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Prison & probation
Written by Ingo Ilja Michels   
Friday, 15 December 1995 00:00

The Prevention of Infectious Diseases in Prison

Paper Presented ath the 6th international Conference on the Reduction of Drug Related Harm, Florence, 26 - 30 March 1995

Round Table Session: The Politics of AIDS and Prisons (29 March 1995).

Dr. Ingo Ilja Michels

(Coordinator of Drug Policy and Drug Work in the State of Bremen)

Dr. Heino Stöver



In the last twenty years, drug users have become a steadily increasing sub-population among prison inmates. Besides overcrowding, drug use in prison has become the main problem of prisons in Germany. Those drug users, who are not able or willing to stop iv drug use run the risk of contracting various infectious diseases (HIV and various hepatitis types). In prison, syringes and needles are not allowed. According to man report of inmates, the sharing of needles is very widespread. That is why pathogenic agents (HIV, HBV, HCV) are easily transmitted.

This contribution gives

1. an overview over the prevalence of drug use and spread of viral infections in prison (as far as data are available),

2. summarizes main topics of the current discussion about effective prevention of infectious diseases

3. outlines necessary measures to be taken to effectively prevent infectious diseases.

1. Prevalence of drug use and spread of viral infections in prison

In 1992 about 60,000 persons were held in German prisons. Of those, about 18,000 were held on remand. This reflects an overall imprisonment ratio of 72 per 100,000.

It is estimates that at least one third (that means 20,000 inmates) of the general prison population is supposed to be drug users. The proportion of women among the drug using population is much higher than the proportion of men. Prison becomes more and more a dominating period of the drug carrer of drug users: Some epidemiological studies (Koch/Ehrenberg 1992; Kleiber 1991) outsinde prisons found out that nearly 60% of all interviewed drug users had prison experiences. One recent study (AMSEL-Forschungsproject) clearly points out that the time of imprisonment exceeds the time of therapy.

Penal institutions are no drugfree or sexfree areas. This has also been recognized by the ministre of health in Germany: He estimates that despite strict controls, more than 40% out of the estimated 20,000 drug users in prison continue their use of illegal injectable drugs. These figures have been confirmed by epidemiological studies (Koch/Ehrenberg 1992, 53).

Although there are differences from prison to prison, from north to south and from urban to rural prisons, drugs seem to be easily available in prison. The recent study of the DEUTSCHE AIDS-HILFE indicates that drugs can be obtained mostly without any problems.

1.1. Hepatitis B and C

Undoubtedly, the infectious diseases of hepatitis B and C is far more widespread among drug users in prison than HIV. Despite this fact, the discussion about life-threatening diseases in the past was mainly focussing on the more spectacular and new infectious disease HIV. Only in recent years, it became evident that the more resistent hepatitis virus (HBV, HCV) is very widespread among drug users inside and outside prison. Meanwhile experts speak of a "desmoterian" (that means prison-typical) infectious disease in Germany, becaus prison seems to be the essential transmission milieu of the virus.

In contrast to Hepatitis B, at this moment no vaccination has been developped against Hepatitis C.

Data collection for the spread of Hepatitis B and C has just begun. A study recently carried out in a prison for women in Lower-Saxony (JVA Vechta, 170 female inmates) has clearly pointed out that seroconversions (tested Hepatitis-negative at the beginning of imprisonment, tested positiv while in prison without any release in between) take place to a considerable number: 20 serconversions of hepatitis B and C could be documentated in the last two years. A seroconversion undoubtedly occured in prison. For another 20 cases a serconversion also took place, but with interrruptions in term of imprisonment (Keppler/Nolte/Stöver 1995).

1.2. HIV-infection

The spread of the relatively sensitive HI-Virus in prison probably has been overestimated in recent years. The epidemiological situation can be characterized as follows: In the first quarter of 1994 406 men and 55 women in prison were officialy knwon to be HIV-infected. With regard to the total prison population, the proportion of HIV-infected prisoners is in the different states between 0,12 and 2,8% for men and 0,48% and 8% for women. These figures do not reflect an estimated number of unreported cases: The number and practice of HIV-testing in prison is varying widely throughout the 16 German states. Compulsory testing is legal only in the state of Bavaria, where almost all prisoners are tested. Officially testing is still carried out on a voluntary basis with the explicit threat of forced testing as a possibility at least, for high risk groups. In other states such as Northrhine-Westfalia, prisoners only are encourage to take the test. The prinicipal reason for the high take-up is that those, who refuse, are treated as if they were HIV-positive until tested (explicit policy in Hessen, Saarland, Baden-Württemberg and Bavaria). In other states such as Berlin the percentage of tested prionsers is below 50 per cent. The extreme case is Bremen, where testing is not only voluntary but anonymous as far as the prison administration is concerned.

So a considerable number of prisoners are not tested and therefore the result is not known to the penal institution administration. Apart from the official registration of HIV-positive tested prisoners, AIDS service organisations outside estimate that some 1,000 HIV-positive inmates live in German prisons.

The mulit-centre epidemiological study of KLEIBER (1991) found out that there is a close connection between intravenous drug use in prison and the probability of HIV-infection.

2. Main topics of the current discussion about effective prevention of infectious diseases

The WHO-Guidelines concerning HIV-infection and AIDS in Prisons (WHO, Geneva, March 1993), stating that preventive measures for HIV/AIDS inside and outside prisons should be complementary and compatible, do not play an important role in the current debate. Nor do the recommendations of the WHO, Regional Bureau Europe (Stöver/Schuller 1992, 107), although they develop a realistic and effective scale of AIDS-preventive measures in prison:

- measures to reduce the number of i.v. drug users,

- measures to prevent drug use,

- Informations about the risks of intravenous application

- Information about the risks of needle sharing

- Demonstrations of the use of disinfectants. Provision of disinfectants and means for the hygienic iv drug use

- Provision of sterile needles and syringes.

While a growing number of experts - mainly from a health point of view - is arguing in favour of an (at least experimental) provision of sterile needles and syringes, most prison governors and the administration of justice in the different states and on federal level argues against this - undoubtly most effective - measure.

Their argumentation is: Instead of the provision of syringes, more preventive efforts should be undertaken on the educational level, emphasizing the personal-commucicative aspect. One of the recommendations beeing made at the moment as an alternative to instrumental preventive measures is the strong emphasizing of "counselling". This phenomenon is critically discussed in the following:

2.1. "Counselling should be developped"

Counselling of prisoners is handled mainly through written materials and some videos (Berlin), which describe risk behaviour and infection transmission routes. The propaganda's message encourages a complete change of risk behaviour. For example, a leaflet issued by the justice administration in Berlin states: "Stop injecting, get off drugs! Stop tattooing and piercing your earlobe! Stop anal sexual intercourse!'But the demand for abstinence to prevent infection is unrealistic given the widespread drug use in prison. The strategy of promoting abstinence is one-dimensional and reminiscent of the civil drug counselling system before the identification of HIV at the beginning of the 80ies.

Prevention by personal-communication, established as model projects in some prisons, is mainly confined to test-counselling and legal advice. These also fail to reflect the reality of everyday life of drug-using prisoners, which is the need to use drugs in a relatively safe manner and to avoid additional danger.

Moreover the possibility of personal communication about infectious diseases and adequate prevention between a prisoner and the psycho-social prison service is limited, particularly if no practical preventive means are made available. One without the other merely exaggerates the level of blame and shame rather than implementing the policies of "safer sex" and "safer use".

Counselling prison officers remains even more a problem. Some AIDS schemes are trying to develop continuing education programmes for officers because their knowledge of drug use, transmission of infectious diseases, the value of testing seems disappoiningly limited.

3. Necessary measures to be taken to effectively prevent infectious diseases: Condoms, sterile needles and syringes, bleach, methadone and safer-use and safer-sex-training

Condoms are available in most of the prisons (although the demand seems to be relatively small). Sterile needles and syringes are banned throughout the German prison system. The main legal argument against needle distribution was that the distributors were liable as accomplices of the drug users. However, this has been removed by section 29 of the German drug Law in 1992 (Betäubungsmittelgesetz) which states that "providing drug addicts with sterile one-way syringes does not constitute the offence of furthering the use of illegal drugs".

Despite this change of the law and despite growing political demands to the contrary, there remains strong resistance from prison administrations and state ministries against the provision of sterile injection equipment to drug using prisoners. The main arguments are that:

- drug-free prisoners might be encouraged to start using drugs.

- providing sterile needles might be misunderstood as a signal to legalize drugs rather than appreciated as a public health measure against infectious diseases,

- prison officers are concerned that they are required to undertake contradictory tasks: on the onehand they must search cells and confiscate drugs and equipment but, on the other, sterile needles should be tolerated as a preventive health measure,

- syringes and needles might be used as weapons against the personel,

- a contradicition would be created to the task of the penal institutions, to prepare the prisoner for a life without drugs and punishable offences.

Counter-arguments by supporters of needle provision are that

- syringes and needles are already available in prisons and the shortage of such equipment does not deter prisoners from using or starting to use drugs, even intravenously

- the reverse is true: the shortages lead to extensive needle sharing or the manufacture of even more dangerous equipment such as sharpened ball point pens.

- the introduction of clean needles would safeguard existing drug users from HIV and hepatitis-infections

-although prison staff are sceptical about the introduction of sterile syringes and needls, they are capable of being convinced of the need for change, as it is illustrated by the growing acceptance of the dispensing of methadone in prison. The message must be one of harm reduction not one of supporting hedonistic drug use.

Several organizations, such as Deutsche AIDS-Hilfe, demand a "safer use -training" for prisoners which should reduce the level of risk. The training involves

- how to use bleach or thermic disinfectants;

- how to inject hygienically;

- how to avoid overdoses after prison release;

- differential risks of different ways to consume drugs and the consequences of polytoxicomanic drug use.

Very controversially discussed in Germany is the recommendation to introduce bleach as a kind of "next best solution" in prison. Attempts to provide prisoners with bleach (as in a Swiss prison - Regensdorf) have already been made in Hamburg and Berlin. The result of a pilot project in Hamburg was that the prisoners did not fill up the bleach bottles, knowing that they could be easily identified as drug users. From Berlin, where an comparable attempt is currently made, no results are available at this moment.

Critical voices state that bleach is not totally reliable nor is it a substitute for albeit clean but blunt needles which can damage veins.

Also the "thermic disinfection" which involves immersion heaters to sterilize needles is discussed. But such a development also needs instruction because users need to be told the time that equipment needs to be boild.

It is also discussed to expand methadone treatment as an offer to injecting illegal drug users. Methadone has now become part of prison medical treatment by some doctors for i.v. drug users. In contrast to this use outside prison, the doctors see it as an alternative prevention for infectious diseases: the oral application and the blocking of the heroin craving are supposed to stop drug injecting and needle sharing. So, prison doctors who prescribe methadone explicitely argue against providing sterile "works" for prisoners because it runs against the treatment programme. This is problematic as only a few prison doctors prescribe methadone for maintenance rather than for detoxification. Moreover, the cost of the programme means that it is still severely restricted in terms of availability, and even then some prisoners may "top up" with other injectable drugs, and those not treated with methadone probably continue to practice high risk injections.


„Amsel"-Forschungsprojekt, Projektgruppe Rauschmittelfragen, Abschlußbericht Bd. 1, Jugendberatung und Jugendhilfe, Frankfurt: Selbstverlag

Koch, U.; Ehrenberg, S. (1992): Akzeptanz AIDS-präventiver Botschaften: Evaluation der Aufklärungs- und Beratungsarbeit bei i.v. Drogenabhängigen in der Bundesrepublik Deutschland. In: Deutsche AIDS-Hilfe (Hrsg.): AIDS und Drogen II, AIDS-Forum D.A.H., Bd. IX, Berlin (Selbstverlag)

Keppler, K.; Nolte, F.; Stöver, H. (1995): Seroconversions of Hepatitis in a women prison. (in press)

Kleiber, D. (1991): Die HIV/AIDS-Problematik bei i.v. Drogenabhängigen in der Bundesrepublik Deutschland - unter besonderer Berücksichtigung der Situation hafterfahrener Drogenabhängiger. In: Busch, M.; Heckmann, W.; Marks, E. (Hrsg.): HIV/AIDS und Straffälligkeit. Eine Herausforderung für Strafrechtspflege und Straffälligenhilfe. Bonn: Forum Verlag, S. 25-40

Stöver, H.; Schuller, K. (1992): Praxis und Politik der Vergabe von sterilem Spritzbesteck an Drogenabhängige zur HIV/AIDS-Prävention in einer ausgewählten Zahl von Mitgliedsstaaten der europäischen Region der Weltgesundheitsorganisation (WHO). In: Deutsche AIDS-hilfe (Hrsg.): AIDS und Drogen II, AIDS-Forum D.A.H., Bd. IX, Berlin: Selbstverlag, S. 101ff

Recommended HIV-Prevention Strategies for i.v. Drug Users in Prison of the WHO-Regional Bureau for Europe

- measures to reduce the
number of iv drug users

- Informations about the
risks of iv application

- Information about the risks
of needle sharing

- Demonstrations of the use
of disinfectants. Provision
of disinfectants and means
for the hygienic iv. drug

- Provision of sterile needles
and syringes

Effective prevention strategies for the target group of iv. drug users in prison:

1. Provision of sterile syringes

2. Safer-use training

3. Hepatitis B - Vaccination

4. Counselling of prison staff to improve their knowledge about infectious diseases and drug use

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