Prisoners and detainees worldwide have higher burdens of HIV, viral hepatitis and tuberculosis than the communities from which they come, and the regular cycling of infected people in and out of incarceration is worsening the epidemics both inside and outside of prison, new Johns Hopkins Bloomberg School of Public Health-led research suggests.
The researchers, reporting July 17 in a series of studies on HIV and prisoners in The Lancet, say that while in many nations HIV and other infectious diseases can be controlled during incarceration, prisoners are often released home without access to medications that control their illnesses. In the case of HIV, newly released prisoners often see their viral loads spike, putting them at a greater risk of transmitting the virus to their partners or those with whom they share needles used for injecting drugs. Drug users who return to the community are also at an increased risk of sharing needles during the post-release period, and for overdose injuries, if their access to drug treatment is interrupted on release.
"There is a global standard that says that prisoners deserve the same standard of health care as the communities they come from," says Chris Beyrer, MD, MPH, the Desmond M. Tutu Professor of Public Health and Human Rights at the Bloomberg School and the guest editor of the Lancet series. "But in country after country, this standard is not being met, and our failure to handle the post-release linkage to care and services is the single most important thing that has to change. The idea that we can ignore these epidemics among prisoners is bad public health."
The global standards are named for the late Nelson Mandela, the former president of South Africa, who was a prisoner himself and contracted TB while incarcerated.
One of the Lancet papers finds that of the estimated 10.2 million people incarcerated worldwide on any given day in 2014, 389,000 (3.8 percent) live with HIV; 1,546,500 (15.1 percent) have hepatitis C; 491,000 (4.8 percent) have chronic hepatitis B; and 286,000 (2.8 percent) have active tuberculosis. Their findings come from a review of the scientific literature on infectious disease and prisoners, and mathematic modeling. In low- and middle-income countries, one study found, the prevalence of HIV in prisons is between 10 and 20 percent.
"Consistently, there is a much higher prevalence of HIV in prison settings relative to the general population," says Andrea L. Wirtz, PhD, one of the study's co-authors and an assistant scientist in the Department of Epidemiology at the Bloomberg School.
Research suggests that transmission within prisons is generally low, though hepatitis C is frequently spread through tattooing and TB can be spread through unsanitary conditions.
Meanwhile, in the United States, 14 percent of all people with HIV cycle through the criminal justice system every year, making health care in prison a major method of treatment including antiretroviral medication that reduces the risk of transmission, according to the scientists. The medications are often not available to prisoners upon their release. Risk of these infections increases with both increased frequency and duration of imprisonment.
At the same time, there are now drugs to cure hepatitis C, they say, and TB is becoming more drug resistant, making proper care of inmates more important than ever.
Decreasing the incarceration rate for people who inject drugs could reduce the burden of HIV among prisoners, the researchers contend. Their study looked at incarceration around the world and found that the U.S. rate of 716 incarcerated people per 100,000 is nearly five times the global average of 146 people per 100,000. The fact that African Americans in the United States are disproportionately represented inside prisons is driving the increasing rates of HIV among all African Americans. They also point out that while whites and blacks in the United States use drugs at similar rates, black men are nine times more likely to be incarcerated for drug offenses.
In 27 nations, the researchers say, drug users are detained in compulsory drug detention centers that in many cases are glorified labor camps and do not provide appropriate drug treatment. Decriminalizing drug use and possession of drugs in those nations—while providing drug treatment elsewhere—could tamp down the spread of infections.
"We can and should do better to both reduce the numbers of those incarcerated and the length of their sentences and to improve prevention, treatment and post-release linkage to care for prison-associated infectious diseases," Beyrer says. "Meeting community health care standards in correctional settings, especially in low-income and middle-income countries will require political will, financial investment and support from medical and humanitarian organizations across the globe, but it can and must be done.
"Global control of HIV, viral hepatitis and tuberculosis will not be achieved without addressing the unmet health needs of prisoners."
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