Special Report: Prison Exchange (When drugs and Aids collide)

Joel (not his real name) did not react when a health professional told him he had tested positive for the human immunodeficiency virus (HIV), the virus that causes Acquired Immunodeficiency Syndrome (Aids).

The injecting drug user just casually returned to his cell at the Cebu City Jail.

More than 16 percent of male inmates and three percent of female inmates in the Cebu City Jail had HIV, according to a Department of Health study conducted in October 2014.

Because practically all prisoners will return to the community, HIV in prisons is a concern for the community as well.

On World Aids Day today, Sun.Star Cebu begins a three-part report on Cebu’s struggle to contain the spread of the virus in a closed setting like prison, as well as in the community, amid an acceleration in new HIV infections caused by injecting drug use.

Easy pass

At any given time, prisons worldwide hold more than 10.2 million people as pre-trial detainees or sentenced prisoners. But some 30 million people move from prison to the community and back yearly, the United Nations Office on Drugs and Crime (UNODC) said, making it easy for communicable diseases like HIV and hepatitis to pass from the prison community to the general population.

HIV is transmitted through sexual contact, needle sharing of injecting drug users, transfusion of infected blood products, needle prick injuries and mother-to-child transmission.

There is no cure for HIV infection. Treatment with antiretroviral drugs merely delays the replication of the virus, so that people with HIV can stay healthy longer and lead productive lives.

Since 30 males and two females out of a total of 250 randomly selected inmates surveyed tested positive for HIV, the HIV prevalence in the Cebu City Jail is 13 percent.

This is much higher than the HIV prevalence in the general population in Cebu City, which is less than one percent.

In its 2009 policy brief on HIV testing and counseling in prisons, the UNODC said it was common for HIV infection rates among prisoners to be higher than in the general population. It cited sexual activity and injecting drug use in prisons as helping spread the virus among inmates.

In the United States, the HIV prevalence rate in prisons is 2.4 times higher than in the general adult population. In Argentina, it’s 10 times higher and in Ukraine 15 times higher than in their general populations, said the Joint United Nations Program on HIV/Aids in 2014.

Injecting drugs

How the Cebu City Jail inmates got HIV is unclear. But a whopping 93 percent of the HIV positive male inmates were injecting drug users (IDU), with 40 percent of the IDUs sharing needles with others during their last injection.

One-third of the HIV positive males had tried male-to-male sex; 83 percent had been tattooed in prison.

In the Philippines, sexual contact is still the main mode of HIV transmission. Male-to-male sex accounted for 73 percent of cases; male-female sex, 20 percent of cases; and intravenous drug use, four percent of cases from 1984 to August 2015.

But in Central Visayas, injecting drug use has overtaken sexual contact as the main mode of transmission.

From January 1984 to September 2015, intravenous drug use (1,264 cases) accounted for half of the 2,539 HIV cases reported, followed by sexual contact (1,253 cases for homosexual, heterosexual and bisexual sex), DOH 7 data showed.

Where users are

To find the drug users, one simply has to look in prison, as the UNODC said, “People who use drugs often have a history of incarceration.”

Drug users often engage in theft to pay for their habit. And drugs also cause hallucinations, fueling violent behavior.

In the Philippines, the Comprehensive Dangerous Drugs Act of 2002, which criminalizes not just the manufacture and sale but also the use of dangerous drugs, contributes to the high number of drug users in jail.

Around half of the inmates at Cebu City Jail (CCJ) are in for drug-related offenses. But most of the study participants (86 percent of males and 57 percent of females), regardless of offense, had done drugs at some point in their lives.

In the CCJ, 37 percent of male and seven percent of female inmates were injecting drug users, with 40 percent of them sharing syringes during their last injection. Most injected Nalbuphine (the generic name of Nubain). Others injected shabu.

Some 14 percent of male inmates admitted injecting in prison. They shared syringes 74 percent of the time.

Missing patients

Last March, then Cebu City Jail warden Johnson Calub said only 12 inmates had HIV.

Asked about the discrepancy in the figures, Dr. Ilya Tac-an, head of the Cebu City Health Department’s Social Hygiene Clinic, said the 12 likely were only those HIV positive inmates who had been identified.

In the 2014 DOH study where 32 inmates had been found HIV positive, no names had been taken as it was only a study.

“We treated 12 inmates,” she told Sun.Star Cebu. “But from this 12, we are now treating only six or seven because the others were already transmitted to (New Bilibid Prison in) Muntinlupa or (Leyte Regional Prison in) Abuyog after they were convicted, or they were already released.”

Jails run by the Bureau of Jail Management and Penology (BJMP), like the Cebu City Jail, are only for inmates awaiting trial or sentenced to prison terms of three years and below. Those sentenced to longer terms go to jails run by the Bureau of Corrections, said SJO3 Roselle Escaño, chief of the community relations office and media relations office of BJMP 7.

On the other HIV positive inmates, Tac-an said: “There might have been five others who did not have treatment because their CD4 levels were still okay. But you can have treatment even if your CD4 is still okay—if you are ready for it. But before the start of treatment, you still need an x-ray, a test for hepatitis B, and a complete blood count. You have to rule out tuberculosis because you have to treat TB first before doing ART (antiretroviral therapy).”

“But some were not x-rayed yet,” she said last month. “Tinagsa man og pangayo og (Because jail officials sought one by one the) court order for the inmates to go out of jail to have their x-ray done.”

This means 20 HIV positive inmates have yet to be treated.

Lowering risk

CD4 cells are white blood cells that help protect the body from infection. HIV destroys CD4 cells.

In 2013, the World Health Organization (WHO) recommended starting ART when a person’s CD4 cell count falls to 500 cells per cubic millimeter—“when their immune systems are still strong.”

Lowering the amount of the virus in the blood lowers the risk of passing it to others, which was why regardless of CD4 count, ART was recommended for all pregnant and breastfeeding women with HIV, and for all HIV-positive partners with uninfected partners.

Last September, however, the WHO changed the guidelines, saying anyone with HIV should begin ART as soon after diagnosis as possible.

Treatment

The HIV positive inmates have been counseled in prison.

Tac-an said the Cebu City Health Department (CHD) also trained nurses in the Cebu City Jail to treat them. There’s a once a day tablet to take.

Asked if the persons with whom the HIV positive inmates had had sex or drugs had been located, whether inside or outside of prison, Tac-an said: “We don’t do contact tracing. We encourage them to tell their partners about their status. But none of the 12 (HIV positive inmates) has sent anybody to the City Health Department (for testing).”

This means many more people, both inside and outside the jail, could be HIV positive and oblivious to it.

Tac-an believes the inmates got infected before they entered prison because it was only when HIV prevalence increased outside the jail that HIV prevalence also rose inside the jail.

There has been HIV testing in the CCJ since 1993. But the first HIV positive results turned up only in 2010, the year the prevalence of HIV in IDUs in the community jumped to 53 percent, from less than one percent the year before.

Condom use

To prevent the spread of HIV in jail, the CHD recommends HIV testing and treatment, and condom use.

Forty percent of male inmates had sex in prison, whether with fellow male inmates or visitors. But they used condoms only 10 percent of the time even if one-third of the prisoners knew that condoms were available.

“We left more than 10 boxes with the Cebu City Jail clinic in 2013. Each box had 444 condoms. They haven’t asked for more because these condoms are not distributed. They are given only if the prisoners ask for them,” Tac-an said.

With CCJ having more than 2,400 male inmates, even if fewer than 1,000 of them had sex, the supply should have long been used up already if they had practiced safe sex. No females reported having sex in jail.

“We don’t distribute the condoms because the inmates might make a business out of it and sell the condoms,” the BJMP’s Escaño said.

“But we encourage them to use condoms during conjugal visits,” said Chief Insp. Priscillana Gilboy, regional chief of the BJMP 7 health service office. CCJ visiting hours are 1-5 p.m. Tuesday through Friday and the whole day on weekends.

Only male inmates get conjugal visits. Females don’t due to the risk of pregnancy.

Education

Gilboy said inmates were aware of HIVs and other sexually transmitted infections.

“All nurses of the BJMP are required to conduct information drives on diseases, not just on HIV, twice a month. The CCJ conducts these in the basketball area, which can hold up to 200-300 inmates,” Escaño said.

CHD personnel also give lectures on HIV and hepatitis prevention at the jail.

“We hold seminars once a year, in two to three batches,” said Tac-an. But she said attendance to their lectures was voluntary.

Hepatitis

The problem of HIV in Cebu is compounded by the problem of hepatitis C, a liver infection caused by the hepatitis C virus. The 2014 DOH study showed that more than 1,000 male inmates in the jail (or almost half of the male inmates) had hepatitis C.

Hepatitis C is also prevalent in the community. In 2011, Dr. Genesis Samonte, epidemiologist at the HIV Surveillance and Strategic Information Unit of the DOH’s National Epidemiology Center, said Cebu had the highest prevalence of hepatitis C in the country.

Hepatitis C is acquired the same way as HIV—through blood transfusion, sharing of needles by drug users, sexual contact, and less likely, through childbirth. Hepatitis C can lead to chronic liver complications like cirrhosis and liver cancer.

An HIV positive person who also has hepatitis C will die faster because the drug that combats HIV is toxic to the liver, which in hepatitis C patients is already weak, said Samonte.

“There is no treatment for hepatitis C from the City Health Department because it is very expensive. The treatment will cost more than P300,000,” Tac-an said.

This is for a pill that will really kill the virus, she said. It has fewer side effects, and the treatment will take only three months. But it is also not available in the Philippines.

Identification

As for HIV positive inmates, the CHD can treat them for free—if their status is known.

But mandatory testing cannot be done on inmates. The Philippine Aids Prevention and Control Act of 1998 prohibits HIV testing without consent, except for persons charged with crimes of rape, seduction or administering injurious substances; when determination of HIV status is needed in annulment cases; and for persons making a blood or organ donation.

Tac-an said some inmates refuse testing because “mahadlok og dugo (they are fearful of their blood being drawn). Others said they’ll have themselves tested once outside prison only; others fear their status will be made known in the jail.”

She said the Cebu City Jail warden also stopped the CHD from conducting HIV tests at the jail after the HIV positive results started appearing, due to his concerns on the absence of guidelines on the handling of inmates found to be HIV positive in jail.

Dr. Gilboy said this lack of guidelines did not stop other jails, like the Mandaue, Lapu-Lapu and Talisay City Jails, from requesting HIV screening for their inmates from the BJMP 7.

Out and proud

Even without testing, Gilboy said, the BJMP has a way to learn about the inmates’ health.

“On entering jail, an Inmate’s Health Record (IHR) is made, where inmates are asked about their risk factors. They’re asked about their exposure to sexually transmitted infections, use of drugs,” she said. “Some were diagnosed with HIV already before entering prison. Some even seem proud to have HIV, as if they don’t know the risks and consequences of having it.”

She cited the case of a female inmate who was a sex worker.

Gilboy said the inmate flaunted her HIV positive status, as if it was proof of her beauty that she had so many customers—although it was her dispatcher boyfriend, an injecting drug user, who first got HIV and passed it on to her through sex.

Before she was imprisoned, she was already on ART. The CHD followed up on her after her release from jail.

In the male dorm, Gilboy said, HIV positive males disclose their own status to their cell mates. “HIV positive people feel powerful. They themselves tell their cell mates about the medicine they are taking.”

Contrary to the jail warden’s fears, the HIV positive prisoners were not stigmatized, as their diagnosis did not scare their cell mates, she said.

HIV positive inmates in the CCJ are not isolated.

To ensure their monitoring, Gilboy said, when inmates are transferred to another jail, their health records are passed on to the next jail. If they are released, they will be referred to the nearest rural health unit.

Not fool-proof

The IHR is not fool-proof, however, as it relies on the honesty of inmates. And the BJMP has no link with the CHD on medical records that might be used as a third party reference if the inmate cannot be trusted to be truthful during the interview for the IHR.

Gilboy revealed the challenges of getting the truth from inmates and giving them the medical help they need.

“Most inmates are recidivists. If they are diagnosed outside with HIV, we could link them with the local government units (LGUs). But the problem is inmates don’t give their real names or places of residence. They use different aliases (even when they return to jail),” she said.

Policy

The BJMP 7 recently received the guidelines on HIV, which were approved in June. Gilboy said the HIV policy will result in a “more effective and sustained response to HIV and Aids.”

“It says basic STI/HIV education should be given to newly admitted inmates. Tattooing and body piercing in BJMP jails are strictly not allowed. HIV testing shall be done in the lab in the prison clinic. The BJMP and the LGU will coordinate in the testing. If found HIV positive, inmates shall be referred for ART. Pre-test and post-test counseling will be conducted,” she said.

Under the policy, the BJMP will also collaborate with the DOH on HIV proficiency training, decisions on isolation will be made by medical staff only, and HIV patients will get equal access to work areas and programs available to the general prison population.

Illegal

What about preventing inmates from getting syringes and needles in the first place so that they stop injecting drugs and lower their risk of getting or passing on HIV and other blood-borne diseases?

Drug use and possession of drug paraphernalia are illegal. Yet they occur even in jail. In May, a visitor was caught hiding 10 disposable syringes wrapped in a condom in her vagina. Two months earlier, she had also been caught smuggling in an ampule of a regulated painkiller.

Because drug use is illegal, there is no proper disposal of used or tainted syringes and needles, presenting a health risk to inmates as well as jail personnel who might find them.

Sun.Star Cebu sought the CCJ’s former and present jail wardens to ask how they could better prevent the entry of drugs into the prison, but they declined to be interviewed.

As for rehabilitating the drug addicts in jail so that they stop trying to smuggle in drugs, the CHD’s Tac-an said there was no program to rehabilitate drug addicts in jails anywhere in the Philippines.

Locus

With the prevalence of HIV higher in prison than in the community, prison is the ideal place to test for and treat HIV.

Beyond the risk to the community, there is the inmate to be considered.

Prisoners are entitled to health care equal to that afforded to everyone else. This right is guaranteed under Article 25 of the United Nations Universal Declaration of Human Rights.

(first of three parts)

(Tomorrow: Syringe scrimmage)

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