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About half of all injecting drug users have histories of imprisonment; about half of all prisoners have histories of injecting drug use; and about half of all imprisoned injecting drug users inject drugs in prison.¹

Infection with hepatitis C virus (HCV) is common among Australian injecting drug users and prisoners. Butler and colleagues' study of prisoners entering the New South Wales correctional system (in this issue of the Journal) showed that almost a third were seropositive for HCV, rising to two-thirds of those with a history of injecting drug use. HCV infection was significantly associated with a history of previous imprisonment, which accords with the results of other studies.² Similarly, surveys of Australian injecting drug users find that histories of incarceration are among the strongest associations with HCV seropositivity. ³ A major survey of prison entrants in Victoria found high incidences of infection with both HCV and hepatitis B virus (HBV) among returning prison entrants -- 41 per 100 person-years among young male injecting drug users.⁴

While these data do not prove that infections are acquired in prison, the prison environment makes spread of blood-borne viruses more likely. The boredom, frustration and hopelessness felt by many prisoners potentially contribute to drug use. Many prisoners have no investment in the future, which will probably contain little except unemployment, further drug use and further imprisonment -- 64% of prison entrants in Victoria have been imprisoned previously. ⁵ They may believe they have nothing to lose (and some escape to gain) from drug use. In addition, prison policies may aggravate the problem of disease transmission. For example, sharing of injecting equipment is much more common in prison (where equipment is very scarce) than outside (where it is relatively freely available). ¹ Efforts to detect drug use, such as urine screening, may drive prisoners from smoking marijuana (which has metabolites that can be detected in the urine for many days) to injecting heroin and amphetamines (which are rapidly cleared from the body). Prison practices may also prevent prisoners taking precautions against spread of bloodborne viruses. For example, despite official policy, urine screening is alleged by prisoners to be anything but random; in some prisons, prisoners claim that a request for bleach (for disinfecting injecting equipment) is followed the next day by a urine test. ⁶ Sanctions against drug use, such as loss of contact visits as punishment for a "dirty" urine, simply reinforce the original reasons for drug use. ⁶

The situation varies for different bloodborne viruses. Despite the opportunities for transmission by injecting drug use, there has been very little transmission of HIV in Australian prisons. ⁷ However, this is not because conditions are not right for such transmission. It is because there is very little HIV among prison entrants as a result of harm reduction programs in the general community -- fewer than 5% of Australian injecting drug users were seropositive for HIV. ⁴ The recognition that reducing the spread of HIV is a more urgent priority than eradicating drug use (were the latter possible) has allowed our national AIDS and drug strategies to adopt such harm-reduction approaches (e.g., needle and syringe exchange and methadone maintenance programs).

On the other hand, HCV is causing an epidemic among Australian injecting drug users that will be difficult to control. ² Prisons are a key to this control; without rational approaches to the twin problems of injecting drug use and of HCV transmission in prisons, the epidemic will continue. The first step should be the recognition that incarceration offers nothing but ill to most injecting drug users. Alternative approaches to their problems will benefit both them and society.

A serious reconsideration of the opportunities for spread of bloodborne viruses in prisons is the next step. Measures should include everything from lowering the cost to prisoners of razors and toothbrushes (so they will not share them), to provision of sterile injecting and tattooing equipment, peer education programs, transition programs to assist movement back to society (including referral to needle exchanges), proper drug substitution and drug treatment programs and hepatitis B vaccination. ⁸

It cannot be said often enough that the punishment is deprivation of liberty, and that is all. Prisoners should have available to them all the means for protecting themselves against infection with bloodborne viruses that are available outside prison, without qualification. Prison authorities and governments must realise that the responsibility for the infection of a prisoner with a bloodborne virus, because means for prevention were not available within the prison, rests with them.

Nick Crofts
Head, Epidemiology and Social Research,
The Macfarlane Burnet Centre for Medical Research, Melbourne, VIC.

1. Crofts N, Webb-Pullman J, Dolan K. An analysis of trends over time in social and behavioural factors related to the transmission of HIV among injecting drug users and prison inmates. Evaluation of the National HIV/AIDS Strategy 1993-94 to 1995-96, Technical Appendix 4. Canberra: AGPS, 1996.
2. Crofts N, Stewart T, Hearne P, et al. Spread of blood-borne viruses among Australian prison entrants. BMJ 1995; 310: 285-288.
3. Crofts N, Jolley D, Kaldor J, et al. The epidemiology of hepatitis C virus infection among Australian injecting drug users. J Epidemiol Community Health. In press.
4. Kaldor JM, Elford J, Wodak A, et al. HIV prevalence among IDUs in Australia: a methodological review. Drug Alcohol Rev 1993; 12: 175-184.
5. Victorian Correctional Services Annual Prison Census, 1995. Melbourne: Department of Justice, 1996.
6. Crofts N, Thompson S, Wale E, Hernberger F. Risk behaviours for blood-borne viruses in a Victorian prison. Aust N Z J Criminol 1996; 29: 20-28.
7. Dolan K, Hall W, Wodak A, Gaughwin M. Evidence of HIV transmission in an Australian prison [letter]. Med J Aust 1994; 160: 734.
8. Dolan K, Wodak A, Penny R. AIDS behind bars. AIDS 1995; 9: 825-832.