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Rapid Assessment in Prisons

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Rapid Assessment in Prisons

December 19th, 2005 - January 20th, 2006


   Prepared by:
   Zelichenko Alexander
   CONTENTS page No.
   List of Abbreviations
   ART Anti-Retroviral Therapy
   CARHAP The Central Asian HIV/AIDS Programme
   GUIN Main Department for Sentence Implementation
   HIV Human Immunodeficiency Syndrome
   HR Harm Reduction
   IDU Injection Drug Users
   NGO Non-Government Organization
   PI Penitentiary Institution
   PLWHA People living with HIV/AIDS
   STI Sexually Transmitted Infections
   SW Sex Workers
   TB Tuberculosis
   VCT Voluntary counseling and testing
      -- Introduction
   The Central Asian HIV/AIDS Programme (CARHAP) aims to contribute to the aversion of a generalized HIV/AIDS epidemic in the Central Asia Region with special attention to vulnerable groups such as injection drug users (IDUs) and overlapping groups as sex workers (SW) in programme oblasts and prisons in Kyrgyzstan, Tajikistan and Uzbekistan. The project purpose is to be achieved through implementing the activities based on the principles of harm reduction (HR). While contributing to preventing HIV transmission into the general population, harm reduction equally aims at preventing the spread of hepatitis and other blood-borne infections, reducing the risk of overdose and other drug-related fatalities, and lessening the negative effects drug use may have on individuals and communities including poverty and crime.
   Key activities of the programme include: (a) the scale-up of comprehensive HR activities targeting people who are engaged in high risk behavior; (b) building capacity of decision-makers; (c) support for strengthening implementation of the UN Three Ones principles; and (d) enhancing the policy and legal environment for effective awareness and prevention programmes.
   In support of the project activities a rapid assessment has been undertaken in 8 prisons in Kyrgyzstan with the view to obtain baseline data that will guide the programme in selecting prisons for scaling-up HR services; support the design criteria for funding of HR service organizations; direct organizational capacity-building of potential implementing partners for HR activities; and guide effective M&E at different implementation levels. The following tasks have been addressed during this assignment:
      -- Identify medical and other services provided to inmates in prisons;
      -- Assess the prevalence of drug use and other forms of risk behavior among inmates;
      -- Evaluate the quality and comprehensiveness of services paying special attention to services such as voluntary counseling and testing (VCT), syringes and needle exchange, condom distribution, drug, HIV, STI, TB treatment and substitution therapy, referrals and outreach activities;
      -- Identify capacity-building needs of providers of HR services in prisons;
      -- Assess the organization of HR services especially with respect to managing and monitoring their activities;
      -- Assess patterns of collaboration between the penal authorities, medical services and NGOs delivering HR services to inmates.
        -- Methodology
   Using the instruments developed by the CARHAP's Regional Office, the assessment involved interviewing prison's Directors, their Deputies and commanding officers; medical personnel; employees and volunteers of NGOs providing HR services in prisons; as well as inmates themselves. The assessment also incorporates personal observations made by the Consultant during his visits and analysis of reporting documentation provided by the Prison Administration, the Medical Service and NGOs.
   As approved by the Minister of Justice, the rapid assessment was conducted in 8 (eight) penitentiary institutions of the Kyrgyz Republic. Their list along with the dates of the Consultant's visits there is provided below:
      -- Penitentiary institution No.2 for women - December 19-20, 2005;
      -- PI No.3 - December 21-22;
      -- PI No.1 - December 23-26;
      -- PI No.8 - December 27-28;
      -- PI No.14 - January 3-4, 2006;
      -- PI No.36 - January 5-6;
      -- PI No.10 - January 9-10;
      -- PI No.25 (Detention Centre) - January 11-12;
   In accordance with protocol, the rapid assessment started with the GUIN Chief colonel Mukaev Kapar Babaevich and briefing him on the goals and objectives of the upcoming exercise. GUIN deputy chief colonel of internal service, Kalygulov Batyr Tobokelovich, and the officer of the department of the Ministry of Justice on GUIN Reform, director of NGO "Inter-Demilge" lieutenant-colonel, Raushan Abdildaeva, were present as well. In addition, the recently appointed GUIN chief was informed in detail about the purpose and expected results of CARHAP and the need to assess the current situation in the penitentiary institutions of Kyrgyzstan.
   The GUIN chief expressed sincere interest in participating in the program and his willingness to facilitate the rapid assessment. He assigned Damir Usenbaev, a senior officer of the Department to work with the researcher.
        -- Limitations & Concerns
   The questionnaires that had been prepared in advance for conducting the interviews were not sufficiently adapted for penitentiary institutions. Most of these tasks and questions were intended for medical staff of municipal hospitals, for evaluation of "Harm Reduction" program on levels of administrative units (oblast, national), and for interviewing the program clients out of closed penitentiary institutions.
   In view of the reasons given above, the Consultant has adapted the questionnaires as follows:
  -- Questionnaire for inmates;
  -- Questionnaire for service providers and medical staff;
  -- Questionnaire for penal authorities.
   In addition, as requested, the Consultant adapted the template that was provided for the Oblast Reports.
      -- Penitentiary Institution No.2
   2.1 General Information about the Institution
   The institution is located in Chui oblast. Officially the PI No.2 is a prison of general regime, i.e. by law, only those inmates who are convicted for the first time should be kept in this prison. However, this regulation is not applied here since PI No.2 is the only prison in the country for female inmates. Out of 554 inmates, 136 (or 25% of the prison population) were convicted for drug related crimes.
   PI No 2 provides income-generating activities such as production of bed linen and clothes for the inmates and armed forces. The proceeds earned this way are used for nutrition, medical and sanitary services (for example X-ray), and covering of administrative costs. Penal management collaborates with all the religious confessions in the Republic, who are sponsoring the activities in the prisons.
   In addition the prison administration is open for cooperation with international donors, NGOs and commercial partners (medical equipment and heating appliances from South Korea). The "Kulukan" NGO repaired and equipped the laundry place, paid for through the grant "Healthy Communities" from the Soros Foundation. UNICEF is financing the repair and equipment of the "children house".
   The GFATM and "Inter-Demilge" are implementing syringe and needle exchange programs, and provide essential drugs. Medical and other staff of the prison was trained by "Inter-Demilge" with support of the Republican AIDS center, Soros Foundation, East-West AIDS Foundation and Stephan Batoria International Fund in Harm Reduction and drug prevention.
   2.2 Prevalence of HIV Risks Among Inmates
   The institution contains five hundred fifty four (554) inmates, one hundred thirty six (136) of them were convicted for drug-related crimes.
   Drugs arrive in limited quantities, mainly through new inmates dispatched from the Detention Centre. Limited supply results in drugs being too expensive for most inmates. According to the estimates provided by the Prison Administration and confirmed by inmates, about 20 prisoners consume drugs while injectors account for about a half of this number. Among injectors drugs of choice are heroin and opium. The inmates boil the solution before injection. Also, there were attempts to smuggle marijuana and hashish into the facility. Furthermore, there are reports about inmates injecting dimedrol causing life-threatening injuries. As a result of dimedrol injections, 4 inmates were hospitalized in 2005. In addition, there are numerous attempts to smuggle alcohol or produce it locally.
   The number of drug users among inmates is limited due to low supply of heroin to the institution as the paying capacity of inmates is low and dealers are not interested to provide drugs to those who cannot afford them. Furthermore, no "Common Fund, " a practice typical in all-male prisons, has been established among inmates of this institution. The "Common Fund" is usually supplied from the proceeds of illegal activities of gang members on the outside and used to pay for drug consumption of their "colleagues" who ended up behind bars.
   2.3 Medical and Other Services Offered to Inmates
   2.3.1 Information and Education
   HIV prevention information and services are available to inmates. On a bi-monthly basis, employees of the Medical Service of the Main Department of Sentence Implementation, and NGOs such as "Inter-Demilge", "Koz-Karash" and others conduct roundtable discussions, lectures, and presentations for inmates. For example, on December 1, 2005 inmates had a tea-party with informal presentations on HIV prevention issues. At the conclusion of this event each participant received a bag containing food items and stationary to be shared with other inmates. The prison's Director stated that these packages were also distributed during the period of prison revolts (November 2005) when the centralized provision of food to his institution was interrupted. It is only by relying on these inmates managed to get through.
   Special attention is paid to preventing and treating tuberculosis. According to Viktor Pavlovich Starostenko, the prison's Director, two years ago the situation with tuberculosis among inmates was particularly serious. At that time Ainura Kulmatovna Syrgataeva was appointed the Head of the prison's Medical Unit. At its own expense, the Administration arranged TB testing among inmates, equipped treatment facility and provided intensive treatment to 7 patients with active form of TB. With support from international donors, the institution acquired cattle and rabbits to supply TB patients with milk and meat. Additional support comes from the GUIN's Medical Service and GFTAM who provided drugs and technical advice on arranging TB service in the institution. As a result of these measures, the TB situation has improved in this prison.
   2.3.2 Drug Treatment
   For twenty eight (28) female inmates the conviction includes undergoing compulsory treatment for drug addiction. The duration of treatment is between six (6) months and eighteen (18) months. In 2005 (4) four inmates joined the treatment program for drug addiction and (12) completed it. Due to medicine and other treatment techniques being unavailable, drug treatment is limited to detoxification. However, as inmates are admitted into the penitentiary institution only upon going through the pre-trial and trial period at the Detention Centre, it is there where they undergo the abstinence syndrome. In other words, they do not need detoxification services by the time they arrive at the penitentiary institution.
   Depending on their health conditions, in prison inmates receive vitamin therapy, injections of glucose and other medical substances. However, psychotherapy is the primary method of drug treatment practiced at this institution. This service is provided by Ainura Kulmatovna Syrgataeva, chief of the Medical Unit, and sometimes by a certified psychologist whose services are made available through the Soros Foundation-Kyrgyzstan. It should be mentioned that Mrs Syrgataeva attended the training programme on psychological counseling offered by the "Atlantis" project. Psychotherapy and counseling sessions are conducted at the request of inmates and the latter testify to the effectiveness of this method as well as to the professional qualities of staff members.
   It should be noted that the current legislation requires the inmate to complete compulsory drug treatment before s/he can be considered for parole or early release programme. This legal provision stimulates drug users to hide their habit during the pre-trial and trial stages in order to avoid the condition on compulsory drug treatment being included in their sentences. However, drug users among inmates do not have any incentive to conceal their dependency so that many of them are seeking drug treatment voluntarily, i.e. in addition to those who are sentenced to compulsory drug treatment by court. Psychotherapy and counseling sessions are especially popular among inmates.
   2.3.3 Syringe and Needle Exchange
   The syringe and needles exchange program has been is operation for about three years. At present the exchange is conducted by the trained nurse and the chief of the Medical Unit. The exchange also engages a volunteer among inmates. The volunteer receives 10-15 syringes to be exchanged during weekends and there is strict control over her returning the exchanged syringes. Syringes and needles are supplied centrally, through the GUIN and the NGO "Inter-Demilge". The exchange takes place at the premises occupied by the Medical Unit. The facility tends to be crowded yet the medical staff manages to conduct information sessions with each client. Brochures and booklets on HIV prevention are available there as well. The clients interviewed note friendly attitude of medical staff of the exchange.
   2 and 5 ml syringes are given out through the exchange and these types of syringes meet preferences among clients. Their number has come up from 8 to 16 during 2005. In addition, there are those who utilise the exchange services on non-regular basis and their number is about 50 inmates. To get new syringes, a client or a volunteer has to bring used ones, count them in front of medical staff and put them in a disposal box. Then the client receives the same number of new syringes, i.e. the 1:1 exchange. In total, 1140 syringes were exchanged in 2005. According to medical staff of the exchange, needles and syringes are offered only to known drug users among inmates. The latter are informed about the exchange services through their fellow inmates.
   On a monthly basis, the service generates reports that reflect the number of clients, the number of syringes given out and the number of syringes returned. At least once a month used syringes are destroyed in the presence of prison officials.
   2.3.4 HIV testing, PLWHA and availability of ART
   All arriving inmates have to undergo compulsory HIV testing. The pre- and post-test counseling is provided by the Chief of the Medical Unit who has been trained for that. Blood is drawn at the prison's Medical Unit while blood samples are processed at the Republican AIDS Center.
   Currently there are four PLWHA among inmates, one PLWHA died of AIDS-related causes earlier this year.
   As reported by prison's Administration, medical staff and inmates themselves, there is no stigma and discrimination against the PLWHA at this institution. PLWHA do not conceal their status and other inmates treat them with compassion. The respondents explain this supportive attitude by inmates being well aware of HIV transmission routes so that they know that causal contacts with PLWHA are safe for them. On the other hand, inmates report avoiding TB patients as even casual contacts with the latter can be contagious.
   Starting in August 2005, ART has been made available to PLWHA among inmates. Periodically, PLWHA undergo blood testing with specialists from the Medical Academy of the Kyrgyz Republic providing their conclusion on test results. Based on their recommendations, the Republican AIDS Centre may provide ART to those patients who need it. So far, there have been no actual cases of ART provision as no PLWHA has reached that stage.
   2.4 Potential for Scale-up
   The medical staff (two nurses and the Chief of the Medical Unit) expressed their willingness to get training in new methods of drug treatment.
   It appears that an eventual introduction of methadone would be met with resistance from the prison's Director and the Chief of the Medical Unit. However, the Deputy Director expressed his support for it.
   There is facility for needle exchange at the Medical Unit, yet it has to be renovated and equipped.
   The institution also has video-equipped rooms where information sessions on HIV and drug prevention can be held. Also, there is an open-air facility where presentations to inmates can be conducted.
   Specific suggestions from the prison's Administration on scaling-up HIV prevention services are listed below:
      -- To continue the syringe and needle exchange;
      -- To continue information and education sessions on HIV prevention (lectures, presentations, seminars, round tables, booklet and brochure distribution etc.)
      -- To continue and expand TB prevention and treatment programme;
      -- To implement programs "Anonymous alcoholics" and "Anonymous drug users".
      -- To introduce a rehabilitation programme modeled after the "Atlantis" project
      -- To train medical staff in new methods of drug treatment and supply medicines for drug treatment.
      -- Penitentiary Institution No.3
   3.1 General Information about the Institution
   Located in Chui oblast, this is a high-security institution containing one thousand five hundreds ninety nine (1,599) inmates. The institution includes the GUIN's TB Hospital where 237 inmates with active form of tuberculosis receive their treatment. There is a Mental Ward attached to the Hospital. The institution also has a production facility where a limited number of inmates are employed.
   3.2 Prevalence of HIV Risks Among Inmates
   3.2.1 Injection Drug Use
   Two hundred twenty three (223) inmates - or 14 percent of their total number - have been convicted for drug-related crimes. There is a widespread court practice to sentence people with minor amounts of drugs in possession to long-term imprisonment. To illustrate this point, the administration of the facility drew up a list of such inmates who serve their sentences at PI No3 (Appendix 1). Although these are the repeated offenders, the limited amounts of drugs found in their possession do not justify sentencing them to long-term imprisonment, as this does not constitute a threat to public security. Similar cases can be found in other penitentiary institutions in Kyrgyzstan, which suggests that the current Drug Law has to be revised.
   According to Imankul Andashevich Teltaev, Deputy Director of the Institution, about 300 inmates - or 20 percent of their total number -- use drugs. All of them inject drugs, mainly heroin. About 10-12 of them are drug dependent so that they have to get drugs on a daily basis. According to the Deputy Director, to maintain their image of successful drug-getters, sometimes they inject dimedrol, the medicine used to reinforce the effect of heroin, in front of other inmates. Furthermore, IDUs tend not to boil the solution but inject dimedrol and drugs (heroin, opium) as soon as they dissolve them in tap water.
   Inmates themselves estimate that from 70 to 85 percent of the imprisoned population use drugs. The price for one dose of heroin is 50 soms, which is higher than on the outside. At the same time there are reports about inmates supplying drugs to those on the outside, which suggests that drugs are widely available at this institution. Note that in 2005 no cases of drug smuggling into the Institution were registered.
   There are cases of overdose among inmates although their number is decreasing due to the effective drug prevention programme being implemented at this Institution. Medical staff also reports that inmates tend to inject salt to an overdose victim even before bringing him to the medical facility. Usually, taking this measure prevents the victim from dying of overdose.
   3.2.2 Tattoos
   Tattoos are losing their appeal among inmates with only about 20% of those interviewed responding positively to the question: "Have you made a tattoo while in prison?" However, these inmates relied on non-sterile equipment despite their being aware of the risks of getting infected with HIV, HCV and other blood-bourn diseases.
   3.2.2 MSM
   MSM is one of the most stigmatized groups of inmates who are not even allowed to enter medical facilities when other inmates are there. They have separate residential quarters and dining facilities and are assigned the most unpleasant tasks in cleaning the territory and public accommodations, etc.
   At the penitentiary institution No.3 about fifteen (15) inmates are MSM. They report that up to 20 per cent of inmates use their services. Usually sexual services are purchased for tea, food, clothing and tobacco. Yet drugs and money can also be offered as a mode of compensation. MSM deny that other inmates resort to violence to get their services.
   At the same time none of the MSM interviewed reports using condoms, even though two of them received medical treatment for syphilis in 2003. One of the respondents admits that he used to practice safe sex but then condoms became unavailable and it was difficult to convince his partners to use condoms to begin with. Even when distributed, the Global Fund doesn't provide condoms for anal sex. The dominant motives among MSM for not using condoms are (a) unwillingness of clients to use condoms, (b) uneasiness about offering condom use to client, (c) condoms being unavailable. At the same time, MSM are well informed about the risk of HIV infection during unprotected sex.
   MSM deny injection drug use in their midst.
   None of them has undertaken voluntary HIV testing as they are not concerned about the possibility of their being HIV infected.
   3.3 Medical and Other Services Offered to Inmates
   3.3.1 Information and Education
   At this Institution IEC on HIV/AIDS and drug prevention as well as on harm reduction issues is being implemented by the Medical Service of the GUIN, Department for Penitentiary Reform of the Ministry of Justice, the Republican AIDS Center and numerous NGOs such as "Inter-Demilge", "Koz-Karash", RANAR, AFEW, RANS, "Oasis" and others. The IEC is conducted in the form of lectures, talks, seminars and brochure and booklet distribution. There are requests from the administration and inmates themselves to intensify IEC at this institution.
   3.3.2 Drug Treatment
   According to the current regulations, the inmates sentenced to compulsory drug treatment are sent to the Pentitentiary Institution No47 where the GUIN's Narcological Hospital is located. However, as reported by Janyl Jarkymbekovna Osmonova, the prison's psychiatrist, drug treatment is also often sought by those inmates-IDUs who do not have a clause about compulsory treatment in their sentences. Usually, their treatment is limited to receiving vitamins and some medicine.
   3.3.3 Rehabilitation
   The institution is the site for the Rehabilitation Center operated by the "Atlantis" project. Initiated by the NGO "Inter-Demilge" and funded by the "Soros Foundation-Kyrgyzstan", this project began its operations in February 2004. The institution's administration provided premises for a rehabilitation center, which were renovated by inmates themselves. The Centre is headed by Tatyana Vladimirovna Kovaleva, psychologist at the PI No3. She is assisted by Abdykerim Apievich Ismailov whose official capacity is security officer. So far, rehabilitation services have been provided to ninety (90) inmates. Thirty (30) percent of them have not been using drugs for 6 or more months, which testifies to the effectiveness of the services provided.
   In addition, the "Atlantis" project delivers effective IEC on HIV/AIDS and drug prevention. Inmates report learning more about HIV/AIDS from the "Atlantis" materials than during their previous 5-6 years in prison. As an illustration, the programme to commemorate the World AIDS Day developed by the Atlantis and the Medical Service of the GUIN is included in this report (Appendix 2).
   During the interview, Dmitriy Stanislavovich Samarin, the consultant of the "Atlantis" project, also suggested the extension of rehabilitation services to those inmates who are released into the community (Appendix 3).
   3.3.4 Syringe and Needle Exchange
   The PI No.3 is GUIN's core institution for the needle and syringe exchange program. The programme is located in a newly-renovated facility at the Infirmary and it has been in operation since 2002. The exchange is handled by Anara Sagynbekovna Kojokeeva, the Chief of Medical Unit, who is assisted by a nurse.
   Syringes are provided by GUIN and are exchanged at a 1:1 ratio by these 2 staff members who are praised by inmates for their being friendly and accessible. Yet no exchange through volunteers among inmates is allowed. The programme has 124 steady clients with 9200 syringes exchanged in 2005. Clients' preferences are limited to 5ml syringes and this is the type of syringes being provided by donors. Along with syringes clients receive needles, condoms, bleach and tissue. On average, from (45) forty five up to (75) seventy five inmates visit the exchange every day. Recently there has been an increase in the number of clients participating in the exchange.
   New clients are registered in a special form and assigned codes that consist of first letters of his first name, mother's last name and mother's first name. Each new client also receives information about drug-related harms. Most inmates feel free to participate in exchange as the programme has been in operation for 3 years and no repressions against its clients have been initiated. In fact, security officers express their understanding and support for the exchange and encourage inmates to seek its services. The only category of inmates avoiding direct contact with the exchange is gang leaders who tend to send their subordinates to exchange syringes.
   Used syringes are placed into a paper box to be destroyed by security officers on a daily basis.
   3.3.5 Condom Distribution
   The Medical Unit provides condoms to every inmate who asks for them. Condoms are supplied by the NGOs "Inter-Demilge", "Oasis" and "Help Zone". Over 2000 condoms were distributed in 2005. In this respect special attention is accorded to MSMs who are stigmatized to the extent that they may not ask for medical assistance even when they have serious diseases. Among this category of inmates condoms are distributed through their informal leader.
   3.3.6 PLWHA and ART
   There are twenty four (24) PLWA among inmates at this institution; all of them were diagnosed with HIV before being imprisoned. As their HIV status has not been revealed, other inmates and guards treat these inmates in a non-discriminatory way.
   ART is available and three (3) patients have been receiving it. The ART is provided for one month with regular blood tests to determine the effect of treatment among patients. Blood samples of PLWHA are processed at the laboratory of the Republican AIDS Centre.
   3.4 Potential for Scale-up
   Officially, the funding for the Rehabilitation Centre expired in October 2005 and none of the staff has been paid since then. The prison's Administration is interested in continuing the activities of the Rehabilitation Centre and looks for potential sources of funding. The institution has the infrastructure in place and specialists to deliver rehabilitation services are available. All of them have been trained at a similar rehabilitation center in Poland where the "Atlantis" approach originated.
   The Administration's officials express the view that HR programmes such as syringe/needle exchange and IEC decrease the risk of infection and overdose. Moreover, Deputy Director welcomes the introduction of methadone substitution therapy to this institution.
      -- Penitentiary Institution No.1
   4.1 General Information about the Institution
   Opened in 1924, PI No1 is the oldest penitentiary institution of the Kyrgyz Republic. One thousand four hundreds ninety three (1,493) inmates serve their sentences in a high-security environment. Attached to the institution is the production facility that has been destroyed during the riots. As a result, employment opportunities for inmates are no longer available. The institution is located in Chui oblast.
   There are six hundreds sixty three (663) TB patients among inmates, that is 44.4 percent of their total number.
   4.2 Prevalence of HIV Risks Among Inmates
   About thirty (30) per cent of inmates have been convicted for drug-related crimes. According to the Administration's officials, between thirty (30) and fifty (50) percent of inmates use drugs. All of them are IDU, 25-30 years, with heroin and opium being their drugs of choice. In 2005 two cases of attempted smuggling of marijuana were registered by security officials at this institution.
   Inmates put the prevalence of drug use at seventy (70) percent. A dose of heroin costs about 50 soms including three pills of dimedrol to reinforce the effect of heroin. The drugs are available around the clock.
   Every Friday criminal gangs share drugs among inmates for free to demonstrate their influence and to gain inmates' respect and subordination.
   There is a limited number of MSM who provide their services to other inmates in exchange for food, tea or cigarettes. Usually, the partners avoid using condoms during these contacts.
   4.3 Medical and Other Services Offered to Inmates
   4.3.1 Information and Education
   The officers and inmates interviewed recall two presentations on HIV/AIDS prevention conducted by the Medical Service of GUIN, as well as those delivered by the NGO "Oasis" where condoms were also distributed. The respondents are of the opinion that the number of these presentations has to increase as the level of educational attainment among inmates have been going down as most of them come from remote villages. That is why there is a need in expanding the distribution of information materials on HIV prevention (booklets and brochures) in Kyrgyz language.
   In addition, medical staff of the institution delivers presentations on HIV and drug prevention issues to groups of inmates. For example, every Saturday medical staff visits inmates' wards where they have roundtable discussions on these issues with up to 50 inmates.
   Every Wednesday prison's personnel have staff meetings during which the Chief of the Medical Unit delivers presentations on HIV and TB prevention.
   4.3.2 Needle Exchange
   There is no separate room for needle exchange. Needles and syringes are provided in the treatment facility where other inmates (non-clients of the exchange) receive medical services so that the latter have to wait in line to get treatment. There are 170 steady clients of the exchange with about 2000 syringes being exchanged on a monthly basis. Although 10ml syringes are particularly popular among clients, they receive 5ml and 2ml syringes. Insulin (laser-processed) needles are also in demand. Steady clients receive up to 9 syringes per week while newcomers get 1-2 syringes per week. The number of clients attending the exchange depends on drug supply to the institution. Between forty (40) and one hundred twenty (120) clients exchange syringes on a daily basis.
   The head of Medical Service of the prison is in charge of the exchange; she is assisted by a nurse. Yet medical staff is flexible about providing their services and for certain categories of inmates secondary exchange is allowed. This refers to (a) gang leaders who would never register with needle exchange programme but may use its services by sending their subordinates to get syringes for their group; and (b) MSM, who are not even allowed to enter medical facilities, according to the informal rules established by criminal gangs in prisons. As a result, medical staff either arranges exchange services for MSMs outside of infirmary or exchange syringes through the informal leader of MSM group. They receive positive references from inmates.
   Before getting services, clients are asked to show track marks and informed about drug-related harm. Clients' data (name, year of birth, ward) are entered into registration journal. Steady clients receive individual codes
   The policy of the Medical Service is to limit exchange services both in terms of the volume of clients and the number of syringes exchanged on a daily basis.
   The used syringes are placed by inmates in a box located in the infirmary. Every 2 or 3 days medical staff destroys this box in the presence of security officers.
   4.3.3 Condom Distribution
   Condoms are supplied by the Medical Service of the GUIN; they are distributed among inmates who are visited by their spouses, MSM as well as those who ask for condoms. There are no registration forms for condom distribution. The MSM interviewed during this assessment reports receiving no condoms through the prison's Medical Unit although he did recall getting condoms together with instructions on how to use them through the NGO "Oasis".
   4.3.4 PLWHA and ART
   There are (8) eight PLWHA among inmates who are discriminated against by other inmates. Stigma and discrimination forces PLWHA to live in a separate ward. No ART is available to these patients.
   HIV testing is not available to inmates at this institution.
   4.4 Potential for Scale-Up
   The prison's Administration is ready to provide premises for seminars and presentations on HIV prevention issues. The Administration is interested in expanding information campaign to prison's personnel including guards and security officers. Furthermore, the Medical Unit is interested in arranging a VCT Center; medical staff has to undergo VCT training to provide this service.
      -- Penitentiary Institution No.8
   5.1 General Information about the Institution
   Located in Chui oblast, the penitentiary institution No.8 is a medium-security facility containing one thousand sixty three (1,063) inmates. There are no production facilities attached to this institution.
   5.2 Prevalence of HIV Risks Among Inmates
   5.2.1 Injecting Drug Use
   Administration officials estimate that about one hundred twenty (120) of inmates - or about 10% their total number - use drugs. Among them are 15-18 inmates who are drug dependent. Most of them are 18-25 years of age. There are reports about injecting drug use losing its appeal among inmates as the gang leader here does not approve of drugs
   The inmates evaluate that about (20) twenty percent of them inject drugs. Heroin is used for intravenous injections with IDUs making 3-4 injections a week.
   5.2.2 Tattoos
   About one-third of inmates made tattoos while in prison. Usually, tattoos are made with non-sterile equipment.
   5.2.3 MSM
   Out of 16 MSM, 8 are clients of needle exchange, i.e. inject drugs. 4 MSM offer their services to about 10 other inmates with most of their sexual contacts being unprotected.
   5.3 Medical and Other Services Offered to Inmates
   5.3.1 Information and Education
   The staff of the Medical Unit conducts individual counseling and group sessions on HIV prevention issues with inmates. Some presentations have been aired over the local radio.
   Most respondents are informed about HIV/AIDS prevention measures, and attended the lectures and presentations on this issue. Some inmates are willing to undergo drug treatment and would like to be transferred to the PI No.47 or PI No.3 where rehabilitation centers "Atlantis" have been in operation.
   5.3.2 Needle Exchange
   The inmates are well informed about the Needle Exchange Programme and consider it to be an effective method of HIV prevention. They are also of high opinion about medical staff working there.
   The Needle Exchange Programme is located in a separate room of the institution's Infirmary. With support from the NGO "Inter-Demilge" the facility was renovated in November 2004.
   It is necessary to note accurate reporting documentation on syringe and condoms exchange.
   3 staff members and 3 volunteers run the exchange services to one hundred nineteen (119) clients. Among them are 10-15 clients who exchange syringes every day. Syringes are exchanged on a one-to-one basis and only one per day, plus two needles. In total, 2,400 syringes were exchanged in 2005 with 10ml being especially popular among inmates.
   MSM exchange their needles through a volunteer. Upon having received 10 syringes at the Medical Unit, the volunteer exchanges them in the ward where MSM live. 8 out of 16 MSM-inmates (50%) participate in the exchange. Upon his return, the volunteer shows the used syringes to the medical staff and then disposes of them.
   For reporting purposes the programme collects information on:
  -- number of clients (monthly);
  -- number of syringes given out (monthly);
  -- number of syringes collected (monthly).
   5.3.3 Condom Distribution
   Overall, two thousands four hundred (2,400) condoms were distributed among inmates in 2005. However, this service is no longer available as there is no supply of condoms to the institution.
   5.4 Potential for Scale-up
   The Administration welcomes the introduction of HR programmes and expanding their coverage to prison's personnel.
   Both the Administration and inmates are interested in a rehabilitation centre being opened in their institution. The Administration is well-informed about the operation of the "Atlantis" project in PI No3 and PI No47 and prepared to provide assistance in arranging the delivery of a similar programme at their institution.
      -- Penitentiary Institution No.14
   6.1 General Information about the Institution
   Located in Chui province, the Penitentiary Institution No.14 is a facility for juvenile delinquents that hold seventy eight (78) teenagers. There is a technical college, a high school and a production facility attached to this institution. However, the capacities of these facilities are under-utilised as some inmates are just learning to read and write at the penitentiary institution.
   6.2 Prevalence of HIV Risks Among Inmates
   According to prison officials, the supply of drugs is limited so that most inmates do not have access to them. They estimate that if access were granted up to 70% of inmates would use drugs.
   Currently there are 5-6 IDUs who inject on a daily basis. Their average age is 17-18 years.
   Making tattoos is popular among inmates, this is usually done without sterile equipment. There are cases of tattoo-related infection.
   No MSM are reported at this institution.
   6.3 Medical and Other Services Offered to Inmates
   No harm reduction services are being provided to inmates at this institution. The level of inmates' awareness of HIV transmission routes and prevention skills is low.
   Prison Administration is divided over the issue of introducing needle exchange in this institution.
   Drug treatment is provided to those inmates who are sentenced to it by court. Usually it is limited to vitamins being dispensed to inmates.
      -- Penitentiary Institution No.36 (settlement)
   7.1 General Information about the Institution
   The settlement is located in the city of Bishkek. The list of inmates includes two hundred twenty nine (229) names. However, one hundred five (105) of them have escaped and only one hundred twenty three (123) convicts are serving their sentences at this institution. Seventy inmates are employed. Some inmates live at home, the remaining 56 inmates reside at the settlement's dormitory.
   7.2 Prevalence of HIV Risks Among Inmates
   Seventeen (17) inmates - sixteen men and one woman - have been convicted for drug-related crimes. According to prison's officials, 25-30 inmates use drugs with 5 injectors being among them. Their average age is 25-30, with opium and heroin being their drugs of choice. Generally, inmates use drugs outside of the settlement.
   7.3 Medical and Other Services Offered to Inmates
   No harm reduction services apart from limited information campaigns on HIV prevention and compulsory drug treatment are being provided in this institution. In delivering these campaigns, the administration of institution cooperates with the only non-governmental organization "Pangea", International Public Fund.
   Some inmates have to undergo compulsory drug treatment as this is the condition of their release imposed by court. Until 2005 the Narcological Centre provided drug treatment for inmates free of charge. However, since then treatment has to be paid for. As most inmates cannot afford the fees, drug treatment is not available to them and without their having gone through treatment they cannot be released.
   7.4 Potential for Scale-up
   The Administration welcomes HIV prevention seminars for inmates and staff and is prepared to support arranging needle exchange and substitution therapy in the settlement. The Administration has active interest in arranging free-of -charge drug treatment at this institution.
      -- Penitentiary Institution No.10
   8.1 Information about the Institution
   Institution No.10 is located in Jalal-Abad and holds 829 inmates. 20% of them are convicted for drug-related crimes. The Administration actively promotes religious communities and sports clubs among inmates.
   8.2 Prevalence of HIV Risks Among Inmates
   Administration estimates that up to 30% inmates use drugs, mostly marijuana and hashish. IDUs are a distinct minority accounting for only about 10% of drug users. However, inmates report that there are about 100 IDUs in this prison. To prepare injections they use tap water without even boiling it. Yet the supply of heroin to this institution is limited. Based on the number of syringes exchanged, GUIN's Administration estimated that in early 2005 over 1 kilogram of heroin entered the institution every month. As a result, the institution's Administration imposed restrictions on the number of client of the needle exchange programme. These restrictions were lifted later.
   Tattoos are made infrequently but they are made with non-sterile equipment.
   8.3 Medical and Other Services Offered to Inmates
   8.3.1 Information and Education sessions for Inmates
   The Regional AIDS Centre, GUIN's Medical Service and AFEW delivered several information sessions on HIV prevention for inmates and prison staff in 2005. These events received positive reviews among inmates.
   8.3.2 Needle exchange
   Needle Exchange is maintained by the prison's Medical Service. The exchange ratio is 1:1 and there are strict registration requirements. The number of clients stands at 29. On average, 300 syringes are exchanged on a monthly basis. Needle exchange is sponsored by the NGO "Inter-Demilge".
   Due to its remote location, the supply of syringes to this institution is interrupted from time to time.
   8.3.3 Condom Distribution
   Condoms are supplied by the Regional AIDS Centre and available at the room where inmates stay with their spouses when the latter visit.
   8.3.4 Drug Treatment
   Drug treatment is provided to those inmates who were sentenced to it. The prison's Medical Service does not have a position for drug specialist so that inmates have to pay 300 soms to invite a narcologist from Jalal-Abad to provide treatment and counseling. The waiting time for that can be as long as 6 months. Without going through drug treatment, inmates cannot be released.
   8.3.5 HIV Testing
   HIV testing is provided by the Regional AIDS Centre. In 2004 over 800 inmates were tested for HIV with 14 new HIV cases detected. Since then only newcomers have been tested for HIV. Inmates report that no VCT is being provided to them.
   8.4 Potential for Scale-up
   The Administration is interested in establishing a rehabilitation centre modeled after the "Atlantis" project. The facility for rehabilitation centre is available but it needs to be renovated.
      -- Penitentiary Institution No.25 (Detention Centre)
   9.1 General Information about the Institution
   The Detention Centre (SIZO) No. 25, is located in Osh city. As of January 11, 2006, the Centre holds four hundred fifty seven (457) of inmates and suspects. One hundred thirty five (135) of them are being investigated for drug-related crimes.
   9.2 Prevalence of HIV Risks Among Inmates
   Administration believes that about 30% of inmates are using drugs. Inmates report that 50-70% of their fellow inmates are injecting drugs. Heroin is available with a dose costing about 50 soms.
   Inmates report being told not to seek drug treatment services at the Detention Centre. The medical staff claims that there are no facilities, medicine and equipment to provide this treatment.
   There are 13 PLWHA at the Centre and some of them complain about being discriminated against by other inmates and prison staff.
   9.3 Medical and Other Services Offered to Inmates
   9.3.1 Information and Education
   The institution features regular information sessions for inmates and staff members delivered by the staff of its Medical Service, Regional AIDS Centre, and AFEW.
   9.3.2 Condom Distribution
   In 2005 Regional AIDS Center distributed one thousand (1,000) condoms among those kept at the Detention Centre. The condoms were available at the room where inmates stay with their spouses when the latter's visits.
   9.3.3 HIV Testing, PLWHA and ART
   At present there are thirteen (13) PLWHA, including two women among the detainees. All of them are injecting drug users. Two of which receive antiretroviral therapy through supplies from the Regional AIDS Center.
   HIV testing is provided on a voluntary basis although there is compulsory testing for certain groups: IDUs, patients with STIs, and pregnant women. VCT is not being provided.
      -- Conclusions
   This RA covers 8 penitentiary institutions that vary in terms of their security regime, demographic characteristics of inmates (male; female; children) and geographic location. Based on the results of the assessment, the following conclusions can be made about the state of drug treatment, HIV and HR programmes being implemented at the penitentiary institutions included in this assessment:
      -- Although IEC on preventing HIV/AIDS and injection drug use is being implemented to some extent, there is no mechanism for coordination, or agreed-upon methods and systematic approach in delivering IEC.
      -- Rehabilitation center "Atlantis" in PI No.3 has demonstrated its effectiveness in HIV/AIDS and drug prevention as most of their clients are without drugs for 6 or more months. There is an identified need to establish Altlantis programme in settlement 32 in order for ex inmates to continue their rehabilitation
      -- There is practice of long-term sentencing for minor drug-related crimes, which results in prisons being overcrowded.
      -- Considerable differences are noted between Administration and inmates in their estimates of the prevalence of injection drug use in prisons. The inmates' estimates tend to be considerably higher than those provided by prison officials.
      -- The practice of compulsory drug treatment of IDUs in prisons is inhumane and not effective as there is no trained staff, treatment or facilities to provide these services.
      -- Needle/Syringe Exchange Programmes in penitentiary institutions have proven to be an effective method of HIV prevention as there are no reported new cases of HIV infection among their clients.
      -- In some prisons there is an inadequate supply of HIV prevention materials including needles & syringes, bleach, alcohol swipes, as well as condoms.
      -- In several prisons there is a lack of separate rooms for HR services.
      -- There is a need to start substitution therapy in penitentiary institutions like PI No.3, which have a considerable number of IDUs as well as drugs.
      -- Although there appears to be no stigma and discrimination of PLWA in prisons, in many cases this is due to inmates concealing their HIV+ status.
      -- There are limited provisions for VCT, ART and treatment of opportunistic infections in prisons.
      -- Currently hardly any HR services are being provided in detention center # 25 (in Osh), although inmates may spend from 6month to 1 year in this institution.
      -- Recommendations
   In light of the aforementioned the following measures are recommended:
      -- HR activities in prisons should be based on the National HIV/AIDS Programme, 2006-2010 as this document provides the framework for coordination among relevant ministries, donor organizations and NGOs, and be coordinated by GUIN.
      -- To establish an Information Centre to coordinate IEC activities in prisons. The Centre could be attached to the Medical Service of GUIN.
      -- To create a unified mechanism for implementing preventive programs and establish a unified monitoring and evaluation system within GUIN.
      -- To develop a multi-sectoral strategy with representatives of GUIN's Medical Service, Republican AIDS Center, and other stakeholders for delivering HR services in prisons.
      -- To open VCT and HIV Prevention Centers at each penitentiary institution and supply these facilities with information materials. To train medical personnel and psychologists in delivering VCT.
      -- To establish STI screening, by training of medical personnel in syndromic management and by drug supply.
      -- To work towards behavior change through increasing the quality and coverage of behaviour change communication (BCC) by capacity building activities among staff and inmates in penitentiary institutions, whereby seeking greater involvement of inmates and personnel, and crating enabling environments. The BCC interventions should include the following components:
      -- increasing general awareness of prevention methods for tuberculosis, HIV/AIDS, drug addiction, hepatitis C, and STI;
      -- peer education and training of peer educators among prison's personnel and inmates;
      -- reducing stigma and discrimination of PLWHA and ensuring their compliance with ART
      -- providing information about HR services and programs offered in- and outside of prison (psychological, medical, legal, social);
      -- advocating policies and guidelines in order to improve the general situation in the prisons;
      -- To support the activities of the advocacy group promoting new drug legislation aimed at reducing the imprisoned population and increased access to HIV/AIDS prevention and treatment in prisons.
      -- To recommend the Working Group on New Drug Law to reconsider legal provisions regarding drug treatment in prisons.
      -- To arrange separate rooms for Syringe/Needle Exchange Programme in those institutions, where these programmes do not yet have their own premises.
      -- To start Syringe Exchange Program and to equip specialised rooms at those penitentiary institutions, where these programmes are not being implemented at present.
      -- To establish HR services in detention center # 25.
      -- To increase the range of injection equipment provided by SEP.
      -- To provide the GUIN's Medical Service with equipment for disinfection and disposal of medical waste as well as with supplies such as syringes, tourniquets, gloves, bleach, alcohol swipes and condoms and ensure adequate supply of HIV prevention materials to inmates.
      -- To provide financial and technical and methodological assistance in introducing Methadone Maintenance Therapy for injection drug users in prisons. On a pilot basis, the therapy could be introduced at the Penitentiary institutions No.3 and No.47.
   16) To expand the operation of rehabilitation program "Atlantis" to penitentiary institutions other
   than PI No.3 and No.47, and to settlement No.32 in order for ex inmates to continue their
   Appendix 1: Examples of Convictions for Drug -Related Crimes (PI No.3)
   type of drug
   Ahmedov N.
   246 part.1
   0,90 g of hashish
   Karasuu area
   Arykbaev M.K.
   246 part.2
   6 years
   0,440 g of opium
   Pervomay area
   Ananyev V.M.
   246 part.2
   5 years
   10,776 g of marijuana
   Sverdlovsk area
   Kovylin L.E.
   246 part.2
   6 years
   0,62 g of opium
   Sokuluk area
   Baev E.A.
   246 part.2
   4 years
   42,485 g of marijuana
   Sverdlovsk area
   Okhrimenko A.A.
   246 part.2
   5 years
   1,168 g of opium
   Sverdlovsk area
   Bogza O.V.
   246 part.2
   4 years
   34,815 g of marijuana
   Sverdlovsk area
   246 part.1
   1year 6months
   0,2 g of hashish
   Leninsk area
   Kartunov D.A.
   246 part.1
   1year 6months
   0,3 g of heroin
   Jailskiy area
   Shevchuk D.A.
   246 part.1
   2 years
   0,9 g of hashish
   Leninsk area
   Appendix 2: Programme
   Date: December 1, 2005
   Place: PI No.3, the Rehabilitation Centre "Atlantis"
   Participants: inmates-patients of the Rehabilitation Centre; officers of the PI No.3; medical staff of GUIN and officers of the Department for Penitentiary Reform, Ministry of Justice; representatives of GFATM and NGOs "Inter-Demilge", AFEW, and Ranar; relatives of inmates.
   Upon the participants having been introduced, the floor was given to the Director of the PI No.3 for official opening ceremony. There were also guest speakers - representatives of the Department for Penitentiary Reform, Ministry of Justice; and the GFATM - who provided updates on the HIV situation globally and in Kyrgyzstan. Their presentations were followed by a concert in support of PLWHA during which poems, songs, sketches, games, and dances were performed by patients of the "Atlantis' programme. Then the contest of HIV prevention posters among inmates of the PI No.3 was arranged with winners receiving prizes and gifts. The employees of the medical unit conducted the quizzes on HIV/AIDS issues where correct answers were also rewarded with prizes.
   The scenario of this celebration was used to arrange similar events in other penitentiary institutions.
   Appendix 3: Pilot project: "Extending the Programme "Atlantis" to the Institution-Settlement"
   Implemented by the NGO RANAR, rehabilitation centers "Atlantis" (PI No47 and PI No3) have demonstrated their effectiveness in HIV/AIDS and drug prevention as 30% of their clients are "drug free" for more than 1 year. However, to ensure successful social reintegration of former inmates, the activities of rehabilitations centers need to be extended to the outside.
   As a rule, most clients are released into institutions-settlements where no social assistance services are being provided. There are no specialists to provide social assistance services to IDUs among inmates there and the personnel of these institutions need to be trained in legal aspects of HIV/AIDS prevention within the penitentiary system.
   At the same time NGOs RANAR and RANS have a pool of qualified specialists who can provide social assistance services. Given that most inmates from PIs No47 and No3 are released in the Institution-Settlement No32, it is proposed to arrange post-rehabilitation and social assistance programme for inmates at this institution. Furthermore, the Administration of this institution is prepared to provide premises to arrange the delivery of social assistance services.
   A sponsor is needed to cover start-up costs such as renovation and personnel expenses. RANAR plans to seek government funding to sustain this programme in the long term.
   Appendix 4: Dynamics of syringe exchange for September-November 2005 (Penitentiary Institution No.8)
   0x01 graphic

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