Predictors of mortality within prison and after release among persons living with HIV in Indonesia
Received 30 October 2016
Accepted for publication 12 January 2017
Published 8 March 2017 Volume 2017:8 Pages 25—35
Checked for plagiarism Yes
Review by Single-blind
Peer reviewer comments 3
Editor who approved publication: Dr Thomas Unnasch
Gabriel J Culbert,1,2 Forrest W Crawford,3–5 Astia Murni,6 Agung Waluyo,2 Alexander R Bazazi,7,8 Junaiti Sahar,2 Frederick L Altice7–9
1Department of Health Systems Science, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA; 2Center for HIV/AIDS Nursing Research, Faculty of Nursing, Universitas Indonesia, Depok, Indonesia; 3Department of Biostatistics, Yale School of Public Health, 4Operations, Yale School of Management, 5Department of Ecology and Evolutionary Biology, Yale University, New Haven, CT, USA; 6Directorate General of Corrections, Indonesian Ministry of Law and Human Rights, Jakarta, Indonesia; 7Department of Epidemiology of Microbial Diseases, School of Public Health, 8Department of Medicine, Section of Infectious Diseases, AIDS Program, School of Medicine, Yale University, New Haven, CT, USA; 9Centre of Excellence for Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
Objectives: HIV-related mortality is increasing in Indonesia, where prisons house many people living with HIV and addiction. We examined all-cause mortality in HIV-infected Indonesian prisoners within prison and up to 24 months postrelease.
Materials and methods: Randomly selected HIV-infected male prisoners (n=102) from two prisons in Jakarta, Indonesia, completed surveys in prison and were followed up for 2 years (until study completion) or until they died or were lost to follow-up. Death dates were determined from medical records and interviews with immediate family members. Kaplan–Meier and Cox proportional hazards regression models were analyzed to identify mortality predictors.
Results: During 103 person-years (PYs) of follow-up, 15 deaths occurred, including ten in prison. The crude mortality rate within prison (125.2 deaths per 1,000 PYs) was surpassed by the crude mortality rate (215.7 deaths per 1,000 PYs) in released prisoners. HIV-associated opportunistic infections were the most common probable cause of death. Predictors of within-prison and overall mortality were similar. Shorter survival overall was associated with being incarcerated within a specialized “narcotic” prison for drug offenders (hazard ratio [HR] 9.2, 95% confidence interval [CI] 1.1–76.5; P=0.03), longer incarceration (HR 1.06, 95% CI 1.01–1.1; P=0.01), and advanced HIV infection (CD4+ T-cell count <200/µL, HR 4.8, 95% CI 1.2–18.2; P=0.02). Addiction treatment was associated with longer survival (HR 0.1, 95% CI 0.01–0.9; P=0.03), although treatment with antiretroviral therapy (ART) or methadone was not.
Conclusion: Mortality in HIV-infected prisoners is extremely high in Indonesia, despite limited provision of ART in prisons. Interventions to restore immune function with ART and provide prophylaxis for opportunistic infections during incarceration and after release would likely reduce mortality. Narcotic prisons may be especially high-risk environments for mortality, emphasizing the need for universal access to evidence-based HIV treatments.
Keywords: antiretroviral therapy, HIV/AIDS, Indonesia, mortality, prisoners, substance use
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