Prevalence and associated risk factors of HIV in prisons in Balochistan, Pakistan: a cross-sectional study

Introduction

Globally; about 36.7 million people were living with HIV. HIV infection causes AIDS and is epidemic throughout the world. In 2016; about 1.8 million were reported as newly infected and 1 million died from AIDS related illnesses in the same period (http://www.unaids.org). In Pakistan, an estimated 0.13 million peoples are infected with HIV, out of which only 17% are registered with the AIDS Control programme and 54% of total registered people currently living with HIV/AIDS are getting treatment from antiretroviral therapy (ART) centres (http://www.nacp.gov.pk). The prevalence rate of HIV is 0.1% in Pakistan (http://www.unaids.org). AIDS was limited and epidemic among key populations over the decades in Pakistan, but the latest evidence suggests that there is a shift from key populations through transmission via needle-sharing by injecting drug users (IDUs) to sexual transmission via multiple sexual partners, and further transmission to their intimate partners is increasing¹. According to Integrated Biological and Behavioural Survey (IBBS), HIV prevalence was 38.4% among people who inject drugs (PWIDs), about 7.1% among transgender (TG), 3.5% among men who have sex with men and 2.2% among female sex workers^1–3.

Prisons are the easily approachable venues for health interventions but unfortunately, the prisoners are among the most marginalized and restricted populations where access to health services, interventions and surveys are very limited⁴. Prisoners are one of the most vulnerable population for acquiring infectious diseases especially HIV because people from diverse background, communities and risk factors are kept together for varying time⁵. The prevalence of HIV is alarmingly increasing in PWIDs and evidence through IBBS indicated that 38.5% of PWIDs were arrested in past 12 months which makes the other prisoners also vulnerable as PWIDs have access to drugs in the prisons². A study of HIV-positive prisoners in five jails in Sindh, Pakistan indicates that 12.3% of jail prisoners have ever used drugs by injection in the jails⁶.

The revised Pakistan AIDS Strategy III, developed in 2017 by the National AIDS Control Program (NACP) to guide Pakistan’s overall national response for HIV and AIDS till 2020, through focused interventions with set targets, costs, roles and responsibilities has emphasized on adopting precision targeting (including prisoners) to achieve the required level of impact on the epidemic¹. The Balochistan AIDS Control Program (BACP) conducted awareness and screening of prisoners in Central Prison Gaddani in 2017 and found that 27 (6.85%) out of 394 prisoners were positive for HIV. Most of the studies from the country have found that HIV is prevalent at about 2% in prisoners which is much higher than the prevalence in the general population^4,5,7–13.

Availability of limited data across the different prisons of the province and high prevalence of HIV found in central jail Gaddani warranted evidence to be produced by conducting a detailed study in other prisons of Balochistan as well. The study aimed to assess the prevalence and risk factors of HIV in prisoners of four major prisons of Balochistan.

Methods

Results

Initial screening and demographic information

A total of 2084 prisoners were screened, of whom 33 were found to be positive for HIV (Figure 1). All the HIV-positive prisoners were approached for assessment of risk factors but only 16 gave informed written consent for the interview.

Figure 1. Flow diagram of prisoners screened and interviewed for HIV in prisons in Balochistan.

*Test 1 = Alere Determine HIV-1/2 Ag/Ab Combo for detection of Antigent/Antibody, **Test 2 = Uni-Gold HIV, **Test 3 = SD Bioline HIV-1/2 3.0.

The median age of the prisoners was 25 years (range 13–80 years, 94.23% in 15–45 years age group) years and 53 (50.9%) of them were married. The majority of them were uneducated (36.53%) or had been in education for less than 5 years (16.34%). Among them, 15% were unemployed and 8% were working on daily wages before the imprisonment. Around 93% of the prisoners were from Balochistan, 4% from other provinces and 3% from other countries (Table 1).

Table 1. Sociodemographic characteristics of prisoners interviewed for assessment of risk factors for HIV.

Variable	HIV positive, n (%)	HIV negative, n (%)	Total, n (%)
Total	16 (15.4)	88 (84.6)	104
Age, years
<15	0	1 (0.96)	1 (0.96)
15–45	16 (100)	82 (78.8)	98 (94.2)
45–65	00	02 (1.92)	02 (1.92)
65 and above	00	03 (2.88)	03 (2.88)
Sex
Male	16 (100)	88 (100)	104 (100)
Place of origin
Within province	16 (100)	81 (77.8)	97 (93.2)
Out of province	00	04 (3.84)	04 (3.84)
Out of country	00	03 (2.88)	03 (2.88)
Education
Not educated	09 (56.3)	29 (33.0)	38 (36.5)
<5 years	01 (6.25)	16 (18.1)	17 (16.3)
6–10 years	02 (12.5)	20 (22.7)	22 (21.2)
11–14 years	04 (25.0)	20 (22.7)	24 (23.1)
>14 years	00	02 (2.27)	02 (1.92)
Religious	00	01 (1.13)	01 (0.96)
Occupation
Unemployed	02 (12.5)	14 (15.9)	16 (15.3)
Employed*	12 (75.0)	68 (77.3)	80 (76.9)
Daily wages	02 (12.5)	06 (6.81)	08 (7.69)
Marital status
Unmarried	10 (62.5)	41 (46.6)	51 (49.0)
Married	06 (37.5)	47 (53.4)	53 (51.0)

*Employed includes prisoners who have worked both in public, private sector and/or self-employed.

Around 75% HIV infected prisoners were convicted, 75% had spent less than five years, 25% had spent more than ten years in prisons. 22% of total interviewed prisoners had been ever arrested for drug related offense (Table 2).

Table 2. Imprisonment status of prisoners in prisons setting of Balochistan evaluated during March-June 2018 (n=104).

Variable	HIV positive, n (%)	HIV negative, n (%)	Total, n (%)
Total	16 (15.4)	88 (84.6)	104
Type of imprisonment
Under trial	03 (18.8)	26 (29.5)	29 (27.8)
Convicted	13 (81.3)	62 (70.5)	75 (72.1)
Time imprisoned, years
< 1	08 (50)	37 (42.0)	45 (43.2)
1–5	04 (25)	34 (38.6)	38 (36.5)
6 – 10	00	12 (13.6)	12 (11.5)
> 10	04 (25)	05 (5.7)	09 (8.65)
Ever arrested for drug- related offense
No	10 (62.5)	71 (80.7)	81 (77.8)
Yes	06 (37.5)	17 (19.3)	23 (22.1)

Discussion

This study was conducted in four major jails in Balochistan, Pakistan, and revealed that the HIV prevalence was 1.6%, which is much higher than the prevalence rate in general population in Pakistan³. A previous study conducted in Quetta jail indicates that the HIV prevalence was 0.5%¹⁶. A limitation of that study was generalizability to the whole province as the sample size was very small (only 200 prisoners were screened) and the prisoners of Quetta jail, although large in number, were mostly under trial, so the long-term sentenced prisoners were excluded from being assessed. The study findings are consistent with studies conducted in other provinces where the HIV prevalence ranged from 1 to 2.9%^{4,5,7,9,11,13}.

Based on our study findings, the majority of the HIV-positive prisoners belonged to the 15–45 years age group. The same age range was also found to be significant in other studies conducted in Pakistan^5,11,13. Education status was also found as an important factor in HIV risk assessment, as a large majority of HIV positive prisoners (62.5%) were not educated or had been educated for less than 5 years, as found by another study conducted in Lahore¹¹.

The prisoners who were single had a higher prevalence of HIV, as 62.5% of HIV-positive prisoners were unmarried. The findings are consistent with a study conducted in different jails of six cities in Sindh province¹³, Imprisonment status and duration of imprisonment was significant as 81% of HIV-positive prisoners were convicted and 25% prisoners had spent more than 10 years in prisons.

A substantial proportion of HIV-infected prisoners were involved in behaviour considered to be presumptive risk factors associated with HIV; 68.8% were involved in extramarital sex and 43.8% had engaged in homosexual practices. A study of prisoners in Karachi found involvement of prisoners in homosexuality and sexual encounters with females to be 21.3% and 45.9%, respectively⁴. Moreover, drug addiction, especially injectable drugs involving the sharing of needles, was also found to be present in significant majority of the HIV infected prisoners. Risk of acquiring of HIV increases in prisons as studies shows that 38.5% of PWID were arrested in past 12 months and around 12.3% of arrested PWID had access to injectable drugs in prisons^2,17.

The young age of the prisoners, being less educated, having low socioeconomic status, addiction to injectable drugs, having multiple sex partners, sharing needles and involvement in drug related offense were notable findings of the study and consistent with studies conducted elsewhere in Pakistan^4,5,7–13.

Prison settings highly favour the spread of infectious disease as the prisoners from different sociodemographic backgrounds like low literacy levels and having pre-imprisonment risk factors such as drug use, extramarital sex encounters etc. are forced to live together in confined space without having recreational facilities⁴. The prisoners are vulnerable to acquiring new infections in prisons due to overcrowding, poor medical facilities (especially diagnostic investigations) and the unavailability of harm reduction approaches such as the use of condoms or needle exchange program¹⁸. All these factors may not only lead to greater chances of spread of infections like HIV among the jails but can also be a major concern among the general population due to frequent flow of prisoners into the community⁴.

Aside from the many risk factors responsible for spread of infections in prison settings, prisons are still favourable venues for the screening and treatment of HIV, as the prisoners are confined to limited vicinity and easily approachable for diagnosis, treatment and health education. If the prisoners are approached within the prisons for diagnosis and treatment, this can help halt the spread of HIV to the general population and vice versa⁴.

The level of health services provided in prisons plays an important role in dealing with the associations of HIV-infected persons with the community. In a resource-constrained country like Pakistan, the chain of transmission can be broken by introducing urgent prevention efforts, including health education, initial screening at the time of entry of prisoners in prions, routine periodic screening of all the prisoners and treatment of infected prisoners in each prison so that its spread within the prisons and to the community after release of the prisoner could be minimized⁴. The presence of HIV-infected prisoners warrants that information and education programs are made accessible in the prisons to stop the spread of infectious diseases in the prisons, with particular emphasis on transmission through injectable drug use and high-risk sexual activities. Training the health care providers to identify and treat those suspected of being, or known to be infected with HIV and the provision of testing services may help in early diagnosis of infections and their treatment to reduce the spread of infection.

Being a comprehensive study covering four major jails of Balochistan province the study is strengthened by universal sampling for screening in which all the prisoners present during the study period were screened for HIV. The risk factors may vary in those prisoners who were not interviewed.

Conclusion

The high prevalence of HIV in prisons in Balochistan, compared with the non-prison population, indicates that preventive strategies should be designed and implemented carefully to minimize the spread of infection among the prisons and ultimately their linkages to the community. Early diagnosis of HIV infection through screening, initiation of treatment, addressing the stigma universally attached with the disease, peer based, risk reduction education program and linking HIV-positive inmates to the community care after release are effective ways of preventing the spread of infection.

Data availability