Status of HIV and hepatitis C virus infections among prisoners in the Middle East and North Africa: review and synthesis.

INTRODUCTION: The status of HIV and hepatitis C virus (HCV) infections among incarcerated populations in the Middle East and North Africa (MENA) and the links between prisons and the HIV epidemic are poorly understood. This review synthesized available HIV and HCV data in prisons in MENA and highlighted opportunities for action. METHODS: The review was based on data generated through the systematic searches of the MENA HIV/AIDS Epidemiology Synthesis Project (2003 to December 15, 2015) and the MENA HCV Epidemiology Synthesis Project (2011 to December 15, 2015). Sources of data included peer-reviewed publications and country-level reports and databases. RESULTS AND DISCUSSION: We estimated a population of 496,000 prisoners in MENA, with drug-related offences being a major cause for incarceration. Twenty countries had data on HIV among incarcerated populations with a median prevalence of 0.6% in Afghanistan, 6.1% in Djibouti, 0.01% in Egypt, 2.5% in Iran, 0% in Iraq, 0.1% in Jordan, 0.05% in Kuwait, 0.7% in Lebanon, 18.0% in Libya, 0.7% in Morocco, 0.3% in Oman, 1.1% in Pakistan, 0% in Palestine, 1.2% in Saudi Arabia, 0% in Somalia, 5.3% in Sudan and South Sudan, 0.04% in Syria, 0.05% in Tunisia, and 3.5% in Yemen. Seven countries had data on HCV, with a median prevalence of 1.7% in Afghanistan, 23.6% in Egypt, 28.1% in Lebanon, 15.6% in Pakistan, and 37.8% in Iran. Syria and Libya had only one HCV prevalence measure each at 1.5% and 23.7%, respectively. There was strong evidence for injecting drug use and the use of non-sterile injecting-equipment in prisons. Incarceration and injecting drugs, use of non-sterile injecting-equipment, and tattooing in prisons were found to be independent risk factors for HIV or HCV infections. High levels of sexual risk behaviour, tattooing and use of non-sterile razors among prisoners were documented. CONCLUSIONS: Prisons play an important role in HIV and HCV dynamics in MENA and have facilitated the emergence of large HIV epidemics in at least two countries, Iran and Pakistan. There is evidence for substantial but variable HIV and HCV prevalence, as well as risk behaviour including injecting drug use and unprotected sex among prisoners across countries. These findings highlight the need for comprehensive harm-reduction strategies in prisons

Impact of conflict and displacement on risk behaviours amongst people who inject drugs in Kabul, Afghanistan

BACKGROUND: Theoretical work posits that drug-related risk behaviour increases during armed conflict; however, few studies have been conducted in conflict settings. The objective of this analysis is to determine whether conflict or local displacement impact risk behaviours among people who inject drugs (PWID) in Kabul, Afghanistan. METHODS: Consenting PWIDs aged ≥18 years completed interviews at 3, 6, 9, 12, 18, and 24 months of follow-up. Quarters with peak conflict or local displacement exposure were defined and associations with injecting drug use and sexual risk behaviours analysed with generalized estimating equations. RESULTS: Of 483 PWID enrolled, 385 completed ≥1 follow-up visit (483.8 person-years) between 2007 and 2009. All participants were male, with 35% initiating injecting as a refugee. Sharing syringes (Odds Ratio (OR))=8.53, 95% Confidence Interval (CI): 2.58 – 28.2) and sexually transmitted infection (STI) symptoms (OR=1.72, 95% CI: 1.00 – 2.96) increased significantly during peak conflict quarters, while odds of STI symptoms (OR=0.06, 95% CI: 0.02 – 0.20) and arrest (OR=0.61, 95% CI: 0.40 – 0.93) were significantly lower during periods of displacement. CONCLUSION: Syringe sharing significantly increased during peak conflict periods amongst PWID in Kabul. Programming should include instruction for coping with conflict and prepare clients for harm reduction needs during conflict