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Factors associated with death from tuberculosis and HIV/aids in prisons: integrative review

Abstract

Objective

Analyze the epidemiological profile and the factors associated with death from tuberculosis and HIV/aids in the prison system.

Methods

Integrative review, conducted in July 2020, whose research question and keywords were outlined through the PEO strategy. The searches were undertaken in the MEDLINE, CINAHL, Scopus, ASP, SocINDEX, Embase and LILACS databases. Two independent reviewers selected the studies and extracted the data. To assess the methodological quality of the articles included in the review, specific tools proposed by the Joanna Briggs Institute were used.

Results

1,329 studies were retrieved, four of which were included in the review. The epidemiological profile and factors associated with death from tuberculosis in the prison system included the following variables: age ≥ 43 years, illiterate or low education level, concomitant pulmonary and extrapulmonary tuberculosis, non-performance of directly observed treatment and history of alcohol abuse. As for death from HIV and aids, males, mean age of 34 years, singles, black and Hispanic race/color, drug use and prolonged imprisonment, advanced infection and recent initiation of antiretroviral therapy stood out.

Conclusion

The epidemiological profile and the factors associated with death from tuberculosis and HIV/aids in the prison system show the need for a risk stratification with a continuous and comprehensive approach to the care provided to the population affected by these health conditions.

Prisions; Tuberculosis; Acquired immunodeficiency syndrome; Death

Resumo

Objetivo

Analisar o perfil epidemiológico e os fatores associados ao óbito por tuberculose e HIV/aids no sistema prisional.

Métodos

Revisão integrativa, realizada em julho de 2020, cuja pergunta de estudo e palavras-chave foram delineadas por meio da estratégia PEO. As buscas foram realizadas nas bases de dados MEDLINE, CINAHL, Scopus, ASP, SocINDEX, Embase e LILACS. A seleção de estudos e a extração dos dados foram feitas por dois revisores independentes. A avaliação da qualidade metodológica dos artigos incluídos na revisão foi conduzida com a utilização de instrumentos específicos propostos pelo Joanna Briggs Institute.

Resultados

Foram recuperados 1.329 estudos, dos quais quatro foram incluídos na revisão. O perfil epidemiológico e os fatores associados ao óbito por tuberculose no sistema prisional contemplaram as seguintes variáveis: idade ≥ 43 anos, analfabetos ou baixa escolaridade, concomitância de tuberculose pulmonar e extrapulmonar, não realização de tratamento diretamente observado e histórico de abuso de álcool. Quanto ao óbito por HIV e aids, destacaram-se o sexo masculino, média de idade de 34 anos, solteiros, raça/cor preta e hispânica, uso de drogas e aprisionamento prolongado, infecção avançada e início recente de terapia antirretroviral.

Conclusão

O perfil epidemiológico e os fatores associados ao óbito pela tuberculose e pelo HIV/aids no sistema prisional mostram a necessidade de uma estratificação de risco com abordagem continuada e integral da assistência prestada à população afetada por tais condições de saúde.

Prisões; Tuberculose; HIV; Síndrome de imunodeficiência adquirida; Morte

Resumen

Objetivo

Analizar el perfil epidemiológico y los factores asociados al fallecimiento por tuberculosis y por VIH/sida en el sistema penitenciario.

Métodos

Revisión integradora, realizada en julio de 2020, cuya pregunta de estudio y palabras clave fueron definidas por medio de la estrategia PEO. Las búsquedas fueron realizadas en las bases de datos MEDLINE, CINAHL, Scopus, ASP, SocINDEX, Embase y LILACS. La selección de estudios y la extracción de datos fueron llevadas a cabo por dos revisores independientes. La evaluación de calidad metodológica de los artículos incluidos en la revisión fue realizada con la utilización de instrumentos específicos propuestos por el Joanna Briggs Institute.

Resultados

Fueron recuperados 1.329 estudios, de los cuales cuatro fueron incluidos en la revisión. El perfil epidemiológico y los factores asociados al fallecimiento por tuberculosis en el sistema penitenciario contemplaron las siguientes variables: edad ≥ 43 años, analfabetos o escolaridad baja, concomitancia de tuberculosis pulmonar y extrapulmonar, no realización de tratamiento directamente observado e historial de exceso de alcohol. Respecto al fallecimiento por VIH y sida, las variables destacadas fueron el sexo masculino, edad promedio de 34 años, solteros, raza/color negro e hispánico, uso de drogas y encarcelación prolongada, infección avanzada e inicio reciente de tratamiento antirretroviral.

Conclusión

El perfil epidemiológico y los factores asociados al fallecimiento por tuberculosis y por VIH/sida en el sistema penitenciario demuestran la necesidad de una estratificación de riesgo con un enfoque continuo e integral de la atención brindada a la población afectada por tales condiciones de salud.

Prisiones; Tuberculose; Síndrome de inmunodeficiencia adquirida; Muerte

Introduction

According to the United Nations Joint Programme on HIV/Aids (UNAIDS), from the beginning of the epidemic in the 1980s until the end of 2019, 75.7 million people had been diagnosed with HIV around the world, 32.7 million of whom had died from aids-related diseases. In 2018, deaths from Aids worldwide were estimated at about 770,000 people, a significant reduction compared to 2004, when 1.7 million deaths happened.(11. UNAIDS Brasil. Programa Conjunto das Nações Unidas sobre HIV/AIDS. Estatísticas globais sobre HIV 2021. Brasília (DF): UNAIDS Brasil; 2020 [citado 2020 Out 11]. Disponível em: https://unaids.org.br/estatisticas/
https://unaids.org.br/estatisticas/...
)

As for tuberculosis (TB), considered an opportunistic disease to HIV, it remains a serious public health problem, with an alarming number of reported cases, like in 2019, when approximately ten million people became ill and 1.5 million died from TB. It is noteworthy that the percentage of HIV cases among people with TB in the world was 8.2% in 2019.(22. World Health Organization (WHO). Global Tuberculosis Report. Geneva: WHO; 2020 [cited 2020 Oct 11]. Available from: https://apps.who.int/iris/rest/bitstreams/1312164/retrieve
https://apps.who.int/iris/rest/bitstream...
)

Among the population segments, there are key populations to cope with HIV / aids, among which men who have sex with men, gays, sex workers, transgender people, people who use alcohol and other drugs and people deprived of freedom are highlighted.(33. Organização Panamericana de Saúde Brasil (OPAS). HIV/AIDS information sheet. Brasília (DF): OPAS Brasil; 2018 [citado 2020 Out 11]. Disponível em: https://www.paho.org/bra/index.php?option=com_content&view=article&id=5666:folha-informativa-hiv-aids&Itemid=812
https://www.paho.org/bra/index.php?optio...
)

Regarding TB, socioeconomic factors are highly relevant in the occurrence of the disease, presenting higher rates in populations living in developing countries.(44. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Boletim Epidemiológico de Turbeculose 2020. Brasília (DF): Ministério da Saúde; 2020 [citado 2020 Out 11]. Disponível em: http://www.aids.gov.br/pt-br/pub/2020/boletim-epidemiologico-de-turbeculose-2020
http://www.aids.gov.br/pt-br/pub/2020/bo...
) As for the vulnerabilities HIV / aids and TB have in common, the population that uses alcohol or illicit drugs and persons deprived of freedom stand out.(55. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Boletim Epidemiológico de HIV/Aids 2019. Brasília (DF): Ministério da Saúde; 2019 [citado 2020 Out 11]. Disponível em: http://www.aids.gov.br/pt-br/pub/2019/boletim-epidemiologico-de-hivaids-2019
http://www.aids.gov.br/pt-br/pub/2019/bo...
)

Among persons deprived of freedom, other aspects influence the occurrence of TB and HIV, such as overcrowding of prison units and the risk behaviors of detainees, such as consensual and non-consensual sexual relations, in addition to the use of injectable drugs.(66. Wali A, Khan D, Safdar N, Shawani Z, Fatima R, Yaqoob A, et al. Prevalence of tuberculosis, HIV/AIDS, and hepatitis; in a prison of Balochistan: a cross-sectional survey. BMC Public Health. 2019;19:1631.)

Considering the great magnitude of TB and HIV among persons deprived of freedom, who are part of the key population for the occurrence of both conditions, death may reveal weaknesses in the implementation and execution of prevention, treatment and case monitoring. In addition and motivated by the challenges inherent in achieving the goals of the world policies to control these health conditions by 2030, which aim to reduce the number of HIV deaths to zero(77. Instituto de Pesquisa Econômica Aplicada. (IPEA). Plataforma Agenda 2030. Brasília (DF): IPEA; 2020 [citado 2020 Out 11]. Disponível em: http://www.agenda2030.org.br/ods/3/
http://www.agenda2030.org.br/ods/3/...
) and deaths from TB (End TB Strategy) by 90%,(88. World Health Organization (WHO). The end TB strategy. Geneva: WHO; 2015 [cited 2020 Oct 11]. Available from: http://www.who.int/tb/End_TB_brochure.pdf?ua=1
http://www.who.int/tb/End_TB_brochure.pd...
) this study aimed to analyze the epidemiological profile and the factors associated with death from TB and HIV/aids in the prison system.

Methods

This integrative review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).(99. Page MJ, Moher D, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ. 2021;372:n71.) This type of review is used for its potential to synthesize results on the state of the art of a given topic, in addition to substantiating conducts and decision-making based on the challenges met, recommending future research, directing critical reflections on the topic addressed.(1010. Cronin MA, George E. The Why and How of the Integrative Review. Org Res Methods. 2020 July 6. doi:10.1177/1094428120935507) For this, the following steps were followed: construction of the guiding question of the study; bibliographic search in the databases; selection of primary studies; data extraction; methodological evaluation of the included studies; synthesis, presentation and analysis of the review results.

For the bibliographic search, initially, the guiding question of the study, “what is the epidemiological profile and what factors are associated with deaths from TB and HIV/aids among persons deprived of freedom in the prison system?”, was identified by means of the PEO strategy,(1111. Moola S, Munn Z, Sears K, Sfetcu R, Currie M, Lisy K, et al. Conducting systematic reviews of association (etiology): The Joanna Briggs Institute’s approach. Int J Evid Based Healthc. 2015;13(3):163-9.) proposed by the Joanna Briggs Institute, in which P (population of interest) corresponded to persons deprived of freedom in the prison system due to TB or HIV/aids; E (exposure), to the epidemiological profile and associated factors; O (outcome), to death. Then, based on that question, the descriptors could be identified to search in the databases.

Using the descriptors identified in Portuguese, which are part of the controlled vocabulary of the Descriptors in Health Sciences (DeCS), it was possible to identify their synonyms, as well as the corresponding terms in Spanish and English. For the descriptors in English, the following were also consulted: Medical Subject Headings (MeSH) and Embase Subject Headings (EMTREE). In addition, background searches were undertaken out in the databases, in order to identify the free vocabulary used in the publications.

The databases used in the searches were: Excerpta Medica dataBASE (Embase® - https://www.embase.com), Scopus, owned by Elsevier (https://www.scopus.com Medline or Publisher Medlin (accessed through the PubMed platform - https://pubmed.ncbi.nlm.nih.gov/) and Latin American and Caribbean Literature in Health Sciences (LILACS-accessed through the Regional Portal of the Virtual Health Library - https://pesquisa.bvsalud.org/portal/advanced). Finally, the searches performed in the databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Academic Search Premier (ASP) and SocINDEX were run simultaneously through the EBSCOhost platform, accessed through the CAPES Journals website (https://www.periodicos.capes.gov.br). This platform automatically excludes duplicates found in these databases. In the searches in LILACS, the vocabulary was used in Portuguese, English and Spanish while, for the searches in the other databases, the vocabulary in English was used. It should be noted that, in order to obtain a greater number of publications on the subject, no time frame and country/continent of publication was established for the bibliographic survey.

The searches were carried out in July 2020, using specific strategies according to each database and the Boolean operators AND and OR (Chart 1). The Boolean operator OR was used between the words of the same group (“word” OR “word”), and AND was used between the set of words of the different groups (“set of words of Group 1” AND “set of words of Group 2” and “set of words of Group 3”).

Chart 1
Article search strategies for the integrative literature review on the epidemiological profile and factors associated with deaths from TB and HIV/aids among people deprived of freedom in the prison system

With the search results at hand, the references were exported to the online systematic review application Rayyan QCRI of the Qatar Computing Research Institute.(1212. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210.) Then, the duplicate publications were excluded, and two independent reviewers read the titles and abstracts of the others. They chose publications for full reading and possible inclusion in the study based on the following criteria: complete descriptive or observational studies, which used people deprived of freedom as a study population and discussed the epidemiological profile or the factors associated with death from TB and HIV/aids. Publications addressing populations serving sentences beyond the prison environment and studies identifying factors associated with unfavorable outcomes concomitant with the deaths were excluded.

The full reading of the articles permitted a more accurate selection of the articles to be included in the review. These were submitted simultaneously to a narrative synthesis and extraction of the data, using a specific adapted tool(1313. Ursi ES. Prevnção de lesões de pele no perioperatório: revisão integrativa da literatura [tese]. Ribeirão Preto (SP): Universidade de São Paulo; 2005 [citado 2021 Maio 12]. Disponível em: https://teses.usp.br/teses/disponiveis/22/22132/tde-18072005-095456/publico/URSI_ES.pdf
https://teses.usp.br/teses/disponiveis/2...
) to search for the following information: title of the article, journal, authors, country of study, language, year of publication, type of study, objective of the study, study population, sample calculation, sampling, characteristics of the studied population, source of data collection, dependent variable, independent variables, length of the study, statistical treatment, main results and conclusions.

Finally, to assess the methodological quality of the articles, instruments proposed by the Joanna Briggs Institute (JBI – https://joannabriggs.org/ebp/critical_appraisal_tools) were used.(1414. Moola S, Munn Z, Tufanaru C, Aromataris E, Sears K, Sfetc R, et al. Chapter 7: Systematic reviews of etiology and risk. In: Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis. Austrália: JBI; 2020 [cited 2021 May 12]. Available from: https://jbi-global-wiki.refined.site/space/MANUAL/3283910762/Chapter+7%3A+Systematic+reviews+of+etiology+and+risk
https://jbi-global-wiki.refined.site/spa...
) Thus, for three articles, the instrument that evaluates cohort studies was used and, for another, the instrument that evaluates prevalence studies (descriptive).

Results

Based on the search in the databases, 1,329 studies were recovered, excluding 482 due to duplication, and 838 after reading the titles and abstracts. Nine selected publications were read in full, four of which were included in this review (Figure 1).(1515. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.)

Figure 1
Flow chart of the number of publications analyzed at each stage of the integrative literature review on the epidemiological profile and the factors associated with deaths from TB and HIV/aids among persons deprived of freedom in the prison system

All of the four articles included1616. Culbert GJ, Crawford FW, Murni A, Waluyo A, Bazazi AR, Sahar J, et al. Predictors of Mortality within Prison and after Release among Persons Living with HIV in Indonesia. Res Rep Trop Med. 2017;8:25–35. were published in English, and these were carried out in Indonesia,(1616. Culbert GJ, Crawford FW, Murni A, Waluyo A, Bazazi AR, Sahar J, et al. Predictors of Mortality within Prison and after Release among Persons Living with HIV in Indonesia. Res Rep Trop Med. 2017;8:25–35.) Brazil,(1717. Ribeiro Macedo L, Reis-Santos B, Riley LW, Maciel EL. Treatment outcomes of tuberculosis patients in Brazilian prisons: a polytomous regression analysis. Int J Tuberc Lung Dis. 2013;17(11):1427-34.) United States(1818. Gido R. A demographic and epidemiological study of New York State inmate AIDS mortalities, 1981-1987. Prison J. 1989;69(1):27–32.) and South Africa.(1919. Telisinghe L, Hippner P, Churchyard GJ, Gresak G, Grant AD, Charalambous S, et al. Outcomes of on-site antiretroviral therapy provision in a South African correctional facility. Int J STD AIDS. 2016;27(13):1153–61.) These publications occurred between 1989 and 2017, being three cohort studies(1616. Culbert GJ, Crawford FW, Murni A, Waluyo A, Bazazi AR, Sahar J, et al. Predictors of Mortality within Prison and after Release among Persons Living with HIV in Indonesia. Res Rep Trop Med. 2017;8:25–35.,1717. Ribeiro Macedo L, Reis-Santos B, Riley LW, Maciel EL. Treatment outcomes of tuberculosis patients in Brazilian prisons: a polytomous regression analysis. Int J Tuberc Lung Dis. 2013;17(11):1427-34.,1919. Telisinghe L, Hippner P, Churchyard GJ, Gresak G, Grant AD, Charalambous S, et al. Outcomes of on-site antiretroviral therapy provision in a South African correctional facility. Int J STD AIDS. 2016;27(13):1153–61.) and one with a descriptive design (Chart 2).(1818. Gido R. A demographic and epidemiological study of New York State inmate AIDS mortalities, 1981-1987. Prison J. 1989;69(1):27–32.)

Chart 2
Description of the articles included in the integrative literature review on the epidemiological profile and factors associated with deaths from TB and HIV/aids among persons deprived of freedom in the prison system

The objectives and synthesis of the main results found in the scientific production on the epidemiological profile and the factors associated with deaths from TB and HIV / aids among persons deprived of freedom in the prison system are shown in Table 2. The profile and factors associated with deaths from TB in the prison system included the following variables: age ≥ 43 years, illiterate or low education level, concomitant pulmonary and extrapulmonary TB, non-performance of Directly Observed Treatment (DOD) for TB and history of alcohol abuse.(1717. Ribeiro Macedo L, Reis-Santos B, Riley LW, Maciel EL. Treatment outcomes of tuberculosis patients in Brazilian prisons: a polytomous regression analysis. Int J Tuberc Lung Dis. 2013;17(11):1427-34.) As for death from HIV and aids, the male sex stood out,(1818. Gido R. A demographic and epidemiological study of New York State inmate AIDS mortalities, 1981-1987. Prison J. 1989;69(1):27–32.) average age 34 years,(1818. Gido R. A demographic and epidemiological study of New York State inmate AIDS mortalities, 1981-1987. Prison J. 1989;69(1):27–32.) single,(1818. Gido R. A demographic and epidemiological study of New York State inmate AIDS mortalities, 1981-1987. Prison J. 1989;69(1):27–32.) race / black and Hispanic,(1818. Gido R. A demographic and epidemiological study of New York State inmate AIDS mortalities, 1981-1987. Prison J. 1989;69(1):27–32.) drug use,(1616. Culbert GJ, Crawford FW, Murni A, Waluyo A, Bazazi AR, Sahar J, et al. Predictors of Mortality within Prison and after Release among Persons Living with HIV in Indonesia. Res Rep Trop Med. 2017;8:25–35.,1818. Gido R. A demographic and epidemiological study of New York State inmate AIDS mortalities, 1981-1987. Prison J. 1989;69(1):27–32.) prolonged imprisonment,(1616. Culbert GJ, Crawford FW, Murni A, Waluyo A, Bazazi AR, Sahar J, et al. Predictors of Mortality within Prison and after Release among Persons Living with HIV in Indonesia. Res Rep Trop Med. 2017;8:25–35.) advanced virus infection(1616. Culbert GJ, Crawford FW, Murni A, Waluyo A, Bazazi AR, Sahar J, et al. Predictors of Mortality within Prison and after Release among Persons Living with HIV in Indonesia. Res Rep Trop Med. 2017;8:25–35.,1818. Gido R. A demographic and epidemiological study of New York State inmate AIDS mortalities, 1981-1987. Prison J. 1989;69(1):27–32.) and recent onset or non-use of antiretroviral therapy (ART).(1919. Telisinghe L, Hippner P, Churchyard GJ, Gresak G, Grant AD, Charalambous S, et al. Outcomes of on-site antiretroviral therapy provision in a South African correctional facility. Int J STD AIDS. 2016;27(13):1153–61.)

Discussion

Limitations in this study are the small number of articles found in the databases on the research subject and one study that portrayed the epidemiological profile of aids cases in the 80s, which points to the need for current studies that contribute to reflections on the identification of the epidemiological profile and the factors associated with death from TB and HIV/aids among people deprived of freedom, in order to improve the quality of health care for both conditions and avoid unfavorable outcomes that could be avoided and managed. In addition, bibliographic material may be present in other databases than those consulted in this study. Nevertheless, the study results may contribute to the proposal of actions to prevent complications, such as death, by stratifying the risk of TB and HIV/aids cases in the prison system.

The articles included in this integrative review presented heterogeneous approaches to the research problem, as they worked separately with death among persons deprived of freedom with TB(1717. Ribeiro Macedo L, Reis-Santos B, Riley LW, Maciel EL. Treatment outcomes of tuberculosis patients in Brazilian prisons: a polytomous regression analysis. Int J Tuberc Lung Dis. 2013;17(11):1427-34.) or with HIV / aids,(1616. Culbert GJ, Crawford FW, Murni A, Waluyo A, Bazazi AR, Sahar J, et al. Predictors of Mortality within Prison and after Release among Persons Living with HIV in Indonesia. Res Rep Trop Med. 2017;8:25–35.,1818. Gido R. A demographic and epidemiological study of New York State inmate AIDS mortalities, 1981-1987. Prison J. 1989;69(1):27–32.) or even among people living with HIV under ART.(1919. Telisinghe L, Hippner P, Churchyard GJ, Gresak G, Grant AD, Charalambous S, et al. Outcomes of on-site antiretroviral therapy provision in a South African correctional facility. Int J STD AIDS. 2016;27(13):1153–61.) In this sense, in order to align these different approaches to the epidemiological profile and factors associated with death from these causes among persons deprived of freedom, the findings of these studies were grouped according to sociodemographic, clinical, behavioral and case treatment characteristics. It is important to highlight the small number of studies included in the review, as well as the non-simultaneous approach of TB and HIV in the studies identified, revealing an important gap in the production of scientific knowledge about mortality from TB/HIV co-infection in the prison context, therefore configuring new research opportunities in this area.

As for the sociodemographic characteristics, the only study regarding death from TB pointed out that this outcome occurs mainly among people aged ≥43 years and illiterate.(1717. Ribeiro Macedo L, Reis-Santos B, Riley LW, Maciel EL. Treatment outcomes of tuberculosis patients in Brazilian prisons: a polytomous regression analysis. Int J Tuberc Lung Dis. 2013;17(11):1427-34.)In the literature, another study was found that shows unfavorable outcomes of TB treatment among persons deprived of freedom associated with adults ≥ 35 years of age.(2020. Khan AH, Sulaiman SA, Muttalif AR, Hassali MA, Aftab RA, Khan TM. Incidence and risk factors associated with tuberculosis treatment outcomes among prisoners. Infect Dis Clin Pract. 2019;27(3):148–54.) This expresses a pattern of deaths due to TB among adults within prisons, but still in the productive stage, which highlights the importance of health actions focused on offering proper treatment for TB throughout imprisonment, in addition to joint actions of health facilities in prisons and community-based facilities, especially to attend to the cases of exacerbation of the disease among people as age advances, and which may therefore exhibit an overlap of chronic health conditions, making them more vulnerable.(2121. Zhang P, Xiong J, Zeng J, Zhan S, Chen T, Wang Y, et al. Clinical evaluation of active tuberculosis-related deaths in Shenzhen, China: a descriptive study. Int J Gen Med. 2021;14:237–42.) This pattern entails reflections on the correctional, socio-educational and health rights enforcement role of the prison system, reflecting on the worsening health conditions and mortality of those who, in theory, should be prepared to return to society and working life once they are released.

In addition, in this review, the low or no education of those who died from TB(1717. Ribeiro Macedo L, Reis-Santos B, Riley LW, Maciel EL. Treatment outcomes of tuberculosis patients in Brazilian prisons: a polytomous regression analysis. Int J Tuberc Lung Dis. 2013;17(11):1427-34.) corroborates the results of another study, which identified that people with nine or more years of study presented a higher chance of a favorable outcome when compared to individuals without education.(2222. Santos JN, Sales CM, Prado TN, Maciel EL. Factors associated with cure when treating tuberculosis in the state of Rio de Janeiro, Brazil, 2011-2014. Epidemiol Serv Saude. 2018;27(3):e2017464.) These findings raise hypotheses that illiterate individuals or individuals with low education are more vulnerable because they have not had access to education and, consequently, have a lower level of knowledge regarding the disease, signs and symptoms, forms of transmission, prevention and treatment.(2323. Freitas IM, Popolin MP, Touso MM, Yamamura M, Rodrigues LB, Santos Neto M, et al. Factors associated with knowledge about tuberculosis and attitudes of relatives of patients with the disease in Ribeirão Preto, São Paulo, Brazil. Rev Bras Epidemiol. 2015;18:326–40.) This raises the risk of death from the disease and reinforces the importance of health education actions within prison environments, which need to occur and be offered by health professionals and prison agents, enabling emancipatory dialogues for care and forms of prevention.(2424. Brasil GC, Batista RS, Gomes AP, Colodette RM, Oliveira DM, Moreira TR. Knowledge about tuberculosis in individuals deprived of liberty of a regional penitentiary in the Zona da Mata Mineira – Brazil. Cien Nat. 2021;43(Esp):1-19.)

For persons deprived of freedom who died of aids, the associated epidemiological profile shows a predominance of males, adults with an average age of 34 years, black and Hispanic race/color and not being married.(1818. Gido R. A demographic and epidemiological study of New York State inmate AIDS mortalities, 1981-1987. Prison J. 1989;69(1):27–32.) Because this is a descriptive study, it is assumed that the profile of death in people with aids in the prison system(1818. Gido R. A demographic and epidemiological study of New York State inmate AIDS mortalities, 1981-1987. Prison J. 1989;69(1):27–32.) converges to the profile of people in deprivation of freedom in the country (United States) at the time of study. In addition, results of a survey conducted in that country in 2016 show that aids cases are still disproportionately distributed among black people, including adult men and young people,(2525. Centers for Disease Control and Prevention. (CDD). National Center for HIV STD and TB Prevention. Division of HIV/AIDS Prevention. Fact Sheet - HIV/AIDS among African Americans. Atlanta: CDC; 2019 [cited 2021 May 12]. Available from: https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/cdc-hiv-aa-508.pdf
https://www.cdc.gov/nchhstp/newsroom/doc...
)highlighting the consequences of violence, structural racism and social exclusion, which affect these individuals inside and beyond prisons.

Given the sociodemographic profile of individuals who may have an unfavorable outcome for the treatment of TB and HIV, the prison health team needs to be aware of the people who will use the service through the stratification of risks of chronic diseases, whether during admission, confinement, or release, allowing the identification of social groups with similar health care needs, the rupture with supply-based care, characteristic of fragmented systems, and the implementation of care based on the health needs of the population, an essential element of the care offered in the healthcare networks.(2626. Oliveira RL, Azevedo LS, Macêdo ED, Aguiar ML, Abreu AS, Privado LB, et al. Relatos de uso de tabaco, álcool e drogas ilícitas entre pacientes em tratamento para tuberculose. Braz J Health Review. 2020;3(5):14866-77.) This situation tends to be intensified due to the potential invisibility of people living with chronic conditions, and especially those within the prison system. It is necessary to incorporate the systematic search for respiratory symptoms, the singular follow-up of sick people according to risk profiles and the inclusion of strategies that promote assisted self-care and the monitoring of regular treatment use for both TB and HIV.

Among the clinical characteristics, having the mixed form of TB (pulmonary + extrapulmonary) was associated with death from the disease among people deprived of freedom.(1717. Ribeiro Macedo L, Reis-Santos B, Riley LW, Maciel EL. Treatment outcomes of tuberculosis patients in Brazilian prisons: a polytomous regression analysis. Int J Tuberc Lung Dis. 2013;17(11):1427-34.) A study conducted in prisons in four Malaysian states also identified that the concomitant occurrence of pulmonary and extrapulmonary forms increased the chances of unfavorable treatment outcomes among persons deprived of freedom.(2020. Khan AH, Sulaiman SA, Muttalif AR, Hassali MA, Aftab RA, Khan TM. Incidence and risk factors associated with tuberculosis treatment outcomes among prisoners. Infect Dis Clin Pract. 2019;27(3):148–54.) This aspect is noteworthy as the mixed clinical form of TB is more frequent in people living with HIV / aids, who are also included as a risk group for the outcome of death within prisons.(1717. Ribeiro Macedo L, Reis-Santos B, Riley LW, Maciel EL. Treatment outcomes of tuberculosis patients in Brazilian prisons: a polytomous regression analysis. Int J Tuberc Lung Dis. 2013;17(11):1427-34.)

Individuals with advanced HIV infection were more likely to develop opportunistic infections,(1616. Culbert GJ, Crawford FW, Murni A, Waluyo A, Bazazi AR, Sahar J, et al. Predictors of Mortality within Prison and after Release among Persons Living with HIV in Indonesia. Res Rep Trop Med. 2017;8:25–35.) such as pneumonia from Pneumocystis carinii(1818. Gido R. A demographic and epidemiological study of New York State inmate AIDS mortalities, 1981-1987. Prison J. 1989;69(1):27–32.) and TB itself,(1717. Ribeiro Macedo L, Reis-Santos B, Riley LW, Maciel EL. Treatment outcomes of tuberculosis patients in Brazilian prisons: a polytomous regression analysis. Int J Tuberc Lung Dis. 2013;17(11):1427-34.) culminating in death. The prison units need to get organized in combination with the health services, with campaigns aimed at the prevention of sexually transmitted infections and for the follow-up of compliance with the treatment of HIV, TB and other opportunistic infections, as well as the incorporation of strategies to follow up the compliance and therapeutic response of people on drug treatment, with emphasis on DOT.

Regarding the behavioral aspects associated with death among persons deprived of freedom, it was identified in the studies that alcoholism contributed to death from TB.(1717. Ribeiro Macedo L, Reis-Santos B, Riley LW, Maciel EL. Treatment outcomes of tuberculosis patients in Brazilian prisons: a polytomous regression analysis. Int J Tuberc Lung Dis. 2013;17(11):1427-34.) It should be noted that alcohol abuse can impact unfavorable outcomes,(2727. Ragan EJ, Kleinman MB, Sweigart B, Gnatienko N, Parry CD, Horsburgh CR, et al. The impact of alcohol use on tuberculosis treatment outcomes: a systematic review and meta-analysis. Int J Tuberc Lung Dis. 2020;24(1):73–82.) mainly because it affects the drug treatment of the disease and the nutritional situation of the population deprived of freedom, which is already impaired by the conditions of imprisonment.(1717. Ribeiro Macedo L, Reis-Santos B, Riley LW, Maciel EL. Treatment outcomes of tuberculosis patients in Brazilian prisons: a polytomous regression analysis. Int J Tuberc Lung Dis. 2013;17(11):1427-34.,2828. Macedo LR, Maciel EL, Struchiner CJ. Vulnerable populations and the outcome of tuberculosis cases in Brazil. Cien Saude Colet. 2021;26(10):4749-59.) The focus of attention to the treatment of alcohol dependence should be the agenda of discussions, especially of multi-and interdisciplinary teams, so that possible interventions are carried out in order to promote behavioral changes through harm reduction proposals and motivational interviews.(2929. Lima SS. O cuidado aos usuários de drogas em situação de privação de liberdade. Physis Rev Saude Coletiva. 2019;29(3):e290305.)

The abuse of intravenous drugs was a predictor of death in aids cases, showing the interface between the treatment of chemical addicts and the possibility of longer life expectancy of HIV cases,(1616. Culbert GJ, Crawford FW, Murni A, Waluyo A, Bazazi AR, Sahar J, et al. Predictors of Mortality within Prison and after Release among Persons Living with HIV in Indonesia. Res Rep Trop Med. 2017;8:25–35.) as well as the importance of tracking the risk factors that may contribute to an unfavorable outcome of cases within prison units. For this screening to be possible, the presence of mental health professionals in the multidisciplinary team is important. They can contribute to the construction of knowledge of people deprived of freedom about the adoption of behaviors aimed at reducing the use/abuse of illicit drugs in the prison environment, using the same strategies as for the treatment of alcohol dependence. Nevertheless, the limitations regarding the completeness of the human resources frameworks in health within the prison system are acknowledge, which require strategies of participation and openness to professionals/different specialties, including matrix-based strategies and/or teleconsultations, exploring virtual tools and technologies for the qualification of the care offered.

Regarding treatment, a study showed that not practicing DOT in prison units is a factor associated with death from TB among people deprived of their freedom.(1717. Ribeiro Macedo L, Reis-Santos B, Riley LW, Maciel EL. Treatment outcomes of tuberculosis patients in Brazilian prisons: a polytomous regression analysis. Int J Tuberc Lung Dis. 2013;17(11):1427-34.) DOT is widely recommended, as a treatment regimen, to strengthen compliance with TB treatment, aiming at reducing death and other unfavorable outcomes and, consequently, controlling the disease, both within and beyond the prisons (in case of leaving the prison unit in open or semi-open prison regimes), and may include, as treatment supervisors, people from the community, family members, health professionals, prison officers and even other detainees.(1717. Ribeiro Macedo L, Reis-Santos B, Riley LW, Maciel EL. Treatment outcomes of tuberculosis patients in Brazilian prisons: a polytomous regression analysis. Int J Tuberc Lung Dis. 2013;17(11):1427-34.)

Thus, in addition to the aforementioned assignments, prison health units should also offer TB screening through the active search for respiratory symptomatic patients, diagnostic tests for TB and serological tests for HIV during imprisonment, confinement and release, because it allows people deprived of freedom to be diagnosed early, treated and, consequently, to promote impacts based on the decrease in cases of aggravation of both diseases, as well as through disruptions in the transmission chain for communicants in the prison environment, during visits or in the community.(3030. Mabud TS, Alves ML, Ko AI, Basu S, Walter KS, Cohen T, et al. Evaluating strategies for control of tuberculosis in prisons and prevention of spillover into communities: An observational and modeling study from Brazil. Plos Med. 2019;16(1):e1002737.) In addition, for HIV, the importance of early diagnosis of the infection and the organization of the health team for the systematic monitoring of the detainee is reinforced, as mortality from this cause among people deprived of freedom was higher among those who had recently started ART or who did not use this treatment.(1919. Telisinghe L, Hippner P, Churchyard GJ, Gresak G, Grant AD, Charalambous S, et al. Outcomes of on-site antiretroviral therapy provision in a South African correctional facility. Int J STD AIDS. 2016;27(13):1153–61.)

It is important to highlight that, among persons deprived of freedom with HIV/aids, the included studies have shown that death was associated with prolonged imprisonment in prisons specialized in drug offenses(1616. Culbert GJ, Crawford FW, Murni A, Waluyo A, Bazazi AR, Sahar J, et al. Predictors of Mortality within Prison and after Release among Persons Living with HIV in Indonesia. Res Rep Trop Med. 2017;8:25–35.) and in state maximum security prisons.(1818. Gido R. A demographic and epidemiological study of New York State inmate AIDS mortalities, 1981-1987. Prison J. 1989;69(1):27–32.) These findings raise reflections on the prioritization of safety to the detriment of health and the undervaluation of chronic diseases, which can lead to death without the proper management and sensitization of professionals to the longitudinality and completeness of care within prison environments, with a view to integration with other points of care of the health network, which often depends on prior release for the detainees to visit health services beyond prison walls, police escort and overcoming barriers and bureaucratic elements that hinder access to health as a constitutional right.

The focus of the epidemiological profile and the factors associated with death due to TB and HIV/aids education in the prison system need to be on the standing agenda of discussion between the managers of the health care and legal system. As the State is responsible for the protection of detainees, these outcomes in prison settings reflect a significant gap when it comes to addressing both of these diseases, and also in the efforts made in the correctional process for the sake of the recovery and rehabilitation of the prisoners, in order to return them healthily and with productive potential to society. When thinking about the degrading conditions of prison environments, it is understood that the deaths would be caused by deprivation or state neglect of the right and access to health.(3131. Chies LA, Almeida BR. Muertes en prisión preventiva en Brasil. Prisiones que matan; muertes que importan poco. Rev Cien Sociales. 2020;33(47):67–90.) This omission in the practice of individual rights and guarantees is complicated to the extent that the criminal and penitentiary policy, in practice, is still configured as a device that proposes to “make people die”, exposing individuals to risks, segregation and discrimination.(3232. Foucault M. Em defesa da sociedade, curso no Collège de France. São Paulo: Martins Fontes; 2005. 382 p.)

The methodological quality of the studies included in this review appointed limitations, which restrict inferences on the research topic. In the cohort studies,(1616. Culbert GJ, Crawford FW, Murni A, Waluyo A, Bazazi AR, Sahar J, et al. Predictors of Mortality within Prison and after Release among Persons Living with HIV in Indonesia. Res Rep Trop Med. 2017;8:25–35.,1717. Ribeiro Macedo L, Reis-Santos B, Riley LW, Maciel EL. Treatment outcomes of tuberculosis patients in Brazilian prisons: a polytomous regression analysis. Int J Tuberc Lung Dis. 2013;17(11):1427-34.,1919. Telisinghe L, Hippner P, Churchyard GJ, Gresak G, Grant AD, Charalambous S, et al. Outcomes of on-site antiretroviral therapy provision in a South African correctional facility. Int J STD AIDS. 2016;27(13):1153–61.) there were limitations regarding the confounding variables and the strategies to minimize them, the strategies to minimize follow-up losses, and the unreliability of exposure measures and outcomes due to the use of secondary sources. In the descriptive study,(1818. Gido R. A demographic and epidemiological study of New York State inmate AIDS mortalities, 1981-1987. Prison J. 1989;69(1):27–32.) the results should be addressed with caution, due to the statistical analysis used.

Conclusion

The epidemiological profile of the population who died from TB and HIV/aids in the prison system is characterized by male persons, aged over 30 years, black, illiterate or with low education, unmarried, who have the mixed form of TB, do not received DOT, have a history of alcohol and other drugs abuse, and who have been in prolonged imprisonment.

Knowledge of the characteristics of persons deprived of freedom who die from TB and HIV/aids reinforces the need to look more cautiously at their multifaceted risk profiles, which encompass the sociodemographic, clinical and behavioral aspects identified.

These characteristics show the need for a continuous and integral approach to the care provided to the population affected by these health conditions. The goal should be to achieve favorable treatment outcomes, through efforts for the effective integration of TB and HIV actions in the prison context, as well as of the prison unit in all the services of the care network, in addition to early detection, using clinical tools to stratify the detainees’ risk for the purpose of designing and implementing singular case monitoring strategies, including the valuation of DOT.

Acknowledgements

This study was funded by the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) – Funding Code 001 and the Brazilian National Council for Scientific and Technological Development (CNPq) – Research Productivity Grant Level 2 for AA Monroe-process 304517/2018-6.

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Edited by

Associate Editor (Peer review process): Ana Lúcia de Moraes Horta (https://orcid.org/0000-0001-5643-3321) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, SP, Brazil

Publication Dates

  • Publication in this collection
    29 Aug 2022
  • Date of issue
    2022

History

  • Received
    16 June 2021
  • Accepted
    07 Dec 2021
Escola Paulista de Enfermagem, Universidade Federal de São Paulo R. Napoleão de Barros, 754, 04024-002 São Paulo - SP/Brasil, Tel./Fax: (55 11) 5576 4430 - São Paulo - SP - Brazil
E-mail: actapaulista@unifesp.br