Prevention would be better than care

EDITOR—Edwards et al point out that the main cause of HIV in prisoners is injecting drug use.1 Work done in Scottish prisons indicates that 4% of the male prison population have continued their previous community injecting practices and 8% of male prisoners start injecting in prison. 2 3

Measures for reducing viral transmission in the community, such as needle exchange, are not available in British prisons. It is possible, therefore, that many of the prisoners referred internally had contracted HIV by sharing injecting equipment while incarcerated. The recommendation by Edwards et al that HIV status should be confirmed in all prisoners should therefore be qualified with a recommended frequency. Although, as Edwards et al point out, prison provides an opportunity for inmates to receive care for bloodborne viral disease, which is provided, it also provides an opportunity for prevention which is not provided beyond advice and bleach tablets. I demonstrated the feasibility of a behavioural technique by using buprenorphine in a secure delivery device successfully to prevent injecting in a Scottish prison in 2000; further evaluation of this (or any other harm reduction measure) has been eschewed by those who have the administrative authority to address this important issue. It is admirable that King's College Hospital provides care for prisoners with HIV, but prisoners will continue to be at risk until the government admits that prisons are state sponsored culture media for bloodborne viruses.

Real commitment to prevention is needed

EDITOR—Edwards et al show that the specialist management of HIV within prisons can be of a standard equivalent to that outside, and that most HIV infection is related to injecting drug use.1 Many injecting drug users pass through the prison system, and of these a high proportion will continue to inject.1^–3 The prevalence of bloodborne infections is much higher in prisons, and this facilitates their transmission onwards into the community.

Prevention of bloodborne infection in prisons is not of an equivalent standard to that in the community. What is needed is a commitment to implement proved harm reduction strategies such as education about safe injecting practices, needle exchange schemes, opiate replacement programmes, and the free distribution of condoms without prescription. Current prison service policy, which is the responsibility of the British Home Office, does not facilitate these interventions.

I have participated in providing a training course in communicable diseases and their prevention to prison staff from English prisons. The course is run by Camden and Islington Community Health Services NHS Trust, and funded by Her Majesty's Prison Service. Over the past few years about 90% of English prisons have sent teams to be trained. Unfortunately this training is about to cease, and no plans are in place to replace it. Many of the staff attending have shown a commitment to prevention but are frustrated by a lack of political will to change policy. Harm reduction strategies in prisons are controversial and in conflict with prison rules and the safety of staff and prisoners. Without adequate funding and leadership in policy change there will be no change in the current situation. It is encouraging that the care of HIV infection in prison is being funded and is successful. A real commitment to prevention is now overdue.