Modeling the potential impact of providing ART and OAT in prison and upon release on HIV incidence among PWID in Tijuana, Mexico Add other affiliations for Leo and Natasha Annick Bórquez, Daniela Abramovitz, Leo Beletsky, Steffanie A. Strathdee, Peter Vickerman, MC Boily, Natasha K Martin Division of Global Public Health, University of California San Diego Lisbon Addictions, 10/25/2017

Conflict of interest None to declare

Incarceration as an opportunity to reach PWID with health services Incarceration has been consistently associated with increased risk of bloodbourne infections among PWID1-2 Right to health in prison is an international norm WHO/UNODC recommend comprehensive package of HIV prevention, care, and support for incarcerated people2 Prisons as opportune settings to: Reach PWID with health services since low access in the community3 Start opioid agonist therapy (OAT) and antiretroviral treatment (ART), as treatment can be directly observed and monitored2-3 Quantifying the potential impact of implementing HIV and OAT interventions in prison is important to inform policy making and advocate for change Dolan K, Wirtz AL, Moazen B, et al. Global burden of HIV, viral hepatitis, and tuberculosis in prisoners 18 and detainees. Lancet 2016 Csete J. et al. Public health and international drug policy, The Lancet Commissions, 2016; 387: 1427–80 Beyrer C, et al. Prisoners, prisons, and HIV: time for reform. The Lancet, July 14 2016 Risks inside prison as less to no access to sterile syringes/condoms Risks upon release as a result of hardship (homelessness, unemployment) and regaining access to drugs

Tijuana, as case study Large PWID population (5,000-10,000) “Proyecto El Cuete IV”: cohort study following 734 PWID in Tijuana bi- annually from 2011-2020 HIV test self-reports of sexual and drug- using behaviors, policing, incarceration, and access to HIV and harm reduction services Among PWID, HIV prevalence is 3.5%, HIV incidence is 1-2%/year Access to HIV and harm reduction services is very low (<3% receiving ART or OAT)

Prison as a setting to reach PWID in Tijuana 85% and 59% of male and female PWID have ever been incarcerated Mean number of 5 (SD: 4.6) and 3 (SD: 2.7) incarcerations since starting injecting for male and female PWID, respectively Average sentence length: 4 months

Aims Use mathematical modeling to: 1) Estimate the potential impact of providing ART or/and OAT in prisons and upon release on HIV incidence among PWID in Tijuana 2) Assess the impact of also scaling up ART and OAT among PWID in the community Graph to justify aim 2: more likely to implement these services I the community than in prison according to experiences from countries which have done either or both so exploring this scenario too (even if the main aim of this study is to explore the use of prisons as settings to link PWID to health services Source: Csete J. et al. The Lancet Commissions, 2016

Methods Dynamic, deterministic compartmental model of HIV transmission among PWID Injecting and sexual transmission Disaggregated by sex, incarceration stage, OAT and HIV stage including ART Varied parameters associated with demography, incarceration patterns and HIV transmission Fitted to data on HIV prevalence and incidence using Latin Hypercube Sampling and resampled best fitting simulations

Intervention scenarios ART OAT Prison and release Community Scenario 1 Scenario 2 Scenario 3 Scenario 4 Coverage of ART/OAT in the “community scenario” varies because I use a rate and it translates into different coverages depending on the epidemic projection. These are not the exact min and max, will provide these.

Intervention characteristics ART OAT Prison Community Efficacy 30%-75% reduction in sexual and injecting transmission 54%(33%-68%) reduction in acquisition through injecting Drop out rate 0/year 0.2/year 1/year Coverage S-1 100% declines 0% Coverage S-2 Coverage S-3 Coverage S-4 45-55% 20%-30%

Model diagram: Scenario 1 Scenario 2 Scenario 3 Scenario 4 Never Incarcerated Recently Incarcerated Not Recently Incarcerated Prison Off OAT On OAT Off ART On ART

Proportion of new HIV infections averted among PWID in Tijuana from 2018 to 2030 through providing ART or/and OAT in prison and upon release. Mean: 45.8% Mean: 30.1% Mean: 20.2% Mean: 18.5%

Conclusions Prisons could provide a valuable opportunity for initiating PWID on to HIV and drug treatment in Tijuana Nearly a third of new HIV infections could be averted between 2018-2030 through the provision of ART and OAT in prison, conditional on linkage upon release. Substantial (although still suboptimal) scale up of ART and OAT in the community would further curb the epidemic by preventing nearly 50% of new HIV infections

Limitations and future work Self reported behaviors Model’s capacity to reproduce epidemic dynamics Future work should examine: Explore feasibility of implementing these services in prisons in Tijuana through qualitative interviews with previously incarcerated PWID, health care providers in prison and decision makers. Explore synergies between OAT and ART adherence and incarceration rates Evaluate cost-effectiveness Bayesian sensitivity

Acknowledgments Thank you! Funding: -NIDA U.S.-Mexico drug abuse prevention research fellowship -UC-MEXUS CONACyT postdoctoral fellowship -UC San Diego Center for AIDS Research (NIAID P30 AI36214) -NIDA grant R01 DA0 19829 -NIDA grant R01 DA037773-01A1 Patty González Zúñiga Kenya Lazos All the participants of El Cuete study Thank you! Pictures from “Tomorrow is a long time: Tijuana’s unchecked HIV/AIDS epidemic” by John Cohen and Malcom Linton

Extra slides

Model fitting:

Modeling Analysis: Never incarcerated Prison 2012 2017 Baseline Never incarcerated Prison Recently incarcerated (< 6 months ago) Previously Incarcerated (> 6months ago) Number of new HIV infections Reproduce observed trends Simplified cohort model used to estimate: -Proportion ever incarcerated when starting injecting -Primary incarceration rate RR HIV RR HIV