Prisons are a high-risk environment for HIV transmission with drug use and needle sharing, tattooing with homemade and unsterile equipment, high-risk sex and rape commonplace. Overcrowding as well as stress, malnutrition, drugs, and violence weaken the immune system, making people living with HIV more susceptible to getting ill.3 Yet, 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 inmates living with HIV barely receive the most basic healthcare. Moreover, mandatory HIV testing is enforced by some prison authorities, which is often seen as a breach of human rights.
HIV prevalence within prisons varies between 2 and 50 times those of general adult populations.4 HIV infection rates are particularly high among incarcerated women. A report from Indonesia found that HIV prevalence was several times higher among female prisoners (6%) than male prisoners (1%).5
Why are prisoners particularly at risk of HIV?
"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." 6
Injecting drug use
The use of contaminated injecting equipment when using drugs is one of the primary routes of HIV transmission in prisons. Many prisoners begin injecting drugs for the first time in prison.7 Where there are high numbers of imprisoned people who inject drugs (PWID), there is a higher risk of HIV transmission.
Worldwide, between 56% and 90% of people who inject drugs will be incarcerated at some point.8 In 2012, in Mauritania, HIV prevalence was an estimated 24.8% among prisoners, and 40% of this group were thought to inject drugs.9
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 10
Even if PWID are aware of the risks of HIV infection through sharing needles, if a clean needle is not available, many may still take the risk. In Ireland, 70% of PWID surveyed reported sharing needles while imprisoned, compared to 45.7% in the month before incarceration.11
"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 12
"There are a lot of people who come in, and haven't done drugs before who become addicted inside and 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 13
Sexual violence, unsafe sex and other high-risk behaviours
Prison populations consist mainly of men aged 19 to 35 years old - a segment of the population that is at higher risk of HIV infection prior to entering prison.14 The prevalence of sexual activity in prisons is largely unknown and thought to be significantly under reported due to denial, fear of stigma and homophobia as well as the criminalisation of same sex conduct.15
- Unavailability of condoms
Sexual activities are often forbidden in prisons, with some believing the provision of condoms condones such behaviour and potentially leads to an increase in such activities. For example, most prisons in the United Kingdom 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'.16
"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 17
A study of HIV transmission among male prisoners in Georgia, United States of America (USA), found that only 30% of those who reported having consensual sex used condoms or improvised condoms (like rubber gloves or plastic wrap).18
- Rape and sexual abuse
While most sex in prisons is consensual, rape and sexual abuse is used to exercise dominance over other inmates.19 Roughly 25% of prisoners suffer violence each year, while 4% to 5% experience sexual violence and 1% to 2% are raped.20
A survey by the U.S. Department of Justice in 2011-2012 showed how 4% of state and federal prison inmates and 3.2% of jail inmates experienced one or more incidents of sexual victimisation by another inmate or prison staff.21 By contrast, another study from the USA estimated that 16% of male prisoners were being pressurised or forced into sexual contact.22
Women prisoners are also vulnerable to sexual assault, including rape by both male prisoners and male prison staff. They are also at risk of sexual exploitation and may engage in sex for the exchange of goods.23
Tattooing is still commonplace among incarcerated people. It usually involves multiple skin punctures with recycled, sharpened, and altered implements including staples, paper clips and plastic ink tubes found inside ballpoint pens.24
Those who perform the tattooing tend not to have new or sterilised tattooing equipment. Some people use metal points connected to a battery or other electrical source which increases the number of skin punctures, elevating the risk of HIV transmission.25
There have only been a few reported cases of HIV transmission due to tattooing. However, one study of Iranian prisoners reported a significant association between HIV prevalence and tattooing.26
Punitive laws and overcrowding
For example, sex workers are at a high risk of incarceration as more than 100 countries criminalise sex work or aspects of sex work.28 Likewise, 76 countries criminalise same sex activity, increasing this risk for men who have sex with men.29 In addition, there are 72 countries that have adopted HIV-specific laws that prosecute people living with HIV for a range of offences.30
In places with weak criminal justice systems, people who are detained may have to wait for long periods during the investigation of a crime, while awaiting trial and before sentencing. These delays increase their likelihood of HIV infection while in prison.31
Moreover, inappropriate, ineffective and excessive national laws and criminal justice policies lead to high incarceration levels and overcrowding. In 20 countries, many of which are in Africa, the occupancy rate in prisons is over 200%. In both the Comoros and Benin, it is over 350%.32
Overcrowding also allows diseases like tuberculosis (TB) to thrive and people living with HIV are more likely to develop TB because their immune systems are severely weakened.33 It also makes HIV services harder to access and increases the risk of violence and abuse as well as poor nutrition.34
Denial of access to prevention and treatment services
In many places, HIV and other relevant health services in prisons are severely limited or are simply not available either due to government policy or a lack of resources. In 2012, antiretroviral treatment (ART) for HIV was available to prisoners in just 43 countries.35 In the USA, a survey showed that while 90% of prisons provided ART, only half offered substance abuse counselling and support specific to inmates living with HIV.36
Although some countries make condoms available to prisoners, other do not on the basis that sex is banned or for security reasons.37 Prison guards have been reported to refuse condoms to inmates to exercise power over them.38 Despite the tuberculosis (TB) being the leading cause of death among prisoners in many countries, only 63 countries provide TB treatment in prisons, while screening for hepatitis is equally uncommon.39 40 41
Even where treatment is available, its effectiveness can be undermined by substandard prison conditions, poor nutrition and violence.42 Moreover, prison health services often have too few or poorly trained staff, inadequate health assessments on entry, poor record keeping, and breaches of confidentiality. Even in adequately staffed facilities, prison staff have negative attitudes towards key populations, contributing to poor monitoring and treatment of HIV as well as TB, hepatitis and drug dependency.43
Preventing HIV among prisoners
Despite the high risk of HIV transmission among prisoners, HIV prevention and treatment programmes are often limited in prisons and other closed settings. Those that do exist also rarely link to national HIV prevention programmes.
In 2012, a comprehensive package of 15 key HIV interventions for prisoners was put forward by the United Nations Office on Drugs and Crime (UNODC) and includes:
- HIV testing and counselling (HTC)
- treatment, care and support
- information, education and communication
- harm reduction
- condom programmes.44
Some of the main interventions to prevent HIV among prisoners, and their effectiveness, are detailed below.
HIV testing and counselling (HTC)
Evidence shows that if HIV testing and counselling is made readily available on entry to prison and throughout incarceration, uptake increases. This is especially true if HTC is part of a comprehensive treatment and care programme.
Compulsory or mandatory testing (that requires all inmates have an HIV test) is used in some prisons as a means of identifying those who are living with HIV so that they can provide treatment and support, and protect staff and other inmates.45 In 2008, 24 states in the USA were testing all inmates for HIV upon admission or at some point during incarceration.46
However, research suggests that mandatory testing and segregation of prisoners living with HIV breaches human rights by taking away the right of the individual to make their own decisions, is costly, inefficient and has negative consequences for these prisoners.47 48
"The test was forced upon me also no counselling was given or offered. I was held in isolation until the results were known." 49
By contrast, voluntary HIV testing has been found to increase the likelihood that prisoners are tested and receive their results before they are discharged or transferred to another prison.50 Rapid testing in particular allows prisoners to know their HIV status in minutes.51
Opt-out testing (where people have the option to refuse an HIV test) has also been found to be popular among prisoners and staff. A study of incarcerated men in Jamaica who were offered opt-out HIV testing recorded an acceptance rate of 63%.52
Other studies have shown how HTC programmes can be more cost-effective if done in conjunction with other prevention initiatives such as providing condoms and testing for sexually transmitted infections (STIs). For example, a study of incarcerated men who have sex with men (MSM) at Los Angeles County Men's Jail estimated that a 10-year intervention offering HIV and STI testing, as well as condoms, could save $180,000 in treatment costs.53
Treatment, care and support
Antiretroviral treatment (ART) can decrease mortality among prisoners living with HIV as well as the general population, however, there is not always access to these services in prisons. For example, treatment access in Malawi has improved dramatically among the general population but key affected populations such as prisoners still rarely have access to ART.54
Studies have shown that when provided with access to ART, prisoners can respond well to treatment, and adherence can be as high as in the general population.55
To increase treatment adherence in prisons, confidentiality must be guaranteed and positive relationships with prison health staff is essential. A study from Namibia also identified insufficient access to food, and a lack of knowledge about how HIV is transmitted and managed as barriers to good adherence.56
"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 57
Moreover, any progress made during incarceration can be lost when someone is discharged. To ensure continuation of treatment when discharged, linkage to community-based care with an adequate supply of antiretroviral drugs (ARVs) is vital.58
HIV information, education and communication
"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." 59
Up to 50% of the USA prison population are illiterate, and many are not native English speakers. As a result, inmates often cannot understand the HIV prevention information they are given or it fails to address their particular needs.60
However, there is evidence that well-designed HIV and AIDS education and information programmes can improve prisoners knowledge and that there is a need particularly in low- and middle-income countries.61
Research has reported successful behaviour change (particularly upon release) partly as a result of prison-based educational initiatives. However, the effectiveness of these efforts is difficult to measure, particularly any changes in HIV transmission among prisoners as a result of these programmes.62
Peer education - prisoners educating other prisoners about HIV - has been found to be the most effective way of delivering these programmes.
One programme in Ghana recruits inmates who are literate, have good communication skills and can maintain confidentiality as peer educators. The peer educators receive five days of training on HIV prevention, stigma and discrimination, STIs, sexual and gender-based violence and facilitation skills. They run film sessions and drama performances on HIV-related issues and distribute educational materials. Confidential HTC is also provided with referrals to treatment and support services.63
In 2014, the programme reached nearly 220,000 prisoners and 248 prison officers with advocacy sessions. Roughly 30,000 prisoners received HTC for HIV, 228 of whom tested positive and were referred for treatment.64
Making needles and syringes and opioid substitution therapy (OST) available in prisons has been shown to reduce injecting drug use and needle sharing by up to 75%, thereby reducing the risk of HIV.65
- Needle and syringe programmes (NSPs)
Needle and syringe programmes provide drug users with access to clean needles and syringes, in order to reduce the frequency of injecting with contaminated equipment. Globally, only eight countries in 2014 implemented NSPs in prisons - all of these were in Europe and Central Asia. Typically, a dispensing machine is placed in a discreet location.66
NSPs have been shown to lead to reductions in needle sharing in prisons, decreases in drug abuse and ultimately, lower levels of HIV transmission.67
In Kyrgyzstan, a NSP intervention study in one prison saw a marked decrease in the injection and use of drugs.68 Research conducted in seven prisons in Iran found that 57% of prisoners on admittance had a drug addiction. Two months after the implementation of harm reduction interventions including NSPs, only 10% were still using drugs.69
Prisoners and staff interviewed in Pereiro de Aguiar prison in Ourense, Spain, believed that the implementation of a needle and syringe programme reduced drug use and improved hygiene and living conditions. Between 1999 and 2009, HIV prevalence fell from 21% to 8.5%.70
- Opioid substitution therapy (OST)
Opioid substitution therapy is another harm reducing approach that aims to reduce heroin use by providing a substitute in the form of either methadone or buprenorphine. However, in 2014, OST was available in prisons in only 43 countries.71
Prison-based OST programmes can be effective in reducing injecting drug use and needle sharing and have additional benefits for the health of prisoners and the community.72
Moreover, a number of studies have also reported high acceptance and retention rates. In one study from Geneva, Switzerland, OST was offered to all dependent users and all patients accepted treatment.73 Another study monitoring the roll out of OST in Tihar Prisons in India recorded a 98% retention rate after 12 months.74
However, delays in OST implementation can have a negative impact on the health of prisoners. Education should be provided with or before OST and there should be better linkage to treatment between prison-based healthcare and community-based healthcare to avoid potential relapse after release from prison.75 76
There is evidence that condoms are provided in a wide range of prison settings, including in countries where same-sex activity is criminalised, and that prisoners use condoms during sexual activity when they are made available, leading to reductions in HIV transmission.
Indeed, prisons that have implemented condom programmes to date have not reversed their policies.77 These schemes are generally accepted by staff and inmates, and very few problems, such as drug smuggling, have been reported.78
Moreover, the evidence has shown how they do not to lead to increases in sexual activity, are not a threat to security staff or operations and most importantly, decrease HIV transmission.79
For example, one study from Australia compared condom use during anal sex among prisoners in New South Wales (NSW) and Queensland prisons. While anal sex prevalence was equally low in NSW (3.3%) and Queensland (3.6%) prisons, in NSW prisons, where condoms are freely distributed, a much higher proportion of prisoners who engaged in anal sex used a condom (56.8%) than in Queensland (3.1%). Moreover, there was no evidence of increased consensual or non-consensual sexual activity.80
However, where there are deeply held prejudices against homosexuality, education about condoms as well as their provision should be introduced to counter the stigma that people engaging in same-sex activity face.81
The way forward
Prisoners are part of the community, people work in prisons, others visit prisons, and most prisoners will be discharged at some point. As a result, HIV in prisons is both a public health and a human rights issue that needs to be addressed urgently for an effective response to the epidemic. However, worldwide, governments are failing to address this.
A substantial body of evidence shows that targeted HIV prevention programmes can reduce HIV transmission within prison populations. Existing efforts need to be scaled-up, particularly comprehensive HIV prevention and treatment programmes in order to provide prisoners living with HIV with the services they need.
Protective laws, policies and programmes that are adequately resourced, monitored and enforced can also improve the health and safety of prisoners as well as the community as a whole.
"Failure to provide prisoners with the same health care options available to the general population violates human rights and international standards." - Harm Reduction Coalition 82
Photo credit: ©iStock.com/melnichuk_ira. Photos are used for illustrative purposes. They do not imply any health status or behaviour on the part of the people in the photo.
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