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School of Public Health and Community Medicine

HIV and Harm Reduction in Prisons

Professor Kate Dolan

Program of International Research and Training

National Drug and Alcohol Research Centre

UNSW, Sydney, Australia

UNODC Scientific Event

Science Addressing Drugs And Health: State of the Art

11 March 2014, Vienna, Austria

Background 10 million prisoners - 3 million remandees in the world

BUT 30 million individuals enter and leave prison - 90% male

Prison populations grew by 25% in the last 15 years

Drug dependence key factor in prison growth

US popn up 13%, prison popn up 33%, PWIDs prisoners up 43%.

1/3 of 200,000 heroin users in US imprisoned annually

60% of PWIDs in a 12-city study been in prison.

Re-incarceration rates very high for PWIDs

In Australia, 84% of PWIDs inmates were re-incarcerated in 2 yrs of

release versus 44% of all prisoners. They had a mean of 5

imprisonments.

Background

HIV is a major health problem for prisons around the world.

Prison settings have characteristics that increase HIV transmission.

HIV, HBV, HCV, TB & mental illness more prevalent in prison

High HIV infection and the over-representation of PWIDs in prisons

combined risk behaviour create a critical public-health issue for

prison authorities.

Unless HIV is controlled in the prison setting it may not be controlled in

broader community of some countries.

Prison settings are a practical point of HIV prevention and treatment

Background Few clear documented cases of HIV transmission in prison

Because it is difficult to gain access and the vast turnover of inmates

HIV transmission does occur in prison, and can be extensive.

HIV prevention programs for prisoners are rare

Prisons are very expensive while HIV programs are not.

the US prison system costs US$74 billion ($25,144 per inmate).

the Australian prison system cost $2.4 billion ($50,874 per inmate).

Hepatitis C and TB are very common in prison populations

Aim

Systematic review of the HIV situation in prisons for all countries on

A. Imprisonment rates

B. HIV prevalence among male, female, PWIDs, MSM, sex workers and

transgender prisoners,

C. HIV transmission and incidence

D. AIDS related mortality

E. Provision of HIV programs

The time period under observation was from January 2008 to April 2013.

Methods

• A multilingual (English, German, Spanish, Croatian, French, Arabic,

Portuguese and Russian) desk review of the literature

• A survey of UN staff and experts

• List of Countries from

http://www.unaids.org/en/regionscountries/countries/

Imprisonment rates from the International centre for prison studies

http://www.prisonstudies.org/info/worldbrief/















Results

We identified 4,640 peer reviewed papers and 8,292 documents (see

figure 1).

Total included documents (N=261)

The Review Procedure

Pee-reviewed

literature

(N=12570), Medline

(N=5194), Web of

Science (N=5001),

Embase (N=2375)

Results from duplicate

removal in each

database (N=6111),

Medline (N=2045), Web

of Science (N=2832),

Embase (N=1234)

Combination of search

results and duplication

removal (N=4640)

Excluded articles

on basis of title

(N=3549),

Abstracts

(N=390), and un-

removed

duplicates

(N=340)

Full text exclusion

(N=305)

Total included

peer-reviewed

paper (N=56)

Documents sent by

UNODC officer

(N=169)

Results of exclusion

due to irrelevant

content or being out of

date (N=92)

Total included

received files

(N=77)

Results of

search in 238

Grey Literature

Databases

(N=8292)

Results after

title exclusion

(N=611)

Total included

Grey

Literature

documents

(N=128)

Total included documents (N=261)

Table 1: Countries with data on imprisonment rates and HIV prevalence and regional

imprisonment rates

HIV prevalence among inmates Imprisonment

rate

No. of

countries

Region

MSM PWIDs Female Male All

1

1

6

6

10

182

20

East/ Southern

Africa

1

2

2

12

68

25

West/Central

Africa

1

5

4

8

129

35

Asia and Pacific

1

332

16 Caribbean

3

6

6

12

220

30 Eastern Europe

and Central Asia

3

4

3

210

17 Latin American*

2

3

4

7

128

21 Middle East and

North African

2

1

1

2

6

127

22 Other Countries

3

9

26

28

58

146

196 Total

Table 2: the percentage of PWIDs in prison populations

Country Past IDU %

Afghanistan 1

Hungary 1

Belgium 2

Kenya 3

Cape Verde 3

Thailand 3

Iran 3 (Females)

Tanzania 6

Netherlands 8

UK 1 - 8

Latvia 9

Brazil 10

Spain 9 - 24

Ukraine 35 - 48

Australia 17 – 68

Table 3: HIV positive in prison populations

East and South Africa %

Mozambique 5- 17

Kenya 6 – 27

Rwanda 6

Ethiopia 7

Uganda 11

South Africa 16

Swaziland 35

Zambia 42


West and Central African Region

%

Nigeria 2

Cape Verdi 2

Niger 3

Senegal 3

Cote d’Ivoire 4

Mauritania 4

Burkina Faso 5

Cameroon 5-8

Togo 7

DR Congo 8

Ghana 10-20


Asia and Pacific Region

%

Australia 0

Sri Lanka 0

Pakistan 2

Cambodia 3

Malaysia 6

India 7

Indonesia 7

Vietnam 10


Eastern Europe and Central

Asia

%

Hungary <1

Azerbaijan 3

Lithuania 4

Russian Federation 4

R. Moldova 5

Kazakhstan 2-6

Latvia 7

Romania 1-10

Estonia 14

Ukraine 10-20


Latin America Region

%

Chile 2

Argentina 3

Mexico 1- 12

Brazil 6 (males)


Middle East and North African Region

%

Egypt 0

Iran 0 – 2

Morocco < 1

Oman < 1

Saudi Arabia < 1

Afghanistan 1 – 4


Other Countries Region

%

Netherlands 0

Hong Kong 1

Luxembourg 1

USA 1 Females

Italy 4

Portugal 6

Spain 6 – 11

Table 10: Injecting and sharing in prison populations and in IDU prisoners

Country % injected % shared

Russia 10 66

Greece 20 83

Greece 24 92

Thailand 25 78

IDU INMATES

Afghanistan 17

Australia 31 70

Scotland 37

Scotland 58

Pakistan 22-70 56

Australia 74 90

Table 11: Outbreaks of HIV transmission in prison populations and in IDU prisoners

Country incidence

Thailand

35/per 100

Lithuania

300 inmates infected in 6 months

Doubled number of HIV cases

Russia

400 inmates infected in a few months

Iran Two outbreaks with hundreds infected

Australia At least 4 up to 12

Scotland 12

Afghanistan 17

Table 12: TB in prison populations

Prevalence

/100,000

MDR- TB % Incidence %

Russia 4,560 12 – 55

Georgia 5,995 13

Azerbaijan, 89

Thailand 568 19

Zambia 4,000 9

Brazil 30

USA 0.4—8

Table 13: Hepatitis C transmission in prison

Location Incidence in PWIDs in prison per 100 person yr

Scotland Taylor 3

US Macalino 5

UK Champion 12

Australia Dolan HITS 34 18 13

Australia Dolan 24 in MMT 32 no MMT

Mortality after prison release

0.95

0.96

0.97

0.98

0.99

1

0 3 6 9 12 15 18 21 24 27 30 33 36

Rate of survival

Left prison on

methadone

Left prison not

on methadone

Table 14. Summary of the number of countries with HIV programs

Region East

Sth

Africa

West

Central

Africa

Asia

Pacific

Caribbean East

Europe

Latin MENA Other Total

No of

countries

20 25 35 16 30 17 21 24 196

NSP 6 1 4 11

OST 5 7 2 10 24

VCT 8 5 13 1 3 8 6 11 65

HIV treat 8 3 8 2 8 4 8 41

STI 5 1 9 1 6 1 4 7 34

Condoms 6 3 7 7 1 5 29

IEC 8 3 10 1 12 6 5 9 54

Prevent,

treat

Hepatitis

8 1 4 11 2 4 16 42

TB 8 3 7 1 11 6 2 4 42

Evaluations of harm reduction in prison

Positive evaluations have been documented for all programs

Condoms – decrease in unsafe sex

OST– decrease in injecting and sharing , trend to decrease HCV

NSP – decrease in injecting and sharing, no HIV/ HCV transmission

HIV education – improved knowledge

Recommendations

Good prisoner health is good public health: High turnover of inmates

mean diseases contracted inside leave prison.

Start and continue ARV and TB treatment is essential to prevent HIV

drug resistance and MDR-TB.

Reduce prison populations: Provide OST also stops mortality. Divert

drug offenders to treatment whenever possible. Provide NSP and

condoms to reduce HIV transmission in prison.

Prisoners have a legal right to medical treatment same level as in the

community.

Compassionate release from prison should be available to inmates in

the final stages of AIDS.

Acknowledgment

Co-authors

Babak Moazen, Atefeh Noori, Shadi Rahimzadeh, Farshad

Farzadfar, Stuart Kinner and Ernie Drucker.