Last week at the UN Crime Commission, delegates and experts gathered at a side-event to discuss how to address the HIV epidemic in prisons. The panel all agreed – to achieve the target under Goal 3 of the Sustainable Development Agenda to end the HIV epidemic by 2030 – strong support (including political will and financial resources) has to urgently be dedicated to addressing the disproportionately high rates of people in prison with HIV/AIDS. In my presentation, I explained that as a starting point, prisons should turn to the UN Nelson Mandela Rules and the UN Bangkok Rules on women offenders and prisoners for guidance on this issue.
Prisoners are more likely to have HIV/AIDS than someone in the community. Despite this, prisons are struggling to prevent the transmission of HIV to other prisoners and staff and fail to meet the needs of those who are HIV+. Instead they are frequently isolated and almost always stigmatised. Guidance provided in the UN Nelson Mandela Rules and the UN Bangkok Rules provides a solid starting point for prison administrations’ efforts towards the proper prevention, treatment and care of HIV/AIDS in prison, while upholding the right to dignity of those affected.
Both sets of Rules have now not only consolidated existing human rights and criminal justice standards, but also medical ethics for healthcare professionals. These include principles on the continuity of care, equivalence of care, medical confidentiality and informed consent.
Firstly, the Rules reiterate that prisoners are patients, and that the commitment to medical confidentiality applies equally in prison as it does elsewhere. The only exception here is if “maintaining confidentiality would result in a real and imminent threat to the patient or to others”. Confidentiality is crucial for prisoners with HIV who are often ‘labelled and isolated’ unnecessarily. There is no medical reason to separate prisoners with HIV from others, so routine communication of HIV status to the prison administration should never happen. There should be no ‘mark, label, stamp or other visible sign’ to indicate HIV status on prisoners’ files (as outlined in the WHO Guidelines on HIV infection and Aids in Prison).
Adherence to the principle of informed consent, another key medical ethic, is also required in prisons by both the Mandela Rules and the Bangkok Rules. HIV testing in a prison setting still requires informed consent and special measures need to be put in place which recognise that prisoners may feel that they cannot reject an offer of testing by prison health-care staff, or may even be coerced into “accepting” an HIV test.
Secondly, prison food – an issue for many prisons globally where poor quality and small quantities are the norm – poses a particular challenge to the treatment of HIV. For instance, in one country it was reported that even where anti-retroviral therapy was available, the prisoners declined to take their medication for fear of the impact on their bodies of taking them on an empty stomach. Malnutrition among people infected with HIV or TB can lead to secondary immunodeficiency, which can increase the risk of infection.
The Nelson Mandela Rules require that, ‘[e]very prisoner shall be provided by the administration at the usual hours with food of nutritional value adequate for health and strength, of wholesome quality and well prepared and served’. They also state that the physician or competent public health body should regularly inspect and advise the prison director on food. Their advice should include paying attention to the particular nutritional needs of prisoners with HIV.
The Bangkok Rules supplement the Nelson Mandela Rules by adding a ‘gender lens’ to the application of prison standards. Discrimination and violence are a common thread in the lives of many women prisoners, which means that a higher proportion of them are HIV+ compared to their male counterparts. Their complex and unique health needs, including those related to infectious diseases, are often unmet.
The Bangkok Rules recognise that medical treatment for women should be different than for the treatment offered to men. For instance, components of a HIV/AIDS treatment and prevention strategy should also include reproductive health and family planning advice, information on the transmission of STIs and HIV, and ways to reduce those risks.
The stigma and discrimination faced by prisoners with HIV/AIDS can be huge, especially for women. Sensitisation and capacity-building programmes on the prevention, treatment and care for HIV/AIDS is encouraged in the Bangkok Rules. When such training was delivered as part of a PRI project in Central Asia, results suggested that women prisoners were more aware of the importance of continuing treatment after release, and that the programme helped to reduce stigma of HIV, with staff becoming more willing to discuss openly the issues faced by women.
One last issue to mention in any discussion of an HIV/AIDS plan for prisons is what might be termed the ‘elephant in the room’ – restricted access to harm reduction services, in the name of drug control. To achieve the target of ending AIDS under Goal 3 of the Sustainable Development Agenda 2015-2030, this ‘elephant’ needs to be addressed, as Gen Sander of Harm Reduction International explains in a recent expert blog for PRI.
As the discussion concluded last week in Vienna, the foundations needed to prevent, treat and care HIV/AIDS in prisons are already there (including the UN Nelson Mandela and Bangkok Rules and the UN’s comprehensive package of interventions). The evidence for the need, and positive impact of such measures, if implemented, is well documented. Now it’s just a matter of putting them in place.