International Journal of Prisoner Health

Healthcare resources are inadequate to address the burden of illness among HIV-infected male prisoners
in Malaysia
Joseph Bick Gabriel J. Culbert Haider Al-Darraji Clayton Koh Veena Pillai Adeeba Kamarulzaman Frederick Altice
Article information:
To cite this document:
Joseph Bick Gabriel J. Culbert Haider Al-Darraji Clayton Koh Veena Pillai Adeeba Kamarulzaman Frederick Altice ,
(2016),"Healthcare resources are inadequate to address the burden of illness among HIV-infected male prisoners in
Malaysia", International Journal of Prisoner Health, Vol. 12 Iss 4 pp. -
Permanent link to this document:
http://dx.doi.org/10.1108/IJPH-06-2016-0017
Downloaded on: 02 December 2016, At: 18:05 (PT)
References: this document contains references to 0 other documents.
To copy this document: permissions@emeraldinsight.com
The fulltext of this document has been downloaded 7 times since 2016*
Users who downloaded this article also downloaded:
(2016),"Facets of psychopathy in relation to trauma-exposure and posttraumatic stress symptomology in a sample of
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

incarcerated male offenders", International Journal of Prisoner Health, Vol. 12 Iss 4 pp. -
(2016),"Access to healthcare services during incarceration among female inmates", International Journal of Prisoner Health,
Vol. 12 Iss 4 pp. -

Access to this document was granted through an Emerald subscription provided by emerald-srm:188318 []
For Authors
If you would like to write for this, or any other Emerald publication, then please use our Emerald for Authors service
information about how to choose which publication to write for and submission guidelines are available for all. Please
visit www.emeraldinsight.com/authors for more information.
About Emerald www.emeraldinsight.com
Emerald is a global publisher linking research and practice to the benefit of society. The company manages a portfolio of
more than 290 journals and over 2,350 books and book series volumes, as well as providing an extensive range of online
products and additional customer resources and services.
Emerald is both COUNTER 4 and TRANSFER compliant. The organization is a partner of the Committee on Publication
Ethics (COPE) and also works with Portico and the LOCKSS initiative for digital archive preservation.

*Related content and download information correct at time of download.

 Healthcare resources are inadequate to address the burden of illness among HIV-

infected male prisoners in Malaysia

1. INTRODUCTION

HIV prevalence in Malaysia is high (15.8%, 95% Confidence Interval [CI]: 12.5-

19.2%) among people who inject drugs (PWID) (Bazazi et al., 2015, Degenhardt et al.,

2014), with recent evidence of a generalizing epidemic of sexual transmission from

Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

male PWID to their female sexual partners (Ministry of Health, 2015). Although HIV

transmission and mortality have decreased 19% globally (Joint United Nations

Programme on HIV/AIDS, 2014), HIV-related mortality has increased by 20% in

Malaysia. Fewer than half (41.6%) of all eligible adults in Malaysia were prescribed

antiretroviral therapy (ART) in 2012 (Joint United Nations Programme on HIV/AIDS,

2013), and ART coverage among PWID remains only 5% (Degenhardt et al., 2014),

resulting in one of the least well-controlled epidemics in Asia (Joint United Nations

Programme on HIV/AIDS, 2013).

Concomitant with the burgeoning HIV epidemic, Malaysia’s punitive drug laws

resulted in a 45% increase in its prison population from 2000 to 2013, and an

incarceration rate of 171/100,000 in 2015 (Walmsley, 2016). Consequently, PWID are

housed in overcrowded prisons (99.6% over designed occupancy capacity) (Institute for

Criminal Policy Research, 2015), where HIV prevalence (5.3%) is 13-fold greater than in

the community (0.4%) (Joint United Nations Programme on HIV/AIDS, 2014). Annually,

over 80,000 individuals transition through at least one of 39 prisons nationwide, with

many more in pre-trial detention or compulsory drug detention centers (Institute for

Criminal Policy Research, 2015). This translates to ~4,200 people living with HIV (PLH),
 nearly all of whom will eventually return to the community. International guidelines for

HIV prevention and treatment in prisons (World Health Organization, 2014c) have yet to

be widely adopted in Malaysian prisons. It is therefore crucial to understand the health

status of HIV-infected prisoners in Malaysia in order to provide appropriate and effective

prevention and treatment during incarceration and after release to the community.

2. METHODS

2.1 Study Design

Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

In this descriptive, cross sectional study, sequential sampling was used to recruit

HIV-infected male prisoners who were already aware of their HIV status. From October

2012 through March 2013, 225 HIV-infected prisoners were seen for clinical care, 221

(98.2%) of these provided informed consent for complete evaluation and uniform

collection of data. Participants underwent a comprehensive physical examination,

medical record review and clinically indicated laboratory testing. Only the initial

comprehensive clinical assessment was used to describe the sample.

2.2 Setting

This clinical study was conducted at Malaysia’s largest all-male prison (census=

~4,200). In 2009, the Centre of Excellence for Research in AIDS (CERiA) at the

University of Malaya introduced methadone maintenance treatment (MMT) with

transitional risk reduction services for opioid-dependent HIV+ prisoners (Copenhaver et

al., 2011, Wickersham et al., 2013a, Wickersham et al., 2013b) as part of a research

study. In recognition of the lack of HIV services for study participants, CERiA

established an HIV clinic within the prison staffed by an infectious disease physician
 and an administrative assistant. This study comprises the initial clinical evaluation of all

HIV-infected prisoners, irrespective of their participation in the parent study.

2.3 Medical Care in Malaysian Prisons

Table 1 compares human resources for healthcare provision in this Malaysian

prison to those in the community. Health workforce density in this prison (<1 per 1,000)

was far lower than in the Malaysian general population (World Health Organization,

2014b), below the minimum level (2.5 per 1,000 persons) needed to avoid poor health
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

outcomes (World Health Organization, 2007), and lacked nurses and pharmacy staff.

Only two physicians were directly involved in patient care.

HIV-infected prisoners are segregated in overcrowded, poorly ventilated housing

units that facilitate TB transmission (Al-Darraji et al., 2014a, Abed Al-Darraji et al., 2013,

Margolis et al., 2013). Although HIV testing on admission is compulsory, further HIV

monitoring (e.g. CD4 and viral load) and medications to prevent and treat opportunistic

infections are not routinely available. Most ART regimens include older, less well-

tolerated medications (e.g. stavudine, nevirapine) and treatment interruptions are

common due to supply chain disruptions. Prison guards who have no formal health

assessment training regulate prisoners’ access to care. ART is dispensed by prisoners

and guards as directly observed therapy on weekdays and self-administered on

evenings and weekends.

2.4 Study Participants

Eligible participants were HIV-infected male prisoners ≥18 years of age receiving

HIV subspecialty care within the prison clinic. Participation was voluntary and patients

received the same clinical services regardless of study participation. Custody staff was
 not present during consent procedures or clinical examinations. Informed consent and

medical histories were conducted in English or Bahasa Malaysia. Four patients who

spoke neither English nor Bahasa Malaysia received the same clinical examination as

study participants but were not included in the study.

2.5 Study Measures

Study participants underwent a complete physical examination, structured

medical history, and systematic medical record review conducted by an HIV specialist
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

physician (JB). Data were also obtained from diagnostic studies obtained as part of

routine standard of care provided by the parent NIH grant (R01 DA025943), including

metabolic profile and testing for syphilis, viral hepatitis, and latent tuberculosis infection

(LTBI). Findings from physical exams, laboratory tests, and chart reviews were

communicated to patients at their next clinic visit. Data on how patients were managed

after the initial evaluation, however, was not included in this study.

Table 2 describes study measures and diagnostic criteria used in this study.

Tuberculosis (TB) was assessed by routine examination of two early-morning sputum

specimens using GeneXpert MTB/RIF (Abed Al-Darraji et al., 2013), acid-fast bacillus

(AFB) smear microscopy, and mycobacteriology culture, regardless of symptoms.

Active TB was diagnosed based upon a positive culture result. Tuberculin skin testing

(TST) was used to assess for LTBI in the absence of active TB. TST induration ≥5mm

was considered reactive. CD4 lymphocyte count monitoring was performed using Alere

Pima™ CD4 analyzer (Jani et al., 2011). Scabies was assessed through physical

examination. Hypertension (Kenning et al., 2014) and kidney disease (Levey et al.,

2003) were diagnosed utilizing established guidelines. Medical records supplemented

 self-reported mental illness. Substance use during the year before incarceration was

assessed by self report. Heavy drinking was defined as more than 14 drinks per week

during the year before incarceration, which is associated with having or developing an

alcohol use disorder (AUD) (National Institute on Alcohol Abuse and Alcoholism, 2010).

Medical records were used when patient self-report was discrepant from medical chart

review.

2.6 Data Analysis

Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

Data was entered and analyzed in Microsoft Excel 2013 for Windows (Version

8.1). Tests of binomial proportions were performed using MedClac online statistical

software (https://www.medcalc.org/calc/comparison_of_proportions.php). We reviewed

the published literature for age and gender-matched data on disease prevalence in

incarcerated populations globally, the Malaysian adult population (ages 15-49), and

Malaysian aboriginal peoples, which we compared to point prevalence estimates in our

sample, using a binomial test of proportions (Altman, 1991). We used the upper bound

for prevalence rates as our comparison.

2.7 Ethical Statement

This study was conducted in accordance with international standards for

research with prisoners (Lazzarini and Altice, 2000). Institutional review boards at

University of Malaya and Yale University approved the study. Attendance in the prison

HIV clinic was voluntary, and not predicated upon involvement in the parent NIH study.

Participants provided written informed consent and received no compensation for their

time.

3. RESULTS
 3.1 Communicable Diseases

On average, participants were 35.2 years old (range: 21-66, SD=10.1), mostly

Malay (71%), and had multiple previous incarcerations (mean=5.1, SD=2.6). Table 3

shows comparisons of age-unadjusted disease prevalence rates in HIV-infected

prisoners and Malaysian adult populations. Most participants (90.4%, 95%CI=85.7-

93.9%) were reactive for hepatitis C virus (HCV) antibody screening compared to less

than 2.5% of Malaysian adults (p<0.001) (Noor Haslina et al., 2012, Duraisamy et al.,
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

1993). Nearly one-quarter (23.9%) had been previously treated for active TB and 13.1%

(95%CI=8.9-18.2%) had current active TB, compared to less than one percent (0.13%)

of Malaysian adults (p<0.001) (World Health Organization, 2015b). Among those

without current or past active TB, most (81.2%, 95%CI=75.4-86.1) had a reactive TST

suggestive of LTBI, even higher than Malaysian healthcare workers (52.1-59.0%,

p<0.001) (Margolis et al., 2013). Comparison data for prevalence of LTBI and past

active TB in the Malaysian general population were unavailable. Reactive syphilis titers

(RPR >1:8) suggestive of untreated infection in 18 participants (8.1%, 95%CI=4.8-12.5)

were higher compared to Malaysian adults (0.02%, p<0.001) (Newman et al., 2015).

Over one third (37.3%, 95%CI=30.9-44.0) had clinical findings consistent with active

scabies, approximately 3-fold higher than among Malaysian aboriginal peoples (11.9%,

p<0.001) (Norhayati Binti Moktar et al., 1998).

3.2 Non-communicable Diseases

The age-unadjusted prevalence rates for hypertension (17.1%, 95%CI=12.3-

22.7, p=0.003), and diabetes (4.0%), were lower than found in the general Malaysian

adult population (Guariguata et al., 2014, Letchuman et al., 2010, To et al., 2012,
 Ministry of Health, 2006), while prevalence of asthma (5.8%, 95%CI=3.1-9.7, p=0.276)

was not statistically different (To et al., 2012). The observed rate of hypertension (Table

4), in participants 50-59 years of age (77.7%, 95%CI=52.2-93.5%), however, was

significantly higher than the expected rate in Asian males of similar age (24.8%,

p<0.001) (Kearney et al., 2005). The expected prevalence for diabetes (7.6%)

(Letchuman et al., 2010) based on the age-adjusted Malaysian adult population was

higher than the observed prevalence (4.0%, 95%CI=1.8-7.5%, p=0.04), but was lower
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

(2.7%, 95%CI=0.9-5.8%) for chronic kidney disease compared to the Malaysian adult

population (9.1%, p=0.001) (Hooi et al., 2013). Nearly all participants (88.2%) had

dental pathology on examination, compared to 19.2% in Malaysian aboriginal peoples

(p<0.001).

3.3 Substance Use and Mental Illness

Substance use and psychiatric disorders were more prevalent in HIV-infected

prisoners than in the general population. Prevalence of tobacco smoking in the year

before incarceration by participants (71.9% 95%CI= 65.4-77.7) was higher compared to

Malaysian adult males (46.5%, p<0.001) (Lim et al., 2013). Prevalence of opioid

injection in this sample (83.7%, 95%CI=78.1-88.3) was higher than the estimated

prevalence of opioid injection in PLH nationwide (77.4%, p=0.02) (United Nations Office

on Drugs and Crime, 2009a), or among Malaysian adults (1.33%, p<0.001) (United

Nations Office on Drugs and Crime, 2009a). Heavy alcohol drinking (30.8%,

95%CI=24.7-37.3) during the year before incarceration was 7.5- to 17-fold higher than

rates of heavy drinking in males (1.8-4.1%, p<0.001) nationally (World Health

Organization, 2014a). HCV and TB were more prevalent in PWID compared to those
 without a drug injection history. Participants who reported a history of drug injection

(n=185) were more likely to be HCV co-infected (98.9% v. 47.2%, p<0.001), latently

infected with tuberculosis (86.2% v. 52.0%, p<0.001) or report a history of active

tuberculosis (25.9% v. 13.9%, p=0.13), than those who reported no drug injection.

Figure 1 shows that over a quarter of PWID (26.4%) were both HCV co-infected and

reported heavy drinking levels consistent with having an alcohol use disorder (AUD).

Prevalence of select psychiatric conditions (schizophrenia, bipolar disorder, or

Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

depression) was self-reported by 15.8% of participants, over 3-fold higher than the

prevalence of all major mental disorders in the Malaysian adult population

(Krishnaswamy et al., 2012).

3.4 HIV Diagnosis and Treatment

Most participants (66.9%) were diagnosed with HIV during a previous (56.5%) or

current (10.5%) incarceration through mandatory testing in prison. Figure 2 shows the

HIV treatment cascade for persons living with HIV (PLH) before incarceration. Although

most (89.5%) were aware of their HIV status before the current incarceration, few

(22.1%) had ever undergone CD4 testing or had been prescribed ART (16.7%).

Overall, two thirds (65.6%) of PLH were prescribed ART in prison. Figure 3

shows the HIV treatment cascade for PLH during incarceration. Upon entry into prison,

73.7% of participants met eligibility criteria for ART (CD4<350 cells/µL) and 26.2% had

markedly advanced HIV (CD4<200 cells/µL). Yet 34.4% of those eligible for ART,

including 22.8% of those with advanced HIV (CD4<200/µL), were not receiving it during

incarceration.

4. DISCUSSION
 This study contributes to the growing body of international research on prisoner

health, demonstrating a profound mismatch between the extraordinarily high burden of

diseases in HIV-infected Malaysian prisoners, and the limited resources allocated to

address those needs. Although mandatory HIV testing, which does not conform to

international guidelines (United Nations Office on Drugs and Crime , 2009b), identifies a

crucial number of PLH in Malaysia (Bazazi et al., 2015), subsequent provision of HIV

treatment falls short of expected individual or public health benefits (Basu et al., 2005).
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

Nearly all prisoners will eventually be released to the community. Failure to provide

health services to this medically and socially marginalized population during

incarceration contributes to poor health outcomes and contributes substantially to

ongoing HIV transmission (Vagenas et al., 2013, Spaulding et al., 2009, Altice et al.,

2016). Most HIV-infected prisoners in Malaysia are also PWID and face considerable

post-release challenges including community physicians who are unwilling to prescribe

ART to these patients (Ferro et al., Under review). Without effective interventions during

the transition from prison, many of these patients are likely to regress along the HIV

care continuum (Meyer et al., 2011a).

Although this study was limited to male prisoners in one of 39 prisons in Malaysia

(Institute for Criminal Policy Research, 2015), findings suggest that Malaysian prisons,

especially those located in high HIV prevalence urban areas are important sites for

providing clinical services to PLH (Springer et al., 2011). Most participants (66.9%) were

first diagnosed through mandatory HIV testing in prison, and most (89.5%) were already

aware of their HIV status before the current incarceration. Very few, however, had

undergone CD4 cell assessments, and even fewer had been prescribed ART (16.7%)
 before the current incarceration. Our findings suggest that while many first become

aware of their HIV status in prison, subsequent staging, treatment, and transitional

services (i.e. discharge planning, linkage-to-care services, and continuation of ART

post-release) are suboptimal for this population.

In countries like Malaysia where HIV prevalence in PWID is high, prisons

become increasingly important sentinel clinical care sites. Most HIV-infected prisoners

(73.7%) had advanced HIV (CD4<350 cells/µL) and were eligible for ART according to
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

the 2012 international and Malaysian guidelines. A critical minority had advanced

(CD4<200 cells/µL) HIV, necessitating prophylaxis for opportunistic infections. Although

the rate of ART utilization among ART-eligible prisoners (65.6%) was 57% higher than

in the Malaysian general population (41.6%), a third of those eligible for ART (34.4%)

were not receiving it. Revised international guidelines expanding ART to all PLH,

regardless of CD4 count (World Health Organization, 2015a, Insight Start Study Group

et al., 2015), will almost certainly widen the treatment gap for prisoners and PWID.

Previous studies have suggested two potential sources or delayed ART initiation in

prisoners. First, discriminatory attitudes by Malaysian physicians (Ferro et al., Under

review) and medical students (Earnshaw et al., 2014, Jin et al., 2014) toward key

populations likely contribute to suboptimal ART coverage. A national sample of HIV-

treating Malaysian physicians indicated that they would not prescribe ART for a patient

who injects (52.3%) or was recently released from prison (38.8%), even at critically low

CD4 counts (CD4<200cell/µL) (Ferro et al., Under review). Physicians’ reluctance to

prescribe ART to PWID was significantly reduced if a patient was also prescribed

methadone (Ferro et al., Under review) suggesting that concerns about ART adherence,
 although mainly unsupported by adherence research with PWID (Feelemyer et al.,

2014), may underpin decisions to defer ART in this population. Second, social-

contextual factors unique to the prison setting may interfere with patient acceptance of

ART. For example, prisoners may delay or decline ART if they mistrust their physician

(Altice et al., 2001) or perceive that taking ART raises their chances of being subjected

to stigma, discrimination or violence (Culbert, 2014, Culbert et al., 2015b). Myths and

misconceptions about the potential risks and benefits of medications to treat HIV and
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

addiction (e.g. methadone) may also be spread through contact with peers and

misinformed prison staff (Polonsky et al., 2016, Polonsky et al., 2015, Culbert et al.,

2015a, Bachireddy et al., 2011, Culbert et al., 2015c). Although more research is

needed to understand why eligible patients do not receive ART in prison, organizational

changes that protect the safety and confidentiality of inmates receiving ART would likely

increase ART acceptance and utilization.

Worldwide, jails and prisons often lack sufficient clinical staffing to adequately

attend to the extremely high burden of disease among prisoners. Health workforce

density in this Malaysian prison (<1 per 1,000) was far below community workforce

densities in Southeast Asia (4.3 per 1,000) and the Western Pacific (5.8 per 1,000) and

below the minimum level (2.5 per 1,000) needed to avoid poor health outcomes (World

Health Organization, 2007). While multiple factors (e.g. poor pay, vacant posts, high

turnover, poor work environments) may contribute to staff shortages, other low-resource

settings have successfully task-shifted ART initiation and management from physicians

to nurses or other non-physician healthcare staff as a cost effective approach to

increase the number of PLH receiving treatment – especially important given new
 treatment guidelines that recommend starting ART at any CD4 lymphocyte count (World

Health Organization, 2015a). Using task-shifting, nurses can achieve HIV treatment

outcomes equivalent to those achieved by physicians and in some cases higher rates of

retention and patient satisfaction (Callaghan et al., 2010), which may prove especially

useful for reaching PWID where discrimination and criminalization are barriers to

treatment (Ti and Kerr, 2013). Another area worthy of exploration is the use of

telemedicine to enhance decision-making support, facilitate health service delivery, and

Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

educate prison-based health care staff. HIV subspecialty care implemented remotely via

telemedicine in state correctional systems in the U.S. was associated with greater

virologic suppression and higher CD4+ cell counts in prisoners (Young et al., 2014).

Another approach to address disparities in healthcare delivery is Project ECHO™(Arora

et al., 2007, Arora et al., 2011a, Arora et al., 2011b, Komaromy et al., 2016), a tele-

education program that uses a collaborative learning environment to train non-specialty

physicians to deliver specialty services.

Policies segregating HIV-infected prisoners with high TB burden and weakened

immune systems into overcrowded and poorly ventilated housing units elevates the risk

of TB transmission and mortality (Mohle-Boetani et al., 2002) (Urrego et al., 2015, Dara

et al., 2015). Our findings are similar to the high prevalence of LTBI among prisoners

(Al-Darraji et al., 2014a, Margolis et al., 2013, Culbert et al., 2016), PWID (Al-Darraji et

al., 2014b) and employees (Al-Darraji et al., 2015) in Malaysian prisons and higher than

in other at-risk community populations in Southeast Asia (Margolis et al., 2013,

Meijerink et al., 2015). The prevalence of active TB infection (13.1%) was 100-fold

higher than in the Malaysian adult population (0.13%) (World Health Organization,
 2013). In high TB/HIV settings, like prisons, provision of continuous isoniazid prevention

therapy (IPT) (Al-Darraji et al., 2012, Den Boon et al., 2016), intensified case finding,

improved infection control, and effective ART (Suthar et al., 2012), are essential for

reducing TB incidence and mortality as part of a public health approach.

Scabies prevalence in our prison sample (37.3%) may be explained by extreme

overcrowding in prisons. Scabies causes intense discomfort, and can lead to secondary

bacterial infections, acute post-streptococcal glomerulonephritis, and debilitating and

Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

highly-infectious crusted scabies in persons with immune suppression (Walton and

Currie, 2007). Scabies is mainly a disease of poverty and overcrowding and not

influenced by hygiene practices or access to water. Interventions to control scabies in

prisons, therefore, must reduce overcrowding as well as provide effective treatment,

environmental decontamination, and regular access to clothing and linen exchange

(Bick, 2007).

The point prevalence for HCV co-infection (90.4.%) among incarcerated

Malaysian PLH was similar to rates of HCV co-infection in drug-using PLH in Indonesia

(90.2%) (Meijerink et al., 2015), Malaysia (Choo et al., 2015) and Central and South

Asia (Ruisenor-Escudero et al., 2014, Solomon et al., 2015, Azbel et al., 2013), yet

much higher than the estimated (pooled) HCV prevalence among jail/prison detainees

globally (range 23%-29%) and Southeast Asia (13%-38%) (Larney et al., 2013). Drug

injection remains the primary mechanism for HCV transmission. Although highly

effective and curative treatments are now available for HCV (Afdhal et al., 2014,

Kowdley et al., 2014), these new well-tolerated medications are extremely expensive

and not available to Malaysian prisoners. Failure to treat HCV-infected prisoners

 increases the likelihood for an epidemic of end-stage liver disease among current and

former prisoners, similar to what has already been reported in high-income settings

(Luhmann et al., 2015). Difficult to treat HCV genotypes that previously exhibited a

limited geographical distribution could become more widespread (Ruta and Cernescu,

2015).

The prevalence of untreated syphilis in this sample (8.1%) was higher than in

Malaysian foreign workers (7.2%) (Ministry of Health, 2012) or male prisoners in

Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

Indonesia (5.1%) (Blogg et al., 2014), Brazil (5.3%) (El Maerrawi and Carvalho, 2015),

or Mexico (1.8%) (Bautista-Arredondo et al., 2015) but lower compared to male

prisoners in Kyrgyzstan (16.2%) (Azbel et al., 2015). High rates of syphilis and HCV co-

infection demonstrate the need to screen for these infections and introduce risk

reduction counseling into routine health maintenance for this population. Although the

prevalence of certain non-communicable diseases (NCDs) including asthma (5.8%),

hypertension (17.1%), diabetes (4.0%), and kidney disease (2.7%) was lower in

prisoners than in the Malaysian adult population (Letchuman et al., 2010, Ministry of

Health, 2006, To et al., 2012), age-specific rates for hypertension in older prisoners

were higher than expected. Use of self-reported data and medical chart review may

have contributed to underestimating actual prevalence. Poor nutritional status in some

prisoners may also explain lower than expected rates of some NCDs in a relatively

young (mean age=35.2 years) population.

This study provides a conservative estimate of non-drug related psychiatric

illnesses (15.8%), which are more common in HIV-infected Malaysian prisoners (Zahari

et al., 2010), compared to Malaysian adults (Krishnaswamy et al., 2012). Psychiatric co-
 morbidities in this population increase the risk for HIV transmission (Meade and

Sikkema, 2005), and, in the setting of HIV and substance use, are associated with

longer prison sentences, which in turn may increase their risk of ART non-adherence

(Milloy et al., 2012) and death (Patterson, 2013). Rates of heavy or “at-risk” drinking in

this study (30.8%) were somewhat higher than in a previous study within the same

prison (17.5%) (Zahari et al., 2010), potentially due to inclusion of binge drinking, which

frequently occurs (28.3%) in Malaysian males who drink (Mutalip et al., 2014) and could
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

interfere with ART adherence after release (Vagenas et al., 2015). Tobacco smoking in

this sample (71.9%), twice that reported among Malaysian adult males (35.4%),

represents an extremely serious health risk in PLH, given that many lose more years of

life to smoking than to HIV itself (Pacek and Cioe, 2015).

Although the sheer magnitude of disease burden is extraordinarily high in this

clinical case series, some limitations exist. First, mental illness may be under-reported

and biased due to self-reported data, which could be improved by using standardized

screening instruments. Findings here should not be applied to women, but studies

elsewhere show that women prisoners with HIV have an even higher burden of disease

(Meyer et al., 2014a, Meyer et al., 2015, Meyer et al., 2011b, Meyer et al., 2014b).

Some comparison prevalence estimates from the Malaysian general population

included females, and therefore may not accurately reflect prevalence in age-matched

male populations. Most participants were PWID, which mirrors the epidemic in

Malaysia, but makes these findings less generalizable to the non-PWID prison

population.

5. CONCLUSIONS
 HIV-infected male prisoners are an especially vulnerable population with high co-

morbidity of infectious diseases and substance use disorders. Together, these

comorbidities negatively and synergistically reinforce HIV risk and pose serious public

health concerns. Although Malaysian prisons are important sites for diagnosis and

treatment of communicable and non-communicable diseases, the resources allocated

for the treatment of HIV-infected prisoners are paradoxically inadequate to address the

complex health needs of PLH most of whom will soon be released to the community.
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

Interventions to increase the number of incarcerated PLH receiving treatment for HIV,

HCV, TB, and addiction should be prioritized to improve health outcomes and prevent

the emergence of drug resistance and transmission after release.

 References

Al-Darraji, H.A., Abd Razak, H., Ng, K.P., Altice, F.L. & Kamarulzaman, A. 2013. The
diagnostic performance of a single GeneXpert MTB/RIF assay in an intensified
tuberculosis case finding survey among HIV-infected prisoners in Malaysia. PloS
One, Vol. 8, No. 9, pp. e73717.

Afdhal, N., Zeuzem, S., Kwo, P., Chojkier, M., Gitlin, N., Puoti, M., Romero-Gomez, M.,
Zarski, J.-P., Agarwal, K., Buggisch, P., Foster, G.R., Bräu, N., Buti, M.,
Jacobson, I.M., Subramanian, G.M., Ding, X., Mo, H., Yang, J.C., Pang, P.S.,
Symonds, W.T., Mchutchison, J.G., Muir, A.J., Mangia, A. & Marcellin, P. 2014.
Ledipasvir and Sofosbuvir for Untreated HCV Genotype 1 Infection. New
England Journal of Medicine, Vol. 370, No. 20, pp. 1889-1898.
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

Al-Darraji, H.A., Kamarulzaman, A. & Altice, F.L. 2012. Isoniazid preventive therapy in
correctional facilities: a systematic review. International Journal of Tuberculosis
and Lung Disease, Vol. 16, No. 7, pp. 871-9.

Al-Darraji, H.A., Kamarulzaman, A. & Altice, F.L. 2014a. Latent tuberculosis infection in
a Malaysian prison: implications for a comprehensive integrated control program
in prisons. BMC Public Health, Vol. 14, No., pp. 22.

Al-Darraji, H.A., Tan, C., Kamarulzaman, A. & Altice, F.L. 2015. Prevalence and
correlates of latent tuberculosis infection among employees of a high security
prison in Malaysia. Occupational and Environmental Medicine, Vol. 72, No. 6, pp.
442-7.

Al-Darraji, H.A., Wong, K.C., Yeow, D.G.E., Fu, J.J., Loeliger, K., Paiji, C.,
Kamarulzaman, A. & Altice, F.L. 2014b. Tuberculosis screening in a novel
substance abuse treatment center in Malaysia: Implications for a comprehensive
approach for integrated care. Journal of Substance Abuse Treatment, Vol. 46,
No. 2, pp. 144-149.

Altice, F.L., Azbel, L., El-Bassel, N., Dvoryak, S., Stover, H., Brooks-Pollard, E., Martin,
N., Booth, R., Smyrnov, P., Taxman, F.S., Dolan, K. & Vickerman, P. 2016. The
Perfect Storm: Incarceration and Multi-Level Contributors to Perpetuating HIV
and Tuberculosis in Eastern Europe and Central Asia. Lancet, Vol., No., pp. In
Press

Altice, F.L., Mostashari, F. & Friedland, G.H. 2001. Trust and the acceptance of and
adherence to antiretroviral therapy. Journal of Acquired Immune Deficiency
Syndromes, Vol. 28, No. 1, pp. 47-58.

Altman, D.G. 1991. Practical statistics for medical research, London, Chapman and
Hall.
 Arora, S., Geppert, C.M., Kalishman, S., Dion, D., Pullara, F., Bjeletich, B., Simpson, G.,
Alverson, D.C., Moore, L.B., Kuhl, D. & Scaletti, J.V. 2007. Academic health
center management of chronic diseases through knowledge networks: Project
ECHO. Acad Med, Vol. 82, No. 2, pp. 154-60.

Arora, S., Kalishman, S., Dion, D., Som, D., Thornton, K., Bankhurst, A., Boyle, J.,
Harkins, M., Moseley, K., Murata, G., Komaramy, M., Katzman, J., Colleran, K.,
Deming, P. & Yutzy, S. 2011a. Partnering urban academic medical centers and
rural primary care clinicians to provide complex chronic disease care. Health Aff
(Millwood), Vol. 30, No. 6, pp. 1176-84.

Arora, S., Thornton, K., Murata, G., Deming, P., Kalishman, S., Dion, D., Parish, B.,
Burke, T., Pak, W., Dunkelberg, J., Kistin, M., Brown, J., Jenkusky, S.,
Komaromy, M. & Qualls, C. 2011b. Outcomes of treatment for hepatitis C virus
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

infection by primary care providers. N Engl J Med, Vol. 364, No. 23, pp. 2199-
207.

Azbel, L., Polonsky, M., Wegman, M., Kurmanalieva, A., Shumanskaya, N., Asanov, A.,
Wickersham, J.A., Dvoryak, S. & Altice, F.L. 2015. Intersecting epidemics of HIV,
HCV and syphilis among soon-to-be released prisoners in Kyrgyzstan. AIDS
Patient Care and STDs, Vol., No., pp. In Press.

Azbel, L., Wickersham, J.A., Grishaev, Y., Dvoryak, S. & Altice, F.L. 2013. Burden of
infectious diseases, substance use disorders, and mental illness among
Ukrainian prisoners transitioning to the community. PloS One, Vol. 8, No. 3, pp.
e59643.

Bachireddy, C., Bazazi, A.R., Kavasery, R., Govindasamy, S., Kamarulzaman, A. &
Altice, F.L. 2011. Attitudes toward opioid substitution therapy and pre-
incarceration HIV transmission behaviors among HIV-infected prisoners in
Malaysia: implications for secondary prevention. Drug and Alcohol Dependence,
Vol. 116, No. 1-3, pp. 151-7.

Basu, S., Smith-Rohrberg, D., Hanck, S. & Altice, F.L. 2005. HIV testing in correctional
institutions: evaluating existing strategies, setting new standards. AIDS & Public
Policy Journal, Vol. 20, No. 1-2, pp. 3-24.

Bautista-Arredondo, S., Gonzalez, A., Servan-Mori, E., Beynon, F., Juarez-Figueroa, L.,
Conde-Glez, C.J., Gras, N., Sierra-Madero, J., Lopez-Ridaura, R., Volkow, P. &
Bertozzi, S.M. 2015. A Cross-Sectional Study of Prisoners in Mexico City
Comparing Prevalence of Transmissible Infections and Chronic Diseases with
That in the General Population. PloS One, Vol. 10, No. 7, pp. e0131718.

Bazazi, A.R., Crawford, F., Zelenev, A., Heimer, R., Kamarulzaman, A. & Altice, F.L.
2015. HIV Prevalence Among People Who Inject Drugs in Greater Kuala Lumpur
Recruited Using Respondent-Driven Sampling. AIDS and Behavior, Vol. 19, No.
12, pp. 2347-57.
 Bick, J.A. 2007. Infection control in jails and prisons. Clinical Infectious Diseases, Vol.
45, No. 8, pp. 1047-55.

Blogg, S., Utomo, B., Silitonga, N., Ayu N. Hidayati, D. & Sattler, G. 2014. Indonesian
National Inmate Bio-Behavioral Survey for HIV and Syphilis Prevalence and Risk
Behaviors in Prisons and Detention Centers, 2010. SAGE Open, Vol. 4, No. 1,
pp.

Callaghan, M., Ford, N. & Schneider, H. 2010. A systematic review of task- shifting for
HIV treatment and care in Africa. Hum Resour Health, Vol. 8, No., pp. 8.

Choo, M.K., El-Bassel, N., Adam, P.C., Gilbert, L., Wu, E., West, B.S., Bazazi, A.R., De
Wit, J.B., Ismail, R. & Kamarulzaman, A. 2015. Prevalence and Correlates of HIV
and Hepatitis C Virus Infections and Risk Behaviors among Malaysian
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

Fishermen. PloS One, Vol. 10, No. 8, pp. e0118422.

Copenhaver, M.M., Tunku, N., Ezeabogu, I., Potrepka, J., Zahari, M.M., Kamarulzaman,
A. & Altice, F.L. 2011. Adapting an Evidence-Based Intervention Targeting HIV-
Infected Prisoners in Malaysia. AIDS Res Treat, Vol. 2011, No., pp. 131045.

Culbert, G.J. 2014. Violence and the perceived risks of taking antiretroviral therapy in
US jails and prisons. International Journal of Prisoner Health, Vol. 10, No. 1, pp.
1-17.

Culbert, G.J., Bazazi, A.R., Waluyo, A., Murni, A., Muchransyah, A.P., Iriyanti, M.,
Finnahari, Polonsky, M., Levy, J.A. & Altice, F.L. 2015a. The influence of
medication attitudes on utilization of antiretroviral therapy (ART) in Indonesian
prisons. AIDS and Behavior, Vol., No., pp.

Culbert, G.J., Earnshaw, V.A., Wulanyani, N.M., Wegman, M.P., Waluyo, A. & Altice,
F.L. 2015b. Correlates and Experiences of HIV Stigma in Prisoners Living With
HIV in Indonesia: A Mixed-Method Analysis. J Assoc Nurses AIDS Care, Vol. 26,
No. 6, pp. 743-57.

Culbert, G.J., Pillai, V., Bick, J., Al-Darraji, H., Wickersham, J.A., Wegman, M., Bazazi,
A.R., Ferro, E.G., Copenhaver, M., Kamarulzaman, A. & Altice, F.L. 2016.
Addressing the HIV, TB, Addiction, and Incarceration Syndemic in Southeast
Asia: Lessons Learned from Malaysia. Journal of Neuroimmune Pharmacology,
Vol., No., pp. In Press.

Culbert, G.J., Waluyo, A., Iriyanti, M., Muchransyah, A.P., Kamarulzaman, A. & Altice,
F.L. 2015c. Within-prison drug injection among HIV-infected male prisoners in
Indonesia: a highly constrained choice. Drug Alcohol Depend, Vol. 149, No., pp.
71-9.

Dara, M., Acosta, C.D., Melchers, N.V., Al-Darraji, H.A., Chorgoliani, D., Reyes, H.,
Centis, R., Sotgiu, G., D'ambrosio, L., Chadha, S.S. & Migliori, G.B. 2015.
 Tuberculosis control in prisons: current situation and research gaps. International
Journal of Infectious Diseases, Vol. 32, No., pp. 111-7.

Degenhardt, L., Mathers, B.M., Wirtz, A.L., Wolfe, D., Kamarulzaman, A., Carrieri, M.P.,
Strathdee, S.A., Malinowska-Sempruch, K., Kazatchkine, M. & Beyrer, C. 2014.
What has been achieved in HIV prevention, treatment and care for people who
inject drugs, 2010–2012? A review of the six highest burden countries.
International Journal of Drug Policy, Vol. 25, No. 1, pp. 53-60.

Den Boon, S., Matteelli, A., Ford, N. & Getahun, H. 2016. Continuous isoniazid for the
treatment of latent tuberculosis infection in people living with HIV. AIDS, Vol. 30,
No. 5, pp. 797-801.

Duraisamy, G., Zuridah, H. & Ariffin, M.Y. 1993. Prevalence of hepatitis C virus
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

antibodies in blood donors in Malaysia. Medica Journal of Malaysia, Vol. 48, No.
3, pp. 313-316.

Earnshaw, V.A., Jin, H., Wickersham, J., Kamarulzaman, A., John, J. & Altice, F.L.
2014. Exploring intentions to discriminate against patients living with HIV/AIDS
among future healthcare providers in Malaysia. Trop Med Int Health, Vol. 19, No.
6, pp. 672-679.

El Maerrawi, I. & Carvalho, H.B. 2015. Prevalence and risk factors associated with HIV
infection, hepatitis and syphilis in a state prison of Sao Paulo. International
Journal of STD and AIDS, Vol. 26, No. 2, pp. 120-7.

Feelemyer, J., Des Jarlais, D., Arasteh, K. & Uusküla, A. 2014. Adherence to
Antiretroviral Medications Among Persons Who Inject Drugs in Transitional, Low
and Middle Income Countries: An International Systematic Review. AIDS and
Behavior, Vol., No., pp. 1-9.

Ferro, E.G., Wickersham, J., Marcus, R., Culbert, G.J., Steffen, A.D., Pauls, H.A.,
Westergaard, R.P., Lee, C.K., Kamarulzaman, A. & Altice, F.L. Under review.
Physician decisions to defer antiretroviral therapy in key populations: implications
for overcoming health disparities among people living with HIV in Malaysia. Vol.,
No., pp.

Guariguata, L., Whiting, D.R., Hambleton, I., Beagley, J., Linnenkamp, U. & Shaw, J.E.
2014. Global estimates of diabetes prevalence for 2013 and projections for 2035.
Diabetes Research and Clinical Practice, Vol. 103, No. 2, pp. 137-49.

Hooi, L.S., Ong, L.M., Ahmad, G., Bavanandan, S., Ahmad, N.A., Naidu, B.M.,
Mohamud, W.N. & Yusoff, M.F. 2013. A population-based study measuring the
prevalence of chronic kidney disease among adults in West Malaysia. Kidney
International, Vol. 84, No. 5, pp. 1034-40.

Insight Start Study Group, Lundgren, J.D., Babiker, A.G., Gordin, F., Emery, S., Grund,
B., Sharma, S., Avihingsanon, A., Cooper, D.A., Fatkenheuer, G., Llibre, J.M.,
 Molina, J.M., Munderi, P., Schechter, M., Wood, R., Klingman, K.L., Collins, S.,
Lane, H.C., Phillips, A.N. & Neaton, J.D. 2015. Initiation of Antiretroviral Therapy
in Early Asymptomatic HIV Infection. N Engl J Med, Vol. 373, No. 9, pp. 795-807.

Institute for Criminal Policy Research. 2015. World Prison Brief: Malaysia [Online].
Available: http://www.prisonstudies.org/country/malaysia [Accessed Spetember 27,
2015 2015].

Jani, I.V., Sitoe, N.E., Chongo, P.L., Alfai, E.R., Quevedo, J.I., Tobaiwa, O., Lehe, J.D.
& Peter, T.F. 2011. Accurate CD4 T-cell enumeration and antiretroviral drug
toxicity monitoring in primary healthcare clinics using point-of-care testing. AIDS,
Vol. 25, No. 6, pp. 807-812 10.1097/QAD.0b013e328344f424.

Jin, H., Earnshaw, V.A., Wickersham, J.A., Kamarulzaman, A., Desai, M.M., John, J. &
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

Altice, F.L. 2014. An assessment of health-care students' attitudes toward

patients with or at high risk for HIV: implications for education and cultural
competency. AIDS Care, Vol. 26, No. 10, pp. 1223-8.

Joint United Nations Programme on HIV/AIDS 2013. HIV in Asia and the Pacific.

Joint United Nations Programme on HIV/AIDS 2014. The Gap Report.

Kearney, P.M., Whelton, M., Reynolds, K., Muntner, P., Whelton, P.K. & He, J. 2005.
Global burden of hypertension: analysis of worldwide data. The Lancet, Vol. 365,
No. 9455, pp. 217-223.

Kenning, I., Kerandi, H., Luehr, D., Margolis, K., O'connor, P.G., Pereira, C., Schlichte,
A. & Wooley, T. 2014. Hypertension diagnosis and treatment. Institute for Clinical
Systems Improvement.

Komaromy, M., Duhigg, D., Metcalf, A., Carlson, C., Kalishman, S., Hayes, L., Burke,
T., Thornton, K. & Arora, S. 2016. Project ECHO: A new model for educating
primary care providers about treatment of substance use disorders. Subst Abus,
Vol., No., pp. In press.

Kowdley, K.V., Gordon, S.C., Reddy, K.R., Rossaro, L., Bernstein, D.E., Lawitz, E.,
Shiffman, M.L., Schiff, E., Ghalib, R., Ryan, M., Rustgi, V., Chojkier, M., Herring,
R., Di Bisceglie, A.M., Pockros, P.J., Subramanian, G.M., An, D., Svarovskaia,
E., Hyland, R.H., Pang, P.S., Symonds, W.T., Mchutchison, J.G., Muir, A.J.,
Pound, D. & Fried, M.W. 2014. Ledipasvir and Sofosbuvir for 8 or 12 Weeks for
Chronic HCV without Cirrhosis. New England Journal of Medicine, Vol. 370, No.
20, pp. 1879-1888.

Krishnaswamy, S., Subramaniam, K., Jemain, A.A., Low, W.Y., Ramachandran, P.,
Indran, T. & Patel, V. 2012. Common mental disorders in Malaysia: Malaysian
mental health survey, 2003-2005. Asia-Pacific Psychiatry, Vol. 4, No. 3, pp. 201-
209.
 Larney, S., Kopinski, H., Beckwith, C.G., Zaller, N.D., Jarlais, D.D., Hagan, H., Rich,
J.D., Van Den Bergh, B.J. & Degenhardt, L. 2013. Incidence and prevalence of
hepatitis C in prisons and other closed settings: results of a systematic review
and meta-analysis. Hepatology, Vol. 58, No. 4, pp. 1215-24.

Lazzarini, Z. & Altice, F.L. 2000. A review of the legal and ethical issues for the conduct
of HIV-related research in prisons. AIDS & Public Policy Journal, Vol. 15, No. 3-
4, pp. 105-35.

Letchuman, G.R., Wan Nazaimoon, W.M., Wan Mohamad, W.B., Chandran, L.R., Tee,
G.H., Jamaiyah, H., Isa, M.R., Zanariah, H., Fatanah, I. & Ahmad Faudzi, Y.
2010. Prevalence of diabetes in the Malaysian National Health Morbidity Survey
III 2006. Medical Journal of Malaysia, Vol. 65, No. 3, pp. 180-6.
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

Levey, A.S., Coresh, J., Balk, E., Kausz, A.T., Levin, A., Steffes, M.W., Hogg, R.J.,
Perrone, R.D., Lau, J. & Eknoyan, G. 2003. National Kidney Foundation Practice
Guidelines for Chronic Kidney Disease: Evaluation, Classification, and
Stratification. Annals of Internal Medicine, Vol. 139, No. 2, pp. 137-147.

Lim, H.K., Ghazali, S.M., Kee, C.C., Lim, K.K., Chan, Y.Y., Teh, H.C., Yusoff, A.F.,
Kaur, G., Zain, Z.M., Mohamad, M.H. & Salleh, S. 2013. Epidemiology of
smoking among Malaysian adult males: prevalence and associated factors. BMC
Public Health, Vol. 13, No., pp. 8.

Luhmann, N., Champagnat, J., Golovin, S., Maistat, L., Agustian, E., Inaridze, I., Myint,
W.M., Butsashvili, M. & Bouscaillou, J. 2015. Access to hepatitis C treatment for
people who inject drugs in low and middle income settings: Evidence from 5
countries in Eastern Europe and Asia. International Journal on Drug Policy, Vol.
26, No. 11, pp. 1081-7.

Margolis, B., Al-Darraji, H.A., Wickersham, J.A., Kamarulzaman, A. & Altice, F.L. 2013.
Prevalence of tuberculosis symptoms and latent tuberculous infection among
prisoners in northeastern Malaysia. Int J Tuberc Lung Dis, Vol. 17, No. 12, pp.
1538-44.

Meade, C.S. & Sikkema, K.J. 2005. HIV risk behavior among adults with severe mental
illness: a systematic review. Clinical Psychology Review, Vol. 25, No. 4, pp. 433-
57.

Meijerink, H., Wisaksana, R., Lestari, M., Meilana, I., Chaidir, L., Van Der Ven, A.J.,
Alisjahbana, B. & Van Crevel, R. 2015. Active and latent tuberculosis among
HIV-positive injecting drug users in Indonesia. Journal of the International AIDS
Society, Vol. 18, No. 1, pp. 19317.

Meyer, J.P., Cepeda, J., Springer, S.A., Wu, J., Trestman, R.L. & Altice, F.L. 2014a.
HIV in people reincarcerated in Connecticut prisons and jails: an observational
cohort study. Lancet HIV, Vol. 1, No. 2, pp. e77-e84.
 Meyer, J.P., Cepeda, J., Taxman, F.S. & Altice, F.L. 2015. Sex-Related Disparities in
Criminal Justice and HIV Treatment Outcomes: A Retrospective Cohort Study of
HIV-Infected Inmates. Am J Public Health, Vol. 105, No. 9, pp. 1901-10.

Meyer, J.P., Chen, N.E. & Springer, S.A. 2011a. HIV Treatment in the Criminal Justice
System: Critical Knowledge and Intervention Gaps. AIDS Research and
Treatment, Vol., No., pp. 680617.

Meyer, J.P., Springer, S.A. & Altice, F.L. 2011b. Substance abuse, violence, and HIV in
women: a literature review of the syndemic. J Womens Health, Vol. 20, No. 7, pp.
991-1006.

Meyer, J.P., Zelenev, A., Wickersham, J.A., Williams, C.T., Teixeira, P.A. & Altice, F.L.
2014b. Gender disparities in HIV treatment outcomes following release from jail:
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

results from a multicenter study. Am J Public Health, Vol. 104, No. 3, pp. 434-41.

Milloy, M.J., Montaner, J. & Wood, E. 2012. Barriers to HIV treatment among people
who use injection drugs: implications for 'treatment as prevention'. Current
Opinion in HIV and AIDS, Vol. 7, No. 4, pp. 332-8.

Ministry of Health, Malaysia 2006. NCD Risk Factors in Malaysia. Kuala Lumpur.

Ministry of Health, Malaysia 2012. Annual report.

Ministry of Health, Malaysia 2015. Global AIDS Response Progress Report, Malaysia.
Kuala Lumpur: Malaysian Ministry of Health.

Mohle-Boetani, J.C., Miguelino, V., Dewsnup, D.H., Desmond, E., Horowitz, E.,
Waterman, S.H. & Bick, J. 2002. Tuberculosis outbreak in a housing unit for
human immunodeficiency virus-infected patients in a correctional facility:
transmission risk factors and effective outbreak control. Clinical Infectious
Diseases, Vol. 34, No. 5, pp. 668-76.

Mutalip, M.H., Kamarudin, R.B., Manickam, M., Abd Hamid, H.A. & Saari, R.B. 2014.
Alcohol consumption and risky drinking patterns in Malaysia: findings from NHMS
2011. Alcohol and Alcoholism, Vol. 49, No. 5, pp. 593-9.

National Institute on Alcohol Abuse and Alcoholism 2010. Rethining drinking: Alcohol
and your health. National Institutes of Health.

Newman, L., Rowley, J., Vander Hoorn, S., Wijesooriya, N.S., Unemo, M., Low, N.,
Stevens, G., Gottlieb, S., Kiarie, J. & Temmerman, M. 2015. Global Estimates of
the Prevalence and Incidence of Four Curable Sexually Transmitted Infections in
2012 Based on Systematic Review and Global Reporting. PloS One, Vol. 10, No.
12, pp. e0143304.

Noor Haslina, M.N., Khairiah, Y., Zakuan, Z.D., Shafini, M.Y., Rosnah, B. & Marini, R.
2012. Seroprevalence of hepatitis C virus infection among blood donors in a
 teaching hospital in northeastern Malaysia. Southeast Asian Journal of Tropical
Medicine and Health, Vol. 43, No. 3, pp. 669-673.

Norhayati Binti Moktar, M., Noor Hayati, M.I., Nor Fariza, N., Rohani, A.K., Halimah,
A.S., Sharom, M.Y. & Zainal Abidin, A.H. 1998. Health status of Orang Asli
(aborigine) community in Pos Piah, Sungai Siput, Perak, Malaysia. Southeast
Asian Journal of Tropical Medicine and Public Health, Vol. 29, No. 1, pp. 58-61.

Pacek, L.R. & Cioe, P.A. 2015. Tobacco Use, Use Disorders, and Smoking Cessation
Interventions in Persons Living With HIV. Current HIV/AIDS Reports, Vol., No.,
pp.

Patterson, E.J. 2013. The dose-response of time served in prison on mortality: New
York State, 1989-2003. American Journal of Public Health, Vol. 103, No. 3, pp.
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

523-8.

Polonsky, M., Azbel, L., Wickersham, J.A., Marcus, R., Doltu, S., Grishaev, E., Dvoryak,
S. & Altice, F.L. 2016. Accessing methadone within Moldovan prisons: Prejudice
and myths amplified by peers. International Journal on Drug Policy, Vol. 29, No.,
pp. 91-5.

Polonsky, M., Azbel, L., Wickersham, J.A., Taxman, F.S., Grishaev, Y., Dvoryak, S. &
Altice, F.L. 2015. Challenges to implementing opioid substitution therapy in
Ukrainian prisons: Personnel attitudes toward addiction, treatment, and people
with HIV/AIDS. Drug and Alcohol Dependence, Vol. In Press, No., pp.

Ruisenor-Escudero, H., Wirtz, A.L., Berry, M., Mfochive-Njindan, I., Paikan, F., Yousufi,
H.A., Yadav, R.S., Burnham, G. & Vu, A. 2014. Risky behavior and correlates of
HIV and Hepatitis C Virus infection among people who inject drugs in three cities
in Afghanistan. Drug and Alcohol Dependence, Vol. 143, No., pp. 127-33.

Ruta, S. & Cernescu, C. 2015. Injecting drug use: A vector for the introduction of new
hepatitis C virus genotypes. World Journal of Gastroenterology, Vol. 21, No. 38,
pp. 10811-23.

Solomon, S.S., Mehta, S.H., Srikrishnan, A.K., Solomon, S., Mcfall, A.M.,
Laeyendecker, O., Celentano, D.D., Iqbal, S.H., Anand, S., Vasudevan, C.K.,
Saravanan, S., Lucas, G.M., Kumar, M.S., Sulkowski, M.S. & Quinn, T.C. 2015.
Burden of hepatitis C virus disease and access to hepatitis C virus services in
people who inject drugs in India: a cross-sectional study. Lancet Infectious
Diseases, Vol. 15, No. 1, pp. 36-45.

Spaulding, A.C., Seals, R.M., Page, M.J., Brzozowski, A.K., Rhodes, W. & Hammett,
T.M. 2009. HIV/AIDS among Inmates of and Releasees from US Correctional
Facilities, 2006: Declining Share of Epidemic but Persistent Public Health
Opportunity. PloS One, Vol. 4, No. 11, pp. e7558.
 Springer, S.A., Spaulding, A.C., Meyer, J.P. & Altice, F.L. 2011. Public health
implications for adequate transitional care for HIV-infected prisoners: five
essential components. Clinical Infectious Diseases, Vol. 53, No. 5, pp. 469-79.

Suthar, A.B., Lawn, S.D., Del Amo, J., Getahun, H., Dye, C., Sculier, D., Sterling, T.R.,
Chaisson, R.E., Williams, B.G., Harries, A.D. & Granich, R.M. 2012. Antiretroviral
therapy for prevention of tuberculosis in adults with HIV: a systematic review and
meta-analysis. PLoS Medicine, Vol. 9, No. 7, pp. e1001270.

Ti, L. & Kerr, T. 2013. Task shifting redefined: removing social and structural barriers to
improve delivery of HIV services for people who inject drugs. Harm Reduct J,
Vol. 10, No., pp. 20.

To, T., Stanojevic, S., Moores, G., Gershon, A.S., Bateman, E.D., Cruz, A.A. & Boulet,
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

L.P. 2012. Global asthma prevalence in adults: findings from the cross-sectional
world health survey. BMC Public Health, Vol. 12, No., pp. 204.

United Nations Office on Drugs and Crime 2009a. Malaysia country advocacy brief:
Injecting drug use and HIV.

United Nations Office on Drugs and Crime 2009b. HIV testing and counselling in prisons
and other closed settings. Vienna.

Urrego, J., Ko, A.I., Da Silva Santos Carbone, A., Paiao, D.S., Sgarbi, R.V., Yeckel,
C.W., Andrews, J.R. & Croda, J. 2015. The Impact of Ventilation and Early
Diagnosis on Tuberculosis Transmission in Brazilian Prisons. American Journal
of Tropical Medicine and Hygiene, Vol., No., pp.

Vagenas, P., Azar, M., Copenhaver, M., Springer, S., Molina, P. & Altice, F. 2015. The
impact of alcohol use and related disorders on the HIV continuum of care: a
systematic review. Current HIV/AIDS Reports, Vol., No., pp. 1-16.

Vagenas, P., Azbel, L., Polonsky, M., Kerimi, N., Mamyrov, M., Dvoryak, S. & Altice,
F.L. 2013. A review of medical and substance use co-morbidities in Central Asian
prisons: implications for HIV prevention and treatment. Drug and Alcohol
Dependence, Vol. 132 Suppl 1, No., pp. S25-31.

Walmsley, R. 2016. World Prison Population List (11th Edition). 11th ed. London.

Walton, S.F. & Currie, B.J. 2007. Problems in diagnosing scabies, a global disease in
human and animal populations. Clinical Microbiology Reviews, Vol. 20, No. 2, pp.
268-79.

Wickersham, J.A., Marcus, R., Kamarulzaman, A., Zahari, M.M. & Altice, F.L. 2013a.
Implementing methadone maintenance treatment in prisons in Malaysia. Bulletin
of the World Health Organization, Vol. 91, No. 2, pp. 124-9.
 Wickersham, J.A., Zahari, M.M., Azar, M.M., Kamarulzaman, A. & Altice, F.L. 2013b.
Methadone dose at the time of release from prison significantly influences
retention in treatment: implications from a pilot study of HIV-infected prisoners
transitioning to the community in Malaysia. Drug and Alcohol Dependence, Vol.
132, No. 1-2, pp. 378-82.

World Health Organization 2007. Regional strategy on human resources for health
2006-2015. Manila: Western Pacific Regional Office.

World Health Organization. 2013. Tuberculosis country profile: Malaysia [Online].

Available: http://www.who.int/tb/country/data/profiles/en/ [Accessed September
28, 2015.

World Health Organization 2014a. Global status report on alcohol and health.
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

Luxembourg.

World Health Organization 2014b. Human resources for health country profiles:
Malaysia. Manila.

World Health Organization 2014c. Prisons and Health, Copenhagen, Denmark, WHO
Regional Office for Europe.

World Health Organization 2015a. Guideline on when to start antiretroviral therapy and
on pre-exposure prophylaxis for HIV. Geneva.

World Health Organization. 2015b. Tuberculosis county profile: Malaysia [Online].

Available:
https://extranet.who.int/sree/Reports?op=Replet&name=/WHO_HQ_Reports/G2/PROD/E
XT/TBCountryProfile&ISO2=my&outtype=pdf [Accessed November 12, 2015.

Young, J.D., Patel, M., Badowski, M., Mackesy-Amiti, M.E., Vaughn, P., Shicker, L.,
Puisis, M. & Ouellet, L.J. 2014. Improved virologic suppression with HIV
subspecialty care in a large prison system using telemedicine: an observational
study with historical controls. Clinical Infectious Diseases, Vol. 59, No. 1, pp.
123-6.

Zahari, M.M., Hwan Bae, W., Zainal, N.Z., Habil, H., Kamarulzaman, A. & Altice, F.L.
2010. Psychiatric and substance abuse comorbidity among HIV seropositive and
HIV seronegative prisoners in Malaysia. American Journal of Drug and Alcohol
Abuse, Vol. 36, No. 1, pp. 31-8.
 Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

Table 1: Disparities in human resources for healthcare delivery in Malaysian communities and prisons
Health occupation category In Community In Prison*
Number Per 1,000 Number Per 1,000
population population
Physicians 36,607 1.26 3 0.71
Nurses 74,788 2.58 0 0
Medical assistants 11,162 0.39 1 0.23
Dentists 4,253 0.15 0 0
Pharmacists 8,632 0.30 0 0
Legend: * average daily census = 4,200 prisoners in Malaysia’s largest prison
 Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

Table 2. Study measures and diagnostic criteria for co-morbidities of HIV-infected prisoners
Disease Measure
Communicable diseases
Hepatitis C virus (HCV) Anti-HCV antibody serologic test
Active Syphilis Positive RPR Titer > 1:8 and no history of treatment
TB (active) Positive culture and/or GeneXpert
Latent TB infection (LTBI) Tuberculin skin test (TST) reactivity ≥ 5mm in persons without current or past active TB
Scabies Physical examination
HIV clinical testing
HIV infection Documentation of ≥ 1 reactive HIV antibody with confirmatory test in medical record
ART utilization Self-report, medical record review, pharmacy records
Date of HIV diagnosis Self report and medical record review
CD4+ lymphocyte count Alere Pima CD4 analyzer
Non-communicable disease
Diabetes (Type II) Patient self-report or documentation of elevated A1C or blood glucose in medical record
Asthma Patient self-report and chart review
Hypertension 2 consecutive measurements at 2 different visits; systolic >140 or diastolic >90
Chronic kidney disease Estimated GFR <60 mL/min/1.73m2 using Cockcroft Gault formula
Dental pathology Intraoral examination; significant if ≥ 1 broken or ≥ 2 missing teeth
Mental illness
Depression Patient self-report and medical chart review
Schizophrenia/psychosis Patient self-report and medical chart review
Bipolar disorder Patient self-report and medical chart review
Substance use (during year before incarceration)
Drug injection of opioids Self-report illicit drug injection of opioids
Tobacco use Self-report cigarette smoking
Alcohol use Self-report >14 standardized drinks containing alcohol weekly
Legend: TB=tuberculosis; GFR=glomerular filtration rate; ART=antiretroviral therapy
 Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

Table 3. Age-unadjusted disease prevalence comparisons among prisoners and general population (n=221)
HIV-infected Malaysian adult z-value 95% CI of p-value
Disease prisoners population* observed
n (%) (%) proportion
Communicable disease
Hepatitis C virus (HCV) 200 (90.4) (2.5)1 83.69 85.7, 93.9 <0.001
Untreated syphilis 18 (8.1) (0.023)2 79.18 4.8, 12.5 <0.001
3
Tuberculosis (current active) 29 (13.1) (0.13) 53.51 8.9, 18.2 <0.001
Tuberculosis (past active) 53 (23.9) N/A
Latent tuberculosis infection (LTBI) 113 (81.2%) (52.1-59.0)4 6.71 75.4, 86.1 <0.001
Scabies 84 (37.3) (11.9)5 11.62 30.9, 44.0 <0.001
Non-communicable disease
Diabetes mellitus 9 (4.0) (9.8-11.6)6 2.90 1.8, 7.5 0.003
Asthma 13 (5.8) (5.0-7.5)7 0.27 3.1, 9.7 0.276
8
Hypertension 38 (17.1) (26.3) 3.10 12.3, 22.7 0.001
Kidney disease 6 (2.7) (9.07)9 3.29 0.9, 5.8 0.001
10
Dental pathology 195 (88.2) (19.2) 26.04 83.2, 92.1 <0.001
Psychiatric Disorders
Depression 24 (10.8) (5.57)11 3.39 7.03, 15.66 <0.001
Schizophrenia/psychosis 7 (3.1) N/A
Bipolar 4 (1.8) N/A
Substance use (year before incarceration)
Drug injection of opioids 185 (83.7) (1.11-1.56)12 106.08 78.1, 88.3 <0.001
13
Cigarette smoking 159 (71.9) (45.6) 7.85 65.4, 77.7 <0.001
Heavy drinking 68 (30.8) (1.8-4.1)14 20.01 24.7, 37.3 <0.001
1
Legend: *Age-unadjusted prevalence in Malaysian adult populations; CI=confidence interval; McDonald, Mohamed,
Dahlui, Naning, & Kamarulzaman, 2014; Noor Haslina et al., 2012; 2Newman et al., 2015; 3World Health Organization,
2015; 4Margolis, Al-Darraji, Wickersham, Kamarulzaman, & Altice, 2013; 5Norhayati binti Moktar et al., 1998; 6Guariguata
et al., 2014; Letchuman et al., 2010; 7To et al., 2012; 8Ministry of Health, 2006; 9Hooi et al., 2013; 10Norhayati binti Moktar
et al., 1998; 11Ferrari et al., 2013; 12United Nations Office on Drugs and Crime, 2009; 13Lim et al., 2013; 14World Health
Organization, 2014;
 Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

Table 4. Comparison of age-specific rates for selected non-communicable diseases in HIV-infected prisoners
and the Malaysia adult population (n=221)
Disease Age (years) Observed Expected* z-value 95% CI of observed p-value
N (%) N (%) proportion
1
Hypertension 20-29 (n=73) 2 (2.7) 8.1 (11.1) 2.277 0.3, 9.5 0.02
30-39 (n=87) 9 (10.3) 11.8 (13.6) 0.898 4.8, 18.6 0.36
40-49 (n=36) 12 (33.3) 6.4 (17.8) 2.431 18.5, 50.9 0.01
50-59 (n=18) 14 (77.7) 4.4 (24.8) 5.197 52.2, 93.5 <0.001
60-69 (n=7) 4 (57.1) 2.1 (30.8) 1.507 18.3, 90.0 0.13
All ages (n=221) 41 (18.5) 32.8 (14.8) 1.549 13.6, 24.2 0.12

Diabetes2 20-29 (n=73) 1 (1.3) 1.8 (2.5) 0.657 0.03, 7.2 0.65
30-39 (n=87) 4 (4.5) 4.8 (5.6) 0.446 1.2, 11.2 0.65
40-49 (n=36) 2 (5.5) 4.5 (12.6) 1.284 0.6, 18.5 0.19
50-59 (n=18) 1 (5.5) 4.0 (22.6) 1.735 0.1, 27.2 0.08
60-69 (n=7) 1 (14.2) 1.7 (25.3) 0.676 0.3, 57.7 0.49
All ages (n=221) 9 (4.0) 16.8 (7.6) 2.020 1.8, 7.5 0.04
Legend: *Based on estimated age-specific rates in the Malaysia adult population; CI=confidence interval;
1
Kearney et al., 2005; 2Guariguata et al., 2014; Letchuman et al., 2010;
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

Figure 1. Prevalence of HCV, Alcohol Use, and Drug Injection in HIV+ Prisoners
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

Figure 2.
HIV Care Cascade Before Incarceration
Downloaded by University of Leeds At 18:05 02 December 2016 (PT)

Figure 3. HIV Care Cascade Within Prison