Tackling HIV/AIDS in prisons in Ukraine Deputy Head State Prison Department Prof. Dr. Ed. Natalya Kalashnik

Prison system capacities in Ukraine Number of Prisons – 149 with 130,000 inmates Number of Prisons – 149 with 130,000 inmates 10 female settings (6,800) 10 female settings (6,800) 11 for adolescent (2,200) 11 for adolescent (2,200) Pre-detention centers – 32 with 31,000 inmates Pre-detention centers – 32 with 31,000 inmates 22 health care facilities 22 health care facilities 10 TB clinics 10 TB clinics

Policy & Legal environment 1. Law of Ukraine Addressing HIV and social protection of the population 2. Decree Cabinet of Ministers of Ukraine (2004) Strategic concept of GoU on prevention spread of HIV/AIDS by Decree Cabinet of Ministers of Ukraine (2004) National AIDS Program State Prison Department: Sectoral AIDS Program (2004) harmonized with National AIDS Program

State Prison Department AIDS Program AIDS program: Goals: Goals: Prevention of HIV transmission Prevention of HIV transmission Scaling up access to treatment Scaling up access to treatment Specific objectives: Specific objectives: IEC targeting inmates and staff IEC targeting inmates and staff Behaviour change among inmates Behaviour change among inmates Decrease mother to child transmission Decrease mother to child transmission Access to diagnostic, treatment and support Access to diagnostic, treatment and support Set up and scale up harm reduction programs Set up and scale up harm reduction programs Establishing collaboration with NGOs Establishing collaboration with NGOs

Epidemiology HIV and TB in prisons HIV prevalence SPD per 100, per 100,000 Ukraine per 100, per 100, SPD per 100, per 100,000 Ukraine per 100, per 100,000 TB Prevalence

HCV prevalence* * - HCV notification and reporting is not incorporated in national regulations * - HCV notification and reporting is not incorporated in national regulations According to sentinel surveillance data (2004) among inmates/IDU – HCV prevalence – 98% According to sentinel surveillance data (2004) among inmates/IDU – HCV prevalence – 98%

HIV testing in prisons According to SPD regulations (differ from National HIV testing protocol) According to SPD regulations (differ from National HIV testing protocol) Voluntary and confidential (code system) Voluntary and confidential (code system) Pre- and post-test counseling as part of service Pre- and post-test counseling as part of service Trained staff (specially assigned for each of the prison) Trained staff (specially assigned for each of the prison) HIV test result delivered by trained staff (specially assigned physician-consultant in each setting) HIV test result delivered by trained staff (specially assigned physician-consultant in each setting) In 2006 – 15.8% of inmates were tested In 2006 – 15.8% of inmates were tested

HIV/AIDS education HIV education is embedded in the National and SPD AIDS programs HIV education is embedded in the National and SPD AIDS programs For inmates (program implementing upon arrival and before release): For inmates (program implementing upon arrival and before release): Channeled through physician-consultant (lectures, individual consultations, etc.) Channeled through physician-consultant (lectures, individual consultations, etc.) Channeled through NGOs: (peer concept, distribution of info brochures, individual consultations, self-support groups incl. theater performance) + church (FBO) + students volunteers Channeled through NGOs: (peer concept, distribution of info brochures, individual consultations, self-support groups incl. theater performance) + church (FBO) + students volunteers For staff: For staff: Lectures and info brochures (as part of education and post-education curricula) Lectures and info brochures (as part of education and post-education curricula) Post-graduate education (incl. study tours, trainings) Post-graduate education (incl. study tours, trainings) Special attention to PEP and HIV on workplace Special attention to PEP and HIV on workplace

Sexual behaviour According to the policies condoms is not included in the list of prohibited items According to the policies condoms is not included in the list of prohibited items Distribution mainly through NGOs (where projects are available) – 35 projects Distribution mainly through NGOs (where projects are available) – 35 projects Starting from 2007 plan to procure condoms through the World Bank Loan and distribute (free of charge) Starting from 2007 plan to procure condoms through the World Bank Loan and distribute (free of charge) Strategies to address aggressive sexual behaviour: education/information/religion/use of psychologists Strategies to address aggressive sexual behaviour: education/information/religion/use of psychologists

Transmission by injection Up to date Special measures to reduce drug supply Special measures to reduce drug supply Surveillance and search among inmates and visitors, ad hoc search in premises, surveillance of staff and vehicles Surveillance and search among inmates and visitors, ad hoc search in premises, surveillance of staff and vehicles Collaboration with Dept. On illicit drug supply (OBNON) to prevent drug traffic Collaboration with Dept. On illicit drug supply (OBNON) to prevent drug traffic Medical observation of inmates/drug users Medical observation of inmates/drug users Measures to decrease drug demand and use Measures to decrease drug demand and use Primary and secondary prevention (Information, Education and Communication campaign, disinfectants) Primary and secondary prevention (Information, Education and Communication campaign, disinfectants) Treatment (detoxification and drug-free programs) Treatment (detoxification and drug-free programs) Rehabilitation Rehabilitation Reform inside SPD Reform inside SPD

Transmission by injection Planned for 2007 Introduction of substitution therapy (ST) in prisons is under the question (ST in Ukraine is limited by pilot programs with buprenorphine, while scaling up ST and start use of methadone still challenging) Introduction of substitution therapy (ST) in prisons is under the question (ST in Ukraine is limited by pilot programs with buprenorphine, while scaling up ST and start use of methadone still challenging) Jointly with Canadian HIV/AIDS Legal Network and International Harm Reduction Association planned pilot needle and syringe program (NSP) in 2 prisons Jointly with Canadian HIV/AIDS Legal Network and International Harm Reduction Association planned pilot needle and syringe program (NSP) in 2 prisons

Antiretroviral treatment (ART) Ukraine started scaling up ART since 2004 (State budget and GFATM) - up to date around 5,000 pts. on ART (while the needs 17,500) Ukraine started scaling up ART since 2004 (State budget and GFATM) - up to date around 5,000 pts. on ART (while the needs 17,500) Since 2006 ART available in prisons (55 received, needs -200) Since 2006 ART available in prisons (55 received, needs -200) ART regimens correspond to the national treatment guidelines (also WHO) ART regimens correspond to the national treatment guidelines (also WHO) Provision of ART jointly with NGOs (with donors financial support) Provision of ART jointly with NGOs (with donors financial support) CD4 available through regional AIDS centers and 1 st and 2 nd line regimens according to the national treatment protocols (NNRTI and PI-based regimens) CD4 available through regional AIDS centers and 1 st and 2 nd line regimens according to the national treatment protocols (NNRTI and PI-based regimens) Treatment of opportunistic infections: according to the national protocols Treatment of opportunistic infections: according to the national protocols PMTCT: starting from 2 nd trimester: coverage 100% PMTCT: starting from 2 nd trimester: coverage 100%

Management of HIV infected prisoners HIV status is confidential (results deposited in secure place) HIV status is confidential (results deposited in secure place) HIV tests results (encoded) accessible only for physician-consultant and without informed consent cannot inform other medical staff HIV tests results (encoded) accessible only for physician-consultant and without informed consent cannot inform other medical staff HIV infected imprisoned under general conditions HIV infected imprisoned under general conditions Comprehensive measures to prevent stigma and discrimination (voluntary testing, confidentiality, general conditions of imprisonment, trainings for staff) Comprehensive measures to prevent stigma and discrimination (voluntary testing, confidentiality, general conditions of imprisonment, trainings for staff)

Technical assistance needed Improve legislation Improve legislation Develop standards and model package of services for inmates Develop standards and model package of services for inmates Local evidence to confirm NSP and ST benefits and operational modalities Local evidence to confirm NSP and ST benefits and operational modalities Involve NGOs and supervise the quality of services provided through NGOs Involve NGOs and supervise the quality of services provided through NGOs Develop comprehensive IEC Develop comprehensive IEC

The way forward Re-socialization through empowerment and education Re-socialization through empowerment and education Change society attitude towards inmates (especially outside the system) Change society attitude towards inmates (especially outside the system) Provide incentives for seeking prevention and treatment Provide incentives for seeking prevention and treatment Increase self-estimation of inmates Increase self-estimation of inmates New programs: Be good for everybody and Save your life New programs: Be good for everybody and Save your life