Prevention of HIV/AIDS in Prisons

Implementers: NGO "Medical Reforms in Penitentiary Institutions" in Cooperation with the Ministry of Justice, Department of Penitentiary Institutions, Medical Section. Technical support has been provided by the United Nations Theme Group on HIV/AIDS in Moldova and the International Harm Reduction Development Programme.

Country Republic of Moldova
Year 1997
Topic Area Prisons, Injecting Drug Use
Funding Soros Foundation Moldova, International Harm Reduction Development Programme /NY
  1. Prevent and reduce the spread of HIV/AIDS/STIs and drug-related harm in several pilot prisons.
  2. Improve access to counseling and information, education, and communication activities for prison inmates and prison staff.
  3. Instructively influence the behavior of the inmates regarding the risk of infections.
  4. Make syringes, needles, bleach, condoms, as well as tattoo and shaving equipment available to all inmates.
  5. Reduce the risk of transmission of blood-borne infections, including AIDS through shaving and tattoo equipment largely shared among inmates.
  6. Allow inmates with progressive life-threatening diseases, including AIDS and TB, to be released earlier in the course of the disease, before they are terminally ill, so that they do not constitute a threat to public safety.
  7. Reduce the level of stigmatization and eradicate all forms of discrimination against HIV-positive inmates through advocacy.
Background The first case of HIV infection in the prisons of Moldova was registered in October 1996. The average daily "prison population" consists of approximately 10,000 inmates and 2,000 staff members. At that time health authorities of penitentiary institutions officially admitted their awareness of the fact that some inmates injected drugs and shared injecting equipment or tattoo equipment. In addition, unprotected sexual intercourse was widespread among prisoners, as shown by a syphilis epidemics involving 52 inmates registered in 1996.

Withdrawal syndromes and opioid overdose was common occurrence among prisoners using injecting drugs. Both the Head of the Penitentiary Department and of the Medical Section had a rather pragmatic attitude towards possible solutions and they were aware that the situation might become explosive if HIV spread out on top of the other health problems in prisons.

Thus, in 1997 the Department of Penitentiary Institutions, relying on technical assistance offered by the United Nations Theme Group on HIV/AIDS, developed in cooperation with NGO "Medical Reforms in Penitentiary Institutions" a project proposal on prevention of HIV/AIDS/STIs in penitentiary institutions based on harm reduction strategy, which was further financed by the Soros Foundation – Moldova and the International Harm Reduction Development Programme, New York. In order to assure continuity of the project, in December 1999, the Ministry of Justice issued order 115 "On a harm reduction pilot programme to be implemented in penitentiary institutions". Following a training of the prison administration staff, the project was launched based on harm reduction activities (making bleach, condoms, and shaving equipment available in specific places, such as the visiting rooms, medical service, and prison cells, as well as exchanging needles and providing information) initially in two institutions.

The intention of the Ministry of Justice and the Ministry of Health to expand the project to other penitentiary institutions has been clearly expressed by including such activities in the National Programme on Prevention and Control of HIV/AIDS/STIs 2001–2005. Both the Ministry of Justice and the Ministry of Health would see the intervention of international donors instrumental for the implementation of HIV/STI prevention programmes based on the harm reduction strategy, at least for some more years.

Main Activities
  1. Rapid behavioural assessment and sentinel surveillance.
    • Adjustment/development of study protocols.
    • Random sampling and testing of residual blood in used syringes collected over the period of 3–4 weeks.
    • Data analysis and reporting.
    • Adjustment of the planned prevention activities based on the research results.
  2. Information, education, and communication (IEC).

    • Advocacy meeting for key decision makers and prison administration.
    • Development, pre-test, adjustment and printing of IEC materials for the prison management and for inmates.
    • Trainings on prevention of HIV/AIDS/STIs for prison inmates and the prison management.
  3. Supply IEC materials, peer education, condoms, bleach, needles, syringes and shaving equipment to injecting drug users (IDU).

    • Selection and training of staff and volunteers for outreach work.
    • Establishment and equipment of needle exchange points.
    • Development of mechanisms and procedures for needle exchange disposals and collection of used needles.
    • Purchase, storage and distribution of syringes, condoms, shaving equipment and bleach to outreach workers and needle exchange points.
    • Development and implementation of work schedules for outreach workers and staff at needle exchange points (volunteers and paid staff)
    • Monitoring and supervision of outreach workers and voluntary staff at needle exchange points.
  4. Early diagnosis and effective treatment of STIs, voluntary HIV counseling and testing, and psychological support to inmates.

    • Training of health care providers in voluntary HIV counseling and testing.
    • Training of health care providers and project staff in psychological support.
    • Training of health care providers in drug use treatment.
    • Establishment of a referral system.
Outcomes/ outputs Major outcomes are:

  • A group of trained experts on HIV/AIDS prevention from among inmates in prisons has been established, who can then be used as trainers.
  • Injecting equipment and counseling has become available for prison inmates on a regular basis.
  • Psycho-social support service in prisons and use of conflict management strategies to avoid discrimination against PLHIV in prisons has been applied.
  • Behavioral and sentinel surveillance studies have been conducted, this providing government authorities with realistic data for relevant planning.
  • Political support for harm reduction activities in penitentiary institutions has been obtained.
  • Stigmatization and discrimination of HIV/AIDS positive inmates have been reduced.
Evaluation Findings Several formal evaluations of the project have been conducted. The first evaluation was based on a special mission held by a Tripartite Review Committee established for the purpose of evaluation which was lead by an International Technical Advisor. The outcomes of the mission were compiled in a report where information on numbers of trainings, syringes and condoms was presented in comparative dynamics. The report also contained recommendations for further improvement of the project.

The second evaluation on behavioral patterns of inmates was conducted by NGO "Medical Reforms in Penitentiary Institutions" in cooperation with the Department of Penitentiary Institutions. The study group consisted of 494 inmates and staff members coming from 8 prisons, representing the "prison population" of Moldova. The participants had to fill out a questionnaire consisting of 97 items. Data was computerized by use of an EPINFO soft questionnaire. Lamentable lack of knowledge, risky attitude and risky behavior were defined as main causes of spread of blood-borne infections in penitentiaries.

In 2000, the National AIDS Centre in cooperation with the Medical Section of the Department of Penitentiary Institutions conducted a sentinel surveillance study based on guidelines developed by the World Health Organization (WHO) in 1995. The sentinel surveillance showed that, out of 1057 inmates, 978 were males, and 79 females (12:1). There were 32 (3.27%) positive samples in the male group and 3.8% in the female group. The average rate of extension of HIV among inmates varied in the range of 2.2 – 3.8%. Except for the official evaluation, the positive feedback from inmates indicated a continuous need for such projects. The evaluation also looked at resistance to the project, especially on behalf of inmates. It was noted that inmates prefer to enter the prisons of Braneshti, since all of them know that syringes and needles are available within the prison.

The quality of life of inmates has improved, since shaving and injecting equipment became available and could be disinfected. This can be measured in terms of distributed equipment.

The evaluations identified several weaknesses such as lack of professional training of volunteers since the prison is a closed community and inmate volunteers could not share experience with other such projects and lack of peer-education training for inmates.

Lesson Learned Although coverage is still very limited due to the fact that prison population is limited, the experience from the project showed that needle exchange in prisons can serve first of all as a powerful awareness tool, and only secondly as a tool of reducing blood-borne infections. Several premises have been crucial to the success of the project: advocacy with the decision-makers and training of the prison staff.

A lesson learnt from this project is that the success of the project depends very much on the outreach work of volunteers chosen from among inmates, as this yielded a higher degree of confidentiality. The role of informal leaders from among inmates is crucial in achieving early and sustainable results. Also, sentence to prison is not a sentence to death from AIDS, and the project clearly showed that there is a large gap between the needs of prison inmates regarding HIV/AIDS/STI information and safe equipment and what government is prepared to provide.

An equally important lesson is that harm reduction projects in prisons works best when there is a match of political support on behalf of government authorities, in this case the prison administration and informal leaders from among inmates. The successful implementation of project activities determined the decision-makers to expand it to other prisons, provided that financial means were obtained from external sources at least for several more years.