|Prison & probation|
|Written by Kate Dolan|
AIDS, DRUGS AND RISK BEHAVIOUR IN PRISON: STATE OF THE ART
Kate Dolan, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
The study of HIV transmission, risk behaviours and prevention in the prison setting is a difficult but important task. The difficulties lie in gaining access to inmates, obtaining representative samples and reliable reports of risk behaviour, and collecting conclusive evidence of HIV transmission in prison. This area of research is important because the high level of inmate turnover means that HIV transmission in prison threatens HIV control in the community when inmates are released. Research is required to evaluate the effectiveness of HIV prevention measures in prisons as little such evidence exists. Most studies of HIV transmission in prisons have found few cases. This has been interpreted as HIV transmission being low in prisons. Yet there are. conditions in most prison systems that are conducive to the transmission of HIV but which also hinder detection of transmission. Approximately one-third of all inmates inject drugs while in prison but they serve short sentences and are therefore under-represented in annual cohort studies of transmission. The dramatic reduction in injecting risk -behaviour in community settings has not occurred in prisons. Efforts to prevent HIV infection will be undermined if concerted efforts do not include prisoners.
After considering the characteristics of prisoners and ethics of prison research, this article reviews the literature on the prevalence of HIV infection among prisoners, the proportion of prisoners who are drug injectors and the risk behaviours in which prisoners engage such as drug injecting, tattooing and sexual activity. In order to improve our understanding of the likelihood of HIV infection in prison, the evidence of HIV transmission in prison is also reviewed and the notion of mixing, or the extent of intermingling of inmates that is integral to prison systems, is considered.
Correctional facilities can be stressful, crowded and violent places where drug withdrawal is common (Turnbull and Stimson, 1994). Although imprisonment has been shown in some studies to reduce drug use (Shewan et al., 1994), inmates have reported injecting drugs (Taylor et al., 1995) and engaging in homosexual activities (Dolan, 1994) for the first time while incarcerated. These have been attributed to boredom and the single sex nature of correctional establishments.
Research into special populations usually raises a number of ethical issues. Prisoners, haying lost many basic civil rights, are a particularly vulnerable group. The World Health Organization emphasised the importance of ethics committees in its guidelines for HIV research in prison: 'independent examination by an ethical review committee should be carried out for all research procedures in prisons and ethical principles must be strictly observed. The results of such studies should be used to benefit prisoners (WHO, 1993, p2).
One major role of ethics committees is to ensure that potential respondents or subjects are not harmed by research. But ethics committees also have the potential to produce long-term detrimental effects on the very populations they are trying to protect.
The lack of prison data has made it difficult to argue a case for implementing HIV prevention in correctional facilities. It was reported in a study of HIV transmission in a US prison that 'prior ethic committee review precluded individual interviews for high risk histories' (Brewer et al., 1988; p366). Consequently, the study was unable to determine whether HIV transmission occurred in prison or prior to prison. It was also impossible to obtain an appropriate denominator for the measurement of incidence, i.e. confining the population studied to those who reported engaging in risk behaviour in' prison rather than the entire study sample.
Inmates' knowledge, attitudes and behaviour were studied in Toronto in order to produce AIDS educational material. But the effectiveness of such material produced is likely to have been impaired as (permission to conduct (the) study was granted pro-, viding the behaviour questions did not inquire I about sex and drug use in prison' Joepell, 1992, p39).
The WHO guidelines on HIV in prison recommend studies of risk behaviour to inform planning policies and intervention, but they stipulate that 'prison administrations should not seek to influence the scientific aspects of such research procedures, their interpretation or their publication'( 1993, p2).
Collecting data on risk behaviours in prison is important because the absence of such data can be used to justify inaction. In the UK, for example, 'Home Office ministers have not been convinced that making condoms available for use in prison, would be appropriate or helpful' (Groves, 1991).
This suggests that the ministers leave open the possibility that in the future they may be convinced of the appropriateness of providing condoms in prison. They have, however, ruled out the possibility of syringe exchange: 'even though the [prison medical] service recognises that some inmates will gain access to injectable drugs and will share injecting equipment, needle exchange schemes in prison cannot be contemplated' (Groves, 1991).
Most prison authorities have had policies to test prison entrants for HIV infection (Harding and Schaller, 1992). Sometimes this has been on a mandatory basis even though voluntary testing can be just as accurate in determining HIV prevalence (Hoxie et al., 1990). However, in a voluntary pilot HIV testing programme among inmates in London, onlyO.3% of the 54% who agreed to participate tested positive. This was probably an underestimate as another study found 5% of recently released prisoners were infected in 1990 (Turnbull et al., 1992). This low level of compliance may be partly a result of the restrictions imposed on infected inmates orinmates thought to be infected (Turnbull et al., 1993). Infected inmates are often segregated which precludes confidentiality of their HIV status (Harding and Schaller, unpublished).
HIV surveillance has been the most common form of HIV research in prison (Table 2). HIV prevalence among prisoners has ranged from 0% in Iowa, USA in 1986 (Glass et al., 1988) to 34% in Catalonia, Spain in 1989 (Martinet al., 1990). The high prevalence reported among Spanish prisoners reflects the high prevalence of HIV among IDUs and their considerable over-representation in the prison population.
EVIDENCE OF HIV TRANSMISSION IN PRISON
The only study to conclusively demonstrate significant HIV transmission in prison setting (Tayloret al., 1995) was fortuitously prompted by several acute cases of hepatitis B infections. These infections, along with two possible primary HIV infections, suggested surprisingly high levels of risk behaviours. (This study is described on page 10 as Study T)
The most common methodology used to study HIV incidence in prison has been repeated mass screening of inmates, usually on entry and annual follow-up. This method underestimates HIV incidence for several reasons. Prisons are dynamic institutions where the number of annual prison entrants and internal transfers is usually double and treble the daily census. With so many movements into, out of and around the prison system, annual cohort studies will over-represent inmates with longer sentences who are less likely to become infected with HIV Conversely, drug-using offenders who are at most risk of infection in prison will be under-represented in cohort studies as they tend to be held on remand (awaiting trial) or serve short sentences.
The next most common methodology is studies of inmates incarcerated for very lengthy periods. The extensive duration of imprisonment suggests that it is highly unlikely that the inmates could have acquired HIV infection before imprisonment and still be alive. However, the main shortcoming with these studies is that the denominator for the number infected is unknown and so rates of transmission can, not be estimated.
In the following section, evidence of HIV transmission in prison from reports and studies was considered in three ways. Evidence was considered first on the strength of methodology to demonstrate transmission; second, on the extent of transmission that may have occurred; and third, on aspects of the study design that may have influenced the results.
HIV infection among IDUs presenting for drug treatment in Bangkok rose from 2% in early February to 2 7% by early March in 198 7 (Wright et al., 1994) and up to 43% in September 1988 (Choopanya, 1989). The dramatic increase closely followed an amnesty on the king's birthday when numerous prisoners were released. Substantial HIV transmission in prison is believed to have been responsible for rapid dissemination of HIV (Wright et al., 1994).
This study was only suggestive of transmission having occurred in prison, but indicated that the extent can be potentially considerable.
This evidence is only suggestive of HIV infection in prison and there was no indication of the extent of transmission as no denominator was provided.
This can be regarded as a definite case of HIV infection occurring in prison, but no indication of the extent of transmission can be made.
The possibility that the inmates were infected before entering prison cannot be excluded. The extent of reported transmission was very low, but the study sampled only long-term prisoners and the extent of transmission may have been underestimated.
The evidence of infection occurring in prison was strong, but not beyond doubt. Again, the sample studied consisted of long-term prisoners who are probably at lower risk.
No evidence of HIV transmission was detected in this study. However, the only data presented on the sample suggests that this military sample was atypical of civilian prison populations. In the sample, 15% and 38% of inmates had drug and sex offences, respectively. As these proportions in the general prison population are usually reversed, it would be unwise to generalise to other prison systems. As previously indicated, inmates in maximum security generally have very limited opportunities to associate with other inmates, engage in risk behaviour and to become infected with HIV The policy of segregating HIV infected inmates may also have reduced the risk of HIV transmission. No information was provided on how the 913 inmates who were tested had been selected. The follow-up rate was low (59%) although the duration of follow-up was long (mean = 15 months; 542 inmates represented 685 person-years of prison).
The 2% incidence for hepatitis B was high, but it was not possible to determine whether these transmissions occurred in prison. Also, no information was provided on the baseline prevalence of hepatitis B, risk behaviours or whether these inmates were segregated. Although no evidence of HIV transmission emerged, the extent to which generalisations can be made from a maximum security military prison to prisons with different security levels or with a civilian population is unclear.
Inmates who refused to participate or were missed in the follow-up were significantly more likely to have been committed for a drug offence, be black or have a sentence of less than five years. Furthermore, inmates who had been released before generating eligibility lists differed on most characteristics from those enrolled in the study. These characteristics were thought to be associated with shorter sentence lengths. The authors noted that 'prior ethic committee review precluded individual interviews for high risk histories'(1 988, p366).
Although the study demonstrated HIV transmission had occurred, it was unclear whether inmates had become infected before or during imprisonment. The study concluded that the extent of transmission was limited to two inmates. However, 83% of all prison entrants were excluded from the study and excluded inmates were similar to inmates who were infected at entry. The study sample under-represented drug injectors who would be at a far greater risk of HIV infection than other prisoners. This suggests that the study design may have resulted in transmission being underestimated. Nevertheless, application of this incidence figure to the Maryland prison population indicates that 60 HIV infections occur annually (Hammett et al., 1993).
It was unclear whether the infections occurred in prison as inmates had only been incarcerated for a relatively short period before they tested negative. The extent of transmission was limited to three inmates becoming infected. However, inmates on short sentences were under-represented and, consequently, incidence may also have been under-represented.
The evidence of transmission in prison was' strong but infection could have still occurred before incarceration. The extent of transmission was higher than all other studies but was still low. The study relied on mass screening over a one-year period which meant short term prisoners were missed.
Although only 38% of drug injecting inmates were tested, there was a strong association between becoming infected and injecting in prison in early 1993 (p<0.01). Fifteen inmates who had injected in Glenochil tested negative but were still in the window period for HIV seroconversion at the time of the study.
Definitive evidence that HIV infection had occurred in prison was based on early banding patterns on Western Blot tests, antigen results, HIV negative and positive test results, primary symptomatic HIV infection and dates of incarceration. Of the 14 infected inmates, definite evidence of HIV transmission in prison existed for eight, of whom six had become infected in Glenochil Prison, while the possibility of infection in another prison could not be excluded for two others. Another six infections also possibly occurred in prison, but infection occurring outside prison could not be excluded. All inmates infected in prison reported extended periods of sharing syringes.
This study differed from previous studies in three ways: first, it comprised a methodical approach to an apparent outbreak; second, it used precise biological measures to provide irrefutable confirmation of behavioural data; and third, risk behaviour data were collected. It was unfortunate that the inmates who had been transferred to other prisons or released were not followed up. However, the official report speculated on the possible extent of the outbreak in Glenochil (Scottish Affairs Committee, 1994) after discussions with prison medical officers and estimated that, assuming untested inmates were as likely to be IDUs (and therefore become infected) as those who had been tested, then the total number of infected inmates would be between 22 and 43 inmates (compared with the eight detected cases). They also acknowledged that 258 inmates were missed because theywere either transferred (74%) or released (26%) within the six month study period and that some of these may have been infected.
The proportion of IDUs in prison populations can be measured in two ways. First, by the proportion of prisoners reporting a history of injecting drug use (see Table 3) and, second, by the proportion of IDUs reporting a history of imprisonment (see Table 4).
In a multi-site study of IDUs in Europe, between 20 and 57% of IDUs reported a previous incarceration on a mean of two occasions. With few incentives to report either a history of injecting or imprisonment, these figures would probably be underestimates. In this study, only 27% of IDUs in London reported a history of imprisonment, whereas three other studies of IDUs in London found previous imprisonment rates of more than 50% (Dolan et al., 1993).
Being in prison does not necessarily mean that IDUs will engage in risk behaviour. Indeed, IDUs are more likely to stop injecting than continue while in prison (Shewan et al., 1994). Approximately one in four injectors reported continuing to inject drugs while in prison in the UK (see Table 5). Likewise, injecting in prison is not a risk for HIV unless syringes are shared. Therefore, ascertaining the likelihood of sharing is crucial to understanding the potential for HIV spread in prison. Injecting equipment is scarce in prisons and, therefore, is often shared (see Table 5). Even though fewer IDUs inject in prison, a higher proportion of IDUs overall share in prison than in the community (Dolan et al., 1996). While only one quarter of IDUs imprisoned in the UK were injecting, approximately two-thirds of these shared syringes while incarcerated.
Based on current UK data, we can estimate that for every 100 IDUs in a one-year period, 20 will go to prison, five will inject in prison and three of these will share syringes. With the number of IDUs in England (conservatively) estimated to be 75,000 (Advisory Committee on the Misuse of Drugs, 1988), then, each year, approximately 15,000 IDUs are likely to be imprisoned of whom 3750 IDUs will inject and 2475 IDUs will share injecting equipment while in prison.
Few male prisoners report being sexually active in prison (see Table 7). Slightly more male IDU prisoners report male-to-male sexual activity (see Table 8). Some prisoners are particularly vulnerable to sexual assault, such as young prisoners (Heilpern, 1995) and transgender prisoners (Dolan et al., 1996).
Factors identified with syringe sharing among Scottish prisoners were: injecting a wide range of drugs in prison; using temgesic; and discontinuing methadone treatment on prison entry (Shewan et al., 1994).
The approach of most prison authorities to HIV infection conflicts with that of authorities in community settings. Prison authorities in many jurisdictions have vigorously pursued HIV testing programmes in preference to implementing prevention strategies. Therefore, HIV prevalence among prison entrants has been well documented in most countries (although England and Wales are exceptions). In addition, ample data exist on inmates risk' behaviours in a number of countries.
One of the major challenges lies in collecting definite evidence of HIV transmission occurring in prison. Transmission data may best be obtained by a case study approach involving short-term prisoners.
While prisons have the potential for transmitting infections, such as HIV and tuberculosis, they also present opportunities to provide prevention and treatment to a vast number of individuals. But correctional authorities are often (understandably) conservative in their management of prisons and prison medical services are almost always under-funded. These two factors have resulted in poor health care for prisoners, which are a very disadvantaged population compared with community members. The medical case load would be proportionally greater among prison populations and, therefore, prison medical services require proportionately more funding.
Prisoners are a very vulnerable population in many ways and are often treated in a manner that has no parallel in the community. It has been recommended that 'for practical and ethical reasons, measures for the control of AIDS in the prison environment should follow closely the strategy for the community in general. This policy implies an approach based on individual responsibility, in which each prisoner is treated as being autonomous and personally responsible for his own health and for the consequences of his behaviour. Prisoners should be informed about AIDS risk and given the opportunity to take prophylactic measures' (Hardling, 1987, p1262).
The notion of mixing, as mentioned earlier, bias potentially dire consequences for public health, as experienced in Bangkok. The general population needs to be informed about the vast level of intermingling that prison systems promote. Perhaps then the priority of infection prevention among prisoners may receive the attention it deserves. Prison authorities need to be reminded of their duty to care for those in their custody. Some successive attempts to improve a number of HIV issues in prison have been the result of lengthy court battles.
I wish to thank the Psychiatrische Universitatsklinik of Berne for inviting me to present the paper based on this article at the Conference. 1 am very grateful to the Swiss Federal Office of Health for generously funding my visit.
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