HIV transmission may be prevented in the prison setting by administering antiretroviral medication to prisoners within three days of needle-sharing with an HIV-positive prisoner, a new Australian study has reported.
It is the first study to document the use of HIV post-exposure prophylaxis in prisons.
Published in this week’s edition of the Australian Medical Journal, the study describes two index prisoners infected with both HIV and HCV (hepatitis C virus) who disclosed recent needle-sharing with other prisoners. One index prisoner also had active hepatitis B.
Following further investigation, the authors identified 104 prisoners who had shared needles in recent days and were potentially exposed to HIV and HCV. Baseline testing showed that none had HIV infection, while 72% were infected with hepatitis C and 69% were infected with or immune to hepatitis B.
Of the 104 inmates potentially exposed to HIV, 56 were eligible for post-exposure prophylaxis (PEP), having been exposed within the previous 72 hours. Thirty-four men took PEP with AZT and 3TC for an average of 18 days. Eight men reported full compliance with PEP, and a quarter completed the four-week course of therapy. Some trading of PEP drugs was reported amongst prisoners and as a result prison health staff began administering PEP as directly observed therapy.
No cases of HIV infection were found at follow-up testing a year later. However, only 61% of the 104 potentially exposed prisoners received follow-up testing, and the researchers acknowledged that seroconversions might have occurred among those lost to follow-up.
“The key finding of this study is that the provision of PEP inside prison is feasible but its implementation is complicated by administration difficulties,” study author Dr Andrew Grulich told aidsmap. “Providing PEP within prisons is challenging, firstly because prisoners don’t want to admit to using, and secondly because it’s difficult to assess the level of risk.”
The study highlights some of the potential problems of PEP in prisons, including the difficulty of accurate risk assessment and prompt initiation of therapy, ongoing risk behaviours, poor compliance, and inadequate follow-up. The authors have called for the development of guidelines for the use of PEP in prisons.
The study also looked at transmission of hepatitis B and hepatitis C. Inmates susceptible to HBV infection at baseline received HBV vaccination or immunoglobulin and no new cases of hepatitis B were detected during follow-up.
While only 29 men were susceptible to HCV infection at baseline, four (14%) were found to be infected with hepatitis C at follow-up testing. Researchers were reluctant to attribute these HCV seroconversions to the documented exposures due to multiple exposures and ongoing risk behaviours by the prisoners involved. Nevertheless, they conclude that their findings “are consistent with the higher probability of transmitting HCV compared with HIV through sharing needles and syringes’.
“PEP is only a very small part of the prevention arsenal,” Dr Grulich said. “The study highlights the need for other inventions such as needle exchange and bleach within prisons. PEP is the last option.“
O’Sullivan BG et al. Hepatitis C transmission and HIV post-exposure prophylaxis after needle- and syringe-sharing in Australian prisons. Australian Medical Journal 178: 546-549, 2003.