Incarceration and spread of disease

The historical connection between infectious disease and incarceration dates back to 1666, when it was noted that while British prisoners were being tried for their crimes they often infected people in the courtroom (Stern, 2001). There are two main theories as to why there is such a high prevalence of infectious disease in jail: the first is that at-risk populations are concentrated in the prison environment, while the second focuses on the fact that the risk environment as a whole is much higher in prison. The truth is probably a combination of the two. Data from the US reveal that approximately 2.4 percent of the entire population -mostly minorities - is either incarcerated or awaiting trial, with almost a quarter being related to drug offenses, and these numbers continue to grow (Polonsky et al., 1994; Fox et al., 2005).

The burden of infectious disease in entrants to the penal system is significantly higher than in the general population, and is commonly related to a history of IDU (Horsburgh et al., 1990; Simbulan et al., 2001; Ruiz et al., 2002; Alizadeh et al., 2005; Drobniewski et al., 2005; Kushel et al., 2005). For example, the prevalence of HIV is over 10 times higher in incarcerated populations than in the general population (Vlahov et al., 1991). Moreover, the risk environment (all risks external to the individual) becomes much more dangerous when a person is incarcerated (Watson etal, 2004). The normally complex social networks of free injection drug users are inherently simplified while incarcerated, due to the limited population, thus causing exaggerated high-risk behaviors such as sharing injection devices (Rhodes et al., 1999a). Secondary to the previously discussed strategies of zero-tolerance policing on drug use, most injection drug users will be incarcerated as a result of their drug use, and will continue to use drugs while in prison (Dufour et al, 1996). Consequently, there has been incidence of infectious disease in prisons, including HIV, HCV, and HBV, secondary to drug use worldwide (Dolan and Wodak, 1999; Khan et al, 2005; Taylor et al, 1995, 2000; Thaisri et al., 2003). These same conditions have resulted in multiple reports demonstrating that incarceration is an independent risk factor for the incidence of HIV, HCV and HBV among injection drug users (Briggs et al, 2001; Mishra et al, 2003; Small et al, 2005). Based on these reports, it is now time to implement the various harm-reduction strategies with proven efficacy, including education, opioid substitution therapy, and needle exchange, in prisons (Choopanya et al, 2003; Dolan et al, 2003, 2004; Nelles et al, 1998).

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