Strengthening HIV-associated Non-Communicable Disease Research Capacity to Improve the Health of People Living in Mozambican Prisons

About This Grant

Around the world, HIV concentrates in carceral settings. In Mozambique, the 12% nationwide HIV prevalence is about doubled in its prisons. If research finds pioneering programs for new areas of HIV care, such as managing non-communicable diseases (NCD), are effective in high prevalence prisons, they rapidly inform US carceral healthcare, where HIV prevalence is 1.1%. Recruiting and delivering interventions are faster when prevalence is high. Addressing HIV poses challenges to carceral systems globally due to low resources and overcrowding. Currently, the Mozambican prison system holds 2.5 times its capacity. Nonetheless, nearly all people in their prisons living with HIV know their status and take antiretrovirals. Of those treated, ~75% are suppressed. HIV care everywhere is now expanding focus to managing not just co-infections (like TB) but also HIV-associated NCDs, to prevent premature mortality. Findings from new prison programs can be scaled up for other low- and middle-income countries (LMIC) facing limited healthcare infrastructure and an HIV burden 10-20x that is found in US facilities. Years of collaboration between Emory, Servico Nacional Penitenciario or SERNAP, and the non-governmental organization Health through Walls has resulted in two TB/HIV screening studies managed by a tablet-based data management system. We will transition to the Virtu Cares Electronic Health Record (EHR). We are inviting the National Health Service, Instituto Nacional de Saude (INS), along with consultants in cardiovascular disease and health economics to join our collaboration and build up research infrastructure. Members of SERNAP's Health Service prioritized 5 NCDs: smoking, other substance use disorders (SUD), depression, hypertension (HTN), and malnutrition. We will integrate screening for these conditions into mass screenings for TB in 2026-7 and compare NCD prevalence in those with and without HIV. Over the following year, we will invite colleagues from a local university and INS to roll-out interventions to address these issues and then measure improvement. The team will compare residents living with/without HIV, while pursuing the following aims: (1) Refine the EHR, add screening for SERNAP's 5 priority NCD to HIV/TB screening, compare those with/without HIV; (2) Work with Mozambican academic/public health leaders to refine/deliver interventions to prison residents; measure readiness to change, then address in a status-neutral manner multiple NCDs: SUD via 12-step groups; smoking cessation via cognitive behavioral therapy; HTN via smoking cessation, diet, and medical management; and malnutrition, via a nutrition program; track results longitudinally; (3) Conduct follow-up, facility-wide screenings, using the EHR to measure improved NCD management; administer evaluations among staff and patients about the EHR and interventions and implementation fidelity/acceptability. We will then use the RE-AIM implementation framework to evaluate both the EHR and the status-neutral delivery of NCD interventions. We anticipate that integrating NCD/HIV management will improve prison healthcare in both LMIC and the US.