Unsafe sex and drug use in India’s prisons is leading to high HIV rates

The National AIDS Control Organisation’s recently launched prisons intervention programme has found that a large number of prison inmates contract HIV because of unsafe sex and the sharing of needles within prisons. Preliminary data from the programme shows that 2.5% of more than 35,000 prisoners tested are HIV positive. The rate of HIV infection among the general adult population is much lower at 0.28%.

The data was gathered with the consent of prisoners in 15 prisons where the programme is being implemented. The majority of HIV positive cases were from Mizoram, with 60 of 455 inmates testing positive – an infection rate of 13%.

“A significantly high number of HIV positive people were intravenous drug users,” said Dr Kanudeep Kaur from Emmanuel Hospital Association, which coordinates the prison intervention programme with the Punjab State Aids Control Society.

Prisoners are also falling ill with hepatitis C and tuberculosis. More than 21,000 inmates at nine prisons in Punjab were tested for hepatitis C and 22% were found to have the disease. About 21% of almost 600 prisoners had tuberculosis. In prisons in the North East, 16% of inmates tested were positive for hepatitis C and about 3% had tuberculosis.

Range of health services

NACO first held a consultations on guidelines to prevent HIV in prison in 2014. In July 2016, NACO launched the programme in 15 prisons across Punjab, Assam, Manipur, Mizoram, Nagaland and Meghalaya.

Although some prisons in India like Tihar Jail in Delhi and Arthur Road Jail in Mumbai have had harm reduction programmes to prevent drug use, sharing of needles and other behaviour considered risky, this is the first concerted effort to prevent HIV transmission among prison inmates.

“It is most important to look at the most marginalised population,” said Sanjeeva Kumar, director general of NACO. “This is a section of society whose health concerns do not matter to many people.”

There are more than four lakh prisoners in India’s 1,401 prisons. NACO has decided to focus the HIV intervention on prisons in areas with high HIV prevalence and large numbers of intravenous drug users, such as Punjab and states in the North East.

Abraham Lincoln, who coordinates NACO’s prison intervention programme, said that the organisation plans to expand the programme to 90 prisons including in Bihar, Uttar Pradesh, Uttarakhand and Rajasthan.

The HIV programme in prisons includes services like providing information on HIV, testing and counselling, and connecting HIV positive inmates to antiretroviral therapy centres. The programme also provides testing and treatment for other sexually transmitted diseases. NACO is also concerned that HIV positive inmates can eventually transmit the disease outside prison, especially to members of their families. Many prisoners are undertrials who might be acquitted and leave prison. Others might get out on bail or after serving a short sentence. The programme also seeks to prevent this spread. Programme officers visit families of prisoners who might be released. “We try to improve adherence to treatment by going to their families (with the inmate’s consent) and counsel them about the disease,” said Kailash Ditya, deputy team leader of NACO’s North East technical support unit.

High risk of contracting disease

India has very little data on HIV prevalence and high risk behaviors in prison but some studies like the National Integrated Biological and Behavioral Surveillance 2014-’15 among high risk groups report drug injecting practices in prisons in every state. A study at Arthur Road jail in 2006 showed that men often have unprotected sex with other men, which might be consensual or coercive. Nalinikanta Rajkumar, president of the Community Network for Empowerment, who conducted hepatitis C screening activities inside Sajiwa Jail in Imphal has observed inmates sharing razors which increases the risk of contracting the disease.

Then, there is the environment conducive to tuberculosis. “If you look at inmates who stay for long periods of time in prison, they come from poor socio-economic strata,” said Vijay Raghavan, dean of the social protection office at the Tata Institute of Social Sciences. “Their nutrition levels prior to prison was already low. In prison, the conditions are such that there is increased vulnerability to diseases such as tuberculosis.”

Raghavan also pointed out that one of the major problems in prisons is a lack of medical facilities and a shortage of doctors and paramedics.

Resistance from police, prison staff

Implementing the programme has already thrown up some challenges at the prisons, which are already short-staffed.

In Uttar Pradesh, where testing for HIV and TB has started in four jails, some jail superintendents expressed apprehension to initiate HIV screening, said Umesh Mishra from the Uttar Pradesh State Aids Control Society. “They say that screening can be a security issue,” he said. NACO officials said that prison authorities are wary of letting people from outside the prison establishment interact with prisoners.

A programme coordinator who works with Guwahati Central Jail authorities said that during a talk to prisoners on the routes of HIV transmission which includes the unprotected sex, prison officials told them not to talk about “obscene subjects”.

No harm reduction programme

The World Health Organisation’s representative to India Henk Bekedam said during the consultation that inmates’ HIV risk can be minimised by giving drug users clean needles and syringes and by providing them opioid substitution therapy.

The needle and syringe programme is one of the 15-key interventions advocated for HIV prevention, treatment and care in prisons by the United Nations Office on Drugs and Crime and by WHO. However, most countries have not instituted this intervention citing security concerns.

Opioid substitution therapy involves giving a drug user a long-acting opioid like buprenorphine under medical supervision and along with psychosocial interventions, which helps reduce drug withdrawals and cravings and reduces the likelihood of the patient resorting to illegal means to get drugs.

All inmates can also be given condoms, said Bekedam.

Of the prisons in the programme, Shillong District Jail provides opioid substitution therapy to drug users. Punjab prisons only allow drug detoxification programmes to be carried out, which helps manage withdrawal symptoms. Kaur said that the Punjab government too wants to start opioid replacement therapy in prisons. But Lincoln said that the jail manual does not allow them to start either a clean needles and syringes programme or distribute condoms.

“The prison officials are in denial mode,” said an activist working with the prison intervention programme. “They say sex is not taking place in prison. They also say there are no drugs in prison. If we accept that both drugs and needles are smuggled inside prisons, then it poses a big question mark on the security at prisons.”

Meanwhile, one area where the HIV prisons intervention programme seems to be helping is to lend inmates a ear. “Prisoners are often relieved to have a friendly face and a ready ear to listen in prison,” said a programme coordinator in Guwahati. “Incarceration has a physical and a mental effect on people’s lives. They often cry just by talking to us.”