What happens to people living with HIV who inject drugs in prison?

Within-prison drug injection among HIV-infected Ukrainian prisoners: prevalence and correlates of an extremely high-risk behaviour.

Izenberg JM, Bachireddy C, Wickersham JA, Soule M, Kiriazova T, Dvoriak S, Altice FL. Int J Drug Policy. 2014 Sep;25(5):845-52. doi: 10.1016/j.drugpo.2014.02.010. Epub 2014 Feb 28.

Background: In Ukraine, HIV-infection, injection drug use, and incarceration are syndemic; however, few services are available to incarcerated people who inject drugs (PWIDs). While data are limited internationally, within-prison drug injection (WP-DI) appears widespread and may pose significant challenges in countries like Ukraine, where PWIDs contribute heavily to HIV incidence. To date, WP-DI has not been specifically examined among HIV-infected prisoners, the only persons that can transmit HIV.

Methods: A convenience sample of 97 HIV-infected adults recently released from prison within 1-12 months was recruited in two major Ukrainian cities. Post-release surveys inquired about WP-DI and injection equipment sharing, as well as current and prior drug use and injection, mental health, and access to within-prison treatment for HIV and other comorbidities. Logistic regression identified independent correlates of WP-DI.

Results: Complete data for WP-DI were available for 95 (97.9%) respondents. Overall, 54 (56.8%) reported WP-DI, among whom 40 (74.1%) shared injecting equipment with a mean of 4.4 (range 0-30) other injectors per needle/syringe. Independent correlates of WP-DI were recruitment in Kyiv (AOR 7.46, p=0.003), male gender (AOR 22.07, p=0.006), and active pre-incarceration opioid use (AOR 8.66, p=0.005).

Conclusions: Among these recently released HIV-infected prisoners, WP-DI and injection equipment sharing were frequent and involved many injecting partners per needle/syringe. The overwhelming majority of respondents reporting WP-DI used opioids both before and after incarceration, suggesting that implementation of evidence-based harm reduction practices, such as opioid substitution therapy and/or needle/syringe exchange programmes within prison, is crucial to addressing continuing HIV transmission among PWIDs within prison settings. The positive correlation between Kyiv site and WP-DI suggests that additional structural interventions may be useful.

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Editor’s notes: This is a powerful article contributing to the evidence base on the vulnerability of the health of people living in prisons. It highlights a particularly vulnerable sub-population of people living in prisons who are HIV positive. The study uses an innovative approach in recruiting a sample of people living with HIV recently released from prison, reporting a history of injecting drug use (n=95) on the basis that outside of prison people will be able to talk more freely about their drug use. The rationale for this study is simple: to document the existence of HIV risk associated with injecting drug use among people living in prisons. It is important since Ukraine and other countries of the former Soviet Union, have underplayed the need for HIV programmes including needle syringe programmes by denying that injecting drug use takes place in prison. This provides empirical evidence that it does, and among HIV positive people living in prisons, so the risk of HIV transmission to people who inject is high. It provides further evidence for the urgent need for HIV programmes among people who inject drugs  in prison. This is of particular relevance in the context of Ukraine, which has one of the fastest growing HIV epidemics globally, with infection driven by injecting drug use. The punitive approach to drug use in Ukraine is well highlighted through the study, by the fact that 76% of the sample were in prison on a drug-related charge. This paper confirms that injecting or other injecting risk behaviours occurred in prison, as has been evidenced elsewhere, and the majority of the sample injected prior to incarceration. It also shows that there is a lack of HIV programmes in place, particularly considering half the sample was aware of their diagnosis prior to imprisonment and the remainder found out while in prison. The study also shows a high prevalence of TB or history of TB (69%) but low levels of treatment while in prison. These illustrate a clear disregard for the health of people living in prisons, which is a breach of human rights, as well as being a poor public health strategy. Unlike other countries in the region, Ukraine does provide opiate substitution therapy to people who inject drugs, as part of an HIV prevention and treatment strategy. This paper provides further evidence for the need to extend this package of programmes to prison populations

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