Behind high prison walls, the concept of safe sex may be as foreign as that of freedom.
But some say this situation must change, especially because studies suggest that the prevalence of HIV infection in U.S. prisons and jails is six to 10 times higher than that seen in the general free population.
Recently, the National Minority AIDS Council, an AIDS advocacy group, recommended that prisons curb the spread of the virus by distributing condoms to prisoners.
The idea is not a new one.
According to the not-for-profit organization Human Rights Watch, prisons in Mississippi and Vermont, and jails in New York, Philadelphia, Washington D.C., San Francisco and Los Angeles already distribute condoms to inmates.
Several countries, including Canada, Australia, and most countries in the EU, also distribute condoms to prisoners.
"Whether legal or not, sex between inmates is occurring, and we must do what we can to provide vehicles for responsible sexual behavior, including the use of condoms," said Eli Coleman, professor and director of the Program in Human Sexuality at the University of Minnesota Medical School.
"These measures should be adopted worldwide as a means of promoting safety in our prisons. This is sound public health policy," Coleman said.
Some prisons, however, are reluctant to provide condoms to prisoners.
"In our system, engaging in sex in prison or sodomy is a Class 1 misconduct," said Sheila Moore, deputy press secretary for the Pennsylvania Department of Corrections in Harrisburg, Pa. "It's against the rules. Passing out condoms in prisons is also a security issue. Things such as drugs can be smuggled in."
It is difficult to pin down an exact statistic on how many prisoners are having sex. Various studies have arrived at figures ranging from 2 percent to 30 percent.
But research also shows that prison sex is risky sex.
One study in 2002 estimated that about one-quarter of the U.S. population infected with HIV had spent some time each year in a prison or jail.
Hence, a certain number of prisoners who go in HIV negative come out HIV positive. Health experts say distributing condoms to these prisoners would be a wise approach to the problem.
Some say that distributing condoms in prisons and jails may also prevent taxpayers from eventually having to pay to care for HIV-infected inmates.
"If prisoners transmit [sexually transmitted infections] or HIV/AIDS to each other, the public will have to spend the money to take care of them," said Dr. June Reinisch, director emeritus of the Kinsey Institute for Research in Sex, Gender and Reproduction.
"Whether you are on the side of caring about their health or are against their having sexual interactions -- which we are unlikely to influence one way or another by providing condoms or not -- we may be saving the public millions of dollars in health-care costs for taking care of the sick prisoners," Reinisch said.
The pros and cons of distributing condoms in prison must be weighed before decisions are made.
"I think that this approach is worth a try," said Dr. Fred Berlin, associate professor of psychiatry at the Johns Hopkins University School of Medicine. "The reality is that individuals do have sex in prison. However, good data should be maintained documenting both the perceived benefits, as well as any problems that might develop."
Some prisons argue, though, that passing out condoms could create a host of unexpected problems.
In short, they say that behind bars, a condom is more than just a condom.
"We recognize the public health benefit, but a lot of people who do not work in the prison system cannot completely appreciate what inmates do with foreign objects," said Bill Sessa, spokesman for the Department of Corrections and Rehabilitation for the state of California in Sacramento. "They can make a lethal weapon out of dental floss."
In October, California Gov. Arnold Schwarzenegger vetoed a piece of legislation that would have allowed condoms to be distributed in the state's correctional facilities.
Sessa says the vetoed bill was not the first time the issue had come up.
"[Condoms] can also easily be used to hide drugs, or smuggle contraband around the prison," he said.
There is also the concern that condoms do nothing to prevent the incidence of nonconsensual sex among inmates.
"It's terrible that prisons cannot protect inmates from nonconsensual sex, but frequently they cannot, and it's even worse when a raped prisoner becomes HIV positive," said Julia Ericksen, professor and chair of the department of sociology at Temple University in Philadelphia. "So, even here, condoms make sense."
Proponents of condom distribution in prisons say the measure would cost only pennies per inmate.
Condom distribution is more preferable than more direct intervention to prevent sex among inmates, such as additional monitoring or isolation.
"More stringent monitoring, well you could do that," said Dr. Rebecca Finn, director of HIV services for the New York City Department of Corrections.
"But you'd need more people. It would be more expensive. And I'm not sure it would really do anything. If people are going to be sexually active, they're going to find out ways to do it whether they're being monitored or not," Finn said.
Finn adds that because many prisons are so large -- Riker's Island, for example, holds between 10,000 and 12,000 inmates -- isolation would not be a feasible alternative.
"Isolation is just not healthy," she said. "People end up getting mentally very unstable if you isolate them."
Sex education is another option currently used by many prisons.
"Our inmate- and employee-education programs for treatment and counseling of infected inmates is in line with state-of-the-art recommendations and consistent with or ahead of usual community practice," said Harrisburg's Moore. "We might not be able to prevent inmates from engaging in sex, but we feel that we need to continue to educate them."
But Finn says education can go only so far -- particularly when inmates don't have the resources available to ensure their sexual encounters are as safe as possible.
"Whether we think it's appropriate or not for inmates to have sex with each other, they do," Finn said. "If we refuse to accept the fact that when you put all these inmates together in a dormitory setting that they're going to be sexually active, then I think we are inviting new disease to occur."
Despite their crimes, some observers say, prisoners do not deserve extra punishment while incarcerated.
"No matter what, no prisoner deserves to get HIV as part of his punishment," Ericksen said.