Transcript Slide 27

Prevalence of and risk factors for blood-borne
viruses among prison inmates and entrants in
Ireland: an overview
Jean Long
• Prevalence of antibodies to hepatitis B, hepatitis C and HIV and
risk factors in Irish prisoners: results of a national cross
sectional survey (BMJ 2000;321:78-82)
Allwright S, Bradley F, Long J, Barry J, Thornton L, Parry JV.
• Prevalence of antibodies to hepatitis B, hepatitis C and HIV and
risk factors in entrants to Irish prisons: a national cross
sectional survey (BMJ 2001;323:1-6)
Long J, Allwright S, Barry J, Reaper-Reynolds S, Thornton L,
Bradley F, Parry JV.
• Prisoners’ views of injecting drug use and harm reduction in
Irish prisons (Journal of Drug Policy 2004; in press)
Long J, Allwright S, Begley C.
Acknowledgements
• Prisoners who participated
• Management and officers working in the participating prisons
• Department of Justice, Equality and Law Reform for allowing the
team access to the prisons and provided funding for two of the
studies
• Health Research Board in Ireland who provided funding for one
of these studies
• Administrative staff and data collectors employed by Trinity
College
Rationale for prevalence surveys
• Determine the prevalence of antibodies to hepatitis B
core antigen, hepatitis C virus and HIV
• Examine risk factors for infection
Methods for prevalence surveys
Cross-sectional study
Self completed anonymous, unlinked, risk factor questionnaire
Oral fluid specimen for antibody testing
• Inmates
• Entrants
– September to November 1998
– 6th April to 1st May 1999
– 9 of 15 prisons
– 5 of 7 prisons
– 2,680 prisoners on average per day – 11,000 entrants per year
– Sample required 1,200
– Sample required 534
Result 1 Response rates
• Inmates
– 1205 of the 1366 selected prisoners
participated (88%)
• Entrants
– 607 of the 627 available prisoners
took part (97%)
Results 2 Respondents characteristics
• Inmates
– Median age of
respondents was 25
years (range 16 to 67)
– 57 (4.8%) were women
• Entrants
– Median age (range) was
23 years (range 15 to
73).
– 41 (7%) were women
– One third (197/591) had
never previously been in
prison
Results 3 Injecting drug use
• Inmates
– 43.2% ( 509/ 1178) had
ever injected
– 20.8% ( 104/501 )
started injecting in prison
• Entrants
– 7% (14/197) of those
entering prison for the
first time reported ever
injecting drugs vs 40%
(157/394) of those
previously in prison
– 18.5% ( 29/157) started
injecting in prison
Results 4 Prevalence of blood-borne viruses among
prisoners in Ireland
37
40
35
30
21.8
25
Inmates (n=1193)
Entrants (n=596)
20
15
10
8.7
6.2
2
2
5
0
Hepatitis B
Hepatitis C
HIV
Results 5 Injectors versus non injectors in the
inmates survey
90
81.3
80
70
Percentage
60
50
Injectors
Non injectors
40
30
20
10
18.5
1.5
3.7
Hepatitis B
Hepatitis C
3.5
0.9
0
HIV
Results 6 Injectors versus non injectors in the
entrants survey
80
71.7
70
Percentage
60
50
Injectors
Non injectors
40
30
20
10
0
17.9
1.2
1.4
Hepatitis B
Hepatitis C
5.8
0.5
HIV
Percentage
Prevalence of blood-borne viruses among injector
prisoners in the Republic of Ireland
90
80
70
60
50
40
30
20
10
0
81.3
71.7
Inmates (n=509)
Entrants (n=173)
18.5 17.9
3.5
Hepatitis B
Hepatitis C
5.8
HIV
Risk factors for hepatitis C among injectors
• Sharing needles in prison (odds ratio 4 times more
likely)
• Ever had hepatitis B vaccine (odds ratio 2 times more
likely)
• Spent more than three months in prison (odds ratio 2
times more likely, not significant)
Slide 27
Total
Positive
Antibodies to hepatitis C virus (531/666)
Survey
Census
509
414
Committal
157
117
Prison
Outside Dublin
100
67
Dublin
566
464
Age group
<30 years
514
411
>30 years
125
97
Months spent in prison over the last 10 years
<3 months
56
26
3-11 months
68
50
12-36 months
171
135
> 36 months
353
310
Missing
Years since first injecting
< 3 years
> 3 years
Sharing needles in prison
No
Yes
18
Prevalence
Odds ratio
(95% CI)
pvalue
74.5
81.3
1
1 (0.6-1.6)
1.0
67.0
82.0
1
1.9 (1.0-3.5)
0.05
80.0
77.6
1
0.8 (0.4-1.4)
0.3
46.4
73.5
79.0
87.8
1
2.1 (0.9-5.2)
1.9 (0.9-4.0)
2.1 (0.9-4.5)
0.1
0.1
0.07
0.09
130
493
83
414
63.9
84.0
1
1.6 (0.9-2.7)
239
409
149
371
62.3
90.7
1
4.2 (2.5-7.2)
One or more doses of hepatitis B vaccine
No
258
181
Yes
373
325
2
Whole model  =85.4, p0.0001
70.2
87.1
1
2.0 (1.2-3.2)
<0.00
01
0.007
Risk factors for hepatitis C among non injectors
• Increasing time spent in prison
• Smoking heroin in the year prior to the survey (4
times more likely)
• Testing positive for hepatitis B core antigen 12 times
more likely)
Slide 28
Total
Positive
Prevalence
Odds ratio
(95% CI)
Antibodies to hepatitis C virus (30/905) among non injectors
Survey
Census
669
25
3.7
1
Committal
236
5
2.1
1.1 (0.4-2.9)
Months spent in prison over the last 10 years
<3 months
154
2
1.3
1
3-11 months
190
5
2.6
2.4 (0.5-18.3)
12-36 months
230
5
2.2
1.5 (0.3-11.4)
> 36 months
267
18
6.7
5.2 (1.3-35.2)
Smoked heroin in the previous 12 months
No
756
17
2.3
1
Yes
145
13
9.0
3.6 (1.6-7.7)
Oral fluid positive for anti-HBc
No
893
27
3.0
1
12.4 (2.4-52.4)
Yes
12
3
25.0
2
Whole model
 = 29.0 p <0.0001
p-value
0.9
0.3
0.6
0.04
0.001
0.001
Study objective
• Document injecting practices in prison versus outside
prison
Methods
• Grounded theory approach was employed
– Prisoners expert witnesses
• Purposive sampling
– Injectors (16) and non injectors (15)
• Detained in two prisons
Methods (cont)
• April and May 2000
• Semi-structured questionnaire and topic guide
– Taped interviews
– Topic guide developed as new issues emerged
• Interviews transcribed
• Data entered into ethnograph and coded
• Audit trail maintained
– Codes to categories to themes
Respondents’ characteristics (n=31)
• Male: 31 (100%)
• Median age in years (range): 26 (18 to 37)
• Residence in Dublin: 21 (68%)
• Completed second level education: 2 (6.5%)
• Spent 3 of the last 10 years in prison: 21 (68%)
• Crime related to drug or alcohol misuse: 23 (75%)
• Ever injected: 16 (52%)
• Ever used heroin: 24 (77%)
• Problematic alcohol misuse: 5 (16%)
1. Injectors take risks during detention that they
would not take outside prison.
A. The low availability of heroin encouraged the
change from smoking heroin to injecting it
“
...I was only in ((prison)) off the streets …. at the time and I had a
couple of, em, mates here … and they were getting heroin in and
they were more or less sayin' "well we haven't really got it to give it
to you to smoke, but there's a turn on ((heroin taken by injection))
there if you want it”, you know what I mean?
”
B. Those who own a syringe and needle rent them
to other injectors as a means of acquiring the drugs
to maintain their habit
“
If you own a syringe in here you can feed a habit, you can keep
your habit going ‘cos every day of the week someone's going to
come to you with heroin and say "listen, I have gear ((heroin)),
do you want a bit of it for a lend of your syringe" and that's the
way things work, you know?
”
C. Scarcity of injecting equipment meant that
sharing circles were far wider than outside prison
“ Yeah well, ah yeah, well it's obvious the risk factors are an
awful lot higher for the simple reason, there's only a certain
amount of needles and syringes in prison.
There'd be people I'd be wary of sharing with, but there'd be
days ((in prison)) when things'd be that bad that you'd have to
use it 'cos you'd be that sick ((suffering from withdrawals)), that
craving, you know? Well, you'd know people who'd have one
((needle and syringe)) and you'd approach them and ask them
for a lend of it. Now you'd know yourself that it's probably after
being around the prison for years….
”
D. Cleaning practices were inadequate for injecting
equipment
“
Just water, just ……
……Give them a good rinse. Oh, er, like I'd put a bit of bleach on it
or something, but, em, it wouldn't make any difference, no, I'd
still just rinse it out before I'd do anything. ……er, I wouldn't use
straight after anybody, even rinsing it, …..it's all to put me mind
at ease, you what I mean?
”
Non injectors reported observations were
consistent with injectors reported practices
“
…..Out in the yard and there's, er, ten or twelve of them sitting
in circles, ganged up together and they've got two syringes and
they've got a milk carton ((for the water to clean the needle and
syringe)) and they've water and probably a jam tray ((used to
cook the heroin)) or something and they're shooting heroin on
the jam tray and they're just dipping it ((needle)) in the water
and that's it, that's how they're cleaning it……
”
Conclusion and recommendations at the time of
the studies:
• Prison is a high risk environment for hepatitis:
– Infection control
– Harm reduction (injectors and non injectors)
• Including drug treatment services
– Surveillance
What has happened since these studies?
• Between 1997 and 2000, the Irish Prison Service commissioned
a number of studies
• During 2000 and 2001, the Irish Prison Service along with other
agencies developed both drug treatment service plans and
health care plans
• Introduced of:
– Evidence based methadone treatment services; expansion
of drug free units; provision of hepatitis B vaccine; and
employment of registered nurses
• There is, of course, much more to do….
– Harm reduction, hepatitis C and STI treatment, drug free treatment and
mental health care
• Need for routine health care and drug treatment information