People in custodial settings

Overview

People in custodial settings are often from marginalised and disproportionally criminalised groups, including Aboriginal and Torres Strait Islander people, people who use drugs, sex workers, trans and gender diverse people, and people from culturally and linguistically diverse (CALD) backgrounds.
Injecting drug use and unsafe tattooing occur in custodial settings. Given the lack of appropriate and accessible harm reduction measures, incarceration is a risk factor for blood borne virus (BBV) infection and sexually transmitted infection (STI) transmission.
Unwanted sex, including sexual assault, can occur in custodial settings; additionally people may engage in different sexual practices (prison sex, including sex between men) from when they are in the general community.
There is a high prevalence of BBVs, especially hepatitis C, among people in custodial settings.

Infection	Consideration
Chlamydia	Consider self-collection of samples for testing.
Gonorrhoea	Consider self-collection of samples for testing. If NAAT test result is positive, take swab at relevant site(s) for culture, before treatment.
HIV	Repeat human immunodeficiency virus (HIV) testing 45 days after the patient’s most recent HIV exposure if the patient was potentially exposed within 45 days before the initial test (window period).
Syphilis	Syphilis is increasingly prevalent among Aboriginal and Torres Strait Islander people. As this population makes up a disproportionately high percentage of prison entrants, syphilis screening should be considered.
Hepatitis A	Vaccinate if not immune (if available).
Hepatitis B (HBV)	Vaccinate if not immune. Serological testing after HBV vaccination should be considered in custodial settings, to check HBV surface antibody level.
Hepatitis C (HCV)	Confirm HCV status for all people reporting a history of incarceration or injecting drug use. If HCV antibody positive, test for HCV RNA to determine if the patient has chronic HCV. Offer annual HCV testing to patients who continue to inject drugs, due to the risk of (re)infection. Curative direct-acting antivirals (DAAs) are now available as a highly effective and well-tolerated treatment.

NAAT – Nucleic Acid Amplification Test

Specimen collection guidance

Clinician collected | Self-collection

Clinical indicators for testing

All people should be offered screening for STIs and BBV infections on admission to prison, and regularly throughout their incarceration period, by appropriately trained staff.
All incarcerated people should be able to access advice and screening for STIs and BBV infections.
It is not recommended to routinely test for herpes and genital warts with serology.

Special considerations

Pregnancy test where appropriate.

If testing results are positive, refer to STI management section for advice:

Offer contact tracing for any person diagnosed with an STI or BBV infection.

Anyone diagnosed with a chronic infection (e.g. HIV, HBV, HCV) should be linked to care as soon as possible, with treatment commenced while in custody whenever possible.

Even if all test results are negative, use the opportunity to:

Educate about safer sex practices and harm reduction practices including condoms, lubricants, bleaching agents for needles, and pre- and post-exposure prophylaxis against HIV, and explore how to support incarcerated patients to access these harm reduction strategies.
Vaccinate for hepatitis A and B, if susceptible and vaccines available.
People diagnosed with an STI on initial screening, or who have ongoing risk factors, should be advised to have ongoing 3-monthly screening for STIs and HIV.
People with ongoing risk factors for HCV should be advised to have ongoing HCV screening, either 6-, or 12-monthly depending on their level of risk.