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October 31, 2017, Vienna.
Over ten million people are held in prison globally at any time and the number passing through prison systems annually is significantly higher due to rapid ‘churn’. The prevalence of HIV, Hepatitis B & Hepatitis C viruses, sexually transmitted infections (STIs) and tuberculosis (both active and latent disease) among people in prisons is estimated to be two to ten times higher than in the general population. Often co-infection is seen due to overlapping risk factors, both biological and psycho-social, with can be exacerbated by the prison environment itself. This poses a significant risk not only to the health and wellbeing of people incarcerated in prison and the people working there but also the wider community.
In recent decades, huge advances in the diagnosis and treatment of HIV have been made which have saved & transformed lives globally. However, access to HIV prevention, treatment and care programmes is often lacking in prisons, and in many case, these programmes are not equivalent to those provided in the community. To address this, UNODC have commissioned Prof. Heino Stover (University of Frankfurt) to write a “Technical Guide” to improve the diagnosis and treatment of HIV among people in prisons with specific focus on continuity of care from the community to custody, throughout the patient journey within the prison estate, and on release back to the community. A group of international experts was invited by UNODC to Vienna to review the draft and suggest improvements, especially linking to wider international guidance and supporting global impact. The experts included representatives from international public health organisations like WHO, the European Centre for Disease Surveillance and Control (ECDC) & the USA’s Centre for Disease Control (CDC); international experts in infectious diseases and HIV; public health experts, and very significantly a range of NGOs working with people in prisons across the globe, including Penal Reform International and the International Committee of the Red Cross.
During the two day event, experts reviewed in detail all aspects of the guidance, with particular focus on the patient care pathway- optimizing opportunities for diagnosis, access to antiretroviral treatment and retention in care, in custody and in the community. There were excellent examples of both great work and the scale of the current challenge from NGOs working in Kyrgyzstan, Zambia, Vietnam & Kenya as well as CDC’s PEPFAR programme which supports work in a range of low and middle income countries globally. There were suggestions on how to ensure this guidance also supports wider work on co-infections like Hepatitis B & C, STIs and TB given the risks of all infections in populations in prisons. There was also a specific focus on the issue of the management of drug dependence especially the risk of overdose following release and the role of naloxone programmes in preventing drug-related deaths in the community among recently released prisoners.
While we left Vienna with a considerable amount of new work to do, it was a very positive and energising meeting. There is clearly a commitment at international level to ensure HIV prevention and treatment programmes ‘leave no one behind’ and a recognition of the importance of prisons as a setting and prisons populations as a key population for interventions as part of wider control programmes. As some who began their medical career managing patients in prisons when HIV was an untreatable condition causing terrible illness and suffering, I was heartened to reflect on how far we have come. But we have not yet realised the full potential of improved diagnostic and therapeutic interventions for HIV among people in prison and this risks not only failing to improve their health but also failing to tackle a global health problem with risks to all.
