School of Public Health and Community Medicine HIV prevalence, incidence and mortality in prison: A global overview Professor Kate Dolan and Babak Moazen Program of International Research and Training National Drug and Alcohol Research Centre UNSW, Sydney, Australia

Background Prison settings have characteristics that increase HIV transmission Elevated levels of HIV, HBV, HCV, TB & mental illness Widespread risky behaviour, few prevention/treatment measures Unless HIV is controlled in prison it may be uncontrolled in the community Yet prison settings are a practical point of HIV prevention and treatment

Background Drug dependence key factor in prison growth US popn up 13% prison popn up 33% PWIDs prisoners up 43% 1/3 of 200,000 heroin users in US imprisoned annually 60% of PWIDs in a 12-city study been in prison Re-incarceration rates very high for PWIDs- In Australia, 84% of PWIDs inmates were re-incarcerated in 2 yrs of release versus 44% of all prisoners. They had a mean of 5 imprisonments.

Aim Global systematic review of the HIV situation in prisons on A.Imprisonment rates B HIV prevalence C HIV incidence D AIDS related mortality E Services provided in prison The time period under observation January 2008 to April 2013.

Methods A multilingual (English, German, Spanish, Croatian, French, Arabic, Portuguese and Russian) desk review of the literature A survey of UN staff and experts List of Countries from Imprisonment rates from the International centre for prison studies

Results Identified 4,640 peer reviewed papers and 8,292 documents Total number of documents used was million prisoners - 3 million on pre trial remand in the world BUT 30 million individuals enter and leave prison - 90% male The world average rate of incarceration was 144 per 100,000

Imprisonment rates for each Region per 100,000 adult popn Imprisonment rateNo. of countriesRegion East/ Southern Africa 6825 West/Central Africa Asia and Pacific Caribbean Eastern Europe and Central Asia Latin American Middle East and North African Other Countries Total

Data located on HIV prevalence for each region and key populations HIV prevalence among inmates No. of countriesRegion MSMPWIDsFemaleMaleAll East/ Southern Africa West/Central Africa Asia and Pacific 116 Caribbean Eastern Europe and Central Asia Latin American* Middle East and North African Other Countries Total

Range of HIV prevalence for each Region by sex and all prison popn % All Male % female %Region 6 – – 75 East/ Southern Africa 1 – – 17 West/Central Africa 0 – – 30 Asia and Pacific 4-- Caribbean 0 – Eastern Europe and Central Asia 0 – – 4 Latin American – 4 Middle East and North African Other Countries

Range of HIV prevalence in prison populations East and Southern Africa % Ethiopia8 Kenya6 – 27 Malawi Mauritius23 Mozambique17 Rwanda2 - 8 South Africa16 Swaziland Uganda Tanzania Zambia

Range of HIV prevalence in prison populations West and Central African Region % Burkina Faso5 Cameroon5-8 Cape Verdi2 Cote d’Ivoire3 – 17 DR Congo8 Ghana10-20 Mali0 - 3 Mauritania4 Niger3 Nigeria2 Senegal3 Togo7

Range of HIV prevalence in prison populations Asia and Pacific % Australia0 Cambodia3 China0 – 30 India6 – 10 Indonesia1 – 30 Malaysia6 Pakistan2 Sri Lanka0 Thailand3

Range of HIV prevalence in prison populations Caribbean % Saint Vincent and the Grenadines4

Range of HIV prevalence in prison populations Eastern Europe and Central Asia % Azerbaijan 3 Estonia Georgia Hungary 1 Kazakhstan Latvia 6 Lithuania 4 Moldova Romania 1 – 10 Tajikistan Ukraine

Range of HIV prevalence in prison populations Latin America % Argentina3 Brazil10 Chile2 Mexico1 - 12

Range of HIV prevalence in prison populations Middle East and North African Region % Afghanistan1 – 4 Egypt0 Iran0 – 2 Lebanon<1 Morocco< 1 Oman< 1 Saudi Arabia< 1

Range of HIV prevalence in prison populations Other Countries Region % Italy4 Luxembourg1 Netherlands0 Portugal6 Spain6 – 11 USA1

Outbreaks of HIV transmission in prison populations and in IDU prisoners Country incidence Thailand35/per 100 Lithuania 300 inmates infected in 6 months Doubled number of HIV cases Russia400 inmates infected in a few months IranTwo outbreaks with hundreds infected AustraliaAt least 4 up to 12 Scotland12 Afghanistan17

HIV incidence in prison CountryYear% among males % among females % of total prisoners Number of cases Mozambique Kazakhstan Latvia Lithuania Romania

HIV incidence in prison CountryYear% among males% among females % of total prisoners Number of cases Spain Moldova Russia Tajikistan (m) (m) 21 (f) (m) 28 (f) (m) 29(f) Ukraine Afghanistan (M) 0 (F) (M) 0 (F) (m) 1(F) (M) 1(F) (M) 0 (F)

AIDS related mortality in prison populations CountryYear% among malesNumber of cases among males Republic of Moldova % 10.5% 22.9% Romania Russian Federation Ukraine

Summary of the number of countries per Region with HIV programs

Conclusions and Recommendations Good prisoner health is good public health: High turnover of inmates mean diseases contracted inside leave prison. High imprisonment rates in regions- non custodial sentences Few data on prevalence, incidence and mortality Low prevalence in Latin & MENA time to intervene increase ARV, OST, condoms Reduce prison populations: OST in community, divert PWIDs Legal obligation to medical treatment same level as in the community. Compassionate release from prison for inmates in final stages of AIDS.

Acknowledgment Co-authors Atefeh Noori, Shadi Rahimzadeh, Farshad Farzadfar and Fabienne Hariga