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1.  HIV risk after release from prison: a qualitative study of former inmates 
Background
Former prison inmates are at risk for HIV and Hepatitis C (HCV). This study was designed to understand how former inmates perceived their risk of HIV and HCV after release from prison, the behaviors and environmental factors that put patients at risk for new infection and the barriers to accessing health care.
Methods
Qualitative study utilizing individual, face-to-face, semi-structured interviews exploring participants’ perceptions and behaviors putting them at risk for HIV and HCV and barriers to engaging in regular medical care after release. Interview transcripts were coded and analyzed utilizing a team-based general inductive approach.
Results
Participants were racially and ethnically diverse and consisted of 20 men and 9 women with an age range of 22–57 years who were interviewed within the first two months after their release from prison to the Denver, Colorado community. Four major themes emerged: 1) risk factors including unprotected sex, transactional sex, and drug use were prevalent in the post-release period; 2) engagement in risky behavior occurred disproportionately in the first few days after release; 3) former inmates had educational needs about HIV and HCV; and 4) former inmates faced major challenges in accessing health care and medications.
Conclusions
Risk factors for HIV and HCV were prevalent among former inmates immediately after release. Prevention efforts should focus on education, promotion of safe sex and needle practices, substance abuse treatment, and drug- free transitional housing. Improved coordination between correctional staff, parole officers and community health care providers may improve continuity of care.
doi:10.1097/QAI.0b013e31821e9f41
PMCID: PMC3685495  PMID: 21522015
2.  Release from Prison — A High Risk of Death for Former Inmates 
The New England journal of medicine  2007;356(2):157-165.
BACKGROUND
The U.S. population of former prison inmates is large and growing. The period immediately after release may be challenging for former inmates and may involve substantial health risks. We studied the risk of death among former inmates soon after their release from Washington State prisons.
METHODS
We conducted a retrospective cohort study of all inmates released from the Washington State Department of Corrections from July 1999 through December 2003. Prison records were linked to the National Death Index. Data for comparison with Washington State residents were obtained from the Wide-ranging OnLine Data for Epidemiologic Research system of the Centers for Disease Control and Prevention. Mortality rates among former inmates were compared with those among other state residents with the use of indirect standardization and adjustment for age, sex, and race.
RESULTS
Of 30,237 released inmates, 443 died during a mean follow-up period of 1.9 years. The overall mortality rate was 777 deaths per 100,000 person-years. The adjusted risk of death among former inmates was 3.5 times that among other state residents (95% confidence interval [CI], 3.2 to 3.8). During the first 2 weeks after release, the risk of death among former inmates was 12.7 (95% CI, 9.2 to 17.4) times that among other state residents, with a markedly elevated relative risk of death from drug overdose (129; 95% CI, 89 to 186). The leading causes of death among former inmates were drug overdose, cardiovascular disease, homicide, and suicide.
CONCLUSIONS
Former prison inmates were at high risk for death after release from prison, particularly during the first 2 weeks. Interventions are necessary to reduce the risk of death after release from prison.
doi:10.1056/NEJMsa064115
PMCID: PMC2836121  PMID: 17215533
3.  Characteristics of inmates witnessing overdose events in prison: implications for prevention in the correctional setting 
Background
Although prevention of opiate overdose has been gaining attention as a harm reduction measure with community drug users, there is scarce information about drug overdose in prison. In correctional institutions without a drug free environment, awareness of overdose events is an important public health concern. This study explores the frequency with which inmates in a state penitentiary system report having witnessed drug overdose events in prison. It also explores whether participants who have witnessed an overdose in prison and know someone who died from an overdose in prison significantly differ from those that do not in selected sociodemographic variables and drug use history to identify a target population for prevention interventions.
Methods
Data comes from a cross-sectional survey of sentenced inmates in the state prisons of Puerto Rico. A complex probabilistic, multistage sampling design was used. A total of 1,179 individuals participated for an 89% response rate.
Results
Factors associated with witnessing an overdose event in prison include: male sex, age 25 or older, drug use during current incarceration, and drug injection in prison. Factors associated with knowing someone who died from an overdose in prison include: male sex, age between 25–35, previous incarcerations, and drug use during current incarceration.
Conclusion
Witnessing a drug overdose is a frequent occurrence within the prison system. The likelihood of witnessing an overdose is greater with being male, polydrug use and drug injection in prison. Findings signal an urgent public health challenge that requires prompt interventions to reduce this drug related harm within the correctional system, including adequate access to medication with opiate agonists.
doi:10.1186/1477-7517-6-15
PMCID: PMC2718878  PMID: 19589157
4.  Social and structural aspects of the overdose risk environment in St. Petersburg, Russia 
Background
While overdose is a common cause of mortality among opioid injectors worldwide, little information exists on opioid overdoses or how context may influence overdose risk in Russia. This study sought to uncover social and structural aspects contributing to fatal overdose risk in St. Petersburg and assess prevention intervention feasibility.
Methods
Twenty-one key informant interviews were conducted with drug users, treatment providers, toxicologists, police, and ambulance staff. Thematic coding of interview content was conducted to elucidate elements of the overdose risk environment.
Results
Several factors within St. Petersburg’s environment were identified as shaping illicit drug users’ risk behaviors and contributing to conditions of suboptimal response to overdose in the community. Most drug users live and experience overdoses at home, where family and home environment may mediate or moderate risk behaviors. The overdose risk environment is also worsened by inefficient emergency response infrastructure, insufficient cardiopulmonary or naloxone training resources, and the preponderance of abstinence-based treatment approaches to the exclusion of other treatment modalities. However, attitudes of drug users and law enforcement officials generally support overdose prevention intervention feasibility. Modifiable aspects of the risk environment suggest community-based and structural interventions, including overdose response training for drug users and professionals that encompasses naloxone distribution to the users and equipping more ambulances with naloxone.
Conclusion
Local social and structural elements influence risk environments for overdose. Interventions at the community and structural levels to prevent and respond to opioid overdoses are needed for and integral to reducing overdose mortality in St. Petersburg.
doi:10.1016/j.drugpo.2008.07.002
PMCID: PMC2696401  PMID: 18774283
naloxone; overdose; risk environment; emergency medical services; Russia; structural intervention
5.  Ukrainian prisoners and community reentry challenges: implications for transitional care 
Purpose
The study aims to assess reentry challenges faced by Ukrainian prisoners and to determine the factors associated with having a greater number of challenges in order to suggest pre- and post-release interventions with the aim of facilitating community reintegration.
Design/methodology/approach
A representative national cross-sectional study with a sample size of 402 prisoners was conducted among imprisoned adults within six months of release. The study consisted of interviews and biological testing for infectious diseases. Anticipated reentry challenges were assessed using a structured questionnaire.
Findings
The most difficult and relatively important challenges identified were finding a job or a stable source of income and staying out of prison following release. Risk-specific challenges pertinent to drug users and HIV-infected individuals were assessed as difficult, but generally less important. Similarly, challenges associated with reducing drug relapse were ranked as less important, with only 0.6 percent identifying opioid substitution therapy as a helpful measure. In the multivariate analysis, having a greater number of challenges is associated with previous incarcerations, drug use immediately before incarceration and lower levels of social support.
Practical implications
To facilitate community re-integration, it is vital to design interventions aimed at reducing recidivism and improvement of social support through comprehensive case management as well as to improve understanding about and address drug dependence issues among inmates by implementing evidence-based treatment both within prisons and after release.
Originality/value
This is the first comprehensive assessment of community reentry challenges by prisoners in the former Soviet Union.
doi:10.1108/17449201311310760
PMCID: PMC4138714  PMID: 25152767
Prisoners; Drug use; HIV; AIDS; Ukraine; Community reentry; Recidivism; Social support; Communities
6.  Accessing Antiretroviral Therapy Following Release From Prison 
Context
Interruption of antiretroviral therapy (ART) during the first weeks after release from prison may increase risk for adverse clinical outcomes, transmission of human immunodeficiency virus (HIV), and drug-resistant HIV reservoirs in the community. The extent to which HIV-infected inmates experience ART interruption following release from prison is unknown.
Objectives
To determine the proportion of inmates who filled an ART prescription within 60 days after release from prison and to examine predictors of this outcome.
Design, Setting, and Participants
Retrospective cohort study of all 2115 HIV-infected inmates released from the Texas Department of Criminal Justice prison system between January 2004 and December 2007 and who were receiving ART before release.
Main Outcome Measure
Proportion of inmates who filled an ART prescription within 10, 30, and 60 days of release from prison.
Results
Among the entire study cohort (N=2115), an initial prescription for ART was filled by 115 (5.4%) inmates within 10 days of release (95% confidence interval [CI], 4.5%-6.5%), by 375 (17.7%) within 30 days (95% CI, 16.2%-19.4%), and by 634 (30.0%) within 60 days (95% CI, 28.1%-32.0%). In a multivariate analysis of predictors (including sex, age, race/ethnicity, viral load, duration of ART, year of discharge, duration of incarceration, parole, and AIDS Drug Assistance Program application assistance), Hispanic and African American inmates were less likely to fill a prescription within 10 days (adjusted estimated risk ratio [RR], 0.4 [95% CI, 0.2-0.8] and 0.4 [95% CI, 0.3-0.7], respectively) and 30 days (adjusted estimated RR, 0.7 [95% CI, 0.5-0.9] and 0.7 [95% CI, 0.5-0.9]). Inmates with an undetectable viral load were more likely to fill a prescription within 10 days (adjusted estimated RR, 1.8 [95% CI, 1.2-2.7]), 30 days (1.5 [95% CI, 1.2-1.8]), and 60 days (1.3 [95% CI, 1.1-1.5]). Inmates released on parole were more likely to fill a prescription within 30 days (adjusted estimated RR, 1.3 [95% CI, 1.1-1.6]) and 60 days (1.5 [95% CI, 1.4-1.7]). Inmates who received assistance completing a Texas AIDS Drug Assistance Program application were more likely to fill a prescription within 10 days (adjusted estimated RR, 3.1 [95% CI, 2.0-4.9]), 30 days (1.8 [95% CI, 1.4-2.2]), and 60 days (1.3 [95% CI, 1.1-1.4]).
Conclusion
Only a small percentage of Texas prison inmates receiving ART while incarcerated filled an initial ART prescription within 60 days of their release.
doi:10.1001/jama.2009.202
PMCID: PMC2936238  PMID: 19244192
7.  Understanding drug-related mortality in released prisoners: a review of national coronial records 
BMC Public Health  2012;12:270.
Background
The prisoner population is characterised by a high burden of disease and social disadvantage, and ex-prisoners are at increased risk of death following release. Much of the excess mortality can be attributed to an increased risk of unnatural death, particularly from drug overdose; however, relatively few studies have investigated the circumstances surrounding drug-related deaths among released prisoners. This study aimed to explore and compare the circumstances of death for those who died from accidental drug-related causes to those who died from all other reportable causes.
Methods
A nationwide search of the Australian National Coroners Information System (NCIS) was conducted to identify reportable deaths among ex-prisoners from 2000 to 2007. Using a structured coding form, NCIS records for these cases were interrogated to explore causes and circumstances of death.
Results
Coronial records for 388 deceased ex-prisoners were identified. Almost half of these deaths were a result of accidental drug-related causes (45%). The majority of accidental drug-related deaths occurred in a home environment, and poly-substance use at or around the time of death was common, recorded in 72% of drug-related deaths. Ex-prisoners who died of accidental drug-related causes were on average younger and less likely to be Indigenous, born in Australia, married, or living alone at or around the time of death, compared with those who died from all other reportable causes. Evidence of mental illness or self-harm was less common among accidental drug-related deaths, whereas evidence of previous drug overdose, injecting drug use, history of heroin use and history of drug withdrawal in the previous six months were more common.
Conclusions
Drug-related deaths are common among ex-prisoners and often occur in a home (vs. public) setting. They are often associated with use of multiple substances at or around the time of death, risky drug-use patterns, and even among this markedly disadvantaged group, extreme social disadvantage. These findings reflect the complex challenges facing prisoners upon release from custody and indicate a need to consider drug overdose within the wider framework of ex-prisoner experiences, so that preventive programmes can be appropriately structured and targeted.
doi:10.1186/1471-2458-12-270
PMCID: PMC3464778  PMID: 22475069
8.  Psychosocial and contextual correlates of opioid overdose risk among drug users in St. Petersburg, Russia 
Background
Opioid overdose in Russia is a problem that has grown more severe as heroin abuse expanded over the past decade, yet few studies have explored it in detail. In order to gain a clearer understanding of the situation, 60 drug users, both in and out of drug treatment in St. Petersburg, were interviewed concerning their overdose experience and knowledge about overdose recognition and prevention.
Methods
Using a semi-structured interview, we sought to identify and describe local attitudes, knowledge and experience (both self-sustained and witnessed) of opioid overdose. Bi-variate and multiple logistic regressions were performed in order to identify the relationship between overdose experience and sociodemographic factors, risk behaviors, and clinical psychiatric measures.
Results
We found that having experienced or witnessed an opioid overdose within the previous year was common, overdose knowledge was generally high, but nearly half the participants reported low self-efficacy for effectively intervening in an overdose situation. In bivariate analyses, self-reported family problems (i.e., perceived problematic family interactions) were positively associated with both experiencing (t56 = 2.49; p < 0.05) and with witnessing a greater number of overdoses in the previous year (rhos = 0.31; p < 0.05). Having previously overdosed [Adjusted Risk Ratio (ARR) 1.7, 95% Confidence Interval (CI) 1.1–2.6] and higher SCL-90-R somatization scores (ARR 1.2, 95% CI 0.96 – 1.5) were independently associated in multivariable analyses with self-sustained overdose experience in the past year. Greater perceived likelihood of experiencing a future overdose and concern about medical problems were independently associated with witnessing a higher number of overdoses within the previous year. Over two thirds of the participants expressed interest in receiving training in overdose prevention and response.
Conclusion
Opioid overdose experience is very common among drug users in St. Petersburg, Russia, and interest in receiving training for overdose recognition and prevention was high. Future research should target the development of effective overdose recognition and prevention interventions, especially ones that include naloxone distribution and involve drug users' families.
doi:10.1186/1477-7517-6-17
PMCID: PMC2724502  PMID: 19630963
9.  A qualitative study of overdose responses among Chicago IDUs 
Background
Opioid overdose is a leading cause of death among injection drug users. Over half of injection drug users report at least one nonfatal overdose during their lifetime. Death from opioid overdose rarely occurs instantaneously, but rather over the course of one to three hours, allowing ample time for providing life-saving measures. In response to the prevalence of overdoses in the U.S., there are a growing number of overdose prevention and naloxone distribution programs targeting the injection drug using community.
Methods
We explored injection drug users' experiences with opioid overdose response, examining differences between overdose responses in which naloxone was and was not used. The current study is based upon qualitative interviews (N = 31) with clients of the Chicago Recovery Alliance needle exchange program who had witnessed an overdose in the past six months. The interviews explored participants' drug use history, personal overdose experiences, and details concerning their last witnessed overdose. Verbatim transcripts were coded and analyzed thematically to address major study questions.
Results
Participants were 81% were male, their median age was 38. They reported having injected a median of 10 years and having witnessed a median of six overdoses in their lifetime. All described overdoses were recognized and responded to quickly. None of the overdoses resulted in a fatality and naloxone was successfully administered in 58% of the last witnessed overdoses. Administering naloxone for the first time was characterized by trepidation, but this feeling dissipated as the naloxone quickly took effect. Emergency medical personnel were called in 10 of the 31 described overdoses, including four in which participants administered naloxone. The overwhelming majority of experiences with police and paramedics were positive
Conclusion
Overall, our small study found that the overdose prevention efforts build on extensive knowledge possessed by IDUs. Teaching IDUs how to use naloxone is an effective risk reduction strategy.
doi:10.1186/1477-7517-5-2
PMCID: PMC2245921  PMID: 18218071
10.  HIV infection and risk factors among Bangkok prisoners, Thailand: a prospective cohort study 
Background
Incarceration has been associated with HIV infection among injection drug users. However, data on HIV risk factors of the inmates during incarceration are rarely reported from Thailand.
Methods
A prospective cohort of 689 male inmates in a Bangkok central prison was studied during 2001–2002. Follow up visits were conducted for 5 months, with testing for HIV and other infections and interviewing of demographics and risk behaviors.
Results
Among 689 male inmates, half (50.9 %) were drug injectors. About 49% of the injectors had injection during incarceration. Most (94.9%) of the injectors had shared injection paraphernalia with others. Successful follow up rate was 98.7% after 2,581 person-months observation. HIV incidence was 4.18 per 100 person – years among all inmates, and 11.10 per 100 person – years among the injection inmates. Multivariate analysis identified variables associated with HIV prevalence: history of injection [OR = 2.30, 95%CI: 1.91–2.77], positive urine opiate test [OR = 5.04, 95%CI: 2.63–9.67], history of attendance to drug withdrawal clinics [OR = 2.00, 95%CI: 1.19–3.35] and presence of tattoos on the body [OR = 1.23, 95%CI: 1.01–1.52].
Conclusions
The main HIV risk factors of Bangkok inmates were those related to drug injection. Harm reduction measures and HIV intervention strategies should be implemented to prevent more spread of HIV among the inmates and into the community.
doi:10.1186/1471-2334-3-25
PMCID: PMC270083  PMID: 14580265
11.  Public Health Implications for Adequate Transitional Care for HIV-Infected Prisoners: Five Essential Components 
In the United States, 10 million inmates are released every year, and human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) prevalence is several-fold greater in criminal justice populations than in the community. Few effective linkage-to-the-community programs are currently available for prisoners infected with HIV. As a result, combination antiretroviral therapy (cART) is seldom continued after release, and virological and immunological outcomes worsen. Poor HIV treatment outcomes result from a myriad of obstacles that released prisoners face upon reentering the community, including homelessness, lack of medical insurance, relapse to drug and alcohol use, and mental illness. This article will focus on 5 distinct factors that contribute significantly to treatment outcomes for released prisoners infected with HIV and have profound individual and public health implications: (1) adaptation of case management services to facilitate linkage to care; (2) continuity of cART; (3) treatment of substance use disorders; (4) continuity of mental illness treatment; and (5) reducing HIV-associated risk-taking behaviors as part of secondary prevention.
doi:10.1093/cid/cir446
PMCID: PMC3156144  PMID: 21844030
12.  Enrollment in Outpatient Care Among Newly Released Prison Inmates with HIV Infection 
SYNOPSIS
Objectives
Although many prisoners infected with human immunodeficiency virus (HIV) initiate and adhere to treatment regimens while incarcerated, the benefits of in-prison therapy are frequently lost after community reentry. Little information is available on the percentage of released inmates who establish community-based HIV outpatient treatment in a timely fashion. We sought to determine the proportion of HIV-infected Texas prison inmates who enrolled in an HIV clinic within 90 days after release and to identify variables associated with timely linkage to clinical care.
Methods
This was a retrospective cohort study of 1,750 HIV-infected inmates who were released from the Texas Department of Criminal Justice (TDCJ) and returned to Harris County between January 2004 and December 2007. We obtained demographic and clinical data from centralized databases maintained by TDCJ and the Harris County Health District, and used logistic regression analysis to identify factors associated with linkage to post-release outpatient care.
Results
Only 20% of released inmates enrolled in an HIV clinic within 30 days of release, and only 28% did so within 90 days. Released inmates ≥30 years of age were more likely than their younger counterparts to have enrolled in care at the 30- and 90-day time points. Inmates diagnosed with schizophrenia were more likely to have initiated care within 30 days. Inmates who received antiretroviral therapy while incarcerated and those who received enhanced discharge planning were more likely to begin care at both time points.
Conclusions
A large proportion of HIV-infected inmates fail to establish outpatient care after their release from the Texas prison system. Implementation of intensive discharge planning programs may be necessary to ensure continuity of HIV care among newly released inmates.
PMCID: PMC2788410  PMID: 20408389
13.  Enrollment in Outpatient Care Among Newly Released Prison Inmates with HIV Infection 
Public Health Reports  2010;125(Suppl 1):64-71.
SYNOPSIS
Objectives
Although many prisoners infected with human immunodeficiency virus (HIV) initiate and adhere to treatment regimens while incarcerated, the benefits of in-prison therapy are frequently lost after community reentry. Little information is available on the percentage of released inmates who establish community-based HIV outpatient treatment in a timely fashion. We sought to determine the proportion of HIV-infected Texas prison inmates who enrolled in an HIV clinic within 90 days after release and to identify variables associated with timely linkage to clinical care.
Methods
This was a retrospective cohort study of 1,750 HIV-infected inmates who were released from the Texas Department of Criminal Justice (TDCJ) and returned to Harris County between January 2004 and December 2007. We obtained demographic and clinical data from centralized databases maintained by TDCJ and the Harris County Health District, and used logistic regression analysis to identify factors associated with linkage to post-release outpatient care.
Results
Only 20% of released inmates enrolled in an HIV clinic within 30 days of release, and only 28% did so within 90 days. Released inmates ≥30 years of age were more likely than their younger counterparts to have enrolled in care at the 30- and 90-day time points. Inmates diagnosed with schizophrenia were more likely to have initiated care within 30 days. Inmates who received antiretroviral therapy while incarcerated and those who received enhanced discharge planning were more likely to begin care at both time points.
Conclusions
A large proportion of HIV-infected inmates fail to establish outpatient care after their release from the Texas prison system. Implementation of intensive discharge planning programs may be necessary to ensure continuity of HIV care among newly released inmates.
PMCID: PMC2788410  PMID: 20408389
14.  Sexual behavior and knowledge of human immunodeficiency virus/aids and sexually transmitted infections among women inmates of Briman Prison, Jeddah, Saudi Arabia 
BMC Infectious Diseases  2014;14:290.
Background
To reduce the incidence of HIV and sexually transmitted infections (STIs), it is necessary to target high-risk populations such as prison inmates. This study aims to explore the range of knowledge on HIV and STIs, sexual behaviors, and adoption of preventive measures among women inmates.
Methods
This was a survey conducted between July 1, 2012 and July 29, 2012 among women inmates at Briman Prison, Jeddah, Saudi Arabia. The author gave an educational lecture on STIs in a conference room at the prison. Educational material was distributed to the attendees after the lecture, and the survey was conducted one week later. All the participants were asked to complete an anonymous 40-item self-administered questionnaire in the presence of a professional health assistant and a translator, for non-Arabic speakers. Data collected included the personal data of the respondent, her alleged criminal background, penal status, accumulative time in prison, history of smoking, alcohol or drug addiction, knowledge about the seven most common STIs, symptoms, modes of transmission, prevention, sexual activity, addiction, and means of protection. Descriptive analysis was performed using Microsoft Excel.
Results
We interviewed 204 women aged 16-60 years (mean, 33.3 years). Most of the respondents (n = 170; 83 · 0%) were not aware of STIs; 117 respondents (57 · 4%) did not undergo screening for STIs before marriage or intercourse, while only 59 (28 · 9%) did. Over half of the respondents (n = 107; 52.5%) thought they knew how to protect themselves from STIs. Nevertheless, 87 (42.6%) were uncertain about the role of condoms in protection from STIs and (n = 41; 20.1%) thought condoms provide 100% protection against STIs, while 72 respondents (35.3%) thought condoms did not confer 100% protection against STIs. Only 10 respondents (4.9%) used condoms to protect themselves from STIs. Saudi women (P = 0.033) and those with a higher level of education (P < 0.01) were significantly more likely to have better knowledge.
Conclusion
Women inmates at Briman Prison have poor knowledge of STIs as well as risky sexual behaviors. Campaigns aimed at increasing awareness of STIs should also target prison inmates, who in general constitute high-risk populations.
doi:10.1186/1471-2334-14-290
PMCID: PMC4048581  PMID: 24884734
15.  A Descriptive Model of Patient Readiness, Motivators, and Hepatitis C Treatment Uptake among Australian Prisoners 
PLoS ONE  2014;9(2):e87564.
Background
Hepatitis C virus infection (HCV) has a significant global health burden with an estimated 2%–3% of the world's population infected, and more than 350,000 dying annually from HCV-related conditions including liver failure and liver cancer. Prisons potentially offer a relatively stable environment in which to commence treatment as they usually provide good access to health care providers, and are organised around routine and structure. Uptake of treatment of HCV, however, remains low in the community and in prisons. In this study, we explored factors affecting treatment uptake inside prisons and hypothesised that prisoners have unique issues influencing HCV treatment uptake as a consequence of their incarceration which are not experienced in other populations.
Method and Findings
We undertook a qualitative study exploring prisoners' accounts of why they refused, deferred, delayed or discontinued HCV treatment in prison. Between 2010 and 2013, 116 Australian inmates were interviewed from prisons in New South Wales, Queensland, and Western Australia. Prisoners experienced many factors similar to those which influence treatment uptake of those living with HCV infection in the community. Incarceration, however, provides different circumstances of how these factors are experienced which need to be better understood if the number of prisoners receiving treatment is to be increased. We developed a descriptive model of patient readiness and motivators for HCV treatment inside prisons and discussed how we can improve treatment uptake among prisoners.
Conclusion
This study identified a broad and unique range of challenges to treatment of HCV in prison. Some of these are likely to be diminished by improving treatment options and improved models of health care delivery. Other barriers relate to inmate understanding of their illness and stigmatisation by other inmates and custodial staff and generally appear less amenable to change although there is potential for peer-based education to address lack of knowledge and stigma.
doi:10.1371/journal.pone.0087564
PMCID: PMC3937313  PMID: 24586281
16.  Mortality from overdose among injecting drug users recently released from prison: database linkage study. 
BMJ : British Medical Journal  1998;316(7129):426-428.
OBJECTIVE: To assess whether injecting drug users have a higher than usual risk of death from overdose in the 2 weeks after release from prison. DESIGN: Soundex coding of surnames and information on date of birth were used to link entry and release dates from the local prison between 1983 and 1994 with clinical data from Edinburgh City Hospital's cohort of male injecting drug users who are infected with HIV. SETTING: Edinburgh City Hospital and Edinburgh Prison. SUBJECTS: 316/332 male injecting drug users infected with HIV in the City Hospital HIV cohort; 16 were excluded because they were enrolled after developing AIDS or because their precise date of death was not available. MAIN OUTCOME MEASURE: Relative risk of dying from overdose before developing AIDS and relative risk of dying of all causes before developing AIDS during the 2 weeks after release from prison; this was compared with relative risks of death during other time at liberty. RESULTS: 238/316 (75%) injecting drug users served time in the prison between 1983 and 1994. 33 out of 316 injecting drug users who were infected with HIV died before developing AIDS during 517,177 days at risk. 20 of these men died of an overdose; 6 of these deaths occurred within 2 weeks of release during 5903 days at risk. Death rates from overdose before the development of AIDS were 1.02/1000 days during the 2 weeks after release (recently released) and 0.029/1000 days during other times of liberty. The relative risk of death from overdose became 7.7 (1.5 to 39.1) after temporal matching (when the comparison was limited to the first 2 weeks after release v the next 10 weeks). The crude relative risk in an analysis combining stratified prison term and the 2 weeks after release was 4.5 (1.7 to 11.7) for death from overdose. After temporal matching these risks became 1.8 (0.4 to 9.2). CONCLUSION: Prisons should evaluate interventions to reduce the risk of death from overdose after release.
PMCID: PMC2665604  PMID: 9492665
17.  Risk factors for hepatitis C infection and perception of antibody status among male prison inmates in the hepatitis C incidence and transmission in prisons study cohort, Australia 
The objective of this study was to compare the prevalence of risk factors for hepatitis C virus (HCV) infection among male prison inmates enrolling into a prospective cohort in Australia. We tested 121 inmates who were previously untested or were previously known to be anti-HCV antibody negative for anti-HCV antibodies by enzyme-linked immunosorbent assay. HCV-positive inmates were classified as cases (n=25) and HCV-negative inmates as controls (n=96). The study found that cases were less educated than controls and confirmed that prior imprisonment, drug injection, and a longer duration of injecting were risk factors for HCV infection. More than half of those who tested HCV positive perceived that they did not have HCV infection, and 44% were unsure of their HCV status. Those inmates who were incorrect about their HCV status tended to be less educated and were more likely to have been previously imprisoned than those who were correct about their HCV status. Inmates who were unsure of their HCV status were less likely to have been tested for HCV than those who had a clear perception of their HCV status, even if incorrect. Three (12%) inmates who tested positive denied injecting drug use, but reported other risk factors. Prisons are likely to remain an important site for the diagnosis of HCV infection and targeted interventions aimed at risk reduction among inmates with low education levels and a previous imprisonment history.
doi:10.1093/jurban/jth129
PMCID: PMC3455941  PMID: 15273267
Hepatitis C virus (HCV); Injecting drug user (IDU); prison; risk behaviors
18.  Patients, prisoners, or people? Women prisoners' experiences of primary care in prison: a qualitative study 
Background
The development of primary care services within prisons has been central to improvements in the provision of health care in this setting over the past decade. Despite national imperatives to involve patients in the development of services and numerous policy initiatives, there has been no systematic evaluation of changes in the delivery of primary care and little published evidence of consultation with prisoners.
Aim
To explore women prisoners' experiences of primary healthcare provision in prison.
Design of study
Qualitative study using focus groups and interviews.
Setting
Two women's prisons in southern England.
Method
Six focus groups involving 37 women were conducted, as well as 12 semi-structured individual interviews. Focus groups and interviews were recorded, transcribed, and analysed thematically.
Results
Women prisoners' perceptions of the quality of prison health care were mixed. There were accounts of good-quality care where practitioners were regarded as knowledgeable and respectful, but many perceived that the quality of care was poor. They complained about difficulties accessing care or medication, disrespectful treatment, and breaches of confidentiality by practitioners. They voiced the belief that staff were less qualified and competent than their counterparts in the community.
Conclusion
The prison environment presents unique challenges to those providing health care, and much work has been done recently on modernising prison health care and improving professional standards of practice. However, the accounts of women prisoners in this study suggest that there is a gap between patient experience and policy aspirations.
doi:10.3399/bjgp08X330771
PMCID: PMC2529223  PMID: 18801272
prisoners; qualitative research; quality of health care; women
19.  “I know if I drink I won’t feel anything”: Substance use relapse among depressed women leaving prison 
Purpose
The purpose of this article is to explore treatment needs and factors contributing to engagement in substance use and sobriety among women with co-occurring substance use and major depressive disorders as they return to the community from prison.
Design
This article used qualitative methods to evaluate the perspectives of 15 women with co-occurring substance use and major depressive disorders on the circumstances surrounding their relapse and recovery episodes following release from a U.S. prison. Women were recruited in prison; qualitative data were collected using semi-structured interviews conducted after prison release and were analyzed using grounded theory analysis. Survey data from 39 participants supplemented qualitative findings.
Findings
Results indicated that relationship, emotion, and mental health factors influenced women’s first post-prison substance use. Women attributed episodes of recovery to sober and social support, treatment, and building on recovery work done in prison. However, they described a need for comprehensive pre-release planning and post-release treatment that would address mental health, family, and housing/employment and more actively assist them in overcoming barriers to care.
Practical implications
In-prison and aftercare treatment should help depressed, substance using women prisoners reduce or manage negative affect, improve relationships, and obtain active and comprehensive transitional support.
Originality/value
Women with co-occurring mental health and substance use disorders are a high-risk population for negative post-release outcomes, but limited information exists regarding the processes by which they relapse or retain recovery after release from prison. Findings inform treatment and aftercare development efforts.
doi:10.1108/IJPH-02-2013-0009
PMCID: PMC4112961  PMID: 25083160
Prison; women; substance use disorder; major depressive disorder; treatment
20.  Prevalence, Risk Factors and Social Context of Active Pulmonary Tuberculosis among Prison Inmates in Tajikistan 
PLoS ONE  2014;9(1):e86046.
Setting
Tuberculosis (TB) is highly prevalent in prisons of the former Soviet Union.
Objective
To understand the behavioral, demographic and biological factors placing inmates in Tajikistan at risk for active TB.
Design
We administered a behavioral and demographic survey to 1317 inmates in two prison facilities in Sughd province, Tajikistan along with radiographic screening for pulmonary TB. Suspected cases were confirmed bacteriologically. Inmates undergoing TB treatment were also surveyed. In-depth interviews were conducted with former prisoners to elicit relevant social and behavioral characteristics.
Results
We identified 59 cases of active pulmonary TB (prevalence 4.5%). Factors independently associated with increased prevalence of active TB were: HIV-infection by self-report (PR 7.88; 95%CI 3.40–18.28), history of previous TB (PR 10.21; 95%CI 6.27–16.63) and infrequent supplemental nutrition beyond scheduled meals (PR 3.00; 95%CI 1.67–5.62). Access to supplemental nutrition was associated with frequency of visits from friends and family and ability to rely on other inmates for help.
Conclusion
In prison facilities of Tajikistan, HIV-infection, injection drug use and low access to supplemental nutrition were associated with prevalent cases of active pulmonary TB. Policies that reduce HIV transmission among injection drug users and improve the nutritional status of socially isolated inmates may alleviate the TB burden in Tajikistan’s prisons.
doi:10.1371/journal.pone.0086046
PMCID: PMC3896449  PMID: 24465861
21.  ‘It’s more about the heroin’: Injection drug users’ response to an overdose warning campaign in a Canadian setting 
Addiction (Abingdon, England)  2013;108(7):1270-1276.
Aims
To assess heroin injectors’ perceptions of and responses to a warning issued by public health officials regarding high-potency heroin and increases in fatal overdoses.
Design
Semi-structured qualitative interviews
Setting
Vancouver, Canada.
Participants
Eighteen active heroin injectors
Measurements
Semi-structured interview guide focussing on heroin injectors’ perceptions of and responses to the overdose warning, including reasons for failing to adhere to risk reduction recommendations.
Findings
Although nearly all participants were aware of the warning, their recollections of the message and the timing of its release were obscured by on-going social interactions within the drug scene focussed on heroin quality. Many injection drug users reported seeking the high potency heroin and nearly all reported no change in overdose risk behaviours. Responses to the warning were shaped by various social, economic and structural forces that interacted with individual behaviour and undermined efforts to promote behavioural change, including sales tactics employed by dealers, poverty, the high cost and shifting quality of available heroin, and risks associated with income-generating activities. Individual-level factors, including emotional suffering, withdrawal, entrenched injecting routines, perceived invincibility and the desire for intense intoxication also undermined risk reduction messages.
Conclusions
Among heroin injectors in British Columbia, a 2011 overdose warning campaign appeared to be of limited effectiveness and also produced unintended negative consequences that exacerbated overdose risk.
doi:10.1111/add.12151
PMCID: PMC3913056  PMID: 23551565
heroin; injection drug use; overdose; public health warning
22.  Overdose experiences among injection drug users in Bangkok, Thailand 
Background
Although previous studies have identified high levels of drug-related harm in Thailand, little is known about illicit drug overdose experiences among Thai drug users. We sought to investigate non-fatal overdose experiences and responses to overdose among a community-recruited sample of injection drug users (IDU) in Bangkok, Thailand.
Methods
Data for these analyses came from IDU participating in the Mit Sampan Community Research Project. The primary outcome of interest was a self-reported history of non-fatal overdose. We calculated the prevalence of past overdose and estimated its relationship with individual, drug-using, social, and structural factors using multivariate logistic regression. We also assessed the prevalence of ever witnessing an overdose and patterns of response to overdose.
Results
These analyses included 252 individuals; their median age was 36.5 years (IQR: 29.0 - 44.0) and 66 (26.2%) were female. A history of non-fatal overdose was reported by 75 (29.8%) participants. In a multivariate model, reporting a history of overdose was independently associated with a history of incarceration (Adjusted Odds Ratio [AOR] = 3.83, 95% Confidence Interval [CI]: 1.52 - 9.65, p = 0.004) and reporting use of drugs in combination (AOR = 2.48, 95% CI: 1.16 - 5.33, p = 0.019). A majority (67.9%) reported a history of witnessing an overdose; most reported responding to the most recent overdose using first aid (79.5%).
Conclusions
Experiencing and witnessing an overdose were common in this sample of Thai IDU. These findings support the need for increased provision of evidence-based responses to overdose including peer-based overdose interventions.
doi:10.1186/1477-7517-7-9
PMCID: PMC2880311  PMID: 20465842
23.  Take-Home Emergency Naloxone to Prevent Heroin Overdose Deaths after Prison Release: Rationale and Practicalities for the N-ALIVE Randomized Trial 
The naloxone investigation (N-ALIVE) randomized trial commenced in the UK in May 2012, with the preliminary phase involving 5,600 prisoners on release. The trial is investigating whether heroin overdose deaths post-prison release can be prevented by prior provision of a take-home emergency supply of naloxone. Heroin contributes disproportionately to drug deaths through opiate-induced respiratory depression. Take-home emergency naloxone is a novel preventive measure for which there have been encouraging preliminary reports from community schemes. Overdoses are usually witnessed, and drug users themselves and also family members are a vast intervention workforce who are willing to intervene, but whose responses are currently often inefficient or wrong. Approximately 10% of provided emergency naloxone is thought to be used in subsequent emergency resuscitation but, as yet, there have been no definitive studies. The period following release from prison is a time of extraordinarily high mortality, with heroin overdose deaths increased more than sevenfold in the first fortnight after release. Of prisoners with a previous history of heroin injecting who are released from prison, 1 in 200 will die of a heroin overdose within the first 4 weeks. There are major scientific and logistical challenges to assessing the impact of take-home naloxone. Even in recently released prisoners, heroin overdose death is a relatively rare event: hence, large numbers of prisoners need to enter the trial to assess whether take-home naloxone significantly reduces the overdose death rate. The commencement of pilot phase of the N-ALIVE trial is a significant step forward, with prisoners being randomly assigned either to treatment-as-usual or to treatment-as-usual plus a supply of take-home emergency naloxone. The subsequent full N-ALIVE trial (contingent on a successful pilot) will involve 56,000 prisoners on release, and will give a definitive conclusion on lives saved in real-world application. Advocates call for implementation, while naysayers raise concerns. The issue does not need more public debate; it needs good science.
doi:10.1007/s11524-013-9803-1
PMCID: PMC3795186  PMID: 23633090
24.  A pilot survey of attitudes and knowledge about opioid substitution therapy for HIV-infected prisoners 
Journal of opioid management  2008;4(2):81-86.
A majority of inmates in the state of Connecticut Department of Corrections use opioids or are opioid dependent before incarceration. None of the state’s prisons offer opioid substitution therapy other than for detoxification or maintenance therapy for women during pregnancy. On release to the community, most prisoners relapse to drug use and this has been associated with higher recidivism rates, and less adherence to antiretroviral medications for HIV-infected persons. Nationally and internationally, methadone (METH) and buprenorphine (BUP) have been found to decrease relapse to drug use, decrease recidivism rates, improve adherence to antiretroviral medications, decrease HIV-risk taking behaviors, and improve mortality. However, the general knowledge about opioid substitution therapy among correctional facility staff has been reported as substandard. This pilot study compiled results of answers to anonymous surveys from 27 individuals who work directly with inmates in a patient-care capacity for the Connecticut Department of Corrections (CT DOC) and CT DOC case-management referral program (Project TLC) in the year 2006. The surveys included questions regarding current attitudes and knowledge about opioid substitution therapy for prisoners. A minority of respondents refer released prisoners with a history of opioid dependency to METH or BUP treatment. The majority of correctional workers and case-management referral workers did not have knowledge about BUP or METH’s ability to improve health and decrease HIV risk taking behaviors. This study found that more education of individuals treating and caring for HIV-infected opioid dependent prisoners is needed.
PMCID: PMC2476214  PMID: 18557164
HIV; AIDS; incarceration; Criminal Justice System; prison; opioids; buprenorphine; methadone; prisoners
25.  Jails, prisons, and the health of urban populations: A review of the impact of the correctional system on community health 
This review examined the interactions between the correctional system and the health of urban populations. Cities have more poor people, more people of color, and higher crime rates than suburban and rural areas; thus, urban populations are overrepresented in the nation's jails and prisons. As a result, US incarceration policies and programs have a disproportionate impact on urban communities, especially black and Latino ones. Health conditions that are overrepresented in incarcerated populations include substance abuse, human immunodeficiency virus (HIV) and other infectius diseases, perpetration and victimization by violence, mental illness, chronic disease, and reproductive health problems. Correctional systems have direct and indirect effects on health. Indirectly, they influence family structure, economic opportunities, political participation, and normative community values on sex, drugs, and violence. Current correctional policies also divert resources from other social needs. Correctional systems can have a direct effect on the health of urban populations by offering health care and health promotion in jails and prisons, by linking inmates to community services after release, and by assisting in the process of community reintegration. Specific recommendations for action and reseach to reduce the adverse health and social consequences of current incarceration policies are offered.
doi:10.1093/jurban/78.2.214
PMCID: PMC3456366  PMID: 11419576
Criminal Justice Policy; Health of Incarcerated Populations; Jail Health Services; Urban Health

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