The burden of infectious disease among inmates of and releasees from US correctional facilities, 1997

Research Note — Review of Corrections-Based Therapy for Opiate-Dependent Patients: Implications for Buprenorphine Treatment among Correctional Populations

Inmates with a history of opiate dependence represent a substantial proportion of the correctional population in the United States. Opiate use has negative consequences for both the inmate and society, including increased recidivism rates, increased infectious disease prevalence, avoidable emergency room use, decreased access to primary care services, and overdose. While there have been great successes in community-based treatment of opiate dependence, these successes have not yet been achieved in correctional settings. This paper reviews the pharmacological treatment options for opiate-dependent inmates, along with potential application for community-to-correctional approaches. The recent approval by the Food and Drug Administration (FDA) of physician-prescribed buprenorphine and the new opportunities it presents to corrections-based treatment are also explored in depth. Successful implementation of such strategies is likely to result in desirable health and social outcomes for both the inmate and the community at large.

Stigma, sexual risks, and the war on drugs: Examining drug policy and HIV/AIDS inequities among African Americans using the Drug War HIV/AIDS Inequities Model

The relationship between drug policy and HIV vulnerability is well documented. However, little research examines the links between racial/ethnic HIV disparities via the Drug War, sexual risk, and stigma. The Drug War HIV/AIDS Inequities Model has been developed to address this dearth. This model contends that inequitable policing and sentencing promotes sexual risks, resource deprivation, and ultimately greater HIV risk for African-Americans. The Drug War also socially marginalizes African Americans and compounds stigma for incarcerated and formerly incarcerated persons living with HIV/AIDS. This marginalization has implications for sexual risk-taking, access to health-promoting resources, and continuum of care participation. The Drug War HIV/AIDS Inequities Model may help illuminate mechanisms that promote increased HIV vulnerability as well as inform structural intervention development and targeting to address racial/ethnic disparities.

Injectable pharmacotherapy for opioid use disorders (IPOD)

BACKGROUND

Despite the growing prevalence of opioid use among offenders, pharmacotherapy remains an underused treatment approach in correctional settings. The aim of this 4-year trial is to assess the clinical utility, effectiveness, and cost implications of extended-release naltrexone (XR-NTX, Vivitrol®; Alkermes Inc.) alone and in conjunction with patient navigation for jail inmates with opioid use disorder (OUD).

METHODS

Opioid-dependent inmates will be randomly assigned to one of three treatment conditions before being released to the community to include: 1) XR-NTX only; 2) XR-NTX plus patient navigation (PN), and 3) enhanced treatment-as-usual (ETAU) with drug education and a community treatment referral. Before release from jail, participants in the XR-NTX and XR-NTX plus PN conditions will receive their first XR-NTX injection. Those in the XR-NTX plus PN condition also will meet with a patient navigator. Participants in both XR-NTX conditions will be scheduled for medical management sessions twice monthly for months 1-3, monthly medical management sessions for months 4-6, with monthly injections for 5months post-release (which, given the pre-release injection, results in a 6-month medication phase). Follow-up data collection will occur at 1, 3, 6, and 12months post release.

RESULTS

We discuss the study's rationale, aims, methods, and anticipated findings. The primary outcome is the presence of a DSM 5 OUD diagnosis 1year after randomization (6months after the end of the active treatment phase).

DISCUSSION

We hypothesize that providing XR-NTX prior to release from jail will be particularly beneficial for this extremely high-risk population by reducing opioid use, associated criminal behavior, and injection-related disease risk. ClinicalTrials.Gov: NCT02110264.

A Qualitative Study of Substance Use and Sexual Behavior Among 18- to 29-Year-Old Men While Incarcerated in the United States

The article describes men’s perceptions of and experience with substance use and sexual behavior during incarceration. Grounded theory content analyses were performed on qualitative interviews conducted with 80 men, aged 18 to 29, in four U.S. states. Participants believed that drugs were easily available in prison. Half reported using substances, primarily marijuana or alcohol, while incarcerated. Key themes included the role of correctional personnel in the flow of substances in prison and the economic significance of substance traffic king. With regard to sexual behavior, most men acknowledged that it occurred but were hesitant to talk in-depth about it. There was a strong belief in “don’t look, don’t tell,” and sex in prison was often associated with homo sexual behavior or identity. Sex during incarceration was reported by 12 men, mostly with female partners. Participants were pessimistic about HIV/STD/hepatitis prevention efforts inside correctional facilities. These findings highlight the need for risk reduction programs for incarcerated men.

Infectious Diseases and the Criminal Justice System

The United States leads the world in incarceration, which disproportionately affects disadvantaged individuals, including those who are mentally ill, poor, homeless and racial minorities. Incarceration is disruptive to families and communities and contributes to health disparities in sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). The objective of this grand rounds is to review (1) the epidemiology of incarceration in the United States, (2) the social factors which contribute to high rates of STIs in incarcerated individuals and (3) the HIV care cascade in incarcerated and recently released individuals. Routine screening and treatment for STIs and HIV in the criminal justice system can identify many new infections and has the potential to both improve individual outcomes and reduce transmission to others. Increased collaboration between the department of health and department of corrections, as well as partnerships between academic institutions and the criminal justice system, have the potential to improve outcomes in this vulnerable population.

Male Incarceration Rates and Rates of Sexually Transmitted Infections: Results From a Longitudinal Analysis in a Southeastern US City

BACKGROUND

In the United States, rates of certain sexually transmitted infections (STIs) are increasing. Contextual factors seem to play an important role in shaping STI transmission dynamics. This longitudinal study explores the relationship between one contextual determinant of health (the male incarceration rate) and rates of newly diagnosed STIs in census tracts in Atlanta, GA.

METHODS

The sample consisted of all census tracts in Atlanta (n = 946). Annual data on STI diagnoses were drawn from the Georgia surveillance system for 2005 to 2010; annual male incarceration data were drawn from the Georgia Department of Corrections for 2005 to 2010; and data on potential confounders were drawn from the US Census. Multivariable growth models were used to examine the association between the male incarceration rate and rates of newly diagnosed STIs, controlling for covariates.

RESULTS

Census tracts with higher baseline male incarceration rates had a higher baseline rate of newly diagnosed STIs. Census tracts with increasing male incarceration rates experienced a more rapid increase in their rate of newly diagnosed STIs. Census tracts with medium and high baseline male incarceration rates experienced a decrease in their rate of newly diagnosed STIs over time.

CONCLUSIONS

The present study strengthens the evidence that male incarceration rates have negative consequences on sexual health outcomes, although the relationship may be more nuanced than originally thought. Future multilevel research should explore individual sexual risk behaviors and networks in the context of high male incarceration rates to better understand how male incarceration shapes rates of STIs.

Rasch Analysis and Differential Item Functioning of a Social Support Measure in Jail Inmates With HIV Infection

The protective effects of social support on health have been documented in a variety of groups. For HIV-infected persons released from correctional settings, strong social support may be particularly important for obtaining effective postrelease medical treatment and supportive services. Researchers and program evaluators seeking to improve access and adherence to postrelease HIV medical care in this population need accurate measures for the level and type of social support, but current measures have not been fully validated for incarcerated individuals with HIV infection. We used the Rasch model to test the Medical Outcomes Study (MOS) social support survey. Data for the analysis were collected as part of the EnhanceLink project in the five urban jails where the MOS was administered. Findings indicate that the MOS survey items may not capture the entire variability of person abilities. Respondents showed problems in discriminating among response options, indicating potential systematic bias. In addition, while there was no significant gender difference, overall levels of social support differed by gender. Further research is warranted to develop more effective social support measurement tools that can better guide interventions for persons transitioning from jail and prison to the community.

After the Fact: A Brief Educational Program on HIV Postexposure Prophylaxis for Female Detainees in a Local Jail

Women who have been in jail are at increased risk of acquiring HIV when they are in the community. Nonoccupational postexposure prophylaxis (nPEP) reduces HIV transmission following high-risk behaviors and is an effective HIV prevention strategy. The authors designed a 15-minute interactive educational program to increase inmates' knowledge of nPEP. Before the program, participants self-reported high HIV risk yet low risk perception and lack of nPEP awareness. After the program, nPEP knowledge scores increased by 40% regardless of demographic or HIV-risk characteristics. This study demonstrates that a brief, easy-to-deliver educational intervention can be carried out in a jail, is effective at raising awareness of both HIV risk and nPEP, and may be useful for others seeking to increase use of this prevention strategy for high-risk women during incarceration.

Trajectories of Health and Behavioral Health Services Use among Community Corrections-Involved Rural Adults

This article seeks to establish time-based trajectories of health and behavioral health services utilization for community corrections-involved (CCI) adults and to examine demographic and clinical correlates associated with these trajectories. To accomplish this aim, the authors applied a latent class growth analysis (LCGA) to services use data from a sample of rural CCI adults who reported their medical, mental health, and substance use treatment utilization behavior every 60 days for 1.5 years. LCGA established 1.5-year trajectories and demographic correlates of health services among rural CCI adults. For medical services, three classes emerged (stable-low users, 13%; stable-intermediate users, 40%; and stable-high users, 47%). For mental health and substance use services, three classes emerged (stable-low, 69% and 61%, respectively; low-baseline-increase, 10% and 12%, respectively; high-baseline decline, 21% and 28%, respectively). Employment, gender, medication usage, and depression severity predicted membership across all services. Results underscore the importance of social workers and other community services providers aligning health services access with the needs of the CCI population, and highlight CCI adults as being at risk of underservice in critical prevention and intervention domains.

African American Female Offender's Use of Alternative and Traditional Health Services After Re-Entry: Examining the Behavioral Model for Vulnerable Populations

This is the first known study to use the Gelberg-Andersen Behavioral Model for Vulnerable Populations to predict African American women's use of three types of health services (alternative, hospitalization, and ambulatory) in the 18 months after release from prison. In the multivariate models, the most robust predictors of all three types of service utilization were in the vulnerable theoretical domains. Alternative health services were predicted by ethnic community membership, higher religiosity, and HIV/HCV. Hospitalizations were predicted by the lack of barriers to health care and disability. Ambulatory office visits were predicted by more experiences of gendered racism, a greater number of physical health problems, and HIV/HCV. Findings highlight the importance of cultural factors and HIV/HCV in obtaining both alternative and formal health care during community re-entry. Clinicians and policymakers should consider the salient role that the vulnerable domain plays in offender's accessing health services.

A Pilot Study of Rapid Hepatitis C Testing in Probation and Parole Populations in Rhode Island

Hepatitis C virus (HCV) affects between five and seven million individuals in the United States and chronic infection can lead to liver disease, cirrhosis, and hepatocellular carcinoma. Probation/parole offices are a novel setting for rapid HCV testing, providing outreach to populations at increased risk for HCV infection and/or transmitting HCV to others. While some correctional facilities offer HCV testing, many individuals who present to probation/parole offices are never or briefly incarcerated and may not access medical services. We conducted a rapid HCV testing pilot at probation/parole offices in Rhode Island. Overall, 130 people accepted rapid HCV testing, of whom 12 had reactive tests. Only four of these individuals presented to a community-based clinic for confirmatory testing, despite being offered a monetary incentive. Identifying and addressing barriers to HCV confirmatory testing and follow-up care is critical to increasing the uptake of HCV care and treatment in this vulnerable population.

Incarcerated Black Women in the Southern USA: A Narrative Review of STI and HIV Risk and Implications for Future Public Health Research, Practice, and Policy

Incarcerated black women in the southern USA are understudied despite the high prevalence of sexually transmitted infections (STI) and human immunodeficiency virus (HIV). These incarceration and health disparities are rooted in centuries of historically inequitable treatment. Amidst the current dialogue on mass incarceration in the south and its relationship to the health of the black community, individual and environmental risk factors for STI/HIV transmission are seldom paired with discussions of evidence-based solutions. A narrative review of the literature from January 1995 to May 2015 was conducted. This sample of the literature (n = 18) revealed that partner concurrency, inconsistent condom use, sex work, previous STI, and drug abuse augmented individual STI/HIV risk. Recommended interventions include those which promote healthier relationships, cultural competence, and gender specificity, as well as those that enhance prevention skills. Policy recommendations include improving cultural sensitivity, cultural competence, and cultural humility training for clinicians, as well as substantially increasing funding for prevention, treatment, and rehabilitative services. These recommendations are timely given the recent national attention to incarceration, STI, and HIV disparities, particularly in the southern USA.

A longitudinal study of health outcomes for people released from prison in Fiji: the HIP-Fiji project

OBJECTIVE

To examine the health of prisoners and ex-prisoners in Fiji, including risk behaviours, service access and HIV status.

METHODS

Longitudinal study of 198 men and women recruited prior to release from prison in Fiji, interviewed in the weeks preceding release, and again 1 and 4 months post-release. Dried blood spot samples taken at baseline were tested for HIV.

RESULTS

Eighty percent of participants completed at least one follow-up interview. The prevalence of HIV was low (1%), despite evidence of widespread STI and BBV risk behaviours. A history of risky substance use was normative and more than a third reported high psychological distress prior to release. Fewer than one in four reported accessing health care within a month of release from prison.

CONCLUSIONS

The health needs of this population are significant but differ in important ways from those of incarcerated populations in other countries. Further research is needed to inform evidence-based care for prisoners and ex-prisoners in Pacific Island nations.

HIV/AIDS in Lebanese prisons: challenges and proposed actions

PURPOSE

The purpose of this paper is to discuss the extent of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) crisis in Lebanese prisons, propose functional reforms for Roumieh prisons (the country's largest male top-security prison), and outline the main challenges to HIV/AIDS prevention, intervention, and treatment.

DESIGN/METHODOLOGY/APPROACH

All recommendations were based on previous successful stories, international prison standards as well as cultural considerations.

FINDINGS

This paper argues that prevention and interventions starts within the prison community including inmates, guards, and other prison and provision of appropriate health care, education, and prison infrastructure.

SOCIAL IMPLICATIONS

These strategies are not only important in limiting prevention and transmission of HIV/AIDS, but also contribute in optimizing quality of life within the prison system.

ORIGINALITY/VALUE

This paper is the first of its kind to discuss the prison situation in Lebanese prisons in terms of public health promotion and reforms.

Recall of Nadir CD4 Cell Count and Most Recent HIV Viral Load Among HIV-Infected, Socially Marginalized Adults

Lower nadir CD4 cell counts and higher HIV viral loads are associated with increased risks of adverse events in the progression of HIV disease. In cases where medical records are inaccessible or incomplete, little evidence is available regarding whether nadir CDR cell count or HIV viral load is reliably reported in any patient population. We compare survey data collected from 207 HIV-infected individuals detained in San Francisco jails to data collected from electronic medical records (EMR) kept by the jails and community health providers. The sensitivity of self-reported nadir CD4 cell count less than 200 was 82 % [95 % confidence interval (CI) 68, 88], and the sensitivity of reporting an undetectable most recent HIV viral load was 93 % (95 % CI 84, 97). This suggests that in a highly socially marginalized population, nadir CD4 cell count and most recent HIV viral load are recalled accurately when compared to EMR.

Point-of-care testing for HIV in an Irish prison setting: results from three major Irish prisons

HIV is more prevalent in the prison population compared to the general population. Prison inmates are at an increased risk of blood-borne infections. Considerable stigma has been documented amongst inmates with HIV infection. In collaboration with the schools, healthcare facilities, prison authorities and inmate Irish Red Cross groups in Wheatfield, Cloverhill and Mountjoy prisons in Dublin, Ireland, the Department of Genito Urinary Medicine and Infectious Diseases at St James' Hospital in Dublin developed a campaign for raising awareness of HIV, educating inmates about HIV and tackling HIV stigma. Following this campaign, large-scale point-of-care testing for HIV was offered over a short period. In total, 741 inmates were screened for HIV. One inmate tested positive for HIV. We experienced a large number of invalid test results, requiring formal laboratory serum testing, and a small number of false positive results. Large-scale point-of-care testing in the Irish prison setting is acceptable and achievable.

Toward a Demographic Understanding of Incarceration Disparities: Race, Ethnicity, and Age Structure

OBJECTIVES

Non-Hispanic blacks and Hispanics in the United States are more likely to be incarcerated than non-Hispanic whites. The risk of incarceration also varies with age, and there are striking differences in age distributions across racial/ethnic groups. Guided by these trends, the present study examines the extent to which differences in age structure account for incarceration disparities across racial and ethnic groups.

METHODS

We apply two techniques commonly employed in the field of demography, age-standardization and decomposition, to data provided by the Bureau of Justice Statistics and the 2010 decennial census to assess the contribution of age structure to racial and ethnic disparities in incarceration.

FINDINGS

The non-Hispanic black and Hispanic incarceration rates in 2010 would have been 13-20 % lower if these groups had age structures identical to that of the non-Hispanic white population. Moreover, age structure accounts for 20 % of the Hispanic/white disparity and 8 % of the black/white disparity.

CONCLUSION

The comparison of crude incarceration rates across racial/ethnic groups may not be ideal because these groups boast strikingly different age structures. Since the risk of imprisonment is tied to age, criminologists should consider adjusting for age structure when comparing rates of incarceration across groups.

Vaccinations in prisons: A shot in the arm for community health

From the first day of imprisonment, prisoners are exposed to and expose other prisoners to various communicable diseases, many of which are vaccine-preventable. The risk of acquiring these diseases during the prison sentence exceeds that of the general population. This excess risk may be explained by various causes; some due to the structural and logistical problems of prisons and others to habitual or acquired behaviors during imprisonment. Prison is, for many inmates, an opportunity to access health care, and is therefore an ideal opportunity to update adult vaccination schedules. The traditional idea that prisons are intended to ensure public safety should be complemented by the contribution they can make in improving community health, providing a more comprehensive vision of safety that includes public health.

An exploratory study of therapeutic misconception among incarcerated clinical trial participants

BACKGROUND

Therapeutic misconception, the misunderstanding of differences between research and clinical care, is widely prevalent among non-incarcerated trial participants. Yet little attention has been paid to its presence among individuals who participate in research while incarcerated.

METHODS

This study examined the extent to which seventy-two incarcerated individuals may experience therapeutic misconception about their participation in one of six clinical trials, and its correlation with participant characteristics and potential influences on research participation.

RESULTS

On average, participants endorsed 70% of items suggestive of therapeutic misconception. The tendency toward therapeutic misconception was significantly higher among: African Americans and Latinos compared to Whites; older and less educated participants; enrollment in a substance abuse-related trial; and correlated with a belief that the trial was the only way to obtain needed treatment.

CONCLUSIONS

Therapeutic misconception may be particularly high among select incarcerated individuals and is associated with a perceived lack of treatment options. Further examination of therapeutic misconception among incarcerated research participants is needed.

HIV Knowledge Among a Longitudinal Cohort of Juvenile Detainees in an Urban Setting

The authors investigated HIV knowledge change among a cohort of juvenile detainees. Participants completed an HIV knowledge survey at baseline and up to 4 more times over 6 years. The authors calculated knowledge scores; the time serial trend of scores was modeled using generalized estimating equations. A baseline survey was completed by 798 participants, ages 14 to 18 years; mean HIV knowledge scores ranged from 11.4 to 14.1 (maximum score = 18). Males had significantly lower HIV knowledge scores than females at baseline only. Over time, Hispanic participants had significantly lower scores than non-Hispanic Black and non-Hispanic White participants. Overall, HIV knowledge increased but was still suboptimal 5 years after baseline. These findings suggest the need to develop and strengthen HIV prevention education programs in youth detention settings.

Substantial overlap between incarceration and tuberculosis in atlanta, georgia, 2011

Standard tuberculosis case reporting captures incarceration at diagnosis only. This retrospective analysis of 106 US-born adults with prevalent tuberculosis in 2011 found that 46.2% had documented histories of being in jail or prison, including 16.0% during the year before diagnosis.

The impact of brief messages on HSV-2 screening uptake among female defendants in a court setting: a randomized controlled trial utilizing prospect theory

Epidemiologic data demonstrate that women involved with the criminal justice system in the United States are at high risk for sexually transmitted infections, including herpes simplex virus type 2 (HSV-2). Female defendants were recruited from a misdemeanor court to assess whether brief framed messages utilizing prospect theory could encourage testing for HSV-2. Participants were randomly assigned to a message condition (gain, loss, or control), completed an interviewer-administered survey assessing factors associated with antibody test uptake/refusal and were offered free point-of-care HSV-2 serologic testing. Although individuals in the loss-frame group accepted testing at the highest rate, an overall statistical difference in HSV-2 testing behavior by group (p ≤ .43) was not detected. The majority of the sample (74.6%) characterized receiving a serological test for HSV-2 as health affirming. However, this did not moderate the effect of the intervention nor was it significantly associated with test acceptance (p ≤ .82). Although the effects of message framing are subtle, the findings have important theoretical implications given the participants' characterization of HSV-2 screening as health affirming despite being a detection behavior. Implications of study results for health care providers interested in brief, low cost interventions are also explored.

Multilevel challenges to engagement in HIV care after prison release: a theory-informed qualitative study comparing prisoners' perspectives before and after community reentry

Background

Although prison provides the opportunity for HIV diagnosis and access to in-prison care, following release, many HIV-infected inmates experience clinical setbacks, including nonadherence to antiretrovirals, elevations in viral load, and HIV disease progression. HIV-infected former inmates face numerous barriers to successful community reentry and to accessing healthcare. However, little is known about the outcome expectations of HIV-infected inmates for release, how their post-release lives align with pre-release expectations, and how these processes influence engagement in HIV care following release from prison.

Methods

We conducted semi-structured interviews (24 pre- and 13 post-release) with HIV-infected inmates enrolled in a randomized controlled trial of a case management intervention to enhance post-release linkage to care. Two researchers independently coded data using a common codebook. Intercoder reliability was strong (kappa = 0.86). We analyzed data using Grounded Theory methodology and Applied Thematic Analysis. We collected and compared baseline sociodemographic and behavioral characteristics of all cohort participants who did and did not participate in the qualitative interviews using Fisher’s Exact Tests for categorical measures and Wilcoxon rank-sum tests for continuous measures.

Results

Most participants were heterosexual, middle-aged, single, African American men and women with histories of substance use. Substudy participants were more likely to anticipate living with family/friends and needing income assistance post-release. Most were taking antiretrovirals prior to release and anticipated needing help securing health benefits and medications post-release. Before release, most participants felt confident they would be able to manage their HIV. However, upon release, many experienced intermittent or prolonged periods of antiretroviral nonadherence, largely due to substance use relapse or delays in care initiation. Substance use was precipitated by stressful life experiences, including stigma, and contact with drug-using social networks. As informed by the Social Cognitive Theory and HIV Stigma Framework, findings illustrate the reciprocal relationships among substance use, experiences of stigma, pre- and post-release environments, and skills needed to engage in HIV care.

Conclusion

These findings underscore the need for comprehensive evidence-based interventions to prepare inmates to transition from incarceration to freedom, particularly those that strengthen linkage to HIV care and focus on realities of reentry, including stigma, meeting basic needs, preventing substance abuse, and identifying community resources.

Efficacy of a group-based multimedia HIV prevention intervention for drug-involved women under community supervision: project WORTH

IMPORTANCE

This study is designed to address the need for evidence-based HIV/STI prevention approaches for drug-involved women under criminal justice community supervision.

OBJECTIVE

We tested the efficacy of a group-based traditional and multimedia HIV/STI prevention intervention (Project WORTH: Women on the Road to Health) among drug-involved women under community supervision.

DESIGN, SETTING, PARTICIPANTS, AND INTERVENTION

We randomized 306 women recruited from community supervision settings to receive either: (1) a four-session traditional group-based HIV/STI prevention intervention (traditional WORTH); (2) a four-session multimedia group-based HIV/STI prevention intervention that covered the same content as traditional WORTH but was delivered in a computerized format; or (3) a four-session group-based Wellness Promotion intervention that served as an attention control condition. The study examined whether the traditional or multimedia WORTH intervention was more efficacious in reducing risks when compared to Wellness Promotion; and whether multimedia WORTH was more efficacious in reducing risks when compared to traditional WORTH.

MAIN OUTCOMES AND MEASURES

Primary outcomes were assessed over the 12-month post-intervention period and included the number of unprotected sex acts, the proportion of protected sex acts, and consistent condom use. At baseline, 77% of participants reported unprotected vaginal or anal sex (n = 237) and 63% (n = 194) had multiple sex partners.

RESULTS

Women assigned to traditional or multimedia WORTH were significantly more likely than women assigned to the control condition to report an increase in the proportion of protected sex acts (β = 0.10; 95% CI = 0.02-0.18) and a decrease in the number of unprotected sex acts (IRR = 0.72; 95% CI = 0.57-0.90).

CONCLUSION AND RELEVANCE

The promising effects of traditional and multimedia WORTH on increasing condom use and high participation rates suggest that WORTH may be scaled up to redress the concentrated epidemics of HIV/STIs among drug-involved women in the criminal justice system.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01784809.

A systematic review of the effectiveness and cost-effectiveness of peer-based interventions to maintain and improve offender health in prison settings

Background

Offender health is deemed a priority issue by the Department of Health. Peer support is an established feature of prison life in England and Wales; however, more needs to be known about the effectiveness of peer-based interventions to maintain and improve health in prison settings.

Objectives

The study aimed to synthesise the evidence on peer-based interventions in prison settings by carrying out a systematic review and holding an expert symposium. Review questions were (1) what are the effects of peer-based interventions on prisoner health and the determinants of prisoner health?, (2) what are the positive and negative impacts on health services within prison settings of delivering peer-based interventions?, (3) how do the effects of peer-based approaches compare with those of professionally led approaches? and (4) what are the costs and cost-effectiveness of peer-based interventions in prison settings?

Data sources

For the systematic review, 20 electronic databases including MEDLINE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature and EMBASE were searched from 1985. Grey literature and relevant websites were also searched. To supplement the review findings 58 delegates, representing a variety of organisations, attended an expert symposium, which provided contextual information.

Review methods

Two reviewers independently selected studies using the following inclusion criteria: population – prisoners resident in prisons and young offender institutions; intervention – peer-based interventions; comparators: review questions 3 and 4 compared peer-led and professionally led approaches; outcomes – prisoner health or determinants of health, organisational/process outcomes or views of prison populations; study design: quantitative, qualitative and mixed-methods evaluations. Two reviewers extracted data and assessed validity using piloted electronic forms and validity assessment criteria based on published checklists. Results from quantitative studies were combined using narrative summary and meta-analysis when appropriate; results from qualitative studies were combined using thematic synthesis.

Results

A total of 15,320 potentially relevant papers were identified of which 57 studies were included in the effectiveness review and one study was included in the cost-effectiveness review; most were of poor methodological quality. A typology of peer-based interventions was developed. Evidence suggested that peer education interventions are effective at reducing risky behaviours and that peer support services provide an acceptable source of help within the prison environment and have a positive effect on recipients; the strongest evidence came from the Listener scheme. Consistent evidence from many predominantly qualitative studies suggested that being a peer deliverer was associated with positive effects across all intervention types. There was limited evidence about recruitment of peer deliverers. Recurring themes were the importance of prison managerial and staff support for schemes to operate successfully, and risk management. There was little evidence on the cost-effectiveness of peer-based interventions. An economic model, developed from the results of the effectiveness review, although based on data of variable quality and a number of assumptions, showed the cost-effectiveness of peer-led over professionally led education in prison for the prevention of human immunodeficiency virus (HIV) infection.

Limitations

The 58 included studies were, on the whole, of poor methodological quality.

Conclusions

There is consistent evidence from a large number of studies that being a peer worker is associated with positive health. Peer support services can also provide an acceptable source of help within the prison environment and can have a positive effect on recipients. This was confirmed by expert evidence. Research into cost-effectiveness is sparse but a limited HIV-specific economic model, although based on a number of assumptions and evidence of variable quality, showed that peer interventions were cost-effective compared with professionally led interventions. Well-designed intervention studies are needed to provide robust evidence including assessing outcomes for the target population, economic analysis of cost-effectiveness and impacts on prison health services. More research is needed to examine issues of reach, utilisation and acceptability from the perspective of recipients and those who choose not to receive peer support.

Study registration

This study was registered as PROSPERO CRD42012002349.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Design and methods of a double blind randomized placebo-controlled trial of extended-release naltrexone for HIV-infected, opioid dependent prisoners and jail detainees who are transitioning to the community

BACKGROUND

People with opioid dependence and HIV are concentrated within criminal justice settings (CJS). Upon release, however, drug relapse is common and contributes to poor HIV treatment outcomes, increased HIV transmission risk, reincarceration and mortality. Extended-release naltrexone (XR-NTX) is an evidence-based treatment for opioid dependence, yet is not routinely available for CJS populations.

METHODS

A randomized, double-blind, placebo-controlled trial of XR-NTX for HIV-infected inmates transitioning from correctional to community settings is underway to assess its impact on HIV and opioid-relapse outcomes.

RESULTS

We describe the methods and early acceptability of this trial. In addition we provide protocol details to safely administer XR-NTX near community release and describe logistical implementation issues identified. Study acceptability was modest, with 132 (66%) persons who consented to participate from 199 total referrals. Overall, 79% of the participants had previously received opioid agonist treatment before this incarceration. Thus far, 65 (49%) of those agreeing to participate in the trial have initiated XR-NTX or placebo. Of the 134 referred patients who ultimately did not receive a first injection, the main reasons included a preference for an alternative opioid agonist treatment (37%), being ineligible (32%), not yet released (10%), and lost upon release before receiving their injection (14%).

CONCLUSIONS

Study findings should provide high internal validity about HIV and opioid treatment outcomes for HIV-infected prisoners transitioning to the community. The large number of patients who ultimately did not receive the study medication may raise external validity concerns due to XR-NTX acceptability and interest in opioid agonist treatments.

CLINICAL TRIAL NUMBER

NCT01246401.

Increased hospital and emergency department utilization by individuals with recent criminal justice involvement: results of a national survey

BACKGROUND

Individuals involved with the criminal justice system have increased health needs and poor access to primary care.

OBJECTIVE

To examine hospital and emergency department (ED) utilization and related costs by individuals with recent criminal justice involvement.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Non-institutionalized, civilian U.S. adult participants (n = 154,356) of the National Survey on Drug Use and Health (2008-2011).

MAIN MEASURES

Estimated proportion of adults who reported past year 1) hospitalization or 2) ED utilization according to past year criminal justice involvement, defined as 1) parole or probation, 2) arrest without subsequent correctional supervision, or 3) no criminal justice involvement; estimated annual expenditures using unlinked data from the Medical Expenditure Panel Survey.

KEY RESULTS

An estimated 5.7 million adults reported parole or probation and an additional 3.9 million adults reported an arrest in the past year. Adults with recent parole or probation and those with a recent arrest, compared with the general population, had higher rates of hospitalization (12.3 %, 14.3 %, 10.5 %; P < 0.001) and higher rates of ED utilization (39.3 %, 47.2 %, 26.9 %; P < 0.001). Recent parole or probation was an independent predictor of hospitalization (adjusted odds ratio [AOR], 1.21; 95 % confidence interval [CI], 1.02-1.44) and ED utilization (AOR, 1.35; 95 % CI, 1.12-1.63); Recent arrest was an independent predictor of hospitalization (AOR, 1.26; 95 % CI, 1.08-1.47) and ED utilization (AOR, 1.81; 95 % CI, 1.53-2.15). Individuals with recent criminal justice involvement make up 4.2 % of the U.S. adult population, yet account for an estimated 7.2 % of hospital expenditures and 8.5 % of ED expenditures.

CONCLUSIONS

Recent criminal justice involvement is associated with increased hospital and ED utilization and costs. The criminal justice system may offer an important point of contact for efforts to improve the healthcare utilization patterns of a large and vulnerable population.

Can hepatitis C be eradicated in the United States?

The advent of highly effective antiviral regimens will make the eradication of hepatitis C in high-income countries such as the United States technically feasible. But eradicating hepatitis C will require escalating our response to the epidemic in key domains, including surveillance and epidemiology, prevention, screening, care and treatment, policy, research, and advocacy. Surveillance must be nimble enough to quickly assess the magnitude of new transmission patterns as they emerge. Basic prevention strategies - community-based outreach and education, testing and counseling, and access to sterile injection equipment and opioid substitution therapies - must be scaled up and adapted to target groups in which new epidemics are emerging. All adults should be screened for hepatitis C, but special efforts must focus on groups with increased prevalence through community outreach and rapid testing. Government, industry, and payers must work together to assure full access to health services and antiviral drugs for everyone who is infected. Access to the new regimens must not be compromised by excessively high prices or arbitrary payer restrictions. Partnerships must be forged between hepatitis providers and programs that serve people who inject illicit drugs. Healthcare providers and systems, especially primary care practitioners, need education and training in treating hepatitis C and caring for substance-using populations. Services must be provided to the disadvantaged and stigmatized members of society who bear a disproportionate burden of the epidemic. Environments must be created where people who use drugs can receive prevention and treatment services without shame or stigma. Action is needed to end the policy of mass incarceration of people who use drugs, reduce the stigma associated with substance use, support the human rights of people who use drugs, expand social safety net services for the poor and the homeless, remove the legal barriers to hepatitis C prevention, and build public health infrastructure to reach, engage, and serve marginalized populations. Governments must take action to bring about these changes. Public health agencies must work with penal institutions to provide prevention and treatment services, including antiviral therapy, to those in need in jails and prisons or on probation or parole. Research is needed to guide efforts in each of these domains. Strong and sustained political advocacy will be needed to build and sustain support for these measures. Leadership must be provided by physicians, scientists, and the public health community in partnership with community advocates and people living with or at risk for hepatitis C. Eliminating hepatitis C from the United States is possible, but will require a sustained national commitment to reach, test, treat, cure, and prevent every case. With strong political leadership, societal commitment, and community support, hepatitis C can be eradicated in the United States. If this is to happen in our lifetimes, the time for action is now. This article forms part of a symposium in Antiviral Research on "Hepatitis C: next steps toward global eradication."

The case for improving the health of ex-prisoners

The global prison population exceeds 10 million and continues to grow; more than 30 million people are released from custody annually. These individuals are disproportionately poor, disenfranchised, and chronically ill. There are compelling, evidence-based arguments for improving health outcomes for ex-prisoners on human rights, public health, criminal justice, and economic grounds. These arguments stand in stark contrast to current policy and practice in most settings. There is also a dearth of evidence to guide clinicians and policymakers on how best to care for this large and growing population during and after their transition from custody to community. Well-designed longitudinal studies, clinical trials, and burden of disease studies are pivotal to closing this evidence gap.

Incarceration and Post-release Health Behavior

This study investigates the link between incarceration and health behavior among a sample of young adults from the National Longitudinal Study of Adolescent Health (N = 1,670). The association is analyzed using propensity score methods and a strategic comparison group: respondents who have been convicted of crimes, but not incarcerated. Findings suggest that former inmates consume more fast food and have a higher likelihood of smoking than do similarly situated peers. These associations operate partly through increased financial strife and decreased social standing. Given the role of health behavior in predicting future health outcomes, poor health behavior may be a salient force driving health and mortality risk among the formerly incarcerated population.

Hepatitis C seroprevalence among prison inmates since 2001: still high but declining

OBJECTIVES

Although the hepatitis C epidemic in the United States disproportionately affects correctional populations, the last national estimates of seroprevalence and disease burden among these populations are more than a decade old. We investigated routine hepatitis C surveillance conducted in state prison systems and updated previous estimates.

METHODS

We surveyed all U.S. state correctional departments to determine which state prison systems had performed routine hepatitis C screening since 2001. Using seroprevalence data for these prison systems, we estimated the national hepatitis C seroprevalence among prisoners in 2006 and the share of the epidemic borne by correctional populations.

RESULTS

Of at least 12 states performing routine testing from 2001 to 2012, seroprevalences of hepatitis C ranged from 9.6% to 41.1%. All but one state with multiple measurements demonstrated declining seroprevalence. We estimated the national state prisoner seroprevalence at 17.4% in 2006. Based on the estimated total U.S. correctional population size, we projected that 1,857,629 people with hepatitis C antibody were incarcerated that year. We estimated that correctional populations represented 28.5%-32.8% of the total U.S. hepatitis C cases in 2006, down from 39% in 2003.

CONCLUSIONS

Our results provide an important updated estimate of hepatitis C seroprevalence and suggest that correctional populations bear a declining but still sizable share of the epidemic. Correctional facilities remain important sites for hepatitis C case finding and therapy implementation. These results may also assist future studies in projecting the societal costs and benefits of providing new treatment options in prison systems.

Social and economic factors associated with recent and lifetime incarceration among Puerto Rican drug users

Using a sample of 280 Puerto Rican drug users with a history of incarceration residing in Massachusetts, we explore whether a significant association exists between social and economic factors (maintaining social network contacts, receiving public assistance) and lifetime incarceration. Analysis of survey data using regression methods shows that respondents who live in their own home, receive public assistance, and have recent familial contact are significantly less likely to have been incarcerated in the past 6 months. Among study participants, men and those who initiated heroin use at younger ages are more likely to have greater lifetime incarceration totals. Practice implications are discussed.

Prevalence of HIV and Hepatitis B, C, D Infections and Their Associated Risk Factors among Prisoners in Southern Khorasan Province, Iran

BACKGROUND

Prison inmates are among the high risk population for dangerous infections such HIV, HBV, HCV and other contagious diseases. In spit of many data about the prevalence and risk factors for blood born diseases among prisoners in the world, such data are spares from Iran. The aim of this study was to determine the prevalence and associated risk factors for HIV, HBV, HCV and HDV infections among a large sample of prison inmates in Iran.

METHODS

In a cross-sectional study in 2009-2010, 881 inmates in three prisons of Southern Khorasan Province in Iran were selected based on a systematic, stratified random sampling method. Sera were analyzed for HBV, HDV, HCV and HIV infections by appropriate commercial ELISA kits. An anonymous questionnaire was used to collect the demographic data and information about risk factors.

RESULTS

Overall, 881 prisoners (mean age: 34.7±11.4 years, range: 11-84 years, M/F ratio:4.5/1) were participated in this study. The prevalence of HBV and HCV infection was 6.9% and 7.7%, respectively. Among the HBsAg positive subjects, 6.6% (4/61) and 9.8% (6/61) had HDV and HCV super-infection, respectively. Only one case (0.1%) had HIV infection that was co-infection with HCV. Drug abuse and history of traditional phlebotomy were associated risk factors for HBV infection (P<0.05) and history of drug injection was associated with HCV infection (P<0.05).

CONCLUSIONS

This study show fairly higher prevalence of blood borne infections among prisoners and indicate drug abuse and phlebotomy as the associated risk factor. Implementation of appropriate screening tests and preventive programs is suggested in prisons.

Reducing Ex-offender Health Disparities through the Affordable Care Act: Fostering Improved Health Care Access and Linkages to Integrated Care

Despite steadily declining incarceration rates overall, racial and ethnic minorities, namely African Americans, Latinos, and American Indians and Alaska Natives, continue to be disproportionately represented in the justice system. Ex-offenders commonly reenter communities with pressing health conditions but encounter obstacles to accessing care and remaining in care. The lack of health insurance coverage and medical treatment emerge as the some of the most reported reentry health needs and may contribute to observed health disparities. Linking ex-offenders to care and services upon release increases the likelihood that they will remain in care and practice successful disease management. The Affordable Care Act (ACA) offers opportunities to address health disparities experienced by the reentry population that places them at risk for negative health outcomes and recidivism. Coordinated efforts to link ex-offenders with these newly available opportunities may result in a trajectory for positive health and overall well-being as they reintegrate into society.

Design and methods of a double blind randomized placebo-controlled trial of extended-release naltrexone for alcohol dependent and hazardous drinking prisoners with HIV who are transitioning to the community

BACKGROUND

HIV-infected prisoners have a high prevalence of alcohol use disorders and commonly relapse to alcohol soon after release to the community which is linked to high morbidity, poor antiretroviral therapy (ART) adherence and increased sexual risk-taking behaviors. Extended-release naltrexone (XR-NTX) effectively reduces relapse to alcohol in alcohol dependent persons, yet it remains unexamined among criminal justice system (CJS) populations transitioning to the community.

METHODS

A randomized double-blind, placebo-controlled trial of XR-NTX to improve HIV treatment outcomes via reducing relapse to alcohol use after prison release for HIV-infected hazardous drinking and alcohol dependent prisoners is discussed.

RESULTS

Acceptability of study participation is high with 86% of those referred who met eligibility criteria and 85% of those who were able to receive injections prior to release accepted injections, yet important implementation issues are identified and addressed during the study and are discussed in this paper.

CONCLUSION

Medication-assisted therapies for prevention of relapse to alcohol use for CJS populations transitioning to the community, especially for HIV-infected patients, are urgently needed in order to reduce alcohol relapse after release and improve HIV treatment outcomes and contribute to improved individual and public health.

Implementing drug abuse treatment services in criminal justice settings: Introduction to the CJ-DATS study protocol series

BACKGROUND

Despite a growing pipeline of effective clinical treatments, there remains a persistent research-to-practice gap in drug abuse services. Delivery of effective treatment services is especially lacking in the U.S. criminal justice system, where half of all incarcerated persons meet the need for drug abuse or dependence, yet few receive needed care. Structural, financial, philosophical and other barriers slow the pace of adoption of available evidence-based practices. These challenges led to the development of a multi-site cooperative research endeavor known as the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS), funded by the National Institute on Drug Abuse (NIDA). CJ-DATS engages university-based research teams, criminal justice agencies, and community-based treatment providers in implementation research studies to test strategies for enhancing treatment service delivery to offender populations.

METHODS

This Introduction reviews the mission of NIDA, the structure and goals of the CJ-DATS cooperative, and the implementation studies being conducted by the participating organizations. The component Study Protocols in this article collection are then described.

DISCUSSION

CJ-DATS applies implementation science perspectives and methods to address a vexing problem - the need to link offender populations with effective treatment for drug abuse, HIV, and other related conditions for which they are at high risk. Applying these principles to the U.S. criminal justice system is an innovative extension of lessons that have been learned in mainstream healthcare settings. This collection is offered as both an introduction to NIDA's work in this area, as well as a window onto the challenges of conducting health services research in settings in which improving public health is not the organization's core mission.

Gender and risk behaviors for HIV and sexually transmitted infections among recently released inmates: A prospective cohort study

Women in prison have a higher prevalence of HIV than men. After release from prison, former inmates have the opportunity to engage in risk behaviors for HIV and other sexually transmitted infections (STIs). We sought to assess change in risk behaviors over time and the association of gender with risk behavior in the postrelease period. In this prospective cohort study, we interviewed 200 former inmates (51 women) approximately two weeks (baseline) and three months (follow-up) after release and tested them for HIV infection at follow-up. We examined the association of gender with unprotected vaginal or anal sex in the last seven days using chi-square and Fisher's exact tests and multivariable logistic regression. At baseline, 22% of men and 41% of women reported unprotected vaginal sex (p < 0.01) and 5% of men and 8% of women reported unprotected anal sex (p = 0.51). Being younger (OR for each decade increase 0.48, 95% CI = 0.29-0.80), being gay/lesbian or being bisexual (compared with being heterosexual, OR = 4.74, 95% CI = 1.01-22.17 and OR = 3.98, 95% CI = 1.41-11.26, respectively), or reporting a drug of choice of heroin/speedballs or cocaine/crack (compared with marijuana/no drug of choice, OR = 24.00, 95% CI = 5.15-111.81 and OR = 3.49, 95% CI = 1.20-10.18, respectively) was associated with unprotected vaginal or anal sex after adjusting for race, homelessness, and hazardous drinking. At follow-up, 21% of men and 44% of women reported unprotected sex (p = 0.005), and female gender (OR = 4.42, 95% CI = 1.79-10.94) and hazardous drinking (compared with not meeting criteria for hazardous drinking, OR = 3.64, 95% CI = 1.34-9.86) were associated with unprotected sex, adjusting for race and homelessness. In this population with a high prevalence of HIV, we demonstrated persistent engagement in sexual risk behavior during the postrelease period. Enhanced efforts to promote sexual health and reduced risk behavior among both male and female current and former prison inmates are needed, including improved access to preventive care and HIV and STI screening, testing, and treatment.

Emergency department utilization among recently released prisoners: a retrospective cohort study

Background

The population of ex-prisoners returning to their communities is large. Morbidity and mortality is increased during the period following release. Understanding utilization of emergency services by this population may inform interventions to reduce adverse outcomes. We examined Emergency Department utilization among a cohort of recently released prisoners.

Methods

We linked Rhode Island Department of Corrections records with electronic health record data from a large hospital system from 2007 to 2009 to analyze emergency department utilization for mental health disorders, substance use disorders and ambulatory care sensitive conditions by ex-prisoners in the year after release from prison in comparison to the general population, controlling for patient- and community-level factors.

Results

There were 333,369 total ED visits with 5,145 visits by a cohort of 1,434 ex-prisoners. In this group, 455 ex-prisoners had 3 or more visits within 1 year of release and 354 had a first ED visit within 1 month of release. ED visits by ex-prisoners were more likely to be made by men (85% vs. 48%, p < 0.001) and by blacks (26% vs. 16%, p < 0.001) compared to the Rhode Island general population. Ex-prisoners were more likely to have an ED visit for a mental health disorder (6% vs. 4%, p < 0.001) or substance use disorder (16%vs. 4%, p < 0.001). After controlling for patient- and community-level factors, ex-prisoner visits were significantly more likely to be for mental health disorders (OR 1.43; 95% CI 1.27-1.61), substance use disorders (OR 1.93; 95% CI 1.77-2.11) and ambulatory care sensitive conditions (OR 1.09; 95% CI 1.00-1.18).

Conclusions

ED visits by ex-prisoners were significantly more likely due to three conditions optimally managed in outpatient settings. Future work should determine whether greater access to outpatient services after release from prison reduces ex-prisoners’ utilization of emergency services.

HIV-positive and in jail: race, risk factors, and prior access to care

Black individuals represent 13 % of the US population but 46 % of HIV positive persons and 40 % of incarcerated persons. The national EnhanceLink project evaluated characteristics of HIV-positive jail entrants at ten sites and explored associations between race and HIV disease state. Between 1/2008 and 10/2011, 1,270 study participants provided demographic and clinical data. Adjusted odds ratios (aORs) were calculated for advanced HIV disease (CD4 < 200 cells/mm(3)) and uncontrolled viremia (viral load > 400 copies/ml) for Black (n = 807) versus non-Black (n = 426) participants. Sixty-five percent of HIV-positive jail participants self-identified as Black. Among all participants, fewer than half had a high school diploma or GED, the median number of lifetime arrests was 15, and major mental illness and substance abuse were common. Black participants were more likely to be older than non-Black participants, and less likely to have health insurance (70 vs 83 %) or an HIV provider (73 vs 81 %) in the prior 30 days. Among all male study participants (n = 870), 20 % self-identified as homosexual or bisexual. Black male participants were more likely to be homosexual or bisexual (22 vs 16 %) and less likely to have a history of injection drug use (20 vs 50 %) than non-Black male participants. Advanced HIV disease was associated with self-identification as Black (aOR = 1.84, 95 % CI 1.16-2.93) and time since HIV diagnosis of more than two years (aOR = 3.55, 95 % CI 1.52-8.31); advanced disease was inversely associated with age of less than 38 years (aOR = 0.41, 95 % CI 0.24-0.70). Uncontrolled viremia was inversely associated with use of antiretroviral therapy (ART) in the prior 7 days (aOR = 0.25, 95 % CI 0.15-0.43) and insurance coverage in the prior 30 days (aOR = 0.46, 95 % CI 0.26-0.81).

CONCLUSIONS

The racial disparities of HIV and incarceration among Black individuals in the US are underscored by the finding that 65 % of HIV-positive jail participants self-identified as Black in this ten-site study. Our study also found that 22 % of Black male participants self-identified as men who have sex with men (MSM). We believe these findings support jails as strategic venues to reach heterosexual, bisexual, and homosexual HIV-positive Black men who may have been overlooked in the community. Among HIV-positive jail entrants, Black individuals had more advanced HIV disease. Self-identification as Black was associated with a lower likelihood of having health insurance or an HIV provider prior to incarceration. HIV care and linkage interventions are needed within jails to better treat HIV and to address these racial disparities.

Post-release substance abuse outcomes among HIV-infected jail detainees: results from a multisite study

HIV-infected individuals with substance use disorders have a high prevalence of medical and psychiatric morbidities that complicate treatment. Incarceration further disrupts healthcare access and utilization. Without appropriate diagnosis and treatment, drug relapse upon release exceeds 85 %, which contributes to poor health outcomes. A prospective cohort of 1,032 HIV-infected jail detainees were surveyed in a ten-site demonstration project during incarceration and six-months post-release, in order to examine the effect of predisposing factors, enabling resources and need factors on their subsequent drug use. Homelessness, pre-incarceration cocaine and opioid use, and high drug and alcohol severity were significantly associated with cocaine and opioid relapse. Substance abuse treatment, though poorly defined, did not influence post-release cocaine and opioid use. An approach that integrates multiple services, simultaneously using evidence-based substance abuse, psychiatric care, and social services is needed to improve healthcare outcomes for HIV-infected persons transitioning from jails to the community.

Conducting Ethical Research with Correctional Populations: Do Researchers and IRB Members Know the Federal Regulations?

Conducting or overseeing research in correctional settings requires knowledge of specific federal rules and regulations designed to protect the rights of individuals in incarceration. To investigate the extent to which relevant groups possess this knowledge, using a 10-item questionnaire, we surveyed 885 IRB prisoner representatives, IRB members and chairs with and without experience reviewing HIV/AIDS correctional protocols, and researchers with and without correctional HIV/AIDS research experience. Across all groups, respondents answered 4.5 of the items correctly. Individuals who have overseen or conducted correctional research had the highest scores; however, even these groups responded correctly only to slightly more than half of the items. These findings emphasize the need for ongoing training in federal guidelines governing correctional research, particularly for those individuals who are embarking on this type of research.

Rapid HIV testing for individuals on probation/parole: outcomes of an intervention trial

Many probationers and parolees do not receive HIV testing despite being at increased risk for obtaining and transmitting HIV. A two-group randomized controlled trial was conducted between April, 2011 and May, 2012 at probation/parole offices in Baltimore, Maryland and Providence/Pawtucket, Rhode Island. Male and female probationers/parolees were interviewed (n = 1,263) and then offered HIV testing based on random assignment to one of two conditions: (1) On-site rapid HIV testing conducted at the probation/parole office; or (2) Referral for rapid HIV testing off site at a community HIV testing clinic. Outcomes were: (1) undergoing HIV testing; and (2) receipt of HIV testing results. Participants were significantly more likely to be tested on-site at a probation/parole office versus off-site at a HIV testing clinic (p < 0.001). There was no difference between the two groups in terms of receiving HIV testing results. Findings indicate that probationers/parolees are willing to be tested on-site and, independent of testing location, are equally willing to receive their results. Implications for expanding rapid HIV testing to more criminal justice related locations and populations are discussed.

Indications for testing among reported cases of HCV infection from enhanced hepatitis surveillance sites in the United States, 2004-2010

OBJECTIVES

Centers for Disease Control and Prevention has recommended a 1-time HCV test for persons born from 1945 through 1965 to supplement current risk-based screening. We examined indications for testing by birth cohort (before 1945, 1945-1965, and after 1965) among persons with past or current HCV.

METHODS

Cases had positive HCV laboratory markers reported by 4 surveillance sites (Colorado, Connecticut, Minnesota, and New York) to health departments from 2004 to 2010. Health department staff abstracted demographics and indications for testing from cases' medical records and compiled this information into a surveillance database.

RESULTS

Of 110, 223 cases of past or current HCV infection reported during 2004-2010, 74, 578 (68%) were among persons born during 1945-1965. Testing indications were abstracted for 45, 034 (41%) cases; of these, 29 ,544 (66%) identified at least 1 Centers for Disease Control and Prevention-recommended risk factor as a testing indication. Overall, 74% of reported cases were born from 1945 to 1965 or had an injection drug use history.

CONCLUSIONS

These data support augmenting the current HCV risk-based screening recommendations by screening adults born from 1945 to 1965.

HIV-risk characteristics in community corrections

OBJECTIVE

Individuals in the criminal justice system engage in behaviors that put them at high risk for HIV. This study sought to identify characteristics of individuals who are under community corrections supervision (eg, probation) and at risk for HIV.

METHODS

Approximately 25,000 individuals under community corrections supervision were assessed for HIV risk, and 5059 participants were deemed high-risk or no-risk. Of those, 1519 exhibited high sexual-risk (SR) behaviors, 203 exhibited injection drug risk (IVR), 957 exhibited both types of risk (SIVR), and 2380 exhibited no risk. Sociodemographic characteristics and drug of choice were then examined using univariate and binary logistic regression.

RESULTS

Having a history of sexual abuse, not having insurance, and selecting any drug of choice were associated with all forms of HIV risk. However, the effect sizes associated with the various drugs of choice varied significantly by group. Aside from those common risk factors, very different patterns emerged. Female gender was a risk factor for the SR group but was less likely to be associated with IVR. Younger age was associated with SR, whereas older age was associated with IVR. Black race was a risk factor for SR but had a negative association with IVR and SIVR. Living in a shelter, living with relatives/friends, and being unemployed were all risk factors for IVR but were protective factors for SR.

CONCLUSIONS

Distinct sociodemographic and substance use characteristics were associated with sexual versus injection drug use risk for individuals under community corrections supervision who were at risk for HIV. Information from this study could help identify high-risk individuals and allow tailoring of interventions.

HIV among persons incarcerated in the USA: a review of evolving concepts in testing, treatment, and linkage to community care

PURPOSE OF REVIEW

People who are incarcerated have a disproportionately high risk of HIV infection. They also tend to have risk factors associated with underutilization of antiretroviral therapy (ART) such as substance abuse, mental illness, and poor access to care. In this review, we describe how incarceration is a marker of vulnerability for suboptimal HIV care, and also how criminal justice settings may be leveraged as a platform for promoting testing, linkage, and retention in HIV care for a high-risk, marginalized population.

RECENT FINDINGS

In both prisons and jails, routine, opt-out HIV testing strategies are more appropriate for screening correctional populations than traditional, risk-based strategies. Rapid HIV testing is feasible and acceptable in busy, urban jail settings. Although ART is successfully administered in many prison settings, release to the community is strongly associated with inconsistent access to medications and other structural factors leading to loss of viral suppression.

SUMMARY

Collaborations among HIV clinicians, criminal justice personnel, and public health practitioners represent an important strategy for turning the tide on the HIV epidemic. Success will depend upon scaled-up efforts to seek individuals with undiagnosed infection and bring those who are out-of-care into long-term treatment.

High prevalence but low awareness of hepatitis C virus infection among heroin users who received methadone maintenance therapy in Taiwan

BACKGROUND

This study investigates the prevalence and correlates of hepatitis C virus (HCV) infections among heroin dependent individuals who received methadone maintenance therapy in Taiwan. Also, we investigate users' awareness of HCV.

METHODS

Participants were 773 heroin users entering the methadone maintenance treatment (MMT) program at Tsaotun Psychiatric Center in Taiwan. The presence of HCV antibodies was detected. Multivariate logistic regression was used to identify the relationship between HCV infection and correlates.

RESULTS

The prevalence of HCV infection was 90.8%. All participants who were HIV-positive were also infected with HCV. Multivariate logistic regression analysis showed that the route of heroin administration (injection), HIV-infection, and criminal records were significantly related to HCV infection. Few (34.8%) HCV positive heroin users were aware of their infection.

CONCLUSION

An extremely high prevalence of HCV infection but low awareness of their infection status was found among MMT patients in Taiwan. These findings highlight the importance of education regarding risky behaviors and the necessity for HCV treatment for this population in Taiwan.

Burden of infectious diseases, substance use disorders, and mental illness among Ukrainian prisoners transitioning to the community

Background

The epidemics of incarceration, substance use disorders (SUDs), and infectious diseases are inextricably intertwined, especially in the Former Soviet Union (FSU). Few objective data documenting this relationship regionally are available. We therefore conducted a comprehensive, representative country-wide prison health survey in Ukraine, where one of the world’s most volatile HIV epidemics persists, in order to address HIV prevention and treatment needs.

Methods

A nation-wide, multi-site randomly sampled biobehavioral health survey was conducted in four Ukrainian regions in 13 prisons among individuals being released within six months. After consent, participants underwent standardized health assessment surveys and serological testing for HIV, viral hepatitis, and syphilis.

Results

Of the 402 participants (mean age = 31.9 years), 20.1% were female. Prevalence of HIV, HCV, HBV, and syphilis was 19.4% (95% CI = 15.5%–23.3%), 60.2% (95% CI = 55.1%–65.4%), 5.2% (95% CI = 3.3%–7.2%), and 10% (95% CI = 7.4%–13.2%), respectively, with regional differences observed; HIV prevalence in the south was 28.6%. Among the 78 HIV-infected inmates, 50.7% were unaware of their HIV status and 44 (56.4%) had CD4<350 cells/mL, of which only five (11%) antiretroviral-eligible inmates were receiving it. Nearly half of the participants (48.7%) reported pre-incarcertion drug injection, primarily of opioids, yet multiple substance use (31.6%) and alcohol use disorders (56.6%) were common and 40.3% met screening criteria for depression.

Conclusions

This is the only such representative health study of prisoners in the FSU. This study has important implications for regional prevention and treatment because, unlike elsewhere, there is no recent evidence for reduction in HIV incidence and mortality in the region. The prevalence of infectious diseases and SUDs is high among this sample of prisoners transitioning to the community. It is critical to address pre- and post-release prevention and treatment needs with the development of linkage programs for the continuity of care in the community after release.