London School of Hygiene & Tropical Medicine

Focussing on the health of prisoners is vital in order to control HIV and tuberculosis (TB) epidemics globally, according to a major six-part Series published in The Lancet on HIV and related infections in prisoner populations. The findings, which are being  presented at the International AIDS Conference in Durban, demonstrate that the mass imprisonment of drug users has led to far higher levels of HIV, TB and hepatitis B and C among prisoners than found in the general population.

It is estimated that worldwide, 56-90% of people who inject drugs will be imprisoned at some point. The Series highlights that levels of HIV infection are 20 times higher among prisoners in western Europe than the civilian population (4.2% vs 0.2%). In most areas of the world HIV infection rates are higher in female inmates than male inmates. While most prisoners are men, women and girls are the fastest growing imprisoned group worldwide.

New estimates in the Series predict 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, and imprisonment could be responsible for three-quarters of new tuberculosis infections among people who inject drugs.

The risk is not isolated to prisons, with around 10.2 million people imprisoned worldwide at any given time and an estimated 30 million passing through prison systems annually, undiagnosed and untreated infections can spread to communities when prisoners return home. This movement can also cause interruptions to treatments, which poses a risk to former prisoners and their communities.

Martin McKee, Professor of European Public Health at the School, who was a co-author on the Series, said: "This Series shows that prisons and other detention facilities play an important role in the AIDS epidemic. Yet there are still far too many gaps in our knowledge of what is happening in prisons, especially in low and middle income countries. This has consequences for not only prisoners but also staff and the population at large.

"Crucially, our study shows the importance of reducing the number of drug users in prisons and providing opioid substitution therapy for those who are incarcerated as key parts of the struggle against AIDS."

Prisons and detention centres have become hubs for infection spread due to high rates of injecting drug use in some settings, lack of access to condoms, unhygienic conditions and overcrowding.

Evidence published in the Series shows that countries can lower infectious disease transmissions by scaling up harm reduction and treatment strategies in prisons, such as opioid agonist therapy (OAT) - a form of substitution therapy to help users reduce drug use, antiretroviral therapy (ART), sterile needle and syringe exchange and condom distribution. While these interventions have proven successful when applied, the programmes are severely underfunded and impeded by rules in both high and low income countries. For example, only 43 countries offer OAT and less than 1% of prisoners worldwide who need the treatment actually receive it.

Prof Martin McKee co-authored Series paper one, which investigated the global burden of HIV, hepatitis and TB in prisoners and detainees. Modelling conducted in the paper suggests that the most effective way to control and even reduce the incidence of infection in prisoners and wider communities is to reduce the mass incarceration of people who inject drugs. Reducing the number of prisoners who inject drugs by 25% could see a 7-15% drop in new cases of HIV in the drug-injecting prison population after five years. The paper also suggests that by scaling up OAT to those in need, a quarter of new HIV cases in this population could be prevented.

In their accompanying Comment, Prof McKee and colleagues call for urgent reform. They write that "The Nelson Mandela Rules provide benchmarks to achieve meaningful reform in access to health care for those detained. We can, and should, do better to reduce both the numbers of those incarcerated and the length of their sentences, and to improve prevention, treatment, and post-release linkage to care for prison-associated infectious diseases. Meeting community standards of care in correctional settings, especially in low-income and middle-income countries, will require political will, financial investment, and support from medical and humanitarian organisations across the globe, but it can and must be done. Global control of HIV, viral hepatitis, and tuberculosis will not be achieved without addressing the unmet health needs of prisoners."

Publication:

• HIV and related infections in prisoners, The Lancet, July 2016

Related links:

• What will it take to end HIV? - Feature