Pubdate: Sat, 03 Dec 2005
Source: Lancet, The (UK)
Section: The Lancet 2005; 366:1834-1835
Copyright: 2005 The Lancet Ltd
Contact:  http://www.thelancet.com/
Details: http://www.mapinc.org/media/231
Authors: Evan Wood, Julio Montaner, Thomas Kerr
Bookmark: http://www.mapinc.org/hr.htm (Harm Reduction)
Bookmark: http://www.mapinc.org/find?136 (Methadone)
Bookmark: http://www.mapinc.org/find?137 (Needle Exchange)

HIV RISKS IN INCARCERATED INJECTION-DRUG USERS

"I've known syringes that have gone through 30--40 people's hands.

I swear to God. They have been used by that many different people", 
so said an inmate referring to syringe sharing in a Canadian prison.1 
The HIV/AIDS epidemic remains a global crisis affecting millions of lives.

While sub-Saharan Africa has the largest burden of HIV/AIDS, in many 
other regions now hardest hit by HIV, such as parts of Asia, eastern 
Europe, and the former Soviet Union, injection-drug users (IDUs) and 
their sexual contacts account for most new infections.2 There is an 
urgent need for interventions to curb the transmission of HIV in this 
population. Unfortunately, in most settings, public resources for the 
problem of injection-drug use are used to fund criminal-justice 
interventions rather than sound public-health programmes.3,4 As a 
result, most countries now have record numbers of IDUs behind bars.3 
In turn, there have been vastly disproportionate rates of 
incarceration of HIV-infected individuals. In one study, more than 
25% of those with HIV in the USA passed through a correctional 
facility each year,5 and in settings around the world where HIV is 
endemic in IDUs, the HIV burden is higher in inmates.3

The incarceration of IDUs has major consequences for public health 
because of the potential for infectious-disease transmission between 
drug-using inmates.

This potential is particularly applicable to HIV transmission, a 
point which received significant attention after a study in a 
Scottish prison.6 Unfortunately, public-health policy-makers have 
mostly failed to respond appropriately to these concerns and, despite 
the diversity of incarcerated populations and prison settings, 
increased HIV risk has been independently associated with 
incarceration in a wide range of settings from Thailand to Canada.1,7--9

Within prisons, HIV-infected populations are often kept close to 
high-risk populations, and these social-network characteristics 
undoubtedly contribute to HIV risk behaviour in these environments.1 
Unfortunately, this problem is made worse because prevention methods 
proven in the community are rarely available in prison. This is 
despite the consensus of many international guidelines that the 
standard of health care for prisoners must be similar to that for the 
general community.

For example, in 1990, the UN General Assembly adopted the principle 
that: "Prisoners shall have access to the health services available 
in the country without discrimination on the grounds of their legal 
situation."10 This principle of equivalence applies to even the most 
controversial HIV-prevention programmes, including needle exchange. 
For instance, in 1993, WHO published a guideline that: "in countries 
where clean syringes and needles are made available to injecting drug 
users in the community, consideration should be given to providing 
clean injecting equipment during detention."10 Whilst there have been 
successes with prison-based needle exchange in several countries,11 
including various resource-limited countries, in most settings where 
HIV is endemic in IDUs this intervention and other strategies, such 
as methadone maintenance therapy, have not been used.

Incarceration does not reduce overall levels of illicit drug use, or 
the related health, social, and fiscal harms.12 Thus the policy of 
mass incarceration of non-violent drug-offenders needs review. 
However, in the short term, there is an urgent need to ensure that 
standards of HIV prevention in prisons are consistent with the best 
available evidence and the standards outlined in international 
guidelines. As HIV continues to spread rapidly in IDU populations 
throughout the world, global control of the epidemic will require 
prison systems to move beyond their traditional role of custody, and 
accept responsibility for the prevention of HIV transmission between inmates.

EW and TK declare that they have no conflict of interest. JM has 
received lecture and consulting fees and research support from ART companies.

JM is a co-holder of patent PCT/EP02/05151 about nevirapine, which he 
was required to take out as part of his employment; he has received 
no income from this patent, and should he do so, any such income will 
not be used for personal purposes.

References

1.  Small W, Kain S, Laliberte N, Schechter MT, O'Shaughnessy MV, 
Spittal PM. Incarceration, addiction, and harm reduction: inmates 
experience injecting drugs in prison. Subst Use Misuse 2005; 40: 831-843.

2.  McCoy CB, Rodriguez F. Global overview of injecting drug use and 
HIV infection. Lancet 2005; 365: 1008-1009.

3.  Ball A. Multi-centre study on drug injecting and risk of HIV 
infection: a report prepared on behalf of the International 
Collaborative Group for the World Health Organization Programme on 
Substance Abuse. Geneva: World Health Organization, 1995:.

4.  The Lancet. Rethinking America's "War on Drugs" as a 
public-health issue. Lancet 2001; 357: 971.

5.  Hammett TM, Harmon MP, Rhodes W. The burden of infectious disease 
among inmates of and releasees from US correctional facilities, 1997. 
Am J Public Health 2002; 92: 1789-1794.

6.  Taylor A, Goldberg D, Emslie J, et al. Outbreak of HIV infection 
in a Scottish prison. BMJ 1995; 310: 289-292.

7.  Beyrer C, Jittiwutikarn J, Teokul W, et al. Drug use, increasing 
incarceration rates, and prison-associated HIV risks in Thailand. 
AIDS Behav 2003; 7: 153-161.

8.  Dolan KA, Wodak A. HIV transmission in a prison system in an 
Australian State. Med J Aust 1999; 171: 14-17.

9.  Burattini M, Massad E, Rozman M, Azevedo R, Carvalho H. 
Correlation between HIV and HCV in Brazilian prisoners: evidence for 
parenteral transmission inside prison. Rev Saude Publica 2000; 34: 431-436.

10. Office of the High Commissioner for Human Rights. Basic 
principles for the treatment of prisoners. Dec 14, 1990:

11. Dolan K, Rutter S, Wodak AD. Prison-based syringe exchange 
programmes: a review of international research and development. 
Addiction 2003; 98: 153-238.

12. The Lancet. Losing tolerance with zero tolerance. Lancet 2005; 
365: 629-630. 
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MAP posted-by: Beth Wehrman