These are described in detail in the Aims and methods section on page 32.
ReviewHIV in prison in low-income and middle-income countries
Introduction
HIV has been identified as a major health problem for prisons around the world.1 Prisons have characteristics that can increase the risk of HIV transmission. HIV, hepatitis B, hepatitis C, and tuberculosis are usually more prevalent in prison populations than in the surrounding community.2 Injecting drug users (IDUs) are vastly over-represented, often accounting for half of all prison inmates,3 but only 1–3% of the broader community.4 There has been much success in limiting HIV transmission among IDUs in the community,5 but this success will be undermined if efforts to prevent HIV transmission in prison are insufficient.
Imprisonment is a common and recurring event for most IDUs. Over 60% of IDUs in a 12-city study reported a history of imprisonment,6 and in one Australian study, IDUs reported an average of five imprisonments.7 Furthermore, prison populations are dynamic with a vast number of movements of prisoners, prison staff, and visitors in and out of the prison setting. These two attributes of prison populations—a high proportion of IDUs and a high turnover of inmates—contribute to the spread of blood-borne viruses among prisoners and the broader community.8, 9
Documented cases of HIV transmission in prison are uncommon.10, 11, 12, 13, 14, 15 This lack of evidence is because of the difficulties in gaining access to prison populations rather than HIV transmission being an insignificant problem. Internationally, HIV prevention efforts in prisons have lagged behind those in the surrounding communities. HIV education is the most widely used HIV prevention intervention in prisons.16 Only a small, but increasing, number of countries provide methadone maintenance programmes,17 needle and syringe programmes,18 or condoms16 to prisoners.
The situation regarding HIV and IDUs in prisons in low-income and middle-income countries is unclear because accurate data are limited and difficult to access. Indications that the situation might be more detrimental than in high-income countries include the fact that 90% of HIV cases live in low-income countries,19 that HIV prevalence is often higher in the general community in low-income countries than in high-income countries,20 and that three-quarters of the estimated 13 million IDUs live in low-income and middle-income countries.4
Most research in HIV prevention and transmission in prisons has occurred in high-income countries.21 To gain a better understanding of the situation in low-income and middle-income countries, a thorough and systematic review is required.
Section snippets
Aims and methods
The aim of the review was to produce a coherent summary of knowledge of the problems of HIV and injecting drug use in prisons in low-income and middle-income countries. The following data from these countries were collected: (1) imprisonment per 100 000 adult population, (2) HIV prevalence among general prisoners, (3) proportion of prisoners who were IDUs, (4) HIV prevalence among IDU prisoners, and (5) HIV transmission in prison.
Data collection was done in 2003–04. Data collection methods are
Results
Of the 152 countries included as low-income or in transition, information on imprisonment was found for 142 (table 1). Information on HIV prevalence in prison was available for 76 countries and was greater than 10% in 18 countries: Brazil,24 Burkina Faso,25 Cameroon,26 Côte d'Ivoire,27 Cuba,28 Estonia,29 Indonesia,30 Lithuania,1 Malawi,31 Malaysia,32 Romania,33 Rwanda,34 Slovakia,35 South Africa,36 Ukraine,37 Vietnam,38 Yemen,39 and Zambia.40
Information on the proportion of IDUs in prison was
Discussion
Data were obtained for most countries on imprisonment and for about 50% on HIV prevalence among general prisoners, but very little data were available on the proportion of IDUs in prison populations or their prevalence of HIV. There were only seven reports of HIV transmission in prison in the 152 low-income or middle-income countries. In addition, the data tended to be varied and unsystematic in nature.
Since IDUs are the dominant HIV risk group in many low-income and middle-income countries,
Conclusions
National and jurisdictional governments have a responsibility to ensure that the problem of HIV in prison is accorded the same level of urgency as HIV in the general community.
For governments wanting to tackle the issue of HIV transmission in prison, there are several strategies to consider. In order of priority, these include the following: (1) reducing imprisonment;128 (2) providing prison staff and inmates with HIV education;129 (3) providing methadone maintenance treatment to inmates using
Search strategy and selection criteria
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