Incidence and risk for acute hepatitis C infection during imprisonment in Australia

Interventions to reduce harms related to drug use among people who experience incarceration: systematic review and meta-analysis

BACKGROUND

Mortality, suicide, self-harm, and substance use are elevated among people who are incarcerated. There is a wide range of heterogeneous interventions aimed at reducing these harms in this population. Previous reviews have focused on specific interventions or limited their findings to drug use and recidivism and have not explored interventions delivered after release from prison. Our aim is to examine the effect of interventions delivered to people who use drugs during incarceration or after release from incarceration, on a wide range of outcomes.

METHODS

In this systematic review and meta-analysis, we searched Embase, MEDLINE, and PsycINFO databases up until Sept 12, 2023 for studies published from Jan 1, 1980 onwards. All studies evaluating the effectiveness of any intervention on drug use, recidivism outcomes, sexual or injecting risk behaviours, or mortality among people who use psychoactive drugs and who were currently or recently incarcerated were included. Studies without a comparator or measuring only alcohol use were excluded. Data extracted from each study included demographic characteristics, interventions, and comparisons. Pooled odds ratios and risk ratios were calculated using random-effects meta-analyses.

FINDINGS

We identified 126 eligible studies (47 randomised controlled trials and 79 observational studies) encompassing 18 interventions; receiving opioid-agonist treatment (OAT) in prison reduced the risk of death in prison (one study; hazard ratio 0·25; 95% CI 0·13-0·48), whereas receiving OAT in the first 4 weeks following release reduced risk of death in the community (two studies; relative risk 0·24; 95% CI 0·15-0·37). Therapeutic community interventions reduced re-arrest at 6-12 months (six studies; odds ratio [OR] 0·72; 95% CI 0·55-0·95) and reincarceration at 24 months (two studies; OR 0·66; 95% CI 0·48-0·96). There was scarce evidence that OAT and syringe service provision are effective in reducing injecting risk behaviours and needle and syringe sharing.

INTERPRETATION

There are effective interventions to reduce mortality and recidivism for people who use drugs who have been incarcerated. Nonetheless, there are also substantial gaps in the research examining the effect of interventions on risk behaviours and mortality during incarceration and a need for randomised designs examining outcomes for people who use drugs after release.

FUNDING

Australian National Health and Medical Research Council.

Reimbursing incarcerated individuals for participation in research: A scoping review

BACKGROUND

Little is known about global practices regarding the provision of reimbursement for the participation of people who are incarcerated in research. To determine current practices related to the reimbursement of incarcerated populations for research, we aimed to describe international variations in practice across countries and carceral environments to help inform the development of more consistent and equitable practices.

METHODS

We conducted a scoping review by searching PubMed, Cochrane library, Medline, and Embase, and conducted a grey literature search for English- and French-language articles published until September 30, 2022. All studies evaluating any carceral-based research were included if recruitment of incarcerated participants occurred inside any non-juvenile carceral setting; we excluded studies if recruitment occurred exclusively following release. Where studies failed to indicate the presence or absence of reimbursement, we assumed none was provided.

RESULTS

A total of 4,328 unique articles were identified, 2,765 were eligible for full text review, and 426 were included. Of these, 295 (69%) did not offer reimbursement to incarcerated individuals. A minority (n = 13; 4%) included reasons explaining the absence of reimbursement, primarily government-level policies (n = 7). Among the 131 (31%) studies that provided reimbursement, the most common form was monetary compensation (n = 122; 93%); five studies (4%) offered possible reduced sentencing. Reimbursement ranged between $3-610 USD in total and 14 studies (11%) explained the reason behind the reimbursements, primarily researchers' discretion (n = 9).

CONCLUSIONS

The majority of research conducted to date in carceral settings globally has not reimbursed incarcerated participants. Increased transparency regarding reimbursement (or lack thereof) is needed as part of all carceral research and advocacy efforts are required to change policies prohibiting reimbursement of incarcerated individuals. Future work is needed to co-create international standards for the equitable reimbursement of incarcerated populations in research, incorporating the voices of people with lived and living experience of incarceration.

Criminal Justice Involvement after Release from Prison following Exposure to Community Mental Health Services among People Who Use Illicit Drugs and Have Mental Illness: a Systematic Review

Illicit drug use and mental illness are common among people in prison and are associated with higher rates of reoffending and reimprisonment. We conducted a systematic review, searching MEDLINE, Embase, and PsycINFO to January 10, 2022, for studies reporting criminal justice involvement following exposure to community mental health services among people released from jail or prison who use illicit drugs and have mental illness. Our search identified 6954 studies; 13 were eligible for inclusion in this review. Studies were separated into three broad categories based on community mental health service type. Eleven of 13 studies reported a reduction in criminal justice involvement among participants exposed to community mental health services compared to a comparison group. Findings indicate a need to expand and improve integration and referral mechanisms linking people to community mental health services after jail or prison release, alongside a need for tailored programs for individuals with complex illicit drug use and mental health morbidities.

Is hepatitis C virus (HCV) elimination achievable among people who inject drugs in Tijuana, Mexico? A modeling analysis

BACKGROUND

In 2019, Mexico became the first Latin American country committed to hepatitis C virus (HCV) elimination, but the amount of intervention scale-up required is unclear. In Tijuana, HCV among people who inject drugs (PWID) is high; yet there is minimal and intermittent harm reduction, and involuntary exposure to compulsory abstinence programs (CAP) occurs which is associated with increased HCV risk. We determined what combination intervention scale-up can achieve HCV elimination among current and former PWID in Tijuana.

METHODS

We constructed a dynamic, deterministic model of HCV transmission, disease progression, and harm reduction among current and former PWID parameterized to Tijuana (~10,000 current PWID, 90% HCV seropositive, minimal opiate agonist therapy [OAT] or high coverage needle/syringe programs [HCNSP]). We evaluated the number of direct-acting antiviral (DAA) treatments needed from 2019 to achieve elimination targets (80% incidence reduction, 65% mortality reduction by 2030) with: (a) DAAs alone, (b) DAAs plus scale-up of OAT+HCNSP (up to 50% coverage of OAT and HCNSP separately, producing 25% of PWID receiving both), (c) DAAs plus CAP scale-up to 50%. Scenarios examined the number of DAAs required if prioritized to current PWID or provided regardless of current injection status, and impact of harm reduction interruptions.

RESULTS

Modeling suggests among ~30,000 current and former PWID in Tijuana, 16,160 (95%CI: 12,770-21,610) have chronic HCV. DAA scale-up can achieve the incidence target, requiring 770 treatments/year (95%CI: 640-970) if prioritized to current PWID. 40% fewer DAAs are required with OAT+HCNSP scale-up to 50% among PWID, whereas more are required with involuntary CAP scale-up. Both targets can only be achieved through treating both current and former PWID (1,710 treatments/year), and impact is reduced with harm reduction interruptions.

CONCLUSIONS

Elimination targets are achievable in Tijuana through scale-up of harm reduction and DAA therapy, whereas involuntary CAP and harm reduction interruptions hamper elimination.

Violence and hepatitis C transmission in prison-A modified social ecological model

BACKGROUND

Transmission of hepatitis C virus (HCV) among the prisoner population is most frequently associated with sharing of non-sterile injecting equipment. Other blood-to-blood contacts such as tattooing and physical violence are also common in the prison environment, and have been associated with HCV transmission. The context of such non-injecting risk behaviours, particularly violence, is poorly studied. The modified social-ecological model (MSEM) was used to examine HCV transmission risk and violence in the prison setting considering individual, network, community and policy factors.

METHODS

The Australian Hepatitis C Incidence and Transmission Study in prisons (HITS-p) cohort enrolled HCV uninfected prisoners with injecting and non-injecting risk behaviours, who were followed up for HCV infection from 2004-2014. Qualitative interviews were conducted within 23 participants; of whom 13 had become HCV infected. Deductive analysis was undertaken to identify violence as risk within prisons among individual, network, community, and public policy levels.

RESULTS

The risk context for violence and HCV exposure varied across the MSEM. At the individual level, participants were concerned about blood contact during fights, given limited scope to use gloves to prevent blood contamination. At the network level, drug debt and informing on others to correctional authorities, were risk factors for violence and potential HCV transmission. At the community level, racial influence, social groupings, and socially maligned crimes like sexual assault of children were identified as possible triggers for violence. At the policy level, rules and regulations by prison authority influenced the concerns and occurrence of violence and potential HCV transmission.

CONCLUSION

Contextual concerns regarding violence and HCV transmission were evident at each level of the MSEM. Further evidence-based interventions targeted across the MSEM may reduce prison violence, provide opportunities for HCV prevention when violence occurs and subsequent HCV exposure.

Prevalence of and risk factors for HBV and HCV among incarcerated people who inject drugs in Iran: A cross sectional study

Background

This study aimed at determining the prevalence of and risk factors for hepatitis B virus (HBV) and hepatitis C virus (HCV) among incarcerated people who inject drugs (PWID) in Iran in 2015–16.

Methods

The required data was collected from a database provided by Iranian national bio-behavioral surveillance surveys (BBSSs) on 11,988 prisoners selected from among 55 prisons in 19 provinces in 2015–16. The data on demographics and behavioral variables were collected through interviews and the status of exposure to HBV and HCV were determined using ELISA blood test. A total of 1387 individuals with a history of drug injection in their lifetime were enrolled into the study. Data were analyzed using the survey package in Stata/SE software, Version 14.0. Univariate and multivariate logistic regression tests were used to investigate the relationships between risk factors and outcomes.

Results

The mean age of the incarcerated PWID was 36.83 ± 8.13 years. Of all the studied subjects, 98.46% were male and 50.97% were married. The prevalence of HCV and HBV among the subjects were 40.52 and 2.46%, respectively. The prevalence of HCV was associated with age ≥ 30 years, being single, illiteracy and low level of education, prison term> 5 years, history of piercing, and extramarital sex in lifetime (P < 0.05).

Conclusions

The prevalence of HCV is alarmingly high. In general, it is recommended to adopt measures to screen and treat patients with HCV and vaccinat incarcerated PWID without a history of vaccination against HBV.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-020-05541-2.

Detection, stratification and treatment of hepatitis C-positive prisoners in the United Kingdom prison estate: Development of a pathway of care to facilitate the elimination of hepatitis C in a London prison

The United Kingdom is committed to eliminating hepatitis C virus (HCV) infection by 2025. The prison estate provides an opportunity to identify and treat HCV-positive individuals in a high-prevalence environment. We designed and implemented a pathway of care within a London prison to diagnose, stratify and link HCV-positive prisoners into care. This study was a two-phase case study of a HCV care pathway. New arrivals to the prison were offered blood-borne virus screening with dried blood spot testing at their secondary health check. Those with active infection completed disease stratification tests and were reviewed at a weekly hospital-based multidisciplinary team meeting to determine management. In Phase-2, the pathway was redesigned to improve testing and the referral of HCV-positive prisoners into treatment. Over the 30-month evaluation period, 12,946 people were received in the prison. During Phase-1, 19.6% of new arrivals completed blood-borne virus testing, with 7.3% identified as HCV-positive. Just 8.3% of HCV-positive individuals were treated or referred for treatment in Phase-1. During Phase-2, 30% of new receptions completed BBV testing and 3.9% were identified as HCV-positive. Linkage into care was improved, with 38.9% treated or referred during the second phase. Poor access to testing and referral to treatment limit the effectiveness of care provision for prisoners with HCV. Elimination of HCV in prisons requires local service configuration to ensure high uptake of testing, with all HCV-positive cases then offered treatment during custody or referral on to treatment after release.

The Impact of Medications for Opioid Use Disorder on Hepatitis C Incidence Among Incarcerated Persons: A Systematic Review

Hepatitis C virus (HCV) is highly prevalent in the criminal justice system and in persons who inject drugs, particularly opioids. Data on the impact of medications for opioid use disorder (MOUD) are abundant for infectious and noninfectious outcomes but are limited for justice-involved settings. This systematic review and meta-analysis focuses on the impact of MOUD on HCV incidence for persons in prisons and jails. Six studies were included in the qualitative synthesis, of which four were included for meta-analysis. A varied MOUD effect on HCV incidence was observed in part due to wide variability in prison and jail risk environments.

Modelling integrated antiretroviral treatment and harm reduction services on HIV and overdose among people who inject drugs in Tijuana, Mexico

INTRODUCTION

The HIV epidemic in Tijuana, Mexico is concentrated in key populations, including people who inject drugs (PWID). However, HIV interventions among PWID are minimal, and federal funding was provided for compulsory abstinence programmes associated with HIV and overdose. Alternatively, opioid agonist therapy reduces overdose, reincarceration, HIV, while improving antiretroviral therapy (ART) outcomes. We assessed potential impact and synergies of scaled-up integrated ART and opioid agonist therapy, compared to scale-up of each separately, and potential harms of compulsory abstinence programmes on HIV and fatal overdose among PWID in Tijuana.

METHODS

We developed a dynamic model of HIV transmission and overdose among PWID in Tijuana. We simulated scale-up of opioid agonist therapy from zero to 40% coverage among PWID. We evaluated synergistic benefits of an integrated harm reduction and ART scale-up strategy (40% opioid agonist therapy coverage and 10-fold ART recruitment), compared to scale-up of each intervention alone or no scale-up of low coverage ART and no harm reduction). We additionally simulated compulsory abstinence programmes (associated with 14% higher risk of receptive syringe sharing and 76% higher odds of overdose) among PWID.

RESULTS

Without intervention, HIV incidence among PWID could increase from 0.72 per 100 person-years (PY) in 2020 to 0.92 per 100 PY in 2030. Over ten years, opioid agonist therapy scale-up could avert 31% (95% uncertainty interval (UI): 18%, 46%) and 22% (95% UI: 10%, 28%) new HIV infections and fatal overdoses, respectively, with the majority of HIV impact from the direct effect on HIV transmission due to low ART coverage. Integrating opioid agonist therapy and ART scale-up provided synergistic benefits, with opioid agonist therapy effects on ART recruitment/retention averting 9% more new infections compared to ART scale-up alone. The intervention strategy could avert 48% (95% UI: 26%, 68%) of new HIV infections and one-fifth of fatal overdoses over ten years. Conversely, compulsory abstinence programmes could increase HIV and overdoses.

CONCLUSIONS

Integrating ART with opioid agonist therapy could provide synergistic benefits and prevent HIV and overdoses among PWID in Tijuana, whereas compulsory abstinence programmes could cause harm. Policymakers should consider the benefits of integrating harm reduction and HIV services for PWID.

Envelope-Specific IgG3 and IgG1 Responses Are Associated with Clearance of Acute Hepatitis C Virus Infection

Hepatitis C virus (HCV) can be cleared naturally in a subset of individuals. However, the asymptomatic nature of acute HCV infection makes the study of the early immune response and defining the correlates of protection challenging. Despite this, there is now strong evidence implicating the humoral immune response, specifically neutralising antibodies, in determining the clearance or chronicity outcomes of primary HCV infection. In general, immunoglobulin G (IgG) plays the major role in viral neutralisation. However, there are limited investigations of anti-HCV envelope protein 2 (E2) isotypes (IgM, IgG, IgA) and IgG subclasses (IgG1-4) in early HCV infection. In this study, using a rare cohort of 14 very recently HCV-infected individuals (4-45 days) with varying disease outcome (n = 7 clearers), the timing and potency of anti-HCV E2 isotypes and IgG subclasses were examined longitudinally, in relation to neutralising antibody activity. Clearance was associated with anti-E2 IgG, specifically IgG1 and IgG3, and appeared essential to prevent the emergence of new HCV variants and the chronic infection outcome. Interestingly, these IgG responses were accompanied by IgM antibodies and were associated with neutralising antibody activity in the subjects who cleared infection. These findings provide novel insights into the early humoral immune response characteristics associated with HCV disease outcome.

"A spray bottle and a lollipop stick": An examination of policy prohibiting sterile injecting equipment in prison and effects on young men with injecting drug use histories

BACKGROUND

Australian young male prisoners with histories of injecting drug use are more likely to report injecting in prison, to do so more frequently, and to be involved in more un-safe injecting-related practices than their older counterparts. Despite international evidence that prison needle and syringe programs are both feasible and effective in reducing the harms associated with injecting drug use in prison, these young men do not have access to such equipment.

METHODS

We critically analyse the interview transcripts of 28 young men with histories of injecting drug use who were recently released from adult prisons in Victoria, Australia, and prison drug policy text. We use Bacchi's 'What's the problem represented to be?' approach to examine how the 'problem' of injecting drug use in prison is represented in prison drug policy, including the assumptions that underpin these problematisations, and the subjectification and lived effects that are produced for the young men in our study.

RESULTS

Our analysis reveals how prison drug policy enables the creation and re-use of homemade injecting equipment crafted from unsterile items found in prison, and that in doing so the policy produces a range of stigmatising subjectification effects and other harmful material effects (such as hepatitis C virus transmission and injecting related injury and harms). Findings highlight, how injecting drug use is represented in policy silences other ways of understanding the 'problem' that may have less harmful effects for incarcerated young men who inject drugs.

CONCLUSION

We argue that somewhat paradoxically, the approach of prohibiting access to sterile injecting equipment in prison-which is constituted as a solution for addressing such harms-in fact helps to produce them.

Characteristics associated with anti-HCV serological markers in prisoners in the state of Paraná, Brazil: a case-control study

Background

The prison system in Paraná, Brazil, is experiencing serious problems related to the increasing number of prisoners. Control of hepatitis C virus (HCV) has become more intense because the incarcerated population is considered a high-risk group for contagious diseases due to the favorable conditions found in prisons for the spread of these morbidities. The objective of this study was to identify features associated with hepatitis C infection among male prisoners in correctional institutions of Paraná state, Brazil.

Methods

This was a case-control study (27 cases and 54 controls) of men incarcerated in 11 penitentiaries in Paraná, Brazil. Information was obtained through a questionnaire in a cross-sectional epidemiological survey on HCV infection during the period from May 2015 to December 2016. Eligible men were recruited after testing positive for anti-HCV antibodies. Cases and controls were selected based on serological results of enzyme-linked immunosorbent assays and were matched by age, location of the penitentiary, and time in prison. Logistic regression analysis was used to identify risk factors for HCV seropositivity.

Results

The main significant independent risk factor for the acquisition of HCV infection was the use of injectable drugs (OR = 4.00; 95%CI:1.41–11.35; p < 0.001).

Conclusions

This study provides evidence that HCV infection is associated with drug use by this population. This information is pivotal for tailoring prevention programs and guiding specific socioeducational measures that aim to reduce or prevent HCV transmission within the prison setting.

A method for detecting hepatitis C envelope specific memory B cells from multiple genotypes using cocktail E2 tetramers

Hepatitis C (HCV) is a rapidly mutating RNA virus, with a strong propensity to cause chronic infection and progressive liver disease. Recent evidence has shown that early appearance of neutralizing antibodies in primary infection is associated with clearance. Little is known about the characteristics of HCV-specific B cells and their correlation with outcomes in primary infection, as there is a lack of sensitive tools for HCV-specific B cells which are present at very low frequency. We describe the development and optimisation of tetramer staining for flow cytometric detection of HCV-specific B cells using a cocktail of two recombinant HCV Envelope-2 (rE2) glycoproteins (from genotype 1a and 3a; Gt1a and Gt3a) and streptavidin dyes. The optimal weight to weight (w/w) ratio of streptavidin-phycoerythrin (PE) and rE2 proteins were determined for sensitive detection using HCV E2-specific hybridoma cell lines and peripheral blood mononuclear cells (PBMC) from HCV-infected individuals. In a cross-sectional set of PBMC samples collected from 33 subjects with either chronic infection or previous clearance, HCV E2-specific B cells (CD19⁺CD20⁺CD10^-IgD^-tetramer⁺) were detected in 29 subjects (87.8%), with a mean frequency of 0.45% (0.012-2.20%). To validate the specificity of tetramer staining, 367 HCV E2-specific B cells were single cell sorted from 9 PBMC samples before monoclonal antibodies (mAbs) were synthesised, with 87.5% being reactive to E2 via ELISA. Of these mAbs, 284 and 246 clones were reactive to either Gt1a or Gt3a E2 proteins, respectively. This is a sensitive and robust method for future studies investigating B cell responses against the HCV Envelope protein.

Optimising Hepatitis C care in an urban Aboriginal and Torres Strait Islander primary health care clinic

OBJECTIVE

Describe the sociodemographic and clinical characteristics of patients with Hepatitis C Virus (HCV) attending an urban Indigenous primary health clinic (IPHC) in Brisbane, Australia.

METHODS

A retrospective chart review of sociodemographic characteristics, presence of liver disease and treatments, lifestyle behaviours and comorbidities in patients with a HCV infection was conducted between October 2015 and March 2016.

RESULTS

One hundred and thirteen patients with confirmed HCV infection were aged between seven and 63 years; 66% were male, and 84% were Indigenous. Sixty-nine per cent had been incarcerated; 41% had experienced conflict or domestic violence; 47% were injecting drugs; 72% had depression; and 61% had anxiety. Cirrhosis was present in 7/95 patients with adequate data and associated with age (p=0.02). Eleven patients had commenced direct acting antiviral (DAA) therapy in the 18 months that it had been available.

CONCLUSIONS

The study highlights the opportunities for enhancing treatment of patients with HCV infection. Opportunities to improve treatment rates in an Indigenous primary healthcare include optimising diagnostic pathways, improving patient engagement, and general practitioner and peer worker participation. Implications for public health: HCV poses a serious threat to public health in Australia and IPHCs are key sites to addressing this for Indigenous people. Optimising care of patients with HCV attending IPHC requires recognition of the complex health needs and social context, to reduce the incidence and consequences of HCV infection.

History of detention and the risk of hepatitis C among people who inject drugs in Germany

OBJECTIVES

The aim of this study was to investigate the association between detention experience and hepatitis C virus (HCV) status, the role of duration and frequency of detention, and whether risk behaviours practiced in detention could explain an observed increase in risk.

METHODS

Current drug injectors (injecting in the last 12 months) were recruited to participate in a sero-behavioural, cross-sectional survey using respondent-driven sampling in eight German cities during the years 2011-2014. Using multivariable logistic regression, the association between HCV status and reported detention experience was investigated.

RESULTS

A total of 1998 participants were included in the analysis. Of these, 19.9% reported no detention experience, 28.6% short and rare experience (≤3.5 years in total, ≤3 times), 12.1% short but frequent experience, 7.1% long but rare experience, and 32.4% long and frequent experience. After correcting for HCV risk factors, the association between detention experience and HCV status remained statistically significant. By adjusting the model for intramural risk behaviours, the odds ratios of detention experience were reduced but remained significant.

CONCLUSIONS

The proportion of people who inject drugs positive for HCV increased with both frequency and duration of their detention experience. As intramural risk behaviours could not fully explain this increase, it appears that transfers between community and custody may confer additional risks.

Accelerating the elimination of viral hepatitis: a Lancet Gastroenterology & Hepatology Commission

Viral hepatitis is a major public health threat and a leading cause of death worldwide. Annual mortality from viral hepatitis is similar to that of other major infectious diseases such as HIV and tuberculosis. Highly effective prevention measures and treatments have made the global elimination of viral hepatitis a realistic goal, endorsed by all WHO member states. Ambitious targets call for a global reduction in hepatitis-related mortality of 65% and a 90% reduction in new infections by 2030. This Commission draws together a wide range of expertise to appraise the current global situation and to identify priorities globally, regionally, and nationally needed to accelerate progress. We identify 20 heavily burdened countries that account for over 75% of the global burden of viral hepatitis. Key recommendations include a greater focus on national progress towards elimination with support given, if necessary, through innovative financing measures to ensure elimination programmes are fully funded by 2020. In addition to further measures to improve access to vaccination and treatment, greater attention needs to be paid to access to affordable, high-quality diagnostics if testing is to reach the levels needed to achieve elimination goals. Simplified, decentralised models of care removing requirements for specialised prescribing will be required to reach those in need, together with sustained efforts to tackle stigma and discrimination. We identify key examples of the progress that has already been made in many countries throughout the world, demonstrating that sustained and coordinated efforts can be successful in achieving the WHO elimination goals.

Prevalence of Drug Injection, Sexual Activity, Tattooing, and Piercing Among Prison Inmates

Prisoners engage in a range of risk behaviors that can lead to the transmission of viral infections, such as HIV, hepatitis B and hepatitis C. In this review, we summarize the epidemiologic literature from 2007 to 2017 on 4 key risk behaviors for human immunodeficiency virus and hepatitis C virus among prisoners globally: drug injection, sexual activity, tattooing, and piercing. Of 9,303 peer-reviewed and 4,150 gray literature publications, 140 and 14, respectively, met inclusion criteria covering 53 countries (28%). Regions with high levels of injection drug use were Asia Pacific (20.2%), Eastern Europe and Central Asia (17.3%), and Latin America and the Caribbean (11.3%), although the confidence interval for Latin America was high. Low levels of injection drug use in prison were found in African regions. The highest levels of sexual activity in prison were in Europe and North America (12.1%) and West and Central Africa (13.6%); low levels were reported from the Middle East and North African regions (1.5%). High levels of tattooing were reported from Europe and North America (14.7%), Asia Pacific (21.4%), and Latin America (45.4%). Prisons are burdened with a high prevalence of infectious diseases and risk behaviors for transmission of these diseases, and, commonly, a striking lack of evidence-based infection control measures, even when such measures are available in the surrounding community. Given that most prisoners return to these communities, failure to implement effective responses has repercussions not only prisoner health but also for public health.

Understanding the Determinants of BnAb Induction in Acute HCV Infection

Despite recent advances in curative therapy, hepatitis C virus (HCV) still remains a global threat. In order to achieve global elimination, a prophylactic vaccine should be considered high priority. Previous immunogens used to induce broad neutralising antibodies (BnAbs) have been met with limited success. To improve immunogen design, factors associated with the early development of BnAbs in natural infection must first be understood. In this study, 43 subjects identified with acute HCV were analysed longitudinally using a panel of heterogeneous HCV pseudoparticles (HCVpp), to understand the emergence of BnAbs. Compared to those infected with a single genotype, early BnAb development was associated with subjects co-infected with at least 2 HCV subtypes during acute infection. In those that were mono-infected, BnAbs were seen to emerge with increasing viral persistence. If subjects acquired a secondary infection, nAb breadth was seen to boost upon viral re-exposure. Importantly, this data highlights the potential for multivalent and prime-boost vaccine strategies to induce BnAbs against HCV in humans. However, the data also indicate that the infecting genotype may influence the development of BnAbs. Therefore, the choice of antigen will need to be carefully considered in future vaccine trials.

Telementoring for hepatitis C treatment in correctional facilities

Introduction

Prevalence of hepatitis C virus (HCV) is substantially higher among prisoners than the general population. In Australia until recently, only a small proportion of prisoners with HCV received antiviral therapy. The direct-acting antivirals (DAAs) for HCV are highly effective, with a low burden of side effects. Since 2016, DAAs are available to all Australians with HCV. However, currently in Australia, they can only be prescribed by or in consultation with experienced prescribers. This study evaluated a telementoring service to upskill doctors and nurse practitioners working in correctional facilities.

Methods

The telementoring service was implemented in five correctional facilities. Qualitative interviews were used to examine the perceived clinical effectiveness and organisational impacts of the service. Content analysis of the interviews was used to identify key themes.

Results

In the first ten months of the service, there were 16 telementoring sessions with 173 patients discussed. Sixteen staff participated in qualitative interviews. From these, three key themes were identified: access to antiviral therapy; organisational impacts (cost, increased staff knowledge and confidence, staff time, and workload); and, adaptations of the care model and future opportunities.

Conclusion

Telementoring is an effective method to facilitate eligible prescriber status to medical doctors and upskill other clinicians in correctional facilities to increase capacity to treat HCV.

Direct-acting antiviral treatment of acute hepatitis C virus infections

INTRODUCTION

Hepatitis C contributes to significant morbidity and mortality worldwide. AHCV is defined as documented infection within 6 months of exposure. Treating acute hepatitis C virus (AHCV) with direct-acting antiviral agents in persons who inject drugs, HIV-positive men who have sex with men, and patients who acquire HCV nosocomially can contribute to the elimination of disease globally, preclude the morbidity and mortality of chronic disease, and prevent further transmission. Areas covered: In this review, we describe the epidemiology of AHCV, its natural history, the considerations involved in the decision of whether to treat AHCV, and the most current DAA therapy guidelines. PubMed was queried using key words and bibliographies were evaluated for relevant articles. Expert commentary: Despite the obvious benefits of AHCV treatment, clinical management is limited by the ability to identify asymptomatic cases and the absence of fully supported guidelines. However, clinical research is advancing and identifying specific regimens, decreasing treatment durations, and creating strategies to target at risk groups and screen for AHCV.

Longitudinal injecting risk behaviours among people with a history of injecting drug use in an Australian prison setting: The HITS-p study

BACKGROUND

HCV transmission remains high in prisons globally. Understanding injecting risk behaviours in prisons is crucial to effectively develop and implement HCV prevention programs in this setting including treatment as prevention.

METHODS

HITS-p is a cohort study which enrolled people with a history of injecting drug use in prisons in NSW, Australia from 2005 to 2013. Participants completed an interview at enrolment and follow-up visits to determine injecting behaviours. Generalized estimating equation (GEE) and logistic regression methods were used to assess injecting risk behaviours prior to and following prison entry and to investigate injecting risk behaviours in prison.

RESULTS

Overall, 499 participants with a history of injecting drug use were included (median age, 26 years; 65% male). Participants were significantly less likely to inject drugs following incarceration. Among injectors, participants were less likely to inject ≥weekly but more likely to share a needle/syringe. At enrolment, the proportion reporting any injecting, ≥weekly injecting, and needle/syringe sharing in prison was highest among younger individuals. Younger age was associated with both re-initiation and continuation of injecting drug use following prison entry. Among those continuously imprisoned, younger age was associated with increased odds of any injecting, ≥weekly injecting, and sharing a needle/syringe.

CONCLUSIONS

Upon entry to prison, injecting drug use decreased but syringe sharing increased among injectors. Younger individuals are most likely to exhibit high-risk injecting behaviours in prison. These data highlight the need for improved HCV prevention strategies (including improved needle/syringe access and scale up of HCV therapy) for those at increased risk of HCV transmission in prison, including younger individuals.

Ongoing incident hepatitis C virus infection among people with a history of injecting drug use in an Australian prison setting, 2005-2014: The HITS-p study

Hepatitis C virus (HCV) transmission is high in prisons. This study investigated trends in HCV incidence and associated factors among a cohort of prisoners with a history of injecting drug use in New South Wales, Australia. Data were available from the Hepatitis C Incidence and Transmission Study-prisons (HITS-p) from 2005 to 2014. Temporal trends in HCV incidence were evaluated. Factors associated with time to HCV seroconversion among people with ongoing injecting was assessed using Cox proportional hazards. Among 320 antibody-negative participants with a history of injecting drug use (mean age 26; 72% male), 62% (n=197) reported injecting drug use during follow-up. Overall, 93 infections were observed. HCV incidence was 11.4/100 person-years in the overall population and 6.3/100 person-years among the continually imprisoned population. A stable trend in HCV incidence was observed. Among the overall population with ongoing injecting during follow-up, ≥weekly injecting drug use frequency was independently associated with time to HCV seroconversion. Among continuously imprisoned injectors with ongoing injecting during follow-up, needle/syringe sharing was independently associated with time to HCV seroconversion. This study demonstrates that prison is a high-risk environment for acquisition of HCV infection. Needle and syringe sharing was associated with HCV infection among continually imprisoned participants, irrespective of frequency of injecting or the type of drug injected. These findings highlight the need for the evaluation of improved HCV prevention strategies in prison, including needle/syringe programmes and HCV treatment.

Epidemiology of Infectious Disease-Related Death After Release from Prison, Washington State, United States, and Queensland, Australia: A Cohort Study

OBJECTIVES

People in prison may be at high risk for infectious diseases and have an elevated risk of death immediately after release compared with later; their risk of death is elevated for at least a decade after release. We compared rates, characteristics, and prison-related risk factors for infectious disease-related mortality among people released from prisons in Queensland, Australia, and Washington State, United States, regions with analogous available data.

METHODS

We analyzed data from retrospective cohort studies of people released from prison in Queensland (1997-2007, n=37,180) and Washington State (1999-2009, n=76,208) and linked identifiers from each cohort to its respective national death index. We estimated infectious disease-related mortality rates (deaths per person-years in community) and examined associations using Cox proportional hazard models.

RESULTS

The most frequent infectious disease-related underlying cause of death after release from prison was pneumonia (43%, 23/54 deaths) in the Australian cohort and viral hepatitis (40%, 69/171 deaths) in the U.S. cohort. The infectious disease-related mortality rate was significantly higher in the U.S. cohort than in the Australian cohort (51.2 vs. 26.5 deaths per 100,000 person-years; incidence rate ratio = 1.93, 95% confidence interval 1.42, 2.62). In both cohorts, increasing age was strongly associated with mortality from infectious diseases.

CONCLUSION

Differences in the epidemiology of infectious disease-related mortality among people released from prison may reflect differences in patterns of community health service delivery in each region. These findings highlight the importance of preventing and treating hepatitis C and other infectious diseases during the transition from prison to the community.

Social Determinants of HIV/HCV Co-Infection: A case Study from People Who Inject Drugs in Rural Puerto Rico

•

Co-infection correlates with age, longer period of drug use, medical insurance coverage and sexual identity.

•

LGBT PWID are vulnerable to co-infection. Stigma, commercial sex and violence compounds risk.

•

Culturally sensitive prevention strategies focused on this particular population should be implemented to avoid co-infection.

The Prison Economy of Needles and Syringes: What Opportunities Exist for Blood Borne Virus Risk Reduction When Prices Are so High?

Aim

A formal Needle and Syringe Program (NSP) is not provided in Australian prisons. Injecting equipment circulates in prisons as part of an informal and illegal economy. This paper examined how this economy generates blood-borne virus (BBV) risk and risk mitigation opportunities for inmates.

Method

The HITS-p cohort recruited New South Wales inmates who had reported ever injecting drugs and who had a negative HCV serological test within 12 months prior to enrolment. For this study, qualitative interviews were conducted with 30 participants enrolled in HITS-p. Participants included 10 women and were incarcerated in 12 prisons.

Results

A needle/syringe was nominated as being typically priced in the ‘inside’ prison economy at $100-$150, with a range of $50-$350. Purchase or hire of equipment was paid for in cash (including transactions that occurred outside prison) and in exchange for drugs and other commodities. A range of other resources was required to enable successful needle/syringe economies, especially relationships with visitors and other prisoners, and violence to ensure payment of debts. Strategies to mitigate BBV risk included retaining one needle/syringe for personal use while hiring out others, keeping drug use (and ownership of equipment) “quiet”, stealing used equipment from the prison health clinic, and manufacture of syringes from other items available in the prison.

Conclusions

The provision of prison NSP would disrupt the inside economies built around contraband needles/syringes, as well as minimise BBV risk. However, any model of prison NSP should be interrogated for any unanticipated markets that could be generated as a result of its regulatory practices.

Spontaneous viral clearance of hepatitis C virus (HCV) infection among people who inject drugs (PWID) and HIV-positive men who have sex with men (HIV+ MSM): a systematic review and meta-analysis

Background

Hepatitis C virus (HCV) infection causes significant morbidity and mortality among people who inject drugs (PWID) and HIV+ men who have sex with men (MSM). Characterizing spontaneous viral clearance of HCV infection among PWID and HIV+ MSM is important for assessing the burden of disease and treatment strategies in these populations.

Methods

Electronic and other searches of medical literature were conducted. Reports were eligible if they presented original data from upper-middle- and high-income countries on laboratory-confirmed HCV infection and spontaneous viral clearance among PWID or HIV+ MSM. Pooled estimates of spontaneous viral clearance were generated using fixed-effect and random-effects models. Meta-regression examined potential predictors related to individual characteristics and research methodology.

Results

The meta-analysis estimated that spontaneous viral clearance occurs in 24.4 % of PWID and 15.4 % of HIV+ MSM. In univariate meta-regression among PWID, male sex and age were significantly associated with spontaneous viral clearance, and in multivariate analysis, male sex and HIV positivity were predictors of spontaneous viral clearance; among HIV+ MSM no variables were found to affect spontaneous viral clearance.

Conclusion

The variability in estimates of spontaneous viral clearance between HIV+ MSM and PWID suggests the impact of HIV co-infection and HCV re-infection. Due to limited data on additional factors that may affect the natural history of HCV, more research is needed to further understand spontaneous viral clearance in these risk groups.

Protocol registration

The protocols for the PWID and HIV+ MSM research were registered with PROSPERO (CRD42014008805; CRD42013006462).

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1807-5) contains supplementary material, which is available to authorized users.

Seroprevalence of hepatitis B and C among domestic and healthcare waste handlers in Belo Horizonte, Brazil

Infection with the hepatitis B and C viruses may occur through contact with infected body fluids, including injury with infected sharps. Collectors of domestic or healthcare wastes are potentially exposed to these infections. The aim of this article is to investigate the risk factors associated with the prevalence of hepatitis B and C viruses (HBV and HCV) infection among domestic and healthcare waste workers in Belo Horizonte, Brazil. A cross-sectional study of hepatitis B and C infection was conducted from November 2014 to January 2015, through blood sample collection and interviews about socio-demographic factors with 61 workers exposed to healthcare waste ('exposed') and 461 exposed only to domestic wastes ('unexposed'). The prevalence of antibodies to HCV (Anti-HCV) antibodies was 3.3% in 'exposed' workers and 0.9% in 'unexposed', and of antibody to hepatitis B core antigen (Anti-HBc) was 9.8% and 5.6% in 'exposed' and 'unexposed' workers, respectively. Only 207 (44.9%) of those exposed to domestic waste and 45 (73.8%) of those handling healthcare waste were effectively immunised against hepatitis B virus (HBV). Exposures to domestic waste and to healthcare wastes were associated with similar risks of infection with HBV. The risk of hepatitis C virus (HCV) infection was marginally higher among healthcare waste workers compared with domestic waste workers, probably because of needlestick accidents owing to deficient sharps management systems. Immunisation against hepatitis B and screening tests to ensure the success of vaccination should be a condition for recruitment for both groups of waste workers.

The International development of PROQOL-HCV: An instrument to assess the health-related quality of life of patients treated for Hepatitis C virus

BACKGROUND

Hepatitis C virus (HCV) compromises Health-related Quality of Life (HRQL) with detriments to Physical, Mental and Social health domains. Treatment with interferon and ribavirin is associated with side effects which further impair HRQL. New treatments appear potent, effective and tolerable. However, Patient Reported Outcomes instruments that capture the impact on HRQL for people with hepatitis C are largely non-specific and will be needed in the new treatment era. Therefore, we developed a conceptually valid multidimensional model of HCV-specific quality of life and pilot survey instrument, the Patient Reported Outcome Quality of Life survey for HCV (PROQOL-HCV).

METHODS

HCV patients from France (n = 30), Brazil (n = 20) and Australia (n = 20) were interviewed to investigate HCV-HRQL issues raised in the scientific literature and by treatment specialists. Interviews were recorded, transcribed and translated into English and French.

RESULTS

Fifteen content dimensions were derived from the qualitative analysis, refined and fitted to four domains: (1) Physical Health included: fatigue, pain, sleep, sexual impairment and physical activity; (2) Mental Health: psychological distress, psychosocial impact, and cognition; (3) Social Health: support, stigma, social activity, substance use; (4) TREATMENT: management, side effects, and fear of treatment failure. The impact of some dimensions extended beyond their primary domain including: physical activity, cognition, sleep, sexual impairment, and the three treatment dimensions. A bank of 300 items was constructed to reflect patient reports and, following expert review, reduced to a 72-item pilot questionnaire.

CONCLUSION

We present a conceptually valid multidimensional model of HCV-specific quality of life and the pilot survey instrument, PROQOL-HCV. The model is widely inclusive of the experience of hepatitis C and the first to include the treatment dimension.

Illicit and injecting drug use among Indigenous young people in urban, regional and remote Australia

INTRODUCTION AND AIMS

To examine patterns of illicit drug use among Australian Indigenous young people, identify correlates of frequent use separately in urban, regional and remote settings and characterise those who inject.

DESIGN AND METHOD

Cross-sectional design at 40 Indigenous events. Self-complete surveys were administered to Indigenous people aged 16-29 years using mobile devices.

RESULTS

2,877 participants completed the survey. One in five reported using cannabis at least weekly in the previous year, but the use of other drugs was less prevalent. Patterns of drug use were largely similar across regions, although more participants in urban and regional areas reported using ecstasy (12% vs 11% vs 5%) and cocaine (6% vs 3% vs 1%) and more reported weekly cannabis use (18% vs 22% vs 14%). Injecting was rare (3%) but those who did inject reported a high incidence of needle sharing (37%). Methamphetamine (37%), heroin (36%) and methadone (26%) were the most commonly injected drugs, and injecting was related to prison experience (AOR 5.3 95% CI 2.8-10.0).

DISCUSSION AND CONCLUSION

Attention is needed in relation to cannabis use, particularly among those Indigenous young people living in regional and urban settings. Also, although injecting is uncommon, it is associated with prison involvement. Priority must be given to reducing the numbers of Indigenous youth entering justice settings, delaying the age at first entry to justice settings, and reducing the risk of BBV acquisition while in custody through, for example, prison-based NSP, BBV education, and Indigenous-specific treatment that emphasises connection to country and culture. [Bryant J, Ward J, Wand H, Byron K, Bamblett A, Waples-Crowe P, Betts S, Coburn T, Delaney-Thiele D, Worth H, Kaldor J, Pitts M. Illicit and injecting drug use among Indigenous young people in urban, regional and remote Australia. Drug Alcohol Rev 2016;35:447-455].

Incident Hepatitis C Virus Genotype Distribution and Multiple Infection in Australian Prisons

Hepatitis C virus (HCV) is a highly diverse pathogen that is classified into seven distinct genotypes. Simultaneous or sequential reinfection with multiple HCV genotypes is recognized in high-risk populations, such as injecting drug users (IDUs). Multiple infection is of clinical concern as different genotypes have various sensitivities to current antiviral therapies. Therefore, a better understanding of the frequency of multiple infection and of the genotypes currently being transmitted is clinically relevant. An Australian cohort of IDUs (n = 123), identified with primary incident infection, was followed for multiple infection by regular HCV RNA testing between 2005 and 2013. A total of 354 samples were tested. Sequencing of primary incident infections revealed that genotype 3a was the most common circulating genotype, followed by genotype 1a. Examination of longitudinally collected samples identified complex patterns of multiple infection, including reinfection and superinfection. In those with multiple infection, there was no apparent evidence of homotypic immunity conferring protection against reinfection of the same subtype. This study revealed frequent multiple infection in a high-risk prisoner cohort, illustrating the complex nature of HCV infection and reinfection and highlighting the need for pan-genotypic antiviral therapies.

Public health and international drug policy

In September 2015, the member states of the United Nations endorsed sustainable development goals (SDG) for 2030 that aspire to human rights-centered approaches to ensuring the health and well-being of all people. The SDGs embody both the UN Charter values of rights and justice for all and the responsibility of states to rely on the best scientific evidence as they seek to better humankind. In April 2016, these same states will consider control of illicit drugs, an area of social policy that has been fraught with controversy, seen as inconsistent with human rights norms, and for which scientific evidence and public health approaches have arguably played too limited a role.

The previous UN General Assembly Special Session (UNGASS) on drugs in 1998 – convened under the theme “a drug-free world, we can do it!” – endorsed drug control policies based on the goal of prohibiting all use, possession, production, and trafficking of illicit drugs. This goal is enshrined in national law in many countries. In pronouncing drugs a “grave threat to the health and well-being of all mankind,” the 1998 UNGASS echoed the foundational 1961 convention of the international drug control regime, which justified eliminating the “evil” of drugs in the name of “the health and welfare of mankind.” But neither of these international agreements refers to the ways in which pursuing drug prohibition itself might affect public health. The “war on drugs” and “zero-tolerance” policies that grew out of the prohibitionist consensus are now being challenged on multiple fronts, including their health, human rights, and development impact.

The Johns Hopkins – Lancet Commission on Drug Policy and Health has sought to examine the emerging scientific evidence on public health issues arising from drug control policy and to inform and encourage a central focus on public health evidence and outcomes in drug policy debates, such as the important deliberations of the 2016 UNGASS on drugs.

The Johns Hopkins-Lancet Commission is concerned that drug policies are often colored by ideas about drug use and drug dependence that are not scientifically grounded. The 1998 UNGASS declaration, for example, like the UN drug conventions and many national drug laws, does not distinguish between drug use and drug abuse. A 2015 report by the UN High Commissioner for Human Rights, by contrast, found it important to emphasize that “[d]rug use is neither a medical condition nor does it necessarily lead to drug dependence.” The idea that all drug use is dangerous and evil has led to enforcement-heavy policies and has made it difficult to see potentially dangerous drugs in the same light as potentially dangerous foods, tobacco, alcohol for which the goal of social policy is to reduce potential harms.

Understanding differences in HIV/HCV prevalence according to differentiated risk behaviors in a sample of PWID in rural Puerto Rico

BACKGROUND

Blood contained in needles and injection equipment has been identified as a vector for HIV and HCV transmission among people who inject drugs (PWID). Yet, there is often a wide discrepancy in prevalence for both viruses. While microbiological differences between viruses influence prevalence, other variables associated with the way drugs are acquired and used, also play a role.

METHODS

Respondent-driven sampling (RDS) methods recruited a sample of 315 current intravenous drug users in rural Puerto Rico. Information about type and frequency of use, HIV and HVC risk behaviors (sharing needles, cookers, cotton, and water), sexual behaviors, and alcohol use was collected. HIV and HCV statuses were assessed via rapid antibody tests. T tests compare means of participants who tested positive (reactive) to those who tested negative. Logistic regression analyses were used to validate the association of the risk factors involved.

RESULTS

Tests showed a significant difference in HIV (6%) and HCV (78.4%) prevalence among a population of current PWID. The main risk behaviors in HCV transmission are the sharing of injection "works", (e.g., cookers, cotton, and water). Sharing works occurred more than twice as often as the sharing of needles, and HCV+ and HCV- individuals reported the same needle sharing habits.

CONCLUSIONS

Washing and rinsing injection works with water seems to prevent HIV transmission, but it is unable to prevent HCV infection. While education about the need to clean injection equipment with bleach might be beneficial, equipment sharing--and the subsequent risk of HVC--might be unavoidable in a context where participants are forced to pool resources to acquire and use intravenous drugs.

Hepatitis C virus and HIV seroprevalences, sociodemographic characteristics, behaviors and access to syringes among drug users, a comparison of geographical areas in France, ANRS-Coquelicot 2011 survey

BACKGROUND

People who use drugs (PWUDs) are at a high risk for hepatitis C virus (HCV) and human immunodeficiency virus (HIV), but they have different characteristics depending on the local context. In France, seroprevalence, sociodemographic, and behavior information have only been studied at a national level rather than at a local level. The aim of this study was to describe and examine profile and drug use practice differences in seven French cities and departments and to assess whether these differences can explain HCV and HIV seroprevalence variations between French geographical areas.

METHODS

Data were collected from the cross-sectional ANRS-Coquelicot survey conducted for the second time in 2011 among drug users having injected or snorted drugs at least once in their life. Professional interviewers administrated a face-to-face questionnaire in six different areas in France: Paris, Marseille, Bordeaux, Lille, Strasbourg and the Seine-Saint-Denis department (Paris suburbs). Participants were asked to self-collect a fingerpick blood sample in order to search for the presence of anti-HIV and anti-HCV antibodies and to estimate seroprevalence in PWUDs.

RESULTS

Overall, HCV and HIV seroprevalence was 44% [95% CI: 39.6-47.9] and 10% [95% CI: 7.5-12.6] respectively. The highest HCV seroprevalence was 56% in Marseille and the lowest was 24% in Bordeaux and for HIV the highest was 18% in Seine-Saint-Denis and the lowest was 0% in Lille. The population's age differed between areas and could mostly explain HCV seroprevalence variation but not exclusively. Profiles and practices, different in each area, can also explain this variation. In multivariate analysis, HCV seroprevalence was lower in Bordeaux (prevalence ratio [PR]=0.64), Strasbourg (PR=0.76), and Seine-Saint-Denis (PR=0.8) than in Paris. Nearly one-third of injectors declared having had difficulties to obtain syringes in the 6 previous months, but disparities existed between areas.

CONCLUSION

HCV risk exposure in PWUDs remains high in France and varies between different areas. Innovative harm reduction strategies including educative programs about safe injecting and supervised consumption rooms need to be developed.

Transmission of Hepatitis C Virus among Prisoners, Australia, 2005-2012

Ongoing transmission is associated with drug injection.

Hepatitis C virus (HCV) is predominantly transmitted between persons who inject drugs. For this population, global prevalence of HCV infection is high and incarceration is common and an independent risk factor for HCV acquisition. To explore HCV transmission dynamics in incarcerated populations, we integrated virus sequences with risk behavior and spatiotemporal data and analyzed transmission clusters among prisoners in Australia. We detected 3 clusters of recent HCV transmission consisting of 4 likely in-custody transmission events involving source/recipient pairs located in the same prison at the same time. Of these 4 events, 3 were associated with drug injecting and equipment sharing. Despite a large population of prisoners with chronic HCV, recent transmission events were identified in the prison setting. This ongoing HCV transmission among high-risk prisoners argues for expansion of prevention programs to reduce HCV transmission in prisons.

Imprisonment of opioid-dependent people in New South Wales, Australia, 2000–2012: a retrospective linkage study

There are few data about the incarceration of opioid-dependent people involving large representative cohorts. We aimed to determine the prevalence and duration of incarceration in a large cohort of opioid-dependent people in Australia using data linkage methods, and estimate the costs associated with their incarceration.Method: Retrospective linkage study of all entrants to opioid substitution therapy (OST) for the treatment of opioid dependence in NSW, 1985–2010, with data on incarceration, 2000-2012. The number and duration of incarcerations were calculated. The average daily cost of incarceration was applied to days of incarceration in the cohort.Results: Among 47,196 opioid-dependent people, 37% (43% of men and 24% of women) had at least one episode of incarceration lasting one or more days. Men had a median of three(ranging between 1-47) incarcerations, and women, two (1-35). Indigenous men spent 23% of follow-up time incarcerated, compared with 8% for non-Indigenous men; similarly, Indigenous women spent a substantially greater proportion of time incarcerated than non-Indigenous women (8% vs. 2%). Costs of incarceration of this cohort between 2000 and 2012 totalled nearly AUD $3 billion.Conclusions: This is the first study to examine incarceration of opioid-dependent people across an entire population of such users. Our findings suggest that a substantial minority of opioid-dependent people experience incarceration, usually on multiple occasions and at significant cost. Treatment for opioid dependence, inside and outside prisons, may help reduce incarceration of this cohort.

Hepatitis C virus infection and prisoners: Epidemiology, outcome and treatment

The studies on hepatitis C virus (HCV) infection in prison populations are few and mostly cross-sectional. We analyzed prevalently the articles appearing on PubMed in the last ten years. HCV infection is frequent in prisoners, prevalences ranging from 3.1% to 38% according to the HCV endemicity in the geographical location of the prison and in the countries of origin of the foreign prisoners and to the prevalence of intravenous drug use, which is the most important risk factor for HCV infection, followed by an older age of prisoners and previous prison terms. HCV replication in anti-HCV-positive cases varies from 45% to 90% in different studies, and the most common HCV genotypes are generally 1 and 3. The response to antiviral treatment is similar in prisoners to that of the general population. Unfortunately, treatment is administered less frequently to prisoners because of the difficulties in management and follow-up. The new directly acting antivirals offer a good therapy option for inmates because of their good efficacy, short duration of treatment and low incidence of side effects. The efforts of the prison authorities and medical staff should be focused on reducing the spread of HCV infection in prisons by extending the possibility of follow-up and treatment to more prisoners with chronic hepatitis C.

The hepatitis C virus epidemics in key populations (including people who inject drugs, prisoners and MSM): the use of direct-acting antivirals as treatment for prevention

PURPOSE OF REVIEW

The burden of hepatitis C virus (HCV) is high among people who inject drugs (PWID) and prisoners, and increasing among HIV-infected MSM, who are key populations for HCV transmission in high-income countries and may also play a role in many in low- and middle-income countries. There is an increasing interest in the use of HCV antiviral treatment for prevention in these populations.

RECENT FINDINGS

Numerous theoretical modelling studies have explored the potential impact of HCV treatment for prevention among PWID in a range of global settings, generally finding that modest and achievable levels of HCV treatment, especially with interferon-free direct-acting antiviral therapy (IFN-free DAAs), could substantially reduce HCV chronic prevalence among PWID within the next 10-20 years. In addition, modelling studies have shown HCV testing and treatment in prison (including prevention benefits) could be cost-effective if continuity of care is ensured, or HCV treatments are shortened with DAAs. Modelling work among HIV-infected MSM has shown that further HCV treatment scale-up is likely required despite high treatment rates in this population. However, no empirical studies have explored whether HCV treatment can reduce HCV prevalence and prevent onwards transmission among those at risk of transmission.

SUMMARY

HCV treatment for key populations such as PWID, prisoners and MSM could become an important HCV prevention intervention, especially in the IFN-free DAA era. However, there is an urgent need to test these hypotheses through empirical studies.

A Cross-Sectional Study of Prisoners in Mexico City Comparing Prevalence of Transmissible Infections and Chronic Diseases with That in the General Population

OBJECTIVES

To describe patterns of transmissible infections, chronic illnesses, socio-demographic characteristics and risk behaviors in Mexico City prisons, including in comparison to the general population, to identify those currently needing healthcare and inform policy.

MATERIALS AND METHODS

A cross-sectional study among 17,000 prisoners at 4 Mexico City prisons (June to December 2010). Participation was voluntary, confidential and based on informed consent. Participants were tested for HIV, Hepatitis B & C, syphilis, hypertension, obesity, and, if at risk, glucose and cholesterol. A subset completed a questionnaire on socio-demographic characteristics and risk behaviors. Positive results were delivered with counseling and treatment or referral.

RESULTS

76.8% (15,517/20,196) of men and 92.9% (1,779/1,914) of women participated. Complete data sets were available for 98.8%. The following prevalence data were established for transmissible infections: HIV 0.7%; syphilis: Anti-TP+/VDRL+ 2.0%; Hepatitis B: HBcAb 2.8%, HBsAg 0.15%; Anti-HCV 3.2%. Obesity: 9.5% men, 33.8% women. Compared with national age- and sex-matched data, the relative prevalence was greater for HIV and syphilis among women, HIV and Hepatitis C in men, and all infections in younger participants. Obesity prevalence was similar for women and lower among male participants. The prevalence of previously diagnosed diabetes and hypertension was lower. Questionnaire data (1,934 men, 520 women) demonstrated lower educational levels, increased smoking and substance use compared to national data. High levels of non-sterile tattooing, physical abuse and histories of sexual violence were found.

CONCLUSION

The study identified that health screening is acceptable to Mexico City prisoners and feasible on a large-scale. It demonstrated higher prevalence of HIV and other infections compared to national data, though low rates compared to international data. Individual participants benefited from earlier diagnosis, treatment and support. The data collected will also enable the formulation of improved policy for this vulnerable group.

Acquiring hepatitis C in prison: the social organisation of injecting risk

Aim

The potential for transmission of hepatitis C virus (HCV) in prison settings is well established and directly associated with sharing of injecting and tattooing equipment, as well as physical violence. This study is one of the first to examine the circumstances surrounding the acquisition of HCV in the prison setting via inmates’ own accounts.

Method

This is a sub-study of a cohort of prison inmates in New South Wales, Australia. Cohort participants were inmates who had reported ever injecting drugs and who had a negative HCV serological test within 12 months prior to enrolment. Cohort participants were monitored every 3 to 6 months for HCV antibodies and viraemia and via behavioural risk practices questionnaire. Participants with a documented HCV seroconversion were eligible to participate in in-depth interviews with a research nurse known to them.

Results

Participants included six inmates (four men, two women) with documented within-prison HCV seroconversion. Participants reported few changes to their injecting practices or circumstances that they attributed to HCV acquisition. Participants believed that they were sharing syringes with others who were HCV negative and trusted that others would have declared their HCV status if positive. Some participants described cleaning equipment with water, but not with disinfectant. In a departure from usual routine, one participant suggested that he may have acquired HCV as a result of using a syringe pre-loaded with drugs that was given to him in return for lending a syringe to another inmate. Participants described regret at acquiring HCV and noted a number of pre- and post-release plans that this diagnosis impacted upon.

Conclusions

Acquiring hepatitis C was not a neutral experience of participants but generated significant emotional reactions for some. Decisions to share injecting equipment were influenced by participants’ assumptions of the HCV status of their injecting partners. The social organisation of injecting, in trusted networks, is a challenge for HCV prevention programs and requires additional research.

Resistance to hepatitis C virus: potential genetic and immunological determinants

Studies of individuals who were highly exposed but seronegative (HESN) for HIV infection led to the discovery that homozygosity for the Δ32 deletion mutation in the CCR5 gene prevents viral entry into target cells, and is associated with resistance to infection. Additionally, evidence for protective immunity has been noted in some HESN groups, such as sex workers in The Gambia. Population studies of individuals at high risk for hepatitis C virus infection suggest that an HESN phenotype exists. The body of evidence, which suggests that protective immunity allows clearance of hepatitis C virus without seroconversion is growing. Furthermore, proof-of-principle evidence from in-vitro studies shows that genetic polymorphisms can confer resistance to establishment of infection. This Review discusses the possibility that genetic mutations confer resistance against hepatitis C virus, and also explores evidence for protective immunity, including via genetically programmed variations in host responses. The data generally strengthens the notion that investigations of naturally arising polymorphisms within the hepatitis C virus interactome, and genetic association studies of well characterised HESN individuals, could identify potential targets for vaccine design and inform novel therapies.

A prospective study of hepatitis C incidence in Australian prisoners

AIMS

To document the relationships between injecting drug use, imprisonment and hepatitis C virus (HCV) infection.

DESIGN

Prospective cohort study.

SETTING

Multiple prisons in New South Wales, Australia.

PARTICIPANTS

HCV seronegative prisoners with a life-time history of injecting drug use (IDU) were enrolled and followed prospectively (n = 210) by interview and HCV antibody and RNA testing 6-12-monthly for up to 4 years when in prison.

MEASUREMENTS

HCV incidence was calculated using the person-years method. Cox regression was used to identify predictors of incident infection using time-dependent covariates.

RESULTS

Almost half the cohort reported IDU during follow-up (103 subjects; 49.1%) and 65 (31%) also reported sharing of the injecting apparatus. There were 38 HCV incident cases in 269.94 person-years (py) of follow-up with an estimated incidence of 14.08 per 100 py [confidence interval (CI) = 9.96-19.32]. Incident infection was associated independently with Indigenous background, injecting daily or more and injecting heroin. Three subjects were RNA-positive and antibody-negative at the incident time-point, indicating early infection, which provided a second incidence estimate of 9.4%. Analysis of continuously incarcerated subjects (n = 114) followed over 126.73 py, identified 13 new HCV infections (10.26 per 100 py, CI = 5.46-17.54), one of which was an early infection case. Bleach-cleansing of injecting equipment and opioid substitution treatment were not associated with a significant reduction in incidence.

CONCLUSIONS

In New South Wales, Australia, imprisonment is associated with high rates of hepatitis C virus transmission. More effective harm reduction interventions are needed to control HCV in prison settings.

Protection against hepatitis C infection via NK cells in highly-exposed uninfected injecting drug users

BACKGROUND & AIMS

HCV seroprevalence surveys in longstanding injecting drug users (IDUs) reveal a small minority who remain seronegative, with some exhibiting HCV-specific cellular immunity. This study aimed to characterise this immunity, assess associations with risk behaviours and protection against infection.

METHODS

A nested case-control series from a prospective cohort of seronegative IDUs was selected with incident cases (IN; n = 28) matched by demographics and risk behaviour to exposed uninfected (EU) subjects (n = 28). Samples were assayed for natural killer (NK) cell phenotypes and function, HCV-specific IFNγ in ELISpot, and HCV-specific CD4 T effector responses. IL28B and HLA-C/KIR2DL3 genotypes were tested.

RESULTS

Numbers of activated (CD69(+)) NK cells in the mature CD56(dim)CD16(+) subset, and cytotoxic (NKp30(+)) cells in the CD56(bright)CD16(+) subset were higher in the EU subjects (p = 0.040, p = 0.038 respectively). EU subjects had higher frequencies of interferon gamma (IFNγ) producing NK cells, and lower frequencies of CD107a expression (p = 0.003, p = 0.015 respectively). By contrast, the frequency, magnitude, and breadth of HCV-specific CD4 and CD8 T cell responses did not differ, nor did IL28B, HLA-C, or KIR2DL3 allele frequencies.

CONCLUSIONS

Sustained NK cell activation contributes to protection against HCV infection. HCV-specific cellular immunity is prevalent in EU subjects but does not appear to be protective.

A comparison of risk factors for hepatitis C among young and older adult prisoners

Internationally, the prevalence of hepatitis C infection is higher among prisoners when compared to the general population, particularly among people who inject drugs. This study estimates the prevalence of, and compares the risk factors for, hepatitis C in young (< 25 years) and older (≥ 25 years) prisoners with a history of injection drug use. Participants were 677 sentenced prisoners in Queensland, Australia, with a lifetime history of injection drug use, recruited in the 6 weeks prior to release from custody. The prevalence of hepatitis C exposure was significantly lower in young prisoners than in older prisoners (20.7% vs. 29.4%, p = .03). Risk factors for hepatitis C varied between young and older prisoners. Young people who inject drugs and who have had shorter time at risk of hepatitis C exposure are an important target group for hepatitis C prevention efforts.

Incidence and correlates of hepatitis C virus infection in a large cohort of prisoners who have injected drugs

BACKGROUND

Hepatitis C virus (HCV) infection is common among prisoners, particularly those with a history of injecting drug use (IDU). Incarcerated people who inject drugs frequently report high-risk injecting practices both in prison and in the community. In spite of rising morbidity and mortality, utilisation of HCV-related services in Australia has been persistently low. This study aimed to describe the incidence, prevalence and correlates of HCV seropositivity in a large cohort of prisoners who have injected drugs, and to identify correlates of receiving confirmation of active infection.

METHODS

Data-linkage to a State-wide statutory notifiable diseases surveillance system was used to investigate the incidence of notified HCV seropositivity, seroconversion and confirmed HCV infection in a cohort of 735 prisoners with a history of IDU, over 14 years of follow up. Hepatitis C test results from prison medical records were used to identify correlates of testing positive in prison.

RESULTS

The crude incidence of HCV notification was 5.1 cases per 100 person-years. By the end of follow up, 55.1% of the cohort had been the subject of a HCV-related notification, and 47.4% of those tested in prison were HCV seropositive. In multivariable analyses, injecting in prison was strongly associated with HCV seropositivity, as was opioid use compared to injection of other drugs. The rate of reported diagnostic confirmation among those with notified infections was very low, at 6.6 confirmations per 100 seropositive participants per year.

CONCLUSIONS

Injecting drugs in prison was strongly associated with HCV seropositivity, highlighting the need for increased provision of services to mitigate the risk of transmission within prisons. Once identified as seropositive through screening, people with a history of IDU and incarceration may not be promptly receiving diagnostic services, which are necessary if they are to access treatment. Improving access to HCV-related services will be of particular importance in the coming years, as HCV-related morbidity and mortality is increasing, and next generation therapies are becoming more widely available.

Exploration of genetically determined resistance against hepatitis C infection in high-risk injecting drug users

Genetic resistance to specific infections is well recognized. In hepatitis C virus (HCV) infection, genetic polymorphisms in IL-28B and the killer cell immunoglobulin-like receptors (KIR) and their HLA class I ligands have been shown to affect clearance of the virus following infection. There are limited data regarding resistance to established HCV infection. Reliable quantification of repeated exposure in high-risk populations, such as injecting drug users (IDU), is a key limitation of previous studies of resistance. Behavioural data and DNA from IDU (n = 210) in the Hepatitis C Incidence and Transmission Study in prisons (HITS-p) cohort were genotyped for polymorphisms in: IL-28B, peptidyl-prolyl isomerase A (PPIA), HLA-C and KIR2. To quantify risk, a composite risk index based on factors predictive of incident HCV infection was derived. Logistic regression analysis revealed the risk index was strongly associated with incident HCV infection (P < 0.0001). The upper tertile of the uninfected individuals had risk indices comparable to the incident cases, but remained uninfected. There were no significant differences in the frequencies of IL-28B or PPIA polymorphisms between these exposed-uninfected cases, or in the frequencies of KIR2-DL3, HLA-C1, or their combination. A framework for the investigation of genetic determinants of resistance to HCV infection has been developed. Several candidate gene associations were investigated and excluded. Further investigation of genetic determinants of resistance to HCV infection is warranted.

Barriers to legal and human rights in Australia in the era of HIV treatment as prevention

This paper analyses developments and debates regarding legal and human rights issues relevant to the Australian HIV response in the context of treatment as prevention (TasP). A refocusing of prevention priorities on individual responsibilities to 'test and treat' without regard to the legal and human rights context is, we argue, problematic. The paper maintains that the justification of testing and treating for the greater good risks eroding the foundations of a human rights-based approach to HIV prevention, and that the TasP agenda as presently conceived may divert attention from pressing law reform issues relating to sex work, illicit drug use, and criminalization of HIV transmission.

Evidence that hepatitis C virus genome partly controls infection outcome

Infection by hepatitis C virus (HCV) leads to one of two outcomes; either the infection resolves within approximately 6 months or the virus can persist indefinitely. Host genetics are known to affect the likelihood of clearance or persistence. By contrast, the importance of the virus genotype in determining infection outcome is unknown, as quantifying this effect traditionally requires well-characterized transmission networks, which are rare. Extending phylogenetic approaches previously developed to estimate the virus control over set-point viral load in HIV-1 infections, we simulate inheritance of a binary trait along a phylogenetic tree, use this data to quantify how infection outcomes cluster and ascertain the effect of virus genotype on these. We apply our method to the Hepatitis C Incidence and Transmission Study in prisons (HITS-p) data set from Australia, as this cohort prospectively identified incident cases including viraemic subjects who ultimately clear the virus, thus providing us with a unique collection of sequences from clearing infections. We detect significant correlations between infection outcome and virus distance in the phylogeny for viruses of Genotype 1, with estimates lying at around 67%. No statistically significant estimates were obtained for viruses of Genotype 3a.

Development of an intervention to increase health service utilisation in ex-prisoners

The world prison population is growing at a rate well in excess of general population growth, with more than 10 million adults currently in custody around the world and around 30 million moving through prison systems each year. There is increasing recognition of the complex and chronic health needs of incarcerated populations, but evidence-based responses to these needs remain elusive. Most prisoners return to the community after a relatively short period of time in custody, however few transitional interventions for prisoners have been subjected to rigorous evaluation. This paper details the process of developing a service brokerage intervention for ex-prisoners in Queensland, Australia, and describes the resultant intervention. The intervention could be adapted for use in other settings and is amenable to methodologically rigorous evaluation. The collaborative design and development process involved extensive consultation with ex-prisoners and key government, community and consumer stakeholders. The intervention evolved considerably during the process of consultation, as we came to better understand the needs and priorities of our target population, and of the community organisations that served them. We consider genuine consultation with consumers, in a safe and supportive environment, to be an integral part of intervention research in this area. Given the poor outcomes experienced by many people after release from prison, evidence-based interventions developed in the way described here are urgently required.

Enhancing assessment and treatment of hepatitis C in the custodial setting

Acute and chronic hepatitis C (HCV) infections are prevalent in custodial settings worldwide, yet provision of antiviral therapies is uncommon. This disparity between the burden of disease and hepatitis service delivery reflects the marginalized patient population, which features high rates of injection drug use and poor mental health. In addition, the prison environment is intended for deprivation of liberty and not healthcare. Screening for HCV infections is provided in most jurisdictions, but uptake rates remain low. Assessment and treatment of inmates is often provided only by community-based services. Despite these challenges, assessment and treatment of inmates with chronic HCV via prison-based services has been shown to be feasible and effective. These services offer the potential to substantively increase HCV treatment uptake and reduce the burden of disease for the community at large. Improvements in the efficacy of HCV therapies via direct-acting antivirals, which also offer reduced treatment duration and decreased toxicities, mean that prison health services will be well placed for the treatment of large numbers of people with HCV who do not access health services in the community.