Empowered lives. Resilient nations.

Policy brief HIV prevention, treatment and care in prisons and other closed settings: a comprehensive package of interventions
Each year over 30 million men and women spend time in prisons and other closed settings,* of whom over one third are pretrial detainees.1 Virtually all of them will return to their communities, many within a few months to a year. Globally, the prevalence of HIV, sexually transmitted infections, hepatitis B and C and tuberculosis in prison populations is 2 to 10 times as high, and in some cases may be up to 50 times as high, as in the general population.2 HIV rates are particularly high among women in detention. Risks affect prisoners, those working in prisons, their families and the entire community. For these reasons, it is essential to provide HIV interventions in these settings, both for prisoners and for those employed by prison authorities.**,3 However, access to HIV prevention, treatment and care programmes is often lacking in prisons and other closed settings. Few countries implement comprehensive HIV prevention, treatment and care programmes in prisons. Many fail to link their programmes in prisons to the national AIDS, tuberculosis or public health programmes. Many fail to provide adequate occupational health services to staff working in prisons.4 In addition to HIV risk behaviours, such as unsafe sexual activities and injecting drug use, factors related to the prison infrastructure, prison management and the criminal justice system also contribute to vulnerability to HIV, tuberculosis
*In this paper, the term prisons and other closed settings refers to all places of detention within a country, and the terms prisoners and detainees to all those detained in those places, including adults and juveniles, during the investigation of a crime, while awaiting trial, after conviction, before sentencing and after sentencing. **Those employed in prisons and closed settings could include prison officialsincluding government officialssecurity officers, prison wardens, guards and drivers, and other employees, such as food services, medical and cleaning staff.

and other health risks in prisons. These factors include overcrowding, violence, poor prison conditions, corruption, denial, stigma, lack of protection for vulnerable prisoners, lack of training for prison staff, and poor medical and social services.5 Finally, addressing HIV in prisons effectively cannot be separated from broader questions of criminal justice and national policy. In particular, reducing the excessive use of pretrial detention and greatly increasing the use of non-custodial alternatives to imprisonment are essential components of any response to HIV and other health issues in prisons and other closed settings.

The comprehensive package: 15 key interventions

1. Information, education and communication 2. Condom programmes 3. Prevention of sexual violence 4. Drug dependence treatment, including opioid substitution therapy 5. Needle and syringe programmes 6. Prevention of transmission through medical or dental services 7. Prevention of transmission through tattooing, piercing and other forms of skin penetration 8. Post-exposure prophylaxis 9. HIV testing and counselling 10. HIV treatment, care and support 11. Prevention, diagnosis and treatment of tuberculosis 12. Prevention of mother-to-child transmission of HIV 13. Prevention and treatment of sexually transmitted infections 14. Vaccination, diagnosis and treatment of viral hepatitis 15. Protecting staff from occupational hazards

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Scope and purpose

This paper is designed to support countries in mounting an effective response to HIV and AIDS in prisons and other closed settings. It takes into consideration principles of international law, including international rules, guidelines, declarations and covenants governing prison health, international standards of medical ethics and international labour standards.6,7,8 In providing guidance to national authorities charged with the management and oversight of prisons and closed settings, it is aimed at supporting decision makers in ministries of justice, authorities responsible for closed settings and ministries of health, as well as authorities responsible for workplace safety and occupational health, in planning and implementing a response to HIV in closed settings.

The 15 key interventions

The comprehensive package consists of the 15 interventions that are essential for effective HIV prevention and treatment in closed settings. While each of these interventions alone is useful in addressing HIV in prisons, together they form a package and have the greatest impact when delivered as a whole.

1 2 3 4

Information, education and communication

Awareness-raising, information and education about HIV, sexually transmitted infections, viral hepatitis and tuberculosis are needed in all closed settings. Programmes delivered by the authorities or by civil society organizations should be supplemented by peer-education programmes, developed and implemented by trained fellow prisoners.9

Condom programmes
In all closed settings, both for men and for women, condoms and water-based lubricant should be provided free of charge. They should be made easily and discreetly accessible to prisoners at various locations without their having to request them and without their being seen by others.10 Condoms should also be provided for intimate visits.

Prevention of sexual violence

Policies and strategies for the prevention, detection and elimination of all forms of violence, particularly sexual violence, should be implemented in prisons.11 Vulnerable prisoners, such as people with different sexual orientation, young offenders and women, must always be held separately from adult or male offenders. Appropriate measures should be established to report and address instances of violence.

Drug dependence treatment including opioid substitution therapy

Evidence-based drug dependence treatment with informed consent should be made available in prisons in line with national guidelines. Considering that opioid substitution therapy is the most effective drug dependence treatment for people dependent on opiates, where it is available in the community, it should be accessible in prisons.12, 13 Authorities should also provide a range of other evidence-based drug dependence treatment options for prisoners with problematic drug use.

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5 6 7 8 9

Needle and syringe programmes

Prisoners who inject drugs should have easy and confidential access to sterile drug injecting equipment, syringes and paraphernalia, and should receive information about the programmes.14

Prevention of transmission through medical or dental services

HIV and hepatitis can be easily spread through the use of contaminated medical or dental equipment. Therefore, prison medical, gynaecological and dental service providers should adhere to strict infection-control and safe-injection protocols, and facilities should be adequately equipped for this purpose.15, 16

Prevention of transmission through tattooing, piercing and other forms of skin penetration
Authorities should implement initiatives aimed at reducing the sharing and reuse of equipment used for tattooing, piercing and other forms of skin penetration, and the related infections.17

Post-exposure prophylaxis
Post-exposure prophylaxis should be made accessible to victims of sexual assault and to other prisoners exposed to HIV. Clear guidelines should be developed and communicated to prisoners, health-care staff and other employees.18, 19

HIV testing and counselling

Prisoners should have easy access to voluntary HIV testing and counselling programmes at any time during their detention. Health-care providers should also offer HIV testing and counselling to all detainees during medical examinations, and recommend testing and counselling if someone has signs or symptoms that could indicate HIV infection, and to female prisoners who are pregnant. All forms of coercion must be avoided and testing must always be done with informed consent, pre-test information, post-test counselling, protection of confidentiality and access to services that include appropriate follow-up, antiretroviral therapy and other treatment as needed.20

10 11

HIV treatment, care and support

In prisons, HIV treatment, including antiretroviral therapy, care and support, should be at least equivalent to that available to people living with HIV in the community and should be in line with national guidelines and based on international guidelines.21 Support, including nutritional supplements, should be provided to patients under treatment. Particular efforts should be undertaken to ensure continuity of care at all stages, from arrest to release.

Prevention, diagnosis and treatment of tuberculosis

Given the high risk for transmission of tuberculosis and high rates of HIV-tuberculosis co-morbidity in closed settings, all prisons should intensify active case-finding, provide isoniazid preventive therapy and introduce effective tuberculosis control measures.22

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In particular, people living with HIV should be screened for tuberculosis and people with tuberculosis should be advised to have an HIV test. All people living with HIV without symptoms of active tuberculosis (no current cough, fever, weight loss or night sweats) should be offered isoniazid preventive therapy. Prisons and cells should be well ventilated and have good natural light. Tuberculosis patients should be segregated until they are no longer infectious, and education activities should cover coughing etiquette and respiratory hygiene. Tuberculosis programmes, including treatment protocols, should be aligned and coordinated with or integrated in national tuberculosis control programmes and work closely with the HIV programme. Continuity of treatment is essential to prevent the development of resistance and must be ensured at all stages of detention.

12 13 14 15

Prevention of mother-to-child transmission of HIV

The full range of prevention of mother-to-child HIV transmission interventions, including family planning and antiretroviral therapy, should be easily accessible to women living with HIV, to pregnant women and to breastfeeding mothers in prisons, in line with national guidelines and based on international guidelines.23, 24 Children born to mothers living with HIV in prison should be followed up, in accordance with those guidelines.

Prevention and treatment of sexually transmitted infections

Sexually transmitted infections, particularly those that cause genital ulcers, increase the risk for transmission and acquisition of HIV. Early diagnosis and treatment of such infections should therefore be part of HIV prevention programmes in prisons.

Vaccination, diagnosis and treatment of viral hepatitis

Prisons should have a comprehensive hepatitis programme, including the provision of free hepatitis B vaccination for all prisoners, free hepatitis A vaccination to those at risk, and other interventions to prevent, diagnose and treat hepatitis B and C equivalent to those available in the community (including condom, needle and syringe programmes and drug dependence treatment as needed).

Protecting staff from occupational hazards

Occupational safety and health procedures on HIV, viral hepatitis and tuberculosis should be established for employees. Prison staff and workers in prisons should receive information, education and training by labour inspectors and specialists in medicine and public health enabling them to perform their duties in a healthy and safe manner. Prison staff should never be subject to mandatory testing and should have easy access to confidential HIV testing. Employees should have free access to hepatitis B vaccination and easy access to protective equipment, such as gloves, mouth-to-mouth resuscitation masks, protective eyewear, soap, and search and inspection mirrors, and to post-exposure prophylaxis in cases of occupational exposure.25 Workplace mechanisms for inspecting compliance with applicable standards and reporting occupational exposures, accidents and diseases should also be established.26

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Additional interventions
Some other interventions have not been included in the package of 15 key interventions but nevertheless are important and should not be overlooked. These include the distribution of toothbrushes and shavers in basic hygiene kits, adequate nutrition, intimatevisit programmes, palliative care and compassionate release for terminal cases.

covenants.29 The right to health includes the right to medical treatment and to preventive measures as well as to standards of health care at least equivalent to those available in the community.30 Access to health services in prisons should be consistent with medical ethics, national standards, guidelines and control mechanisms. Similarly, prison staff need a safe workplace and have the right to proper protection and adequate occupational health services. Protecting and promoting the health of detainees goes beyond simply diagnosing and treating diseases as they appear in individual detainees. It includes issues of hygiene, nutrition, access to meaningful activity, recreation and sport, contact with family, freedom from violence or abuse by other detainees and freedom from physical abuse, torture and cruel, inhuman or degrading treatment at the hands of prison officers.31 Medical ethics should always guide all health interventions in closed settings, and therefore interventions should always be geared towards the best interests of the patient. All treatments should be voluntary, with the informed consent of the patient, and people living with HIV should not be segregated.32 These principles recognize that some groups of prisoners have special needs to be addressed and that incarceration is not a treatment for mentally ill people or for drug dependent people, for example. The principles also include safeguards against arbitrary arrest and extended pretrial detention, which are inextricably linked to overcrowding and the transmission of HIV, sexually transmitted infections, viral hepatitis and tuberculosis in closed settings.

Guiding principles
1. Prison health is part of public health
The vast majority of people in prisons eventually return to their communities. Any diseases contracted in closed settings, or made worse by poor conditions of confinement, become matters of public health.27, 28 HIV, hepatitis and tuberculosis and all other aspects of physical and mental health in prisons should be the concern of health professionals on both sides of the prison walls. It is pivotal to foster and strengthen collaboration, coordination and integration among all stakeholders, including ministries of health and other ministries with responsibilities in prisons, as well as community-based service providers. Equally important is ensuring continuity of care. In order to ensure that the benefits of treatment (such as antiretroviral therapy, tuberculosis treatment, viral hepatitis treatment or opioid substitution therapy) started before or during imprisonment are not lost, as well as to prevent the development of resistance to medications, provision must be made to allow people to continue these treatments without interruption, at all stages of detention: while the person is in police and pretrial detention, in prison, during institutional transfers and after release.

Other key recommendations

The following good-practice recommendations focus on ensuring an enabling and non-discriminatory environment for the introduction and implementation of the comprehensive package of HIV interventions. In the absence of such conditions, implementation could be challenging and intervention could be less effective.

2. Human rights approach and principle of equivalence of health in prisons

Prisoners should have access to medical treatment and preventive measures without discrimination on the grounds of their legal situation. Health in prison is a right guaranteed in international law, as well as in international rules, guidelines, declarations and

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1. Ensure that prison settings are included in national HIV, tuberculosis and drug dependence treatment programming
A health-in-prisons programme should be an integral part of national efforts to provide access to HIV and tuberculosis services, as well as to evidencebased drug dependence treatment.33 Prison authorities should establish strong linkages with community-based care and involve outside service providers in delivering care in prisons. Whenever adequate care cannot be provided in prisons, detainees should be able to access health services in the community.

Additional reading
This policy brief and its recommendations are based on a comprehensive review and analysis of evidence, on existing United Nations guidance and on an extensive consultation process regarding HIV in prisons. For more details and for a complete list of references, see the technical background paper on HIV prevention, treatment and care in prisons and other closed settings: a comprehensive package of interventions (see www.unodc.org/aids). This brief is part of a set of documents produced by WHO, UNODC and UNAIDS aimed at providing evidence-based information and guidance to countries on HIV prevention, treatment, care and support in prisons and other closed settings. HIV testing and counselling in prisons and other closed settings (2009).
This policy brief and its technical background document provide guidance on how to provide evidencebased and human rights-based access to HIV testing in prisons. www.unodc.org/documents/hivaids/UNODC_WHO_UNAIDS_2009 _ Policy_brief_HIV_TC_in_prisons_ ebook_ENG.pdf

2. Adequately fund and reform health care in closed settings

Health-care budgets for prisons must reflect the relatively greater needs of the prison population, and health care in these settings should be recognized as an integral part of the public health sector. It should not be limited to medical care, but should emphasize early disease detection and treatment, health promotion and disease prevention.34 Qualified health officers must have the autonomy to decide the treatment needed for their patients, including on transfers to public health services. Addressing detainees health needs will contribute to rehabilitation and successful reintegration into the community. In the longer term, transferring control of health in closed settings to public health authorities will have a positive impact on both prison and public health in general, and specifically on the delivery of the comprehensive package of HIV interventions in closed settings.

Policy brief

HIV testing and counselling in prisons and other closed settings

Background
At the 2005 World Summit1 and at the United Nations General Assembly High-Level Meeting on HIV/AIDS in June 2006,2 governments endorsed the scaling up of HIV prevention, treatment, care and support with the goal of coming as close as possible to universal access by 2010. Achieving this goal requires participation by all stakeholders, including prison systems. Greater access to HIV testing and counselling for prisoners is an essential component of countries efforts to reach universal access to HIV prevention, treatment and care. HIV programmes have been introduced in prisons in many countries, but most are small in scale and rarely comprehensive in nature. This document promotes a strategy for improving access to HIV testing and counselling in prisons as part of a comprehensive HIV programme. Globally, at any given time, there are over 9 million people in prisons with an annual turnover of 30 million moving from prison to the community and back again.3 The rates of HIV infection among prisoners in many countries are higher than in the general population and risk behaviours, including consensual and non-consensual sexual activity and injecting drug use, are prevalent.4, 5 Outbreaks of HIV infection have occurred in prisons in several countries,4 demonstrating how rapidly HIV can spread in prison unless effective action is taken to prevent transmission. There is a high degree of mobility between prisons and the community and therefore implementation of public health initiatives within the prison will also be beneficial to the public health of communities.6 In May 2007, WHO and UNAIDS released the Guidance on provider-initiated HIV testing and counselling in health facilities.7 The Guidance and the UNAIDS/WHO Policy statement on HIV testing8 provide a useful framework and contain important principles and recommendations that should guide the approach to expanding access to HIV testing and counselling for prisoners. In particular, they: t Strongly support efforts to scale up testing and counselling services through diverse methods, including client-initiated and providerinitiated testing and counselling; t Acknowledge that the scaling up of testing and counselling must be accompanied by (a) access to HIV prevention, treatment, care and support services; and (b) a supportive environment for people living with HIV and those most at risk for acquiring HIV infection; t Unequivocally oppose mandatory or compulsory testing and counselling; t Emphasize that, regardless of whether HIV testing and counselling is client- or providerinitiated, it should always be voluntary. In this policy statement the term prisons also refers to other places of detention, including pre-trial detention, and the term closed settings to compulsory treatment and rehabilitation centres and settings where migrants may be detained, such as immigration detention or removal centres; the term prisoner has been used to describe all males and females who are held in such places. The policy statement, however, does not apply to juvenile offenders, regardless of where they are detained, as special considerations apply to them.

3. Ensure the availability of gender-responsive interventions

Particular attention should be given to the specific needs and concerns of women. Women should have access to all interventions in the comprehensive package, but these interventions should be tailored to their specific needs and include, for example, attention to womens sexual and reproductive health needs.35, 36 There is also a need for broader initiatives that acknowledge that the problems encountered by women in prisons often reflect, and are augmented by, their vulnerability, especially to sexual violence, and the abuse many of them have suffered outside or inside the prisons.37

Women and HIV in prison settings (2008).

This policy brief describes the essential needs of women in prisons in relation to their situation and HIV. Available in various languages. www.unodc.org/documents/hivaids/Women%20and%20HIV%20 in%20prison%20settings.pdf.

Women and HIV in prison settings

Prisons are high-risk settings for the transmission of HIV.
However, HIV prevention, treatment, care and support programmes are not adequately developed and implemented to respond to HIV in prisons.1 Moreover, prison settings do not usually address gender-specic needs. Both drug use and HIV infection are more prevalent among women in prison than among imprisoned men.2 Women in prison are vulnerable to gender-based sexual violence; they may engage in risky behaviours and practices such as unsafe tattooing, injecting drug use, and, are more susceptible to self-harm.3

Women in prisons
Women prisoners present specic challenges for correctional authorities despite, or perhaps because of the fact that they constitute a very small proportion of the prison population. The prole and background of women in prison, and the reasons for which they are imprisoned, are different from those of men in the same situation.4 In particular, injecting drug users and sex workers are overrepresented. Once in prison, womens psychological, social and health care needs will also be different. It follows that all facets of prison facilities, programmes and services must be tailored to meet the particular needs of women offenders. Existing prison facilities, programmes and services for women inmates have all been developed initially for men, who have historically accounted for the largest proportion of the prison population.

How many women are imprisoned?

Globally, female prisoners represent about 5 per cent of the total prison population, but this proportion is increasing rapidly, particularly in countries where levels of illicit substance use are high. In 2005, worldwide, on any given date more than half a million women and girls were detained in prisons, either awaiting trial or serving sentences.5 Three times this number (about 1.5 million) will be imprisoned in the course of any given year.

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4. Address stigma and the needs of particularly vulnerable people

Some people are particularly vulnerable to abuse and to HIV and other negative health outcomes in prisons, including people who use drugs, young adults, people with disabilities, people living with HIV, transgendered persons and other sexual minorities, indigenous people, racial and ethnic minorities, and people without legal documents or lacking legal status. Paying particular attention to their protection and to their needs in efforts to address HIV prevention and treatment in closed settings is therefore essential.

Evidence for Action Technical Papers: Effectiveness of Interventions to Address HIV in Prisons (2007).
EVIDENCE FOR ACTION TECHNICAL PAPERS

EFFECTIVENESS OF INTERVENTIONS TO ADDRESS HIV IN PRISONS

These papers provide a comprehensive review of the effectiveness of interventions to address HIV in prison settings. Currently available in English and Russian. www.who.int/hiv/pub/prisons/ e4a_prisons/en/index.html

ISBN 978 92 4 159619 0

5. Undertake broader prison and criminal justice reforms

Addressing HIV in prisons cannot be separated from wider questions of human rights and reform. Conditions in prisons, the way in which they are managed, criminal justice and national policy: all have an impact on the responses developed to address HIV, hepatitis and tuberculosis in prisons. "" Improve conditions. Overcrowding, violence, inadequate natural lighting and ventilation, and lack of protection from extreme climatic conditions are common in closed settings in many regions of the world. When these conditions are combined with inadequate means for personal hygiene, inadequate nutrition, poor access to clean drinking water and inadequate health services, the vulnerability of people in prisons to HIV infection and other infectious diseases is increased, as is related morbidity and mortality. For those reasons, efforts to implement the comprehensive package should go hand in hand with reforms aimed at addressing these under lying living and working conditions. "" Reduce the excessive use of pretrial detention. Pretrial detainees account for over a third of all the people in prisons around the world. Prisoners are frequently held in overcrowded, substandard conditions without medical treatment or any measures for infection control. International standards clearly state that pretrial detention should be an exceptional measure used sparingly. Therefore, programmes providing safe alternatives to pretrial detention for persons accused of low-level crimes should be implemented.38

HIV/AIDS Prevention, Care, Treatment, and Support in Prison Settings: A Framework for an Effective National Response (2006).
A Framework for an Effective National Response

This publication provides a framework for mounting an effective national response to HIV in prisons. Available in various languages. www.unodc.org/unodc/en/hivaids/publications.html

WHO/HIV/2004.05

Evidence for action on HIV/AIDS and injecting drug use

POLICY BRIEF: REDUCTION OF HIV TRANSMISSION IN PRISONS

BACKGROUND

Reduction of HIV transmission in prisons (2004).

This policy brief provides a 2-page summary of the evidence related to HIV prevention programmes in prisons. Available in languages. many different

he rates of HIV infection among inmates of prisons and other detention centres in many countries are signicantly higher than those in the general population. Examples include countries in Western and Eastern Europe, Africa, Latin America and Asia. The available data on HIV infection rates in prisons cover inmates who were infected outside the institutions before imprisonment and persons who were infected inside the institutions through the sharing of contaminated injection equipment or through unprotected sex. Certain populations that are highly vulnerable to HIV infection have a heightened probability of incarceration because of their involvement in behaviours such as drug use and sex work.

PREVENTION PROGRAMMES IN PRISONS

In 1993 WHO issued guidelines on HIV infection and AIDS in prisons [1]. They included the following paragraphs. 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. The general principles adopted by national AIDS programmes should apply equally to prisoners and to the community. "Drug-dependent prisoners should be encouraged to enrol in drug treatment programmes while in prison, with adequate protection of their condentiality. Such programmes should include information on the treatment of drug dependency and on the risks associated with different methods of drug use. 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 opiatedependent individuals in the community, this treatment should also be available in prisons. In countries where bleach is available to injecting drug users in the community, diluted bleach or another effective viricidal agent,

together with specic 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. Since the early 1990s, various countries have introduced prevention programmes in prisons. Such programmes usually include education on HIV/AIDS, voluntary testing and counselling, the distribution of condoms, bleach, needles and syringes, and substitution therapy for injecting drug users. In 1991, 16 of 52 criminal justice systems surveyed in Europe had made bleach available, and by 1997 about 50% had done so. Various countries provide clean needles and syringes to inmates and implement substitution treatment. However, many of these programmes are small in scale and restricted to a few prisons. None of the countries where evaluations of such programmes have been carried out have reversed their policies.

EVIDENCE
Four elements of prevention programmes in prisons have been studied extensively: the provision of bleach
1

World Health Organization. HIV in prisons: A reader with particular relevance to the newly independent states. In: WHO guidelines on HIV infection and AIDS in prisons, Copenhagen: World Health Organization; 2001. p. 233-7.

www.who.int/hiv/topics/idu/prisons/en/index.html

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"" Reduce incarceration of people who use drugs and people with mental health problems. A significant percentage of the prison population comprises individuals convicted of offences related to their own drug use, who are drug dependent or live with mental health problems. Many of the problems created by HIV infection, drug use and mental health issues in closed settings may be reduced if (a) non-custodial alternatives to imprisonment are implemented in the community; (b) drug laws are reformed to reduce incarceration for drug use and for possession of drugs for personal use; and (c) evidence-based services, including drug and mental health treatment, are accessible in the community.39,40 "" End the use of compulsory detention for the purpose of drug dependence treatment. In a number of countries, people identified as using drugs are detained in closed centres in the name of treatment or rehabilitation. Such detention usually takes place without due process or clinical assessment. Prisoners are often denied evidence-based drug dependence treatment and HIV-related and other basic health services To protect their health and human rights, prisoners should be released and the centres closed.41 Until they are closed, providing HIV interventions in the centres is required, but without legitimizing the existence of those centres.

Adapting the guidance to national and local situations

The comprehensive package and the recommendations in this paper should be implemented in all prisons and other closed settings in a country. To this end, a national coordination mechanism should be established and composed of key national stakeholders, including the ministries and other authorities responsible for prisons, other relevant ministries such as those for health and labour, national AIDS committees, national tuberculosis programmes and civil society, including organizations of people living with HIV. The comprehensive package and other recommendations should be integrated in national AIDS and tuberculosis-related plans, and resources should be allocated for their implementation. Country-level strategic planning should be directed towards implementing, as soon as possible, all elements of the package and achieving universal access to HIV prevention, treatment, care and support for people in prisons and other closed settings. In countries with injecting drug use, implementation of drug dependence treatment, in particular opioid substitution therapy, and needle and syringe programmes in prisons should be a priority. At all stages, harmonization with activities in the community is critical for the continuity of prevention, treatment, care and support services.

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notes
1 Open Society Foundations, Improving health in pretrial detention: pilot interventions and the need for evaluation (New York, 2011). Available from www.opensocietyfoundations.org/publications/improving -health-pretrial-detention. 2 WHO, UNODC, UNAIDS. Interventions to address HIV in prisons. Evidence for action technical papers. Geneva, WHO, 2007. Available at www.who.int/hiv/pub/prisons/e4a_prisons/en/index.html. 3 International Labour Organization, Recommendation (No. 200) concerning HIV and AIDS and the World of Work, 2010. Available from www.ilo.org/aids/WCMS_142706/lang--en/index.htm. 4 World Health Organization, International Labour Organization and Joint United Nations Programme on HIV/AIDS, The Joint WHO-ILO-UNAIDS policy guidelines on improving health workers access to HIV and TB prevention, treatment, care and support services: a guidance note (Geneva, International Labour Office, 2010). 5 United Nations Office on Drugs and Crime, World Health Organization and Joint United Nations Programme on HIV/AIDS, HIV in Places of Detention: A Toolkit for Policymakers, Programme Managers, Prison Officers and Health Care Providers in Prison Settings (Vienna, United Nations Office on Drugs and Crime, 2008). Available from www.unodc.org/documents/hiv-aids/V0855768.pdf. 6 7 8

International Labour Organization, Forced Labour Convention, 1930 (No. 29). International Labour Organization, Abolition of Forced Labour Convention, 1957 (No.105).

International Labour Organization, Recommendation (No. 200) concerning HIV and AIDS and the World of Work, 2010.
9 O. A. Grinstead and others, Reducing post-release HIV risk among male prison inmates: a peer-led intervention, Criminal Justice and Behavior, vol. 26, No. 4 (1999), pp. 453-465; R. S. Broadhead and others, Drug users versus outreach workers in combating AIDS: preliminary results of a peer-driven intervention, Journal of Drug Issues, vol. 25, No. 3 (1995), pp. 531-564; R. S. Broadhead and others, Harnessing peer networks as an instrument for AIDS prevention: results from a peer-driven intervention, Public Health Reports, vol. 113, Suppl. 1 (1998), pp. 42-57. 10 World Health Organization, United Nations Office on Drugs and Crime and Joint United Nations Programme on HIV/AIDS, Interventions to Address HIV in Prisons: Prevention of Sexual Transmission, Evidence for Action Technical Papers (Geneva, World Health Organization, 2007). 11 Ibid. 12 World Health Organization, United Nations Office on Drugs and Crime and Joint United Nations Programme on HIV/AIDS, Interventions to Address HIV in Prisons:Drug Dependence Treatments, Evidence for Action Technical Papers (Geneva, World Health Organization, 2007). 13 R. Jrgens, A. Ball and A. Verster, Interventions to reduce HIV transmission related to injecting drug use in prison, Lancet Infectious Diseases, vol. 9, No. 1 (2009), pp. 57-66. 14 World Health Organization, United Nations Office on Drugs and Crime and Joint United Nations Programme on HIV/AIDS, Interventions to Address HIV in Prisons: Needle and Syringe Programmes and Decontamination Strategies, Evidence for Action Technical Papers (Geneva, World Health Organization, 2007). 15 World Health Organization, Revised Injection Safety Assessment Tool (Tool C Revised): Tool for the Assessment of Injection Safety and the Safety of Phlebotomy, Lancet Procedures, Intravenous Injections and Infusions (Geneva, 2008). Available from www.who.int/injection_safety/Injection_safety_final-web.pdf. 16 World Health Organization and International Labour Organization, Joint ILO/WHO Guidelines on Health Services and HIV/AIDS (Geneva, International Labour Office, 2005). Available from www.ilo.org/aids/ Publications/WCMS_116240/lang--en/index.htm . 17 World Health Organization, United Nations Office on Drugs and Crime and Joint United Nations Programme on HIV/AIDS, Interventions to Address HIV in Prisons: Needle and Syringe Programmes and Decontamination Strategies. 18 World Health Organization and International Labour Organization, Post-exposure Prophylaxis to Prevent HIV Infection: Joint WHO/ILO Guidelines on Post-exposure Prophylaxis (PEP) to Prevent HIV Infection (Geneva, World Health Organization, 2007). Available from http://whqlibdoc.who.int/publications/2007/9789241596374_eng.pdf. 19 The Joint WHO-ILO-UNAIDS policy guidelines on improving health workers access to HIV and TB prevention, treatment, care and support services: a guidance note, 2010. www.ilo.org/aids/Publications/ WCMS_149714/lang--en/index.htm. 20 United Nations Office on Drugs and Crime, World Health Organization and Joint United Nations Programme on HIV/AIDS, HIV testing and counselling in prisons and other closed settings: policy brief (2009). 21 World Health Organization, Antiretroviral Therapy for HIV Infection in Adults and Adolescents: Recommendations for a Public Health Approach2010 Revision (Geneva, 2010). Available from www.who.int/ hiv/pub/arv/adult2010/en/. 22 World Health Organization, Guidelines for Intensified Tuberculosis Case-finding and Isoniazid Preventive Therapy for People Living with HIV in Resource-constrained Settings (Geneva, 2011). 23 World Health Organization, Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants: Recommendations for a Public Health Approach2010 Version (Geneva, 2010). Available from http://whqlibdoc.who.int/publications/2010/9789241599818_eng.pdf . 24 World Health Organization and others, Towards the Elimination of Mother-to-Child Transmission of HIV (Geneva, World Health Organization, 2011). Available from http://whqlibdoc.who.int/publications/2011/9789241501910_eng.pdf.

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25 World Health Organization and International Labour Organization, Post-exposure Prophylaxis to Prevent HIV Infection. 26 International Labour Organization, Recommendation (No. 200) concerning HIV and AIDS and the World of Work, 2010. 27 See, e.g. World Health Organization, Regional Office for Europe, Declaration on Prison Health as Part of Public Health, adopted at the joint World Health Organization/Russian Federation International Meeting on Prison Health and Public Health, held in Moscow on 24 October 2003. 28 The Madrid Recommendation: Health Protection in Prisons as an Essential Part of Public Health, adopted at a meeting held in Madrid on 29 and 30 October 2010. Available from www.euro.who.int/__data/ assets/pdf_file/0012/111360/E93574.pdf. 29 Basic Principles for the Treatment of Prisoners (General Assembly resolution 45/111, annex). 30 R. Jrgens and B. Betteridge, Prisoners who inject drugs: public health and human rights imperatives, Health and Human Rights vol. 8, No. 2 (2005), pp. 47-74. 31 Standard Minimum Rules for the Treatment of Prisoners (Human Rights: A Compilation of Inter national Instruments, Volume I (First Part), Universal Instruments (United Nations publication, Sales No. E.02.XIV.4 (Vol. I, Part 1)), sect. J, No. 34). 32 Principle 1, of the Principles of Medical Ethics relevant to the role of health personnel, particularly physicians, in the protection of prisoners and detainees against torture and other cruel, inhuman or degrading treatment or punishment (General Assembly resolution 37/194, annex). 33 United Nations Office on Drugs and Crime, World Health Organization and Joint United Nations Programme on HIV/AIDS, HIV/AIDS Prevention, Care, Treatment and Support in Prison Settings: A Framework for an Effective National Response (Vienna, United Nations Office on Drugs and Crime, 2006). 34 Lars Mller and others, eds., Health in Prisons: A WHO Guide to the Essentials in Prison Health (Copenhagen, World Health Organization, Regional Office for Europe, 2007). Available from www.euro.who. int/__data/assets/pdf_file/0009/99018/E90174.pdf. 35 United Nations Office on Drugs and Crime and Joint United Nations Programme on HIV/AIDS, Women and HIV in prison settings (2008). 36 B. van den Bergh and others, Womens health in prison: action guidance and checklists to review current policies and practices, (Copenhagen, World Health Organization, Regional Office for Europe, 2011). 37 United Nations Rules for the Treatment of Women Prisoners and Non-custodial Measures for Women Offenders (the Bangkok Rules) (General Assembly resolution 65/229, annex). 38 J. Csete, Consequences of injustice: pre-trial detention and health, International Journal of Prisoner Health, vol 6, no 2 (2010), pp 47-58; R. Jrgens and T. Tomasini-Joshi, Editorial, International Journal of Prisoner Health, vol 6, no 2 (2010), pp 45-46; M. Schnteich, The scale and consequences of pretrial detention around the world, in Justice Initiatives: Pretrial Detention, (Open Society Justice Initiative, Spring 2008), pp. 11-43. 39 Handbook of Basic Principles and Promising Practices on Alternatives to Imprisonment, Criminal Justice Handbook Series (United Nations publication, Sales No. E.07.XI.2). 40 United Nations Office on Drugs and Crime, From coercion to cohesion: treating drug dependence through health care, not punishment, discussion paper based on a scientific workshop, Vienna, 28-30 October 2009 (2010). Available from www.unodc.org/docs/treatment/Coercion_Ebook.pdf . 41 International Labour Organization and others, Joint statement: compulsory drug detention and rehabilitation centres (2012). Available from www.unaids.org/en/media/unaids/contentassets/documents/ document/2012/JC2310_Joint%20Statement 6March12FINAL_en.pdf.

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