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Ralf Jürgens (#691) Scaling u p harm redu ction and treatment in prisons in the former Soviet Union Harm Reduction 2008 Barcelona, 14 May 2008 Ralf Jürgens Consultant, Canadian HIV/AIDS Legal Network 1 Acknowledgements Funders Canadian International Development Agency International Harm Reduction Development United Nations Development Programme World Health Organization Swiss Cooperation International Renaissance Foundation 2 Background • High (or rapidly growing) HIV (and HCV) rates • Injecting drug use remains the most common source of infection • HIV and HCV epidemics accompanied by high incarceration rates: – 627 per 100,000 iRin Russ ia – 419 per 100,000 in Ukraine – 150 per 100,000 in Spain – 116 per 100,000 in Canada – 88 per 100,000 in Germany 3 HIV and HCV Prevalence in Prisons • Shattering the myths (1): We know enough about the seriousness of the problem – PlPrevalence dtitftdata exists for most count tihiries, showing high rates – Even where rates of HIV are still (relatively) low, HCV rates are high – “early“ intervention is needed – Some prison systems hide data from seroprevalence reseach and continue to refer to known or registered cases of HIV and AIDS in prisons 4 HIV and HCV Prevalence in Prisons in Ukraine • Number of HIV+ prisoners according to State Department: 4700 (2.7% of the prison population) • Researc h in 5 reg ions, 7 pr isons (2004) • n=831 •self-reportdted s tttatus ( anonymous questi onnai re) – 8% HCV, 5% HIV • bloo d test ing – HIV: between 16 and 32% of prisoners tested HIV- positive – HCV: between 75.5 and 91.5% (2 regions) 5 Drug Use in Prisons • Shattering the myths (2): We know enough about drug use in prisons – Drugs can and do enter into prisons. – Many prisoners are in prison because of offences related to drugs - people who use drugs outside often find a way to use inside. – Other prisoners start using drugs in prison. 6 Injecting Drug Use in Prison • Russia – A studyyg among 1,087 prisoners showed that 43% had injected drugs in their lives – 20% injected in the penal institution – 64% used injecting equipment that had already been used by somebody else – 13.5% started injecting in prison 7 Injecting Drug Use in Prison • Ukraine – Studies have shown that a significant proportion of prisoners use drugs in prison. – In one study that used urinalysis, 65 of 390 samples of prisoners tested positive for drugs, including marijuana, amphetamines, morphine, and cocaine. – MiMany prisoners ijdhdldinject and share needles and syringes. ¾ No country has been able to stop drug use, includinggj injecting drug use, in p rison. 8 HIV Transmission in Prison • Sha tter ing th e myth s ( 3)W): We k now enoug h ab out risk of transmission in prisons – Outbreaks of HIV infection in prisons have been documented in the region (Lithuania & Russia) and elsewhere. • Ukraine: cohort study in 2 prisons – 400 blood samples in Dec 2004, 276 in August 2005 – 6 of 276 prisoners became infected in prison between Dec 2004 and August 2005 (2 in prison 1, 4 in prison 2) 9 Interventions to address HIV in prisons • Shattering the myths (4): We know what works – and what does not work: – WHO/UNODC/UNAIDS Evidence for Action Papers: Interventions to Address HIV in Prisons • comprehensive paper • needle and syringe programs and bleach • drug dependence treatment •reducing se xua l t ra n smi ssi on • providing HIV treatment, care and support http://www.who.int/hiv/idu/prison/en/index.html (English and Russian) HIV Education Programs • Sha tter ing the mythths (5): In forma tion & educa tion programs result in increased knowledge (eg, Vaz, Gloyd & Trindade, 1996), but are not harm reduction • Evidence of effect of increased knowledge on behaviour is limited (Bra it hwa ite, Hammett & Mayb berry, 1996) • Peer education is more effective (Grinstead et al, 1999) • In forma tion and educa tion are onlly one small component of a comprehensive HIV programme: prisoners need access to prevention measures that enable them to act upon the information Prevention of sexual transmission • Shatte rin g th e m yth s (6) Pr ovi din g con dom s i s feasible in prison settings, but access is limited and providing condoms is not enough • No security problems or other negative consequences • Prisoners use condoms when condoms are easilyyy and discreetly accessible • Condom programs in the region are often limited to a small number of prisons • Access to condoms remains limited 12 Prevention of sexual transmission • Need for measures to combat rape and sexual abuse – Changing the institutional culture tolerating sexual violence – MltiMulti-prongedhd approaches: • Prevention efforts (prisoners education, classification, structural interventions such as better lighting, better shower and sleeping arrangements) • Staff training, investigation, prosecution, victim services • Documenting incidents Needle & syringe programs • Shatteringgy( the myths (7))p: NSPs in prisons in the reg ion can be established quite easily, provided there is leadership • Evaluations have consistently shown – decrease in sharing – no increase in drug use and/or injecting – no negative impact on safety and security; in particular, needles have not been used as weapons – bleach insufficient • Best practice needle and syringe programs in prisons in Moldova and Kyrgyz Republic • Pilot ppjrojects in Romania are starting • Pilot projects in Azerbaijan to start by end 2008 • Ukraine? 14 HIV treatment, care & support • Shattering the myths (8) Access to ART is increasing, but too slowly – human rights and public health disaster • States have committed to universal access to HIV prevention, treatment & care - including for prisoners • Access to testing & counselling and to ART in prisons is poor (Ukraine: 100 prisoners on ART in 2007) • Treatment goals are based on known cases of HIV, rather than real need • Official coverage data questionable • Providing access to ART in prisons and ensuring continuity of treatment is a challenge - bu t it is necessarnecessary and feasible 15 HIV treatment, care & support • Prisoners respond well to ART • Adherence rates can be as high or higher than outidtside • acceptance dependent on trust in physician and hea lth care system; trust in HIV medica tions; prisoners’ interpersonal relationship with physicians & peers • adherence dependent on side effects, social isolation, institutional factors • adherence can be very high also among IDUs, particu lar lly those on OST 16 HIV treatment, care & support • Sustainable treatment programmes, integrated into countries’ general HIV treatment programmes (or linked to them) should be created. • Action at all levels • intl: ppprisons as part of intl effort to scale u p treatment • natl: prison dept on HIV coordinating bodies & involved in all aspects of treatment scale-up; MoH & Ministry responsible for prisons should collaborate closely • regional/local: partnerships between prisons & health clinics, hospitals, universities & NGOs; integrated treatment programmes 17 HIV treatment, care & support • Ensuri ng continu ity of care is fun damen ta l • arress,t, detention in p olice cell s,ps, pre-trial detention, imprisonment, transfer within prisons or to other prisons, release • each of these situations need to be addresse d & mechani sms establi s he d to ensure uninterrupted ART • particular attention to discharge planning & linkage to community aftercare 18 OhOther Necessary Steps • introduction (or scale -up) of substitution therapy in countries needs to include prisons from the beginning • better coordination of activities of international agencies, and better collaboration • be tter di ssem ina tion o f ex is ting resources • increased focus on improving prison conditions • increased focus on reducing pre-trial detention and increasing programs in pre-trial detention • increased focus on reducing the number of people in prison • improving conditions for staff (e.g., more staff, b)better pay) 19 For more info … • Contact Ralf Jürgens at [email protected] • Visit the prison section of the website of the Canadian HIV/AIDS Legal Network: www.aidslaw.ca • Visit the prison section of the WHO website: http://www.who.int/hiv/idu/prison/en/index.html 20.
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