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Globally, one-in-nine incarcerated people have a history of IV drug use. In Australia and New Zealand, it’s one-in-two. The University of New South Wales (UNSW) has become the first to quantify, in two systematic reviews, both the prevalence of blood-borne diseases for incarcerated people, and access to a handful of well-known healthcare programs. It found that no country, worldwide, had all the programs available.
InSight+ spoke with one of the lead authors about the world first, benchmark research.
Dr Thomas Santo Jr. is a member of the University of New South Wales’ (UNSW) Global Consortium to Advance Data on the Epidemiology and Health Impacts of Illicit Drug Use. The consortium is an initiative of the National Drug and Alcohol Research Centre (NDARC), and includes multiple international collaborators and non-government organisations.
Dr Santo and his colleague Dr Louisa Degenhardt led the reviews, the first looking at the prevalence of both IV drug use and blood-borne disease in incarcerated people, the second at the accessibility of treatment programs for the same diseases in carceral settings.
“Around half the people who entered incarceration had a history of injecting drug use – one-in-nine. That’s 50 times higher than the general population,” said Dr Santo.
“We knew that we would find higher levels, but the level of disparity was even more astonishing.”
It also found that 3.7% percent are living with HIV (25.1 times higher than non-incarcerated people); 2.5% have active tuberculosis (45.3 times higher), 11.7% have a current hepatitis C virus (HCV) infection (15.6 times higher), among other statistics.
The coverage review looked at opioid agonist treatment (OAT) programs, needle syringe programs (NSPs), HIV testing and antiretroviral therapy (ART), HCV testing and direct-acting antiviral (DAA) treatment, tuberculosis screening and treatment, hepatitis B virus (HBV) testing, treatment, and vaccination in carceral settings.
It found that fewer than 2% of the 11.3 million people incarcerated worldwide live in countries offering any of the standard treatment programs studied.
Not a single country offered incarcerated people access to all treatment programs.
“If we can benchmark things for people who are in prison, it may be a call to action. We hope that’s what it will be.”
A history of research into drug use
Dr Louisa Degenhardt has produced regular reports into prevalence and coverage related to opioid agonist treatment (OAT) and needle syringe programs (NSP) in the larger community (here and here).
“Prison studies have always been excluded from that,” said Dr Santo.
“We know from the literature that people who are incarcerated face these issues more often. But it’s never been quantified.”
“We didn’t limit our research to just people injecting drugs. We looked at people who are in prison, the injecting drug use prevalence, the different blood-borne viral diseases, as well as the services that relate to them.”
“People who inject drugs are more disproportionately affected by these diseases, but they’re also more disproportionately incarcerated.”
“We have international targets related to eliminating hepatitis C, HIV and AIDS and other goals for expanding treatment for these, including sustainable development goals.”
“We are falling way behind in terms of human rights. As well as what we are providing in the community versus what we’re providing in prisons.”
“There are countries committed to improvements through the Mandela rules and others to equal levels of care for incarcerated people and the community. And clearly there’s not even a baseline of those services.
“It’s a failure on a global level.”
Alarming statistics
Dr Santo said that incarcerated people play a big part in global health.
“There’s 11.3 million people incarcerated globally. And even though 11 million people at one time are incarcerated, 20-30 million go through the release cycle every year.”
“If you have people that are at the highest risk of, say, HIV, hepatitis C, or tuberculosis in society, and you’re placing them in one location where you don’t provide the services for them, then the prevalence within that location is going to go up.”
“So, the fact that those numbers hadn’t been quantified before was important.”
“The numbers include 4% living with HIV — 25 times higher than the general population. Almost 16 times higher for hepatitis C; 45 times higher for tuberculosis, and two times higher for hepatitis B.”
“It tends to be that the places that have the highest burden are often the places that we either couldn’t find information for regarding treatment or testing, or they didn’t confirm that they didn’t have it.”
“And so that goes to that cycle of the problem.”
Continuity of care
Dr Santo said that paying more attention to prisons is important for continuing healthcare.
“When people are going into forced withdrawal, and many are receiving treatment for a chronic condition, and we break up that treatment cycle, continuing treatment gets difficult.”
“In particular for OAT, it’s super important in relation to risk of suicide and overdose.”
“Often people are receiving their OAT in tandem with, for example, hepatitis C treatment. Somewhere like Australia, where the systems are broken up, to reconnect them just gets interrupted.”
Australia and New Zealand
Dr Santo said that one-in-two incarcerated Australians having a history of injecting drug use is shocking, and shows systemic issues in how health and incarceration intersect in Australia.
“Australia is a signatory to the Nelson Mandela Rules, which clearly state that people in custody should receive healthcare equivalent to that available in the community. But what we’re seeing is a systemic failure to meet that standard in practice.”
Dr Santo noted that this will have a particularly harmful effect for some groups, including incarcerated women, and First Nations peoples.
“For sub-populations of people who are already disproportionately affected by incarceration and its associated harms, the absence of key health services is likely to compound those harms. For example, we also estimated that 68.5% of incarcerated women in Australasia have a history of injecting drug use, which is the highest prevalence of any region-sex combination globally.”
“These are interventions that have been part of the Australian public health response for decades, so the issue is not feasibility, it is access.”
Dr Santo said that the fact that incarcerated people cannot access Medicare was another factor that drives inequity.
“The exclusion of people who are incarcerated from Medicare creates another layer of disadvantage. A recent letter to the editor published in the Medical Journal of Australia highlighted how the discriminatory exclusion of people in custody disproportionately affects First Nations people, and rightly argued that ending it is critical to progress on Closing the Gap targets around both health and wellbeing and reducing Indigenous incarceration.”
Redressing the balance
Dr Santo said that redressing the disparities would include incarcerated people and the general population having the same service infrastructure.
“Another thing is investment. Prisoners are always going to be the last on the agenda for health care when it comes to countries and funding.”
“But if countries are committed to meeting goals — like, on a more positive note, Australia with hepatitis C — funding was able to create some movement in relation to the prevalence in prison.”
“We have great needle syringe coverage. But the fact that we have none in prisons, it just undermines all those efforts.”
“When prisons are put as a priority for health services, and not left to the last agenda point, it will start there.”
Funding for the studies came from the NRMHC, the Kirby Institute, and individual grants.
Becca Whitehead is a freelance journalist and health writer. She lives in Naarm and is a regular contributor to the MJA’s InSight+.
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