Outbreak of HIV infection in a Scottish prison

Evaluating effectiveness of syringe exchange programmes: current issues and future prospects

Although a large body of international literature has found syringe exchange programmes (SEPs) to be associated with reduced incidence of blood borne pathogens among injection drug users, recent studies have fuelled controversy surrounding SEP effectiveness. Existing studies are observational in nature and have seldom considered ecologic aspects affecting SEP functioning and evaluation. The authors apply concepts from infectious disease epidemiology to discuss the direct and indirect effects of SEP upon the spread of blood borne pathogens in drug users, their social networks and the broader community. Further, the authors discuss social policies, particularly drug control policies, which have directly and/or indirectly limited SEP functioning at local and national levels. A critical review of the literature suggests that biases common to observational studies can account for higher HIV incidence among SEP attenders relative to non-attenders. Strong selection factors often lead high-risk drug users to be over-represented among SEP attenders. Failure to account for these factors and the indirect effects of SEPs can bias interpretations of programme effectiveness. Future SEP evaluations should consider behavioural data, the local ethnographic context, the prevalence of infectious disease in the groups under study and the structural components of SEP that are most and least effective at reducing incidence of blood borne pathogens. Hierarchical models that take into account the ecological dimensions of SEP are recommended as an approach for future studies. Beyond methodologic concerns, the authors discuss social, legal and programmatic obstacles that must be overcome in order to maximise SEP effectiveness.

High-risk behaviors during incarceration in African-American men treated for HIV at three Los Angeles public medical centers

OBJECTIVES

This paper describes research that examined the association between high-risk sexual and drug-using behaviors during incarceration and HIV infection for African-American men receiving HIV care at three public medical centers in Los Angeles County (LAC), California.

METHODS

A case-control study was conducted in which 305 HIV-infected African-American men and 305 neighborhood controls, ages 20 to 49, were frequency-matched by age.

RESULTS

After controlling for anal sex while not incarcerated, we found no association between anal sex during incarceration and HIV (odds ratio [OR], 1.1; 95% confidence interval [CI], 0.6-2.2). Among men with a history of incarceration (n = 332), the percentage reporting anal sex with men outside of incarceration (45%) was greater than those reporting anal sex while incarcerated (16%). Injection drug use (IDU) during incarceration was also not associated with HIV when controlling for IDU outside of incarceration (OR, 1.6; 95% CI, 0.5- 4.9). Increased time in jail or prison was associated with less HIV infection (p =.001).

CONCLUSIONS

Although high-risk behaviors are more common in the community than in the incarcerated setting for this study group, incarcerated populations represent a high-risk group for whom access to prevention messages is limited. Periods of incarceration represent a unique opportunity to convey prevention messages that focus on high-risk behaviors outside the incarcerated setting.

Prevalence of HIV among pregnant women in Dundee 1988-1997: evidence to gauge the effectiveness of HIV prevention measures

OBJECTIVES

During November 1988-July 1990, an HIV prevalence survey of pregnant women in Dundee, which used a combined voluntary diagnostic testing and voluntary unlinked anonymous approach, revealed a rate of 0.3%, the highest recorded prevalence among such a population in the U.K. at the time. To determine if, and why, any changes in HIV prevalence had occurred during the early to mid 1990s, further studies were conducted.

METHODS

During January 1993-December 1997, antenatal patients of, and women undergoing therapeutic termination of pregnancy at, Ninewells Hospital, Dundee, were offered a diagnostic HIV antibody test. For those declining, residual sera from rubella specimens were tested for HIV antibodies using an unlinked anonymous approach which did not necessitate the securement of informed consent. Information about injecting drug use was obtained from all women and linked to their HIV test results.

RESULTS

For all pregnant women, a significant decline in HIV prevalence (P<0.05) from 0.3% (19/6228) during 1988-1990 to 0.12% (22/17899) during 1993-1997 was observed. For those who injected drugs, prevalence decreased significantly (P<0.05) from 27.5% (11/40) to 7% (6/85), while among women who had never injected drugs prevalence decreased slightly, but not significantly (P>0.05), from 0.13% (8/6188) to 0.09% (16/17814).Prevalence in the non-injectors who reported no sexual intercourse with an injector was low at 0.04% (8/17682) during 1993-1997. No significant trends in HIV prevalence were seen over the 5 years up to 1997.

CONCLUSION

The decline in HIV prevalence among pregnant women in Dundee during the early to mid-1990s can be explained predominantly by the control of HIV transmission among the city's injectors, and from them to the wider heterosexual population. It is likely that interventions designed to reduce needle/syringe sharing among injectors have been successful. It is imperative that the preventive effort is not allowed to be weakened.

Arrest and detention in international travelers

BACKGROUND

Our objective was to examine the characteristics of international travelers from Canada who have been arrested or detained while abroad, and to review the health implications of incarceration.

METHOD

An EpiInfo 6 program was created to analyse all of the Consular reports received in 1995 via the Secure Integrated Global Network (SIGNET) which provides communications and computerization services to the Department of Foreign Affairs and International Trade, Canada. The Consular Management and Operations System was designed to support the delivery of consular services by the Department, and to link Headquarters in Ottawa with missions in other countries through case management files, including a "Prisoners" file. Information obtained included personal demographics (age, gender), date, country, and reason for arrest or detention, and outcome of judicial process.

RESULTS

There were 1, 086 arrest or detention reports received from Consular services via SIGNET in 1995. Males outnumbered females 5.6:1. Most individuals arrested were young: 57.5% were less than 40 years, and 79% were less than 50 years. Drug related charges were cited in 33.1% of all cases, with 52.8% of arrested females charged with drug related offenses. The documented conviction rate was 96%. The majority of detained Canadian travelers were held in countries within the Americas (791 cases - 69.2%), with 642 (59.1%) being detained in the USA.

CONCLUSIONS

Arrest and detention is an unusual occurrence for international travelers but relative youth, male gender, and female drug couriers were identifiable risk characteristics. Public awareness campaigns can be targeted to specific population demographics, but all international travelers need to be counseled on the consequences of transgressing laws in foreign countries.

HIV transmission in a prison system in an Australian State

OBJECTIVE

To investigate possible HIV transmission among prison inmates.

SETTING

A prison system in an Australian State.

PARTICIPANTS

13 ex-prisoners and their prison contacts.

METHODS

Ex-prisoners who claimed to have been infected with HIV in prison and their prison contacts were interviewed about HIV risk behaviour. Entries in prison and community medical records were used by a three-member expert panel to establish the likelihood of primary HIV infection and its possible timing and location.

MAIN OUTCOME MEASURES

Determination of whether HIV infection probably occurred in prison.

RESULTS

There was a very high probability that at least four of 13 ex-prisoners investigated acquired HIV in prison from shared injection equipment. Another two ex-prisoners most probably acquired HIV infection outside prison. The location of infection for the remaining seven could not be determined.

CONCLUSIONS

HIV transmission in prison has substantial public health implications as most drug-using prisoners soon return to the community. HIV prevention strategies known to be effective in community settings, such as methadone maintenance treatment and syringe exchange schemes, should be considered for prisoners.

A bleach program for inmates in NSW: an HIV prevention strategy

Syringe cleaning guidelines for injecting drug users (IDUs) were revised in 1993. This paper examines efforts by IDUs in NSW prisons to adopt the revised guidelines in 1994. Consecutive inmates (229) nearing release were visited and asked to call a toll free number for an interview once released. Respondents (102) did not differ from non-respondents (127). Many respondents (64%) reported ever injecting and many of these reported injecting (58%), sharing (48%) and syringe cleaning (46%) when last in prison. Some (23%) respondents reported adopting the revised syringe cleaning guidelines. Tattooing (38%) was reported more often than sexual activity in prison (4%). A new methodology for prison research was found to be feasible in this study. The potential for HIV to spread in prison still poses major public health challenges.

Early mortality of undiagnosed but prevalent (in 1983-1984) HIV infection in Lothian injectors who tested hepatitis B surface antigen positive (group A) or negative but were high risk for blood-borne virus transmission (group B) in 1983-1984

OBJECTIVE

To estimate the early death-rate in HIV infected injectors whose HIV infection was during the injection-related HIV outbreak in Lothian region in Scotland in 1983-1984, which was coincident with Hepatitis B transmissions.

SETTING

Regional Virus Laboratory in Edinburgh.

SAMPLES

Sera from 1983-1984, originally received for Hepatitis B surface antigen testing, from individuals aged 15-55 years who were positive for Hepatitis B surface antigen in 1983-1984 (group A: census) or tested negative but were at high risk for blood-borne virus transmission according to their reason for testing (group B: 50% sample).

METHODS

Survival status of individuals in groups A and B who had not been diagnosed with HIV disease by the end of December 1995 was checked against the deaths' records of the Registrar General for Scotland. Stored sera from 1983-1984 for patients who had died early (that is: in 1983-1984) were tested anonymously for HIV and Hepatitis C antibodies; and prior to testing, causes of death were scored by RPB according to the likelihood of their being HIV or drugs related.

RESULTS

Three early deaths were found in group A patients who were not known to be HIV infected. None of the deaths was likely to be HIV-related; the sera were not tested in order not to risk deductive disclosure. Twenty-four early deaths were found in group B patients who were not known to be HIV-infected, five of whom were both HIV and Hepatitis C antibody positive, and one other was HIV antibody negative but Hepatitis C positive. Reclassification after unlinked anonymous testing and multiplying up of the group B results (to account for 50% sample) gave the early death rate (that is: in 1983-1986) as 15/155 (10%) for HIV-infected drug users (95% CI: 6%-13%).

CONCLUSION

Injection-related outbreaks of HIV infection in Lothian in 1983-1984 and at Glenochil Prison in 1993 were each associated with substantial--estimated 10%--early death-rate in HIV-infected injectors. Both HIV outbreaks were coincident with Hepatitis B transmissions, which may be relevant. Further investigations of the death-rate within 2 years of HIV infection are warranted in other exposure categories than injection-related and for injectors who have been immunized against Hepatitis B.

A mathematical model of HIV transmission in NSW prisons

A mathematical model was developed to estimate HIV incidence in NSW prisons. Data included: duration of imprisonment; number of inmates using each needle; lower and higher number of shared injections per IDU per week; proportion of IDUs using bleach; efficacy of bleach; HIV prevalence and probability of infection. HIV prevalence in IDUs in prison was estimated to have risen from 0.8 to 6.7% (12.2%) over 180 weeks when using lower (and higher) values for frequency of shared injections. The estimated minimum (and maximum) number of IDU inmates, infected with HIV in NSW prisons was 38 (and 152) in 1993 according to the model. These figures require confirmation by seroincidence studies.

HIV infection among family planning clinic attenders in Glasgow: why prevalence has remained low in this general population group

OBJECTIVE

During 1991-2, unlinked anonymous testing of dried blood spots from neonatal metabolic screening cards showed the prevalence of HIV among childbearing women from Glasgow to be extremely low at 0.01%. A study was conducted to determine if non-pregnant sexually active women who engaged in unprotected sexual intercourse were more likely to be infected than those who were pregnant.

METHODS

Unlinked anonymous HIV testing of urine specimens submitted by attenders of the family planning clinic in Glasgow for pregnancy testing.

RESULTS

Of 11,990 urine specimens tested, 7664 were from women with a negative pregnancy test and two of these were HIV positive (0.026%); none of the remainder from those with a positive pregnancy test had HIV antibodies.

CONCLUSION

No hidden epidemic was unearthed among a population which had engaged in unprotected sexual intercourse and was not pregnant. Other data from Glasgow strongly suggest that the control of HIV transmission among the city's population of current injectors (HIV prevalence, 1% of 8500) has prevented the spread of infection into its wider heterosexual population. It is essential that preventive measures which have been responsible for this public health success should be maintained.

A lasting public health response to an outbreak of HIV infection in a Scottish prison?

Between April and June 1993, 8 cases of acute clinical hepatitis B infection and 2 seroconversions to HIV infection were detected among drug injecting inmates of HM Prison Glenochil in Scotland. To prevent the further spread of infection, an initiative which involved counselling and voluntary attributable HIV testing was conducted over a 10-day period commencing at the end of June. A team of 18 counsellors and phlebotomists was brought together rapidly as part of a unique organizational exercise in the field of public health. Fourteen cases of HIV infection were identified of which 13 were almost certainly infected in Glenochil. Following the exercise, a range of harm reduction measures for injecting prisoners was introduced; these included the availability of hepatitis B vaccine, provision of bleach tablets which could be used to clean injecting equipment, a methadone detoxification programme, increased training for prison officers and improved access to drug and harm minimization counselling for inmates. By mid-1996 all these measures had been sustained and several could be found in many other prisons throughout Scotland. Follow-up investigations showed no evidence of epidemic spread of HIV during the 12 months after the initiative. While the frequency of injecting and needle/syringe sharing may have decreased over the last 3 years, these activities are still being reported and it is highly likely that transmissions of bloodborne infections, in particular hepatitis C, continue to occur. The surveillance and prevention of infections associated with injecting drug use in the prison setting remain a high public health priority.

Drug Misuse in Scotland: Policy, Prevalence, and Public Health

The paper outlines the nature and extent of illegal drug use in Scotland. The paper provides a detailed discussion of the impact of HIV among injecting drug users in Scotland. It is shown that although HIV remains a major public health concern within parts of Scotland, most notably in Edinburgh and Dundee, HIV infection remains low elsewhere within Scotland. Although concern in relation to HIV has receded in light of the continuing low prevalence, there has been growing concern over the marked increase in drug-related deaths among drug users within parts of Scotland. Within the policy sphere greater attention is now being given to topic of drug prevention and the impact of drug use on community well being.

Direct estimates of prevalent HIV infection in adults in England and Wales for 1991 and 1993: an improved method

OBJECTIVE

To estimate the number of prevalent HIV infections in England and Wales at the end of 1991 and 1993.

METHOD

A direct method was used whereby population estimates derived from the National Survey of Sexual Attitudes and Lifestyle (NATSAL) and prevalence data from the Unlinked Anonymous HIV Prevalence Monitoring Programme (UAPMP) were combined to produce estimates of the number of adults infected and alive in the population.

RESULTS

In the population of England and Wales the numbers of prevalent infections for defined transmission categories, at the end of 1993, were as follows: 12,600 through sex between men, 2500 through injecting drug use, and 6900 through heterosexual intercourse. The overall estimate was 22,800 HIV seropositive individuals.

CONCLUSIONS

The direct method attempts to provide an estimate of the number of HIV infections using population based survey data. These estimates are consistent with other approaches using independent methods. Such methods are essential for inferring recent HIV incidence, projecting future AIDS cases, and for healthcare planning.

HIV infection among male prisoners in South Australia, 1989 to 1994

The prevalence of human immunodeficiency virus (HIV) in male prisoners in South Australia from July 1989 to June 1994 was ascertained from a repeated cross-sectional study. We also compared the criminological and demographic characteristics and histories of drug use of 39 HIV-infected prisoners and a randomly selected sample of 86 uninfected prisoners admitted at the same time. The numbers of HIV-infected prisoners in prison in any month ranged from 4 to 12. Prevalence among the total prison population ranged from 0.4 per cent to 1.4 per cent, and among the subpopulation of injecting drug users from 1.25 per cent to 4.36 per cent. Many HIV-infected prisoners continued after their diagnosis to have lifestyles that resulted in imprisonment. Infected prisoners were significantly older, had spent longer in prison and were more likely to be users of heroin (OR = 13.1) and methadone (OR = 25.4) than controls. Infection with HIV among South Australian prisoners has been continuous since at least the mid-1980s. The recidivism among many of the infected prisoners contributes to the variation in prevalence but also raises concerns about their management. Greater effort to minimise the recidivism of the HIV-infected prisoners could reduce the prevalence of HIV in the prison population.

The molecular epidemiology of human immunodeficiency virus type 1 in six cities in Britain and Ireland

We have sequenced the p17 coding regions of the gag gene from 211 patients infected either through injecting drug use (IDU) or by sexual intercourse between men from six cities in Scotland, N. England, N. Ireland, and the Republic of Ireland. All sequences were of subtype B. Phylogenetic analysis revealed substantial heterogeneity in the sequences from homosexual men. In contrast, sequence from over 80% of IDUs formed a relatively tight cluster, distinct both from those of published isolates and of the gay men. There was no large-scale clustering of sequences by city in either risk group, although a number of close associations between pairs of individuals were observed. From the known date of the HIV-1 epidemic among IDUs in Edinburgh, the rate of sequence divergence at synonymous sites is estimated to be about 0.8%. On this basis we estimate the date of divergence of the sequences among homosexual men to be about 1975, which may correspond to the origin of the B subtype epidemic.

Should patients with facial fractures be regarded as high risk for HIV?

OBJECTIVE

To determine the prevalence of HIV seropositivity in patients with facial fractures in Edinburgh, UK.

DESIGN

A prospective study of 100 consecutive patients in 1994.

SETTING

Department of Maxillofacial Surgery, City Hospital, Edinburgh, UK.

SUBJECTS

100 patients with facial fractures who were willing to participate in the study.

MAIN OUTCOME MEASURES

Details of facial fractures. Assessment of risk factors for HIV. The seroprevalence of HIV based on unlinked anonymous testing of saliva.

RESULTS

None of the participants were HIV positive on saliva testing. Nine patients were found to have one or more risk factors for HIV. Eight patients had been tested for HIV previously.

CONCLUSION

Direct history taking appears to be effective in eliciting risk factors for HIV. A detailed risk factor history should be taken for all patients with facial fractures. Continuation of this study may establish whether or not there is a link between facial bone fractures and HIV seropositivity.

An Overview of Injecting Drug Use and HIV Infection in Edinburgh, Scotland - Maximizing Benefit and Minimizing Harm

Since 1983 parts of Scotland, unlike England, have experienced a major drug-related HIV epidemic. Edinburgh and Lothian currently have a known HIV-infected population of 1,105. A variety of harm-reduction measures, including needle exchanges, methadone prescription, community drug agencies, and targeted prevention campaigns have been implemented since 1985. The number of drug-related HIV infections reported has fallen significantly since 1988. However, sexual transmission remains a cause for concern, particularly among the injecting and non-injecting partners of HIV-positive drug users.

Methadone maintenance treatment and HIV risk-taking behaviour among injecting drug users in Berlin

STUDY OBJECTIVE

To determine whether methadone maintenance treatment (MMT) is effective in reducing the levels of HIV risk-taking behaviour (borrowing and lending of injection equipment, irregular condom use) among injecting drug users (IDUs), and to identify independent predictors of the borrowing of used syringes.

DESIGN

Cross sectional study of IDUs in MMT and not in MMT, using standardised interviews for collection of sociodemographic and behavioural data, and laboratory tests for detecting HIV antibodies.

SETTING AND PARTICIPANTS

The 612 IDUs were recruited at different services for drug users such as treatment centres, walk in agencies, a hospital, and on the streets.

MAIN RESULTS

Of all IDUs, 41% had borrowed and 34% had passed on used injection equipment in the previous six months. In univariate analysis, IDUs receiving MMT had injected less frequently and were significantly less likely to borrow and lend syringes. In logistic regression analysis, MMT was protective against the borrowing of syringes (adjusted odds ratio 0.36, 95% confidence interval 0.2, 0.8), but not against syringe lending nor against sexual risk behaviour (i.e., numbers of sex partners, lack of condom use). Important independent predictors of the borrowing of syringes were injecting drug use in prison, use of sedatives, and sex with another IDU in the previous six months.

CONCLUSIONS

MMT may play a significant role in reducing the levels of borrowing of syringes among IDUs. However, additional prevention measures are needed which should specifically address sexual risk behaviour and target subgroups of IDUs with high levels of needle sharing, such as IDUs who have been in prison and and those who are sedative users.

Patterns of injecting and sharing in a Scottish prison

Although the potential for prisons to act as the setting for HIV transmission has been recognised, there is an enduring lack of knowledge in this area. Data are presented on patterns of injecting and sharing in Edinburgh prison (Scotland), 1993-1994. There was a relatively low level of injecting in Edinburgh prison during this period, with 13% (8/60) of a sample of drug users having injected at some point during their current sentence. The majority (6/8) of those who had injected had shared injecting equipment. Where sharing took place, the level of HIV risk was variable, but would have been higher had cleaning fluids not been available within the prison, or had they not been used by sharers. The implications of this study for drug service provision in prisons is discussed.

Drug injection and HIV prevalence in inmates of Glenochil prison

OBJECTIVE

To determine prevalence of HIV infection and drug injecting behaviour among inmates of Glenochil Prison on a specified date a year after an outbreak of hepatitis B and HIV infection.

DESIGN

Cross sectional: voluntary, anonymous HIV salivary antibody surveillance and linked self completion questionnaire on risk factors.

SETTING

Glenochil prison, Scotland, a year after an outbreak of hepatitis B and HIV transmission related to drug injection.

SUBJECTS

352 prisoners, of whom 295 (84%) took part; 284 questionnaires (96%) passed logical checks.

MAIN OUTCOME MEASURES

HIV prevalence; proportion of all inmates who had ever injected drugs, had ever injected inside prison, had started injecting drugs while inside prison.

RESULTS

More than half (150/284) the current inmates were also in Glenochil Prison during the critical period of January to June 1993, when hepatitis B and HIV were transmitted. Similar proportions of current inmates and men who were also in Glenochil during the critical period were drug users (27% (75/278) v 30% (44/149)). A quarter of injecting drug users (18/72) had first injected inside prison, irrespective of whether they were in Glenochil in January to June 1993 and regardless of the calendar period when they first injected. Significantly more inmates from Glasgow (41%; 56/138) than from Edinburgh (21%; 7/34) or elsewhere (11%; 12/106) were injecting drug users. On testing for HIV, seven saliva samples out of 293 gave positive results--four were presumed to be from inmates known to be infected with HIV, and the others from injecting drug users from Glasgow, all of whom had been in Glenochil during January to June 1993, when two of the three had injected drugs and had been tested for HIV, with negative results. The ratio of overall (2.4%) to disclosed (1.4%) HIV prevalence was 1.7. For men who had injected drugs in Glenochil during January to June 1993, HIV prevalence was estimated at 29%.

CONCLUSION

Between a quarter and a third of prisoners who injected drugs in Glenochil in January to June 1993 were infected with HIV. There is widespread ongoing risk of bloodborne virus infection within prisons, which is probably long standing but demands urgent attention.