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

Prescribing methadone in prison predicts linkage to HIV care after release from prison: A randomized and patient preference trial

PURPOSE

The transition from prison is hazardous, especially for people with HIV and opioid use disorder. To determine the impact of methadone on linkage to HIV care in people with HIV and opioid use disorder, we prospectively compared those allocated to pre-release methadone or not.

METHODS

A prospective, open-label trial of 310 people with HIV and opioid use disorder at Malaysia's largest prison were allocated to pre-release methadone up to 24 weeks before release or not by randomization (n = 64) or preference (n = 246); 296 were included in the final analytical sample. Directed acyclic graphing was used to theorize the relationship between pre-release methadone and post-release linkage to HIV care and identify confounding variables. An inverse probability weighted Cox proportional hazards model estimated the impact of pre-release methadone on linkage to HIV care through 360 days after release.

RESULTS

Overall, 218 (73.6 %) of 296 study participants initiated methadone before release. Receiving pre-release methadone significantly predicted linkage to HIV care at all time points through 360 days (aHR = 1.87; 95 % CI 1.15-2.85) after release. The corresponding numbers needed to treat with pre-release methadone for one increased linkage to HIV care at 30 and 360 days were 14 (95 % CI 9.2-62.4) and 5 (95 % CI 3.4-22.0), respectively.

CONCLUSIONS

While treatment with methadone should be available to everyone with opioid use disorder, it should especially be included as part of an HIV treatment-as-prevention strategy for people in prisons, especially by the time of release. It can optimize HIV treatment outcomes by jumpstarting the HIV treatment cascade.

Feasibility of a mHealth survey application for incarcerated and postrelease people living with HIV in a low-resource setting

Mobile health (mHealth) holds considerable promise as a way to give people greater control of their health information, privacy, and sharing in the context of HIV research and clinical services. The purpose of this study was to determine the feasibility of an mHealth research application from the perspective of three stakeholder groups involved in an HIV clinical trial in Jakarta, Indonesia: (a) incarcerated people living with HIV (PLWH), (b) research assistants (RAs), and (c) research investigators. Incarcerated PLWH (n = 150) recruited from two large all-male prisons completed questionnaires, including questions about mHealth acceptability, on an mHealth survey application using a proprietary data collection software development platform. RAs who administered questionnaires (n = 8) rated the usability of the software application using the system usability scale (SUS) and open-ended questions. Research investigators (n = 2) completed in-depth interviews, that were coded and analyzed using the technology acceptance model (TAM) as a conceptual framework. Over 90% of incarcerated PLWH felt the mHealth application offered adequate comfort, privacy, and accuracy in recording their responses. RAs' SUS scores ranged from 60% to 90% (M = 76.25) and they found the mHealth survey application challenging to learn, but highly satisfying. Compared with paper-based data collection, researchers felt that electronic data collection led to improved accuracy and efficiency of data collection and the ability to monitor data collection remotely and in real time. The researchers perceived the learnability of the application as acceptable but required self-instruction.

Exploring the acceptability of HIV partner notification in prisons: Findings from a survey of incarcerated people living with HIV in Indonesia

Assisted HIV partner notification services provide a safe and effective way for people living with HIV (PLHIV) to inform their partners about the possibility of exposure and to offer them testing, treatment, and support. This study examined whether or not PLHIV in prison might be willing to participate in assisted HIV partner notification services and their reasons for and against disclosing their HIV-positive status to their partners. PLHIV (n = 150) recruited from Jakarta's two largest all-male prisons completed an interviewer-administered questionnaire collecting demographic and risk behavior data, and attitudes toward HIV disclosure and partner services. Among those who were sexually active and/or injecting drugs before incarceration, two-thirds (66.4%, 91/137) endorsed provider referral as an acceptable way to notify their sex partners, and nearly three quarters (72.4%, 89/123) endorsed provider referral to notify their drug-injecting partners. Only a quarter (25.1%) of participants reported that their main sex partner had ever received an HIV test. Participants with anticipated stigma were less likely to endorse provider referral for sex partners (adjusted odds ratio [aOR] = 0.58, 95% CI: 0.35, 0.96) and drug-injecting partners (aOR = 0.54, 95% CI: 0.29, 1.00). Relationship closeness was associated with higher odds of endorsing provider referral for drug-injecting partners (aOR = 2.08, 95% CI: 1.25, 3.45). Protecting partners from infection and a moral duty to inform were main reasons to disclose, while stigma and privacy concerns were main reasons not to disclose. Most incarcerated PLHIV have at-risk partners in the community who they would be willing to notify if provided with assistance. Assisted partner notification for prison populations offers a promising public health approach to accelerate diagnosis, treatment, and prevention of HIV infection in the community, particularly among women.

The Mortality After Release from Incarceration Consortium (MARIC): Protocol for a multi-national, individual participant data meta-analysis

INTRODUCTION

More than 30 million adults are released from incarceration globally each year. Many experience complex physical and mental health problems, and are at markedly increased risk of preventable mortality. Despite this, evidence regarding the global epidemiology of mortality following release from incarceration is insufficient to inform the development of targeted, evidence-based responses. Many previous studies have suffered from inadequate power and poor precision, and even large studies have limited capacity to disaggregate data by specific causes of death, sub-populations or time since release to answer questions of clinical and public health relevance.

OBJECTIVES

To comprehensively document the incidence, timing, causes and risk factors for mortality in adults released from prison.

METHODS

We created the Mortality After Release from Incarceration Consortium (MARIC), a multi-disciplinary collaboration representing 29 cohorts of adults who have experienced incarceration from 11 countries. Findings across cohorts will be analysed using a two-step, individual participant data meta-analysis methodology.

RESULTS

The combined sample includes 1,337,993 individuals (89% male), with 75,795 deaths recorded over 9,191,393 person-years of follow-up.

CONCLUSIONS

The consortium represents an important advancement in the field, bringing international attention to this problem. It will provide internationally relevant evidence to guide policymakers and clinicians in reducing preventable deaths in this marginalized population.

KEY WORDS

Mortality; incarceration; prison; release; individual participant data meta-analysis; consortium; cohort.

Prisons: ignore them at our peril

PURPOSE OF REVIEW

People with HIV and HCV are concentrated within criminal justice settings globally, primarily related to criminalization of drug use. This review examines updated prevention and treatment strategies for HIV and HCV within prison with a focus on people who inject drugs and the challenges associated with the provision of these services within prisons and other closed settings and transition to the community.

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.

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.

Are there differences in HIV retention in care between female and male patients in Indonesia? A multi-state analysis of a retrospective cohort study

BACKGROUND

Little is known about HIV treatment outcomes in Indonesia, which has one of the most rapidly growing HIV epidemics worldwide.

METHODS

We examined possible differences in loss to follow-up (LTFU) and survival between HIV-infected females and males over a 7-year period in an HIV clinic in Bandung, West Java. Data imputation was performed on missing covariates and a multi-state Cox regression was used to investigate the effects of sex and other covariates on patient transitions among four states: (1) clinic enrollment with HIV, (2) initiation/continuation/re-initiation of antiretroviral therapy (ART), (3) LTFU, and (4) death.

RESULTS

We followed 3215 patients (33% females), for a total of 8430 person-years. ART was used by 59% of patients at some point. One-year retention was 73% for females and 77% for males (p = 0.06). One-year survival was 98% for both females and males (p = 0.15). Females experienced a higher relative hazard to transition from HIV to LTFU (adjusted hazard ratio 1.21; 95% confidence interval 1.00-1.45), but this decreased after adjustments for clinical variables (aHR 0.94; 95% CI 0.79-1.11). Similarly, a lower relative hazard in females to transition from ART to death (aHR 0.59; 95% CI 0.35-0.99) decreased after adjustments for demographic variables.

CONCLUSION

This Indonesian cohort has low ART uptake and poor overall pre- and post-ART retention. Female-male differences in survival and retention were gone after adjusting for clinical and sociodemographic factors such as CD4 count and education level. Efforts should be made to improve retention among patients with lower education.

Retention in clinical trials after prison release: results from a clinical trial with incarcerated men with HIV and opioid dependence in Malaysia

Background: Study retention is a major challenge in HIV clinical trials conducted with persons recruited from correctional facilities. Objective: To examine study retention in a trial of within-prison methadone initiation and a behavioral intervention among incarcerated men with HIV and opioid dependence in Malaysia. Methods: In this 2x2 factorial trial, 296 incarcerated men with HIV and opioid dependence were allocated to (1) an HIV risk reduction intervention, the Holistic Health Recovery Program for Malaysia (HHRP-M), (2) pre-release methadone initiation, (3) both interventions, or (4) standard care (NCT02396979). Here we estimate effects of these interventions on linkage to the study after prison release and completion of post-release study visits. Results: Most participants (68.9%) completed at least one post-release study visit but few (18.6%) completed all 12. HHRP-M was associated with a 13.5% (95% confidence interval (CI): 3.8%, 23.2%) increased probability of completing at least one post-release study visit. Although not associated with initial linkage, methadone treatment was associated with an 11% (95% CI: 2.0%, 20.6%) increased probability of completing all twelve post-release study visits. Being subject to forced relocation outside Kuala Lumpur after prison release decreased retention by 43.3% (95% CI: -51.9%, -34.8%). Conclusion: Retaining study participants in HIV clinical trials following prison release is challenging and potentially related to the broader challenges that participants experience during community reentry. Researchers conducting clinical trials with this population may want to consider methadone and HHRP as means to improve post-release retention, even in clinical trials where these interventions are not being directly evaluated.

All-cause mortality among people with HIV released from an integrated system of jails and prisons in Connecticut, USA, 2007-14: a retrospective observational cohort study

BACKGROUND

People transitioning from prisons or jails have high mortality, but data are scarce for people with HIV and no studies have integrated data from both criminal justice and community settings. We aimed to assess all-cause mortality in people with HIV released from an integrated system of prisons and jails in Connecticut, USA.

METHODS

We linked pharmacy, custodial, death, case management, and HIV surveillance data from Connecticut Departments of Correction and Public Health to create a retrospective cohort of all adults with HIV released from jails and prisons in Connecticut between 2007 and 2014. We compared the mortality rate of adults with HIV released from incarceration with the general US and Connecticut populations, and modelled time-to-death from any cause after prison release with Cox proportional hazard models.

FINDINGS

We identified 1350 people with HIV who were released after 24 h or more of incarceration between 2007 and 2014, of whom 184 (14%) died after index release; median age was 45 years (IQR 39-50) and median follow-up was 5·2 years (IQR 3·0-6·7) after index release. The crude mortality rate for people with HIV released from incarceration was 2868 deaths per 100 000 person-years, and the standardised mortality ratio showed that mortality was higher for this cohort than the general US population (6·97, 95% CI 5·96-7·97) and population of Connecticut (8·47, 7·25-9·69). Primary cause of death was reported for 170 individuals; the most common causes were HIV/AIDS (78 [46%]), drug overdose (26 [15%]), liver disease (17 [10%]), cardiovascular disease (16 [9%]), and accidental injury or suicide (13 [8%]). Black race (adjusted hazard ratio [HR] 0·52, 95% CI 0·34-0·80), having health insurance (0·09, 0·05-0·17), being re-incarcerated at least once for 365 days or longer (0·41, 0·22-0·76), and having a high percentage of re-incarcerations in which antiretroviral therapy was prescribed (0·08, 0·03-0·21) were protective against mortality. Positive predictors of time-to-death were age (≥50 years; adjusted HR 3·65, 95% CI 1·21-11·08), lower CD4 count (200-499 cells per μL, 2·54, 1·50-4·31; <200 cells per μL, 3·44, 1·90-6·20), a high number of comorbidities (1·86, 95% CI 1·23-2·82), virological failure (2·76, 1·94-3·92), and unmonitored viral load (2·13, 1·09-4·18).

INTERPRETATION

To reduce mortality after release from incarceration in people with HIV, resources are needed to identify and treat HIV, in addition to medical comorbidities, psychiatric disorders, and substance use disorders, during and following incarceration. Policies that reduce incarceration and support integrated systems of care between prisons and communities could have a substantial effect on the survival of people with HIV.

FUNDING

US National Institutes of Health.

Cultural Adaptation of a Medication Adherence Intervention With Prisoners Living With HIV in Indonesia: A Pragmatic Approach to Intervention Development

Cultural adaptation is a research strategy used to tailor evidence-informed interventions for new populations and settings. We describe a pragmatic approach used to culturally adapt a nurse-led medication adherence intervention, Adherence Through Home Education and Nursing Assessment (ATHENA), for prisoners living with HIV in Indonesia. Researchers reviewed data from completed studies in Indonesia and identified core components of the ATHENA intervention considered essential for effectiveness. Adaptations likely to render ATHENA acceptable and feasible in the Indonesian prison setting were proposed. An intervention led by nurses and peer educators was feasible and congruent with existing models in Indonesian prisons. Involving prisoners with HIV in successive developmental phases helped to ensure a good cultural fit. In the context of prisons and other freedom-limiting environments, a pragmatic approach that integrates members of the target population within an anti-oppressive Freirian pedagogical framework is highly appropriate for adapting evidence-informed interventions.