The Effect of Incarceration on Tuberculosis Treatment Outcomes in Brazil: a Retrospective Cohort Study

Abstract

Background: Tuberculosis notifications in Latin American prisons have more than doubled over the past two decades; however, treatment outcomes and their determinants among incarcerated individuals in this region are not well understood. Methods: Newly diagnosed drug-susceptible tuberculosis cases reported to Brazils Sistema de Informação de Agravos de Notificação (SINAN) between January 2015 and December 2017 were included. Multivariate logistic regression was used to assess socioeconomic and clinical factors associated with treatment success among incarcerated individuals. Results: Incarcerated individuals (n=17,776) had greater treatment success than non-incarcerated individuals (n=160,728; 82.2% vs 75.1%, p<0.0001), including after adjusting for demographic and clinical risk factors (adjusted Odds Ratio [aOR]: 1.27; 95% CI: 1.19-1.34). These differences were partially mediated by increased use of directly observed therapy among incarcerated individuals (DOT) (61% vs 47%, p<0.001), which was associated with greater efficacy in the incarcerated population (aOR 2.56 vs aOR 2.17; p<0.001). DOT was associated with improved treatment success among incarcerated subpopulations at elevated risk of poor outcomes. Conclusion: Tuberculosis treatment success among incarcerated individuals in Brazil is higher than non-incarcerated individuals, but both fall below WHO targets. Expanding the use of DOT and services for socially and medically vulnerable individuals may improve outcomes in carceral settings.