A qualitative study of healthcare providers' attitudes toward assisted partner notification for people with HIV in Indonesia.

BACKGROUND: Assisted partner notification (APN) is recommended as a public health strategy to increase HIV testing in people exposed to HIV. Yet its adoption in many countries remains at an early stage. This qualitative study sought the opinions of HIV health service providers regarding the appropriateness and feasibility of implementing APN in Indonesia where such services are on the cusp of adoption. METHODS: Four focus group discussions totaling 40 health service providers were held in Jakarta, Indonesia to consider APN as an innovative concept and to share their reactions regarding its potential implementation in Indonesia. Voice-recorded discussions were conducted in Bahasa, transcribed verbatim, and analyzed. RESULTS: Participants recognized APN's potential in contacting and informing the partners of HIV-positive clients of possible viral exposure. They also perceived APN's value as a client-driven service permitting clients to select which of three partner notification methods would work best for them across differing partner relationships and settings. Nonetheless, participants also identified personal and health system challenges that could impede successful APN adoption including medical and human resource limitations, the need for specialized APN training, ethical and equity considerations, and lack of sufficient clarity concerning laws and government policies regulating 3rd party disclosures. They also pointed to the job-overload, stress, personal discomfort, and the ethical uncertainty that providers might experience in delivering APN. CONCLUSION: Overall, providers of HIV services embraced the concept of APN but forecast practical difficulties in key service areas where investments in resources and system change appeared necessary to ensure effective and equitable implementation.

Exploring HIV stigma among future healthcare providers in Indonesia.

Future healthcare professionals are an important group for interventions to eliminate HIV stigma in the health workforce. Researchers examined HIV stigma and its relationship with healthcare discipline, HIV knowledge, and religiosity among nursing, medical, and midwifery students (N = 505) in three regions of Indonesia. In a multivariable linear model, higher HIV stigma was associated with male sex, lower levels of income and HIV knowledge, and higher levels of religiosity. An interaction of healthcare discipline and province was also significant. Medical students in Jakarta had higher predicted stigma scores compared to nursing students in Jakarta and compared to medical students in other provinces. Nursing students in Papua had lower predicted stigma scores compared to medical and midwifery students in Papua and compared to nursing students elsewhere. Strategies to reduce HIV stigma in the Indonesian health workforce should include a strong focus on pre-clinical educational settings and consider public nursing institutions as providing possible best practice models.

Impact of prerelease methadone on mortality among people with HIV and opioid use disorder after prison release: results from a randomized and participant choice open-label trial in Malaysia.

INTRODUCTION: Mortality is elevated after prison release and may be higher in people with HIV and opioid use disorder (OUD). Maintenance with opioid agonist therapy (OAT) like methadone or buprenorphine reduces mortality in people with OUD and may confer benefits to people with OUD and HIV leaving prison. Survival benefits of OAT, however, have not been evaluated prospectively in people with OUD and HIV leaving prison. METHODS: This study prospectively evaluated mortality after prison release and whether methadone initiated before release increased survival after release in a sample of men with HIV and OUD (n = 291). We linked national death records to data from a controlled trial of prerelease methadone initiation conducted from 2010 to 2014 with men with HIV and OUD imprisoned in Malaysia. Vital statistics were collected through 2015. Allocation to prerelease methadone was by randomization (n = 64) and participant choice (n = 246). Cox proportional hazards models were used to estimate treatment effects of prerelease methadone on postrelease survival. RESULTS: Overall, 62 deaths occurred over 872.5 person-years (PY) of postrelease follow-up, a crude mortality rate of 71.1 deaths per 1000 PY (95% confidence interval [CI] 54.5-89.4). Most deaths were of infectious etiology, mostly related to HIV. In a modified intention-to-treat analysis, the impact of prerelease methadone on postrelease mortality was consistent with a null effect in unadjusted (hazard ratio [HR] 1.3, 95% CI 0.6-3.1) and covariate-adjusted (HR 1.2, 95% CI 0.5-2.8) models. Predictors of mortality were educational level (HR 1.4, 95% CI 1.0-1.8), pre-incarceration alcohol use (HR 2.0, 95% CI 1.1-3.9), and lower CD4+ T-lymphocyte count (HR 0.8 per 100-cell/mL increase, 95% CI 0.7-1.0). CONCLUSIONS: Postrelease mortality in this sample of men with HIV and OUD was extraordinarily high, and most deaths were likely of infectious etiology. No effect of prerelease methadone on postrelease mortality was observed, which may be due to study limitations or an epidemiological context in which inadequately treated HIV, and not inadequately treated OUD, is the main cause of death after prison release. TRIAL REGISTRATION: NCT02396979. Retrospectively registered 24/03/2015.

Sleep disturbance, associated symptoms, and quality of life in adults living with HIV in Jakarta, Indonesia.

Adverse symptom experiences, including sleep disturbances, are important negative predictors of quality of life (QoL), but few studies conducted in low-income countries have examined the impact of poor sleep and its associated symptoms on QoL among people living with HIV (PLWH). To this end, 200 PLWH who were receiving treatment with antiretroviral therapy (ART) were recruited through a community nongovernment organization in Jakarta, Indonesia. Validated instruments measured QoL, sleep disturbance, fatigue, pain, ART adherence, substance use, drug use severity, and methadone treatment. Descriptive statistics, bivariate correlations, and multivariate linear regression were conducted to identify independent correlates of QoL. Overall, participants perceived their QoL as being good to very good (mean = 105.70, standard deviation = 14.7) and higher among women than men (p < 0.05). After adjusting for sex, education, drug-use severity, and ART adherence, QoL was negatively associated with fatigue, insomnia, and pharmacological treatment with methadone. Along with other known symptoms of HIV, sleep problems and their complications are important to clinically address and research more fully to assure satisfying QoL among PLWH.

Feasibility of a mHealth survey application for incarcerated and postrelease people living with HIV in a low-resource setting.

Mobile health (mHealth) holds considerable promise as a way to give people greater control of their health information, privacy, and sharing in the context of HIV research and clinical services. The purpose of this study was to determine the feasibility of an mHealth research application from the perspective of three stakeholder groups involved in an HIV clinical trial in Jakarta, Indonesia: (a) incarcerated people living with HIV (PLWH), (b) research assistants (RAs), and (c) research investigators. Incarcerated PLWH (n = 150) recruited from two large all-male prisons completed questionnaires, including questions about mHealth acceptability, on an mHealth survey application using a proprietary data collection software development platform. RAs who administered questionnaires (n = 8) rated the usability of the software application using the system usability scale (SUS) and open-ended questions. Research investigators (n = 2) completed in-depth interviews, that were coded and analyzed using the technology acceptance model (TAM) as a conceptual framework. Over 90% of incarcerated PLWH felt the mHealth application offered adequate comfort, privacy, and accuracy in recording their responses. RAs' SUS scores ranged from 60% to 90% (M = 76.25) and they found the mHealth survey application challenging to learn, but highly satisfying. Compared with paper-based data collection, researchers felt that electronic data collection led to improved accuracy and efficiency of data collection and the ability to monitor data collection remotely and in real time. The researchers perceived the learnability of the application as acceptable but required self-instruction.

A qualitative study of diphenhydramine injection in Kyrgyz prisons and implications for harm reduction.

BACKGROUND: To reduce opioid dependence and HIV transmission, Kyrgyzstan has introduced methadone maintenance therapy and needle/syringe programs into prisons. Illicit injection of diphenhydramine, an antihistamine branded as Dimedrol®, has been anecdotally reported as a potential challenge to harm reduction efforts in prisons but has not been studied systematically. METHODS: We conducted qualitative interviews in Kyrgyz or Russian with prisoners (n = 49), former prisoners (n = 19), and stakeholders (n = 18), including prison administrators and prisoner advocates near Bishkek, Kyrgyzstan from October 2016 to September 2018. Interviews explored social-contextual factors influencing methadone utilization in prisons. Transcripts were coded by five researchers using content analysis. Dimedrol injection emerged as an important topic, prompting a dedicated analysis. RESULTS: After drinking methadone, some people in prison inject crushed Dimedrol tablets, a non-prescription antihistamine that is banned but obtainable in prison, to achieve a state of euphoria. From the perspectives of the study participants, Dimedrol injection was associated with devastating physical and mental health consequences, including psychosis and skin infections. Moreover, the visible wounds of Dimedrol injecting contributed to the perception of methadone as a harmful drug and supporting preference for heroin over methadone. CONCLUSION: Dimedrol injecting is a potentially serious threat to harm reduction and HIV prevention efforts in Kyrgyzstan and elsewhere in the Eastern European and Central Asian region and requires further investigation.

Possible selves, psychological well-being, and substance use in young men within 12 months post-incarceration.

OBJECTIVE: Community reentry post-incarceration is fraught with challenges. The investigators examined the influence of highly personalized goals (possible selves) on psychological well-being, drug use, and hazardous drinking in recently incarcerated young men returning to the community. DESIGN AND SAMPLE: In this cross-sectional study, 52 young men released from jail or prison within the past 12 months were recruited from community-based organizations and reentry events. MEASUREMENTS: Participants completed open-ended possible selves measure and psychological well-being and substance use questionnaires. RESULTS: Possible selves accounted for 19%-31% of the variance in sense of purpose, environmental mastery, and personal growth. Having a feared delinquent possible self was associated with lower sense of purpose. Having many feared possible selves was associated with lower environmental mastery. Having an expected possible self related to interpersonal relationships was associated with higher personal growth and environmental mastery. Men having a feared delinquent possible self or an expected possible self related to material/lifestyle were more likely to use marijuana than men who did not. CONCLUSION: The content and number of possible selves may be an important focus for assessment by public health nurses in correctional and community settings serving young men post-incarceration. Longitudinal studies with larger samples are needed.

Adherence to Antiretroviral Therapy Among Incarcerated Persons with HIV: Associations with Methadone and Perceived Safety.

With adequate support, people with HIV (PWH) may achieve high levels of adherence to antiretroviral therapy (ART) during incarceration. We examined factors associated with ART utilization and adherence among incarcerated PWH (N = 150) in Indonesia. ART utilization was positively associated with HIV status disclosure (adjusted odds ratio [aOR] = 5.5, 95% CI 1.2-24.1, p = 0.023), drug dependency (aOR = 3.9, 95% CI 1.2-12.6, p = 0.022), health service satisfaction (aOR = 3.2, 95% CI 1.7-6.2, p < 0.001), and perceived need for medical treatment (aOR = 1.6, 95% CI 1.1-2.5, p = 0.011), and negatively associated with chance locus of control (aOR = 0.3, 95% CI 0.1-0.7, p = 0.013). Most participants utilizing ART (74.5%) reported less than "perfect" ART adherence. ART adherence was independently associated with perceived personal safety (ß = 0.21, 95% CI 0.01-0.40, p = 0.032) and methadone utilization (ß = 0.84, 95% CI 0.10-1.67, p = 0.047). PWH receiving methadone had a sixfold higher adjusted odds of being highly-adherent to ART (aOR = 6.3, 95% CI 1.1-35.7, p = 0.036). Interventions that increase methadone utilization and personal safety may improve ART adherence among incarcerated PWH.

The Influence of Medication Attitudes on Utilization of Antiretroviral Therapy (ART) in Indonesian Prisons.

Negative attitudes toward HIV medications may restrict utilization of antiretroviral therapy (ART) in Indonesian prisons where many people living with HIV (PLH) are diagnosed and first offered ART. This mixed-method study examines the influence of medication attitudes on ART utilization among HIV-infected Indonesian prisoners. Randomly-selected HIV-infected male prisoners (n = 102) completed face-to-face in-depth interviews and structured surveys assessing ART attitudes. Results show that although half of participants utilized ART, a quarter of those meeting ART eligibility guidelines did not. Participants not utilizing ART endorsed greater concerns about ART efficacy, safety, and adverse effects, and more certainty that ART should be deferred in PLH who feel healthy. In multivariate analyses, ART utilization was independently associated with more positive ART attitudes (AOR = 1.09, 95 % CI 1.03-1.16, p = 0.002) and higher internalized HIV stigma (AOR = 1.03, 95 % CI 1.00-1.07, p = 0.016). Social marketing of ART is needed to counteract negative ART attitudes that limit ART utilization among Indonesian prisoners.

Impart: findings from a prison-based model of HIV assisted partner notification in Indonesia.

INTRODUCTION: Assisted partner notification (APN) safely and effectively increases partner awareness of HIV exposure, testing and case identification in community settings. Nonetheless, it has not been specifically developed or evaluated for use in prison settings where people with HIV often are diagnosed and may have difficulty contacting or otherwise notifying partners. We developed Impart, a prison-based APN model, and evaluated its efficacy in Indonesia to increase partner notification and HIV testing. METHODS: From January 2020 to January 2021, 55 incarcerated men with HIV were recruited as index participants from six jail and prison facilities in Jakarta in a two-group randomized trial comparing the outcomes of self-tell notification (treatment as usual) versus Impart APN in increasing partner notification and HIV testing. Participants voluntarily provided names and contact information for sex and drug-injection partners in the community with whom they had shared possible HIV exposure during the year prior to incarceration. Participants randomized to the self-tell only condition were coached in how to notify their partners by phone, mail or during an in-person visit within 6 weeks. Participants randomized to Impart APN could choose between self-tell notification or anonymous APN by a two-person team consisting of a nurse and outreach worker. We compared the proportion of partners in each group who were notified of exposure by the end of 6 weeks, subsequently tested and HIV diagnosed. RESULTS: Index participants (n = 55) selected 117 partners for notification. Compared to self-tell notification, Impart APN resulted in nearly a six-fold increase in the odds of a named partner being notified of HIV exposure. Nearly two thirds of the partners notified through Impart APN (15/24) completed HIV testing within 6 weeks post notification compared to none of those whom participants had self-notified. One-third of the partners (5/15) who completed HIV testing post notification were diagnosed as HIV positive for the first time. CONCLUSIONS: Voluntary APN can be successfully implemented with a prison population and within a prison setting despite the many barriers to HIV notification that incarceration presents. Our findings suggest that the Impart model holds considerable promise to increase partner notification, HIV testing and diagnosis among sex and drug-injecting partners of HIV-positive incarcerated men.

An Analysis and Evaluation of the Information-Motivation-Behavioral Skills (IMB) Model for Antiretroviral Therapy.

We use Fawcett and DeSanto-Madeya's framework to critique Fisher and Fisher's information-motivation-behavioral skills model and determine its usefulness and applicability for nursing. Our analysis and evaluation show that the model is a parsimonious and useful situation-specific theory for guiding nursing research and practice because it shows good fit with the nursing context, has social and theoretical significance, and exhibits empirical and pragmatic adequacy. More consistency in using terms referring to each concept would help to improve the model's internal consistency. The model's testability could also be improved by measuring health outcomes (eg, viral load or CD4 count) in future research.

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.

Exploring the acceptability of HIV partner notification in prisons: Findings from a survey of incarcerated people living with HIV in Indonesia.

Assisted HIV partner notification services provide a safe and effective way for people living with HIV (PLHIV) to inform their partners about the possibility of exposure and to offer them testing, treatment, and support. This study examined whether or not PLHIV in prison might be willing to participate in assisted HIV partner notification services and their reasons for and against disclosing their HIV-positive status to their partners. PLHIV (n = 150) recruited from Jakarta's two largest all-male prisons completed an interviewer-administered questionnaire collecting demographic and risk behavior data, and attitudes toward HIV disclosure and partner services. Among those who were sexually active and/or injecting drugs before incarceration, two-thirds (66.4%, 91/137) endorsed provider referral as an acceptable way to notify their sex partners, and nearly three quarters (72.4%, 89/123) endorsed provider referral to notify their drug-injecting partners. Only a quarter (25.1%) of participants reported that their main sex partner had ever received an HIV test. Participants with anticipated stigma were less likely to endorse provider referral for sex partners (adjusted odds ratio [aOR] = 0.58, 95% CI: 0.35, 0.96) and drug-injecting partners (aOR = 0.54, 95% CI: 0.29, 1.00). Relationship closeness was associated with higher odds of endorsing provider referral for drug-injecting partners (aOR = 2.08, 95% CI: 1.25, 3.45). Protecting partners from infection and a moral duty to inform were main reasons to disclose, while stigma and privacy concerns were main reasons not to disclose. Most incarcerated PLHIV have at-risk partners in the community who they would be willing to notify if provided with assistance. Assisted partner notification for prison populations offers a promising public health approach to accelerate diagnosis, treatment, and prevention of HIV infection in the community, particularly among women.

Ethical Challenges of HIV Partner Notification in Prisons.

Partner services provide a safe and humane way for people living with HIV (PLWH) to alert their sex and/or drug-injecting partners to the possibility of HIV exposure and the need for HIV testing, yet little is known about the ethical challenges of delivering partner services in prisons. In this article, we consider 7 key ethical and methodological questions that should be considered when developing, testing, or implementing partner services in prison settings. These questions relate to the ethics of: (1) mandatory HIV testing, (2) health illiteracy, (3) level of prison staff involvement, (4) protecting confidentiality, (5) minimizing harm, (6) achieving equivalency with community standards of care, and (7) providing HIV prevention and treatment services to index patient and their partners. By assisting PLWH in prison to inform partners with whom they may have shared HIV exposure either before or during incarceration, partner services can help to identify cases of undiagnosed HIV infection for testing and linkage to medical care. The acceptability and effectiveness of a future partner services model for PLWH in prison depends critically on answering these 7 questions to assure the highest ethical standards of research and practice.

Retention in clinical trials after prison release: results from a clinical trial with incarcerated men with HIV and opioid dependence in Malaysia.

Background: Study retention is a major challenge in HIV clinical trials conducted with persons recruited from correctional facilities. Objective: To examine study retention in a trial of within-prison methadone initiation and a behavioral intervention among incarcerated men with HIV and opioid dependence in Malaysia. Methods: In this 2x2 factorial trial, 296 incarcerated men with HIV and opioid dependence were allocated to (1) an HIV risk reduction intervention, the Holistic Health Recovery Program for Malaysia (HHRP-M), (2) pre-release methadone initiation, (3) both interventions, or (4) standard care (NCT02396979). Here we estimate effects of these interventions on linkage to the study after prison release and completion of post-release study visits. Results: Most participants (68.9%) completed at least one post-release study visit but few (18.6%) completed all 12. HHRP-M was associated with a 13.5% (95% confidence interval (CI): 3.8%, 23.2%) increased probability of completing at least one post-release study visit. Although not associated with initial linkage, methadone treatment was associated with an 11% (95% CI: 2.0%, 20.6%) increased probability of completing all twelve post-release study visits. Being subject to forced relocation outside Kuala Lumpur after prison release decreased retention by 43.3% (95% CI: -51.9%, -34.8%). Conclusion: Retaining study participants in HIV clinical trials following prison release is challenging and potentially related to the broader challenges that participants experience during community reentry. Researchers conducting clinical trials with this population may want to consider methadone and HHRP as means to improve post-release retention, even in clinical trials where these interventions are not being directly evaluated.

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

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.

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 post-release. 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 in released prisoners (215.7 deaths per 1,000 PYs). 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<200cells/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. CONCLUSIONS: 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. Narcotics 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 Human Immunodeficiency Virus Incidence and Mortality in Malaysia.

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.

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 Malaysia's 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.