HIV/AIDS and HCV in Prisons
A Select Annotated Bibliography

Other Forms of Drug Dependence Treatment

Essential Resources

Ashley OS, Marsden ME, Brady TM (2003). Effectiveness of substance abuse treatment programming for women: a review. Am J Drug Alcohol Abuse, 29(1): 19-53.

Recent research has shown that women and men differ in substance abuse etiology, disease progression, and access to treatment for substance abuse. Substance abuse treatment specifically designed for women has been proposed as one way to meet women's distinctive needs and reduce barriers to their receiving and remaining in treatment. However, relatively few substance abuse treatment programs offer specialized services for women, and effectiveness has not been fully evaluated. This article reviews the literature on the extent and effectiveness of substance abuse treatment programming for women and provides an overview of what is known about the components of successful treatment programs for women. Thirty-eight studies of the effect on treatment outcomes of substance abuse treatment programming for women were reviewed. Seven were randomized, controlled trials, and 31 were nonrandomized studies. In the review, six components of substance abuse treatment programming for women were examined: child care, prenatal care, women-only programs, supplemental services and workshops that address women-focused topics, mental health programming, and comprehensive programming. The studies found positive associations between these six components and treatment completion, length of stay, decreased use of substances, reduced mental health symptoms, improved birth outcomes, employment, self-reported health status, and HIV risk reduction. These findings suggest that to improve the future health and well-being of women and their children, there is a continued need for well-designed studies of substance abuse treatment programming for women.

European Monitoring Centre for Drugs and Drug Addiction (2003). Treating drug users in prison - a critical area for health promotion and crime reduction policy. Drugs in focus 7.

Available in 12 languages via www.emcdda.eu.int/index.cfm?fuseaction=public.
Content&nNodeID=439&sLanguageISO=EN

On 4 pages, presents a very good overview of key policy issues related to drug dependence treatment in prisons.

Harrison L et al. (2003). The Effectiveness of Treatment for Substance Dependence within the Prison System in England: A Review. Canterbury: Centre for Health Services Studies.

Available via http://www.kent.ac.uk/chss/frames/index.htm

The aims of this review were to identify treatments that are used for those with substance dependence, describe the current regimes available in prison, and to evaluate the effectiveness of the treatments, drawing on research evidence from the UK and the US. It starts by saying that "treatment in prison will never be a viable alternative to treatment in the community, because of the high cost of imprisonment ... Given that many offenders have severe problems with illicit drugs, however, it would be unethical not to utilise the opportunity that imprisonment provides for treatment and rehabilitation." The review points out that there has been a lack of systematic evaluations of drug treatments operating in the British prison system. Some of the findings include: 1) there have been few independent studies of 12 Steps facilitation methods, and the evaluation studies to date have been methodologically poor; 2) cognitive-behavioural therapies have a consistent record for effectiveness, having value in motivating people to change behaviour; 3) evidence is lacking for the effectiveness of educational programs, but may have some benefit for imparting specific information to improve health and reduce risk-taking behaviour; 4) there is good evidence that methadone maintenance reduces injecting risk behaviour in prison, reduces the risk of overdose on release and has a positive impact on crime rates; 5) therapeutic communities in US prisons have claimed consistent reduction in reconviction rates and relapse into drug use, but the existing research is methodologically flawed. In particular, the authors point out that in many studies of therapeutic communities, success is claimed for prisoners completing treatment, and prisoners who drop out (often in the first months after admission) are excluded from the analysis. In addition, successful therapeutic communities are linked to aftercare programs, but two evaluations that included a group attending only a "half-way house" program found that this group did as well as those who had intensive treatment in both prison and the community, raising the possibility that limiting provision to a transitional therapeutic community would be more cost effective than providing a multistage structure.

The review concludes by pointing out, once again, that the greatest threat to the success of prison-based treatment comes from the failure of throughcare and aftercare arrangements, which are partly beyond the control of the prison authorities.

Henderson DJ (1999). Drug abuse and incarcerated women. A research review. Journal of Substance Abuse Treatment, 16(1): 23-30.

The paper reviews what is known about the treatment and aftercare needs of women prisoners and proposes an agenda for future research.

Mears DP et al. (2003). Drug Treatment in the Criminal Justice System: The Current State of Knowledge. Washington, DC: Urban Institute.

Available via www.urban.org.

Mitchell O, Wilson DB, MacKenzie DL (2005). Systematic review protocol. The effectiveness of incarceration-based drug treatment on criminal behavior. Submitted to the Campbell Collaboration, Criminal Justice Review Group.

Available via http://www.aic.gov.au/campbellcj/reviews/titles.html.

By early 2006, the authors will undertake a systematic review of the available evidence regarding the effectiveness of incarceration-based drug treatment interventions in reducing drug use and recidivism. More specifically, the review will focus on the following questions: Are incarceration-based drug treatment programs effective in reducing recidivism and drug use? Approximately how effectives are these programs? Are there particular types of dug treatment programs that are especially effective or ineffective? What program characteristics differentiate effective programs from ineffective programs? These questions will be addressed using meta-analytic synthesis techniques. In many ways, the review will be an extension of the work of Pearson and Lipton, 1999, infra. The review protocol describes the background of the review, its objectives, the methods that will be used, and the timeframe. There is a plan to update the review every three years.

Pearson FS, Lipton DS (1999). A meta-analytical review of the effectiveness of corrections-based treatment for drug abuse. The Prison Journal, 79(4): 384-410.

Pearson and Lipton systematically reviewed the research assessing the effectiveness of corrections-based drug treatment programs in reducing recidivism. Their review conducted a comprehensive search for quasi-experimental and experimental evaluations of interventions carried out in correctional settings, conducted in any country, and published between 1968 and 1996. Their search revealed 30 studies meeting their eligibility citeria. Their synthesis of the findings from these studies indicated that boot camp and group-counseling interventions were ineffective in reducing recidivism among drug users. On the other hand, therapeutic communities were effective in reducing recidivism, while the authors found too few studies evaluating other types of interventions to draw strong conclusions. However, they characterized the evidence assessing the effectiveness of methadone maintenance, drug education, cognitive behavioural, and 12-step programs as promising.

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

Available via www.ccsa.ca.

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: How effective are efforts to limit the availability of alcohol and other drugs 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?

Points out that the majority of programs currently offered to prisoners throughout the world have been developed without a clear theoretical base, empirical evidence, or strong adherence to accepted best practice guidelines. Highlights that unique intervention and service models are needed for women, ethnic minorities, and younger prisoners. Stresses that research suggests that for most offenders with drug use problems, the optimal treatment involves prison-based treatment, complimentary community-based follow up treatment, and on-going maintenance, support, and after-care services.

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

http://www.who.int/hiv/pub/idu/en/drugdependencefinaldraft.pdf

Reviews the evidence on drug dependence treatment in preventing HIV among IDUs.

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

A 300-page report providing an overview on current prison policy and practice directed to adult female drug users in European prisons; and summarizing the result of an investigation of female drug users in selected prisons of five European countries. The report contains a set of recommendations on women specific treatment options in prisons.

Other Resources

Andrews D et al. (1990). Does correctional treatment work? A clinically-relevant and psychologically-informed meta-analysis. Criminology, 28: 369-404.

Identifies principles that are key to determining the development of an appropriate treatment response in prisons.

Belenko S, Peugh J (2005). Estimating drug treatment needs among state prison inmates. Drug Alcohol Depend, 77(3): 269-281.

Growing prison populations in the US are largely due to drug-related crime and drug use. Yet, relatively few inmates receive treatment, existing interventions tend to be short-term or non-clinical, and better methods are needed to match drug-involved inmates to level of care. Using data from the 1997 Survey of Inmates in State Correctional Facilities, a nationally representative sample of 14,285 inmates from 275 state prisons, the authors present a framework for estimating their levels of treatment need. The results indicate high levels of drug involvement, but considerable variation in severity/recency of use and health and social consequences. The authors estimate that one-third of male and half of female inmates need residential treatment, but that half of male and one-third of female inmates may need no treatment or short-term interventions. Treatment capacity in state prisons is quite inadequate relative to need, and improvements in assessment, treatment matching, and inmate incentives are needed to conserve scarce treatment resources and facilitate inmate access to different levels of care.

Burrows J et al. (2000). The nature and effectiveness of drugs throughcare for released prisoners. London: Home Office Research, Development and Statistics Directorate (Research Findings No. 109).

Summary available via http://www.homeoffice.gov.uk/rds/rf2000.html.

In this study (for more details, see the section on "Release Planning and Aftercare"), the principal motivation for prisoners seeking treatment was reported to be abstinence. "But 23 per cent wanted to continue to use drugs while keeping their drug use under control and a further 20 per cent wanted to reduce the harm that they could cause themselves and those close to them." Harrison et al. (2003, supra) point out that, while it is not uncommon for clients to have differing motivation and most community-based drug agencies would negotiate the goals of intervention with the client, in the prison system the focus of all treatment programs is on abstinence from drugs. Other goals, like harm reduction, do not seem to be considered legitimate. According to Harrison et al, there "is a clear for this de facto policy to be reconsidered, as most of evidence for the effectiveness of drug treatment in the criminal justice system relates to interventions aimed at harm reduction, like methadone maintenance."

Correctional Service Canada (2002). Substance Abuse Programming: A Proposed Structure. Ottawa: CSC (No R-120).

Available via http://www.csc-scc.gc.ca/text/rsrch/reports/reports_e.shtml

Correctional Service Canada (2003). The High Intensity Substance Abuse Program (HISAP): Results from the Pilot Programs.Ottawa: CSC (No R-140).

Available via http://www.csc-scc.gc.ca/text/rsrch/reports/reports_e.shtml

Council of Europe (2002). Drugs in prisons. Draft list of issues to be examined when evaluating arrangements for the treatment of drug users detained in prisons. Strasbourg: European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment.

Dowden C, Blanchette K (2002). An evaluation of the effectiveness of substance abuse programming for female offenders. International Journal of Offender Therapy and Comparative Criminology, 46: 220-230.

A recent meta-analysis reported that substance abuse treatment was associated with moderate reductions in recidivism for female offenders, but very few of the tests of treatment (k = 4) focused on adults. The purpose of this study was to contribute to this relatively sparse area of scientific inquiry by exploring the effectiveness of substance abuse programming in reducing recidivism for a sample of 98 federally sentenced female offenders in Canada. Results revealed a significant reduction in general recidivism for treated substance abusers. Moreover, the data indicated that violent reoffending was also reduced for the treated group, although the difference did not reach statistical significance.

Farbring A (1995). A treatment programme for drug users at the ÖSTERÅKER prison: Design and evaluation. Report of the 2nd Seminar of the European Network of Services for Drug Users in Prison. Prisoners Resource Service: London, at 17-19.

See also Farbring A (1997). Efficiency of drug treatment in prisons. In: O'Brien O (ed). Report of the 3rd European Conference on Drug and HIV/AIDS Services in Prison. Cranstoun Drug Services: London, at 39-41

The Österåker prison, a high security prison just outside Stockholm, has run a treatment program for drug users since 1978. The program has been evaluated by independent researchers every year, originally in a three-year longitudinal study in the early 1980's, and later through two separate 5-year longitudinal studies by the National Prison Administration and SAFAD (the Swedish Agency for Administrative Development), an independent institution, whose task is to evaluate the efficiency of government institutions. All the individuals who have participated in the program since 1978 have been followed up for 2 years after release from prison. The results show that between 50% and 70% of the 287 people who have been through the program have not relapsed to crime during the two year follow up. When compared to a control group, these rates were shown to be statistically significant. The author concludes: On the basis of the 20 years of running the program, there have been some basis components for an effective and efficient treatment program, such as the need for the whole prison to be involved and the recruitment of skilled and experienced staff to the treatment program. While these points can assist greatly in the successful implementation of drug treatment, and in reducing recidivism, it should be said that running the program is difficult and more expensive than traditional prison activities.

Farabee D et al (1999). Barriers to implementing effective correctional drug treatment programs. The Prison Journal, 79(2): 150-162.

The article summarizes both the research literature and the experiences of the authors regarding six common barriers to developing effective correctional treatment programs in the United States, and offers potential solutions for each.

Gaes GG et al. (1999). Adult correctional treatment. In: Tonry M, Petersilia J (eds). Prisons, Crime and Justice: A Review of Research, Volume 26. Chicago: University of Chicago Press.

The authors highlight a number of methodological flaws in their meta-analysis of prison-based research. One problem is found in studies comparing outcomes for prisoners who received treatment and who received post-community supervision orders, and untreated prisoners who had shorter supervision periods following release. By comparing the treatment group with a control group that receives less support, results are biased in favour of finding a treatment effect. The authors also found evidence of selection bias. Another difficulty in comparing programs is that the program content is rarely described in detail to outsiders.

Griffith JD et al. (1999). A cost-effectiveness analysis of in-prison therapeutic community treatment and risk classification. The Prison Journal, 79(3): 352-368.

Three-year outcome data from 394 parolees (291 treated, 103 untreated comparison) were examined to determine the relative cost-effectiveness of prison-based treatment and aftercare, controlling for risk of recidivism. Findings showed that intensive services were cost-effective only when the entire treatment continuum was completed, and that the largest economic impact was evident among high-risk cases. Therefore, assignments to correctional treatment should consider an offender's problem severity level, and every effort should be made to engage them in aftercare upon release from prison.

HM Prison Service (1995). Drug Misuse in Prison: Policy and Strategy. HM Prison Service: London.

Reducing the level of drug misuse is one of the seven priorities in the Prison Service's Corporate Plan. This consultation document outlines prison policies, strategies, mandatory drug testing procedures and various other issues regarding drug use in prison. Main strategies focus on reducing the supply of drugs, reducing the demand for drugs and following measures that will reduce the potential for damage to the health of prisoners, staff and the wider community.

Hough M (1996). Drugs misuse and the criminal justice system: A review of the literature. Drug Prevention Initiative Paper 15. Central Drug Prevention Unit: London.

This report is a selective review of the recent English-language research on links between drug use and crime and on ways within the criminal justice system of reducing demand for illegal drugs amongst dependent drug users and others who fund their drug use through crime. Chapter 2 looks at the research on drugs and crime. The research on the impact of interventions is summarized in chapters 3 to 5. Chapter 6 offers some concluding thoughts.

Inciardi J (1996). Reduction and service delivery strategies in criminal justice settings. Journal of Substance Abuse Treatment, 13(5): 421-428.

Argues that because drug use treatment results in substantial declines in the use of heroin, cocaine, and other drugs, treatment per se can play a significant role in reducing the spread of HIV among those coming to the attention of the criminal justice system. Most promising are continuous and integrated treatment services that are tied to the stages of correctional supervision; primary treatment while incarcerated; secondary treatment while on work release, halfway house or community supervision; and tertiary treatment in ongoing aftercare.

Inciardi J et al (1997). An effective model of prison-based treatment for drug-involved offenders. Journal of Drug Issues, 27(2): 261-278.

A multistage therapeutic community treatment system has been instituted in the Delaware correctional system and its effectiveness has captured the attention of the National Institute of Health, the Department of Justice, members of Congress and the White House. Treatment occurs in a three-stage system, with each phase corresponding to the client's changing correctional status-incarceration, work release and parole. In this paper, 18 months follow-up data are analyzed for those who receive treatment in: 1) a prison-based therapeutic community only; 2) a work release therapeutic community followed after by aftercare; and 3) the prison-based therapeutic community followed by the work release therapeutic community and aftercare. These groups are compared with a no-treatment group. Those receiving treatment in the two-stage (work release and aftercare) and three-stage (prison, work release and aftercare) models had significantly lower rates of drug relapse and criminal recidivism, even when adjusted for other risk factors. The study concludes that the results support the effectiveness of a multistage therapeutic community model for drug-involved offenders and the importance of a work release transitional therapeutic community as a component of this model.

Johnson PT et al. (2004). Treatment need and utilization among young entering the juvenile correction center. Journal of Substance Abuse Treatment, 26(2): 117-122.

For a summary, see the section "Special Populations: Youth."

Johnson H (2004). Drugs and Crime: A Study of Incarcerated Female Offenders. Canberra: Australian Institute of Criminology (Research and public policy series, no. 63).

Knight K, Hillier ML, Simpson DD (1999). Journal of Psychoactive Drugs, 31(3): 299-304.

Points out that although three key evaluations have provided support for the effectiveness of drug treatment within the criminal justice system, direct comparisons of outcomes across these evaluations are limited by variations in their measurement systems and the structure of official records on which they are based. The article addresses some of the issues relating to the assessment of treatment outcomes for drug-using offenders and provides recommendations for future research.

Knight K, Simpson DD, Hiller ML (1999). Three-year reincarceration outcomes for in-prison therapeutic community treatment in texas. Prison Journal, 79(3): 337-351.

This study examined reincarceration records for 394 non-violent offenders during three years following prison. Those who completed both ITC and aftercare were the least likely to be reincarcerated (25 percent), compared to 64 percent of the aftercare dropouts and 42 percent of the untreated comparison groups. The findings support the effectiveness of intensive treatment when it is integrated with aftercare.

Langan PN, Bernadette M, Pelissier M (2001). Gender differences among prisoners in drug treatment. Journal of Substance Abuse, 13(3): 291-301.

This study found support for the argument that substance abuse treatment programs which were originally designed for men may be inappropriate for the treatment of women.

Leukefeld C, Tims F (eds). Drug Abuse Treatment in Prisons and Jails, NIDA Research Monograph 118. Rockville: Maryland.

Lipton DS (1995). The Effectiveness of Treatment for Drug Abusers under Criminal Justice Supervision. Washington: DC, National Institute of Justice Research Report.

Pallone JN (ed) (2003). Treating Substance Abusers in Correctional Contexts: New Understandings, New Modalities. Center of Alcohol Studies, Rutgers-New Jersey, New Brunswick. Haworth press.

This book presents an overview of new and emerging models for treatment of drug-involved offenders in a variety of settings. A chapter entitled "Treating Substance Abusers in Correctional Contexts" looks at treatment modalities available to offenders inside and outside correctional institutions, with community organizations and mental health and social service agencies enlisted in a continuum of care as the courts and criminal justice system provide oversight-and often, funding. The book explores types of treatment that operate under the surveillance of courts and the criminal justice system, ranging from in-house programs for offenders under confinement in prisons and jails to residential substance abuse treatment and substance abuse treatment programs in the community. Through qualitative, exploratory, and descriptive studies, outcome assessments, event-history analysis, and intensive interviews, the book examines recovery relapse prevention, rehabilitation, diversion, therapeutic justice, and the impact of prison-based substance abuse treatment programs.

Palmer J (2003). Clinical Management and Treatment of Substance Misuse for Women in Prison. London: NHS, Central and North West London (Mental Health NHS Trust).

PDM Consulting Ltd (1998). Evaluation of prison drug treatment and rehabilitation services: executive report. London: HMPS.

Between 1995 and 1997, the UK Prison Service piloted 21 treatment programs in 19 prisons. These programs were evaluated by private consultants PDM. Their recommendations are managerial rather than clinical. They advocate improved coordination with the National Health Service, probation and social services and other agencies, and the continual improvement of existing treatment programs.

Pelissier BM et al. (2001). Federal prison residential drug treatment reduces substance use and arrests after release. American Journal of Alcohol and Drug Abuse, 27: 315-337.

This 19-site evaluation of prison-based residential drug treatment programs operated by the US Federal Bureau of Prisons found that after 6 months, 20% of program participants versus 36% of untreated prisoners had at least one positive urinalysis. Moreover, 3.1% treated compared with 15% untreated offenders were re-arrested on a new charge.

Pelissier BM et al. (2003). Gender differences in outcomes from prison-based residential treatment. J Subst Abuse Treatment, 24(2): 149-160.

This study examines gender similarities and differences in background characteristics, the effectiveness of treatment, and the predictors of post-release outcomes among incarcerated drug-using offenders. The sample of 1,842 male and 473 female treatment and comparison subjects came from a multi-site evaluation of prison-based substance abuse treatment programs. Three-year follow-up data for recidivism and post-release drug use were analyzed using survival analysis methods. Despite the greater number of life problems among women than men, women had lower three-year recidivism rates and rates of post-release drug use than did men. For both men and women, treated subjects had longer survival times than those who were not treated. There were both similarities and differences with respect to gender and the other predictors of the two post-release outcomes. Differences in background characteristics and in factors related to post-release outcomes for men and women suggest the plausibility of gender-specific paths in the recovery process.

Peters RH et al. (1997). Treatment of substance-abusing jail inmates. Examination of gender differences. Journal of Substance Abuse Treatment, 14(4): 339-349.

The study was designed to identify gender differences in psychosocial characteristics and substance use treatment needs among jail inmates. Results indicate that female inmates more frequently experienced employment problems, had lower incomes, more frequently reported cocaine as the primary drug of choice, and were more likely to report depression, anxiety, suicidal behavior, and a history of physical and sexual abuse. Implications for developing specialized treatment approaches for female offenders are discussed.

Porporino FJ et al. (2002). An outcome evaluation of prison-based treatment programming for substance abusers. Substance Use and Misuse, 37: 1047-1077.

This study of the Correctional Service of Canada substance abuse programs found that 16% of program participants (including drop-outs and other non-completers) were reconvicted following one year on release compared with 23% of a matched comparison group.

Prendergast LM, Hall AE, Wexler KH (2003). Multiple measures of outcome in assessing a prison-based drug treatment program. Treating Substance Abusers in Correctional Contexts: New Understandings, New Modalities. Journal of Offender Rehabilitation, 37(3/4): 65 - 94.

Evaluations of prison-based drug treatment programs typically focus on one or two dichotomous outcome variables related to recidivism. In contrast, this paper uses multiple measures of outcomes related to crime and drug use to examine the impact of prison treatment. Crime variables included self-report data of time to first illegal activity, arrest type, and number of months incarcerated. Days to first reincarceration and type of reincarceration are based on official records. Drug use variables included self-report data of the time to first use and drug testing results. Prisoners randomly assigned to treatment performed significantly better than controls on: days to first illegal activity, days to first incarceration, days to first use, type of reincarceration, and mean number of months incarcerated. No differences were found in type of first arrest or in drug test results. Subjects who completed both prison-based and community-based treatment performed significantly better than subjects who received lesser amounts of treatment on every measure. Survival analysis suggested that subjects were most vulnerable to recidivism in the 60 days after release. Although the overall results from the analyses presented support the effectiveness of prison-based treatment, conclusions about the effectiveness of a treatment program may vary depending on which outcomes are selected. The results of this study argue for including more than fewer outcomes in assessing the impact of prison-based substance abuse treatment.

Ramsay M (ed) (2003). Prisoners' drug use and treatment: seven research studies. Home Office Research Study 267. London: Home Office Research, Development and Statistics Directorate.

The report brings together seven studies, some of which review the effectiveness of treatment, both in the prisons of England and Wales and internationally. A major theme is the importance of aftercare: "Without good-quality aftercare, both in prison and on release, drug treatment is much less likely to be successful." Another key theme is for treatment to be geared to the needs of different kinds of prisoners, for instance in terms of gender and ethnicity.

Shewan D et al. (1994). Evaluation of the Saughton Drug Reduction Programme. Main Report. Central Research Unit: Edinburgh.

Shewan D et al. (1996). The impact of the Edinburgh Prison (Scotland) Drug Reduction Programme, Legal and criminological psychology, 1, 83-94.

Sims, B (2003). Substance Abuse Treatment with Correctional Clients Practical Implications for Institutional and Community Settings. Haworth Press.

Swartz JA, Lurigio AJ (1999). Final thoughts about IMPACT: a federally funded, jail-based, drug-user-treatment program. Substance Use and Misuse, 34(6): 887-906.

A federal demonstration project in the Cook County Jail, called IMPACT (Intensive Multiphased Program of Assessment and Comprehensive Treatment), provided residential drug-user treatment to more than 3,000 prisoners during its 5 years of operation between January 1991 and October 1995. In that time, much was learned about initiating and conducting a complex, intensive, longer-term drug-user-treatment program in a jail setting. This article describes IMPACT and summarizes the results of a process and an outcome evaluation of the program and a series of focus groups. Based on these studies, the authors recommend ways to improve the design and implementation of drug-user treatment programs in jails.

The National Center on Addiction and Substance Abuse (1998). Behind Bars: Substance Abuse and America's Prison Population. New York: Columbia University.

Trace M (1998). Tackling drug use in prison: a success story. International Journal of Drug Policy, 9: 277-282.

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.

Turnbull PJ, McSweeney T (2000). Drug Misuse in Offenders in Prison and after Release. Council of Europe.

Sets out the findings from a survey on drug treatment and aftercare provided by prisons as well as the results of a literature review.

Walters G et al. (1992). The Choice Programme: a comprehensive residential treatment programme for drug-involved federal offenders. International Journal of Offender Therapy and Comparitive Criminology, 36(1): 21-29.

Wexler H, Falkin G, Lipton D (1990). Outcome evaluation of a prison therapeutic community for substance abuse treatment. Criminal Justice and Behaviour, 17(1): 71-92.

This is the first large-scale study that provides evidence that prison-based TC treatment can produce significant reduction in recidivism rates for males and females.

Drug Supply Reduction Measures

"Drug-Free Units"

Brandewiede P (1995). Drug free departments in penal institutions in Hamburg. Drug Out in Prison: Measures Against Drug Abuse in Penal Institutions, 49-52.

Says that drug free departments in Hamburg's prisons have proved positive as a treatment for several addicted persons.

Breteler M et al, (1996). Enrollment in a drug-free detention program: the prediction of successful behaviour change of drug-using inmates. Addictive Behaviors, 21(5): 665-669.

Factors predicting the behaviour change of drug-using detainees were investigated in detainees in two penitentiaries in The Netherlands. Subjects attended either a standard program or a Drug-Free Detention Program and were assessed at the beginning of detention, at release/transfer and at two years after the end of detention. Predictors of post-program contact with treatment agencies and changes in criminal recidivism, substance abuse and psychosocial functioning were investigated using regression analysis.

Incorvaia D, Kirby N (1997). A formative evaluation of a drug-free unit in a correctional services setting. International Journal of Offender Therapy and Comparative Criminology, 41(3): 231-249.

Provides evidence from Australia that the establishment of drug free wings makes a significant difference to reducing the use of drugs in prison.

Jonson U (1995). Models of drug-free departments in Swedish prisons. Drug Out in Prison: Measures Against Drug Abuse in Penal Institutions, 43-47.

Argues that each prison with a drug free department must develop a drug policy of its own, which clearly defined rules, principles and structures. Says that to maintain the behaviour changes it is necessary that the drug user receive support from the social environment after release from prison.

Schippers GM et al. (1998). Effectiveness of a drug-free detention treatment program in a Dutch prison. Substance Use & Misuse, 33(4): 1027-1046.

In a Rotterdam jail information was gathered from 86 male prisoners who volunteered to enter the drug-free detention program, and 42 from other wings. After 1 year the drug-free detention group more actively searched and accepted treatment. No differences were found in drug use, recidivism, or physical, social, and psychological problems.

Van den Hurk A (1995). Drug free units in Dutch prisons: an interesting challenge. In: Drug Out in Prisons: Measures against Drug Abuse in Penal Institutions, 37-41.

Evaluation of two drug free units (DFUs) has shown that DFUs have a less hostile atmosphere and more open communication, among prisoners as well as with the staff. In comparison with regular regimes in prison DFUs offer better protection from drugs and DFUs offer significantly more continuity of care after release. However, after two years follow-up no differences between DFU-inmates and regular inmates regarding several drug-related life styles could be demonstrated.

Urinalysis

Berger A (1995). Welcome to cell block heroin. New Scientist 1995; 21 October: 14-15.

Argues that compulsory drug testing may have several unwanted effects in the prisons. Cannabis users may convert to using hard drugs to decrease the chance of detection by drug tests. As a result prisoners may increase their risk of exposure to HIV through intravenous injections. In addition, mandatory drug testing may interfere with HIV and drug abuse research being done within the prisons.

Bird AG et al (1997). Harm reduction measures and injecting inside prison versus mandatory drugs testing: results of a cross sectional anonymous questionnaire survey. British Medical Journal, 315(7099): 21-24.

The objectives were to determine both the frequency of injecting inside prison and use of sterilizing tablets to clean needles in the previous four weeks; to assess the efficiency of random drug testing at detecting prisoners who inject heroin inside prison; to determine the percentages of prisoners who had been offered vaccination against hepatitis B at Lowmoss prison, Glasgow, and Aberdeen prison on 11 and 30 October 1996. 293 (94%) of all 312 inmates at Lowmoss and 146 (93%) of all 157 at Aberdeen completed the questionnaire, resulting in 286 and 143 valid questionnaires. The main outcome measure was the frequency of injecting inside

prison in the previous four weeks by injector inmates who had been in prison for at least four weeks. 116 (41%) Lowmoss and 53 (37%) Aberdeen prisoners had a history of injecting drug use. 42 Lowmoss prisoners (estimated 207 injections and 257 uses of sterile tablets) and 31 Aberdeen prisoners (229 injections, 221 uses) had injected inside prison in the previous four weeks.

The authors stated: "The combined data showed that 51% (57/112) of injectors who had been in prison for more than four weeks had injected in the past four weeks while inside. Their mean number of injections was 6.0 (SD 5.7). If we assume that the substance injected remained in the urine for three days (as occurs with heroin), then these prisoners would be liable to have a positive result in random mandatory drugs tests on a maximum of 18 days out of 28. If, however, random mandatory drugs testing did not operate at weekends, as in England and Wales, and prisoners could organise their injecting accordingly (for Friday evenings and one Tuesday and one Wednesday evening, say), then they may test positive on many fewer days-for example, on (4 Mondays + (Wednesday + Thursday + Friday) + (Thursday + Friday))=9 days out of 28. On these assumptions we would expect only two thirds to one third of prisoners who are injecting heroin inside prison to test positive in random mandatory drugs tests."

They concluded that "random mandatory drugs testing is therefore likely seriously to underestimate prisoners' injection related drug use problems. Underestimation will entail underresourcing of these and other prisons in respect of the healthcare and drug reduction needs of their injector inmates."

Chadwick T (1996). Jail drug tests encourage prisoners to switch to heroin. Drug Forum Focus, 12: 4-6.

This article looks at problems arising as a result of mandatory drug testing, particularly the switch from cannabis to less detectable opiates. It says that one significant problem that has come about is that if a prisoner tests positive for opiates, a distinction cannot be made between legitimate use of painkillers and illegal heroin use. Painkillers may be used to mask illegal heroin use. One in every four prisoners with positive opiate test results has used painkillers as a defence against charges of illegal drug use.

Edgar K, O'Donnell I. (1998). Mandatory Drug Testing in Prisons: The Relationship Between MDT and the Level and Nature of Drug Misuse (Home Office Research Study 189). London, Home Office.

Fraser AD et al. (2001). Experience with urine drug testing by the Correctional Service of Canada. Forensic Science International 121(1-2): 16-22.

The paper describes the urine drug-screening program implemented by the Correctional Service of Canada, as well as drug test results in this program for 1999. See also MacPherson, 2001, MacPherson, 2004, and Kendall & Pearce, 2000, infra.

Fraser AD, Zamecnik J (2002). Substance abuse monitoring by the Correctional Service of Canada. J Am Acad Psychiatry Law, 30(4): 513-519.

The Correctional Service of Canada implemented a urine drug-testing program over a decade ago. Offenders residing in federal correctional institutions and living in the community on conditional release were subject to urine drug testing. The objective of this study is to describe this testing program and the extent of drug use by conditional release offenders in 2000. Total number of urine specimens analyzed in 2000 was 38,431 (6.7% were dilute). The positive rate for one or more drugs was 27.2% in 2000 in conditional release offenders. In the community setting 28,076 normally concentrated (nondilute) specimens were tested (9.6% were positive for cannabinoids and 3.3% positive for cocaine metabolite). In the 1,270 dilute specimens collected from conditional release offenders in 2000, 12.8% were positive for cannabinoids and 10.6% were positive for cocaine metabolite. The authors conclude that forensic urine drug testing provides an objective measure of drug use when assessing offenders living in the community on conditional release from correctional institutions in Canada.

Gore S, Bird A (1995). Mandatory drug tests in prison (letter). British Medical Journal, 310: 595.

A letter to the editor argues that "the current disjointed policy - mandatory drug tests and the home secretary's long deferred decision on harm reduction measures versus the inspectorate's clinical model of drug reduction and the willing anonymous testing HIV surveillance funded by the Department of Health - poses unacceptable risks to prisoners' health and public health.These risks are of hepatitis B, which is of long standing; of hepatitis C, which is unquantified; and of HIV infection, which is undocumented in England. Action regarding health care in prisons will follow only the collection of valid scientific data establishing the scale and seriousness of problems."

Gore S, Bird A (1996). Cost implications of random mandatory drug tests in prison. The Lancet, 348: 1124-1127.

Random and compulsory urine testing of prisoners for drugs was introduced in 1995 as a control initiative in eight prisons across England and Wales. Despite the absence of evidence of its effectiveness, testing was extended to all prisons in England and Wales by March 1996. The present study examines the cost of testing and suggests alternative ways in which this expenditure may be better utilized. The costs of refusals, confirmatory tests and punishment of confirmed positive tests were combined to arrive at the average costs of random compulsory drug testing. These costs were then compared to the healthcare budget for a prison and the cost of implementing a credible prisons' drug reduction program. The costs, estimated at between £22,800 and £16,000 over 28 days, turn out to be equivalent to twice the cost of running a credible drugs reduction and habitation program, and around half the total healthcare expenditure for a prison of 550 inmates. In addition, given that in Scotland around 5% of IDUs are incarcerated at any one time, these findings suggest that 5% of current resources for drugs prevention and treatment, and IDU targeted HIV/AIDS prevention, should be directed towards the prisons since 5% of the inmates are at any one time IDUs.

Gore S, Bird A, Ross A (1996). Mandatory drug tests and performance indicators for prisons. British Medical Journal, 312: 1411-1413.

This article starts by saying: "A mandatory drug testing of prisoners applies throughout England and Wales. Data from the 1995 pilot study in eight prisons show that the proportion testing positive for opiates or benzodiazepines rose from 4.1% to 7.4% between the first and the second phase of random testing and that there was a 20% increase over 1993-4 in the provisional total of assaults for 1995. Interpretation of these data is difficult, but this is no excuse for prevarication over the danger that this policy may induce inmates to switch from cannabis (which has a negligible public health risk) to injectable class A drugs (a serious public health risk) in prison. The performance indicators for misuse of drugs that are based on the random mandatory testing programme lack relevant covariate information about the individuals tested and are not reliable or timely for individual prisons."

Gore SM, Bird AG, Cassidy J (1999). Prisoners' views about the drugs problem in prisons, and the new Prison Service Drug Strategy. Commun Dis Public Health, 2(3): 196-197.

375 out of 575 prisoners (222/299 drug users and 153/267 non-users) who responded to a self-completion health care questionnaire at two prisons in 1997 commented on drugs in prisons. 148 out of 176 responses expressed negative opinions about mandatory drugs testing, and 107 said that MDT promoted switching to or increased use of heroin/hard drugs. 62 suggested that more help/counselling was needed for drug users, 52 segregation of drug users/drug-free wings, and 50 more security on visits/in corridors after medication.

Hughes R. (2000). Drug injectors and prison mandatory drug testing. Howard Journal Of Criminal Justice, 39(1): 1-13.

Drawing on qualitative research carried out with male and female drug injectors this article considers their views and experiences of MDT. Five broad themes arose from the analysis of these data. These themes include people's experiences of the test, their strategies to evade drug detection, punishments for testing positive, the effect of MDT on patterns of drug use, and the notions of power and risk in relation to MDT. The article concludes with a discussion on the worth of this policy.

Kadehjian L (1995). Drug testing in the US correctional systems. Drug Out in Prison: Measures against Drug Abuse in Penal Institutions, 15-18.

Argues that "urine drug testing has proven itself to be an invaluable tool in addressing the problems of drug use. Only by accurately identifying drug users, can a society address their healthcare, social, and criminal problems and have effective treatment programs. There are many myths about testing, but the scientific facts prove its accuracy and reliability when properly performed, and accordingly has been accepted by scientists and courts alike. Testing technology, especially EMIT method, has advanced to the point where on-site testing outside of a formal laboratory can meet necessary scientific and legal standards of accuracy. New methods are being developed, such as hair and sweat testing, but much work remains before these methods are widely accepted by the scientific and legal communities."

Kendall P, Pearce M (2000). Drug testing in Canadian jails: to what end? Canadian Journal of Public Health, 91(1): 26-28.

The authors analyzed the data from the urinalysis program of the Correctional Service of Canada, whose stated purpose is to reduce substance use in federal prisons in Canada. On the basis of their analysis, they concluded that it is highly questionable whether the program has reduced drug use: "Our own view is that the urinalysis program has failed to meet the test of reducing drug use ... Although the feared shift in use from slowly excreted drugs like marijuana, with little public health risk, to rapidly excreted drugs like cocaine and heroin, with serious public health risks, is not evidenced by the results reported here, the potential to encourage harms through a switch to more dangerous drug use still exists. Given this continuing risk and the absence of evidence of benefit, we recommend that CSC halt routine random urinalysis and instead reallocate the $2 million spent on annual testing... to enhanced addiction information and treatment programs. In addition, CSC should reconsider its current ban on needle exchange programs..."

MacDonald M (1997). Mandatory Drug Testing in Prisons. Centre for Research into Quality, The University of Central England in Birmingham.

www.uce.ac.uk/crq/publications/mdt.pdf.

This report contains the results of a research project which assessed the policy implications of the Mandatory Drug Testing (MDT) program, as part of the Home Office's commitment to the reduction and supply of drugs within prisons in England and Wales.

To provide an evaluation of the effectiveness of current Home Office policy at one large local prison the research explored the perceptions of both prison staff and prisoners. Quantitative data was derived from a questionnaire distributed to staff and qualitative elaboration of the outcomes was obtained through in-depth interviews with staff and focus groups with prisoners. 109 staff responded to the questionnaire, 28 staff were interviewed in depth and a total of 89 prisoners were involved in focus groups.

A majority of officers thought that MDT would reduce drug use a little but that it would have very little impact on heavy users of 'hard' drugs. Prisoners did not think that MDT would act as a deterrent, and, furthermore, it is likely to increase anger, frustration and tension. About a third of the prison staff thought there would be change from 'soft' to 'hard' drug use. Many indicated that there is already a noticeable shift from 'soft' to 'hard' drug usage, not least because of the prevalent view that 'hard' drugs were less easily detectable than cannabis: a view to which the prisoners concurred.

Half the prison staff thought that MDT would lead to more use being made of drug-treatment programs but three quarters thought that prisoners are requesting a place on a drug treatment program because of positive drug-testing results rather than a genuine desire for help with their drug-related problems.

Many staff and prisoners were of the view that drug-testing has been introduced without linking it into any planned drug-treatment program. Some of the prison staff were of the opinion that the lack of drug-treatment initiatives were due to under-resourcing.

For many of the participants in the research, reducing the demand for drugs and restricting supply was seen as far more important than drug testing. However, few respondents thought that any of the available measures were likely to be very effective at reducing drug use in prison. Medical examination on admission to prison to identify current drug users and the promotion of a multidisciplinary approach, via training and education of prison staff, to combat drug usage were seen as the most effective measures.

The study concluded that MDT was established in an attempt to reduce the amount of drug use in prison. "Resources and effort have, as predicted been focused on testing and restricting supply and little has been done in relation to follow-up. With a lack of adequate counselling facilities, the program provides no real attempt to address drug use in prison, indeed it simply adds to tension by randomly penalising people for using drugs - notably cannabis - to an extent that goes well beyond any sanction that would be applied for the same offence outside prison. Overcrowding and underfunding stops any effective treatment and worsens the environment, reducing the opportunity for prisoners to do constructive activity. Prisoners consistently argue that drug-taking is directly linked to inactivity. In summary, the MDT process is counterproductive. It deflects attention from the real issue of the purposes and funding of the prison system. Drug testing also deflects attention from other crucial areas like the spread of HIV and AIDS in prison. MDT increases tension in prisons, appears to be encouraging a shift from 'soft' to 'hard' drugs, is adding to the workload of an already overburdened staff, is costing a lot of money that could be better spent and is failing to provide adequate treatment and follow-up procedures. It is, thus, primarily an indiscriminate punitive regime that is adding to the overcrowding in British prisons by effectively adding extra weeks to prisoners sentences. Indeed, the introduction of MDT was heavy handed, resulting in many prisoners having days added to their sentences, that the process has had to be radically modified. This has led to a fundamental questioning of the feasibility, practicality and relevance of MDT."

MacPherson P (2001). Random urinalysis program: policy, practice, and research results. Forum on Corrections Research, 13: 54-57.

This paper describes some of the results from the random component of urinalysis testing conducted by Correctional Service Canada. As of July 1996, 5% of offenders in custody are randomly selected for urinalysis each month. The data analyzed in the paper included all tests requested under the random urinalysis program at each federal institution in Canada from July 1996 to March 2000. The total number of tests requested during this time period was 24,766. The national positive rate for all drugs has shown a slight increase from 11% in 1996 to 12% in 2000. However, the percent of offenders refusing to submit a sample for random urinalysis has increased significantly, from 9% to 14%. The paper says that no evidence of changing drug use patterns could be found, since there was no increase in the percentage of samples testing positive for opiates or cocaine over the testing period. See also Kendall & Pearce, 2000, supra.

MacPherson P (2001). Use of Random Urinalysis to Deter Drug Use in Prison: A Review of the Issues. Ottawa: Addictions Research Branch, Correctional Service of Canada (2004 No R-149).

www.csc-scc.gc.ca/text/rsrch/reports/r149/r149_e.shtml

The report outlines the major issues associated with urine testing, and provides background information on the rationale for implementing a program of random testing in prisons. Future research reports will examine issues such as the impact of non-random request distribution on random urinalysis outcome, trends in urinalysis results, and the consequences of testing positive and refusing to provide. The report acknowledges that urinalysis has its limitations, and that results of urine tests must be interpreted with caution "due to the myriad of possible factors that could influence the results. In addition to the technical challenges in interpretation of results, such as variability in clearance rates of drugs of abuse, differences in individual physiology, and cross-reactivity in urinalysis screening procedures, there are operational factors such as discernable patterns in sample collection that could potentially influence the accuracy of the results. These can pose serious challenges to effective implementation of a program of random urine testing."

Riley D (1995). Drug testing in prisons. The International Journal of Drug Policy, 6(2): 106-111.

Singleton N et al. (2005). The impact of mandatory drug testing in prisons. UK: Home Office Online Report 03/05.

The full report is available via http://nicic.org/Library/020248. A shorter, 4-page version entitled " The impact and effectiveness of mandatory drug testing in prisons" is available via www.homeoffice.gov.uk/rds/rfpubs1.html (paper no 223).

A comprehensive study on the impact of mandatory drug testing in prisons. It starts by saying that "previous research has cast some doubt on the extent to which random mandatory drug testing (RMDT) provides a reliable measure of drug use. It has also been suggested that the perceived greater likelihood of detection of cannabis (with metabolites detectable for ten days or more in the case of heavy use) may result in some prisoners deciding to use drugs which have a relatively brief period of detection (heroin in particular)." 39% of prisoners had used some illicit drug at some time in their current prison, but only one percent of prisoners reported having injected in the current prison. The study reported that overall RMDT positivity rates have declined since 1997, which is largely due to a decline in cannabis positivity while opiate use has remained apparently unchanged. It concluded that RMDT underestimates the overall prevalence of use; that the MDT program appears to be actively discouraging drug use, particularly cannabis use; that MDT in combination with other security and control strategies has had a substantial impact on cannabis supply and use within prisons, but has had less impact on heroin use. It points out that "many factors, other than MDT, are linked with prisoners' use of drugs, such as peer pressure, changes in treatment, boredom, availability of drugs, repeated imprisonment and the inappropriateness of stimulants in a custodial setting." One percent of all prisoners were identified who said that they had changed from cannabis to heroin. A larger group (5% of all prisoners) had used heroin in their current prison but not in the month before custody. This group gave ease of availability and need as the main reasons for taking us heroin. However, 16% of them said that the fact that heroin was less easily identified was a factor. It suggests that given the different status of cannabis and opiates outside prison and the different levels of harm associated with their use, the practice of making no distinction in punitive terms between those testing positive to cannabis and opiates should be reviewed.

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

Available via www.ccsa.ca.

Contains a good, brief summary of issues related to the effectiveness of prison-based urinalysis programs in reducing offender drug use, saying that examinations of such programs paint "an inconclusive picture with respect to effectiveness of mandatory drug testing in genuinely reducing the rate of drug use among incarcerated offenders and those on release."

HIV Testing and Counselling

Counselling and testing are an important part of an HIV prevention program. At the same time, they are a pre-requisite for access to care, treatment, and support for people testing HIV-positive.

Amankwaa AA, Amankwaa LC, Ochie CO Sr (1999). Revisiting the debate of voluntary versus mandatory HIV/AIDS testing in U.S. prisons. J Health Hum Serv Adm, 22(2): 220-236.

This article presents arguments and issues related to testing inmates. It argues that mandatory testing is an important adjunct to minimizing the impact of the spread of the virus both within prison and in the non-offender population. This is contrary to WHO and UNAIDS guidelines. See also Jürgens, 2001, infra.

Andrus JK et al. (1989). HIV testing in prisoners: is mandatory testing mandatory? Am J Public Health, 79(7): 840-842.

Andrus et al studied 977 newly incarcerated Oregon inmates to compare voluntary versus mandatory HIV testing in the prison setting. All inmates were offered HIVcounseling and testing. Blood drawn for routine syphilis serology from those who declined this offer was also tested for HIVafter personal identifiers had been removed. 1.2% (12) prisoners were HIV positive. However, 62.5 percent (611) inmates were considered at risk for HIV infection by being an intravenous drug user, a male homosexual, or hepatitis B core antibody (HBcAb) positive. The ratio of at-risk, as yet uninfected inmates to those already HIV infected was 53 to 1. Two-thirds of all inmates including those at-risk chose to receive counseling and testing. The study concluded that "in areas where most at-risk inmates are not yet infected, it may be more appropriate for HIV prevention activities in prison to focus on voluntary programs that emphasize education and counseling rather than mandatory programs that emphasize testing."

Beauchemin J, Labadie JF (1997). Évaluation de l'utilité et de l'accessibilité des services de counselling et de dépistage du VIH en milieu carcéral - Services offerts par le CLSC Ahuntsic à la Maison Tanguay et à l'Établissement de détention de Montréal. Rapport final: août 1997. Montréal: Direction de la santé publique de Montréal-Centre and CLSC Ahuntsic.

This report on the evaluation of the counseling and testing services offered in two provincial prisons in Montréal - a prison for men and a prison for women - concludes that "maintaining, even improving, access to HIV testing and counselling services is justified ... in all provincial correctional establishments." In the two prisons studied, testing and counseling services were offered by a local public health clinic rather than the prison health service. The evaluation showed that the services reached a clientele at high risk of HIV infection and that many of the clients reached had not used counseling and testing services on the outside. The report suggests ways to further improve testing and counseling services in prisons.

Behrendt C et al. (1994). Voluntary testing for human immunodeficiency testing (HIV) in prison population with a high prevalence of HIV. Am J Epidemiol, 139(9): 918-926.

This study evaluated voluntary testing for HIV in a prison population with a high HIV seroprevalence. Data on demographic variables and participation in voluntary testing were linked to a blinded HIV serosurvey of consecutive Maryland prison entrants (April-July 1991). Among 2,842 entrants, HIV seroprevalence was 8.5% (men, 7.9%; women, 15.3%). Voluntary testing was accepted by 47% of the entrants, and it identified 34% of the HIV-seropositive prisoners detected by serosurvey. Refusers of testing were more likely to test HIV positive than were accepters (adjusted odds ratio (OR) = 1.84, 95% confidence interval (CI) 1.58-2.16). Among 100 entrants asked why they refused testing, primary reasons given included low risk of HIV, fear of testing HIV-seropositive, and lack of interest. The authors conclude that voluntary testing appears only moderately successful in identifying HIV-seropositive inmates in a high seroprevalence prison population. However, the alternative, mandatory HIV testing of prisoners, can be construed as discriminatory and unethical when similar screening is not imposed on the population at large. Data presented here suggest strategies to improve acceptance of voluntary testing, especially by high-risk prisoners.

Burchell AN et al. (2003). Voluntary HIV testing among inmates: sociodemographic, behavioral risk, and attitudinal correlates. J Acquir Immune Defic Syndr, 32(5):534-541.

The authors sought to determine the prevalence and correlates of self-reported HIV testing among prisoners in correctional centers in Ontario, Canada. A cross-sectional survey was conducted with a stratified random sample of 597 male and female adult inmates. The participation rate was 89%. 58% had ever been tested, and 21% had voluntarily tested while incarcerated in the past year. The predominant motivations for testing while incarcerated were injection drug use or fear of infection inside, possibly through contact with blood, during fights, or even by casual contact. The authors concluded that voluntary HIV testing in prison should be encouraged, and that prisoners should receive appropriate counseling and information to allow realistic assessment of risk.

Cotten-Oldenburg NU et al. (1999). Voluntary HIV testing in prison: do women inmates at high risk for HIV accept HIV testing? AIDS Education and Prevention, 11(1): 28-37.

This study examined the proportion of women inmates who accepted HIV testing and the sociodemographic, criminal, and HIV-related risk characteristics associated with accepting such testing in a state prison offering voluntary HIV testing. A consecutive sample of 805 women felons admitted to the North Carolina Correctional Institution for Women between July 1991 and November 1992 was interviewed. 71% of the women accepted HIV testing. The authors concluded that a prison-based voluntary HIV testing program appears to be reaching a substantial proportion of women prisoners potentially at risk for HIV.

Curran L, McHugh M, Nooney K. (1989) HIV counselling in prisons. Counselling Psychology Quarterly, 2(1), 33-51.

Desai AA et al. (2002). The importance of routine HIV testing in the incarcerated population: The Rhode Island experience. AIDS Education and Prevention, 14(5 Suppl: HIV/AIDS in Correctional Settings): 45-52.

Routine HIV testing in the correctional setting offered to all inmates at entry has played an important role in the diagnosis of HIV in Rhode Island. Diagnosis and treatment of HIV in prisons can further public health goals of HIV control, prevention, and education. Routine HIV testing can be incorporated into primary and secondary prevention programs in correctional facilities. In Rhode Island, where HIV testing is routine at entry into the correctional facility, approximately one third of all persons who test positive are identified in the correctional facility. The proportion of males and females testing positive in the correctional facility versus those testing positive in other facilities has shown a gradual decrease, with positive female HIV tests declining more substantially in recent years. Specific groups, such as males, African Americans, and injection drug users continue to be more likely diagnosed in the state correctional facility than in other testing sites. These differences may reflect barriers to health care access that other community initiatives have failed to address.

Grinstead O et al. (2003). HIV and STD testing in prisons: perspectives of in-prison service providers. AIDS Education and Prevention, 15(6): 547-560.

72 service providers working in US prisons were interviewed about their experiences with and perceptions regarding HIV and STD testing in prison. Suggestions are made about how to improve testing services.

Hoxie N et al. (1990). HIV seroprevalence and the acceptance of voluntary HIV testing among newly incarcerated male prison inmates in Wisconsin. American Journal of Public Health, 80(9): 1129-1131.

In 1986-88, voluntary and blinded HIV testing was conducted among Wisconsin male prison entrants. The HIV seroprevalence was 0.30 percent in 1986, 0.53 percent in 1987, and 0.56 percent in 1988. The seroprevalence rates among entrants tested voluntarily did not differ from those tested blindly. Voluntary HIV testing was accepted by 71 percent of male prison entrants in 1988; among entrants reporting intravenous drug use 83 percent consented to voluntary HIV testing. Voluntary HIV testing of entrants appears to be an effective screening strategy in Wisconsin prisons.

Hughes R (2002). 'Getting checked and having the test': drug injectors' perceptions of HIV testing - findings from qualitative research conducted in England. Eur Addict Res, 8(2): 94-102.

This paper is based on a study that used in-depth interviews with drug injectors to explore drug injectors' perceptions of HIV risk outside and inside prison. HIV testing was an integral part of drug injectors' perceptions of risk. Three main themes emerged from the analysis of these data: first, reasons for not taking a test; second, reasons for taking a test; and third, the impact of testing upon subsequent behaviour. The paper ends with a summary and conclusions highlighting implications for future research and policy development.

Jürgens R, Gilmore N (1995). Prison, sida et divulgation de renseignements médicaux. Criminologie 1995; 28(1) [paper in French].

A legal and ethical analysis of claims that medical information pertaining to HIV-infected prisoners should be divulged to prison staff.

Jürgens R (2001). HIV testing of prisoners. In: HIV Testing and Confidentiality: Final Report. Montreal: Canadian HIV/AIDS Legal Network (2^nd edition).

www.aidslaw.ca/Maincontent/issues/testing/07
mandate1.html#HIV%20Testing%20of%20Prisoners

A comprehensive assessment of the issues surrounding HIV testing for prisoners, concluding that there is "no public health or security justification for compulsory or mandatory HIV testing of prisoners... Rather, prisoners ... should be encouraged to voluntarily test for HIV, with their informed, specific consent, with pre-and post-test counselling, and with assurance of the confidentiality of test results."

Ramratnam B et al. (1997). Former prisoners' views on mandatory HIV testing during incarceration. Journal of Correctional Health Care, 4: 155-164.

In Rhode Island, US, intake nurses routinely encourage all new committed persons to accept HIV testing, but it is not mandatory until after conviction. More than 90% of prisoners agree to routine testing on entry. Post-discharge surveys have shown that, in retrospect, 78% of former prisoners welcomed the opportunity to receive testing when that testing was part of a comprehensive HIV management program.

Sabin KM et al. (2001). Characteristics and trends of newly identified HIV infections among incarcerated populations: CDC HIV voluntary counseling, testing, and referral system, 1992-1998. Journal of Urban Health, 78: 241-255.

The authors report on publicly funded HIV voluntary counseling, testing, and referral (VCTR) services provided to incarcerated persons in the United States. The use of VCTR services by incarcerated persons rose steadily from 1992 to 1998, and 56% of HIV+ tests were newly identified. High numbers of tests that recorded risk behaviors for contracting HIV indicate that correctional facilities provide an important access point for prevention efforts.

Sanders Branham L (1988). Opening the bloodgates: the blood testing of prisoners for the AIDS virus. Connecticut Law Review, 20: 763-834.

The article discusses the legal questions concerning mandatory testing of prisoners for antibodies to HIV. It concludes that mandatory testing would violate prisoners' rights, has no rational justification, and presents a potent danger to prisoners' personal interests.

Turnbull PJ, Dolan K, Stimson G (1993). HIV testing, and the care and treatment of HIV positive people in English prisons. AIDS Care, 5(2): 199-206.

Varghese B, Peterman TA (2001). Cost-effectiveness of HIV counseling and testing in US prisons. Journal of Urban Health, 78: 304-312.

This study presents the cost-effectiveness of offering HIV counseling and testing (CT) to soon-to-be-released inmates in US prisons. A decision model was used to estimate the costs and benefits (averted HIV cases) of HIV testing and counseling compared to no CT from a societal perspective.

Care, Support, and Treatment for HIV and HCV

Care, Support, and Treatment for HIV

Altice FL, Mostashari F, Friedland GH (2001). Trust and the acceptance of and adherence to antiretroviral therapy. Journal of Acquired Immune Deficiency Syndrome, 28: 47-58.

Using a cross-sectional survey design within four ambulatory prison HIV clinics, 205 HIV-infected prisoners eligible for ART were recruited between March and October 1996. Detailed interviews were conducted that included personal characteristics, health status and beliefs, and validated standardized scales measuring depression, health locus of control, social desirability and trust in physician, medical institutions and society. Acceptance and adherence were documented by self-report and validated for a subset by pharmacy review. Clinical information was obtained from standardized chart review. Adherence was defined as having taken >=80% of ART. The acceptance of (80%) and adherence to (84%) ART among this group of prisoners was high. Multiple regression models demonstrated that correlates of acceptance of and adherence to ART differed. Acceptance was associated with trust in physician (8% increase for each unit increase with trust in physician scale) and trust in HIV medications (threefold reduction for those mistrustful of medication). Side effects (OR = 0.09), social isolation (OR = 0.08), and complexity of the antiretroviral regimen (OR = 0.33) were associated with decreased adherence. The prevalence of health beliefs suggesting an adverse relationship between ART and drugs of abuse was high (range 59 to 77%). Adherence did not differ among those receiving directly observed therapy (82%) or self-administration (85%). Altice et al concluded that ART can be successfully administered in a correctional setting.

Amankwaa AA, Bayon AL, Amankwaa LC (2001). Gaps between HIV/AIDS policies and treatment in correctional facilities. J Health Hum Serv Adm, 24(2): 171-198.

American College of Physicians, National Commission on Correctional Health Care, and American Correctional Health Services Association (1992). The Crisis in Correctional Health Care: The Impact of the National Drug Control Strategy on Correctional Health Services. Annals of Internal Medicine, 117(1): 72-77.

A joint position paper pointing out how existing problems in prisons in the US have been exacerbated by the "war on drugs." The paper recommends that the drug control strategy, with its emphasis on incarceration, be reconsidered; that correctional health-care budgets reflect the growing needs of the inmate population; that correctional health care be recognized as an integral part of the public health sector; that correctional care evolve from its present reactive "sick call" model into a proactive system that emphasizes early disease detection and treatment, health promotion, and disease prevention.

Anonymous (1999). Decrease in AIDS-related mortality in a state correctional system - New York, 1995-1998. Morbidity and Mortality Weekly Report, 47: 1115-1117.

The New York State Department of Corrections reported an AIDS-related death rate of 40,7 deaths per 10,00 prisoners in 1990; in 1998, the rate had decreased to 6,1 deaths per 10,000 prisoners.

Bobrik A et al. (2005). Prison health in Russia: the larger picture. Journal of Public Health Policy, 26: 30-59.

See also supra, under "HIV and HCV transmission."

Provides an overview of the health situation, including HIV/AIDS, in prisons in the Russian Federation, with the purpose of identifying the major public health problems in the criminal justice system of the Federation. Remarks that "for many inmates, imprisonment is one of a few opportunities to obtain the much needed health care and counseling. Concentration in the penitentiary system of individuals with mental disorders, alcoholism, drug addiction and infectious diseases creates a unique possibility for implementation of a wide range of effective public health interventions. Properly organized correctional health services can make a major contribution to society at large by offering medical care and health promotion, by detecting and curing a large number of TB and STI cases, by providing hepatitis B vaccination and HIV counseling, by linking inmates to community services after release, and by assisting in the process of community reintegration. The period of confinement should serve both the health of individual and society at large." Notes that at the time of writing only 2 to 3 percent of prisoners with HIV/AIDS (ie about 1,000) had indications for HAART (because the majority of PLWHA in Russian correctional facilities contracted HIV in 1998-2000). But in five years, about 70 percent (25,000) will be in need of HAART. Highlights that in implementing a sustainable HIV treatment program, special emphasis needs to be placed on the continuity of care for HIV-positive prisoners on their admission in and release from the correctional institutions.

Correctional Service Canada (2004). A health care needs assessment of federal inmates in Canada. Canadian Journal of Public Health, 95(suppl 1): S1-S63.

A comprehensive profile of the health needs of federal prisoners in Canada. The study begins with an overview of health services provided by Correctional Services Canada (CSC) and a description of the prisoner population, including sociodemographic indicators. Other sections address inmate mortality, physical health conditions, infectious diseases, and mental health issues. The final section provides a summary, the key findings, and some conclusions. The study found that prisoners have consistently poorer health status when compared with the general Canadian population, regardless of the indicator chosen. With respect to infectious diseases, the study found that prisoners are more than twice as likely to have been infected with HBV, more than 20 times more likely to have been infected with HCV, more than 10 times more likely to have been infected with HIV, and much more likely to be infected with TB.

The study points out that health services in the CSC have traditionally been "individual care-based and therefore reactive," and that a "much greater population health focus is required." It acknowledges that the range of public health services that exist in Canadian communities is underdeveloped in prisons, and that there is a need for a public health infrastructure to fulfill the core functions of public health services within prisons - ie, to assess the health status of prisoners; have an effective surveillance system for infectious and chronic diseases; fulfill the CSC Health Services' mandate in health promotion; have coordinated actions to prevent diseases and injuries; protect the health of prisoners; and evaluate the effectiveness, accessibility, and quality of health services. The study continues by saying that a "functioning prison public health system is required to ensure the appropriate management and control of infectious diseases. CSC has a distinct interest in ensuring the prevention of transmission among inmates and from inmates to prison staff. Canadians have a vested interest in ensuring that the pool of individuals infected with HIV, HCV, TB, and STDs is not amplified through the country's prison system." It concludes by pointing out that prisoners "have the same right to health services as other Canadians," and that prisoners "come from the community and return to the community." Therefore, "addressing their health needs will contribute to the inmate's rehabilitation and successful reintegration into the community."

De Groot AS, Hammett TM, Scheib RG. Barriers to care of HIV-infected inmates: a public health concern. The AIDS Reader May/June 1996: 78-87.

Concludes that limitations on access to HIV services would likely lead to higher public health-care expenditures overall and enhance the growth of the HIV epidemic.

De Groot AS, Jackson EH, Stubblefield S (2000). Clinical Trials in Correctional Settings: Proceedings of a conference held in Providence, RI, Oct 14-15 1999. Rhode Island Journal of Medicine, 83 (12): 376-379.

De Groot AS et al. (2001). HIV Clinical Trials in Correctional Settings: Right or Retrogression? AIDS Reader, 11(1): 34-40.

Demoures B, Nkodo-Nkodo E, Mbam-Mbam L (1998). [Primary health care in a prison environment, the Cameroon experience (article in French)]. Santé, 8(3): 212-216.

Some non-governmental organizations are taking action to improve health care conditions in prisons. This article describes such a project, conducted in the town of Ngaoundere, Adamaoua Province, Cameroon. The prison houses 400 prisoners, mostly men. Catholic missionaries have been involved in improving conditions since 1988, at the request of a magistrate from the local tribunal. They have introduced a community store, handicrafts and the teaching of reading and writing, carried out by the prisoners themselves. The Catholic Health Service was asked to join the project in October 1992. Its participation was part of the provincial policy of collaboration between private and public organizations for the improvement of health institutions. Meetings between health workers and prisoners first created an opportunity for the prisoners to talk about their concerns and what they wanted. A health committee, consisting of about 10 prisoners took several initiatives related to hygiene. Access to curative care was then improved by increasing the stock of medicines to include 37 drugs, standardizing the therapeutic recommendations (including those of the national program against tuberculosis) and increasing the prisoners' access to health care by making the pharmacy self-sufficient. The pharmacy's prices are low and the wardens and their families are encouraged to use it. Any profit made goes towards a "solidarity fund" managed by the prisoners, which enables them to buy their own drugs (3 to 5 patients are seen each day by the nurse). Most of the diseases reported between July 1994 and July 1995 were infectious, including scabies infections and acute respiratory infections. Fifteen cases of tuberculosis were diagnosed and treated. AIDS was not a major problem in the prison at the time but this was expected to change.

Dixon PS et al. (1993). Infection with the human immunodeficiency virus in prisoners: meeting the health care challenge. Am J Med, 95: 629-635.

Editorial (1991). Health care for prisoners: implications of "Kalk's refusal." The Lancet, 337: March 16: 647-648.

Argues that "acceptable ethical standards and quality of care would be easier to achieve if prison health services were entirely independent of prison administrations."

Farley JL et al. (2000). Comprehensive medical care among HIV-positive incarcerated women: the Rhode Island experience. J Womens Health Gend Based Med, 9(1): 51-56.

Flanigan TP, Rich JD, Spaulding A (1999). HIV care among incarcerated persons: a missed opportunity. AIDS, 13: 2475-2476.

Fischl M et al. (2001). Impact of directly observed therapy on long-term outcomes in HIV clinical trials [abstract 528]. In: Program and abstracts of the 8^th Conference on Retroviruses and Opportunistic Infections (Chicago). Alexandria, VA: Foundation for Retroviruses and Human Health.

Presents data supporting the effectiveness of DOT for HAART in the prison setting. The authors compared the virological responses of HIV-positive prisoners and non-prisoners enrolled in the same AIDS Clinical Trials Group trials who were receiving 3- or 4-drug combination regimes. At week 80 of the study, 95% of the prisoners who received medication with use of DOT had virus loads of under 400 copies/mL, compared with only 75% of the nonincarcerated persons, even though the prisoners had lower CD4 cell counts and higher HIV RNA levels at baseline.

Frank L (1999). Prisons and public health: emerging issues in HIV treatment adherence. J Assoc Nurses AIDS Care, 10(6): 24-32.

Prisons and jails, due to their structure, operation, and staff, may present many barriers to HIV treatment and adherence to complicated and expensive HIV treatment regimens. Frank argues that changes and modifications of prison health care delivery are required to accommodate the needs of HIV-positive prisoners. Approaches to improving correctional HIV care and treatment include training health care personnel, prevention education for inmates, increasing access to voluntary HIV testing, comprehensive treatment planning, and continuity of care. Policy changes for correctional systems include adopting current HIV care standards and immediate evaluation for and access to HIV treatment upon entry into the institution.

Gallego O et al. (2003). High rate of resistance to antiretroviral drugs among HIV-infected prison inmates. Med Sci Monit, 9(6): CR217-221.

The aim of the study was to examine the prevalence of genotypic resistance to ARV drugs in a large group of HIV-positive individuals incarcerated in penal facilities. The authors analyzed the reverse transcriptase and protease genes on plasma samples collected from 309 HIV-positive prisoners in Madrid. In order to compare the prevalence of resistance at different periods and detect any trend over time, half of the samples from ARV-naive and half from pre-treated subjects were randomly collected in 1999 and in 2001. Overall, 63.7% of specimens harbored plasma HIV-RNA above 1000 copies/ml. Genotypic data were obtained in 94.4% of them. Primary resistance mutations among 127 drug-naive subjects were recognized in 13% in 1999 vs. 15% in 2001. In contrast, drug resistance was found in 35% and 59% of 182 pre-treated subjects in 1999 and 2001. The authors concluded that drug resistance has increased over the two years among inmates on ARV drugs and currently affects 59% of those failing treatment. A nearly 3-fold increase has been noticed for NNRTI resistance. In comparison with HIV-positive subjects outside jail on ARV drugs, prisoners are more likely to experience virological failure, but show a lower rate of drug resistance; this affects particularly drugs with a low genetic barrier (i.e. NNRTI and 3TC).

Glaser JB, RB Greifinger (1993). Correctional health care: A public health opportunity. Ann Int Med, 118: 139-145.

Points out that prisons are key points of contact with millions of individuals at high risk of HIV infection who are largely out of reach of the medical system in the community

Griffin MM et al. (1996). Effects of incarceration on HIV-infected individuals. Journal of the National Medical Association, 88: 639-644.

This study in the pre-HAART era found that the CD4 cell counts of untreated prisoners declined more rapidly than did those of untreated persons outside of prison. The study attributed the decline to the stress of incarceration itself.

Harding T (1997). Do prisons need special health policies and programs? International Journal of Drug Policy, 8(1): 22-30.

Prison medicine has a strange identity, stranded in a no man's land between two major social systems, that of health delivery and that of criminal justice. The uncomfortable and marginal status of the discipline is not the result of choices nor orientations of prison health care staff. It is caused by pressures created by criminal justice policy - especially prisons' policy - and decades of neglect by the 'health establishment': ministries of health, medical associations and faculties of medicine have regarded prisons as extra-territorial, as far as health care is concerned. Until the AIDS epidemic, the World Health Organization had not devoted one single activity, consultation or study to the prison environment. Until ten years ago, major medical journals almost never carried articles about health or medical care in prisons. The failures of prison health care have led to serious public health concerns within many prison systems. Concentrating on these failures may obscure an important consideration that prison medicine might be a false and misleading concept. Places of detention present such a degree of diversity in terms of population, length of stay, regimen and factors affecting health that 'prison medicine' could usefully be subdivided into a number of component parts: health care for marginal groups; health provision in situations of rupture; combating environments conducive to transmission of airborne diseases; psychiatric care under conditions of security, etc. Prison medicine should wither away and be replaced by the pervasive presence of appropriate elements of public health, preventive measures and health care delivery.

Jolofani D, DeGabriele J (1999). HIV/AIDS in Malawi Prisons. Penal Reform International.

A study of HIV transmission and the care of prisoners with HIV/AIDS in Zomba, Blantyre and Lilongwe Prisons. Produced in English, Russian, Czech, and Romanian. See at http://www.penalreform.org/english/frset_pub_en.htm for more information.

Kerr T et al. (2004) Determinants of highly active antiretroviral discontinuation among injection drug users. Canadian Journal of Infectious Diseases, 15(suppl A): 86A. Canadian Association for AIDS Research Conference. Montreal: May 13-17, 2004.

A study showing that incarceration is independently associated with discontinuation of HAART.

Miller SK, Rundio A Jr (1999). Identifying barriers to the administration of HIV medications to county correctional facility inmates. Clin Excell Nurse Pract, 3(5): 286-290.

The purpose of this study was to investigate the process of HIV medication administration at a county correctional facility. Anecdotal data suggested serious barriers to the process. Professional and licensed practical nursing staff practicing at a New Jersey county correctional facility participated in focus group interviews designed to discuss the process of medication administration and potential barriers to that process. Analysis of data revealed five contextual themes: uniqueness of the county correctional facility setting, barriers perceived by nursing staff, prisoners' perceptions of HIV infection, internal systems' barriers, and the role of systems external to the correctional facility.

Mostashari F et al. (1998). Acceptance and adherence with antiretroviral therapy among HIV-infected women in a correctional facility. Journal of Acquired Immune Deficiency Syndrome and Human Retrovirology, 18: 341-348.

Study showing that trust in the prison health care system is strongly correlated with drug adherence.

Palepu A et al. (2003). Alcohol use and incarceration adversely affect HIV-1 RNA suppression among injection drug users starting antiretroviral therapy. Journal of Urban Health, 80(4): 667-675.

Among HIV-infected injection drug users who were on antiretroviral therapy, any alcohol use and incarceration in the 6 months prior to initiating antiretroviral therapy were negatively associated with achieving HIV-1 RNA suppression. They concluded that, in addition to addiction treatment for active heroin and cocaine use, the identification and treatment of alcohol problems should be supported in this setting. As well, increased outreach to HIV-infected drug users recently released from prison to ensure continuity of care needs to be further developed.

Palepu A et al. (2004). Initiating highly active antiretorviral therapy and continuity of HIV care: the impact of incarceration and prison release on adherence and HIV treatment outcomes. Antivir Ther, 9(5): 713-719.

In this study, Palepu et al. examined the effect of incarceration within 12 months of initiating highly active antiretroviral therapy (HAART) on non-adherence and HIV-1 RNA suppression. They compared the adherence and virological outcomes among participants in a population-based HIV/AIDS Drug Treatment Program in British Columbia, Canada, by history of incarceration in a provincial prison. Participants who were HIV-infected, naive to HAART and who were prescribed treatment between 1 July 1997 and 1 March 2002 were eligible for this study. Logistic regression was used to determine the factors associated with non-adherence and Cox proportional hazards modelling was used to determine the factors associated with HIV-1 RNA suppression adjusting for age, gender, history of drug use, baseline HIV-1 RNA, baseline CD4 cell count, type of antiretroviral regimen [two nucleosides + protease inhibitor (PI) vs two nucleosides + non-nucleoside reverse transcriptase inhibitor (NNRTI)], physician's HIV-related experience for each subject and adherence as measured by pharmacy refill compliance.

There were 1746 subjects (101 incarcerated/1645 non-incarcerated) who started antiretroviral therapy between 1 July 1997 and 1 March 2002. Of those incarcerated, 50 initiated HAART while in prison and 27 subjects were released but returned to prison in the follow-up period. Subjects received antiretroviral therapy while incarcerated for a median number of 4 months [interquartile range (IQR): 2-10]. Multiple logistic regression results showed that a history of incarceration within 12 months of initiating HAART independently increased the odds of non-adherence [adjusted odds ratio (AOR): 2.40; 95% confidence interval (95% CI): 1.54-3.75]. A history of injected drug use was also associated with non-adherence (AOR: 1.49; 95% CI: 1.17-1.90). The following factors were negatively associated with non-adherence: older age (AOR: 0.81; 95% CI: 0.72-0.91), male sex (AOR: 0.50; 95% CI: 0.38-0.65) and higher physician HIV-related experience (AOR: 0.97; 95% CI: 0.96-0.98). In addition, a history of incarceration within 12 months of initiating HAART reduced the odds of achieving HIV-1 RNA suppression [adjusted hazards ratio (AHR): 0.68; 95% CI: 0.51-0.89]. Other factors negatively associated with viral suppression included a history of drug injection (AHR: 0.79; 95% CI: 0.69-0.91), two nucleosides + PI vs two nucleosides + NNRTI (AHR: 0.77; 95% CI: 0.69-0.87), higher baseline HIV-1 RNA (AHR: 0.66; 95% CI: 0.62-0.70). Higher adherence was positively associated with viral suppression (AHR: 1.38; 95% CI: 1.34-1.42). Among the 101 subjects who were incarcerated in the first year of starting HAART, the time spent in jail was positively associated with HIV-1 RNA suppression (HR: 1.06; 95% CI: 1.02-1.10). The authors concluded that HIV-infected subjects with a history of incarceration within 12 months of initiating HAART have higher odds of non-adherence and, consequently, lower probability of achieving HIV-1 RNA suppression. The longer their sentence, however, the higher the probability of virological suppression. The British Columbian provincial prison system provided a structured setting for HAART but subjects are unable to continue this level of adherence upon release. Strategies to ensure continuation of HIV/AIDS care for HIV-infected individuals leaving the criminal justice system must be a public health priority.

Perez-Molina JA et al (2002). Differential characteristics of HIV-infected penitentiary patients and HIV-infected community patients. HIV Clin Trials, 3(2): 139-147.

Physicians for Human Rights (2002). Dual Loyalty & Human Rights in Health Professional Practice. Proposed Guidelines & Institutional Mechanisms. Physicians for Human Rights and School of Public Health and Primary Health Care, University of Cape Town, Health Sciences Faculty.

Available via www.phrusa.org

Acknowledges that health care staff in prison are often in a difficult position and may be asked to put allegiance to their patients aside. Contains proposed guidelines for practice in prison.

Pontali E (2005). Antiretroviral treatment in correctional facilities. HIV Clinical Trials, 6(1): 25-37.

Pontali set out to identify and describe the relevant issues and difficulties associated with provision of antiretroviral therapy in correctional facilities. He performed a review and analysis of currently available literature and experiences on antiretroviral treatment (ART) in the prison setting. He found that antiretroviral therapy is administered to HIV-positive prisoners in many countries. Numerous issues have been identified and discussed; among the most relevant are availability of basic and specific HIV care, prisons as entry point for HIV care for marginalized populations, policy and guidelines for ART, specialized HIV care in prison, modality of administration of ART, adherence to ART, and continuity of care between prison and community. Pontali concluded that antiretroviral treatment is a feasible intervention in the context of correctional facilities. To ensure full benefit of ART for those prisoners in need, in each country there should be plans for ART provision in correctional facilities and the necessary arrangements should be made to ensure ART administration and optimal adherence to it.

Potler C, Sharp V, Remick S (1994). Prisoners' access to HIV experimental trials: legal, ethical, and practical considerations. Journal of Acquired Immune Deficiency Syndromes, 7(10): 1086-1094.

Provides a series of policy recommendations that should be considered when providing access to experimental HIV agents to prisoners.

Soto Blanco JM, Perez JR, March JC (2005). Adherence to antiretroviral therapy among HIV-infected prison inmates (Spain). Int J STD AIDS, 16(2): 133-138.

This cross-sectional study was carried out in two Spanish prisons. A group of 177 HIV-infected prison inmates were interviewed. Standardized personal interviews using a structured questionnaire were conducted to assess sociodemographic features and prison setting characteristics, clinical variables, social support and drug consumption. A simplified four-item questionnaire for self-reported adherence was used. A total of 24.3% were non-adherent. Predictors of non-adherence in the multivariate analysis included poor or lack of ability to follow the prescribed treatment regimen, no visits in a month, anxious and/or depressed mood, difficulty in taking medication, receiving methadone treatment, cannabis consumption and robbery as the reason for imprisonment. Adherence to antiretroviral therapy was higher than in the wider community. However, other variables related to the correctional setting, such as assignments within the facility, adaptability of the prison system to authorize the cell being opened in the event of missed medication, or legal situation had no effect on adherence for inmates with HIV disease.

Springer et al. (2004). Effectiveness of antiretroviral therapy among HIV-infected prisoners: reincarceration and the lack of sustained benefit after release to the community. Clinical Infectious Diseases, 38: 1754-1760.

The aim of the study was to examine the HIV-1 RNA level (VL) and CD4 lymphocyte response to HAART during incarceration and upon reentry to the correctional system, Springer et al. conducted a retrospective cohort study of longitudinally linked demographic, pharmacy, and laboratory data from the Connecticut prison system. During incarceration, the mean CD4 lymphocyte count increased by 74 lymphocytes/ mu L, and the mean VL decreased by 0.93 log10 copies/mL (P<.0001). 59% of the subjects achieved a VL of <400 copies/mL at the end of each incarceration period. For the 27% of subjects who were reincarcerated, the mean CD4 lymphocyte count decreased by 80 lymphocytes/ mu L, and the mean VL increased by 1.14 log10 (P<.0001). Although HAART use resulted in impressive VL and CD4 lymphocyte outcomes during the period of incarceration, recidivism to prison was high and was associated with a poor outcome. More effective community-release programs are needed for incarcerated patients with HIV disease.

Stein G, Headley L (1996). Forum on prisoners' access to clinical trials: summary of recommendations. AIDS & Public Policy Journal, 11(1): 3-20.

To forge a consensus on acceptable standards for enrolling prisoners in clinical studies, a Forum on Prisoner Access to Clinical Trials was convened in 1994, which issued 10 recommendations specifically to benefit prisoners with HIV.

Stephenson BL et al. (2005). Effect of release from prison and re-incarceration on the viral loads of HIV-infected individuals. Public Health Rep, 120(1): 84-88.

The purpose of this study was to determine the effect of release from prison and subsequent re-incarceration on the viral loads of HIV-infected individuals receiving highly active antiretroviral therapy (HAART). Fifteen re-incarcerated HIV-infected prisoners on HAART were identified from a retrospective cohort of HIV-infected prison inmates released from 1 January 1997 to 31 August 1999. The re-incarcerated prisoners were matched (1:2) to 30 HIV-infected incarcerated prisoners on HAART who remained incarcerated during the re-incarcerated participants' release time period. The outcomes measured were plasma HIV RNA levels, CD4+ lymphocyte counts, percentage of re-incarcerated and incarcerated participants with plasma HIV RNA levels <400 copies/mL, and the median change in plasma HIV RNA levels of the re-incarcerated and incarcerated participants at the end of the study. At the beginning of the study, 8/15 re-incarcerated participants had plasma HIV RNA levels <400 copies/mL, compared with 15/30 incarcerated participants. At the end of the study, only three of those eight re-incarcerated participants had plasma HIV RNA levels <400 copies/mL, compared with 14/15 incarcerated participants (p=0.0086). Stephenson et al concluded that release from prison was associated with a deleterious effect on virological and immunological outcomes. These data suggest that comprehensive discharge planning efforts are required to make certain that HIV-infected inmates receive access to quality care following incarceration.

Tomasevski K (1992). Prison Health. International Standards and National Practices in Europe. Helsinki: Helsinki Institute for Crime Prevention and Control.

The book contains the results of the first survey of the common problems in prison health and the different models of providing prison health services in Europe and in Canada. The issues addressed include: main problems in prison health (includes a section on HIV/AIDS); availability of health care; prisoners' access to health care; research involving prisoners; and "standard-setting in prison health" (which includes professional, ethical, and human rights standards).

Turnbull PJ, Dolan K, Stimson G (1993). HIV testing, and the care and treatment of HIV positive people in English prisons. AIDS Care, 5(2): 199-206.

Van Heerden J (1996). Prison Health Care in South Africa. University of Cape Town.

Wohl D et al. (2000). Adherence to directly observed therapy of antiretrovirals in a state prison system [abstract 357]. In: Proceedings of the 38^th annual meeting of the Infectious Diseases Society of America (Philadelphia). Alexandria, VA: Infectious Diseases Society of America.

In contrast to Fischl, above, Wohl et al showed there was no significant difference in adherence, as measured by electronic memory caps, between self-medication and DOT.

Wohl D et al. (2003). Adherence to directly observed antiretroviral therapy among human immunodeficiency virus-infected prison inmates. Clin Infect Dis, 36: 1572-1576.

The authors prospectively assessed adherence to antiretroviral therapy regimens among 31 HIV-positive prisoners who were receiving antiretrovirals via DOT. Adherence was measured by self-report, pill count, electronic monitoring caps, and, for DOT only, medication administration records. Overall, median adherence was 90%, as measured by pill count; 86%, by electronic monitoring caps; and 100%, by self-report. Adherence, as measured by electronic monitoring caps, was >90% in 32% of the subjects. In 91% of cases, adherence, as measured by medication administration records, was greater than that recorded by electronic monitoring caps for the same medications administered by DOT. Objective methods of measurement revealed that adherence to antiretroviral regimens administered wholly or in part by DOT was <or=90% in more than one-half of the patients. Different methods used to measure adherence revealed significantly different levels of adherence. These findings suggest that use of DOT does not ensure adherence to antiretroviral therapy.

Wohl D et al. (2004). Access to HIV care and antiretroviral therapy following release from prison. 11^th Conference on Retroviruses and Opportunistic Infections, 8-11 February, abstract 859.

Annually, 1 in 5 HIV-positive persons in the US passes through a correctional facility. While HIV care is largely available in prisons, HIV-positive releasees may face challenges in accessing health care. Further, HIV RNA levels of former inmates have been observed to increase during periods of release. Wohl et al studied two cohorts: 86 HIV-positive state prison inmates who were interviewed within 3 months prior to and 30 to 60 days post-release; and 84 HIV-positive inmates released from prison and then re-incarcerated (recidivists) who received the same interview shortly after re-incarceration. All were asked about access to HIV care while free.

Of the 86 subjects interviewed before release, 59% were receiving ART. More than three quarters agreed that after release they "can get medical care whenever needed" but 68% said "covering cost of medical visits will be problem"; 36% said that they "will go without care due to cost" and 26% that "it will be hard to get emergency care." Post-release interviews were conducted in 95% of those eligible (2 subjects died and 5 were re-incarcerated shortly after release) a mean of 36 days post-release. 59% said they had seen a health care provider. All of those prescribed ART reported receiving medication to take home at release (mean 32 day supply) but 15% had gone without ART for >2 days since release. Among the 84 recidivists, 34% had not received HIV care while free; 46% gauged their health to be the same and 28% worse than when last released; 63% received ART since release but 41% were not on ART at re-incarceration and a third of ART-treated subjects had run out of medication a mean 159 days after release for an average of 203 days. Half had a case manager; 54% thought that covering medical costs between incarcerations was a problem; 39% said that they went without care due to cost and 26% responded that it was hard to get medical care when needed. The study concluded that, following release, HIV-positive former prison inmates experience difficulty maintaining HIV care, continuing medical therapy and affording health care; and that, coupled with data from the same cohorts indicating high rates of post-release HIV transmission risk behaviors, these results support efforts to strengthen the continuity of HIV care following prison release for the benefit of individual and public health.

Zaitzow BH (1999). Women prisoners and HIV/AIDS. J Assoc Nurses AIDS Care, 10(6): 78-89.

Highlights the need for correctional policy to address the health care needs of women prisoners with HIV/AIDS.

HCV Treatment

Allen S et al. (2003). Treatment of chronic hepatitis C in a state correctional facility. Annals of Internal Medicine, 138: 187-191.

In Rhode Island, 93 prisoners with chronic HCV infection were treated with interferon-alpha with ribavirin. Response rates were similar to previously published rates achieved in the community; 63% (50 of 79) of patients achieved viral clearance after 6 months of therapy, and 46% (26 of 57) achieved sustained response 6 months after treatment. The authors concluded that the incarcerated population (which is disproportionately affected by addiction and psychiatric illness) can be effectively treated for HCV infection with interferon and ribavirin. The correctional setting may provide an opportunity to safely treat patients with these two challenging comorbid conditions.

Centers for Disease Control and Prevention (2003). Prevention and control of infections with hepatitis viruses in correctional settings (PDF Version). Morbidity and Mortality Weekly Report, 52: RR-1.

Available at www.cdc.gov/mmwr/PDF/rr/rr5201.pdf

Farley J et al (2005). Hepatitis C treatment in a Canadian federal correctional population: Preliminary feasibility and outcomes. International Journal of Prisoner Health, 1(1): 13-18.

The study reports preliminary data on HCV treatment in a federal correctional population sample in British Columbia, using Pegetron combination therapy. HCV RNA results are presented at week 12 of treatment, a strong predictor of treatment outcome. Just over four fifths (80.8%) of prisoner patients had no detectable HCV RNA at week 12; prisoners with genotype 2 and 3 fared better than those with genotype 1. The study concludes that "these preliminary results suggest that HCV treatment is feasible and promises to be efficacious in correctional populations." It calls upon "Canadian correctional health policy and program makers ... to provide resources ... to systematically make HCV treatment available to infected individuals in the correctional system as one of a wide range of steps to reduce HCV prevalence and related burden of illness in the Canadian population."

Farley J et al. (2005). Feasibility and Outcome of HCV Treatment in a Canadian Federal Prison Population. Am J Public Health, 95: 1737-1739.

Hammett T (2003). Adopting more systematic approaches to hepatitis C treatment in correctional facilities. Annals of Internal Medicine, 138: 235-236.

Macalino G et al. (2004). Hepatitis C and incarcerated populations. International Journal of Drug Policy, 15; 103-114.

Macalino G, Dhawan D, Rich JD (2005). A Missed Opportunity: Hepatitis C Screening of Prisoners. Am J Public Health, 95: 1739-1740.

In 2003, the Centers for Disease Control and Prevention issued recommendations to screen all inmates with a history of injection drug use or other risk factors for hepatitis C. The authors compared self-reported risk factors for hepatitis C with serostatus from inmates in the Rhode Island Department of Corrections. Of the male inmates who were hepatitis C positive, 66% did not report injection drug use. Risk-based testing underestimates the hepatitis C virus prevalence in correctional settings and limits the opportunity to diagnose and prevent hepatitis C infection.

Paris P et al. (2005). Cost of hepatitis C treatment in the correctional setting. Journal of Correctional Health Care, 11(2).

34 percent of inmates are infected with hepatitis C. There are significant variables affecting the cost of disease management. This paper estimates the effects of these variables and the range of costs. Representative data from correctional systems with varying hepatitis C management protocols were assigned to each variable to estimate program cost. Depending on prevalence, whether or not vaccination is included, and which biopsy stages are treated, cost of management of a hypothetical population of 3,000 inmates ranged widely, from $646,768 to $2,706,740 from diagnosis to completion of evaluation and/or treatment.

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

Skipper C et al. (2003). Evaluation of a prison outreach clinic for the diagnosis and prevention of hepatitis C: implications for the national strategy. Gut, 52: 1500-1504.

Sterling R et al. (2004). Treatment of chronic hepatitis C virus in the Virginia Department of Corrections: Can compliance overcome racial differences to response? American Journal of Gastroenterology, 99: 866-871.