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

Using nominal group technique with people who are incarcerated in Canadian federal prisons to identify barriers and solutions to improving Prison Needle Exchange Program uptake

BACKGROUND

Prison needle exchange programs (PNEPs) are a critical component for harm reduction in prisons. Little is known about the PNEP access barriers for people who are incarcerated, but the low uptake in the Canadian program highlights these constraints. We aimed to identify the barriers and potential solutions for increasing PNEP coverage in the nine Canadian federal prisons where they operate.

METHODS

Eighteen focus groups were conducted in nine prisons using nominal group technique (NGT) with two stakeholders: peer advocates and people who use or identified as potential users of the PNEP. NGT uses a round-robin technique followed by generating a list of barriers to PNEP enrolment within their prison. Participants then allocated votes to rank the highest priority barriers, followed by an identical process to generate solutions to address the top three barriers. Interview transcripts describing participant narratives during this process were de-identified and coded to generated themes. Barriers and solutions receiving >10 % of votes within respective participant groups, alongside associated narratives, are discussed more fully.

RESULTS

Fear of repercussions due to drug use, lack of confidentiality, and fear of being targeted and sanctioned by correctional authorities were perceived by both stakeholder groups as the top barriers inhibiting PNEP enrolment. Stigma (peer advocates) and the application process for the program (PNEP users) were also ranked as a priority. Proposed solutions included education and external oversight of PNEP (i.e., not via correctional officers) by both groups. Peer advocates regarded improving participant confidentiality and a supervised/safe injection site as potential enablers for program participation, while PNEP users identified wrap-around services as likely to improve access.

CONCLUSION

Barriers to increasing PNEP coverage in Canadian federal prisons proposed by participants highlight the importance of trust and perceived repercussions surrounding program participation. These barriers and proposed solutions highlight a need for changes in implementation to PNEP delivery if the potential health benefits of PNEPs are to be realised.

Understanding hepatitis C virus (HCV) health literacy and educational needs among people in prison to enhance HCV care in prisons

BACKGROUND

Hepatitis C virus (HCV) is a significant concern within prison populations. Provision of HCV testing and treatment for people in prison is expanding and a key component of global elimination efforts. Despite growing service availability, several challenges remain in HCV testing and treatment engagement during incarceration. The PIVOT study demonstrated that a 'one-stop-shop' intervention (point-of-care HCV RNA testing, Fibroscan®, nurse-led clinical assessment, and fast-tracked direct-acting antiviral prescription) enhanced HCV testing and treatment at a reception prison in Australia. Utilising Squier et al's Health Literacy Skills Framework, this analysis aimed to understand HCV health literacy and educational needs among people at a reception prison in Australia.

METHODS

Semi-structured interviews were conducted with twenty-four male PIVOT study participants. Purposive sampling ensured comparable representation of those with: 1) prior HCV testing history (standard pathology / no prior testing), and 2) injecting drug use history (IDU; ever / never).

RESULTS

Varied HCV health literacy levels and educational needs were evident amongst people in prison. Whilst those with multiple incarceration episodes and IDU history (prior knowledge) appeared to have stronger HCV health literacy than those without, substantial gaps in HCV health literacy were evident. Knowledge of HCV transmission risks in prison was high, and most understood the importance of HCV testing and treatment in prison (comprehension), but ability to engage with HCV testing and treatment services, participation in safe injecting behaviours (health-related behaviours), and knowledge of re-infection and re-treatment, within the context of the prison environment, were suboptimal. There was a general desire for increased HCV education in prison.

CONCLUSION

Gaps in HCV health literacy among people in prison were evident, indicating opportunities for improvement. A targeted HCV education program for people in prison, addressing the gaps identified in this analysis, may enhance HCV testing, treatment, and prevention by fostering stronger HCV health literacy among people in prison.

Hepatitis B and hepatitis C virus infections and associated factors among prisoners in Gondar City, Northwest Ethiopia

BACKGROUND

Globally, hepatitis B virus (HBV) and hepatitis C virus (HCV) cause considerable morbidity and mortality from their acute and chronic infections. The transmission of the viruses within the prisons is high due to overcrowding, and other risk behaviors such as drug use, and unsafe sexual practices. This study aimed at determining the prevalence and associated factors of HBV and HCV infections among prisoners in Gondar city, Northwest Ethiopia.

METHODS

A cross-sectional study was conducted in the Gondar City Prison Center from May 1, 2022, to July 30, 2022. A total of 299 prison inmates were selected by using a systematic random sampling technique. A semi-structured questionnaire was used to collect data on sociodemographic, clinical, behavioral and prison related factors. Five milliliters of blood sample were collected, and the serum was separated from the whole blood. The serum was tested for HBV surface antigen (HBsAg) and anti-HCV antibody by using an Enzyme-Linked Immunosorbent Assay (ELISA). Data was entered using EpiData version 4.6.0 and exported to SPSS version 20 for analysis. Logistic regression analysis was done to assess the association between the independent variables and HBV and HCV infections. P-values < 0.05 were considered statistically significant.

RESULTS

The overall seroprevalence of HBV or HCV infections was 10.4%. The seroprevalence of HBV and HCV infections was 7.0% and 4.0%, respectively. It has been demonstrated that having several heterosexual partners, sharing sharp materials in prison, having longer imprisonment, and having a body tattoo are significantly associated with HBV infection. The presence of a body tattoo, a history of surgical procedures, and previous imprisonment are associated risk factors for HCV infection.

CONCLUSION

The prevalence of HBV and HCV were high-intermediate and high, respectively. Therefore, preventative and control initiatives are needed in prisons to decrease the rate of infection and transmission.

Incarceration history is associated with HIV infection among community-recruited people who inject drugs in Europe: A propensity-score matched analysis of cross-sectional studies

AIMS

We measured the association between a history of incarceration and HIV positivity among people who inject drugs (PWID) across Europe.

DESIGN, SETTING AND PARTICIPANTS

This was a cross-sectional, multi-site, multi-year propensity-score matched analysis conducted in Europe. Participants comprised community-recruited PWID who reported a recent injection (within the last 12 months).

MEASUREMENTS

Data on incarceration history, demographics, substance use, sexual behavior and harm reduction service use originated from cross-sectional studies among PWID in Europe. Our primary outcome was HIV status. Generalized linear mixed models and propensity-score matching were used to compare HIV status between ever- and never-incarcerated PWID.

FINDINGS

Among 43 807 PWID from 82 studies surveyed (in 22 sites and 13 countries), 58.7% reported having ever been in prison and 7.16% (n = 3099) tested HIV-positive. Incarceration was associated with 30% higher odds of HIV infection [adjusted odds ratio (aOR) = 1.32, 95% confidence interval (CI) = 1.09-1.59]; the association between a history of incarceration and HIV infection was strongest among PWID, with the lowest estimated propensity-score for having a history of incarceration (aOR = 1.78, 95% CI = 1.47-2.16). Additionally, mainly injecting cocaine and/or opioids (aOR = 2.16, 95% CI = 1.33-3.53), increased duration of injecting drugs (per 8 years aOR = 1.31, 95% CI = 1.16-1.48), ever sharing needles/syringes (aOR = 1.91, 95% CI = 1.59-2.28) and increased income inequality among the general population (measured by the Gini index, aOR = 1.34, 95% CI = 1.18-1.51) were associated with a higher odds of HIV infection. Older age (per 8 years aOR = 0.84, 95% CI = 0.76-0.94), male sex (aOR = 0.77, 95% CI = 0.65-0.91) and reporting pharmacies as the main source of clean syringes (aOR = 0.72, 95% CI = 0.59-0.88) were associated with lower odds of HIV positivity.

CONCLUSIONS

A history of incarceration appears to be independently associated with HIV infection among people who inject drugs (PWID) in Europe, with a stronger effect among PWID with lower probability of incarceration.

Perceived access to opioid agonist treatment in prison among people with a history of injection drug use: A qualitative study

INTRODUCTION

Opioid agonist treatment (OAT) is associated with a reduced likelihood of hepatitis C incidence, nonfatal overdose, and (re)incarceration among people who inject drugs (PWID), yet factors underpinning decisions to access OAT in prison and postrelease are not well understood. The aim of the qualitative study was to explore the perspectives of OAT access while in prison among PWID recently released from prison in Australia.

METHODS

Eligible participants enrolled in the SuperMix cohort (n = 1303) were invited to take part in a semi-structured interview in Victoria, Australia. Inclusion criteria were informed consent, aged ≥18 years, history of injection drug use, incarcerated for ≥3 months, and released from custody <12 months. The study team analysed data via a candidacy framework to account for macro-structural influences.

RESULTS

Among 48 participants (33 male; ten Aboriginal), most injected drugs in the prior month (n = 41), with heroin most frequently injected (n = 33) and nearly half (n = 23) were currently on OAT (primarily methadone). Most participants described the navigation and permeability of OAT services in prison as convoluted. If not on OAT pre-entry, prison policies often restricted access, leaving participants to withdraw in cells. In turn, some participants commenced OAT postrelease to ensure OAT continuity of care if reincarcerated. Other participants who experienced delayed access to OAT in prison stated no need to initiate while in prison or postrelease as they were now "clean". Last, implementation of OAT delivery in prison (e.g., lack of confidentiality) frequently led to changes in OAT type to avoid peer violence (pressure to divert OAT).

CONCLUSION

Findings draw attention to simplistic notions of OAT accessibility in prisons, illuminating how structural determinants influence choice in PWID decision-making. Suboptimal access and acceptability of OAT delivery in prisons will continue to place PWID at risk of harm postrelease (e.g., overdose).

Mixed-methods evaluation of point-of-care hepatitis C virus RNA testing in a Scottish prison

OBJECTIVES

Hepatitis C virus (HCV) poses a global public health threat. Prisons are a focus of prevention efforts due to high infection burdens. Expedition of treatment for incarcerated people is critical, as many are short-term sentenced. We evaluated point-of-care (PoC) HCV RNA testing in a maximum-security Scottish prison and assessed its impact on transition to treatment. We also evaluated costs and determinants of implementation.

DESIGN

Mixed-methods evaluation of a single-centre care pathway pilot using National Health Service (NHS) data from 2018 to 2021. Descriptive statistics and survival analysis were undertaken. Cost analysis was assessed from a provider perspective. Healthcare staff participated in semistructured interviews and thematic analysis with a deductive approach was undertaken to identify implementation determinants.

SETTING

A large maximum-security Scottish prison health centre administered by the NHS.

PARTICIPANTS

296 incarcerated NHS patients (all men) and six NHS staff members (two men and four women).

INTERVENTIONS

HCV testing using the Cepheid GeneXpert platform with Xpert HCV VL Fingerstick assay.

OUTCOME MEASURES

The main outcome was survival (in days) from HCV test to treatment initiation. Secondary outcomes were cost-per-cure obtained and implementation determinants.

RESULTS

During the pilot, 167 Xpert tests were administered, with an 84% completion rate, and treatment transition was superior for those who received it (p=0.014). Where PoC tests were administered, shorter survival to treatment was observed (19 vs 33 days: adjusted HR (aHR) 1.91 (1.03-3.55), p=0.040; 19 vs 50 days; aHR 3.76 (1.67-8.46), p=0.001). PoC was costlier than conventional testing. In qualitative analysis, most facilitators were observed among characteristics of individual domain while most barriers were noted in the inner setting.

CONCLUSIONS

Integrating PoC HCV RNA diagnosis into nurse-led HCV care in a maximum-security prison health centre shortens survival to HCV treatment. However, there are cost implications to this approach and multiple determinants that impact on implementation should be addressed.

Medication for opioid use disorder treatment continuity post-release from jail: A qualitative study with community-based treatment providers

BACKGROUND

People released from jail are at elevated opioid overdose risk. Medications for opioid use disorder (MOUD) are effective in reducing overdoses. MOUD treatment was recently mandated in seven Massachusetts jails, but little is known about barriers and facilitators to treatment continuity post-release. We aimed to assess MOUD provider perspectives on treatment continuity among people released from jail.

METHODS

We conducted qualitative interviews with 36 medical, supervisory, and administrative staff at MOUD programs that serve jail-referred patients. We used the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation science framework to guide development of instruments, codes, and analyses. We employed deductive and inductive coding, and a grounded theory analytical approach to identify salient themes.

RESULTS

Inner context findings highlighted necessary adjustments among jail staff to approve MOUD treatment, especially with agonist medications that were previously considered contraband. Participants perceived that some staff within jails favored abstinence-based recovery, viewing agonists as a crutch. Bridging results highlighted the importance of inter-agency communication and coordination to ensure information transfer for seamless treatment continuity in the community post-release. Pre-release planning, release on pre-scheduled dates, medication provision to cover gaps between jail release and intake at community MOUD sites, and exchange of treatment information across agencies were viewed as paramount to success. Unexpected early releases and releases from court were viewed as barriers to treatment coordination. Outer context domains were largely tied to social determinants of health. Substantial barriers to treatment continuity included shelter, food security, employment, transportation, and insurance reactivation.

CONCLUSION

Through qualitative interviews with community-based MOUD staff, we identified salient barriers and facilitators to treatment continuity post-release from jails. Findings point to needed investments in care coordination, staffing, and funding to strengthen jail-to-community-based MOUD treatment, removing barriers to continuity, and decreasing opioid overdose deaths during this high-risk transition.

A syndemic examination of injecting drug use, incarceration and multiple drug-related harms in French opioid users

PURPOSE

People who inject drugs (PWID) face multiple health problems, including infectious diseases and drug overdoses. Applying syndemic and risk environment frameworks, this paper aims to examine the co-occurrence and clustering of drug-related harms and their association with incarceration experience with or without in-prison drug injection.

DESIGN/METHODOLOGY/APPROACH

The authors used data from a cross-sectional survey conducted in 2015 among 557 active opioid injectors. Self-reported data were collected through face-to-face or online questionnaires. They distinguished three harm categories, namely, viral infections, bacterial infections and overdoses, and built an index variable by summing the number of harm categories experienced, yielding a score from 0 to 3. Association between incarceration experience and co-occurrence of harms was modelled using a multinomial logistic regression.

FINDINGS

Of the 557 participants, 30% reported lifetime experience of drug-related viral infection, 46% bacterial infection and 22% drug overdose. Multinomial logistic models showed that those who injected drugs during incarceration were more likely to report two (aOR = 2.35, 95% CI: 1.03-5.36) and three (aOR = 9.72, 95% CI: 3.23-29.22) harm categories than those who had never been incarcerated. They were also more likely to report three harm categories than formerly incarcerated respondents who did not inject drugs in prison (aOR = 5.14, 95% CI: 1.71-15.48).

ORIGINALITY/VALUE

This study provides insights of the syndemic nature of drug-related harms and highlights that drug injection during incarceration is associated with co-occurring harms. Public health interventions and policy changes are needed to limit the deleterious impact of prison on PWID.