Human immunodeficiency virus, hepatitis B and hepatitis C in an Indonesian prison: prevalence, risk factors and implications of HIV screening

Odds of HIV among incarcerated drug users: a systematic review and meta-analysis of Asian countries

Background

HIV makes up a large portion of infectious diseases globally. People injecting drugs in prisons are at high risk for contracting HIV infection. Prisons house ~10.2 million people globally, making them a high-risk setting for HIV transmission. This systematic review summarizes the available data on the odds of developing HIV infection among imprisoned people who inject drugs (PWIDs) in Asian regions.

Methods

The authors electronically assessed published studies from January, 2000 to December, 2022, including studies that investigated the odds of HIV in imprisoned PWIDs. We extensively searched PubMed, ERIC, and Cochrane Central and Google Scholar with no constraints in language or time. All the observational studies evaluating the chances of HIV in Asian prisoners with an exposure group of PWIDs and a control group of non-injecting-drug users were included in our analysis.

Results

The databases search yielded 254 potential studies, 10 observational studies of which having a total of 17 333 participants were included. A low or moderate risk of bias was reported in all the studies except one case-control. The pooled analysis showed a significant association between PWIDs and the chances of contracting HIV infection (Odds ratio=6.40; 95% CI=3.89-10.52; P<0.00001; I2=53%).

Conclusion

This study found a vital correlation between injecting-drug usage during imprisonment and HIV transmission speed. The results of this meta-analysis support the need to prevent HIV and conducting treatment programs in high-risk settings like prisons.

A social ecological model (SEM) to exploring barriers of and facilitators to the implementation of opioid agonist treatment (OAT) programmes in prisons

PURPOSE

Opioid agonist treatment (OAT) programmes in prisons play a significant role in preventing the human immunodeficiency virus (HIV). Despite its proven effectiveness, both the availability and coverage of prison OAT programmes remain low. This Indonesian study explores facilitators of, and barriers to, the delivery of methadone programmes in prisons using the social ecological model (SEM).

DESIGN/METHODOLOGY/APPROACH

The study used a qualitative case study approach comprising two prisons with, and one prison without, methadone programmes. Purposive and snowball sampling was used to recruit study participants. In total, 57 in-depth interviews were conducted with prison governors, health-care staff, prison officers and prisoners. Data was analysed thematically.

FINDINGS

The study findings identified facilitators of and barriers to the delivery of prison OAT programmes at all three levels of the SEM as follows: intrapersonal barriers including misperceptions relating to HIV transmission, the harm reduction role of OAT programmes, methadone dependency and withdrawal symptoms; interpersonal barriers such as inflexible OAT treatment processes and the wide availability of illicit drugs in prisons and; social-structural barriers, notably the general lack of resources.

RESEARCH LIMITATIONS/IMPLICATIONS

The findings highlight the importance of and overlap between, organisational and inter-personal, as well as intrapersonal factors. Such an approach is particularly important in the context of the implementation and delivery of methadone programmes in low/middle income countries, where the lack of resources is so significant.

PRACTICAL IMPLICATIONS

Three main strategies for improvement were suggested as follows: the development of comprehensive education and training programmes for prisoners and all prison staff; the re-assessment of practices relating to the delivery of methadone, and a comprehensive review of harm reduction strategy in prisons, that should consider the role of prisoners' families to increase support for prisoner participation; the re-assessment of prison policies to support the delivery of methadone programmes in prisons.

SOCIAL IMPLICATIONS

The author suggests that ongoing international support and national drug policies are vital to the continuation and sustainability of methadone programmes in prisons.

ORIGINALITY/VALUE

This study contributes to the overall evidence base for OAT programmes in middle-income prison contexts.

The global and regional prevalence of hepatitis C and B co-infections among prisoners living with HIV: a systematic review and meta-analysis

BACKGROUND

Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are common among individuals with human immune deficiency virus (HIV) infection worldwide. In this study, we did a systematic review and meta-analysis of the published literature to estimate the global and regional prevalence of HCV, HBV and HIV coinfections among HIV-positive prisoners.

METHODS

We searched PubMed via MEDLINE, Embase, the Cochrane Library, SCOPUS, and Web of science (ISI) to identify studies that reported the prevalence of HBV and HCV among prisoners living with HIV. We used an eight-item checklist for critically appraisal studies of prevalence/incidence of a health problem to assess the quality of publications in the included 48 cross-sectional and 4 cohort studies. We used random-effect models and meta-regression for the meta-analysis of the results of the included studies.

RESULTS

The number of the included studies were 50 for HCV-HIV, and 23 for HBV-HIV co-infections. The pooled prevalence rates of the coinfections were 12% [95% confidence interval (CI) 9.0-16.0] for HBV-HIV and 62% (95% CI 53.0-71.0) for HCV-HIV. Among HIV-positive prisoners who reported drug injection, the prevalence of HBV increased to 15% (95% CI 5.0-23.0), and the HCV prevalence increased to 78% (95% CI 51.0-100). The prevalence of HBV-HIV coinfection among prisoners ranged from 3% in the East Mediterranean region to 27% in the American region. Also, the prevalence of HCV-HIV coinfections among prisoners ranged from 6% in Europe to 98% in the East Mediterranean regions.

CONCLUSIONS

Our findings suggested that the high prevalence of HBV and HCV co-infection among HIV-positive prisoners, particularly among those with a history of drug injection, varies significantly across the globe. The results of Meta-regression analysis showed a sliding increase in the prevalence of the studied co-infections among prisoners over the past decades, rising a call for better screening and treatment programs targeting this high-risk population. To prevent the above coinfections among prisoners, aimed public health services (e.g. harm reduction via access to clean needles), human rights, equity, and ethics are to be seriously delivered or practiced in prisons. Protocol registration number: CRD42018115707 (in the PROSPERO international).

Adherence to Antiretroviral Therapy Among Incarcerated Persons with HIV: Associations with Methadone and Perceived Safety

With adequate support, people with HIV (PWH) may achieve high levels of adherence to antiretroviral therapy (ART) during incarceration. We examined factors associated with ART utilization and adherence among incarcerated PWH (N = 150) in Indonesia. ART utilization was positively associated with HIV status disclosure (adjusted odds ratio [aOR] = 5.5, 95% CI 1.2-24.1, p = 0.023), drug dependency (aOR = 3.9, 95% CI 1.2-12.6, p = 0.022), health service satisfaction (aOR = 3.2, 95% CI 1.7-6.2, p < 0.001), and perceived need for medical treatment (aOR = 1.6, 95% CI 1.1-2.5, p = 0.011), and negatively associated with chance locus of control (aOR = 0.3, 95% CI 0.1-0.7, p = 0.013). Most participants utilizing ART (74.5%) reported less than "perfect" ART adherence. ART adherence was independently associated with perceived personal safety (β = 0.21, 95% CI 0.01-0.40, p = 0.032) and methadone utilization (β = 0.84, 95% CI 0.10-1.67, p = 0.047). PWH receiving methadone had a sixfold higher adjusted odds of being highly-adherent to ART (aOR = 6.3, 95% CI 1.1-35.7, p = 0.036). Interventions that increase methadone utilization and personal safety may improve ART adherence among incarcerated PWH.

Prevalence of Drug Injection, Sexual Activity, Tattooing, and Piercing Among Prison Inmates

Prisoners engage in a range of risk behaviors that can lead to the transmission of viral infections, such as HIV, hepatitis B and hepatitis C. In this review, we summarize the epidemiologic literature from 2007 to 2017 on 4 key risk behaviors for human immunodeficiency virus and hepatitis C virus among prisoners globally: drug injection, sexual activity, tattooing, and piercing. Of 9,303 peer-reviewed and 4,150 gray literature publications, 140 and 14, respectively, met inclusion criteria covering 53 countries (28%). Regions with high levels of injection drug use were Asia Pacific (20.2%), Eastern Europe and Central Asia (17.3%), and Latin America and the Caribbean (11.3%), although the confidence interval for Latin America was high. Low levels of injection drug use in prison were found in African regions. The highest levels of sexual activity in prison were in Europe and North America (12.1%) and West and Central Africa (13.6%); low levels were reported from the Middle East and North African regions (1.5%). High levels of tattooing were reported from Europe and North America (14.7%), Asia Pacific (21.4%), and Latin America (45.4%). Prisons are burdened with a high prevalence of infectious diseases and risk behaviors for transmission of these diseases, and, commonly, a striking lack of evidence-based infection control measures, even when such measures are available in the surrounding community. Given that most prisoners return to these communities, failure to implement effective responses has repercussions not only prisoner health but also for public health.

Blood-borne viral co-infections among human immunodeficiency virus-infected inmates

Purpose - The purpose of this paper is to evaluate the prevalence of HBV and/or HCV co-infection among HIV-infected inmates entering the correctional facility. Design/methodology/approach - Prospective collection of data of HIV-infected inmates entered the institution over a ten-year period. Findings - During study period 365 consecutive different inmates were evaluated. HCV co-infection was observed in more than 80 per cent of the tested HIV-infected inmates, past HBV infection in 71.6 per cent and active HBV co-infection was detected in 7.1 per cent; triple coinfection (HIV, HCV and HBs-Ag positivity) was present in 6 per cent of the total. Originality/value - This study confirms high prevalence of co-infections among HIV-infected inmates. Testing for HBV and HCV in all HIV-infected inmates at entry in any correctional system is recommended to identify those in need of specific care and/or preventing interventions.

Predictors of Mortality within Prison and after Release among Persons Living with HIV in Indonesia

Objectives

HIV-related mortality is increasing in Indonesia, where prisons house many people living with HIV and addiction. We examined all-cause mortality in HIV-infected Indonesian prisoners within prison and up to 24 months postrelease.

Materials and methods

Randomly selected HIV-infected male prisoners (n=102) from two prisons in Jakarta, Indonesia, completed surveys in prison and were followed up for 2 years (until study completion) or until they died or were lost to follow-up. Death dates were determined from medical records and interviews with immediate family members. Kaplan–Meier and Cox proportional hazards regression models were analyzed to identify mortality predictors.

Results

During 103 person-years (PYs) of follow-up, 15 deaths occurred, including ten in prison. The crude mortality rate within prison (125.2 deaths per 1,000 PYs) was surpassed by the crude mortality rate (215.7 deaths per 1,000 PYs) in released prisoners. HIV-associated opportunistic infections were the most common probable cause of death. Predictors of within-prison and overall mortality were similar. Shorter survival overall was associated with being incarcerated within a specialized “narcotic” prison for drug offenders (hazard ratio [HR] 9.2, 95% confidence interval [CI] 1.1–76.5; P=0.03), longer incarceration (HR 1.06, 95% CI 1.01–1.1; P=0.01), and advanced HIV infection (CD4⁺ T-cell count <200/µL, HR 4.8, 95% CI 1.2–18.2; P=0.02). Addiction treatment was associated with longer survival (HR 0.1, 95% CI 0.01–0.9; P=0.03), although treatment with antiretroviral therapy (ART) or methadone was not.

Conclusion

Mortality in HIV-infected prisoners is extremely high in Indonesia, despite limited provision of ART in prisons. Interventions to restore immune function with ART and provide prophylaxis for opportunistic infections during incarceration and after release would likely reduce mortality. Narcotic prisons may be especially high-risk environments for mortality, emphasizing the need for universal access to evidence-based HIV treatments.

Injecting drug use, sexual risk, HIV knowledge and harm reduction uptake in a large prison in Bali, Indonesia

PURPOSE

The purpose of this paper is to describe HIV-related risk behavior and knowledge of HIV among inmates of Kerobokan prison Bali, Indonesia.

DESIGN/METHODOLOGY/APPROACH

A cross-sectional survey of inmates of using a structured questionnaire and sample framework to reflect narcotic use among inmates and the prison gender mix.

FINDINGS

Among 230 inmates recruited to the study self-reported prevalence of injecting drug use was 7.4 percent (95 percent CI 4.0-10.8 percent). Respondents who participated in a prison based methadone treatment program were all still injecting drugs, these made up 13/17 of the IDU. In total, 47 percent (95 percent CIs 45-55 percent) of respondents who reported injecting also reported sharing needles within the last week. Sexual intercourse while in prison was reported by 3.0 percent (95 percent CI 0.82-5.26 percent) of study respondents. One-third of non-injectors were unaware of the preventative role of condom use. This study suggests that despite harm reduction initiatives within Kerobokan prison HIV risk behavior continues and there is a considerable lack of awareness of the importance of condom use in preventing HIV.

RESEARCH LIMITATIONS/IMPLICATIONS

The authors relied on self-reported risk behavior that may be subject to reporting bias. The sampling strategy may not reflect the true ratio inmates using or not using narcotics.

PRACTICAL IMPLICATIONS

The current harm reduction approach, including methadone substitution treatment should be optimized within the Indonesian prison setting.

ORIGINALITY/VALUE

This is the first study reporting HIV-related risk behavior from an Indonesian prison with an established methadone substitution program.

Routine or targeted HIV screening of Indonesian prisoners

PURPOSE

Routine HIV screening of prisoners is generally recommended, but rarely implemented in low-resource settings. Targeted screening can be used as an alternative. Both strategies may provide an opportunity to start HIV treatment but no formal comparisons have been done of these two strategies. The paper aims to discuss these issues.

DESIGN/METHODOLOGY/APPROACH

The authors compared yield and costs of routine and targeted screening in a narcotic prison in Indonesia. Routine HIV screening was done for all incoming prisoners from August 2007-February 2009, after it was switched for budgetary reasons to targeted ("opt-out") HIV screening of inmates classified as people who inject drugs (PWIDs), and "opt-in" HIV testing for all non-PWIDs.

FINDINGS

During routine screening 662 inmates were included. All 115 PWIDs and 93.2 percent of non-PWIDs agreed to be tested, 37.4 percent and 0.4 percent respectively were HIV-positive. During targeted screening (March 2009-October 2010), of 888 inmates who entered prison, 107 reported injecting drug use and were offered HIV testing, of whom 31 (29 percent) chose not to be tested and 25.0 percent of those tested were HIV-positive. Of 781 non-PWIDs, 187 (24 percent) came for testing (opt-in), and 2.1 percent were infected. During targeted screening fewer people admitted drug use (12.0 vs 17.4 percent). Routine screening yielded twice as many HIV-infected subjects (45 vs 23). The estimated cost per detected HIV infection was 338 USD for routine and 263 USD for targeted screening.

ORIGINALITY/VALUE

In a resource limited setting like Indonesia, routine HIV screening in prison is feasible and more effective than targeted screening, which may be stigmatizing. HIV infections that remain unrecognized can fuel ongoing transmission in prison and lead to unnecessary disease progression and deaths.

Sero-Prevalence of Bloodborne Tumor Viruses (HCV, HBV, HTLV-I and KSHV Infections) and Related Risk Factors among Prisoners in Razavi Khorasan Province, Iran, in 2008

BACKGROUND

Prisoners are at high risk of blood borne and sexually transmitted infections due to their high involvement in risky behaviors. In this descriptive/cross-sectional study, the prevalence, sero-prevalence, and risk factors for bloodborne tumor viruses including HTLV-I, HBV, HCV, and KSHV were evaluated among inmates of two central prisons in the northeast of Iran.

METHODS

Blood samples of 1114 inmates were analyzed for the presence of anti HTLV-I, KSHV, and HCV antibodies and HBsAg by ELISA. PCR tests were performed to confirm the presence of these viruses in plasma and identify the current infections.

RESULTS

The sero-prevalence of HCV, HBV, HTLV-I, and KSHV was 24.5%, 4.2%, 3.4%, and 3.2% and the prevalence of HCV, HBV, HTLV-I, and KSHV was 19.1%, 2.1%, 2%, and 3%, respectively. HCV infection was significantly associated with history of imprisonment, tobacco consumption, alcohol consumption, intravenous drug use, length of imprisonment, and type of crime committed. Thirty one (2.8%) prisoners had HCV-KSHV co-infection, 16 (1.5%) had HCV-HTLV-I co-infection, and 14 (1.3%) had HBV-HCV co-infection. Triple co-infection was observed in seven cases and one case had four infections concomitantly.

CONCLUSIONS

This epidemiological study indicated different rates and transmission risks for these viruses. HCV was the most contagious viral infection and HTLV-I was the weakest in the prisoners. Apart from KSHV infection which its prevalence was as twice as in the general population, the prevalence of HBV and HTLV-I in prisoners was nearly in ranges of the general population.

Women with HIV in Indonesia: are they bridging a concentrated epidemic to the wider community?

Background

Male injecting drug users drove the onset of the HIV epidemic in Indonesia but over time more women have been diagnosed. We examined the relative proportion of female patients in an HIV cohort and characterized their probable transmission route and reproductive profile.

Designs

Prospective cohort study in a referral hospital in West Java.

Methods

Interviews with standardized questionnaires, physical and laboratory examinations were done for 2622 individuals enrolled in HIV care between 2007 and 2012. The proportion of women in this cohort was compared with national estimates. The general characteristics of HIV-infected women and men as well as the sexual and reproductive health of HIV-infected women were described.

Results

The proportion of female patients enrolled in HIV care increased from 22.2 % in 2007 to 38.3 % in 2012, in line with national estimates. Women were younger than men, fewer reported a history of IDU (16.1 vs. 73.8 %, p < 0.001) and more were tested for HIV because of a positive partner (25.5 vs. 4.0 %, p < 0.001). The majority of women were in their reproductive age, had children, and were not using contraceptives at the time of enrolment.

Conclusion

HIV-infected women in Indonesia have specific characteristics that differ them from women in the general population. Further research to elucidate the characteristics of women exposed to HIV, their access to testing and care and sexual and reproductive needs can help reduce transmission to women and children in the context of concentrated HIV epidemic in Indonesia.

HIV-related knowledge and attitudes among Indonesian prison officers

PURPOSE

Prison officers have a vital role in running a secure and healthy living environment for the inmates. The purpose of this article is to examine the relationship between HIV/AIDS-related knowledge and attitude towards inmates living with HIV among the officers in an Indonesian narcotics prison.

DESIGN/METHODOLOGY/APPROACH

A total of 93 officers from a narcotics prison in Bandung, Indonesia voluntarily participated in this cross-sectional study by completing a self-reported questionnaire. A Prior focus group discussion was also held among selected participants.

FINDINGS

Statistical data analyses indicate that all domains of HIV/AIDS-related knowledge, i.e. knowledge of HIV-transmission, general HIV/AIDS knowledge and knowledge of HIV-prevention, have substantial positive correlations with the prison officers' attitude towards inmates living with HIV. These results show that the more knowledgeable the officers are, the less likely they are to respond in an unfavourable manner to inmates living with HIV and vice versa.

RESEARCH LIMITATIONS/IMPLICATIONS

Despite the limited participants involved in this study, the knowledge gaps that are identified in this study should be the starting point for the development of educational interventions for prison officers.

PRACTICAL IMPLICATIONS

Sufficient educational programs and the latest materials need to be made available within the prison.

SOCIAL IMPLICATIONS

Commitment from prison authorities as well as a proper policy are also needed.

ORIGINALITY/VALUE

This study helped prison authorities to identify areas for knowledge development of the officers. Hopefully the positive attitude towards inmates living with HIV will be developed.

Costs of HIV/AIDS treatment in Indonesia by time of treatment and stage of disease

BACKGROUND

We report an economic analysis of Human Immunodeficiency Virus (HIV) care and treatment in Indonesia to assess the options and limitations of costs reduction, improving access, and scaling up services.

METHODS

We calculated the cost of providing HIV care and treatment in a main referral hospital in West Java, Indonesia from 2008 to 2010, differentiated by initiation of treatment at different CD4 cell count levels (0-50, 50-100, 100-150, 150-200, and >200 cells/mm(3)); time of treatment; HIV care and opportunistic infections cost components; and the costs of patients for seeking and undergoing care.

DISCUSSION

Before antiretroviral treatment (ART) initiation, costs were dominated by laboratory tests (>65 %), and after initiation, by antiretroviral drugs (≥60 %). Average treatment costs per patient decreased with time on treatment (e.g. from US$580 per patient in the first 6 month to US$473 per patient in months 19-24 for those with CD4 cell counts under 50 cells/mm(3)). Higher CD4 cell counts at initiation resulted in lower laboratory and opportunistic infection treatment costs. Transportation cost dominated the costs of patients for seeking and undergoing care (>40 %).

CONCLUSIONS

Costs of providing ART are highest during the early phase of treatment. Costs reductions can potentially be realized by early treatment initiation and applying alternative laboratory tests with caution. Scaling up ART at the community level in certain high prevalence settings may improve early uptake, adherence, and reduce transportation costs.

Substance Use and HIV Among Female Sex Workers and Female Prisoners: Risk Environments and Implications for Prevention, Treatment, and Policies

Female sex workers (FSWs) and female prisoners experience elevated HIV prevalence relative to the general population because of unprotected sex and unsafe drug use practices, but the antecedents of these behaviors are often structural in nature. We review the literature on HIV risk environments for FSWs and female prisoners, highlighting similarities and differences in the physical, social, economic, and policy/legal environments that need to be understood to optimize HIV prevention, treatment, and policy responses. Sex work venues, mobility, gender norms, stigma, debt, and the laws and policies governing sex work are important influences in the HIV risk environment among FSWs, affecting their exposure to violence and ability to practice safer sex and safer drug use behaviors. Female prisoners are much more likely to have a drug problem than do male prisoners and have higher HIV prevalence, yet are much less likely to have access to HIV prevention and treatment and access to drug treatment in prison. Women who trade sex or are imprisoned and engage in substance use should not be considered in separate silos because sex workers have high rates of incarceration and many female prisoners have a history of sex work. Repeated cycles of arrest, incarceration, and release can be socially and economically destabilizing for women, exacerbating their HIV risk. This dynamic interplay requires a multisectoral approach to HIV prevention and treatment that appreciates and respects that not all women are willing, able, or want to stop sex work or drug use. Women who engage in sex work, use drugs, or are imprisoned come from all communities and deserve sustained access to HIV prevention and treatment for substance use and HIV, helping them and their families to lead healthy and satisfying lives.

Within-prison drug injection among HIV-infected male prisoners in Indonesia: a highly constrained choice

BACKGROUND

In Indonesia, incarceration of people who inject drugs (PWID) and access to drugs in prison potentiate within-prison drug injection (WP-DI), a preventable and extremely high-risk behavior that may contribute substantially to HIV transmission in prison and communities to which prisoners are released.

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.

The health of female prisoners in Indonesia

Purpose

– Indonesian law provides prisoners with basic rights, including access to education, health care and nutrition. Yet, structural and institutional limitations, notably overcrowding and under-resourcing, prohibits penal institutions from fulfilling these commitments for female prisoners. The purpose of this paper is to explore their health concerns.

Design/methodology/approach

– Six prisons and one detention centre were researched, comprising: female prisoners (n=69); clinical officers (six); clinic heads (seven); wardens (seven); heads of prisons (seven); and a Directorate representative. Data were collected through observation, focus group discussions, in-depth interviews and a semi-structured questionnaire. Raw data were transcribed and analysed thematically, adopting the General Principles of Grounded Theory.

Findings

– Both “formal” and “informal” health-coping strategies were dependent upon a range of factors which determined access to treatment, medicines and other items procured both inside and outside of the prison, as well as referral services. Informal systems of support existed for women, especially in regard to pregnancy and raising of babies born in detention. Systems that maintain harmony within cell blocks were identified as an important informal coping strategy.

Originality/value

– This research is important in informing policy and practice. There is a clear need for gender-sensitive legislative frameworks, penal policies and prison rules to ensure women's needs are addressed. The identified coping strategies were considered viable, but do not replace the need for a health system providing women prisoners with levels of care as available in the community, including commensurate budgeting, personnel, access and referral to more specialised external health services.

Hepatitis B virus prevalence, risk factors and genotype distribution in HIV infected patients from West Java, Indonesia

BACKGROUND

Indonesia currently faces both an increasing HIV incidence and a high hepatitis B virus (HBV) burden.

OBJECTIVE

The objective of our study is to examine the prevalence, risk factors, and genotypic distribution of HBV infection among HIV infected patients in West Java, Indonesia.

STUDY DESIGN

A cross sectional study was conducted among a cohort of HIV infected patients in 2008. Demographic and disease related variables were compared between HBV negative and positive patients. Logistic regression was applied to determine risk factors for HBV co-infection. HBV and HIV genotyping was performed in co-infected patients.

RESULTS

Of 636 HIV-infected patients, the rate of HBV co-infection was 7%. The proportion of males was higher in HBV/HIV co-infected patients than in HIV mono-infected patients (93% vs. 72%, P=0.001). A history of injecting drug use (IDU), but not tattooing, was associated with HBV co-infection [P=0.035 OR 2.41 (95% CI 1.06-5.47)]. In the HIV and HBV treatment naive patients, CD4 cells counts <50cells/mm(3), HIV-RNA plasma ≥10,000copies/ml and AST level above normal were more often found in patients with high HBV-DNA levels (≥20,000IU/ml) as compared to those with low HBV DNA (<20.000IU/ml) (P<0.05). As in the general population, B3 was the dominant subtype in HBV co-infected patients.

CONCLUSION

The prevalence of active HBV infection and the genotype distribution among HIV infected individuals is similar to the overall population in Java. However, an increased prevalence was observed in men with a history of IDU, underlining the need for routine HBV screening and monitoring.

Detection of highly prevalent hepatitis B virus co-infection with HIV in Indonesia

AIM

The prevalence of hepatitis B virus (HBV) co-infection with HIV is increasing worldwide because of shared transmission routes. This study aimed to assess the prevalence of HBV and HIV co-infection in Indonesia, and its molecular and clinical characteristics.

METHODS

A total of 118 serum samples from HIV-infected patients (age 33.3 ± 8.9 years, 99 male, 19 female) collected in 2009 were serologically examined. HBV DNA was assessed by polymerase chain reaction (PCR) analysis targeting the S region.

RESULTS

Overall, 15.3% (18/118) of the patients were hepatitis B surface antigen (HBsAg) positive, whereas 27.1% (32/118) were HBsAg negative but HBV DNA positive, and were considered to have occult HBV infection. HBsAg antibodies and/or HBV core antibodies were detected in 45.6% (31/68) of HBV DNA negative patients.

CONCLUSION

HBV co-infection, including occult HBV infection, was common in Indonesian HIV patients. Hepatic damage by the interaction of host immunity and HBV is still a remaining issue in these immunosuppressive patients, and further study will be needed.

Virological failure and drug resistance during first line anti-retroviral treatment in Indonesia

The virological response and development of drug resistance during first-line anti-retroviral treatment (ART) were studied in Indonesia where the majority of patients infected with HIV have a history of injecting drug use, which is often linked with lower treatment adherence and development of drug-resistance. As many as 575 patients starting ART between September 2007 and March 2010 in Hasan Sadikin Hospital Bandung were followed prospectively. Clinical and laboratory monitoring was performed every 6 months. Plasma samples with HIV-RNA ≥ 400 copies/ml were examined for drug resistance mutations. Most patients were male (72.3%), 59.7% had a history of injecting drug use, and the median CD4+ cells count before start of ART was 35 cells/mm(3) (IQR 10-104). From 438 HIV patients with HIV-RNA measurements, 40 (9.1%) subjects had HIV-RNA ≥ 400 copies/ml after 24 weeks (median follow-up 16 (IQR 8-25) months). Of these failing patients 16 (47%) subjects had drug resistance mutations, predominantly M184V (35.3%), Y181C (23.5%), K103N (11.7%), and TAMs (11.7%). A history of treatment discontinuation ≥ 1 month, reported by 5.3% (23) of patients, was strongly associated with virological failure (adjusted OR 12.64, 95% CI 4.51-35.41); and a history of injecting drug use was not (OR 0.75, 95% CI 0.38-1.46). This is the largest and most systematic evaluation of virological response to first line ART in Indonesia. Patients in this cohort responded well to first line ART, with low rates of virological failure and drug resistance. A history of injecting drug use should not be a reason to withhold ART in this setting.

Risk prison and hepatitis B virus infection among inmates with history of drug injection in Isfahan, Iran

Objectives. Hepatitis B virus (HBV) is a health problem among injection drug users (IDUs) in prison. The aim of this study is to evaluate the association of factors of incarceration with HBV infection in prisoners with history of drug injection in Isfahan, Iran. Methods. In a cross-sectional study, all IDUs inmates were enrolled. Sociodemographic characteristics and associated risk factors were obtained. Blood samples were collected and serological markers for HBV were analyzed. For data analysis, odds ratio and logistic regression were used. Results. Of the IDUs inmates, 970 subjects participated in the study. History of imprisonment (OR: 1.82, 95% CI: 1.28–2.57), multiple incarceration (OR: 1.43, 95% CI: 1.01–2.02), and total duration of imprisonment (OR: 2.70, 95% CI: 1.94–3.74) were significantly associated with prevalence of HBV among IDUs inmates. Multivariate analysis of associated factors showed that only total duration of incarceration is significantly associated with HBV infection. Conclusion. In conclusion, according to our results, multiple and duration of incarcerations will be considered as important risk factors of HBV infection in IDUs inmates. This fact makes it important to set some screening and prevention programs in prisons to decrease the risk of being infected and prevent the transmission of these diseases.

Clinical and virological characteristics of hepatitis B or C virus co-infection with HIV in Indonesian patients

Hepatitis virus-related liver disease increases substantially the mortality rate of patients with HIV on highly active antiretroviral therapy (HAART). Therefore, early diagnosis of hepatitis B virus (HBV) and hepatitis C virus (HCV) is important. However, the prevalence of HBV and HCV infection in Indonesian patients infected with HIV is unknown. Therefore, this study examined the molecular and clinical characteristics of HBV and HCV in 126 patients infected with HIV, mostly on HAART, at Dr. Sardjito Hospital, Yogyakarta, Indonesia. The rates of triple infection, HIV/HCV co-infection, HIV/HBV co-infection, and mono-infection were 4.8%, 34.1%, 3.2%, and 57.9%, respectively. Seven HCV genotypes were detected, with genotypes 1a, 1b, 1c, 3a, 3k, 4a, and 6n found in 23 (52%), 1 (2%), 4 (9%), 5 (11%), 7 (16%), 3 (6%), and 1 (2%) patients, respectively, indicating multiple modes of transmission. HBV-DNA was detected in 2/10 patients with hepatitis B surface antigen; both patients were HAART naive. Univariate analysis revealed that male sex, higher education level, injection drug use, sexual contact, alanine aminotransferase ≥40 IU/L, and aspartate aminotransferase-to-platelet ratio index > 0.5 were associated with HCV co-infection. In multivariate analysis, injection drug use (OR: 26.52; 95% CI: 3.52-199.54) and alanine aminotransferase ≥40 IU/L (OR: 6.36; 95% CI: 1.23-32.89) were independently associated with HCV co-infection. HCV co-infection was common among Indonesian patients infected with HIV, particularly among injecting drug users, and was a risk factor for disease progression of HIV.

Challenges in Providing Treatment and Care for Viral Hepatitis among Individuals Co-Infected with HIV in Resource-Limited Settings

Hepatitis B and C infections are prevalent among HIV-infected individuals with different epidemiologic profiles, modes of transmission, natural histories, and treatments. Southeast Asian countries are classified as "highly prevalent zones," with a rate of hepatitis B and C coinfection in people living with HIV/AIDS of approximately 3.2-11%. Majority of hepatitis B coinfection is of genotype C. Most of the patients infected with hepatitis C in Thailand have genotype 3 which is significantly related to intravenous drug use whereas, in Vietnam, it is genotype 6. The options for antiretroviral drugs are limited and rely on global funds and research facilities. Only HBV treatment is available for free through the national health scheme. Screening tests for HBV and HCV prior to commencing antiretroviral treatment are low. Insufficient concern on hepatitis-virus-related liver malignancy and long-term hepatic morbidities is noted. Cost-effective HCV treatment can be incorporated into the national health program for those who need it by utilizing data obtained from clinical research studies. For example, patients infected with HCV genotype 2/3 with a certain IL-28B polymorphism can be treated with a shorter course of interferon and ribavirin which can also help reduce costs.