Feasibility and acceptability of saliva-based testing for the screening of SARS-CoV-2 infection in prison.

Background: Saliva molecular tests have shown a similar sensitivity and specificity compared to nasopharyngeal test for SARS-CoV-2 diagnosis in both symptomatic and asymptomatic individuals. The SARS-CoV-2 pandemic affected Lombardy prisons, generating the need for extensive contact tracing activities and for detecting asymptomatic carriers. The availability of a less invasive test in a setting that hosts a high-risk and often hard-to-reach population, suggests its possible use in prisons. Methods: The study was carried out on a population of new incomers in Milan San Vittore pre-trial prison. All the new incomers were submitted to quarantine and to saliva test and nasopharyngeal swab (NPS) for SARS-CoV-2 detection at the entry and at the end of quarantine before their admission in community (Protocol 1-February 2nd to March 5th, 2021). Starting from March 8th to July 30th, 2021, the screening protocol was adjusted to avoid biases in sample collection (Protocol II), and saliva testing was performed at entrance. Results: 12/1,120 enrolled subjects were excluded from the study. Among the 1,080 processed samples, 1 tested positive, 5 weakly positive, 1,069 negative, 3 were invalid, and 2 samples tested positive for the viral gene N2 only, with Ct value above 38. During Protocol I, 6/156 coupled saliva/NPS tests were discordant due to food ingestion prior saliva collection, prompting us to establishing Protocol II. Conclusions: Saliva molecular testing is feasible in prison setting, being less invasive and easier to use, and reliable. Acceptability was very high even in a complex context as that of newly incarcerated persons.

HCV spread among female incarcerated population and treatment pathways to viral elimination in Italian prison settings: clinical perspectives and medico legal aspects.

BACKGROUND: Hepatitis C virus (HCV) infection is more frequent among incarcerated people than in general population. In the DAAs era, the short schedules and the low risk of adverse reactions, increased the number of HCV treatments. However, the most part of literature reports lack of incarcerated women inclusion in studies on field. Our aim is to assess the screening execution, HCV prevalence, and DAAs treatment among incarcerated women. A focused insight on quick vs standard diagnosis and staging approach will be also provided. METHODS: Incarcerated women from 4 Italian regions' penitentiary institutes were included. HCV screening was executed with HCV saliva test (QuickOral Test®) or phlebotomy. Stage of liver fibrosis was evaluated with FIB-4 value or fibroscan®, based on physicians' decision. Treatment prescription followed national protocols. RESULTS: We included 156 women, 89 (57%) were Italian, mean age was 41 ± 10 years, and 28 (17.9%) were people who inject drugs (PWIDs). Overall, the HCV seroprevalence was 20.5%. Being PWID and on opioid substitution therapy (OST) were significantly associated with serological status (p-value < 0.001). Of them, the 75.5% of patients had active infection, the most frequent genotype was 3a (50%). Among them, 4 (16.6%) and 6 (25%) had psychosis or alcohol abuse history. The 62.5%, 25% and 12.5% had low, intermediate, and advanced fibrosis, respectively. Out of the 24 HCV-RNA positive patients, the 75% underwent to DAAs treatment. The sustained virological response (SVR12) was achieved in 88.8% of cases. When evaluating the influence of quick diagnosis and staging methods vs standard phlebotomy and fibroscan® on SVR12, FIB-4 use showed higher performance for retainment in treatment during prison staying (p = 0.015), while the use of quick saliva test had no influence on the outcome (p = 0.22). CONCLUSION: HCV seroprevalence and active infections are very high among incarcerated women. More tailored interventions should be focused on HCV diagnosis and treatment in female prison population. The use of quick staging methods (FIB-4) is useful to increase SVR12 achievement without delays caused by the fibroscan® awaiting.

Evaluation of viral load in patients with Ebola virus disease in Liberia: a retrospective observational study.

BACKGROUND: Viral load in patients with Ebola virus disease affects case fatality rate and is an important parameter used for diagnostic cutoffs, stratification in randomised controlled trials, and epidemiological studies. However, viral load in Ebola virus disease is currently estimated using numerous different assays and protocols that were not developed or validated for this purpose. Here, our aim was to conduct a laboratory-based re-evaluation of the viral loads of a large cohort of Liberian patients with Ebola virus disease and analyse these data in the broader context of the west Africa epidemic. METHODS: In this retrospective observational study, whole blood samples from patients at the Eternal Love Winning Africa Ebola treatment unit (Monrovia, Liberia) were re-extracted with an optimised protocol and analysed by droplet digital PCR (ddPCR) using a novel semi-strand specific assay to measure viral load. To allow for more direct comparisons, the ddPCR viral loads were also back-calculated to cycle threshold (Ct) values. The new viral load data were then compared with the Ct values from the original diagnostic quantitative RT-PCR (qRT-PCR) testing to identify differing trends and discrepancies. FINDINGS: Between Aug 28 and Dec 18, 2014, 727 whole blood samples from 528 individuals were collected. 463 (64%) were first-draw samples and 409 (56%) were from patients positive for Ebola virus (EBOV), species Zaire ebolavirus. Of the 307 first-draw EBOV-positive samples, 127 (41%) were from survivors and 180 (59%) were from non-survivors; 155 (50%) were women, 145 (47%) were men, and seven (2%) were not recorded, and the mean age was 29·3 (SD 15·0) years for women and 31·8 (SD 14·8) years for men. Survivors had significantly lower mean viral loads at presentation than non-survivors in both the reanalysed dataset (5·61 [95% CI 5·34-5·87] vs 7·19 [6·99-7·38] log10 EBOV RNA copies per mL; p<0·0001) and diagnostic dataset (Ct value 28·72 [27·97-29·47] vs 26·26 [25·72-26·81]; p<0·0001). However, the prognostic capacity of viral load increased with the reanalysed dataset (odds ratio [OR] of death 8·06 [95% CI 4·81-13·53], p<0·0001 for viral loads above 6·71 log10 EBOV RNA copies per mL vs OR of death 2·02 [1·27-3·20], p=0·0028 for Ct values below 27·37). Diagnostic qRT-PCR significantly (p<0·0001) underestimated viral load in both survivors and non-survivors (difference in diagnostic Ct value minus laboratory Ct value of 1·79 [95% CI 1·16-2·43] for survivors and 5·15 [4·43-5·87] for non-survivors). Six samples that were reported negative by diagnostic testing were found to be positive upon reanalysis and had high viral loads. INTERPRETATION: Inaccurate viral load estimation from diagnostic Ct values is probably multifactorial; however, unaddressed PCR inhibition from tissue damage in patients with fulminant Ebola virus disease could largely account for the discrepancies observed in our study. Testing protocols for Ebola virus disease require further standardisation and validation to produce accurate viral load estimates, minimise false negatives, and allow for reliable epidemiological investigation. FUNDING: Intramural Research Program of the National Institute of Allergy and Infectious Diseases, National Institutes of Health.

COVID-19 Infection Among Incarcerated Individuals and Prison Staff in Lombardy, Italy, March 2020 to February 2021.

Importance: Owing to infrastructural and population characteristics, the prison setting is at increased risk for transmission of SARS-CoV-2 and for severe clinical outcomes. Because of structural and operational reasons, research in prison settings is challenging and available studies are often monocentric and have limited temporal coverage; broader-based research is necessary. Objectives: To assess the extent and dynamics of the COVID-19 pandemic within the prison system of a large Italian region, Lombardy, and report the infection prevention and control measures implemented. Design, Setting, and Participants: This repeated cross-sectional study was carried out from March 1, 2020, through February 28, 2021 (first wave, March-June 2020; second wave, October 2020-February 2021) in the prison system of Lombardy, which includes 18 detention facilities for adults. All incarcerated persons and the prison staff of the penitentiary system of the Lombardy region participated in the study. Exposures: The main exposures of interest were the weekly average number of incarcerated individuals placed in quarantine in single or shared isolation rooms, the rate of sick leave by symptomatic and asymptomatic prison staff reported to the prison occupational medicine department on a weekly basis, and the level of overcrowding. Main Outcomes and Measures: The primary outcome measures were weekly COVID-19 crude case rates, weekly test positivity rate, and the relative risk of acquiring the infection for prison staff, incarcerated persons, and the general population. Results: The study population comprised a mean of 7599 incarcerated individuals and 4591 prison staff. Approximately 5.1% of the prison population were women; demographic characteristics of the prison staff were not available. During the study, COVID-19 occurred in 1564 incarcerated individuals and 661 prison staff. Most of these cases were reported during the second wave (1474 in incarcerated individuals, 529 in prison staff), when stringent measures previously enforced were relaxed. During both epidemic waves, incarcerated individuals and prison staff had a higher relative risk for COVID-19 infection than the general population during both the first wave (incarcerated individuals: 1.30; 95% CI, 1.06-1.58; prison staff: 3.23; 95% CI, 2.74-3.84) and the second wave (incarcerated individuals: 3.91; 95% CI, 3.73-4.09; prison staff: 2.61; 95% CI, 2.41-2.82). Conclusions and Relevance: The findings of this study suggest that the prison setting was an element of fragility during COVID-19 pandemic, with a high burden of COVID-19 cases among both the incarcerated individuals and prison staff. The prison setting and prison population need to be included and possibly prioritized in the response during epidemic events.

COVID-19 outbreak investigation and response in a penitentiary setting: the experience of a prison in Italy, February to April 2020.

Prisons are high-risk settings for COVID-19 and present specific challenges for prevention and control. We describe a COVID-19 outbreak in a large prison in Milan between 20 February and 30 April 2020. We performed a retrospective analysis of routine data collected during the COVID-19 emergency in prison. We analysed the spatial distribution of cases and calculated global and specific attack rates (AR). We assessed prevention and control measures. By 30 April 2020, 57 confirmed COVID-19 cases and 66 clinically probable cases were recorded among a population of 1,480. Global AR was 8.3%. The index case was a custodial officer. Two clusters were detected among custodial staff and healthcare workers. On 31 March, a confirmed case was identified among detained individuals. COVID-19 spread by physical proximity or among subgroups with cultural affinity, resulting in a cluster of 22 confirmed cases. Following index case identification, specific measures were taken including creation of a multidisciplinary task-force, increasing diagnostic capacity, contact tracing and dedicated isolation areas. Expanded use of personal protective equipment, environmental disinfection and health promotion activities were also implemented. Outbreaks of COVID-19 in prison require heightened attention and stringent comprehensive measures.

The epidemic burden on prisons in Lombardy (Italy) during the first wave of the COVID-19 pandemic: the transmission and measures of prevention in detention facilities.

PURPOSE: Early on in the COVID-19 pandemic, the scientific community highlighted a potential risk of epidemics occurring inside prisons. Consequently, specific operational guidelines were promptly released, and containment measures were quickly implemented in prisons. This paper aims to describe the spread of COVID-19 in detention facilities within the Lombardy region of Italy during March to July 2020, and the impact of the prevention and control measures implemented. DESIGN/METHODOLOGY/APPROACH: A descriptive retrospective analysis of case distribution was performed for all COVID-19 cases identified among people in detention (PiD) and prison officers (POs). A comparison of the epidemic burden affecting different populations and a correlation analysis between the number of cases that occurred and prevention measures implemented were also carried out. FINDINGS: From this study, it emerged that POs were at a high risk of contracting COVID-19. This study observed a delay in the occurrence of cases among PiD and substantial heterogeneity in the size of outbreaks across different prisons. Correlation between reported cases among PiD and registered sick leave taken by POs suggested the latter contributed to introducing the infection into prison settings. Finally, number of cases among PiD inversely correlated with the capacity of each prison to identify and set up dedicated areas for medical isolation. ORIGINALITY/VALUE: Prevention and control measures when adopted in a timely manner were effective in protecting PiD. According to the findings, POs are a population at high risk for acquiring and transmitting COVID-19 and should be prioritized for testing, active case finding and vaccination. This study highlights the critical importance of including prison settings within emergency preparedness plans.

Antigenic rapid test for SARS-CoV2 screening of individuals newly admitted to detention facilities: sensibility in an asymptomatic cohort.

Background: Since the start of the Sars-CoV-2 pandemic, attention was called on the potential risk of COVID-19 outbreaks occurring inside prisons. In detention facilities, timely and accurate diagnosis is essential for allowing case isolation and contact tracing to avoid the spread of the infection. Until recently, reverse-transcriptase polymerase chain reaction (rt-PCR) was the recommended method to diagnose SARS-CoV-2 infection. However, antigen-detecting rapid diagnostic tests (ag-RDT) have emerged as point-of-care testing techniques. Objectives: Here, we evaluate the use of ag-RDT for screening of individuals newly admitted to San Vittore prison (SV), a pre-trial prison, in Milan (Lombardy region, Italy), during the second SARS-CoV2 epidemic peak. Methods: During the period 1 October-31 December 2020, ag-RDT and rt-PCR were performed individuals newly admitted to SV. Results: Among 504 detained individuals tested, 21 (4,2%) resulted positive to rt-PCR. Of these, 10 had tested negative with ag-RDT and 11 had concordant results. Rt-PCR cycle threshold (CT) values were above 35 for the individuals with ag-RDT negative test, therefore the cases missed by the ag-RDT are unlikely to transmit disease. For all the individuals with ag-RDT positive results, CT values were below or equal to 27. In our study population, ag-RDT sensitivity was 52.4% (29.8%-74.3%), positive predictive value (PPV) was 100% and negative predictive value was 98.0% (96.8%-98.7%). Discussion: Our study showed that ag-RDT is a promising and useful component of serial testing strategies in prison settings to perform SARS-CoV2 screening at admission based to its high PPV, ease of use, lower costs and resource needs.

HCV micro-elimination in two prisons in Milan, Italy: A model of care.

People in prison represent a high-risk population for HCV infection control. With the advent of new direct antiviral agents (DAAs) HCV micro-elimination in prison setting became a feasible strategy. We assessed the impact of an intervention for HCV testing and treatment in 2017 and 2018 in a jail (San Vittore,SV) and a prison for sentenced individuals (Opera,OP). A dedicated protocol was applied and implemented over the two years. We collected data on demographics, HCV testing and treatment on all inmates present on 31 October 2017 and 2018. In the two facilities, there were 2,366 and 2,369 inmates in 2017 and 2018 respectively; the majority were men (95.6%; 96.4%) and Italians (57.0%; 61.9%) with a median age of 41 years. Prevalence of lifetime reported drug use remained high (46.5%; 44.2%). HCV screening coverage was 89% in both years, while HCV RNA test coverage increased (90.6%; 99.0%). HCV seroprevalence remained stable (10.1%; 9.2%). In 2017 among inmates with HCV chronic infection 90 (42.4%) individuals had started DAAs treatment and 106 (54.6%) in 2018; of whom 38 (17.9%) and 74 (38.1%) achieved the SVR. The viremic pool decreased significantly over time (SV,24.4%; 15.4%;OP, 16.1%; <1%). Among inmates with HCV-positive serology in 2018, 121 (81.0%) were never linked to care before incarceration. Our study showed how a targeted and well-implemented HCV test-and-treat intervention in prison was feasible and effective in achieving micro-elimination. Viral hepatitis elimination agenda may help drawing interest onto this neglected population and bringing prison health higher up in the global public health agenda.

"I take my pills every day, but then it goes up, goes down. I don't know what's going on": Perceptions of HIV virological failure in a rural context in Mozambique. A qualitative research study.

BACKGROUND: HIV prevalence in Mozambique is estimated to be 13.2%. Routine viral load for HIV monitoring was first implemented in the rural area of Tete in 2014. Programmatic data showed an unexpected high proportion of high viral load results, with up to 40% of patients having a viral load above 1000 copies/ml. OBJECTIVES: This qualitative study aimed to explore perceptions about virological failure and viral load monitoring from the perspective of HIV positive patients on first-line antiretroviral therapy (ART) and health-care workers. METHODS: The study was conducted in seven rural communities in Changara-Marara district, Tete province, Mozambique. A total of 91 participants took part in in-depth interviews (IDIs) and focus group discussions (FGDs), including health-care workers (n = 18), patients on ART in individual care or Community Adherence Groups (CAGs) who experienced virological failure and virological re-suppression (n = 39) and CAG focal points (n = 34). Purposive sampling was used to select participants. Interviews and FGDs were conducted in Nhuengue and Portuguese. IDIs and FGDs were translated and transcribed before being coded and thematically analysed. RESULTS: Emergent themes showed that patients and health-care workers attributed great importance to viral load monitoring. A supressed viral load was viewed by participants as a predictor of good health and good adherence. However, some patients were confused and appeared distressed when confronted with virological failure. Viral load results were often little understood, especially when virological failure was detected despite good adherence. Inadequate explanations of causes of virological failure, delayed follow-up viral load results, repeated blood tests and lack of access to second-line ART resulted in reduced confidence in the effectiveness of ART, challenged the patient-provider relationship and disempowered patients and providers. CONCLUSION: In this rural context undetectable viral load is recognized as a predictor of good health by people living with HIV and health-care workers. However, a lack of knowledge and health system barriers caused different responses in patients and health-care workers. Adapted counselling strategies, accelerated viral load follow-up and second-line ART initiation in patients with virological failure need to be prioritized.

A comparison of self-report and antiretroviral detection to inform estimates of antiretroviral therapy coverage, viral load suppression and HIV incidence in Kwazulu-Natal, South Africa.

BACKGROUND: Accurately identifying individuals who are on antiretroviral therapy (ART) is important to determine ART coverage and proportion on ART who are virally suppressed. ART is also included in recent infection testing algorithms used to estimate incidence. We compared estimates of ART coverage, viral load suppression rates and HIV incidence using ART self-report and detection of antiretroviral (ARV) drugs and we identified factors associated with discordance between the methods. METHODS: Cross-sectional population-based survey in KwaZulu-Natal, South Africa. Individuals 15-59 years were eligible. Interviews included questions about ARV use. Rapid HIV testing was performed at the participants' home. Blood specimens were collected for ARV detection, LAg-Avidity HIV incidence testing and viral load quantification in HIV-positive individuals. Multivariate logistic regression models were used to identify socio-demographic covariates associated with discordance between self-reported ART and ARV detection. RESULTS: Of the 5649 individuals surveyed, 1423 were HIV-positive. Median age was 34 years and 76.3% were women. ART coverage was estimated at 51.4% (95%CI:48.5-54.3), 53.1% (95%CI:50.2-55.9) and 56.1% (95%CI:53.5-58.8) using self-reported ART, ARV detection and both methods combined (classified as ART exposed if ARV detected and/or ART reported) respectively. ART coverage estimates using the 3 methods were fairly similar within sex and age categories except in individuals aged 15-19 years: 33.3% (95%CI:23.3-45.2), 33.8% (95%CI:23.9-45.4%) and 44.3% (95%CI:39.3-46.7) using self-reported ART, ARV detection and both methods combined. Viral suppression below 1000cp/mL in individuals on ART was estimated at 89.8% (95%CI:87.3-91.9), 93.1% (95%CI:91.0-94.8) and 88.7% (95%CI:86.2-90.7) using self-reported ART, ARV detection and both methods combined respectively. HIV incidence was estimated at 1.4 (95%CI:0.8-2.0) new cases/100 person-years when employing no measure of ARV use, 1.1/100PY (95%CI:0.6-1.7) using self-reported ART, and 1.2/100PY (95%CI:0.7-1.7) using ARV detection. In multivariate analyses, individuals aged 15-19 years had a higher risk of discordance on measures of ARV exposure (aOR:9.4; 95%CI:3.9-22.8), while migrants had a lower risk (aOR:0.3; 95%CI:0.1-0.6). CONCLUSIONS: In KwaZulu-Natal, the method of identifying ARV use had little impact on estimates of ART coverage, viral suppression rate and HIV incidence. However, discordant results were more common in younger individuals. This may skew estimates of ART coverage and viral suppression, particularly in adolescent surveys.

Journey towards universal viral load monitoring in Maputo, Mozambique: many gaps, but encouraging signs.

Introduction: Viral load (VL) monitoring for people on antiretroviral therapy (ART) is extremely challenging in resource-limited settings. We assessed the VL testing scale-up in six Médecins Sans Frontières supported health centres in Maputo, Mozambique, during 2014-15. Methods: In a retrospective cohort study, routine programme data were used to describe VL testing uptake and results, and multi-variate logistical regression to estimate predictors of VL testing uptake and suppression. Results: Uptake of a first VL test was 40% (17 236/43 579). Uptake of a follow-up VL test for patients with a high first VL result was 35% (1095/3100). Factors associated with a higher uptake included: age below 15 years, longer time on ART and attending tailored service delivery platforms. Virological suppression was higher in pregnant/breastfeeding women and in community ART Group members. Patients with a high first VL result (18%; 3100/17 236) were mostly younger, had been on ART longer or had tuberculosis. Out of 1095 attending for a follow-up VL test, 678 (62%) had virological failure. Of those, less than one-third had started second line ART. Conclusion: This was the first study describing the uptake and results of VL testing scale-up in Mozambique. Identified gaps show patient and programmatic challenges. Where service delivery was customized to patient needs, VL monitoring was more successful.

Plasmodium Parasitemia Associated With Increased Survival in Ebola Virus-Infected Patients.

BACKGROUND: The ongoing Ebola outbreak in West Africa has resulted in 28 646 suspected, probable, and confirmed Ebola virus infections. Nevertheless, malaria remains a large public health burden in the region affected by the outbreak. A joint Centers for Disease Control and Prevention/National Institutes of Health diagnostic laboratory was established in Monrovia, Liberia, in August 2014, to provide laboratory diagnostics for Ebola virus. METHODS: All blood samples from suspected Ebola virus-infected patients admitted to the Médecins Sans Frontières ELWA3 Ebola treatment unit in Monrovia were tested by quantitative real-time polymerase chain reaction for the presence of Ebola virus and Plasmodium species RNA. Clinical outcome in laboratory-confirmed Ebola virus-infected patients was analyzed as a function of age, sex, Ebola viremia, and Plasmodium species parasitemia. RESULTS: The case fatality rate of 1182 patients with laboratory-confirmed Ebola virus infections was 52%. The probability of surviving decreased with increasing age and decreased with increasing Ebola viral load. Ebola virus-infected patients were 20% more likely to survive when Plasmodium species parasitemia was detected, even after controlling for Ebola viral load and age; those with the highest levels of parasitemia had a survival rate of 83%. This effect was independent of treatment with antimalarials, as this was provided to all patients. Moreover, treatment with antimalarials did not affect survival in the Ebola virus mouse model. CONCLUSIONS: Plasmodium species parasitemia is associated with an increase in the probability of surviving Ebola virus infection. More research is needed to understand the molecular mechanism underlying this remarkable phenomenon and translate it into treatment options for Ebola virus infection.

Interpretation of Negative Molecular Test Results in Patients With Suspected or Confirmed Ebola Virus Disease: Report of Two Cases.

Quantitative reverse-transcription polymerase chain reaction (qRT-PCR) is the most sensitive quantitative diagnostic assay for detection of Ebola virus in multiple body fluids. Despite the strengths of this assay, we present 2 cases of Ebola virus disease (EVD) and highlight the potential for false-negative results during the early and late stages of EVD. The first case emphasizes the low negative-predictive value of qRT-PCR during incubation and the early febrile stage of EVD, and the second case emphasizes the potential for false-negative results during recovery and late neurologic complications of EVD. Careful interpretation of test results are needed to guide difficult admission and discharge decisions in suspected or confirmed EVD.

Combined pegylated interferon and ribavirin for the management of chronic hepatitis C in a prison setting

The elevated frequency of chronic hepatitis C virus (HCV) infection found among prison inmates, and the availability of improved pharmacological cure for this potentially life-threatening disorder, make investigations conducted in this somewhat neglected area very relevant, since only a few, open-label experiences have been reported till now. In the metropolitan prison of Bologna (Italy), HCV seroprevalence was found to be over 31 percent in 2003, so that a pilot feasibility study based on treatment with pegylated interferon plus ribavirin was initiated, after careful counseling carried out by a joint commission of health care personnel of the correctional facility and infectious diseases consultants. Thirty-nine patients were enrolled, and despite expected dropouts due to difficulty in maintaining the same level of counseling pressure over time, and the particularly unfavorable climatic conditions during Summer 2003, a sustained virological response was obtained for 8 out of the 21 patients who remained evaluable after the first three month follow-up, although we need to take into account that a high percentage of subjects (67 percent) were selected for therapy due to their favorable HCV genotypes (types 2 and 3). Our preliminary experience shows that an intrinsically complicated therapy, such as the administration of pegylated interferon plus ribavirin, can attain a relatively high success rate, even in a very unfavorable and uncomfortable context, such as a prison, where only enforced counseling, active participation of institutional health care operators, and patient's willingness to maintain an elevated level of co-operation and adherence, can overcome most structural and relational difficulties.

Combined pegylated interferon and ribavirin for the management of chronic hepatitis C in a prison setting.

The elevated frequency of chronic hepatitis C virus (HCV) infection found among prison inmates, and the availability of improved pharmacological cure for this potentially life-threatening disorder, make investigations conducted in this somewhat neglected area very relevant, since only a few, open-label experiences have been reported till now. In the metropolitan prison of Bologna (Italy), HCV seroprevalence was found to be over 31% in 2003, so that a pilot feasibility study based on treatment with pegylated interferon plus ribavirin was initiated, after careful counseling carried out by a joint commission of health care personnel of the correctional facility and infectious diseases consultants. Thirty-nine patients were enrolled, and despite expected dropouts due to difficulty in maintaining the same level of counseling pressure over time, and the particularly unfavorable climatic conditions during Summer 2003, a sustained virological response was obtained for 8 out of the 21 patients who remained evaluable after the first three month follow-up, although we need to take into account that a high percentage of subjects (67%) were selected for therapy due to their favorable HCV genotypes (types 2 and 3). Our preliminary experience shows that an intrinsically complicated therapy, such as the administration of pegylated interferon plus ribavirin, can attain a relatively high success rate, even in a very unfavorable and uncomfortable context, such as a prison, where only enforced counseling, active participation of institutional health care operators, and patient's willingness to maintain an elevated level of co-operation and adherence, can overcome most structural and relational difficulties.

[HIVAb, HCVAb and HBsAg seroprevalence among inmates of the prison of Bologna and the effect of counselling on the compliance of proposed tests]. / Prevalenza per HIV, HBV e HCV nei detenuti del carcere di Bologna ed effetti del counselling sul livello di adesione alla proposta dei test.

OBJECTIVES: The aims of the study were to evaluate the HIVAb, HCVAb and HBsAg seroprevalence among Italian and foreign inmates of the prison of Bologna, to evaluate if the extensive counselling of "new" inmates has significantly enhanced adherence to laboratory tests. DESIGN: The serological status was determined by a blood withdraw following the informed consent. Before asking their consent, patients were informed by cultural mediators who had been instructed about the aims of the study/exam during introductory meetings. The initial step managed by mediators was followed by further individual counselling interventions, carried out by hospital infective disease unit, prison and prison drug abuse service physicians. The laboratory tests were performed in an external structure. SETTING: Prison of Bologna. PARTICIPANTS: The study was conducted on 433 subjects among a whole population of 900 inmates in the local prison: 390 subjects were males (90.1%) and 43 were females (9.9%). The median age of the whole population was 34.86 years (+/- 9.9). The studied population counted 147 (33.9%) intravenous drug users (IDU) and 286 not addicts (66.1%). As regards nationality, 212 subjects were Italian (48.9%) and 221 (51.1%) foreigners. Among the total 433 inmates considered, 78 (18%) were known as previous IDU with conviction history or condemned to long term sentences, while 59 (13.6%) were inmates recently convicted active IDU assisted by the internal drug abusers service. The third group was composed by 296 inmates imprisoned during the summer (103 Italians and 193 foreigners) self declared not IDU. RESULTS: A. 12.5% of inmates were HIV positive, 8.1% HBV positive and 31.1% HCV positive. 25 subjects were found positive both to HIV and HCV; 1 both to HIV and HBV and 5 to HIV, HBV and HCV. HIV positivity is more common among Italian vs. foreigners inmates, among IDU vs. not IDU. HCV positivity is more common among Italian vs. foreigners inmates, and among IDU vs. not IDU. The distribution of HBV seropositivity among the different groups shows no statistically significant differences. All subjects receiving multi-focal counselling reached better compliance levels: 10% vs. 1% for HIV, 16% vs. 1% for HBV and 35% vs. 0.3% for HCV, with statistically significant coefficients of contingency. CONCLUSIONS: In the prison of Bologna drug addiction is prevalent in italian seropositive personers and it is often associated with HIV and HCV positivity. Foreign inmates, mostly in the not-IDU group, show a lower prevalence of these two infections. Multi-focal counselling before test increased significantly the adherence of inmates to the study.