BMJ No 7099 Volume 315
Papers Saturday 5 July 1997
Harm reduction measures and injecting inside prison versus mandatory drugs testing: results of a cross sectional anonymous questionnaire survey
A Graham Bird, Sheila M Gore, Sharon J Hutchinson, Stephanie C Lewis, Sheila Cameron, Sheila Burns on behalf of the European Commission Network on HIV infection and hepatitis in prison
See Papers p 18, p 30, Letters p 61, and Personal view p 65
Abstract
Objectives: (a) To determine both the frequency of injecting inside prison and use of sterilising tablets to clean needles in the previous four weeks; (b) to assess the efficiency of random mandatory drugs testing at detecting prisoners who inject heroin inside prison; (c) to determine the percentage of prisoners who had been offered vaccination against hepatitis B.Design: Cross sectional willing anonymous salivary HIV surveillance linked to a self completion risk factor questionnaire.
Setting: Lowmoss prison, Glasgow, and Aberdeen prison on 11 and 30 October 1996.
Subjects: 293 (94%) of all 312 inmates at Lowmoss and 146 (93%) of all 157 at Aberdeen, resulting in 286 and 143 valid questionnaires.
Main outcome measures: Frequency of injecting inside prison in the previous four weeks by injector inmates who had been in prison for at least four weeks.
Results: 116 (41%) Lowmoss and 53 (37%) Aberdeen prisoners had a history of injecting drug use but only 4% of inmates (17/395; 95% confidence interval 2% to 6%) had ever been offered vaccination against hepatitis B. 42 Lowmoss prisoners (estimated 207 injections and 258 uses of sterilising tablets) and 31 Aberdeen prisoners (229 injections, 221 uses) had injected inside prison in the previous four weeks. The prisons together held 112 injector inmates who had been in prison for more than four weeks, of whom 57 (51%; 42% to 60%) had injected in prison in the past four weeks; their estimated mean number of injections was 6.0 (SD 5.7). Prisoners injecting heroin six times in four weeks will test positive in random mandatory drugs testing on at most 18 days out of 28.
Conclusions: Sterilising tablets and hepatitis B vaccination should be offered to all prisoners. Random mandatory drugs testing seriously underestimates injector inmates' harm reduction needs.
Introduction
Willing anonymous salivary HIV (WASH) surveillance in Scottish
prisons provided consistent estimates in 1991-5 of the prevalence of
risk behaviours inside and outside prisons, of their geographic and
sentencing correlates, and of the prevalence of HIV among inj Questions were added in 1996 to evaluate prisoners' access to harm
reduction measures, including hepatitis B vaccination. Sterilising
tablets have been available to all Scottish prisoners since December
1993 for purposes including the cleaning of needles and works. But are
they being used for the intended harm reduction purpose? Random
mandatory drugs testing has been challenged as "a means of gathering
information."(7, 8) We used volunteered information on the
frequency of injecting inside prison in the previous four weeks to
estimate the likely efficiency of random mandatory drugs testing at
detecting inmates who inject class A drugs such as heroin inside
prison. So far as we know this is the first such
study.
Willing anonymous salivary HIV surveillance was conducted with
ethical approval and as described(1-3, 9) by external teams
of volunteers at Lowmoss prison on 11 October and at Aberdeen prison on
30 October 1996. Saliva samples were tested for HIV antibodies at the
regional virus laboratories in Glasgow and Edinburgh respectively. On
the surveillance days AGB briefed prisoners about why the survey was
being performed, and explained the linkage of questionnaire and saliva
sample by sealed number pair (chosen at random by the
prisoners)(2) and that the survey and research team were
unconnected with random mandatory drugs testing (due to be introduced
to both prisons in 1997). The participation rate was 94% (293 of 312 prisoners) at Lowmoss
and 93% (146/157) at Aberdeen (table 1). Two Lowmoss prisoners (both
injectors) tested positive for HIV antibody. HIV prevalence was 0.7%
overall and 1.7% (2/116) for injector inmates. At Aberdeen one saliva
sample was insufficient and two prisoners (both non-injectors and
heterosexual, one known to the p
Table 2 gives prisoners' answers to questions about injecting, use of
sterilising tablets, and uptake of he
Injecting drug users and injecting inside prison Forty two Lowmoss prisoners (15% of all inmates; 37% of injector
inmates) and 31 Aberdeen prisoners (22% of all inmates; 58% of
injector inmates) had injected in prison in the previous four weeks.
The pr
Sterilising tablets and hepatitis B vaccination
Only 4% of Lowmoss's inmates (11/262) and 5% of inmates of Aberdeen
prison (6/133) had ever been offered vaccination against hepatitis B.
The low reported offer rate is the more surprising because 43% of
convicted prisoners in Lowmoss and Aberdeen pr Results at Aberdeen prison indicated that local injecting drug use
was as prevalent but more recent than in Glasgow. Injecting behaviour
in Aberdeen prison m
Use of sterilising tablets Hepatitis B immunisation
Frequency of injecting inside prison: implications for random
drugs testing Random mandatory drugs testing is therefore likely seriously to
underestimate prisoners' injection related drug use problems.
Underestimation will entail underresourcing of these and other prisons
in respect of the healthcare and drug reduction needs of their injector
inmates.
Obligations to injector inmates If the current limited access to harm reduction measures is perpetuated
it represents a serious gulf between the standards of health care and
public health available to the same individuals in prison and outside.
Prison medical service policy promotes equality but is short on
delivery.(21)
We thank HM prison governors Mr Bill Middleton (Lowmoss) and Mr
John Bywalec (Aberdeen) and their officers for welcoming WASH
surveillance, for the efficiency of the escort, and for domestic
arrangements for the volunteer team; Mrs Linda McDonald and Mrs Karen
Wilson, and Mr Tom Shaw, for overseeing saliva samples at the regional
virus laboratories in Gl
Funding: Medical Research Council (grant G9102632) and
the European Commission (grant DGV, SOC-95-202181-05F02).
(Accepted 25 April 1997)
Churchill Hospital, MRC Biostatistics
Unit, MRC-BIAS, Regional Virus Laboratory, Regional Virus
Laboratory,
Correspondence to: Dr Gore
(sheila.gore@mrc-bsu.cam.ac.uk)
References
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salivary HIV (WASH) surveillance studies and self-completion
risk-factor questionnaire in establishments of the Scottish Prison
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(ANSWER) 1995;39:1-4.
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surveillance in Saughton prison, Edinburgh. AIDS
1992;6:725-33.
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HIV surveillance with risk factor elicitation at Scotland's largest
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Drug injection and HIV prevalence in inmates of Glenochil prison.
BMJ 1995;310:293-6.
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Aberdeen. Scotsman 1997 Jan 14:13.
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14 Taylor A, Goldberg D, Emslie J, Wrench J, Gruer L, Cameron S,
et al. Outbreak of HIV infection in a Scottish prison.
BMJ 1995;310:289-92.
15 Crofts N, Stewart T, Hearne P, Ping X Y, Breshkin A M, Locarnini
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17 Task Force to Review Services for Drug Misusers. Report
of an independent review of drug treatment services in England.
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19 Nelles J, Fuhrer A. Drug and HIV prevention at
Hindelbank penitentiary. Abridged report of the evaluation
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20 Jurgens R. HIV/AIDS in prisons: final report.
Montreal: Canadian HIV/AIDS Legal Network and Canadian AIDS Society,
1996.
21 Her Majesty's Inspectorate of Prisons for England and Wales.
Patient or prisoner? A new strategy for health care in
prisons. London: Home Office, 1996.
Methods
Results
Table 1 - Composition of study groups in HM prisons
Lowmoss and Aberdeen
Lowmoss
Aberdeen Total No of
prisoners 312 157
Total No of respondents 293 146
Response rate (%) (94) (93) No
(%) excluded for failing logical checks 7
(2) 3 (2) No completing valid
questionnaire 286 143 Table 2 - Results of questionnaire survey at Lowmoss
and Aberdeen. Figures are numbers (percentages) of prisoners Lowmoss Aberdeen
All participants (n=286) Injector inmates
(n=116) All participants
(n=143) Injector inmates (n=53)
Q9 In which year did you first inject drugs
(excluding insulin)? No of
non-respondents 4 0 1 0
Never injected 166
(59) 0 89
(63) 0 1982 or earlier 20
(7) 20 (17) 6
(4) 6 (11) 1983-5 27
(10) 27 (23) 2
(1) 2 (4) 1986-8 17
(6) 17 (15) 4
(3) 4 (8) 1989-91 17
(6) 17 (15) 9
(6) 9 (17) 1992-4 19
(7) 19 (16) 13
(9) 13 (25) 1995 or later 16
(6) 16 (14) 19
(13) 19 (36) Q10 When did you last
inject drugs before coming into prison this time (including remand
prison)? No of
non-respondents 7 3 2 1
Never injected 166
(59) 0 92
(65) 3 (6) On day came into prison 21
(8) 21 (19) 15
(11) 15 (29) On day before coming into
prison 40 (14) 40
(35) 12 (9) 12 (23)
In week before coming into prison 12
(4) 12 (11) 6
(4) 6 (12) Between one and four weeks before
coming into prison 7 (3) 7
(6) 6 (4) 6 (12)
More than four weeks before coming into prison 33
(12) 33 (29) 10
(7) 10 (19) Q11 Have you ever
injected while inside? No of
non-respondents 10 0 1 0
Yes 66 (24) 66
(57) 39 (27) 39 (74)
No 210 (76) 50
(43) 103 (73) 14 (26)
Q12 Did you start injecting while
inside? No of
non-respondents 19 1 6 1
Yes 5 (2) 5
(4) 10 (7) 10 (19)
No 262 (98) 110
(96) 127 (93) 42 (81)
Q14 How many times have you injected drugs in
prison in last four weeks? No of
non-respondents 12 2 1 0
Never 232 (85) 72
(63) 111 (78) 22 (42)
One or more times 42 (15) 42
(37) 31 (22) 31 (58)
Q15 How many times have you used sterilising
tablets to clean needles or works in prison in last four weeks?
No of
non-respondents 15 3 3 0
Never 229 (85) 71
(63) 112 (80) 26 (49)
One or more times 42 (15) 42
(37) 28 (20) 27 (51)
Q18 Have you ever had an acute attack of
hepatitis or yellow jaundice? No of
non-respondents 3 2 4 0
Yes 31 (11) 27
(24) 7 (5) 7 (13)
No 252 (89) 87
(76) 132 (95) 46 (87)
Q19 Have you ever been offered vaccination
against hepatitis B? No of
non-respondents 24 11 10 1
Yes, and completed full course of three
injections 6 (2) 4
(4) 2 (2) 1 (2) Yes,
but received only one or two injections 3
(1) 1 (1) 2
(2) 2 (4) Yes, but declined offer 2
(1) 1 (1) 2
(2) 1 (2) No, never offered 251
(96) 99 (94) 127
(95) 48 (92)
Forty five per cent (52/116) of Lowmoss's injecting drug users
began their injecting career in 1989 or later compared with 77%
(41/53) of Aberdeen prison's injector inmates, 19 of whom had started
injecting very recently (in 1995 or later). Fifty four per cent
(61/113) of Lowmoss's injecting drug users had injected on the day of
entering prison or the day before, as had 52% (27/52) of injecting
drug users at Aberdeen. Fifty seven per cent (66/116)
of Lowmoss's injecting drug users had ever injected inside prison but
only five (4%) had started to inject inside; at Aberdeen these figures
were 74% (39/53; P<0.03) and 19% (10/52; P<0.01).
Injector inmates' answers to questions about both injecting in
prison and the use of sterilising tablets to clean injecting equipment
in the past four weeks were broadly concordant (Lowmoss: estimated 207
injections and 258 uses of sterilising tablets to clean needles or
works; Aberdeen: estimated 229 injections and 221 uses of sterilising
tablets) (table 3). In both prisons local arrangements satisfactorily
allowed prisoners to access sterilising tablets for the harm reduction
purpose intended.Table 3 - Frequencies of injecting and of using
sterilising tablets among injector inmates at Lowmoss and Aberdeen No of times injected in past four
weeks No of times used sterilising tablets
to clean needles or works in prison in past four weeks
Never Once 2-5 6-10 11-20 21-50
Never 85 3 6 0 1 1
Once 2 5 5 2 1 0
2-5 3 0 20 2 0 0
6-10 1 2 5 13 1 1
11-20 0 0 0 1 2 1
21-50 0 0 0 0 1 0
>50 1 0 0 0 0 0
Data on these questions were missing for four Lowmoss
prisoners.
Discussion
In contrast with England and Wales,(11, 12) the
Scottish Prison Service has provided sterilising tablets in accordance
with the World Health Organisation's recommendations(13)
since December 1993.(14) Prisoners regularly used these
tablets to clean injecting equipment.
In contrast with almost universal acceptance by prison officers,
at most 5% of the inmates studied had ever been offered immunisation
against hepatitis B. Similarly low rates were discovered in audit
studies in Oxford and Anglia prisons (J Cassidy, personal
communication) and in over 3500 prisoners in Victoria,
Australia,(15) where only 5% of non-immune prisoners had
been immunised. Other studies suggest that low awareness(16)
and unwillingness (M Rotliy, personal communication) contribute to low
immunisation uptake by injecting drug users. Specific resources need to
be allocated to prison medical services, general practitioners, and
drug treatment centres for universal offering of hepatitis B
immunisation to prisoners and former prisoners as
routine.(17, 18)
The combined data showed that 51% (57/112) of injectors who had
been in prison for more than four weeks had injected in the past four
weeks while inside. Their mean number of injections was 6.0 (SD 5.7).
If we assume that the substance injected remained in the urine for
three days (as occurs with heroin), then these prisoners would be
liable to have a positive result in random mandatory drugs tests
on a maximum of 18 days out of 28. If, however, random mandatory drugs
testing did not operate at weekends, as in England and Wales, and
prisoners could organise their injecting accordingly (for Friday
evenings and one Tuesday and one Wednesday evening, say), then
they may test p
The current extent of injecting among inmates of our prisons
demands that we think again about society's obligation to these
addicted people. As they continue to take class A drugs by injection
inside prison, we must enable them to do so more safely. This requires
that ready access to sterilising tablets should be extended to all
prisoners in Britain, not just to those in Scotland. It also requires
that all prisoners who could benefit from substitute prescribing should
receive it, the primary goal being to help them stop injecting; drug
reduction is a secondary objective. If sterilising tablets are used
suboptimally they may not protect absolutely against bloodborne virus
transmission; hence prisoners, like other citizens in Britain, need
access to various harm reduction measures. Some are denied methadone,
all are denied needle exchange. Prison needle exchange has been
pioneered in Switzerland,(19) is being evaluated in Germany,
and is under consideration in Canada.(20)
Key Messages
Half of injector inmates of two Scottish prisons who had been
in prison for more than four weeks had injected in the previous four
weeks - an average of six times Injector inmates used sterilising tablets to clean injecting
equipment as often as they injected Only 4% of inmates had ever been offered vaccination against
hepatitis B Vaccination against hepatitis B and sterilising tablets are
prisoners' rights Random mandatory drugs testing is likely to detect only one
third to two thirds of heroin injectors in prison and so seriously
underestimates injector inmates' drug reduction needs
Conflict of interest: None.
Oxford OX3 7LJ
A Graham
Bird, consultant immunologist
Cambridge CB2 2SR
Sheila M Gore, senior
statistician
Edinburgh EH9
3JN
Sharon J
Hutchinson, statistician
Stephanie C
Lewis, statistician
Glasgow G20 9NB
Sheila Cameron, clinical
virologist
Edinburgh EH10 5SB
Sheila
Burns, clinical
virologist
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