HIV and Related I nfections - PowerPoint Presentation

Slide1

HIV

and

Related

I

nfections

in PrisonersSlide2

HIV and related infections in prisoners

The Perfect Storm

:

Incarceration and the High Risk Environment Perpetuating HIV, HCV and Tuberculosis in Eastern Europe and Central AsiaSlide3

Frederick L Altice: Yale University, USA

Lyuba Azbel: Yale University (USA) & London School of Tropical Hygiene

Jack Stone

:

Imperial

College,

UKEllen Brooks-Pollock: Imperial College, UK

Pavlo Smyrnov: Ukrainian Alliance for Public Health, UkraineSergii Dvoriak: Ukrainian Institute of Public Health Policy, Ukraine

Faye S. Taxman: George Mason University, USA

Nabila El-Bassel: Columbia University, USANatasha Martin: USCD, USA & Imperial College, UKRobert Booth: University of Colorado, USAHeino Stover: University of Frankfurt, GermanyKate Dolan: University of New South Wales, AustraliaPeter Vickerman: Imperial College, LondonAcknowledgements toUNODC: Ehab Saleh & Signe Rotberga ,

Authors and Affiliations

HIV and related infections in prisonersSlide4

Percent Change in New HIV infections: 2005 to 2015Slide5

Eastern Europe and Central Asia: Historical Context

15 UNAIDS-Designated

EECA Countries

– evolved from dissolution of the Soviet Union in

1991

Diverse cultures and religions with distinct political, economic and social trajectories after independence

They share socio-political, philosophical and organizational vestiges of the former Soviet Union that now shape the synergistic epidemics of mass incarceration, substance use disorders, and infectious diseases (HIV, viral hepatitis and TB)Aside from Russian and the 3 Baltic countries,

the other 11 EECA countries are LMICAfter the collapse of the Soviet Union, heroin routes opened along the Northern and Balkan routes, resulting in an expanding opioid epidemic, with high levels of drug injection and transmission of blood-borne infectionsSlide6

Evolving Epidemics in EECA

Criminal Transitions: After the collapse of the Soviet Union, laws and policing markedly changed to address the opioid trade and other criminal activities, resulting in massive and unprecedented incarceration, especially of PWID

HIV (and HCV) incidence markedly increased in PWID, who increasingly became incarcerated, with suboptimal availability of proven HIV prevention strategies like OAT, NSP and ART

The Soviet healthcare system, including within prisons, disintegrated with inadequate TB medications and treatment default, giving rise to both community and prison-related MDR/XDR TB, which is three-fold higher in prisons than in the communitySlide7

Research

StrategyComprehensive review of the literature and survey of grey literature and country websites in English and Russian

In collaboration with UNODC, we conducted a standardized survey of prisons assessing the criminal justice system: organization; “registered” patients with HIV, HCV and TB; treatment and prevention interventions and numbers on treatment

Ukraine case study

: statistical analyses and mathematical modeling from serial national biobehavioral surveys of PWID, comprehensive 2015 national survey of PWID and 2011 national survey of prisoners to assess the population attributable fraction (PAF) of incarceration on new HIV infections in PWID and PAF of incarceration on TB in PWID and the general community over a 15-year horizonSlide8

In

Out

Prison Environment

Community

Laws and policing selects members with poor health status and/or at risk for HIV, TB, or viral hepatitis

Concentration

Amplification

Deterioration

Dissemination

High risk behaviors, new social networks, transmission to new community members

Post-Release

Morbidity and MortalitySlide9

Community

Risk Environment

Macro Factors

Micro Factors

Economic

- Housing, employment challenges

-

Funding for OAT, NSP, ART

- Economic

vulnerability- Individuals costs  corruptionSocial

- Family structure/support- Stigma of drug users, SW, OAT

- Homelessness

- Injection networks- Sexual networks

- Loneliness & isolationPolicy

-

Official “

registration” for addiction & HIV

-

Laws governing drug use

- Alternatives to incarceration

-

Policing activities

- Availability

and coverage of OAT, NSP, ART

-

Eligibility for OAT and ART

Physical

-

Population

mobility/migration

- Access to transport routes/drug markets

- Local displacement of PWIDs

- Venues

for drug injection

-

Prevalence of PWID and HIV

in the community

and in key populations

Prison Risk Environment

Macro Factors

Micro Factors

Economic

-

High levels of within

prison drug injection

-

Funding for OAT &

Harm Reduction/HIV

prevention & treatment services

- Economically and socially disempowered

populations concentrated within prison

Within prison drug trade run

by prison mafia

Economic vulnerability within prison

Discrimination

for within prison employment

opportunities

Social

-

E

xclusion

from social participation and

meaningful social roles

-

Disruption of social &

risk

networks

- Gender

inequalities and gendered risk

- Ethnic inequalities

-

Prison staff and peer stigma, attitudes, and

myths

about

OAT, PLH,

and PWIDs

- Social norms & networks of PWIDs &PLH

-

Lack of social support

-

Prison hierarchy (caste)

Policy

-

Policies governing

OAT, NSP, condoms, ART

- Health and human rights

policies toward

prisoners

-

Transitional care services

-

Dosing of OAT

- Availability

& quality of

free

OAT, NSP, condoms,

ART

- Screening policies for IDU & HIV

Physical

-

OAT engagement (prison vs. community)

- Location within drug trade routes- Prison population mixing- OAT/NSP dispensing practices- Availability of transitional/continuous care- Location of OAT, ART, NSP sites - Injection locations- Spatial inequalities- Prevalence of WP-DI & HIV

Possible Mechanisms- Stigma increases social and economic vulnerability- Increases substance use from despair and lack of social support - Increases within prison drug injection / initiation- Increases injection risks and transmission of blood-borne viruses - Discourages OAT entry and retention- Decreased opportunities to negotiate protective practices- Increases vulnerability to violence- Increases likelihood of recidivism- Increases within prison HIV transmission- Relapse to drug use after release, overdose - Stop taking ART after release

Possible Mechanisms- Increases exposure to drugs- Factors that contribute to entry into drug use and SW- Reduces safety and increases violence toward PWID, PLH and SWs- Decreases ability to reduce risk by negotiating safer injection practices, negotiating condom use and avoiding violence- Social stigma and marginalization drives risk underground and not amenable to prevention and treatment services

Opportunities for Prevention & Intervention- Expanded OAT, NSP, ART in both community and prison settings- Changes in laws that govern drug use- Interventions with police; introduction of alternatives to incarceration (drug courts, probation, parole)- Interventions to rebrand OAT to reduce staff & peer stigma- Interventions to reduce isolation and stigma of OAT patients - Gender-based equality and empowerment efforts- Removal of names-based “registries” for HIV and addiction

Drug Use & HIV Vulnerability

Drug Use

&

HIV Vulnerability

Amplifying HIV Risk and

Prevention in PrisonsSlide10

HIV, HCV, TB and Opioid Use Disorders

Opioid use disorders: 30-50% of prisoners are PWID (mostly opioids)

High

levels of within-prison drug

injection

Historical role of Narcology

and attitudes toward opioid agonist treatmentsHIV: about 50% of PLWHA know their diagnosis, but the HIV continuum varies greatly thereafterHCV: prevalence 30-60% of all prisoners, but testing is uncommon and no treatment available aside from a HCV elimination program in GeorgiaIn EECA, incarceration is associated with TB and MDR/XDR TB with MDR TB typically 3-fold higher in prisoners than in the communityInadequate diagnostics and treatment algorithms, especially with HIV/TBInadequate supply of medicationsEnabling environment that promotes MDR TB Inadequate transitional servicesMultiple structures and oversight undermine care in the CJSSlide11

HIV in Prisons in Countries of Eastern Europe and Central Asia

HIV and related infections in prisonersSlide12

?

?Slide13

?

?

Concentration of PLWHA in Prisons Compared to the CommunitySlide14

HIV Prevention Strategies in Prisons in Countries of Eastern Europe and Central Asia

HIV and related infections in prisonersSlide15

No Opioid Agonist Treatments in CJS (N=7)

Account for over 85% of all prisoners living with HIV in the regionSlide16

Opioid Agonist Treatments Only

Within Police Lock-Up (N=3)Slide17

Opioid Agonist Treatments in Prison (N=5)

PWID account for >30% of prisoners in most EECA countries

When available, OAT coverage is <1% and mostly as pilot programs

Some prison OAT programs discontinue treatment before release or do not have transitional servicesSlide18

Needle/Syringe Programs in Prison (N=5)Slide19

Provides ALL 15 Recommended

HIV Prevention Interventions (N=3)

See Panel 2: Candles Burning in the Night

Small countries that have boldly introduced these programs with international funding despite regional pressures

These programs are now in jeopardySlide20

Ukraine Case Study

Lower middle-income country embroiled in political/economic conflict

45 million people with highest adult HIV prevalence (1.2%) in EECA

310,000 estimated PWID

HIV prevalence: 15% to 45%

Proportion on OAT: 2.7%Proportion on ART: <5% (only 20% of all PLWHA)

Ever incarcerated: at least 52%, with an average of 5 incarcerations, 1 year eachHIV prevalence higher in previously incarcerated PWID (28% vs 13%)Compared to PWID never incarcerated, previously incarcerated PWID had much higher HIV risk behaviors, but it was mostly heightened in the 12 months after release and then returned to pre-incarceration risk levels

HIV and related infections in prisonersSlide21

Figure 2

The Lancet

 DOI: (10.1016/S0140-6736(16)30856-X)

HIV and related infections in prisoners

Stone, Jack et al

Abstract: WE-AC-04 (Session Room 2), 16:30-18:00Slide22

Figure 3

The Lancet

 DOI: (10.1016/S0140-6736(16)30856-X)

Azbel

L et al,

PLoS

One, 2013

Azbel

L et al, JIAS, 2014

Makarenko

J, DAD, 2016

Incarceration and Contribution to TB in Ukraine

Data derived from nationally-representative prison

1,2

and PWID community surveys

3

Incarceration accounts for 6.2% of all incident TB

cases

(population-attributable fraction)

Among PWID, however, incarceration contributes to 75% of new TB cases in PWID with HIV

PWID

Community

13% relative increase/year

6

% relative increase/yearSlide23

HIV and related infections in prisoners

Recommendations

Reduce incarceration for key populations, especially PWID

Introduce and scale-up HIV prevention with OAT, NSP and ART, including effective transitional programs post-release

Improve testing and treatment strategies (continuum of care) for HIV, HCV and TB

Eliminate the gap between prison and community treatment and prevention services, including structural impediments for service delivery and continuity

Integrate services given the high rate of medical and psychiatric co-morbiditySlide24

Sasha’s Voice

“Prisons here in Russia are places where people like me go to die.”

“Many who went to the infirmary never left except in a pine box, because their TB medications didn’t work anymore.”

“We were 36 men in a closet with only 12 beds. We stood, coughed on each other, while others slept in shifts. Most guys, including me, would stop or dispose of our TB medications so that we could get sick and move from our closet to the infirmary where we’d get our own bed.”

Azbel

L et al,

PLoS

One, 2013

Azbel

L et al, JIAS, 2014Makarenko J, DAD, 2016Slide25

HIV

and related infections in prisoners