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Background: High HIV prevalence is an ongoing challenge in Zambian correctional facilities. To provide inmates with the benefits of treatment as prevention (TasP), generate evidence to tailor universal test and treat (UTT) in correctional settings, and coordinate tuberculosis screening among HIV-infected inmates, we launched a UTT implementation research study at Lusaka Central (LC), one of Zambia''s largest correctional facilities. We present interim findings here.
Methods: We offered immediate ART to inmates with newly diagnosed HIV or previously diagnosed HIV not yet on ART, regardless of CD4 or WHO stage. To enable UTT, we strengthened the LC health system by: training corrections officers and health workers; hiring a study nurse and clinician; and supporting routine HIV testing services (HTS) and viral load (VL) testing. To evaluate impact, we strengthened routine data systems, and prospectively collected data along the HIV cascade for a cohort of HIV-positive inmates consenting to immediate ART.
Results: From June?December 2016, 1,662 inmates were offered and 1,413 (85.0%) accepted HTS; 198 (14.0%) were found HIV-infected [177 men (89.4%), 21 women (10.6%)]. 172 (86.9%) were referred to the study for immediate ART with 149 (86.6%) meeting study eligibility criteria; 149 (100%) enrolled and 149 (100%) started ART [135 men (90.6%), 14 women (9.4%)] within 1 day (IQR:1-5 days). Mean age was 33.2 years (sd:7.8 years). Median baseline CD4 was 284 cells/mm3 (IQR:191-401). Prior to ART, 144 (96.6%) inmates underwent TB screening, 7 were diagnosed with tuberculosis by Xpert and 3 clinically; all 10 (100%) started anti-tuberculosis treatment. After 5 months, 88 (59.1%) inmates receiving immediate ART remained in study follow-up and 61 (40.9%) had been released or transferred, with non-significantly more women (n/N=9/14, 64.3%) than men (n/N=79/135, 58.5%) retained in the cohort (p=0.68). Of 13 inmates with VL testing after ≥3 months on ART, 11 (84.6%) were suppressed (VL≤40 copies/ml).
Conclusions: Implementing UTT within a large correctional facility resulted in high uptake of HTS and immediate ART for inmates with advanced immunosuppression, and facilitated tuberculosis screening, diagnosis and treatment. Logistical complexities posed by the Zambian correctional setting, including frequent inmate transfer and release, threaten to interrupt the HIV care continuum for HIV-positive inmates.

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