HIV Screening, PrEP Program in Zambia May Serve as Model for Prisons Worldwide

High uptake of HIV pre-exposure prophylaxis (PrEP) is possible in prison populations that have adequate resources and support from the criminal justice health system, according to research published in The Lancet.

The study authors implemented a PrEP program supporting 16 criminal justice facilities across 4 provinces in Zambia between October 1, 2020, and March 31, 2021. Prior to implementing the program, there were stakeholder engagement meetings held with Zambia Correctional Service officials to discuss PrEP benefits. The researchers also trained Zambia Correctional Service health care workers on PrEP management using the national PrEP training package.

People who were incarcerated and found to be at substantially high risk of HIV, after screening, were offered voluntary HIV testing and counselling.

Individuals who received an HIV diagnosis were set up to receive antiretroviral therapy (ART), and individuals who tested negative for HIV and met the national HIV prevention eligibility criteria were offered PrEP treatment. The researchers then assessed PrEP uptake and used descriptive statistics to characterize program beneficiaries and the cascade of PrEP services.

During the PrEP program period, the authors reached 12,367 individuals older than 15 years with HIV risk assessment and counselling; 11,794 (95.4%) were men and 573 (4.6%) were women. Men aged 25 to 29 years made up the largest proportion of individuals reached with these services in general and those who initiated PrEP, which is consistent with known demographics of Zambia's incarcerated population. The authors also noted the small number of women in the study is reflective of incarceration trends in Zambia and does not pose a limitation to the study.

Of this study group, 2610 individuals received HIV testing, with 357 (13.7%) receiving an HIV diagnosis. Additionally, 1276 individuals did not have HIV and were PrEP eligible, and 1190 (93.3%) individuals in this group initiated PrEP.

The authors said the high number of individuals in the study not receiving HIV testing (78.9%) may be due to several reasons:

• Individuals presented to the facility when counsellors were not available to offer HIV testing
• Individuals were deemed not at risk for HIV based on the Ministry of Health HIV risk screening tool
• Individuals already received an HIV diagnosis
• Individuals declined testing due to testing within the past 3 months
• Individuals received a negative HIV self-test result

“Previous reports from Zambia suggest that considerable investments in peer education, HIV test supply chain management, and human resources for health are required to improve HIV testing uptake in criminal justice settings,” they said.

According to the authors, this cross-sectional observational study demonstrated that HIV treatment and prevention methods used in prisons in Zambia could potentially serve as a model for other prisons worldwide.

“Delivery of PrEP to people who are incarcerated is feasible with adequate resourcing and support to the criminal justice health system, and can result in high uptake among eligible individuals,” the study authors said. “Further assessment is needed of PrEP persistence and adherence, and the perceptions of people who are incarcerated regarding their HIV risk and preferences for combination HIV prevention services.”

The study was funded by the US President's Emergency Plan for AIDS Relief through the CDC.

Reference

Lindsay B, Nyirongo N, Mwango L, et al. Initial implementation of HIV pre-exposure prophylaxis for people who are incarcerated in Zambia: a cross-sectional observational study. Lancet HIV. 2023;10(1):e24-e32. doi:10.1016/S2352-3018(22)00220-X