People who use drugs were over 50% more likely to acquire
hepatitis C between 2004 and 2019 if they spent even a brief period in prison,
a prospective study carried out in Montréal, Canada, reports.
Improving harm reduction services in short-stay correctional
facilities and exploring alternatives to custodial sentences or remand for
people who use drugs might have an impact on hepatitis C infection rates in
people who use drugs, the researchers say.
Prison is a high-risk environment for hepatitis C
transmission. Prison populations have a high prevalence of hepatitis C and drug
use is common despite prohibitions on the use of drugs in prisons. Lack of harm
reduction measures in most countries means that sharing of injecting equipment
or inadequate cleaning is common. Opioid substitution therapy that could
minimise injecting activity is also unavailable in many settings, especially
short-stay facilities such as pre-trial remand prisons.
Medical care for hepatitis C is patchy in prisons. Some
countries, such as Spain and the United Kingdom, have made comprehensive
efforts to diagnose hepatitis C and offer treatment for everyone who enters the
prison system. But in other countries, health care in prisons is less well
Incarceration can also interrupt drug treatment or attempts
to alter drug using behaviours, leading to post-imprisonment relapses into drug
Researchers at the University of Bristol investigated the
impact of imprisonment on hepatitis C acquisition in people who use drugs in
Hepatitis Cohort. The cohort has been recruiting people who use drugs since
2004 without hepatitis C antibodies, and since 2011, people who use drugs who
have been cured of hepatitis C.
Cohort members were included in this analysis if they were
tested at least twice for hepatitis C and underwent a behavioural
questionnaire, which included questions about incarceration. Between 2004 and
2019, 712 people were eligible for inclusion in the study and had a median of
six study visits.
Study participants had a median age of 38 years, 81% were
male, 32% had been homeless in the three months prior to the study visit and
44% had been diagnosed with a mental health condition. Just under half (47%)
were injecting drugs daily and 33% reported sharing injecting equipment in the
previous six months. Twenty-six per cent were receiving opioid substitution
Thirty-five per cent of participants reported at least one
episode of incarceration during the previous two years and the median number of
episodes was two. Eleven per cent reported that they had been incarcerated in
the previous three months.
Those imprisoned within the past three months were
significantly younger, more likely to be homeless, had a shorter history of
injecting drugs and were less likely to have either a college education or
stable employment than other cohort members.
The overall incidence of hepatitis C was 9.9 cases per 100.
After adjusting for demographic factors, homelessness, year and opioid
substitution therapy, people who experienced an episode of incarceration of
less than two years were 56% more likely to acquire hepatitis C compared to
those who were not incarcerated.
Short-term incarceration lasting less than a week or
incarceration at a police station (short-term remand) were each independently
associated with increases in the risk of hepatitis C of approximately 80%.
The study investigators say that it is unlikely that people
who experienced short-term incarceration acquired hepatitis C in prison or on
remand. Only ten people in the study population reported that they had injected
drugs in prison. Instead, short-term incarceration appears to have a disruptive
effect, by creating uncertainty and instability.
Several previous studies have shown that levels of drug use
and sharing of injecting equipment increase in the period immediately after
release from prison, reflecting financial and psychological stress as well as
stigmatisation. Short-term incarceration may also disrupt opioid substitution
The study investigators recommend that everyone entering
short-term incarceration should be screened for substance use and offered
opioid substitution therapy where indicated. At release, people who use drugs
should be offered harm reduction supplies and linked to services that can
Alternatives to incarceration for minor drug-related
offences should also be prioritised.