HIV prevention in prison

Blood-borne diseases like HIV and hepatitis C can spread quickly in prison. It is important that prisoners are made aware that unprotected sex and sharing needles during injecting drug use are the two main ways that HIV is passed on in prison.

Between a third and a half of new prisoners are estimated to be problem drug users.¹ Moreover, 69% of those who enter prison have taken drugs within the previous 12 months. Of these, 40% report injecting drug use within the 28 days preceding imprisonment.²

There is an especially high prevalence of people who inject drugs in local, remand and women’s prisons.

In a study of prisoners and HIV in England and Wales in 1997 to 1998, 75% of adult male IDUs and 69% of adult female IDUs had shared needles/syringes inside prison.³

As many reports on the subject acknowledge, intravenous drug use in prison may be under-reported simply because it is illegal. The possession of needles in prison is a punishable offence, which could encourage prisoners to share them.

An early Scottish study demonstrated the link between outbreaks of HIV infection in prison and intravenous drug use. Of 29 prisoners of Glenochil prison who injected heroin, 14 were found to be HIV-positive. Thirteen of them had a common strain of HIV, suggesting they had been infected through sharing needles.⁴

One widely recognised way to minimise the spread of HIV among IDUs is through needle-exchange programmes. Through a needle-exchange scheme IDUs can get access to clean needles, so they’re less likely to share syringes with other drug users. A needle-exchange scheme can also act as a gateway through which users learn about safer injection practices and equipment disposal, safer sex education and access to other prevention services.

International evidence suggests that in prisons where needle-exchange programmes operate, they reduce needle sharing, reduce drug overdoses, lead to a decrease in abscesses and injection-related infections and facilitate referrals of users to treatment programmes.⁵

At the time of writing, no prisons in the UK offer needle exchange. Proposals for a pilot scheme in Scotland have been met with heavy opposition from prison-service workers who are concerned that needles may be used as weapons and put staff at risk of injury.

The Prison Health Performance & Quality Indicators (PHPQIs) state that information on harm minimisation should be accessible; there is no requirement for actual harm minimisation services to be provided.

In January 2008, the European Court of Human Rights rejected a case brought by a prisoner who alleged that the failure of UK prison authorities to introduce needle exchanges violated his human rights and created a risk to his health and life.⁶

Disinfectant tablets are not fully effective in eliminating blood-borne viruses such as HIV. But in the absence of sterile needles they often represent the best protection prisoners who are intravenous drug users have against the condition, since they can be used to clean needles.

Prisons in England, Scotland and Wales have been instructed to provide disinfectant tablets to decontaminate needles. They should be available on request from prison staff.⁷

They are not available in Northern Ireland.

Although tattooing is officially prohibited, the practice is common. There is a potential for blood to be present on tools that are reused, leading to a risk of HIV transmission. Disinfectant tablets can help reduce the risk of infection.

In England, Scotland, Wales and Northern Ireland, the prison services carry out random drug testing in order to deter drug use. This practice is controversial since research suggests it is not effective in influencing prisoners who inject heroin to seek treatment.⁸

Unprotected sexual intercourse, whether it is consensual or not, is one of the main ways HIV is transmitted in prisons.

In general, there is little reliable evidence available on consensual sexual activity in prisons. This could be because sex in prison is illegal, and participants may fear being disciplined or abused by prison staff or other prisoners if they talk about it. Also, men who identify as heterosexual may have sex with other male inmates while in prison.

A Home Office study from 1995 found that between 1.6 and 3.4% of a random sample of 1009 prisoners had sex with another man while in prison.⁹ Because of under-reporting for the reasons outlined above, in reality the figure could be much higher.

During 2013 and 2014, the Howard League for Penal Reform’s Commission on Sex in Prison will gather and review evidence on the issue, including information about coercive sex.¹⁰

An Australian study compared sexual behaviour of prisoners in a state where condoms are provided (New South Wales) with that in a state where condoms are not available (Queensland). A representative sample of 2018 prisoners was recruited.¹¹

Overall, 3.4% had ever had anal sex in prison. In total, 7.1% had had some form of sex, usually consensual oral sex or mutual masturbation. The proportion reporting anal sex was no higher in the state where condoms were available, but unsurprisingly, far more men reported ever having used a condom (56.8% compared to 3.1%).

A number of prisoners had experienced coercive sex (1.0%) or been threatened with sexual assault (6.8%); these figures were similar in both states.

When sex is not consensual, and an element of force is involved, there is a greater likelihood of tearing and bleeding, which increases the risk of HIV transmission. If a prisoner is forced into sex they should report the matter to prison staff immediately.

HM Prison service says that consensual sex in prison is illegal because prison cells are “public places”. Sexual offences legislation states that sexual activity has to take place “in private”.¹² People working alongside prisoners living with HIV argue that if sex itself is illegal, prisoners are far less likely to bother accessing condoms.

The Prisoner Discipline Procedures (Prison Service Instruction 47/2011) state:

“There is no Rule specifically prohibiting sexual acts between prisoners, but if they are observed by someone who finds (or could potentially find) their behaviour offensive, a charge under PR 51 (20) / YOI R 55 (22) [concerning abusive words or behaviour] may be appropriate, particularly if the act occurred in a public or semi-public place within the establishment, or if the prisoners were ‘caught in the act’ during a cell search.  But if two prisoners sharing a cell are in a relationship and engage in sexual activity during the night when they have a reasonable expectation of privacy, a disciplinary charge may not be appropriate.”¹³

Prison Service Order 3845 states:

“Condoms may be prescribed if in the clinical judgment of the doctor there is a risk of HIV or STD transmission.”¹⁴

The Prison Health Performance and Quality Indicators (PHPQI) state that prisoners should be aware of means of accessing condoms, and have access both to barrier protection and to lubricants.¹⁵

Condoms are currently not available in prisons in Northern Ireland.

A report by the Prison Reform Trust and NAT¹⁶ found that:

• the guidance on condom prescription is not always implemented
• prisoners are often inhibited from asking for condoms because of lack of confidentiality
• when available, the process to obtain condoms can be very slow.

Prison governors interpret the guidance on condoms differently. While they are easily accessible in some prisons, in others they are difficult or impossible to come by. 

Some prison staff say that condoms should not be issued freely to prisoners because they could be used as weapons or to smuggle drugs. (Australian research¹⁷, following the introduction of condoms, showed that the first concern was not justified.) Many organisations working with prisoners living with HIV argue that the benefits in reducing HIV transmission outweigh the risks.

In some prisons, condoms have to be issued by a prison’s medical staff, which generally lowers uptake. This means that prisoners often have to make an appointment in order to get them. This can have an impact on their right to confidentiality about their sexuality or HIV status. Some prisons only issue condoms in advance of home leave.

Some prison medical staff only give out one condom at a time. Some prisoners have been asked to return soiled condoms after use before they could be issued with another.

In some prisons, a ‘C-Card’ scheme operates whereby healthcare staff may issue certain prisoners with a credit-card-sized card. The prisoner then doesn’t have to tell staff out loud that they need a condom, they just flash the card.

Uptake of condoms tends to be greatest where access is anonymous or discreet, for instance through condom-vending machines in the healthcare wing. 

In 1999, the official policy on condoms was challenged in the case of R v. Home Secretary ex p Fielding.¹⁸ The challenge was unsuccessful because it was argued that the Prison Service should not seek to encourage homosexual activity in prison. However, the court highlighted the fact that condoms should be issued when prison medical staff were satisfied that a genuine request was being made by a practising homosexual who would otherwise have unsafe sex.

Prisoners have the right to confidential HIV testing and relevant counselling.

Prison Service Order 3845 states:

“HIV antibody testing is available in confidence to any inmate who is concerned that he or she might be infected; the arrangements will vary between establishments and must be checked out locally.”

“It is a national requirement that everyone being tested for HIV should be counselled to ensure that they understand both how the virus is spread and the implications of a positive test. There should be at least one person in every prison who has been trained to counsel people who ask for HIV testing.”¹⁹

Moreover, BASHH’s National guidance on commissioning sexual health and blood borne virus services in prisons²⁰ states that all prisoners should have a risk assessment for sexual health and blood-borne virus infection by trained staff.

In practice, fewer individuals attending sexual health services in prisons receive an HIV test than in other NHS sexual health services. Moreover, follow-up counselling services can be variable. Voluntary organisations often bridge the gap when prison counselling services don’t meet prisoners’ needs.

Prisoners should be able to access sexual health services.

The Prison Health Performance and Quality Indicators (PHPQI) state that prisoners should have access to a genitourinary medicine (GUM) service (either provided externally or in house).¹⁵

The British Association for Sexual Health and HIV (BASHH) issued National guidance on commissioning sexual health and blood borne virus services in prisons in 2011.²⁰ According to this, all prisoners should have access to a doctor or nurse trained in sexual health; these clinicians must have clear and accessible pathways to the local specialist genitourinary medicine service. Consultations should be private and confidential.