Drugs, HIV, and prisons.
Drugs, HIV, and prisons.
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毒品、艾滋病毒和监狱。
DOI：
10.1136/bmj.302.6791.1477
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发表时间：
1991
影响因子：
--
通讯作者：
J. Strang
中科院分区：
文献类型：
--
作者：
M. Farrell;J. Strang
20世纪80年代，欧洲注射吸毒的流行率急剧上升;仅在联合王国，估计就有75000-150000名注射者。“为了应对这一增长以及随之而来的感染艾滋病毒的风险，治疗机构采取了更灵活的方法，试图吸引使用者接受治疗并与他们保持联系。在这个不断扩大的服务网络中，监狱仍然是一个巨大的漏洞。6在英国监狱中，共有10%的男性和25%的女性在入狱前经常使用鸦片制剂或兴奋剂，78还押囚犯的比例可能更高。苏格兰的数据显示，2735%的囚犯注射过毒品，9而在大多数欧洲国家，估计约有30%的囚犯有吸毒史。司法系统面临的挑战是将更多的吸毒者从刑事司法系统转移到治疗系统，并为被监禁者提供适当的治疗。在英国，这些囚犯不仅不可能得到治疗，而且他们感染艾滋病毒的风险实际上可能会增加。主要的风险是由于缺乏无菌注射设备而共用注射设备。'0-' 3在两项对监狱中注射者的研究中，四分之三的人共用注射设备。大多数人在使用前尝试清洁脏设备，但使用的清洁方法效果不佳。1.“监狱中注射行为的普遍性对于监禁是否是感染艾滋病毒的一个独立风险因素至关重要。苏格兰的小型研究发现，三分之二的注射者在监狱里注射过（第1506页）。在两个英国囚犯的样本中，一个没有发现在监狱中注射的证据，而另一个报告说，27%的注射者在监狱中进行注射。二.虽然对监狱中注射毒品流行率的估计相差很大，但仍然可以采取基本的预防措施。很难想象任何一所监狱都能提供注射设备，但是一所监狱可以--旧金山弗朗西斯科和墨尔本的监狱也可以--提供漂白剂和如何清洁设备的指导。同样重要的是防止囚犯开始注射毒品。监狱是非典型的环境，囚犯可能在压力下从事新的吸毒或性行为。在这种情况下，那些依赖阿片类药物但一直吸食毒品的人可能会开始注射以缓解戒断症状。在监禁的第一周，这种风险可能特别高，可以通过提供阿片类药物解毒来降低。提供避孕套将有助于降低艾滋病毒性传播的风险，但英国的系统拒绝这样做，理由是这可能会鼓励同性恋行为。无论是否被禁止，都会发生一些性活动，特别是在英国监狱的多人牢房中，在一项研究样本中，10%的受试者报告说在监禁期间从事过性活动。相比之下，Power等人对苏格兰监狱的研究报告了极低的性活动水平（第1507页）。14.无论性活动的程度如何，提供避孕套应被视为对安全性行为的认可。欧洲有16个监狱系统提供避孕套，并报告说这一政策没有问题。6直到最近，大多数英国监狱的吸毒者几乎没有寻求治疗的动机。相反，对那些披露吸毒史的人的反应往往是隔离、脱衣搜查和牢房搜查。监狱医疗服务最近的指引建议，除非特别禁忌，否则应定期为所有吸食鸦片成瘾的新囚犯提供口服美沙酮的戒毒计划。15.向伦敦霍洛威监狱的妇女提供的服务不仅可以作为戒毒的典范，而且可以作为后续支助和康复的典范。1987年，霍洛威引入了美沙酮戒毒;现在这是一种规范，吸毒者也知道这一点，结果是大多数囚犯披露了他们的吸毒情况。对性传播疾病有保密服务，对保健也有普遍的注意。外部机构，如匿名戒毒会、积极妇女组织（感染艾滋病毒妇女的支持团体）和戒毒团体可以进入监狱，帮助妇女制定获释后的计划。苏格兰的斯道顿监狱计划试行一个类似的减少毒品项目。监狱部门需要考虑一系列治疗方案。戒毒指导方针是一个开始，但监狱医务人员还需要与当地专家联络，并确保他们和监狱官员接受管理药物使用的培训。特别是，监狱应停止隔离感染艾滋病毒的囚犯。“6隔离意味着那些没有被隔离的人没有受到感染，因此实际上可能助长高风险行为。这也是不人道的。监狱改革信托基金会的一份报告认为，布里斯托监狱是照顾艾滋病毒感染者的典范
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 2735% 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 opiates but has always smoked drugs may start injecting to relieve the symptoms ofwithdrawal. The risk may be particularly high in the first week of imprisonment and could be reduced by providing opiate detoxification. Providing condoms would help reduce the risk of sexual transmission of HIV, but the British system refuses to do so on the grounds that it might encourage homosexual acts. Prohibited or not, some sexual activity will occur, especially in the multiply occupied cells of British prisons, where 10% of subjects in one study sample reported having engaged in sexual activity while incarcerated. By contrast Power et al's study of Scottish prisons reports extremely low levels of sexual activity (p 1507). 14 Irrespective of the level of sexual activity the practice of safer sex should be seen to be endorsed by providing condoms. Sixteen prison systems in Europe make condoms available and have reported no problems with this policy.6 Until recently drug users in most British prisons have had little incentive to seek treatment. Instead, the response to those who disclosed a history of drug use was often isolation, strip searches, and cell searches. Recent guidelines from the prison medical service now recommend that a detoxification programme with oral methadone should be routinely offered to all new prisoners with opiate addiction unless specifically contraindicated. 15 The services provided to women in Holloway prison, London, could serve as a model, not only for detoxification but also for follow up support and rehabilitation. Detoxification with methadone was introduced in Holloway in 1987; it is now the norm and drug users know it to be, with the result that most prisoners disclose their drug use. A confidential service for sexually transmitted diseases exists, and there is a general diligence about health care. Outside agencies such as Narcotics Anonymous, Positively Women (a suipport group for women with HIV infection), and drug rehabilitation groups have access to the prison to help women develop plans for after their release. Staughton prison in Scotlancl plans topilot a similar drug reduction programme. The prison service needs to consider a range of treatment options. The guidelines on detoxification are a start, but prison medical officers need also to liaise with local specialists and ensure that they and prison officers receive training in managing drug use. In particular, prisons should stop segregating prisoners who have HIV infection.'6 Segregation implies that those who are not segregated are not infected and may therefore actually facilitate high risk behaviour. It is also inhumane. A report from the Prison Reform Trust held Bristol prison to be a model of care for those with HIV