Azar Kariminia

Factors associated with mortality in a cohort of Australian prisoners

We examined factors associated with increased mortality in a cohort of 85,203 adults with a history of imprisonment in New South Wales, Australia, between 1988 and 2002. Information on death was collected through linkage to the Australian National Death Index. The influence of demographic and criminological factors on the standardised mortality ratio (SMR) for all-cause mortality, and deaths due to drug overdose and suicide was examined using negative binomial regression models. The number of deaths identified was 5,137 (4,714 men, 423 women, 303 in custody). The overall SMR was 3.7 (3.6–3.8) in men and 7.8 (7.1–8.5) in women. SMRs raised for deaths due to drug overdose (men: 12.8, women: 50.3) and suicide (men: 4.8, women: 12.2). The high SMR was associated with hospitalisation for mental illness, multiple imprisonments, and early stage of follow-up independently of causes of death. Being released from prison increased the SMRs for all-cause and drug-related mortality, but not suicide. For women, significant trends for decreasing risk with increasing age were noted. Minority groups, in particular men, had a lower risk of death than white people. In men a sex or drug offence was associated with a lower risk and a property or violence offence was related to higher mortality. Our results reinforce how disadvantaged prisoners are, measured by mortality as the most fundamental scale of human wellbeing. Certain demographic and imprisonment characteristics are indicators of high mortality among this population. The underlying causes of some of these characteristics such as mental illness or multiple imprisonments are potentially treatable and preventable. Prison health services need to develop interventions targeting high-risk groups to avoid this situation.

Prisoners are at risk for hepatitis C transmission

Objective: Determine the incidence of hepatitis C virus antibodies among a cohort of prisoners. Design: Follow-up study of a random sample of prisoners who participated in a cross-sectional survey in 1996. Setting: 29 correctional centres in New South Wales (Australia). Participants: 181 adult prisoners (163 men and 18 women). Results: The incidence of hepatitis C virus antibody among the 90 inmates who were seronegative at the first test in 1996 was 7.1 per 100 person-years (16 seroconverters). Among the 90 inmates, 37 had re-entered the prison system following release into the community and 53 had been continuously detained. The seroconversion rate was higher among the re-entrants compared with those who had been continuously incarcerated (10.8 vs. 4.5 per 100 person-years, p=0.07). However, when the data was stratified by injecting status, the seroconversion rate in the two groups was similar. Most of the seroconverters had histories of injecting drug users (14/16). The overall incidence among injectors was 19.3 per 100 person years (95% CI: 9.1–29.2). Conclusions: Hepatitis C transmission occurs inside the prison with injecting drug use the likely cause. Among non-injectors, tattooing was the most likely mode of transmission. Harm minimisation measures with proven effectiveness need to be considered for this environment.

Mental health status of Aboriginal and non-Aboriginal Australian prisoners

Objective: To compare the mental health of Aboriginal and non-Aboriginal prisoners in New South Wales. Methods: The sample consisted of a cross-sectional random sample of sentenced prisoners, and a consecutive sample of reception prisoners. The sample was drawn from 29 correctional centres (27 male, two female) across New South Wales. Overall, 1208 men (226 Aboriginal), and 262 women (51 Aboriginal) participated in the study. Mental illness was detected using the Composite International Diagnostic Interview (CIDI-A) and a number of other screening measures incorporated into the programme. Results: No differences were detected in mental illness between Aboriginal and non-Aboriginal men, apart from depression, which was lower in the latter group. Aboriginal woman were more likely than non-Aboriginal women to screen positive for symptoms of psychosis in the prior 12 months and have a higher 1 month and 12 month prevalence of affective disorder; they also had higher psychological distress scores. Suicidal thoughts and attempts were the same in both groups. Conclusions: These findings confirm that the demand for mental health services in prisons is considerable, and that Aboriginal women are one of the most vulnerable groups. Services and programmes providing an alternative to incarceration are needed, as are culturally sensitive approaches to treatment.

The self-reported health status of prisoners in New South Wales.

Objective:To describe the physical health of the New South Wales prisoner population.

Outcomes of antiretroviral therapy in children in Asia and Africa: a comparative analysis of the IeDEA pediatric multiregional collaboration.

Background:We investigated 18-month incidence and determinants of death and loss to follow-up of children after antiretroviral therapy (ART) initiation in a multiregional collaboration in lower-income countries. Methods:HIV-infected children (positive polymerase chain reaction <18 months or positive serology ≥18 months) from International Epidemiologic Databases to Evaluate AIDS cohorts, <16 years, initiating ART were eligible. A competing risk regression model was used to analyze the independent risk of 2 failure types: death and loss to follow-up (>6 months). Findings:Data on 13,611 children, from Asia (N = 1454), East Africa (N = 3114), Southern Africa (N = 6212), and West Africa (N = 2881) contributed 20,417 person-years of follow-up. At 18 months, the adjusted risk of death was 4.3% in East Africa, 5.4% in Asia, 5.7% in Southern Africa, and 7.4% in West Africa (P = 0.01). Age < 24 months, World Health Organization stage 4, CD4 < 10%, attending a private sector clinic, larger cohort size, and living in West Africa were independently associated with poorer survival. The adjusted risk of loss to follow-up was 4.1% in Asia, 9.0% in Southern Africa, 14.0% in East Africa, and 21.8% in West Africa (P < 0.01). Age < 12 months, nonnucleoside reverse transcriptase inhibitor I–based ART regimen, World Health Organization stage 4 at ART start, ART initiation after 2005, attending a public sector or a nonurban clinic, having to pay for laboratory tests or antiretroviral drugs, larger cohort size, and living in East Africa or West Africa were significantly associated with higher loss to follow-up. Conclusions:Findings differed substantially across regions but raise overall concerns about delayed ART start, low access to free HIV services for children, and increased workload on program retention in lower-income countries. Universal free access to ART services and innovative approaches are urgently needed to improve pediatric outcomes at the program level.

Counting the cost: estimating the number of deaths among recently released prisoners in Australia.

OBJECTIVE To estimate the number of deaths among people released from prison in Australia in the 2007-08 financial year, within 4 weeks and 1 year of release. DESIGN, PARTICIPANTS AND SETTING Application of crude mortality rates for ex-prisoners (obtained from two independent, state-based record-linkage studies [New South Wales and Western Australia]) to a national estimate of the number and characteristics of people released from prison in 2007-08. MAIN OUTCOME MEASURES Estimated number of deaths among adults released from Australian prisons in 2007-08, within 4 weeks and 1 year of release, classified by age, sex, Indigenous status and cause of death. RESULTS It was estimated that among people released from prison in 2007-08, between 449 (95% CI, 380-527) and 472 (95% CI, 438-507) died within 1 year of release. Of these, between 68 (95% CI, 56-82) and 138 (95% CI, 101-183) died within 4 weeks of release. Most of these deaths were not drug-related. CONCLUSION The estimated annual number of deaths among recently released prisoners in Australia is considerably greater than the annual number of deaths in custody, highlighting the extreme vulnerability of this population on return to the community. There is an urgent need to establish a national system for routine monitoring of ex-prisoner mortality and to continue the duty of care beyond the prison walls.TO THE EDITOR: Kinner and colleagues described the high proportion of deaths among recently released prisoners in Australia...

Mortality among prisoners: how accurate is the Australian National Death Index?

Objective: The effectiveness of the National Death Index (NDI) in identifying deaths among different populations has been studied before. Prisoners represent a segment of the population that might be expected to be difficult to link. The objective of this research was to evaluate the accuracy of the Australian NDI to ascertain the mortality status of prisoners in New South Wales, Australia.

Survival of HIV-Infected Children: A Cohort Study From the Asia-Pacific Region

Background:Combination antiretroviral therapy (ART) has been used for HIV-infected children in many Asian countries since 2002. This study describes survival outcomes among HIV-infected children in a multicenter regional cohort in Asia. Patients and Methods:Retrospective and prospective data collected through March 2009 from children in 5 countries enrolled in TREAT Asias Pediatric HIV Observational Database were analysed. Multivariate Cox proportional hazard models were used to assess factors associated with mortality in children who received ART. Results:Among 2280 children, 1752 (77%) had received ART. During a median follow-up of 3.1 years after ART, 115 (6.6%) deaths occurred, giving a crude mortality rate of 1.9 per 100 child-years [95% confidence interval (CI): 1.6 to 2.4]. The mortality rate was highest in the first 3 months of ART (10.2 per 100 child-years; 95% CI: 7.5 to 13.7) and declined after 12 months (0.9 per 100 child-years; 95% CI: 0.7 to 1.3). Those with a low recent CD4 percentage, who started ART with lower baseline weight-for-age Z score, or with WHO clinical stage 4 had an increased risk of death. Of 528 (23%) children who never received ART, 36 (6.8%) died after presenting to care, giving a crude mortality rate of 4.1 per 100 child-years (95% CI: 3.0 to 5.7), with a lost-to-program rate of 31.5 per 100 child-years (95% CI: 28.0 to 35.5). Conclusions:The high mortality during the first 3 months of ART and in those with low CD4 percentage support the implementation of early diagnosis and ART initiation.

Cohort profile: the TREAT Asia pediatric HIV observational database.

This cohort profile focuses on the Therapeutic Research Education and AIDS Training (TREAT) Asia Pediatric HIV Observational Database (TApHOD) a collaborative cohort of HIV-infected children in the Asia-Pacific region. It describes many aspects of this cohort including: how it was established the objectives the sample characteristics of participating sites patient characteristics measurements findings attrition strengths and weaknesses and funding information.

Aboriginal and non‐Aboriginal health differentials in Australian prisoners

Objective: Compare the self‐reported physical and mental health of Aboriginal and non‐Aboriginal prisoners in New South Wales (NSW).