HIV in Indian prisons: Risk behaviour, prevalence, prevention & treatment

Material & Methods

Relevant published material was searched from 1993 to 2010 and unpublished information from key experts relating to HIV in prisons in India was obtained by request. Specific information included three main areas: (i) Rates of imprisonment; (ii) HIV testing, prevalence and risk behaviours; and (iii) HIV prevention, care and treatment.

The online databases Web of Science, PubMed and Scopus were searched using the search string “(HIV or AIDS or HIV/AIDS) and prison or jail or gaol or correctional and India”. Grey literature was accessed by searching the following websites: National Crime Records Bureau http://ncrb.nic.in/; The International Centre for Prison Studies http://www.kcl.ac.uk/schools/law/research/icps; International AIDS Society http://www.iasociety.org/; UNAIDS http://www.unaids.org/en/; UNODC Regional Centre for South Asia http://www.unodc.org/india/index.html; and WHO Regional Office for South-East Asia http://www.searo.who.int/. Only English-language documents were reviewed.

Where gaps in the data remained, key experts were contacted via e-mail or telephone and requests for specific information were made. Key experts included international agencies, non government organizations (NGOs) working in prisons and/or the community in target countries and officials from relevant government ministries and prison administrative bodies.

Results & Discussion

Prison population: The latest figures available on Indian prison population were 376,396 adult prisoners for 200716, making for an imprisonment rate of 32 per 100,000 of national population17.

Around two-thirds of inmates were pre-trial detainees17. A high proportion of pre-trial detainees means a very large inmate turnover. For example, in Tihar Jail, New Delhi, about 12,000 inmates were held while about 60,000 prisoners were admitted and a similar number were discharged annually17. Indian prisons were overcrowded. Across all correctional facilities, the average occupancy level was 136 per cent16. The three areas with the largest overcrowding were Uttar Pradesh (201%) followed by Chhattisgarh (193%) and Delhi (185%).

HIV risk behaviours: No prevalence data regarding drug use in Indian prisons were identified. Two sources identified denial of the possibility of drug use in prisons as an impediment to addressing HIV in prisons1218.

Sex between inmates was reportedly common, at least in one prison19. In a study conducted in Arthur Road Jail, Mumbai, 72 per cent of a sample of 752 (75 employees and 677 inmates) said that they thought sex between men was common in prisons and 11 per cent engaged in homosexual activity in prison20.

No evidence was found on the prevalence of tattooing in prisons in India. There were reports from Mumbai of interpersonal violence (involving lacerations, bites and bleeding in two or more participants), which could present risks of HIV transmission19.

HIV prevalence: No recent HIV prevalence data were identified; existing data were from the mid-to-late 1990s. One national study of HIV prevalence in prisons found that 1.7 per cent of male and 9.5 per cent of female inmates were HIV positive21. In other studies HIV prevalence in individual prisons ranged from 0.5 to 6.9 per cent (Table). Eighteen of 27 inmates who died at Arthur Road Jail, Mumbai, in a six month period were HIV positive29. No information on HIV transmission in Indian prisons was found.

HIV prevention: Education: HIV education programmes tended to be ad-hoc and relied on NGOs for facilitation. A sexual health programme, Partnership for Sexual Health, was conducted in 2000 in 11 jails in Andhra Pradesh. Three staff members provided HIV education, counselling, referral and medical treatment30. The Mumbai District AIDS Control Society and the International Labour Organisation have conducted a workplace HIV prevention programme at the Arthur Road Jail20. In West Bengal, the Vivekananda International Health Centre has delivered an HIV education programme in 20 prisons reaching 50,000 prisoners and staff26. In Gujarat, an HIV information and education programme was conducted by NGOs31.

HIV prevention: Drug dependency treatment: Many prisoners who were placed in drug treatment programmes, were on remand and, therefore, often released before completing treatment32. Drug offenders received at Tihar Jail, New Delhi were admitted to a de-addiction centre for detoxification and treatment of withdrawal symptoms. A psychiatrist worked with prisoners for approximately one week33. In 2005, there were three detoxification centres with 72 detoxification beds: 60 for adult males and 12 for adolescents.

After detoxification, drug offenders were segregated and placed in a therapeutic community run by NGOs. As many as 800 prisoners live within the therapeutic communities at Tihar3233, where prisoners served as team leaders and supervisors. Staff members such as psychiatrists, psychologists, sociologists and social workers, served as trainers, facilitators and counsellors. Inmates were engaged in counselling, education, meditation, family therapy, anger and grief workshops and recreational activities3233.

Tihar Jail hosts the only opioid substitution treatment programme in an Indian prison34. The programme commenced in 2008; no data on the number of prisoners receiving treatment were reported.

HIV prevention: Harm reduction programmes: A government run prison intervention in Andhra Pradesh included condom distribution35, but this was stopped as being against prison policy18. No information regarding bleach distribution was identified and there were no prison based needle and syringe programmes in India1836.

HIV care and treatment: Only one source provided information about access to antiretroviral treatment (ART) while in prison. A programme providing legal aid to prisoners had assisted some HIV positive inmates to continue ART while in prison18.

The present findings revealed that only a few HIV prevention, care and treatment interventions have been implemented in prisons in India. Although no data were located on drug injecting in prison, internationally, injecting drug use is a transmission route for HIV inside prisons37–40. Two studies reported that sexual activity occurred in prisons. Unprotected sex is an HIV transmission route in prisons4142 and the high levels of overcrowding and lack of access to condoms in Indian prisons may be conducive to unprotected sex. Distribution of condoms has previously been disallowed due to legislation against sex between men43 ; however, this law was overturned in July 200944. The provision of condoms in prison has been found to be feasible and is not associated with increases in sexual behaviour4546.

Some limited, sporadic HIV prevalence data were available, but such data become obsolete rapidly. Regular, nation-wide or State-based collection of HIV/STI prevalence data and information regarding HIV risk behaviours is recommended. This will provide a knowledge base to plan HIV prevention, treatment and care interventions in prison. Such a system could be based on reports available from such surveys conducted in other countries, for example, the Australian National Prison Entrants’ Bloodborne Virus Survey47.

Limited HIV prevention programmes were available in Indian prisons. HIV information, education and communication programmes such as those in prisons in Mumbai, Andhra Pradesh should be expanded to all prisons across the country. Improving access to drug dependency treatment, including scaling-up of opioid substitution treatment, would be another positive step48. Harm reduction strategies, including condom distribution programmes and needle and syringe programmes, will further assist in reducing the risk of HIV transmission in prison. Several developing countries have introduced methadone maintenance in prison. These countries include Indonesia, Iran and Moldova48.

Treatment of HIV and STI is also important in stemming HIV in prisons. Voluntary counselling and testing should be promoted and access to HIV and STI treatment improved.

UNODC recommended that the Government of India initiate a process of inquiry in major prisons in India, and where necessary, set up the required facilities for the treatment of drug users32. Large numbers of prisoners under trial pass through India’s prisons each year. Legal reforms to increase non-custodial options for monitoring offenders who have been charged but not yet tried are strongly recommended.