Why focus on hepatitis B and C within prisons?

Hepatitis B virus (HBV) and hepatitis C virus (HCV) are major causes of cirrhosis, liver cancer, liver transplantation, and liver related deaths.

Globally, the World Health Organization (WHO) estimated that in 2022, there were 254 million people living with hepatitis B and 50 million people living with hepatitis C, with these infections accounting for 1.3 million deaths each year (WHO, 2024).

Situation in Europe

In Europe, WHO estimates that there are 10.6 and 8.6 million people who have chronic hepatitis B and C infection respectively, of which the majority remain undiagnosed (WHO, 2024).

In the European Union (EU), the prevalence of hepatitis B and C infection is highest among key populations including some migrant populations, people who inject drugs, men who have sex with men, people in prison and sex workers (ECDC, 2024).

The prison setting is an important focus for hepatitis elimination efforts, as the prevalence of hepatitis B and C is high among people with prison experience. Prevalence is also high among people who inject drugs a population that often has significant overlap with the prison population. These factors make prisons a key priority setting for targeted hepatitis interventions.

It has been estimated that around 58% of people who inject drugs have ever been incarcerated (Wiessing L, 2021), with available data suggesting that the proportion of people in prison reporting injecting drug use during their stay in prison ranged from <1% to 39% depending on the EU country (Carpentier C, 2018).

Based on surveys conducted between 2010 and 2019 in nine European countries, the lifetime prevalence of injecting drug use during imprisonment in nine countries ranged from 1.2% in Spain to 32.4%% in Lithuania (EUDA, 2024).

With the high rates of incarceration and the high risk of acquiring HCV among people who inject drugs through the sharing of injecting equipment, the burden of HCV in the prison population of people who inject drugs is high.

One recent global study estimated that imprisoned people who inject drugs having eight times the prevalence of hepatitis C virus than people in prison who do not inject drugs (Winter RJ, 2022). In a study published in 2020 looking at HCV infection in prisons in EU, European Economic area (EEA) and United Kingdom (UK), seroprevalence of HCV antibodies ranged from 2·3% to 82·6%, while data on viraemic infections based on HCV-RNA prevalence ranged from 5·7% to 82% (Nakitanda AO, 2020).

In relation to hepatitis B, people living in prison also face a disproportionate burden of HBV due to different factors including exposure to injecting drug use, unsafe tattooing practices and unprotected sex (Smith JM, 2017).

Furthermore, some people entering prison might not be vaccinated against hepatitis B, either because they are part of birth cohorts that were not covered by childhood vaccination programmes or because they are coming from countries with low vaccination coverage (Vicente-Alcalde N, 2020).

A recent systematic review of studies conducted among countries in the EU/EEA found that the prevalence of HBV among people living in prison ranges from 0.6% in France to 8.3% in Greece (Bivegete S, 2023).

Prisons are also a high-risk environment for the transmission of HCV, given the occurrence of injecting drug use inside prison, and scarcity of access to clean injecting equipment in most prison settings. Other transmission routes in prison settings may include unsafe tattoo or body piercing practices, sharing of razors, and less commonly, unprotected sex.

These behaviours increase the risk of exposure to other blood-borne virus such as HBV and HIV. Overcrowding in prisons and lack of hygienic conditions may also constitute as risk factors in some circumstances for the spread of respiratory, gastrointestinal or blood-borne virus infections.

Issues with addressing hepatitis B and C in prison settings

While many interventions to prevent and control hepatitis B and C in prisons have been demonstrated to be effective, including the provision of various blood-borne virus prevention measures, targeted case finding and antiviral treatment (ECDC/EMCDDA, 2018a; ECDC/EMCDDA, 2018b), progress towards elimination of viral hepatitis in prison settings is hindered due to a variety of factors.

These factors include insufficient resources, lack of training and under-developed public health surveillance and/or monitoring systems, which can all impede efforts to scale-up or implement services.

Additionally, there remains gaps in the evidence base and in the data surrounding interventions to prevent blood-borne viruses transmission in prisons (Palmateer N, 2022; EMCDDA, 2022).

Furthermore, the management of healthcare services in prisons in Europe is heterogeneous and under the remit of a variety of ministries, including Ministries of Justice, Interior and Health.

These differences in managerial structures present unique challenges to the provision of health services across prison settings and in some circumstances may pose barriers to the scale up of interventions for the elimination of hepatitis B and C.

These factors, outlined in the subsequent sections of this toolkit, need to be addressed to not only improve individual health outcomes of people living in prison, but also to reduce any transmission of HBV and HCV in the prison and within the wider community beyond upon release