Tackling HIV/AIDS in prisonsTackling HIV/AIDS in prisonsin Ukrainein Ukraine

Deputy Head State Prison DepartmentDeputy Head State Prison DepartmentProf. Dr. Ed. Natalya KalashnikProf. Dr. Ed. Natalya Kalashnik

Prison system capacities in Prison system capacities in UkraineUkraine

Number of Prisons – 149 with 130,000 Number of Prisons – 149 with 130,000 inmates inmates 10 female settings (6,800)10 female settings (6,800) 11 for adolescent (2,200)11 for adolescent (2,200)

Pre-detention centers – 32 with 31,000 Pre-detention centers – 32 with 31,000 inmatesinmates

22 health care facilities22 health care facilities 10 TB clinics10 TB clinics

Policy & Legal environmentPolicy & Legal environment

1.1. Law of Ukraine “ Addressing HIV and social Law of Ukraine “ Addressing HIV and social protection of the population”protection of the population”

2.2. Decree Cabinet of Ministers of Ukraine (2004) Decree Cabinet of Ministers of Ukraine (2004) “Strategic concept of GoU on prevention “Strategic concept of GoU on prevention spread of HIV/AIDS by 2011”spread of HIV/AIDS by 2011”

3.3. Decree Cabinet of Ministers of Ukraine (2004) Decree Cabinet of Ministers of Ukraine (2004) “National AIDS Program 2004-2008”“National AIDS Program 2004-2008”

4.4. State Prison Department: Sectoral AIDS State Prison Department: Sectoral AIDS Program (2004) harmonized with National Program (2004) harmonized with National AIDS ProgramAIDS Program

State Prison Department State Prison Department AIDS ProgramAIDS Program

AIDS program:AIDS program: Goals: Goals:

Prevention of HIV transmissionPrevention of HIV transmission Scaling up access to treatmentScaling up access to treatment

Specific objectives:Specific objectives: IEC targeting inmates and staffIEC targeting inmates and staff Behaviour change among inmatesBehaviour change among inmates Decrease mother to child transmissionDecrease mother to child transmission Access to diagnostic, treatment and supportAccess to diagnostic, treatment and support Set up and scale up “harm reduction” programsSet up and scale up “harm reduction” programs Establishing collaboration with NGOsEstablishing collaboration with NGOs

Epidemiology HIV and TB in Epidemiology HIV and TB in prisonsprisons

HIV prevalenceHIV prevalence

20052005 20062006

SPDSPD 1234.4 1234.4 per per 100,000100,000

1188.3 1188.3 per per 100,000100,000

UkraineUkraine 133.5 133.5 per per 100,000100,000

154.3 154.3 per per 100,000100,000

20052005 20062006

SPDSPD 1826.1 1826.1 per per 100,000100,000

1357.1 1357.1 per per 100,000100,000

UkraineUkraine 219.1 219.1 per per 100,000100,000

218.7 218.7 per per 100,000100,000

TB Prevalence

HCV prevalence*HCV prevalence*

* - HCV notification and reporting is not * - HCV notification and reporting is not incorporated in national regulationsincorporated in national regulations

According to sentinel surveillance data According to sentinel surveillance data (2004) among inmates/IDU – HCV (2004) among inmates/IDU – HCV prevalence – 98%prevalence – 98%

HIV testing in prisonsHIV testing in prisons

According to SPD regulations (differ from According to SPD regulations (differ from National HIV testing protocol)National HIV testing protocol)

Voluntary and confidential (code system)Voluntary and confidential (code system) Pre- and post-test counseling as part of servicePre- and post-test counseling as part of service Trained staff (specially assigned for each of the Trained staff (specially assigned for each of the

prison)prison) HIV test result delivered by trained staff HIV test result delivered by trained staff

(specially assigned physician-consultant in each (specially assigned physician-consultant in each setting) setting)

In 2006 – 15.8% of inmates were tested In 2006 – 15.8% of inmates were tested

HIV/AIDS educationHIV/AIDS education HIV education is embedded in the National and HIV education is embedded in the National and

SPD AIDS programsSPD AIDS programs For inmates (program implementing upon arrival For inmates (program implementing upon arrival

and before release):and before release): Channeled through physician-consultant (lectures, Channeled through physician-consultant (lectures,

individual consultations, etc.)individual consultations, etc.) Channeled through NGOs: (peer concept, Channeled through NGOs: (peer concept,

distribution of info brochures, individual distribution of info brochures, individual consultations, self-support groups incl. theater consultations, self-support groups incl. theater performance) + church (FBO) + students performance) + church (FBO) + students volunteersvolunteers

For staff:For staff: Lectures and info brochures (as part of education Lectures and info brochures (as part of education

and post-education curricula)and post-education curricula) Post-graduate education (incl. study tours, Post-graduate education (incl. study tours,

trainings)trainings) Special attention to PEP and HIV on workplaceSpecial attention to PEP and HIV on workplace

Sexual behaviourSexual behaviour

According to the policies condoms is not According to the policies condoms is not included in the “list of prohibited items”included in the “list of prohibited items”

Distribution mainly through NGOs (where Distribution mainly through NGOs (where projects are available) – 35 projectsprojects are available) – 35 projects

Starting from 2007 plan to procure condoms Starting from 2007 plan to procure condoms through the World Bank Loan and distribute through the World Bank Loan and distribute (free of charge) (free of charge)

Strategies to address aggressive sexual Strategies to address aggressive sexual behaviour: education/information/religion/use of behaviour: education/information/religion/use of psychologists psychologists

Transmission by injectionTransmission by injectionUp to dateUp to date

Special measures to reduce drug supplySpecial measures to reduce drug supply Surveillance and search among inmates and visitors, ad hoc Surveillance and search among inmates and visitors, ad hoc

search in premises, surveillance of staff and vehiclessearch in premises, surveillance of staff and vehicles Collaboration with Dept. On illicit drug supply (OBNON) to Collaboration with Dept. On illicit drug supply (OBNON) to

prevent drug trafficprevent drug traffic Medical observation of inmates/drug usersMedical observation of inmates/drug users

Measures to decrease drug demand and useMeasures to decrease drug demand and use Primary and secondary prevention (Information, Education and Primary and secondary prevention (Information, Education and

Communication campaign, disinfectants)Communication campaign, disinfectants) Treatment (detoxification and “drug-free” programs)Treatment (detoxification and “drug-free” programs) Rehabilitation Rehabilitation Reform inside SPDReform inside SPD

Transmission by injectionTransmission by injectionPlanned for 2007Planned for 2007

Introduction of substitution therapy (ST) in Introduction of substitution therapy (ST) in prisons is under the question prisons is under the question ((ST in Ukraine is ST in Ukraine is limited by pilot programs with buprenorphine, while scaling up ST limited by pilot programs with buprenorphine, while scaling up ST and start use of methadone still challengingand start use of methadone still challenging))

Jointly with Canadian HIV/AIDS Legal Jointly with Canadian HIV/AIDS Legal Network and International Harm Reduction Network and International Harm Reduction Association planned pilot Association planned pilot needle and needle and syringe program (NSP)syringe program (NSP) in 2 prisons in 2 prisons

Antiretroviral treatment (ART)Antiretroviral treatment (ART) Ukraine started scaling up ART since 2004 (State budget and GFATM) - up to Ukraine started scaling up ART since 2004 (State budget and GFATM) - up to

date around 5,000 pts. on ART (while the needs 17,500)date around 5,000 pts. on ART (while the needs 17,500)

Since 2006 ART available in prisons (55 received, needs -200)Since 2006 ART available in prisons (55 received, needs -200)

ART regimens correspond to the national treatment guidelines (also WHO)ART regimens correspond to the national treatment guidelines (also WHO)

Provision of ART jointly with NGOs (with donors financial support)Provision of ART jointly with NGOs (with donors financial support)

CD4 available through regional AIDS centers and 1CD4 available through regional AIDS centers and 1stst and 2 and 2ndnd line regimens line regimens according to the national treatment protocols (NNRTI and PI-based regimens)according to the national treatment protocols (NNRTI and PI-based regimens)

Treatment of opportunistic infections: according to the national protocolsTreatment of opportunistic infections: according to the national protocols

PMTCT: starting from 2PMTCT: starting from 2ndnd trimester: coverage 100% trimester: coverage 100%

Management of HIV infected Management of HIV infected prisonersprisoners

HIV status is confidential (results deposited in HIV status is confidential (results deposited in secure place)secure place)

HIV tests results (encoded) accessible only for HIV tests results (encoded) accessible only for physician-consultant and without informed physician-consultant and without informed consent cannot inform other medical staffconsent cannot inform other medical staff

HIV infected imprisoned under general HIV infected imprisoned under general conditionsconditions

Comprehensive measures to prevent stigma and Comprehensive measures to prevent stigma and discrimination (voluntary testing, confidentiality, discrimination (voluntary testing, confidentiality, general conditions of imprisonment, trainings for general conditions of imprisonment, trainings for staff)staff)

Technical assistance neededTechnical assistance needed

Improve legislationImprove legislation Develop standards and model package of Develop standards and model package of

services for inmatesservices for inmates Local evidence to confirm NSP and ST Local evidence to confirm NSP and ST

benefits and operational modalitiesbenefits and operational modalities Involve NGOs and supervise the quality of Involve NGOs and supervise the quality of

services provided through NGOsservices provided through NGOs Develop comprehensive IECDevelop comprehensive IEC

The way forwardThe way forward

Re-socialization through Re-socialization through empowerment and educationempowerment and education

Change society attitude towards Change society attitude towards inmates (especially outside the inmates (especially outside the system)system)

Provide incentives for seeking Provide incentives for seeking prevention and treatmentprevention and treatment

Increase self-estimation of inmates Increase self-estimation of inmates New programs: “Be good for New programs: “Be good for

everybody” and “Save your life”everybody” and “Save your life”