Transcript Optimizing Treatment and Management of HIV/AIDS in Persons of

HIV, Tuberculosis and Criminal Justice
The 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
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Overcrowding & poor nutrition
Increased “selection” of high risk persons entering
prisons (PWIDs, homeless, PWLHA)
Creating the Perfect Storm
Environment
Host
Crowding
Poor ventilation
Prevalence &
Incidence of
active & LTBI
MDR strains (%)
PWIDs
Homeless
Malnourished
Other Prison
Settings
3
Organism
TB
Dynamics
Communities
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 coinfection.
● 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
4
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)
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-
HIGH cross-sectional active TB prevalence using
Gene Xpert plus culture for TB case finding
-
Symptom-based screening fared poorly
LTBI and the Prison Risk Environment
100%
87.6%
90%
88.8%
81.0%
80%
70%
60%
52.1%
50%
40%
36.0%
30%
TST+ independently
correlated with
previous incarcerations
20%
10%
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Community
SE Asia
Healthcare
Workers, MY
Open Prison,
Kelantan, MY
Closed Prison Prison Officers
Selangor, MY Selangor, MY
Dye, JAMA,
1999
Rafiza, BMC Infect
Dis, 2011
Margolis, IJTBLD,
2013
Al-Darraji, BMC
Pub Health, 2013
Al-Darraji, Unpub
Data, 2013
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
AOR (95% CI)
4.61 (1.76-12.10)
● 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
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Deterministic Compartmental TB Model
Reinfection
Susceptible
S
Latent TB
(Recent) L1
Rapid
Progression
Reactivation
Active TB
A
Reinfection
Treatment /
Self-Cure
Relapse
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Latent TB
(Remote) L2
Immune
Stabilization
TB Recovery
R
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
40%
% change in prevalence
35%
30%
25%
20%
15%
10%
5%
16%
35%
28%
37%
Symptom
screening
CXR
Sputum AFB
Xpert
0%
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Basu S et al, In Preparation
Reduction in TB Incidence Using
Various Screening Interventions
% change in incidence
60%
50%
40%
30%
20%
10%
39%
31%
Symptom
screening
CXR
49%
52%
0%
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Sputum AFB
Xpert
Basu S et al, In Preparation
Reduction in TB Mortality Using
Various Screening Interventions
75%
% change in mortality
65%
55%
45%
35%
25%
15%
5%
-5%
15
47%
52%
61%
67%
Symptom
screening
CXR
Sputum AFB
Xpert
Basu S et al, In Preparation
Potential Intervention Approaches
to Prevent TB Transmission
Improve Screening for
TB Methods
●
●
●
●
Symptom-based screening
CXR screening
Sputum AFB screening
Gene Xpert +/- culture
Alter Prison Environment
●
●
●
●
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Increase Ventilation
UV light
Specialty TB Prisons
Stop HIV segregation
Decrease Host Susceptibility
to TB Infection
● Isoniazid Preventive
Therapy (HIV+s? TST+s?)
● Routine HIV Testing and
Provision of ART
Structural Changes
● Alternatives to
incarceration for PWIDs
● OST for PWIDs
Simultaneous Use of Different Classes
of TB Control Strategies
Routine HIV
Testing,
Linkage to
ART
OST for
Opioid
Dependent
Patients
Alternatives
to
Incarceration
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Isoniazid
Preventive
Therapy
Combination
TB Control
Strategies
Routine TB
Screening
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
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● Malaysia Prisons
Department
● Sergey Dvoryak –
UIPHP
● Lucas Weissing
● Study participants!