The naloxone investigation (N-ALIVE) randomized trial commenced in the UK in May 2012, with the preliminary phase involving 5,600 prisoners on release. The trial is investigating whether heroin overdose deaths post-prison release can be prevented by prior provision of a take-home emergency supply of naloxone. Heroin contributes disproportionately to drug deaths through opiate-induced respiratory depression. Take-home emergency naloxone is a novel preventive measure for which there have been encouraging preliminary reports from community schemes. Overdoses are usually witnessed, and drug users themselves and also family members are a vast intervention workforce who are willing to intervene, but whose responses are currently often inefficient or wrong. Approximately 10% of provided emergency naloxone is thought to be used in subsequent emergency resuscitation but, as yet, there have been no definitive studies. The period following release from prison is a time of extraordinarily high mortality, with heroin overdose deaths increased more than sevenfold in the first fortnight after release. Of prisoners with a previous history of heroin injecting who are released from prison, 1 in 200 will die of a heroin overdose within the first 4 weeks. There are major scientific and logistical challenges to assessing the impact of take-home naloxone. Even in recently released prisoners, heroin overdose death is a relatively rare event: hence, large numbers of prisoners need to enter the trial to assess whether take-home naloxone significantly reduces the overdose death rate. The commencement of pilot phase of the N-ALIVE trial is a significant step forward, with prisoners being randomly assigned either to treatment-as-usual or to treatment-as-usual plus a supply of take-home emergency naloxone. The subsequent full N-ALIVE trial (contingent on a successful pilot) will involve 56,000 prisoners on release, and will give a definitive conclusion on lives saved in real-world application. Advocates call for implementation, while naysayers raise concerns. The issue does not need more public debate; it needs good science.

Juveniles in custody are affected by sexually transmitted infections due to risky behaviors. Therefore, they have a disproportionate burden of hepatitis B virus (HBV) and human immunodeficiency virus (HIV). In this study, the prevalence and associated characteristics of hepatitis B and HIV infections were assessed in young prisoners.

In this cross-sectional study, prevalence of HBV and HIV infections was assessed among young prisoners during 2008-2009. A checklist consisting of demographic, social, and risk factors was filled out and blood was drawn for their tests. Sera were analyzed for hepatitis B surface antigen (HBs Ag), hepatitis B surface antibody (HBs Ab), hepatitis B core antibody (HBc Ab) and HIV Ab, and Western blot test was performed on antibody-positive HIV.

A total number of 160 young prisoners (147 boys and 13 girls) were evaluated. The mean age of the subjects was 16.59 ± 1.24 year. HBs Ag, HBc Ab, HBs Ab, and HIV Ab were detected in 1 (0.63%), 1 (0.63%), 52 (32.5%), and 1 (0.63%), respectively.

With respect to national vaccination program against HBV infection, the juvenile prisoners had low prevalence of HBs Ab.

The high prevalence of HIV infection among prisoners and pre-trial detainees, combined with overcrowding and sub-standard living conditions sometimes amounting to inhuman or degrading treatment in violation of international law, make prisons and other detention centres a high risk environment for the transmission of HIV. Ultimately, this contributes to HIV epidemics in the communities to which prisoners return upon their release. We reviewed the evidence regarding HIV prevalence, risk behaviours and transmission in prisons. We also reviewed evidence of the effectiveness of interventions and approaches to reduce the risk behaviours and, consequently, HIV transmission in prisons. A large number of studies report high levels of risk behaviour in prisons, and HIV transmission has been documented. There is a large body of evidence from countries around the world of what prison systems can do to prevent HIV transmission. In particular, condom distribution programmes, accompanied by measures to prevent the occurrence of rape and other forms of non-consensual sex, needle and syringe programmes and opioid substitution therapies, have proven effective at reducing HIV risk behaviours in a wide range of prison environments without resulting in negative consequences for the health of prison staff or prisoners.The introduction of these programmes in prisons is therefore warranted as part of comprehensive programmes to address HIV in prisons, including HIV education, voluntary HIV testing and counselling, and provision of antiretroviral treatment for HIV-positive prisoners. In addition, however, action to reduce overcrowding and improve conditions in detention is urgently needed.

Canada has licensed a human papilloma virus (HPV) vaccine for adolescent females, with the goal of decreasing the incidence of HPV infection and associated cervical cancer. This study identifies the juvenile detainee population as a high-risk group for HPV infection and therefore an important target for primary prevention.

A retrospective chart review.

Sundance Juvenile Detention Center, Kingston, Ontario, Canada.

Female detainees admitted between 2003 and 2006.

Papanicolaou (Pap) test results, sexually transmitted infection (STI) rates, and associated risk factors were collected from 119 charts.

Of 57 recorded Pap smears, 46 (80.7%) were normal, 5 (8.8%) were reported as atypical squamous cells of unknown significance, and 6 (10.5%) were reported as low-grade squamous intraepithelial lesion. Of the women tested, 4% were positive for gonorrhea, 10% for chlamydia, 32% for bacterial vaginosis, and 5% for trichomonas; none were positive for syphilis. Of the girls, (91) (77%) had negative HIV and hepatitis B tests, two girls were hepatitis-C-positive, three had clinical evidence of genital herpes, and one showed evidence of pelvic inflammatory disease. There were 75 (63%) girls who reported sexual activity; 87% of them used contraception or protection of some kind, albeit inconsistently. Of these young females, 12 (10%) had engaged in prostitution and 13 (11%) had allegedly been raped or sexually assaulted.

Female juvenile detainees in Kingston, Ontario, have higher rates of STIs, associated risk factors, and abnormal Pap tests than the general female adolescent population. This new information confirms that this population is at risk for HPV infection and subsequent cervical cancer.

Juveniles in custody are disproportionately affected by sexually transmitted infections (STI) and blood-borne viruses (BBV) due to high rates of risk behaviours.

A literature review was undertaken with the aim of providing evidence-based recommendations on STI/BBV screening in Australian juvenile correctional facilities. Relevant research was identified using Premedline and Medline databases, followed by a manual search of reference lists in relevant articles identified in the database search. A total of 36 relevant publications were identified and reviewed.

STI/BBV knowledge in incarcerated youth is poor and accompanied by high rates of sexual and blood-borne risk behaviours. The prevalence of these infections is considerable. High rates of asymptomatic gonococcal and chlamydial infections exist, which can be easily diagnosed on self-collected specimens using new nucleic acid amplification technology. HIV infections are rare although continued vigilance is needed in view of substantial risk factors for infection. Hepatitis C prevalence is high, although much lower than that of adult prisoners, signifying a possible window of opportunity for Hepatitis C prevention. Many remain at risk of Hepatitis B, and it is important to assess the need for vaccination in this group.

Screening for STI/BBV in incarcerated juveniles is of major public health importance and all individuals should be offered screening in conjunction with risk-reduction education during their admission to juvenile detention centres.

Outbreaks of acute hepatitis B among inmates of 6 prisons in 3 regions of northern England occurring from 1992 through 1994 were found to be associated with a single hepatitis B virus (HBV) variant, which was carried by 20 of the 24 case patients. We instigated a study of cases of acute hepatitis B to trace the spread and prevalence of this variant.

A denaturing gradient gel electrophoresis assay was optimized to detect the HBV variant, and cases of acute HBV infection in 3 regions in England occurring from 1990 through 1996 were screened for its presence. Samples from HBV-transmission incidents that were received for molecular investigation were also tested.

The variant was identified in 117 (41%) of the 266 cases of acute hepatitis examined in representative regions in England. In North Humberside, but not in southeast England or the West Midlands, a trend toward an increase in the prevalence of the variant was observed. Furthermore, the same variant was identified in the case patients or the individuals implicated in transmission in 11 (22%) of 51 transmission incidents occurring in England from 1997 through 2002. The spread of the variant was primarily associated with injection drug use.

The finding of a single, genetically identical variant (over the 600 bp sequenced) occupying a large niche among the circulating viruses was unexpected. This finding has major implications for the use of DNA sequencing analysis in the investigation of chains of transmission. The study also highlights the need for better protection of at-risk groups through vaccination against HBV, a strategy that currently achieves poor coverage.

American prisons have increasing numbers of inmates incarcerated for drug offenses. This population is at high risk for HIV-infection and may continue HIV transmission risk behaviors while incarcerated. We find that 31% of injection drug users with a history of imprisonment had used illicit drugs in prison, and nearly half of these persons had injected drugs while incarcerated. Male gender and number of times incarcerated were associated with drug use in prison. Interventions for drug-using prisoners that are advocated in some European prisons, such as needle exchange programs and methadone maintenance, need attention in the United States.

To determine the prevalence of antibodies to hepatitis B core antigen, hepatitis C virus, and HIV in entrants to Irish prisons and to examine risk factors for infection.

Cross sectional, anonymous survey, with self completed risk factor questionnaire and oral fluid specimen for antibody testing.

Five of seven committal prisons in the Republic of Ireland.

607 of the 718 consecutive prison entrants from 6 April to 1 May 1999.

Prevalence of antibodies to hepatitis B core antigen, hepatitis C virus, and HIV in prison entrants, and self reported risk factor status.

Prevalence of antibodies to hepatitis B core antigen was 37/596 (6%; 95% confidence interval 4% to 9%), to hepatitis C virus was 130/596 (22%; 19% to 25%), and to HIV was 12/596 (2%; 1% to 4%). A third of the respondents had never previously been in prison; these had the lowest prevalence of antibodies to hepatitis B core antigen (4/197, 2%), to hepatitis C (6/197, 3%), and to HIV (0/197). In total 29% of respondents (173/593) reported ever injecting drugs, but only 7% (14/197) of those entering prison for the first time reported doing so compared with 40% (157/394) of those previously in prison. Use of injected drugs was the most important predictor of antibodies to hepatitis B core antigen and hepatitis C virus.

Use of injected drugs and infection with hepatitis C virus are endemic in Irish prisons. A third of prison entrants were committed to prison for the first time. Only a small number of first time entrants were infected with one or more of the viruses. These findings confirm the need for increased infection control and harm reduction measures in Irish prisons.

To determine the prevalence of antibodies to hepatitis B core antigen, hepatitis C virus, and HIV in the prison population of the Republic of Ireland and to examine risk factors for infection.

Cross sectional, anonymous, unlinked survey, with self completed risk factor questionnaire and provision of oral fluid specimen for antibody testing.

Nine of the 15 prisons in the Republic of Ireland.

1366 prisoners, of whom 1205 (57 women) participated. In the smaller prisons all prisoners were surveyed, while in the three largest prisons one half of the population was randomly sampled. Three small prisons believed not to have a problem with injecting drug use were excluded.

Prevalence of antibodies to hepatitis B core antigen, antibodies to hepatitis C virus, and antibodies to HIV. Self reported risk factor status.

Prevalence of antibodies to hepatitis B core antigen was 104/1193 (8.7%; 95% confidence interval 7.2% to 10.5%), to hepatitis C virus, 442/1193 (37%; 34.3% to 39.9%), and to HIV, 24/1193 (2%; 1.3% to 3%). The most important predictor of being positive for hepatitis B and hepatitis C was a history of injecting drug use. Thirty four women (60%) and 474 men (42%) reported ever injecting drugs. A fifth (104) of 501 injecting drug users reported first injecting in prison, and 347 (71%) users reported sharing needles in prison.

Infection with hepatitis C secondary to use of injected drugs is endemic in Irish prisons. Better access to harm reduction strategies is needed in this environment.

To determine prevalence of HIV infection and risk behaviors in commercial sex workers (CSWs), drug users, and prisoners in Sindh, Pakistan.

A medical clinic was established in a "red-light" district of Karachi. Eighty-one CSWs who registered at the clinic between November 1993 and June 1994 were provided HIV counseling and testing and administered a risk factor questionnaire. Next, 316 male drug users were tested for HIV-1 antibody from April to July 1994. Finally, a voluntary serosurvey of HIV-1 and HIV-2 and risk behaviors of 3525 prisoners in Sindh was conducted between July 1994 and December 1994. Abbott Recombinant HIV third-generation enzyme-linked immunosorbent assay (ELISA) and confirmatory testing with Western blot analysis were used in all three groups.

None of 81 CSWs tested for HIV-1 antibody were positive. None of 316 drug users tested positive for HIV-1 antibody. Of 3441 male prisoners, 1 was HIV-1 infected, and of 84 female prisoners, 1 was HIV-1 infected. No prisoner was positive for HIV-2 antibody.

The prevalence of HIV in CSWs, drug users, and prisoners in Sindh is low at present. Intervention programs implemented at this stage can make an impact in HIV prevention.

Between April and June 1993, 8 cases of acute clinical hepatitis B infection and 2 seroconversions to HIV infection were detected among drug injecting inmates of HM Prison Glenochil in Scotland. To prevent the further spread of infection, an initiative which involved counselling and voluntary attributable HIV testing was conducted over a 10-day period commencing at the end of June. A team of 18 counsellors and phlebotomists was brought together rapidly as part of a unique organizational exercise in the field of public health. Fourteen cases of HIV infection were identified of which 13 were almost certainly infected in Glenochil. Following the exercise, a range of harm reduction measures for injecting prisoners was introduced; these included the availability of hepatitis B vaccine, provision of bleach tablets which could be used to clean injecting equipment, a methadone detoxification programme, increased training for prison officers and improved access to drug and harm minimization counselling for inmates. By mid-1996 all these measures had been sustained and several could be found in many other prisons throughout Scotland. Follow-up investigations showed no evidence of epidemic spread of HIV during the 12 months after the initiative. While the frequency of injecting and needle/syringe sharing may have decreased over the last 3 years, these activities are still being reported and it is highly likely that transmissions of bloodborne infections, in particular hepatitis C, continue to occur. The surveillance and prevention of infections associated with injecting drug use in the prison setting remain a high public health priority.

To assess the likelihood of participation bias in a large population-based sex survey, and its possible effect on estimates of HIV risk behaviours.

Construction of general hypotheses about non-participants through comparisons of willing and unwilling participants.

British adults aged 16-59 years were surveyed in 1990-1991. Interviews consisted of a face-to-face section combined with a self-completion booklet (n = 18876). Interviewers recorded interviewee embarrassment. Homosexual experience and number of lifetime heterosexual partners (grouped 0, 1, 2 or more) were recorded prior to booklet offer. Logistic regression was performed, with embarrassment and booklet refusal as outcome variables, assessing their association with sexual behaviour after controlling for demographic variables. Assuming that, in sexual behaviour, non-participants are closer to the embarrased and the booklet refusers ('unwilling' participants) than to others, these analyses provide an indication of the nature of participation bias.

Higher refusal an embarrassment rates were associated with both reporting no homosexual experience and fewer heterosexual partners.

Under our untestable assumption, these results are consistent with non-participants being generally at lower risk of HIV infection. Methods need to be developed both to reduce participation bias in sex surveys, and to incorporate it in analysis.

Compulsory urine testing of prisoners for drugs, a control initiative, was introduced in eight prisons in England and Wales early in 1995. Despite no evidence of effectiveness, testing was extended to all prisons in England and Wales by March 1996. We consider the cost of testing.

We combined the costs of refusals, confirmatory tests, punishment of confirmed positives for cannabis or for class A drugs to estimate the average costs of random compulsory drugs testing. These costs were then compared to: i) the healthcare budget for a prison; and ii) the cost of putting in place a credible prisons' drugs reduction programme. We then used Scottish data on incarceration and regional prevalence of injecting drug users to estimate the extent of the injecting drug use problem that prisons face.

Costs per 28 days of the random mandatory drugs testing control initiative in an establishment for 500 inmates where refusal rate is a) 10% or b) nil; and 35% of urine samples test positive, one tenth of them for class A drugs were estimated at between a) 22,800 UK pounds and b) 16,000 UK pounds per 28 days [a) $US35,100 and b) $US24,600]. This cost was equivalent to twice the cost of running a credible drugs reduction and rehabilitation programme, and around half the total healthcare expenditure for a prison of 500 which averaged 41,114 UK pounds per 28 days [$US64,860]. Major cost-generating events were the punishment of refusals--over one third of cost a)--and testing positive for cannabis--over 50% of cost a). In Scotland, around 5% of injecting drug users (IDUs) are incarcerated at any time: 5% of Lothian's drugs care, treatment and prevention costs and 2.5% of its HIV/AIDS prevention budget in 1993-94 amounted to 101,300 UK pounds per annum--or 7770 UK pounds per 28 days ($US11,970)--and about 35% of monthly MDT costs.

We suggest that 5% of current resources for drugs prevention and treatment and for IDU-targetted HIV/AIDS prevention should be directed towards the prisons because in the prisons, where 5% of the clients are at any time, injectors have less access to harm reduction measures than on the outside.

Prisons contain individuals at high risk of HIV infection, notably through intravenous drug use. For complex political, social and legal reasons penal institutions in the UK are unable to provide condoms and clean needles. The outbreak of HIV and hepatitis B that occurred in a Scottish prison in 1993 focused attention on the potential problems. Debate about the issue is hampered by a lack of useful information. Current data about risk behaviour and seroprevalence is reviewed, and compared with experience in other countries. Injecting drug use in prison appears to be common, and the majority who inject in prison share equipment, which can be used many times. Sexual activity may be a smaller risk factor, but does occur between men in prison. In addition, prisoners appear to have high rates of partner change between sentences. The true prevalence of HIV in UK prisons is difficult to assess, but the available data suggest it is between 0.1 and 4.5%, lower than in Southern Europe and the USA. A window of opportunity still exists to prevent further outbreaks of HIV in UK penal institutions and to maintain these low prevalence rates. Strenuous, and possibly unpalatable measures are needed now.

To determine prevalence of HIV infection and drug injecting behaviour among inmates of Glenochil Prison on a specified date a year after an outbreak of hepatitis B and HIV infection.

Cross sectional: voluntary, anonymous HIV salivary antibody surveillance and linked self completion questionnaire on risk factors.

Glenochil prison, Scotland, a year after an outbreak of hepatitis B and HIV transmission related to drug injection.

352 prisoners, of whom 295 (84%) took part; 284 questionnaires (96%) passed logical checks.

HIV prevalence; proportion of all inmates who had ever injected drugs, had ever injected inside prison, had started injecting drugs while inside prison.

More than half (150/284) the current inmates were also in Glenochil Prison during the critical period of January to June 1993, when hepatitis B and HIV were transmitted. Similar proportions of current inmates and men who were also in Glenochil during the critical period were drug users (27% (75/278) v 30% (44/149)). A quarter of injecting drug users (18/72) had first injected inside prison, irrespective of whether they were in Glenochil in January to June 1993 and regardless of the calendar period when they first injected. Significantly more inmates from Glasgow (41%; 56/138) than from Edinburgh (21%; 7/34) or elsewhere (11%; 12/106) were injecting drug users. On testing for HIV, seven saliva samples out of 293 gave positive results--four were presumed to be from inmates known to be infected with HIV, and the others from injecting drug users from Glasgow, all of whom had been in Glenochil during January to June 1993, when two of the three had injected drugs and had been tested for HIV, with negative results. The ratio of overall (2.4%) to disclosed (1.4%) HIV prevalence was 1.7. For men who had injected drugs in Glenochil during January to June 1993, HIV prevalence was estimated at 29%.

Between a quarter and a third of prisoners who injected drugs in Glenochil in January to June 1993 were infected with HIV. There is widespread ongoing risk of bloodborne virus infection within prisons, which is probably long standing but demands urgent attention.

OBJECTIVE--To investigate the possible spread of HIV infection and its route of transmission among prison inmates. DESIGN--In response to an outbreak of acute clinical hepatitis B and two seroconversions to HIV infection, counselling and testing for HIV were offered to all inmates over a two week period in July 1993. Information was sought about drug injecting, sexual behaviour, and previous HIV testing. SETTING--HM Prison Glenochil in Scotland. SUBJECTS--Adult male prisoners. MAIN OUTCOME MEASURES--Uptake of HIV counselling and testing; occurrence and mode of HIV transmission within the prison. RESULTS--Of a total 378 inmates, 227 (60%) were counselled and 162 (43%) tested for HIV. Twelve (7%) of those tested were positive for antibody to HIV. One third (76) of those counselled had injected drugs at some time, of whom 33 (43%) had injected in Glenochil; all 12 seropositive men belonged to this latter group. Thirty two of these 33 had shared needles and syringes in the prison. A further two inmates who injected in the prison were diagnosed as positive for HIV two months previously. Evidence based on sequential results and time of entry into prison indicated that eight transmissions definitely occurred within prison in the first half of 1993. CONCLUSION--This is the first report of an outbreak of HIV infection occurring within a prison. Restricted access to injecting equipment resulted in random sharing and placed injectors at high risk of becoming infected with HIV. Measures to prevent further spread of infection among prison injectors are urgently required.