Transcript WHO Evidence for Action (E4A) Series

HIV and HCV in prisons:
From evidence to action
Firenze, ICAR 2011, 27 March 2011
Ralf Jürgens, Canada
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Acknowledgements
Annette Verster & Andrew Ball (WHO)
Peer reviewers
UNODC, UNAIDS
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Background
 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
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HIV prevalence in selected countries
 Country
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 HIV Prevalence in
Prisons
Canada
 1-12%
USA
 1.9%
Brazil
 3.2-20%
Italy
 7%
Spain
 Up to 14%
Russian Federation  Up to 4%
Viet Nam
 28.4%
Indonesia
 4-22%
Ukraine
 16-32% (5 regions)
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 Est. Adult HIV
Prevalence
 0.2-0.5%
 0.4-1.0%
 0.3-1.6%
 0.3%
 0.4-1.0%
 0.7-1.8%
 0.3-0.9%
 0.1-0.2%
 0.8-4.3%
Background: risk behaviours
Risk behaviours are prevalent in prisons
– Consensual & non consensual sex
– Injecting drug use
– Tattooing
– Sharing of razors and toothbrushes
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Background: 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 nonconsensual sex do occur
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Background: 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 females
Source: WHO, UNODC, UNAIDS, 2007
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Background: 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
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Injecting & needle sharing in prison
Thailand
RF
Greece
England
Canada
Australia high
Australia Low
USA
Thailand
RF high
RF low
Mauritius high
Mauritius
Greece
England
Canada high
Canada low
Australia high
Australia low
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% sharing
% injecting
100
90
80
70
60
50
40
30
20
10
0
80
70
60
50
40
30
20
10
0
What could happen – what we can prevent
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Extensive HIV transmission can occur in prisons, significantly
contributing to the spread of HIV among the general population.
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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.
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Six studies among people who inject drugs in Thailand found that
imprisonment was associated significantly with HIV infection.
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What could happen – what we can prevent
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Outbreaks of HIV in prisons have been documented in a number of
countries, incl Scotland, Australia, Lithuania, and Russia.
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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.
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284 prisoners (15% of the prison population) were diagnosed HIVpositive between May and August 2002.
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Prison 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
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Public 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.
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Interventions 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
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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
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Prevention 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)
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Prevention 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
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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
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NSPs in prisons
 Today, 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
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Prison Colony 18, Branesti, Moldova
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Evidence NSPs
Prison
Incidence
HIV&HCV
Needle sharing
Am Hasenburg (D)
Basauri (Es)
No HIV
Hannoversand (D)
Drug use
Injecting
No increase
No increase
No increase
No increase
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
Decrease
No increase
Vechta (D)
No HIV
No increase
No increase
Vierlande (D)
No HIV
No increase
No increase
(Stöver & Nelles, 2003; Stark et al., 2005; Rutter et al., 2001)
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Single cases
Little change or
reduction
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
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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
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Determinants of success
Prisoners must have confidential, easy access
Prisoners must have access to the type of
injecting equipment they want and need
Support 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
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Recommendations NSPs in prisons
WHO,UNODC, UNAIDS recommend:
– Introduce NSPs urgently
– Provide easy and confidential access to NSPs
– Distribution through peers or NGOs
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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 important
 Not taking evidence-based measures would mean condoning
the spread of HIV among prisoners and ultimately to the
community outside prisons
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How much do NSPs in prisons cost?
Very little – see Moldova example
Cost effective – every euro spent on prison NSP saves
many euros that would otherwise have to be spent on
treatment of infectious diseases
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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 NSPs
Provide information on limited effectiveness
Continue efforts to introduce NSPs
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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)
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Evidence: 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
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Evidence: 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
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Recommendations: 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
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NSP & 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
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HIV prevalence in Spanish prisons
35%
30%
25%
32%
28%
20%
24% 23%
15%
22%
18%
10%
16%
13%
11%
5%
9%
8%
7%
0%
1989 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2009
46% of prisoners had a history of injecting drug use
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Prisoners on MMT in Spanish prisons
10000
8816 8729 8778 8585
9000
8080 7567
7866
8000
7344 7431 7108
6589
7000
6000
5162
11%
5000
4000
3192
3000
1572
2000
1000
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
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Evolution
25000
of Needle Exchange Programs 40
35
30
25
15000
20
10000
15
10
5000
5
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Needles 2582 4943 7056 8584 11339 12970 18260 22356 22989 20626 13998 10582 10038
Prisons
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1
2
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4
9
11
27
38
35
34
37
31
34
30
0
Prisons
Needles
20000
6%
Conversions to HIV and HCV
5%
4%
3%
2%
1%
0%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
% 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%
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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
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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
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HIV in prisons: other necessary steps
Pro-actively offer (and recommend) HIV and HCV
testing
Ensure uninterrupted treatment
Reduce overcrowding & improve prison conditions
Provide work & other meaningful activities for prisoners
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HIV 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)
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Conclusion: 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
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