than in those not diagnosed in TDCJ (58% vs. 37%), but considering the TDCJ population has a much higher proportion of black men than the general population, this isn’t too surprising.
Now we are going to look at mode of transmission. For these slides, we applied an imputation process for cases with no reported risk. Miranda is going to explain how the risk imputation works in more detail with her presentation coming up next. Looking at the mode of transmission between those women diagnosed in TDCJ and those women not diagnosed in TDCJ, we see some big differences. There was a higher proportion of women diagnosed in TDCJ who had injection drug use as their mode of transmission than women not diagnosed in TDCJ (72% vs. 15%). One possible explanation for this is that the incarceration rate for injection drug users could be much higher than in the general population.
Before discussing this slide, I’d like to point out that, especially for men, obtaining risk information in the prison system can be difficult. If you’re an MSM in a prison, how comfortable are you going to be in admitting such, especially if you’re worried about there being trouble if other inmates found out? This slide shows the imputed mode of transmission for men diagnosed in TDCJ and for men not diagnosed in TDCJ. Again, we see a much higher proportion of <enter> IDU among TDCJ diagnoses than among non-TDCJ diagnoses (57% vs. 7%) and a much lower proportion of <enter> MSM in the TDCJ diagnoses than among non-TDCJ diagnoses (19% vs. 76%). There is also a difference in the proportion of men who are <enter> IDU/MSM in cases diagnosed in TDCJ than cases not diagnosed in TDCJ. As with women, the high proportions of IDU could also be a result of a higher incarceration rate for IDU, but it could also be the result of men not disclosing all of their risk factors.
Now let’s look at concurrent diagnosis for those diagnosed in TDCJ and those not diagnosed in TDCJ. The light green bar represents the proportion of people diagnosed in TDCJ who had an AIDS diagnosis within 12 months of their HIV diagnosis. The dark green bar represents those not diagnosed in TDCJ who had an AIDS diagnosis within 12 months of their HIV diagnosis. As you can see, 20% of those diagnosed in TDCJ had an AIDS diagnosis within twelve months, but 34% of those not diagnosed in TDCJ had an AIDS diagnosis within 12 months. This could be an indication that people diagnosed with HIV in TDCJ are being diagnosed earlier in their infection than those not diagnosed in TDCJ. If this is the case, TDCJ’s mandatory testing program could be responsible.
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