Alabama Prison at Center of Suit Over AIDS Policy

26th October, 2003
The New York Times
Adam Liptak

Robin Nelson/ZUMA Press

Prisoners lining up for their AIDS medication last March at the Limestone Correctional Facility, where they are segregated from the other inmates.

HARVEST, Ala. — Prisoners who need AIDS or H.I.V. medication at the Limestone Correctional Facility here must get up at 3 in the morning to stand in line for it. The wait can take 45 minutes. Then they repeat the exercise at 10 in the morning, and again at 3 in the afternoon.

Those who are too sleepy or sick to stand in line miss out, a federal lawsuit maintains.

Whether convicted of shoplifting or murder, every male felon in Alabama who has AIDS or H.I.V. is sent to this medium-security prison near Huntsville. Here they live, eat, sleep, exercise, see the doctor and wait in lines in a unit strictly segregated from the rest of the prison.

Alabama is the only state to keep inmates with H.I.V. or AIDS isolated from other prisoners — not only in its cells, but in all prison programs.

This policy was meant, prison officials have said, to limit the health and security problems posed by infected prisoners, and the courts have endorsed it as a reasonable reaction to the dangers of H.I.V.

But its critics say that at least as practiced in Alabama, segregation is dangerous and inhumane to those prisoners, subjecting them to shoddier health care, a greater risk of communicable diseases and harsher living conditions than those of other inmates.

"Human beings who are H.I.V.-positive and incarcerated in Alabama have died of treatable diseases, treatable in any country in this world and certainly treatable under even minimal medical care offered in the United States," said David M. Lipman, a Miami lawyer who represents the prisoners in the class-action lawsuit.

Mr. Lipman and other lawyers for Limestone's inmates with H.I.V. filed the suit in federal court in Birmingham last November, contending that the prisoners' living conditions and medical care were a form of cruel and unusual punishment. A medical expert for the plaintiffs, Dr. Stephen Tabet, who specializes in infectious diseases at the University of Washington, concluded that being admitted to Limestone with AIDS was akin to a death sentence.

The rate of AIDS-related deaths among Alabama prisoners in 2000 was more than twice the national prison average, according to the Justice Department. Thirty-nine men with H.I.V. have died at Limestone since 1999. A recent state-sponsored audit called the six AIDS deaths at the prison in the first 10 months of 2002 a "remarkably high" number.

Until recently, the H.I.V.-positive prisoners were held in a vast converted warehouse filled with row after row of beds — the perfect setting, the lawsuit says, for the spread of infections that can be deadly among people with compromised immune systems.

As of the end of 2000, the Justice Department says, there were slightly more than 25,000 inmates in the nation's prisons who were known to be infected with H.I.V., accounting for more than 2 percent of all prisoners. Nearly half were in three states: New York, Florida and Texas.

But only 20 states, including Alabama, test all prisoners for H.I.V., so the number of infected prisoners may be substantially higher.

In approving Alabama's practice of segregation, the courts have noted that states that integrate H.I.V.-positive inmates with the rest of the prison population see many more new H.I.V. infections than does Alabama.

Alabama spends less money per prisoner than any other state, both as a general matter and for medical care. Yet just the medicine for only one H.I.V.-positive inmate costs $8,000 to $12,000 a year, according to the state audit. The sole doctor here, who is responsible for the care of 1,823 prisoners, including 237 with H.I.V., said this medication cost even more. The tension between scant resources and great need has taken an enormous toll, the lawsuit says.

Prison officials declined to comment for this article, citing the pending suit, but in legal papers they have denied the prisoners' claims. Naphcare, the company that until recently was under contract to maintain medical services for the prisoners, defended its work.

"Naphcare provides quality, compassionate health care to Alabama inmates," said David Davis, a spokesman for the company. Naphcare disputes the conclusions of the state audit and has sued its authors for libel.

Dr. Tabet, the plaintiffs' expert, reviewed the medical files of 38 of the prisoners who died of H.I.V.-related causes here in recent years, and issued a report critical of Limestone's patient care.

"Consistently, patients died of preventable diseases," said Dr. Tabet, whose review concluded before a 39th inmate died in October. He noted many instances of pneumonia and wasting, conditions associated with AIDS that he said should not have been fatal.

Dr. Tabet also said he had found that many patients did not get their medication or understand the importance of taking it. Others told him that they could not tolerate the medicines on an empty stomach early in the morning.

The prison's medical director, Dr. Colette Simon, who served as an employee of Naphcare but may remain here now that its contract has been canceled, disputed Dr. Tabet's conclusions.

"The standard of care is good," she said.

Dr. Simon, Limestone's only physician, a specialist in infectious diseases who has worked at several New York City hospitals, is praised by all the parties to the suit. The plaintiffs dropped her as a defendant in March, saying they had found her to be "well qualified and competent to provide H.I.V./AIDS medical treatment." Naphcare remains a defendant, along with several state officials.

Dr. Simon said she had turned down opportunities to work in smaller prisons that employ three or four doctors. The need is greater here, she said, adding that inmates here received better care than they would in the outside world. Obtaining the expensive medicine needed to control H.I.V. is easier here, she added, than after they are released.

"Having more help would be good," she said, but "the care would still be the same."

Dr. Simon took issue with Dr. Tabet's recommendation that prisoners be given quantities of medicine to take as needed without supervision. She said this could lead to hoarding, barter and overdoses.

"All they have to do is come when they are called," she said of the prisoners. "And people who are so weak they cannot go to pill call are not in the dorm. They're in my infirmary."

Dr. Simon said that she tried to reason with and cajole prisoners in an effort to get them to take their medicine, but acknowledged that she did not always succeed.

The state canceled Naphcare's contract in May without giving a reason, though the company has said it suspects that the state audit was to blame. The company continued to provide services while a new bidding process was completed. [On Oct. 17, the contract was awarded to another company, Prison Health Services.]

It was only in early October that all 237 H.I.V.-positive inmates at Limestone were moved from the former warehouse that had been their home for years. The lawsuit said the warehouse was often too hot or cold and was infested with spiders, rats and birds. The new units, called dormitories by prison officials, are customary cellblocks, with rows of two-man cells arranged on two levels surrounding a common area.

The cellblocks are in some ways less appealing than the warehouse, which has high ceilings, a big yard and more light and space, if less privacy. In the cellblocks, prisoners mill about and watch television in the smaller common area. The warehouse, now occupied by other prisoners, is reminiscent of a bare-bones military barracks.

Lawyers for the prisoners, who had been harshly critical of conditions in the warehouse, said the recent move was a victory that would slow the spread of infectious diseases. But they said other problems, like access to medicine, remained.

Segregating prisoners in order to focus on their health has its defenders. Anne S. De Groot, associate professor of community health at Brown University and an editor of the H.I.V. Education Prison Project Report, said programs in California and Texas "work well because prison authorities can focus their H.I.V. treatment in one location."

"There is no reason to segregate prisoners except to centralize medical care," Professor De Groot said. That, she added, is not the rationale offered by Alabama, whose care here she described as "substandard even compared to the general standard in correctional systems."