“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 Professor Chris Beyrer of Johns Hopkins University and outgoing President of the International AIDS Society. He was speaking during a symposia dedicated to a special issue of The Lancet, published to coincide with the 21st International AIDS Conference (AIDS 2016) in Durban, South Africa, containing a comprehensive series of reviews on HIV and related infections in prisoners.
The global burden of HIV, viral hepatitis and TB in prisoners
“We know there were about 10 million people in prison in mid-2015,” said Professor Kate Dolan from the National Drug and Alcohol Research Centre, University of New South Wales in Sydney, Australia (and one of the issue’s co-editors). She led a team conducting a comprehensive review of available data from 196 countries from 2005 to 2015 to determine the global number of inmates with HIV, hepatitis C virus (HCV), hepatitis B virus (HBV) and tuberculosis (TB), as well as the pooled estimated prevalence of the diseases by region.
Results: Of 10 million inmates*
Number of inmates infected
TB (active disease)
However, Prof Dolan pointed out that prisons are very dynamic institutions – with people coming and going all of the time. They calculated that around 30 million people transit through prisons each year – so the actual burden of disease could be much higher.
There are marked differences in the disease burdens across regions
“What stands out to me is the very high level of hepatitis C,” she said. The burden of hepatitis C is over 10% in six different regions of the world, and over 20% in two 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.
HIV prevalence is high in East and Southern Africa – reflecting the higher community level of the infection – while the West and Central Africa region has a very high level of hepatitis B.
Only 25 countries had data on active TB. The risk of TB transmission is high in overcrowded prisons, so the lack of data on TB cases in prisons is especially concerning.
Data on the incidence of all types of new infections while in prison were even harder to gather. Dolan and her colleagues could only find information on new cases while within prison from five countries in the world over the last decade.
Modelling studies also demonstrated the potential effects of changing policies regarding incarcerating people who use drugs or offering harm reduction and opioid substitution therapy (OST) such as methadone or buprenorphine, to people who inject drugs in prison. For instance, reducing the incarceration of people who inject drugs in prison would reduce the HIV rate by 7 to 15%. Increasing the provision of OST in prison to people who inject drugs by 20% would decrease the HIV rate by 28%.
She concluded that along with improving treatment in the community, which would reduce the burden of disease in prison, “we need to introduce alternatives to imprisonment – it would be much better to treat people with a drug problem in the community with an effective drug treatment programme. We need to improve prison healthcare – almost universally it is worse than in the surrounding community. We also need to test and treat and prevent infections in prisoners,” she said.
The provision of prevention, treatment and care for HIV and infections in prisons
The challenges of providing health services are greatly complicated by the intersecting vulnerabilities of prisoners, who have overlapping health and social needs.
“The [infection] prevalence [in prisons] is so high that this is an excellent venue for diagnosis, treatment and linkage to care. 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. These are disadvantaged populations,” said Professor Josiah Rich of Brown University who has a long history of working to improve health services in prison systems.
“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, said Prof. Adeeba Kamarulzaman of the University of Malaya in Kuala Lumpur, Malaysia, but are also at higher risk of acquiring these infections while imprisoned.
Her study found that basic prevention interventions were lacking in most countries:
- Condoms are only provided in 45 countries.
- Needle-syringe programmes, which have classically been deemed as very controversial – even though the evidence shows they are effective – are only present within the prisons of eight countries.
- Very few countries offer OST. 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 therapy for treatment and prevention is currently only available to prisoners in 43 countries.
One major issue is that health systems in prisons are separate and independent from their respective national health systems.
“Those two [systems] often don’t talk to each other and therefore not only do prisoners lack these prevention programmes that are so badly needed but often even basic primary care is not available in many prisons,” said Prof. Kamarulzaman.
Human rights and the war on drugs
Professor Rich noted that the United States houses almost one in four of the world’s prisoners, mainly due to the intensive imprisonment of people convicted of drug offences in the United States.
“Criminalisation of key populations is one of the most troublesome, vicious aspects of criminal law,” said Leonard Rubenstein, a lawyer and long-time human rights advocate working as the Director of the Program on Human Rights, Health and Conflict at Johns Hopkins Bloomberg School of Public Health. Twenty-one per cent of the people in prisons in the world are incarcerated for drug offenses – 80% of those for possession. In 75 countries, same-sex sexual activity is criminalised; and sex work is almost universally criminalised. Sixty-three countries have laws criminalising HIV transmission. “But it is really drug criminalisation 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 criminal justice or imprisonment to the time of release. At every stage we have massive violations,” said Rubenstein. The cycle begins with criminalisation of key populations (which drives people away from treatment and care since that could lead to potential arrest). It continues with abusive policing practices that target minorities – especially African-Americans in the US – and key populations in particular (absurdities such as having condoms in one’s possession as evidence of sex work). Then there is a frequent lack of due process in the courts and over-criminalisation (millions are held in detention for years without a trial). Then conditions in the prisons are unsafe – no access to prevention, no ventilation or respiratory infection control – which leads to the spread of infections. Finally, even if a prisoner should receive 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, and international and regional treaties that have the force of law. Increasingly, courts and other responsible bodies are applying them to prisoners, and that has the possibility of transforming the world,” said Rubenstein.
How do we break the cycle?
“We have to address each of these [links in the cycle]. We have to use the law, the concept as well as the obligations of human rights to change. And we have good models of success,” he said, citing examples such as the fall of HIV transmission after the decriminalisation of drug use in Portugal.
He called for the adoption of the UN Standards on Treatment of Prisoners – called `The Mandela Rules`, which mandate that prisons must be managed in a manner to respect and protect the human rights and dignity of prisoners; and that prison should be viewed as a place for preparation of the reintegration of prisoners back into society – minimising differences with the outside world.
Reports on prisons in sub-Saharan Africa
However, a challenge in some resource-limited parts of the world where the burden of infectious diseases is extremely high and the health services are already overstretched is that the “focus on prisoners is lost completely”, said Dr Salome Charalambous of the Aurum Institute, who led the team that reviewed the situation of prisoners in sub-Saharan Africa. Only two countries in the region had specific healthcare policies for prisons.
She did highlight some promising interventions in the region, such as:
- Judicial reforms that are planned to try to reduce overcrowding (in South Africa).
- Voluntary HIV and TB entry screening programmes in place, in Zambia and South Africa.
- The integration of mental health services into a health package for prisoners in Malawi.
- And a task sharing project that involves detainees in care provision in Rwanda, Zimbabwe, Zambia and South Africa.
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,” said Professor Frederick Altice of Yale University.
The prevalence of HIV among prisoners is very high – 20 to 45 times greater in prisons than in communities (and over 10% in four countries). And in the region, incarceration is associated with TB and MDR/XDR TB, with MDR TB typically three-fold higher in prisoners than in the community. Among people living with HIV who inject drugs, incarceration contributes to 75% of new TB cases.
Changing policies to reduce the incarceration of people who inject drugs, as well as providing harm reduction services, could have a dramatic effect on the burden of infectious diseases in these facilities. But many of the countries in the region have long been hostile to the idea of harm reduction, and particularly to OST.
Professor Altice believes that linking development aid to healthcare reforms in prison, could leverage policy changes – and that the examples of success from the countries that do implement harm reduction approaches could persuade other countries in the region to follow suit.
“There is a really elegant study from Ukraine four or five years ago which looked at the cost-effectiveness, and showed that scaling up antiretroviral therapy and scaling up OAT [opioid agonist therapy] together would avert the most infections…[and be] the most cost-effective strategy in general.”
Whether this will be an effective strategy in countries that are now refusing foreign aid and that have been historically antagonistic to harm reduction and OST is unclear.
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 Prof 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 will seek to rehabilitate prisoners rather than to continue punishing 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.
Dolan K et al. Global epidemiology of HIV, HCV, and TB among prisoners. 21st International AIDS Conference, Durban, abstract TUSY0702, 2016.
Kamarulzaman A et al. Prevention of HIV, HCV, and TB among prisoners and detainees. 21st International AIDS Conference, Durban, abstract TUSY0703, 2016.
Rich J et al. Clinical care for the incarcerated patient with HIV, viral hepatitis, and TB. 21st International AIDS Conference, Durban, abstract TUSY0704, 2016.
Rubenstein L et al. HIV, prisoners, and human rights. 21st International AIDS Conference, Durban, abstract TUSY0705, 2016.
Charalambous S et al. HIV and TB in prisoners in Sub-Saharan Africa. 21st International AIDS Conference, Durban, abstract TUSY0706, 2016.
Altice F et al. The perfect storm: incarceration and multi-level contributors to perpetuating HIV and TB in Eastern Europe and Central Asia. 21st International AIDS Conference, Durban, abstract TUSY0707, 2016.
Rafube, K. Time to act: a call to action for HIV, HCV and TB among prisoners. 21st International AIDS Conference, Durban, abstract TUSY0708, 2016.