Skip Navigation


Journal of Public Health Advance Access originally published online on April 2, 2008
Journal of Public Health 2008 30(2):126-132; doi:10.1093/pubmed/fdn021
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
30/2/126    most recent
fdn021v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (3)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Werb, D.
Right arrow Articles by Wood, E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Werb, D.
Right arrow Articles by Wood, E.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

© The Author 2008, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved

HIV risks associated with incarceration among injection drug users: implications for prison-based public health strategies{dagger}



Daniel Werb, Research Assistant1

Thomas Kerr, Research Scientist1,2

Will Small, Ethnographic Researcher1

Kathy Li, Senior Statistician1

Julio Montaner, Director1,2

Evan Wood, Research Scientist1,2
1 British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608 – 1081 Burrard Street, Vancouver, B.C., V6Z 1Y6, Canada
2 Department of Medicine, University of British Columbia, Vancouver, Canada

Address correspondence to Evan Wood, E-mail: uhri{at}cfenet.ubc.ca, dgraham{at}cfenet.ubc.ca

Background Recent policy announcements in Canada and the United States may potentially affect the risk environment for HIV transmission among incarcerated injection drug users (IDU). We sought to evaluate the potential impact of incarceration on HIV risk behaviour among the IDU enrolled in a prospective cohort study.

Methods We examined patterns of incarceration among 1247 IDU participants enrolled in a 6-year prospective cohort study in Vancouver, Canada, and tested for potential associations between HIV risk behaviour and incarceration. Correlates of incarceration were identified using generalized estimating equations (GEE).

Results At baseline, factors significantly associated with incarceration included daily injection heroin and injection cocaine use and inconsistent condom use with casual sexual partners. In a GEE analysis, factors independently associated with incarceration included: used syringe borrowing (adjusted odds ratio [AOR] = 1.36; [95% CI: 1.16–1.60]), used syringe lending (AOR = 1.31; [95% CI: 1.12–1.55]) and inconsistent condom use with casual sexual partners (AOR = 1.16; [1.02–1.33]). All variables P < 0.05.

Conclusion In our study, incarceration was independently associated with HIV transmission and acquisition behaviours. These findings suggest that increased rates of incarceration of IDU may be associated with increased HIV transmission among this group.

Keywords: drug policy, HIV, IDU, incarceration, prison, syringe sharing


   Background
TOP
 Background
Methods
 Results
 Conclusions
 Funding
 Acknowledgements
 References
 
The incarceration of large numbers of addicted individuals has the potential to create environments within which social networks at high risk for the spread of infectious disease can readily form.1–5 While the risk of HIV transmission in prisons has been recognized as a major health concern by the United States Centers for Disease Control and Prevention,6 the Commission on Safety and Abuse in America's Prisons7 and the Correctional Services of Canada (CSC),8 the implementation of evidence-based public health programmes responsive to the particular health needs of incarcerated injection drug users (IDU) has been slow in North America.9,10 In Canada, despite repeated calls for a more comprehensive approach to HIV prevention in correctional institutions and positive preliminary data from pilot prison-based syringe exchanges in some settings,11 the CSC has failed to implement such programmes.12 Similarly, the majority of American prisons lack harm reduction and preventive public health interventions such as condom distribution and methadone maintenance treatment, and no American or Canadian prison has instituted pilot prison-based syringe exchange programmes.13 Although data are very limited, this delay is problematic since there have been warnings about the potential for HIV transmission in prison for several years14–17 and because of the high rate of imprisonment in both Canada and the United States.18 However, this issue is not restricted to North America. In Russia, for instance, which has the second highest rate of imprisonment in the world behind the United States,18 a recent qualitative study of IDU in three Russian prisons demonstrated the critical role of correctional institutions in the transmission of HIV, while study participants reported high levels of syringe sharing and other risk behaviours among incarcerated Russian IDU.19

Additionally, a cohort study of IDU from Vancouver recently demonstrated that having been incarcerated in the last six months was independently associated with a greater than 2.5-fold risk of HIV seroconversion.20 Explanations for this statistical association were not explored since the principle objective of this earlier study was to evaluate the risks of HIV seroconversion related to injection cocaine.20 It remains unknown, therefore, whether selection factors or elevated rates of syringe sharing and unsafe sex (i.e. inconsistent condom use) among incarcerated addicts may explain these earlier findings. Given the potential significance of these findings to recent policy announcements that may affect the risk environment of correctional institutions in Canada and in certain American states,21,22 the present study was undertaken to fully assess the potential association between HIV risk behaviour and incarceration experiences among a prospective cohort study of IDU.


   Methods
TOP
 Background
 Methods
Results
 Conclusions
 Funding
 Acknowledgements
 References
 
Data for these analyses were collected through the Vancouver Injection Drug Users Study (VIDUS), a previously described prospective cohort.23 In brief, at baseline and semi-annually, study participants complete an interviewer-administered questionnaire and provide blood samples for diagnostic testing. The questionnaire elicits a range of information, including information specific to incarceration. The study has been ethically approved by the University of British Columbia/Providence Health Care Ethics Review Boards, and all study participants provide written consent prior to enrolment.

All participants who completed follow-up visits between 1 June 1999 and 1 December 2005 were evaluated in the present study, and rates of incarceration were measured semi-annually among this sample. Since analyses of factors potentially associated with incarceration included serial measures for each subject, we used generalized estimating equations (GEE) for binary outcomes with logit link for the analysis of correlated data to determine which factors were independently associated with incarceration during the follow-up period. These methods provided standard errors adjusted by multiple observations per person using an exchangeable correlation structure.24,25 Our GEE analysis included an all-available-pairs procedure in order to account for individuals lost to follow-up or whose follow-up was intermittent. This method has been previously shown to account for missing data in GEE analyses while ensuring that bias remains negligible.26

Socio-demographic and drug using characteristics considered in these analyses were selected based on previous investigations of drug use among Vancouver IDU23,27 and included the following: age, gender, Aboriginal ethnicity, frequency of heroin or cocaine use, involvement in the sex trade, syringe borrowing or lending and reporting inconsistent condom use with casual or regular partners. Variable definitions were consistent with previous analyses: individuals who reported heroin or cocaine injection once a day or more were defined as frequent heroin or cocaine users, respectively.27 Condom use with regular or casual partners was evaluated as a marker of sex-related risk. In addition, participants who reported having been incarcerated were asked if they had injected drugs while in jail. Those who reported injecting drugs were then asked to elaborate on the number of times they had injected while incarcerated and whether they used new injecting equipment every time.

Of the above variables, the primary independent variables of interest in the present study were those identified as HIV risk behaviours, specifically, used syringe lending or borrowing and inconsistent condom use. We were also aware that the epidemiological nature of the study, with its semi-annual follow-up structure, was such that it was not possible to know with certainty if risks associated with incarceration merely reflected selection biases. Therefore, we used a modelling approach that employed intensive covariate adjustment in order to explore if the above HIV risk behaviours were independently associated with incarceration after adjustment for all other measured high-risk behaviours. Specifically, we identified all variables associated with incarceration in bivariate GEE analyses, and in order to adjust for potential confounding, we then fit a multivariate logistic GEE model using the a priori defined model building protocol of adjusting for all variables that were statistically significant at the P < 0.05 level in bivariate analyses. All statistical analyses were performed using SAS software (version 9.1, SAS, Cary, NC, USA). All P-values are two sided.


   Results
TOP
 Background
 Methods
 Results
Conclusions
 Funding
 Acknowledgements
 References
 
In total, 1247 IDU were seen for follow-up during the study period, including 490 (39.3%) women and 369 (29.6%) individuals of Aboriginal ancestry. Two hundred and fifty-five (20.4%) individuals were HIV-infected at baseline, and 51 (4.1%) individuals became HIV-infected during follow-up. Overall, the 1247 participants contributed to 9867 observations. Rates of attrition were low throughout the study period, with 1142 participants (91.6%) having at least one follow-up visit. The median number of follow-ups was 9 (interquartile range [IQR] = 4–12), and being incarcerated in the last six months was reported in 1632 (16.5%) instances. In total, 624 (50.0%) participants reported being incarcerated at least once during follow-up, and the median number of incarcerations was 2 (IQR = 1–4). In subanalyses, 92 (14.7%) participants admitted that they had injected drugs while incarcerated during follow-up. Among these individuals, the median number of injections while incarcerated was 6 (IQR = 3–10). Additionally, among those who injected in prison, 56 (60.9%) reported injecting with a used syringe. Factors associated with incarceration at baseline among this cohort are presented in Table 1.


View this table:
[in this window]
[in a new window]

  		Table 1 Baseline characteristics of IDU stratified by incarceration (n = 1247)

 
The bivariate GEE analyses shown in Table 2 indicated that demographic and drug use factors significantly and positively associated with incarceration included: frequent cocaine injection (odds ratio [OR] = 1.75, [95% CI: 1.56–1.98], P < 0.001); frequent heroin injection (OR = 2.02, [95% CI: 1.78–2.29], P < 0.001); involvement in the sex trade (OR = 1.37, [95% CI: 1.17–1.59], P < 0.001); syringe borrowing (OR = 2.04, [95% CI: 1.78–2.32], P < 0.001); syringe lending (1.95, [95% CI: 1.70–2.24], P < 0.001); and inconsistent condom use with a casual sex partner (OR = 1.38, [95% CI: 1.21–1.57], P < 0.001). Those who reported having been incarcerated were less likely to be female (OR = 0.62, [95% CI: 0.52–0.73], P < 0.001) or older (OR = 0.96, [95% CI: 0.95–0.96] per year older, P < 0.001). Aboriginal ethnicity (OR = 0.98, [95% CI: 0.82–1.18], P = 0.852) and inconsistent condom use with a regular partner (OR = 1.00, [95% CI: 0.89–1.12], P = 0.957) were not found to be associated with incarceration.


View this table:
[in this window]
[in a new window]

  		Table 2 Bivariate and multivariate logistic generalized estimating equation analysis of factors associated with incarceration during follow-up (n = 1247)

 
In multivariate GEE analysis, syringe borrowing (AOR = 1.36, [95% CI: 1.16–1.60], P < 0.001), syringe lending (AOR = 1.31, [95% CI: 1.12–1.55], P = 0.001) and inconsistent condom use with casual sex partners (AOR = 1.16, [95% CI: 1.02–1.33], P = 0.024) remained independently associated with being incarcerated in the prior six months despite adjustment for age, gender, frequency of cocaine or heroin injection and involvement in the sex trade. The statistical significance of the covariates we adjusted for is shown in Table 2.


   Conclusions
TOP
 Background
 Methods
 Results
 Conclusions
Funding
 Acknowledgements
 References
 
Main finding of this study
In the present study, over a 6-year period, ~50% of IDU participants reported being incarcerated and ~15% of those incarcerated reported injecting in prisons. Furthermore, syringe lending, syringe borrowing and inconsistent condom use with casual sexual partners were all independently associated with incarceration despite intensive adjustment for all measured potential confounders.

What this study adds
Our findings build on our earlier work which identified an association between incarceration and HIV infection by demonstrating that, if causal, this earlier association may be due to both sexual and injecting related HIV risk behaviour occurring in prison settings.20 More research is required in order to fully characterize the association between the risk behaviours we observed and the risk of incarceration among this cohort. Our current study is unable to fully explicate the association we observed between risk behaviours for HIV transmission and the incarceration of IDU, and as such we are unable to state whether the risk factors we identified increase risk of incarceration or whether incarceration increases the incidence of risk behaviour among our cohort. Regardless of the exact nature of this association, however, our findings nevertheless have serious public health implications, particularly considering the high rate of syringe borrowing and lending in correctional institutions that study participants reported. A recent study suggested that the number of known HIV cases in Canadian prisons has risen by 35% in the last 5 years,8,28 while studies have reported HIV rates several times that of the national average among prisoners in the United States.6,29 Health authorities such as the World Health Organization (WHO) and UNAIDS have consequently urged the U.S. government to introduce harm reduction strategies into American correctional institutions.30,31

What is already known on this topic
A range of studies have suggested that funding for addiction treatment interventions is many times more cost-effective than incarceration.27,32,33 It is noteworthy that these studies have not accounted for the cost of new HIV infections resulting from incarceration or prevented by addiction treatment, and that some estimates place the lifetime cost of treating HIV infection at approximately $350 000 in the United States34 and upwards of $250 000 in Canada.35,36 As well, despite prior recommendations,12,31,37–40 no American or Canadian correctional institutions have yet to implement prison-based pilot syringe exchange studies or safer injection education programmes,13,41 and a Canadian pilot study to encourage safer tattooing practices was recently halted.42 With respect to our findings, it is important to note that the most incarcerated IDU will return to their communities after serving relatively short sentences. As a majority of those who injected in prison during the study period reported injecting with used syringes, the return of incarcerated IDU to home communities could have a deleterious impact on public health through the transmission of prison-acquired blood-borne viruses such as HCV and HIV.

A number of health research and governmental bodies in a variety of jurisdictions have stated that one of the primary barriers to the reduction of the transmission of HIV and HCV within correctional facilities is the lack of sterile syringes.11,43 Potential negative consequences of prison-based syringe exchange programmes, such as usage of needles as weapons and an increase in drug use among incarcerated IDU, have also failed to materialize in settings where prison-based needle exchanges have been implemented.43 Though Health Canada and health authorities in other settings have been recommending their rapid implementation for over a decade,30,37,44 pilot prison-based syringe exchange programmes have yet to be implemented in North America. This is of concern, given experiences in other settings in which legal action has been undertaken against the government by individuals who acquired HIV in prison.45 It is noteworthy in this regard that genetic studies of the viral genome may allow for the accurate determination of prison-acquired HIV.46

Limitations of this study
Our study is limited by the fact that VIDUS is not a random sample. However, we have previously shown that the VIDUS cohort is representative of local IDU.27 As well, rates of HIV risk behaviour have likely been significantly underestimated due to socially desirable reporting, and due to the observed phenomena of IDU tending to under-report these behaviours.47 Self-reported incarceration rates have also likely been significantly underestimated; while we were unable to link external records of incarceration to participant self-report, in many cases participants were interviewed from correctional institutions. Finally, because VIDUS participants are interviewed semi-annually, in many instances, we were unable to determine whether the HIV risk behaviours reported by study participants occurred during, prior to, or following periods of incarceration within the 6-month period prior to the reporting of these behaviours. However, it is noteworthy that we adjusted for a large number of potential confounders and an independent effect remained, and that the rate of syringe sharing in prison was high when we specifically queried for this behaviour.

In summary, we found that half of the IDU participating in a prospective cohort study were incarcerated at some point during a 6-year period. A substantial number of the IDU who were incarcerated also reported injecting while in prison, and a majority of these individuals reported injecting with used syringes. Given the restrictions on syringe possession in North American correctional institutions, our findings that used syringe lending and borrowing were independently associated with incarceration is unsurprising. In the light of our findings, and the known cost-effectiveness of the alternatives to incarceration,48 community diversion programmes49 and expanded addiction treatment50 may have the potential to reduce the harm associated with high-risk behaviours, such as injection drug use and unprotected sex, in correctional facilities. Finally, since evidence suggests that the potential exists for transmission of HIV in prisons, pilot prison-based HIV prevention programmes such as condom distribution, methadone maintenance therapy and syringe exchange programmes may be required in order to reduce the high risk of HIV and HCV transmission among incarcerated IDU and to minimize the impact of incarceration on public health.


   Funding
TOP
 Background
 Methods
 Results
 Conclusions
 Funding
Acknowledgements
 References
 
The study was supported by the US National Institutes of Health and the Canadian Institutes of Health Research. Thomas Kerr is supported by a Michael Smith Foundation Scholar Award and a Canadian Institutes for Health Research New Investigator Award. Will Small is supported by a Michael Smith Foundation for Health Research Senior Graduate Studentship and a Canadian Institutes of Health Research Doctoral Research Award.


   Acknowledgements
TOP
 Background
 Methods
 Results
 Conclusions
 Funding
 Acknowledgements
References
 
We would like to thank the VIDUS participants for their ongoing contribution to the study and to the input of VIDUS' Community Advisory Board. We also thank Caitlin Johnston, Deborah Graham, Steve Kain, Peter Vann, Cody Callon, Sidney Crosby, Vanessa Volkommer, Aaron Eddie, Trevor Logan, Cristy Power, Daniel Kane and Calvin Lai for their administrative assistance for their administrative assistance. Evan Wood had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.


   Footnotes
 
{dagger} Presented in part at the 16th Annual Canadian Conference on HIV Research, Toronto, ON, Canada, 26–29 April 2007. Back


   References
TOP
 Background
 Methods
 Results
 Conclusions
 Funding
 Acknowledgements
 References
 

  1. Buavirat A, Page-Shafer K, van Griensven GJ, et al. Risk of prevalent HIV infection associated with incarceration among injecting drug users in Bangkok, Thailand: case-control study. BMJ (2003) 326(7384):308.[Abstract/Free Full Text]
  2. Dolan KA, Wodak A. HIV transmission in a prison system in an Australian state. Med J Aust (1999) 171(1):14–7.[Web of Science][Medline]
  3. Crofts N, Stewart T, Hearne P, et al. Spread of bloodborne viruses among Australian prison entrants. BMJ (1995) 310(6975):285–8.[Abstract/Free Full Text]
  4. Centers for Disease Control and Prevention (CDC), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Prevention and control of tuberculosis in correctional and detention facilities: recommendations from CDC, endorsed by the Advisory Council for the Elimination of Tuberculosis, the National Commission on Correctional Health Care, and the American Correctional Association. MMWR Recomm Rep (2006) 55(RR-9):1–44.[Medline]
  5. Centers for Disease Control and Prevention. Tuberculosis outbreaks in prison housing units for HIV-infected inmates—California, 1995–1996. MMWR Morb Mortal Wkly Rep (1999) 48(4):79–82.[Medline]
  6. Centers for Disease Control and Prevention. HIV transmission among male inmates in a state prison system—Georgia, 1992–2005. In: MMWR Morb Mortal Wkly Rep (2006) 55(15):421–26.[Medline]
  7. Gibbons JJ, Katzenbach NB. A report of the commission on safety and abuse in America's prisons. (2006) Washington, D.C: Vera Institute of Justice.
  8. Correctional Services of Canada. Infectious Disease Prevention and Control in Canadian Federal Penitentiaries 2000–01 (2003) Ottawa: Correctional Services Canada.
  9. Flanigan TP, Rich JD, Spaulding A. HIV care among incarcerated persons: a missed opportunity. AIDS (1999) 13(17):2475.[CrossRef][Web of Science][Medline]
  10. Martin RE, Gold F, Murphy W, et al. Drug use and risk of bloodborne infections: a survey of female prisoners in British Columbia. Can J Public Health (2005) 96(2):97–101.[Web of Science][Medline]
  11. Jurgens R, Kerr T, Lines R, et al. Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Expertise (2006) Toronto: Canadian HIV/AIDS Legal Network.
  12. Correctional investigator. Correctional Inverstigator's Analysis of CSC Action Plan in Response to the Report of the Canadian Human Rights Commission (2005) Ottawa: Correctional Investigator Canada.
  13. Okie S. Sex, drugs, prisons, and HIV. N Engl J Med (2007) 356(2):105–8.[Free Full Text]
  14. Spaulding A, Stephenson B, Macalino G, et al. Human immunodeficiency virus in correctional facilities: a review. Clin Infect Dis (2002) 35(3):305–12.[CrossRef][Web of Science][Medline]
  15. Freudenberg N. Jails, prisons, and the health of urban populations: a review of the impact of the correctional system on community health. J Urban Health (2001) 78(2):214–35.[Web of Science][Medline]
  16. Dufour A, Alary M, Poulin C, et al. Prevalence and risk behaviours for HIV infection among inmates of a provincial prison in Quebec City. AIDS (1996) 10(9):1009–15.[Web of Science][Medline]
  17. Hankins CA, Gendron S, Handley MA, et al. HIV infection among women in prison: an assessment of risk factors using a nonnominal methodology. Am J Public Health (1994) 84(10):1637–40.[Abstract/Free Full Text]
  18. Walmsley R. World Prison Population List (2003) London: International Centre for Prison Studies.
  19. Sarang A, Rhodes T, Platt L, et al. Drug injecting and syringe use in the HIV risk environment of Russian penitentiary institutions: qualitative study. Addiction (2006) 101(12):1787–96.[CrossRef][Web of Science][Medline]
  20. Tyndall MW, Currie S, Spittal P, et al. Intensive injection cocaine use as the primary risk factor in the Vancouver HIV-1 epidemic. AIDS (2003) 17(6):887–93.[CrossRef][Web of Science][Medline]
  21. Kaiser Network. California Gov. Schwarzenegger vetoes prison condom distribution bill. Kaiser Network. 2006-10-02.
  22. Department of Justice. Conditional Sentencing Reform Bill (Backgrounder) (2006) Ottawa: Department of Justice.
  23. Kerr T, Palepu A, Barness G, et al. Psychosocial determinants of adherence to highly active antiretroviral therapy among injection drug users in Vancouver. Antivir Ther (2004) 9(3):407–14.[Web of Science][Medline]
  24. Liang KY, Zeger SL. Longitudinal data using generalized linear models. Biometrika (1986) 73:13–22.[Abstract/Free Full Text]
  25. Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes. Biometrics (1986) 42(1):121–30.[CrossRef][Web of Science][Medline]
  26. Lipsitz SR, Molenberghs G, Fitzmaurice GM, et al. GEE with Gaussian estimation of the correlations when data are incomplete. Biometrics (2000) 56:528–36.[CrossRef][Web of Science][Medline]
  27. Wood E, Tyndall MW, Spittal PM, et al. Unsafe injection practices in a cohort of injection drug users in Vancouver: Could safer injecting rooms help? CMAJ (2001) 165(4):405–10.[Abstract/Free Full Text]
  28. Lines R. Action on HIV/AIDS in prisons: too little, too late—a report card (2002) Montreal: Canadian HIV/AIDS Legal Network.
  29. Polonsky S, Kerr S, Harris B, et al. HIV prevention in prisons and jails: obstacles and opportunities. Public Health Rep (1994) 109(5):615–25.[Web of Science][Medline]
  30. UNAIDS. Prisons and AIDS: UNAIDS Point of View (1997) Geneva: UNAIDS Information Centre.
  31. WHO. Status Paper on Prisons, Drugs and Harm Reduction (2005) Copenhagen: World Health Organization.
  32. Kim S, Coletti SD. Benefit-cost analysis of drug abuse prevention programs: a macroscopic approach. J Drug Educ (1995) 25(2):111.[Web of Science][Medline]
  33. Rehm J, Gschwend P, Steffen T, et al. Feasibility, safety, and efficacy of injectable heroin prescription for refractory opioid addicts: a follow-up study. Lancet (2001) 358(9291):1417–23.[CrossRef][Web of Science][Medline]
  34. Schackman BR, Gebo KA, Walensky RP, et al. The lifetime cost of current human immunodeficiency virus care in the United States. Med Care (2006) 44(11):990.[CrossRef][Web of Science][Medline]
  35. Levy AR, James D, Johnston KM, et al. The direct costs of HIV/AIDS care. Lancet Infect Dis (2006) 6(3):171–7.[CrossRef][Web of Science][Medline]
  36. Albert T, Williams G, Remis R, et al. Canadian Policy Research Network: The Economic Burden of HIV/AIDS in Canada (1998) Ottawa: Renouf Publishing Co. Ltd.
  37. Correctional Service Canada. HIV/AIDS in prisons: Final Report of the Expert Committee on AIDS and Prisons (1994) Ottawa: Minister of Supply and Services.
  38. Ehrmann T. Community-based organizations and HIV prevention for incarcerated populations: three HIV prevention program models. AIDS Educ Prev (2002) 14((5 Suppl B)):75–84.[CrossRef][Web of Science][Medline]
  39. Clarke JG, Stein MD, Hanna L, et al. Active and former injection drug users report of HIV risk behaviors during periods of incarceration. Subst Abus (2001) 22(4):209–16.[CrossRef][Medline]
  40. Centers for Disease Control and Prevention. HIV/AIDS education and prevention programs for adults in prisons and jails and juveniles in confinement facilities—United States, 1994. 1996. Report No 45.
  41. Small W, Kain S, Laliberte N, et al. Incarceration, addiction and harm reduction: inmates experience injecting drugs in prison. Subst Use Misuse (2005) 40(6):831–43.[CrossRef][Web of Science][Medline]
  42. CBC. Prison tattoo parlours get the axe. In: CBC (2006) Available at http://www.cbc.ca/canada/story/2006/12/04/tattoo-program.html (17 December 2006, date last accessed).
  43. Dolan K, Rutter S, Wodak AD. Prison-based syringe exchange programmes: a review of international research and development. Addiction (2003) 98(2):153–8.[CrossRef][Web of Science][Medline]
  44. World Health Organization. WHO guidelines on HIV infection and AIDS in prisons (1993) Geneva: WHO. Report No (WHO/GPA/DIR/93.3).
  45. Guardian. UK prisoner takes legal action on lack of needle exchange. Guardian (2005).
  46. Yirrell DL, Robertson P, Goldberg DJ, et al. Molecular investigation into outbreak of HIV in a Scottish prison. BMJ (1997) 314(7092):1446–50.[Abstract/Free Full Text]
  47. Des Jarlais DC, Paone D, Milliken J, et al. Audio-computer interviewing to measure risk behaviour for HIV among injecting drug users: a quasi-randomised trial. Lancet (1999) 353(9165):1657–61.[CrossRef][Web of Science][Medline]
  48. O'Callaghan F, Sonderegger N, Klag S. Drug and crime cycle: evaluating traditional methods versus diversion strategies for drug-related offences. Aus Psych (2004) 39(3):188.[CrossRef]
  49. Broner N, Mayrl DW, Landsberg G. Outcomes of mandated and nonmandated New York City jail diversion for offenders with alcohol, drug and mental disorders. Prison J (2005) 85(1):18.[CrossRef]
  50. Zaric GS, Barnett PG, Brandeau ML. HIV transmission and the cost-effectiveness of methadone maintenance. Am J Pub Health (2000) 90(7):1100–11.[Abstract/Free Full Text]

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?



This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
30/2/126    most recent
fdn021v1
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (3)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Werb, D.
Right arrow Articles by Wood, E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Werb, D.
Right arrow Articles by Wood, E.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?