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Prevention of Transmission of
HIV, Hepatitis B & C and
Tuberculosis in Prisoners
HIV and related infections in prisoners
Authors and Affiliations
• Adeeba Kamarulzaman – University of Malaya
• Stewart E. Reid - Centre for Infectious Disease Research, Zambia and
University of Alabama at Birmingham
• Amee Schwitters - Department of HIV/AIDS, WHO
• Lucas Wiessing - European Monitoring Centre for Drugs and Drug Addiction
• Nabila El-Bassel - Columbia University
• Kate Dolan - University of New South Wales
• Babak Moazen - Tehran University of Medical Sciences
• Andrea L. Wirtz - Johns Hopkins Bloomberg School of Public Health
• Annette Verster - Department of HIV/AIDS, WHO
• Frederick L. Altice - Yale School of Medicine
HIV and related infections in prisoners
Concentration
Laws and policing selects members
with poor health status and/or at
risk for HIV, TB, or viral hepatitis
Amplification
Deterioration
Prison Environment
In
High risk behaviors,
new social networks,
transmission to new
community members
Dissemination
Community
Post-Release
Morbidity and Mortality
Amplification
During incarceration
Drug Use
• Sharing scarce injecting paraphernalia
• Within-prison drug injection - Iran (6%), Mexico (61%), Australia (13.2%) Ukraine (57%)
• Over 70% shared equipment in Ukraine and Indonesia
Sexual transmission
• Formation of new and sometimes coercive sexual partnerships with
multiple individuals
• Sex can be exchanged for food, sleeping space privileges or commodities such as soap
Dissemination
Community Re-entry
• Immediate post-release period - highest risks for relapse to drug
use and drug-related death (overdose) among PWUD
• Heightened sexual and injection risk behaviours
• Disruption in social networks
• Difficulties with finding employment and housing
• Lack of financial and family support
Risk of transmission of TB within prison and into
the community
• Poor ventilation, overcrowding
• Poor nutrition, stress, drug use and HIV infection
• Suboptimal health infrastructure
•
•
•
•
Absence of routine entry screening
Delayed case detection and treatment
Delayed contact tracing
Inadequate and/or interrupted treatment
Evidence of Effectiveness of HIV and HCV Interventions in Prison Settings
Author, year
Beneficial
Ferrer-Castro et
al, 2012
Intervention
Outcomes
NSP


Likely to be beneficial
Rumble et al,
C&T
2015
Opt-in /out


Butler et al, 2012 Condoms


Findings
Syringes distributed Decreased HIV prevalence
and returned
from 21% to 8.5%
HIV, HCV prevalence Decreased HCV prevalence
from 40% to 26.1%
HIV testing
successful
HIV testing
acceptance
HIV testing acceptance
47-89%
Higher acceptance opt-out
testing (22% to 98%) vs opt-in
(40-73%)
Condom use
No evidence that availability
Increased frequency of condoms increases sex
Evidence of Effectiveness of HIV and HCV Interventions in Prison Settings
Author, year
Intervention
Likely to be beneficial
Hedrich et al, 2011 OAT
Outcomes
Findings



Injection
Illicit opioid use
Post-release heroin and
cocaine use
Larney, 2010


Illicit opioid use
Needle sharing
Comparison of OAT to no OAT:
Reduced injection 34% vs. 70%
Reduced illicit opioid use 94% to
21%,
Reduced post-release heroin and
cocaine use
Reduced (62-91%) illicit opioid
use
Reduced needle sharing by 4773%.

HCV and HIV incidence
OAT/NSP
Unknown effectiveness
Hedrich et al, 2011 OAT
Lack of studies focusing on impact
of OAT on HCV (3 studies) and HIV
(1 study) incidence in prison.
Prevention of TB transmission
• WHO recommends combination of active and passive case-finding
• Symptoms and CXR as initial screening tools
• Sputum-smear microscopy or Xpert MTB/RIF
• Symptom-based approaches limited
• Overlap with symptoms related to HIV, malnutrition and other ID
• Zambian study
• N = 2514 participants screened for TB
• 62% had one or more of the WHO-recommended screening symptoms
• 33% of bacteriologically confirmed TB cases did not report any of the
typical screening symptoms
• Need for an algorithm based on different criteria in different
settings to facilitate more aggressive screening, diagnosis and
treatment of prison-based cases
Recommended Prevention Strategies
HIV and hepatitis C
• Treatment-as-prevention to increase testing, treatment access, and
engagement in care
• OAT initiated in prison and continued post-release
• Sterile needle and condom distribution
Hepatitis B
• Routine screening, treatment, and vaccination
Tuberculosis
• Screening at intake and ensuring treatment completion
• Legislation and international guidelines to address ventilation etc.
HIV and related infections in prisoners
Number of countries providing HIV prevention services
NSP
OAT services
Condoms
ART
All 6 services
8
43
45
43
8
SPAIN
• HIV prevalence - 24% in early 90s
• Introduction of comprehensive program
• OAT, NSP, health education, peer support programmes
• Disease surveillance and evaluation
From 2000 to 2008
• HIV seroconversion reduced from 0.6% to 0.09%
• HCV incidence 5.1% to 1.5 %
• TB incidence declined by 85%
Islamic Republic of Iran
Prison OAT program 1999-2014
HIV Incidence
MMT Expansion
40,952 41,111
3.83
38,256
3.12
3.05
3.24
28,826
2.83
2.78
25,407 25,000
19,539
1.71
1.81
1.56
2.01
1.54
1.37
1.28
1.01
8,040
0
0
0
100
300
1999
2000
2001
2002
2003
1,400
2004
2,800
2005
2006
2007
2008
2009
2010
2011
2012
2013
Barriers to Implementation of Prevention Services
Individual barriers
• Low client motivation, inadequate knowledge and myths about
addiction, HIV and the benefits of treatment
• Discriminatory attitudes, abuse, denialism and moral judgment about
sex and drug use
Structural barriers
• Poor infrastructure, lack of access to medical care, extreme
overcrowding
Legal barriers
• Criminalisation of behaviours of key populations leading to overincarceration
Two disparate cultures
•
The criminal justice system organized to punish the
offender and protect society
The public health system organized to promote the health
of individuals and society
Unfortunately these two systems are often not aligned
•
•
•
•
•
different policies
different funding sources
separate personnel
HIV and related infections in prisoners
Summary
• Prisons form a conducive environment for the concentration
and transmission of HIV, HBV, HCV and TB
• Incarceration provide an opportunity to implement
programmes
• Implementation of effective interventions have fallen short
in high and low income settings alike
• Multiple individual and structural barriers
• Systemic and organisational level changes required
• Collaboration between the criminal justice and public health
systems.
HIV and related infections in prisoners
HIV and related infections in prisoners
HIV and related
infections in prisoners