BACKGROUND: People who inject drugs (PWID) experience a high prevalence of incarceration and might be at high risk of HIV and hepatitis C virus (HCV) infection during or after incarceration. We aimed to assess whether incarceration history elevates HIV or HCV acquisition risk among PWID. METHODS: In this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO databases for studies in any language published from Jan 1, 2000 until June 13, 2017 assessing HIV or HCV incidence among PWID. We included studies that measured HIV or HCV incidence among community-recruited PWID. We included only studies reporting original results and excluded studies that evaluated incident infections by self-report. We contacted authors of cohort studies that met the inclusion or exclusion criteria, but that did not report on the outcomes of interest, to request data. We extracted and pooled data from the included studies using random-effects meta-analyses to quantify the associations between recent (past 3, 6, or 12 months or since last follow-up) or past incarceration and HIV or HCV acquisition (primary infection or reinfection) risk among PWID. We assessed the risk of bias of included studies using the Newcastle-Ottawa Scale. Between-study heterogeneity was evaluated using the I2 statistic and the P-value for heterogeneity. FINDINGS: We included published results from 20 studies and unpublished results from 21 studies. These studies originated from Australasia, western and eastern Europe, North and Latin America, and east and southeast Asia. Recent incarceration was associated with an 81% (relative risk [RR] 1·81, 95% CI 1·40-2·34) increase in HIV acquisition risk, with moderate heterogeneity between studies (I2=63·5%; p=0·001), and a 62% (RR 1·62, 95% CI 1·28-2·05) increase in HCV acquisition risk, also with moderate heterogeneity between studies (I2=57·3%; p=0·002). Past incarceration was associated with a 25% increase in HIV (RR 1·25, 95% CI 0·94-1·65) and a 21% increase in HCV (1·21, 1·02-1·43) acquisition risk. INTERPRETATION: Incarceration is associated with substantial short-term increases in HIV and HCV acquisition risk among PWID and could be a significant driver of HCV and HIV transmission among PWID. These findings support the need for developing novel interventions to minimise the risk of HCV and HIV acquisition, including addressing structural risks associated with drug laws and excessive incarceration of PWID. FUNDING: Engineering and Physical Sciences Research Council, National Institute for Health Research, National Institutes of Health.

BC Centre for Excellence in HIV AIDS and Division of AIDS Faculty of Medicine University of British Columbia Vancouver BC Canada

Burnet Institute Melbourne VIC Australia

Burnet Institute Melbourne VIC Australia; Department of Epidemiology and Preventive Medicine Monash University Melbourne VIC Australia

Burnet Institute Melbourne VIC Australia; Department of Medicine University of Melbourne Melbourne VIC Australia

Center on Drug and Alcohol Research University of Kentucky KY USA

Centre hospitalier de l'Université de Montreal Montréal QC Canada

Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD USA

Department of Epidemiology University of Kentucky College of Public Health KY USA; Center on Drug and Alcohol Research University of Kentucky KY USA

Department of Family Medicine Université de Montréal Montréal QC Canada; Centre hospitalier de l'Université de Montreal Montréal QC Canada

Division of Infectious Diseases and Global Public Health University of California San Diego La Jolla CA USA

Faculty of Public Health and Policy London School of Hygiene and Tropical Medicine London UK

Infectious Diseases AIDS and Clinical Immunology Research Center Tbilisi Georgia

Infectious Diseases AIDS and Clinical Immunology Research Center Tbilisi Georgia; Faculty of Medicine Tbilisi State University Tbilisi Georgia

International Charitable Foundation Alliance for Public Health Kiev Ukraine

James P Grant School of Public Health BRAC University Dhaka Bangladesh

Kirby Institute for Infection and Immunity Faculty of Medicine University of New South Wales Sydney NSW Australia

National Infection Service Public Health England London UK

National Institute of Public Health of Québec QC Canada; Faculty of Medicine and Health Sciences University of Sherbrooke Longueuil QC Canada

National Monitoring Centre for Drugs and Addiction Prague Czech Republic; Department of Addictology The 1st Medical Faculty Charles University and General University Hospital Prague Prague Czech Republic; National Institute of Mental Health Klecany Czech Republic

Population Health Sciences Bristol Medical School University of Bristol Bristol UK

Population Health Sciences Bristol Medical School University of Bristol Bristol UK; Division of Infectious Diseases and Global Public Health University of California San Diego La Jolla CA USA

Public Health Institute Liverpool John Moores University Liverpool UK; National Infection Service Public Health England London UK

School of Health and Life Sciences Glasgow Caledonian University Glasgow UK

School of Health and Life Sciences Glasgow Caledonian University Glasgow UK; Health Protection Scotland National Health Service National Services Scotland Glasgow UK

Section of Infectious Diseases Taipei City Hospital Taipei City Government Taipei Taiwan

University Hospital Centre of Québec Research Centre Laval University QC Canada; National Institute of Public Health of Québec QC Canada

Yale School of Medicine Department of Medicine Section of Infectious Diseases AIDS Program New Haven CT USA

Comment In

Lancet Infect Dis. 2018 Dec;18(12):1301-1302. doi: 10.1016/S1473-3099(18)30538-3. PubMed

Comment In

Lancet Infect Dis. 2019 Feb;19(2):130-131. doi: 10.1016/S1473-3099(18)30801-6. PubMed

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