Prisons, injecting drug use, and BBVs
HIV Australia | Vol. 9 No. 1 | April 2011
LORANA BARTELS examines injecting drug use and the transmission of HIV and other blood borne viruses in Australian prisons, finding a need for more specialist interventions.
The Australian Institute of Criminology (AIC) has long been concerned with the prevalence and transmission of HIV and other blood borne viruses (BBVs) in Australian prisons. In 1991, the AIC noted that 'the increase in identified HIV seropositive prisoners in Australia's gaols ... is of major concern, and raises serious questions concerning legal obligations within the prison community'.1
In 1994, the AIC published recommendations on prison HIV peer education, noting the need for such education to cover hepatitis prevention as well as HIV, and that it should be targeted to minority groups.2
Many years later little has changed. There are still no needle and syringe programs (NSPs) in Australian custodial settings, and the specific needs of Indigenous and female prisoners remain unmet.
The most recent Australian data on the prevalence of HIV and other BBVs among prison inmates are from the 2007 National Prison Entrants' Bloodborne Virus and Risk Behaviour Survey ('the survey'), which involved 740 prison entrants from all jurisdictions except the Northern Territory.3
Less than 1% of prison inmates who were tested upon admission during the survey period tested positive to HIV. However, due to inconsistent testing policies for BBVs in correctional facilities across various states,4 it is likely that this is an incomplete picture. In South Australia, for example, The Kirby Institute (formerly the National Centre in HIV Epidemiology and Clinical Research [NCHECR]) reported that only 15% of South Australian male admissions were tested for HIV in 2009.5
The survey found that 21% of prison entrants screened upon admission tested positive to hepatitis B.6 This figure was highest in NSW and Western Australia (27% and 28%)and lowest in Queensland and Tasmania (9%); hepatitis was alsomuch more common among injecting drug users (IDUs).
The survey found that 35% of prison entrants that were screened tested positive to hepatitis C. The rate was highest in NSW and Victoria (42% and 41%) and lowest in Western Australia (21%). Injecting drug users weremuch more likely to test positive to hepatitis C than non-IDUs (60%).
In terms of prevalence, hepatitis C appears to represent the greatest concern in relation to BBVs in Australian prisons. To this end,in 2008 the Ministerial Advisory Committee on AIDS, Sexual Health and Hepatitis (MACASHH) released Hepatitis C Prevention, Treatment and Care: Guidelines for Australian Custodial Settings.7 These have been endorsed by all Australian health and corrections ministers.
NSPs in correctional settings
Prison-based NSPs have been running in a number of countries for over ten years, including Switzerland, Germany and Spain8 - but to date no NSPs have been established in Australian prisons. This is despite the fact that international research on provision of NSPs in prisons has shown reductions in needle sharing, and reduction in rates of BBV transmission.9,10,11 In an evaluation of community-based NSPs in Australia, NCHECR estimated that for every dollar invested in such programs, more than four dollars were over ten years if only direct costs were included, with greater returns expected over the longer term.12
The Australian Government has recently released three strategies which call for NSP trials in custodial settings: the Sixth National HIV Strategy 2010–201313; the Third National Aboriginal and Torres Strait Islander Blood Borne Viruses and Sexually Transmissible Infections Strategy 2010–201314; and the Third National Hepatitis C Strategy 2010–2013.15 The strategies have all recommended that:
In view of the well-documented return on investment and the effectiveness of Australian community-based NSPs, it is appropriate … for state and territory governments to identify opportunities for trialling this approach in Australian custodial settings. This is also supported by the international evidence demonstrating the effectiveness of prison NSPs.
There is also political will. In January 2011, the ACT Chief Minister, Jon Stanhope, acknowledged it was ‘inevitable and appropriate and indeed the appropriate moral response for us to consider a needle exchange’ in the ACT prison.16 Furthermore, the NSW Coalition made a pre-election promise to consider an NSP trial in NSW prisons. At the time of publication, no further announcements have been made regarding this issue since the Coalition was elected to govern.17
Although both moves have met with some resistance, principally from prison staff,18,19 it would now appear certain that this long overdue measure will at least be trialled in an Australian jurisdiction.
Responding to the needs of specific groups
Up to two-thirds of all female inmates have hepatitis C, compared with one in three male inmates who test antibody positive for the virus.20,21 In addition, female prisoners report a higher incidence of continued injecting drug use (IDU) while in prison than men, with the survey indicating that female prison entrants were more likely than men to have injected drugs (73% versus 53%) and that injecting drug users were much more likely to test positive for hepatitis C than non-IDUs (78% versus 13%).22
The intersection of gender, drug use and BBVs has been explicitly acknowledged by the NSW Department of Corrective Services, which notes that despite ‘representing only a small proportion of the overall imprisoned population, women experience higher levels of substance abuse ... than males [and] higher rates of infection with blood borne viruses’.23
Internationally, the Kyiv Declaration on Women’s Health in Prison24 sets out key principles in relation to the health needs and treatment of female prisoners, including the need for specialist health care which is readily adjusted to meet individual needs in relation to HIV (including counselling and support), hepatitis and other infectious diseases.
The AIC recently reviewed good practice for women’s prisons.25 It examined developments in corrections policies, women’s prison system management, corrections programs for women, and programs to address physical and mental health issues. The paper identified a number of positive developments in relation to the prevention and management of BBVs for women in some Australian custodial settings, such as:
provision of information on BBVs on admission after a health screening, and compulsory attendance at BBV education sessions;
monthly hepatitis C clinics at the Boronia Pre-release Centre for Women in Western Australia, where a visiting gastroenterologist provided access to the latest treatment options; and
a review of hepatitis services and expansion of the range of services provided by sexual health nurses in NSW.
The review also considered the use of HIV prison-based peer programs in two New York State prisons.26 Although most of the women in the programs were not HIV-positive, they were trained to provide counselling and educational workshops and facilitate support.
A 2001 study indicated that Indigenous injecting drug users in Sydney were more likely to be imprisoned than non-Indigenous users, the researchers suggesting that ‘prison may be an ideal opportunity to promote treatment and bloodborne virus testing and to address some of the barriers identified by Indigenous IDUs’.27
The 2007 National Prison Entrants’ Bloodborne Virus and Risk Behaviour Survey data also indicated that IDU is more prevalent among Indigenous than non-Indigenous prison entrants (61% versus 53%).28 In addition, 43% of the Indigenous prison entrants screened tested positive to hepatitis C, compared with 33% of non-Indigenous entrants; this figure rose to three-quarters (72%) for Indigenous female prison entrants. For hepatitis B, 42% of entrants tested, tested positive, compared with 17% for non-Indigenous entrants. The figures for women were 39% and 22% respectively.29
Notably, between 2004 and 2007 the Study found there was an increase among Indigenous IDUs in the prevalence of both hepatitis B and C antibodies (from 29% to 42%, and 38% to 43% respectively).30 This increase led the study’s authors to call for targeted culturally appropriate prevention strategies including education, hepatitis B vaccination, and hepatitis C treatment. This was particularly necessary, given that none of the Indigenous respondents reported having received treatment for hepatitis C.
The National Corrections Drug Strategy 2006–2009 recognised the need for specific culturally valid policy and program initiatives to address the needs of Indigenous people in correctional and community-based facilities and services. In addition, the Third National Aboriginal and Torres Strait Islander Blood Borne Viruses and Sexually Transmissible Infections Strategy 2010–201331 states that limited access to confidential and culturally appropriate health services exacerbates the challenges to Indigenous prisoners’ health and wellbeing, and that routine screening and vaccination for BBVs and STIs should be introduced in prison and juvenile detention facilities.
The message is clear
This overview clearly reveals that Australia needs to pay heed to international studies that show the efficacy of prison-based NSP programs, and to Australian studies that highlight the need to target female and Indigenous inmates in prison-based BBV prevention programs. The rate of HIV in prisons may remain low in the general prison population, but data showing increasing rates of injecting drug use among Indigenous and female prisoners should not be ignored.
The views contained in this paper are those of the author and do not represent the Australian Government.
1 Norberry, J. (1991). HIV/AIDS, prisons and the law. Trends and Issues in Crime and Criminal Justice, No. 32. AIC, Canberra. Available at: http://www.aic.gov.au/ (accessed 21 March 2011).
2 Robinson, J. (1994). HIV prison peer education. Australian Institute of Criminology, Canberra. Available at: http://www.aic.gov.au (accessed 21 March 2011).
3 Butler, T., Papanastasiou, C. (2008). National prison entrants’ bloodborne virus and risk behaviour survey 2004 & 2007. National Drug Research Institute (NDRI) and National Centre in HIV Epidemiology and Clinical Research (NCHECR), Perth and Sydney. Available at http://ndri.curtin.edu.au (accessed 21 March 2011).
4 Ibid. Butler and Papanastasiou found that: ‘The Northern Territory and Tasmania engage in compulsory HIV testing of prisoners, Queensland, South Australia, and Western Australia have voluntary screening, and New South Wales has a targeted approach. HIV screening coverage varies across the states’.
5 NCHECR. (2010). HIV, viral hepatitis and sexually transmissible infections in Australia. Annual Surveillance Report. NCHECR, Sydney. Available at: http://hiv.cms.med.unsw.edu.au (accessed 21 March 2011).
6 Butler, T., Papanastasiou, C., op. cit.
7 Ministerial Advisory Committee on AIDS, Sexual Health and Hepatitis (MACASHH). (2008). Hepatitis C prevention, treatment and care: Guidelines for Australian custodial settings: Evidence base for the guidelines. Available at: http://www.health.gov.au (accessed 21 March 2011).
8 Anex (2010). With conviction: The case for controlled needle and syringe programs in Australian Prisons. Anex, Melbourne. Available at: http://www.anex.org.au/hmpc-paper-on-nsp-in-prison/ (accessed 21 March 2011).
9 Hunt, D., Saab, S. (2009). Viral hepatitis in incarcerated adults: a medical and public health concern. American Journal of Gastroenterology, 104(4), 1024–1031.
10 Jurgens, R., Ball, A., Verster, A. (2009). Interventions to reduce HIV transmission related to injecting drug use in prison. Lancet Infectious Diseases, 9, 57–99.
11 Lines, R., J rgens, R., Betteridge, G., St ver, H. (2005). Taking action to reduce injecting drug-related harms in prisons: The evidence of effectiveness of prison needle exchange in six countries. International Journal of Prisoner Health, 1(1), 49–64.
12 NCHECR and UNSW. (2009). Return on investment 2: Evaluating the cost-effectiveness of needle and syringe programs in Australia. Department of Health and Ageing (DoHA), Canberra, NCHECR, Australia, 8. Available at: http://hiv.cms.med.unsw.edu.au (accessed 21 March 2011).
13 DoHA. (2010a). Sixth National HIV Strategy 2010–2013. DoHA, Canberra, 26. Available at http://www.health.gov.au (accessed 21 March 2011).
14 DoHA. (2010b). Third National Aboriginal And Torres Strait Islander Blood Borne Viruses and Sexually Transmissible Infections Strategy 2010–2013. DoHA, Canberra, 34. Available at: http://www.health.gov.au (accessed 21 March 2011).
15 DoHA. (2010c). Third National Hepatitis C Strategy 2010–2013. DoHA, Canberra.Canberra, 18. Available at: http://www.health.gov.au (accessed 21 March 2011).
16 Towell, N. (2011, 6 January). Stanhope supports needle program. Canberra Times. Available at: http://www.canberratimes.com.au (accessed 21 March 2011).
17 Jacobsen, G. (2011, 19 February). Coalition open to wide-ranging prison reforms. The Sydney Morning Herald. Available at: http://www.smh.com.au (accessed 21 March 2011).
18 Hall, B. (2011, 5 January). Fight looms on jail needle plan. Canberra Times. Available at: http://www.canberratimes.com.au (accessed 21 March 2011).
19 Knott, M. (2011, 24 February). O’Farrell faces prison revolt on needles. Crikey. 24 February. Available at: http://www.crikey.com.au (accessed 21 March 2011).
20 Butler, T., Papanastasiou, C., op. cit.
21 MACASHH, op. cit.
22 Butler, T., Papanastasiou, C., op. cit.
23 New South Wales Government. (2010). Women Offenders. Corrective Services NSW website. Available at: http://www.correctiveservices.nsw.gov.au (accessed 21 March 2011).
24 UN Office on Drugs and Crime and WHO. (2009). Women’s health in prison: Correcting gender inequity in prison health. Available at: http://www.unodc.org (accessed 21 March 2011).
25 Bartels, L., Gaffney, A. (2011). Good practice in women’s prisons: A literature review. Technical and Background Paper No. 41, Australian Institute of Criminology, Canberra. Available at: http://www.aic.gov.au (accessed 21 March 2011).
26 See Collica, K. (2010). Surviving incarceration: Two prison-based peer programs build communities of support for female offenders. Deviant Behavior, 31. 314–347.
27 Day, C., Dolan, K. (2001). Characteristics of Indigenous injecting drug users in Sydney: Gender, prison history and treatment experiences. Paper presented at the Best Practice Interventions in Corrections for Indigenous People Conference, Sydney, 8–9 October 5, 2011. Available at: http://www.aic.gov.au (accessed 21 March 2011).
28 Butler, T., Papanastasiou, C., op. cit.
31 DoHA, (2010b), op. cit.
Lorana Bartels (BA LLB LLM GDLP PhD) is a Senior Research Analyst at the Australian Institute of Criminology. Her first book, Qualitative Criminology: Stories from the Field, was recently published by Hawkins Press.