Background
Methods
Data collection
Definition of the scores of adherence:
-
The first was “Effectiveness of interventions to address HIV in prisons”, written by the WHO in 2007, in collaboration with UNAIDS and UNODC, which is the most detailed document on HIV prevention in prison settings [10]. The purpose of this recommendation was to document and define the conditions required to implement all interventions with proven efficacy for HIV- and HCV-transmission prevention in prison settings.
-
The second document was “HIV prevention, treatment and care in prisons and other closed settings: a comprehensive package of interventions”, written by the UNODC in 2012, in collaboration with UNAIDS, WHO, ILO and UNDP. It describes 15 key interventions to prevent HIV and viral hepatitis transmission in prison settings [11]. It is shorter than its WHO counterpart, but lists all current (as of 2015) interventions to implement in prison settings, except bleach, whose efficacy in preventing HIV-HCV in the prison context has not been proven. In particular, it describes three important measures, among others, which were not clearly detailed in the 2007 WHO document: access to ARV, HBV vaccination and prevention measures for tattooing and piercing.
International Recommendations | Score | |
---|---|---|
Information-Education-Communication | •Availability of Information/education at entry or during prison stay | 0.5 |
•Peer education programs available | 0.5 | |
•AND availability of clean injecting equipment + condoms (0 if not)a |
1
| |
Testing - Counseling | •Testing for HIV, HBV, HCV systematically proposed at entry (RC) and during prison stay (all prisons) | |
•AND availability of clean injecting equipment + condoms (0 if not)* |
1
| |
Condoms - Lubricants | •Condoms available in various locations | 1 |
•Water-based lubricants available | 0.5 | |
•Male condoms and lubricants accessible and female condoms accessible for prisons with female prisoners | 0.5 | |
2
| ||
Opioid Substitution Therapy | •Induction at entry (RC) + induction during prison stay + continuity of OST at entry (all prisons) | 1 |
•No ceiling dosage | 0.5 | |
•No buprenorphine crushing or dilution | 0.5 | |
2
| ||
Bleach | •At least 2 locations/access for bleach inside prison (penitentiary distribution, purchasable inside prison, available in medical unit) | |
•AND Intelligible information for HR purposes accessible for all prisoners |
1
| |
HBV Vaccinationb | •Systematic HBV vaccination proposal for all seronegative prisoners |
1
|
Post-Exposition Prophylaxis | •All prisoners informed of PEP availability inside prison |
1
|
Needle Exchange Programs | •NEP are available |
1
|
ARV treatmentb | •ARV are accessible | 0.5 |
•Prescriptions follow national guidelines | 0.5 | |
1
| ||
Prevention of transmission through tattooing, piercingb | •Existing initiatives aiming at reducing the sharing and reuse of equipment used for tattooing, piercing and other forms of skin penetration |
1
|
TOTAL |
12
|
Statistical analysis
Results
Belgium (N = 17) | Austria (N = 27) | Denmark (N = 29) | Italy (N = 35) | |
---|---|---|---|---|
number of prisoners on the day of the study | 6046 | 8724 | 3361 | 14229 |
number of prisoners on the day of the study per prison - Mean (min-max) | 356 (50–1126) | 312 (58–1146) | 116 (14–489) | 407 (30–1519) |
number of prisoners on the day of the study per prison- n(%) | ||||
<100 | 2 (11.8) | 3 (10.7) | 17 (58.6) | 5 (14.3) |
[100-350[ | 9 (52.9) | 14 (50.0) | 11 (37.9) | 15 (42.9) |
[350-600[ | 2 (11.8) | 9 (32.1) | 1 (3.4) | 9 (25.7) |
≥600 | 4 (23.5) | 2 (7.1) | 0 (0.0) | 6 (17.1) |
Number of personnel available / prison - Mean (min-max) | ||||
Sanitary staff | 14 (3–48) | 10 (2–69) | 5 (1–36) | 24 (6–75) |
Doctors | 3 (1–7) | 5 (1–28) | 2 (1–7) | 14 (3–43) |
Nurses | 10 (1–36) | 5 (1–44) | 3 (0–19) | 10 (2–34) |
Security staff | 254 (42–707) | 109 (22–421) | 77 (11–460) | 211 (30–950) |
Social workers | 7 (1–18) | 4 (1–12) | 2 (1–8) | 5 (1–17) |
Number of personnel available/100 prisoners - Mean (min-max) | ||||
Sanitary staff | 4 (2–12) | 4 (1–43) | 5 (2–18) | 8 (2–37) |
Doctors | 1 (0.4-6) | 2 (0.4-8) | 2 (0.4-7) | 5 (1–23) |
Nurses | 3 (1–6) | 2 (0.2-28) | 1 (0–5) | 3 (1–13) |
Security staff | 70 (48–86) | 37 (27–74) | 64 (34–170) | 29 (17–160) |
Social worker | 2 (0.4-7) | 2 (1–7) | 3 (0.4-9) | 2 (1–3) |
Available Consultation- n(%) | ||||
HIV (yes vs. no) | 2 (11.8) | 28 (100) | 28 (95.6) | 30 (85.7) |
HCV/HBV (yes vs. no) | 2 (11.8) | 28 (100) | 28 (95.6) | 30 (85.7) |
Psychiatric (yes vs. no) | 14 (82.4) | 26 (92.9) | 25 (86.2) | 35 (100) |
Attendance of any NGO (yes vs. no) | 7 (50) | 5 (19.2) | 0 (0) | 11 (31.4) |
Type- n(%) | ||||
RC only | 5 (29) | 16 (55) | 30 (86) | |
PS only | 5 (29) | 10 (36) | 3 (11) | 5 (14) |
SPS only | 1 (3) | |||
JUV only | ||||
RC-PS | 5 (29) | 4 (14) | 3 (11) | |
PS-JUV | 2 (7) | |||
PS-SPS | 1 (3) | |||
RC-SPS | 4 (14) | |||
RC-PS- SPS | 2 (12) | 1 (3) | ||
RC-PS- SPS-JUV | 12 (43) | |||
Gender- n(%) | ||||
Male | 12 (71) | 13 (46) | 3 (10) | 18 (56) |
Female | 1 (6) | 1 (4) | 0 | 0 |
Mixed | 4 (24) | 14 (50) | 26 (90) | 14 (54) |
Descriptive results
E4 analysis
Belgium (N = 17/35) | Austria (N = 28/28) | Denmark (N = 29/50) | Italy (N = 35/205) |
P
*
| |
---|---|---|---|---|---|
Information-Education-Communication |
0
|
0
|
0
|
0
| |
• Availability of Information/education at entry or during prison stay | 15 (88.2) | 28 (100.0) | 3 (10.3) | 13 (37.1) |
<10
−3
|
• Peer education programs available | 4 (23.5) | 2 (7.1) | 4 (13.8) | 1 (2.9) |
0.07
|
• Availability of clean injecting equipment + condoms | 0 | 0 | 0 | 0 | |
Testing – Counseling |
0
|
0
|
0
|
0
| |
• Testing for HIV, HBV, HCV systematically proposed at entry (RC) and during prison stay (all prisons) | 3 (17.7) | 11 (39.3) | 8 (27.6) | 35 (100.0) |
<10
−3
|
• Availability of clean injecting equipment + condoms | 0 | 0 | 0 | 0 | |
Condoms - Lubricants |
9 (52.9)
|
8 (28.6)
|
2 (6.9)
|
0 (0.0)
|
0.002 ł
|
• Condoms available in various locations | 12 (70.6) | 14 (50.0) | 14 (48.3) | 0 (0.0) |
0.29 ł
|
• Water-based lubricants available | 13 (76.5) | 23 (82.1) | 6 (20.7) | 0 (0.0) |
<10-3 ł
|
• Male condoms and lubricants accessible and female condoms accessible for prisons with female prisoners | 14 (82.4) | 14 (50.0) | 13 (44.8) | 0 (0.0) |
0.04 ł
|
Opioid Substitution Therapy |
4 (23.5)
|
6 (21.4)
|
7 (24.1)
|
5 (14.3)
|
0.66
|
• Induction at entry (RC) + induction during prison stay + continuity of OST at entry (all prisons) | 11 (64.7) | 20 (71.4) | 24 (82.8) | 12 (34.3) |
0.0001
|
• No ceiling dosage | 8 (47.1) | 15 (53.6) | 19 (65.5) | 30 (85.7) |
0.05
|
• No buprenorphine crushing or dilution | 15 (88.2) | 17 (60.7) | 11 (37.9) | 17 (48.6) |
0.002
|
Bleach |
0 (0.0)
|
11 (39.3)
|
11 (37.9)
|
0 (0.0)
|
<10
−3
|
• At least 2 locations/access for bleach inside prison (penitentiary distribution, purchasable inside prison, available in medical unit) | 0 (0.0) | 20 (71.4) | 17 (58.6) | 0 (0.0) |
<10
−3
|
• Intelligible information for HR purposes accessible to all prisoners | 4 (23.5) | 13 (46.4) | 12 (41.4) | 0 (0.0) |
0.30 ł
|
HBV Vaccination (systematic proposal for unprotected inmates) |
0 (0.0)
|
4 (14.3)
|
3 (10.3)
|
18 (51.4)
|
<10
−3
|
Post-Exposition Prophylaxis (inmates informed of the availability of PEP) |
0 (0.0)
|
11 (39.3)
|
1 (3.5)
|
27 (77.1)
|
<10
−3
|
Needle Exchange Programs |
0
|
0
|
0
|
0
| |
ARV treatment |
14 (82.4)
|
27 (96.4)
|
29 (100.0)
|
33 (94.3)
|
0.11
|
• ARV are accessible | 17 (100.0) | 27 (100.0) | 29 (100.00) | 33 (89.2) |
0.24
|
• Prescriptions follow national guidelines | 14 (82.4) | 27 (96.4) | 29 (100.0) | 33 (94.3) |
0.11
|
Prevention of transmission through tattooing, piercing |
2 (11.8)
|
0 (0.0)
|
5 (17.2)
|
0 (0.0)
|
0.01
|
Total score, median (Q1-Q3) | 4.0 (3.5-4.5) | 4.5 (3–6.5) | 4.0 (3.0-4.5) | 3.5 (2.5-4) | 0.0014 |
E5 analysis
Coef (IC95 %) |
p
| |
---|---|---|
Country | ||
Austria | 1 | |
Belgium | −0.50 (−1.25 ; 0.26) |
0.20
|
Denmark | −0.93 (−1.52 ; −0.34) |
0.002
|
Italy | −1.71 (−2.28 ; −1.14) |
<10
−3
|
France | −0.95 (−1.45; −0.45) |
0.0002
|
Regressions analysis
Belgium (N = 11) | Austria (N = 19) | Denmark (N = 29) | Italy (N = 35) | |||||
---|---|---|---|---|---|---|---|---|
Coef (IC95 %) |
P
| Coef (IC95 %) |
P
| Coef (IC95 %) |
P
| Coef (IC95 %) |
P
| |
Number of prisoners on the day of the study/100 | 0.03 (−0.14;0.19) |
0.72
| 0.14 (−0.15;0.44) |
0.33
| 0.06 (−0.31;0.45) |
0.73
| −0.01 (−0.09;0.08) |
0.85
|
Number of personnel available/number of prisoners on the day of the study | ||||||||
Sanitary staff | 0.09 (−27.20;27.38) |
0.99
| 5.94 (−2.03;13.91) |
0.13
| −0.14 (−13.33;13.05) |
0.98
| 2.36 (−3.17;7.89) |
0.39
|
Doctors (*100) | −0.71 (−1.48; 0.06) |
0.07
| 0.43 (−0.05;0.91) |
0.08
| −0.01 (−0.24;0.22) |
0.89
| 0.03 (−0.04;0.12) |
0.42
|
Full time doctors (*100) | -- | -- | 0.40 (−1.12;1.93) |
0.59
| -- | |||
Nurses (*100) | −0.05 (−0.43;0.33) |
0.75
| 0.10 (−0.02;0.22) |
0.11
| 0.02 (−0.28;0.33) |
0.89
| 0.05 (−0.09;0.20) |
0.47
|
Full time nurses (*100) | -- | -- | 0.09 (−0.33;0.51) |
0.66
| -- | |||
Security staff |
−5.67 (−10.92;-0.43)
|
0.04
| 6.47 (−0.75;13.70) |
0.07
| −0.71 (−2.09;0.66) |
0.30
| −0.18 (−1.15;1.52) |
0.78
|
Social workers | −10.25 (−37.30;16.80) |
0.41
| 52.63 (−16.04;121.30) |
0.12
| −5.31 (−25.96;15.32) |
0.60
| −5.37 (−54.13;-43.57) |
0.82
|
Available Consultation | ||||||||
HIV (yes vs. no) | −0.11 (−1.47;1.26) |
0.86
| -- | −0.67 (−2.86;1.51) |
0.53
| 0.17 (−0.71;1.05) |
0.70
| |
HCV/HBV (yes vs. no) | −0.11 (−1.47;1.26) |
0.86
| -- | −0.67 (−2.86;1.51) |
0.53
| −0.30 (−1.17;0.57) |
0.49
| |
Psychiatric (yes vs. no) | −1.00 (−2.67;0.68) |
0.21
| 0.18 (−2.38;2.74) |
0.89
| −0.32 (−1.48;0.83) |
0.60
| -- | |
Attendance of any NGO (yes vs. no) | −0.41 (−1.48;0.65) |
0.39
| 0.70 (−1.24;2.63) |
0.46
| -- | −0.55 (−1.18;-0.08) |
0.08
| |
Number of different prison types | ||||||||
1 | ||||||||
2 | −0.14 (−1.65;1.37) |
0.83
| −0.87 (−2.86;1.11) |
0.36
| −0.15 (−1.07;0.77) |
0.74
| -- | |
3 | −0.14 (−1.65;1.37) |
0.83
| −1.56 (−3.20;0.08) |
0.06
| −0.40 (−2.65;1.85) | 0.72 | -- | |
Mixed male/female prison | ||||||||
No | 1 | |||||||
Yes | 0.02 (−0.67;0.71) |
0.95
|
−1.72 (−2.52 ;-0.92)
|
<10
−3
| 0.08 (−0.62;0.78) |
0.81
| −0.50 (−1.13;0.13) |
0.11
|
Type of prison | ||||||||
RC | 1 |
1
| 1 | 1 | ||||
PS | −0.13 (−0.87;0.62) |
0.73
| 0.70 (−0.40;1.81) |
0.21
| 0.23 (−0.60;1.06) | 0.58 | 0.07 (−0.82;0.95) |
0.88
|
SPS | −0.13 (−1.27;1.02) |
0.82
| -- |
--
| −0.05 (−0.93;0.82) | 0.90 | -- |
--
|
JUV | -- | -- | 0.27 (−1.05;1.58) |
0.68
| -- | -- | -- |
--
|
Coef (IC95 %) |
p
| |
---|---|---|
Penitential density for 100 places | −0.02 (−0.04 ; 0.002) |
0.08
|
Percentage of prisoners primarily sentenced for drug offences | −0.02 (−0.08 ; 0.03) |
0.33
|
Number of prisoners per security staff member | 0.44 (−0.51 ; 1.39) |
0.37
|
Number of prisoners per other professional | −0.01 (−0.04 ; 0.01) |
0.22
|