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The Equivalence Principle
The 1993 World Health Organization Guidelines on HIV infection and AIDS in prisons state, as a general principle, that prisoners have the right to receive health care, including preventive measures, equivalent to that available in the community without discrimination. Most Canadian prison health-care services do their best to provide prisoners with HIV or AIDS with good care, and often refer prisoners to outside specialists for HIV-related care. However, prisoners report that they sometimes receive care and treatment that is not up to the standard that they received in the community, or even in other prisons they have been in.

Other issues include : the increase in the number of sick prisoners ; prisons not being equipped to deal with prisoners who require long-term, ongoing care and treatment (including palliative care) ; and the difficulty of accessing investigational drugs and alternative therapies.

Antiretroviral Therapies
Left untreated, most people infected with HIV will eventually go on to develop HIV-related illnesses (morbidity) and die (mortality). The standard for treating HIV infection involves a combination of antiretroviral medications known as Highly Active Antiretroviral Therapy (HAART). Throughout Canada, prisoners with HIV/AIDS are prescribed HAART medications. Many HAART regimes are complex. Some medications must be taken with food, some on an empty stomach, some once a day, some twice, many at specific, fixed times of day every day. Taking HAART medications as prescribed is crucial to good health. Several studies have shown that 90 to 95 percent of doses must be taken as prescribed in order to achieve optimal suppression of HIV in the body. Non-medically indicated interruptions in HAART can have serious detrimental consequences for individual prisoner’s health and for public health.

Non-medically indicated (and non consensual) interruptions in HAART occur in prisons, both federally and provincially. We know this from anecdotal evidence and from epidemiological studies. Prisoners report going without their HAART medications for days, not getting their dose at the prescribed time of day, or the correct dose. Doses are missed because medications are not reordered, prisoners are too ill to get their medications from health services, lock-downs, and lack of access to medications in segregation. Prisoners also report missing doses of HAART when they are arrested and incarcerated, make court appearances, or transferred between provincial and federal systems or even between institutions in the same system. Prisoners also report being released from custody without HAART or without sufficient medication to hold them until they are able to get a supply in the community.

Adequate Medication for Pain
Prisoners with HIV/AIDS also report they do not receive adequate medication for pain. Many prisons are reluctant to provide narcotic pain relief as it conflicts with the “zero-tolerance” to drugs ethos of the prison system. This is compounded by attitudes toward drug users, who typically require higher doses of pain medication than non-users because of their high tolerance for narcotics. Prisoners requesting higher doses of pain medication may be perceived as wanting to “get high” in prison. Without appropriate pain medication, prisoners may resort to illicit drugs, and unsafe injecting, to manage their pain.

Coroners Inquests
Many of the failings of prison systems were brought to light in a 1997 inquest into the care of Billy Bell, a prisoner who died of AIDS-related causes at Kingston Penitentiary. At the inquest into Billy Bell’s death, a specialist from the HIV clinic at the Kingston General Hospital, Dr Sally Ford, testified about how the prison failed to provide Billy the quality care that her patients outside the prison receive. The prison pharmacy would run out of doses of AZT and Billy would miss his dose days at a time. Billy also experienced difficulty accessing proper pain management medication. Many of the same issues were raised again at an inquest in 2001. Michael Joseph LeBlanc probably became infected with HIV and HCV while incarcerated. In November 1999, he died at the Regional Hospital in Kingston Penitentiary, in extreme physical, psychological, and emotional distress.

Recommendation
Prisons must ensure that prisoners receive care, support, and treatment equivalent to that available to people living with HIV/ AIDS in the community. At a minimum, prisoners must have equivalent access to :

pain control, including narcotics where medically indicated ;

investigational drugs, and complementary and alternative therapies ;

information on treatment options ;

uninterrupted HAART ;

health promotion strategies in order to slow the progression of their disease, including proper nutrition, vaccination, and programs to treat addictions.

In the longer term, prison health care should evolve from a reactive sick-call system to a proactive system emphasizing early detection, health promotion, and prevention.
 

Additional Reading
T Kerr et al. Determinants of highly active antiretroviral discontinuation among injection drug users. Canadian Journal of Infectious Diseases 2004 ; 15(suppl A) : 86A. Canadian Association for AIDS Research Conference. Montreal : May 13-17, 2004. A study showing that incarceration is independently associated with discontinuation of HAART.

R Lines. Death exposes treatment of prisoners living with HIV/AIDS. Canadian HIV/AIDS Policy & Law Newsletter 1997/98 ; 3(4)/4(1) : 29-30 at 29. At www.aidslaw.ca/Maincontent/otherdocs/Newsletter/Winter9798/24LINES1E.html See also G Betteridge. Inquest into the death of a prisoner co-infected with HIV and hepatitis C : how many more will there be ? Canadian HIV/AIDS Policy & Law Review 2001 ; 6(1) : Available at www.aidslaw.ca/Maincontent/otherdocs/Newsletter/vol6nos1-22001/prisons2.htm

Third, revised and updated version, 2004. Copies of this info sheet are available on the Network website at http://www.aidslaw.ca/Maincontent/issues/prisons.htm and through the Canadian HIV/AIDS Information Centre (email : aidssida@cpha.ca). Reproduction of the info sheet is encouraged, but copies may not be sold, and the Canadian HIV/AIDS Legal Network must be cited as the source of this information. For further information, contact the Network (tel : 514 397-6828 ; fax : 514 397-8570 ; email : info@aidslaw.ca). Ce feuillet d’information est également disponible en français.

Funded by Health Canada under the Canadian Strategy on HIV/AIDS. The findings, interpretations, and views expressed in this publication are entirely those of the author and do not necessarily reflect the official policy or position of Health Canada.

© Canadian HIV/AIDS Legal Network, 2004