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Prisoners and HIV/AIDS
Globally, 10 million people are incarcerated, with 6 countries locking up at least one in every 200 of their citizens. 1 HIV prevalence within prisons is estimated to be between 2 and 50 times those of general adult populations. 2 Prisons are a high-risk environment for HIV transmission with drug use and needle sharing, tattooing with homemade and unsterile equipment and high-risk sex and rape commonplace.
Overcrowding only serves to increase the spread of opportunistic infections as stress, malnutrition, drugs, and violence weaken the immune system, making HIV-positive individuals more susceptible to getting ill.
However, prisoner wellbeing is often neglected and overlooked. HIV prevention programmes are rarely made available to inmates, and many prisoners with HIV are unable to access life-saving antiretroviral treatment. In many parts of the world, prison conditions are poor and HIV-positive inmates barely receive the most basic healthcare and food. Moreover, mandatory testing is enforced by some prison authorities, which is often seen as a breach of human rights.
These issues are not confined to male prisoners; due to the high proportion of injecting drug users within prisons, female inmates have also been severely affected by HIV and AIDS.
HIV prevalence in prisons around the world
- North America
More than two million people are incarcerated in the United States, giving it the highest prison population in the world. In 2007, 1.4 percent of the total prison population were reported to be living with HIV or AIDS. Of the male inmates, 1.3 percent were known to be living with the virus, compared with 1.7 percent of female inmates. Although these figures are falling, 3 4 5 a 2007 study showed the rate of confirmed AIDS cases among state and federal prisoners was still 2.4 times greater than that of the general population. 6
- South America
The prevalence rates for some sub-Saharan African countries is extremely high; an estimated 41.4 percent of incarcerated people in South Africa are infected with HIV. 9 Generally, the HIV prevalence in the country reflects the prevalence in prisons. For example, South Africa has both a high percentage of HIV positive inmates, as well as a high HIV prevalence among the general population (10.8 percent). 10
In Eastern Europe, HIV prevalence among the prison population is also significant. 11 In 2010, it was estimated that 55,000 of Russia's 846,000 inmates were infected with HIV. 12 In Estonia, four studies revealed HIV prevalence in prisons ranging from 8.8 to 23.9 percent. 13 In contrast, HIV prevalence rates in Western Europe are much lower due to successful prevention interventions targeting injecting drug use (IDU) early in the epidemics. For example, one study in France estimated HIV prevalence rates for both male and female inmates at 2 percent. 14
In 2008, roughly 5 million people in Asia were living with HIV. India accounts for roughly half these infections. 15 While HIV prevalence among the general population in India is low (0.25-0.43 percent), among vulnerable groups, HIV prevalence is much higher. In at least five States, HIV prevalence among injecting drug users (IDUs) in prison is greater than 10 percent, with a high of 24 percent in Maharashtra. 16
How is HIV transmitted in prisons?
HIV is transmitted in prisons in a number of ways. These range from injecting drug use to high-risk sexual behaviour, tattooing to violence. Many studies claim a record of incarceration is often associated with HIV infection, particularly in Western and Southern Europe. 17
“Prison conditions are often ideal breeding grounds for onward transmission of HIV infection. They are frequently overcrowded. They commonly operate in an atmosphere of violence and fear. Tensions abound, including sexual tensions. Release from these tensions, and from the boredom of prison life, is often found in the consumption of drugs or in sex.” - UNAIDS 18
Injecting drug use in prisons
The use of contaminated injecting equipment when using drugs is one of the primary routes of HIV transmission in prisons. Outside of sub-Saharan Africa, injecting drug use accounts for just under a third of HIV infections. 19 Multi-country studies have found that between 56 percent and 90 percent of people who inject drugs have been incarcerated. 20 The estimated percentage of inmates who inject drugs ranges between 0 and 30 percent. 21
Where there are high numbers of imprisoned injecting drug users (IDUs), there is a higher risk of HIV transmission. Within prisons it is difficult to obtain clean injecting equipment – possessing a needle is often a punishable offence - and therefore many people share equipment that has not been sterilised between uses.
“When I scored smack [heroin] I rented or bought works that had been used God knows how many times.” - 27 year old male, imprisoned for six months 22
“I injected every second day, once a day with works I had to hire, which had been used by others.” - 27 year old male, imprisoned for three months. 23
IDUs may be aware of the risks of HIV infection through sharing needles. However, if a clean needle is not available, many may still take the risk:
“As long as you can get the gear you inject as soon as you have a chance.” - 27 year old male, imprisoned for four months. 24
“Sometimes the needle gets rinsed in a bowl of water after being used, but that doesn't do much. Other times it's just passed from girl to girl. I mean, if you want a hit and you want it bad, you are not going to stop everything and clean your needle...” - Paula 25
A number of studies have found that IDUs are more likely to share injecting equipment within prison than before imprisonment. In the Republic of Ireland, 70.5 percent of the IDUs surveyed reported sharing needles while imprisoned, compared to 45.7 percent in the month before incarceration. 26
Sexual transmission in prisons
One of the primary means of HIV transmission is via unprotected sexual intercourse. In many prisons, consensual sexual activities are common among inmates even though they may be forbidden under prison rules. It is difficult to determine to what extent such activities occur, as those involved risk punishment if exposed to fellow inmates or prison officers. Therefore the majority of incidences go unreported. 27
Non-consensual sex is also common; the need for prison and penal reform has been highlighted as an essential approach to preventing HIV transmission through sexual abuse. 28 Reducing prison populations has been highlighted as one way in which this may be achieved.
Factors that contribute to an increased risk of HIV transmission through sexual intercourse in prison are:
- Unavailability of Condoms
Condoms, which can prevent HIV infection if used consistently and correctly, are often considered contraband within prisons. A study of HIV transmission among male prisoners in Georgia, America, found that only 30 percent of those who reported any consensual sex used condoms or improvised condoms. 29
The often violent nature of non-consensual sex can cause tearing and bleeding, which increases the risk of HIV transmission. Rape in prisons is rarely reported, but one US study estimated that 16 percent of male prisoners were being pressurised or forced into sexual contact. 30 A survey by the U.S. Department of Justice showed in the period 2011-12, 4 percent of state and federal prison inmates and 3.2 percent of jail inmates experienced one or more incidents of sexual victimisation by another inmate or a member of the prison's staff. 31
Tattooing in prisons
Although illegal in most prisons, tattooing is still commonplace among incarcerated people. It is usually associated with the desire to advertise a group or membership status, or results from peer pressure, or simply boredom. Tattooing in prisons usually involves multiple skin punctures with recycled, sharpened, and altered implements including staples, paper clips and plastic ink tubes found inside ballpoint pens. 32 Indeed, those who perform the tattooing tend not to have proper, fresh or sterilised tattooing equipment, posing a serious risk of HIV transmission. However, there have only been a few reported cases of suspected transmission due to contaminated equipment. 33
Similarly, body piercing has becoming more popular in prison, as in the outside community, and clean instruments for this practice are likewise, unavailable. 34
Violence in prisons
Incidents of interpersonal violence (including fights involving lacerations, bites, and bleeding in two or more participants) present some risks for HIV transmission. Although transmission in this way is rare, housing more than 1 inmate per cell, is now common in crowded institutions, and a major factor behind incidents of violence and sexual assault. 35
HIV prevention in prisons
Despite the high risk of HIV transmission within prisons, HIV prevention programmes are often not provided for inmates. Prisoners are entitled to the same human rights standards as non-incarcerated people and this includes protection from any communicable illness.
The following prevention initiatives have been tested within prisons, producing many positive results.
Education in prisons
Prisoners represent a crucial and huge target population for HIV education programs. Up to 50 percent of the U.S. prison population are illiterate, and many are not native English speakers. In order to be effective, educational programs must be modified as much of the literature available on HIV transmission either cannot be understood by inmates or fails to address many of their particular needs. 36
HIV education within prisons is considered one of the least controversial prevention methods. Many prisoners are from societal groups that are hard to reach for HIV prevention programmes, and so prison settings provide an ideal opportunity to target these groups. The World Health Organisation (WHO) recommends:
“Prisoners and prison staff should be informed about HIV/AIDS and about ways to prevent HIV transmission, with special reference to the likely risks of transmission within prison environments and to the needs of prisoners after release.” 37
Across the world, the evidence suggests that inmates do not receive an adequate level of HIV education. 38 39 However, information is not enough to reduce HIV transmission within prisons. The equipment needed to prevent HIV, such as condoms and clean needles are often not available, so although education may provide inmates with the knowledge about HIV prevention, the resources do not exist in order for inmates to protect themselves.
- HIV Peer Education: HIV peer education refers to the process of prisoners educating other prisoners about HIV.
To date, a peer education approach has been used to good effect in such programs as basic literacy, where prisoners with particular skills act as tutors for other prisoners. For example, two formerly convicted criminals at Kisii district prison in Kenya have been trained to educate fellow inmates about how HIV is prevented, transmitted and treated. 40 It is hoped this initiative will help fill the gap between Kenya's HIV epidemic and its shortage of skilled healthcare staff.
Furthermore, these knowledgable individuals can help prevent the spread of HIV by dispelling the myths about transmission and encourage testing. Misconceptions are rife in a prison setting, according to Peter Magati, the officer in charge of welfare at Kisii prison: "Education levels are often low and the problem is compounded by practices such as sex in exchange for food, sharing of sharp objects and little access to condoms." 41
Likewise, Didacus, an inmate-turned-peer educator said: "People thought condoms weren't 100 per cent effective, so you should use more than one at the same time. Or that shaking hands, eating with someone who is HIV positive or any other close association could transmit the disease."
In some prisons, custodial officers have also been trained to provide education to other custodial officers. 42
Harm reduction programmes in prisons
Harm reduction programmes aim to reduce the harm caused by injecting drug use without condoning or prohibiting drug use. These programmes include:
- Needle and Syringe Exchange Programmes (NSPs)
NSPs provide access to clean syringes in order to reduce the frequency of injecting with contaminated equipment. The European department of the World Health Organisation recommends that where resources are available, NSPs should be introduced to prisons, regardless of the current HIV prevalence. 43 In 1992, Switzerland was the first country to distribute syringes to inmates through a prison doctor. 44
NSPs currently operate in over 60 prisons in 10 countries across Europe, Central Asia and Iran. 45 Typically, a dispensing machine is placed in a discreet location. A review of the programmes found no unintended negative consequences, such as increased drug use or the use of needles as weapons. 46 In addition, such programmes have led to a significant reduction in the number of IDUs that share equipment. 47
“Prisons need a needle exchange. There are a lot of people who come in, and haven't done drugs before, and become addicted inside. People become highly addicted inside, come out with a HIV or hepatitis C infection...I saw a young guy who came in on a 16-month sentence, became addicted to drugs and contracted HIV. He ended up hanging himself in his cell. If they had... needle exchanges in institutions a long time ago, it would have saved a lot of people's lives. So many people have become infected from one dirty needle. - "Corey, Halifax, Nova Scotia 48
- Bleach Provision
Providing IDUs with bleach to clean injecting equipment is a strategy more commonly used in prisons. 49 However, this prevention method is not thought to be very effective. The WHO suggests that bleach should only be used where NSPs are impossible to implement due to fear or hostility from community members or authorities. 50
- Opoid Substitution Therapy (OST)
OST is another harm reducing approach that aims to reduce heroin use by providing a substitute in the form of either Methadone or Buprenorphine. Within prisons that use the scheme, a growing body of evidence has shown a decline in the frequency of injecting among those taking Methadone. 51 In most developed countries, some type of dependence treatment programme is used, although many remain inadequate.
Condom distribution in prisons
The WHO suggests that all prisons implement condom distribution programmes to prevent the sexual transmission of HIV. Providing condoms and other safer sex measures for female prisoners is important due to the reported frequency of sexual activity among inmates and between prisoners and prison staff. 52
Some prisons do make condoms freely available – usually through a dispensing machine placed in a discreet location. These schemes have generally been accepted by staff and inmates, and very few untoward security problems, such as drug smuggling, have been reported. 53 There have been no reports of a reversal in policy following the introduction of condoms into prisons. 54
However, many prisons do not provide condoms for inmates. As sexual activities are usually forbidden in prisons, it is thought that providing condoms would condone such behaviour and could lead to an increase in such activities. Most prison authorities in the UK only provide condoms when prescribed by a doctor and will refer to section 74 of the Sexual Offences Act 2003, which prohibits sexual activity in a 'public place'. 55
“Now condoms are hard to come by in prison. As I went down to the medical quarters twice a day (to get my medication), I used to ask there. But I was rationed to one a day (...) I was told that if I took the dirty condom back - to prove it had been used – they would give me more (...) But even taking dirty condoms back didn't always guarantee fresh supplies.” - An HIV positive inmate in the UK who was forced to have sex with a fellow inmate in exchange for protection from other violent inmates. 56
HIV testing in prisons
- Compulsory testing: All inmates are required to have an HIV test.
Even though the WHO believe that compulsory testing should be prohibited, 57 it is still a method used in many prisons. In 2008, 24 states in America tested all inmates for HIV upon admission or at some point during incarceration. 58 Prison authorities believe there is a need to identify those who are living with HIV so they can provide treatment and support, and protect staff and other inmates from transmission. However, there is no evidence to suggest this form of HIV management is more effective than others. 59 Some people consider that mandatory testing breaches human rights, as it takes away the right of the individual to make their own decisions. 60
- Optional testing: A testing service is offered and inmates can decide whether to have a test.
In 2009, the American Centres for Disease Control and Prevention (CDC) published guidelines on HIV testing in correctional settings. The document advocates the use of 'opt out' HIV testing, where the inmate is informed that a HIV test will be performed unless they decline. This strategy is thought to increase diagnoses of HIV infection (potentially increasing earlier diagnoses), reduce stigma associated with testing, and improve early access to care and prevention. 61
The WHO recommend that prisons should provide easy access to voluntary HIV testing and counselling for inmates; this method has proven to increase testing uptake. 62 Testing should be kept confidential, as those who test positive often face stigma if their status is revealed to inmates or staff. The following comments are from inmates in a UK prison. 63
“Because I had the test the screws made dodgy comments and tried to give the other inmates the impression I had AIDS”.
“The test was forced upon me also no counselling was given or offered. I was held in isolation until the results were known”.
“If you get allocated to the blood test wing the only way the authorities will treat you as HIV negative is if you have the test. So they are twisting your arm”.
- No testing: Unless prisoners specifically request to be tested.
If testing is unavailable or testing programmes are not properly carried out, there is a risk that prisoners infected with HIV will not be diagnosed until they develop symptoms. In two prisons in Bangkok, Thailand, the majority of the 112 prisoners diagnosed within prison were only diagnosed once they had developed an opportunistic infection. 64
HIV treatment and care in prisons
Once a person has been diagnosed with HIV, at some point they will need antiretroviral drugs (ARVs) to delay the onset of AIDS. In many countries, access to these drugs is limited and in prisons, even more so. Malawi, for example, has recently scaled-up access to ARVs for its large HIV-positive population, but vulnerable and neglected populations such as prison inmates rarely receive the medication. 65
Many prisons do not receive adequate funding from governments and so healthcare services within prisons desperately lack appropriate resources to treat HIV positive inmates. In particular, there has been controversy concerning HIV treatment and care in South African prisons. In 2006, inmates in Westville Prison went on a hunger strike demanding access to antiretroviral medication. Administration obstacles meant that a number of HIV positive prisoners had been denied the drugs, even though they were in urgent need of treatment. 66
Even in countries where drugs are readily available, relocation, adherence issues and complications within the prison system can make it difficult for HIV positive prisoners to adhere to their antiretroviral drug regimen. A study of HIV-positive inmates in a UK prison found that three-quarters had experienced breaks in their treatment due to transfers between prisons or prison wings, court attendance and hospital visits. 67 Studies of prison inmates in the United States have revealed that only a small percentage of those who had been taking ARVs within prison continued taking the drugs upon their release. 68 69 Treatment interruptions are not recommended as they can lead to treatment failure.
A nutritious diet is vital for antiretroviral drugs to work properly. In resource-poor communities, prison authorities are often unable to provide nutritious meals for inmates, which means they will be less likely to benefit from the medication and more likely to experience disease progression. 70 71
"Most inmates are going for days and months without proper food... This has led to a deterioration of health for most inmates, especially those living with HIV. Some are not provided with regular counselling and treatment which further compromises their health" - A prison guard at Chikurubi Maximum Prisons, Zimbabwe 72
Poor prison conditions such as overcrowding, a shortage of clean water, inadequate natural lighting and ventilation and poor facilities for personal hygiene can also worsen the situation for those who are suffering from illness. 73 People living with HIV are at much higher risk of Tuberculosis (TB). One report found minimal ventilation, a significant immuno-compromised population and overcrowding contributed to a suspected tuberculosis rate in a number of Zambian prisons. 74 In South Africa, it has been stated that if prisons conformed to the government's own standards of acceptable numbers of prisoners in cells, the risk of TB for inmates would be cut by a third. Conforming to international standards would halve the risk. 75
Post-exposure prophylaxis (PEP) is a treatment option that may be used to prevent HIV infection following an exposure to HIV. Making PEP available in prisons would decrease the risk of HIV infection among victims of sexual assault. 76
What needs to be done?
Worldwide, governments have failed to address HIV among prison populations. A substantial body of evidence shows that HIV prevention measures effectively reduce HIV related risk-behaviours both within the general community and within prison populations. This needs to be scaled-up among inmates. Recommended HIV testing guidelines need to be followed, and prison conditions improved, in order to provide HIV-positive prisoners with the healthcare they need.
“Failure to provide prisoners with the same health care options available to the general population violates human rights and international standards.” - Harm Reduction Coalition 77
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