Prison-based needle and syringe programmes (PNSP) – Still highly controversial after all these years

Hepatitis C virus reinfection following direct acting antiviral treatment in the prison setting: the SToP-C study

BACKGROUND

Injection drug use (IDU) following treatment for hepatitis C virus (HCV) may lead to reinfection, particularly if access to harm reduction services is suboptimal. This study assessed HCV reinfection risk following direct-acting antiviral therapy within Australian prisons that had opioid agonist therapy (OAT) programs but did not have needle and syringe programs (NSP).

METHODS

The Surveillance and Treatment of Prisoners with hepatitis C (SToP-C) study enrolled people incarcerated in four prisons between 2014-2019. Participants treated for HCV were followed every 3-6 months to identify reinfection (confirmed by sequencing). Reinfection incidence and associated factors were evaluated.

FINDINGS

Among 388 participants receiving treatment, 161 had available post-treatment follow-up and were included in analysis (92% male; median age 33 years; 67% IDU in prison; median follow-up 9 months). Among those with recent (in the past month) IDU (n=71), 90% had receptive needle/syringe sharing. During 145 person-years (PY) of follow-up, 18 cases of reinfection were identified. Reinfection incidence was 12.5/100 PY (95%CI: 7.9-19.8) overall, increasing to 28.7/100 PY; (95%CI 16.3-50.6) among those with recent IDU and needle/syringe sharing. In adjusted analysis, recent IDU with needle/syringe sharing was associated with increased reinfection risk (adjusted hazard ratio [AHR] 14.62; 95%CI 1.84-116.28; p=0.011) and longer HCV testing interval with decreased risk (i.e., chance of detection; AHR 0.41 per each month increase; 95%CI 0.26-0.64; p<0.001).

CONCLUSION

A high rate of HCV reinfection was observed within prison. Post-treatment surveillance and retreatment are essential to limit the impact of reinfection. High-coverage OAT and NSP should be considered within prisons.

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’).

Injecting substance use in prisons in the United States: a case for needle exchange programs

Despite efforts to prevent illicit substance use in prisons, inmates in many countries still have access to them, along with associated paraphernalia. In the United States, a large proportion of people in prison are there due to drug-related charges. The secretive nature of illicit substance use in prison and the opposition to implementing harm reduction interventions such as needle exchange programs have put prisoners who engage in such practices at high risk for infectious bloodborne diseases. While states have their reasons for opposing the implementation of needle exchange programs in prisons, evidence shows that keeping illicit substances out of prisons is difficult. Programs allowing needle exchange programs are currently illegal in the United States. The authors propose that states reconsider their stance on needle exchange programs as the implementation of such programs in several penal institutions worldwide have proven to be successful in reducing bloodborne diseases and promoting and preserving the health of prisoners. By prohibiting needle exchange programs in prison states are not only denying prisoners' access to health care but are also violating prisoner's right to health as recommended by international instruments on prisoner rights. This article advocates for the implementation of needle exchange programs in the United States prison system with a focus on states. It does this by drawing attention to the effectiveness of such programs around the world and to the fact that incarceration does not necessarily reduce illicit substance use.

Hepatitis C virus infection in EU/EEA and United Kingdom prisons: opportunities and challenges for action

BACKGROUND

Hepatitis C virus (HCV) transmission in the European Union, European Economic Area and United Kingdom is driven by injecting drug use (IDU), which contributes to the high burden of chronic infection among people in prisons. This study aimed to describe the context, epidemiology and response targeting HCV in prisons across the region.

METHODS

We retrieved and collated HCV-related data from the World Health Organization's Health in Prisons European Database and the European Centre for Disease Prevention and Control's hepatitis C prevalence database. Prisons population data were obtained from the Council of Europe Annual Penal Statistics on prison populations (SPACE I).

RESULTS

There were 12 to 93,266 people in prisons, with rates of 31·5 to 234·9 per 100,000 population. Median age was between 31 and 40 years, with up to 72% foreign nationals. Average detention time ranged from one to 31 months. Ministries of Health had sole authority over prisons health, budget administration and funding in 27, 31 and 8% of 26 reporting countries, respectively. Seroprevalence of HCV antibodies ranged from 2·3% to 82·6% while viraemic infections ranged from 5·7% to 8·2%, where reported. Up to 25·8 and 44% reported current and ever IDU, respectively. Eight countries routinely offered HCV screening on an opt-out basis. Needle and syringe programmes were available in three countries. Among the nine countries with data, the annual number of those who had completed HCV treatment ranged between one and 1215 people in prisons.

CONCLUSIONS

HCV burden in prisons remains high, amidst suboptimal levels of interventions. Systematic monitoring at both local and regional levels is warranted, to advance progress towards the elimination of HCV in the region.

Hepatitis C virus (HCV) care in Canadian correctional facilities: Where are we and where do we need to be?

Approximately 25% of people in Canadian correctional facilities have been previously exposed to hepatitis C virus (HCV). Despite being a high-prevalence setting, most Canadian prisons have thus far failed to engage the majority of those with chronic HCV infection in care. Several factors, including the lack of systematic screening programs, lack of on-site and trained health care personnel to improve access to care and treatment during incarceration, and the absence of standardized procedures needed to facilitate linkage to care following release likely contribute to poor engagement along the HCV care cascade for people in prison. HCV screening and engagement in care for people in prison can be improved through the implementation of universal opt-out screening upon admission and consideration of multidisciplinary care models for the provision of care. As well, the dissemination of prison-based needle and syringe programs to avert new HCV infections and re-infections should be considered. To meet the World Health Organization (WHO) 2030 HCV elimination goals, engaging researchers, clinicians and other health care providers, policy makers, correctional officials, and members of community in dialogue will be an essential first step going forward.

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.

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.

Incarceration history and risk of HIV and hepatitis C virus acquisition among people who inject drugs: a systematic review and meta-analysis

BACKGROUND

People who inject drugs (PWID) experience a high prevalence of incarceration and might be at high risk of HIV and hepatitis C virus (HCV) infection during or after incarceration. We aimed to assess whether incarceration history elevates HIV or HCV acquisition risk among PWID.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO databases for studies in any language published from Jan 1, 2000 until June 13, 2017 assessing HIV or HCV incidence among PWID. We included studies that measured HIV or HCV incidence among community-recruited PWID. We included only studies reporting original results and excluded studies that evaluated incident infections by self-report. We contacted authors of cohort studies that met the inclusion or exclusion criteria, but that did not report on the outcomes of interest, to request data. We extracted and pooled data from the included studies using random-effects meta-analyses to quantify the associations between recent (past 3, 6, or 12 months or since last follow-up) or past incarceration and HIV or HCV acquisition (primary infection or reinfection) risk among PWID. We assessed the risk of bias of included studies using the Newcastle-Ottawa Scale. Between-study heterogeneity was evaluated using the I2 statistic and the P-value for heterogeneity.

FINDINGS

We included published results from 20 studies and unpublished results from 21 studies. These studies originated from Australasia, western and eastern Europe, North and Latin America, and east and southeast Asia. Recent incarceration was associated with an 81% (relative risk [RR] 1·81, 95% CI 1·40-2·34) increase in HIV acquisition risk, with moderate heterogeneity between studies (I2=63·5%; p=0·001), and a 62% (RR 1·62, 95% CI 1·28-2·05) increase in HCV acquisition risk, also with moderate heterogeneity between studies (I2=57·3%; p=0·002). Past incarceration was associated with a 25% increase in HIV (RR 1·25, 95% CI 0·94-1·65) and a 21% increase in HCV (1·21, 1·02-1·43) acquisition risk.

INTERPRETATION

Incarceration is associated with substantial short-term increases in HIV and HCV acquisition risk among PWID and could be a significant driver of HCV and HIV transmission among PWID. These findings support the need for developing novel interventions to minimise the risk of HCV and HIV acquisition, including addressing structural risks associated with drug laws and excessive incarceration of PWID.

FUNDING

Engineering and Physical Sciences Research Council, National Institute for Health Research, National Institutes of Health.

“I Lost Me Visits”

Utilizing Bacchi’s poststructuralist approach, “What’s the problem represented to be?,” we critically examine how the “problem” of drug use in prison is represented within a key initiative—the Identified Drug User program (IDUP)—of prison drug policy in one Australian jurisdiction. We use two data sources for our analysis: interview transcripts of recently incarcerated young men (aged 19–24) with histories of injecting drug use and selected prison drug policy and program documents. We examine how the “problem” of drug use in prison is problematized within the IDUP and question commonly accepted ways of thinking that underpin the program. We explore the discursive and subjectification effects of problem representations which produce young men as “rational” and “choosing” and, at the same time, as “untrustworthy” and “deserving of punishment.” We highlight how these effects have consequences for young men’s connections to family while incarcerated which can work against the very issues the IDUP is trying to address. We make two claims in particular: that the IDUP produces harmful effects for young men and their families and that the harmful effects produced are, paradoxically, those the IDUP aims to avoid. Our analysis offers insights into how drug use in prison could be thought about differently, including suggestions that might reduce at least some of its adverse effects.

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.

The Prison Economy of Needles and Syringes: What Opportunities Exist for Blood Borne Virus Risk Reduction When Prices Are so High?

Aim

A formal Needle and Syringe Program (NSP) is not provided in Australian prisons. Injecting equipment circulates in prisons as part of an informal and illegal economy. This paper examined how this economy generates blood-borne virus (BBV) risk and risk mitigation opportunities for inmates.

Method

The HITS-p cohort recruited New South Wales inmates who had reported ever injecting drugs and who had a negative HCV serological test within 12 months prior to enrolment. For this study, qualitative interviews were conducted with 30 participants enrolled in HITS-p. Participants included 10 women and were incarcerated in 12 prisons.

Results

A needle/syringe was nominated as being typically priced in the ‘inside’ prison economy at $100-$150, with a range of $50-$350. Purchase or hire of equipment was paid for in cash (including transactions that occurred outside prison) and in exchange for drugs and other commodities. A range of other resources was required to enable successful needle/syringe economies, especially relationships with visitors and other prisoners, and violence to ensure payment of debts. Strategies to mitigate BBV risk included retaining one needle/syringe for personal use while hiring out others, keeping drug use (and ownership of equipment) “quiet”, stealing used equipment from the prison health clinic, and manufacture of syringes from other items available in the prison.

Conclusions

The provision of prison NSP would disrupt the inside economies built around contraband needles/syringes, as well as minimise BBV risk. However, any model of prison NSP should be interrogated for any unanticipated markets that could be generated as a result of its regulatory practices.