Staying safe inside: HIV and hepatitis C health care in prison

Policies on safer sex and needle exchange in UK prisons seem to have stalled. With a high and increasing prevalence of hepatitis C in our jails, and HIV figures last researched properly in 1997, guest writer Chris O’Connor asks whether the UK could do a lot better.

Health care and prevention of HIV and hepatitis C in prisons is euphemistically described as ‘challenging’. To understand the challenges of devising policies to prevent blood-borne viruses in a prison, one needs to look not only at health policies devised by agencies outside the prison walls, but also the experience of those inside, whether living with or treating these conditions.

Even when the outside powers have proposed measures such as a needle exchange, inside prison walls, the answer has been no. Security issues; a growing, transient population; fears around stigma and confidentiality; these are just some of the unique challenges of caring for incarcerated people – and that’s without worrying about drug injection and sex between men.

Surveillance out of whack

A new report by the Health Protection Agency (HPA), published this September,¹ says: “There still remains a significant number of people passing through the prison estate without being tested for blood-borne viruses, and this situation needs to change.”

In particular, they say that current surveillance systems, necessary to develop HIV and hepatitis C services, are “inadequate”.

Yusef Azad, Director of Policy at the National AIDS Trust (NAT), agrees: “There is a significant and worrying gap in the data which is essential to close if we are to get a proper understanding of how many prisoners remain undiagnosed, or at risk of infection. NAT has been calling for a new anonymous survey of blood-borne viruses in prisons for several years.”

Now there has been movement. The 2010 HPA report includes – for the first time since 1997/98 – unlinked anonymous surveillance figures for prisoners with hepatitis C and HIV. But they tell a complex story.

The last time there was a specific survey of HIV prevalence in prisoners was back in 1997. In this survey, from a sample of 3942 prisoners drawn from eight of the UK’s 130 or so prisons, 7% tested positive for hepatitis C and 0.4% for HIV.²

The 2010 data set consisted of results from prisoners who were tested for hepatitis C (but not HIV) as part of their routine health care. This covered the period 2005 to 2008 and included 39 prisons (30% of the prison estate). Of the 10,723 tested for hepatitis C antibodies, 24% tested positive.

This apparently large increase may be due to the fact that these were prisoners assessed specifically for healthcare problems and may also be partly due to different prisons being included: in the big prisons in north-west England, hepatitis C prevalence is known to be above average. But it also appears partly real.

Prison can be a safe and even a good place to be diagnosed and treated. We have experience of women managing to turn their lives around after diagnosis, having established stability in prison.

Sophie Strachan, Positively UK

To assess HIV prevalence, the HPA looked at its existing SOPHID (Survey of Prevalent HIV Infections) database of people accessing HIV treatment and care services. It states that: “In 2008 171 prisoners were reported to be resident in English prisons at the time of reporting, and an additional 82 individuals were reported as resident in prison prior to 2008”. What this latter figures means is “some of these may be in prison and some are not: we don’t know”.

With the UK prison population numbering some 85,000, the lower SOPHID figure would imply that HIV prevalence in prison was 0.2% - exactly the same prevalence as in the UK general adult population aged 15 to 59. Even if you include the 82 ‘possibles’, it’s still only 0.3%: lower than in 1997, against a background where the general adult population HIV prevalence has more than doubled.

The HPA says that these HIV figures are “likely to underestimate the true figure, with under-reporting particularly affecting prisoners with shorter custodial sentences”. Their rough estimate is that there are about 300 to 500 people with HIV in prison- about 0.5% or double the general-population prevalence. This means that the number of people accessing HIV care in prisons is lower than the number who actually have the virus.

The HPA adds that injecting drug use (IDU) risk is likely to be substantially under-reported too, with the 19% of prisoners identified as injecting drug users likely to underestimate the true total.

Who takes responsibility?

Prison health in England used to be run by Her Majesty’s Prison Service itself, but in 2000 responsibility was moved to the Department of Health, and in 2006 budgets and administration were transferred to primary care trusts (PCTs), like every part of the NHS. Scotland, with its own legal and prisons system, is undergoing the same process. In Wales, health care is funded by the National Assembly and commissioned by local health boards, and in Northern Ireland it is the responsibility of one regional health and social care trust. The commissioning of prison health care by PCTs has led to contracts that split into a variety of services and a patchwork of providers.

A prison healthcare worker who preferred to remain anonymous told HTU: “PCTs don’t know how to run a prison healthcare unit, and so they farm it out as quick as they can.”

In late 2009, Secure Healthcare, a not-for-profit organisation which had the contract for Wandsworth Prison, went bankrupt, forcing NHS managers to step in to ensure care for 1600 prisoners. The collapse of Secure came only three months after it signed a three-year contract extension with Wandsworth PCT.³

Although Secure had made some service improvements, Anne Owers, the Chief Inspector of Prisons, visited Wandsworth in June 2009 and noted “staff vacancies... no immunisation clinic... too many external appointments cancelled or missed”.⁴

A concern for contractors in this area is indemnity. As a contractor, Secure was not governed by NHS indemnity and had to provide its own expensive clinical negligence insurance.

Staff from the HIV charity Positively UK (formerly Positively Women) visit three women’s prisons on a regular basis; the organisation has a long history of supporting women at HMP Holloway. They also face uncertainty over their future role. Their current access agreement at Holloway is with the Royal Free Hospital, which has not been shortlisted for the new healthcare contract there: it is believed the prison authorities wanted a GP-led polyclinic instead. The Independent Monitoring Board’s annual report on HMP Holloway for 2009 states that: “the Board regrets the fact that [Islington] PCT does not appear to have a full understanding of the complexities of prison healthcare.”⁵

Opportunity unlocked

Despite these changes, the move to NHS governance has largely been seen as a positive step. Dr Wassim Malas is a GP who was formerly a doctor at a large prison with health care run under Home Office guidance and, more recently, at a privately operated prison where health care came under the NHS umbrella.

“There was a huge difference between the two,” he says. “Previously, the priority was the running of the prison and getting people to court. If a prisoner had an appointment with an HIV consultant, and there was no staff to escort him, he missed that appointment.” It could be weeks, if not months, before the prisoner obtained another consultation and they might experience an equally long gap in HIV medication.

“People in prisons are now a lot more aware and they try harder to ensure a prisoner sees [their] consultant,” adds Dr Malas. “Previously a prisoner had no voice; the stigma around HIV and hepatitis C was so strong that they couldn’t kick up a fuss if they had no meds. Now, where I have worked, it is much more open, and prisoners are usually not afraid to say they are on medication.”

Mark Wilson is a sexual health nurse specialist who works for the Terrence Higgins Trust. Dealing with a number of positive prisoners in HMPs Dartmoor, Exeter and Channings Wood in Devon, he says that the supply of antiretrovirals at the prisons where he works is generally not an issue. “If a prisoner is deemed okay to keep drugs in his cell then it is usually not a problem. ARVs are prescribed a month at a time because of the turnover of prisoners and to help with adherence issues. But difficulties can arise when a prisoner is deemed a threat to himself and cannot keep his own medication: supervised dosing every twelve hours can be a nightmare.”

Sophie Strachan, prison worker with Positively UK, comments: “Prison can be a safe and even a good place to be diagnosed and treated. We have experience of women managing to turn their lives around after diagnosis, having established stability in prison.” She says she has seen at first hand the need for HIV-positive women to receive peer support. Having turned up at one prison to offer support to one prisoner, seven other HIV-positive women also wanted a visit – with two more requesting one next time.

Positively UK adds that a list of medical conditions specified in the British HIV Association (BHIVA)/British Association for Sexual Health and HIV (BASHH) testing guidelines should trigger a HIV test but they often don’t. They support opt-out testing “providing prison staff and healthcare workers are trained and a positive diagnosis does not result in discrimination”.⁶

Let’s talk about sex

Sex between men in prison is an area shrouded in obscurity. It’s not allowed, it does happen, but how often it does is unknown. There were two surveys investigating risk behaviour associated with blood-borne viruses in prison in the 1990s. The first showed that between 1.6 and 3.4% of adult male prisoners had sex with another man whilst in prison and the second one 4%, with little use of condoms.^7,8

Anecdotally, sex is socially frowned upon by the prisoners. One nurse told HTU: “If a guy is having gay sex he leaves himself open to a punishment beating. I have had three guys admitting to having sex with a man since I have worked in prison, and they were all on the vulnerable prisoners unit (VPU).

“It is extremely rare on the main wing. On the VPU it is relatively common, say 20% of the guys in there, although the majority of it seems to be oral sex. A lot more research needs to be done.”

A statement by a Department of Health spokesperson to HTU said: “Prison authorities owe a duty of care to protect all prisoners. Sexual activity between prisoners carries with it a known public health risk. Prison staff must therefore make condoms, dental dams and water-based lubricants available to any prisoner who requests them.” The statement goes on to say that healthcare staff should assess risk, “…provide appropriate information and guidance on sexual health education and any necessary counselling”.

It is prison service policy to prescribe condoms where appropriate. But in practice, condom distribution is difficult. Wassim Malas says: “Ten years ago I tried to issue a gay guy a condom. The nursing staff was up in arms and I had to write a prescription – his confidentiality was definitely compromised. Condoms would draw attention if you requested one. I never had a big box of condoms to dish out; sex between men in prison is dangerous.”

To some in prison health care, condom provision provides more problems than solutions. One nurse told HTU: “Security in prison hates condoms; they are seen as being used for ‘plugging’ [smuggling drugs or mobile phones in through the anus]. I have only had two to three requests for a condom since I worked in prison.”

In 2009 there was a pilot condom-supply scheme at a male prison in the south of England. Support was raised from staff and health managers, staff concerns were identified and addressed in workshops, and condom distribution was gradually introduced across the prison. No untoward incidents were reported.

Confidentiality in prisons is a huge issue. Positively UK workers have to space their appointments so that prisoners do not meet en route, and many prisoners often cancel at the last moment through fear of being identified as HIV-positive.

Mark Wilson says: “The reality of life and health care in prison means staff have to be flexible in their approach…and assertive in understanding the needs of the prison establishment and the prisoner. We have to work out effective compromises.”

One HIV consultant working in prisons says: “Someone who is involved in risky behaviour, needles or sex, who comes to me looking for help, I respect his right to anonymity. What happens in health care stays in health care – or it should. But I have consulted with one prisoner about his HIV while he was surrounded by four prison officers - he needed to see me, but was classed as dangerous, and so his confidentiality was totally compromised.”

Needle exchange pilot scheme stonewalled

Successful efforts to reduce blood-borne viruses among injecting drug users have included the use of needle exchange programmes. Within UK prisons, however, such a strategy has so far failed even to be assessed. The best that has been done so far is a Prison Service Instruction ordering prisons to provide disinfectant tablets.

No needle exchange provision or pilot projects have been planned in England, Wales or Northern Ireland. But when Scotland rolled out phase two of its Hepatitis C Action Plan in May 2008,⁹ it included recommendations for a study into the pros and cons of needle exchange.

This has hit a wall. According to Ruth Parker, a Substance Misuse Manager at the Scottish Prison Service, “There continues to be a failure to negotiate with the Scottish Prison Officers Association to support the introduction of an in-prison needle and syringe exchange feasibility pilot.” The SPOA says it is negotiating, but so far has refused to entertain the idea of needle exchange.

David Johnson of Scottish HIV charity Waverley Care says this pilot clean-needle scheme, at HMP Aberdeen, has been touted for many years. “There is a lot of opposition from prison staff: if they are not behind it, it will be difficult to implement.”

He adds that, as part of the action plan, hepatitis C has become the focus of attention in prisons and HIV prevention could be left behind.

“After the 'Glenochil outbreak' in 1994, when 13 out of one group of prisoners became infected with HIV through sharing home-made injecting kit, HIV awareness was really raised in prisons – yet it now feels that HIV has slipped down the agenda,” he says.

A 2010 report recommended a pilot scheme which would see a tattoo studio established in a long-stay prison to prevent hepatitis C transmission – but that has also met with a blank. The report suggested prison bosses should increase inmate education about tattooing and make clean materials available.¹⁰

A study in the International Journal of Drug Policy 2008, showed that 54% of Scotland’s 8000 prisoners said they had a tattoo, including 18% who claimed to have had theirs done while in jail. The link between hepatitis C and tattooing is well-established.

As with needle exchange in prisons, the disconnect between evidence-based approaches to public health and what is deemed acceptable by staff and public continues. The Scottish Prison Officers Association warned in the local press: "It raises the issue of where do we stop if we do something like this. We've never been approached about this, but it wouldn't be appropriate. If we have these tattoo kits in, do we then bring in hairdressers from outside?”

Wider dimensions

Globally, “prisons and HIV are a public health challenge of crisis proportions”, to quote Joanne Csete of the Canadian HIV/AIDS Legal Network,¹¹ at this year’s International AIDS Conference in Vienna. She was speaking at one of several sessions around HIV and correctional systems. We do not have enough space here to discuss how prisons worldwide serve as amplifiers of TB, HIV and hepatitis infections.

Instead, an example of one country’s good practice. Mercedes Gallizo Llamas is Secretary-General of the Spanish Prison Administration. She told the conference that in 1996 24% of inmates of Spanish jails were HIV-positive. By 2009, the proportion had fallen to 7%.

This was possible because, confronted with a huge public health threat, the Spanish authorities moved fast to curb it. Voluntary and confidential HIV tests were made available to all, and syringe exchange, health education, access to condoms and lubricant and methadone maintenance programmes were all introduced. As a result, the annual incidence of new HIV infections within prisons decreased from 0.6% in 2000 to 0.09% in 2008.

“We needed a change in the mentality of prison authorities and politicians,” said Ms Llamas. “There was a fear of risk. We had to prove the risks were unfounded: the results spoke for themselves.”¹²

Mark Wilson says that the view from the prison wing is similar. “Prison officers want to do the right thing: they just don’t know what the right thing is.”

Further reading

For more on prisons and many other issues, NAM has just published Social and legal issues for people with HIV, a 140-page practical guide on non-medical issues that can affect people with HIV.