The goal of this interventional study is to evaluate three tuberculosis (TB) screening and prevention strategies in prisons in Paraguay. The main questions it aims to answer are:

• Which strategy is more effective for reducing the incidence rate of active TB?
• Which strategy is more effective for reducing the TB infection rate?
• Are these strategies safe, feasible, and cost-effective in prison settings?

Researchers will compare three cluster-based, non-randomized programmatic strategies implemented in three prisons. These strategies differ in the frequency of screening, the diagnostic methods used, and the approach to tuberculosis preventive therapy (TPT).

Participants will:

• undergo informed consent and clinical evaluation
• receive TB screening through symptom assessment, chest digital X-ray with CAD, and rapid molecular testing, depending on site strategy
• undergo IGRA testing and preventive therapy assessment, depending on the assigned strategy
• be followed for 18 months, with screening rounds every 6 months or annually depending on the prison

Inclusion Criteria:

1. Be a person deprived of liberty (PDL) residing in one of the participating penitentiary centers during the study period.
2. Be 18 years of age or older at the time of enrollment.
3. Be present in the penitentiary facility at the time of a screening round or enter the facility during the study period.
4. Provide informed consent to participate in the study.

Exclusion Criteria:

1. Are currently undergoing treatment for active tuberculosis at the time of the screening round.
2. Have a medical condition that, in the opinion of the clinical staff, prevents the safe performance of the planned diagnostic procedures.

Individual participant data underlying the results reported in this study will be shared after de-identification. Shared data will include demographic characteristics, incarceration-related variables, screening participation, diagnostic test results for active tuberculosis and latent tuberculosis infection, treatment initiation and completion for tuberculosis preventive therapy, and follow-up outcomes across screening rounds. Data will be provided in a coded format with removal of direct identifiers to protect participant confidentiality.

Data will be available beginning 6 months after publication of the primary study results and will remain available for 5 years following publication. Supporting documents, including the study protocol and statistical analysis plan, will be available at the time of publication.

De-identified individual participant data and supporting documents will be available to qualified researchers who provide a methodologically sound proposal. Requests must be submitted to the study investigators and will be reviewed by the study steering committee and relevant ethical oversight bodies. Data will be shared under a data use agreement that ensures confidentiality, prohibits re-identification, and limits use to the approved research objectives. Access will be provided through secure electronic transfer.