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

Unravelling the experiences of incarcerated individuals living with HIV on ART: a qualitative study in Ghanaian prisons

PURPOSE

The Joint United Nations Programme on HIV/AIDS (UNAIDS) goal to end the acquired immunodeficiency syndrome (AIDS) epidemic as a public health threat by 2030 emphasises the importance of leaving no one behind. To determine progress towards the elimination goal in Ghana, an in-depth understanding of human immunodeficiency virus (HIV) care from the perspective of vulnerable populations such as persons living with HIV in incarceration is necessary. This study aims to explore the experiences of incarcerated individuals living with HIV (ILHIV) and on antiretroviral therapy (ART) in selected Ghanaian prisons to help inform policy.

DESIGN/METHODOLOGY/APPROACH

The study adopted a qualitative approach involving in-depth interviews with 16 purposively selected ILHIV on ART from purposively selected prisons. Interviews were conducted between October and December 2022. Thematic analysis was performed using the ATLAS.Ti software.

FINDINGS

Three themes were generated from the analysis: waking up to a positive HIV status; living with HIV a day at a time; and being my brother's keeper: preventing HIV transmission. All participants underwent HIV screening at the various prisons. ILHIV also had access to ART although those on remand had challenges with refills. Stigma perpetuated by incarcerated individuals against those with HIV existed, and experiences of inadequate nutrition among incarcerated individuals on ART were reported. Opportunities to improve the experiences of the ILHIV are required to improve care and reduce morbidity and mortality.

ORIGINALITY/VALUE

Through first-hand experiences from ILHIV in prisons, this study provides the perception of incarcerated individuals on HIV care in prisons. The insights gained from this study can contribute to the development of targeted interventions and strategies to improve HIV care and support for incarcerated individuals.

HIV policies in Australian prisons: a structured review assessing compliance with international guidelines

Globally, people living with the Human Immunodeficiency Virus (HIV) are over-represented in incarcerated populations. The current study aimed to provide a national (Australian) snapshot of current HIV prison policies against the United Nations' (UN) 15 key HIV interventions for prisons. Publicly available policies, reports, and data were obtained, and interviews were conducted with prison health staff in five of eight Australian jurisdictions. We rated whether policies were compliant, partially compliant, or not compliant to the UN interventions and assigned an overall grade (A to E, where A = most compliant and E = least compliant) for each jurisdiction. Three jurisdictions received a B grade, three received a C grade, and two were not assessed due to insufficient data. In all jurisdictions HIV policies fell short of full compliance to most UN interventions. Prison-based needle and syringe programs and initiatives beyond education to reduce HIV transmission from body modification procedures (eg, tattooing) were absent in all jurisdictions. No condom programme existed in one jurisdiction and access issues were reported in others. Opioid substitution therapy, and peer-education access varied across and within most jurisdictions. Findings indicate that more action is required to meet the UN recommended interventions for HIV prevention in prisons.

Introducing methadone maintenance therapy into Ukrainian prisons: a qualitative study of criminal subculture, Russia's full-scale invasion, and contested methadone objects

Background

After pilot testing, methadone was newly being introduced into Ukrainian prisons in 2021 as part of a national scale-up strategy to treat opioid use disorder and prevent transmission of HIV and HCV infections. Opioid agonist therapy (OAT) scale-up in Eastern Europe and Central Asia prisons has been hampered by varying levels of influence of criminal subculture, an extralegal informal governance by a social hierarchy that operates in parallel to formal prison authorities. This study examined the socio-environmental factors influencing the uptake of methadone treatment in Ukrainian prisons, including changes that evolved during Russia's full-scale invasion of Ukraine and the displacement of people deprived of liberty (PDL) from conflict to non-conflict regions.

Methods

In-depth qualitative interviews (N = 37) were conducted from January 2021 to October 2022 in the only two Ukrainian prisons where methadone was being introduced with PDL (N = 18). These two prisons continued to provide methadone after the full-scale invasion. Former PDL (N = 4) were also interviewed and prison staff (N = 15). Interviews were audio-recorded, transcribed, and translated into English. Four authors independently reviewed, coded, and applied a phenomenological framework for data analysis, delineating themes related to criminal subculture, drug use, methadone uptake, and evolving changes during the Russian invasion.

Findings

Criminal subculture perceptions varied, with some seeing it as strongly discouraging drug use among certain groups, while others described it as a residual and weak influence from a more distant past. The influence of the subculture on methadone treatment uptake, however, was less clear. PDL and prison staff struggled to identify and articulate differences between illicit street-bought methadone, used recreationally, and medically prescribed methadone. Thus, the meaning of "methadone" varies in interpretation as it is being introduced, making it potentially conflicting for patients to opt into this evidence-based treatment. As Russia invaded Ukraine in 2022, PDL from conflict zones were transferred to non-conflict regions where methadone was being introduced. The prison environment became more enabling for PDL to start methadone as they were segregated and not subject to the existing criminal subculture's rules and lacked the social ties necessary to procure drugs illegally.

Conclusion

It appears that the criminal subculture is variable and evolving in Ukrainian prisons and appears to be impacted differently by the invasion of Russia. As methadone scale-up in prisons expands, it will be important to distinguish the meaning of methadone perpetuated negatively by the prison subculture versus that in which it is intended as a medical treatment by the formal prison authorities. The current invasion of Ukraine by Russia provides a potential disruption to alter this course.

Assessment of genetic diversity among wild rose in Morocco using ISSR and DAMD markers

Background

Morocco is considered one of the main biodiversity hotspots in the Mediterranean region and contains various plant species including wild and domestic Rosa. This genus is the most important among cultivated ornamental plants in the world, with a high economic value in cosmetics, pharmaceutical industries, and floriculture. In the present study, genetic diversity among the collected accessions of wild Rosa species in Morocco was assessed using Inter-Simple Sequence Repeat (ISSR) and Directed Amplification of Minisatellites DNA (DAMD) markers.

Results

Results confirmed that both markers used have a good efficiency to assess genetic diversity in wild roses. Ten ISSR and eight DAMD primers amplified 276 and 203 loci, with an average of 27.4 and 25 polymorphic alleles per primer, respectively. The polymorphic information content (PIC) values were 0.34 with ISSR and 0.31 with DAMD. Analysis of molecular variance (AMOVA) showed that genetic variation in wild rose occurs mainly within populations (86%) rather than between populations (14%). The region of Azrou (Middle Atlas of Morocco) is the area that registered the highest genetic diversity in the present study with He = 0.21. The 39 rose accessions were divided into three main groups with among-group similarity of 30%. Principal component analysis and the hierarchical classification were consistent with genetic relationships derived by structure analysis.

Conclusion

The findings revealed that the patterns of grouping are weakly correlated with geographical origin. ISSR and DAMD markers showed that the accessions have a good genetic diversity.

Multi-level implementation factors that influence scale-up of methadone maintenance treatment in Moldovan prisons: A qualitative study

INTRODUCTION

People who inject drugs (PWID) are overrepresented in prison populations, especially in the Eastern European and Central Asian region (EECA), where HIV incidence and mortality continue to rise. Modeling data suggest that methadone maintenance treatment (MMT) scale-up in prison with continuation after release could substantially reduce new HIV infections. Moldova, one of four countries in the EECA to have introduced MMT in prisons, has faced challenges with its scale-up.

METHOD

To improve implementation of MMT in Moldovan prisoners, we analyzed the qualitative interviews of 44 recently released Moldovan prisoners with opioid use disorder who either accepted or rejected MMT while incarcerated; these 44 were among a subset of 56 participants in a quantitative survey who had complete interview data. After translating and back-translating interviews, we used content analysis to identify key barriers and facilitators to MMT uptake.

RESULTS

Our qualitative analyses revealed that positive attitudes toward methadone facilitated treatment uptake, yet the study identified three thematic barriers as to why PWID do not accept MMT while in prison, including: 1) negative personal attitudes toward MMT; 2) stigmatization of MMT by informal hierarchies within prison; and 3) distrust of the formal prison hierarchy (i.e., administration), which provides MMT.

CONCLUSION

Overall, the social forces of the two prisoner hierarchies and distrust between them appeared to outweigh the perceived benefits of MMT and impacted MMT uptake. Here we provide strategies to promote MMT more effectively in prison settings.

Harm reduction: a public health approach to prison drug use

PURPOSE

As prison drug use continues to be a concern worldwide, harm reduction practices serve as an alternative approach to traditional abstinence-only or punishment-oriented methods to address substance use behind bars. The purpose of this study is to present a summary of research surrounding prison-based harm reduction programs.

DESIGN/METHODOLOGY/APPROACH

This narrative review of the international literature summarizes the harms associated with prison drug use followed by an overview of the literature surrounding three prison-based harm reduction practices: opioid agonist therapy, syringe exchange programs and naloxone distribution.

FINDINGS

A collection of international research has found that these three harm reduction programs are safe and feasible to implement in carceral settings. Additionally, these services can effectively reduce some of the harms associated with prison drug use (e.g. risky injection practices, needle sharing, fatal overdoses, etc.). However, these practices are underused in correctional settings in comparison to their use in the community.

ORIGINALITY/VALUE

Various policy recommendations are made based on the available literature, including addressing ethical concerns surrounding prison populations' rights to the same standard of health care and services available in the community. By taking a public health approach to prison drug use, harm reduction practices can provide a marginalized, high-risk population of incarcerated individuals with life-saving services rather than punitive, punishment-oriented measures.

A social ecological model (SEM) to exploring barriers of and facilitators to the implementation of opioid agonist treatment (OAT) programmes in prisons

PURPOSE

Opioid agonist treatment (OAT) programmes in prisons play a significant role in preventing the human immunodeficiency virus (HIV). Despite its proven effectiveness, both the availability and coverage of prison OAT programmes remain low. This Indonesian study explores facilitators of, and barriers to, the delivery of methadone programmes in prisons using the social ecological model (SEM).

DESIGN/METHODOLOGY/APPROACH

The study used a qualitative case study approach comprising two prisons with, and one prison without, methadone programmes. Purposive and snowball sampling was used to recruit study participants. In total, 57 in-depth interviews were conducted with prison governors, health-care staff, prison officers and prisoners. Data was analysed thematically.

FINDINGS

The study findings identified facilitators of and barriers to the delivery of prison OAT programmes at all three levels of the SEM as follows: intrapersonal barriers including misperceptions relating to HIV transmission, the harm reduction role of OAT programmes, methadone dependency and withdrawal symptoms; interpersonal barriers such as inflexible OAT treatment processes and the wide availability of illicit drugs in prisons and; social-structural barriers, notably the general lack of resources.

RESEARCH LIMITATIONS/IMPLICATIONS

The findings highlight the importance of and overlap between, organisational and inter-personal, as well as intrapersonal factors. Such an approach is particularly important in the context of the implementation and delivery of methadone programmes in low/middle income countries, where the lack of resources is so significant.

PRACTICAL IMPLICATIONS

Three main strategies for improvement were suggested as follows: the development of comprehensive education and training programmes for prisoners and all prison staff; the re-assessment of practices relating to the delivery of methadone, and a comprehensive review of harm reduction strategy in prisons, that should consider the role of prisoners' families to increase support for prisoner participation; the re-assessment of prison policies to support the delivery of methadone programmes in prisons.

SOCIAL IMPLICATIONS

The author suggests that ongoing international support and national drug policies are vital to the continuation and sustainability of methadone programmes in prisons.

ORIGINALITY/VALUE

This study contributes to the overall evidence base for OAT programmes in middle-income prison contexts.

Prevalence of Intimate Partner Violence, Substance Use Disorders and Depression among Incarcerated Women in Lima, Perú

Background: Globally, there is evidence supporting the co-occurrence of intimate partner violence (IPV), substance use disorders (SUD) and mental health disorders among women in prisons, however, there is limited research investigating these domains in the Andean region where rates of female incarceration have increased. The study objective was to explore the prevalence of IPV, SUD and depression among incarcerated women in a Peruvian prison and explore associations among these variables and related correlates. Methods: 249 incarcerated women responded to a questionnaire about IPV, substance use, depression, and sexual behavior, and were screened for HIV/sexually transmitted diseases (STDs). Univariate analysis and logistic regression were used to estimate relative risk and the influence of substance use and depression on IPV rates. Results: Twelve months prior to incarceration, of the women with sexual partners pre-incarceration (n = 212), 69.3% experienced threats of violence, 61.4% experienced ≥1 acts of physical violence, and 28.3% reported ≥1 act of sexual aggression. Pre-incarceration, 68.1% of drug-using women had a SUD, and 61.7% of those who consumed alcohol reported hazardous/harmful drinking. There were 20 (8.0%) HIV/STD cases; and 67.5% of the women reported depressive symptoms. Compared to women with no experiences of physical violence, a greater proportion of women who experienced least l violent act had depressive symptoms and engaged in sex work pre-incarceration. Depression was associated with physical violence (adjusted relative risk = 1.35, 95% confidence interval: 1.14–1.58). Recommendations: The findings provide evidence of a syndemic of IPV, substance abuse and depression among incarcerated women in a Peruvian prison. To help guide policy makers, further research is needed to determine if this is indicative of trends for other at-risk women in the region, and viable options to treat these women during incarceration to prevent recidivism and other long-term negative sequalae.

Genetic diversity analysis in a mini core collection of Damask rose (Rosa damascena Mill.) germplasm from Iran using URP and SCoT markers

BACKGROUND

Rosa damascena Mill is a well-known species of the rose family. It is famous for its essential oil content. The aim of the present study was to assess the genetic diversity and population structure of a mini core collection of the Iranian Damask rose germplasm. This involved the use of universal rice primers (URP) and start codon targeted (SCoT) molecular markers.

RESULTS

Fourteen URP and twelve SCoT primers amplified 268 and 216 loci, with an average of 19.21 and 18.18 polymorphic fragments per primer, respectively. The polymorphic information content for URR and SCoT primers ranged from 0.38 to 0.48 and 0.11 to 0.45, with the resolving power ranging from 8.75 to 13.05 and 9.9 to 14.59, respectively. Clustering was based on neighbor-joining (NJ). The mini core collection contained 40 accessions and was divided into three distinct clusters, centered on both markers and on the combination of data.

CONCLUSION

Cluster analysis and principal coordinate analysis were consistent with genetic relationships derived by STRUCTURE analysis. The findings showed that patterns of grouping did not correlate with geographical origin. Both molecular markers demonstrated that the accessions were not genetically diverse as expected, thereby highlighting the possibility that gene flow occurred between populations.

The state of harm reduction in prisons in 30 European countries with a focus on people who inject drugs and infectious diseases

BACKGROUND

People who inject drugs are often imprisoned, which is associated with increased levels of health risks including overdose and infectious diseases transmission, affecting not only people in prison but also the communities to which they return. This paper aims to give an up-to-date overview on availability, coverage and policy framework of prison-based harm reduction interventions in Europe.

METHODS

Available data on selected harm reduction responses in prisons were compiled from international standardised data sources and combined with a questionnaire survey among 30 National Focal Points of the European Monitoring Centre for Drugs and Drug Addiction to determine the level of availability, estimated coverage and policy framework of the interventions.

RESULTS

Information about responses to health harms in prisons is limited and heterogeneous. Cross-country comparability is hampered by diverging national data collection methods. Opioid substitution treatment (OST) is available in 29 countries, but coverage remains low (below 30% of people in need) in half of the responding countries. Needle and syringe programmes, lubricant distribution, counselling on safer injecting and tattooing/piercing are scarcely available. Testing for infectious diseases is offered but mostly upon prison entry, and uptake remains low in about half of the countries. While treatment of infections is mostly available and coverage is high for human immunodeficiency virus (HIV) and tuberculosis, hepatitis B and C treatment are less often provided. Health education as well as condom distribution is usually available, but provision remains low in nearly half of the countries. Post-release linkage to addiction care as well as to treatment of infections is available in a majority of countries, but implementation is often partial. Interventions recommended to be provided upon release, such as OST initiation, take-home naloxone and testing of infections, are rarely provided. While 21 countries address harm reduction in prison in national strategic documents, upon-release interventions appear only in 12.

CONCLUSIONS

Availability and coverage of harm reduction interventions in European prisons are limited, compared to the community. There is a gap between international recommendations and 'on-paper' availability of interventions and their actual implementation. Scaling up harm reduction in prison and throughcare can achieve important individual and public-health benefits.

PrEP in Prisons: HIV prevention in incarcerated populations

PURPOSE

The purpose of this paper is to discuss the possibility of using pre-exposure prophylaxis (PrEP) as an HIV harm reduction intervention in prisons. PrEP is primarily discussed in relation to men who have sex with men (MSM), meaning other high-risk populations, such as prisoners, are often side-lined. The authors wanted to consider how it could prove beneficial beyond the MSM community.

DESIGN/METHODOLOGY/APPROACH

First, the authors discuss whether the common objections to existing HIV harm reduction interventions in prisons, such as needle exchanges, are applicable to PrEP. The authors then apply common objections to the provision of PrEP in the general population to the provision of PrEP in a prison context in order to assess their strength. Finally, the authors discuss what the authors anticipate to be a key objection to PrEP in prisons: post-incarceration access.

FINDINGS

The authors argue that both sets of common objections considered are easily refuted in the case of PrEP in prisons. The unique setting and nature of the intervention are such that it is without immediately apparent flaws. In addressing post-incarceration access, the authors suggest that a longitudinal consideration of a prisoner's HIV risk undermines the objection.

ORIGINALITY/VALUE

This discussion is of importance due to the significantly heightened risk of HIV infection prisoners are subject to. Not only do effective HIV prevention interventions in prisons contribute to fair access to health for incarcerated individuals, but also to the wider fight against HIV. The authors demonstrate that PrEP has potential as a new approach and call for further research in this area.

Identifying and managing infectious disease syndemics in patients with HIV

PURPOSE OF REVIEW

We will present recent articles focusing on HIV synergistic interactions with other sexually transmitted infections, tuberculosis, and hepatitis, as well as recent advances in the study of social and behavioral determinants that facilitate this clustering of infectious disease. For each synergistic interaction, we highlight evidence-based interventions that clinicians and policymakers should consider to tackle HIV and infectious disease syndemics.

RECENT FINDINGS

Significant advances in understanding the behavioral and structural determinants of HIV and other infectious disease synergisms have been made in the past years. Intervention strategies based on these new models have also been developed. It is now well understood that treating infectious disease syndemics will require a multidisciplinary and multipronged approach.

SUMMARY

HIV is synergistic with multiple other infectious diseases because the risk behaviors that lead to HIV acquisition may be similar to the other infections. The influence of HIV on the other infection may be due to immunosuppression associated with disease progression resulting in increased susceptibility (e.g., HIV and tuberculosis), especially when patients are not virologically suppressed using antiretroviral therapy. In reverse, another infectious disease may, when not treated, influence HIV disease progression. Social/structural determinants like homelessness, mass incarceration, and structural discrimination precipitate psychiatric comorbidity, substance use, and risky sex behavior which lead to the spread and co-occurrence of infectious disease.

HIV control programs reduce HIV incidence but not HCV incidence among people who inject drugs in HaiPhong, Vietnam

In Vietnam, harm reduction programs to control HIV among people who inject drugs (PWID) were implemented approximately 10 years ago. Since then, the HIV prevalence has declined in this population, however, the impact of these programs on the rate of new HIV and Hepatitis C (HCV) infections remains unknown as high mortality can exceed the rate of new infections. We evaluated HIV and HCV incidences in a cohort of active PWID in HaiPhong in 2014, who were recruited from a community-based respondent driven sampling (RDS) survey and followed for 1 year. Only HIV-negative or HCV-negative participants not on medication assisted treatment (MAT) were eligible. HIV/HCV serology was tested at enrollment and at 32- and 64-week follow-up visits. Among 603 RDS participants, 250 were enrolled in the cohort, including 199 HIV seronegative and 99 HCV seronegative PWID. No HIV seroconversion was reported during the 206 person-years (PY) of follow-up (HIV incidence of 0/100PY, one-sided 97.5%CI:0-1.8/100 PY). Eighteen HCV seroconversions were reported for an incidence of 19.4/100 PY (95%CI;11.5-30.7). In multivariate analysis, "Injecting more than twice daily" was associated with HCV seroconversion with an adjusted odds ratio of 5.8 (95%CI;1.8-18.1). In Hai Phong, in a context that demonstrates the effectiveness of HIV control programs, the HCV incidence remains high. New strategies such as mass access to HCV treatment should be evaluated in order to tackle HCV transmission among PWID.

Consumption of psychoactive substances in prison: Between initiation and improvement, what trajectories occur after incarceration? COSMOS study data

Background

Few studies have examined the consumption trajectories of inmates after entry to prison. The aim of this study was to assess the changes in the consumption of psychoactive substance between the period before detention and during incarceration and to characterize the profiles of prisoners with similar consumption trajectories during incarceration.

Methods and findings

A multicenter, cross-sectional study was performed in all of the prisons from one region of France. All prisoners incarcerated during their 3rd months, over 18 years old, and with a sufficient level of French fluency to participate in the study were recruited over a period of 12 months. A total of 800 prisoners were recruited. All prisoners were interviewed face-to-face by a trained interviewer. A majority of prisoners had used at least one psychoactive substance in the weeks prior to incarceration. During incarceration, a substantial reduction in alcohol and illicit drug consumption was observed. The initiation of consumption and an increase in consumption were primarily related to medications. Five different profiles of consumption before incarceration were identified. These profiles all had a high probability of migrating to a similar profile during detention, characterized by less severe consumption of psychoactive substances.

Conclusions

Based on their consumption profile prior to incarceration, most prisoners would benefit from a specific medical evaluation as soon as possible following entry into detention. Prison could be an opportunity for reduced consumption and/or the initiation of treatment for the majority of prisoners, despite the pejorative development observed for a minority of prisoners during incarceration.

"A spray bottle and a lollipop stick": An examination of policy prohibiting sterile injecting equipment in prison and effects on young men with injecting drug use histories

BACKGROUND

Australian young male prisoners with histories of injecting drug use are more likely to report injecting in prison, to do so more frequently, and to be involved in more un-safe injecting-related practices than their older counterparts. Despite international evidence that prison needle and syringe programs are both feasible and effective in reducing the harms associated with injecting drug use in prison, these young men do not have access to such equipment.

METHODS

We critically analyse the interview transcripts of 28 young men with histories of injecting drug use who were recently released from adult prisons in Victoria, Australia, and prison drug policy text. We use Bacchi's 'What's the problem represented to be?' approach to examine how the 'problem' of injecting drug use in prison is represented in prison drug policy, including the assumptions that underpin these problematisations, and the subjectification and lived effects that are produced for the young men in our study.

RESULTS

Our analysis reveals how prison drug policy enables the creation and re-use of homemade injecting equipment crafted from unsterile items found in prison, and that in doing so the policy produces a range of stigmatising subjectification effects and other harmful material effects (such as hepatitis C virus transmission and injecting related injury and harms). Findings highlight, how injecting drug use is represented in policy silences other ways of understanding the 'problem' that may have less harmful effects for incarcerated young men who inject drugs.

CONCLUSION

We argue that somewhat paradoxically, the approach of prohibiting access to sterile injecting equipment in prison-which is constituted as a solution for addressing such harms-in fact helps to produce them.

The prevalence of syphilis in HIV-seropositive patients: a retrospective study at the regional hospital in Agadir, Morocco

Introduction

HIV and syphilis are major public health problems in Morocco. The region of Souss-Massa, south-west of the country, hold more than 24% of HIV seropositive cases registered in Morocco during 2009. The aim of this study is to evaluate the seroprevalence of syphilis among HIV seropositive patients in the region of Souss-Massa, south-west of Morocco.

Methods

To evaluate the seroprevalence of syphilis and neurosyphilis among HIV seropositive patients, we retrospectively investigated the medical records of HIV-infected patients attending the regional hospital located in the city of Agadir, during the period comprised between 2011 and 2016.

Results

The population studied involved 1381 males (49.18%) and 1427 females (50.82%) HIV seropositive patients. Among them, 481 patients were seropositive for syphilis and three cases were diagnosed with neurosyphilis. The sex ratio distribution was 243 male (52.71%) and 218 female (47.29%). The prevalence of syphilis among the studied population was estimated to 16.42% with a slight dominance in male (17.63%) compared to female (15.28%). By contrast, neurosyphilis was only detected in male patients, with a prevalence estimated to 0.11%.

Conclusion

Even if the prevalence of HIV and syphilis is stable in the region of Souss-Massa, the prevalence of syphilis among HIV seropositive patients remained high and correlated positively with that of HIV infection. We did not find a significant difference between the genders, in relation to the prevalence of HIV and syphilis. We concluded that it was essential to continue monitoring the population, in order to improve the prevention and the access to the medical care in the south-west of Morocco.

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.

Understanding and Improving the Health of People Who Experience Incarceration: An Overview and Synthesis

The world prison population is growing at a rate that exceeds the rate of population growth. This issue of Epidemiologic Reviews comprises articles in which researchers summarize what is known about some of the key health issues facing people in prison, particularly in relation to human immunodeficiency virus and other blood-borne viral infections. A key recurring theme is that addressing the health needs of people in prison is important to reducing health inequalities at the population level—that prisoner health is public health. The reviews also highlight some critical evidence gaps, notably the lack of evidence from low- and middle-income countries, and the limited number of longitudinal studies in which health behaviors, health outcomes, or health service experiences after release from prison are documented. Despite growing evidence of the poor health of detained adolescents, none of the included reviews considered this population. Further research on the health of young people who cycle through juvenile detention should be a priority. Despite a rapidly growing literature on the health of people who experience incarceration, some critical health issues remain poorly understood, and there has been insufficient attention devoted to co-occurring health conditions and the consequent need for coordinated care. Key populations in custodial settings remain understudied, limiting capacity to develop targeted, evidence-based responses to their health needs. The quality of many studies is suboptimal, and although rigorous, independent research in correctional settings can be challenging, it is not impossible and is critical to laying the groundwork for evidence-based reform.

Dynamic Models of Infectious Disease Transmission in Prisons and the General Population

Incarcerated populations experience elevated burdens of infectious diseases, which are exacerbated by limited access to prevention measures. Dynamic models are used to assess the spread and control of diseases within correctional facilities and repercussions on the general population. Our systematic review of dynamic models of infectious diseases within correctional settings identified 34 studies published between 1996 and 2017. Of these, 23 focused on disease dynamics and intervention in prison without accounting for subsequent spread to the community. The main diseases modeled in these studies were human immunodeficiency virus (HIV; n = 14, 41%), tuberculosis (TB; n = 10, 29%), and hepatitis C virus (HCV; n = 7, 21%). Models were fitted to epidemiologic data in 14 studies; uncertainty and sensitivity analyses were conducted in 8, and validation of model projection against empirical data was done in 1 study. According to the models, prison-based screening and treatment may be highly effective strategies for reducing the burden of HIV, TB, HCV, and other sexually transmissible infections among prisoners and the general community. Decreasing incarceration rates were projected to reduce HIV and HCV infections among people who inject drugs and TB infections among all prisoners. Limitations of the modeling studies and opportunities for using dynamic models to develop quantitative evidence for informing prison infection control measures are discussed.

Health Outcomes for Clients of Needle and Syringe Programs in Prisons

High levels of drug dependence have been observed in the prison population globally, and the sharing of injecting drug equipment in prisons has contributed to higher prevalence of bloodborne diseases in prisoners than in the general population. Few prison needle and syringe programs (PNSPs) exist. We conducted a systematic review to assess evidence regarding health outcomes of PNSPs. We searched peer-reviewed databases for data relating to needle and syringe programs in prisons. The search methodology was conducted in accordance with accepted guidelines. Five studies met review inclusion criteria, and all presented evidence associating PNSPs with one or more health benefits, but the strength of the evidence was low. The outcomes for which the studies collectively demonstrated the strongest evidence were prevention of human immunodeficiency virus and viral hepatitis. Few negative consequences from PNSPs were observed, consistent with previous evidence assessments. More research is needed on PNSP effectiveness, and innovative study designs are needed to overcome methodological limitations of previous research. Until stronger evidence becomes available, policymakers are urged to recognize that not implementing PNSPs has the potential to cause considerable harm, in light of what is currently known about the risks and benefits of needle and syringe programs and PNSPs and about the high prevalence of human immunodeficiency virus and viral hepatitis in prisons.

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.

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.

Hospital admissions for HIV-infected prisoners in Italy

Purpose The purpose of this paper is to give a description of the clinical conditions and patient demographics of inpatient admissions of human immunodeficiency virus (HIV)-infected inmates in three hospital wards that provide hospital care for inmates in Italy. Design/methodology/approach This is a retrospective review of hospital medical admissions of patients living with HIV from January 1 to December 31, 2014, in three Italian referral centers for hospitalization of inmates. Findings A total of 85 admissions for 85 different HIV-infected inmates occurred in 2014 in the three centers participating to the study. Most patients (54.1 percent) were co-infected with hepatitis C. Discharge diagnosis largely varied ranging from common HIV-related co-morbidities to completely independent diagnosis. The most commonly observed discharge diagnoses were chronic hepatitis C, liver cirrhosis, opiate dependence and thrombocytopenia. Originality/value Discharge diagnosis between HIV-infected inmates and HIV-infected patients in freedom are strikingly and significantly different. A large number of hospitalized HIV-infected inmates were affected by chronic viral hepatitis and liver cirrhosis; this is probably a direct consequence of the high prevalence of HCV and/or HBV co-infections in the inmate population in Italy. In addition, a significantly lower proportion of cancer diagnosis was observed among inmates; this is possibly justified by the fact that in our Italian settings when HIV infection is at advanced stages or if cancer treatment is started those affected are released from prison and can continue their diagnostic and treatment follow-up in freedom.

Drug use in prisons: strategies for harm reduction (ANRS-PRIDE Program)

The existence of risky practices related to drug use inside prisons is a reality everywhere and is a major issue for the community as a whole. The level of implementation of harm reduction (HR) measures recommended by the World Health Organization (WHO) and the United Nations Office on Drugs and Crime (UNODC) is very often poor and reveals inadequate concern about public health issues in the prison environment, without any respect for the principle of equivalence for prevention and health assistance with the general community. In 2009, the French National Agency for Research on AIDS and Viral Hepatitis (ANRS) developed a comprehensive research program focusing on the prevention of infectious risks in prison settings. Different steps were defined and scheduled, and included i) an inventory of harm reduction (HR) measures, ii) a qualitative survey on the reality of risky practices, iii) an assessment of the social acceptability of HR measures, and iv) an intervention trial exploring the feasibility of upgrading existing HR strategies. A progressive implementation of this program has shown it is feasible, but in France, it requires tenacity, simple long-term objectives, support from a scientific authority, pedagogical interventions for all involved, as well as constant discussion with the authorities. The implementation of this program in other countries is equally simple to manage.

Longitudinal injecting risk behaviours among people with a history of injecting drug use in an Australian prison setting: The HITS-p study

BACKGROUND

HCV transmission remains high in prisons globally. Understanding injecting risk behaviours in prisons is crucial to effectively develop and implement HCV prevention programs in this setting including treatment as prevention.

METHODS

HITS-p is a cohort study which enrolled people with a history of injecting drug use in prisons in NSW, Australia from 2005 to 2013. Participants completed an interview at enrolment and follow-up visits to determine injecting behaviours. Generalized estimating equation (GEE) and logistic regression methods were used to assess injecting risk behaviours prior to and following prison entry and to investigate injecting risk behaviours in prison.

RESULTS

Overall, 499 participants with a history of injecting drug use were included (median age, 26 years; 65% male). Participants were significantly less likely to inject drugs following incarceration. Among injectors, participants were less likely to inject ≥weekly but more likely to share a needle/syringe. At enrolment, the proportion reporting any injecting, ≥weekly injecting, and needle/syringe sharing in prison was highest among younger individuals. Younger age was associated with both re-initiation and continuation of injecting drug use following prison entry. Among those continuously imprisoned, younger age was associated with increased odds of any injecting, ≥weekly injecting, and sharing a needle/syringe.

CONCLUSIONS

Upon entry to prison, injecting drug use decreased but syringe sharing increased among injectors. Younger individuals are most likely to exhibit high-risk injecting behaviours in prison. These data highlight the need for improved HCV prevention strategies (including improved needle/syringe access and scale up of HCV therapy) for those at increased risk of HCV transmission in prison, including younger individuals.

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.

High variability of TB, HIV, hepatitis C treatment and opioid substitution therapy among prisoners in Germany

BACKGROUND

In Germany, medical care of prisoners is completely separated from extramural health care. The extent and quality of medical care among prisoners in Germany are therefore largely unknown. We performed a secondary data analysis of pharmacy sales data for tuberculosis (TB), HIV, hepatitis C (HCV) and opioid substitution treatment (OST) delivered to prisons in 11 federal states (FS) in Germany between 01/2012 and 03/2013. The aims of this study were to assess (i) the treatment availability for the selected diseases and OST in German prisons, (ii) the proportion of prisoners treated per FS and overall for TB, HIV, HCV and OST during the study period.

METHODS

Substances unique to or typically used for the treatment of each disease were defined as marker substances with defined daily doses (DDD). For each marker substance we assessed the cumulative number of DDD, the average daily number of DDD (DDD_d) and average treatment prevalence per day in percent (adTP). Accordingly, the DDD_d represents one person treated per day and the adTP means the proportion of prisoners treated per day. We compared the adTP of the diseases with previously measured prevalences.

RESULTS

We obtained data from pharmacies supplying prisons in 11 of 16 German FS. Of the included prisons, 41% were supplied with medicines for TB, 71% for HIV and 58% for HCV and OST. Twice as many delivered marker substances for TB were indicated for the continuation phase and chemoprevention than the intensive phase. The HIV adTP ranged from 0.06% to 0.94%, HCV adTP ranged from 0.03% to 0.59% and OST adTP ranged from 0% to 7.90%. The overall adTP for the respective treatment was 0.39% for HIV, 0.12% for HCV and 2.18% for OST.

CONCLUSIONS

According to our findings treatment rates for TB were consistent with the expected TB prevalence, at least in Berlin. HIV treatment seems to be offered to an adequate proportion of estimated infected prisoners. In contrast, the HCV treatment prevalence was low. High variation among FS in provision of all treatments, particularly of OST, point to inconsistent treatment practices, although nationwide extramural treatment guidelines for Germany exist.

A naturalistic longitudinal analysis of post-detoxification outcomes in opioid-dependent patients

INTRODUCTION AND AIMS

To provide an assessment of outcomes in a cohort of opioid-dependent patients post-detoxification.

DESIGN AND METHODS

This study employed an observational longitudinal cohort design. Patients who completed detoxification in the three major Drug Dependency Units in Ireland during a 14-month period were included in the study (n = 143). Patients opting for one of the three pathways post-detoxification (inpatient aftercare, outpatient aftercare or no formal aftercare) were assessed in the final week of detoxification and followed up after 3, 6 and 9 months. The primary outcome was abstinence following detoxification.

RESULTS

A Cox (adjusted) model indicated participants who opted for outpatient aftercare treatment lapsed/relapsed at a rate of 52% higher than the inpatient aftercare group (hazard ratio = 1.52, 95% confidence interval 0.75-3.08, P = 0.24). Moreover, time to lapse/relapse was considerably shorter for the no formal aftercare group (hazard ratio = 7.68, 95% confidence interval 4.30-13.73, P = 5.75 × 10^-12 ). Abstinence rates for outpatient aftercare and inpatient aftercare are about equal after 9 months.

DISCUSSION AND CONCLUSION

Patients who opt for aftercare post-detoxification have significantly better outcomes at follow up when compared to no formal aftercare. In addition, patients' intention to attend aftercare affected their outcomes regardless of eventual treatment path.

The naked truth about HIV and risk taking in Swedish prisons: A qualitative study

BACKGROUND

This qualitative study explores former prison inmates' perceptions and attitudes towards HIV risk inside Swedish prisons.

METHOD

In 2014, eight semi-structured interviews were conducted with former male prisoners to gain a deeper understanding of situations perceived to be associated with risk of HIV transmission. The material gathered from the interviews was analyzed by manifest and latent qualitative content analysis.

RESULTS

The findings revealed that risky behavioral practices, such as sharing needles, unprotected sexual activity, and lack of openness about HIV status represented potential health threats with regard to the risk of HIV transmission.

CONCLUSIONS

Evidence from the study indicates that educational interventions regarding HIV and the transmission routes are required for HIV prevention in Swedish prisons.

A qualitative assessment of an abstinence-oriented therapeutic community for prisoners with substance use disorders in Kyrgyzstan

BACKGROUND

Kyrgyzstan, where HIV is concentrated in prisons and driven by injection drug use, provides a prison-based methadone maintenance therapy program as well as abstinence-oriented therapeutic community based on the 12-step model called the "Clean Zone." We aimed to qualitatively assess how prisoners navigate between these treatment options to understand the persistence of the Clean Zone despite a lack of evidence to support its effectiveness in treating opioid use disorders.

METHODS

We conducted an analysis of policy documents and over 60 h of participant observation in February 2016, which included focus groups with a convenience sample of 20 therapeutic community staff members, 110 prisoners across three male and one female prisons, and qualitative interviews with two former Clean Zone participants. Field notes containing verbatim quotes from participants were analyzed through iterative reading and discussion to understand how participants generally perceive the program, barriers to entry and retention, and implications for future treatment within prisons.

RESULTS

Our analyses discerned three themes: pride in the mission of the Clean Zone, idealism regarding addiction treatment outcomes against all odds, and the demonization of methadone.

CONCLUSION

Despite low enrollment and lack of an evidence base, the therapeutic community is buttressed by the strong support of the prison administration and its clients as an "ordered" alternative to what is seen as chaotic life outside of the Clean Zone. The lack of services for Clean Zone patients after release likely contributes to high rates of relapse to drug use. The Clean Zone would benefit from integration of stabilized methadone patients combined with a post-release program.

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.

[Individuals, structures, and risks: an overview of primary HIV prevention in Portugal]

This article debates the principal guidelines and procedures that shape HIV/AIDS prevention in Portugal, focusing on risk reduction in the two major scenarios for spread of the epidemic: sexuality and injection drug use. The analysis views the risks of infection as expressions of practices that are densely interwoven into social structures and cultural frameworks. Based on this conception, the article seeks to evaluate and understand the extent to which preventive strategies take a broad and integrative underlying approach by including individuals and their circumstances. Meanwhile, the study identifies some of the main structural constraints impeding the achievement of more favorable conditions for minimizing risks and adopting safe behaviors. These analytical exercises include not only policy and program guidelines, but also processes in daily reality, showing how the non-implementation of measures already guaranteed by law poses powerful structural barriers to HIV prevention.

Global Mental Health in Action: Reducing Disparities One Community at a Time

There are great disparities in mental health care around the world. Traditional approaches to mental health care have not been found to be transferrable to many parts of the world and are inadequate to address these disparities. Unconventional approaches are needed that match the traditions of care-seeking and care-giving within the communities where they are delivered. The authors review the global mental health literature and discuss how marriage and family therapists are in a particularly good position to have worldwide impact on mental health disparities. Five principles of global mental health are presented along with an example of how these principles are applied through the Reducing Mental Health Disparities One Community at a Time (RD1CT) model.

Injecting drug use, sexual risk, HIV knowledge and harm reduction uptake in a large prison in Bali, Indonesia

PURPOSE

The purpose of this paper is to describe HIV-related risk behavior and knowledge of HIV among inmates of Kerobokan prison Bali, Indonesia.

DESIGN/METHODOLOGY/APPROACH

A cross-sectional survey of inmates of using a structured questionnaire and sample framework to reflect narcotic use among inmates and the prison gender mix.

FINDINGS

Among 230 inmates recruited to the study self-reported prevalence of injecting drug use was 7.4 percent (95 percent CI 4.0-10.8 percent). Respondents who participated in a prison based methadone treatment program were all still injecting drugs, these made up 13/17 of the IDU. In total, 47 percent (95 percent CIs 45-55 percent) of respondents who reported injecting also reported sharing needles within the last week. Sexual intercourse while in prison was reported by 3.0 percent (95 percent CI 0.82-5.26 percent) of study respondents. One-third of non-injectors were unaware of the preventative role of condom use. This study suggests that despite harm reduction initiatives within Kerobokan prison HIV risk behavior continues and there is a considerable lack of awareness of the importance of condom use in preventing HIV.

RESEARCH LIMITATIONS/IMPLICATIONS

The authors relied on self-reported risk behavior that may be subject to reporting bias. The sampling strategy may not reflect the true ratio inmates using or not using narcotics.

PRACTICAL IMPLICATIONS

The current harm reduction approach, including methadone substitution treatment should be optimized within the Indonesian prison setting.

ORIGINALITY/VALUE

This is the first study reporting HIV-related risk behavior from an Indonesian prison with an established methadone substitution program.

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.

Twelve Committed Men: the feasibility of a community-based participatory HIV-prevention intervention within a Canadian men's correctional facility

OBJECTIVES

The intervention objectives were to evaluate and describe the feasibility of using a community-based research (CBR) approach to adapt and implement HIV-prevention materials and tools with incarcerated men. We found no prior published reports about CBR HIV-prevention education in Canadian correctional facilities.

METHODS

Twelve members of the correctional Peer Education Committee (PEC) and Aboriginal PEC, whom a correctional nurse identified as being interested in preventive health, were purposively invited to participate. Eight participants were serving life sentences, three were Aboriginal and their education levels ranged from below grade 8 to 11 years of post-secondary education. The setting was a medium-security federal correctional facility, housing 324 men. The intervention was guided by CBR and 'greater involvement of people with AIDS' principles. Participants were invited to attend four workshops, over seven days in May 2014, and to provide their insights regarding future scaled-up CBR HIV prevention. Each workshop included an HIV-prevention presentation and a focus group discussion, two of which were audio-recorded.

FINDINGS

All participants attended all sessions. Synthesis of mixed-method findings, with quantitative and qualitative data triangulation, demonstrated two major outcomes: 'new knowledge was generated' regarding feasibility of CBR HIV prevention in a men's correction facility; and 'capacity building occurred' with increased participants' social capital. Thirty incarcerated men requested HIV testing following the intervention, because participants spread their knowledge about HIV prevention to others. Participants asked to become 'health ambassadors' - champion advisors for future scaled-up CBR HIV-prevention intervention for the entire correctional facility.

CONCLUSION

CBR HIV prevention is feasible within a Canadian men's correctional facility.

HIV, prisoners, and human rights

Worldwide, a disproportionate burden of HIV, tuberculosis, and hepatitis is present among current and former prisoners. This problem results from laws, policies, and policing practices that unjustly and discriminatorily detain individuals and fail to ensure continuity of prevention, care, and treatment upon detention, throughout imprisonment, and upon release. These government actions, and the failure to ensure humane prison conditions, constitute violations of human rights to be free of discrimination and cruel and inhuman treatment, to due process of law, and to health. Although interventions to prevent and treat HIV, tuberculosis, hepatitis, and drug dependence have proven successful in prisons and are required by international law, they commonly are not available. Prison health services are often not governed by ministries responsible for national public health programmes, and prison officials are often unwilling to implement effective prevention measures such as needle exchange, condom distribution, and opioid substitution therapy in custodial settings, often based on mistaken ideas about their incompatibility with prison security. In nearly all countries, prisoners face stigma and social marginalisation upon release and frequently are unable to access health and social support services. Reforms in criminal law, policing practices, and justice systems to reduce imprisonment, reforms in the organisation and management of prisons and their health services, and greater investment of resources are needed.

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.

Prevention of transmission of HIV, hepatitis B virus, hepatitis C virus, and tuberculosis in prisoners

The prevalence of HIV, hepatitis B virus, hepatitis C virus, and tuberculosis are higher in prisons than in the general population in most countries worldwide. Prisons have emerged as a risk environment for these infections to be further concentrated, amplified, and then transmitted to the community after prisoners are released. In the absence of alternatives to incarceration, prisons and detention facilities could be leveraged to promote primary and secondary prevention strategies for these infections to improve prisoners health and reduce risk throughout incarceration and on release. Effective treatment of opioid use disorders with opioid agonist therapies (eg, methadone and buprenorphine) prevents blood-borne infections via reductions in injection in prison and after release. However, large gaps exist in the implementation of these strategies across all regions. Collaboration between the criminal justice and public health systems will be required for successful implementation of these strategies.

Confronting the HIV, Tuberculosis, Addiction, and Incarceration Syndemic in Southeast Asia: Lessons Learned from Malaysia

Throughout Southeast Asia, repressive drug laws have resulted in high rates of imprisonment in people who inject drugs (PWID) and people living with HIV (PLH), greatly magnifying the harm associated with HIV, tuberculosis, and addiction. We review findings from Malaysia's largest prison to describe the negative synergistic effects of HIV, tuberculosis, addiction, and incarceration that contribute to a 'perfect storm' of events challenging public and personal health and offer insights into innovative strategies to control these converging epidemics. The majority of PLH who are imprisoned in Malaysia are opioid dependent PWID. Although promoted by official policy, evidence-based addiction treatment is largely unavailable, contributing to rapid relapse and/or overdose after release. Similarly, HIV treatment in prisons and compulsory drug treatment centers is sometimes inadequate or absent. The prevalence of active tuberculosis is high, particularly in PLH, and over 80 % of prisoners and prison personnel are latently infected. Mandatory HIV testing and subsequent segregation of HIV-infected prisoners increases the likelihood of tuberculosis acquisition and progression to active disease, amplifying the reservoir of infection for other prisoners. We discuss strategies to control these intersecting epidemics including screening linked to standardized treatment protocols for all three conditions, and effective transitional programs for released prisoners. For example, recently introduced evidence-based interventions in prisons like antiretroviral therapy (ART) to treat HIV, isoniazid preventive therapy to treat latent tuberculosis infection, and methadone maintenance to treat opioid dependence, have markedly improved clinical care and reduced morbidity and mortality. Since introduction of these interventions in September 2012, all-cause and HIV-related mortality have decreased by 50.0 % and 75.7 %, respectively. We discuss the further deployment of these interventions in Malaysian prisons.

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 Potential Impact of a Hepatitis C Vaccine for People Who Inject Drugs: Is a Vaccine Needed in the Age of Direct-Acting Antivirals?

BACKGROUND AND AIMS

The advent of highly effective hepatitis C (HCV) treatments has questioned the need for a vaccine to control HCV amongst people who inject drugs (PWID). However, high treatment costs and ongoing reinfection risk suggest it could still play a role. We compared the impact of HCV vaccination amongst PWID against providing HCV treatment.

METHODS

Dynamic HCV vaccination and treatment models among PWID were used to determine the vaccination and treatment rates required to reduce chronic HCV prevalence or incidence in the UK over 20 or 40 years. Projections considered a low (50% protection for 5 years), moderate (70% protection for 10 years) or high (90% protection for 20 years) efficacy vaccine. Sensitivities to various parameters were examined.

RESULTS

To halve chronic HCV prevalence over 40 years, the low, moderate and high efficacy vaccines required annual vaccination rates (coverage after 20 years) of 162 (72%), 77 (56%) and 44 (38%) per 1000 PWID, respectively. These vaccination rates were 16, 7.6 and 4.4 times greater than corresponding treatment rates. To halve prevalence over 20 years nearly doubled these vaccination rates (moderate and high efficacy vaccines only) and the vaccination-to-treatment ratio increased by 20%. For all scenarios considered, required annual vaccination rates and vaccination-to-treatment ratios were at least a third lower to reduce incidence than prevalence. Baseline HCV prevalence had little effect on the vaccine's impact on prevalence or incidence, but substantially affected the vaccination-to-treatment ratios. Behavioural risk heterogeneity only had an effect if we assumed no transitions between high and low risk states and vaccinations were targeted or if PWID were high risk for their first year.

CONCLUSIONS

Achievable coverage levels of a low efficacy prophylactic HCV vaccine could greatly reduce HCV transmission amongst PWID. Current high treatment costs ensure vaccination could still be an important intervention option.

Public health and international drug policy

In September 2015, the member states of the United Nations endorsed sustainable development goals (SDG) for 2030 that aspire to human rights-centered approaches to ensuring the health and well-being of all people. The SDGs embody both the UN Charter values of rights and justice for all and the responsibility of states to rely on the best scientific evidence as they seek to better humankind. In April 2016, these same states will consider control of illicit drugs, an area of social policy that has been fraught with controversy, seen as inconsistent with human rights norms, and for which scientific evidence and public health approaches have arguably played too limited a role.

The previous UN General Assembly Special Session (UNGASS) on drugs in 1998 – convened under the theme “a drug-free world, we can do it!” – endorsed drug control policies based on the goal of prohibiting all use, possession, production, and trafficking of illicit drugs. This goal is enshrined in national law in many countries. In pronouncing drugs a “grave threat to the health and well-being of all mankind,” the 1998 UNGASS echoed the foundational 1961 convention of the international drug control regime, which justified eliminating the “evil” of drugs in the name of “the health and welfare of mankind.” But neither of these international agreements refers to the ways in which pursuing drug prohibition itself might affect public health. The “war on drugs” and “zero-tolerance” policies that grew out of the prohibitionist consensus are now being challenged on multiple fronts, including their health, human rights, and development impact.

The Johns Hopkins – Lancet Commission on Drug Policy and Health has sought to examine the emerging scientific evidence on public health issues arising from drug control policy and to inform and encourage a central focus on public health evidence and outcomes in drug policy debates, such as the important deliberations of the 2016 UNGASS on drugs.

The Johns Hopkins-Lancet Commission is concerned that drug policies are often colored by ideas about drug use and drug dependence that are not scientifically grounded. The 1998 UNGASS declaration, for example, like the UN drug conventions and many national drug laws, does not distinguish between drug use and drug abuse. A 2015 report by the UN High Commissioner for Human Rights, by contrast, found it important to emphasize that “[d]rug use is neither a medical condition nor does it necessarily lead to drug dependence.” The idea that all drug use is dangerous and evil has led to enforcement-heavy policies and has made it difficult to see potentially dangerous drugs in the same light as potentially dangerous foods, tobacco, alcohol for which the goal of social policy is to reduce potential harms.

HIV and HCV prevalence and incarceration-related risks among injecting drug users in three West Bank governorates

In the Middle East, the HIV epidemic among injecting drug users (IDUs) seems to be in an early phase, which increases the importance of prevention and systematic risk surveillance. To gain information about HIV and HCV infection rates among IDUs in the West Bank, a biobehavioral survey was conducted using time-location sampling in the Ramallah, Hebron, and Bethlehem governorates in 2013. The researchers recruited 288 Palestinian IDUs ages 16-64 (Mage = 39.2, SD = 11.11). While no HIV cases were found in the sample, 41% of participants tested positive for HCV. Imprisonment was common among participants (83%), so we explored the association of incarceration experience with HCV infection and HIV testing. In multivariate assessments, incarceration was shown to increase the odds of being infected with HCV and ever tested for HIV. HIV prevention should be strengthened in West Bank prisons and correctional facilities, and imprisonment for drug use re-examined.

Black Americans and Incarceration: A Neglected Public Health Opportunity for HIV Risk Reduction

Black Americans are incarcerated at disproportionate rates, largely due to racial differences in the application of drug laws. Human immunodeficiency virus (HIV) prevalence rates among Black Americans are also disproportionately high. Moreover, availability of and access to HIV prevention services in correctional settings are limited. Recognizing that Blacks are at an elevated risk of contracting HIV, and that incarceration worsens health outcomes, this paper addresses the importance of implementing comprehensive prison-based HIV programs and prevention interventions to improve the health of this vulnerable population. In the absence of a vaccine, prevention interventions can serve as an effective method of systematically addressing HIV-related health disparities. Prevention strategies offered within correctional settings provide a unique opportunity to engage a high-risk population when its members may be receptive to behavior modification.