A sentence in prison should not also mean a life sentence with a deadly disease. Yet prisons can be hotbeds of infectious diseases.

In nearly all countries, prisoners bear far higher burdens of HIV, tuberculosis (TB) and hepatitis, than the wider community. In Malaysia, levels of HIV infection among prisoners are 15 times higher than the general population, according to a 2010 study by University of Malaya’s Centre of Excellence in Research on AIDS (CERiA) and Yale University.

Some of the highest numbers worldwide for latent TB were seen in Kajang prison, the nation’s largest prison, in a 2014 study by Universiti Malaya (UM) researchers. They found nearly 90% of prisoners tested positive to tuberculin skin tests, which checks exposure to TB.

Now, public health experts are urging action on the issue, warning this is “key” to control the HIV and TB epidemics worldwide.

“We have learnt from several years of working closely with the prison’s department and in particular with Kajang Prison, there are many health issues that need to be seriously addressed,” says University Malaya’s Medical Faculty Dean Professor Dr Adeeba Kamarulzaman. “These diseases do not remain within the prison walls as prisoners ultimately return to the community.”

Professor Dr Adeeba Kamarulzaman has done extensive research on HIV and related infections in prisoners.

Professor Dr Adeeba Kamarulzaman has done extensive research on HIV and related infections in prisoners.

Prisons can act as “incubators” of TB, HIV and hepatitis C, says Professor Chris Beyrer, from the Johns Hopkins Bloomberg School of Public Health in Baltimore, US. “The high level of mobility between prison and the community means that the health of prisoners should be a major public health concern.”

Worldwide, 30 million people pass through prison every year, going back to their communities with these diseases.

Beyrer was the lead author, and Dr Adeeba a co-author, of a series of papers in The Lancet on HIV and related infections in prisoners, presented recently at the International AIDS Conference in Durban, South Africa. The series say the mass imprisonment of drug users – and failure to provide prevention and treatment – is driving HIV and TB transmission. In Eastern Europe, estimates show up to half of all new HIV infections over the next 15 years will stem from HIV transmission among prisoners who inject drugs.

A survey published this year on 18 local prisons by the Human Rights Commission of Malaysia (Suhakam) concluded that while the country’s prisons were designed to maximise public safety, they were “unable to minimise the transmission of infectious diseases”. It concluded, “Prisons may have turned into breeding grounds for infectious diseases,” which could have “devastating impacts” on overall public health.

Higher risks of infections

There are now more than 50,000 prisoners in Malaysia, almost double the figure from 2000. The increase is not just due to a larger population.

The “prison population rate”, calculated per 100,000 of national population, has spiked, going from 23 in 1972 to 116 in 2000 to 172 today, according to the World Prison Brief. This rate is far higher than many western European countries; in Asia, only Thailand and Singapore imprison more people.

The “War on Drugs” has led to more and more drug users being thrown behind bars. Now, drug users often make up the majority of a prison population. In Kajang prison, about 60% of prisoners are there for drug offences. Overall in Malaysia, Indonesia, Myanmar, Philippines and Thailand, roughly 50-70% of prisoners are in jail for drug-related crimes.

With bulging prisons, infectious diseases have spread. There are many reasons for this. Firstly, injecting drug users (IDUs) are at high risk of infection. The threat of arrest or police harassment may deter them seeking prevention and treatment.

Secondly, the prison environment augments the spread of disease. As the World Health Organisation says, “Ill-health thrives in settings of poverty, conflict, discrimination and disinterest. Prison is an environment that concentrates precisely these issues.”

Overcrowding and poor ventilation facilitate the spread of TB. Poverty, poor nutrition, drug use and stress weaken the immune system, increasing the likelihood of TB developing.

High risk behaviour, including sex and drug injection, also continues in prisons, although authorities are loath to admit it. Extraordinary HIV outbreaks have occurred in prisons in Thailand, Ukraine, Lithuania and Iran.

Overcrowding in prisons facilitates the spread of infectious diseases.

Overcrowding in prisons facilitates the spread of infectious diseases.

Finally, healthcare is inadequate in prisons; prevention and treatment programmes are often non-existent. TB screening, for example, is not common in local prisons, despite the known problem of TB. In the 2014 TB study in Kajang prison, 92% of prisoners had not been tested before for TB.

The Suhakam prison survey found only a third of prisoners received treatment for HIV. Death rates among prisoners with HIV were “extraordinarily high” seven years ago in Kajang prison when Dr Adeeba’s team began working there.

“With the introduction of treatment and clinical services, [death] rates have come down substantially. But there is still much to be done,” she says.

Treat, not jail

Stop the mass jailing of drug users and treat them instead – that’s the message of public health experts in the Lancet series. Incarceration seems particularly futile given relapse often occurs soon after release from prison.

“We need to take a very hard look and ask ourselves do we really need to put all these people in prison in the first place? Putting away people for minor, non-violent drug use does not solve anything,” says Dr Adeeba. “If anything, it creates another problem and that is these diseases get amplified and concentrated within the prison walls [and] then disseminated into the community.”

“The most effective way of controlling infection in prisoners and the wider community is to reduce mass imprisonment of injecting drug users,” says Beyrer, President of the International AID Society.

In the Lancet series, researchers calculated that a 25% reduction in the number of IDUs imprisoned would result in a 7–15% drop in new HIV cases among them.

Providing opioid substitution drugs (OST), such as methadone and buprenorphine, during and after imprisonment could prevent more than a quarter (28%) of new HIV cases in IDUs in five years.

Also recommended were treatment for HIV (antiretroviral therapy), hepatitis B vaccinations, condom distribution, and needle exchange. Such interventions have proved successful elsewhere. In Iran, HIV prevalence among IDUs dropped from 18% to just 2% in 2007 after four years of a prevention package including voluntary HIV testing, opiate substitution therapy, condoms and needle exchange.

Prevention and treatment programmes in local “Cure and Care” clinics helped avert roughly 3,000 new HIV infections since 2006, Universiti Malaya’s CERiA found.

Other recommendations in the Lancet papers include having a minimum standard of health care. In their survey, Suhakam found some of the most basic provisions, such as essential medicines and sanitary pads for women, in short supply. Dental treatment was overlooked in almost all prisons. Even the supply of clean water was an issue.

Lawyer P. Uthayakumar, who was imprisoned in Kajang for sedition in 2013, also highlighted poor prison conditions. He showed a brown, worn toothbrush to the media, saying it was shared by five people. “What I feared most while in prison was that I would fall ill,” he told the press.

Suhakam has recommended that responsibility for prison health services be transferred to the Ministry of Health from the Ministry of Home Affairs.

It also cited the UN’s “Mandela rules”, named after Nelson Mandela who got TB during his many years in prison, which call for prisoners to have the same standard of healthcare as the community.