Research
Prevalence of HIV and hepatitis C virus infections
among inmates of Quebec provincial prisons
Céline Poulin MSc, Michel Alary MD PhD, Gilles Lambert MD, Gaston Godin PhD,
Suzanne Landry MA, Hélène Gagnon MA, Éric Demers MSc, Elena Morarescu MD MSc,
Jean Rochefort MSc, Christiane Claessens MSc
@

See related articles pages 257 and 262

Abstract
Background: To determine the prevalence of HIV and hepatitis C virus (HCV) infections and examine risk factors for these
infections among inmates in Quebec provincial prisons.
Methods: Anonymous cross-sectional data were collected from
January to June 2003 for men (n = 1357) and women (n = 250)
who agreed to participate in the study and who completed a
self-administrated questionnaire and provided saliva samples.
Results: The prevalence of HIV infection was 2.3% among
the male participants and 8.8% among the female participants. The corresponding prevalence of HCV infection was
16.6% and 29.2%, respectively. The most important risk factor was injection drug use. The prevalence of HIV infection
was 7.2% among the male injection drug users and 0.5%
among the male non-users. Among the women, the rate was
20.6% among the injection drug users, whereas none of the
non-users was HIV positive. The prevalence of HCV infection
was 53.3% among the male injection drug users and 2.6%
among the male non-users; the corresponding values
among the women were 63.6% and 3.5%.
Interpretation: HIV and HCV infections constitute an important public health problem in prison, where the prevalence is
affected mainly by a high percentage of injection drug use
among inmates.
Une version française de ce résumé est disponible à l’adresse
www.cmaj.ca/cgi/content/full/177/3/252/DC1

DOI:10.1503/cmaj.060760

CMAJ 2007;177(3):252-6

I

n the province of Quebec, as elsewhere, HIV and hepatitis C virus (HCV) infections in incarcerated populations
are of concern to public health and correctional service
authorities.1–3 Many studies have shown that the prevalence
of HIV infection is higher in the incarcerated population
than in the general population,4–7 and more recently other
studies have shown that a greater proportion of inmates are
infected with HCV than with HIV.8–14

252

People admitted to correctional facilities often have a history of injection drug use, needle-sharing and high-risk sexual behaviours.5,7,9,15 The practice of such risky behaviours is
frequently continued during incarceration,5,9,10,15–17 along
with other potentially risky activities, such as being tattooed.5,7,8,16 To date, there has been limited information regarding the burden of HCV infection among inmates of
provincial prisons in Quebec, where HIV and HCV testing is
available to inmates only on request. Better knowledge of infection rates would help disease prevention and management
program planning.
We sought to determine the prevalence of HIV and HCV
infections among inmates in 7 provincial prisons in Quebec
and to identify risk factors associated with prevalent HCV infection in this population.

Methods
Background
We selected 7 provincial prisons from a total of 17 in the
province of Quebec, to represent a diversity of settings. Of
the 5 men’s prisons, 1 was in Montréal, 1 was in Québec City,
and 3 were in smaller cities in the eastern, western and
northern regions of the province. The 2 women’s prisons
were both in urban settings (Québec City and Montréal). The
total capacity of the participating prisons was 2077 beds for
men and 162 beds for women, thus representing 52% of all
4303 beds in the Quebec network of provincial detention
centres. On admission, information such as name, length of
sentence and date of release is recorded in each prison’s
computer database.

From the Unité de recherche en santé des populations (Poulin, Alary, Godin,
Landry, Demers, Morarescu), Centre hospitalier affilié universitaire de
Québec; Département de médecine sociale et préventive (Alary), Université
Laval, Québec; Institut national de santé publique du Québec (Alary, Lambert, Rochefort, Claessens), Québec and Montréal; Direction régionale de
santé publique de Montréal-Centre (Lambert), Montréal; Chaire de
recherche du Canada sur les comportements et la santé (Godin), Université
Laval, Québec; Faculté des sciences infirmières (Godin, Gagnon), Université
Laval, Québec; Laboratoire de Santé publique du Québec (Rochefort,
Claessens), Sainte-Anne-de-Bellevue, Que.

CMAJ • July 31, 2007 • 177(3)
© 2007 Canadian Medical Association or its licensors

Research

Study population
All male inmates with a period of incarceration of more than
24 hours who were on the computer list the day before the
data-collection period in each of the participating prisons
were eligible for inclusion. The data collection for men was
carried out one prison at a time and took place from January
to June 2003. We excluded inmates considered by the prison
staff to pose a danger to the survey team.
The study population was similarly defined for women.
However, to achieve a sufficiently large sample, we used the
computer list from 3 (in Montréal) or 2 (in Québec City) different days at 2-month intervals between January and June
2003. No woman was recruited more than once in the study.

Data collection
During the data collection period, a correctional officer, specially hired for the study, used the computer list to identify eligible inmates and invite them to meet an interviewer. As a token of appreciation, a deposit of $10 was made in the
personal account of inmates who agreed to meet the interviewer. They were met in a private room where they were advised of the study’s objectives. Informed consent was obtained, and only the research interviewer knew who had
refused to participate. Information on how to get confidential
counselling and testing, both outside and inside prison, was
provided to all.
Participants were asked to complete a short, anonymous,
self-administered questionnaire about their sociodemographic characteristics and HIV/HCV risk behaviours, both
outside and inside prison. The questionnaire was initially developed in French, translated into English and then translated
back to French to ensure consistency. The interviewer was
available to provide clarification and to help fill in the questionnaire if necessary.
Two samples of saliva were collected from each participant with the the use of the OraSure device (OraSure Technologies Inc., Beaverton, Ore.). All samples were sent to the
Laboratoire de santé publique du Québec, where they were
tested for HIV and HCV antibodies. No identifier was recorded on the questionnaire or on the saliva specimens, but
a sticker with a nonidentifying code number, covered by a
second opaque sticker, was placed on both saliva tubes and
the questionnaire, to link the laboratory results with the
questionnaires.

Laboratory procedures
HIV antibodies were detected with the use of the Vironostika HIV-1 Microelisa System (BioMérieux, Durham, NC).
Samples initially showing positive results for HIV were
retested in duplicate and were declared positive if at least 2
of the 3 results were positive.18 For the detection of HCV
antibodies, a modified commercial kit — Ortho HCV 3.0
ELISA Test System (Ortho Clinical Diagnostics Inc., Raritan, NJ)19 — was used.

Statistical analysis
The prevalence of HIV and HCV infections and 95% confidence intervals (CIs) were calculated separately for men and

women. Prevalence odds ratios (ORs) were used as the measure of association between risk factors and infections. Because HIV epidemiology in prisons is relatively well known,
the analysis focused on HCV prevalence and associated risk
factors. In the univariate analysis we used the χ2 test for categorical variables and Student’s t test for continuous variables. We used logistic regression for multivariable analysis.
Statistical significance was set at a 5% alpha level (2-tailed).

Ethical considerations
This study was approved by the ethics committees of both the
Centre hospitalier affilié universitaire de Québec and Laval
University, Québec. This project also received the support of
the president of the Montréal Inmates’ Rights Organisation.

Results
Study participants
A total of 1607 inmates (1357 men and 250 women) agreed to
participate in the study. Among the women, the total number
of participants exceeded the number of beds because of multiple periods of recruitment and no refusals. Among the men,
the number of participants represents 65.3% of the total potential number. Nonparticipation was due mainly to the limited number of time slots for recruitment and logistical
arrangements with the authorities of each prison. The precise
number of refusals is not known, but it was less than 20.
The men were younger than the women on average (mean
age 33.3 v. 35.5 years; p < 0.001), and 63% of the participants
did not complete high school. Most of the participants were
French Canadians, but there were more English Canadian
women than men (13.2% v. 4.9%; p < 0.001). Aboriginal people represented 4.1% and 4.8% of the male and female participants, respectively, whereas 12.2% of the men and 4.8% of
the women were of other ethnocultural groups (Haitian, Hispanic and African).

History of incarceration
Male participants had been incarcerated for longer than the
women on average (mean duration of detention at study enrolment 100.8 v. 60.0 days, p < 0.001; mean duration of sentence 332.1 v. 289.5 days, p < 0.001). Women more often
than men were recidivists (mean number of incarcerations
per inmate 7.6 v. 6.4; p < 0.001), but examination of accumulated durations of previous sentences revealed that the men
had been incarcerated for longer than the women (mean total
duration of incarceration, 40.5 v. 26.0 months; p < 0.001).

Risk behaviours
Table 1 shows the high level of risk behaviours outside and
inside prison. More women than men reported risky sexual
behaviour, injection drug use, and tattooing and piercing outside prison, but more men than women reported injection
drug use and tattooing while inside prison. In addition, 156
men (11.5%) and 6 (2.4%) women reported performing tattooing or piercing on other inmates while inside prison,
among whom 76.3% (n = 119) and 50% (n = 3),3 respectively,
reported having done so with sterile equipment.

CMAJ • July 31, 2007 • 177(3)

253

Research

HIV and HCV prevalence and associated risk factors
The overall prevalence of HIV infection was 3.4% (54/1607); it
was significantly higher among the women than among the
men (8.8% [22/250] v. 2.4% [32/1357], p < 0.001) (Table 2).
The overall prevalence of HCV infection was 18.5%
(298/1607); among the women and men it was 29.2%
(73/250) and 16.6% (225/1357), respectively (p < 0.001). HIV
and HCV infections mainly affected injection drug users.
Most of the HIV-positive men (68.8%) and women (59.1%)
also had HCV infection. There was no statistically significant
difference in HIV and HCV prevalence according to the location of the detention centres (data not shown). Twenty percent of the HIV-positive inmates (11/54) and 40% of the HCVpositive inmates (119/298) did not know their serostatus
(reported their last test results as negative or unknown, or
had never been tested).
Among the participants who reported injection drug use,
the risk factors independently associated with prevalent HCV
infection were being female (prevalence OR 1.7, 95% CI
1.01–2.8), being 30 years of age or older compared with being
less than 30 (30–39 years, prevalence OR 2.08, 95% CI 1.2–
3.5; 40 years or older, prevalence OR 2.8, 95% CI 1.6–4.9),
sharing needles outside prison (prevalence OR 2.2, 95% CI
1.5–3.3), attending needle-exchange programs (prevalence
OR 2.7, 95% CI 1.6–4.5) and having sex with injection drug
users (prevalence OR 1.8, 95% CI 1.2–2.8). Injecting drugs
while inside prison was also associated with HCV infection
(prevalence OR 3.6, 95% CI 1.7–7.5), whereas performing tattoos and piercings on other inmates was a protective factor
(prevalence OR 0.4, 95% CI 0.19–0.67). Interaction terms between the participant’s sex and all the other independent variables were systematically considered in the model. With all p

values greater than 0.15, none of these terms was retained in
the final model.

Interpretation
In this cross-sectional survey of 7 provincial prisons in
Quebec, we found that the prevalence of HCV infection was
much higher than that of HIV infection (18.5% v. 3.4%).
Applying the sex-specific prevalences we found to the
27 184 people (2547 women and 24 637 men) admitted to
Quebec’s provincial detention centres from April 2005 to
March 2006 (Guy Samson, Ministry of Public Security of
Quebec: personal communication, 2006), we estimated
that there are about 800 HIV-positive (95% CI 500–1150)
and 4800 HCV-positive (95% CI 4200–5500) inmates admitted yearly to these prisons, where only sentences of less
than 2 years are served.
Injection drug use was by far the most important risk factor for both HIV and HCV infections, with more than 90% of
the participants infected by either of these viruses reporting
this behaviour before their imprisonment. Among the participants who reported injection drug use, we found that needlesharing, persistence of injection drug use while incarcerated,
participation in a needle-exchange program and having sex
with injection drug users were factors independently associated with HCV infection. However, the latter 2 associations
are not likely to be causal. Indeed, it has been shown that needle-exchange programs attract injection drug users with
higher levels of risky behaviour,20,21 whereas sexual activity
with injection drug users might be a proxy measure of other
undetermined risk factors, since the sexual transmission of
HCV is inefficient.22–24

Table 1: Risk behaviours for HIV and hepatitis C virus (HCV) infections among 1357 male and 250 female inmates in 7 Quebec provincial
prisons
Outside prison

Inside prison

Men, no. (%)

Women, no. (%)

p value

Men, no. (%)

Injection drug use

377 (27.8)

107 (42.8)

< 0.001†

60 (4.4)

2

Needle sharing*

201 (53.3)

60 (56.1)

0.42

38 (63.3)

1 (50.0)

657 (48.4)

151 (60.4)

< 0.001†

514 (37.9)

102 (15.5)

47 (31.1)

< 0.001†

94 (18.3)

416 (30.7)

136 (54.4)

< 0.001†

29 (2.1)
6 (20.7)

Behaviour

Tattooing, receipt of
With non-sterile equipment*
Piercing, receipt of
With non-sterile equipment*
Sex with injection drug user
Unprotected*
Anal sex
Unprotected*
Oral sex for money or drugs
Unprotected*
Anal or vaginal sex for money or drugs
Unprotected*

12

(0.8)
(4.8)

5 (41.7)
10

p value
0.006†
0.65
< 0.001†
0.12

(4.0)

0.07

3 (30.0)

0.80

60 (14.4)

13 (9.6)

0.39

353 (26.0)

112 (44.8)

< 0.001†

NA

NA

—

272 (77.1)

93 (83.0)

0.16

NA

NA

—

577 (42.5)

126 (50.4)

0.020†

20 (1.5)

NA

—

478 (82.8)

106 (84.1)

0.57

16 (80.0)

NA

—

106 (7.8)

117 (46.8)

< 0.001†

NA

—

NA

85 (80.2)

81 (69.2)

0.008†

82 (6.0)

105 (42.0)

< 0.001†

17 (1.3)

1

(0.4)

0.24

51 (62.2)

44 (41.9)

0.002†

16 (94.1)

1 (100.0)

0.80

Note: NA = not asked.
*Among subjects who reported the behaviour on the previous line.
†Statistically significant difference between men and women.

254

Women, no. (%)

CMAJ • July 31, 2007 • 177(3)

NA

NA

—

Research

The prevalence of HIV infection we found was similar to
that reported in previous studies in prison populations in
Montréal4,25 and Québec City,5 with no upward or downward
shifts. Furthermore, our results are consistent with those obtained in Canadian,8,11,13,25–28 American12,29 and European prisons.9,30,31 However, this is the first time that the activity of performing tattooing or piercing on other inmates was identified
as a protective factor. This result may reflect the adoption of
harm-reduction behaviour by tattoo artists for themselves and
for those they tattoo.
Different limitations to this study must be considered.
First, the prisons were not chosen randomly, which could
lead to a selection bias. This bias was, however, minimized by
the broad geographic diversity of the prisons selected. Second, recall and social desirability biases related to selfreported behaviour are also possible. These biases were reduced because the questionnaire was self-administered and
anonymous. Finally, causal inference in the analysis of risk
factors for HCV infection is limited by the cross-sectional design of the study.
In conclusion, we found a high HIV and HCV prevalence
among inmates, representing a large number of people infected by either HIV or HCV (> 5000) transiting yearly
through Quebec's provincial prisons where the population
turnover is high
In conclusion, we found a high prevalence of HIV and
HCV infections among inmates, which represents a large
number of people infected by either HIV or HCV (> 5000)
transiting yearly through Quebec’s provincial prisons, where
the population turnover is high. Furthermore, a relatively
large proportion of HIV- or HCV-positive inmates are unaware of their infection. Consequently, we believe that HIV
and HCV antibody testing and counselling should be offered
to all inmates entering prison. In addition, prevention programs, which include ongoing education and harm-reduction measures in prisons, are warranted. Given the high rate
of recidivism and short duration of stay in provincial prisons,
coordination between correctional facilities and programs in
the community may benefit the community at large.

This article has been peer reviewed.
Competing interests: None declared.
Contributors: Céline Poulin participated in the design of the study and was
responsible for writing the manuscript. Michel Alary was responsible for
the design of the study and the data analysis and interpretation. Gilles Lambert and Gaston Godin participated in the design of the study and contributed to the interpretation of the results. Suzanne Landry and Hélène
Gagnon were responsible for coordinating the data collection and contributed to the interpretation of the results. Éric Demers performed the statistical analysis. Elena Morarescu was involved in the data interpretation
and wrote an early draft of the paper. Jean Rochefort and Christiane
Claessens were responsible for the design of the laboratory aspects of the
study and carried out the laboratory testing. All of the authors participated
in revising the manuscript critically for important intellectual content and
approved the final version of the paper.
Acknowledgements: We thank the authorities and staff of the collaborating
detention centres and the authorities of the Ministry of Public Security of
Quebec for facilitating this study. We also thank the data collection staff for
their dedication. Finally, this study would not have been possible without the
excellent collaboration of all the inmates to whom participation in the study
was proposed.
This study was funded by the Canadian Institutes for Health Research
(grant no. EOP-58193) and by the Service de lutte contre les infections transmissibles sexuellement et par le sang of the Ministère de la Santé et des Services sociaux du Québec. Dr. Alary is a National Researcher of the Fonds de la
recherche en santé du Québec.

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Table 2: Prevalence of HIV infection and hepatitis C virus (HCV)
infection among 1607 inmates in select Quebec provincial
prisons, by sex and self-reported status of injection drug use
Prevalence (95% confidence interval), %
Injection drug use

HIV infection

Men (n = 1357)

HCV infection

2.4 (1.6–3.3)

16.6 (14.6–18.7)

Yes (n = 377)

7.2 (4.8–10.3)

53.3 (41.1–58.5)

No (n = 980)

0.5 (0.2–1.2)

2.6 (1.7–3.7)

Women (n = 250)

8.8 (5.6–13.0)

29.2 (23.6–35.3)

Yes (n = 107)

20.6 (13.4–29.5)

63.6 (53.7–72.6)

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55.6 (51.0–60.1)

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Correspondence to: Dr. Michel Alary, Unité de recherche en santé
des populations, Centre hospitalier affilié universitaire de Québec,
1050 chemin Ste-Foy, Québec QC G1S 4L8

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