Should prisons have government-sanctioned tattoo shops?

Nothing says "I've been in prison" like an armful of tattoos. Worldwide, studies report that up to half of prisoners get tattoos while doing time. Because prison tattooing is illegal, inmates create their inking equipment with whatever they can scrounge: ink made from burned Styrofoam cups, shampoo, or anything else that can be turned into a dark liquid is injected through makeshift tattoo guns using parts from radios, PlayStations, or anything else with a rudimentary motor. And a needle can be crafted from just about anything sharp—even a staple.

Now, a newly published review of more than 100 studies has confirmed the connection between tattoos and hepatitis C virus. Nowhere is that relationship more apparent than within prison walls. Rates of HCV are 10 to 20 times higher in prisons, compared with the population at large; as many as one-third of the more than 2 million inmates in the United States are infected. As a blood-borne disease, HCV is easily transmitted through dirty tattoo needles and can survive for some time in ink. Considering the high prevalence of HCV, the popularity of illegal tattooing, and the commonness of sharing used ink needles, the disease is probably being spread through this route. Studies have found higher HCV rates among tatted-up prisoners than in their ink-free inmates.

So it makes sense that many prison and human rights advocates are looking at safer tattooing programs as a way to lower HCV transmission rates. Correction Services Canada ran a pilot program from 2005 to 2006 offering sanitary tattooing by inmates and education about blood-borne diseases. It was shut down prematurely by the incumbent government, but even the short run demonstrated its clear benefits.

Though it's impossible to know for sure whether any cases of HCV were avoided, a look at the expenses of the program vs. the expenses of an inmate with HCV show the potential benefits of such an investment. Start-up and implementation cost about $913,000.  Considering the high costs of treating HCV and HIV (mildly transmissible through tattooing), the program could be considered cost-effective if one out of every 38 tattoo sessions avoided an HCV infection, if one out of every 50 sessions avoided a case of HIV, or if one out of every 248 sessions avoided a liver transplant (a late-stage option for many HCV sufferers). Given the frequency of tattooing and the high HCV rates among people entering prison, these figures are realistic.

The shop art cost about $5 for a two-hour session—cheaper than so-called range tattoos, which typically cost $10 to $15 on the prison black market—creating an incentive to take the sterile route. The potential savings could improve even more since a long-term program would enable purchases of bulk ink and nondisposable nozzles. As a side perk, the shops provide useful employment for inmates, giving them not only an activity while behind bars but also a skill that's marketable on the outside.

Prisoners weren't the only ones to benefit from the program. While the official tattoo shop was in operation, guards seized less ink-slinging contraband, and they reported feeling less concerned about needle-stick injuries. Such injuries aren't routine, but they do happen during cell searches, both on purpose and by accident, and are a common fear among prison staff members.

Saving money and protecting guards aren't the only reasons to embrace government-sanctioned prison tattoo shops. We should also keep in mind how much suffering is in store for inmates who contract HCV. These are persuasive arguments for government-sanctioned prison tattoo shops. Because the disease is silent, up to 75 percent of those with HCV don't even know they're infected until it's too late for treatment. Many people do not respond to the currently available medications, and liver transplants are costly and not always available. Although some patients do spontaneously recover, most don't, and there is no way to predict who will develop end-stage complications, which include cirrhosis and cancer.

Why not just test inmates and treat those who are positive for HCV? By law, HCV testing cannot be compulsory. Many prisons don't even offer it. And although some states have solid health care for prisoners, many do not, so those in need of HCV treatment don't necessarily receive standard care: a 48-week treatment with two drugs, pegylated interferon plus ribavirin. Many states refuse to medicate prisoners who might leave prison before completing the course; because an incomplete treatment is unlikely to help patients, it's a waste of money to start what can't be finished. (New York City is an exception here, allowing abridged treatment for prisoners who will follow up with a regional doctor upon release.) Even more problematic, one of the major side effects of interferon is depression, so anyone seeking treatment must be in good mental health before the drugs are given—and prisoners are disproportionately affected by mental illness.

Still, as a strategy to reduce HCV transmission, safer-tattooing initiatives are not without problems: For instance, a lot of prison-borne tattoos signify gang associations; and during the Canadian pilot program, other inmates reportedly preferred the work of prisoners not employed at the shop. A safe-tattoo program would have to forbid such body art, so some market for DIY tattooing would remain.

Also, as Anne Spaulding of Emory University School of Medicine, notes, most HCV in prisons is imported, not acquired on the premises. One study reported that a third of all people in the United States infected with HCV pass through a correctional facility each year. If that's the case, then clean tattooing in the big house is not going to slice HCV rates either inside or outside penitentiaries.

But legal tattooing could still hold one major advantage: as a steppingstone toward public acceptance of prison needle-exchange programs. As an HCV risk factor, tattooing pales in comparison with injection drug use, which also transmits HIV.Studies report extremely high levels of drug injection in prisons. Many inmates switch from pot to heroin because, with no wafting smoke, it's easier to hide from the guards. But actual needles are a scarce commodity. Inmates will inject themselves with anything—pens, coat hangers, whatever—often with a tattoo chaser to conceal the puncture wounds. When inmates do get their hands on a real needle, sharing is commonplace; they'll even pay to use a dirty one. "About 10 of us used the same needle," says one Canadian prisoner of her first experience injecting drugs, which was while she was incarcerated. "We had to keep sharpening it on a matchstick cover."

Several countries have launched needle and syringe exchange programs within correctional facilities. Swiss prisons have vending machines that provide clean needles upon deposit of a used one. Similar programs are in place in Spain, Germany, Moldova, Kyrgyzstan, and Belarus. Combined with education and methadone treatment for addicts, the efforts have brought HIV prison transmission rates to nearly zero in several countries and have also led to reduced overdosing, increased referral to treatment programs, and increased awareness of infection risk—without increasing drug use.

Still, state and federal prison systems in the United States remain resistant to all of these options. Security concerns regarding increased needle-stick injuries persist, though evidence shows that these programs actually reduce such problems. Politically, the approaches are a hard sell, too. HCV patients are already short on advocates, and prisoners with HCV even more so. A tattoo program could be a small step toward addressing the major public health problem that is HCV—and HIV, for that matter—in prisons.

The future has never looked brighter for HCV sufferers. In 2011, two new drugs with cure rates of up to 75 percent will be approved. New regimens that omit the depression-inducing interferon component are also coming available. The joint is the perfect place to treat people since they are in a fixed place (unlike, say, the homeless population, which also has sky-high hep C rates). As David Thomas of Johns Hopkins Medical Institute, a world-renowned expert on hepatitis, explains, considering that so many HCV carriers end up behind bars, a rigorous, comprehensive prevention and treatment program in prisons could go miles toward eradicating the disease.

Why should taxpayer dollars be used for clean needles and cheap tattoos? This kind of thinking lays its own trap.Most jail sentences are for fewer than three months, and most prison sentences are two to three years. Health problems on the inside will eventually find their way to the outside.

Up to 300 million people are infected with HCV worldwide. With no vaccine available, finding ways to prevent transmission is essential to reining in this epidemic. Preventing just one dirty needle in the haystack could save lives and significant public health care dollars. Installing safer tattooing programs in prisons is a simple, low-cost step in the right direction.