Prevention

Compared with the general public, people living in prison in the EU have a higher prevalence of infection with viral hepatitis and other communicable diseases including HIV, syphilis, gonorrhoea, chlamydia and tuberculosis and are at higher risk of exposure to these infections (Dolan K, 2016). This higher prevalence of viral hepatitis, especially hepatitis C, is mainly due to the high prevalence of people with experience of drug injecting among the prison population.

Prevention measures and harm reduction interventions in the prison setting can effectively reach vulnerable groups of the population, including through OAT.

Although there are not many studies analysing the impact of OAT on blood-borne virus transmission in prison, evidence is sufficient in respect to effectiveness of OAT in reducing injecting behaviours in prison and after release and sharing of injecting equipment in prisons. There is also sufficient evidence demonstrating the effectiveness of OAT in reducing transmission in the community (ECDC/EMCDDA, 2023).

Implementing OAT in prison has been shown to be beneficial in reducing post-release mortality, deaths in prison, injecting behaviour in prison, post-release injecting, reduced substance use in prison and has been shown to be beneficial in retaining patients in treatment post release (ECDC/ECMDDA, 2018).

Linkage to drug treatment in the community at prison release is a key intervention; studies demonstrate that post-release, prison OAT patients are more likely to continue treatment, facing a lower risk of drug-related death (ECDC/EMCDDA, 2018).

The updated guidance from EUDA and ECDC on the prevention of infections among people who inject drugs, recommends that OAT to be provided in the prison setting for preventing injecting risk behaviour and for reducing injecting frequency among people who inject opioids and indicates that this could be beneficial to HCV and HIV prevention (ECDC/EMCDDA, 2023).

For the latest evidence on drug-related interventions including OAT, naloxone training and prescription, and NSP in prison, see EUDA’s best practice portal - evidence database, the 2023 ECDC/EMCDDA guidance on the prevention of infectious diseases among PWID, the 2021 EMCDDA report on Prison and Drugs in Europe and the INHSU Global Guidelines for Viral Hepatitis Service Delivery in Prisons.

While there are few studies on the effectiveness of NSPs in prison to reduce HCV transmission, the 2023 ECDC and EUDA guidance recommends the provision of sterile needles and syringes in prison. This recommendation is based on the existing evidence on effectiveness of those interventions in the community and the principle of equivalence of care (ECDC/EMCDDA, 2018, ECDC/EMCDDA, 2023).

View an overview of key harm reduction interventions and how they work.

Comprehensive information around prevention measures that should be considered for implementation in the prison setting can be found in these two guidance documents:

The RISE-Vac project, spanning from 2021 to 2024, focuses on improving health outcomes for the prison population in Europe through increased vaccine literacy and uptake.

Recognising that low vaccine coverage remains a critical public health challenge, RISE-Vac addresses the unique needs of prison populations, which often have high turnover and significant numbers of unvaccinated individuals. Prisons serve as an ideal setting to offer comprehensive healthcare and vaccination services, providing an opportunity to reach these hard-to-reach groups effectively.

RISE-Vac employs a multifaceted approach to enhance vaccine coverage among prisoners. The project gathers existing evidence on vaccination strategies tailored for the prison environment, complemented by prospectively collected data on the attitudes and vaccine learning of both inmates and prison staff.

Additionally, RISE-Vac assesses vaccination status and uptake during incarceration. Using a co-creation methodology, the project develops customized information and training materials aimed at increasing vaccine literacy among the prison community.

Moreover, RISE-Vac pilots innovative vaccination delivery models to meet the specific needs of various prison settings, aligning with national public health priorities. By reinforcing the principle that prison health is public health, RISE-Vac offers data-driven, evidence-based tools to guide European countries in enhancing the health status of prisoners and, by extension, the broader population.

View the model of care which has successfully implemented interventions around hepatitis B vaccination in Italy.

The HBV vaccine, available since 1982, has shown high efficacy in the prevention of HBV infection (95%), as well as in the prevention of chronic liver disease, cirrhosis and HBV-related hepatocellular carcinoma (WHO, 2018).

The WHO recommends hepatitis B vaccination, testing and treatment for hepatitis B as part of their recommended package for people living in prisons and other closed settings (WHO, 2023). Studies have demonstrated that an accelerated vaccination schedule may be an effective choice in prison settings for ensuring rapid protection in most people (Stasi C, 2020).

Given the transient nature of many populations at risk, the most pragmatic solution might be to vaccinate as quickly as possible while the persons are attending services. One recently licensed vaccine in Europe which may not yet be available yet in all countries – Heplisav B – only requires two doses over one month and has an earlier onset of protection and may be considered as an option.

For further information on hepatitis B vaccination see Fact Sheet- HBV Vaccination

These proposed preventative recommendations all aim to help EU Member States to achieve the UN’s Sustainable Development Goals (SDGs)1; specifically target 3.3: ‘By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases.’

Challenge	Proposed Solution
Limited resources: resource constraints including shortages of healthcare staff, funding for consumables and infrastructure can impede the implementation of prevention and harm reduction programs	Development of an implementation plan in collaboration with prison management and local/national authorities, considering the Ministry in charge of healthcare in prisons, that outlines expected resources. Health professionals can agree at the beginning of the year on this plan for health interventions aimed at the elimination of hepatitis: firstly with prison administration; and secondly with local authorities (depending on the country). In the plan there should be indication of the services provided, the target population, the time frame, the human and financial resources needed Build strong collaboration local/national authorities, considering the Ministry in charge of healthcare in prisons, external public health officials and community health organisations to identify solutions. Protocols between services should be established to increase synergies: e.g. when an individual leaves prison, contact should be made with the external service in the week/s preceding release
Stigma and discrimination: Shame, or fear of judgement may discourage people living in prison from actively seeking testing or treatment services or participating in harm reduction initiatives	Implementing comprehensive education and awareness campaigns for all people in prisons (healthcare providers, custodial officers and people living in prison) along with offering confidential testing and treatment services, can help reduce stigma and discrimination associated with viral hepatitis. Consideration should be given to providing custodial staff with training around blood-borne viruses and drugs. Peer support workers can be helpful in understanding issues and in sharing information and encouraging people living in prison to engage with all steps of the care pathway. As a first step, map whether any peer association exist working either inside the prison or externally based but working in prisons.
Complex legal and regulatory environment: differences in access to and/or availability of harm reduction measures may be influenced by the regulatory environment in EU countries.	Engaging with legal experts and policy-makers to streamline regulations and develop clear protocols tailored to prison settings that can facilitate the implementation of prevention, testing and treatment services while ensuring compliance with laws and regulations.
Limited availability of/access to harm reduction measures, including OAT and NSP: Limited access to OAT (e.g., methadone or buprenorphine) or the lack of availability of NSPs and other harm reduction measures in prison can impede efforts to address drug use-related risk factors for viral hepatitis transmission.	Evidence-based harm reduction strategies, including the provision of opioid agonist therapy, should be scaled up. These services should be included in the implementation plan. Implementing pilot programs within selected prisons to demonstrate the impact of opioid agonist therapy in improving health outcomes can encourage broader adoption.
Inadequate testing ,diagnosis and linkage to care for individuals testing positive for HBV or HCV: Delayed diagnosis can hinder detection and treatment of viral hepatitis. This is particularly crucial for preventing the ongoing transmission of the virus within prison populations and reducing the risk of complications associated with the infection.	Implementing routine and accessible screening programs, coupled with training for healthcare staff on viral hepatitis diagnosis, can improve early detection and diagnosis rates among people living in prison. Testing should be available at different timepoints such as at entrance to the prison, during the prison stay and when leaving prison and clear care-pathways in place to ensure individuals testing positive are linked to care in a timely way.
Staff training and task-shifting: Lack of appropriate training for health and prison staff around infection control practices and knowledge about hepatitis B and C interventions both increases stigma in the prison and hinders the facilitation of testing and treatment for people living in prison. The lack of or absence of task shifting/sharing also presents a challenge. This can result in delays in diagnosis, suboptimal management of the disease, and increased burden on already stretched healthcare resources within the prison system.	Healthcare providers should be empowered to deliver viral hepatitis care. Set up the conditions to allow prison staff (especially custodial staff) to access online courses during working time. Consider the utilisation of technology-based training modules and resources, such as online courses or virtual simulations, to supplement in-person training and ensure continuous education for prison staff on infection control measures and viral hepatitis interventions. Training should address issues such staff fear of needles and syringes in the work setting which can be a challenge for the effective prevention and control of hepatitis in the prison setting. Task shifting, which involves delegating specific healthcare tasks to less specialised providers, is often crucial in resource-limited settings such as prisons where there may be a shortage of highly trained medical personnel.
Transitions to community care: Ensuring a smooth transfer of healthcare responsibilities requires coordination between prison healthcare providers and community health services. The lack of such coordination can result in disruptions to ongoing treatment, missed opportunities for testing, and increased risks of viral hepatitis transmission.	Establishing protocols for the exchange of medical information and engagement with community healthcare providers is essential to bridge this gap and maintain a continuum of care for individuals moving between these settings. See Section 4: Monitoring and Evaluation. Protocols should follow high ethical standards for the respect of anonymity and confidentiality and treatment of vulnerable populations. Implementing comprehensive discharge planning protocols, including coordination with community healthcare providers, medication adherence support, and linkage to social services, can facilitate smooth transitions to community care and reduce the risk of treatment interruption.
Cultural and language barriers: The diversity of prison populations in Europe, with individuals from various cultural and linguistic backgrounds, and the high proportion of migrant populations, can pose challenges in effectively communicating health information and tailoring interventions to specific needs.	Offering culturally competent and where possible multilingual healthcare services, along with providing education and resources tailored to diverse cultural backgrounds, can bridge the gap and improve access to testing and treatment services. Examples include the provision of brochures in different languages or the use of cultural mediators.
Lack of data: A lack of robust data may lead to an underestimation of the extent of the problem and hamper efforts around the effective implementation of evidence-based preventative measures.	Implementing standardised data collection protocols and leveraging electronic health records can help generate reliable and comprehensive data, enabling informed decision-making and program evaluation for improved outcomes. See Section 4: Monitoring and Evaluation.
Limited space: Dedicated areas where privacy can be available for testing, counselling and harm reduction services may be difficult to establish due to space constraints.	Agree on a dedicated space for testing, etc. with the prison administration. This can be specified in the implementation plan. Linking with external mobile clinics or mobile harm reduction units to provide services, or providing telemedicine services can help overcome space constraints and reach a larger population of people living in prison for testing and treatment.

Prevention

Challenges and solutions related to prevention