METHODS: From 2010 to 2014, men with HIV (N = 212) and opioid dependence before incarceration were enrolled in MMT within 6 months of release from Malaysia's largest prison and followed for 12-months post-release. As a prospective trial, allocation to MMT was at random and later by preference design (predictive nonetheless). MMT dosing was individually targeted to minimally achieve 80 mg/day. Time-to-event analyses were conducted to model linkage to MMT after release.
FINDINGS: Of the 212 participants allocated to MMT, 98 (46 %) were prescribed higher dosages (≥80 mg/day) before release. Linkage to MMT after release occurred in 77 (36 %) participants and significantly higher for those prescribed higher dosages (46% vs 28 %; p = 0.011). Factors associated with higher MMT dosages were being married, on antiretroviral therapy, longer incarceration periods, having higher levels of depression, and methadone preference compared to randomization. After controlling for other variables, being prescribed higher methadone dosage (aHR: 2.53, 95 %CI: 1.42-4.49) was the only independent predictor of linkage to methadone after release.
INTERPRETATION: Higher doses of methadone prescribed before release increased the likelihood of linkage to MMT after release. Methadone dosing should be introduced into international guidelines for treatment of opioid use disorder in prisons and further post-release benefits should be explored.
FUNDING: National Institute of Drug Abuse (NIDA).
RECENT FINDINGS: The prevalence of HIV and HCV are several-fold higher in the criminal justice system than within the broader community particularly in regions with high prevalence of injecting drug use, such as Asia, Eastern Europe and North America and where drug use is criminalized. Strategies to optimize management for these infections include routine screening linked to treatment within these settings and medication-assisted treatments for opioid dependence and access to syringe services programs. We build upon the 2016 WHO Consolidated Guidelines through the lens of the key populations of prisoners. Linkage to treatment postrelease, has been universally dismal, but is improved when linked to medication-assisted therapies like methadone, buprenorphine and overdose management. In many prisons, particularly in low-income and middle-income settings, provision of even basic healthcare including mental healthcare and basic HIV prevention tools remain suboptimal.
SUMMARY: In order to address HIV and HCV prevention and treatment within criminal justice settings, substantial improvement in the delivery of basic healthcare is needed in many prisons worldwide together with effective screening, treatment and linkage of treatment and prevention services to medication-assisted therapies within prison and linkage to care after release.
METHODS: From October 2012 to May 2013, prisoners housed in two distinct units (HIV-negative and HIV-positive) were approached to participate in the TB screening study. Consenting prisoners submitted two sputum samples that were examined using GeneXpert MTB/RIF, smear microscopy and liquid culture. Socio-demographic and clinical information was collected and correlates of active TB, defined as having either a positive GeneXpert MTB/RIF or culture results, were assessed using regression analyses.
RESULTS: Among the total of 559 prisoners, 442 (79.1%) had complete data; 28.7% were HIV-infected, 80.8% were men and the average age was 36.4 (SD 9.8) years. Overall, 34 (7.7%) had previously undiagnosed active TB, of whom 64.7% were unable to complete their TB treatment in prison due to insufficient time (<6 months) remaining in prison. Previously undiagnosed active TB was independently associated with older age groups (AOR 11.44 and 6.06 for age ≥ 50 and age 40-49 years, respectively) and with higher levels of immunosuppression (CD4 < 200 cells/ml) in HIV-infected prisoners (AOR 3.07, 95% CI 1.03-9.17).
CONCLUSIONS: The high prevalence of previously undiagnosed active TB in this prison highlights the inadequate performance of internationally recommended case-finding strategies and suggests that passive case-finding policies should be abandoned, especially in prison settings where HIV infection is prevalent. Moreover, partnerships between criminal justice and public health treatment systems are crucial to continue TB treatment after release.
AIMS: This mixed method study examined the prevalence, correlates, and social context of WP-DI among HIV-infected male prisoners in Indonesia.
METHODS: 102 randomly selected HIV-infected male prisoners completed semi-structured voice-recorded interviews about drug use changes after arrest, drug use cues within prison, and impact of WP-DI on HIV and addiction treatment. Logistic regression identified multivariate correlates of WP-DI and thematic analysis of interview transcripts used grounded-theory.
RESULTS: Over half (56%) of participants reported previous WP-DI. Of those, 93% shared injection equipment in prison, and 78.6% estimated sharing needles with ≥ 10 other prisoners. Multivariate analyses independently correlated WP-DI with being incarcerated for drug offenses (AOR = 3.29, 95%CI = 1.30-8.31, p = 0.011) and daily drug injection before arrest (AOR = 5.23, 95%CI = 1.42-19.25, p = 0.013). Drug availability and proximity to drug users while incarcerated were associated with frequent drug craving and escalating drug use risk behaviors after arrest. Energetic heroin marketing and stigmatizing attitudes toward methadone contribute to WP-DI and impede addiction and HIV treatment.
CONCLUSIONS: Frequent WP-DI and needle sharing among these HIV-infected Indonesian prison inmates indicate the need for structural interventions that reduce overcrowding, drug supply, and needle sharing, and improve detection and treatment of substance use disorders upon incarceration to minimize WP-DI and associated harm.