title: The perfect storm: incarceration and the high-risk environment perpetuating transmission of HIV, hepatitis C virus, and tuberculosis in Eastern Europe and Central Asia.
abstract: Despite global reductions in HIV incidence and mortality, the 15 UNAIDS-designated countries of Eastern Europe and Central Asia (EECA) that gained independence from the Soviet Union in 1991 constitute the only region where both continue to rise. HIV transmission in EECA is fuelled primarily by injection of opioids, with harsh criminalisation of drug use that has resulted in extraordinarily high levels of incarceration. Consequently, people who inject drugs, including those with HIV, hepatitis C virus, and tuberculosis, are concentrated within prisons. Evidence-based primary and secondary prevention of HIV using opioid agonist therapies such as methadone and buprenorphine is available in prisons in only a handful of EECA countries (methadone or buprenorphine in five countries and needle and syringe programmes in three countries), with none of them meeting recommended coverage levels. Similarly, antiretroviral therapy coverage, especially among people who inject drugs, is markedly under-scaled. Russia completely bans opioid agonist therapies and does not support needle and syringe programmes-with neither available in prisons-despite the country's high incarceration rate and having the largest burden of people with HIV who inject drugs in the region. Mathematical modelling for Ukraine suggests that high levels of incarceration in EECA countries facilitate HIV transmission among people who inject drugs, with 28-55% of all new HIV infections over the next 15 years predicted to be attributable to heightened HIV transmission risk among currently or previously incarcerated people who inject drugs. Scaling up of opioid agonist therapies within prisons and maintaining treatment after release would yield the greatest HIV transmission reduction in people who inject drugs. Additional analyses also suggest that at least 6% of all incident tuberculosis cases, and 75% of incident tuberculosis cases in people who inject drugs are due to incarceration. Interventions that reduce incarceration itself and effectively intervene with prisoners to screen, diagnose, and treat addiction and HIV, hepatitis C virus, and tuberculosis are urgently needed to stem the multiple overlapping epidemics concentrated in prisons.
authors.affiliation: School of Medicine and School Public Health, Yale University, New Haven, CT, USA. Electronic address: frederick.altice@yale.edu.
authors.forename: Frederick L
authors.initials: FL
authors.lastname: Altice
authors.affiliation: Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Lyuba
authors.initials: L
authors.lastname: Azbel
authors.affiliation: School of Social and Community Medicine, Bristol University, Bristol, UK.
authors.forename: Jack
authors.initials: J
authors.lastname: Stone
authors.affiliation: School of Social and Community Medicine, Bristol University, Bristol, UK.
authors.forename: Ellen
authors.initials: E
authors.lastname: Brooks-Pollock
authors.affiliation: ICF International Alliance for Public Health, Kiev, Ukraine.
authors.forename: Pavlo
authors.initials: P
authors.lastname: Smyrnov
authors.affiliation: Ukrainian Institute on Public Health Policy, Kiev, Ukraine.
authors.forename: Sergii
authors.initials: S
authors.lastname: Dvoriak
authors.affiliation: Department of Criminology, Law and Society, George Mason University, Fairfax, VA, USA.
authors.forename: Faye S
authors.initials: FS
authors.lastname: Taxman
authors.affiliation: School of Social Work, Columbia University, New York, NY, USA.
authors.forename: Nabila
authors.initials: N
authors.lastname: El-Bassel
authors.affiliation: School of Social and Community Medicine, Bristol University, Bristol, UK; Division of Global Public Health, University of California San Diego, San Diego, CA, USA.
authors.forename: Natasha K
authors.initials: NK
authors.lastname: Martin
authors.affiliation: Department of Psychiatry, University of Colorado, Denver, CO, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Booth
authors.affiliation: Institute of Addiction Research, Frankfurt University of Applied Sciences, Frankfurt, Germany.
authors.forename: Heino
authors.initials: H
authors.lastname: Stöver
authors.affiliation: National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.
authors.forename: Kate
authors.initials: K
authors.lastname: Dolan
authors.affiliation: School of Social and Community Medicine, Bristol University, Bristol, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Vickerman
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use; D000995:Antitubercular Agents / Q000627:therapeutic use*; D000998:Antiviral Agents / Q000627:therapeutic use*; D001209:Asia, Central; D003415:Crime; D005061:Europe, Eastern; D015658:HIV Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000635:transmission; D006526:Hepatitis C / Q000188:drug therapy / Q000453:epidemiology* / Q000635:transmission; D006801:Humans; D015994:Incidence; D018671:Needle-Exchange Programs; D058850:Opiate Substitution Treatment; D011329:Prisoners / Q000706:statistics & numerical data*; D011330:Prisons / Q000706:statistics & numerical data*; D012306:Risk; D012307:Risk Factors; D012725:Sexual Behavior; D015819:Substance Abuse, Intravenous / Q000453:epidemiology* / Q000517:prevention & control / Q000628:therapy*; D014376:Tuberculosis / Q000188:drug therapy / Q000453:epidemiology* / Q000635:transmission
chemical_list: D019380:Anti-HIV Agents; D000995:Antitubercular Agents; D000998:Antiviral Agents