HIV prevention in prisons HIV prevention in prisons --

Experience of BulgariaExperience of BulgariaEighth Meeting of the Eighth Meeting of the ““HIV/AIDS Think TankHIV/AIDS Think Tank””

25 and 26 April 2007 Luxembourg, Jean Monnet building25 and 26 April 2007 Luxembourg, Jean Monnet building, ,

MINISTRY OF HEALTH

Hristo TaskovNational Center of Infectious and Parasitic Diseases at MoH, Sofia

REPUBLIC of BULGARIAREPUBLIC of BULGARIA

Country profileCountry profile

–– Area : 111Area : 111,,000 km000 km22

–– Population: 7.6 millions (millions Population: 7.6 millions (millions according to NSI, 2001 census)according to NSI, 2001 census)

Bulgarian 84.5%Bulgarian 84.5%Turkish 9.6%Turkish 9.6%Roma 4.1% Roma 4.1% other and unspecified 1.8% other and unspecified 1.8%

–– Municipalities: 28Municipalities: 28–– GDP: 77 billions USDGDP: 77 billions USD–– GNI per capita:GNI per capita: 33,,450 USD450 USD– Life expectance: 72.5 years–– Population growth rate:Population growth rate:

--0.837% (NSI, 2006)0.837% (NSI, 2006)–– Unemployment:Unemployment: 9% (according to 9% (according to

NSI, 2006)NSI, 2006)–– Poverty Headcount ratio: 6.4%Poverty Headcount ratio: 6.4%

* Data from National Statistical Institute * Data from National Statistical Institute and World Bankand World Bank

Source: Ministry of Health, 2007

Registered HIV cases - newly registered and cumulative number per year, Bulgaria, 1986-2006

4 45 67 87 91 98 109121139153187217243270319359402465515

598689

4

41

22 20

4 711 12

1814

3430

26 27

49

40 43

63

50

83

91

0

100

200

300

400

500

600

700

800

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006

Cum

ulat

ive

num

ber

of r

egis

tere

d H

IV c

ases

0

10

20

30

40

50

60

70

80

90

100

New

ly r

egis

tere

d ca

ses

per

year

Cumulative number Newly registered

State of HIV infection in Bulgaria (1)State of HIV infection in Bulgaria (1)

Modes of transmission of the HIV infection, Bulgaria, 1986-2006

Sexual transmission

87%

Mother-to-child transmission

1%

Injecting drug use9%

Infected blood and blood products*

3%

* Last cases registered in 1996

Distribution of HIV cases by gender, Bulgaria, 1986-2005

Male67,3%

Female32,7%

State of HIV infection in Bulgaria (2)State of HIV infection in Bulgaria (2)

Source: Ministry of Health, 2007

New registered HIV cases in New registered HIV cases in 20062006

–– 91 cases91 cases

Diagnostic testing Diagnostic testing -- 1616Screening testingScreening testing–– Blood donors Blood donors -- 77–– Pregnant Pregnant -- 22–– IVDUIVDU -- 3232–– PrisonersPrisoners -- 33–– Others Others (manly from (manly from VCTsVCTs) ) -- 3131

From them referred by From them referred by VCTsVCTs -- 4040

Penal InstitutionsPenal InstitutionsMINISTRY OF JUSTICEMINISTRY OF JUSTICE–– 12 prisons,12 prisons,–– 1 correctional place for minors (161 correctional place for minors (16--18 years)18 years)

Number of prisoners in Bulgaria

9102 9390 9 888

11 289

0

2000

4000

6000

8000

10000

12000

14000

2001 2002 2003 2005Year

Num

ber o

f pris

oner

s

Map of prisonsMap of prisons

National HIV/AIDS Framework National HIV/AIDS Framework and basis for HIV prevention, testing, and basis for HIV prevention, testing,

treatment and care in prisonstreatment and care in prisons

National Strategy and National National Strategy and National Action PlanAction Plan for Prevention and Control of for Prevention and Control of HIV/AIDS and STDs (2001HIV/AIDS and STDs (2001--2007)2007)

Target Groups of the Target Groups of the National HIV/AIDS program 2001National HIV/AIDS program 2001--20072007

Injecting drug usersInjecting drug users

Sex workersSex workers

Roma peopleRoma people

Men having sex with menMen having sex with men

Prisoners Prisoners Young peopleYoung people

People living with HIVPeople living with HIV

People living with TBPeople living with TB

National HIV/AIDS Framework National HIV/AIDS Framework and basis for HIV prevention, testing, and basis for HIV prevention, testing,

treatment and care in prisonstreatment and care in prisons

National Strategy and National Action PlanNational Strategy and National Action Plan for for Prevention and Control of HIV/AIDS and STDs (2001Prevention and Control of HIV/AIDS and STDs (2001--2007)2007)

Program Program ““Prevention and Control of Prevention and Control of HIV/AIDSHIV/AIDS””,, implemented with a Global implemented with a Global Fund grant (2004 Fund grant (2004 -- 2008)2008)

104

26

26

63

25

Razgrad

Program “Prevention and Control of HIV/AIDS”

InjectingDrug Users

Roma community

CommercialSex Workers

Young People

Local AIDS CoordinatingOffices

SecondGeneration

SentinelSurveillance

Units

Prevention ofHIV/AIDS among: MAP OF ACTIVITIES

VCT Centers

Operating

Planned

16 VCT site

11 Mobile units

8 Health centers for Roma population

5 Drop-in Centers for IDUs

VCT services networkVCT services networkanonymous free of chargeanonymous free of charge

National HIV/AIDS Framework National HIV/AIDS Framework and basis for HIV prevention, testing, and basis for HIV prevention, testing,

treatment and care in prisonstreatment and care in prisons

National Strategy and National Action PlanNational Strategy and National Action Plan for for Prevention and Control of HIV/AIDS and STDs (2001Prevention and Control of HIV/AIDS and STDs (2001--2007)2007)

Program Program ““Prevention and Control of HIV/AIDSPrevention and Control of HIV/AIDS””, , implemented with a Global Fund grant (2004 implemented with a Global Fund grant (2004 -- 2008)2008)

Regulation Regulation №№ 12 of the Ministry of 12 of the Ministry of JusticeJustice for medical care for confined for medical care for confined persons in effect from January 2007persons in effect from January 2007

Regulation Regulation №№ 12 of the Ministry of Justice 12 of the Ministry of Justice for medical care for confined personsfor medical care for confined persons

ArticleArticle. . 36.36.

(2) (2) HIV testing is offered at the time of HIV testing is offered at the time of imprisonment as screening.imprisonment as screening.

(3) (3) Diagnostic HIV testing is offered during Diagnostic HIV testing is offered during the of imprisonment.the of imprisonment.

(4) (4) Screening and diagnostic HIV testing are Screening and diagnostic HIV testing are offered following the principles of offered following the principles of confidentiality, informed consent and the right to confidentiality, informed consent and the right to refuse. refuse.

Regulation Regulation №№ 12 of the Ministry of Justice 12 of the Ministry of Justice for medical care for confined personsfor medical care for confined persons

(5) (5) Voluntary and anonymous HIV Voluntary and anonymous HIV counseling and testing is ensured for counseling and testing is ensured for all inmates.all inmates.

(6) HIV positive people are (6) HIV positive people are guaranteed:guaranteed:-- confidentiality of their HIV status;confidentiality of their HIV status;-- medical examination, antiretroviral medical examination, antiretroviral

treatment and care. treatment and care.

HIV surveillance in prisonsHIV surveillance in prisons

ProviderProvider--initiating initiating testingtesting (screening and (screening and diagnostic)diagnostic)–– optopt--in, with in, with informed consent and informed consent and right to refuseright to refuse

ClientClient--initiated testinginitiated testing ––anonymous voluntary anonymous voluntary counseling and testing counseling and testing (VCT)(VCT)

22ndnd generation sentinel generation sentinel surveillance surveillance –– biological biological and behavioral dataand behavioral data

Number of HIV+ prisoners by years

1

2 2

7 7

5

0

1

2

3

4

5

6

7

8

2002 2003 2004 2005 2006 April 2007

Num

ber o

f cas

es

HIV second generation sentinel HIV second generation sentinel surveillance in prisonssurveillance in prisons

Started in 2006 in 4 Started in 2006 in 4 prisonsprisons600 prisoners:600 prisoners:–– tested for HIV, HBV, tested for HIV, HBV,

HCV and SyphilisHCV and Syphilis–– collection of collection of

behavioral databehavioral dataPlaned for 2007:Planed for 2007:–– In 5 prisonsIn 5 prisons–– 750 prisoners750 prisoners

Places for 2-nd generation sentinel surveillance

in prisons

Places for 2-nd generation sentinel surveillance

in prisons

Biological data from SGSSBiological data from SGSS-- 2006 2006 average for the countryaverage for the country

Biological results of Inmates from SGSS 2006

0%

12%

14%

6%

0%

2%

4%

6%

8%

10%

12%

14%

16%

1

% p

ositi

ve

HIV HBV HCV Syphilis

n=600

8%

31%

5%

21%

7%5%

9%7%

5%

9% 9%7%

0

0,05

0,1

0,15

0,2

0,25

0,3

0,35

HBV HCV Syphilis

SofiaBurgasPlevenStara Zagora

Biological data from Biological data from SGSSSGSS--2006 2006 –– by citiesby cities

N= 150Per city

National HIV/AIDS Framework National HIV/AIDS Framework and basis for HIV prevention, testing, and basis for HIV prevention, testing,

treatment and care in prisonstreatment and care in prisons

National Strategy and National Action PlanNational Strategy and National Action Plan for Prevention and for Prevention and Control of HIV/AIDS and STDs (2001Control of HIV/AIDS and STDs (2001--2007)2007)

Program Program ““Prevention and Control of HIV/AIDSPrevention and Control of HIV/AIDS””, implemented , implemented with a Global Fund grant (2004 with a Global Fund grant (2004 -- 2008)2008)

Regulation Regulation №№ 12 of the Ministry of Justice 12 of the Ministry of Justice for medical care for for medical care for confined persons in effect from January 2007confined persons in effect from January 2007

Joint Order of the Minister of Health and Joint Order of the Minister of Health and the Minister of Justicethe Minister of Justice, regulating outreach , regulating outreach activities of the VCT centres in prisons (2007 activities of the VCT centres in prisons (2007 ––2008)2008)

HIV voluntary counseling, testing HIV voluntary counseling, testing and prevention in prisonsand prevention in prisons

Provided by the VCT Provided by the VCT centers centers Counseling and Counseling and testing for HIV, HBV, testing for HIV, HBV, HCV and Syphilis HCV and Syphilis Distribution of Distribution of information materials information materials and condomsand condomsScalingScaling--up:up:–– 2005 2005 –– in 2 prisonsin 2 prisons–– 2006 2006 -- in 5 prisonsin 5 prisons–– 2007 2007 -- in all prisonsin all prisons

Network for VCT services in prisons2007

Performance results of VCT Performance results of VCT centers in prisonscenters in prisons

Total number of prisoners Total number of prisoners counseled and testedcounseled and tested

(2005 (2005 –– March 2007)March 2007)

–– for HIV 2,826for HIV 2,826

–– For Syphilis 1,767For Syphilis 1,767

Number of prisoner tested per month

64

113

235

17

86

175

0

50

100

150

200

250

2005 2006 2007

Num

ber

of p

rison

ers

HIV Syphilis

Number and percentage of cases Number and percentage of cases positive for HIV and Syphilispositive for HIV and Syphilis

HIV cases among tested prisoners

0

1

2

3

4

5

6

7

8

2005 2006 2007

Num

ber o

f H

IV +

cas

es

No positive % positive

1 0.1

2

0.1%

5

0.7%

n=765 n=1357 n=704March

Syphilis cases among tested prisoners

0

10

20

30

40

50

2005 2006 2007

Num

ber o

f H

IV +

cas

es

No positive % positiven=207 n=1034 n=526

March

26

13%

45

4.4%

26

4.9%

New registered HIV cases in New registered HIV cases in 20062006

–– 91 cases91 cases

Diagnostic testing Diagnostic testing -- 1616Screening testingScreening testing–– Blood donors Blood donors -- 77–– Pregnant Pregnant -- 22–– IVDUIVDU -- 3232–– PrisonersPrisoners -- 33–– Others Others (manly from (manly from VCTsVCTs) ) -- 3131

From them referred by From them referred by VCTsVCTs -- 4040

Treatment and care for HIV Treatment and care for HIV infected prisonersinfected prisoners

All HIV+ prisoners have access to treatment All HIV+ prisoners have access to treatment and careand careFollowFollow--up and ART are provided by 4 AIDS up and ART are provided by 4 AIDS treatment centers.treatment centers.Treatment protocol is consistent with the Treatment protocol is consistent with the ““European Guidelines for the Clinical Management European Guidelines for the Clinical Management and Treatment of HIV Infected Adults in Europe and Treatment of HIV Infected Adults in Europe 20052005””Monitoring of patientsMonitoring of patients::–– Before ART Before ART -- every 6 monthsevery 6 months–– During ART :During ART :

Clinical examination Clinical examination –– every monthevery monthCD4 and viral load CD4 and viral load –– every 3every 3--4 months4 monthsResistance testing Resistance testing -- in case of treatment failurein case of treatment failure

Treatment and care for HIV Treatment and care for HIV infected prisonersinfected prisoners

Number of HIV+ prisoners receiving ART

1

2 2

7 7

5

1

0

1

6

7

2

0

1

2

3

4

5

6

7

8

2002 2003 2004 2005 2006 April2007

Num

ber

HIV + cases Receiving ART

CONCLUSIONSCONCLUSIONSPOSITIVE ACHIEVEMENTS:POSITIVE ACHIEVEMENTS:

All forms of HIV testing in prisons are voluntary.All forms of HIV testing in prisons are voluntary.Confidentiality is guaranteed by regulation.Confidentiality is guaranteed by regulation.All prisons are covered by anonymous All prisons are covered by anonymous VCTVCTservices. services. VCTVCT staff distributes information materials and staff distributes information materials and condoms.condoms.HIV 2HIV 2--nd nd generation sentinel surveillance is generation sentinel surveillance is introduced successfully in prisons.introduced successfully in prisons.Methadone treatment is allowed from outside.Methadone treatment is allowed from outside.All HIV+ prisoners have access to monitoring of All HIV+ prisoners have access to monitoring of disease and antiretroviral treatment according the disease and antiretroviral treatment according the National guidelinesNational guidelines

CONCLUSIONSCONCLUSIONS

PROBLEMS TO BE RESOLVED:PROBLEMS TO BE RESOLVED:

Training of medical staff in prisons for HIV Training of medical staff in prisons for HIV counseling and testing.counseling and testing.To make To make accessaccess to to condoms easy.condoms easy.

Distribution of clean injecting equipment for drug Distribution of clean injecting equipment for drug users is not allowed in prisons. users is not allowed in prisons.

The 2004 criminalization of the possession of a The 2004 criminalization of the possession of a single dose of illegal drugs have increased the single dose of illegal drugs have increased the number of drug users in the prisons and number of drug users in the prisons and impeded HIV prevention interventions among impeded HIV prevention interventions among IDUsIDUs..

Thank youThank you

National HIV/AIDS Framework National HIV/AIDS Framework and basis for HIV prevention, testing, and basis for HIV prevention, testing,

treatment and care in prisonstreatment and care in prisons

National Strategy and National Action PlanNational Strategy and National Action Plan for for Prevention and Control of HIV/AIDS and STDs (2001Prevention and Control of HIV/AIDS and STDs (2001--2007)2007)

Program Program ““Prevention and Control of HIV/AIDSPrevention and Control of HIV/AIDS””,,implemented with a Global Fund grant (2004 implemented with a Global Fund grant (2004 -- 2008)2008)

Regulation Regulation №№ 12 of the Ministry of Justice12 of the Ministry of Justice for for medical care for confined persons in effect from January medical care for confined persons in effect from January 20072007

Joint Order of the Minister of Health and the Joint Order of the Minister of Health and the Minister of JusticeMinister of Justice, regulating outreach activities of , regulating outreach activities of the VCT centres in prisons (2007 the VCT centres in prisons (2007 –– 2008)2008)

This paper was produced for a meeting organized by Health & Consumer Protection DG and represents the views of its author on thesubject. These views have not been adopted or in any way approved by the Commission and should not be relied upon as a statement of the Commission's or Health & Consumer Protection DG's views. The European Commission does not guarantee the accuracy of the dataincluded in this paper, nor does it accept responsibility for any use made thereof.