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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
Firenze, 27 March 20112 |
AcknowledgementsAcknowledgements
Annette Verster & Andrew Ball (WHO)
Peer reviewers
UNODC, UNAIDS
Firenze, 27 March 20113 |
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
Firenze, 27 March 20114 |
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
Firenze, 27 March 20115 |
Background: risk behavioursBackground: risk behaviours
Risk behaviours are prevalent in prisons – Consensual & non consensual sex– Injecting drug use– Tattooing– Sharing of razors and toothbrushes
Firenze, 27 March 20116 |
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
Firenze, 27 March 20117 |
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
Firenze, 27 March 20118 |
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
Firenze, 27 March 20119 |
Injecting & needle sharing in prison Injecting & needle sharing in prison
0102030405060708090
100
Au
stralia Lo
w
Au
stralia hig
h
Can
ada
En
glan
d
Greece
RF
Th
ailand
% sharing
010
2030
4050
60
7080
Au
stralia low
Au
stralia hig
h
Can
ada lo
w
Can
ada h
igh
En
glan
d
Greece
Mau
ritius
Mau
ritius h
igh
RF
low
RF
hig
h
Th
ailand
US
A
% injecting
Firenze, 27 March 201110 |
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.
Firenze, 27 March 201111 |
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.
Firenze, 27 March 201112 |
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
Firenze, 27 March 201115 |
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.
Firenze, 27 March 201116 |
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
Firenze, 27 March 201117 |
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
Firenze, 27 March 201118 |
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)
Firenze, 27 March 201119 |
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
Firenze, 27 March 201120 |
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
Firenze, 27 March 201121 |
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
Firenze, 27 March 201123 |
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)
Firenze, 27 March 201124 |
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
Firenze, 27 March 201125 |
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
Firenze, 27 March 201127 |
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
Firenze, 27 March 201128 |
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
Firenze, 27 March 201129 |
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
Firenze, 27 March 201130 |
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
Firenze, 27 March 201131 |
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
Firenze, 27 March 201132 |
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)
Firenze, 27 March 201133 |
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
Firenze, 27 March 201134 |
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
Firenze, 27 March 201135 |
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
Firenze, 27 March 201136 |
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
Firenze, 27 March 201137 |
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
Firenze, 27 March 201138 |
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%
Firenze, 27 March 201139 |
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
Firenze, 27 March 201140 |
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
Firenze, 27 March 201141 |
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
Firenze, 27 March 201142 |
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
Firenze, 27 March 201143 |
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
Firenze, 27 March 201144 |
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)
Firenze, 27 March 201145 |
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