Burden of substance use disorders, mental illness, and correlates of infectious diseases among soon-to-be released prisoners in Azerbaijan

Substance Use and Misuse among Sexual and Gender Minority Communities Living in Former Soviet Union Countries: A Scoping Review

Objectives

We reviewed literature examining substance use among sexual and gender minorities (SGM) living in the former Soviet Union (USSR) nations.

Methods

Searches were conducted across five databases (PubMed, SocINDEX, CINAHL, PscyInfo, LGBTQ + Source) to identify peer-reviewed literature.

Results

Across 19 studies, high hazardous substance use prevalence was documented. Substance use was correlated with (a) sexual health and behaviors and (b) mental wellbeing and the use of other substances.

Conclusion

We discuss minority stress implications and challenges presented by the paucity of evidence in the literature examining substance use among SGM women and SGM living in countries unrepresented in reviewed studies.

Odds of HIV among incarcerated drug users: a systematic review and meta-analysis of Asian countries

Background

HIV makes up a large portion of infectious diseases globally. People injecting drugs in prisons are at high risk for contracting HIV infection. Prisons house ~10.2 million people globally, making them a high-risk setting for HIV transmission. This systematic review summarizes the available data on the odds of developing HIV infection among imprisoned people who inject drugs (PWIDs) in Asian regions.

Methods

The authors electronically assessed published studies from January, 2000 to December, 2022, including studies that investigated the odds of HIV in imprisoned PWIDs. We extensively searched PubMed, ERIC, and Cochrane Central and Google Scholar with no constraints in language or time. All the observational studies evaluating the chances of HIV in Asian prisoners with an exposure group of PWIDs and a control group of non-injecting-drug users were included in our analysis.

Results

The databases search yielded 254 potential studies, 10 observational studies of which having a total of 17 333 participants were included. A low or moderate risk of bias was reported in all the studies except one case-control. The pooled analysis showed a significant association between PWIDs and the chances of contracting HIV infection (Odds ratio=6.40; 95% CI=3.89-10.52; P<0.00001; I2=53%).

Conclusion

This study found a vital correlation between injecting-drug usage during imprisonment and HIV transmission speed. The results of this meta-analysis support the need to prevent HIV and conducting treatment programs in high-risk settings like prisons.

Opioid use and HIV treatment services experiences among male criminal justice-involved persons in South Africa: a qualitative study

BACKGROUND

Opioid use disorder (OUD) is overrepresented among people with criminal justice involvement; HIV is a common comorbidity in this population. This study aimed to examine how formerly incarcerated men living with HIV and OUD in South Africa experienced HIV and OUD services in correctional facilities and the community.

METHODS

Three focus group discussions were conducted with 16 formerly incarcerated men living with HIV and OUD in Gauteng, South Africa. Discussions explored available healthcare services in correctional facilities and the community and procedural and practice differences in health care between the two types of settings. Data were analyzed thematically, using a comparative lens to explore the relationships between themes.

RESULTS

Participants described an absence of medical services for OUD in correctional facilities and the harms caused by opioid withdrawal without medical support during incarceration. They reported that there were limited OUD services in the community and that what was available was not connected with public HIV clinics. Participants perceived correctional and community HIV care systems as readily accessible but suggested that a formal system did not exist to ensure care continuity post-release.

CONCLUSIONS

OUD was perceived to be medically unaddressed in correctional facilities and marginally attended to in the community. In contrast, HIV treatment was widely available within the two settings. The current model of OUD care in South Africa leaves many of the needs of re-entrants unmet. Integrating harm reduction into all primary care medical services may address some of these needs. Successful HIV care models provide examples of approaches that can be applied to developing and expanding OUD services in South Africa.

Feasibility testing of a peer support programme for prisoners with common mental disorders and substance use

BACKGROUND

The prevalence of mental disorders and substance use among prisoners is high. Convicted prisoners of 'good behaviour' can be part of a peer support system in prisons.

AIM

To evaluate the feasibility of a peer support programme for prisoners with common mental disorders and substance use in prison.

METHOD

The study used a mixed method research design, with a quasi-experimental approach (single group pre-post without control). It was conducted in two phases: Phase I. Thirty-five peers/convicted prisoners were recruited through advertisements on the prisoners' community radio station. Volunteers with good behaviour reports were given training over 5 days to recognise mental and substance use disorders and provide basic peer support in prison; their attitudes and knowledge were tested before and after the training.

PHASE II

Feasibility of the peer support programme was tested by (i) recording the number of cases identified and referred, (ii) pre- and post-evaluation of well-being, coping, and symptom severity of those supported and (iii) evaluating qualitatively the experience of the peer supporters and service users.

RESULTS

Thirty-five peer supporters identified 49 cases over 3 months. These cases showed significant improvement in well-being (Z -1.962; p < 0.050) and reduction in symptom severity (Z -1.913; 0.056). There was a significant improvement in the peers supporters' self-esteem from pre- to post-training (t -3.31; p < 0.002), improvement in their benevolence (t -4.37; p < 0.001) and a significant reduction in their negative attitudes to mental illness (Z -3.518; p < 0.001). A thematic model of peer support encompassed self-experienced benefits for the peer supporter, wider recognition of peer supporters in the prison, challenges to this kind of support, experience of training and visions for future work.

CONCLUSION

The peer support programme was experienced positively by the peer-supporters and supported. Common mental disorders, substance use and suicidality were recognised and appropriately referred. A full-scale evaluation of this promising programme is warranted.

Hepatitis C prevalence in incarcerated settings between 2013–2021: a systematic review and meta-analysis

Background

The introduction of highly effective direct-acting antiviral therapy has changed the hepatitis C virus (HCV) treatment paradigm. However, a recent update on HCV epidemiology in incarcerated settings is necessary to accurately determine the extent of the problem, provide information to policymakers and public healthcare, and meet the World Health Organization's goals by 2030. This systematic review and meta-analysis were performed to determine the prevalence of HCV Ab and RNA in incarcerated settings.

Methods

For this systematic review and meta-analysis, we searched PubMed, Embase, Scopus, and Web of Science for papers published between January 2013 and August 2021. We included studies with information on the prevalence of HCV Ab or RNA in incarcerated settings. A random-effects meta-analysis was done to calculate the pooled prevalence and meta-regression to explore heterogeneity.

Results

Ninety-two unique sources reporting data for 36 countries were included. The estimated prevalence of HCV Ab ranged from 0.3% to 74.4%. HCV RNA prevalence (available in 46 sources) ranged from 0% to 56.3%. Genotypes (available in 19 sources) 1(a) and 3 were most frequently reported in incarcerated settings. HCV/HIV coinfection (available in 36 sources) was highest in Italy, Estonia, Pakistan, and Spain. Statistical analysis revealed that almost all observed heterogeneity reflects real differences in prevalence between studies, considering I² was very high in the meta-analysis.

Conclusions

HCV in incarcerated settings is still a significant problem with a higher prevalence than in the general population. It is of utmost importance to start screening for HCV (Ab and RNA) in incarcerated settings to give clear, reliable and recent figures to plan further treatment. This is all in the context of meeting the 2030 WHO targets which are only less than a decade away.

Trial registration

PROSPERO: CRD42020162616

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14623-6.

"Who are You and What are You Doing Here?": Social Capital and Barriers to Movement along the HIV Care Cascade among Tajikistani Migrants with HIV to Russia

Tajikistani migrants who work in Russia and acquire HIV seldom receive HIV treatment while in Russia. Barriers to engagement in the HIV care cascade were identified from in-depth, semi-structured interviews with purposefully sampled Tajikistani migrants (n = 34) with HIV who had returned from Russia. Data were analyzed using thematic analysis, drawing from Putnam's theory of social capital, showing how bridging and bonding social capital relate to poor engagement in HIV care. We identified three barriers to Tajikistani migrants' movement through the HIV care cascade: (1) Russia's migration ban on people with HIV interrupts social capital accumulation and prevents access to HIV treatment within Russia; (2) mistrust of authority figures, including healthcare providers, leads to avoiding treatment and harm-reduction services upon their return to Tajikistan; and (3) because of pervasive discrimination, Tajikistani migrants form weak social ties while in Russia, which exacerbates risk, including with Russian citizens, and deters engagement with HIV care. Deploying a treatment as prevention strategy and abolishing Russia's ban on people with HIV would improve both individual and public health.

Prevalence of HIV, HCV and HBV in Central Asia and the Caucasus: A systematic review

BACKGROUND

Human immunodeficiency virus (HIV), hepatitis C virus (HCV) and hepatitis B virus (HBV) are substantial public health threats in the region of Central Asia and the Caucasus, where the prevalence of these infections is currently rising.

METHODS

A systematic review of MEDLINE, Embase and PsycINFO was conducted with no publication date or language restrictions through October 2019. Additional data were also harvested from national surveillance reports, references found in discovered sources, and other "grey" literature. It included studies conducted on high-risk populations (people who inject drugs (PWID), female sex workers (FSW), men who have sex with men (MSM), prisoners, and migrants) in Central Asia: Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan; and the Caucasus: Armenia, Azerbaijan, Georgia, and Northern Caucasus region of the Russian Federation.

RESULTS

Wide ranges were noted for HIV prevalence: PWID 0-30.1%, MSM 0-25.1%, prisoners 0-22.8%, FSW 0-10.0%, and migrants 0.06-1.5%, with the highest prevalence of these high-risk groups reported in Kazakhstan (for PWID), Georgia (for MSM and prisoners) and Uzbekistan (for migrants). HCV prevalence also had a wide range: PWID 0.3-92.1%, MSM 0-18.9%, prisoners 23.8-49.7%, FSW 3.3-17.8%, and migrants 0.5-26.5%, with the highest prevalence reported in Georgia (92.1%), Kyrgyzstan (49.7%), and migrants from Tajikistan and Uzbekistan (26.5%). Similarly, HBV prevalence had a wide range: PWID 2.8-79.7%, MSM 0-22.2%, prisoners 2.7-6.2%, FSW 18.4% (one study), and migrants 0.3-15.7%.

CONCLUSION

In Central Asia and the Caucasus, prevalence of HIV, HCV and HBV remains exceedingly high among selected populations, notably PWID and MSM.

Dyadic analysis of criminal justice involvement and hiv risks among couples who inject drugs and their intimate partners in almaty, kazakhstan

BACKGROUND

Incarceration increases HIV risk behaviors and strains intimate partnerships of couples of people who inject drugs (PWID) in Kazakhstan. Studies are yet to examine dyadic relationships between criminal justice involvement and injection drug and sexual HIV risk behaviors of couples who inject drugs in Kazakhstan. This study examined associations between individual and partner level criminal justice involvement and injection drug and sexual HIV risk behaviors among 216 intimate dyads (n = 432) of PWID in Almaty, Kazakhstan.

METHODS

The Actor Partner Interdependence Model (APIM) using structural equation modeling examined individual (actor), partner and dyadic patterns (actor-partner) of associations between arrest, incarceration and drug crime conviction of dyads of male and female intimate partners of PWID using baseline data from Project Renaissance, a couples-focused HIV prevention intervention for PWID and their intimate partners.

RESULTS

Results from the APIM identified significant associations between lifetime (β=0.10, CI95%=0.01.20, p=.021) and recent (β=0.12, CI95%=0.01.26, p=.045) arrest and increased risk of injection drug use with any partner for female partners. Partner-only effects were identified in which male PWID's recent arrest was associated with an increase in their study partners' injection drug risk behaviors (β=0.10 CI95%=0.02, 0.20, p=.044). For female partners, prior incarceration was associated with increased engagement in injection drug risk behaviors (β=0.10 CI95% =0.02, 0.20, p=.035) with any partner. For male partners' prior incarceration was associated with injection drug risk behaviors with their study partners (β=0.10 CI95%= 0.02, 0.20. p<.05). Female partners prior drug crime conviction was associated with their own (β=0.14 CI95%=0.01, 0.28, p=.048) and their intimate partners' (β=0.18, CI95%=0.03, 0.33, p=.024) engagement in injection drug risk behaviors with any injecting partner. Recent drug crime conviction (β=0.12, CI95%=0.01, 0.24, p=.038) and arrest (β=0.13, CI95%, p=.022) was associated with increased engagement in sexual risk behaviors among female partners.

CONCLUSION

Findings from this study identified differences in how criminal justice involvement impacts sexual and injection drug and sexual risk behaviors between male and female partners of PWID. Future research must investigate how structural interventions at the dyadic level could address the negative impact of criminal justice involvement on sexual and injection drug HIV risks within the contexts of couples who are PWID.

Prisons: ignore them at our peril

PURPOSE OF REVIEW

People with HIV and HCV are concentrated within criminal justice settings globally, primarily related to criminalization of drug use. This review examines updated prevention and treatment strategies for HIV and HCV within prison with a focus on people who inject drugs and the challenges associated with the provision of these services within prisons and other closed settings and transition to the community.

RECENT FINDINGS

The prevalence of HIV and HCV are several-fold higher in the criminal justice system than within the broader community particularly in regions with high prevalence of injecting drug use, such as Asia, Eastern Europe and North America and where drug use is criminalized. Strategies to optimize management for these infections include routine screening linked to treatment within these settings and medication-assisted treatments for opioid dependence and access to syringe services programs. We build upon the 2016 WHO Consolidated Guidelines through the lens of the key populations of prisoners. Linkage to treatment postrelease, has been universally dismal, but is improved when linked to medication-assisted therapies like methadone, buprenorphine and overdose management. In many prisons, particularly in low-income and middle-income settings, provision of even basic healthcare including mental healthcare and basic HIV prevention tools remain suboptimal.

SUMMARY

In order to address HIV and HCV prevention and treatment within criminal justice settings, substantial improvement in the delivery of basic healthcare is needed in many prisons worldwide together with effective screening, treatment and linkage of treatment and prevention services to medication-assisted therapies within prison and linkage to care after release.

Tattooing among Iranian prisoners: results of the two national biobehavioral surveillance surveys in 2015-2016

BACKGROUND

Tattooing is among identified risk factor for blood-borne diseases.

OBJECTIVE

This study aims to determine the prevalence of tattooing during lifetime and in prisons and its related factors among Iranian prisoners.

METHODS

This is a cross-sectional study. The required data was obtained from hepatitis B and C surveillance surveys in prisons in 2015-2016 that was collected through face-to-face interview. 12,800 prisoners were selected by multi-stage random sampling from 55 prisons of 19 provinces in Iran. Weighted prevalence and associated factors (using Chi-Square test and multivariate logistic regression) were determined by Stata/SE 14.0 survey package.

RESULTS

Out of 12,800 prisioners, 11,988 participated in the study (93.6% participation rate). The prevalence of tattooing in lifetime and in prisons was 44.7% and 31.1% respectively. The prevalence of tattooing during lifetime was significantly associated with age<35 years, being single, illiteracy, history of imprisonment, drug use, piercing during lifetime, extramarital sex and history of STI; the prevalence of tattooing in prison had a significant association with history of imprisonment, drug use, piercing in prison, and history of extramarital sex (p<0.05).

STUDY LIMITATIONS

Information and selection bias was one of the study limitations.

CONCLUSION

The results of this study showed that the prevalence of tattooing during lifetime and in prison among prisoners was significantly high especially in high-risk groups such as drug users and sexually active subjects. Given the role of tattooing, drug injection and sex in the transmission of blood-borne diseases, harm reduction programs are recommended to reduce these high-risk behaviors in prisons.

Characteristics associated with anti-HCV serological markers in prisoners in the state of Paraná, Brazil: a case-control study

Background

The prison system in Paraná, Brazil, is experiencing serious problems related to the increasing number of prisoners. Control of hepatitis C virus (HCV) has become more intense because the incarcerated population is considered a high-risk group for contagious diseases due to the favorable conditions found in prisons for the spread of these morbidities. The objective of this study was to identify features associated with hepatitis C infection among male prisoners in correctional institutions of Paraná state, Brazil.

Methods

This was a case-control study (27 cases and 54 controls) of men incarcerated in 11 penitentiaries in Paraná, Brazil. Information was obtained through a questionnaire in a cross-sectional epidemiological survey on HCV infection during the period from May 2015 to December 2016. Eligible men were recruited after testing positive for anti-HCV antibodies. Cases and controls were selected based on serological results of enzyme-linked immunosorbent assays and were matched by age, location of the penitentiary, and time in prison. Logistic regression analysis was used to identify risk factors for HCV seropositivity.

Results

The main significant independent risk factor for the acquisition of HCV infection was the use of injectable drugs (OR = 4.00; 95%CI:1.41–11.35; p < 0.001).

Conclusions

This study provides evidence that HCV infection is associated with drug use by this population. This information is pivotal for tailoring prevention programs and guiding specific socioeducational measures that aim to reduce or prevent HCV transmission within the prison setting.

Drug injection within prison in Kyrgyzstan: elevated HIV risk and implications for scaling up opioid agonist treatments

Purpose Within-prison drug injection (WPDI) is a particularly high HIV risk behavior, yet has not been examined in Central Asia. A unique opportunity in Kyrgyzstan where both methadone maintenance treatment (MMT) and needle-syringe programs (NSP) exist allowed further inquiry into this high risk environment. The paper aims to discuss these issues. Design/methodology/approach A randomly selected, nationally representative sample of prisoners within six months of release in Kyrgyzstan completed biobehavioral surveys. Inquiry about drug injection focused on three time periods (lifetime, 30 days before incarceration and during incarceration). The authors performed bivariate and multivariable generalized linear modeling with quasi-binomial distribution and logit link to determine the independent correlates of current WPDI. Findings Of 368 prisoners (13 percent women), 109 (35 percent) had ever injected drugs, with most (86 percent) reporting WPDI. Among those reporting WPDI, 34.8 percent had initiated drug injection within prison. Despite nearly all (95 percent) drug injectors having initiated MMT previously, current MMT use was low with coverage only reaching 11 percent of drug injectors. Two factors were independently correlated with WPDI: drug injection in the 30 days before the current incarceration (AOR=12.6; 95%CI=3.3-48.9) and having hepatitis C infection (AOR: 10.1; 95%CI=2.5-41.0). Originality/value This study is the only examination of WPDI from a nationally representative survey of prisoners where both MMT and NSP are available in prisons and in a region where HIV incidence and mortality are increasing. WPDI levels were extraordinarily high in the presence of low uptake of prison-based MMT. Interventions that effectively scale-up MMT are urgently required as well as an investigation of the environmental factors that contribute to the interplay between MMT and WPDI.

Evaluation of HIV risk and outcomes in a nationally representative sample of incarcerated women in Azerbaijan, Kyrgyzstan, and Ukraine

Eastern European and Central Asian (EECA) is the only region globally where HIV incidence continues to rise. HIV is concentrated among high risk groups like prisoners. HIV prevalence is higher among women than men in both prisons and communities. Data are lacking on the HIV care continuum among female prisoners to inform effective HIV prevention and treatment interventions. This study examined HIV risk, prevalence of infectious diseases, access to care, and psychiatric comorbidities among a representative sample of 220 female prisoners in Azerbaijan, Kyrgyzstan, and Ukraine. Prevalence of comorbid substance use and psychiatric disorders was high with nearly one-third reporting pre-incarceration drug injection and alcohol use disorder (AUD). Half of the sample reported anxiety and depression. Among the subset of 26 (11.8%) women testing HIV+, 44% had CD4 counts <350 cells/μL but less than 2% were on antiretroviral therapy (ART). Most (88.5%) women with HIV were in Ukraine, where women also experienced higher rates of hepatitis C than in Azerbaijan or Kyrgyzstan. Women in Kyrgyzstan prisons experienced higher rates of syphilis compared to the other two countries. Findings suggest that, to achieve global HIV prevention and treatment targets, HIV testing and linkage to care must be scaled up among incarcerated women in the EECA.

Prevalence of Drug Injection, Sexual Activity, Tattooing, and Piercing Among Prison Inmates

Prisoners engage in a range of risk behaviors that can lead to the transmission of viral infections, such as HIV, hepatitis B and hepatitis C. In this review, we summarize the epidemiologic literature from 2007 to 2017 on 4 key risk behaviors for human immunodeficiency virus and hepatitis C virus among prisoners globally: drug injection, sexual activity, tattooing, and piercing. Of 9,303 peer-reviewed and 4,150 gray literature publications, 140 and 14, respectively, met inclusion criteria covering 53 countries (28%). Regions with high levels of injection drug use were Asia Pacific (20.2%), Eastern Europe and Central Asia (17.3%), and Latin America and the Caribbean (11.3%), although the confidence interval for Latin America was high. Low levels of injection drug use in prison were found in African regions. The highest levels of sexual activity in prison were in Europe and North America (12.1%) and West and Central Africa (13.6%); low levels were reported from the Middle East and North African regions (1.5%). High levels of tattooing were reported from Europe and North America (14.7%), Asia Pacific (21.4%), and Latin America (45.4%). Prisons are burdened with a high prevalence of infectious diseases and risk behaviors for transmission of these diseases, and, commonly, a striking lack of evidence-based infection control measures, even when such measures are available in the surrounding community. Given that most prisoners return to these communities, failure to implement effective responses has repercussions not only prisoner health but also for public health.

Substance Use During Imprisonment in Low- and Middle-Income Countries

Substance use disorders are among the most common health problems of people involved with the criminal justice system. Scaling up addiction services in prisons is a global public health and human rights challenge, especially in poorly resourced countries. We systematically reviewed the prevalence of substance use in prison populations in low- and middle-income countries. We searched for studies reporting prevalence rates of nicotine, alcohol, illicit drug, and injection drug use during imprisonment in unselected samples of imprisoned people in low- and middle-income countries. Data meta-analysis was conducted and sources of heterogeneity were examined by meta-regression. Prevalence of nicotine use during imprisonment ranged from 5% to 87%, with a random-effects pooled estimate of 56% (95% confidence interval (CI): 45, 66) with significant geographical heterogeneity. Alcohol use varied from 1% to 76% (pooled prevalence, 16%, 95% CI: 9, 25). Approximately one-quarter of people (25%; 95% CI: 17, 33; range, 0–78) used illicit drugs during imprisonment. The prevalence of injection drug use varied from 0% to 26% (pooled estimate, 1.6%, 95% CI: 0.8, 3.0). Lifetime substance use was investigated in secondary analyses. The high prevalence of smoking in prison suggests that policies regarding smoking need careful review. Furthermore, the findings underscore the importance of timely, scalable, and available treatments for alcohol and illegal drug use by people involved with the criminal justice system.

Intimate relationships and patterns of drug and sexual risk behaviors among people who inject drugs in Kazakhstan: A latent class analysis

BACKGROUND

Multiple drug and sexual risk behaviors among people who inject drugs (PWID) in intimate relationships increase the risk of HIV and HCV transmission. Using data on PWID in intimate partnerships in Almaty, Kazakhstan, this study performed latent class analysis (LCA) on drug and sexual risk behaviors and estimated associations between dyadic relationship factors and membership in latent classes.

METHODS

LCA was performed on a sample of 510 PWID (181-females/FWID, 321-males/MWID) to identify levels of drug and sexual risk behaviors. Generalized structural equation modeling with multinomial regressions estimated associations between relationship factors (length risk reduction communication, risk reduction self-efficacy) and class membership after adjusting for substance use severity, overdose, depression, binge drinking, intimate partner violence, structural factors, and sociodemographic characteristics. Models were sex-stratified to include FWID and PWID.

RESULTS

A 3-class model best fit the data and consisted of low, medium, and high-risk classes. GSEM found that greater injection self-efficacy was associated with a lower likelihood of membership in the high-risk class for PWID and FWID. For MWID, greater length of the relationship was associated with a lower likelihood of membership in the medium-risk class. Greater relationship communication was associated with increased risk of membership in the high-risk latent class for MWID.

CONCLUSIONS

Future research must investigate if increasing risk reduction and safe sex self-efficacy could reduce drug and sexual risk behaviors and HIV transmission among PWID and their intimate partners. Interventions are needed that reduce power inequities within relationships as a method of increasing self-efficacy, particularly among women.

Differences by sex in associations between injection drug risks and drug crime conviction among people who inject drugs in Almaty, Kazakhstan

BACKGROUND

The criminalization of drug use leads to high rates of drug crime convictions for engaging in injection drug use behaviors, introducing barriers to HIV prevention and drug treatment for PWID. Females (FWID) face unique vulnerabilities to HIV compared to males (MWID) in Kazakhstan. This study examined sex differences in associations between HIV/HCV infection, HIV knowledge, injection drug risk behaviors, and conviction for a drug crime in a sample of people who inject drugs (PWID) in Almaty, Kazakhstan.

METHODS

Analyses were performed on baseline data from 510 PWID and stratified by males (MWID) (329) and females (FWID) (181) from Kazakhstan in a couples-focused HIV prevention intervention. Logistic regression analyses using mixed effects (AOR) examined associations between HIV/HCV infection, HIV knowledge, injection drug risk behaviors, drug use severity, drug treatment history and conviction for a drug crime.

RESULTS

About three quarters of PWID reported drug crime conviction (73.92%, n = 377). HCV infection was associated with increased odds of drug crime conviction for FWID (AOR = 4.35, CI95 = 1.83-10.31, p < .01) and MWID (AOR = 3.62, CI95 = 1.09-12.07, p < .01). HIV transmission knowledge was associated with increased odds of conviction for MWID (AOR = 1.19, CI95 = 1.00-1.41, p < .05). Injection drug risk knowledge was associated with lower odds of conviction (AOR = .75, CI95 = .59-.94, p < .05) for FWID. Receptive syringe sharing (AOR = 3.48, CI95 = 1.65-7.31, p < .01), splitting drug solutions (AOR = 4.12, CI95 = 1.86-7.31, p < .05), and injecting with more than two partners (AOR = 1.89, CI95 = 1.06-3.34, p < .05) was associated with increased odds of conviction for FWID. Receptive syringe or equipment sharing with intimate partners was associated with conviction for both MWID (AOR = 1.90, CI95 = 1.03-3.92, p < .05) and FWID (AOR = 1.95, CI95 = 1.02-3.70, p < .05). For FWID, injection drug use in public spaces was associated with conviction (AORME = 3.25, CI95 = 1.31-7.39, p < .01). Drug use severity was associated with increased odds of conviction for FWID (AOR = 1.29, CI95 = 1.09-1.53, p < .001) and MWID (AOR = 1.24, CI95 = 1.09-1.41, p < .001). Ever receiving drug treatment was associated with conviction for MWID (AOR = 2.31, CI95 = 1.32-4.12, p < .01).

CONCLUSION

High-risk behaviors, HCV infection and more severe substance use disorders are associated with drug crime conviction for PWID, particularly FWID. Structural interventions are necessary to increase the engagement of PWID with drug crime convictions in HIV prevention and substance abuse treatment.

Perceptions of Health-Related Community Reentry Challenges among Incarcerated Drug Users in Azerbaijan, Kyrgyzstan, and Ukraine

Facing competing demands with limited resources following release from prison, people who inject drugs (PWID) may neglect health needs, with grave implications including relapse, overdose, and non-continuous care. We examined the relative importance of health-related tasks after release compared to tasks of everyday life among a total sample of 577 drug users incarcerated in Ukraine, Azerbaijan, and Kyrgyzstan. A proxy measure of whether participants identified a task as applicable (easy or hard) versus not applicable was used to determine the importance of each task. Correlates of the importance of health-related reentry tasks were analyzed using logistic regression, with a parsimonious model being derived using Bayesian lasso method. Despite all participants having substance use disorders and high prevalence of comorbidities, participants in all three countries prioritized finding a source of income, reconnecting with family, and staying out of prison over receiving treatment for substance use disorders, general health conditions, and initiating methadone treatment. Participants with poorer general health were more likely to prioritize treatment for substance use disorders. While prior drug injection and opioid agonist treatment (OAT) correlated with any interest in methadone in all countries, only in Ukraine did a small number of participants prioritize getting methadone as the most important post-release task. While community-based OAT is available in all three countries and prison-based OAT only in Kyrgyzstan, Kyrgyz prisoners were less likely to choose help staying off drugs and getting methadone. Overall, prisoners consider methadone treatment inapplicable to their pre-release planning. Future studies that involve patient decision-making and scale-up of OAT within prison settings are needed to better improve individual and public health.

Attitudes Toward Addiction, Methadone Treatment, and Recovery Among HIV-Infected Ukrainian Prisoners Who Inject Drugs: Incarceration Effects and Exploration of Mediators

In this study, we use data from a survey conducted in Ukraine among 196 HIV-infected people who inject drugs, to explore attitudes toward drug addiction and methadone maintenance therapy (MMT), and intentions to change drug use during incarceration and after release from prison. Two groups were recruited: Group 1 (n = 99) was currently incarcerated and Group 2 (n = 97) had been recently released from prison. This paper's key finding is that MMT treatment and addiction recovery were predominantly viewed as mutually exclusive processes. Group comparisons showed that participants in Group 1 (pre-release) exhibited higher optimism about changing their drug use, were less likely to endorse methadone, and reported higher intention to recover from their addiction. Group 2 participants (post-release), however, reported higher rates of HIV stigma. Structural equation modeling revealed that in both groups, optimism about recovery and awareness of addiction mediated the effect of drug addiction severity on intentions to recover from their addiction.

Intersecting epidemics of HIV, HCV, and syphilis among soon-to-be released prisoners in Kyrgyzstan: Implications for prevention and treatment

BACKGROUND

Central Asia is afflicted with increasing HIV incidence, low antiretroviral therapy (ART) coverage and increasing AIDS mortality, driven primarily by people who inject drugs (PWID). Reliable data about HIV, other infectious diseases, and substance use disorders in prisoners in this region is lacking and could provide important insights into how to improve HIV prevention and treatment efforts in the region.

METHODS

A randomly sampled, nationwide biobehavioural health survey was conducted in 8 prisons in Kyrgyzstan among all soon-to-be-released prisoners; women were oversampled. Consented participants underwent computer-assisted, standardized behavioural health assessment surveys and testing for HIV, HCV, HBV, and syphilis. Prevalence and means were computed, and generalized linear modelling was conducted, with all analyses using weights to account for disproportionate sampling by strata.

RESULTS

Among 381 prisoners who underwent consent procedures, 368 (96.6%) were enrolled in the study. Women were significantly older than men (40.6 vs. 36.5; p=0.004). Weighted prevalence (%), with confidence interval (CI), for each infection was high: HCV (49.7%; CI: 44.8-54.6%), syphilis (19.2%; CI: 15.1-23.5%), HIV (10.3%; CI: 6.9-13.8%), and HBV (6.2%; CI: 3.6-8.9%). Among the 31 people with HIV, 46.5% were aware of being HIV-infected. Men, compared to women, were significantly more likely to have injected drugs (38.3% vs.16.0%; p=0.001). Pre-incarceration and within-prison drug injection, primarily of opioids, was 35.4% and 30.8%, respectively. Independent correlates of HIV infection included lifetime drug injection (adjusted odds ratio [AOR]=38.75; p=0.001), mean number of years injecting (AOR=0.93; p=0.018), mean number of days experiencing drug problems (AOR=1.09; p=0.025), increasing duration of imprisonment (AOR=1.08; p=0.02 for each year) and having syphilis (AOR=3.51; p=0.003), while being female (AOR=3.06; p=0.004) and being a recidivist offender (AOR=2.67; p=0.008) were independently correlated with syphilis infection.

CONCLUSION

Drug injection, syphilis co-infection, and exposure to increased risk during incarceration are likely to be important contributors to HIV transmission among prisoners in Kyrgyzstan. Compared to the community, HIV is concentrated 34-fold higher in prisoners. A high proportion of undiagnosed syphilis and HIV infections presents a significant gap in the HIV care continuum. Findings highlight the critical importance of evidence-based responses within prison, including enhanced testing for HIV and sexually transmitted infections, to stem the evolving HIV epidemic in the region.

The perfect storm: incarceration and the high-risk environment perpetuating transmission of HIV, hepatitis C virus, and tuberculosis in Eastern Europe and Central Asia

Despite global reductions in HIV incidence and mortality, the 15 UNAIDS-designated countries of Eastern Europe and Central Asia (EECA) that gained independence from the Soviet Union in 1991 constitute the only region where both continue to rise. HIV transmission in EECA is fuelled primarily by injection of opioids, with harsh criminalisation of drug use that has resulted in extraordinarily high levels of incarceration. Consequently, people who inject drugs, including those with HIV, hepatitis C virus, and tuberculosis, are concentrated within prisons. Evidence-based primary and secondary prevention of HIV using opioid agonist therapies such as methadone and buprenorphine is available in prisons in only a handful of EECA countries (methadone or buprenorphine in five countries and needle and syringe programmes in three countries), with none of them meeting recommended coverage levels. Similarly, antiretroviral therapy coverage, especially among people who inject drugs, is markedly under-scaled. Russia completely bans opioid agonist therapies and does not support needle and syringe programmes-with neither available in prisons-despite the country's high incarceration rate and having the largest burden of people with HIV who inject drugs in the region. Mathematical modelling for Ukraine suggests that high levels of incarceration in EECA countries facilitate HIV transmission among people who inject drugs, with 28-55% of all new HIV infections over the next 15 years predicted to be attributable to heightened HIV transmission risk among currently or previously incarcerated people who inject drugs. Scaling up of opioid agonist therapies within prisons and maintaining treatment after release would yield the greatest HIV transmission reduction in people who inject drugs. Additional analyses also suggest that at least 6% of all incident tuberculosis cases, and 75% of incident tuberculosis cases in people who inject drugs are due to incarceration. Interventions that reduce incarceration itself and effectively intervene with prisoners to screen, diagnose, and treat addiction and HIV, hepatitis C virus, and tuberculosis are urgently needed to stem the multiple overlapping epidemics concentrated in prisons.

Clinical care of incarcerated people with HIV, viral hepatitis, or tuberculosis

The burden of HIV/AIDS and other transmissible diseases is higher in prison and jail settings than in the non-incarcerated communities that surround them. In this comprehensive review, we discuss available literature on the topic of clinical management of people infected with HIV, hepatitis B and C viruses, and tuberculosis in incarcerated settings in addition to co-occurrence of one or more of these infections. Methods such as screening practices and provision of treatment during detainment periods are reviewed to identify the effect of community-based treatment when returning inmates into the general population. Where data are available, we describe differences in the provision of medical care in the prison and jail settings of low-income and middle-income countries compared with high-income countries. Structural barriers impede the optimal delivery of clinical care for prisoners, and substance use, mental illness, and infectious disease further complicate the delivery of care. For prison health care to reach the standards of community-based health care, political will and financial investment are required from governmental, medical, and humanitarian organisations worldwide. In this review, we highlight challenges, gaps in knowledge, and priorities for future research to improve health-care in institutions for prisoners.

Pre-incarceration police harassment, drug addiction and HIV risk behaviours among prisoners in Kyrgyzstan and Azerbaijan: results from a nationally representative cross-sectional study

Introduction

The expanding HIV epidemic in Azerbaijan and Kyrgyzstan is concentrated among people who inject drugs (PWID), who comprise a third of prisoners there. Detention of PWID is common but its impact on health has not been previously studied in the region. We aimed to understand the relationship between official and unofficial (police harassment) detention of PWID and HIV risk behaviours.

Methods

In a nationally representative cross-sectional study, soon-to-be released prisoners in Kyrgyzstan (N=368) and Azerbaijan (N=510) completed standardized health assessment surveys. After identifying correlated variables through bivariate testing, we built multi-group path models with pre-incarceration official and unofficial detention as exogenous variables and pre-incarceration composite HIV risk as an endogenous variable, controlling for potential confounders and estimating indirect effects.

Results

Overall, 463 (51%) prisoners reported at least one detention in the year before incarceration with an average of 1.3 detentions in that period. Unofficial detentions (13%) were less common than official detentions (41%). Optimal model fit was achieved (X²=5.83, p=0.44; Goodness of Fit Index (GFI) GFI=0.99; Comparative Fit Index (CFI) CFI=1.00; Root Mean Square Error of Approximation (RMSEA) RMSEA=0.00; PCLOSE=0.98) when unofficial detention had an indirect effect on HIV risk, mediated by drug addiction severity, with more detentions associated with higher addiction severity, which in turn correlated with increased HIV risk. The final model explained 35% of the variance in the outcome. The effect was maintained for both countries, but stronger for Kyrgyzstan. The model also holds for Kyrgyzstan using unique data on within-prison drug injection as the outcome, which was frequent in prisoners there.

Conclusions

Detention by police is a strong correlate of addiction severity, which mediates its effect on HIV risk behaviour. This pattern suggests that police may target drug users and that such harassment may result in an increase in HIV risk-taking behaviours, primarily because of the continued drug use within prisons. These findings highlight the important negative role that police play in the HIV epidemic response and point to the urgent need for interventions to reduce police harassment, in parallel with interventions to reduce HIV transmission within and outside of prison.

The Prevalence of Hepatitis B and C Among Prisoners in Kahramanmaras, Turkey

Background

Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are among the most important health issues in Turkey. Human immunodeficiency virus (HIV) infections are less frequently observed in the country. The individuals who had blood transfusions, patients undergoing hemodialysis, and intravenous drug addicted individuals, people who had tattoos/piercings, communal living environments, contamination of a family member, and prisoners are the main risk groups.

Objectives

The current study aimed to discuss the prevalence and the genotypes of hepatitis and HIV infections among a specific group, namely individuals incarcerated in prisons.

Patients and Methods

Two-hundred and sixty-six prisoners sentenced for crimes such as robbery, sexual assault, assault substance abuse or selling drugs in the Kahramanmaras closed prison were recruited for the study. Demographic data and the presence of hepatitis B, hepatitis C and HIV were investigated in the study subjects.

Results

Out of the 266 cases included in the study, 89.5% were male, 10.5% were female and the mean age was 31.21 ± 8.99 years. Risk factors were detected in 27.4% of the subjects. Out of the 73 subjects, among whom the risk factors were detected, 20.3% had intravenous substance use, 3.8% had a history of operation/transfusion, 1.9% had a history of indentation and 1.5% had unprotected sexual contact. The rate of hepatitis B surface antigen (HBsAg) positivity was 2.6%, the ratio of anti-HBs positive subjects was 35.0% and immunity was achieved with vaccination in 43% of the subjects. Anti-HCV was positive in 17.7% of the prisoners and the genotype 3 and genotype 1 were 68.1% (n = 32) and 2.1% (n = 1), respectively.

Conclusions

Continued substance abuse among most of the drug addicted individuals in prisons, common use of injection materials, tattoos and other circumstances that cause blood contact increase the risk of blood-borne infections.