467313

7313The Prison JournalTartaro and Levy

© 2012 SAGE Publications

Reprints and permission:

TPJ93110.1177/003288551246

sagepub.com/journalsPermissions.nav

The Prison Journal

An Evaluation of an 93(1) 57­–79

© 2012 SAGE Publications
Reprints and permission:
HIV Testing Program sagepub.com/journalsPermissions.nav
DOI: 10.1177/0032885512467313
in the Jail Setting: Results http://tpj.sagepub.com

and Recommendations

Christine Tartaro1 and Marissa P. Levy1

Abstract
Prison and jail inmates tend to be involved disproportionately in behavior
that places them at risk for HIV transmission. The state of New Jersey, and
its urban areas in particular, has a high rate of African American residents
living with HIV or AIDS. In an effort to reach several urban areas where
individuals have not yet been diagnosed, a southern New Jersey county jail
has begun offering free rapid HIV tests on a voluntary basis. Results indicate
that correctional facilities were among the most common places for inmates
to receive testing and that those tested were involved in numerous high-risk
sexual and/or drug activities. Recommendations for future testing and edu-
cation programs are provided.

Keywords
HIV/AIDS testing, jails, high-risk sexual and drug activities

Since the first reported case of an AIDS infected patient residing inside a cor-
rectional facility in 1983 (Spaulding et al., 2002), the transmission of HIV,
medical treatment of infected inmates, and the safety of staff and noninfected
inmates has been a concern of corrections administrators worldwide. The

1
The Richard Stockton College of NJ, Galloway, NJ, USA

Corresponding Author:
Christine Tartaro, The Richard Stockton College of NJ Dept. of Criminal Justice,
101 Vera King Farris Drive, Galloway, NJ 08205, USA
Email: Christine.tartaro@stockton.edu

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
58 The Prison Journal 93(1)

number of identified inmates with HIV/AIDS grew rapidly during the 1980s
and 1990s, stabilizing in the 2000s. On December 31, 2008, state and federal
prisons in the United States held nearly 22,000 inmates who were HIV posi-
tive or had AIDS. These inmates comprise 0.8% of the federal and 1.6% of
the state prison populations (Maruschak, 2009). However, these statistics do
not count any of the more than 800,000 inmates housed in jails on any given
day or the 13 million who pass through the doors of jails in the United States
annually.
The Centers for Disease Control (2007) found that 54% of male adults and
adolescent HIV transmission cases in 2005 were likely a result of males hav-
ing sex with males (MSM), 21% from injection drug use (IDU), 8% a combi-
nation of IDU and MSM, and 7% from other high-risk sexual contact
activities. Female transmission likely involved IDU in 36% of the cases and
high-risk sexual contact in 8%.

High Risk Behaviors Among Inmates

Bauserman and colleagues (2003) noted that HIV infection rates tend to be
higher among incarcerated populations for two reasons. First, males and
African Americans tend to be at higher risk for HIV transmission, and these
two groups are also disproportionately represented in the incarcerated popu-
lation. Second, inmates tend to be involved in the high risk activities that are
associated with HIV transmission. Gough et al. (2010) conducted a system-
atic review of HIV prevalence and found a rate of .02 per 100 residents in
the general United States population compared to 0.08 per 100 for people
who are continuously incarcerated and 2.92 per 100 for people who are
released and then reincarcerated. Begier et al. (2010) estimated that the HIV
prevalence for individuals entering New York City jails was 2.5 to 3.5 higher
than the general population for males and 14 to 20 times higher for females.
Moseley and Tewskbury (2006) surveyed inmates residing in three prisons
in Louisiana and received 2,287 usable responses. During the month prior to
their most recent incarceration, 18% of the respondents reported participating
in IDU, more than one-third (35.4%) gave money or gifts in exchange for sex,
and 16% gave sex for money or gifts during this time. Seventy-nine percent of
the male respondents reported having heterosexual sex without a condom
in the month leading up to the most recent incarceration. During their incar-
ceration, 5% reported anal sex without any type of protection, and 2.2%
reported anal sex with some sort of protection. Nearly three percent of respon-
dents reported IDU during incarceration, with 2.3% reporting sharing needles.

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
Tartaro and Levy 59

Hoxie and colleagues (1990) examined the HIV test results of nearly
2,000 inmates who volunteered for testing in Wisconsin during 1987 and
1988 and found that HIV infection was strongly associated with IDU. Inciardi
et al. (2007) discussed a dangerous practice called “booting” or “kicking”
that is sometimes performed by IDUs. Booting involves drawing some blood
into the syringe, mixing the blood with the drug, and then injecting the drug
into the vein. This is done so the user can confirm that he or she actually has
the needle in the vein. Some drug users also believe that mixing the drug with
blood increases its effect. Typically, there are traces of blood left on the
syringe. If the syringe is shared with others, this can increase the chance of
HIV transmission.
Stanton-Tindall and colleagues (2007) conducted focus groups with
36 female inmates in correctional facilities in Kentucky and Delaware.
Several of the women admitted to high-risk sexual behavior and attributed
their participation in that activity to alcohol and drug use. Some inmates
noted that they were not very concerned about HIV infection, despite their
high-risk behavior, because they believed that it happens to “other people.”
They also reported that they shied away from being assertive about the use of
protection during sex out of fear of being rejected by their partners. The result
of their fear, denial and drug and alcohol use is their continued participation
in activities that are associated with HIV transmission. McClelland, Teplin,
Abram, and Jacobs (2002) interviewed 940 women in the Cook County Jail
(Chicago) about their high-risk behaviors and found that 8.5% reported shar-
ing needles. Thirty-two percent who had vaginal sex reported never using
condoms, while 50% who participated in oral sex and 74% who had anal sex
also reported never using protection. One third of the women interviewed had
traded sex for money or drugs.
Swartz, Lurigio, and Weiner (2004) surveyed inmates serving time in the
Illinois prison system about how they might react to various high risk situa-
tions. Half of the 630 participants reported that they believed they already
participated in activity that could have led to exposure to HIV. More than one
third (34%) of respondents said that they would have unprotected sex with a
new partner even if the partner objected to using a condom. Twelve percent
reported intravenous drug use. Of the inmates who admitted to IDU, 23%
said that they would share needles in order to avoid withdrawal symptoms.
Sixteen percent of the inmates agreed with the statement that “my gut feeling
is I’ll get AIDS someday, no matter what I do,” indicating that they believed
that becoming HIV positive was a matter of fate rather than a matter of
prevention.

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
60 The Prison Journal 93(1)

Benefits of HIV Testing

in the Correctional Setting
HIV tests are offered at a variety of locations, including physicians’ offices,
hospitals, health clinics, specific HIV testing facilities, and clinics special-
izing in the treatment of sexually transmitted diseases. One of the most
important and utilized locations for HIV testing is inside correctional facili-
ties. Desai, Latta, Spaulding, Rich, and Flanigan (2002) studied a voluntary
HIV testing program at a Rhode Island men’s prison, comparing the charac-
teristics of inmates testing HIV positive to those who tested positive in the
community. During the 10-year study period (1989-1999), one third of all
HIV positive tests in Rhode Island came from inside the state correctional
facility, which held both pretrial and sentenced inmates. An important find-
ing of this study is that, when compared to the other testing sites, the cor-
rectional facility reported more HIV positive tests for African American
males and reported intravenous drug users. Desai et al. (2002) suggested that
this can be explained by the infrequent contact that these groups have with
medical professionals outside prisons and jails.
While testing in correctional facilities has been an important strategy for
identifying and treating people with HIV, the majority of inmates do go
through the correctional system without ever being tested. Duffus et al.
(2009) studied HIV transmission in South Carolina and found that 48% of
individuals who were both HIV positive and had criminal records had been
arrested at least once prior to testing positive. Of these people, 65% (1,268)
had been arrested after the time they were likely infected, but they were
released from custody without being diagnosed. The New York Department
of Health and Mental Hygiene incorporated the offer of a HIV test as part of
the intake routine for New York Jails in 2004.
In a four-state study, Kacanek and colleagues (1997) interviewed prison
inmates who had been tested for HIV while incarcerated. They also found
that having the test available in prison gave inmates access to a health system
that they did not have in the community. When asked why they agreed to
be tested in prison, some responded that this is the only location where they
ever receive HIV testing, since they did not visit doctors and only went to the
hospital for emergencies. Incarceration can also provide inmates some time
to reflect on their actions and the consequences of those actions. Spaulding
and colleagues (2002) noted that “incarceration often awakens a person to
acknowledge that the behavior that led him or her to be incarcerated—such
as drug use or commercial sex work—may have placed him or her at risk for
HIV infection” (p. 307) What is clear from the existing research is that HIV

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
Tartaro and Levy 61

testing in the correctional setting allows health professionals to reach out to

groups (African Americans and IDUs) who otherwise would not pursue test-
ing in the community.
HIV correctional testing programs have the potential to address two
important issues that can impact the chances of inmates’ contracting HIV in
the future. The first issue is failure to receive the test results. Sullivan, Lansky,
and Drake (2004) studied failure to return for HIV test results among com-
munity high risk groups. The researchers interviewed volunteers from gay
bars to represent the males having sex with males groups (MSM), recruited
intravenous drug users and went to clinics to interview high-risk heterosexu-
als. Of the 2,241 respondents, 10% of the MSM group, 27% of the intrave-
nous drug users and 20% of the high risk heterosexuals reported failing to
return for HIV test results at least once. Of those who failed to return for
results, 29% assumed that the testing center would search for them if the test
was positive, 31% cited fear of the results, and 43% responded that they were
too busy or forgot.1
One potential HIV testing complication in the correctional setting is the
possibility that inmates will be released prior to the test results being pro-
cessed. The Rhode Island Department of Corrections has been offering HIV
testing to inmates in prison and jail for several years. Unfortunately, due to
the quick turnover of jail populations, many inmates have been released prior
to receiving results. Rarely do these inmates contact the correctional facility
following their release to inquire about their test results. When interviewed
upon reincarceration, they justified their lack of inquiries because “no news
is good news” (Beckwith et al., 2007). Failure to return or call for test results
is harmful for two reasons. First, as the Beckwith et al. results suggested,
some people will interpret the lack of information as a clean bill of health and
will continue to participate in high-risk activities. Second, inmates who do
not receive test results are unable to benefit from risk reduction counseling
that tends to take place at testing centers where people return to receive their
results (Beckwith et al., 2007; Kacanek et al., 1997). Researchers have sug-
gested that the best way to avoid failure to return is to use rapid testing equip-
ment in (Beckwith et al., 2007; Sullivan et al., 2004). Beckwith et al. (2010)
evaluated a jail-based HIV testing program where inmates were randomly
selected to receive either the rapid results test or the traditional HIV test. All
inmates subject to the rapid results test receive their results prior to release,
whereas only 28% of the traditional test group was informed of their HIV
status.
The second benefit of prison and jail testing programs is that it presents an
opportunity to educate inmates about healthy practices. Correctional facility

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
62 The Prison Journal 93(1)

staff members responsible for testing programs can build an HIV-awareness

program around the tests. As was noted earlier, prison and jail inmates gener-
ally have high-risk lifestyles where they repeatedly engage in behaviors that
could expose them to blood or other bodily fluids (Krebs, 2002; Martin,
Cayla, Moris, Alonso, & Perez, 1998; Moseley & Tewksbury, 2006).
Researchers have cited a number of obstacles to HIV prevention work
with offenders. One problem is the prison or jail culture itself. The inmate
subculture tends to promote antisocial thoughts and behaviors, and inmates
frequently talk to each other about their plans for their first few days out on
the streets (Inciardi et al., 2007). These plans often include behavior (sex and
drug use) that places them at risk for exposure to HIV. Another problem is
that there are misconceptions about HIV and its transmission. Researchers
who have interviewed offenders have reported that they often believe one can
tell from a person’s appearance if he or she has HIV/AIDS (Decker &
Rosenfeld, 1995; Stanton-Tindall et al., 2007). Additionally, some believe
married people, regardless of their fidelity to the marriage, cannot contract
HIV (Decker & Rosenfeld, 1995). Still other males inside corrections facili-
ties and in the community consider male-male sexual contact to be hetero-
sexual behavior for the person performing the insertive role (Donaldson,
1993; Lichtenstein, 2000; West, 2001). The most damaging misconception,
however, is the belief that HIV transmission is a matter of fate rather than a
matter of education and prevention (Swartz et al., 2004) or that some indi-
viduals are somehow immune from HIV transmission (Stanton-Tindall et al.,
2007). Inmates who believe that they have no control over their fate may
know the facts about HIV transmission but still hold the opinion that none of
the information applies to them. All of these issues can be addressed in either
pre- or post-test counseling sessions.

Existing Testing Programs

The Centers for Disease Control (CDC) provided funding to state health
departments in Florida, Louisiana, New York, and Wisconsin with the goal
of providing rapid HIV testing to jail inmates between December, 2003 and
May, 2006. The jails involved in the project booked approximately 550,000
people during the study period, and 33,211 voluntary tests were performed
(6% of bookings). Of the 33,211 rapid tests, 440 (1.3%) were positive. Four
hundred, twenty-two inmates (96%) accepted the offer for a confirmatory
test. Of those tests, 409 (97%) were positive, 8 (2%) were negative, and 5
(1%) were inconclusive. MacGowen and colleagues (2009) conducted

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
Tartaro and Levy 63

multivariate analyses to identify characteristics of inmates who tested posi-

tive. Age (35 years or older), race (Black), male-to-male sexual contact, sex
with an at-risk partner, and male-to-male sexual contact plus IDU were
associated with higher odds of HIV transmission. For female inmates, sex
with an at-risk partner and race (Black) were related to odds of HIV trans-
mission.
The Rhode Island Adult Correctional Institution includes an optional HIV
test as part of the processing procedure for sentenced inmates. Between 1998
and 2000, medical personnel conducted 5,390 HIV tests on 4,269 male
inmates. Two percent of the inmates tested positive for HIV. Those who
tested positive were more likely to be Black or Hispanic, to be more than 40
years old, and to be involved in IDU (Macalino et al., 2004).
The Georgia Department of Corrections initiated a mandatory HIV test-
ing program for inmates entering the system in 1988. Jail inmates were
tested if they volunteered or were referred by medical staff member.
Between 1988 and 2005, 88 inmates tested negative upon prison entry but
tested positive during their sentence. It is possible that some of these
inmates were infected prior to entering the prisons but that seroconversion
did not take place until sometime during incarceration. It is also possible,
though, that some of these inmates became infected during incarceration.
The CDC found that HIV seroconversion in this study was associated with
male-on-male sexual contact in prison, prison tattooing, and having served
at least five years of the current sentence. Other variables associated with
positive test results were age (above 26) and race (Black; Centers for
Disease Control, 2005).
Kacanek and colleagues (1997) interviewed inmates who were nearing
their prison release date in California, Mississippi, Rhode Island, and
Wisconsin. The participants were asked about their feelings on voluntary
HIV prison testing. Inmates who chose to take the test did so because it was
free, they were curious about their HIV status, it was convenient, they thought
it was mandatory, and because prison is their primary source of medical care.
Several of the inmates remarked that prison was the only place where they
had been offered free tests.
Beckwith et al. (2007) found that there are challenges to convincing
inmates, regardless of their risk, to participate in the testing programs. The
researchers recruited volunteers from the Rhode Island Department of
Corrections to take an HIV test and complete a survey about their high-risk
activities. Those who did not participate and get the HIV test declined because
some did not want to know the results. Others declined because they did not

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
64 The Prison Journal 93(1)

want to miss dinner or their shower time, or they preferred to play cards dur-
ing the time when the test was being administered.

The HIV Testing Program

at the Atlantic County Jail
The Atlantic County Jail in southeastern New Jersey subcontracted with
AtlantiCare Health Services to offer HIV testing to inmates housed at the jail
beginning in April 2009. The jail was awarded a grant to set up the testing
program due to the county’s high HIV transmission rate. The New Jersey
Department of Health and Senior Services (2008) reported that there were
more than 70,000 cases of HIV/AIDS in New Jersey by December 2007, and
more than half of the New Jersey infection cases include non-Hispanic
Blacks. Additionally, four out of five New Jersey females living with HIV/
AIDS are minorities. Notably, New Jersey ranked fifth among the fifty states
in the number of African Americans living with AIDS as of 2001. Atlantic
County has one of the highest numbers of people living with HIV/AIDS in
the state, with 1,775 residents. One in 33 African American men in Atlantic
City is living with HIV/AIDS, and this is second only to Newark, where one
in 30 African American men are infected.
An AtlantiCare case manager has been working with the inmate jail ser-
vices staff to offer inmates free HIV tests. Jail personnel allow inmates to
enter the jail, go through initial intake, and then wait for 24 to 72 hours to
sober up, detox, and adjust to being in jail. After that period of time, the jail
administers a biopsychosocial instrument to assess inmates’ needs. During
that time, the staff members offer inmates the free rapid HIV test. Inmates
who consent are placed on a list and called to testing in the order in which
they requested the test. When the time comes for those individuals to be
tested, they are brought in small groups (average of 5 inmates per group) to
the jail inmate services section. The case manager reminds the inmates that
the decision to take the HIV test is theirs, and they are asked again whether
they want to consent. Inmates who refuse to stay for the counseling and test
are told that they may come back later if they change their minds. If inmates
refuse the test due to already having been tested, the case manager reminds
them to follow up with that testing agency for the results.
Inmates who choose to remain for the counseling and testing are told
about why HIV testing is important, what is involved with the testing proce-
dure, and the confidentiality of testing. At that point, the inmates separate and
the case manager administers the test to each inmate individually in a private
area. While the inmates await results, the group is convened so the case man-
ager can begin the education portion of the program. This involves a review

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
Tartaro and Levy 65

of the group’s knowledge base, providing positive feedback for accurate

information and corrections when they are misinformed. The case manager
discusses behaviors related to increased risk for contracting HIV, especially
behaviors that are common among incarcerees, such as “jail house tattoos”
and fighting and biting. This counseling program lasts approximately 20 min,
which is long enough for the test results to return. The inmates again separate
and the case manager meets with each inmate individually to discuss the test
results. When the result is negative, the case manager discusses the 14-week
seroconversion period and that individual’s specific risks that were self-
reported on the risk assessment form. Inmates who are close to release are
encouraged to engage in a conversation about the jail’s reentry program. If
inmates indicate interest, they are given referrals to mental and/or physical
health treatment, infectious disease clinics, drug and alcohol treatment ser-
vices, needle exchange programs, and other reentry services. They also
receive a list of health service providers in the community. Those who expect
to be incarcerated for a longer period of time are referred to appropriate ser-
vices within the jail. Inmates who are close to being transferred to state prison
are encouraged to seek services at the new facility.
All inmates who test positive on the initial test receive a confirmatory
blood test that takes 7 days for the results to be processed. Those who test
positive on the confirmatory test are given counseling and medical treatment.
The drug regimen is part of the other medications the offender receives, so it
is not apparent to other inmates that the individual is being treated for HIV.
Once released, the inmates who do not have commercial health insurance are
offered community-based resources through an AtlantiCare office in Atlantic
County.

Method
All participating inmates were asked by jail staff members responsible for
administering the HIV tests to consent to share their information with two
researchers from a local college. Participants were promised confidentiality
and were assured that their information was to be used exclusively for
research purposes. Those who consented to the HIV test did have the option
of continuing with the test without participating in the research. The
researchers developed a short instrument that included demographic infor-
mation as well as questions about reasons for wanting to be tested, their HIV
test history, and self-reported high-risk behavior.
Testing began on April 30, 2009, and the researchers collected data
through December 31, 2009. The jail did not keep precise records of the num-
bers queried for their interest in an HIV test. However, the staff members

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
66 The Prison Journal 93(1)

reported that approximately half of those who were asked expressed interest.
Approximately 1,700 inmates initially agreed to undergo testing. They were
asked if they would like to be put on the testing list when they went through
initial jail medical intake. Inmates typically had to wait 1 to 3 days, and
sometimes longer between the time of their initial consent and the time that
the case manager administering the test was able to meet with them. The
grant provided funding for only one case manager to participate in this proj-
ect, so the tests were only administered by one person during normal business
hours, and no tests occur when that person was out sick or on vacation.
Between the time of initial consent and the time that the test was to be con-
ducted, 75 inmates changed their minds about being tested. An additional 624
inmates were released from jail before the testing could be conducted. A total
of 956 inmates consented and remained in the jail long enough to be tested.
Of these, 26 received multiple tests at the jail, with 25 inmates receiving two
tests and one inmate being tested three times. In sum, 983 HIV tests were
administered during the data collection period. Of the 956 inmates who par-
ticipated, 698 (73%) consented to releasing their personal information for the
study. Those who declined to share their information with the researchers
reported concerns about confidentiality. Some inmates commented that they
knew faculty and staff at the college where the two researchers worked, and
a few of those who declined to allow researchers access to their information
noted that they knew the two researchers.

Results
Frequencies

Again, 75 inmates changed their minds between their needs assessment and
the time when they were called to take the test. The reasons why they
declined the test after initially consenting varied. As was noted earlier, the
wait between agreeing to the test and being called to take it varied from one
day to several days, depending on the number who wanted to take the test
and the availability of the case manager. The result is that inmates had a few
days to reconsider their decision. Some began to think about what they per-
ceived as the “dangers” of testing and might have been discouraged by other
inmates who were against the testing program. One reason given for refusing
the test was the belief that the jail already took too much blood from them (a
likely reference to the mandatory syphilis test). Other reasons were related to
inmates believing that the test was inconvenient. Some declined because they
were asked to go to the testing area while they were watching a favorite

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
Tartaro and Levy 67

television show, the inmates were sleeping, or they did not want to enter the
testing area because it is cold. Some female inmates experienced delays in
testing because they needed to be escorted past the male housing areas, so it
was necessary to find officers who could handle the escort.
Of those who consented to testing and releasing their information for the
study, 90% (598) were New Jersey residents, with 36% residing in Atlantic
City (Table 1). Five percent (30) of participants were from Pennsylvania, 2%
(15) resided in New York and 3% (22) were from outside of the tristate area.
Females (20%) were overrepresented in the participant group. Seventy-nine
percent (546) were males and 1% identified as transgender. Nearly 90%
(608) of the participants reported that they were not homeless at the time of
their most recent incarceration. Slightly more than half of the participants
were Black, 34 % were White, 2 % were Asian, 1% American/Pacific Islander
and 10% identified themselves as another race. One hundred fifteen respon-
dents identified themselves as Hispanic. Of those inmates, 76% were Puerto
Rican, 10% were Mexican, 6% were Central/South American, 4% were
Cuban, and 4% traced their heritage to another country. Most participants
(86%) identified English as their primary language. Eight percent use bilin-
gual (English and Spanish), 4% identified Spanish as their first language, and
2% indicated that another language was their primary. Slightly more than
three-quarters (77%) were single at the time that the test was taken. Eleven
percent were married, and 9% were separated, divorced, or widowed. Three
quarters of respondents were unemployed prior to their incarceration. The
mean age of participants was 32 (SD = 10.72).
The researchers obtained demographic information of inmates residing in
the jail during the study period. The inmate population consisted of 81.2%
males and 18.8% females, so that females were only slightly overrepresented
among HIV-test participants (78.8% males and 20.3% females released their
information to researchers). The racial and ethnic composition of the HIV
test participants was also similar to the demographics for the entire jail.
Slightly more than one third of the test participants were White, compared to
35% of the jail population. Hispanics were slightly overrepresented among
participants, with 16.5% of inmates who volunteered for testing self-identifying
as Hispanic compared to 13% of the jail population. The average age for
participants was 32.3, which was just slightly younger than the mean age of
jail detainees (34.2). Overall, the group that consented to the HIV tests and
shared their information with the researchers seemed to closely match the
demographics of inmates housed in the jail during the study period. Sixty-
five percent of the inmates received an HIV test for the first time. Of those
who had tested previously, 384 (95%) had negative results on previous tests,

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
68 The Prison Journal 93(1)

Table 1. Descriptive Statistics for Jail Inmate HIV Testing Program (N = 698)—
Atlantic County, New Jersey
Variable F % M SD
Residential state (N = 6,654)
  New Jersey 598 89.9  
 Pennsylvania 30 4.5  
  New York 15 2.3  
 Other 22 3.3  
Residential city (N = 668)
  Atlantic City 238 35.6  
 Philadelphia 26 3.9  
 Other 404 60.5  
Gender (N = 693)
 Male 546 78.8  
 Female 141 20.3  
 Transgender 6 0.9  
Homeless (N = 689)
 No 608 88.2  
 Yes 81 11.8  
Race (N = 615)  
 White 208 33.8  
 Black 330 53.7  
 Asian 11 1.8  
  American/Pacific Islander 7 1.2  
 Other 59 9.6  
If Hispanic, what region? (N = 115)
 Mexican 11 9.6  
  Puerto Rican 87 75.7  
 Cuban 5 4.3  
  Central/South American 7 6.1  
 Other 5 4.3  
Language (N = 649)
 English 558 86.0  
  English and Spanish 51 7.9  
 Spanish 25 3.9  
 Other 15 2.2  
Marital status (N = 692)
 Single 532 76.8  
 Married 76 11.0  
 Separated/divorced/widowed 64 9.3  
 Other 20 2.9  
(continued)

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
Tartaro and Levy 69

Table 1. (continued)

Variable F % M SD
Employment status (N = 691)
 Unemployed 514 74.4  
 Full-time 94 13.6  
 Part-time 28 4.0  
 Self-employed 27 3.9  
 Other 28 4.1  
Age at testing 32.29 10.72  
Salary US$16,673.46 US$27,756.50  

17 (4.2%) did not know their previous test results, and three (0.7%) had
received positive test results. On average, those who tested previously par-
ticipated in their last test more than 2 years ago (mean = 2.21, SD = 2.92).
When asked about the location of prior tests, the modal response was a cus-
todial facility (35.3%) with doctor offices, hospitals, medical centers and
Veteran’s centers as a close second (34.3%). Sixteen percent of previously
tested inmates visited a clinic, shelter or mobile unit. Eleven percent were
tested at a rehabilitation center or half-way house, and 4% went to an AIDS
center for testing. See Table 2.
As was previously reported, 25 participants were either reincarcerated or
remained incarcerated long enough to take additional HIV tests in the jail.
Twenty-four of the 698 participants took two tests, and one person took three
tests. Inmates were asked about why they were interested in being tested at
this particular time. Eighty percent (501) responded that they were curious
about their status. Approximately 15% indicated that they had been involved
in high risk behavior including, unprotected sex (8.5%), drug use (2.6%),
both sex and drug use (2.2%), his or her partner is HIV positive or the respon-
dent was concerned about a previous rape, bite, or blood transfusion. Three
percent replied that “there’s nothing better to do” or “it’s free,” and 2%
replied “why not?” While the researchers were only able to obtain detailed
information about 698 of the 956 inmates who participated in testing, jail
staff members were able to provide the total number of positive and negative
tests. Of the 956 inmates who took the test, three inmates (0.3%) tested posi-
tive for HIV. After these three people were informed of their positive test,
two disclosed that they had previously tested positive.
Prior to testing, inmates were also asked specific questions about their
sexual and drug use behavior. The results are displayed in Table 3. Inmates

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
70 The Prison Journal 93(1)

Table 2. HIV Testing Data for (N = 698)—Atlantic County, New Jersey

Variable F % M SD
Tested before? (N = 692)
 No 246 35.5  
 Yes 446 64.5  
Results of previous tests  
(N = 404)
 Negative 384 95.1  
 Positive 3 0.7  
 Unknown 17 4.2  
Years since last test 2.21 2.917
Where were you last tested (N = 382)
  Rehab/halfway house 40 10.5  
 Doctor/hospital/medical 131 34.3  
center/VA
  Clinic/shelter/mobile unit 61 16.0  
 Facility (juvenile detention 135 35.3  
center, jail, prison)
  AIDS center 15 3.9  
Variable F %  
Number of tests inmates took
  One test 673 96.4  
  Tested twice at jail 24 3.4  
  Tested three times at jail 1 0.1  
Reason for getting tested now (N = 626)
 Wanted to know/curious 501 80.0  
about status
 Nothing better to do/it’s 17 2.7  
free
  Why not? 13 2.1  
  Unprotected sex 53 8.5  
  Drug use 16 2.6  
  Both sex and drug behavior 14 2.2  
  Partner is HIV+ 5 0.8  
 Blood transfusion/rape/ 4 0.6  
bitten
 Other 3 0.5  
Test results for inmate participants (n = 956)
 Negative 953 99.7  
 Positive 3 0.3  

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
Tartaro and Levy 71

Table 3. Sexual Contact Data for Jail Inmate HIV Testing Program (N = 698)—
Atlantic County, New Jersey
Variable F (yes) % (yes)
Engage in sexual contact with males (N = 666) 131 20.8
Engage in sexual contact with females (N = 664) 527 82.2
Anal contact (N = 674) 125 18.6
Oral contact (N = 675) 498 73.9
Vaginal contact (N = 676) 608 90.1
Unprotected sex (N = 676) 543 80.4
Contact with a person who is HIV+ (N = 675) 10 1.5
Contact with MSM (N = 676) 6 0.9
Had sex while intoxicated (N = 489) 185 37.9
Exchange sex for drugs (N = 489) 45 9.2
Sex w/person who exchanges sex for drugs (N = 488) 53 10.9
Sexual contact with a person who uses IV drugs? (n = 676) 71 10.5
Sex w/anonymous partner (N = 489) 85 17.4
Sex w/person w/hemophilia/transfusion/transplant (N = 489) 6 1.2
Sex w/transgender person (N = 489) 6 1.2
Last sexual contact (years)? (N = 641) 0.31 0.57
  Within last month 336 52.3
  Within last 3 months 138 21.6
  Within last 6 months 78 12.2
  Within last 9 months 36 5.6
  Within last year 19 3.0
  Within last 2 years 16 2.5
  More than 2 years ago 18 2.8

tended to be sexually active, with 20% reporting sexual contact with males
and 82% reporting sexual contact with females. The 82% is likely an under-
estimation; when inmates were asked about recent types of sexual contact,
90% reported vaginal contact. Seventy-four percent of respondents reported
oral sexual contact, and 18% reported anal contact. Eighty percent of respon-
dents admitted to having unprotected sex. Two percent of participants
reported sexual contact with someone known to be HIV positive, and 1% had
male-male sexual contact. Thirty-eight percent had sex while intoxicated.
Nine percent exchanged sex for drugs, 11% had sex with someone who had
exchanged sex for drugs, and 11% reported sexual contact with an intrave-
nous drug user. Sex with an anonymous partner was reported by 17% of
participants. One percent reported sex with someone who has hemophilia or
received an organ transplant or blood transfusion, and 1% reported having

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
72 The Prison Journal 93(1)

Table 4. Drug Data for Jail Inmate HIV Testing Program (N = 698)—Atlantic
County, New Jersey
Variable F (yes) % (yes)
Contact with a person who uses IV drugs? (N = 676) 71 10.5
IV drug user yourself? (N = 668) 114 16.3
Share needles? (N = 676) 56 8.3
Last used drugs (years)? (N = 29) 0.246 0.271
  Within last month 15 51.7
  Within last 3 months 6 20.7
  Within last 6 months 4 13.8
  Within last year 4 13.8

sex with a transgendered person. The mean time between last sexual contact
and testing was 4 months, but the distribution was irregular (SD = 0.57).
Slightly more than half (52%) of respondents reported that their most recent
sexual contact occurred within the previous month. Eighty-six percent of
respondents reported sexual contact within the past 6 months.
Information regarding participants’ self-reported drug use is displayed in
Table 4. Sixteen percent of respondents identified themselves as intravenous
drug users, and 8% indicated that they have shared needles.

Cross-Tabulations
Cross-tabulations with chi-square tests of independence were conducted to
determine whether inmates who had tested previously were at a higher risk
for exposure to HIV than those who decided to test for the first time in the
jail. The results are displayed in Table 5. There were no significant differ-
ences in self-reported high-risk behavior of inmates who had been tested
before versus those who were participating in testing for the first time.

Discussion
The results of this study clearly support the findings of other researchers that
incarcerated populations partake in behaviors that put them at high risk for
HIV transmission. The testing program at the Atlantic County Jail began in
April 2009 and continues to operate today. Thousands of inmates are being
offered the opportunity for free, confidential testing in a setting where they
likely have fewer distractions than while residing in the community. Inmates

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
Tartaro and Levy 73

Table 5. Chi-square Tests of Independence Inmates Who Had Tested Previously

Versus First Time Testers
Not tested Tested
before before
Self-reported behaviors f % f % χ2 Sig.
Unprotected sex 179 75.8 344 79.1 .930 .335
a a
Sex w/ HIV+ person 0 0.0 10 2.3
Sex with IV drug user 19 8.1 52 12.0 2.463 .117
IV drug use 31 13.1 82 18.8 3.475 .062
Exchanged sex for drugs 11 6.8 32 9.8 1.213 .271
Had sex with someone who  
exchanged sex for drugs
a
A chi-square test was not conducted due to low expected frequencies.

are also promised free medical care for the duration of their jail stay, and
those who live in the county and lack health insurance are assured that they
will receive outpatient treatment from a local service provider upon release.
The program recently received funding to expand testing to include other
sexually transmitted diseases.
Custodial institutions are important testing centers, since they house cap-
tive populations who tend to live unhealthy lives and rarely receive regular
health checks. Two-hundred forty-five inmates in this study were tested for
HIV for the first time in the jail. An additional one hundred seventy-five
inmates were tested before but had received those tests in either a custodial or
rehabilitation setting. It is possible that some of these inmates would have
sought HIV testing elsewhere, but these findings support previous research
that found correctional facilities to be among the most popular testing centers
for high-risk individuals (Desai et al., 2002; Kacanek et al., 1997). The use of
the rapid finger-prick tests allowed the jail to address the problem of inmates
being released prior to obtaining the result, thus eliminating the possibility
that positive inmates assumed that they are negative because no one told
them otherwise.
A surprising finding here was that only three inmates out of the 956 who
were tested during the data collection period tested positive for HIV. As was
noted earlier, The New Jersey Department of Health and Senior Services
(2008) reported that New Jersey is ranked fifth among the states for African
Americans living with HIV/AIDS, and within New Jersey, Atlantic City is
second only to Newark for the proportion of African American men living

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
74 The Prison Journal 93(1)

with AIDS. In light of this information, it was expected that there would be
more positive tests. One possible explanation is that inmates are selectively
opting out of tests if they have reason to believe that they might be HIV posi-
tive. Andrus et al. (1989) did explore this possibility by comparing voluntary
HIV test results to blood samples drawn from inmates who did not want to be
tested for HIV but had to participate in syphilis testing in an Ohio prison.
There appeared to be no significant differences in self-reported high-risk
behaviors (intravenous drug use, homosexual activity, testing positive for
hepatitis B) between the individuals who consented to the HIV test and those
who declined. Inmates in the Andrus et al. study were asked if they thought
they had been exposed to HIV, and 85% of the inmates who answered affir-
matively chose to take the test. It is not clear whether these results are gener-
alizable to other facilities and locations in the United States, but it does
provide evidence that not all high-risk people avoid HIV tests. Ideally, the
researchers of the current study would have liked to have been able to ask
members of a comparison group about their high-risk activities. It is unlikely,
however, that inmates who were concerned about privacy issues and did not
trust the jail staff to do the HIV test would be willing to answer such personal
questions about their sex and drug use behavior.
The extent of self-reported high-risk behaviors among those who volun-
teered to participate in the testing program underscores the need to educate
inmates about unsafe sex and drug use behaviors. It is important to remember
that some previous studies have found that some inmates have become fairly
knowledgeable about what constitutes HIV high-risk transmission behaviors.
A significant hurdle to transforming that knowledge into healthy practices,
though, is the belief that either HIV transmission happens to other people or
that transmission is a matter of fate. Until these beliefs are changed, warnings
about the importance of safe sex and drug use practices will be considered
irrelevant. The jail described in the current study provides a very short educa-
tion program about HIV to those who participate in testing. While this pro-
gram might provide inmates with some information about HIV and its
transmission, such a short program is unlikely to be effective in changing the
beliefs of people who think that transmission is a matter of fate rather than
behavior. Time is always a challenge when working with transient jail inmate
populations. While it would be difficult to develop and facilitate a course on
healthy living practices, a much longer program that addresses the myths of
fate and immunity as they relate to health and risky behaviors would likely do
more to combat these beliefs than a 20 minutes overview of HIV. Previous
research has emphasized the importance of culturally appropriate materials
and the need to have instructors who are from diverse racial and ethnic

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
Tartaro and Levy 75

backgrounds (particularly multilingual staff members), as this tends to

increase the credibility of the program’s message (Kantor, 2006; Leh, 1999).
The CDC has recommended the adoption of opt-out HIV testing for cor-
rections facilities. Under an opt-out screening system, HIV tests are handled
as part of routine health screening, and inmates are informed that they will be
tested unless they specifically decline. This can normalize HIV testing,
increase diagnosis for HIV infection, and improve access to clinical care for
those who are positive and prevention services to those who are negative. The
HIV test is not part of routine medical screening, and those who agree to take
the test must make a separate trip to the medical area and sign a consent form.
As was noted earlier, this additional trip is considered an inconvenience to
some inmates, and the consent form might scare inmates who are already
suspicious of having to sign anything. Wisconsin and Rhode Island has been
using opt-out screening for several years, but New Jersey has not yet adopted
this system. A change to an opt-out system would likely increase the number
of HIV tests performed at the jail each year, and the tests could be done more
efficiently during the regular medical screening (CDC, 2008).

Limitations and Suggestions

for Future Research
As in any jail evaluation, a systematic approach to data collection and storage
is salient to the tracking of inmates and maintenance of records. The jail in
this study suffers, like most, from understaffed and overworked conditions.
As this particular HIV testing program moves forward, it would certainly help
if the jail could either hire an additional case manager or bring in an alternate
on the days when the full-time case manager is out sick or on vacation. During
the 5 months that the researchers observed the program, more than 600
inmates volunteered for testing but were released from custody before the
staff member was available to do the test. An additional 75 inmates had
agreed to testing but then changed their minds while they waited their turn.
More staffing dedicated to HIV testing might have resulted in testing of an
additional 700 inmates who, at one point, were interested in receiving the test.
As this and other jails move forward with HIV testing, the educational
component of this program is crucial in the prevention of future cases of HIV.
The focus on HIV testing only covers one aspect of HIV transmission. The
primary reason to test is to notify infected individuals so they will get treat-
ment and prevent the spread of HIV. For those who do not test, educational
counseling may be the only way to convey information to protect oneself from
contracting HIV. As such, the educational counseling should be considered as

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
76 The Prison Journal 93(1)

both part of the testing sequence as well as a stand-alone session. Inmates who
do not agree to be tested in the facility should have an opportunity to learn
about HIV. Currently, the program in this jail is set up such that the “educa-
tional counseling” is given between the time when the blood is drawn and the
results are ready. Inmates who are not tested do not have access to such
counseling.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or pub-
lication of this article.

Note
1. Sullivan et al. (2004) noted that the percentages did not add to 100 because respon-
dents were permitted to choose more than one reason for failure to return.

References
Andrus, J. K., Fleming, D. W., Knox, C., McAlister, R. O., Skeels, M. R., Conrad, R. E.,
& Foster, L. R. (1989). HIV testing in prisoners: Is mandatory testing mandatory?
American Journal of Public Health, 79, 840-842.
Bauserman, R. L., Richardson, D., Ward, M., Shea, M., Bowlin, C., Tomoyasu, N., &
Solomon, L. (2003). HIV prevention with jail and prison inmates: Maryland’s pre-
vention case management program. AIDS Education and Prevention, 15, 465-480.
Beckwith, C. G., Atunah-Jay, S., Cohen, J., Macalino, G., Poshkus, M., Rich, J. D.,
& Lally, M. A. (2007). Feasibility and acceptability of rapid HIV testing in jail.
AIDS Patient Care, 21(1), 41-47.
Beckwith, C. G., Liu, T., Bazerman, L. B., DeLong, A. K., Desjardins, S. F.,
Poshkus, M. M., & Flanigan, T. P. (2010). HIV risk behavior before and after
HIV counseling and testing in jail: A pilot study. Journal of Acquired Immune
Deficiency Syndrome, 53, 485-490.
Begier, E. M., Bennani, Y., Forgione, L., Punsalang, A., Hanna, D. B., Herrera, J.,
& Parvez, F. (2010). Undiagnosed HIV infection among New York City Jail
Entrants, 2006: Results of a blinded serosurvey. Journal of Aquired Immune Defi-
ciency Syndrome, 54(1), 93-101.
Centers for Disease Control and Prevention. (2005). Morbidity and Mortality Weekly
Report, 55(15), 1-5.

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
Tartaro and Levy 77

Centers for Disease Control and Prevention. (2007). HIV/AIDS surveillance report.
(Vol. 17). Atlanta, GA: Department of Health and Human Services.
Centers for Disease Control and Prevention. (2008). HIV testing implementation guid-
ance for correctional settings. Retrieved from http://www.cdc.gov/hiv/topics/
testing/resources/guidelines/correctional-settings/
Decker, S., & Rosenfeld, R. (1995). “My wife is married and so is my girlfriend”:
Adaptations to the threat of AIDS in an arrestee population. Crime & Delinquency,
41(1), 37-53.
Desai, A. A., Latta., E. T., Spaulding, A., Rich, J. D., & Flanigan, T. P. (2002). The
importance of routing HIV testing in the incarcerated population: The Rhode
Island experience. AIDS Education and Prevention, 14(Suppl. B), 45-52.
Donaldson, S. (1993). A million jockers, punks, and queens: Sex among American
male prisoners and its implications for concepts of sexual orientation. Retrieved
from www.spr.org
Duffus, W., Youmans, E., Stephens, T., Gibson, J. J., Albrecht, H., & Potter, R.
(2009). Missed opportunities for early HIV diagnosis in correctional facilities.
AIDS Patient Care and STDs, 23, 1025-1032.
Gough, E., Kempf, M. C., Graham, L., Manzanero, M., Hook, E. W., Bartolucci, A.,
& Chamot, E. (2010). HIV and hepatitis B and C incidence rates in US correc-
tional populations and high risk groups: A systematic review and meta-analysis.
BMC Public Health, 10, 777-791.
Hoxie, N. J., Vergeront, J. M., Frisby, H. R., Pfister, J. R., Golubjatnikov, R., &
Davis, J. P. (1990). HIV seroprevalence and the acceptance of voluntary HIV
testing among newly incarcerated male prison inmates in Wisconsin. American
Journal of Public Health, 80, 1129-1131.
Inciardi, J. A., Surratt, H. L., Martin, S. S., O’Connell, D. J., Salandy, A. D., &
Beard, R. A. (2007). Developing a multimedia HIV and Hepititus intervention
for drug-involved offenders reentering the community. The Prison Journal,
87(1), 111-142.
Kacanek, D., Eldridge, G. D., Neeley-Moore, J., MacGowan, R. J., Binson, D.,
Flanigan, T. P., & Sosman, J. M. (1997). Young incarcerated men’s perceptions
of an experiences with HIV testing. American Journal of Public Health, 97,
1209-1215.
Kantor, E. (2006). Comprehensive, up-to-date information on HIV/AIDS treatment,
prevention, and policy from the University of California San Francisco. HIV
InSite. San Francisco, CA: University of California, San Francisco. Retrieved
from http://hivinsite.ucsf.edu/InSite?page=kb-07-04-13
Krebs, C. P. (2002). High-risk HIV transmission behavior in prison and the prison
subculture. The Prison Journal, 82(1), 19-49.

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
78 The Prison Journal 93(1)

Leh, S. K. (1999). HIV infection in U.S. correctional systems: Its effect on the com-
munity. Journal of Community Health Nursing, 16(1), 53-63.
Lichtenstein, B. (2000). Secret encounters: Black men, bisexuality, and AIDS in Ala-
bama. Medical Anthropology Quarterly, 14, 374-393.
Macalino, G. E., Vlahov, D., Sanford-Colby, S., Patel, S., Sabin, K., Salas, C., &
Rich, J. D. (2004). Prevalence and incidence of HIV, hepatitis B virus, and hepa-
titis C virus infections among males in Rhode Island Prisons. American Journal
of Public Health, 94, 1218-1223.
MacGowen, R., Margolis, A., Richardson-Moore, A., Wang, T., Lalota, M., French, T.,
& Griffitsh, S. D. (2009). Voluntary rapid human immunodeficiency virus (HIV)
testing in jails. Sexually Transmitted Diseases, 36(2), S9-S13.
Maruschak, L. M. (2009). HIV in prisons, 2007-2008. Washington, DC: U.S. Depart-
ment of Justice, Bureau of Justice Statistics.
Martin, V., Cayla, J. A., Moris, M. L., Alonso, L. E., & Perez, R. (1998). Predictive
factors of HIV- infection in injecting drug users upon incarceration. European
Journal of Epidemiology, 14, 327-331.
McClelland, G. M., Teplin, L. A., Abram, K. M., & Jacobs, N. (2002). HIV and AIDS
risk behaviors among female jail detainees: Implications for public health policy.
American Journal of Public Health, 92, 818-825.
Moseley, K., & Tewksbury, R. (2006). Prevalence and predictors of HIV risk behav-
iors among male prison inmates. Journal of Correctional Health Care, 12(2),
132-144.
New Jersey Department of Health and Senior Services. (2008). New Jersey HIV/AIDS
Report. Trenton: New Jersey Department of Health and Senior Services.
Spaulding, A., Stephenson, B., Macalino, G., Ruby, W., Clarke, J. G., & Flanigan, T. P.
(2002). Human immunodeficiency virus in correctional facilities: A review. HIV/
AIDS, 35, 305-312.
Stanton-Tindall, M., Leukefeld, C., Palmer, J., Oser, C., Kaplan, A., Krietemeyer, J.,
& Surratt, H. L. (2007). Relationships and HIV risk among incarcerated women.
The Prison Journal, 87, 143-165.
Sullivan, P. S., Lansky, A., & Drake, A. (2004). Failure to return for HIV test results
among persons at high risk for HIV infection. Epidemiology and Social Science,
35, 511-518.
Swartz, J. A., Lurigio, A. J., & Weiner, D. A. (2004). Correlates of HIV-risk behav-
iors among prison inmates: Implications for tailored AIDS prevention program-
ming. The Prison Journal, 84, 486-503.
West, A. (2001). HIV/AIDS education for Latina inmates: The delimiting impact of
culture on prevention effects. The Prison Journal, 81(1), 20-41.

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015
Tartaro and Levy 79

Bios

Christine Tartaro is professor of criminal justice, Richard Stockton College of

New Jersey. Currently serving as a research consultant for her local jail, her research
interests include suicide, prison and jail violence, the mentally ill in the corrections
system, jail design, and the history of punishment and crime prevention.

Marissa P. Levy is associate professor of criminal justice, Richard Stockton College

of New Jersey. She has evaluated several programs at the Atlantic County Jail. Her
research interests include ecological criminology, evaluation, crime prevention, crime
mapping, and methods of research.

Downloaded from tpj.sagepub.com at Scott Memorial Library @ Thomas Jefferson University on March 10, 2015