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The syndemics of addiction, HIV and TB are concentrated in criminal justice settings (CJS). HIV and TB contribute most to mortality among the ~50-60 million people who transition through prisons annually. Malaysia has the highest HIV prevalence among people who inject drugs (PWIDs) in Asia where criminalization of drugs is harsh, resulting in the highest HIV prevalence among prisoners and the second highest incarceration rate in Asia. While mortality decreased 39% in Asia, it has increased in Malaysia where treatment of HIV and TB are inadequately treated among PWIDs, especially in prisoners.

Over the past 10 years, researchers at Yale University and the University of Malaya have continuously collaborated on research involving key populations, including PWIDs, prisoners, MSM and both female and transgender sex workers. Our research has multidisciplinary at the interface of addiction and infectious diseases like HIV, TB, HCV and sexually transmitted infections. Our research has been supported through funding for a number of pre- and post-doctoral students and junior faculty members through our Fogarty-sponsored Global Health Equity Scholars program, Doris Duke Charitable Global Health Training, Fulbright scholarships and through NIDA-sponsored research grants. Project Harapan II builds upon past studies and these collaborations.

The specific aims of this study are:

1) To conduct empiric studies of TB, including:

a) TB diagnostics (symptoms, CXR, TST, AFB smear, Gene Xpert, and sputum culture) to optimize TB screening

b) a RCT of TB prevention strategies among HIV+ and HIV- prisoners comparing a 12-week short-course of once-weekly isoniazid/rifapentine vs a standard 40-week course of daily isoniazid in a population with high HCV prevalence and potential for hepatotoxicity

c) a RCT of HIV= and HIV- prisoners with TB who have insufficient time to complete treatment within prison and comparing treatment completion rates for those who refuse OAT with those who accept it, but who are randomized to methadone or buprenorphine therapy to facilitate continuity of care post-release

2) To use data from aim 1 combined with publicly available TB data to conduct agent-based modeling for comparative and cost- effectiveness analyses of TB screening, prevention and treatment strategies among prisoners with and without HIV, incorporating the contribution of latent TB infection and prevalent TB disease on community transmission post-release.

Funding Provided by: 
National Institute on Drug Abuse (NIDA)

Project Period: 
2016 - 2021

  • Professor of Medicine (Infectious Diseases) and of Epidemiology (Microbial Diseases); Affiliated Faculty, Yale Institute for Global Health; Director, Yale Center for Clinical and Community Research, Department of Medicine; Director, HIV in Prisons Program; Director, Community Health Care Van; Academic Icon Professor of Medicine, University of Malaya-Centre of Excellence for Research in AIDS (CERiA)

    Frederick (Rick) L. Altice is a professor of Medicine, Epidemiology and Public Health and is a clinician, clinical epidemiologist, intervention and implementation science researcher at Yale University School of Medicine and School of Public Health. Dr. Altice’s primary research focuses on interventions and implementation science at the interface between infectious diseases and addiction and he has conducted research in several global health settings. He also has a number of projects working in the criminal justice system, including transitional programs addressing infectious diseases, medications for opioid use disorder (methadone, buprenorphine, extended release naltrexone), mental illness, homelessness and social instability. Specific topics include alcohol, opioid, stimulant and nicotine use disorders on HIV treatment outcomes, HIV and addiction treatment, interface with the criminal justice system, and pharmacokinetic drug interactions between treatment for substance use disorders and antiretroviral and tuberculosis therapy. At a basic level, his research focuses on clinical epidemiology, especially in key populations at risk for HIV (e.g., MSM, TGW, PWID, prisoners, sex workers) and development, adaptation and evaluation of of biomedical and behavioral interventions to improve treatment outcomes. His research, however, has evolved and included development and testing of mobile technologies (mHealth) to intervene with key populations to promote health outcomes.  His research is especially concentrated in health services research techniques with a focus on implementation science, seeking to introduce and scale-up evidence-based interventions in numerous contexts. A number of implementation science strategies are underway to examine scale-up of medication-assisted therapies to treat opioid use disorder in community, criminal justice and in primary care settings. Most recently, his work has been augmented through use of decision science techniques to understand and promote patient preferences, including the development of informed and shared decision-making aids. His work has emerged primarily with a global health focus with funded research projects internationally in Malaysia, Ukraine, Moldova, Armenia, Kyrgyzstan, Peru, and Indonesia. He has participated in projects through the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, Centers for Disease Control and Prevention, Substance Abuse and Mental Health Services Agency, Special Projects of National Significance with HRSA, and the Center for Substance Abuse Treatment. He is currently also collaborating on projects with the WHO, UNAIDS, USAID, PEPFAR and UNODC. Current internationally funded projects in dedicated research sites that are being conducted in Malaysia, Ukraine, Moldova, Azerbaijan, Armenia, Kyrgyzstan and Peru. His research and training sites in Malaysia (2005), Peru (2010) and Ukraine (2005) are dedicated training and research sites for the Global Health Equity Scholars Fogarty Training Program and the Doris Duke International Fellowship program. He is currently the director for two International Implementation Science Research and Training Centers with collaborations between Yale University and the University of Malaya and Sichuan University.
  • Project Coordinator

    Ahsan Ahmad is a Research Associate at the Department of Medicine, Section of Infectious Diseases, AIDS Program at the Yale School of Medicine and a visiting Research Associate at the Centre of Excellence for Research in AIDS (CERiA), at University Malaya, Faculty of Medicine, in Kuala Lumpur, Malaysia. Currently, he is managing a 5-year grant from the National Institute on Drug Abuse (Grant#: 1R01DA041271) examining addiction, HIV, and tuberculosis in the Malaysian criminal justice setting.  His current work is on the nexus of infectious disease epidemiology, substance use and addiction, prison and detention health, migrant health, human rights, and drug policy in Southeast Asia. Serving as the Program Director for the All-Party Parliamentary Group for the Reform of Prisons and All Places of Detention (APPG) Secretariat, and the founding Secretariat for the Malaysian Alliance for Drug Policy Reform at CERiA, a think tank of multi-sector leaders and influencers researching and advocating for evidence-based drug policy—funded by Open Society Foundations, and supported by national and international agencies—his work demonstrates strategic investment in data-driven, evidence-based health policymaking in the region. Ahsan also explores disproportionate sentencing in relation to drug crimes in the wider area of criminal justice policies on drugs, with particular focus on drug threshold quantities, prisons, and the death penalty in Southeast Asia at the Death Penalty Research Unit, at the Faculty of Law, at Oxford University.
  • Assistant Professor of Medicine (AIDS); Affiliated Faculty, Yale Institute for Global Health

    Jeffrey Wickersham is Assistant Professor of Medicine in the section of infectious diseases.  His research is focused on improving HIV treatment and prevention outcomes among sexual and gender minorities, including transgender women, gay men, and bisexual men.  Dr. Wickersham's research has focused on development of biomedical and behavioral interventions, including peer/patient navigation, implementation of pre-exposure prophylaxis (PrEP) for HIV prevention, development of artificial intelligence-based "chatbot" technology to improve uptake of HIV testing, and adaptation of mHealth applications for transgender women to scale-up HIV testing and linkage to PrEP services. Most of this research is being conducted in Southeast Asia, primarily at sites in Malaysia and Thailand.Active ResearchIntegrated online-to-offline (O2O) model of care for HIV prevention and treatment among men who have sex with menGrant No:  R34 MH128114-01A1Online HIV self-testing (HIVST) with virtual e-counseling provides an innovative approach to improving and retaining individuals in regular HIV testing. This study combines online HIVST with a novel online-to-offline intervention to improve post-testing linkage to prevention care (HIV-) and treatment (HIV+) among MSMStrengthening the HIV care continuum for transgender women living with HIV in MalaysiaGrant No:  R21 MH128114-01A1This study aims to improve HIV treatment outcomes among transgender women in Malaysia by adapting an evidence-based peer navigation program. The award leverages dyadic data analysis to explore the unique peer-patient relationship and its impact on HIV treatment outcomes.Gamification to enhance engagement in HIV prevention and co-morbid conditions in YMSMGrant No:  R21 AI167773-01A1This award leverages gamification through an evidence-based smartphone application to engage young men who have sex with men in HIV testing and HIV prevention interventions.Developing an Artificial Intelligence Chatbot to Promote HIV Testing Grant No:  R21AI152927This NIAID-funded R21 focuses on the development and evaluation of an artificial intelligence-based "chatbot" application to improve uptake of HIV testing among men who have sex with men (MSM), including gay and bisexual men, in Malaysia.  The project will leverage machine learning technology to create an adaptive and resourceful tool that links and retains vulnerable, high-risk MSM in routine HIV testing and prevention services.Improving HIV testing and PrEP for transgender women through mHealthGrant No:  R21AI157857This multiple PI award (Yale: Jeffrey Wickersham; UConn: Roman Shrestha) aims to adapt and evaluate the feasibility and acceptability of a mHealth smartphone application to improve HIV testing uptake and retention, as well as facilitate linkage to PrEP, for transgender women in Malaysia. The selected application will include a clinician's portal that can empower smaller, community-based health care providers to engage with transgender patients and facilitate continuity of care.