HIV/AIDS and HCV in Prisons
A Select Annotated Bibliography
HIV and HCV Transmission in Prison
This section covers studies that were able to demonstrate HIV and/or HCV transmission in prisons, as well as studies showing that imprisonment correlates with HIV and/or HCV and/or HBV infection. A short section on sexually transmitted infections was also included.
To make materials more accessible, the section is divided into the following subsections:
For each of the regions, the territory covered by the World Health Organization's regional offices can be found via http://www.who.int/about/en/.
 Overviews
Dolan K (1997). AIDS, Drugs, and risk behaviour in prison: state of the art. International Journal of Drug Policy, 8(1).
A summary of the evidence available as of 1997.
Dolan K (1997/98). Evidence about HIV transmission in prisons.  Canadian HIV/AIDS Policy & Law Newsletter, 3(4)/4(1): 32-35.
Another excellent, shorter summary of the evidence available as of 1997, at www.aidslaw.ca/Maincontent/otherdocs/
Newsletter/Winter9798/26DOLANE.html.
Gill O, Noone A, Heptonstall J (1995). Imprisonment, injecting drug use, and bloodborne viruses (editorial). British Medical Journal, 310: 275-276.
This editorial states that associations between imprisonment, injecting drug use, HIV, and other bloodborne viruses have been recognized, but there is still debate over whether or not imprisonment is a risk factor for HIV. Measuring incidence of HIV acquired in prison through IDU is difficult and therefore makes it hard to determine if imprisonment increases or decreases HIV transmission. It concludes: "Uncertainty may remain about whether imprisonment causes injecting drug use or increases overall transmission of bloodborne viruses, but there is no doubt that it provides an opportunity to capitalize on access to those at risk. If the efforts applied to studying transmission could be redirected to developing and evaluating appropriate and acceptable preventive measures, and creative use made of the high turnover rate, this would have a substantial impact on the reservoir of bloodborne viral infections in the population."
Health Canada - Public Health Agency of Canada (2004). Hepatitis C virus transmission in the prison/inmate population. Canada Communicable Disease Report, 30(16): 141-148.
www.phac-aspc.gc.ca/publicat/ccdr-rmtc/04vol30/dr3016ea.html
Provides an overview of HCV transmission in prisons.
Krebs CP, Simmons M (2002). Intraprison HIV transmission: an assessment of whether it occurs, how it occurs, and who is at risk. AIDS Education and Prevention, 14 (Suppl B): 53-64.
It is apparent that high-risk HIV transmission behaviours occur inside prison; however, data validly documenting instances of intraprison HIV transmission are rare. This study validly identifies 33 inmates in a large sample of state prison inmates who contracted HIV inside prison and presents data on how they likely contracted HIV. It further compares these inmates to inmates who did not contract HIV inside prison in terms of age, race, and level of education. Documenting the burden posed by HIV transmission inside prison, providing insight into how they contract HIV inside prison, and what types of inmates are at risk will help public and correctional health officials reform their current education and prevention practices and ultimately reduce or prevent HIV transmission both inside and outside prison.
Maguire H et al. (1995). Testing in prison is uncommon (letter). British Medical Journal, 310: 1265.
Highlights some of the reasons why there are difficulties in measuring the incidence of HIV infection acquired in prison.
Rosen HR (1997). Acquisition of hepatitis C by a conjunctival splash. American Journal of Infection Control, 9: 566-569.
Documents by Region
Americas
Central and Southern America
Burattini, M, et al. (2000) Correlation between HIV and HCV in Brazilian prisoners: evidence for parenteral transmission inside prison. Rev Saude Publica, 34(5), 431-436.
Mathematical techniques were applied to estimate time-dependent incidence densities of HIV infection among prisoners. The analysis was based upon the results of a cross-sectional survey carried out in a sample of 631 prisoners of a major penitentiary institution of Sao Paulo. The use of mathematical techniques "raised the suspicion of active HIV transmission inside the prison." Incidence density ratio derivation showed that the risk of acquiring HIV infection increases with the time of imprisonment, peaking around three years after incarceration.
Diaz RS et al. (1999). Use of a new "less-sensitive enzyme immunoassay" testing strategy to identify recently infected persons in a Brazilian prison: estimation of incidence and epidemiological tracing. AIDS, 13: 1417-1418
Diaz et al. used a less sensitive enzyme immunoassay testing strategy to identify recently infected persons in a Brazilian prison. A total of 113 of 846 (13.4%) prisoners tested HIV-positive. Of 78 HIV-positive prisoners for whom serum was available for testing using the sensitive enzyme immunoassay testing strategy, 5 had recent infections, probably acquired within the prison. The annual HIV incidence rate among susceptible prisoners was estimated at 2.8% per year (95% CI: 2.4 - 3.4% per year).
Guimaraes T et al. (2001). High prevalence of hepatitis C infection in a Brazilian prison: identification of risk factors for infection. Brazilian Journal of Infectious Diseases, 5(3): 111-118.
Hacker MA et al. (2005). The role of "long-term" and "new" injectors in a declining HIV/AIDS epidemic in Rio de Janeiro, Brazil. Subst Use Misuse, 40(1): 99-123.
Between October 1999 and December 2001, 609 active/ex-IDUs were recruited from different communities, interviewed, and tested for HIV. Multiple logistic regression was used to identify independent predictors of HIV serostatus for long-term and new injectors. Among male long-term injectors, "to have ever injected with anyone infected with HIV" (Adj OR = 3.91; 95% CI 1.09-14.06) and to have "ever been in prison" (Adj OR = 2.56; 95% CI 1.05-6.24) were found to be significantly associated with HIV infection.
Kallas EG et al (1998). HIV seroprevalence and risk factors in a Brazilian prison. Braz J Infect Dis, 2(4): 197-204.
The study was designed to determine the HIV seroprevalence among inmates of Casa de Detencao de Sao Paulo; to identify independent risk factors for HIV acquisition; and to determine whether there has been transmission of HIV infection in the prison. From 20 December 1993 to 5 January 1994, 780 inmates were interviewed using a standardized questionnaire and had their blood drawn for HIV testing. Of 766 inmates tested, 105 (13.7%) were positive, and 24 (3.1%) had indeterminate test results. Multivariate logistic regression analysis identified the following variables as independent risk factors for HIV seropositivity: age less than 29 years-old; previous incarceration in Casa de Detenca; more than one sexual partner in the last year in Casa de Detenca; and intravenous drug use before admission to Casa de Detenca.
Marins JR et al (2000). Seroprevalence and risk factors for HIV infection among incarcerated men in Sorocaba, Brazil. AIDS and Behavior, 4(1): 121-128.
The study describes prevalence and risk factors for HIV infection among 1,059 prisoners in 2 prisons in Sorocaba, Brazil. Sociodemographics, prison history, and sexual and drug exposures were assessed by interviewer-administered questionnaire. HIV infection was detected in 115 (12.6%) inmates. Sex with female visitors was reported by 66%, and homosexual practices with other inmates by 10%. Independent predictors of HIV infection were age <35 years (OR = 1.9, 95% CI 1.1-3.4), birthplace (natives of Sorocaba; OR = 2.1, 95% CI 1.2-3.8), and number of previous incarcerations (1 compared to 0) (OR = 1.7, 95% CI 1.07-2.7).
Massad E et al. (1999). Seroprevalence of HIV, HCV and syphilis in Brazilian prisoners: Preponderance of parenteral transmission. European Journal of Epidemiology, 15(5): 439-445.
Provides a detailed description of the clinical and epidemiological findings of the study by Burattini et al. (2000, supra).
Osti, NM et al (1999). Human Immunodeficiency virus seroprevalence among inmates of the penitentiary complex of the region of Campinas, State of Sao Paulo, Brazil. Memórias do Instituto Oswaldo Cruz 1999; 94(4): 479-83.
693 male prisoners from three penitentiaries, two (A and B) maximum-security and one (C) minimum-security facility, located in Campinas, Brazil were studied for the presence of HIV antibodies, using a cross-sectional design. Sera reactivity for HIV antibodies was 14.4%. The highest frequency of anti-HIV antibodies was found in the A and B maximum-security prisons: 17% and 21.5%, respectively. In prison C, the frequency of reagents was 10.9%. 73 prisoners, initially negative, were checked again five and seven months later. Three of them, all from the maximum-security facilities, became reactive in the MEIA test, with confirmation in the WB, suggesting that serological conversion had occurred after imprisonment.
Varella D et al (1996). HIV infection among Brazilian transvestites in a prison. AIDS Patient Care STDS, 10(5): 299-302.
Eighty-two male transvestites imprisoned in Casa de Detencao (Sao Paulo, Brazil) were tested for HIV antibodies, and completed a questionnaire investigating their demographics, arrest and imprisonment records, sexual practices, and drug use. Data were then analyzed to evaluate the incidence of HIV infection and its association with various behavioural and other factors. Sixty-four of 82 (78%, 95% confidence interval [CI], 67-87%) transvestites were positive for HIV infection. The factors associated with significant differences in positivity among these individuals were the time spent in prison and the number of sexual partners during the previous year.
Canada
Correctional Service Canada (1999). Springhill Project Report. Ottawa: CSC.
A document compiling various reports on an outbreak intervention at a Canadian federal prison, Springhill Institution.
Elwood Martin R et al. (2005). Drug use and risk of bloodborne infections: A survey of female prisoners in British Columbia. Canadian Journal of Public Health, 96(2): 97-101.
Clinicians working in a women's prison in British Columbia observed hepatitis C sero-conversion among inmates, prompting this study to determine: the characteristics of women who do and do not report illicit drug use in prison; patterns of drug use inside prison; factors associated with illicit drug use that might contribute to bloodborne transmission inside prison. A cross-sectional observational data set was created using an anonymous 61-item self-administered survey. 83 percent of eligible inmates participated. 93 percent reported a prior history of illicit drug use, of whom 70% reported a history of injection drug use. 36 percent reported illicit drug use in prison, and 21% reported injection drug use in prison. 52 percent reported hepatitis C sero-positivity, and 8% reported HIV sero-positivity. Of the 22 women who reported prison injection drug use, 91% reported hepatitis C infection and 86% reported injecting with shared needles inside prison, with or without bleach cleaning. The study concluded that "Canadian prisons are risk situations for transmission of bloodborne pathogens, and provide opportunities for harm reduction strategies."
Hagan H. (2003). The relevance of attributable risk measures to HIV prevention planning. AIDS, 17: 911-913.
Hagan conducted an external evaluation of the data presented by Tyndall et al (2003) and suggests that 21% of HIV infections among IDUs in Vancouver in 1996-2001 may have been attributable to infection during incarceration.
Tyndall et al. (2003). Intensive injection cocaine use as the primary risk factor in the Vancouver HIV-1 epidemic. AIDS, 17: 887-893.
This study of IDUs in Vancouver demonstrated that having been incarcerated in the last six months was independently associated with a markedly elevated rate of incident HIV infection. This association was not fully evaluated since the objective of the study was to evaluate the risk of HIV seroconversion related to injection cocaine. Nevertheless, an external evaluation of the data suggested that 21% of HIV infections among IDUs in Vancouver in 1996-2001 may have been attributable to infection during incarceration (see Hagan, 2003, supra).
Wood E et al. (2005). Recent incarceration independently associated with syringe sharing by injection drug users. Public Health Reports, 120: 150-156.
This study found that HIV-infected IDUs were significantly more likely to report lending a used syringe at six-month follow-up if they had been incarcerated during the same period. Similarly, among individuals who were HIV-negative at baseline, syringe borrowing was markedly elevated among individuals who had been incarcerated at least overnight at some point during the follow-up period. The study suggests that the earlier finding by Tyndall et al, 2003 (see supra) may not be explained by selection biases. Further, it provides evidence to support the conclusion that HIV may be spreading in prisons since it found that behaviours that can directly contribute to HIV infection were strongly and independently associated with reports of recent incarceration.
United States of America
Adimora AA et al. (2000). Incarceration and heterosexual HIV infection among rural African Americans [abstract 486]. In: 7th Conference on Retroviruses and Opportunistic Infections: program and abstracts (San Francisco). Alexandria, VA: Foundation for Retroviruses and Human Health.
This study showed that the major risk behaviour for newly diagnosed heterosexually acquired HIV infection among African-American women in the US who did not engage in high-risk behaviour was having sex with a partner who had a history of incarceration
Boutwell A, Rich JD (2004). HIV infection behind bars. Clinical Infectious Diseases, 38: 1761-1763.
Brewer TF et al. (1988). Transmission of HIV-1 within a statewide prison system. AIDS, 2: 363-367.
Brewer et al. tested 393 prisoners twice in Maryland in 1985 and detected two prisoners who had seroconverted in prison. The seroconverters had spent 60 and 146 days in prison when they had last tested negative for HIV infection. It was not possible to determine with certainty that they had contracted HIV behind bars, although this was probable. In the study, inmates who refused to participate or were missed at follow-up were significantly more likely to have committed a drug offence, to be black, or to have received sentences of less than five years. As these characteristics were associated with HIV infection at entry, it is likely that those most at risk of HIV infection were underrepresented in the study. Using the results of this study, Hammett calculated that up to 60 new cases of HIV infection were occurring annually in the Maryland prison population (Hammett et al, 1993).
Castro K et al (1991). HIV transmission in correctional facilities. Presented at the VIIth International Conference on AIDS, Florence, 16-21 June 1991, p 314.
HIV prevalence among prison entrants in Illinois was 3.9 percent (n=2390) in 1989. After one year in prison, eight inmates had seroconverted. The evidence of transmission in prison was strong, but again acquisition of infection prior to incarceration could not be excluded. The study relied on mass screening of prisoners serving sentences of at least one year, meaning that short-term prisoners were excluded.
Centers for Disease Control (1986). Acquired Immunodeficiency Syndrome in correctional facilities: Report of the National Institute of Justice and the American Correctional Association. Morbidity and Mortality Weekly Review, 35 (12): 195-199.
One of the early US studies on HIV incidence among US prisoners. HIV testing was offered in 1985 to inmates who had been imprisoned in Maryland for at least seven years. Approximately one-third of inmates accepted testing. Of these, two (one percent) tested HIV-positive. Both had been incarcerated for nine years.
Centers for Disease Control and Prevention (2001). Hepatitis B outbreak in a state correctional facility, 2000. Morbidity and Mortality Weekly Report, 50(25): 529-532.
Editor (2004). Study links incarceration and HIV rates in black communities. AIDS Policy & Law, 19(6): 5.
Many studies have documented the prevalence of HIV in prisons, but researchers now have established a link between rates of imprisonment among African-Americans in the US and the high HIV/AIDS rates in African-American communities outside of prison.
A study conducted by University of North Carolina epidemiologist James Thomas found a "robust correlation" between incarceration rates and rates of HIV and sexually transmitted diseases. Researchers noted that in North Carolina, African-Americans comprise more than 70 percent of HIV/AIDS cases and about 60 percent of the state's 35,000 prisoners. Nationwide, more than half of all new HIV infections in the US occur among African-Americans, and African-American women comprise 72 percent of new HIV cases among all women. Of the 2,1 million people currently incarcerated in the US, 40 percent are African-American.
Fox et al. (2005). Hepatitis C virus infection among prisoners in the California state correctional system. Clinical Infectious Diseases, 41(2): 177-186.
In a study of HCV infection among prisoners in the California state correctional system, prevalence of HCV infection was 34.3% overall and 65.7% among those with a history of IDU. Independent correlates of HCV infection among both IDU and non-IDU prisoners included cumulative time of incarceration.
Gauney W, Gido R (1986). AIDS: a demographic profile of New York State inmates' mortalities 1981-1985. New York: New York State Commission of Correction.
In New York, six HIV-positive prisoners were identified who had been incarcerated without interruption before infection became prevalent in their communities.
Gendney K (1999). State of Nevada Department of Prisons, unpublished data.
May and Williams (infra, 2002) refer to this unpublished data. From 1985 through 1988, the state of Nevada tested approximately 13,000 prisoners upon entry and exit to the prison system and found 12 (0.09%) prisoners had seroconverted.
Horsburgh CR, JQ Jarvis, T MacArthur, T Ignacio, P Stock (1990). Seroconversion to Human Immunodeficiency virus in prison inmates. American Journal of Public Health, 80(2): 209-10.
Repeated testing of 1069 inmates in Nevada in 1985 found that three inmates had seroconverted in prison. The 3 seroconverters had spent a relatively short time in prison when they last tested negative for HIV infection, and some of them may have been infected prior to imprisonment. The authors of the study concluded that HIV transmission among inmates was rare in Nevada.
Kelley PW et al. (1986). Prevalence and incidence of HTLV-111 infection in a prison. Journal of the American Medical Association, 256(16): 2198-99.
The first study to investigate HIV seroconversion in prisons. One percent of 913 inmates in a US maximum- security prison was HIV-positive in 1983. Repeated testing of 542 inmates who remained incarcerated found no cases of HIV seroconversion. However, the sample was atypical of prison populations, with an underrepresentation of drug offenders (15 percent) and an overrepresentation (38 percent) of sex offenders. In addition, inmates in maximum security often have limited opportunities to associate with other inmates and to engage in risk behaviours.
Khan AJ et al. (2005). Ongoing Transmission of Hepatitis B Virus Infection among Inmates at a State Correctional Facility. Am J Public Health, 95: 1793-1799.
The study sought to determine HBV infection prevalence, associated exposures, and incidence among male inmates at a state correctional facility. A cross-sectional serological survey was conducted in June 2000, and susceptible inmates were retested in June 2001. At baseline, 230 inmates (20.5%; 95% confidence interval [CI]=18.2%, 22.9%) exhibited evidence of HBV infection, including 11 acute and 11 chronic infections. Inmates with HBV infection were more likely than susceptible inmates to have injected drugs (38.8% vs 18.0%; adjusted prevalence odds ratio [OR]=3.0; 95% CI=1.9, 4.9), to have had more than 25 female sex partners (27.7% vs 17.5%; adjusted prevalence OR=2.0; 95% CI=1.4, 3.0), and to have been incarcerated for more than 14 years (38.4% vs 17.6%; adjusted prevalence OR=1.7; 95% CI=1.1, 2.6). One year later, 18 (3.6%) showed evidence of new HBV infection. Among 19 individuals with infections, molecular analysis identified 2 clusters involving 10 inmates, each with a unique HBV sequence. The study documented ongoing HBV transmission at a state correctional facility and concluded that similar transmission may occur at other US correctional facilities and could be prevented by vaccination of inmates.
Macalino GE et al. (2004). Prevalence and incidence of HIV, hepatitis B virus, and hepatitis C virus infections among males in Rhode Island prisons. American Journal of Public Health, 94(7): 1218-1223.
The study observed intake prevalence for 4,269 sentenced prisoners at the Rhode Island Adult Correctional Institute between 1998 and 2000 and incidence among 446 continuously incarcerated prisoners (for 12 months or more). HIV, HBV, and HCV prevalence were 1.8%, 20.2% and 23.1%, respectively. Incidence per 100 person-years was 0 for HIV, 2.7 for HBV, and 0.4 for HCV.
Mutter RC, RM Grimes, D Labarthe. Evidence of intraprison spread of HIV infection. Archives of Internal Medicine 1994; 154: 793-795.
All prisoners in the Florida Department of Corrections who had been continuously incarcerated since 1977 were identified. The medical records of these prisoners were reviewed to determine whether they had been tested for HIV infection and, if tested, whether the results were positive. Results were considered positive if there were reactions to two enzymelinked immunosorbent assays confirmed by Western blot assay. If an individual tested positive, the medical record was reviewed to determine whether the patient had been treated for conditions consistent with HIV infection. The results present strong evidence for intraprison transmission of the HIV infection. Given that most inmates serve relatively short sentences, there is a strong possibility that prison-acquired HIV infection will be carried into the "free-world". Preventive programs in prison may be important in controlling HIV infection in our society.
Rich JD et al. (1999). Prevalence and incidence of HIV among incarcerated and reincarcerated women in Rhode Island. Journal of Acquired Immune Deficiency Syndrome, 22: 161-166.
This study explores recent temporal trends in HIV prevalence among women entering prison and the incidence and associated risk factors among women reincarcerated in Rhode Island. Results from mandatory HIV testing from 1992 to 1996 for all incarcerated women were examined. In addition, a case control study was conducted on all seroconverters from 1989 to 1997. In all, 5836 HIV tests were performed on incarceration in 3146 women, 105 of whom tested positive (prevalence, 3.3%). Between 1992 and 1996, the annual prevalence of HIV among all women known to be HIV-positive was stable (p = .12). Age >25 years, nonwhite race, and prior incarceration were associated with seropositivity. Of 1081 initially seronegative women who were retested on reincarceration, 12 seroconverted during 1885 person-years (PY) of follow-up (incidence, 0.6/100 PY). Self-reported injection drug use (IDU; odds ratio [OR], 3.7; 95% confidence interval [CI], 1.3-10.1) was significantly associated with seroconversion, but sexual risk was not (OR, 1.1; 95% CI, 0.4-3.5). Incarceration serves as an opportunity for initiation of treatment and linkage to community services for a population that is at high risk for HIV infection. This study demonstrated that in Rhode Island time in the community - rather than in prison - places repeatedly incarcerated women at risk for HIV infection.
Samuel MC et al. (2001). Association between heroin use, needle sharing and tattoos received in prison with hepatitis B and C positivity among street-recruited injecting drug users in New Mexico, USA. Epidemiology and Infection, 127(3): 475-484.
Study showing that receipt of a tattoo in prison/jail was associated with HBV and HCV infections.
Tsang T, Horowitz E, Vugia D (2001). Transmission of hepatitis C through tattooing in a United States prison. American Journal of Gastroenterology, 96 (4): 1304-1305.
Vlahov D et al. (1993). Prevalence and incidence of hepatitis C virus infection among male prison inmates in Maryland. European Journal of Epidemiology, 5: 566-569.
To identify incidence of antibody to HCV among 265 male prison inmates, Vlahov et al assayed paired serum specimens obtained at intake in 1985-1986 with follow-up specimens in 1987. Intake prevalence was 38%. Seroincidence was 1.1/100 person years in prison. According to the authors, this finding "might reflect saturation of high-risk subgroups or possibly reduced frequency of exposures following incarceration."
Eastern Mediterranean
Zamani S et al. (2005). Prevalence of factors associated with HIV-1 infection among drug users visiting treatment centres in Tehran, Iran. AIDS, 19(7): 709-716.
Among male injectors with HIV-1 prevalence of 15.2%, a history of shared injection inside prison (adjusted odds ration (OR, 12.37; 95% CI, 2.94-51.97) was the main factor associated with HIV-1 infection. The study concluded that harm reduction programs should be urgently expanded, particularly in correctional settings.
Europe
Western and Southern Europe
Allright S et al. (2000). Prevalence of antibodies to hepatitis B, hepatitis C, and HIV and risk factors in Irish prisoners: results of a national cross sectional survey. British Medical Journal, 321: 78-82.
Anon C et al. (1995). The hepatitis C virus among the prison population in Valencia [article in Spanish]. Rev Esp Enferm Dig, 87(7): 505-508.
This study, undertaken in 1991 among 750 prisoners in a prison in Valencia, found that HCV infection was correlated with the duration and number of imprisonments.
Arrada A, Zak Dit Zbar O, Vasseur V (2001). Prevalence of HBV and HCV infections and incidence of HCV infection after 3, 6 and 12 months detention in La Sante prison, Paris. Ann Med Interne, 152 Suppl 7: 6-8. [article in French]
In June 1998, a screening program was initiated to determine the prevalence of HBV and HBC infections in prisoners and to determine the incidence after 3, 6 and 12 months detention. The screening program was proposed to 900 prisoners in a Paris prison (Maison d'arret de Paris-La Sante) from 3 June to 10 November 1998. The program included hepatitis B and hepatitis C serology at incarceration. For prisoners who were seronegative for HCV at incarceration, a new HCV serology was proposed after 3, 6 and 12 months detention. It was postulated that HCV contamination could occur during incarceration (syringe sharing, tattooing). After one year of incarceration, no seroconversions for HCV were observed among the prisoners participating in this study. These findings should be interpreted with caution due to the particular detention conditions at the prison involved, raising important methodology interrogations concerning this type of survey.
Babudieri S et al. (2005). Correlates of HIV, HBV, and HCV infections in a prison inmate population: Results from a multicentre study in Italy. Journal of Medical Virology, 76 (3): 311-317.
A cross-sectional study was undertaken on the correlates of infection for HIV, HBV, and HCV in a sample of prisoners from eight Italian prisons. A total of 973 prisoners were enrolled [87.0% males, median age of 36 years, 30.4% intravenous drug users (IDUs), 0.6% men who have sex with men]. In this sample, high seroprevalence rates were found (HIV: 7.5%; HCV: 38.0%; anti-HBc: 52.7%; HBsAg: 6.7%). HIV and HCV seropositivity were associated strongly with intravenous drug use (OR: 5.9 for HIV; 10.5 for HCV); after excluding IDUs and male homosexuals, the HIV prevalence remained nonetheless relatively high (2.6%). Tattoos were associated with HCV positivity (OR: 2.9). The number of imprisonments was associated with HIV infection, whereas the duration of imprisonment was only associated with anti-HBc. In conclusion, a high prevalence of HIV, HCV, and HBV infections among inmates was observed. Frequency of imprisonment and tattoos were associated, respectively, with HIV and HCV positivity. Although it is possible that the study population is not representative of Italy's prison inmate population, the results stress the need to improve infection control measures in prisons.
Bath G et al. (1993). Imprisonment and HIV prevalence. The Lancet, 342(8883): 1368.
This letter is a response to the Pickering and Stimson letter Syringe sharing in prison (see infra). The author argues that stringent surveillance does not prevent injecting in prisons. It is noted that the association between imprisonment and HIV positivity might be a result of a confounding factor that leads to both HIV positivity and to imprisonment. For example, reckless behaviour might put a drug user at risk of both these outcomes. However, in view of the evidence of drug use in prisons, imprisonment may well have been a factor in the spread of HIV.
Bellis M et al. (1997). Prevalence of HIV and injecting drug use in men entering Liverpool prison. British Medical Journal, 315: 30-31.
New prisoners, who were in prison for the first time for their current remand, were asked to complete a short anonymous questionnaire about their sexual and drug-related behaviour. In addition, they were asked to provide saliva samples. The study examined the potential role of English prisons in drug-related transmission of HIV and other blood-borne viruses. It was concluded that although imprisonment may decrease the number of people injecting drugs, there is still an increased risk of infection among those who do inject while in prison.
Champion J et al. (2004). Incidence of hepatitis C virus infection and associated risk factors among Scottish prison inmates: a cohort study. American Journal of Epidemiology, 159: 514-519.
To gauge the incidence of HCV infection and associated risk factors among prisoners during their imprisonment, the authors recruited adult males in a long-stay Scottish prison into a cohort study between April 1999 and October 2000. On two occasions (at 0 and 6 months), saliva was collected for anonymous HCV antibody testing. For prisoners who reported never having injected drugs, ever having injected drugs, having injected drugs during follow-up, and having shared needles/syringes during follow-up, HCV incidences per 100 person-years of incarceration risk were 1, 12, 19, and 27, respectively. Ever having injected drugs (relative risk= 13.0, 95% CI: 1.5, 114.3) and having shared needles/syringes during follow-up (relative risk= 9.0, 95% CI: 1.1, 71.7) were significantly associated with HCV seroconversion.
Christensen P et al. (2000). Prevalence and incidence of bloodborne viral infections among Danish prisoners. European Journal of Epidemiology, 16(11): 1043-1049.
Christensen et al. conducted a prospective study in a Danish medium security prison for males. The prisoners were offered an interview and blood test for hepatitis and HIV at inclusion as well as at release from prison or end of study. Of 403 prisoners available, 325 (79%) participated in the initial survey and for 142 (44%) a follow-up test was available. 43% (140/325) of the participants were IDUs of whom 64% were positive for HBV and 87% for HCV markers. No cases of HIV were found. 32% of all prisoners could transmit HBV and/or HCV by blood contact. 70% of IDUs had shared injecting equipment, and 60% had injected inside prison. Only 2% of IDUs were vaccinated against HBV. Duration of injecting drug use, numbers of imprisonments, and injecting in prison were independently and positively associated with the presence of HBV antibodies among IDUs by logistic regression analysis. The HBV incidence was 16/100 PY (95% CI: 2-56/100 PY) and the HCV incidence 25/100 PY (1-140) among IDUs. The authors concluded that IDUs in prison have an incidence of hepatitis B and C 100 times higher than reported in the general Danish population; that they should be vaccinated against hepatitis B; and that new initiatives to stop sharing of injecting equipment in and outside prison are urgently needed.
Christie B (1993). HIV outbreak investigated in Scottish jail. British Medical Journal, 307: 151-152.
Davies A et al. (1995). HIV and injecting drug users in Edinburgh: Prevalence and correlates. Journal of Acquired Immune Deficiency Syndrome Human-Retroviral, 8: 399-405.
A city-wide sample of injecting drug users who had injected in the previous six months were administered with a questionnaire about drug use, syringe sharing, sexual behaviour and imprisonment. It was found that HIV infection was significantly associated with being 27 to 36 years of age, injecting for the first time between 1975 and 1980 and injecting during 1980-1987 in particular, sharing equipment, being imprisoned and finally residing in north Edinburgh. The authors concluded that "the findings suggest that the potential for HIV transmission by contaminated equipment still exists in Edinburgh, and this is particularly so in prison, where IDUs do not have access to new needles and syringes."
Estebanez PE et al. (1990). Jails and AIDS. Risk factors for HIV infection in the prisons of Madrid. Gaceta sanitaria, 4(18): 100-105.
The study found tattooing to be an independent risk factor for HIV infection among a group of 383 male and female prisoners in Madrid, Spain.
Estebanez PE et al. (2000) Women, drugs and HIV/AIDS: results of a multicentre European study. International Journal of Epidemiology, 29: 734-43.
A multicentred, cross-sectional study was undertaken to explore the multitude of possible factors associated with HIV in a population of female injecting drug users. Face-to-face interviews were conducted with 1198 female IDUs recruited from a variety of settings in Paris, Madrid, Rome, London and Berlin. Their HIV status was determined from antibody testing of blood or saliva samples or from written confirmation of HIV test results from a physician. A hierarchical logistic regression model was used to identify direct and indirect associations between socioeconomic factors, marginalization and risk behaviour with HIV prevalence. The HIV prevalence in the sample of female IDUs was 27.8% (range: 1.4% in London and 52.6% in Madrid). Factors independently associated with HIV prevalence in the regression analysis included previous imprisonment (OR = 1.4).
Goldberg D. Outbreak of HIV infection in a Scottish prison: why did it happen? Canadian HIV/AIDS Policy & Law Newsletter 1996; 2(3): 13-14. The account of why the outbreak of HIV infection occurred in a Scottish prison (see Taylor, infra).
Available at
www.aidslaw.ca/Maincontent/otherdocs/
Newsletter/April1996/14avrilE.html.
Goldberg D et al. (1998). A lasting public health response to an outbreak of HIV infection in a Scottish prison? Int J STD AIDS, 9(1): 25-30.
Gore S, A Bird (1993). Transmission in jail. Prisons need protocols for HIV outbreaks. British Medical Journal, 307: 147-148.
Refers to the outbreak of hepatitis B and HIV transmissions in a Scottish jail. States that the prison services have worked hard to educate inmates to avoid HIV infection but, unlike other citizens, prisoners are denied condoms and cannot disinfect any needle that they might use. Nearly half of Edinburgh's adult injector inmates had injected during incarceration; one sixth of 16-20 year old in October 1992 in Polmont, Scotland's largest male young offenders' institution, were injectors, of whom a quarter had injected during their prison terms. Outside prison, needle exchanges were well established and it is the possession of prohibited injectable substances, not the actual injecting, that breaks the law. A prison sentence, prohibiting access to clean needles for injectors, may become a death sentence.
The prison services' second achievement is to have encouraged officer volunteers to train as HIV counsellors so that confidential, personal HIV testing is available to inmates. The studies, conducted by independent research teams, have shown that inmates are more likely than the outside population to have injected drugs, to have had many female sexual partners, and to have had sex with other men. The clear public health implication of this research is that prisoners have a greater need than the general population for practical means of harm reduction - both condoms and rehabilitation programs for drug users. Concludes that "HIV education alone is not enough to escape the death sentence of HIV transmission in jail."
Gore S et al. (1995). Drug injection and HIV prevalence in inmates of Glenochil prison. British Medical Journal, 310, 293-296.
The objective was to determine the prevalence of HIV infection and drug injecting behaviour among inmates of Glenochil Prison on a specified date a year after an outbreak of hepatitis B and HIV infection. A cross sectional design was used: voluntary, anonymous HIV salivary antibody surveillance and linked self completion questionnaire on risk factors. With 352 prisoners in Glenochil prison, of whom 295 (84%) took part, 284 questionnaires (96%) passed logical checks. The main outcome measure was HIV prevalence; the proportion of all inmates who had ever injected drugs, had ever injected inside prison, and had started injecting drugs while inside prison.
More than half (150/284) the prisoners participating had also been in Glenochil Prison during the critical period of January to June 1993, when hepatitis B and HIV were transmitted. A quarter of injecting drug users (18/72) had first injected inside prison. On testing for HIV, seven saliva samples out of 293 gave positive results - four were presumed to be from inmates known to be infected with HIV, and the others from injecting drug users in Glasgow, all of whom had been in Glenochil during January to June 1993, when two of the three had injected drugs and had been tested for HIV, with negative results. For men who had injected drugs in Glenochil during January to June 1993, HIV prevalence was estimated at 29%. Between a quarter and a third of prisoners who injected drugs in Glenochil in January to June 1993 were infected with HIV.
Gore SM, Bird A (1998). Study size and documentation to detect injection-related hepatitis C in prison. QJM, 91(5): 353-357.
The authors used existing data on hepatitis C prevalence, injection-related hepatitis C transmission and needle use in prisons and new data on infectiousness, to estimate the size of study required to detect injection-related hepatitis C in UK prisons. A pilot study of 500 prisoners followed for 10 weeks would have a 65% chance of detecting a hepatitis C seroconversion, conservatively assuming one injection per prisoner per week, and a 3% transmission rate per injection, but uncertainty might persist as to whether transmission had occurred during a short incarceration or before it. If the actual transmission rate was 10%, as recently documented, then such a study would have more adequate statistical power. A definitive study of 3000 prisoners for 10 weeks would expect to detect about six seroconversions, even with conservative estimates of injection frequency and transmission rate. According to the authors, adequate design and power of these studies is important because of the complacency that could result from false negative findings. They suggest six risk-factor themes that studies should document.
Granados et al. (1990). HIV seropositivity in Spanish prisons. Presented at the VIth International AIDS Conference, San Francisco. Abstract no Th.D.116.
In Spain, HIV infection has been associated with imprisonment.
Holsen et al. (1993). Prevalence of antibodies to hepatitis C virus and association with intravenous drug abuse and tattooing in a national prison in Norway. European Journal of Clinical Microbiology and Infectious Diseases, 12(9): 673-676.
Holsen et al performed a study in order to determine the prevalence of HCV antibodies, the risk factors for HCV infection and the markers of hepatic diseases in a population of prisoners. 46% of prisoners included in the study were anti-HCV positive. Intravenous drug use was the predominant risk factor for HCV infection, although a history of tattooing was found by logistic regression analysis to be a significant risk factor independent of intravenous drug use. The article mentions that most anti-HCV positive prisoners had a history of previous incarcerations.
Jürgens R. Alarming Evidence of HIV Transmission in Prisons. Canadian HIV/AIDS Policy & Law Newsletter 1995; 1(2): 2-3.
Presents data from a study undertaken in a Scottish prison (see Taylor, infra), which provided definitive evidence that outbreaks of HIV infection can and will occur in prisons unless HIV prevention is taken seriously. It raises the question of governments' and prison administrations' moral and legal responsibility for the spread of HIV and HCV among inmates and to the public.
Keppler K, Nolte F, Stöver H. Transmission of Infectious Diseases in Prison: Results of a Study in the Prison for Women in Vechta, Lower Saxony, Germany. Originally published in German in Sucht 1996; 42(2): 98-107. See also Keppler K and Stöver H. (1999) Transmission of infectious diseases during imprisonment - results of a study and introduction of a model project for infection prevention in Lower Saxony. Gesundheitswesen, 61(4): 207-213 [article in German]. Summarized in English in Canadian HIV/AIDS Policy & Law Newsletter 1996; 2(2), 18-19 (available via
www.aidslaw.ca/Maincontent/otherdocs/
Newsletter/January1996/17studieE.html)
Results of a German study, undertaken in the prison for women in Vechta, showed that at least 20 women had definitely been infected while in prison. 1032 health records were examined to evaluate data on the prevalence of HIV, hepatitis A, B and C, and syphilis among female prisoners between 1992 and 1994. About one-third of the study population were IDUs, and 74 percent had been tested for the above-mentioned infectious diseases at least once. Prevalence of infectious diseases was as follows:
- HIV: 4.9 percent among IDUs, 0.5 percent among non-IDUs
- hepatitis A: 65.6 percent among IDUs, 34.7 percent among non-IDUs
- hepatitis B: 78 percent among IDUs, 12.7 percent among non-IDUs
- hepatitis C: 74.8 percent among IDUs, 2.9 percent among non-IDUs
- syphilis: 4.5 percent among IDUs, 5.1 percent among non-IDUs.
Records of prisoners who underwent at least two tests for the same disease were examined to determine whether seroconversion had occurred during uninterrupted prison sentences. For 41 IDUs, seroconversion could be documented; of these, 20 (48.8 percent) had definitely been infected while in prison.
Koulierakis G et al. (2000). HIV risk behaviour correlates among injecting drug users in Greek prisons. Addiction, 95(8):1207-16.
The study aimed to identify the correlates of injecting drug use within prison. A national cross-sectional study was undertaken in ten Greek prisons, with a representative sample of 1000 male inmates. 861 questionnaires were completed and analyzed. 290 inmates (33.7%) reported injecting drugs at some time in their lives, of whom 174 (60%) had injected while imprisoned. Among those who had injected while imprisoned, 145 (83%) had shared equipment while incarcerated. Logistic regression analysis suggested that total time in prison, previous drug conviction, being a convict (as opposed to on remand) and having multiple female sexual partners one year before incarceration were significant HIV risk behaviour correlates. For every year of imprisonment, the risk of injection in prison increased by about 17% [OR = 1.17 (95% CI: 1.07-1.27)]. Inmates with a previous drug-related conviction were about twice as likely to inject within prison [OR = 1.97 (95% CI: 1.16-3.33)]. Finally, convicted inmates were marginally significantly more prone to inject in prison [OR = 1.58 (95% CI: 0.92-2.74)]. The study concluded that variables related to the inmates' prison career influence HIV risk behaviours within prison; and that there is a need to assist IDUs in reducing the likelihood of high-risk behaviour by considering factors such as frequency of incarceration, length of time incarcerated and availability of detoxification programs in prison.
Malliori M et al. A survey of bloodborne viruses and associated risk behaviours in Greek prisons. Addiction 1998; 93(2): 243-251.
Martin V et al. (1998) Predictive factors of HIV-infection in injecting drug users upon incarceration. European Journal of Epidemiology, 14(4): 327-331.
The objective was to identify predictors of HIV-infection in injecting drug users upon incarceration. 639 IDU or ex-IDU prisoners admitted to a provincial prison of Northwestern Spain between 1 Jan 1991 and 31 December 1995 were studied. Prevalence of HIV infection was 46.9%. For those incarcerated for the first time prevalence fell from 38% in 1991 to 19% in 1995. Those with multiple incarceration histories and long-term prisoners were associated with higher risk of HIV infection.
McBride AJ, Ali IM, Clee W (1994). Hepatitis C and injecting drug use in prisons. British Medical Journal, 309: 876.
The authors measured antibody to HCV in 157 IDUs in Mid Glamorgan (Great Britain) whose history of imprisonment was known. Of those with a history of imprisonment, 46% had antibodies compared with 29% of those with no history of imprisonment (X2=4,87, df=1, P<0.05).
McKee KJ, Power KG (1992). HIV/AIDS in prisons. Scottish Medical Journal, 37: 132-137.
The authors suggest that imprisonment may reduce, rather than increase, the overall risk of HIV transmission.
Medley G, KA Dolan, G Stimson (1993). A model of HIV transmission by syringe sharing in English prisons using surveys of injecting drug users. Presented at the VIIIth International Conference on AIDS, Amsterdam, abstract no MoD 0038, p 75.
Using a mathematical model, this study calculated the level of transmission in prison in England. It estimated the number of prisoners with a history of IDU, the number who continued injecting in prison, and the proportion of the latter who shared syringes. The prevalence of HIV and the number of syringes in circulation were taken into account. The study estimated that two percent of sharers would become infected each year. See also Dolan, Kaplan, Wodak, Hall and Gaughwin, 1994, for a very similar study in Australia.
Muller R et al. (1995). Imprisonment: A risk factor for HIV infection counteracting education and prevention programmes for intravenous drug users. AIDS, 9: 183-190.
A multisite cross-sectional study was conducted through standardized questionnaires and blood saliva samples involving IDUs in Berlin to examine changes in risk behaviour for HIV infection as well as its determinants. Particular attention was paid to the specific risk patterns associated with imprisonment. The research found that needle sharing in prison was the most important risk factor for HIV infection. In total, 58% of IDUs reported reduced risk behaviours, due to changes related more to injection behaviour than sexual practices. This would suggest that information and campaigns and other prevention measures appear to have produced risk awareness in IDUs. The situation in prisons, with a lack of sterile injecting equipment and no effective disinfectants, however, runs counter to prevention methods implemented outside prisons. An important task for future strategies should be to enable IDUs to avoid HIV transmission while in prison.
Pallas JR et al. (1999). Coinfection by HIV, hepatitis B and hepatitis C in imprisoned injecting drug users. European Journal of Epidemiology, 15(8): 699-704.
This study, undertaken in two prisons in northern Spain, showed that reincarceration and long-term injection were the foremost risk factors for HBC-HCV and for HIV-HBV-HCV coinfection among IDU prisoners.
Pallas JR et al. (1999). Risk factors for monoinfections and coinfections with HIV, hepatitis B and hepatitis C viruses in northern Spanish prisoners. Epidemiol Infect, 123: 95-102.
Richardson C, Ancelle-Park R, Papaevangelou G (1993). Factors associated with HIV seropositivity in European injecting drug users. AIDS, 7: 1485-1491.
Reports that HIV infection has been associated with imprisonment in France.
Seaman SR, Bird SM (2001) Proportional hazards model for interval-censored failure times and time-dependent covariates: application to hazard of HIV infection of injecting drug users in prison. Stat Med, 20(12): 1855-70.
Interval-censored survival data are data in which the failure times are not known precisely, but are known to lie within an interval. Such data can be analyzed using a proportional hazards model with piecewise-exponential baseline hazard, a model which can be fitted by an EM algorithm easily programmed in standard statistical software. In this paper we extend the model to allow for time-dependent covariates and left-truncation, and demonstrate its use by assessing the effect of imprisonment on hazard of HIV infection in a cohort of injecting drug users from Edinburgh. No conclusive effect of incarceration on hazard of HIV infection was found, but there was a suggestion that imprisonment might have been a significant relative risk factor for infection in the later period, when risk behaviour among drug users in the community was reduced.
Stark K, Muller R (1993). HIV prevalence and risk behaviour in injecting drug users in Berlin. Forensic Sci Int, 62(1-2): 73-81.
This study of German IDUs demonstrated that HIV infection was strongly associated with borrowing injecting equipment in prison.
Stark K et al. Prevalence and determinants of anti-HCV seropositivity and of HCV genotype among intravenous drug users in Berlin. Scandinavian Journal of Infectious Diseases 1995; 27(4) 331-337.
A cross-sectional study to identify risk factors for seropositivity for antibodies against HCV among IDUs. Syringe sharing in prison was an independent risk factor for anti-HCV positivity.
Stark K et al. Determinants of HIV infection and recent risk behaviour among injecting drug users in Berlin by site of recruitment. Addiction 1995; 90(10): 1367-1375.
Syringe sharing in prison was the most important independent determinant of HIV infection among IDUs in the study.
Stark K et al. History of syringe sharing in prison and risk of hepatitis B virus, hepatitis C virus, and human immunodeficiency virus infection among injecting drug users in Berlin. International Journal of Epidemiology 1997; 26(6): 1359-1366.
A history of syringe sharing in prison was significantly associated with HBV, HCV, and HIV infection.
Taylor A et al. (1995). Outbreak of HIV infection in a Scottish prison. British Medical Journal, 310(6975): 289-292.
Describes what can happen if comprehensive HIV prevention measures in prison are not implemented: an outbreak of HIV infection in a Scottish prison, where it has been estimated that between 22 and 43 inmates contracted HIV within a short period of time.
Taylor A, D Goldberg (1996). Outbreak of HIV infection in a Scottish prison: why did it happen? Canadian HIV/AIDS Policy & Law Newsletter, 2(3): 13-14.
Available (in English and French) at
www.aidslaw.ca/Maincontent/otherdocs/
Newsletter/April1996/14avrilE.html
Weild AR et al. (2000). Prevelance of HIV, hepatitis B, and hepatitis C antibodies in prisoners in England and Wales: a national survey. Communicable Disease and Public Health, 3(2): 121-126.
Prisoners in eight of the 135 prisons in England and Wales were surveyed in 1997 and 1998 to study the prevalence of and risk factors for transmission of bloodborne viruses in prison. Among all those tested (3930) 0.4% (14) were positive for anti-HIV and 7% (293) for anti-HCV. 24% reported ever having injected drugs, 30% of whom (224/747) reported having injected in prison.
Three quarters of those who injected in prison (167/224) shared needles or syringes. The presence of anti-HCV was associated with injecting inside prison and number of previous times in prison. The authors concluded that the results suggest that hepatitis viruses are being transmitted in prisons through sharing non-sterile injecting equipment and that a risk of HIV transmission exists.
Yirrell D et al. (1997). Molecular investigation into outbreak of HIV in a Scottish prison. British Medical Journal, 314: 1446.
A follow-up study to the outbreak investigation at Glenochil Institution undertaken by Taylor et al. (1995), showing that the number of prisoners infected with HIV during the 1993 outbreak was more than twice that previously thought.
Eastern Europe
Caplinskas S, Likatavicius G (2002). Recent sharp rise in registered HIV infections in Lithuania. Eurosurveillance Weekly, 6(2).
Online version: http://www.eurosurveillance.org/ew/2002/020627.asp
Reports that 207 prisoners were diagnosed as having contracted HIV at the Alytus maximum-security prison in Lithuania in 2002. As reported by Bobrik, see infra, with reference to Russian publications, this figure grew to 296 people during a follow-up examination.
Caplinskiene I, Caplinskas S, Griskevicius A (2003). Narcotic abuse and HIV infections in prisons [article in Lithuanian]. Medicina (Kaunas), 38(8): 797-803.
Reports that the number of drug using people in Lithuanian prisons has been growing every year: in the beginning of 2001, 1010 people in total were on a record of dispensary care, 8.8% of all imprisoned persons at that time. This percentage reached 12.25% in the beginning of 2002 and 13.3% in the beginning of 2003. Drug availability and unsafe use of illegal drugs, especially sharing of needles and syringes in one of the fourteen country's penal establishments - Alytus strict regime correctional facility -resulted in a rapid HIV outbreak in spring 2002. 300 prisoners infected with HIV were identified during voluntary testing. Shortage in treatment of drug use, in rehabilitation and occupation of prisoners provide conditions for rapid spread of HIV and other blood-born infections in Lithuanian penitentiaries. Many prisoners are not able to reintegrate into society after their release because of broken social relationships, lack of social services in the country, therefore they often relapse to drug use.
Russian Federation
Bobrik A et al. (2005). Prison health in Russia: the larger picture. Journal of Public Health Policy, 26: 30-59.
Providing three references to Russian publications, Bobrik reports that in 2001, 260 prisoners became HIV-infected in a correctional colony in Tatarstan, Russia. Bobrik also reports that in some regions, sharp rises in HIV cases were registered following an amnesty and mass release of prisoners, citing Wright et al (see below), but also Badrieva & Karchevsky (Building volunteer network: secondary needle exchange, peer education. Kazan 2001, 72). Bobrik also discusses the interrelationship of prison health with health of society at large: "Penitentiary institutions in various respects have direct and indirect effects on health. Indirectly, they influence family composition, economic opportunities of households, and normative community values on life-style, sex, drugs, and violence. Prisons often have a direct impact on the epidemiological situation in society. For instance, back in the 17th and 18th centuries in England it was noted that when prisoners came to court for their trials they could infect jurors and judges with jail fever. Nowadays, transmission of tuberculosis and meningococcal infection from inmates to the prison staff and civilians has been similarly well documented. In some regions, sharp rise in HIV cases was registered following an amnesty and mass release of prisoners. In 2002 a single outbreak in the Alytus prison (see Caplinskas, below) radically changed the entire HIV statistics in Lithuania, which up to that moment was considered a low-affected country. Russian penitentiary institutions always had a considerable impact on the general TB epidemiological situation in the country - in the early 1990's, the persons released from correctional labor institutions accounted for up to 20% of tuberculosis incident cases and 57% of smear-positive cases among the civilian population."
Heimer R et al. (2005). Imprisonment as risk for HIV in the Russian Federation: evidence for change. 16th International Conference on the Reduction of Drug Related Harm.
In a study of 826 currently injecting drug users in various cities in the Russian Federation, 44.8% reported ever having been to prison. Four health factors were correlated with imprisonment (HIV-positivity; TB+, overdose, and abscesses), while three were not (STDs, HBV, and HCV). The study concluded that reductions in imprisonment for drug-related offences are a public health and human rights priority.
South-East Asia
Beyrer C et al. (2003) Drug use, increasing incarceration rates, and prison-associated HIV risks in Thailand. AIDS and Behavior, 7(2): 153-161.
Buavirat et al. (2003) Risk of prevalent HIV infection associated with incarceration among injecting drug users in Bangkok, Thailand: case-control study. British Medical Journal, 326(7384): 308.
Found that injecting drug users in Bangkok are at significantly increased risk of HIV infection through sharing needles with multiple partners while in holding cells before incarceration. Concluded that the time spent in holding cells is an important opportunity to provide risk reduction counselling and intervention to reduce the incidence of HIV.
Buavirat A, Sacks R, Chiamwongpat S. HIV risk behaviors during incarceration among intravenous drug users in Bangkok, Thailand: a qualitative approach. AIDS Public Policy.
Choopanya K et al. (1991). Risk factors and HIV seropositivity among injecting drug users in Bangkok. AIDS, 1509-1513.
The first risk assessment among a large cohort of Bangkok IDUs found only two risk factors to be independently associated with HIV infection: having shared needles with two or more individuals in the previous 6 months and having been in prison. Controlling for all other risks, Bangkok IDUs with a history of prison were about twice as likely to be HIV-infected as those who had never been jailed. In terms of absolute risks, 70% of all IDUs in this study had been incarcerated at least once, and 80% of all those with HIV infection had ever been jailed.
Choopanya K et al. (2002). Incarceration and risk for HIV infection among injection drug users in Bangkok. Journal of AIDS, 29: 86-94.
One of the more recent reports of HIV infection rates during incarceration in Thailand, measured at 35/100 person-years at risk (95% CI 21.2, 55.2) among jailed Bangkok IDUs. It provides strong evidence of a causal relationship between incident HIV infection and incarceration.
Kitayaporn D et al. (1994). HIV-1 incidence determined retrospectively among drug users in Bangkok, Thailand. AIDS, 8: 1443-1450.
Kitayaporn D et al. (1998). Infection with HIV-1 subtypes B and E in injecting drug users screened for enrollment into a prospective cohort in Bangkok, Thailand. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 19: 289-295.
From May through August 1995, a cross-sectional survey was conducted among IDUs drawn from 15 drug treatment clinics in Bangkok. On multiple logistic regression analysis, HIV-seropositivity was associated with, among other factors, incarceration. The study concluded that Bangkok IDUs continue to be at high risk for HIV infection related to needle sharing and incarceration.
Thaisri H et al (2003). HIV infection and risk factors among Bangkok prisoners, Thailand : a prospective cohort study. BMC Infectious Diseases, 3: 25.
A prospective cohort of 689 male prisoners in a Bangkok central prison was studied during 2001-2002. Follow-up visits were conducted for 5 months. Among 689 male prisoners, half (50.9 %) were drug injectors. About 49% of the injectors had injected during incarceration. Most (94.9%) of the injectors had shared injection paraphernalia with others. Successful follow up rate was 98.7% after 2,581 person-months observation. HIV incidence was 4.18 per 100 person - years among all prisoners, and 11.10 per 100 person - years among the injection prisoners. Multivariate analysis identified variables associated with HIV prevalence: history of injection [OR = 2.30, 95%CI: 1.91-2.77], positive urine opiate test [OR = 5.04, 95%CI: 2.63-9.67], history of attendance to drug withdrawal clinics [OR = 2.00, 95%CI: 1.19-3.35] and presence of tattoos on the body [OR = 1.23, 95%CI: 1.01-1.52]. The authors concluded that the main HIV risk factors of Bangkok prisoners were those related to drug injection: "Harm reduction measures and HIV intervention strategies should be implemented to prevent more spread of HIV among the inmates and into the community."
Vanichseni S et al. (2001). Continued high HIV-1 incidence in a vaccine trial preparatory cohort of injection drug users in Bangkok, Thailand. AIDS, 15: 397-405.
In this cohort of IDUs in Bangkok, people who injected while incarcerated had a higher incidence of HIV infection (35.3 per 100 person years of observation) than those who had been incarcerated but had not injected (11.3 per 100) and those who had not been incarcerated (4.9 per 100). The authors concluded that the "great risk associated with incarceration warrants special attention. Although the risk associated with incarceration is not fully characterized, it is likely that a large proportion of this risk results from the sharing of drug injection equipment in settings where access to clean syringes and needles is severely limited."
Wright N et al. (1994). Was the 1988 HIV epidemic among Bangkok's injecting drug users a common source outbreak? AIDS, 8: 529-532.
Western Pacific
Australia
Butler T et al. (1997). Hepatitis B and C in New South Wales prisons: prevalence and risk factors. Medical Journal of Australia, 166: 127.
The authors set out to determine the prevalence of HBV and HCV infection among prisoners entering the New South Wales correctional system and to determine risk factors for infection. Multivariate analysis identified previous imprisonment as a significant predictor for HCV infection.
Butler T et al. (1999). Seroprevalence of markers for hepatitis B, C and G in male and female prisoners - NSW, 1996. Australian and New Zealand Journal of Public Health, 23(4), 377-384.
The objectives of the study were to 1) establish the prevalence of markers for HBV, HCV and HGV in a sample of male and female prisoners; 2) examine exposure to multiple viruses; and 3) compare risk factors for HGV infection with known risk factors for HBV and HCV. Overall detection was 35% for HBV, 39% for HCV and 10% for HGV. Exposure rates were higher in female prisoners than males. Thirty-five per cent of inmates were unaware of their HCV status. The multivariate analysis identified Aboriginality, long-term injecting and injecting while in prison as risk factors for HBV. HCV risk factors were female sex, non-Aboriginality, institutionalisation and IDU-associated behaviours. For HGV, female sex and previous imprisonment were significant risk factors but IDU was not.
Crofts N et al. (1995). Spread of bloodborne viruses among Australian prison entrants. British Medical Journal, 310: 285-288.
The objective was to assess the spread of blood-borne viruses among prison entrants in Victoria, Australia. Voluntary confidential testing of all prison entrants for markers of exposure to blood-borne viruses with collection of data on demography and risk factors over 12 months was conducted. The study was conducted in Her Majesty's Prisons, Pentridge and Fairlea, Victoria, Australia. 3429 male and 198 female prison entrants (>99% of all prison entrants) were included; 344 entered prison and were tested more than once.
1564 (46%) gave a history of use of injected drugs, 1418 (39%) were anti-hepatitis C positive including 914 (64%) of the men who injected drugs, 91 (2.5%) were positive for antibody to HIV. The incidence rate for infection with hepatitis C virus was 18.3 per 100 person years; in men who injected drugs and were aged less than 30 years (29% of all prison entrants) it was 41 per 100 prison years.
Seroconversion to hepatitis C was associated with young age and shorter stay in prison. The study concluded that HCV (and HBV) are spreading rapidly through some prison populations of injecting drug users in Victoria, particularly among men aged less than 30 years at risk of imprisonment in whom rates of spread are extreme; this group constitutes a sizeable at risk population for spread of HIV. This spread is occurring in a context of integrated harm reduction measures outside prisons for prevention of viral spread but few programs within or on transition from prisons; it poses an urgent challenge to these programs.
With regard to whether transmission occurred in prison, the authors said: "We do not have data to draw conclusions about the timing of transmission of these viruses in this population. There were three possible periods: before first prison entry, during imprisonment, and after initial imprisonment but before the second entry. There is evidence of transmission of these viruses within prisons, and a local study found a prison history to be an independent risk factor for exposure to hepatitis C among male injecting drug users in Victoria. Other evidence suggests that the period immediately after release from prison is the most risky in terms of transmission of bloodborne viruses. The association of seroconversion with shorter stay in prison and longer period outside prison is intriguing but susceptible to conflicting explanations. One is the possibility that the most dangerous time for transmission of these viruses is in the remand yards, where the shorter stay prisoners spend their time and where injecting is reputedly most unsafe. Alternatively, most of this transmission might be occurring on release and is detected only in those who are out of prison for three months or more because of the seroconversion period."
Crofts N (1997). A cruel and unusual punishment. Sentencing prisoners to hepatitis infection as well as to loss of liberty is a violation of human rights. Medical Journal of Australia, 166: 116.
Dolan K, Hall W, Wodak A, Gaughwin M (1994). Evidence of HIV transmission in an Australian prison. The Medical Journal of Australia, 160(11): 734.
A prisoner was reported to have tested negative after six years in prison in 1987 and then tested positive while incarcerated without interruption. Medical files confirmed his report of severe symptoms were consistent with primary HIV infection.
Dolan K. AIDS, drugs and risk behaviour in prison: state of the art.
Accessed at http://www.drugtext.org/library/articles/97811.htm on 3 August 2005.
Dolan, K et al. (1996) A Network of HIV Infection among Australian Inmates. Abstract No 6594, XIth International Conference on AIDS, Vancouver, 7-11 July 1996.
Dolan K et al. (1998). A mathematical model of HIV transmission in NSW prisons. Drug & Alcohol Dependence, 50: 197-202.
Proposes mathematical modeling as a useful technique for estimating HIV transmission in prisons. Using conservative assumptions, where measurement of relevant variables for the model was unavailable, a relatively large number of HIV infections were estimated to occur in prisons through sharing of injection equipment. Importantly, these observations were made even in a country where HIV prevalence among injection drug users is low.
Dolan K, Wodak A (1999). HIV transmission in a prison system in an Australian State. Medical Journal of Australia, 171(1): 14-17.
Epidemiological and genetic evidence was also used to confirm an outbreak of HIV in an Australian prison. Criteria for establishing that HIV infection had indeed occurred in prison included: HIV-antibody test results, documented primary HIV infection assessed by a panel of HIV experts, time and location in prison, risk behaviour in prison, and genetic relatedness of HIV sequences obtained from respondents. Attempts to trace 27 IDUs resulted in 21 being located. Of these, six had died of AIDS and two declined to participate for fear of repercussions for transmitting HIV. 13 were enrolled. Overall, it was concluded that infection occurred in prison for 4 subjects and in the community for two. The location of infection for the remaining seven could not be determined. 11 participants reported syringe sharing in prison, two also reported receiving a tattoo in prison, and one also reported unprotected anal sex.
Dolan K. Can hepatitis C transmission be reduced in Australian prisons? Medical Journal of Australia 2001; 174: 378-379.
Gates J et al. (2004). Risk factors for hepatitis C infection and perception of antibody status among male prison inmates in the Hepatitis C Incidence and Transmission in Prisons Study cohort, Australia. Journal of Urban Health, 81(3): 448-452.
A prospective study to estimate HCV transmission in prisoners in Australia, the Hepatitis C Incidence and Transmission in Prisons Study (HITS), serologically screened male prisoners for HCV infection at enrollment. A case-control analysis of those screened was undertaken and compared the prevalence of risk factors for HCV infection among prisoners positive and negative for anti-HCV antibody. The study confirmed that a history of prior imprisonment was a risk factor associated with HCV infection.
Haber PS et al. (1999). Transmission of hepatitis C within Australian prisons. Medical Journal of Australia, 171: 31-33.
Presents 4 cases of HCV infection occurring during periods of continuous imprisonment. All four subjects were seronegative for HCV after 4-52 months' continuous imprisonment, and remained in continuous full-time custody until seroconversion was documented. According to the authors, "the cases presented ... probably represent only a small fraction of inmates acquiring new HCV infection in prison." They recommended detailed studies of the incidence and risk factors for HCV transmission in prisons, followed by development and implementation of control measures.
Hellard ME, Hocking JS, Crofts N (2004). The prevalence and the risk behaviours associated with the transmission of hepatitis C virus in Australian correctional facilities. Epidemiology Infect, 132(3): 409-15
This study measured the prevalence and the risk factors associated with HCV antibody-positive prisoners. A total of 630 prisoners completed a questionnaire about risk behaviours associated with HCV transmission and were tested for HCV antibody from a blood test. Of these 362 (57.5%) prisoners were HCV antibody positive. A total of 436 (68.8%) prisoners reported ever injecting drugs and 332 reported injecting drugs in prison. HCV-positive prisoners were more likely to have injected drugs (OR 29.9) and to have injected drugs in prison during their current incarceration (OR 3.0). Tattooing was an independent risk factor for being HCV positive (OR 2.7). This is the first study conducted on prisoners that has identified having a tattoo in prison as a risk factor for HCV. Injecting drugs whilst in prison during this incarceration was also a risk factor for HCV. The authors concluded that "prisoners who injected drugs outside of prison continue to inject in prison but in a less safe manner."
MacDonald M, Crofts N, Kaldor J (1996). Transmission of hepatitis C virus: rates, routes and cofactors. Epidemiol Rev, 18: 137-148.
O'Sullivan B et al. (2003). Hepatitis C transmission and HIV post-exposure prophylaxis after needle-and syringe-sharing in Australian prisons. Medical Journal of Australia, 178(11): 546-549.
In 2 prisons in Australia, in November 2000 prisoners disclosed that they were HIV-positive and had shared needles and syringes in the previous weeks. There were 4 seroconversions to HCV within 14 months of the potential exposure (14% of those susceptible in the cohort), but no recorded HIV or HBV seroconversions. In the first documented use of HIV PEP in the prison setting anywhere in the world, 46 prisoners were offered PEP, and 34 elected to receive it, but only 8 completed the full PEP course. The study concluded that while HIV PEP may be administered in the prison setting, special consideration of prison circumstances is necessary to ensure accurate risk assessment, consideration of ongoing risk behaviours, prompt initiation of therapy, good compliance and adequate follow-up. Specific guidelines for the use of PEP in prisons should be developed by correctional health services to improve the administration of PEP in the prison setting.
Post JJ, Dolan K et al. (2001) Acute hepatitis C virus infection in an Australian prison inmate: tattooing as a possible transmission route. Medical Journal of Australia, 174: 183-184.
Post et al. report a well-defined case of acute HCV infection and subsequent viral clearance in a prisoner after tattooing. A man who had been continuously imprisoned since 1997 presented with symptoms of jaundince, dark urine, malainse, nausea, anorexia, sweats and headache in April 1999. He had never been tattooed before entering prison, but was tattooed on 4 occasions inside prison. The 2 most recent episodes were within the recognized incubation period for HCV infection of 3-20 weeks. He denied injection drug use, needlestick injury, sharing of razors or toothbrushes and having sex while in prison. Nevertheless, the authors say that undisclosed injection drug use cannot not be completely discounted as the route of transmission and concluded: "Although tattooing represents a biologically plausible means for the transmission of HCV, this case illustrates that undisclosed injecting drug use may be a confounder in studies where tattooing is the only acknowledged risk factor for transmission of HCV."
Thompson et al. (1996) Hepatitis C transmission through tattooing: a case report. Australia and New Zealand Journal of Public Health, 20(3): 317-318.
Reports the case of a prisoner for whom tattooing was the likely source of HCV infection. Many of the tattoos were carried out in prison using equipment that was multiply shared with other prisoners with limited access to means of disinfection.
Van Beek I et al. (1998). Infection with HIV and hepatitis C virus among injecting drug users in a prevention setting: retrospective cohort study. British Medical Journal, 317: 433-437.
Past imprisonment has also been associated with HCV infection by van Beek et al. who found in Sydney, Australia, that HCV incidence was substantially higher among IDUs who had been imprisoned (60,8/100 person years) than those who had not (12,5/100 person years). In the proportional hazards regression analyses, independent predictors of HCV seroconversion were age less than 20 years and a history of imprisonment. The authors concluded: "An important finding from the study was the strong relation between a history of imprisonment and the incidence of hepatitis C virus. We could not determine on the basis of available data whether the period of imprisonment was between the last negative and first positive test result in subjects who acquired hepatitis C virus infection. The observed association may be due to risk behaviour in prison or a consequence of an association between history of imprisonment and chaotic lifestyle, which may in turn be a surrogate marker of injecting risk behaviour. In either case, the association observed in this study population deserves further investigation, specifically to assess whether preventing the spread of hepatitis C virus should be better dealt with in the prison setting."
Wallace J, Milne GR, Barr A (1972). Total screening of blood donations for Australia (hepatitis associated) antigen and its antibody. British Medical Journal, i: 663-664.
The association between imprisonment, use of injecting drugs, and the transmission of another bloodborne virus, HBV, was recognized in this study more than 30 years ago.
Transmission of STIs
Well-documented evidence exists for syphilis and gonorrhea intra-prison transmission resulting from sexual contacts among prisoners.
Alcabes P, Braslow C (1988). A cluster of cases of penicillinase-producing Neisseria gonorrhoe in an adolescent detention center. NY State J Medicine, 88: 495-496.
Bobrik A et al. (2005). Prison health in Russia: the larger picture. Journal of Public Health Policy, 26: 30-59.
Mentions that intraprison outbreaks of sexually transmitted diseases have been documented in the Russian Federation, like a syphilis infection of 76 prisoners at the correctional colony IK-11 in the Krasnodar Krai.
Puisis M, Levine W, Mertz K (1998). Overview of sexually transmitted diseases. In: Puisis M (ed) Correctional Medicine, 127-140.
Smith WH (1965). Syphilis epidemic in a southern prison. Journal of the Medical Association of the State of Alabama, 35: 392-394.
Van Hoeven KH, Rooney WC, Joseph SC (1990). Evidence of gonococcal transmission within a correctional system. American Journal of Public Health, 80: 1505-1506.
Wolfe MI et al (2001). An outbreak of syphilis in Alabama prisons: correctional health policy and communicable disease control. American Journal of Public Health, 91(8): 1220-1225.
At least 4 outbreaks of syphilis occurred in Alabama prisons from 1991 to 1996. This study investigated syphilis outbreaks reported at 3 Alabama State men's prisons in early 1999. 39 case patients with early syphilis were identified. Recent jail exposure and prison transfer were associated with being a source case patient. The study reported that transmission of HIV did not occur in this outbreak in conjunction with the transmission of syphilis, but said that an "HIV outbreak could easily go undetected in the prison system." It continued by saying: "Given the sexual mixing of prisoners who are HIV infected and uninfected in most prisons and jails, the transmission of HIV in prisons could be a much larger problem than is currently appreciated."
Zachariah R et al (2002). Sexually transmitted infections among prison inmates in a rural district of Malawi. Trans R Soc Trop Med Hyg, 96(6): 617-619.
As part of an HIV prevention strategy targeting high-risk groups, sexually transmitted infection (STI) clinics are offered to all prisoners in Thyolo district, southern Malawi. Prison inmates are not, however, allowed access to condoms as it is felt that such an intervention might encourage homosexuality which is illegal in Malawi. A study was conducted between January 2000 and December 2001 in order to determine the prevalence, incidence, and patterns of STIs among male inmates of 2 prisons in this rural district. A total of 4229 inmates were entered into the study during a 2-year period. Of these, 178 (4.2%) were diagnosed with an STI. 50 (28%) STIs were considered incident cases acquired within the prisons (incidence risk 12 cases/1000 inmates/year). The authors concluded that this study shows that a considerable proportion of STIs among inmates are acquired within prison. In a setting of same-sex inmates, this suggests inter-prisoner same-sex sexual activity. The findings have implications for HIV transmission and might help in developing more rational policies on STI control and condom access within Malawi prisons.
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