 Thank you to the organizers to allow me to present the work of MSF in Malawi Prisons. Before getting into the abstract itself, I will just introduce a bit what is the context in Malawi Prisons to give you an understanding of where we work. So Malawi Prisons are characterized by a lack of hygiene and inadequate sanitation. They have a very poor ratio of latins and showers per prisoners, which can cause a lot of diarrheal and skin diseases. It has a big overcrowding. Some prisons have more than 340% of their capacity with a poor ventilation, which increases the risk of TB and respiratory infections transmission inside prison cells. This is a typical sale of Malawi Prisons, where there should be only 20 prisoners, but they are more or less 60 prisoners at the time. They sleep by floor, and they have no space in between each other. The normal Mandela rules establish that every prisoner should have square meters, but this is not the case in Malawi Prisons. This small graph is just to show a mathematical modeling that we did last year in prisons, particularly in Malawi Prisons, where we could see that the congestion in relation to TB risk of transmission is relatively high in prison. The black dotted line is the prevalence in Malawi Prisons by then 0.71%. So with the congestion of 340% and prisoners staying over a year in prison, we expect at least 198 new cases of TB in prison. At the same time, it is challenging in regards of treatment that they receive, internal dynamics, different power games inside prison that can cause violence. There is an inadequate nutrition, which represents malnutrition and vitamin deficiencies like pellagra. That's the meal that they receive once a day per day is based in enceema, which is a maize paste, and sometimes they receive beans as well. So MSF is working currently in two prisons in Malawi. But normally there are three big prisons that represent 50% of the population of Malawi Prisons, which is around 15,000. So we are working in Lillongwe, in Maula Prison, where it has a capacity of 800 prisoners. But normally it holds more than 2,700 prisoners. And the HIV prevalence that we have found in this prison is 14.2%, which is more or less in relation to the prevalence in Lillongwe city. In Chichiri prison, it's in the southern region of Malawi, where it has a capacity of 500 to 600 prisoners. But it holds 1,870 prisoners, where the HIV prevalence is around 22.5%. In relation with plantar prevalence, which is higher in the southern part of Malawi. So what we have been doing in the last four years, from 2014 to 2017, is introducing a three-phase model of screening and model of care, which is based in the southern African development communities model. Where we test and screen prisoners at entry, stay, and exit. And we do it for HIV, TB. We do symptomatic screening, followed by gene expert, or sputum microscopy. We do STI testing, syphilis rapid test, hepatitis B vaccination, and nutrition assessment for body mass index. We do the same at STI, but for the STI we do two big mass screenings per year, where we go cell by cell and we do the same testing. And we offer as well counseling and patient support. And at the same time, we support the clinic in prison, where we have human resources and medication that we provide additionally. And we do the same package at exit before prisoners go out from prison. This is a bit of the result that we have during the time of the intervention before getting into the TB screening package. So from 2014 to 2017, in both prisons, we have improved the testing for prisoners when they are coming into prison. And the initiation has increased. But we have some challenges in regards to bio-load in Maula prison during 2017 because of some challenges of the machine. But overall, the bio-load and detectability is almost 89% to 92% above prisons. The ART initiation among newly diagnosed prisoners has decreased over time. At the beginning, it was taking more than 60 to 70 days to initiate patients on treatment after they've been tested positive. Nowadays, we are having only a few days before the initiate treatment. The aim of our study in prison was to assess how TBK's finding changed over time from 2014 to 2017 and determine the factors associated with developing TB disease while prisoners are in prison. So we started in 2014 with symptomatic screening, the classical WHO symptoms. In 2015, we added GeneXpert as an additional screening tool. And in 2017, during the big mass screening, we added some mobile X-ray machine, collaboration with a partner called Challenge TB, where we included the mobile X-ray with digital and reading by clinicians for the assessment of TB. So this is a retrospective analysis of data from the team collected data from 2014 to 2017. Case notification rate was calculated for new cases, as reported as never being treated previously. To determine the person's time at risk, we used a sum of monthly inmate count excluding TB treatment for incident cases. And we used a three-month cut-off to separate prevalent cases from entry cases with incident cases, which are more than three months in this case. And we applied a multivariate logistic regression to assess factors associated with the development of TB. This analysis made the criteria of the MSF ERB for exemption. So we have seen that from 2014 to 2017, the TB case notification has increased substantially. From 2014 in Maula prison, we had 430 over 100,000 prisoners. And in 2017, with the additional screening method, we are at 4,621. And similarly to Chichiri from 430, we came to 3,346. And that compared to the national TB estimated incidence, which is 192 over 100,000 persons per year. In regard to patient characteristics from 2014 to 2017, we notified 468 TB cases. Out of them, 63 or 13.5% had exapulmonary TB. 464 were males, which represents 99%. And the median age was 32 years old. TB HIV co-infection is relatively high in Malawi. In prison, it's the same case. We have 46%, which represents 113. And prisoners having a body mass index less than 18.5%, represents 21%. What risk factors are associated with developing TB in prison? Out of the 17,000 prisoners that were assessed, 80%, which is 376 out of 468, had TB after three months into entering into prison. So incidence in prison is high. That means that transmission is happening inside prison, as I explained in the initial slides. So all the prisoners that have been diagnosed as TB initiated treatment. And the risk for developing TB is associated highly with HIV at 3.8 volts compared to the HIV negative ones. The nutrition as well is an important factor, which represents prisoners having a volume of body mass index inferior at 18.5. This represents two outs radius compared to the ones having a good nutrition. And time-incalculated impression is the highest one, representing 7.1 times compared to the ones that are less than 12 months in prison. This slide is just to show the screening and lab tests that we use for TB and the progression over time, from 2014 to 2017. As I said, we started with automatic TB screening. And we had the gene expert only by 2015 and the ChSX-ray mobile digital one by 2017 only. What limitations we found in our study being a retrospective analysis, we have some data problems at the beginning of the intervention 2014-2015 that were improved from 2015 forward. There is a high turnover of prison population in prison, which represents a huge problem. There are prisoners that stay only for a short period of time. We have no conviction and they are remanded prisoners. So it is a very dynamic population. What can we conclude of our study in prison is that Malawi prisons remain a high risk setting for acquiring and developing TB in prison. And that's because of the challenges that prisoners are confronted with. So poor notation, a high congested cell, and poor ventilation. An implementation of systematic TB screening may have improved significantly the TB case finding in prison, adding the X-ray that we had in 2017. This model can be replicated in similar contexts and in similar prisons in Malawi. And we should start new strategies for preventing prisoners to develop active TB in prisons like preventive treatment that now it is available for latent TB treatment. What are the next steps for us? We have developed this toolkit, which is a basic pragmatic toolkit to start other prisons with the three phases modeling of a screening. This is a toolkit that it is used currently in the country. We have introduced to the prison health services and it is available as well online in the Southern African Medical Unit site. We are sharing our experiences with other prisons in Malawi and other organizations. So they come to our prisons where we show how this implementation is done so they can take back these to the prison. And we are working in continuous advocacy about overcrowding foods and living conditions because it's still the main challenges in Malawi. And that's the last step. We are working in a proposal for including X-ray as a screening tool for entry, stay and exit into prisons. And we are trying to as well to work in a prevention strategy for treatment for latent TB. So we are trying to do a 3-HP rifafantine isoniazid treatment for latent TB. So this proposal is ongoing as a work currently and we are going to present it to our headquarters. Thank you so much for your attention.