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The high prevalence of HIV infection among prisoners and pre-trial detainees, combined with overcrowding and sub-standard living conditions sometimes amounting to inhuman or degrading treatment in violation of international law, make prisons and other detention centres a high risk environment for the transmission of HIV. Ultimately, this contributes to HIV epidemics in the communities to which prisoners return upon their release. We reviewed the evidence regarding HIV prevalence, risk behaviours and transmission in prisons. We also reviewed evidence of the effectiveness of interventions and approaches to reduce the risk behaviours and, consequently, HIV transmission in prisons.A large number of studies report high levels of risk behaviour in prisons, and HIV transmission has been documented. There is a large body of evidence from countries around the world of what prison systems can do to prevent HIV transmission. In particular, condom distribution programmes, accompanied by measures to prevent the occurrence of rape and other forms of non-consensual sex, needle and syringe programmes and opioid substitution therapies, have proven effective at reducing HIV risk behaviours in a wide range of prison environments without resulting in negative consequences for the health of prison staff or prisoners.The introduction of these programmes in prisons is therefore warranted as part of comprehensive programmes to address HIV in prisons, including HIV education, voluntary HIV testing and counselling, and provision of antiretroviral treatment for HIV-positive prisoners. In addition, however, action to reduce overcrowding and improve conditions in detention is urgently needed.

This article examines the issue of prison needle-exchange programmes (PNEP) based upon the international experience and evidence in six countries. A review of existing literature was undertaken together with original research comprising site visits to prison needle-exchange programmes in four countries operating such initiatives in October 2002. During the course of the research, prison needleexchange programmes were initiated in two other countries, Kyrgyzstan and Belarus. Site visits were not possible in respect of these two countries, and data was gathered via conversations with staff and funding organisations involved and by the examination of documentary evidence. The paper presents an overview of the PNEP initiated and a commentry on the outcomes. Based upon the evidence emerging from the investigation, the paper concludes that while prison syringe-exchange programmes have been implemented in diverse environments and under differing circumstances, the results of the programmes have been remarkably consistent. Improved prisoner health and reduction of needle sharing have been achieved. Fears of violence, increased drug consumption, and other negative consequences have not materialised. Based on the evidence and experience, it can be concluded unequivocally that prison needle-exchange programmes effectively address the health-related harms associated with needle sharing in prisons and do not undermine institutional safety or security.

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