The global burden of injecting drug use, HIV, hepatitis and TB in prisons: findings from INHSU 2025

At the 2025 International Conference on Health and Hepatitis Care in Substance Users (INHSU 2025), Scientia Professor Louisa Degenhardt (NDARC, UNSW Sydney) presented findings from a major global review — The global epidemiology of injecting drug use, HIV, viral hepatitis and tuberculosis among people who are incarcerated: a multistage systematic review — revealing the scale of infectious diseases and injecting drug use among incarcerated populations worldwide.

The review represents the first effort to date to consolidate peer-reviewed and gray literature on this topic, drawing on nearly 72,000 documents and extensive engagement with experts and international agencies including WHO, UNODC, UNAIDS and the European Union Drugs Agency.

The findings are clear: disease burden in prisons is extraordinarily high, and without addressing health disparities in carceral settings, global efforts to eliminate HIV, viral hepatitis, and TB will continue to fall short.

VIEW ABSTRACT

The International Network on Hepatitis in Substance Users (INHSU) spoke with Professor Degenhardt about what this review means and what she hopes it will help change.

Why does this research matter?

We conducted this review to ensure that a current and comprehensive review of the prevalence of injecting drug use and infectious diseases among incarcerated people was available worldwide. There is a lack of robust evidence on population estimates of the health problems in people who are incarcerated, causing major barriers for national, regional, and global policymakers in evaluating progress towards UN Sustainable Development Goals. This is the first complete review of this topic that incorporates peer-reviewed and grey literature, involved extensive interactions with key agencies focused on incarcerated populations.

What do you hope this research could help change?

The incarcerated population is a critical but often neglected group in global disease elimination efforts. Without urgent action, the high burden of infectious diseases in prisons will continue to undermine public health progress worldwide.

What do you want people to remember?

The extraordinarily high burden of HIV, TB, and viral hepatitis in carceral settings identified here poses a significant challenge to global disease elimination efforts. The risk of within-prison disease transmission, compounded by poor access to screening and treatment, not only affects incarcerated individuals but also drives infection rates in the broader population. Addressing this crisis requires an urgent public health response to expand evidence-based screening, prevention, and treatment interventions within prisons, and ensuring continuity of care both for transition into incarceration and post-release.

What surprised you most?

Of 71,981 screened documents, 2,740 were eligible for data extraction. There are approximately 11,323,000 people aged 15-64 years incarcerated globally, with their incarceration rate being 221 per 100,000 (29 per 100,000 among females and 399 per 100,000 among males).

Substantial variation in rates across countries and regions were observed, with the highest regional rate being in North America. Globally, we estimate that 11·1% of people who are incarcerated have ever injected drugs (1,252,500; 95%CI 966,500-1,594,000), 52·9 times higher than the general population. We estimate that 3·2% (95%CI 2·1-4·6) of people who are incarcerated globally are living with HIV (12·2 times higher than the general population); 11% (95%CI 7·2-16·3) have current HCV infection (16·4 times higher); 4·5% (95%CI 2·4-8·1) have current HBV infection (2·3 times higher) and 2·0% (95%CI 1·3-2·9) have active TB (48·1 times higher than the general population).

Overall, we estimate that one in nine people (11%) who are incarcerated globally have injected drugs, which is over 50 times higher than in the general population. There was substantial variation across regions both in prevalence in incarcerated populations, from 2.1% (Sub Saharan Africa) to 50.7% (Australasia), and in IDU prevalence compared to the general population. Crucial here is the magnitude of the elevated prevalence of infectious diseases in carceral settings relative to the general population, particularly for active TB (48.1-fold higher prevalence), HCV (16.2-fold higher) and HIV (12.2-fold higher). This review also estimated, for the first time, prevalence estimates for both females and males and compared prevalence within carceral settings to that of the general population.

What would you like to see happen next?

Governments and international organisations must prioritise:

1. Routine screening, prevention, and treatment of HIV, HCV, HBV, and TB in carceral settings
2. Services to prevent drug-related harm and treat drug dependence, including OAT and NSPs
3. Stronger linkage-to-care programs to ensure continuity of treatment post-release
4. Reform of the criminal legal system to reduce unnecessary incarceration, particularly for people who use drugs
5. Integration of prison health with national health systems to ensure equivalent healthcare for all

These strategies will not only protect the health of incarcerated individuals but also yield broader community benefits, strengthening national and global efforts to end HIV, TB and viral hepatitis as public health threats.