Hepatitis C virus transmission in the prison/inmate population

Sexual behaviour

Engaging in high-risk sexual practices is a known risk behaviour associated with the transmission of HCV in the prison/inmate population. High-risk sexual practices associated with HCV infection in this population include a history of sexually transmitted disease (STD); sexual intercourse (SI) with a known past or current IDU; SI with five or more lifetime partners; and, for females, SI during menses(44). Homosexual behaviour is identified as a significant risk behaviour in some studies, but not in others(17,44). Such behaviour may be underreported, given that it is prohibited in prisons and carries a negative stigma(17).

Of all high-risk sexual practices, a history of STD has been found to have the strongest association with HCV infection, presenting an odds ratio of 29.3⁽⁴⁴⁾. SI, not considered an inefficient route of transmission of HCV, carries a greater risk if one or more partners are infected with an STD or engage in unsafe sexual practice. HCV transmission presumably requires that both partners have lesions in the skin located in or around the genitalia, permitting the virus to pass from one partner to the other. Such a situation is more likely to be found in individuals with genital infectious diseases⁽⁴⁴⁾. When one partner or both engage in IDU, spouses or regular sexual partners of persons with HCV are at greater risk of infection⁽⁴⁴⁾. SI during menses places women at significantly greater risk of HCV infection since there is a chance that the endometrium may become a portal for the HCV virus during menstruation⁽⁴⁴⁾.

High-risk sexual behaviours are considered to be proxy behaviours, as they may be the identified route of HCV transmission. However, infection generally results indirectly from an individual with a history of IDU and/or sharing drug injection paraphernalia and engaging in sexual practices with other individuals.

Discussion

There is no vaccine to prevent HCV infection ⁽¹⁰⁾. Compared with vaccine- preventable diseases, therefore, transmission of HCV is more probable and its effect greater in the prison inmate population. Inmates, especially in the United States, generally suffer from poorer health than the general population because of specific socio-economic factors such as poverty, poor access to health care, and high rates of self-abuse – IDU, alcohol abuse, multiple sexual partners ⁽³³⁾ – outside prison ⁽³⁵⁾. Moreover, their prison-related experiences may augment their risk status. When released back into the community ? often to the same high-risk communities as before incarceration ⁽³³⁾ ? this group can present a significant risk to the general population if there is no proper follow-up support ⁽²⁷⁾.

IDU in conjunction with sharing of improperly sterilized drug paraphernalia, previous imprisonment, tattooing and high-risk sexual behaviours account for the majority of new infections in prisons. Those who inject drugs and share equipment outside of prison are at the highest risk, and these individuals continue their habits upon incarceration (24,29,31). The risk factors mentioned cannot be interpreted as direct and independent risk behaviours for HCV infection; rather, they are more likely associated with sharing drug injection paraphernalia or constitute a marker for other, undetermined high-risk behaviours (20,21).

Attempts to control drug use in prisons have not been successful, and inmates continue to inject drugs and transmit bloodborne pathogens such as hepatitis C. The availability of sterile injection equipment has been shown to substantially reduce the transmission of bloodborne pathogens in areas where needle exchange programs (NEPs) are used and in selected prison settings⁽²²⁾. Several European prisons are piloting the implementation of NEPs ^(7,45,46) ? one clean needle and syringe provided in exchange for one used needle and syringe ⁽⁴⁵⁾. In one particular example, preliminary findings indicate that the use of an NEP in a prison in Switzerland (Hindlebank) contributed significantly to a reduction in the number of new cases of hepatitis, to improved health status of prisoners, and to a decrease in the frequency of needle sharing, although there was no significant reduction in drug consumption ⁽⁴⁶⁾. Needles were not used as weapons.

The issue of needle exchange is both complex and controversial. Providing sterile needles to inmates is widely recommended as a health measure necessary to reduce the spread of infectious diseases in Canadian prisons ^(45,46). However, since CSC is concerned about the health of inmates, the security of the institution, and the encouragement of law-abiding behaviour, it does not provide needle exchange services to inmates ⁽⁴⁷⁾. According to CSC, such a policy would compromise its current zero tolerance policy towards drug use and drug trafficking in prison and would be seen as condoning illegal drug use. In spite of this, CSC currently provides bleach kits for cleaning needles to all inmates of federal institutions⁽⁴⁷⁾. Regardless of the correctional system?s acknowledgement of the extent of drug injection practices in its facilities, it is clear that this population lacks resources and education on safer injecting practices in order to prevent the spread of HCV infection.

Globally, preventive measures promoted in the community are not transferable wholesale into the correctional system because prison populations turn over rapidly. This limits the effectiveness of unplanned prevention initiatives⁽⁴⁸⁾. Furthermore, many correctional health care practitioners in the United States routinely consider the duration of incarceration in their decision about whether to treat HCV-infected inmates, while Canadian inmates diagnosed with hepatitis C are treated according to the same health care guidelines as are applied to the general population. In some cases, treatment in the US is justified only if an offender will not have access to outside care for an extended period⁽²⁸⁾ and correctional facilities have set criteria to determine who should be screened and treated⁽²⁸⁾. This further complicates the implementation of consistent and routine checks for all inmates in this population. These factors contribute to significant barriers in HCV education and treatment within this setting.

Limitations of the review

In correctional facilities the variability in estimated HCV prevalence is partially attributable to inmates who participate in research studies but may not be representative of all inmates. Many inmates decline to participate in studies or provide blood samples because they claim not to have engaged in any high-risk behaviours⁽²⁶⁾. These two factors result in low generalizability and underreporting of risk behaviours affecting prevalence statistics in correctional facilities worldwide. As well, inmates who do participate can be reluctant to give data regarding risk behaviours, the majority of which constitute institutional offences^(17,32).

The literature reviewed is often plagued with inadequate collection of inmate behavioural characteristics or an incomplete depiction of past history and lifestyle behaviours known to contribute to HCV status. Therefore, it is unclear whether study findings are confounded by other high-risk behaviours inside or outside prison that the researchers fail to consider in their study design.

Many research studies confirm and support past findings on the risk behaviours that prison inmates typically engage in. Independent risk factors and behaviours are difficult to pinpoint since the majority of studies focus on a cluster of known risk behaviours. Research studies lack more in-depth details regarding the motivations behind risk behaviours, which could aid in more effective planning and implementation of preventive measures.