One in nine people in prisons globally have a history of injecting drug use and their risk of HIV, viral hepatitis and tuberculosis is up to 45 times higher than in the general population.
Yet access to infectious disease prevention, treatment and harm reduction services remains woefully inadequate, with most countries failing to provide basic coverage, according to two landmark reviews published in the International Journal of Drug Policy.
Scientia Professor Louisa Degenhardt – Research Director at the National Drug and Alcohol Research Centre (NDARC), UNSW Sydney – said the findings confirmed that prison populations were a critical target group for eliminating HIV, viral hepatitis and tuberculosis.
“Prisons function as high-risk environments that amplify infectious disease transmission, which means we shouldn’t view this as just a prison health issue but a community-wide public health imperative,” said Professor Degenhardt, who was lead investigator.
“Routine HIV, viral hepatitis and tuberculosis screening, along with HBC vaccination and harm reduction programs, such as needle and syringe programs (NSPs) and opioid agonist treatment (OAT), should be standard practice.”
In the first systematic review, the international team of researchers used data from more than 2,900 papers and reports to estimate the global prevalence of injecting drug use and key infectious diseases among people who are incarcerated.
They found that of the 11.3 million people aged 15-64 years incarcerated globally, one in nine (11.9%) had ever injected drugs – a rate 51 times higher than in the general population.
The lifetime prevalence of injecting drug use varied substantially across regions, from 3% in Sub-Saharan Africa to 51% in Australasia.
The authors also found that nearly 4% of the global prison population are living with HIV, 11.7% have current hepatitis C virus (HCV) infection, 4.4% have current hepatitis B virus (HBV) infection, and 2.5% have active tuberculosis.
Compared to the general population, these prevalence rates among incarcerated people up to 16 times higher for viral hepatitis, 25 times higher for HIV, and 45 times higher for tuberculosis.
“The extraordinarily high burden of HIV, viral hepatitis and tuberculosis in carceral settings identified here poses a significant challenge to global disease elimination efforts,” Professor Degenhardt said.
But as the researchers found in their second systematic review, the availability of crucial interventions and treatments to reduce injecting drug-related harms was alarmingly low.
NDARC Postdoctoral Research Fellow Dr Thomas Santo Jr, who led this phase of the project, said many countries were failing to meet even the most basic standards of care.
“The global shortage of services that prevent and treat infectious disease and harms related to injecting drug use in carceral settings is a critical public health issue and, compared with community standards, a breach of human rights,” Dr Santo said.
For instance, OAT was available in at least one prison in 59 countries, yet only 20 countries covering 5% of the global incarcerated population had OAT available in all prisons.
Rarer still was access to NSPs, which were seen in one or more carceral settings in 10 countries, with just three – Luxembourg, San Marino and Spain – providing it in all prisons.
Furthermore, less than half of all countries had routine testing and treatment for HIV, viral hepatitis and tuberculosis available in one or more carceral settings.
“Fewer than 2% of the 11.3 million people incarcerated worldwide live in a country that offers any of these interventions in at least one prison facility,” Dr Santo said.
“This systemic global failure to provide essential services to a critical population not only exacerbates social and health inequity but also undermines efforts to curb the spread of these preventable infectious diseases in prisons and the wider community.”
The Australian context
The researchers said Australia stood out for the high rates of injecting drug use in prison populations – about one in two have ever injected drugs, including almost 70% of women.
Incarcerated people in Australia were also up to nine times more likely to be living with hepatitis C and HIV compared to the general population.
“Part of the problem is access to OAT in Australian prisons is inconsistent, while NSPs are virtually non-existent – two crucial interventions that not only cut the risk of overdose, but greatly reduce the likelihood of acquiring these blood-borne viruses,” Dr Santo said.
Another barrier was the fragmented provision of prison health care services itself.
“When someone enters prison in Australia, they lose access to Medicare and their health care shifts into separate state and territory prison health services,” Dr Santo said.
“That separation makes it harder to follow people through their treatment, to know who’s actually getting care and to make sure they’re supported when they return to the community.”
“Until we close that gap, people in prison and their families will continue to carry a heavy burden from infections, opioid dependence and other preventable health problems, and from the disruption this causes in their lives and communities.”
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