Out now - "National Prison Entrants Bloodborne Virus and Risk Behaviour Report 2004, 2007, 2010 and 2013

Prisoner populations are characterised by engagement in risk behaviours, most notably injecting drug use. Consequently they are at an increased risk of exposure to bloodborne viruses such as hepatitis B, hepatitis C and HIV. Previous Australian research has shown that hepatitis C is between thirty to forty times higher among prisoners compared with the general community. Surveillance of this population is important to monitor trends in the prevalence of bloodborne viruses and changes over time in risk behaviours. This is the fourth NPEBBVS conducted thus far; others have been undertaken triennially since 2004. 
The study represents a consecutive survey of prison entrants conducted over a two week period. In previous years the survey has been conducted over two weeks in October but the 2013 survey varied between jurisdictions (Table 1). Participants in 2013 were 793  of the 1,235 consecutive prison entrants in all jurisdictions who were offered the survey. Twenty three reception centres across Australia participated in the survey (Table 2). 
The survey screened for the following markers: HIV antibody and antigen, hepatitis B surface antibody and antigen, hepatitis B core antibodies (IgM and IgG), hepatitis B e-antigen and antibody, hepatitis C antibody, Treponema pallidum antibody, Chlamydia trachomatis DNA and Neisseria gonorrhoea DNA (see Appendix 1 for test details). 
Test results are made available to participants and appropriate treatment pathways identified including education and advice, hepatitis B vaccination, treatment for sexually transmissible infections, and referrals for hepatitis C treatment.
Risk behaviour and demographic information were collected using a short questionnaire covering injecting drug use, illicit drug consumption, tobacco smoking, body piercing and tattooing, sexual activity, hepatitis C testing and treatment, willingness to be treated for hepatitis C, hepatitis B and cervical cancer immunisation (Appendix 2). 
Demographic & criminographic characteristics
The final sample consisted of 793 participants.  The overall response rate to the survey was 64%.
Thirty three percent of the sample was identified as Aboriginal or Torres Strait Islander, which is slightly higher than the national census snapshot proportion of Indigenous prisoners (27%).1  Similarly, women represented 14% of the sample, which is higher than the proportion of women prisoners in Australia (8%).1
Most of those taking part in the 2013 survey (76%) lived in ‘highly accessible’ and ‘accessible’ areas prior to prison based on the Accessibility/Remoteness Index of Australia.2  Living in ‘highly accessible’ and ‘accessible’ areas was more common among people who reported injecting drugs (84%) compared with those who did not (69%).
Eight out of ten prisoners with a history of injecting drug use reported they had previously been incarcerated and 60% had been in prison in the past year.
Bloodborne viruses 
As in 2010, no cases of HIV were detected among those prisoners screened in 2013.   
In 2013, the overall prevalence of hepatitis C antibody was 31%, an increase from 22% in 2010.  Among states with more than thirty prisoners tested for hepatitis C antibodies, the prevalence ranged from 52% in Queensland to 8% in the Northern Territory.  
As in previous years, hepatitis C antibody prevalence was higher among those with a history of injecting drug use than those who had not injected (58% versus 4% in 2010), and higher among women who injected than men who injected (67% versus 56% in 2010).  
Among Indigenous injecting drug users, the prevalence of hepatitis C antibody remained stable between 2010 and 2013 (54% and 52%).
Nationally, only 11 prisoners (9% of those reporting they were hepatitis C positive) stated they had ever received treatment for hepatitis C. Two prisoners reported they were currently receiving treatment for hepatitis C.  
Nationally, 18% of those tested were positive for hepatitis B core-antibody.   
The prevalence of hepatitis B core-antibody among Indigenous injecting drug users remained stable between 2010 and 2013 at 18%, and similarly the prevalence remained stable among non-Indigenous prison entrants 19% in 2010 and 20% in 2013. 
Nationally, 44% of those screened in 2013 showed no evidence of immunity against hepatitis B either through past exposure or vaccination and are, therefore, vulnerable to infection. 
Among jurisdictions testing more than thirty prisoners, the highest proportion of prisoners who had been vaccinated against hepatitis B infection was Queensland (44%). 
Of the 149 prison entrants in 2013 who reported they had been vaccinated against hepatitis B, only 58% had hepatitis B surface-antibody levels signifying immunity. Conversely, 66 individuals reported that they had not been vaccinated against hepatitis B but the tests revealed that 30% of them had hepatitis B surface-antibody levels considered as conferring immunity.  
Sexually transmissible infections
Among female prisoners 35% reported they had not been vaccinated against cervical cancer with 18% unsure of their vaccination status.  
Rates of sexually transmissible infections were no higher than in the general population - chlamydia (5% of men, 4% of women), and gonorrhoea (only one male participant tested positive). For syphilis, around 1% of men and 1% of women had markers consistent with past or present infection.  While 1% of all those tested had markers indicating possible current infection with syphilis, only 3 individuals (2 men and 1 woman) had serological markers suggesting possible current infection. 
Risk behaviours
Less than half of those screened in 2013 reported they had ever injected drugs (45%), which is similar to 2010 (44%). Of those with a history of injecting, 67% had injected in the past month. 
A history of injecting drug use was most common among prison entrants in Western Australia (60%) and least common among those in the Northern Territory (6%).
Amphetamine was the most common drug to be last injected (68%); a 13% increase from 2010. Heroin was the second most common drug to be injected at 20%; a 20% reduction from 2010.  
Most injecting drug users had done so for more than 3 years (86%) suggesting that the prisoner population is characterised by longer term drug users. 
Nine out of ten injecting drug users reported using clean needles for ‘all’ or ‘most’ of their injections in the month prior to coming into prison.    
Tobacco smoking remains at epidemic proportions among prisoners with 90% of prisoners reporting they are current tobacco smokers. The proportion of injectors who report they are current tobacco smokers was 97%, and 87% for non-injectors, which is unchanged from 2010.
The median age of first tobacco smoking was 13 for those with histories of injecting drug use and 15 for non-injectors. 
Approximately two-thirds of injectors (65%) and non-injectors (68%) reported cannabis use in the month prior to the survey.  
Most prisoners reported having sex in the three months prior to the survey (85%). 
A small number of prison entrants (3%) reported they had been paid for sex in the three months prior to the survey.  
Prisoners reported inconsistent condom use, regardless of whether with male or female partners. 
Implications of the Findings
Prison provides an important public health opportunity to monitor high-risk populations for exposure to bloodborne infections and, if appropriate, initiate prevention and treatment measures. 
Given the high prevalence of hepatitis C and hepatitis B in this population compared with the non-incarcerated community, it is important that this survey be regularly conducted to inform policy and health services planning for this at-risk group at local, state and national level. The findings from the NPEBBVS are utilised by the Commonwealth Government’s national communicable diseases strategies and highlight prisoners as a ‘priority population. 
Prevention initiatives need to target prison entrants, particularly those with a history of injecting drugs and who are in prison for the first time to initiate prevention strategies including education, hepatitis B vaccination, and hepatitis C treatment. 
Nationally, 44% of all prison entrants were vulnerable to hepatitis B infection and had not been vaccinated or previously exposed to hepatitis B or hepatitis B carriers. This group should be vaccinated as a matter of priority given this population’s engagement in risk behaviours that put them at an increased risk of infection. Accelerated vaccination schedules are effective and should be considered for this population given their mobility inside prison and, in many cases, their inability to complete the recommended six month schedule due to being released back into the community after fairly short periods in detention.
While the prevalence of HIV has remained low in all jurisdictions across surveys (2004, 2007, 2010 and 2013), the NPEBBVS has an important role to play in monitoring this trend given the prisoner population is comprised of those who engage in practices which put them at an increased risk of HIV infection. 
In 2004, 18% of those who reported they were negative for hepatitis C tested positive for HCV antibodies, in 2007, 16% reported they were negative but tested positive, in 2010, 7% reported they were negative but tested positive and in 2013, 8% reported they were negative but tested positive. This reinforces the benefits of ongoing testing of prisoners for bloodborne pathogens such as hepatitis C to reduce the number who are unaware of their exposure to hepatitis C and prevent further transmission. 
In 2013, 11 (9%) prison entrants reported they had ever received treatment for hepatitis C (up from 5% in 2010), including five Aboriginal prison entrants. This suggests that this population has great potential to increase treatment uptake for hepatitis C. 
Amphetamine remains the most frequently reported drug last injected by prison entrants. Amphetamine substitution therapies should be investigated and service providers need to ensure that staff receive training in recognising and managing amphetamine withdrawal on entry to prison.
Tobacco smoking is at epidemic proportions among prisoners with almost 9 out of 10 prisoners reporting they currently smoke and no apparent downward trend in the numbers who report they are current smokers.  Effective smoking cessation programs that sustain cessation in the community are needed for this population. 
To download a copy of the latest report, click here.