Transcript Slides - View the full AIDS 2016 programme

HIV and Related Infections
in Prisoners
The Perfect Storm:
Incarceration and the High Risk
Environment Perpetuating HIV, HCV
and Tuberculosis in Eastern Europe
and Central Asia
HIV and related infections in prisoners
Authors and Affiliations
•
•
•
•
•
•
•
•
•
•
•
•
•
•
,
Frederick L Altice: Yale University, USA
Lyuba Azbel: Yale University (USA) & London School of Tropical Hygiene
Jack Stone: Imperial College, UK
Ellen Brooks-Pollock: Imperial College, UK
Pavlo Smyrnov: Ukrainian Alliance for Public Health, Ukraine
Sergii Dvoriak: Ukrainian Institute of Public Health Policy, Ukraine
Faye S. Taxman: George Mason University, USA
Nabila El-Bassel: Columbia University, USA
Natasha Martin: USCD, USA & Imperial College, UK
Robert Booth: University of Colorado, USA
Heino Stover: University of Frankfurt, Germany
Kate Dolan: University of New South Wales, Australia
Peter Vickerman: Imperial College, London
Acknowledgements toUNODC: Ehab Saleh & Signe Rotberga
HIV and related infections in prisoners
Percent Change in New HIV infections: 2005 to 2015
Eastern Europe and Central Asia: Historical Context
• 15 UNAIDS-Designated EECA Countries – evolved from dissolution of the
Soviet Union in 1991
• Diverse cultures and religions with distinct political, economic and social
trajectories after independence
• They share socio-political, philosophical and organizational vestiges of the
former Soviet Union that now shape the synergistic epidemics of mass
incarceration, substance use disorders, and infectious diseases (HIV, viral
hepatitis and TB)
• Aside from Russian and the 3 Baltic countries, the other 11 EECA countries are
LMIC
• After the collapse of the Soviet Union, heroin routes opened along the
Northern and Balkan routes, resulting in an expanding opioid epidemic, with
high levels of drug injection and transmission of blood-borne infections
Evolving Epidemics in EECA
• Criminal Transitions: After the collapse of the Soviet Union, laws and
policing markedly changed to address the opioid trade and other
criminal activities, resulting in massive and unprecedented
incarceration, especially of PWID
• HIV (and HCV) incidence markedly increased in PWID, who
increasingly became incarcerated, with suboptimal availability of
proven HIV prevention strategies like OAT, NSP and ART
• The Soviet healthcare system, including within prisons, disintegrated
with inadequate TB medications and treatment default, giving rise to
both community and prison-related MDR/XDR TB, which is three-fold
higher in prisons than in the community
Research Strategy
• Comprehensive review of the literature and survey of grey literature
and country websites in English and Russian
• In collaboration with UNODC, we conducted a standardized survey
of prisons assessing the criminal justice system: organization;
“registered” patients with HIV, HCV and TB; treatment and
prevention interventions and numbers on treatment
• Ukraine case study: statistical analyses and mathematical modeling
from serial national biobehavioral surveys of PWID, comprehensive
2015 national survey of PWID and 2011 national survey of prisoners
to assess the population attributable fraction (PAF) of incarceration
on new HIV infections in PWID and PAF of incarceration on TB in
PWID and the general community over a 15-year horizon
Concentration
Laws and policing selects members
with poor health status and/or at
risk for HIV, TB, or viral hepatitis
Amplification
Deterioration
Prison Environment
In
High risk behaviors,
new social networks,
transmission to new
community members
Dissemination
Community
Post-Release
Morbidity and Mortality
Community Risk Environment
Macro Factors
Micro Factors
Economic
- Housing, employment challenges
- Funding for OAT, NSP, ART
- Economic vulnerability
- Individuals costs  corruption
Social
- Family structure/support
- Stigma of drug users, SW, OAT
- Homelessness
- Injection networks
- Sexual networks
- Loneliness & isolation
Policy
- Official “registration” for addiction & HIV
- Laws governing drug use
- Alternatives to incarceration
- Policing activities
- Availability and coverage of OAT, NSP, ART
- Eligibility for OAT and ART
Physical
- Population mobility/migration
- Access to transport routes/drug markets
- Local displacement of PWIDs
- Venues for drug injection
- Prevalence of PWID and HIV in the community
and in key populations
Amplifying HIV Risk and
Prevention in Prisons
Prison Risk Environment
Macro Factors
Micro Factors
- High levels of within prison drug injection
- Funding for OAT & Harm Reduction/HIV
prevention & treatment services
- Economically and socially disempowered
populations concentrated within prison
•
•
•
- Exclusion from social participation and
meaningful social roles
- Disruption of social & risk networks
- Gender inequalities and gendered risk
- Ethnic inequalities
-Prison staff and peer stigma, attitudes, and myths
about OAT, PLH, and PWIDs
- Social norms & networks of PWIDs &PLH
- Lack of social support
- Prison hierarchy (caste)
Policy
- Policies governing OAT, NSP, condoms, ART
- Health and human rights policies toward
prisoners
- Transitional care services
- Dosing of OAT
- Availability & quality of free OAT, NSP, condoms,
ART
- Screening policies for IDU & HIV
Physical
- OAT engagement (prison vs. community)
- Location within drug trade routes
- Prison population mixing
- OAT/NSP dispensing practices
- Availability of transitional/continuous care
- Location of OAT, ART, NSP sites
- Injection locations
- Spatial inequalities
- Prevalence of WP-DI & HIV
Economic
Social
Within prison drug trade run by prison mafia
Economic vulnerability within prison
Discrimination for within prison employment
opportunities
Possible Mechanisms
- Increases exposure to drugs
- Factors that contribute to entry into drug use and SW
- Reduces safety and increases violence toward PWID, PLH
and SWs
- Decreases ability to reduce risk by negotiating safer injection
practices, negotiating condom use and avoiding violence
- Social stigma and marginalization drives risk underground
and not amenable to prevention and treatment services
Drug Use & HIV Vulnerability
Opportunities for Prevention & Intervention
- Expanded OAT, NSP, ART in both community and prison
settings
- Changes in laws that govern drug use
- Interventions with police; introduction of alternatives to
incarceration (drug courts, probation, parole)
- Interventions to rebrand OAT to reduce staff & peer stigma
- Interventions to reduce isolation and stigma of OAT patients
- Gender-based equality and empowerment efforts
- Removal of names-based “registries” for HIV and addiction
Drug Use & HIV Vulnerability
Possible Mechanisms
- Stigma increases social and economic vulnerability
- Increases substance use from despair and lack of social
support
- Increases within prison drug injection / initiation
- Increases injection risks and transmission of blood-borne
viruses
- Discourages OAT entry and retention
- Decreased opportunities to negotiate protective practices
- Increases vulnerability to violence
- Increases likelihood of recidivism
- Increases within prison HIV transmission
- Relapse to drug use after release, overdose
- Stop taking ART after release
HIV, HCV, TB and Opioid Use Disorders
• Opioid use disorders: 30-50% of prisoners are PWID (mostly opioids)
• High levels of within-prison drug injection
• Historical role of Narcology and attitudes toward opioid agonist treatments
• HIV: about 50% of PLWHA know their diagnosis, but the HIV continuum varies
greatly thereafter
• HCV: prevalence 30-60% of all prisoners, but testing is uncommon and no
treatment available aside from a HCV elimination program in Georgia
• In EECA, incarceration is associated with TB and MDR/XDR TB with MDR TB
typically 3-fold higher in prisoners than in the community
•
•
•
•
Inadequate diagnostics and treatment algorithms, especially with HIV/TB
Inadequate supply of medications
Enabling environment that promotes MDR TB
Inadequate transitional services
• Multiple structures and oversight undermine care in the CJS
HIV in Prisons in Countries of Eastern
Europe and Central Asia
HIV and related infections in prisoners
19.4
HIV Prevalence (%) in Prisoners
20
20.4
15
14.1
10.3
10
6.5
5
4.1
3.8
4.7
3.9
1.9
0
0
?
?0
2.4
2.4
0.4
TUR RUS BEL GEO LIT
UKR LAT AZE KAZ EST MOL KYR UZB ARM TAJ
Concentration of PLWHA in Prisons
Compared to the Community
50.0
Fold-Increase in PLWHA in Prisons
51.5
40.0
37.0
34.0
29.1
30.0
23.5
19.5
20.0
16.2
10.0
6.0
3.0
0.0
0.0
?
14.1
12.0
4.3
6.0
0.0
?
TUR RUS BEL GEO LIT
UKR LAT AZE KAZ EST MOL KYR UZB ARM TAJ
HIV Prevention Strategies in Prisons in
Countries of Eastern Europe and Central Asia
HIV and related infections in prisoners
Incarceration per 100,000 population
600
No Opioid Agonist Treatments in CJS (N=7)
500
Mean Global Incarceration Rate: 144/100,000 population
400
Account for over 85% of all prisoners
living with HIV in the region
300
200
100
0
TUR RUS UKR BEL GEO LIT LAT AZE KAZ EST MOL KYR UZB ARM TAJ
Incarceration per 100,000 population
600
500
Opioid Agonist Treatments Only
Within Police Lock-Up (N=3)
400
300
200
100
0
TUR RUS UKR BEL GEO LIT LAT AZE KAZ EST MOL KYR UZB ARM TAJ
Incarceration per 100,000 population
600
Opioid Agonist Treatments in Prison (N=5)
500
400
• PWID account for >30% of prisoners in most EECA countries
• When available, OAT coverage is <1% and mostly as pilot
programs
• Some prison OAT programs discontinue treatment before
release or do not have transitional services
300
200
100
0
TUR RUS UKR BEL GEO LIT LAT AZE KAZ EST MOL KYR UZB ARM TAJ
Incarceration per 100,000 population
600
Needle/Syringe Programs in Prison (N=5)
500
400
300
200
100
0
TUR RUS UKR BEL GEO LIT LAT AZE KAZ EST MOL KYR UZB ARM TAJ
Incarceration per 100,000 population
600
500
400
Provides ALL 15 Recommended
HIV Prevention Interventions (N=3)
• See Panel 2: Candles Burning in the Night
• Small countries that have boldly introduced these programs
with international funding despite regional pressures
• These programs are now in jeopardy
300
200
100
0
TUR RUS UKR BEL GEO LIT LAT AZE KAZ EST MOL KYR UZB ARM TAJ
Ukraine Case Study
• Lower middle-income country embroiled in political/economic conflict
• 45 million people with highest adult HIV prevalence (1.2%) in EECA
• 310,000 estimated PWID
•
•
•
•
HIV prevalence: 15% to 45%
Proportion on OAT: 2.7%
Proportion on ART: <5% (only 20% of all PLWHA)
Ever incarcerated: at least 52%, with an average of 5 incarcerations, 1 year each
• HIV prevalence higher in previously incarcerated PWID (28% vs 13%)
• Compared to PWID never incarcerated, previously incarcerated PWID had
much higher HIV risk behaviors, but it was mostly heightened in the 12
months after release and then returned to pre-incarceration risk levels
HIV and related infections in prisoners
Figure 2
Stone, Jack et al
Abstract: WE-AC-04 (Session Room 2), 16:30-18:00
HIV and related infections in prisoners
The Lancet DOI: (10.1016/S0140-6736(16)30856-X)
Figure 3
Incarceration and Contribution to TB in Ukraine
PWID
6% relative
increase/year
Community
13% relative
increase/year
The Lancet DOI: (10.1016/S0140-6736(16)30856-X)
• Data derived from nationallyrepresentative prison1,2 and
PWID community surveys3
• Incarceration accounts for 6.2%
of all incident TB cases
(population-attributable
fraction)
• Among PWID, however,
incarceration contributes to 75%
of new TB cases in PWID with
HIV
1. Azbel L et al, PLoS One, 2013
2. Azbel L et al, JIAS, 2014
3. Makarenko J, DAD, 2016
Recommendations
• Reduce incarceration for key populations, especially PWID
• Introduce and scale-up HIV prevention with OAT, NSP and ART,
including effective transitional programs post-release
• Improve testing and treatment strategies (continuum of care)
for HIV, HCV and TB
• Eliminate the gap between prison and community treatment
and prevention services, including structural impediments for
service delivery and continuity
• Integrate services given the high rate of medical and psychiatric
co-morbidity
HIV and related infections in prisoners
Sasha’s Voice
• “Prisons here in Russia are places where people like me go to die.”
• “Many who went to the infirmary never left except in a pine box,
because their TB medications didn’t work anymore.”
• “We were 36 men in a closet with only 12 beds. We stood,
coughed on each other, while others slept in shifts. Most guys,
including me, would stop or dispose of our TB medications so that
we could get sick and move from our closet to the infirmary
where we’d get our own bed.”
1. Azbel L et al, PLoS One, 2013
2. Azbel L et al, JIAS, 2014
3. Makarenko J, DAD, 2016
HIV and related
infections in prisoners