Capacity building for institutions involved in surveillance and prevention of communicable diseases in Latvian’s penitentiary system
Final Report Twinning Light Project LV/2005/SO- 01TL
Heino Stöver, Marc Lehmann, Solvita Olsena, Inga Upmace, Iveta Skripste, Franz Trautmann, Caren Weilandt
Acknowledgements: Many thanks to the following persons, who substantially supported this EU-Twinning project: Mr. Pauls ALDINS, Ms. Ilze ANDERSONE, Mr. Roberts BALODIS, Ms. Leonora BEBERE, Ms. Zinta BERZINA, Mr. Matthias BLÜMEL, Ms. Sarma BRAUNA, Ms. Inga BULMISTRE, Ms.Andra CIRULE, Ms. Zane DZILUMA, Ms. Alicia Ebeling, Ms. Vera Erdmann, Ms Regina FEDOSEJEVA, Mr. Johannes FEEST, Mr. Andris FERDATS, Mr. Roberts GIRGENSONS, Ms. Gunta GRISLE, Ms. Diana GULBE, Mr. Osamah HAMOUDA, Ms. Kristine IGNATE, Ms. Eva IKAUNIECE, Ms Christiane JESSE, Mr. Maris JIRGENS, Ms. Danuta KANDELE, Mr. Karlheinz KEPPLER, Ms. Kristine KIPENA, Mr. Rimuns KLENAUSKS, Ms. Christine KLUGE HABERKORN, Ms. Bärbel KNORR, Mr. Ivars KOKARS, Mr. Eberhard KRAFT, Ms. Lidija LAGANOVSKA, Ms. Inga LANDSMANE, Ms. Anda LAZDINA, Ms. Ines LEHMANN, Mr. Ainars LEITANS, Mr. Nikolaj PICOHA, Ms. Irina LUCENKO, Mr. Detlef MEYER, Mr. Aleksandr MOLOKOVSKIJ, Ms. Ivita NAGLE, Ms. Raina NIKIFOROVA, Mr. Jurij PEREVOSCIKOV, Mr Manfred PAPENHAGEN, Ms. Anete PELNE, Mr. Viktor PNEVSKIJ, Mr. Oleg POLAKOV, Ms. Zane PUPOLA, Ms. Baiba PURVLICE, Ms. Doris RADUN, Mr. Jurij REPNIKOV, Ms. Vija RIEKSTINA, Ms Katja ROTHE-GRANOTTE; Ms. Marite ROMANOVA, Ms. Signe ROTBERGA, Mr. Dirk SCHÄFFER, Mr SCHULTZ, Ms. Sarmite SKAIDA, Ms .Inga SMATE, Mr. Oleg SMISLAJEV, Ms. Olga TALERE, Mr. Andreas THIEL, Ms. Nadezda TROSJUKA, Mr. Marcis Trapencieris, Ms. Ieva TUCA, Mr. Vadim VIKTOROV, Ms. Dace VILUMA, Ms. Olga ZEILE, Ms. Valentina ZELDAJEVA.
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TABLE OF CONTENTS
EXECUTIVE SUMMARY .............................................................................................. 7 List of Abbreviations ............................................................................................................................................. 10 List of charts ........................................................................................................................................................... 12 List of tables............................................................................................................................................................ 13
I. INTRODUCTION ..................................................................................................... 14 II. METHODOLOGY ................................................................................................... 17 III. ANALYSIS ............................................................................................................ 19 1. International guidance documents ................................................................................................................... 19 2. Information on the Latvian prison system ....................................................................................................... 24 2.1. Prison Staff .................................................................................................................................................... 28 2.2. Infrastructure ................................................................................................................................................. 29 2.3. Financial Resources ...................................................................................................................................... 32 3. Legal framework of health care provision in prisons - Substitution therapy opportunities in penal institutions: necessary changes in legislation ....................................................................................................... 34 4. Surveillance of infectious diseases in Latvia .................................................................................................... 36 4.1. HIV/AIDS ..................................................................................................................................................... 36 4.2. TB ................................................................................................................................................................. 37 4.3. Hepatitis B/C ................................................................................................................................................. 38 4.4. STI................................................................................................................................................................. 39 5. Epidemiology of infectious diseases in Latvian prisons .................................................................................. 40 5.1. HIV/AIDS ..................................................................................................................................................... 40 5.1.1. HIV-Testing and VCT ................................................................................................................................ 41 5.1.3. Prevalence and incidence ........................................................................................................................... 42 5.1.4. Community................................................................................................................................................. 45 5.2. TB ................................................................................................................................................................. 47 5.2.1. Screening/testing inmates and personnel ................................................................................................... 50 5.2.2. Prevalence and Incidence ........................................................................................................................... 51 5.2.3. Treatment ................................................................................................................................................... 52 5.2.4. Community................................................................................................................................................. 53 5.3. Hepatitis ........................................................................................................................................................ 54 5.3.1. HBV/HCV – testing ................................................................................................................................... 55 5.3.2. Prevalence and incidence ........................................................................................................................... 55 5.3.4. Treatment ................................................................................................................................................... 55 5.3.4. Community................................................................................................................................................. 56 5.4. STIs ............................................................................................................................................................... 56 5.4.1. Screening/testing ........................................................................................................................................ 57 5.4.2. Prevalence and incidence ........................................................................................................................... 57 5.4.3. Community................................................................................................................................................. 58 5.5. Co-infections ................................................................................................................................................. 58 6. Drug Use and drug users in prisons ................................................................................................................. 58 4
6.1. Drug testing ................................................................................................................................................... 61 6.2. Supply Reduction .......................................................................................................................................... 61 7. Anonymous Survey on knowledge, attitudes and behaviour of Latvian prison staff towards infectious diseases and drugs .................................................................................................................................................. 65 8. Interventions ....................................................................................................................................................... 68 8.1. Prevention of infectious diseases .................................................................................................................. 68 8.2. Drug prevention and treatment ...................................................................................................................... 68 9. Collaboration ...................................................................................................................................................... 69 9.1. Latvian Infectology Centre (LIC) ................................................................................................................. 69 9.2. Riga Centre of Psychiatry and Addiction Disorders (RCPAD)..................................................................... 71 9.3. Tuberculosis and Lung Disease State Agency (TLDSA) .............................................................................. 72 9.4. State Probation Service (SPS) ....................................................................................................................... 73 9.5 NGOs and Civil Society ................................................................................................................................. 74
IV. CONCLUSIONS .................................................................................................... 76 1. Analysis of the legal situation .......................................................................................................................... 76 2. Surveillance ...................................................................................................................................................... 77 3. Prevention of infectious diseases and drug addiction ....................................................................................... 78
V. RECOMMENDATIONS .......................................................................................... 83 1. Political leadership ............................................................................................................................................. 84 2. Legislative and policy reform ............................................................................................................................ 84 3. Prison conditions ................................................................................................................................................ 85 4. Funding and resources ....................................................................................................................................... 85 5. Health standards and continuity of care and treatment ................................................................................. 86 6. Comprehensive and accessible HIV/AIDS services ......................................................................................... 87 6.1. Surveillance ................................................................................................................................................... 87 6.2. Prevention and treatment of infectious diseases and drug addiction ............................................................. 88 6.3. Involvement of NGOs and Civil Society ...................................................................................................... 92 7. Staff training and support ................................................................................................................................. 93 8. Evidence-based practice .................................................................................................................................... 94 9. International, national, and regional collaboration ........................................................................................ 94
VI. ANNEX.................................................................................................................. 96 Annex 1: Prison System in Latvia at a glance...................................................................................................... 96 Annex 2: Programme study visit .......................................................................................................................... 97 Annex 3: List of participants study visit .............................................................................................................. 98 Annex 4: Report about laboratory confirmed HIV infection for adult person or teenager older than 13 .. 100 Annex 5: Photos of field visis to Latvian Prisons .............................................................................................. 103
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Annex 6: Analysis of the legal framework ......................................................................................................... 106 Annex 7: Anonymous Survey on knowledge, attitudes and behaviour of Latvian prison staff towards infectious diseases and drugs............................................................................................................................... 130 Annex 8: Meeting of Project experts with representatives of Latvia’s NGOs ................................................ 150 Annex 9: Number of mental diagnoses accordingly to ICD-10 classification ................................................. 151 Annex 10: Seminar for prison doctors, nurses and responsible persons of the health administration ........ 152 Annex 11: List of participants of the seminar in Jurmala, June 7, 2007. ........................................................ 153 Annex 12: Number of communicable diagnoses in Latvia’s prisons ............................................................... 154 Annex 13: Photos of opening ceremony of Olaine prison hospital................................................................... 155 Annex 14: List of key experts interviewed during the field visits in Latvia: ................................................... 157 Annex 15: List of prisons visited date and persons interviewed ...................................................................... 158 Annex 16: Questionnaire for prison staff “Anonymous Study on Health in Prison” (English) .................... 159 Annex 17: Questionnaire for prison staff “Anonymous Study on Health in Prison” (Latvian/Russian) ..... 170 Annex 18: Draft Overview on Documents on HIV, DU, Harm Reduction and Prisons................................ 182 Annex 19: Agenda and Participants List “Round Table Discussion” ............................................................. 187
VII. REFERENCES ................................................................................................... 193
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Executive Summary 1
This EU-Twinning project has been conducted between the two project leaders , the Latvian ―Public Health Agency‖ and the German ―Gesellschaft für technische Zusammenarbeit (GTZ)‖ between March and September 2007. In 54 days both project partner teams, all experts in their fields, have been working on the overall task of ―Capacity building for institutions involved in surveillance and prevention of communicable diseases in the penitentiary system‖. This has been done by first analyzing the legal framework of health care provision in prisons. Second an analysis of the situation regarding the prevention and treatment of infectious diseases in prisons has been carried out, in which 8 out of 15 prisons have been visited. Nearly 100 interviews with key persons and experts have been conducted in order to get an overview of the spread of infectious diseases in the community and particularly in prisons and the way the health threats of blood – borne viruses, other infectious diseases and intravenous drug users IDUs in prisons are dealt with. Several additional sources have been used to get an overview, such as a vocational training for prison doctors in Jurmala, a study tour to German prisons, prison hospitals and surveillance institutions, round table discussion with NGOs and Civil Society representatives, and the cooperation with the parallel running UNODC project ―HIV/AIDS prevention and care among injecting drug users and in prison settings in Estonia, Latvia and Lithuania.‖ With the latter fruitful co-operations which led to synergy effects have been achieved. Finally the conclusions and recommendations have been discussed with responsible key persons from the ministries of Justice and Health, key persons from the State Agencies, other (international and national) experts and NGO/Civil Society representatives (see Annex 19). The results have been discussed in order establish a basis for an implementation of the findings and to enhance a sustainable response to the health threats various infectious diseases and drug addiction are posing for health care in prisons and public health care as well. What were the findings? First of all the Latvian prison population has been constantly reduced within the last 10 years (from 10,070 in 1998, which is 410 per 100,000 inhabitants to 6,500, which still is 235 per 100,000 Latvian inhabitants and formed the second highest proportions in Europe in 2004). Also the number of prisoners receiving conditional release has been considerably increased, and the State Probation Service has been established. This is the positive structural background of prison reform. The HIV prevalence among Latvian prisoners was around 6% in 2006 and thus very high compared to the general society (0.17%; 3,870 reported HIV-cases in July 31 2007), which means that the HIV prevalence in prison is 36 times higher than in the community. Compared with other European countries th
this figure is also very high. Every 6 HIV case is detected in prisons, a figure which highlights the importance of efforts to target prevention and treatment in prisons. The number of AIDS cases is also increasing year by year, and in 2006 it was 40 times higher than in 2000. Parallel to the epidemiological
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Under the administrative bodies of the Latvian Ministry of Finance (represented by Mrs. Ruta Konstante) and the German Federal Ministry of Health, Division ―Combating HIV/AIDS‖ (represented by Mr. Andreas Lemmer and Ms. Gisela Lange) 7
situation in prisons the HIV prevalence rate in the general population of Latvia also tripled in the years 2000-2006. The HIV epidemic in Latvian prisons is clearly driven by intravenous drug use as key mode of transmission (more than 90% of HIV infected prisoners were former or are current i.v. drug users). According to the latest estimations by researchers of the Public Health Agency of Latvia the number of opiate users (i.e. IDUs) is about 11-20% of all inmates. According to the population survey report (2003), a study among prisoners revealed that 31% of prisoners used drugs, 24% had injected drugs before imprisonment, 14% continued to inject drugs in prisons; more than 80% of intravenous drug using prisoners reported needle sharing inside prison. The incidence of HIV is 2.0% of all performed tests (2,600) in 2006 and 0.2% in the general society, which means a 10-fold higher figure in prisons. This has to be viewed on the background of two developments. First the rate of new infections per million Latvian citizens is 129.6 cases (WHO/UNAIDS 2005), which are nearly double of the EU-average rate. Second in prisons the number of HIV-tests has been constantly reduced due to financial constraints and lack of resources and infrastructure since 2000 and is now 2,600 (new entries per year 3.500). That means that the likelihood to detect HIV-cases within these voluntary testing on admission to prison is reduced as well. The same accounts for the epidemiological trend of TB. Due to a lack of TB control equipment the number of TB-cases in prisons decreased also in the last 7 years (from 361 cases in 1999 to 73 in 2006). Latvia belongs to the top 14 countries of MDR-TB, and the likelihood of these cases also to be found among the key target group of IDUs, who often were homeless and living on the streets before imprisonment, is relatively high. The risk of undetected TB (or even MDR-TB) is also very high when the equipment for detection is missing. Another challenging threat is the spread of hepatitis B and C. 584 cases of HCV and 32 of HBV have been detected in 2006. Until now screening, testing, diagnosis and treatment regarding hepatitis has not been developed completely in Latvian prisons due to a lack of financial resources. There are no cases of antiviral treatment of HVB or HVC reported from the prison system. Co-infections (HIV/TB and HIV/hepatitis B/C) are an increasing problem in Latvia; it is estimated that 1.4% of TB cases in 2001 were co-infected with HIV. This highlights the importance of integrated HIV/TB and even HBV and HCV programmes and targeting groups that appear to be driving the epidemic. An ―Anonymous Survey on knowledge, attitudes and behaviour of Latvian prison staff towards infectious diseases and drugs‖ among Latvian prison staff, carried out within this EU-Twinning project (see Annex 7), finally revealed a lack of knowledge on HIV and Hepatitis transmission and prevention, needed for a better understanding of those infected. Also their attitudes towards HIV or hepatitis infected prisoners shows that three quarters of the respondents think that the guards should be informed about inmates´ HIV status and over 80% share the opinion that positive prisoners risk to infect the prison staff. About 8
half of them think it is necessary to put HIV positive inmates in a separate building. Their answers to the questions on the occurrence of consensual and non-consensual sexual activities of prisoners revealed alarmingly high rates of in particular non-consensual sex and sexual violence. These epidemiological data describe prisons as a setting characterized by multiple burdens: high spread of blood borne viruses (HIV, HBV/HCV), other infectious diseases (TB, STIs), co-infections, and drug addiction. A substantial number of prisoners are suffering from either of these health damages or more than one. Many data are alarmingly high. A massive response to these health challenges is needed. But the Latvian prison health care is overburdened in tackling these health threats of prisoners, staff and finally partners, family and friends of prisoners adequately: A lack of financial resources for prevention (e.g. hepatitis B vaccination of staff and inmates), treatment and care, unclear division of labour of Ministries of Health and Justice, absence of cooperation of State Agencies in order to develop a comprehensive care or even a case management of infected prisoners, inadequate connection with community health agencies, are characterising insufficient responses. Prevention of infectious diseases and drug use, drug treatment itself, a hepatitis strategy, the involvement of NGOs and Civil Society, political leadership and commitment as well as clear strategic planning of actions against the spread of infectious diseases and the treatment, care and support of ill prisoners, are missing. Starting from these findings the project partner teams developed recommendations in order to improve the response and to scale up the efforts needed to combat the spread of blood-borne viruses, other infectious diseases and intravenous drug use effectively. Apart from general awareness raising and education, information and communication, prevention of the spread of HIV among IDUs especially in prisons mainly is performed by harm reduction programmes (provision of substitution treatment, needle exchange programmes) to make the intravenous drug users stop using injecting and stop sharing needles. Recommendations are focusing on scaling-up measures in order to keep up with the dynamic of infectious diseases and drug use. Political leadership, legislative and policy reform, prison conditions funding and resources, health standards, comprehensive and accessible HIV/AIDS services, staff training and support, implementation of evidence-based practices and international, national and regional collaboration has to be increased massively and in a structured way in order to tackle the health problems of prisoners in the future. The Round Table discussion at the end of the project with key persons was encouraging to step into the direction of co-ordinated and evidence-based responses towards the severe health challenges of infectious diseases in prisons. The currently up dated HIV/AIDS and TB strategy planning should be linked and develop a dual approach for comprehensive responses to fight these infectious diseases.
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List of Abbreviations AIDS
Acquired Immunodeficiency Syndrome
ASPC
AIDS and STI Prevention Centre
BBV
Blood Borne Viruses
BMG
German Federal Ministry of Health
CoM
The Cabinet of Ministers
EU
European Union
GPA
Global Plan of Action
GP
General practitioner
HAART
Highly Active Antiretroviral Treatment
HBV
Hepatitis B Virus
HCV
Hepatitis C Virus
HIV
Human Immunodeficiency Virus
IDU
Intravenous Drug User
LIC
Latvian Infectology Centre
LVL
Latvian Lats (1 LVL=0.7028 EUR)
MoH
Ministry of Health
MoJ
Ministry of Justice
MS
Member State(s)
MSM
Men having sex with men
NFP
National Focal Point
NGO
Nongovernmental organization
PA
Prison Administration of Latvia
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PEP
Post exposition prophylaxis
PHA
Public Health Agency of Latvia
PLWHA
People living with HIV/AIDS
RCPAD
Riga Centre of Psychiatry and Addiction Disorders
SPS
State Probation Service
STI
Sexually Transmitted Infections
SW
Sex Worker
TB
Tuberculosis
TLDSA
Tuberculosis and Lung Disease State Agency of Latvia
UNDP
United Nations Development Program
UNICEF
United Nations Children's Fund
VCT
Voluntary Testing and Counselling
WB
World Bank
WHO
World Health Organization
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List of charts Chart 1: Dislocation of prisons in Latvia ........................................................................... 24 Chart 2: Structure of the Prison Administration .................................................................. 25 Chart 3: Convicts by term of deprivation of liberty. .............................................................. 25 Chart 4: Convicts by age. ............................................................................................ 26 Chart 5: The Latvian penitentiary index ........................................................................... 26 Chart 6: Distribution of convicts by type of crime committed. .................................................. 27 Chart 7: Budget for prison services ................................................................................ 32 Chart 8: Necessary costs for adequate medical care ........................................................... 33 Chart 9: Newly diagnosed HIV infection rate per million population in 2005 ................................ 40 Chart 10: Number of performed tests in prisons, number of positive tests and number of recurrent positive cases. ......................................................................................................... 41 Chart 11: The number of performed tests in the community and in prisons and the respective percentage of positive test results. ................................................................................. 42 Chart 12: HIV prevalence rate in prison settings and general population in Latvia......................... 45 Chart 13: Trends in newly diagnosed HIV infections and AIDS cases by year of reporting............... 45 Chart 14: Key indicators TB in Latvia .............................................................................. 48 Chart 15: TB profile for Latvia....................................................................................... 49 Chart 16: Top 14 sites MDR-TB (all cases), world, 2004 ....................................................... 49 Chart 17: TB incidence in Latvia from 1971 till 2006. ........................................................... 53 Chart 18: HBV incidence (per 100 000 inhabitants) in WHO European Region (2005) ................... 54 Chart 19: HCV incidence (per 100 000 inhabitants) in WHO European Region (2005) ................... 54 Chart 20: Syphilis incidence (per 100 000 inhabitants) in WHO European Region (2005) ............... 56 Chart 21: Gonorrhoea incidence (per 100 000 inhabitants) in WHO European Region (2005) .......... 57 Chart 22: Contingent of drug addicted persons and primary addiction rate in Latvia. ..................... 60 Chart 23: Combat of the use of narcotics in prisons for the period 2002-2006 - Quantity of narcotic and psychotropic substances seized in prisons. ...................................................................... 61
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List of tables Table 1: Development of the number of convicted persons due to the Section 253 of the Criminal Law of Latvia ................................................................................................................... 27 Table 2: Staff of Latvia prisons...................................................................................... 28 Table 3: Number of inmates in Latvia prison settings. .......................................................... 30 Table 4: Newly diagnosed HIV cases in the community and in prison settings by year of diagnosis, checked for double entries. ......................................................................................... 43 Table 5: Number of HIV and AIDS cases in Latvian prisons. .................................................. 44 Table 6: TB prevalence in Latvian prisons. ....................................................................... 51 Table 7: Tuberculosis forms in the prisons by type and sex in 2006. ........................................ 51 Table 8: Tuberculosis in prisons by institution in 2006. ......................................................... 52 Table 9: Incidence and Prevalence of TB in prisons (1999-2006) ............................................ 53 Table 10: Prevalence of hepatitis in Latvian prisons. ........................................................... 55 Table 11: Number of Hepatitis B and C in Latvia by the year of diagnosis. ................................. 56 Table 12: Number of Syphilis and Gonorrhoea cases in Latvia by the year of diagnosis. ................ 58 Table 13: Lifetime prevalence of drug use in prisons: Number of inmates who have used narcotic substances in their life. ............................................................................................... 59
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I. Introduction Since the appearance of HIV/AIDS, the disease has been a challenge for prison systems in all countries. In many European countries the risk and incidence of HIV and other BBVs are higher in prisons than in the general population. Poor prison conditions, inadequate prevention and health care, high risk behaviour, such as needle sharing, forced or voluntary sex between men, tattooing and piercing are the main risk factors. Prisoners are the bridging population that poses a major threat in terms of spreading HIV, hepatitis, STI and Tuberculosis to the general population. Governments are called upon to act, not only in the interest of individual and public health but also to protect people in prison from infection. Prisoners are still part of our communities and they are entitled to the same level 2
of care and protection provided to people on the outside . Protecting them from infection is not only a legal responsibility but protects the communities they return to as well (see Møller et al. 2007). The programmes and services necessary to meet these responsibilities are well known and documented (Lines et al. 2006; Stöver et al. 2007). But still far too few EU MS have implemented the measures and programmes known to be effective for several reasons, e.g. they go against the conception of many governments, prison officials and often the public at large and negative public attitudes towards prisoners and equivalent health care services continue to be barriers to objective and pragmatic discussions of prison health policy. Many have difficulties to accept that condoms, opioid substitution treatment, needle and syringe exchange, safer use/safer sex trainings or even detailed information material are needed in prisons. Policies that prioritize zero tolerance for drug use over evidence-based harm-reduction and drug demand initiatives aggravate the dangers of infections in prisons. It takes political commitment and courage to implement potentially controversial health and harm-reduction programmes demanded by prisoners, human rights activists and the medical profession as well. Beside public opinion and lack of political will there are other obstacles like lack of state resources and technology or combinations of political and resource factors. The Latvian Government is well aware of these problems and obstacles and is addressing them for instance by seeking technical support through this Twinning Project on ―Capacity building for institutions involved in surveillance and prevention of communicable diseases in the penitentiary system‖. The HIV prevalence among Latvian prisoners was around 6% in 2006 and thus very high compared to 3
other European countries. According to the population survey report (2003) , a study among prisoners revealed that 31% of prisoners used drugs, 24% had injected drugs before imprisonment, 14% continued to inject drugs in prisons; more than 80% of intravenous drug using prisoners reported needle 2
See also Stöver/Lines (2006): Silence still = death: 25 years of HIV/AIDS in prisons. In: Matic, S.; Lazarus, J.V.; Donoghoe , M.C. (ed.) World Health Organisation/WHO – Regional Office for Europe (ed.): HIV/AIDS in Europe. 25-Years On., p. 67 3 Drug Abuse Prevalence in Latvia: Population Survey Report 2003 14
sharing inside prison. Due to the lack of preventive measures inside Latvian‘s prisons and the high prevalence rates of HIV prisoners are at high risk of acquiring HIV and/or other infectious diseases like hepatitis B/C and/or TB. The regulations No. 358 of CoM from 19 October 1999 ―About medical care for prisoners and convicts in prison settings‖ determines health examination and health prevention in Latvia‘s prisons. All prisoners and convicts receive medical inspection by entering prisons (including x-ray of lungs, test on STIs and HIV). Guidelines of the Tuberculosis and Lung Disease State Agency ―Tuberculoses reduction programme in prisons 2005 – 2010‖ define that all prisoners should receive x-ray investigation by entry into prison and after that annually for prevention of Tuberculosis. However, this policy is not implemented sufficiently (see chapter 4.2.). As regards testing and counselling, VCT (Voluntary Counselling and Testing) seems not to be provided according to international standards in the prison setting and according to the description of the prison procedures. According to the Project Fiche of the Twinning Project, there is an insufficient collection and documentation of anamnesis which leads to the situation that about 70% of notifications about HIV 4
tested persons are recurrent. The Latvian AIDS Prevention Centre collects data on the prevalence of HIV infection by incarceration, but there is no reliable data available about persons who are contracting HIV during their period of imprisonment. High quality surveillance of infection diseases in prisons is essential for providing reliable and timely epidemiological data and information for policy makers. The recommendations for HIV/AIDS surveillance in Europe by EUROHIV state that ―HIV/AIDS surveillance data is vital to monitor the HIV epidemic and evaluate the public health responses, and all countries in Europe should: Implement national reporting systems for HIV and AIDS cases. Improve the quality of data reported, especially regarding probable routes of transmission.‖
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The surveillance for STIs, Hepatitis B and C and TB in prisons of Latvia is insufficient due to the lack of political commitment, resources, capacities and trained prison staff. Harm reduction and prevention measures for permanent prisoners are lacking. So far, prevention activities in Latvia have been fragmentary. Voluntary treatment for drug abuse and harm reduction measures are not available in Latvia‘s prisons. The situation is caused by the lack of funding, experience and knowledge about how to implement and maintain successful surveillance and prevention of communicable diseases.
4
Since March 1, 2007 – the Public Health Agency HIV / AIDS Surveillance in Europe (End-year report 2005, No. 73; Summary); see http://www.eurohiv.org/reports/report_73/pdf/resume.pdf (accessed 28th of August 2007) 5
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Prevention measures are based on surveillance data. As far as there is no evidence about persons who became HIV infected during their prison sentence, the spread of infectious diseases in prisons is not proven and accordingly the necessity of prevention programs seems not to be justified. The Twinning experts were asked to analyse the actual situation in Latvia as regards surveillance and prevention of communicable diseases in Latvian‘s penitentiary system and derive conclusions and recommendations for the improvement of the above mentioned problems. We hope to contribute to a containment of Latvia‘s concentrated epidemic. If with the political leadership priority and resources are concentrated on groups most at risk of (various) infections, the epidemic clearly visible in prisons can be contained and prevented from spreading into the general population. However, a severe health challenge like the spread of BBVs and other infectious diseases, i.v. drug use, mental health problems, need a massive response by using all strategies and tools available, effective and in line with human rights. Part II of this report outlines the methods used within this EU-Twinning project, in part III the analysis of the actual situation is described and in the final parts IV and V conclusions and recommendations are to be found.
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II. Methodology The analysis of the situation outlined in the following chapter is based on: 6 Analysis of the legal Framework Interviews with key experts (see list in Annex 14) Prison visits to 8 prisons (see list in Annex 15) Document analysis Focus Group discussion with NGOs involved in Prevention activities in prison (list of participants, see Annex 1) Anonymous survey on knowledge, attitudes and behaviour of prison staff (see chapter III.7) Seminar with prison doctors in Jurmala (list of participants, timetable, see Annexes 10 and 11) Study tour to Germany (list of participants and timeframe see Annexes 2 and 3) Literature search: Additional literature to the country specific literature collected during the missions was obtained through literature search conducted in the PubMed database. Also literature
searches
(www.unaids.org),
in
the
Baltic
internet
databases
Health
of
WHO
(www.baltichealth.org),
(www.who.int),
UNAIDS
www.prisonstudies.org,
www.Eurohiv.org and euroTB (www.eurotb.org) were performed. Team members of the Twinning project: Latvia: Mr Andris Ferdats Head of AIDS and STI Prevention centre of PHA Ms Inga Upmace, Deputy Head of AIDS and STI Prevention centre of PHA Ms Iveta Skripste, the public health specialist of AIDS and STI Prevention centre of PHA Ms Anda Karnite, the public health specialist of AIDS and STI Prevention centre of PHA Ms Solvita Olsena (SIA „Medicīnas tiesību institūts‖) Germany: Mr Heino Stöver (University of Bremen) Mr Marc Lehmann (Juvenile prison, Hameln) Ms Caren Weilandt (WIAD, Bonn) Mr Franz Trautmann (Trimbos Institute, Utrecht/Netherlands) Ms Gisela Lange (Federal Ministry of Health). Documents and Reports Two reports have been elaborated by the German and Latvian Project team
: A start-up (inception)
including the status report of Latvia after starting the project and adjustment of the plan of executing of 6
In close cooperation with the currently running UNODC project ―HIV/AIDS prevention and care among injecting drug users and in prison settings in Estonia, Latvia and Lithuania‖ (AD/XEE/06/J20) 17
the project if applicable. And this final report summarising the completion of the assignment, comprising findings referring to the verified documents and, if appropriate their revised versions and making recommendations to the beneficiary. Moreover it contained the financial status of the assignment at the end of project. Thereby it enables the European Commission to fully understand the technical aspects, as well as the economic and financial impact of the measure. The final report contains the financial status of the assignment at the end of project and will be handed over to CFCA in English.
Workplan, implementation and cooperation The activities are interrelated and overlapping. Therefore the sequencing of activities and the implementation time frame are based on the Latvian suggestions and specified in the proposal submitted. The phases of the implementation will be defined in a final, if necessary adapted work plan elaborated in co-operation Latvian and German experts within two weeks after having signed the contract. The convenient plan of action and the methodology are to be set-up by the experts. In order to benefit from synergy effects the Twinning Project has been closely cooperating with the United Nations Office on Drugs and Crime (UNODC) project ―HIV/AIDS prevention and care among injecting drug users and in prison settings in Estonia, Latvia and Lithuania.‖ This project is lasting four years and is likely to achieve more sustainable effects in Latvia and the Baltic region. Together with the coordinator, Ms. Signe Rotberga, common working areas have been identified and fruitful collaboration has been carried out on several stages of the project, but most intensively on the module of analysis of the legal situation, recommendation and during the preparation, conduction and discussions on improvements of the HIV-prevention system in Latvia. One central component of the MS proposal was the adaptation and finally translation of the manual ―Risk Reduction for Drug Users in Prison – Encouraging Health Promotion for Drug Users within the Criminal Justice System‖ (ed. Franz Trautmann/Heino Stöver) into Latvian (an English, Russian, Estonian, and German version is already available). This manual is directed to an interactive skill and knowledge building for staff and inmates. Within the project a core technical group has been established to carry out this adaptation process within a specific training.
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III. Analysis 1. International guidance documents Good prison health is good public health The vast majority of people committed to prison eventually return to the wider society. Therefore reducing the transmission of HIV in prisons is an important element in reducing the spread of infection in society outside of prisons. Good prisoner health is good custodial management Protecting and promoting the health of prisoners benefits not only the prisoners, but also increases workplace health and safety for prison staff. Respect for human rights and international law Respecting the rights of those at risk of or living with HIV/AIDS is good public health policy and good human rights practice. Therefore States have an obligation to develop and implement prison legislation, policies, and programmes consistent with international human rights norms. Adherence to international standards and health guidelines The standards and norms outlined in established international human rights instruments and public health guidelines should guide the development of responses to HIV/AIDS in prisons. Equivalence in prison health care Prisoners are entitled, without discrimination, to a standard of health care equivalent to that available in the outside community, including preventive measures. Evidence-based interventions The development of prison policy, legislation, and programmes should be based upon empirical evidence of their effectiveness at reducing the risks of HIV transmission, and improving the health of prisoners. Holistic approach to health HIV/AIDS is only one of many complex – and often related – health care challenges facing prison officials and prisoners. Therefore, efforts to reduce the transmission of HIV in prisons, and to care for those living with HIV/AIDS, must be holistic and integrated with broader measures to tackle inadequacies in general prison conditions and health care. Addressing vulnerability, stigma, and discrimination HIV/AIDS programmes and services must be responsive to the unique needs of vulnerable or minority populations within the prison system, as well as combat HIV/AIDS related stigma and discrimination. Collaborative, inclusive, and intersectoral cooperation and action 19
While prison authorities have a central role in implementing effective measures and strategies to address HIV/AIDS, this task also requires cooperation and collaborative action that integrates the mandates and responsibilities of various local, national, and international stakeholders. Monitoring and quality control Regular reviews and quality control assessments – including independent monitoring – of prison conditions and prison health services should be encouraged as an integral component of efforts to prevent the transmission of HIV in prisons and to provide care for prisoners living with HIV/AIDS. Reducing prison populations: Overcrowded prison conditions are detrimental to efforts to improve prison living standards and prison health care services, and to preventing the spread of HIV infection among prisoners. Therefore, action to reduce prison populations and prison overcrowding should accompany – and be seen as an integral component of – a comprehensive prison HIV/AIDS strategy. 7
Furthermore there are essential European Recommendations on Drugs (18 June 2003) ―On the prevention and reduction of health-related harm associated with drug dependence‖ (2003/488/EC) points out that Member States should, in order to reduce substantially the incidence of drug-related health damage (such as HIV, Hepatitis B and C and Tuberculosis) and the number of drug related deaths, make available a range of different services and facilities, particularly aiming at risk reduction. To prevent drug abuse EU Member States should ―consider making available to drug abusers in prison access to services similar to those provided to drug abusers not in prison, in a way that does not compromise the continuous and overall efforts of keeping drugs out of prison‖. This sets the frame for a general orientation at the principle of equivalence of health services inside and outside prisons. 8
The EU Action Plan on Drugs 2005-2008 (OJ 2005/C168/01 of 8/7/2005) based on the framework of 9
the EU Drugs Strategy makes provision for an improvement of prevention and treatment services in prisons that will entail an additional need on the part of the Commission for technical support and expertise: The preparation of a Recommendation to develop ―prevention, treatment and harm reduction services for people in prisons, reintegration services on release from prisons and methods to monitor/analyse drug use among prisoners‖. The latter will be released by the EU-Commission in 2008. Furthermore UNAIDS (2005) pointed out that ―…prisoners have a human right to have access to health care, including HIV preventive measures, and to be treated and cared for as are members of the general population. Particularly for drug injecting prisoners, a comprehensive package of services should be made available. The general principles adopted by national AIDS programmes need to be applied equally to prisoners and to members of the outside community. Prison authorities have a central
7
http://europa.eu.int/eur-lex/pri/en/oj/dat/2003/l_165/l_16520030703en00310033.pdf http://europa.eu.int/eur-lex/lex/LexUriServ/site/en/oj/2005/c_168/c_16820050708en00010018.pdf 9 http://register.consilium.eu.int/pdf/en/04/st15/st15074.en04.pdf 8
20
role in implementing effective HIV-control measures. However, this task is not solely the responsibility of prison systems, and cooperation with and among other government entities, especially in the health and criminal justice sectors, is needed. It is essential to create a framework of prison rules that promotes an effective response to HIV and AIDS, because prison rules have the potential to promote or impede progress on reducing HIV transmission in prisons and caring for those inmates living with HIV and AIDS.‖ The World Health Organization‘s Status Paper on Prisons, Drugs and Harm Reduction (May 2005) says that the evidence that HIV transmission can be reduced in prisons through prevention programmes is now overwhelming. Such programmes usually include: Information, education and communication on HIV/AIDS Voluntary testing and counselling Distribution of condoms Distribution of bleach or other disinfectants including target group specific information on how to use bleach to disinfect needles and syringes Exchange of needles and syringes Substitution therapy including counselling and psychosocial support. Additional components of harm reduction programmes with a significant potential to reduce individual risk behaviour include treatment and care related to HIV/AIDS, Hepatitis and Tuberculosis, including access to highly active antiretroviral therapy. The fact that progress in the implementation of these measures within the European prison systems is still slow and insufficient is becoming increasingly unacceptable. Justified by the comprehensive monitoring report on Latvia‘s preparation for membership: acquis Chapter 13 ―Social policy and employment‖ which says that in the field of public health, the legislative transposition of the acquis remains to be completed in the fields of tobacco and communicable diseases. New legislation, in particular rules on communicable diseases notification, surveillance and reporting forms, is required. The list of diseases to be notified should be revised to include all diseases listed in EU legislation and should include also EU case definitions. Further efforts are necessary to ensure the capacity needed to be incorporated into the Community communicable disease surveillance and control structures. Justified by the programme of Community action in the field of public health (2003-2008) which says (Article 3, point 2) that activities related to the monitoring systems of major diseases as well as development of health promotion and disease prevention activities should be realized in Community. Moreover, activities for the exchange of information on best practice in public health and the effectiveness of health polices as well as for obtaining advice from high level experts should be implemented.
21
This report builds on legal obligations, commitments, recommendations, and standards on HIV/AIDS, prison health, prison conditions, and human rights articulated in (Lines 2006): Universal Declaration of Human Rights [1948] United Nations Standard Minimum Rules for the Treatment of Prisoners [1955] International Covenant on Civil and Political Rights [1966] United Nations Principles of Medical Ethics relevant to the Role of Health Personnel, particularly Physicians, in the Protection of Prisoners and Detainees against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment [1982] United Nations Basic Principles for the Treatment of Prisoners [1990] Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment [1988] United Nations Standard Minimum Rules for Non-custodial Measures (The Tokyo Rules) [1990] World Health Organization‘s Guidelines on HIV Infection and AIDS in Prisons [1993] Joint United Nations Programme on HIV/AIDS (UNAIDS) Statement on HIV/AIDS in Prisons [April 1996] Recommendation No R (98)7 of the Committee of Ministers to Members States Concerning the Ethical and Organisational Aspects of Health Care in Prisons [Council of Europe: April 1998] International Guidelines on HIV/AIDS and Human Rights [1998] World Medical Association Declaration of Edinburgh on Prison Conditions and the Spread of Tuberculosis and Other Communicable Diseases [October 2000] Declaration of Commitment on HIV/AIDS (―UNGASS Declaration‖) [United Nation General Assembly Special Session on HIV/AIDS: June 2001] Prison, Drugs and Society: A consensus Statement on Principles, Policies and Practices [WHO Europe/Pompidou Group of the Council of Europe: September 2001] United Nations Committee on Economic, Social, and Cultural Rights: General Comment on the Right to the Highest Attainable Standard of Health. Twenty-second session, Geneva [2002] International Labour Office Code of Practice on HIV/AIDS and the World of Work [2002] Warsaw Declaration: A Framework for Effective Action on HIV/AIDS and Injecting Drug Use [November 2003] Moscow Declaration: Prison Health as part of Public Health [WHO Europe: October 2003] Dublin Declaration on HIV/AIDS in Prisons in Europe and Central Asia [February 2004] Dublin Declaration on Partnership to fight HIV/AIDS in Europe and Central Asia [February 2004] Policy Brief: Reduction of HIV Transmission in Prisons [WHO/UNAIDS: 2004] Policy Statement on HIV Testing [UNAIDS/WHO: 2004] Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention [WHO/UNODC/UNAIDS: 2004] Effectiveness of sterile needle and syringe programming in reducing HIV/AIDS among injecting drug users: Evidence for action technical paper [WHO: 2004] 22
UNAIDS (2005): HIV/AIDS Prevention, Treatment and Care among Injecting Drug Users and in Prisons. Ministerial Meeting on ―Urgent response to the HIV/AIDS epidemics in the Commonwealth of Independent States‖ Moscow, 31 March to 1 April 2005 Recommendation Rec (2006)2 of the Committee of Ministers to member States on the European Prison Rules [Council of Europe: January 2006] UNODC: HIV/AIDS Prevention, Care, Treatment and Support in Prison Settings WHO: Health in prisons. A WHO guide to the essentials in prison health This report has been inspired and was driven by 4 new key documents released (2007) by WHO, UNAIDS and UNODC only recently in the Evidence for Action Technical Papers Series: Effectiveness of Interventions to Manage HIV in Prisons – Provision of condoms and other measures to decrease sexual transmission Effectiveness of Interventions to Manage HIV in Prisons – Opioid substitution therapies and other drug dependence treatment Effectiveness of Interventions to Manage HIV in Prisons – HIV care, treatment and support Effectiveness of Interventions to Manage HIV in Prisons – Needle and syringe programmes and bleach and decontamination strategies
23
2. Information on the Latvian prison system The Republic of Latvia is an independent country since May 4, 1990 and has been a member state of 2
the EU since May 1, 2004. The territory covers 64 589 km , and the number of inhabitants was 2 281 300 on the January 1, 2007. There are 14 prisons and one correction institution for juveniles in Latvia. According to data of the Latvian Prison Administration the total number of inmates in all Latvian prisons is 6.548 including pretrial detainees and remand prisoners (data on January 1, 2007). Chart 1: Dislocation of prisons in Latvia
The prisons may be characterized as follows: 3 investigation prisons — Riga Central Prison, Liepaja Prison and Brasa Prison; 6 closed-type prisons — Daugavpils, Valmiera, Griva, Jelgava, Parlielupe and Matisa prisons; 3 semi-closed-type prisons — Ilguciems Women's, Skirotava and Jekabpils prisons; 2 open-type prisons — Olaine and Vecumnieki Prisons; One correctional institution for juveniles. — Cesis In Riga Central prison the prison hospital was located. Since 01.08.2007 Latvia is running a new prison hospital outside Riga in Olaine prison and all patients will be transferred.
24
Chart 2: Structure of the Prison Administration
Prisons in Latvia Structure of Prison Administration (PA) Prison administration (central body)
15 detention centres
JuvCI
Open prisons
Training centre
Semi-closed prisons
Closed prisons
Remand prisons
JuvCI– Juvenile Correctional institution (up to 21 years of age) 140 inmates max. Woman Prison (Iļģuciems) – adults and juveniles; 400 inmates max
Regarding the numbers of approximately 7,000 prisoners at any given day and 10,000 per year there is no such high turn-over rate. According to the PA the average length of sentences is 4.5 years (Chart 3). 50 % of the convicts are sentenced to a term exceeding 5 years. The distribution in age show the majority is between 18 and 40 years old (Chart 4). Chart 3: Convicts by term of deprivation of liberty.
Source: PA
25
400
300
200 Per 100.000
Chart 4: Convicts by age.
Source: PA. Chart 5: The Latvian penitentiary index
600
500
100
0
a si us ia R on t Es via ia t n La ua th d Li lan ia n Po ma y o r . R ga e p . un R p s H ch Re ale ze C ak &W ov d Sl lan l g a En tug r Poain a s ri Sp lga and g u rl r B the bou e N xem Lu y l a Ita tri y us n A rma e y G rke Tu nce a m Fr giu el e B ec re n G ede Sw and l Ire lta rk a a M m en d D lan n y Fi w a a or i N ven o s Sl ru yp d C la n e Ic
The Latvian penitentiary index (number of inmates per 100 000 inhabitants) of 333 (2005.01.01.) is one
of the highest among EU Member states and in Europe at all.
26
Approx. 10% of the convicts are punished on the basis of Section 253 of the Criminal Law of Latvia: ―Unauthorised Manufacture, Acquisition, Storage, Transportation and Conveyance of Narcotic and Psychotropic Substances‖ (Chart 6, Table 1) Chart 6: Distribution of convicts by type of crime committed.
Source: PA Table 1: Development of the number of convicted persons due to the Section 253 of the Criminal Law of Latvia
absolute figures [n]
01.01.2002
01.01.2003
01.01.2004
01.01.2005.
01.01.2006.
118
245
408
429
476
2.5
5.3
8.2
8.6
10.0
In percent of total number of convicts [%]
The development over time shows an increasing number of convicted persons due to the Section 253 of the Criminal Law of Latvia: ―Unauthorised Manufacture, Acquisition, Storage, Transportation and Conveyance of Narcotic and Psychotropic Substances‖.
27
2.1. Prison Staff The prison staff is paid by the MoJ. The general budget for the staff in all prisons was 15 982 774 LVL (2007). The staff is working in a hierarchic structure and wearing uniform and rank signs.
Table 2: Staff of Latvia prisons. Rank In total in prison settings: Medical staff Including: Medical doctors Nurses Specialists Officers Social workers Guards
Number 3032.5 172.5
% 100 5.7 69.5 87 16
660 24 794
2.3 2.9 0.5 21.8 0.8 26.2 Source: PA
The medical staff is in general externally educated and trained. Most of the medical staff are medical doctors or enlisted nursing staff. The number of medical staff is 172.5 including doctors 69.5 and enlisted nursing staff 87. The medical staffs are working under the head of the medical department on the prison level, under the prison chief and observation of prison administration. According to the 10
medical Treatment Law in Latvia medical practitioners should be certificated every 5 years . In all bigger prisons a psychiatrist is working besides a doctor who is responsible for general medical care. We were told that in general there is a chance to keep one‘s own certificates actual. On the other hand we haven‘t seen any medical library or direct access to the internet for the doctors in any prison. In general the English language of most of the medical staff is very poor. This decreases the chance to get proper information from internet or medical papers. We didn‘t hear about any supervision of medical staff or teams. Most of the doctors are specialized in medical disciplines or sub disciplines. Most of them are qualified in internal medicine or psychiatry. In Latvia the qualification as narcologist is still used but only one of the prison doctors is holding this diploma. In accordance with governmental regulations prison staff has to undergo an annually medical check up for infectious diseases at their private doctor, who has to certify fitness for the job as medical worker. This system needs to be controlled by the prison system. An example for best practice is found in one prison, where this is controlled in combination with the request on leave. Each time prison staff requests leave they have to demonstrate their certificate of fitness.
10
Certificate of a medical practitioner – a document issued by the Union of Professional Organisations of Medical Practitioners of Latvia, the Latvian Medical Association, or the Latvian Nurses Association that certifies the professional proficiency of the relevant person and indicates that the medical practitioner as a specialist is competent to independently engage in the practice of medical treatment (specialist practice) in the relevant field 28
The medical teams reported that it‘s difficult to recruit doctors and enlisted staff in general in Latvia especially for prisons it is even harder due to the low social prestige of prison staff an the reduced income. The reason for a lack of medical staff is a migration to countries with elevated levels of salaries. On prison visits we are told that if prisoners complain they won‘t receive adequate medical care this is proofed by prison administration and the medical staff is charged even if there is not enough money to buy necessary medical care. Furthermore we heard that one doctor is leaving the system and that there was no substitute found. On the other hand we met staff even serving for several years in prison services. Three times a year the MoJ holds meetings for prison doctors. We attended one of these meetings for the heads of medical departments in Jurmala (Annexes 10 and 11). On these meetings medical care issues in prison service, new regulations and problems are discussed. Only in one prison a system with guidelines or standards on medical care on a very basic level could be identified during our visits. The medical system performs care on that what is even held for best ―practice‖. From the medical department some sets of data like basic statistics is reported to the prison administration. They hold data on infectious diseases, mental disorders and spend money for health care. Before prison staff starts to work as wardens they are trained in the Educational Centre of the Prison Administration in Jurmala. This training includes lections on prevention of infectious diseases and self protection. As far as we were informed there are no details on harm reduction or working on addiction problems included.
2.2. Infrastructure Most of the prisons are resisting from old times and consist of old buildings (Annex 5). We haven‘t seen a completely new prison built (with the exception of the new Prison hospital running from August 1, 2007, Annex 13). Some parts are renewed within the last few years. In many prisons the signs of long term use are obvious and lack of money for even minor repairs is missing. Due to these circumstances the living conditions mainly are poor. Still dormitories for more than 40 persons are in use. Not all cells have their own toilet. Several toilets and washing areas are dirty, wet and of low hygienic standard. The ventilation in some parts is poor. Some kitchens are under poor hygienic conditions. The number of prisoners in Latvia is decreasing (see Table 3 below) and by this overcrowding is not the urgent problem any longer.
29
Table 3: Number of inmates in Latvia prison settings. Prison
Number of
Number of
inmates
inmates
July, 2003
16.07.2007
Limit (2006)
1.
Brasa
487
348
600
2.
Central prison
1919
959
1900
3.
Cesis
157
108
140
4.
Daugavpils
740
438
600
5.
Griva
913
789
850
6.
Ilguciems
440
314
400
7.
Jekbpils
352
614
700
8.
Jelgava
710
586
600
9.
Liepaja
417
199
330
10.
Matisa
490
469
770
11.
Olaine (open prison)
41
41
41
-
298
Olaine prison hospital (since 01.08.2007) 12.
Parlielupe
547
460
530
13.
Skirotava
324
432
570
14.
Valmiera
860
693
800
15.
Vecumnieki
52
109
80
8449
6559
920911
total
Source: PA According to Olga Zeile, Director of Sectoral policy department of MoJ (2007) a new concept of Prison Development has been developed and accepted by the CoM in May 2, 2005 with the main purpose to solve problems related to prisons infrastructure (overcrowding and safety); the implementation of the Concept is planned in several ways: complex reconstruction of 8 prisons; enlargement of 3 prisons – construction of new blocks in existing prisons (cameras per 700 convicts in each of 3 prisons); reconstruction of infrastructure in 4 prisons; Latvian Prison Hospital – it will be transferred to new premises in Olaine prison. The activities are planned in 6 stages until 2014. Medical departments, existing in all prisons are different. In Cesis prison there is a partially renewed medical department. The new prison hospital started to work on August 1 2007, the old one has been st
closed on the 31 of July 2007. The conditions in the central prison and the old prison hospital were 11
8,911+298 (new prison hosp. Olaine)=9209 30
very poor (see Annex 5). For example in the Central prison prisoners were held (short periods) in very small boxes with wooden floor waiting for a transport or the doctor. Mainly the floor is not of rough structure with difficulties in disinfection. Some medical departments are running few beds for sick inmates. In general in the medical departments the hygienic basic standards are given. They have running cold water, soap, disinfectants for hygienic hand disinfection, hygienic roles, deposits for medical sharps, basins for surgical instruments, hygienic gloves. Medical needles and syringes are for one way use. Staff is wearing white protection coats. To improve the situation these coats should stay in medical departments when medical staff is moving in the prison. The medical equipment is mainly simple and old. Equipment for sterilization was seen but no facilities for further preparation of surgical or dental instruments. Instruments are partly just kept in disinfectant. Procedures of recapping of medical sharps are still seen. Medical sharps are generally given in separate waste but unsafe plastic bottles are partially still in use. The equipment for X-ray, necessary for proper diagnostic process in Tuberculosis was functioning only in the prison hospital. Doctors reported that all older X-ray machines were shut down due to new regulations in radiation protections. Some prisons reported that they have developed cooperation to local external health care systems, other needs to transfer patients to prison hospital. The expected mobile X-ray system of the Tuberculosis agency might be used for surveillance and diagnostic procedures in prisons but the costs must be paid from the medical budget. Higher levels of medical care needed to be bought for external services, e.g. the general public health care system. Impressions of living circumstances and medical departments and kitchens with pictures are given in the Annex 5 by photography.
31
2.3. Financial Resources Chart 7: Budget for prison services
Financial situation of Latvian prison system (LVL) 45000000 40000000 35000000 30000000 25000000 20000000 15000000 10000000 5000000 0
30730785
16392705
2003
16899251
2004
21353637
2005
2007
Actual financing
The actual given budget for prison services is shown in Lats for the last 4 years. It includes costs for all prisons functions: regular payments, capital expenditures, salaries. etc.; also approx. 100 000 LVL are included for medical .care. It should be kept in mind that the increase of finances (Chart 7) in the last years is due to the funds for the new hospital! (Pukite/Fedosojeva 2007) Sub budgets for medical care result in an annual budget of about 12 Lats per prisoner per year. Compared with the actual costs for medical procedures this is very low. For an HIV-Antibody test (HIV 1 and 2) costs are about 4.- Lats for one person. Cost for chest X-ray procedure by mobile system is calculated with 7.28 LVL per one procedure. The full diagnostic process for Hepatitis B or C before therapy starts with 327.0 Lats. Screening for hepatitis C and B costs about 6.- per procedure. One vaccination dose against hepatitis B costs about 25.- LVL plus diagnostic testing before (all data approximately). Harm reduction measures are not yet funded within the prison budget. Due to these facts the prison administration calculated the necessary costs for adequate medical care like follows (Pukite/Fedosojeva 2007), see chart 8.
32
Chart 8: Necessary costs for adequate medical care Optimal amount of finances for Latvian prison system (LVL) 45000000 40000000 35000000 30000000 25000000 20000000 15000000 10000000 5000000 0
40551769 32978260 23484413
2003
26464634
2004
2005
2007
Needed financing to meet EU and Latvian standards
33
3. Legal framework of health care provision in prisons - Substitution therapy opportunities in penal institutions: necessary changes in legislation12 Interrupting HIV transmissions amongst injecting drug using networks in prisons affords substantial efforts in introducing harm reduction and drug substitution programmes. What needs to be done to ensure coordinated multisectoral policy support and a supportive legal framework? An essential part will be constructive, multilevel engagement of health with law enforcement and the prisons administration. What legal or structural changes are needed? With the support of the UNODC project ―HIV/AIDS prevention and care among injecting drug users and in prison settings in Lithuania, Latvia and Estonia‖ these questions had been answered by Solvita Olsena in a legal assessment (see also Annex 6). Every convict is entitled to receive without any discrimination health care, including preventive measures, in the same scope as the society in general. Those convicts, who received a substitution therapy, should be provided with an opportunity to receive thereof also in a place of confinement, but in a state, where in the society such therapy is available to people depending upon opiates, it should be also available in the places of confinement (WHO Guidelines on HIV infection and AIDS in prison, 1993). Analyzing LR effective legislative instruments (laws, CM regulations), one should come to conclusion that the availability of methadone or buprenorphine therapy in penal institutions is significantly restricted both by legal provisions on the procedure for treatment of drug-dependent persons and the restricted rights of convicts to receive state-guaranteed health care services, and regulations on financing of health care services. In order to exterminate the existing discrimination, to restrict the spread of infectious diseases, specifically HIV and AIDS, as well as to fight the use of narcotics in prisons it is necessary to elaborate, adopt and implement practically such legal proceedings, which secure attainment of the aforementioned objective. When elaborating changes in legal provisions one should take into consideration Latvian international commitments in the sphere of human rights, epidemiological safety and HIV/AIDS control (2004 Dublin Declaration and Dublin Declaration on HIV/AIDS in prisons). Necessary changes in legislation. 1. Whereas at present Treatment Law prescribes that the dependence can be treated solely at drug treatment clinics it is necessary to amend Article 61 of this Law. The term ―drug treatment clinic‖ contained in the said Article should be expanded, defining that the treatment of drug – dependent patients occurs at clinics. . 2. It is necessary to check the competency of the Ministries of Health and of Internal Affairs defined in legal provisions at the whole and specifically in the sphere of prisoners‘ health care, taking into consideration the prescribed in Treatment Law. It is necessary to check the competency of the Ministries of Health and of Internal Affairs in the sphere of control of spread of HIV/AIDS and drugs, infectious diseases and restriction, taking into consideration the functions of state bodies defined in Epidemiological Safety Law. It would be useful, considering the UNAIDS defined the „Three ones‖ principle, which prescribes that in the state a common HIV/ AIDS control program, a single state
12
Solvita Olsena prepared the report for the United Nations Office on Drugs and Crime project
―HIV/AIDS prevention and care among injecting drug users and in prison settings in Lithuania, Latvia and Estonia‖. No part of this report may be reproduced, stored, transmitted, or disseminated without prior permission from UNODC. Thanks to Signe Rotberga, who is the coordinator of this UNODC project, for the permission to integrate the report in this document (for the full legal analysis, please see chapter 6)..
34
institution, which implements all necessary measures and which is a single state institution, which supervises and valuates efficiency of all measures, are deemed necessary. 3. It is necessary to valuate the competency of the state bodies existing at present, for instance, the Public Health Agency, the State Health Mandatory Insurance Agency, the Latvian Infectology Center, the State Agency of Tuberculosis and Lung Diseases, the Prison Administration in the sphere of health care and infection control. It is necessary to valuate the necessity to precise the competency so that the convicts would be provided with an opportunity to receive necessary health care services, but, specifically, the health care services connected with diagnostics, treatment and prevention of infectious diseases, including HIV/AIDS. 4. Taking into consideration the rights of convicts, as guaranteed under Article 17 of Treatment Law, to receive health care services without any discrimination, it is necessary to amend the CM Regulations No. 199 „ Regulations on health care of detainees and convicts in remand prisons and institutions of confinement‖ and the C< Regulations No. 104613 „Health care organization and financing procedure‖. The amendments must contain such a model of convicted people health care, which equally sufficiently secures the rights of convicted patients to receive health care services, including the methadone therapy, and also secures realization the objective of custody in the necessary scope. Whereas at present the convicts receive health care services in a very limited scope, it is necessary to define in legal provisions the legal proceeding for the transitional period. 5. The CM Regulations No. 42914, ―Procedure for treatment of alcohol, narcotic, psychotropic and toxic substances – dependent patients‖ should be amended so that to decentralize and to expand the availability of the replacement therapy. In the Regulations it is necessary to provide for the procedure how opiate – dependent persons can receive the therapy in clinics existing in places of confinement. These Regulations should contain an internationally acknowledged practice in treatment of drugdependent persons, for instance, it is necessary to expand a circle of health professionals eligible to treat the dependents, it is necessary to consider a partial change of criteria effective at present15. The new regulations should cover an internationally acknowledged practice in treatment of dependent persons, during elaboration of which the below documents should be applied: 1) WHO, UNAIDS and UNODC elaborated document „Effectiveness of Interventions to Manage HIV in Prisons – Opioid substitution therapies and other drug dependence treatment, Evidence for Action Technical Papers ,WHO, UNODC, UNAIDS, 2007‖ (the document is available in the electronic version at: http://www.who.int/hiv/idu/en/). 2) WHO/UNODC/UNAIDS „Position Paper on Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention‖; 3) Legal aspects of substitution treatment. An insight in to nine EU countries, EMCDDA, 2003; 4) Dublin declaration on HIV/AIDS in prisons 5) The Lisbon Agenda for prisons. 6. It is necessary to choose more efficient juridical method for changing of legal provisions at the CM level. It is necessary to consider two opportunities – first of all, to supplement the existing legislation with new norms, secondly: to elaborate new CM regulations.
13
Regulations No. 1046 of the Cabinet of Ministers„Health care organization and financing procedure‖, 19.12. 2006. 14 The Cabinet of Ministers passed on the 24th of September 2002 Regulations No. 42914 ―Procedure for treatment of alcohol, narcotic, psychotropic and toxic substances – dependent patients‖. 15 Clinical studies on the efficiency of the methadone therapy have evidenced that criteria contained in presently effective regulations considerably reduce the circle of people, who may be treated with the methadone therapy. One should consider that in the presently effective regulations there has been made a grammar mistake in the recitation of juridical criteria. 35
4. Surveillance of infectious diseases in Latvia In the following the surveillance situation regarding infectious diseases is being presented for the community and the prison system.
4.1. HIV/AIDS The monitoring of HIV/AIDS in Latvia is in the responsibility of the Public Health Agency under the MoH. The key surveillance instrument for monitoring is the HIV epidemic in Latvia is HIV case reporting. It is mandatory for health staff to offer HIV test to all TB patients, pregnant women, IDUs, sex workers, STI patients, and prisoners at entry to prison system, and to ensure VCT. For the general population in Latvia a scheme for HIV testing looks as follows: The doctor provides VCT and addresses the patient to the laboratory where primary HIV test (ELISA, 4th generation) is carried out. If the blood sample is HIV positive laboratory forwards it to HIV/AIDS reference laboratory of the LIC for confirmation with Western Blot and/ or Immunoblot. LIC‘s reference laboratory is the only one confirming HIV diagnosis in Latvia. If the sample test is confirmed as seropositive in the reference laboratory as well, the laboratory sends the report to PHA‘s ASPC, and the second together with the test result and empty reporting form (Annex 4) to the doctor who initially sent the patient to do the HIV test. The doctor fills the form and sends by mail to PHA‘s ASPC which monitors all HIV and AIDS cases. The scheme for testing prison inmates basically is the same: The prison‘s general doctor sends the patient‘s blood sample to one of HIV-testing laboratories or directly to LIC‘s HIV/AIDS reference laboratory to perform HIV test since there are not laboratories in prisons. In the case of positive result the reference laboratory sends one report form to PHA‘s ASPC and the other one together with the test result to the prison doctor. The doctor fills the form and sends it to PHA‘s ASPC. Since reporting form contents information if the HIV infected person is a prisoner and the personal identification number (awarded to every resident of Latvia) it is possible to select newly infected prison inmates from the data basis. The HIV test is not repeated as a routine during the stay or at release, except if requested by the inmates or by the medical staff. There is no routine screening for tuberculosis infection or disease among HIV positive inmates without symptoms (mainly because of lack of X-ray equipment in most of the prisons, which may lead to undetected TB; Zellweger 2006, 3). 36
4.2. TB The monitoring of TB in Latvia is responsibility of the Tuberculosis and Lung Disease State Agency (TLDSA) under MoH. Latvian legislation determinates mandatory examination for TB for short-term apprehend persons without domicile, asylum seekers located in special centers and those persons who has applied for residence permit, and also for illegal immigrants in special encampment. Generally GP appoints his patients with symptoms or patients form risk population for TB examinations. The other group who is submitted for TB screening is persons working in educational and foodprocessing institutions (mandatory health examinations). Diagnosis of TB should be confirmed by the sputum examination and X-ray. In the case of active TB diagnosis person is appointed to local TB centre (26 in Latvia) or to the hospital, and the report sent to the SATLD for the TB register. Treatment is free of charge. If the person with active TB refuses treatment he should be treated perforce in special guarded hospital ―Ceplisi‖ for the 3 months period. In prison system TB screening is done by questionnaire, clinical aspects and smears. The policy explained from prison side varies from prison to prison. In some prisons they do smears on all incoming prisoners in others they only do in suspicious case. Only in Prison hospital X-ray is available. In Cesis prison they have cooperation with local public health care for X-ray. Extended diagnostic is only performed in prison hospital. All patients needing treatment have to be transferred to prison hospital. The case reporting is done when diagnostic is secured. Reporting is addressed to tuberculosis register. Every person on admission passes TB examinations including special questionnaire (elaborated by the SATLD) and X-ray where it‘s possible. Next questionnaires are carried out after every 6 months. For TB suspects and/ or complains during imprisonment bacteriological analysis of sputum is carried out and X-ray where it is possible. If Prison doctor finds symptoms of TB the prisoner is sent to the prison hospital for next examinations, including X-ray. In the case of new confirmed TB diagnosis all documentation is sent to the SATLD for recommendations on treatment. Decision about necessary treatment adopts SATLD together with specialists of prison hospital. Patients stay in prison hospital as long smears are positive or other risks of spreading of infections exist.
37
In the case of MDR TB SATLD gives regular (each month) recommendations on treatment and consultations are provided by special Central Advisory Committee of Doctors (Latvian: Centrālā ārstu konsultatīvā komisija). Treatment of TB in prison hospital continues for 6 months, and after if there are not complications, prisoner is transferred to the prison and lodged in special isolation ward. In the case of MDR TB or due to the complications prisoner stays in the prison hospital for longer time. Medications for TB treatment prison hospital gets from SATLD (state program under the MoH) but examinations are under the PA budget. All prison doctors and nurses are educated on TB by SATLD.
4.3. Hepatitis B/C No special epidemiological surveillance for hepatitis B and C exists in Latvia. Case reporting system is a part of general information system on all infectious diseases (excepting HIV and TB). Legislation sets mandatory reporting on Hepatitis B and C cases to PHA. All data about number of hepatitis patients has been collected and analyzed at least twice a year by the Health Statistics and medical Technologies State Agency. Only blood donors are submitted to Hepatitis B and C screening. Generally examination on hepatitis B and C are carried out by the medical indications. The confirmation of diagnosis has been occurred by LIC.
Examinations for diagnosing Hepatitis B and C are free of charge in the case if patient is
addressed by GP. On patient‘s own initiative he should pay himself. For confirmation the diagnosis of HBV, HCV accordingly to LIC‘s guidelines the liver biopsy should be carried out which is paid service. If there is need for special therapy on the basis of performed tests doctor of infectology introduces the Council of hepatologists, and only in compliance with Council‘s decision treatment should be started. Since 2006 both – Hepatitis B and Hepatitis C treatment (also acute HCV) should be partly – 25% covered by patients themselves and 75% by the state program. Before 2006 there was not state program for hepatitis treatment, and practically all treatment was paid by the patient. There is no diagnostic screening for hepatitis either on entering than on leaving prison. Only patients being positive for HIV testing will undergo a diagnostic process during HIV consultation by the LIC. On request prisoner can get hepatitis tests for his own money. In clinically suspicious cases e.g. jaundiced additional diagnostic can be carried out by prison doctors. Extended diagnostic preparing therapy in not carried out, even in cases of positive Hepatitis. The explanation given for the deficiency is; that there won‘t be money for the treatment which is much more expensive than the diagnostic process. Treatment for Hepatitis B and C in prison is not given. Even additional procedures like Vaccination against Hepatitis B in Cases of C are not performed. See chapter III.2.3 and III.9.1 38
4.4. STI Generally for diagnosing STIs people should address private practicing specialists and pay for themselves, or to address a specialist who is in contract with the State Agency for Compulsory Health Insurance. In the second case patient should pay only for patent installment. The Antenatal program in Latvia includes Syphilis and Gonorrhea screening for pregnant women on registration of pregnancy, and since June 2006 for Chlamydia. Also all donors‘ blood is tested for Syphilis. Laboratorial and medical examinations for Syphilis and Gonorrhea are mandatory in the case if patient has infected other persons or on suspicion of it. In the case of sexually transmitted diagnosis (Syphilis, Gonorrhea, Chlamydia and Herpes) specialists are able to report in 72 hours to the Public health Agency (till 28.02.2007 to the State Agency for Sexually Transmitted and Skin Diseases). Treatment for STIs is ambulatory. Patients should pay for the treatment of STIs by themselves, excluding Doxicyclinum for Syphilis treatment which is partly paid by the state‘s budget. Diagnostic screening in the Latvian prison system except brief clinical examination on admission is not established. Every prisoner on admission has been inspected by the doctor, and if any indication of STI exists necessary examinations are provided free of charge. The same happens during imprisonment. Some years ago all prisoners were tested for Syphilis on admission but because of very few positive cases it was stopped for saving financial resources. In the case if patient has infected other persons or on suspicion of it mandatory examinations for prisoners are carried out in the Prison hospital. All treatment of STIs is provided in prison hospital free of charge (from the budget of PA) contestant it is in community. The responsibility for different types of medical care (HIV, Hepatitis, TB and Addiction is shared between different independent state institutions. For all kinds of combinations of infectious diseases (e.g. HIV and TB or HCV) and/or addiction there is no direct case management or therapeutic conference between prison or Prison hospital, RCPAD, LIC and TLDSA. The infectious disease reports are given to several different recipients.
39
5. Epidemiology of infectious diseases in Latvian prisons
5.1. HIV/AIDS Latvia belongs to those countries in the EU with very high infection rates per million population (see chart 9). With 129.6 cases it is nearly double of the EU-average rate. It is estimated that 7600 people by the end of 2003 were living with HIV in Latvia, equal to a prevalence of 0.6% (UNAIDS 2004). To a high degree the spread of HIV is driven by unsafe drug injection. The majority of HIV infected people are young male injecting drug users, who mainly got infected through sharing of needles, syringes and/or drug paraphernalia (see also WHO 2005). The HIV prevalence among IDUs was estimated at 17.3% in 2002 (UNAIDS 2004). 81% of all new HIV cases in 2001 were among IDUs (Cabinet of Ministers 2003). There are also HIV infected individuals among other high-risk groups such as commercial sex workers (CSWs) and men who have sex with men (MSM), but they constitute less than 20% of all HIV infected persons in Latvia. UNAIDS (2005) recommends for countries with such transmissions via unsafe drug use that ―interventions to control HIV among IDU should be the cornerstone of HIV prevention strategies‖. Chart 9: Newly diagnosed HIV infection rate per million population in 2005 0,0
Estonia Portugal United Kingdom Luxemb ourg Latvia Belgium France Ireland Netherlands Italy Austria Denmark Cyprus Greece Malta Sweden Lithuania Germany Finland Slovenia Poland Hungary Czech Repub lic Slovakia "EU average" Bulgaria Romania
50,0
100,0
150,0
200,0
148,3 135,5 129,6 102,3 88,5 76,7 74,6 64,5 55,3 52,5 51,5 50,4 47,3 43,4 35,0 29,6 26,1 18,3 16,9 10,9 8,8 3,9 71,7 10,7 9,4
250,0
300,0
251,1
Source: EuroHIV end-year report 2005, No. 73
40
350,0
400,0
450,0
500,0 467,0
5.1.1. HIV-Testing and VCT Testing is useful for screening diagnostic of new cases and surveillance of seroconversion in prison. According to the actual numbers of HIV tests shown in chart 10 and the number of resident prisoners of about 6.500 and an estimated annual number of at least 3.500 new entries to prison, e.g. in the year 2006 approx. 900 prisoners have not been tested for HIV. Chart 10: Number of performed tests in prisons, number of positive tests and number of recurrent positive cases.
HIV testing in Prisons in Latvia (Source: Public Health Agency)
300
10000
9000
8722 250
8000
244 7267
7000 6684
200
6209
6000
180
5369
150
5000 140 115
100
4000
120 110
102
100
3094
3000 2600
87 71 50
56
68 52
47
2000 1000
0
0 2000
2001
2002
No. of newly diagnosed HIV cases in prison settings
2003
2004
No. of recurrent cases
2005
2006
No of tests performed in prisons
Source: PHA
In general HIV testing in prison is voluntary and basic pre-test counselling and post-test counselling in case of a positive test result are performed. The above chart illustrates the development of the test policy in prisons over the time. VCT seems to be applied insufficiently, otherwise the high number of repeated tests of HIV positive prisoners (in 2005 87 out of total 139 HIV positives were recurrently tested; in 2006 – 68 out of 115) can not be explained. The interviewed medical staff stated that VCT is an integral part of the HIV testing process. It should be in accordance with the Latvian legislation (Regulations of CoM No.628, Nov.4, 2003, ―Organizational Procedures for restriction of the spread of HIV and AIDS and the Treatment of HIV-Infected persons 41
and AIDS Patients‖). The figures in chart 10 support the assumption that this policy is applied insufficiently. According to information from the PA, not special training course on VCT for prison doctors has been offered for several years.
5.1.3. Prevalence and incidence All prisoners entering the prison system pass a medical examination including an HIV test (except if they explicitly refuse) within the first three days after arrest. The tests are performed in external, certified laboratories. Positive results (by ELISA) are confirmed by Western Blot in the reference laboratory of LIC. The list of inmates with a positive result is known to the medical staff of the prison and cases are reported anonymously but with personal identification code to the PHA. Further examinations (CD4 counts, viral load, chest X-ray) and prescription of antiretroviral therapy (ARV) is decided by the specialist from the LIC in close collaboration with the medical doctor in charge of the prison. The first HIV case in Latvia‘s prison settings was reported in December of 1997. In total up to December 2006 971 HIV cases (27.4% of the cumulative Latvian HIV cases) have been diagnosed on entry to prisons. However, no conclusions at all can be drawn from this figure to the incidence rate of HIV infections in Latvian prisons or on the number of HIV infections contracted inside prisons because it is not known whether the infection was contracted before or during detention. Up to now, HIV testing is only performed on entry to prison and not repeated during the course of imprisonment nor on release. The relatively high percentage of cumulative newly diagnosed HIV cases among prisoners might also be caused by different testing policies in the community and in prison. As shown in the previous chart 10, only in the year 2000 close to 9.000 HIV tests have been performed in prisons and in the following three years between 6.000 and 7.000 inmates have been tested for HIV on entry to prisons. The following chart (11) illustrates the number of performed tests in the community and in prisons and the respective percentage of positive test results. Here it becomes obvious, that the proportion of positive test results among the testes samples is much higher in prisons than outside. Chart 11: The number of performed tests in the community and in prisons and the respective percentage of positive test results.
42
Newly diagnosed HIV cases in prison settings and community and No.of tested in prison settings and community 900
200000
807 0,5% 800
180000
172387
170595
163873
161849
700
160000
155128
153193 142333
140000
542 0,3%
600
120000
466 0,3%
500
403 0,2%
100000
400
323 0,2%
200
299 0,2%
244 3%
300
40000
120 2%
71 1%
100 8722
7267
6684
0 2000
2001
6209
2002
No. of newly diagnosed HIV cases in prison settings
2003 No. of new HIV cases
52 2%
47 2%
5369
3094
2004
2600
2005
No. of tested in prison settings
20000
No. of tested in the community
It is quite difficult to estimate the HIV incidence in the prison population. The uptake rate (% of prisoners tested) is not known, but as chart 9 illustrates, the number of performed HIV tests in prisons decreased significantly over the time and dropped from over 8.700 in the year 2000 to 2.600 in year 2006. This means that either the testing policy in prisons or the rate of prisoners refusing to be tested must have changed significantly over time, since the total number of prisoners did not alter much over this period of time nor did the average length of sentence. Furthermore, the denominator for the calculation of the incidence rate is unknown and could only be roughly estimated, because we do not have information on the turnover and thus on how many persons passed the prison system annually. Table 4: Newly diagnosed HIV cases in the community and in prison settings by year of diagnosis, checked for double entries.
Newly diagnosed HIV cases in general population 63 25 163 241 466 43
0
2006
Source: PHA
1987-1996 1997 1998 1999 2000
80000 60000
180 3%
140 2%
299 0,2%
Newly diagnosed HIV cases in prison settings
Newly diagnosed HIV cases in prison settings (%)
0 1 39 77 140
0 4 24 32 30
2001 2002 2003 2004 2005 2006 Total Source: PHA
807 542 403 323 299 299 3.631
244 180 120 71 52 47 971
30 33 30 22 17 16 27,4
Approximately one fifth of all newly diagnosed HIV cases since the beginning of the epidemic in Latvia have been diagnosed in prisons. Table 5: Number of HIV and AIDS cases in Latvian prisons. 2000
2001
2002
2003
2004
2005
2006
Point prevalence, December 31
197
385
522
468
454
410
401
% of all inmates
2.2 %
4.3 %
6.2 %
5.7 %
5.9 %
5.9 %
6.1 %
2
12
23
59
51
72
81
2
5
19
32
30
45
59
HIV infected:
AIDS cases within the year Point prevalence, December 31 Source: PA
The above chart shows the number of known HIV and AIDS cases at a given day by year according to the statistics of the PA. Here it becomes obvious, that the HIV prevalence rate in the prison population increased tremendously over time from 2.2% in the year 2000 up to 6.1% in December 2006, meaning that it nearly tripled within 6 years period, and it is 36 times higher than in general population (see chart 12). The number of AIDS cases is also increasing year by year, and in 2006 it was 40 times higher than in 2000. Parallel to the epidemiological situation in prisons the HIV prevalence rate in the general population of Latvia also tripled in the years 2000-2006.
44
Chart 12: HIV prevalence rate in prison settings and general population in Latvia.
HIV prevalence in prison settings and general population 7
6,2
6
5,7
5,9
5,9
6,1
5 4,3 4
3
2
2,2
1
0
0,07
0,04 2000
2001
0,12
0,10 2002
2003
HIV prevalence rate in prison settings
0,14
0,13 2004
2005
0,14 2006
HIV prevalence rate in general population
Source: data by PHA and PA According to the PA, 98 % of inmates infected with HIV/AIDS and viral hepatitis B and C have been using narcotic substances before, so intravenous drug use seems to be the predominant route of transmission. 32 (54%) prisoners diagnosed with AIDS (n=59) were receiving antiretroviral therapy in prisons on December 2006.
5.1.4. Community The HIV epidemic in Latvia has so far followed trends and patterns which are common in other Eastern European countries. The introduction of easily available heroin in Latvia in 1998 coincided with a dramatic increase in the number of newly diagnosed HIV infection cases, mostly among the population of IDUs. The trend reached its peak in 2001 and, since then, has substantially decreased (Chart 13). Chart 13: Trends in newly diagnosed HIV infections and AIDS cases by year of reporting.
45
HIV/AIDS Cases by Year of Diagnosis December 31, 2006 - Latvia
900 807
800 700 600 500
542
466
400
403
300 1
200
1
6 2
100 0 1989 1990
163
3 1
1 1987 1988
323
241
1991 1992
1 1
5 3
8 2
2
1
299
299
21 17 25 3 5 3
13 18 23 40 56 75 77 3 3 7 8 23 1 2 7 15 4 6 4 14 19
1993 1994 1995 1996 1997 1998 1999 2000 2001
2002
2003
72
53
31 30 22
14
HIV AIDS Deaths in HIV Death in AIDS
2004
2005
2006
Source: State HIV/AIDS case reporting database, PHA Sexual transmission, mostly among MSM had been the dominant mode before 1998. Very few cases were reported and HIV did not spread to other groups. Thus in it´s early stage the Latvian HIV epidemic showed similarities with the initial stages of the epidemic in most Northern European countries with homosexual contacts as the major transmission 16
route. HIV-1 subtype B was shown to dominate in this population . The rapid increase of HIV-1 infection among IDUs in Latvia follows similar local explosive outbreaks of infection with HIV-1 subtype A and A/B recombinant variants in the several regions of the former Soviet Union, including southern parts of the Russian Federation, Ukraine, Belarus and Kaliningrad. From the molecular epidemiological investigations it became clear, that the Latvian HIV-1 epidemic among IDUs 17
was related to the epidemic in the former Soviet Union countries . One lineage among the Russian HIV-1 subtype A1 variants appears to have established the outbreak in Ukraine and Latvia. However it is difficult to determine the direction of transmission between these countries.
16
Balode et al. Rapid Spread of HIV Type 1 Subtype A1 among Intravenous Drug Users in Latvia and Slower Spread of Subtype B among Other Risk Groups. AIDS Research and Human Retroviruses, 20 (2): 245-249, 2004 17 Ferdats et al. An HIV Type 1 Subtype A Outbreak among Injecting Drug Users in Latvia. AIDS Research and Human Retroviruses, 15 (16): 1487-1490, 1999 46
There are indications for the spread of dominating A1 variant from IDUs to other population groups. This increases the risk of further spread of HIV infections from high risk population groups via ―bridging 18
population‖ (IDU´s sexual partners) into the general population . The year 1993 was a turning point for the development of the national response to the HIV/AIDS epidemic in Latvia. Riga hosted the meeting of Ministers of Health and Finance of Central and Eastern European countries on ―HIV/AIDS: Investment in Health‖. The policy document ―The Riga Initiative‖ has 19
been adopted to express commitment to invest in HIV prevention . This aimed to keep low HIV prevalence in the region. Despite this initiative, the situation has changed dramatically and in a short period of time, Eastern Europe became the region with the fastest growing rates of HIV infection in the 20
world . The national HIV/AIDS policy is based on the National Public Health Strategy and three consecutive national programmes to limit the spread of HIV/AIDS in Latvia. The national policy is assisted by several UN organisations (UNDP, WHO, WB, UNICEF) and programmes (WHO/ GPA, UNAIDS). In 1993, the Ministry of Welfare created the AIDS Prevention Centre. Since 1997 the AIDS Prevention Centre
21
became the leading national HIV/AIDS coordinating authority, managing and coordinating the National 22
AIDS Prevention Program .
5.2. TB TB and especially Latvia‘s high MDR-TB rates are a serious threat to the Latvian prison medical care and to the society at large. Together with a comparable high HIV-rate among prisoners increasing HIV/MDR-TB co-infections can be noticed. People with HIV-infections become infected with TB far more often than healthy individuals because the immune system is damaged already. Overcrowding, inadequate ventilation, and bad sanitation facilities remain commonplace in the 15 institutions. ―Mihils Azarenko, chief of Riga‘s Central Prison estimates that around 600 inmates in his institution are currently living in unsatisfactory conditions. He believes that to achieve EU recommendations of 4 square meters of space per prisoner, the country would need 2,000 extra cells, or two entire new prisons.‖ (Brown 2004, 2085) Outdated medical equipment in the prison system has not been replaced by now. According to Dr Inga Nagele (head of the TB unit in Riga‘s the old prison hospital) diagnosis of TB in the prison is painful 18 Balode et al. Rapid Spread of HIV Type 1 Subtype A1 among Intravenous Drug Users in Latvia and Slower Spread of Subtype B among Other Risk Groups. AIDS Research and Human Retroviruses, 20 (2): 245-249, 2004 19 WHO/ GPA. The Riga Initiative: A Call for Action 1993-1996; Riga, Latvia, 1993 20 UNDP Report (2004): HIV/AIDS in Eastern Europe and the Commonwealth of Independent States. Reversing the Epidemic, Bratislava 21 Since March 1, 2007 AIDS Prevention Centre has been joined to The Public Health Agency who is a legal successor of all functions, rights and liabilities 22 Regulation No. 71 of the Cabinet of Ministers (February 11, 1997) ―The Framework for the AIDS Prevention Centre‖ 47
slow: ―She and her colleagues still identify MDR-TB infected inmates by culturing regular sputum samples testing the colonies‘ susceptibility to drugs - process developed by Robert Koch in 1882. It takes weeks to establish drug resistance with this method during which time patients are treated with potentially ineffective drugs, a practice that fuels resistance.‖ (Brown 2004, 2085) Chart 14: Key indicators TB in Latvia
48
Chart 15: TB profile for Latvia
Chart 16: Top 14 sites MDR-TB (all cases), world, 2004
Top 14 sites MDR-TB (all cases); world, 2004 All cases (%) 23.4
Kazakhstan
20.1
Estonia
19.5
Georgia
18.9
Moldova
18.8
Azerbaijan
18.5
Uzbekistan
16.8
Russian Fed.
16.4
Lithuania
13.6
Ukraine
11.5
Latvia
10.9
Tajikistan
10.6
Kyrgyzstan
10.4
Belarus
08.9
China
Estimated ~ 70 000 MDR-TB cases in EUR 5
Zignol M, Hosseini MS, Wright A et al. Global incidence of multidrug-resistant tuberculosis. JID 2006, 194:479-485.
49
Latvia belongs to the top 14 countries with MDR-TB in the world, which highlights the necessity for preventive and treatment approaches.
5.2.1. Screening/testing inmates and personnel According to the PA the following Medical activities on TB are carried out in the Latvian prison system: Examination of prisoners for TB on entry and during the detention (This seems to be problematic since 2006 as the majority of equipment is out of order; X-ray is generally possible only in the Prison hospital). TB patients isolation All new TB cases and relapses are treated in the Latvian Prison Hospital DOTS and DOTS plus in-patient treatment is carried out in the hospital and outpatient treatment is carried out in isolated units/cells. All new TB patients and MDR TB patients are consulted in TLDSA All TB patients are registered in the National TB Register High level prison administration officials, guards and medical staff are educated about TB Good information exchange system is organized between Prison Medical Service and SATLD. Prison medical staff notifies the local community TB out-patient medical centres about the persons who are being released from prisons and are in need to continue the treatment Organizational and technical management (the isolated out-patient units or cells are created in 7 prisons) In 2007 a new challenge emerged in Latvian prisons: restrictions of TB preventive measures caused by closing of X-ray rooms almost in all prisons. In 2006 in 10 prisons X-ray rooms were closed because the X-ray equipment there was old and did not meet modern standards and the new Rules of Cabinet of Ministers. Currently MoJ and MoH are working to improve the situation. In previous years in order to decrease and normalize TB prevalence the main WHO principles were implemented in Latvian prisons: prisoners health care should be equivalent to that available in the outside community; Integration of prison medicine into the public medicine. The Medical Department of the Latvian Prison Administration participated in the creation of the Draft of the National TB Control Programme 2008 – 2012. The example with TB incidence and prevalence in Latvian prisons demonstrates that only with joint efforts (prison medicine and public medicine) it is possible to improve and normalize the situation with
50
infectious diseases in prisons. This makes the necessity of the integration of prison medicine and public medicine extremely obvious.
5.2.2. Prevalence and Incidence Table 6: TB prevalence in Latvian prisons. 1999
2000
2001
2002
2003
2004
2005
2006
745
562
518
491
344
278
249
149
361
301
265
222
168
135
112
73
0
0
5
16
24
11
19
13
Tuberculosis (TB) year prevalence point prevalence, Dec.31 AIDS + TB point prevalence, Dec.31
Source: PA
Table 7: Tuberculosis forms in the prisons by type and sex in 2006. Gender Tuberculosis of respiratory organs Extra pulmonary tuberculosis All form tuberculosis
Total
15-17
18-24
25-34
35-44
45-54
55-60
61-64
male
39
0
5
21
6
6
1
0
65& more 0
female
4
0
1
3
0
0
0
0
0
male
0
0
0
0
0
0
0
0
0
female
0
0
0
0
0
0
0
0
0
male female
39 4
0 0
5 1
21 3
6 0
6 0
1 0
0 0
0 0
Source: TLDSA In 2006 TB was diagnosed for 51 persons in Latvia‘s prisons. This includes 44 firstly diagnosed cases and 7 relapses (5 on admission and 2 during imprisonment) (Table 8).
51
Table 8: Tuberculosis in prisons by institution in 2006.
Prisons
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
Brasa Central Cesis Daugavpils Griva Ilguciems Jekabpils Jelgava Liepaja Matīsa Olaine Parlielupe Skirotava Valmiera Vecumnieki Total
Diagnosis during imprisonment (int.al. relapses)
Diagnosis on admission (int.al. relapses)
2 7 (1) 0 0 5 3 2 1 1 (1) 1 0 1 3 5 0 31 (2)
1 12 (3) 0 3 (1) 0 1 0 0 1 1 0 0 0 1 (1) 0 20 (5) Source: TLDSA
5.2.3. Treatment Since 1996 – 1997 the Medical Department of the PA and the TLDSA have begun a close collaboration on: assessment of the TB situation in the prison system professional training of PA specialists. All TB therapy, including DOT, is managed by TLDSA according to the WHO and their own guidelines. - prison administration - primary care physicians - phthisiopulmonologists - nurses - laboratory specialists - consultation of TB patients 52
- exchange of information - providing prisons with specific medicines - ensuring prisons with specific examinations and manipulations. Due to good collaboration between PA and TLDSA that eventually was good collaboration between MoJ and MoH the TB situation in prisons considerably improved (table 9).
Table 9: Incidence and Prevalence of TB in prisons (1999-2006) Incidence
Prevalence on 31 Dec
Year prevalence
1999
279
361
745
2006
44
149
73
5.2.4. Community Chart 17: TB incidence in Latvia from 1971 till 2006.
TB incidence in Latvia 1971 - 2006 80 72,9
74,5
74 68,3 68,4
70
per 100 000 inhabitants
65,1
60
70,5
65,4
63,3
59
57,4
59
51,5
50
50,4
47,4 41,9 39,6 37,6
40
53,5 49,7
44,1 35,8
38,4
33,3 32,3
30
30,9
32
29,3
30,8
33,3
29
26,9
28,6
27,4
28,7
20 10
06
05
20
04
20
02
03
20
20
01
20
99
00
20
20
98
19
96
95
97
19
19
19
94
19
92
93
19
19
91
19
89
90
19
19
88
19
86
87
19
19
85
19
84
19
82
83
19
19
81
19
79
80
19
19
78
19
76
77
19
19
75
19
73
19
72
19
19
19
71
0
Although the incidence rate (49.7 per 100,000) is decreasing, it still did not reach the lowest level in 1990 (27.4 per 100,000).
53
5.3. Hepatitis Chart 18: HBV incidence (per 100 000 inhabitants) in WHO European Region (2005)
Latvia‘s HBV incidence is in the range 7.22 (in 2005) and the HCV incidence is 4.57 (in 2006). Chart 19: HCV incidence (per 100 000 inhabitants) in WHO European Region (2005)
54
5.3.1. HBV/HCV – testing Since there is no budget for Hepatitis testing in prisons tests are only performed for HIV positive prisoners on the initiative of LIC. Also problematic in necessary examinations for prescribing therapy as there is demand for liver biopsy performed only in LIC. So Hepatitis diagnostic and treatment would require police guided transportation to LIC. Obviously at the moment there is no hepatologist working (or planned to work) in the new prison hospital.
5.3.2. Prevalence and incidence Table 10: Prevalence of hepatitis in Latvian prisons. HBV chron. Point prevalence, Dec.31, 2006 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
Brasa Central Cesis Daugavpils Griva Ilguciems Jekabpils Jelgava Liepaja Matisa Olaine Parlielupe Skirotava Valmiera Vecumnieki Prison hospital TOTAL:
9 1 7 1 4 1 4 1 3
1 32
HCV chron. Point prevalence, Dec.31, 2006 29 131 2 10 21 39 9 82 15 39 9 65 29 91 13 584
Source: PA At the end of 2006 nearly 9% of the total prison population has got a chronic HCV, 0.5% a chronic HBV. These figures are even underestimating the problem of the spread of hepatitis B and C, because prison medical care does not comprehensively screen and test prisoners on hepatitis.
5.3.4. Treatment There are no cases of HVB or HVC treatment reported from Latvia prison settings. Theoretically treatment is possible on the same treats as for general population, i.e. partly covered by the state program (75%) and partly – by the patient (25%). Nonetheless prisoner will have to pay additionally for guard and transport to LIC as liver biopsy is necessary, and it should be realized only in LIC.
55
5.3.4. Community Table 11: Number of Hepatitis B and C in Latvia by the year of diagnosis. 2002
2003
2004
2005
2006
totally
492
337
214
170
167
per 100 000 inhabitants
21
15
9.2
7.4
7.3
HBV (acute)
HCV (acute)
.
totally
149
121
113
110
105
per 100 000 inhabitants
6.4
5.2
4.9
4.8
4.6
506
768
1134
1029
1339
21.8
32.9
48.8
44.7
58.3
HCV (chron., firstly diagnosed) totally per 100 000 inhabitants Source: PHA
5.4. STIs Chart 20: Syphilis incidence (per 100 000 inhabitants) in WHO European Region (2005)
Regarding Syphilis the incidence in Latvia was 18.82 cases per 100,000 in 2005.
56
Chart 21: Gonorrhoea incidence (per 100 000 inhabitants) in WHO European Region (2005)
The number of Gonorrhoea increased from 29.49 (2005) to 32.5 cases in 2006.
5.4.1. Screening/testing There is no screening offered and performed of STIs in Latvia prisons. Only on suspicion or prisoner‘s grievance examinations are carried out and PA have to pay for every test done in the prison settings. Only for HIV positive prisoners examinations on STIs are done by LIC.
5.4.2. Prevalence and incidence Point prevalence on December 31, 2006 of STIs in Latvia prison settings was low: 18 cases of Syphilis (20 in 2005) and none of Gonorrhoea.
57
5.4.3. Community Table 12: Number of Syphilis and Gonorrhoea cases in Latvia by the year of diagnosis. 2002
2003
2004
2005
2006
totally
679
784
584
443
483
per 100 000 inhabitants
29
33,6
25,1
19,3
21,1
Syphilis
Gonorrhoea totally per 100 000 inhabitants
555
481
537
668
746
23,66
20,6
23,1
28,9
33 Source: PHA
The number of Syphilis cases is decreasing in the Latvian society, in prisons 18 cases were detected in 2006. An increase in the number of Gonorrhoea cases in Latvia can be noticed from 2002 to 2006 (34%). In the same period number of reported Syphilis was decreasing (-29%). No data from the prisons were available.
5.5. Co-infections Whereas in the previous chapters the epidemiological situation of single infections has been described and analysed, in the following co-infection (e.g. HIV and TB; HIV/HCV) should be looked at. At least HIV/TB is an increasing problem in Latvia; it is estimated that 1.4% of TB cases in 2001 were co-infected with HIV (Morozova et al 2003). In 2004 the Latvian Ministry of Health reported 40 new cases of co-infection with HIV and TB (Latvia Ministry of Health 2005). This highlights the importance of integrated HIV/TB and even HBV and HCV programmes and targeting groups that appear to be driving the epidemic. Especially these co-infections have to be examined in their impact on clinical management of drug dependence in an HAART context. A threefold strategy combining HIV/TB/hepatitis control should be developed, between the different national HIV/TB/hepatitis programmes.
6. Drug Use and drug users in prisons 23
The number of i.v. drug users in Latvia is estimated to be approx. 15.000 . According to a study
24
of the
Institute of Philosophy and Sociology (2003) drug use has been prevalent in prisons since 1997. Prior to that prisoners tended to use alcohol to intoxicate themselves. Since it is easier to hide drugs, and thus 23
Data prepared for EMCDDA ―2007 National Report‖ (personal communication Mr Marcis Trapencieris, Researcher at the Public Health Agency Riga) 24 Institute of Philosophy and Sociology, University of Latvia, Population Survey on Drug Abuse Prevalence, 2003 (Riga, Latvia) 58
easier to bring them into prison, cases of drunkenness have decreased in recent years. The most prevalent drugs used in prisons are cannabis, amphetamines, and heroine; ecstasy, cocaine, opiates and barbiturates were mentioned least often. Heroine is used mainly by those prisoners addicted or already done so prior to imprisonment. Cocaine is used mainly by wealthier prisoners. Assessments of the number of drug users vary: one expert claimed that unofficially almost everyone at his prison uses drugs. Other experts claimed that the number of users in prison is between 10 and 30 percent. According to the latest estimations of researchers of the PHA the number of opiate users (i.e. IDUs) is 25
about 11-20% of all inmates . In Latvia‘s prison system no drug prevention or treatment programmes are operating. Due to a division of labour responsibilities for drug services in the community are clearly divided among some centres, but none of them is providing services in prisons. 98 % of inmates infected with HIV/AIDS and viral hepatitis B and C have been using narcotic substances before.
26
This fact points out the relevance of (injecting) drug use for the spreading of
infectious blood born disease. Table 13: Lifetime prevalence of drug use in prisons: Number of inmates who have used narcotic substances in their life.
2002
2003
2004
2005
2207
1413
1100
1041
26.8 %
17.18 %
14.11 %
14.1 %
Users of narcotic and psychotropic substances [n] [%], N
Source: PA; data provided by medical units of prisons According to above mentioned survey 65 % of prison inmates have used narcotic substances ever in their life including 5% started using in prison. The differences between prison data and data acquired in the Survey can be explained by the facts that: - inmates are reluctant to report drug usage due to fear about the possible impairment of their status; - there is an increase in activities aimed at combating narcotics since 2002.
25
Personal communication Mr Marcis Trapencieris, Researcher at the Public Health Agency Riga Source: PA, R. Fedosejeva part of presentation: LATVIA HIV/AIDS Prevention and Care in Prison Settings Today and Tomorrow 2007. 26
59
Official statements of prison staff during our field visits differed from ―no problems with drugs‖ to ―severe problems‖. Nobody was able to give detailed information. Some aspects mentioned shall be reported: Due to a lack of money there is not much use of cocaine, Cannabis and amphetamines are very popular, barbiturates are still common and heroine is decreasing. IV use is still standard. According to the Survey almost 20 - 24% respondents admit to having drugs intravenously prior to imprisonment and 10 - 14% admitted infections while in prison as well. The most widespread method for disinfecting syringes and needles is dousing then with boiling water (44% of IDUs use this method), and disinfectants are not available in prison settings. Prisons count annually the number of patients consulting medical services for mental disorders. The full data are shown in the Annex 9. The statistic is just an estimate and underestimation should to be considered. The results are grouped in accordance to the International Classification of Diseases 10. These data point out for F 10 (alcohol) 843, F11-19 other substances and intravenous drugs (see Annex ) as number of patients on December 31, 2006. Data on drug addiction in general Latvian population are poor. In the Yearbook of Health Care Statistics in Latvia 2005 (Ministry of Health of the Republic of Latvia 2006, pp 100ff) prevalence and incidence for ―Mental and behavioural disorders due to psychoactive substance use‖ is 3.1/1.1 per 100,000 and 0.1/0.5 % of mental disorders. In the same source the distribution for newly registered drug dependence to certain substances is figured with percentages for Opiates 50,6, Cannabis 1,7, Sedatives 2,9, Amphetamines 13,8, Inhalants 1,7 and Other 29.3. Regarding the corresponding table over year others includes multiple substance use. Information by which way data are collected is not available. In accordance with the legislation in the state register are included persons who were registered during last year due to addiction of psychoactive substances and persons under effect of narcotic or psychoactive substances. Till February 28, 2007 data collecting on drug abuse was under responsibility of the State Agency of Drug Abuse (after – PHA). According to the Agency‘s Annual report 2005 there were registered 174 patients (7.5 per 100 000 inhabitants) with primary diagnosis of psychotropic substances. In 2004 the number was 201 or 8.7 per 100 000 inhabitants. In the last years the number of registered people with drug and psychotropic substances addiction decreases. However, this does not mean that also drug using decreases. It could be explained with changes of drug using habits in last years and with adjustment of legislation regarding registration of patients. Chart 22 demonstrates changes in prevalence and incidence of addiction rate in Latvia during last 15 years. Chart 22: Contingent of drug addicted persons and primary addiction rate in Latvia.
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Contingent of drug-addicted persons and primary addiction rate in Latvia (per 100,000 inhabitants)
140 120 100 80 60 40 20 0 1980
1985
1990
contingent
1995
2000
2005
addiction rate
Source: State Agency of Drug Abuse, Annual report 2005 The number of persons registered with primary addiction reached the top in 2000/2001 (in the same year the highest number of newly diagnosed HIV cases was registered), and afterwards decreases. The contingent of drug users is increasing since the middle of 80ies and in the beginning of new century was 6 times higher. But we have to notice that there are disclosed data from official registers which actually is very weak because there is no system of reporting, and the majority of patients stay out of any registration.
6.1. Drug testing In general drug testing by biochemical methods is only done in suspicious cases on request of the prison staff to medical staff. The samples are normally analysed at the Riga Centre of Psychiatry and Addiction Disorders (RCPAD). There the staff is able to perform a full analysis. This is expensive but necessary for legal reasons when the result shall be used in court cases. Immunochemical methods for screening procedures are not used. If results turn out positive, a prisoner will be punished and has to pay for the test. A general screening program for illegal drug consumption is not performed. Some statistic data used by prison administration are resulting in contacts to medical system.
6.2. Supply Reduction According to the PA measures against the use of drugs in prisons are necessary. One of the most important measures in the prevention of addiction is the reduction of supply (by preventing the narcotic and psychotropic substances from entering the detention centres). Chart 23: Combat of the use of narcotics in prisons for the period 2002-2006 - Quantity of narcotic and psychotropic substances seized in prisons.
61
Narcotic substances 1400
1211,4
Quantity (gr.)
1200 1000 800 600
795,6
767,29
2005
2006
539,94
400 200 0 2003
2004 Year
Source: PA Typical ways of supply of narcotic and psychotropic substances to prisons are through: 1. Parcels; 2. Perimeter drops; 3. By agency of prison staff or visitors; 4. By agency of detained persons arriving to the prison transported by State Police. 5. By inmates after periods of leave; In order to prevent the narcotic and psychotropic substances from entering prisons by way of parcels, changes were introduced in legislation in 2003, which prohibited addressing parcels containing food products to inmates. The drug supply measures are affected by education and motivation of staff. A low payment of staff reduces motivation to cut down supply and elevates the risk that staff gets involved in drug ‗transports‗. For visitors a proper body search is obligate but effecting the rights of the visitors. After leaves of prisoners the risk of drug transportation especially by body packing is increased. A clearly structured process after detection including urine testing of suspected prisoners, reporting system, prevention of repetition of same way of supply and criminal charge is helpful.
62
Source: PA
Source: PA Infrastructural circumstances of the prison including technical equipment needed to be reflected. A typical overthrow to prison walls is easier, if the outside area is hard to observe and allows hidden approach. Manpower for observation is needed and cooperation with outside forces like police must be arranged. Technical equipment, for example systems to locate mobile phones or radio disturbing systems, is helpful. Drug distribution is typically organised by mobile phones. In September 2005, Prison Administration received a financial allocation from the national budget for the purchase of special 63
equipment for preventing the convicts from using the possibility to use mobile communications. The installation of the said equipment should have been completed in 2006, however there is an unspecified delay. According to the PA (Ms R. Fedosejeva) there were mobile telephones seized: - 1056 in 2004; - 932 in 2005; - 1217 in 2006. X-ray for incoming parcels is common in other countries. If the drugs are already inside the walls, drug sniffing dogs increase the chance of detection. We heard that such dogs could be lent from the border police. An effective suppression might require a certain number of dogs in prison service. The advantage is that the dog guide even knows the typically hidden places in his institution. Experience shows that the staff of one prison is normally not able to carry out a widespread search in all the units or even the whole prison besides their normal work. A possible system might be, to build an especially trained alert group including confident staff from several prisons, which can be called for such searches. They could acts on short notice. This team will be alerted typically at night time, lead by an experienced officer, and collected at a meeting point. They will start their work without announcement. Such groups named ―Special Security Service‖
27
are used in Germany and are very helpful even to find
weapons or mobile phones in prisons. On action normally the targeted prison won‘t be informed upon arrival. If there are suspicious circumstances, a single prison can request the use of this service The old buildings and the situation in large cells or sleeping halls decrease the chances for a widespread proper search. The same applies for personal belongings for example green plants which are classical places to hide drugs even complicate this.
27
In Germany: ―Besonderer Sicherheitsdienst‖ 64
7. Anonymous Survey on knowledge, attitudes and behaviour of Latvian prison staff towards infectious diseases and drugs The objectives of this survey
28
were to examine prison staff's knowledge about HIV and hepatitis, in
particular about transmission and prevention, to determine their subjective view concerning the prevalence of infectious diseases in their prison, their own risk of getting infected at work and their work conditions in general. Furthermore, detailed information on attitudes of prison staff towards drug use, drug user, and people living with HIV and/or hepatitis and the implementation of possible prevention measures should be gathered as well as information on health behaviour in terms of utilisation of vaccination and screening. The staff members were asked to complete a short questionnaire (in Russian and Latvian language versions were available, see Annex 16+17), participation was anonymous and voluntary, each Latvian prison was asked to send 6 filled questionnaires back to the Ministry of Justice (2 answered by staff from the medical department, 2 by the prison administration and 2 by guards). 78 filled questionnaires from 12 (out of 15 prisons) were sent back to the MoJ. Although the sample size is quite small, not representative in any terms and biased by a higher educational level, the results give us an impression on knowledge, attitudes, behaviour and practice of the persons working in Latvians prisons and proposes questions, which should be investigated further on with a larger and more representative sample. All results have to be interpreted carefully taking these limitations into account. The most common problems in the staff‘s view mentioned by the majority of respondents are a lack of staff (79%), followed by lack of staff‘s safety (78%), overcrowding (56%) and lack of hygiene of the premises (53%). A lack of information on infectious diseases was also stated by more than a quarter of respondents and lack of sanitary equipment by 18%. This indicates quite worrying subjective working conditions, in particular, the fact that nearly 80% feel a lack of their own safety at work is alarming. The subjective knowledge (―how would you assess your knowledge‖) on Tuberculosis and HIV/ADS (87% respectively 82% state very good or rather good knowledge) are better compared to Hepatitis (around 70% very good or rather good). However, there are quite high rates of those who stated that they feel rather bad or even very bad informed about HIV/AIDS (13%), TB (18%), Hepatitis B (30%) and Hepatitis C (27%). These results are striking if keeping in mind that our sample is biased by a high educational level with over 50% of respondents with a college or university degree. One can assume that the percentage of those prison staff members who feel not sufficiently informed about infectious diseases might be much higher if we have had a representative sample of the prison staff.
28
See the full report of this survey in Annex 7, the questionnaires in Latvian and English in
Annex 16+17 65
Asked about problems related to their work, it became obvious that drug related problems were on top of the list with around 50% of respondents stating that these problems disturb their work (drug use, drug trafficking, violence and inmates hiding syringes in the cell). For HIV and Hepatitis around on third of prison staff mentioned that these infections exist in their prison and disturb their work. It was also quite striking that a relatively high (30%) proportion of prison staff state that sexual contacts between prisoners are of concern in their prison. Sexual contacts are partly tabooed and therefore it is surprising that nearly 60% of the respondents say that sexual contacts between prisoners in their prison do exist. This has strong implications for (free and anonymous) condom distribution inside Latvian prisons. Just a small minority of respondents felt being at no risk of contracting infectious diseases due to their work conditions. Up to half of the prison staff presumed themselves at high risk related to HIV Hepatitis and TB. Also alarmingly high is the percentage of prison staff members (around rep. above 50%) who state that during their work as a prison officer they have ever bee confronted with an event that made them fear to become infected by TB, Hepatitis or HIV. This together with the fact that nearly 80% of the respondents stated that they feel a lack of staff‘s safety means that the daily working conditions of prison staff are frightening and associated with fear of becoming infected by prisoners. There is a danger that this might have implications for instance for prison staff‘s willingness to intervene in cases of emergency. Asked for their estimations about the prevalence of infectious diseases in their prison, between one fourth and one third of respondents had no idea about the infection rates among prisoners, which indicates a high degree of uncertainty or at least a lack of available information and knowledge. The questions on violence revealed alarming high rates of violence between inmates and also between inmates and staff. Psychological violence seems predominant: Nearly 80% of the interviewed staff believes that there is psychological violence (threats, bullying, and intimidation) in their prison and also more than half of them thinks that there is sexual violence and other physical violence like fist fights or attacks with weapons. Over one fourth of the prison staff stated that there is psychological violence like threats, bullying, intimidation between inmates and prison staff in their prison. Although these results have to be interpreted carefully on the one hand because of the small sample size and on the other hand because we have a kind of convenience sample which is not representative, the answers to the violence questions are quite worrying, because it might be that prison staff is at risk to be forced or threatened to be involved into drug smuggling. In general, this danger becomes higher the lower the payment of the prison staff is. Also the answers to the questions on the occurrence of consensual and non-consensual sexual activities of prisoners revealed alarmingly high rates of non-consensual sex (28% rape between prisoners and 39% sexual intercourse as a form of currency). These results support the urgent necessity of making condoms easily available and easily accessible for all prisoners anonymously and free of charge.
66
Between one third and half of the sample did not provide any estimation on types and quantities of drug consumption of prisoners. But among those who estimated consumption rates, alcohol and tablets were reported as the most common drugs followed by cannabis/hashish and heroin/opiates. The assumption that related problem are prevalent within Latvians prisons, is also supported by the data on injection behaviour among prisoners. Asked for an estimation of the rate of injecting drug users in their prison, about 60% did not know an answer or did not answer the question. But more than one quarter of the interviewed staff members confirmed intravenous drug use in their prison on different levels. The largest group perceive between 5-20% IDU´s among the inmates of their prison. Prison staff‘s knowledge on HIV and Hepatitis transmission and prevention is lacking. It becomes obvious that there is still a relatively high percentage of prison staff with either uncertainties related to the main transmission routes of infectious diseases or wrong perceptions. In particular, over one third of respondents believe that HIV can be transmitted via saliva and still nearly 30% do not know that HIV can not be transmitted by mosquito bites and 15% do not know about possible transmissions by sharing razor blades. The knowledge on hepatitis is even worse. Asked about attitudes towards HIV or hepatitis infected prisoners, more than three quarters of the respondents think that the guards should be informed about inmates´ HIV status and over 80% share the opinion that positive prisoners risk to infect the prison staff. About half of them think it is necessary to put HIV positive inmates in a separate building. The majority of the staff members would refuse to work, eat or associate with a hepatitis infected person, which implies that the fears of getting infected through social contacts are overestimated. Just 64% of the respondents are aware that a vaccination exists against Hepatitis B and 17.9% believe that there is also a vaccine available against Hepatitis C, which in fact is not the case. This indicates that knowledge about vaccination, in particular on Hepatitis B vaccination should be improved in order to promote the uptake rate of Hepatitis B vaccination among prison staff. Asked about the acceptance of preventive measures in prison, more than 90% of the respondents agree to provide prison staff and prisoners with information on infectious diseases, to make condoms available in the long-term visiting rooms and to organise workshops among prisoners held by trained health educators on infectious diseases. But also more than 90% agree on the implementation of systematic testing procedures of prisoners for HIV and Hepatitis in order to prevent the spread of HIV and Hepatitis. However, this testing policy is in fact no effective measure to prevent infectious diseases, even the opposite might be the case, because testing on admission and making the test results available for prison staff (more than three quarters think that the guards in prison should be informed about the prisoner‘s HIV status) might lead to a false feeling of security. In general, prison staff should be aware of routs of transmission, prevention measures and emergency measures like post exposure prophylaxis and then just simply treat every prisoner as if he/she was infected.
67
8. Interventions
8.1. Prevention of infectious diseases Effective harm reduction programmes to control the HIV/AIDS epidemic being fuelled by HIV positive IDUs are not available in Latvian prisons. There are no structural programmes or activities in the field of the prevention of infectious diseases. According to the PA 14 projects on education and preventive activities were organized and implemented in recent years. Examples named are lectures, peer education, distribution of disinfectants and condoms. Parts of these activities have been organised by or together with NGOs (see 9.5). Generally these projects were incidental temporary activities, due to a lack of structural funding. Some were pilot projects. However, even when they were going quite well, further implementation was impossible. That means that the provision of services mainly has been stopped with the end of the projects. In the community ten municipalities provide needle exchange and rehabilitation programmes for IDUs and Riga City provides financing for the NGO ―DIA+LOGS‖ that provides services for IDUs including training (see WHO 2005). Prevention of the spread of HIV among IDUs mainly is performed by harm reduction programmes (needle exchange programmes, provision of substitution treatment29 to make the IDUs stop using injecting and stop sharing needles. The up-scaling of these activities in Latvia have not been able to keep up with the spread of HIV/AIDS. This goes for society but much more for prisons. There is little analysis of previous achievements, limitations, ‗lessons-learned‘, experiences in Latvians HIV response in prisons. The work of NGOs and the results of their work have not been monitored and documented. Generally it would be helpful to learn more about the scope, content, costs and results of the measures undertaken.
8.2. Drug prevention and treatment There are no specialized drug prevention or treatment services available in Latvian prisons, except for an educational programme in the Cesis correctional institution for juveniles. The latter is using an approach similar to life skills programmes focusing on different life areas of young people including drug use. In the community some 115 patients receive substitution treatment (which is a coverage rate of less 30
than 1% of the estimated 12-15.000 i.v. drug users in Latvia . None of the drug addicted prisoners
29 apart from general awareness raising and education, information and communication 30 WHO/UNODC/UNAIDS recommend a coverage of 10-19% (moderate) and 20-39% (good) as being adequate indicator for access to prevention for IDUs (In: WHO/UNODC/UNAIDS: Technical Guide for Countries to set targets for Universal Access to HIV Prevention, Treatment, Care for injecting drug users (IDUs). 68
receives substitution treatment or other rehabilitative services. In the community the number of patients in substitution treatment is quite stable on a low level (2000: 107 patients; 2007: 115). Subata (2007, 5) points out that this treatment form is not popular among opioid users: ―MMT has a low prestige among IDU. This is the main reason why IDU are not willing to come to MMT programme and there is no waiting list‖. Thus it could not develop a real impact on the spread of HIV or saving of lives of IDU with HIV by their involvement to ARV therapy.
9. Collaboration
9.1. Latvian Infectology Centre (LIC) The LCI is responsible for specialised diagnostic and treatment research of infectious diseases except tuberculosis. It is cooperating with the PA and prisons especially in the field of blood borne infectious diseases HIV and Hepatitis B and C viruses. The information in this chapter is for an important part based on visits to LIC (a hospital) and interviews with Dr. Paul Aldins (the head of the HIV/AIDS unit of LIC). A HIV-test is not obligatory but is offered to all incoming inmates. Only a very small percentage is refusing the tests, according to Dr. Aldins less than 1%. Pre and post test counselling is done by the doctor. The blood samples of the inmates who agree with the test are sent to the LIC and tested for HIV antibodies. If positive - a Western Blot or other confirmation test is done. Then again positive a consultation with the specialist in prison follows. A full diagnostic procedure for HIV including CD 4 count and virus load, hepatitis, additional infections like herpes AB, CMV AB, EBV AB, Toxoplasmosis AB, oral Candida swab, Syphilis test and basic clinical chemistry and blood count are done. At the same time HIV test is repeated by second sample. Regarding all results a therapeutic decision is made. Primary therapy is dependent from genotypic resistant check since 2007. Procedures for phonotypical resistant test and drug monitoring are not available. The drugs are monthly sent to prison and further recommendations like hepatitis B and pneumococcal vaccination is made. The patients get one to three months follow-up, success of treatment is monitored by viral load. The decision for therapy is following the European guidelines. Acute infections, symptomatic disease, class C and severe infections class B are treated. Cases with 5
less than 200 CD 4 cells or under 350 CD 4 cells and virus load higher than 2x10 1 are generally treated. HAART is given independently from the length of the sentence. But if the sentence does not last longer than a few weeks it is not started in prisons. Even cases of vertical transmission would be treated but Dr. Aldins hasn‘t come across these cases. For cases combined with addiction he normally would recommend consultation of a narcologist but this is a problem in prison. He doesn‘t think that substitution treatment might improve the success of HIV treatment. Dr. Aldins believes that the status of equivalence of health care level inside and outside prison is reached for HIV and TB but not for 69
hepatitis. The ARV-drugs are paid by the LIC and monthly given to the prison doctor and he/she is responsible for the provision either by the nurse or other persons. If the treatment is leading to negative results, then change of treatment is discussed and performed. Very ill patients of AIDS infections are reported as not eligible for the prison and a decision is made by court depending of the risk for the society. Generally, Dr. Aldins sees the prison stay as an opportunity to perform all tests and to start health promotion activities. One central problem for nearly all health care measures is release. Prisoners with ARV-treatment get the medicine and should go to the specialist of the LIC, but many do not show up, especially when they come from the country side. Lack of continuity of treatment is quite common. Regarding PEP (post exposition prophylaxis) of HIV for prison staff and inmates Dr. Aldins expresses that arrangements are made that treatment can be started within 4 hours even for cases in prisons outside Riga and that there is a 24 hour service in his hospital. Additionally he explains that PEP for cases of sexual contact, e.g. ruptured condoms is not free of charge. He would recommend a regular system of work medicine for all prison staff. In Latvia it is general law that each person with risk contacts 31
more than once a month shall be vaccinated against hepatitis B and the employer has to pay . Vaccinations against tetanus and diphtheria are generally free of charge for Latvian population. Defined groups get influenza A vaccine too. The numbers of seroconversions in prisons for hepatitis B, C or HIV are not known. No data are collected but Dr. Aldins thinks that some transmissions occur in prison. Due to the fact that normally no retesting after the window phase and at point of release from prison is done he can‘t say more. More specific is the situation regarding hepatitis C There is an increased number of infected medical staff in Latvia. In general the state takes 75 % of treatment costs and patient 25%. The diagnostic tests in general are free of charge. Mr. Aldins told us that even for prisoners the costs sharing is valid, but prisoner have additionally to pay for costs of transfer to the LIC, each case shall get a liver biopsy there. The general testing is not free of charge except for cases with HIV. Medicine is given monthly and treatment is monitored by the virus load. Most of the cases are subtype I (about 70%) followed by III (about 30%). Others forms are very rare. Drug use is a contraindication. He believes that treatment under substitution is possible. About definition of diagnosis of acute hepatitis Dr. Aldins replied the guidelines of the LIC classify if infection occurred less than four month ago, if fresh seroconversion is known, ALT is higher than 20 ULN and ALT is positive and HCV RNA positive and excluded other reasons. Asked for fields with chance of improvement his opinion is that the medical service in prison generally has a good chance for improvement. This is true for the situation of buildings and equipment. First of all the poor standard of the prison hospital with a TB department without windows and poor hygienic 31
However, prison staff is not explicitly mentioned in the vaccination regulations 70
standards needs to be changed. He is waiting for the opening of the new prison hospital. He would recommend ultrasound scanner and X-ray for each prison. This is also true for the qualification and payment of staff. Low payment results in a lack of motivation especially in some cases. To improve this he would recommend that the position of doctors in the system should be adjusted to an acceptable level. Doctors should not be on the lowest level of social prison staff hierarchy. Then the number of medical staff needs to be increased and staff should be trained and qualified more frequently on a regular basis. Any unemployment of prisoners must be stopped. He knows about many written complaints of prisoners about medical care. This takes a lot of working time of the doctors and in some cases doctors are punished for the ineffective situation with a fine. His personal feeling is that there are not enough social workers in the community.
9.2. Riga Centre of Psychiatry and Addiction Disorders (RCPAD) The information in this chapter is for an important part taken from an interview with Dr. Inga Landsmane: The profession of ―Narcologist‖ is reachable by further specialization for four years for Psychiatrists. There are about 90 persons enlisted for this specialization and organized in an own organization independent from psychiatric society. The qualification as narcologist is needed for prescribing substitution substances. As far as known actually there is only one narcologist working in one specific prison. Prisoner can‘t access the existing public health addiction treatment in the community. The RCPAD is divided in inpatient and outpatient departments – separate for patients with addiction diagnosis and mental diagnosis. The inpatient dept. has 100 beds, in the outpatients several specialists are working covering various issues, among others drink and drive problems. The outpatient areas are the first level of professional addiction diagnostic except of street work which is provided by another institution – the Riga Addiction Prevention Centre (performing primary prevention of addictions). Additionally to street work there are psychological support centers in the community. These departments exist in several towns of Latvia. These outpatient departments offer specialist consultations. They first do diagnostic on addiction and they decide the way of treatment with the patient. For inpatient treatment they have detoxification programmes of 5 days for alcohol and 10 days for drug users. These programs are supported with medication. After this, patients can take part in short motivation programs 1 week for alcohol and 14 days in drugs. This stage is followed by the MINESOTA program for 28 days. All these programs are executed in completely closed wards. After treatment in hospital patients can be transferred to a rehabilitation programme. For this the government keeps 4 clinics available. Half of them are for teenager below 18 yrs, one with 40 and the other with 15 places. Both adult units have space for 20 clients each. One of the rehabilitation centers runs a special program for social rehabilitation of alcohol addicted.
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Discussing the cooperation with LIC Dr. Landsmane explains that patients who are suspected for infectious diseases are asked to go there for further diagnostic procedures. Only some of them are able to reach this. There is no direct and formal cooperation between the institutions and no coordination of treatment processes. There is no regular treatment of hepatitis C under substitution for example. The cooperation with TLDSA is similarly poor. In the narcological hospital they don´t perform chest x-ray for tuberculosis diagnostic on a regular basis and they don´t take action on infectious diseases. If people are failing in the treatment process they may start again in an outpatient department. There is some waiting time before a restart. For withdrawal and motivation program about 1 week and about one month for Minesota program. For drug dependents after five unsuccessful trials they discuss substitution treatment. All really needed processes for treatment of addiction are free of charge for Latvian citizens. Some supportive services must be paid. There is no free treatment for foreigners. In addition to the above mentioned efforts the RCPAD holds patients under substitution treatment. Actually they have 70 methadone clients, 45 clients under Buprenorphine and 64 Finish persons are under substitution treatment in just one private praxis. In Latvia there are some private institutions e.g. hospitals, offering addiction treatment, too. The RCPAD centre is under pressure due to the lack of money. They have some wards and patients living under really poor conditions, it seems that there is not much difference to the situation in some prisons. The equipment is really old and the roof is leaking. The walls are partially wet and black aspergillum was seen. On the men‘s ward for withdrawal are dormitories for about 12-15 clients. Dr. Landsmane explains that most of the patients in her hospital are in very bad health conditions. The conditions even outside prison seemed to be very poor. On the question under which conditions she could imagine that narcological specialist could be interested for work in prison services she replies, that there might be interest for a monthly income of 700-800 Lats and proper working condition like own office, internet access, and necessary assistance of an enlisted nurse with special training for work in addiction (additional education process) and staff trained in social or pedagogical matters. She has no imagination how the situation in prison can be improved. Asked for fields of improvement but additional budget for her institution she would plan a treatment unit for teenager und enforce substitution treatment especially with Buprenorphine.
9.3. Tuberculosis and Lung Disease State Agency (TLDSA) The institute is responsible for the nationwide surveillance of tuberculosis including prisoner‘s cases. They have detailed statistics and also produce statistics on the situation in prisons. One important part are statistics showing the number of cases ‗imported‘ into prisons versus cases of infections occurring in prison. The criteria for either of these are a stay of more than six months in prison. At the moment 72
they don‘t observe cases of staff infections but they had some in the last years. The general rule is that health care staff, educational staff, people working with food and staff of public services needs a chest X-ray annually to check for TB. The family doctor is responsible. They also have general statistic of TB incidence in prison of last two years. These statistics will be attached in copy to this report. A way for hand over prisoners to outside community is implemented. 2 years ago the government shut down most of X-ray equipment in prison so that they are not sure if the actual decrease in number of cases is resulting by success of preventive strategies or by under diagnosing due to lack of facilities. Up to now prison hospital is doing TB smears. This will change with new hospital by outsourcing. A mobile X-ray system, manned with two employees is operating since July. This eventually could be purchased by prison administration or prisons for detection of TB.
9.4. State Probation Service (SPS) SPS is quite new in Latvia working only for 4 years. Riga City has got five prisons, four for men, Basic information on health status are coming from the client. There are two different groups of clients: one group has served the full sentence, and ex-prisoner under supervision of SPS, whose sentence has been suspended. In case of illegal activities SPS has to cooperate with the justice institutions. SPS is cooperating with NGO ―DIA+LOGS―, providing needle-exchange programmes, plus motivation programme. Actually there are nine persons under the suspension of sentence in the NGO ―DIA+LOGS‖. SPS has plans to cooperate with an NGO ―Apzinas ekologija‖ but the problem for cooperation is because the mentioned NGO until now isn‘t an official provider of social services. The leading question during the field visit was: In how far is SPS connecting health care services and the satisfaction of health care needs of their clients from the prison to the community? Basically SPS is concentrating on legal aspects of health care service re HIV/AIDS .Information about the HIV/AIDS status is given and passed only if the client agrees (informed consent). PS‘s post penitentiary support is focussing also on health issues. It depends on the client of how he/she wants to solve the problems of HIV/AIDS, if he/she has discovered that he/she has got HIV/AIDS. The client is transferred to competent institutions in the community. The intention of the SPS is to persuade clients to pay more attention to their health issues in the future. SPS is looking for contacts to NGOs. Basically there is one key project in Riga city. The staff of SPS needs some additional information for their staff to work with clients on issues like drug use and infectious diseases. The key question is how can staff be staff educated? The interviewees of the SPS stressed the fact that they need more information and training to understand the drug addicted clients in order to understand them, when they are under supervision, 73
They are approaching prisoners being released in order to make plans, because health is a major issue to for resocialisation. Successful work and support depends from many factors (e.g. what kind of drugs they used before). They meet the persons already in prison. If they tell them they are using drugs it is ok. They try to transfer clients to a 12 step Minnesota programme in 28 days after prison (Akrona/Riga): Most of the clients are alcoholics, in other centres of social rehabilitation they work with colleagues, but without specialisation of addiction. A person in prison will speak openly about his/her addiction, if he/she wants to get out of the prison before the term for instance – then cooperation can be achieved! After release from this person then is immediately sent to a treatment institution. If prisoner has health problems they advise them to special doctor, if necessary also connections are being made with family doctor and social rehabilitation institutions. SPS employees are trying to motivate ex-prisoners to solve health problems, but success depends on the person. What SPS is doing in any case is to provide information with social health system. At the moment they are not cooperating with substitution treatment centre. Health constitutes only one issue among others of SPS‘ work. The main goal of all efforts is to integrate prisoners into society again. This requires professional skills, education etc. A diversion form or an alternative to imprisonment like ―Treatment instead of punishment‖ does not exist in Latvian Penal Law at the moment. If a prisoner applies for being released earlier, SPS writes a report with data and information of what the client says. SPS employees try to analyze how severe the problem, they have no insight into the medical file of the prisoner, only with informed consent of him/her. The success of the work of the Probation Service depends on the concrete work with prisoners and is based on a trust relationship. Health care issues are one major factor for reintegration.
9.5 NGOs and Civil Society Based on the information we have received from different sources, among others different representatives of the prison system, probation services and a meeting with a number of NGOs working in prisons we got the picture that NGOs play a modest role when it comes to prevention of infectious diseases among drug users in prisons. Their contribution is on a rather incidental, irregular basis through temporary activities, depending on the availability of external funding (e.g. OSI, Global Funds). There are no official guidelines or regulations with regards to the involvement of NGOs in prisons.
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Some activities are / have been addressing juveniles and some adults. ―Youth against AIDS‖ has been involved for nearly 10 years in HIV prevention work in prisons, among others by peer education activities. However, their work in prisons has stopped 4 years ago due to lack of funding. There also has been counselling on sexual risk behaviour for inmates by NGO ―Apzinas ekologija‖ Their activities also included the development of a pilot training for prison guards. The NGO HIV.LV (run by former drug users) was invited by the national probation service, to develop a programme for juvenile prisoners in Cesis, Daugavpils including 60 lessons addressing a variety of issues of prevention and treatment of infectious diseases. NGOs also sometimes provide prisons with information leaflets (for inmates and for guards) and with condoms. This in fact seems to be the only source for these leaflets in prisons. „DIA+LOGS‖ had a project in 2002-2004 – provided psychosocial support and education on HIV/AIDS for HIV+ prisoners.
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IV. Conclusions Looking at the global objectives of this EU-Twinning Project, i.e. analysis of current legislation, optimization of the integrated surveillance and prevention system of communicable diseases (HIV, STI, hepatitis, tuberculosis) in prison settings in Latvia, three main questions have to be answered after the stock taking in the first parts of this report: What are the constrains in the legal framework for introducing measures to improve HIV/AIDS prevention and surveillance? What are prerequisites for good practice in surveillance of infectious diseases in the prison system and what are priorities regarding the development of good practice in Latvia What are prerequisites for good practice in prevention of infectious diseases in prisons and what are priorities regarding the development of good practice in Latvia?
1. Analysis of the legal situation An analysis of the legal situation revealed that professional and financial responsibilities in delivering comprehensive health care comparable to that in the community (here the prevention and treatment of communicable diseases) in Latvian prisons are not clearly defined in every case between different Ministries and institutions. On the one hand the MoH has the task to control infectious diseases in Latvian society (by Law of Treatment stating that all health care is under MoH, and the Law of Epid.Safety says that all surveillance and prevention is also under MoH).. On the other hand preventions for all infectious diseases and drug addiction strategies are not or to a very low degree carried out and financed by the MoH in prisons. Obviously the responsibilities and division of labour regarding health care for prisoners generally and specifically the prevention and treatment of infectious diseases and drug addiction between MoJ and MoH, other state agencies and NGOs have not been made explicitly clear. Still it is not clear, who is delivering the same standard of HIV/AIDS (and other infectious diseases) prevention and treatment in prisons as in the community, as stated in several declarations Latvian government supported (e.g. Dublin Declaration on Partnership to fight HIV/AIDS in Europe and Central Asia). Cooperation and communication regarding prevention and treatment and a coordinated approach in the management of infectious diseases and drug addiction in prisons between different state agencies therefore is lacking. A conflict area where this unclear situation of prison health care is coming up regularly is the topic of financing of health care measures (prevention, treatment and equipment). Two different systems (prison health care and public health care), with not completely defined areas of responsibility and financial 76
obligations will also lead in the future to insufficient services regarding HIV/AIDS-prevention and treatment and drug treatment in prisons. Some legal regulations do not foresee certain prevention and treatment procedures for prisons (e.g. for substitution treatment). Other evidence-based HIV/AIDS preventive measures (e.g. needle exchange projects) are not allowed in prisons. Regarding drug services in general, there is no legal provision for narcological services in prisons.
2. Surveillance The HIV prevalence rate in the prison population increased tremendously over the time from 2.2% in the year 2000 up to 6.1% in December 2006, meaning that it nearly tripled within 6 years period, and it is 36 times higher than in the general population (0.17%; July 2007). The HIV/AIDS test frequency in prisons has been reduced in the past years: Due to financial constrains, approx. 1,000 new entries have not been HIV-tested in the year 2006. No data are available about the dynamics of infectious diseases during custody: Do new HIV/HBV or HCV-infections occur among prisoners during their custody? No data are available about sexual contacts in prisons, which are needed for increased and targeted efforts for prevention. According to the survey undertaken within this study (see chapter III.7) high rates of non-consensual sex among prisoners are estimated by the prison staff (28% rape between prisoners and 39% sexual intercourse as a form of currency). These results and the fact that some i.v. drug using prisoner may earn their money for drugs with sex work afterwards and during leaves, support the urgent necessity of making condoms easily available and easily accessible for all prisoners anonymously and free of charge. Hepatitis has not been ‗discovered‘ yet (any testing, diagnostic or therapy). With this co-infections (HIV/HBV or HIV/HCV), even super-infections are possible. TB and especially Latvia‘s high MDR-TB rates are a serious threat to the prison medical care and to the society at large. Latvia belongs to the top 14 countries with MDR-TB in the world. Together with a comparable high HIV-rate among prisoners increasing HIV/MDR-TB co-infections can be noticed. People with HIV-infections become infected with TB far more often than healthy individuals because the immune system is damaged already. Overcrowding, inadequate ventilation, and bad sanitation facilities remain commonplace in the 15 institutions. During our visits to the prisons we found old equipment. A major facility in coping TB, the X-ray equipment is missing in the prison system except in the prison hospital. Thus TB screening is not being carried out for all prisons: An integrated concept of funding of diagnostic and treatment of MoH, MoJ, Ministry of Interior, Ministry of Defence does not exist. 77
Within this EU-Twinning project a seminar with prison doctors in Jurmala had been organised in June 2007 (see Programme in Annex 10); the following measures have been discussed by the participating doctors: Due to financial constraints the number of HIV tests is decreasing for years. For an HIV-antibody test (HIV 1 and 2) the costs are about 4.- Lats for one person – this is one third of the annual rate of 12 Lats per prisoner per year. Diagnostics: - For HIV – equipment and reagents for HIV tests are paid by the health budget (MoH) but prisons (MoJ) have to pay for the examination process (obscurity about regulations on finances); - For HBV, HCV, STIs diagnostics prisons have to pay; - TB – the financial regulations are sufficient but in many prisons X-ray equipment is too old or out of order; - Other infectious diseases - foreseeable problems regarding diagnostics because of a lack of finances. Problems: - HIV, STIs and other infectious diseases: a legislation on diagnostics does exist, but there is no financial allocation in the budget of MoJ to tackle these diseases, - Repeated HIV-tests for HIV-positive persons highlight the lack of effective VCT and communication between doctor/health care personnel and prisoner. Moreover this practice is expensive and should be avoided.
3. Prevention of infectious diseases and drug addiction There are no structural programmes or activities in the field of the prevention of infectious diseases targeting inmates. There just have been some incidental temporary programmes and activities, due to a lack of structural funding. Some were pilot projects. However, even when they were going quite well, further implementation was impossible. HIV/AIDS It seems that it is still unclear who exactly should perform and coordinate HIV/AIDS-preventive activities in prisons. There is no regular service or integration of NGOs, the prison medical system is not ready for HIV/AIDS preventive work, the State Probation Service and other state institutions (listed in chapter III.9.) are not involved in HIV-preventive work (e.g. production and dissemination of leaflets, provision of condoms, disinfectants, trainings for inmates and staff to increase the knowledge about and attitudes towards HIV/AIDS).
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Regarding HIV/AIDS treatment obviously there is little if any direct communication and cooperation between the different agencies (e.g. of RCPAD with LIC, or TLDSA) and no coordination of treatment processes. The same is true for treatment and prevention of drug addiction: obviously no infrastructure for this has been developed in prisons and for the period immediately after release. Nor have NGOs been systematically integrated into HIV/AIDS prevention on a regular basis and not only on the spot. Although the HIV incidence figures are decreasing in prisons, high risk behaviour in prisons still exists, the exact pattern of risk behaviour and risk dynamics are not known. The spread of HIV/AIDS in prisons is predominantly driven by intravenous drug use. According to the survey almost 20 - 24% respondents admit to having drugs intravenously prior to imprisonment and 10 - 14% admitted infections while in prison as well. In Latvia‘s prison system no drug prevention or treatment programmes are operating. Due to a division of labour responsibilities for drug services in the community are clearly divided among some centres, but none of them is providing services in prisons. Often a denial of the existence of risk behaviours by prison staff and prisoners themselves can be observed. Harm reduction measures are neglected: There is hardly any discussion about sexual violence and rape in prison; there are no referral systems in place if rape among prisoners occurs. No post exposure prophylaxis and active hepatitis B vaccination for prisoners is in place, if sexual violence occurs. There are only few figures available regarding the spread of Hepatitis B and C. Although testing and diagnostic are not so expensive, it can‘t be paid be the limited health care budget. The policy not to diagnose because of a lack of money for treatment is problematic. Within a financial frame of about 12 Lats per prisoner per year for health measures in the annual budget of the PA, the full diagnostic process for Hepatitis B or C before therapy starts (327.0 Lats) and screening for Hepatitis C and B (about 6.- per procedure) are unaffordable. Treatment of AIDS 62% of all AIDS-diseased persons receive HAART. The critical point is that obviously HAART in the beginning is only prescribed in the Central Prison by LIC and then continued by the prison doctor. HAART is available free of charge for Latvian inhabitants. In a few cases prisoners refused the transport to the Central prison for various reasons. One reason may be that prisoners might get known as HIV positive in the prison. In any case the transportation to the Prison hospital causes enormous organisational and financial efforts regarding provision of safety with guards etc. The Sexual and Reproductive Health Law states that ―the examination, treatment and monitoring of HIV infected persons and AIDS patients shall be carried out by an infectologist at a medical treatment institution‖, and this is why a specialized doctor from LIC only attend the prison hospital to see and treat the HIV-infected prisoner. 79
The idea is that there must be one infectologist trained especially for prison services, may be based at the prison hospital and performing all consultations in the bigger prison. On the side of cost analysis the policy to transfer groups of patients to prison hospital just for diagnostic process is not very effective because standard diagnostic process could undergone in local prisons as well. Only for budgetary and responsibility reason this procedure is ineffective. The collected results following a guideline may be including blood sample could be sent to prison hospital. Only if then additional interrogation and examination is necessary the patient should be transferred. There might be a special role for inmates in accordance with ―The Sexual and reproductive Health law to ensure diagnostic and medical treatment intramurus. TB Due to a lack of diagnostic instruments (X-ray equipment) TB cases might remain undiscovered and be treated too late. The situation aggravated since 2006. Hepatitis B/C An increasing number of persons are either Hepatitis C and/or Hepatitis B infected, sometimes with seroconversion in prisons mainly caused by injecting drugs with unsterile injection equipment. This problem is not adequately dealt with by prison medical care. There are no regulations for prison services in this field. Hepatitis B vaccination is unsatisfactory among inmates and staff. STIs The spread of STIs increases the risk of transmissions of HIV infection. By this a full diagnostic process even in this field needs to be established. A curriculum for the training of prisoners and prison staff is missing. The value of preventive work done by NGOs in prisons who are generally better accepted and who could provide peer-based information and education has not been identified yet. Drug prevention and treatment As stated above drug prevention and drug treatment are not available in Latvian prisons. In a number of prisons drug using inmates are placed in isolation for a detoxification period of ten days after admission. In some cases the withdrawal is supported by medication (a reduction scheme), in some cases not. Withdrawal and reduced drug availability increases risky consumption processes. Funding/Resources The funding of prisoner health care is insufficient. Actually the funds are in the responsibility of different ministries. Obviously no clear division of financing has been developed between MoH and MoJ (resp. Prison Administration). Although the budget for prisons in Latvia has been increased in the last year (4
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Mio Lats more), however, this goes mainly into security, building of the new prison hospital and other sub-funds. The money for health care in prison is quite limited. According to the PA it is 12 LVL per prisoner per year for outpatient treatment activities in prisons. Although HIV figures among prisoners are among the highest in Europe very little money has been spent on improving the situation for the reduction and prevention of infectious diseases. Medical departments in Prisons are different equipped. The X-Ray equipment is out of service. Equipment on hygienic processes like sterilisators and instrument cleaning systems or emergency equipment is partially really poor and old. Collaboration Governmental institutes and organisations: The different governmental institutes and services, i.e. the Latvian Infectology Centre , the Riga Centre of Psychiatry and Addiction Disorders, the Tuberculosis and Lung Disease State Agency and the State Probation Service do contribute their share to the surveillance and prevention of infectious diseases in prisons. However, the cooperation and exchange between these centres seems to be quite limited. There seem to be only incidental contacts. The same applies for the cooperation between the governmental and non-governmental organisations. NGOs: As stated above, NGOs contribute to the prevention of infectious diseases in prisons on a rather incidental, irregular basis through temporary activities. However, at the moment there is no systematic access of NGOs to prisons to contribute their share. Their access depends on the availability of external funding (e.g. OSI, Global Funds) and the good will of individuals in the prison system. There are no official guidelines or regulations with regards to the involvement of NGOs in prisons. Furthermore, NGOs report that they face some bureaucratic barriers with regard to funding of their work. There is a lack of continuity of care, regularly resulting in treatment interruptions for clients admitted to prisons or inmates when released. NGOs can contribute to this continuity of care (and treatment) by assuring the link of care services before, during and after imprisonment. An important finding is that prison staff states that NGO work in the field of the prevention of infectious diseases is needed. NGOs can serve essential specialist knowledge e.g. on risk behaviour and specifics of the target group. Interventions addressing staff The main results of the anonymous survey (see chapter III.7) among prison staff can be summarised as follows: 81
Lack of staff and drug related problems are on top of the work related problem list Lack of knowledge prevalence of infectious diseases and related risk behaviours became obvious Thee are high levels of uncertainty at work and staff feels a lack of safety at work High levels of either psychological and physical violence between prisoners and as well between prisoners and staff have been reported More than one quarter of the interviewed staff members confirmed intravenous drug use in their prison on different levels High
percentage
of
prison
staff
with
either
uncertainties
related
to
the
main
transmission routes of infectious diseases or wrong perception were found Attitudes towards HIV positive inmates were driven by overestimated fear of infection Knowledge about Hepatitis B vaccination should be improved The vast majority of prison staff regard systematic testing procedures of prisoners for HIV and Hepatitis as effective prevention strategy Evidence based harm reduction measures are generally not accepted by most of the respondents
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V. Recommendations The objectives of the Latvian Prison Medical Service presented at the kick-off meeting of this EUTwinning Project can serve as direction for formulating recommendations. They had been described as follows: to stop the increase of TB cases to continue activities on HIV/AIDS to begin activities on HCV and HBV to start activities on drug addiction. Having in mind these questions and objectives in this fourth chapter of the report we will formulate recommendations. These are based on the UNODC document (UNODC/WHO/UNAIDS 2006) referred to as a baseline earlier (in chapter III, 1.), nine areas of successful actions leading to sustainable results are recommended that serve as a basis for future strategies to upscale interventions and measures of HIV/AIDS prevention in Latvian prisons. These include: 1. Political leadership According to the Declaration of Commitment—United Nations General Assembly Special Session on HIV/AIDS [―UNGASS Declaration‖], ―Strong leadership at all levels of society is essential for an effective response to the [HIV/AIDS] epidemic.‖14 This is particularly true in the area of prisons. 2. Legislative and policy reform Recommendations to create frameworks of legislation, prison policy, and prison rules that promote effective and sustainable responses to HIV/AIDS in prisons. 3. Prison conditions Recommendations to house prisoners in conditions that meet the recognized minimum international standards. 4. Funding and resources Recommendations to develop and implement national and international funding plans to address HIV/AIDS in prisons on the national, regional, and local levels. 5. Health standards and continuity of care and treatment Recommendations to meet international obligations to provide health care within prisons equivalent to that available to the outside population, and to ensure continuity of health care services between correctional institutions and jurisdictions, and between the prison and the community. 6. Comprehensive and accessible HIV/AIDS services 83
Recommendations to implement comprehensive HIV/AIDS prevention and education, voluntary counselling and HIV testing (VCT), HIV/AIDS care and treatment for prisoners, and drug dependence treatment programmes in prisons. 7. Staff training and support Recommendations to provide all prison staff with the knowledge, training, and support on HIV/AIDS necessary to meet the requirements and responsibilities of their work. 8. Evidence-based practice Recommendations to implement HIV/AIDS policies and programmes based upon established need, on empirical evidence of effectiveness, and evaluated models of best practice. 9. International, national, and regional collaboration Recommendations to share knowledge and expertise on effective prison management and HIV/AIDS nationally and internationally, and to enhance the development of evidence-based practices by building upon the successes of other countries and jurisdictions
1. Political leadership In order to reach a sustainable policy an overall systematic approach with clear descriptions of division of labour between MoH and MoJ on the basis of a comprehensive HIV/AIDS strategy
32
and Action Plan
(to be evaluated within certain periods with clear indicators and quantitative targets for introducing HAART and harm reduction services into prison populations) is needed to combat i.v. drug use and infectious diseases in prisons. A joint approach with clearly defined goals and at least an understanding of the severe health threats in prisons and how to manage them needs to be elaborated within such a plan. Also in the division of labour and divided responsibilities the competencies of all state agencies with respect to prevention, surveillance and treatment of infectious diseases, should be clarified. Moreover, political leadership is needed to allocate funds and resources in order to achieve the same standard of health care for prisoners than for the other members of society. Permanent coordination and facilitation among the various stakeholders will be of crucial importance.
2. Legislative and policy reform33 To amend the Medical Treatment Law, article 61, to change term ―addiction treatment institutions‖ to the term ―health care institutions‖ is needed. 32
Project ―Program for restriction the spread of HIV and AIDS, 2008-2012‖
33 These recommendations have been elaborated by Solvita Olsen within the UNODC project ―HIV/AIDS prevention and care among injecting drug users and in prison settings in Estonia, Latvia and Lithuania‖ (AD/XEE/06/J20) 84
To clarify competencies of MOH and MOJ in respect to 1) the health care for prisoners, 2) treatment of addiction 3) HIV/AIDS in prisons. To clarify the competence of other state agencies, for example Public Health Agency, in respect to prisoner‘s health. To consider how to implement the Patients rights mentioned in the Medical Treatment Law, article 17, in respect to inmates. To amend CoM Regulations No.199 of 20 MLh 2007 “Rules of Health Care of Prisoners and Convicted Persons in Investigation Prisons and Detention Institutions” in order not to minimize difference of state provided health services between inmates and persons in the community. To amend CoM Regulations No.429
34
of 24 September 2002 ―Procedures for the Treatment of Patients
Addicted to Alcohol, Narcotics, Psychotropic and Toxic Substances‖. There should be introduced much more decentralised model for reasonable accessibility of methadone therapy in all Latvia and in all prisons in Latvia. A model of substitution treatment should be organised more decentralised, not only in one specific centre. Health care institutions in prisons should have right to provide substitution therapy. A diagnosis and treatment of a narcological disease shall be determined and provided by medical doctors according to international practice and standards. In the prison settings diagnosis for patients addicted to narcotics should be determined by psychiatrist. The criteria for substitution therapy (methadone, buprenorphine or analogous) should be reconsidered and partly changed according to clinical evidence.
3. Prison conditions During the prison visits many observations with regard to a necessary improvement of housing of prisoners (like dormitories etc.) have been made. Many medical units were found to need an improvement and better equipment. Large dormitories with up to 80 prisoners were seen. Many prisoners continue to remain 20-23 hours in their cells. A serious absence of employment is the ground 35
for boredom and passivity . The campaign to increase the quality of living conditions especially in the older prison should be enforced.
4. Funding and resources An increase of the health related prison budget is recommended, the rules of responsibility of medical care of prisoner should be checked and the recommended target of equivalence of care of prison health and public health must be envisaged. Responsibilities and resources are shared between different
34
With amendments: the Cabinet of Ministers Regulations No.50, 18 January 2005, The Cabinet of Ministers Regulations No.751, 4 October 2005, The Cabinet of Ministers Regulations No.244, 10 April 2007 35
See also Latvian Centre for Human Rights (2006) 85
institutions. This makes a sufficient health care in prisons difficult. The problem of medical care for foreign prisoners must be addressed. A process for discussion of problems with politicians should be started. The argument that ministries are refusing to take over responsibility for prisoner‘s health care should no longer be reasonable for a lack of care. The result of sufficient health care must be reached independently from the political decision or responsibility. To insure all prisoners in the national health care system / insurance and to transfer responsibility to the public health system or to endow MoJ with a sufficient fund is finally a political decision. An urged and final political decision is needed to make it possible for the prison system to reach the status of equivalence of care. Independent from responsibilities there should be a clearly defined budget plan for health measures in prisons. One part of this should be a personal budget, i.e. a budget per inmate, reflecting the individual costs (testing, diagnostic and treatment etc.). The second part of this should be a fixed budget for general tasks, like equipment, training, surveillance for running the medical departments. The part depending on numbers of prisoner should be adjusted to the national average of health care needs but extended by some addition regarding the fact, that prison population in general is more affected by medical problems. Inmates result from a negative selection of prevalence in the field of several diseases like infections or mental disorders including addiction. The prison community is generally more representing people of lower social strata or missing access to medical care before imprisonment which increases the need for medical measures. A general plan about necessary equipment for basic medical care for all prisons needs to be developed. This must include especially X-ray machines, units for hygienic preparation of medical and surgical instruments including dental equipment, and information technology for statistic purposes and quick access to actual medical information. A cost-effectiveness analysis must be part of the decision.
5. Health standards and continuity of care and treatment There are some general guidelines for health interventions carried out in the community which also should be applied for health services in prisons. Interventions should be evidence-based or based on good practice. Health care should be provided to prisoners free of charge and without discrimination at a level equivalent to that in the community, including referral and access to community health services when necessary. This should include among others measures to prevent the spread of infectious diseases, voluntary testing with pre- and post-test counselling (VCT), drug treatment services, HIV/AIDS treatment (including antiretroviral treatments) and care, mental health services, palliative care interventions, and measures to prevent mother to child transmission of HIV.
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6. Comprehensive and accessible HIV/AIDS services
6.1. Surveillance At the moment several different forms for each infectious disease to be reported to different centres are in use. The reporting system should be reformed. This should be more unique and put in one form to get a better overview in order to tackle co-infections. Cross-linking of TB and HIV registries should be considered. During the seminar with prison doctors in Jurmala in June 2007 (see Programme in Annex 10) the following measures have been discussed: - Duly information from the Prison Administration about changes in the reporting system on different infections; - Improvement of the exchange of information between the medical staff of all prisons; - Provide medical departments of prisons with internet access. Furthermore the following recommendations have been elaborated: - To obtain a sufficient budget line in the Prison Administration for medicine; - To acquire new X-ray machines for prisons who need or use mobile one of TB centre; - A need for sentinel surveys and improvement of surveillance; - Comprehensive monitoring for patients with chronic diseases (HIV etc.); - To a comprehensive health record system for each prisoner; - To revise and optimize number of medical staff in prisons; - To consolidate existing legislation and draw out paragraphs concerning to medical issues in prisons (make a useful handbook). The ―Status paper on prisons and tuberculosis - TB control in prisons: minimum standards‖ by Pierpaolo de Colombani Medical Officer TB WHO-EURO, HP/CDS/TUB states the following points: The ideal TB control programme in a prison includes: Government structures in both prison and civil sector Written agreement between prison and civil sector Prevention of TB (early detection, no overcrowding, good nutrition, ventilation and light, infection control) Access to TB diagnosis and treatment for all prisoners Equal treatment, including for MDR-TB and TB-HIV Continued treatment following release from prison The penitentiary system must have: 87
Adequate number of staff with updated training Mechanism for timely investigation of TB suspects Quality-assured smear microscopy Quality drug susceptibility testing in reference laboratory Supply of quality second-line drugs Recording and reporting shared with the civil sector Consistent reporting of (infectious) diseases a) keep statistic on diagnostic running, extend it and add statistic on performed treatments (not only HAART and DOTS) b) detection of seroconversions while imprisonment c) reduction of underreporting and under diagnosing d) information transfer from outside at admission and to outside at discharge e) the personal identification number might be useful
6.2. Prevention and treatment of infectious diseases and drug addiction An information and prevention programme for all prisons should be developed, defining what information should be given to inmates and how this should be done. This should be a regular programme, i.e. a structural part of the health services in prisons. It is recommended to include the following elements in this information programme: Information at admission for each prisoner, including information on inmates‘ rights, risks of infectious diseases, how to protect yourself against infectious diseases, risks of drugs and drug use, how to reduce the risks of drug use and treatment options. Counselling, training seminars and information for both inmates and staff; Peer support; Distribution of condoms; Distribution of disinfectants to clean syringes Distribution of sterile needles and syringes Information or training before release to prepare inmates with drug using experience for the risks after release not only covering information on infectious diseases but also about matters as enhanced overdose risk after release. Prerequisites to be taken into account are: the involvement of NGOs on a regular basis in the planning and implementation of this programme (see 6.3.); structural funding of the programme;
88
supportive and well-informed staff. This can be reached by promoting staff‘s education in health issues, e.g. through extra vacation days; prevention / information material for inmates should be available in the languages common in the prison population. This material should be generally available and not only distributed by medical services. Medical procedures: The medical interventions in prison and also community need to be standardized in the field of infectious diseases such as Hepatitis, HIV/AIDS, STI‘s and additional mental and addiction problems. All national procedures should be adjusted to medical guidelines published from international medical societies. Medical procedures inside prisons must follow the principle of equivalence. Treatment inside and outside the prison system must be clear and easy. Hand over cases between the medical systems must be standardized. Started interventions should be continued after imprisonment and discharge. Double diagnostic and therapeutic procedures should be avoided and the way of patients file /medical record must be clarified. Case management should be practiced for all patients suffering from infectious diseases with or without additional problems as mental disorder and addiction. The rules for cases refusing diagnostic and therapeutic interventions must be defined. The new prison hospital seems to be an optimal coordination point for this. All necessary medical specialists and rights for intervention like prescription of HAART or TB therapy and all medical procedures should be bundled up there. For all kinds of medical interventions a controlling system, checking that the process is accurately following these guidelines needs to be established. Typically the implementation of check lists and protocols are helpful. Like a ―plan, do, check act circle‖ the system needs to be involved in quality management36. Cost effectiveness must be kept in mind. The responsibility for the budgetary side must be clear and the needed money must be given. Medical teams need actual training and sufficient equipment. Use of new systems for prevention of needle stick injuries should be established. HIV/AIDS HIV diagnostic must be widespread and repeatedly offered and undergone by all prisoners. Similar to hepatitis testing the diagnostic window and seroconversions during imprisonment must be covered. Voluntary counselling and testing (VCT) should be offered in an atmosphere which guarantees confidentiality (no guards should be present in the room). The first 3 days after admission might not be the best period to offer HIV-testing, because of the stress prisoners undergo in this period. The circumstance that the only successful prevention is to avoid contacts makes it necessary to fulfil other strategies for prevention and harm reduction (see above). Vaccination is not possible.
36
http://www.euro.who.int/document/SHA/WHO_Chapter_5_web.pdf 89
The actual Latvian concept of consequent therapy should be continued but the access for all prisoners must be made as easy as possible. There should be no reason to reject therapy due to circumstances explained by the fact of imprisonment or belonging side effects. The treatment process must be available on local level of each prison and only specific decisions should be made in a centre, (prison hospital). For example the full necessary spectrum of laboratory testing can be done on local level. The full responsibility for the therapeutic process must be available in the prison system without external interventions or restrictions. Because of the common situation of additional medical problems especially TB-infection and drug addiction there is a special need for case management. The compliance for some cases might be increased by substitution treatment for addicted prisoners. There is a need for improvement of pre-test counselling on admission (qualification of staff). HIV screening should be repeated after 6 months and at release (on a voluntary basis) and the X-ray at release in HIV negative inmates (to assess the rate of possible infection in prison) (see Zellweger 2006, 5). Hepatitis B/C Hepatitis B infections are a problem to be prevented by vaccination. Bearing this in mind each prisoner sentenced longer than a few days must be vaccinated. The fast immunisation programme should be preferred to reach early immunity. In addition the whole prison personnel needs to be included in a vaccination campaign (HAV/HBV). The diagnostic and therapeutic process for Hepatitis in prisons including reporting and statistic needs to be unified for all prisons in accordance to guidelines. The diagnostic window must be closed. This means that testing on admission is not enough and a least in risk groups must be repeated after 3 months. To prevent transfer back into the community it is necessary to retest at the end of the prison sentence. This can detect seroconversions in prisons and gives basic information how sufficient prevention programs are. At least medical staff must be included in repeated diagnostic processes to reduce the risk of infecting prisoner by medical teams. Roles for infected medical personnel must be established including prohibition of invasive procedures. A system of case management of detected Hepatitis B and C patients including cases of additional medical problems like HIV/AIDS, TB, mental disorders or addiction must be elaborated. The rules for cases refusing therapy must be defined. A certain amount of money must be laid down for this including the adequate money for antiviral therapy. The cost effectiveness of early treatment regarding development of liver cirrhosis and cancer of the liver must be considered. TB Regarding the number of TB infected persons in prison and the number of infections acquired in prison the efforts against TB in prison needed to be scaled up massively. The diagnostic and therapeutic process for TB in prisons including reporting and statistic needs to be unified for all prisons in accordance to guidelines. Different levels of diagnostic (Questionnaire, smear, serotesting, X-ray….) must be used sensible. In places where no X-ray equipment is available or can be 90
established, cooperation with a local hospital and the use of mobile systems for chest X-ray must be considered (Local equipment in some bigger units). This can be done for example combined with a schedule including all prisons after short periods. A system of case management of TB cases including cases of additional medical problems like HIV, Hepatitis, mental disturbance or addiction must be built. All procedures like examination of contact persons follow up and hand over back to the community and the public heath system must be included. Again the rules for cases refusing therapy must be defined. In infectious cases compulsion must be checked. As long as the infection rate for TB is increased in prison recheck prisoner before discharge. Diagnostic and subsequent treatment of HCV and TB. Organize a meeting between prisoners on TB treatment released before the end of treatment and a social worker / community nurse in charge of TB management, to facilitate further treatment and decrease default rate. Increase the frequency of training of medical and non-medical prison staff on TB and HIV issues, and other BBV infections. Clarify the role of MoH and MoJ, regarding financing of HIV hepatitis and TB activities Consider the use of Interferon-Gamma blood tests for the detection of infection among contacts of TB patients, particularly in HIV positive inmates (could be performed as a pilot study; see Zellweger 2006). STI’s Carrying STI‘s is a risk factor for infections with blood borne disease (hepatitis and HIV) and requires consequent diagnostic and therapeutic interventions. Especially clinical examination and blood testing for STI‘s (mainly Syphilis) must be considered. Again the diagnostic window and tests on discharge are part of the management in this field. Most of the therapies are not so expensive than for the above mentioned viral problems. Drug prevention and treatment Drug prevention understood as drug education (i.e. information on among others risks of drug use and on how to deal with these risks) and drug treatment (both with the aim to limit and the aim to stop drug use) should be considered as standard element of health services in prisons. This drug treatment should, on the one hand, consist of therapeutic programmes and, on the other hand, (motivational) counselling. The latter is especially important to motivate inmates to change their behaviour. Drug treatment should not only be considered for opiate use but also for amphetamine use, as the latter seems to be quite frequent in Latvian prisons. It is important to have a basic programme of drug prevention and treatment options for problem drug use or addiction in prisons. This should be as far as possible standardised, comparable and connectable to the services available in the community and available in all prisons. The following elements should be considered for this basic programme: Information leaflets 91
Drug education seminars, (if possible as part of a broader health education approach) (Motivational) counselling as first step for inmates to consider their situation Abstinence oriented treatment; Health education programmes, i.e. not abstinence-oriented training program. Participants are taught how to reduce risks involved in drug use. Substitution maintenance treatment (Stöver/Lines 2006). For the implementation of these programmes the expertise of persons working in existing treatment programmes outside the prisons and staff should be integrated. With regards to the prevention of infectious diseases substitution maintenance treatment should be considered. Also in the community this treatment option is not yet well developed in Latvia. Currently there are just 70 clients on methadone and 45 clients on Subutex® and 64 Finish persons under substitution treatment (on a population of around 15.000 i.v. drug users), which forms a very low coverage rate with substitution treatment (European average approx. 30%). When it comes to the development of drug prevention and drug treatment cooperation with drug services in the community is a prerequisite. These services have not only the required expertise (both on abstinence-oriented and on harm reduction, e.g. maintenance treatment), they also can assure the needed continuity of treatment, from the time before imprisonment till the time after release. Finally, it should be considered like in many European countries to introduce a legal act to allow diversion (e.g. ―treatment instead of punishment‖). In a number of countries the law allows the court to impose treatment instead of imprisonment for offenders who have committed drug-related crimes. This again is a direct health-oriented measure. Like the police, the court with its sentences can affect health in an indirect way. By refraining from a prison sentence the above-mentioned negative effects of imprisonment on health and psychosocial wellbeing can be avoided. One example is the so-called community sentences, generally entailing the obligation to work a certain period of time in non-profit social or cultural institutions. Another option developed in recent years in the Netherlands is social training and educational sentences meant as alternative punishment especially for young first offenders. These sentences entail, among other things, drug education, social skills training and orientation on education and work perspectives of the offender.
6.3. Involvement of NGOs and Civil Society The involvement of NGOs and professionals from outside the prisons should be encouraged in order to provide comprehensive and multi-faceted health, mental health, social, drug dependence, and 92
HIV/AIDS prevention services to prisoners, and create structures to enable the families of prisoners living with HIV/AIDS to access prisons and take a constructive and active role in providing care and support. At the moment there is no systematic access of NGOs and civil society to prisons HIV/AIDS or anti drug programmes of prevention and treatment. Access depends on coincidental money (funding mainly by international donors) and the good will of single persons responsible within the prison system, thus the coverage poor and patchy. NGOs and civil society should be given a much greater role in planning, implementing and evaluating the prevention efforts for target groups. NGOs should be integrated on a regular basis and a system should be established by responsible administrations to allow access for NGOs to bring in their expertise. Establish alliances between NGOs and other authorities (local and national) like local health authorities, drugs and AIDS agencies to facilitate work with prison NGOS should remain independent and ensure the respect of prisoners rights first. Often there is a lack of continuity of care, once the person is released from prison. This results quite often into treatment interruptions for PLWHA. Use the expertise of NGOs in working with target population in the community to ensure referral and continuity of care Include prison administration in existing local social networks (education, treatment, financial care etc) Facilitate exchange of good practices between NGOs and prison administrations in different countries.
7. Staff training and support A prerequisite for the successful implementation of interventions for drug using inmates in prisons is that prison staff understands and supports the measures taken. This applies equally for drug prevention and treatment and for prevention and treatment of infectious diseases. To achieve this understanding and support the following steps should be considered: ●
Information campaign focusing on basic understanding of drug and infectious diseases related issues inside prisons and the preventive measures to be taken.
●
Workshops and /or seminars focusing on basic knowledge about drugs, drug use, infectious diseases, safe behaviour (including how staff can protect themselves effectively), etc.
●
Training seminars for staff how to deal / work with drug using inmates, including knowledge, skills (basic counselling skills) and attitude
●
Provide education/training on HIV/AIDS and other communicable diseases, routes of transmission in the workplace, confidentiality, drug use, HIV and hepatitis prevention measures, HIV testing and treatment opportunities, drug dependence treatment, universal precautions and use of protective 93
equipment, and the rationale and content of prison rules and policies related to HIV/AIDS to all prison staff as part of their initial training, and update this training on a regular basis during the course of employment. Ensure that all staff receives regular training. ●
Consult with staff and NGOs on the development of education materials and programmes and the methods of delivering training programmes, and encourage and support the development of staff peer education initiatives and materials for prison staff.
●
Ensure that the training of prison staff addresses HIV/hepatitis-related discrimination; homophobia; reduces staff opposition to the provision of HIV prevention measures to prisoners; emphasises the importance of confidentiality and non-disclosure of HIV status and other medical information; and promote the compassionate treatment of prisoners living with HIV/AIDS and/or drug dependency. Ensure that the content of all training is specific to the duties and responsibilities of the various categories of prison staff (i.e. security staff, medical and nursing staff, etc.) and that it is relevant to the specific realities of the prison environment.
●
Provide regular training to prison doctors and health care workers to enable them to maintain and improve their skills and knowledge current with developments in all health areas, in particular drug dependence, HIV/AIDS, hepatitis, TB, STIs, and mental health prevention, care, treatment, and support. A comprehensive case management is needed and should be trained, because prisoners who were or still are i.v. drug users, sex workers are often exposed to several health threats.
●
Implement policies and training to minimize the risk of workplace exposure (i.e. needle-stick injuries). Provide mechanisms to ensure a safe physical environment such as hand washing stations, health waste management and disposal, appropriate ventilation systems (especially for the accommodation of patients with smear positive tuberculosis), and utilizing universal precautions.
●
Ensure that in the event of workplace exposure to HIV, prison staff members have access to appropriate post-exposure prophylaxis and counselling. Ensure that the health insurance plans for prison staff include the coverage of antiretroviral treatments.
●
Provide hepatitis B vaccinations free of charge for all prison staff members.
8. Evidence-based practice The analysis of the epidemiological situation and health status of prisoners has shown, that evidencebased prevention measures have to be introduced and where existing scaled up massively in order to give an effective response to the multitude and severity of health threats (especially infectious diseases and drug use) prisoners are facing in Latvian prisons.
9. International, national, and regional collaboration There are some general guidelines which should be kept in mind. It is important to create a wellfunctioning systems of referral and cooperation between services in one prison, between prisons/within the prison system and between services in prisons and the community. This system of referral and cooperation should include medical services, mental health services, social services, drug services (including substitution treatment), and HIV prevention services to ensure continuity of care and 94
treatment from community into prisons, during imprisonment and, following release, from prison into community. For a well functioning system it is necessary to have a clear agreement between all involved parties. This should be a binding agreement, i.e. on paper, signed by all parties and, where needed, supported by a governmental or legal directive. A formal agreement between the involved Ministries (Justice, Health, and Social Affairs) should be considered to assure the required consensus among and support from the governmental bodies. It also can be considered to integrate prison health services into wider community health services. Governmental institutes and organisations For a more efficient approach it should be considered to create a structural form of cooperation and exchange of information between the different governmental organisations. For this one could install (at least temporarily) a national working group on infectious diseases in prisons or even broader: on health issues in prisons (e.g. financing of prevention and treatment) to create a consensus on priority issues, on steps to be taken and on a division of tasks. To increase its effectiveness, this working group also should include representatives of NGOs as they also contribute to the prevention of infectious diseases in prisons. NGOs The involvement of NGOs and professionals from outside the prisons should be encouraged in order to provide a comprehensive approach of the drug and infectious disease problem. A more standardised, structural approach should be considered based on clear guidelines and made possible by regular/structural funding, preferably also including structural governmental funding, and thereby acknowledging the need for NGO involvement. NGOs should be integrated in a formal cooperation with authorities (local and national) like local health authorities, drugs and AIDS agencies to facilitate their work in prisons. Ministerial guidelines – preferably mandatory by legal requirement – should be considered in which NGO involvement is regulated. There have been quite some initiatives in recent years which could be continued and/or used as point of departure for further development.
95
VI. Annex Annex 1: Prison System in Latvia at a glance37 Country
LATVIA
Ministry responsible
Ministry of Justice
Prison administration
Latvian Prison Administration
Contact address
Ieslodzijuma vietu parvalde, Stabu iela 89, LV-1009 Riga, Latvia
Telephone / fax / website
tel: +371 7 208 325 fax: +371 7 278 697 url: http://www.ievp.gov.lv/
Head of prison administration (and title)
Visvaldis PUKITE, Director
Prison population total (including pre-trial detainees / remand prisoners)
6,676 at 5.6.2006 (national prison administration)
Prison population rate (per 100,000 of national population)
292 - based on an estimated national population of 2.29 million at June 2006 (from Council of Europe figures)
Pre-trial detainees / remand prisoners (percentage of prison population)
26.5% (5.6.2006)
Female prisoners (percentage of prison population)
5.6% (5.6.2006)
Juveniles / minors / young prisoners incl. definition (percentage of prison population)
2.7% (1.10.2005 - under 18)
Foreign prisoners (percentage of prison population)
0.5% (of sentenced prisoners, 1.10.2005)
Number of establishments / institutions
15 (2006)
Official capacity of prison system
9,166 (1.10.2005 - including 200 places in the prison hospital)
Occupancy level (based on official capacity)
79.0% (1.10.2005)
Recent prison population trend (year, prison population total, prison population rate)
1992 1995 1998 2001 2004
37
8,340 9,457 10,070 8,831 8,179
www.prisonstudies.org King‘s College London 96
(314) (374) (410) (373) (353)
Annex 2: Programme study visit Monday 11.6.07 - Berlin 09:00 – 11:45 Womens prison Berlin Lichtenberg. Nearly all of the 16 German 'Länder' (states) have one special prison for women. Here we see needle-exchange programme, HIV-preventive measures, substitution treatment, working abilities, etc. Mr. Matthias Blümel, director acc. by Ms. Caren Weilandt (WIAD) 13:00 – 15:30 Robert-Koch-Institute (National Centre for Surveillance of Diseases (surveillance) Ms. Dr. Doris Radun
Tuesday 12.6.07 – Berlin /►Hamburg 11.00 -13.00 Deutsche AIDS-Hilfe Berlin, National Umbrella Organisation with approx. 150 regional/municipal organisations of AIDS Self-Help. Most important NGOs in HIV/AIDS prevention, treatment, care and support (prevention, hepatitis B vaccination programme; Integration of NGOs). Mr. Dirk Schäffer + Berliner AIDS Hilfe, Ms. Ines Lehmann acc. by Prof. Dr. Heino Stöver
Wednesday 13.6. – Hamburg (start) ► Hameln 09:00 -11:30 Hamburg, Prison hospital -most of the 16 German 'Länder' (states) have their own prison hospital (HIV/AIDS surveillance and prevention). Mr. Andreas Thiele acc. by Prof. Dr. Heino Stöver
Wednesday 13.6. 16.00–18.00 Hameln, Juvenile Prison (Lower-Saxony; surveillance, documentation and monitoring, provision of condoms) Mr. Dr. ML Lehmann
Thursday 14.6. – Hameln (start) ► Vechta acc. by Ms. Christine Kluge Haberkorn 12.00 – 16.00 Vechta (The only women‘s prison of Lower-Saxony; prevention, substitution programme, education), Mr. Dr. Karlheinz Keppler
Friday 15.6. - Vechta (start) ► Bremen 10.30 – 16.00 University of Bremen (VWG 1590), seminar on HIV/AIDS prevention strategies applied in Europe with several experts working in the prison setting (prison doctors, nurses, social worker, psychologists etc.) and in NGOs. Prof. Dr. Heino Stöver 97
Annex 3: List of participants study visit
Best practices in surveillance and prevention of communicable diseases in penitentiary system in Germany Study Tour 17 Experts from Public Health Sector, ministries and prisons (Latvia, Estonia, Lithuania) 10 – 16 June 2007 LIST OF PARTICIPANTS No.
Name of the participant
Estonia
Organisation
Contact details (telephone, fax, e-mail)
Itinerary SUN-10-JUNE 15.25 Tallinn – Amsterdam – Berlin (Tegel) 21.40 SAT-16-JUNE 18.20 Bremen – Amsterdam – Tallinn 23.55
1. Ms. Ene Katkosilt
Ministry of Justice, Department of Prisons, Social Welfare Division
Ms. Hälis Telling
Tallinn Prison, nurse
Mr. Latsin Alijev
NGO Convictus Eesti, leader of prisons support groups
2.
3. 4. Ms. Piret Paap
Tartu Prison, head of medical department, doctor
5. Mr. Meelis Smitt
Latvia
Representative from Police Board, Ministry of Interior
Tõnismägi 5a, 15191 Tallinn Tel. + 372 6208 217 Fax. +372 6208 272
[email protected] Magasini 35, Tallinn Tel. +372 612 7526
[email protected] Tel. +372 56506376 Fax. +372 6410133
[email protected] Turu 56, Tartu Tel: +372 7500 820 Fax: +372 7500 805
[email protected] Tel: +372 612 3212
[email protected]
Itinerary SUN-11-JUNE 07.00 Riga – Berlin (Tegel) 07.40 SAT-16-JUNE 10.25 Bremen – Riga 13.25
6. Ms. Angelika Krumina
7. 8. 9. 10. 11.
Ms. Kristine Kipena Ms. Regina Fedosejeva
Consultant, NGO Dia+Logs Riga Stradins University Ministry of Justice Prison Administration, Ministry of Justice
Ms. Inga Upmace
Public Health Agency
Ms. IS Skripste
Public Health Agency
Ms. Raina Nikiforova
Public Health Agency
Lithuania
Tel: +371 2911 3833 Tel/Fax: +371 756 3811
[email protected] Tel: +371-703 69 09
[email protected] Tel: +371 720 81 39
[email protected] Tel: +371 73 77 575
[email protected] Tel: +371 737 2275
[email protected] [email protected]
Itinerary SUN-10-JUNE 07.35 Vilnius –Berlin (Tegel) 08.10 SAT-16-JUNE 15.45 Berlin (Tegel) – Copenhagen – Vilnius 23.00
98
12. Mr. Marius Rakstelis 13. Mr. Remigijus Gliaudelis 14. Ms. Birute Semenaite
Department of Criminal Justice, Ministry of Justice of the Republic of Lithuania Deputy Director, Prison Department Health Care Division, Prison Department
15. Mr. Gintaras Kezys
Head of Health Care Division, Marijampole Correction House
16. Mr. Vytautas Ilevicius
NGO Caritas, project coordinator
17. Ms. Signe Rotberga
UNODC Project Office for the Baltic States
99
Gedimino 30/1, LT-01104 Tel. +370 5 2662874
[email protected] L. Sapiegos g. 1, LT-10312 Vilnius Fax. +370 5 2752778 Tel. +370 5 2719003
[email protected] L. Sapiegos g. 1, LT-10312 Vilnius Fax. +370 5 2752778 Tel.: +370 5 2719085
[email protected] Sporto g. 7 LT-68051 Marijampole Tel.: +370 343 70425 Tel: +370 687 17 684 Fax: +370 343 75961
[email protected] [email protected] Aukstaiciu g. 10 LT-44147 Kaunas Tel.: +370 37 2262 92 Tel: +370 606 13 746 Fax: +370 37 205549
[email protected] A.Goštautot 40A, LT-01001 Vilnius Tel. +370-5 2107-412 Fax. +370-5 2107-401
[email protected]
Annex 4: Report about laboratory confirmed HIV infection for adult person or teenager older than 13 I.
General information
Name of institution
Patient‘s registration Nr. Surname code* Patient‘s personal identification number Year of birth Gender: male / female Education: 1. some elementary 2. elementary 3. secondary 4. special secondary 5. university 6. never attended school Registration Nr. in the reference laboratory Nationality: Latvian/ Russian/ Gypsy/ other. Occupation: works/ doesn‘t work/ studies/ other Place of residence in Latvia (city, town, region, without the address) If patient lives in Riga name the district Citizenship: citizen of Latvia/ resident/ foreigner HIV is diagnosed in reference laboratory (date) II. Information about patient Sexual orientation
homosexual
bisexual
heterosexual
unknown
Intravenous drug user Prisoner (name of the prison ..................) Blood/ organ donor Blood/ organ recipient Patient has hemophilia or other coagulopathy Patient suffers from a sexually transmitted disease
syphilis
chlamididosis
gonorrhea 100
other
Pregnant woman (.........weeks) Other information III. Patient’s health status Acute HIV infection General manifestations:
fever
pharyngitis
lymphadenopathy
arthalgia/ myalgia
nausea, vomiting, diarrhea
weight loss
other
Neuropathic manifestations:
meningitis
encephalitis
peripheral neuropathy
myelopathy
other
Dermatological manifestations:
erythematous maculo papular rash
mucocutaneous ulceration
other
asymptomatic HIV infection
Symptomatic HIV:
candidiasis, oropharingeal (trush)
vulvo – vaginal candidiasis persistent, frequent, poorly responsive to therapy
cervical displasia/ cervical carcinoma
constitutional symptoms such as fever >1 month
diarrhoea >1 month
weakness, sweating in nights
oral hairy leukoplakia
herpes zoster involving
idiopathic trombocitopenic purpura
visceral leishmaniasis
listeriosis
pelvic inflammatory disease
peripheral neuropathy
other 101
IV. Possible transmission way: Sexual contact with HIV infected person:
incident contact
with co - habitant
with regular partner
with bisexual man
with IDU
Result of medical manipulations Intravenous drugs using with common syringe Unknown Patient thinks he/she was infected in: Latvia Other country Doesn‘t know V. Cause of testing
Patient‘s desire
Clinical indications
Epidemiological indications
Blood/ semen/ organ donor
By the request of governmental institution
Previously was tested for HIV infection:
Yes: year, place (country)
Result: positive/ negative;
No
Unknown
VI. Immunological parameters
Amount of CD4 cells
Viral load
Information about doctor: Signature / N.Surname Date Stamp ANNOTATIONS * Information about coding principles of patient‘s surname.
102
Annex 5: Photos of field visis to Latvian Prisons Conditions of accommodation in different Latvian Prisons
103
Conditions of sanitary facilities in different Latvian Prisons
104
Conditions of medical facilities in different Latvian Prisons
105
Annex 6: Analysis of the legal framework38 A. Legal framework of health care provision in prisons
A.1. The provision of health care The health care in Latvians prisons is organized by the Ministry of Justice (Prison administration). There are medical units in all 15 prisons (provide out-patient treatment) Latvian Prison hospital (partly provides in-patient treatment). The health care in prisons is financed by the Ministry of Justice and partly by the Ministry of Health (programmes for Tuberculosis and HIV/AIDS). Every prison has a medical department which ensures prisoners with primary health care and partly with secondary health care. Latvian Prison Hospital ensures in-patient care. All doctors, doctors‘ assistants and nurses are registered specialists. 95% of doctors and 83% of nurses are certified specialists. Olga Zeile
39
points out the difficulties with the existing model of health care in prisons:
As in many other European countries, two parallel systems of health care are existing in Latvia (the health care of convicted persons is not integrated in general public health care system): on the one hand the responsibility for organization and providing of health care of convicted persons in prisons is upon the Ministry of Justice (which direct competence is not connected with health care), and on the other hand the health care of general society is provided and financed by the Ministry of Health. This ―division of labour‖ leads to the situation that patients in prisons do not receive equal medical care compared to the patients in the public health care system (for example, compensated medicaments), because the prison system can not duplicate all services offered in public health. This situation leads to incomplete medical treatment of prisoners and a lack of infrastructure in the prison health care system. One of the biggest achievements in efforts to improve the situation, is that salaries of the medical personnel in prisons is equal to doctors in public health systems (until the year 2005/2006 salaries of medical personnel in prisons differed from general medical personal). The law provides for specific health care scope for prisoners, depending of their health condition, prevalence of different psychological deflections, infectious deceases, HIV/ AIDS, tuberculoses among prisoners. The lack of financing does not allow provision of adequate health care of convicted persons. 38
The analysis of the legal framework has been elaborated by Solvita Olsen within the UNODC project ―HIV/AIDS prevention and care among injecting drug users and in prison settings in Estonia, Latvia and Lithuania‖ (AD/XEE/06/J20) 39 Olga Zeile (2007), Latvijas Republikas Tieslietu Ministrija 106
Health care budget of convicted persons is far too insufficient. It is caused by general lack of money in prison system There is a problem situation with the treatment of some infectious diseases (for example, viral hepatitis C), so the general principal of health care system ―the money follows the patient‖ does not work. Lack of compliance medical divisions‘ and Latvian Prison hospital‘s premises to the normative Concept of Prison Development (accepted by Cabinet of Ministers on the 2nd May 2005) foresees that Latvian Prison Hospital will be transferred to new premises in Olaine prison/ According to Olga Zeile, the MoJ elaborated the ―Concept on Prisoners Health Care‖ and it was looked through in the Cabinet of Ministers in 2006. The main goal of the Concept was: the level of health care provided to the convicted persons shall be equal to the level of care received by the general public taking into account the special needs and restrictions of convicts. The Concept also provided a shift of the responsibility for the Prison Hospital to the MoH, but the Cabinet of Ministers did not support this concept and gave a task to MoJ and MoH to continue the work with re-drafting the Concept. The MoJ is now re-drafting the Concept, where detailed clarification of general competencies of ministries will be included together with clarification of such competencies for different diagnosis (addiction, TB, HIV, hepatitis, etc). Also, there are plans to define ―prison hospital‖ and ―prison doctor‖ as parts of public health care system, which allows to execute the principle ―money follows the patient‖. By this concept it is envisaged that •
Inmates are treated by highly professional staff;
•
Inmates are receiving medical care available for the general public;
•
A cost effective organization of the health care system is given.
New Prison Hospital: st
•
New Prison Hospital was opened in 31 of July 2007 in Olaine prison
•
Total amount of budgetary allocations for building and provision of equipment for new prison
hospital in 2005 – 1 630 000 LVL; 2006 – 1 010 000 LVL; 2007 – 1 120 000 LVL •
New Prison Hospital is built in accordance with the all necessary standards and therefore it will
provide medical care of prisoners in suitable circumstances A.2. Legal Regulation of Prisoners’ Health Care: Review of Legal Rules in Latvia
40
Constitutional basis of medical treatment services insured by State is stated in clause 111 of the Constitution: ―The State shall protect human health and guarantee a basic level of medical assistance for everyone‖. In turn, in clause 91 of the Constitution, there is secured a principle of lawfulness and legal equality ―All human beings in Latvia shall be equal before the law and the courts. Human rights shall be realised without discrimination of any kind.‖ 40 Solvita Olsena, MD, JD, ―Medicīnas tiesību institūts‖ Ltd., director 107
Competence of the State institutions in ensuring the health care is divided between the Ministry of Health and the Ministry of Justice. Functions41 of the Ministry of Health are, as follows: 1) to develop the health policy, 2) to organize and coordinate implementation of the health policy; 3) to discharge other functions prescribed by other external regulatory enactments. In order, to ensure implementation of the mentioned functions, the ministry develops, in the field of the public health, the State policy in the sub-sectors of epidemiological safety, health promotion and reducing harmfulness of addictive substances, but in the field of the health care 1) develops the State policy in the sub-sectors of disease prevention, diagnostics, medical treatment, patient rehabilitation and organizing the health care; 2) supervises the registers of medical practitioners and medical treatment institutions, as well as patients registers and registers of persons suffering from particular diseases; 3) supervises health care quality assurance at the medical treatment institutions, 4) supervises accessibility of the health care services. The Ministry of Justice in the field42 of the system of penalties and penal enforcement: 1) develops and implements the State policy in the field of the system of criminal penalties and the system of administrative penalties and penal enforcement, 2) organizes enforcement of criminal penalties and activities of probation system. But functions of the State administrative institution Latvian Prison Administration subordinated to the Ministry of Justice are to ensure pre-trial detention as a security measure and imprisonment as a criminal punishment43. The Latvian Prison Administration ensures the health care of prisoners (subparagraph 4.4), as well as arranges measures of the mental care and education of prisoners (subparagraph 4.5). The Medical Treatment Law (hereinafter referred to as the MTL) stipulates a general procedure of receiving health care services in the Republic of Latvia. In clause 17 of the MTL, there is stated a set of those people, who have right to receive a health care guaranteed by the Sate, as well as a procedure of providing medical assistance: ―The amount of medical assistance guaranteed by the State in accordance with the procedures prescribed by CoM shall be provided to citizens of Latvia, non-citizens, aliens and stateless persons, whose passports include a personal identity number and who are registered in the Population Register, as well as to persons detained, arrested and sentenced with deprivation of liberty. Such assistance shall be provided at the time and place where it is necessary, and medical treatment in such cases shall be carried out in accordance with the clinical guidelines developed in the procedure prescribed by CoM‖. paragraphs 2 and 3 of clause 17 of the MTL stipulate rights of a child in health care: ―Any child residing in the territory of Latvia, also a child who has not been allocated a personal identity number and who has not been registered in the Population Register, has the right to receive the medical assistance guaranteed by the State as set out in paragraph one of this Section. Children have the right to receive free of charge the medical assistance guaranteed by the State‖. 41
The Cabinet of Ministers Regulations No.286 of 13 April 2004 ―The Ministry of Health Regulation‖ Regulations of the Ministry of Justice 43 In accordance with paragraph 3 of the Cabinet of Ministers Regulations No.827 of 1 November 2005 ―The Latvian Prison Administration Statutes‖ 42
108
In turn, clause 16 of the MTL stipulates: ―Everybody has the right to receive emergency medical assistance in accordance with procedures prescribed by CoM‖. In clause 4 of the MTL 4, there is stipulated that the procedure for organizing and financing health care, the procedure for forming queues of pretenders for receiving planned health care services, the types and amounts of medical treatment services that are paid for from the State basic budget and from the resources of recipients of services, as well as the procedures for such payments shall be determined by CoM. Implementing delegation provided by this clause, there were issued the CoM Regulations No. 1046 of 19.12.2006 ―Health Care Organization and Financing Procedure‖. In accordance with paragraph 13 of these regulations: ―Health care services paid from the State budget are provided by those medical treatment institutions, which have entered into contract with the agency, as well as the State agencies and the State administrative institutions, which health care services provide in accordance with bylaws‖. Paragraph 76.2. 2. of CoM Regulations 1046 stipulates that a person shall receive secondary health care services, by seeking, at his or her own initiative, help from narcologist, if the person is addicted to alcohol, narcotic or psychotropic substances (codes of diagnoses in accordance with ICD–10: F10–F16; F18–F19; F63.0). Paragraph 17.2 of CoM Regulations 1046 stipulates that the Ministry of Justice covers expenses for the persons, who are in the detention institutions subordinated to the Latvian Prison Administration (except for medicaments for treatment of tuberculosis and HIV/AIDS, which are paid from the State budget funds foreseen for health care). Thus, the health care services for prisoners are not paid from the health care budget. But in accordance with paragraph 33.2 of these regulations, the agency blocks registration of the persons, who are in the detention institutions, as patients. Thus, when the person is taken in the detention institution, he or she, in accordance with CoM regulations, is prohibited from the health care system, which is ensured to all other patients by State. Health care of prisoners is stipulated, together with the Medical Treatment Law, by the ―Penal Code‖ and the ―Law on Procedure of Pre-Trial Detention‖. Clause 78 of the Penal Code44 stipulates: ―Medical Services of penal institutions provide medical care guaranteed by State to the persons sentenced to imprisonment and those put under arrest in accordance with the procedure and in the scope prescribed by CoM. The persons sentenced to 44
The Penal Code governs relations: This Code governs rules and procedure of penal enforcement stipulated by the Criminal Law, legal status of convicted persons, competence of the State and municipal bodies in penal enforcement. 109
imprisonment and those put under arrest receive other medical care in accordance with the procedure prescribed by the Medical Treatment Law. Paragraph two of the mentioned clause stipulates the procedure of providing emergency medical assistance at other medical treatment institution: ―If the persons sentenced to imprisonment need emergency medical assistance, which is impossible to provide at the medical treatment institution of the penal institution, this assistance is provided to them in another medical treatment institution. The penal institution ensures guarding of the convicted person‖. Clause 22 of the Law on Procedure of Detention45 stipulates that a prisoner shall receive health care services in accordance with the procedure and in the scope prescribed by CoM. A prisoner has right to receive, at his or her expense, health care services, provision of which is not stipulated by CoM regulations, if the prisoner pays all expenses connected with provision of the mentioned health care services (also, expenses for the guarding). If prisoner needs emergency medical assistance which is impossible to provide at the investigation prison medical treatment institution, this assistance is provided to him or her at another medical treatment institution, and prison governor ensures guarding the prisoner. Implementing delegation provided by these laws, CoM has issued the Regulations No.199 of 20 MLh 2007 ―Rules of Health Care of Prisoners and Convicted Persons in Investigation Prisons and Detention Institutions”, which stipulate the procedure of health care of prisoners in more detail. 1. The regulations stipulate a scope of health care services for persons put under arrest or convicted persons (hereinafter referred to as the prisoner) and the procedure of providing these services in investigation prisons and detention institutions (hereinafter referred to as the prison). 2. A prisoner in the prison shall receive free of charge: 2.1. The primary health care, except for the planned dental care; 2.2. The emergency dental care; 2.3. The secondary health care, which is to be provided as emergency care, as well as the secondary health care, which is provided by prison doctors according to their medical speciality; 2.4. The most effective and cheap, in the context of their cost, medicines, which have been prescribed by a prison medical practitioner. 3. Out-patient health care of a prisoner is ensured at the prison medical care unit, but inpatient care – in the Latvian Prison Hospital. 4. No later than within three days after a prisoner has been taken to a prison, medical practitioner shall perform health examination of the prisoner. 5. Preventive heath examination of a prisoner shall be performed once a year. Director of the Latvian Prison Administration annually determines kinds of preventive examination. 45
Law on Procedure of Detention. Purpose of the law is to ensure proportionate observance of human rights and interests of criminal procedure during performance of measure of restraint — imprisonment. Clause 3: Convicted person is a person, whom an investigation judge or a court has put under restraint - imprisonment. Detention is executed in the investigation prison or in the department of investigation prison created in the penitentiary. 110
6. Primary health care services to a prisoner shall be provided at the prison medical treatment unit or in the location of the prisoner. Planned primary health care services are provided during reception hours of patients determined in the prison order of the day. 7. A prisoner shall receive primary health care services: 7.1. By seeking, at his or her initiative, help from a prison doctor, a doctor assistant or a dentist; 7.2. by invitation of a prison doctor or a doctor assistant. 8. Prison doctor shall estimate health status of a prisoner and, if necessary, send it to receiving the secondary health care services to other specialist at the prison medical care unit or to the Latvian Prison Hospital. 9. Prisoner shall receive the secondary health care services according to the order of a prison doctor or a doctor assistant or by seeking, at his or her initiative, help from prison doctors – specialist. 10. There shall be prohibited to send a prisoner, who is ill with acute disease and has not completed a course of treatment in accordance with medical comment, to another prison or to convoy him or her for performance of criminal proceedings. 11. Prisoner shall take medicaments only in the presence of prison personnel, except for the case, when there is received a special order of a prison doctor. 12. If a prisoner has received injury or get poisoned and there are suspicions of possible commitment of act of crime, a doctor, a doctor assistant or a sick-nurse informs, after providing the medical care, the prison administration about the case occurred in writing. 13. Prisoner shall be sent to the Latvian Prison Hospital for in-patient treatment according to medical indications with the prison doctor‘s appointment card and the Latvian Prison Administration order. 14. If it is impossible to provide emergency medical assistance in a prison, a prisoner, ensuring the guarding, can be sent to the medical treatment institution, located outside the detention institution. 15. If there is received a prisoner‘s application, which is agreed in writing with a prison doctor, the prison administration can agree on consultation and medical treatment of the prisoner with management of such medical treatment institution, which is located outside the detention institution. Expenses connected with providing health care services, as well as carriage and guarding costs are covered from the prisoner funds. 16. In the cases of persistent or permanent restrictions of physical or mental capacity, a prison doctor, estimating health status of the patient, shall send the prisoner to the Medical Commission for ExpertExamination of Health and Working Ability. Thus, the abovementioned rules stipulate the right of every prisoner to receive the health care services. The mentioned rules also stipulate the procedure for organizing and financing health care. Procedures for the Treatment of Alcohol Addiction and Addiction to Narcotic, Psychotropic and Toxic Substances, Gambling or Computer Games A separate chapter of the MTL governs medical treatment of alcohol addiction and addiction to narcotic, psychotropic and toxic substances, gambling or computer games. In accordance with that stated in clause 61 of the MTL 61: ―Treatment of alcoholics and addicts of narcotic, psychotropic and toxic substances, gambling or computer games shall be voluntarily if the addict wishes, in addiction treatment institutions in accordance with the procedures prescribed by CoM.‖ So, the legislator has stated that 111
treatment of addiction in the Republic of Latvia shall be performed by treatment institutions of specific profile – addiction treatment institutions. Using delegation provided in this legal rule, CoM has issued the Regulations No.42946 of 24 September 2002 ―Procedures for the Treatment of Patients Addicted to Alcohol, Narcotics, Psychotropic and Toxic Substances‖. These regulations are, as follows: I. General Provisions 1. The regulations prescribe the procedures by which the medical treatment of patients addicted to alcohol, narcotic, psychotropic and toxic substances (hereinafter referred to as patients) shall be performed in addiction treatment institutions voluntarily, if they wish. 2. Addiction treatment institutions shall be outpatient addiction treatment institutions, an addiction treatment department of a medical treatment institution and an in-patient addiction treatment institution regardless of their type of ownership and subordination. 3. If a duty to be treated for addiction to alcohol, narcotic, psychotropic or toxic substances has been imposed by a court in accordance with paragraph seven of clause 55 of the Criminal Law upon a convicted person, the fulfilment thereof shall be ensured in accordance with the procedures prescribed by these regulations. 4. The anonymous treatment of patients in addiction treatment institutions is prohibited. 5. A diagnosis of a narcological disease for a patient shall be determined by a certified narcologist. 6. An addiction treatment institution is entitled to involve in the care of a patient a psychologist, psychotherapist, social worker, nursing personnel and nursing attendants, teacher, person working in the field of sport and a medical rehabilitation specialist, as well as other specialists, if it is provided for in the medical treatment contract. II. Medical Treatment Contract 7. A patient shall be treated in an addiction treatment institution on the basis of a medical treatment contract, which has been entered into between the patient and the addiction treatment institution. 8. A medical treatment contract shall be drawn up in writing in accordance with the requirements specified in these regulations and in the Civil Law. 9. The following information shall be indicated in the medical treatment contract: 9.1. The given name, surname, personal identity number and place of residence of a patient; 9.2. The name, address and registration number of the addiction treatment institution; 9.3. The medical treatment conditions for the patient; 9.4. The rights and duties of the patient; 9.5. The rights and duties of the addiction treatment institution, as well as the duty to ensure confidentiality; 9.6. The pay for the health care services provided for in the contract in accordance with the price list approved by the addiction treatment institution, as well as the term of payment; 9.7. The procedures for the consideration of disputes and compensation for losses; 46
With amendments: the Cabinet of Ministers Regulations No.50, 18 January 2005 The Cabinet of Ministers Regulations No.751, 4 October 2005 The Cabinet of Ministers Regulations No.244, 10 April 2007 112
9.8. The duration of the contract; and 9.9. The conditions of the termination of the contract. 10. The medical treatment contracts shall be registered and stored in the addiction treatment institution during one year after the completion of the medical treatment course. The procedures, by which the medical treatment contracts are registered and stored in the addiction treatment institutions, as well as by which confidentiality is ensured, shall be specified in the internal regulations of the relevant institution, which have been developed in accordance with the requirements specified in the Personal Data Protection Law, in these regulations and other regulatory enactments. III. Rights and Duties of the Patient 11. A patient has the following rights: 11.1. within the scope of the health care system, to freely choose the type of narcological assistance and the addiction treatment institution; 11.2. to decide regarding the acceptance or refusal of the narcological assistance offered, except for the cases, where a patient is under severe intoxication of alcohol, narcotic or psychotropic substances and his or her life is endangered or mental dysfunction has appeared, due to which he or she endangers himself or herself, his or her relatives and other persons; 11.3. To be treated with the appropriate means on the basis of the principles of humanism, respect and professionalism, as well as observing confidentiality; 11.4. To receive medical services, which are included in the minimum of health care services guaranteed by the State? 11.5. To obtain information regarding his or her health status, possible alternative health care types and a prognosis for his or her health status; 11.6. to submit complaints regarding the narcological assistance received and, if they are justified, to receive a reimbursement in accordance with the procedures prescribed by the regulatory enactments for the losses caused; and 11.7. To receive a statement from the addiction treatment institution after the completion of the medical treatment course. 12. A patient has the following duties: 12.1. To treat with respect the rights of other patients; 12.2. To take into account precisely the instructions of a doctor during the medical treatment course and creating the motivation for abstinence; 12.3. To observe the internal regulations of the medical treatment institution, while receiving the narcological assistance; and 12.4. To cover the expenses for the services connected with the provision of the narcological assistance, if they are not included in the health care services minimum guaranteed by the State. IV. Registration of Patients and Dynamic Observation 13. In order to ensure successive treatment and motivate them for further treatment, which reduces recurrence, addiction treatment institutions shall perform registration of patients and dynamic observation. 14. In performing the registration of patients, the following shall be included in the relevant list: 113
14.1. Patients, who have had alcohol and intoxication psychosis; 14.2. Patients with addiction to alcohol, which has caused social and biological consequences; 14.3. Minor users of alcohol, narcotic or psychotropic substances; and 14.4. Patients of addiction to alcohol and psychotropic substances. 15. Upon entering into a medical treatment contract, patients shall be notified regarding the registration. 16. Information regarding the registered patients shall be provided in accordance with the procedures prescribed by regulatory enactments. 17. If a diagnosis, which is connected with the use of substances of addiction, is specified for a person, he or she shall be observed preventively. V. Replacement Treatment of Patients Addicted to Narcotic Substances 18. The replacement method of treatment of patients addicted to narcotic substances (hereinafter referred to as replacement treatment) shall be used for the treatment of patients addicted to opioid narcotic substances (hereinafter referred to as a patient addicted to narcotic substances). 19. Medicinal products, the active substance of which is methadone or buprenorphine, shall be used in the replacement treatment. 20. A narcologist may send a patient addicted to narcotic substances to the State limited liability company ―Riga Psychiatry and Narcology Centre‖. The SLLC ―Riga Psychiatry and Narcology Centre‖ shall take a decision regarding the commencement of the replacement treatment, if: 20.1. a narcologist, assessing the physical and psychical state of health and motivation of a patient addicted to narcotic substances, as well as taking into account the criteria referred to in sub-paragraph 21.1 of these regulations, reasonably considers that it is necessary to commence the replacement treatment for a patient addicted to narcotic substances; 20.2. A patient addicted to narcotic substances has been undergoing medical treatment at the relevant narcologist for at least six months. 21. The doctor‘s council established by the SLLC ―Riga Psychiatry and Narcology Centre‖ (hereinafter referred to as the doctor‘s council) shall decide on: 21.1. the commencement of the replacement treatment, if a patient addicted to narcotic substances is a pregnant female or suffers from HIV, AIDS, hepatitis B or hepatitis C, syphilis, tuberculosis or other severe chronic diseases, due to which it is not possible to stop using narcotic substances, and if a patient addicted to narcotic substances: 21.1.1. is more than 18 years old; 21.1.2. is addicted to narcotic substances for no less than five years; or 21.1.3. Has undergone treatment unsuccessfully at least two times; 21.2. Medicinal products used in the replacement treatment and daily intake thereof; and 21.3. Change of medicinal products used in the replacement treatment or on increase of the daily intake. 22. A medical treatment contract referred to in paragraph 7 of these regulations shall be entered into before the commencement of the replacement treatment, where in addition to the information referred to in paragraph 9 of these regulations, there shall be indicated that a patient addicted to narcotic substances has received information regarding: 114
22.1. The possible side effects from medicinal products used in the replacement treatment; 22.2. The duration and costs of the replacement treatment; 22.3. The prohibition to use other narcotic and psychotropic substances or medicinal products during the replacement treatment without an order of the doctor; 22.4. The criteria, due to which a replacement treatment is terminated; and 22.5. The necessity to make analyses during the replacement treatment. 23. Replacement treatment with methadone shall be performed in the outpatient department of the SLLC ―Riga Psychiatry and Narcology Centre‖. The mentioned department shall ensure the receipt of the daily intake of methadone specified in the decision of the doctors‘ council in the presence of a medical practitioner. 24. Replacement treatment with buprenorphine shall be commenced in the department of the SLLC ―Riga Psychiatry and Narcology Centre‖. The mentioned department shall ensure the receipt of the daily intake of buprenorphine specified in the decision of the doctors‘ council in the presence of a medical practitioner and carry out observation of the patient addicted to narcotic substances for at least seven days. 25. After the end of the medical treatment course referred to in paragraph 24 of these regulations, the doctors‘ council, if necessary, shall clarify the daily intake of buprenorphine and decide on the continuation of the replacement treatment in the SLLC ―Riga Psychiatry and Narcology Centre‖ or in one of the following medical treatment institutions: 25.1. The limited liability company ―Slimnīca ―Ģintermuiža‖‖; 25.2. The limited liability company ―Daugavas slimnīca‖; 25.3. The SLLC ―Straupes narkoloģiskā slimnīca‖; or 25.4. The institution of the city council of Liepāja ―Liepājas pilsētas centrālā slimnīca‖. 26. The replacement treatment of a patient addicted to narcotic substances with buprenorphine shall be continued in the SLLC ―Riga Psychiatry and Narcology Centre‖ or in the out-patient department of the medical treatment institutions referred to in paragraph 25 of these regulations at least for 30 days, ensuring that a daily intake of buprenorphine specified in a decision of doctors‘ council is received by the patient addicted to narcotic substances in the presence of one of the medical personnel. 27. If a patient addicted to narcotic substances has a statement issued by a family doctor or a sickleave certificate, the attending doctor of the SLLC ―Riga Psychiatry and Narcology Centre‖ or the medical treatment institution referred to in paragraph 25 of these regulations may take a decision, that the daily intake narcotic medicinal products to be used in the replacement treatment shall be dispensed for use at home. A deed of transfer and acceptance shall be drawn up regarding the dispensing of the medicinal products, as well as an entry in the outpatient medical card and in the strict accounting register of narcotic medicinal products shall be made. 28. If it is necessary for a patient addicted to narcotic substances to be treated in another in-patient medical treatment institution, the SLLC ―Riga Psychiatry and Narcology Centre‖ or a medical treatment institution referred to in paragraph 25 of these regulations shall provide the necessary information regarding the replacement treatment, as well as, if it is necessary, shall hand over, by a deed of transfer and acceptance, to the inpatient medical treatment institution the narcotic medicinal products to be used 115
in the replacement treatment and required for a patient addicted to narcotic substances. An entry regarding the handing over of the medicinal products in the strict accounting register or narcotic medicinal products shall be made. 29. The State limited liability company ―Riga Psychiatry and Narcology Centre‖, medical treatment institutions referred to in paragraph 25 of these regulations and the inpatient medical treatment institution referred to in paragraph 28 of these regulations shall keep and register the narcotic medicinal products to be used in the replacement treatment and shall make entries in the medical history, prescription sheet or outpatient‘s medical card, as well as in the strict accounting register of narcotic medicinal products in accordance with the requirements of regulatory enactments regarding the register of narcotic medicinal products in medical treatment institutions. 30. After the completion of the treatment course referred to in paragraph 24 and 26 of these regulations, the SLLC ―Riga Psychiatry and Narcology Centre‖ or the medical treatment institution referred to in paragraph 25 of these regulations shall evaluate the progress of the replacement treatment of the patient addicted to narcotic substances and decide on the type of further treatment of the patient addicted to narcotic substances: 30.1. The continuing of the replacement treatment course in accordance with the procedures referred to in paragraph 28 of these regulations; or 30.2. The continuing of the replacement treatment course under the supervision of a narcologist. 31. If a decision referred to in sub-paragraph 30.2 of these regulations is taken, a statement regarding the results of the replacement treatment shall be issued to the patient addicted to narcotic substances and he or she shall be sent to undergo treatment at the narcologist referred to in paragraph 20 of these regulations. 32. If a narcologist can ensure the permanent supervision of a patient addicted to narcotic substances, the narcologist shall submit a submission in writing to the SLLC ―Riga Psychiatry and Narcology Centre‖ regarding a request to issue the buprenorphine replacement therapy programme card (hereinafter referred to as the card) to a patient addicted to narcotic substances. A copy of the statement referred to in paragraph 31 of these regulations and certification in writing shall be attached to a submission, that a patient addicted to narcotic substances will be ensured with permanent supervision during the further replacement treatment. 33. The doctors' council shall evaluate the submission of the narcologist and the documents attached thereto and decide on the issue of a card. A card shall be issued within three days after receipt of a submission. The term of validity of a card is one year. 34. A narcologist shall prescribe, on a special prescription form, the medicinal products containing buprenorphine to a patient addicted to narcotic substances, to which a card has been issued, for outpatient treatment for no more than seven days, and not exceeding the daily intake of buprenorphine specified by the doctors‘ council. 35. A narcologist, who prescribes medicinal products containing buprenorphine for outpatient medical treatment of a patient addicted to narcotic substances, shall be responsible for the permanent supervision of the patient addicted to narcotic substances. The duty of a narcologist is to motivate a
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patient addicted to narcotic substances to reduce the intake of medicinal products of the replacement treatment and to choose other medical treatment methods. 36. If the card is lost, a narcologist shall submit a submission to the SLLC ―Riga Psychiatry and Narcology Centre‖ with a request to issue a duplicate of the card. A submission shall be appended with an explanation from the patient addicted to narcotic substances regarding the reasons for losing the card. A card shall be issued within three days after receipt of a submission. 37. If the term of validity of a card has expired, then, in order to receive a replacement card, a narcologist shall send the patient addicted to narcotic substances to the doctors‘ council and provide information regarding the course of replacement treatment. 38. The State limited liability company ―Riga Psychiatry and Narcology Centre‖ shall ensure: 38.1. The production of cards in accordance with a sample specified in the regulatory enactments regarding the circulation of narcotic medicinal products and substances; 38.2. The issue of cards to a narcologist, on the basis of a submission in writing; 38.3. The issue of duplicates of cards in the case referred to in paragraph 36 of these regulations on the basis of a narcologist‘s submission in writing; 38.4. The registration of the issue of cards, duplicate cards and cancelled cards; 38.5. The cancellation of the card, if the replacement treatment has discontinued; and 38.6. Registration of the patients addicted to narcotic substances and the compiling of information regarding the course of the replacement treatment. 39. If a patient addicted to narcotic substances agrees to terminate the replacement treatment on the recommendation of a narcologist, a narcologist shall ensure the reducing of the intake of medicinal products at the out-patient clinic or send a patient addicted to narcotic substances to the SLLC ―Riga Psychiatry and Narcology Centre‖ or to the in-patient department of the medical treatment institution referred to in paragraph 25 of these regulations, which shall ensure the reduction of the intake of medicinal products. 40. The replacement treatment of a patient addicted to narcotic substances shall be discontinued, if: 40.1. carrying out the analyses, it is determined, that a patient addicted to narcotic substances is using alcohol, other narcotic or psychotropic substances and medicinal products or medicinal products without a doctor‘s order during medical treatment; 40.2. Serious side effects from the use of the medicinal products have been observed in a patient addicted to narcotic substances; 40.3. a patient addicted to narcotic substances without a justifiable reason fails to attend at the SLLC ―Riga Psychiatry and Narcology Centre‖ or to the outpatient department of the medical treatment institution referred to in paragraph 25 of these regulations for more than five days or does not attend a narcologist at the specified time; or 40.4. If a patient addicted to narcotic substances uses the medicinal products, not taking into account the instructions on the use of the medicinal products, or distributes them to other persons. 41. A narcologist and the medical treatment institution referred to in paragraph 25 of these regulations shall notify the SLLC ―Riga Psychiatry and Narcology Centre‖, within seven days, regarding the patients
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addicted to narcotic substances, for whom the replacement treatment has been terminated or discontinued.‖ Procedure of the Treatment of HIV and AIDS Main principles of treatment of HIV-infected persons and AIDS patients are stipulated by the Sexual and Reproductive Health Law. In accordance with that stated by paragraph two of clause 11 of this law: ―the examination, treatment and monitoring of HIV-infected persons and AIDS patients shall be carried out by an infectologist at a medical treatment institution‖. But in accordance with that stated by clause 5 of this law, the Cabinet shall determine the organisational procedure for restriction of the spreading of human immunodeficiency virus (HIV) and AIDS, and the treatment of HIV-infected persons and AIDS patients. Using delegation provided by the Sexual and Reproductive Health Law, CoM has issued the regulation No. 628 of 4 November 2003 ―Organisational procedures for restriction of the spread of human immunodeficiency virus infection (HIV) and AIDS and the treatment of HIV-infected persons and AIDS patients‖. In this regulation there are included the following procedures: I. General Provisions 1. 1. These Regulations prescribe the procedures by which measures for the restriction of the spread of HIV and acquired immune deficiency syndrome (hereinafter – AIDS) shall be organised: epidemiological surveillance, the treatment of infected persons and AIDS patients, medical and social rehabilitation, the information and education of inhabitants in the field of HIV infection and AIDS prevention. 2. The Ministry of Education and Science, in co-operation with the State institution ―AIDS Prevention Centre‖ (hereinafter – AIDS Prevention Centre) and the State Agency ―Health Promotion Centre‖, shall include issues regarding the prevention of HIV infection in health education programmes for the education of children and youth. The AIDS Prevention Centre, in co-operation with interested State and non-governmental institutions, shall implement measures for the information and education of inhabitants in the field of prevention of HIV infection. II. Examination for the Determination of HIV Infection 3. In order to determine a possible HIV infection and contraction of AIDS, perform epidemiological surveillance, as well as to provide consultative, medical and psychosocial assistance to persons infected with HIV, a performance of the appropriate examinations shall be necessary. 4. A person shall be examined in order to determine HIV infection only on the basis of an informed consent of the person and observing confidentiality, except in cases where law enforcement authorities require such examination in accordance with the procedures specified by regulatory enactments. 5. A medical practitioner shall order a person to laboratory testing for HIV infection. The medical treatment practitioner has a duty to provide the person to be examined with:
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5.1. a pre-test consultation in which the medical treatment practitioner informs the person to be examined regarding the purposes, procedure, possible results and consequences of the test, as well as regarding the ways of spreading the HIV infection and individual prevention; and 5.2. A post-test consultation in which the medical treatment practitioner informs the person to be examined regarding the test results. If the test results confirm the presence of HIV in the body, the medical treatment practitioner has a duty to provide the infected person with psychological support, to explain the opportunities of medical and social care, the rights and duties of the infected person, as well as the individual preventive measures in order to prevent the infection of other persons. 6. Minors shall be examined in order to determine HIV infection on the basis of a personal request, a request of the parents of the minor, a request of a guardian and a parish court or a written request of law enforcement authorities. 7. A medical practitioner shall comply with the procedures for ensuring the confidentiality of information specified in the regulatory enactments governing the field of medical treatment, if such information is related to the infection of a person with HIV or his or her contraction of AIDS. 8. A medical practitioner has the right to reveal the information referred to in paragraph 7 of these Regulations only if a patient has confirmed in writing that the medical practitioner has been released from the duty to remain silent and may inform a concrete person (for example, the sexual partners or relatives of the patient) regarding the infection of the person with HIV or his or her contraction of AIDS. 9. HIV-infected persons and AIDS patients are prohibited to become tissue, organ and gamete donors. III. State Epidemiological Surveillance of the Spread of HIV Infection and AIDS 10. The AIDS Prevention Centre shall methodologically manage, co-ordinate, supervise and ensure the State epidemiological surveillance of the spread of HIV infection and AIDS (a continuous, dynamic monitoring of the epidemic process of the HIV infection, research of the epidemiological situation, forecasting of the process of the epidemic, the planning of preventive measures and the evaluation of effectiveness). 11. The AIDS Prevention Centre shall establish and keep a register of cases of HIV infection and contraction of AIDS and inform other interested institutions, observing the procedures for the use of restricted access information. 12. A medical practitioner shall inform the AIDS Prevention Centre regarding each newly discovered case of HIV infection or AIDS contraction, as well as regarding each case of the death of an infected person in accordance with the regulatory enactments regulating the registration of infectious diseases. 13. The Ministry of Health shall finance the epidemiological surveillance of the spread of the HIV infection and AIDS within the framework of the State budget resources assigned thereto. IV. Treatment of HIV-Infected Persons and AIDS Patients 14. HIV-infected persons and AIDS patients shall be treated, applying to them all the rights and duties of inhabitants and patients in health care, as well as ensuring the referred to persons with medical treatment services in accordance with the procedures prescribed by the regulatory enactments regulating the field of medical treatment.
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15. The State Agency ―Infectology Centre of Latvia‖ shall methodologically manage the medical care of infected persons and AIDS patients, as well as ensure post-exposure prevention and consultative medical care. Responsibility of Prisoners, if They Took Narcotic or Psychotropic Substances Clause 2532 of the Criminal Law. Unauthorised Acquisition, Storage, and Sale of Narcotic and Psychotropic Substances without a Physician‘s Designation (1) For a person who commits unauthorised acquisition or storage in small amounts of narcotic or psychotropic substances without the purpose of sale thereof, or who commits use of narcotic or psychotropic substances without a physician‘s designation, if commission thereof is repeated within a period of one year, — the sentence is deprivation of liberty for a term not exceeding two years, or community service, or a fine not exceeding fiFTy times the minimum monthly wage. (2) For a person who commits unauthorised sale of narcotic or psychotropic substances in small amounts, — the applicable sentence is deprivation of liberty for a term not exceeding three years, or custodial arrest, or community service, or a fine not exceeding eighty times the minimum monthly wage. This clause is also related to the prisoners who took narcotics repeatedly within a period of one year, if only this is revealed in the detention institution. They can be sentenced with another criminal penalty. Clause 41 of the Latvian Penal Code, which stipulates main regulations of detention institutions: ―It is not allowed for convicted persons to keep with themselves the money, valuables, as well as things prohibited for the use in detention institutions. Prohibited things and money found with the convicted persons are taken out. A list and quantity of those things and property that can be with the convicted persons and procedure of taking money out are governed by ―Internal regulations of detention institutions‖. In clause 35 of the Law on Procedure of Detention and in clause 70 of the Penal Code, there is stated: the use, keeping or distribution of alcohol, narcotic or psychotropic substances and refusal from the check, so that to state if the person put under arrest has taken alcohol, narcotic or psychotropic substances, are gross violations of internal regulations of investigation prisons and regime for serving punishment. For these violations, there are applied administrative penalties prescribed by the mentioned laws. Clause 22 of the Latvian Prison Administration Law stipulates rights of an official 1) in accordance with procedure prescribed by laws and other regulatory enactments, to require that persons interrupt violations of a law and other activities, which disturb fulfilment of duties of the official, as well as to use means of enforcement foreseen against lawbreakers; 2) in accordance with procedure prescribed by CoM, to visit the persons put under arrest and convicted persons in the detention institution, so that to state if they have taken alcohol, narcotic or psychotropic substances; 3) in accordance with procedure prescribed by law, to perform examination of persons, a check of persons‘ things and clothes, to take 120
out things, products and substances, which are prohibited for bringing in, using and keeping in the detention institution. In accordance with that stipulated by clause 22 of the Latvian Prison Administration Law, CoM has issued the Regulations No.918 of 6 December 2005 ―Procedures of Examination of the Persons Put Under Arrest and Convicted Persons in the Detention Institutions, to State if They Took Alcohol, Narcotic or Psychotropic Substances‖ 1.The regulations stipulate the procedures of examination in the detention institutions of the persons put under arrest and convicted persons (hereinafter referred to as the prisoner), so that to state, if he or she has taken alcohol, narcotic or psychotropic substances, if there have been appeared suspicions of taking alcohol, narcotic or psychotropic substances. 2. The prisoner shall be examined by officer of the detention institution (hereinafter referred to as the officer). 3. If there have been appeared suspicions of taking alcohol, there shall be used a portable measuring device for determination of alcohol concentration (alcohol tester), which meets the requirements determined in the regulatory enactment on measuring devices for determination of alcohol concentration in the exhaled air. The prisoner shall be examined two times with a time interval of 20 minutes. 4. If there have been appeared suspicions of taking narcotic or psychotropic substances, there shall be used short-term bioassay tests for determination of narcotic and psychotropic substances. 5.The officer, who has examined the prisoner, shall prepare the examination report for determination of alcohol effect (appendix 1) or the examination report for determination of effect of narcotic and psychotropic substances (appendix 2) and write the relevant information in the registration log book (appendix 3). 6. In the report, there shall be written the values of the measuring device (alcohol tester) or the shortterm test for determination of narcotic and psychotropic substances. To the report, there shall be attached printouts of the measuring device (alcohol tester), which certify measurements specified in the report. 7. In the conclusion of the report, there shall be written results of prisoner‘s examination, specifying if the prisoner took alcohol, narcotic or psychotropic substances. 8. If the prisoner refuses from examination, entry in the report about that shall be made.
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9. If results of the short-term test for determination of narcotic and psychotropic substances are positive, the following examination is performed in accordance with the procedure prescribed by the regulatory enactment on examination of effect of alcohol, narcotic, psychotropic or toxic substances. 10. If there is stated that the prisoner took alcohol, narcotic or psychotropic substances or if the prisoner refuses from the examination, the report shall be attached to decision on disciplinary punishment of the prisoner. In accordance with paragraph 44 of CoM Regulations No.423 of 30 May 2006 ―Internal Regulations of Detention Institutions”, a convicted person has the following duties connected with the health care measures and taking drugs: 1) in accordance with orders of penitentiary administration, to obey necessary medical examination and vaccination; 2) to take medicines immediately after their receipt in the presence of employee of a detention institution; 3) to fulfil lawful requirements of employees of a detention institution; 4) to obey examination, so that to state if alcohol, narcotic or psychotropic substances were taken. Paragraph 45 of the regulations stipulates that it is prohibited for a convicted person to acquire, manufacture, use or keep products and substances, which are prohibited in a detention institution. Collection and Processing of Personal Data Collection and processing of personal data are governed by various laws, as well as by regulations of CoM. General principles of personal data protection are stipulated by the Council of Europe Convention for the Protection of Individuals with Regard to Automatic Processing of Personal Data and the Personal Data Protection Law. This law also includes provisions of the Directive 95/46/EC of the European Parliament and of the Council of 24 October 1995 on the protection of individuals with regard to the processing of personal data and on the free movement of such data. Clause 50 of the MTL stipulates a duty of medical practitioners to ensure confidentiality. In this clause, there is stated: (1) Information regarding the medical treatment of a patient, the diagnosis and prognosis of a disease (hereinafter referred to as – information regarding a patient), as well as information obtained by medical practitioners during the medical treatment process regarding the private life of a patient and his or her closest relatives, shall be confidential. (2) Information regarding a patient may be provided to: 1) Other medical practitioners for the purpose of achieving the objectives of the medical treatment; 2) The Medical Commission for Expert-Examination of Health and Working Ability (MCEEHWA); and 3) The Quality Control Inspection for Expert-Examination in Medical Care and Ability to Work; 4) The State Agency for Compulsory Health Insurance for management of the health care services; 5) The State Labour Inspectorate — for investigation and registration of employment injuries and occupational diseases. (3) Information regarding a patient shall be provided to a court, the Office of the Prosecutor, the police, the State institution on the children and family matters (State inspectors for the protection of the rights of 122
children), an Orphan‘s court (a parish court), as well as to investigative institutions only at the written request of such institutions if there is a permission signed by the head of the medical treatment institution. (4) Information regarding a patient may be used in scientific research if the anonymity of the patient is guaranteed or his or her consent has been received. (5) Military registration and enlistment offices of the national armed forces are entitled to request from medical treatment institutions the information regarding the state of health of the reserve soldiers and reservists in accordance with the procedures prescribed by CoM. (6) The State Fire Fighting Service has right to request from medical treatment institutions the statistical data of the damage for persons‘ health made in consequence of effect of hazards of fire and statistical data of the cases, when, in consequence of effect of damage for a person made by hazards of fire, the person has died. Treatment institutions may not disclose personal data to the State Fire Fighting Service. (7) Medical practitioners and medical treatment institutions provide information of a patient to the persons and institutions referred to in paragraph two of this clause no later than within 15 days after receiving a request. In accordance with that stipulated by paragraph 13 of the Epidemiological Safety Law, information concerning persons who have infectious diseases, persons in respect of whom there is professionally determined causes for suspicion that they have become infected with infectious diseases, as well as concerning decedents whose death was caused by infectious diseases shall be confidential and utilised only in relation to the performance of medical treatment, prophylaxis and counter-epidemic measures to the extent necessary to implement such measures. Health care practitioners, the epidemiologists of the Public Health Agency (hereinafter also referred to as epidemiologists) and State sanitary inspectors, pursuant to the procedures prescribed by regulatory enactments, shall provide such information only to: 1) other health care practitioners and institutions; 2) authorities, which register infectious diseases, perform their epidemiological surveillance and organise counter-epidemic measures; and 3) the courts, police or prosecutorial institutions pursuant to a written request from them. In accordance with that stated by the regulation of CoM No. 7 of 5 January 1995 ―Procedures for Registration of Infectious Diseases‖, medical practitioners shall inform the AIDS Prevention Centre on discovered HIV and AIDS cases.
A.3. Legal possibilities and requirements for substitution treatment in prisons47
People in prison have the same right to health as people outside, and the lives and health of people in prison are connected to those of people outside prison in many ways. If we protect them, we also protect our broader communities…As the representatives of 55 governments from Europe and Central 47
Solvita Olsena, MD, JD, ―Medicīnas tiesību institūts‖ Ltd., director 123
Asia gather in Dublin this week to discuss ―Breaking the Barriers‖ in the fight against HIV/AIDS, we call upon them to begin by breaking down the barriers over which they have total control – the barriers that have thus far prevented comprehensive HIV/AIDS services from being implemented in prisons. Dublin Declaration on HIV/AIDS in Prisons in Europe and Central Asia 24 February 2004
The aim of the study is to analyse LR legislation that prescribes the procedure for the treatment of imprisoned drug addicted patients, utilising methadone and buprenorphine substitution therapy. Shortcomings in legislation must be identified following the study and proposals must be worked out for the improvement of existing legislation. Methadone therapy is one of the healthcare services which the State provides for persons that are suffering from opioid dependency. Methadone and buprenorphine substitution therapy programmes are available as part of outpatient treatment in Latvia48. The procedure for the provision of methadone therapy is prescribed by the Medical Treatment Law and Cabinet of Ministers regulations. Analysis of these legal norms will be included in the study in the form of a review of the overall legislation regulating methadone therapy. When analysing the legislation which prescribes the possibilities of imprisoned persons to receive methadone therapy, the procedure according to which the overall legislation regarding methadone therapy can be applied in places of imprisonment must be scrutinised. The fact that there 1091 drug addicts were imprisoned in Latvian prisons on January 1, 200749 prompts one to conclude that drug addiction is a significant problem in places of imprisonment. There is an evident requirement to ensure the treatment and rehabilitation of imprisoned drug addicts, as well as to carry preventive measures aimed at reducing drug addiction. The provision of methadone therapy in places of imprisonment is one of the options that must be explored; however, to date this therapy has not been available in places of imprisonment for legal, organisational and financial reasons. Both the procedure that must be observed so that patients addicted to opioids can receive substitution treatment and the organisation and payment for this treatment are prescribed in LR regulatory enactments. The main principles in this field are prescribed by the Medical Treatment Law (hereinafter MTL), however, these have been regulated in more detail by CoM (hereinafter - C of M). Meanwhile, the main principles for the healthcare of imprisoned persons are prescribed within the „Punishment Enforcement Code‖ (hereinafter - PEC) and the „Imprisonment Procedure Law‖ (hereinafter - IPL), however, healthcare for prisoners has been regulated in more detail by the C of M. When analysing these regulatory enactments, the regulatory enactment hierarchy must be observed according to
48 49
Outpatient treatment, http://www.narko.lv/?nid=47#, analysed on 14.06.2007. Incarceration Centre Authority Public Overview 2006. 124
regulatory enactments arising from the laws issued by the Saeima (MTL, PEC, IPL) takes precedence over C of M regulations. In accordance with the provisions of Section 61 of the MTL, treatment of patients addicted to narcotic substances takes place willingly at their behest at narcological treatment institutions. In implementing the delegation prescribed in the law, the C of M has issued regulations50 that prescribed the procedure for the treatment of patients addicted to narcotic substances in more detail. The C of M has prescribed what narcological treatment institutions are51, who provides the treatment of addicts and in what form, the duties that must be observed by patients and how the substitution treatment of patients addicted to narcotic substances is carried out. The regulations prescribe that the diagnosis of a narcological illness shall be determined by a certified narcologist52 and the basis for the treatment is an agreement entered into between the patient and institution in question. The procedure according to which the method of substitution treatment of patients addicted to narcotic substances is practiced is prescribed in detail in C of M regulations. Substitution treatment is used for the treatment of people addicted to opioid narcotic substances, utilising active substances – methadone or buprenorphine. In order for a patient to be able to receive substitution therapy, a narcologist must refer him or her to the VSIA „Riga Psychiatry and Narcology Centre‖ (hereinafter – Narcology Centre). This narcological treatment institution is the only one that can make a decision regarding the commencement of substitution therapy. Decision making takes place by assessing the physical and psychic health condition and motivation of the patient addicted to narcotic substances, as well as, by taking the criteria referred to in Sub-clause 21.1. of these regulations into account. The narcologist must have justified grounds for believing that a patient addicted to narcotic substances needs to start substitution treatment, and furthermore the patient addicted to narcotic substances must have undergone treatment with the relevant narcologist for at least six months. The council of doctors established at the Narcology Centre reaches a decision regarding the commencement of substitution treatment, if the patient addicted to narcotic substances is pregnant or is suffering from HIV, AIDS, hepatitis B or hepatitis C, syphilis, tuberculosis or other severe chronic illnesses, as a result of which it is not possible to suspend the use of narcotic substances and if the patient addicted to narcotic substances is older than 18 years of age, has been addicted to narcotic substances for not less than five years and has undergone treatment at least twice unsuccessfully. Substitution treatment with methadone is carried out by the Outpatient Department of the Narcology Centre. On the other hand, treatment with buprenorphine is commenced at the Outpatient Department of the Narcology Centre (seven days), but can be continued at both the Narcology Centre, as well as at the 50
The Cabinet of Ministers issued regulations No.42950, dated September 24, 2002, ―Procedures for the Treatment of Patients Addicted to Alcohol, Narcotics, Psychotropic and Toxic Substances‖. 51 Section 2 of the regulations 52 Section 5 of the regulations 125
treatment institutions referred to in the regulations in Jelgava, Daugavpils, Straupe and Liepāja. A patient addicted to narcotic substances receives his or her prescribed daily dosage at the treatment institution in the presence of a doctor or nurse. The use of drugs at home or at another treatment institution is possible in specially prescribed instances. After 30 days, buprenorphine therapy may be continued in accordance with the procedure specially prescribed – under the supervision of a narcologist. Accordingly, the legislator has prescribed that the treatment of addictions shall be carried out by special profile – narcological treatment institutions. In observing this legislation, it would be necessary to establish narcological treatment institutions at places of imprisonment, because to date there is no precedent of a narcological treatment institution being established at an incarceration centre. Since the motivation for this strict restriction prescribed by this particular regulatory enactment cannot be clearly understood, the opportunity to amend the provisions of Section 61 of the MTL must be considered, providing for a possibility whereby patients addicted to narcotic substances may also be treated at treatment institutions in places of imprisonment. The C of M has prescribed a procedure for the diagnosis and treatment of addiction to narcotic substances which is inaccessible to prisoners. In accordance with the procedure prescribed by the C of M, diagnosis of alcohol, narcotic, psychotropic and toxic substance addiction can only be carried out by a narcologist. Unless one of the aforementioned diagnoses has been ascribed to a prisoner prior to his or her conviction, then such a diagnosis can only be carried out at an incarceration centre by a narcologist employed at the relevant incarceration centre, however to date no narcologist has been or is employed at an incarceration centre. The justification and necessity of this restriction must be evaluated in order to resolve this situation. There is an opportunity to amend the existing regulation and to determine that addiction diagnoses may also be carried out by other specialised doctors, such as psychiatrists. Taking the procedure for methadone and buprenorphine therapy prescribed by the C of M previously described into consideration, one can conclude that this treatment is not available for prisoners. The C of M has prescribed that only the Narcology Centre and the council of doctors established by it is entitled to make a decision regarding the commencement of methadone and buprenorphine therapy. Furthermore, methadone therapy is only being continued at the Narcology Centre, but buprenorphine therapy is ongoing at another four treatment institutions outside Riga. None of the narcological treatment institutions is specified in C of M regulations that are entitled to make a decision regarding the commencement of treatment and to provide substitution therapy are located at places of imprisonment. Theoretically it is possible that a prisoner could receive methadone or buprenorphine therapy at the Narcology Centre at his or her own personal expense. Section 15 of C of M regulations „Regulations regarding healthcare for prisoners and convicted persons at investigation prisons and liberty removal institutions‖ prescribes that: „If a submission has been received from a prisoner that has been 126
harmonised in writing with the prison doctor, the prison administration may reach an agreement with the management of a treatment institution that is located outside the incarceration centre regarding the consultation and treatment of the prisoner. Expenses related to the provision of healthcare services, as well as transport and security expenses shall be covered from the funds of the prisoner‖. Accordingly, the prisoner, by fully paying for the healthcare service, as well as the transport and security expenses, could be escorted to the Narcology Centre and to receive treatment. However, this possibility is only theoretical and cannot be practically utilised for the solution of the problem of drug addiction in prisons. In analysing the question of the legal aspects of methadone and buprenorphine therapy, the procedure for the organisation and financing of these healthcare services must also be analysed. In Section 17 of the MTL, it is stated that the volume of medical assistance guaranteed by the State is issued to prisoners and persons sentenced to the forfeiture of their liberty in accordance with the procedure prescribed by CoM. The law not prescribe the entitlement of the C of M to restrict the rights prisoners to receive healthcare services. However, the C of M has prescribed the restriction of such rights. In accordance with Section 33.2. of C of M regulations No. 104653 „Procedures for the Organisation and Financing of Health Care‖, the agency shall block the registration of persons who are in places of imprisonment54. Section 17.2. of the C of M regulations No. 1046 prescribes that the Ministry of Justice shall cover the cost for healthcare services received by prisoners, with the exception of medicinal products for the treatment of tuberculosis and HIV/AIDS which shall be paid for out State budget funds provided for healthcare. Accordingly, as soon as a person arrives at a place of imprisonment, he or she is denied access to the State health care system. Moreover, C of M regulations No. 199 „Regulations regarding healthcare for prisoners and convicted persons at investigation prisons and liberty removal institutions‖ go even further in restricting the rights of prisoners to receive the degree of medical assistance guaranteed by the State as prescribed by the MTL. Therefore, one is forced to conclude that the procedure for the organisation and financing of healthcare as prescribed by the C of M is unjustifiably discriminatory in regard to the rights of prisoners to utilise their rights to receive healthcare services as prescribed within regulatory enactments. The C of M has breached the principle of legality, precedence among laws and equality of persons. From the perspective of guaranteeing the rights of private persons it would not important how the C of M provides for the payment of healthcare services for prisoners from the budgets of the Justice or Health ministries. However, the volume of such funds must be such that it ensures the fulfilment of the rights guaranteed in the law. If the Ministry of Justice has not been allocated the budget required for the healthcare of prisoners, then is a basis for considering that the fulfilment of the rights of prisoners is being unjustly restricted and that prisoners are being discriminated against. From the perspective of State administrative legal theory, there is no clear justification for Section 17.2. of C of M regulations No. 1046 that provides for the payment of healthcare services for prisoners from 53
Cabinet of Ministers Regulations No. 1046, „Procedures for the Organisation and Financing of Healthcare‖, dated 19.12. 2006. 54 State Agency for Compulsory Health Insurance 127
the budget of the Ministry of Justice. Neither the Saeima nor the C of M has delegated the duty of the organisation and provision of healthcare services to the Ministry of Justice; these are the direct duties of the Ministry of Justice. In accordance with its very nature, the Ministry of Justice does not possess competence in the field of healthcare. Accordingly, the competence of the Ministries of Health and Justice in this area must be reviewed, because the legal procedure for the healthcare of prisoners is discriminatory and prisoners are being denied the right to receive healthcare services in the amount prescribed by the MTL. There are grounds for believing that the Ministry of Health would be more competent in its ability to resolve healthcare matters involving prisoners. One is forced to conclude that access to methadone or buprenorphine therapy in places of imprisonment is vitally restricted by both the regulatory enactments governing the procedure for the treatment of persons addicted to narcotic substances and the limited rights of prisoners to receive the healthcare services provided by the State, as well as the regulations governing the financing of healthcare services. Respect for human rights and international law The international community has generally accepted that prisoners retain all rights that are not taken away as a fact of incarceration.i
Loss of liberty alone is the punishment, not the deprivation of
fundamental human rights. Like all persons, therefore, prisoners are have a right to enjoy the highest attainable standard of health. This right is guaranteed under international law in Article 12 of the International Covenant on Economic, Social, and Cultural Rights, in Article 25 of the United Nations Universal Declaration of Human Rightsii and in various other international covenants, declarations, or chartersiii, in particular General Comment No.14 (May 2000) on the Right to the Highest Attainable Standard of Health adopted by the U.N. Committee on Economic Social and Cultural Rights. International law also prohibits states from inflicting inhuman or degrading treatment on people in detention.iv This prohibition specifically ―compels the authorities not only to refrain from provoking such treatment, but also to take the practical preventive measures necessary to protect the physical integrity and the health of persons who have been deprived of their liberty.‖v It has been recognised that, ―An inadequate level of health care can lead rapidly to situations falling within the scope of the term ‗inhuman and degrading treatment‘.‖vi Therefore, international law mandates that states have an obligation to develop and implement legislation, policies, and programmes consistent with international human rights that promote health in prisons, and reduce the spread HIV infection as well as other infectious diseases. Adherence to international standards and health guidelines Numerous international instrumentsvii and health declarationsviii detail the generally accepted rules, guidelines, principles, and standards related to prison conditions, prison medical care, and/or HIV/AIDS 128
prevention and treatment in prison settings. The standards and norms outlined in these documents reflect established international human rights instruments and good public health practice, and should guide the development of appropriate, ethical, and effective responses to HIV/AIDS in prisons. Equivalence in prison heath care Prisoners are entitled, without discrimination, to a standard of health care equivalent to that available in the outside community, including preventive measures. This principle of equivalence is fundamental to the promotion of human rights and best health practice within prisons, and is supported by international guidelines on prison health and prisoners‘ rightsix, as well as national prison policy and legislation in many countries.
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Annex 7: Anonymous Survey on knowledge, attitudes and behaviour of Latvian prison staff towards infectious diseases and drugs55
Table of Contents
121
1.
Objective
123
2.
Methods
123
3.
Results
123
3.1
Sample, demography and professional situation
123
3.2
Perceived problems in the prison
125
3.3
Knowledge on infectious diseases
125
3.4
Difficulties caused by specific behaviour and situations
126
3.5
Perception of infectious diseases
127
3.6
Violence in prison
128
3.7
Sexual contacts in prison
128
3.8
Estimated drug use in prison
129
3.9
Perception of drug users
130
3.10
Infectious diseases in personal relationships
130
3.11
Knowledge and beliefs on HIV and Hepatitis transmission and prevention
130
3.12
Attitudes towards HIV and Hepatitis positive persons
133
3.13
Knowledge on vaccination
134
3.14
Strategies to prevent the spread of infectious diseases in prison
135
3.15
Information offered on infectious diseases and medical examination
136
4.
Summary and conclusions
137
5.
Recommendations
140
55 Written by Caren Weilandt, Acknowledgements: Regina Fedosejeva, Latvian Prison Administration supported the distribution of the questionnaires, Anda Karnite, Latvian Public Health Agency, did the data entry and supported data analysis, Iveta Skripste, Latvian Public Health Agency, translated the questionnaire into Latvian and Russian language 130
1.
Objectives
The objectives of the survey was to examine prison staff's knowledge about HIV and hepatitis, in particular about transmission and prevention, to determine their subjective view concerning the prevalence of infectious diseases in their prison, their own risk of getting infected at work and their work conditions in general. Furthermore, detailed information on attitudes of prison staff towards drug use, drug users, and people living with HIV and/or hepatitis and the implementation of possible prevention measures should be gathered as well as information on health behaviour in terms of utilisation of vaccination and screening.
2.
Methods
The questionnaires for prison staff was sent by the Latvian Prison Administration to all 15 prisons in Latvia in the first week of April 2007. The Ministry asked each prison to send at least 6 filled questionnaires back until mid May, 2 should be answered by staff from the medical department, 2 by the prison administration and 2 by guards. Participation was anonymous and voluntary. The questionnaire was bilingual in Latvian and Russian language. The staff members were asked to complete a short questionnaire (see Annex 16 for the English and Annex 17 for the Latvian/Russian version). This questionnaire consisted of closed questions related to demography, professional rank, personal view of problematic topics in the prison, evaluation of individual risk to contract infectious diseases at the workplace, estimates of the prevalence of infectious diseases among prisoners, violence in prison, prevalence of drug use, attitudes towards drug user and people living with HIV and/or hepatitis in general, knowledge about transmission of HIV and hepatitis B and C, prevention of these infections and vaccination, attitudes towards the (possible) implementation of prevention strategies in prison, reception of information on infectious diseases and individual participation in testing/screening for infectious diseases. Data were entered, checked, cleaned and analysed using SPSS. Frequencies and cross tabulations were used to describe and analyse the data.
3.
Results
3.1
Sample, demography and professional situation
In total 78 filled questionnaires from 12 (out of 15 prisons) were sent back to the Prison Administration. In total, around 3.000 people are working in all 15 prisons of Latvia. 131
Table 1: Staff participating in the different Criminal Executive Institutions Prison
participants
Central prison
6
Cesis
6
Daugavpils
6
Giva
6
Ilguciems
6
Jekabpils
6
Matisa
6
Olaine
6
Parlielupe
6
Skirotava
6
Valmiera
6
no information on prison site
12
Total
78
No questionnaires respectively no questionnaires with indications about the prison site were sent back from the following prisons: Brasa, Vecumniecki, Jelgava and Liepaja. 60.3 % of the participants are male and 39.7% female. They are between 22 and 58 years old with a mean of 40.15 (SD 9,1) and a median of 42 years (17.6% of the staff are up to 30 years old, 28.4% between 31 an 40 years, 43.2% between 41 and 50 years and 10.8% older). Their educational level was as follows: Semi-skilled 11.5%, trained/skilled 28.2 %, college/university 56.4 % and 3.8% did not answer this question. This means that the sample is biased by a higher educational level. The persons interviewed have been working in the penitentiary system between one year and 32 years with a mean of 11.9 and a median of 9 years (28.9% have been working up to 5 years, 28.9% between 6 and 10 years, 11.8% between 11 and 15 years and 30.2% even longer). Regarding their actual professional rank, 12.8 % are guards, 43.6 % administrative workers, 17.9 % are physicians and 6.4% nursing staff and 6.4 social workers (others 10.3% and n.a. 2.6%) 56.4% spent most of their working time in the normal detention sector of the prison and additionally 5.1% in isolated quarters. 25.6% are first of all working in the administration sector and 21.8% in the medical service.
132
3.2
Perceived problems in the prison
In the questionnaire, a list of possible problems in the prison was presented and the participants were asked which of these problems exist in their prison. The most common problems in the staff‘s view mentioned by the majority of respondents are lack of staff (79.5%), followed by lack of staff‘s safety (78.2%), overcrowding (56.4%) and lack of hygiene of the premises (53.8%). A lack of information on infectious diseases was also stated by more than a quarter of respondents (27.3%) and lack of sanitary equipment by 17.9%. Table 2: Perceived problems in the prison Problem
Yes %
Don’t know %
lack of staff
79.5
2.6
lack of staffs safety
78.2
2.6
Overcrowding
56.4
3.8
lack of hygiene of the premises
53.8
0.0
lack of information on infectious diseases
26.9
5.1
Lack of sanitary equipment
17.9
6.4
This data indicates quite worrying subjective working conditions for the staff inside Latvian prisons. In particular, the fact that nearly 80% feel a lack of their own safety at work is very alarming.
3.3
Knowledge on infectious diseases
The respondents were asked how they would assess their knowledge on infectious diseases. The answers are listed in table 3. Table 3: Subjective ratings of knowledge on infectious diseases Very good
Rather good
Rather bad
Very bad
HIV/AIDS
21.8
65.4
11.5
1.3
TB
23.1
59.0
16.7
1.3
Hep B
16.7
52.6
23.1
7.7
Hep C
15.7
56.4
16.7
10.3
Comparing the four infectious diseases, the subjective knowledge on Tuberculosis and HIV/ADS (87% respectively 82% state very good or rather good knowledge) are better compared to Hepatitis (around 70% very good or rather good). However, there are quite high rates of those who stated that they feel rather bad or even very bad informed about HIV/AIDS (12,8%), TB (18,0%), Hepatitis B (30,8%) and Hepatitis C (27,0%). These results are striking if keeping in mind that our sample is biased by a high educational level with over 50% of respondents with a college or university degree. One can assume that the percentage of those prison staff members who feel not sufficiently informed about infectious diseases might be much higher if we had a representative sample of the prison staff. Of those 133
respondents without a college/university degree, state that they feel rather bad or very bad informed about HIV/AIDS (23.5%), TB (20.5%), Hepatitis B (32.4%), and Hepatitis C (26.5%).
3.4
Difficulties caused by specific behaviour and situations
The prison staff was asked to state if some specific situations/problems or behaviours influence their work. The answer categories were as follows: Situation/problem does not exist (in this prison), exists and disturbs the work, exists, but does not disturb the work and don‘t know. The problems in table 4 are sorted by decreasing percentage of statements for the item ―exists and disturbs my work‖. Table 4: Perception of problems inside prison Does not exist
Exists and disturbs your work
Exists but does not disturb your work
Don’t know
Drug use of prisoners
16.7
50.0
28.2
5.1
Tuberculosis infections among prisoners
17.9
47.4
26.9
7.7
Drug trafficking in the prison
14.1
43.6
15.4
26.9
6.4
43.6
21.8
26.9
Inmates hiding syringes in the cell
17.9
39.7
17.9
24.4
Alcohol use of prisoners
19.2
38.5
20.5
21.8
9.0
35.9
41.0
14.1
Hepatitis (viral infections of the liver) among prisoners
10.3
33.3
39.7
16.7
Sexual contacts between prisoners
14.1
29.5
28.2
28.2
violence
HIV infection among prisoners
Just a minority of respondents (between 9 and 19%) state that the listed problems or problematic behaviours do not exist in their prison. It is obvious that drug related problems are on top of the list (drug use, drug trafficking, violence and inmates hiding syringes in the cell). Almost half of the respondents stated that Tuberculosis infections do exist and affects their work negatively. For HIV (35.9) and Hepatitis (33.3) a lower percentage of prison staff mentioned that they exist in their prison and disturb their work. It is also quite striking that a relatively high (29.9) percentage of prison staff state that sexual contacts between prisoner are of concern in their prison. Sexual contacts are partly tabooed and therefore it is surprising that nearly 60% of the respondents say that sexual contacts between prisoners in their prison do exist. This has strong implications for (free and anonymous) condom distribution inside Latvian prisons. 134
3.5
Perception of infectious diseases
Table 5 shows the distribution of the individual risks prison staff members feel related to infectious diseases. The related question was ―Do you think because of your work you have a risk to contract…‖ Just a small minority of respondents feel being at no risk of contracting infectious diseases due to their work conditions. Up to half of the prison staff feels at high risk related to HIV (43.6), Hepatitis (50.0) and TB (48.7). Also alarmingly high is the percentage of prison staff members who state that during their work as a prison officer they have ever bee confronted with an event that made them fear to become infected by TB, Hepatitis or HIV. This together with the fact that nearly 80% of the respondents stated that they feel a lack of staff‘s safety means that the daily working conditions of prison staff are frightening and associated with fear of becoming infected by prisoners. There is a danger that this might have implications for instance for prison staff‘s willingness to intervene in cases of emergency.
Table 5: Subjective risk related to infectious diseases in the prison
Disease
No risk
Low risk
High risk
Don’t know
have experienced event which made fear to become infected %
Tuberculosis
3.8
46.2
48.7
1.3
59.0
Hepatitis B/C
1.3
41.0
50.0
7.7
48.7
HIV/AIDS
1.3
53.8
43.6
1.3
48.7
Asked for their estimations about the prevalence of infectious diseases in their prison, between one fourth and one third of respondents had not idea about the infection rates among prisoners, which indicates a high degree of uncertainty or at least a lack of available information and knowledge. For those who gave an estimation about prevalence rates, Hepatitis C is the one with the highest estimated rate (29.5% guess a prevalence rate of over 10%), followed by HIV (12.8% estimated prevalence rate), Hepatitis B (13.1% estimated prevalence rate) and Tuberculosis (8.9% estimated prevalence rate). Table 6: Perceived rates of infections among prisoners Rate
Tuberculosis %
Hepatitis B%
Hepatitis C%
HIV %
none
5.1
1.3
0.0
0.0
< 1%
26.9
16.7
7.7
12.8
1–5%
26.9
16.7
19.2
14.1
6-10%
10.3
16.7
14.1
33.3
11-20%
3.8
6.4
14.1
11.5
> 20%
5.1
6.4
15.4
2.6
don't know
21.8
35.9
29.5
25.6
135
In the group of respondents without a university/college degree (n=32 vs. n=44 with university/college degree), the percentage of those who do not know anything about the spread of infectious diseases is much higher, i.e. around 40% for HIV, Hepatitis B and C and for TB around 30%.
3.6
Violence in prison
The distribution of the answers to the questions on violence between inmates and also between inmates and prison staff are listed in Table 7. This reveals alarming high rates of violence between inmates. Only between 10 and 25% of respondents denied that there is violence between inmates. Psychological violence is predominant: Nearly 80% of the interviewed staff believes that there is psychological violence (threats, bullying, and intimidation) in their prison and also more that half of them thinks that there is sexual violence and other physical violence like fist fights or attacks with weapons. Violence between inmates and guards was denied by between 50% as regards psychological and over 80% for other forms of violence. But the answers also revealed that over one fourth of the prison staff stated that there is psychological violence like threats, bullying, intimidation between inmates and prison staff in their prison. There is a clear tendency that the perceived violence between inmates and also between prisoners and guards is overwhelmingly of psychological nature. Although these results have to be interpreted carefully on the one hand because of the small sample size and on the other hand because we have a kind of convenience sample which is not representative, the answers to the violence questions are quite worrying, because it might be that prison staff is at risk to be forced or threatened to be involved into drug smuggling. In general, this danger becomes higher the lower the payment of the prison staff is. Table 7: Violence in prison Yes
Don’t know
Sexual violence among prisoners
51.3
25.6
Other physical violence among prisoners
62.8
12.8
Psychological violence among prisoners
79.5
10.3
Sexual violence among between prisoners and staff
3.8
10.3
Other physical violence between prisoners and staff
5.1
10.3
Psychological violence between prisoners and staff
26.9
23.1
3.7
Sexual contacts in prison
According to the Latvian Prison Administration, long term visiting rooms are available in all prisons of the country. The number of rooms depends on the size of the prison and varies between 3 and 10 rooms. This means that in general that least some prisoners have the chance to stay with their partners in these rooms and could have consensual sex. 136
But the answers to the questions on the occurrence of consensual and non-consensual sexual activities of prisoners (see table 8) revealed alarmingly high rates of in particular non-consensual sex and sexual violence. These results support the urgent necessity of making condoms easily available and easily accessible for all prisoners anonymously and free of charge. Currently prisoners do not have the possibility to get condoms for free in the medical department or elsewhere. Inmates in closed or semi-closed prisons can order condoms from the prison shop only by writing an order form and submitting this to the prison staff (MC regulations Nr.423, 30.05.2006) which is of course a high threshold. Table 8: Sexual contacts in prison Yes
Don’t know
Consensual sex between prisoners
64.1
25.6
Rape between prisoners
28.2
32.1
Sexual intercourse between prisoners as a
38.5
46.2
form of currency
3.8
Estimated drug use in prison
Asked about their knowledge, what types of drugs inmates use in their prison, and requested for an estimation of quantities (Table 9), the prison staff report alcohol and tablets as the most common drugs followed by cannabis/hashish and heroin/opiates. Between one third and half of the sample did not provide any estimation on drug consumption of prisoners. But among those who estimated consumption rates, it became obvious that there is a substantial drug related problem within Latvians prisons, which is also supported by the data on injection behaviour among prisoners (see Table 10). Table 9: Perceived drug use in prison Drug
0-1%
1-4%
5-10%
11-20%
> 21%
don’t know
Alcohol
16.7
5.1
19.2
2.6
20.6
32.1
Cannabis/hashish
9.0
3.9
6.4
12.8
12.8
51.3
Heroin/opiates
14.1
2.6
21.8
7.7
0.0
46.2
Tablets
3.9
6.5
15.4
7.7
19.2
39.7
Asked for an estimation of the rate of injecting drug users in their prison, about 60% did not know an answer or did not answer the question. But more than one quarter of the interviewed staff members confirmed intravenous drug use in their prison on different levels. The largest group perceive between 5-20% IDU´s among the inmates of their prison. Again, because of the small sample size, these findings have to be regarded as a tendency and have to be interpreted carefully. 137
Table 10: Perceived rate of injecting drug users among prisoners Rate of IDU among prisoners
3.9
%
0%
12.8
1–4%
2.6
5-10%
11.6
10-20%
10.3
> 21%
3.9
don't know
48.7
n.a.
9.0
Perception of drug users
83.3% of the staff thinks that drug users in general have to be considered as sick and need medical support. Correspondingly, 62.8% deny that drug user do not deserve support. On the other hand, they are perceived as a danger: 98.7% of the staff states that the drug user in general may infect others with HIV or hepatitis.
3.10
Infectious diseases in personal relationships
Asked, if “someone that you know well (friend(s), relative(s), family)” is infected, 24.4% of the interviewed prison staff gave an affirmative answer on this for Hepatitis B/C, 14.1% for Tuberculosis and 3.8.% for HIV/AIDS. This means that the vast majority of staff working in prison has no personal experience with HIV and tuberculosis and three third with hepatitis B/C.
3.11
Knowledge and beliefs on HIV and Hepatitis transmission and prevention
The following table lists the percentage of wrong answers to the question ―Do you think the AIDS virus (HIV) can be transmitted the following way? in decreasing order. It becomes obvious that there is still a relatively high percentage of prison staff with either uncertainties related to the main transmission routes of HIV or wrong perceptions. In particular, over on third of respondents believe that HIV can be transmitted via saliva and still nearly 30% do not know that HIV can not be transmitted by mosquito bites and 15% do not know about possible transmissions by sharing razor blades.
138
Table 11: Knowledge of prison staff on HIV transmission
HIV can be transmitted ...
wrong answer %
Don’t know
by the saliva of an HIV infected person (e.g. spitting, kissing)
34.6 (yes)
11.5
by a mosquito bite
14.1 (yes)
16.7
by shaving with the razor blade of an HIV infected person
11.5 (no)
3.8
by drinking from the same glass of an HIV infected person
6.4 (yes)
9.0
2.6 (no)
0.0
2.6 (yes)
6.4
1.3 (no)
2.6
0.0 (yes)
6.4
by blood sharing/brotherhood rituals
0.0 (no)
1.3
during sexual intercourse without condom
0.0 (no)
0.0
during an injection through contact with the toilet seat by tattooing by shaking the hand of an HIV infected person
Asked for effective and ineffective practices to protect oneself against HIV/AIDS, about 90% of the persons interviewed believe that having sex with only one partner is an effective prevention measure, 79.5% of choosing correctly sexual partners, 64.1% of having an HIV blood test regularly, 30.8% of asking each partner for the result of an HIV blood test, and still 17.9 % of washing oneself after having sex (16.7%). When analysing these answers according to educational level, there are no striking differences between the groups with or without University/college degree, which means that among prison staff there is in general still a need for information and education on transmission of HIV/AIDS and protection measures. Table 12: Practices to protect oneself against HIV/AIDS Practice
effective %
ineffective %
Don’t know
N.A.
using a condom
92.3
1.3
1.3
5.1
having one sex partner
89.7
9.0
1.3
0.0
correctly chosen sexual partners
79.5
17.9
2.6
0.0
regularly testing for HIV
64.1
32.1
3.8
0.0
asking partner for HIV status
30.8
61.5
2.6
5.1
washing after sex
17.9
80.8
1.3
0.0
using contraceptive pills
0.0
93.6
6.4
0.0
Compared to the prison staff‘s knowledge on the transmission of HIV, the respective knowledge regarding Hepatitis B is much poorer: around 10 to 25 % of the respondents did not know the answer to the transmission question and there were high proportions of wrong answers as regards the transmission by sharing glasses, saliva and sexual intercourse.
139
Table 13: Knowledge of prison staff on hepatitis B transmission Hepatitis B can be transmitted …
wrong answer %
by drinking from the same glass of an Hep B positive person
28.2 (yes)
24.4
by the saliva of an Hep B positive person (e.g. spitting, kissing)
21.8 (no)
19.2
during sexual intercourse without condom
19.2 (no)
26.9
through contact with the toilet seat
10.3 (yes)
25.6
by shaking the hand of an Hep B positive person
10.3 (yes)
16.7
6.4 (no)
14.1
3.8 (yes)
26.9
by tattooing
2.6 (no)
14.1
during an injection
0.0 (no)
10.3
by blood sharing/brotherhood rituals
0.0 (no)
9.0
by shaving with the razor blade of an Hep B positive person by a mosquito bite
Don’t know
Table 14: Knowledge of prison staff on hepatitis C transmission Hepatitis C can be transmitted …
wrong answer %
Don’t know
by the saliva of an Hep C positive person (e.g. spitting, kissing)
48.7 (yes)
24.4
by shaving with the razor blade of an Hep C positive person
14.1 (no)
12.8
by drinking from the same glass of an Hep C positive person
11.5 (yes)
25.6
during sexual intercourse without condom
11.5 (no)
15.4
by a mosquito bite
9.0 (yes)
29.5
by shaking the hand of an Hep C positive person
5.1 (yes)
12.8
through contact with the toilet seat
3.8 (yes)
15.4
by tattooing
2.6 (no)
12.8
during an injection
1.3 (no)
6.4
by blood sharing/brotherhood rituals
0.0 (no)
9.0
The same applies for the knowledge on the transmission of hepatitis C: up to 30 % did not know the answer to the transmission routes an around half of the interviewed prison staff members thought that Hepatitis C can be transmitted by saliva. This lack of knowledge might lead to unnecessary fears of prison staff regarding the possible transmission of infectious diseases.
140
3.12
Attitudes towards HIV and Hepatitis positive persons
The prison staff was asked about their acceptance of possible relationships with HIV positive persons. 47.4% would not share cutlery with an infected person and 41.0% do not accept to eat with an HIV infected person, 16.7% would not continue meeting or associating with him or her and 20.5% would refuse to work with an HIV positive person. Table 15: Attitudes towards HIV positive persons If you knew that someone is HIV infected, would you accept…
No %
to work with him/her
20.5
To eat with him/her
41.0
To continue meeting or associating with him/her
16.7
To share the cutlery with him/her
47.4
This means that in general for the majority of respondents the acceptance of HIV positive persons is quite good. Although the fact that close to half of the interviewed staff would refuse to eat with an HIV infected person or share the cutlery with him/her indicates irrational fears of transmission by saliva respectively wrong concepts of routs of transmission. The staff were also asked, if they agreed with some statements regarding HIV positive prisoners. 76.9% of the respondents think that the guards should be informed about inmates´ HIV status. In the view of 79.5% risks an HIV positive inmate to infect the inmates who share his cell and 82.1% share the opinion that positive prisoners risk to infect the prison staff. 44.9% of them think it is necessary to put HIV positive inmates in a separate building. 80.8% agree with the statement, that HIV positive inmates should be treated the same way as other prisoners, which is somehow contradictory to the fact that strong minorities think that it is necessary to put HIV positive inmates in a separate building. But asked for special prison activities, large groups of the staff think, that it is necessary to forbid them to participate: a majority in the case of cooking (71.8%) and strong minorities regarding sports (40.5%) and a few working (7.7%). Table 16: Attitudes towards HIV positive prisoners Agree with the following items
No %
It is necessary to put HIV infected prisoners in a separate building
44.9
HIV infected prisoners need help and sympathy
78.2
The guards should be informed about prisoners HIV status
76.9
An HIV infected prisoner risks to infect the prisoners who share his cell
79.5
An HIV infected prisoner risks to infect the prison staff
82.1
HIV positive inmates should be treated the same way as other prisoners
80.8
It is necessary to forbid HIV positive inmates to participate in the following prison activities ... cooking
71.8 141
... working
7.7
... sports
14.1
The general attitudes towards hepatitis positive persons differ significantly from those against HIV positive persons: the majority of the staff members would refuse to work, eat or associate with a hepatitis infected person, which implies that the fears of getting infected through social contacts are overestimated. Table 17: Attitudes towards Hepatitis positive persons If you knew that someone is Hepatitis B or C infected, would you accept…
No %
to work with him/her
74.4
To eat with him/her
56.4
To continue meeting or associating with him/her
76.9
To share the cutlery with him/her
39.7
3.13
Knowledge on vaccination
While 85.9% of the sample knows that there is no vaccination available against HIV, 37.2% believe that there is a vaccination available against Tuberculosis. Just 64% of the respondents are aware that a vaccination exists against Hepatitis B and 17.9% believe that there is also a vaccine available against Hepatitis C, which in fact is not the case. Table 18: Knowledge on vaccination Vaccination exists against …
yes %
no %
don't know %
n.a.
Tuberculosis
37.2
46.2
11.5
5.1
Hepatitis B
64.1
16.7
9.0
10.3
Hepatitis C
17.9
66.7
11.5
3.8
1.3
85.9
7.7
5.1
HIV
These results indicate that knowledge about vaccination, in particular on Hepatitis B vaccination should be improved in order to promote the uptake rate of Hepatitis B vaccination among prison staff. It was not asked if the prison staff received a vaccination against hepatitis B themselves, so we can not estimate the coverage rate.
142
3.14
Strategies to prevent the spread of infectious diseases in prison
The question ―What do you think about implementing the following strategies in your prison to prevent the spread of HIV and hepatitis?‖ offered to the prison staff a list of answers to agree or disagree with. The following order of affirmative answers shows the relevance of measures in the staff‘s perspective. More than 90% of the respondents agree to provide prison staff and prisoners with information on infectious diseases, to make condoms available in the long-term visiting rooms for conjugal visits and to organise workshops among prisoners held by trained health educators on infectious diseases. But also more than 90% agree on the implementation of systematically testing procedures of prisoners for HIV and Hepatitis in their prison in order to prevent the spread of HIV and Hepatitis. In fact, the systematically testing policy is implemented in all prisons in Latvia (according to information from the Ministry of Justice, over 90% of prisoners are tested for HIV on admission, but not e.g. after the window period or on release), and not for Hepatitis. However, this testing policy is in fact no effective measure to prevent infectious diseases, even the opposite might be the case, because testing on admission and making the test results available for prison staff (refer to table 12: 76.9 of the respondents think that the guards in prison should be informed about the prisoner‘s HIV status) might lead to a false feeling of security. In general, prison staff should be aware of routs of transmission, prevention measures and emergency measures like post exposure prophylaxis and then just simply treat every prisoner as if he/she was infected. Between 80 and 90% of the interviewed staff also support to provide long-term visiting rooms for conjugal visits, to make condoms available for prisoners anonymously and free of charge, to implement peer education programmes and to vaccinate staff as well as prisoners against Hepatitis B. There are two (in fact very effective and evidence based) harm reduction measures, which are generally not accepted by most of the respondents, which are making sterile syringes and needles available for the prisoners using injectable drugs and providing sterile needles for tattooing. This might be due to the fact that both, drug use and tattooing is prohibited inside prisons and staff could feels, that these measures might support illegal behaviours. Table 19: Acceptance of strategies to prevent the spread of infectious diseases in prison Strategy
agree %
disagree %
n.a.
provide prison staff with information on infectious diseases
94.9
0.0
5.1
provide prisoners with information on infectious diseases
94.9
3.8
1.3
make condoms available in the long-term visiting rooms for conjugal visits
93.6
6.4
0.0
organise workshops among prisoners held by trained health educators on infectious diseases
93.6
1.3
5.1
143
systematically test inmates for hepatitis B/C
91.0
3.8
5.1
systematically test inmates for HIV
91.0
3.8
5.1
provide long-term visiting rooms for conjugal visits
89.7
10.3
0.0
vaccinate prison staff against hepatitis B
84.6
9.0
6.4
make condoms available for prisoners anonymously and free of charge
82.1
17.9
0.0
train educators among the prisoners on infectious diseases
78.2
21.8
0.0
vaccinate prisoners against hepatitis B
79.5
12.8
7.7
make sterile syringes and needles available for the prisoners using injectable drugs
28.2
71.1
0.0
provide sterile needles for tattooing
17.9
82,1
0.0
3.15
Information offered on infectious diseases and medical examination
Asked if they have been offered information concerning the ways of transmission and prevention of infectious diseases, 76.9% of the prison staff answer with ―yes‖ for tuberculosis, 82.1% for HIV/AIDS, 66.7% for hepatitis B and 70.5 for Hepatitis C. 75.6% state, that due to their work in prison, they have ever been tested for tuberculosis, 60.3% for HIV/AIDS, 48.7% for hepatitis B and 42.3 for hepatitis C. However, there was no information in the questionnaire about the time of the last testing. 90% of the persons interviewed stated that they have had radiography of the thorax for professional reasons. Most of them (74.4%) recently, i.e. less than a year ago.
144
Summary and conclusions
The objectives of this survey was to examine prison staff's knowledge about HIV and hepatitis, in particular about transmission and prevention, to determine their subjective view concerning the prevalence of infectious diseases in their prison, their own risk of getting infected at work and their work conditions in general. Furthermore, detailed information on attitudes of prison staff towards drug use, drug user, people living with HIV and/or hepatitis and the implementation of possible prevention measures should be gathered as well as information on health behaviour in terms of utilisation of vaccination and screening. The staff members were asked to complete a short questionnaire (in Russian and Latvian language versions were available), participation was anonymous and voluntary, each Latvian prison was asked to send 6 filled questionnaires back to the Ministry of Justice (2 answered by staff from the medical department, 2 by the prison administration and 2 by guards). 78 filled questionnaires from 12 (out of 15 prisons) were sent back to the MOJ. Although the sample size is quite small, not representative in any terms and biased by a higher educational level, the results give us an impression on knowledge, attitudes, behaviour and practice of the persons working in Latvians prisons and proposes questions, which should be investigated further on with a larger and more representative sample. All results have to be interpreted carefully taking these limitations in account. The most common problems in the staff‘s view mentioned by the majority of respondents are lack of staff (79%), followed by lack of staff‘s safety (78%), overcrowding (56%) and lack of hygiene of the premises (53%). A lack of information on infectious diseases was also stated by more than a quarter of respondents and lack of sanitary equipment by 18%. This indicates quite worrying subjective working conditions; in particular, the fact that nearly 80% feel a lack of their own safety at work is alarming. The subjective knowledge (―how would you assess your knowledge‖) on Tuberculosis and HIV/ADS (87% respectively 82% state very good or rather good knowledge) are better compared to Hepatitis (around 70% very good or rather good). However, there are quite high rates of those who stated that they feel rather bad or even very bad informed about HIV/AIDS (13%), TB (18%), Hepatitis B (30%) and Hepatitis C (27%). These results are striking if keeping in mind that our sample is biased by a high educational level with over 50% of respondents with a college or university degree. One can assume that the percentage of those prison staff members who feel not sufficiently informed about infectious diseases might be much higher if we have had a representative sample of the prison staff. Asked about problems related to their work, it became obvious that drug related problems were on top of the list with around 50% of respondents stating that these problems disturb their work (drug use, drug 145
trafficking, violence and inmates hiding syringes in the cell). For HIV and Hepatitis around on third of prison staff mentioned that these infections exist in their prison and disturb their work. It was also quite striking that a relatively high (30%) proportion of prison staff state that sexual contacts between prisoners are of concern in their prison. Sexual contacts are partly tabooed and therefore it is surprising that nearly 60% of the respondents say that sexual contacts between prisoners in their prison do exist. This has strong implications for (free and anonymous) condom distribution inside Latvian prisons. Just a small minority of respondents felt being at no risk of contracting infectious diseases due to their work conditions. Up to half of the prison staff presumed themselves at high risk related to HIV Hepatitis and TB. Also alarmingly high is the percentage of prison staff members (around rep. above 50%) who state that during their work as a prison officer they have ever bee confronted with an event that made them fear to become infected by TB, Hepatitis or HIV. This together with the fact that nearly 80% of the respondents stated that they feel a lack of staff‘s safety means that the daily working conditions of prison staff are frightening and associated with fear of becoming infected by prisoners. There is a danger that this might have implications for instance for prison staff‘s willingness to intervene in cases of emergency. Asked for their estimations about the prevalence of infectious diseases in their prison, between one fourth and one third of respondents had not idea about the infection rates among prisoners, which indicates a high degree of uncertainty or at least a lack of available information and knowledge. The questions on violence revealed alarming high rates of violence between inmates and also between inmates and staff. Psychological violence seems predominant: Nearly 80% of the interviewed staff believes that there is psychological violence (threats, bullying, and intimidation) in their prison and also more that half of them thinks that there is sexual violence and other physical violence like fist fights or attacks with weapons. Over one fourth of the prison staff stated that there is psychological violence like threats, bullying, intimidation between inmates and prison staff in their prison. Although these results have to be interpreted carefully on the one hand because of the small sample size and on the other hand because we have a kind of convenience sample which is not representative, the answers to the violence questions are quite worrying, because it might be that prison staff is at risk to be forced or threatened to be involved into drug smuggling. In general, this danger becomes higher the lower the payment of the prison staff is. Also the answers to the questions on the occurrence of consensual and non-consensual sexual activities of prisoners revealed alarmingly high rates of non-consensual sex (28% rape between prisoners and 39% sexual intercourse as a form of currency). These results support the urgent necessity of making condoms easily available and easily accessible for all prisoners anonymously and free of charge.
146
Between one third and half of the sample did not provide any estimation on types and quantities of drug consumption of prisoners. But among those who estimated consumption rates, alcohol and tablets were reported as the most common drugs followed by cannabis/hashish and heroin/opiates. The assumption that related problem are prevalent within Latvians prisons, is also supported by the data on injection behaviour among prisoners. Asked for an estimation of the rate of injecting drug users in their prison, about 60% did not know an answer or did not answer the question. But more than one quarter of the interviewed staff members confirmed intravenous drug use in their prison on different levels. The largest group perceive between 5-20% IDU´s among the inmates of their prison. Prison staff‘s knowledge on HIV and Hepatitis transmission and prevention is lacking. It becomes obvious that there is still a relatively high percentage of prison staff with either uncertainties related to the main transmission routes of infectious diseases or wrong perceptions. In particular, over on third of respondents believe that HIV can be transmitted via saliva and still nearly 30% do not know that HIV can not be transmitted by mosquito bites and 15% do not know about possible transmissions by sharing razor blades. The knowledge on hepatitis is even worse. Asked about attitudes towards HIV or hepatitis infected prisoners, more than three quarters of the respondents think that the guards should be informed about inmates´ HIV status and over 80% share the opinion that positive prisoners risk to infect the prison staff. About half of them think it is necessary to put HIV positive inmates in a separate building. The majority of the staff members would refuse to work, eat or associate with a hepatitis infected person, which implies that the fears of getting infected through social contacts are overestimated. Just 64% of the respondents are aware that a vaccination exists against Hepatitis B and 17.9% believe that there is also a vaccine available against Hepatitis C, which in fact is not the case. This indicates that knowledge about vaccination, in particular on Hepatitis B vaccination should be improved in order to promote the uptake rate of Hepatitis B vaccination among prison staff. Asked about the acceptance of preventive measures in prison, more than 90% of the respondents agree to provide prison staff and prisoners with information on infectious diseases, to make condoms available in the long-term visiting rooms and to organise workshops among prisoners held by trained health educators on infectious diseases. But also more than 90% agree on the implementation of systematic testing procedures of prisoners for HIV and Hepatitis in order to prevent the spread of HIV and Hepatitis. However, this testing policy is in fact no effective measure to prevent infectious diseases, even the opposite might be the case, because testing on admission and making the test results available for prison staff (more than three quarters think that the guards in prison should be informed about the prisoner‘s HIV status) might lead to a false feeling of security. In general, prison staff should be aware of routs of transmission, prevention measures and emergency measures like post exposure prophylaxis and then just simply treat every prisoner as if he/she was infected.
147
The main results are: Lack of staff and drug related problems are on top of the work related problem list Lack of knowledge prevalence of infectious diseases and related risk behaviours High levels of uncertainty at work, lack of safety at work High levels of either psychological and physical violence between prisoners and as well between prisoners and staff More than one quarter of the interviewed staff members confirmed intravenous drug use in their prison on different levels High
percentage
of
prison
staff
with
either
uncertainties
related
to
the
main
transmission routes of infectious diseases or wrong perception Attitudes towards HIV positive inmates are driven by overestimated fear of infection Knowledge about Hepatitis B vaccination should be improved Systematic
testing
procedures
of
prisoners
for
HIV
and
Hepatitis
is
regarded
as effective prevention strategy Evidence based harm reduction measures are generally not accepted by most of the respondents
Recommendations
Provide education/training on HIV/AIDS and other communicable diseases, routes of transmission in the workplace, confidentiality, drug use, HIV and hepatitis prevention measures, HIV testing and treatment opportunities, drug dependence treatment, universal precautions and use of protective equipment, and the rationale and content of prison rules and policies related to HIV/AIDS to all prison staff as part of their initial training, and update this training on a regular basis during the course of employment. Ensure that all staff receives regular training. Consult with staff and NGOs on the development of education materials and programmes and the methods of delivering training programmes, and encourage and support the development of staff peer education initiatives and materials for prison staff. Ensure that the training of prison staff addresses HIV/hepatitis-related discrimination; homophobia; reduces staff opposition to the provision of HIV prevention measures to prisoners; emphasises the importance of confidentiality and non-disclosure of HIV status and other medical information; and promote the compassionate treatment of prisoners living with HIV/AIDS and/or drug dependency. Ensure that the content of all training is specific to the duties and responsibilities of the various categories of prison staff (i.e. security staff, medical and nursing staff, etc.) and that it is relevant to the specific realities of the prison environment. 148
Provide regular training to prison health care workers to enable them to maintain and improve their skills and knowledge current with developments in all health areas, in particular drug dependence treatment and HIV/AIDS prevention, care, and treatment. Implement policies and training to minimize the risk of workplace exposure (i.e. needle-stick injuries). Provide mechanisms to ensure a safe physical environment such as hand washing stations, health waste management and disposal, appropriate ventilation systems (especially for the accommodation of patients with smear positive tuberculosis), and utilizing universal precautions. Ensure that all prison staff is provided hepatitis B vaccinations at no cost. Ensure that in the event of potential workplace exposure to HIV, prison staff has access to appropriate post-exposure prophylaxis and counselling. Ensure that health insurance plans for prison staff are inclusive for coverage of antiretroviral treatments.
149
Annex 8: Meeting of Project experts with representatives of Latvia’s NGOs June 6, 2007, Riga, Klijanu Str. 7, The Public Health Agency Name 1. 2. 3.
4.
5.
Eva IKAUNIECE
NGO Latvian Red Cross
Address Skolas Str.1, Riga, LV-1050
Zane PUPOLA
Youth Against AIDS
Blaumana Str. 5A23, Riga, LV-1011
Zane DZILUMA Baiba PURVLICE
Aleksandrs MOLOKOVSKIS
Latvia‘s Family Planning Association „Papardes zieds‖ - Association HIV.LV - Baltic Positive Network (Latvian focalpoint) - „DIA+LOGS‖ prison project consultant
Grecinieku Str. 34, Riga, LV-1050 1) Gaismas Str. 19. k.-8, Kekava, Riga, LV-2123 2) Mardi Str. 3, Tallinn, Estonia 3) Dzirnavu Str. 135, Riga, LV-1050
E-mail
[email protected] [email protected] [email protected]
[email protected]
[email protected]
AGIHAS 6.
Ivars
(Support Group for
Linezera Str. 3,
KOKARS
People Living with
Riga, LV-1006
[email protected]
HIV/AIDS) 7.
Sarma
- HIV. LV
BRAUNA
- ―Apzinas ekologija‖
[email protected]
150
Annex 9: Number of mental diagnoses accordingly to ICD-10 classification in Latvia’s prisons Number of mental diagnoses accordingly to ICD-10 classification in Latvia’s prisons (point prevalence on December 31, 2006) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
Brasa Central Cesis Daugavpils Griva Ilguciems Jekabpils Jelgava Liepaja Matisa Olaine Parlielupe Skirotava Valmiera Vecumnieki
TOTAL: Source: Prison Administration
F00 - F99 335 501 41 142 317 263 187 465 95 134 30 271 211 409 39 3582
F10 28 38 0 30 71 62 44 48 10 8 10 100 56 316 22 843
151
F11 - F14 115 110 6 35 52 117 52 180 11 72 9 111 95 122 4 1091
Annex 10: Seminar for prison doctors, nurses and responsible persons of the health administration June 7, 2007-09-02 Educational Centre of the Prison Administration in Jurmala. AGENDA
9:30
Introduction and Welcome
9:45
Overview Twinning project
10:00 10:20
Prison Health care – challenges and evidence-based responses re drug addiction, prevention of infectious diseases Overview: HIV/AIDS challenges and responses
10:40 11:00
Coffee break Reporting procedure (legislation) on infections in prisons
11:30
Selected issues of prison health care
12:00 13:00 13:30
Lunch Rapid Assessment and Response and the manual ―Risk Reduction for drug users in prisons‖ Two working groups: 1. ―How to improve HIV/AIDS and other infectious diseases) prevention?‖ 2. ―How to improve HIV/AIDS surveillance?‖
15:30 16:00
Plenary Session: Presentation of Working Group Results Discussion
152
Prof. Dr. Heino Stöver, Bremen University Dr. Inga Upmace, AIDS and STI Prevention Centre, the Public Health Agency of Latvia Prof. Dr. Heino Stöver, Bremen University Dr. Regina Fedosejeva, Prison Administration of Latvia Dr. Raina Nikiforova, Unit of Epidemiological Surveillance, the Public Health Agency of Latvia Dr. Marc Lehmann, prison of Hameln, Germany Franz Trautmann, Utrecht, Netherlands Dr. Inga Upmace, Iveta Skripste Franz Trautmann Dr. Marc Lehmann Prof. Dr. Heino Stöver
Annex 11: List of participants of the seminar in Jurmala, June 7, 2007. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.
Ms Regina Fedosejeva Mr Roberts Girgensons Ms Valentina Frolova Ms Natalija Kapina Ms Lidija Laganovska Mr Vadim Viktorov Mr Jevgenij Agafonov Ms Marija Dirmane Ms Olga Tālere Ms Leonora Bebere Ms Valentina Zeldajeva Ms Inta Karnata Mr Jurij Repnikov Ms Danuta Kandele Mr Igaunis Ms Vera Močalova Mr Nikolai Zinj Ms Dzintra Petersone Mr Maris Jirgens Mr Nikolai Lubin Ms Lidija Bubnenkova Mr Arvids Cereckis Ms Inga Nagele Aleksandra Ivanova
Prison Administrastion, Head of Medical Department Prison Administrastion, Deputy Head of Medical Department Prison Administrastion, chief specialist of Medical Department Parlielupe prison, Head of Medical Unit Matisa prison, Head of Medical Unit Jelgava prison, Head of Medical Unit Jekabpils prison, Head of Medical Unit Griva prison, Head of Medical Unit Cesis correctional institution for juveniles, Head of Medical Unit Ilguciems prison, Head of Medical Unit Skirotava prison, Head of Medical Unit Valmiera prison, Head of Medical Unit Central prison, Head of Medical Unit Brasa prison, Head of Medical Unit Vecumnieki prison, Head of Medical Unit Olaine prison, Head of Medical Unit Daugavpils prison, Head of Medical Unit Liepaja prison, Head of Medical Unit Prison Hospital, Chief Prison Hospital, Head of Psycho neurological ward Prison Hospital, Head of Medical ward Prison Hospital, Head of surgical ward Prison Hospital, Head of pthisiatrical ward Prison Hospital, Chief of laboratoryf
153
Annex 12: Number of communicable diagnoses in Latvia’s prisons TB
2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
Central Cesis Daugavpils Griva Ilguciems Jekabpils Jelgava Liepaja Matisa Olaine Parlielupe Skirotava Valmiera Vecumnieki Prison hospital TOTAL:
Point prevalen ce, Dec.31, 2006 3 2
Year prevalence
HIV Incidence
23 5 5
35 73
149
44
AIDS
HBV chron.
HCV chron.
Syphilis
Gonorrhoea
Diphtheria
Point prevalence, Dec.31, 2006
Patients on HAART
Point prevalence, Dec.31, 2006
Point prevalence, Dec.31, 2006
Year prevalence
Year prevalence
Year prevalence
81 2
8
5
9
16
1 43
1 7
1 2
70 9 16 12 60 25 62 2 18
13
5
1 4 5 5 6
4 2 3 5
131 2 10 21 39 9 82 15 39 9 65 29 91
9
5
1
13
18
59
32
32
584
18
0
0
Point prevalence, Dec.31, 2006
401
Year prevalence
613
Source: Prison Administration of Latvia
154
1 7 1 4 1 4 1 3
2
Annex 13: Photos of opening ceremony of Olaine prison hospital July 30, 2007
Operating room
Toilet in ward, surgery department
Ward, surgery department
Walking area for TB patients from outside (guard‘s view)
Toilet in ward for disabled patients
Walking area for TB patient
TB department
TB ward
155
TB ward
Hospital building
Waiting room before admission
First aid room
New prison hospital in Olaine is provided for 130 patients + 70 TB patients in separate building. Main hospital is 4 stories building. On the first floor – admission, specialists‘ rooms (X-ray, dentist, gynaecologist, ultra-sound, AIDS etc.), first aid, visiting rooms. On the second – therapeutics department (40 beds), on the third – psychiatry dep. (60 beds), on the forth – surgery (30 beds). Staff – about 60 persons. Chief of the hospital – the same person that of the old hospital Dr Maris Jirgens, his deputy – Dr Vadim Viktorov (previously was the chief of the Jelgava prison‘s medical department). Hospital is large and very nice. Wards for one to 4 persons, well ventilated, light, all surfaces easy cleanable, normal WCs in wards, also wards with special equipment for disabled inmates. TB department is located in separate building with quite normal working squares especially for TB patients. This building isn‘t totally renovated, just repaired. Looks very OK, also well cleanable and ventilated. Wards capacity up to 6 persons but they consider that 2 beds are in reserve.
156
Annex 14: List of key experts interviewed during the field visits in Latvia: Latvian Infectology Centre Tuberculosis and Lung Disease State Agency Riga Centre of Psychiatry and Addiction Disorders State Probation Service
Public Health Agency
Dr. Pauls ALDINS Dr. Andra CIRULE Dr. Vija RIEKSTINA Dr. Sarmite SKAIDA Dr. Inga LANDSMANE Irina PURITE Aleksandra KERNA Andris BARKANS Vija VANAGA Inga BULMISTRE Jurij PEREVOSCIKOV Irina LUCENKO Ieva TUCA Raina NIKIFOROVA
Ministry of Health
Inga SMATE Dace VILUMA Gunta GRISLE
Ministry of Justice
Kristine KIPENA
Prison Administration UNODC Project Office for the Baltic States
Regina FEDOSEJEVA Signe ROTBERGA
157
Head of HIV/AIDS unit Deputy director Head of the State TB register Head doctor of the Narcological service Head of Outpatient treatment unit Head Parole board specialist Chairmen of Riga City Department Post penitentiary help specialist Public health specialist, counselor of the HIV/AIDS Counseling Centre Head of Epidemiological surveillance unit Deputy head of Epidemiological surveillance unit Public health specialist of AIDS and STI prevention centre Epidemiologist of Epidemiological surveillance unit Deputy director of Department of Health Head of Division of Epidemiological safety, Department of Health Deputy head of Division of Epidemiological safety, Department of Health Head of the Unit of Punishment Execution Policy Head of the Medical Department Regional Project Coordinator
Annex 15: List of prisons visited date and persons interviewed 1.
Ilguciems prison
May 22, 2007
Nadezda TOROSJUKA Leonora BEBERE
2.
Brasa prison
May 23, 2007
Ainars LEITANS Danuta KANDELE
3.
Skirotava prison
May 23, 2007
Nikolaj PICOHA Valentine ZELDAJEVA
4.
Central prison and Prison hospital Matisa prison
May 24, 2007
Jurij REPNIKOV
Cesis correctional institution for juveniles
June 5, 2007
5. 6.
May 24, 2007
Maris JIRGES Viktor PNEVSKIJ Lidija LAGANOVSKA Roberts BALODIS Olga TALERE Zinta BERZINA
7.
Jelgava prison
June 6, 2007
Diana GULBE Oleg POLAKOV Vadim VIKTOROV
8.
Parlielupe prison
June 6, 2007
Rimuns KLENAUSKS Oleg SMISLAJEV Marite ROMANOVA
158
Chief Head of Medical Department Deputy chief Deputy head of Medical Department Deputy chief Head of Medical Department Head of Medical Department Chief of Prison hospital Chief Head of Medical Department Chief Head of Medical Department Deputy head of Medical Department Senior nurse Chief Head of Medical Department Deputy chief Deputy chief Senior nurse
Annex 16: Questionnaire for prison staff “Anonymous Study on Health in Prison” (English) The European Network on Drugs and Infections Prevention in Prison (ENDIPP) in collaboration with the Latvian Prison Administration implements a study about infectious diseases in prison in order to support preventive measures and services. Participation is voluntary and strictly anonymous. Your personal results will not be transmitted to anybody. At the same time, a corresponding study among prisoners is carried out. Thank you in advance for your collaboration and honesty. 1.
2.
Do the following problems exist in your prison? No
Don't know
01
lack of hygiene of the premises
1
2
3
02
lack of staff
1
2
3
03
lack of staff's safety
1
2
3
04
lack of sanitary equipment (gloves, etc.)
1
2
3
05
overcrowding
1
2
3
06
lack of information on infectious diseases
1
2
3
How do you assess your knowledge on ... very good
3.
Yes
rather good
rather bad
very bad
01
HIV/AIDS
1
2
3
4
02
Tuberculosis
1
2
3
4
03
Hepatitis B
1
2
3
4
04
Hepatitis C
1
2
3
4
Do the following behaviour and situations influence your work? Does not exist
Exists and disturbs your work
Exists but does not disturb your work
Don't know
05
drug use of prisoners
1
2
3
4
06
drug trafficking in the prison
1
2
3
4
07
inmates hiding syringes in the cells
1
2
3
4
08
alcohol use of prisoners
1
2
3
4
09
violence
1
2
3
4
10
sexual contacts between prisoners
1
2
3
4
11
HIV infection among prisoners
1
2
3
4
159
12
tuberculosis infection among prisoners
1
2
3
4
13
hepatitis (viral infection of the liver) among prisoners
1
2
3
4
160
4.
Do you think that because of your work you have a risk to contract: No risk
5.
6.
8.
9.
High risk
Don‘t know
01
HIV/AIDS
1
2
3
4
02
Tuberculosis
1
2
3
4
03
Hepatitis B/C
1
2
3
4
During your work as a prison officer, have you ever been confronted with an event which made you fear to become infected by: Yes
No
01
HIV/AIDS
1
2
02
Tuberculosis
1
2
03
Hepatitis B/C
1
2
For each following disease, according to you, how many prisoners in this prison are infected by: None
7.
Low risk
Less than 1%
1 - 5%
5 - 10%
10-20%
More than 20%
Don‘t know
01
HIV/AIDS
1
2
3
4
5
6
7
02
Tuberculosis
1
2
3
4
5
6
7
03
Hepatitis B
1
2
3
4
5
6
7
04
Hepatitis C
1
2
3
4
5
6
7
Do you think there is violence between prisoners in this prison? Yes
No
Don't know
01
sexual violence (sex against somebody's will )
1
2
3
02
other physical violence (fist fights, attacks with weapons)
1
2
3
03
psychological violence (threats, bullying, intimidation)
1
2
3
Do you think there is violence between prisoners and guards in this prison? Yes
No
Don't know
01
sexual violence (sex against somebody's will )
1
2
3
02
other physical violence (fist fights, attacks with weapons)
1
2
3
03
psychological violence (threats, bullying, intimidation)
1
2
3
Yes
No
1
2
What forms of sexual contacts occur within this prison?
01
conjugal visits with wife/partner/girlfriend 161
Don't know 3
02
consensual sex between prisoners
1
2
3
03
rape (non-consensual sex) between prisoners
1
2
3
04
sexual intercourse between prisoners as a form of currency (i.e. to pay for goods or services)
1
2
3
162
10.
According to you, how many prisoners are using one or more of the following drugs in this prison? Please state a percentage between 0 for nobody and 100 for everybody for each drug. If you don't know exactly, please give an estimate! percentage of prisoners using drugs (0 for nobody – 100 for all)
Drugs used (injection, smoking, inhaling)
11.
01
cannabis/hashish
02
alcohol
03
heroin/opiates
04
tablets
According to you, how many prisoners are INJECTING DRUGS in this prison? Please state a percentage between 0 for nobody and 100 for everybody. If you don't know exactly, please give an estimate! Percentage of prisoners injecting drugs (0 for nobody – 100 for all): ______________%
12.
Don't know
What do you think about injecting drug users in general? Agree
The injecting drug user in general:
13.
Don't know
Disagree
01
Has to be considered as sick and needs medical treatment
1
2
02
Doesn‘t deserve support
1
2
03
Risks to infect others with HIV or Hepatitis
1
2
Do you think the AIDS VIRUS (HIV) can be transmitted the following way? Yes
No
Don‘t know
01
during sexual intercourse without condom
1
2
3
02
through contact with the toilet seat
1
2
3
03
by drinking from the glass of an HIV infected person
1
2
3
04
by the saliva of an HIV infected person (e.g. spitting, kissing,)
1
2
3
05
by a mosquito bite
1
2
3
06
during an injection
1
2
3
07
by shaving with the razor blade of an HIV infected person
1
2
3
08
by tattooing
1
2
3
09
by blood sharing/brotherhood rituals
1
2
3
10
by shaking the hand of an HIV infected person
1
2
3
163
14.
What do you think about each of the following practices to protect yourself against HIV/AIDS? Effective
15.
16.
17.
Ineffective
Don‘t know
01
to wash yourself after having sex
1
2
3
02
to choose correctly your sexual partners
1
2
3
03
to have sex with only one partner
1
2
3
04
to use a condom
1
2
3
05
to use contraceptive pills
1
2
3
06
to ask each partner for the result of an HIV blood test
1
2
3
07
to have an HIV blood test regularly
1
2
3
For each following disease, is someone that you know well (friend s , relative s , family, colleague s , neighbour s ) infected by: Yes
No
Don't know
01
HIV/AIDS
1
2
3
02
Tuberculosis
1
2
3
03
Hepatitis B/C
1
2
3
If you knew that someone is HIV infected, would you accept: Yes
No
01
to work with him/her
1
2
02
to eat with him/her
1
2
03
to continue meeting or associating with him/her
1
2
04
to share the cutlery with him/her
1
2
Do you agree with the following: It is necessary to forbid HIV infected prisoners to participate in the following prison activities:
Agree
Disagree
01
- sports
1
2
02
- cooking
1
2
03
- working
1
2
04
It is necessary to put HIV infected prisoners in a separate building
1
2
05
HIV infected prisoners need help and sympathy
1
2
06
the guards should be informed about prisoners‘ HIV status
1
2
07
an HIV infected prisoner risks to infect the prisoners who share his cell
1
2
08
an HIV infected prisoner risks to infect the prison staff
1
2
09
HIV infected prisoners should be treated the same way as other
1
2
164
prisoners
18.
19.
20.
18. Do you think that the virus of HEPATITIS B can be transmitted: Yes
No
Don‘t know
01
during sexual intercourse without condom
1
2
3
02
through contact with the toilet seat
1
2
3
03
by drinking from the glass of an Hepatitis B infected person
1
2
3
04
by the saliva of an Hepatitis B infected person (e.g. spitting, kissing)
1
2
3
05
by a mosquito bite
1
2
3
06
during an injection
1
2
3
07
by shaving with the razor blade of an Hepatitis B infected person
1
2
3
08
by tattooing
1
2
3
09
by blood sharing/brotherhood rituals
1
2
3
10
by shaking the hand of an Hepatitis B infected person
1
2
3
Do you think that the virus of HEPATITIS C can be transmitted: Yes
No
Don‘t know
01
during sexual intercourse without condom
1
2
3
02
through contact with the toilet seat
1
2
3
03
by drinking from the glass of an Hepatitis C infected person
1
2
3
04
by the saliva of an Hepatitis C infected person (e.g. spitting, kissing)
1
2
3
05
by a mosquito bite
1
2
3
06
during an injection
1
2
3
07
by shaving with the razor blade of an Hepatitis C infected person
1
2
3
08
by tattooing
1
2
3
09
by blood sharing/brotherhood rituals
1
2
3
10
by shaking the hand of an Hepatitis C infected person
1
2
3
If you knew that someone is Hepatitis B or C - infected, would you accept: Yes
No
01
to work with him/her
1
2
02
to eat with him/her
1
2
03
to continue meeting or associating with him/her
1
2
04
to share the cutlery with him/her
1
2
165
166
21.
22.
According to your knowledge, does a vaccination exist against…? Yes
No
Don't know
01
HIV/AIDS
1
2
3
02
Tuberculosis
1
2
3
03
Hepatitis B
1
2
3
04
Hepatitis C
1
2
3
What do you think about implementing the following strategies in your prison to prevent the spread of HIV and Hepatitis? Agree
23.
Disagree
01
Provide long-term visiting rooms for conjugal visits.
1
2
02
Make condoms available in long-term visiting rooms for conjugal visits.
1
2
03
Make condoms available for prisoners anonymously and free of charge.
1
2
04
Provide sterile syringes and needles for prisoners using injectable drugs.
1
2
05
Provide sterile needles for tattooing.
1
2
06
Provide prisoners with information on infectious diseases.
1
2
07
Train educators among prisoners on infectious diseases.
1
2
08
Organize workshops among prisoners held by trained health educators on infectious diseases.
1
2
09
Systematically test prisoners for HIV
1
2
10
Systematically test prisoners for Hepatitis B/C
1
2
11
Provide prison staff with information on infectious diseases
1
2
12
Vaccinate prisoners against Hepatitis B
1
2
13
Vaccinate prison staff against Hepatitis B
1
2
In your prison, have you been offered information concerning the way of transmission and prevention of infectious diseases? Yes
No
Don't know
01
HIV/AIDS
1
2
3
02
Tuberculosis
1
2
3
03
Hepatitis B
1
2
3
04
Hepatitis C
1
2
3
167
24.
25.
Due to your work in prison have you ever been tested for following diseases? No
01
HIV/AIDS
1
2
02
Tuberculosis
1
2
03
Hepatitis B
1
2
04
Hepatitis C
1
2
Due to your work, when have you had the last radiography of the thorax? Less than a year
More than a year
1
26.
Yes
Never
2
Don‘t know
3
4
In which section of the prison do you spend MOST of your working time? 01
in administration
1
02
in normal detention
1
03
in isolated quarters
1
04
in medical service
1
years
27.
How old are you?
28.
Are you
29.
What is your highest educational level with regard to the task performed in prison?
1
male
2
female
unskilled
1
semi-skilled (small introduction)
2
trained/skilled (i.e. certificate as warden)
3
college/university degree (i.e. jurist, doctor)
4
30.
How long have you been working in the penitentiary service?
31.
What is your actual professional rank? administrative worker guard psychologist social worker nursing staff physician other
168
1 2 3 4 5 6 7
years
Thank you very much!
169
Annex 17: Questionnaire for prison staff “Anonymous Study on Health in Prison” (Latvian/Russian) Anonīms pētījums par veselību cietumos Eiropas Cietumu narkotiku un infekciju profilakses tīkls (The European Network on Drugs and Infections Prevention in Prison) sadarbībā ar Latvijas Tieslietu ministrijas Ieslodzījuma vietu pārvaldes Medicīnas daļu veic pētījumu par infekciju slimībām cietumos, lai veicinātu profilakses pasākumu attīstību. Dalība šajā pētījumā ir brīvprātīga un pilnīgi anonīma. Jūsu atbildes tiks izmantotas tikai apkopotā veidā. Tajā pašā laikā atbilstošs pētījums tiks veikts arī ieslodzīto vidū. Jau iepriekš pateicamies par Jūsu sadarbošanos un atklātību. Анонимное исследование о здоровье в тюрьмах Европейская сеть по противодействию наркотикам и инфекциям в тюрьмах (The European Network on Drugs and Infections Prevention in Prison) в содействии с Медицинским отделом Управления мест заключения Министерства юстиции Латвийской Республики для развития профилактических мероприятий проводит исследование об инфекционных заболеваниях в тюрьмах. Участие в этом исследовании добровольное и анонимное. Заранее благодарим за Ваше содействие и откровенность. Lūdzu, atbilstošo atbildi apvelciet ar aplīti! Пожалуйста обведите кольцом Ваш ответ! 1. Vai Jūsu cietumā ir šādas problēmas? Существуют ли в Вашей тюрьме следующие проблемы? Jā Да 01 02 03 04
05 06
Nepietiekoša telpu higiēna Недостаточная гигиена помещений Darbinieku trūkums Недостаток работников Nepietiekoša darbinieku drošība Недостаточная безопасность работников Sanitāro priekšmetu trūkums (piem., gumijas cimdi) Отсутствие предметов санитарии (например резиновых перчаток) Pārslodze Перегрузка Informācijas trūkums par infekciju slimībām Нехватка информации об инфекционных заболеваниях 2. Kā Jūs novērtējat savas zināšanas par: Как Вы оцениваете свои знания: 170
Nē
Nezinu
Нет
Не знаю
01
02
03
01
02
03
01
02
03
01
02
03
01
02
03
01
02
03
01 02 03 04
HIV/AIDS о ВИЧ/ СПИДе Tuberkulozi о туберкулезе B hepatītu о гепатите В C hepatītu о гепатите С
Ļoti labas
Diezgan labas
Ļoti sliktas
Сравнительно хорошие
Diezgan sliktas Сравнительно плохие
Очень хорошие 01
02
03
04
01
02
03
04
01
02
03
04
01
02
03
04
3. Vai sekojoša uzvedība un situācijas ietekmē Jūsu darbu? Влияют ли на вашу работу следующие ситуации и поведение? Tas Tas notiek un nenotiek traucē darbā Такое бывает 05 06 07 08 09 10 11 12 13
Ieslodzītie lieto narkotikas Заключенные применяют наркотики Nelegāla narkotiku aprite cietumā Нелегальный оборот наркотиков в тюрьме Ieslodzītie slēpj kamerās šļirces Заключенные прячут шприцы в камерах Ieslodzītie lieto alkoholu Заключенные применяют алкоголь Vardarbība Насилие Seksuāli kontakti ieslodzīto starpā Сексуальные контакты между заключенными HIV izplatība ieslodzīto vidū ВИЧ у заключенных Tuberkulozes izplatība ieslodzīto vidū Туберкулез у заключенных Hepatītu izplatība (vīrusu infekcijas aknās) ieslodzīto vidū Гепатиты (воспаление печени) у заключенных
Такое бывает и мешает работе
Очень плохие
Tas notiek, bet netraucē darbā Такое бывает, но не мешает работе
Nezinu Не знаю
01
02
03
04
01
02
03
04
01
02
03
04
01
02
03
04
01
02
03
04
01
02
03
04
01
02
03
04
01
02
03
04
01
02
03
04
4. Vai Jūs domājat, ka darbā esat pakļauts riskam inficēties ar: Считаете ли Вы, что на работе подвергаетесь риску инфвицироватся: Nav Zems Augsts riska risks risks Нет Низкий Высокий риска риск риск 01 HIV/AIDS 01 02 03 ВИЧ/ СПИДом 02 Tuberkulozi 01 02 03 Туберкулезом 03 B, C hepatītiem 01 02 03 Гепатитами В и С 171
Nezinu Не знаю 04 04 04
5. Vai laikā, kopš strādājat ieslodzījuma vietā, esat nonācis situācijā, kad varēja notikt inficēšanās ar: С тех пор как Вы работаете в тюрьме были ли ситуации, когда Вы подвергались риску инфицироваться: Jā Nē Да Нет 01 HIV/AIDS 01 02 ВИЧ/ СПИДом 02 Tuberkulozi 01 02 Туберкулезом 03 B, C hepatītiem 01 02 Гепатитами В и С
6. Cik daudz ieslodzīto šajā cietumā, pēc Jūsu domām, ir inficēti ar: По Вашему: какое количество заключенных заражены: Neviens Mazāk 1-5% 5-10% 10-20% par 1% Никто
01 02 03 04
HIV/AIDS ВИЧ/ СПИДом Tuberkulozi Туберкулезом Hepatītu B Гепатитом B Hepatītu C Гепатитом C
Меньше 1%
1-5%
5-10%
10-20%
Vairāk par 20% Больше чем 20%
Nezinu Не знаю
01
02
03
04
05
06
07
01
02
03
04
05
06
07
01
02
03
04
05
06
07
01
02
03
04
05
06
07
7. Vai domājat, ka starp ieslodzītajiem šajā cietumā ir vardarbība? По Вашему: существует ли насилие между заключенными в этой тюрьме? Jā Nē Nezinu Да 01
02
03
Seksuālā vardarbība (piespiedu seksuālās attiecības) Сексуальное насилие (принудительные сексуальные отношения) Cita vieda fiziskā vardarbība (kautiņi, cīņas ar ieročiem) Физическое насилие другой формы (драки, драки с применением оружия) Psiholoģiskā vardarbība (draudi, ņirgāšanās, iebiedēšana) Психологическое насилие (угрозы, издевательство, запугивание)
Нет
Не знаю
01
02
03
01
02
03
01
02
03
8. Vai domājat, ka šajā cietumā ir vardarbība starp ieslodzītajiem un uzraugiem? По Вашему: существует ли насилие между заключенными и надзирателями в этой тюрьме? Jā Nē Nezinu 172
Да 01
02
03
Seksuālā vardarbība (piespiedu seksuālās attiecības) Сексуальное насилие (принудительные сексуальные отношения) Cita vieda fiziskā vardarbība (kautiņi, cīņas ar ieročiem) Физическое насилие другой формы (драки, драки с применением оружия) Psiholoģiskā vardarbība (draudi, ņirgāšanās iebiedēšana) Психологическое насилие (угрозы, издевательство, запугивание)
Нет 01
02
03
01
02
03
01
02
03
9. Kāda veida seksuālās attiecības ir šajā cietumā? Какого рода сексуальные отношения существуют в этой тюрьме, Jā Nē Да 01
02
03
04
01 02 03 04
„laulāto‖ vizītes (sieva/ vīrs, partnere/ partneris, draudzene/ draugs) Супружеские визиты (жена/ муж, партнерша/ патрнер , подруга/ друг) Seksuālas attiecības starp ieslodzītajiem ar abpusēju piekrišanu Сексуальные отношения между заключенными по согласию обеих сторон Izvarošanas starp ieslodzītajiem (seksuālas attiecības bez piekrišanas) Изнасилование между заключенными (принудительные сексуальные отношения) Seksuālie sakari starp ieslodzītajiem kā „valūtas‖ forma (t.i., samaksa par precēm vai pakalpojumiem) Сексуальные отношения между заключенными как форма «валюты» (т.е., плата за товары или услуги)
Не знаю
Nezinu
Нет
Не знаю
01
02
03
01
02
03
01
02
03
01
02
03
10. Cik daudz ieslodzīto, pēc Jūsu domām, cietumā lieto vienu vai vairākas no minētajam vielām? Lūdzu, atzīmējiet procentus, kur 0 nozīmē – neviens un 100 nozīmē – visi, attiecībā uz katru no narkotiku veidiem. Ja nezināt precīzi, norādiet aptuveni! По Вашему: какое количество заключенных в этой тюрьме применяют одно или несколько из названных веществ? Пожалуйста укажите в процентах относительно каждому виду наркотиков, где 0 означает – никто, а 100 – все принимают. Если не знаете, укажите приблизительно! Narkotikas lietojošo Nezinu ieslodzīto procents (0 – neviens, 100 – visi) Процент заключенных Не знаю принимающих наркотики (0 – никто, 100 – все) Kanabis/ hašišs/ marihuāna 0 Канабис/ гашиш/ марихуана Alkohols 0 Алкоголь Heroīns/ opiāti 0 Героин/ опиаты Tabletes 0 173
Таблетки 11. Cik daudz ieslodzīto, pēc Jūsu domām, šajā cietumā INJICĒ NARKOTIKAS? Lūdzu, atzīmējiet procentus, kur 0 nozīmē – neviens un 100 nozīmē – visi, attiecībā uz katru no narkotiku veidiem. Ja nezināt precīzi, norādiet aptuveni! По Вашему: какое количество заключенных в этой тюрьме ИНЬЕЦИРУЮТ (КОЛЯТ) НАРКОТИКИ? Пожалуйста укажите в процентах относительно каждому виду наркотиков, где 0 означает – никто, а 100 – все принимают. Если не знаете, укажите приблизительно! Ieslodzīto procents, kas injicē narkotikas 0 Nezinu (0 – neviens, 100 – visi) ______________% Процент заключенных, которые колят 0 Не знаю наркотики (0 – никто, 100 – все) ______________% 12. Ko Jūs domājat par injicējamo narkotiku lietotājiem vispār? Что Вы вообще думаете о наркоманах, которые колят наркотики? Injicējamo narkotiku lietotāji kopumā: Наркоманы, колящие наркотики в общем: Piekrītu Nepiekrītu Соглашаюсь Не соглашаюсь 01 uzskatāmi par slimiem un būtu jāārstē 01 02 больные люди и нуждаются в лечении 02 nepelna atbalstu 01 02 не заслуживают поддержки 03 rada citiem draudus inficēties ar HIV un hepatītiem 01 02 создают угрозу инфицирования ВИЧ и гепатитами окружающим 13. Vai domājat, ka HIV vīruss, kas izraisa AIDS, var tikt pārnests sekojošā veidā? Думаете ли Вы, что ВИЧ (вирус вызывающий заболевание СПИДом) переносится в следующем виде: Jā Nē Nezinu Да 01 02 03 04
05 06 07 08
Dzimumakta laikā, nelietojot prezervatīvu Во время полового акта, если не пользовтаться презервативом Kontaktā ar tualetes sēdekli При контакте с сидением унитаза Dzerot no HIV inficētas personas glāzes Если пить из одного стакана с ВИЧ инфицированным No HIV inficētas personas siekalām (atkrēpojot, klepojot, skūpstoties) Со слюной ВИЧ инфицированного человека (отхаркивая, покашливая, при поцелуях) No oda koduma От укуса комара Injekciju laikā Во время иньекций Skujoties ar HIV inficētas personas žileti Если пользоваться одним лезвием для бритья с ВИЧ инвицированным Tetovējoties Во время татуирования 174
Нет
Не знаю
01
02
03
01
02
03
01
02
03
01
02
03
01
02
03
01
02
03
01
02
03
01
02
03
09 10
Asiņu apmaiņā (brālības rituālos) При обмене кровью (ритуалы побратимости) Sarokojoties ar HIV inficētu personu При рукопожатии с ВИЧ инфицированным
01
02
03
01
02
03
14. Ko Jūs domājat par katru no sekojošajiem pasākumiem, lai pasargātu sevi no inficēšanās ar HIV/AIDS? Что Вы думаете об эффективности каждого из последующих мероприятий, чтобы избежать заражения ВИЧ? Efektīvs Neefektīvs Nezinu 01 02 03
04 05 06
07
Эффективный
Неэффективный
Не знаю
01
02
03
01
02
03
01
02
03
01
02
03
01
02
03
01
02
03
01
02
03
Nomazgāšanās pēc seksa Мыте после секса Pārdomāta seksa partneru izvēlēšanās Продуманный выбор сексуальных партнеров Seksuālas attiecības tikai ar vienu partneri Сексуальные отношения только с одним партнером Prezervatīva lietošana Применение презерватива Kontraceptīvo tablešu lietošana Применение контрацептивных таблетов Jautāt katram partnerim par viņa HIV testa (analīžu) rezultātu Спрашивать у каждого партнера о результате его / ее ВИЧ-теста (анализов) Regulāri veikt HIV testu (analīzes) Регулярно обследоваться на ВИЧ (делать анализы)
15. Vai kāds no Jūsu tuvu pazīstamiem cilvēkiem (draugi, radinieki, ģimenes locekļi, kolēģi, kaimiņi) ir inficējies ar kādu no minētajām infekcijām? Есть ли среди Ваших близких знакомых (друзья, родственники, члены семьи, коллеги, соседи) кто-то зараженный ниже упомянутыми инфекциями? Jā Nē Nezinu Да 01 02 03
HIV/AIDS ВИЧ/ СПИДом Tuberkuloze Туберкулезом Hepatīti B vai C Гепатитами В или С
Нет
Не знаю
01
02
03
01
02
03
01
02
03
16. Ja Jūs zinātu, ka kāds ir inficēts ar HIV, vai Jūs piekristu: Если бы Вы знали кого-то ВИЧ инфицированного, согласились бы ли Вы: Jā Nē Да Нет 01 Strādāt ar viņu kopā 01 02 175
02 03 04
01 02 03 04 05
06 07
08
09
Работать вместе с ним Ēst ar viņu kopā Кушать вместе с ним Turpināt satikties un biedroties ar viņu Продолжать встречаться и общаться с ним Lietot ar viņu kopīgus galda piederumus Пользоваться общимы настольными принадлежностьями
01
02
01
02
01
02
17. Vai piekrītat sekojošajam: ir nepieciešams aizliegt HIV inficētiem ieslodzītajiem piedalīties šādās cietuma aktivitātēs: Соглашаетесь ли Вы со следующим: нужно запретить ВИЧ инфицированным заключенным участвовать в ниже следующих мероприятиях в тюрьме: Piekrītu Nepiekrītu Соглашаюсь Не соглашаюсь Sportā 01 02 В спорте Ēdiena gatavošanā 01 02 В приготовлении пищи Strādāšanā 01 02 В работе HIV inficētos būtu jāievieto atsevišķā ēkā 01 02 ВИЧ инфицированных следует поместить в отдельном помещении HIV inficētajiem ieslodzītajiem nepieciešamа palīdzība un līdzcietība 01 02 ВИЧ инфицированнымзаключенным необходима помощь и сострадание Uzraugiem jābūt informētiem par ieslodzīto HIV statusu 01 02 Надзиратели должны знать о ВИЧ статусе заключенных HIV inficēts ieslodzītais pakļauj riskam inficēties kameras biedrus 01 02 ВИЧ инфицированный заключенный создает угрозу заразиться его соседям по камере No HIV inficēta ieslodzītā var inficēties cietuma darbinieki 01 02 От ВИЧ инфицированного заключенного могут заразиться работники тюрьмы HIV inficētie ieslodzīti jāārstē tāpat kā pārējie ieslodzītie 01 02 ВИЧ инфицированные заключенные требуют такогоже лечения как остальные заключенные
18. Vai domājat, ka B hepatīta vīruss var tikt pārnests sekojošā veidā? Думаете ли Вы, что вирус гепатита Б переносится в следующем виде: Jā Nē Да 01 02 03
Dzimumakta laikā, nelietojot prezervatīvu Во время полового акта, если не пользовтаться презервативом Kontaktā ar tualetes sēdekli При контакте с сидением унитаза Dzerot no vienas glāzes ar cilvēku, kam ir B hepatīts Если пить из одного стакана с человеком 176
Нет
Nezinu Не знаю
01
02
03
01
02
03
01
02
03
04
05 06 07 08 09 10
зараженным гепатитом В No ar B hepatītu inficētas personas siekalām (atkrēpojot, klepojot, skūpstoties) Со слюны человека зараженного гепатитом В (отхаркивая, покашливая, при поцелуях) No oda koduma От укуса комара Injekciju laikā Во время иньекций Skujoties ar B hepatīta inficētas personas žileti Если пользоваться одним лезвием для бритья с человеком зараженным гепатитом В Tetovējoties Во время татуирования Asiņu apmaiņā (brālības rituālos) При обмене кровью (ритуалы побратимости) Sarokojoties ar cilvēku, kam ir B hepatīts При рукопожатии с человеком зараженным гепатитом В
01
02
03
01
02
03
01
02
03
01
02
03
01
02
03
01
02
03
01
02
03
19. Vai domājat, ka C hepatīta vīruss var tikt pārnests sekojošā veidā? Думаете ли Вы, что вирус гепатита C переносится в следующем виде: Jā Nē Да 01 02 03
04
05 06 07 08 09 10
Dzimumakta laikā, nelietojot prezervatīvu Во время полового акта, если не пользовтаться презервативом Kontaktā ar tualetes sēdekli При контакте с сидением унитаза Dzerot no vienas glāzes ar cilvēku, kam ir С hepatīts Если пить из одного стакана с человеком зараженным гепатитом С No ar С hepatītu inficētas personas siekalām (atkrēpojot, klepojot, skūpstoties) Со слюны человека зараженного гепатитом С (отхаркивая, покашливая, при поцелуях) No oda koduma От укуса комара Injekciju laikā Во время иньекций Skujoties ar С hepatīta inficētas personas žileti Если пользоваться одним лезвием для бритья с человеком зараженным гепатитом С Tetovējoties Во время татуирования Asiņu apmaiņā (brālības rituālos) При обмене кровью (ритуалы побратимости) Sarokojoties ar cilvēku, kam ir С hepatīts При рукопожатии с человеком зараженным гепатитом С
Нет
Nezinu Не знаю
01
02
03
01
02
03
01
02
03
01
02
03
01
02
03
01
02
03
01
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01
02
03
01
02
03
01
02
03
20. Ja Jūs zinātu, ka kāds ir inficēts ar B vai C hepatītu, vai Jūs piekristu: Если бы Вы знали кого-то инфицированного гепатитом В или С, согласились бы ли Вы: Jā Nē Да Нет 01 Strādāt ar viņu kopā 01 02 177
02 03 04
Работать вместе с ним Ēst ar viņu kopā Кушать вместе с ним Turpināt satikties un biedroties ar viņu Продолжать встречаться и общаться с ним Lietot ar viņu kopīgus galda piederumus Пользоваться общими настольными принадлежностьями
01
02
01
02
01
02
21. Kā Jūs domājat, vai iespējams vakcinēties pret: Думаете ли Вы, что можно вакцинироваться от:
01 02 03 04
01
02
03
04
05 06 07
HIV/AIDS ВИЧ/ СПИДа Tuberkulozi Туберкулеза B hepatītu Гепатита В C hepatītu Гепатита C
Jā
Nē
Nezinu
Да
Нет
Не знаю
01
02
03
01
02
03
01
02
03
01
02
03
22. Ko Jūs domājat par sekojošu pasākumu ieviešanu Jūsu cietumā, lai novērstu HIV un hepatītu izplatīšanos? Что Вы думаете по поводу внедрения следующих мероприятий в Вашей тюрьме, чтобы предотвратить распространение ВИЧ и гепатитов? Piekrītu Nepiekrītu Соглашаюсь Не соглашаюсь Nodrošināt ilgstošās tikšanās telpas laulāto un seksa partneru vizītēm 01 02 Обеспечить помещения длительных свиданий для супружеских пар и сексуальных партнеров Nodrošināt prezervatīvu pieejamību ilgstošās tikšanās telpās laulāto un seksa partneru vizītēm 01 02 Обеспечить доступность презервативов в помещениях длительных свиданий для супружеских пар и сексуальных партнеров Nodrošināt anonīmu bezmaksas prezervatīvu pieejamību ieslodzītajiem 01 02 Обеспечить заключенным анонимный доступ к бесплатным презервавам Nodrošināt sterilus injicēšanas piederumus (šļirces un adatas) tiem ieslodzītajiem, kas lieto injicējamās narkotikas 01 02 Обеспечить стерильные принадлежности (шприцы и иглы) тем заключенным, которые иньицируют наркотики Nodrošināt sterilus piederumus tetovēšanai 01 02 Обеспечить стерильные принадлежности для татуирования Nodrošināt ieslodzītos ar informāciju par infekcijām 01 02 Обеспечить заключенных информацией об инфекциях Sagatavot no ieslodzīto vidus „trenerus‖ (apmācītājus), 01 02 kas izglītotu pārējos par infekcijām 178
08
09 10
11
12 13
Подготовить «тренеров» (обучателей) из круга заключенных, которые обучают остальных об инфекциях Rīkot ieslodzītajiem apmācības par infekcijām, ko vadītu profesionāli veselības speciālisti Организовать обучения для заключенных об инфекциях под руководством профессиональных работников здравохранения Sistemātiski veikt ieslodzīto izmeklēšanu uz HIV Проводить систематическое обследование заключенных на ВИЧ Sistemātiski veikt ieslodzīto izmeklēšanu uz B un C hepatītiem Проводить систематическое обследование заключенных на гепатиты В и С Nodrošināt cietuma darbiniekus ar informāciju par infekcijām Обеспечить работников тюрьмы информацией об инфекциях Vakcinēt ieslodzītos pret B hepatītu Вакцинировать заключенных от гепатита В Vakcinēt cietuma darbiniekus pret B hepatītu Вакцинировать работников тюрьмы от гепатита В
01
02
01
02
01
02
01
02
01
02
01
02
23. Vai Jums darbā (cietumā) ir piedāvāta informācija par infekciju izplatības ceļiem un profilaksi? Была ли Вам предложена информация о путях распространения инфекций и профилактики во время Вашей работы в тюрьме? Jā Nē Nezinu Да 01 02 03 04
01 02 03 04
Par HIV/AIDS о ВИЧ/ СПИДе Par tuberkulozi о туберкулезе Par B hepatītu о гепатите В Par C hepatītu о гепатите С
Нет
Не знаю
01
02
03
01
02
03
01
02
03
01
02
03
24. Vai Jūsu darba laikā cietumā kādreiz esat izmeklēts uz šādām saslimšanām? Обследовались ли Вы во время Вашей работы в тюрьме на следующие заболевания? Jā Nē Да Нет HIV/AIDS 01 02 ВИЧ/ СПИД Tuberkuloze 01 02 туберкулез B hepatīts 01 02 гепатит В C hepatīts 01 02 гепатит С 25. Kad pēdējo reizi Jūsu darba laikā cietumā Jums veikts krūšu kurvja rentgens? Когда последний раз по во время Вашей работы в тюрьме Вам делали рентген грудной клетки? 179
Mazāk kā pirms gada
Vairāk kā pirms gada
Nekad
Nezinu
Меньше, чем год назад 01
Больше, чем год назад 02
Никогда
Не знаю
01 02 03 04
03
04
26. Kurā cietuma daļā Jūs pavadāt LIELĀKO DAĻU sava darba laika? В какой части тюрьмы Вы проводите НАИБОЛЬШУЮ ЧАСТЬ своего рабочего времени? Administrācijā 01 В администрации Zonā vai kameru korpusā 01 В зоне или в камерном корпусе Izolētajos iecirkņos 01 В изолирнванном участке Medicīnas daļā 01 В медицинской части 27. Kāds ir Jūsu vecums? Ваш возраст?
gadi/ лет 28. Jūsu dzimums? Ваш пол? 01 Vīrietis / Мужчина
02 Sieviete / Женщина
29. Kāds ir Jūsu izglītības līmenis attiecībā uz cietumā veicamo darbu? Уровень Вашего образования относительно Вашей работы в тюрьме: Neapmācīts 01 Необученный Daļēji apmācīts 02 Частично обученный Kvalificēts (ir profesijas sertifikāts) 03 Квалифицированный (имеется сертификат профессии) Augstākā izglītība (jurists, ārsts u.tml.) 04 Высшее образование (юрист, врач и.т.п.) 30. Cik ilgi strādājat penitenciārajā sistēmā? Как долго Вы работаете в пенитенциарной системе?
gadus / лет 31. Kāda ir Jūsu šī brīža dienesta pakāpe (dienesta stāvoklis)? Какой Ваш служебный ранг сегодня? Administrācijas darbinieks 01 Административный работник Uzraugs 02 Надзиратель Psihologs 03 Психолог Sociālais darbinieks 04 180
Социальный работник Medicīnas māsa Медицинская сестра Ārsts/ ārsta palīgs/ feldšeris Врач/ помощник врача/ фельдшер Cits Другой
05 06 07
PALDIES! СПАСИБО!
181
Annex 18: Draft Overview on Documents on HIV, DU, Harm Reduction and Prisons
182
183
184
185
186
Annex 19: Agenda and Participants List “Round Table Discussion”
Capacity building for institutions involved in surveillance and prevention of communicable diseases in Latvian’s penitentiary system Europa City Riga Hotel, 5th September 2007 Agenda 12:30 Coffee/Reception 13:00 – 15:00 Introduction (Inga Upmace/Heino Stöver) EU-Twinning in the framework of the German HIV/AIDS strategy (Gisela Lange) Presentation of the development of the EU-Twinning Project (Heino Stöver) Discussion Epidemiological trends: Infectious diseases in the community and in prisons (Inga Upmace) Discussion Notes from Latvian prison visits: The need for a comprehensive approach in the management of infectious diseases and drug addiction (Marc Lehmann) Discussion 15:00 – 15:30 Coffee break 15:30 – 17:00 Analysis of the legal situation (Solvita Olsena) 187
Discussion Presentation of Recommendations (Heino Stöver) Discussion Summary and closing remarks (Gisela Lange)
188
1. No.
Full name (surname, name)
Position
Institution
Mailing address, phone
E-mail
Linezera str.3, Riga, Latvia, LV-1006 Phone: +371 67014532
[email protected]
1
ALDINS Pauls
Head of AIDS unit
Latvian Infectology Centre
2
BEBERE Leonora
Head of med.unit
Ilguciems prison
3
CIRULE Andra
Deputy Director on Medical Issues
Tuberculosis and Lung Disease State Agency
4
CIVCS Ainars
Deputy director
Public Health Agency
FEDOSEJEVA Regina
Head of Medical Department
Prison Administration
GRISLE Gunta
Deputy Head of Epidemiological Safety Division
Ministry of Health
IGNATE Kristine
Public health specialist of AIDS and STI Centre
5
6
7
189
Public Health Agency
p.o. Cekule, Stopinu p. Riga reg., LV 2118, Phone: +371 67048246 Klijanu Street 7, Riga, LV1012, Phone: +371 67081537 Stabu Street 89, Riga, LV1009, Phone: +371 67208139 Brivibas Street 72, Riga, LV-1011, Phone: +371 67876089 Klijanu Street 7, Riga, LV1012, Phone: +371 67372275
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
8
KANDELE Danuta
Head of med.unit Head of the Unit of Punishment Execution Policy
9
KIPENA Kristine
10
KOKARS Ivars
11
LANGE Gisela
Short-TermExpert of the Project
12
LEHMANN Marc
Short-TermExpert of the Project
13
MOLOKOVSKIS Aleksandrs
14
NAGLE Ivita
Brasa prison Ministry of Justice NGO “AGIHAS”
-
NGO “HIV.LV”
Chief specialist of Department of International Affairs and 190
Public Health Agency
Brivibas street 91, Riga, LV1001, Phone: +371 67162616 Klijanu Street 7, Riga, LV1012, Ministerium für Gesundheit, Am Propsthof 78a, D-53121, Bonn Phone: +49 (0) 1888 4413216 Jugendanstalt Hameln, Tundernsche Str.50 31789 Hameln Germany, Phone: +49 5151 904 409 Gaismas Street 19, k-8, 123, Kekava, LV2123, Phone: +371 26062077 Klijanu Street 7, Riga, LV1012, Phone: +371 67081565
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
Projects
15
NIKIFOROVA Raina
16
OLSENA Solvita
Epidemiologist of Infectious Diseases Epidemiological Surveillance Unit Director
Head of Health
Public Health Agency
Klijanu Street 7, Riga, LV1012, Phone: +371 67081594
[email protected]
Ltd. “Medicinas tiesibu instituts”
Phone: +371 26162000
[email protected]
Brivibas Street 72, Riga, LV-1011, Latvia Phone: +371 67876087
[email protected]
Ministry of Health
17
PABLAKA Silvija
18
PLOCINA Marija
Head of med.unit
Central prison
19
ROTBERGA Signe
Regional Project Coordinator
UNODC Project Office for the Baltic States
20
SEJA Agita
21
22
SKAIDA Sarmite
SKRIPSTE Iveta
Care Unit
NGO “DIA+LOGS”
Head doctor of the Narcological service Public Health Specialist of AIDS and STI Prevention 191
Riga Centre of Psychiatry and Addiction Disorders Public Health Agency,
PO Box 62, LT01001, Vilnius, Phone: +370 5210 7412 Dzirnavu str.135, Riga, LV-1050, Phone: +371 67243101 Hospitalu str.55, Riga, LV-1013, Phone: +371 67388012 Klijanu Street 7, Riga, LV1012, Phone: +371
[email protected]
[email protected]
[email protected]
[email protected]
Centre
67081622
STÖVER Heino
Leader of the Project
TRAPENCIERIS Marcis
Researcher of Unit of epidemiological surveillance of addictions
Public Health Agency
25
UPMACE Inga
Deputy head of AIDS and STI Prevention Centre
Public Health Agency
26
VIKTOROV Vadim
Deputy director
Prison Hospital
27
VILUMA Dace
Head of Unit of Epidemiological Safety
Ministry of Health
28
ZELDAJEVA Valentina
Head of med.unit
Skirotava prison
29
AUGRS Andris
Interpreter
23
24
192
Universität Bremen, Fachbereich 06, Postf. 330 440, D28334, Bremen Phone: +49 (0) 421 218-2577/-3173 Klijanu Street 7, Riga, LV1012, Phone: +37167081575 Klijanu Street 7, Riga, LV1012, Phone: +371 67081621
Brivibas Street 72, Riga, LV-1011, Latvia Phone: +371 67876080
[email protected]
[email protected]
[email protected]
[email protected]
VII. References Brown, H.: Looking to the future in Latvia. The Lancet, Vol. 364, December 11, 2004, p. 2083-2086 Fedosejeva, R. (2007): LATVIA: HIV/AIDS Prevention and Care in Prison Settings Today and Tomorrow. Presentation on the UNODC Kick-Off-Meeting 13.-14.02.2007, Vilnius Institute of Philosophy and Sociology, University of Latvia ((2003): DRUG ABUSE PREVALENCE in Latvia - Population survey report. Riga Latvian Centre for human Rights (2006): Monitoring Report on Closed Institutions in Latvia. http://www.humanrights.org.lv/html/news/publications/29031.html
Lines, R. (2006): From equivalence of standards to equivalence of objectives: The entitlement of prisoners to health care standards higher than those outside prisons, International Journal of Prisoner Health, 2 (4): 269–280. Lines, R., Jürgens, R., Betteridge, G.,Stöver, H. (2006) Taking Action to Reduce Injecting Drug-related Harms in Prisons: The Evidence of Effectiveness of Prison Needle Exchange in Six Countries. International Journal of Prisoner Health,1:49-64 (see also www.aidslaw.ca) Ministry of Health of the Republic of Latvia (2006):; Statistics and Medical Technology State Agency: Yearbook of Health Care Statistics in Latvia 2005; Riga 2006 Møller, L.; Stöver, H., Jürgens, R., Gatherer, A.; Nikogosian, H. (ed.): Health in prisons. A WHO guide to the essentials in prison health. Copenhagen, 2007 (also available in Russian) Morozova I, Riekstina V, Sture G, Wells C, Leimane V. Impact of the growing HIV-1 epidemic on multidrug-resistant tuberculosis control in Latvia. Int.J.Tuberc.Lung Dis. 2003;7(9):903-6. Müller, K, Kehler, J, Lechner, S, Neunsinger, S, and Rabe, F. (2004): Transforming the Latvian Health System. Accessibility of health services from a pro-poor perspective. Bonn, German Development Institute Pukite, V.; Fedosejeva, R. (2007): ‗‘Control of Tuberculosis, HIV/AIDS and other infectious diseases in the prisons of Latvia‖, Workshop organized by the WHO Regional Office for Europe, MoJ, Latvia; 26.06.2007, Riga Stöver, H.; Lines, R.: Silence Still = Death. 25 years of HIV/AIDS in Prisons. World Health Organisation/WHO – Regional Office for Europe (ed.): 25-Years of HIV/AIDS in Europe. 2006 193
MoH of
Stöver, H.; MacDonald, M,; Atherton, S.; Harm Reduction for Drug Users in European Prisons. Oldenburg/Germany, London/UK 2007 Subata, E.: Evaluation of methadone maintenance therapy program in Latvia, April 10, 2007 UNODC, World Health Organization and the Joint United Nations Programme on HIV/AIDS (2006): HIV/AIDS Prevention, Care, Treatment and Support in Prison Settings A Framework for an Effective National Response UNAIDS (2005): HIV/AIDS Prevention, Treatment and Care among Injecting Drug Users and in Prisons. Ministerial Meeting on ―Urgent response to the HIV/AIDS epidemics in the Commonwealth of Independent States‖ Moscow, 31 March to 1 April 2005 WHO/EURO (2005): HIV/AIDS and TB interventions in Estonia, Latvia and Lithuania - Economic, health financing and health system implications. Version 12/10 2005 Zeile, Olga (2007): National health care policy in prisons of Latvia. Presentation of the Kick-Off Meeting of the UNODC project ―HIV/AIDS prevention and care among injecting drug users and in prison settings in Estonia, Latvia and Lithuania in Vilnius, 13.2.2007 Zellweger, J.-P. (2006): Recommendations for the Improvement of the Surveillance, Prevention, Treatment and Care System of HIV and TB in the Penitentiary System in Latvia. WHO temporary adviser, University Medical Policlinic, Lausanne. Report December 2006
i
UN Human Rights Committee ‗General Comment 21: Humane treatment of persons deprived of liberty (Art. 10)‘ (10 April 1992) Compilation of General Comments and General Recommendations Adopted by Human Rights Treaty Bodies UN Doc.HRI/GEN/1/Rev.6 para 3. ii International Covenant on Economic, Social and Cultural Rights (adopted 16 December 1966, entered into force 3 January 1976) 993 UNTS 3 art 12.;). Universal Declaration of Human Rights (adopted 10 December 1948) UNGA Res 217 A(III) (UDHR) art 5.; International Covenant on Civil and Political Rights (adopted 16 December 1966, entered into force 23 MLh 1976) 999 UNTS 171 art 25. iii Numerous international instruments are relevant to the rights of prisoners in the context of the HIV/AIDS epidemic. These include the Universal Declaration of Human Rights; the International Covenant on Civil and Political Rights; the International Covenant on Economic, Social and Cultural Rights; the African Charter on Human and Peoples’ Rights; the American Convention on Human Rights; the Additional Protocol to the American Convention on Human Rights in the Area of Economic, Social and Cultural Rights; the American Declaration of the Rights and Duties of Man; the [European] Convention for the Protection of Human Rights and Fundamental Freedoms; the European Social Charter. Most of these covenants, charters, and conventions are based on the United Nations Universal Declaration of Human Rights, which has the status of customary international law and as such is binding on all states. States that have ratified or acceded to any one of these covenants, declarations, or charters have agreed that they are legally bound to respect, protect, and fulfil human rights, including the right to equality and non-discrimination; the right to life; the right to security of the person; the right not to be subjected to torture or to cruel, inhuman, or degrading treatment or punishment; and the right to enjoyment of the highest attainable standard of physical and mental health. [G. Betteridge. Prisoners’ Health & Human Rights in the HIV/AIDS Epidemic: DraFT background paper for ―Human Rights at the Margins: HIV/AIDS, Prisoners, Drug Users, and the Law—A satellite of the XV International AIDS Conference‖. Canadian HIV/AIDS Legal Network: Montreal (July 2004).] iv Universal Declaration of Human Rights (n 5) art 7.; Convention for the Protection of Human Rights and Fundamental Freedoms (European Convention on Human Rights, as amended) (ECHR) art 3.; American Declaration of the Rights and Duties of Man, OAS Res XXX adopted by the Ninth International Conference of 194
American States (1948) reprinted in Basic Documents Pertaining to Human Rights in the Inter-American System OEA/Ser L V/II.82 Doc 6 Rev 1 at 17 (1992) art 25.; American Convention on Human Rights (entered into force 18 July 1978) OASTreaty Series No 36 1144 UNTS 123 reprinted in Basic Documents Pertaining to Human Rights in the Inter-American System, OEA/Ser.L.V/II.82 doc.6 rev.1 at 25 (1992) art 5.; African Charter on Human and Peoples‘ Rights (adopted 27 June 1981, entered into force 21 October 1986) (1982) 21 ILM 58 (Banjul Charter) art 5. v Pantea v Romania (2005) 40 EHRR 26 para 189. For more on the positive obligation of states to safeguard the physical integrity of prisoners, see UN Human Rights Committee ‗General Comment 21: Humane treatment of persons deprived of liberty (Art. 10)‘ (10 April 1992) Compilation of General Comments and General Recommendations Adopted by Human Rights Treaty Bodies UN Doc.HRI/GEN/1/Rev.6 para 3.; Caesar v Trinidad and Tobago (Judgement) Inter-American Court of Human Rights Ser C (11 MLh 2005) para 97.; Minors in Detention v Honduras (Judgement) Inter-American Commission on Human Rights Case 11.491 (10 MLh 1999) para 135.; John D Ouko v Kenya (2000) African Commission on Human and Peoples‘ Rights Comm No 232/99 para 23. vi European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment 3rd General Report on the CPT's activities covering the period 1 January to 31 December 1992 (1993) para 31. vii These instruments include the Basic Principles for the Treatment of Prisoners; the Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment; the Standard Minimum Rules for the Treatment of Prisoners; and Recommendation No R (98)7 of the Committee of Ministers to Member States Concerning the Ethical and Organisational Aspects of Health Care in Prison. viii These declarations include the WHO Guidelines on HIV Infection and AIDS in Prisons; the Declaration of Commitment – United Nations General Assembly Special Session on HIV/AIDS; the International Guidelines on HIV/AIDS and Human Rights; and the Dublin Declaration on HIV/AIDS in Prisons in Europe and Central Asia. ix United Nations Basic Principles for the Treatment of Prisoners states ―Prisoners shall have access to the health services available in the country without discrimination on the grounds of their legal situation.‖ Adopted by General Assembly Resolution 45/111, annex, 45 U.N. GAOR Supp. (No. 49A) at 200, U.N. Doc. A/45/49 (1990); United Nations Principles of Medical Ethics relevant to the Role of Health Personnel, particularly Physicians, in the Protection of Prisoners and Detainees against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment states ―Health personnel, particularly physicians, charged with the medical care of prisoners and detainees have a duty to provide them with protection of their physical and mental health and treatment of disease of the same quality and standard as is afforded to those who are not imprisoned or detained.‖ Adopted by General Assembly resolution 37/194of 18 (December 1982). World Health Organization Guidelines on HIV Infection and AIDS in Prisons states ―All prisoners have the right to receive health care, including preventive measures, equivalent to that available in the community without discrimination…with respect to their legal status.‖ (WHO, Geneva: 1993). p.4; UNAIDS‘s Statement on HIV/AIDS in Prisons states ―With regard to effective HIV/AIDS prevention and care programmes, prisoners have a right to be provided the basic standard of medical care available in the community.‖ Statement on HIV/AIDS in Prisons to the United Nations Commission on Human Rights at its FiFTy-second session, April 1996.
195
