The number of prisoners living with HIV varies between countries. America has the highest prison population in the world, around 1.5 percent of whom are HIV positive. Although this figure has declined, HIV prevalence is still higher for incarcerated populations than for the general population. In fact it has been estimated that between 17 and 25 percent of people living with HIV in America pass through the correctional system.
Studies from prisons in Brazil and Argentina reveal a particularly high HIV prevalence - ranging from 3.2 to 20 percent in Brazil and 4 to 10 percent in Argentina. The prevalence rates for some sub-Saharan African countries are also high; an estimated 41.4 percent of incarcerated people in South Africa are infected with HIV. Generally, the HIV prevalence in the country reflects the prevalence in prisons. So while South Africa has a high percentage of HIV positive inmates, the HIV prevalence in the general population is also high, at an estimated 17.8 percent.
In Europe, many of the eastern countries have a high HIV prevalence among the prison population. In 2010, it was estimated that 55,000 of Russia’s 846,000 inmates were infected with HIV. In Estonia, four studies revealed HIV prevalence in prisons ranging from 8.8 to 23.9 percent. In comparison, the last study in England and Wales in 1997-1998 revealed a much lower prevalence of 0.3 percent among men and 1 percent among women.
Why is there a higher HIV prevalence in prisons?
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.
How is HIV transmitted in prisons?
As it is difficult for researchers to gain access to prisoners, there are few documented cases of HIV transmission within prisons. However, this does not mean that HIV is not a significant risk to prisoners.
“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.”
Although this view from UNAIDS refers to prisons in the 1990s, it still applies to many prisons across the world today. Injecting drug use, high-risk sexual behaviour, and tattooing are common within prisons, each posing a risk of HIV transmission. According to studies, a record of incarceration is often associated with HIV infection, particularly in western and southern Europe.
Injecting drug use
The use of contaminated injecting equipment when using drugs is an effective route of HIV transmission; outside sub-Saharan Africa injecting drug use accounts for just under a third of infections. Multi-country studies have found that between 56 percent and 90 percent of people who inject drugs have been incarcerated. The estimated percentage of inmates who inject drugs ranges between 0 and 30 percent.
“I injected cocaine when I was in prison. I injected cocaine about twice a month. I used a homemade needle to inject and discarded it after I used it, or gave it to someone else. The homemade needle had a very thick gauge and it would hurt when I injected. Sometimes my arm would become inflamed after I used it.”
David Bruce Cossey, Vancouver, British Columbia
Where there is a high number of imprisoned injecting drug users there is a higher risk of HIV transmission. Within prisons it is difficult to obtain clean injecting equipment - possessing a needle is often a punishable offence - and therefore many people share equipment that has not been sterilised between uses. In a study of prisoners and HIV in England and Wales in 1997-1998, 75 percent of adult male IDUs and 69 percent of adult female IDUs had shared needles/syringes inside prison.
“I injected every second day, once a day with works I had to hire, which had been used by others.” 27 year old male, imprisoned for three months.
“When I scored smack [heroin] I rented or bought works that had been used God knows how many times.” 27 year old male, imprisoned for six months
IDUs may be aware of the risks of HIV infection through sharing needles. However, if a clean needle is not available, many may still take the risk.
“As long as you can get the gear you inject as soon as you have a chance.” 27 year old male, imprisoned for four months.
“Sometimes the needle gets rinsed in a bowl of water after being used, but that doesn’t do much. Other times it’s just passed from girl to girl. I mean, if you want a hit and you want it bad, you are not going to stop everything and clean your needle…” Paula
A number of studies have found that IDUs are more likely to share injecting equipment within prison than before imprisonment. In the Republic of Ireland, 70.5 percent of the IDUs surveyed reported sharing needles while imprisoned, compared to 45.7 percent in the month before incarceration.
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.33
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.
World Health Organization (2007) ‘Effectiveness of interventions to address HIV in prisons’