Arresting HIV in Malawi prisons Implementation of the HIV test-and-treat strategy in Malawi prisons: experience, challenges, and effectiveness Mendelsohn S 1, Aluda C 1, Ortuno R 1, Shigayeva A 1, Hilderbrand K 2,3, Goemaere E 2 1 MSF Malawi, 2 Southern African Medical Unit, MSF, Cape Town, South Africa, 3 Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa
Disclosure I am a contracted employee of Médecins Sans Frontières I have no other potential conflict of interest to disclose
Maula Prison HIV prevalence: 14.2% (95% CI: 12.8 15.7%) vs. 11.8%* in Lilongwe Courtesy Luca Sola/MSF Chichiri Prison HIV prevalence: 22.5% (95% CI 20.3 24.9%) vs. 18.2%* in Blantyre Courtesy Luca Sola/MSF *Malawi PHIA. Ministry of Health. 2015-2016.
Lack hygiene, inadequate sanitation diarrhoeal & skin disease Cruel and degrading treatment Overcrowding (>340% capacity), poor ventilation TB and resp infections Inadequate nutrition malnutrition, vit deficiencies (e.g. pellagra, iron def) Courtesy Luca Sola/MSF
Prison mortality, 2016 Mortality rate (annual deaths/1000 inmates) 12 10 8 6 4 2 0 Non-HIV mortality: 3.0 (n=8) HIV related mortality: 3.7 (n=10) Non-HIV mortality: 1.6 (n=3) HIV related mortality: 6.3 (n=12) Non-HIV mortality: 8.83. CDR: 11.7 (UNICEF, 2012) HIV related mortality: 2.87 (WHO, 2012) Maula prison, 2016 Chichiri prison, 2016 Malawi general population, 2012
Three-stage model of care Entry Stay Exit
Prison Entry (< 14 days) Screening at entry, 6-monthly during stay and at exit HIV TB STIs Syphilis Nutrition Mental health Prison Exit Linkage to care
During Prison Stay Six-monthly mass screening ART clinic: initiation, VL monitoring, PAGs, Rx of OIs Patient support unit: adherence counselling, peer educators PEP TB active case finding, contact tracing, isolation, and Rx Nutrition programme Primary healthcare clinic (incl. mental health) & dispensary Hepatitis B vaccination
1 st 90: HIV testing of new prison entries, 2016 290, 5.7% 180, 3.5% 369, 7.2% On ART or HIV positive at entry New HIV diagnosis in prison HIV negative 4293, 83.7% Not tested for HIV in 2016
Implementation of test-and-start strategy 2014 Malawi guidelines: CD4 < 500 WHO Stage 3/4, Children <5, pregnant/breastfeeding May 2016 guidelines: Test-and-start ALL HIV positive individuals eligible for immediate ART initiation, regardless of CD4 or WHO stage MSF: implemented T&S in Maula & Chichiri prisons July 2016 Rationale: Reduce transmission (Granich RM et al, Lancet, 2009) Reduce progression to advanced disease
2 nd 90: ART Initiation (new prison entries) ART inititiated on prison entry ART eventually initiated in prison Left prison prior to ART initiation Not on ART from prison clinic Mean Days to ART initiation 100% 90% 80% 2 3 1 19 24 20 16 6 34 1 1 6 28 19 1 7 90 80 70 70% 60% 50% 40% 30% 20% 10% 30 49 19 27 45 57 32 34 30 44 30 58 59 63 60 50 40 30 20 10 Days to ART initiation 0% 0 2016 q4 2016 q3 2016 q2 2016 q1 2015 q4 2015 q3 2015 q2 2015 q1
2 nd 90: HIV positive inmates on ART, RIC On ART Not on ART 1000 100% 750 79 86 92 102 123 112 50 29 93.9% 96.4% 95% Inmates 500 250 89.3% 88.7% 88.9% 88.0% 86.6% 87.5% 90% 85% 0 80% 2016 q4 2016 q3 2016 q2 2016 q1 2015 q4 2015 q3 2015 q2 2015 q1
90 90 90 Cascade 100.0% 2015 2016 90-90-90 Target 90.0% 95.7% (4300/4492) 94.3% (4842/5132) 88.0% (746/848) 96.4% (787/816) 91.2% (285/306) 90.7% (468/516) 80.0% 82.4% (516/626) 70.0% 60.0% 50.0% 1st 90: % of new entries in 2016 tested for HIV 2nd 90: % of HIV positive inmates on ART 53.5% (306/572) % of inmates on ART with VL results out of all eligible for VL 3rd 90: % with VL <1000 copies / ml out of those with VL results
Outcome: 6-month VL suppression Chichiri VL > 1000 VL < 1000 50 98.0% 45 40 95.6% 95.2% 95.6% 90.7% 96.0% 94.0% 35 30 25 20 15 10 5 0 94.6% 93.5% 90.3% 85.7% 43 40 43 39 35 29 28 24 93.8% 15 2 2 2 2 4 2 3 4 1 2015 Q1 2015 Q2 2015 Q3 2015 Q4 2016 Q1 2016 Q2 2016 Q3 2016 Q4 2017 Q1 92.0% 90.0% 88.0% 86.0% 84.0% 82.0% 80.0%
Outcome: Linkage to care at Chichiri Telephonic follow up Lost Not followed up Physical clinic follow up No record at clinic 40 40 35 35 30 9 30 25 20 15 10 5 0 74% 16 16 26 2 41% 5 38% 11 55% 6 11 Dec-16 Jan-17 Feb-17 Mar-17 25 20 15 10 5 0 84%; 16 91%; 32 3 3 Feb-17 Mar-17
Challenges Revolving door & linkage to care Sustainability Criminalisation of MSM: No condoms Delays in referrals Patient factors: Inability to disclose to family Lack of privacy / confidentiality Stress and mental illness related to incarceration Diet Living conditions Short stay remandees Voluntary testing? Vulnerable population Denial of ART in police custody Courtesy Luca Sola/MSF
Opportunities Captive audience Patient/prisoner support unit: Adherence counsellors Lay peer educators (prisoners) Prisoner ART groups (PAGs) Clinic proximity Courtesy Luca Sola/MSF DBS vs. whole blood for VL
Conclusion The three stage model of care is effective in achieving 90-90-90 targets, prevention of HIV transmission, and reduction in mortality Test-and-treat strategy feasible in prison setting Good retention in care and viral suppression. Linkage to care on release poor. Courtesy Luca Sola/MSF This model can be replicated in similar contexts