Continuum of hepatitis C care cascade in prison and following release in the direct-acting antivirals era.

BACKGROUND: People with criminal justice involvement contribute remarkably to the rising hepatitis C virus (HCV) burden; however, the continuum of care is a major barrier to prison-based programs. We aimed to evaluate a comprehensive HCV care model in an Iranian provincial prison. METHODS: Between 2017-2018, in the Karaj Central Prison, newly admitted male inmates received HCV antibody testing and venipuncture for RNA testing (antibody-positive only). Participants with positive RNA underwent direct-acting antiviral (DAA) therapy (Sofosbuvir/Daclatasvir). Sustained virological response was evaluated at 12 weeks post-treatment (SVR12). RESULTS: Overall, from 3485 participants, 182 (5.2%) and 117 (3.4%) tested positive for HCV antibody and RNA, respectively. Among 116 patients who were eligible for treatment, 24% (n = 28) were released before treatment and 72% (n = 83) initiated DAA therapy, of whom 81% (n = 67/83) completed treatment in prison, and the rest were released. Of total released patients, 68% (n = 30/44) were linked to care in community, and 70% (n = 21/30) completed treatment, including 60% (n = 12/20) and 90% (n = 9/10) among those who were released before and during treatment, respectively. The overall HCV treatment uptake and completion were 89% (n = 103/116) and 85% (n = 88/103), respectively. From people who completed treatment, 43% (n = 38/88) attended for response assessment and all were cured (SVR12 = 100%). CONCLUSIONS: Integrated HCV care models are highly effective and can be significantly strengthened by post-release interventions. The close collaboration of community and prison healthcare systems is crucial to promote high levels of treatment adherence. Future studies should investigate the predictors of engagement with HCV care following release.

Patterns of Drug Use and Related Factors Among Prisoners in Iran: Results from the National Survey in 2015.

Drug use by prisoners is one of the world's most important problems. We sought to determine the pattern of drug use behavior and related factors among prisoners of Iran in 2015. This cross-sectional study was part of the bio-behavioral surveillance survey conducted among 6200 prisoners in 26 prison sites in Iran who were selected through multi-stage sampling. Data were collected through questionnaires and interviews which inquired about participants' demographics and drug use behaviors. We analyzed study data using descriptive statistics, and crude and adjusted logistic regressions, in STATA-12. Of all prisoners, 74.0% had a history of lifetime drug use, and 16.6% of drug users had a history of lifetime injection drug use (IDU). According to the results of a multivariate logistic regression, male sex, being between the ages of 24 and 45, having a history of imprisonment, and having a history of lifetime high-risk sexual behavior were significant risk factors for lifetime drug use. Also, male sex, single status, and a history of previous imprisonment were significant risk factors for lifetime IDU. The prevalence of drug use in Iran's prison population is high and alarming. There is a continuing need for harm reduction programs, including the methadone maintenance treatment, among imprisoned drug users and IDUs.

Prevalence and risk factors for HBV and HCV in prisoners in Iran: a national bio-behavioural surveillance survey in 2015.

OBJECTIVES: To provide more accurate estimates of the prevalence of Hepatitis B (HBV) and Hepatitis C (HCV) and their contributing factors among prisoners in Iran. METHODS: Cross-sectional study of 6200 Iranian prisoners in 2015. Data were collected through questionnaires and interviews. HBV infection and HCV exposure status of the participants was determined by HBsAg and HCV antibodies blood tests using enzyme-linked immunosorbent assay (ELISA). Data were analysed in STATA-12. RESULT: Prevalence of HCV exposure was 9.48% (95% CI: 8.73-10.27), and prevalence of HBV was 2.48% (95% CI: 2.07-2.89) in the general prison population. In multivariate analysis, the most important risk factor for HBV was a history of drug use in lifetime (adjusted odds ratio, AOR: 1.8, 95% CI: 1.17-3.02). The main risk factors for HCV exposure were a history of drug use in lifetime (AOR: 4.08, CI: 2.56-6.27), age over 30 (AOR: 2.68, CI: 2.01-3.56), and having tattoos (AOR = 1.67, CI: 1.35-2.07). CONCLUSION: Although vaccination is used to control HBV among prisoners, prevalence of HCV exposure is alarming in the prison population of Iran, especially among people who inject drugs. Eliminating viral hepatitis in Iran by 2030 requires a national commitment and rapid measures for targeting this high-risk group. Given the increased efficiency of HCV treatment in recent years, prisons provide an opportunity to access patients for treatment.

HIV prevalence and related risk behaviours among prisoners in Iran: results of the national biobehavioural survey, 2009.

OBJECTIVES: To estimate the prevalence of HIV and related risk behaviours among prisoners in Iran in 2009. METHODS: Using multistage random sampling, we recruited 5,530 prisoners from 27 prisons in Iran. Behavioural data were collected using a face-to-face questionnaire-based interview, and HIV status was determined by ELISA of dried blood spots. Weighted estimates were calculated based on the sampling probability and response rate. RESULTS: HIV prevalence was 2.1% (95% CI 1.2 to 3.6). One in eight prisoners (12.3%, 95% CI 8.0% to 16.6%) had been tested for HIV in the last year and received results, 20.5% (95% CI 15.1 to 27.4%) had comprehensive knowledge about HIV and 24.7% (95% CI 17.9% to 32.9%) reported condom use at last vaginal/anal sex in prison. Although 16.5% (95% CI 12.5% to 21.5%) acknowledged a lifetime history of drug injection, only 22 prisoners reported drug injection inside the prison in the month preceding the interview. Of note, 12.9% (95% CI 10.6% to 15.6%) had been tattooed in prison. There were significant associations between HIV prevalence and a history of drug injection (adjusted odds ratio (AOR): 7.8, 95% CI 4.7 to 13.2), tattooing (AOR: 2.1, 95% CI 1.1 to 4.2) and age over 30 years (AOR: 1.4, 95% CI 1.1 to 1.9). CONCLUSIONS: Considerable HIV prevalence among prisoners is found in Iran. Expanding harm reduction programmes inside prisons with inclusion of sexual risk reduction programmes and post-release programmes will help directly prevent acquisition and transmission of infection inside prisons and indirectly slow onward transmission in the outside communities.

Treatment and outcomes of pediatric patients with cancer and COVID-19 at MAHAK pediatric cancer treatment and research center, Tehran, Iran.

The COVID-19 pandemic has been particularly devastating for Iran. Children with cancer are generally immunosuppressed and especially vulnerable to SARS-CoV-2 infections. We report the treatment and outcomes of pediatric oncology patients with COVID-19 at the MAHAK Pediatric Cancer Treatment and Research Center (MPCTRC) in Tehran. We enrolled pediatric oncology patients who experienced SARS-CoV-2 infections from March 18, 2020, to January 28, 2021. The COVID-19 diagnostic criteria at MPCTRC were based on imaging and clinical presentation because of specific challenges diagnosing SARS-CoV-2 infections with molecular testing, which was locally developed and conducted at centers other than MPCTRC. We enrolled nine outpatients and eight inpatients (mean age = 9 years), seven of whom had a diagnosis of leukemias, and five who had brain tumors. COVID-19 symptoms were mild in fourteen patients, and three patients were asymptomatic. Of twelve patients who received molecular testing for SARS-CoV-2 infection, eight were negative and four were positive. Of nine patients tested for IgG and IgM antibodies, one was positive. Three patients died of COVID-19, all of whom were hospitalized. Mild COVID-19 symptoms did not appear to affect the outcomes of the pediatric patients with cancer who received treatment at MPCTRC during the study period.

Comparison of HIV Indicators after the Implementation of a New Model for TB and HIV Management in an Iranian Prison.

OBJECTIVES: A new national clinical guideline for the management of tuberculosis and HIV in Iranian prisons was released in 2011. The aim of this study was to compare HIV indicators in the case and control prisons after implementation of the new guideline. METHODS: This report examines outcomes observed during the pilot phase of its implementation at a case prison from October 2013 to June 2014 compared to a control prison that had not yet implemented the guideline. The case prison included incarcerated individuals in the Great Tehran Prison. A prison in Alborz province was considered as a control group. Pearson's Chi-squared, two-sample t-test, paired t-test and Kruskal-Wallis were used for the analysis. RESULTS: The intervention significantly increased the total number of inmates tested for HIV and of diagnoses of HIV-positive inmates in the case prison compared to the control prison (P<0.001). Moreover, coverage of antiretroviral therapy was higher in the case prison compared to the control prison (P=0.015). CONCLUSION: We recommend the implementation of this guideline in all Iranian prisons.

Performance of a rapid diagnostic test for screening of hepatitis C in a real-life prison setting.

BACKGROUND: Hepatitis C virus (HCV) point-of-care testing using rapid diagnostic test (RDT) is the solution for large-scale, feasible, fast and reliable screening of HCV infection. OBJECTIVES: The aim of this study was to evaluate the diagnostic performance of HCV RDT for screening of HCV infection in a real-life prison setting. STUDY DESIGN: This study was conducted on individuals admitted and incarcerated in the Central Prison of Karaj, 2017-2018. For all inmates, anti-HCV testing using a RDT on finger-stick blood in the prison and ELISA at the laboratory were performed. For evaluation of reproducibility, more than 1000 cases were recruited for re-evaluation of the HCV RDT using anticoagulated blood in the laboratory. RESULTS: Among 1788 participants, 76 (4.25%) and 106 (5.93%) were positive for anti-HCV using RDT and ELISA, respectively. Among 34 cases with discordant results using the RDT and ELISA, 17 were the result of testing error in prison, 7 false positive of ELISA and 10 false negative of RDT in individuals with HCV spontaneous clearance. The sensitivity of the RDT with inclusion of testing error in prison for detection of anti-HCV was 75%. However, with exclusion of testing error in prison and considering HCV RNA as the reference method for diagnosis of current HCV infection the sensitivity reached 100%. The RDT was 100% reproducible using both evaluations in prison and the laboratory. CONCLUSIONS: The RDT is a reliable and feasible method for screening of anti-HCV in settings such as a prison. However, the testing should be performed in a standard procedure to have the optimal diagnostic performance.

Revision and Implementation of "Clinical Guideline for Tuberculosis and HIV in Prisons", Great Tehran Prison, Iran.

AIM: To evaluate the feasibility of the revised "Clinical Guideline for HIV and TB" in the Great Tehran Prison during October 2013 to June 2014. METHODS: The guideline includes all aspects of HIV/TB diagnosis based on active case finding (ACF), treatment and care services. Before the implementation, a focus group discussion was conducted, and attended by experts on prison health. The objective was to identify defects and limitations of the guideline. After the discussion, the guideline was revised. The Great Tehran Prison contains three separate units; all prisoners are taken first to "reception and identification unit (quarantine)" and then send to two housing units according to their legal status. An HIV ACF strategy was employed in the quarantine, and two units through a voluntary provider-initiated HIV testing. Three staff of the triangular clinic trained the prisoners about common routes of HIV transmission and the symptoms of TB in the units. In the quarantine, all prisoners were examined for all HIV-risk factors, HIV testing and symptoms of TB. In unit one, healthcare staff continued the ACF process, while in unit two, the peers of prisoners were assigned as the healthcare communicators to proceed with the strategy. At this caring process, when the test result was positive, then the process of care, treatment and follow ups was initiated. Moreover, the use of directly observed therapy (DOT) for antiretroviral therapy (ART) and TB was applied to the sick prisoners. There was also a follow-up caring for released prisoner to refer them to care and treatment services outside the prison. RESULTS: The guideline was implemented in the prison successfully. CONCLUSION: Regarding feasibility of the guideline, the investigators of this study suggest that the guideline should be implemented in other prisons across the country.

Prevalence and Associated Factors of HIV Infection among Male Prisoners in Tehran, Iran.

BACKGROUND: This is a cross-sectional survey conducted on 6900 male prisoners in Great Tehran Prison from October 2013 to May 2014. METHODS: In order to find HIV positive prisoners in the prison's quarantine and two housing units, we used HIV active case finding (ACF) strategy by rapid screening test. In ACF, healthcare staff and trained prisoners asked inmates to answer relevant questions about history of risky behaviors related to HIV as well as to be tested voluntarily by HIV rapid test. A positive result was confirmed by ELISA screening and Western blot tests. Furthermore, to find the prevalence of specific HIV risk factors among prisoners were assessed using a questionnaire, and the results were analyzed by STATA software, providing univariate and multivariate modeling. RESULTS: There were 85 HIV positive patients. The prevalence of HIV was 1.23%. The risk factors independently associated with HIV infection were age (adjusted odds ratio of 3.46 for 35-44 yrs., 95% CI:1.01-11.92), duration of imprisonment (adjusted odds ratio of 4.22 for ≥10 yr., 95% CI: 1.92-9.24 ), history of  injection drug use (adjusted odds ratio of 5.01, 95% CI: 2.24-11.18), history of needle sharing (adjusted odds ratio of 2.28, 95% CI: 1.25-4.16) and tattooing (adjusted odds ratio of 1.84, 95% CI: 1.05-3.24). CONCLUSIONS: The prevalence and risk factors of HIV infection should be recognized by policy makers for intensifying harm reduction programs and reforming the HIV guidelines in prisons.

Drug Use among Iranian Drivers Involved in Fatal Car Accidents.

BACKGROUND: Although the problem of substance use among drivers is not limited to certain parts of the world, most epidemiological reports on this topic have been published from industrial world. AIM: To investigate pattern of drug use among Iranian drivers who were involved in fatal road accidents. METHODS: This study enrolled 51 Iranian adults who were involved in fatal vehicle accidents and were imprisoned thereafter. Data came from a national survey of drug abuse that was done among Iranian prisoners. The survey collected data at the entry to seven prisons in different regions of the country during a 4-month period in 2008. Self-reported lifetime, last year, and last month drug use was measured. Commercial substance screening tests were applied to detect recent substance use (opioids, cannabinoids, methamphetamines, and benzodiazepines). RESULTS: The commercial substance screening test showed three distinct patterns of recent illicit drug use: opioids (37.3%), cannabinoids (2.0%), opioids and cannabinoids (13.7%). 29.4% were also positive for benzodiazepines. The substance use screening test detected 23.5% of participants who had used drugs but did not disclose any substance use. CONCLUSION: Opioids are the most common illicit drugs being used by Iranian drivers who are involved in fatal car accidents. The high rate of substance use prior to fatal car accidents in Iran advocates for the need for drug use control policies and programs as major strategies for injury prevention in Iran. There is also a need for substance screening among all drivers involved in fatal car accidents in Iran, as more than 20% of users may not disclose substance use.