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.