Prisoners and infectious diseases by Professor Kate Dolan and the Lancet HIV team
While enormous progress has been made with advances in treatment meaning AIDS is a now a manageable condition, there are still groups who have been left behind. Prisoners are one such group whose contribution to preventable infectious diseases is significantly out of proportion to its population size.
Worldwide the health needs of prisoners receive little attention from researchers or advocates working to improve responses for these diseases, and scant funding for prevention or treatment interventions. The reasons for this neglect include the very factors that make prisoners and detainees vulnerable to infection and unable to access treatment: unjust and inappropriate laws coupled with underfunded and overcrowded prisons. As well, large numbers of individuals are in lengthy pre-trial detention. If treatment for drug dependency is provided in prison it is unlikely to be best practice. And in compulsory drug detention centres, which are still prevalent in China and South East Asia and hold over 600,000 people suspected of drug use, treatment comprises forced labour which is known to be ineffective in reducing drug use.
Over the last few decades, the catastrophic War on Drugs has targeted people who use drugs. They have been incarcerated in profoundly misguided and harmful approaches instead of receiving substance use treatment. Mass incarceration has destroyed countless individual lives, had lasting negative effects on prisoners’ families and communities, and, in many settings, increased community rates of HIV, tuberculosis, multidrug-resistant tuberculosis, and hepatitis C.
A special six part Lancet series on HIV, hepatitis C, hepatitis B and TB in the world’s prisons was launched at the AIDS Conference. The collection of papers make grim reading.
While there are approximately 10 million people in prison today, it is estimated that up to three times that number - 30 million people - enter and leave prison each year. This equates to 4.5 million people with hepatitis C, almost one million with HIV and 1.5 million with hepatitis B infection being detained annually. In most countries though, these people are detained without access to life saving treatment for these infections. Those who enter prison uninfected are at an elevated risk of becoming infected as few countries provide the range of prevention programs required to halt transmission inside. Mr Leonard Rubenstein, lead author on the paper addressing human rights in the series, calls the lack of access to treatment and prevention programs a pervasive human rights violation.
One of the most striking findings from the series is that the prevalence of hepatitis C infection exceeds 10% in prison populations in six of the nine regions in the world (See graph 1). This elevated level is almost entirely due to the mass incarceration of people who inject drugs and the high levels of hepatitis C among them. Worldwide, between 50% and 90% of people who inject drugs will be incarcerated at some point. In parts of Europe, over a third of inmates have a history of drug injection and in Australia it’s about half of inmates. This is in stark contrast with levels of drug injection in the general population which are less than half of one per cent in Europe and Australia.
HIV, HCV, HBV & TB prevalence by region
While those in the community may not feel at risk, virtually all inmates are released back to their communities and cycle in and out of prison frequently. Most prisoners serve short sentences of about six months or less and are at high risk of becoming infected while inside.
The first step in addressing HIV and related infectious diseases among those incarcerated is to reduce the numbers of people in prison and detention for substance use, sex work, and other non-violent offences. This effort will require policies that send fewer people to prison and for shorter prison sentences. This change can happen only if there is agreement on what prisons—and what imprisonment—are for. Conventionally, incarceration has had four possible goals: retribution (punishment); deterrence; incapacitation (stopping the prisoner from reoffending while they are in prison); and rehabilitation (reducing the risk that they will reoffend after release). The evidence for each of these goals is much less clear than it is often made out to be.
Legislators often cite public demand for retribution to justify long prison terms with harsh regimes. Yet research shows that they consistently overestimate public demand for harsh treatment and for retribution rather than rehabilitation.
While Australia has led the way in the control of HIV in prison, it still has to control hepatitis B and hepatitis C. UNSW research found the 14 out of every 100 persons who injects drug acquires hepatitis C in NSW prisons each year (Luciano et al., 2014). We still have very patchy coverage of treatment and prevention in Australian prisons. And we have some communities who are very high risk of imprisonment in Australia – aboriginal communities.
It is past time for a rethink on the uses of incarceration, and on ways of mitigating the effects mass incarceration has had on the overlapping epidemics we all seek to control.
Luciani, F. Bretana, NA. Teutsch, S. Amin, J. Topp, L. Dore, GJ. Maher, L. Dolan, K. & Lloyd AR. A prospective study of hepatitis C incidence in Australian prisoners. Addiction, 2014;1-12. <e3893>