Global coverage of interventions for reduction of injecting drug use-related harm, HIV, viral hepatitis and tuberculosis in prisons and other carceral settings: a systematic review

Background:

People who are incarcerated experience disproportionately high rates of injecting drug use and infectious disease, including HIV, viral hepatitis and tuberculosis. However, comprehensive global data regarding the availability of services that prevent and manage infectious disease, injecting drug use and related harms remain limited and outdated. We provide the first systematic review to comprehensively examine the availability and coverage of infectious disease prevention, treatment, and harm reduction services for incarcerated populations globally.

Methods:

We conducted a systematic review of evidence for provision of opioid agonist treatment (OAT), needle syringe programs (NSPs), HIV testing and antiretroviral therapy (ART), hepatitis C virus (HCV) testing and direct-acting antiviral (DAA) treatment, tuberculosis screening and treatment, hepatitis B virus (HBV) testing, treatment, and vaccination in carceral settings. We searched from peer-reviewed and grey literature databases between 2000 and 2025 and used the most recent data available for each indicator.

Findings:

OAT was documented in 59/207 countries (29 %), and NSPs in ten (5 %). HIV testing was documented in 86 countries (42 %) and ART in 79 countries (38 %). HCV testing was confirmed in 55 (27 %), with DAA treatment in 47 (23 %). HBV testing was identified in 51 countries (25 %), treatment in 36 (17 %), and vaccination in 41 (20 %). Tuberculosis screening was documented in 96 countries (46 %) and treatment in 81 (39 %). Fewer than 2 % (approximately 172,000) of the 11.3 million people incarcerated worldwide live in countries that offer OAT, NSPs, and treatment for HIV, HCV, HBV, and tuberculosis in at least one carceral facility. There is not a single country where incarcerated people have access to all such services in every facility. Programme level evidence was rarely available.

Interpretation:

The global shortage of services that prevent and treat infectious disease and harms related to injecting drug use in carceral settings is a critical public health issue and, compared with community standards, a breach of human rights. This study underscores the urgent need for international collaboration and policy reform to scale up and stabilise services that address the health needs of incarcerated populations, ultimately improving health outcomes for both incarcerated populations and wider community.

Funding:

Australian National Health and Medical Research Council.