Syringe sharing in prison

Does opioid substitution treatment in prisons reduce injecting-related HIV risk behaviours? A systematic review

OBJECTIVES

To review systematically the evidence on opioid substitution treatment (OST) in prisons in reducing injecting-related human immunodeficiency virus (HIV) risk behaviours.

METHODS

Systematic review in accordance with guidelines of the Cochrane Collaboration. Electronic databases were searched to identify studies of prison-based opioid substitution treatment programmes that included assessment of effects of prison OST on injecting drug use, sharing of needles and syringes and HIV incidence. Published data were used to calculate risk ratios for outcomes of interest. Risk ratios were not pooled due to the low number of studies and differences in study designs.

RESULTS

Five studies were included in the review. Poor follow-up rates were reported in two studies, and representativeness of the sample was uncertain in the remaining three studies. Compared to inmates in control conditions, for treated inmates the risk of injecting drug use was reduced by 55-75% and risk of needle and syringe sharing was reduced by 47-73%. No study reported a direct effect of prison OST on HIV incidence.

CONCLUSIONS

There may be a role for OST in preventing HIV transmission in prisons, but methodologically rigorous research addressing this question specifically is required. OST should be implemented in prisons as part of comprehensive HIV prevention programmes that also provide condoms and sterile injecting and tattooing equipment.

Proportional hazards model for interval-censored failure times and time-dependent covariates: application to hazard of HIV infection of injecting drug users in prison

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 analysed 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.

Needle sharing and high-risk sexual behaviors among IV drug users in Southern Thailand

This study sought to determine the prevalence of needle sharing and high HIV risk sexual behaviors and to identify characteristics associated with these practices in southern Thailand. Data were obtained using a structured questionnaire from 298 male intravenous drug users (IVDUs) seen in a methadone clinic during the previous year. The prevalence of HIV was 37%, and that of needle-sharing in the preceding months was 45%, although only 10% claimed to have had unsafe sex with a casual partner or prostitute in the same period. Determinants for needle sharing included shorter duration of drug injection, diminished knowledge of HIV prevention, a carefree attitude toward risk of HIV infection, and lower levels of income. Young single IVDUs with a low knowledge of HIV prevention were most likely not to use a condom. In conclusion, needle sharing among the study subjects was still a common practice, whereas high HIV risk sexual behavior was not. Attitudinal change may be necessary to reduce needle-sharing behavior and not just information on disease transmission.

HIV antibody seroprevalence and associated risk factors in sex workers, drug users, and prisoners in Sindh, Pakistan

OBJECTIVE

To determine prevalence of HIV infection and risk behaviors in commercial sex workers (CSWs), drug users, and prisoners in Sindh, Pakistan.

METHODS

A medical clinic was established in a "red-light" district of Karachi. Eighty-one CSWs who registered at the clinic between November 1993 and June 1994 were provided HIV counseling and testing and administered a risk factor questionnaire. Next, 316 male drug users were tested for HIV-1 antibody from April to July 1994. Finally, a voluntary serosurvey of HIV-1 and HIV-2 and risk behaviors of 3525 prisoners in Sindh was conducted between July 1994 and December 1994. Abbott Recombinant HIV third-generation enzyme-linked immunosorbent assay (ELISA) and confirmatory testing with Western blot analysis were used in all three groups.

RESULTS

None of 81 CSWs tested for HIV-1 antibody were positive. None of 316 drug users tested positive for HIV-1 antibody. Of 3441 male prisoners, 1 was HIV-1 infected, and of 84 female prisoners, 1 was HIV-1 infected. No prisoner was positive for HIV-2 antibody.

DISCUSSION

The prevalence of HIV in CSWs, drug users, and prisoners in Sindh is low at present. Intervention programs implemented at this stage can make an impact in HIV prevention.

HIV in UK prisons: a review of seroprevalence, transmission and patterns of risk

Prisons contain individuals at high risk of HIV infection, notably through intravenous drug use. For complex political, social and legal reasons penal institutions in the UK are unable to provide condoms and clean needles. The outbreak of HIV and hepatitis B that occurred in a Scottish prison in 1993 focused attention on the potential problems. Debate about the issue is hampered by a lack of useful information. Current data about risk behaviour and seroprevalence is reviewed, and compared with experience in other countries. Injecting drug use in prison appears to be common, and the majority who inject in prison share equipment, which can be used many times. Sexual activity may be a smaller risk factor, but does occur between men in prison. In addition, prisoners appear to have high rates of partner change between sentences. The true prevalence of HIV in UK prisons is difficult to assess, but the available data suggest it is between 0.1 and 4.5%, lower than in Southern Europe and the USA. A window of opportunity still exists to prevent further outbreaks of HIV in UK penal institutions and to maintain these low prevalence rates. Strenuous, and possibly unpalatable measures are needed now.