Anne-Claire Bréchet Bachmann. Numerous studies have shown the prevalence of sexually transmitted and blood-borne infections (STBBI) in prisons. There are a variety of reasons for this. People who use intravenous drugs, as well as people from countries with high rates of STBBIs, are overrepresented in Swiss prisons. Being in prison itself increases the risk factors: unprotected sex, use of drugs, sharing injection materials. Prisoners might also share razors for shaving their beard or their head. These practices provide the right conditions for transmitting infections due to possible droplets of blood remaining on the blades.

There is also the problem of tattooing. We know that this practice exists in prisons, but the materials used are inappropriate and are mostly homemade. Prisoners are therefore exposed to toxic inks and, when the same instruments are used over again, there is a risk of getting an infection. These various factors therefore require a variety of risk reduction approaches.

ACBB. It is important to talk about screening before even thinking about treatment. We have to be able to identify those who may have contracted HIV, hepatitis B, hepatitis C, syphilis or any other STBBI prior to their incarceration. So it is essential to be able to do systematic blood testing when entering prison. If a blood test turns out to be positive for one of these STBBIs, the person concerned is offered the appropriate treatment. Some prisoners refuse the recommended testing after they’ve undergone the prison entry medical exam and are seen by a physician later. Our goal is not to pressure anyone, but to explain the importance and advantage of getting tested, to try to reassure them and understand the reason for the refusal. Various reasons may be at play: language barriers, fear of having blood taken, fear of stigmatisation or of a breach of confidentiality. Some prisoners absolutely refuse. Others refuse basically because of the traumatic experience of entering prison. We are presently conducting a study at Champ-Dollon prison to better understand the reasons for refusing. The goal is to see what can be done to improve test acceptance.

Education must also accompany screening tests. It is essential that prisoners know how STBBIs are contracted as well as how to practice protection and prevention.

We really insist on the importance of not sharing razor blades, electric razors and even toothbrushes. But that is not enough. It is also important to offer prisoners ways of protecting themselves at the same time. This means making condoms available and implementing needle exchange programmes by offering injection kits to people who inject. Our role, as health personnel, is to do the exchange without any judgment by simply saying: ”We are doing this because you inject yourself. Here is a kit. After you have used it, this is how you can turn it in and get another one“.

Needle exchange has been going on in the canton of Geneva for more than 25 years. A similar programme was first implemented in Champ-Dollon prison, then to all the other prisons in the canton.

But the Geneva situation is more of an exception than a rule: in Switzerland, many cantons are still opposed to this kind of programme.
Medication-assisted treatments (opioid agonist treatment) are however widely available. They are recommended to anyone entering prison with a treatment plan in place, as well as to those who arrive with addiction issues without a treatment plan. With regard to the latter, the aim is not to withdraw them but rather to find a medication for addiction treatment to minimise possible withdrawal symptoms. Follow-ups are carried out throughout the therapy. Naturally, this always depends on the prisoner’s willingness: we also provide care when they wish to withdraw completely.

ACBB. The issue is always one of money and the cost of these measures. There is often a higher rate of STBBIs among prisoners than the general population. Their care is very much an opportunity for public health: many prisoners go in and out of prison on a regular basis. They risk transmitting these STBBIs during their time outside. The measures taken in prison therefore have a direct impact on the overall health of the population. Yet, it is a constant battle to have infected prisoners and asymptomatic carriers receive care.

At the same time, we, as health personnel, can always make room for improvement. We can still improve the screening process and the way we provide care to those who need treatment. We try, for example, to provide care as quickly as possible. But it is not always that easy.

Sometimes it is difficult to come up with a treatment plan when we do not know the length of the prisoner’s stay or how we can provide follow-up. The difficulty is always how to ensure continuity of care once the prisoner is transferred or released from prison.

Even if our goal is to at least guarantee continuity of care for people, it is still not always achievable. It is a goal that can be improved, but which depends very much on the type of population concerned. The challenges are different for people integrated in society who have a roof over their head, and those who are homeless without a residence permit. However, there are community resources available that guarantee continuity of care for prisoners leaving prison. It is also our role to provide information about the released prisoners to those providing care and to see that they can obtain their treatment until they are admitted to a halfway house. For example, if prisoners are released on a Friday night or a Saturday morning, they can receive up to three days of treatment. This allows them to survive until Monday and to receive the next part of their medication at the halfway house. The goal is to prevent people from suffering from withdrawal and to avoid any risky behaviours that may lead to overdose.

More generally, there are still many challenges around risk reduction. We continue, for example, to explore ways of making tattooing practices less risky. The idea is to also see what prisoners’ expectations are. Perhaps tattooing is not as prevalent as it was a few years ago, and the focus is now elsewhere. Our work also consists of identifying needs and to see how we can meet them.

We must also remember that what is available in prison is a reflection of what is accepted and implemented in the community. In the Geneva canton, there are, among other things, injection sites and heroin prescription treatment programmes for people with substance use disorder. Their existence makes it easier to develop these types of programmes in prisons. However, there are obstacles like logistics, funding and the issue of acceptance. Risk reduction is not usually a prison administration priority, so our work to change this must continue.