Prevalence of HIV, HCV, and TB in prisons
HIV infection is a serious problem in prison systems in the region, and one that requires immediate action. Levels of HIV infection among prison populations tend to be much higher than in the population outside prisons. They are particularly high in countries in which there are high rates of HIV infection among people who inject drugs, many of whom spend time in prison, and some of whom continue to inject while incarcerated. Seroprevalence studies undertaken in prisons in Eastern European countries and in some countries in Central Asia have documented among the highest HIV prevalence rates in prison in the world, often vastly exceeding the “official numbers” provided by prison administrations (which are based on the number of prisoners living with HIV known to the administration). For example, in Ukraine, in an HIV seroprevalence study undertaken in 2004, between 16 and 32 percent of prisoners at the seven facilities in which the study was undertaken tested positive for HIV.

HCV rates are even higher, with studies showing that over 90 percent of prisoners in some prisons in the region live with HCV.

High rates of HIV and HCV in prisons are often accompanied by high rates of tuberculosis (TB), and prisons constitute breeding grounds for TB and multidrug-resistant TB (MDR-TB) and can fuel TB/HIV co-epidemics. In some countries in the region, one third of all TB cases are in prisoners. The Baltic States and the Russian Federation have the highest rates of MDR TB in the world.  Late diagnosis and treatment, poor prison conditions, poor nutrition and overcrowding help spread the disease.

Drug use, HIV and HCV, and prisons
Illicit drugs are available in prisons around the world despite the sustained efforts of prison systems to prevent illicit drug use by prisoners – by doing what they can to prevent the entry of drugs into prisons, tightly controlling distribution of prescription medications, and enforcing criminal prohibitions on illicit drug possession and use among prisoners.

Many prisoners come to penal institutions with established drug habits. In fact, many prisoners are in prison in the first place because of offences related to drugs. These may be crimes related to drug production, possession, trafficking or use, or crimes committed to acquire resources to purchase drugs.

Many prison systems have seen significant increases in their population (and consequent overcrowding) attributable in large measure to a policy of actively pursuing and imprisoning those dealing with and consuming illegal substances. People who used drugs prior to imprisonment often find a way to continue drug use on the inside. Other prisoners start using drugs in the penal institution, as a means to release tensions and to cope with being in an overcrowded and often violent environment.

Of particular concern in the context of HIV and HCV is that studies have shown that injecting drug use is prevalent in prisons in the region.

Risk of HIV and HCV transmission
Many of those who inject drugs in penal institutions share needles and syringes. Because it is more difficult to smuggle needles and syringes into penal institutions than it is to smuggle drugs into them, needles and syringes are very scarce. Often, only a handful of needles will circulate among a large population of prisoners who inject drugs. For example, in Russia, prisoners have reported that a single syringe may serve a whole wing of 40 cells, be used by as many as 200 individuals, or be passed through the chain link fence that is supposed to separate HIV-positive from HIV-negative prisoners. Often, the injecting equipment is home-made, with needle substitutes fashioned out of hardened plastic and ball-point pens, often causing damage to veins, scarring, and severe infections.

Evidence of rapid spread of HIV and HCV, as the result of high rates of injecting drug use and needle sharing due to the lack of access to sterile injection equipment, has been documented in a number of prison systems, including in countries in Eastern Europe. In Central Asia prison populations have been called a “driver” of tuberculosis and HIV epidemics and are aggravating HCV epidemics.

Risk of overdose upon release
Even people who inject drugs who manage to stop (or reduce frequency of) injecting while in prison often resume injecting once released from prisons, and do so with increased risk for fatal overdose as a result of reduced tolerance to opiates. Extensive research has noted a large number of deaths during the first weeks after discharge from prison that are attributed to drug overdose. This points to the utility and necessity of prison through care of drug treatment to counteract such risk situations and highlights the importance of providing methadone maintenance treatment not only as an HIV prevention strategy in prisons (see below), but as a strategy to reduce overdose deaths upon release.

Public health implications – why everyone should care
Due to the closed nature of prisons, the health of prisoners is an issue that rarely comes to the attention of the public at large. However, the health of prisoners is an issue of public health concern. Prison presents a prime opportunity to respond to behaviours that pose a high risk of  transmission of HIV and HCV, such as needle sharing, using proven public health measures such as needle exchange programs.

Everyone in the prison environment – prisoners, prison staff, and their family members – benefits from enhancing the health of prisoners and reducing the incidence of communicable disease. Measures to decrease the risk of HIV and HCV transmission make prisons a safer place to live and work.

The high degree of mobility between prison and community means that communicable diseases and related illnesses transmitted or exacerbated in prison do not remain there. When people living with HIV and/or HCV are released from incarceration, prison health issues necessarily become community health issues.

What needs to be done?
Much can be done to reduce the risk of transmission of diseases such as HIV and HCV through injecting drug use in prisons. All countries in the region have introduced some HIV and HCV interventions in prisons, but most exclude needle and syringe programs, although there is evidence from prisons in a number of countries, including Moldova and Kyrgyzstan, that they are effective in decreasing the risk of infection and have not had any negative, unintended consequences (see the section on evidence for more details). Access to evidence-based drug dependence treatment, in particular methadone maintenance treatment for prisoners dependent on opioids, also remains extremely limited, even in countries that have made some treatment available. There is an urgent need to introduce comprehensive programs, including:

• information and education, particularly through peers

• provision of condoms and interventions to combat sexual violence

• voluntary counselling and HIV testing

• HIV treatment, care and support, including provision of antiretroviral treatment, for all prisoners who need it

• needle and syringe programs

• evidence-based drug dependence treatment, in particular, methadone maintenance treatment.

Human rights and prison reform
Finally, addressing HIV, HCV, and TB in prisons effectively cannot be separated from wider questions of human rights and prison reform. People in prison are vulnerable to human rights violations and they are vulnerable to HIV, HCV, and TB. Prison conditions, the way in which prisons are managed, and national policy all impact on the issues of HIV, HCV, and TB in prisons.

Overcrowding, violence, inadequate natural lighting and ventilation, and lack of protection from extreme climatic conditions are common in many prisons in the region.  When these conditions are combined with inadequate means for personal hygiene, inadequate nutrition, lack of access to clean drinking water, and inadequate health services, the vulnerability of prisoners to HIV infection and other infectious diseases is increased, as is related morbidity and mortality.  Sub-standard conditions can also complicate or undermine the implementation of effective responses to health issues by prison staff.  Therefore, action to prevent the spread of infections in prisons and to provide health services to prisoners living with HIV, HCV, and/or TB is integral to – and enhanced by – broader efforts to improve prison conditions. This is why efforts to stop the transmission of HIV in prisons must start with making HIV prevention measures available, but should include reforms aimed at addressing these underlying conditions.

Prisoners retain all rights that are not taken away as a fact of incarceration. Loss of liberty alone is the punishment, not the deprivation of fundamental human rights.  Like all persons, prisoners have a right to enjoy the highest attainable standard of health. In the context of HIV, HCV, and TB, this includes a right to comprehensive and evidence-based prevention tools and effective treatment for those who need it.