Comparison of combined HIV prevention interventions for prisoners: a network meta-analysis

HIV prevalence among incarcerated populations is three to four times higher than in the general population, driven by overcrowding, stigma, limited healthcare access, and high-risk behaviors. This systematic review and Bayesian network meta-analysis, conducted according to PRISMA-NMA 2020 guidelines, evaluated combined HIV prevention strategies in prisons. Six randomized or quasi-experimental studies published between 2014 and 2020, including 2.445 incarcerated participants, were analyzed. Interventions were compared directly and indirectly using a hierarchical model and ranked by SUCRA. Retention in care combined with antiretroviral therapy (ART) adherence was the most effective strategy (SUCRA = 84.9%), followed by linkage or reengagement in care plus ART adherence (80.9%) and education with partner reduction (73.2%). Behavioral-only interventions, such as condom distribution and counseling, showed moderate-to-low efficacy (approximately 35-37%), while structural interventions, including change teams, produced heterogeneous results often constrained by implementation barriers. Overall heterogeneity was moderate. The findings indicate that biomedical strategies ensuring ART retention and adherence should be the cornerstone of HIV prevention in prisons, with behavioral and structural interventions serving as complementary components of integrated, multi-component prevention packages.