HIV and hepatitis C: Diseases that run rampant in Canadian prisons

In April, the Corrections Service of Canada released a report which revealed considerably higher rates of HIV infections among inmates in federal prisons than had been previously officially acknowledged. Indeed, the reported rate of 4.6 per cent, based on a 2007 survey of prisoners, was more than twice the previous official estimates, and the reported rate of hepatitis C -- a staggering 31 per cent of prisoners -- was also higher.

'If a town of that size had rates like these, it would be treated like a public health emergency,' says Seth Clarke, federal community development co-ordinator with the Prisoners' HIV/AIDS Support Action Network.

A veteran of the Canadian prison system, Douglas Foreman calculates that he's been incarcerated in 11 different institutions since he was first sentenced in 1978.

It was in his first year in prison -- Archambault, at the time a maximum security penitentiary in Quebec -- that he participated in an activity that was common among his peers.

"I injected once with a fellow inmate. He was sitting beside me and I watched him prepare the hit then he prepared one for me," Foreman said in a telephone interview from his current home, La Macaza Institution, also in Quebec.

"I didn't even know I would shoot up. He injected me. I would never have known how to."

Foreman is an unusual guy -- an HIV-positive man who is out as a homosexual in prison, and a harm reduction activist who is also pushing for more comprehensive healthcare in prisons.

The 52-year-old lifer never mastered correct technique; that was the only time he injected drugs. But Foreman, who contracted HIV through unsafe sex in the mid-1980s, was in 1991 diagnosed with hepatitis C (HCV, then known as non-A non-B hepatitis). That made him an early member of the soon-to-grow ranks of co-infected Canadian inmates.

Today, up to 80 per cent of inmates with HIV also have HCV, experts estimate. And these days, it is the liver failure associated with untreated HCV -- not the opportunistic infections linked to AIDS -- that is the leading cause of death for the co-infected.

Canadian prisons are the epicentre for HCV and HIV in this country. Prisons lie along the tension-filled fault line of two social tectonic plates: inmate culture -- a hard-edged environment that includes violence, despair and drugs -- and a prison system that has failed to implement adequate measures to help reduce the risk transmitting the viruses. The consequence is rates of HCV that epidemiologist estimate to be at least 20 times higher in the prison than the general Canadian population, and rates of HIV that are 10 to 20 times higher.

For almost two decades, AIDS organizations, doctors, and researchers have been raising the alarm about HIV rates in prison and, more recently, the skyrocketing rates of HCV, a disease which spreads more easily and rapidly than HIV. They visit prisons regularly, push to do independent research inside, and document conditions in thoughtful and thorough reports.

These advocates underscore the urgent need to introduce needle exchange programs to reduce transmission rates in prison -- to this date, there are no such programs in Canada. They point to the costs associated with HIV and HCV treatment compared to those for prevention, and to the public health implications of prisons as a breeding ground for infections that spread as inmates return to the community.

But the battle is uphill because of changes of government (with the attendant need to educate newly-minted politicians to the issues), opposition to needle exchange programs from the Union of Canadian Correctional Officers, and the lack of sympathy for inmates exhibited by politicians and much of the general public.

"When you mention prisons, the first thing people think of is Paul Bernardo or Clifford Olson, but the vast majority of inmates are chronic addicts and so many have been abused as children," says Diane Smith Merrill, an HIV/AIDS outreach worker who visits the eight prisons in the Kingston, Ontario, area.

"Just because the walls are there, doesn't mean that inmates are somehow alien," she says, arguing that "all of us are helped" if prisoners are provided with access to harm reduction measures, mental health and addiction services and, when they are released, decent housing.

HCV is so rampant in prisons that it amounts to "a new epidemic," says Dr. Peter Ford, a specialist who has treated HIV-positive prisoners in Ontario for more than two decades.

Ford, whose ground-breaking early research drew attention to the prevalence of HIV in Canadian penitentiaries, believes that about 40 per cent of the approximately 13,000 federal prison inmates in Canada are infected with HCV.

And, alarmingly, research shows that some inmates who have undergone the costly, time consuming and difficult treatment for HCV become re-infected with the virus.

"We do a good job of identifying and treating HCV in prison," says Dr. John Farley, a Vancouver-based specialist who treats HIV and HCV patients both in prison and in the community. "But the fact is that a relatively higher number than we see in the community are becoming re-infected because we are not addressing the in-prison risk factors, mainly drug addiction issues, that lead to this. "

Ford, who has retired from his regular medical practice but continues work a few days a month treating his HIV-positive patients in Ontario federal institutions, traveled to Ottawa on Nov. 5th last year in a bid to educate members of the federal Standing Committee on Public Safety and National Security about the issues in prisons.

"So what we're looking at," he told the politicians, "is a problem with a communicable blood-borne disease, which is being imported into the prisons and is proliferating within the prisons."

The situation "has some very serious public health overtones because these folks are going to get out and they're going to go on doing what got them infected in the first place." As well, like HIV, HCV "can be spread by sexual transmission -- just under 10 per cent is spread by sexual transmission -- so the risk is going to move beyond the intravenous drug users to their sexual partners."

Canada is just beginning to reap the results of a wave of HCV infections that grew in the early 1990s, when it was known as non-A non-B hepatitis. Untreated, HCV takes 10 to 20 years to progress to liver failure, though that process can be speeded up with alcohol use, says Ford. "Corrections is going to find itself looking after people with terminal liver failure, and this is a very expensive prospect," he told the committee.

That inmate HIV and HCV infection rates are so much higher than those in the general Canadian population shouldn't be a surprise for a number of reasons:

• Physical and emotional conditions inside prisons foster the impulse to escape through injection drug use, typically with shared needles, and risky sex. "It's a stress-filled environment," says Foreman.

• A significant proportion of inmates are doing time for drug-related offences. The Public Health Agency of Canada figures indicate that almost 70 per cent of prisoners have substance abuse problems.

• Injection drug use is common in Canadian prisons, yet the system has not allowed the introduction of needle exchange programs which have been successful at holding down infection rates in the community, are in place in prisons in many other countries, and have been endorsed for use in prisons by groups such as the Canadian Medical Association.

• The stigma associated with HIV means inmates are reluctant to be tested inside the prisons, where confidentiality is hard to maintain, and HIV-positive addicts who do know their status are likely to be silent if their condition jeopardizes their access to shared drugs.

• The availability of already officially-sanctioned prevention and harm reduction measures, as well as treatment -- particularly for HCV and to deal with side effects of drugs -- varies widely throughout the prison system.

Meanwhile, insiders say the fallout from the 2008 ban on tobacco in prisons has led to an increase in high-risk activities, and proposed federal legislative changes that restrict prisoner rights will only increase tension levels within the institutions.

But already the risk of violence is a constant inside prison. "We are all aware of conflicts," Foreman explains. "It escalates our stress and anxiety and you never know what will happen. There could be a fight with knives or other homemade weapons, we could get locked down and everybody pays. Just today, three guys were brought to the hole, and we don't know who or why."

Some inmates "turn to self mutilation and some become quite self destructive. [Intravenous] drug use is one way of sabotaging their own existence."

In this climate, drugs are used for managing physical, emotional or psychological pain, says Seth Clarke, federal community development co-ordinator with the Prisoners' HIV/AIDS Support Action Network (PASAN). Because the drugs are contraband, there's pressure to use them up quickly in order not to be caught and face consequences such as a lengthened sentence, he notes Seth Clarke. (Though officially an Ontario organization, PASAN is "de facto seen as a federal one," says Clarke, since it is the only AIDS service organization whose sole mandate is to advocate on behalf of prisoners.)

Prisoners "don't have access to sterile equipment. Normally, in our harm reduction work we would stress the importance of not sharing needles, but we absolutely know that inmates share needles, and they don't have a choice. Telling them not to inject is not a conversation starter, so we try to tell them how to take care of the needle" and avoid developing open sores that would increase the opportunities for infection.

Meanwhile, the official position of Public Safety Canada is: "The Government of Canada has a zero tolerance policy for drugs in our institutions. Providing needles for illicit drug use runs counter to that policy."

Spokesperson David Charbonneau adds: "Illicit drugs in federal prisons compromise the safety and security of correctional staff as well as our communities. Illicit drug use undermines the success of rehabilitation programming."

In British Columbia, Dr. Farley has observed the extreme pressure on prisoners to conform and join cliques. "Many of them have mediocre coping skills, easily fall in line and then put themselves at risk. I would say that at least 15 to 20 per cent [of inmates] started injection drug use in prison."

Still, outsiders are usually surprised at the extent of injection drug use in prison.

Dr. Ford says it was likely the introduction of random urine testing that boosted the numbers of injection drug users. "Drug use in prisons has changed enormously over the years I have been doing this." His research in one federal prison showed that the proportion of those injecting drugs more than doubled to 25 per cent between 1994 and 1998, after the urine testing was introduced.

While marijuana stays in the system for a couple of weeks, and thus can be detected through the urine tests, drugs such as cocaine and heroin are cleared quickly, he explains. "We think that is what happened. People turned to harder drugs. You couldn't give marijuana away today in prisons doing regular urine testing."

According to Foreman and others, about 40 per cent of the drugs in prison are smuggled in by correctional officers, either because the guards are making extra money or they are being blackmailed by inmates. The other 60 per cent comes in through visits to prison and by prisoners returning from community service, and these drugs are usually "hidden in body cavities or ingested," Foreman says.

Foreman witnessed and applauded the introduction into prisons of harm reduction measures, including condoms and dental dams for safer sex and bleach for cleaning needles, in the early 1990s. But the bleach for needles is not effective at killing the hep C virus, Ford says, and research by the Canadian HIV-AIDS Legal Network shows that even those approved harm reduction approaches are not consistently available in prisons in Canada.

Research consistently shows that inmates "have substantially higher prevalence rates of mental health and substance use problems compared with the general population," and inmates have a statutory right to an "appropriate level of high-quality mental health and substance use services, states Mental Health and Substance Abuse Services in Correctional Settings, a 2009 report from the University of British Columbia based International Centre for Criminal Law Reform and Criminal Justice Policy.

But despite this, treatment to help inmates with drug addiction is inadequate. "There's a big overlap between mental illness and drug addiction; you can't separate the two," Ford told the federal committee. He added that there's not much attempt to address the addiction issues: "Addiction is a crime, as far as Corrections is concerned. It is in fact an illness, in the same way alcoholism is an illness."

Some programs do exist to help inmates deal with addiction problems, says Farley. "But we need to make more services available -- we have to evaluate them, build on the ones that work and discard the others."

The availability of treatment for HCV and for the side effects from the drugs to deal with HIV and HCV is another concern for outreach workers and physicians. "Unfortunately there is not as much emphasis on treating hep C in prison as there is on treating HIV. I have a waiting list for inmates who require treatment for hep C," says Dr. Farley. "Ironically, the prison setting is very good" for treating HCV because it's a stable setting, compared to the community, where unstable living conditions frequently present challenges, he says.

Meanwhile, interpretation of the criteria for receiving HCV treatment, which costs at least $20,000 a person, appears to vary among jurisdictions. For example, in British Columbia, inmates who are released can continue treatment in community, Dr. Farley says, while in Ontario Dr. Ford says inmates aren't eligible if they are due for parole in the next three months since it is a six-month course of treatment.

Even if eligible, some inmates refuse HCV treatment since "it can make you weak, and the last place you want to be weak is inside," says Smith Merrill. However, she agrees with Dr. Farley: "Some of them [inmates with HIV] actually do better inside -- they get meds, get meals and get rest. But that is such a terrible statement about our society, that people physically do better inside because of the lack of housing and unstable conditions outside."

The 2008 ban on tobacco use in federal prisons has also had far-reaching effects. Tobacco has replaced drugs as the main contraband coming into prison, creating other "knock-on problems," as Ford says.

Without cigarettes to help calm their nerves, and because of the scarcity of illegal drugs, inmates are becoming more desperate to get high. As a result, many inmates with HIV and HCV -- who take medications such as Gravol (dimenhydrate) to counteract nausea, the antidepressant bupropion (Welbutrin), and gabapentin (Neurontin) to treat neuropathy -- are being intimidated into handing these over to fellow prisoners to inject.

"What I hear and see is much more abuse of medications. People are injecting garbage like Gravol, and this didn't use to happen. Addicts will inject anything that gives them a high," Ford adds.

What this means for Ford and Farley is that, increasingly, prescriptions they write are being ignored by the prison doctors, who know what goes on and who have the final say on which prescriptions are filled. "We've seen a big change over last year on what is available, in prescriptions but also nutritional supplements and vitamins." " says Farley. "Just today I had to write a letter to justify treatment" for the side effects from HIV meds.

The tobacco ban may also be having other unintended effects. "Tobacco was the jailhouse currency," Doug explains, "Now any tobacco that comes in is sold at astronomical prices. What has taken its place [in everyday bartering] is sexual services and ‘boy Friday' services."

Given the rates of HIV and HCV in prisons "we should go where the problem is and spend significantly more resources to address the issues," he says. "The community has to recognize that part of our community is prisons and we are creating health issues for everyone by the way we deal with inmates."

What is to be done? Imprison fewer people, offer more effective drug addiction programs in prisons, address the total needs of inmates and introduce needle exchange services, say Dr. Ford and Dr. Farley. End the nightmare of inadequate housing for prisoners when they are released, says Smith Merrill.

For his part, Foreman was diagnosed with full-blown AIDS in mid-December last year. "Rates of HIV in prison are much higher than people say. I was in a minimum security prison three years ago where there were 250 inmates. At a seminar on HIV, I declared who I was and afterwards 25 men came up and told me they were also HIV positive."

But Foreman's current preoccupation is his fight to be treated for his HCV. He knows that, untreated, it is the HCV he acquired back in 1991 that poses the greatest risk to health his today.

The following three articles can be found here [1]:
Under the Skin: A People's Case for Prison Needle and Syringe Programs. 2010. Canadian HIV/AIDS Legal Network.
Clean Switch: The Case for Prison Needle and Syringe Programs in Canada. 2009. Canadian HIV/AIDS Legal Network.
Hard Time: HIV and hepatitis C Prevention Programming for Prisoners in Canada. 2007. Canadian HIV/AIDS Legal Network and Prisoners' HIV/AIDS Support Action Network (PASAN).

Summary of Emerging Findings from the 2007 National Inmate Infectious Diseases and Risk-Behaviours Survey is available by clicking here [2].

Ann Silversides is a freelance journalist based in Perth, Ontario.

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