Substitution treatment and HCV / HIV infection in German

prisons

B. Schulte1, H. Stöver2, K Thane1,2, C. Schreiter1, D. Gansefort1, J. Reimer1

1 Centre for Interdisciplinary Addiction Research, University of Hamburg

2 Bremen Institute for Addiction Research, University of Bremen

Corresponding author:

Bernd Schulte

Centre for Interdisciplinary Addiction Research (CIAR)

Department of Psychiatry, University Medical Centre Hamburg-Eppendorf (UKE)

Martinistraße 52, 20246 Hamburg

Tel.: +49 40 42803-7906

Fax: +49 40 42803-8351

E-mail: B.Schulte@uke.uni-hamburg.de

2

Substitution treatment and HCV / HIV infection in German prisons

Abstract

Injection drug use (IDU) and IDU-related infectious diseases such as hepatitis C virus (HCV)

and human immunodeficiency virus (HIV) infections are highly prevalent among prisoners

worldwide. However, little is known about the prevalence of IDUs and HCV/HIV and the

availability of respective treatment options in German prisons. Data, provided by prison

physicians of 31 prisons, representing 14,187 inmates, were included in this analysis. The

proportion of IDUs among all prisoners was 21.9%. Substitution treatment was available in

three out of four prisons (74.2%). Overall, 1,137 substitution treatments were provided

annually with a wide range of treatment aims. The prevalence rate was 14.3% for HCV and

1.2% for HIV. Around 5.5% of all HCV-infected prisoners were in antiviral treatment

annually, 86.5% of all HIV-positive subjects in antiretroviral HIV treatment.

Generally, substitution treatment, HCV and HIV testing and treatment are available.

However, due to abstinence-oriented treatment aims substitution treatment is rarely available

as maintenance treatment, and HCV/HIV treatment is mainly provided for patients with an

existing treatment before imprisonment. The gap between knowledge and adequate medical

care should be reduced. The selection process in this analysis might lead to overestimating the

availability of substitution and HCV treatment.

3

Background

Problem drug use in prisons

Worldwide, drug offenders are overrepresented in prisons. The average percentage of drug

offenders in the European Union is 18.5% (Council of Europe, 2004), with particularly high

rates in Greece (63.0%), Italy (29.4%), and Norway (29.1%) (Council of Europe, 2007).

However, in most Eastern European countries like Bulgaria and Romania the number of

inmates due to drug offences is of minor relevance (Council of Europe, 2007). In March 2006,

approx. 64,500 persons were incarcerated in German prisons (not counting pre-trial inmates);

a substantial proportion (n=9580; 14.9%) of whom was sentenced for drug related offences

such as drug trafficking, drug related crime, etc. (Statistisches Bundesamt Deutschland,

2007). Of course, these data are only an approximation, because drug-using inmates are not

confined to the prison population sentenced for drug-related offences, and not all drug-related

offences are committed by drug users.

Globally the prevalence rates of psychotropic substance use and dependence were found to be

up to ten times higher among prisoners than in the general population, ranging from 10% to

48% in male inmates and 30% to 60% in female inmates (Fazel et al., 2006). In 2006, the

European Monitoring Centre for Drugs and Drug Addiction (EMCDDA, 2006a) estimated the

lifetime prevalence rates of injecting drug use (IDU) among prisoners in Europe at 7% to

38%, the prevalence rates of prisoners injecting drugs in prison at 1% to 15% with great

differences between prisons (EMCDDA, 2006a). Though some studies indicated less frequent

IDU in prison than in the community (Dolan et al., 1996; Keene, 1997; Shewan et al., 1995),

other experts estimated that up to 75% of the inmates with a history of IDU continue drug use

in prison (Hellard et al., 2004; Lines et al., 2005; Lines et al., 2006; Stark et al., 2006; Stöver,

2002), and up to 25% of injecting drug users (IDUs) started injecting while in prison (Gore et

al., 1995). For Germany, experts estimate that up to 50% of the inmates in German prisons

4

have experience with illicit drugs (mostly cannabis), and at least 25% must be considered as

'problematic drug users' (PDUs), which are defined as IDUs or drug users with a long-

duration/regular use of heroin, cocaine and/or amphetamines (Michels et al., 2007). Radun et

al. found in their cross-sectional study in six German prisons a weighted lifetime prevalence

of IDU of 29.6% (n=464) among 1,497 prisoners (Radun et al., 2007). The German Federal

Ministry of Health estimates that approximately 10,000 IDUs were incarcerated in German

prisons in 2003, without specifying whether they were current or former IDUs

(Bundesministerium für Gesundheit, 2003). In summary, drug use is seen as one of the main

problems of the current prison systems with effects on security measures and on the

relationships between prisoners and staff (Restellini, 2007).

Injecting drug use and blood-borne diseases in prisons

Through its strong association with blood-borne virus diseases, IDU was found to be the

predominant risk behaviour for the transmission of human immunodeficiency virus (HIV) and

hepatitis C virus (HCV) infections. While drug related risk behaviour such as needle sharing

was found to be a main reason for outbreaks of HCV and HIV in different prisons (Bobrik et

al., 2005; Goldberg et al., 1998; Taylor et al., 1995), prisoners are also at high risk of

acquiring HCV through tattooing (Hellard et al., 2007). Vescio et al. found that IDU and

tattooing are predictors for being HCV-positive in prisons; in this study IDUs were

approximately 24 times more likely to be HCV-positive than non-IDUs, inmates exposed to

tattooing three times more likely to be HCV-infected than those not exposed (Vescio et al.,

2008). Imprisonment itself was found to be an independent risk factor for both an infection

with HCV (Backmund et al., 2003; Hellard et al., 2004; March et al., 2007; Stark et al., 1997)

and with HIV (Hagan, 2003; March et al., 2007; Tyndall et al., 2003).

Globally, high prevalence rates of HCV and HIV infections were found in prisons, especially

in populations of prisoners with former or current IDU. While HCV prevalence rates between

5

12% and 41% were found among prisoners without a history of IDU, clearly higher rates

(between 61% and 75%) were found among those with a history of IDU (Chang et al., 1999;

Weinbaum et al., 2003). Dolan et al. found HIV prevalence rates of more than 10% in prisons

in 20 countries, with increased prevalence rates in countries where IDU occurs (Dolan et al.,

2007). Pontali et al. recently showed extremely high prevalence rates (90%) of HCV co-

infection in a sample of HIV-infected prisoners (Pontali & Ferrari, 2008). Werb et al. found,

that incarceration is independently associated with HIV transmission (Werb et al., 2008).

In European prisons, great variations of HCV prevalence rates were found ranging from 20%

to 40% among all prisoners and from 32% to 79% in former or current IDUs (Donoghoe,

2006). HIV infections in European prisons are generally higher in Eastern European countries

(4% to 12%), and also in Portugal (11%) (WHO, 2005). In most Western European countries

with early prevention interventions for HIV, prevalence rates among prisoners are typically

less than 1% (WHO, 2005). Generally a higher proportion of the female prisoners is infected

with HCV (11% - 74%) and/or HIV (3% - 62%) reflecting a stronger affection of women by

drug related infectious diseases (Skoretz et al., 2004; Vescio et al., 2008; Zurhold et al.,

2005). In Germany, Radun et al. recently showed high prevalence rates for HCV (17.6%) and

HIV infections (0.8%) among 1,497 prisoners of six German prisons (Radun et al., 2007).

Every second prisoner (50.6%) who ever injected drugs was found to be HCV-positive, 1.6%

of the prisoners with a history of IDU use were found to be HIV-positive (Radun et al., 2007).

Stark et al. found even higher prevalence rates for HCV (82%) and HIV (18%) in incarcerated

current and former IDUs in two German prisons in Berlin (Stark et al., 2006).

Opioid substitution treatment and HCV/HIV treatment in prisons

For the treatment of opiate dependence as well as of HCV/HIV infections, effective treatment

protocols were developed in the last decades. In the last 20 years opiate substitution treatment

(OST) advanced in Europe to the most successful treatment standard for opiate dependence

6

with more than 550,000 treated patients in 15 member states of the European Union in 2005

(Stöver, 2007). With adequate dosage regimes and sufficient treatment durations, opioid

substitution treatment (OST) was found to be strongly effective in the treatment of opiate

dependence, resulting in reduced illicit drug use and improvements of health and social

functioning (Kleber et al., 2006). Similar results were found to be achievable in penal

institutions, especially with regard to reduced rates of drug injection and re-incarcerations,

reduced drug-seeking behaviour and improved prison safety (BISDRO & WIAD, 2008; Dolan

et al., 2005; Stallwitz & Stöver, 2007; WHO et al., 2007). However, Stöver et al. (2006)

found heterogeneous and inconsistent regulations and treatment modalities in prisons

regarding OST across Europe, which diverge from the treatment standards outside prisons

(Stöver et al., 2006). Opiate dependent users outside of prisons typically have better access to

OST than those in prison (Larney & Dolan, 2008; Stöver, 2007). In Germany there is a

scarcity of aggregated data about substitution treatment in prisons. Experts estimate that 500-

700 opiate dependent prisoners out of approximately 10,000 eligible patients benefit from

substitution treatment in German prisons (Michels et al., 2007; Stöver, 2007).

The antiviral combination therapy with pegylated interferon and ribavirin for HCV and the

highly active antiretroviral therapy (HAART) for HIV represent the current medical standards

for the treatment of chronic HCV and HIV infections, and both treatment regimes are

worldwide approved in most countries. For both HCV and HIV, treatment effectiveness in

IDUs and non-IDUs is comparable if carried out in addiction medicine settings (Morris &

McKeganey, 2007; Reimer et al., 2005; Robaeys et al., 2005). Especially OST has beneficial

effects on HIV/HCV treatment outcome.

Aim and methods

The aim of this study is to achieve a first national overview of the drug related prison health

care situation in Germany by an assessment of the percentage of IDUs and drug related

7

infectious diseases in German prisons. In each German prison, one physician was asked to

take part in a survey about prevalence rates and treatment options for IDUs and drug related

infectious diseases in the respective prison.

An anonymous semi-structured questionnaire was developed including the most relevant

items about the prevalence and health care situation of opiate dependent inmates and drug

related infectious diseases in German prisons (Table 1).

- Please insert table 1 -

A total of 252 prison physicians were previously contacted by phone and invited to participate

in the survey; if they consented they received a questionnaire including a free return envelope.

The data of returned questionnaires were entered in SPPS and analyzed by using descriptive

statistics. All results are based upon the data provided by one physician of each of the

respective prisons.

Results

A total of 124 (49.4%) questionnaires were sent back by the participating physicians (Table

2). These prisons represent 43,313 inmates (66.6% of approx. 65,000 sentenced prisoners).

The majority of the returned questionnaires were not filled in completely. Most questionnaires

were sent back by physicians of prisons for sentenced inmates (n=51; Table 2). Due to

missing information about the prison type, 49 prisons were excluded from any further

analysis. Another 20 out of the 51 questionnaires from prisons for sentenced inmates were

excluded because of incompleteness (defined as missing data in more than 2 of 16 items).

Finally, questionnaires from 31 prisons were included in the analysis, representative of 14,187

inmates, 22.3% of all prisoners in Germany in March 2006 (Figure 1)

- Please insert figure 1 -

8

Prevalence of IDU and related substitution and detoxification treatment

On average 22% of the inmates (n=3,111 of 14,187 prisoners) were former or current IDUs

(Table 2). In three out of four prisons (74.2%) OST is in general available, mostly with

methadone (71%), the most widely used opioid in maintenance treatment in Germany,

followed by buprenorphine (35.5%) and levomethadone (12.9%) (Table 3). Access to

substitution treatment depends on several criteria, such as continuation of an existing

substitution treatment before imprisonment, a short term of imprisonment and confirmed co-

morbidity such as psychosis or infectious diseases (Table 3). The aims of substitution

treatment in prisons oftentimes remained undisclosed. Dose reduction, continuation of an

existing substitution treatment before imprisonment, achievement of mental and psychiatric

stability were the aims most often mentioned (Table 3). About 1,137 patients were provided

substitution treatment in 24 of the included 31 prisons each year.

Prevalence of HCV, and HCV treatment

All prisons provided a laboratory for HCV diagnosis. Main criteria for HCV testing were

belonging to a risk group for HCV infection (HCV 32.3%) and requests by inmates (29.0%)

(Table 4). One out of 7 inmates (14.3%) was found to be infected with HCV, with a high

variability in the prevalence in the respective prisons, ranging from 0 to 80% (Table 2). All

included prisons provided in general antiviral treatment options for HCV. As for HIV/AIDS,

treatment access depends on inclusion criteria like continuation of an existing treatment

before imprisonment (29%), clinical parameters (22.6%), consultation of external experts

(16.1%), and compliance of the patient (12.9%) (Table 5). Main exclusion criteria for antiviral

HCV treatment are a short duration of imprisonment (38.7%) and drug abuse (38.7%) (Table

4). Per year 111 HCV-infected inmates were treated in 21 prisons.

Prevalence of HIV, and HIV treatment

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In nearly all prisons, a laboratory for HIV (96.8%) was available. Criteria for HIV testing

included mainly requests by inmates (29%) and belonging to a risk group for HIV infection

(22.6 %) (Table 5). The prevalence of HIV in the participating prisons was 1.2%, ranging

from 0.2% to 10.8% (Table 2). In 30 out of 31 prisons, antiretroviral treatment (ART) is in

general available, depending mainly on clinical criteria such as CD4 cell account and viral

load, recommendation by external experts and continuation of ART in order to avoid viral

resistance (Table 5). Exclusion criteria for ART (mainly missing adherence) were rarely

quoted. The number of treated HIV-positive prisoners was estimated at about 147 per year in

30 prisons, resulting in a treatment ratio of 89%.

Discussion

For the first time this survey provides information about the prevalence of IDU, HCV/HIV

infections, and the availability of respective treatment options in a broad sample of 31

German prisons, based on data and estimations provided by prison physicians. In German

prisons IDUs and IDU-related infectious diseases such as HCV and HIV are highly

overrepresented compared to the community: One out of five inmates was found to be a

former or current IDU (>70 times higher than in the community, which is estimated about

0.3% (EMCDDA, 2006b)), a high percentage of them (14.7%) was found to be HCV positive

(>25 times higher than in the general population, which is 0.4% -0.7% (Robert-Koch-Institut,

2007)), and 1.2% were infected with the HI-Virus (>24 times higher than in the general

population, which is about 0.05%) (UNAIDS, 2007). A considerable variability in prevalence

rates of HIV from 0-11% and for HCV and 0-80%, can mainly be explained by differences in

the proportion of prisoners who are IDUs and partly through differences in seroprevalence

among IDU in the respective community (Vescio et al., 2008).

We found high rates of former or actual IDUs (22%) in German prisons, generally

comparable to the recent findings of Radun et al. (2007; 17.6%). Whilst OST is not available

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in all German prisons, more than 1,100 OSTs per year were provided in 23 German prisons,

which exceeds the estimations of German experts (up to 800 in all German prisons;

approximately 1% of all prisoners (Keppler, 2007; Michels et al., 2007; Stöver, 2007)). This

difference is may be due to the strong abstinence-oriented indication and time limited criteria

and aims for OST in German prisons, which imply short and limited treatment durations more

in the sense of detoxification than maintenance treatment (Knorr, 2007). These criteria are in

contrast to the treatment goals of maintenance treatment outside of prisons (e.g. improvement

of patients’ health, prearrangement of drug free life, reduction of drug related risks).

Maintenance treatment without the aim of abstinence is generally not accepted in German

prisons, despite the meanwhile undisputed successes of this treatment option (Keppler, 2007).

Otherwise, detoxification treatment approaches (abstinence oriented and limited in time) in

prison settings were found to be ineffective resulting in high proportions of drug use relapses

and drug related deaths after release from prison (Crowley, 1999). In comparison, research

data indicate that maintenance treatment is more effective than detoxification programmes in

promoting retention in drug treatment and abstinence from illicit drug use (Kastelic et al.,

2008). Evaluations of prison-based OSTs have shown strong evidence that OST is effective in

reducing intravenous drug use, which plays also a major role in the prevention of infectious

diseases. In the absence of proven and effective harm reduction measures provided in the

community (such as needle exchange programmes; apart from one prison in Berlin) prison-

based OST either continued or initiated in prison settings becomes a key instrument in

preventing the spread of HCV/HIV among IDUs (WHO et al., 2007). BISDRO/WIAD (2008)

showed that prison-based OST is not only beneficial for the patients but for the institution as

well. Moreover, OST offers daily contact between the health care services in prison and the

prisoners, a relationship that can serve as a bridge for raising further health issues and a

linkage with other strategies for managing opioid dependence and preventing HIV/HCV

transmissions. However, an adequate provision of OST in prisons requires a sufficient number

11

of medical and social staff. The recommended maximum limit of patients treated in OST per

physician is 50, resulting in an enormous demand of medical staff, when taking into account

the high number of IDUs in German prisons. Furthermore, a high proportion of physicians in

German prisons do not have additional training in addiction medicine, which is a requirement

to provide substitution treatment to IDUs. Therefore, prospectively more physicians

specifically skilled in addiction medicine are needed in German prisons.

Prisons present an important setting for screening and testing of HCV/HIV infections as these

facilities are often used by prisoners for the first time, both relevant prerequisites for the

provision of interventions like counselling and treatment (McGovern et al., 2006). However, a

general screening for HCV/HIV does not take place in German prisons. Despite the fact, that

targeting IDUs for HCV/HIV-testing in prisons is effective and cost-effective (Sutton et al.,

2006), we found only individual criteria (such as inmate member of risk group, request by

inmate, clinical signs) for testing blood-borne infection diseases. Given the fact, that

especially drug users in general represent a hidden population in prisons, an important option

for the identification of HCV/HIV-infected IDUs remains unused.

Prisons provide a good opportunity for the treatment of HCV and/or HIV, although studies

specifically describing HCV/HIV treatment in prison are rare (Macalino et al., 2004;

McGovern et al., 2005; Oser et al., 2007; Springer et al., 2007). In this analysis drug use and

assumed poor compliance of IDUs were found to be main contraindications for HCV/HIV-

treatment, despite the fact, that several studies have shown the effectiveness of HCV/HIV-

treatment in substituted opiate dependents (Morris & McKeganey, 2007; Robaeys et al.,

2005). As current medical guidelines state that drug users are eligible for antiviral HCV

treatment, substantial efforts have to be made to improve access to HCV treatment in German

prisons. Main indication criterias for HCV/HIV-treatment (continuation of existing treatment,

recommendation by external expert, respectively doctor in the prison hospital) indicate that

12

HCV/HIV-treatment in German prisons often are based on external decisions and rarely on

the decision of the internal medical unit.

One limitation of this analysis is that it is not verifiable if the retrieved results are based on the

prison data or on estimations of the respective prison physician. Also a selection bias can not

be precluded. Prisons with established structures for the provision of OST and HCV/HIV

treatment may be taking more frequently part in this analysis, which might lead to

overestimating the availability of OST and HCV/HIV treatment in German prisons. The high

ranges in the prevalence rates and number of treatments within the prisons may lead to the

assumption that saved data in German prison are rare. Indeed, prisons without these saved

data may have more missing data and may be more frequently excluded from this analysis.

In addition, given the high prevalence of IDUs, HCV and HIV in German prisons, changes in

prison related policy are needed, to improve surveillance, testing, prevention and treatment in

German prisons. Reducing health inequalities for the target group of IDUs and the

implementation of the principle of equivalence of health care in prison health and public

health are essential arguments to stipulate the improvement of health care services for opiate

dependent prisoners.

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