Curbing the spread of HIV through prisoner partner notification
Culbert explores curbing spread of HIV in Indonesian prisons
Could the path to curbing the spread of HIV in Indonesia run through its prisons?
UIC College of Nursing associate professor Gabriel Culbert, PhD ’12, BSN ’04, RN, is exploring this question with a $3 million grant from the NIH. Agung Waluyo, PhD ’11, a professor at the University of Indonesia who is a UIC Nursing alumnus, is co-principal investigator on the grant.
The first-of-its-kind program, called Impart, uses health workers to confidentially notify and offer HIV testing to partners of HIV-positive prisoners in eight prisons in Indonesia.The program helps contact the partners of inmates who are outside of prison – those who shared an exposure, such as sex or needle-sharing, before incarceration, Culbert says.
“I’m a believer that the intervention has the potential to offer people longer and more fruitful lives,” Culbert says. “Unfortunately, in Indonesia and many other countries, partners do not always have the information they need to protect themselves from HIV or get into treatment if needed.”
The number of Indonesian adults and children with HIV is estimated at more than half a million. In 2023, an estimated 24,000 new infections occurred and 26,000 people lost their lives due to AIDS-related illness.
Indonesia, which is the fourth largest country in the world, is one of a few countries that provides universal HIV treatment to its citizens. However, an estimated one-third of people with HIV are undiagnosed, Culbert says.
“Partner notification is gradually being adopted in lots of countries but … no one has ever done this in prison or jail or other criminal legal settings, which is shocking when you think about how much more important it is in prisons,” Culbert says. “[Prisons are where many] people are being diagnosed, and where the prevalence of HIV is several times higher [than the general population].”
Expanding on pilot program success
In its pilot phase, the program led to a sixfold increase in notification of inmates’ drug and sex partners. Half of those notified also received HIV testing, and one-third of those tested were diagnosed as HIV-positive for the first time.
“Most partners were wives and other women, and that’s important because they are the new face of the epidemic in Indonesia,” Culbert says. “In Indonesia, many new infections are found among women whose only risk factor is that they’re in a relationship with a male partner who injects drugs or has sex with other partners of the same or opposite sex.”
The new grant will allow Culbert and Waluyo to expand on the success of the pilot program and bring it to a much larger scale, while also looking at how to sustain the program for the future. They are partnering with one of Indonesia’s most well-established non-governmental organizations, Yayasan Pelita Ilmu Foundation. Already providing HIV services, this program will bring field workers into the prison system.
Waluyo says there is stigma around sex work, drug use and other high-risk behaviors in Indonesia, which makes it difficult to prevent or address the spread of HIV. Many of the behaviors that lead to HIV transmission are criminalized, making a prison-based system even more important. There are about 270,000 prisoners in Indonesia.
“Because they are performing high-risk behaviors, it is not easy for them to get access to health services,” Waluyo says. “These key populations – like men who have sex with men, sex workers, and drug users – have been discriminated against and isolated from the community.”
Waluyo says another problem is a lack of continuity between the Indonesia’s Ministry of Law and Human Rights, which runs the prisons, and the Ministry of Health. Someone who is receiving regular health checks and treatment in prison is not seamlessly referred to regular health checks or treatment outside of prison and vice versa.
“This study is helping to connect the dots between these two ministries,” Waluyo says.
The study will involve key stakeholders at different levels of government and non-government organizations to try to make it sustainable after the grant ends, Culbert says.
Global implications
Culbert says the program could be adopted by other countries looking for a national HIV prevention strategy. It’s one of the few interventions that cuts across key populations within the HIV epidemic: sex workers, people who inject drugs, people in prison and partners of prisoners.
“We’re focusing on HIV and Indonesia currently, but what we’re doing could be adapted for other diseases and other countries,” Culbert says.
Further, he says the pilot showed that the program has the potential to be very effective at identifying people who don’t know they have HIV and getting them into treatment.
“Many people have been working a long time to understand how to find people with undiagnosed HIV,” Culbert says. “That’s not just a question in the U.S. Every country wants to know how to identify people who do not know that they’re infected, and that’s what this intervention does.”