Hepatitis B, hepatitis C, and HIV in correctional
populations: a review of epidemiology and prevention
Cindy M. Weinbauma, Keith M. Sabinband Scott S. Santibanezc
The 2 million persons incarcerated in US prisons and jails are disproportionately
affected by hepatitis B virus (HBV), hepatitis C virus (HCV) and HIV, with prevalences
of infection two to ten times higher than in the general population. Infections are largely
due to sex- and drug-related risk behaviors practised outside the correctional setting,
although transmission of these infections has also been documented inside jails and
should include hepatitis B vaccination, HCV and HIV testing and counseling, medical
management of infected persons, and substance abuse treatment in incarcerated
? 2005 Lippincott Williams & Wilkins
AIDS 2005, 19 (suppl 3):S41–S46
Keywords: prison, hepatitis B, hepatitis C, HIV, inmates, epidemiology,
prevention, hepatitis B vaccination, review
Individuals incarcerated in prisons and jails in the United
States have a disproportionate burden of infectious
diseases, including infections with hepatitis B virus
(HBV), hepatitis C virus (HCV), and HIV . Although
incarcerated individuals comprise only approximately
0.8% of the USpopulation, it is estimated that 12–15% of
all Americans with chronic HBV infection, 39% of those
with chronic HCV infection, and 20–26% of those with
HIV infections have a history of incarceration [2,3].
Adult jail and prison populations totaled 2.03 million at
the end of 2002, a 77% increase from 1990. Jails hold
arrestees and individuals sentenced for less than one year;
prisons hold inmates sentenced for one year or longer.
Racial/ethnic minorities are overrepresented in national
Hispanic, and 3% other races. Approximately 6.8% of
adult prisoners are women, a 112% increase since 1990
[4,5]. Turnover in correctional facilities is rapid, with an
estimated 12.6 million admissions and 12.6 million
releases from local jails in 2000, and 663 500 admissions
and 632 200 releases from prisons [1,2,6]. In addition to
individuals institutionalized in the correctional system,
over 4.7 million individuals were under community
supervision (probation and parole) at year end 2002; this
non-institutionalized population will not be discussed in
this paper because of the lack of risk and disease-related
This paper will discuss the epidemiology of HBV, HCV,
HIV, and HIV/HCV co-infections among inmates and
releasees of correctional facilities, and strategies for the
prevention of these infections in correctional settings.
HBV, HCV, and HIV are bloodborne pathogens. HBV
and HIVare efficiently transmitted by percutaneous (e.g.
needlestick) or permucosal exposure to infectious blood
or body fluids (e.g. semen, vaginal fluid); HCV is most
efficiently transmitted by percutaneous exposure to
infectious blood. Of all acute hepatitis B cases reported
in the United States, sexual contact accounts for more
than half of all newly acquired infections; approximately
40% had recent heterosexual exposure to an infected
partner or to multiple partners, and 15% were men who
have sex with men (MSM). In addition, 14% of
individuals with acute hepatitis B reported recent
injection drug use . For hepatitis C cases, 60% are
associated with injection drug use and 15% with sexual
exposures. Among individuals with reported HIV
From theaDivision of Viral Hepatitis, thebGlobal AIDS Program, and thecDivision of HIV/AIDS Prevention, Centers for Disease
Control and Prevention, Atlanta, GA, USA.
Correspondence to Cindy Weinbaum, MD, MPH, Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600
Clifton Road, MS G-37, Atlanta, GA 30333, USA.
ISSN 0269-9370 Q 2005 Lippincott Williams & Wilkins
infection, 51% reported sexual risk behaviors without
injection drug use (33% MSM and 18% heterosexual),
and 18% reported injection drug use .
inmate populations compared with the rest of the US
population. Among juvenile detainees, a history of
injection drug use was reported by 3.3–6% [2,10].
Although surveys of adult prison inmates have not
assessedinjection druguseversus otherdrug use, 73–83%
of prison inmates reported a history of drug use, and 45–
57% reported the use of drugs in the month before their
offence. Among arrestees, 9% (range 0–25%) of women
and 7% (range 2–19%) of men entering 34 jails used
injection drugs in the year before arrest; among adult jail
inmates, current injection drug use was reported by 18%,
and any drug use in the month before incarceration was
reported by 55% [11–13]. Drug use also occurs inside
correctional facilities: injection drug use during incar-
By comparison, among non-institutionalized individuals
in the United States, injection drug use was reported
by approximately 0.15% annually among individuals aged
12 years and older .
Incarcerated populations are also at higher risk of the
population. High rates of gonorrhea, Chlamydia, and
syphilis have been described among entering inmates,
and many inmates reported multiple sex partners and
inconsistent condom use both before incarceration and
after release [15–21]. Sexual behavior also occurs within
correctional facilities. Although the frequency is difficult
to quantify, 4–30% of inmates reported sex (oral or anal)
while incarcerated [22–24]. The occurrence of sex in
prison is evidenced by occasional outbreaks of sexually
transmitted diseases in prisons .
Burden of disease
Hepatitis B virus
Approximately 5% of the civilian, non-institutionalized
US population has serological evidence of past or
present HBV infection, and 0.4–0.5% has chronic
HBV infection. The overall prevalence of HBV infection
differs among racial/ethnic populations, and is highest
(40–70%) among individuals who have emigrated
from areas with a high endemicity of HBV infection
(e.g. Asia, Pacific Islands, Africa, Middle East). The
prevalence of infection among black individuals (11.9%)
is fivefold greater than among white individuals (2.6%)
Among prison inmates, the prevalence of serological
markers for current or past HBV infection is 13–47%,
and varies by region. Prevalence is higher among women
(37–47%) than men (13–32%). Chronic HBV infection
is found in 1.0–3.7% of prison inmates, two to six
times the US prevalence estimate, and is comparable to
rates of chronic infection found in surveys of injection
drug users (IDU) (5–10%), and among MSM (1.5–6%)
Upon release, susceptible inmates may be at increased risk
of transmission because they continue to practise high-
risk behaviors. A study of recidivist women found an
HBV seroconversion rate of 12.2 per 100 person-years
between incarcerations , compared with an estimated
US population (G. Armstrong, CDC, personal com-
Whereas the majority of HBV infections among
incarcerated individuals are acquired in the community,
transmission has been identified in prison, and incidence
rates have ranged from 0.8 to 3.8% per year [2,28].
Among cases of acute hepatitis B reported to the Centers
for Disease Control and Prevention (CDC)’s Sentinel
Counties Study of Viral Hepatitis, 5.6% had a history of
incarceration during the disease incubation period .
HBV transmission in the prison setting most commonly
Hepatitis C virus
An estimated 3.9 million individuals (1.8%) in the
civilian, non-institutionalized US population have been
infected with HCV, of whom approximately 2.7 million
(1.3%) are chronically infected. In 1990, two-thirds of
individuals infected with HCV were aged 30–49 years.
Black individuals had a higher prevalence of HCV
infection than white individuals (3.2% compared with
1.5%), and men had a higher prevalence than women (2.5
versus 1.2%) .
The incidence of acute hepatitis C has declined by over
80% since 1989, primarily as a result of a decrease in cases
among IDU . However, both the incidence and
prevalence of HCV infection among IDU remain high.
HCV infection is acquired more rapidly after the
initiation of injection drug use than either HBV or
HIV infection. The rate of acquisition of HCV infection
among young IDU is four times higher than the rate of
acquisition of HIV infection. In 1980s studies, approxi-
mately 80% of newly initiated IDU were infected with
HCV within 2 years. More recent studies have suggested
that the rate of HCVacquisition has declined; however,
incidence remains high at 10–15% per year . Higher
rates of HCV acquisition compared with other blood-
borne pathogens are probably related to the high
prevalence of chronic HCV infection among IDU,
which results in a greater likelihood of exposure to an
HCV-infected individual through the sharing of syringes
and drug paraphernalia.
S42AIDS 2005, Vol 19 (suppl 3)
Among prison inmates, 16–41% have serological
evidence of HCV infection, and approximately 12–
35% have chronic HCV infection. Rates vary according
to the percentage of IDU in the population and by
geographical region. In a Wisconsin study of 1148
inmates, 13% were HCV positive. Of the 126 inmates
(11%) reporting injection drug use, 74% were HCV
positive; testing these inmates identified 61% of the
prison’s anti-HCV-positivepopulation . When routine
entry laboratory tests found an elevation of liver
enzyme levels, these two criteria identified 80% of
HCV-positive prisoners. Among HCV-positive inmates
entering jail in Massachusetts, 21% were anti-HCV-
positive, 84% of whom reported using ‘street drugs’ in
the 3 months before incarceration and 49% of whom
reported sharing needles .
The risk of HCVacquisition during incarceration is not
well established. Two studies that examined the incidence
of HCV infection among prison inmates found rates of
0.4–1.1 infections per 100 person-years of incarceration
among men [28,32].
At the end of 2002, there were approximately 850 000–
950 000 HIV-infected individuals in the United States,
and an estimated 384 906 persons living with AIDS
[9,33]. In 30 areas with longstanding confidential name-
based HIV reporting, approximately 73% of individuals
with HIV/AIDS were men, 50% were black, 38% were
white, and 10% were Hispanic. Approximately 40 000
US residents become infected with HIVannually. AIDS
incidence increased throughout the 1980s, declined from
. HIV incidence among IDU has decreased since the
mid-1980s but differs greatly by geographical area; in the
1990s, the incidence in the eastern United States was one
to three cases per 100 person-years, compared with less
than 0.5 per 100 person-years in the west. HIV incidence
among military personnel and blood donors was less than
0.03 per 100 person-years, more than 100 times lower
than that among MSM or IDU .
Whereas systematic HIV testing is not performed in all
US prisons, prison systems report known HIV infections.
The prevalence of known HIV infection in US prisons
has slowly declined from 2.3% of the prison population in
1995 to 1.9% in 2001 . This downward trend was
noted among both men (2.3–1.9%) and women (4.0–
a small numberof states. Three states, New York, Florida,
and Texas, accounted for nearly half of all HIV-infected
inmates in state prisons in 2001 .
Overall, the HIV prevalence in prisons generally reflects
regional prevalence trends, with higher rates in the
northeast and south . In 2001, the prevalence of HIV
infection was 4.9% among inmates in the northeast, 2.2%
in the south, 1.0% in the midwest, and 0.8% in the west.
The proportion of HIV-positive inmates was highest in
New York (8.1%), Rhode Island (4.4%) and Florida
HIVprevalence is highestamong incarcerated women. In
nine states, over 5% of female inmates were known to be
HIV positive, and in three states, New York (14.9%),
Rhode Island (12.1%), and Nevada (12.0%), over 10% of
female inmates were known to be HIV positive. In
contrast, New York (7.8%) was the only state in which
over 5% of male inmates were known to be HIV positive.
The rates of HIV infection and AIDS are comparable in
jails to those observed in prisons .
The majority of HIV infections among incarcerated
individuals are acquired in the community; low levels of
transmission have been identified in prison, with an
incidence of zero to four per 1000 person-years [24,28].
Although prisons have not conducted polymerase chain
reaction studies to determine HIV incidence with
certainty, incidence studies carried out using antibody
testing have taken the ‘window period’ into account.
Rates of HIV transmission that are lower than rates
of other sexually transmitted pathogens in the prison
setting probably reflect the lower prevalence and lesser
transmissibility of this pathogen.
HIV/hepatitis C virus co-infection
Limited published data are available regarding HIV/HCV
co-infection among US prisoners. In a recent study of
entrants to Maryland correctional facilities , 30% had
antibodies to HCV, 6.6% had antibodies to HIV, and
HIV/HCV co-infection was present in 4%. Among those
with HCV infection, 11–14% had HIV infection;
conversely, among those with HIV infection, 65% had
HCV infection. Another prison study found that 8.2% of
inmates with HCVantibodies had HIV co-infection, and
70% of HIV-infected inmates had HCV infection (CDC,
unpublished data). In a study of detainees entering three
large city jails , where 2.7% were HIV infected, the
HIV/HCV co-infection rate was approximately 1%. In a
study of young IDU, 75% of whom had a history of
incarceration, approximately 4% were co-infected with
HIV and HCV (R. Garfein, CDC, personal communi-
cation, May 2004).
Hepatitis B, hepatitis C, and HIV/AIDS
prevention in correctional settings
Jails and prisons are opportune venues for public health
and correctional authorities to collaborate to reach
populations with high prevalences of HBV, HCV, and
HIV infections and risk factors for these infections.
Corrections-based hepatitis B vaccination has been
Hepatitis B, hepatitis C, and HIV in correctional populations Weinbaum et al.S43
recommended by the Advisory Committee on Immu-
nization Practices and the CDC since 1982, selective
HCV testing by CDC since 1998, and HIV testing by the
US Public Health Service since 1987 [31,40,41]. One
continued after release was shown to reduce slightly the
percentage of inmates having unprotected anal/vaginal
sex after prison discharge (from 86% in the 90 days pre-
incarceration, to 68% 24 weeks after release) compared
with a group that received a single-session intervention
(89% unprotected sex in the 90 days pre-incarceration, to
78% 24 weeks after release) .
Incarceration may also be an opportunity for many drug-
using offenders to access substance abuse treatment,
essential to prevent HIV and HCV transmission.
However, the availability of substance abuse programs
of inmates need some level of substance abuse treatment,
in 1997, only 10% of state inmates had received drug
treatment since admission [11,42]. Since that time,
methadone treatment has become available in at least
seven US jail systems, but only for inmates who were
receiving treatment before incarceration. Only two
jurisdictions, San Juan, Puerto Rico and New York
City, offer methadone to inmates who were not in
treatment before arrest (H. Catania, New York, personal
between some correctional systems, local jurisdictions,
academic institutions and community-based organiz-
ations to provide prevention services within jails and
prisons. However, financial and institutional constraints
prevent immunization, substance abuse, and collaborative
prevention programs from being widely implemented
Hepatitis B virus
In a study of individuals with reported acute hepatitis B,
29% had a history of incarceration, including 40% of
individuals reporting multiple sex partners, 58% of IDU,
22% of MSM, and 20% of individuals with no reported
behavioral risk factor. The implementation of hepatitis B
vaccination programs in prison and jail settings could thus
prevent a high proportion of all new hepatitis B cases
Hepatitis B immunization programs have been imple-
mented in prison and jail systems in several states.
However, vaccine funding has been a significant barrier
survey found that 401 out of 1584 state adult correctional
facilities in 36 states and the District of Columbia
reported the deliveryof at least one three-dose hepatitis B
immunization series. However, only 37 correctional
facilities (2%) reported offering hepatitis B vaccine to all
inmates. An additional 153 facilities reported a policy of
immunizing all inmates, but had not given any vaccine
doses in the 12 months before the survey .
Hepatitis B immunization is well accepted in prison and
jail settings. In an immunization program in the Texas
Department of Criminal Justice, hepatitis B vaccination
was offered to 75% of eligible inmates, and was accepted
by 72% in prisons and 85% in state jails. However, the
program was stopped when funding was no longer
available . A similar vaccine acceptance rate was
found during a demonstration project in Denver City Jail
Hepatitis C virus
HCVantibody testing of individuals in existing programs
that provide medical care to IDU (e.g. correctional
institutions, HIV counseling and testing sites, and drug
treatment programs) is an efficient strategy for identifying
HCV-positive individuals who may then be medically
evaluated and educated about the prevention of liver
disease . In 2000, a survey found that HCV testing
was available in 79% of state prison facilities, which
housed 94% of all inmates. The criteria for testing varied:
132 facilities (6% of all inmates) tested broadly (at
admission, at random, or all at some other time); 604
facilities (56% of inmates) tested on inmate request; 492
(48% of inmates) tested on the basis of high-risk
indicators, and 1000 (86% of inmates) tested on the
basis of clinical indication .
In state prisons, 17 911 tests were positive for anti-HCV
between 1 July 1999 and 30 June 2000, and in that time
frame 6046 inmates were treated for hepatitis C .
Limited data suggested that approximately 7–27% of all
inmates identified with HCV infection ultimately begin
treatment . Many inmates have been excluded from
treatment because of short lengths of prison stay, drug and
alcohol use, and clinical contraindications including
mental illness .
HIV testing was available upon inmate request in 45 states
and in the Federal Bureau of Prisons in 1999. Forty-seven
jurisdictions offered testing if it was clinically indicated.
Only 19 state systems offered testing to all incoming
inmates, whereas three jurisdictions tested all inmates in
custody. The Federal Bureau of Prisons tests all inmates at
In 2003, the CDC initiated the ‘Advancing HIV
Prevention Initiative’, which included a ‘Demonstration
Project of Routine HIV Rapid Testing of Inmates’ in
short-stay correctional facilities in four states . The
goals of the project are to increase access to voluntary
testing, increase the proportion of HIV-positive inmates
who know their HIV serostatus and are referred to
prevention and treatment services, and prevent new
infections (R. MacGowan, CDC, personal communi-
cation, May 2004).
S44 AIDS 2005, Vol 19 (suppl 3)
Injection drug use and sexual behaviors, among other
factors, have resulted in concentrations of populations
of the United States. Treatment of infected individuals is
expensive and difficult, and co-infection further com-
plicates the treatment of chronic viral hepatitis and AIDS
with multiple hepatotoxic medications and adverse
events. However, because this single population is at
risk for all of these infections, opportunities exist for
public health and corrections to collaborate to develop
integrated approaches to HBV, HCV, and HIV preven-
Upon incarceration, all adults and the majority of
juveniles lose access to the usual public and private
healthcare and disease prevention services. Their health-
care becomes the sole responsibility of either the cor-
rectional system (federal, tribal, state, or local), or less
frequently, the public health system. Although correc-
tional facilities are only required to provide adequate,
reactive healthcare, entry into the correctional system
provides an opportunity for a population at risk of HBV,
HCV, and HIV infections to access preventative health-
care, including immunization, health education, sub-
stance abuse treatment, and risk reduction.
Although there are opportunities for prevention efforts,
vaccination is well accepted, but vaccine programs
have not been widely implemented in correctional
settings, largely as a result of a lack of funding for adult
immunization. Substance abuse treatment programs are
also lacking in prisons, and barriers exist to the
widespread implementation of collaborative programs
needed to prevent reversion to pre-incarceration habits
after prison release. HCV testing is widelyavailable, often
by inmate request or identified inmate risk, and HIV
testing, counseling, and prevention education is still more
available. Whereas an integrated approach to disease
prevention among inmates has been piloted in correc-
tional facilities, it has not yet become a standard of
correctional healthcare .
The importance of including incarcerated populations
in community-based disease prevention and control
strategies is now recognized by many public health,
Improved medical care and prevention services for
incarcerated populations benefits communities by reduc-
ing disease transmission and medical costs. Because
incarcerated individuals have a high frequency of
infection with HIV and hepatitis viruses, community
prevention and control of these infections and their
disease consequences requires the inclusion of this
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