With an estimated 30 million people passing in and out of prisons every year, prisoners will be key to controlling HIV and tuberculosis epidemics and reducing hepatitis spread worldwide, according to a major six-part series on HIV and related infections in prisoners, published in The Lancet and being presented at the International AIDS Conference in Durban, South Africa this week.1

“Prisons can act as incubators of tuberculosis, hepatitis C, and HIV and the high level of mobility between prison and the community means that the health of prisoners should be a major public-health concern. Yet, screening and treatment for infectious diseases are rarely made available to inmates, and only around 10% of people who use drugs worldwide are being reached by treatment programmes”, an author of the Series and President of the International AIDS Society Professor Chris Beyrer, John Hopkins Bloomberg School of Public Health, Baltimore, said in a prepared statement. “The most effective way of controlling infection in prisoners and the wider community is to reduce mass imprisonment of injecting drug users.”2



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Data presented in the series show that with growing numbers of injecting drug users in prison, the prevalence of infectious diseases has also increased. For example: levels of HIV infection are 20 times higher among prisoners in western Europe than the civilian population (4.2% vs 0.2%), and around three times higher among prisoners in eastern and southern Africa (15.6% vs 4.7%) and north America (1.3% vs. 0.3%). 

While most prisoners are men, women and girls are the fastest growing imprisoned group worldwide, and in most regions of the world, levels of HV infection are higher in female inmates than male prisoners including eastern Europe and central Asia (22% vs 8.5%). High rates of hepatitis C are also seen among prisoners, with 1 in 6 inmates in parts of Europe and the USA carrying hepatitis C virus, according to the series.

Active tuberculosis prevalence is also higher in prisons than the general population in all settings, according to the series. One study demonstrated that prevalence was 40 times higher in one prison in Brazil than the general population. Moreover, new estimates produced for the Series suggest that up to half of all new HIV infections over the next 15 years in eastern Europe will stem from increased HIV transmission risk among inmates who inject drugs; and imprisonment could be responsible for three-quarters of new tuberculosis infections among people who inject drugs, and around 6% of all yearly tuberculosis infections. High rates of injecting drug use in some settings, lack of access to condoms, unsanitary conditions, and gross overcrowding have made prisons and detention centers high risk environments for spread of these infections. 

Almost half of countries in sub-Saharan Africa report that prisons are at 150% capacity or higher. Increased frequency and duration of imprisonment increase individual risk for these infections, particularly HIV and tuberculosis. 

But these health issues do not remain confined to prisons. With around 10.2 million people imprisoned worldwide at any given time (nearly 2.2 million in the USA alone), and an estimated 30 million passing in and out of prison each year, substantial numbers of undiagnosed and untreated infections in prison can spread to the community when prisoners return home. Treatment interruptions upon release threaten former prisoners and their communities, according to the researchers. 

The Series brings together a wealth of evidence to show that countries can reduce and even reverse infectious disease transmission by scaling up proven harm reduction and treatment strategies in prisons like opioid agonist therapy (OAT), antiretroviral therapy (ART), hepatitis B vaccination, condom distribution, and sterile needle and syringe exchange. 

Modelling conducted for the Series suggests that reducing mass incarceration of people who use drugs, in this case lowering the number of prisoners who inject drugs by 25%, could result in a 7–15% drop in new cases of HIV among injecting drug users in the community over 5 years. Similarly, scaling up OAT (eg, methadone and buprenorphine) to all those in need in prison, and after release, could prevent over a quarter (28%) of new HIV cases in people who inject drugs in just 5 years, according to the series. 

Although such interventions have proved successful in prisons and are required by international human rights law, they are severely underfunded and are often impeded by discrimination and restrictive prison rules in all countries—both in high- and low- income countries. 

The authors of the series make several recommendations to improve access to health care for prisoners—leading with the urgent need to recognize the contribution of prison health to health inequalities, and to make prison health a priority by convincing governments that health policy must be based on the best available evidence. Other recommendations include addressing the fundamental right of prisoners to a minimum standard of health care at least equivalent to the wider community; and to increase cooperation and coordination between criminal justice and public health systems.

Reference

1. Dolan K, Wirtz AL, Moazen B, et al. Global burden of HIV, viral hepatitis, and tuberculosis in prisoners and detainees. Lancet. 2016;  doi.org/10.1016/S0140-6736(16)30466-4.

2. International AIDS Society Communications. Mass imprisonment of drug users driving global epidemics of HIV, hepatitis, and tuberculosis. Press release. 2016. Presented at: AIDS 2016. July 19. Durban, South Africa.