High variability of TB, HIV, hepatitis C treatment and opioid substitution therapy among prisoners in Germany

Abstract

BackgroundIn Germany, medical care of prisoners is completely separated from extramural health care. The extent and quality of medical care among prisoners in Germany are therefore largely unknown. We performed a secondary data analysis of pharmacy sales data for tuberculosis (TB), HIV, hepatitis C (HCV) and opioid substitution treatment (OST) delivered to prisons in 11 federal states (FS) in Germany between 01/2012 and 03/2013. The aims of this study were to assess (i) the treatment availability for the selected diseases and OST in German prisons, (ii) the proportion of prisoners treated per FS and overall for TB, HIV, HCV and OST during the study period.MethodsSubstances unique to or typically used for the treatment of each disease were defined as marker substances with defined daily doses (DDD).For each marker substance we assessed the cumulative number of DDD, the average daily number of DDD (DDDd) and average treatment prevalence per day in percent (adTP). Accordingly, the DDDd represents one person treated per day and the adTP means the proportion of prisoners treated per day. We compared the adTP of the diseases with previously measured prevalences.ResultsWe obtained data from pharmacies supplying prisons in 11 of 16 German FS. Of the included prisons, 41% were supplied with medicines for TB, 71% for HIV and 58% for HCV and OST. Twice as many delivered marker substances for TB were indicated for the continuation phase and chemoprevention than the intensive phase. The HIV adTP ranged from 0.06% to 0.94%, HCV adTP ranged from 0.03% to 0.59% and OST adTP ranged from 0% to 7.90%. The overall adTP for the respective treatment was 0.39% for HIV, 0.12% for HCV and 2.18% for OST.ConclusionsAccording to our findings treatment rates for TB were consistent with the expected TB prevalence, at least in Berlin. HIV treatment seems to be offered to an adequate proportion of estimated infected prisoners. In contrast, the HCV treatment prevalence was low. High variation among FS in provision of all treatments, particularly of OST, point to inconsistent treatment practices, although nationwide extramural treatment guidelines for Germany exist.

Prevalence of Opioid Dependence and Opioid Agonist Treatment in the Berlin Custodial Setting: A Cross-Sectional Study

“…This discrepancy may reflect the differences in the OAT practices at the transition from the extramural to the intramural sector across various federal states. For instance, in Saarland, no prisons are supplied with OAT medicines, and in Lower Saxony, all prisons are supplied with such substances (24). Our research demonstrated lower rates of opioid dependence among women than previous studies, which estimated dependence on opioids between 27-50% in the women's custodial setting (55,56).…”

“…Thus, compensation imprisonment represented a predictor for OAT most likely due to factors related to this sub-prison. Several authors discuss differences in attitudes held toward liberal and harm-reduction drug politics-which translate into different institutional policies and regulations-as a main reason for the general hesitation to use OAT in prisons and its high implementation variability between different federal states (24,30,34,60). Yet the variability of implementation seems not only to be limited to the national level (24), but also to apply to the federal state level.…”

“…Several authors discuss differences in attitudes held toward liberal and harm-reduction drug politics-which translate into different institutional policies and regulations-as a main reason for the general hesitation to use OAT in prisons and its high implementation variability between different federal states (24,30,34,60). Yet the variability of implementation seems not only to be limited to the national level (24), but also to apply to the federal state level. This variability in treatment implementation at every institutional level-within countries and federal states-has been observed in other European countries (33).…”

“…Even if Germany was one of the first European countries to implement OAT in the custodial setting, it still had remarkably low rates of prison population receiving OAT twenty years later (22), while the prevalence of IDU among people in detention is estimated higher compared to other European countries (23). Moreover, as in other European countries, high variability exists in treatment practice on a national level (21,24). OAT practice in German prisons even subject to trial in front of the European Court of Human Rights in 2016 (25).…”

“…The estimates concerning the rates of people in detention receiving OAT are similarly heterogeneous. In 2017, a large-scale secondary data analysis of pharmacy sales data estimated that, on a national level, merely 10% of all opioid-dependent people in detention received adequate substitution treatment but also mentioned the high variability between the various federal states (24). Meanwhile, the results of the national report concerning substance-related dependence problems suggest that, in Berlin, 52% of all opioid-dependent people in detention receive substitution treatment (29).…”