firenze, 27 march 2011 1 |1 | hiv and hcv in prisons: from evidence to action firenze, icar 2011, 27...

Firenze, 27 March 20111 |

HIV and HCV in prisons: From evidence to actionHIV and HCV in prisons: From evidence to action

Firenze, ICAR 2011, 27 March 2011

Ralf Jürgens, Canada


AcknowledgementsAcknowledgements

Annette Verster & Andrew Ball (WHO)

Peer reviewers

UNODC, UNAIDS


BackgroundBackground

HIV rates in prisons & pre-trial detention are much higher than in the community outside prisons

Even where HIV rates remain low, HCV rates are high – often exceeding 50%

Very high co-infection rates (HCV co-infection observed in more than 90% of HIV-positive prisoners in Genova)

Sources: WHO, UNODC, UNAIDS, 2007; Jürgens, Ball, Verster, 2009; Pontali , Ferrari, 2008; Dolan et al., 2007, Macalino et al., 2004, Dolan & Wodak, 1999; MacDonald, 2005; Bobrik et al., 2005; Taylor et al., 1995


HIV prevalence in selected countriesHIV 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% 7% Italy

0.4-1.0% 1.9% USA

0.2-0.5% 1-12% Canada

Est. Adult HIV Prevalence

HIV Prevalence in Prisons

Country


Background: risk behavioursBackground: risk behaviours

Risk behaviours are prevalent in prisons – Consensual & non consensual sex– Injecting drug use– Tattooing– Sharing of razors and toothbrushes


Background: sexual activityBackground: sexual activity

Difficult to obtain reliable data– Methodological and ethical challenges– Sex violates prison regulations– Feelings of shame and homophobia: prisoners decline to participate

in studies– Admitting to having been raped in prison goes against prisoner code

Nevertheless, evidence is clear: consensual and non-consensual sex do occur


Background: sexual activityBackground: sexual activity Africa: (Nigeria, Zambia, Mozambique): 4-5.5%

South America: 10% (Brazil)

Asia: 20% (Thailand)

Central & Eastern Europe:– Russia (9.7-12%; much higher among long-term prisoners)– Slovakia: 19% of female, 5.6% of adult male, 8.3% of juveniles– Slovenia: 19.3%– Hungary: 9%– Armenia: 2.9% penetrative (36% against their will)

Western Europe, Canada, Australia: 1-12% among males, up to 37% among femalesSource: WHO, UNODC, UNAIDS, 2007


Background: drug use in prisonsBackground: drug use in prisons

Drugs can and do enter into prisons

Many prisoners are in prison because of offences related to drugs, and find a way to use inside

Some discontinue using drugs in prisons

Other prisoners start using (and/or injecting) drugs in prison

No country has been able to stop drug use in prisons


Injecting & needle sharing in prison Injecting & needle sharing in prison

0102030405060708090

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Au

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Au

stralia hig

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Can

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En

glan

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Greece

RF

Th

ailand

% sharing

010

2030

4050

60

7080

Au

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Au

stralia hig

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Can

ada lo

w

Can

ada h

igh

En

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d

Greece

Mau

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Mau

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igh

RF

low

RF

hig

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Th

ailand

US

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% injecting


What could happen – what we can preventWhat could happen – what we can prevent

• Extensive HIV transmission can occur in prisons, significantly contributing to the spread of HIV among the general population.

• Thailand: HIV prevalence rate among injectors rose from a negligible percentage to over 40% between Jan & Sept 2008, fuelled by transmission of HIV in prisons.

• Six studies among people who inject drugs in Thailand found that imprisonment was associated significantly with HIV infection.


What could happen – what we can preventWhat could happen – what we can prevent

• Outbreaks of HIV in prisons have been documented in a number of countries, incl Scotland, Australia, Lithuania, and Russia.

• In Lithuania, in May 2002 the number of new HIV-positive test results among prisoners found in a two-week period equalled all the cases of HIV identified in the entire country during all of the previous years combined.

• 284 prisoners (15% of the prison population) were diagnosed HIV-positive between May and August 2002.


Prison conditions contribute to the problemPrison conditions contribute to the problem

Severe overcrowding

Lack of work and meaningful activities

Decaying physical infrastructure

Lack of adequate medical care

Lack of nutritious food & clean water

Abuse & corruption

Prisoner-on-prisoner violence


Public health implicationsPublic health implications

1. Health of prisoners = issue of public health concern

2. All people in Italy would benefit from enhancing the health of prisoners and reducing the incidence of communicable diseases

• prisoners and their families• prison staff• the families outside prison

3. Communicable diseases transmitted in prison do not remain there.


Interventions to address HIV in prisonsInterventions to address HIV in prisons

We know what works – and what does not work:– WHO/UNODC/UNAIDS Evidence for Action Papers: Interventions

to Address HIV in Prisons

www.who.int/hiv/topics/idu/prisons/en/– Jürgens R, Ball A, Verster A. Interventions to reduce HIV

transmission related to injecting drug use in prison. Lancet Infect Dis 2009; 9(1): 57-66

International expert & UN consensus since 1993: HIV & HCV prevention & treatment in prisons are essential, for public health & human rights


Education and informationEducation 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


Prevention of sexual transmissionPrevention of sexual transmission

Providing condoms is feasible in prison settings

No security problems or other negative consequences

Prisoners use condoms when condoms are easily and discreetly accessible - prisoners should never have to ask for condoms or seen by others when they take a condom

Source: WHO, UNODC, UNAIDS, 2007; Correctional Service Canada, 1999; Dolan, Lowe & Shearer, 2004; May and Williams, 2002; Yap et al., 2007)


Prevention of sexual transmissionPrevention of sexual transmission

Need for measures to combat rape and sexual abuse– Changing the institutional culture tolerating sexual

violence

– Multi-pronged approaches are needed:• Prevention efforts (prisoners education, classification, structural interventions

such as better lighting, better shower and sleeping arrangements)• Staff training, investigation, prosecution, victim services• Documenting incidents

Post Exposure Prophylaxis (PEP) should be available


Needle and syringe programmes (NSPs)Needle and syringe programmes (NSPs)NSPs in the community exist in most countries, including Italy

Studies have found NSPs– to be effective in reducing HIV spread

– do not lead to increased drug use

First established in prisons in Switzerland in 1992

Since then, introduced in 12 countries in western and eastern Europe and central Asia


NSPs in prisonsNSPs in prisonsToday, NSPs are operating in a growing number of countries,

in all types of prisons and prison systems:

– In well funded prison systems (eg, Spain, Switzerland, Germany) and severely under-funded prison systems (eg Moldova, Iran)

– In institutions with drastically different physical arrangements for the housing of prisoners, from single cell to barracks

– In prisons of all security classifications and sizes

– In men’s and women’s institutions


Prison Colony 18, Branesti, Moldova


Evidence NSPsEvidence NSPs

PrisonIncidence HIV&HCV

Needle sharingDrug useInjecting

Am Hasenburg (D)No increaseNo increase

Basauri (Es)No HIVNo increaseNo increase

Hannoversand (D)No increaseNo increase

Hindelbank (CH)No HIVDecreaseNo increase

Lehrter Strasse & Lichtenburg (D)No HIV but HCVNo increaseNo increase

Linger 1 (D)No HIVNo increaseNo increase

Realta (CH)No HIVSingle casesDecreaseNo increase

Vechta (D)No HIVNo increaseNo increase

Vierlande (D)No HIVLittle change or reduction

No increaseNo increase

(Stöver & Nelles, 2003; Stark et al., 2005; Rutter et al., 2001)


Evidence NSPs 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


How is needle exchange done?How is needle exchange done?

PNEPs utilize various methods for distributing injecting equipment– Hand-to-hand exchange by nurses and/or the prison

physician– Distribution by one-for-one automated syringe dispensing

machine– Distribution by prisoner trained as peer outreach workers– Distribution by external NGOs or other health professional

who come into the prison for this purpose


Determinants of success Determinants of success

Prisoners must have confidential, easy accessPrisoners must have access to the type of

injecting equipment they want and needSupport of the prison administration, staff, and

prisoners is crucial (educational workshops for these groups should be part of implementation of NSPs)

Start with pilot project in a few prisons, monitor and evaluate, then scale up


Recommendations NSPs in prisons Recommendations NSPs in prisons

WHO,UNODC, UNAIDS recommend:– Introduce NSPs urgently

– Provide easy and confidential access to NSPs

– Distribution through peers or NGOs


Could providing NSP send out the wrong message?Could providing NSP send out the wrong message?

Could it be seen as “being soft” on drug use?– As tolerating or condoning drug use in prisons?

– As giving up the fight against drugs in prisons?

No: drug use remains illegal and measures to continue fighting drugs in prisons continue

But the fight against HIV is equally importantNot taking evidence-based measures would mean condoning

the spread of HIV among prisoners and ultimately to the community outside prisons


How much do NSPs in prisons cost?How much do NSPs in prisons cost?

Very little – see Moldova exampleCost effective – every euro spent on prison NSP saves

many euros that would otherwise have to be spent on treatment of infectious diseases


Could providing bleach be enough?Could providing bleach be enough?

Studies have shown that providing bleach in prisons for decontamination purposes is feasible and does not compromise security

But: Doubts about effectiveness– Conditions in prisons reduce probability of effective

decontamination→ Bleach programmes cannot replace NSPsProvide information on limited effectivenessContinue efforts to introduce NSPs


Is providing NSPs enough?Is providing NSPs enough?

NSPs are important component of efforts to reduce risk of HIV through injecting

But alone they are not enough to eliminate the risk

Effective, evidence-based drug dependence treatment is also needed, in particular methadone maintenance treatment (MMT)


Evidence: MMT in prisonsEvidence: MMT in prisons

MMT is available in growing number of countries and is most effective treatment for opioid dependence– reduced used of opioids, reduced mortality, reduced HIV

risk behaviours, reduced criminal activity

MMT in prisons is feasible and effective – most important benefit: reduced injecting drug use and

associated needle sharing, if correct dose & length of treatment


Evidence: MMT in prisonsEvidence: MMT in prisons

Additional proven benefits of MMT in prison, for prison systems, society, and prisoners:

– facilitates entry and retention in post-release treatment– decreases re-incarceration– positive effect on institutional behaviour– helps reduce risk of overdose upon release

No negative side effects:– no problems for security & no violent behaviour– risk of diversion has been successfully addressed


Recommendations: MMT in prisonsRecommendations: MMT in prisons

WHO, UNODC & UNAIDS recommend:– introduce and scale up MMT urgently in prisons– ensure that those on MMT in the community can continue

MMT upon arrest and imprisonment


NSP & MMT: Learning from SpainNSP & MMT: Learning from Spain

Spain introduced and scaled up both MMT and NSPs This has resulted in significant decreases in HIV and

HCV prevalence and incidence


HIV prevalence in Spanish prisonsHIV prevalence in Spanish prisons

32%

28%

24% 23%22%

18%16%

13%11%

9% 8% 7%

0%

5%

10%

15%

20%

25%

30%

35%

1989 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2009

46% of prisoners had a history of injecting drug use


Prisoners on MMT in Spanish prisonsPrisoners on MMT in Spanish prisons

1572

3192

5162

6589

7866

8816 8729 8778 85858080 7567

7344 74317108

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

11%


Evolution of Needle Exchange ProgramsEvolution of Needle Exchange Programs

0

5000

10000

15000

20000

25000

Nee

dles

0

5

10

15

20

25

30

35

40

Priso

ns

Needles 2582 4943 7056 8584 11339 12970 18260 22356 22989 20626 13998 10582 10038

Prisons 1 2 4 9 11 27 38 35 34 37 31 34 30

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009


Conversions to HIV and HCVConversions to HIV and HCV

0%

1%

2%

3%

4%

5%

6%

% Conv. HIV 0.6% 0.7% 0.14% 0.15% 0.17% 0.15%0.06% 0.16% 0.09%0.08%

% Conv. HCV 5.1% 4.0% 2.8% 2.4% 2.0% 2.0% 1.7% 1.7% 1.5% 1.5%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009


Could we do sth else instead of NSP & MMT?Could we do sth else instead of NSP & MMT?

Other measures would not be as effective

Drug interdiction efforts are very costly

They only reduce, but do not completely eliminate drug use in prisons


Drug demand & supply reduction measuresDrug 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 highImproving documentation & evaluation of these

measures should be a priorityPrison systems with drug testing programs should

reconsider testing for cannabis


HIV in prisons: other necessary stepsHIV in prisons: other necessary steps

Pro-actively offer (and recommend) HIV and HCV testing

Ensure uninterrupted treatmentReduce overcrowding & improve prison conditionsProvide work & other meaningful activities for prisoners


HIV in prisons: other necessary stepsHIV in prisons: other necessary steps

Provide non-custodial alternatives for people convicted of offences directly related to their drug dependence (possession of amounts for personal use or petty crimes committed to support drug use)

“Governments 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.” (WHO, 1987)


Conclusion: From evidence to actionConclusion: From evidence to action

All prisoners have the right to receive … preventive measures equivalent to [those] available in the community” (WHO, 1993)

Time to move from evidence to action in Italy: access to condoms, NSPs, MMT, voluntary HIV & HCV testing & treatment, as part of comprehensive HIV & HCV strategy for prisons and pre-trial detention, is urgently needed for prisoners

firenze, 27 march 2011 1 |1 | hiv and hcv in prisons: from evidence to action firenze, icar 2011, 27...

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