1. 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

2. 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

3. 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.

4. 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.

5. 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 http://www.unaids.org/en/regionscountries/countries/ Imprisonment rates from the International centre for prison studies http://www.prisonstudies.org/info/worldbrief/

6. Results Identified 4,640 peer reviewed papers and 8,292 documents Total number of documents used was 261 10 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

7. Imprisonment rates for each Region per 100,000 adult popn Imprisonment rateNo. of countriesRegion 18220 East/ Southern Africa 6825 West/Central Africa 12935 Asia and Pacific 33216 Caribbean 22030 Eastern Europe and Central Asia 21017 Latin American 12821 Middle East and North African 12722 Other Countries 144196 Total

8. Data located on HIV prevalence for each region and key populations HIV prevalence among inmates No. of countriesRegion MSMPWIDsFemaleMaleAll 11661020 East/ Southern Africa 1221225 West/Central Africa 154835 Asia and Pacific 116 Caribbean 3661230 Eastern Europe and Central Asia 34317 Latin American* 234721 Middle East and North African 2112622 Other Countries 39262858196 Total

9. Range of HIV prevalence for each Region by sex and all prison popn % All Male % female %Region 6 – 340 - 50 2 – 75 East/ Southern Africa 1 – 193 - 5 0 – 17 West/Central Africa 0 – 290 - 2 0 – 30 Asia and Pacific 4-- Caribbean 0 – 151 - 33 1 - 38 Eastern Europe and Central Asia 0 – 120 - 18 1 – 4 Latin American 0 - 40 - 1 0 – 4 Middle East and North African 0 - 81 - 4 1 - 2 Other Countries

10. Range of HIV prevalence in prison populations East and Southern Africa % Ethiopia8 Kenya6 – 27 Malawi41 - 42 Mauritius23 Mozambique17 Rwanda2 - 8 South Africa16 Swaziland0 - 75 Uganda11 - 13 Tanzania5 - 15 Zambia26 - 42

11. 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

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

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

14. Range of HIV prevalence in prison populations Eastern Europe and Central Asia % Azerbaijan 3 Estonia 1 - 38 Georgia 0 - 5 Hungary 1 Kazakhstan 2 - 12 Latvia 6 Lithuania 4 Moldova 1 - 3 Romania 1 – 10 Tajikistan 6 - 18 Ukraine 12 - 33

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

16. 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

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

18. 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

19. HIV incidence in prison CountryYear% among males % among females % of total prisoners Number of cases Mozambique2008-120.230.260.24 Kazakhstan 2008 77 2009 75 2010 43 Latvia 2008 0.2 2009 0.16 2010 0.17 Lithuania 2008 1 2009 10 2010 28 2011 0.4 Romania 20080.18 20090.15 20100.11 20110.11 20120.16

20. HIV incidence in prison CountryYear% among males% among females % of total prisoners Number of cases Spain 20080.09 20090.0 20100.0 20110.04 20120.02 Moldova2012 12 Russia2008 229 Tajikistan2009 258 (m) 2010 279 (m) 21 (f) 2011 475 (m) 28 (f) 2012 514 (m) 29(f) Ukraine2008 0.9961 2009 0.82318 2010 11.23690 2011 10.42819 2012 10.6 Afghanistan 2008 1 (M) 0 (F) 2009 21 (M) 0 (F) 2010 6 (m) 1(F) 2011 0 (M) 1(F) 2012 7 (M) 0 (F)

21. AIDS related mortality in prison populations CountryYear% among malesNumber of cases among males Republic of Moldova 2008 2009 2011 12.7% 10.5% 22.9% Romania2008 2009 2010 2011 2012 3103331033 Russian Federation 2008 128 Ukraine2008 2009 2010 2011 2012 85 169 180 388 313

23. Summary of the number of countries per Region with HIV programs

24. 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.

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