The research project Policies for Equitable Access to Health (PEAH) published AFEW’s op-ed on prison healthcare in the countries of Eastern Europe and Central Asia. The article explorer why prisoners are at greater risk for contracting infections like HIV and TB, why this inequity should not be tolerated, and how this issue is innately connected to the public health of the general population. There will be a follow-up article that explores current programs that seek to significantly minimize the impact of communicable and infectious diseases and how the causes of increased susceptibility of prisoners can be mitigated.
HIV and TB in Prisons
by Corie Leifer*, MSc., supervised by Anke van Dam, MD AIDS Foundation East-West (AFEW)
Communicable and Infectious Diseases in Eastern Europe and Central-Asia
Despite new technology and advances in treatments and medicines, the growth in the number of new HIV infections in Eastern Europe and Central Asia (EECA) remains steady. In Europe, between 2004 and 2013 the number of new HIV infections increased 80% from 76,000 new cases to more than 136,000. Of these 136,000 new infections in Europe, 105,000 were in EECA. In EECA in this same nine-year period, the number of new HIV cases has doubled. Furthermore, this region has the highest prevalence of injecting drug users. There is a well-established connection between injecting drug use and contracting HIV. In fact, of the 3.7 million injecting drug users in the region, roughly one-quarter are believed to be infected with HIV. Tuberculosis is also prevalent in this region. More and more cases of multi-drug resistant Tuberculosis are diagnosed. This makes that TB has become one of the causes of death this region. More than 95% of deaths due to TB occur in low- and middle- income countries.
Communicable and Infectious Diseases in Prisons in EECA
The prevalence of HIV in prisons is estimated to be between 2 and 50 times greater than that in the general population. Within EECA, Kazakhstan has the lowest HIV prevalence among prisoners with 2% infected. Tajikistan has the highest rate of HIV infection in prisoners in the region with nearly 7%, accounting for nearly one-fifth of all people infected with HIV in Tajikistan. Additionally, the risk of contracting TB in prison is estimated at 60–100-times higher compared than outside of prison. Within the prison population, there is an increased rate of mortality due to TB infection when compared with that of the general population.
AIDS Foundation East-West (AFEW) is one of the few international networks that works in prisons in EECA to help reduce the burden of infectious and communicable diseases such as HIV and TB. As experts in prison health in this region, AFEW continues to play an integral role in developing the necessary links between governmental and civil society organizations to improve the health of prisoners.
Why Does It Matter?
Prison health has no priority on the different, political, global, agenda’s. It is often assumed that the imprisonment is a result of one or more bad decisions. In many countries, people may be imprisoned for years while awaiting a trial, only to be found innocent of the crime for which they are charged. Regardless of the reason for imprisonment, the punishment of a prisoner should revolve around the lack of freedom, not the lack of healthcare.
Human Rights
It states in the Constitution of the World Health Organization that “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being”. Whether or not a prisoner belongs behind bars is completely irrelevant to, and should not impede upon, his or her human rights. In 2006, the Council of Europe declared that prison conditions must never infringe upon human dignity. Prisoners do not have the same option as the general population to search for a practitioner with whose services they are happy. Prisoners have no other choices in regards to their medical health except to use the medical staff and resources provided by the prison. Therefore, it has been decided by the Council of Europe that “states are under the obligation to respect the right to health by… refraining from denying or limiting equal access for all persons, including prisoners or detainees … to preventive, curative and palliative health services”. In fact, due to the importance of this responsibility, governments can be held legally responsible “for failure to prevent all forms of avoidable health impairment or damage to the well-being of its prisoners”. Within the context of health, prisons should provide enough space, light, fresh air, clean sanitary facilities, clothing, heating, and adequate nutrition.
Impact on General Population
Prisoners are rarely imprisoned for life. There is a high turnover in prisons, with many prisoners only spending days, weeks, or months behind bars. Before their imprisonment, prisoners are members of the general population. After their release, they return to the community. There are also members of the general population who work in prisons, have relationships with prisoners, or work with prisoners who participate in outside work placement situations. Therefore, the exchange of diseases between the prison population and the general population is inevitable. There are many examples of outbreaks of TB and HIV in prisons tied to increased prevalence of the respective disease in the community in Thailand, Lithuania, Latvia, England, and other places around the world. “Major HIV outbreaks occurred among prisoners in Glenochill, Scotland in 1993 and in the Alytus prison in Lithuania in 2002.”
Causes
Before tackling any issue, public health or otherwise, the source of the issue must be understood. Therefore, disease management must first address the how the disease is transferred from one person to another and then investigate how the factors fueling the spread of the disease can be diminished.
HIV and TB have different means of transmission. HIV is spread through the exchange of infected blood or semen. The main methods of transmission are unprotected (voluntary or involuntary) sexual intercourse or through the sharing of needles, which may be used for injecting drugs or applying homemade tattoos. TB is spread much easier through merely inhaling the bacteria.
There are many factors that contribute to the rapid spread of communicable and infectious diseases through prisons. A lack of many factors also contributes to the devastation caused by the disease(s).
Lack of Proper Facilities
Prisons are often lacking appropriate facilities to ensure the health and safety of the prisoners that it houses. It is especially problematic in places where incarceration is punishment for minor crimes such as petty drug offenses because of an increase in the number of prisoners. In many places around the world, the prison population is increasing, but the capacity of prison services is not growing at the same rate. “While overcrowding is a health issue all over Europe, the situation is particularly serious in some of the countries of EECA, where overcrowding goes hand in hand with health problems.” The overcrowding not only leads to a lack of personal space which will inevitably lead to the spread of contagious diseases, but it also overwhelms the plumbing and sanitation services and water and food supply. Additionally, the poor ventilation, minimal access to clean drinking water, non-existent nutritional considerations, and lack of lighting and heating contribute greatly to the susceptibility of prisoners to contracting contagious diseases. Ukraine, for instance, fulfills more than 120% of their capacity for housing prisoners.
Lack of Structure, Procedures and Oversight
In many countries, there is little to no link or alignment of prison health services with national health services or national efforts to address communicable and infectious diseases. Often prison health services operate parallel to, not in conjunction with, national health programs. This creates duplicated efforts, a lack of consistency, and incomplete information. By integrating prison health services and national health services, prisons would be better able to provide medical care comparable to those provided to the general population, the importance of which is discussed above. In fact, prison health is not even regulated by the Ministry of Health in many countries; rather it falls under the jurisdiction of the Ministry of Justice.
Not only are prison health services not aligned with national health services, but in many cases they also do not maintain the same standards and regulations. There are not clear policies or guidelines regarding healthcare protocols, job descriptions of health personnel or quality evaluation. There are also few, if any, infection control measures, medication administration protocols, or systematic screening, counseling or testing for communicable and infectious diseases. This can lead to disconnected, inefficient health services and a decreased quality of care. Without the standards and procedures, clinical decisions may be guided by opinions and feelings, rather than medical criteria. Furthermore, confidentiality and safety may be compromised, as well as the health of the patient.
The lack of standards and protocols leads to poor record keeping, which in turn leads to poor evaluation, quality, and health management. There is minimal, if any, record keeping, monitoring, or evaluation of the health of prisoners. There is a lack of baseline information, morbidity statistics, and status update information. There are not systemized and uniform procedures and forms used for collecting health information. Without this information and standardization, tracking the progress of the health of prisoners is nearly impossible. As a result, prison health statistics are mainly absent from the health data provided by most countries.
Lack of Harm Reduction Measures
Injecting Drug Use (IDU) remains the main cause of the spread of HIV in EECA. This is the case for both the general population and for prisoners. In fact, injecting drug use is the cause of 50–70% of cumulative HIV cases in the region. In prison specifically, this phenomenon is made worse by needle sharing. In Central Asia, it is estimated that 5-25% of prisoners have drug dependence issues and as many as 70% share injecting tools.
Drug users and prisoners are often overlapping populations. There are two main reasons for this, and each exacerbates the other. The first reason is that drug users are overrepresented in prisons and detention centers. This is due to the illegality of drug use. For instance, in Georgia, even trace amounts of drugs in a used syringe can be enough to lead to an arrest. Such strict laws almost guarantee that drug dependence will lead to criminal prosecution. Between 5% and 38% of prisoners in Europe report injecting drugs prior to imprisonment. The second reason that prisoners are more likely to use drugs is due to their incarceration. In fact, between 2% and 56% of prisoners surveyed reported injecting drugs while in prison. Drugs remain available in prisons, despite the confining circumstances. However, safe injecting tools are not as widely available. This leads to an inevitable situation of many people using the same needle to inject drugs. Drug use can lead to incarceration, and incarceration can lead to drug use. As is clear, this is a cycle that is difficult to break.
There is a lack of Needle Syringe Exchange Programs, and therefore clean needles in prisons. Additionally, there is minimal Opioid Substitution Therapy (OST) available to prisoners. “As of 2010, 74 countries worldwide had opioid substitution therapy available in the community. Of these countries, only 39 also had this therapy available in prisons.”
Lack of Proper Medical Care
Limited medical care within the prison setting is a multi-faceted problem. As already discussed, without procedures and standards for screening, counseling, or testing, prisoners may be exposed to avoidable health risks. Additionally, medical care is often not complete, timely, comprehensive or individualized.
There are few to no provisions made to continue to ensure that healthcare and treatment is sought by and provided to prisoners who have recently been released. This is despite the fact that continuity of care has been proven to be essential to ensuring treatment adherence and therefore helping prevent drug-resistant strains of disease from developing.
The absence of proper medical care is also a product of a lack of well-trained personnel. Working within the prison system is often regarded as not prestigious or possibly unsafe. There is minimal training provided and many employees are young and do not have extensive professional experience. This might foster an incompetent workforce and deter highly skilled professionals.
Proper medical care includes offering “access at the right time to a general practitioner or to specialized care.” Specialized care includes reproductive healthcare for women. Even though women make up a small percentage of the prison population, the rate of infection with HIV for incarcerated women is often higher than that in the male prison population. This is in part due to an increased likelihood of drug dependence and injecting drugs in imprisoned women when compared with imprisoned men. In prisons in many countries there are no provisions taken to provide qualified specialized care for female prisoners.
Conclusion
Prison health is public health. Unlike the prisoners, the spreading of a contagious disease is not confined by the walls of the prisons. It is, therefore, not only in the best interest of the prisoners to provide them with healthcare, but it is also in the best interest of society. This is not only the most humane approach, but also the most cost-effective and socially beneficial. In health issues, it is almost always the case that prevention is the most cost-effective method to disease management. Preventing the spread of disease is a much more feasible task than managing an already prolific outbreak. Prevention measures include addressing the “factors related to the prison infrastructure, prison management and the criminal justice system (that) contribute to vulnerability to HIV, TB and other health risks in prisons.” Prisoners have an increased probability of contracting a contagious disease due, in part, to the lack of hygiene, proper medical care, and personal space. Therefore, the epidemics cannot be brought under control until at least some of the many contributing factors are addressed.
Citations
www.euro.who.int/en/health-topics/health-determinants/prisons-and-health/prisons-and-health
Prison and Health Data and Statistics. World Health Organization, 2010. www.euro.who.int/en/health-topics/health-determinants/prisons-and-health/data-and-statistics accessed March 25, 2015.
aidspan.org/gfo_article/improvement-hivtb-prevention-treatment-and-care-prisons
www.euro.who.int/en/media-centre/sections/press-releases/2014/europes-hiv-response-falls-short-in-curbing-the-epidemic-80-more-new-hiv-cases-compared-to-2004
ec.europa.eu/health/sti_prevention/docs/ev_20130527_co05_en.pdf
Get the Facts. Common Sense for Drug Policy, 2012. drugwarfacts.org/cms/chapter/eeca accessed March 25, 2015.
www.euro.who.int/__data/assets/pdf_file/0005/126473/e94437.pdf
www.unodc.org/documents/hiv-aids/publications/Prisons_and_other_closed_settings/Good-governance-for-prison-health-in-the-21st-century.pdf
www.who.int/mediacentre/factsheets/fs104/en/
www.avert.org/prisoners-hivaids.htm
www.euro.who.int/en/health-topics/communicable-diseases/hivaids/policy/policy-guidance-for-key-populations-most-at-risk2/hiv-in-prisons
www.prisonstudies.org/highest-to-lowest/occupancy-level
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*Corie Leifer (Office Manager since January 2013), was born in 1981 in Connecticut, USA. After earning a bachelor degree in communications and another in nursing in the United States, she moved to the Netherlands in 2011 to earn a Master of Health Science degree with a focus on International Public Health from Vrije Universiteit in Amsterdam. During this study, Corie completed her internship at AFEW and subsequently joined AFEW as Office Manager. As a research intern, she investigated the use of SMS campaigns to reduce the spread of HIV/AIDS. Corie has international marketing and communications experience, having worked at Operation Smile, Inc. and Trader Publishing Company prior to returning to school. Corie is also a Registered Nurse licensed in the Commonwealth of Virginia, USA.
