Women Prisoners and Female Partners of Male Prisoners
- Harm reduction strategies such as education, distribution of clean needles and condom provision within prisons can reduce the risk of HIV infection in female prison populations.
- Providing voluntary, confidential, no-cost HIV testing (with written informed consent), along with access to antiretroviral therapy can reduce HIV transmission.
1. Making opioid agonist treatment available in prisons can be effective in reducing HIV transmission.
A systematic review in accordance with the guidelines of the Cochrane Collaboration found that compared to inmates without access to opioid agonist treatment, the risk of injecting drug use was reduced by 55% and the risk of needle and syringe sharing was reduced by 47% for inmates treated with opioid agonists. No study reported a direct effect of prison opioid agonist treatment on HIV incidence. Opioid agonist treatment is provided in prisons in 30 countries, including Indonesia and Iran.
A review with 21 studies concerning opioid maintenance treatment in prisons found that benefits of prison opioid maintenance treatment was similar to those in community settings, with an opportunity to recruit opioid users into treatment. However, all the studies done in resource-limited settings were with men only.
“Given that many prisoners have severe problems with illegal drugs, it would be unethical not to use the opportunity that imprisonment provides for treatment” (Jurgens et al., 2009b: 62). A 2009 review of international implementation of opioid agonist, along with a 2004 Cochrane review, found that opioid agonist treatment is the most effective treatment available for heroin dependence, resulting in reduced heroin use, HIV transmission and mortality. Opioid agonist treatment is currently available in community and prison settings in: Albania, Azerbaijan, Belarus, Bosnia and Herzegovina, Bulgaria, China, Croatia, Czech Republic, Estonia, Georgia, Hong Kong, Hungary, India, Iran, Kyrgyzstan, Latvia, Lebanon, Lithuania, Macedonia, Malaysia, Mauritius, Mexico, Moldova, Myanmar, Nepal, Poland, Romania, Serbia, Slovakia, Slovenia, South Africa, Taiwan, Thailand, Ukraine, Uzbekistan and Vietnam. However, China and Russia, countries with large prison populations, do not provide any of these services in prison.
2. Harm reduction strategies such as education, distribution of clean needles and condom provision within prisons can reduce the risk of HIV infection in female prison populations. (Farabee and Leukefield, 1999; Dolan et al., 1998, cited in Farmer, 1999).
A study of harm reduction programs in prisons in Moldova from 2007 to 2008 with seven site visits to prisons, including one women’s prison, and one site visit to a pretrial detention facility, along with interviews with prisoners, pretrial detainees, staff of an NGO that provides harm reduction services in prisons and penitentiary staff officials and employees at national and local levels found that comprehensive harm reduction services in prisons has suggested a reduction in the prevalence of HIV and Hepatitis C and reduction in HIV-related stigma and discrimination. Prior to the project, both guards and prisoners isolated and avoided prisoners who were thought to be HIV-positive. In 1999, legal changes made safe distribution of clean needles within prisons allowable and harm reduction is now part of the national HIV/AIDS plan from 2006 to 2010. In 1999, prison authorities allowed distribution of clean needles within prisons only because they were legally required to do so; but by 2007, prison officials realized that distribution of needles resulted in a decline in HIV cases and increased safety for staff and prisoners. Starting in 1999, peer educators within prisons distributed safe needles and razors, with almost 100% of needles distributed returned. Shared razors can transmit Hepatitis C and distribution of razors gives an incentive for all prisoners to visit peer distributors. All prison staff are trained to act as though all prisoners are HIV-positive and therefore to use rubber gloves when handling blood or other bodily fluids, thus reducing HIV stigma. Estimates are that the number of HIV-positive prisoners has decreased from 200 in 2002 to 145 in 2008, with more prisoners requesting HIV tests. Prisoners report never sharing injecting drug equipment. Used syringes are incinerated on prison grounds. Prison officials would like to conduct a scientifically rigorous evaluation to show that the reduction in HIV cases is due to the program; however, a randomized controlled trial would be unethical.
Needle exchange programs have been introduced to 12 countries in Western and Eastern Europe and Central Asia. A comprehensive review of the published literature on harm reduction programs in prisons found that “there is evidence that needle and syringe programmes are feasible in a wide range of prison settings, including in men’s and women’s prisons... There is evidence that providing clean needles [is] effective in reducing... HIV infections. At the same time, there is no evidence to suggest that prison-based needle exchange programs have serious, unintended negative consequences. In particular, they do not appear to lead to increased drug use or injecting, nor are they used as weapons” (Jurgens, 2007b: 5; Jurgens et al., 2009b: 61). In addition, “since most prisoners leave prison at some point to return to their community, implementing needle and syringe programs in prisons benefits not only prisoners and prison staff, but also the people in the sexual and drug injecting networks in which prisoners participate after their release” (Jurgens et al., 2009b: 61).
3. Providing voluntary, confidential, no-cost HIV testing (with written informed consent), along with access to antiretroviral therapy can reduce HIV transmission. [See also Treatment]
A study in Indonesia with 888 incoming prisoners and 886 resident prisoners (96.5% men) found that providing written informed consent for voluntary, confidential, no-cost HIV testing along with access to antiretroviral therapy resulted in all prisoners eligible for antiretroviral therapy started on treatment. Of 888 incoming prisoners, 639 agreed to be tested, 46 were HIV-positive and had their CD4 count measured, the 17 with CD4 counts under 200 and were started on treatment. Of 886 resident prisoners, 57 agreed to be tested, 17 were HIV-positive and had their CD4 count measured. Eight had CD4 counts under 200 and initiated treatment (Nelwan et al., 2010). Given that treatment reduces the risk of transmission as well as improving health, and that prisoners often return to communities where they have sexual and/or injecting drug relationships, accessing treatment within prisons can reduce overall transmission.
Between 2008 and 2010, a project in a prison in Côte d’Ivoire provided HIV testing upon request. Women represent 3% of the prison population. Among 15,355 detainees, 10,817 received counseling. Of these 73% accepted HIV testing. HIV seroprevalence was 5.6% (men, 5.1% and women 17.1%) compared with a national prevalence of 3.9%. Active TB was diagnosed in 172 of the 1,348 persons screened for TB of whom 27% were co-infected with HIV. Care and drug therapy was provided to 446 HIV-positive prisoners and guards.