Jorge Alave, MD

GHES LMIC Fellow 2014-2015

US Institution: Yale University

Project Title: Factors associated to antituberculosis treatment adherence among Peruvian Prisoners

Peru has one of the highest TB incidence rates in the Americas and is among the 22 countries accounting for 80% of the new TB cases worldwide. TB cases are concentrated among prisoners due to crowding and disproportionate numbers of HIV-positive individuals at risk for TB who enter from the community. In South America’s largest prison (census=9,500), ~600 new TB cases are diagnosed annually using passive screening methods. Of these, >40% are recurrent TB cases (inadequately treated) and ~5% have documented MDR/XDR TB, suggesting that non-adherence and default from treatment contribute to these poor outcomes. Moreover, data suggest that prisoners with TB who are released from prison are likely not to complete therapy, therefore contributing to increased rates of default and non-adherence.

The specific aims of this project are: 1. To determine the adherence levels to TB treatment among prisoners with TB in Peru and examine the individual and structural correlates of optimal (>90%) and perfect (100%) adherence in a setting with DOT is provided. 2. Using mixed methods, to explore the factors associated with transition to the community for prisoners with TB who have not completed treatment within prison. After completion of the structured survey, participants will undergo an exploratory qualitative assessment exploring in more detail themes that may contribute to default after release, including the patient’s understanding of TB as a disease, the importance of TB treatment, contribution of default to drug-resistance, as well as facilitating factors that may assist in TB treatment completion such as social support, distance from community treatment centers, TB-related stigma, etc. For individuals with substance use disorders, exploration of possible treatments (e.g., naltrexone for alcohol use disorders) will be explored. Technology-based facilitators (e.g., cell phone reminders, GIS, eCaps) will also be explored. Together this information will be used to create an intervention to improve TB treatment outcomes for prisoners in Peru, where TB disproportionately affects the health of the country.