Response to Building Dialogue on Prison Health: Improving Access to Harm Reduction in Federal Prisons

Consistent with recommendations from the United Nations Office on Drugs and Crime on HIV prevention and care in prisons (UNODC 2013), the Correctional Service Canada (CSC) has a very comprehensive and forward-looking approach to addressing the management and prevention of blood-borne and sexually transmitted infections for inmates.

CSC currently has policies and programs that support 14 of 15 initiatives identified by UNODC. CSC policies and programs provide services well beyond what most community agencies and organizations are able to offer, either as stand-alone programs or offered collaboratively as packaged services. Harm reduction services available within CSC include

• • inmate screening and testing for HIV and HCV at intake and offered throughout incarceration;

• • normalization of HIV testing and simplified pre- and post-test counselling as per national Canadian guidelines;

• • health education and awareness programs;

• • anti-HIV-stigma campaigns;

• • culture and gender appropriate peer support programs;

• • risk factor awareness and counselling;

• • screening and vaccination for viral hepatitis (A and B);

• • health promotion/prevention initiatives on the risks of tattooing;

• • addiction screening and referral to substance abuse programs;

• • opiate substitution therapy;

• • condom/dental dam distribution;

• • bleach distribution;

• • mental health referral/counselling;

• • overdose emergency response (naloxone) and counselling, and availability of take-home naloxone on release;

• • post-exposure prophylaxis (PEP);

• • pre-exposure prophylaxis (PrEP);

• • routine access to medical specialist for HIV and hepatitis C virus (HCV) treatment consultation and management;

• • discharge planning;

• • latent tuberculosis infection (LTBI) screening and testing (via tuberculin skin testing [TST] and interferon-gamma release assay [IGRA]) and access to treatment;

• • screening and testing for active tuberculosis (TB) infection and treatment; and

• • staff education and training.

Combined, this suite of comprehensive initiatives has a significant and favourable impact on the health and well-being of persons in custody as outlined below.

HIV/HCV Screening, Testing, and Seroconversion

While it is well understood that most inmates acquire infection in the community before they enter CSC, this fact is frequently under-acknowledged by the HIV/HCV stakeholders and advocates.

Enhanced surveillance data show that 80% of HCV cases (CSC 2016a) and 85% of HIV cases (CSC 2016b) are known at admission, either because the person already knew their status or was newly diagnosed via routine voluntary screening. Participation in voluntary screening for HIV and HCV on admission is high, estimated at 78% in 2014 (CSC 2016d) and 96% by April 2017 (CSC preliminary data analysis, unpublished).

Preliminary analysis of enhanced surveillance data over 2005–2012 provides estimates of HIV and HCV seroconversion (testing negative for HIV or HCV and subsequently testing positive), which were about 1 person per 1,000 person-years for HIV (CSC 2016f) and 25 persons per 1,000 person-years for HCV (CSC 2016e). Furthermore, roughly half of the people meeting the definition for seroconversion had multiple releases and admissions; therefore, it is unknown if exposure occurred in CSC or outside in the community. In addition, some individuals may have acquired infection by means other than injecting drugs while in prison (e.g., non-sterile tattooing, unsafe sex).

Prevalence of HIV and Achieving the "90-90-90" Targets

The prevalence of HIV among CSC inmates has declined from 2.02% in 2007 to 1.19% in 2014 (CSC 2016d). Through the Government of Canada, CSC supports United Nations AIDS HIV "treatment as prevention" targets of "90-90-90" by the year 2020. Preliminary results for CSC in 2016–2017 indicate that 96% of newly admitted offenders to CSC accepted a voluntary blood test for HIV; 94% of inmates known to be living with HIV were on HIV treatment; and 91% of inmates on HIV treatment demonstrated viral suppression at follow-up.

Prevalence of HCV

The prevalence of HCV among inmates declined from 32.7% in 2007 to 18.2% in 2014 (CSC 2016c). Moreover, over the past couple of years, CSC has been an early adopter of new all-oral anti-hepatitis C medications and initiated an affirmative treatment approach that resulted in the doubling of the number of inmates initiated on treatment from roughly 300 in 2015–2016 to...