CIDRZ’s Prisons Projects: Where and when did it all start?

Where are we now?

Sisa Hatwiinda Clement N Moonga

Helene Smith

Wave 1 TB REACH Prisons Program

Sisa Munkombwe Hatwiinda

Zambian Correctional Service - Context • 87 prison facilities (2015) • 18,102 inmates (2015) • 23% prison population on remand (2015) • Official holding capacity 6,100 (2015) • Average occupancy level (2015) ~277% • 2.7% of prison population female (2015) • 3% Juveniles

• Overall prison HIV prevalence 27-30% • Estimated 50% women HIV infected • TB Prevalence 6,428 per 100,000 population (6%) TB 14 times higher than the national

TB prevalence (0.46%) • 34 health professionals in total in 2013

Enhanced TB Screening in Zambian Prisons (Stop TB Partnership TB REACH (WHO) - Completed

• Implementation of sustainable TB screening programs for 11,000 prisoners

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Wave 1 TB REACH - Prisons Program

Objectives

• To determine prevalence of TB & HIV in 6 Zambian prisons • To evaluate screening tool for TB & new diagnostics for TB • To increase laboratory capacity within the prison services

Key Activities • Isolation cells built: 2 prisons • Medical Ward facility built: 1 prison • Laboratory infrastructure: 3 sites • 74 inmate Peer Educators received 5-day training

and assisted with implementation activities • Establishing TB screening: Entry, Mass, Exit, Prison

Community, referral of symptomatics – Symptoms, digital chest X-ray , sputum smear, culture – HIV VCT – Treatment decision by clinical officers – Establishing linkages for TB and HIV care at 6 prisons

Infrastructure Improvements: Lusaka TB screening and Isolation Facility

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Before After

Key Findings

High TB and HIV rates in prisons (14% higher than national prevalence) • Exit TB rates significantly higher

than Entry rates or community • HIV rates higher than

community rates • HIV rates significantly higher at

Exit compared to Entry levels Prison Services lack the capacity and human resource to conduct rigorous screening for communicable diseases

Policy Implications Highlighted the extent of disease burden and conditions in prisons • Human resource for health

capacity improvement for prisons services

• TB & HIV control should also target key populations such as prisoners

• Systematic screening for both TB & HIV among prisoners

• Screening should use sensitive tools such as Xpert MTB/RIF

Lessons Learned from Wave 1: TB REACH

• 3 ‘I’s Project • ZaPHSS • TasP • CONTINUUM

3 ‘I’s Program

MOH ART and TB program with CDC and USAID applied to OGAC to implement WHO 3’I’s:

• Intensified Case Finding • Isoniazid Preventive Therapy • Infection Control

• Roll out Xpert MTB/RIF in Zambia CIDRZ implemented in Lusaka and Southern Provinces: 3 prisons and 15 health facilities

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Results

TB • 6551 screened for TB (71% of prison admissions) • 143 diagnosed with TB (2.1% of screened) • 144 started on TB treatment (99% of those

diagnosed with TB) HIV • 97% HIV test acceptance rate • 17% HIV positive • 72% linked to HIV care

Zambian Prisons Health Systems Strengthening (ZaPHSS)

Clement N Moonga MScGH

ZaPHSS Brief Overview Overall Goal: To develop and capacitate a prison health system that will plan, manage and implement improved health services in Zambian Prison facilities.

Specific Objectives • Strengthening the decision-making framework and management

structure for prison health services in Zambia • Develop the capacity of the Prison Health Directorate to assess,

plan and implement health services in prison facilities • Develop the capacity of facility-based Prison Health Committees

to plan and implement sustainable prison health services

ZaPHSS Brief Overview (2)

Grant Provider 3 year project funded by the European Union

Partners ZPS, MCDMCH, MOH & MHA Also working with SHARe II and UNODC

Coverage 11 Prisons: Livingstone, Kamwala, Lusaka Central, 4 Mukobeko Group, Mpima, Mwembeshi, Kamfinsa & Kansenji

Achievements Ministry Level • Signed an MOU with MOH, MHA and

MCDMCH • MOH appointed FPP for Prison Health • Advocated for lifting of employment

freeze, MHA recruited 33 ZCS HCW • Through CAPAH advocated for increased

budgetary allocation to ZCS Prisons HQ Level • Built capacity of ZCS HD & introduced

Joint Planning in PHAC • Developed ZaPHSS Framework • Revised ZCS Training Curriculum to

include basic health package and • HRH increased 34 – 80 from Feb 2013

to May 2017

Prisons Facility Level

• Pioneered the PrHC initiative (comprising Staff & Inmates)

• Introduced Health Needs Assessments • Entry Screening for HIV and TB • OIC returns to ZCS HQ include PrHC

reports

Achievements (2)

Research Successfully conducted mixed-methods study: “Understanding Zambian Prison Health: Inmate Health and Access to Health Care” • Conducted as a collaborative exercise to ensure feedback

and ownership of the research

Dissemination of Research Results • European Congress on

Tropical Medicine and International Health (2015)

• European and Developing

Countries Clinical Trials Partnership (2016)

• AIDS 2016 • PHAC

Topp, S.M., et al., Mapping the Zambian prison health system: An analysis of key structural determinants. Glob Public Health, 2016: p. 1-18 http://www.tandfonline.com/doi/full/10.1080/17441692.2016.1202298 Topp, S.M., et al., Exploring the drivers of health and healthcare access in Zambian prisons: a health systems approach. Health Policy Plan, 2016 https://academic.oup.com/heapol/article-lookup/doi/10.1093/heapol/czw059 Topp, S.M., et al., Health and healthcare access among Zambia's female prisoners: a health systems analysis. Int J Equity Health, 2016. 15(1): p. 157 https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-016-0449-y

Outcomes/Impacts

• Improved collaboration ZCS and (MOH-MHA) • Reduced morbidity and mortality in prisons • Improved hygiene in most covered prisons • Increased awareness of prison health needs by

ZCS command and GRZ • Improved collaboration Inmates and staff on

health matters

Some Recommendations • Form Prison Health Committees in each facility to provide

ground-level support to ZPS-HD for identifying, planning and implementing facility-based health services (preventive & curative)

• Leverage inmate knowledge by training or re-training a cadre to provide peer education on TB, HIV and other health issues

• Strengthen pre-service health education for incoming prison officers – helping them to understand and act on different types of health requests

• Strengthen presence & understanding of health protocol within prisons, to ensure officers act consistently & appropriately in all (not just some) cases

• Improve officer-to-inmate ratio – results in less deputising of inmates, reduces power of one inmate over another

SHORT TERM

LONG TERM

TasP

Treatment as Prevention in Correctional Facilities in Zambia and South Africa

Helene Smith

Background Incarcerated people:

• Come from communities with higher HIV and TB prevalence • May have individual-level risk factors for HIV acquisition

(e.g. substance abuse) • May not seek or may have limited access to health care

HIV transmission may be driven by one or more of the following (based on limited data):

• Voluntary, coerced, and/or forced sex within correctional settings

• Sharing of needles or other sharps

Disease Transmission in Correctional Facilities & Communities

COMMUNITY

High turnover & Revolving door effect

(Re-incarceration)

Enhanced dissemination to

related community (Prison Camp)

Increased post incarceration morbidity &

mortality

Entry

Corrections Staff (daily interaction)

Transfer to and from

other correctional

facilities

CORRECTIONAL FACILITIES

Concentration & Amplification of

TB and HIV

Exit

Treatment as Prevention

HCT + immediate ART = “Universal Test and Treat” (i.e. UTT)

Why Test & Treat • Standard HIV prevention interventions (condoms and

lubricant, PrEP and PEP) are not accessible - challenging legal and policy environments

• Quality observational and clinical trial data demonstrates that individuals who are fully virologically suppressed on ART DO NOT transmit HIV

HPTN 052 showed a 96% reduction in risk of incident HIV infection among sero-discordant heterosexual couples in 4 SSA countries.

Large cohort study from KwaZulu-Natal in South Africa revealed a 40% decrease in HIV incidence with high population-level ART coverage.

Primary Research Question

Is TasP/UTT a feasible strategy to prevent HIV transmission,

increase access to HIV treatment, and coordinate the TB care continuum

in correctional facilities in Zambia and South Africa?

Study Aims 1. Characterize and assess the performance of the integrated

HIV/TB care continuum under TasP compared to international targets of 90% uptake at each step.

2. Assess inmate- and system-level barriers to, and facilitators of, implementing and sustaining TasP in Zambian and South African correctional settings.

3. Characterize costs, resources, and other programmatic inputs required for TasP implementation in Correctional Facilities.

4. Examine policy-maker attitudes and preferences regarding TasP policy adoption in Zambian and South African Correctional Facilities.

TasP Progress to Date Enrolments • Commenced on 23rd June, 2016 • Offered HTS: 4,493 (4,229 accepted) (94.1%) • 741 found to be HIV-infected (17.5%) • Enrolled 389 (88.7% male) • 100% have accepted immediate ART

Mean: 32.4 [SD: 7.9] Total range: 18 - 70

Median baseline: 280 [IQR: 179 – 408] Total range: 10 - 847

94.3% ≤ 1,000 copies/ml) Total range: 19 – 66,114

“Continuum”

Understanding Longitudinal Clinical Outcomes and Post-release Retention in Care

among HIV-infected Prisoners in Lusaka, Zambia

Helene Smith

Disease Transmission in Correctional Facilities & Communities

COMMUNITY

High turnover & Revolving door effect

(Re-incarceration)

Enhanced dissemination to

related community (Prison Camp)

Increased post incarceration morbidity &

mortality

Entry

Corrections Staff (daily interaction)

Transfer to and from

other correctional

facilities

CORRECTIONAL FACILITIES

Concentration & Amplification of

TB and HIV

Exit

Background • SSA prisons concentrate large numbers of people

with, and at risk for, HIV infection. • Evidence suggests that inmates can start ART while

detained and achieve excellent outcomes while in prison.

• Benefits are often lost after release due to poor retention in HIV care.

• Factors driving this problem are unstudied: Alcohol Use Disorders (AUDs) are thought to play an important role

Study Goal & Objectives

Goal: To develop a model transitional care program for HIV-infected releasees in Zambia Objectives:

1. Assess clinical outcomes for HIV-infected prisoners after release

2. Explore factors from health behaviour theory that are associated with post-release retention in care, with a special focus on alcohol use disorders

3. Conduct formative research to determine releasee and stakeholder knowledge, attitudes, and preferences surrounding possible transitional care interventions

Continuum Progress to Date

• Commenced on 13th March, 2017 • Enrolled 82 • 68 (83%) Male & 14 (17%) Female • 73 (89%) ART & 9 (11%) ART Naïve • Follow-up / Tracing commenced 31st October

2017

Future Directions: Expand scope of work to Juveniles

Proposed Project: Building the capacity of the Zambia Correctional Service to provide holistic and integrated health services to juvenile offenders • Submitted to the Elton John AIDs Foundation

Acknowledgements Investigators & Key Staff

Dr Monde Muyoyeta - Director TB Dept/TB REACH Wave 2 Dr Stewart Reid -TasP Co-PI Dr German Henostroza - Director ZaPHSS/TB REACH Wave 1 Dr Michael Herce - Investigator of Record – TasP/Continuum Dr Stephanie Topp - Technical Advisor – ZaPHSS Laura Beres - 1st ZaPHSS Manager Clement N Moonga - Manager ZaPHSS/TA TasP Brenda Kayumba – Manager 3 ‘I’s Dr Mary Kagujje - CCS/Mgr TB Reach Wave 5 Helene Smith - Manager TasP/Continuum) Barbara L Kaswaya - Manager TB Programs Sisa Hatwiinda - Prisons FPP Constance Mudenda - Coordinator - ZaPHSS Sylvia Fungamwango - AA

Other TB Department Staff

• Muyunda Siyambango

• Lillian Kashela • Phillip Chilembo • Chisenga Yenga • Anold Kayuni • Mirriam Nanyangwe • Peter Chisenga

• Florence Nzala • Stenbridge Bbindu • Morgan Muteke • Precious Sakanya • Besa Chibwe • Joshua Ho • Onesmus Mweemba

Funders & Partners

Zambia Prison Services European Union