Prevalence of HIV and injecting drug use in men entering Liverpool prison

BMJ 1997; 315 doi: (Published 05 July 1997) Cite this as: BMJ 1997;315:30
  1. Mark A Bellis, senior lecturera (m.a.bellis{at},
  2. Andrew R Weild, research associatea,
  3. Nick J Beeching, senior lecturerb,
  4. Ken J Mutton, consultant virologistc,
  5. Qutub Syed, regional epidemiologistd
  1. a Sexual Health and Environmental Epidemiology Unit, Department of Public Health, University of Liverpool, Liverpool L69 3GB
  2. b Liverpool School of Tropical Medicine, Liverpool L3 5QA
  3. c Liverpool Public Health Laboratory, Liverpool L9 7AL
  4. d Communicable Disease Surveillance Centre (North West), Public Health Laboratory, Liverpool L9 7AL
  1. Correspondence to: Dr Bellis
  • Accepted 21 May 1997


Studies in countries other than England and Wales suggest that a comparatively high proportion of people entering prison have a history of injecting drug use before imprisonment and that drug use does not always stop once people are incarcerated.1 Consequently the sharing of injecting equipment by drug users in a Scottish prison led to the infection of at least 13 inmates with HIV.2 Currently, little information is available on the number of drug users entering prisons in England and Wales, their HIV prevalence, or their levels of injecting drug use once incarcerated. Therefore, discussion about the potential for injecting related HIV transmission within these prisons often requires extrapolation from data gathered in other countries.3 To examine the potential role of English prisons in drug related transmission of HIV and other bloodborne viruses we administered questionnaires to new prisoners at a large men's prison and tested them for HIV antibodies.

Subjects, methods, and results

We defined new prisoners as men arriving at prison for the first occasion relating to their current remand (that is, awaiting trial or sentencing) or sentence. Over 10 weeks in early 1996, 969 such prisoners at reception to HM prison, Liverpool, were asked to complete a short, anonymous questionnaire on their drug related and sexual behaviour and provide a saliva sample.4 Though participation was voluntary, compliance was high—921 (95.0%) subjects completed all or part of the questionnaire and 905 (93.4%) provided a matched saliva sample, of which one tested positive. Most participants (881/906; 97.2%) originated within the British Isles, and ages ranged from 21 to 70 years (median 28), 63.2% (577/913) of subjects being aged 30 or under. Prisoners on remand accounted for 43.2% (396/916) of the sample. Previously 47.2.% (416/882) of subjects had been incarcerated before the age of 21 and 66.8% (588/880) had been in an adult prison.


Of 219 subjects with a history of injecting drugs and incarceration, only 36 (16.4%; table 1) had ever injected in prison. Though this suggests that imprisonment reduces injecting behaviour, for those who continue to inject while incarcerated levels of risk behaviour are substantially increased. Thus the prevalence of ever sharing injecting equipment rose from 31.5% (82/260) among all new arrivals with a history of injecting to 55.6% (20/36) sharing when injecting while incarcerated (χ2=8.08; P<0.005). Furthermore, men who had ever injected as well as current injectors (that is, those who had injected in the past month) were disproportionately represented among those returning for second (26.0% ever, 19.7% current) or further sentences (42.0% ever, 29.9% current). Consequently, incarceration may reduce the numbers of subjects injecting drugs but only at the cost of increasing the risks of infection among those who inject while imprisoned and without necessarily preventing relapse into injecting on release.

Table 1

Summary of injecting drug use behaviour by new arrivals at HM prison, Liverpool. Figures are numbers (percentages) of subjects

View this table:

Of roughly 7000 men received into HM prison, Liverpool, every year, over a quarter (table 1) may previously have injected drugs. In this survey only one such subject was HIV positive (an injecting drug user currently unaware of his infection), reflecting low levels of HIV in the local injecting communities.5 However, the frequent exchange of subjects between such communities and the prison population means that drug use in prison cannot be taken in isolation. Indeed, prisons represent a valuable opportunity to educate drug users, familiarising them with safe injecting practice and the range of health services (community drugs teams, syringe exchange schemes) available, if not when incarcerated then certainly on release. Alternatively, if levels of HIV or other bloodborne viruses increase outside prison the high levels of sharing that occur when drugs are injected in prison may multiply numbers of infections and redistribute these among different drug using groups when inmates are released.


We are grateful for the support of Cathy James, Mike Jenkins, Norman Tucker, and Robert Lyons from Liverpool prison and to the Home Office for permitting this study, the prison inmates for participating, and Sheila Gore and Graham Bird for advice.

Funding: North West Regional Health Authority.

Conflict of interest: None.


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