Straight outta WA: tracing the success of a state-wide prison-based BBV education programadmin
Straight outta WA: tracing the success of a state-wide prison-based BBV education program
HIV Australia | Vol. 14 No. 1 | March 2016
By Matthew Armstrong
People entering the Australian criminal justice system experience extreme health inequities compared to the broader population, with elevated risks for communicable and chronic disease, high levels of drug and alcohol addiction, and little to no prior contact with healthcare services outside of the prison setting.1 2
Given that these elevated risks are well known, and that prisoners are named as a priority population in Australia’s national HIV and hepatitis C strategies3 4, prison health care services and programs provide a critically important avenue for access to BBV and sexual health screening and education.
The HIP HOP Program
The Health In Prison Health Outta Prison (HIP HOP) Program is a two-part health information education package, operating across all prisons in Western Australia (WA), specifically designed to suit the needs of people in prison settings.
The program is funded by the Department of Corrective Services; HepatitisWA currently holds the contract to provide HIP HOP within all metropolitan prisons and youth detention centres, as well as the Bunbury, Karnet and Wooroloo Prisons. In other regional areas, the program is facilitated by the Department of Corrective Services themselves, or contracted out to other local service providers.
The two-hour program is compulsory for all prisoners. It is designed to effectively target offenders during different stages of their incarceration, from prison entry through to release.
Both state and national public health principles have been incorporated into the education methodology.
Its primary aim is to reduce the incidence of BBVs, sexually transmissible infections (STIs) and drug-related harm by providing a dedicated safe space for prisoners to receive accurate information about these topics, and to discuss their own experiences and concerns with health educators and peers. The program is aimed at:
- increasing awareness among prison populations in relation to BBVs and STIs, by facilitating discussion on topics including prevalence, transmission, prevention, risk behaviours, testing, vaccination and treatment options
- increasing understanding of the concept of harm reduction in relation to BBVs, the effectiveness of needle and syringe programs (where available), and ensuring personal safety when outside of prison
- increasing awareness in relation to ‘blood awareness’ and health and safety issues
- decreasing stigma around people living with BBVs, and understanding the psycho-social impact of living with a BBV
- increasing awareness of the BBV and STI testing and treatments services available to prisoners, and how to access HepatitisWA’s services.
The HIP HOP Program covers a wide range of topics, including detailed information on specific BBVs and STIs, their natural outcomes, liver health, the importance of healthy lifestyle, available treatments and testing pathways in prison. It also covers the concept of harm minimisation, harm reduction strategies, and prison-specific transmission and prevention strategies.
The birth of HIP HOP
The first Sexual Health and Blood-borne Virus Program in WA was formed in response to an incident of HIV transmission in a prison setting. The incident generated sufficient concern among prison staff and inmates to mobilise a six-month pilot program, held at two maximum security prisons.
The workshops were two hours long, with initial participants being handpicked to ensure the most suitable and influential prisoners took part. Feedback from participants and staff indicated that the program was seen as effective and highly valued, and it went on to become an officially tendered contract.
Following on from the success of these pilot workshops, in 1997 a new BBV and sexual health education program was created, called the Keeping Safe Project. The project was fully funded by the Department of Corrective Services, and was co-facilitated by the Hepatitis C Council of WA (now rebranded as HepatitisWA) and the WA AIDS Council.
State government funding enabled education workshops to be held at six metropolitan prisons and one semi-regional prison. Unlike the pilot program, participation in the Keeping Safe Project was compulsory for all prisoners. Despite some operational and attitudinal resistance during the program’s implementation, the workshops went ahead successfully and received very positive anecdotal feedback from participants.
A formal evaluation, conducted in 2005, indicated a perception among inmates that the Keeping Safe workshops were seen as being relevant only for people who inject drugs and men that have sex with men; this had the potential to stigmatise those taking part and to discourage others from joining the program. To make the workshops appear more accessible, the scope of the project was broadened out to include additional BBV risk behaviors such as participation in blood sports and fights.
In addition, the project redesign focused more on a model of ‘problem solving’ rather than ‘information giving’. The new program also created separate target messages for both entering and exiting the prison system.
The redesigned program was rebadged as Health In Prison Health Outta Prison (HIP HOP), and launched in 2006. The program continues successfully to this day as the primary BBV and sexual health education program operating at every prison in Western Australian.
Prisoners and BBV risk
The continuation of funding for this highly successful program has been in part due to the Department of Corrective Services acknowledging that they are one of the biggest notifiers of viral hepatitis infection in WA.5 This is due largely to the high proportion of individuals who have a history of injecting drug use prior to entering a correctional facility.6
It is currently estimated that 91% of all new hepatitis C infections in the community are attributed to people sharing drug injecting equipment.7 Research has shown it is possible that up to 55% of prisoners have a history of injecting drug use8, and that a further 34% of prisoners with a history of injecting drugs will continue to inject while in prison9. Of those prisoners, potentially up to 90% will share drug injecting equipment while in prison10.
It is also recognised that prisoners may engage in other BBV risk behaviours, such as unsterile tattooing and body art, violent and ritualistic behaviours, unsafe sexual practices and unsanitary hygiene practices. It is currently estimated that the hepatitis C prevalence amongst Australian prisoners is between 23–47%, and even up to 70% for female prisons in some studies11.
Program evaluation and feedback
Over the last six months, HepatitisWA has facilitated 200 HIP HOP workshops across the metropolitan prisons, reaching approximately 1,580 prisoners. Feedback from prisoners remains very positive. The results of our evaluations have shown that at the completion of training almost all prisoners (98%) could identify the major forms of hepatitis C transmission, and also identify effective prevention strategies for BBVs and STIs.
In addition, a high percentage of prisoners thought the workshop had assisted them in feeling confident in protecting themselves (98%). Also, the majority of participants (87%) indicated they would be willing to undertake an STI and BBV screening as a result of the workshop.
Although primary prevention is the main aim of the program, it is very difficult to measure any long-term impact on rates of infection. It is currently not mandatory for testing to be conducted on prisoners entering or exiting the prison system, so we can only speculate on the impact the information provided through HIP HOP has on rates of high risk behaviours (such as sharing injecting equipment).
Anecdotally, we often receive reports from previous participants claiming the course has helped them make informed decisions about taking risks while incarcerated. Discussion around prevention and harm reduction during the sessions can be very lively, and the safe space we create during the workshop enables participants to openly discuss their attitudes towards their current and future behaviours.
Sometimes the candid nature of this discussion shows us that we have provided enough information for prisoners to choose to abstain from high risky behaviours; however, this is not always the case. Some prisoners are open to admitting that they will continue to take risks despite the information we have provided, and the reasons for this are varied and complex.
Although all prisoners have access to BBV education and information regarding the harms associated with sharing injecting equipment, anecdotal evidence suggests injecting drug use rates in prisons remains high. There is much evidence to show that in the absence of access to sterile injecting equipment prisoners will continue to inject, putting themselves and others at risk of BBV transmission, such as hepatitis C.
Such infections have the potential to develop into a life threatening condition decades later. This is why the advent of new hepatitis C treatments, which became available to both prisoners and the general community through the pharmaceutical benefits scheme (PBS) from 1 March 2016, are so vitally important.
These new treatments have few side effects and provide a cure in up to 90% of cases. It is possible that if managed effectively, access to the new treatments could eradicate hepatitis C in the future. Unfortunately the availability of treatments in isolation will not solve the problem of hepatitis C in the community or in prisons.
The factors that contribute to the rapidly growing prevalence of hepatitis C in Australian prisons also need to be addressed. The solution must also include the provision of opiate replacement therapies and access to prison-based needle and syringe programs in tandem with treatment.
The West Australian Department of Corrective Services is to be congratulated for implementing a comprehensive prevention and harm reduction program like HIP HOP, as well as the provision of safe sex equipment, in all prisons. What is now urgently needed is the political will to implement needle and syringe programs within all Australian prisons.
3 Department of Health (DoH). (2014). Fourth National Hepatitis C Strategy 2014–2017. Commonwealth of Australia, Canberra.
4 DoH. (2014). Seventh National HIV Strategy 2014–2017, Commonwealth of Australia, Canberra.
5 Government of Western Australia (WA). Department of Corrective Services, op. cit.
7 Hepatitis C virus projections working group: Estimates and projections of the hepatitis C virus epidemic in Australia 2006.National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney.
8 Butler, T., Lim D., Callander, D. (2011). National Prison Entrants’ Bloodborne Virus and Risk Behaviour Survey Report 2004, 2007, and 2010. Kirby Institute, University of New South Wales, Sydney and National Drug Research Institute, Curtin University, Perth.
9 Dolan, K., Teutsch, S., Scheuer, N., Levy, M., Rawlinson, W., Kaldor, J. (2010). Incidence and risk for acute hepatitis C infection during imprisonment in Australia. European Journal of Epidemiology25(2),143–148.
Matthew Armstrong is Workforce Development Officer at HepatitisWA.