Prisoners, prisons, and HIV: time for reform.

Prisoners and detainees worldwide have higher burdens of HIV, viral hepatitis, and tuberculosis than the communities from which they come. This disease burden among prisoners has been recognised since the early years of these inter-related pandemics. Yet the health needs of prisoners receive little attention from researchers or advocates working to improve responses for these diseases, and scant funding for prevention or treatment interventions. This Lancet Series on HIV and related infections in prisoners shows that the reasons for this neglect include the very factors that make prisoners and detainees vulnerable to infection and unable to get treatment: unjust and inappropriate laws; underfunded and overcrowded prisons with large numbers of individuals in lengthy pre-trial detention; policing practices that lead to imprisonment with compulsory drug detention centres that provide no evidence-based treatment for substance use disorders and inadequate health care; and discriminatory criminal justice systems. The inter-related epidemics of HIV, viral hepatitis, and tuberculosis in prisoners have been seen as part of broader syndemics, which include mass incarceration without needle and syringe programmes, substance use, and mental disorders. In the decades long, failed War on Drugs, people who use drugs have been incarcerated in profoundly misguided and harmful approaches to treatable substance use disorders. Mass incarceration has destroyed countless individual lives, had lasting negative eff ects on prisoners’ families and communities, and, in many settings, increased community rates of HIV, tuberculosis, multidrug-resistant tuberculosis, and hepatitis C virus (HCV). The threat of incarceration, police harassment, and interference with access to HIV and HCV prevention and treatment services has also had an enormous impact on people who use drugs and other marginalised populations, including sex workers, men who have sex with men, and migrants and refugees. It is past time for a rethink on the uses of incarceration, and on ways of mitigating the eff ects mass incarceration has had on the overlapping epidemics we all seek to control. The need for a rethink is especially important because of how the incarcerated population is changing. Although most of the world’s 10·2 million estimated prisoners and detainees are men, women and girls are the fastest growing incarcerated population worldwide. The Institute for Criminal Policy Research reported a 50% increase in the number of women and girls incarcerated between 2000 and 2015 to about 700 000 worldwide, 205 000 (29%) of whom were in the USA alone. The human, social, and fi nancial costs of mass incarceration in the USA are severe—most especially among communities of colour. Among US women, HIV burdens are also most concentrated among women and girls of colour: in 2014 the rate of new HIV infections was 34·8 per 100 000 people in African American women compared with 1·8 per 100 000 in white women. The fi rst task in addressing HIV and related infectious diseases among those incarcerated is to reduce the numbers of people in prison and detention for substance use, sex work, and other non-violent off ences. This eff ort will require policies that send fewer people to prison and reduce the length of sentences. This change can happen only if there is agreement on what prisons—and what imprisonment—are for. Conventionally, incarceration has had four possible goals: retribution (punishment);