University of Zambia Medical Library

Prisons and AIDS (UNAIDS Best Practice Collection Point of View: April 1997)

• In many prisons around the world there are high rates of infection with the human immunodeficiency virus (HIV), the virus that causes AIDS. At the same time, prisoners often also have tuberculosis (TB), syphilis and various strains of viral hepatitis.
• For example, HIV prevalence in French prisons is about ten times that of the General population, while the prevalence of TB is three times the national Average. In south-eastern France, 12.7% of prisoners tested HIV-positive in a 1994-95 survey. In Santa Fe province, Argentina, between 11.3% and 14% of prisoners tested HIV-positive in 1995. In the United States in 1994, there were 5.2 cases of AIDS per 1,000 prisoners, almost six times the rate in the general adult population.
• The prison population is not eternally sealed off, but is constantly changing, with people going in and out. In some places, the average stay in prison is quite short. For example, Ireland has an average prison population of around 2,200, with an annual turnover of about 10,000 and an average prison sentence of 3-4 months.
• Several factors make prisons an ideal breeding ground for onward transmission of HIV infection. Overcrowding is one such factor. In 1995, the prison population of the United States was 1.6 million, a doubling over ten years. In a major Eastern European prison, individual cells hold up to 35 prisoners each. Violence, often a feature of prison life, produces tensions, recriminations and an atmosphere of fear.
• Many of those in prison are there because of drug use or trafficking, and they often find ways to continue drug use inside. Drug injecting with shared, non-sterile equipment is the factor probably accounting for the greatest number of new HIV cases in prisons worldwide.
• In Lower Saxony, Germany, a survey in a women's prison showed about a third of those sampled were injecting drug users, many continuing their habit in prison. Of those injecting, 4.9% were infected with HIV, as against 0.5% of the non-injectors. In Central Prison in Lisbon, Portugal, a survey of 1,442 prisoners entering between 1994 and 1996 found 63% to be drug dependent and potentially in need of treatment.
• Unprotected sex between men is another important factor for HIV transmission among prison inmates.
• A 1993 survey in Rio de Janeiro, Brazil suggested that 73% of male prisoners had had sex with other men in prison. In New South Wales, Australia, a study in 1994 found that 8% of prisoners reported having engaged in anal or oral sex in prison. As with other self-reported findings, the true figure is likely to be higher. In Kamfinsa prison, Zambia, 8.4% of men reported anal sex in a study in 1995.
• Apart from consensual sex, male rape is not uncommon in some prisons. Given that force will be used, and that condoms will almost certainly not be employed, the risks of HIV transmission are high.
• Tattooing and other forms of skin piercing are common and carry some risk of HIV transmission, since the equipment is rarely sterilized. Blood brotherhood rituals, involving the mixing and exchange of blood, also occur.
• HIV transmission in prison settings can be reduced by: provision of liquid household bleach, and instructions as to its correct use for sterilizing needles and syringes, as well as for cleaning tattooing equipment; needle exchange programmes, whereby a used needle is exchanged free for a sterile (clean) one; discreet and easy access to condoms and lubricants for all prisoners.
• Other factors which can help in reducing HIV transmission are an end to overcrowding in prisons, and control of prison health by the public health authorities, acting freely and independently of the prison service.

Conditions ideal for HIV spread:
Prison conditions are often ideal breeding grounds for onward transmission of HIV infection. They are frequently overcrowded. They commonly operate in an atmosphere of violence and fear. Tensions abound, including sexual tensions. Release from these tensions, and from the boredom of prison life, is often found in the consumption of drugs or in sex. When the drugs are injected, which they frequently are, needles -- being scarce, illegal and difficult to hide -- are almost always shared. In fact, the needles are often ingenious home-made devices, crafted from things such as ball-point pens.

Prison staff also at risk:
Both prisoners and prison staff run the risk of HIV infection in prisons. Prison officers may become infected, for instance, if they stick themselves on a hidden, infected needle while conducting a routine search of lockers.

Not cut off . . . but part of society:
Prisons, in fact, are not cut off from the world outside. Most prisoners leave prison at some point to return to their community, some after only a short time inside. Some prisoners enter and leave prison many times. In Ireland, with a prison population of around 2,200, the annual turnover of prisoners is about 10,000 and the average sentence 3-4 months. Furthermore, out of the estimated 1,600 people in that country with HIV, some 300 to 500 have been through the prison system. What is so special about prison conditions as regards HIV, compared with the outside world? The fact is that inmates (and to a lesser extent staff) who are still free of infection are particularly susceptible to the virus. Prisoners are frequently denied the means to protect themselves from high-risk behaviours. They may also lack access to information, education and reasonable medical care.

How has this alarming situation arisen?
What are the main problems that have created the alarming situation existing today in most of the world's prisons -- in some cases, the situation that exists as well in society at large?

Drug injecting:
Many prisoners crave some form of drugs. Many of them are in prison in the first place because of offences related to drugs. The doubling of the prison population (to a total of 1.6 million men and women) in the United States in the decade up to 1995 -- and its consequent overcrowding -- are in large part due to a policy of actively pursuing and imprisoning those dealing in and consuming illegal substances. Whatever the legal merits of that policy, from the point of view of the spread of HIV it has proved disastrous. Recent figures have shown that 2.3% of inmates in state prisons, and 1.0% in federal prisons in the US are HIV positive. In 1992, 24% of all deaths in US state prisons were due to AIDS. Sharing of injecting equipment is a highly efficient way of rapidly passing HIV around -- much more so than sexual contact. A recent survey in a women's prison in Lower Saxony (Germany) showed that about a third of those sampled were injecting drug users. Of those injecting, 4.9% of them were infected with HIV, as against 0.5% of the non-injecting women. In Thailand -- a country that has endured one of the fastest spreads of the epidemic in Asia -- the first wave of HIV infections occurred in 1988 among drug injectors. From a negligible percentage at the beginning of the year, the prevalence rate among injectors rose to over 40% by September, fuelled in part by transmission of the virus as injectors moved in and out of prison.

Sex in prisons:
Sexual contact between men is common in prisons around the world. Estimates vary considerably. A 1993 survey in Rio de Janeiro, Brazil, suggested that 73% of male prisoners had had sex with other men in prison, while surveys in Zambia, Australia, England and Canada have come up with figures of between 6% and 12% -- figures which are probably low because of denial and under-reporting. The sex may be consensual, but it can also be coerced, to a greater or lesser degree. Rape also exists, and in some prisons is considered usual, sometimes as a form of institution-alized initiation, where it can take the form of gang rape. Many inmates are in prison for violent crimes. Some are mentally unstable. In the tense and claustrophobic atmosphere of prisons -- with their own rules, hierarchies, alliances and enmities among the prisoners -- attacks on prisoners, including sexual ones, can easily occur. Systems of enslavement also exist. Sex between men in prisons includes anal sex. Unprotected, this is a high-risk factor for transmission of HIV. The risk is even higher if lubrication is not used, and if sex is forced, as in the case of rape. Condoms are not available in prisons as a rule. In women's prisons where there are male prison staff, sex between men and women may also take place, creating a risk of HIV transmission.

Tattooing, skin piercing and blood brotherhood rites:
Tattooing is common in prisons and equipment is frequently shared, creating a risk of HIV transmission. There are similar risks where skin piercing is practised. The practice in some prisons of ``blood brotherhood'' rites, clearly presents a high risk of HIV infection.

Lack of education, information and medical care:
The potential for the spread of HIV is usually increased by a lack of information and education, and by a lack of proper medical care. In particular, other diseases transmitted in prison are often not treated properly, including diseases which can be transmitted by shared blood. Apart from HIV and syphilis, these include hepatitis B and C. And other sexually transmitted diseases (STDs), such as syphilis and gonorrhoea -- if left untreated -- can greatly increase an individual's vulnerability to HIV through sexual contact. A particularly serious health consideration is tuberculosis (TB), which can easily spread in overcrowded prison conditions. People with HIV are especially vulnerable to TB, and HIV-positive people with TB can transmit this disease to those not infected with HIV. The contribution of overcrowding to the climate of violence and tension in prisons is great, as is, indirectly, its contribution to the spread of HIV and TB.

What can we do to stop the spread of HIV in prison?
Demand reduction, harm reduction and treatment for drug-dependent prisoners. What can be done to stop the spread of HIV in prisons through injecting drugs? One of the first measures is to offer treatment for those who wish to continue substitution therapy (e.g. with methadone) that may have been started on the outside. Offering treatment to reduce demand or to help break addiction is another important measure. These steps are crucial and respect the rights of prisoners to the kind of care and concern that is available on the outside, rather than simply denying that drug injecting takes place inside, a reaction that is still all too common.

But long experience has shown that drugs, needles and syringes will find their way through the thickest and most secure of prison walls. In the past few years prison authorities in a number of countries have taken active steps to find constructive ways to reduce the risk of HIV spread through injecting. These usually come under the heading of ``harm reduction'' or ``risk reduction''. They are not necessarily easy options to embark on, and they have ethical as well as practical problems attached to them. They have usually been undertaken as a pilot project, or a form of experiment, in the first place. Success with them to date has led to their being continued, and indeed extended into other prisons and other countries. Hindelbank (see box) was not in fact the first prison to make clean needles available free to prisoners, though it was the first to evaluate such a scheme scientifically. Oberschöngrün, also in Switzerland, started an unofficial scheme in 1993. Since the success of Hindelbank, other prisons -- including two in Germany and one in Geneva -- have launched their own schemes. An important way for a prison service to get started on such a scheme, and to overcome all the objections that are liable to be raised, is to treat it very much as an experiment in the first place, and to evaluate it after, say, a year of operation. Another strategy is to provide liquid bleach, together with instructions on correct use, to sterilize needles and syringes. This is perhaps an easier intervention to introduce into prisons, partly for the reason that bleach already exists -- almost unnoticed -- in many prisons, for the purposes of cleaning toilets. Several prisons in Europe, Australia, Africa and Central America have brought in this policy. There was a fear that bleach could be misused, for attacks on prison staff or other prisoners, for instance, but this has not been a problem.

UNAIDS recommends that prison services should actively find ways of setting up pilot schemes to reduce the risk of HIV infection among drug-using prisoners through treatment programmes and through risk reduction by distributing free, clean needles and syringes, as well as by providing bleach, together with appropriate instructions. This is already being done in a growing number of prisons throughout the world. Peer educators (including ex-prisoners, and ex-injectors) can provide education on using clean injecting equipment, as well as help in drug cessation programmes. Only through these means will the appalling spread of HIV through needle sharing in prisons -- with its direct impact on the general community -- be reduced.

Providing condoms:
Recognizing the fact that sexual contact does occur and cannot be stopped in prison settings, and given the high risk of disease transmission that it carries, UNAIDS believes it vital that condoms, together with lubricant, should be readily available to prisoners. This should be done either using dispensing machines or supplies in the prison medical service. Over the past decade, a good number of countries have begun to distribute condoms in their prisons. Unfortunately, there still exists a strong current of denial in many places about male-to-male sex (especially in prison) and a corresponding refusal to do anything which might be seen as condoning it. These attitudes will have to change if societies want to see the rate of HIV infection -- inside prison and outside of it -- decrease.

An end to overcrowding and a lessening of violence:
The risk of disease transmission and the atmosphere of violence created are two more reasons for actively seeking reforms to reduce prison overcrowding. It is important to prevent violent attacks on prisoners, including sexual abuse and rape -- condoms are not going to be of use. Prison staff should be trained to avoid unnecessary force or brutality, and to respect the rights, dignity and well-being of prisoners.

Making tattooing safe:
For tattooing, a simple expedient is to provide bleach to sterilize tattooing needles and guns. Since tattooing is generally regarded as a more acceptable practice than drug injecting (even many prison officers are tattooed -- in Europe, about 30% of them), this preventive measure can be introduced more easily than bleach for injecting needles. In fact, bleach for tattooing equipment can be a way of introducing the option of bleach for drug injectors. However, blood brotherhood practices cannot be made ``safe'' by using clean equipment. Education on the high disease risks of such practices may eventually discourage them from taking place.

Adequate health care and information:
Facilities for general health checks, including particularly for STDs, should be provided in prisons, along with all necessary information. As regards tuberculosis, its prompt detection and proper treatment in prison settings are particularly important from a public health point of view, all the more so since multi-drug-resistant TB is becoming more common.

No isolation of prisoners on grounds of HIV status:
Sometimes prisoners are isolated or placed in a particular wing of the prison. Measures of these kinds, if they are to be carried out, should be done without any reference to whether the prisoners are or are not infected with HIV.

Health in prisons -- whose responsibility?
All the methods so far listed are of vital importance. But there is one structural change which, on its own, could have a very great impact in the long run on AIDS in prison. This is to transfer control over prison health to public health authorities. Of course, in making such a move, proper resources must be provided at the same time, and freedom of action of the new prison health authorities guaranteed. Some countries have already introduced such a change in prison health administration. Norway was one of the first. And in France, where prison health was transferred to the Ministry of Health in 1994, a positive impact is already evident. Each prison in France is twinned with a public hospital. Condoms are available in the medical unit and there are discussions in progress on distributing clean needles and syringes. In Les Baumettes prison in Marseilles, conditions have improved noticeably since the transfer of responsibility for health.

"HIV/AIDS in prisons remains a difficult and controversial subject. The activities in prisons that spread HIV - notably sex and drug use - are usually criminal within the prison environment and meet with disciplinary measures, not health measures. Often there are not enough resources to provide basic health care in prisons, much less HIV/AIDS programmes. Yet the situation is an urgent one. It involves the rights to health, security of person, equality before the law and freedom from inhuman and degrading treatment. It must be urgently addressed for the sake of the health, rights and dignity of prisoners; for the sake of the health and safety of the prison staff; and for the sake of the communities from which prisoners come and to which they return. With regard to effective HIV/AIDS prevention and care programmes, prisoners have a right to be provided the basic standard of medical care available inthe community." Statement by UNAIDS to the United Nations Commission on Human Rights at its Fifty-second session - April 1996

"If there is one thing, more than anything else, which should be done, it is that health in prisons must come under the responsibility of the public health authorities. The link between health in the community and health in prisons must be made as strong as possible." Professor Tim Harding, University Institute for Legal Medicine, Geneva

The Hindelbank experiment: providing clean needles:
A one-year experiment to provide sterile needles was launched at Hindelbank women's prison, Switzerland, in June 1994. A year later, because of the success of the project, it was decided to continue with it. The prison holds up to 100 women, in six wings, with most of the prisoners serving sentences for drug offences. In the project, dispensing machines were set up in various accessible locations (showers, toilets, storage areas) to provide sterile needles.

Prisoners were allowed to keep one (but no more than one) piece of injecting equipment, and only in a specially designated cabinet. The evaluation at the end of the first year of the project's operation showed that there had been no new cases of HIV or hepatitis in the prison and that the prisoners' health had improved. Furthermore, a significant decrease in needle sharing was observed, there was no evident increase in drug consumption, and needles had not been used as weapons.

UNAIDS Best Practice materials:
The Joint United Nations Programme on HIV/AIDS (UNAIDS) is preparing materials on subjects of relevance to HIV infection and AIDS, the causes and consequences of the epidemic, and best practices in AIDS prevention, care and support. A Best Practice Collection on any one subject typically includes a short publication for journalists and community leaders (Point of View); a technical summary of the issues, challenges and solutions (Technical Update); case studies from around the world (Best Practice Case Studies); a set of presentation graphics; and a listing of key materials (reports, articles, books, audiovisuals, etc.) on the subject. These documents are updated as necessary.

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Last updated August 27, 1997

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