February 2018

The status of blood-borne viruses in Australian prisons

International and Australian research has shown for decades that prisoner populations have higher rates of blood-borne viruses and sexually transmitted infections – chiefly, hepatitis B (HBV) and hepatitis C (HCV) – than the general community.

“In Australia there are about 50-60,000 people are put into prison each year. Across the country, broadly, about 25 per cent of those prisoners have chronic cases of HBV. That’s at least 10,000 people. In terms of HCV, the incidence is higher again – between 30 and 40 per cent of prisoners,” says Professor Andrew Lloyd, Head of the Viral Immunology Systems Program at Sydney’s Kirby Institute. He’s an infectious disease physician, and has provided hepatitis support to the prisons in New South Wales for decades.

Andrew says certain communities face a higher risk of hepatitis than others.

“Hepatitis in general is higher in women than men,” he explains. “In the Northern Territory, where the prisoner population is heavily Indigenous, the rates of HCV are 10 to 12 per cent higher- a statistic that’s fairly consistent across the country. The rates in immigrant inmates, particularly those from South East Asia, are also high.”

There are a number of reasons hepatitis C rates are higher inside a typical prison environment: amateur tattooing; sexual intercourse; and blood contact as a result of violence. The biggest contributor, however, is the injection of drugs.

Heroin, methamphetamine and methadone are available; smuggled by prisoners, visitors, guards and other staff. But injecting equipment is largely unavailable; so needles and syringes are widely shared, ripe for facilitating spread of blood-borne viruses.

Prisons and prisoner health have always been complicated and difficult areas, both in terms of policy and service provision. But work is being done towards making inroads. In Victoria, the Statewide Hepatitis Program (SHP) was developed in 2015 by Melbourne’s St Vincent’s Hospital in cooperation with the state government. All Victorian prisoners are now screened for hepatitis when entering prison or when relocated. Nurses and hepatologists visit each prison every 2-4 weeks to conduct clinical assessments.

As of 30 September 2017, 953 prisoners had commenced hepatitis C treatment, and of those, 364 prisoners are already considered cured. A cure is defined by a specific blood test being negative at 12 weeks post treatment completion. (reference: https://www.gayletierney.com.au/prisoner-hepatitis-treatment/ )

It was in October 2017 that the Andrews’ government would renew the initiative for another two years.

The program is a great opportunity to treat people in prisons, where there’s a high incarceration rate for drug-related crimes.

Professor Alex Thompson

Professor Alex Thompson

“The program is a great opportunity to treat people in prisons, where there’s a high incarceration rate for drug-related crimes,” says SHP director Professor Alex Thompson.

“Feedback from prisoners has been positive – almost universally. The engagement with the program has been very good. We hope it’ll underline all the work being done to reduce hepatitis in Victoria.”

As prison management and prison health falls under the jurisdiction of state governments, the St Vincent’s program is unable to expand into other Australian states or territories. However, Alex attended a national workshop earlier this year – co-organised by Alex, Andrew and others – looking at prisoner health.

“There were submissions from government and community representatives from each state to discuss the different programs,” Alex says. “It was a great chance to sit down and see what was working and what wasn’t working. I hope that will have some positive outcomes, and that the great outcomes we’re having here in Victoria can be replicated in other states.”

It appears there are. In the ACT, massive inroads have been made in recent years. “The ACT has virtually eliminated HCV from the prisoner population,” says Professor Michael Levy, director of the state’s Justice Health Service. Figures are showing new drugs have helped reduce the number of HCV-positive inmates from 30 per cent of the prison population in 2010 down to just three per cent this year.

But Michael says to keep the numbers down, the National Prison Entrants’ Blood-borne Virus Survey (NPEBBVS) – a questionnaire on risk behaviours, and a blood and urine test carried out by nurses – is going to be crucial.

“The NPEBBVS is one of only two public health data collections (the other is run by the Australian Institute of Health and Welfare) that acknowledge the integral part of public health is prisoner health,” Michael explains.

“Prison entrants are the canaries in the coal mine – early warning populations for health issues of critical importance to the community. These data collections are unique internationally. If they were allowed to lapse, critical insights into the public health of Australia would be lost.”

While treating prisoners is yielding positive outcomes for now, Andrew is calling for the focus to shift toward hepatitis prevention. He says developing new preventative strategies is what will ultimately beat the spread of the virus.

“Many inmates are coming into prisons uninfected, and leaving less than a year later infected. The small amount of research we have looking into prevention [from Andrew’s own research] suggests our older prevention strategies – such as cleaning injecting devices with bleach and distributing condoms – don’t work,” Andrew says.

“You could theoretically implement needle exchange programs, but there isn’t much political support for that issue. We need to be pushing to scale up our efforts as high as possible.”

Evan Young