HIV transmission in a prison system in an Australian State

HIV-Risk Behavior Among Adults with Opioid Use Disorder During 12 Months Following Pre-trial Detention: Results from a Randomized Trial of Methadone Treatment

This was a three group randomized clinical trial of interim methadone and patient navigation involving 225 pre-trial detainees with opioid use disorder in Baltimore. The HIV Risk Assessment Battery (RAB) was administered at baseline (in jail), and at 6 and 12 months post-release. Generalized linear mixed model analyses indicated the condition × time interaction effect failed to reach significance (ps > .05) for both the drug risk and sex risk subscale scores. Therefore, findings suggest that there were no intervention effects on drug or sex risk behaviors. However, increased use of cocaine at baseline was associated with increases in drug- (b = .04, SE = .02) and sex-risk (b = .01, SE = .003) behaviors. These results suggest that interventions targeting cocaine use among pre-trial detainees may serve as a means of reducing HIV risk associated with drug- and sex-risk behaviors.Clinical Trials Registration: Clinicaltrials.gov NCT02334215.

California's Prisoner Protections for Family and Community Health Act : Implementing a Mandated Condom Access Program in State Prisons, 2015-2016

In 2014, California passed Assembly Bill 966, which required condom access for persons incarcerated in all 35 California state prisons (33 men's and 2 women's prisons). The California Correctional Health Care Services and the Sexually Transmitted Disease Control Branch and the Office of AIDS of the California Department of Public Health collaborated in a prison administration-led multidisciplinary implementation workgroup. Our workgroup, representing public health, correctional health, legal and legislative affairs, labor relations, and prison staff members, participated in 4 planning meetings during May-September 2015. We surveyed prison staff members and incarcerated men to identify and address potential challenges; conceptualized a tamper-resistant condom dispenser; developed educational materials, frequently asked questions for staff members, and fact sheets for the public; and conducted forums for custody and medical staff members at each prison. Key lessons learned included the need for high-level custody support, engagement of labor unions early in the decision-making process, and flexibility within defined parameters for sites to determine best practices given their unique institutional population, culture, and physical layout. Condom access was initiated at 4 prisons in July 2015 and expanded incrementally to the remaining 29 men's prisons through July 2016. A total of 243 563 condoms were accessed in the men's prisons, for an average of 354 condoms per 1000 population per month. The start-up dispenser cost was $69 825 (735 dispensers at $95 each). We estimated an annual condom cost of $0.60 per person. Although staff members and incarcerated men expressed concern that this legislation would condone sex and provide repositories for contraband, no serious adverse incidents involving condoms were reported. California demonstrated that condom access is a safe, low-cost intervention with high uptake for a large correctional system and provided a replicable implementation model for other states. Prison condom programs have the potential to decrease transmission of sexually transmitted infections (STIs) among incarcerated persons and their communities, which are often disproportionately affected by STIs, HIV, and other chronic diseases.

Drug injection within prison in Kyrgyzstan: elevated HIV risk and implications for scaling up opioid agonist treatments

Purpose Within-prison drug injection (WPDI) is a particularly high HIV risk behavior, yet has not been examined in Central Asia. A unique opportunity in Kyrgyzstan where both methadone maintenance treatment (MMT) and needle-syringe programs (NSP) exist allowed further inquiry into this high risk environment. The paper aims to discuss these issues. Design/methodology/approach A randomly selected, nationally representative sample of prisoners within six months of release in Kyrgyzstan completed biobehavioral surveys. Inquiry about drug injection focused on three time periods (lifetime, 30 days before incarceration and during incarceration). The authors performed bivariate and multivariable generalized linear modeling with quasi-binomial distribution and logit link to determine the independent correlates of current WPDI. Findings Of 368 prisoners (13 percent women), 109 (35 percent) had ever injected drugs, with most (86 percent) reporting WPDI. Among those reporting WPDI, 34.8 percent had initiated drug injection within prison. Despite nearly all (95 percent) drug injectors having initiated MMT previously, current MMT use was low with coverage only reaching 11 percent of drug injectors. Two factors were independently correlated with WPDI: drug injection in the 30 days before the current incarceration (AOR=12.6; 95%CI=3.3-48.9) and having hepatitis C infection (AOR: 10.1; 95%CI=2.5-41.0). Originality/value This study is the only examination of WPDI from a nationally representative survey of prisoners where both MMT and NSP are available in prisons and in a region where HIV incidence and mortality are increasing. WPDI levels were extraordinarily high in the presence of low uptake of prison-based MMT. Interventions that effectively scale-up MMT are urgently required as well as an investigation of the environmental factors that contribute to the interplay between MMT and WPDI.

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.

Age-Specific Global Prevalence of Hepatitis B, Hepatitis C, HIV, and Tuberculosis Among Incarcerated People: A Systematic Review

PURPOSE

This study aims to compare the global prevalence of hepatitis B, hepatitis C, HIV, and tuberculosis in incarcerated adolescents and young adults (AYAs) and older prisoners.

METHODS

This study is a systematic review and meta-analysis of studies reporting the age-specific prevalence of each infection in prisoners. We grouped age-specific prevalence estimates into three overlapping age categories: AYA prisoners (<25 years), older prisoners (≥25 years), and mixed category (spanning age 25 years). We used random effects meta-analysis to estimate the relative risk (RR) of each infection in AYAs versus older prisoners.

RESULTS

Among 72 studies, there was marked heterogeneity in prevalence estimates among AYA prisoners for all infections: hepatitis B (.4%-25.2%), hepatitis C (.0%-70.6%), HIV (.0%-15.8%), and active tuberculosis (.0%-3.7%). The pooled prevalence of HIV (RR = .39, 95% confidence interval .29-.53, I² = 79.2%) and hepatitis C (RR = .51, 95% confidence interval .33-.78, I² = 97.8%) was lower in AYAs than in older prisoners.

CONCLUSIONS

The prevalence of HIV and hepatitis C is lower in AYA prisoners than in older prisoners. Despite lower prevalence, acquisition begins early among incarcerated populations. There is an urgent need for targeted, age-appropriate prevention, treatment, and harm reduction measures in and beyond custodial settings to reduce the incidence of infection in these extremely vulnerable young people.

Methadone maintenance treatment program in prisons from the perspective of medical and non-medical prison staff: a qualitative study in Iran

BACKGROUND

As one of the most important components of harm reduction strategy for high-risk groups, following the HIV epidemics, Methadone Maintenance Treatment (MMT) has been initiated in prisoners since 2003. In this paper, we aimed to assess the advantages and shortcomings of the MMT program from the perspective of people who were involved with the delivery of prison healthcare in Iran.

METHODS

On the basis of grounded theory and through conducting 14 Focus Group Discussions (FGDs), 7 FGDs among physicians, consultants, experts, and 7 FGDs among directors and managers of prisons (n= 140) have been performed. The respondents were asked about positive and negative elements of the MMT program in Iranian prisons.

RESULTS

This study included a total of 48 themes, of which 22 themes were related to advantages and the other 26 were about shortcomings of MMT programs in the prisons. According to participants' views "reduction of illegal drug use and high-risk injection", "reduction of potentially high-risk behaviors" and "making positive attitudes" were the main advantages of MMT in prisons, while issues such as "inaccurate implementation", "lack of skilled manpower" and "poor care after release from prison" were among the main shortcomings of MMT program.

CONCLUSION

MMT program in Iran's prisons has achieved remarkable success in the field of harm reduction, but to obtain much more significant results, its shortcomings and weaknesses must be also taken into account by policy-makers.

Incarceration of people living with HIV/AIDS: implications for treatment-as-prevention

Contact with the criminal justice system, including incarceration, is a common experience for many people living with HIV/AIDS. Optimism has recently been expressed that correctional facilities could be important locations for treatment-as-prevention (TasP)-based initiatives. We review recent findings regarding the effect of incarceration on patterns of HIV transmission, testing, treatment initiation and retention. We found that the prevalence of HIV infection among incarcerated individuals remains higher than analogous non-incarcerated populations. Recent studies have shown that voluntary HIV/AIDS testing is feasible in many correctional facilities, although the number of previously undiagnosed individuals identified has been modest. Studies have implied enhanced linkage to HIV/AIDS treatment and care in jails in the United States was associated with improvements in the HIV cascade of care. However, for many individuals living with HIV/AIDS, exposure to the correctional system remains an important barrier to retention in HIV/AIDS treatment and care. Future research should evaluate structural interventions to address these barriers and facilitate the scale-up of TasP-based efforts among individuals living in correctional settings.

Incarceration is associated with used syringe lending among active injection drug users with detectable plasma HIV-1 RNA: a longitudinal analysis

Background

Informed by recent studies demonstrating the central role of plasma HIV-1 RNA viral load (VL) on HIV transmission, interventions to employ HIV antiretroviral treatment as prevention (TasP) are underway. To optimize these efforts, evidence is needed to identify factors associated with both non-suppressed VL and HIV risk behaviours. Thus, we sought to assess the possible role played by exposure to correctional facilities on VL non-suppression and used syringe lending among HIV-seropositive people who use injection drugs (PWID).

Methods

We used data from the ACCESS study, a community-recruited prospective cohort. We used longitudinal multivariate mixed-effects analyses to estimate the relationship between incarceration and plasma HIV-1 RNA > 500 copies/mL among antiretroviral therapy (ART)-exposed active PWID and, during periods of non-suppression, the relationship between incarceration and used syringe lending.

Results

Between May 1996 and March 2012, 657 ART-exposed PWID were recruited. Incarceration was independently associated with higher odds of VL non-suppression (Adjusted Odds Ratio [AOR] = 1.54, 95% Confidence Interval [95% CI]: 1.10, 2.16). In a separate multivariate model restricted to periods of VL non-suppression, incarceration was independently associated with lending used syringes (AOR = 1.81, 95% CI: 1.03, 3.18).

Conclusions

The current findings demonstrate that incarceration is associated with used syringe lending among active PWID with detectable plasma HIV-1 RNA. Our results provide a possible pathway for the commonly observed association between incarceration and increased risk of HIV transmission. Our results suggest that alternatives to incarceration of non-violent PWID and evidence-based combination HIV prevention interventions for PWID within correctional facilities are urgently needed.

Effect of prison-based opioid substitution treatment and post-release retention in treatment on risk of re-incarceration

AIMS

People who use heroin are frequently incarcerated multiple times. Reducing re-incarceration of this group is important for reducing both health risks associated with incarceration and the costs of correctional administration. Opioid substitution treatment (OST) in prisons may help to reduce re-incarceration, but research findings on this topic have been mixed. In this study, we examined the effect of OST in prison and after release on re-incarceration.

DESIGN

Longitudinal cohort study. SETTING, PARTICIPANTS AND MEASUREMENTS: Data on OST and incarceration were linked for a cohort of 375 male heroin users recruited originally in prisons in New South Wales, Australia. Data were linked for the period 1 June 1997-31 December 2006. Re-incarceration was examined using recurrent-event survival analysis models. Model 1 examined the effect of OST status at release from prison (i.e. in treatment versus out of treatment on the day of release) on re-incarceration. Model 2 considered the effect of remaining in OST after release on risk of re-incarceration.

FINDINGS

Ninety per cent of participants were re-incarcerated following their first observed release. Pre-incarceration cocaine use was associated with a 13% increase in the average risk of re-incarceration. There was no significant association between simply being in OST at the time of release and risk of re-incarceration; however, in the model taking into account post-release retention in treatment, the average risk of re-incarceration was reduced by 20% while participants were in treatment.

CONCLUSIONS

In New South Wales, Australia, opioid substitution treatment after release from prison has reduced the average risk of re-incarceration by one-fifth.

HIV/AIDS prisoners: a case study on quality of life in Roumieh, Lebanon

Prisons often lack the basic health services required by HIV/AIDS patients. As with many other chronic illnesses, the treatment of HIV is expensive in terms of medication, hygiene, testing and staff training. Strategies to combat the disease have been thoroughly developed, particularly in Europe (WHO/UNAIDS, 2006). The purpose of this study was to assess quality of life (QOL) of the only 5 reported cases of HIV/AIDS patients in Roumieh prison (the country's largest male top-security prison) using the WHOQOL and the WHO guidelines on HIV infection and AIDS in prison. Virtually all prisoners reported that their rights had been violated. Isolation measures were taken to prevent the spread of the disease. According to UNAIDS, this particular measure has been proven ineffective. In conclusion, other approaches should be implemented to respect inmates' rights and reduce transmission of the virus.

HIV and hepatitis B and C incidence rates in US correctional populations and high risk groups: a systematic review and meta-analysis

BACKGROUND

High Human Immunodeficiency Virus (HIV) prevalence and high risk behaviors have been well documented within United States (US) correctional systems. However, uncertainty remains regarding the extent to which placing people in prison or jail increases their risk of HIV infection, and regarding which inmate populations experience an increased incidence of HIV. Describing these dynamics more clearly is essential to understanding how inmates and former detainees may be a source for further spread of HIV to the general US population.

METHODS

The authors conducted a systematic review and meta-analysis of studies describing HIV incidence in US correctional facility residents and, for comparison, in high risk groups for HIV infection, such as non-incarcerated intravenous drug users (IVDU) and men who have sex with men (MSM) in the US. HIV incidence rates were further compared with Hepatitis B and Hepatitis C Virus rates in these same populations.

RESULTS

Thirty-six predominantly prospective cohort studies were included. Across all infection outcomes, continuously incarcerated inmates and treatment recruited IVDU showed the lowest incidence, while MSM and street recruited IVDU showed the highest. HIV incidence was highest among inmates released and re-incarcerated. Possible sources of heterogeneity identified among HIV studies were risk population and race.

CONCLUSIONS

Although important literature gaps were found, current evidence suggests that policies and interventions for HIV prevention in correctional populations should prioritize curtailing risk of infection during the post-release period. Future research should evaluate HIV incidence rates in inmate populations, accounting for proportion of high risk sub-groups.

People who use drugs, HIV, and human rights

We reviewed evidence from more than 900 studies and reports on the link between human rights abuses experienced by people who use drugs and vulnerability to HIV infection and access to services. Published work documents widespread abuses of human rights, which increase vulnerability to HIV infection and negatively affect delivery of HIV programmes. These abuses include denial of harm-reduction services, discriminatory access to antiretroviral therapy, abusive law enforcement practices, and coercion in the guise of treatment for drug dependence. Protection of the human rights of people who use drugs therefore is important not only because their rights must be respected, protected, and fulfilled, but also because it is an essential precondition to improving the health of people who use drugs. Rights-based responses to HIV and drug use have had good outcomes where they have been implemented, and they should be replicated in other countries.

Patterns of drug use and HIV-related risk behaviors among incarcerated people in a prison in Iran

Previous research indicates that prisoners in Iran are at risk of drug-related harm, including acquisition of blood-borne infections. In response, several prevention interventions have been introduced into prisons in Iran, such as methadone maintenance treatment (MMT). MMT is now provided to opioid-dependent prisoners in 142 of the 230 prisons and correctional settings in Iran. A baseline behavioral survey was conducted in Karaj Central prison which mainly holds prisoners with drug-related charges. Overall, 203 male prisoners from randomly selected rooms in two prison blocks were interviewed using a structured questionnaire in 2007, just before the introduction of MMT program in this prison. Among participants, 7% reported never having used illicit drugs in their lifetime, but 51% had used non-injecting illicit drugs, and as high as 42% reported having injected an illicit drug. Up to 79% (160/203) of all participants reported using drugs, and about 6% (12/203) reported drug injecting during their current incarceration term. Same-gender sexual practice during current incarceration term was reported by 2.5% (5/203) of all male prisoners. Comparison between injecting and non-injecting drug-using prisoners indicated that drug injectors had higher rates of previous incarcerations, commenced drug use at a younger age, were more likely to have used illicit drugs in the previous week, were more likely to have been treated by a physician for drug addiction, had higher rates of registration for methadone treatment inside prison, and were more likely to have been tested for HIV infection. These study findings provide a behavioral profile of prisoners in regard to drug-related harm and can be considered in any plan to introduce or improve provision of MMT in prisons in Iran or other countries with similar features.

Scaling up methadone maintenance treatment for opioid-dependent prisoners in Iran

BACKGROUND

Research evidence indicates that prisoners in Iran are at risk of drug-related harm, including acquisition of blood-borne infections. In response, several prevention interventions including methadone maintenance treatment (MMT) have been introduced into prisons in Iran.

METHODS

This report reviews and presents some important information extracted from published articles, and available documents on HIV sentinel surveillance and provision of MMT inside correctional settings in Iran.

RESULTS

Biological surveillance data in 2005 showed that on average about 3% of prisoners in the country tested positive for HIV infection. MTT that constitutes a main component of the Prison Organisation's HIV prevention package is becoming increasingly accessible to opioid-dependent prisoners. Between 2002 and 2008, the number of opioid-dependent prisoners receiving MMT increased steadily from 100 to more than 25000.

CONCLUSION

Experiences in Iran suggest that access to MMT would be helpful for reducing illicit drug injection in a prison setting and can be considered as a major intervention for preventing the transmission of blood-borne infections among prisoners.

Presence of hepatitis C virus in syringes confiscated in prisons in Australia

BACKGROUND AND AIMS

Needlestick injuries are an occupational hazard for prison officers. This study aimed to assess the presence of hepatitis C virus (HCV) in syringes found in prisons.

METHODS

Sixty-nine syringes found in prisons were tested for HCV RNA using previously published methods.

RESULTS

Three syringes tested positive for HCV RNA.

CONCLUSION

Compared to the prevalence of HCV among injecting drug users in prisons, few syringes were found to contain HCV RNA. It is likely that conditions under which syringes are kept in prisons are not favorable for survival of detectable HCV RNA. Further work is needed to establish the risk of HCV transmission posed by needlestick injuries in prison settings.

Incarceration and opioid withdrawal: the experiences of methadone patients and out-of-treatment heroin users

Both heroin-addicted individuals and methadone maintenance patients are likely to face untreated opioid withdrawal while incarcerated. Limited research exists concerning the withdrawal experiences of addicted inmates and their impact on individuals' attitudes and plans concerning drug abuse treatment. In the present study, 53 opioid dependent adults (32 in methadone treatment and 21 out of treatment) were interviewed in an ethnographic investigation of withdrawal experiences during incarceration. When treatment for opioid withdrawal was unavailable, detoxification experiences were usually described as negative and were often associated with a variety of unhealthy behaviors designed to relieve withdrawal symptoms. Negative methadone withdrawal experiences also negatively influenced participants' receptivity to seeking methadone treatment upon release. A minority of participants took a positive view of their withdrawal experience and saw it as an opportunity to detox from heroin or discontinue methadone. Findings support the importance of providing appropriate opioid detoxification and/or maintenance therapy to opioid-dependent inmates.

The harm inside: injection during incarceration among male injection drug users in Tijuana, Mexico

Limited access to sterile syringes and condoms in correctional facilities make these settings high risk environments for HIV transmission. Although incarceration among injection drug users (IDUs) is common, there is limited information regarding specific IDU risk behaviors inside. We examined correlates of incarceration, injection inside and syringe sharing inside among male IDUs recruited in Tijuana, Mexico, using respondent driven sampling (RDS) (n=898). An interviewer administered survey collected data on sociodemographic, behavioral and contextual characteristics. Associations with (a) history of incarceration, (b) injection inside, and (c) syringe sharing inside were identified using univariate and multiple logistic regression models with RDS adjustment. Seventy-six percent of IDUs had been incarcerated, of whom 61% injected inside. Three quarters (75%) of those who injected shared syringes. U.S. deportation [adjusted odds ratio (AOR)=1.61; 95% confidence interval (CI): 1.07, 2.43] and migration (AOR=1.81; 95% CI: 1.12, 2.95) were independently associated with incarceration. Injection inside was independently associated with recent receptive syringe sharing (AOR=2.46; 95% CI: 1.75, 3.45) and having sex with a man while incarcerated (AOR=3.59; 95% CI: 1.65, 7.83). Sharing syringes inside was independently associated with having sex with a man while incarcerated (AOR=6.18; 95% CI: 1.78, 21.49). A majority of incarcerated IDUs reported injecting and syringe sharing during incarceration, and these IDUs were more likely to engage in sex with other men. Corrections-based interventions to reduce injection and syringe sharing are urgently needed, as are risk reduction interventions for male IDUs who have sex with men while incarcerated.

A qualitative inquiry into methadone maintenance treatment for opioid-dependent prisoners in Tehran, Iran

BACKGROUND

This study aimed to investigate the context in which methadone maintenance treatment (MMT) is provided for opioid-dependent prisoners, and to identify barriers against further scale-up of MMT in Ghezel Hesar prison in Tehran.

METHODS

This was a cross-sectional qualitative study using field observations, focus group discussions, and individual interviews. In total, 30 prisoners and 15 prison staff and health policymakers participated in this study in November 2006.

RESULTS

The rate of drug injecting in the prison unit was unanimously reported to have decreased drastically since introducing the MMT program. In addition to the health benefits to MMT recipients, interview data indicates that MMT has had positive effects on socio-economic status of prisoners' families. Nevertheless, several impediments to the provision of MMT services and to its further expansion were also identified, including staff shortages, some degree of methadone diversion, widespread concerns over the possible side effects of methadone, and the stigma attached to methadone treatment.

CONCLUSION

MMT constitutes one of the main components of the Iran Prison Organization's comprehensive HIV prevention package and is becoming increasingly accessible to opioid-dependent prisoners in Iran. Our findings indicate that the MMT program in Ghezel Hesar prison has been helpful for many opioid-dependent prisoners to reduce their risk of drug-related harm and to ease social and financial burden over their families. Meanwhile, existing barriers against provision of MMT should be properly addressed before further scale up of the program.

Interventions to reduce HIV transmission related to injecting drug use in prison

The high prevalence of HIV infection and drug dependence among prisoners, combined with the sharing of injecting drug equipment, make prisons a high-risk environment for the transmission of HIV. Ultimately, this contributes to HIV epidemics in the communities to which prisoners return on their release. We reviewed the effectiveness of interventions to reduce injecting drug use risk behaviours and, consequently, HIV transmission in prisons. Many studies reported high levels of injecting drug use in prisons, and HIV transmission has been documented. There is increasing evidence of what prison systems can do to prevent HIV transmission related to injecting drug use. In particular, needle and syringe programmes and opioid substitution therapies have proven effective at reducing HIV risk behaviours in a wide range of prison environments, without resulting in negative consequences for the health of prison staff or prisoners. The introduction of these programmes in countries with an existing or emergent epidemic of HIV infection among injecting drug users is therefore warranted, as part of comprehensive programmes to address HIV in prisons.

Factors associated with incarceration and incident human immunodeficiency virus (HIV) infection among injection drug users participating in an HIV vaccine trial in Bangkok, Thailand, 1999-2003

AIMS

To determine if incarceration was associated with human immunodeficiency virus (HIV) infection and identify risk factors for incarceration among injection drug users (IDUs) participating in an HIV vaccine trial in Bangkok.

DESIGN

The AIDSVAX B/E HIV vaccine trial was a randomized, double-blind, placebo-controlled study. A proportional hazards model was used to evaluate demographic characteristics, risk behavior and incarceration as predictors of HIV infection and generalized estimation equation logistic regression analysis to investigate demographic characteristics and risk behaviors for predictors of incarceration.

SETTING

The trial was conducted in Bangkok Metropolitan Administration drug-treatment clinics, 1999-2003.

PARTICIPANTS

A total of 2546 HIV-uninfected IDUs enrolled in the trial.

MEASUREMENTS

HIV testing was performed and an interviewer-administered questionnaire was used to assess risk behavior and incarceration at baseline and every 6 months for a total of 36 months.

FINDINGS

HIV incidence was 3.4 per 100 person-years [95% confidence interval (CI), 3.0-3.9] and did not differ among vaccine and placebo recipients. In multivariable analysis, being in jail (P < 0.04), injecting (P < 0.0001), injecting daily (P < 0.0001) and sharing needles (P = 0.02) were associated with HIV infection and methadone maintenance was protective (P = 0.0006). Predictors of incarceration in multivariable analysis included: male sex (P = 0.04), younger age (P < 0.0001), less education (P = 0.001) and being in jail (P < 0.0001) or prison (P < 0.0001) before enrollment.

CONCLUSIONS

Among IDUs in the AIDSVAX B/E trial, incarceration in jail was associated with incident HIV infection. IDUs in Thailand remain at high risk of HIV infection and additional prevention tools are needed urgently. HIV prevention services, including methadone, should be made available to IDUs.

The 2004 Australian prison entrants' blood-borne virus and risk behaviour survey

OBJECTIVES

To assess the prevalence of blood-borne viruses and associated risk factors among prison entrants at seven Australian prisons across four States.

DESIGN

Consecutive cross-sectional design. Voluntary confidential testing of all prison entrants for serological markers of human immunodeficiency virus (HIV), hepatitis C (HCV) and hepatitis B (HBV) over 14 consecutive days in May 2004. Demographic data and data related to risks for blood-borne virus transmission, such as sexual activity, body piercing, tattooing, and injecting drug use, were collected.

RESULTS

National prevalence for HIV was 1%, hepatitis B core antibody 20%, and hepatitis C antibody 34%. Fifty-nine per cent of participants had a history of injecting drug use. Among injecting drug users, the prevalence of HIV was 1%, hepatitis C antibody 56%, and hepatitis B core antibody 27%. Forty-one per cent of those screened reported a previous incarceration. In the multivariate model, Queensland and Western Australian (WA) prison entrants were significantly less likely to test positive to HCV than those in New South Wales (NSW). Amphetamine was the most commonly injected drug in Queensland, Tasmania and WA. In NSW, heroin was the most common drug injected. In the multivariate analysis a history of injecting drug use, being aged 30 years or more, and a prior incarceration were positively associated with hepatitis C infection. For hepatitis B core antibody, age over 30 years and a history of injecting drug use were associated with an increased risk.

CONCLUSIONS

The findings support the view that prisoner populations are vulnerable to blood-borne virus infection, particularly hepatitis B and C. Prisoner populations should be included in routine surveillance programs so as to provide a more representative picture of blood-borne virus epidemiology in Australia.

Socio-demographic determinants of coinfections by HIV, hepatitis B and hepatitis C viruses in central Italian prisoners

BACKGROUND

The coinfections HIV/HCV/HBV are an important health issue in penitentiary communities. The aim of the study was to examine HIV, HBV and HCV coinfections determinants amongst prisoners in the jails of Southern Lazio (Central Italy), in the period 1995-2000.

METHODS

Diagnosis of seropositivities for HIV, HBV and HCV was made using ELISA method. A multiple logistic regression analysis was conducted to verify the influence of socio-demographic factors on the HIV/HBV/HCV coinfections.

RESULTS

HIV/HCV, HBV/HCV and HIV/HBV coinfections were detected in 42 (4%), 203 (17.9%) and 31 (2.9%) inmates, respectively. These coinfections are significantly associated with the status of drug addiction (OR = 16.02; p = 0.012; OR = 4.15; p < 0.001; OR = 23.57; p = 0.002), smoking habits (OR = 3.73; p = 0.033; OR = 1.42; p = 0.088; OR = 4.25; p = 0.053) and Italian nationality (OR = 7.05; p = 0.009; OR = 2.31; p < 0.001; OR = 4.61; p = 0.04).

CONCLUSION

The prevalence of HIV, HBV and HCV seropositivity in jails suggests that information and education programs for inmates could be useful to reduce the spread of such infections.

HIV in prison in low-income and middle-income countries

High prevalence of HIV infection and the over-representation of injecting drug users (IDUs) in prisons combined with HIV risk behaviour create a crucial public-health issue for correctional institutions and, at a broader level, the communities in which they are situated. However, data relevant to this problem are limited and difficult to access. We reviewed imprisonment, HIV prevalence, and the proportion of prisoners who are IDUs in 152 low-income and middle-income countries. Information on imprisonment was obtained for 142 countries. Imprisonment rates ranged from 23 per 100,000 population in Burkina Faso to 532 per 100,000 in Belarus and Russia. Information on HIV prevalence in prisons was found for 75 countries. Prevalence was greater than 10% in prisons in 20 countries. Eight countries reported prevalence of IDUs in prison of greater than 10%. HIV prevalence among IDU prisoners was reported in eight countries and was greater than 10% in seven of those. Evidence of HIV transmission in prison was found for seven low-income and middle-income countries. HIV is a serious problem for many countries, especially where injection drug use occurs. Because of the paucity of data available, the contribution of HIV within prison settings is difficult to determine in many low-income and middle-income countries. Systematic collection of data to inform HIV prevention strategies in prison is urgently needed. The introduction and evaluation of HIV prevention strategies in prisons are warranted.

Drug injecting and syringe use in the HIV risk environment of Russian penitentiary institutions: Qualitative study

BACKGROUND

Evidence highlights the prison as a high risk environment in relation to human immunodeficiency virus (HIV) and hepatitis C virus (HCV) transmission associated with injecting drug use.

METHODS

We undertook qualitative studies among 209 injecting drug users (IDUs) in three Russian cities: Moscow (n = 56), Volgograd (n = 83) and Barnaul in western Siberia (n = 70).

RESULTS

Over three-quarters (77%) reported experience of police arrest related to their drug use, and 35% (55% of men) a history of imprisonment or detention. Findings emphasize the critical role that penitentiary institutions may play as a structural factor in the diffusion of HIV associated with drug injection in the Russian Federation. While drugs were perceived to be generally available in penitentiary institutions, sterile injection equipment was scarce and as a consequence routinely shared, including within large groups. Attempts to clean borrowed needles or syringes were inadequate, and risk reduction was severely constrained by a combination of lack of injecting equipment availability and punishment for its possession. Perceptions of relative safety were also found to be associated with assumptions of HIV negativity, resulting from a perception that all prisoners are HIV tested upon entry with those found HIV positive segregated.

CONCLUSION

This study shows an urgent need for HIV prevention interventions in the Russian penitentiary system.

Evidenced-based treatment of opioid-dependent patients

OBJECTIVE

To provide an overview of treatment options for opioid-dependent patients.

METHOD

We screened all published studies on the treatment of opioid dependence, with a special focus on systematic literature reviews, formal metaanalyses, and recent trials.

RESULTS

Both clinical experience and neurobiological evidence indicate that opioid dependence is a chronic relapsing disorder. Treatment objectives depend on the pursued goals: crisis intervention, abstinence-oriented treatment (detoxification and relapse prevention), or agonist maintenance treatment. The high quality of solid evidence in the literature demonstrates that there are numerous effective interventions available for the treatment of opioid dependence. Crisis intervention, frequently necessary owing to the high overdose rate, can be effectively handled with naloxone. Abstinence-oriented interventions are effective for only a few motivated patients with stable living conditions and adequate social support. Agonist maintenance treatment is considered the first line of treatment for opioid dependence. Numerous studies have shown efficacy for methadone and buprenorphine treatment, while maintenance with other agonists is also becoming available to a greater extent. Maintenance treatment with diamorphine should be made available for the small group of treatment-resistant, severely dependent addicts. Other harm-reduction measures can serve to engage individuals with opioid addiction who are not in treatment.

CONCLUSION

Opioid dependence is a chronic relapsing disease that is difficult to cure, but effective treatments are available to stabilize patients and reduce harm, thereby increasing life expectancy and quality of life.

Initiation of opiate addiction in a Canadian prison: a case report

BACKGROUND

In North America, the harms of illicit drug use have been responded to primarily through law enforcement interventions. This strategy has resulted in record populations of addicted individuals being incarcerated in both Canada and the United States. The incarceration of non-violent drug offenders has become increasingly controversial as studies demonstrate the harms, including elevated HIV risk behavior, of incarcerating injection drug users. Other harms, such as the initiation of illicit drug use by prison inmates who previously did not use drugs, have been less commonly described.

CASE PRESENTATION

We report on the case of an individual who initiated non-injection opiate use in a Canadian prison and developed an addiction to the drug. Upon release into the community, the individual continued using opiates and sought treatment at a clinic. The patient feared that he might initiate injection use of opiates if his cravings could not be controlled. The patient was placed on methadone maintenance therapy.

CONCLUSION

While anecdotal reports indicate that initiation in prison of the use of addictive illicit substances is frequent, documentation through clinical experience is rare, and the public health implications of this behavior have not been given sufficient attention in the literature. Strategies of incarcerating non-violent drug offenders and attempting to keep illicit drugs out of prisons have not reduced the harms and costs of illicit drug use. Effective, practical alternatives are urgently needed; expanded community diversion programs for non-violent drug offenders deserve particular attention.

HIV/AIDS and other infectious diseases among correctional inmates: transmission, burden, and an appropriate response

Correctional inmates engage in drug-related and sexual risk behaviors, and the transmission of HIV, hepatitis, and sexually transmitted diseases occurs in correctional facilities. However, there is uncertainty about the extent of transmission, and hyperbolic descriptions of its extent may further stigmatize inmates and elicit punitive responses. Whether infection was acquired within or outside correctional facilities, the prevalence of HIV and other infectious diseases is much higher among inmates than among those in the general community, and the burden of disease among inmates and releasees is disproportionately heavy. A comprehensive response is needed, including voluntary counseling and testing on request that is linked to high-quality treatment, disease prevention education, substance abuse treatment, and discharge planning and transitional programs for releasees.

Binge drug use independently predicts HIV seroconversion among injection drug users: implications for public health strategies

Several studies have highlighted risk factors that cause HIV vulnerability among injection drug users (IDUs); these studies in turn have prompted public health officials to take action to minimize these risks. We sought to evaluate the potential association between binge drug use and HIV seroconversion and, subsequently, risk factors associated with binge drug use among a cohort of IDUs. To do this, we performed analyses of (1) associations with HIV seroconversion and (2) associations with binge drug use among participants enrolled in the Vancouver Injection Drug Users Study (VIDUS), a prospective cohort of IDU. Because serial measures for each individual were available, we undertook a time-updated Cox regression analysis to detect associations with HIV incidence and variables potentially associated with binge drug use were evaluated by using generalized estimating equations (GEE). Overall, 1548 IDU were enrolled into the VIDUS cohort between May 1996 and May 2003. There were 1013 individuals who were HIV seronegative at enrollment and had at least one follow-up visit; 125 (12%) became HIV positive during the study period for a cumulative incidence rate of 14% at 64 months after enrollment. In the final multivariate model, binge drug use [Adjusted Hazards Ratio: 1.61 (CI: 1.12, 2.31)] was independently associated with HIV seroconversion. In subanalyses, when we evaluated associations with binge drug use in GEE analyses, borrowing [Odds Ratio (OR): 153 (CI: 1.33-1.76)] and lending [OR: 1.73 (CI: 1.50-1.98)] syringes, sex trade work [OR: 1.14 (CI: 1.01-1.29)], frequent cocaine [OR: 2.34 (CI: 2.11-2.60)] and heroin [OR: 1.29 (CI: 1.17-1.43)] injection were independently associated with binge drug use and methadone [OR: 0.80 (CI: 0.71-0.89)] was protective against binge drug use. Our study identified an independent association between binge drug use and HIV incidence and demonstrated several high-risk drug practices associated with bingeing. Given the unaddressed public health risks associated with bingeing, a public health response protocol must be developed to minimize the personal and public health risks associated with the binge use of drugs.

HIV transmission behaviors in jail/prison among puerto rican drug injectors in New York and Puerto Rico

This study examined HIV risk behavior in jail/prison among Puerto Rican drug injectors in New York (NY, n = 300) and Puerto Rico (PR, n = 200), and its relationship with later drug and sex risk behaviors. During 3 years prior to interview, 66% of NY and 43% of PR samples were incarcerated at least once. While incarcerated, 5% of NY and 53% of PR injected drugs. Few reported engaging in sex inside jail/prison (5% in both sites). Of those who engaged in risk behaviors in jail/prison, almost all reported having unprotected sex and sharing injection equipment. The impact of jail/prison risk behaviors on risk behaviors after release differed between the two sites: they were more related to subsequent sex risk behaviors in NY, and subsequent injection risk behaviors in PR. The findings indicate a need for effective drug treatment programs inside jail/prisons to reduce HIV-related risk behaviors among drug injectors during incarceration and after release.

Prevention of infectious disease transmission in correctional settings: a review

OBJECTIVES

To review studies defining risk factors for infectious disease transmission in correctional settings, to determine target objectives, and to assemble recommendations for health promotion in prisons and jails.

METHODS

Electronic databases were searched, using a specific search strategy, from 1993 to 2003.

RESULTS

The principal risk factors in correctional facilities are proximity, high-risk sexual behaviour and injection drug use. Based on the type of disease transmissions and epidemics reported in the literature, four diseases were targeted for which preventive measures should be implemented: tuberculosis, human immunodeficiency virus, hepatitis and sexually transmitted diseases. Knowledge of risk factors helps define effective preventive measures along five main themes of action: information and education, screening, limiting harm from risk behaviour by distributing condoms and exchanging syringes, treatment and vaccinations.

CONCLUSIONS

The effectiveness and feasibility of each of these actions have to be assessed in relation to the specificities of the correctional setting.

Recent incarceration independently associated with syringe sharing by injection drug users

OBJECTIVES

Few prospective studies are available on the relationship between incarceration and HIV risk among injection drug users (IDUs). The authors evaluated self-reported rates of syringe sharing and incarceration among a cohort of IDUs.

METHODS

This study analyzed syringe lending by HIV-infected IDUs and syringe borrowing by HIV-negative IDUs among participants enrolled in the Vancouver Injection Drug Users Study (VIDUS). Since serial measures for each individual were available, variables potentially associated with each outcome (syringe lending and borrowing) were evaluated using generalized estimating equations for binary outcomes.

RESULTS

The study sample consisted of 1,475 IDUs who were enrolled into the VIDUS cohort from May 1996 through May 2002. At baseline, 1,123 (76%) reported a history of incarceration since they first began injecting drugs. Of these individuals, 351 (31%) reported at baseline that they had injected drugs while incarcerated. Among 318 baseline HIV-infected IDUs, having been incarcerated in the six months prior to each interview remained independently associated with syringe lending during the same period (adjusted odds ratio [OR]=1.33; 95% confidence interval [CI] 1.06, 1.69; p=0.015). Similarly, among the 1,157 baseline HIV-negative IDUs, having been incarcerated in the six months prior to each interview remained independently associated with reporting syringe borrowing during the same period (adjusted OR=1.26; 95% CI 1.12, 1.44; p<0.001).

CONCLUSIONS

Incarceration was independently associated with risky needle sharing for HIV-infected and HIV-negative IDUs. This evidence of HIV risk behavior should reinforce public health concerns about the high rates of incarceration among IDUs.

Prevalence of and factors associated with HIV-1 infection among drug users visiting treatment centers in Tehran, Iran

OBJECTIVES

This study was conducted to identify the prevalence of and potential risk factors for HIV-1 infection among drug users visiting drug treatment centers in Tehran, Iran.

DESIGN

Cross-sectional quantitative study.

METHODS

Between October 2003 and May 2004, drug users who visited three public drug treatment centers in Tehran were interviewed and information about their sociodemographics, drug use characteristics, incarceration history, sexual history, and HIV/AIDS knowledge and risk perception were collected. Specimens of oral mucosal transudate were then collected from participants to be tested for HIV-1 antibodies. Logistic regression analysis was conducted on the association between the demographic and behavioral factors with HIV-1 infection.

RESULTS

Overall, 611 (588 male and 23 female) drug users participated in the study. Among male injectors with HIV-1 prevalence of 15.2%, a history of shared injection inside prison [adjusted odds ratio (OR), 12.37; 95% confidence interval (CI), 2.94-51.97] was the main factor associated with HIV-1 infection. Among those who reported no history of injecting drug use, HIV-1 prevalence was 5.4%, and lack of condom use during sex was significantly associated with the infection (adjusted OR, 3.42; 95% CI, 1.25-9.36).

CONCLUSIONS

HIV-1 infection is already prevalent among drug users in Tehran, Iran and shared injection inside prison has been revealed to be a particular risk factor for HIV-1 infection among injecting drug users. Harm reduction programs which have been started in Iran should be urgently expanded particularly in correctional settings and strengthened by condom use promotion to prevent sexual acquisition or transmission of HIV-1 among drug users.

Incarceration, addiction and harm reduction: inmates experience injecting drugs in prison

Within Canadian prisons HIV/AIDS is becoming more common among inmates. While injection drug use in correctional facilities is documented to be a problem, qualitative research into the HIV risks faced by inmates is lacking. The goal of this research was to qualitatively examine HIV risk associated with injecting inside British Columbia prisons. A sample of 26 former male inmates who had recently used drugs within correctional facilities were recruited from a ongoing cohort study of injection drug users in Vancouver, Canada. Data for this study were collected through in-depth interviews conducted in 2001/2002. Analysis of these data involved identifying emergent themes and then exploring these central concepts in further interviews to confirm the accuracy of interpretation. The harms normally associated with drug addiction, and injection drug use are exacerbated in prison. Interpersonal relationships and the possession of exchangeable resources determine access to scarce syringes. The scarcity of syringes has resulted in patterns of sharing amongst large numbers of persons. Continual reuse of scarce syringes poses serious health hazards and bleach distribution is an inadequate solution. The findings of this study emphasize the need for effective harm reduction programs that provide an appropriate response to the problem of injection drug use among inmates.

Evaluation of the condom distribution program in New South Wales Prisons, Australia

Male to male unprotected anal sex is the main route of HIV transmission in Australia. The Australian Study of Health and Relationships, a large, representative population survey of sexual health behaviors, found that six percent of males in the general population have engaged in homosexual activity. These findings were consistent with studies in Europeand North America. Condoms have been shown to reduce the transmission of HIV in the community. Barriers to the use of condoms include access,stigma,and cost? Nevertheless, increased condom use has been reported among homosexual males, sex workers and injecting drug users although recent declines in condom use among homosexuals has presented new challenges in HIV prevention.

The prevalence of male to male sexual activity may be higher in prison than in the general population. Sexual activity in prison can be consensual and non-consensual involving both homosexual / bisexual and heterosexual men.

A randomised controlled trial of methadone maintenance treatment versus wait list control in an Australian prison system

OBJECTIVES

The aim was to determine whether methadone maintenance treatment reduced heroin use, syringe sharing and HIV or hepatitis C incidence among prisoners.

METHODS

All eligible prisoners seeking drug treatment were randomised to methadone or a waitlist control group from 1997 to 1998 and followed up after 4 months. Heroin use was measured by hair analysis and self report; drugs used and injected and syringe sharing were measured by self report. Hepatitis C and HIV incidence was measured by serology.

RESULTS

Of 593 eligible prisoners, 382 (64%) were randomised to MMT (n=191) or control (n=191). 129 treated and 124 control subjects were followed up at 5 months. Heroin use was significantly lower among treated than control subjects at follow up. Treated subjects reported lower levels of drug injection and syringe sharing at follow up. There was no difference in HIV or hepatitis C incidence.

CONCLUSIONS

Consideration should be given to the introduction of prison methadone programs particular where community based programs exist.