Gabriel J. Culbert

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.

Correlates and Experiences of HIV Stigma in Prisoners Living With HIV in Indonesia: A Mixed-Method Analysis.

&NA; In Indonesia, the syndemic nature of HIV, drug use, and incarceration may influence experiences of stigma for HIV‐infected prisoners. This mixed‐method study explores HIV stigma in prisoners living with HIV in Indonesia. Randomly selected male HIV‐infected prisoners (n = 102) from two large prisons in Jakarta completed in‐depth interviews and a structured HIV stigma survey. Quantitative results found four groups of HIV‐infected prisoners with significantly higher HIV stigma levels, including those: (a) with drug‐related offenses, (b) seeking help to decrease drug use, (c) diagnosed with HIV before the current incarceration, and (d) who had not disclosed their HIV status to family members or friends. Qualitative results highlighted the prominent role of HIV stigma in decisions to disclose HIV status to family members, partners, and other prisoners. Interventions should address HIV stigma in HIV‐infected prisoners in Indonesia to achieve HIV treatment as prevention goals.

Understanding the Health Needs of Incarcerated Men Living With HIV/AIDS: A Primary Health Care Approach

Nearly 20% of American men with HIV/AIDS pass through a correctional facility each year. As these men pass through the criminal justice system, discontinuation of health care access and nonadherence to prescribed treatments often occur. Men who are not engaged in health care during and after incarceration are at risk for treatment interruption and disease progression. Correctional facilities are therefore important sites for secondary prevention of HIV/AIDS. Unprecedented scientific attention and resources are currently directed at detecting and treating HIV in the criminal justice system. To support these efforts to increase health care access, we must have a better understanding of the cultural and situational factors that structure opportunities for secondary prevention during incarceration and during the transition from correctional facilities back into the community. This article presents a timely review of the literature on the health needs of incarcerated men living with HIV/AIDS. The author uses the primary health care framework to describe the movement of HIV-positive men through the criminal justice system as a series of strategic opportunities to initiate and establish a process of care. The author concludes that although we understand many of the challenges of providing care to men who become incarcerated, and have evidence of effective health-promoting services, we are only beginning to understand how to make health care services accessible and acceptable to HIV-positive male inmates, and we have not yet used some proven HIV prevention tools.

Healthcare resources are inadequate to address the burden of illness among HIV-infected male prisoners in Malaysia

Purpose Criminalization of drug use in Malaysia has concentrated people who inject drugs (PWID) and people living with HIV into prisons where health services are minimal and HIV-related mortality is high. Few studies have comprehensively assessed the complex health needs of this population. The paper aims to discuss these issues. Design/methodology/approach From October 2012 through March 2013, 221 sequentially selected HIV-infected male prisoners underwent a comprehensive health assessment that included a structured history, physical examination, and clinically indicated diagnostic studies. Findings Participants were mostly PWID (83.7 percent) and diagnosed with HIV while incarcerated (66.9 percent). Prevalence of hepatitis C virus (90.4 percent), untreated syphilis (8.1 percent), active (13.1 percent), and latent (81.2 percent) tuberculosis infection was several fold higher than non-prisoner Malaysian adults, as was tobacco use (71.9 percent) and heavy drinking (30.8 percent). Most (89.5 percent) were aware of their HIV status before the current incarceration, yet few had been engaged previously in HIV care, including pre-incarceration CD4 monitoring (24.7 percent) or prescribed antiretroviral therapy (ART) (16.7 percent). Despite most (73.7 percent) meeting Malaysias criteria for ART (CD4 <350 cells/ μL), less than half (48.4 percent) ultimately received it. Nearly one-quarter (22.8 percent) of those with AIDS (<200 cells/ μL) did not receive ART. Originality/value Drug addiction and communicable disease comorbidity, which interact negatively and synergistically with HIV and pose serious public health threats, are highly prevalent in HIV-infected prisoners. Interventions to address the critical shortage of healthcare providers and large gaps in treatment for HIV and other co-morbid conditions are urgently needed to meet the health needs of HIV-infected Malaysian prisoners, most of whom will soon transition to the community.

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.

Design and implementation of a factorial randomized controlled trial of methadone maintenance therapy and an evidence-based behavioral intervention for incarcerated people living with HIV and opioid dependence in Malaysia

Incarcerated people living with HIV and opioid dependence face enormous challenges to accessing evidence-based treatment during incarceration and after release into the community, placing them at risk of poor HIV treatment outcomes, relapse to opioid use and accompanying HIV transmission risk behaviors. Here we describe in detail the design and implementation of Project Harapan, a prospective clinical trial conducted among people living with HIV and opioid dependence who transitioned from prison to the community in Malaysia from 2010 to 2014. This trial involved 2 interventions: within-prison initiation of methadone maintenance therapy and an evidence-based behavioral intervention adapted to the Malaysian context (the Holistic Health Recovery Program for Malaysia, HHRP-M). Individuals were recruited and received the interventions while incarcerated and were followed for 12months after release to assess post-release HIV transmission risk behaviors and a range of other health-related outcomes. Project Harapan was designed as a fully randomized 2×2 factorial trial where individuals would be allocated in equal proportions to methadone maintenance therapy and HHRP-M, methadone maintenance therapy alone, HHRP-M alone, or control. Partway through study implementation, allocation to methadone maintenance therapy was changed from randomization to participant choice; randomization to HHRP-M continued throughout. We describe the justification for this study; the development and implementation of these interventions; changes to the protocol; and screening, enrollment, treatment receipt, and retention of study participants. Logistical, ethical, and analytic issues associated with the implementation of this study are discussed.

Physician Decisions to Defer Antiretroviral Therapy in Key Populations: Implications for Reducing HIV Incidence and Mortality in Malaysia.

Abstract Background Antiretroviral therapy (ART) is recommended for all people living with human immunodeficiency virus (HIV), yet physician attitudes and prescribing behaviors toward members of key risk populations may limit ART access and undermine treatment as prevention strategies. Methods Physicians in Malaysia (N = 214) who prescribe antiretroviral therapy (ART) responded in an Internet-based survey to hypothetical clinical scenarios of HIV patients, varying by key risk population and CD4+ T-cell count, on whether they would initiate or defer ART compared with a control patient with sexually acquired HIV. Results The proportion of physicians who would defer ART in patients with advanced HIV (CD4 = 17 cells/μL) was significantly higher (P < .0001) for 4 key populations, including people who inject drugs ([PWID] 45.3%) or consume alcohol (42.1%), released prisoners (35.0%), and those lacking social support (26.6%), compared with a control patient (4.2%). People who inject drugs with advanced HIV (CD4 = 17 cells/μL) were 19-fold (adjusted odds ratio [AOR] = 18.9; 95% confidence interval [CI], 9.8–36.5) more likely to have ART deferred compared with the control. This effect was partially mitigated for PWID receiving methadone (AOR = 2.9; 95% CI, 1.5–5.7). At the highest CD4+ T-cell count (CD4 = 470 cells/μL), sex workers (AOR = 0.55; 95% CI, .44–.70) and patients with an HIV-uninfected sexual partner (AOR = 0.43; 95% CI, .34–.57) were significantly less likely to have ART deferred. Conclusions Physicians who prescribe antiretroviral therapy in Malaysia may defer ART in some key populations including PWID and released prisoners, regardless of CD4+ T-cell count, which may help to explain very low rates of ART coverage among PWID in Malaysia. Reducing HIV incidence and mortality in Malaysia, where HIV is concentrated in PWID and other key populations, requires clinician-level interventions and monitoring physician adherence to international evidence-based treatment guidelines.

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

&NA; 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.