The Lancet Special Theme Issue: HIV, Viral Hepatitis, and TB among Prisoners

Guest Editor: Chris Beyrer

Guest Co-Editors: Martin McKee; Joe Amon; Josiah Rich; Adeeba Kamarulzaman; Kate Dolan; Rick Altice

Lead Authors: Kate Dolan; Josiah Rich; Adeeba Kamarulzaman; Leonard Rubenstein; Lilly Tellisinghe; Rick Altice

Description: Prisoners, detainees, and others in closed settings have experienced high HIV disease burdens, barriers to accessing HIV prevention, and challenges in obtaining HIV treatment and care since the HIV pandemic was first recognized. Worldwide, some 10 million men, women and children are in prisons, detention, or in some form of government custody. Globally, an estimated 30 million persons pass through some form of detention each year. These populations are at especially high risk of HIV infection, both as a consequence of risk factors that are in play before incarceration and once in prison, where there are often frequent opportunities for further transmission. Consequently, HIV burdens among the imprisoned are overall 1.5 -4.0 times higher than in the general population. The epidemiology of HIV and of related co-infections and co-morbidities including Tuberculosis, Hepatitis B and C, substance use, and mental health is unique, complex, and continues to challenge humane and pragmatic responses. HIV prevention, treatment, and care programs have proven problematic for incarcerated adolescents and adults in many settings, and are all but absent in others. Indeed, in many contexts, prisons and detention centers have been at the center of HIV, TB, HCV and related epidemics.

The provision of evidence-based services has proven difficult for providers working in closed settings, for correctional systems, judicial systems, governments and communities. The trend toward mass incarceration for drug related offences in many countries, an outcome of the War on Drugs, has greatly enlarged prison and detainee populations in the HIV era, increasing the urgency for new approaches in HIV, including drug policy reform. Yet prisoners, particularly in low and middle income countries, remain understudied and underserved—a key population in the HIV pandemic. Africa, by far the region most affected by HIV globally, has among the most marginalized of all incarcerated populations—many face years in detention without ever being formally charged or tried for alleged offenses—with profound consequences for their health and well-being. In Eastern Europe, Central Asia, South and Southeast Asia, and East Asia prisons, jails, drug detention centers and other forms of detention have been transmission hot zones for HIV, hepatitis B and C, and TB, including MDR-TB.

Most prisoners are eventually released. The problems of reentry to community, linkage to care for persons newly released from prison, and the interactions of prison acquired infections with community risks and vulnerabilities are critical aspects of the epidemiology of HIV in closed settings. The men and women in detention are not, finally, separated from their communities—they are an integral part of them—and so these issues are of profound concern to all who seek an end to the HIV pandemic.

The Lancet special theme series on HIV and Prisoners will address these issues through a series of commissioned comprehensive reviews of this understudied domain. Additional invited Commentaries will address related and critical issues in improving responses to HIV and co-morbidities for incarcerated populations. A Call to Action final paper will summarize the series findings, and lay out an action agenda for HIV among prisoners.

The National Institute on Drug Abuse, MACAIDS, and Open Society Foundations provided financial support for this project