Ground-breaking study on PrEP in prisons reports 93% uptake

Findings from Zambia from the first ever study on PrEP in prisons finds most of those eligible take up the offer.

What is the research about? 

Providing PrEP in prisons. A PrEP programme offering PrEP in pill form was run in 16 Zambian prisons between October 2020 and March 2021. 

The programme worked as follows:  

• Prison peer educators ran group education and counselling sessions on HIV and PrEP.  

• People were then screened for HIV risk, and people who scored highly were offered HIV testing.  

• Those who tested positive were linked to HIV treatment, while those who tested negative were assessed then offered PrEP.  

• Prison peer educators provided support with PrEP adherence. 

Why is this research important? 

UNAIDS [PDF] estimates that, globally, people in prison are around seven times more likely to have HIV than other people. 

In Zambia, prisons have particularly high numbers of people who are at high risk of HIV, such as sex workers, people who inject drugs, gay men and other men who have sex with men, because these groups are criminalised. But Zambian prisons do not provide access to HIV prevention, including condoms and lubricants.  

Although data is limited, it is estimated that 1 in 5 people in prison in sub-Saharan Africa have consensual sex. Coerced sex, transactional sex and rape is also common. These things put people at risk of HIV. Other risks for transmitting HIV include sharing equipment for injecting drugs and for tattooing.  

What did they find out? 

Around 12,400 people were screened for HIV risk (95% were men). Of these, around 2,600 people received HIV testing.  

Of those who tested HIV negative and were assessed for PrEP eligibility, 67% qualified under Zambian Ministry of Health guidelines (a total of 1,280 people). Possible reasons for not qualifying for PrEP include not being sexually active, not having a recent sexually transmitted infection and not sharing equipment to inject drugs.  

Most people (93%) who were offered PrEP took it. This equates to 1,190 people (1,151 men and 39 women). PrEP uptake was 93% among men and 100% among women. 

The age groups with the highest PrEP uptake were 15–24-year-olds (97%) and 50+ (100%). However, uptake did not fall below 89% in any age group. The age group with the highest proportion of people started on PrEP was 25–29 years (24% of all those started on PrEP).  

Among those offered HIV testing, 13·7% tested HIV positive. Testing positive for HIV was much higher among women (20·6%) than men (13·2%). Testing positive was highest among people aged 45–49 (21%) and lowest among those aged 15–19 (4%). 

What does this mean for HIV services? 

It shows that many people in prison are likely to take PrEP if it is offered to them. Uptake was high, despite anal sex being punishable by law and an absence of conjugal visits (visits where a person in prison is allowed to have sex with their partner). However, the fact that condoms are unavailable in Zambian prisons might have influenced uptake. 

The study also shows a successful way to provide PrEP in prison, one of the most significant aspects being the involvement of prisoner peer educators. In fact, prisons provide an opportunity to reach people who are at high risk of HIV with HIV services – particularly people who are often criminalised, such as sex workers and gay men, who are less likely to access healthcare services outside of prison.