Behind the Walls

Some people who smoked drugs on the outside begin to inject them while they are in prison because injection does not produce smoke, which might alert the guards. As well, random urine testing for drugs means that some people may switch from smoking marijuana, which can stay in the body for weeks, to injecting drugs like cocaine and heroin, which clear quickly from the body.

Because there is no official access to sterile syringes in prisons, people resort to sharing injection equipment and this increases the risk of HIV or HCV transmission. Given the high rates of HCV in prisons, the danger of co-infection is very real for people living with HIV. Co-infection comes with its own set of medical issues, including faster liver disease progression, more complicated treatment schedules for both HIV and HCV, and lower HCV treatment success rates. Making matters worse, in prisons, care for hepatitis C lags. Only four percent of HCV-positive prisoners receive treatment. Ironically, as it was for Daniels and her HIV treatment, the routine and structure of prison life can help people succeed with the often year-long regimen of daily pills and weekly injections that make up HCV treatment.

HIV and, with greater difficulty, HCV also pass during sex, and sex is definitely happening in Canadian prisons. In the 2007 survey, 17 percent of male prisoners and 31 percent of female prisoners reported having oral, vaginal or anal sex in the past six months. Almost all reported at least one instance of unprotected sex and a significant proportion said they had sex with someone who was positive for HIV or HCV or whose status they didn't know. A 2008 ban on tobacco in federal prisons may also be playing an indirect and unexpected role in the increased transmission of HIV. "Tobacco was the jail house currency," Foreman explains. "Now any tobacco that comes in is sold at astronomical prices. What have taken its place [in everyday bartering] are sexual services."

Experts realize that reducing HIV and HCV transmission in prisons is going to require programs to reduce the risks associated with injection drug use. Reducing drug use itself is one tactic, and prison programs do exist to help prisoners address their drug dependence. Harm reduction, an approach advocated by many experts and activists, supports such rehabilitation but also acknowledges that injection drug use happens in prisons and encourages looking for ways to make it safer.

Needle and syringe programs seem an obvious solution, yet the Canadian prison system has not allowed their introduction. A zero-tolerance policy for drugs in prisons precludes any activity that would acknowledge drug use. It's true that other prevention and harm reduction measures -- condoms, dental dams, bleach for needles -- are in place. Douglas Foreman applauded their introduction into prisons in the early 1990s, but there's still a long way to go. For example, bleach can kill HIV -- though Cherian points out there is no evidence that it is effective at killing HIV in the makeshift syringes normally found in prisons -- but is not effective at killing HCV. What's more, research shows that even approved prevention tools are not consistently available in Canadian prisons.

As well, tattooing with improvised machines and unsterile equipment is common in prisons and carries the risk of transmitting HIV and HCV. A pilot prison tattooing program started in mid 2005 by Correctional Service of Canada was shut down in December 2006 by the then newly elected federal government, even though a draft report of an evaluation said the program had potential to reduce the risk of transmission.

For national-level research and advocacy about HIV in prisons, the Canadian HIV/AIDS Legal Network has long been at the forefront, holding conferences and producing important documents. "As a legal organization, we can focus on research and policy analysis and advocate for the health and human rights of people in prison in a way that complements the work of grassroots organizations," says Sandra Ka Hon Chu, co-author of two of the organization's detailed reports on the need for needle and syringe programs in prisons. (See resources. The two reports contain many stories of prisoners living with HIV.)

While getting needle and syringe programs into prisons would help slow the spread of HIV and HCV, it might be the growing rates of hepatitis C that finally convince authorities to address the problem. Ford, the HIV specialist whose groundbreaking early research drew attention to the prevalence of HIV in Canadian prisons, argues that HCV is so rampant inside that it amounts to a "new epidemic." In November 2009 he traveled to Ottawa to educate members of the federal Standing Committee on Public Safety and National Security about these issues. "What we're looking at," he told the committee, "is a problem with a communicable blood-borne disease. ... Corrections is going to find itself looking after people with terminal liver failure, and this is a very expensive prospect."

For her part, Daniels has not yet taken treatment for hepatitis C. A few years ago, her friend begged her to wait until she was in a more stable place in her life before considering to undertake the often-grueling treatment. She thinks the time has come and has started talking with her doctor and collecting information. As for Foreman, he is also fighting to be treated for HCV. While both his HIV and HCV infections are critically important, he knows that, untreated, it's the HCV he acquired back in 1991 that poses the greatest risk to his health.