In many countries, prisons are underfunded and overcrowded, and injecting drug use is common. Those who enter prison uninfected are at risk of becoming infected, as few countries provide the range of prevention programs required to halt transmission inside.
Once detained, prisoners are often denied access to life-saving treatment for these infections.
This lack of access to treatment and prevention programs is a human rights violation that must be addressed. A series of articles in the Lancet medical journal – released ahead of next week's AIDS 2016 conference in Durban, South Africa – outlines how.
Incarceration of drug users
In the West, more than one-third of inmates have a history of drug injection. In New South Wales, it's about half of inmates. This is in stark contrast with levels of drug injecting in the general population, which are less than 0.5% in Europe and Australia.
While those in the community may not feel at risk, most inmates are released back to their communities. Many prisoners serve short sentences of about six months or less. And sentences served by women tend to be shorter, three months or so.
As part of the Lancet package, we published a review of prevention programs for prisoners including education, voluntary testing and counselling, needle and syringe programs, methadone, condom provision and antiretroviral therapy for HIV.
Only seven countries – Moldova, Kyrgyzstan, Germany, Luxembourg, Portugal, Spain and Switzerland – provide all six interventions in their prisons. However, the actual level of coverage in these countries remains unknown.
Prevention and treatment
The first step in addressing HIV and related infectious diseases among those incarcerated is to reduce the numbers of people in prison and detention for substance use, sex work and other non-violent offences. This change can only happen if there is agreement on what prisons can realistically do and what alternatives to prison can do better.
When a sizeable proportion of inmates have a history of heroin injecting, they should be provided with methadone. Inmates on methadone are less likely to die from an overdose inside or outside prison, and less likely to pick up infections such as hepatitis C. They are also much less likely to return to prison.
Yet we found just 43 countries provide methadone to inmates. Less than 1% of those who need it get it.
Treatment for HIV is now so advanced the condition is a manageable one rather than a death sentence. Importantly, treatment renders HIV-positive people unable to transmit the infection to others.
However, access to treatment is uneven around the world and especially in prisons. We found HIV among prisoners in virtually every country we studied, yet only 43 countries provided treatment for HIV.
Prisoners should also have access to drugs to prevent HIV transmission (called pre-exposure prophylaxis or PrEP), hepatitis B vaccinations, treatments for hepatitis C infection, and condoms.
Perhaps the the most important intervention is drug treatment or mental health treatment, preferably as an alternative to custodial sentences. More than 60% of prisoners have either a substance abuse problem, a mental illness or a dual diagnosis. These are illnesses that need treatment, not punishment.
What about Australia?
Australia compares very favourably to the rest of the world, but large gaps remain.
We have prison methadone programs in most states. However, Queensland restricts this treatment to pregnant prisoners and other states are not meeting demand for the program.
We still do not have a needle and syringe program in any Australian prison, even though infections are spreading. Years of research has shown these programs are safe to operate and reduce injecting and infectious diseases.
The main drug injected in Australian prisons today is ice. While we are still grappling with how we can best treat these people, users should be provided with cognitive behavioural therapy (CBT) to manage their addiction and the underlying problems that led them to use.
While Australia has led the way in the control of HIV in prison, it still has to control hepatitis B and hepatitis C. For every 100 people in prison who has ever injected drugs, 14 will become infected with hepatitis C each year.
Treatment is available and has been provided in NSW for several years now, but most other states have not yet introduced this costly but effective treatment. If other states follow suit, we could virtually eliminate hepatitis C infection from the prison population.
We need to rethink our approach to drug treatment and management in prisons to control the spread of infectious diseases – in Australia and abroad. Drug dependence is a health problem and should be treated as such.