Last September, the Wilmington, Delaware News Journal reported that Bernard Coston, an inmate at the city’s Gander Hill Prison, died of AIDS on his cell floor, covered in his own feces. The paper went on to expose the state prison system’s often deadly health care conditions, including denying emergency care and delaying treatment. The U.S. Department of Justice then launched an ongoing investigation, and in April, the Delaware state Senate introduced a prison-reform bill. It calls for the mandatory testing of all inmates for HIV, hepatitis B and C and tuberculosis; training guards to recognize when inmates need care; and streamlining the bureaucracy surrounding the filing of medical complaints. “The health conditions are woefully inadequate, and the state’s current administration was not addressing them,” says bill cosponsor Senator Karen Peterson.

With 87 AIDS-related deaths per 100,000 inmates last year, Delaware had the nation’s highest HIV prison mortality rate. AIDS is the second most common cause of death in American prisons, behind only natural causes. Due to shoddy care, incarcerated people with HIV are more than twice as likely to die as positive people outside.

Many prison advocates question whether the legislation can improve these conditions. Ramesh Vemulapalli, MD, who worked in Delaware’s prisons in 2002, before resigning due to disgust with the care, says reformers must train the prisons’ health care providers before guards. “The medical staff has a total lack of knowledge about treating HIV. [During my tenure] patients wouldn’t get meds on time, and they’d develop resistance, and I would order viral load or CD4 tests that would never happen,” he says. “I saw people die who could have lived if they had gotten care earlier.” Gail Stallings Minor, spokeswoman for the Delaware Department of Corrections, said she could not comment due to the ongoing investigation. As for mandatory testing, Jackie Walker from the American Civil Liberties Union’s National Prison Project, says it sparks discrimination: “There is still ignorance and stigma in American prisons, and mandatory testing is a slippery slope to segregation and unequal treatment.” Peterson responds, “We need to identify positive people so they can get the help they need.” Perhaps confirming Walker’s concern, she adds: “Also, we need to keep the other inmates and the guards safe from [positive people].” Christine Whitehead, an attorney hired by the Correctional Officers Association of Delaware to draft the bill, says, “The officers don’t want to see people suffer.”

A few states arm their guards with health training. California’s medical technical assistants (MTAs) decide when inmates need care and perform basic health duties, like distributing meds. Judy Greenspan, of California Prison Focus, reports that guards and prisoners have an adversarial relationship and that adding a medical component causes poor care. “MTAs have been a roadblock to care,” Greenspan says. “They may decide that a sick prisoner is faking.” Antoine Mahan, who is HIV positive, was released from California State Prison at Corcoran in 1999. “A person could literally be dying, and MTAs would tell you to fill out a form,” he says, adding that they forced him to take HIV meds, despite his complaints that the pills made him ill. He would spit them out after the guards left, risking resistance, because he did not trust the guards, who did not trust his concerns. Whitehead, however, says she did not research such existing problems when drafting the Delaware bill. As POZ went to press, both state Senate leaders had endorsed the bill, but it was trapped in the Correction Committee, which was debating the cost of reform. Meanwhile, the cost inside the prisons remains staggering.