Initiated by UNODC, the UNODC/ILO/UNDP/WHO/UNAIDS policy brief entitled " HIV prevention, treatment and care in prisons and other closed settings: a comprehensive package of interventions" was developed and launched. The policy brief helps countries to mount an effective response to HIV and AIDS in prisons and other closed settings taking into consideration principles of international law including international rules, guidelines, declarations and covenants governing prison health, international standards of medical ethics and international labour standards. The 15 key interventions are:

  1. Information, education and communication (IEC)
  2. Condom programmes
  3. Prevention of sexual violence
  4. Drug dependence treatment, including opioid substitution therapy (OST)
  5. Needle and syringe programmes (NSP)
  6. Prevention of transmission through medical or dental services
  7. Prevention of transmission through tattooing, piercing and other forms of skin penetration
  8. Post-exposure prophylaxis
  9. HIV testing and counselling
  10. HIV treatment, care and support
  11. Prevention, diagnosis and treatment of tuberculosis (TB)
  12. Prevention of mother-to-child transmission of HIV
  13. Prevention and treatment of sexually transmitted infections (STIs)
  14. Vaccination, diagnosis and treatment of viral hepatitis
  15. Protecting staff from occupational hazards

Situation

At any given point in time, more than 10.2 million people are held in penal institutions throughout the world. Virtually all prisoners will return to their communities, many within a few months to a year. Health in prisons and other closed settings is thus closely connected to the health of the wider society, especially as it relates to communicable diseases. Globally, prisons are characterized by relatively high prevalence of HIV, hepatitis B virus (HBV),  hepatitis C virus (HCV) and tuberculosis (TB), as well as elevated risks of contracting such diseases and diminished access to health services.

In some settings, the HIV burden among people living in prisons may be up to 50 times higher than in the general population. HIV transmission in prison is often through the multi-use of equipment among people who inject drugs; consensual or coerced unsafe sexual practices; unsafe skin piercing and tattooing practices; multi-use of shaving razors, blood brotherhood rituals and the improper sterilization or reuse of medical or dental instruments. HIV in prison may also be transmitted from mothers living with HIV to their infants during pregnancy or delivery.

Isolated from public health services including national HIV and TB programmes, prisons and other closed settings are seriously neglected in country responses to address HIV and TB prevention, treatment and care.

Women and HIV in prisons

Women and girls represent 5-10 per cent of the prison population, with 700,000 women and girls held in penal institutions throughout the world. Most women in prison are from socially marginalized groups and are more likely to have been engaged in sex work and/or drug use. Studies have shown that women are at least twice as likely as men to contract HIV through unprotected sexual contact. Many have also been victims of gender-based violence or have a history of high-risk sexual behaviour.

HIV and TB in prisons

TB and HIV are major threats to prison health. HIV prevalence among prison populations can be as high as 50 per cent. TB incidence rates are, on average, 23 times higher than in the general population. TB drug resistance and TB related death rates are higher in prisons than in communities.

HIV and PWUD in prisons

People who use or inject drugs may represent up to 50 per cent of the population of prisoners. In prisons, unsafe drug injecting practices are a major risk factor for the transmission of blood-borne infections such as HIV and hepatitis C. The frequency of multi-use needles and syringes is documented as very high among PWID in prisons.

The evidence base for harm reduction is strong and consistent, however such programmes are rarely implemented in prisons. There are political, legal and regulatory barriers to introducing or expanding harm reduction programmes in prisons. In 2015, opioid substitution therapy (OST) was available in prisons in only 43 countries and only seven countries implemented needle and syringe programmes (NSP) in prisons. The burden of HCV among people in prisons is a major public health concern. The global response to HCV in closed settings has been limited, with few countries implementing the necessary preventive interventions or providing treatment for HCV-infected people in prisons. Greater attention towards HCV prevention, diagnosis, and effective delivery of treatment to detained populations is urgently required.

Prison management and criminal justice

According to the International Centre for Prison Studies, prison occupancy is more than 100 per cent in 113 countries, and above 200 per cent in 22 countries. Prison overcrowding is a global problem that undermines efforts to respond effectively to infectious diseases and other health problems. It increases the risk of HIV transmission through sexual and other types of violence and increasing the exposure to infectious diseases such as TB for those living with HIV in prisons.

The high incarceration rates of sex workers, men who have sex with men, people who inject drugs and transgender people stem from inappropriate, ineffective or excessive national laws and criminal justice policies. These laws are widespread across countries and regions. The work of UNODC on prisons and HIV is closely related to its work on criminal justice and prisons reform. The revised United Nations Standard Minimum Rules for the Treatment of Prisoners (The Nelson Mandela Rules), approved in 2015, recognize that prisoners should enjoy the same standards of health care that are available in the community. The rules also indicate that health care services should be organized in close relationship with the general public health administration and in a way that ensures continuity of treatment and care, including for HIV, TB and other infectious diseases, as well as for drug dependence.

Our Results

In line with the comprehensive package of 15 key interventions, Phu Son Prison in Vietnam launched the first opioid substitution therapy (OST) unit for prisoners, with support from UNODC marking a significant milestone in HIV prevention, treatment and care in prison settings in Vietnam. OST is also now available in the Tihar Prisons complex in India.

The Republic of Moldova remains one of the few countries in the world where the comprehensive package is available in prisons. This has resulted in a marked decrease of HIV and HCV prevalence. The needle and syringe programme in Moldova was initially piloted in one prison and gradually extended to 13 prisons in 2014, an average of 90,000 syringes are distributed annually. OST is also available in 13 prisons. Investments have been made to expand access to needle and syringe programmes and OST in prisons located in Transnistria.

In 2015 government authorities in Nepal, in coordination with national and international partners, developed standard operating procedures (SOPs) to scale up HIV prevention, treatment and care services in prison settings and to revise and update related policies. The SOPs addresses the vulnerability of prison populations to HIV and sexually transmitted infections by adopting the 15 key interventions of the comprehensive package including OST, needle and syringe programmes and condoms.

HIV prevalence among people in prison in the Kyrgyz Republic is about 45 times the prevalence in the general population. Addressing this situation, the country has had needle and syringe programmes in prison since 2002 and OST since 2008. OST is available to all persons in prison, including women, and the needle and syringe programme is available in 15 sites.

To add to existing knowledge on HIV in prisons, UNODC collaborated with the All-Ukrainian Network of People Living with HIV in 2014 to develop and print an integrated bio-behavioural surveillance (IBBS) report on the knowledge, behaviour and HIV prevalence of inmates within second generation HIV surveillance. UNODC Kyrgyzstan has developed a training manual on drug and HIV prevention with a particular focus on women prisoners and juveniles.

UNODC advocates gender responsive HIV services for people in prisons.

Collaboration. A partnership established between UNODC and the Brazilian TB Control Programme has increased access to HIV testing in three prison units in Brazil. UNODC also supports HIV and prison networks including the African HIV in Prisons Partnership Network (AHPPN) and the Monitoring Centre for HIV and Prisons in Latin America and the Caribbean. In Europe, UNODC contributes to the WHO-EURO Health in Prisons Project (HIPP).

Photo: UNODC Nepal

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