Incarceration, HIV and Indigenous communities
HIV Australia | Vol. 9 No. 1 | April 2011
MARY ELLEN HARROD, JAMES WARD, SIMON GRAHAM and TONY BUTLER argue that culturally appropriate services for Indigenous prisoners are vital.
Australia’s response to the HIV epidemic, encompassing multi-faceted, targeted prevention efforts including condom distribution and community-based needle and syringe programs (NSPs), has been recognised worldwide as first class – particularly in prevention of the epidemic among marginalised populations including men who have sex with men, sex workers, people who inject drugs, and Australia’s first peoples, Aboriginal and Torres Strait Islanders.
Rates of infection among men who have sex with men, which were at an all-time high in the early 90s, have continued to decline and remain low; HIV diagnoses among sex workers remain rare, as are diagnoses among people who have injected drugs.
Continuous prevention efforts have made this the case. For Aboriginal and Torres Strait Islander people, rates of diagnosis of HIV have remained stable and on par with non-Indigenous people, equating to around 20 notifications a year since the mid- 90s.
The low prevalence of HIV among the Aboriginal and Torres Strait Islander community should be celebrated as a success story for two reasons: firstly, because this has occurred despite the fact that unique factors exist in many of these communities that increase the risk of HIV transmission within them; and secondly, because this low HIV prevalence occurs in an environment where – for almost all other diseases – Aboriginal and Torres Strait Islander people experience higher rates of disease, and poorer health outcomes. The rate of premature death among Aboriginal and Torres Strait Islander people is between two to three times that of non-Indigenous Australians.
There are a number of well-documented factors that increase vulnerability to HIV transmission in Aboriginal and Torres Strait Islander communities. Long standing, high rates of bacterial sexually transmissible infections (STIs), such as gonorrhoea and chlamydia, exist in many Indigenous communities and are a factor known to increase susceptibility to HIV. Efforts to reduce the rates of these common STIs within those communities have been largely unsuccessful, except in a few places in Australia where comprehensive programs have been implemented and sustained (notably, in Tiwi Islands and Nganampa Health Council).1, 2
Other factors that contribute to the increased risk of HIV transmission among Aboriginal and Torres Strait Islanders include less access to appropriate primary health care services, a younger and more mobile population, and recent evidence of a rise in diagnoses among people who inject drugs within communities. Evidence for the rise in injecting drug use is apparent: 20% of new HIV infections diagnosed among Aboriginal Torres Strait Islander people over the last five years were reportedly acquired through injecting drug use, compared to 3% of new infections in the non-Indigenous population.3
Incarceration, HIV and Indigenous communities: the risks
The role of incarceration in driving HIV epidemics at a community level, and the impact of this on Aboriginal Torres Strait Islander people in Australia is less well-documented – however understanding this role is vital to ensure that we close all the gaps in Aboriginal Torres Strait Islander health in Australia.
It is well-recognised that the criminal justice system is a high-risk setting for the transmission of HIV and other blood borne viruses (BBVs) among people who inject,4 and this is particularly true for Indigenous people. Rates of hepatitis C in Australian prisons have been well-established by studies as high – with an overall prevalence rate of 35% among prisoners, and a much higher rate among inmates who identify as injecting drug users (58% among males and 78% among females) in 2007.5,6 Information on the rate of HIV infection in Australian prisons is patchy, partly due to inconsistent HIV screening policies across Australia’s various states/territories.7 Most studies estimate a very low prevalence of HIV (<1%). Worldwide, however, the rate of HIV in prisons is much higher (for example, 8% in Canada, 28% in Vietnam and 44% in South Africa8).
These international figures are a major cause of concern for Aboriginal and Torres Strait Islander communities in Australia. If HIV rates within Australian prisons were to increase along similar lines, the rate of HIV in the Aboriginal and Torres Strait Islander population would surely increase due to:
- the gross overrepresentation of Aboriginal and Torres Strait Islander people in the adult custodial and juvenile justice systems;
- unique factors associated with incarceration for Aboriginal and Torres Strait Islander prisoners; and
- factors within prison settings that heighten the risk of HIV and viral hepatitis transmission.
Ever since the report of the Royal Commission into Aboriginal Deaths in Custody in 1991,9 the rate at which Aboriginal and Torres Strait Islander people are incarcerated has increased dramatically. By way of example, a report from 2003 indicated that indigenous female prisoners were the fastest growing prison population during 1993 to 2003, with a recorded increase of 343% over this ten year period.10
Current figures indicate that Aboriginal and Torres Strait Islander people are still incarcerated more than any other identifiable population in Australia. In 2009–2010, 26% of the adult prison population were identified as Aboriginal and Torres Strait Islander, despite Aboriginal and Torres Strait Islander people representing just over 2% of the Australian population.11
The proportion of Aboriginal and Torres Strait Islander inmates varies between states/territories, with 82% of prisoners in the Northern Territory identifying as Aboriginal and and/or Torres Strait Islander. In Western Australia it is estimated that over 4% of the total Aboriginal and Torres Strait Islander people resident in that state were incarcerated in 2009–2010, a rate 25 times that of non-Indigenous people.12
Young Aboriginal and Torres Strait Islander people (aged up to 17 years) are also over-represented in the juvenile justice system, and are 29 times more likely to be in detention than non-Indigenous youth.13 Although there are fewer Indigenous women in custody they are currently the fastest growing segment of the prisoner population, with the rate of incarceration increasing by 34% between 2002 and 200614, and Aboriginal and Torres Strait Islander women 23 times more likely to be imprisoned than non-Indigenous women.15
The other unique factor likely to have an impact on HIV and blood borne virus transmission among Aboriginal and Torres Strait Islander people in prison are the characteristics of Aboriginal and Torres Strait Islander inmates themselves. They are younger (median age 30.6 for males and 31.5 for females, compared to 34.6 for non-Indigenous males and 36.1 for non-Indigenous females), incarcerated for shorter periods of time on average (two years compared to 3.6 years for non-Indigenous prisoners) and importantly, more likely to be re-incarcerated (76% compared to 45% for non-Indigenous prisoners).16 These factors both directly and indirectly increase the chances of HIV and viral hepatitis transmission – both within the system and outside it.
Prisons and injecting drug use
Within Australian prisons, factors that increase the risk of transmission of BBVs such as HIV and viral hepatitis include the high number of prisoners injecting,17 poor knowledge among prisoners about health risks (particularly among young offenders), and the quality of health care provision while in this setting. Although Australia has a prohibited drug policy prison environment, data from the 2004 and 2007 National Prison Entrants Blood Borne Viral Survey indicates that about a third of all inmates reported injecting drugs while in prison – an environment where clean injecting equipment is not available.18
The knowledge of young offenders about how hepatitis C is transmitted is poor, with 50% of young offenders having no knowledge and only 10% knowing that sharing needles is a risk for transmission.19 Research from the UK also shows that large numbers of people initiate injecting in the high-risk prison environment.20
Finally, the prison population is transient, it being estimated that up to 50,000 individuals move through state and territory prisons each year, providing ample opportunity for prison-to-community transmissions. In NSW, a quarter of prisoners stay less than seven days, and the prisoner population is highly mobile with an estimated 220,000 internal movements of prisoners each year (due to routine activities such as day release, family visits, court transfers, and movements between facilities).
Culturally appropriate care – inside and out
Keeping the rate of HIV infection low requires vigilance on the part of communities and public health authorities, and prevention efforts need to address multiple factors. In prison settings, prevention measures such as access to testing and counselling, provision of condoms, drug treatment, safe tattooing, availability of bleach and access to clean injecting equipment should be freely available to all prisoners.21
In spite of relatively little reported homosexual sex taking place in Australian prisons22 condoms are routinely available in some Australian jurisdictions but injecting equipment is not. This discrepancy in harm prevention policy has no valid policy rationale, given the clear evidence of heightened risk due to the sharing of injecting equipment and the need to prevent transmission of BBVs in this setting.
In spite of calls for culturally appropriate health care for all prisoners and care that is equivalent to that received by the general public,23 very few Australian prisons deliver culturally appropriate health services – that is, services delivered by Aboriginal and Torres Strait Islander people to Aboriginal and Torres Strait Islander people. Such services should be available to Indigenous inmates within prisons, with continuity of care upon release to ensure community transition to appropriate health care and ideally, ongoing care via a local Aboriginal Community Controlled Health Service.24
This model works in practice – a STI/BBV screening and education program led by Aboriginal Health Workers not associated with the correctional system resulted in identifying a number of previously asymptomatic and untreated cases. Widespread support for such programs could be an effective way to find and treat more infections and increase Aboriginal and Torres Strait Islander inmates’ knowledge of risk behaviours for STI/BBV infection.25
The Aboriginal Community Controlled sector in NSW has been active in forging partnerships with Justice Health NSW and local facilities. Examples of partnership initiatives include regular clinical care education and training, including Aboriginal and Torres Strait Islander prison liaison workers in blood borne viral and injecting drug use management, and putting in place agreements for local Aboriginal Community Controlled Health Services to provide care to Aboriginal and Torres Strait Islander inmates at their local prison.
Currently, all prisoners in Australia are denied access to the Medicare and the PBS schemes; provision of health services for prisoners is the sole responsibility of the states and territories. One potential impact of this is that external service providers such as Aboriginal Community Controlled Health Services (to name but one group) have to negotiate with prison health services regarding payment for services provide to Aboriginal prisoners.
There is often disagreement over this and consequently many Aboriginal Community Controlled Health Services do not provide a service to their local prison. It has been suggested that Aboriginal Community Controlled Health Services could undertake the Aboriginal Health Check, provide second opinions for Aboriginal prisoners, or other culturally appropriate health care if Medicare and PBS were accessible to prisoners.26
The provision of adequate health care and prevention services within prison requires a concerted effort where the prison system allows the community sector to take a lead role in implementing workable policies. A longer term solution is to eliminate the grossly disproportionate rate of imprisonment of Aboriginal and Torres Strait Islander people in Australia and is one important part of the picture of genuinely addressing disadvantage and the 20 year gap in life expectancy that Aboriginal and Torres Strait Islander people currently face in Australia.
1 Su, J., Skov, S. (2008). An assessment of the effectiveness of the Tiwi sexual health program 2002-2005 [online]. Aust and NZ J of Public Health (32)6, 554–558.
2 Miller P., Torzillo P., Hateley W. (1999).Impact of improved diagnosis and treatment on prevalence of gonorrhoea and chlamydial infection in remote Aboriginal communities on Anangu Pitjantjatjara Lands. Med J Aust 1999; 170, 429–432.
3 National Centre in HIV Epidemiology and Clinical Research (NCHECR). (2010). Bloodborne viral and sexually transmitted infections in Aboriginal and Torres Strait Islander People: Surveillance and Evaluation Report 2010. NCHECR, Sydney.
4 Hellard, M., Aitken, C. (2004). HIV in Prison: What Are the Risks and What Can Be Done? Sexual Health, 1(2), 07–113.
5 Australian Institute of Health and Welfare (AIHW). (2010). The health of Australia’s prisoners 2009. Cat. no. PHE 123. AIHW, Canberra.
7 Butler, T., Papanastasiou, C. (2008). National Prison Entrants’ Bloodborne Virus and Risk Behaviour Survey Report 2004 and 2007. National Drug Research Institute (NDRI) and NCHECR, Perth and Sydney.
10 Aboriginal and Torres Strait Islander Social Justice Commissioner. (2004). Social Justice Report 2004, 1/2005. Human Rights and Equal Opportunity Commission (HREOC), Sydney, 15. Available at: http://www.hreoc.gov.au (accessed 31 march 2011).
12 AIHW. (2009). Juvenile Justice in Australia 2007–08. Juvenile Justice Series No. 5., Cat. No. JUV 5. AIHW, Canberra.
14 Steering Committee for the Review of Government Service Provision. (2007). Overcoming Indigenous Disadvantage: Key Indicators. Productivity Commission, 128.
15 Steering Committee for the Review of Government Service Provision (SCRGSP). (2011). Report on Government Services 2011, Productivity Commission, Canberra.
16 AIHW. (2010). The health of Australia’s prisoners 2009, Cat. No. PHE 123. AIHW, Canberra.
17 Butler, T., Papanastasiou, C., op. cit.
19 van der Poorten, D., Kenny, D., George, J. (2008). Prevalence and risk factors for hepatitis C in Aboriginal and non-Aboriginal adolescent offenders. Medical Journal of Australia (188)10, 610–614.
20 Boys, A., Farrell, M., Bebbington, P., Brugha, T., Coid, J., Jenkins, R. et al. (2002) Drug use and initiation in prison: results from a national prison survey in England and Wales. Addiction, 97, 1551–1560.
21 Public Health Association of Australia (PHAA). (2007). Prison Health: Minimum National Standards for Correctional Services and Juvenile Detention Policy, PHAA, Canberra.
22 Butler, T., Papanastasiou, C., op. cit.
23 PHAA, (2007), op. cit.
24 Templeton, J., Tyson, B., Meharg, J., Habgood, K., Bullen, P., Malek, S., et al. (2010). Aboriginal health worker screening for sexually transmissible infections and blood-borne viruses in a rural Australian juvenile correctional facility. Journal of Sexual Health, 7(1), 44-8.
25 Aboriginal Health and Medical Research Council (AHMRC) Consultancy Service, Mandala Consulting. (2004). Increasing Access to Services in NSW for Aboriginal People at Risk of contracting or who have Blood Borne Infections, AHMRC, Sydney. Available at: http://www.ahmrc.org.au (accessed 31 March 20110.
26 Waples-Crowe, P., Pyett, P. (2005). The making of a great relationship: A review of a healthy partnership between mainstream and Indigenous organisations. Victorian Aboriginal Community Controlled Health Organisation (VACCHO), Victoria.
Mary Ellen Harrod is Clinical Research Project Leader at the Kirby Centre, University of New South Wales (UNSW). James Ward is Head of Aboriginal and Torres Strait Islander Health Program at the Kirby Centre, UNSW. Simon Graham is research manager at The Kirby Centre, UNSW. Tony Butler is Program Head of the Justice Health Program at The Kirby Centre, UNSW.
* Formerly known as The National Centre in HIV Epidemiology and Clinical Research (NCHECR).
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