The prevalence of hepatitis C infection among inmates is difficult to assess because there is no national surveillance system in custodial settings and inmates have limited access to PCR testing and testing is voluntary. However, it has been estimated that hepatitis C prevalence is in the range of 40 to 60%. Approximately 93% of the prison population are male, but the hepatitis C prevalence in female prisoners is between 50 and 70%. The significantly higher prevalence of hepatitis C amongst female inmates appears to reflect the fact that females are more likely to be convicted of drug related crimes. Overall, the hepatitis C prevalence in custodial settings is much higher than the prevalence of approximately one percent in the general population.
In total, it is estimated that between 30,000 and 35,000 prisoners were incarcerated in Australian prisons during 2005. Of these between 9,000 and 14,000 people had hepatitis C antibodies and 7,000 to 11,000 people had chronic hepatitis C.
The high proportion of people entering prison for drug related offences and the risk of unsafe injecting drug use within custodial settings, means that this group is at high risk of hepatitis C transmission. Other high risk behaviours common in custodial settings include body piercing, tattooing, sharing hair clippers, injury, self harm, fighting and assaults.
Aboriginal and Torres Strait Islander people are significantly overrepresented in adult and juvenile correctional settings. At June 2002, 20% of all prisoners identified as Aboriginal and Torres Strait Islander. Therefore, by association it would appear they would be more at risk of injecting while incarcerated and being infected with hepatitis C.
Time spent in custodial settings tends to be relatively short (the majority of inmates are incarcerated for less than 12 months) and peer education programs have been developed in several jurisdictions in Australia. Peer education programs aim to develop the peer as a positive role model in order to affect cultural shifts in custodial settings. Peer education programs may relate to inmates with hepatitis C supporting eachother to live with the virus or may focus on peers educating eachother about safe injecting practices. Regardless of the style of education program, educators need to be aware of the considerations, barriers and challenges of working in custodial settings.
Prisons are considered a high risk environment for the transmission of hepatitis C. There is a high prevalence of hepatitis C among prison entrants and a significant proportion of inmates report engaging in behaviours where there is a risk for transmission, particularly sharing injecting drug equipment and receiving tattoos.
While people in custodial settings are in principle entitled to the same level of health care and information as the general community, in practice they are unable to adequately protect their own health due to the current constraints of the prison environment. Research indicates that the prevalence of injecting drug use in custodial settings is very high. In the general community around one percent of people inject, while in custody approximately 25% of inmates continue to inject in extremely hazardous circumstances. Prison inmates have limited access to the means of preventing hepatitis C transmission. Needle and Syringe Programs (NSPs) have not been implemented in any Australian prison. Other harm reduction measures such as peer based drug education and bleach provision are available in some jurisdictions but not all. Therefore, it is unrealistic for educators to provide detailed instruction to inmates on safe injecting practices when there are limited provisions to ensure inmates have the opportunity to implement safe practice.
Due to the fact that safe injecting practices are nearly impossible to achieve in custodial settings, alternative methods of administration should be explored such as smoking, snorting, swallowing or shafting (rectal administration). However, another deterrent to effective harm reduction strategies is the discrepancy in the type of sanctions imposed for injected as opposed to non-injected illicit drug use in custodial settings. It has been suggested that the efficacy in detecting cannabis as opposed to heroin may cause some inmates to switch to injecting routes of drug administration.
There are some provisions to encourage safe injecting in custodial settings such as the provision of bleach and instructions about washing syringes with soapy water.
Inmates with hepatitis C also need to be provided with information on the risks associated with unsafe injecting practices and the potential for re-infection with different hepatitis C genotypes. Evidence suggests that people with hepatitis C who are exposed to potential infectious blood can be infected with more than one genotype at a time, which can impact on the natural history of disease progression and treatment efficacy.
Considering the barriers in custodial settings, it is important that inmates are provided with information on safe injecting in the context of access to NSPs in the post release setting.
Educators need to be aware of the relevance and applicability of information provided to inmates on health maintenance activities, for example, healthy diet, exercise and managing stress. Inmates will have limited control over the food they eat and therefore, need to be provided with information that allows them to make healthy choices from the available food. Discussions about regular exercise and stress management need to be adapted to the context of custodial settings and could provide inmates with useful and tangible health maintenance advice. For example, developing an exercise program that accounts for limited space such as the inmate’s cell or at the gym could be useful.
Education programs need to be tailored to the custodial setting and take into account the resources that are available to inmates. However, people living in custodial settings still need to be equipped with relevant health maintenance information for their return into the community.
Tattooing and body piercing pose a particular problem in custodial settings where these procedures are often performed by untrained operators without access to sterile equipment. In addition, other potential sources of blood to blood contact include using blunt hair clippers, sharing razors injury, self harm, fighting and physical and sexual assaults. Spread of hepatitis C through sexual transmission in the context of sexual assault where blood and skin trauma both occur is a possibility.
Education programs which include practical information about the principles of infection control and all the potential sources of hepatitis C transmission could provide inmates with the ability to reduce the risk associated with blood to blood contact in custodial settings.
People who work in custodial settings may not be interested in learning about hepatitis C beyond worksafe issues. Occupational health and safety is the responsibility of the employee’s organisation, however, hepatitis C educators may be contracted to provide specific training about hepatitis C transmission and prevention and infection control.
Structural barriers may prevent or inhibit inmates from accessing health care including hepatitis C treatment and related specialists services such as testing and monitoring. Availability of antiviral therapy for hepatitis C is variable between the states and territories and between custodial settings in the same jurisdiction. The number of inmates treated in all Australian jurisdictions remains low. Hepatitis C treatment availability is restricted by limited correctional health budgets because the costs of hepatitis C treatment must be carried by State and Territory governments. It is also a policy issue that requires concerted lobbying to improve access to treatment for inmates.
Testing for hepatitis C using PCR technology is also limited for inmates due to financial restrictions, therefore, confirmation of a hepatitis C diagnosis may not be possible in custodial settings. Therefore, educators must consider these barriers when providing inmates with information on accessing hepatitis C treatment. At the same time, it is vital that educators provide inmates with information and guidance on accessing hepatitis C services post release from prison.
While it is important to acknowledge the structural barriers, it is vital that educators advocate for inmates to have access to health care including hepatitis C treatment, hepatitis A and B vaccination and monitoring tests such as PCR and liver function tests whilst incarcerated.
Although it is important to consider the barriers to hepatitis C education in custodial settings and to focus providing relevant information in the context of inmates’ limited access to resources and supports, it is equally as important to provide inmates with information on all aspects of hepatitis C including access to specialist treatment services, NSPs and information and support services for their release into the community. Developing specific education programs that target inmates due for release is one method of ensuring the information is provided to those that need it.
Some inmates may experience hepatitis C education fatigue or overload, believing that they have “heard it all before” and believe they are well informed about hepatitis C. Acknowledging that some inmates are informed about hepatitis C is crucial to avoid fuelling the fatigue and subsequently turning them away from the safety message. At the same time using creative and interactive education strategies such as games, videos and knowledge quiz activities could make learning about hepatitis C more interesting.
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Hellard, M., Crofts, N. and Hocking, J. for the Burnet Institute: Epidemiology & Social Research Unit. (2004). Hepatitis C virus among inmates in Victorian correctional facilities: report of the prevalence of hepatitis C virus and the risk behaviours associated with the transmission of hepatitis C virus in Victorian correctional facilities.
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