Article
A Comparison of Risk Factors for Hepatitis C Among Young and Older Adult Prisoners
Journal of Correctional Health Care 2014, Vol. 20(4) 280-291 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078345814541536 jcx.sagepub.com
Kate van Dooren, PhD1, Stuart A. Kinner, PhD2,3,4, and Margaret Hellard, PhD4,5,6
Abstract Internationally, the prevalence of hepatitis C infection is higher among prisoners when compared to the general population, particularly among people who inject drugs. This study estimates the prevalence of, and compares the risk factors for, hepatitis C in young (< 25 years) and older ( 25 years) prisoners with a history of injection drug use. Participants were 677 sentenced prisoners in Queensland, Australia, with a lifetime history of injection drug use, recruited in the 6 weeks prior to release from custody. The prevalence of hepatitis C exposure was significantly lower in young prisoners than in older prisoners (20.7% vs. 29.4%, p ¼ .03). Risk factors for hepatitis C varied between young and older prisoners. Young people who inject drugs and who have had shorter time at risk of hepatitis C exposure are an important target group for hepatitis C prevention efforts. Keywords hepatitis C, young adults, prisoners, injection drugs, prevention
Background Internationally, the prevalence of hepatitis C infection is higher among prisoners when compared to the general population (Butler et al., 1997; Fazel & Baillargeon, 2011; Harzke et al., 2009; Macalino et al., 2004; Miller, Bi, & Ryan, 2008). In Australia, the prevalence of hepatitis C exposure among prison receptions has been estimated to be 35% and is as high as 77% for prisoners with a history of injection drug use (Hellard, Hocking, & Crofts, 2004). Incarceration represents an important
1 Queensland Centre for Intellectual and Developmental Disability, School of Medicine, The University of Queensland, Brisbane, Australia 2 Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia 3 School of Medicine, The University of Queensland, Brisbane, Australia 4 School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia 5 Centre for Population Health, Burnet Institute, Melbourne, Australia 6 The Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
Corresponding Author: Kate van Dooren, PhD, The University of Queensland, The Mater Hospital, Raymond Terrace, South Brisbane, Queensland 4001, Australia. Email: [email protected]
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opportunity to target a population who otherwise underutilize health services (Calzavara et al., 2007; Fazel & Baillargeon, 2011). Most prisoners spend a relatively short time in custody before returning to the community, and many return to risky patterns of behavior soon after release (Baldry, McConnell, Maplestone, & Peeters, 2003; Kinner, 2006). Therefore, identifying and treating hepatitis C among prisoners has the potential to confer significant public health benefit (Morrow & Project START Study Group, 2009). Community-based studies have identified those at greatest risk of hepatitis C in community settings. Subgroups of people who inject drugs, including females and ethnic minority groups, are at higher risk, as are those with a history of prior imprisonment, longer history of injection drug use, polydrug use, and those who share injecting equipment and needles (Maher, Chant, Jalaludin, & Sargent, 2004; Maher, Jalaludin, & Chant, 2006). In Australian prisons, tattooing has also been identified as an independent risk factor for hepatitis C, with other reported risk factors including piercings, shared toothbrushes, use of unclean barber shears and razors, and fights with other inmates (Hellard, Aitken, & Hocking, 2007; Jafari, Copes, Baharlou, Etminan, & Buxton, 2010; Post et al., 2001). There is persuasive evidence that the associations between these risk factors and in-prison injection are of considerable concern from both prison and public health perspectives (Kinner, Jenkinson, Gouillou, & Milloy, 2012). Another important at-risk subgroup is young people, internationally defined as those aged less than 25 years (Maher et al., 2006). In the community, young people who inject drugs report significantly different drug use patterns and higher rates of risk behaviors compared to their older counterparts (Degenhardt et al., 2008; Gidding, Amin, Dore, Ward, & Law, 2010; Jafari et al., 2010). They are more likely to get tattoos, have a greater dependence on others for administering their first injection and obtaining injecting equipment, and have shorter time exposure to education about hepatitis C transmission (Abelson et al., 2006; Australian Government Department of Health and Ageing, 2010; Cassar, Staffard, & Burns, 2009; Jafari et al., 2010). Approximately half of the people who inject drugs and who are hepatitis C positive become infected with hepatitis C within two to five years of their initial injection, highlighting the need for harm reduction measures to prevent the transmission of hepatitis C among young people who inject drugs (Maher et al., 2006; Miller, Hellard, Bowden, Bharadwaj, & Aiken, 2009; Miller et al., 2008). Young incarcerated people who inject drugs are likely to have greater health-related needs compared to their community peers, given the high prevalence of social disadvantage and poor health outcomes among prisoner populations (Australian Institute of Health and Welfare, 2010; Hammett, Roberts, & Kennedy, 2001). The high prevalence of hepatitis C among young people in Australian juvenile detention centers has led to calls for age-appropriate education on injecting practices, as well as prevention interventions and therapeutic treatment of substance use (Edlin, 2002). However, little evidence exists to support the development and implementation of such programs for young people who inject drugs and who are incarcerated in adult prisons. To inform the debate on whether young prisoners in adult prisons require age-specific interventions, this study estimates the prevalence of, and compares the risk factors for, hepatitis C in young and older prisoners who inject drugs. In this study, we focus on (a) demographic factors, to identify whether specific subgroups experience greater prevalence of hepatitis C, and (b) risky substance use behaviors in prison.
Methods Data Collection Data were collected using face-to-face, confidential interviews in seven adult correctional centers in Queensland, Australia (N ¼ 1,325). These interviews provided baseline data for a randomized
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controlled trial of an intervention designed to improve health outcomes for ex-prisoners, with baseline assessment preceding randomization (Kinner, 2008; Kinner, Lennox, & Taylor, 2009). This study uses cross-sectional data arising out of the baseline assessment, which covered demographic characteristics and preincarceration living circumstances, criminal history, hepatitis C status, patterns of alcohol and other drug use, and risky substance use behaviors. Interviews typically took 60 to 90 minutes to complete. Ethical clearance for the study was granted by The University of Queensland’s Behavioural and Social Sciences Ethical Review Committee and the Queensland Corrective Services Research Committee.
Participants For the purposes of this study, sentenced prisoners who reported ever injecting drugs (referred to as those with a lifetime history of injection drug use), who were within 6 weeks of release from custody (full-time or parole) at the time of interview, and who provided informed, written consent were eligible to participate. Those on remand (pretrial detainees) were excluded due to uncertainty regarding release. Young prisoners were defined as those aged < 25 years and older prisoners as those aged 25 years.
Measures Participants were considered hepatitis C positive if prison medical records indicated that the prisoner had antibodies to the hepatitis C virus (anti-HCV positive), indicating previous exposure to hepatitis C with or without current infection. Among our eligible participants, 59.8% (N ¼ 405) had such records. We included independent variables identified from the literature as risk factors for hepatitis C in community and/or prison settings, including lifetime history of injection drug use; history of sharing injecting equipment in prison; and daily preincarceration use of alcohol, cannabis, methamphetamines, or heroin. We also included female sex, sexual identity other than heterosexual (i.e., gay, lesbian, bisexual, or transgendered [GLBT]), previous juvenile or adult incarceration, and history of tattooing while incarcerated. Characteristics known to differ between young people and adults, such as educational attainment (10 years of education is the mandatory minimum in Australian schools), current marital status, and employment and accommodation status in the six months prior to current incarceration, were also included (Commission for Children and Young People and Child Guardian, 2007; Queensland Department of Employment and Training, 2002).
Data Analysis We evaluated the differences between young and older prisoners using Pearson’s w2 test for categorical data and t-tests for continuous variables. To test the associations between hepatitis C status and demographics, criminal history, and health risk behaviors, we first conducted univariate logistic regression. Variables with an association at p .10 in univariate analyses were included in a multivariate logistic regression model. Through a process of backward elimination, we removed variables that were not significant from the multivariate model, so that all variables in the final model were significant at p .05. All analyses were performed using STATA v.11 (StataCorp, 2009).
Results First we compared the study participants with all prison releases in Queensland during the period of recruitment. The sample included 164 participants aged < 25 years (interquartile range [IQR] ¼ 20.0
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Table 1. Characteristics of Study Sample and All Adults Released From Queensland Prisons During the Period of Recruitment.
Mean age in years (IQR) Male (%) Indigenous (%) Married on prison reception (%) Mean sentence length in years (IQR) Previous imprisonment (%) Self-harm history (%)
Participants (N ¼ 677)
All Releases (N ¼ 10,788)
p
30.5 (25.0–36.0) 76.3 20.3 4.13 1.55 (0.00–2.00) 76.5 25.7
32.5 (24.0–39.0) 89.0 30.5 7.49 1.52 (0.00–2.00) 59.0 19.0
< .001 < .001 < .001 .12 .71 < .001 < .001
Note. IQR ¼ interquartile range.
to 23.0 years) and 513 participants aged 25 years (IQR ¼ 29.0 to 42.0 years) with valid responses on all variables of interest. Consistent with the restriction of our sample to prisoners who inject drugs, study participants were significantly more likely than other prisoners to have served a previous prison sentence and to have been flagged by prison staff as being at risk of self-harm, and significantly less likely to identify as indigenous or to be male (Table 1). Among study participants, 27.3% were anti-HCV positive. Hepatitis C prevalence was significantly lower among young prisoners who inject drugs than among older prisoners who inject drugs (20.7% vs. 29.4%, p ¼ .03).
Differences in Demographics and Risk Behaviors Compared to their older counterparts, young prisoners reported a higher mean age of first drug injection (p < .001) and were significantly more likely to report preincarceration unemployment (p < .001; Table 2). Compared to their young counterparts, older prisoners were significantly more likely to report a history of being tattooed in prison (p ¼ .04); however, there were no significant differences between age groups with respect to sharing needles or equipment in prison (p > .05).
Predictors of Hepatitis C Exposure Univariate analysis. In univariate analyses, for both age groups previous incarceration in adult prison and history of injecting drugs and being tattooed in prison were associated with being anti-HCV positive (Table 3). However, there were differences between the groups. For young prisoners only, GLBT sexual identity, low educational attainment, preincarceration daily heroin use, and being married were associated with being anti-HCV positive (all ps .10). For older prisoners only, female sex, history of previous juvenile incarceration, and preincarceration daily methamphetamine use were associated with being anti-HCV positive (p .10). Multivariate analysis. For young prisoners, GLBT sexual identity (adjusted odds ratio [AOR] ¼ 6.67, 95% confidence interval [CI] [1.98, 22.5]) and low educational attainment (AOR ¼ 2.57, 95% CI [1.03, 6.40]) were significant, independent correlates of being anti-HCV positive. For both age groups, history of injecting in prison was strongly and significantly associated with being antiHCV positive (< 25 years: AOR ¼ 2.37, 95% CI [1.03, 5.45]; 25 years AOR ¼ 2.08, 95% CI [1.37, 3.16]). Among the older group, female sex (AOR ¼ 2.11, 95% CI [1.31, 3.40]) and history of juvenile incarceration (AOR ¼ 1.67, 95% CI [1.10, 2.52]) were significant, independent correlates of being anti-HCV positive.
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Table 2. Descriptive Statistics for Young and Older Prisoners With Lifetime History of Injection Drug Use.
Demographics Mean age in years (IQR) Femalea (%) Indigenous (%) Married (%) GLBT (%) < 10 years of schooling (%) Unemployedb (%) Unstable accommodationb (%) History of incarceration History of juvenile incarceration (%) Previous adult incarceration (%) Hepatitis C status Antibody positive (%) Risky behaviors Tattooed in prisonc (%) Mean age of first injection drug use in years (IQR) Daily used: Alcohol (%) Cannabis (%) Methamphetamines (%) Heroin (%) Ever injected drugs in prisonc (%) Ever used someone else’s needle in prisonc (%) Ever used someone else’s equipment in prisonc (%)
Young (Aged < 25 Years) N ¼ 164
Older (Aged 25 Years) N ¼ 513
p
21.7 (20.0–23.0) 22.6 26.8 29.3 9.15 59.2 56.7 20.7
33.3 (29.0–42.0) 24.2 19.1 36.5 7.02 46.8 40.9 24.2
< .001 .67 .03 .09 .37 .01 < .001 .37
37.8 86.7
32.0 72.0
.17 < .001
20.7
29.4
.03
24.4 18.6 (14.0-18.0)
32.9 16.2 (15.0-21.0)
35.4 47.6 31.1 13.4 33.5 25.0 23.8
33.7 39.0 28.3 18.9 39.6 19.9 18.1
.04 < .001 .70 .05 .49 .11 .17 .16 .11
Note. IQR ¼ interquartile range. GLBT ¼ gay, lesbian, bisexual, or transgendered. a Females were oversampled in the study. b In 6 months prior to incarceration. c Lifetime history. d In 3 months prior to incarceration.
Discussion It is now well documented that the prevalence of hepatitis C is high among prisoners (Butler et al., 1997; Fazel & Baillargeon, 2011; Harzke et al., 2009; Macalino et al., 2004; Miller et al., 2008), and the results of our study are consistent with this. Importantly, this study has identified that, while still unacceptably high, the prevalence of hepatitis C is lower in young soon-to-be-released prisoners who inject drugs than among their older counterparts. Further, there are differences in the risk factors for hepatitis C between the two groups. Our findings suggest that there are unique, age-specific opportunities to prevent hepatitis C infection in prisoners aged < 25 years. Understanding hepatitis C risk in young people who inject drugs and who are soon to be released into the community will help inform interventions specifically targeted at this group (Dolan et al., 2010), ultimately improving both the health of young prisoners and the health of the communities to which they return (Levy, 2005). In our study, young prisoners reported later initiation into injecting and were less likely to have been tattooed in prison, although prison tattoos were reported by a substantial minority of both groups. Conversely, compared to their older counterparts, young prisoners were characterized by a higher prevalence of low educational attainment and, despite their younger age, a higher
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Table 3. Univariate and Multivariate Analysis of Factors Associated With Hepatitis C Among Young and Older Prisoners With Lifetime History of Injection Drug Use. Young (Aged < 25 Years) OR (95% CI) Sex Female vs. male Indigenous Australian Yes vs. no Unstable accommodationa Yes vs. no Unemploymenta Yes vs. no Marital status Married vs. other Sexual identity GLBT vs. heterosexual Schooling 10 years vs. < 10 years Previous juvenile incarceration Yes vs. no Previous adult incarceration Yes vs. no Tattoo in prison (ever) Yes vs. no Mean age of first injection drug use Each year younger Used daily (yes vs. no)b Alcohol Cannabis Methamphetamines Heroin Ever injected in prison Yes vs. no Ever shared needle in prison Yes vs. no Ever shared equipment in prison Yes vs. no
AOR (95% CI)
Older (Aged 25 Years) OR (95% CI)
AOR (95% CI)
1.59 [0.68, 3.72]
1.45 [0.94, 2.23] 2.11 [1.31, 3.40]
0.80 [0.33, 1.93]
0.89 [0.55, 1.46]
1.51 [0.63, 3.64]
1.13 [0.73, 1.76]
1.30 [0.60, 2.82]
1.22 [0.83, 1.79]
1.98 [0.90, 4.34]
0.85 [0.57, 1.26]
3.95 [1.32, 11.8] 6.67 [1.98, 22.5] 0.92 [0.43, 1.95] 2.23 [0.97, 5.17] 2.57 [1.03, 6.40] 1.32 [0.90, 1.92] 1.62 [0.76, 3.48]
1.64 [1.10, 2.43] 1.67 [1.10, 2.52]
2.67 [0.96, 7.40]
2.11 [1.10, 4.08]
2.36 [1.05, 5.31]
1.66 [1.12, 2.46]
0.85 [0.73, 0.99]
0.99 [0.95, 1.02]
0.99 1.13 1.50 2.54
1.09 [0.73, 1.05 [0.71, 1.45 [0.96, 1.46 [0.92,
[0.45, 2.19] [0.53, 2.41] [0.68, 3.30] [0.97, 6.71]
1.63] 1.54] 2.19] 2.32]
2.07 [0.96, 4.48] 2.37 [1.03, 5.45] 1.80 [1.23, 2.65] 2.08 [1.37, 3.16] 1.90 [0.84, 4.29]
1.12 [0.70, 1.79]
2.08 [0.91, 4.73]
1.11 [0.68, 1.80]
Note. AOR ¼ adjusted odds ratio; OR ¼ odds ratio; CI ¼ confidence interval. a In 6 months prior to incarceration. b In 3 months prior to incarceration.
prevalence of previous adult incarceration. For all drugs except cannabis, young and older prisoners reported a similar prevalence of daily use in the three months prior to incarceration. Risk factors for hepatitis C varied between young and older prisoners, indicating a need for agespecific preventive interventions. For young prisoners, the risk of hepatitis C was higher for those who identified as GLBT and for those with poor educational attainment. The increased risk associated with GLBT sexual identity may be related to riskier drug-use practices in this population or with other risk factors not explored here. Although HCV is generally not well transmitted sexually, there are increasing reports of the sexual transmission of HCV in HIV-infected men who have sex with men (Bryant, Brener, Hull, & Treloar, 2010; Danta et al., 2007; Jin et al., 2010; National Centre in HIV Epidemiology and Clinical Research, 2009). As discussed subsequently, further research,
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particularly qualitative research, is needed to understand health-related risk behaviors among this group (Small, Kain, Schechter, O’Schaughnessy, & Spittal, 2005; Tompkins, Neale, Sheard, & Wright, 2007). The association between poor educational attainment and hepatitis C risk suggests that even among prisoners with a history of injection drug use, social disadvantage is a marker for elevated health risk. Among older prisoners only, risk factors for hepatitis C included previous incarceration as a juvenile and female sex. Among the older cohort, these factors may be markers of general ‘‘risk’’. Older females who have experienced the revolving door of prison may experience particularly poor physical health, whereas for young females, frequent incarceration may not yet have impacted physical health outcomes or health-related risk behaviors (Goulding, 2004). However, given that women face unique risks for hepatitis C infection, its prevention in young, female prisoners remains a high priority (Bryant et al., 2010; Bryant & Treloar, 2007). Due to gender differences in injecting risk behaviors, women who inject drugs are more likely to have overlapping sexual and drug use networks, to have a sexual partner who injects drugs, and to report being injected by others (Iversen, Wand, Gonnermann, & Maher, 2010). Shared use of injecting equipment may reflect social, sexual, and economic dynamics, where women feel compelled to share unclean equipment due to the intimacy of their sexual relationship, economic dependence on their partner, or history of or current abuse associated with lack of control or fear (Roberts, Mathers, & Degenhardt on behalf of the Reference Group to the United Nations on HIV and Injecting Drug Use, 2010). Indigenous Australians are overrepresented in Australian prisons by a factor of 14 (Australian Institute of Health and Welfare, 2010). Although in our study the prevalence of hepatitis C was lower among Indigenous Australians, given that more than one in four of the young prisoners in our sample identified as Indigenous, culturally appropriate health interventions are clearly critical, including those specific to injection drug use, risky sexual practices, and other modes of bloodborne infection transmission. Wherever possible, researchers and practitioners should be guided by Indigenous Australian health, research, and community leaders—for example, a campaign called ‘‘Love Your Liver’’ may be useful in prison and for throughcare education and prevention efforts.
Study Limitations This study had a number of limitations. First, the cross-sectional design precludes drawing causal inferences—longitudinal studies of young prisoners and ex-prisoners are required. Second, because this is not an incidence study we were unable to determine where or when the infection was acquired or the impact of prevention strategies (van Beek, Dwyer, Dore, Luo, & Kaldor, 1998). Third, while we focused on risky injecting behaviors, hepatitis C can also be transmitted through other mechanisms and, beyond tattooing, we did not explore these as risk factors (National Centre in HIV Epidemiology and Clinical Research, 2009). Fourth, our estimate of hepatitis C prevalence was likely an underestimate, given that we restricted our definition to a diagnosis recorded in prison medical records (and less than two thirds of our sample had such records) and that universal testing for hepatitis C is not conducted in Queensland prisons (van Gemert et al., 2010). Fifth, we relied on self-report to identify health-related risk behaviors, which can result in underestimation of risk-related behaviors; however, our findings are consistent with prevalence estimates in other Australian studies (Butler et al., 1997; Dolan et al., 2010; van Beek et al., 1998). Finally, it was outside the scope of this study to report on injection drug use patterns in prison (such as frequency of injection or cutting agent). Few studies have reported on injecting patterns (Kinner et al., 2012); however, evidence suggests that people inject less but share equipment more when they are incarcerated (Hellard et al., 2004; Kinner, Moore, Spittal, & Indig, 2013). Notably, even infrequent
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risk-taking behavior is associated with a high rate of HCV transmission. A recent Australian study estimated that frequency of injection in prisons varied from ‘‘isolated instances’’ to ‘‘daily or more,’’ with overall frequency of use decreasing during incarceration compared to the month prior to incarceration (Fetherston, Carruthers, Butler, Wilson, & Sindicich, 2013). Qualitative studies may be useful to determine, in richer detail, in-prison injecting patterns among prisoners and those recently released.
Implications for Future Research These findings have important public health implications for a high-risk and vulnerable segment of the population. Australia’s third National Hepatitis C Strategy (2010–2013) identifies young people as a priority population that requires access to harm reduction knowledge and skills, peer education and peer support, and age-appropriate clinical services (Australian Government Department of Health and Ageing, 2010). Clearly, these services should be extended to young people incarcerated in adult prison facilities. To be most effective, such interventions would benefit from more evidence about who among young prisoners is at greatest risk of hepatitis C and about the effectiveness and acceptability of different interventions for this population. Treatment of problematic substance use is also critical (Edlin, 2002). Given the high prevalence of mental illness experienced by young people in adult prisons (van Dooren, Kinner, & Forsyth, 2013; van Dooren, Richards, Lennox, & Kinner, 2013), treatment, education, and prevention efforts must take into account the mental health status of individuals (Mistler et al., 2006). Lifestyle factors, medication side effects, and access to and quality of health care are also important factors for young prisoners with mental illness that are amenable to change. Interventions that have high levels of participation and acceptance among individuals with hepatitis C and mental illness should be prioritized (de Hert et al., 2011). Unfortunately, Australia’s national hepatitis C strategy does not identify the GLBT population as a priority group, despite strong associations between injection drug use, sexual risk practices, and bloodborne infection (Danta et al., 2007; Lea et al., 2013). In prison and community settings in Australia, more attention is needed from policy makers, practitioners, and researchers to inform context-specific interventions that take into account the differences between heterosexual and GLBT populations, importantly in terms of injection drug use and risky sexual practices. Promisingly, other national strategies and policies in Australia have recognized and responded to the vulnerability of this group (as well as young people) in relation to mental health (e.g., Australia’s National Suicide Prevention Strategy) and the need for increased access to education and information for service providers (Carman, Corboz, & Dowsett, 2012). These recommendations are critical to service providers working with prisoners. In 2011, the Australian government funded $22.6 million for community prevention activities for high-risk groups including the GLBT community, and ideally evaluations will inform future interventions for this group. In the interim, a dedicated research agenda specific to young GLBT (ex-)prisoners to explore sexual risk and injection drug use patterns will best address the underrepresentation of this group in public health and prisoner health debate. Hepatitis C treatment will change over the next few years; it will be highly efficacious and tolerable, and treatment as prevention is being muted (Doyle, Aspinall, Liew, Thompson, & Hellard, 2013; Hellard, Doyle, Sacks-Davis, Thompson, & McBryde, 2014). However, treatment is likely to be very expensive, and it is more cost effective to educate a young prisoner about the risks of hepatitis C transmission and how to avoid infection than to initiate treatment once the same individual has become infected. Ideally, young prisoners who have not commenced injection drug use should be educated about hepatitis C, vectors for transmission, and strategies to minimize the risk of transmission, including through behaviors beyond injection drug use (e.g., risky sexual practices, unsafe tattooing or piercings). Such education programs could be delivered by experts whom
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young people are likely to access following their release from prison, such as youth workers, to help improve the continuity of support (Borzycki & Baldry, 2003). To inform these education programs, more evidence relating to the prevalence of and risk factors for hepatitis C among young prisoners is needed. Our findings are consistent with a growing body of work supporting the implementation of needle and syringe programs (NSPs) in Australian prisons (Dias, Kinner, Ware, & Lennox, 2013; Kinner et al., 2013). Currently, none of Australia’s states or territories provide clean injecting equipment in prisons, despite the success of these programs in other countries (Fetherston et al., 2013). The principle of equivalence (Lines, 2006) focuses attention on the social justice disparities that arise from the slow and piecemeal implementation of NSPs in prisons compared to the community, despite compelling evidence that NSPs reduce the spread of infection among people who inject drugs without collateral harm (Dolan, Rutter, & Wodak, 2003). Should such programs be implemented in Australian prisons, collaboration with younger prisoners and the youth sector in the design and development of prison NSPs will be essential (Dolan et al., 2003).
Conclusions While it might be considered too late for ‘‘early’’ intervention, secondary prevention to reduce transmission of hepatitis C can still be successful in adult prison facilities. Young people who inject drugs and who have had shorter time at risk of hepatitis C exposure are an important target group for hepatitis C prevention efforts. A combination of education and harm reduction interventions, focused on both the time in prisons and importantly the time immediately postrelease, has the greatest potential to reduce the burden of hepatitis C among this at-risk population. Authors’ Note K.v.D. conceived of the study, performed the statistical analysis, and drafted the manuscript. S.K. participated in the design of the study and helped to draft the manuscript. M.H. helped to draft the manuscript. All authors have read and approved the final manuscript.
Acknowledgment The authors wish to thank Queensland Corrective Services for assistance with data collection, and Passports study participants for sharing their stories. The views expressed herein are solely those of the authors, and in no way reflect the views or policies of Queensland Corrective Services.
Declaration of Conflicting Interests The authors disclosed no conflicts of interest with respect to the research, authorship, and/or publication of this article. For information about JCHC’s disclosure policy, please see the Self-Study Exam.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: K.v.D. is supported by a scholarship from Australian National Health and Medical Research Council (NHMRC) grant #409966. S.K. is supported by NHMRC career development award #1004765. M.H. is supported by an NHMRC Senior Researcher Fellowship. The Passports project is funded by NHMRC grant #409966.
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Fetherston, J., Carruthers, S., Butler, T., Wilson, D., & Sindicich, N. (2013). Rates of injection in prison in a sample of Australian-injecting drug users. Journal of Substance Use, 18, 65–73. doi:10.3109/14659891. 2012.760008 Gidding, H. F., Amin, J., Dore, G. J., Ward, K., & Law, M. G. (2010). Hospital-related morbidity in people notified with hepatitis C: A population-based record linkage study in New South Wales, Australia. Journal of Hepatology, 53, 43–49. doi:10.1016/j.jhep.2010.01.036 Goulding, D. (2004). Severed connections: An exploration of the impact of imprisonment on women’s familial and social connectedness. Perth, Australia: Centre for Social and Community Research, Murdoch University. Hammett, T. M., Roberts, C., & Kennedy, S. (2001). Health-related issues in prisoner reentry. Crime and Delinquency, 47, 390–409. Harzke, A. J., Baillargeon, J. G., Kelley, M. F., Diamond, P. M., Goodman, K. J., & Paar, D. P. (2009). HCV-related mortality among male prison inmates in Texas, 1994-2003. Annals of Epidemiology, 19, 582–589. Hellard, M., Doyle, J. S., Sacks-Davis, R., Thompson, A. J., & McBryde, E. (2014). Eradication of hepatitis C infection: The importance of targeting people who inject drugs. Hepatology, 59, 366–369. doi:10.1002/hep. 26623 Hellard, M., Hocking, J., & Crofts, N. (2004). The prevalence and the risk behaviours associated with the transmission of hepatitis C virus in Australian correctional facilities. Epidemiology and Infection, 132, 409–415. Hellard, M. E., Aitken, C. K., & Hocking, J. S. (2007). Tattooing in prisons—Not such a pretty picture. American Journal of Infection Control, 35, 477–480. doi:10.1016/j.ajic.2006.08.002 Iversen, J., Wand, H., Gonnermann, A., & Maher, L. (2010). Gender differences in hepatitis C antibody prevalence and risk behaviours amongst people who inject drugs in Australia 1998-2008. International Journal on Drug Policy, 21, 471–476. doi:10.1016/j.drugpo.2010.04.004 Jafari, S., Copes, R., Baharlou, S., Etminan, M., & Buxton, J. (2010). Tattooing and the risk of transmission of hepatitis C: A systematic review and meta-analysis. International Journal of Infectious Diseases, 14, e928–e940. doi:10.1016/j.ijid.2010.03.019 Jin, F., Prestage, G. P., Matthews, G., Zablotska, I., Rawstorne, P., Kippax, S. C., . . . Grulich, A. E. (2010). Prevalence, incidence and risk factors for hepatitis C in homosexual men: Data from two cohorts of HIV-negative and HIV-positive men in Sydney, Australia. Sexually Transmitted Infections, 86, 25–28. doi:10.1136/sti.2009.038182 Kinner, S. (2006). Continuity of health impairment and substance misuse among adult prisoners in Queensland, Australia. International Journal of Prisoner Health, 2, 101–113. Kinner, S., Jenkinson, R., Gouillou, M., & Milloy, M. (2012). High-risk drug-use practices among a large sample of Australian prisoners. Drug and Alcohol Dependence, 126, 156–160. doi:10.1016/j.drugalcdep.2012.05.008 Kinner, S. A. (2008). Passports to advantage: Health and capacity building as a basis for social integration. Flinders Journal of Law Reform, 10, 581–589. Kinner, S. A., Lennox, N. G., & Taylor, M. (2009). Randomised controlled trial of a post-release intervention for prisoners with and without an intellectual disability. Journal on Developmental Disabilities, 15, 72–76. Kinner, S. A., Moore, E., Spittal, M. J., & Indig, D. (2013). Opiate substitution treatment to reduce in-prison drug injection: A natural experiment. International Journal of Drug Policy, 24, 460–463. doi:10.1016/j. drugpo.2013.01.004 Lea, T., Mao, L., Bath, N., Prestage, G., Zablotska, I., de Wit, J., & Holt, M. (2013). Injecting drug use among gay and bisexual men in Sydney: Prevalence and associations with sexual risk practices and HIV and hepatitis C infection. AIDS and Behavior, 17, 1344–1351. doi:10.1007/s10461-013-0409-0 Levy, M. (2005). Prisoner health care provision: Reflections from Australia. International Journal of Prisoner Health, 1, 65–73.
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Lines, R. (2006). From equivalence of standards to equivalence of objectives: The entitlement of prisoners to health care standards higher than those outside prisons. International Journal of Prisoner Health, 2, 269–280. Macalino, G. E., Hou, J. C., Kumar, M. S., Taylor, L. E., Sumantera, I. G., & Rich, J. D. (2004). Hepatitis C infection and incarcerated populations. International Journal of Drug Policy, 15, 103–114. Maher, L., Chant, K., Jalaludin, B. I. N., & Sargent, P. (2004). Risk behaviors and antibody hepatitis B and C prevalence among injecting drug users in south-western Sydney, Australia. Journal of Gastroenterology and Hepatology, 19, 1114–1120. doi:10.1111/j.1440-1746.2004.03438.x Maher, L., Jalaludin, B., & Chant, K. (2006). Incidence and risk factors for hepatitis C seroconversion in injecting drug users in Australia. Addiction, 101, 1499–1508. Miller, E., Hellard, M., Bowden, S., Bharadwaj, M., & Aiken, C. (2009). Markers and risk factors for HCV, HBV and HIV in a network of injecting drug users in Melbourne, Australia. Journal of Infection, 58, 375–382. Miller, E. R., Bi, P., & Ryan, P. (2008). Hepatitis C virus infection in South Australian prisoners: Seroprevalence, seroconversion, and risk factors. International Journal of Infectious Diseases, 13, 201–208. Mistler, L. A., Brunette, M. F., Marsh, B. J., Vidaver, R. M., Luckoor, R., & Rosenberg, S. D. (2006). Hepatitis C treatment for people with severe mental illness. Psychosomatics, 47, 93–107. doi:10.1176/appi.psy. 47.2.93 Morrow, K. M., & Project START Study Group. (2009). HIV, STD, and hepatitis risk behaviors of young men before and after incarceration. AIDS Care, 21, 235–243. National Centre in HIV Epidemiology and Clinical Research. (Ed.). (2009). HIV/AIDS, viral hepatitis and sexually transmissible infections in Australia: 2009 Annual surveillance report. Sydney, Australia: The University of NSW. Post, J., Dolan, K., Whybin, L., Carter, I., Haber, P., & Lloyd, A. (2001). Acute hepatitis C virus infection in an Australian prison inmate: Tattooing as a possible transmission route. Medical Journal of Australia, 174, 183–184. Queensland Department of Employment and Training. Office of Youth Affairs. (2002). Queensland Youth Charter: The Queensland Government’s commitment to engaging with young people. Brisbane, Australia: Author. Roberts, A., Mathers, B., & Degenhardt, L., On behalf of the Reference Group to the United Nations on HIV and Injecting Drug Use. (2010). Women who inject drugs: A review of the risks, experiences and needs. Sydney, Australia: National Drug and Alcohol Research Centre, University of New South Wales. Small, W., Kain, S., Schechter, M., O’Schaughnessy, M., & Spittal, P. (2005). Incarceration, addiction and harm reduction: Inmates experience injecting drugs in prison. Substance Use and Misuse, 40, 831–843. StataCorp. (2009). Stata statistical software: Release 11. College Station, TX: StataCorp LP. Tompkins, C. N., Neale, J., Sheard, L., & Wright, N. (2007). Experiences of prison among injecting drug users in England: A qualitative study. International Journal of Prisoner Health, 3, 189–203. van Beek, I., Dwyer, R., Dore, G. J., Luo, K., & Kaldor, J. M. (1998). Infection with HIV and hepatitis C virus among injecting drug users in a prevention setting: Retrospective cohort study. British Medical Journal, 317, 433–437. van Dooren, K., Kinner, S., & Forsyth, S. (2013). Risk of death for young ex-prisoners in the year following release from adult prison. Australian and New Zealand Journal of Public Health, 37, 377–382. van Dooren, K., Richards, A., Lennox, N., & Kinner, S. (2013). Complex health-related needs among young, soon-to-be-released prisoners. Health and Justice, 1, 1–8. doi:10.1186/2194-7899-1-1 van Gemert, C., Bergeri, I., Downing, S., Hellard, M. E., Sacks-Davis, R., & Stoove, M. (2010). Evaluation of hepatitis C surveillance in Queensland 2009-2010. Victoria, Australia: Centre for Population Health, Burnet Institute.
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A Comparison of Risk Factors for Hepatitis C Among Young and Older Adult Prisoners
Journal of Correctional Health Care 2014, Vol. 20(4) 280-291 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078345814541536 jcx.sagepub.com
Kate van Dooren, PhD1, Stuart A. Kinner, PhD2,3,4, and Margaret Hellard, PhD4,5,6
Abstract Internationally, the prevalence of hepatitis C infection is higher among prisoners when compared to the general population, particularly among people who inject drugs. This study estimates the prevalence of, and compares the risk factors for, hepatitis C in young (< 25 years) and older ( 25 years) prisoners with a history of injection drug use. Participants were 677 sentenced prisoners in Queensland, Australia, with a lifetime history of injection drug use, recruited in the 6 weeks prior to release from custody. The prevalence of hepatitis C exposure was significantly lower in young prisoners than in older prisoners (20.7% vs. 29.4%, p ¼ .03). Risk factors for hepatitis C varied between young and older prisoners. Young people who inject drugs and who have had shorter time at risk of hepatitis C exposure are an important target group for hepatitis C prevention efforts. Keywords hepatitis C, young adults, prisoners, injection drugs, prevention
Background Internationally, the prevalence of hepatitis C infection is higher among prisoners when compared to the general population (Butler et al., 1997; Fazel & Baillargeon, 2011; Harzke et al., 2009; Macalino et al., 2004; Miller, Bi, & Ryan, 2008). In Australia, the prevalence of hepatitis C exposure among prison receptions has been estimated to be 35% and is as high as 77% for prisoners with a history of injection drug use (Hellard, Hocking, & Crofts, 2004). Incarceration represents an important
1 Queensland Centre for Intellectual and Developmental Disability, School of Medicine, The University of Queensland, Brisbane, Australia 2 Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia 3 School of Medicine, The University of Queensland, Brisbane, Australia 4 School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia 5 Centre for Population Health, Burnet Institute, Melbourne, Australia 6 The Nossal Institute for Global Health, The University of Melbourne, Melbourne, Australia
Corresponding Author: Kate van Dooren, PhD, The University of Queensland, The Mater Hospital, Raymond Terrace, South Brisbane, Queensland 4001, Australia. Email: [email protected]
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opportunity to target a population who otherwise underutilize health services (Calzavara et al., 2007; Fazel & Baillargeon, 2011). Most prisoners spend a relatively short time in custody before returning to the community, and many return to risky patterns of behavior soon after release (Baldry, McConnell, Maplestone, & Peeters, 2003; Kinner, 2006). Therefore, identifying and treating hepatitis C among prisoners has the potential to confer significant public health benefit (Morrow & Project START Study Group, 2009). Community-based studies have identified those at greatest risk of hepatitis C in community settings. Subgroups of people who inject drugs, including females and ethnic minority groups, are at higher risk, as are those with a history of prior imprisonment, longer history of injection drug use, polydrug use, and those who share injecting equipment and needles (Maher, Chant, Jalaludin, & Sargent, 2004; Maher, Jalaludin, & Chant, 2006). In Australian prisons, tattooing has also been identified as an independent risk factor for hepatitis C, with other reported risk factors including piercings, shared toothbrushes, use of unclean barber shears and razors, and fights with other inmates (Hellard, Aitken, & Hocking, 2007; Jafari, Copes, Baharlou, Etminan, & Buxton, 2010; Post et al., 2001). There is persuasive evidence that the associations between these risk factors and in-prison injection are of considerable concern from both prison and public health perspectives (Kinner, Jenkinson, Gouillou, & Milloy, 2012). Another important at-risk subgroup is young people, internationally defined as those aged less than 25 years (Maher et al., 2006). In the community, young people who inject drugs report significantly different drug use patterns and higher rates of risk behaviors compared to their older counterparts (Degenhardt et al., 2008; Gidding, Amin, Dore, Ward, & Law, 2010; Jafari et al., 2010). They are more likely to get tattoos, have a greater dependence on others for administering their first injection and obtaining injecting equipment, and have shorter time exposure to education about hepatitis C transmission (Abelson et al., 2006; Australian Government Department of Health and Ageing, 2010; Cassar, Staffard, & Burns, 2009; Jafari et al., 2010). Approximately half of the people who inject drugs and who are hepatitis C positive become infected with hepatitis C within two to five years of their initial injection, highlighting the need for harm reduction measures to prevent the transmission of hepatitis C among young people who inject drugs (Maher et al., 2006; Miller, Hellard, Bowden, Bharadwaj, & Aiken, 2009; Miller et al., 2008). Young incarcerated people who inject drugs are likely to have greater health-related needs compared to their community peers, given the high prevalence of social disadvantage and poor health outcomes among prisoner populations (Australian Institute of Health and Welfare, 2010; Hammett, Roberts, & Kennedy, 2001). The high prevalence of hepatitis C among young people in Australian juvenile detention centers has led to calls for age-appropriate education on injecting practices, as well as prevention interventions and therapeutic treatment of substance use (Edlin, 2002). However, little evidence exists to support the development and implementation of such programs for young people who inject drugs and who are incarcerated in adult prisons. To inform the debate on whether young prisoners in adult prisons require age-specific interventions, this study estimates the prevalence of, and compares the risk factors for, hepatitis C in young and older prisoners who inject drugs. In this study, we focus on (a) demographic factors, to identify whether specific subgroups experience greater prevalence of hepatitis C, and (b) risky substance use behaviors in prison.
Methods Data Collection Data were collected using face-to-face, confidential interviews in seven adult correctional centers in Queensland, Australia (N ¼ 1,325). These interviews provided baseline data for a randomized
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controlled trial of an intervention designed to improve health outcomes for ex-prisoners, with baseline assessment preceding randomization (Kinner, 2008; Kinner, Lennox, & Taylor, 2009). This study uses cross-sectional data arising out of the baseline assessment, which covered demographic characteristics and preincarceration living circumstances, criminal history, hepatitis C status, patterns of alcohol and other drug use, and risky substance use behaviors. Interviews typically took 60 to 90 minutes to complete. Ethical clearance for the study was granted by The University of Queensland’s Behavioural and Social Sciences Ethical Review Committee and the Queensland Corrective Services Research Committee.
Participants For the purposes of this study, sentenced prisoners who reported ever injecting drugs (referred to as those with a lifetime history of injection drug use), who were within 6 weeks of release from custody (full-time or parole) at the time of interview, and who provided informed, written consent were eligible to participate. Those on remand (pretrial detainees) were excluded due to uncertainty regarding release. Young prisoners were defined as those aged < 25 years and older prisoners as those aged 25 years.
Measures Participants were considered hepatitis C positive if prison medical records indicated that the prisoner had antibodies to the hepatitis C virus (anti-HCV positive), indicating previous exposure to hepatitis C with or without current infection. Among our eligible participants, 59.8% (N ¼ 405) had such records. We included independent variables identified from the literature as risk factors for hepatitis C in community and/or prison settings, including lifetime history of injection drug use; history of sharing injecting equipment in prison; and daily preincarceration use of alcohol, cannabis, methamphetamines, or heroin. We also included female sex, sexual identity other than heterosexual (i.e., gay, lesbian, bisexual, or transgendered [GLBT]), previous juvenile or adult incarceration, and history of tattooing while incarcerated. Characteristics known to differ between young people and adults, such as educational attainment (10 years of education is the mandatory minimum in Australian schools), current marital status, and employment and accommodation status in the six months prior to current incarceration, were also included (Commission for Children and Young People and Child Guardian, 2007; Queensland Department of Employment and Training, 2002).
Data Analysis We evaluated the differences between young and older prisoners using Pearson’s w2 test for categorical data and t-tests for continuous variables. To test the associations between hepatitis C status and demographics, criminal history, and health risk behaviors, we first conducted univariate logistic regression. Variables with an association at p .10 in univariate analyses were included in a multivariate logistic regression model. Through a process of backward elimination, we removed variables that were not significant from the multivariate model, so that all variables in the final model were significant at p .05. All analyses were performed using STATA v.11 (StataCorp, 2009).
Results First we compared the study participants with all prison releases in Queensland during the period of recruitment. The sample included 164 participants aged < 25 years (interquartile range [IQR] ¼ 20.0
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Table 1. Characteristics of Study Sample and All Adults Released From Queensland Prisons During the Period of Recruitment.
Mean age in years (IQR) Male (%) Indigenous (%) Married on prison reception (%) Mean sentence length in years (IQR) Previous imprisonment (%) Self-harm history (%)
Participants (N ¼ 677)
All Releases (N ¼ 10,788)
p
30.5 (25.0–36.0) 76.3 20.3 4.13 1.55 (0.00–2.00) 76.5 25.7
32.5 (24.0–39.0) 89.0 30.5 7.49 1.52 (0.00–2.00) 59.0 19.0
< .001 < .001 < .001 .12 .71 < .001 < .001
Note. IQR ¼ interquartile range.
to 23.0 years) and 513 participants aged 25 years (IQR ¼ 29.0 to 42.0 years) with valid responses on all variables of interest. Consistent with the restriction of our sample to prisoners who inject drugs, study participants were significantly more likely than other prisoners to have served a previous prison sentence and to have been flagged by prison staff as being at risk of self-harm, and significantly less likely to identify as indigenous or to be male (Table 1). Among study participants, 27.3% were anti-HCV positive. Hepatitis C prevalence was significantly lower among young prisoners who inject drugs than among older prisoners who inject drugs (20.7% vs. 29.4%, p ¼ .03).
Differences in Demographics and Risk Behaviors Compared to their older counterparts, young prisoners reported a higher mean age of first drug injection (p < .001) and were significantly more likely to report preincarceration unemployment (p < .001; Table 2). Compared to their young counterparts, older prisoners were significantly more likely to report a history of being tattooed in prison (p ¼ .04); however, there were no significant differences between age groups with respect to sharing needles or equipment in prison (p > .05).
Predictors of Hepatitis C Exposure Univariate analysis. In univariate analyses, for both age groups previous incarceration in adult prison and history of injecting drugs and being tattooed in prison were associated with being anti-HCV positive (Table 3). However, there were differences between the groups. For young prisoners only, GLBT sexual identity, low educational attainment, preincarceration daily heroin use, and being married were associated with being anti-HCV positive (all ps .10). For older prisoners only, female sex, history of previous juvenile incarceration, and preincarceration daily methamphetamine use were associated with being anti-HCV positive (p .10). Multivariate analysis. For young prisoners, GLBT sexual identity (adjusted odds ratio [AOR] ¼ 6.67, 95% confidence interval [CI] [1.98, 22.5]) and low educational attainment (AOR ¼ 2.57, 95% CI [1.03, 6.40]) were significant, independent correlates of being anti-HCV positive. For both age groups, history of injecting in prison was strongly and significantly associated with being antiHCV positive (< 25 years: AOR ¼ 2.37, 95% CI [1.03, 5.45]; 25 years AOR ¼ 2.08, 95% CI [1.37, 3.16]). Among the older group, female sex (AOR ¼ 2.11, 95% CI [1.31, 3.40]) and history of juvenile incarceration (AOR ¼ 1.67, 95% CI [1.10, 2.52]) were significant, independent correlates of being anti-HCV positive.
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Table 2. Descriptive Statistics for Young and Older Prisoners With Lifetime History of Injection Drug Use.
Demographics Mean age in years (IQR) Femalea (%) Indigenous (%) Married (%) GLBT (%) < 10 years of schooling (%) Unemployedb (%) Unstable accommodationb (%) History of incarceration History of juvenile incarceration (%) Previous adult incarceration (%) Hepatitis C status Antibody positive (%) Risky behaviors Tattooed in prisonc (%) Mean age of first injection drug use in years (IQR) Daily used: Alcohol (%) Cannabis (%) Methamphetamines (%) Heroin (%) Ever injected drugs in prisonc (%) Ever used someone else’s needle in prisonc (%) Ever used someone else’s equipment in prisonc (%)
Young (Aged < 25 Years) N ¼ 164
Older (Aged 25 Years) N ¼ 513
p
21.7 (20.0–23.0) 22.6 26.8 29.3 9.15 59.2 56.7 20.7
33.3 (29.0–42.0) 24.2 19.1 36.5 7.02 46.8 40.9 24.2
< .001 .67 .03 .09 .37 .01 < .001 .37
37.8 86.7
32.0 72.0
.17 < .001
20.7
29.4
.03
24.4 18.6 (14.0-18.0)
32.9 16.2 (15.0-21.0)
35.4 47.6 31.1 13.4 33.5 25.0 23.8
33.7 39.0 28.3 18.9 39.6 19.9 18.1
.04 < .001 .70 .05 .49 .11 .17 .16 .11
Note. IQR ¼ interquartile range. GLBT ¼ gay, lesbian, bisexual, or transgendered. a Females were oversampled in the study. b In 6 months prior to incarceration. c Lifetime history. d In 3 months prior to incarceration.
Discussion It is now well documented that the prevalence of hepatitis C is high among prisoners (Butler et al., 1997; Fazel & Baillargeon, 2011; Harzke et al., 2009; Macalino et al., 2004; Miller et al., 2008), and the results of our study are consistent with this. Importantly, this study has identified that, while still unacceptably high, the prevalence of hepatitis C is lower in young soon-to-be-released prisoners who inject drugs than among their older counterparts. Further, there are differences in the risk factors for hepatitis C between the two groups. Our findings suggest that there are unique, age-specific opportunities to prevent hepatitis C infection in prisoners aged < 25 years. Understanding hepatitis C risk in young people who inject drugs and who are soon to be released into the community will help inform interventions specifically targeted at this group (Dolan et al., 2010), ultimately improving both the health of young prisoners and the health of the communities to which they return (Levy, 2005). In our study, young prisoners reported later initiation into injecting and were less likely to have been tattooed in prison, although prison tattoos were reported by a substantial minority of both groups. Conversely, compared to their older counterparts, young prisoners were characterized by a higher prevalence of low educational attainment and, despite their younger age, a higher
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Table 3. Univariate and Multivariate Analysis of Factors Associated With Hepatitis C Among Young and Older Prisoners With Lifetime History of Injection Drug Use. Young (Aged < 25 Years) OR (95% CI) Sex Female vs. male Indigenous Australian Yes vs. no Unstable accommodationa Yes vs. no Unemploymenta Yes vs. no Marital status Married vs. other Sexual identity GLBT vs. heterosexual Schooling 10 years vs. < 10 years Previous juvenile incarceration Yes vs. no Previous adult incarceration Yes vs. no Tattoo in prison (ever) Yes vs. no Mean age of first injection drug use Each year younger Used daily (yes vs. no)b Alcohol Cannabis Methamphetamines Heroin Ever injected in prison Yes vs. no Ever shared needle in prison Yes vs. no Ever shared equipment in prison Yes vs. no
AOR (95% CI)
Older (Aged 25 Years) OR (95% CI)
AOR (95% CI)
1.59 [0.68, 3.72]
1.45 [0.94, 2.23] 2.11 [1.31, 3.40]
0.80 [0.33, 1.93]
0.89 [0.55, 1.46]
1.51 [0.63, 3.64]
1.13 [0.73, 1.76]
1.30 [0.60, 2.82]
1.22 [0.83, 1.79]
1.98 [0.90, 4.34]
0.85 [0.57, 1.26]
3.95 [1.32, 11.8] 6.67 [1.98, 22.5] 0.92 [0.43, 1.95] 2.23 [0.97, 5.17] 2.57 [1.03, 6.40] 1.32 [0.90, 1.92] 1.62 [0.76, 3.48]
1.64 [1.10, 2.43] 1.67 [1.10, 2.52]
2.67 [0.96, 7.40]
2.11 [1.10, 4.08]
2.36 [1.05, 5.31]
1.66 [1.12, 2.46]
0.85 [0.73, 0.99]
0.99 [0.95, 1.02]
0.99 1.13 1.50 2.54
1.09 [0.73, 1.05 [0.71, 1.45 [0.96, 1.46 [0.92,
[0.45, 2.19] [0.53, 2.41] [0.68, 3.30] [0.97, 6.71]
1.63] 1.54] 2.19] 2.32]
2.07 [0.96, 4.48] 2.37 [1.03, 5.45] 1.80 [1.23, 2.65] 2.08 [1.37, 3.16] 1.90 [0.84, 4.29]
1.12 [0.70, 1.79]
2.08 [0.91, 4.73]
1.11 [0.68, 1.80]
Note. AOR ¼ adjusted odds ratio; OR ¼ odds ratio; CI ¼ confidence interval. a In 6 months prior to incarceration. b In 3 months prior to incarceration.
prevalence of previous adult incarceration. For all drugs except cannabis, young and older prisoners reported a similar prevalence of daily use in the three months prior to incarceration. Risk factors for hepatitis C varied between young and older prisoners, indicating a need for agespecific preventive interventions. For young prisoners, the risk of hepatitis C was higher for those who identified as GLBT and for those with poor educational attainment. The increased risk associated with GLBT sexual identity may be related to riskier drug-use practices in this population or with other risk factors not explored here. Although HCV is generally not well transmitted sexually, there are increasing reports of the sexual transmission of HCV in HIV-infected men who have sex with men (Bryant, Brener, Hull, & Treloar, 2010; Danta et al., 2007; Jin et al., 2010; National Centre in HIV Epidemiology and Clinical Research, 2009). As discussed subsequently, further research,
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particularly qualitative research, is needed to understand health-related risk behaviors among this group (Small, Kain, Schechter, O’Schaughnessy, & Spittal, 2005; Tompkins, Neale, Sheard, & Wright, 2007). The association between poor educational attainment and hepatitis C risk suggests that even among prisoners with a history of injection drug use, social disadvantage is a marker for elevated health risk. Among older prisoners only, risk factors for hepatitis C included previous incarceration as a juvenile and female sex. Among the older cohort, these factors may be markers of general ‘‘risk’’. Older females who have experienced the revolving door of prison may experience particularly poor physical health, whereas for young females, frequent incarceration may not yet have impacted physical health outcomes or health-related risk behaviors (Goulding, 2004). However, given that women face unique risks for hepatitis C infection, its prevention in young, female prisoners remains a high priority (Bryant et al., 2010; Bryant & Treloar, 2007). Due to gender differences in injecting risk behaviors, women who inject drugs are more likely to have overlapping sexual and drug use networks, to have a sexual partner who injects drugs, and to report being injected by others (Iversen, Wand, Gonnermann, & Maher, 2010). Shared use of injecting equipment may reflect social, sexual, and economic dynamics, where women feel compelled to share unclean equipment due to the intimacy of their sexual relationship, economic dependence on their partner, or history of or current abuse associated with lack of control or fear (Roberts, Mathers, & Degenhardt on behalf of the Reference Group to the United Nations on HIV and Injecting Drug Use, 2010). Indigenous Australians are overrepresented in Australian prisons by a factor of 14 (Australian Institute of Health and Welfare, 2010). Although in our study the prevalence of hepatitis C was lower among Indigenous Australians, given that more than one in four of the young prisoners in our sample identified as Indigenous, culturally appropriate health interventions are clearly critical, including those specific to injection drug use, risky sexual practices, and other modes of bloodborne infection transmission. Wherever possible, researchers and practitioners should be guided by Indigenous Australian health, research, and community leaders—for example, a campaign called ‘‘Love Your Liver’’ may be useful in prison and for throughcare education and prevention efforts.
Study Limitations This study had a number of limitations. First, the cross-sectional design precludes drawing causal inferences—longitudinal studies of young prisoners and ex-prisoners are required. Second, because this is not an incidence study we were unable to determine where or when the infection was acquired or the impact of prevention strategies (van Beek, Dwyer, Dore, Luo, & Kaldor, 1998). Third, while we focused on risky injecting behaviors, hepatitis C can also be transmitted through other mechanisms and, beyond tattooing, we did not explore these as risk factors (National Centre in HIV Epidemiology and Clinical Research, 2009). Fourth, our estimate of hepatitis C prevalence was likely an underestimate, given that we restricted our definition to a diagnosis recorded in prison medical records (and less than two thirds of our sample had such records) and that universal testing for hepatitis C is not conducted in Queensland prisons (van Gemert et al., 2010). Fifth, we relied on self-report to identify health-related risk behaviors, which can result in underestimation of risk-related behaviors; however, our findings are consistent with prevalence estimates in other Australian studies (Butler et al., 1997; Dolan et al., 2010; van Beek et al., 1998). Finally, it was outside the scope of this study to report on injection drug use patterns in prison (such as frequency of injection or cutting agent). Few studies have reported on injecting patterns (Kinner et al., 2012); however, evidence suggests that people inject less but share equipment more when they are incarcerated (Hellard et al., 2004; Kinner, Moore, Spittal, & Indig, 2013). Notably, even infrequent
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risk-taking behavior is associated with a high rate of HCV transmission. A recent Australian study estimated that frequency of injection in prisons varied from ‘‘isolated instances’’ to ‘‘daily or more,’’ with overall frequency of use decreasing during incarceration compared to the month prior to incarceration (Fetherston, Carruthers, Butler, Wilson, & Sindicich, 2013). Qualitative studies may be useful to determine, in richer detail, in-prison injecting patterns among prisoners and those recently released.
Implications for Future Research These findings have important public health implications for a high-risk and vulnerable segment of the population. Australia’s third National Hepatitis C Strategy (2010–2013) identifies young people as a priority population that requires access to harm reduction knowledge and skills, peer education and peer support, and age-appropriate clinical services (Australian Government Department of Health and Ageing, 2010). Clearly, these services should be extended to young people incarcerated in adult prison facilities. To be most effective, such interventions would benefit from more evidence about who among young prisoners is at greatest risk of hepatitis C and about the effectiveness and acceptability of different interventions for this population. Treatment of problematic substance use is also critical (Edlin, 2002). Given the high prevalence of mental illness experienced by young people in adult prisons (van Dooren, Kinner, & Forsyth, 2013; van Dooren, Richards, Lennox, & Kinner, 2013), treatment, education, and prevention efforts must take into account the mental health status of individuals (Mistler et al., 2006). Lifestyle factors, medication side effects, and access to and quality of health care are also important factors for young prisoners with mental illness that are amenable to change. Interventions that have high levels of participation and acceptance among individuals with hepatitis C and mental illness should be prioritized (de Hert et al., 2011). Unfortunately, Australia’s national hepatitis C strategy does not identify the GLBT population as a priority group, despite strong associations between injection drug use, sexual risk practices, and bloodborne infection (Danta et al., 2007; Lea et al., 2013). In prison and community settings in Australia, more attention is needed from policy makers, practitioners, and researchers to inform context-specific interventions that take into account the differences between heterosexual and GLBT populations, importantly in terms of injection drug use and risky sexual practices. Promisingly, other national strategies and policies in Australia have recognized and responded to the vulnerability of this group (as well as young people) in relation to mental health (e.g., Australia’s National Suicide Prevention Strategy) and the need for increased access to education and information for service providers (Carman, Corboz, & Dowsett, 2012). These recommendations are critical to service providers working with prisoners. In 2011, the Australian government funded $22.6 million for community prevention activities for high-risk groups including the GLBT community, and ideally evaluations will inform future interventions for this group. In the interim, a dedicated research agenda specific to young GLBT (ex-)prisoners to explore sexual risk and injection drug use patterns will best address the underrepresentation of this group in public health and prisoner health debate. Hepatitis C treatment will change over the next few years; it will be highly efficacious and tolerable, and treatment as prevention is being muted (Doyle, Aspinall, Liew, Thompson, & Hellard, 2013; Hellard, Doyle, Sacks-Davis, Thompson, & McBryde, 2014). However, treatment is likely to be very expensive, and it is more cost effective to educate a young prisoner about the risks of hepatitis C transmission and how to avoid infection than to initiate treatment once the same individual has become infected. Ideally, young prisoners who have not commenced injection drug use should be educated about hepatitis C, vectors for transmission, and strategies to minimize the risk of transmission, including through behaviors beyond injection drug use (e.g., risky sexual practices, unsafe tattooing or piercings). Such education programs could be delivered by experts whom
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young people are likely to access following their release from prison, such as youth workers, to help improve the continuity of support (Borzycki & Baldry, 2003). To inform these education programs, more evidence relating to the prevalence of and risk factors for hepatitis C among young prisoners is needed. Our findings are consistent with a growing body of work supporting the implementation of needle and syringe programs (NSPs) in Australian prisons (Dias, Kinner, Ware, & Lennox, 2013; Kinner et al., 2013). Currently, none of Australia’s states or territories provide clean injecting equipment in prisons, despite the success of these programs in other countries (Fetherston et al., 2013). The principle of equivalence (Lines, 2006) focuses attention on the social justice disparities that arise from the slow and piecemeal implementation of NSPs in prisons compared to the community, despite compelling evidence that NSPs reduce the spread of infection among people who inject drugs without collateral harm (Dolan, Rutter, & Wodak, 2003). Should such programs be implemented in Australian prisons, collaboration with younger prisoners and the youth sector in the design and development of prison NSPs will be essential (Dolan et al., 2003).
Conclusions While it might be considered too late for ‘‘early’’ intervention, secondary prevention to reduce transmission of hepatitis C can still be successful in adult prison facilities. Young people who inject drugs and who have had shorter time at risk of hepatitis C exposure are an important target group for hepatitis C prevention efforts. A combination of education and harm reduction interventions, focused on both the time in prisons and importantly the time immediately postrelease, has the greatest potential to reduce the burden of hepatitis C among this at-risk population. Authors’ Note K.v.D. conceived of the study, performed the statistical analysis, and drafted the manuscript. S.K. participated in the design of the study and helped to draft the manuscript. M.H. helped to draft the manuscript. All authors have read and approved the final manuscript.
Acknowledgment The authors wish to thank Queensland Corrective Services for assistance with data collection, and Passports study participants for sharing their stories. The views expressed herein are solely those of the authors, and in no way reflect the views or policies of Queensland Corrective Services.
Declaration of Conflicting Interests The authors disclosed no conflicts of interest with respect to the research, authorship, and/or publication of this article. For information about JCHC’s disclosure policy, please see the Self-Study Exam.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: K.v.D. is supported by a scholarship from Australian National Health and Medical Research Council (NHMRC) grant #409966. S.K. is supported by NHMRC career development award #1004765. M.H. is supported by an NHMRC Senior Researcher Fellowship. The Passports project is funded by NHMRC grant #409966.
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