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AIDS 2016: Neglect of Infectious Disease in Prisons Highlighted at Conference

A special issue of The Lancet was published to coincide with the recent 21st International AIDS Conference in Durban, containing a comprehensive seriesof reviews on the burden of HIV, hepatitis B, hepatitis C, and tuberculosis (TB) among prisoners worldwide.

[Produced in collaboration with Aidsmap.com]

"Prisoners are among the most neglected of the key populations; they bear higher burdens of HIV, viral hepatitis, and tuberculosis than in the communities from which they come," said outgoing International AIDS Society president Chris Beyrer of Johns Hopkins University.

The issue, which Beyrer and Pamela Das of The Lancet organized, is part of a series of issues focusing on the needs of key populations in the HIV epidemic. It contains several major papers on the global epidemiology of HIV and related infections among prisoners and addresses their human right to health care. It also covers the array of specific prison-related challenges to providing critical prevention, treatment, and care services to prisoners.

Global Burden of HIV, Viral Hepatitis, and TB in Prisons

"We know there were about 10 million people in prison in mid-2015," said Kate Dolan from the National Drug and Alcohol Research Centre at the University of New South Wales in Sydney, and one of the issue’s co-editors.

Dolan's team conducted a comprehensive review of available data from 196 countries from 2005 through 2015 to determine the number of inmates with HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), and TB, as well as the pooled estimated prevalence of the diseases by region. See full text of the review here.

Infections among 10 Million Inmates

Infection	Number of inmates	Percentage infected
HIV	389,000	3.8%
Hepatitis B	491,500	4.9%
Hepatitis C	1,546,500	15.1%
TB (active disease)	286,000	2.5%

However, Dolan pointed out that prisons are very dynamic institutions, with people coming and going all the time. The researchers calculated that around 30 million people transit through prisons each year -- so the actual burden of disease among those passing through prison systems could be as much as 3 times higher.

"What stands-out to me is the very high level of hepatitis C," Dolan said. The burden of HCV infection is over 10% in 6 different regions of the world, and over 20% in 2 regions (East Asia and the Pacific, and Eastern Europe and Central Asia). "This is pretty much due to the 'over incarceration' of people who inject drugs and their high level of hepatitis C," she added.

There are marked differences in disease burdens across regions, as well as large discrepancies in the amount of data available, Dolan noted. For instance, there is very little data from the Caribbean. HIV prevalence is high in East and Southern Africa -- reflecting higher community levels -- while West and Central Africa has a very high level of hepatitis B.

Only 25 countries had data on active TB, and the actual number of people with latent TB would be much greater. Unlike HIV, HBV, and HCV, there is no simple blood test that can accurately detect active TB, and screening and diagnostic procedures vary by country. The risk of TB transmission is high in overcrowded prisons, so the lack of data on TB cases among prisoners is especially concerning.

Data on the incidence of new infections while in prison was even harder to gather. Dolan's team could only find information from 5 countries over the last decade on new cases occurring while inmates were imprisoned.

Modeling studies demonstrate the potential effects of changing policies on incarcerating people who use drugs or offering harm reduction and opioid agonist substitution therapy (OST) such as methadone or buprenorphine to injection drug users in prison. For instance, reducing incarceration of people who inject drugs would reduce the HIV rate in prisons by 7% to 15%. Increasing the provision of OST in prisons by 20% would decrease the HIV rate by 28%.

Along with improving treatment in the community, which would reduce the burden of disease in prison as well, "we need to introduce alternatives to imprisonment -- it would be much better to treat people with a drug problem in the community," Dolan concluded. "We need to improve prison healthcare -- almost universally it is worse than in the surrounding community," she added. "We also need to test and treat and prevent infections in prisoners."

Prevention, Treatment, and Care in Prisons

The challenges of providing health services are greatly complicated by the intersectional vulnerabilities of prisoners, who have overlapping health and social needs. 

"The prevalence [in prisons] is so high that this is an excellent venue for diagnosis, treatment, and linkage to care," said Josiah Rich of Brown University, who has a long history of working to improve health services in prison systems.

"But it's not as simple as that because this population is impacted, not only by HIV, viral hepatitis, and tuberculosis, but also poverty, addiction, mental illness, and the list goes on and on," he noted. "These are disadvantaged populations. In my own state of Rhode Island, we’ve identified that a third of the burden of HIV in the entire state is in the department of corrections."

Prisoners not only have a high prevalence of blood-borne viruses and TB, but are also at higher risk of acquiring these infections while imprisoned, said Adeeba Kamarulzaman of the University of Malaya in Kuala Lumpur.

Her study found that basic prevention interventions were lacking in most countries:

• Condoms are only provided in 45 countries.
• Needle and syringe programs -- which are very controversial even though evidence shows they are effective -- are only available in prisons in 8 countries.
• Very few countries offer opioid agonist therapy; in the few Central Asian and other countries where it is offered, it is usually on a pilot basis reaching less than 1% of the people who need it.
• Antiretroviral therapyfor HIVtreatment and prevention is currently only available to prisoners in 43 countries.

One major issue is that health systems in prisons are separate from and independent oftheir respective national health systems.

"Those two [systems] often don’t talk to each other,and therefore not only do prisoners lack these prevention programs that are so badly needed,but often even basic primary care is not available in many prisons,"Kamarulzaman said.

Human Rights and the War on Drugs

Professor Rich noted that the United States is highly overrepresented in the research on infectious diseases in prison -- not surprising, given that the U.S. accounts for 2.3 million of the 10 million prisoners worldwide, primarily due to the war on drugs and people who use them.

"Criminalization of key populations is one of the most troublesome, vicious aspects of criminal law," said Leonard Rubenstein, director of the Program on Human Rights, Health, and Conflict at Johns Hopkins Bloomberg School of Public Health. He noted that 21% of the people in prison worldwide are incarcerated for drug offenses -- 80% of those for possession. In 75 countries, same-sex sexual activity is criminalized, sex work is almost universally criminalized, and 63 countries have laws criminalizing HIV transmission. "But it is really the drug criminalization that is filling prisons across the world," he said.

"The problem is that we have a cycle -- you might even call it a cascade of human rights violations at every stage -- from the criminal law before anyone encounters the criminal justice system or imprisonment to the time of release," said Rubenstein.

The cycle begins with criminalization of key populations, which drives people away from care since that could lead to arrest. It continues with abusive policing practices that target minorities -- especially African-Americans in the U.S. -- and key populations (for instance, absurdities such possession of condoms being used as evidence of sex work). There is frequently lack of due process in the courts, and conditions in prisons are unsafe, often with no access to prevention and poor ventilation or lack of respiratory infection control. Finally, even if a prisoner receives care in a facility, for most there is a lack of continuity of care once they return to their communities.

But human rights could be an important frame for both understanding this problem and responding to these human rights violations. "The human rights approach is based upon global, international, and regional treaties that have the force of law," Rubinstein said. "Increasingly, courts and other responsible bodies are applying them to prisoners, and that has the possibility of transforming the world."

"We have to address each of these [links in the cycle]. And we have good models of success," he continued, citing examples such as the decline in HIV transmission after the decriminalization of drug use in Portugal. 

Prisons in Sub-Saharan Africa

However, the "focus on prisoner’s is lost completely" in some resource-limited parts of the world where the burden of infectious diseases is high and the health services are already overstretched, said Salome Charalambous of the Aurum Institute, who led the team that reviewed the situation of prisoners in sub-Saharan Africa. They found that there was little information available about the prevalence of TB and HIV in prisons in sub-Saharan Africa and only 2 countries in the region had specific healthcare policies for prisons.

However, she highlighted some promising interventions in the region, such as judicial reforms to reduce overcrowding in South Africa, voluntary HIV and TB prison screening programs in Zambia and South Africa, integration of mental health services into a health package for prisoners in Malawi, and a task-sharing project that includes detainees in care provision in Rwanda, Zimbabwe, Zambia, and South Africa. But these best practices are the exception to the rule rather than standard practice in the region.

Eastern Europe and Central Asia

Meanwhile, Eastern Europe and Central Asia "is a highly volatile region with concentrated epidemics among people who inject drugs that have incredibly high rates of incarceration," according to Frederick Altice of Yale University.

Compared to sub-Saharan Africa, these countries have low HIV prevalence overall, but the prevalence among prisoners is very high -- 20 to 45 times greater in prisons than in communities, and over 10% in 4 countries. Incarceration is associated with TB, and multidrug-resistant and extensively drug-resistant TB are typically 3-fold higher among prisoners than in the community. Among HIV-positive people who inject drugs, incarceration contributes to 75% of new TB cases in the region, and many of these cases are multidrug-resistant.

Changing policies to reduce incarceration of people who use drugs, as well as providing harm reduction services, could have a dramatic effect on the burden of infectious diseases in prisons. But many countries in the region have long been hostile to the idea of harm reduction, and particularly to opioid substitution therapy.

Altice believes that linking development aid to healthcare reforms in prison could leverage policy changes, and that the examples of success from countries that do implement harm reduction approaches could persuade others to follow suit.

For instance, he said, a study from Ukraine showed that scaling up antiretroviral therapy and scaling up opioid substitution therapy together would avert the most infections and be the most cost-effective strategy.

Key Messages Moving Forward

"The first thing that has to happen obviously -- and this is what we really highlight in the call to action -- is that we need to be incarcerating many fewer people, that incarceration is not, for example, an evidence-based approach to drug treatment and substance use dependency," said Beyrer. "The second thing is that for the people who are incarcerated and released, we have to do much better with linkage to care."

In the end, countries will need to adopt a human rights approach that seeks to rehabilitate prisoners rather than continuing to punish them as they try to reintegrate into their communities. But this will take political will and advocacy, as well providing a platform for those who have been voiceless.

The session was closed by Pastor Karabo Rafube from Prison to Pulpit, who was imprisoned for several years, during which time he contracted TB, and has since become an advocate for prisoner’s human rights.

"Across Africa are prisons that are full of people who are denied care," he said. "This is unacceptable…for when we take away a man or a woman’s freedom, we must take on the responsibility to provide for their wellbeing with adequate food, decent sanitization, and a right to representation and a timely trial -- but also with prevention and treatment for these deadly diseases."

9/7/16

References

The Lancet Special Theme Issue: HIV, Viral Hepatitis, and TB among Prisoners. 21st International AIDS Conference (AIDS 2016), July 18-22, 2016, Durban, South Africa. Session TUSY07.

K Dolan. Global epidemiology of HIV, HCV, and TB among prisoners. 21st International AIDS Conference (AIDS 2016), July 18-22, 2016, Durban, South Africa. Presentation TUSY0702.

A Kamarulzaman. Prevention of HIV, HCV, and TB among prisoners and detainees. 21st International AIDS Conference (AIDS 2016), July 18-22, 2016, Durban, South Africa. Presentation TUSY0703.

J Rich. Clinical care for the incarcerated patient with HIV, viral hepatitis, and TB. 21st International AIDS Conference (AIDS 2016), July 18-22, 2016, Durban, South Africa. Presentation TUSY0704.

L Rubenstein. HIV, prisoners, and human rights. 21st International AIDS Conference (AIDS 2016), July 18-22, 2016, Durban, South Africa. Presentation TUSY0705.

S Charalambous. HIV and TB in prisoners in Sub-Saharan Africa. 21st International AIDS Conference (AIDS 2016), July 18-22, 2016, Durban, South Africa. Presentation TUSY0706.

F Altice. The perfect storm: incarceration and multi-level contributors to perpetuating HIV and TB in Eastern Europe and Central Asia. 21st International AIDS Conference (AIDS 2016), July 18-22, 2016, Durban, South Africa. Presentation TUSY0707.

K Rafube. Time to act: a call to action for HIV, HCV and TB among prisoners. 21st International AIDS Conference (AIDS 2016), July 18-22, 2016, Durban, South Africa. Presentation TUSY0708.