In the JournalsPerspective

HIV, hepatitis, TB burden among prisoners driven by IDUs, insufficient care

Although prisoners and detainees constitute a substantial proportion of the global burden of HIV, hepatitis and tuberculosis, many incarcerated persons do not receive adequate clinical care for these transmissible diseases, according to a series of studies and commentaries recently published in The Lancet.

This increased incidence is primarily driven by the frequent incarceration of injection drug users (IDUs), who are at greater risk for infection and transmission than non-IDUs, according to the studies. Therefore, implementation of IDU-specific interventions — such as opioid agonist therapy or needle-exchange programs — alongside other standard prevention measures could lead to a significant reduction in prisoner infection rates, researchers wrote, and should be pursued in the interests of public health and ethical treatment.

“Prisons can act as incubators of [TB], hepatitis C and HIV, and the high level of mobility between prison and the community means that the health of prisoners should be a major public health concern,” Chris Beyrer, MD, MPH, professor of epidemiology at Johns Hopkins Bloomberg School of Public Health and president of the International AIDS Society, said in a press release. “Yet, screening and treatment for infectious diseases are rarely made available to inmates, and only around 10% of people who use drugs worldwide are being reached by treatment programs.”

Chris Beyrer

Chris Beyrer

Targeted interventions could greatly reduce diseases prevalent among IDUs

According to a literature review of 299 publications conducted by Kate Dolan, PhD, professor at the National Drug and Alcohol Research Center, and colleagues, an estimated 10.2 million people were incarcerated worldwide on any given day in 2013. Of these, 15.1% have HCV, 4.8% had chronic HBV, 3.8% had HIV and 2.8% had active TB. These cases were greater than those reported among the general population, they wrote, and were higher among female inmates than male inmates.

Further analyses modeling HIV transmission showed that lowering the incarceration rate of IDUs by 10% to 50% over a 5-year period could potentially reduce communitywide cumulative HIV incidence in IDUs by 0.9% to 7.6% in high-prevalence communities, and by 1.1% to 15.4% in moderate-prevalence communities. Similarly, prison-based opioid agonist therapy with either post-release retention in treatment or post-release ART also would reduce HIV incidence in this population.

These trends appear to be more drastic in regions more heavily affected by the HIV epidemic, such as sub-Saharan Africa, as well as those with an increased prevalence of IDUs, such as Eastern Europe and central Asia (EECA). According to a pair of studies focused on these two regions, levels of HIV ranged from 2.3% to 34.9% among incarcerated persons in sub-Saharan Africa, and TB infection rates were calculated to be 0.4% to 16.3%. The researchers also wrote that 28% to 55% of all new HIV infections in EECA during the next 15 years will occur among previously or currently incarcerated IDUs.

“Investment in surveillance infrastructure is needed to improve country-level data on the prevalence of these infections and to inform policy and programmatic responses,” Dolan and colleagues wrote. “This is particularly important in regions where injection drug use is increasing and the burden of HIV is already high.”

Proper care a matter of public health, human rights

While targeted transmission prevention would benefit at-risk prisoners, Adeeba Kamarulzaman, MBBS, FRACP, dean of the faculty of medicine and professor of medicine and infectious diseases at the University of Malaya in Malaysia, and colleagues noted that opioid agonist therapy, condom provision, ART, vaccination, needle-exchange programs and infection control were infrequent among the prisons of both low-income and high-income countries. They wrote that only eight countries report the provision of these six high-impact interventions, and that certain preventions are stigmatized or expressly forbidden in several countries despite their established effectiveness. Failure to implement these interventions represents a growing risk to those inside and outside of the prison system, they wrote.

“The fluidity of people between prisons and the community — staff and prisoners — means that undiagnosed and untreated infections in prisons and ineffective transitional programs to the community result in accelerated community-based infections after the release of prisoners,” Kamarulzaman and colleagues wrote. “Despite many evidence-based interventions documented to reduce the negative consequences of these infections and international guidelines calling for the implementation of these interventions, an enormous gap remains in the introduction and expansion of these services in prisons.”

Outside of prevention, prisoners worldwide also are less likely to receive adequate clinical care and disease testing, Josiah D. Rich, MD, MPH, professor of medicine and epidemiology at the Warren Alpert Medical School of Brown University, and colleagues wrote. In their review of 285 articles and reports, they found that along with injection drug use, numerous structural barriers, stigma, mental illness and resource limitations often complicate prisoners’ health care. These failures to provide treatment, education, and appropriate linkage to care not only impact the health of prisoners and the surrounding communities, they wrote, but also represent a violation of the 2012 Geneva Declaration on health care in prisons, and should be immediately addressed by criminal justice systems and health organizations.

“For prison-based health care to reach the same standards as those provided in the community, financial support in the range of tens of billions of dollars will be needed, along with support from medical and humanitarian organizations across the globe,” they wrote.

These and other inequalities in care — including prison overcrowding, poor sanitation, physical and sexual abuse, and housing in stressful and violent conditions — represent severe human rights transgressions perpetrated by justice systems and governments across the world, Leonard S. Rubenstein, JD, LLM, senior scientist at the Johns Hopkins Center for Public Health and Human Rights, and colleague wrote. To restore prisoners’ “rights to health and to be free from discrimination and cruel or inhuman treatment,” they called for judicial, policing and criminal justice reforms of practices targeting disadvantaged races, ethnicities and social classes; IDUs; sex workers and persons with same-sex behaviors; and persons with stigmatized diseases.

“Structural, social, legal and political injustices that lead to disproportionate risk of HIV and to incarceration can and must be addressed,” Rubenstein and colleagues wrote. “The use of prison, and pretrial detention, in response to nonviolent crimes must be reduced. People in prisons must have their human rights respected.”

The full series of six studies and their accompanying commentaries can be found at www.thelancet.com/series/hiv-in-prisons. – by Dave Muoio

References:

Altice FL, et al. Lancet. 2016;doi:10.1016/S0140-6736(16)30856-X.

Dolan K, et al. Lancet. 2016;doi:10.1016/S0140-6736(16)30466-4.

Kamarulzaman A, et al. Lancet. 2016;doi:10.1016/S0140-6736(16)30769-3.

Rich JD, et al. Lancet. 2016;doi:10.1016/S0140-6736(16)30379-8.

Rubenstein LS, et al. Lancet. 2016;doi:10.1016/S0140-6736(16)30663-8.

Telisinghe L, et al. Lancet. 2016;doi:10.1016/S0140-6736(16)30578-5.

Disclosure: Please see the full studies for a list of all authors’ relevant financial disclosures.

Although prisoners and detainees constitute a substantial proportion of the global burden of HIV, hepatitis and tuberculosis, many incarcerated persons do not receive adequate clinical care for these transmissible diseases, according to a series of studies and commentaries recently published in The Lancet.

This increased incidence is primarily driven by the frequent incarceration of injection drug users (IDUs), who are at greater risk for infection and transmission than non-IDUs, according to the studies. Therefore, implementation of IDU-specific interventions — such as opioid agonist therapy or needle-exchange programs — alongside other standard prevention measures could lead to a significant reduction in prisoner infection rates, researchers wrote, and should be pursued in the interests of public health and ethical treatment.

“Prisons can act as incubators of [TB], hepatitis C and HIV, and the high level of mobility between prison and the community means that the health of prisoners should be a major public health concern,” Chris Beyrer, MD, MPH, professor of epidemiology at Johns Hopkins Bloomberg School of Public Health and president of the International AIDS Society, said in a press release. “Yet, screening and treatment for infectious diseases are rarely made available to inmates, and only around 10% of people who use drugs worldwide are being reached by treatment programs.”

Chris Beyrer

Chris Beyrer

Targeted interventions could greatly reduce diseases prevalent among IDUs

According to a literature review of 299 publications conducted by Kate Dolan, PhD, professor at the National Drug and Alcohol Research Center, and colleagues, an estimated 10.2 million people were incarcerated worldwide on any given day in 2013. Of these, 15.1% have HCV, 4.8% had chronic HBV, 3.8% had HIV and 2.8% had active TB. These cases were greater than those reported among the general population, they wrote, and were higher among female inmates than male inmates.

Further analyses modeling HIV transmission showed that lowering the incarceration rate of IDUs by 10% to 50% over a 5-year period could potentially reduce communitywide cumulative HIV incidence in IDUs by 0.9% to 7.6% in high-prevalence communities, and by 1.1% to 15.4% in moderate-prevalence communities. Similarly, prison-based opioid agonist therapy with either post-release retention in treatment or post-release ART also would reduce HIV incidence in this population.

These trends appear to be more drastic in regions more heavily affected by the HIV epidemic, such as sub-Saharan Africa, as well as those with an increased prevalence of IDUs, such as Eastern Europe and central Asia (EECA). According to a pair of studies focused on these two regions, levels of HIV ranged from 2.3% to 34.9% among incarcerated persons in sub-Saharan Africa, and TB infection rates were calculated to be 0.4% to 16.3%. The researchers also wrote that 28% to 55% of all new HIV infections in EECA during the next 15 years will occur among previously or currently incarcerated IDUs.

“Investment in surveillance infrastructure is needed to improve country-level data on the prevalence of these infections and to inform policy and programmatic responses,” Dolan and colleagues wrote. “This is particularly important in regions where injection drug use is increasing and the burden of HIV is already high.”

Proper care a matter of public health, human rights

While targeted transmission prevention would benefit at-risk prisoners, Adeeba Kamarulzaman, MBBS, FRACP, dean of the faculty of medicine and professor of medicine and infectious diseases at the University of Malaya in Malaysia, and colleagues noted that opioid agonist therapy, condom provision, ART, vaccination, needle-exchange programs and infection control were infrequent among the prisons of both low-income and high-income countries. They wrote that only eight countries report the provision of these six high-impact interventions, and that certain preventions are stigmatized or expressly forbidden in several countries despite their established effectiveness. Failure to implement these interventions represents a growing risk to those inside and outside of the prison system, they wrote.

“The fluidity of people between prisons and the community — staff and prisoners — means that undiagnosed and untreated infections in prisons and ineffective transitional programs to the community result in accelerated community-based infections after the release of prisoners,” Kamarulzaman and colleagues wrote. “Despite many evidence-based interventions documented to reduce the negative consequences of these infections and international guidelines calling for the implementation of these interventions, an enormous gap remains in the introduction and expansion of these services in prisons.”

Outside of prevention, prisoners worldwide also are less likely to receive adequate clinical care and disease testing, Josiah D. Rich, MD, MPH, professor of medicine and epidemiology at the Warren Alpert Medical School of Brown University, and colleagues wrote. In their review of 285 articles and reports, they found that along with injection drug use, numerous structural barriers, stigma, mental illness and resource limitations often complicate prisoners’ health care. These failures to provide treatment, education, and appropriate linkage to care not only impact the health of prisoners and the surrounding communities, they wrote, but also represent a violation of the 2012 Geneva Declaration on health care in prisons, and should be immediately addressed by criminal justice systems and health organizations.

“For prison-based health care to reach the same standards as those provided in the community, financial support in the range of tens of billions of dollars will be needed, along with support from medical and humanitarian organizations across the globe,” they wrote.

These and other inequalities in care — including prison overcrowding, poor sanitation, physical and sexual abuse, and housing in stressful and violent conditions — represent severe human rights transgressions perpetrated by justice systems and governments across the world, Leonard S. Rubenstein, JD, LLM, senior scientist at the Johns Hopkins Center for Public Health and Human Rights, and colleague wrote. To restore prisoners’ “rights to health and to be free from discrimination and cruel or inhuman treatment,” they called for judicial, policing and criminal justice reforms of practices targeting disadvantaged races, ethnicities and social classes; IDUs; sex workers and persons with same-sex behaviors; and persons with stigmatized diseases.

“Structural, social, legal and political injustices that lead to disproportionate risk of HIV and to incarceration can and must be addressed,” Rubenstein and colleagues wrote. “The use of prison, and pretrial detention, in response to nonviolent crimes must be reduced. People in prisons must have their human rights respected.”

The full series of six studies and their accompanying commentaries can be found at www.thelancet.com/series/hiv-in-prisons. – by Dave Muoio

References:

Altice FL, et al. Lancet. 2016;doi:10.1016/S0140-6736(16)30856-X.

Dolan K, et al. Lancet. 2016;doi:10.1016/S0140-6736(16)30466-4.

Kamarulzaman A, et al. Lancet. 2016;doi:10.1016/S0140-6736(16)30769-3.

Rich JD, et al. Lancet. 2016;doi:10.1016/S0140-6736(16)30379-8.

Rubenstein LS, et al. Lancet. 2016;doi:10.1016/S0140-6736(16)30663-8.

Telisinghe L, et al. Lancet. 2016;doi:10.1016/S0140-6736(16)30578-5.

Disclosure: Please see the full studies for a list of all authors’ relevant financial disclosures.

    Perspective

    Jeanne M. Marrazzo

    This collection of studies provides a startlingly clear and chilling summary of the extent to which incarcerated persons are already infected with preventable chronic viral illnesses, like HIV and viral hepatitis, and worse, the lack of targeted therapeutic programs offered to them.

    Settings for incarceration provide an unparalleled opportunity for intervening in this group of people, who are less likely than the general population to access preventive health care services outside of such settings. Yet, as the authors point out, proven and critical biomedical interventions like opioid agonist therapy, HIV pre-exposure prophylaxis, HIV treatment, immunizations, syringe exchange and infection control are used all too infrequently. The impact of such targeted interventions on this population during incarceration has the potential for huge health benefits, not only to those incarcerated, but to vulnerable contacts (including sexual and drug-sharing partners) they then encounter upon release. Directing resources for the health of the incarcerated could provide a big benefit to society at large.


    Jeanne M. Marrazzo, MD, MPH
    Director, division of Infectious Diseases, University of Alabama at Birmingham School of Medicine

    Disclosure: Marrazzo reports no relevant financial disclosures.