Results from the First National HIV/AIDS and Prisons Workshop
The Workshop's goal was not to develop new recommendations. Participants agreed that the 88 recommendations in the Final Report of the Expert Committee on AIDS in Prisons,[1] and the comprehensive strategy proposed by PASAN in 1992[2] contain the elements necessary for an effective HIV/AIDS prevention and care strategy in prisons. The problem, as pointed out by them, is that recommendations are not being implemented at all, or are being done so slowly and unevenly.
Participants therefore called upon provincial and federal governments to act immediately to implement all recommendations put forward by ECAP and PASAN. At the same time, they acknowledged that some positive initiatives – such as condom and bleach distribution, a peer education and support pilot program, and availability of anonymous testing for HIV – are being undertaken or planned.
The following is a brief summary of some of the main issues discussed at the Workshop.
Testing and Confidentiality
Participants supported CSC's recent decision to make anonymous testing for HIV available to prisoners in federal prisons.[3] They pointed out that this will allow inmates who have so far been reluctant to be tested because of concern that test results will not remain confidential to come forward for testing. At the same time, participants emphasized that testing offered by prison health-care staff also needed to be made more accessible and acceptable to prisoners. This could be done by offering them the option of non-nominal testing, by training prison health-care staff in the delivery of pre- and post-test counselling, and by better protecting the confidentiality of medical information.
Educational Programs for Inmates
Participants heard about a successful education program in British Columbia, where a health educator, contracted jointly to federal and provincial correctional services, provided education for inmates and staff in all prisons. They also heard about a peer education and support pilot program in one institution in New Brunswick,[4] and saw a video presentation by a group of inmates at Matsqui Institution who have been providing peer education and health promotion to their fellow inmates for several years. However, the importance of peer education programs still does not seem to be fully understood by provincial and federal correctional services. This was evidenced by the testimony of one inmate, who submitted a proposal for developing a peer educator training curriculum at Frontenac Institution. His proposal was refused because the institution did not "see the need for any inmate to be employed in a full-time capacity doing this type of work with his peers. Our focus is on Core Programming, which includes literacy, Living Skills Programs, Substance Abuse Programs and Mental Health Treatment for those who are in need.... This is not an appropriate time for us to consider creating a new job."[5] It became evident that staff and prison administrators need to be informed and educated about the importance of peer education efforts, pointing out that they are cost-efficient and potentially life-saving programs. A plan needs to be developed to ensure that the New Brunswick initiative is reproduced wherever possible, and that institutions are provided with the means that will allow them to create paid inmate peer educator positions.
Preventive Measures for Inmates
Condoms, Dental Dams, Lubricant
Participants were outraged that some provincial prison systems in Canada still do not make condoms, dental dams, and lubricant available to prisoners. Even where they are imprisoned for short periods of time, some inmates in provincial prisons nevertheless engage in sexual activity and are at risk of contracting HIV infection. Participants further criticized the fact that in many provincial and some federal prisons, condoms, lubricant, and dental dams for female prisoners, although available, are difficult to obtain. They called upon all prison systems and individual wardens to make condoms, dental dams, and lubricant easily and discreetly available through a variety of distribution channels, as has been recommended by ECAP and PASAN.
Bleach
Participants welcomed CSC's recent decision to make bleach easily and discreetly available in all institutions.[6] They called upon CSC to issue clear directives to ensure that bleach distribution is implemented quickly and evenly in all institutions. They further urged that all provincial systems follow suit and make bleach available.
Sterile Needles
Most participants agreed that sterile needles should be made available in prisons. Rather than discuss whether they should be made available, participants – including prison staff – therefore focused on how this should be done. They felt that Canada could learn much from the Swiss experience, where sterile needles are being made available as part of a pilot project.[7] They suggested that CSC and provincial systems face the inevitable: sterile needles need to be made available in prisons in the interest of prisoners, staff, and the public. Therefore, as recommended by ECAP and PASAN, prison systems and governments should start putting in place the measures that will make needle distribution possible. According to participants, these include: broad consultation with prison staff and the unions; the drafting of legal opinions, as was done in Switzerland;[8] education of the public about (1) the fact that making needles available in prisons does not mean condoning drug use or giving prisoners the right to use drugs; (2) the benefits to society from making needles available: prevention of the spread of HIV among prisoners and to society, and avoidance of health-care costs related to it. While they generally agreed that needles can and should be made available to prisoners who inject drugs, participants conceded that in some prisons this may not be possible because of security problems, or may not be necessary because of low rates of injection drug use.
Methadone
A vocal minority of participants at the workshop vehemently opposed making methadone available to prisoners and to people using drugs outside prisons. They argued that "methadone does not really help people to get off drugs" and that "those in methadone maintenance programs only exchange one sort of dependence, that on narcotic drugs, against another, that on methadone." Those in favour of making methadone available emphasized that this was a pragmatic measure necessary to reduce injection drug use and the resulting risk of HIV infection. In other words: methadone maintenance may not be completely harmless, but its possible harms are insignificant when compared to the much bigger harms resulting from injection drug use. Participants pointed to ample data supporting the effectiveness of methadone maintenance programs in reducing the risk of HIV infection.[9] They stressed that people who are forced to withdraw from methadone because they are incarcerated usually return to narcotic use, often within the prison system, and often via injection. They concluded that methadone maintenance programs need to be established in prisons, particularly for those already in a program at the time of their incarceration. They also called upon federal and provincial health authorities to increase the availability of such programs on the outside.
Tattooing Equipment
Participants criticized CSC's response to ECAP's and PASAN's recommendations with regard to tattooing. They felt that tattoo equipment and supplies should be classified as hobby-craft equipment and authorized for use in the institutions, particularly in view of the fact that 54% of respondents in the survey undertaken by Trudy Nichol, Project Coordinator of the pilot bleach distribution program at Matsqui Institution, admitted having received tattoos in prison.[10]
Protective Measures for Staff
Most of the staff present agreed that they did not need more protective equipment and that, in order to protect themselves, they did not need to know who in the institution is living with HIV, but needed to use available precautions with all inmates. They further agreed that measures to reduce HIV infection among inmates were also in their own interest. For example, at Matsqui Institution inmates are told to clean injection equipment with bleach before and after use. Correctional officers pointed out that the risk of suffering a needle-stick injury with a contaminated needle was thus significantly reduced by making bleach available. Similarly, in the Swiss needle distribution pilot, measures have been undertaken to ensure that correctional officers are in less danger of accidental needle-stick when searching prisoners' cells: prisoners are allowed to keep only one syringe in their cell, and only in a glass in a cupboard.
Health Care
It was agreed that most prison health-care services do their best to provide inmates living with HIV or AIDS with optimal care, and that often inmates are referred to outside specialists for HIV-specific diagnosis and treatments. However, concern was voiced about a marked increase in the number of sick inmates. It was pointed out that prisons are not equipped to deal with inmates who require long-term, ongoing care and treatment. It was further pointed out that prisoners with HIV or AIDS continue to find it difficult, if not impossible, to access investigational drugs or nonconventional therapies – although in its response to ECAP's Final Report CSC promised to facilitate inmates' access to specialized or experimental treatments. Another concern was the difficulty of obtaining narcotics routinely given for pain relief to patients on the outside. In prison, it was said, these narcotics are often denied even to those in severe pain.[11]
Compassionate Release
Participants were told about some inmates dying in prison or being released just before they died, to their deathbed. They insisted that more needs to be done to ensure that inmates with progressive life-threatening diseases who do not represent a threat to public safety be released earlier in the course of their disease.
Women Inmates
Participants felt that not enough has been done in response to ECAP's recommendations regarding the needs of female inmates, although CSC had accepted the recommendations. Apart from pointing to the need for education and prevention programs specifically designed for female inmates, most participants agreed that society and prison systems were generally failing the needs of women in Canadian prisons, many of whom have suffered a history of abuse.
Aboriginal Inmates
As with women inmates, participants felt that not much has been done to respond to the needs of aboriginal inmates. They also expressed concern about the hyperincarceration of aboriginals in Canadian provincial and federal prisons.
Young Offenders
It was pointed out that many young offenders are at high risk of contracting HIV, but that little is done by provincial prison systems to address this risk. PASAN presented a first draft of a comprehensive AIDS strategy for young offenders and is seeking input into it.[12]
Inmates' Voices
Participants regretted that only few inmates had been granted day passes to attend the Workshop. They felt that prisoners living with HIV or at risk of contracting HIV in prison are the real experts we need to listen to and can learn from. It was generally agreed that prisoners and ex-prisoners who attended, or who had prepared video presentations, made an invaluable contribution to the Workshop.
Staff's Voices
Although many more staff than prisoners attended the Workshop, it was still felt that more health-care staff, correctional officers, administrators, and other staff could and should have benefited from and participated in the discussion. Staff's voices need to be heard, because changes to prison policies can only be made with, not against, them.
Legal and Ethical Issues
One of the plenaries was organized by the Joint Canadian AIDS Society and Canadian HIV/AIDS Legal Network Project on Legal and Ethical Issues Raised by HIV/AIDS.[13] Two presentations were devoted to an analysis of some of the legal issues raised by HIV/AIDS in prison.[14] They addressed questions of access to condoms, bleach, clean needles, and methadone in prisons: Do prisoners have a right to the means that would allow them to protect themselves against contracting HIV and other diseases in prisons? Can prison systems be forced to provide condoms, bleach, and needles? Can and should the law be used to achieve changes in policies?
Drug Policy
One of the presentations at the Workshop critically reviewed Canada's drug policy and its impact on the spread of HIV in prisons. Participants agreed that many of the problems raised by HIV/AIDS in prisons are the result of Canada's drug policy which, instead of providing drug users with much-needed treatment, care, and support, criminalizes their behaviour and puts many of them in prison. The financial and human costs of this policy are enormous, and prison systems are burdened with a problem society fails to deal with, and that they are even less equipped to deal with.
Conclusion
Not surprisingly, the Workshop revealed the need for more action from federal and provincial governments and prison systems: many of ECAP's and PASAN's recommendations – including some recommendations CSC agreed with in its response to ECAP's report – have not been implemented. Participants criticized the lack of action that clearly puts many – prisoners, staff, and members of the public – at risk of their lives, and called upon governments and the prison systems to finally act upon ECAP's and PASAN's recommendations. Unless they do so, courts or a commission such as that currently examining the safety of Canada's blood supply may one day have to explore why not enough was done to prevent HIV infection in prisons, although everyone was aware of the risks and knew the measures that could be taken to reduce them. At the same time, participants acknowledged that the situation with regard to HIV/AIDS in prisons in Canada has improved over the last years, and expressed their willingness to work together and learn from each other to make further necessary changes possible. Finally, because they felt that the Workshop had provided them with much-needed information, participants said that the event should be repeated in 1997.
- Ralf Jürgens and Julia Barnett
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ENDNOTES
[1] Correctional Service Canada. HIV/AIDS in Prisons: Final Report of the Expert Committee on AIDS in Prisons. Ottawa: Minister of Supply and Services Canada, 1994.
[2] PASAN. HIV/AIDS in Prison Systems: A Comprehensive Strategy. A Brief from the Prisoners with AIDS/HIV Support Action Network (PASAN) to the Minister of Correctional Services and the Minister of Health. Toronto: The Network, June 1992.
[3] See Canadian HIV/AIDS Policy & Law Newsletter vol 1 no 4 (July 1995) at 1, 15.
[4] See infra, C Ploem. Pilot Inmate AIDS Peer Education Project Underway in New Brunswick.
[5] Letter dated 28 October 1994 from S Sinclair, Frontenac Institution, to D Foreman.
[6] See Canadian HIV/AIDS Policy & Law Newsletter vol 1 no 4 (July 1995) at 1, 15.
[7] See Canadian HIV/AIDS Policy & Law Newsletter vol 1, no 4 (July 1995) at 2.
[8] See Canadian HIV/AIDS Policy & Law Newsletter, vol 1, no 3 (April 1995) at 2.
[9] See supra, D Riley. Methadone and HIV/AIDS.
[10] See Canadian HIV/AIDS Policy & Law Newsletter, vol 1, no 4 (July 1995) at 15.
[11] See infra, S Ford. Health-Care for Prisoners Living with HIV/AIDS.
[12] See infra, Editor. A Comprehensive Young Offender HIV/AIDS Policy.
[13] See Canadian HIV/AIDS Policy & Law Newsletter, vol 1, no 4 (July 1995), 7 at 9.
[14] See infra, the articles by I Malkin and R Elliott.