1. Firenze, 27 March 2011 1 |1 | HIV and HCV in prisons: From evidence to action Firenze, ICAR 2011, 27 March 2011 Ralf Jürgens, Canada

2. Firenze, 27 March 2011 2 |2 | Acknowledgements Annette Verster & Andrew Ball (WHO) Peer reviewers UNODC, UNAIDS

3. Firenze, 27 March 2011 3 |3 | Background HIV rates in prisons & pre-trial detention are much higher than in the community outside prisons Even where HIV rates remain low, HCV rates are high – often exceeding 50% Very high co-infection rates (HCV co-infection observed in more than 90% of HIV-positive prisoners in Genova) Sources: WHO, UNODC, UNAIDS, 2007; Jürgens, Ball, Verster, 2009; Pontali, Ferrari, 2008; Dolan et al., 2007, Macalino et al., 2004, Dolan & Wodak, 1999; MacDonald, 2005; Bobrik et al., 2005; Taylor et al., 1995

4. Firenze, 27 March 2011 4 |4 | HIV prevalence in selected countries 0.3-1.6% 3.2-20% Brazil 0.8-4.3% 16-32% (5 regions) Ukraine 0.1-0.2% 4-22% Indonesia 0.3-0.9% 28.4% Viet Nam 0.7-1.8% Up to 4% Russian Federation 0.4-1.0% Up to 14% Spain 0.3% 7% Italy 0.4-1.0% 1.9% USA 0.2-0.5% 1-12% Canada Est. Adult HIV Prevalence HIV Prevalence in Prisons Country

5. Firenze, 27 March 2011 5 |5 | Background: risk behaviours Risk behaviours are prevalent in prisons – Consensual & non consensual sex – Injecting drug use – Tattooing – Sharing of razors and toothbrushes

6. Firenze, 27 March 2011 6 |6 | Background: sexual activity Difficult to obtain reliable data – Methodological and ethical challenges – Sex violates prison regulations – Feelings of shame and homophobia: prisoners decline to participate in studies – Admitting to having been raped in prison goes against prisoner code Nevertheless, evidence is clear: consensual and non- consensual sex do occur

7. Firenze, 27 March 2011 7 |7 | Background: sexual activity Africa: (Nigeria, Zambia, Mozambique): 4-5.5% South America: 10% (Brazil) Asia: 20% (Thailand) Central & Eastern Europe: – Russia (9.7-12%; much higher among long-term prisoners) – Slovakia: 19% of female, 5.6% of adult male, 8.3% of juveniles – Slovenia: 19.3% – Hungary: 9% – Armenia: 2.9% penetrative (36% against their will) Western Europe, Canada, Australia: 1-12% among males, up to 37% among females Source: WHO, UNODC, UNAIDS, 2007

8. Firenze, 27 March 2011 8 |8 | Background: drug use in prisons Drugs can and do enter into prisons Many prisoners are in prison because of offences related to drugs, and find a way to use inside Some discontinue using drugs in prisons Other prisoners start using (and/or injecting) drugs in prison No country has been able to stop drug use in prisons

9. Firenze, 27 March 2011 9 |9 | Injecting & needle sharing in prison

10. Firenze, 27 March 2011 10 | What could happen – what we can prevent Extensive HIV transmission can occur in prisons, significantly contributing to the spread of HIV among the general population. Thailand: HIV prevalence rate among injectors rose from a negligible percentage to over 40% between Jan & Sept 2008, fuelled by transmission of HIV in prisons. Six studies among people who inject drugs in Thailand found that imprisonment was associated significantly with HIV infection.

11. Firenze, 27 March 2011 11 | What could happen – what we can prevent Outbreaks of HIV in prisons have been documented in a number of countries, incl Scotland, Australia, Lithuania, and Russia. In Lithuania, in May 2002 the number of new HIV-positive test results among prisoners found in a two-week period equalled all the cases of HIV identified in the entire country during all of the previous years combined. 284 prisoners (15% of the prison population) were diagnosed HIV- positive between May and August 2002.

12. Firenze, 27 March 2011 12 | Prison conditions contribute to the problem Severe overcrowding Lack of work and meaningful activities Decaying physical infrastructure Lack of adequate medical care Lack of nutritious food & clean water Abuse & corruption Prisoner-on-prisoner violence

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15. Firenze, 27 March 2011 15 | Public health implications 1.Health of prisoners = issue of public health concern 2.All people in Italy would benefit from enhancing the health of prisoners and reducing the incidence of communicable diseases prisoners and their families prison staff the families outside prison 3. Communicable diseases transmitted in prison do not remain there.

16. Firenze, 27 March 2011 16 | Interventions to address HIV in prisons We know what works – and what does not work: – WHO/UNODC/UNAIDS Evidence for Action Papers: Interventions to Address HIV in Prisons www.who.int/hiv/topics/idu/prisons/en/ – Jürgens R, Ball A, Verster A. Interventions to reduce HIV transmission related to injecting drug use in prison. Lancet Infect Dis 2009; 9(1): 57-66 International expert & UN consensus since 1993: HIV & HCV prevention & treatment in prisons are essential, for public health & human rights

17. Firenze, 27 March 2011 17 | Education and information Information & education programs result in increased knowledge (eg, Vaz, Gloyd & Trindade, 1996) However, evidence of effect of increased knowledge on behaviour is limited (Braithwaite, Hammett & Mayberry, 1996) Peer education is more effective (Grinstead et al, 1999) Education is not enough

18. Firenze, 27 March 2011 18 | Prevention of sexual transmission Providing condoms is feasible in prison settings No security problems or other negative consequences Prisoners use condoms when condoms are easily and discreetly accessible - prisoners should never have to ask for condoms or seen by others when they take a condom Source: WHO, UNODC, UNAIDS, 2007; Correctional Service Canada, 1999; Dolan, Lowe & Shearer, 2004; May and Williams, 2002; Yap et al., 2007)

19. Firenze, 27 March 2011 19 | Prevention of sexual transmission Need for measures to combat rape and sexual abuse –Changing the institutional culture tolerating sexual violence –Multi-pronged approaches are needed: Prevention efforts (prisoners education, classification, structural interventions such as better lighting, better shower and sleeping arrangements) Staff training, investigation, prosecution, victim services Documenting incidents Post Exposure Prophylaxis (PEP) should be available

20. Firenze, 27 March 2011 20 | Needle and syringe programmes (NSPs) NSPs in the community exist in most countries, including Italy Studies have found NSPs – to be effective in reducing HIV spread – do not lead to increased drug use First established in prisons in Switzerland in 1992 Since then, introduced in 12 countries in western and eastern Europe and central Asia

21. Firenze, 27 March 2011 21 | NSPs in prisons Today, NSPs are operating in a growing number of countries, in all types of prisons and prison systems: – In well funded prison systems (eg, Spain, Switzerland, Germany) and severely under-funded prison systems (eg Moldova, Iran) – In institutions with drastically different physical arrangements for the housing of prisoners, from single cell to barracks – In prisons of all security classifications and sizes – In men’s and women’s institutions

22. Firenze, 27 March 2011 22 | Prison Colony 18, Branesti, Moldova

23. Firenze, 27 March 2011 23 | Evidence NSPs PrisonIncidence HIV&HCV Needle sharingDrug useInjecting Am Hasenburg (D) No increase Basauri (Es) No HIVNo increase Hannoversand (D) No increase Hindelbank (CH) No HIVDecreaseNo increase Lehrter Strasse & Lichtenburg (D) No HIV but HCVNo increase Linger 1 (D) No HIVNo increase Realta (CH) No HIVSingle casesDecreaseNo increase Vechta (D) No HIVNo increase Vierlande (D) No HIVLittle change or reduction No increase (Stöver & Nelles, 2003; Stark et al., 2005; Rutter et al., 2001)

24. Firenze, 27 March 2011 24 | Evidence NSPs No negative consequences – No increase in drug use or injecting – needles are not used as weapons Increased referral to drug dependence treatment Increased staff safety

25. Firenze, 27 March 2011 25 | How is needle exchange done? PNEPs utilize various methods for distributing injecting equipment – Hand-to-hand exchange by nurses and/or the prison physician – Distribution by one-for-one automated syringe dispensing machine – Distribution by prisoner trained as peer outreach workers – Distribution by external NGOs or other health professional who come into the prison for this purpose

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27. Firenze, 27 March 2011 27 | Determinants of success Prisoners must have confidential, easy access Prisoners must have access to the type of injecting equipment they want and need Support of the prison administration, staff, and prisoners is crucial (educational workshops for these groups should be part of implementation of NSPs) Start with pilot project in a few prisons, monitor and evaluate, then scale up

28. Firenze, 27 March 2011 28 | Recommendations NSPs in prisons WHO,UNODC, UNAIDS recommend: – Introduce NSPs urgently – Provide easy and confidential access to NSPs – Distribution through peers or NGOs

29. Firenze, 27 March 2011 29 | Could providing NSP send out the wrong message? Could it be seen as “being soft” on drug use? – As tolerating or condoning drug use in prisons? – As giving up the fight against drugs in prisons? No: drug use remains illegal and measures to continue fighting drugs in prisons continue But the fight against HIV is equally important Not taking evidence-based measures would mean condoning the spread of HIV among prisoners and ultimately to the community outside prisons

30. Firenze, 27 March 2011 30 | How much do NSPs in prisons cost? Very little – see Moldova example Cost effective – every euro spent on prison NSP saves many euros that would otherwise have to be spent on treatment of infectious diseases

31. Firenze, 27 March 2011 31 | Could providing bleach be enough? Studies have shown that providing bleach in prisons for decontamination purposes is feasible and does not compromise security But : Doubts about effectiveness – Conditions in prisons reduce probability of effective decontamination → Bleach programmes cannot replace NSPs Provide information on limited effectiveness Continue efforts to introduce NSPs

32. Firenze, 27 March 2011 32 | Is providing NSPs enough? NSPs are important component of efforts to reduce risk of HIV through injecting But alone they are not enough to eliminate the risk Effective, evidence-based drug dependence treatment is also needed, in particular methadone maintenance treatment (MMT)

33. Firenze, 27 March 2011 33 | Evidence: MMT in prisons MMT is available in growing number of countries and is most effective treatment for opioid dependence – reduced used of opioids, reduced mortality, reduced HIV risk behaviours, reduced criminal activity MMT in prisons is feasible and effective – most important benefit: reduced injecting drug use and associated needle sharing, if correct dose & length of treatment

34. Firenze, 27 March 2011 34 | Evidence: MMT in prisons Additional proven benefits of MMT in prison, for prison systems, society, and prisoners: – facilitates entry and retention in post-release treatment – decreases re-incarceration – positive effect on institutional behaviour – helps reduce risk of overdose upon release No negative side effects : – no problems for security & no violent behaviour – risk of diversion has been successfully addressed

35. Firenze, 27 March 2011 35 | Recommendations: MMT in prisons WHO, UNODC & UNAIDS recommend: – introduce and scale up MMT urgently in prisons – ensure that those on MMT in the community can continue MMT upon arrest and imprisonment

36. Firenze, 27 March 2011 36 | NSP & MMT: Learning from Spain Spain introduced and scaled up both MMT and NSPs This has resulted in significant decreases in HIV and HCV prevalence and incidence

37. Firenze, 27 March 2011 37 | HIV prevalence in Spanish prisons 46% of prisoners had a history of injecting drug use

38. Firenze, 27 March 2011 38 | Prisoners on MMT in Spanish prisons 11%

39. Firenze, 27 March 2011 39 | Evolution of Needle Exchange Programs

40. Firenze, 27 March 2011 40 | Conversions to HIV and HCV

41. Firenze, 27 March 2011 41 | Could we do sth else instead of NSP & MMT? Other measures would not be as effective Drug interdiction efforts are very costly They only reduce, but do not completely eliminate drug use in prisons

42. Firenze, 27 March 2011 42 | Drug demand & supply reduction measures Some systems have vastly expanded drug interdiction measures (drug dogs, modern drug detection analysis, urinalysis, “drug-free units”, etc) Drug use has remained high Improving documentation & evaluation of these measures should be a priority Prison systems with drug testing programs should reconsider testing for cannabis

43. Firenze, 27 March 2011 43 | HIV in prisons: other necessary steps Pro-actively offer (and recommend) HIV and HCV testing Ensure uninterrupted treatment Reduce overcrowding & improve prison conditions Provide work & other meaningful activities for prisoners

44. Firenze, 27 March 2011 44 | HIV in prisons: other necessary steps Provide non-custodial alternatives for people convicted of offences directly related to their drug dependence (possession of amounts for personal use or petty crimes committed to support drug use) “Governments may … wish to review their penal admission policies, particularly where drug abusers are concerned, in the light of the AIDS epidemic and its impact on prisons.” (WHO, 1987)

45. Firenze, 27 March 2011 45 | Conclusion: From evidence to action All prisoners have the right to receive … preventive measures equivalent to [those] available in the community” (WHO, 1993) Time to move from evidence to action in Italy : access to condoms, NSPs, MMT, voluntary HIV & HCV testing & treatment, as part of comprehensive HIV & HCV strategy for prisons and pre-trial detention, is urgently needed for prisoners