Prevalence and risk of blood-borne and sexually transmitted viral infections in incarcerated youth in Salvador, Brazil: opportunity and obligation for intervention

Human T-lymphotropic virus 1/2 infection among prisoners of a major penitentiary complex of Goiás State, Central-West Brazil

Introduction

Studies on human T-lymphotropic virus 1/2 (HTLV-1/2) infection are scarce in incarcerated population. Therefore, this study estimated the prevalence of HTLV-1/2 infection among prisoners of the major penitentiary complex of Goiás State, Central-West Brazil, comparing it with available data from other Brazilian regions.

Methods

A cross-sectional study was conducted with 910 prisoners of the major penitentiary complex in the State of Goiás, Central-West Brazil. All participants were interviewed, and their serum samples were tested for anti-HTLV-1/2 using an enzyme-linked immunosorbent assay (ELISA; Murex HTLV-I + II, DiaSorin, Dartford, UK). Seropositive samples were submitted for confirmation by a line immunoassay (INNO-LIA HTLV I/II, Fujirebio, Europe N.V., Belgium).

Results

The majority of participants were males (83.1%), between 25 and 39 years old (56.1%; mean age: 31.98 years), self-reported brown ethnicity (56.2%) and reported 9 years or less of formal education (41.4%). Most reported using non-injectable illicit drugs and various sexual behaviors that present risk for sexually transmitted infections (STIs). The prevalence of anti-HTLV-1/2 was 0.33% (95% CI: 0.07-0.96), HTLV-1 (0.22%) and HTLV-2 (0.11%). The two HTLV-1 seropositive prisoners reported high-risk sexual behaviors, and the HTLV-2 seropositive individual was breastfed during childhood (> 6 months) by her mother and three other women.

Conclusion

These data revealed a relatively low seroprevalence of HTLV-1/2 in prisoners in Central-West Brazil, and evidence of HTLV-1 and HTLV-2 circulation in the major penitentiary complex of Goiás State. Given the prevalence of high-risk sexual behaviors, there is a crucial need to intensify education and health programs in prisons to effectively control and prevent HTLV-1/2 and other STIs.

Global prevalence of hepatitis C in prisoners: a comprehensive systematic review and meta-analysis

Hepatitis C virus (HCV), one of the most significant causes of liver inflammation, has a high annual mortality rate. The unfavorable hygiene conditions and inadequate health monitoring in many prisons increase the risk of blood-borne infections such as hepatitis C. The growing incidence of this disease among prisoners results in overspill transmission to the general population from undiagnosed prisoners that have been released. Therefore, the aim of this study was to investigate the prevalence of hepatitis C among the world's prison population. A systematic review and meta-analysis of studies on the prevalence of hepatitis C was carried out using the keywords "Prevalence", "Hepatitis C", and "Prisoner" in the Iranian and international databases SID, MagIran, Iran Doc, Science Direct, Scopus, PubMed, and Web of Science (WoS) from January 1990 to September 2020. After transferring the articles to the information management software EndNote and eliminating duplicate studies, the remaining studies were reviewed based on inclusion and exclusion criteria, three stages of primary and secondary evaluation, and qualitative evaluation. Comprehensive meta-analysis software and Begg and Mazumdar and I² tests were used for data analysis and assessment of dissemination bias, and heterogeneity, respectively. Out of 93 studies (22 from Asia, 26 from Europe, seven from Africa, 29 from America, and nine from Australia) with a total sample size of 145,823 subjects, the prevalence of hepatitis C in prisoners worldwide was estimated to be 17.7% (95% confidence interval, 15-20.7%). The highest prevalence of hepatitis C on the continents included in this study was reported in prisoners incarcerated in Australia and Oceania, with 28.4% (95% CI: 21.6-36.4) in nine studies, and Europe, with 25.1% (95% CI: 19.4-31.8) in 26 studies. All studies used an ELISA test for the detection of HCV antibodies. The results showed a prevalence of HCV of 17.7% in prisoners worldwide, ranging between 10 and 30% over five continents (Asia, Europe, America, Africa, and Australia and Oceania). The highest prevalence was reported in Australia and Oceania (28.4%), indicating the need to pay more attention to this issue on the continent. It is necessary to reduce the incidence of the disease in prisons by appropriate policy-making and the development of accurate and practical programs, including the distribution of free syringes and examination, testing, and screening of prisoners.

Human T-Lymphotropic Virus-1/2 Infection in Central Brazil Prisons: A Multicenter Study

Human T-lymphotropic virus (HTLV) infection is endemic in some group populations. Prisoners are at high risk of acquiring HTLV infection mainly due to the environment of closed penal institutions, socioeconomic conditions, and risk behaviors. This study aimed to investigate the prevalence, the occurrence of new cases of HTLV infection after a 1-year follow-up, and circulating subtypes of HTLV-1 among prisoners from twelve closed prisons in Mato Grosso do Sul state, Central Brazil. A total of 1,507 prisoners were randomly enrolled in the cross-sectional study. Out of the 1,507 participants, 1,000 prisoners, susceptible to HTLV infection, were included in the prospective cohort study. In the cross-sectional study, serological evidence of HTLV infection was 0.4% (CI 95%: 0.1-0.7), tested for anti-HTLV antibodies by enzyme-linked immunosorbent assay (ELISA). Three samples were positive for HTLV-1, two samples were positive for HTLV-2, and 1 sample was indeterminate by the Western blot method. The presence of HTLV proviral DNA was detected in all positive samples by amplification of the HTLV tax gene through nested-PCR. Phylogenetic analysis showed that HTLV-1 samples belonged to the Cosmopolitan subtype Transcontinental subgroup. From a cohort of 1,000 individuals, no new case of HTLV infection was detected. Although the prevalence rate of HTLV infection found in this study was similar to that observed in the Brazilian general population, the lack of access to preventive interventions and harm reduction measures all contribute to increasing the risk of HTLV transmission and acquisition among this key and vulnerable population.

Management and control of tuberculosis control in socially complex groups: a research programme including three RCTs

Background

Socially complex groups, including people experiencing homelessness, prisoners and drug users, have very high levels of tuberculosis, often complicated by late diagnosis and difficulty in adhering to treatment.

Objective

To assess a series of interventions to improve tuberculosis control in socially complex groups.

Design

A series of observational surveys, evaluations and trials of interventions.

Setting

The pan-London Find&Treat service, which supports tuberculosis screening and case management in socially complex groups across London.

Participants

Socially complex groups with tuberculosis or at risk of tuberculosis, including people experiencing homelessness, prisoners, drug users and those at high risk of poor adherence to tuberculosis treatment.

Interventions and main outcome measures

We screened 491 people in homeless hostels and 511 people in prison for latent tuberculosis infection, human immunodeficiency virus, hepatitis B and hepatitis C. We evaluated an NHS-led prison radiographic screening programme. We conducted a cluster randomised controlled trial (2348 eligible people experiencing homelessness in 46 hostels) of the effectiveness of peer educators (22 hostels) compared with NHS staff (24 hostels) at encouraging the uptake of mobile radiographic screening. We initiated a trial of the use of point-of-care polymerase chain reaction diagnostics to rapidly confirm tuberculosis alongside mobile radiographic screening. We undertook a randomised controlled trial to improve treatment adherence, comparing face-to-face, directly observed treatment with video-observed treatment using a smartphone application. The primary outcome was completion of ≥ 80% of scheduled treatment observations over the first 2 months following enrolment. We assessed the cost-effectiveness of latent tuberculosis screening alongside radiographic screening of people experiencing homelessness. The costs of video-observed treatment and directly observed treatment were compared.

Results

In the homeless hostels, 16.5% of people experiencing homelessness had latent tuberculosis infection, 1.4% had current hepatitis B infection, 10.4% had hepatitis C infection and 1.0% had human immunodeficiency virus infection. When a quality-adjusted life-year is valued at £30,000, the latent tuberculosis screening of people experiencing homelessness was cost-effective provided treatment uptake was ≥ 25% (for a £20,000 quality-adjusted life-year threshold, treatment uptake would need to be > 50%). In prison, 12.6% of prisoners had latent tuberculosis infection, 1.9% had current hepatitis B infection, 4.2% had hepatitis C infection and 0.0% had human immunodeficiency virus infection. In both settings, levels of latent tuberculosis infection and blood-borne viruses were higher among injecting drug users. A total of 1484 prisoners were screened using chest radiography over a total of 112 screening days (new prisoner screening coverage was 43%). Twenty-nine radiographs were reported as potentially indicating tuberculosis. One prisoner began, and completed, antituberculosis treatment in prison. In the cluster randomised controlled trial of peer educators to increase screening uptake, the median uptake was 45% in the control arm and 40% in the intervention arm (adjusted risk ratio 0.98, 95% confidence interval 0.80 to 1.20). A rapid diagnostic service was established on the mobile radiographic unit but the trial of rapid diagnostics was abandoned because of recruitment and follow-up difficulties. We randomly assigned 112 patients to video-observed treatment and 114 patients to directly observed treatment. Fifty-eight per cent of those recruited had a history of homelessness, addiction, imprisonment or severe mental health problems. Seventy-eight (70%) of 112 patients on video-observed treatment achieved the primary outcome, compared with 35 (31%) of 114 patients on directly observed treatment (adjusted odds ratio 5.48, 95% confidence interval 3.10 to 9.68; p < 0.0001). Video-observed treatment was superior to directly observed treatment in all demographic and social risk factor subgroups. The cost for 6 months of treatment observation was £1645 for daily video-observed treatment, £3420 for directly observed treatment three times per week and £5700 for directly observed treatment five times per week.

Limitations

Recruitment was lower than anticipated for most of the studies. The peer advocate study may have been contaminated by the fact that the service was already using peer educators to support its work.

Conclusions

There are very high levels of latent tuberculosis infection among prisoners, people experiencing homelessness and drug users. Screening for latent infection in people experiencing homelessness alongside mobile radiographic screening would be cost-effective, providing the uptake of treatment was 25–50%. Despite ring-fenced funding, the NHS was unable to establish static radiographic screening programmes. Although we found no evidence that peer educators were more effective than health-care workers in encouraging the uptake of mobile radiographic screening, there may be wider benefits of including peer educators as part of the Find&Treat team. Utilising polymerase chain reaction-based rapid diagnostic testing on a mobile radiographic unit is feasible. Smartphone-enabled video-observed treatment is more effective and cheaper than directly observed treatment for ensuring that treatment is observed.

Future work

Trials of video-observed treatment in high-incidence settings are needed.

Trial registration

Current Controlled Trials ISRCTN17270334 and ISRCTN26184967.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 9. See the NIHR Journals Library website for further project information.

Age-Specific Global Prevalence of Hepatitis B, Hepatitis C, HIV, and Tuberculosis Among Incarcerated People: A Systematic Review

PURPOSE

This study aims to compare the global prevalence of hepatitis B, hepatitis C, HIV, and tuberculosis in incarcerated adolescents and young adults (AYAs) and older prisoners.

METHODS

This study is a systematic review and meta-analysis of studies reporting the age-specific prevalence of each infection in prisoners. We grouped age-specific prevalence estimates into three overlapping age categories: AYA prisoners (<25 years), older prisoners (≥25 years), and mixed category (spanning age 25 years). We used random effects meta-analysis to estimate the relative risk (RR) of each infection in AYAs versus older prisoners.

RESULTS

Among 72 studies, there was marked heterogeneity in prevalence estimates among AYA prisoners for all infections: hepatitis B (.4%-25.2%), hepatitis C (.0%-70.6%), HIV (.0%-15.8%), and active tuberculosis (.0%-3.7%). The pooled prevalence of HIV (RR = .39, 95% confidence interval .29-.53, I² = 79.2%) and hepatitis C (RR = .51, 95% confidence interval .33-.78, I² = 97.8%) was lower in AYAs than in older prisoners.

CONCLUSIONS

The prevalence of HIV and hepatitis C is lower in AYA prisoners than in older prisoners. Despite lower prevalence, acquisition begins early among incarcerated populations. There is an urgent need for targeted, age-appropriate prevention, treatment, and harm reduction measures in and beyond custodial settings to reduce the incidence of infection in these extremely vulnerable young people.

A scoping review of prevalence, incidence and risk factors for HIV infection amongst young people in Brazil

Background

Despite young people being a key population for HIV prevention, the HIV epidemic amongst young Brazilians is perceived to be growing. We therefore reviewed all published literature on HIV prevalence and risk factors for HIV infection amongst 10-25 year olds in Brazil.

Methods

We searched Embase, LILACS, Proquest, PsycINFO, PubMed, Scopus and Web of Science for studies published up to March 2017 and analyzed reference lists of relevant studies. We included published studies from any time in the HIV epidemic which provided estimates specific to ages 10-25 (or some subset of this age range) for Brazilians on either: (a) HIV prevalence or incidence; or (b) the association between HIV and socio-demographic or behavioral risk factors.

Results

Forty eight publications met the inclusion criteria: 44 cross-sectional, two case-control, two cohort. Four studies analysed national data. Forty seven studies provided HIV prevalence estimates, largely for six population subgroups: Counselling and Testing Center attendees; blood donors; pregnant women; institutional individuals; men-who-have-sex-with-men (MSM) and female sex workers (FSW); four provided HIV incidence estimates. Twelve studies showed HIV status to be associated with a wide range of risk factors, including age, sexual and reproductive history, infection history, substance use, geography, marital status, mental health and socioeconomic status.

Conclusions

Few published studies have examined HIV amongst young people in Brazil, and those published have been largely cross-sectional and focused on traditional risk groups and the south of the country. Despite these limitations, the literature shows raised HIV prevalence amongst MSM and FSW, as well as amongst those using drugs. Time trends are harder to identify, although rates appear to be falling for pregnant women, possibly reversing an earlier de-masculinization of the epidemic. Improved surveillance of HIV incidence, prevalence and risk factors is a key component of efforts to eliminate HIV in Brazil.

Revisiting the use of condoms in Brazil

INTRODUCTION

It is known that a single prevention strategy is not enough to control multiple HIV epidemics around the world and in Brazil. However, it is not only necessary to recognize the importance of condoms as part of the policy of HIV/AIDS prevention but also discuss its limits. In this article, we aim to investigate the use of condoms in Brazil, draw critical reflections, and understand how they can once again be highlighted in Brazil's prevention strategy going forward.

METHODS

A narrative review of literature was conducted using keywords in PubMed. Reports from national surveys that guide the epidemiological and behavioral surveillance of the Brazilian Ministry of Health were also included.

RESULTS

A total of 40 articles and 3 reports were included in the review and 11 intervention studies to promote the condom use; the main findings were as follows: 1) Despite the increase in national studies on sexual behavior, little attention is given to the role of condom use; 2) There are few studies examining the factors associated with condom use among key populations such as men who have sex with men (MSM), female sex workers (FSW), drug users (DU), and transvestites and transexuals (TT), while substantial studies focus on adolescents and women; 3) Evidence suggests that a combination of interventions is more effective.

DISCUSSION

new prevention technologies must not lose sight of the critical importance of condoms, and efforts to reintroduce them should focus on the role of pleasure in addition to their potential to minimize the risk of HIV.

One-fourth of the prisoners are underweight in Northern Ethiopia: a cross-sectional study

BACKGROUND

Despite the fact that prisoners are exposed to different health problems, prison health problems are often overlooked by researchers and no previous study has investigated nutritional problems of prisoners in Ethiopia.

METHODS

Cross-sectional data were collected from 809 prisoners from nine major prison setups in the Tigray region of Ethiopia. A proportional stratified sampling technique was used to select the total number of participants needed from each prison site. The outcome of this study was underweight defined as body mass index (BMI) of less than 18.5 kg/m². Multivariable binary logistic regression was performed to identify determinants of underweight at a p-value of less than 0.05.

RESULTS

The prevalence of underweight was 25.2% (95% CI; 22.3%- 28.3%). Khat Chewing (OR = 2.08; 95% CI = 1.17, 3.70) and longer duration of incarceration (OR = 1.07; 95% CI = 1.01, 1.14) were associated with a significantly increased risk of underweight. Additionally, previous incarceration (OR = 1.54; 95% CI = 0.99, 2.42) was a relevant determinant of underweight with a borderline significance. In contrast, family support (OR = 0.61; 95% CI = 0.43, 0.85) and farmer occupation (OR = 0.59; 95% CI = 0.36, 0.98) compared to those who were unemployed were important protective determinants significantly associated with lower risk of underweight.

CONCLUSION

In summary, the burden of underweight was higher among prisoners in Tigray region who had respiratory tract infections. The study has enhanced our understanding of the determinants of underweight in the prison population. We strongly recommend that nutritional support, such as therapeutic feeding programs for severely or moderately underweight prisoners, and environmental health interventions of the prison setups should be urgently implemented to correct the uncovered nutritional problem and its associated factors for improving the health status of prisoners.

First description of HTLV-1/2 seroprevalence in HIV-infected inmates in Mozambique

No study has yet been conducted to estimate the burden of co-infection of HIV and HTLV-1/2 in inmates in sub-Saharan Africa. To investigate prevalence of co-infection in inmates in Mozambique, a total of 2140 inmates were screened for HIV, of which 515 were HIV seropositive. All HIV seropositive inmates were further screened for HTLV infection, and eight (1.55%) were co-infected. Co-infection was higher in females (3.45% [2/58; CI: 0.42-11.91]) as compared to males (1.35% [6/445; CI: 0.55-3.06]). Early screening of HTLV in prisons is urgently needed in Mozambique in order to improve the care provided to incarcerated individuals, including initiation of ART.

Sero-Prevalence of Bloodborne Tumor Viruses (HCV, HBV, HTLV-I and KSHV Infections) and Related Risk Factors among Prisoners in Razavi Khorasan Province, Iran, in 2008

BACKGROUND

Prisoners are at high risk of blood borne and sexually transmitted infections due to their high involvement in risky behaviors. In this descriptive/cross-sectional study, the prevalence, sero-prevalence, and risk factors for bloodborne tumor viruses including HTLV-I, HBV, HCV, and KSHV were evaluated among inmates of two central prisons in the northeast of Iran.

METHODS

Blood samples of 1114 inmates were analyzed for the presence of anti HTLV-I, KSHV, and HCV antibodies and HBsAg by ELISA. PCR tests were performed to confirm the presence of these viruses in plasma and identify the current infections.

RESULTS

The sero-prevalence of HCV, HBV, HTLV-I, and KSHV was 24.5%, 4.2%, 3.4%, and 3.2% and the prevalence of HCV, HBV, HTLV-I, and KSHV was 19.1%, 2.1%, 2%, and 3%, respectively. HCV infection was significantly associated with history of imprisonment, tobacco consumption, alcohol consumption, intravenous drug use, length of imprisonment, and type of crime committed. Thirty one (2.8%) prisoners had HCV-KSHV co-infection, 16 (1.5%) had HCV-HTLV-I co-infection, and 14 (1.3%) had HBV-HCV co-infection. Triple co-infection was observed in seven cases and one case had four infections concomitantly.

CONCLUSIONS

This epidemiological study indicated different rates and transmission risks for these viruses. HCV was the most contagious viral infection and HTLV-I was the weakest in the prisoners. Apart from KSHV infection which its prevalence was as twice as in the general population, the prevalence of HBV and HTLV-I in prisoners was nearly in ranges of the general population.

Prevalence of hepatitis C virus in Brazil's inmate population: a systematic review

OBJECTIVE

To estimate the prevalence of hepatitis C virus infection in Brazil’s inmate population.

METHODS

Systematic review on hepatitis C virus infection in the inmate population. Brazilian studies published from January 1, 1989 to February 20, 2014 were evaluated. The methodological quality of the studies was assessed using a scale of 0 to 8 points.

RESULTS

Eleven eligible studies were analyzed and provided data on hepatitis C virus infection among 4,375 inmates from seven states of Brazil, with a mean quality classification of 7.4. The overall hepatitis C virus prevalence among Brazilian inmates was 13.6% (ranging from 1.0% to 41.0%, depending on the study). The chances of inmates being seropositive for hepatitis C virus in the states of Minas Gerais (MG), Sergipe (SE), Mato Grosso do Sul (MS), Rio Grande do Sul (RS), Goiás (GO) and Espirito Santo (ES) were 84.0% (95%CI 0.06;0.45), 92.0% (95%CI 0.04;0.13), 88.0% (95%CI 0.09;0.18), 74.0% (95%CI 0.16;0.42), 84.0% (95%CI 0.08;0.31) and 89.0% (95%CI 0.01;0.05) respectively, lower than that observed in the Sao Paulo state (seroprevalence of 29.3%). The four studies conducted in the city of Sao Paulo revealed a lower prevalence in more recent studies compared to older ones.

CONCLUSIONS

The highest prevalence of hepatitis C virus infection in Brazil’s inmate population was found in Sao Paulo, which may reflect the urban diversity of the country. Despite Brazilian studies having good methodological quality to evaluate the prevalence of the hepatitis C virus, they are scarce and lack data on risk factors associated with this infection, which could support decisions on prevention and implementation of public health policies for Brazilian prisons.

A systematic review and meta-analysis of the prevalence of chlamydia, gonorrhoea and syphilis in incarcerated persons

Communicable diseases are common in people who are incarcerated. We aimed to define the prevalence of chlamydia, gonorrhoea and syphilis in people who are incarcerated and to identify subgroups with the highest risk of infection. We searched for prevalence studies of chlamydia, gonorrhoea or syphilis in incarcerated populations. Pooled estimates were generated, and meta-regression was conducted. Random effects models yielded pooled prevalence estimates of 5.75% (95% confidence interval [CI] 5.01, 6.48) and 12.31% (95% CI 10.61, 14.01) for chlamydia in men and women, 1.4% (95% CI 1.09, 1.70) and 5.73% (4.76, 6.69) for gonorrhoea in men and women, and 2.45% (95% CI 2.08, 2.82) and 6.10% (95% CI 4.75, 7.46) for syphilis in men and women, respectively. Each infection was associated with female gender in meta-regression models. Chlamydia, gonorrhoea and syphilis are highly prevalent in these populations. Primary and secondary prevention efforts could improve individual and population health.

Seroprevalence of hepatitis B virus infection and associated factors among prison inmates in state of Mato Grosso do Sul, Brazil

INTRODUCTION: This study aimed to estimate the prevalence of HBV infection and associated factors among prison inmates in Campo Grande, MS. METHODS: A total of 408 individuals were interviewed regarding sociodemographic characteristics, associated factors and HBV vaccination using a standardized questionnaire. Blood samples were collected from all participants and serological markers for HBV were detected by enzyme-linked immunosorbent assay. Hepatitis B surface antigen (HBsAg) and/or antibodies against hepatitis B core antigen (anti-HBc) positive samples were tested for HBV-DNA by polymerase chain reaction. RESULTS: The overall prevalence of HBV infection was 17.9% (95%CI: 14.4-22.0). The HBsAg carrier rate was 0.5%; 56 (13.7%) individuals had been infected and developed natural immunity and 15 (3.7%) were positive for anti-HBc only. Ninety eight (24%) prisoners had only anti-HBs, suggesting that they had low vaccine coverage. An occult HBV infection rate of 0% was verified among anti-HBc-positive individuals. Multivariate analysis of associated factors showed that age > 35 years-old, low schooling level and illicit drug use are significantly associated with HBV infection. CONCLUSIONS: Analysis of the data showed HBV infection prevalence similar or slightly lower than that reported in other of Brazilian prisons. Independent predictors of HBV infection in this population include older age, low schooling level and illicit drug use.

Risk factors and prevalence of tuberculosis, human immunodeficiency virus, syphilis, hepatitis B virus, and hepatitis C virus among prisoners in Pakistan

OBJECTIVE

The objective of this study was to evaluate the burden of sexual- and injection drug use-related infections in male prisoners in Karachi, Pakistan.

METHODS

We administered a structured questionnaire in a cross-sectional survey of 365 randomly selected imprisoned men. We analyzed blood for the human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) by ELISA, and for syphilis by rapid plasma reagin with Treponema pallidum hemagglutination assay confirmation. Subjects with possible tuberculosis (World Health Organization criteria) provided sputum samples for an acid-fast bacillus smear and culture.

RESULTS

The prevalence of tuberculosis was 2.2% (95% CI 0.71-3.8%). Of 357 of the randomly selected prisoners (eight refused to give blood), 2.0% (95% CI 0.6-3.4) were HIV-infected; syphilis was confirmed in 8.9% (95% CI 6.0-11.8%), HBV in 5.9% (95% CI 3.5-8.3%), and HCV in 15.2% (95% CI 11.7-18.8). By self-report, 59.2% had used any illicit drugs, among whom 11.8% (95% CI 8.5-15.0) had injected drugs. The median length of stay in the prison had been 3.2 (range 1-72) months.

CONCLUSIONS

All four infections were prevalent among the prisoners in Pakistan. Prisons are excellent venues for infectious disease screening and intervention given the conditions of poverty and drug addiction. Collaboration with community-based health providers is vital for post-discharge planning.