Prevalence of and risk factors for blood-borne viruses among prison inmates and entrants in Ireland: an overview

Jean Long

• Prevalence of antibodies to hepatitis B, hepatitis C and HIV and risk factors in Irish prisoners: results of a national cross sectional survey (BMJ 2000;321:78-82) Allwright S, Bradley F, Long J, Barry J, Thornton L, Parry JV.

• Prevalence of antibodies to hepatitis B, hepatitis C and HIV and risk factors in entrants to Irish prisons: a national cross sectional survey (BMJ 2001;323:1-6) Long J, Allwright S, Barry J, Reaper-Reynolds S, Thornton L, Bradley F, Parry JV.

• Prisoners’ views of injecting drug use and harm reduction in Irish prisons (Journal of Drug Policy 2004; in press) Long J, Allwright S, Begley C.

Acknowledgements

• Prisoners who participated• Management and officers working in the participating

prisons• Department of Justice, Equality and Law Reform for

allowing the team access to the prisons and provided funding for two of the studies

• Health Research Board in Ireland who provided funding for one of these studies

• Administrative staff and data collectors employed by Trinity College

Rationale for prevalence surveys

• Determine the prevalence of antibodies to hepatitis B core antigen, hepatitis C virus and HIV

• Examine risk factors for infection

Methods for prevalence surveys

• Inmates– September to November 1998– 9 of 15 prisons– 2,680 prisoners on average per

day– Sample required 1,200

• Entrants– 6th April to 1st May 1999– 5 of 7 prisons– 11,000 entrants per year– Sample required 534

Cross-sectional study

Self completed anonymous, unlinked, risk factor questionnaire

Oral fluid specimen for antibody testing

Result 1 Response rates

• Inmates– 1205 of the 1366 selected

prisoners participated (88%)

• Entrants– 607 of the 627 available

prisoners took part (97%)

Results 2 Respondents characteristics

• Inmates– Median age of

respondents was 25 years (range 16 to 67)

– 57 (4.8%) were women

• Entrants– Median age (range)

was 23 years (range 15 to 73).

– 41 (7%) were women

– One third (197/591) had never previously been in prison

Results 3 Injecting drug use

• Inmates– 43.2% ( 509/ 1178)

had ever injected– 20.8% ( 104/501 )

started injecting in prison • Entrants

– 7% (14/197) of those entering prison for the first time reported ever injecting drugs vs 40% (157/394) of those previously in prison

– 18.5% ( 29/157) started injecting in prison

Results 4 Prevalence of blood-borne viruses among prisoners in Ireland

37

8.7

2

21.8

6.2

2

0

5

10

15

20

25

30

35

40

Hepatitis B Hepatitis C HIV

Inmates (n=1193)

Entrants (n=596)

Results 5 Injectors versus non injectors in the inmates survey

18.5

81.3

3.51.5 3.7 0.90

10

20

30

40

50

60

70

80

90

Hepatitis B Hepatitis C HIV

Perc

enta

ge

InjectorsNon injectors

Results 6 Injectors versus non injectors in the entrants survey

17.9

71.7

5.81.2 1.4 0.5

0

10

20

30

40

50

60

70

80

Hepatitis B Hepatitis C HIV

Perc

enta

ge

InjectorsNon injectors

Prevalence of blood-borne viruses among injector prisoners in the Republic of Ireland

18.5 17.9

3.5

81.3

5.8

71.7

0102030405060708090

Hepatitis B Hepatitis C HIV

Perc

enta

ge

Inmates (n=509)Entrants (n=173)

Risk factors for hepatitis C among injectors

• Sharing needles in prison (odds ratio 4 times more likely)

• Ever had hepatitis B vaccine (odds ratio 2 times more likely)

• Spent more than three months in prison (odds ratio 2 times more likely, not significant)

Slide 27

Total Positive

Prevalence Odds ratio (95% CI)

p-value

Antibodies to hepatitis C virus (531/ 666) Survey

Census 509 414 74.5 1 Committal 157 117 81.3 1 (0.6-1.6) 1.0

Prison Outside Dublin 100 67 67.0 1 Dublin 566 464 82.0 1.9 (1.0-3.5) 0.05

Age group <30 years 514 411 80.0 1 >30 years 125 97 77.6 0.8 (0.4-1.4) 0.3

Months spent in prison over the last 10 years <3 months 56 26 46.4 1 3-11 months 68 50 73.5 2.1 (0.9-5.2) 0.1 12-36 months 171 135 79.0 1.9 (0.9-4.0) 0.1 > 36 months 353 310 87.8 2.1 (0.9-4.5) 0.07 Missing 18

Years since first injecting < 3 years 130 83 63.9 1 > 3 years 493 414 84.0 1.6 (0.9-2.7) 0.09

Sharing needles in prison No 239 149 62.3 1 Yes 409 371 90.7 4.2 (2.5-7.2) <0.00

01 One or more doses of hepatitis B vaccine

No 258 181 70.2 1 Yes 373 325 87.1 2.0 (1.2-3.2) 0.007

Whole model 2=85.4, p0.0001

Risk factors for hepatitis C among non injectors

• Increasing time spent in prison

• Smoking heroin in the year prior to the survey (4 times more likely)

• Testing positive for hepatitis B core antigen 12 times more likely)

Slide 28

Total Positive Prevalence Odds ratio (95% CI)

p-value

Antibodies to hepatitis C virus (30/ 905) among non injectors Survey

Census 669 25 3.7 1 Committal 236 5 2.1 1.1 (0.4-2.9) 0.9

Months spent in prison over the last 10 years <3 months 154 2 1.3 1 3-11 months 190 5 2.6 2.4 (0.5-18.3) 0.3 12-36 months 230 5 2.2 1.5 (0.3-11.4) 0.6 > 36 months 267 18 6.7 5.2 (1.3-35.2) 0.04

Smoked heroin in the previous 12 months No 756 17 2.3 1 Yes 145 13 9.0 3.6 (1.6-7.7) 0.001

Oral fluid positive for anti-HBc No 893 27 3.0 1 Yes 12 3 25.0 12.4 (2.4-52.4) 0.001

Whole model 2 = 29.0 p <0.0001

Study objective

• Document injecting practices in prison versus outside prison

Methods

• Grounded theory approach was employed– Prisoners expert witnesses

• Purposive sampling– Injectors (16) and non injectors (15)

• Detained in two prisons

Methods (cont)

• April and May 2000

• Semi-structured questionnaire and topic guide– Taped interviews– Topic guide developed as new issues emerged

• Interviews transcribed

• Data entered into ethnograph and coded

• Audit trail maintained – Codes to categories to themes

Respondents’ characteristics (n=31)

• Male: 31 (100%)• Median age in years (range): 26 (18 to 37)• Residence in Dublin: 21 (68%)

• Completed second level education: 2 (6.5%)

• Spent 3 of the last 10 years in prison: 21 (68%) • Crime related to drug or alcohol misuse: 23 (75%)

• Ever injected: 16 (52%)• Ever used heroin: 24 (77%)• Problematic alcohol misuse: 5 (16%)

1. Injectors take risks during detention that they would not take outside prison.

A. The low availability of heroin encouraged the change from smoking heroin to injecting it

“...I was only in ((prison)) off the streets …. at the time and I

had a couple of, em, mates here … and they were getting heroin in and they were more or less sayin' "well we haven't really got it to give it to you to smoke, but there's a turn on ((heroin taken by injection)) there if you want it”, you know what I mean?

”

B. Those who own a syringe and needle rent them to other injectors as a means of acquiring the drugs to maintain their habit

“If you own a syringe in here you can feed a habit, you

can keep your habit going ‘cos every day of the week someone's going to come to you with heroin and say "listen, I have gear ((heroin)), do you want a bit of it for a lend of your syringe" and that's the way things work, you know?

”

C. Scarcity of injecting equipment meant that sharing circles were far wider than outside prison

“ Yeah well, ah yeah, well it's obvious the risk factors are an awful lot higher for the simple reason, there's only a certain amount of needles and syringes in prison.

There'd be people I'd be wary of sharing with, but there'd be days ((in prison)) when things'd be that bad that you'd have to use it 'cos you'd be that sick ((suffering from withdrawals)), that craving, you know? Well, you'd know people who'd have one ((needle and syringe)) and you'd approach them and ask them for a lend of it. Now you'd know yourself that it's probably after being around the prison for years….

”

D. Cleaning practices were inadequate for injecting equipment

“ Just water, just ……

……Give them a good rinse. Oh, er, like I'd put a bit of bleach on it or something, but, em, it wouldn't make any difference, no, I'd still just rinse it out before I'd do anything. ……er, I wouldn't use straight after anybody, even rinsing it, …..it's all to put me mind at ease, you what I mean?

”

Non injectors reported observations were consistent with injectors reported practices

“ …..Out in the yard and there's, er, ten or twelve of

them sitting in circles, ganged up together and they've got two syringes and they've got a milk carton ((for the water to clean the needle and syringe)) and they've water and probably a jam tray ((used to cook the heroin)) or something and they're shooting heroin on the jam tray and they're just dipping it ((needle)) in the water and that's it, that's how they're cleaning it……

”

Conclusion and recommendations at the time of the studies:

• Prison is a high risk environment for hepatitis:

– Infection control

– Harm reduction (injectors and non injectors) • Including drug treatment services

– Surveillance

What has happened since these studies?• Between 1997 and 2000, the Irish Prison Service

commissioned a number of studies

• During 2000 and 2001, the Irish Prison Service along with other agencies developed both drug treatment service plans and health care plans

• Introduced of:– Evidence based methadone treatment services;

expansion of drug free units; provision of hepatitis B vaccine; and employment of registered nurses

• There is, of course, much more to do….– Harm reduction, hepatitis C and STI treatment, drug free treatment

and mental health care

• Need for routine health care and drug treatment information