Why is there a higher prevalence in prison?
Injecting drug use and incarceration are closely linked; many injecting drug users (IDUs) pass through the correctional system because of drug-related offences. As IDUs are at a greater risk of HIV infection, this group is often more likely to be infected with HIV than other incarcerated populations. In the absence of HIV preventative measures in prisons, this can pose a greater risk of HIV transmission among inmates.
HIV transmission in prison:
“Prison conditions are often ideal breeding grounds for onward transmission of HIV infection. They are frequently overcrowded. They commonly operate in an atmosphere of violence and fear. Tensions abound, including sexual tensions. Release from these tensions, and from the boredom of prison life, is often found in the consumption of drugs or in sex.” UNAIDS
One of the primary routes of HIV transmission is through sexual intercourse. In many prisons both consensual and non-consensual sexual activities are common among inmates even though they may be forbidden under prison rules. It is difficult to determine to what extent such activities occur, as those involved risk punishment if exposed to fellow inmates or prison officers. Therefore the majority of incidences go unreported. The need for prison and penal reform has been highlighted as an essential approach to preventing HIV transmission through sexual abuse. Reducing prison populations has been highlighted as one way in which this may be achieved.
A number of factors contribute to an increased risk of HIV transmission through sexual intercourse in prison:
Unavailability of condoms: Condoms, which can prevent HIV infection if used consistently and correctly, are often considered contraband within prisons. A study of HIV transmission among male prisoners in Georgia, America, found that only 30 percent of those who reported any consensual sex used condoms or improvised condoms.
Rape: The often violent nature of non-consensual sex can cause tearing and bleeding, which increases the risk of HIV transmission. Rape in prisons is rarely reported, but the WHO estimate that prevalence ranges from 0 to 16 percent.In 2003 in the United States it was estimated that over 1 million inmates had been sexually assaulted in the past 20 years.
Although illegal in most prisons, tattooing is still commonplace among incarcerated people. It is usually associated with the desire to advertise a group or membership status, or results from peer pressure, or often just boredom. Those who perform the tattooing tend not to have proper, sterilised tattooing equipment, posing another risk of HIV transmission. However, there have only been a few reported cases of suspected transmission due to contaminated equipment.
Fights and assaults are common in prison and carry a risk of HIV infection if people are exposed to blood and bodily fluids. Although transmission in this way is rare, the risk is still present and can be enhanced by factors that contribute to increased levels of violence, such as overcrowding in cells.
Despite the high risk of HIV transmission within prisons, HIV prevention programmes are often not provided for inmates. Some fear that these programmes will encourage illegal or undesirable behaviours. However, prisoners are entitled to the same human rights standards as non-incarcerated people and this includes protection from any communicable illness.
The following prevention initiatives have been tested within prisons, the majority of the time producing positive results.
Educating people about HIV/AIDS can prevent new HIV infections, improve the quality of life of HIV positive people and help to reduce stigma and discrimination. It is usually considered an essential component of HIV prevention.
Harm reduction programmes