What is the European situation on viral hepatitis elimination in prison?
Viral hepatitis epidemiology in the prison population
Section titled “Viral hepatitis epidemiology in the prison population”More than 11 million people are held in prison worldwide (UNODC, 2021). There are around 2 000 prison establishments in EU countries, Norway, Türkiye and the United Kingdom (EMCDDA, 2022).
The number of people living in prison in the EU in 2021 was around 475 000, equating to 106 people living in prison per 100 000 inhabitants, with variation in this rate across countries (Eurostat, 2021).
The highest rates in 2021 were in Hungary and Poland (both 191 per 100 000), followed by Slovakia (185 per 100 000). The lowest rates were in Finland (51 per 100 000), Slovenia (54 per 100 000), and the Netherlands (65 per 100 000).
Approximately one fifth of the prison population in the EU are reported to be held in prison without a final judgement (i.e. on remand) (Eurostat, 2024).
Over half (58%) of people who inject drugs have ever been incarcerated (Wiessing L, 2021) and the proportion of people in prison reporting injecting drug use during their stay in prison ranged from <1% and 39% (Carpentier C, 2018).
Approximately 5% of the EU prison population (around 41 000) are women. The prison population has an estimated mean age of 37 years, with some variation across countries from a mean age of 34 years in Denmark to 41 years in Italy (EMCDDA, 2022).
One in five people in prison in the EU had a foreign citizenship in the prison where the country is located (Eurostat, 2021). A high proportion of people in prison in Europe are migrants from countries where HBV and HCV endemicity is higher (see section on Migrant populations).
People who inject drugs are a key population for hepatitis B and C due to the sharing of injecting equipment and are over-represented in prison settings in the EU/EEA.
There is an association between injecting drug use and imprisonment through a number of factors, whether the drug law offences themselves, bearing in mind that criminal penalties related to drug use vary across Europe, or the related offences, such as property crime, public disorder or violence (EMCDDA, 2024).
People living in prison are more likely to have used drugs or use drugs and more likely to experience drug-related harms than those in the community.
Incarceration and drug use are therefore intertwined and lead to increased risks of infection with communicable diseases. Prisons are a high-risk environment themselves due to several factors which all contribute to increased levels of further transmission in the prison setting:
- Drug injecting occurring inside prison with contaminated injecting equipment;
- Lack of sterile injecting equipment (i.e. needles and other paraphernalia) supplies;
- Scarce availability of drugs inside prisons, which may prompt individuals to use modes of administration that increase the effects of the drugs, such as injection;
- Suboptimal access to harm reduction interventions;
- Tattooing and piercing in conditions with suboptimal infection prevention and control.
On account of the higher risks for infection transmission associated with various behaviours that are more common among people in prison compared with the general population, including drug use, people living in prison have a higher prevalence of HBV and HCV, as well as other blood-borne viruses such as HIV and other infectious diseases such as tuberculosis.
A recent meta-analysis of prevalence studies across the European region reported that just over a quarter (25.1%) of all people living in prison are positive for anti-HCV (95% CI 19% to 32%) (Salari N, 2022). A regional estimate is not available for HBV prevalence, but a review of studies conducted among people living in prison in the EU/EEA found that as high as one in 12 (8.3%) people in prison in one setting were chronically infected (Bivegete S, 2023).
Viral hepatitis services in prisons
Section titled “Viral hepatitis services in prisons”The hepatitis B and C burden in prisons is high, but whilst prisons can provide an important platform to scale up testing and treatment for viral hepatitis available data suggest that there are suboptimal levels of prevention and control interventions targeted at these infections across the EU/EEA (Nakitanda AO, 2021; Nakitanda AO, 2020; ECDC, 2024a; EMCDDA 2022).
However, it is important to note that data on coverage are largely incomplete or outdated, so a complete understanding of the scale of services currently provided is lacking.
Based on the latest policy data from EUDA and ECDC and a review of available data across countries in the EU/EEA, screening for both HBV and HCV is reported by most countries to be available in prisons across the region. However, the true extent of screening among the prison population is unknown and universal opt-out testing, where testing is conducted unless an individual explicitly declines, is only offered in a minority of the countries (Nakitanda AO, 2021; Nakitanda AO, 2020; ECDC, 202a; EMCDDA 2022).
Treatment for both hepatitis B and C is also reported to be available in prisons in many countries, but there is a lack of data on coverage, so an understanding of the numbers treated is lacking (EMCDDA, 2019).
In terms of prevention, most countries in the region report the availability of HBV vaccination for people in prison, but again data on coverage are very limited. Although few prisons are reported to have implemented needle and syringe programmes (NSP) in the EU/EEA, opioid agonist treatment (OAT) is now available in prisons in most countries, although the scale of implementation is unknown (Nakitanda AO, 2021; Nakitanda AO, 2020; ECDC, 2024a; EMCDDA 2022; Kronfi N, 2025).
Aside transmission of infections through injecting drug use material, nosocomial transmission is also an important transmission route in prisons, especially for HBV. However, data are not readily available on infection control procedures such as the sterilisation of health service equipment or the use of safety-engineered devices.
Sexual transmission is another important transmission route for both HBV and HCV, with available data relating to safe sex interventions suggesting shortfalls in the availability of condoms and lubricants.
Barriers limiting the scale up of services for the prevention and control of hepatitis B and C in prisons are widespread at a structural, systems and individual levels. For example, a lack of testing for HBV and HCV in prisons may relate to suboptimal access to healthcare services in many prison settings; the lack of NSP in prison may relate to the reluctance of staff and prison authorities and illegal nature of drug use (Tarján A, 2019; Stöver H, 2016).