Addiction, HIV and Tuberculosis in Malaysian Criminal Justice Settings

 描述（由申请人提供）：成瘾，艾滋病毒和结核病的综合症集中在刑事司法环境（CJS）。艾滋病毒和结核病是每年约5000万至6000万从监狱过渡过来的人死亡的主要原因。马来西亚是亚洲注射毒品者中艾滋病毒感染率最高的国家，而亚洲对毒品的刑事定罪是严厉的，导致囚犯中艾滋病毒感染率最高，监禁率在亚洲第二高。虽然亚洲的死亡率下降了39%，但马来西亚的死亡率却有所上升，因为在马来西亚，艾滋病毒和结核病的治疗对艾滋病患者，特别是囚犯的治疗不足。在过去的10年里，耶鲁大学和马来亚大学的研究人员不断合作研究涉及关键人群，包括PWID，囚犯，MSM以及女性和变性性工作者。我们的研究在成瘾和艾滋病毒，结核病，丙型肝炎病毒和性传播感染等传染病的界面上具有多学科性。我们的研究一直通过资金支持一些前和博士后学生和初级教师通过我们的福格蒂赞助的全球健康公平学者计划，多丽丝杜克慈善全球健康培训，富布赖特奖学金和通过NIDA赞助的研究赠款。我们的研究活动的核心是我们基于监狱的研究中的一些发现，这些发现为当前的R 01提交提供了信息，包括：支持下一代研究问题的这些目标的成就包括：1）艾滋病毒阳性囚犯的死亡率特别高，主要是结核病; 2）艾滋病毒阳性和艾滋病毒阴性囚犯和监狱工作人员中潜伏性结核病感染（LTBI）的高流行率; 3）囚犯作为高风险环境的新角色有助于在过渡到社区的囚犯中继续传播结核病; 4）美沙酮和丁丙诺啡等阿片类激动剂疗法（OAT）在促进社区环境中（包括获释囚犯）的护理保留和改善艾滋病毒和结核病结果方面的有效性; 5）尽管OAT的这些调查结果令人鼓舞，但囚犯和惩教人员对使用它们的负面态度削弱了它们的潜在好处;和6）挑战现有结核病筛查建议的初步研究，监狱中的诊断和预防战略是本提案中两个相关和连续的具体目标的核心：1）进行结核病的经验性研究，包括：a）结核病诊断（症状、CXR、TST、AFB涂片、Gene Xpert和痰培养），以优化结核病筛查; B）一项在HIV阳性和HIV阴性囚犯中开展的结核病预防策略RCT，比较了每周一次的异烟肼/利福喷丁12周短期疗程与标准的40-在HCV高患病率和潜在肝毒性的人群中，每天服用异烟肼一周;和c）HIV=和HIV-1的RCT没有足够时间在监狱内完成治疗的结核病囚犯，并比较拒绝接受OAT和接受OAT的囚犯的治疗完成率，但被随机分配接受美沙酮或丁丙诺啡治疗，以促进释放后护理的连续性;和2）利用目标1的数据，结合可获得的结核病数据，进行基于代理人的建模，以便对感染和未感染艾滋病毒的囚犯的结核病筛查、预防和治疗策略进行比较和成本效益分析，合并潜在结核感染和流行结核病对释放后社区传播的贡献。

 DESCRIPTION (provided by applicant): The syndemics of addiction, HIV and TB are concentrated in criminal justice settings (CJS). HIV and TB contribute most to mortality among the ~50-60 million people who transition through prisons annually. Malaysia has the highest HIV prevalence among people who inject drugs (PWIDs) in Asia where criminalization of drugs is harsh, resulting in the highest HIV prevalence among prisoners and the second highest incarceration rate in Asia. While mortality decreased 39% in Asia, it has increased in Malaysia where treatment of HIV and TB are inadequately treated among PWIDs, especially in prisoners. Over the past 10 years, researchers at Yale University and the University of Malaya have continuously collaborated on research involving key populations, including PWIDs, prisoners, MSM and both female and transgender sex workers. Our research has multidisciplinary at the interface of addiction and infectious diseases like HIV, TB, HCV and sexually transmitted infections. Our research has been supported through funding for a number of pre- and post-doctoral students and junior faculty members through our Fogarty-sponsored Global Health Equity Scholars program, Doris Duke Charitable Global Health Training, Fulbright scholarships and through NIDA-sponsored research grants. Central to our research activities have been a number of findings from our prison-based studies that inform the current R01 submission, including: Accomplishments from these aims that support the next generation of research questions include: 1) extraordinary mortality among HIV+ prisoners, primarily form TB; 2) high prevalence of latent TB infection (LTBI) among HIV+ and HIV- prisoners and prison personnel alike; 3) the emerging role of prisoners as high risk environments contributing to onward TB transmission among prisoners transitioning to the community; 4) effectiveness of opioid agonist therapies (OAT) like methadone and buprenorphine in promoting retention in care and improved HIV and TB outcomes in community settings, including among released prisoners; 5) despite these promising findings from OAT, negative attitudes by prisoners and correctional staff toward their use undermine their potential benefits; and 6) preliminary studies challenging existing recommendations for TB screening, diagnostics and prevention strategies in prisons that are central to the two related and sequential specific aims in this proposal: 1) To conduct empiric studies of TB, including: a) TB diagnostics (symptoms, CXR, TST, AFB smear, Gene Xpert, and sputum culture) to optimize TB screening; b) a RCT of TB prevention strategies among HIV+ and HIV- prisoners comparing a 12-week short-course of once-weekly isoniazid/rifapentine vs a standard 40-week course of daily isoniazid in a population with high HCV prevalence and potential for hepatotoxicity; and c) a RCT of HIV= and HIV- prisoners with TB who have insufficient time to complete treatment within prison and comparing treatment completion rates for those who refuse OAT with those who accept it, but who are randomized to methadone or buprenorphine therapy to facilitate continuity of care post-release; and 2) To use data from aim 1 combined with publically available TB data to conduct agent-based modeling for comparative and cost- effectiveness analyses of TB screening, prevention and treatment strategies among prisoners with and without HIV, incorporating the contribution of latent TB infection and prevalent TB disease on community transmission post-release.