The perfect storm: incarceration and the high-risk environment perpetuating transmission of HIV, hepatitis C virus, and tuberculosis in Eastern Europe and Central Asia

Abstract

Despite global reductions in HIV incidence and mortality, the 15 UNAIDS-designated countries of Eastern Europe and Central Asia (EECA) that gained independence from the Soviet Union in 1991 constitute the only region where both continue to rise. HIV transmission in EECA is fuelled primarily by injection of opioids, with harsh criminalisation of drug use that has resulted in extraordinarily high levels of incarceration. Consequently, people who inject drugs, including those with HIV, hepatitis C virus, and tuberculosis, are concentrated within prisons. Evidence-based primary and secondary prevention of HIV using opioid agonist therapies such as methadone and buprenorphine is available in prisons in only a handful of EECA countries (methadone or buprenorphine in five countries and needle and syringe programmes in three countries), with none of them meeting recommended coverage levels. Similarly, antiretroviral therapy coverage, especially among people who inject drugs, is markedly under-scaled. Russia completely bans opioid agonist therapies and does not support needle and syringe programmes-with neither available in prisons-despite the country's high incarceration rate and having the largest burden of people with HIV who inject drugs in the region. Mathematical modelling for Ukraine suggests that high levels of incarceration in EECA countries facilitate HIV transmission among people who inject drugs, with 28-55% of all new HIV infections over the next 15 years predicted to be attributable to heightened HIV transmission risk among currently or previously incarcerated people who inject drugs. Scaling up of opioid agonist therapies within prisons and maintaining treatment after release would yield the greatest HIV transmission reduction in people who inject drugs. Additional analyses also suggest that at least 6% of all incident tuberculosis cases, and 75% of incident tuberculosis cases in people who inject drugs are due to incarceration. Interventions that reduce incarceration itself and effectively intervene with prisoners to screen, diagnose, and treat addiction and HIV, hepatitis C virus, and tuberculosis are urgently needed to stem the multiple overlapping epidemics concentrated in prisons.

Figure 1. Projected HIV trends among people who inject drugs in Ukraine

Figure shows projected median trends for people who inject drugs. (A) HIV prevalence among individuals in the community (both never-incarcerated and previously incarcerated). (B) HIV prevalence among incarcerated individuals. (C) HIV incidence among individuals in the community (both never-incarcerated and previously incarcerated). (D) HIV incidence among incarcerated individuals. Scenarios shown are for the status quo, and if there was either: no effect of incarceration on transmission risk after 2015; no further incarceration after 2015; or initiation of opioid agonist therapy in prisons with 50% coverage among incarcerated people who have ever injected drugs who are maintained on therapy for a year after release. Data points with 95% CIs are shown for comparison and shading represents the 95% credibility intervals for the status quo projection (light blue shading) and if incarceration had no effect on transmission risk after 2015 (pink shading).

Figure 2. Prevention of new HIV infections

Figure shows percentage of new HIV infections that would be averted over 15 years (from 2015 and 2030) under the following scenarios: if incarceration no longer elevated transmission risk (full and conservative projections); if there was no further new incarceration of people who inject drugs; or if prison opioid agonist therapy was scaled up with or without retention after release. Bars show the median projections, while error bars show the 95% credibility intervals. Text above the error bars are the median projections and the corresponding 95% credibility interval. OAT=opioid agonist therapy.

Figure 3. Association between number of years incarcerated and prevalence of ever having tuberculosis among prisoners (A) and people who inject drugs in the community (B) in Ukraine

The points are the mean proportion of prisoners or people who inject drugs in the community reporting ever having tuberculosis for different reported years in prison; the error bars are 95% bootstrapped CIs about the mean. The solid green line is the best logistic fit to the data, and the green shaded area is bounded by the best logistic fits to the lower and upper confidence bounds of the data. Data for prisoners are derived from a 2011 PUHLSE national prison survey.^, Data for those in the community are derived from a multi-site ExMAT survey of people who inject drugs in Ukraine in 2015.

Figure 4. An overview of the criminal justice system in Eastern Europe and Central Asia

*Anyone arrested may be sentenced and bypass SIZO if convicted immediately.

Figure 5. Relationship of the risk environment in community and criminal justice settings in Eastern Europe and Central Asia

OAT=opioid agonist therapy. NSP=needle and syringe programmes. ART=antiretroviral therapy. MDR-TB=multidrug-resistant tuberculosis.

Figure 6. Incarceration in EECA countries and availability of opioid agonist therapies and needle and syringe programmes

EECA=Eastern Europe and Central Asia. OAT=opioid agonist therapy. NSP=needle and syringe programme.