Equity inside and out? HIV, treatment access and prisonersadmin
Equity inside and out? HIV, treatment access and prisoners
HIV Australia | Vol. 14 No. 1 | March 2016
By Michael Frommer and Tony Maynard
Many people believe that under the Medicare system, all Australians are provided with universal access to health services and pharmaceuticals. However, prisoners have always been excluded from Medicare coverage, with all prison health care provided by state and territory governments.
While human rights law states that all prisoners have the right to health care equivalent to that provided to the general community1, concerns have been expressed by some researchers about the adequacy of medical services and care available within correctional facilities, compared with services available under Medicare2.
This article explains the rationale for excluding prisoners from accessing Medicare, and then examines how this plays out for people with HIV and other blood borne viruses (BBVs) who are incarcerated.
Prior to the introduction of Medicare, publically-funded health services were provided by state and territory governments. This was consistent with the division of responsibilities for service provision between state and federal governments.
Australia’s universal health care system, originally called Medibank, was adopted in 1975 and then removed with the change of government. The universal health care system was reborn in 1984, with the Medicare Benefits Schedule (MBS) and the Pharmaceutical Benefits Scheme (PBS) centrally administered under the Health Insurance Act 1973.
An amendment to the Health Insurance Act states that ‘Medicare benefit is not payable in respect of a professional service … under an arrangement with … an authority established by a law of the Commonwealth, a law of a State or a law of an internal Territory.’
As prisons are state established entities, prisoners are not eligible for Medicare subsidised services.
The question that arises is whether, without access to Medicare-subsidised services, prisoners with HIV and other BBVS are receiving inferior access to services. First, a quick snapshot of background numbers/demographics.
Prison population demographics
Australia’s prison population is increasing in both numbers and rates. The most recent figures quoted in the Australian Institute of Health and Welfare report, The Health of Australia’s Prisoners 2015show that 187.3 per 100,000 adults were in custody during 2013–14, up from 172.4 in 2012–13.3
As of 30 June 2014, there were 33,170 prisoners in Australia but over the entire year, more than 50,000 moved through the prison system.
The Australian prison population in primarily male (92%), and more than two thirds of detainees (68%) are 40 years of age or younger (compared with around 38% in the wider community).4
Aboriginal and Torres Strait Islander people are significantly overrepresented in Australian prisons, comprising just 2% of the general population but making up 27% of the prison population.5The reasons for this over-representation are complex, with entrenched social and economic disadvantage being among the key drivers.
Blood borne viruses in prisons
All prisoners are offered screening for BBVs and STIs on entry. This voluntary policy has been in place since 1999 when it replaced the mandatory testing policies of the 1990s; however, anecdotal reports suggest that due to fear of disclosure, many prisoners decline to be tested.
Stigma and discrimination also discourage HIV-positive prisoners from disclosing their status, therefore reliable statistics on the number of people living with HIV in Australia’s 94 prisons are scant.
The numbers are estimated from The Health of Australia’s Prisoners 2015 ‘snapshot’ analysis of prison entrants. The report uses data obtained from the National Prisoner Health Data Collection (NPHDC), conducted over a two weeks period in 76 out of 91 public and private prisons in all Australian states and territories.6
In 2015, this ‘snapshot’ found that of 501 entrants who were tested, none tested positive for HIV, a result unchanged since 2010. Clearly this is not a reflection of the actual numbers who are incarcerated.
At any given time there are believed to be 30 to 40 HIV-positive prisoners in NSW prisons alone. This shows that Australia, as a high-income country, has significantly lower rates of HIV infection among prisoners than do neighbouring middle and low income countries.
In the case of hepatitis C, the situation is markedly different. Up to two-thirds of females screened for hepatitis C on entry to Australian prisons are found to be HCV positive, compared to around one-third of male prisoners.7
For Aboriginal and Torres Strait Islanders in prison, the rates of hepatitis C are much higher. Figures cited in the National Hepatitis C Strategy state that 43% of Aboriginal and Torres Strait Islander people in custodial settings have hepatitis C, compared with 33% of non-Indigenous detainees.8
Treatment for BBVs in prisons should be provided in line with International frameworks from the United Nations (UN) and the World Health Organization (WHO) and supported by national principles in Australia, which state that prisoners have the right to access an equivalent standard of healthcare as available in the wider community, irrespective of their legal situation.9
In some states and territories, the state or territory Department of Health provides prison health services, but in others such as NSW and Victoria, these services are provided by the Department of Justice or Corrections. Public/sexual health nurses are employed in all prisons except for the most remote rural ones, so screening, care and treatment are widely available.
Health education programs are the most widely used strategy for reducing the spread of BBVs in prisons, but while prisoners are informed about the risks of infection and transmission, they are not consistently provided with the means to reduce their risk of acquiring BBVs.
Harm minimisation measures such as opioid substitution programs, and dental dam/condom dispensers are available in many prisons; however needle and syringe programs are not provided anywhere.
Access to services
Due to the voluntary nature of participation in BBVs and STIs screenings for prison entrants, it is not possible to determine exact numbers of people with HIV in prisons, nor the subset of this population who have difficulties accessing appropriate medication.
Anecdotal reports indicate that because of the stigma and prejudice associated with HIV infection, some prisoners forego medications to protect themselves from being identified and thus being subjected to discrimination.
For example, an infectious diseases nurse in Victoria informed the National Association of People With HIV Australia (NAPWHA) that very few of the prisoners living with HIV attend the health clinic because they are afraid their status will be leaked, and as a result they will suffer harassment and sometimes violence from other prisoners.
NAPWHA is aware of one case in NSW where an HIV-positive prisoner had to be moved to another jail after he was bashed, when it leaked out that his daily visits to the clinic were to pick-up his HIV medications.
In the Northern Territory (NT), we understand that occasionally a person with HIV may experience a day or two without being able to access treatment when first admitted to prison; however this is not generally a problem.
Sometimes there are issues with getting prison nurses in the NT to use correct blood tubes for viral load and CD4 counts, but this is simply due to a nurse’s lack of familiarity with these tests. To avoid the problem, sexual health coordinators usually label and send the tubes out to the nurses.
There are no reported problems with arranging medical appointments, provided that a letter is sent to the administrative person at the prison with one or two weeks’ notice.
Access to treatment in prison is a mixed picture. It is a concern if prisoners who know their status conceal this information and don’t take medication while in prison to avoid stigma and discrimination from staff or other inmates.
NAPWHA, however, has not been made aware of any systemic problems in relation to HIV-positive people accessing medication in prison. We thus believe that while stigma remains a concern, people living with HIV who are prepared to disclose their HIV-positive status are generally able to access treatment in prison.
The Fourth National Hepatitis C Strategy 2014–2017 and the Fourth National Aboriginal and Torres Strait Islander Blood-Borne Viruses and Sexually Transmissible Infections Strategy 2014–2017recognise prisoner populations as priority populations for hepatitis C.
Uptake of treatment for hepatitis C has historically been low in both the community and in prison, due to the considerable side-effects associated with interferon in the treatment regimens. Prisoners’ access to treatments has also been patchy.
In 2013, The National Prison Entrant Bloodborne Virus Survey found that only 11 (9%) of inmates with hepatitis C had reported receiving HCV treatment (up from 5% in 2010), including five Aboriginal prison entrants.10 This suggests an urgent need to further increase hepatitis C treatment uptake among prisoners.
From March 1, 2016, the new interferon-free direct acting oral antivirals (DAA) became available to all Australians with hepatitis C, including those in prison. These drugs have very high cure rates following a 12–24 week course.
Given the high rates of HCV in Australian prisons, providing access to these treatments will have a significant impact. In NSW, for example, it’s estimated that between 500 and 600 prisoners will be able to access treatment and be cured of their hepatitis C infection.11
People in prisons generally receive adequate HIV treatment and support, despite not being able to access Medicare-subsidised services. However, with high rates of hepatitis C and injecting and a lack of needle exchanges, further spread/transmission of hepatitis C is likely, along with the potential for HIV transmission.
There is a great need for comprehensive BBV prevention, including introduction of needle and syringe programs, as well as adequate access to sexual health prevention measures.
People in offshore detention
Due to restrictions on accessing information regarding the wellbeing of people detained offshore on Nauru, Manus and Christmas Island, it is hard to get a precise picture of how detainees with HIV and other BBVs are faring, including their ability to access treatment.
There have been, however, several anecdotal reports of poor or even completely non-existent access to appropriate HIV care and support.
One informant, who worked with detainees on Nauru as a case manager, stated that HIV health care must be seen in the context of the general impoverished state of health care available in detention.
He stated, ‘The guys I see just say “I get sick, I feel unwell, I go to the doctor,” and sometimes they have to book an appointment, sometimes it takes a long time. Sometimes there are no doctors on the island, and then they just get a Panadol, some painkillers … no specialised treatments.’
He was certain that none of the three HIV-positive people who he saw were receiving ARVs.
John-Paul Sanggaran was a medical officer at Christmas Island detention centre. He expressed concern to AFAO about a host of problems he observed, which led to substandard health care, including for people with HIV.
An individual newly diagnosed with HIV might need specialist psychological services to deal with the ramifications of the diagnosis, but this support, he states, is not available in a remote offshore detention centre.
He described these environments as generally uncaring and unsupportive, with significant stigma attached to the virus, made worse by religious beliefs and moral judgements among asylum seekers.
A particularly disturbing example of problematic treatment was where an individual diagnosed with HIV while on Christmas Island was housed in White compound, which is a behavioural management unit.
An individual may be placed in the White compound if deemed to be ‘non-compliant’ by centre management, due to aggressive behaviour, or if they are considered at risk of harm from others.
For people in immigration detention, where the overall health landscape is dire, at the very least individuals should receive counselling upon diagnosis and have reliable access to antiretroviral medications.
While the public debate around immigration detention is extremely contentious, coordination among partners in the non-government sector (NGO) sector and direct advocacy to government should be pursued.
1 See: Reyes, H. (2001). Extract from HIV in Prisons: A reader with particular relevance to the newly independent states, chapter 2, pp.9–18, World Health Organization-Europe “HIPP” (Health in Prisons Project), 2001. Retrieved from: www.icrc.org
2 Pleuckhahn, T., Kinner, S., Sutherland, G., Butler, T. (2015). Are some more equal than others? Challenging the basis for prisoners’ exclusion from Medicare, Medical Journal of Australia, 203(9). 359–361. doi: 10.5694/mja15.00588
8 Department of Health (DoH). (2014). Fourth National Hepatitis C Strategy 2014–2017. Commonwealth of Australia, Canberra.
10 Butler, T., Callander, D., Simpson, M. (2015). National Prison Entrants’ Bloodborne virus survey 2004, 2007, 2010 and 2013. The Kirby Institute for Infection and Immunity in Society, UNSW Australia, Sydney. Retrieved from: kirby.unsw.edu.au
Michael Frommer is Policy Analyst at Australian Federation of AIDS Organisations (AFAO).
Tony Maynard is Treataware Project Officer at National Association of People With HIV Australia (NAPWHA).