Short stay in prison increases the risk of hepatitis for people who use drugs

3 Sep 2021 Keith Alcorn
Originally published on

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 resourced.

Incarceration can also interrupt drug treatment or attempts to alter drug using behaviours, leading to post-imprisonment relapses into drug use.

Researchers at the University of Bristol investigated the impact of imprisonment on hepatitis C acquisition in people who use drugs in the Montréal 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 therapy.

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 therapy.

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 provide support.

Alternatives to incarceration for minor drug-related offences should also be prioritised.