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Standing Committee on Health
04/05/2015
Hepatitis C in Australia

CARRUTHERS, Dr Susan, Research Fellow, National Drug Research Institute

DAVIES, Ms Catherine Ellen, Assistant Branch Secretary (Victoria) and Federal Vice President, CPSU-SPSF Group

DIDLICK, Mr John, Executive Officer, Hepatitis ACT

LOVEDAY, Mr Stuart Kinnoch, Chief Executive Officer, Hepatitis NSW

McDEVITT, Mr Vince, Australian Capital Territory Secretary, Community and Public Sector Union

MARTON, Ms Rebeka Romola, Industrial Officer, Western Australian Prison Officers' Union and CPSU-SPSF Group

MOORE, Adjunct Professor Michael John, Chief Executive Officer, Public Health Association of Australia

SMITH, Mr Andrew James, Assistant Secretary, Western Australian Prison Officers' Union

STOOVE, Associate Professor Mark Andrew, Private capacity

TYRRELL, Ms Helen, Chief Executive Officer, Hepatitis Australia

WALKER, Ms Melanie Jayne, Deputy Chief Executive Officer, Public Health Association of Australia

WRIGHT, Mr Troy Stephen, Senior Industrial Officer, Community and Public Sector Union

Committee met at 11:29

CHAIR ( Mr Irons ): I declare this hearing open in our inquiry into hepatitis C in Australia. This is a roundtable hearing. I think all of you have appeared before, so we will not go through the introductions, because we want to make sure we get the discussion going. Do you as witnesses appearing before the committee have any objection to being recorded by the media during participation in this roundtable hearing? No. If you have not already done so, please read the document on the witness table referring to parliamentary privilege. I will assume that you have all read it. Do you have any comments to make on the capacity in which you appear?

Prof. Moore : I am also an adjunct professor at the University of Canberra, and I am Vice-President and President-Elect of the World Federation of Public Health Associations.

CHAIR: Thank you. I ask a committee member to move that the media be allowed to film the proceedings today in accordance with the rules set down for committees, which include not interfering with committee proceedings and not taking footage or still images of members, committee staff, witnesses, papers or laptop screens.

Mr WATTS: So moved.

CHAIR: There being no objection, it is so resolved. Now I will ask each organisation to make a brief opening statements, of no more than three minutes. The reason for that is, if we make them too long, we will not get into any of the discussion, which is what this hearing is about. So, for each organisation, will have one person making a brief opening statement.

Dr Carruthers : What I am about to present is really the position of the National Drug Research Institute, which is based at Curtin University in Perth. Firstly, on the prevalence of hepatitis C, I just need to state that, while drugs and drug users remain criminalised, hep C will remain a major public health issue and transmission will continue to occur. That includes transmission within the prison system. NDRI is an advocate of needle and syringe programs in prisons. There is adequate evidence from across the world, mostly from the European countries but also from Iran, that needle and syringe programs in prisons are effective. They have not suffered from any of the adverse events that have been predicted. I would just like to remind everyone that the World Health Organization in 2005 stated:

When prison authorities have any evidence that injecting is occurring, they should consider an exchange scheme …

They also provided, at the same time, guidelines on how this might occur.

There is evidence that harm reduction measures can be adopted in prison settings with none of the feared negative consequences. The academic literature demonstrates quite clearly that this can occur. I presented this academic evidence when the inquiry was in Perth. One size does not fit all, however. The programs that are in place around the world would need to be modified, of course, to fit the Australian setting. But there are many examples of how this might work and the various models.

It might be an idea for prison officers to be able to go to some of these countries and actually see how these programs work. The languages may not be the same; the prison settings may not be the same; however, with more than 10 years now of successful needle and syringe programs in some prisons across Europe and in Iran, it really behoves us to take that evidence on board. Perhaps prison officers should go over there and see exactly how the prisons work, what the various programs are and how they work within and then come back and actually have a look at how these might work in the Australian setting.

Sharing is inevitable in the community. In the prison setting it is inevitable because there are no clean needles and syringes. We have ample evidence of some of the needles and syringes that are around prisons being used by 20, 30, 50, 100 different users, with very little opportunity to clean them between use.

The final point that I would like to make is that harm reduction education for prisoners is frequently discussed and, to a certain extent, occurs in most prisons. Prisons are state based institutions. Therefore, what happens in one state does not necessarily happen in another. However, in WA we do have a very good program called HIP HOP, which all prisoners are required to undertake.

In my most recent research in the private prison, prison officers told me that they had no idea what HIP HOP was. They had no idea what it told prisoners and it was suggested that some of the prison officers do take part in this program to see what sort of harm reduction and harm prevention material is being offered.

Another point I would like to make is that my own research in prisons in WA strongly suggests that prison officers have very little knowledge of drug use. They know about people's drug use, what drugs are available, what sorts of effects they have and what the charges are. But they said to me quite clearly that they did not understand what drug dependence was or the compulsion of some people to use drugs. Their view was: drugs are illegal, you should not use them. That, obviously, is the view of many in the community. However, if there were a greater understanding of drug dependence, the compulsion to use, why people use drugs in prison—and there are a variety of reasons—then I think we would go a long way to helping prison officers understand the situation in prisons.

CHAIR: Thank you. I will give you a minute's notice before the three minutes are up, just by tapping on this. We do need to keep it brief, so we can all have a say.

Prof. Stoove : I head the justice health and the HIV research programs at the Burnet Institute. I currently sit on the Victorian Justice Health Ministerial Advisory Committee. What I am about to say is not representative of the Burnet Institute or that committee; it is representative of my reading of the international evidence in relation to prison needle and syringe programs, and prevention.

I would first like to state that the most effective way of preventing the transmission of hepatitis C in prisons is not to incarcerate people for injecting related offences in the first place. There is a far greater benefit derived from dealing with and managing drug-using behaviours amongst offenders in the community than there is from imprisonment. Under Australia's current legislative and policy framework, how do we deal with prevention of hepatitis C in Australian prisons? In the current system I think the prevention of hepatitis C in prison is nigh on impossible.

In Australian prisons we grossly disproportionately incarcerate people with injecting-drug use histories. Many are currently dependent on injecting drugs—something that led to their incarceration in the first place. We incarcerate people in environments where injecting drugs is widely available and acknowledged to be widely available and in environments that have the highest clustered prevalence of hepatitis C in the country. We do this in an environment where we do not provide clean needles and syringes as the most effective way of preventing blood-borne viruses amongst people who inject drugs.

In my opinion, this situation represents a breach of human rights and is inconsistent with the established international legal principles, stating that prisoners should have access to health services available in their country without discrimination on legal grounds. It is also inconsistent with the 2012 standard guidelines for Corrections in Australia that states:

… provided with access to health care, to the same standard as in the community, in response to need, with an appropriate range of preventative services …

Needle and syringe programs constitute a fundamental part of the appropriate range of preventative services. NSPs are the most effective public health intervention in Australia for blood-borne virus prevention amongst people who inject drugs. The question therefore should be: why is Australia yet to even trial a prison NESP?

Opponents have tended to focus on two points. Firstly, workplace health and safety concerns and, secondly, condoning and encouraging illicit drug use amongst prisoners or prisoners returning to or continuing drug use in custody. These are legitimate concerns, but what does the international evidence say here? Thirteen countries around the world have implemented NSPs since Switzerland first introduced one in 1992.

The large amount of evidence reported publicly on these experiences in those prisons suggests that there are no reported incidents of needles and syringes being used as weapons, no reports of accidental needle punches amongst prison staff, no evidence of increased trafficking or availability of drugs, no evidence of increased drug use but good evidence that prison NSPs have helped facilitate referral and increased participation in drug treatment programs and have reduced blood-borne virus transmission dramatically.

CHAIR: Thank you. Your time is up.

Prof. Moore : In May 2011 the ACT government engaged the Public Health Association to prepare a report on the implementation—not whether or not it should be—of a needle and syringe program in the ACT jail, the Alexander Maconochie Centre. As part of that process I visited a series of prisons in Europe and did a report to the ACT, which has been provided to this committee as an attachment.

Following that, I happened to be in Iran a year or two later. I had a meeting with the head of prisoner health in Iran, who provided insight into the needle and syringe program that they had run in Iran. The evaluation they had done was probably the single most significantly sound academic evaluation I have seen of any needle and syringe program at all and for that reason it was particularly interesting. My personal experience in dealing with custodial officers where there were needle and syringe programs was also interesting because, in almost every case, in the initial instance prison officers had opposed them. By the time I spoke to them three or four years later and, in some cases, longer than that, they were very strongly supportive of the programs.

To follow on from what Susan Carruthers was saying, it would be fantastic if a representative of prison officers could go to some of these places, in Lichtenstein in Berlin, Switzerland and Spain to talk to prison officers.

The final thing I would like to say is that the ACT government response to our report is also available. It concluded that it was appropriate to implement regulated access to sterile injecting equipment. There are different ways of doing it. We provide a series of possibilities. It will never operate in the same way as it does in the general community, but there are ways where prisoners can get access to a needle and syringe program. I will just allow my deputy to add a couple of points within our allocation of three minutes.

Ms Walker : I am here in my capacity as deputy CEO of the Public Health Association of Australia. I should also declare, though, that I have unpaid roles as vice-president of Hepatitis Australia and also as president of Hepatitis ACT. But I am not here in that capacity today. I think that is important for the purpose of transparency.

I will just take up where my three colleagues have left off. One of the main messages out of all this international research is that there have been some very similar and positive results from differing models of needle and syringe programs in prisons overseas. If we were just talking about one or two examples, you could say that perhaps they are not transferable. But we are talking about a dozen or so countries that have implemented needle and syringe programs in 50 or so different prisons. They have developed those models based on their particular circumstances to meet their particular needs. But when you look at the outcomes from those initiatives you will see they are remarkably similar in terms of the outcomes, despite the differing methodology. I think that is really important to acknowledge. I also think it is important to acknowledge that a NSP is not the only mechanism for—

CHAIR: You are over your time.

Ms Walker : I am sorry; I thought I had three minutes.

CHAIR: No, three minutes for each organisation.

Ms Walker : If we were talking about initiatives as a whole, our four asks would be: needle and syringe programs as part of comprehensive preventive strategies; Medicare access for prisoners, which is an issue that is not often highlighted but very much needed; equity in treatment, in terms of both alcohol and other drug programs and hep C treatment; and consistency in comprehensive data and reporting across jurisdictions and at the national level. Thank you.

Mr Wright : Good morning and thank you for allowing us to appear again. On behalf of the Community and Public Sector Union and its members, I would like to say that we appreciate this opportunity to speak to you and point out that we are represented again today by either officials or serving prison officers from New South Wales, Victoria, South Australia, Western Australia and the ACT. The CPSU's interest is obviously particularly in regard to the proposal to introduce a needle and syringe exchange program into the nation's prisons anywhere. We, as a union, believe and our members believe there is a serious and tangible risk to occupational health and safety if such a scheme was to proceed. We believe that risk is twofold: either through a deliberate attack through the use of a needle as a weapon or an accidental needle-stick injury, which could lead to the transmission of a serious blood-borne illness, which is exactly the sort of illness we are talking about and are concerned about today.

That said, we like to point out that the CPSU are not close minded in supporting efforts to eradicate blood-borne viruses and we hope we can we relay that to you during today's proceedings. We have a number of ideas and suggestions for the committee that are alternatives to NSEP and should be taken up before an NSEP is even considered.

I will point out briefly that I understand that the morning session is particularly about the prevalence. The concern from our union's perspective is that the prevalence of hepatitis C transmission in custody is not known. We would support any efforts or any work that comes out of the standing committee to establish that. We are aware that the inmate population across the country has higher than usual numbers of hepatitis C. We do not know the degree—it is purely speculation—to which that is transmitted in custody. It is arguable that many drug users in jail already have the illness and are not transmitting it to each other through shared needles. We cannot be sure, but we will support any efforts by any organisation to establish the problem before we leap to the solution.

In regard to prevention of the problem, we would like to point out that there are a number of other efforts that we believe could be made but are far safer and may be more effective in addressing the transmission of blood-borne viruses than an NSEP. We have spoken previously to the committee about safe tattooing practices and safe barbering practices, and there are some other minor adjustments that we suggest could be adopted in all custodial settings that may go a long way.

The third point we would make is that harm minimisation comes along hand in hand with supply reduction strategies and demand reduction strategies. We can identify multiple ways that we are not getting assistance, and we could do the job better to reduce the supply of drugs in custody and reduce the demand of drugs in custody. That would include better implemented AOD programs for inmates, better capacity to search visitors and staff through machinery, dogs—all those sorts of measures—and, thirdly, and probably most importantly, would include reducing the overcrowding problem that all our jurisdictions currently experience.

We think those are tangible measures that should all be adopted way in advance of an NSEP, which is possibly like using a brick to kill an ant, if you like. We believe the problem has not been sufficiently identified before we can move on to the solution stage. We would support all efforts to do so. Thank you for your time.

Ms Tyrrell : I would like first to acknowledge the traditional owners of the land and pay my respect to elders past and present. Prisoner health is a state and territory responsibility. As such, there is variation in the hepatitis C prevention services across jurisdictions. We need to remember that most prisoners return to the community within a few years and that the federal government has a keen interest in ensuring that no prisoner leaves custody with poorer health than when they entered. This is the basis of international human rights instruments and protocols to which Australia is a signatory.

We know hepatitis C is an immense prisoner health issue. Prevalence among prisoners as a whole is around one in three for male prisoners and two in three for female prisoners, with higher prevalence rates among Indigenous prison entrants. New infections are predominantly caused by sharing contaminated equipment to inject illicit drugs, and therefore hepatitis C prevention efforts have to accept that, despite every effort to stop drugs entering prison, drug use is a fact of life in every single Australian prison.

Documented cases of in-prison transmission of hepatitis C between inmates have been recorded in every Australian state and territory, and a pragmatic approach to drug use is therefore needed to reduce the risk to inmates leaving prison with a potentially life-threatening hepatitis C infection and to reduce the risk of prison authorities being sued for breaches of their duty of care.

The longstanding and government endorsed National Drug Strategy provides the framework for a pragmatic approach. It supports three complementary, not contradictory, approaches to drug use. These are supply reduction, demand reduction and harm reduction.

The document Hepatitis C prevention treatment and care: guidelines for Australian custodial settings was adopted in 2008 by the Corrective Services Ministers' Conference, the corrective services administrators conference, the Australian Health Ministers' Advisory Council and the Australian Health Ministers' Conference.

The evidence base for the guidelines clearly demonstrates that demand and harm reduction measures for hepatitis C can be safely and effectively introduced into custodial settings for the benefit not only of prisoners but also for custodial officers; however, implementation is inordinately slow, and national reporting of progress is virtually non-existent.

Leadership is needed, and the Australian government can and should demonstrate leadership and consider incentives to encourage jurisdictions to adopt evidence based interventions for the benefit of prisoners, for the benefit of custodial officers and for the benefit of all Australians. Thank you.

Mr Didlick : With my respects to the traditional owners, thank you for the opportunity to contribute on behalf of Hepatitis ACT's community of interest, all of which have a stake in the outcomes of today's hearing.

Hepatitis ACT routinely delivers services within the ACT prison. We work with detainees and staff, increasing awareness and knowledge of risk, prevention and management. Our only interest is the health and wellbeing of people who live and work for the prison and their families.

In advocating for better prevention and management of hep C in prisons, Hepatitis ACT would not support measures that increase the risks or harms. We would not trade off one stakeholder against another, because we do not believe that creating safer and healthier prisons needs to have winners and losers. Safer and healthier prisons are in the best interests of everyone.

We are advocating change, so it is important for us to consider the current situation and the key points on which competing voices disagree. In this parliamentary inquiry, the CPSU has stated they do not believe that prisons are awash with drugs and they do believe that abstinence is the most effective way to prevent blood-borne viruses. I would ask: how is that approach going; what outcomes does it produce; and who benefits from that approach? Fortunately, there is a large and credible evidence base on which to draw so that modern, rational policies can be founded on evidence rather than ideology.

In the ACT's prison, detainees have access to drugs, mobile phones, injecting equipment and more. Unfortunately, drugs and syringes are available to them, but the means of prevention are not. Around 48 mobile phones have been seized from detainees in the ACT prison—32 in the last eight months. If prison authorities cannot prevent detainees from getting mobile phones, what hope do we realistically hold for abstinence?

Between the commissioning of the AMC in 2009 and September 2014, there have been 51 notifications of hepatitis C. Experts from ACT Health have said that that the number of notified in prison transmissions is a significant underestimate.

The reality is that we incarcerate a large number of people with drug problems in overcrowded conditions and then we fail to prevent the supply of contraband, including drugs and injecting equipment. Given that reality, how can we seriously expect abstinence and prohibition to solve the spread of blood-borne viruses from and within our prisons? Contraband-free prisons are unattainable pipedreams and expecting widespread adoption of the 'Just say no' mantra in prison is fanciful.

The way that we manage the realities of blood-borne viruses in prisons is outdated, inadequate and harmful. In the ACT's prison, just like other prisons, a needle and syringe program already exists. It is unregulated. It recirculates a limited range of unsterile equipment and it has the wrong people in charge of its operation. If that unregulated program were being considered at this round table for implementation today, people would think we were mad. Why then are some people so determined to keep it? Healthier and safer prisons are attainable. The people who work and live in our prisons and their families deserve nothing less. Thank you.

Mr Loveday : I too wish to pay my represents to the Aboriginal custodians of the land on which we meet today and pay my respects to their elders past and present. I would like to declare that in a private capacity I also serve as a member of the New South Wales Justice Health and Forensic Mental Health Network Board. In addition, in a voluntary capacity, I am a member and current president of the board of CRC, the Community Restorative Centre—a not-for-profit charity in New South Wales, working to support prisoners post release back into the broader community in New South Wales.

Throughout the course of this prevalence and prevention part of the hearing, I wish to highlight three things. Firstly, the prevalence and the incidence of hepatitis C in New South Wales prisons and compare that incidence and prevalence with that of the broader community. Secondly, I would like to note some of the factors influencing those higher rates in prisoners. And, thirdly, I would like to include a request that the Standing Committee on Health make a strong recommendation for the introduction of controlled needle and syringe exchange programs in correctional settings in each state and territory jurisdiction. It is probably best if most of that information comes out in the question and answer sessions. I will be referring to two main studies: the 2009 NSW Inmate health survey and the 2013, just released, National prison entrants’ bloodborne virus and risk behaviour survey report from 2013, which lays out the prevalence and incidence data.

I would like to conclude this opening remark with a comment from my colleagues at NUAA, the New South Wales Users and Aids Association, who recently launched a book called Stories from the other side. They had hoped to be here today but they were unable to make it because of flight delays; so I do not have a copy of that book with me, but I will certainly provide it to the committee. The comment there is that people in prisons are entitled to the basic human right of appropriate health care, including NSP access—needle and syringe program access. We know that injecting occurs and sharing of injecting equipment is widespread in prisons and that the needle and syringe program in the broader community works to prevent hepatitis C and HIV transmission. We must have access to NSP inside prisons. I am happy to continue in the Q and A session.

CHAIR: I am sure that some of my colleagues will have questions for all of you during that process, but I will kick off with a couple of questions. Helen, you talked about the rates in different populations within the prison system. I went to a HIV forum on Friday which talked about rates in prisons and rates generally. One of the things they said was that data collection was their biggest issue in getting proper evidence. Have you have based your rates on a report, or is there an evidence based report that the committee can look at to get those rates so as to know that they are factual?

Ms Tyrrell : There is a periodic prison entrance survey. I think the most recent survey has just been released. Melanie, do you have a copy?

Ms Walker : I have a copy, and I am happy to table it.

CHAIR: Thank you. Helen, you also talked about the transmission of hep C within prisons. If you do not test prisoners when they go into prison and you do not test them when they leave prison, how can you decide what the transmission rates are?

Ms Tyrrell : That depends on the different prisons and their particular policies with regard to testing. We need to remember that testing of prisoners needs to be voluntary. That is the first point. Should prisoners agree to testing on entry, they can also agree to testing when they return from periods outside of prison and/or on exit. That is where the data is gathered from. John may like to expand on the particular issues with regard to the ACT, where I know there is very clear evidence of the percentage of prisoners who have been infected in prison versus those outside prison, and a group where it is less clear.

CHAIR: Would you like to comment on that John?

Mr Didlick : It is true that the data lacks a little clarity. For example, as to the AMC, we know how many notifications have been made from the AMC, but we also know that testing there is suboptimal and that the notification criteria create an underreporting. There is good data—and Professor Stoove will have a better handle on it than me—from the HITS-p study in New South Wales, and I think this was the evidence that Professor Greg Dore gave to this committee: that there is an estimated incidence of 14.08 per cent, basically; so, 14 people out of 100 who inject drugs contract hepatitis C in Australian prisons.

CHAIR: Does someone else want to add to that?

Prof. Stoove : As to the most recent publication out of the HITS-p, I would like to draw attention to the Reekie study published in the Medical Journal of Australia—the first author's name is R-E-E-K-I-E—in 2014. That reported incidence of hepatitis C infection comparable to what we see in the community, and that is despite more limited access to injectable drugs in prison. The rates were comparable. That is a major study, led by Professor Andrew Lloyd, of individuals permanently incarcerated, over time, and who tested hepatitis C negative at a baseline bleed and subsequently tested hepatitis C positive over time. So there is no conclusion other than that they contracted hepatitis C in New South Wales prisons and at a rate that is comparable to what is seen in the community.

CHAIR: Did anyone else have any comments on that?

Mr Loveday : Yes. It often depends on what studies you are comparing that with. There is the annual surveillance report 2014, put out by the Kirby Institute. There is a roughly 15 per cent incidence rate in prison. So one person in eight who comes into prison in New South Wales per year will contract hepatitis C inside prison. If you look at the incidence rate in the broader community, the annual surveillance report 2014 refers to two studies. One is the HITS—which stands for Hepatitis C Incidence and Transmission Study. There is one in prison and there is one in the community, so it is HITS-p and HITS-c. There they saw a 10.2 per cent per 100 person-years incidence rate in the broader community in 2009, and 3.9 per cent per 100 person-years in 2013. Allied to that, the annual surveillance report refers to the Kirketon Road Centre, which is a primary health centre for people who live on the streets and people who inject drugs in King's Cross in Sydney; there—and this is quite conflicting—it is around 5.4 per cent per 100 person-years in 2009 and 13 per cent per 100 person-years in 2013. So, either way you look at it, even though the studies are slightly different, you will see that the incidence rate of hepatitis C in prisons is slightly higher than in the broader community, if you look at those two studies in the annual surveillance report. That is a very worrying concern, given what Professor Stoove said, about the availability of drugs in prison being much lower than in the broader community.

CHAIR: John, just before we go on, can you just give us a very brief overview, for the rest of the committee—they might not know what it is—of the ACT non-controlled needle and syringe exchange program that you said is operating in the prison that you said you would not present anywhere else, just as to how it works.

Mr Didlick : I think Mr Jones described it as the counterfactual in hearings previously. There is access to needles in prisons now—all prisons.

CHAIR: Just the one you described—the ACT one you spoke about—and how it operates.

Mr Didlick : The ACT one, as to how it operates? Have you got a more specific question for me than that?

Mr STEPHEN JONES: How do people in prisons get syringes at the moment?

Mr Didlick : They pay.

Mr STEPHEN JONES: How do they get into prisons?

Mr Didlick : A number of different ways.

Ms HALL: Who do they pay?

Mr Didlick : They pay each other and they pay people in the community.

Prof. Stoove : Could I add to that. We are currently undertaking a major study in Victorian prisons. We are about a quarter of the way through recruiting 500 prisoners with a history of injecting drug use in prison. Anecdotal reports from my participants suggests that a single needle tip would sell for somewhere between $150 and $200 inside prison.

Dr Carruthers : And I would like to add to that. From a study in Western Australian prisons which looked at needles and syringes as contraband, a person who actually has in their possession a needle and syringe can be paid in money, sometimes up to $200 and $300 in WA, but also in drugs themselves. They will rent that piece of equipment. If you want to sell it, it will cost them a lot more. But, per use, you usually exchange it for drugs.

CHAIR: Any comments from others?

Mr Smith : I think it is important to note—and I thank you for that comment—that there is a tangible value to a needle, wherever it is supplied from, and one of the problems that we would like to identify and explore is the fact that having a needle exchange does not necessarily remove needles from that environment, and the prison environment may still see the needle as having a tangible value to currency in the system, as funds available to a prisoner. So it is very important to note that, however the needle is obtained and by whom it is obtained, it has a tangible value. It is a very, very expensive commodity. By providing them in the prison, you are providing a currency, a value. I not saying to go one way or the other; I am saying that it needs to be recognised that they are currently a currency within the prison.

Mr STEPHEN JONES: What is a condom worth?

Mr Smith : Condoms in WA prisons are provided free of charge to prisoners, by vending machine.

Mr STEPHEN JONES: I am just trying to think of an analogy. I am assuming, and tell me if I am wrong, that a needle has a tangible value because it is contraband. If it were not contraband, would it be the same as a condom?

Prof. Moore : We actually had some indication of this from the report that the Iranians did—and I am not recommending this as a method, I have to say—where they provided very widespread availability of syringes and then measured how many were returned voluntarily. In the first year, it was in the 80-plus per cent, but it went right up into the 90-plus per cent. I am just looking for the exact figures now and I will provide them to you shortly. They actually increased the return rate very, very significantly, to where almost all were being returned, which indicates that, under those circumstances, like condoms they wound up having no value.

Dr Carruthers : I think it is worth noting as well the high level of engagement that injecting drug users have with needle and syringe programs when they are outside prison. I have, unhelpfully, handed over my copy of that prison entrants study, but I think the statistic highlighted in that executive summary is that 90 per cent of prison entrants were active users of needle and syringe programs to exchange needles prior to going into prison. So there is a high level of awareness among the cohort and a high level of desire, I have to say, not to contract blood-borne viruses. I think it is safe to say that, if they were allowed or able to access clean needles in the prison context, there would be pretty high motivation to do that. People do not want to catch blood-borne viruses. They do not want to take those things home to their family when they leave prison. So I do not think you can underestimate that as a motivating factor for engaging with such a program.

Mr Smith : I would definitely make the comment, having been a prison officer myself for eight years and having interviewed and spoken to a lot of prisoners over that time—thousands—that prisoners entering into the prison do not want to contract a blood-borne virus. However, I believe firmly that they have a misunderstanding of what the dangers are. They are not trained when they enter the prison. We provide them with very little information on blood-borne viruses like hep C and others, and I believe that is probably the biggest area that we need to concentrate on. In our studies in WA, we actually asked the Western Australian Department of Corrective Services to provide us with figures; they were not able, or they were not willing, to provide them to us. But my own experience is that prisoners are provided with written material, although a large proportion of the prisoners that come in are illiterate. They are provided with two minutes to read a booklet. They have many more worries on their mind than reading a booklet and therefore, once they enter the domestic part of the prison, they are untrained. They are uneducated on hepatitis C, hepatitis B and HIV. We should start with education when prisoners come into the prison. I totally agree with you. They are asked the question. However, they are not educated from that point forward.

Prof. Moore : It is not an either/or, nor is it sequential. There is the sequential approach and the either/or approach. We would agree with you very strongly. I could not agree more strongly, but we do not say you should do it sequentially. The figures that I mentioned: 8.1 per cent of needles were not returned in the first round; a year later, 2.38 per cent were not returned. So, if you like, over 97 per cent of needles were returned.

Ms Tyrrell : I furiously agree with Andy. You cannot position NSPs as the answer. It is part of a suite of interventions that are needed. Any missing cog in the wheel is going to weaken the overrule response. This has to be looked at as a whole. Exactly as Michael says, this is not about sequential issues and it is not about either/or; it is about providing the best possible protection of health for prisoners and for custodial officers, and for the community by extension, by the provision of the best possible prevention that is evidence based. There is an evidence base for every intervention we have been talking about.

Mr STEPHEN JONES: Could I take you up on that point. Evidence from Burnet, Curtin and Hepatitis Australia made a very good point, in my view, about the human right of prisoners to access the best possible health care. How can we, as a committee, ensure that in pursuing that right we do not make it the enemy of the prison officers' right to attend work every day in a safe and healthy work environment?

Ms Tyrrell : The provision of a healthy work environment is part and parcel of what we are all trying to achieve. It is not contradictory. It is one and the same.

Mr STEPHEN JONES: Can I explore that with you? Professor Moore a moment ago went through some statistics—impressive, in my view—from overseas jurisdictions about the return rate of syringes. I think you said that after two years of operation only two per cent went missing.

Prof. Moore : Yes, 2.38.

Mr STEPHEN JONES: Perhaps that 2.38 could be the syringes that are used for purposes other than were intended. Perhaps they do become the currency. Perhaps they do become the risk factor. How do you ensure which models could be put in place to ensure that there is, if you like, a one-for-one and they do not go missing?

Ms Tyrrell : We have a huge body of evidence that indicates that provision of needles and syringes to prisoners does not increase drug use, does not increase harm to prisoners themselves and does not increase harm to prison officers. It is a huge body of evidence. We need to get on and start implementing things in order to give the prison officers the confidence that this can be done. At the moment we are working at a level of theory. We need to get to a level of practice. I believe that only when that practice is established will we really convince prison officers who are perhaps ideologically opposed to what we are trying to do that there is benefit to them in doing it.

CHAIR: Has anyone come forward with a program or a template that the prison officers would be comfortable with? I can understand what their feeling would be. You are saying there is heaps of evidence and they are ideologically opposed to it, but, if you have heaps of evidence, you should be able to have a template or a program that proves prison officers are safe. Is that being presented to the prison officers?

Prof. Stoove : I am not sure if it has actually been presented, but I certainly passed documents on to the committee prior to attending. I think the most relevant recent document was the handbook produced by the United Nations Office on Drugs and Crime, which is essentially in some ways a compendium handbook into how you go about implementing a prison-based needle and syringe program. It will in my opinion be ostensibly the Bible of how you go about doing this over the next decade or so. It contains a whole range of case studies from different countries around the world as to different models. As people have suggested already, there is no one-size-fits-all. Different models have been implemented in different countries. They all have pros and cons. The actual recommendation is really that you have a range of different mechanisms to dispense needle and syringes and a range of mechanisms to allow them to be returned.

The UNODC document, recently published as an advance copy, is probably the quintessential document that members of both this committee and the CPSU should start with in terms of engaging in a dialogue about what may be acceptable ways. The document also states that no needle and syringe trial should not be implemented on a systems-wide level. The point we are at in Australia at the moment is to look for trial sites within different jurisdictions that may be more suited and to appropriately monitor and evaluate them over time, even beyond when they finish a pilot or trial period, in the same way we have an open monitoring and evaluation of drugs that are approved by the PBAC. There should be ongoing systems to monitor the benefits and potentially the adverse consequences.

The evidence that is presented in various documents is for both formal evaluations over a set amount of time and also reports from ongoing monitoring and surveillance systems within prisons. When we talk about evidence, while there are limitations in particular defined evaluation programs, none of the evidence in relation to creating an unsafe workplace has emerged from the routine reporting of incidences in prisons that operate needle and syringe programs. It is not just defined research; it is ongoing surveillance and monitoring as well.

Mr WATTS: Just on that, a question that I have asked repeatedly through these hearings in the last two months goes to two specific areas of evidence. If anyone here can jump in with answers to these, please do. It seems like, when we doing that evaluation work, we obviously need to benchmark against the current position. What evidence is there about current levels of drug availability and usage in prisons? What evidence is there about current transmission methods of hepatitis C within prisons? I understand the evidence in the broader community. It is very clear; you do not need to convince me on that. Obviously, in a number of respects, it is a different environment within a prison context. There could be other explanations. I am trying to get at whether there is any data on this to inform our decision making.

Prof. Stoove : The most reliable repeated evidence that is collected over time would be the prison entrance survey that is published out of the Kirby Institute, which Melanie has just handed over. To be honest with you, research in the prison space in Australia—particularly amongst people with a history of injecting drug use—is incredibly scant. The NHMRC funded study that I am currently collecting baseline data for is the only prospective cohort study that will have been conducted in Australia of prisoners with a history of injecting drug use.

There was a pilot study that informed that, which was funded by the Victorian Department of Health, albeit about recruited prisoners in the community in weeks after their release. About a third of those participants—there was about 140 participants—reported injecting during their most recent incarceration and about a third of those prisoners, so about 10 per cent overall, reported injecting weekly or more often during their most recent sentence. The research is scant. The Kirby Institute report, I think, also reports on self-reported injecting drug use in their most recent incarceration, also.

Mr Wright : Could we add a few comments to those questions. The committee has already heard statements today that keeping drugs out of jails is virtually impossible, or is impossible. We strongly disagree with that. We are constantly hearing these statements that drug use in our nation's prisons is akin to that in some sort of Brazilian favela, and we believe that is not only incorrect but also insulting to the work that we go about every day. Drug use rates in custody are not as high as in the community, because our members make a concerted effort in their roles every day to keep the supply of drugs down. The second point we wanted to make in respect to the research question and the prevalence question is that there seems to be three arguments that support the idea of an introduction of an NSEP.

The first document that may be cited as support is the prisoner entrance health survey. We would emphasise that that is an entrance health survey; we do not get one after people leave custody, so again we do not know the transmission rate for sure, and what has happened in custody. Again I would revert to our earlier points that we made to the committee—that even if we knew that, we have not worked out how those people have contracted hepatitis or another blood-borne virus in custody. We have identified for the committee various other areas that we are concerned about, and we would support efforts of the committee to address that before a needle and syringe exchange program.

The second body of research that is often referred to is the international experience. The research we have done is that needle and syringe exchange programs are usually introduced in cultures where there is a liberalisation of the drug culture generally. We do not have that in Australia, so it would be a very different, disjointed approach from outside custody-inside custody to suddenly adopt this approach that we are to turn a blind eye. We just do not believe a lot of the international experiences, and today is the first time I have heard about Iran. We do not believe that there are international experiences that can be drawn as like-for-like in the Australian community. The countries that we are aware of that have needle and syringe exchange programs occurring are either extremely liberalised European countries or, now, Iran. I have worked in Corrections for 13 years, and I know absolutely nothing about the Iranian correctional system, and I suspect very few people at this table do, with the exception of the gentleman who has given the evidence about it. But I do believe it would not be a correlating example that you could possibly draw from.

The third thing that we keep hearing evidence to support this idea—that transmissions are rifer in custody—are sort of anecdotal surveys of groups of inmates. Again, we would emphasise there are more than 90 correctional centres in Australia—maximum security, medium security, male, women, remand—all sorts of variables are entered into that mix. I respect that the idea would be to adopt it in one or two jails, in which case we would be saying: how would you pick those jails, why would you pick those jails and how would that be an effective survey base? But I do not believe that you can effectively say that in one jail we have spoken to some inmates and found a few, and therefore let's extrapolate that data into a national figure. We do not believe that is an appropriate way to conduct research. That is why the CPSU, as one of its commitments, is fully in support of the committee if it would like to recommend that further, effective research be undertaken, that we establish a problem before we implement a solution for a problem that may not exist, and may not exist to the extent that is being stated today.

Mr WATTS: We have heard lots of evidence about how passionate people are about the effectiveness of interventions in the community, and that has been really taken on board. We have heard a lot of evidence about how passionate prison workers are about the role that they are performing in protecting both prisoners' health and their own health. You can appreciate the difficulty of sitting where I am and hearing two very passionate stories and the two key data points that you would make a decision about how to intervene in this space. There is just not data on this to form a baseline to make a judgement. How would you suggest policymakers go about making a policy decision? I agree with the comments before—that this is not an either-or thing, but the nature of resource constraint is obviously prioritisation and how you go about prioritising interventions in this space. What do you suggest we should do in this situation?

CHAIR: Just keep going like the feds do not run any prisons.

Mr Didlick : Indeed. I want to come back to a point you made about data. I have in front of me, and I am happy to table, The health of Australia's prisoners 2012, a publication from the Australian Institute of Health and Welfare. In relation to injecting drug users, it states:

Research has found that IDUs in Australian prisons were 24 times more likely to have hepatitis C virus than prisoners who were non-IDUs, and at least 8 times more likely to contract the virus while in prison than non-IDUs …

I think that is the data you are looking for.

Mr WATTS: Thank you.

Ms Davies : Does that data explain how many prisoners have tattoos that they have had done in jail?

Mr Didlick : The data does not talk about tattooing—

Ms Davies : Or sharing cells?

Mr Didlick : If you will let me answer, the data says that injecting drug users in Australian prisons were at least eight times more likely to contract the virus while in prison than non-injecting drug users in Australian prisons.

Mr Smith : I would like to ask another question on that. Speaking from Western Australian experience, it is not mandatory for any testing; it is an opt-in when prisoners come into a prison. To make a general statement that Australia-wide it is a certain percentage—where does that data come from? When prisoners enter the Western Australian system, they are not tested. We have 5,500 prisoners, and possibly a movement of between 2,000 and 3,000 are coming in and out generally during the year. How do you arrive at that figure if they are not actually tested? It cannot be relative.

Mr STEPHEN JONES: Can I ask a general question. We all understand the difficulties of collecting robust data on an illicit activity in a prison environment. You do not have to be Einstein to get the problem with that. But is anyone seriously submitting that there is a negligible issue here? Is anybody seriously telling the committee that we have a negligible issue here that we need not turn our mind to?

Mr Smith : I think what we are alluding to, certainly on the side of the table, is the fact that we do not have the data.

Mr STEPHEN JONES: But we have some.

Mr Smith : When we are looking at hepatitis C in Australian prisons, and certainly from a Western Australian experience, we are looking at a myriad of ways of controlling a disease that we do not have figures on. We have figures in the community of one or two per cent. We are drawing our prison population from part of the community that is that percentage. Obviously, inside the prison hepatitis C is a problem. But we have a way of approaching it, and needle exchange is not the problem. Speaking from a prison officer's perspective, the discovery of needles is not a major problem within the prison. So, in answer to your question, I think it is a small part of the problem, but our approach to it needs to be all-encompassing, and we have alluded to that again, and we have Professor Moore—

Ms HALL: You have said that there is a problem, but I am hearing that you are not solving that problem; the problem continues on and on. You have offered a couple of solutions that I think are reasonable, but it is not the only solution. You have never visited, you have never looked at the models; you have never spoken to the prison officers working in the system overseas. To look at this issue, surely we have to open our minds a little.

Mr Smith : Absolutely, and our opening statement by Mr Wright was exactly that. We are not closed minded. What we are saying is that we have not been provided with true statistics on the Australian model. We have not been provided with a model of introducing a program that would suit the Australian legislation, and certainly state-by-state legislation. We are happy to engage in conversation to overcome the problems—some of them we have put forward—but we have not been approached to do that. It is very narrow-minded to say that prison officers are just saying it is a threat because the needle might be a threat as a weapon. We are trying to engage a number of conversations around legislative problems, and occupational health and safety problems, and these need to be discussed and they have not been discussed. We have not been invited.

Ms HALL: Have you attempted to engage?

Mr Smith : We have been excluded from being engaged, certainly within the ACT model—

Ms HALL: Have you tried to engage?

Prof. Stoove : No, you have not been excluded at all; that is just incorrect.

Ms Walker : I would just like to make a couple of points about the last bit of conversation. I think it is a really important point to acknowledge that supply reduction is vitally important, and I do not think anyone is arguing that. I think it is important to also acknowledge the really important work that custodial officers do around the country in that area. It is not that we are saying that that is not effective or that they are not doing a great job—they are; they are doing a wonderful job all around the country every day. In prisons around the world, the evidence shows that there has not been a single prison where it has been 100 per cent effective. I guess that is what we are saying: unless you guys have a magic wand, you can do a great job and we can try to enhance those efforts, but it is not going to be 100 per cent effective and that is why we need these other measures.

The other point I would like to make is that, in relation to all the models that have operated overseas, there have been no needle stick injuries to staff in prisons where regulated needle and syringe programs have operated. Whereas here in Australia we have had needle stick injuries to staff, unfortunately, in prisons where there are not regulated needle and syringe programs operating at the moment.

The ACT is moving forward with the development of a model. In relation to assessment of various models and the overseas ones, we did look at a number of models in the Public Health Association of Australia's report from 2011, and we assessed the viability of those, and there have been a number of reports of that ilk. But the CPSU and Vince, we are really hopeful, in the next little while are going to be involved in a working group looking at the particular needs of the ACT and whether that can be operationalised. We have got some really strong hope that the right players are going to be at the table in terms of moving this forward, but we really have a lot of faith in the work of custodial officers in Australia; and if this can be done overseas I cannot see any reason why, with the skilled workers we have in this country, they will not be able to find a way forward in terms of operationalising it within our context.

CHAIR: Helen, did you have a comment?

Ms Tyrrell : In terms of the evidence, I just want to point out that there are some 50 pages of evidence in the Hepatitis C prevention, treatment and care: guidelines for Australian custodial settingsthat was adopted by the Corrective Services Ministers' Conference. I would like to read out a quote from the Corrective Services Ministers' Conference in 2004. It says that what they are envisaging for correctional services is that they provide:

… a full range of health and drug services and support for prisoners with hepatitis C or who are at risk of infection including taking action to minimise the harm experienced by drug users when, despite efforts aimed at prevention and desistance, they continue to use drugs in a manner that is harmful to themselves or to others and which increases the risk of the transmission of hepatitis C.

It is an acknowledged problem by the corrective services ministers. So this is not just about community, researchers and public health officials. The corrective services ministers acknowledge that supply reduction on its own is not going to be enough.

Mrs SUDMALIS: I need some clarification. There were a couple of comments related to the stats that are being presented—I think it was Mr Didlick—that there was an estimate of a certain percentage, and from a previous presentation, that a lot of the statistics that are gleaned from the correctional services are via self-disclosure. You already have a group of people who, because of their lifestyle choices in large part, are at higher risk than the whole population. So you have a concentration of statistical potential. So of course your statistics of occurrence are going to be greater. I do not think anybody is arguing that we need to address this problem, but to all intents and purposes you must have a baseline from which to make, firstly, an economic choice of change and, secondly, a productive choice of change. And that is not there at the moment. Even though you say that they have all agreed—yes, there are statistics there—it is not clear in this forum right here and now that because we do not test every prisoner when they go in, and they do not all self-disclose, and they are not all going to be honest anyway, we do not have that critical baseline. I think that is very important.

Prof. Stoove : Could I also add: there is a significant amount of evidence in the community amongst people who inject drugs. Of the first 100 prisoners that we recruited to our study, 80 per cent were antibody positive to hepatitis C. In the community we know that for people who have injected drugs for any meaningful period of time, anywhere between 60 and 80 per cent will be positive for hepatitis C antibodies and many will be chronically infected with hepatitis C.

We also know in community studies of people who inject drugs the number of past incarcerations they have had. Our injecting drug user cohort study that was recruited from the community in Melbourne, at baseline—and these people had a median age of 28 years—had a median of four previous incarcerations. We know from the community that people who inject drugs have an extraordinarily high prevalence of hepatitis C, and those people cycle in and out of the justice system and in and out of prisons. Every piece of research is an estimate. Unless we can do a population census of the prison and compel them to provide blood, every piece of data is an estimate. But to simply say there is no evidence in this case or there is insufficient evidence to act is not an appropriate synopsis of the situation.

Prof. Moore : Perhaps I can add a couple of political analogies to this. Neal Blewett, when he made the decision to run needle and syringe programs in Australia—by the way, supported by Peter Baume from the other side of politics—had these exact issues. It was the same story—there was never exact evidence; it was never quite right—but he made the decision to proceed, supported it that way, and we know now, because he also put into place the evaluations, that tens of thousands of lives have been saved.

The second political analogy that I would like to draw attention to is the now very strong supporter of a needle and syringe program in the jail, Jon Stanhope. As Chief Minister of the ACT, he decided that with all of the new technology in the ACT prison perhaps we could keep drugs out of the prison. That was the argument that was put at the time. In no way do I dismiss the efforts of the people who work in the prison. Having been in many prisons, I think they do a brilliant job and they have my admiration. This is a really difficult job. But the reality is that no matter how much we improve our technology, bring more dogs in or whatever the systems are, unless we go to an incredibly draconian approach on how we deal with visitors, prisoners and staff, there will be drugs in prisons. We do know the problem. We may not know the exact size of the problem, but we do know that we support very strongly the range of suggestions put by prison officers. But we also believe that it is appropriate to run a needle and syringe program in the jails. I would not, for one minute, recommend what they did in Iran. Whatever we are doing, we would take a one-for-one stance. That would be the view of the Public Health Association. It was actually quite surprising what they did in Iran, but there are some interesting extrapolations we can draw from it.

Mr STEPHEN JONES: Professor Moore, we would not be having this conversation if there was not overwhelming evidence in the general population that NSPs have worked. The question is: can they work in a very different environment, a controlled penal environment or the justice environment of a prison? I am sure in any flight of fancy neither Neal Blewett nor Peter Baume would have suggested that NSPs in the general community be either conducted or supervised by police officers.

Prof. Moore : Indeed. In fact—

Mr STEPHEN JONES: But the problem we have in a prison environment is that the whole environment is controlled by prison officers. So what are the tin tacks? What is the practical model in which you could put in place a NSP in a prison? Evidence before this committee in earlier hearings has been, 'It actually contradicts another obligation that a prison officer has—to detect and report contraband within the prison environment.' How do you put in place something—I think we acknowledge that you cannot just pick something up that works very well in the general community, plonk it down in a prison environment and expect the same result. We are not convinced of that.

Prof. Moore : In our report for the ACT government, we suggested a number of approaches that would actually take it out of the hands of prison officers, recognising that this was an issue. I agree with you; it would be inappropriate for prison officers to run a needle and syringe program. It is not necessary. There are ways of operating a needle and syringe program within the health areas of prisons, and a series of them, by the way, do not have to involve custodial officers.

I agree with you: we would not expect the police to run a needle and syringe program in the general community, and it would be inappropriate, from the view of the Public Health Association, to ask custodial officers to run them. Supply reduction is a very important part of their job—and I think they actually do it very well; though some get through—and they also have a significant role working with others around demand reduction. These should not be reduced; they should be increased at the same time.

Prof. Stoove : One of the most fundamental aspects of the success of a prison needle and syringe program will be trust in relation to confidentiality and accessibility and anonymity to some extent. Michael is exactly right: I do not think a model where custodial staff were responsible for distributing needles and syringes would work. There has been a case study done of a pilot NSP in Lisbon in Portugal that involved program staff exchanging needles and syringes that could have been done at the cell door and not necessarily at programs. Over a 12-month period not a single needle and syringe was exchanged. The primary reason for that was prisoners reporting a lack of trust in the system.

The engagement of staff and the CPSU is absolutely crucial in that the deed of agreement that has been signed or is about to be signed requests that there is a negotiation that occurs in goodwill. I think that goodwill does need to start—as many have said today—with a genuine engagement with the evidence and international experience from prison staff internationally and the evidence that has been collected in this space.

Ms Tyrrell : I would echo that point of Mark's that good faith negotiations need to take place, and to do that I do believe that the CPSU position of 'needles and prison officers out' needs to be assuaged. I would also like to say that I do have confidence that prison officers can change their mind. I point to the case of Geoffrey Pearce, which the CPSU might be surprised to me hear raising. Geoffrey Pearce was the prison officer in New South Wales who contracted HIV via an attack with a needle and later died. Geoffrey Pearce, following his infection, actually became a supporter of prison needle exchange and undertook education within prisons to actually support the education of people within that environment about the benefits of prison needle exchange. So I do believe attitudes can change.

Mr Loveday : I would like to share some further evidence relating to the behaviours that lead to hepatitis C transmission within prison; that is, the 2009 NSW inmate health survey: Key findings reportprimary author, Devon Indig. I would refer briefly back to the prison entrants' survey—the newer one; 2013—and I am happy to table this. It states that nine out of 10 injecting drug users reported using clean needles for all or most of the injections in the month prior to coming to prison. Moving away from that smaller sample size to the much bigger sample size, the inmate health survey from 2009 states that 71 per cent of men who injected in prison reported at least one person had used the needle prior to them using it on their last occasion inside; 20 per cent said that it had been used by six or more people; and two-thirds of women who injected in prison reported that at least one person had used the needle before them. Fewer than one in five men and women had attempted to access bleach in 2009.

CHAIR: Is that all in this information here?

Mr Loveday : Yes, it is. I am happy to table it.

CHAIR: We will accept it as evidence.

Mr Loveday : Thank you. I just wanted to report that there is some data on tattooing and body piercing where 39 per cent of men and 20 per cent of women reported getting tattoos in prison and 14 per cent of men and women reported piercing in prison. So I would just like to reiterate the point that what is needed is a suite of harm reduction, of prevention, issues. That is the main point that I wanted to make.

CHAIR: Thanks, Stuart. Troy, you have a response?

Mr Wright : Just briefly, for the record—because I am conscious that these matters are being recorded and Mr Pearce's family may take offence at that—Mr Pearce was a strong advocate for people that contracted HIV, but he was never an advocate for an NSE program. We would be reluctant to have that on a public document, which may cause offence. That is our understanding from someone who is close to his family who is with us today.

Also, once again, we reiterate that we support as well a likely approach that Ms Tyrrell described as a 'cog' of a raft of implementation or possible measures that can be taken. We believe that education is an important part of that cog. Safe tattooing is an important part of that cog. Increased AOD is an important part of that cog. And we would like to see that cog formed that way by a reduction in overcrowding issues, which exacerbate every single problem we have talked about today. If we construct that cog that way, we may not even need a needle exchange program in custody. We may have a cog that adequately addresses transmission issues in custody and that suits all the purposes stated at this table.

CHAIR: I have just one quick question further for you, Helen. You stated that the corrective services ministers all made an agreement. What have they done about it? Have they done anything about their statement?

Ms Tyrrell : Their implementation of this?

CHAIR: Yes. Have they done anything? It is great to have an agreement.

Ms Tyrrell : There is such poor national reporting I cannot tell you the answer to that. One of the things that the federal government may like to look at is: what incentives can we have around reporting of progress against the implementation of guidelines like this? It is murky.

CHAIR: Thank you. Before I suspend the hearing, I ask a member to move that the documents presented today by the organisations around the table be incorporated in the committee's records as exhibits. That is moved by Mr Wyatt, thank you. After the break, we will resume on the topic of treatment in prisons. Thank you.

Proceedings suspended from 12:47 to 13:18

CHAIR: We will resume the hearing. We will go straight into brief opening statements with regards to the commencement of the second part of today's round table on the treatment of hepatitis C in prisons. I invite each organisation to make a brief statement of no more than two minutes in relation to the topic.

Dr Carruthers : In terms of treatment in prisons, prisons do present for some prisoners an ideal opportunity to take part in hepatitis C treatment. But I fully understand the whole range of barriers to taking up treatment as treatment is at the moment. Current treatment, other than trials which are going on in prisons, is with interferon and ribavirin, which is six to 12 months duration. Obviously, prisoners have to be in there for a long enough period of time. That period of time includes the work up, because there are a lot of prisoners in prison at the moment who have to be allocated to a public hospital or a tertiary hospital liver clinic. There are long waiting lists. For some prisoners, after the work-up period where have been diagnosed as antibody positive and viremic, it can take up to a year in some instances for prisoners to go through the system. Then if they have the particular genotype, they have to be on treatment for 12 months. The time is protracted.

However, with the new treatments coming on board—which have far fewer side effects; they have none of the mental health side effects—that will be for a much shorter duration. That will be somewhere between six and 12 weeks. Hopefully, they will not be associated with the section 100 scheme in the Pharmaceutical Benefits Scheme. If those drugs are available in the near future, then many, many more prisoners can be treated. For many prisoners who I have spoken to, being treated for hepatitis C and ensuring that they can get rid of the virus is a real wake-up call for them. They understand that treatment is to be taken seriously and that this presents an opportunity for them to start a new period of their life. Many of them are determined after they have been treated that they will not grow back to their risky behaviours. I think the future for the treatment of prisoners with hepatitis C, depending on the availability of the new drugs, is a very positive story.

Prof. Stoove : Given the high proportions of people who inject drugs who transition through prisons, the high prevalence of chronic hepatitis C in those locations and the established health infrastructure the exists within prisons, prisons are the ideal location to consider hepatitis C treatment. As Susan said, the availability of new, highly tolerable, short duration and highly effective hepatitis C therapies will make it an even more ideal location. Key barriers that existed previously under previous treatment regime—such as the severe side effects, the need to engage significant resources from tertiary hospitals and a treatment length that often exceeded the length of someone's sentence—are now largely eliminated through new therapies.

New technologies, as well, in relation to the non-invasive staging of liver disease through FibroScans, which will hopefully soon be under then Medicare rebate. Also, they enhance the feasibility of the monitoring and staging of hepatitis C, which undoubtedly will be a necessary consideration depending on what the PBAC comes back with in relation to restrictions on the new drugs. That staging of liver disease really will be probably a compulsory part of accessing hepatitis C therapy.

The new era of treatment also genuinely brings in an era to think about treatment as prevention for hepatitis C, which is a terminology that is certainly well-founded now in HIV and is beginning to be talked about in relation to hepatitis C. That is essentially bringing down the prevalence of hepatitis C to such an extent through therapies that the likelihood of onward transmission decreases of time. We are certainly doing that in some trials around the treatment of networks of injecting drug users in the community in Melbourne. Andrew Lloyd will be commencing work shortly in New South Wales prisons, essentially by driving down the prevalence to such an extent that the likelihood of transmission reduces. That is hopefully a less controversial part of the prevention of hepatitis C in prisons.

Prof. Moore : The most important thing for us is equity and continuity. Mark did raise the issue of Medicare. I just remind everyone that Medicare access for prisoners is not there yet. Actually, we think it is a very, very important thing to be there. Whatever treatment should be done in the context of the range of other alcohol and drug issues—for example, opioid substitution therapy and so forth. We do have treatment already operating in many ways, which is facilitated by prisoners and facilitated by custodial officers. We just need to just build on those and keep the picture complete. By the way, when I say 'equity', I mean within the prison system and compared to the broader community.

Mr Wright : The CPSU, as a union that represents prison officers, obviously has limited views on medical treatment. But what we would point to is that our understanding, from the case study of people that we are looking at at the moment, is that treatment also involves access to appropriate alcohol and drug intervention, education or treatment programs. That is what we see as a priority in custody.

We just emphasise to the committee that most of the jurisdictions that the CPSU represents and that are here today are experiencing levels of overcrowding at high if not record levels. From our figures, New South Wales as at two weeks ago had an inmate population of 11,500. The capacity of the system is 11,600. Victoria had a population as at two weeks ago of 6,500, for a system capacity of 6,000. South Australia is 200 over capacity, at 2,700, and WA is more than a thousand over capacity, at 5,500 prisoners.

What that overcrowding results in is not only more people in cells, exacerbating the risk of transmission of blood-borne viruses because people may be exposed to needles, but also longer waiting lists for what AOD programs are available. It leads to delays in obtaining any sort of intervention for issues with AOD. That can then become cyclical, because often people come up for parole, they have not appropriately addressed their offending behaviour in the eyes of the authorities, their parole is delayed and the population increases or is maintained. It just continues and continues. So our position to the committee in considering the question of treatment is to take into account not just medical treatment but the adequate provision of AOD intervention in custody.

Ms Tyrrell : As previous witnesses have alluded to, prisoners automatically lose their Medicare and Pharmaceutical Benefits Scheme entitlements when they enter a custodial setting, because prison health is a state and territory rather than an Australian government responsibility. The problem with this is that it does not facilitate national consistency in health care for prisoners. Calls have been made previously for a review of prisoner access to Medicare and the PBS in prisons, and we support that review.

Prisoners who previously were eligible for Medicare can, however, access medicines on the section 100 highly specialised drugs program of the Pharmaceutical Benefits Scheme. This includes the current hepatitis C medicines. However, hepatitis C treatment is rapidly improving and new oral medicines with far fewer side effects and higher cure rates have recently been recommended to government by the Pharmaceutical Benefits Advisory Committee following their March meeting. In their commentary, PBAC state that all new oral treatments could appropriately be listed under the general schedule. What that means is that the jurisdictions will pick up the cost of hepatitis C treatment. That is a problem, because shifting those treatment costs to the states and territories will undoubtedly exacerbate hepatitis C treatment access issues within prisons.

While Hepatitis Australia strongly supports the new hepatitis C medicines being listed on the general schedule, as it will support better access within the general community, we also believe that provisions need to be put in place to better support access to hepatitis C treatment in prisons. We understand that it may be possible to make a dual listing under section 100 and the general schedule, and that may be a solution to this problem.

I would also like to touch on treatment as prevention. Within the prevention section of the fourth national strategy is the following action:

Consider the impact of new drug therapies that will cure the large majority of hepatitis C cases.

This alludes to treatment as prevention. Trials are underway in New South Wales prisons. What we would like to say absolutely categorically is the best outcomes will be achieved through a comprehensive approach to prevention and treatment. Again, it is not an either/or scenario.

I would also like to make a final point, that we do not have any clinicians here today, and stress that without their input responding to technical treatment questions is going to be quite difficult.

Mr Didlick : Hepatitis ACT's only interest is the health and wellbeing of people who work and live in the prisons and their families. In the Alexander Maconochie Centre, the ACT's prison, around 10 detainees are treated for hepatitis C at any one time. Although that is a small number considering the size of the affected population in the prison, the rate of treatment outweighs what is available in the community.

Just like in the community, people living with hepatitis C in the prison, who are offered a chance at treatment, need to make a choice between an arduous treatment and forgoing the opportunity to cure hepatitis C.

Detainees who have explored this choice with our educators seem to hold a range of views. Some say that prison is a great opportunity to undergo treatment. That might be because life on the outside can be too complex or hectic to maintain a course of daily treatments or there are other priorities; or it might be because the treatment side effects are better dealt with in prison away from the demands of everyday life. Other people say that the clinical advice they are receiving is that they should wait for more effective medicines to be available; and others say they will not consider an arduous curative treatment whilst the means of preventing future infections are denied from them.

Whilst Hepatitis ACT has been a strong advocate for increasing rates of treatment over the years—and we continue to be—we do have sympathies for the arguments against undertaking treatment, if it involves suboptimal medicines delivered in the absence of a comprehensive evidence based suite of prevention strategies. In that respect, there are no interventions that can be applied to hepatitis C in prisons that stand alone.

To maximise the benefits of hep C treatment, it must be accompanied by a comprehensive suite of prevention strategies, including ongoing education for detainees and staff; enabling environments; specialist alcohol and other drug treatments, testing, vaccination and liver health monitoring; access to post-exposure prophylaxis; evidence based policies; primary prevention strategies such as NSP; discrete consistent access to bleach, disinfectants and prophylactics; and, finally, access to one's own personal effects and safe barbering.

Mr Loveday : I would like to put on the record that I will present to the committee an article published in The Hep Review based on interviews with people who worked with Mr Geoffrey Pearce in the period when he was living with HIV which would provide evidence for the position given by Helen Tyrrell earlier.

In this section, I would like to cover—not now but as we go throughout—the importance of testing, monitoring and surveillance and reporting on that: looking at the New South Wales nurse-led model of care, heavily protocol driven, which is now being rolled out in some of the other states and territories; looking at the patchiness of treatment across the country; looking at the role of opioid substitution treatment, OST, and its role in treatment preparedness for hepatitis C—again, I am emphasising the mixed methods of addressing hepatitis C and calling on the committee to recognise the national guidelines, which have been agreed; looking at the barriers to throughcare, post or while treatment is going on or post treatment back into the broader community after release; the barriers to effective health care within prison; the overcrowding which Troy referred to earlier; and the number of medical employments cancelled because of the system requirements, movement between prisons, staff shortages, lockdowns, prisoners themselves cancelling appointments because they do not want to lose their place in their original prison. Finally, I will look at treatment as prevention, the SToP-C study that Mark Stoove referred to carried out both at the Kirby and then in a community setting, and the treatment as prevention initiative in Victoria—so an extensive suite of topics.

Mr WYATT: One of the things that struck me in reading your New South Wales report during the lunchbreak—just the sections I had a look at—was the level of detail in terms of the blood and urine testing, and then the blood sampling. What treatment regimes go into place after that testing?

Mr Loveday : Was that referring to a study?

Mr WYATT: Yes, this is referring to your report. On page 23 it says that the physical health examination has a number of elements. Prisoners who volunteered for the research initiative or for this report were checked but they were also checked with blood and urine testing, and I notice one of them is the hep C plus HIV, herpes simplex and syphilis. What interests me is that once all these results are compiled what is the treatment regime that then goes into place given that some of these prisoners may have been at a point of transition out into the community again or to another centre?

Mr Loveday : Is this in relation to the SToP-C study which is about to commence?

Mr WYATT: Yes.

Mr Loveday : I am not a clinical expert on that. I chair the protocol steering committee, but could I ask that the questions of detail are asked to the clinical people at the Kirby Institute—Professor Gregory Dore and Professor Andrew Lloyd. My understanding is that, in phase 1 of the study, 450 prisoners at each of two maximum security prisons will be able to access interferon-free therapies. I do not know the implication—and I presume that it will be referred on for further health management—of the results of the other test that you refer to. But I presume that it is clinical research which is being carried out in order to prepare the prisoner, the person, with hepatitis C for full and comprehensive health care alongside the treatment which is being offered under the SToP-C study.

Mr WYATT: When you consider the report of the 2009 NSW inmate health survey: Key findings report there is extremely rich data in that report in terms of the status of prisoner health. What intrigues me is that we have a number of key players both external and internal to prison systems yet we seem as a society not to have the capacity to bring together all of the elements that could help an individual overcome of their health problems, including access to treatments that are due to come on line through the PBAC that will cure hep C, or in other instances deal with some of the other problems. The section on smoking, alcohol and other drugs states:

Cannabis was the most common drug ever used (81%), followed by amphetamines (57%), cocaine (45%) and ecstasy (44%). The use of heroin decreased from 2001 to 2009 (from 49% to 41%), while the use of crystalline methamphetamine (ice) increased over this same time period from 11% to 42%, which reflect changes in illicit drug markets during this time.

Yet we seem to have silos in operation. I would have thought in a First World country we would have been far better in the way that we coordinated. That is taking into consideration the concern of prison officers plus public health officials who see the public health modelling and also corrective health services. In your view, is there a way that we can do this far better than we are doing now?

Mr Loveday : I would agree that there is a way we can do it a whole lot better for the state of New South Wales, where I have lived and worked in this area for the last 20 years. With the allocating out, the devolution, of health responsibilities to local health districts, with the addition of some state-wide speciality networks—of which the Justice Health and Forensic Mental Health Network is one—I think we do need to see a far greater amount of attention paid to effective collaboration both when people come into prison and when people are released from prison. Many people are in prison for very, very short periods of time, and it is extremely difficult, especially now with the current arduous regime of hep C treatment, to manage people effectively if they are outside, within and outside the system again. So I would agree that there is a far greater strategic plan required for better collaboration between community based health services—and that would be between the local health districts anyway—but also within the state-wide speciality networks. I could not agree with you more.

Mr WYATT: What concerns me is that, if we look at a typical profile of a prisoner, based on this report, every socioeconomic indicator around an individual is in a sense a disparity that puts them in a position where they often do not make informed choices because they are reacting to life, they are reacting to circumstances when they understand what the issue is. I want to go back to a question Jill asked much earlier. Why aren't we doing better education programs informing people of what hepatitis C means, how it works within their body, instead of giving them a brochure to read? Based on literacy levels in this report alone, you would have to say 70 per cent of prisoners would have Buckley's chance of understanding what they are reading, let alone have the capacity to read.

Mr Loveday : Again speaking from the New South Wales context, we can do a small amount with the resources that are available. Hepatitis NSW produces a magazine called Transmission. It is predominantly about hepatitis C. It sometimes has a prevention focus and it sometimes has a treatment focus. It is used by Corrective Services New South Wales as a literacy tool. It is also used by them in a very welcome partnership way as a health promotion tool. It has been translated into a video format which is shown on the CCTV screens inside. There are different ways of approaching health literacy, and we are trying to adapt and adopt as many of the effective ones as we possibly can. I could not agree more that the production of a brochure is not enough. You need fuller discussion. You need far better education. You need peer education. You need to educate the community. We used to have that in New South Wales but we do not have it any more; that peer program disappeared. I think it runs in other states and territories—and WA do the HIP HOP program. Other people could have a view on that as well.

Ms Walker : Dr Wyatt, in terms of the silos and access and continuity issues that you were talking about, I thought I would highlight some of the really innovative work that has been going on in the ACT context. And I will get John to have a bit more of a talk about some of the work he has been doing in the prison. In the ACT there is a therapeutic community that is operated by an external drug and alcohol organisation, Karralika programs. They run a therapeutic community external to the jail and, since the creation of the jail here, they have been running that program within the prison. It creates better continuity of service delivery within the prison setting and then for people coming out of the jail as well. Likewise, Hepatitis ACT has been contracted to do a lot of work in the prison in terms of education and health promotion with custodial officers—in particular, new custodial officers coming on board—and also with the cohort of prisoners. And I will let John elaborate on the good work he is doing there.

The other thing that is really great in the ACT is a very strong emphasis on through-care and through-care planning. Within Corrections ACT there is a whole team of people working on transition planning—so making those better connections for people coming out and having a comprehensive care plan and addressing those underlying issues you are talking about in terms of socioeconomics stuff. I can only speak to the ACT, but I know there are some really innovative models going on around the country that are trying to break down those silos and make better access between that prison environment and the community. Acknowledging that people spend on average a year and a half in prison and then go back to the community it is really important that they are connected with those services which can assist them to address their underlying problems not just while they are in prison but when they are coming out as well.

Mr WYATT: Your point is valid. It is always fascinating when you establish drug and alcohol committees. We talk about having a spectrum of the population but I have very rarely seen prison officers on drug and alcohol committees. I have very rarely seen prison officers on bodies established to address a particular health issue that is prevalent within a prison population. That is why I am talking about silos. We fall back into a silo mentality. We do not look at engaging everybody who should be involved if we are trying to reach a resolution. If we are not involving people, we will end up with differing views and positions that never reach a compromise.

Prof. Stoove : You may want to look at some of the Scandinavian models around correctional systems.

Mr WYATT: I don't have to look at them. I would say that all of you need to look at them.

Prof. Stoove : Or someone else may want to look at them. We are in a difficult situation given that jurisdictional governments control correctional settings. Often in Scandinavia—and there are a number of peer reviewed papers in this area—responsibilities for the good order of prisons are taken on by programs staff who are there to deliver therapeutic programs. There is also a much more fundamental role among correctional officers for the effective delivery of health programs in those prisons. There is a wealth of both quantitative and qualitative evidence showing how effective those types of programs can be. I could not agree more in relation to the siloing of those issues.

My best knowledge relates to the Victorian system. Part of it is investment in relation to the transitional programs in particular and where investment goes. Sometimes investment is dependent upon the current legislative agenda of different governments. We have just gone through a period of rapid expansion in the prison population in Victoria because of the removal of a whole range of legislative levers to keep people out of prison. As I said earlier, I think a lot of these issues are far better managed in the community than they would be in correctional settings. In Victoria, I am not sure of the exact number but hundreds of millions of dollars has just been spent commissioning a new prison and many more hundreds of millions of dollars has been spent on commissioning new prison beds. If that type of investment was redirected to transitional programs in our state, we could create almost a world's best practice system in relation to supporting people with complex health issues, particularly mental health and drug and alcohol co-morbidities. We could create a first-class system on an international basis within the Victorian jurisdiction alone. Sometimes I think it falls back to political priorities in a lot of these areas.

Mr WYATT: Let me respond to your comment about political priorities. Sometimes organisations can push reform. Even though you have legislative constraints, industrial constraints and safety issues, often a group of people coming together can effect change in a far greater way than what a government can legislate for—because it is to do with will, commitment and passion and a belief that we need to protect all those involved plus provide a service to those who are in need of it. That is why I made the comment about silos. We have incredible individuals sitting around this table giving evidence. I go back to a comment Tim made earlier, which was that we are hearing two conflicting positions in some senses but in reality there are common elements to that which should be worked from and then the differences should be addressed over a period of time in which we would get better outcomes. We have to be cognisant of the demands that come from both parties.

Ms HALL: Ken and I have been talking about this issue all morning. I would like to reinforce what he said, which is that the best results can be obtained by having everybody at this table sitting down and working together to try and get the best outcome not only for the prison population but for the community as a whole. What treatments are available in jail for people who are hep C positive?

Dr Carruthers : The current treatment is a combination of interferon and ribavirin. Interferon is injected once a week and ribivirin tablets are taken daily. That treatment is associated with quite severe side effects—mental as well as physical. New treatments are already developed which are in chemical trial stage at the moment. They will be implemented in New South Wales prisons. They are not interferon based, they are tablet only. They have far few side-effects associated with them and also have a 90 per cent success rate. But they are not yet available to the general public in Australia, let alone prisons.

Ms HALL: But they will be?

Dr Carruthers : Depending on whether the PBS decides to cover them.

Ms Walker : Even if they do get listed on the PBS, we still have that problem of prisoners losing their access to Medicare when they go into prison. Even if they do get funded for the general community, the way that it is going at the moment, and what Helen was saying in terms of it depending on which schedule they are listed on, potentially the jurisdictions will have to front for the full bill of that rather than what you would face in the general community. There are some significant barriers to be overcome. The Medicare access issue is so important, not just in terms of hepatitis C treatment but across the board, because jurisdictions are footing the bill for incredibly expensive treatments and not getting any of that rebate. When they are forced to cap their corrections budget in terms of what they spend on people, you get a hell of a lot less bang for your buck, because you are having to pay that full cost rather than recouping any of it. I guess that is why what Mr Wyatt is saying is so important. These people are spending relatively short periods of time behind bars and then returning to the community, and yet their access to things is so limited, because they are losing their Medicare rights when they go in there as well. Everything that is delivered to them by jurisdictions is multiple times more expensive. You can spend quite a lot on someone without delivering nearly as much as you could in a community setting, so it is a huge barrier.

Ms HALL: And access to PBS.

Ms Walker : Yes, exactly.

Mr Loveday : Just for the record, there is a third drug called simeprevir, which is provided for people with hep C genotype 1, but again that and all treatments as a whole are not available in any widespread way to prisoners with hepatitis C across all states and territories.

Ms HALL: It is not automatically offered?

Mr Loveday : Treatment can be offered, but it is better rolled out in some states and territories than in others.

Ms HALL: What determines whether or not it will be offered?

Mr Loveday : Availability of resources—for instance, in Victoria, there has just been a recent public announcement that the Victorian government has applied $2.2 million to develop health centres to roll out hep C treatment. Before they did not have treatment. It requires resourcing for the systems and the services in addition to what we have been talking about—the drugs themselves.

Ms Tyrrell : There are a lot of practical issues in terms of delivering the current treatments, as well, in that many prisoners are moved between facilities. Some prisons, for example in New South Wales, offer treatment currently, and others do not. If you are going to move between one prison and another, then you may be going from a prison that has put you onto treatment to a prison that does not. New South Wales has sorted that out pretty well in terms of having clusters of prisons and transferring prisoners between those different facilities, but it is a significant issue in many jurisdictions.

Mr STEPHEN JONES: Thanks for your evidence, everyone. How are the general health and wellbeing programs funded inside a prison setting? Are they all funded from within the corrective services budget, or are there separate funding sources? I am talking about government-funded programs not NGOs.

Ms Tyrrell : Governance arrangements for health in prisons vary by jurisdiction. Some will be under health; some will be under corrective. It varies.

Ms HALL: Is it possible for us to get a list of the funding of those programs? That would be quite useful.

Dr Carruthers : I think WA is the only state now, and correct me if I am wrong, where health is provided by the Department of Corrective Services. It is in-house. Other states have moved their health services, and they are now provided by the state health service. We can get that for you.

Prof. Stoove : Victorian justice health sits within the department of justice. Victoria recently moved to a single tender for health services aside from a couple of examples of private prisons that had existing relationships—St Vincent's provides health care to Port Phillip Prison, for example. Under a competitive tender process, a service will try and pitch at what they think the department can afford.

In relation to something even as simple as hepatitis C testing, an antibody test for hepatitis C is relatively cheap. When someone tests antibody-positive, they should be tested to see if they are chronically infected. As we know, people are able to clear hepatitis C naturally. To my knowledge, in the Victorian system very few people who test antibody-positive are subsequently tested using a PCR. It is a much more expensive test. Somebody may have been told that they are antibody-positive several times over their injecting career, for want of a better term, but have never progressed to a PCR and have never been told that they are chronically infected. Telling someone that they are chronically infected with hepatitis C can have a preventive benefit. Previously, someone who has been told that they are antibody-positive may share injecting equipment with someone else who has hepatitis C thinking, 'It doesn't matter. I've got hepatitis C anyway,' when they have cleared the virus and they do not know, because they have never progressed to a PCR test. Certainly, part of the Victorian government strategy is to establish an appropriate care system for people with hepatitis C, starting with an appropriate testing algorithm. So they progress to a PCR test and then are appropriately assessed using a nurse-led model. Part of that system that will be developed is to pave the way and have a system in place so that, when the new drugs become available, we have a system on the ground that is able to respond to that.

Mr STEPHEN JONES: Following up on the evidence of Professor Stoove, in the view of any of the prison officer organisations, are there resources, expertise and capacity within the prison system to deliver post-testing, communication and education to the affected prisoner group?

Mr Wright : Again, that would come down to a matter of priorities. The mission statement of most corrections departments is to reduce the rate of reoffending. Obviously, the first point of that is the security and the maintenance of centres, and within that programs are designed about addressing the offending rather than addressing health needs. I do not like drawing that distinction myself and I do not want that to appear to be a siloing issue, but, as far as priorities for a state corrections department go, the health needs of inmates would be somewhat lower than if that were looked after by the health department, if you like, just based on conflicting priorities. We have enough trouble making sure that things like AOD intervention, which firmly fits within a correctional department's priorities, is adequately resourced.

Mr STEPHEN JONES: Do you have a view about whether those AOD program should be funded from inside the corrective services budget or separately?

Mr Wright : I probably do not have a view. They are probably best delivered by Corrections—

Mr STEPHEN JONES: I have no doubt about that. Knowing the way we work, every ministry has its priorities. You are given a bucket of money and they have to make a decision about whether that money is spent on a new detection instrument, extra staffing or something that they believe really fits in another portfolio. I am pretty sure I know which way they would go.

Mr Wright : I could not speak for my organisation, but, personally, having been on the parole board for several years, I have a strong view that it should be delivered by Corrections, because the population undertaking those programs is so specific. A program that may work in a health centre about considering stopping drug use is quite different to a program you would deliver in a custodial setting for people who have had long-term addictions and committed offences and, generally, whose life is in a rabble. They are very specific. The best programs I am aware of in any of the systems are ones that have been designed by corrections departments and have been delivered within corrections departments, because they hit that group.

Mr STEPHEN JONES: Has the funding for those programs been maintained in proportional terms over the years? We have seen a big escalation in prisoner numbers, but what about the funding for those programs?

Mr Wright : Since we had the opportunity to speak to the committee we have been talking amongst ourselves about our experiences on that, and I think it is probably not a generalisation to say that, when corrections departments feel the financial pinch, it is their non-custodial operations that probably get hit a bit earlier than the custodial operations. We are aware of some good programs. Holistically, it happens from cradle to grave during a sentence. It happens at the start of sentences, because we have issues where overcrowding results in people spending a lot of time in watch-houses and inappropriate centres and not even getting into a jail at the start of their sentence and therefore that intervention is not right. Then during the sentence the jails are overcrowded; there is that movement issue; there are waiting lists; people miss programs. Then, at the end of their sentence, they hit parole and they have not done appropriate intervention, and they are kept back. So it happens right through. Day-release is another program that we would like but is something that gets cut back and not resourced appropriately, and people do not get to access that either, and that is a great opportunity, to test that. So it just happens right through the sentence. Unfortunately, I think it is usually the first victim of cuts. We have already provided evidence that the numbers in our systems are at record highs in many jurisdictions. So we are entering unprecedented and uncharted waters at the moment, and we are not quite sure where that will take us.

Mr STEPHEN JONES: Would you say that that is actually a threat as to the spread of blood-borne diseases like hepatitis C?

Mr Wright : That has been our line throughout: if people come out with active addictions from custody and continue to use, I am sure that everyone at this table would agree that they are at greater risk of contracting a blood-borne virus than if they can come out of custody with a bit of a period of being completely drug-free, having had that opportunity. The professor up there pointed out, I think, earlier, that jails offer a great opportunity to provide treatment to people with hepatitis C. We also argue that jails provide a great opportunity to provide AOD intervention in a way that would never normally be provided in the community. It gets them off the treadmill; if we can get them off the treadmill at any point, we can do it in jail. And if we are not doing that, and they are coming out without that issue being addressed, then absolutely: if they continue to have an active addiction, as I am sure the committee is well aware, they are at a higher chance of contracting a blood-borne virus.

Prof. Stoove : I would add: I could not agree more that we need to invest more in prison drug and alcohol treatment programs. But for us to expect that prison AOD programs would be able to achieve long-term abstinence and cessation from drug use, when many community programs are unable to demonstrate that, I just find a little silly. I guess that is the nature and the distinction between—

Mr STEPHEN JONES: Why do you say that, when it is a much more controlled environment? I could accept that proposition if you said that over a long duration it may not have the same success.

Prof. Stoove : Potentially, while they are in custody—absolutely. The problem is that the social determinants of drug use and ongoing drug use mean that these people will return to ubiquitous drug-using environments. The real investment that needs to occur here is in supporting them through transition—supporting them in the community. The nature of harm reduction in relation to demand reduction in relation to treatment is the acknowledgement that, over time, people will return to patterns of drug use. The trajectory of someone's injecting career is typified by patterns of cessation and abstinence that are usually predicated not on formal drug and alcohol treatment but issues of stability in their life—relationship stability, financial stability and housing stability. It is those types of things in the long-term trajectory studies that typify or predict periods of cessation and abstinence. So I think that it is just a little naive to think that the effective delivery of an alcohol and drug program to target individuals either in prison or in the community is some type of a silver bullet for these types of issues. Most of us today have talked about holistic approaches, and they need to happen in relation to AOD programs and the social programs that support people in prison and through into the community.

CHAIR: So if there is a trigger at any point during an IDU's life span, are you going to tell me that—running a program, where they might come off that program successfully—a trigger will just put them back into that situation?

Prof. Stoove : It is often a particular life event. Anecdotally, I have seen stories. One of the bugbears I have in the Victorian system is the non-recurrent serving of warrants. People come out of prison and think, 'Right, now I'm going to go straight.' I have heard firsthand stories where people say, 'I got back with my girlfriend; we found some community housing; I got a part-time job, and then, bang, I was walking down the street and got hit with the warrant that was outstanding,' which really should have been served at the time of their previous incarceration or their previous court hearings. It is usually a particular life event that occurs or a particular serendipitous moment of re-engaging with an old friend that really triggers a return to use. I am not sure how many in this room would have tried to give up smoking over their life. It takes multiple cracks at it before you remain smoke free over an extended period of time, and it is even more the case when you have so many social determinants that hang over the top of problematic drug use.

CHAIR: John, I think you were trying to make a comment before. Were you?

Mr Didlick : I was responding to the particular point made about the placement of corrective services to operate drug and alcohol programs. I am aware that the ACT only has one prison, so it might appear like an anecdote, but it is the experience that I have to contribute. There are a range of interventions offered in the Alexander Maconochie Centre that are drug and alcohol programs. The best one, in my view, is a residential therapeutic community program. It is operated by an NGO with what I believe is Australian government funding. It is delivered as a partnership between ACT Corrective Services and Karralika, but it is a Karralika program. It is a therapeutic community model. If I might say so, that is the only part of the prison that I regularly visit where I see people with extensive drug use histories who are abstinent.

I think some of the comments made by the committee and by others allude to a treatment goal of abstinence, from drug and alcohol programs. Whilst that is sometimes possible, it is not always possible. We should—and we do, or some do—recognise that a reduction in harms associated with somebody's drug use is in fact a good outcome from drug and alcohol programs. Abstinence is not attainable for everybody. It is just not. Can it be, in the right circumstances, if the planets align? Maybe, but the reality shows us that it is not attainable.

People in prison continue to use drugs. Why is that? It is not because they do not know that they produce harms. People do not take risks because they do not know that hepatitis C is a possibility. I worked with a prisoner a little while ago who said to me, 'You need to know that we know a lot about prevention, and we know a lot about hepatitis C, but the bit that you don't get is that the immediate benefits of using a drug outweigh the immediate benefits of prevention.' That is because of their lived experience. That is because of the environment they are in and their histories.

CHAIR: Going back to the prison environment, what would the biggest health issue be? You talked about priorities, Troy. If you tend to lose resources, you tend to take away from non-custodial services. But, in the prison population—and I know you are not clinicians—what would the major health issue within a prison environment be?

Mr Wright : Does violence qualify as a health issue?

CHAIR: Yes. That is what I am asking. There would be more hospital visits from violence—

Mr Wright : Yes, inmate on inmate and inmate on officer.

Mr Smith : Mental health is something that we do not have very much financial dedication to. Increasingly, prison officers have to deal with mental issues that we are not trained to deal with, and the provision of funds is not there to put professional people in to deal with that. So we are seeing those then present themselves as violent occurrences and other crimes. So my answer to that, in my experience, would be mental health issues.

Prof. Moore : Combined with alcohol and drugs.

Mr Smith : Alcohol and drugs, yes, obviously.

Prof. Moore : I am not disagreeing with you.

Mr Smith : But it all exacerbates each other.

Prof. Moore : Exactly.

CHAIR: How are the interferon treatments delivered in a custodial environment now and what sort of involvement do the prison officers play in that?

Mr Smith : I can only speak from Western Australia, but it becomes a medical effect and prison officers are not then party to that information. As a prison officer, you would not be aware of who was on what program. It is purely medical. A prisoner would be called down to a medical centre and get treatment for any number of things, but prison officers are not party to what they are on.

CHAIR: If somebody is visiting the doctor or the nurse once a week, they are not there because they have got flu.

Mr Smith : To be honest with you, you can have a unit with perhaps 110 prisoners in it, you have got eight officers on for the day and they have other duties. So whilst we attempt to have personal contact as much as we can, we would not know.

Dr Carruthers : I will add that, in my experience with interviewing in the rural setting—so prisons in Albany and in Bunbury—where there are fewer prisoners it is much easier for health staff and prison officer staff to keep in touch with what is going on, and they do it very, very well. There are very good reports, certainly in the Albany prison, of where prison officers were aware of who was on hepatitis C treatment, they were aware of what the side effects were and they treated the prisoners accordingly. It was: 'You're having a bad day. We know that you're on interferon. Fine. Go back to your cell and sleep it off.' But that is in a smaller rural prison, some of which are medium to low security, so the security issues are not as much, and that works particularly well. I saw very good communication between the prisoners, health staff and the prison officers, and I spoke to all three.

Mr Smith : Once again, it comes back to the correlation between the number of staff available and the number of prisoners. In the larger institutions—I worked at Hakea prison which had over 1,000 prisoners—you cannot possibly have that one to one relationship.

Dr Carruthers : Absolutely not.

Mr Smith : However, you do have—and I have had many—experiences where prisoners will be open with you, telling you where they are at and why their behaviour is such, and you can react to that, and there are some really good officers and some good relationships.

Dr Carruthers : Absolutely.

Mr Smith : But it is a prisoner who would come forward with the information. You are certainly not a party to it, in answer to your question.

Dr Carruthers : In the smaller prisons, it is not only the prisoners coming forward but also the nursing staff—more the nursing staff rather than the doctors because the doctors tend to come in and out—who will say to the prison guard: 'This person, prisoner X, is on interferon. On Fridays he has his interferon. On Saturday he is going to feel really under the weather and may be bad tempered. Give him a break.' And that happens. But that is in the smaller prisons.

Mr Smith : I would also like, if I can, to just come back to a point made earlier on. I do not want it to be glossed over that some of the programs are of little or no use. Just like when you are trying to give up smoking you might do it many times, prisoners will get onto a program and you might see them come back into prison and go onto the same program again. You go, 'Weren't you on this before?' They say, 'Yeah, but I'm making progress.' So it is a positive thing when they re-attend the program. They might do it two or three times, but eventually it will have a greater and greater effect. So I do not want it to be brushed over—coming back to Mr Wright's point earlier on—that the funding for those programs and the ability for prison officers to have a direct response and an involvement in those programs is pointless. It is a really important thing for prisoners not to reoffend and not to continue their drug use.

Mr Wright : For the benefit of the committee, I can advise that the New South Wales system is a little bit different. It is an example of where Justice Health runs the health programs and Corrections run the corrections side of things. The interaction between the prison officer and the program is limited. They know that the inmate has a medical hold and they are to be kept at that jail and they will attend the clinic. That could be for any purpose. There is a barrier of medical confidentiality, as there should be, and the inmate returns, sometimes with a certificate saying: 'I need to be in my cell for the rest of the day.' It is probably known, but at least that boundary is attempted to be maintained between the health and the corrections sides of the operations. I think that is the case in Victoria as well. It is something similar.

Prof. Moore : It is also the case in the ACT. That is why in our recommendation we said that we believed that it was appropriate to have the NSP operating as part of the treatment within the medical centre and separate from custodial officers.

Ms Tyrrell : I think what we are hearing here is the huge variation in health interventions across different types of prisons within a jurisdiction and across jurisdictions, and I would like to make the point that there are jurisdictions in Australia where even access to opioid substitution programs is absolutely minimal for male prisoners. It might be there for female prisoners in some prisons. There is a huge variation in what is provided in terms of the drug and alcohol treatments.

CHAIR: And that goes back to the corrective ministers' priorities or does it go back to the health departments of the states' priorities?

Ms Tyrrell : The jurisdiction I am talking about is Queensland. I do not know whether you have any specific—

Mr Wright : No, we do not.

Dr Carruthers : The Northern Territory is the same; there is no—

Ms Marton : That is the case in Western Australia. Unfortunately, as recent as a few weeks ago, I attended Casuarina Prison, which is in my jurisdiction, and the comment back from the officers and some of the mental health nurses was that, because of the budget cuts, they were not able to service the needs of those on drugs or suffering from mental illness, which often intertwines with each other, and they were really stretched. In fact, they are facing further cuts as well, which is very disappointing.

CHAIR: There was interferon treatment for prisoners in Western Australia, wasn't there, through the Royal Perth Hospital? Is that correct?

Ms Marton : I believe so.

CHAIR: And that has been reduced as well, hasn't it?

Mr WYATT: It has been capped.

Prof. Moore : And this is in the context of course of growing incarceration rates in Australia and hence the overcrowding of prisons. We heard the difference in numbers in New South Wales and Victoria and you wonder what is going on with incarceration rates as well. In some ways it is difficult to address all of these questions when prison officers are having to deal with overcrowding of prisons, because we cannot keep up with the rates. Yet there are jurisdictions around the world that are managing to reduce their incarceration rates rather than increasing them and using alternatives particularly around the area of mental health, which we have talked about. It winds up being a custodial officer's issue and it is entirely inappropriate.

Ms Davies : One of the challenges which has been alluded to is the transition to release, particularly with long-term treatments for anything, including drug and alcohol programs, that are extended. The transition to release in Victoria has two extremes. If you are released from a private prison in a regional area you get a bus fare to Melbourne and one night's accommodation. Even if you are released on a Friday that is all you get. At the other end of that is the Judy Lazarus Transition Centre, which has capacity for 25 prisoners who are at the end of their sentence. They live there with intensive case management for four to six months before they are released and they establish ties to the community, they sometimes get back to their old job and they are stable and have stable lives before they leave the centre.

Your chance of being re-incarcerated in a private prison in Victoria is 40 per cent within two years of your release. But, if you are go through JLTC it is less than 10 per cent. Yes, it is an expensive program upfront, but the long-term benefits of that program are absolutely amazing. It makes a very big difference to long-term treatment and the success that people have in staying off drugs if they are clean when they are released. It has incredible benefits but it is very expensive. All of the things that we are talking about today are very, very expensive and, for us, the corrections budget is already more than a billion dollars and it is going to be under more and more pressure. It is a huge conflict. In many cases we know what to do but just cannot afford to do it.

Mr Loveday : I would make a point on the rates of incarceration of Indigenous people, Aboriginal and Torres Strait Islander people, in Australia. Not only is there a vast over-representation of Aboriginal people but you also have higher rates of hepatitis C prevalence. It is about 3½ times higher than in the non-Indigenous community. So you have got two factors there impacting on the direct health outcomes and status of Aboriginal and Torres Strait Islander people.

Ms Tyrrell : Could I just make a quick point. When I joined Hepatitis Australia 10 years ago, Victoria had the lowest incarceration rate in the country because they had fantastic diversion programs for people who injected drugs so that they did not end up in prison. Without hearing they are building a multimillion-dollar additional prison, I think this goes to the fundamentals. We need to keep people out of prison if there are opportunities to do so.

Ms Davies : I think there is a sense that people in Victoria are incarcerated for drug use only. That is in fact not true. Most people will have a drug use charge as an aside with other, more serious charges, usually drug trafficking or commercial drug trafficking. You would not get incarcerated in Victoria for simply drug use.

CHAIR: Can you add some comments?

Mr WYATT: I just want to clarify Mr Wright's comments on silos. When I talk of silos I talk about silos across agencies, not silos within budget because appropriation requires agencies to expend their budgets on the programs based on their core function and role. So I would not want to see Corrective Services or prison services move money out of administration for health purposes or for the programs they establish to keep people out of prisons. It is more around all of those involved in dealing with hepatitis C or health issues, both community and the agencies in each jurisdiction, working much more closely together and considering the views of each other in reaching a resolution that will better help an individual than we currently are.

CHAIR: We do not have long to go and we have to wrap up at 2.30 because some of my colleagues have to catch planes. I would like to thank you all for coming together today and, hopefully, there has been some useful dialogue for the committee and for our secretariat to take on board and maybe for each of you to take on board as well and, as the saying goes, move forward and try to get together and continue that dialogue. I am sure my colleagues would agree that it would be great to see that dialogue continue.

However, I am going to give you the opportunity, because we have about six minutes left, to make a very brief comment about what you would maybe like to see in our report that would help as well.

Dr Carruthers : I would like an emphasis on the fact that no one harm reduction strategy will work and that we need a raft of them, including drug and alcohol treatment, drug-free units, needle and syringe programs, the ability to clean needles and syringes, and that each one is given equal weight.

CHAIR: If you agree with Susan, you do not have to add to it.

Prof. Stoove : I echo the sentiments of members of the committee and people who have provided evidence today of hoping that people can get together in the same room and have a conversation and a dialogue that engages not only with the evidence but also with the lived experience of people who work in prisons in the hope that we can come together with a solution that is acceptable to all parties and, at least, to identify one place in Australia where we may be able to trial something that is a little bit out of the box and establish our own evidence around whether it is effective or otherwise.

Prof. Moore : I think if we are going to use Troy's cog analogy, let us make sure it is comprehensive and we have all the teeth in the cog from the beginning. We would like to see a recommendation around Medicare access for prisoners and equity in treatment across Australia in terms of opioid substitution treatment, alcohol and drugs, and hepatitis C. Finally, I think we need consistency and a comprehensive collection of data and reporting but not to slow things down. Of course, the NSP is part of a comprehensive program.

CHAIR: Melanie, would you like to add to that?

Ms Walker : No, I think Michael has summed it up pretty well. Thank you.

CHAIR: We might leave it to Mr McDevitt to make a comment, because he is closer to the ACT's problem.

Mr McDevitt : Sure. Rather than speak about what we would like to see in the report, it is easier to speak about what we would not like to see in the report. The pursuit of evidence and better data is essential before further contemplation of rolling out a needle and syringe program. I think there is significant scope to make a fairly immediate and reasonable impact on the spread of blood-borne viruses, with the cooperation of custodial officers through the pursuit of tattooing for instance, and other things, so those sorts of programs.

I think there needs to be recognition that the dramatic overcrowding and underfunding of correctional facilities across the nation is dramatically impacting right across the spectrum, including the failure for instance of inmates to participate through care programs and all the rest, such as the deliverables. So it is all being compromised.

When the system is clearly struggling, to even contemplate a quantum leap forward to rolling out needles at this time would be premature, I think, and potentially dangerous.

Mr Smith : I would just like to add that some of the things that have come forward have been enlightening, but I think we are still only just touching on some of the things that we need to share between organisations. We have so much more that we can offer and things that we have not discussed here. We are looking at needle exchange, but we have not discussed sterilisation equipment, which could be done cheaper and more immediate and the provision of training for prisoners within prisons is something we have been trying to do and supporting for years. If the committee provides a forum or an opportunity for people to exchange information and move forward, we could certainly get closer to a safer environment for prisoners when it comes to hepatitis C.

CHAIR: I think there are enough adults in the room that we could probably take on that role now and leave the committee out of it.

Ms Tyrrell : The first point is that we really need to focus on keeping people out of prison. That is the single most effective intervention we can make in terms of prisoner health, to keep people out of prison wherever possible.

Another point I would like to stress is that I certainly would like to see some national dataset. I think the federal government can possibly incentivise that. I would really like the committee to put their mind to how progress might be incentivised through jurisdictions, given that prisoner health is a jurisdictional matter and not a federal matter.

I would also like to say that we cannot leave any cog out of the wheel. It has to be a comprehensive approach that we take. I think we have got a much clearer understanding today that what we are about is not just prisoner health; it is also about providing a safe environment for prisoners and custodial officers to work in. That point really needs to be stressed. Everything that we are putting forward is about creating a safe environment for prison officers as well.

Mr Didlick : I agree with those points. I would like to see as an outcome of this process national leadership on difficult issues. I think there has been a struggle between evidence and ideology. I do not think evidence can in fact shift ideology. So if we are waiting for a consensus we will be waiting for a long time.

Mr Loveday : I agree with all the points that my colleagues have made so far. In addition, I think it is really important to note that we have a broad suite of consistent, evidence-based harm reduction and prevention services, with a particular additional focus on the provision of a controlled needle and syringe exchange, perhaps with a federally funded pilot in each jurisdiction leading the way in that regard. Also, a key issue is to have consistent and equitable access to health services across all jurisdictions, be that in AOD treatment, mental health services and support, and blood-borne virus treatment—that is, hepatitis C included. I would like to take up a suggestion one of my colleagues made the other day—I do not think it has been mentioned—and that is to have prisoner health placed on the COAG agenda. It is such an important public and personal health issue that I think to have prisoner health raised in its status to the COAG level would give it the credence it deserves, so that would be my final recommendation.

CHAIR: Once again, thank you for coming along today. It has been worthwhile. I would like to thank Mr Wyatt for not only initiating the original inquiry but also agreeing with me that we needed to have it today after we took evidence from previous hearings; the committee again for turning up today; the committee secretariat for all the work they have done; Broadcasting who are behind us here and recording it for Hansard; all the witnesses who have appeared today—we appreciate your time; we know how busy you are but it is an important issue and I think it is great that you have turned up today; and any other people who have been in the audience for coming along and listening to what we have got to say. I look forward to releasing the report once it is finished. Thank you once again.

Resolved that the proceedings be published.

Committee adjourned at 14:31