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High risk behaviour is common in prisons in Berlin

BMJ 1995; 310 doi: (Published 13 May 1995) Cite this as: BMJ 1995;310:1264
  1. R Muller,
  2. K Stark,
  3. I Guggenmoos-Holzmann
  1. Senior biostatistician Medical research assistant Head of department Institute of Medical Statistics, Free University of Berlin, Benjamin Franklin Medical Centre, 12000 Berlin, Germany

    EDITOR,—The issue of 4 February provides important further evidence that injecting drug users in prisons are at high risk of acquiring parenterally transmitted diseases. In a recent study among 612 injecting drug users in Berlin 418 reported a history of imprisonment.1 Of these, 202 continued to inject while in prison and 152 of these started sharing needles during their imprisonment. Needle sharing in prison proved to be the most important risk factor for HIV infection as well as a major risk factor for infection with hepatitis B and C viruses (adjusted odds ratio 10.0, 1.7, and 9.8 respectively). On the other hand, injecting drug users proved to have substantially reduced their risk behaviour outside prison. Of the study's participants, 352 (58%) stated that they had not shared needles at all or had shared only with a regular partner during their injecting career. This proportion had been about 20% in a previous study.2

    Thus information campaigns and other preventive measures such as needle exchange programmes seem to have successfully generated awareness of risk and changes in behaviour among injecting drug users. High risk behaviour is still common1 only where injecting drug users are not able to protect themselves according to their new awareness of risk—that is, inside prisons. Thus successes in prevention outside prisons are in severe danger of being damaged by the unacceptable situation inside prisons.

    O Noel Gill and colleagues raise the question of why the seroprevalence of HIV among injecting drug users in the community has not been rising if HIV is being transmitted frequently in prison.3 If the above information is taken into account, one possible answer is a shift in the risk of infection from outside prison to inside: a reduction in risk and incidence outside prison seems to be counteracted by high risk behaviour inside. The result could be as stable prevalence in community based samples while populations in prison face a high incidence; this is corroborated by other studies.4 5

    In Berlin, as a consequence of the study results mentioned above, a political debate has started about how to reduce risks of transmission in prison settings. As a first step, a medical kit containing health information leaflets and a bleach-like disinfectant was made available for injecting drug users entering prison. This measure, however, is unlikely to be effective: on the one hand, injecting drug users in prison settings usually do not have the time to clean used injection equipment thoroughly; on the other hand, even thorough cleaning does not result in real safety.6 A better approach would be the controlled provision of sterile injecting equipment (as has just started in Hindelbank prison in Switzerland) or methadone maintenance for imprisoned injecting drug users, which has recently been made available for those who were already in such a programme outside prison.

    This risk of HIV infection in injecting drug users during imprisonment should be addressed immediately. The situation in prisons counteracts any preventive successes outside prisons.


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