HIV Testing and Counselling in Estonian Prisons, 2012 to 2013: Aims, Processes and Impacts
Total Page：16
File Type：pdf, Size：1020Kb
Research articles HIV testing and counselling in Estonian prisons, 2012 to 2013: aims, processes and impacts K Kivimets ([email protected])1, A Uusküla2 1. The Estonian Ministry of Justice, Prison Department, Rehabilitation Division, Jõhvi, Estonia 2. Department of Public Health, University of Tartu, Tartu, Estonia Citation style for this article: Kivimets K, Uusküla A. HIV testing and counselling in Estonian prisons, 2012 to 2013: aims, processes and impacts. Euro Surveill. 2014;19(47):pii=20970. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20970 Article submitted on 18 February 2014 / published on 27 November 2014 We present data from an observational cohort study who have been involved with sex work, which is fre- on human immunodeficiency virus (HIV) prevention quently associated with injection drug use and contact and control measures in prisons in Estonia to assess with HIV-infected sexual partners, are at additional risk the potential for HIV transmission in this setting. HIV of HIV being infected when entering prison. [11] The testing and retesting data from the Estonian prison high prevalence of HIV infection and drug dependence health department were used to estimate HIV preva- among prisoners, combined with the sharing of inject- lence and incidence in prison. Since 2002, voluntary ing drug equipment, make prisons a high-risk environ- HIV counselling and testing has routinely been offered ment for the transmission of HIV. Therefore, the World to all prisoners and has been part of the new prison- Health Organization (WHO) has recommended that HIV ers health check. At the end of 2012, there were 3,289 testing in prison settings should be prioritised [12]. prisoners in Estonia, including 170 women: 28.5% were drug users and 15.6% were infected with HIV. Of A review by Dolan et al. suggests that prisons are a par- the HIV-positive inmates, 8.3% were newly diagnosed ticular focus of the HIV epidemic in several countries in on prison entry. In 2012, 4,387 HIV tests (including Europe, and that HIV infection rates are substantially retests) were performed in Estonian prisons. Among higher among prisoners than among the general popu- 1,756 initially HIV-negative prisoners who were in lation in some countries in eastern Europe, e.g. above prison for more than one year and therefore tested for 10% nationally in Estonia, Romania, and Slovakia, and HIV twice within 12 months (at entry and annual test- in a single prison or region in Lithuania and Ukraine ing), one new HIV infection was detected, an incidence [13]. Less is known about the implementation and of 0.067 per 100 person-years (95% confidence interval effectiveness of HIV prevention and harm reduction (CI): 0.025–5.572). This analysis indicates low risk of programmes introduced in prisons in these countries. HIV transmission in Estonian prisons. Implementation of HIV management interventions could impact posi- This article assesses the prevalence of HIV infec- tively on the health of prisoners and the communities tion among prisoners, and describes prison policies to which they return. and practices on voluntary HIV testing and counsel- ling (VCT) and retesting in Estonian prisons between Introduction January 2012 and March 2013. In most countries, the rates of human immunodefi- ciency virus (HIV) infection, tuberculosis (TB) and hep- Situation in Estonia atitis B and C among prisoners are higher than those Estonia is a small country in north-eastern Europe in the general population [1] owing to risk behaviour with a population of ca 1.3 million [14]. In 2009, the before and during incarceration. These risks include estimated HIV prevalence among 15−49 years-olds in injection drug use [2,3], exchange of sex for money Estonia was 1.2% compared with 1.0% in Russia and or drugs [4], multiple sex partners [5], and low socio- 1.1% in Ukraine. In 2011, Estonia had the third high- economic status (homeless people). [6-8] Many people est rates of HIV diagnosis in Europe (27.3/100,000), who inject drugs (PWID) engage in low-level criminal after Russia (44.1/100,000 in 2010) and Ukraine activity to support their drug use and many experi- (38.0/100,000) [15]. Estonia has one of the highest ence incarceration at least once in their lifetime [9]. prevalences of PWID among people aged 15–64 years Research has shown that HIV-infected people are fre- (1.5% in 2007) coupled with a 40–90% HIV prevalence quently incarcerated during the course of their disease, among PWID [16,17]. with an estimated 17% of people living with HIV/AIDS in the United States (US) and incarcerated at some There are four prisons in Estonia: Tartu, Tallinn, Viru, point in a given year [10]. In addition, female prisoners and Harku and Murru. Data from the Estonian Ministry www.eurosurveillance.org 31 of Justice show that the prison population was ca Data and data sources 3,300 in January 2013 [18], translating into an impris- onment rate of 246 per 100,000 population. According Prison health reports to the Health Services Organisation Act, healthcare in Data on the occurrence of drug dependence among prisons is part of the national healthcare system [19]. inmates were obtained from the quarterly health Prisoners’ treatment costs are covered through the reports from prisons summarised in the Estonian Ministry of Justice from the state budget [20]. Ministry of Justice Drug Monitoring Report 2012 [24] which compiles all prison data on drug use, treatment HIV/AIDS prevention in prisons is based on the national and other preventive activities for the period from 1 HIV/AIDS Strategy 2006–2015. The main objective is January to 31 December 2012. Defining drug addiction to block HIV transmission inside prison. Antiretroviral status was based on ICD 10 diagnosis codes F11–F16 therapy (ART) is available in all prisons and is admin- and F18–F19 [25]. istered according to the national guidelines, which require that ART should be initiated at a CD4 T cell These data were used to describe the prison popula- count < 350 cells/mm3. Condoms are distributed free of tion in Estonia in 2012, including HIV prevalence and charge in long-term visiting rooms. Drug prevention in ART coverage among those with HIV. the prison system was commenced in 1998. Until 2003 the focus was primarily on reducing the supply by Prison goals database inspection, but recently more attention has been paid The prison goals database is an electronic database to reducing the demand by treatment and rehabilita- containing aggregated information about HIV infec- tion of drug addicts [21]. Two types of drug dependency tion, HIV testing and retesting. Since the introduction treatment are offered in Estonian prisons. Abstinence- of mandatory reporting of HIV testing in 2011, the data- based treatment is the most common and is available base has been updated monthly by all prison medical in all prisons. The only form of opiate substitution is departments. Data on HIV testing between 1 January methadone maintenance treatment and coverage is and 31 December 2012 was extracted from the prison increasing every year. No prisons in Estonia offer nee- goals database. These data were used to describe HIV dle exchange programmes. testing and retesting conducted in prisons in 2012. On entry, all detained persons undergo an initial health Prison electronic patient database check and VCT is a component of every new prisoner The prison electronic patient database is an informa- health check [20]. VCT is carried out by medical per- tion system containing information from the elec- sonnel and performed with the informed consent of the tronic health records designed for prison healthcare. prisoner. Retesting for those who were HIV-negative at Individualised HIV testing and retesting results for the previous/initial testing is offered once a year or more period from 1 January to 31 March 2013 were collected often if necessary, i.e. if a prisoner can identify a spe- from the electronic prison patient database. Analysis cific incident of HIV exposure. Exposure incidents are was limited to prisoners who had been in prison for tattooing, fighting, self-harm with dirty razors, unpro- more than one year and had previously had a nega- tected sexual intercourse or injecting. tive HIV test, i.e. those who were eligible for retesting. This information was used to explore the occurrence of All HIV tests are performed in regional HIV screening newly acquired HIV infections (HIV incidence) among laboratories (in Jõhvi, Tartu and Tallinn) using fourth- the prison population. generation HIV screening tests (i.e. Vironostika HIV Uniform II Ag/Ab, BioMerieux method). Confirmatory The data sources used for this study cover all the pris- HIV testing (for those testing positive in a screening ons in Estonia. Data on HIV/hepatitis C virus (HCV) test) is done at the national HIV/AIDS reference labora- testing and results, history of injection drug use, and tory in Tallinn (using the INNO LIA HIV I/II Score Western condom use during conjugal visits (from the case man- blot algorithm) [22]. According to the Communicable agement interview held following HIV diagnosis) on Diseases Prevention and Control Act [23] new cases of inmate newly infected in prison were also collected HIV are reported to the Estonian Health Board, an insti- from the prison electronic patient database. tution responsible for infectious disease surveillance in Estonia. Statistical analysis Descriptive statistics (proportions with 95% confi- Methods dence intervals (CIs)) were calculated using Microsoft This work was based on the analysis of administrative Excel 2010. HIV incidence and 95% CIs were calculated data. The term ‘prisoner’ is used for all those, includ- using Poisson distribution. ing adults and juveniles, detained during the investiga- tion of a crime, while awaiting trial, after conviction, The study complied with local data protection regula- before sentencing, and after sentencing.