Jürgens et al. Journal of the International AIDS Society 2011, 14:26 http://www.jiasociety.org/content/14/1/26 REVIEW Open Access HIV and incarceration: prisons and detention Ralf Jürgens1*, Manfred Nowak2 and Marcus Day3 Abstract The high prevalence of HIV infection among prisoners and pre-trial detainees, combined with overcrowding and sub-standard living conditions sometimes amounting to inhuman or degrading treatment in violation of international law, make prisons and other detention centres a high risk environment for the transmission of HIV. Ultimately, this contributes to HIV epidemics in the communities to which prisoners return upon their release. We reviewed the evidence regarding HIV prevalence, risk behaviours and transmission in prisons. We also reviewed evidence of the effectiveness of interventions and approaches to reduce the risk behaviours and, consequently, HIV transmission in prisons. A large number of studies report high levels of risk behaviour in prisons, and HIV transmission has been documented. There is a large body of evidence from countries around the world of what prison systems can do to prevent HIV transmission. In particular, condom distribution programmes, accompanied by measures to prevent the occurrence of rape and other forms of non-consensual sex, needle and syringe programmes and opioid substitution therapies, have proven effective at reducing HIV risk behaviours in a wide range of prison environments without resulting in negative consequences for the health of prison staff or prisoners. The introduction of these programmes in prisons is therefore warranted as part of comprehensive programmes to address HIV in prisons, including HIV education, voluntary HIV testing and counselling, and provision of antiretroviral treatment for HIV-positive prisoners. In addition, however, action to reduce overcrowding and improve conditions in detention is urgently needed. Review of Tibet and Qinjang), Nepal, Jordan, Paraguay, Togo, Forgotten prisoners: a global crisis of conditions in Nigeria, Sri Lanka, Indonesia, Denmark (including detention Greenland), the Republic of Moldova (including Trans- A global crisis of conditions in detention is being wit- nistria), Equatorial Guinea, Uruguay, Kazakhstan, nessed by the United Nations Special Rapporteur on Jamaica and Papua New Guinea. Torture and Other Forms of Cruel, Inhuman or Degrad- Since torture usually takes place behind closed doors, ing Treatment or Punishment. The Special Rapporteur the Special Rapporteur spends a significant amount of exercises a mandate entrusted to him by the highest time during the fact-finding missions in prisons, remand human rights body of the United Nations (UN), the centres, police lock-ups, psychiatric institutions, and Human Rights Council, to investigate the situation of special detention facilities for women, children, asylum torture and ill-treatment in all countries of the world. seekers, migrants and people who use drugs. By asses- He presents reports about his findings and recommen- sing conditions of detention in each country he visits, dations to the General Assembly in New York and the the UN Special Rapporteur on Torture also acts as a de Human Rights Council in Geneva. facto special rapporteur on prison conditions. In addition to conducting research and dealing with a Governments have no legal obligation to invite the high number of individual complaints, since 2005, he UN Special Rapporteur to their countries, and several has carried out fact-finding missions to roughly 20 governments, notably in the Middle East, have refused countries in all regions of the world, among them Geor- investigations into torture and ill-treatment in their gia, Mongolia, China (including the autonomous regions countries. Others have invited the Rapporteur and later cancelled or “postponed” their invitations, often at the * Correspondence: [email protected] last minute: the USA (in respect of the detention facil- 1 97 de Koninck, Mille-Isles, Quebec, J0R 1A0, Canada ities in Guantánamo Bay), the Russian Federation, Full list of author information is available at the end of the article © 2011 Jürgens et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Jürgens et al. Journal of the International AIDS Society 2011, 14:26 Page 2 of 17 http://www.jiasociety.org/content/14/1/26 Zimbabwe and Cuba. Sometimes, the strict terms of Two epidemics: HIV and incarceration referencearethereasonforthereluctanceofstatesto HIV hit prisons early and it hit them hard. The rates of receive the Special Rapporteur. These terms include the HIV infection among prisoners in many countries are possibility of: carrying out unannounced visits to places significantly higher than those in the general population. of detention; bringing a team of experts into prisons, Coincident with the HIV/AIDS epidemic, many coun- including a forensic expert, with the necessary equip- tries have been experiencing a significant increase in the ment to document torture and ill-treatment (e.g., photo incarcerated population, often as a result of an intensifi- and video cameras); and conducting private (unsuper- cationoftheenforcementofdruglawsinaneffortto vised) interviews with detainees [1]. limit the supply and use of illegal drugs. Each of the two The conclusions of the UN Special Rapporteur are “epidemics” - HIV and incarceration - has affected the alarming: with very few exceptions (such as Denmark other. and Greenland) [2], torture in detention facilities is For the purposes of this paper, the term, “prisoner”,is practiced in most of the countries he has visited, often used broadly to refer to adult and juvenile males and in a routine, widespread or even systematic manner, females detained in criminal justice and correctional such as in Nepal [3] and Equatorial Guinea [4]. In some facilities: during the investigation of a crime; while countries, including Sri Lanka [5] and Jordan [6], the awaiting trial; after conviction and before sentencing; Special Rapporteur observed that the methods of torture and after sentencing. Although the term does not for- used are simply shocking and remind one of times mally cover persons detained for reasons relating to forgotten. immigration or refugee status, and those detained with- But for most of the detainees interviewed by the UN out charge, most of the considerations in this paper Special Rapporteur, their experience of torture during apply to them, as well. The term, “prison”,isusedto the first days or weeks of police custody aimed at refer to all criminal justice and correctional facilities. extracting a confession or information was little com- The HIV epidemic in prisons pared with the continued suffering of detainees. They HIV surveillance has been the most common form of had endured this suffering during many months of HIV research in prison, although this has largely been police custody with no more than a place to sit on the restricted to high-income countries. Data from low- and dirty floor (e.g., in Equatorial Guinea, Jamaica [7] and middle-income countries are more limited [17]. Even Papua New Guinea [8], during many years of pre-trial within high-income countries, the precise number of detention virtually forgotten by prosecutors, judges and prisoners living with HIV is difficult to estimate. Rates the outside world (e.g., in Nigeria [9], Paraguay [10] and of HIV infection reported from studies undertaken in a Uruguay [11]), and during decades of incarceration in single prison or region may not accurately reflect HIV overcrowded prisons, often in isolation or under intoler- prevalence in prisons across the country. able conditions on death row and similar strict confine- Nevertheless, reviews of HIV prevalence in prison ment for long-term prisoners (e.g., Mongolia [12], have shown that HIV infection is a serious problem, and Georgia [13] and Moldova [14]). one that requires immediate action [18]. In most coun- In China, an unbearable pressure of re-education and tries, HIV prevalence rates in prison are several times brainwashing is exerted on the entire prison population, higher than in the community outside prisons, and this ranging from special re-education through labour camps is closely related to the rate of HIV infection among to remand centres and correctional institutions, until people who inject drugs in the community and the pro- the will and dignity of the person concerned is finally portion of prisoners convicted for drug-related offences broken [15]. In his 2009 report to the UN General [19]. In other countries, particularly in sub-Saharan Assembly, the Special Rapporteur concluded that “in Africa, elevated HIV prevalence rates in prisons reflect many countries of the world, places of detention are the high HIV prevalence rates in the general population constantly overcrowded, and filthy locations, where [20]. Everywhere, the prison population consists of indi- tuberculosis and other highly contagious diseases are viduals with greater risk factors for contracting HIV rife [, ...] lack the minimum facilities necessary to allow (and HCV and TB) compared with the general popula- for a dignified existence [16].” tion outside of prisons. Such characteristics include In other words, conditions of detention in many coun- injecting drug use, poverty, alcohol