According to Laura M. Maruschak of the Bureau of Justice Statistics, in HIV in Prisons and Jails, 2004 (November 2006), the number of HIV-positive state and federal prisoners has declined each year since 1999, when there were 25,807 infected prisoners. Between 2003 and 2004 the number of HIV-positive inmates in state and federal prisons fell from 23,663 to 23,046. Maruschak notes that during 2004 the number of AIDS cases in state and federal prisons rose from 5,944 to 6,027. The rate of AIDS cases in state and federal prisoners (fifty per ten thousand prison inmates) continued to be more than three times higher than the 2004 case rate in the total U.S. population (fifteen per ten thousand people).

Every year since statistics have been gathered, AIDS-related conditions have been the second-leading cause of death for state prison inmates, behind ''illness/natural causes.'' However, the proportion of deaths attributable to AIDS has declined markedly since 1995. Maruschak notes that out of the total number of inmate deaths in state prisons in 1995, 32% of the total were from AIDS. However, by 2004, 6% of inmate deaths were from AIDS. This remarkable decline in AIDS-related deaths is also reflected by the statistics in the rate of deaths per one hundred thousand inmates. In 1995 the death rate in state prisons due to AIDS was one hundred per one hundred thousand inmates; in 2004 the rate had decreased to ten per one hundred thousand in both state and federal prisons. The sharp drop may be the result of effective treatment with protease inhibitors and combination antiretroviral therapies.

A similar trend is also apparent when the inmate death figures from federal prisons in 2003 and 2004 are examined. Of the total number of inmate deaths in federal prisons in 2003 (347), 315 (91%) were from natural causes other than AIDS, and 14 (4%) were from AIDS. By the following year, 295 (89%) out of a total of 333 deaths were from natural causes other than AIDS, whereas 18 (5%) were from AIDS. The decline is more modest than the data for state prisons because the data for federal prisons was compiled over two years instead of seven.

At the conclusion of 2004, Maruschak indicates that 23,046 U.S. inmates were confirmed as being infected with HIV. This represents 1.8% of the custody population at that time--a decrease from the 2.2% of inmates known to be HIV infected in 1998. This modest decrease has not been geographically uniform, however. At year-end 2004, the state of New York held a fifth of all inmates (4,500, or 20%) known to be HIV-positive. In contrast, California held 1,212 (5%) of all HIV-positive inmates.

At the end of 2004 an estimated 6,027 U.S. inmates had confirmed cases of AIDS--more or less unchanged from the previous year's estimate of 5,944 confirmed cases. The 2004 number was, however, a decrease from the estimated 7,039 cases confirmed in 1999.

This decrease was not uniform for males and females. Of the total U.S. prison population in 2004, Maruschak states that 2.4% of female inmates were known to be HIV positive, in contrast to 1.7% of male inmates. The increased infection rate for females was not mirrored in the number of AIDS-related deaths, however. In state prisons in both 2003 and 2004, the number of male deaths (202 and 138, respectively) was far greater than the number of female AIDS-related deaths (8 and 7, respectively).

Maruschak indicates that the statistics from state prisons reveal age and racial differences. The number of deaths in state prisons in 2003 and 2004 was greatest for thirty-five to forty-four-year-olds (ninety-seven and sixty-nine, respectively), followed by those forty-five and older (seventy-four and fifty-four, respectively). Fewer deaths were evident in the twenty-five to thirty-four age category (thirty-eight and twenty, respectively).

According to Maruschak, the data also reveal that the reason for incarceration is not strongly associated with a prisoner's HIV status, however, inmates held on property offenses had the highest HIV-positive rates in 2004. Among state inmates, public-order offenders (0.9%) were the least likely to report being HIV positive. Interestingly, among federal prisoners, drug offenders (0.7%) were the least likely to report being HIV positive. Less surprising is that a history of previous drug use is associated with whether a prisoner is HIV positive. Only 1.3% of the state prisoners and 1.5% of federal prisoners with no previous drug use were HIV positive, in contrast to 2.8% of the state prisoners and 1.3% of federal prisoners who had used a needle to inject drugs and 5.1% of state prisoners and 2.6% of federal prisoners who shared a needle in drug injection.

Public education campaigns about the ''safer'' use of drugs and syringes appear to be reducing HIV infection in the general public. However, these measures seem to be having no effect in prisons. Many incarcerated IDUs continue to inject while in prison, often sharing needles because injection equipment is in short supply. Indeed, Ralf Jurgens of the Canadian HIV/AIDS Legal Network notes in ''Is the World Finally Waking up to HIV/AIDS in Prisons?'' (Infectious Disease in Corrections Report, vol. 7, no. 9, September 2004) that 97% of incarcerated IDUs reported borrowing syringes while in prison. The consequences of this behavior are evident in the high rate of HIV infection among prisoners who shared a needle for drug injection before incarceration (5.1% of tested state prison inmates who reported results and 2.6% of federal inmates).

This is a dilemma for prisons, where syringes and needles are prohibited, as are illegal drugs, and chemicals for disinfecting the illicit needles are not readily available to prisoners. Even though state and federal prison officials in the United States want to stop the spread of HIV among inmates, most cannot keep pace with or stem the flow of illegal drugs into prisons. To minimize the spread of HIV in prisons, countries such as Switzerland and the United Kingdom provide prisoners with disinfectant or clean needles. U.S. officials believe that these actions endorse illegal drug use. Instead, they focus on providing treatment and rehabilitation programs for drug-addicted prisoners.

In ''Sex, Drugs, Prisons, and HIV'' (New England Journal of Medicine, vol. 356, no. 2, January 11, 2007), Susan Okie states that the Rhode Island prison system's HIV testing practices are highly regarded by U.S. public health experts and are considered to be among the best in the country. Nonetheless, Okie observes that even the Rhode Island program fails to meet international guidelines for reducing the risk of HIV in prisons. The World Health Organization and the Joint United Nations Program on HIV/AIDS recommend that prisoners have access to bleach to clean injecting equipment and that drug treatment, methadone maintenance, and needle-exchange programs be offered to inmates. Okie notes that in 2007 condoms were provided on a limited basis in just two state prison systems (Vermont and Mississippi) and five county jail systems (New York, Philadelphia, San Francisco, Los Angeles, and Washington, DC). There are just a few methadone maintenance programs and no U.S. prison has even tested the feasibility of a needle-exchange program.

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