Presentation at Inside Reform, Policy Event, National Gallery of Ireland, 2 June 2017
In her paper Dr Janet Weston (LSHTM) looked at the various groups that engaged with HIV/AIDS in prisons in England and Ireland during the 1980s. She delineated how they conceptualised the issue and its longer-term impact on prison healthcare. In the early 1980s the linkage between HIV/AIDS, as a blood-borne virus, and intravenous drug use was established. This linkage brought attention to the prison as a site of HIV infection and transmission. International studies found that prison populations had rates of HIV seropositivity far in excess of any other group and that often the response of prison medical services to the issue was scientifically unsound and ethically dubious.
Podcast of Reforming Prisons in the 1980s: The Impact of AIDS
In England, at the national level, both groups and individuals began to pay attention to the problem of AIDS and the prison from the mid-to-late 1980s. This included the UK’s Advisory Council on the Misuse of Drugs, a body established by statute in the early 1970s, which produced a series of highly influential reports between 1988 and 1993 on drug use in relation to HIV and AIDS. These reports intended to fundamentally transform the UK’s drug policy in the light of HIV/AIDS and as part of that aim they focussed extensively on prisons and made specific recommendations. The National AIDS Trust, a body set up by the Department of Health, was also becoming interested in HIV in prisons at this time. Additionally, the UK Prison Reform Trust, reflecting its pre-existing concern with prison healthcare, was also increasingly occupied by the problem of HIV and AIDS in the prison population. Prison medical care in England had been the object of considerable scrutiny during the 1970s and 1980s and this informed many of the subsequent investigations into AIDs in prisons.
In Ireland, during the 1980s, HIV and AIDs in prisons occupied a lower profile than in England. There was relatively little official or public interest in prisons generally and even less in prison healthcare. The response to HIV and AIDS in prisons in Ireland remained quite low-key until the 1990s. The Department of Justice was generally unwilling to engage on the issue and reluctant to receive advice from external bodies. National strategies in Ireland around AIDs and drug use, when they did begin to emerge, only touched very briefly on prisons. More proactive and specific engagement came from individuals who were directly involved in the criminal justice system, such as social workers, probation officers and welfare officers. However, the critiques of these practitioners tended to be quite muted since they were normally talking about their colleagues and places of work. Prison Visiting Committees also mentioned HIV/AIDS as part of their wider criticisms of prisons and the medical services available in prisons. The National Task Force on AIDS, established by Catholic Social Services, also showed an interest in prison healthcare. This task force, whose broad membership was well informed on the issue, tried to influence policy through quiet backchannels.
AIDS Activism and the Prison
However, prisons and prisoners were not prominent features of AIDS activism in either country. Most such groups lacked the expertise and networks to be effective agents of prison reform. Further, prison healthcare was too far outside their core activities and perhaps also brought with it too many negative connotations that already stigmatised groups were not keen to embrace.
Conceptualisation of HIV/AIDS
In England the reports of the Advisory Council on the Misuse of Drugs provided a template for reform. They highlighted the high prevalence of HIV among injecting drug users and presented drug users as the primary route of transmission into the heterosexual population. Their focus on prisons was determined by the following factors: many drug-users passed through prisons; many of these would have a history of injecting drug use and some of prostitution; and many prisoners would not have had previous contact with helping agencies. Prisons were also presented as places where fear, misinformation and potentially high-risk activities might be common. These reports conceptualised HIV-infected prisoners upon their release as a potential threat to the non-drug using, heterosexual non-prison population. Other activists in the UK tended to follow a similar line. They called for improved targeted health promotion activities in prisons, confidential HIV testing, the provision of condoms, the prescribing of methadone to try and reduce injecting, and the provision of bleach for cleaning injecting equipment. Their efforts sought to bring prisons into line with the HIV prevention activities going on in the wider community. HIV and AIDS was one of number of health issues that was used by activists to push for the modernisation of prison healthcare and to insist upon the equivalence of prison health service provision with the wider community.
Segregation of Prisoners with HIV/AIDS
In Ireland, the issue was conceptualised quite differently and discussion focused on the segregation of prisoners with HIV and AIDS. This was difference in emphasis was largely determined by the existence of a separation unit that operated in Mountjoy Prison, Dublin, from 1985 until 1995. Segregation in Ireland was heavily criticised on a number of grounds. It was alleged that it: discouraged prisoners from seeking medical help; that the small segregation unit in Mountjoy was totally unsuitable healthcare environment; that, as ill-health and the incidence of deaths increased in the unit its population succumbed to depression and self-harm.
Unlike in England, in Ireland, the issue of HIV and AIDs in prisons was neither considered to be part of a wider community strategy for HIV prevention nor an issue that could be used to leverage prison healthcare modernisation. Rather, it was conceived as isolated problem within the sequestered domain of the isolation unit. The separation of such prisoners precluded their framing as constituting a threat to the wider community. Instead, the danger of HIV and AIDS in prisons was thought of as salient only to prisoners and prison staff.
Impact on Prison Healthcare in England
These differences in the conceptualisation of HIV and AIDS in prisons meant that the syndrome impacted very differently on the prison health systems of each country. Ultimately, in English prisons the effect of HIV and AIDS was relatively modest. It encouraged greater communication across different parts of the prison service, greater cooperation with external bodies and led to some specific policy shifts. However, the most significant reform of the era was the takeover of prison healthcare by the NHS; a transition finalised in 2006. HIV/AIDS played a minor role in this transition but it was far from being the most important factor. Much more significant were concerns about mental illness in prisons and criticisms of the quality and qualifications of the members of the prison medical service. Such criticisms had predated the advent of HIV and AIDS and continued on after the major fears about AIDS had subsided.
Impact on Prison Healthcare in Ireland
In Ireland, the impact of HIV/AIDS was much more dramatic. It led to recruitment of a director of prison medical services and prompted a good deal of internal strife regarding the separation unit and how healthcare for prisoners was being provided. Again, HIV and AIDS was not the only health issue driving change. It was, however, the issue that prompted this self-scrutiny and radically elevated the profile of healthcare in prisons. This eventually led to an enormous degree of change in the Irish prison medical service including: the recruitment of registered nurses; the introduction of a prison pharmacy services; the introduction of prison drug-treatment programmes; prison mass screening programmes; and the establishment of standards for prison healthcare against which the service could be measured. While many of these reforms were not in place until the 2000s,HIV/AIDS provided a singular important impetus for such changes.