Research Paper
Longitudinal injecting risk behaviours among people with a history of injecting drug use in an Australian prison setting: The HITS-p study

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Abstract

Background

HCV transmission remains high in prisons globally. Understanding injecting risk behaviours in prisons is crucial to effectively develop and implement HCV prevention programs in this setting including treatment as prevention.

Methods

HITS-p is a cohort study which enrolled people with a history of injecting drug use in prisons in NSW, Australia from 2005 to 2013. Participants completed an interview at enrolment and follow-up visits to determine injecting behaviours. Generalized estimating equation (GEE) and logistic regression methods were used to assess injecting risk behaviours prior to and following prison entry and to investigate injecting risk behaviours in prison.

Results

Overall, 499 participants with a history of injecting drug use were included (median age, 26 years; 65% male). Participants were significantly less likely to inject drugs following incarceration. Among injectors, participants were less likely to inject ≥weekly but more likely to share a needle/syringe. At enrolment, the proportion reporting any injecting, ≥weekly injecting, and needle/syringe sharing in prison was highest among younger individuals. Younger age was associated with both re-initiation and continuation of injecting drug use following prison entry. Among those continuously imprisoned, younger age was associated with increased odds of any injecting, ≥weekly injecting, and sharing a needle/syringe.

Conclusions

Upon entry to prison, injecting drug use decreased but syringe sharing increased among injectors. Younger individuals are most likely to exhibit high-risk injecting behaviours in prison. These data highlight the need for improved HCV prevention strategies (including improved needle/syringe access and scale up of HCV therapy) for those at increased risk of HCV transmission in prison, including younger individuals.

Introduction

In most countries, drug policies often result in the incarceration of people who inject drugs (PWID) for the use or possession of drugs (Dolan et al., 2016). Injecting drug use is known to continue in the prison setting (Bretana et al., 2015; Dolan et al., 2016; Hayashi et al., 2009; Kinner, Jenkinson, Gouillou, & Milloy, 2012; Pollini et al., 2009) and is a key route for the transmission of HIV and hepatitis C virus (HCV) infections (Hajarizadeh, Grebely, & Dore, 2013; Lavanchy, 2009; Nelson et al., 2011). However, in most countries, harm reduction strategies, such as high-coverage needle and syringe programs (NSP) and opioid substitution therapy (OST), that have been demonstrated to be effective in the prevention of HIV and HCV infections, are unavailable in prisons (Aspinall et al., 2014; Degenhardt et al., 2010; Grebely et al., 2015; Hagan, Pouget, & Des Jarlais, 2011; MacArthur et al., 2014; Nolan et al., 2014; Platt et al., 2016; Tsui, Evans, Lum, Hahn, & Page, 2014; Turner et al., 2011; van den Berg et al., 2007; White, Dore, Lloyd, Rawlinson, & Maher, 2014). Combined with the disproportionately high prevalence of blood borne viruses among prison inmates globally (Dolan et al., 2016), correctional centres are a high-risk environment for the acquisition and transmission of HCV and HIV (Abiona, Balogun, Adefuye, & Sloan, 2009; Butler, Levy, Dolan, & Kaldor, 2003; Cunningham et al., 2017; Fazel, Bains, & Doll, 2006; Indig et al., 2009; Larney et al., 2013). As such, prisons represent a key setting to deploy both prevention and treatment strategies for PWID. In Australia, while the prevalence of HIV in prisons is low (<1%) the seroprevalence of HCV is considerably higher with approximately half of PWID in prison being HCV antibody positive (Butler, Callander, & Simpson, 2015).

There exists limited data globally on injecting risk behaviours among PWID in prisons to inform the effective targeting of harm reduction and treatment strategies. Previous studies that have investigated injecting risk behaviours in prison settings have been limited to single prisons or have been retrospective or cross-sectional, thus limiting the evaluation of longitudinal injecting risk behaviours prior to and during imprisonment (Fazel et al., 2006; Kinner, Milloy et al., 2012; A. Watkins, Mak, & Connelly, 2011; Wright, Tompkins, & Farragher, 2015). In an observational cohort of people with a history of injecting drug use at risk of HCV infection in Australia (the HITS-p study), the incidence of primary HCV infection was 6.3 cases per 100 person-years among the continuously imprisoned population (Cunningham et al., 2017). Further, needle and syringe sharing in prison was associated with incident HCV infection, highlighting the importance of ongoing injecting risk behaviours for acquisition of HCV infection in prison (Cunningham et al., 2017). As such, we sought to investigate injecting risk behaviours among a population of prisoners with a history of injecting drug use, including a longitudinal characterisation of injecting behaviours among those entering prison, and among those continuously in prison. These data are needed to assist in designing more sophisticated strategies to prevent HCV transmission in the prison setting.

This study aimed to investigate changes in injecting risk behaviours and drug use patterns prior to, and during, incarceration among people with a history of injecting drug use enrolled in the HITS-p cohort between 2005 and 2014. This study also aimed to evaluate factors associated with re-initiation of injecting drug use and the association between age and ongoing injecting risk behaviours in prison.

Section snippets

Study design and population

HITS-p was a prospective cohort of prisoners enrolled between 2005 and 2013 and followed until 2014 in New South Wales (NSW), Australia. Enrolment occurred in two distinct enrolment periods (2005–2009 and 2012–2014) with a period of no enrolment in the intervening time. Adult male and female inmates were recruited in 23 of 35 correctional centres in NSW and followed across 30 centres as described previously (Dolan et al., 2010).

Participants were enrolled into the HITS-p cohort if they: were

Participant characteristics

In total, 499 participants who enrolled in HITS-p from 2005 to 2009 were included in this analysis. The baseline participant characteristics are presented in Table 1. The majority of participants were male (65%) with a median age of 26 years. The median time in prison at enrolment was five months (IQR, 3–11 months) and the mean was 11 months (SD, 21 months). Overall, 71% (n = 354) of participants reported injecting drugs in the three months before entering prison and 31% (108/354) continued to

Discussion

This study investigated injecting risk behaviours among a cohort of PWID in the prison setting. The results demonstrate that following entry into prison, participants were less likely to report any injecting drug use, but among those who did inject, they were more likely to report sharing a needle/syringe. Younger age was associated with increased odds of continuing injecting, re-initiation of injecting, and ongoing injecting during follow-up in prison. These findings highlight the need for

Role of funding source

Nothing declared.

Contributors

AL, FL were responsible for design and implementation of the HITS-p study. EBC, JG, AL, LD, SL, GJD were responsible for design and implementation of this analysis. EBC, JG, BH, JA, NAB were responsible for analysis of the data. EBC was responsible for writing the manuscript. All authors reviewed and gave approval for publication.

Conflicts of interest

GJD is a consultant/advisor and has received research grants from AbbVie, Abbot Diagnostics, Bristol-Myers Squibb, Cepheid, Gilead, GlaxoSmithKline, Merck, Janssen and Roche. JG is a consultant/advisor and has received research grants from AbbVie, Bristol-Myers Squibb, Cepheid, Gilead Sciences and Merck/MSD. AL is a consultant/advisor and has received research grants from Bristol-Myers Squibb, Gilead and Merck.

Acknowledgements

The Kirby Institute is funded by the Australian Government Department of Health and Ageing and is affiliated with the Faculty of Medicine, UNSW. Sydney. The views expressed in this publication do not necessarily represent the position of the Australian Government. The HITS-p investigators include: Andrew Lloyd, Kate Dolan, Paul Haber, William Rawlinson, Carla Treloar, Greg Dore, Lisa Maher, and Fabio Luciani. The HITS-p cohort has been supported by grants from NHMRC (Nos. 222887 and 1016351)

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    1

    Contributed equally.

    2

    The HITS-p investigators are listed in Acknowledgments.

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