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Transcript of 1 HIV, Tuberculosis and Criminal Justice The Perfect Storm Frederick L. Altice, M.D., M.A. Professor...
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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 ventilation
Screening & RxOrganism
Prevalence & Incidence of active & LTBI
MDR 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 InterventionsBasu 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
ha
ng
e i
n p
rev
ale
nc
e
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
ha
ng
e i
n i
nc
ide
nc
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
ha
ng
e i
n m
ort
ali
ty
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!