From the beginning of the AIDS epidemic in 1981, the association between HIV, tuberculosis, and prisons was apparent,1 with HIV responsible for a steep rise in tuberculosis in US prison populations.2 This is important because the prevalence of HIV in prisons in many countries is high, with one review reporting levels greater than 10% in 20 low-income and middle-income countries.3 Several factors have a role in the epidemics of HIV, tuberculosis, and related infections in prisons.4 Many individuals who are most likely to be incarcerated are at greatest risk of these infections, whether because of injection drug use for HIV and viral hepatitis or poverty and overcrowding for tuberculosis. Drug injection is common in prison inmates, ranging from 2% to 38% in Europe, 34% in Canada, and up to 55% in Australia, in stark contrast with the percentage in the general population, estimated at 0·3% in the European Union and 0·2% in Australia.5 Prisons provide many opportunities both for the spread4 and prevention of these infections.6
The situation is complicated further by the expansion of parallel prison systems for those suspected of drug use in at least 27 countries. These compulsory drug detention centres operate extrajudicially and often under the guise of drug treatment (panel 1).20 Punishment and inhumane conditions are widespread, but evidence-based treatment for drug dependence and infectious diseases is rare or non-existent.7, 21 However, prisons not only pose a threat to the health of people incarcerated within them. They also pose a risk to staff and to the population at large, because detainees are not a static population, but move around the prison system and back and forth from the outside world.
The risks particularly lie at the interface between prisons and society outside. In the USA, HIV incidence is highest in detainees who were released and re-incarcerated compared with continuously incarcerated prisoners, people who inject drugs with no history of incarceration, and men who have sex with men (MSM; panel 2).4 The period immediately after release is especially risky for receptive syringe sharing, acquisition of HIV and hepatitis C virus (HCV), and mortality.29, 30, 31, 32 Thus, the transition between the prison and community settings represents a high-risk environment, especially for people with substance use disorders.31 This is important because, although an estimated 10·2 million people were incarcerated at any time in 2014, over 30 million individuals transition from prison to the community each year.33 Prisons act as incubators for tuberculosis and HIV, because they are associated with higher levels of infection than in the surrounding populations,3, 34 yet many countries have parallel and vertical systems, with fragmented policy responses to these interlinked issues—prisons, HIV, viral hepatitis, and tuberculosis—and interruptions of surveillance and treatment during transitions. This Series paper encourages a coordinated response by reviewing the global epidemiology of HIV, HCV, HBV, and tuberculosis in prison populations.35, 36
Key messages
- •
Prevalence of HIV, HCV, HBV, and tuberculosis is higher in prison populations than in the general population, mainly because of the criminalisation of drug use and the detention of people who inject or use drugs
- •
We strongly support the UN's 2012 call to close compulsory drug detention centres and expand voluntary, evidence-based treatment in the community
- •
Mathematical modelling suggests that incarceration and re-incarceration of people who inject drugs contributes to the overall HIV epidemic and a reduction in incarceration of this population will reduce the incidence of HIV
- •
Evidence-based prevention and treatment such as opioid agonist therapy and antiretroviral therapy can substantially reduce the incidence of HIV, HCV, and HBV, and reduce drug dependence in this population
- •
Responses to co-infection with HIV and tuberculosis should include an integrated, patient-centred model of prevention and care, with systematic screening of high-risk groups and equitable access to effective treatment
- •
The most effective way of controlling infection in prisoners and the broader community is to reduce mass incarceration of people who inject drugs