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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)

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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)

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CommunitiesOther Prison

Settings

Creating the Perfect Storm

TB Dynamics

HostPLWHA (%)

PWIDsHomeless

Malnourished

EnvironmentCrowding

Poor ventilationScreening &

Rx

OrganismPrevalence & Incidence of active & LTBIMDR strains

(%)

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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

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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

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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

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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 Xpert plus culture for TB case finding

- Symptom-based screening fared poorly

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LTBI and the Prison Risk Environment

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

36.0%

52.1%

Healthcare Workers, MY

Rafiza, BMC Infect Dis, 2011

CommunitySE Asia

Dye, JAMA, 1999

87.6%

Open Prison, Kelantan, MYMargolis, IJTBLD,

2013

88.8%

Closed Prison Selangor, MYAl-Darraji, BMC

Pub Health, 2013

81.0%

Prison OfficersSelangor, MYAl-Darraji, Unpub

Data, 2013

TST+ independently correlated with

previous incarcerations

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Prevalence of LTBI Among Prisoners in Kelantan, Malaysia

*

**p=0.005

Margolis, IJTBLD, In Press

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Independent Correlates of TST+ and TB Symptoms (N=259)

● TST reactivity- Previously incarcerated 4.61 (1.76-12.10)

Margolis, IJTBLD, In Press

● 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)

AOR (95% CI)

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Deterministic Compartmental TB Model

SusceptibleS

Latent TB(Recent) L1

Latent TB(Remote) L2

Active TB A

TB Recovery R

Treatment / Self-Cure

Reactivation Reinfection

ImmuneStabilization

Reinfection

Relapse

Rapid Progression

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Key Assumptions● Passive diagnosis is baseline simulation to

compare interventions against● Systematic reviews used to generate estimates

of intervention sensitivity among 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

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Reduction in TB Prevalence Using Various Screening Interventions

Symptom screening

CXR Sputum AFB

Xpert0%

5%

10%

15%

20%

25%

30%

35%

40%

16% 35% 28% 37%% c

hang

e in

pre

vale

nce

Basu S et al, In Preparation

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Reduction in TB Incidence Using Various Screening Interventions

Symptom screening

CXR Sputum AFB Xpert0%

10%

20%

30%

40%

50%

60%

39% 31% 49% 52%

% c

hang

e in

inci

denc

e

Basu S et al, In Preparation

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Reduction in TB Mortality Using Various Screening Interventions

Symptom screening

CXR Sputum AFB

Xpert-5%

5%

15%

25%

35%

45%

55%

65%

75%

47% 52% 61% 67%% c

hang

e in

mor

talit

y

Basu S et al, In Preparation

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Potential Intervention Approachesto Prevent TB Transmission

● Symptom-based screening● CXR screening● Sputum AFB screening● Gene Xpert +/- culture

● Isoniazid Preventive Therapy (HIV+s? TST+s?)

● Routine HIV Testing and Provision of ART

● Increase Ventilation● UV light ● Specialty TB Prisons● Stop HIV segregation

Improve Screening for TB Methods

Decrease Host Susceptibility to TB Infection

Alter Prison Environment● Alternatives to

incarceration for PWIDs● OST for PWIDs

Structural Changes

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Simultaneous Use of Different Classes of TB Control Strategies

Combination TB Control Strategies

Routine HIV Testing,

Linkage to ART

Isoniazid Preventive

Therapy

Routine TB Screening

Alternatives to

Incarceration

OST for Opioid

Dependent Patients

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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

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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

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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!