8 AIDS and Drug Misuse in Prisons

The Significance of Prisons

8.1 The prison system is of major significance to our enquiry for a number of reasons. Large numbers of drug misusers spend some time in prison during their drug misusing career. Prison Department figures show that during 1986-87 3051 new inmates in England and Wales were found to have some degree of dependence on drugs. Other evidence suggests that the numbers are much larger: for example, a recent study of 121 drug misusers in London found that a quarter had been in prison during the past 12 months. Many drug misusers entering prison are likely to have injected, often with shared equipment, and growing numbers are likely to be HIV positive. Many of the women will have financed their drug misuse through prostitution.

8.2 Many drug misusers entering prison have had no previous contact with helping agencies. Almost all will find it much more difficult to obtain drugs inside prison. Many will therefore be at an appropriate point to reassess their drug misuse. Thus, prison represents a unique opportunity to reach large numbers of drug misusers for the first time, educate them towards safer practices and draw them into contact with a network of help that could reduce the risks to themselves and others.

8.3 Although prison is an artificial environment in which intentions cannot be fully tested, its potential to bring about sustained behaviour change is important. Efforts to achieve this are underlined by the need to minimise the risk of HIV transmission within prisons. Here, two special factors apply. First, although the scale of injecting drug misuse is likely to be minimal, if a syringe does get into the prison it is likely to be widely shared. Second, there is evidence to suggest that homosexual acts occur on a significant scale amongst male prisoners, including amongst some of those who are heterosexual when in the community.

8.4 We endorse the principle contained in the World Health Organisation consensus statement. `Consultation on Prevention and Control of AIDS in Prisons' (November 1987) which reads, `The general principles adopted by National AIDS Programmes should apply equally to prisons as to the general community'. The action necessary in prisons to combat the spread of HIV amongst drug misusers mirrors that required in the community generally i.e.

—    prevent drug misuse wherever possible;
—    maximise the number of drug misusers who are identified;
—    work with each of them to encourage the adoption of safer practices (both while in prison and after discharge);
—    educate those drug misusers who cannot be specifically identified, through publicity and general education for all inmates about HIV and safer practices.

Many of the conclusions and recommendations elsewhere in this report will apply either fully or particularly to prisons. In this Chapter we focus on some of the features and action peculiar to prisons.

Identification of Drug Misusers

8.5 Identification of drug misusers generally occurs on reception into prison when the new inmate is medically examined and asked to complete a questionnaire which includes questions about drug misuse. The rate of success in identifying drug misusers appears to be low (as illustrated in para 8.1). There are a number of factors which militate against successful identification:

a. medical officers on reception are required to deal with a large number of new prisoners in a short space of time. The medical examination is therefore likely to be fairly cursory in most cases;
b. the training of prison medical officers on drug misuse is patchy and many have little or no experience of working with drug misusers outside prison;
c. most drug misusers are likely to conceal their drug use as they fear stigmatisation including perhaps a discriminatory allocation policy and stricter security at visits and generally. Many may feel they have nothing to gain by declaring their drug misuse and plenty to lose;
d. the advent of HIV makes these problems more severe: identification of a history of injecting makes a prisoner liable to possible isolation and possible pressure to be tested for HIV antibodies.

8.6 Better training for prison medical officers — perhaps through short term attachments to specialist drug services in the community — will help in better identification. Spending more time with each prisoner on reception and conducting a more thorough medical examination is also important. This might be achieved through a revision of working practices or extra resources may be needed. But probably most important is providing incentives for drug misusers to come forward and minimising the deterrents for them to do so. Thus they need to believe that real help can be provided (including, where necessary, a short-term prescription to facilitate withdrawal), and that they will not suffer discriminatory treatment in any of the ways referred to above.

Treatment and Throughcare

8.7 The Prison Medical Service policy is that treatment to assist withdrawal from drugs is a matter for the individual clinical judgement of the prison medical officer concerned. We have heard evidence that practice differs significantly between prisons. Whilst withdrawal over 2-3 weeks using oral methadone appears to be fairly common in at least one prison, the use of methadone, or other drugs to control withdrawal symptoms, seems to be rare in other establishments. Abstinence in the short- (or fairly short-) term will normally be the appropriate goal in the special circumstances which prevail in prisons. But as elsewhere, the best treatment to bring about this goal should be selected from the full range of options. The prospect of a comfortable withdrawal from drugs may be the best incentive available to drug misusing prisoners to identify themselves.

8.8 Availability of advice and counselling within prisons remains patchy and we have detected no improvement compared to the position described in the Advisory Council's report of 1979. In respect of specialised therapeutic regimes, of the kind recommended in 1979, there has been a decrease. The evidence we have received suggests that, in some prisons at least, it has become more difficult in recent years for outside voluntary agencies to gain access. Against this background, we welcome the Prison Department's recent policy statement on throughcare of drug misusers in the prison system in England and Wales. The policy statement puts great emphasis on the work of the probation service. We have heard evidence of how overstretched the probation service is within prisons and of how little training and experience many seconded probation officers have in the field of drug misuse. A significant improvement in resources and training will be needed if the probation service is to fulfil its role.

Education about HIV

8.9 Controlling the spread of HIV in prisons, as in the community, depends largely on education to minimise risky behaviour. This applies both at a general level and an individual one, where one-to-one work may be necessary to educate a drug misuser away from risky practices. A good deal of effort has already gone into educating prison officers and other staff about AIDS and HIV and a video has been produced for them. We welcome this initiative as we consider it essential that prison staff be fully informed about HIV if they are to respond positively to the new demands it places upon them. Education on AIDS/HIV for prisoners still has a long way to go. We have been told that leaflets, such as the government leaflet `AIDS — Don't Die of Ignorance' and the Health Information Trust's leaflet especially devised for prisoners, have been made available to prisons but we have heard evidence that distribution of leaflets within prisons has not always occurred. The Prison Department is currently considering the production of an educational video for inmates; we think such a video would make a useful contribution to formal education on AIDS/HIV and we hope it will be produced soon.

8.10 General education should be accompanied by the opportunity for private and confidential counselling on risk-reduction (as discussed in Chapter 5). Both general education and individual counselling should cover activities whilst in prison and following release. Thus education on heterosexual and mother to foetus transmission will be needed. The latter may be a potential problem in women already pregnant on admission to prison where there is a history of antecedent high-risk behaviour. We will address this in our second report. Similarly, education will need to cover the risks of injecting drug misuse and how, they can be avoided, since some prisoners will return to drug misuse after release. It will also be important to recognise that homosexual acts do occur in prisons and to provide advice on the risks and how they can be avoided. Prison medical officers could in theory provide confidential advice on risk-reduction but we doubt that many prisoners would see this as a realistic option. We consider that outside agencies, usually in the voluntary sector, can play an important role as providers of this type of counselling and education and we recommend that the Prison Service should make full use of them as is indicated in the newly developed policy on throughcare for drug misusers. In order for this to develop satisfactorily opportunities for access by these agencies will need to be greatly improved.

Provision of Injecting Equipment and Condoms

8.11 The question of provision of injecting equipment in prisons is very different from that in the community generally. We have looked carefully at this issue but we cannot recommend the exchange or provision of equipment in prisons as a realistic option.

8.12 The Prison Department has argued that possession of condoms by prisoners cannot be allowed because it would condone homosexual acts. Such acts are regarded as unlawful in prison because nowhere within a prison can be deemed to constitute a private place. However, we have heard evidence that homosexual acts do occur in prisons to a significant extent. There are also indications that some men who are usually heterosexual engage in homosexual acts while in prison. Such activity, followed by a return to heterosexual activity after release could play an important role in spreading the virus amongst the heterosexual population. Thus, although such acts may be regarded as unlawful, it is clear that this does not stop them occurring.

8.13 The Government's forward-looking approach in setting up the pilot syringe exchange schemes provides a contrast to the approach of the Prison Department. Providing syringes in the general community does not condone illegal drug use. It is difficult to see how allowing access to condoms in prison could be regarded as condoning unlawful acts when placed within the context of the public health considerations involved. Clearly the safest course of action is for inmates to avoid anal intercourse but we have no doubt that, even with good health education, it will still occur to some extent. Use of condoms will offer some protection in these cases, though their effectiveness is limited. We note that a number of countries have recently decided to make condoms available in prisons. We recommend that the Prison Department give urgent consideration to means of providing confidential but easy access to condoms.

HIV Antibody Testing

8.14 We discussed the question of HIV antibody testing in Chapter 5 and urged that caution be exercised beforehand. The same considerations apply to testing in prisons. Even though chaotic drug use is unlikely to occur in a prisoner found antibody positive s/he may still suffer severe psychological effects. These in turn may have both short and long-term behavioural effects. Moreover, a prisoner who is known to be antibody positive may suffer stigmatisation and victimisation.

8.15 We therefore commend the Prison Medical Service's policy statement that testing should only be undertaken with consent and following counselling. Prison probation officers will often be best placed — because of their skills and relative independence — to provide such counselling and we consider that they should be given the necessary training. This counselling should involve a full explanation of how the individual will be allocated and treated in prison if found positive. It is important that prisoners are not rushed into having a test and particularly that testing should not be done at the time of reception. Counselling should be provided at two meetings with time for reflection in between.

8.16 Where a prisoner is known to be HIV positive he or she is placed under Viral Infectivity Restrictions (VIR). VIR was devised for inmates who were infected with Hepatitis B, which is far more infectious than HIV. We understand that Prison Medical Officers will decide, in the light of individual circumstances, which restrictions under the VIR headings are necessary in the care of someone who is HIV positive. Prison staff with an `operational need to know' are informed of prisoners' VIR status. In practice this means that the confidentiality available to prisoners is rather limited. We appreciate the difficulties here but we hope that prison staff can be persuaded that in practice there will rarely be a `need to know'. We are also concerned that the labelling of inmates in this way may result in inadequate health and safety precautions being taken with untested prisoners, who may of course be infected with the virus. We will return to the management of HIV positive drug misusers in prison in our Second Report.

Liaison with Community Services

8.17 The new emphasis on throughcare for drug misusers in Prison Department policy is welcome. It recognises the need for outside agencies to become involved with drug misusers who will be discharged into the district so as to provide them with support after release. In order to promote better liaison, District Drug Advisory Committees should have particular regard to the needs of prison populations and should develop links with local prisons. Regional Drug Advisory Committees should include in their membership a regional representative from the prison service.

Diversion from Prison

8.18 The problem of prison overcrowding is well known. The advent of HIV makes it even more undesirable that two or more prisoners should share a cell built for one with no toilet facilities. The possibility of homosexual acts in prison leading to HIV spreading in the heterosexual population means that every effort should be made to avoid imprisoning anyone who could adequately be dealt with in some alternative way.

8.19 Some drug misusers commit serious offences for which custody is an inevitable outcome. However, others are imprisoned for comparatively minor offences even though the relative ineffectiveness of such measures in preventing drug-related re-offending has long been recognised. We consider that increased use should be made of existing filters so as to minimise the numbers actually reaching prison, and especially to avoid unnecessary remands in custody. In particular, we consider that a more imaginative use of the probation order (with or without the condition of attendance at a day centre) would combine society's concern for the general problem with social work assistance to the individual. This in turn, would provide better opportunities than prison for risk-reduction advice to be given over a prolonged period. It would also produce greater hope of positive change with offenders being introduced to a range of alternative, more constructive, interests.

8.20 In conclusion, we recommend that:

a. efforts to identify drug misusers in prison and to encourage them to identify themselves should be further increased;
b. further resources should be made available to enable the probation service to fulfil its role under the Prison Department's commendable new policy on throughcare;
c. urgent measures should be taken to improve the education of prisoners about HIV and risk-reduction. Full use should be made of outside agencies;
d. further consideration should be given to the possibility of prisoners being allowed easy confidential access to condoms;
e. District Drug Advisory Committees should have particular regard to the needs of prison populations and should develop links with local prisons. Regional Drug Advisory Committees should include in their membership a regional representative from the prison service;
f. increased use should be made of existing filters so as to minimise the number of drug misusers actually reaching prison and every effort should be made to avoid unnecessary remands in custody.