Prison program for HIV PrEP enrolls 93% of eligible people
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More than 90% of eligible incarcerated people initiated HIV PrEP during a study conducted in 16 Zambian criminal justice facilities in what researchers said was likely the first description of a PrEP program in a criminal justice system.
“While HIV testing is conducted routinely upon correctional facility entry and the Government of Zambia began offering PrEP services in the general population in 2016, PrEP was not made available to incarcerated people prior to the program described in the study,” Brianna R. Lindsay, MPH, PhD, epidemiologist at the Center for International Health, Education, and Biosecurity, told Healio. “Literature reviews showed that there [are] limited data to suggest biomedical prevention tools are being made available in criminal justice settings worldwide. Therefore, we wanted to describe these activities, how they were implemented, and how individuals within the facilities responded to the availability of these services.”
Lindsay and colleagues performed a cross-sectional observational study from Oct. 1, 2020, and March 31, 2021, during which they implemented a PrEP program supporting 16 criminal justice facilities in four Zambian provinces.
According to the study, before implementation, the researchers held stakeholder engagement meetings with Zambia Correctional Service officials to discuss PrEP benefits and trained Zambia Correctional Service health care workers in PrEP management using the national PrEP training package.
During the study, people who were incarcerated and screened positive for substantial HIV risk by use of a standardized HIV risk assessment tool were offered voluntary HIV testing and counseling. Those who tested positive were linked to ART, whereas those who tested negative and met national HIV prevention eligibility criteria were offered PrEP. Researchers then assessed PrEP uptake and used descriptive statistics to characterize program beneficiaries and subsequent PrEP services.
Throughout the study, the researchers reached 12,367 people aged older than 15 years with HIV risk assessment and counseling. Of these, 2,610 received HIV testing, with 357 (13.7%) testing HIV positive, and positivity being significantly higher in women (20.6%) than in men (13.2%).
According to the study, 1,276 people were identified as HIV negative and PrEP eligible, of whom 1,190 (93.3%) initiated PrEP. The researchers found that the age group with the highest proportion reached and who initiated PrEP was those aged 25 to 29 years, representing 19.2% of all people reached and 24.1% of those who initiated PrEP.
Based on these findings, Lindsay said that providing PrEP in correctional facilities could not only prevent transmission within facilities — although she said the extent to which this occurs is unknown — but also within the general population by reducing infections overall and establishing prevention services after release. She added that the post-release period is thought to be a particularly high-risk time based on data from the United States showing high substance use and sexual activity during this period.
Additionally, Lindsay said that people involved with the criminal justice system can alternate in and out of prison, which suggests that HIV prevention efforts are likely to be interrupted after release; however, no published data exist from sub-Saharan Africa on how people who were previously incarcerated access HIV prevention after release.
“PrEP services can be provided with high reach and uptake among eligible individuals who are incarcerated,” Lindsay said. “Future work should characterize individual-level, system-level, and structural-level factors associated with PrEP uptake, adherence, and persistence in this population, and reasons for discontinuation, especially following release.”
In an accompanying commentary, Lucy Chimoyi, MS, epidemiologist and scientist at The Aurum Institute, and Salome Charalambous, PhD, deputy chief scientific officer at The Aurum Institute, wrote that the recurrent nature of prisons settings and the high-risk populations within make them key players in HIV prevention.
“Prison settings concentrate key populations who are at high risk for HIV, and this risk increases further as a result of consensual or coerced unprotected sexual intercourse and sharing of inadequately sterilized needles or grooming equipment,” they wrote. “The cyclical nature of prison facilities and communities — with individuals moving in and out — warrants emphasis on continuation of care.”
They added that if PrEP use is initiated in prison settings and follow-up for completion is conducted in communities after release, “HIV transmission is likely to be interrupted,” although further studies are needed to access completion and incident HIV in these settings.
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