Kora DeBeck ^a and Thomas Kerr ^{a, b}

a. British Columbia Centre for Excellence in HIV/AIDS; b. Department of Medicine, University of British Columbia

Almost a decade ago, over 150 United Nations members (including Great Britain, the United States and Canada) joined together and signed a declaration committing them to achieving a ‘drug free world’ by 2008. After investing billions of dollars toward this goal, prohibition (a.k.a. ‘the war on drugs’) has failed to meet its objective of eliminating or even significantly reducing the availability of illegal drugs. Despite this, enforcement and incarceration remain the dominant approaches to drug policy throughout the world, including in those regions hardest hit by injection drug use-driven HIV epidemics, such as the former Soviet Union and Southeast Asia. [1]

The reliance on enforcement has consistently been shown to increase rather than decrease the harms associated with injection drug use, including risks for HIV infection. For example, commonly applied law enforcement strategies such as police crackdowns in drug markets have been found to increase the stigmatisation of people who use drugs and also undermine public health efforts by pushing drug users away from health and social services, including syringe exchanges. Further, a large number of studies have demonstrated that injection drug users (IDU) are often reluctant to access syringe exchanges or carry syringes on their person out of fear of arrest, and that sterile syringes are often confiscated by police. Such effects, not surprisingly, have been associated with increased rates of syringe sharing. Lastly, when police presence increases in drug markets, IDU are known to rush during the injection process to avoid confrontation with police, and in doing so often skip important steps in the injection process. For example, IDU may be less likely to clean injection sites prior to injection or dress wounds afterward, and risk of vascular damage increases as syringes are inserted in a hurried manner. These practices substantially increase risks for abscesses and bacterial infections, a problem that has been previously found to account for a majority of hospitalizations among IDU. [1]

While previous research examining the harms associated with drug enforcement has focused primarily on policing, a growing body of research is now pointing to the harms associated with incarceration. [2]

Some of the earliest work in this area focused on high risk injecting occurring in prisons, and eventually research from a handful of settings found incarceration to be strongly associated with HIV infection among IDU. This led to the establishment of prison-based needle exchanges in many settings, which have since been found to be effective in reducing syringe sharing. [3]

More recently, a growing number of researchers have been turning their attention to the impact of incarceration on HIV treatment among IDU.

It has been well-established that HIV positive IDU populations have low levels of HIV treatment up-take as well as high rates of treatment discontinuation relative to other HIV-positive populations. In Canada, we found that 50% of HIV-positive IDU participating in the Vancouver Injection Drug Users Study (VIDUS) prematurely discontinued HIV treatment. [4]

Although there are a range of potential explanations for poor adherence to HIV treatment among IDU, recent investigations indicate that interactions with the criminal justice system (primarily incarceration) are a contributing factor. In a study of 160 HIV-positive IDU in Vancouver, IDU who reported having been recently incarcerated were almost 5 times more likely to prematurely discontinue HIV treatment than those who had not experienced recent incarceration. [4]

Among all study participants who prematurely discontinued treatment, the most commonly cited reason for discontinuation was being in jail, with 44% of participants citing this reason. The second most commonly cited reason was problems with side-effects (41%). Reasons for discontinuing treatment that were cited by a smaller number of participants included being fed up with HAART (7%) and interactions with methadone (3%).

The evidence regarding incarceration and HIV treatment is not, however, entirely consistent. For example, in contrast to research undertaken in Vancouver, studies conducted in the United States, specifically Rhode Island, found that HIV-positive individuals incarcerated for 6 months or longer and receiving HIV therapy throughout this time experienced a reduction in their viral load and an increase in their CD4 lymphocyte counts – both strong indicators of successful treatment and adherence to HIV therapy. [5]

While this finding may appear to contradict other research, a recent study conducted in Vancouver by Palepu and colleagues has shown that individuals with extended prison sentences were more likely than those with shorter sentences to achieve virological suppression. [6]

More specifically, these authors found that IDU with a history of incarceration within 12 months of initiating HAART had a reduced likelihood of achieving HIV-1 RNA suppression. This is concerning as the majority of incarceration events experienced by IDU in many setting are relatively brief. In Canada, statistics indicate that the incarceration period for 70% of drug possession cases is 30 days or less and the incarceration period for 64% of drug trafficking cases is 6 months or less. [7. 8]

Given the research of Palepu and colleagues, the short duration of the majority of drug-related sentences are likely to interfere with the delivery of HIV treatment. In addition, research suggests that post-incarceration transitions back to community pose further risks to HIV therapy success among IDU. [5]

Clearly, these finding suggest that interactions with the criminal justice system are negatively affecting adherence and subsequently hindering treatment success among IDU populations. Potential explanations for low adherence in prison settings, while not fully evaluated, include: HIV-related discrimination and fear of disclosure, routines in prison that are not conducive to adherence, and poor delivery of HIV treatment within prisons. It has been argued that the structural characteristics of prisons and the associated routines make maintaining a treatment regimen in prison challenging. The dispensing intervals and dietary requirements associated with some regimens may not be easily accommodated within prisons, and prisoners may also be likely to miss medications if they go to court, are transferred, or released. It has also been suggested that prisoners may avoid taking treatment in prison in an effort to conceal their HIV status. [4]

It is well known that disclosure of HIV positive status in prison settings can result in significant negative consequences (e.g., intimidation, violence) for prisoners, and HIV-positive prisoners have been known to voluntarily enter protective custody to ensure their safety. [9]

Lastly, disclosure of HIV status may limit an active IDU’s access to shared drugs and syringes within prisons. [2]

In light of these issues, it is clear that efforts should be made to ensure that HIV-positive prisoners are given additional support designed to prevent premature discontinuation of treatment. In particular, efforts should be made to ensure that HIV-positive prisoners receive medications in a manner that preserves privacy, accommodates dietary requirements, and responds to changes in prison routines. As well, in order to reduce concerns regarding the impact of HIV disclosure on access to syringes, prison-based needle exchanges should be implemented more widely.

The impact of incarceration, sentence length and prison-release on HIV treatment adherence and outcomes warrants further investigation. However, it is already clear that much more must be done to ensure that prisoners receive and benefit from HIV treatment during all interactions with the criminal justice system and upon release prison.

References

1. Kerr T, Small W, Wood E. The public health and social impacts of drug market enforcement: A review of the evidence. International J Drug Policy. 2005;16:210-220.
2. Small W, Wood E, Jurgens R, Kerr T. Injection drug use, HIV/AIDS and incarceration: evidence from the Vancouver Injection Drug Users Study. HIV AIDS Policy Law Rev. Dec 2005;10(3):1, 5-10.
3. Kerr T, Wood E, Betteridge G, Lines R, Jurgens R. Harm reduction in prisons: a ‘rights-based analysis’. Critical Public Health. 2004;14(4):345-360.
4. Kerr T, Marshall A, Walsh J, Palepu A, Tyndall M, Montaner J, Hogg R, Wood E. Determinants of HAART discontinuation among injection drug users. AIDS Care. Jul 2005;17(5):539-549.
5. Springer SA, Pesanti E, Hodges J, Macura T, Doros G, Altice FL. Effectiveness of antiretroviral therapy among HIV-infected prisoners: reincarceration and the lack of sustained benefit after release to the community. Clin Infect Dis. Jun 15 2004;38(12):1754-1760.
6. Palepu A, Tyndall MW, Chan K, Wood E, Montaner JS, Hogg RS. Initiating highly active antiretroviral therapy and continuity of HIV care: the impact of incarceration and prison release on adherence and HIV treatment outcomes. Antivir Ther. Oct 2004;9(5):713-719.
7. La Prairie C, Gliksman L, Erickson PG, Wall R, Newton-Taylor B. Drug treatment courts-a viable option for Canada? Sentencing issues and preliminary findings from the Toronto court. Substance Use and Misuse. 2002(37):1529-1566.
8. Canada S. Adult criminal court data tables 1998/99. Ottawa: Canadian Centre for Justice Statistics; 2000.
9. Jürgens R. HIV/AIDS in Prisons: Final Report. Montreal: Canadian HIV/AIDS Legal Network; 1996.