Specific population groups
Women in prison
Section titled “Women in prison ”While constituting only around 5% of the prison population in Europe (Aebi MF, 2024), women in prison face unique challenges related to viral hepatitis that result from a complex interplay of social, and structural factors.
Women in prison have complex social and health profiles and have often received scarce or inadequate healthcare before imprisonment (van den Bergh BJ, 2014). At the start of 2019, there were 41 114 women incarcerated in the 27 EU Member States, Norway, Türkiye and the United Kingdom, representing around 5% of the total prison population (EMCDDA, 2022).
Most women are in prison for drug-related crimes, including drug law offenses (drug use and trafficking) and crimes committed to support or related to their drug use. Worldwide the proportion of women in prison for drug-related offences is higher than the proportion of men in prison for such offences (UNODC, 2018).
Based on data from 10 countries (Australia, Austria, England, France, Germany, Iceland, Ireland, the Netherlands, New Zealand, United States), a systematic review of studies reported a pooled estimate of drug use disorders in the year before entering prison of 51% among women and 30% among men (ECDC, 2018).
In a systematic review with data from 12 European countries, the rates of lifetime prevalence of any illicit drug use before prison were estimated at 62% in women in prison and 41% in men in prison (Van de Baan FC, 2022).
The specific health needs of incarcerated women can be overlooked in the context of viral hepatitis prevention and treatment programs, although women in prison report higher rates of infectious diseases, including HIV/AIDS, hepatitis B, hepatitis C and syphilis, than men in prison and the general female population, as they are more likely to participate in risky behaviours, including sex work and injecting drug use, including sharing of injecting equipment, outside prison.
All interventions delivered in the prison healthcare setting should be gender-responsive and take into account the often complex profiles and life trajectories as well as the many stigmas that women face (i.e. stigma for being in prison and/or using drugs and/or as mothers in prison and/or as migrant populations etc).
Pregnant women in detention may need special attention, including for the prevention of vertical transmission of HBV. Ante-natal care should be provided to the same standards as in the community and in accordance with applicable national and international guidelines (ECDC, 2018).
The EMTCT Plus initiative, focused on the Elimination of Mother-to-Child Transmission of HIV, has a counterpart in the context of viral hepatitis B (HBV). In the context of women in prison, the EMTCT Plus approach aims to prevent the transmission of HBV and HIV from mothers to their children while providing comprehensive care and support for HIV and HBV positive mothers and their families.
This initiative involves ensuring that pregnant inmates with HBV receive appropriate antenatal care, including HBV testing and monitoring, to prevent vertical transmission. It also encompasses access to HBV treatment, counselling, and support services for both mothers and their infants.
Implementation of the EMTCT Plus initiative for HBV in prisons requires collaboration among prison health services, public health agencies, and community organisations to ensure effective care and support for HBV-positive pregnant women throughout their incarceration and post-release (Pan American Health Organisation, 2017).
Limited access to gender-responsive healthcare services and resources, coupled with potential stigma surrounding women’s health issues and a lack of preparation of staff on providing gender-responsive interventions, can impede early diagnosis and timely treatment initiation.
Moreover, the prevalence of viral hepatitis among incarcerated women may be influenced by pre-existing health disparities, histories of trauma, and a higher likelihood of engaging in behaviours associated with transmission of infectious diseases.
Addressing the disproportionate impact of viral hepatitis on women in prison necessitates a gender-responsive approach, recognising and mitigating these multifaceted challenges to ensure equitable access to testing, treatment, and support services within correctional facilities.
Migrants populations and minority groups
Section titled “Migrants populations and minority groups ”Migrant populations are disproportionately represented in prisons and face distinct challenges related to viral hepatitis, reflecting a convergence of health, social, and structural determinants. These individuals may bring varied health backgrounds and experiences, influencing their risk of viral hepatitis exposure prior to incarceration.
Depending on their circumstances, migrant populations may encounter issues such as inadequate access to healthcare services, language barriers, and limited health literacy that may contribute to delayed diagnosis and treatment initiation.
Such factors may also impede their ability to engage in pre-entry or post-release preventive measures. Linkage to care post-release might also present an issue in some countries. Additionally, some individuals may serve part of their sentences in their country of origin, or face deportation upon release. In such cases, developing pathways for continuity of care across countries is essential to ensure effective linkage to services in the country of origin.
Addressing the specific needs of migrant populations in prison settings involves tailoring interventions to consider cultural diversity, linguistic nuances, and facilitating comprehensive healthcare access to mitigate the impact of viral hepatitis within this vulnerable group.
People from minorities, such as the Roma population, should also be considered, as they have specific cultures which in some case bring different challenges when addressing health problems inside prison, including hepatitis and drug use (ECMDDA, 2023). The use of cultural mediators and professionals with knowledge on different groups would be instruments to appropriately address their health needs.
Youth in prison
Section titled “Youth in prison ”Youth are often more vulnerable to viral hepatitis due to a combination of factors. Firstly, incarcerated youth may engage in higher rates of risky behaviours, including injection drug use or unsafe sexual practices, which increase the risk of contracting hepatitis B and C.
Secondly, limited access to healthcare services within prison settings, including preventive measures such as vaccination or screening for viral hepatitis, contributes to a lack of awareness about the disease and its transmission routes. In relation to testing, one study conducted in six prisons in Austria in 2018 found that 50.7% of individuals aged between 14 and 26 years did not know their HCV status and 36.6% of the study cohort had not been tested in prison (Silbernagl M, 2018).
Substance use, particularly injection drug use, is more prevalent among incarcerated youth compared to the general population of the same age (EMCDDA, 2024), further increasing their risk of hepatitis transmission. Addressing these challenges requires targeted prevention and intervention efforts to protect the health of youth in European prison settings.