Hard time

The state says 8.5 percent of women in prison are HIV-positive. Some health professionals say that number is much higher. What can be done to help women at risk?

by Sarah McNaught

Surrounded by smoke that swirls from the remnant of a cigarette stuck between her fingers, Kim sits motionless. Her frail frame rests on the cracked cement stoop in front of a rundown three-story apartment building on the Abington/Weymouth border. The tall brunette has a sallow complexion and sunken features. She looks much older than her 32 years. Kim pushes the long sleeves of her black jersey up to her elbows, careful to keep the open sores and track marks in the creases of her arms covered.

On a drizzly night in April 1994, Kim was picked up by police behind a Walgreen Drug Store on Main Street in Weymouth. A cruiser patrolling the empty parking lot had noticed movement within the big blue dumpster at the back of the lot. It was Kim, "dumpster diving," as she puts it. "I was looking for unopened food, old furniture, or anything else I could find."

At the request of the police, Kim emptied her pockets, revealing a small piece of tinfoil stuck inside the cellophane of her cigarette pack. Inside, packed in a tight white square, was about $45 worth of heroin. A quick check revealed that Kim had defaulted on a previous drug charge. Within weeks, Kim had been charged, arraigned, tried, and convicted of possession; she served 18 months and was ordered to receive mandatory drug counseling, which she didn't attend.

"When I was in jail, all I wanted to do was get out and get high," she explains as she takes the last long drag of her cigarette. She stomps it out on the pavement and reaches for another one from the crumpled soft-pack of Winstons laying on the stoop beside her. "I didn't give a fuck about anything else. I just wanted out."

In February 1997, when Kim was battling what she thought was a bad case of bronchitis, she went to a local health center. There she informed the doctor that she had been sick for more than three months. She also admitted she was an intravenous drug user and that she occasionally sold sex for drugs or drug money.

"I was so sick I didn't care what they tested me for, just so long as they gave me something that got rid of what I had," she explains. "Then I found out what I had couldn't be gotten rid of." Kim was diagnosed with a progressive strain of HIV and was informed that she had full-blown AIDS. Today, Kim says she is just waiting to die and staying high until it happens.

Kim is not sure when she contracted HIV; doctors say it may have been before she went to prison. It would not be unusual if she had the disease while she was in jail but it went undetected. HIV testing is not required for inmates, and many prefer to avoid being tested and accessing HIV services because of the potential impact that disclosure of their status might have on their relationships with fellow inmates, correctional officers, and health-care staff, according to a 1996 report published in the AIDS Reader.

"And beyond the fear of being found out, some females have never had access to a gynecologist or even a general practitioner and have no reason to believe they may be ill," explains Ellen Miller-Mack, a nurse practitioner and HIV coordinator at the Brightwood Riverview Health Center in Springfield who also works in the AIDS unit at Hampden Correction Facility in Ludlow. "These women would never participate in voluntary testing because they simply don't seek health care."

Also, the majority of HIV-positive female inmates have experienced some form of abuse or emotional trauma that has steered them toward a high-risk lifestyle.

Take Debi Cuccinelli. She was diagnosed as being HIV-positive in 1987 while serving a prison sentence for drugs, robbery, and prostitution. In 1994, while serving a sentence at MCI-Framingham for testing positive for narcotics while on probation, she met Dr. Anne De Groot, TB/HIV research-laboratory chief at the Brown University School of Medicine's International Health Institute, who worked at MCI-Framingham as an HIV doctor from 1992 to 1995. In her first interview with Cuccinelli, De Groot asked her if she had ever been abused as a child.

"When I was six -- maybe before that, I'm not sure of my exact age -- my brother started to touch and kiss me different from my other brothers," explains Cuccinelli. "I remember the first day he raped me as if it were today. I was getting out of the tub and he was going pee. No one was home. I put my robe on and went to my room. He came too. I sat on my bed. He pushed me down and pushed himself inside of me. It hurt so bad I was crying. He said if I told Mom he would break my dollhouse and I would never be able to go to the park. I didn't understand. But he said I made him."

Cuccinelli says the abuse went on for four years, until her brother found a girlfriend and stopped abusing her as often. Cuccinelli says she was hurt by her brother's sudden lack of attention and began acting out. She eventually told her mother about the abuse. "She hit me and said to stop making up stories and sent me to my room," remembers Cuccinelli, who is now 37. "She said if I ever lied like that I would end up in a bad girls' school."

With nowhere to turn, Cuccinelli attempted suicide at the age of 10. When she was 11, she ran away and ended up in court for skipping school. Just as her mother had said, Cuccinelli was sent away to a juvenile detention center for girls. At the age of 12, she began prostituting, and by 15 she was shooting heroin. Eventually, she began robbing people's homes for drug money. Since 1986, she has been in and out of prison five times.

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The number of female prisoners with AIDS continues to surpass that of male prisoners. In addition, statistics released in March by the Justice Department's Bureau of Justice Statistics (BJS) state that the prevalence of HIV infection among women in prison is 35 times higher than the rate of HIV infection in non-incarcerated women.

According to the Department of Corrections' (DOC) 1998 annual report, as of January 1, 1998, there were 12,119 inmates in state facilities in Massachusetts, and another 12,000 in county facilities. Six percent of the inmates were women. According to the Department of Public Health's AIDS bureau, 5.5 percent of men entering prison are infected with HIV. The bureau reports that 8.5 percent of women entering prison are infected.

The number of cases of incarcerated women with HIV is actually much higher, according to De Groot. But, she says, the precise number cannot be accurately determined because of the lack of mandatory testing and the fact that many inmates who know they are HIV-positive keep quiet. Nonetheless, by working closely with inmates, offering them counseling and understanding, and treating them with respect, De Groot and her colleagues have been able to convince many to get tested voluntarily. The 1996 AIDSReader report, which De Groot co-authored, reflects that fact: it identifies the number of HIV-infected women at one of the state prison sites as being as high as 15 percent in 1993 (compared to the 4.5 percent reported by the prison), and as high as 20 percent in 1994.

"The majority of incarcerated women are there because of drugs or drug-related charges," says Miller-Mack. (A full two-thirds, according to BJS.) "That means they have participated in activities that foster such illnesses as HIV." Miller-Mack says these women use dirty needles, or crack pipes without rubber stoppers, which cause burns and open wounds on the mouth. "Many of them exchange sex, particularly oral sex, for drugs or drug money," she explains. "There are multiple risks for contracting the HIV virus and these women have participated in at least one, if not more, of these activities."

De Groot reports that the prevalence of such behaviors and of histories of childhood sexual abuse among women at MCI-Framingham are high. In fact, according to De Groot, the majority of her patients at the prison who were infected with HIV were survivors of childhood sexual violence. "Childhood sexual abuse is often the root of adolescent misbehavior and is directly associated with later participation in illicit drug use and sex work," she says, referring to studies released at the Conference on HIV Infection in Women, in Washington, DC, in 1995.

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State corrections officials insist that the AIDS epidemic in Massachusetts prisons is under control. "Although the rate of infection is higher, the actual number of HIV cases diagnosed in prison is lower than it was 10 years ago," says Tim Gagnon, head of the state's Department of Public Health's AIDS Bureau. "And today, the majority of people who are HIV-positive in the prison system are accounted for due to increased testing, whether it be blind [anonymous] or voluntary."

But, as Gagnon states, the rate of infection is higher, and such things as mandatory testing and condom distribution in prisons remain taboo in this state. According to BJS, however, even though Massachusetts is said to have the third highest rate of AIDS among inmates in the country, it is also touted as having one of the most aggressive treatment programs.

In Massachusetts and Rhode Island, according to De Groot, on-site services are provided by board-certified infectious-disease specialists, although HIV clinics are not available at all of the state prisons and jails in Massachusetts. Lemuel Shattuck Hospital in Jamaica Plain serves as an off-site clinic for inmates.

Health workers argue that there is as much a need for prevention as there is for medication. Women must be educated in order to thwart the disease or, at least, to treat it before it becomes too advanced, as in Kim's case.

There are many prevention and treatment programs now available in the state's prison system. For instance, the Hampden County Correctional Center has been nationally accredited as having one of the best HIV programs in the country. The center offers something that isn't always offered at other facilities -- a correlating drug treatment and sexual abuse survivors' group. Patty Marion, the women's health nurse at Hampden, with the assistance of Becky Parent, the facility's fitness instructor, developed a unique health-related eight-week curriculum. The topics include HIV, self-esteem and empowerment, nutrition and exercise, cancer prevention, stress management, and the physiology of the body.

Other programs available at women's prisons involve courses covering anatomy and physiology of the reproductive tract, sexually transmitted diseases, female birth control, and breast exams. "Many of these women have never had regular gynecological exams and may have contracted something they know nothing about," says Miller-Mack. "In prison, these women are able to access physicals and pelvic exams as well as be offered medication, education, and counseling that they would have no access to on the street."

Such programs are vital to solving the problem. "I had come to believe during my three years of practice at the women's prison in Massachusetts that it was extremely important to understand the framework of my patients' lives if I was to have any positive effect on their disease," says De Groot. "I became convinced that they would not adhere to the medications or complicated regimens that I prescribed if they did not value themselves as human beings."

Of course, the issue is not about simply receiving treatment once diagnosed, but also preventing HIV infection by stopping the behaviors that lead to it -- such as sexual abuse, drug use, and random sexual partnerships. "If I weren't molested by my mother's boyfriends, if I didn't see her doing drugs all the time off the kitchen table, maybe I wouldn't have gotten hooked, maybe I wouldn't have gotten sick," says Kim. "All I know now is by the time they started talking to me in jail about drugs and sex and seeing the doctor, it was too late for me."

Sarah McNaught can be reached at smcnaught[a]phx.com.