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Talley - Bases - Win Mod Looking at the distribution of the participating prisons across the country and at the composition of HIV-risk factors among inmates, our data seems to be reasonably representative of the Italian prison population. This discrepancy was also confirmed in newly admitted prisoners HIV testing rate For these reasons, the imprisonment period should be considered as an opportunity to treat a hard-to-reach population in freedom [ 21 — 27 ].

Finally, we cannot exclude the possibility that the real prevalence of HIV infection might have been underestimated by the low rate of testing. Some findings deserve attention in our study. Firstly, foreign detainees represent Secondly, Italian prison population contains nearly one-third of prisoners with a history of drug misuse at some time in their lives.

Given the interplay between transmissible diseases, drug use, low-to middle-income countries origin and incarceration, there is a need to develop approaches to increase the acceptance of testing by raising an awareness in prisoners regarding infections, Appropriate testing pathways in prison should be optimized to ensure adequate pre- and post-test discussion, and to develope care pathways that enable treatment in prison as well as continuity of care upon release [ 28 — 32 ]. It is essential that prison healthcare personnel, in particular infectious disease specialists, make every effort to increase the offer of HIV screening in prison; indeed, the knowledge of HIV status among inmates is the only condition for HIV prisoners to access antiretroviral drugs and to obtain continuity of care when released [ 31 , 32 ].

Moreover, we found a high proportion of patients with concomitant chronic viral hepatitis caused by HBV in 6. The very high proportion of patients with HCV coinfection could represent a probably unique option to treat these patients. With the introduction of all-oral anti HCV directly-acting antiviral DAA drug combinations that eliminate interferon and its side effects, treatment uptake outside the prison setting is rapidly increasing. The prison setting, with the possibility of DOT also for HCV, could represent a key option in order to obtain HCV eradication and reduce the progression of liver disease for the single patient as well as reducing the chance of transmission inside or, outside prison, after release.

Even in a prison setting, standard-of-care strategies have showed that health outcomes among HIV-infected inmates improve significantly. It is well established that the availability of combination antiretroviral therapy in prison is largely responsible for decreased AIDS-related mortality and morbidity among inmates in the recent years in high-income countries [ 33 — 38 ]. Our study shows that the vast majority of the known HIV-infected inmates were under therapy often taken with daily DOT.

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Nevertheless, several obstacles to HIV treatment in prison still remain. High costs, difficulties in maintaining confidentiality, lack of trust in correctional staff as well as the social dynamics of correctional facilities are all implicated as barriers to HIV treatment, as suggested by our findings. We found that almost two out of three of the treated prisoners were given PI-based regimens compared to nearly one in four who received NNRTIs-based combination. Most patients probably then continue the regimens they receive in the community setting. The choice of PI-based HAART is probably due to the perceived low adherence by the physician in freedom and the high proportion of PI-based schedules is the continuation of ongoing treatment.

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However, when considering organization problems in prison, together with the need to treat prisoners with complex behaviors in a problematic context, caregivers should aim at reducing pill burden and dosing frequency [ 32 , 37 , 39 — 42 ]. The availability of single tablet regimens with good forgiveness can be an option that combines efficacy, safety and low pill burden giving the opportunity to the patients to continue such combinations even after incarceration [ 39 — 49 ].

It is thus mandatory to remember that regimen simplification can be implemented only if the suppression of HIV-RNA is ensured. This data highlights the need for the physician working in prison to be more proactive in convincing patients to start HAART since there is a clear benefit in term of morbidity and mortality reduction [ 36 — 40 ]. The persistence of unprotected sexual relations as well as the injection of drugs without sterile equipment or with needle sharing during incarceration strengthens even more the need to test and treat HIV-infected inmates in order to reduce virus transmission, as observed in other settings [ 53 — 57 ].

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Upon release only approximately two-third of the prisoners were followed up by infectious disease specialists. The loss to follow up of one-third of patients highly stresses the need to integrate HIV prevention and treatment services both outside and within correctional institutions. The integration of care should include access to medical discharge planning and referral to community-based HIV care providers, both being of utmost importance to guarantee continuity of care when inmates are released back into the community [ 58 — 64 ].

Treating HIV-infected inmates poses significant challenges, but there are several obstacles to the proper intake of anti-HIV drugs, not only due to patients. Prison doctors may be wary of managing complicated treatment regimens which often have adverse side effects, especially in high-risk populations such as IVDU. Inadequate prison infrastructures are a significant barrier to implementing comprehensive HIV care in Italy.

Problems occur with patient non compliance, medical contraindications and high medication costs. Finally, inmates may be reluctant to seek testing and treatment because of fear, denial or distrust of the competence of correctional medical staff. HIV treatment in Italian prisons is not uniform and this undermines the ability to provide high-quality care for the inmates infected with HIV.

Diagnostics, treatment and care are offered to the majority of HIV-infected inmates, but the costs of not treating a part of this population could be significantly higher. Prisons should represent an integral part of strategies to slow down the HIV and possibly the HCV epidemic through the successful treatment of infected inmates and missed opportunities for treatment could have negative consequences not only on the incarcerated population, but on society as a whole.

Therefore, nationwide programs, integrated with the National Health System, should be implemented to increase the quality of care in Italian prisons and encourage linkage to care after prison release. Bernasconi del Luca, Lecco; A. Buonomo, La Spezia; A. Chimenti, Massa; E. Conti, Padova; A. De Cicco, Reggio Calabria; V. De Marco, Bari; C. Fiscon, Verona; R. Giglio, Lauro AV ; M.

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Gottardi, Trento; G. Guastini, Terni; F. Guzzo, Belluno; B. Koehler, Viterbo; A. Manunta, Sassari; D. Palermo, Palermo; G. Panico, Carinola CE ; M. Sapienza, Enna; D. Vitucco, Alba CN. Competing interest. The authors declare no conflict of interest regarding the present manuscript. All authors reviewed the manuscript during preparation, provided critical feedback and approved the final manuscript. Monarca, Email: moc.

Madeddu, Email: ti. Ranieri, Email: ti. Carbonara, Email: ti. Leo, Email: ti.

Sardo, Email: ti. Choroma, Email: ti. Casari, Email: ti. Marri, Email: ti. Muredda, Email: ti. Nava, Email: ti. National Center for Biotechnology Information , U. BMC Infect Dis. Published online Dec Monarca , G. Madeddu , R. Ranieri , S.

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