The Third National Hepatitis C Strategy 2010 - 2013

5.3 People in custodial settings

Page last updated: July 2010

People in custodial settings are at increased risk of exposure to hepatitis C because of the high number in prison for drug-related offences, the high prevalence of hepatitis C in prison populations and the associated use of non-sterile injecting equipment, and the sharing of tattooing and piercing equipment and other blood-to-blood contact. The combination of the transmission of hepatitis C in custodial settings and prisoner recidivism presents a challenge to controlling the infection in these settings and in the broader community.27

Two priority populations at risk of hepatitis C exposure are significantly overrepresented in custodial settings—people who inject drugs and Aboriginal and Torres Strait Islander peoples who represent 24 per cent of Australia’s prison population. The 2007 National Prison Entrants’ Bloodborne Virus and Risk Behaviour Survey28 found that 35 per cent of prisoners tested positive to hepatitis C antibodies, 40 times higher than in the general population, and significantly higher than in juvenile justice facilities.29

Initiating hepatitis C prevention and treatment measures in custodial settings is hampered by structural barriers. These include lack of capacity to implement the full range of evidence-based, harm-reduction interventions, particularly NSPs which are a critical element of the national response to hepatitis C.30, 31 However, custodial settings can provide people at high risk of infection with access to education, diagnosis and treatment as well as screening for other BBVs, particularly hepatitis B and vaccination where indicated.32

Each state and territory has its own independent systems for police, courts, prisons and juvenile institutions. Health services are provided variously by health or justice jurisdictions and supplied directly, or contracted, by public and private custodial facilities. Australia’s prison systems are relatively small and isolated from each other. This presents challenges for coordinating research and policy development, implementing, evaluating and educating. However, these challenges have been overcome within the custodial environment to enable effective responses to a number of key public health issues including BBV and STI initiatives such as provision of condoms, access to bleach, provision of opioid pharmacotherapies, and the National Prison Entrants BBV & Risk Behaviour Survey.

The provision of sterile injecting equipment in Australian prisons is a controversial issue for some in the community. An increasing number of international jurisdictions have implemented or are actively contemplating the implementation of NSPs in prisons. To date there is no evidence of adverse outcomes associated with these programs. However, several positive or beneficial outcomes have been documented from programs that have undergone evaluation, including: no documented increase in illicit or injecting drug use; significant reductions in equipment reusing/sharing; no documented attacks or violence; no documented seroconversion for HIV or hepatitis; and acceptance of the program by staff and prisoners. In view of the well documented return on investment and effectiveness of Australian community-based NSPs, it is appropriate throughout the life of this strategy for state and territory governments to identify opportunities for trialling this in Australian custodial settings. This is also supported by the international evidence demonstrating the effectiveness of prison NSPs.

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In addition, it is essential that the full range of BBV and STI prevention strategies be maintained in Australian custodial settings, including:

  • increasing the provision of, and access to, bleach and disinfectants where no safer alternatives are provided for decontaminating spills, surfaces or equipment
  • easily accessible education and counselling—including peer education and support on HIV and STIs, hepatitis B, hepatitis C and injecting drug use—as a fundamental health promotion technique to support risk reduction practices
  • increasing access to drug treatment programs, including opioid pharmacotherapy programs which have reduced BBV transmission in custodial settings, as well as detoxification and drug rehabilitation programs.
Strategies should also be explored for developing and promoting Australian infection control standards for tattooing and body art to further reduce the risk of BBV transmission in custodial settings.

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27 Ministerial Advisory Committee on AIDS, Sexual Health and Hepatitis, Hepatitis C Subcommittee, 2008, Hepatitis C Prevention, Treatment and Care: Guidelines for Australian Custodial Settings. July.
28 Butler T & Papanastasiou C 2008, National Prison Entrants’ Bloodborne Virus and Risk Behaviour Survey Report 2004 and 2007. National Drug Research Institute (Curtin University) & National Centre in HIV Epidemiology and Clinical Research (University of New South Wales).
29 van der Pooten D, Kenny DT & George J ‘Prevalence and Risk Factors for hepatitis C in Aboriginal and non-Aboriginal adolescent offenders’, Medical Journal of Australia 2008; 188 (10): pp. 610–614 <http://www.mja.com.au/public/issues/188_10_190508/van10170_fm.html#0_pgfId-1092050>
30 Dolan K, Rutter S & Wodak AD 2002, ‘Prison-based syringe exchange
programmes: a review of international research and development’ Addiction,
vol. 98, pp. 153–158.
31 Dolan K, Shearer J, White B, Zhou J, Kaldor J & Wodak AD 2005, ‘Four-year Follow-up of imprisoned male heroin users and methadone treatment: mortality, re-incarceration and hepatitis C infection’, Addiction, 100, pp. 820–828.
32 Dolan K, Shearer J, White B, Zhou J, Kaldor J & Wodak AD 2005, ‘Four-year Follow-up of imprisoned male heroin users and methadone treatment: mortality, re-incarceration and hepatitis C infection’, Addiction, 100, pp. 820–828.