Hepatitis C infection and incarcerated populations

Accessing hepatitis C direct acting antivirals among people living with hepatitis C: a qualitative study

BACKGROUND

Hepatitis C is curable with direct-acting antivirals (DAAs). However, treatment uptake remains low among marginalized populations such as people who inject drugs. We sought to understand challenges to treatment uptake with DAAs among people living with hepatitis C and compare treatment experiences between people who do and do not inject prescription and/or unregulated drugs.

METHODS

We conducted a qualitative study using focus groups with 23 adults aged 18 years and over who completed DAA treatment or were about to begin such treatment at the time of the study. Participants were recruited from hepatitis C treatment clinics across Toronto, Ontario. We drew upon stigma theory to interpret participants' accounts.

RESULTS

Following analysis and interpretation, we generated five theoretically-informed themes characterizing the experiences of individuals accessing DAAs: "being 'worthy' of the cure", "spatially enacted stigma", "countering social and structural vulnerability: the importance of peers", "identity disruption and contagion: attaining a 'social cure'" and "challenging stigma with population-based screening". Overall, our findings suggest that structural stigma generated and reproduced through healthcare encounters limits access to DAAs among people who inject drugs. Peer-based programs and population-based screening were proposed by participants as mechanisms for countering stigma within health care settings and 'normalizing' hepatitis C among the general population.

CONCLUSIONS

Despite the availability of curative therapies, access to such treatment for people who inject drugs is limited by stigma enacted in and structured within healthcare encounters. Developing novel, low-threshold delivery programs that remove power differentials and attend to the social and structural determinants of health and reinfection are needed to facilitate further scale up of DAAs and support the goal of eradicating hepatitis C as a public health threat.

Hepatitis C virus risk among young people who inject drugs

Background

Injection drug use (IDU) is the leading risk factor for hepatitis C virus (HCV) transmission in the U.S. While the general risk factors for HCV transmission are known, there is limited work on how these factors interact and impact young people who inject drugs (YPWID).

Methods

Project data were drawn from a study of 539 New York City (NYC) residents ages 18-29 who were recruited via Respondent-Driven Sampling and, reported past-month non-medical use of prescription opioids and/or heroin. Analyses are based on a subsample of 337 (62%) who reported injecting any drug in the past 12 months. All variables were assessed via self-report, except HCV status, which was established via rapid antibody testing. Integrating the observed statistical associations with extant literature on HCV risk, we also developed a qualitative system dynamics (SD) model to use as a supplemental data visualization tool to explore plausible pathways and interactions among key risk and protective factors for HCV.

Results

Results showed a 31% HCV antibody prevalence with an overall incidence of 10 per 100 person-years. HCV status was independently correlated with having shared cookers with two or more people (AOR = 2.17); injected drugs 4–6 years (AOR = 2.49) and 7 or more years (AOR = 4.95); lifetime homelessness (AOR = 2.52); and having been incarcerated two or more times (AOR = 1.99). These outcomes along with the extant literature on HCV risk were used to develop the qualitative SD model, which describes a causal hypothesis around non-linearities and feedback loop structures underlying the spread of HCV among YPWID.

Conclusions

Despite ongoing harm reduction efforts, close to a third of YPWID in the community sample have been exposed to HCV, have risks for injection drug use, and face challenges with structural factors that may be preventing adequate intervention. The qualitative SD model explores these issues and contributes to a better understanding of how these various risk factors interact and what policies could potentially be effective in reducing HCV infections.

Is Illicit Substance Use Gender-Specific? The Basic Points of Mental and Health Disorders

Among the groups of users of illicit substances, a high percentage are persons deprived of their liberty; at the same time, each social and age group is also affected, to one degree or another. The purpose of this study is to provide general data on the relationship between different psychostimulants, clinical and socio-demographic studies, and gender, both among the general population and in one of the most at-risk groups. This review identifies the use of illicit substances as gender-specific in the general population. A detailed study of the causal relationship between the use of illicit substances and gender was carried out. Electronic databases Academic Search Complete, PubMed, HealthCare, Web of Science, and Google Scholar were searched for relevant studies up to 2022 associated with drug abuse and mental and health disorders. The analysis indicated that the human population showed significant differences between the sex of the consumer as to the type of drug consumers, development of addiction, and relapse. We focus on the pathological changes caused by drug use, the personal and physiological individual traits that influence drug choice, and the extent of use in one of the most affected groups of individuals. The study may provide some guidance in developing gender-specific treatment and prevention, including response to some pharmacological and behavioral therapies. The review is intended for a wide audience of social workers, toxicologists, and pharmacologists.

Exploring the Genomic Architectures of Health, Physical Traits and Antisocial Behavioral Outcomes: A Brief Report

A widely replicated finding across the behavioral sciences is that antisocial behaviors correlate with an array of health problems. Less clear, however, is the precise nature of this association. There is reason to suspect that a direct causal link exists between incarceration-a consequence of some antisocial behaviors-and certain negative health outcomes, for instance. However, it might be the case that broader phenotypes like antisocial behavior may correlate with certain health and physiological traits at a genomic level. We explore this possibility from a theoretical vantage point, while also presenting some preliminary data from existing secondary sources. Tentatively, no significant genetic correlations emerged across a host of health, physiological, and wellbeing outcomes after correction for multiple testing. However, more work is needed exploring this topic. We propose that future studies should make use of larger, more diverse samples and examine the genetic overlap between homogeneous clusters of antisocial behavioral subtypes and disease traits or symptoms.

History of detention and the risk of hepatitis C among people who inject drugs in Germany

OBJECTIVES

The aim of this study was to investigate the association between detention experience and hepatitis C virus (HCV) status, the role of duration and frequency of detention, and whether risk behaviours practiced in detention could explain an observed increase in risk.

METHODS

Current drug injectors (injecting in the last 12 months) were recruited to participate in a sero-behavioural, cross-sectional survey using respondent-driven sampling in eight German cities during the years 2011-2014. Using multivariable logistic regression, the association between HCV status and reported detention experience was investigated.

RESULTS

A total of 1998 participants were included in the analysis. Of these, 19.9% reported no detention experience, 28.6% short and rare experience (≤3.5 years in total, ≤3 times), 12.1% short but frequent experience, 7.1% long but rare experience, and 32.4% long and frequent experience. After correcting for HCV risk factors, the association between detention experience and HCV status remained statistically significant. By adjusting the model for intramural risk behaviours, the odds ratios of detention experience were reduced but remained significant.

CONCLUSIONS

The proportion of people who inject drugs positive for HCV increased with both frequency and duration of their detention experience. As intramural risk behaviours could not fully explain this increase, it appears that transfers between community and custody may confer additional risks.

Rural Incarcerated Women: HIV/HCV Knowledge and Correlates of Risky Behavior

Rural incarcerated women have an increased risk of acquiring the human immunodeficiency virus (HIV) and the hepatitis C virus (HCV) due to prevalent engagement in drug use and sexual behaviors. Limited research has investigated HIV and HCV knowledge in this high-risk population. Furthermore, the interplay of sociodemographic factors (i.e., education, age, income, and sexual orientation) and risky behavior is understudied in this population. The present study evaluated a sample of adult, predominately White women from rural Kentucky ( n = 387) who were recruited from local jails. The sample had high HIV and HCV knowledge but also reported extensive risk behaviors including 44% engaging in sex work and 75.5% reporting a history of drug injection. The results of multiple regression analysis for risky sexual behavior indicated that sexual minority women and those with less HIV knowledge were more likely to engage in high-risk sexual behaviors. The regression model identifying the significant correlates of risky drug behavior indicated that HIV knowledge, age, and income were negative correlates and that sexual minority women were more likely to engage in high-risk drug use. When HCV knowledge was added to the regression models already including HIV knowledge, the interaction was significant for drug risk. Interventions for rural imprisoned women should consider the varied impact of sociodemographic background and prioritize HIV education to more effectively deter risky sexual and drug behaviors.

Risk behaviours and viral infections among drug injecting migrants from the former Soviet Union in Germany: Results from the DRUCK-study

BACKGROUND

High prevalence of drug use and injection-related risk behaviours have been reported among former Soviet Union (FSU)-migrants. To investigate hepatitis C (HCV) and HIV seroprevalence and related risk behaviours in this subgroup in Germany, we compared first generation FSU-migrants and native Germans using data from a sero-behavioural survey of people who inject drugs (PWID).

METHODS

Current injectors were recruited using respondent-driven sampling in eight German cities in 2011-2014. Questionnaire-based interviews were conducted and dried blood spots collected and tested for anti-HCV, HCV-RNA, and anti-HIV1/2. Descriptive and multivariable analyses (MVA) were performed.

RESULTS

A total of 208 FSU-born and 1318 native German PWID were included in the analysis. FSU-migrants were younger than Germans (median age: 33 vs. 39 years), and more often male (83.1% vs. 75.9%, p = 0.022). HCV seroprevalence was 74.5% in FSU-migrants vs. 64.6% in Germans (p = 0.006), HIV seroprevalence was 5.8% and 4.6%, respectively (p = 0.443). The proportion of FSU-migrants reporting injecting-related risk behaviours was higher than among Germans: injecting daily (39.4% vs. 30.2%, p = 0.015), with friends (39.2% vs. 31.2%, p = 0.038), cocaine (32.7% vs. 23.8%, p = 0.044), more than one drug (18.2% vs. 9.6%, p = 0.006), and sharing filters/cookers (35.5% vs. 28.0%, p = 0.045). No statistically significant differences were observed in HIV/HCV testing rates (range: 50.7%-65.6%), opioid substitution treatment (43.9% vs. 50.5%), and access to clean needles/syringes (89.8% vs. 90.3%). In MVA, risk for HCV-infection was increased in male FSU-migrants compared to German males (OR 3.32, p = 0.006), no difference was identified between female FSU-migrants and German females (OR: 0.83, p = 0.633).

CONCLUSION

Male FSU-migrants were at highest risk of being HCV infected. Therefore, targeted actions are needed to ensure access and acceptance of harm reduction measures, including HCV-testing and -treatment for this subpopulation of PWID.

Age-Specific Global Prevalence of Hepatitis B, Hepatitis C, HIV, and Tuberculosis Among Incarcerated People: A Systematic Review

PURPOSE

This study aims to compare the global prevalence of hepatitis B, hepatitis C, HIV, and tuberculosis in incarcerated adolescents and young adults (AYAs) and older prisoners.

METHODS

This study is a systematic review and meta-analysis of studies reporting the age-specific prevalence of each infection in prisoners. We grouped age-specific prevalence estimates into three overlapping age categories: AYA prisoners (<25 years), older prisoners (≥25 years), and mixed category (spanning age 25 years). We used random effects meta-analysis to estimate the relative risk (RR) of each infection in AYAs versus older prisoners.

RESULTS

Among 72 studies, there was marked heterogeneity in prevalence estimates among AYA prisoners for all infections: hepatitis B (.4%-25.2%), hepatitis C (.0%-70.6%), HIV (.0%-15.8%), and active tuberculosis (.0%-3.7%). The pooled prevalence of HIV (RR = .39, 95% confidence interval .29-.53, I² = 79.2%) and hepatitis C (RR = .51, 95% confidence interval .33-.78, I² = 97.8%) was lower in AYAs than in older prisoners.

CONCLUSIONS

The prevalence of HIV and hepatitis C is lower in AYA prisoners than in older prisoners. Despite lower prevalence, acquisition begins early among incarcerated populations. There is an urgent need for targeted, age-appropriate prevention, treatment, and harm reduction measures in and beyond custodial settings to reduce the incidence of infection in these extremely vulnerable young people.

Ongoing incident hepatitis C virus infection among people with a history of injecting drug use in an Australian prison setting, 2005-2014: The HITS-p study

Hepatitis C virus (HCV) transmission is high in prisons. This study investigated trends in HCV incidence and associated factors among a cohort of prisoners with a history of injecting drug use in New South Wales, Australia. Data were available from the Hepatitis C Incidence and Transmission Study-prisons (HITS-p) from 2005 to 2014. Temporal trends in HCV incidence were evaluated. Factors associated with time to HCV seroconversion among people with ongoing injecting was assessed using Cox proportional hazards. Among 320 antibody-negative participants with a history of injecting drug use (mean age 26; 72% male), 62% (n=197) reported injecting drug use during follow-up. Overall, 93 infections were observed. HCV incidence was 11.4/100 person-years in the overall population and 6.3/100 person-years among the continually imprisoned population. A stable trend in HCV incidence was observed. Among the overall population with ongoing injecting during follow-up, ≥weekly injecting drug use frequency was independently associated with time to HCV seroconversion. Among continuously imprisoned injectors with ongoing injecting during follow-up, needle/syringe sharing was independently associated with time to HCV seroconversion. This study demonstrates that prison is a high-risk environment for acquisition of HCV infection. Needle and syringe sharing was associated with HCV infection among continually imprisoned participants, irrespective of frequency of injecting or the type of drug injected. These findings highlight the need for the evaluation of improved HCV prevention strategies in prison, including needle/syringe programmes and HCV treatment.

Risk factors for prevalent hepatitis C virus-infection among inmates in a state prison system in Mexico

Objectives

To estimate the prevalence of HCV-infection and identify associated factors among inmates in the State Prison System of Guanajuato in Mexico (Sep-2011 to Feb-2012).

Methods

Cross-sectional, observational study in 10 prisons in the State of Guanajuato in Mexico (2011–2012). We offered HCV-testing and applied audio computer-assisted self-interviews to all adults imprisoned in the State Prison System. We used a complex survey analysis to estimate the distribution of variables and its corresponding 95% confidence intervals, taking into consideration the expected cluster effect by common characteristics within prisons. Inverse probability weights were applied to correct potential biased estimates arising from non-participation in accrual activities and non-response rates. We fitted multivariate logistic regression models to identify risk-behaviors associated to HCV-infection.

Results

We included data of 2,519 participating inmates. Prevalence of HCV-infection was 4.9 (95%CI = 3.6–5.9). Most HCV-infected inmates were male (99%). Before being incarcerated, inmates with HCV-infection were more frequently tattooed, used and injected drugs more frequently, and were more likely to share materials for injecting, when compared with those non-infected. During incarceration, HCV-infected inmates got tattoos and used drugs more often than non-infected, including injecting-drugs and sharing materials. Injecting-drug use (OR = 7.6, 95%CI, 2.5–23.4), sharing materials for injecting-drugs (OR = 19.6, 95%CI, 4.7–81.7) and being tattooed at least once before incarceration (OR = 2.1, 95%CI, 1.1–3.9), but not during incarceration, were independently associated to HCV-infection.

Conclusions

The prevalence of HCV-infection among inmates in the State of Guanajuato in Mexico is considerably higher than in the general population. The most important risk factors for HCV in this inmate population were injecting-drugs and sharing materials for injections before incarceration. High-risk behaviors during imprisonment are very high particularly among those already infected. HCV diagnostic and treatment services, and harm-reduction programs for incarcerated injecting-drug users in Mexico should be integrated to control the HCV epidemic in Mexico.

Epidemiology of Infectious Disease-Related Death After Release from Prison, Washington State, United States, and Queensland, Australia: A Cohort Study

OBJECTIVES

People in prison may be at high risk for infectious diseases and have an elevated risk of death immediately after release compared with later; their risk of death is elevated for at least a decade after release. We compared rates, characteristics, and prison-related risk factors for infectious disease-related mortality among people released from prisons in Queensland, Australia, and Washington State, United States, regions with analogous available data.

METHODS

We analyzed data from retrospective cohort studies of people released from prison in Queensland (1997-2007, n=37,180) and Washington State (1999-2009, n=76,208) and linked identifiers from each cohort to its respective national death index. We estimated infectious disease-related mortality rates (deaths per person-years in community) and examined associations using Cox proportional hazard models.

RESULTS

The most frequent infectious disease-related underlying cause of death after release from prison was pneumonia (43%, 23/54 deaths) in the Australian cohort and viral hepatitis (40%, 69/171 deaths) in the U.S. cohort. The infectious disease-related mortality rate was significantly higher in the U.S. cohort than in the Australian cohort (51.2 vs. 26.5 deaths per 100,000 person-years; incidence rate ratio = 1.93, 95% confidence interval 1.42, 2.62). In both cohorts, increasing age was strongly associated with mortality from infectious diseases.

CONCLUSION

Differences in the epidemiology of infectious disease-related mortality among people released from prison may reflect differences in patterns of community health service delivery in each region. These findings highlight the importance of preventing and treating hepatitis C and other infectious diseases during the transition from prison to the community.

HIV/AIDS in Lebanese prisons: challenges and proposed actions

PURPOSE

The purpose of this paper is to discuss the extent of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) crisis in Lebanese prisons, propose functional reforms for Roumieh prisons (the country's largest male top-security prison), and outline the main challenges to HIV/AIDS prevention, intervention, and treatment.

DESIGN/METHODOLOGY/APPROACH

All recommendations were based on previous successful stories, international prison standards as well as cultural considerations.

FINDINGS

This paper argues that prevention and interventions starts within the prison community including inmates, guards, and other prison and provision of appropriate health care, education, and prison infrastructure.

SOCIAL IMPLICATIONS

These strategies are not only important in limiting prevention and transmission of HIV/AIDS, but also contribute in optimizing quality of life within the prison system.

ORIGINALITY/VALUE

This paper is the first of its kind to discuss the prison situation in Lebanese prisons in terms of public health promotion and reforms.

A comparison of risk factors for hepatitis C among young and older adult prisoners

Internationally, the prevalence of hepatitis C infection is higher among prisoners when compared to the general population, particularly among people who inject drugs. This study estimates the prevalence of, and compares the risk factors for, hepatitis C in young (< 25 years) and older (≥ 25 years) prisoners with a history of injection drug use. Participants were 677 sentenced prisoners in Queensland, Australia, with a lifetime history of injection drug use, recruited in the 6 weeks prior to release from custody. The prevalence of hepatitis C exposure was significantly lower in young prisoners than in older prisoners (20.7% vs. 29.4%, p = .03). Risk factors for hepatitis C varied between young and older prisoners. Young people who inject drugs and who have had shorter time at risk of hepatitis C exposure are an important target group for hepatitis C prevention efforts.

Factors associated with recently acquired hepatitis C virus infection in people who inject drugs in England, Wales and Northern Ireland: new findings from an unlinked anonymous monitoring survey

Monitoring infections and risk in people who inject drugs (PWID) is important for informing public health responses. In 2011, a novel hepatitis C antibody (anti-HCV) avidity-testing algorithm to identify samples compatible with recent primary infection was introduced into a national surveillance survey. PWID are recruited annually, through >60 needle-and-syringe programmes and prescribing services. Of the 980 individuals that could have been at risk of HCV infection, there were 20 (2%) samples that were compatible with recent primary infection. These were more common among: those imprisoned ⩾5 times [8/213; adjusted odds ratio (aOR) 8·7, 95% confidence interval (CI) 2·04-37·03]; women (8/230; aOR 3·8, 95% CI 1·41-10·38); and those ever-infected with hepatitis B (5/56; aOR 6·25, 95% CI 2·12-18·43). This study is the first to apply this algorithm and to examine the risk factors associated with recently acquired HCV infection in a national sample of PWID in the UK. These findings highlight underlying risks and suggest targeted interventions are needed.

The case for improving the health of ex-prisoners

The global prison population exceeds 10 million and continues to grow; more than 30 million people are released from custody annually. These individuals are disproportionately poor, disenfranchised, and chronically ill. There are compelling, evidence-based arguments for improving health outcomes for ex-prisoners on human rights, public health, criminal justice, and economic grounds. These arguments stand in stark contrast to current policy and practice in most settings. There is also a dearth of evidence to guide clinicians and policymakers on how best to care for this large and growing population during and after their transition from custody to community. Well-designed longitudinal studies, clinical trials, and burden of disease studies are pivotal to closing this evidence gap.

Development of an intervention to increase health service utilisation in ex-prisoners

The world prison population is growing at a rate well in excess of general population growth, with more than 10 million adults currently in custody around the world and around 30 million moving through prison systems each year. There is increasing recognition of the complex and chronic health needs of incarcerated populations, but evidence-based responses to these needs remain elusive. Most prisoners return to the community after a relatively short period of time in custody, however few transitional interventions for prisoners have been subjected to rigorous evaluation. This paper details the process of developing a service brokerage intervention for ex-prisoners in Queensland, Australia, and describes the resultant intervention. The intervention could be adapted for use in other settings and is amenable to methodologically rigorous evaluation. The collaborative design and development process involved extensive consultation with ex-prisoners and key government, community and consumer stakeholders. The intervention evolved considerably during the process of consultation, as we came to better understand the needs and priorities of our target population, and of the community organisations that served them. We consider genuine consultation with consumers, in a safe and supportive environment, to be an integral part of intervention research in this area. Given the poor outcomes experienced by many people after release from prison, evidence-based interventions developed in the way described here are urgently required.

Screening for Hepatitis C as a Prevention Enhancement (SHAPE) for HIV: an integration pilot initiative in a Massachusetts County correctional facility

OBJECTIVES

The Massachusetts Department of Public Health (MDPH) and the Barnstable County Sheriff's Department (BCSD) in Massachusetts initiated a pilot program in July 2009 offering education and hepatitis C virus (HCV) antibody testing to inmates and detainees, concurrent with routine HIV testing. The initiative was implemented to assess the feasibility of integrating HCV screening into an HIV screening program in a correctional setting and the efficacy of linking HCV antibody-positive inmates to clinical care upon release.

METHODS

Through the Screening for Hepatitis C as a Prevention Enhancement initiative, HCV and HIV testing were offered to inmates and detainees shortly after admission, and by request at any time during incarceration. In preparation for release, referrals were made to community-based medical providers for HCV follow-up care. Data from BCSD were compared with routine surveillance data received by MDPH. Confirmatory HCV test results received by April 15, 2012, were considered indicators of appropriate post-release clinical care.

RESULTS

From July 2009 through December 2011, 22% (n=596) and 25% (n=667) of 2,716 inmates/detainees accepted HCV and HIV testing, respectively. Of those tested for HCV antibody, 20.5% (n=122) were positive. Of those tested for HIV antibody, 0.8% (n=5) were positive. Of the inmates who tested HCV positive at BCSD and had been released, 37.8% were identified as receiving post-release medical care.

CONCLUSIONS

We determined that integration of HCV education and screening into correctional facilities is feasible and reveals high rates of HCV infection. Although this model presupposes programmatic infrastructure, elements of the service design and integration could inform a range of correctional programs. Effective linkage to care, while substantial, was not routine based on our analysis, and may require additional resources given its cost and complexity.

Physical health outcomes in prisoners with intellectual disability: a cross-sectional study

BACKGROUND

People with intellectual disability (ID) in the general population and people in prison experience unrecognised medical conditions and inadequate disease prevention. Among prisoners, those with an ID may be particularly disadvantaged. The aim of this study was to identify demographic, health and health-related characteristics of adult prisoners who screened positive for ID.

METHODS

Cross-sectional data were collected via face-to-face administration of a structured questionnaire in seven prisons in Queensland, Australia, between 2008 and 2010. Participants were adult prisoners within 6 weeks of release from custody. We identified ID using a pragmatic screening tool. Prisoners who scored <85 on the Hayes Ability Screening Index and either (a) reported having attended a special school or (b) reported having been diagnosed with an ID were considered to have screened positive for ID. We compared the characteristics of participants who screened positive and negative for ID using univariable and multivariable logistic regression.

RESULTS

Screening positive for ID was associated with younger age, identifying as Indigenous and lower educational achievement. Prisoners who screened positive for ID were more likely to have been diagnosed with medical conditions such as heart disease (odds ratio; 95% confidence interval = 2.1; 1.0-4.2) and hearing problems (2.2; 1.3-3.7), after adjustment for age, sex, education level and Indigenous status. Screen-positive prisoners were less likely to have received preventive care interventions such as testing for hepatitis A infection (0.4; 0.2-0.6), and immunisation for tuberculosis (0.4; 0.2-0.8). Prisoners with possible ID were more likely to be obese (1.7; 1.1-2.7).

CONCLUSIONS

Adult prisoners who screen positive for ID have worse health outcomes than their non-disabled peers. An improved understanding of physical health characteristics prior to release can direct treatment and support pathways out of the criminal justice system and inform transitional planning of health services for this profoundly disadvantaged group.

Incidence and prevalence of hepatitis C in prisons and other closed settings: results of a systematic review and meta-analysis

People detained in prisons and other closed settings are at elevated risk of infection with hepatitis C virus (HCV). We undertook a systematic review and meta-analysis with the aim of determining the rate of incident HCV infection and the prevalence of anti-HCV among detainees in closed settings. We systematically searched databases of peer-reviewed literature and widely distributed a call for unpublished data. We calculated summary estimates of incidence and prevalence among general population detainees and detainees with a history of injection drug use (IDU), and explored heterogeneity through stratification and meta-regression. The summary prevalence estimates were used to estimate the number of anti-HCV positive prisoners globally. HCV incidence among general detainees was 1.4 per 100 person-years (py; 95% confidence interval [CI]: 0.1, 2.7; k = 4), and 16.4 per 100 py (95% CI: 0.8, 32.1; k = 3) among detainees with a history of IDU. The summary prevalence estimate of anti-HCV in general detainees was 26% (95% CI: 23%, 29%; k = 93), and in detainees with a history of IDU, 64% (95% CI: 58%, 70%; k = 51). The regions of highest prevalence were Central Asia (38%; 95% CI 32%, 43%; k = 1) and Australasia (35%; 95% CI: 28%, 43%; k = 9). We estimate that 2.2 million (range: 1.4-2.9 million) detainees globally are anti-HCV positive, with the largest populations in North America (668,500; range: 553,500-784,000) and East and Southeast Asia (638,000; range: 332,000-970,000).

CONCLUSION

HCV is a significant concern in detained populations, with one in four detainees anti-HCV-positive. Epidemiological data on the extent of HCV infection in detained populations is lacking in many countries. Greater attention towards prevention, diagnosis, and treatment of HCV infection among detained populations is urgently required.

Risk practices among aboriginal people who inject drugs in New South Wales, Australia

This paper describes patterns of injecting drug use and blood borne virus (BBV)-related risk practices among Australian Aboriginal and non-Aboriginal people who inject drugs (PWID). A total of 588 participants, 120 of whom self-identified as Aboriginal completed a questionnaire. Aboriginal participants were more likely to have been in prison (37.6 vs. 16.5 %), to inject daily (72.7 vs. 55.0 %), to share ancillary equipment (64.9 vs. 44.8 %) and less likely to know about BBV transmission (72.0 vs. 87.7 %) and treatment (47.2 vs. 67.6 %). Aboriginal participants used services such as BBV testing and drug treatment at a comparable rate to non-Aboriginal participants. The findings suggest that Aboriginal PWID are at greater risk for acquiring BBV. The prison setting should be used to deliver health promotion information and risk reduction messages. More information is needed on Aboriginal people's access and use of services to ensure beneficial services are received in the most appropriate settings.

Low incidence of hepatitis C virus among prisoners in Scotland

AIMS

To estimate hepatitis C virus (HCV) incidence and HCV risk among Scottish prisoners.

DESIGN

National sero-behavioural survey; dried blood spots were collected in order to identify recent HCV infections (i.e. HCV antibody-negative and HCV polymerase chain reaction (PCR)-positive).

SETTING

All 14 closed prisons in Scotland.

PARTICIPANTS

A total of 5187 prisoners responded to the survey (79% of available prisoners on survey days) comprising 5076 individuals (after removing incomplete returns and participants surveyed in more than one prison); 95% men, 32% (1625) reported an injecting history (PWID) and median sentence of 9.5 months. HCV antibody samples were available for 4904 participants; there was sufficient sera for HCV PCR for 2446 prisoners who had been in prison for at least 75 days.

MEASUREMENTS

The estimate of in-prison recent infections is based on prisoners incarcerated for a sufficient period, i.e. at least 75 days, so that recent infections could be attributed to prison.

FINDINGS

Overall HCV prevalence was 19%; 53% among people who reported an injecting history and 3% among other prisoners. Three recent infections probably acquired in prison were detected. None of the cases reported injecting during their current sentence or any other potential exposure. Estimated incidence was 0.6-0.9% overall and 3.0-4.3% among PWID (assuming all infections acquired through injecting). Fifty-seven per cent (929) of PWID were receiving opiate substitution treatment (OST) at the time of the survey. Of all prisoners, 2.5% and 8% of PWID reported injecting during their current period of incarceration.

CONCLUSION

The low incidence of HCV infections in Scottish prisons is due most probably to the low occurrence of in-prison injecting and high coverage of OST. Low HCV risk can be achieved in prisons without necessarily introducing needle exchange programmes, but close monitoring of risk behaviours is essential. If risk increases, provision of needle exchange should be considered.

High-risk drug-use practices among a large sample of Australian prisoners

BACKGROUND

Drug injection in prison is associated with a high risk of transmission of blood-borne pathogens including hepatitis C (HCV). The aim of this study was to estimate the prevalence and identify independent correlates of recent in-prison injecting drug use (P-IDU) among a large sample of adult prisoners in Queensland, Australia.

METHODS

Confidential, structured interviews with 1,322 adult prisoners in Queensland, Australia. Prevalence estimates were corrected for sampling bias using inverse probability weighting. Independent correlates of recent P-IDU were identified using multivariable Poisson regression with backwards elimination.

RESULTS

We estimated that among all adult prisoners in Queensland, Australia, the prevalence of lifetime IDU was 55.1%, of lifetime P-IDU 23.0%, and of recent (during current sentence) P-IDU 13.2%. Significant, independent correlates of recent P-IDU included male gender (ARR=3.07, 95% CI 1.83-5.12), being unemployed prior to incarceration (ARR=1.34, 95% CI 1.01-1.76), use of three or more drug types prior to incarceration (ARR=1.80, 95% CI 1.40-2.31), a history of needle/syringe sharing (ARR=5.00, 95% CI 3.06-8.16), receiving a tattoo during the current prison sentence (ARR=2.19, 95% CI 1.67-2.86) and HCV exposure (ARR=1.47, 95% CI 1.08-2.02). Older age was protective (ARR=0.90 per 5 years older, 95% CI 0.83-0.99).

CONCLUSION

Drug injection in prison is common and, given the associations between in-prison drug injection and syringe sharing, unsafe tattooing and HCV exposure, poses a risk to both prisoner health and public health. There remains an urgent need to implement evidence-based infection control measures, including needle and syringe programs, within prison settings.

HIV and incarceration: prisons and detention

The high prevalence of HIV infection among prisoners and pre-trial detainees, combined with overcrowding and sub-standard living conditions sometimes amounting to inhuman or degrading treatment in violation of international law, make prisons and other detention centres a high risk environment for the transmission of HIV. Ultimately, this contributes to HIV epidemics in the communities to which prisoners return upon their release. We reviewed the evidence regarding HIV prevalence, risk behaviours and transmission in prisons. We also reviewed evidence of the effectiveness of interventions and approaches to reduce the risk behaviours and, consequently, HIV transmission in prisons. A large number of studies report high levels of risk behaviour in prisons, and HIV transmission has been documented. There is a large body of evidence from countries around the world of what prison systems can do to prevent HIV transmission. In particular, condom distribution programmes, accompanied by measures to prevent the occurrence of rape and other forms of non-consensual sex, needle and syringe programmes and opioid substitution therapies, have proven effective at reducing HIV risk behaviours in a wide range of prison environments without resulting in negative consequences for the health of prison staff or prisoners.The introduction of these programmes in prisons is therefore warranted as part of comprehensive programmes to address HIV in prisons, including HIV education, voluntary HIV testing and counselling, and provision of antiretroviral treatment for HIV-positive prisoners. In addition, however, action to reduce overcrowding and improve conditions in detention is urgently needed.

Ethical and legal consideration of prisoner's hunger strike in Serbia

Hunger strike of prisoners and detainees remains a major human rights and ethical issue for medical professionals. We are reporting on a case of a 48-year-old male sentenced prisoner, intravenous heroin user, who went on a hunger strike and died 15 days later. Throughout the fasting period, the prisoner, who was capable of decision making, refused any medical examination. Autopsy findings were not supporting prolonged starvation, while toxicology revealed benzodiazepines and opiates in blood and urine. Cause of death was given as "heroin intoxication" in keeping with detection of 6-MAM. Legal and ethical issues pertinent to medical examination and treatment of prisoners on hunger strike are explored in accordance with legislation and professional ethical standards in Serbia. A recommendation for the best autopsy practice in deaths following hunger strike has been made.

Interventions to reduce HIV transmission related to injecting drug use in prison

The high prevalence of HIV infection and drug dependence among prisoners, combined with the sharing of injecting drug equipment, make prisons a high-risk environment for the transmission of HIV. Ultimately, this contributes to HIV epidemics in the communities to which prisoners return on their release. We reviewed the effectiveness of interventions to reduce injecting drug use risk behaviours and, consequently, HIV transmission in prisons. Many studies reported high levels of injecting drug use in prisons, and HIV transmission has been documented. There is increasing evidence of what prison systems can do to prevent HIV transmission related to injecting drug use. In particular, needle and syringe programmes and opioid substitution therapies have proven effective at reducing HIV risk behaviours in a wide range of prison environments, without resulting in negative consequences for the health of prison staff or prisoners. The introduction of these programmes in countries with an existing or emergent epidemic of HIV infection among injecting drug users is therefore warranted, as part of comprehensive programmes to address HIV in prisons.

HCV in incarcerated populations: an analysis of gender and criminality on risk

While studies have explored the prevalence and correlates for hepatitis C (HCV) infection in substance-using and incarcerated populations these studies have not examined the attributes of criminal histories for those with HCV infection. This study examines the HCV infection rate as it relates to criminal risk factors using baseline data from a randomized trial of re-entering offenders and examines how these risk factors vary by gender. The HCV-positive population had a longer amount of time in confinement (105 vs. 61 months) than those who tested negative. HCV positive men were more likely to currently be receiving drug treatment than women. Criminal risk was positively associated with HCV infection while controlling for major risk factors (OR 1.25,95% CI: 1.07, 1.46), suggesting that the relationship was not spurious. While criminologists tend to examine risk relative to public safety threats, it appears that the public health needs equally require attention. Policy issues are examined regarding how services can be delivered to treat those with HCV infections within the correctional system and address criminal risk factors.

The impact of legalizing syringe exchange programs on arrests among injection drug users in California

Legislation passed in 2000 allowed syringe exchange programs (SEPs) in California to operate legally if local jurisdictions declare a local HIV public health emergency. Nonetheless, even in locales where SEPs are legal, the possession of drug paraphernalia, including syringes, remained illegal. The objective of this paper is to examine the association between the legal status of SEPs and individual arrest or citation for drug paraphernalia among injection drug users (IDUs) in California from 2001 to 2003. Using data from three annual cross-sections (2001-03) of IDUs attending 24 SEPs in 16 California counties (N = 1,578), we found that overall, 14% of IDUs in our sample reported arrest or citation for paraphernalia in the 6 months before the interview. Further analysis found that 17% of IDUs attending a legal SEP (defined at the county level) reported arrest or citation for drug paraphernalia compared to 10% of IDUs attending an illegal SEP (p = 0.001). In multivariate analysis, the adjusted odds ratio of arrest or citation for drug paraphernalia was 1.6 [95% confidence interval (CI) = 1.2, 2.3] for IDUs attending legal SEPs compared to IDUs attending illegal SEPs, after controlling for race/ethnicity, age, homelessness, illegal income, injection of amphetamines, years of injection drug use, frequency of SEP use, and number of needles received at last visit. IDUs attending SEPs with legal status may be more visible to police, and hence, more subject to arrest or citation for paraphernalia. These findings suggest that legislative efforts to decriminalize the operation of SEPs without concurrent decriminalization of syringe possession may result in higher odds of arrest among SEP clients, with potentially deleterious implications for the health and well-being of IDUs. More comprehensive approaches to removing barriers to accessing sterile syringes are needed if our public health goals for reducing new HIV/HCV infections are to be obtained.

Estimating the cost-effectiveness of detecting cases of chronic hepatitis C infection on reception into prison

BACKGROUND

In England and Wales where less than 1% of the population are Injecting drug users (IDUs), 97% of HCV reports are attributed to injecting drug use. As over 60% of the IDU population will have been imprisoned by the age of 30 years, prison may provide a good location in which to offer HCV screening and treatment. The aim of this work is to examine the cost effectiveness of a number of alternative HCV case-finding strategies on prison reception

METHODS

A decision analysis model embedded in a model of the flow of IDUs through prison was used to estimate the cost effectiveness of a number of alternative case-finding strategies. The model estimates the average cost of identifying a new case of HCV from the perspective of the health care provider and how these estimates may evolve over time.

RESULTS

The results suggest that administering verbal screening for a past positive HCV test and for ever having engaged in illicit drug use prior to the administering of ELISA and PCR tests can have a significant impact on the cost effectiveness of HCV case-finding strategies on prison reception; the discounted cost in 2017 being pound2,102 per new HCV case detected compared to pound3,107 when no verbal screening is employed.

CONCLUSION

The work here demonstrates the importance of targeting those individuals that have ever engaged in illicit drug use for HCV testing in prisons, these individuals can then be targeted for future intervention measures such as treatment or monitored to prevent future transmission.

Hepatitis C treatment in a Canadian federal correctional population: Preliminary feasibility and outcomes

Hepatitis C virus (HCV) infection is a major public health concern in Canada, which now mostly affects marginalized populations, including correctional inmates. These populations ‐ until recently ‐ have largely been excluded from HCV pharmacotherapy. We report preliminary data on HCV treatment in a federal correctional population sample in British Columbia (BC), using Pegetron combination therapy. HCV RNA results are presented at week 12 of treatment, a strong predictor of treatment outcome. Just over four‐fifths (80.8%) of inmate patients had no detectable HCV RNA at week 12; inmates with genotype 2 and 3 fared better than those with genotype 1. These preliminary results suggest that HCV treatment is feasible and promises to be efficacious in correctional populations.