Pubdate: Mon, 16 Apr 2001
Source: Medical Journal of Australia (Australia)
Copyright: 2001 Medical Journal of Australia
Contact:  http://www.mja.com.au/
Details: http://www.mapinc.org/media/259
Author: Kate A Dolan
Bookmark: http://www.mapinc.org/find?143 (Hepatitis)

CAN HEPATITIS C TRANSMISSION BE REDUCED IN AUSTRALIAN PRISONS?

Strategies To Reduce The Number Of People Who Inject Drugs And To Minimise 
Harm Should Help, But The Cooperation Of Correctional Authorities Is Essential

Approximately 20 000 people were incarcerated in Australia at the end of 
1999(1). Another 20 000 had cycled through our prison systems in that year, 
but had been released by December 1999. This dynamic movement of people in 
and out of prisons not only increases the possibilities for transmission of 
infections such as hepatitis C virus (HCV) and HIV, but also makes it very 
difficult to detect transmission.

Hepatitis C infection is endemic among Australian prisoners. In New South 
Wales prisons, approximately a third of male and two-thirds of female 
inmates are infected. Corrections Health Service had the second-highest 
number of hepatitis C notifications for an Area Health region in NSW in its 
debut report(2). HCV incidence is likely to be high in prison, but to date 
there have been few cases reported(3).

Nevertheless, several studies have found that a history of imprisonment is 
associated with HCV infection(4). These findings, from both Australia(3) 
and overseas(4), raise two questions:

* What is the incidence of HCV for various transmission modes in prison.; and

* Can HCV transmission be reduced in prison.

Despite gaps in our knowledge, there is sufficient evidence to address the 
two most frequent modes of transmission: injecting drug use and tattooing. 
About a quarter of prisoners inject drugs while

incarcerated(3). Virtually all drug injecting occurs with used injecting 
equipment shared among numerous partners. Therefore, the primary goal has 
to be to reduce drug injecting in prison. One way to achieve this is to 
reduce the number of drug injectors in prison(5).

There is abundant evidence that community-based methadone treatment reduces 
injecting, crime and the subsequent incarceration of drug users(6), yet 
only a third of the demand for methadone treatment is met in the community(6).

Another way to reduce the level of drug injecting in prison is to provide 
methadone maintenance treatment for prisoners. In one study, prisoners 
maintained on methadone injected half as often as those out of treatment, 
but only when doses reached 60 mg and treatment was provided for the entire 
term of the prison sentence(7). The NSW prison methadone program started in 
1987, but meets only a quarter of the potential demand for treatment(5). 
Prison methadone programs have been recently introduced or expanded in 
Queensland, South Australia, Victoria, Tasmania and the Australian Capital 
Territory.

Drug injecting in prison is also likely to be reduced if prisoners receive 
lesser punishment for the use of non-injectable drugs compared with 
injectable drugs. Yet prisoners receive the same penalty whether they test 
positive on urinalysis for cannabis or for heroin. Research into mandatory 
drug screening in United Kingdom prisons found that inmates moved from 
smoking cannabis (detectable in urine for weeks) to injecting heroin 
(detectable in urine for only a day or two) after mandatory drug testing 
was introduced(8). South Australia and Tasmania have introduced 
differential penalties for different drugs, with the aim of reducing drug 
injecting in prison. Victoria is considering a similar system.

Another way to reduce drug injecting is to facilitate non-injecting routes 
of administration among injecting drug users. Preliminary results from a 
cognitive behavioural trial indicated that some injecting drug users will 
shift to non-injecting methods of use (A Wodak, Director, Alcohol and Drug 
Service, St Vincent's Hospital, Sydney, personal communication). Prisons, 
where injecting is so risky and common, are ideal settings for a trial of 
this intervention.

Without doubt, the most controversial strategy is prison needle and syringe 
exchange programs. These programs have been successfully implemented in 
Switzerland, Germany and Spain in 17 different prisons(9). However, they 
reduce sharing of injecting equipment rather than drug injecting itself, 
and the problems of fatal overdose, abscesses, and inmates' involvement in 
the prison drug trade may persist. If prison needle and syringe exchange 
programs are unacceptable, then much more effort must be directed towards 
meeting the demand for drug treatment by prisoners.

HCV transmission in prison may also occur through tattooing. One way to 
reduce tattoo-related hepatitis C transmission is to train select inmates 
in infection control procedures and to provide them with autoclaves and 
single-use ampoules of ink. Penalties for tattooing in prison should be 
removed. Allowing professional tattooists to visit prison is likely to be 
too expensive for inmates.

So how can these strategies be implemented. The first step would have to be 
increasing the number of general practitioners who prescribe methadone both 
in the community and in prison. Less than 1% of GPs prescribe methadone in 
NSW(10). The opportunities for improvement here are enormous.

Almost all other strategies listed above require the cooperation of prison 
authorities. Yet, correctional services administrators (comprising prison 
commissioners from each jurisdiction) have signalled their resistance to 
examining hepatitis C infection in prison by declining to even discuss 
recommendations made in the Review of the Third National HIV/AIDS 
Strategy(11). Until prison authorities are made to recognise that prisons 
play a significant role in the hepatitis C epidemic, it is unlikely that 
hepatitis C transmission will be reduced in Australian prisons.

Kate A Dolan Senior Lecturer National Drug and Alcohol Research Centre 
University of New South Wales, Sydney, NSW

1. Corrective Services, Australia. Canberra: Australian Bureau of 
Statistics, December 1999. (Catalogue no. 4512.0.)

2. NSW Department of Health. Healthy people 2005: new directions for public 
health in NSW. NSW Public Health Bull 2000; 11: 198.

3. Dolan K. The epidemiology of hepatitis C infection in prison populations 
[discussion paper]. Canberra: Commonwealth Department of Health and Aged 
Care, 2000.

4. MacDonald M, Crofts N, Kaldor J. Transmission of hepatitis C virus: 
rates, routes and cofactors. Epidemiol Rev 1996; 18: 137-148.

5. Dolan K. Surveillance and prevention of hepatitis C infection in 
Australian prisons. A discussion paper. Technical Report No. 95. Sydney: 
National Drug and Alcohol Research Centre, 2000.

6. Ward J, Mattick R, Hall W. Methadone maintenance treatment and other 
opioid replacement therapies. Amsterdam: Harwood Academic Press, 1998.

7. Dolan KA, Hall W, Wodak A. Methadone maintenance reduces injecting in 
prison. BMJ 1996; 312: 1162.

8. Gore SM, Bird AG. Mandatory drug tests in prisons. BMJ 1995; 310: 595.

9. Rutter S, Dolan K, Wodak A, Heilpern H. Prison syringe exchange: a 
review of international research and program development. Technical Report 
No. 112.

10. NSW Health Department. The NSW drug treatment services plan, 2000-2005: 
better health good health care. Sydney: NSW Health Department, 2000.

11. Proving partnership. Review of the National HIV/AIDS Strategy 1996-97 
to 1998-99. Canberra: Australian National Council on AIDS and Related 
Diseases, 1999.
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