Elsevier

The Lancet

Volume 388, Issue 10049, 10–16 September 2016, Pages 1089-1102
The Lancet

Series
Global burden of HIV, viral hepatitis, and tuberculosis in prisoners and detainees

https://doi.org/10.1016/S0140-6736(16)30466-4Get rights and content

Summary

The prison setting presents not only challenges, but also opportunities, for the prevention and treatment of HIV, viral hepatitis, and tuberculosis. We did a comprehensive literature search of data published between 2005 and 2015 to understand the global epidemiology of HIV, hepatitis C virus (HCV), hepatitis B virus (HBV), and tuberculosis in prisoners. We further modelled the contribution of imprisonment and the potential impact of prevention interventions on HIV transmission in this population. Of the estimated 10·2 million people incarcerated worldwide on any given day in 2014, we estimated that 3·8% have HIV (389 000 living with HIV), 15·1% have HCV (1 546 500), 4·8% have chronic HBV (491 500), and 2·8% have active tuberculosis (286 000). The few studies on incidence suggest that intraprison transmission is generally low, except for large-scale outbreaks. Our model indicates that decreasing the incarceration rate in people who inject drugs and providing opioid agonist therapy could reduce the burden of HIV in this population. The prevalence of HIV, HCV, HBV, and tuberculosis is higher in prison populations than in the general population, mainly because of the criminalisation of drug use and the detention of people who use drugs. The most effective way of controlling these infections in prisoners and the broader community is to reduce the incarceration of people who inject drugs.

Introduction

From the beginning of the AIDS epidemic in 1981, the association between HIV, tuberculosis, and prisons was apparent,1 with HIV responsible for a steep rise in tuberculosis in US prison populations.2 This is important because the prevalence of HIV in prisons in many countries is high, with one review reporting levels greater than 10% in 20 low-income and middle-income countries.3 Several factors have a role in the epidemics of HIV, tuberculosis, and related infections in prisons.4 Many individuals who are most likely to be incarcerated are at greatest risk of these infections, whether because of injection drug use for HIV and viral hepatitis or poverty and overcrowding for tuberculosis. Drug injection is common in prison inmates, ranging from 2% to 38% in Europe, 34% in Canada, and up to 55% in Australia, in stark contrast with the percentage in the general population, estimated at 0·3% in the European Union and 0·2% in Australia.5 Prisons provide many opportunities both for the spread4 and prevention of these infections.6

The situation is complicated further by the expansion of parallel prison systems for those suspected of drug use in at least 27 countries. These compulsory drug detention centres operate extrajudicially and often under the guise of drug treatment (panel 1).20 Punishment and inhumane conditions are widespread, but evidence-based treatment for drug dependence and infectious diseases is rare or non-existent.7, 21 However, prisons not only pose a threat to the health of people incarcerated within them. They also pose a risk to staff and to the population at large, because detainees are not a static population, but move around the prison system and back and forth from the outside world.

The risks particularly lie at the interface between prisons and society outside. In the USA, HIV incidence is highest in detainees who were released and re-incarcerated compared with continuously incarcerated prisoners, people who inject drugs with no history of incarceration, and men who have sex with men (MSM; panel 2).4 The period immediately after release is especially risky for receptive syringe sharing, acquisition of HIV and hepatitis C virus (HCV), and mortality.29, 30, 31, 32 Thus, the transition between the prison and community settings represents a high-risk environment, especially for people with substance use disorders.31 This is important because, although an estimated 10·2 million people were incarcerated at any time in 2014, over 30 million individuals transition from prison to the community each year.33 Prisons act as incubators for tuberculosis and HIV, because they are associated with higher levels of infection than in the surrounding populations,3, 34 yet many countries have parallel and vertical systems, with fragmented policy responses to these interlinked issues—prisons, HIV, viral hepatitis, and tuberculosis—and interruptions of surveillance and treatment during transitions. This Series paper encourages a coordinated response by reviewing the global epidemiology of HIV, HCV, HBV, and tuberculosis in prison populations.35, 36

Key messages

  • Prevalence of HIV, HCV, HBV, and tuberculosis is higher in prison populations than in the general population, mainly because of the criminalisation of drug use and the detention of people who inject or use drugs

  • We strongly support the UN's 2012 call to close compulsory drug detention centres and expand voluntary, evidence-based treatment in the community

  • Mathematical modelling suggests that incarceration and re-incarceration of people who inject drugs contributes to the overall HIV epidemic and a reduction in incarceration of this population will reduce the incidence of HIV

  • Evidence-based prevention and treatment such as opioid agonist therapy and antiretroviral therapy can substantially reduce the incidence of HIV, HCV, and HBV, and reduce drug dependence in this population

  • Responses to co-infection with HIV and tuberculosis should include an integrated, patient-centred model of prevention and care, with systematic screening of high-risk groups and equitable access to effective treatment

  • The most effective way of controlling infection in prisoners and the broader community is to reduce mass incarceration of people who inject drugs

Section snippets

Disease burden in prisoners and detainees

We did a comprehensive review of studies of prevalence and incidence data on HIV, HCV, HBV, tuberculosis, and co-infection with tuberculosis and HIV in prisoners and detainees, published between Jan 1, 2005, and Nov 30, 2015, for 196 countries in 2015 (appendix p 2, 4).37 We searched for studies with biological markers of each infection in general prisoners and in people who inject drugs, MSM, female sex workers, and transgender people, in prisons, jails, and compulsory drug detention centres.

Pooled estimated HIV prevalence in prisoners

74 of 196 countries37 had HIV prevalence data in 2015 (200 datapoints) in prisoners (appendix p 8). The regions most affected were the two African regions (east and southern Africa and west and central Africa), which have a high prevalence in the general population, and the two European regions (eastern Europe and central Asia and west Europe), reflecting the over-representation of people who inject drugs in prison—a group with a high prevalence of HIV infection. Transmission via injection drug

Pooled estimated HCV prevalence in prisoners

46 of 196 countries had HCV prevalence data (171 datapoints; hepatitis C antibody) in prisoners from 2005 to 201537 (appendix p 8). HCV infection in prisoners is high worldwide, exceeding 10% in six regions (Figure 1, Figure 3, appendix p 15). This finding reflects the increased infectivity and earlier HCV entry into populations of people who inject drugs compared with HIV.59

Epidemic patterns of HCV infection related to injection drug use persist in Europe. HCV prevalence estimates were high in

Pooled estimated HBV prevalence in prisoners

43 of 196 countries had HBV prevalence data (56 datapoints) in prisoners from 2005 to 2015 (figure 3, appendix pp 8, 20).37 The prevalence of HBsAg in prisoners in west and central Africa was very high at 23·5% (95% CI 19·8–27·5)—the highest burden of all four types of infection and across the nine regions. High levels of chronic HBV infection were also reported in east and southern Africa (5·7%, 95% CI 2·9–9·4) and in eastern Europe and central Asia (10·4%, 1·9–24·6). In other regions, HBV

Prevalence of active tuberculosis and co-infection with HIV in prisoners

Estimates of active tuberculosis in prison populations were higher than in the general population in almost all settings, with investigators of one study, from the Dourados prison in Brazil, estimating that prevalence of tuberculosis was 40 times higher than in the general population.63

25 of 196 countries reported tuberculosis prevalence data (46 datapoints) and 17 of 196 countries prevalence data on co-infection with HIV and tuberculosis (25 datapoints) in prisoners from 2005 to 2015 (figure 4

Incidence of HIV, HCV, HBV, and tuberculosis in prisoners

Few incidence studies were found on HIV (three countries), HCV (four), HBV (two), and tuberculosis (14; appendix p 32). Spain had detailed annual HIV incidence data from 2000 to 2014 that revealed a steady decline from 0·70% to 0·04% per year over 14 years.68 A large prospective study of hepatitis C incidence in prisons in Australia reported an annual incidence of 14·1%,69 which was high compared with Scotland (0·9%),70 the USA (0·4%),71 and Spain (1·7%).72

Of the 14 countries with tuberculosis

HIV, HCV, HBV, and tuberculosis in imprisoned MSM, female sex workers, and transgender people

Estimates of infectious diseases in key populations who become imprisoned (eg, MSM, female sex workers, and transgender people) are less frequently reported than in people who inject drugs. In 2008, HIV prevalence in Ghana in imprisoned female sex workers (n=73) was 11% and 8·9% in MSM (n=403).81 HIV prevalence in imprisoned MSM was 43·8% in Nigeria (n=32 in 2009), 2·6% in Iran (n=113), and 5·5–34·0% in the USA.82, 83, 84, 85, 86, 87, 88, 89, 90 The only study of transgender prisoners was done

Mathematical modelling of HIV transmission and prevention in people who inject drugs

We modelled the contribution of incarceration and re-incarceration on HIV incidence in people who inject drugs and examined the effects of a reduced rate of incarceration, introduction of prison-based opioid agonist therapy followed by post-release opioid agonist therapy, and post-release antiretroviral treatment retention on HIV incidence.

In our model, the increased risk for HIV transmission was captured by behaviour change in people who inject drugs who temporarily receptively share syringes

Summary of findings

This Series paper provides clear evidence that the findings, replicated in many individual studies, that higher prevalence of HIV in individuals who are detained than in the population from which they arise, is almost universal. However, it also shows that the detailed epidemiology of HIV in people who are detained varies considerably, reflecting the disease burden, the dominant mode of transmission in the population as a whole, and the role of incarceration. In most regions of the world, HIV

Conclusion

We found a consistently higher prevalence of HIV, HCV, HBV, and tuberculosis in prisoners than in the general population across all regions and especially in imprisoned people who inject drugs.38, 61, 116 Interventions to prevent, identify, and treat these infections in prisons are poorly implemented, particularly in low-income and middle-income countries and in populations such as people who inject drugs, where care and treatment remain challenging in community settings. Investment in

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