HIV and Hepatitis C Research Proposal

DEFINITION OF THE PROBLEM

The spread of diseases particularly HIV and Hepatitis C in prisons is an ongoing problem. Combating HIV and Hepatitis C requires putting more attention towards the main elements that cause this health issue. Problems of needle use for drugs and tattooing, unprotected sex and piercings are all associated with the spread of diseases within prisons. Research has shown that tattooing and injection drug use has been a major influence on the increasing rates of Hepatitis C and HIV in prisons around the world. Tattooing and injection drug use within Canadian federal prisons requires attention and proactive responses in order to tackle the issue. The implementation of harm reduction programs is essential to reduce and prevent the unsafe practices of tattooing and injection drug use and is vital in order to reduce the number of new cases of Hepatitis C and HIV each year.

SCOPE OF THE PROBLEM

Tattooing and needle drug use within prisons and jails is a worldwide problem. Needle use within prisons leads to health and safety issues for both offenders and staff. The use of shared needles for tattooing and drug use leads to the spread of blood borne diseases such as: Hepatitis C and HIV. The Correctional Service of Canada (2009) reports that 30-40% of inmates have Hepatitis C, and HIV infection is “estimated to be 10 times higher within the federal institutions than in the general population” (Public Health Program). Tattooing and needle drug use is prohibited in Canadian institutions, however offenders still find the methods to continue needle use practices. Drug use and tattooing is a reality in prisons around the world, and “drugs get through even the thickest walls” (Public Health Program). Offenders continue to find ways to get drugs into prisons and continue to use many accessible tools to make tattooing devices. It has been a persistent problem, and “Hepatitis C and HIV rates have remained higher in prisons than in the general population” (Elliott, 2007, p 262).

Providing safe tools and programs related to the prevention of spreading diseases will cut down health care costs and prevent the spread inside and outside prison walls when offenders are released into the communities we live in. The Correctional Service of Canada (2009) revealed that from the years“2000 and 2002, the number of HIV and Hepatitis C offenders released to the community has increased”. Offenders released into the community with “Hepatitic C, increased to 60%, from 1,156 in the year 2000 to 1,856 in 2002, and for HIV there was a 13% increase from 162 in the year 2000 to 183 in 2002” (Correctional Service of Canada, 2009).

HISTORY OF THE PROBLEM

Tattooing and injection drug use is a problem within prisons that affects offenders, staff and the public when offenders are released to the community. A study conducted by Poulin and colleagues (2007; as cited in Elliot, 2007, p.262) found that 63% of male inmates and 50.0 % of female inmates reported injection drug use and reported sharing needles. The National Inmate survey of the Correctional Service of Canada “found that 45% of federal prisoners have received tattoos” and approximately “11% of inmates inject drugs and 30% share dirty needles” (Kondro, 2007, p.1). The survey also found that “approximately 37.9% of male offenders and 4.8% of female offenders reported receiving tattoos inside prisons and reported using non sterile equipment” (Kondro, 2007, p.2). The results from the study almost mirror the results conducted almost a decade earlier on tattooing in prisons. From 1997 to 2004, there has been an “increase in contraband seizures of tattoo related paraphernalia within federal Canadian prisons and there were 48 recorded staff injuries resulting from a puncture with a sharp object directly related to tattoo needles” (Correctional Service of Canada, 2009). HIV rates in “federal Canadian prisons is 1.7%, which is 10 times higher than the rate in the general Canadian population (0.13%)” (Thomas, 2005, p.3). Reported HIV cases in federal Canadian prisons in 1989 was 14, in 1996 it rose to 159 and in 2001 it rose to 233 (Thomas, 2005, p.3). Hepatitis C infection rates in federal


Canadian prisons are “23.6%, which is 20 times higher than in the general population” (Thomas, 2005, p.3). The Correctional Service of Canada reports “new Hepatitis C cases remain relatively steady since 2000, ranging from 533 to 570 a year” (p.3).

CURRENT STATUS

The Correctional Service Of Canada has developed some harm reduction programs to reduce the risk of diseases within Canadian prisons. The policy surrounding harm reduction in the Correctional Service of Canada (2003) is “aimed at reducing negative health, social and economic consequences of harmful behaviours such as injection drug use and unsafe sex.” (p.9). The Correctional Service of Canada

admits that “abstinence from risky behaviours is undoubtedly the most desirable goal, but this may not be achievable or desirable for a person in a risky situation” (p.9). Instead of “focusing on abstinence as the only worthwhile treatment goal, harm reduction approaches focus on minimizing the consequences of risky behaviour” (p.9).

Harm reduction approaches currently used within Canadian federal prisons range from educational pamplets, the distribution of products to aid in the prevention of the spread of diseases and providing offenders with methadone. Condoms, bleach, pamphlets on cleaning needles, sharing needles and the transmission of diseases are readily available and posted throughout offender’s living units. Bleach is regularly provided to offender’s living units and instructions how to properly clean needles are posted. Methadone maintenance programs are also available for “offenders with serious heroin and other opioid addictions, where the route of choice is intravenous” (Correctional Service of Canada, 2003, p. 9). Offenders are also subject to random urinalysis to determine drug use and a positive test, results in a serious institutional charge.

Canadian Organizations and Health Agencies have requested more programs and initiatives to be implemented within the Correctional Service of Canada to tackle the spread of diseases. In 2003, Prisoners with HIV/AIDS Support Action Network prepared a report with recommendations to the Correctional Service of Canada. The recommendations requested to the CSC were to: decriminalise tattooing and provide a safe tattoo parlour for tattooing and body piercing (Collins, Dias, Dickenson and Vidovich). In 2005, the Correctional Service of Canada (2009) started a safe tattooing pilot initiative at each of the five regions in Canada to reduce the risk of diseases from “dirty needles”. The tattooing initiative came to a halt when the Conservative Government cancelled the tattoo project the following year due to cost.

In 2005, The Canadian Human Rights Commission recommended that a pilot project for needle exchange be implemented in three or more correctional facilities. A recommendation that the pilot

project be monitored and assessed after two years was also suggested. The Correctional Service of Canada (2009) responded to the request by stating that they would be analyzing results of the effectiveness of needle exchange programs by The Public Health Agency of Canada, before considering.

In 2005, at The Canadian Medical Association’s annual meeting, the association provided a recommendation for the Correctional Service of Canada to implement and evaluate at least one pilot needle exchange program under its jurisdiction (Betteridge, Jurgens, Laticevschi, Lines, Nelles & Stover, 2004, p.5). At the end of the same year, the Canadian Centre of Substance Abuse released a paper that revealed, “it does not expressly endorse prison needle exchange programs” (Betterridge et al, 2004, p.5). The Canadian Centre of Substance Abuse admitted however, that studies showing the effectiveness, the positive experiences with the programs in other countries and the positive results of community programs, provide “ample justification for the government to consider implementing pilot


studies to assess the effectiveness and feasibility of prison-based needle exchange programs in the near future” (Betteridge et al, 2004, p.5).

In 2003 and 2005, The Correctional Investigator “who is the legislatively mandated ombudsperson for federal prisons called for the introduction of prison needle exchange programs”(Betteridge et al, 2004, p.5). In 2003, the Correctional Investigator recommended that the “CSC implement a needle exchange program in three or more institutions by 2005, requesting the results be monitored, disclosed and assessed after two years” (Correctional Investigator, 2003, p.5). The Correctional Investigator recommended the implementation again in 2005, when the project still had not been put into action.

In 2006, the Public Health Agency of Canada informed The Correctional Service of Canada “that prison needle-exchange programs decreased needle-sharing practices, did not undermine safety and security and did not lead to increased drug use among prisoners” (Elliot, 2007, p.263). The Public Health Agency revealed that it costs an estimated $22,000 to treat an offender in prison with Hepatitis C and an estimated cost of $29,000 for HIV (Elliot, 2007). Research revealed “it would be far more cost-effective to provide offenders in prison with clean needles and syringes than to treat their HIV or Hepatitis infections” (Elliot, 2007, p.264). The United Nations agency also recommended, “that prisons should ensure access to the full range of HIV prevention services available outside the community, which include sterile needles and syringes and sterile tattooing equipment” (Elliot, 2007, p.264). The Correctional Service of Canada (2009) responded to the Public Health Agency’s request by stating,

“that the primary focus for CSC in the near term would be on reducing the supply of drugs in its institutions”.

The Correctional Service of Canada has been provided with extensive research that has revealed that needle exchange programs are benefical and they have also been provided with research from other


countries that support needle exchange programs. With all the overwhelming research available, it
“demonstrates that Canada continues to ignore or reject the evidence” (Elliot, 2007, p263). Unfortunately, harm reducution programs are constently affected due to political issues. According to
Elliot (2007), “if the political will cannot muster to implement evidence-based measures to protect the health of those in states custody, it may be time to put the evidence of this ongoing denial of human rights before the courts” (p.264). There is currently no recent information that the Correctional Service of Canada is exploring the implementation of needle based progams, or the re-implementation of the tattoo project in the near future.

OTHER JURISDICTIONS STRATEGIES

Countries around the world have taken the plunge and implemented prison needle exchange programs. As of 2007, prison needle exchange programs have been implemented in more than “60 prisons of varying sizes and security levels in Switzerland, Germany, Spain, Moldova, Kyrgyzstan, Belarus, Armenia, Luxembourg, Romania, Portugal and Iran” (Canadian HIV/AIDS Legal Framework, 2009, p. 6). In Kyrgyzstan and Spain the “needle exchange programs have been rapidly scaled up and operate in a large number of prisons” and are being considered in “jurisdictions such as Azerbaijan, Ukraine, Belgium and Scotland” (p.6).

An international evaluation of prison needle exchange programs was conducted in Germany, Spain, Krygystan and Moldovan. The study found that injection drug use did not increase and needle sharing in most prisons was strongly reduced (Betteridge et al, 2004). There are a number of different methods that prisons have incorporated to provide offenders with clean needles and there are essential factors that increase the success of needle exchange programs. Hand-by-hand distribution by nurses, outreach workers, non-governmental organizations and automated dispensing machines are methods currently


being used in prisons around the world to provide needles. Adequate access to needles, confidentiality
and support from prison staff have been identified as being necessary for positive needle exchange program success. (Betteridge et al, 2004).

Switzerland was the first country to implement a needle exchange program. Switzerland prisons use a dispensing method for needle exchange. The offenders are provided a dummy needle, and use it to begin their needle exchange on a one-to-one basis. The dispenser also provides “alcohol swabs, ascorbic acid, filters, plaster, and sodium chloride” (Betteridge et al, 2004, p.27). Switzerland prisons have not yet evaluated their prison needle exchange programs; however Switzerland has indicated that there are no new recorded transmissions of HIV, Hepatitis B or C. “The Switzerland Ministry of Justice confirms there is a “necessity for such programs and regions are now requiring needle exchange programs in all prisons in Switzerland” (Dolan, Heilpern, Rutter & Wodak, 2001, p.112). Prison staff were “initially skeptical of the program, but over time there became a broad support for it” (Betteridge et al, 2004, p.21). Switzerland prisons have no documented instances where syringes were used as weapons (Betteridge et al, 2004).

Germany prisons used dispensing methods, and nurse hand-by-hand distribution. Two prisons in

Germany evaluated their needle exchange program for two years. One prison had 169 participants and the other prison had 83 participants. The numbers of exchanged needles were 16,390 and 4,517. The percentage of returned needles was 98.9% and 98.3% (Betteridge et al, 2004, p.587). The prison in Germany with 169 participants used a dispensing machine that provided needle exchange and the individuals remained anonymous. The second prison with 83 participants had health care staff provide clean needles when the offenders returned used needles. The health care staff were required to keep all participants confidential. The evaluation found that “providing clean needles did not lead to an increase in drug use, and the amount of drugs seized within the prison did not change with the availability of


needle exchange” (Betterridge et al, 2004, p.28). Offenders entering into drug treatment programs
increased and there were no instances recorded where a needle was used as a weapon (p.32). After six years of successful evidence, the needle exchange program was cancelled due to political attack (p.28).

Spain prisons have non-governmental agencies running the needle exchange programs. The non-governmental staff attended the prison for approximately 5 hours each day in a discrete area. “In addition to a sterile needle, “the offenders’ receive a kit that contains an alcohol swab, distilled water, a hard container for carrying the needle, and a condom” (Betteridge et al, 2004, p.32) Correctional officers report very positive experiences with the needle exchange program and there have been “no reported problems or conflicts with prisoners as a result of the program, and there were no instances of syringes being used as weapons” (p.34). The needle exchange programs in Spain also found rates of intravenous drug use have remained unaffected, there are no recorded incidents of needle injuries, no increase in conflict among offenders or between offenders and staff support for the programs has grown. (p.25). Today, based on the positive results, legislation and policy for needle exchange programs have been developed for all 69 prisons within Spain.

Moldovan prisons used two stages to distribute clean needles when they started implementation of needle exchange programs. During the first stage of their needle exchange program, they had nursing staff hand out clean needles and during the second stage (which is currently being used) volunteers who were specially trained administered the needle exchange with the offenders. Moldovan has three prison needle exchange programs and have no reported instances of syringes being used as weapons, and no problems with dirty needles (Betteridge et al, 2004). Krygystan prisons require offenders to book medial appointments in order to conduct their needle exchange. The nurses would administer the needle exchange during the offenders’ booked “medical appointment”. Krygystan currently has established needle exchange programs in all prisons within their country. Krygystan prisons have no

reported instances of syringes being used as weapons, and “prison medical staff have identified a reduction in injection-related health problems such as abscesses” (Betteridge et al, 2004, p.42).

BEST PRACTICES

The organizations and agencies that recommend the implementation of needle exchange programs

provide the recommendations based on their research from other countries and communities that have found positive results. Needle exchange programs have been operating in communities since the 1980’s. Community needle exchange programs have generally been considered as “one of the most important factors in preventing HIV epidemics among injection drug users” (Public Health Program).

Needle exchange programs “have been studied in great detail for over 20 years and have been proven to be an important mechanism for reducing the risk of infection from the use of nonsterile injecting equipment” (Canadian HIV/AIDS Legal Framework , 2009, p.5). There have been numerous evaluations of community needle exchange programs “that have demonstrated that they reduce the risk of HIV and Hepatitis C and the programs are found to be cost effective” (p.6). Countries around the world that have implemented needle exchnage programs have reported positive benefits. It is obvious from international reviews that prison needle exchange programs; 1) reduce risky behaviours and disease transmissions 2) they do not endanger staff, or offenders, and 3) they do not increase drug use, or injection use (Thomas, 2005, p.6). Critics of needle exchange programs believe that they may send a message that intervenous drug use would be accepted. Needle exchange programs “do not condone drug use, it is a pragmatic public health measure that should accompany other efforts to reduce harms related to drug use, such as drug treatment programs, including methadone maintaince” (Public Health Program, 2004, p.2).

The method of adminsitering needle exchange programs has varied from dispensing machines, hand-


by-hand by nursing staff, non-governmental staff, or volunteers. A certain method has not been found to be more benefical than the other. It has been noted that the needle exchnage programs require confidentialty, accessibilty and support from staff. Adopting the method that Krygystan’s prisons use would be an easy and simple method to provide the needle exchange. The offender would book a medical appointment, and needle exchange would take place during the appointment. Volunteers, or non-governmental staff would be responsible for handing out the new needles, to ensure that it is not an added task for health care staff. The volunteer’s would also be responsible for putting together safe packages that contained educational materials on safe needle use and diseases, alcoholic swabs, bleach and condoms.

Canadian federal prisons are the only prisons in the world that implemented and evaluated a safe tattoo project. Many AIDS organizations have requested that Australian prisons implement safe tattooing projects. Australia explored the idea in 1998, but it was never implemented (Booker, Levy, McDonald & Treloar, 2007). Canada’s safe tattoo project’s goals were to minimize the transmission of blood borne infectious diseases, minimize the risk of CSC injuries, educate and promote health and wellness” (Correctional Service of Canada, 2009). According to The Correctional Service of Canada, (2009) inmate tattooists were provided with training on safe tattooing practices, infectious diseases and were monitored in a designated controlled environment. The pilot project was to be implemented and evaluated after two years; however the Conservative government cancelled the program after a year. Former Public Safety Minister Stockwell Day stated, “Our government will not spend taxpayers' money on providing tattoos for convicted criminals” (CBC News, 2007). Unfortunately, the government viewed the pilot project as a benefit to offenders, and did not look at it as a public health advantage.

In 2009, the Correctional Service of Canada developed an evaluation team to investigate the


effectiveness of the tattoo project. The evaluation team revealed, “the tattoo program was cost effective
if 1 in every 38 tattoo sessions resulted in an avoided Hepatitis infection, or if 1 of every 50 tattoo sessions resulted in an avoided HIV infection” (Correctional Service of Canada, 2009). The Correctional Service of Canada (2009) also reported the cost of Hepatitis related expenditures in 2005 was $2, 645, 134.00 and noted that the prison tattoo initiative was also cost effective if 1 out of 248 sessions resulted in an avoided liver transplant. The evaluation also found a number of positive
findings with the tattoo project:

1. It resulted in an “enhanced level of knowledge and awareness amongst staff and inmates regarding blood borne infectious disease prevention and control practices”.

2. “Initial results of the initiative indicate potential to reduce harm, reduce exposure to health risk, and enhance the health and safety of staff members, inmates and the general public with higher risk groups”.

3. It provided additional “employment opportunities for inmates in the institution, and work skills that are transferable to the community”.

4. “The cost of the Safer Tattooing Practices Initiative is low respective to the potential benefit” (Correctional Service of Canada, 2009).

The evaluation report conducted in 2009 demonstrates the positive benefits to implementing safe tattoo projects in institutions that have high rates of Hepititis C and HIV. Implementing needle exchange programs and safe tattoo projects will prevent diseases and increase the awareness of serious diseases. The reality is that most offenders will return to the community, and it is essential and cost-effective to implement prevention programs, rather than paying for treatment in the future.

The evaluation on the tattoo project did not find any negative issues on how the program was being


run. The Social Programs Officer was responsible for hiring the tattoo artists and supervising the tattoo
shop; as well as the equipment. The inmate tattooist was responsible for complying to all rules and policy, attending educational seminars on diseases, cleaning and procedures. The inmate tattooist was also required to comply to tattooing guidelines. All tattoo pictures were approved by the Security Intelligence Officers to ensure the offenders were not participating in gang tattooing and the offenders applied for a session by submiting a request for a tattoo. Cover-ups on hands, neck or face were based on approval by the Warden. The offenders were responsible for paying for their tattoos through their
bank accounts. According to the evaluation conducted in 2009, “the long term impacts of the program would reduce risk of infection (HIV, Hepatitis C& other blood borne diseases) in the inmate populations, CSC staff and community while maintaining security and it would contribute to successful re-integration (Correctional Service of Canada, 2009)

OPTIONS /PROS AND CONS

1. Implement needle exchange programs in all Canadian federal prisons that have high rates of HIV/Hepatitis cases.

§ Advantages: Decrease the spread of Hepatitis C and HIV.

§ Offenders will be provided with safe needles, alcoholic swabs, protective cases, and educational materials.

§ Decrease treatment cost for Hepatitis C and HIV.

§ Staff will less likely experience pricks from needles during a cell searching. The offenders would not need to “hide” the needles.

§ Disadvantages: The added cost to implement the program.

2. Implement a Safe Tattoo project in all Canadian federal prisons that have high rates of HIV/Hepatitis cases.

§ Advantages: Decrease the spread of Hepatitis C and HIV.

§ Decrease the manufacturing homemade tattooing devices.

§ Staff would less likely experience pricks from tattooing needles.

§ It would provide offenders with awareness of diseases.

§ The offender’s hired as tattooists would be provided with specialized training, and it could be used as an employment opportunity in the community.

§ The immediate cost outweighs the future cost that would be incurred to pay for treatment from diseases.

§ Disadvantages: The immediate added cost.

3. Implement a needle exchange program and a Safe Tattoo Project in all Canadian federal prisons that have high rates of HIV/Hepatitis cases.

§ Advantages: Same advantages as described above.

§ Running the projects simultaneously would significantly decease and prevent the spread of diseases within prisons and in the community when the offenders are released.

§ Decrease treatment costs and health care costs in the future.

§ Disadvantages: The added cost of administering the projects.

4. Maintain the current programs and do not implement any other programs.

§ Advantages: No additional cost.

§ Disadvantages: The increasing rate of HIV and Hepatitis C will continue to rise in prisons each year and the public will continue to be at risk when the offenders are released.

RECOMMENDATION

Option 3 is recommended, as it would target both risky behaviours (tattooing and injection drug use) that lead to the increased rates of Hepatitis C and HIV cases. Implementation of both harm reduction
programs would effectively enhance the prevention of spreading diseases within prison walls, which will ultimately impact the community when the offenders are released. The cost of the programs will outweigh the potential health care costs that would be incurred for treatment. The implementation of

the needle exchange program should begin first and after a year implementation of the tattoo project should commence.

EVALUATION

The most beneficial method to evaluate the success of the needle exchange and tattoo program would be to complete a formative evaluation two years after implementation of the programs. The main goal for the needle exchange and tattoo program is prevention; therefore the main evaluation would be to monitor the new cases of blood borne diseases to ensure they are not increasing at the same rate as they were without the programs. Currently, the Correctional Service of Canada (2009) reports since 2000, new cases of HIV a year are approximately 233 and Hepatitis C ranges from 533 to 570. The evaluation would also look at how the program is delivered and the evaluation would provide recommendations of changes to the delivery, or methods to enhance the program.

SUCCESS

6 months

§ The needle exchange program is up and running in prisons with high rates of Hepatitis C and HIV.

§ Offenders start using safe clean needles, and the need to share needles is eliminated.

12 months

§ Reduction of 15% of new cases of Hepatitis C and HIV in the offender population.

§ Implementation of Tattoo Project in prisons with high rates of Hepatitis C and HIV.

24 months

§ Reduction of 30% of new cases of Hepatitis C and HIV in the offender population

§ The seizure rate of homemade tattooing devices is decreased.

Needle exchange programs and tattoo projects are two harm reduction programs that will prevent new cases of blood borne diseases within the Canadian offender population. The programs are required in order to protect the public, as the majority of the offenders in prisons will be released to the community. It is imperative that we take appropriate steps and actions to protect the public. Research reveals that there are clear benefits to both programs, and the success in just 24 months supports that needle exchange programs and tattoo projects in prisons will be effective preventative measures for blood borne diseases.