The HIV and AIDS epidemic presents a major challenge to prison populations across the world. HIV prevalence within prisons is often far higher than in the general community, and prisons are a high-risk environment for HIV transmission. However, when it comes to tackling the epidemic, prisoners are often neglected and overlooked.

Prevention programmes that have been shown to reduce HIV transmission are rarely available for inmates, and many prisoners with HIV are unable to access life-saving antiretroviral treatment. In many parts of the world prison conditions are far from satisfactory and HIV positive inmates barely receive the most basic healthcare and food. When it comes to HIV testing, some prison authorities enforce mandatory testing, 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/AIDS.

HIV prevalence in prisons around the world

The number of prisoners living with HIV varies between countries. America has the highest prison population in the world, around 1.7% of whom are HIV positive.¹ Although this figure has declined, the HIV prevalence is still higher for incarcerated populations than for the general population.² It has been estimated that around a quarter of people living with HIV and AIDS in America pass through the correctional system.³

Studies from prisons in Brazil and Argentina reveal a particularly high HIV prevalence – ranging from 3.2 to 20% in Brazil and 4 to 10% in Argentina.⁴ The prevalence rates for some sub-Saharan African countries are also high; an estimated 41.4% of incarcerated people in South Africa are infected with HIV.⁵ Generally, the HIV prevalence in the country reflects the prevalence in prisons. So while South Africa has a high percentage of HIV positive inmates, the HIV prevalence in the general population is also high, at an estimated 18.1%.

In Europe, many of the eastern countries have a high HIV prevalence among the prison population.⁶ Russia for example, has an estimated prevalence of 4% in prisons,⁷ and in 2002 Estonia reported a 12% prevalence. In comparison, the last study in England and Wales in 1997-1998 revealed a much lower prevalence of 0.3% among men and 1% among women.⁸

Why is there a higher HIV prevalence in prisons?

Injecting drug use and incarceration are closely linked; many injecting drug users (IDUs) pass through the correctional system because of drug-related offences. As IDUs are at a greater risk of HIV infection there tends to be an over-representation of HIV infected IDUs among incarcerated populations. This poses a greater risk of HIV transmission within prisons, which is compounded by a lack of HIV preventative measures.

How is HIV transmitted in prisons?

As it is difficult for researchers to gain access to prisoners, there are few documented cases of HIV transmission within prisons.⁹ However, this does not mean that HIV is not a significant risk to prisoners.

“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” UNAIDS¹⁰

Although this view from UNAIDS refers to prisons in the 1990s, it still applies to many prisons across the world today. Injecting drug use, high-risk sexual behaviour, and tattooing are common within prisons, each posing a risk of HIV transmission.

Injecting drug use

The use of contaminated injecting equipment when using drugs is an effective route of HIV transmission; outside sub-Saharan Africa injecting drug use accounts for just under a third of infections.¹¹ The estimated percentage of inmates who inject drugs ranges between 0 and 30%.¹²

Where there is a high number of imprisoned injecting drug users 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. In a study of prisoners and HIV in England and Wales in 1997-1998, 75% of adult male IDUs and 69% of adult female IDUs had shared needles/syringes inside prison.¹³

“When I scored smack [heroin] I rented or bought works that had been used God knows how many times ”

“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.¹⁴

“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.¹⁵

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.¹⁶

“As long as you can get the gear you inject as soon as you have a chance ”

“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...” Paula¹⁷

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.¹⁸

Sexual transmission

In many prisons both consensual and non-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.¹⁹

One of the primary routes of HIV transmission is through sexual intercourse. Although it is difficult to know to what extent HIV is transmitted in this way within prisons, a number of factors contribute to an increased risk:

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.²⁰

Rape: 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 the WHO estimate that prevalence ranges from 0 to 16 percent.²¹

Tattooing

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 often just boredom. Those who perform the tattooing tend not to have proper, sterilised tattooing equipment, posing another risk of HIV transmission. However, there have only been a few reported cases of suspected transmission due to contaminated equipment.²²

Violence

Fights and assaults are common in prison and carry a risk of HIV infection if people are exposed to blood and bodily fluids. Although transmission in this way is rare, the risk is still present and can be enhanced by factors that contribute to increased levels of violence, such as overcrowding in cells.

HIV prevention in prisons

Despite the high risk of HIV transmission within prisons, HIV prevention programmes are often not provided for inmates. Some fear that these programmes will encourage illegal or undesirable behaviours. However, 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, the majority of the time producing positive results.

Education

Educating people about HIV/AIDS can prevent new HIV infections, improve the quality of life of HIV positive people and help to reduce stigma and discrimination. It is usually considered an essential component of HIV prevention.

HIV education within prisons is one of the least controversial prevention methods. Due to the higher risk of HIV transmission within prison, and transmission once released from prison, it is essential that inmates receive information about HIV. Many prisoners are from groups of society that are hard to reach for HIV prevention programmes and so prison settings provide an ideal opportunity to target these groups. The WHO recommend:

“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”.²³

Across the world, inmates do not receive an adequate level of HIV education. In the UK, over half of the prison healthcare managers in one study said they were dissatisfied with the educational HIV and hepatitis material available to them.²⁴ In a Californian prison, former prisoners reported that they received no HIV/AIDS education whilst incarcerated.²⁵

However, information is not enough to reduce HIV transmission within prisons. The commodities 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, frequently the resources are not there for inmates to protect themselves. HIV education is only one part of HIV prevention and other supplementary methods are needed.

Harm reduction programmes

Harm reduction programmes aim to reduce the harm caused through injecting drug use without condoning or prohibiting drug use. These programmes, which include needle exchanges, drug substitution therapy and bleach provision, are rarely used within prisons.

Needle exchanges 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, needle exchange programmes should be introduced to prisons, regardless of the current HIV prevalence.²⁶ In 1992 Switzerland was the first country to distribute syringes to inmates through a prison doctor.

Today needle exchanges operate in a number of prisons;²⁷ usually a dispensing machine is placed in a discreet location. Countries to successfully implement such schemes are Germany, Spain, Moldova and Kyrgyzstan.²⁸ A review of the programmes found that no unintended negative consequences, such as increased drug use or the use of needles as weapons, were reported.²⁹ More importantly, such programmes have led to a significant reduction in the number of IDUs that share equipment.³⁰

Providing IDUs with bleach to clean injecting equipment is a strategy more commonly used in prisons.³¹ However, this prevention method is not thought to be very effective. The WHO suggest that bleach should only be used in community or correctional settings where needle exchanges are impossible to implement due to fear or hostility from community members or authorities.³²

Drug substitution therapy is another harm reduction approach that is implemented both within the community and within prisons. The aim is to reduce heroin use by providing a substitute in the form of either methadone or buprenorphine. In England and Wales in 2005, maintenance therapy was used by 43% of prisons in the study sample.³³ Within prisons that use the scheme, a growing body of evidence has shown a decline in the frequency of injecting among those taking methadone.³⁴ In most developed countries some type of dependence treatment programme is used, although many remain inadequate.

Condom distribution

The WHO suggest that all prisons implement condom distribution programmes to prevent the sexual transmission of HIV.

“Prison authorities in jurisdictions where condoms are currently not provided should introduce condom distribution programmes and expand implementation to scale as soon as possible”.³⁵

The WHO also recommended providing condoms and other safer sex measures for female prisoners due to the reported frequency of sexual activity among inmates and between prisoners and prison staff.³⁶

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'.³⁷

“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.³⁸

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.³⁹

Studies that assess the impact of condom distribution programmes on the frequency of high-risk behaviours and HIV transmission within prisons are rare; there is a need for more research in this area.

HIV testing in prisons

HIV testing is not only important for diagnosing those with HIV and offering them support, treatment and care, but also provides an opportunity to identify those taking part in risky behaviours, and provides a chance to offer them information and advice.

Although HIV testing services vary between prisons, they usually fall into one of the following categories:

• Compulsory testing, whereby all inmates are required to have an HIV test;
• optional testing, whereby a testing service is offered and inmates can decide whether to have a test;
• or, no testing, unless prisoners specifically request to be tested.

Even though the WHO believe that compulsory testing should be prohibited,⁴⁰ it is still a method used in many prisons. In 2006, 21 states in America tested all inmates for HIV upon admission or at some point during incarceration.⁴¹ Prison authorities believe there is a need to identify those who are infected with HIV so they can provide treatment and support, and protect staff and other inmates from becoming infected. However, there is no evidence to suggest this form of HIV management is more effective than others.⁴² Some people consider that mandatory testing breaches human rights, as it takes away the right of the individual to make their own decisions.⁴³

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 an 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, preserve human resources by streamlining the process, and improve early access to care and prevention.⁴⁴

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.⁴⁵ 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.⁴⁶

“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”.

Although these comments are from 1991, this type of HIV stigma and discrimination relating to testing still exists in many prisons today.

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.⁴⁷

HIV treatment and care in prisons

Once a person has been diagnosed with HIV, at some point they will need antiretroviral drugs to delay the onset of AIDS. In many countries access to these drugs is limited, and the situation can be far worse in prison. Malawi, for example, has recently scaled-up access to antiretroviral drugs for its large HIV positive population, but vulnerable and neglected populations, such as prison inmates, rarely receive the medication.⁴⁸

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.⁴⁹

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 stick 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, transfers between prison wings, court attendance and hospital visits.⁵⁰ Even after release from prison there are concerns about access to antiretroviral treatment. Studies of prison inmates in America have revealed that only a small percentage of those who had been taking ARVs within prison continued taking the drugs upon their release.^{51 52} The barriers that prevented those from accessing ARVs upon release meant that many could have experienced interruptions in their treatment regimen. 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. A number of studies show that malnourished people taking antiretroviral drugs are more likely to experience disease progression.^{53 54}

“we hardly had enough food to eat, not enough water, our cells were hot, dingy and smelly in summer and extremely cold in winter”

Poor prison conditions, such as overcrowding, a shortage of clean water, inadequate natural lighting /ventilation, and poor facilities for personal hygiene can also worsen the situation for those who are suffering from illness and disease.⁵⁵

“Generally, life was unbearable; we hardly had enough food to eat, not enough water, our cells were hot, dingy and smelly in summer and extremely cold in winter” - a man who spent 3 years in Chikurubi maximum security prison, Zimbabwe.⁵⁶

Other health problems may result from segregating HIV positive inmates into a separate prison area or wing. An outbreak of tuberculosis was one of the unintended consequences of segregating inmates infected with HIV in a South Carolina prison during 1999-2000.⁵⁷ Separate housing for HIV positive prisoners does not reduce the spread of STDs or other blood-borne infections, has few healthcare benefits and may increase HIV related stigma from other inmates and staff.⁵⁸

“Segregation has lead to the reassignment of inmates to distant sites that are far from family members – possibly reducing the quality of prisoners' lives, destabilising their social support networks, and mixing inmates with different security status”. WHO⁵⁹

What needs to be done?

Worldwide, governments have failed to address HIV among prison populations. Even though 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, the majority of inmates do not have access to these programmes. Recommended HIV testing guidelines are rarely followed, and poor prison conditions make it impossible 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.⁶⁰

Without sufficient protection from HIV and adequate treatment and care, prisoners will continue to suffer from the devastating effects of the epidemic.

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