HIV and Harm Reduction in Prisons School of Public Health and Community Medicine Professor Kate Dolan Program of International Research and Training National Drug and Alcohol Research Centre UNSW, Sydney, Australia UNODC Scientific Event Science Addressing Drugs And Health: State of the Art 11 March 2014, Vienna, Austria
Background 10 million prisoners - 3 million remandees in the world BUT 30 million individuals enter and leave prison - 90% male Prison populations grew by 25% in the last 15 years Drug dependence key factor in prison growth US popn up 13%, prison popn up 33%, PWIDs prisoners up 43%. 1/3 of 200,000 heroin users in US imprisoned annually 60% of PWIDs in a 12-city study been in prison. Re-incarceration rates very high for PWIDs In Australia, 84% of PWIDs inmates were re-incarcerated in 2 yrs of release versus 44% of all prisoners. They had a mean of 5 imprisonments.
Background HIV is a major health problem for prisons around the world. Prison settings have characteristics that increase HIV transmission. HIV, HBV, HCV, TB & mental illness more prevalent in prison High HIV infection and the over-representation of PWIDs in prisons combined risk behaviour create a critical public-health issue for prison authorities. Unless HIV is controlled in the prison setting it may not be controlled in broader community of some countries. Prison settings are a practical point of HIV prevention and treatment
Background Few clear documented cases of HIV transmission in prison Because it is difficult to gain access and the vast turnover of inmates HIV transmission does occur in prison, and can be extensive. HIV prevention programs for prisoners are rare Prisons are very expensive while HIV programs are not. the US prison system costs US$74 billion ($25,144 per inmate). the Australian prison system cost $2.4 billion ($50,874 per inmate). Hepatitis C and TB are very common in prison populations
Aim Systematic review of the HIV situation in prisons for all countries on A. Imprisonment rates B. HIV prevalence among male, female, PWIDs, MSM, sex workers and transgender prisoners, C. HIV transmission and incidence D. AIDS related mortality E. Provision of HIV programs The time period under observation was from January 2008 to April 2013.
Methods A multilingual (English, German, Spanish, Croatian, French, Arabic, Portuguese and Russian) desk review of the literature A survey of UN staff and experts List of Countries from http://www.unaids.org/en/regionscountries/countries/ Imprisonment rates from the International centre for prison studies http://www.prisonstudies.org/info/worldbrief/
Results We identified 4,640 peer reviewed papers and 8,292 documents (see figure 1). Total included documents (N=261)
The Review Procedure Results of search in 238 Grey Literature Databases (N=8292) Results after title exclusion (N=611) Total included Grey Literature documents (N=128) Documents sent by UNODC officer (N=169) Results of exclusion due to irrelevant content or being out of date (N=92) Total included received files (N=77) Excluded articles on basis of title (N=3549), Abstracts (N=390), and unremoved duplicates (N=340) Total included documents (N=261) Full text exclusion (N=305) Total included peer-reviewed paper (N=56) Pee-reviewed literature (N=12570), Medline (N=5194), Web of Science (N=5001), Embase (N=2375) Results from duplicate removal in each database (N=6111), Medline (N=2045), Web of Science (N=2832), Embase (N=1234) Combination of search results and duplication removal (N=4640)
Table 1: Countries with data on imprisonment rates and HIV prevalence and regional imprisonment rates Region No. of countries Imprisonment rate HIV prevalence among inmates All Male Female PWIDs MSM East/ Southern Africa 20 182 10 6 6 1 1 West/Central Africa 25 68 12 2 2 1 Asia and Pacific 35 129 8 4 5 1 Caribbean Eastern Europe and Central Asia 16 30 332 220 1 12 6 6 3 Latin American* Middle East and North African 17 21 210 128 3 7 4 4 3 3 2 Other Countries Total 22 196 127 146 6 58 2 28 1 26 1 9 2 3
Table 2: the percentage of PWIDs in prison populations Country Past IDU % Afghanistan 1 Hungary 1 Belgium 2 Kenya 3 Cape Verde 3 Thailand 3 Iran 3 (Females) Tanzania 6 Netherlands 8 UK 1-8 Latvia 9 Brazil 10 Spain 9-24 Ukraine 35-48 Australia 17 68
Table 3: HIV positive in prison populations East and South Africa % Mozambique 5-17 Kenya 6 27 Rwanda 6 Ethiopia 7 Uganda 11 South Africa 16 Swaziland 35 Zambia 42
Table 4: HIV positive in prison populations West and Central African Region % Nigeria 2 Cape Verdi 2 Niger 3 Senegal 3 Cote d Ivoire 4 Mauritania 4 Burkina Faso 5 Cameroon 5-8 Togo 7 DR Congo 8 Ghana 10-20
Table 5: HIV positive in prison populations Asia and Pacific Region % Australia 0 Sri Lanka 0 Pakistan 2 Cambodia 3 Malaysia 6 India 7 Indonesia 7 Vietnam 10
Table 6: HIV positive in prison populations Eastern Europe and Central Asia % Hungary <1 Azerbaijan 3 Lithuania 4 Russian Federation 4 R. Moldova 5 Kazakhstan 2-6 Latvia 7 Romania 1-10 Estonia 14 Ukraine 10-20
Table 7: HIV positive in prison populations Latin America Region % Chile 2 Argentina 3 Mexico 1-12 Brazil 6 (males)
Table 8: HIV positive in prison populations Middle East and North African Region % Egypt 0 Iran 0 2 Morocco < 1 Oman < 1 Saudi Arabia < 1 Afghanistan 1 4
Table 9: HIV positive in prison populations Other Countries Region % Netherlands 0 Hong Kong 1 Luxembourg 1 USA 1 Females Italy 4 Portugal 6 Spain 6 11
Table 10: Injecting and sharing in prison populations and in IDU prisoners Country % injected % shared Russia 10 66 Greece 20 83 Greece 24 92 Thailand 25 78 IDU INMATES Afghanistan 17 Australia 31 70 Scotland 37 Scotland 58 Pakistan 22-70 56 Australia 74 90
Table 11: Outbreaks of HIV transmission in prison populations and in IDU prisoners Country incidence Thailand 35/per 100 Lithuania 300 inmates infected in 6 months Doubled number of HIV cases Russia 400 inmates infected in a few months Iran Two outbreaks with hundreds infected Australia At least 4 up to 12 Scotland 12 Afghanistan 17
Table 12: TB in prison populations Prevalence /100,000 MDR- TB % Incidence % Russia 4,560 12 55 Georgia 5,995 13 Azerbaijan, 89 Thailand 568 19 Zambia 4,000 9 Brazil 30 USA 0.4 8
Table 13: Hepatitis C transmission in prison Location Incidence in PWIDs in prison per 100 person yr Scotland Taylor 3 US Macalino 5 UK Champion 12 Australia Dolan HITS 34 18 13 Australia Dolan 24 in MMT 32 no MMT
Mortality after prison release 1 0.99 Rate of survival Left prison on methadone 0.98 0.97 0.96 Left prison not on methadone 0.95 0 3 6 9 12 15 18 21 24 27 30 33 36
Table 14. Summary of the number of countries with HIV programs Region No of countries East Sth Africa West Central Africa Asia Pacific Caribbean East Europe Latin MENA Other Total 20 25 35 16 30 17 21 24 196 NSP 6 1 4 11 OST 5 7 2 10 24 VCT 8 5 13 1 3 8 6 11 65 HIV treat 8 3 8 2 8 4 8 41 STI 5 1 9 1 6 1 4 7 34 Condoms 6 3 7 7 1 5 29 IEC 8 3 10 1 12 6 5 9 54 Prevent, treat Hepatitis 8 1 4 11 2 4 16 42 TB 8 3 7 1 11 6 2 4 42
Evaluations of harm reduction in prison Positive evaluations have been documented for all programs Condoms decrease in unsafe sex OST decrease in injecting and sharing, trend to decrease HCV NSP decrease in injecting and sharing, no HIV/ HCV transmission HIV education improved knowledge
Recommendations Good prisoner health is good public health: High turnover of inmates mean diseases contracted inside leave prison. Start and continue ARV and TB treatment is essential to prevent HIV drug resistance and MDR-TB. Reduce prison populations: Provide OST also stops mortality. Divert drug offenders to treatment whenever possible. Provide NSP and condoms to reduce HIV transmission in prison. Prisoners have a legal right to medical treatment same level as in the community. Compassionate release from prison should be available to inmates in the final stages of AIDS.
Acknowledgment Co-authors Babak Moazen, Atefeh Noori, Shadi Rahimzadeh, Farshad Farzadfar, Stuart Kinner and Ernie Drucker.