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Tackling Blood-borne Viruses in Prison - Uk Report 2007

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Tackling Blood Borne Viruses
in Prison – A framework for best
practice in the UK.


Why tackle BBVs?
Who is this guide for?


The Four Key Aims


Strategic Policy and Leadership


Introducing the Prisoner Pathway


Reception and Induction


Custody and Transfers


Release and Resettlement


Involving Community Partners


Meeting the Needs of Staff

10 Promoting Health and Equality
11 Useful Websites and Acknowledgements
12 References
13 Appendices

APRIL 2007

1 Why tackle blood-borne viruses?
1 Why tackle blood-borne viruses?
There has never been a more urgent need for prisons in the UK to tackle
the spread of blood-borne viruses (BBVs). BBVs are viral infections
passed between people through blood or other bodily fluids. BBVs can
cause severe illness and death. Those of greatest concern in the prison
context are HIV and hepatitis B (HBV) and C (HCV). You can find out
more about BBVs in Appendix 2.

Key Fact:
63% of 2654 IDUs surveyed
in England and Wales had
been in a prison or a young
offenders’ establishment 30% with a history of
imprisonment had been in
prison at least five times.
16% of those who had been
in prison reported injecting
whilst in prison.5

Prisoners are some of the most vulnerable people in the UK to BBV
infection. Why?
• Because there is evidence of higher rates of BBVs amongst
those received into the prison system.
• Because the sharing of injecting equipment for drug use poses
a very high risk of BBV transmission – a high proportion of
injecting drug users (IDUs) will be incarcerated at some point,
often more than once.1
• Because there is some evidence that people who offend are at
greater risk of BBV exposure due to heightened sexual risk taking.2
• Because prisons are an environment where risk practices
(sharing injecting equipment, unprotected sex and tattooing)
may continue to take place.3,4
Prisons are not isolated institutions and failing to respond effectively to
BBVs puts everyone at risk; prisoners, staff, their families and the wider
community. As well as harming individuals, BBV infection also uses up
valuable prison healthcare resources. Yet BBVs are preventable
diseases. As professionals responsible for healthcare of people in prison
you owe it to prisoners and staff to accord the issue its proper priority
and government policy makes it clear what is expected.6,7,8
Fortunately, there are prisons all over the country doing good work to get
to grips with the problem. Simple measures can often make a big impact.
In this guide, we aim to give accessible advice about what needs to be
done and how services for people in prison around the country can move
forward. We know that local circumstances can vary and that prison
health services will be at different stages of development in their
responses to BBVs. The important point is to make progress towards
best practice. In this guide, we aim to assist you to think through where
your establishment is now and where you would like to be. Whatever
stage you are at, we intend that there will be useful guidance and tips for
you and your establishment.
Who is this guide for?
This guide is intended as a practical resource for those who have
responsibilities for the health and well being of prisoners and prison staff
in the UK. In particular this is aimed at Prison Governors, Heads of
Healthcare, Commissioners and other responsible staff in primary care
trusts and health boards, and healthcare professionals who work with
prisoners and prison staff. It will also be a valuable tool for those
responsible for inspection, audit and performance management in
We are indebted to the Expert Working Group that informed the
development of this guide. Members are listed in Appendix 1.
APRIL 2007

2 The four key aims
2 The four key aims
In order to strategically plan the response to tackling BBVs in your
prison, it is necessary to be clear about what you are trying to achieve.
There will be at least four key aims to strive for and to check progress
against. These are:

Practice Idea:
Don’t ‘re-invent the wheel’.
Use professional networks to
identify prisons with
established BBV policies –
these can easily be adapted
to your establishment's


HIV and Hep C are a bigger

problem than you know. I know
a lot of lads with Hep and they
don’t take precautions as
people might suspect them of
having something. Prisons run
on fear and people don’t want
to make their lives more


difficult. Male Prisoner 11

Processes must be in place to prevent the onward transmission
of BBVs.
This requires:
• prisoners and staff must understand what BBVs are, how they are
transmitted and how this can be prevented,
• prisoners and staff also having the means to prevent the
transmission of BBVs. For example, it is less than helpful to
instruct prisoners and staff on the value of HBV vaccination
without making it available.
Processes must be in place to enable the early diagnosis of BBVs.
This requires:
• the availability of free, voluntary and confidential testing services,
with pre and post test discussion provided in accordance with good
practice guidelines, [See UK National Guidelines on HIV
testing 2006, and Hepatitis C: essential information for
professionals and guidance on testing 2004.9, 10
• the availability of information for prisoners and staff about what
BBV tests are currently available and what the results mean.
High quality treatment and care for those infected with BBVs must
be available.
This requires:
• access to high quality, confidential, clinical primary care services,
with expertise in BBVs,
• access to high quality, confidential secondary care, which should
include, hepatology services, genitourinary medicine (GUM),
substance misuse treatment, mental health services and advice
and social support.
• dedicated outreach into prisons of relevant health services to
minimise the need for movement of prisoners between different
The prison environment must be one where prisoners and staff are
treated with respect and robust action is taken to prevent and respond
to stigmatising or discriminatory treatment of anyone because they have
(or are suspected of having) a BBV infection.
This requires:
• educational interventions for prisoners and staff that challenge
myths and inaccuracies about BBVs, raise awareness about the
harm that discriminatory practice can cause (e.g. poor prison
relations, reluctance to test) and allow people to clarify
understandings and unwarranted fears,
• robust policies that clearly state that discrimination related to BBV
infection will not be tolerated, and the measures that will be
enacted to prevent and respond to it.
In the following sections, we will be looking in more detail about how
these aims can be met in practice but here it is important to say that
these four elements are the essential features that every establishment
should be working towards in its response to BBVs in prison.
APRIL 2007

3 Strategic policy and leadership
3 Strategic policy and leadership
Leadership and policy development are important to ‘prepare the ground’
for any changes that an effective strategic response to BBVs may entail.
This should include five key elements:

Demonstrating leadership – Professionals providing services for prisoners
must strongly communicate that BBV work is a priority. How can this
be done?
• by taking personal responsibility for setting in motion the necessary
strategic development processes
• by assembling the right team to take work forward
• by ensuring the team has sufficient seniority to take decisions and
implement them.
• by giving them the resources and authority to do
what is necessary
• by taking a personal interest in monitoring results.
Allocating responsibility – Responsibility for tackling BBVs in prison is
shared between the prison service, the local NHS, local community
organisations and prisoners themselves. The following therefore need to
be included in determining the response for your prison:
• custodial staff
• healthcare managers
• NHS commissioners
• primary and secondary healthcare staff
• substance misuse workers
• external professionals providing health and social care services.

Practice Idea:
Don’t assume that allocating
responsibility means yet
another working group existing prison working
groups on drugs, healthcare
services or other aspects of
prison management can take
on the role, with newly coopted members if necessary.

It would be good practice to involve prisoners (or their advocates) as
appropriate. It is vital to be explicit about accountabilities; no-one should
be in any doubt about what they are expected to contribute to the
prison’s efforts to tackle BBVs.

Developing a policy – A written prison policy is necessary to clearly
communicate a service’s intended aims and actions to tackle BBVs.
Some ideas for what this might include are detailed in our checklist
overleaf. This need not be a lengthy or complex document. Existing
policies can be updated or elements of other policies incorporated (e.g.
health and safety, drugs, equality or confidentiality policies etc.). National
guidance is available and your policy should take account of this.12,13
Involving staff – It is important to bring all relevant staff groups on board
early and proper consultation is essential. This should include:
• information on the urgency of addressing BBVs in prison and the
benefit to staff, prisoners and the community alike,
• clarity on the policy and resulting actions to be taken,
• education and advice that gives factual information as well as
enabling staff to clarify uncertainties and safely discuss anxieties,
• building competencies by providing practice-based instruction on
what staff need to do to prevent the spread of BBVs and how to
relate in a professional and non-discriminatory way to those who
are infected or at risk.

APRIL 2007

3 Strategic policy and leadership
Leadership is especially important here; staff should understand that the
agenda on tackling BBVs must move forward and that a well-planned
strategic response is the best way to protect the interests of all who live
and work in prisons.

Working in partnership – Prisons working alone cannot effectively tackle
BBVs and neither should they be expected to. Commissioning of prison
health services is now the responsibility of the NHS and Commissioners
must be assertively encouraged and enabled to play their part. Many nonstatutory organisations have a history of effective work with prisons but
many more could make a real contribution to prison BBV work if they
were supported and encouraged to take the first step. It is important to
work together to identify the mutual benefits of greater involvement of
community services and voluntary organisations, and overcome any
barriers that currently hinder this.

Your BBV Policy – A Checklist

• Basic facts: how BBVs are spread, prevented and treated.
Why prisons and PCTs must respond effectively.

• The aims and objectives of the policy. How it will be
monitored and updated. Who is responsible for it.

• Measures to be taken to educate and inform prisoners
and staff about BBVs.

• Guidance on minimising the risk of BBV exposure for staff
and prisoners and responding to exposure incidents.

• Services to enable prisoners to be confidentially vaccinated
and/or tested, and have access to treatment for BBVs.

• Relevant occupational health arrangements for staff.14
• Measures to support and advise infected prisoners
and staff.

• Measures to support continuity of care into
the community.

• Policy statements on confidentiality, non-discrimination and
respectful treatment.

• Sources of further information and advice.

APRIL 2007

4 Introducing the prisoner pathway
4 Introducing the prisoner pathway
A potentially helpful model for strategically planning your response is to
map out the prisoner’s experience as a pathway through incarceration.
Our model (see Appendix 3) maps this out in four key stages; yours might
include more detail relating to the unique features of your prison. The
objective is to identify specific points in the pathway where there are
opportunities to take action.

Reception (custody period = 24hrs to 1 week) – This can be a difficult
and stressful time, especially for new prisoners but there is potential to
identify prisoners at risk so that follow-up testing, treatment and support
can be provided and to get immediate treatment to those who need it.
Super-accelerated HBV vaccination can commence (see phase 1 for
Phase 1 (custody period = 1 month or less) – During this period, basic
awareness-raising should take place and BBV testing should be offered,
with signposting to appropriate services in the community for those
released. While many prisoners will be detained for only a short time,
HBV vaccination for those over 18 can be completed in 21 days using a
super-accelerated schedule (0, 7, 21 days). For young offenders aged
up to 18, the attending physician can prescribe the super-accelerated
schedule on an individual basis. Where this is not possible, the
accelerated schedule should be used (0, 1, 2 months).
Phase 2 (custody period = 2–5 months) – For those detained for several
months, there are opportunities to carry out more involved interventions.
By this time, all consenting prisoners should have been fully vaccinated
(three doses) against HBV. Health education should be provided that
enables prisoners to assess personal risk and complete voluntary BBV
testing. Secondary care treatment (e.g. GUM, hepatology) should be
accessed where necessary and social and psychological support should
be offered for prisoners who need help in coming to terms with a positive
diagnosis. Risk reduction and harm minimisation education is vital for all
those diagnosed or at risk.
Phase 3 (custody period = 6 months or more) – At this stage, treatment
relationships with external secondary care providers (hepatology, GUM)
should be well established for those diagnosed positive, where
appropriate. The emphasis should also be on social and psychological
support for living with a long-term condition (particularly for those with
HCV and HIV).
Transfer – For transferred prisoners, continuity of care is vital to enable
HBV vaccination to be completed and outstanding BBV test results to be
appropriately communicated. The principle of continuity of care applies to
any BBV treatment commenced to minimise the disruption caused. This
is particularly important in the case of anti-retroviral therapy for those
living with HIV where even missing a single dose can have serious
health implications.

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4 Introducing the prisoner pathway

Resettlement – Specific BBV related needs must be integrated into
release planning. The aim should be to ensure that prisoners are linked
into local primary care and community services and that there is minimal
disruption to ongoing clinical treatment. Access to ongoing drug
treatment and mental health support will be vital for many. Access to
benefits, employment/training, suitable accommodation and family/social
support are also vital in providing a stable environment that can help
prisoners to reduce their risk-taking and better cope with any positive
diagnosis received.
A flexible and sustainable approach based on steady progress offers the
best method for equipping staff and prisoners with the knowledge,
competencies and means to prevent BBV transmission and respond to
the needs of those infected. In the following sections we look at these
aspects in more detail.

HMP Buckley Hall – HCV Clinic
HMP Buckley Hall won a Butler Trust
award in 2000 for its exceptional
work in addressing HCV infection
among prisoners. A (PCT funded)
HCV clinic is provided twice weekly
and staffed by two specially trained
Anonymous and confidential HCV
testing is offered as part of the
initial reception health screen. An
HCV clinic referral will be made if
requested and following reported
risk behaviour. Patients are usually
seen within 1-2 weeks. Nurses
assess the need for testing and
provide pre and post test
information and advice. Where
indicated and requested by the
patient, blood testing is carried out.
Results are usually obtained within
six weeks.
If negative, individualised harm
minimisation education is provided.
A positive result leads to additional
counselling to enable the patient to
understand the result and come to
terms with the diagnosis.
Experience indicates that clinic
access in the days following a
positive diagnosis is especially
important. As well as written
information, individual contact has
proved important in responding to
prisoner needs.
Referrals are made to NHS
hepatology services where there are
three or more months to serve. If
serving a shorter sentence, the
prisoner will be signposted to a GP
in his area of residence. HIV testing
is also offered and HIV positive
patients are referred to in-reach
GUM services. The clinic is now
seeking to establish an HCV support
group for prisoners.
For further information:
Sarah Gordon, HMP Buckley Hall,
01706 514300

APRIL 2007

5 Reception and induction
5 Reception and induction
Experienced prison staff know that reception is a time of particularly
heightened vulnerability for many prisoners, especially those imprisoned
for the first time. Clearly, reception is not the right time to begin complex
BBV related work when there may well be other seemingly more pressing
needs. However, there are a significant number of key actions that can
be taken to prepare the ground for more involved activities at a later
stage. HBV vaccination for those over 18 can be completed in 21 days
using a super-accelerated schedule (0, 7, 21 days). For young offenders
aged up to 18, the attending physician can prescribe the superaccelerated schedule on an individual basis. Where this is not possible,
the accelerated schedule should be used (0, 1, 2 months).

Practice Idea:
NAM produces a poster that
depicts the major ART
drugs. This can be used to
help a confused or uncertain
prisoner to identify their
current treatment
Contact NAM for details,
020 7840 0050

Reception – Every prisoner must undergo health reception screening.
This presents an important opportunity to:
• identify those already being treated for BBVs – this is very
important in the case of prisoners taking HIV anti-retroviral therapy
(see below),
• identify those at significant risk due to injecting drug misuse or
other risk for follow-up within one month.
Induction – Arrangements to induct prisoners into the establishment will
vary but it is customary to include information about healthcare services.
This can be used as an opportunity to inform prisoners, without
unnecessarily alarming them, about the risks of BBV transmission, the
steps the prison is taking to control the risk and how prisoners can
access HBV vaccination and BBV testing, treatment and support. This is
an opportunity to provide basic facts, which can be followed up with more
in-depth education and individualised support as necessary. As well as
factual information, induction is an opportunity to assert the prison’s
ethos and values that discriminatory behaviour related to BBV status is
unacceptable. The goal is to create a climate where those at risk feel
able to access healthcare services and support. Done well, it also
imparts the message that the establishment takes prisoner welfare
Prisoners and HIV Anti-retroviral Treatment
Reception health screening must urgently prioritise continuity of HIV AntiRetroviral Treatment (ART) for prisoners who are taking it. Here, nothing
less than excellence in practice will do. ART is a drug combination taken
to control the replication of HIV in the body and to protect the immune
system. It is literally life-saving medication. Getting the drug combination
right can be complex and ART can be a demanding treatment regime to
follow: drugs have to be taken in the correct sequence, at the right time
according to specific instructions - some must be taken with food, some
must be refrigerated. At least 95% adherence to treatment is required
-` even one or two missed doses can be seriously problematic.15

APRIL 2007

5 Reception and induction
As well as the health implications, treatment disruption is likely to cause
very significant anxiety to any prisoner receiving ART. Every prison must
therefore have the following in place:
• a clinical protocol for the management of newly received prisoners
taking ART followed by referral to an HIV specialist as soon as is
practicable but no later than two months of reception,
• immediate access to supplies of drugs making up common
ART combinations,
• referral to an HIV specialist within one month if there is any
change or interruption in treatment. Local HIV specialists should
be consulted for advice.

Induction & Reception – A Checklist

• Use the full reception healthcare screening process to
identify BBV related risk and offer HBV vaccination – put
mechanisms in place for trained staff to confidentially follow
this up.

• Ensure that the induction process includes brief
information about what BBVs are and how they are prevented
and treated. Stress prison-related risks: sharing injecting
equipment, tattooing and unprotected sex.

• Inform prisoners about how they can access items to help
them to avoid risk while in prison: e.g. condoms, disinfectant

• Inform prisoners about the BBV related services available:
HBV vaccination, BBV testing and treatment, and how they
can access them. Stress that services are voluntary
and confidential.

• Give accessible, written information that reinforces verbal

• Identify a named individual that prisoners can access in
confidence for information or advice about the services

• Ensure that BBVs are included in instruction about equality
and anti-bullying. Prisoners and staff need to understand that
bullying, harassment, speculation or gossip related to
another’s BBV status is unacceptable and could be
considered a breach of discipline.

APRIL 2007

6 Custody and transfers
6 Custody and transfers
The length of a prisoner’s sentence will determine how much work can be
done regarding BBVs. Naturally, the aim is to do as much as possible to
meet prisoner needs in whatever time is available and to assure
continuity when the prisoner is released or transferred. Appendix 3
presents a timeline for the completion of key tasks. However, your own
map of the prisoner pathway should identify what is feasible for your
establishment (but note – every single dose of HBV vaccination is
important). Remember, the aim is progress – your own map and
strategy should be realistic but challenging. The following sections
outline the custody phases in more detail.

Custody phase 1 (1 month or less) – a significant number of prisoners
will spend a month or less in prison. Therefore, the aim here is to build
upon reception and induction activities (see section 5) or to prepare the
prisoner for transfer or release. During this phase, in addition to
reception/induction activities, the following should be completed:
• Every prisoner already receiving anti-retroviral or HCV treatment
should have their treatment immediately maintained and be under
the care of a specialist consultant.
• Every prisoner requiring it should be under the care of clinical staff
and CARATs regarding substance misuse needs. This should
include maintenance therapy where clinically indicated and harm
minimisation advice that includes information on BBVs.16
• HBV vaccinations should be completed (on a super-accelerated
schedule). This should include information on how prisoners can
complete vaccination and receive a booster in the community if
released before completion.
• All prisoners requiring them should have begun to obtain condoms,
dental dams and disinfectant tablets where available (see Condoms
and Syringes - Current Policy).

Phase 2 (2–5 months) – Building on phase 1, the emphasis here should
be on enabling prisoners to gain more detailed information, to assess
their own risk behaviour and to consider the benefit of BBV testing via
personalised information and advice. This can be done by prison
healthcare staff or visiting professionals. Access to secondary care
services for those who need them following testing should be initiated.
During this phase:
• Prisoners involved in injecting drug use should be offered an
appointment with a nurse or other advisor that includes an
assessment of personal risk of BBV infection and information about
currently available tests and treatments. For those undergoing
BBV testing, pre and post-test discussion is essential.
• Results for HIV tests should be returned within one week. For an
HCV test, enough blood should be taken so that if the initial antiHCV test is positive, it can be followed immediately by an HCV RNA
test and the results given at the same time. Results should be
returned within two weeks. Risk reduction advice for all, with
psychological support for those testing positive will be important to
accompany this testing process.

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6 Custody and transfers
• Referral to NHS hepatology or HIV specialists where appropriate,
according to locally developed management protocols, must be
arranged without delay when a positive diagnosis is received.
• Every prisoner who requires ongoing access to condoms or
(where available) disinfectant tablets must be in receipt of them.

Phase 3 (6 months or more) – During this phase there are two key
priorities – ensuring that uninfected prisoners remain so during
imprisonment and providing coordinated, ongoing medical treatment
and support to infected prisoners who need it. During this phase:
• There must be continuing access to condoms.
• Disinfectant tablets should be made available to clean drugs
paraphanalia for those who continue to use in prison.
• Treatment relationships with HIV and/or hepatology specialists
should be well underway, as should tailored substance misuse
• Those following medication regimes must be enabled and
supported to follow them. Prison pharmacists can assist by
developing appropriate drug administration protocols and advising
prisoners on adherence. Care must be taken to ensure that
medication administration does not inadvertently lead to disclosure
of a prisoner's BBV status. Wherever possible, in-possession
medication should be encouraged.
• Psychological and social support should be offered to enable
infected prisoners to come to terms with living with a long-term
condition and, within the limits of prison life, to make the
lifestyle changes necessary to preserve and improve their health.
A range of staff can assist, including GUM advisors, nutritionists,
substance misuse workers, physical education staff, counsellors
and mental health professionals as well as primary and secondary
care staff and custody officers.

HMP Wandsworth –
THT In-reach
Since 2005, a partnership between
HMP Wandsworth and the Terrence
Higgins Trust (THT) has led to the
provision of one-to-one support and
information sessions for prisoners.
An innovative aspect of the project is
that appointments can be arranged
via other prisoners providing peer
support. For some prisoners, this
enables greater accessibility as they
do not have to make their request
via an officer or member of
healthcare staff.
Workers from the Outreach team at
THT visit the prison on a monthly
basis giving confidential information
and support. This may address
issues such as sexual health,
sexuality, discrimination,
relationships or HIV, as well as
broader aspects of prison life. The
team cannot issue condoms but can
signpost on how these can be
obtained within the prison. The team
see around 6-8 men per visit. The
in-reach activity is funded by THT.
For further information: Keith
Burgess, Head of Onslow Centre,
HMP Wandsworth, 020 8588
4000, or Stephen Connolly, LADS
Team, Terrence Higgins Trust,
020 7812 1600

Transfer – Because the prison population is a highly mobile one, as far as
possible, BBV-related needs must be integrated into planning for transfer.
Key factors to consider in relation to transfer issues are outlined in our
queries checklist overleaf. Local arrangements in your prison will inform
how these issues are addressed but it will be important to reassure
prisoners that as far as possible, steps have been taken to minimise
disruption. Remember, what may be routine administrative issues for
the establishment can be regarded by prisoners as very serious
medical concerns (e.g. ensuring the continuity of ART treatment).

APRIL 2007

6 Custody and transfers
Condoms and Syringes – Current Policy
Ultimately, much BBV related work in prisons aims to educate
prisoners to adopt less risky behaviours. This requires giving them
the means to do so. It is important to have an accurate
understanding of what the national policy position is on providing
access to condoms and clean syringes.

Condom distribution –
England and Wales – prisons can make condoms, dental dams and
water based lubricants available to prisoners via the ‘Dear Dr. letter’
policy where there is a sexual risk of HIV transmission.17 A Patient
Group Directive (PGD) can be helpful in enabling nursing staff to
‘prescribe’ condoms. Best practice is to distribute condoms through
prison nurses under a PGD directive with no questions asked.
Scotland – Condom and dental dam provision was successfully
piloted in HMP Greenock in 2005. The provision of condoms and
dental dams have been adopted as policy and this is now in the
stage of implementation across the Scottish Prison estate.
Northern Ireland – At the time of publication condoms are not
available for prisoners.
Clean injecting equipment –
Currently, no UK prison offers needle exchange (NEX). However, the
Scottish Prison Service hopes to pilot NEX starting in late 2007.
HMP Aberdeen has been providing injecting paraphernalia such as
citric, water, swabs, spoons and information on safer injecting since
late 2005. The Scottish Prison Service also stores needle exchange
packs for prisoners on reception into prison and returns them on
release, if they are still required.

Practice Idea:
As well as updated Inmate
Medical Records, record
HBV vaccinations on a small
card, to be retained by
prisoners. Prisoners could
give this to staff following
transfer allowing nurses to
easily identify those with
injections outstanding.

In the absence of NEX, disinfectant tablets are available to prisoners
in Scotland and, following a pilot in four prisons in late 2006, will be
rolled out nationally in England and Wales in early 2007.
In Northern Ireland, there is no provision of disinfectant tablets.

The position is clear – in England, Wales and Scotland there is no
bar on the provision of condoms to prisoners and indeed prisons
are expected to make them available where there is a risk of HIV
transmission. Disinfectant tablets should also be made available.

APRIL 2007

6 Custody and transfers
Transfer Questions and Concerns:
• Is it in the prisoner’s interests to suggest a ‘medical
hold’ to preserve continuity of external specialist
hepatology/HIV treatment? Ask the prisoner's
HIV/hepatitis clinician for their view on the medical
advisability/timing of transfer, giving them at least 24
hours notice.
• Is the Inmate Medical Record (IMR) comprehensive
and up-to-date regarding BBV-related needs/treatment?
• How will any outstanding BBV test results be
communicated following the move?
• If the prisoner is taking complex medication (e.g. ART
or Interferon), have prior arrangements been made with
the new prison to continue this without disruption?
• If the prisoner is accessing condoms or disinfectant
tablets to reduce risk, will they be able to obtain them in
the new prison?

HMP Maghaberry, Northern Ireland – Drugs & BBV Risk
Funded by HMP Maghaberry, Northlands drugs workers and trained custodial staff
deliver a 10-week group-based educational and support intervention for prisoners.
Using a harm-minimisation approach, the programme examines the broader
aspects of drug-related risk (physical, social, emotional and legal). One of the
sessions is entirely devoted to BBVs. A Home Office educational video is used to
introduce the subject, which was produced for a prison audience. Participants are
given factual information, often by a member of the medical services team. This is
followed by a group discussion where participants can clarify information and
discuss issues from their own perspective.

HMP Littlehey – Real Voices
HMP Littlehey’s award-winning Real
Voices project was set up in 2002
in collaboration with local NHS
services. The aims of the project
are to reduce isolation by giving
prisoners a forum to discuss issues
of sexuality in a secure, safe, and
non-judgemental environment; to
promote safer sexual practices
through health education; and to
promote HBV vaccination/testing
and testing for HIV. The project also
‘prescribes’ condoms in accordance
with a locally devised protocol.
The project advertises within the
prison and is usually oversubscribed,
attracting 25 – 30 men to each
monthly session. Prisoners help to
set the agenda and can raise
problems and issues related to sex
and sexuality; obtaining information
and advice where needed. Outside
speakers, videos and group work
helps to stimulate discussion. This
might focus on issues of identity,
relationships, sexual health,
discrimination etc.
Some participants are living with HIV
and the group benefits from visits by
the local HIV Nurse Specialist, HIV
counsellor and HIV social worker.
Referrals can be made within the
prison to the GUM clinic session for
confidential HIV and Hepatitis
testing. Referrals can also be made
to secondary care services in the
community where necessary. The
Clinical Nurse Manager, who leads
this groundbreaking project, has
found that it has helped to foster
greater awareness among staff and
prisoners alike regarding sexual
diversity and given prisoners a
valued space to enhance their sexual
health in a broader sense. The
project is supported by
Huntingdonshire PCT.
For further information: Helen
Burr, Clinical Nurse Manager,
HMP Littlehey, 01480 333 000

Although written materials are available, facilitators have found that prisoners
appreciate the opportunity for discussion and this is especially important for
prisoners with low basic skills levels.
For further information: Christine McClements, Northlands, 028 777 204 86

APRIL 2007

7 Release and Resettlement
7 Release and Resettlement
The resettlement of prisoners is a specialist and complex area of
offender management requiring skilled multi-agency intervention. While
every prisoner is unique, the general resettlement needs of prisoners are
well known. These generally include:
• Secure and appropriate accommodation
• Education and training
• Employment (people living with HIV may face particular barriers in
finding employment)
• Fast and efficient access to welfare benefits
• Ongoing substance misuse treatment
• Ongoing mental health services and continuity of healthcare
• Support in re-establishing and rebuilding relationships with
families 18
Effective resettlement benefits prisoners in numerous ways. Done well, it
can also address BBV-related needs. For example, it is obvious that
secure accommodation, employment and substance misuse treatment
are critical in enabling prisoners to move away from chaotic lifestyles
where BBV risk behaviour is more likely. However, in addition to meeting
general resettlement needs, some prisoners will have specific BBV
related needs; either because they are living with a BBV or remain at
considerable risk. Therefore, vulnerable prisoners should be:

Practice Idea:
Organise supervised sessions
where prisoners due for release
can make free calls to NHS
Direct. NHS Direct provides
information on accessing local
NHS services including GPs.
The telephone could be system
‘locked’ to dial only NHS Direct
numbers. A risk-assessed
prisoner could be trained to
assist with the administration of
the sessions under the
supervision of resettlement
NHS Direct - England, Wales &
Northern Ireland: 0845 46 47
NHS Direct - Scotland:
08454 24 24 24

• Supported and enabled to identify a GP in their intended area of
residence via prison resettlement services (see practice idea).
• Provided with appropriate appointments with GUM or other clinics
arranged before discharge.
• Offered HBV vaccination for sexual partners of prisoners via their
GP, this can be offered through an anonymous scheme whereby
the partner’s details are given to the local Consultant in
Communicable Disease Control (CCDC) for contact tracing
and action.
• Assured of continuity of any BBV-related clinical care initiated in
prison via effective liaison between prison and community
healthcare services. Ideally, secondary care providers in the
community should be notified of planned release in advance
wherever possible. Protocols must be developed to facilitate
appropriate sharing of prisoners’ personal healthcare information
in accordance with data protection requirements.
• Given adequate supplies of medication to cover the transitional
period. While this will be informed by clinical judgement, the
amount given should be sufficient to cover circumstances where
prisoners experience extended delays in accessing healthcare
services in the community.
• Effectively referred via CARATS to community drug treatment
teams that can offer harm minimisation approaches in the
community, including Needle Exchange (NEX). Those previously
involved in chaotic forms of sex work should also be advised of any
local support projects.

APRIL 2007

7 Release and Resettlement
Ensuring Positive Futures


EPF is an innovative
employability programme for
people living with HIV in the
UK. Careers advice, training
and welfare support are just
some of the ways that the
programme works with HIV
positive people to help them
train, find employment and
retain jobs. The programme is
open to all HIV positive people
including ex-offenders. The
programme also works with
employers and trade unions
to create a fair working
environment for HIV
positive people. See
for more details.


Practice Idea:
The Telephone Helpline
Association publishes a
directory of over 1000 UKbased helplines responding to
issues such as: health, disability,
mental health, children and
young people, rape and sexual
abuse, drugs and alcohol, HIV
and AIDS, hepatitis C, family
and parenting and legal and civil
rights. Prison education
services could work with
prisoners to identify and develop
a list of local helplines for your
area. An attractively designed
and appropriately presented list
could then be given to prisoners
prior to release.
The directory costs £20 and
can be ordered on Tel:
020 7939 0641
For more information see:

• Signposted, via resettlement services, to local and national
telephone helplines and crisis services that can assist. This should
include those specifically offering support to those living with BBVs.
A simple information resource, designed with prisoners in mind,
should be made available to all released prisoners (see practice
Presented below are the goals of resettlement as defined by HMPS for
England and Wales. It is important to remember that involving prisoners
as much as possible in arranging their own healthcare prior to release is
a highly desirable resettlement activity in its own right, which can
contribute to broader resettlement aims.

The Goals of Resettlement


In general terms, a resettlement regime:
concentrates on preparation for release and
resettlement; reduces institutionalisation;
requires prisoners to exercise considerable
and increasing levels of personal
responsibility; accords prisoners considerable
and increasing levels of trust; progressively
tests the ability of prisoners to function
independently and in the community; and
enables prisoners to return to the community
with a reduced risk of re-offending and risk of
harm to the public.19


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8 Involving community partners
8 Involving community partners


Voluntary and community
organisations are an
established part of the
services and support in many
relationship between the
Prison Service and voluntary
and community groups is likely
to grow rather than diminish
as the Prison Service begins
to focus more on resettlement
and reduction in the rates of
re-offending. It is therefore
vital that this relationship
should be made to work as
effectively as possible.” Rt.
Hon Paul Boateng MP, then
Minister for Prisons and
Probation, 2001 23


Practice Idea:
Avoid the trap of allowing
partnerships with external
agencies to become ‘stale’
and continue out of habit.
New organisations are
regularly formed that may
better meet your strategic
aims. The strategy
development group should be
tasked with devising
mechanisms for keeping this
under review.

It is well established that external agencies have a vital role to play in
many facets of prison work. CLINKS (the national organisation supporting
voluntary work with offenders) claims that over 900 voluntary
organisations provide over 2000 services to offenders, with more than
7000 volunteers contributing to offender rehabilitation.20 However, some
organisations can still experience a ‘glass wall’, which makes it more
difficult for them to gain access to prisons. This is especially the case for
organisations working with prisoners from minority ethnic backgrounds,
lesbian and gay prisoners and those focussing on HIV and AIDS.21 Yet
these are often the very organisations with the greatest expertise in
BBV-related work. It is therefore important to:
• Review the profile of voluntary and community organisations
working in your prison and ensure that organisations with specific
BBV expertise are included.
• If not, identify the barriers to their involvement and use your
strategic plan to devise actions to attract and integrate them.
• Where there are already such organisations in place, keep
relationships under regular review (see practice idea).
CLINKS offers general good practice guidance on partnerships with
voluntary and community organisations as well as an online directory of
organisations already working in prisons.22 Reproduced overleaf is their
list of key questions to consider in initiating new relationships with
external voluntary and community organisations. In addition to general
principles, the following issues may require consideration when initiating
new partnerships with organisations specialising in BBV-related work:
• Many such agencies utilise harm minimisation approaches in
relation to drug misuse and sexual risk. Misunderstanding and
differences in organisational culture can lead to tensions if not
addressed. This needs to be discussed and resolved before work
• Given the stigma and discrimination attached to BBVs, especially
HIV, organisations working in this field are often highly conscious of
issues of disclosure and confidentiality and will expect to work to a
high standard in this regard. Explicit negotiation will need to take
place to maintain a balance between observing strict confidentiality
and the expectations of prisons regarding disclosure of
information. Discussions should also consider mutually acceptable
operational arrangements for ensuring that prisoners can access
in-reach services confidentially.
• Due to their historical origins, many such organisations have a
‘user-led’ ethos and include staff and volunteers with direct
experience of the issues they address (e.g. former drug users, HIV
positive people, gay men etc.). Steps must be taken to ensure
that anti-discriminatory policy, practice and procedure offers equal
protection from discrimination for external workers in the prison.

APRIL 2007

8 Involving community partners

HMP Holloway –
Positively Women
Positively Women (a national
women’s HIV charity) and the
Women’s Health Clinic at HMP
Holloway (provided by the Royal Free
Hospital NHS Trust) work
collaboratively to provide a highly
responsive advice and support
service for women prisoners living
with HIV. The collaboration builds on
the long-term relationship that
Positively Women has with HMP
Working in partnership with the
clinic Health Advisors, Positively
Women’s Drugs and Prison Worker
offers person-centred support to
clients in living well with HIV and
addressing the multifaceted
problems that HIV positive women in
prison face. Clients are referred via
the clinic and can obtain advice and
support on a range of issues
affecting them.

Key Questions for Initiating New Working
• Who are you going to invite?
• What role do you see them playing?
• Why do you want to involve external organisations in
your work?
• Where are they going to work and who is going to
support them?
• When do you want them to start and how often will
you want them to come into your establishment: daily,
weekly monthly etc.?
• How will their involvement be organised? 22

A significant number of clients are
injecting drug users and/or sex
workers and experience has shown
that for many, issues of HIV run
alongside concerns about substance
misuse, immigration, childcare and
mental health. Responding to their
needs as women living with HIV
generally requires a holistic and
multi-agency response, which the
Drugs and Prison Worker seeks to
For further information:
Maria Hortelao, Positively Women,
020 7713 0444

APRIL 2007

9 Meeting the needs of staff
9 Meeting the needs of staff
This section should be read in conjunction with the appropriate Health
and Safety and Occupational Health guidance for the prison service as a
whole and your establishment. There is a legal obligation to look after the
health and safety of all prison staff and this includes reducing the risk
from BBVs as far as is reasonably practicable. See the ‘Key Resources’
box overleaf for BBV-related guidance.

Training - All staff should receive ongoing BBV training to enable them to
identify the risks of transmission and how to prevent them. Advanced
training can include more about living with BBVs, from treatment to the
stigma and discrimination faced by people living with BBVs, and
particularly HIV. You may want to consider bringing in people from
voluntary or community organisations as part of the training. It will be
important to make clear the need to treat prisoners living with BBVs
without stigma or discrimination. Training can enable staff to protect
themselves and reduce discrimination. As a more realistic understanding
of transmission risks develop, the risk of discriminatory treatment of
prisoners with BBVs can be reduced.

Practice Idea:
In addition to putting PEP
arrangements in place with
your main healthcare
provider, contact your local
casualty department to
discuss arrangements for
out-of-hours treatments.

Prevention - The risk of transmission of BBVs from prisoners to prison
staff is very small providing proper risk-reduction steps are taken. All staff
should be made aware of established health and safety procedures and
how to follow them.
A vaccine exists for HBV and an immunisation programme should be set
up to minimise the likelihood of HBV transmission to those staff at risk as
required in England and Wales by PSO 8900 and recommended by the
Scottish Executive. This programme needs to have an identified
administrator who can liaise with either in-house or external occupational
health. All staff at risk of exposure should be offered immunisation and
must attend an initial appointment. The programme should be
monitored, audited and reviewed - careful record-keeping is also
essential. Annexe 9 to Guidance Note 02/2005, ‘Setting up an
Immunisation Programme for HMP staff’, provides very useful and
important detailed information.24

Dealing with exposure incidents - Staff should be made aware of what to
do when an exposure incident occurs. All exposure incidents should be
reported immediately and staff should be immediately referred to a
designated healthcare professional. There is post exposure prophylaxis
(PEP) treatment available for both HBV and HIV but it must be taken soon
after exposure. There is no PEP available for HCV. PSI 05/2007 25 sets
out the Prison Service arrangements in England for the treatment of staff
who may have been at risk of exposure to BBVs.
Post exposure treatment for HBV:
HBV immunoglobulin can be given after exposure to HBV to protect
against transmission. Treatment following exposure to HBV should be
given to all staff, whether vaccinated or not, as immunity to HBV may not
be total. It is most effective given within 48 hours of exposure.

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9 Meeting the needs of staff
Post Exposure treatment for HIV:
PEP for HIV is currently available for those exposed to HIV through
workplace accidents such as needle stick injuries. Studies have indicated
that PEP can reduce the risk of contracting HIV by 80%. Treatment
involves taking two to three pills a day for 28 days. There are severe side
effects, including diarrhoea, headaches and vomiting. To be most
effective PEP should be started within one hour of exposure but can be
started up to 72 hours after exposure.
The recent PSI (05/2007) provides new mandatory instructions in
relation to PEP for staff in England. Staff at risk of exposure need
information on risks, the need to be assessed for PEP following possible
significant exposure, and local arrangements for referral following such
exposure. The PSI includes a draft letter for the member of staff to take
with them to the occupational health or casualty department. You should
consult with your local units to set up a protocol for referring your staff
when required. This should ensure that staff are ‘fast-tracked’ given the
need for timely administration of PEP.

Staff awareness – A Checklist

Key Resources
Health and Safety Guidance
Note 02/2005
‘Risk Assessment and
Immunisation for
Communicable Disease’

• Staff are given training on BBVs, including risks of
transmission, prevention, PEP and treatment.

• An HBV Immunisation programme is in place, with an
identified administrator – all staff have initial appointment to
discuss immunisation.

• Staff are given information and training on stigma and
discrimination faced by people living with BBVs, particularly HIV

Annexe 9 to Guidance Note
02/2005 ‘Setting up an
Immunisation Programme for
HMP staff’
PSI 05/2007 [on PEP]
Amendment to PSO 8900 –
Occupational Health

• Staff are given accessible, written information that
reinforces verbal information.

• Full risk assessments are carried out to identify risks of
BBV transmission to staff.

• A named individual is identified that staff can access in
confidence for information or advice about the
services offered.

• Staff are given a BBV action card to ensure they
understand what to do in the event of exposure.

• A log is kept of all exposure incidents and action taken.
• There are clear procedures in place for following up
exposure incidents in order to learn from them.

APRIL 2007

10 Promoting health and equality
HIV and Disability
From December 2005, HIV
positive people are
considered to have a
disability according to the
provisions of the Disability
Discrimination Act 1995
from the moment of their
diagnosis. This means that
they enjoy the full protection
of the DDA as a person with
a disability. In addition, from
December 2006, public
bodies, including the prison
service have to comply with
the disability equality duty.
This is a legal duty to take
active steps to promote
equality for disabled people,
including people living with
HIV. To find out more see the
Point of Diagnosis website:
and NATs guide: HIV and
Your Disability Equality

10 Promoting health and equality
BBVs are not ‘socially neutral’ diseases – myths and beliefs can influence
the way that people affected or at risk are treated. Discrimination or
abuse related to BBVs, especially HIV, is often fuelled by ignorance about
how BBVs are transmitted and/or prejudice against the groups most
affected (in the UK, gay men, African communities, migrants and IDUs).
This can be linked to homophobia, racism or anti-immigration sentiment.
Whatever the cause, such discrimination has no place in society, and
that includes prisons, and must be effectively dealt with in order to
• Unprofessional behaviour from prison staff acting on their
prejudices rather than prioritising the welfare and rehabilitation
of prisoners.
• Bullying and intimidation among prisoners, with affected prisoners
excluded and victimised, also leading to discipline problems
for staff.
• BBV-related discrimination against staff, potentially leading to workrelated stress, absenteeism and ultimately disciplinary cases or
legal action.
• Breaches of prison service policy, the law and prisoner’s human
rights (see side bar on prisoners’ health and human rights).
Stigma and discrimination also hinder efforts to tackle BBV transmission
and provide good quality healthcare. This is recognised in the practice
codes of every major professional body governing healthcare in the UK.
Why is tackling discrimination so important in relation to BBVs?
• Because effective healthcare is compromised when people at risk
are afraid to come forward for BBV testing; missing out on advice
about changing behaviour and access to treatment. Treatment not
only saves lives but reduces infectiousness to others.
• Because stigma and discrimination create mistrust between
patients and healthcare providers that can threaten therapeutic
relationships beyond the provision of BBV-related care.
• Because stigma and discrimination are contrary to ‘the wholeprison’ approach to health promotion that every prison should be
striving for (see below).
It is an oversimplification to suggest that stigma and discrimination are
easily tackled but concrete actions can make a difference:
• Review policy – If necessary, update policies on equality and
diversity, disability and healthcare to ensure that they include clear
prohibitions against discrimination related to BBV or ‘health status’.
• Publicise the policy – Prominently display anti-discriminatory
statements using accessible language. Include specific reference to
HIV and hepatitis.
• Introduce genuine accountability – Prisoners and staff need to
know what to do if they believe discrimination has occurred.
Wherever the complaint originates, investigation must be fair,
independent and timely – justice must not only be done but be
seen to be done if people are to have faith in the complaints
APRIL 2007

10 Promoting health and equality
The Health Promoting
As part of the ‘decency
agenda’, prison service policy
requires that all prisons work
towards becoming ‘health
promoting prisons’. This
recognises that ‘health’ is
not something that
healthcare practitioners
alone create but is brought
about by reducing health
inequalities and attending to
the broader social and
environmental determinants
of health. See:
Health Promoting Prisons:
A Shared Approach
The Health Promoting Prison

• Educate and inform – Provide quality information for various prison
audiences. Look for creative approaches. Can BBVs be integrated
into broader prisoner education? Can staff use online resources
rather than relying on logistically difficult training sessions?
Remember, it is important to create safe opportunities to clarify
information and explore attitudes and values.

Prisoner Health and Human Rights
International treaties on health and human rights create consensus
and place obligations on signatory states to protect human health,
including that of prisoners. While a full overview cannot be given
here, some important provisions include:
• The International Covenant on Economic Social and Cultural
Rights (Article 12) “the right of everyone to the highest
attainable standard of physical and mental health.”
• The Convention on All Forms of Discrimination Against Women
(Article 12) “take all appropriate measures to eliminate
discrimination against women in the field of healthcare.”
• The Convention on the Rights of the Child (Article 24) “the right
of the child to the enjoyment of the highest attainable standard
of health and to facilities for the treatment of illness and
rehabilitation of health.”
• The European Convention on Human Rights places a duty to
protect people in detention from ‘inhuman or degrading
treatment’, which can include failure to provide adequate
medical care (Keenan vs. UK 2001).26

APRIL 2007

11 Useful websites and acknowledgements

11 Useful websites
National AIDS Trust


Hepatitis C

British Liver Trust

We would like to thank all those who contributed to the
development of this guide, particularly the Expert Working
Group (see Appendix 1), those who contributed practice
examples, and the Northmoor Trust for their generous
support of this project.
Additional thanks also go to:
Nicola Douglas
Andy Downs-Keen, Prison Advice and Care Trust
Mary Guinness, HM Prison Service
Stephen Heller-Murphy, Scottish Prison Service
Juliet Lyon, Prison Reform Trust
Joy Millward, Hepatitis C Trust
Anne Norton, HM Prison Service
Adrienne Testa, Health Protection Agency

APRIL 2007

12 References
12 References
1. Health Protection Agency (2003) Shooting Up: Infections
Among Injecting Drug Users in the United Kingdom 2002.
London: Health Protection Agency.
2. Strang, J., Heuston, J., Gossop, M. et al. (1998)
Research Findings 82: HIV/AIDS Risk Behaviour Among
Adult Male Prisoners. Home Office.

3. Centers for Disease Control and Prevention. (2006) HIV
Transmission Among Male Inmates in a State Prison System
– Georgia, 1992-2005. MMWR Weekly. April 21; 55(15):
4. Strang, J., Heuston, J., Whiteley, C., et al (2000) Is
Prison Tattooing a Risk Behaviour for HIV and Other
Viruses? Results From a National Survey of Prisoners in
England and Wales. Criminal Behaviour and Mental Health
10, 60-66.
5. Health Protection Agency (2003) Shooting Up: Infections
Among Injecting Drug Users in the United Kingdom 2002.
London: Health Protection Agency.
6. Department of Health (2004) Choosing Health. Making
Healthy Choices Easier. London: Department of Health.
7. Department of Health (2002) Health Promoting Prisons
– A Shared Approach. London: Department of Health.

11. National AIDS Trust & Prison Reform Trust (2005) HIV
and Hepatitis in UK Prisons. Addressing Prisoners’
Healthcare Needs. PRT: London.
12. HM Prison Service (01/06/1999) PSO 3845 Blood
Borne and Related Communicable Diseases
13. HM Prison Service (11/10/02) PSI 50/2001
Hepatitis C: Guidance for Those Working with Drug Users.
14. HM Prison Service (30/09/04) PSO 8900
Occupational Health
15. National AIDS Manual (2006) Living With HIV. London:
16. HM Prison Service (20/12/00) PSO 3550 Clinical
Services for Substance Misusers
17. HM Prison Service (28/7/06) Clinical Guidance Note Issuing Condoms to Prisoners
18. Home Office (2006) A Five Year Strategy for Protecting
the Public and Reducing Re-offending. London: Home Office.
19. HM Prison Service (23/10/01) PSO 2300
20. See
21. HMPS (2001) Getting It Right Together. Working with
the Voluntary and Community Sector.
22. See

8. Scottish Prison Service (2002) The Health Promoting
Prison. A Framework for Promoting Health in the Scottish
Prison Service. Edinburgh: Health Education Board
for Scotland.

23. HMPS (2002) Get Linked.

9. BASHH (2006) UK National Guidelines on HIV Testing

25. HHM Prison Service (05/2007) PSI 05/2007
Amendments to PSO 8900 Occupational Health

10. Department of Health (2004) Hepatitis C Essential
Information for Professionals and Guidance on Testing.
London: Department of Health

26.Lines, R (2006) 'A Duty to Protect' - Prisoners' Rights to
Health in International Human Rights Law. Presentation to
the International Prisoner Health Conference, June 19-20,
Tallinn, Estonia

24. HM Prison Service (02/2005) Guidance Note on
setting up an immunisation programme for HMP staff

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13 Appendix 1 Expert Working Group Members
13 Appendices
Appendix 1: List of
Expert Working Group
Appendix 2: BBVs –
The Basics
Appendix 3: Offender
Pathway Diagram
Appendix 4: Useful
Policy Documents

Appendix 1
Expert Working Group Members
All professional titles refer to those held by the individual at the time the
group was formed
Ms Caroline Broad
Health of Healthcare - HMP & YOI East Sutton Park
Mr Charles Bushell
General Secretary - Prison Governors Association
Mr Brian Caton
General Secretary - Prison Officers Association
Ms Zoe Couzens
Health Protection Specialist - Infection and Communicable Disease
Service, National Public Health Service for Wales
Dr Phil Evans
Clinical Director - HMP Wakefield
Dr Daniel Forton
Consultant Hepatologist, St George's Hospital
Mr Charles Gore
Chief Executive - Hepatitis C Trust
Ms Heather Gourlay
Infection Control Advisor - Scottish Prison Service
Mr Tony Hassall
Governor - HMP & YOI Holloway
Dr Richard Lau
Consultant in GU Medicine - Courtyard Clinic, St Georges NHS Trust
Dr Phillip McClements
Director of Prison Health, Department of Health, Social Services and
Public Safety (Northern Ireland)
Ms Alice Ann Murphy
BBV/Harm Reduction Nurse, HMP Shotts
Dr Autilia Newton
Consultant in Communicable Disease Control - Humber Health Protection
Ms Ann Norman
Nurse Advisor - Royal College of Nursing


13 Appendix 1
Dr Eamonn O'Moore
Consultant in Communicable Disease Control - Oxford City PCT
Dr Mary Piper
Senior Public Health Advisor - Prison Health
Mr John Podmore
Governor - HMP Brixton
Ms Josie Smith
Research Scientist - Infection and Communicable Disease Service,
National Public Health Service for Wales
Ms Nicole Strumpf
Drug and Prison Worker - Positively Women
Dr Alan Tang
Consultant in GU Medicine - Florey Unit, Royal Berkshire Hospital

APRIL 2007

13 Appendix 2 HBV - the Basics
Appendix 2. BBVs – the Basics
Hepatitis B (HBV)
HBV is a blood borne virus that causes hepatitis (inflammation of the
liver) and can also cause long-term liver damage. The incubation period
is 40-160 days. During the acute phase of the illness following exposure
many people may experience no symptoms while others may experience a
flu-like illness including a sore throat, tiredness, joint pains, loss of
appetite, nausea and vomiting. Acute infection can be severe causing
abdominal discomfort and jaundice. Mortality during the acute phase of
infection is less than 1 per cent. Failure to clear HBV infection after six
months leads to the chronic carrier state. Many people who become
chronic carriers have no symptoms and are unaware that they are
infected. These individuals will remain infectious and will be at risk of
developing cirrhosis and primary liver cancer.
The World Health Organization (WHO) estimates that in the UK the
prevalence of chronic HBV infection is low, at around 0.3 per cent of the
general population. However, HBV is more common in other parts of the
world such as South East Asia, Africa, the Middle and Far East and
Southern and Eastern Europe and due to the changing nature of
immigration to the UK, there is marked geographic variation in the rates
of HBV prevalence across the UK.
The virus is present in bodily fluids such as blood, semen, saliva and
vaginal fluid and is very infectious. Transmission routes are:
• Sharing injecting drug equipment, including spoons and filters.
• Sharing tattooing, acupuncture or piercing equipment.
• Unprotected sex.
• Contact with infected blood through an open wound, cut, scratch
or bite.
• Mother-to-baby during pregnancy and childbirth.
• Improperly sterilised medical equipment.
• Needle-stick injuries.
• Blood transfusions and organ donation in countries where blood is
not screened. 1
Prisoners are identified as being at particular risk of HBV. This relates
particularly to the high proportion of prisoners who have been (and/or
are) injecting drug users. The last survey on rates of blood borne viruses
in prisoners was conducted in 1998 and reported a HBV prevalence of 8
per cent among prisoners and 20 per cent among injecting drug users in
A vaccine is available and is 95 per cent effective at preventing infection
from HBV in uninfected individuals. 3
In prison settings it is recommended that the super-accelerated
vaccination schedule be used (0, 7, 21 days), with the first dose

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13 Appendix 2 HBV - the Basics
administered as part of the reception health check. The first dose of
vaccine will afford some level of protection. However, it is important to
complete all three doses, ideally with a booster vaccination at one year to
ensure full protection. Blood tests before or after vaccination are not
recommended in prison settings since prisons are considered a high risk
environment for HBV infection and there should be no delay in
vaccination. The HBV vaccine is very safe and there are no
contraindications from receiving extra doses.
• Get vaccinated.
• Keep cuts, scratches, bites new tattoos and open wounds clean
and covered with a waterproof plaster.
• If any blood spills occur, clean with disinfectant appropriate for
BBV hazard. 4
• Never share toothbrushes, razors, scissors, hair clippers or other
personal items that may come into contact with blood.
• Never share injecting drug equipment; this includes syringes,
filters, spoons and water as well as needles.
• Use disinfectant tablets to clean injecting equipment, razors etc
• Never share tattooing, acupuncture or body piercing equipment.
• Always practice safer sex, i.e. sex with a condom.
Symptoms may not develop for up to six months and some people may
experience no symptoms, yet still remain infectious. The main
symptoms are:
• Nausea
• Vomiting
• Stomach ache
• Diarrhoea 4
• Jaundice
If chronic HBV occurs, it can cause cirrhosis of the liver. Symptoms of
this include:
• Internal bleeding, identified by vomiting blood or blood in the faeces
(causing black, tarry faeces).
• Effects on the brain, such as loss of memory, slurred speech,
confusion and unconsciousness.
• Fluid retention.
• Liver cancer. 4
HBV is diagnosed by a simple blood test.
Liver function tests can also be carried out to measure substances in the
bloodstream that may indicate liver damage. A liver biopsy can be carried
out to assess the extent of damage.

Most people will recover from HBV without treatment. People who

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13 Appendix 2 HBV - the Basics
develop chronic HBV will be monitored by a liver specialist to determine
whether treatment is necessary. An antiviral treatment called Interferon
is the main way of treating HBV. It prevents the virus from replicating and
causing further liver damage.
Injections of the drug are given three times a week for at least three
months, with the patient administering their own injections. Interferon is
effective in 40 per cent of cases. 5 The treatment does cause side
effects in many people, including sickness, headaches, fever, tiredness,
muscle aches and depression. Regular check ups and blood tests are
needed to monitor the side effects.
Another available treatment is lamivudine. This does not work in all cases
and people can become resistant to it. It is taken in tablet form, once a
day for at least a year.
In severe cases of HBV, a liver transplant may be an option; this is
successful in 60-80% of people who are critically ill. The transplant does
not cure the virus and the new liver will become infected, which can
cause complications later. 6

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13 Appendix 2 HCV - the Basics
Hepatitis C (HCV)
HCV is a blood-borne virus that can severely damage the liver. Recent
research has shown that HCV can also affect other areas of the body,
including the immune system and the brain. The first six months following
infection is called the acute stage and around 20 per cent of people clear
the virus during this time without intervention. Most people, however, go
on to develop chronic HCV.
The main route of transmission for HCV is blood. It can be transmitted
• A small amount of infected blood getting into the bloodstream
through, for example, an open wound, cut or scratch.
• Sharing injecting drug use equipment.
• Sharing straws or rolled notes etc for drug use.
• Sharing or using unsterilised tattooing, acupuncture or body
piercing equipment.
• Sharing razors or toothbrushes.
• Mother-to-baby during pregnancy and birth. Breast-feeding is
thought to be safe if the mother has no symptoms. Although if the
mother has cracked and bleeding nipples and the baby has cuts in
the mouth there may be a risk.
• Unprotected sex, specifically where blood or trauma are involved.
Research has shown that transmission is rare but there is a
growing number of gay men contracting HCV through sex,
particularly if they are already infected with HIV and their immune
system is weak. It is also believed to be more likely in sex with
multiple partners, anal sex or where other sexually transmitted
infections are present.
• Medical or dental work abroad.
Prisoners are identified as being at particular risk of HCV. This relates
particularly to the high proportion of prisoners who have been (and/or
are) injecting drug users. The result is that HCV prevalence was
according to the most recently available data (1998) for England 7 per
cent among prisoners and 31 per cent among injecting drug users in
prison. 2
There is currently no vaccine for HCV.
• Keep cuts, scratches, and open wounds clean and covered with a
waterproof plaster.
• If any blood spills occur, clean with undiluted household bleach/
appropriate disinfectant. 4
• Never share toothbrushes, razors, scissors, or other personal
items that may come into contact with blood.
• Never share injecting drug equipment; this includes syringes,
filters, spoons and water as well as needles.
• Never share equipment for snorting drugs.
• Never share tattooing, acupuncture or body piercing equipment.
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13 Appendix 2 HCV - the Basics
• Always practice safer sex, i.e. sex with a condom.
• Wash your hands after any incident involving blood, whether it is
yours or somebody else’s.
• Wear disposable rubber gloves if handling anyone else’s blood or
anything that may be contaminated with blood.
Many people have no symptoms and can remain undiagnosed for years.
When symptoms do occur they can come and go and are often mistaken
for other illnesses. Symptoms include:
• Fatigue
• Anxiety
• Weight loss
• Alcohol intolerance
• Loss of appetite
• Pain around the liver
• Concentration problems
• Sickness/nausea
• Digestive problems
• Flu like symptoms (fever, headaches, chills and night sweats)
• Jaundice.
There seems to be no relationship between the degree of liver damage
and the experience of symptoms. The course of damage to the liver is
also varied although it typically occurs slowly over 20 to 40 years: some
people will progress to develop fibrosis and cirrhosis (scarring) of the
liver, liver cancer or end stage liver disease, which may ultimately require
a liver transplant, while others experience very little liver damage even
after many years. Symptoms of end stage liver disease include:
• Internal bleeding, identified by vomiting blood or blood in the faeces
(causing black, tarry faeces).
• Effects on the brain, such as loss of memory, slurred speech,
confusion and unconsciousness.
• Fluid retention.7
HCV is diagnosed through a series of blood tests. The first test looks to
see if antibodies to HCV are present in the body, indicating that infection
has taken place and the body is trying to fight the virus off. It can take up
to six months before antibodies become present, the ‘window period’.
If the first test is positive, a second test will take place on the same blood
sample to confirm that antibodies are present. If this test is also positive
a third test on a new sample may also take place. A positive result in
these cases means that the person has been exposed to HCV at some
point. It does not confirm if they are still infected or if the body has
cleared itself of the virus.
To establish whether a person is still infected further tests must take
place that look for the presence of the virus itself, rather than antibodies.
If this comes back negative than the person has been infected in the
past, but has cleared the virus and is no longer infected. If it is positive
then they currently have HCV. 7
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13 Appendix 2 HCV - the Basics
Not all people with HCV are considered suitable for treatment. In some
cases patients are simply monitored to see whether damage to the liver
is occurring or progressing.
Where treatment is advised, this is provided through combination therapy
of two drugs: Interferon and Ribavirin. Interferon is given by injection, and
patients must have either one or three injections a week (depending on
which version they are prescribed) for six to twelve months. Ribavirin is
taken orally, twice a day.
Treatment causes side effects in many. Side effects can include:
anaemia, depression, fatigue, nausea, headaches and flu like symptoms.
As a result of this regular monitoring and blood tests are required to
monitor treatment and side effects. Treatment for HCV is very
demanding and people undergoing it require a high level of commitment
and support from others.
As with HBV, in severe cases a liver transplant is sometimes beneficial,
although the new liver will become infected with HCV again.
All people with HCV require regular medical check ups by a specialist,
whether they are receiving treatment or not.

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13 Appendix 2 HIV - the Basics
HIV stands for Human Immunodeficiency Virus. It is the virus that causes
people to develop AIDS. HIV damages the body’s immune system, making
that person vulnerable to certain infections. Having HIV does not mean
that you have AIDS. It may take several years for HIV to damage the
immune system so much that a person becomes unwell. During that time
a person with HIV can be well and live with the virus for many years
without developing AIDS.
AIDS stands for Acquired Immune Deficiency Syndrome. A person is
considered to have AIDS when the immune system has become so weak
that it can no longer fight off a whole range of diseases with which it
would normally cope. If HIV is diagnosed late, treatment may be less
effective in preventing AIDS.
HIV can be transmitted through bodily fluids such as semen, vaginal
fluids, blood, and breast milk. It can be transmitted through:
• Unprotected vaginal or anal sex.
• Sharing injecting drug use equipment.
• Sharing tattooing, acupuncture or body piercing equipment.
• Mother-to-child, either during pregnancy, birth or through
• Donated blood, blood products or organs in countries where these
are not screened.
There is currently no vaccine available for HIV.
• Always practice safer sex, i.e. sex with a condom.
• Never share injecting drug equipment. This includes syringes,
filters, spoons and water as well as needles.
• Never share tattooing, acupuncture or body piercing equipment.
• Wear disposable rubber gloves if handling anyone else’s blood or
anything that may be contaminated with blood.
• Keep cuts, scratches, and open wounds clean and covered with a
waterproof plaster.
• If any blood spills occur, clean with undiluted household bleach.
There are no specific symptoms for HIV, although some people may
experience an illness after being exposed to HIV, this is called a ‘seroconversion illness’. Symptoms include:
• Prolonged fever (4 – 14 days) and aching limbs
• Red blotchy rash over the trunk
• Sore throat
• Ulceration in the mouth or genitals
• Diarrhoea
• Severe headaches
• Aversion to the light. 8

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13 Appendix 2 HIV - the Basics
The severity of symptoms varies between individuals and some may not
develop any symptoms at all. All the symptoms mentioned can also be
symptoms of other illnesses so their appearance should not be assumed
to mean a person is infected with HIV. After this, people with HIV can live
for years without developing any further signs of infection. As HIV
suppresses the immune system, the body becomes vulnerable to
opportunistic infections. These are illnesses that the body can usually
recover from quickly but as the immune system is damaged they become
more of a problem. Previously some of these illnesses were termed ‘AIDS
defining illnesses’ and their appearance resulted in a diagnosis of AIDS.
However, with the advent of treatment, the idea of AIDS defining illnesses
becomes less useful. A person can be diagnosed with AIDS, receive
treatment, and recover. For more information on the stages of HIV
infection go to
HIV is diagnosed through a blood test, which checks for antibodies to HIV.
If antibodies are present it shows that the person has been infected.
After a positive result, further tests can be done to measure the level of
HIV in a person’s blood and whether they need to start treatment to
contain the virus.
Treatment for HIV, called antiretroviral treatment (ART), is available and
slows the development of HIV in the body, ensuring people stay healthier
for longer. Treatment regimes usually involve taking several different pills
a day and can have significant side effects. These can include:
• Nausea/vomiting
• Headache
• Fever
• Fatigue
• Diarrhoea
• Fat redistribution
• Loss of appetite
• Skin rashes
• Flatulence
• Pancreatitis 9
When taking treatment for HIV it is important the drugs are taken at the
right dose, right time and in the way prescribed by the doctor (for
example, some drugs must be taken without food, some with high fat
food). If the treatment regime is not followed properly, for example if a
break in treatment occurs, the HIV inside the body can develop
resistance to the drugs and the treatment will fail. Even missing a few
doses or taking them late can be critical.

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13 Appendix 2 References
1. British Liver Trust (2006) HBV Fact Sheet, London: British Liver Trust
2. Weild AR, Gill ON, Bennett D, Livingstone SJ, Parry JV, Curran L.
Prevalence of HIV, hepatitis B, and hepatitis C antibodies in prisoners in
England and Wales: a national survey. Commun Dis Public Health. 2000
Jun;3(2):121–126. [PubMed]
3. WHO (2000) Hepatitis B Factsheet no 204,
4. HM Prison Service (01/2004) Guidance Note, Dirty Protests
5. Scully, L (1997) Treatment of Chronic HBV Virus Infection
6. British Liver Trust (2006) HBV fact sheet
7. +VE (2004) A rough guide to Hep C, Middlesex: How’s That Publishing
8. NAM (2006) Stages of HIV infection
9. +VE (2004) A rough guide to HIV, Middlesex: How’s That Publishing

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13 Appendix 3 Offender Pathway Diagram
Reception: 24hrs – 1 Week
Aims – 1) Identify prisoners at risk for
potential follow-up, 2) get immediate
treatment to those who need it, 3)
commence HBV vaccination programme.

Actions – Reception
Use reception health screen to identify those at risk and provide
ongoing BBV medication to those prescribed it prior to
Actions – Induction
Provide basic information about: 1) BBV risks, transmission and
treatment, 2) HBV Vaccination, HBV/HCV/HIV testing and
treatment services, 3) anti-discriminatory policy, 4) named
individual(s) for further information, 5) policy on access to condoms
and disinfectant tablets.
All prisoners offered HBV vaccination on super-accelerated schedule
(0, 7, 21days)

Phase 1: One Month or Less
Aims – 1) Continue HBV vaccination, 2)
initiate follow-up of prisoners identified
at risk.

Actions – 1) HBV vaccination schedule continued 2) raise
awareness of BBV testing, 3) those on medical treatment for BBV
infection under specialist care, 4) all prisoners requiring it under
clinical substance misuse care and CARATS support, 5) all
prisoners requiring them given regular access to condoms and/or
disinfectant tablets.

Phase 2: Two to Five Months
Aims –1) Enable prisoner to make informed
appraisal of risk, 2) enable prisoner to
access voluntary BBV testing, 3) establish
secondary care treatment pathways where
required, 4) enable prisoners to practice
ongoing risk reduction.

Actions – 1) Provide opportunity for individualised discussion with
healthcare professional on personal BBV risk, 2) offer voluntary BBV
testing and provide result(s), 3) arrange secondary care referrals as
appropriate, 4) provide ongoing access to condoms and
disinfection tablets.

Phase 3: Six Months Plus
Aims –1) Ongoing medical treatment and
care for those infected, 2) ongoing risk
reduction for those at risk of infection who
are currently BBV negative or of unknown
BBV status.

Actions – 1) Stable treatment relationships established for infected
prisoners with secondary care services, 2) social/psychological
support for those infected regarding living with a long-term
condition, 3) ongoing access to condoms and disinfectant tablets, 4)
ongoing access to information and advice on personal risk reduction
(including HBV vaccination for those not previously covered by initial
super-accelerated programme).

Resettlement Planning
Aims –1) Integration of BBV-related issues
into resettlement planning.

Actions – 1) Integrate awareness of BBV related needs into
planning for accommodation, employment, training/education,
family/social support, 2) provide assistance in identifying and
registering with a GP in the community, 3) where possible, liaise
with secondary care providers in advance regarding imminent
release, 4) ensure CARATS referral to community substance misuse
services where necessary, 5) arrange adequate supplies of
medication to cover transitional arrangements, 6) sign-post to local
and national BBV related support services.

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13 Appendix 4 Useful Policy Documents
Appendix 4: Useful Policy Documents
England and Wales
HM Prison Service (01/06/1999) PSO 3845 Blood Borne and Related
Communicable Diseases
HM Prison Service (11/10/02) PSI 50/2001 Hepatitis C: Guidance for
those working with drug users
HM Prison Service (20/12/00) PSO 3550 Clinical Services for
Substance Misusers
HM Prison Service (23/10/2003) PSO 3200 Health Promotion
HM Prison Service (29/05/02) PSI 25/2002 The Protection and Use
of Confidential Health Information in Prisons and Inter-agency
Information Sharing
HM Prison Service (15/06/2002) PS0 4190 Strategy for Working with
the Voluntary and Community Sector
HM Prison Service (2004) Performance Standards - Health Services
for Prisoners
HM Prison Service (30/09/04) PSO 8900 Occupational Health
HM Prison Service (05/2007) PSI 05/2007 Amendments to PSO
8900 Occupational Health
All of the above available from
HM Prison Service (02/2005) Guidance Note on setting up an
immunisation programme for HMP staff.
Department of Health (2002) Health Promoting Prisons – A Shared
Approach. London: Department of Health.
Department of Health (2001) The National Strategy for Sexual Health
and HIV. London: Department of Health.
National Offender Management Service (2005) Strategy for the
Management and Treatment of Problematic Drug Users within the
Correctional Services. NOMS
Department of Health (2004) Hepatitis C Action Plan for England.
London: Department of Health.

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13 Appendix 4 Useful Policy Documents
Scottish Prison Service (12/05/06) Health Care Standard 10.
Prescribing for Clinical Management of Drug and Alcohol Dependency.
Edinburgh: Scottish Prison Service.
Scottish Prison Service (2002) The Health Promoting Prison. A
Framework for Promoting Health in the Scottish Prison Service.
Edinburgh: Health Education Board for Scotland.
Scottish Prison Service (2005) The Direction of Harm Reduction in the
SPS. From Chaotic Drug Use to Abstinence. Edinburgh: Scottish
Prison Service.
Scottish Prison Service (undated) Health Needs Assessment.
Scottish Executive (2005) Hepatitis C: Proposed Action Plan in Scotland.
Edinburgh: Scottish Executive.
The Scottish Office (1999) Tackling Drugs in Scotland. Action in
Scottish Executive (2005) Respect and Responsibility Strategy and Action
Plan for Improving Sexual Health. Edinburgh: Scottish Executive.
Northern Ireland
Northern Ireland Prison Service (2005) Standing Order 10: Health Care
Northern Ireland Prison Service (2005) Standing Order 1: Reception,
Removal and Discharge
Northern Ireland Prison Service (2006) Policy on Alcohol and
Substance Misuse
Northern Ireland Office (1999) Drugs Strategy for Northern Ireland.
Belfast: Northern Ireland Office.

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