Section I: Vulnerable populations
Hepatitis B, hepatitis C, and HIV in correctional populations: a review of epidemiology and prevention
Weinbaum, Cindy Ma; Sabin, Keith Mb; Santibanez, Scott Sc
aDivision of Viral Hepatitis
bGlobal AIDS Program
cDivision of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA.
Correspondence to Cindy Weinbaum, MD, MPH, Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Road, MS G-37, Atlanta, GA 30333, USA. E-mail: email@example.com
The 2 million persons incarcerated in US prisons and jails are disproportionately affected by hepatitis B virus (HBV), hepatitis C virus (HCV) and HIV, with prevalences of infection two to ten times higher than in the general population. Infections are largely due to sex- and drug-related risk behaviors practised outside the correctional setting, although transmission of these infections has also been documented inside jails and prisons. Public health strategies to prevent morbidity and mortality from these infections should include hepatitis B vaccination, HCV and HIV testing and counseling, medical management of infected persons, and substance abuse treatment in incarcerated populations.
Individuals incarcerated in prisons and jails in the United States have a disproportionate burden of infectious diseases, including infections with hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV . Although incarcerated individuals comprise only approximately 0.8% of the US population, it is estimated that 12–15% of all Americans with chronic HBV infection, 39% of those with chronic HCV infection, and 20–26% of those with HIV infections have a history of incarceration [2,3].
Adult jail and prison populations totaled 2.03 million at the end of 2002, a 77% increase from 1990. Jails hold arrestees and individuals sentenced for less than one year; prisons hold inmates sentenced for one year or longer. Racial/ethnic minorities are overrepresented in national prison populations, which are 45% black, 34% white, 18% Hispanic, and 3% other races. Approximately 6.8% of adult prisoners are women, a 112% increase since 1990 [4,5]. Turnover in correctional facilities is rapid, with an estimated 12.6 million admissions and 12.6 million releases from local jails in 2000, and 663 500 admissions and 632 200 releases from prisons [1,2,6]. In addition to individuals institutionalized in the correctional system, over 4.7 million individuals were under community supervision (probation and parole) at year end 2002; this non-institutionalized population will not be discussed in this paper because of the lack of risk and disease-related data .
This paper will discuss the epidemiology of HBV, HCV, HIV, and HIV/HCV co-infections among inmates and releasees of correctional facilities, and strategies for the prevention of these infections in correctional settings.
HBV, HCV, and HIV are bloodborne pathogens. HBV and HIV are efficiently transmitted by percutaneous (e.g. needlestick) or permucosal exposure to infectious blood or body fluids (e.g. semen, vaginal fluid); HCV is most efficiently transmitted by percutaneous exposure to infectious blood. Of all acute hepatitis B cases reported in the United States, sexual contact accounts for more than half of all newly acquired infections; approximately 40% had recent heterosexual exposure to an infected partner or to multiple partners, and 15% were men who have sex with men (MSM). In addition, 14% of individuals with acute hepatitis B reported recent injection drug use . For hepatitis C cases, 60% are associated with injection drug use and 15% with sexual exposures. Among individuals with reported HIV infection, 51% reported sexual risk behaviors without injection drug use (33% MSM and 18% heterosexual), and 18% reported injection drug use .
A history of injection drug use is common in detainee and inmate populations compared with the rest of the US population. Among juvenile detainees, a history of injection drug use was reported by 3.3–6% [2,10]. Although surveys of adult prison inmates have not assessed injection drug use versus other drug use, 73–83% of prison inmates reported a history of drug use, and 45–57% reported the use of drugs in the month before their offence. Among arrestees, 9% (range 0–25%) of women and 7% (range 2–19%) of men entering 34 jails used injection drugs in the year before arrest; among adult jail inmates, current injection drug use was reported by 18%, and any drug use in the month before incarceration was reported by 55% [11–13]. Drug use also occurs inside correctional facilities: injection drug use during incarceration has been reported by 3–28% of adult inmates . By comparison, among non-institutionalized individuals in the United States, injection drug use was reported by approximately 0.15% annually among individuals aged 12 years and older .
Incarcerated populations are also at higher risk of the sexual transmission of disease than the non-institutionalized population. High rates of gonorrhea, Chlamydia, and syphilis have been described among entering inmates, and many inmates reported multiple sex partners and inconsistent condom use both before incarceration and after release [15–21]. Sexual behavior also occurs within correctional facilities. Although the frequency is difficult to quantify, 4–30% of inmates reported sex (oral or anal) while incarcerated [22–24]. The occurrence of sex in prison is evidenced by occasional outbreaks of sexually transmitted diseases in prisons .
Burden of disease
Hepatitis B virus
Approximately 5% of the civilian, non-institutionalized US population has serological evidence of past or present HBV infection, and 0.4–0.5% has chronic HBV infection. The overall prevalence of HBV infection differs among racial/ethnic populations, and is highest (40–70%) among individuals who have emigrated from areas with a high endemicity of HBV infection (e.g. Asia, Pacific Islands, Africa, Middle East). The prevalence of infection among black individuals (11.9%) is fivefold greater than among white individuals (2.6%) [25,26].
Among prison inmates, the prevalence of serological markers for current or past HBV infection is 13–47%, and varies by region. Prevalence is higher among women (37–47%) than men (13–32%). Chronic HBV infection is found in 1.0–3.7% of prison inmates, two to six times the US prevalence estimate, and is comparable to rates of chronic infection found in surveys of injection drug users (IDU) (5–10%), and among MSM (1.5–6%) .
Upon release, susceptible inmates may be at increased risk of transmission because they continue to practise high-risk behaviors. A study of recidivist women found an HBV seroconversion rate of 12.2 per 100 person-years between incarcerations , compared with an estimated incidence of 0.03 per 100 person-years among the general US population (G. Armstrong, CDC, personal communication, 2002).
Whereas the majority of HBV infections among incarcerated individuals are acquired in the community, transmission has been identified in prison, and incidence rates have ranged from 0.8 to 3.8% per year [2,28]. Among cases of acute hepatitis B reported to the Centers for Disease Control and Prevention (CDC)'s Sentinel Counties Study of Viral Hepatitis, 5.6% had a history of incarceration during the disease incubation period . HBV transmission in the prison setting most commonly occurs through sexual activity and injection drug use .
Hepatitis C virus
An estimated 3.9 million individuals (1.8%) in the civilian, non-institutionalized US population have been infected with HCV, of whom approximately 2.7 million (1.3%) are chronically infected. In 1990, two-thirds of individuals infected with HCV were aged 30–49 years. Black individuals had a higher prevalence of HCV infection than white individuals (3.2% compared with 1.5%), and men had a higher prevalence than women (2.5 versus 1.2%) .
The incidence of acute hepatitis C has declined by over 80% since 1989, primarily as a result of a decrease in cases among IDU . However, both the incidence and prevalence of HCV infection among IDU remain high. HCV infection is acquired more rapidly after the initiation of injection drug use than either HBV or HIV infection. The rate of acquisition of HCV infection among young IDU is four times higher than the rate of acquisition of HIV infection. In 1980s studies, approximately 80% of newly initiated IDU were infected with HCV within 2 years. More recent studies have suggested that the rate of HCV acquisition has declined; however, incidence remains high at 10–15% per year . Higher rates of HCV acquisition compared with other bloodborne pathogens are probably related to the high prevalence of chronic HCV infection among IDU, which results in a greater likelihood of exposure to an HCV-infected individual through the sharing of syringes and drug paraphernalia.
Among prison inmates, 16–41% have serological evidence of HCV infection, and approximately 12–35% have chronic HCV infection. Rates vary according to the percentage of IDU in the population and by geographical region. In a Wisconsin study of 1148 inmates, 13% were HCV positive. Of the 126 inmates (11%) reporting injection drug use, 74% were HCV positive; testing these inmates identified 61% of the prison's anti-HCV-positive population . When routine entry laboratory tests found an elevation of liver enzyme levels, these two criteria identified 80% of HCV-positive prisoners. Among HCV-positive inmates entering jail in Massachusetts, 21% were anti-HCV-positive, 84% of whom reported using ‘street drugs’ in the 3 months before incarceration and 49% of whom reported sharing needles .
The risk of HCV acquisition during incarceration is not well established. Two studies that examined the incidence of HCV infection among prison inmates found rates of 0.4–1.1 infections per 100 person-years of incarceration among men [28,32].
At the end of 2002, there were approximately 850 000–950 000 HIV-infected individuals in the United States, and an estimated 384 906 persons living with AIDS [9,33]. In 30 areas with longstanding confidential name-based HIV reporting, approximately 73% of individuals with HIV/AIDS were men, 50% were black, 38% were white, and 10% were Hispanic. Approximately 40 000 US residents become infected with HIV annually. AIDS incidence increased throughout the 1980s, declined from the mid-1990s to 1999, but has remained stable since then . HIV incidence among IDU has decreased since the mid-1980s but differs greatly by geographical area; in the 1990s, the incidence in the eastern United States was one to three cases per 100 person-years, compared with less than 0.5 per 100 person-years in the west. HIV incidence among military personnel and blood donors was less than 0.03 per 100 person-years, more than 100 times lower than that among MSM or IDU .
Whereas systematic HIV testing is not performed in all US prisons, prison systems report known HIV infections. The prevalence of known HIV infection in US prisons has slowly declined from 2.3% of the prison population in 1995 to 1.9% in 2001 . This downward trend was noted among both men (2.3–1.9%) and women (4.0–3.1%). HIV-positive inmates tended to be concentrated in a small number of states. Three states, New York, Florida, and Texas, accounted for nearly half of all HIV-infected inmates in state prisons in 2001 .
Overall, the HIV prevalence in prisons generally reflects regional prevalence trends, with higher rates in the northeast and south . In 2001, the prevalence of HIV infection was 4.9% among inmates in the northeast, 2.2% in the south, 1.0% in the midwest, and 0.8% in the west. The proportion of HIV-positive inmates was highest in New York (8.1%), Rhode Island (4.4%) and Florida (3.6%) .
HIV prevalence is highest among incarcerated women. In nine states, over 5% of female inmates were known to be HIV positive, and in three states, New York (14.9%), Rhode Island (12.1%), and Nevada (12.0%), over 10% of female inmates were known to be HIV positive. In contrast, New York (7.8%) was the only state in which over 5% of male inmates were known to be HIV positive. The rates of HIV infection and AIDS are comparable in jails to those observed in prisons .
The majority of HIV infections among incarcerated individuals are acquired in the community; low levels of transmission have been identified in prison, with an incidence of zero to four per 1000 person-years [24,28]. Although prisons have not conducted polymerase chain reaction studies to determine HIV incidence with certainty, incidence studies carried out using antibody testing have taken the ‘window period’ into account. Rates of HIV transmission that are lower than rates of other sexually transmitted pathogens in the prison setting probably reflect the lower prevalence and lesser transmissibility of this pathogen.
HIV/hepatitis C virus co-infection
Limited published data are available regarding HIV/HCV co-infection among US prisoners. In a recent study of entrants to Maryland correctional facilities , 30% had antibodies to HCV, 6.6% had antibodies to HIV, and HIV/HCV co-infection was present in 4%. Among those with HCV infection, 11–14% had HIV infection; conversely, among those with HIV infection, 65% had HCV infection. Another prison study found that 8.2% of inmates with HCV antibodies had HIV co-infection, and 70% of HIV-infected inmates had HCV infection (CDC, unpublished data). In a study of detainees entering three large city jails , where 2.7% were HIV infected, the HIV/HCV co-infection rate was approximately 1%. In a study of young IDU, 75% of whom had a history of incarceration, approximately 4% were co-infected with HIV and HCV (R. Garfein, CDC, personal communication, May 2004).
Hepatitis B, hepatitis C, and HIV/AIDS prevention in correctional settings
Jails and prisons are opportune venues for public health and correctional authorities to collaborate to reach populations with high prevalences of HBV, HCV, and HIV infections and risk factors for these infections. Corrections-based hepatitis B vaccination has been recommended by the Advisory Committee on Immunization Practices and the CDC since 1982, selective HCV testing by CDC since 1998, and HIV testing by the US Public Health Service since 1987 [31,40,41]. One multi-session behavioral intervention begun in prison and continued after release was shown to reduce slightly the percentage of inmates having unprotected anal/vaginal sex after prison discharge (from 86% in the 90 days pre-incarceration, to 68% 24 weeks after release) compared with a group that received a single-session intervention (89% unprotected sex in the 90 days pre-incarceration, to 78% 24 weeks after release) .
Incarceration may also be an opportunity for many drug-using offenders to access substance abuse treatment, essential to prevent HIV and HCV transmission. However, the availability of substance abuse programs in prisons is limited. Although it is estimated that 70–85% of inmates need some level of substance abuse treatment, in 1997, only 10% of state inmates had received drug treatment since admission [11,42]. Since that time, methadone treatment has become available in at least seven US jail systems, but only for inmates who were receiving treatment before incarceration. Only two jurisdictions, San Juan, Puerto Rico and New York City, offer methadone to inmates who were not in treatment before arrest (H. Catania, New York, personal communication). Collaborations have developed between some correctional systems, local jurisdictions, academic institutions and community-based organizations to provide prevention services within jails and prisons. However, financial and institutional constraints prevent immunization, substance abuse, and collaborative prevention programs from being widely implemented .
Hepatitis B virus
In a study of individuals with reported acute hepatitis B, 29% had a history of incarceration, including 40% of individuals reporting multiple sex partners, 58% of IDU, 22% of MSM, and 20% of individuals with no reported behavioral risk factor. The implementation of hepatitis B vaccination programs in prison and jail settings could thus prevent a high proportion of all new hepatitis B cases [8,44].
Hepatitis B immunization programs have been implemented in prison and jail systems in several states. However, vaccine funding has been a significant barrier to program implementation nationally. In 2000, a national survey found that 401 out of 1584 state adult correctional facilities in 36 states and the District of Columbia reported the delivery of at least one three-dose hepatitis B immunization series. However, only 37 correctional facilities (2%) reported offering hepatitis B vaccine to all inmates. An additional 153 facilities reported a policy of immunizing all inmates, but had not given any vaccine doses in the 12 months before the survey .
Hepatitis B immunization is well accepted in prison and jail settings. In an immunization program in the Texas Department of Criminal Justice, hepatitis B vaccination was offered to 75% of eligible inmates, and was accepted by 72% in prisons and 85% in state jails. However, the program was stopped when funding was no longer available . A similar vaccine acceptance rate was found during a demonstration project in Denver City Jail .
Hepatitis C virus
HCV antibody testing of individuals in existing programs that provide medical care to IDU (e.g. correctional institutions, HIV counseling and testing sites, and drug treatment programs) is an efficient strategy for identifying HCV-positive individuals who may then be medically evaluated and educated about the prevention of liver disease . In 2000, a survey found that HCV testing was available in 79% of state prison facilities, which housed 94% of all inmates. The criteria for testing varied: 132 facilities (6% of all inmates) tested broadly (at admission, at random, or all at some other time); 604 facilities (56% of inmates) tested on inmate request; 492 (48% of inmates) tested on the basis of high-risk indicators, and 1000 (86% of inmates) tested on the basis of clinical indication .
In state prisons, 17 911 tests were positive for anti-HCV between 1 July 1999 and 30 June 2000, and in that time frame 6046 inmates were treated for hepatitis C . Limited data suggested that approximately 7–27% of all inmates identified with HCV infection ultimately begin treatment . Many inmates have been excluded from treatment because of short lengths of prison stay, drug and alcohol use, and clinical contraindications including mental illness .
HIV testing was available upon inmate request in 45 states and in the Federal Bureau of Prisons in 1999. Forty-seven jurisdictions offered testing if it was clinically indicated. Only 19 state systems offered testing to all incoming inmates, whereas three jurisdictions tested all inmates in custody. The Federal Bureau of Prisons tests all inmates at release .
In 2003, the CDC initiated the ‘Advancing HIV Prevention Initiative’, which included a ‘Demonstration Project of Routine HIV Rapid Testing of Inmates’ in short-stay correctional facilities in four states . The goals of the project are to increase access to voluntary testing, increase the proportion of HIV-positive inmates who know their HIV serostatus and are referred to prevention and treatment services, and prevent new infections (R. MacGowan, CDC, personal communication, May 2004).
Injection drug use and sexual behaviors, among other factors, have resulted in concentrations of populations infected with HBV, HCV, and HIV in the jails and prisons of the United States. Treatment of infected individuals is expensive and difficult, and co-infection further complicates the treatment of chronic viral hepatitis and AIDS with multiple hepatotoxic medications and adverse events. However, because this single population is at risk for all of these infections, opportunities exist for public health and corrections to collaborate to develop integrated approaches to HBV, HCV, and HIV prevention.
Upon incarceration, all adults and the majority of juveniles lose access to the usual public and private healthcare and disease prevention services. Their healthcare becomes the sole responsibility of either the correctional system (federal, tribal, state, or local), or less frequently, the public health system. Although correctional facilities are only required to provide adequate, reactive healthcare, entry into the correctional system provides an opportunity for a population at risk of HBV, HCV, and HIV infections to access preventative healthcare, including immunization, health education, substance abuse treatment, and risk reduction.
Although there are opportunities for prevention efforts, barriers still exist. Pilot programs have found that hepatitis B vaccination is well accepted, but vaccine programs have not been widely implemented in correctional settings, largely as a result of a lack of funding for adult immunization. Substance abuse treatment programs are also lacking in prisons, and barriers exist to the widespread implementation of collaborative programs needed to prevent reversion to pre-incarceration habits after prison release. HCV testing is widely available, often by inmate request or identified inmate risk, and HIV testing, counseling, and prevention education is still more available. Whereas an integrated approach to disease prevention among inmates has been piloted in correctional facilities, it has not yet become a standard of correctional healthcare .
The importance of including incarcerated populations in community-based disease prevention and control strategies is now recognized by many public health, correctional health and correctional professionals. Improved medical care and prevention services for incarcerated populations benefits communities by reducing disease transmission and medical costs. Because incarcerated individuals have a high frequency of infection with HIV and hepatitis viruses, community prevention and control of these infections and their disease consequences requires the inclusion of this population.
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