HIV, Tuberculosis and Criminal Justice The Perfect Storm

1. HIV, Tuberculosis and Criminal JusticeThe Perfect Storm Frederick L. Altice, M.D., M.A. Professor of Medicine and Public Health Yale University (USA) University of Malaya (Malaysia)

2. Prisons and Tuberculosis • Nearly 10 million people imprisoned (4-6X more transition through annually) • Highly dynamic and unpredictable movement • Police detention • Compulsory drug detention centers • Jails (remand) • Prisons • TB & HIV significantly concentrated in prisons • Overcrowding & poor nutrition • Increased “selection” of high risk persons entering prisons (PWIDs, homeless, PWLHA)

3. Creating the Perfect Storm Other Prison Settings Communities

4. Tuberculosis in Prisons • TB outbreaks reported in many prisons, especially MDR-TB in FSU (but also in high income countries with low TB prevalence). • Prison-related TB transmission is more likely to be drug-resistant or associated with HIV co-infection. • A higher proportion of TB patients in prisons have MDR-strains than is the case in patients outside prison (incomplete treatment due to release and poor treatment standards). WHO Europe, Prison health – HIV, drugs and tuberculosis, 2009

5. HIV Segregation and TB Outbreaks • PLWHA are at increased risk for acquisition and progression to active TB • Entry into a HIV segregation unit by a single active TB case results in a high probability of TB transmission and disease progression • Crowding and poor ventilation results in increased transmissibility • Inadequate screening, poor isolation procedures, substandard treatment and default on treatment post-release results in development of drug-resistant strains

6. Prisons, TB and HIV • 50-80% of prison-related mortality related to TB (especially TB/HIV coinfection) • The War on Drug Users has resulted in incredibly high prevalence of PWIDs / drug dependent persons in prisons (up to 50%) in some settings (Eastern Europe and SE Asia) • Prisons are “high risk” work environments for staff, especially related to TB (some staff HIV+) • Nearly all prisoners return to the community and amplify TB risk to family and the general public

7. Case Study: Malaysia • Middle income country: 102 TB cases/100,000 • Prisoners: ~38,000 • Mandatory HIV testing with segregation: 5-6% • Nearly all HIV+ prisoners meet criteria for opioid dependence (methadone available) • No systematic TB screening procedures • See Poster WEPE467 (Al-Darraji et al) • HIGH cross-sectional active TB prevalence using Gene Xpertplus culture for TB case finding • Symptom-based screening fared poorly

8. LTBI and the Prison Risk Environment 100% 88.8% 87.6% 81.0% 90% 80% 70% 60% 52.1% 50% 36.0% 40% 30% TST+ independently correlated with previous incarcerations 20% 10% Prison OfficersSelangor, MY CommunitySE Asia Closed Prison Selangor, MY Open Prison, Kelantan, MY Healthcare Workers, MY Al-Darraji, Unpub Data, 2013 Dye, JAMA, 1999 Al-Darraji, BMC Pub Health, 2013 Margolis, IJTBLD, 2013 Rafiza, BMC Infect Dis, 2011

9. Prevalence of LTBI Among Prisoners in Kelantan, Malaysia * * *p=0.005 Margolis, IJTBLD, In Press

10. Independent Correlates of TST+ and TB Symptoms (N=259) • TST reactivity • Previously incarcerated 4.61 (1.76-12.10) AOR (95% CI) • TB symptoms • Age 1.07 (1.01-1.13) • BMI 0.82 (0.70-0.96) • Negative TST ( CD4) 3.46 (1.20-9.97) Margolis, IJTBLD, In Press

11. Deterministic Compartmental TB Model Reinfection Latent TB(Recent) L1 Latent TB(Remote) L2 SusceptibleS ImmuneStabilization Rapid Progression Reactivation Reinfection Active TBA TB Recovery R Treatment / Self-Cure Relapse

12. Key Assumptions • Passive diagnosis is baseline simulation to compare interventions against • Systematic reviews used to generate estimates of intervention sensitivityamong HIV-negatives and HIV-positives (CD4 stratification) • All new screening interventions are annual, independent of HIV status • HIV prevalence in prison ~5-6% (Malaysia) • Not any significant MDR-TB strains • Impact of 4 Screening Interventions Basu S et al, In Preparation

13. Reduction in TB Prevalence Using Various Screening Interventions Basu S et al, In Preparation

14. Reduction in TB Incidence Using Various Screening Interventions Basu S et al, In Preparation

15. Reduction in TB MortalityUsing Various Screening Interventions Basu S et al, In Preparation

16. Potential Intervention Approachesto Prevent TB Transmission • Symptom-based screening • CXR screening • Sputum AFB screening • Gene Xpert +/- culture Improve Screening for TB Methods Decrease Host Susceptibility to TB Infection • Isoniazid Preventive Therapy (HIV+s? TST+s?) • Routine HIV Testing and Provision of ART Alter Prison Environment Structural Changes • Increase Ventilation • UV light • Specialty TB Prisons • Stop HIV segregation • Alternatives to incarceration for PWIDs • OST for PWIDs

17. Simultaneous Use of Different Classes of TB Control Strategies

18. Isoniazid Preventive Therapy in Correctional Facilities • 18 studies reviewed, including prisons (N=7) and jails (N=11) • None included low or middle income countries (USA, Spain, Singapore) • Completion rates markedly lower in jails than in prisons • Requires ruling out active TB • Not examined in high prevalence setting of PWIDs where HCV prevalence high (hepatoxicity) Al-Darraji, IJTBLD, 2012

19. Summary • Good prisoner health IS good public health! • Approaches to increase detection and treatment of TB in communities should be applied to prisons where the epidemic is concentrated • Alternatives to reduce incarceration should be considered paramount to optimal TB control • Will need to examine the impact of combination clinical TB prevention in real-world settings and apply them to High, Middle and Low Income settings

20. Acknowledgements • University of Malaya • Haider Al-Darraji * • Adeeba Kamarulzaman • Yale University • Jeffrey Wickersham • Sanjay Basu – Stanford • Fabienne Hariga – UNODC • Malaysia Prisons Department • Sergey Dvoryak – UIPHP • Lucas Weissing • Study participants!