Risk factors of sexually transmitted and blood-borne infections and access to harm reduction in Canadian federal prisons

Abstract

Background: Incarcerated people are disproportionally affected by sexually transmitted and blood-borne infections (STBBI) and have a high prevalence of STBBI risk factors.

Objective: This study aimed to determine the prevalence of risk factors for STBBI (tattooing and sexual activities in the last six months), as well as the awareness of, and utilization of harm reduction resources in federal prison.

Methods: A cross-sectional survey was developed and administered across Canada between September 2022 and January 2023. Participants included people who were incarcerated in federal men's and women's institutions in the last six months.

Results: In total, 1,404 people who are incarcerated responded to the survey: 91.5% from men's institutions, and 8.5% from women's institutions. Overall, 44.6% reported that they had received a tattoo at some point during incarceration, and 8.8% reported having had sex in the last six months. Difficulties in accessing barrier-type items for sexual protection were reported by 5.0% of all participants, of which a majority reported difficulties in accessing condoms. Awareness of pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) was reported by 8.7% and 7.1% of participants, respectively. However, utilization was below 1% for both.

Conclusion: Tattooing and sex without barriers could contribute to the transmission of STBBI among people who are incarcerated. Increased efforts to ensure that harm reduction supplies are available in sufficient quantities and in private and known locations are recommended to maximize their utilization. Education on PrEP and PEP availability should be improved to ensure an optimal use by those who could benefit from it.

Introduction

In Canada, STBBI disproportionately affect certain populations, including people who use drugs, people who sell or purchase sex, Indigenous Peoples, and people who experience incarceration ^{Footnote 1}. People who are incarcerated have a higher prevalence of STBBI risk factors, such as sexual activities without barriers and unsterile tattooing (needle/ink sharing), compared to the general population ^{Footnote 2Footnote 3Footnote 4Footnote 5}.

As part of its role of administering sentences of two years or more, Correctional Service Canada (CSC) is responsible for providing essential health care and reasonable access to non-essential health care, in keeping with professional standards ^{Footnote 6}. Consistent with this requirement, CSC has implemented different harm reduction and prevention initiatives to reduce the transmission of STBBI in its institutions over time. These include the Prison Needle Exchange Program and Overdose Prevention Service (supervised consumption site) in selected institutions, as well as the provision of pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), and barrier-type items (condoms, lubricant, and dental dams) in all institutions. Subsequently, the prevalence of HIV and hepatitis C virus (HCV) infections in CSC institutions declined. HIV prevalence decreased from 4.6% in 2007 ^{Footnote 7} to 1.19% in 2014 and 0.93% in 2020 ^{Footnote 8}, while HCV prevalence fell from 31.0% in 2007 ^{Footnote 7} to 21.0% in 2010 and 3.2% in 2021 ^{Footnote 8}.

Surveys are a useful method to measure unobservable data, such as people's preferences, attitudes, and behaviours ^{Footnote 9}. The National Inmate Infectious Diseases and Risk-Behaviours Survey (NIIDRBS), reported by Zacharia et al. in 2007, was undertaken prior to the implementation of the most recent harm reduction measures in CSC ^{Footnote 7}. Since then, the information available on STBBI risk behaviours for members of the Canadian population who are federally incarcerated has been limited.

Therefore, the primary objectives of this study were to determine the prevalence of:

• Tattooing (at any time during incarceration and in the previous six months)
• Device and ink sharing (among those who received a tattoo in the previous six months)
• Sexual activities while incarcerated, including gender of the partner, the use of and difficulties in accessing barrier-type items for sexual protection
• The use and awareness of PrEP and PEP, in Canadian federal prisons

The results of this research will allow for a better understanding of the health needs of people who are incarcerated and will contribute to the maintenance of effective health services programs within correctional institutions.

Methods

Using a questionnaire and method based on the 2007 NIIDRBS, a cross-sectional survey was conducted among a sample of people who are incarcerated in federal institutions between September 2022 and January 2023. A stratified random sampling approach was used to recruit eligible participants in men's institutions, whereas all eligible participants in women's institutions were invited to participate. Each site received an ordered list of individuals who met the survey eligibility criteria, along with a target number of participants to recruit. These targets reflected the site's demographic weight within the total federally incarcerated population in Canada (including targets specific for White, Indigenous, Black, and other racialized participants in men's institutions). To be eligible, participants had to be continuously incarcerated in a federal prison in the previous six months; be able to complete the questionnaire in English or French; and consent to participate through the assistance of a survey administrator.

Two sections of the questionnaire asked questions about risk behaviours while in prison, including tattooing and sex without barriers. The tattooing section contained questions about whether the devices and/or ink had been previously used by someone else. Questions about sexual activity asked participants if they had engaged in sex within the past six months while in federal prison (including oral, vaginal, and/or anal sex), and whether barrier-type protection had been used. Those who said yes were also asked whether they had access to condoms, lubricant, and/or dental dams when it was needed, and the reasons why they may not have had access. Moreover, participants who reported having had sex in the last six months in federal prison were asked about whether they exchanged sex for either money, drugs, or other items (such as canteen items, tobacco, a needle, etc.). Finally, questions examining participants' knowledge of and access to PrEP and PEP within the past six months while in federal prison were included. All questions were dichotomous (e.g., possible responses were 'yes' or 'no' but did contain the option of indicating that the question was not applicable). When non-responses exceeded 50%, results were not reported. The survey was approved by the Health Canada Research Ethics Board, the CSC, and the University of Ottawa Research Ethics Board. For more information on the 2022 National Health Survey (2022 NHS) methodology, see Wanamaker et al., 2024 ^{Footnote 10}. For confidentiality and privacy reasons, questions with less than five respondents were not reported in this study. Frequencies and proportions out of the total sample were calculated for each question. Analyses were conducted using IBM SPSS version 29 ^{Footnote 11}.

Results

A total of 1,404 participants were included in the analysis. A large proportion were from the Québec region (33.2%), housed in medium-security institutions (47.7%), incarcerated in men's institutions (91.5%), aged 31–40 years old (26.7%), and identified as White (41.7%) (Table 1). It was not possible to calculate the survey response rate as not all participating sites recorded the refusals. However, a comparison with the CSC general incarcerated population at the end of the 2022–2023 fiscal year demonstrated that women, and the Québec region, were over-represented in the study sample.

Nearly half of participants reported that they had received a tattoo at some point during their federal incarceration (n=626/1,404; 44.6%), while 53.1% (n=746/1,404) had not, and 2.3% (n=32/1,404) did not answer this question. When asked about tattooing in the last six months, almost a third of the participants reported that they had engaged in this activity (n=186; 29.7%). Among those who received a tattoo in the past six months, almost a quarter indicated that the device that they used had been used before them (n=46; 24.7%) and less frequently, sharing ink (n=14; 7.5%) (Table 2).

Most participants indicated that they did not have sex within the last six months (n=1,204/1,404; 85.8%) or had missing data on the questions regarding sex in prison (77 participants, 5.5%). The remaining 123 participants (8.8%) indicated that they had sex (oral, vaginal, and/or anal) in the last six months while in federal prison. A greater number of participants reported sexual activity with a woman (n=87; 6.2%) than with a man (n=32; 2.3%). When asked about the use of barrier-type protection (condom, lubricant, and dental dams) during sexual activities, more than half of those who had oral or anal sex with a man reported that they never or rarely used barrier-type protection (n=21/32; 65.6%) (Table 3). A similar finding was observed for those who had oral or vaginal sex with a woman, where more than half reported that they never or rarely used barrier-type protection (n=50/87; 57.5%) (Table 4). Among the participants who reported having had sex in the last six months in federal prison, 1.1% (n=15/1,404) exchanged sex for goods.

Among the total sample, 70 participants reported that they had difficulty accessing items for sexual protection (5.0%). The most frequently reported issue was an insufficient quantity. For example, 40.0% (n=28/70) who reported difficulties indicated that when they went to obtain condoms, there were none left. Not knowing where to find condoms, lubricant, and/or dental dams was also frequently reported. Furthermore, participants reported being worried/afraid that other people could see them obtaining these supplies (Table 5).

Finally, participants were asked about their awareness of PrEP and PEP in federal prison. It was found that 8.7% (n=122/1,404) were aware that they could access PrEP in federal prison. Among these participants, 8.2% (n=10/122) said they have been on PrEP in federal prison, of which 50.0% (n=5/10) indicated that they had been on it within the last six months. Similarly, awareness of PEP availability in federal prison was reported by 7.1% (n=100/1,404) of participants. Among this group, 11.0% (n=11/100) reported that they had been on PEP while in federal prison, while a small number (n<5) reported being on PEP within the last six months.

Discussion

This study is the largest to measure the prevalence of STBBI risk factors among federally incarcerated Canadians since 2007. Results indicate that tattooing may be growing in popularity, with 44.6% of participants reporting that they had received a tattoo in 2022, compared to 38.0% in 2007 ^{Footnote 7}. Although this difference is small, it could represent significant clinical implications for CSC in terms of STBBI prevention and treatment. This proportion is higher than what has been reported in Australia and the United States (US). In Australian prisons, the prevalence of tattooing was 13.4% among women and 24.6% among men, while in the US prisons, it was estimated at 8.7% among women and 19.3% among men ^{Footnote 12}. This proportion also appears to be higher among people who are incarcerated compared to the general population. For example, national data from 2006 estimated that 24.0% of the US population had tattoos, and 14.0% had body piercings ^{Footnote 13}. Similarly, 13.0% of the participants in the 2007 survey reported having ever had a piercing ^{Footnote 7}. Given that participants of the 2022 NHS were not asked about body piercings in prison, more research would be needed to determine the prevalence of body-piercing in Canadian prisons. Considering the possibility of being in contact with infected blood, body piercing represents a potential risk for STBBI transmission in prison.

A modest increase in sexual activity during incarceration was observed in 2022 relative to 2007 (2022: 8.8%; 2007: 7.2%) ^{Footnote 14}. However, since these proportions are similar, this difference may not be indicative of a significant upward trend. The results of the present study are consistent with a survey conducted in Australia, where the authors found that 7.0% of men who are incarcerated and 36% of women reported having had sex with another person who is incarcerated ^{Footnote 15}. However, the results of this study may not be directly comparable to existing literature, as the 2022 NHS also included sexual activity with a person who is not incarcerated (i.e., private family visits) and was not restricted to sexual activity with another person who is incarcerated.

Results from this study showed that 65.6% of people who are incarcerated who had sex with men and 57.5% of those who had sex with women reported that they rarely or never used barrier-type protection (e.g., condoms, dental dams). This is consistent with research from the US which showed that although 65% of men who are incarcerated who have sex with men and transgender women reported using condoms, 75% also reported a sexual intercourse without condom ^{Footnote 16}. Comparatively, research from New South Wales, in Australia, showed that 56.8% of men who are incarcerated who engaged in anal sex reported using condoms. It is important to note, that when comparing with Queensland, Australia, where condoms are not provided to people who are incarcerated, the proportion reporting anal sex was equally low. Therefore, the researchers concluded that there was no evidence to suggest that providing condoms increases consensual or non-consensual sexual activity in prison ^{Footnote 17}.

Only a small proportion of participants reported difficulties in accessing harm reduction supplies (5%). Nonetheless, nearly half of these individuals (40%) disclosed that condoms were not available when they needed them. Among those who reported having difficulty accessing supplies, participants reported different reasons, including an insufficient quantity of supplies (most frequently reported), not knowing where to find supplies, and worrying that other people in custody could see them obtaining these supplies. Considering the above findings, this suggests that individuals may be aware of the program to supply barrier-type protection items, but that the lack of supply is preventing use, thereby leading to higher-risk sexual encounters. More research would be needed to determine the reasons why participants reported an insufficiency in supplies. Lack of access and/or insufficient quantity of supplies has significant implications for programming given the results from Scott et al. who found that condoms in prison reduced the annual incidence of syphilis by 99.0%, gonorrhea by 98.0%, hepatitis B by 71.0%, chlamydia by 27.0%, and HIV by 50.0% ^{Footnote 18}.

Finally, this study found that 7% and 8% of participants, respectively, were aware of PrEP and PEP availability in Canadian prisons. These proportions are higher compared to 3% and 4%, respectively, observed in three state prisons in the Northeastern region of the US ^{Footnote 19}. Although this finding is somewhat encouraging, only a small proportion of participants actually used PrEP and PEP in federal prison (less than 1% of all participants).

One strength of this study is that the 2022 NHS was confidential and self-administered, which could have helped to minimize information biases such as social desirability. An interviewer-administered option was available for individuals where low literacy prevented the self-administered option and for those to whom it was preferred. The sample used in this study included all Canadian provinces, as well as people housed in both men's and women's institutions.

Limitations

However, considering a total population of 12,399 individuals at the end of the fiscal year 2020–2021, study participants represented 11.3% of the total CSC population ^{Footnote 20}. Given that the current sample reflects a small proportion of the in-custody population at CSC, this could have had an impact on the representativeness of the sample. Indeed, this study's sample included more women and people who are incarcerated in the Québec region, proportionally, to the total federally incarcerated population. Therefore, results may be more representative of the situation in this region. For example, in a report of the 2022 NHS results focusing on men's institutions (representing 91.5% of the sample), it was found that fewer participants reported having ever been tested for HCV in Québec compared to the other regions ^{Footnote 21}. It is possible that participants who have been tested against STBBI are more likely to be aware of the availability of PrEP and PEP in correctional institutions if they have had a discussion with Health Services staff about this aspect of their health. The same report found that significantly more participants in the Atlantic and Pacific regions had ever received a tattoo while in prison ^{Footnote 21}. The higher proportion of participants from Québec in the sample may therefore have resulted in a lower estimate of tattooing in prison than would be expected at the national level if the sample were fully representative. A small proportion of people who are incarcerated could have been excluded for not being able to participate in English or French. This proportion was not calculated for the 2022 NHS but represented less than 0.5% in the 2007 NIIDRBS ^{Footnote 7}. Although there was no change in STBBI testing and immunization policies during the period of time between the surveys, it is possible that disruptions during the COVID-19 pandemic, as observed in the community ^{Footnote 22}, had an impact on services and the behaviours of participants. Furthermore, although a previous report descriptively reported on differences across correctional institutional security levels ^{Footnote 21}, more advanced analysis is needed to determine whether the risk factors and needs for harm reduction measures differ depending on the security levels of correctional institutions. Finally, as the NIIDRBS was conducted 15 years before the 2022 NHS, the administration of additional surveys would be needed to draw conclusions on trends related to the risk factors among people who are incarcerated federally. Nevertheless, this study provided valuable information on the behaviours of the federally incarcerated population in Canada. Understanding risk behaviours and barriers faced when accessing harm reduction measures is essential to providing adequate protection against STBBI in prison.

Conclusion

The results of this study suggest that device-sharing during tattooing and sexual activities without barriers while incarcerated could be important risk factors of STBBI transmission among people who are incarcerated. Continuous efforts are needed to ensure that the supply of harm reduction items (particularly condoms) in sufficient quantities are available to maximize their utilization and impact on prevention. For future research, there is a need to better understand the relationship between these risk factors to identify opportunities for harm reduction and prevention programs that would likely have the greatest impact on reducing transmission. More research is needed to better understand the impact of tattooing on HIV and HCV risk and to assess the potential of harm reduction programs in federal prisons to reduce transmission. A health promotion campaign could also help increase awareness of the availability of PrEP and PEP in federal prison among individuals at highest risk of HIV and HCV due to tattooing and sexual encounters, and potentially increase participation in these programs.

Authors' statement

MP-G — Conceptualization, formal analysis, writing–original draft, writing–review & editing
KW — Conceptualization, formal analysis, writing–review & editing
JS — Conceptualization, writing–review & editing
ST — Conceptualization, writing–review & editing
DF — Formal analysis, writing–review & editing
WM — Formal analysis, writing–review & editing
SJ — Formal analysis, writing–review & editing

Competing interests

All authors have no competing interest to declare.

ORCID numbers

Marie-Pierre Gendron — 0009-0003-0678-3229
Kayla Wanamaker — 0000-0002-0211-4672
Jonathan Smith — 0009-0002-1687-0062
Shannon Thompson — 0009-0009-6627-4980
Daniella Filoso — 0009-0009-1218-7611
Wardah Mahboob — 0000-0001-7607-6376
Sara Johnson — 0009-0002-1994-4573

Acknowledgements

The authors would like to acknowledge the contribution of the following individuals who made this research possible: Lynne Leonard from the University of Ottawa, Michael Martin, Jean-Pascal Nadeau, Roger Martin, Hallye Ward, Ian Broom, and all Regional Health Services staff of Correctional Service Canada (CSC) who participated to the data collection. Thank you to Paul Sandstrom and Emma R Lee, from the Public Health Agency of Canada's National HIV & Retrovirology Laboratory. Finally, thank you to the people who are incarcerated in CSC institutions who participated in the 2022 National Health Survey for the valuable information they provided.

Funding

This work was supported by Correctional Service Canada.

• Previous Page
• Table of contents
• Next page