HIV/AIDS and HCV in Prisons
A Select Annotated Bibliography

Tattooing

Recognizing the fact that tattooing is prevalent in many prison systems and given the risk of disease transmission that it carries, some systems have introduced measures to make it safer. This section contains documents that discuss the issues related to tattooing in prison.

Awofeso N (2000). Jaggers in the pokey: understanding tattooing in prisons and reacting rationally to it. Australian Health Review, 25(2): 162-169.

The legalisation of tattooing in prisons, as well as the provision of access by inmates to professional tattooists during incarceration, have remained contentious issues between custodial and health authorities in most Western prisons. This article examines the arguments of both stakeholders as well as the attitudes of inmates vis-a-vis tattooing, and suggests a multifaceted approach that takes cognisance of inmates' motivation to have prison tattoos, and (potential) public health implications of tattooing in correctional settings.

Awofeso N, Williams C (2002). Branded - tattooing in prisons. Trop Doct, 30(3): 186-187.

Collins P et al. (2003). Driving the Point Home: A Strategy for Safer Tattooing in Canadian Prisons. Toronto: PASAN, Canadian HIV/AIDS Legal Network, HIV/AIDS Regional Services.

Available via www.pasan.org.

The most comprehensive Canadian policy document on tattooing in prisons. Developed in consultation with inmate committees across the country.

Doll D (1988). Tattooing in prison and HIV infection. The Lancet, 2(9): 66-67.

Jürgens R (2004). Correctional Service Canada to undertake Safer Tattooing Practices Initiative. Canadian HIV/AIDS Policy & Law Review, 9(2): 45-46.

Available at
www.aidslaw.ca/Maincontent/otherdocs/
Newsletter/vol9no22004/prisons.htm#p1

In 1994, the Expert Committee on AIDS and Prisons recommended that tattooing equipment and supplies be authorized for use in federal correctional institutions, and that prisoners who would offer tattooing services to other prisoners be instructed on how to use tattooing equipment safely. Ten years later, Correctional Service Canada (CSC) announced that, as part of a Safer Tattooing Practices Initiative, it would set up safer tattooing pilot projects in six federal prisons in 2004, and evaluate the initiative. Under the Safer Tattooing Practices Initiative, tattoo parlours will be set up in federal prisons in all regions, including in one institution for women. These parlours will be administered by prisoners themselves, under the supervision of CSC staff.

Ko YC et al (1992). Tattooing as a risk of hepatitis C infection. J Med Virol, 38: 288-291.

Long GE, Rickman LS (1994). Infectious complications of tattoos. Clinical Infectious Diseases, 18: 610-619.

Post J et al. (2001). Acute hepatitis C virus infection in an Australian prison inmate: tattooing as a possible transmission route. Medical Journal of Australia, 174: 183-184.

See also above, under "evidence of HIV and HCV transmission."

Reindollar RW (1999). Hepatitis C and the correctional population. American Journal of Medicine, 107(6B): 100S-103S.

Injection Drug Use (Overviews)

This section contains articles and reports that provide overviews of the issues related to injection drug use in prisons while the following sections contain documents dealing with the specific interventions that have been adopted in some prison systems to prevent the spread of HIV and HCV through injection drug use.

Essential Resources

Black E, Dolan K, Wodak A (2004). Supply, Demand and Harm Reduction Strategies in Australian Prisons: Implementation, Cost and Evaluation. A report prepared for the Australian National Council on Drugs. Sydney: Australian National Council on Drugs.

The full report is available via www.ancd.org.au.

One of the few reviews of supply, demand, and harm reduction strategies used in prisons. Because of its importance, the full abstract is reproduced here:

"The increasing use of illicit drugs in Australia in recent decades and the heavy reliance on law enforcement measures to control drugs have resulted in a steadily growing prison population, an increase in the proportion of inmates with a history of drug use, particularly injecting drug use. In response, prison authorities have established a diverse array of supply, demand and harm reduction strategies. This study has found that many of these strategies were poorly documented, their costs were largely unknown and their benefits and adverse consequences have rarely been defined.

Supply reduction strategies are designed to disrupt the production and supply of illicit drugs. The two main specific forms of supply reduction used in Australian prisons were drug detection dogs and urinalysis. All prison systems utilised drug detection dogs and urinalysis. It was apparent these supply reduction strategies were relatively expensive, had not been evaluated and possibly had unintended negative consequences. Supply reduction strategies in Australian prisons need to be evaluated.

Demand reduction strategies aim to reduce the demand for illicit drugs. Examples include detoxification, methadone treatment, inmate programs and counselling and drug-free units. While most demand reduction strategies were implemented in every prison system, the level of implementation varied greatly. Some demand reduction strategies were relatively inexpensive. Each type of demand reduction strategy had been evaluated and most evaluations were favourable. There was strong evidence that the availability of demand reduction strategies was insufficient.

The aim of harm reduction strategies is to directly reduce the harms associated with illicit drug use. The eight harm reduction strategies identified were harm reduction education, peer education, blood-borne viral infection (BBVI) testing, hepatitis B vaccination, condom provision, bleach/detergent provision, naloxone provision and needle and syringe programs. Only three strategies were implemented in every jurisdiction: BBVI testing, hepatitis B vaccination and naloxone provision, even though these were generally inexpensive. Three strategies had been evaluated: illicit drug peer education, condom provision and bleach provision, all favourably. There was evidence of insufficient implementation of harm reduction strategies.

Extensive evaluation of demand and harm reduction strategies in community settings has suggested similar benefits are likely in correctional environments. Considering the importance of developing a more effective response to drug use in prison, there is an urgent need to improve documentation of all strategies, increase the quantity and quality of evaluation and expand the implementation of those strategies best supported by current evidence, namely demand and harm reduction strategies. In addition, measures to reduce the size of the prison population would have great benefit and achieve considerable savings.

In conclusion, supply reduction strategies were widespread, relatively expensive, had not been evaluated and possibly had unintended negative consequences. Demand reduction strategies had a reasonable level of implementation, were relatively inexpensive and evaluation had been favourable. Harm reduction strategies were least likely to be implemented were relatively inexpensive and evaluation had been favourable."

Correctional Service Canada. Evaluation of HIV/AIDS Harm Reduction Measures in the Correctional Service of Canada. Ottawa: CSC, 1999.

The report on the 1998 evaluation of CSC's harm reduction activities.

MacDonald M (2005). A Study of Health Care Provision, Existing Drug Services and Strategies Operating in Prisons in Ten Countries from Central and Eastern Europe. Finland: Heuni.

Available via www.heuni.fi/12542.htm (including an executive summary in English and Russian).

This is a more comprehensive and accessible version of the report immediately below.

MacDonald M (2004). A Study of Existing Drug Services and Strategies Operating in Prisons in Ten Countries from Central and Eastern Europe. Central and Eastern European Network of Drug Services in Prison.

Available via the website of the European Network on Drugs and Infections Prevention in Prisons, at www.endipp.net/?pid=8.

The ten countries involved in the research were Bulgaria, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Romania, Slovakia and Slovenia. The overall aims of the research were to: provide a report of the provision of services for drug dependent prisoners in ten countries; relate the provision of services to current Council of Europe and World Health organization guidelines and to the national strategies operating in each country; promote awareness of the initiatives operating within the sample prisons and to facilitate the sharing of best practice on the national and international level.

The research involved visiting a minimum of two prisons and key NGOs (working in the area of drug addiction) in each of the ten countries. The report contains conclusions and suggestions. Among other things, it says: "A key step in the provision of drug services for prisoners is official recognition that drugs are often available in prison and that some prisoners will engage in high risk behaviour (for example, injecting drug use). The availability of drugs in prison was officially acknowledged in most of the sample countries. The extent of drug use that occurred was variable between prisons within a country.

The prison systems in the sample face a series of competing priorities in the development of their prisons. Harm reduction and drug treatment were not always seen as key priorities. However, the development of such services should be seen in the light of prevention and an opportunity to meet the health and treatment needs of problematic drug users (a group often difficult to reach in the community) that are increasingly represented in prison in all the countries. The importance of introducing harm reduction measures was particularly illustrated by the HIV outbreak at Alytus Correction House in Lithuania. The main cause of this HIV outbreak was established to be injecting drug use rather than unprotected sex in the prison."

Shewan D, Davies JB (eds). Drug Use and Prisons: An International Perspective. Amsterdam: Harwood Academic.

Provides a comprehensive account of patterns of drug use and risk behaviours in prisons, and of the different responses to this feature of prison life. Contains articles from Europe, North and South America, Africa, and Australia.

Stöver H (2000). Manual - Risk Reduction for Drug Users in Prisons (PDF version). Utrecht: Trimbos Institute.

Available via
www.ahrn.net/library_upload/uploadfile/riskreduction.pdf.
The manual describes what can be done to reduce drug-related health risks in prisons. Besides providing basic information on drugs, drug use, infectious diseases and risk reduction strategies, it contains modules of training seminars for prison staff and prisoners.

Stöver H (2001). Study on Assistance to Drug Users in Prisons. Lisbon, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA/2001).

Available at www.archido.de/eldok/docs_en/stoever_habil_2000.htm

(see also the abridged version of the report, entitled "An overview study: Assistance to drug users in European Union prisons," available via www.emcdda.eu.int/)

An overview of all issues related to assistance of drug users in European prisons, including prevalence of HIV/AIDS and risk behaviours, abstinence oriented treatment, substitution therapy, and needle exchange programs.

Stöver H (2002). Drug and HIV/AIDS Services in European Prisons. Oldenburg: University of Oldenburg.

http://docserver.bis.uni-oldenburg.de/publikationen/
bisverlag/2002/stodru02/stodru02.html

This book focuses on the health of drug users in prisons. It is an extended and improved version of the report "Assistance to drug users in European Union prisons - an overview study." Special attention is given to the harm reduction strategies applied in European prisons.

Thomas G (2005). Harm reduction policies and programs for persons involved in the criminal justice system. Ottawa: Canadian Centre on Substance Abuse.

www.ccsa.ca/CCSA/EN/Publications/HarmReductionSeries.htm

This document is intended to provide current, objective and empirically-based information to inform the implementation of policies and programs for promoting the reduction of harms associated with drug use. While its focus is on Canada, it will be useful for other countries as well.

Weekes J, Thomas G, Graves G (2004). Substance abuse in corrections. FAQs. Ottawa: Canadian Centre on Substance Abuse.

Available via www.ccsa.ca, in English and French.

A review (in the form of "frequently asked questions) of issues related to drug use in prisons, with a focus on Canada, but with a lot of information about other countries. Questions addressed include: What proportion of the prison population has a substance abuse problem? To what extent are alcohol and other drugs available in prison? How effective are efforts to limit the availability of alcohol and other drugs in prison? How effective are prison-based urinalysis programs in reducing offender drug use? How serious a problem is injection drug use and needle-sharing in prison? What kind of drug use treatment is available to prisoners and on release in the community? What are the characteristics of "best practice" substance abuse programs in prison? How effective are drug treatment programs for prisoners? In what ways can harm reduction approaches be used successfully in prison settings? Are there needle exchange programs in correctional institutions?

Wood E, Montaner J, Kerr T (2005). HIV risks in incarcerated injection-drug users [comment]. The Lancet, 366: 1834-1835.

Argues that "the policy of mass incarceration of non-violent drug-offenders needs review. However, in the short term, there is an urgent need to ensure that standards of HIV prevention in prisons are consistent with the best available evidence and the standards outlined in international guidelines. As HIV continues to spread rapidly in IDU populations throughout the world, global control of the epidemic will require prison systems to move beyond their traditional role of custody, and accept responsibility for the prevention of HIV transmission between inmates."

World Health Organization (2001). Prisons, Drugs and Society. A Consensus Statement on Principles, Policies and Practices. Berne: WHO (Regional Office for Europe) Health in Prisons Project and the Pompidou Group of the Council of Europe.

Available in English, French, Russian and German via http://www.euro.who.int/prisons/publications/20050610_1

Acknowledges that much more can be done within "prison systems to reduce the harm from drugs and to treat successfully a large number of those prisoners who are addicted to drugs. The promotion of health in prisons can make a major contribution to national strategies for tackling the problems of drugs ... in society." The consensus statement is organized into 4 main parts: 1) principles for working with prisoners who are (or have been) using drugs; 2) policy and practice throughout the criminal justice process; 3) cross cutting issues and special needs; 4) checklists for key staff and governors/managers of prisons.

World Health Organization (2005). Evidence for Action Technical Papers: Effectiveness of Drug Dependence Treatment in Preventing HIV among Injecting Drug Users. Geneva: WHO.

At page 19 concludes: "There is a need to look at costs and expenditure within different social and cultural settings, but currently there is a major expenditure in many countries on imprisonment and prolonged incarceration in detention centres, approaches that are associated with very high relapse rates soon after release. There is no evidence that such an approach is cost effective and much to indicate that comparative cost-effectiveness evaluations need to be conducted if and when new pilot projects on agonist pharmacotherapy are started in some countries. Countries with forced institutional long-term treatment should review their overall treatment strategy and look to redeploy resources from such institutions into community-based drug substitution treatment programmes."

Zurhold H, Stöver H, Haasen C (2004). Female drug users in European Prisons - best practice for relapse prevention and reintegration (PDF version). Hamburg: Centre for Interdisciplinary Addiction Research, University of Hamburg.

Executive summary available at
www.zis-hamburg.de/Female_
prisoners_executive_summary_2004.pdf.
This 12-month study provides an overview of prison policy and practice concerning adult female drug users in European prisons. The objectives were to fill the information gap concerning the extent of the problem; and the availability of drug services for this population across Europe.

Other Resources

Bewley-Taylor D, Trace M, Stevens A (2005). Incarceration of drug offenders: costs and impacts. Oxford: UK: The Beckley Foundation.

Available via www.internationaldrugpolicy.net/publications.htm

British Columbia Corrections Harm Reduction Committee (1996). Corrections Branch Harm Reduction Committee Recommendations. Victoria, BC: The Committee.

The Harm Reduction Committee of the BC Corrections Branch was established to identify strategies "that will effectively reduce the spread of HIV and other communicable diseases in provincial prisons" in BC. Acknowledging that "despite our best efforts at stemming the flow of drugs into our institutions, the reality is that drugs will continue to be used and shared in prison," the Committee made a series of recommendations regarding methadone, needle-exchange programs, bleach, and drug use.

Burrows D (2001). A Best Practice Model of Harm Reduction in the Russian Federation: Final Project Report. Washington, DC/Moscow: World Bank (Health Nutrition and Population Discussion Paper).

Provides an analysis of existing harm reduction programs in the community and in prisons in the Russian Federation, and makes recommendations about how to improve these programs.

Canadian Centre on Substance Abuse & Canadian Public Health Association (1997). HIV, AIDS and Injection Drug Use: A National Action Plan. Ottawa: The Centre & The Association.

States that "conditions in correctional settings must be improved" by increasing access to methadone treatment and conducting "pilot programmes of needle exchange in federal and provincial correctional settings."

European Network of Services for Drug Users in Prison (1994). Summaries for each country of drug laws, prison systems, drug treatment services and drug services in prisons. Cranstoun Projects: London

Provides summaries of drug laws, prison systems, drug treatment services and drug services in prisons in Belgium, Denmark, France, Germany, Greece, Italy, Luxembourg, Portugal, the Republic of Ireland, Spain, the Netherlands and the United Kingdom.

Godin G et al. (2001). Correctional officers' intention of accepting or refusing to make HIV preventive tools accessible to inmates. AIDS Educ Prev, 13(5): 462-473.

The aim of this study was to identify the factors that explain correctional officers' intention of accepting or refusing to make HIV preventive tools (condoms, bleach, tattooing equipment, and syringes) accessible to prisoners. A total of 957 officers completed a questionnaire. Only 21.4% of officers were favourable toward making accessible all of the preventive tools.

Gore SM et al (1999). How many drug rehabilitation places are needed in prisons to reduce the risk of bloodborne virus infection? Commun Dis Public Health, 2(3): 193-195.

Hughes RA, Huby M (2000). Life in prison: Perspectives of drug injectors. Deviant Behavior, 21(5): 451-479.

Although there is a considerable literature on people's lives in prison, little is known about drug injectors inside prison. Drug injectors with prison experience were invited to discuss prison life during qualitative in-depth interviews and small group discussions. Drug injectors were recruited in the community in England and 24 people participated. Analysis of responses identified the following broad themes as important entering prison and early experiences; prison conditions; prison regimes; days in the lives of drug injectors; relationships and social networks; and informal rules and attitudes. This article draws on drug injectors' descriptions to illustrate these findings, in an attempt to help sensitize researchers and policy makers to some of the issues that are at the heart of the problems of responding to drug injectors in prison.

Hughes RA (2003). Illicit drug and injecting equipment markets inside English prisons: a qualitative study. Journal of Offender Rehabilitation, 37(3/4): 47-64.

This paper presents findings from qualitative research, which invited 24 drug injectors with prison experience to discuss the role and operation of illicit drug and injecting equipment markets inside prison. These data were obtained from in-depth interviews and small group discussions. The study found that when sterile injecting equipment was unavailable the need to inject and drug withdrawal were important factors on the reported readiness to share injecting equipment. This finding was broadly consistent both outside and inside prison. However, different patterns of responses between these two environments were influenced by the social context in which HIV risk was considered. These perceptions of HIV risk are situationally specific, but the influence of the need for a drug injection and drug withdrawal on HIV risk behaviour transcends social settings. Thus, the study concluded that HIV risk reduction strategies should be consistent outside and inside prison.

Johnson H (2004). Drugs and Crime: A Study of Incarcerated Female Offenders (Research and Public Policy Series No 63). Canberra: Australian Institute of Criminology.

Available via http://www.aic.gov.au/publications/rpp/63/index.html.

The Australian Institute of Criminology is undertaking research on the drug use careers of adult males, females and juveniles incarcerated in Australian prisons. The objective of the Drug Use Careers of Offenders (DUCO) female study is to contribute to the empirical evidence about the interaction between drug use and criminal offending among incarcerated women. This monograph presents findings from the DUCO female study, which was based on interviews with 470 women incarcerated in Australian prisons. Findings are presented on offending histories, drug use, links between drug and alcohol use and crime, temporal order of drug use and offending, and risk factors for drug use and offending. The results demonstrate important differences in the patterns of drug use of women as compared to men. Understanding patters in offending and drug use, and the connection between the two, may assist in the development of interventions and crime reduction strategies for women offenders.

Results also suggest that drug use and offending by women may not be directly related but are the result of a third factor. Sexual and physical abuse, mental health, and early exposure to drug and alcohol use have been identified as important factors in women's drug taking and offending. Experiences of sexual and physical abuse may lead to drug use as a way to cope with negative emotional reactions or to cope with ongoing abuse. Both drug use and the consequences of sexual and physical abuse leave women vulnerable to crime once drug habits become established. Helping agencies must look for and treat the common factors in both drug use and crime - sexual and physical abuse, mental health problems and other negative family experiences - at an early stage. Interventions that provide assistance to families and children in the early stages may help divert women from drug use and associated harms, including involvement in crime.

Kent H (1996). Should prisons ease drug prohibition to help reduce disease spread? Canadian Medical Association Journal, 155: 1489-1491.

Reports on a session at the 1996 International AIDS conference in Vancouver that focused on the use of harm-reduction policies to reduce the spread of HIV.

Turnbull PJ, Webster R (1998). Demand reduction activities in the criminal justice system in the European Union. Drugs: Education, Prevention and Policy, 5(2): 177-184.

The paper presents the results of a six-month study of drug demand reduction activities within the criminal justice system of the member states of the European Union.

Uchtenhagen A (1997). Prevention outside and inside prison walls. International Journal of Drug Policy, 8(1): 56-61.

Argues that the risk for developing substance dependence is increased in the prison milieu, due to stress factors, the availability of drugs and an over-representation of persons dependent on drugs among the prison population. Recent overviews on projects for primary prevention against substance use in European countries are summarized. The main messages are that knowledge and attitudes can be improved, but with unreliable impact on consumption behaviour, that short programs are not effective and that most programs cannot adequately reach those who are most in need for them. These messages have to be considered when it comes to prevention in the prison milieu. The specific prevention goals for prison populations are identified, and selected strategies mentioned (including control measures, therapeutic and harm reduction measures). Evaluation of such prevention strategies and programs is rare; a few examples are given. More pilot projects are recommended, focusing on relapse prevention of those already dependent, adequate networking with after-care and other agencies outside, and active participation by prisoners in order to improve compliance with the program.