1. 1 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)

2. 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. 3 Communities Other Prison Settings Creating the Perfect Storm

4. 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. 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. 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. 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 Xpert plus culture for TB case finding - Symptom-based screening fared poorly

8. 8 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 Community SE Asia Dye, JAMA, 1999 87.6% Open Prison, Kelantan, MY Margolis, IJTBLD, 2013 88.8% Closed Prison Selangor, MY Al-Darraji, BMC Pub Health, 2013 81.0% Prison Officers Selangor, MY Al-Darraji, Unpub Data, 2013 TST+ independently correlated with previous incarcerations

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

10. 10 Independent Correlates of TST+ and TB Symptoms (N=259) ●TST reactivity - Previously incarcerated4.61 (1.76-12.10) Margolis, IJTBLD, In Press ●TB symptoms - Age1.07 (1.01-1.13) - BMI0.82 (0.70-0.96) - Negative TST (  CD4)3.46 (1.20-9.97) AOR (95% CI)

11. 11 Deterministic Compartmental TB Model Susceptible S Latent TB (Recent) L1 Latent TB (Remote) L2 Active TB A TB Recovery R Treatment / Self-Cure ReactivationReinfection Immune Stabilization Reinfection Relapse Rapid Progression

12. 12 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

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

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

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

16. 16 Potential Intervention Approaches to 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

17. 17 Simultaneous Use of Different Classes of TB Control Strategies

18. 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. 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. 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!