Is the World Finally Waking up to HIV/AIDS in Prisons?

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By Ralf Jürgens, LL.M., Dr.jur, Executive Director, Canadian HIV/AIDS Legal Network

Published: 10/04/2004

This article was reprinted wth permission from the September 2004 issue of Infectious Diseases in Corrections Report (formerly HEPP Report) available online at www.idcronline.org.

Issues related to HIV/AIDS in prisons have traditionally received little attention at the International AIDS Conference. Yet, it is a well-known fact that HIV prevalence within prison populations tends to be much higher than in the general population both in the United States and worldwide. This year's conference, "AIDS 2004," held in Bangkok, Thailand, (July 11-16, 2004) may, however, represent a turning point.

Before the official conference started, a one-day satellite meeting debated issues related to HIV/AIDS in prisons in great depth. At the conference itself, two oral sessions and a large number of poster presentations were dedicated to HIV/AIDS in prisons. In addition, three United Nations agencies released an important policy brief on reduction of HIV transmission in prisons. Although most activities focused on HIV prevention, delegates also debated the question of how HIV treatment, including antiretrovirals (ARVs), can best be made available to inmates. This was particularly important in light of current efforts spearheaded by the World Health Organization to make effective treatments available to three million people in developing countries by 2005.1 While it is impossible to provide a detailed overview of all the prison-related developments presented at AIDS 2004, this article will first provide some background information on HIV/AIDS in prisons worldwide, and then highlight some of the relevant findings presented at the conference.

HIV/AIDS in Prisons Worldwide
HIV Prevalence
In most countries, prevalence of HIV infection within prison populations is much higher than in the general population, with some countries reporting rates in the range of 10 to 25 percent.2 The jurisdictions with the highest HIV-prevalence within prisons are those where rates of HIV infection among injection drug users (IDUs) are high, as this group is dramatically over-represented in correctional institutions.

HIV Transmission in Prison
Incarceration has been associated with HIV infection in several countries,3 including Thailand, where the first wave of HIV infections occurred in 1988 among IDUs. From a negligible percentage at the beginning of the year, the infection rate among IDUs rose to over 40 percent by September, fueled in part by transmission of the virus as many IDUs moved in and out of penal institutions.4 A more recent study concluded that IDUs in Bangkok continue to be "at significantly increased risk of HIV infection through sharing needles with multiple partners while in holding cells before incarceration."5

Additional evidence for rapid HIV transmission in prisons was documented in Scotland in 1993.6 Among 227 Scottish inmates participating in a study of HIV risk behavior and infection at Glenochil institution, 76 (33 percent) reported a history of injection, and 33 (43 percent) of those individuals reported injecting while in the prison. Thirty-two (97 percent) of those who admitted to injecting in prison also reported sharing syringes. Of the 162 individuals who were tested for HIV, twelve (7 percent), tested positive for HIV antibodies. All of these individuals had reported injecting while in the prison. Evidence derived from serial HIV testing and prison admission records confirmed that at least eight of these inmates contracted HIV during the first six months of 1993.

Another example of a documented outbreak occurred in a prison in Lithuania. During random checks undertaken in 2002 by the state-run AIDS Center, 263 prisoners at Alytus prison tested positive for HIV antibodies. Tests at Lithuania's other 14 prisons, which house 11,700 convicts, found only 18 cases of HIV infection. Before the tests at Alytus prison, Lithuanian officials had listed only 300 cases of HIV infection in the whole country, or less than 0.01 percent of the population, the lowest prevalence in Europe. It is believed that the outbreak at Alytus prison was also due to sharing of drug injection equipment.7

HIV Risk Behaviors
Despite the sustained efforts of prison systems to prevent drug use by prisoners, the reality is that drugs can and do enter prisons. Many inmates come to prisons with their drug habits already established. In fact, many inmates are sentenced in the first place because of drug-related crimes. People who used drugs outside often find a way to continue drug use on the inside. Others start using drugs in prison as a way to release tensions and to cope with being in an overcrowded and often violent environment.8

Studies have shown that ongoing injection drug use is also prevalent in prisons in many countries.9 As in the United States, imprisonment is a common event for IDUs worldwide. In a 12-city World Health Organization study of HIV risk behavior among IDUs, between 60 and 90 percent of respondents reported a history of imprisonment since commencing drug injection.10 For IDUs who continue to use while incarcerated, imprisonment increases the risk of contracting blood-borne infections, including HIV and hepatitis C virus (HCV) and hepatitis B virus (HBV). This is because those who inject drugs in prison almost always share needles and syringes. IDUs have contributed to significant risk-reduction in the community through introduction of a variety of measures that include needle exchange, education, and provision of treatment. On the other hand, risk behavior in prisons (with the exception of prisons that have introduced the preventive measures described below) has remained unchanged over the last decade.11 In one Australian study, six of the 36 participants who reported injecting and sharing needles when last in prison also reported that it was the first time they had ever shared syringes.12 Most often, only a handful of needles will circulate among a large population of prisoners who inject drugs.

Because sharing of injection equipment is inherently a high-risk activity, and in some prisons a more common occurrence, sexual activity is considered to be a less significant risk factor in prisons for HIV and HCV transmission. Nevertheless, it does occur and puts prisoners at risk of contracting HIV infection. Homosexual activity occurs inside prisons, as it does outside, as a consequence of sexual orientation. In addition, prison life produces conditions that encourage homosexual activity and the establishment of homosexual relationships between inmates who do not identify themselves as homosexuals. The prevalence of sexual activity in prison is based on such factors as whether the accommodation is single-cell or dormitory, the duration of the sentence, the security classification, and the extent to which conjugal visits are permitted. Studies of sexual contact in prison have shown "inmate involvement to vary greatly."13

Responses of Prison Systems
Initially, response to the issues raised by HIV/AIDS, HCV, and drug use in prisons was slow. In many prison systems worldwide, only small steps were made to develop policies and to provide educational programs for staff and prisoners. However, in recent years a growing number of prison systems have started adopting a pragmatic, public health approach to HIV/AIDS. These systems are making condoms, bleach and even sterile injection equipment and methadone maintenance treatment available, in addition to providing substance abuse treatment and educational programs delivered or supplemented by community-based outside organizations and/or peers.

Responding to Injection Drug Use
Recognizing that drugs, needles, and syringes permeate the most secure of prison walls, and while continuing and often stepping up drug interdiction efforts and substance abuse programs, prison systems around the world are taking steps to reduce the risk of the spread of HIV and other diseases. Some of these measures are not necessarily easy to implement, and there are legal, ethical, as well as practical problems associated with them. These steps have usually been undertaken as a pilot project, but their success to date has led to their continuation, and indeed extension into other prisons and other countries.14

One strategy to reduce the risk of HIV transmission through the sharing of injection equipment is to provide liquid bleach to sterilize needles and syringes. Already in 1991, 16 of 52 prison systems surveyed in Europe made bleach available to prisoners.15 Significantly, no system that has adopted a policy of making bleach available in penal institutions has ever reversed the policy, and the number of systems in Europe that make bleach available has continued to grow every year.16 Bleach is also available in many other prison systems, including in most Canadian prisons17 and in many prisons in Australia.18

While making bleach available to inmates may reduce the spread of HIV from injection drug use in prisons, sterile, never-used needles and syringes are safer than bleach-disinfected, previously-used needles and syringes.19 The probability of effective decontamination is decreased further in prison. Because prisoners can be discovered at any moment by prison staff since injecting and cleaning is a hurried affair. Studies have shown that bleach disinfection takes more time than most prisoners allow. In addition, even when bleach is provided, prisoners may find it difficult to access.20 Finally, bleach is not fully effective in killing HCV.21
Therefore, an increasing number of prison systems have introduced needle exchange or distribution programs. Outside prisons, in many countries such programs have become an integral part of a pragmatic public health response to the risk of HIV transmission among IDUs (and ultimately, to the general public). Extensive studies on the effectiveness of these programs have been carried out. For many years, there has been scientifically sound evidence showing that they are an appropriate and important preventive health measure.22

Introducing needle exchange programs in prisons has been recommended.23 At AIDS 2004, the first comprehensive survey of the experience with existing prison-based needle exchange programs was presented (see below).

Finally, worldwide, an increasing number of correctional systems have introduced methadone maintenance treatment (MMT). Outside prisons, MMT programs have rapidly expanded in many countries over the last decade. There are ample data supporting their effectiveness in reducing high-risk injecting behavior and in reducing the risk of contracting HIV. There is also evidence that MMT is a highly effective treatment available for heroin-dependent IDUs in terms of reducing mortality, heroin consumption, and criminality. Further, MMT attracts and retains more heroin injectors than any other form of treatment. Finally, there is evidence that people who are on MMT and who are forced to withdraw from methadone because they are incarcerated often return to narcotic use, often within the penal institutions, and often via injection.24

As in the community, MMT, if made available to prisoners, has the potential of reducing injecting and syringe sharing in prisons. Evaluations of MMT programs in prisons have shown positive results. For example, in Canada, the federal prison system expanded access to MMT after evaluation demonstrated that MMT has a positive impact on release outcome and on institutional behavior.25

Preventing sexual transmission of HIV
Many prison systems worldwide are also making condoms available to prisoners. In 1991, 23 of the 52 European prison systems surveyed allowed condom distribution.26 Making condoms available has not resulted in any significant security problems,27 and no system that has adopted a policy of making condoms available in prisons has reversed the policy. The number of systems that make condoms available has continued to grow every year. For example, in a number of surveys undertaken in Europe, the proportion of prison systems that made condoms available rose from 53 percent in 1989 to 75 percent in 1992 and 81 percent in 1997. In the most recent survey, condoms were available in all but four systems.28 In 1995 in Australia, 50 prisoners launched a legal action against the state of New South Wales (NSW) for non-provision of condoms, arguing that "[it] is no proper part of the punishment of prisoners that their access to preventative means to protect their health is impeded."29 Since then, at least in part because of the legal action, the NSW government has decided to make condoms available. Other Australian systems, most Canadian systems, a growing number of facilities in the U.S. and elsewhere also make condoms available.

AIDS 2004 Highlights
The Satellite Conference on HIV/AIDS in Prisons
A one-day pre-conference seminar, which brought together 150 people from many different countries and backgrounds, debated issues related to HIV/AIDS in prisons at great length. Entitled "Human Rights at the Margins: HIV/AIDS, Prisoners, Drug Users and the Law," and organized by a group of organizations including the Canadian HIV/AIDS Legal Network and UNAIDS, the conference provided an overview of the state of the HIV/AIDS epidemic in prisons worldwide. Also discussed were responses by prison systems; key public health, human rights, legal and ethical issues; and recommendations about how to increase HIV education, prevention, care, treatment and support efforts in prisons worldwide. A background paper prepared for the conference argues that increased efforts are necessary not only for public health reasons, but are required by international law. With regard to availability of prevention measures, the paper states:

"Measures undertaken to prevent the spread of HIV and other infections will benefit prisoners, staff, and the public. They will protect the health of prisoners, who should not, by reason of their imprisonment, be exposed to the risk of a deadly condition. They will protect staff: lowering the prevalence of infections in prisons means that the risk of exposure to these infections will also be lowered. They will protect the public. Most inmates are in prison only for short periods of time and are then released into their communities. In order to protect the general population, prevention measures need to be available in prisons, as they are outside." 31

With regard to treatment, the paper argues that in high income countries, the right to enjoyment of the highest attainable standard of physical and mental health, in concert with the principle of equivalence, dictates that inmates should have access to a high standard of care, including specialist consultation, diagnostic testing (CD4, viral load, viral resistance) and the full range of ARVs licensed for sale within a particular country.32 The paper is currently being finalized based on feedback received at the conference and peer review."33

Oral Sessions on HIV/AIDS in Prisons at AIDS 2004
The first of two major oral sessions on HIV/AIDS in prisons was entitled, "Not hard-to-reach, but still hard-to-serve? What works in HIV prevention and care in prisons." It included presentations from prison officials from Indonesia,34 Thailand,35 and Iran,36 as well as a presentation on the first comprehensive survey of prison-based needle exchange programs.37 The presenter from Thailand focused on his country's efforts to deal with the problem of TB and HIV coinfection in prisons. The officials from Indonesia and Iran discussed the measures, including condoms, bleach, and MMT, that have been introduced in their countries to respond to HIV/AIDS in prisons. It was encouraging to hear senior officials speak openly about heavily stigmatized and prohibited behaviors such as injection drug use and homosexual activity, and discuss the pragmatic response to prevent the greater evil: the spread of HIV among inmates and ultimately to the community. While Indonesia and Iran have not yet introduced prison-based needle exchange programs, other countries such as Switzerland, Germany, Spain and an increasing number of countries in Eastern Europe have. The survey of such programs that was presented at the session revealed that a steadily increasing number of prisons have established and evaluated needle and syringe exchange or distribution programs. All evaluations of such programs have been favorable. In particular, they have shown improvement in the health of prisoners and reduction of syringe sharing. Feared negative consequences have not materialized: needles have not been used as weapons, and there has been no reported increase in drug consumption. The presentation concluded that prison-based needle exchange programs have proven safe and effective, and the presenters opined that there remain no valid reasons not to introduce them in other prison systems.38

The second oral session was entitled "Preventing HIV spread in prisons" and included presentations from the U.S., Canada, Pakistan, and Thailand:
Barry Zack from California presented on the role of non-governmental organizations (NGOs) as partners of prison systems in the fight against HIV/AIDS.39 He emphasized that a unique opportunity for collaboration exists between penitentiaries and NGOs when it comes to the provision of prevention, social support and transitional HIV services for inmates. He concluded that "prison officials who have worked with NGOs have shown that the collaboration can work for the prison, the NGO, the prisoner and the community."

Richard Wolitski presented the results of "Project START," funded by CDC to develop an HIV, STD, and hepatitis prevention program for young men aged 18-29 who are leaving prison and to test the effectiveness of a number of interventions in reducing sexual risk after leaving prison. Results showed that those prisoners who received enhanced interventions consisting of two pre-release, four post-release, and optional sessions based on participant need were less likely to engage in unprotected sex than prisoners who only received a single pre-release session intervention.40
A Canadian study showed that of 1,475 IDUs enrolled in the Vancouver Injection Drug Users Study (VIDUS), 1,123 (76 percent) reported a history of incarceration since they first began injecting drugs. Of these, 351 (31 percent) reported, via interviews, ever injecting in prison. Among all those interviewed, including those with and without HIV infection, incarceration during the six months prior to the interview was associated with syringe borrowing during that period. The researchers concluded that "incarceration was independently associated with risky needle sharing for HIV-infected and HIV-negative IDUs," and that the "strong evidence of HIV risk behavior should reinforce public health concerns about blood-borne diseases transmission in prisons."41

Both the presentations from Pakistan42 and Thailand43 focused on the growing population of children and juveniles in prisons, and emphasized the need for programs aimed at reducing their vulnerability to HIV/AIDS.

A New Resource
A final important development at AIDS 2004 was the release of a policy brief on reduction of HIV transmission in prisons by three United Nations agencies (the World Health Organization, UNAIDS, and the UN Office on Drugs and Crime).44 Consistent with the message of the satellite conference and most oral presentations at AIDS 2004, the document calls upon governments to step up HIV prevention measures in prisons by adopting comprehensive programs that include all the measures against HIV transmission that are carried out in the community, including needle exchange. It concludes with the following "policy and programming implications":

The prevention of HIV transmission in prisons is mostly hampered by the denial of governments of the existence of injection drug use and sexual intercourse in prisons, rather than by a lack of evidence that key interventions work. There is ample evidence that drug use in general, injecting drug use in particular, and sexual intercourse among inmates are widespread in such institutions. Furthermore, there are data indicating that the risk of HIV infection in prisons is usually higher than in the general community. Once this has been accepted, governments have a wide range of program options for preventing HIV transmission in prisons.

The evidence shows that such programs should include all the measures against HIV transmission, which are carried out in the community outside prisons, including HIV/AIDS education, testing and counseling performed on a voluntary basis, the distribution of clean needles, syringes and condoms, and drug-dependence treatment, including substitution treatment. All these interventions have proved effective in reducing the risk of HIV transmission in prisons. They have also been shown to have no unintended negative consequences. The available scientific evidence suggests that such interventions can be reliably expanded from pilot projects to nationwide programs.45 At the end of the conference, some delegates expressed satisfaction that issues surrounding HIV/AIDS in prisons are starting to receive the attention they deserve. The hope is that by the time of the next International AIDS Conference, to be held in Toronto, Canada in 2006, the world will have better appreciated and responded to the reality of HIV/AIDS in prisons.

References:
1. For more information, see www.who.int/hiv/en/
2. Burattini, M et al. 2000, Correlation between HIV and HCV in Brazilian Prisoners: Evidence for Parenteral Transmission inside Prison, Rev Saude Publica, 34, 431-6; Babudieri, S et al. 2003, [HIV and Related Infections in Italian Penal Institutions: Epidemiological and Health Organization Note], Ann Ist Super Sanita, 39, 251-7; Kallas, EG et al. 1998, HIV Seroprevalence and Risk Factors in a Brazilian Prison, Braz J Infect Dis, 2, 197-204; Raufu, A. 2001, Nigerian Prison Authorities Free HIV Positive Inmates, AIDS Analysis Africa, 12, 15.
3. Rich, JD et al. 1999, Prevalence and Incidence of HIV among Incarcerated and Reincarcerated Women in Rhode Island, J Acquir Immune Defic Syndr, 22, 161-6; Tyndall, MW et al. 2003, Intensive Injection Cocaine Use as the Primary Risk Factor in the Vancouver Hiv-1 Epidemic, AIDS, 17, 887-93; Choopanya, K et al. 2002, Incarceration and Risk for HIV Infection among Injection Drug Users in Bangkok, J Acquir Immune Defic Syndr, 29, 86-94.
4. Jürgens, R. (1996) HIV/AIDS in Prisons: Final Report. Montréal: Canadian HIV/AIDS Legal Network and Canadian AIDS Society, at 45, with reference to Wright et al. Was the 1988 HIV epidemic among Bangkok's injecting drug users a common source outbreak? AIDS 1994; 8: 529-532.
5. Buavirat et al. (2003) Risk of prevalent HIV infection associated with incarceration among injecting drug users in Bangkok, Thailand: case-control study. British Medical Journal 326(7384): 308; see also Thaisri et al. 2003, HIV Infection and Risk Factors among Bangkok Prisoners, Thailand: A Prospective Cohort Study, BMC Infect Dis, 3, 25.
6. Taylor, A. et al. (1995). Outbreak of HIV Infection in a Scottish Prison. British Medical Journal 310(6975): 289-292.
7. Dapkus L. Prison's rate of HIV frightens a nation. Associated Press 29 September 2002.
8. Ibid.
9. European Monitoring Centre on Drugs and Drug Addiction. (2002). 2002 Annual Report on the State of the Drugs Problem in the European Union and Norway. Luxembourg: Office for Official Publications of the European Community; Correctional Service Canada. (1996a) 1995 National Inmate Survey: Final Report. Ottawa: The Service, Correctional Research and Development; Ford, P.M. (1999) HIV and Hep C seroprevalence and associated risk behaviours in a Canadian prison. Canadian HIV/AIDS Policy & Law Newsletter 4(2/3); Dolan, K. (1999). The epidemiology of hepatitis C infection in prison populations. National Drug and Alcohol Research Centre, UNSW; Medecins Sans Frontieres. (2000) Health Promotion Program in the Russian Prison System: Prisoner Survey 2000. Cited in International Harm Reduction Development. Drugs, AIDS, and Harm Reduction: How to Slow the HIV Epidemic in Eastern Europe and the Former Soviet Union. Open Society Institute, New York, 2001; Magis-Rodriguez, C et al. (2000). Injecting drug use and HIV/AIDS in two jails of the North border of Mexico. Abstract for the XIII International AIDS Conference.
10. Ball, A., et al. (1995) Multi-centre Study on Drug Injecting and Risk of HIV Infection: a report prepared on behalf of the international collaborative group for the World Health Organization Programme on Substance Abuse. Geneva: World Health Organization.
11. Dolan, K. (1999). The epidemiology of hepatitis C infection in prison populations. National Drug and Alcohol Research Centre, UNSW, at 6.
12. Ibid.
13. Saum, C.A., et al. (1995) Sex in Prison: Exploring the Myths and Realities. Prison Journal December 1995.
14. UNAIDS. (1997) Prisons and AIDS - UNAIDS Point of View. Geneva: Joint United Nations Programme on HIV/AIDS.
15. Harding, T.W. and Schaller, G. (1992b) HIV/AIDS and Prisons: Updating and Policy Review. A Survey Covering 55 Prison Systems in 31 Countries. Geneva: WHO Global Programme on AIDS.
16. European Network on HIV/AIDS and Hepatitis Prevention in Prisons. Final Report on the EU Project European Network on HIV/AIDS Prevention in Prisons. Bonn and Marseille: The Network, 1997.
17. Lines R. (2002) Action on HIV/AIDS in Prisons: Too Little, Too Late - A Report Card. Montreal: Canadian HIV/AIDS Legal Network.
18. Dolan (1999), supra.
19. US Department of Health & Human Services, Public Health Service, Centers for Disease Control and Prevention. HIV/AIDS Prevention Bulletin, 19 April 1993.
20. Dolan, K., et al. (1996b) Bleach Easier to Obtain But Inmates Still at Risk of Infection in New South Wales Prisons. Technical Report. Sydney, National Drug and Alcohol Research Centre.
21. Hagan, H. and Thiede, H. 2003, Does Bleach Disinfection of Syringes Help Prevent Hepatitis C Virus Transmission? Epidemiology, 14, 628-9.
22. See, eg, Centers for Disease Control and Prevention. (1993) The Public Health Impact of Needle Exchange Programs in the United States and Abroad. Summary, Conclusions and Recommendations. The Centers.
23. See, eg, WHO. (1993) Guidelines on HIV Infection and AIDS in Prisons. Geneva: WHO Global Programme on AIDS.
24. Dolan, K. and Wodak, A. (1996) An International Review of Methadone Provision in Prisons. Addiction Research, 4(1), 85-97.
25. Correctional Service Canada. Research Report: Institutional Methadone Maintenance Treatment: Impact on Release Outcome and Institutional Behaviour. Ottawa: CSC Research Branch, 2002 (No R-119). Available via www.csc-scc.gc.ca/text/rsrch/reports/reports_e.shtml. See also T Kerr, R Jürgens. Methadone Maintenance Therapy in Prisons: Reviewing the Evidence. Montreal: Canadian HIV/AIDS Legal Network, 2004. Available via www.aidslaw.ca/Maincontent/issues/prisons.htm. 26. Harding and Schaller, (1992), supra.
27. K Dolan, D Lowe, J Shearer. Evaluation of the condom distribution program in New South Wales prisons, Australia. Journal of Law, Medicine & Ethics 2004; 32: 124-128.
28. European Network on HIV/AIDS and Hepatitis Prevention in Prisons. 2. Annual Report - European Network on HIV/AIDS Prevention in Prisons. Bonn and Marseille: The Network, 1998.
29. Jürgens, R. (1996) HIV/AIDS in Prisons: Final Report. Montreal: Canadian HIV/AIDS Legal Network and Canadian AIDS Society, at 48.
30. Betteridge, G. Prisoners' Health & Human Rights in the HIV/AIDS Epidemic. Montreal: Canadian HIV/AIDS Legal Network, 2004. Available via www.aidslaw.ca/bangkok2004/e-bangkok2004.htm.
31. Ibid.
32. Ibid.
33. Readers of HEPP Report who would like to provide comments on the paper can do so by sending an email to gbetteridge@aidslaw.ca by 30 September 2004.
34. D Soejoto. First things first: Overcoming policy challenges to HIV programming in prisons. The XV International AIDS Conference, 2004, Abstract no WeCs211, MedGenMed. 2004 Jul 11;6(3):WeCs211 [eJIAS. 2004 Jul 11;1(1):WeCs211].
35. P Akarasewi. TB and HIV coinfection: Implications for prophylaxis and treatment. Abstract no WeCs213.
36. Pafshar. Going national: Experiences in developing nationwide harm reduction in Iran's prisons. Abstract no WeCs214.
37. Jürgens R et al. Prison needle exchange: A review of international evidence and experience. Abstract no ThPeC7472.
38. See also, Lines, R Jürgens, H Stöver, D Latishevschi, J Nelles. Prison Needle Exchange: A Review of International Evidence and Experience. Montreal: Canadian HIV/AIDS Legal Network, 2004; Kerr, T, R Jürgens. Syringe Exchange Programs in Prisons. Reviewing the Evidence. Canadian HIV/AIDS Legal Network, 2004 (available via www.aidslaw.ca/Maincontent/issues/prisons.htm); H Stöver, J Nelles. 10 years of experience with needle and syringe exchange programmes in European prisons: A review of different evaluation studies. International Journal of Drug Policy 2003; 14: 437-444; K Dolan, S Rutter, A Wodak. Prison-based syringe exchange programmes: a review of international research and development in Addiction 2003, 98, 153-158.
39. B Zack. Control of HIV/AIDS in prisons/jails: The international experience and role of non-governmental organizations as collaborative partners. Abstract no. WeOrE1295.
40. RJ Wolitski et al. Project START reduces HIV risk among prisoners after release. Abstract no. WeOrC1296.
41. E Wood et al. Incarceration is independently associated with syringe lending and borrowing among a Canadian cohort of injection drug users. Abstract no. WeOrC1297.
42. AYB Ayub. Prevention of HIV/AIDS and STDs among juvenile prisoners in north west frontier province, Pakistan. Abstract no. WeOrC1299.
43. E Ireland, N Chaiphech. Reducing children's vulnerability to HIV/AIDS and drugs in detention facilities in Thailand. Abstract no. WeOrC1300.
44. World Health Organization. Evidence for action on HIV/AIDS and injection drug use - Policy brief: Reduction of HIV transmission in prisons. Geneva: WHO, 2004 (WHO/HIV/2004.05). Available via www.who.int/en/
45. Ibid.

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