AIVL’s new resource ‘Inside Out V2’
AIVL’s new resource ‘Inside Out V2’ is an updated version of two past AIVL resources, ‘Getting Smart on the Inside’ from 2003 and ‘Inside Out’ from 2009. ‘Getting Smart on the Inside’ functioned as a monthly calendar containing various information relevant to drug harm reduction for people who inject drugs (PWID). ‘Inside Out’ functioned as a ‘prison diary/planner’ with a core focus on treatment and testing for Hepatitis C (HCV) and transitional services available to People in Custodial Settings (PICS).
Since then, many advancements have been made in antiretroviral therapy for HCV, as has access to treatment within and outside of custodial settings. In addition, new services, programs, community, and peer-based organisations have emerged that can assist in the transition from prison back into general society and provide education, information and advice on health, housing, and other issues of relevance, particularly for people living with HCV. There are also more gender-specific services for females within or discharging from custodial settings, along with culturally appropriate services for Aboriginal and Torres Strait Islander People, CALD (Culturally and Linguistically Diverse) communities, and the LGBTQI+ community.
The research that went into this resource revealed some concerning statistics and reinforced the need for government bodies to seriously reconsider their current stance on prohibiting needle syringe exchange programs (NSPs) to operate inside prisons and custodial settings, among other harm reduction measures, such as peer education and condom and dental dam distribution to reduce the alarming spread of BBVs and STIs within these settings. Health equity advocacy in this area continues to be a strategic priority for AIVL.
NSPs in prisons
At present, only 8 countries (all of which are in Europe and Asia) implement NSP programs in prisons and custodial settings. In addition, tattoo and body piercing programs have been implemented in various prisons across Europe and Asia. Despite these programs showing resounding success in reducing rates of BBV transmission, there are still no such programs in Australian prisons (Levy & Treloar 2018).
The provision of HCV-specific harm reduction measures is minimal and inadequate in custodial settings in Australia. There is also a significant gap in data available on the number of people living with HCV in custodial settings in Australia. Despite the limited data available, some sources estimate that 22% of the nation’s population in custodial settings is living HCV positive, with a rate of 30% among males and 50% among females (Australian Institute of Health and Welfare, 2020). PWID and Aboriginal and Torres Strait Islander peoples are both overrepresented among the HCV-positive population and in prisons and custodial settings.
45% of prison inmates report a history of injecting drug use, and 12% of PWID in the community are likely to be incarcerated within the first 12 months after first injecting for drug-related crimes (Palmer et al. 2021). Although there is evidence that indicates the frequency of injecting drug use (IDU) decreases during incarceration, the per-episode risk of HCV transmission increases (Lafferty et al. 2019).
Barriers to accessing health care
People in prison are excluded from the Medicare Benefit Scheme (MBS) and Pharmaceutical Benefits Scheme (PBS). One of the dire consequences of this is that there is no sustainable, scalable mechanism for supporting in-reach by primary care providers, despite strong evidence that early contact with primary care after release from prison is associated with better health outcomes. The Federal Health Minister has the authority to end this exclusion under S19(2) of the Federal Health Insurance Act 1973, yet to date, this has never been implemented.
A major barrier to improved health outcomes for people transitioning from prison to the community is continuity of care. This includes continuity of treatment (including medications like opioid therapy), maintenance of rapport with healthcare staff, and transfer of health and medical information about the patient The continuity of HCV treatment between prison and community is suboptimal. The primary reason being that current funding arrangements present a barrier to continuity of care. As such, the government’s decision to continue to exclude people in prison from Medicare and PBS subsidies (in clear contravention of their human rights) undermines their investment in treating HCV in prison.
New advancements, continued exclusion
Whilst one of the major advantages of new DAAs is that the treatment duration is much shorter which means they typically have fewer side effects. However, as most Australian prison systems do not commence treatment for people who may be released before treatment is completed, high proportions of prisoners who are potentially eligible for treatment are excluded because their sentences are too short (this is particularly evident among people convicted of low-level drug and acquisitive crimes, who typically receive shorter sentences). It seems evident that HCV and other BBV and STI infections will continue to have disproportionally high rates among Australia’s prison populations unless there is a full implementation of all harm reduction modalities both in prisons and outside into the general community.
NSPs must be implemented, and treatment services must be made more accessible. The importance of peer education cannot be overemphasised and should be available both during peoples’ time in custody and afterwards, as it provides access to essential information from a trusted source and is cost-effective.
Australian Institute of Health and Welfare 2020, ‘Health of prisoners’ Australian Government. Canberra, Australia.
Levy M & Treloar C 2018, ‘Health protection and Australian Prisons’ Medical Journal of Australia vol.209 no.10 pp. 460-461
Lafferty L; Rance J; Treloar C, 2019, '‘Fighting a losing battle’: prisoners’ perspectives of treatment as prevention for hepatitis C with inadequate primary prevention measures', Drugs: Education, Prevention and Policy, vol. 26, pp. 502 – 507
Palmer A, Papaluca T, Stoové M, Winter R, Pedrana A, Hellard M, Wilson D, Thompson A and Scott N 2021, ‘A costing analysis of a state-wide, nurse-led hepatitis C treatment model in prison’ International Journal of Drug Policy
Butler T, Richters J, Yap L, Papanastasiou C, Richards A, Scheider K, Grant L, Smith A and Donovan B 2010, ‘Sexual Health and Behaviour of Queensland Prisoners’ National Drug Research Institute University of New South Wales.
Article by: Adrian Gorringe – (Project Officer, AIVL)
AIVL is the national organisation representing people who use/have used illicit drugs and is the peak body for the state and territory peer-based drug user organisations.
Jake Docker, CEO, AIVL – email firstname.lastname@example.org