Prevalence and incidence of bloodborne viral infections among Danish prisoners

Human T-lymphotropic virus 1/2 infection among prisoners of a major penitentiary complex of Goiás State, Central-West Brazil

Introduction

Studies on human T-lymphotropic virus 1/2 (HTLV-1/2) infection are scarce in incarcerated population. Therefore, this study estimated the prevalence of HTLV-1/2 infection among prisoners of the major penitentiary complex of Goiás State, Central-West Brazil, comparing it with available data from other Brazilian regions.

Methods

A cross-sectional study was conducted with 910 prisoners of the major penitentiary complex in the State of Goiás, Central-West Brazil. All participants were interviewed, and their serum samples were tested for anti-HTLV-1/2 using an enzyme-linked immunosorbent assay (ELISA; Murex HTLV-I + II, DiaSorin, Dartford, UK). Seropositive samples were submitted for confirmation by a line immunoassay (INNO-LIA HTLV I/II, Fujirebio, Europe N.V., Belgium).

Results

The majority of participants were males (83.1%), between 25 and 39 years old (56.1%; mean age: 31.98 years), self-reported brown ethnicity (56.2%) and reported 9 years or less of formal education (41.4%). Most reported using non-injectable illicit drugs and various sexual behaviors that present risk for sexually transmitted infections (STIs). The prevalence of anti-HTLV-1/2 was 0.33% (95% CI: 0.07-0.96), HTLV-1 (0.22%) and HTLV-2 (0.11%). The two HTLV-1 seropositive prisoners reported high-risk sexual behaviors, and the HTLV-2 seropositive individual was breastfed during childhood (> 6 months) by her mother and three other women.

Conclusion

These data revealed a relatively low seroprevalence of HTLV-1/2 in prisoners in Central-West Brazil, and evidence of HTLV-1 and HTLV-2 circulation in the major penitentiary complex of Goiás State. Given the prevalence of high-risk sexual behaviors, there is a crucial need to intensify education and health programs in prisons to effectively control and prevent HTLV-1/2 and other STIs.

A multi-level intervention to eliminate hepatitis C from the Region of Southern Denmark: the C-Free-South project

Denmark has signed the WHO strategy to eliminate hepatitis C virus (HCV). In the absence of a national strategy for elimination, a local action plan was developed in the Region of Southern Denmark (RSD). The aim of the strategy is to diagnose 90% of HCV-infected persons and treat 80% of those diagnosed by 2025. The strategy was developed by reviewing Danish data on HCV epidemiology and drug use to identify key populations for screening, linkage to care, and treatment. Based on available published data from 2016, an estimated 3028 persons in the RSD were HCV-RNA positive (population prevalence 0.21%). Of these, 1002 were attending clinical care, 1299 were diagnosed but not in clinical care, and 727 were undiagnosed. Three different interventions targeting the HCV-infected population and two interventions for HCV surveillance are planned to achieve elimination. The “C-Free-South” strategy aims to eliminate HCV in our region by identifying (90%) and treating (80%) of infected persons by the end of 2025, 5 years earlier than the WHO elimination target date.

Global prevalence of hepatitis C in prisoners: a comprehensive systematic review and meta-analysis

Hepatitis C virus (HCV), one of the most significant causes of liver inflammation, has a high annual mortality rate. The unfavorable hygiene conditions and inadequate health monitoring in many prisons increase the risk of blood-borne infections such as hepatitis C. The growing incidence of this disease among prisoners results in overspill transmission to the general population from undiagnosed prisoners that have been released. Therefore, the aim of this study was to investigate the prevalence of hepatitis C among the world's prison population. A systematic review and meta-analysis of studies on the prevalence of hepatitis C was carried out using the keywords "Prevalence", "Hepatitis C", and "Prisoner" in the Iranian and international databases SID, MagIran, Iran Doc, Science Direct, Scopus, PubMed, and Web of Science (WoS) from January 1990 to September 2020. After transferring the articles to the information management software EndNote and eliminating duplicate studies, the remaining studies were reviewed based on inclusion and exclusion criteria, three stages of primary and secondary evaluation, and qualitative evaluation. Comprehensive meta-analysis software and Begg and Mazumdar and I² tests were used for data analysis and assessment of dissemination bias, and heterogeneity, respectively. Out of 93 studies (22 from Asia, 26 from Europe, seven from Africa, 29 from America, and nine from Australia) with a total sample size of 145,823 subjects, the prevalence of hepatitis C in prisoners worldwide was estimated to be 17.7% (95% confidence interval, 15-20.7%). The highest prevalence of hepatitis C on the continents included in this study was reported in prisoners incarcerated in Australia and Oceania, with 28.4% (95% CI: 21.6-36.4) in nine studies, and Europe, with 25.1% (95% CI: 19.4-31.8) in 26 studies. All studies used an ELISA test for the detection of HCV antibodies. The results showed a prevalence of HCV of 17.7% in prisoners worldwide, ranging between 10 and 30% over five continents (Asia, Europe, America, Africa, and Australia and Oceania). The highest prevalence was reported in Australia and Oceania (28.4%), indicating the need to pay more attention to this issue on the continent. It is necessary to reduce the incidence of the disease in prisons by appropriate policy-making and the development of accurate and practical programs, including the distribution of free syringes and examination, testing, and screening of prisoners.

Human T-Lymphotropic Virus-1/2 Infection in Central Brazil Prisons: A Multicenter Study

Human T-lymphotropic virus (HTLV) infection is endemic in some group populations. Prisoners are at high risk of acquiring HTLV infection mainly due to the environment of closed penal institutions, socioeconomic conditions, and risk behaviors. This study aimed to investigate the prevalence, the occurrence of new cases of HTLV infection after a 1-year follow-up, and circulating subtypes of HTLV-1 among prisoners from twelve closed prisons in Mato Grosso do Sul state, Central Brazil. A total of 1,507 prisoners were randomly enrolled in the cross-sectional study. Out of the 1,507 participants, 1,000 prisoners, susceptible to HTLV infection, were included in the prospective cohort study. In the cross-sectional study, serological evidence of HTLV infection was 0.4% (CI 95%: 0.1-0.7), tested for anti-HTLV antibodies by enzyme-linked immunosorbent assay (ELISA). Three samples were positive for HTLV-1, two samples were positive for HTLV-2, and 1 sample was indeterminate by the Western blot method. The presence of HTLV proviral DNA was detected in all positive samples by amplification of the HTLV tax gene through nested-PCR. Phylogenetic analysis showed that HTLV-1 samples belonged to the Cosmopolitan subtype Transcontinental subgroup. From a cohort of 1,000 individuals, no new case of HTLV infection was detected. Although the prevalence rate of HTLV infection found in this study was similar to that observed in the Brazilian general population, the lack of access to preventive interventions and harm reduction measures all contribute to increasing the risk of HTLV transmission and acquisition among this key and vulnerable population.

Univariable associations between a history of incarceration and HIV and HCV prevalence among people who inject drugs across 17 countries in Europe 2006 to 2020 – is the precautionary principle applicable?

Background

People who inject drugs (PWID) are frequently incarcerated, which is associated with multiple negative health outcomes.

Aim

We aimed to estimate the associations between a history of incarceration and prevalence of HIV and HCV infection among PWID in Europe.

Methods

Aggregate data from PWID recruited in drug services (excluding prison services) or elsewhere in the community were reported by 17 of 30 countries (16 per virus) collaborating in a European drug monitoring system (2006–2020; n = 52,368 HIV+/−; n = 47,268 HCV+/−). Country-specific odds ratios (OR) and prevalence ratios (PR) were calculated from country totals of HIV and HCV antibody status and self-reported life-time incarceration history, and pooled using meta-analyses. Country-specific and overall population attributable risk (PAR) were estimated using pooled PR.

Results

Univariable HIV OR ranged between 0.73 and 6.37 (median: 2.1; pooled OR: 1.92; 95% CI: 1.52–2.42). Pooled PR was 1.66 (95% CI 1.38–1.98), giving a PAR of 25.8% (95% CI 16.7–34.0). Univariable anti-HCV OR ranged between 1.06 and 5.04 (median: 2.70; pooled OR: 2.51; 95% CI: 2.17–2.91). Pooled PR was 1.42 (95% CI: 1.28–1.58) and PAR 16.7% (95% CI: 11.8–21.7). Subgroup analyses showed differences in the OR for HCV by geographical region, with lower estimates in southern Europe.

Conclusion

In univariable analysis, a history of incarceration was associated with positive HIV and HCV serostatus among PWID in Europe. Applying the precautionary principle would suggest finding alternatives to incarceration of PWID and strengthening health and social services in prison and after release (‘throughcare’).

Incidence, prevalence and risk factors for hepatitis C in Danish prisons

Hepatitis C virus (HCV) infection is prevalent among people in prison and prisons could therefore represent a unique opportunity to test risk groups for HCV. The aim of this sero-epidemiological study was to determine the incidence and prevalence of HCV infection and the corresponding risk factors in Danish prisons. Participants, recruited from eight Danish prisons, were tested for HCV using dried blood spots and filled out a questionaire with demographic data and risk factors for HCV infection. In total, 76.9% (801/1041) of all eligible prisoners consented to participate. The prevalence of HCV RNA positive prisoners was 4.2% (34/801) and the in-prison incidence rate was 0.7–1.0 per 100PY overall and 18-24/100PY among PWIDs. Infected prisoners were older than the overall population with a mean age of 42 years and only 17.6% (6/34) were younger than 35 years. The prevalence of PWID was 8.5% (68/801) and only 3% (2/68) of PWID were younger than 25 years. Among the PWID, 85.3% (58/68) had ever received opioid substitution therapy (OST) and 47.1% (32/68) were currently receiving OST. Risk factors associated with HCV infection were intravenous drug use, age ≥ 40 years, and being incarcerated ≥ 10 years. In conclusion, the prevalence of PWID in Danish prisons is low, possibly reflecting a decrease in injecting among the younger generation. This together with OST coverage could explain the low prevalence of HCV infection. However among PWIDs in prison the incidence remains high, suggesting a need for improved HCV prevention in prison.

Hepatitis B virus, hepatitis C virus and human immunodeficiency virus infections among people who inject drugs in Kuwait: A cross-sectional study

Injection drug use (IDU) is one of the most significant risk factors for viral hepatitis (B and C) and human immunodeficiency virus (HIV) infections. This study assessed seroprevalence rates of hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) in people who inject drugs (PWID) in Kuwait. We conducted a cross-sectional study from April to September 2017. A total of 521 consecutive subjects, admitted at Al-Sabah Hospital. The serological and virological markers of HBV, HCV, and HIV were tested  using automated platforms. The mean age of the participants was 32.26 yrs, and the sex ratio (Male/Female) was 15.28. The prevalence rates of HBsAg, anti-HCV, and anti-HIV antibodies were 0.38% (95% CI: 0.07-1.53%), 12.28% (95% CI: 9.65-15.48), and 0.77% (95% CI: 0.25-2.23%), respectively. HCV-RNA was evident in 51.72% (95% CI: 38.34-64.87%) among anti-HCV positive participants. Multivariate analysis showed that the high prevalence of HCV infection amongst PWID is associated with age. Whereas, multivariate analysis revealed no significant associations with age and gender regarding HIV and HBV infections. The results suggest that high rates of HBV, HCV, and HIV infections among injecting drug users than the general population. These findings emphasize the importance of introducing interventions and harm reduction initiatives that have a high impact on reducing needle sharing.

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.

Universal opt-out screening for hepatitis C virus (HCV) within correctional facilities is an effective intervention to improve public health

Purpose

Worldwide efforts to identify individuals infected with the hepatitis C virus (HCV) focus almost exclusively on community healthcare systems, thereby failing to reach high-risk populations and those with poor access to primary care. In the USA, community-based HCV testing policies and guidelines overlook correctional facilities, where HCV rates are believed to be as high as 40 percent. This is a missed opportunity: more than ten million Americans move through correctional facilities each year. Herein, the purpose of this paper is to examine HCV testing practices in the US correctional system, California and describe how universal opt-out HCV testing could expand early HCV detection, improve public health in correctional facilities and communities, and prove cost-effective over time.

Design/methodology/approach

A commentary on the value of standardizing screening programs across facilities by mandating all facilities (universal) to implement opt-out testing policies for all prisoners upon entry to the correctional facilities.

Findings

Current variability in facility-level testing programs results in inconsistent testing levels across correctional facilities, and therefore makes estimating the actual number of HCV-infected adults in the USA difficult. The authors argue that universal opt-out testing policies ensure earlier diagnosis of HCV among a population most affected by the disease and is more cost-effective than selective testing policies.

Originality/value

The commentary explores the current limitations of selective testing policies in correctional systems and provides recommendations and implications for public health and correctional organizations.

HIV and hepatitis C virus infections in Quebec's provincial detention centres: comparing prevalence and related risky behaviours between 2003 and 2014-2015

OBJECTIVES

To compare the prevalence of HIV, hepatitis C virus (HCV) infections, and related risky behaviours among inmates in Quebec's provincial prisons between 2003 and 2014-2015.

METHODS

Cross-sectional data were anonymously collected from May 2014 to March 2015 for men (n = 1315) and women (n = 250) and combined with data collected in 2003 to evaluate trends in the last decade. Participants completed a questionnaire and provided saliva samples. The data from the 2003 and 2014-2015 surveys were merged for statistical analysis.

RESULTS

HIV prevalence was stable between 2003 and 2014-2015 for men (2.4% vs. 1.8%, p = 0.4), whereas it decreased for women (8.8% vs. 0.8%, p < 0.001). HCV prevalence decreased between 2003 and 2014-2015 for both men (16.6% vs. 11.9%, p < 0.001) and women (29.2% vs. 19.2%, p = 0.02). HIV and HCV prevalence were higher among people who inject drugs (PWID), for both sexes and both studies. PWID-specific prevalence did not change between 2003 and 2014-2015, except for a decrease in HIV prevalence in PWID women. However, the proportion of prisoners reporting a history of injection drug use outside prison was lower in 2014-2015 than in 2003 for men (19.8% vs. 27.7%, p < 0.0001) and women (28.6% vs. 42.6%, p = 0.002).

CONCLUSION

The lower proportion of PWID inmates in 2014-2015 compared to 2003 explained in large part the decrease in HIV and HCV prevalence. Despite the decrease in prevalence, HIV and HCV infections among incarcerated individuals still represent a major public health problem due to the sizable increase of individuals in Quebec's correctional system over the same period.

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.

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.

Audit into Blood-Borne Virus Services in Her Majesty's Prison Service

The main objective of this study is to assess current hepatitis C services for female prisoners. The study design includes a retrospective audit of inmates’ contact with blood-borne virus (BBV) services and outcomes of service use. The study was carried out at a prison for women in the north of England with 179 prisoners and 69 service users. The outcome measures were proportions in contact with services and outcomes of service use (time to testing/treatment; proportion positive for hepatitis C; HIV status). Almost a quarter of those arriving at the prison have contact with BBV services; most of them report a history of intravenous drug use (75.4%), although one-fifth of such individuals decline testing. The average number of days from imprisonment to testing was 86-half this time if arriving since October 2006. Fifty percent were positive for the hepatitis C antibody, the majority of whom (83.3%) had an active virus and were suitable for treatment. The average number of days from testing to referral was 38. All tested for HIV were negative. Therefore, efficiency is necessary if prisoners are to access BBV services while incarcerated. This is being achieved, although some delays still occur.

Hepatitis C seroconversion in methadone maintenance treatment programs in Wuhan, China

BACKGROUND AND AIMS

To decrease infectious disease transmission, China is expanding methadone maintenance treatment (MMT). This study evaluated the prevalence of hepatitis C virus (HCV) infection at MMT entry, seroconversion rates after admission and potential risk factors for HCV seroconversion during MMT in Wuhan, China.

DESIGN

Cross-sectional survey of all patients entering MMT and prospective follow-up of patients HCV seronegative at admission.

SETTING

All MMT clinics in Wuhan, China.

PARTICIPANTS

A total of 12 755 opiate-dependent individuals entering MMT between May 2006 and June 2011; 1200 participants HCV seronegative at admission were followed.

MEASUREMENTS

Serological tests for HCV and self-report data on risk behaviors at MMT admission; urine toxicology results and repeated assessments of serological status and risk behaviors during treatment on patients HCV seronegative at admission.

FINDINGS

HCV seroprevalence at admission was 72.1% [95% confidence interval (CI) = 71.3-72.9%] and 555/1200 (46.3%, 95% CI = 43.5-49.1%) patients seroconverted to HCV during MMT. The mean time to HCV seroconversion was 3 (95% CI = 2.84-3.07) years with a cumulative seroconversion rate of 34.5 (95% CI = 31.5-36.9) per 100 person-years. Significant predictors of HCV conversion included injection drug use in the past 30 days [relative hazard (RH) 2.0, 95% CI: 1.6 - 2.4, P=0.002] and the rate of opiate-positive urine tests during MMT (RH 2.0, 95% CI = 1.3-3.1, P<0.001).

CONCLUSIONS

Methadone maintenance treatment patients in Wuhan, China show a high prevalence of hepatitis C virus at admission (72.1%) and a high rate of seroconversion during treatment (46.3%). Seroconversion is associated with continuing injection drug use.

Hepatitis B prevalence and incidence in Greenland: a population-based cohort study

Greenland remains a highly endemic area for hepatitis B virus (HBV) infection. This is in sharp contrast to other modern societies, such as Denmark. To address this discrepancy, we investigated the natural history of HBV infection in Greenland by estimating the age-specific incidence of HBV infection, the proportion of chronic carriers, and the rates of hepatitis B surface antigen seroclearance. In total, 8,879 Greenlanders (16% of the population) from population-based surveys conducted in 1987 and 1998 were followed through March 2010. Data on HBV status were supplemented by HBV test results from all available HBV registries in Greenland to determine changes in HBV status over time. Incidence rates of HBV infection and hepatitis B surface antigen seroclearance were estimated after taking into account interval censoring. The incidence of HBV infection in 5-14-year-old subjects was less than 1 per 100 person-years and peaked at 5 per 100 person-years in persons 15-24 years of age. Overall, 17.5% of persons infected in adulthood were estimated to become chronic carriers. HBV is primarily transmitted in adolescence and adulthood in Greenland. In contrast to what is observed in most other populations, HBV-infected adults in Greenland have a high risk of progressing to chronic HBV carriage. This phenomenon might explain how the high rate of infection is maintained in Greenland.

High-risk behaviors after release from incarceration among people who inject drugs in St. Petersburg, Russia

BACKGROUND

Injection drug use, infectious disease, and incarceration are inextricably linked in Russia. We aimed to identify factors associated with time to relapse (first opioid injection after release from prison) and using a non-sterile, previously used syringe at relapse in a sample of people who inject drugs in St. Petersburg.

METHODS

We collected data on time from release to relapse among individuals with a history of incarceration, a subsample of a larger study among people who inject drugs. Proportional hazards and logistic regression were used to identify factors associated with time to relapse and injection with a non-sterile previously used syringe at relapse, respectively.

RESULTS

The median time to relapse after release was 30 days. Factors that were independently associated with relapsing sooner were being a native of St. Petersburg compared to not being native (AHR: 1.64; 95% CI 1.15-2.33), unemployed at relapse compared to employed (AHR: 4.49; 95% CI 2.96-6.82) and receiving a previous diagnosis of HBV and HCV compared to no previous diagnosis (AHR: 1.49; 95% CI 1.03-2.14). Unemployment at relapse was also significant in modeling injection with a non-sterile, previously used syringe at relapse compared to those who were employed (AOR: 6.80; 95% CI 1.96-23.59).

CONCLUSIONS

Unemployment was an important correlate for both resuming opioid injection after release and using a non-sterile previously used syringe at relapse. Linkage to medical, harm reduction, and employment services should be developed for incarcerated Russian people who inject drugs prior to release.

Hepatitis C virus infection epidemiology among people who inject drugs in Europe: a systematic review of data for scaling up treatment and prevention

BACKGROUND

People who inject drugs (PWID) are a key population affected by hepatitis C virus (HCV). Treatment options are improving and may enhance prevention; however access for PWID may be poor. The availability in the literature of information on seven main topic areas (incidence, chronicity, genotypes, HIV co-infection, diagnosis and treatment uptake, and burden of disease) to guide HCV treatment and prevention scale-up for PWID in the 27 countries of the European Union is systematically reviewed.

METHODS AND FINDINGS

We searched MEDLINE, EMBASE and Cochrane Library for publications between 1 January 2000 and 31 December 2012, with a search strategy of general keywords regarding viral hepatitis, substance abuse and geographic scope, as well as topic-specific keywords. Additional articles were found through structured email consultations with a large European expert network. Data availability was highly variable and important limitations existed in comparability and representativeness. Nine of 27 countries had data on HCV incidence among PWID, which was often high (2.7-66/100 person-years, median 13, Interquartile range (IQR) 8.7-28). Most common HCV genotypes were G1 and G3; however, G4 may be increasing, while the proportion of traditionally 'difficult to treat' genotypes (G1+G4) showed large variation (median 53, IQR 43-62). Twelve countries reported on HCV chronicity (median 72, IQR 64-81) and 22 on HIV prevalence in HCV-infected PWID (median 3.9%, IQR 0.2-28). Undiagnosed infection, assessed in five countries, was high (median 49%, IQR 38-64), while of those diagnosed, the proportion entering treatment was low (median 9.5%, IQR 3.5-15). Burden of disease, where assessed, was high and will rise in the next decade.

CONCLUSION

Key data on HCV epidemiology, care and disease burden among PWID in Europe are sparse but suggest many undiagnosed infections and poor treatment uptake. Stronger efforts are needed to improve data availability to guide an increase in HCV treatment among PWID.

Prevalence of human immunodeficiency virus and hepatitis C virus among French prison inmates in 2010: a challenge for public health policy

We evaluated prevalence of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) among prison inmates in France in 2010, in a cross-sectional single-day study based on a two-stage design. Sampling favoured larger establishments and included all types of prisons. Establishments were stratified by geographical region. Estimates were adjusted by post-stratification of the total population of inmates in France. From 60,975 inmates in all 188 prisons on the sampling day, 2,154 were selected from 27 prisons, and 1,876 questionnaires completed. HIV prevalence was estimated at 2.0% (95% confidence interval (CI): 0.9–4.2), 2.6% (95% CI: 0.7–8.8) in women and 2.0% (95% CI: 0.9–4.3) in men; 75% of inmates were receiving treatment for HIV. HCV prevalence was estimated at 4.8% (95% CI: 3.5–6.5) and was higher for women (11.8%; 95% CI: 8.5–16.1) than men (4.5%; 95% CI: 3.3–6.3). Almost half of HCV-infected inmates had chronic hepatitis C and 44% were receiving or had received treatment. HIV and HCV prevalence was six times higher than in the general population, and 2.5% of inmates had viraemic hepatitis C. The moment of incarceration provides an ideal opportunity for testing and treating, limiting spread of HCV and improving patients' prognosis.

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.

Hepatitis B virus exposure and vaccination in a cohort of people who inject drugs: what has been the impact of targeted free vaccination?

BACKGROUND AND AIM

Forty percent of new hepatitis B virus (HBV) infections in Australia occur in people who inject drugs (PWID); long-term infection carries the risk of serious liver disease. HBV incidence among Australian PWID has not been measured since the advent of targeted (2001) and adolescent school-based "catch-up" (1998) vaccination programs. We measured HBV incidence and prevalence in a cohort of PWID in Melbourne, Australia and examined demographic and behavioral correlates of exposure and vaccination.

METHODS

Community-recruited PWID were surveyed about blood-borne virus risk behaviors and their sera tested for HBV markers approximately three-monthly over three years. Incidence was assessed using prospectively collected data. A cross-sectional design was used to examine prevalence of HBV exposure and vaccination at baseline. Poisson regression was used to identify correlates of HBV exposure and vaccination.

RESULTS

At baseline, 33.1% of participants (114/344) had been vaccinated against HBV, 40.4% (139/344) had been exposed (previously or currently infected), and 26.5% (91/344) were susceptible. HBV incidence was 15.7 per 100 person-years. Independent associations with HBV exposure included female gender, South-East Asian ethnicity, drug treatment in the past three months, injecting in prison, and prior exposure to hepatitis C virus. Independent associations with vaccination included being ≤ 25 years old, reporting HBV vaccination, and never having been to prison.

CONCLUSIONS

HBV infection continues at high incidence among Australian PWID despite the introduction of free vaccination programs. Innovative methods are needed to encourage PWID to complete HBV vaccination.

Prevalence and correlates of HCV, HVB, and HIV infection among prison inmates and staff, Hungary

The aim of this national, multicenter, cross-sectional study was to assess the prevalence of hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency viruses (HIV) among prisoners, and to identify related risk behaviors including injection drug use. Overall, 4,894 inmates from 20 prisons were enrolled. To have a comparison group, prison staff were also asked to take part. Altogether, 1,553 of the 4,894 inmates from seven prisons completed a questionnaire on risk behaviors. According to the survey, 1.5%, 4.9%, and 0.04% of the prisoners were tested positive for HBsAg, anti-HCV and anti-HIV, respectively. These prevalence data are among the lowest reported from prisons worldwide, although comparable to the Central European data. The prevalence of HBV, HCV, and HIV in the Hungarian prison staff was low (0.38%, 0.47%, and 0%, respectively). The rate of HCV infection was significantly higher among inmates who have ever injected drugs (22.5%) than among inmates who reported they had never injected drugs (1.1%). This first prevalence study of illegal drug injection-related viral infections among Hungarian prisoners points out that ever injecting drugs is the main reason for HCV infection among inmates. The opportunity to reach drug users infected with HCV for treatment underlines the importance of screening programs for blood-borne viruses in prisons.

Effect of prison-based opioid substitution treatment and post-release retention in treatment on risk of re-incarceration

AIMS

People who use heroin are frequently incarcerated multiple times. Reducing re-incarceration of this group is important for reducing both health risks associated with incarceration and the costs of correctional administration. Opioid substitution treatment (OST) in prisons may help to reduce re-incarceration, but research findings on this topic have been mixed. In this study, we examined the effect of OST in prison and after release on re-incarceration.

DESIGN

Longitudinal cohort study. SETTING, PARTICIPANTS AND MEASUREMENTS: Data on OST and incarceration were linked for a cohort of 375 male heroin users recruited originally in prisons in New South Wales, Australia. Data were linked for the period 1 June 1997-31 December 2006. Re-incarceration was examined using recurrent-event survival analysis models. Model 1 examined the effect of OST status at release from prison (i.e. in treatment versus out of treatment on the day of release) on re-incarceration. Model 2 considered the effect of remaining in OST after release on risk of re-incarceration.

FINDINGS

Ninety per cent of participants were re-incarcerated following their first observed release. Pre-incarceration cocaine use was associated with a 13% increase in the average risk of re-incarceration. There was no significant association between simply being in OST at the time of release and risk of re-incarceration; however, in the model taking into account post-release retention in treatment, the average risk of re-incarceration was reduced by 20% while participants were in treatment.

CONCLUSIONS

In New South Wales, Australia, opioid substitution treatment after release from prison has reduced the average risk of re-incarceration by one-fifth.

Outreach screening of drug users for cirrhosis with transient elastography

AIMS

Transient elastography (TE) is a non-invasive sensitive tool for diagnosing cirrhosis in hospital-based cohorts. This study aimed to evaluate TE as a screening tool for cirrhosis among drug users.

DESIGN

Cross-sectional study.

SETTING

All treatment centres in the county of Funen, Denmark.

PARTICIPANTS

Drug users attending treatment centres during the presence of the study team.

MEASUREMENTS

Liver stiffness measurements (LSM) by transient elastography using the Fibroscan device; blood tests for viral hepatitis, HIV infection and hyaluronic acid (HA) levels; and routine liver tests. Individuals with LSM ≥ 8 kPa were referred to the hospital for treatment evaluation. Individuals with LSM ≥ 12 kPa were recommended a liver biopsy.

FINDINGS

Among 175 drug users negative for hepatitis C, 13% had LSM = 8-11.9 kPa and 4% had LSM ≥ 12 kPa; elevated LSM was associated with a body mass index (BMI) > 30. Among 128 drug users with chronic hepatitis C, 19.5% had LSM = 8-11.9 kPa and 21.1% had LSM ≥ 12 kPa (P < 0.001). Repeat LSM at liver biopsy performed a median 3 months after screening showed a significant decrease (<12 kPa) among 30% (six of 20), and this was independent of alcohol consumption, BMI, age and gender. In 29 patients where liver biopsy was performed a LSM ≥ 16 kPa predicted cirrhosis with 88.9% sensitivity and 90% specificity.

CONCLUSIONS

Transient elastography is a feasible screening tool for cirrhosis among drug users. Transient elastography identifies severe liver fibrosis in a significant proportion of drug users with hepatitis C infections but management should not be based on a single elevated liver stiffness measurement.

The health of prisoners

More than 10 million people are incarcerated worldwide; this number has increased by about a million in the past decade. Mental disorders and infectious diseases are more common in prisoners than in the general population. High rates of suicide within prison and increased mortality from all causes on release have been documented in many countries. The contribution of prisons to illness is unknown, although shortcomings in treatment and aftercare provision contribute to adverse outcomes. Research has highlighted that women, prisoners aged 55 years and older, and juveniles present with higher rates of many disorders than do other prisoners. The contribution of initiatives to improve the health of prisoners by reducing the burden of infectious and chronic diseases, suicide, other causes of premature mortality and violence, and counteracting the cycle of reoffending should be further examined.

HIV and hepatitis B and C incidence rates in US correctional populations and high risk groups: a systematic review and meta-analysis

BACKGROUND

High Human Immunodeficiency Virus (HIV) prevalence and high risk behaviors have been well documented within United States (US) correctional systems. However, uncertainty remains regarding the extent to which placing people in prison or jail increases their risk of HIV infection, and regarding which inmate populations experience an increased incidence of HIV. Describing these dynamics more clearly is essential to understanding how inmates and former detainees may be a source for further spread of HIV to the general US population.

METHODS

The authors conducted a systematic review and meta-analysis of studies describing HIV incidence in US correctional facility residents and, for comparison, in high risk groups for HIV infection, such as non-incarcerated intravenous drug users (IVDU) and men who have sex with men (MSM) in the US. HIV incidence rates were further compared with Hepatitis B and Hepatitis C Virus rates in these same populations.

RESULTS

Thirty-six predominantly prospective cohort studies were included. Across all infection outcomes, continuously incarcerated inmates and treatment recruited IVDU showed the lowest incidence, while MSM and street recruited IVDU showed the highest. HIV incidence was highest among inmates released and re-incarcerated. Possible sources of heterogeneity identified among HIV studies were risk population and race.

CONCLUSIONS

Although important literature gaps were found, current evidence suggests that policies and interventions for HIV prevention in correctional populations should prioritize curtailing risk of infection during the post-release period. Future research should evaluate HIV incidence rates in inmate populations, accounting for proportion of high risk sub-groups.

Decline in hepatitis B infection observed after 11 years of regional vaccination among Danish drug users

The aims of this study were to determine the current prevalence of viral hepatitis and HIV among drug users, and to compare this prevalence with previous findings in the same geographical region. Cross-sectional surveys of drug users attending treatment centers on the island of Funen with approximately 500,000 inhabitants were administered in 1996 and 2007. The 2007 prevalence estimates were: anti-HBc 50.2%, HBsAg 0.9%, anti-HCV 66.8%, HCV-RNA 40%, and anti-HIV 1.1%. The corresponding 1996 prevalence values were: anti-HBc 70% (P < 0.0001), HBsAg 9.8% (P < 0.0001), anti-HCV 82.8% (P < 0.0001), HCV-RNA 56.3% (P = 0.002), and anti-HIV 1% (P = 1). The 2007 prevalence of viral hepatitis decreased due to the increasing proportion of non-injectors. Among injectors, the prevalence remained unchanged except for a significant decrease in HBsAg. The 2007 prevalence of ongoing HBV infection among infected (HBsAg/anti-HBc proportion) was the lowest that to our knowledge has been reported among drug-users. Vaccination coverage among susceptible persons tested in 2007 was 24%, compared to 0.7% in 1996. Therefore, despite an unchanged prevalence of anti-HBc among injecting drug users, a highly significant drop in HBsAg prevalence was seen during the last decade. This observation may be linked causally to an increase in hepatitis B vaccination of the susceptible population. Our findings suggest that even incomplete vaccination, without persistent protective anti-HBs levels, may induce an immune memory sufficient to prevent chronic infection upon transmission.

Incidence of primary hepatitis C infection and risk factors for transmission in an Australian prisoner cohort

BACKGROUND

Hepatitis C virus (HCV) infection is common in prisoner populations, particularly those with a history of injecting drug use (IDU). Previous studies of HCV incidence have been based on small case numbers and have not distinguished risk events in prison from those in the community.

METHODS

HCV incidence was examined in a longitudinal cohort of 488 Australian prisoners with a history of IDU and documented to be seronegative within 12 months prior to enrollment. Inmates were tested for anti-HCV antibodies and viremia, and interviewed about demographic and behavioral risk factors for transmission.

RESULTS

The cohort was predominantly male (65%) with high rates of prior imprisonment (72%) and tattooing (73%), as well as longstanding IDU (mean 8.5 years). Ninety-four incident HCV cases were identified (incidence 31.6 per 100 person years). Independent associations were observed between incident infection and prior imprisonment (p = 0.02) and tattooing (p = 0.03), and surprisingly also with methadone maintenance treatment (MMT) (p < 0.001).

CONCLUSIONS

High rates of new HCV infection were found in this prisoner cohort reflecting their substantive risk behavior profile, despite having remained uninfected for many years. The association with MMT is challenging and highlights the need for better understanding of prison-specific HCV transmission risks, as well as the uptake and effectiveness of prevention programs.

Viral hepatitis B, C and HIV infection in Croatian prisons

Incarcerated persons comprise about 0.4% of the Croatian population, of whom 25-30% misuse drugs. We attempted to determine the structure of the prison population, prevalence of HBV, HCV, HIV markers, co-infections with HBV, HCV and HIV and acute HBV, HCV and HIV infection. In total, 25.9% of prisoners were positive for some markers for viral hepatitis (HBV 11.3%, HCV 8.3%, HBV/HCV 6.3%). Prevalence of HBV infection in intravenous drug users (IDUs) was 26.2% (highly promiscuous group 20.4%, individuals with psychiatric diseases and personality disorders 16.0%). HCV infection in IDUs was 52.0% and 4.9% in the highly promiscuous group. HBV/HCV co-infection was registered in 34.9% of prisoners positive for HBV markers (203/582). Acute HBV infection was detected in 0.5%, and HCV in 1.2%. Only 0.15% (5/3348) of prisoners were anti-HIV positive. It appears that individuals with psychiatric diseases and personality disorders could be an additional risk population for these viral infections.

Prevalence and correlates of hepatitis C infection among male injection drug users in detention, Tehran, Iran

For the benefit of planning for the future care and treatment of people infected with hepatitis C virus (HCV) and to help guide prevention and control programs, data are needed on HCV seroprevalence and associated risk factors. We conducted a cross-sectional sero-behavioral survey of injection drug users (IDU) detained for mandatory rehabilitation during a police sweep of Tehran, Iran, in early 2006. During the study period, a consecutive sample comprising 454 of 499 (91.0%) men arrested and determined to be IDU by urine test and physical examination consented to a face-to-face interview and blood collection for HCV antibody testing. Overall, HCV prevalence was 80.0% (95% confidence interval (CI) 76.2-83.6). Factors independently associated with HCV infection included history of incarceration (adjusted OR 4.35, 95% CI 1.88-10.08), age of first injection < or =25 years (OR 2.72, 95% CI 1.09-6.82), and history of tattooing (OR 2.33, 95% CI 1.05-5.17). HCV prevalence in this population of IDU upon intake to jail was extremely high and possibly approaching saturation. Findings support that incarceration is contributing to the increased spread of HCV infection in Iran and calls for urgent increased availability of HCV treatment, long-term preparation for the care of complications of chronic infection, and rapid scale-up of programs for the primary prevention of parenterally transmitted infections among drug users.

Access to treatment of hepatitis C in prison inmates

We conducted a prospective study to investigate access to treatment in hepatitis C in 268 prisoners. Hepatitis C positivity had been known for 182 prisoners previously and 19 reported previous attempts to treat (10%). In comparison, during our study, 86/268 prisoners (32%) started therapy (P < 0.0001). They represented 41% of 211 prisoners with a positive viral load. In the genotype 2 or 3 group, 46 prisoners (50%) started therapy versus 40 prisoners (33%) with other genotypes (P = 0.01). This difference was due to prisoners waiting for liver biopsy. On an intention to treat basis, 45 prisoners (52%) achieved sustained virological response 6 months after the end of therapy. We conclude that a stay in prison is an effective opportunity to treat a group of hepatitis C patients which otherwise have very limited access to therapy.

Viral hepatitis in incarcerated adults: a medical and public health concern

Viral hepatitis is a common problem in the incarcerated population. It causes significant morbidity and mortality, and incarcerated inmates receive their health care almost exclusively from corrections-based health systems. The seroprevalence of hepatitis B and C infections is increased in this population, and a number of risk factors for viral hepatitis are particularly common and infer higher risk among inmates, including injection drug use (IDU), high-risk sexual activity, and tattoos. IDU, in particular, has been identified as an important and common risk factor for viral hepatitis in inmates, and variable rates of IDU among inmates have been found to be the most important cause of the marked variability of seroprevalence rates for exposure to hepatitis C virus. A number of risk reduction and management strategies have been identified that can decrease transmission to other inmates. Prison-based hepatitis A and hepatitis B vaccination programs, needle exchange programs, methadone maintenance programs, risk education programs, and hepatitis C virus antiviral programs, for example, have been shown to be safe and effective risk reduction and management strategies. Preliminary studies have shown that these strategies are underutilized in the United States. Reasons for this phenomenon are multifactorial, involving financial as well as ethical and political considerations. Additional funding, research, and formal consideration / discussion of the complex issues involving viral hepatitis in the US incarcerated population are clearly important for the sake of inmates and the community at large. In this article, the published medical literature regarding this important topic is reviewed.

Prevalence of hepatitis B virus and risk factors in Brazilian non-injecting drug users

Non-injecting drug users are at high-risk for acquiring hepatitis B virus (HBV), although the factors contributing to this increased risk are not known. In the present study, the overall and occult HBV infection prevalence rates were determined in a large population of non-injecting drug users in the Central-West region of Brazil. HBV genotypes and predictors of infection were also identified. A total of 852 individuals in 34 drug treatment centers were interviewed, and their serum samples were tested for the presence of HBV markers by ELISA. HBsAg and anti-HBc-positive samples were tested for HBV DNA by PCR. Samples with HBV DNA were genotyped by restriction fragment length polymorphism (RFLP). The overall prevalence of HBV infection was 14% (95% CI: 11.7-16.5). A multivariate analysis of risk factors showed that age >30 years, non-white race/ethnicity, duration of drug use >10 years, lifetime number of sexual partners >10, non-use of condoms, and HCV and HIV status were associated significantly with HBV infection. Of the 9 (1%) HBsAg-reactive samples, HBV DNA was present in 2/2 of HBeAg-positive and in 5/7 anti-HBe-positive samples. An occult HBV infection rate of 2.7% (3/110) was found among anti-HBc-positive individuals. All HBV DNA-positive samples were genotyped: seven were genotype A, two were genotype D, and one was genotype F. Finally, few individuals (8%) had serological evidence of a previous HBV vaccination. These findings indicate that preventive interventions are needed for both sexual and drug-related high-risk behavior. Additionally, non-injecting drug users should be targeted for HBV vaccination.

Meta-regression of hepatitis C virus infection in relation to time since onset of illicit drug injection: the influence of time and place

The authors examined the relation between time since onset of illicit drug injection (time at risk) and rates of hepatitis C virus (HCV) infection by using meta-regression. In 72 prevalence studies, median time since onset of injection was 7.24 years and median prevalence was 66.02%. The model showed statistically significant linear and quadratic effects of time at risk on HCV prevalence and significantly higher prevalence in developing and transitional countries and in earlier samples (1985-1995). In developed countries post-1995, mean fitted prevalence was 32.02% (95% confidence interval: 25.31, 39.58) at 1 year of injection and 53.01% (95% confidence interval: 40.69, 65.09) at 5 years. In developing/transitional countries post-1995, mean fitted HCV prevalence was 59.13% (95% confidence interval: 30.39, 82.74) at 1 year of injection. In 10 incidence studies, median time at risk was 5.29 years and median cumulative HCV incidence was 20.69%. Mean fitted cumulative incidence was 27.63% (95% confidence interval: 16.92, 41.70) at 1 year of drug injection. The authors concluded that time to HCV infection in developed countries has lengthened. More rapid onset of HCV infection in drug injectors in developing/transitional countries resembles an earlier era of the HCV epidemic in other regions.

The 2004 Australian prison entrants' blood-borne virus and risk behaviour survey

OBJECTIVES

To assess the prevalence of blood-borne viruses and associated risk factors among prison entrants at seven Australian prisons across four States.

DESIGN

Consecutive cross-sectional design. Voluntary confidential testing of all prison entrants for serological markers of human immunodeficiency virus (HIV), hepatitis C (HCV) and hepatitis B (HBV) over 14 consecutive days in May 2004. Demographic data and data related to risks for blood-borne virus transmission, such as sexual activity, body piercing, tattooing, and injecting drug use, were collected.

RESULTS

National prevalence for HIV was 1%, hepatitis B core antibody 20%, and hepatitis C antibody 34%. Fifty-nine per cent of participants had a history of injecting drug use. Among injecting drug users, the prevalence of HIV was 1%, hepatitis C antibody 56%, and hepatitis B core antibody 27%. Forty-one per cent of those screened reported a previous incarceration. In the multivariate model, Queensland and Western Australian (WA) prison entrants were significantly less likely to test positive to HCV than those in New South Wales (NSW). Amphetamine was the most commonly injected drug in Queensland, Tasmania and WA. In NSW, heroin was the most common drug injected. In the multivariate analysis a history of injecting drug use, being aged 30 years or more, and a prior incarceration were positively associated with hepatitis C infection. For hepatitis B core antibody, age over 30 years and a history of injecting drug use were associated with an increased risk.

CONCLUSIONS

The findings support the view that prisoner populations are vulnerable to blood-borne virus infection, particularly hepatitis B and C. Prisoner populations should be included in routine surveillance programs so as to provide a more representative picture of blood-borne virus epidemiology in Australia.

Prevalence of hepatitis C in a German prison for young men in relation to country of birth

A high prevalence of hepatitis C (HCV) virus infection of up to 80% has been reported for injecting drug users (IDUs) in prison communities. However, there are only very limited data available on the prevalence and course of HCV in young offenders. We performed a study on hepatitis C markers in the largest German Young Offenders' Institution (YOI), a prison for men (aged 16-24 years). In 2002, all 1176 incoming offenders were asked to participate in the study of whom >95% agreed. Ninety-seven inmates (8.6%) tested positive for anti-HCV or HCV RNA, 79% of whom were viraemic. None of the patients had evidence of cirrhosis at presentation. Interestingly, six individuals (6%) tested positive for HCV RNA in the absence of anti-HCV antibodies, four of whom cleared HCV spontaneously during follow-up without either clinical signs of acute hepatitis or developing HCV antibodies. Hepatitis C markers were significantly more prevalent among immigrants from the former Soviet Union (NIS) than among German inmates (31% vs. 6% respectively, P<0.0001). HIV co-infection was found in five individuals, all of whom were German. In contrast, hepatitis B surface antigen (HBsAg) was detected in five NIS immigrants, one Lebanese and one German inmate. HCV genotypes 2 and 3 were more prevalent in immigrants than in German inmates, while biochemical parameters did not differ significantly between the two groups. In conclusion, the prevalence of hepatitis C was relatively low among inmates of German YOIs although there were significant differences in relation to the country of birth. Our data highlight the need for educational programmes for young offenders in order to prevent the further spread of HCV.

Surveillance of HIV and viral hepatitis by analysis of samples from drug related deaths

OBJECTIVES

To determine the prevalence of antibodies against HIV, hepatitis B (HBV) and hepatitis C (HCV) in postmortem samples from drug related deaths (DRDs) in Denmark.

DESIGN

Prospective cohort study. Postmortem samples tested for anti-HIV, anti-HCV anti-HBc and anti-HBs. Comparison to pre-mortem testing when possible. DRDs were searched for in the national register of drug treatment, national prison registers, and the national infectious disease register.

SETTING

National level.

PARTICIPANTS

Drug related deaths admitted to Danish Institutes of Forensic Medicine during 2004.

MAIN OUTCOME MEASURES

Prevalence of antibodies, injection drug use, drug treatment experience and prevalence of cirrhosis.

RESULTS

Samples for analysis were obtained from 78% (233/299) of DRDs. The prevalences of anti-HIV, anti-HCV and anti-HBc were 4% (9/214), 51% (110/215), and 35% (74/209), indicating a persisting low prevalence of HIV and a declining prevalence of HCV and HBV. Injecting ever was detected among 45% of DRDs and this was associated with a significantly higher prevalence of hepatitis B and C. Among the DRDs 56% received drug treatment and 12% had cirrhosis at autopsy. Evidence of vaccination against HBV was found among 16% (21/128).

CONCLUSIONS

Monitoring of viral hepatitis and HIV among DRDs is feasible, and our survey indicates a falling prevalence among Danish drug users. Surveillance based on drug users in treatment may overestimate the true prevalence.

A syringe exchange programme in prison as prevention strategy against HIV infection and hepatitis B and C in Berlin, Germany

In two prisons in Berlin, Germany, provision of sterile injection equipment for injecting drug users (IDUs) started in 1998. To assess the programme's impact, the frequency of injecting drug use and syringe sharing, and the incidence of HIV, HBV, and HCV infection were determined in a follow-up study. Of all IDUs (n=174), 75% continued to inject. After the project start the level of syringe sharing declined from 71% during a 4-month period of previous imprisonment to 11% during the first 4 months of follow-up, and to virtually zero thereafter. Baseline seroprevalences for HIV, HBV, and HCV were 18, 53, and 82%. HIV and HCV seroprevalence at baseline was significantly associated with drug injection in prison prior to the project start. No HIV and HBV seroconversions, but four HCV seroconversions occurred. The provision of syringes for IDUs in appropriate prison settings may contribute to a substantial reduction of syringe sharing. However, the prevention of HCV infection requires additional strategies.