1. Lisbon Addictions Conference — 24 October 2017
ASSOCIATIONS OF HIV AND HCV WITH PRISON HISTORY AMONG PEOPLE WHO INJECT DRUGS IN EUROPE AND BEYOND
Lucas Wiessing (EMCDDA); Eleni Kalamera; Isabelle Giraudon; Linda Montanari; Anneli Uuskula; Kate Dolan; Adeeba Kamarulzaman; EMCDDA DRID study group; Magdalena Rosińska; Lavinius Sava; Ioanna Yiasemi; Luk van Baelen; Anastasios Fotiou; Anna Tarján; D’Jamila Garcia
Lisbon Addictions Conference — 24 October 2017

2. Disclosures No conflicts of interest reported:
Lucas Wiessing none; Eleni Kalamera none; Isabelle Giraudon none; Linda Montanari none; Anneli Uuskula none; Kate Dolan none; Adeeba Kamarulzaman none; EMCDDA DRID study group; Magdalena Rosińska none; Lavinius Sava none; Ioanna Yiasemi none; Luk van Baelen none; Anastasios Fotiou none; Anna Tarján none; Anda Kivite none; Ruth Zimmermann none; D’Jamila Garcia none

3. Background
People who inject drugs (PWID) are frequently incarcerated due to punitive drug laws
A history of incarceration is associated with elevated risks of drug-related problems including high HIV and HCV prevalence and other outcomes (overdose, injecting risk)

4. Aims
To evaluate the association between a history of incarceration and risk of HIV and HCV infection among PWID in Europe (EMCDDA data)
To put results in context of available data from other sources

5. Methods
Aggregate data from EMCDDA monitoring among PWID in 30 countries (EU+2), univariate odds ratio’s for HIV and HCV
Individual level data from a European collaboration of studies in PWID, adjusted odds ratio’s in meta-analysis for HIV, five countries
Ad hoc literature review and contact with key experts for examples from inside and outside Europe (Australia, Canada), for HIV, HCV, mortality and syringe sharing

6. 1. EMCDDA routine aggregated monitoring data, univariate odds ratio’s

7. Results
17 out of 30 countries provided aggregated HIV and/or HCV prevalence data among PWID for , by prison history (ever, never)
For HIV: total n=42479 PWID, ever in prison 27581, of whom HIV (6.2%); never in prison of whom HIV+ 934 (6.2%) – OR 0.99 (95%CI )
For HCV: total n=38956 PWID, ever in prison 25431, of whom HCV , (55.7%); never in prison of whom HCV (39.4%) – OR 1.93 (95%CI )
Among PWID ever in prison, HIV prevalence (0.3 to 64%, median 6.7%) and HCV prevalence (8 to 96%, median 68.5%) varied strongly between countries

8. Recruitment settings Drug treatment centres (DTC) – 5 countries
Needle and syringe programmes (NPS) /low threshold services (LTS) – 4 countries
Combined DTC + NSP/LTS – 4 countries
Combined NSP/LTS + not service based (street /RDS) – 2 countries
Not service based (street /RDS) – 2 countries
5 countries: only drug treatment centres (DTC); AU, BE, CY, GR, PT
4 countries: only needle and syringe programmes (NPS)/ or low threshold services (LTS); EE, LT, PL, DE
4 countries: DTC + NSP/LTS; UK, FR, HR, HU
2 countries: NSP/LTS + outside drug services (street); SE, LV
2 countries: outside drug services (street); RO, TU
RDS: respondent driven sampling

9. 28536
1124
1518
2071

13. Association between prior prison history and HIV infection among PWID in Europe, 2006-2015

14. Association between prior prison history and HCV infection among PWID in Europe, 2006-2015
Slovakia excluded for small n (n=58, OR=1.58, 95%CI )

15. Limitations
Studies are not always comparable between countries (recruitment in treatment, low-threshold services, respondent driven sampling etc. – however: same association seen in a number of countries and across two diseases)
Self-reported prison history may be concealed (however: that is likely to reduce associations)
About half of the 30 EMCDDA collaborating countries (EU+2) do not report data by prison history
No possibility to adjust odds ratio’s for potential confounders in multivariate analysis e.g. age (however: these data should serve as a warning sign, to be further studied)
The cross-sectional nature of the data does not allow inferences about causality
Part of the HIV data, in two countries, concern self-reported test results

16. 2. Individual data from a European collaboration of studies in PWID, adjusted odds ratio’s in meta-analysis for HIV, five countries

17. Association of prison history and HIV: meta-analysis of 9 PWID studies in West and Eastern Europe (Uuskula et al., in preparation)
AOR - adjusted for gender, age, duration of injecting

18. 3. Context from the literature on similar associations for HIV, HCV and other outcomes

19. Associations of prison history and HIV, and HCV among PWID in Greece, Spain, Canada, Australia
Greece: Fotiou et al. (Hepatology, Medicine and Policy, 2016), found similar results in multivariate analysis for PWID entering OST : prison history = 2 to 3 higher risk of HCV infection (regardless HIV infection status), national level 2013 data n=580
Athens: Sypsa et al, (JID 2017); Hatzakis et al, (Addiction 2015): 3320 PWID recruited through a high coverage community-based programme in Athens : 40% (♀) to 50% (♂) ever imprisoned / 11% (♀) to 20% (♂) in last 12 months Prison ever vs never for HIV infection:
Prevalence in Males ♂ : OR = 1.66 (95%CI 1.34 – 2.06)
Prevalence in Females ♀ : OR = 3.09 (95%CI 1.90 – 5.03)
Seroconversion: OR = 2.40 (95%CI 1.27–4.53)
Spain: HIV vs ever in prison (prevalence ratio = 2.03) (Folch, PMID )
Canada: Imprisonment associated with syringe sharing / sex risk p< (Werb, PMID )
Australia: HCV prevalence 13-22% higher for prison history (Chow, ISSN )

20. Other health outcomes associated with prison history?
Global review: mortality “Released prisoners are at increased risk for death following release from prison, particularly in the early period.” (Zlodre, PMCID: PMC )
Global review: structural sexual /injecting risks in female prisoners “Repeated cycles of arrest, incarceration, and release can be socially and economically destabilizing for women, exacerbating their HIV risk.” (Strathdee, PMID: )
Canada: syringe sharing and sexual risks “Incarceration was independently associated with risky needle sharing [after release] for HIV-infected and HIV-negative IDUs.” (Wood, PMCID: PMC )

21. Interventions in prisons to prevent infectious diseases in Europe (EU+2), 2016
Based on workbooks other information
Infectious diseases testing offered (anonymous and voluntary) in most countries (HIV, Hepatitis C and B, tuberculosis) (AT, BE, BG, HR, CY, CZ, EE, FI, FR, DE, EL, HU, IE, IT, LV, LT, LU, NL, NO, PL, PT, RO, SK, SE, UK.
No info/no clear info: MT, ES, TR, DK
It can be just available, offered or recommended
Hepatitis B:
Testing in 21 countries: AT, BE, CY, CZ (n=4889), EE (711 tests), FI, DE, EL, IE, IT, LV (24% tested), LT (97 tests), LU, NL, NO, PL, PT (close to 100%), SK, SL, SE (11494 tests), UK (opt-out programme in England)
Vaccination in 14 countries: BE, DK, EE (299 vaccinated), FI, FR, DE, IE, LU, NO, SL, ES, SE (5386 vaccines), TK, UK – Mainly just available, but in some countries vaccination target all seronegative prisoners, EE officials too; GE: risk groups, SI, SE: everybody; SP: people with a diagnosis of mental health disorder
Treatment in 7 countries: BE, HR, CY, HU (3 prisoners), SL, ES, UK
Hepatitis C:
Testing in 24 countries: AT, BE, HR, CY, CZ (n=4114), EE (2314 tests), FI, FR, DE, EL, HU (2419 prisoners), IT, LV (47%), LT (127 tests), LU, NL, NO, PL, PT (close to 100%), RO, SK, SL, SE (9107 tests), UK (opt-out programme in England)
Tested beteween 9% in LV to 90% in IT: not clear the denominator- low data quality
Treatment in 11 countries: AT, BE (interfuron), HR, CY, DE (antiviral therapy; N=118 in 7 Laender), EL, HU (137 prisoners), ES, SE, UK, LU
Problem of continuity of care: if treatment is interrupted after prison release
HIV:
Testing in 26 countries: AT, BE, BG, HR, CY, CZ, EE, FI, FR, DE, EL, HU, IE, IT, LV, LT, LU, NL, NO, PL, PT, RO, SK, SL, SE, UK.
Treatment in 14 countries: AT, BE, BG (41 subjects), HR (dual anti-viral therapy; 1 person treated and 6 awaiting), CY, EE, DE (N=142 in 6 Laender), EL, HU (20 prisoners), PL (227 inmates), PT (82%), RO (N=226 prisoners), ES, UK, LU
Condom distribution in 14 countries: AT, BE, BG, CZ, DK, EE, FI, FR, DE, LU, PT, RO, SL, ES
Prisons as places to reach drug users not in contact with other services
Awareness, training (if for staff) in 15 countries (AT, BE, BG, HR, DK, EE, DE, HU, IT, PT, RO, SK, SL, ES, TK)
Training for staff in 1 country - EE
Disinfectants:
BE: bleach and disinfectant tablets
LU: ascorbic acid, filters, sterile physiological water, antisepting wipes, small plasters
NO: chlorine/chloramine to disinfect equipment
RO: legal framework on disinfectants foreseen
SI: disinfectants n- latex glosses
England: tablets for sterilizing injecting equipment
Source: EMCDDA 2017 Health and Social Reponses to drug problems. A European Guide

22. Interventions around release from prison (‘through-care’) for drug users in Europe – number of countries reporting out of 30 (EU+2)

23. Coverage of opioid substitution treatment (percentage of estimated high-risk opioid users receiving the intervention)
EMCDDA 2017

24. Coverage of specialised syringe programmes: number of syringes provided per estimated injecting drug user
EMCDDA 2017

25. Conclusions
Strong associations exist between both HIV and HCV prevalence and prison history among PWID in Europe
There is a need to improve interventions to stop prison associated transmission, both in prison and/or after release
This includes offering in prisons: screening, referral, DAA for HCV or HIV treatment, together with prevention and harm reduction and “through-care” on release/transfer
This also includes attaining full coverage and quality of harm reduction and treatment for PWID in the community
Globally, large gaps in care and treatment for drug dependence and associated problems like HIV and HCV infection still exist in prisons, as well as in the community /post release (PMID: ISBN: )

26. Lancet 2016 global HIV in prisons review – Recommendations
Decriminalise minor drug offences—use, possession, and petty sale
Reduce the violence and other harms of drug policing
Make harm reduction measures a central pillar of health systems and drug policy
Invest in treatment for HIV, HCV infection, tuberculosis, and drug dependence
Ensure access to controlled drugs for medical use

27. Thank you for your attention Lucas. Wiessing@emcdda. europa
Thank you for your attention Acknowledgements DRID study group: nominated Drug-related infectious diseases national experts and the Reitox national focal points from the EU 28, Norway and Turkey, for annual reporting of the data to the EMCDDA

29. HIV prevalence (%) among people who have injected drugs less than 2 years, 2006-2015
Dear Eleni, can you please make bar charts in the same format as the other ones (or preferably give me the data in an excel file, I can make the barchart) selecting only the same countries as in the previous graphs for HIV and HCV and adding up all the local data or taking just national rather than having multiple data points per country. Let’s perhaps also select the same years as in the previous graphs, not just , to make everything consistent.

30. HCV antibody prevalence (%) among people who have injected drugs less than 2 years, 2006-2015