Blood borne viruses in prison
Jeffrey Post
Infectious Diseases, Prince of Wales Hospital
The Albion Centre
Justice Health & Forensic Mental Health Network
University of NSW
It is said that no-one truly knows a
nation until one has been inside its
jails. A nation should not be judged
by how it treats its highest citizens,
but its lowest ones
Nelson Mandela
Outline
lEpidemiology
lOpportunities
¡Prevention
¡Treatment
lChallenges
Epidemiology
Rates of incarceration
lAustralia 152 per 100,000
lNew Zealand 202 per 100,000
lUSA 689 per 100,000
lhttp://www.prisonstudies.org/world-prison-brief
NSW prisons
l10578 in full-time custody
l2501 indigenous - overrepresented
l93.2% male
l75.8% prior imprisonment - recidivism
l26% unsentenced
l28.2% sentence <2 years
l2014 NSW Inmate Census
NSW prisons
lMany more come through the system
¡27% incarcerated < 8 days
¡17% 8-30 days
¡56% >30 days
¡only 10% >6 months
lMore than 146,000 movements
Corrections Health Service Corporate Plan 2003-2008
Prisoners are community members
lRelease associated with drug use risk
lOverdose
lUnsafe injecting practice
lBBV acquisition
Dolan K Lancet 2016;338:1089-1102
Imprisonment and drug use
lIn Australia up to 58% of prisoners report
lifetime IDU
Reekie JM Med J Aust. 2014;200:277-80.
BBV Prevalence in prisons
lAustralian prison entrants
ln=1742
l2004, 2007, 2010 – 2 week periods
lHIV: 0.4%
lHBV: HBcAb 21.7% HBsAg 2.3%
lHCV: 33.3 - 23.3% (57% in IDU)
Reekie JM Med J Aust. 2014;200:277-80.
HCV incidence in prison
lNSW
l210 IDUs in prisons followed for 4 years
lHCV incidence 14/100 person years
lBleach and Opioid Agonist Treatment
¡no effect seen on incidence but not powered
Luciani F. Addiction. 2014;109:1695-706.
HBV immunity in prisons
lAustralian males 18-58yo 46.4%
lLower rates of vaccine induced immunity
than general population
lMore past infection in 18-29 yo
Gidding HF. Epidemiol Infect. 2015;143:2813-21.
l2010, NSW, n=204
l52% HBV susceptible
Larney S. Med J Aust. 2013 Apr 15;198(7):376-9.
Risks for BBVs in prisoners
lQueensland
l1322 interviews
lLifetime IDU 55%
lLifetime in prison IDU 23%
¡Associated with:
l needle/syringe sharing (ARR 5.0)
l HCV exposure (ARR 1.47)
l tattoo in current prison sentence (ARR 2.19)
Kinner SA,. Drug Alcohol Depend. 2012;126:156-60.
IDU in the community
l382 Victorian community IDU
lHCV risks include incarceration (RR 1.34)
Miller ER, J Infect. 2009 May;58(5):375-82.
Co-morbidities in prisoners
l48.6% assessed or treated by a doctor for
a mental or emotional problem
Indig D NSW Inmate Health Survey 2009
The interrelated, negative correlation (i.e.
syndemic) of incarceration, substance abuse
disorders, mental illness, and infectious
diseases…complicate the optimal delivery of
medical care in prison settings…
Rich J Lancet 2016, 338:1103-1114
Opportunities - prevention
Needle and syringe programs
lEvidence of effect in preventing HIV
transmission
lLess certain for HCV transmission
lIn prisons in 8 countries
lNo reported seroconversions
lNo reported use as weapons
lReduced needle and syringe sharing
lKamarulzaman Lancet 2016; 388:1115-26
NSP in Australia
lAvailable to PWID in the community
lNot available to PWID in prison
lEndorsed by WHO, AMA, RACP, etc
lConcerns raised about security
lCall for a trial in ACT
Stoove M, Med J Aust 2015; 203:319-320
Opioid agonist therapies
lReduces drug injection and HIV
transmission
lLess certain effect on HCV transmission
lIn prison – reduces heroin use, syringe
sharing and in-prison IDU
lContinuation after release reduces drug-
related mortality risk 8 times
lKamarulzaman Lancet 2016; 388:1115-26
Education
lPeer based education can reduce risk
behaviours
BBV testing
lOpt out HIV testing better uptake than opt-
in
lConcerns re stigma and discrimination
lPrison diagnosis as an entry point to care
lDiagnosis alters risk behaviours
Kamarulzaman Lancet 2016; 388:1115-26
lTest and treat elimination strategies
dependent on diagnosis
Condoms
lEffective
lHave been safely implemented despite
concerns about use as weapons and for
concealment of contraband
HBV immunisation
lAccelerated immunisation schedules
¡3 weeks or 2 months, meta-analysis
¡Short term good anti-HBs titres
¡Less good at 6 months
¡Need long term data
Jin PLoS One. 2015 Jul 21;10(7):e0133464.
¡2 month vs. 6 month in 707 IDU
¡Less infections in IDUs
¡Similar anti-HBs titre loss
Shah DP Am J Pub Health. 2015 Jun;105(6):e36-43.
Opportunities - treatment
(and treatment as prevention)
HCV treatment in prisons
lNurse led model of care
lNSW, n=391
l108 started treatment
lPEG-IFN and RBV mainly
lSVR in those with follow-up 69%
lSAE 12%, discontinuation 7%
lSafe and effective
Lloyd AR. Clin Infect Dis. 2013 Apr;56(8):1078-84.
HCV treatment in prisons
lNSW HCV treatment program
lMainly PEG-IFN and RBV
ln=788, Indigenous 136, CALD 129
lIndigenous and CALD access and
outcomes similar to white patients
Post JJ. Med J Aust. 2013 Oct 7;199(7):464.
HIV treatment in prisons
lHIV PrEP not studied in prisons
lHIV PEP administered after needle and
syringe sharing
O'Sullivan BG. Med J Aust. 2003;178:546-9.
lHIV cART
HCV – treatment as prevention
lStudies ongoing
lUnlike HIV where chronic suppression is
needed HCV treatment is curative with no
ongoing infective risk so R0 would become
zero with treatment
lScale up/population coverage needed?
Challenges
lThe most effective way of controlling
infection in prisoners and the broader
community is to reduce mass incarceration
of people who inject drugs
Dolan K Lancet 2016;338:1089-1102
lDiscrimination
lPunishment above the sentence
lFear of prevention measures as weapons
Conclusions
lPrevention, diagnosis and treatment of
BBVs is feasible in prison populations
lOpportunity to provide care to people who
don’t access the health system easily