Justice Health Communicable Diseases Framework 2017
Reducing the disease burden of bloodborne  
viruses and sexually transmissible infections
in Victoria’s prisons

Authorised and published by the  Victorian Government,
1 Treasury Place
MELBOURNE VIC 3000
May 2017
Printed by Snap, West Melbourne
ISBN 978-1-925549-19-5 (Print format) ISBN 978-1-925549-20-1 (Online (pdf/word) format)

Unless indicated otherwise, content in this publication is provided under a Creative Commons Attribution 3.0 Australia Licence. To view a copy of this licence, visit creativecommons.org/licenses/by/3.0/au It is a condition of the Creative Commons Attribution 3.0 Licence that you must give credit to the original author who is the State of Victoria.
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Contents
1	Foreword	2
2	Executive summary	3
3	Background	5
3.1	Risk behaviours	5
3.2	Healthcare in correctional settings	6
3.2.1	Healthcare services available to Victorian prisoners	7
3.2.2	Using electronic medical records in Victorian prisons	7
4	Communicable diseases	8
4.1	Bloodborne viruses	8
4.2	Sexually transmissible infections	9
5	Policy context	10
5.1	National policy context	10
5.2	State policy context	10
6	Framework overview	12
6.1	Vision for the framework	13
6.2	Guiding principles	13
6.3	Framework goals and objectives	14
7	Monitoring and review	19
8	Key resources	20
9	Acknowledgements	22

1	Foreword
Communicable diseases are a key health priority for Victoria’s prison system. People who are entering prison have very high rates of certain bloodborne viruses. They are also more likely to have engaged in behaviours that put them at a greater risk of acquiring bloodborne viruses and sexually transmissible infections.
The Department of Justice and Regulation undertakes a range of activities within the Victorian prison system to reduce the risk of transmission and the impact of communicable diseases on the prisoner population. 
The inaugural Justice Health Communicable Diseases Framework 2012–2014 was a significant strategic document for managing bloodborne viruses and sexually transmissible infections within Victorian prisons. 
The Justice Health Communicable Diseases Framework 2017 incorporates the work already underway and outlines clear policy objectives which align Victoria with the Commonwealth Government’s National Framework for Communicable Disease Control. The updated strategic framework will be accompanied by implementation plans, detailing services, programs and activities. These documents are intended to guide future priorities to address communicable disease within Victoria’s correctional environment.
The Justice Health Communicable Diseases Framework 2017 is a significant step toward better health outcomes for Victoria’s prisoners. 
I acknowledge and thank a number of stakeholders in the justice and health sectors for contributing to the development of the framework. In particular, I would like to acknowledge Justice Health’s Ministerial Advisory Committee and the Clinical Advisory Committee for their input.

Greg Wilson 
Secretary 
Department of Justice and Regulation

2	Executive summary
Communicable diseases have a significant impact on the Victorian population. Critically, they can be prevented, and some of this impact diverted. The Justice Health Communicable Diseases Framework 2017 has been developed to focus on prevention at its core. The framework aims to provide strategic guidance to prevent, detect and treat bloodborne viruses and sexually transmissible infections among Victorian prisoners.
Bloodborne viruses and sexually transmissible infections in prison
Recent data shows the prevalence rates of bloodborne viruses (BBVs) and human immunodeficiency virus (HIV) to be significantly higher among prison populations than the general community. In some cases, rates of hepatitis C are 25 times higher in prison. Data suggests that the incidence of sexually transmissible infections (STIs) is increasing in the community, resulting in flow-on effects in the prison system. 
There is strong evidence which indicates that people coming into custody are more likely to have a history of engaging in behaviours linked to the transmission of bloodborne viruses and sexually transmissible infections. 
Outcomes of the Justice Health Communicable Diseases Framework 2012–2014
The inaugural Justice Health Communicable Diseases Framework 2012–2014 provided a coordinated approach to managing communicable disease in the Victorian prison system. Under the 2012–2014 framework, a number of new programs and projects commenced and evaluations were completed. 
The Justice Health Communicable Diseases Framework 2012–2014 has achieved a number  of important outcomes:
•	Peer education has been delivered in the prison system as a structured program since 2012. Clear guidelines direct the recruitment and selection process of peer educators. Appointed peers undergo training and receive ongoing supervision and support.
•	Justice Health has introduced or expanded a number of other harm reduction measures in Victorian prisons. These include the availability of condoms and dental dams, alcohol and other drug programs, opioid substitution therapy and bleach. 
•	The Statewide Hepatitis Program was established to address the high prevalence of hepatitis B and C among the prison population. This major public health initiative follows a nurse-led model of care. The program operates across all Victorian prison sites offering assessment, management, and where appropriate, treatment for prisoners with hepatitis B and C. 
The need for an updated framework
Given the potential for transmission of communicable diseases between prisoners and to other members of the community upon release, it is important that prison health services and prison management have a plan to address the factors that contribute to the spread of disease and facilitate access to information, prevention, screening, diagnosis and treatment. Prison also provides an opportunity for prisoners to access regular healthcare and to improve the health of priority populations, over-represented in the correctional setting, including Aboriginal and Torres Strait Islander people and people from culturally and linguistically diverse backgrounds. 
Action on communicable disease in correctional settings is an important part of state and national efforts to address the prevalence of these conditions in the community. 
Nationally, the policy setting is changing and Justice Health has aligned with this shift. A new set of strategies for bloodborne viruses and sexually transmissible infections has been released by the Commonwealth Government, as well as the inaugural National Framework for Communicable Disease Control. The national framework provides a coordinated and strategic approach to preventing, identifying and treating infectious diseases throughout Australia. 
The Victorian Government Department of Health and Human Services recently launched the first Victorian hepatitis B strategy 2016–2020 and the updated Victorian hepatitis C strategy 2016–2020 with a vision to eliminate these diseases as public health concerns by 2030 and to eliminate the associated stigma and discrimination.
The Justice Health Communicable Diseases Framework 2017 sets out the Department of Justice and Regulation’s goals and objectives for action on communicable disease. The two goals align with the National Framework for Communicable Disease Control: 

Goal 1	Improve the prison system’s prevention, detection and response to communicable diseases.	
		
Goal 2	Improve the organisational capability, leadership and delivery of communicable disease control in the prison system.	

A significant program of activities is already underway which aligns with these goals. In particular, the introduction of the Statewide Hepatitis Program in 2015 demonstrates the Victorian Government’s commitment to addressing communicable disease in prisons. 
The Justice Health Communicable Diseases Framework 2017  should be read in conjunction with the Corrections Alcohol and Drug Strategy 2015 which guides the prevention of drugs entering prison and contributes to the development of harm reduction, prevention and treatment approaches to the health impacts of drug use among prisoners. It is not intended as a clinical guideline. Clinicians should refer to Department of Health and Human Services’ (Victoria) Clinicians Health Channel and to the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) for clinical guidance on the management of communicable diseases.
Intersection with other initiatives
Justice Health has a range of projects underway that intersect with the Justice Health Communicable Diseases Framework 2017. These include the Aboriginal Social and Emotional Wellbeing Plan, the Health Promotion Strategy and the strategy on Continuity of Healthcare from Prison to the Community, currently in development. 
In March 2015, Justice Health and Corrections Victoria released the Aboriginal Social and Emotional Wellbeing Plan. The plan acknowledges that Aboriginal and Torres Strait Islander people are over-represented in the prison system and aims to improve the cultural safety of the prison environment. It provides an integrated suite of initiatives designed to improve the mental health and wellbeing of Aboriginal and Torres Strait Islander prisoners during incarceration. It focuses on the need to develop a connected approach that considers the different aspects of social and emotional wellbeing in order to improve health and wellbeing. The Aboriginal Social and Emotional Wellbeing Plan was developed as part of the third phase of the Victorian Aboriginal Justice Agreement, in consultation with government and community stakeholders, and is being implemented across Victoria as a joint initiative between Justice Health and Corrections Victoria. 
The Health Promotion Framework and accompanying strategy have been developed to provide an overarching structure for the delivery of prevention and health promotion interventions in the Victorian prison system. The framework highlights key priority areas and provides guidance on planning future interventions. Recognising the impact of communicable diseases on the prisoner population, communicable diseases were included in the Health Promotion Strategy as a priority area. 
Justice Health is currently working with key stakeholders to identify opportunities to further support prisoners, as they transition from receiving healthcare in prison, back to receiving healthcare in the community.

3	Background
Considerable progress has been made in Australia to reduce mortality from communicable disease over the last century. The factors which have contributed to this progress include improved sanitation, the development of vaccines and antibiotics, and early detection and surveillance systems to respond to outbreaks. Nonetheless, communicable diseases remain a significant problem, some of which are still relatively common in the prison system.
Bloodborne viruses and sexually transmissible infections are preventable diseases placing a significant burden on prisoners and prison health services. Victorian data confirms that the prevalence of some communicable diseases (in particular viral hepatitis) is higher in the prisoner population than among the general population.
3.1	Risk behaviours 
The prison setting is a high-risk environment for the spread of bloodborne viruses and sexually transmissible infections. Some prisoners engage in behaviours which put themselves and other prisoners at risk of infection. Movements of prisoners between the community and prison, and between prisons, potentially increases the exposure of the community and other prisoners to infection.
There is a substantial link between injecting drug use and the spread of bloodborne viruses. Nearly all new (90 per cent) and existing (80 per cent) hepatitis C infections and at least half of all new hepatitis B infections in Australia are attributable to injecting drug use.1 Over a third (35 per cent) of Victorian prison entrants surveyed in 2013, reported injecting drug use and around two thirds of those (67 per cent) had injected drugs in the month prior to their reception into prison.2 
At this time, a trial or introduction of a needle and syringe program (NSP) is not under consideration in Victoria. While the efficacy of needle and syringe programs in community settings is well established, their utility in the custodial environment is complicated by factors including the illegality of drug use within prison, occupational health and safety concerns, and the potential compromise to a safe and secure corrections system. The Justice Health Communicable Diseases Framework 2017 focuses instead on harm reduction and prevention measures.
Skin piercing practices, such as tattooing, scarification and body piercing, and activities (such as barbering and shaving) which can result in skin puncture, are also potential routes for the transmission of hepatitis B and C when equipment is shared between users.3, 4
Unsafe sexual practices increase the potential spread of sexually transmissible infections, HIV and hepatitis B. There is evidence of increased susceptibility to contracting hepatitis C during sex if HIV or another sexually transmissible infection is present.5 It is known that prior to entering prison, many prisoners engage in unsafe sexual activities.6, 7 In recognition of this evidence, condoms and dental dams were introduced into Victorian prisons in 2011.
Vitally, some of this disease burden can be prevented. 
The Corrections Alcohol and Drug Strategy 2015 focuses on a range of issues, including supply control in prisons. Preventing drugs from entering prisons and deterring drug use and trafficking within prisons is a critical component in maintaining a safe and secure prison environment.8 
This framework provides a coordinated approach for Justice Health and contracted health service providers to facilitate access to information, prevention, screening, diagnosis and treatment. 
The strategy and framework should be read in conjunction with one another to provide a complete picture of the prevention and management of communicable diseases in Victoria’s prisons.
3.2	Healthcare in correctional settings
Victorian prison health services seek to provide prisoners with healthcare of a quality and standard equivalent to that provided in the community through the Victorian public health system. However, the poor health status of prisoners, the complexities of the correctional setting, and loss of liberty means that services may not always be directly comparable to those in the community. In addition to this, not all intervention models that are effective in the community are readily transferable to the prison setting.
Primary care is the most commonly accessed health service stream in the prison system. All Victorian prisons have a health centre that functions as a discrete service within the prison and provides general practitioner, nursing and allied health services. For prisoners, it is usually the first point of contact in prison for general medical and mental health services. Access to primary care services is generally by self-referral or through scheduled reviews. General practitioners and mental health nurses provide primary mental health services for prisoners with a managed mental illness. Prisoners with more significant care requirements are referred to specialist mental health services. 
Imprisonment can provide prisoners the opportunity to access culturally safe, quality, integrated health services in a stable and supported environment.9 However, providing healthcare services within the correctional setting can be challenging. Many prison entrants experience physical and mental health co-morbidities, smoke tobacco, and have a history of alcohol and drug misuse.10 Imprisonment itself removes autonomy and may inhibit a prisoner’s self-esteem, affecting their capacity to self-manage risk and treatment.11 Initiatives and change being embedded into the prison system through the work of the Justice Health Aboriginal Social and Emotional Wellbeing Plan will deliver a culturally safe, respective and responsive prison system, embedding cultural values in policy, process, and personal interactions. These core values for cultural safety will not only benefit Aboriginal and Torres Strait Islander people, but the broader population of culturally and linguistically diverse people in the prison system. 
Prisoners are frequently moved within the prison system for management and security purposes. This presents challenges to the continuity of health education and treatment. Seventy-five per cent of sentences imposed are 12 months or less12, so the time available in which to impact the health of prisoners is short. The high turnover of the prison population and the entry of new prisoners with significant health issues can create challenges for prison health services. 
3.2.1	Healthcare services available to Victorian prisoners
Primary healthcare
The first level of health services that is provided in custodial settings to prisoners by medical practitioners, nurses, nurse practitioners and other allied health professionals. Primary healthcare provides a range of services that include certain diagnostic and therapeutic interventions and seeks to promote the health of defined communities to address individual and population health problems.
Primary healthcare services are provided in all Victorian prisons.
Secondary healthcare
Diagnostic and treatment services for prisoners with conditions that require more complex and specialised skills and facilities, usually following referral from a primary care setting. Secondary health services include prison bed-based medical services, forensic mental health services not requiring involuntary admissions and specialist medical outpatient services.
Secondary healthcare is accessible through Port Phillip Prison and the Dame Phyllis Frost Centre for specialist medical services. Prison bed-based medical services are provided at Port Philip Prison and the Hopkins Correctional Centre. Forensic mental health services are available to varying degrees in the majority of Victorian prisons. The Mobile Forensic Mental Health Service provides satellite services from a base at the Metropolitan Remand Centre. All prison sites have access to the Statewide Hepatitis Program. 
Tertiary healthcare
Tertiary healthcare services provide a greater level of specialist care that requires sophisticated forms of diagnostic and treatment services. 
Planned tertiary healthcare is provided at St Vincent’s Hospital Melbourne (St Augustine’s is a secure ward). Local public hospitals are used where emergency care is required.
3.2.2	Using electronic medical records in Victorian prisons
The first phase of the introduction of electronic medical records in all Victorian prisons was completed in April 2015. The electronic medical record, known as JCare, provides real-time information to all healthcare providers across the prison system. The electronic record will support the continuity of care across the justice system, including from reception into prison to discharge into the community.
The electronic medical record for communicable disease control provides a more efficient and effective system of recording, screening, immunisation and disease prevalence among prisoners. This reduces record duplication and provides Justice Health with an accurate source of information on which to audit health service provision and plan future projects. For instance, better access to data on screening will provide an indication of the differences between sites and between particular cohorts of prisoners. 

1	Department of Health 2014, Fourth National Hepatitis C Strategy 2014–2017, Commonwealth of Australia, Canberra; Department of Health and Ageing 2014, Second National Hepatitis B Strategy 2014–2017, Commonwealth of Australia, Canberra.
2	Butler , T., Callander, D., Simpson, M. 2015, National Prison Entrants’ Bloodborne Virus and Risk Behaviour Survey 2004, 2007, 2010 and 2013, Kirby Institute UNSW, Australia.
3	Deloitte Consulting 2003, Victorian Prisoner Health Study,. Department of Justice, Government of Victoria.
4	Department of Health 2014, Fourth National Hepatitis C Strategy 2014–2017, Commonwealth of Australia, Canberra.
5	Tohme, R.A. and Holmberg, S.D. 2010, ‘Is sexual contact a major mode of hepatitis C transmission?’, Hepatology:  52(4), 1497–505.
6	Richter, J., Butler, T., Kirkwood, K., Yap, L., Grant, L., Smith, A., Schneider, K., and Donovan, B. 2008, Sexual Health and Attitudes of Australian Prisoners: NSW Report Summary, School of Public Health and Community Medicine, University of New South Wales, Sydney. <http://www.sphcm.med.unsw.edu.au/SPHCMWeb.nsf/page/ProjSexual>
7	Butler, T., et al., p. 194.
8	Department of Justice and Regulation 2015, Corrections Alcohol and Drug Strategy 2015, State of Victoria, Melbourne.
9	World Health Organization (2014).
10	Australian Institute of Health and Welfare 2015, The Health of Australia’s prisoners 2015, Commonwealth of Australia, Canberra.
11	World Health Organization (2014).
12	World Health Organization (2014).

4	Communicable diseases 
4.1	Bloodborne viruses
Hepatitis B and C are the most common bloodborne viruses in Victorian prisons. All hepatitis viruses result in an inflammation of the liver, but vary in incidence, prevalence, modes of transmission and impact on the infected person. Immunity to one type of hepatitis virus does not protect against the other types; immunisation is available for hepatitis A and B. Prior infection with hepatitis B conveys immunity, unlike hepatitis C where prior infection does not prevent re-infection. 
Protection against co-infection with another bloodborne virus is a priority for people with a bloodborne virus to avoid the increased impact and complications of disease resulting from multiple infections. 
Hepatitis C
Hepatitis C is the most prevalent communicable disease in Victorian prisons. It is spread through exposure to infected blood, generally during injecting drug use or unsafe barbering and tattooing practices. A quarter of people infected with the virus will spontaneously clear the infection without intervention. The remainder, without successful treatment interventions, develop a lifelong chronic infection, which can result in liver cirrhosis, liver cancer or liver failure.13 Chronic hepatitis B and C infection are the underlying cause of a third of all liver transplants.14
The National Prison Entrants’ Bloodborne Virus and Risk Behaviour Survey reported hepatitis C rates of 25 per cent among Victorian prison entrants in 2013.15 By comparison, around one per cent of the general population are diagnosed with the virus.16
The survey found 41 per cent of screened prison entrants that identified as Aboriginal or Torres Strait Islander tested positive for hepatitis C, compared with 23 per cent of non-Indigenous prison entrants.17 
The prevalence of hepatitis C is reflective of the high proportion of prisoners in Victoria who are imprisoned for drug-related offences and the high proportion of prisoners with a history of injecting drug use.
Hepatitis B
Hepatitis B is also a significant issue within Victorian prisons. It is spread through contact with infected blood or body fluids during injecting drug use, unsafe tattooing, unsafe piercing or scarification, barbering or unprotected sex. Nationally, over 50 per cent of new hepatitis B cases are attributed to injecting drug use, which indicates low levels of vaccine uptake or compliance within this group.18
People with a hepatitis B infection are over-represented among the prison population. According to a survey completed in 2013, 15 per cent of Victorian prison entrants tested positive for hepatitis B compared to approximately one per cent in the community.19 In 2013, nearly half (43 per cent) of Victorian prison entrants had no evidence of immunity to the hepatitis B virus, making them susceptible to infection.20
Most people who are infected as adults clear the virus, however, around five per cent of adults will develop a chronic hepatitis B infection. This can eventually lead to liver cancer, liver failure and liver cirrhosis.21
People born in regions of the world with a high prevalence of acute and chronic hepatitis B (parts of Asia, the Mediterranean, the Middle East and Africa) and Aboriginal and Torres Strait Islanders are also at higher risk of hepatitis B infection.22 Corrections Victoria data indicates recent increases in the number of male prisoners who identify as Aboriginal or Torres Strait Islander and male and female prisoners born in North Africa (particularly Somalia) and North East Asia (China).23
Vaccination for hepatitis A is clinically indicated for people with a hepatitis B or C infection to reduce the risk of complications that can result from multiple liver infections.
Human Immunodeficiency Virus (HIV)
HIV is spread through sexual contact, exposure to infected blood or from mother to child during pregnancy.24 Injecting drug use is also a risk factor for HIV transmission. The virus is not as prevalent in Australia’s correctional facilities when compared to Canada, the UK and the USA. Less than one per cent of prison entrants in Australia tested positive for HIV, compared with around 0.1 per cent of the Australian population.25, 26, 27 This is reflective of the lower prevalence of HIV among people who inject drugs in Australia compared to those countries.28
4.2	Sexually transmissible infections
While the rates of sexually transmissible infections (STIs) are comparable between the prison population and the general population29, upward trends in the prevalence of sexually transmissible infections in the community are likely to also be reflected among prisoners. The Third National Sexually Transmissible Infections Strategy 2014–2017 identifies upward trends for most notifiable sexually transmissible infections.30 Increases in the incidence of chlamydia and syphilis in the general community are also reported in the Victorian public health and wellbeing plan 2015–2019.31 All STIs are transmissible through unprotected vaginal or anal sex with an infected person.
Chlamydia
Chlamydia is a very common STI with rates escalating in most parts of Australia. It is often called a ‘silent infection’ because most people do not realise they are infected. It can affect men and women, and if left untreated, can cause infertility in women. 
Gonorrhoea
Gonorrhoea is a common STI that affects men and women. In women, it can be asymptomatic, which may affect detection. Untreated gonorrhoea can lead to infertility in women. 
Syphilis 
Syphilis can affect both men and women and may be asymptomatic. Most syphilis infections occur in men who have sex with men. Syphilis can be transmitted through oral sex, as well as unprotected vaginal or anal sex.

13	Department of Health and Ageing 2008, National Hepatitis C Resource Manual, 2nd edition, Commonwealth of Australia, Canberra.
14	The Kirby Institute 2014), HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2014, The Kirby Institute, UNSW, Sydney.
15	Butler T., Callander, D., Simpson, M. 2015, National Prison Entrants’ Bloodborne Virus and Risk Behaviour Survey 2004, 2007, 2010 and 2013, Kirby Institute UNSW, Australia.
16	Australian Institute of Health and Welfare 2012, The health of Australia’s prisoners 2012, Cat. no. PHE 170, AIHW, Canberra.
17	Butler T., et al., p. 203.
18	Department of Health 2014, Second National Hepatitis B Strategy 2014–2017, Commonwealth of Australia, Canberra.
19	Department of Health and Human Services, ‘Hepatitis B – the facts’ http://ideas.health.vic.gov.au/diseases/hepatitis-b.asp [September 4, 2015].
20	Butler T., et al., p. 213.
21	Department of Health and Human Services, ‘Hepatitis B – the facts’ http://ideas.health.vic.gov.au/diseases/hepatitis-b.asp [September 4, 2015].
22	Wallace, J., McNally, S. and Richmond, J. 2007, National Hepatitis B Needs Assessment 2007, La Trobe University, Melbourne.
23	Corrections Victoria 2015, Key Statistics on the Victorian Prison System: 2009–10 to 2013–14, State of Victoria, Melbourne. 
24	Australian Institute of Health and Welfare 2012, p.56.
25	Read, P. and Douglas, J. 2011, ‘A view from the inside: HIV support and treatment in prisons’, HIV Australia, 9(1), p. 9.
26	Australian Institute of Health and Welfare 2012, p.57.
27	Australian Federation of AIDS Organisations 2015, HIV Statistics in Australia, https://www.afao.org.au/about-hiv/the-hiv-epidemic/hiv-statistics-australia [Accessed 4 January 2016]
28	Central Intelligence Agency, The World Factbook: HIV/AIDS adult prevalence rate, https://www.cia.gov/library/publications/the-world-factbook/rankorder/2155rank.html [Accessed 4 September 4 2015]
29	Butler T., et al., p. 8.
30	Department of Health 2014, Third National Sexually Transmissible Infections Strategy 2014–2017, Commonwealth of Australia, Canberra.
31	Department of Health and Human Services 2015, Victorian public health and wellbeing plan 2015–2019, State of Victoria, Melbourne.

5	Policy context
5.1	National policy context
The commonwealth, state and territory governments, through the Australian Health Ministers’ Conference, are formal parties to a suite of five strategies, which aim to reduce the transmission of sexually transmissible infections and bloodborne viruses:
•	the Second National Hepatitis B Strategy 2014–2017 
•	the Fourth National Hepatitis C Strategy  2014–2017 
•	the Third National Sexually Transmissible Infections Strategy 2014–2017
•	the Fourth National Aboriginal and Torres Strait Islander Blood-borne Viruses and Sexually Transmissible Infections Strategy 2014–2017 
•	the Seventh National HIV Strategy 2014–2017. 
These strategies address the morbidity, mortality and personal and social impacts of communicable diseases. People in custodial settings are among the priority populations for targeted action in all of the strategies. Other priority populations include Aboriginal and  Torres Strait Islander people, people from culturally and linguistically diverse backgrounds, and people who inject drugs. These groups are  all over-represented in correctional settings.
The five strategies set the direction for a coordinated, national response to bloodborne viruses and sexually transmissible infections.  Each strategy has a consistent set of priorities: 
•	prevention 
•	testing 
•	management, care and support
•	workforce
•	enabling environment 
•	surveillance, research and evaluation.
In 2014, the Commonwealth Government released the National Framework for Communicable Disease Control. The framework, developed in collaboration with all states and territories, intends to provide a coordinated and sustained approach to preventing and treating communicable disease, including but not limited to bloodborne viruses and sexually transmissible infection in Australia. 
5.2	State policy context
The Victorian Department of Health and Human Services produces a number of documents relating to health promotion and the prevention of communicable disease including:
•	the Victorian public health and wellbeing plan 2015–2019 
•	The blue book – guidelines for the control of infectious diseases 
•	the Victorian hepatitis B strategy 2016–2020 
•	the Victorian hepatitis C strategy 2016–2020.
The Victorian public health and wellbeing plan 2015–2019 is the second of its kind under the Victorian Public Health and Wellbeing Act 2008. It establishes a vision for population health in Victoria, which focuses on reducing inequalities  in health and wellbeing. 
The health and wellbeing priorities for 2015–19 are:
•	healthier eating and active living
•	tobacco-free living
•	reducing harmful alcohol and drug use
•	improving mental health
•	preventing violence and injury
•	improving sexual and reproductive health.

The Department of Health and Human Services The blue book – guidelines for the control of infectious diseases, provides extensive disease-specific information on identifying and managing communicable disease infections and outbreaks. 
The Victorian hepatitis B strategy 2016–2020 and the Victorian hepatitis C strategy 2016–2020 both mention priority prisoner population and programmatic responses in prisons.
The Department of Health and Human Services is currently co-designing the Aboriginal health, wellbeing and safety strategic plan with the Victorian Aboriginal community. The Aboriginal health, wellbeing and safety strategic plan will provide an integrated approach to improving Aboriginal health, wellbeing and safety in Victoria. It is based on the principles of self-determination, strengthening culture and community and tackling racism. The plan will adopt an outcomes-based framework to address the cultural and social determinants of Aboriginal health and wellbeing to achieve greater equity in health and wellbeing outcomes. 
The Corrections Alcohol and Drug Strategy 2015 encompasses strategies that aim to reduce drug and alcohol-related offending. The strategy guides the way in which alcohol and drug use among prisoners and offenders is managed, focussing on the health, wellbeing and safety of staff and offenders, as well as meeting the long-term interests of the community. Harm minimisation is one of the guiding principles of this strategy. The newest version of the strategy was released in late 2015.32
Justice Health’s Health Policy 2011 directs the planning, management and provision of healthcare across the Victorian prison system. The policy is consistent with the Victorian Government’s strategic directions and the Department of Justice and Regulation’s strategic priorities.
The Justice Health Quality Framework 2012 has been developed to enact the policy statements and drive consistently safe, high-quality and evidence-based care. It incorporates the principles of care delivery as expressed in Justice Health’s Health Policy 2011, the standards to which care must be delivered and the structures, systems and measures by which the quality of care is monitored and improved. These requirements are embedded into contracts with Justice Health’s contracted health service providers.

32	Department of Justice and Regulation 2015, Corrections Alcohol and Drug Strategy 2015, State of Victoria, Melbourne. 

6	Framework overview
The framework is underpinned by guiding principles on the continuum of care. It sets out two goals and 10 objectives to govern holistic and effective action on communicable disease. The framework focuses on bloodborne viruses and sexually transmissible infections, which are more highly prevalent among the prison population than in the general community. 
Activities will focus on a settings-based approach for prisons, aligning with the Victorian public health and wellbeing plan 2015–2019, with a continued focus on reducing the burden of disease. Activity areas will span from prevention to disease management and will include a renewed focus on screening and immunisation, minimising harm and providing treatment where appropriate. 

Figure 1:  Continuum of care model

6.1	Vision for the framework
To lead responsive and contemporary health services and provide advice across the justice system to improve communicable disease control for better prisoner and community health.
6.2	Guiding principles
The principles underpinning the framework, informed by national and local efforts to respond to the burden of communicable disease, are the principles of Justice Health’s Health Policy 2011:
•	A public health opportunity: imprisonment provides prison health services an opportunity to engage and provide treatment to population groups historically disconnected from mainstream health services.
•	Equivalence of care: people in custody will be provided with healthcare of a quality and standard equivalent to that provided in the community through the public health system. Prison-based health services should be responsive to the high-risk profile of prisoners in relation to major communicable diseases.
•	Health promotion and disease prevention: a focus on actively preventing disease transmission and promoting health underpins contemporary approaches to communicable disease control. 
•	Addressing specific needs: while prisoners as a group are at higher risk of acquiring or transmitting communicable diseases, some sub-groups within the prison population are at even greater risk or have specific needs that require targeted or specialised interventions.
•	Confidential and respectful treatment: all prisoners have the right to be treated with compassion and respect when using prison health services and to have the confidentiality of their health information maintained. 
•	Supporting personal responsibility: preventing the spread of many communicable diseases relies to a significant extent upon prisoners adopting and practising responsible protective behaviours. Supporting access to the means of prevention, protection and harm reduction supports prisoners to self-manage risk and to play an active role in their health. 
6.3	Framework goals and objectives
The following section sets out the two overarching goals and the 10 objectives of the framework, relating to prevention, treatment and systemic capability. The framework goals and objectives have been developed to align Victoria with the National Framework for Communicable Disease Control. The national framework provides a coordinated and strategic approach to preventing, identifying and treating infectious diseases throughout Australia. Aligning the two frameworks allows for a more accurate comparison of objectives, initiatives and outcomes. 
The framework will be underpinned by action plans to allow for detailed implementation of activities.

Goal 1: Improve the prison system’s prevention, detection and response to communicable diseases 
Objective 1.1	Promote healthy behaviours 
Objective 1.2	Improve immunisation and screening uptake
Objective 1.3	Strengthen environmental safeguards to prevent disease transmission
Objective 1.4	Increase access to management and treatment options
Objective 1.5	Support continuity of care between prison sites and on release
Objective 1.6	Provide targeted and population-wide health promotion and education

Goal 2: Improve the organisational capacity, leadership and delivery of communicable disease control in the prison system
Objective 2.1	Strengthen leadership and governance
Objective 2.2	Support skilled, knowledgeable workforce
Objective 2.3	Align health technologies with the evidence base
Objective 2.4	Strengthen research and monitoring capacity

Goal 1: Improve the prison system’s prevention,  detection and response to communicable diseases
Contemporary health policy prioritises disease prevention. Preventing the acquisition or spread of communicable diseases, particularly bloodborne viruses and sexually transmissible infections, reduces the long-term burden of disease on individuals and the community.
Effective evidence-based management and treatment can eliminate disease, or slow the progression and deterioration from illness, and improve quality of life.
Prison provides a stable environment in which prisoners have the opportunity to access healthcare, improve their health literacy, and identify and manage health issues which may have gone undetected or untreated in the community. 
Goal 1 will be achieved through the following set  of objectives:
Objective 1.1	Promote healthy behaviours 	
Objective 1.2	Improve immunisation and screening uptake	
Objective 1.3	Strengthen environmental safeguards to prevent disease transmission	
Objective 1.4	Increase access to management and treatment options	
Objective 1.5	Support continuity of care between prison sites and on release	
Objective 1.6	Provide targeted and population-wide health promotion and education 	

The programs and services to support the achievement of Goal 1 are described against the care continuum in Figure 2 (page 16), as well as opportunities for further development. 

Goal 1
Across the care continuum, Goal 1 will be achieved through six objectives and a number of key initiatives.
Objective 1.1 will be achieved by: 
•	Promoting screening and immunisation for preventable diseases.
•	Providing condoms (men’s prisons) and dental dams (women’s prisons).
•	Delivering peer education.
•	Ensuring access to bleach, via peer educators and other safe points of access. 
Objective 1.2 will be achieved by:
•	Promoting screening for bloodborne viruses and sexually transmissible infections to all prisoners on reception to prison and on transfer to a new prison site.
•	Investigating the use of emerging self-screening tools for sexually transmissible infections to improve uptake among specific populations.
•	Considering the impact of motivational interviewing by health staff in encouraging prisoners to be screened, in partnership with health service providers.
•	Promoting immunisation for vaccine-preventable infections, particularly for co-infections (such as hepatitis A, B and C).
Objective 1.3 will be achieved by: 
•	Providing condoms (men’s prisons) and dental dams (women’s prisons).
•	Ensuring access to bleach, via peer educators and other safe points of access.
•	Continuing the commitment to waste disposal.
•	Strengthening outbreak management planning.
•	Maintaining and reviewing infection control policies.

Objective 1.4 will be achieved by: 
•	Providing a comprehensive program to assess, manage and treat prisoners with hepatitis B and hepatitis C (the Statewide Hepatitis Program).
•	Ensuring access to treatment for prisoners with a sexually transmissible infection.
•	Providing an opioid substitution therapy program for prisoners with a history of opioid dependence.
•	Ensuring access to a suite of alcohol and other drugs (AOD) programs. 
•	Reviewing and strengthening chronic healthcare planning processes.
•	Considering the appropriateness of rapid testing for HIV in the prison setting and emerging opportunities for rapid testing for viral hepatitis. 
Objective 1.5 will be achieved by: 
•	Ensuring access to the Statewide Hepatitis Program, which will enable prisoners with hepatitis B and C to manage their condition from any prison site.
•	Reviewing and strengthening chronic healthcare planning processes, including opportunities to provide community referrals for prisoners on release.
•	Strengthen continuity of care for Aboriginal prisoners returning to the community by ensuring Aboriginal people are linked to care with an Aboriginal Community Controlled Health Organisation (ACCHO) or other primary healthcare service.
•	Implementing a transition health strategy to support continuity of care on release, which includes consideration of priority populations such as Aboriginal prisoners and culturally and linguistically diverse populations.

Figure 2: Programs and services delivered across the care continuum to achieve Goal 1

Objective 1.6 will be achieved by: 
•	Promoting screening and immunisation for preventable diseases.
•	Providing condoms (men’s prisons) and dental dams (women’s prisons).
•	Delivering targeted education and peer education programs.
•	Ensuring access to bleach, via peer educators and other safe points of access.
•	Delivering universal and targeted health promotion interventions delivered under the Justice Health Health Promotion Framework.
A number of emerging areas of focus cut across the continuum of care. Over the life of the framework, Justice Health will seek to:
•	Strengthen continuity of care and throughcare for prisoners returning to the community.
•	Strengthen chronic healthcare planning for prisoners at risk of, or with, a chronic disease. 
Action against these objectives will be further informed and implemented by activity plans. 

Goal 2: Improve the organisational capability, leadership  and delivery of communicable disease control in the prison system
The first goal of the framework and its objectives rely upon a workforce equipped with the right knowledge, skills and technology, guided by a strong evidence base, effective monitoring, and planning. In the long term, selective participation in high-value research initiatives can strengthen the evidence-base for interventions that are most effective in the prison environment. 
Goal 2 is system-focused to develop an operating environment that has the capability and capacity to achieve the objectives of Goal 1. The focus of the activities and initiatives will be to support organisational goals, including strengthening leadership and governance for improvement, supporting a skilled workforce and ensuring practice is evidence-based. 
To strengthen the prison system’s capability and capacity, Justice Health seeks to:
Objective 2.1	Strengthen leadership and governance 	
Objective 2.2	Support a skilled, knowledgeable workforce	
Objective 2.3	Align health technologies with the evidence base	
Objective 2.4	Strengthen research and monitoring capacity	

Goal 2
Across the care continuum, Goal 2 will be achieved through four objectives and a number of key initiatives. 
Objective 2.1 will be achieved by: 
•	Expanding the alcohol and other drugs (AOD) quality framework to public prison sites.
•	Appointing individuals with specialist expertise to governance roles, including an infectious disease specialist to the Justice Health Clinical Advisory Committee.

Objective 2.2 will be achieved by: 
•	Building capacity among the health workforce, including the introduction of an Aboriginal Clinical Consultant to support culturally safe healthcare provision.
•	Delivering cultural awareness training to health services staff across the prison system as part of the Aboriginal social and emotional wellbeing plan.
•	Introducing infection control advocates in the health workforce.
•	Emphasising communicable disease-focused continuing education for health staff.
Objective 2.3 will be achieved by: 
•	Harnessing the data capture potential of JCare (electronic health record) to strengthen policy development.
•	Exploring the feasibility of integrating JCare with systems such as the personally controlled electronic health record and the Australian Immunisation Register.
•	Reviewing practice guidelines to ensure prisoners have access to emerging therapies supported by a strong evidence-base, such as treatment for hepatitis C.
Objective 2.4 will be achieved by: 
•	Maintaining a strong clinical audit capacity within Justice Health. 
•	Considering partnerships with expert peak bodies, service providers and government agencies to strengthen research capacity.
•	Implementing the Justice Health Research and Evaluation Framework 2015–2019, which will provide the strategic direction and imperative for future activities.
Action against these objectives will be further informed and implemented by activity plans.

7	Monitoring and review
Progress toward the goals and objectives outlined in the Justice Health Communicable Diseases Framework 2017 will be subject to review in line  with continuous monitoring and quality improvement activities. 
Evidence continues to emerge about the effectiveness of treatment programs, health promotion campaigns and harm reduction strategies. Throughout the life of the framework, consideration will be given to align activities with new evidence, trends and commonwealth or state policy to ensure that the needs of Victoria’s prison population are met. Where feasible and where there is demonstrable benefit, additional activities to reduce the prevalence of communicable diseases will be added to the strategies already in place.
The implementation of JCare, the new electronic health record, will provide new monitoring capabilities. 

Evaluation will be completed on components of the framework. There will also be ongoing monitoring and review of the new Statewide Hepatitis Program, which commenced in 2016. 
The objectives of the Justice Health Communicable Diseases Framework 2017 will be achieved through the implementation of annual action plans. An internal review of the framework will be completed and the role of the framework in delivering its strategic imperatives will be reviewed in two to four years’ time. 
The Justice Health Research and Evaluation Framework 2015–2019 will provide the overarching guidance for all review and evaluation completed under this framework. 

8	Key resources
Jurisdiction	Resource title	Intent/audience	
National	Fourth National Hepatitis C Strategy 2014–2017	The Commonwealth Department of Health and Ageing has developed five national strategies addressing bloodborne viruses and sexually transmissible infections. The strategies share guiding principles, identify priority populations and set the strategic direction for action. These resources are available online at:
www.health.gov.au	
	Second National Hepatitis B Strategy 2014–2017		
	Third National Sexually Transmissible Infections Strategy 2014–2017		
	Fourth National Aboriginal and Torres Strait Islander Blood-borne Viruses and Sexually Transmissible Infections Strategy 2014–2017		
	Seventh National HIV Strategy 2014–2017		
	Health of Australia’s prisoners series	The Australian Institute of Health and Welfare’s series summarises the results of the national prisoner health census, which monitors the health of Australia’s prisoners and measures access to services over time. Available online at:
www.aihw.gov.au/prisoner-health/	
	National Framework for Communicable Disease Control 	A framework to provide a nationally coordinated approach to strengthening defences against communicable disease prevalence in Australia. It is available online at:
www.health.gov.au/internet/main/publishing.nsf/Content/ohp-nat-frame-communic-disease-control.htm	
	National Prison Entrants Bloodborne Virus and Risk Behaviour Survey	Led by the Kirby Institute (UNSW) every three years, this reports on the prevalence of bloodborne viruses, sexually transmissible infections and risk behaviours among prison entrants nationally. It is available online at:
http://kirby.unsw.edu.au/projects/national-prison-entrants-bloodborne-virus-risk-behaviour-survey	
	HIV, viral hepatitis and sexually transmissible infections in Australia: Annual Surveillance Report 2016	The Kirby Institute (under the auspices of the National Centre in HIV Epidemiology and Clinical Research) produces this report which provides a national snapshot of trends in disease prevalence. It is available online at:
http://kirby.unsw.edu.au/surveillance/Annual-Surveillance-Reports	
	Various resources	The Australasian Society for HIV Medicine (ASHM) is the peak organisation for health professionals working with HIV, viral hepatitis and sexually transmissible infections. The resources are available online at:
www.ashm.org.au	
State	Victorian public health and wellbeing plan 2015–2019

	This plan is produced every four years and identifies public health priorities for the state, emphasising the importance of disease prevention. It is available online at:
https://www2.health.vic.gov.au/about/health-strategies/public-health-wellbeing-plan	
	Victorian hepatitis B strategy 2016–2020

	This strategy, the first of its kind, establishes the goal of eliminating hepatitis B as a public health concern by 2030. The strategy sets bold targets to increase prevention, testing and treatment, and to reduce stigma and discrimination. It is available online at:
https://www2.health.vic.gov.au/about/publications/policiesandguidelines/victorian-hepatitis-b-strategy-2016-2020	
	Victorian hepatitis C strategy 2016–2020

	This updated strategy, establishes the goal of eliminating hepatitis C as a public health concern by 2030. The strategy sets bold targets to increase prevention, testing and treatment, and to reduce stigma and discrimination.  It is available online at:
https://www2.health.vic.gov.au/about/publications/policiesandguidelines/victorian-hepatitis-c-strategy-2016-2020	
	Clinicians Health Channel

	Hosted by the Victorian Department of Health and Human Services, this resource provides guidance to clinicians and public health practitioners. It can be accessed at:
https://www2.health.vic.gov.au/clinicianshealthchannel	
	The blue book	This resource is developed by the Department of Health and Human Services and provides in depth information about a wide range of communicable diseases. It is available online at:
https://www2.health.vic.gov.au/about/publications/researchandreports/The%20blue%20book	
	Corrections Alcohol and Drug Strategy 2015	This strategy presents an overarching set of objectives, principles and initiatives that reflect best-practice prison drug management. The strategy aims to minimise harms associated with drug use, recognising the link between injecting drug use and the spread of some communicable diseases. This strategy is an update of the Victorian Prison Drug Strategy. It is available online at:
www.corrections.vic.gov.au/utility/publications+manuals+and+statistics/corrections+alcohol+and+drug+strategy+2015	
	Communicable disease –  The Facts for Correctional Staff	This is a resource for staff working in Victorian prisons, providing guidance for staff managing prisoners with a communicable disease. 	

9	Acknowledgements
Justice Health wishes to acknowledge the following individuals and organisations who contributed to the development of the Justice Health Communicable Diseases Framework 2017:
•	Departmental Advisory Committee on Blood Borne Viruses and Sexually Transmissible Infections, Department of Health and Human Services
•	Sexual Health and Viral Hepatitis Team, Department of Health and Human Services
•	Hepatitis Victoria
•	Justice Health Ministerial Advisory Committee 
•	Justice Health Clinical Advisory Committee.