Lakhasly

Study setting

Central Jail, Aizawl is the largest prison in Mizoram state.Inmates with radiographical signs suggestive of tuberculosis, such as mediastinal/hilar lymphadenopathy, consolidation seen as opacity in a segmental or lobar distribution, cavitation, pleural effusion, segmental or lobar atelectasis, lobar hyperinflation, mucoid impaction, postobstructive pneumonia, and/or randomly distributed diffuse nodules, were examined by the prison doctor and referred to DTC for initiating treatment.Proportions were calculated for pre-intervention socio-demographic, behavioral and clinical characteristics of prison inmates; post-intervention tuberculosis/HIV proportions, including bacteriological confirmed tuberculosis (based on sputum microscopy and/or CBNAAT), clinically diagnosed tuberculosis (based on chest radiography), HIV positive and HIV-tuberclosis coinfection.Intensified screening, done over two days, included a clinical examination by the prison medical officer, tuberculosis and HIV risk assessment by the counselors, tuberculosis symptom screening (cough>2 weeks, fever>2 weeks, significant weight loss, hemoptysis and night sweat) and collection of two sputum samples (spot and early morning) from presumptive tuberculosis cases by the nurse, chest radiography of presumptive tuberculosis cases by x-ray technician and opt-out HIV testing by the laboratory technician.The prison doctor referred all tuberculosis suspects either to the Designated Microscopy Centres (DMC) at Kulikawn Tuberculosis Unit, 10 kilometres from the prison, or to the District Tuberculosis Centre (DTC) at State Referral Hospital, Falkawn, 30 kilometres from the prison, for diagnosis and follow-up.Review of tuberculosis risk factors and symptoms, HIV test results, interpretation of chest radiography, sputum smear microscopy and Cartridge Based Nucleic Acid Amplification Test (CBNAAT) results were completed in 4-5 days.The smear was prepared using the yellow purulent portion of the sputum with stepwise addition of 1% carbol fuchsin, 25% sulphuric acid and 0.1% methylene blue as per standard operating procedure.Sputum samples of HIV positive inmates, collected in falcon tubes, were sent for CBNAAT (Cepheid) to DTC, Falkawn.Data collection

Trained investigators used structured questionnaire in Mizo language to collect information on socio-demographics and TB/HIV-related risk assessment from the inmates.The prison had provision for a medical inspection room, with a doctor, three nurses, pharmacist, laboratory technician, three male inmates designated as medical assistants, and one female inmate designated as laboratory assistant.HIV counseling and testing was provided through mobile unit of integrated counseling and testing centre (ICTC) that visited the Central Jail once in three months.Inmates reactive to the first HIV test were confirmed when the mobile ICTC counselor and laboratory technician visited the Central Jail once every week during the study period.The tests were based on the development of color bands within 20 minutes of adding 20 microlitres of blood and the diluents to interpret the results as non-reactive or reactive for HIV 1/2 antibodies.The technician mixed 2-5 ml sputum sample with 8 ml sample reagent followed by incubation at room temperature and loading of the cartridge with 2 ml mixed sample into the genexpert.The test was performed for the second time only if the test results were "invalid" or "Rif Indeterminate". The test was repeated on the same sample after trouble shooting (as per the user manual) in case of "errors" or "no results".Furthermore, the prison officials ensured that none of the inmates would be penalised in any manner in case they did not wish to participate in the screening and continued to receive all medical services as needed.Inmates detected HIV positive were counselled by the mobile ICTC counsellor at the prison site.

Study setting

Central Jail, Aizawl is the largest prison in Mizoram state. The prison capacity is 545 inmates, including 456 males and 89 females. The prison had provision for a medical inspection room, with a doctor, three nurses, pharmacist, laboratory technician, three male inmates designated as medical assistants, and one female inmate designated as laboratory assistant. Inmates who voluntarily sought care were managed based on the presenting signs and symptoms. There were no facilities for sputum examination and radiography. The prison doctor referred all tuberculosis suspects either to the Designated Microscopy Centres (DMC) at Kulikawn Tuberculosis Unit, 10 kilometres from the prison, or to the District Tuberculosis Centre (DTC) at State Referral Hospital, Falkawn, 30 kilometres from the prison, for diagnosis and follow-up. There was no separate ward in the prison to isolate tuberculosis patients. Supply of anti-tuberculosis drugs was inconsistent. Mizoram State AIDS Control Society provided the facility for routine HIV screening inside the prison. HIV counseling and testing was provided through mobile unit of integrated counseling and testing centre (ICTC) that visited the Central Jail once in three months. Inmates were referred to Civil Hospital, Aizawl for HIV confirmatory test and antiretroviral treatment (ART). There was provision for one ambulance and on any given day only two inmates could be transported at a time to government health institutions in Aizawl city.

Implementation strategy

We did ‘entry screening’ of new inmates, ‘mass screening’ of inmates residing within the prison (serving their sentence before the beginning of the study), and ‘exit screening’ of those released from the prison without mass screening during April-July 2017. Intensified screening, done over two days, included a clinical examination by the prison medical officer, tuberculosis and HIV risk assessment by the counselors, tuberculosis symptom screening (cough>2 weeks, fever>2 weeks, significant weight loss, hemoptysis and night sweat) and collection of two sputum samples (spot and early morning) from presumptive tuberculosis cases by the nurse, chest radiography of presumptive tuberculosis cases by x-ray technician and opt-out HIV testing by the laboratory technician.

Inmates reactive to the first HIV test were confirmed when the mobile ICTC counselor and laboratory technician visited the Central Jail once every week during the study period. HIV screening was done using Meriscreen HIV1/2 WB (whole blood) testing kit. Tests showing reactive results were then confirmed using Comb AIDS RS Advantage HIV-1 and Signal Flow HIV-1 testing kits. The tests were based on the development of color bands within 20 minutes of adding 20 microlitres of blood and the diluents to interpret the results as non-reactive or reactive for HIV 1/2 antibodies. The test was considered as invalid if no band appeared on Control Line or the band appeared only on Test Line.

Sputum samples were taken for smear microscopy to DTC, Falkawn by the project staff. The smear was prepared using the yellow purulent portion of the sputum with stepwise addition of 1% carbol fuchsin, 25% sulphuric acid and 0.1% methylene blue as per standard operating procedure. Project staff collected the results from DTC after two-three days.

Sputum samples of HIV positive inmates, collected in falcon tubes, were sent for CBNAAT (Cepheid) to DTC, Falkawn. The technician mixed 2–5 ml sputum sample with 8 ml sample reagent followed by incubation at room temperature and loading of the cartridge with 2 ml mixed sample into the genexpert. Four samples could be analysed at one time. It took two hours to complete one cycle. The test was performed for the second time only if the test results were “invalid” or “Rif Indeterminate”. The test was repeated on the same sample after trouble shooting (as per the user manual) in case of “errors” or “no results”. Results were collected by the project staff after one week.

Digital radiography machine was used for chest radiographs. Two views of the chest were taken, one by positioning the inmate in a way that the chest was pressed against the image plate with hands on hips and for the second view, the inmate’s side was pressed against the image plate with arms elevated. Inmates who were unable to stand were made to lie down on the table. The inmates were instructed to not move until the procedure was complete in order to minimize the chances of blurring. Results were recorded on a detector and were displayed in a digital format on a computer screen. The same were printed on radiograph films and sent to the radiologist for reading and reporting twice a week. The reports were collected after two-three days by the project staff. Inmates with radiographical signs suggestive of tuberculosis, such as mediastinal/hilar lymphadenopathy, consolidation seen as opacity in a segmental or lobar distribution, cavitation, pleural effusion, segmental or lobar atelectasis, lobar hyperinflation, mucoid impaction, postobstructive pneumonia, and/or randomly distributed diffuse nodules, were examined by the prison doctor and referred to DTC for initiating treatment.

Review of tuberculosis risk factors and symptoms, HIV test results, interpretation of chest radiography, sputum smear microscopy and Cartridge Based Nucleic Acid Amplification Test (CBNAAT) results were completed in 4–5 days. Testing was done as per the tuberculosis diagnostic algorithm of India’s tuberculosis control program and HIV testing guidelines of National AIDS Control Organisation (NACO) [34, 35]. Inmates detected HIV positive were counselled by the mobile ICTC counsellor at the prison site. Their blood samples were sent to Civil Hospital, Aizawl for investigations prior to initiating ART and results were informed on the same day to the prison doctor. HIV positive inmates were referred to the Civil Hospital, Aizawl for further counselling, registration and initiation of ART.

Data collection

Trained investigators used structured questionnaire in Mizo language to collect information on socio-demographics and TB/HIV-related risk assessment from the inmates. Structured case forms were used to document clinical characteristics and laboratory results.

Data management and analysis

Data entry was done using Epi-Info 7.2.2.6 generated formats. Proportions were calculated for pre-intervention socio-demographic, behavioral and clinical characteristics of prison inmates; post-intervention tuberculosis/HIV proportions, including bacteriological confirmed tuberculosis (based on sputum microscopy and/or CBNAAT), clinically diagnosed tuberculosis (based on chest radiography), HIV positive and HIV-tuberclosis coinfection. SPSS was used for data analysis.

Ethical considerations

Participation in the study was voluntary. The inmates had the option of not getting screened. Written informed consent were obtained from all study participants. Identities of the inmates who did not participate were not revealed to the prison officials. Furthermore, the prison officials ensured that none of the inmates would be penalised in any manner in case they did not wish to participate in the screening and continued to receive all medical services as needed. The protocol was approved by Institutional Ethics Committee, Civil Hospital, Aizawl. Approvals were obtained from the Mizoram State AIDS Control Society, Department of Health & Family Welfare, Department of Hospital & Medical Education, Inspector General of Prisons and the Atomic Energy Regulatory