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HIV/AIDS in Prisons: A Review of the International Evidence - Ralf Jurgens
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HIV/AIDS in Prisons: A Review of the International Evidence - Ralf Jurgens

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Presentation made by Ralf Jurgens, an international expert in HIV/AIDS in prisons, at the University of Winnipeg, November 23, 2009. The presentation was a part of a panel discussion on Prisoners' …

Presentation made by Ralf Jurgens, an international expert in HIV/AIDS in prisons, at the University of Winnipeg, November 23, 2009. The presentation was a part of a panel discussion on Prisoners' Rights to HIV Prevention, Treatment and Care, along with Richard Elliott and Jim Motherall. Dr. Michael Eze, Director of the Global College Institute for Health and Human Potential provided a response to the panel, and the evening concluded with Q&A from the audience.
See also the presentation by Richard Elliott: "Clean Switch: The Case for Prison-based Needle and Syringe Programs"

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  • I would like to give special thanks to Ralf Jurgens who has carried out this review and developed the key documents discussed here. As well as all experts and colleagues who provided their feedback and peer reviewed the drafts This series of E4A papers has also been endorsed by UNODC and UNAIDS The E4A papers on HIV/AIDS in prisons will soon become available on the WHO website at [insert address].
  • Rates of HIV infection among prisoners in many countries are significantly higher than those in the general population.. HCV seroprevalence rates are even higher. Studies from around the world show that injecting drug use is a reality in many prisons and that most prisoners who inject will share injecting equipment. Even countries that have invested heavily in drug demand and drug supply reduction efforts in prisons have not been able to stop injecting drug use. Sexual activity, including rape and other forms of non-consensual sexual activity, also are reported from prisons around the world. Outbreaks of HIV infection have been documented in a number of prison systems (Scotland, Australia, Russia, Lithuania, Iran), demonstrating how rapidly HIV can spread in prison unless effective action is taken to prevent transmission. Since the early 1990s, various countries have introduced HIV programmes in prisons. However, many of them are small in scale, restricted to a few prisons, or exclude those interventions which are most effective. There is an urgent need to introduce comprehensive programmes, and to scale them up rapidly.
  • Rates of HIV infection among prisoners in many countries are significantly higher than those in the general population.. HCV seroprevalence rates are even higher. Studies from around the world show that injecting drug use is a reality in many prisons and that most prisoners who inject will share injecting equipment. Even countries that have invested heavily in drug demand and drug supply reduction efforts in prisons have not been able to stop injecting drug use. Sexual activity, including rape and other forms of non-consensual sexual activity, also are reported from prisons around the world. Outbreaks of HIV infection have been documented in a number of prison systems (Scotland, Australia, Russia, Lithuania, Iran), demonstrating how rapidly HIV can spread in prison unless effective action is taken to prevent transmission. Since the early 1990s, various countries have introduced HIV programmes in prisons. However, many of them are small in scale, restricted to a few prisons, or exclude those interventions which are most effective. There is an urgent need to introduce comprehensive programmes, and to scale them up rapidly.
  • Rates of HIV infection among prisoners in many countries are significantly higher than those in the general population.. HCV seroprevalence rates are even higher. Studies from around the world show that injecting drug use is a reality in many prisons and that most prisoners who inject will share injecting equipment. Even countries that have invested heavily in drug demand and drug supply reduction efforts in prisons have not been able to stop injecting drug use. Sexual activity, including rape and other forms of non-consensual sexual activity, also are reported from prisons around the world. Outbreaks of HIV infection have been documented in a number of prison systems (Scotland, Australia, Russia, Lithuania, Iran), demonstrating how rapidly HIV can spread in prison unless effective action is taken to prevent transmission. Since the early 1990s, various countries have introduced HIV programmes in prisons. However, many of them are small in scale, restricted to a few prisons, or exclude those interventions which are most effective. There is an urgent need to introduce comprehensive programmes, and to scale them up rapidly.
  • France, Germany, Italy, Netherlands, Scotland, Sweden This table summarises the information we have on the prevalence of injecting and needle sharing in a number of countries, prisons and from a number of studies. While most study samples are relatively low, we see that injecting rates of up to 34or 74% of the prison population are reported. Even more worrying are the rates of needle sharing among drug injectors in prison settings of between 66-94% of those who inject.
  • Because of the importance of HIV prevention and treatment in prisons, WHO has more recently commissioned a review of the effectiveness of HIV interventions in prisons which will be published this month and are also available on CD rom here at the WHO stand at the conference. Four key documents that consider the effectiveness of: (1) needle and syringe programmes and bleach (2) provision of condoms and prevention of rape, sexual assault and coercion (3) opioid substitution therapy and other drug dependence treatment, as well as some drug demand and supply reduction measures (4) HIV care, treatment and support In addition, there is a comprehensive paper on Effectiveness of Interventions to Manage HIV/AIDS in Prison Settings which, which will soon be published on our website in electronic format only. This comprehensive paper reviews, in addition to the interventions covered in the shorter papers, the evidence regarding other interventions that are part of a comprehensive approach to managing HIV/AIDS in prison settings. These papers contain the most comprehensive analysis of the international evidence related to HIV/AIDS in prisons undertaken to date , with hundreds of references. They complement work undertaken by UNODC , which is publishing HIV/AIDS Prevention, Care, Treatment, and Support in Prison Settings: A Framework for an Effective National Response ; and by the Health in Prison Project of WHO Europe, which last year published a Status Paper on Prisons, Drugs and Harm Reduction . In this presentation, I will focus on the areas covered by the four key documents of the evidence for action papers.
  • The first intervention reviewed is targeted information and education, which is the least controversial measure. The evidence points to the conclusion that it providing information and education leads to increased knowledge. However, the evidence about its effect on risk behaviour in prison is limited. Peer education is more likely to be effective (Grinstead et al, 1999) Therefore, while essential it is not enough!
  • The third key interventions on preventing sexual transmission available research and the experience of the many prison systems in different parts of the world in which condoms have been provided to prisoners for many years, without any reported problems, suggest that providing condoms in prisons is feasible in a wide range of prison settings. No prison system allowing condoms has reversed its policy , and none has reported security problems or any other relevant major negative consequences. In particular, it has been found that condom access is unobtrusive to the prison routine, represents no threat to security or operations , does not lead to an increase in sexual activity , and is accepted by most prisoners and correctional officers once it is introduced. Generally, only minor incidents of misuse such as water balloons, water fights and littering were recorded, and no incidents of drug concealment. Studies have not determined whether infections have been prevented due to condom provision in prison. However, there is evidence that prisoners use condoms to prevent infection during sexual activity when condoms are accessible in prison. It can therefore be considered likely that infections have been prevented. Finally, the evidence suggests that condoms are more likely to be used if they are easily and discreetly accessible to prisoners so that they can pick them up at various locations in the prison, without having to ask for them and without being seen by others. However, the evidence also shows that provision of condoms is not enough to address the risk of sexual transmission of HIV in prisons. Violence, including sexual abuse , is common in many prison systems. Measures to combat aggressive sexual behaviour such as rape, exploitation of vulnerable prisoners, and all forms of prisoner victimization are therefore as important as provision of condoms .
  • Systematic evaluations of the effects of NSPs on risk behaviours and of their overall effectiveness in prisons were carried out in at least 10 projects in Switzerland, Germany, and Spain . There is evidence that NSPs are feasible in a wide range of prison settings, including in men’s and women’s prisons, prisons of all security levels, and small and large prisons. There is also evidence that providing clean needles and syringes is readily accepted by IDUs in prisons and More importantly that they contribute to a significant reduction of syringe sharing over time Which is if crucial importance for reducing HIV transmission .
  • At the same time, there is no evidence to suggest that prison-based NSPs have serious, unintended negative consequences . In particular, they do not appear to lead to increased drug use or injecting , and needles are not used as weapons . Evaluations have found that NSPs in prisons actually facilitate referral of drug users to drug dependence treatment programmes.
  • The review of the evidence suggests that In countries experiencing or threatened by an epidemic of HIV infections among IDUs, there is a need to introduce needle and syringe programmes in prisons and to expand implementation to scale as soon as possible. The higher the prevalence of injecting drug use and associated risk behaviour is in prison, the more urgent introduction of prison-based NSPs becomes. Prisoners need to have easy, confidential access to NSPs. Carefully evaluated pilot programmes of prison-based NSPs may be important in allowing the introduction of these programmes and to overcome objections against such programmes. However, they should not delay the expansion of the programmes, particularly where there already is evidence of high levels of injecting in prisons. Additional research about prison-based NSPs would be beneficial. In particular, more research in resource-poor systems outside Western Europe could allow for more rapid expansion of NSPs in these settings.
  • In contrast to OST, other forms of drug dependence treatment have not usually been introduced in prison with HIV prevention as one of their objectives. It is therefore not surprising that there is little data on the effectiveness of these forms of treatment as an HIV prevention strategy . Good quality, appropriate, and accessible treatment has the potential of improving prison security, as well as the health and social functioning of prisoners, and it can reduce reoffending. Such treatment in prison can help reduce the amount of drug use in prisons and upon release. But there is a need for independent and systematic outcome evaluations of these interventions, and for examining their effectiveness in reducing injecting drug use and needle sharing. Other things may also be required. Research showing that the main reason why some prisoners take drugs when they are in custody is to combat boredom and alienation, and promote relaxation suggests a need for more purposeful activity within prisons. Ultimately, research suggests that reducing the number of people who are in prison because of problems related to their drug use must be a priority. Studies have shown that fear of arrest and sanctions is not a major factor in an individual’s decision on whether to use or deal drugs; and that there is little correlation between incarceration rates and drug use prevalence in particular countries or cities. As early as 1987, WHO, in a statement from the first Consultation on Prevention and Control of AIDS in Prisons, stated that “[g]overnments may … wish to review their penal admission policies, particularly where drug abusers are concerned, in the light of the AIDS epidemic and its impact on prisons.” Similarly, the new UNODC framework document on HIV/AIDS in prisons also suggests that “ action to reduce prison populations and prison overcrowding should accompany – and be seen as an integral component of – a comprehensive prison HIV/AIDS strategy.”
  • In contrast to OST, other forms of drug dependence treatment have not usually been introduced in prison with HIV prevention as one of their objectives. It is therefore not surprising that there is little data on the effectiveness of these forms of treatment as an HIV prevention strategy . Good quality, appropriate, and accessible treatment has the potential of improving prison security, as well as the health and social functioning of prisoners, and it can reduce reoffending. Such treatment in prison can help reduce the amount of drug use in prisons and upon release. But there is a need for independent and systematic outcome evaluations of these interventions, and for examining their effectiveness in reducing injecting drug use and needle sharing. Other things may also be required. Research showing that the main reason why some prisoners take drugs when they are in custody is to combat boredom and alienation, and promote relaxation suggests a need for more purposeful activity within prisons. Ultimately, research suggests that reducing the number of people who are in prison because of problems related to their drug use must be a priority. Studies have shown that fear of arrest and sanctions is not a major factor in an individual’s decision on whether to use or deal drugs; and that there is little correlation between incarceration rates and drug use prevalence in particular countries or cities. As early as 1987, WHO, in a statement from the first Consultation on Prevention and Control of AIDS in Prisons, stated that “[g]overnments may … wish to review their penal admission policies, particularly where drug abusers are concerned, in the light of the AIDS epidemic and its impact on prisons.” Similarly, the new UNODC framework document on HIV/AIDS in prisons also suggests that “ action to reduce prison populations and prison overcrowding should accompany – and be seen as an integral component of – a comprehensive prison HIV/AIDS strategy.”
  • Already in 1993 , WHO responded to growing evidence of HIV infection in prisons worldwide by issuing guidelines on HIV/AIDS in prisons. With regard to health care and prevention of HIV, these guidelines – as well as the recent UNODC framework document on HIV/AIDS in prisons – emphasized that “a ll prisoners have the right to receive health care, including preventive measures, equivalent to that available in the community without discrimination, in particular with respect to their legal status or nationality .” Thirteen years later, there is evidence that measures such as condom distribution, needle and syringe programmes, opioid substitution treatment, and provision of ART are feasible in prisons, and effective in promoting and protecting the health of prisoners and, ultimately, the community .
  • Transcript

    • 1. HIV/AIDS in prisons: A review of the international evidence Winnipeg, 23 November 2009 Ralf Jürgens, consultant
    • 2. Acknowledgements
      • Annette Verster & Andrew Ball (WHO)
      • Peer reviewers
      • UNODC, UNAIDS
    • 3. Background
      • High rates of HIV in prisons
      • Hepatitis C rates even higher
      • Risk behaviours are prevalent in prisons
      • Outbreaks of HIV in prisons have been documented
      • High turnover of populations
      • Sources: Dolan et al., 2007, Macalino et al., 2004, Dolan & Wodak, 1999; MacDonald, 2005; Bobrik et al., 2005; Taylor et al., 1995
    • 4. Background
      • Drugs can and do enter into prisons
      • Many prisoners are in prison because of offences related to drugs – people who use drugs outside often find a way to use inside
      • Other prisoners start using (and/or injecting) drugs in prison
    • 5. HIV prevalence in selected countries
      • 0.3-1.6%
      • 3.2-20%
      • Brazil
      • 0.8-4.3%
      • 16-32% (5 regions)
      • Ukraine
      • 0.1-0.2%
      • 4-22%
      • Indonesia
      • 0.3-0.9%
      • 28.4%
      • Viet Nam
      • 0.7-1.8%
      • Up to 4%
      • Russian Federation
      • 0.4-1.0%
      • Up to 14%
      • Spain
      • 0.3%
      • 0.6-7%
      • Mexico
      • 0.4-1.0%
      • 1.9%
      • USA
      • 0.2-0.5%
      • 1-12%
      • Canada
      • Est. Adult HIV Prevalence 2005
      • HIV Prevalence in Prisons
      • Country
    • 6. Injecting & needle sharing in prison
    • 7. Review of the evidence
      • WHO, UNAIDS, UNODC commissioned review:
      • evidence regarding all interventions that are part of a comprehensive approach to HIV in prison
      • English & Russian version of all papers:
      • www.who.int /hiv/topics/idu/prisons/en/
    • 8. Education and information
      • Information & education programs result in increased knowledge (eg, Vaz, Gloyd & Trindade, 1996)
      • However, evidence of effect of increased knowledge on behaviour is limited (Braithwaite, Hammett & Mayberry, 1996)
      • Peer education is more effective (Grinstead et al, 1999)
      • Education is not enough
    • 9. Needle and syringe programmes
      • First established in Switzerland in 1992
      • Since then, introduced in 12 countries in western and eastern Europe and central Asia
      • Several models for distribution: health care, automatic dispensing machines, peer outreach workers
      • Programs available in all types of prisons: small & large, single cell & barracks, low-, medium- and high-security, prisons for males & prisons for females, etc
    • 10. Evidence NSPs (Stöver & Nelles, 2003; Stark et al., 2005; Rutter et al., 2001) Prison Incidence HIV&HCV Needle sharing Drug use Injecting Am Hasenburg (D) No increase No increase Basauri (Es) No HIV No increase No increase Hannoversand (D) No increase No increase Hindelbank (CH) No HIV Decrease No increase Lehrter Strasse & Lichtenburg (D) No HIV but HCV No increase No increase Linger 1 (D) No HIV No increase No increase Realta (CH) No HIV Single cases Decrease No increase Vechta (D) No HIV No increase No increase Vierlande (D) No HIV Little change or reduction No increase No increase
    • 11. Evidence NSPs
      • No negative consequences
        • No increase in drug use or injecting
        • needles are not used as weapons
      • Increased referral to drug dependence treatment
      • Increased staff safety
    • 12. Recommendations NSPs
      • WHO,UNODC, UNAIDS therefore recommend :
        • Introduce NSPs urgently and expand to scale
        • Easy and confidential access to NSPs
        • Distribution through peers
    • 13. Bleach and decontamination strategies
      • Feasible and does not compromise security
      • Doubts about effectiveness
        • Conditions in prisons reduce probability of effective decontamination
      • Bleach programmes cannot replace NSPs
      • Provide information on limited effectiveness
      • Continue efforts to introduce NSPs
    • 14. Drug demand & supply reduction measures
      • Some systems have vastly expanded drug interdiction measures (drug dogs, modern drug detection analysis, urinalysis, “drug-free units”, etc)
      • Drug use has remained high
      • Improving documentation & evaluation of these measures should be a priority
      • Prison systems with drug testing programs should reconsider testing for cannabis.
    • 15. Conclusion: From evidence to action
      • “ All prisoners have the right to receive health care, including preventive measures, equivalent to that available in the community” (WHO, 1993)
      • Time to move from evidence to action: Universal access to prevention & treatment is also needed for prisoners
      • For more info:
      • www.who.int /hiv/topics/idu/prisons/en/