HIV/AIDS and TB Prevention, Treatment and Care for Female Prisoners (Including Injecting

Prison Health Expert Group

Sixth Meeting

Oslo, Norway

30 September –

1 October 2008

Reference / PH 6/10/1
Title / Project Proposal “HIV/AIDS and TB prevention, treatment and care for female prisoners”
Submitted by / PH EG ITA
Summary / Note / -
Requested action / For information and reference

HIV/AIDS and TB prevention, treatment and care for female prisoners (including injecting drug users)

CONCEPT PAPER

Female prisoners represent between two and ten percent of the total prison population in the world. During the last ten years, the number and percentage of female prisoners has remained relatively stable in the ND area within countries like Denmark, Latvia, Norway, and Sweden. The number of female prisoners has increased in Estonia and Finland. In some other countries, overall trends in the numbers and percentages of female prisoners are more complex, such as in Germany and Poland, where the numbers of female prisoners have increased while the percentage of the total prison population has remained consistent.On average, five percent of the total prison population in the Nordic countries consists of women. In general, “Women have been particularly effected by increasingly though anti-drug laws in some countries which have led to a much faster rate of imprisoned women” (European society of criminology 2007:13).

Background and Justification

1.1 Gender Equality in Prison Health

Female prisoners are a minority but a non-deniable group in all national prison regimes. This

requires equal opportunities and females’ equal access to social, economic and cultural rights. Up until today, female prisoners have been at a disadvantage in obtaining information about their rights as prisoners, gaining access to vocational and educational training, and adequate health care in prisons

1.2Female prisoners

The number of females in prison is lower than the number of males, but the proportion of drug users among female inmates is higher than among male inmates. Injecting drug use with contaminated injecting equipment is particularly prevalent among female prison populations. HIV among female prisoners is higher than that of incarcerated males. Reasons for this include that the majority of females in prisons are members of social groups marginalized not only on the basis of gender, but also on the basis of race, class, sexual orientation, disability, substance use, and occupation. Female prisoners often have more health problems (in number and severity) than male prisoners. Many suffer from chronic health conditions resulting from lives of poverty, drug use, family violence, sexual assault, adolescent pregnancy, malnutrition, and poor preventive health care.

1.3HIV among female prisoners

Women are more at risk of contracting HIV from sexual activities than men are, due to a number of factors: The main groups at risk are young women engaging in at-risk sexual behaviour with multiple partners, engaging in intravenous drug-use, have a history of drug-related offences and are involved in prostitution

1.4Why are female injecting drug users so vulnerable?

The risk factors for HIV infection among injecting drug users differ significantly by gender. Many female injecting drug users trade sex for money or drugs. Female injecting drug users involved in sex work are more vulnerable to HIV infection than males IDU or female injecting drug users who are not involved in sex work. Female injecting drug users who are sex workers are more likely to engage in unprotected sex with single and multiple partners, and to share needles and syringes with their sex partners. Female injecting drug users also commonly report sexual violence, unconnected with sex work. Finally, harassment, imprisonment and extortion are common experiences among female drug users.

1.5Biology

Drug use characteristics are exacerbated by female physiology. Females are at least twice as vulnerable as males to HIV, in terms of being infected via sexual transmission. Sexually transmitted infections, such as syphilis, gonorrhoea, chlamydia, trichomoniasis, genital ulcers and herpes can greatly increase the risk of becoming infected with HIV. Lowered immunity associated with sexually transmitted infections makes it easier for HIV to enter a female body.

1.6Contaminated injecting equipment

The overall rate of females using contaminated injecting equipment is greater than for males. It is a common practice for female drug injectors to use injecting equipment after their partners. It is often impossible for a female to ask for clean injecting equipment from her partner as it implies that she does not trust him. Females also share non-sterile injecting equipment with more people in their social networks than males do.

1.7Discrimination and disgrace

Females who inject drugs are more likely to be stigmatized by society than male injecting drug users because their activities are considered to be doubly deviant. It is generally considered that drug injecting violates social norms of behaviour, and drug injecting by females is considered even worse as it diverges from traditional expectations of women as wives, mothers, daughters and nurturers of families. Because of this stigma, females are more likely to conceal their drug injecting behaviour and their injecting is often undertaken in unsafe circumstances.

1.8Pregnant females

Pregnant injecting drug users, who could be also infected with HIV, form an additional subgroup of female injecting drug users with specific needs. Recognizing that many of the drug-using females are of child-bearing age and that there are intimate connections between unsafe injecting practices and HIV transmission and also between unsafe sexual practices and HIV transmission, countries have experienced increasing numbers of pregnant females who are found to be HIV positive with a history of past or current drug use. In the social and economic contexts where females find it difficult to access appropriate psychosocial and medical support when identified as “HIV positive” and as “drug users”, the co-incidence of these conditions with pregnancy is likely to expose them to severe stigma and discrimination. Issues related to mother-to-child transmission of HIV are also very relevant within this context.

1.9. Concomitant TB

There is an interaction between TB and HIV that tends to worsen both conditions among co-infected individuals. HIV-infection is the strongest risk factor for development of active TB after transmission of TB. Active TB has been associated with faster evolution to profound immuno-suppression among HIV-infected. TB is the main cause of death among people living with HIV/AIDS in the world. Both infections are concentrated in some common high-risk groups like the drug users and prisoners or ex-prisoners and this association can lead to a dramatic increase of co-infection in these segments of the population. The effects of TB on HIV are multiplied due to the presence of MDR TB, which increases mortality and the period of infectiousness and decreases treatment success rates.

In prison settings the risk of transmission of TB is multiplied due sharing the same airspace, overcrowding, lack of proper infection control measures and lack of rapid diagnostic services. The increasing number of drug users and HIV-infected in the prisons does farther increase this risk.

In countries where there is drug user driven HIV epidemic combined with MDR-TB epidemic a close and comprehensive cooperation between the HIV/AIDS program and TB control program especially in prison setting is compulsory in order to prevent a possible dual MDR TB/ HIV epidemic, which would as a consequence increase both HIV and MDR TB in the whole society.

1.10Barriers to getting help

Services are, generally, not gender responsive and the specific needs of female injecting drug users are not met. The lack of trained female service providers, for example, with adequate skills and appropriate attitudes often deters female injecting drug users from accessing services. Female injecting drug users with children may also not seek services due to a fear of hostility from practitioners or of having their children taken away from them. Many HIV/AIDS prevention and care services, including for drug dependence treatment, do not admit women clients, particularly if they are pregnant, HIV positive, or if they have children. The reasons for restrictive admission policies include lack of sex-segregated accommodation and child-care facilities. Females may also encounter barriers in accessing services because of household responsibilities, lack of family support, lack of social networks and lack of financial resources, lack of privacy and confidentiality, and fear of being stigmatised.

1.11What needs to be done?

There is a need for gender responsive comprehensive services which address women’s specific needs. This approach would include:

To improve the legal and policy frameworks with the view to establish favourable environments for rapid, large-scale and comprehensive interventions
Community outreach particularly peer outreach by female peer educators;
Gender-sensitive HIV/AIDS prevention and care materials;
Prevention of TB transmission
Antiretroviral treatment for female drug users and prevention of mother-to-child HIV transmission.
Adherence support measures for female drug users with active TB and/or HIV-infection ensuring the continuity of care on transfer in and out of prison
Capacity development. Strengthen of organizational and operational capabilities of institutions, in order tobetter perform their functions.
To document and disseminate lessons learned within the country and to a wider audience in the Northern Dimension region and beyond

1.12Elements of current proposal

Creation of an enabling environment;
Capacity building and training for service providers in gender-sensitive provision of services;
Direct service provision of a comprehensive package in a gender-sensitive manner;
Sharing the lessons learned
Monitoring and evaluation.

1.13Participation of target group in project design

The first objective of the proposed project activities is to conduct an assessment of the service needs of female prisoners, with the close involvement of female prisoners, in each of the proposed countries, in order to better inform later activities.

The Goal of the Project:

To overview and to analyse internationally available and nationally implemented guidelines on HIV/AIDS and TB case management for female prisoners, to support ongoing activities in Lithuania, Latvia, Estonia, Poland and Belarus prison settings and to strengthen those services through training and interactive workshops. To advice European Commission on HIV/AIDS and TB case management policy for female prisoners within EU and through Nordic Dimension partnership and to promote the development of National policies’

3. Proposed Objectives and Major activities:

3.1 Objective 1 : To develop an enabling environment, which provides conditions that support gender sensitive approaches to HIV prevention, treatment, care and support services to female prisoners.

Major activities:

Development of gender sensitive advocacy and communication materials.
Promotion of gender sensitive and rights-based programme approaches among governmental and civil society service providers.
Policy advocacy for recognition of the need to establish female-specific interventions among injecting drug users.
Formation of self-help groups among female injecting drug users and HIV positive women.

Conduct training and skills-needs assessment among existing and potential service providers,including primary health care nurses and doctors, social workers.

Develop gender sensitive training materials and manuals, locally adapted to specific social and cultural contexts

Performance indicators

-Number of gender sensitive advocacy and communication materials developed (in a timely, satisfactory manner).

-Government and civil society acceptance of and support for female-specific HIV interventions among injecting drug users

Number of training/skills needs assessments conducted (in a timely and satisfactory manner)

Number of manuals/toolkits developed/locally adapted (in a timely and satisfactory manner)

-Number and composition of existing/potential service providers trained to WHO standard

3.2Objective 2: Improve availability and quality of gender sensitive comprehensive packages for prevention of HIV and TB within Prison settings.

Major activities:

Awareness raising of national decision-makers (e.g. Ministry of Justice, Prison Administration) on the need to address the vulnerability of female prisoners to HIV/AIDS and drug use and to provide the comprehensive package of services within prison settings in a gender-sensitive manner, free of stigma and discrimination
Provision of sexual and reproductive health services, general health services, maternal and child health services, HIV and TB services.
Better identification and comprehensive management of health related problems of female intravenous drug users within primary health care team

Carry out intensified TB case finding, in particular among drug users with HIV who are at particular risk of TB.

Performance indicators

Government and civil society acceptance of and support for female-specific HIV interventions for female prisoners

Number of training/skills needs assessments conducted (in a timely and satisfactory manner)

Number of manuals/toolkits developed/locally adapted (in a timely and satisfactory manner)

Number and composition of prison-based educators trained to WHO standard

Number and proportion of female prisoners in need of services, accessing relevant services

3.3 Objective 3: Sharing the lessons learned

Rationale

There is a need to nationally, regionally and internationally connect actors in the field to ensure quality information is broadly shared. This exercise stimulates dialogue among key actors, fuels creativity and inspires the development of innovative approaches and practices, enables key actors to make sound and informed decisions and impacts positively on policy-making. It also facilitates the replication of successful experiences and initiatives and ensures a higher standard of intervention.

Activities

Drafting of the “study tour” program on behalf of best practice partners and on site share of experience on case management (study tour)
Drafting recommendations for HIV/AIDS and TB case management implementation for female prisoners
Document project results and lessons learned on a regular basis, disseminate widely documentation, organize inter-country experience exchange for a through meetings of EG’s of NDPHS on Prison Health and HIV and AIDS, and Primary Heath care.
Share lessons learned through publications and presentations at international conferences and meetings and through the NDPHS web page.
Drafting ND strategy on HIV/AIDS and TB management within Prison settings

Expected outputs

Generation and dissemination of internationally agreed indicators for monitoring and evaluation of project interventions.
Manage national and regional coordination of actors in the field of HIV/AIDS as it relates to injecting drug use and prison through the NDPHS EGs.
Quality and strategic information concerning the implementation of interventions is available due to implemented monitoring and evaluation mechanism.
ND strategy on Prison Health
Project info is entered and disseminated through the NDPHS data base
Publications and other materials available.

3.4Objective 4: Monitoring and evaluation

Major activities:

Provision of:

Quarterly activity reports summarizing project activity during the reporting period
Annual progress reports
Mid-term review
End-of-project reports
Beneficiaries who will be trained under this project will be required to submit a report on their studies and training and measures they consider relevant for their respective offices to follow-up on the studies and or training.
The evaluation will be carried out in a fully transparent way and reports will be made available to the Government Counterparts and other implementing partners.

Performance indicators

Evaluation findings of satisfactory performance

3. Selected Countries

Estonia, Lithuania, Latvia, Poland, Belarus

Contact Information:

Dr. Zaza Tsereteli, MD, MPH

Expert,

Ministry of Health and Care Services, Norway

J.Vilmsi 6-3,

10126 Tallinn,

Estonia

Tel: +372 5 26 93 15

E-mail:

Skype: Zaza.Tsereteli