Prisons
Limited access to HIV prevention in French prisons (ANRS PRI2DE): implications for public health and drug policy
Michel L, Jauffret-Roustide M, Blanche J, Maguet O, Calderon C, Cohen J, Carrieri PM; ANRS PRI²DE study group. BMC Public Health. 2011 May 27;11:400.
Overpopulation, poor hygiene and disease prevention conditions in prisons are major structural determinants of increased infectious risk within prison settings but evidence-based national and WHO guidelines provide clear indications on how to reduce this risk. Michel and colleagues sought to estimate the level of infectious risk by measuring how French prisons adhere to national and WHO guidelines. A nationwide survey targeting the heads of medical (all French prisons) and psychiatric (26 French prisons) units was conducted using a postal questionnaire and a phone interview mainly focusing on access to prevention interventions, i.e. bleach, opioid substitution treatment, HBV vaccination and post-exposure prophylaxis for French prisoners. Two scores were built reflecting adherence to national and WHO international guidelines, ranging from 0 (no adherence) to 10 (maximum adherence) and 0 to 9 respectively. A majority (N = 113 (66%)) of the 171 prisons answered the questionnaires, representing 74% coverage (46,786 prisoners) of the French prison population: 108 were medical units and 12 were psychiatric units. Inmate access to prevention was poor. The median[IQR] score measuring adherence to national guidelines was quite low (4.5[2.5; 5.5]) but adherence to WHO guidelines was even lower 2.5[1.5; 3.5]; post-exposure prophylaxis was absent despite reported risky practices. Unsuitable opioid substitution treatment delivery practices were frequently observed. A wide gap exists between HIV prevention policies and their application in prisons. Similar assessments in other countries may be needed to guide a global policy reform in prison settings. Adequate funding together with innovative interventions able to remove structural and ideological barriers to HIV prevention are now needed to motivate those in charge of prison health, to improve their working environment and to relieve French prisoners from their currently debilitating conditions.
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Editor’s note: Prison populations in France have increased by one-third in the last 10 years, partly due to the criminalisation of drug use. In addition to creating over-population of prisons, criminalisation of drug use is a barrier to implementation of effective harm reduction programmes both in the community and in prisons. Needle syringe programmes are underway in more than 50 prisons in 12 countries, but France is not one of them. Condoms are available in prisons in many countries, the USA being a notable exception at less than 1% of prisons, but they are not always accessible with anonymity. Although 95% of the French prisons in this study report that condoms are available, for the most part this is only in medical units so French prisons score 9% and 12% on adherence to national and WHO/UNAIDS/UNODC guidelines on condom access, respectively. The lesson learned is that countries should measure their performance in prison settings against national and international standards and then design implementation plans to address the shortfall and do so rapidly. Most prisoners are eventually released back into the community¾there is a tangible opportunity that should not be missed, while they are captive, to equip them to be purveyors of positive messages about HIV prevention, testing, stigma, treatment adherence, and support to others.
