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HIV treatment and care among Italian inmates: a one-month point survey



HIV infection, with an estimated prevalence be between 2 and 50 times those of the general adult population is a major health challenge for prison authorities worldwide. Since no nationwide surveillance system is present in Italy, data on HIV prevalence and treatment in prisons are limited to only a few and small observational studies. We aimed to estimate HIV prevalence and obtain an overview on diagnostic and therapeutic activities concerning HIV infection in the Italian penitentiary system.


We piloted a multi-centre cross-sectional study investigating the prevalence of HIV infection and assessing HIV-related medical activities in Italian correctional institutions.


A total of 15,675 prisoners from 25 institutions, accounting for approximately one-fourth of the prison inmates in Italy, were included in the study, of whom, 97.7 % were males, 37.1 % foreigners and 27 % had a history of intravenous drug addiction. HIV-tests were available in 42.3 % of the total population, with a known HIV Infection proportion of 5.1 %. In the month prior to the study, 604 of the 1,764 subjects who entered prison were tested for HIV, with a HIV-positive prevalence of 3.3 %. Among the 338 HIV-positive prisoners, 81.4 % were under antiretroviral treatment and 73.5 % showed undetectable HIV-RNA. In 23/338 (6.8 %) a coinfection with HBV and in 189/338 (55.9 %) with HCV was also present. Among the 67 (19.8 %) inmates with HIV who did not receive HIV treatment, 13 (19.5 %) had T-CD4+ count <350 cells/mm3 and 9 (69.2 %) of these had refused the treatment. The majority of the inmates with HIV-infection were on a PI-based (62.5 %) or on NNRTIs-based (24.4 %) regimen. Only a minority of patients received once daily regimens (17.2 %).


Although clinical and therapeutic management of HIV infection remains difficult in Italian prisons, diagnostics, treatment and care were offered to the majority of HIV-infected inmates. Specific programs should be directed towards the prison population and strict cooperation between prison and health institutions is needed to increase HIV treatment.

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HIV is a major health challenge for prison authorities worldwide. HIV prevalence within prisons is estimated to be between 2 and 50 times those of general adult populations. Available studies show an HIV prevalence ranging from 0.6 % in the UK to 6 % in Spain and 7.2 % in Italy [17].

In Italy measures promoting HIV prevention and control are listed among the health objectives that must be guaranteed to the prison population. HIV tests cannot take place without the consent of the person concerned and may be recommended but not imposed on inmates who display high risk behaviors. Detainees should be informed with all relevant information concerning HIV prevention. Counselling, treatment, care and support services should be part of a comprehensive HIV program aimed at improving health care in prison and at making it equivalent to that available in the community [810]. Nowadays, however, these objectives are largely unmet due to the limitations of the Italian penitentiary system, such as severe budget constraints leading to under-resourced prison settings, prison overcrowding, poor condition of the existing health facilities, undertrained and underpaid prison staffing, frequent inmate transfer between prisons or prison wings, court attendance and hospital visits, lack of a national correctional healthcare database and especially the low offering and execution of HIV screening [911].

Moreover, the data on treatment of HIV infection in prisons are limited to only a few observational studies, thus undermining current policy for improving prison health care system [1014].

The aims of this study were firstly, to evaluate the prevalence of HIV infection among new entry inmates, secondly, to evaluate the number of HIV infected inmates who were actually treated and thirdly to describe the antiretroviral treatments offered and report the reasons for lack of treatment.


A multi-centre cross-sectional survey was carried out from 1 to 30 July 2013 to investigate the prevalence of HIV infection and to assess HIV-related diagnostic and therapeutic activities in Italian correctional institutions. The prevalence of HIV infection was estimated in the imprisoned population on July 31, 2013. Data on HIV testing was evaluated both in the entire prison population and in the prison entrants during the study period. A questionnaire was emailed to the 206 Italian prisons and was voluntarily completed by health professionals based in the prison establishments using information in medical records. The following data was recorded only for inmates who were present during the study period: general data (sex, ethnicity and drug use), HIV data (HIV testing, viro-immunological profile, visit schedule), HIV treatment data (setting, method, frequency of drug dispensation, type of antiretrovirals used, medication refusal). Returned surveys were collected and consolidated using build-in functions of Microsoft Excel. Where gaps in the questionnaire data remained, prison administrative bodies and experts were contacted via e-mail or telephone and requests for specific information were made.

All studies regarding the Italian Penitentiary System have been nationally approved by the Ethics Committee of the University of Rome Tor Vergata (Registro Sperimentazioni 73/05). No specific consent was required since data were collected in anonymous and aggregate form.

Statistical analysis

Data was analyzed using the SPSS statistical software, version 6.0. Results are expressed as proportions. When applicable, a two-tailed hypothesis testing for difference in proportions was used (Proportion Test); a p value of <0.05 was considered significant.


Prison population in Italy

On 31 July 2013 Italian prisons counted 64,873 detainees, almost one per 1,000 inhabitants. Foreign detainees were 22,744. It is worth noting that foreign prisoners had more than doubled between 1990 (15 %) and 2013 (35 %). At the time of the study, Italy’s prisons were the most crowded in the European Union with occupancy at more than 142 % of capacity.

Survey population

On July 31, a total of 15,675 prisoners (15,318 males and 357 females) were included in the survey, accounting for 24.2 % of the total Italian inmates. Thirty-five of the 206 correctional institutions in Italy from 16 of the 20 Italian regions voluntarily answered the questionnaire: 12 in Northern Italy (n = 6,527 inmates), 11 in Central Italy (n = 3,846 inmates) and 12 in Southern Italy (n = 5,302 inmates). The number of prisoners included in the survey ranged from 7.8 % to 69.1 % according to geographical area. Overall, the institutes in Northern Italy accounted for nearly one-third (32.7 %) of the prisoners included in the survey, compared with 21.5 % in Central Italy and 22.7 % in Southern Italy. During the month prior to the survey 1,764 adults were imprisoned. Table 1 shows the characteristics of inmates entered into the study, according to Italian region. The majority of prisoners were men (97.7 %) with native born Italians accounting for 62.9 % of inmates and foreigners 37.1 % (range 2.0 % - 88.0 %). The vast majority of foreign prisoners included individuals from Morocco (19.0 %), Romania (15.8 %), Albania (12.5 %), Tunisia (12.1 %), Nigeria (4.2 %), Algeria (2.6 %), Egypt (2.0 %) and Senegal (1.8 %). Just under one-third of prison inmates (27.0 %) had a history of heroin or cocaine misuse.

Table 1 Total population, number, gender, drug history and foreigners of inmates participating in the survey according to correctional facility region
Table 2 Antiretroviral regimens received by the 275 HIV-infected inmates on ART

HIV and other infectious diseases testing

Among the participating penitentiary institutions, 35/35 (100 %) performed screening tests for HIV, HBV and HCV, 27/35 (77.1 %) for tuberculosis and 31/35 (88.6 %) for syphilis.

A voluntary HIV screening, as part of routine clinical evaluations, was available in 6,630 (42.3 %) of the total population at the time of the study and 338 (5.1 %), 330 (97.6 %) males and 8 (2.4 %) females, of these inmates were HIV-infected. Among the 338 HIV-infected inmates 266/338 (78.7 %) were Italian, 72/338 (21.3 %) were foreigners, 23/338 (6.8 %) were also HBsAg-positive and 189/388 (55.9 %) had anti-HCV antibodies.

Regarding risk factors for HIV infection, 175/338 (51.7 %) reported being intravenous drug users (IVDU), 16/338 (4.7 %) were men having sex with men (MSM) and 147/338 (43.5 %) declared sexual contact risk. Furthermore, 85/163 (52.1 %) of non IVDU reported tattooing or body piercing with unsterile equipment. When considering only the 72 HIV-infected foreigners, 49/72 (68.0 %) reported being IVDU, 20/72 (27.8 %) were heterosexuals and 3/72 (4.2 %) were MSM.

When considering only the 1,764 subjects incarcerated during the month prior to the survey, HIV-test was offered to 1,338 (75.8 %) at prison entry and 604 (45.1 %) of these accepted to be tested, 417 (31.2 %) refused, 276 (20.6 %) were waiting for the results and 41 (3.1 %) were not tested due to their release. Among the 604 tested inmates, 20 (3.3 %) were HIV-Ab positive.

Viro-immunological characteristics of treated patients

All the institutions provided information regarding access to viro-immunological parameters while in prison. Viral load measurement was performed in all of them, lymphocytes subsets immunophenotyping in 94.3 % and genotypic testing for HIV in 74.3 %.

An evaluation of the clinical data of 338 HIV-infected inmates, showed that 81.4 % were receiving an antiretroviral treatment (ART) and that 73.5 % showed an undetectable HIV-RNA (<50 copies/mL).

Fewer than 10 % of the detained patients on therapy, had CD4 lymphocyte counts below 200/mm3 (9.4 %), 18.2 % had between 200/mm3 and 349/mm3, 32.0 % between 350/mm3 and 500/mm3, and 36.4 % above 500/mm3. CD4 lymphocyte count was not available in 4 % of the inmates. By contrast, among the 67 inmates (19.8 %) who were not on ART, less than 5 % of the prisoners had CD4 lymphocyte counts below 200/mm3 (4.5 %), 15.0 % between 200/mm3 and 349/mm3, 10.4 % between 350/mm3 and 500/mm3, and 70.1 % had CD4 above 500/mm3. CD4 lymphocyte count was not available for 4 % of these patients.

HIV treatment and care

The majority of known HIV-positive inmates (275/338; 81.4 %) were receiving antiretroviral treatment at the time of the study. Of them, 172/275 (62.5 %) were receiving a protease inhibitor (PI)-based ART, 72 (21.0 %) a non-nucleoside reverse transcriptase inhibitors (NNRTIs)-based ART and 27 (9.8 %) raltegravir as an integrase inhibitor-based ART. The difference in the proportion of patients treated patients with PI-based regimens compared to those receiving NNRTIs-based regimens was statistically significant (p < 0.005).

PI-based antiretroviral regimens included atazanavir in 88 (32.0 %) patients, lopinavir (18.5 %) in 51, darunavir in 23 (8.4 %), fosamprenavir in 9 (3.3 %) and saquinavir in 1 (0.4 %), as shown in Table 2.

NNRTI-based ART regimens included efavirenz in 50 (18.2 %) patients, nevirapine in 9 (3.3 %), rilpivirine in 8 (2.9 %), and etravirine in 5 (1.8 %). In 41/50 (82 %) patients efavirenz was included in the efavirenz-tenofovirdisoproxilfumarate-emtricitabine co-formulation and in 6/8 (75 %) rilpivirine was part of the rilpivirine-tenofovirdisoproxilfumarate-emtricitabine co-formulation (Table 2).

The backbone in the 275 HIV-positive inmates consisted of 194 (70.5 %) tenofovirdisoproxilfumarate-emtricitabine, 41 (14.9 %) abacavir-lamivudine, 12 lamivudine-zidovudine (4.4 %), and 28 (10.2 %) other NRTI combinations (Table 2).

The medical visit schedule was on weekly basis in 4.3 % of prisoners under ART, on monthly basis in 32.9 %, on quarterly basis in 51.4 % and every 6 months in 11.4 %.

All the correctional institutes had medical facilities able to dispense antiretroviral drugs. Lack of HIV treatment in prisoners with CD4 lymphocyte count < 350/mm3 was due to medication refusal (69.2 %), ongoing medical assessment (23.1 %) and other reasons including fear of side effects, cultural or ethnic beliefs, depression or delusional state (7.7 %).

Medication dispensing by nurse practitioners to those who were under ART occurred in prison (70 %) or at the medical unit (30 %). The methods for dispensing medications were: daily directly observed therapy (DOT, 42.8 %), keep-on-person (KOP, 31.4 %) with daily delivery and a mixed combination (25.7 %). Frequency of dispensing was once a day (17.2 %), twice a day (31.4 %) or ≥ 3 times a day (51.4 %). Once a day regimens were perceived to facilitate DOT by a majority (65.7 %) of the healthcare staff with only 25.7 % considering these regimens useless to DOT.

After prison release, nearly two-thirds (66.4 %) of the prisoners were followed up by infectious disease specialists.


This study was designed to provide a current picture of HIV prevalence, treatment and care in the Italian prison population.

The lack of a comprehensive surveillance system makes it difficult to estimate the prevalence of HIV-infected inmates in the Italian correctional system. Published prevalence data are usually taken from studies conducted on small numbers of prisons or in single regions, this hampering the achievement of definite data. Likewise, little is known about treatment of HIV among inmates [7, 10, 11, 14]. Medical assistance to HIV-infected individuals is a relevant issue in the community of inmates and treatment monitoring is essential to guarantee an appropriate use of antiretroviral drugs and high quality patient care [7, 10, 1518]. Point-prevalence studies based on existing medical data in correctional institutes could help to better understand the spread of HIV as well as elaborate successful prevention and care strategies.

Although our findings are limited by the partial participation of the Italian penal institutes, they contribute to improve our knowledge on HIV infection, treatment and care among HIV-patients detained in Italy. In fact, with more than 15,000 inmates in 35 prisons distributed all over the country, our investigation includes nearly one-quarter of those incarcerated in Italy, with 27.0 % being IVDU and 37.1 % being foreigners at the time of the study.

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.

Despite the low rate of HIV testing identified in our study and the well-known difficulty in inmate patients to admit their disease condition, we found an HIV prevalence above 5 % which is more than 12 times higher than in the general Italian population [19, 20].

This discrepancy was also confirmed in newly admitted prisoners (HIV testing rate 34.2 %, HIV prevalence 3.3 %) and underline that prisons are concentrators of infectious diseases, due also to higher risk behaviours in acquiring blood born viruses (BBV) in people likely to be incarcerated. In our study we show an high rate of IVDU and tattoing/body piercing among both Italian and foreign BBV-infected inmates. For these reasons, the imprisonment period should be considered as an opportunity to treat a hard-to-reach population in freedom [2127]. 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 37.1 % of prisoners, the vast majority coming from low and middle-income countries where the health burden imposed by HIV is further exacerbated by poor socioeconomic conditions, the high prevalence of opportunistic infections, poor access to health care, and widespread drug circulation and abuse. 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 [2832]. 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 6.8 % and by HCV in 55.9 %. Patients with HBV coinfection should start antiretroviral therapy active also against HBV. 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. Some of these combination regimens have achieved sustained virologic response (SVR) in more than 90 % of some subgroups in clinical trials, including null responders to prior interferon-based treatment [33, 34]. Current evidence suggest that HIV/HCV co-infected can achieve the same percentage of response as HCV mono-infected [35]. 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 [3338]. Our study shows that the vast majority of the known HIV-infected inmates were under therapy often taken with daily DOT. Successful HIV suppression was shown in over 72 % of treated patients who had an undetectable HIV-RNA. 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. 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, 3942]. 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 [3949]. It is thus mandatory to remember that regimen simplification can be implemented only if the suppression of HIV-RNA is ensured. Simplification can be a useful approach not only to reach successful viro-immunological outcomes among prisoners under HIV treatment, but also to improve the patient’s quality of life, maintain long-term adherence, avoid toxicities that may develop with prolonged ART and reduce the risk of virologic failure [5052].

Although we found that over 80 % of HIV-infected inmates were treated for HIV with more than 70 % with undetectable viral load in the Italian correctional institutes, this finding does not account for the needs of infected unaware prisoners. Nearly 67 % of patients not receiving HAART at the time of the study had a CD4 cell count <350 cells/mm3, which represents the recognized threshold for therapy initiation in all international guidelines. 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 [3640]. 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 [5357].

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 [5864].

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.



Società Italiana Malattie e Sanità Penitenziaria


Società Italiana di Malattie Infettive e Tropicali


human immune deficiency virus


non nucleoside reverse transcriptase inhibitor


nucleoside reverse transcriptase inhibitors


Protease inhibitor


Hepatitis B Virus


Hepatitis C Virus


antiretroviral therapy


daily directly observed therapy


Keep-on-person therapy


intravenous drug users


directly-acting antiviral


sustained virologic response


acquired immune deficiency syndrome


  1. Semaille C, Le Strat Y, Chiron E, Chemlal K, Valantin MA, Serre P, et al. Prevalence of human immunodeficiency virus and hepatitis C virus among French prison inmates in 2010: a challenge for public health policy. Euro Surveillance 2013; 18 (28).

  2. Fazel S, Baillargeon J. The health of prisoners. Lancet. 2011;377(9769):956–65.

    Article  PubMed  Google Scholar 

  3. Dolan K, Kite B, Black E, Aceijas C, Stimson GV. HIV in prison in low-income and middle-income countries. Lancet Infect Dis. 2007;7(1):32–41.

    Article  PubMed  Google Scholar 

  4. Rotily M, Weilandt C, Bird SM, Kall K, Van Haastrecht HJ, Iandolo E, et al. Surveillance of HIV infection and related risk behaviour in European prisons. A multicentre pilot study. Eur J Public Health. 2001;11(3):243–50.

    Article  CAS  PubMed  Google Scholar 

  5. Marco A, Saiz de la Hoya P, García-Guerrero J, Grupo PREVALHEP. Multi-centre study of the prevalence of infection from HIV and associated factors in Spanish prisons. Rev Esp Sanid Penit. 2012;14(1):19–27.

    Article  CAS  PubMed  Google Scholar 

  6. Chan S, Marsh K, Lau R, Pakianathan M, Hughes G. An audit of HIV care in English prisons. Int J STD AIDS. 2015;26:504–8.

    Article  CAS  PubMed  Google Scholar 

  7. Sagnelli E, Starnini G, Sagnelli C, Monarca R, Zumbo G, Pontali E, et al. Blood born viral infections, sexually transmitted diseases and latent tuberculosis in Italian prisons: a preliminary report of a large multicenter study. Eur Rev Med Pharmacol Sci. 2012;16(15):2142–6.

    CAS  PubMed  Google Scholar 

  8. Westergaard RP, Spaulding AC, Flanigan TP. HIV among persons incarcerated in the USA: a review of evolving concepts in testing, treatment, and linkage to community care. Curr Opin Infect Dis. 2013;26(1):10-6. doi: 10.1097/QCO.0b013e32835c1dd0.

  9. Sordo del Castillo L, RuizPérez I, OlryLabry de Lima A, SotoBlanco JM, AntónBasanta JJ, Girela López E, et al. Factors related to refuse antiretroviral therapy in prison. Gac Sanit. 2008;22(2):120–7.

    Article  PubMed  Google Scholar 

  10. Babudieri S, Starnini G, Brunetti B, Carbonara S, D’Offizi GP, Monarca R, et al. HIV and related infections in Italian penal institutions: epidemiological and health organization note. Annali Istituto Superiore di Sanità. 2003;39(2):251–7.

    Google Scholar 

  11. Dell’Isola S, Caturelli E, Ialungo A, Rastrelli E, Liguori E, Starnini G. Detention and incompatibility of HIV patients in Italy. Annali Istituto Superiore di Sanità. 2013;49(4):332–3.

    Google Scholar 

  12. Springer SA, Altice FL. Managing HIV/AIDS in correctional settings. Curr HIV/AIDS Rep. 2005;2(4):165–70.

    Article  PubMed  Google Scholar 

  13. Meyer JP, Cepeda J, Wu J, Trestman RL, Altice FL, Springer SA. Optimization of human immunodeficiency virus treatment during incarceration: viral suppression at the prison gate. JAMA Intern Med. 2014;174(5):721–9.

    Article  PubMed Central  PubMed  Google Scholar 

  14. Pontali E. Antiretroviral treatment in correctionalfacilities. HIV Clinical Trials. 2005;6(1):25–37.

    Article  PubMed  Google Scholar 

  15. Zaller N, Thurmond P, Rich JD. Limited spending: an analysis of correctional expenditures on antiretrovirals for HIV-infected prisoners. Public Health Rep. 2007;122(1):49–54.

    PubMed Central  PubMed  Google Scholar 

  16. Springer SA, Friedland GH, Doros G, Pesanti E, Altice FL. Antiretroviral treatment regimen outcomes among HIV-infected prisoners. HIV Clin Trials. 2007;8(4):205–12.

    Article  PubMed Central  PubMed  Google Scholar 

  17. Babudieri S, Longo B, Sarmati L, Starnini G, Dori L, Suligoi B, et al. Correlates of HIV, HBV, and HCV infections in a prison inmate population: results from a multicentre study in Italy. J Med Virol. 2005;76:311–7.

    Article  CAS  PubMed  Google Scholar 

  18. Esposito M. The health of Italian prison inmates today: a critical approach. J Correct Health Care. 2010;16(3):230–8.

    Article  PubMed  Google Scholar 

  19. Global report: UNAIDS report on the global AIDS epidemic 2012. Available at: Accessed 9 Dec 2015.

  20. Camoni L, Regine V, Stanecki K, Salfa MC, Raimondo M, Suligoi B. Estimates of the number of people living with HIV in Italy. Bio Med Res Int. 2014;2014:209619. doi:10.1155/2014/209619.

    Google Scholar 

  21. Bollini P, Laporte JD, Harding TW. HIV prevention in prisons. Do international guidelines matter ? Eur J Public Health. 2002;12:83–9.

    Article  PubMed  Google Scholar 

  22. European Centre for Disease Prevention and Control. Thematic report: Prisoners. Monitoring implementation of the Dublin Declaration on Partnership to Fight HIV/AIDS in Europe and Central Asia: 2012 Progress Report. Stockholm: ECDC; 2013.

    Google Scholar 

  23. Dipartimento dell'amministrazione penitenziaria. Ufficio per lo sviluppo e la gestione del sistema informativo automatizzato statistica ed automazione di supporto dipartimentale. Sezione Statistica. Available at: Accessed 9 Dec 2015.

  24. Beckwith C, Bazerman L, Gillani F, Tran L, Larson B, Rivard S, et al. The feasibility of implementing the HIV seek, test, and treat strategy in jails. AIDS Patient Care STDS. 2014;28(4):183–7.

    Article  PubMed Central  PubMed  Google Scholar 

  25. Shrestha RK, Sansom SL, Richardson-Moore A, French PT, Scalco B, Lalota M, et al. Costs of voluntary rapid HIV testing and counseling in jails in 4 states--advancing HIV Prevention Demonstration Project, 2003-2006. Sex Transm Dis. 2009;36(2):S5-8.

  26. Bauserman RL, Richardson D, Ward M, Shea M, Bowlin C, Tomoyasu N, et al. Increasing voluntary HIV testing by offering oral tests in incarcerated populations. AIDS Educ Prev. 2003;15(5):465–80.

    Article  PubMed  Google Scholar 

  27. Centers for Disease Control and Prevention. HIV testing implementation guidance for correctional settings. Atlanta: Centers for Disease Control and Prevention; 2009;1-38.

  28. Beckwith CG, Cohen J, Shannon C, Raz L, Rich JD, Lally MA. HIV testing experiences among male and female inmates in Rhode Island. AIDS Read. 2007;17(9):459-64.

  29. Belenko S, Hiller M, Visher C, Copenhaver M, O'Connell D, Burdon W, et al. Policies and practices in the delivery of HIV services in correctional agencies and facilities: results from a multisite survey. J Correct Health Care. 2013;19(4):293–310.

    Article  PubMed Central  PubMed  Google Scholar 

  30. CDC. HIV testing implementation guidance for correctional settings. Atlanta, GA: US Department of Health and Human Services, CDC; 2009.

    Google Scholar 

  31. Desai AA, Latt AT, Spaulding A, Rich JD, Flanigan TP. The importance of routine HIV testing in the incarcerated population: the Rhode Island experience. AIDS Educ Prev. 2002;14(5 Suppl B):45–52.

    Article  PubMed  Google Scholar 

  32. Beckwith CG, Zaller ND, Fu JJ, Montague BT, Rich JD. Opportunities to diagnose, treat, and prevent HIV in the criminal justice system. J Acquir Immune Defic Syndr. 2010;55(1):49–55.

    Article  Google Scholar 

  33. Lawitz E, Sulkowski MS, Ghalib R, Rodriguez-Torres M, Younossi ZM, Corregidor A, et al. Simeprevir plus sofosbuvir, with orwithout ribavirin, to treat chronic infection with hepatitis C virus genotype 1in non-responders to pegylated interferon and ribavirin and treatment-naïve patients: the COSMOS randomised study. Lancet. 2014;384(9956):1756–65.

    Article  CAS  PubMed  Google Scholar 

  34. Sulkowski MS, Gardiner DF, Rodriguez-Torres M, Reddy KR, Hassanein T, Jacobson I, et al. Daclatasvirplus sofosbuvir for previously treated or untreated chronic HCV infection. N Engl J Med. 2014;370(3):211–21.

    Article  CAS  PubMed  Google Scholar 

  35. Sulkowski MS, Naggie S, Lalezari J, Fessel WJ, Mounzer K, Shuhart M, et al. Sofosbuvir and ribavirin for hepatitis C in patients with HIV coinfection. JAMA. 2014;312(4):353–61.

    Article  PubMed  Google Scholar 

  36. Flanigan TP, Zaller N, Beckwith CG, Bazerman LB, Rana A, Gardner A, et al. Testing for HIV, sexually transmitted infections, and viral hepatitis in jails: still amissed opportunity for public health and HIV prevention. J Acquir Immune Defic Syndr. 2010;55 suppl 2:S78–83.

    Article  PubMed  Google Scholar 

  37. Springer SA, Spaulding AC, Meyer JP, Altice FL. Public health implications for adequate transitional care for HIV-infected prisoners: five essential components. Clin Infect Dis. 2011;53(5):469–79.

    Article  PubMed Central  PubMed  Google Scholar 

  38. Marco A. Evolution of the prison population mortality after introduction antiretroviraltherapy. Rev Esp Salud Publica. 2011;85(3):233–6.

    Article  PubMed  Google Scholar 

  39. Solomon L, Montague BT, Beckwith CG, Baillargeon J, Costa M, Dumont D, et al. Survey finds that many prisons and jails have room to improve HIV testing and coordination of postrelease treatment. Health Aff (Millwood). 2014;33(3):434–42.

    Article  Google Scholar 

  40. Spaulding AC, Booker CA, Freeman SH, Ball SW, Stein MS, Jordan AO, et al. Jails, HIV testing, and linkage to care services: an overview of the EnhanceLink initiative. AIDS Behav. 2013;17(2):S100–7.

    Article  PubMed  Google Scholar 

  41. Saber-Tehrani AS, Springer SA, Qiu J, Herme M, Wickersham J, Altice FL. Rationale, study design and sample characteristics of a randomized controlled trial of directly administered antiretroviral therapy for HIV-infected prisoners transitioning to the community—a potential conduit to improved HIV treatment outcomes. Contemp Clin Trials. 2012;33(2):436–44.

    Article  PubMed  Google Scholar 

  42. Babudieri S, Aceti A, D’Offizi GP, Carbonara S, Starnini G. Directly observed therapy to treat HIV infection in prisoners. JAMA. 2000;284(2):179–80.

    Article  CAS  PubMed  Google Scholar 

  43. Wohl DA, Stephenson BL, Golin CE, Kiziah CN, Rosen D, Ngo B, et al. Adherence to directly observed antiretroviral therapy among human immunodeficiency virus-infected prison inmates. Clin Infect Dis. 2003;36(12):1572–6.

    Article  PubMed  Google Scholar 

  44. Saberi P, Caswell NH, Jamison R, Estes M, Tulsky JP. Directly observed versus self-administered antiretroviral therapies: preference of HIV-positive jailed inmates in San Francisco. J Urban Health. 2012;89(5):794–801.

    Article  PubMed Central  PubMed  Google Scholar 

  45. Wohl DA, Cohen C, Gallant JE, Mills A, Sax PE, Dejesus E, et al. A Randomized, Double-Blind Comparison of Single-Tablet Regimen Elvitegravir/Cobicistat/Emtricitabine/Tenofovir DF Versus Single-Tablet Regimen Efavirenz/Emtricitabine/Tenofovir DF for Initial Treatment of HIV-1 Infection: Analysis of Week 144 Results. J Acquir Immune Defic Syndr. 2014;65(3):e118–20.

    Article  PubMed  Google Scholar 

  46. Clumeck N, Molina JM, Henry K, Gathe J, Rockstroh JK, Dejesus E, et al. A Randomized, Double-blind Comparison ofSingle-Tablet Regimen Elvitegravir/Cobicistat/Emtricitabine/Tenofovir DF vsRitonavir-Boosted Atazanavir Plus Emtricitabine/Tenofovir DF for InitialTreatment of HIV-1 Infection: Analysis of Week 144 Results. J Acquir Immune Defic Syndr. 2014;65(3):e121–4.

    Article  PubMed  Google Scholar 

  47. Molina JM, Cahn P, Grinsztejn B, Lazzarin A, Mills A, Saag M, et al. Rilpivirine versus efavirenz with tenofovir and emtricitabine in treatment-naive adults infected with HIV-1 (ECHO): a phase 3 randomised double-blind active-controlled trial. Lancet. 2011;378(9787):238–46.

    Article  CAS  PubMed  Google Scholar 

  48. Vitoria M, Ford N, Doherty M, Flexner C. Simplification of antiretroviraltherapy: a necessary step in the public health response to HIV/AIDS in resource-limited settings. Antivir Ther. 2014;19(3):31–7.

    Article  CAS  PubMed  Google Scholar 

  49. Astuti N, Maggiolo F. Single-Tablet Regimens in HIV Therapy. Infect Dis Ther. 2014;3(1):1–17.

    Article  PubMed Central  PubMed  Google Scholar 

  50. Bangsberg DR, Ragland K, Monk A, Deeks SG. A single tablet regimen is associated with higher adherence and viral suppression than multiple tablet regimens in HIV+ homeless and marginally housed people. AIDS. 2010;24(18):2835–40.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  51. Maggiolo F, Ripamonti D, Arici C, Gregis G, Quinzan G, Camacho GA, et al. Simpler regimens may enhance adherence to antiretrovirals in HIV-infected patients. HIV Clin Trials. 2002;3:371–8.

    Article  PubMed  Google Scholar 

  52. Parienti JJ, Bangsberg DR, Verdon R, Gardner EM. Better adherence with once-daily antiretroviral regimens: a meta-analysis. Clin Infect Dis. 2009;48(4):484–8.

    Article  PubMed Central  PubMed  Google Scholar 

  53. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493–505.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  54. Ravlija J, Vasilj I, Marijanović I, Vasilj M. Risk behaviour of prison inmates in relation to HIV/STI. Psychiatr Danub. 2014;26(2):395–401.

    PubMed  Google Scholar 

  55. Lyons T, Osunkoya E, Anguh I, Adefuye A, Balogun J. HIVprevention and education in state prison systems: an update. J Correct Health Care. 2014;20(2):105–15.

    Article  PubMed  Google Scholar 

  56. Beckwith C, Bazerman L, Gillani F, Tran L, Larson B, Rivard S, et al. The feasibility of implementing the HIV seek, test, and treat strategy in jails. AIDS Patient Care STDS. 2014;28(4):183–7.

    Article  PubMed Central  PubMed  Google Scholar 

  57. Farel CE, Parker SD, Muessig KE, Grodensky CA, Jones C, Golin CE, et al. Sexuality, sexual practices and HIV risk among incarcerated African-American women in North Carolina. Womens Health Issues. 2013;23(6):357–64.

    Article  Google Scholar 

  58. Binswanger IA, Stern MF, Deyo RA, Heagerty PJ, Cheadle A, Elmore JG, et al. Release from prison - a high risk of death for former inmates. N Engl J Med. 2007;356(2):157–65.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  59. Baillargeon J, Giordano TP, Rich JD, Wu ZH, Wells K, Pollock BH, et al. Accessing antiretroviral therapy following release from prison. JAMA. 2009;301(8):848–57.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  60. Lincoln T, Kennedy S, Tuthill R, Roberts C, Conklin TJ, Hammett TM. Facilitators and barriers to continuing healthcare after jail: a community-integrated program. J Ambul Care Manage. 2006;29(1):2–16.

    Article  PubMed  Google Scholar 

  61. Palepu A, Tyndall MW, Chan K, Wood E, Montaner JS, Hogg RS. Initiating highly active antiretroviral therapy and continuity of HIV care: the impact of incarceration and prison release on adherence and HIV treatment outcomes. Antivir Ther. 2004;9(5):713–9.

    PubMed  Google Scholar 

  62. Stephenson BL, Wohl DA, Golin CE, Tien HC, Stewart P, Kaplan AH. Effect of release from prison and re-incarceration on the viral loads of HIV-infected individuals. Public Health Rep. 2005;120(1):84–8.

    PubMed Central  PubMed  Google Scholar 

  63. Nunn A, Cornwall A, Fu J, Bazerman L, Loewenthal H, Beckwith C. Linking HIV-positive jail inmates to treatment, care, and social services after release: results from a qualitative assessment of the COMPASS Program. J Urban Health. 2010;87(6):954–68.

    Article  PubMed Central  PubMed  Google Scholar 

  64. Baillargeon JG, Giordano TP, Harzke AJ, Baillargeon G, Rich JD, Paar DP. Enrollment in outpatient care among newly released prison inmates with HIV infection. Public Health Rep. 2010;125(1):64–71.

    PubMed Central  PubMed  Google Scholar 

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The SIMSPe–SIMIT Group includes the following members: D. Bernasconi del Luca, Lecco; A. Buonomo, La Spezia; A. Casadei, Forlì; M. Chimenti, Massa; E. Conti, Padova; A. De Cicco, Reggio Calabria; V. De Marco, Bari; C. Di Filippo, Sant’Angelo dei Lombardi (AV); M. Fiscon, Verona; R. Giglio, Lauro (AV); M. Gottardi, Trento; G. Greco, Rossano Calabro (CS); L. 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).

We thank Secretariat of the Italian Society of Infectious and Tropical Diseases (SIMIT), for having organized data collection from 35 Italian correctional facilities participants to the study.

Thanks also to Riccardo Raiteri, for his valuable collaboration on data organization.

No funding have been received for the present study.

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Correspondence to S. Babudieri.

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The authors declare no conflict of interest regarding the present manuscript.

Authors’ contribution

RM, GM and SB contributed to study design, data analyses and interpretation and article writing; RR and SCar contributed to interpretation of data and article writing; GL, MS, FC, SCas, DM, AAM and FAN contributed to data collection; RM and SB coordinated the project. All authors reviewed the manuscript during preparation, provided critical feedback and approved the final manuscript.

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Monarca, R., Madeddu, G., Ranieri, R. et al. HIV treatment and care among Italian inmates: a one-month point survey. BMC Infect Dis 15, 562 (2015).

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