Drugs, HIV, and prisons.

The prevalence of injecting drug use rose dramatically in Europe in the 1980s; in the United Kingdom alone there are an estimated 75000-150000 injectors.' Responding to this increase and to the concomitant risk of infection with HIV, treatment agencies have adopted more flexible approaches to try to attract users to treatment and maintain contact with them.25 Gradually a broad based community approach is evolving that includes doctors, pharmacists, the police, social workers, and probation officers. In this widening net of services the prisons remain a gaping hole.6 Altogether 10% of men and 25% of women in English prisons have used opiates or stimulants regularly before imprisonment,78 and the proportion is probably higher among remand prisoners. Scottish figures suggest that 27-35% of prisoners have injected drugs,9 and in most European countries about 30% of inmates are estimated to have a history of drug use. The challenges for the judicial system are to divert more drug users from the criminal justice system to the treatment system and to provide proper treatment for those who are imprisoned. In Britain these prisoners are not only unlikely to be offered treatment but their risks of contracting HIV infection may actually be increased. The main risk is sharing injecting equipment owing to the lack of sterile injecting equipment.'0-'3 In two studies of those who injected in prison three quarters shared injecting equipment.'2 3 Most made some attempt to clean dirty equipment before use but used poorly effective cleaning methods. 1" The prevalence of injecting behaviour in prison is critical to whether imprisonment is an independent risk factor for acquiring HIV infection. The small Scottish study found that two thirds of injectors had injected in prison (p 1506). 12 In two samples of English prisoners one found no evidence of injecting in prison,' while the other reported that 27% of injectors carried on injecting in prison. II Although estimates of the prevalence of drug injecting in prison vary widely, instituting basic precautionary measures is still possible. Imagining that any prison would provide injecting equipment is difficult, but a prison could-and those in San Francisco and Melbourne do6-provide supplies of bleach and instructions on how to clean equipment. Just as important is preventing prisoners from starting to inject their drugs. Prisons are atypical environments, in which prisoners may be under pressure to engage in novel drug taking or sexual behaviour. In such circumstances someone who is dependent on …