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Sentencing prisoners to hepatitis infection as well as to loss of liberty is a violation of human rights
MJA 1997; 166: 116
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©MJA1997
About half of all injecting drug users have histories of
imprisonment; about half of all prisoners have histories of
injecting drug use; and about half of all imprisoned injecting drug
users inject drugs in prison.1
Infection with hepatitis C virus (HCV) is common among Australian
injecting drug users and prisoners. Butler and colleagues' study of
prisoners entering the New South Wales correctional system (in this issue of the Journal) showed that almost a third were
seropositive for HCV, rising to two-thirds of those with a history of
injecting drug use. HCV infection was significantly associated with
a history of previous imprisonment, which accords with the results of
other studies.2 Similarly,
surveys of Australian injecting drug users find that histories of
incarceration are among the strongest associations with HCV
seropositivity. 3 A major
survey of prison entrants in Victoria found high incidences of
infection with both HCV and hepatitis B virus (HBV) among returning
prison entrants -- 41 per 100 person-years among young male injecting
drug users.4
While these data do not prove that infections are acquired in prison,
the prison environment makes spread of blood-borne viruses more
likely. The boredom, frustration and hopelessness felt by many
prisoners potentially contribute to drug use. Many prisoners have no
investment in the future, which will probably contain little except
unemployment, further drug use and further imprisonment -- 64% of prison entrants in Victoria have been imprisoned previously.
5 They may believe they have nothing
to lose (and some escape to gain) from drug use. In addition, prison
policies may aggravate the problem of disease transmission. For
example, sharing of injecting equipment is much more common in prison
(where equipment is very scarce) than outside (where it is relatively
freely available). 1 Efforts
to detect drug use, such as urine screening, may drive prisoners from
smoking marijuana (which has metabolites that can be detected in the
urine for many days) to injecting heroin and amphetamines (which are
rapidly cleared from the body). Prison practices may also
prevent prisoners taking precautions against spread of bloodborne
viruses. For example, despite official policy, urine screening is
alleged by prisoners to be anything but random; in some prisons,
prisoners claim that a request for bleach (for disinfecting
injecting equipment) is followed the next day by a urine test. 6 Sanctions against drug use,
such as loss of contact visits as punishment for a "dirty" urine,
simply reinforce the original reasons for drug use. 6
The situation varies for different bloodborne viruses. Despite the
opportunities for transmission by injecting drug use, there has been
very little transmission of HIV in Australian prisons. 7 However, this is not because
conditions are not right for such transmission. It is because there is
very little HIV among prison entrants as a result of harm reduction
programs in the general community -- fewer than 5% of Australian
injecting drug users were seropositive for HIV. 4 The recognition that reducing the
spread of HIV is a more urgent priority than eradicating drug use (were
the latter possible) has allowed our national AIDS and drug
strategies to adopt such harm-reduction approaches (e.g., needle
and syringe exchange and methadone maintenance programs).
On the other hand, HCV is causing an epidemic among Australian
injecting drug users that will be difficult to control. 2 Prisons are a key to this control;
without rational approaches to the twin problems of injecting drug
use and of HCV transmission in prisons, the epidemic will continue.
The first step should be the recognition that incarceration offers
nothing but ill to most injecting drug users. Alternative approaches
to their problems will benefit both them and society.
A serious reconsideration of the opportunities for spread of
bloodborne viruses in prisons is the next step. Measures should
include everything from lowering the cost to prisoners of razors and
toothbrushes (so they will not share them), to provision of sterile
injecting and tattooing equipment, peer education programs,
transition programs to assist movement back to society (including
referral to needle exchanges), proper drug substitution and drug
treatment programs and hepatitis B vaccination. 8
It cannot be said often enough that the punishment is deprivation of
liberty, and that is all. Prisoners should have available to them all
the means for protecting themselves against infection with
bloodborne viruses that are available outside prison, without
qualification. Prison authorities and governments must realise
that the responsibility for the infection of a prisoner with a
bloodborne virus, because means for prevention were not available
within the prison, rests with them.
Nick Crofts
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© 1997 Medical Journal of Australia.
Prison authorities and governments must
realise
that the responsibility for the infection of a prisoner
with a
bloodborne virus, because means for prevention were not available
within the prison, rests with them.
We justify depriving people of their liberty for transgressing
social norms on the grounds of protecting society or rehabilitating
the person. However, in the case of illicit drug use, there is little
evidence that either of these objectives is achieved by current
approaches. Imprisonment exposes injecting drug users to greater
risks of infection with bloodborne viruses (such as hepatitis B and C)
than in the community.
Prisons take people from diverse settings who would not otherwise
meet, create the opportunity to spread bloodborne viruses among them
and then send them back to their original social networks as potential
sources of infection.
Head, Epidemiology and Social Research,
The Macfarlane Burnet Centre for Medical Research, Melbourne, VIC.