2.3 Step-by-step strategies

Provide adequate health care
 In most prisons, new inmates are interviewed by the prison's medical service and if necessary, examined. Among others, the medical staff watches out for infectious diseases. But one can also contract an infection inside the prison. Then quick detection and adequate treatment are absolutely essential to prevent the disease from spreading. This particularly applies to tuberculosis - an infectious disease which, just as the flu, can already be caught through normal social contact. But an accident with a used needle requires quick attention too: Infection with hepatitis B can only be prevented if an injection with antibodies is given within 48 hours. Prisoners must not be denied the right to adequate medical care. In addition, effective health care lowers the threshold for prison guards to have contact with inmates. The fear of getting infected will, after all, be greatly reduced.

Provide education
In general, drug users are pretty much aware of the dangers of AIDS and other infectious diseases but often do not know exactly what is considered to be a risk factor. "I never knew that spoons and other things can spread diseases too", a drug user declared in the Dutch magazine, 'Mainline'. The same applies to condom use. Here too, many people do not know the details. For anal sex, for instance, a normal condom is not enough. This becomes clear as soon as the condom tears but naturally it would have been much better, it one would have known this in advance. In short, in order to reduce dangerous behaviour, good and detailed information is an absolute 'must'.

Initiate training programs for prison staff and prisoners 
Information can be given via leaflets but also in the form of training. For instance, courses for prison staff and/or prisoners dealing with the following subjects: Rules for safe condom use, cleaning syringes, first aid in case of an overdose, and what to do in case of pricking accidents with needles. The courses could be given by members of the prison medical service or by outside folks, like specialist advisors and former users.

End overcrowding
In general, European prisons are faced with a structural cell shortage.
Overcrowding leads to containment problems and promotes bad hygienic conditions and infectious diseases.
Building additional cells is the most logical solution but also an expensive one. In addition, it is the responsibility of the Minister of justice.

Improve hygienic conditions
Lack of hygiene increases the risks of hepatitis, infections, abscesses, lice and fleas, etc, Some practical advice:
* Always use gloves when contact with blood is expected. For example, when picking up a used syringe.
* Destroy needles and syringes used for medical purposes, (then they cannot be used for intravenous drug use).
* Watch out for little wounds and use a band aid if you have a wound. This prevents direct blood contact.
* Clean the toilets regularly. For the outside of the toilet bowl and floor: one cup of bleach water for one bucket of water, (1:50). For the inside of the toilet bowl, undiluted bleach water is to be used.
* Blood spatters must be disinfected as quickly as possible. Use gloves, wipe up the blood with tissues, clean the spot with a little soapy water and give everything a good rinse.
* Put the material which has been in contact with blood, semen or vaginal discretion, (for example, a band aid or a condom), in a little plastic bag and throw it in the garbage bag.
* Use plastic bin liners for all garbage containers.
* Sweeping makes little sense, it moves rather than removes dust.
Make sure that the place is washed or vacuumed.
* Set up a complaint and suggestion box for personnel and inmates.
* Organise regular meetings.

Make tattooing safe
The infection risks with tattooing and piercing can easily be prevented:
Distribute bleach water for sterilizing the needles, or provide possibilities for boiling the syringes.

Sin ce tattooing is generally regarded as a more acceptable practice than drug injecting, (even many prison officers are tattooed - in Europe about 30% of them), this preventive measure can be introduced more easily than bleach for injecting needles. In fact, bleach for tattooing equipment can be a way of introducing the option of bleach for drug injectors."

U NAIDS, Point of View, April I 99

Provide condoms for prisoners, plus instructions on how to use them
Sex between men in prison is a fact. However, anal sex without extra-strong condoms is a great risk factor, since often not only semen but blood too, is involved. Therefore, an increasing number of European prisons are distributing condoms. One prison chooses to install a condom vending machine, another opts for condoms being handed out by the prison medical service, because this allows for more anonymity. So before distributing condoms, just check up how big the obstacles are to get condoms in practice. And by women-prisonds: Paying attention to the risks of changing the tools (vibrators) is important. But giving out condoms alone is not enough: Providing information about the safe use of condoms is at least as important.

Ten 'golden rules 'for safe condom use

1 . Use a legally approved condom.

2. Check the expiration date.

3. Use a new condom every time.

4. Avoid touching vagina or anus with the penis before the condom is fitted.

5. Tear open the package carefully, (be careful with long, sharp or broken nails).

6. Only fit the condom when the penis is fully erect.

7. Squeeze out any excess air from the receptacle before unrolling the condom, (the condom might otherwise burst).

8. Roll the condom over the entire length of the penis.

9. After the orgasm, hold on to the base of the condom and withdraw the penis. (Don't wait too long. if the penis gets soft, the condom may slide off). 

10. When finished, make a knot in the condom.

Over the past decade, a good number of countries have begun to distribute condoms in their prisons. Unfortunately, there still exists a strong current of denial in many places about male-to-male sex (especially in prison) and a corresponding refusal to do anything which might be seen as condoning it. These attitudes willhave to change if societies want to see the rate of HIVinfection - inside prison and outside of it - decrease."

UNAIDS, Point of View, April 1997

Provide bleach for prisoners, plus instructions on how to clea n used needles and syringes 
If a prison already supplies bleach water for tattooing needles, it may be a small step to also supply bleach water for the sterilization of used injection needles even if the latter issue is a little more sensitive. But if one realizes that injecting with dirty utensils is the perfect way to spread the HIV,the conclusion that there simply is no other option, is an easy one. Besides that, also non-drug using prisoners do fear infections.

Cleaning syringes 

Boiling
* Rinse the syringe at least three times with cold water (use fresh water every time).
* Take the syringe apart and rinse off the visible blood residue around the plunger and where the needle attaches to the syringe.
* Place needle, syringe and plunger into a little pan with water. Make sure that no air bubbles are left behind. Let the water boil for at least minutes.
* Take the syringe out of the water and re-assemble it.

Bleach water
* Rinse the syringe at least three times with cold water (use fresh water every time).
* Fill the syringe with bleach, shake for at least 30 seconds and squeeze the bleach out through the needle.
* Fill the syringe with bleach once more, shake again for 30 seconds and squeeze the bleach out through the needle once more.
* Finally, rinse the syringe three times with cold water (use fresh water every time).

Attention! When filling the syringe, dra all water and bleach in through the needle and also flush everything out through the needle. Never use bleach or water twice.

Neither of these two methods is on hundred percent safe. The only really safe method of injecting is to shoot up with new gear.

Offer demand-reduction treatments

For inmates who want to kick the habit, therapy in the prison should be possible. An option might be controlled provision of methadone via the medical staff. By now, many prison doctors feel that an addiction requires medical treat ment in a closed institution too. Methadone, (a synthetic opiate), is suitable for users who wish to end their use of heroin. But methadone has disad vantages, too.

The advantages versus the disadvantages:

Advantages
· Methadone is long-acting, (24 to 36 hours), which gives the body a nice long rest *
· In methadone distribution, no needles are involved, which means: No dirty needles.
· Methadone can simply be drunk, or swallowed in the form of pills and is therefore easy to dose.
· Methadone can be prescribed legally.
· Methadone has a calming effect on inmates and promotes the order in the prison.

Disadvantages
In principle, methadone is just as addictive as heroin. According to many users, it even is more addictive. This is because the physical withdrawl from the methadon takes longer (10 20 days).

"Some people fear that the bleach could be misused for attacks on prison staff or other prisoners or for
suicide attempts. This has not happened in any prison where bleach distribution has been tried."

UNAIDS, Technical Update, April 1997