Prisons are hepatitis breeding grounds for drug-injecting inmates

Half of all drug injecting prisoners have hepatitis C because few prisons worldwide successfully prevent hepatitis transmission.

That’s because few prisons worldwide successfully prevent hepatitis transmission amongst inmates injecting drugs behind bars, says Heino Stöver, professor of Addiction Research at the Frankfurt University of Applied Sciences. .

With ‘Prevention’ being the theme for this year’s World Hepatitis Day on the 28th of July, we spoke with Stöver, author of the United Nations Office of Drugs and Crime’s handbook on needle and syringe programmes in prisons. He talks about what more can be done, and the double standard he sees in health care prevention in communities and custodial settings.

ResearchGate: How prevalent is the Hepatitis C Virus (HCV) in prisons and who are most at risk?

Heino Stöver: The HCV prevalence rate is much, much higher in prisons than in general society. When it comes to prisoners who inject drugs – who are the most “at risk” group – the prevalence rate is around 50 percent.

There’s much more variety in the prevalence rate worldwide because it really depends on the prison type and gender involved. However, on a more general level, around every 5th to 7th prisoner has HCV in most western European countries, and it’s definitely more than 10% of the whole prison population worldwide. Although, again, it rises to 50 percent amongst injecting drug prisoners.

RG: How is this a concern for the general population?

HS: We always say “prison health is public health” so there shouldn’t be a double standard of provision. If prisoners are left untreated or undiagnosed, then, after serving their sentence and returning to community, they may start sharing their needles. This is a threat for public health in general, and for their partners and families in particular.

RG: What are Needle and Syringe Programmes and how can they help prisoners?

HS: The programme has developed in the last 30 years into an inevitable tool: It’s about providing sterile equipment to help at-risk people protect themselves against viral diseases.

Drug users behave in a very brave manner to change their behavior. Most people change their behavior substantially in the municipalities where sterile needles are offered, and much of the needle sharing behavior vanishes. The problem is, once these users are incarcerated and sterile needles and syringes are not offered, then they experience what I call a hygienic relapse.

Hepatitis C is a very persistent virus: It can’t simply be cleaned with water or pumping air through the syringe – yet that’s what prisoners will often do because needles are scarce. It’s an emergency for those who are dependent on heroin and get hold of the drug in prison. We have sharing ratios from 1 to 20 to 30 people using the same syringe.

You can imagine what this is contributing to: Prisons have developed into a breeding ground of infectious diseases. The 60 or 70 prisons worldwide that have Needle and Syringe Programmes are just a drop in the ocean.

RG: If only 60-70 prisons have implemented a Needle and Syringe Programme, what other strategies are used to prevent HCV cases amongst inmates, and how do they compare to outside communities?

HS: HCV prevention in prison is almost exclusively limited to verbal advice, leaflets and other measures directed to cognitive behavioral change. Although the outcome of HCV antiviral treatment is comparable to non-substance users and substance users out of prison, the uptake for antiviral treatment in custodial settings is extremely low. This clearly points out that there is a double standard in health care provision in most countries in the world.

I think it’s quite unethical to invest thousands of euros into treatment when people can be easily re-infected while in prison since there’s no prevention strategy available.

RG: How successful are Needle and Syringe Programmes in the prisons implementing them?

HS: They’ve been very successful. I happened to evaluate the first Needle and Syringe Programmes in Germany in 1996, 1997, and ongoing. We found that the phenomenon of sharing needles completely vanished once you deliver a mode of distribution accepted by the prisoner.

RG: What are the common fears of implementing Needle and Syringe Programmes in prison? 

HS: Some might fear that people start to inject or change their drug consumption habit - say from smoking or inhaling to injecting. We have not found any evidence of that.

The second fear is that syringes and needles would be used as weapons against staff and other prisoners. Again, we did not find any incidents of that. In Sydney, Australia, a staff member was threatened with a needle – but this prison didn’t have a needle programme, so it’s a clear threat regardless.

RG: Are any countries or states a prime example of championing hepatitis prevention in prisons?

HS: Spain, definitely. I would call them champions. They’ve implemented needle and syringe programs throughout half of their prisons. Their healthcare provision for drug using prisoners is the most developed and thorough compared with the rest of the world.

RG: Anything else you’d like to add for World Hepatitis Day and its theme ‘prevention’?

Heino Stöver
Heino Stöver

HS: Yes - in terms of hepatitis, it has been said that treatment is prevention. Those who are treated cannot transmit the infection to anyone else. In saying that, prevention is also prevention: We have to implement the same range, size and quality of prevention tools inside and outside the prison. Then, of course, we have to screen, test, diagnose, and treat people while in prison. We need to let them out in a better condition than they arrived in.

Thank you, Heino.

Top right photo courtesy of Edward Corpuz; bottom left courtesy of Heino Stöver