July saw over 18,000 delegates gathering in Durban for the 21st International AIDS Conference. To coincide with this, the Lancet published a six part series addressing HIV and related infections amongst prisoners, highlighting (not for the first time) that infection rates for HIV, TB, and hepatitis B and C, are significantly higher amongst prisoners than the general population.
As these articles recognise, prisons have long been acknowledged as sites of both danger and opportunity in relation to the management of infectious disease. HIV and AIDS gave this a new and global urgency: as early as 1983, the Annals of Internal Medicine discussed prisoners as a high risk group for AIDS, and by 1988 an array of national and international organisations had issued detailed recommendations around HIV and AIDS in places of detention.
What’s striking is how little these recommendations have changed. The provision of information about HIV and AIDS to prisoners, of testing with appropriate counselling, of treatment for heroin addiction and clean needles for those who continue to inject illicit drugs while detained, and access to good clinical care for prisoners with HIV or AIDS were and still are among the primary calls to action. So, too, is the provision of condoms to people in prison, which I talked about at Durham’s Centre for Sex, Gender and Sexualities excellent Summer School last month.
Condoms were permitted in English prisons in the mid-1990s in order to combat the spread of HIV – or rather, they were eventually not-not-permitted. This subtle adjustment in policy was very quietly delivered. Condoms were initially provided to some prisoners on release or home leave in 1991, but Home Office ministers at the time had ‘not been convinced that making condoms available for use in prison would be appropriate or helpful’.1
Although the ministers held firm to this view, the Prison Service’s Directorate of Health Care found a way to sidestep their objections a few years later. Following confirmation in 1994 that a prisoner had been infected with HIV through sexual contact while in prison, all prison doctors were advised that they had a duty of care to prescribe as best they could to reduce infection, which could and should include the prescribing of condoms. It was a strictly medical solution.
But the problem it attempted to address was not an exclusively medical one. This approach left considerable uncertainty and scope for interpretation, since wider prison policies and practices remained unchanged. Litigation and research from the 1990s to the present day has pointed to significant misinformation and inconsistency across the prison estate, putting the health of prisoners at risk. Reliance upon individualised (and somewhat secretive) medical decision-making, without a broader consideration of sex in prisons, the rights of prisoners, and the purpose of imprisonment itself, was not enough to overcome pre-existing institutional priorities and beliefs.
The recent Lancet series has placed such priorities and beliefs under the spotlight by condemning in unequivocal terms the ‘War on Drugs’. HIV transmission has been boosted, the series’ authors argue, by the mass global incarceration of drug users, frequently in poor conditions, without treatment for addiction, and without any means for safer injecting. The impact of HIV on drug treatment options in prisons is something I’ll be addressing in a future blog post.
1 ‘HIV / AIDS: Organisation and procedures at establishment level’, Prison Service Circular Instruction 30/1991.