Prisons should have needle and syringe programmes (NSPs), opioid substitution therapy (OST) and other preventive measures in place to prevent HIV transmission between inmates. These are the conclusions of a Review published in the January edition of Lancet Infectious Diseases, written by Dr Ralf Jürgens, a consultant for HIV/AIDS based in Quebec, Canada, and colleagues on behalf of WHO.
The high prevalence of HIV infection and drug dependence among prisoners, combined with the sharing of injecting-drug equipment, make prisons high-risk environments for the transmission of HIV and also hepatitis C. The authors reviewed the effectiveness of interventions to reduce risky behaviour in this context. This Review forms part of a broader review of interventions to address HIV in prisons commissioned by WHO, together with the UN Office on Drugs and Crime, and UNAIDS, to guide countries in their efforts to scale-up towards universal access to HIV prevention, treatment and care by 2010.
Drug dependence in male prisoners is estimated at 10-48%, and in female prisoners 30-60%. The first needle and syringe programme (NSP) was introduced in Switzerland in 1992, and NSPs have since been implemented over 40 prison in 12 countries in western and eastern Europe and central Asia. In some countries, only a few prisons have NSPs but in Spain and Kyrgyzstan NSPs have been rapidly scaled-up and operate in a high number of prisons. All the available studies show that implementation of an NSP results in needle/syringe sharing declining or stopping altogether, and in these studies no new HIV cases were reported where NSPs were implemented. Other benefits include a reduction in overdoses and deaths, more contact between prisoners and drug-treatment programmes, improved relationships between prisoners and staff, and better awareness of risky behaviours. Needles were not used as weapons, and needle-stick injuries to staff during searches have decreased. The authors say: "The availability of sterile injecting equipment has not resulted in an increased number of prisoners injecting drugs, an increase in overall drug use, or an increase in the amount of drugs in prisons. Once in place, acceptance of NSPs is generally high among staff and prisoners." Furthermore, ensuring that prisoners have easy and confidential access to NSPs has been shown to be a key factor in guaranteeing their success. The Review also discusses use of bleaching to disinfect injecting equipment, but points out that the effectiveness of bleach to kill HIV and hepatitis C is limited outside of the prison context. In prison facilities it is even more difficult to follow the recommended disinfecting procedure properly . The authors say that 'because prisoners can be accosted at any moment by prison officers, injecting and cleaning is a hurried affair."
Evaluations of prison-based methadone maintenance therapy (MMT) have shown many positive results for prisoners, prison systems, and for the communities to which most prisoners eventually return. In particular, all studies found that prisoners who receive this therapy inject substantially less frequently than those not receiving the therapy. Evaluations have also found reduced mortality among prisoners retained in MMT. Maintenance treatment with methadone also has a positive effect on institutional behaviour, thus improving prison safety, and makes prisoners less likely to re-offend and return to prison. This is particularly the case if methadone is provided for longer, uninterrupted periods, if moderate-to-high doses of methadone are provided, and if provision of methadone is accompanied by support.
The authors say: "Far from condoning drug use in prisons, making available to prisoners the means that are necessary to protect them from HIV (and hepatitis C) transmission acknowledges that protection of prisoners' health needs to be the primary objective of drug policy in prisons. As the Scottish report* on drug use and prisons pointed out, 'the idea of a drug free prison does not seem to be any more realistic than the idea of a drug free society' and 'stability may actually be better achieved by moving beyond this concept'." Importantly, promoting and protecting the health of prisoners, through measures like NSPs and MMT programmes has been shown to benefit not only prisoners, but also prison staff and the communities outside prison.
The authors conclude: "The renewed emphasis on HIV and broader health issues in prisons represents a recognition that public health can no longer afford to ignore prison health."
"Interventions to reduce HIV transmission related to injecting drug use in prison."
Ralf Jürgens, Andrew Ball, Annette Verster
The Lancet Infection Vol 9 January 2009
The Lancet Infection