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Hepatitis C infection is endemic among Australian prisoners. In New South Wales prisons, approximately a third of male and two-thirds of female inmates are infected. Corrections Health Service had the second-highest number of hepatitis C notifications for an Area Health region in NSW in its debut report.² HCV incidence is likely to be high in prison, but to date there have been few cases reported.³ Nevertheless, several studies have found that a history of imprisonment is associated with HCV infection.⁴ These findings, from both Australia³ and overseas,⁴ raise two questions:

• What is the incidence of HCV for various transmission modes in prison?; and
  
• Can HCV transmission be reduced in prison?

Despite gaps in our knowledge, there is sufficient evidence to address the two most frequent modes of transmission: injecting drug use and tattooing. About a quarter of prisoners inject drugs while incarcerated.³ Virtually all drug injecting occurs with used injecting equipment shared among numerous partners. Therefore, the primary goal has to be to reduce drug injecting in prison. One way to achieve this is to reduce the number of drug injectors in prison.⁵ There is abundant evidence that community-based methadone treatment reduces injecting, crime and the subsequent incarceration of drug users,⁶ yet only a third of the demand for methadone treatment is met in the community.⁶

Another way to reduce the level of drug injecting in prison is to provide methadone maintenance treatment for prisoners. In one study, prisoners maintained on methadone injected half as often as those out of treatment, but only when doses reached 60 mg and treatment was provided for the entire term of the prison sentence.⁷ The NSW prison methadone program started in 1987, but meets only a quarter of the potential demand for treatment.⁵ Prison methadone programs have been recently introduced or expanded in Queensland, South Australia, Victoria, Tasmania and the Australian Capital Territory.

Drug injecting in prison is also likely to be reduced if prisoners receive lesser punishment for the use of non-injectable drugs compared with injectable drugs. Yet prisoners receive the same penalty whether they test positive on urinalysis for cannabis or for heroin. Research into mandatory drug screening in United Kingdom prisons found that inmates moved from smoking cannabis (detectable in urine for weeks) to injecting heroin (detectable in urine for only a day or two) after mandatory drug testing was introduced.⁸ South Australia and Tasmania have introduced differential penalties for different drugs, with the aim of reducing drug injecting in prison. Victoria is considering a similar system.

Another way to reduce drug injecting is to facilitate non-injecting routes of administration among injecting drug users. Preliminary results from a cognitive behavioural trial indicated that some injecting drug users will shift to non-injecting methods of use (A Wodak, Director, Alcohol and Drug Service, St Vincent's Hospital, Sydney, personal communication). Prisons, where injecting is so risky and common, are ideal settings for a trial of this intervention.

Without doubt, the most controversial strategy is prison needle and syringe exchange programs. These programs have been successfully implemented in Switzerland, Germany and Spain in 17 different prisons.⁹ However, they reduce sharing of injecting equipment rather than drug injecting itself, and the problems of fatal overdose, abscesses, and inmates' involvement in the prison drug trade may persist. If prison needle and syringe exchange programs are unacceptable, then much more effort must be directed towards meeting the demand for drug treatment by prisoners.

HCV transmission in prison may also occur through tattooing. One way to reduce tattoo-related hepatitis C transmission is to train select inmates in infection control procedures and to provide them with autoclaves and single-use ampoules of ink. Penalties for tattooing in prison should be removed. Allowing professional tattooists to visit prison is likely to be too expensive for inmates.

So how can these strategies be implemented? The first step would have to be increasing the number of general practitioners who prescribe methadone both in the community and in prison. Less than 1% of GPs prescribe methadone in NSW.¹⁰ The opportunities for improvement here are enormous.

Almost all other strategies listed above require the cooperation of prison authorities. Yet, correctional services administrators (comprising prison commissioners from each jurisdiction) have signalled their resistance to examining hepatitis C infection in prison by declining to even discuss recommendations made in the Review of the Third National HIV/AIDS Strategy.¹¹ Until prison authorities are made to recognise that prisons play a significant role in the hepatitis C epidemic, it is unlikely that hepatitis C transmission will be reduced in Australian prisons.

Kate A Dolan
Senior Lecturer
National Drug and Alcohol Research Centre
University of New South Wales, Sydney, NSW

1. Corrective Services, Australia. Canberra: Australian Bureau of Statistics, December 1999. (Catalogue no. 4512.0.)
2. NSW Department of Health. Healthy people 2005: new directions for public health in NSW. NSW Public Health Bull 2000; 11: 198.
3. Dolan K. The epidemiology of hepatitis C infection in prison populations [discussion paper]. Canberra: Commonwealth Department of Health and Aged Care, 2000.
4. MacDonald M, Crofts N, Kaldor J. Transmission of hepatitis C virus: rates, routes and cofactors. Epidemiol Rev 1996; 18: 137-148.
5. Dolan K. Surveillance and prevention of hepatitis C infection in Australian prisons. A discussion paper. Technical Report No. 95. Sydney: National Drug and Alcohol Research Centre, 2000.
6. Ward J, Mattick R, Hall W. Methadone maintenance treatment and other opioid replacement therapies. Amsterdam: Harwood Academic Press, 1998.
7. Dolan KA, Hall W, Wodak A. Methadone maintenance reduces injecting in prison. BMJ 1996; 312: 1162.
8. Gore SM, Bird AG. Mandatory drug tests in prisons. BMJ 1995; 310: 595.
9. Rutter S, Dolan K, Wodak A, Heilpern H. Prison syringe exchange: a review of international research and program development. Technical Report No. 112. Sydney: National Drug and Alcohol Research Centre, 2001.
10. NSW Health Department. The NSW drug treatment services plan, 2000-2005: better health good health care. Sydney: NSW Health Department, 2000.
11. Proving partnership. Review of the National HIV/AIDS Strategy 1996-97 to 1998-99. Canberra: Australian National Council on AIDS and Related Diseases, 1999.

©MJA 2001
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