Side Event. Health and HIV in prisons: Effective strategies to address urgent needs

Organised by Penal Reform International with the support of Belgium, Brazil, Czechia, Mexico, Sweden and the International Drug Policy Consortium


Ehab Salah – Advisor on Prisons and HIV, HIV/AIDS Section, UNODC: Thank you very much for joining us today and this very important CND side event on health and HIV in prison settings effective strategies to address urgent needs. Thanks to colleagues who are joining us in person during the last day of the CND. And also, for joining us online as well. First, I would like to thank our colleagues at Penalty Reform International for organizing this important side event. Thanks, PRI, for being leading us in this process. And I’m Ehab. I work for UNODC and I’m coordinating UNODC work on Prisons. I would also like to take the opportunity to thank cosponsors of this side event: Belgium, Brazil, Czech Republic, Mexico, Sweden and International Drug Policy Consortium in addition to you know the HIV section of course.   The topic we are talking about today is health and HIV in prison settings and we our target population here is people in prison. A systemic, systematically neglected population and the age response Globally, we have made a lot of successes when it comes to reducing mortality in many geographical regions, reducing the incidents and new HIV cases in many countries. We have made a lot to achieve our ultimate target to end AIDS as a public health threat and 2030 as emphasized in the SDG’s 3.3 target. However, unfortunately this is not the case for our target population, I mean people in prison. Recent data we are gathering from all countries shows we are not moving and the prevalence is the same way. It’s not reducing. We don’t have enough data to tell us about the incidence cases or the new cases. Service coverage is very low and when it’s there, it’s low quality. And accessibility is always a question mark and This is why we are using this platform of the CND to have this side event to speak about harm reduction and other healthcare services for people who use drugs in prison settings. Without losing any more time, I would like to give the floor to my colleague Olivia Roe to give us some opening remarks for this event. Olivia is the Executive Director for Penalty Reform International, and she was. She’s joining us online today. Olivia you have the floor. 

 Olivia Rope – Executive Director, Penal Reform International: Thank you. Thank you so much. Hope you can all hear me OK. No technical glitches as the first achievement and sorry I can’t be with you all in person, but thank you to all attending this discussion today and I echo thanks to this Cosponsors Member States, UN and civil society partners. Who have joined us on these efforts today.  Well, we meet at a time where there are more people in prison globally than ever before, and people in prison have often had very complex lives with discrimination and violence. Thread through their stories it’s well evidenced. And what this means in terms of health of people in prison is that. For these reasons and others, people in prison are six times more likely to be living with HIV than people outside of prison in the general population. And within this data that we do have, it’s important to reiterate that woman in prison continue to be more likely to be living with HIV than men in prison. With an average HIV prevalence of 5.2% in 2020, compared to 2.9% among men in prison. So, our responses need to be gender sensitive. The disproportionate burden of HIV as well as hepatitis C in prisons is not only links. To the people’s stories, the people that are in prison, stories outside of prison. It’s also linked to prison conditions and responses have insufficient access to comprehensive evidence-base harm reduction services. The number of countries providing harm reduction services has not significantly increased in recent years. Despite the amount of evidence of their effectiveness and where they are available, coverage and access remains inadequate across the prison systems and I’m sure our expert panel will expand on this today. Civil society organizations play a really crucial role in improving access to health care in prison, including responses to HIV and harm reduction services. So we at PRI are really pleased to have been appointed in 2022 as secretariat of the Informal Civil Society Organizations Group on Health and Prison, which currently comprises 39 organizations working across all regions of the world. The group aims to ensure that the voices of civil society working with affected communities are heard, including an intergovernmental process such as the CND, and provide coordinated contribution to UN mechanisms, in particular UNODC’s work on health and prisons. I believe today’s event will showcase some of the vital work being carried out by our colleagues in different regions and context to improve health and prisons, as well as reflecting on some of the key challenges we face today and realizing the right to health and equivalence of care in prison settings. Thank you Ehab for moderating and I’m really looking forward to the discussions today. 

 Aire Kamiyama, IDUCARE, Philippines: In Ideal Care our service delivery community organization in Cebu in the central part of the Philippines. As a community organization, our primarily focus is on drug user as wellbeing. Our work includes outreach in hard communities, especially in a social climate where people use drugs fear for their lives due to the stigma and criminalization. Aside from providing services in our drop-in center, we also works closely with a local government health office in which HIV and health response in jail and prisons for people who use drugs. We do HIV and HCV screening, treatment and case management, condom promotion and distribution. Motivationally interviewing and learning group sessions and harm reductions awareness like wound care and how to use clean needles and syringes. Data from the past 11 years tell us that among persons deprived of liberty who had been tested for HIV, 6% of them are positive. 97 of this is HIV positive on people who use drugs. In the Philippines, the majority of the people in our jails are there for drug charges. So, it is imperative that we assist drug users to understand not only the law but their legal rights. We conduct regularly workshop on legal and harm reductions awareness, including the new HI Below Republic Act. We also provide paralegal assistance and conduct paralegal training for a woman in four female jail facilities, Cebu, Mandawe, Talisa and the Pulapo City. 90% of women we had trained had been charged for drugs. So, this is a great need for jail and prison facilities to prioritize the human and dignified treatment of those who are incarcerated, especially women. And to ensure that the right to help of drug users in jail and prison is upheld. Protecting the health of individuals deprived of their liberty is an urgent matter that needs to be addressed. Increase in population due to nonviolent drug charges. The jail and prison facilities were designed to house the male population. Most facilities don’t have enough space to protect the basic needs of women required by human rights, the care of vulnerable groups, most especially women. The friable of liberty must take into account that specific needs of women. This includes proper nutrition and adequate exercise for pregnant women, as well as amenities to take care of person’s hygiene, especially during menstruation. Basic needs for nutrition, meals and safe drinking water are also essentials. The limited supplies of water hinder treatment. For example, one of them shared how they cannot take the treatment because there was no potable water. If they wanted to drink water, they would need to buy a bottle of mineral water which is very expensive in the facility. Comprehensive screening upon admission covering educational, social, economic, background, trauma, health history and current health status. Harm reduction interventions especially aims to reduce the risk of a drug related deaths to the withdrawal management. How to clean needles and wound care. HIV awareness and counseling. Incorporating harm reduction principles into the training and daily activities of both people deprived of liberty and of the prison staff can have significant impact but encouraging principle of respect and promotion of people rights to help. Harm reduction can lead to the people sent an approach even with the within a jail and prison facility. For example, custodial officer who today only wants to make sure that the person detained will not escape would with harm reduction will prioritize the person wills being and make sure that the person, family and children are able to visit. 

 Thembi Zungu, Deputy Country Director – South Africa Partners: Greetings colleagues, thanks you have for the introduction and thanks CND for the opportunity. We are working in 33 correctional facilities. We were formed in 1997 originally from Massachusetts in Boston and we are registered both countries and we’ve previously worked with the National Department of Health. To actually roll out prevention, treatment and care, and support interventions for people living with HIV. One of each is called Integrated Access to Care and Treatment, where we work both in general communities and then we then piloted in prisons in Port Elizabeth around 2011 and that gave birth to the inclusion of the Integrated Access to Treatment and Care strategy into the National Adherence guidelines to treatment for chronic diseases like hypertension, diabetes and other chronic diseases like hepatitis. Information Dissemination: In 2011 were asked by the Centers for Disease Control and Prevention to adapt the Integrated Access to Care and Treatment intervention into a prevention initiative, and then that gave rise to a program called STEPS, which is an acronym for Strengthening Prevention Services in Correctional Facilities. We started as just on information dissemination and we have grown to a whole cascade of care for inmates in the 33 high volume facilities that are based in housing Eastern Cape, Northern Cape and Free State properties of South Africa. So, the epidemiological context in which we work, generally there is not enough data on prisons in terms of HIV incidence, but a small intervention was done in 2019 to look at a social behavioral factor, risk factors that contribute to HIV, TB, Hepatitis B and Hepatitis C in prison. It was conducted by the Aurum Institute in 2019 of which we were a sub grant, in only two high volume facilities, one in high in urban area in Gauteng, and the other one in Limpopo which is more rural. And the findings actually showed higher incidence of HIV at 26% in urban area. And 12% HIV incidence risk factors, potential risk factors for transmission. We’re really sharing of shaving equipment, tattooing and there’s some evidence, anecdotal evidence that talks to injecting drug use. Overall, the program is in four provinces, where there is a map of South Africa. The lowest in red is Eastern Cape with 10 correctional facilities. In green is Northern Cape, which is the fairest in the country with eight correctional centers and then in GP, which is the smallest in size in the map with 15 correctional centers, but very high volume. We cover 4 regions, 4 provinces and then the other partner that we work with covers the other five provinces of South Africa. Our population coverage right now national in terms of staff in correctional facilities, it’s 8732 just doing administration and custodial work with within 240 prisons. And we only covering about 74 of those prison, which means the others are left not reached with the current program that you are doing and the total community is 140 another 1040. We give direct service delivery through our prevention activities, demand HIV testing with innovations like Prep and HIV self-testing. We provide technical support, training and mentorship to correctional staff on innovations of HIV and viral loads management and some of our clinicians do initiate ART to augment the skills that are within DCS. And we continue to monitor the improvement in terms of the clinical cascade, whether people are testing, whether people are being linked to care and whether inmates are being virally suppressed. And we could offer continuous supporting or making sure that inmates are adhering to treatment and they are actually virally suppressed through the four objectives working with the system. To provide services for the key population group that is inmates. We want to strengthen harm reduction in prisons and link the inmates to care, because it’s pointless to provide the service and not give them treatment. Then we would like to build the capacity of correctional staff to address vulnerabilities through sensitization, in understanding that the inmates still require a treatment like any other person who’s outside the prison, this is stated in the Mandela rules. We would also like to make sure that there is transitioning of health services outside the prison. At this point in time, we are not achieving a lot because there aren’t enough resources and there’s disjointed systems between health and corrections. So, this is just a graph that shows how we flow from the prevention services to HIV testing services, linking to care, starting inmates on treatment, ensuring that they are adhering and virally suppressing. We are showing that at on the outside, which is the communities we are working towards facilitating. Working with community corrections and hoping that an inmate will transition with a package of HIV care, whether on chronic treatment, or on ART, or needing PREP or any other service. Care should continue in the community, outside the prison. These are just pictures of what we do when we’re inside in yellow on my left is there awaiting trial sessions and then under the tent we provide HIV testing, education, and link to care. And then we also give the option of whether they want to be tested with an HIV rapid test or they want to be directly assisted with the HIV self-testing kit next. And then under the objective of building capacity, we also provide COVID-19 education for correctional staff. We also provide data management training for the staff, especially on the system that is being used by correctional system and the Department of Health. What have we learned? So, in terms of HIV testing and linkage in correctional facilities, I think directly assisted HIV self-testing is one innovation that is assisting inmates to quickly get to testing. As I’m speaking now, we are scaling up PrEP to strengthen hand protection in correctional settings for inmates testing HIV negative and then ensuring that the HIV positive inmates are initiated on a base regimen to manage Hepatitis B. Remand detention facilities are kind of being a challenge because inmates are in and out of the correctional centers, but the care is still giving Hepatitis B and C incidents need to be integrated into HIV programs. That especially in the urban facilities there is high rate of injecting drug use. Data management is key to ensure that this continuous patient care in particular around timely viral loads, blood is been taken and then results captured and then enhanced adherence counseling provided for those inmates who are not suppressing. There is a string a strong need to support Hepatitis C cases and their clinical management. Unfortunately, we have approved it the country but there isn’t a national rollout as yet by the National Department of Health. There has been a Hepatitis C demonstration intervention of on a very small scale conducted in a Correctional Center. At the Kgosi Mampuru Central Correctional Center, there is an ongoing need for policy review to determine the priorities in health and custody, including managing HIV in women. At country level, everyone should move along if we say Prep is good for prevention. Everyone would be adhering to that policy, treat all inmates the same they have rights as any other person. The Mandela rules should apply. There is an ongoing need for strengthened capacity of ex inmates and parolees to participate in civil society activities so as to increase their voice, to lessen stigma and enable the ground for reintegration. There’s very less of that because they are in different communities, not coordinated. And lastly, there is insufficient human and financial resources which currently are needed to. 

 Anna Koshikova, Executive Director Eurasian Movement for the Right to Health in Prison: The Eurasian Movement for the Right to Health in Prison brings together people with prison experience, expert in prison house and right protection, with common vision of ensuring that people in prison have the same access to services as people in the community. I will describe challenges and successes in improving access to vital health and harm reduction services in prison in Eastern Europe and Central Asia. Excited to be here, I have participated in CND event back in 2009 and I’m really happy to be here after all these years. I represent the Eurasian movement for the right to health in prisons and we believe that a person’s health level can be higher, can be even higher about after the release from. Prison than before imprisonment and in order to ensure this we work on improvements in prison health policies, systems and practices. We are newly formed organizations that works on prison health issues in the region of Eastern Europe and Central Asia. In terms of ensuring access to HIV, HCV, TB, harm reduction and drug dependence treatment services. Countries of our region differ greatly, but to understand the general context we’re working in, we are working in, we need to understand that we work in the conditions when access to services in prisons is usually not a priority of the regional agenda of stakeholders. Funding of services in prisons is often allocated on the leftover principle, leaving many people behind the vital services. There is a number of political, financial and administrative barriers in service implementation in a closed setting. And as a consequence of all that prisoners often do not have access to many vital services. Even in case these services are available in the same country for people who are not living in prison. Now let’s look at some specific services and in terms of their access of prisoners. To them enter a ART can be considered the most accessible services. Service in prison settings and they demonstrate high coverage rates and good retention rates in treatment, which are often even higher than in civil society sector. Governments tend to commit more and more funding, state funding to support procurement of ART and implementation of HIV treatment programs in prisons. However, there are few challenges that are faced by HIV Treatment Programs in Prison. For instance, the prison regime often affects the quality of life of patients the delivery of pills to the patient often depends on the schedule of medical facility working and it doesn’t include the needs of patients in terms of providing more opportunity for a more convenient treatment option. In terms of the big Treatment, a lot of progress can be made in the last 10 to 15 years. To ensure timely diagnostics and treatment of tuberculosis and to improve the infection controls norms. But at the same time, MDR TB makes up to 40% of all TB cases among prisoners. There are such issues as the necessary, as the obligatory transportation of prisoners to other penitentiary institutions for inpatient treatment, which takes a lot of time and usually is conducted with violations of infection control norms. And there is a big challenge in terms of following up the patients who are being released and from prisons who are TB treatment and some of them tend not to finish TB treatment after they are released from prison. In terms of hepatitis C? The situation is very different from country to country. Some countries assure universal access to hepatitis C Treatment in prisons. For instance, Georgia where hepatitis C treatment in prisons is the part of the National Hepatitis C Elimination Program, while in other countries, even if hepatitis C treatment is available in the civil sector in prisons, often the possibilities are very, very limited. At the same time the HCV prevalence is very high in prisons that we have found data from some countries, for instance Ukraine, where HCV prevalence is up to 40% and there’s very limited access to treatment in many countries and a very long and complicated. Opioid antagonist therapy, again very different situation in different countries. Some countries like Moldova and Kyrgyzstan have ensured we can say universal access to this service for all who needed. But at the same moment there are countries where all OIC is not available at all. There is also very good practices in terms of having one stop shop service provision mode for OAT services and presents for instance in Kyrgyzstan. But as I said, in many countries or it is not available in prisons and people who end up in prisons face treatment interruption. There are a lot of administrative barriers at the level of the facility in terms of provision or OAT in many countries. And there are many myths and stigma, discrimination and prison subculture which influenced the expansion of OAT programs in prison. Again, very different access to harm reduction services in prison settings compared to the civil sector. For instance, Ukraine has very developed harm reduction programs for key populations in civil sector. Just last year is starting harm reduction programs in the prison system. In some countries like Kyrgyzstan and Moldova, there has been a very good progress in terms of conducting harm reduction services, including syringe exchange programs involving volunteers. As social workers from among prisoners at the same time, in many countries these services are not provided at all, and there are many administrative barriers to expand them and also prison subculture, which influenced the expansion of these services greatly.  I’ll wrap up now we can to summarize. We can say that best progress has been achieved so far and organizing ART programs. There is a great lack of implementation social support services. For instance, forming adherence to ART services, proper counseling and before HIV testing, before TB testing, before and after testing and many other social services which are available at civil sector, but are not available for prisoners. Access to services differs greatly as we see from civil sector to prison settings and there are many countries which have ensured great access. To OAT harm reduction, HTV treatment for the civil population, but are not progressing very much in terms of ensuring the same access in prison settings. There is still observed the high level of dependency on donor funding for many activities implemented in prisons, including procurement of vital medications. A significant challenge is also a limited continuity of services between civil and penitentiary the sector when patients who are receiving services in prisons are lost to follow up when they are released from prisons and vice versa. When people who have been receiving services outside of prisons find themselves in prisons, service provision for them often stops because some options of service delivery are not available on prison settings. And overall, there is a very limited access to data and often if we are even implementing some services like OAT for example, it’s difficult to understand how well we are doing because we don’t know how many people actually need it. Also, the closeness of the penitentiary system doesn’t allow us to access all the data on epidemiology, the commonness of the drug dependence problems in prisons. And This is why we cannot build our programs based on evidence and we often rely on our programmatic experience of working in prison.  

 Fariba Soltani, Chief, HIV/AIDS Section & Global Coordinator for HIV/AIDS, UNODC: Thank you very much. I would first really like to thank Penal Reform International for organizing this very important session and to have this discussion also in the context of the CND. Because addressing the health among one of the most neglected populations ever, is the people in prison. So, this is really important to have this discussion. I would also like to thank the Permanent missions of Belgium, Brazil, Czechia, Mexico, Sweden and IDPC for supporting this event. And also supporting UNODC’s work on HIV and what we are all doing together as partners to ensure the people in prisons receive the services that they need. Thank you to Erin, Thembi, Anna for the excellent and very informative presentations and your engagement as essential partners in addressing HIV and health in prisons. I think you are all a part of our NGO group and we really look forward to engage with you further and working with you for this population group. Also Karima, she’s been very much behind this session. So, thank you for all the work that you put into getting this session on the way. I think everything has been said really. I think all the presentations have been so rich. It’s just this session shows how important it is that we deal with the issues that we still require our attention if we want to reach the target set in the global AIDS strategy, if we want to reach ending AIDS by 2030, we cannot forget the prison population. I think this is the only group that really puts prison population at the center and prison health is public health, and we all know that. So, we really look forward to engaging with you working together to making the services available to prison population a reality and it’s a scale which makes a difference to the epidemic. So, thank you very much.  

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