WH0/GPA/DIR/93.3
Original: English
Distr.: Limited
GLOBAL
PROGRAMME
ON AIDS
WHO
GUIDELINES ON
HIV INFECTION AND AIDS
IN PRISONS
GENEVA
MARCH 1993
WORLD
HEALTH
ORGANIZATION
|
UNAIDS/99.xxE (English original, Date) |
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Joint United Nations Programme on HIV/AIDS (UNAIDS) 1999. All rights
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WHO/GPA/DIR/93.3
WHO Guidelines on HIV Infection and AIDS in Prisons
Geneva
March
1993
Contents
B
HIV
testing in prisons
2
C
Preventive
measures
2
(i)
Education
and information
2
(ii)
Sexual
transmission
3
(iii)
Transmission
by injection
3
(iv)
Use of
other substances that may increase the
likelihood of HIV
transmission
3
E.
Confidentiality
in relation to HIV/AIDS
4
F.
Care and
support of HIV‑infected prisoners
5
G.
Tuberculosis
in relation to HIV infection
5
H.
Women
prisoners
6
I.
Prisoners
in juvenile detention centres
6
J.
Foreign
prisoners
7
K.
Semi‑liberty
and release
7
L.
Early
release
7
O.
Evaluation
and research
8
WHO/GPA/DIR/93.3
These guidelines were prepared on the basis of technical advice provided to WHO prior to and during a consultation of experts convened in Geneva in September 1992. The consultation included representatives of international and nongovernmental organizations and government departments with a wide range of experience and background in the health, management, and human rights aspects of HIV/AIDS in prisons.
The guidelines provide standards ‑ from a public health perspective ‑ which prison authorities should strive to achieve in their efforts to prevent HIV transmission in prisons and to provide care to those affected by HIV/AIDS. It is expected that the guidelines will be adapted by prison authorities to meet their local needs.
WHO/GPA/DIR/93.3
A.
General principles
1.
All prisoners have the right to receive health care, including preventive
measures, equivalent to that available in the community without discrimination,
in particular with respect to their legal status or nationality.
3.
In each country, specific policies for the prevention of HIV/AIDS in
prisons and for the care of HIV‑infected prisoners should be defined.
These policies and the strategies applied in prisons should be developed through
close collaboration among national health authorities, prison administrations,
and relevant community representatives, including nongovernmental organizations.
These strategies should be incorporated into, a wider programme of promoting
health among prisoners.
4.
Preventive measures for HIV/AIDS in prison should be complementary to and
compatible with those in the community. Preventive measures should aIso be based
on risk behaviours actually occurring in prisons, notably needle sharing among
injecting drug users and unprotected sexual intercourse. Information and
education provided to prisoners should aim to promote realistically achievable
changes in attitudes and risk behaviour, both while in prison and after release.
5.
The needs of prisoners and others in the prison environment should he
taken into account in the planning of national AIDS programmes and community
health and primary health care services, and in the distribution of resources,
especially in developing countries.
6.
The active involvement of nongovernmental organizations, the involvement
of prisoners, and the non‑discriminatory and humane care of
HIV‑infected prisoners and of prisoners with AIDS are prerequisites for
achieving a credible strategy for preventing HIV transmission.
7.
lt is important to recognize that any prison environment is greatly
influenced by both prison staff and prisoners. Both groups should, therefore
participate actively in developing and applying effective preventive measures,
in disseminating relevant information, and in avoiding discrimination.
8.
Prison administrations have a responsibility to define and put in place
policies and practices that will create a safer environment and diminish the
risk of transmission of HIV to prisoners and staff alike.
9.
Independent research in the field of HIV/AIDS among prison populations
should been encouraged to shed light on ‑ among other things ‑
successful interventions in prisons. Independent examination by an ethical
review committee should be carried out for all research procedures in prisons,
and ethical principles must be strictly observed. The results of such studies
should be used to benefit prisoners, for example by improving treatment regimens
or HIV/AIDS policies in prisons. Prison administrations should not seek to
influence the scientific aspects of such research procedures, their
interpretation or their publication.
1
WHO Guidelines on HIV infection and AIDS in prisons
10.
Compulsory testing of prisoners for HIV is unethical and ineffective, and
should be prohibited.
11.
Voluntary testing for HIV infection should be available in prisons when
available in the community, together with adequate pre‑ and
post‑test counselling. Voluntary testing should only be carried out with
the informed consent of the prisoner. Support should be available when prisoners
are notified of test results and in the period following.
12.
Test results should be communicated to prisoners by health personnel who
should ensure medical confidentiality.
13.
Unlinked anonymous testing for epidemiological surveillance should only
be considered if such a method is used in the general population of the country
concerned. Prisoners should be informed about the existence of any
epidemiological surveillance carried out in the prison where they are, and the
findings of such surveillance should be made available to the prisoners.
(i) Education and information
14.
Prisoners and prison staff should be informed about HIV/AIDS and about
ways to prevent HIV transmission, with special reference to the likely risks of
transmission within prison environments and to the needs of prisoners after
release. The information should be coordinated and consistent with that
disseminated in the general community. Information intended for the general
public (through posters, leaflets, and the mass media) should also be available
to prisoners. All written materials distributed to prisoners should be
appropriate for the educational level in the prison population; information
should be made available in a language and form that prisoners can understand,
and presented in an attractive and clear format.
15.
Prison staff should receive HIV/AIDS prevention information during their
initial training and thereafter on a regular basis.
16.
Prisoners should receive HIV/AIDS education on entry, during their prison
term, and in pre‑release programmes. All prisoners should have an
opportunity to discuss the related information with qualified people.
Face‑to‑face communication, both in groups and on an individual
basis, is an important element in education and information.
17.
Consultation with, and participation of, inmates and staff in the
development of educational materials should be encouraged.
18.
In view of the importance of peer education, both prison staff and
prisoners themselves should be involved in disseminating information.
19. Education on infection control should emphasize the principles of universal precautions and hygiene. The lack of any risk of HIV transmission as a result
2
WHO/GPA/DIR/93.3
of normal
everyday contact should he emphasized. Excessive and unnecessary precautions
while handling HIV‑infected prisoners should be avoided.
(ii) Sexual
transmission
20.
Clear information should be available to prisoners on the types of sexual
behaviour that can lead to HIV transmission. The role of condoms in preventing
HIV transmission should also be explained. Since penetrative sexual intercourse
occurs, in prison, even when prohibited, condoms should be made available to
prisoners throughout their period of detention. They should also be made
available prior to any form of leave or release.
21.
Prison authorities are responsible for combating aggressive sexual
behaviour such as rape, exploitation of vulnerable prisoners (e.g., transsexual
or homosexual prisoners or mentally disabled prisoners) and all forms of
prisoner victimization by providing adequate staffing, effective surveillance,
disciplinary sanctions, and education, work and leisure programmes. These
measures should he applied regardless of the HIV status of the individuals
concerned.
(iii) Transmission by injection
22.
As part of overall general HIV education programmes, prisoners should be
informed of the dangers of drug use. The risks of sharing injecting equipment,
compared with less dangerous methods of drug-taking, should be emphasized and
explained. Drug‑dependent prisoners should be encouraged to enrol in drug
treatment programmes while in prison, with adequate protection of their
confidentiality. Such programmes should include information on the treatment of
drug dependency, and on the risks associated with different methods of drug use.
23.
Prisoners on methadone maintenance prior to imprisonment should be able to
continue this treatment while in prison. In countries in which methadone
maintenance is available to opiate‑dependent individuals in the community,
this treatment should also be available in prisons.
24.
In countries where bleach is available to injecting drug users in the
community, diluted bleach (e.g. sodium hypochlorite solution) or another
effective viricidal agent, together with specific detailed instructions on
cleaning injecting equipment, should be made available in prisons housing
injecting drug users or where tattooing or skin piercing occurs. In countries
where clean syringes and needles are made available to injecting drug users in
the community, consideration should be given to providing clean injecting
equipment during detention and on release to prisoners who request this.
25.
Prison health services must have adequate material and resources available
to ensure that HIV transmission through the use of non‑sterile equipment
during medical procedures does not occur.
26.
Orally ingested or inhaled psychoactive substances, such as cocaine,
solvents and alcohol, some of which are used to a considerable extent in
different prison
3
WHO
Guidelines on HIV infection and AIDS in prisons
settings worldwide, may increase the likelihood of HIV
transmission by impairing judgement and hindering the adoption of preventive
measures by prisoners in circumstances where these measures would be required.
Therefore, actual and potential users of psychoactive drugs should he made aware
of this, as well as of other possible handful effects and consequences of these
substances in the broader context of health education.
27.
Since segregation, isolation and restrictions on occupational activities,
sports and recreation are not considered useful or relevant in the case of
HIV‑infected people in the community, the same attitude should be adopted
towards HIV‑infected prisoners. Decisions on isolation for health
conditions should be taken by medical staff only, and on the same grounds as for
the general public, in accordance with public health standards and regulations.
Prisoners' rights should not he restricted further than is absolutely necessary
on medical grounds, and as provided for by public health standards and
regulations. HIV‑infected prisoners should have equal access to workshops
and to work in kitchens, farms and other work areas, and to all programmes
available to the general prison population.
28.
Isolation for limited periods may be required on medical grounds for
HIV‑infected prisoners suffering from pulmonary tuberculosis in an
infectious stage. Protective isolation may also be required for prisoners with
immunodepression related to AIDS, but should be carried out only with a
prisoner's informed consent. Decisions on the need to isolate or segregate
prisoners (including those infected with HIV) should only be taken on medical
grounds and only by health personnel, and should not be influenced by the prison
administration.
29.
Disciplinary measures, such as solitary confinement for prisoners,
including perpetrators of aggressive, or predatory sexual, acts or those who
threaten such acts, should be decided upon without reference to HIV status.
30.
Efforts should be made to encourage among prisoners supportive attitudes
‑ towards, for example, those affected by HIV/AIDS ‑ in order to
prevent discrimination and to combat fear and prejudice about HIV‑infected
people.
E. Confidentiality in relation to HIV/AIDS
31.
Information on the health status and medical treatment of prisoners is
confidential and should be recorded in files available only to health personnel.
Health personnel may provide prison managers or judicial authorities with
information that will assist in the treatment and care of the patient, if the
prisoner consents.
32.
Information
regarding HIV status may only be disclosed to prison managers if the
health personnel consider,
with due regard to medical ethics, that
this is warranted to ensure the safety and well‑being of prisoners and
staff, applying to disclosure the same principles as those generally applied in
the community. Principles and procedures relating to voluntary partner
notification in the community should he followed for prisoners.
4
WH0/GPA/DIR/93.3
33. Routine communication of the HIV status of prisoners to the prison administration should never take place. No mark, label, stamp or other visible sign should be placed on prisoners' files, cells or papers to indicate their HIV status.
F.
Care and support of HIV‑infected prisoners
34.
At each stage of HIV‑related illness, prisoners should receive
appropriate medical and psychosocial treatment equivalent to that given to other
members of the community. Involvement of all prisoners in peer support
programmes should be encouraged. Collaboration with health care providers in the
community should he promoted to facilitate the provision of medical care.
35.
Medical follow‑up and counselling for asymptomatic
HIV‑infected prisoners should be available and accessible during
detention.
36.
Prisoners should have access to information on treatment options and the
same right to refuse treatment as exists in the community.
37.
Treatment for HIV infection, and the prophylaxis and treatment of related
illnesses, should be provided by prison medical services, applying the same
clinical and accessibility criteria as in the community.
38.
Prisoners should have the same access as people living in the community to
clinical trials of treatments for all HIV/AIDS‑related diseases. Prisoners
should not be placed under pressure to participate in clinical trials, taking
into account the principle that individuals deprived of their liberty may not be
the subjects of medical research unless they freely consent to it and it is
expected to produce a direct and significant benefit to their health.
39.
The decision to hospitalize a prisoner with AIDS or other
HIV‑related diseases must be made on medical grounds by health personnel.
Access to adequately equipped specialist services, on the same level available
to the community, must be assured.
40.
Prison medical services should collaborate with community health services
to ensure medical and, psychological follow‑up of HIV‑infected
prisoners after their release if they so consent. Prisoners should be encouraged
to use these services.
G.
Tuberculosis in relation to HIV infection
41.
The prison environment is often conducive to tuberculosis transmission and
rates may he higher than in the general population. Furthermore, tuberculosis is
increasingly associated with HIV/AIDS, so that the presence of
HIV‑infected prisoners may increase the risk of tuberculosis transmission.
Vigorous efforts are therefore needed to reduce the risks related to the
environment (e.g., by improving ventilation, reducing overcrowding, and
providing adequate nutrition); to detect cases of tuberculosis as early as
possible through screening for tuberculosis on entry and at regular intervals
during imprisonment, and through contact tracing; and to provide effective
treatment.
5
WHO
Guidelines on HIV infection and AIDS in prisons
42.
Diagnostic screening for tuberculosis in prison staff should also be
available. Treatment programmes for prisoners with tuberculosis should be
available in prisons, and adequate follow‑up should be ensured when
treated prisoners are transferred or released.
43.
Epidemiological surveillance of tuberculosis among prison inmates and
prison personnel is needed. Special attention should be paid to the early
detection of outbreaks of drug‑resistant tuberculosis and their control by
public health measures. In particular, strategies should be implemented to
ensure that prisoners complete tuberculosis treatment regimens.
H.
Women prisoners
44.
Special attention should be given to the needs of women prisoners. Staff
dealing with detained women should be trained to deal with the psychosocial and
medical problems associated with HIV infection in women.
45.
Women prisoners, including those who are HIV‑infected, should
receive information and services specifically designed for their needs,
including information on the likelihood of HIV transmission, in particular from
mother to infant, or through sexual intercourse. Since women prisoners may
engage in sexual intercourse during detention or release on parole, they should
be enabled to protect themselves from HIV infection, e.g., through the provision
of condoms and skills in negotiating safer sex. Counselling on family planning
should also be available, if national legislation so provides. However, no
pressure should be placed on women prisoners to terminate their pregnancies.
Women should be able to care for their young children while in detention
regardless of their HIV status.
46.
The following should be available in all prisons holding women:
§
gynaecological consultations at regular intervals, with particular
attention paid to the diagnosis and treatment of STDs
§
family planning counselling services oriented to women's needs
§
care during pregnancy in appropriate accommodation
§
care for children, including those born to HIV‑infected mothers
§
condoms and other contraceptives during detention and prior to parole
periods or release.
I.
Prisoners in juvenile detention centres
47.
Health education programmes adapted to the needs of young prisoners should
he organized to foster attitudes and behaviour conducive to the avoidance of
transmissible diseases including HIV/AIDS. Decisions concerning children and
adolescents, such as notifying parents of their children's HIV status, or
obtaining consent to treatment should be taken on the same grounds as in the
community, with due regard for the principle that the best interests of the
child are paramount.
6
J. Foreign prisoners
48.
The needs of foreign prisoners should he respected without discrimination.
Prison authorities should he trained to respond to requirements such as
assistance with languages, oral contact with families and counselling services.
Adequate measures should be adopted to provide for the protection of
HIV‑infected foreign prisoners in the case of prisoner transfer/exchange
programmes between different countries, extradition proceedings and other
interchanges.
K.
Semi‑liberty and release
49.
Prisoners should not be excluded from measures such as placements in
semi‑liberty hostels or centres, or any other type of open or
low‑security prison, on the grounds of their HIV status, nor should such
placement he contingent upon disclosure of HIV status.
50.
Community‑based medical care, psychological support and social
services should be organized for HIV‑infected prisoners to facilitate
their integration into the community after release.
L.
Early release
51.
If compatible with considerations of security and judicial procedures,
prisoners with advanced AIDS should he granted compassionate early release, as
far as possible, in order to facilitate contact with their families and friends
and to allow them to face death with dignity and in freedom.
52.
Prison medical services should provide full information on such prisoners'
health status, treatment needs and prognosis, if requested by the prisoner, to
the authorities competent to decide upon early release. The needs of those
prisoners without resources in the community should be taken into account in any
early release decision.
M.
Contacts with the community and monitoring
53.
Cooperation with relevant nongovernmental and private organizations, such
as those with expertise in AIDS prevention, counselling and social support,
shouId be encouraged. HIV‑infected prisoners should have access to
voluntary agencies and other sources of advice and help.
54.
Independent organizations concerned with prisoners' interests shouId have
access to HIV‑infected prisoners, if the prisoners so wish, and should
draw attention to any instances of substandard care, discrimination,
non‑respect of ethical principles or deviation from established prison
policies and procedures to ensure the humane treatment of prisoners.
55.
Regular visits to, and supervision of, all prison establishments should be
carried out by public health authorities independent of prison administrations.
7
WHO
Guidelines on HIV infection and AIDS in prisons
56.
Prisoners should he able to complain to an independent competent body
about substandard treatment, discrimination or non‑respect of basic
ethical principles in relation to HIV/AIDS, and effective redress should be
available.
N.
Resources
57.
Adequate resources for prison health care, for related staffing and for
specific HIV/AIDS‑related activities should be ensured by authorities. The
resources made available should be used for preventive measures, counselling,
outpatient consultation, medication, and hospitalization.
O.
Evaluation and research
58.
Studies concerning HIV/AIDS in prison populations are recommended in order
to establish an adequate information base for planning policies and
interventions in this field. Such studies could investigate for example the
prevalence of HIV infection or the frequency of risk behaviours for HIV
transmission.
59.
The implementation of interventions by prison authorities to prevent the
transmission of HIV and to provide care to those affected by HIV/AIDS should be
evaluated. Such evaluations should be used by prison administrations to improve
the design and implementation of interventions.
* * *
8