Infectious Diseases Prevention and Control in Canadian Federal Penitentiaries 2000-01

Publications

Infectious Diseases
Prevention and Control
in Canadian Federal
Penitentiaries 2000-01

RESULTS

Human immunodeficiency virus (HIV)

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HIV infection leads to a progressive and persistent impairment of the immune system and renders an infected person susceptible to opportunistic infections. The presence of such opportunistic infections indicates that HIV infection has progressed to AIDS. Individuals with HIV have a high incidence of co-infection with hepatitis C virus (HCV), with an estimated 22% of HIV-infected persons in 1999 harboring HCV.¹ Because HIV affects the immune system, it is estimated that tuberculosis (TB) carriers who are infected with HIV are also 113 times more likely to develop active TB than those without HIV.² The presence of other sexually transmitted diseases (STDs), particularly those that cause genital ulcers, increases the risk of HIV transmission.^3,4

Most people newly infected with HIV do not know that they have become infected and can unknowingly transmit the virus to others. The majority of HIV-infected persons will develop antibodies to HIV between 6 weeks and 3 months after becoming infected, but may not show clinical symptoms of infection for up to 10 years or more.²

Sexual transmission and contact with infected blood through injection drug use (IDU) are the most common modes of HIV transmission in Canada.⁵ The use of contaminated needles, syringes, or skin-piercing equipment for tattooing also carries a significant risk of transmission.^6,7 Thus, injection drug users and individuals practicing unprotected sex with an infected partner are at high-risk for HIV infection.

Approximately 49,000 cumulative positive HIV test reports have been reported in the general Canadian population since the beginning of the AIDS epidemic in Canada through June 2001.⁵ Studies in Canada estimate the prevalence of reported HIV cases in provincial and federal offenders to be between 2% and 8% of the inmate population^8-15, and thus nearly ten times the reported prevalence of 0.2% in the general Canadian population. Worldwide, inmates of correctional facilities are at greater risk of contracting HIV infection than the general population because they are more likely to engage in high-risk behaviours such as IDU, non-sterile tattooing and unprotected sex,¹⁶ risk behaviours which sometimes continue while incarcerated.^12,17-21

IN SUMMARY

Total reported HIV cases:

• At year-end 2001, 1.8% of all inmates were reported to be HIV-positive, compared to 1.7% in 2000.
• HIV infection rates among women offenders (4.7% in 2001, 5.0% in 2000) were higher than among men offenders (1.7% in 2001, 1.6% in 2000).
• Overall, the rate of reported HIV cases was highest in Quebec Region, with 2.7% of all inmates reporting HIV infection in 2001 and 2.9% in 2000.
• The rate of reported women HIV cases was highest among inmates in Prairie Region (8.2% in 2001, 9.7% in 2000).
• The rate of reported men HIV cases was highest among inmates in Quebec Region (2.6% in 2001, 2.9% in 2000).
• The greatest change in HIV rates was observed among women; rates increased in Atlantic and Quebec, but decreased in Prairie Region.

New reported HIV cases:

• Despite a small increase in inmate population size, the number of newly diagnosed HIV cases decreased from 45 in 2000 to 16 in 2001.
• 69% of all newly identified HIV cases in 2001 and 53% in 2000 were among new admissions to CSC.
• In 2001, testing among new admissions increased by 2.1% over that carried out in 2000 to 24.7% of all new admissions. For general population inmates, testing increased by 2.7% over 2000 to 21.7% in 2001.
• Intake of inmates with an HIV-positive diagnosis prior to incarceration went from 2.3% of all new admissions in 2000 to 2.6% in 2001.
• Releases of HIV-positive inmates rose from 162 to 173 cases in 2001.

HIV in CSC facilities

As part of its comprehensive approach to the public health prevention and management of HIV, CSC offers its inmates the opportunity to discover their HIV infection status, to be counseled on the meaning of their test result and to be educated on ways to reduce their risk of acquiring and transmitting HIV. Medical treatment for HIV-infected inmates is a cornerstone of this broad-based approach and uses universally accepted standards of care.

Between 1989 and 2001, positive HIV test reports in federal inmates increased by an average of 15 cases per year (Figure 2). In addition to the possibility of a real increase in cases, several other factors may account for the reported rise in cases over time. These include better case identification as a result of more testing in institutions, the availability of more sensitive laboratory tests, higher rates of inmate-requested testing as a result of changing perceptions towards HIV/AIDS, and better reporting of HIV cases by institutions to CSC-NHQ.

HIV testing and infection rates

Total positive HIV test reports

The Correctional Service of Canada Infectious Diseases Surveillance System (CSC-IDSS) data indicate that the proportion of inmates with HIV infection has remained stable over the two years of surveillance (1.7% in 2000 and 1.8% in 2001) despite an increase in the absolute number of reported cases from 214 cases in 2000 to 223 cases in 2001.

Figure 3 shows the distribution of positive HIV test reports (proportion of inmates living with HIV) across CSC regions in 2000-01. The highest proportion of reports was noted in Quebec Region at 2.9% and 2.7% in 2000 and 2001, respectively.

New positive HIV test reports

Sixteen new HIV cases were diagnosed among all CSC inmates in 2001, representing close to one-third of the 45 cases identified in 2000 (Table 2).

Infections discovered among new admissions at entry to a CSC reception unit accounted for 69% of all new positive HIV test reports in 2001, up from 53% in 2000.

HIV antibody testing

The testing uptake rate increased for both new admissions and general population inmates in 2000 and 2001, but differed by approximately 3% between the two groups (Table 2). The comparatively higher rate of testing among new admissions may account for the higher rate of HIV case-finding in this group.

In 2001, regional rates for testing uptake ranged from 3.5% to 39.5% for new admissions and from 17.8% to 28.1% for general population inmates. Increases were noted among new admissions in the Prairie and Quebec Regions, while other regions experienced a decrease from testing rates in 2000. Among general population inmates, most regions showed increases in testing uptake in 2001 (Table 2).

Table 2.
Human immunodeficiency virus (HIV) antibody testing among inmates in Canadian federal penitentiaries, 2000-01.

Test positivity serves as a comparative measure of inmates who test positive for HIV in relation to all inmates tested during a given year. For example, among new admissions who were tested for HIV, 1.5% were seropositive in 2000 and 0.6% in 2001. As indicated in Table 2, test positivity rates were higher among new admissions than general population inmates during 2000-01, suggesting that a large proportion of offenders are entering CSC facilities with existing infections.

HIV cases by gender

In 2001, 4.7% (13 cases) of women offenders and 1.7% (210 cases) of all men offenders were reported by institutional Health Services units to be infected with HIV. The rate was slightly higher for women (5.0%, 13 cases) in the previous year (2000) but was similar to that recorded for men (1.6%, 201 cases). Women offenders consistently registered a higher rate of HIV infection than men offenders in all regions except Ontario, where no women cases were reported in 2000-01 (Figure 4).

The proportion of positive HIV test reports was highest among women offenders in Prairie Region. The high rate of HIV in the Prairie Region may be reflective of the concentration of women offenders in this region who were convicted of drug related charges, sex partners of injection drug users, or were sex trade workers. The Prairie Region also experienced the only decrease in positive HIV test reports among women offenders in 2000 compared to 2001.

Unlike the rates of their female counterparts, the proportion of positive HIV test reports among men offenders showed little change between 2000 and 2001. Small increases were observed in Ontario and Prairie Regions and a decrease in Quebec Region. For both years, Quebec Region housed the greatest proportion of men HIV-positive offenders.

Data on testing rates reveal that a higher proportion of women than men undertook testing in 2000-01, which may account for better case-finding among women. The difference in testing rates between men and women offenders was greatest at admission to CSC, where nearly 52% of women were tested for HIV (Table 3), compared to 23% of men in 2001 (Table 4).

Table 3.
Human immunodeficiency virus (HIV) antibody testing among women offenders in Canadian federal penitentiaries, 2000-01.

HIV-positive offender intake and community releases

The proportion of new admissions to CSC with a prior positive diagnosis for HIV varied slightly between 2.3% (104 cases) in 2000 and 2.6% (123 cases) in 2001.

During the same period, the proportion of HIV-positive inmates released from a CSC facility to the community was stable at 1.3% (162 cases) of all incarcerated inmates in 2000 and 1.4% (173 cases) in 2001.

Table 4.
Human immunodeficiency virus (HIV) antibody testing among men offenders in Canadian federal penitentiaries, 2000-01.

HIV treatment

Highly active antiretroviral therapy (HAART) is the standard of care for HIV-infected individuals requiring treatment. The availability of improved HIV treatments has made HIV infection more manageable and has prolonged the quality of life for HIV-positive patients. Treatment delivery is influenced by numerous factors including prevailing treatment guidelines, progression of disease, patient acceptance and compliance, and the extent of adverse reactions related to treatment. HIV-positive inmates who do not require antiretroviral treatment are monitored closely to assess disease progression. As a result, rates of treatment uptake can vary widely by region and from year to year. Furthermore, observed differences in treatment uptake between years may not be significant due to the small number of inmates with HIV infection in each region.

Inmates newly diagnosed by CSC with HIV infection are assessed for treatment, including those offenders entering the federal correctional system with a documented infection. During 2001, 41 federal inmates were newly initiated on voluntary HIV treatment. At year-end 2001, 113 of 223 HIV-positive inmates (50.7%) were following a course of HIV treatment (Table 5). In 2000, 68 inmates were initiated on therapy and 116 of 214 (54.2%) HIV-positive inmates were on HIV treatment at year-end.

Table 5. Treatment of HIV-positive inmates in Canadian federal penitentiaries, 2000-01.

Conclusion

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In Canada and around the world, HIV infection in inmate populations continues to pose a challenge in correctional settings.²⁰

The prevalence of positive HIV test reports in CSC corroborates the results of inmate studies in several provincial and federal institutions in Ontario^8,13-15, Quebec^9-11 and British Columbia¹². The high number of new positive HIV test reports among new admissions to CSC suggests that many inmates were already living with HIV prior to their current incarceration.

Among men offenders, the reported prevalence of HIV infection in this Canadian report (1.7%) is lower than reported rates among inmates in Scotland1^9,22 (4.5%), France²³ (7.1%), Switzerland²⁴ (11%) and Italy²⁴ (17%). The Canadian rate is similar to that reported in Ireland²⁵ (2%) but higher than HIV prevalence in England and Wales (0.4%).²⁶

CSC-IDSS surveillance data clearly show the discrepancy of HIV prevalence between men and women. The higher rate of HIV infection in women may be indicative of the risk profile of this group, in which a high proportion of offenders are convicted of drug related charges, are often sex partners of injection drug users, or were sex trade workers.^9,11,27 Higher rates of HIV infection among women offenders corroborate findings of other studies in the United States^28,29, France²³ and England and Wales.²⁶

High numbers of HIV-positive inmates in prisons are often a reflection of HIV rates among similar risk cohorts in the community.²² Rates of infection among inmates are influenced by several factors, including the proportion of HIV-infected offenders incarcerated, the extent of IDU among inmates and the rate of IDU initiation in penitentiaries.

While risk factor information is currently not captured by the CSC-IDSS, the profile of federal inmates suggests that IDU is a major source of HIV exposure for most inmates. The transmission of HIV through sexual activity is considered to be a less significant risk factor than the sharing of needles and other injection equipment in prison30 but is, nevertheless, a risk behaviour for HIV infection. Several studies indicate that prevalence of HIV in prison, as in the community, is higher among individuals with a history of IDU than among non-users.^16,19,20

In Canada, it is estimated that 30% of Canadians who are living with HIV are unaware of their infection.³¹ Based on the risk behaviours of the incarcerated population, it is estimated that half of all HIV-infected inmates in federal institutions in 1996 may not have been known by Health Services to be infected.¹ Many inmates may not have disclosed their infection status to health services personnel, while others may be unaware of their infection.

Despite improvements in testing uptake, CSC data indicate that a large proportion of inmates were untested for HIV in 2000-01. Inmates may often be reluctant to seek HIV testing for fear of self-identifying risk behaviours.^20,29 The findings from the current report emphasize the need for increased testing of new admissions and continued improvements in testing uptake for general population inmates. Active encouragement by health-care staff to increase testing uptake will help to better define HIV prevalence within federal correctional settings. While no clear explanation exists for the variation in testing rates between regions, the finding is likely the result of differences across regions with regard to screening practice and promotion. Regional variations in testing and treatment uptake will need further investigation.

References

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