Understanding the revolving door: individual and structural-level predictors of recidivism among individuals with HIV leaving jail

Reimbursing incarcerated individuals for participation in research: A scoping review

BACKGROUND

Little is known about global practices regarding the provision of reimbursement for the participation of people who are incarcerated in research. To determine current practices related to the reimbursement of incarcerated populations for research, we aimed to describe international variations in practice across countries and carceral environments to help inform the development of more consistent and equitable practices.

METHODS

We conducted a scoping review by searching PubMed, Cochrane library, Medline, and Embase, and conducted a grey literature search for English- and French-language articles published until September 30, 2022. All studies evaluating any carceral-based research were included if recruitment of incarcerated participants occurred inside any non-juvenile carceral setting; we excluded studies if recruitment occurred exclusively following release. Where studies failed to indicate the presence or absence of reimbursement, we assumed none was provided.

RESULTS

A total of 4,328 unique articles were identified, 2,765 were eligible for full text review, and 426 were included. Of these, 295 (69%) did not offer reimbursement to incarcerated individuals. A minority (n = 13; 4%) included reasons explaining the absence of reimbursement, primarily government-level policies (n = 7). Among the 131 (31%) studies that provided reimbursement, the most common form was monetary compensation (n = 122; 93%); five studies (4%) offered possible reduced sentencing. Reimbursement ranged between $3-610 USD in total and 14 studies (11%) explained the reason behind the reimbursements, primarily researchers' discretion (n = 9).

CONCLUSIONS

The majority of research conducted to date in carceral settings globally has not reimbursed incarcerated participants. Increased transparency regarding reimbursement (or lack thereof) is needed as part of all carceral research and advocacy efforts are required to change policies prohibiting reimbursement of incarcerated individuals. Future work is needed to co-create international standards for the equitable reimbursement of incarcerated populations in research, incorporating the voices of people with lived and living experience of incarceration.

The relationship between reincarceration and treatment of opioid use disorder with extended-release naltrexone among persons with HIV

Background

In the United States, a disproportionate number of persons with HIV (PWH) and opioid use disorder (OUD) are involved in the justice system. Medications for OUD (MOUD) can reduce convictions and incarceration time in persons with OUD. Extended-release naltrexone (XR-NTX) has been shown to reduce craving of opioids, recurrence of use, and overdose and help achieve or maintain HIV viral suppression in PWH with OUD involved with the justice system.

Objectives

This retrospective study aimed to describe factors associated with reincarceration and to evaluate if XR-NTX was associated with reduced reincarceration among PWH and OUD who were released to the community from incarceration.

Methods

Data from participants released to the community from incarceration from a completed randomized controlled trial was analyzed using a generalized linear model to estimate odds ratios associated with reincarceration and a Kaplan-Meier survival analysis to determine time to reincarceration and non-reincarcerated individuals were compared.

Results

Of the 77 participants, 41 (53.2%) were reincarcerated during the 12-month study period. The mean time to reincarceration was 190 days (SD=108.3). Compared with participants who remained in the community, reincarcerated participants were more likely to have major depressive disorder at study baseline, increased opioid cravings, longer mean lifetime incarceration, and a higher physical quality of life score. XR-NTX was not significantly associated statistically with reincarceration in this analysis.

Conclusion

Reducing reincarceration is a public health priority, given the high proportion of PWH and OUD in the U.S. justice system as well as high degrees of persons returning to the community and having care interrupted due to reincarceration. This analysis determined that potentially identifying depression in recently released individuals could improve HIV outcomes, decrease recurrence of opioid use, and reduce reincarceration.

"They Give you a bus Ticket and They Kick you Loose": A Qualitative Analysis of Post-Release Experiences among Recently Incarcerated Women Living with HIV in Metro Vancouver, Canada

To explore the transition from correctional facilities to community among women living with HIV in Vancouver, Canada, we interviewed 19 recently incarcerated women and 6 service providers. Findings highlighted heightened risk of violence at release, a lack of immediate supports, challenges accessing safe housing and addictions treatment, and interruptions in HIV treatment and care. In the face of structural barriers, women blamed themselves for not being able to break the cycle of incarceration. There is a critical need for enhanced pre-release planning with a priority on housing and substance use services, alongside supports that are trauma-and violence-informed and culturally safe.

Prevalence and Social-Structural Correlates of Gender-Based Violence Against Women Living With HIV in Metro Vancouver, Canada

Violence experienced by cisgender (cis) and gender minority women living with HIV is known to be high. More work is needed to better understand how to support women living with HIV who have experienced violence. The objectives of this study are therefore to identify the prevalence and correlates of violence by any perpetrator among women living with HIV in a Canadian setting. Data were drawn from 9 years (January, 2010 to February, 2019) of a longitudinal community-based open cohort study of 350+ cis and trans women living with HIV who were living and/or accessed care in Metro Vancouver, Canada (Sexual Health and HIV/AIDS: Women's Longitudinal Needs Assessment "SHAWNA"). Participants completed baseline and biannual follow-up interviews. Bivariate and multivariable logistic regression with generalized estimating equations (GEE) were performed to identify correlates of recent (last 6 months) violence (physical and/or sexual) by any perpetrator. Adjusted odds ratios (AOR) and 95% confidence intervals (95% CIs) are presented. At baseline, prevalence of violence was high: 95.5% (recent = 19.4%) of participants reported lifetime physical and/or sexual violence, 94.8% (recent = 17.9%) reported lifetime physical violence, and 84.5% (recent = 5.7%) reported lifetime sexual violence. In multivariable logistic regression with GEE, the following variables were associated with higher odds of recent physical/sexual violence: youth (<30 years) (AOR: 1.60, 95% CI [1.15, 2.22]), recent unstable housing/homelessness (AOR: 1.96, 95% CI [1.30, 2.97]), recent food insecurity (AOR: 1.57, 95% CI [1.13, 2.17]), recent incarceration (AOR: 1.85, 95% CI [1.18, 2.91]), recent opioid use (AOR: 1.38, 95% CI [1.04, 1.82]), recent stimulant use (AOR: 2.48, 95% CI [1.72, 3.56]), and lifetime HIV status disclosure without consent (AOR: 1.59, 95% CI [1.13, 2.24]). Trauma- and violence-informed (TVI) policies that include a focus on confidentiality and safe disclosure practices should be integrated into existing housing, incarceration, and harm reduction programs, and HIV care and practice for women living with HIV. Programs and policies that address high levels of violence remain critical.

Pathways From Recent Incarceration to Antiretroviral Therapy Adherence: Opportunities for Interventions to Support Women Living With HIV Post Release From Correctional Facilities

ABSTRACT

Women living with HIV are increasingly incarcerated and experience suboptimal HIV health outcomes post release from incarceration. Drawing on cohort data with cisgender and trans women living with HIV (Sexual Health and HIV/AIDS: Women's Longitudinal Needs Assessment), we used path analysis to investigate pathways from recent incarceration to optimal antiretroviral therapy (ART) adherence. We tested direct effects between recent incarceration, mediating variables, and ART adherence, along with indirect effects between incarceration and ART adherence through each mediator. We assessed model fit using chi-square, root-mean-square error of approximation (RMSEA), and comparative fit index (CFI). Our hypothesized model fit well to the data (χ2(1)=1.100; p=.2943; CFI = 1.000; RMSEA = 0.007). Recent experiences of homelessness, criminalized substance use, and gender-based violence each fully mediated the pathway between recent incarceration and optimal ART adherence. Findings highlight the need for safe and supportive housing, supports for criminalized substance use, and trauma and violence-informed care and practice post release from incarceration.

Policy Solutions to End Gaps in Medicaid Coverage during Reentry after Incarceration in the United States: Experts' Recommendations

Aims

We sought to gather experts' perspectives on Medicaid coverage gaps during reentry to identify high-yield policy solutions to improve the health of justice-involved individuals in the United States.

Subject and Methods

We interviewed 28 experts at the intersection of Medicaid and criminal justice via telephone between November 2018 and April 2019. Interviewees included Medicaid administrators, health and justice officials, policy makers, and health policy researchers. We performed thematic analysis of semi-structured interview transcripts to identify emergent themes and distill policy recommendations.

Results

Three themes emerged: 1) Medicaid coverage gaps during reentry contribute to poor health outcomes and recidivism, 2) Excessive burden on justice-involved people to re-activate Medicaid leads to coverage gaps, and 3) Scalable policy solutions exist to eliminate Medicaid coverage gaps during reentry. Policy recommendations centered on ending the federal "inmate exclusion," delaying Medicaid de-activation at intake, and promoting re-activation by reentry. Experts viewed coverage gaps as problematic, viewed current approaches as inefficient and burdensome to families and systems, and recommended several policy solutions.

Conclusion

By pursuing strategies to eliminate Medicaid gaps during reentry, policymakers can improve health outcomes and efficiency of government spending on healthcare, and may reduce cycles of incarceration.

Implementation of a COVID-19 Infection Control Plan in a Large Urban Jail System

When the COVID-19 pandemic hit the United States, the number of people confined in correctional facilities on a single day numbered 1.8 million. Incarcerated people are at an increased risk of contracting and spreading SARS-CoV-2. Recommendations from the Centers for Disease Control and Prevention on case recognition, management, isolation, and contact tracing are particularly challenging in jails because of the high turnover of incarcerated people. Beginning in late February 2020, the Department of Correctional Health Services in the Los Angeles County Jail system implemented a multipronged COVID-19 mitigation plan that was progressively amended in accordance with local and national recommendations. This plan entailed the creation of housing for people under investigation, SARS-CoV-2 screening upon entry, a mass-testing program, and identification and monitoring of medically vulnerable people. After the identification of the first laboratory-confirmed case on March 29, 2020, predictive models were generated to visualize potential disease spread and gain support for mitigation strategy planning, which forecasted approximately 3300-4600 cumulative cases during a 278-day period. From March 7 through December 31, 2020, the percentage positivity among unique people tested for SARS-CoV-2 was 11.6% (3933 of 33 921 tested). Among those screened at intake, the percentage positivity was 2.0% (502 of 25 702 tested). The ethnic distribution among people with a positive SARS-CoV-2 test result was largely representative of the overall jail population, and most people were asymptomatic. A sustainable, multifaceted mitigation plan that relies on collaboration among medical, custodial, and local public health personnel is essential for limiting the spread of SARS-CoV-2 infection in correctional facilities.

Patient, medical and legal perspectives on reentry: the need for a low-barrier, collaborative, patient-centered approach

BACKGROUND

Worldwide, the United States has the highest incarceration rate per capita. Thousands of people are released from US correctional facilities each year, including many who are impacted by HIV infection and substance use disorder (SUD), two frequently comorbid conditions that present multiple challenges upon reentry. Reentry and care engagement research involving justice-involved people with HIV (PWH) with comorbid SUD has been largely limited to the perspective of those released. To formulate effective interventions for this population aimed at maintaining health and reducing recidivism, it is crucial to collect data from formerly incarcerated individuals with firsthand experience of the reentry process as well as other actors within the reentry framework. Insights from medical and legal service providers working in reentry systems have the potential to address key implementation concerns. To inform an intervention aimed at helping recently-released individuals PWH and SUD, we conducted a qualitative study to assess barriers and facilitators to community reentry from the perspectives of diverse consumers and providers of medical, legal, and reentry services.

RESULTS

Fifteen stakeholders within XXX County participated in in-person interviews. Results indicated that 1) Patients/clients emphasized psychosocial support and individual attitude more than medical and legal participants, who chiefly focused on logistical factors such as finances, housing, and transportation; 2) Patients/clients expressed both medical and legal needs during the reentry period, though medical providers and participants from legal entities mainly expressed concerns limited to their respective scopes of work; 3) All three participant groups underscored the need for a low-barrier, collaborative, patient-centered approach to reentry with the goal of achieving self-sufficiency.

CONCLUSIONS

Findings support and extend existing literature detailing the barriers and facilitators to successful reentry. Our findings underscore the notion that an effective reentry intervention addresses both medical and legal needs, includes an individualized approach that incorporates psychosocial needs, and focuses on establishing self-sufficiency.

Incarceration History and HIV Care Among Individuals Living with HIV in Florida, 2014-2018

The present study examines the HIV continuum of care outcomes among people living with HIV (PLWH) who have either recent (< 12-months) or distal (> 12-months) incarceration history compared to those without an incarceration history. A self-administered survey (as part of the Florida Cohort Study (n = 932)) was used to collect data on demographic information, linkage to care, retention in care, HIV medication adherence, viral suppression, and incarceration history. Those with recent incarceration history were least likely to report HIV medication adherence greater than or equal to 95% of the time (χ² = 8.79; p = 0.0124), always take their medications as directed (χ² = 15.29; p = 0.0005), and to have durable viral suppression (χ² = 16.65; p = 0.0002) compared to those distally or never incarcerated. In multivariable analyses, those never and distally incarcerated had greater odds of care linkage ([vs recently incarcerated] AOR = 2.58; CI: 1.31, 5.07; p = 0.0063, AOR = 2.09; CI: 1.11, 3.95; p = 0.0228, respectively). Those never incarcerated had greater odds of taking ART as directed ([vs recently incarcerated] AOR = 2.53; CI: 1.23 - 5.19; p = 0.0116). PLWH with an incarceration history may need more on-going monitoring and follow-up HIV care than those without previous incarceration regardless of when incarceration occurred.

Characteristics and risk of incarceration among "hard-to-reach" people who use drugs: A five-year prospective cohort study combining self-reports and registry data

BACKGROUND

Incarcerations are associated with an increased risk of morbidity and mortality among people who use drugs (PWUD). In a sample of 884 PWUD, we examine and estimate the risk of incarcerations (i.e., number, duration, and most serious offense).

METHODS

In this prospective cohort study, PWUD were recruited from street- and low-threshold services in seven Norwegian cities in 2013 (Sept-Nov), and followed through the Correctional Service Registry until 20.12.2018. The risk of incarceration during follow-up was examined with multivariable logistic (no incarceration vs. at least one) and multinomial regression models ("no incarcerations", vs. "1″, "≥2″), while accounting for gender, age, homelessness/shelter use, opioid substitution treatment, illegal income sources, injecting behaviours, previous incarcerations, and recruitment city.

RESULTS

During follow-up, there were in total 662 incarceration episodes, and 44.7% of the participants were incarcerated at least once. Overall, 37.5% of those incarcerated had at least one episode due to a drug offense. The average incarceration duration was 65.2 days with 3.5% of the episodes lasting ≥one year. Gender (male), homelessness/shelter use, illegal income sources, injecting stimulants, and previous incarcerations increased the odds of incarceration, while older age decreased the odds. Gender (male), younger age, self-reported theft or theft and dealing, injecting stimulants or heroin and stimulants and previous incarcerations increased the risk of multiple incarcerations.

CONCLUSION

In a five-year prospective study of PWUD, incarcerations were common, and short-term sentences and recidivism were the norm. This is of concern as incarcerations add to an already elevated morbidity and mortality risk in this population.

The Development Of Health And Housing Consortia In New York City

Health and housing consortia in New York City offer a model for bridging the divide between the health care and housing sectors. While staff in these sectors often recognize the need to better integrate their services, there are few models for doing so. In this article we describe the formation of a health and housing consortium in the Bronx, New York City, as well as the successful replication of its model in Brooklyn. While each consortium has some features specific to its service area, the primary goal of both is the same: to provide a neutral space for health care and housing organizations to collaborate in what is otherwise often competitive and fragmented territory. In addition, the work of both consortia coalesces around training and resource development, cross-sector communication, and research and advocacy. We provide examples of the Bronx Consortium's activities in each of these core areas, highlight tangible results to date, and offer recommendations for people interested in undertaking similar efforts.

Transitioning into the Community: Perceptions of Barriers and Facilitators Experienced By Formerly Incarcerated, Homeless Women During Reentry-A Qualitative Study

Formerly incarcerated, homeless women on parole or probation experience individual-and structural-level barriers and facilitators as they prepare to transition into the community during reentry. A qualitative study was undertaken using focus group methods with formerly incarcerated, currently homeless women (N = 18, M_age = 37.67, SD 10.68, 23-53 years of age) exiting jail or prison. Major themes which emerged included the following: (1) access to resources-barriers and facilitators during community transition, (2) familial reconciliation and parenting during community transition, and (3) trauma and self-care support during community transition. These findings suggest a need to develop multi-level interventions at the individual, program and institutional/societal level with a gender-sensitive lens for women who are transitioning to community reentry. It is hoped that providing such resources will reduce the likelihood of homelessness and reincarceration.

Body pack in sick bodies: a retrospective study of somatic and psychiatric comorbidities among body-packers

PURPOSE

Body-packing means concealing packets of illicit psychoactive substances in the digestive or genital system. The purpose of this paper is to investigate profiles of body-packers and comorbidities associated with body-packing.

DESIGN/METHODOLOGY/APPROACH

A retrospective study (2005-2016) was conducted among all patients hospitalized for suspicion of body-packing in the Geneva hospital prison unit (n=287). Data were extracted from medical records and included demographics, somatic/psychiatric diseases, suicidal ideation and psychological distress.

FINDINGS

Body-packers were mostly young men (mean age=33.4). A total of 42.2 percent of the participants had at least one psychiatric or somatic comorbidity reported during incarceration (somatic: 28.2 percent, psychiatric: 18.8 percent). The most frequent somatic diseases were infectious (10.5 percent), cardiovascular (10.1 percent), and endocrinological (4.2 percent) diseases, and more precisely HIV (4.5 percent), hepatitis B (3.5 percent), hepatitis C (1.4 percent), high blood pressure (8.0 percent) and diabetes (4.2 percent). The most frequent psychiatric conditions were substance use disorders (10.5 percent) and mood disorders (8.0 percent). Depressed mood/psychological distress and suicidal ideation were frequently reported during hospitalization (27.2/6.6 percent). Comorbidities were associated with demographics: Females were more likely to have somatic and psychiatric diseases detected during hospitalization in detention and participants from Western, educated, industrialized, rich and democratic countries were more likely to report diseases known before detention.

ORIGINALITY/VALUE

Body-packers bear a heavy burden of disease and psychological distress. This vulnerable subgroup of incarcerated people has been overlooked in previous research and their health needs are not correctly understood. This study was a first step to improve their health care and reintegration.

Epidemiology of Incarceration: Characterizing Jail Incarceration for Public Health Research

BACKGROUND

Each year, 9 million individuals cycle in and out of jails. The under-characterization of incarceration as an exposure poses substantial challenges to understanding how varying levels of exposure to jail may affect health. Thus, we characterized levels of jail incarceration including recidivism, number of incarcerations, total and average number of days incarcerated, and time to reincarceration.

METHODS

We created a cohort of 75,203 individuals incarcerated at the Coconino County Detention Facility in Flagstaff, Arizona, from 2001 to 2018 from jail intake and release records.

RESULTS

The median number of incarcerations during the study period was one (interquartile range [IQR] = 1-2). Forty percent of individuals had >1 incarceration. The median length of stay for first observed incarcerations was 1 day (IQR = 0-5). The median total days incarcerated was 3 (IQR = 1-23). Average length of stay increased by number of incarcerations. By 18 months, 27% of our sample had been reincarcerated.

CONCLUSION

Characteristics of jail incarceration have been largely left out of public health research. A better understanding of jail incarcerations can help design analyses to assess health outcomes of individuals incarcerated in jail. Our study is an early step in shaping an understanding of jail incarceration as an exposure for future epidemiologic research. See video abstract at, http://links.lww.com/EDE/B536.

Recent Incarceration as a Primary Barrier to Virologic Suppression Among Women Living with HIV: Results from a Longitudinal Community-Based Cohort in a Canadian Setting

Women living with HIV (WLWH) are disproportionately represented among incarcerated populations yet there is a paucity of research on how incarceration shapes HIV treatment outcomes for women. Data is drawn from SHAWNA (Sexual health and HIV/AIDS: Women's Longitudinal Needs Assessment), a longitudinal community-based open research cohort with cis and trans WLWH in Metro Vancouver, Canada (2010-2017). Multivariable logistic regression using generalized estimating equations (GEE) longitudinally modeled the effect of incarceration on virologic suppression (HIV plasma VL < 50 copies/mL), adjusting for potential confounders. Amongst 292 WLWH, the majority (74%) had been incarcerated in their lifetime and 17% were incarcerated over the study period. Exposure to recent incarceration was independently correlated with reduced odds of virologic suppression (AOR: 0.42, 95% CI 0.22-0.80). This study suggests critical need for research and interventions to better address factors shaping ART adherence and retention in care for WLWH, both within correctional centres and following release from prison.

Social Determinants of Health and Retention in HIV Care Among Recently Incarcerated Women Living with HIV in Canada

Women living with HIV (WLWH) are over-represented in corrections in Canada, yet little is known about women's experiences post-release. We used CHIWOS cross-sectional data from WLWH to estimate associations between social determinants of health and HIV-related care outcomes among WLWH with recent (within past year) or ever (before past year) incarceration experience. Lifetime incarceration prevalence was 36.9% (6.5% recent; 30.4% ever), with significant differences by province of residence (British Columbia: 10% recent; 52% ever; Ontario: 5%; 24%; Quebec: 6%; 22%; p < 0.001). In adjusted multinomial logistic regression analyses, compared with never incarcerated, recent incarceration was associated with Indigenous ancestry, lower annual income (< $20,000 CAD), unstable housing, current sex work, injection drug use (IDU), and sub-optimal antiretroviral therapy (ART) adherence, while ever incarceration was associated with current sex work, IDU, and experiencing adulthood violence. Our findings have implications regarding supports needed by WLWH in the post-release period, including ART adherence and achieving health and social goals.

Eliminating Gaps in Medicaid Coverage During Reentry After Incarceration

This commentary explores the health and social challenges associated with gaps in Medicaid health insurance coverage for adults and youths exiting the US criminal justice system, and highlights some potential solutions.Because a high proportion of recently incarcerated people come from low-income backgrounds and experience a high burden of disease, the Medicaid program plays an important role in ensuring access to care for this population. However, the Medicaid Inmate Exclusion Policy, or "inmate exclusion," leads to Medicaid being terminated or suspended upon incarceration, often resulting in gaps in Medicaid coverage at release. These coverage gaps interact with individual-level and population-level factors to influence key health and social outcomes associated with recidivism.Ensuring Medicaid coverage upon release is an important, feasible component of structural change to alleviate health inequities and reduce recidivism. High-yield opportunities to ensure continuous coverage exist at the time of Medicaid suspension or termination and during incarceration prior to release.

Violence and other social structural factors linked to incarceration for women living with HIV in Metro Vancouver: need for trauma-informed HIV care in prisons and post-Release

Despite women living with HIV (WLWH) being disproportionately criminalized and overrepresented within correctional facilities, there remains limited longitudinal research with WLWH examining factors that make WLWH vulnerable to incarceration. Data are drawn from SHAWNA (Sexual health and HIV/AIDS: Women's Longitudinal Needs Assessment), a community-based research cohort with cisgender and transgender WLWH in Metro Vancouver, Canada. Multivariable logistic regression using generalized estimating equations (GEE) and an exchangeable working correlation matrix was used to prospectively model correlates of recent incarceration exposure over a seven-year period. Amongst 289 WLWH, 76% had been incarcerated in their lifetime, and 17% had experienced recent incarceration. In multivariable GEE analysis, younger age (AOR: 0.92 per year older, 95% CI: 0.89-0.96), recent homelessness (AOR: 2.81, 95% CI: 1.46-5.41), recent gender-based (physical and/or sexual) violence (AOR: 2.26, 95% CI: 1.20-4.22) and recent opioid use (AOR: 1.83, 95% CI: 1.00-3.36), were significantly associated with recent incarceration. Lifetime exposure to gender-based violence by police (AOR: 1.97, CI: 0.97-4.02) was marginally associated with increased odds of recent incarceration. This research suggests a critical need for trauma-informed interventions for WLWH during and following incarceration. Interventions must be gender specific, include housing and substance use supports, and address the impact of gender-based violence.

Antiretroviral Adherence Following Prison Release in a Randomized Trial of the imPACT Intervention to Maintain Suppression of HIV Viremia

Many people living with HIV (PLWH) pass through correctional facilities each year, a large proportion of whom do not maintain viral suppression following release. We examined the effects of imPACT, an intervention designed to promote post-release viral suppression, on antiretroviral therapy (ART) adherence. PLWH awaiting release from prisons in two southern states were randomized to imPACT (consisting of motivational interviewing, care linkage coordination, and text message medication reminders) versus standard care (SC). ART adherence, measured by unannounced monthly telephone pill counts, was compared between study arms over 6 months post-release. Of 381 participants eligible for post-release follow-up, 302 (79%) completed ≥ 1 of 6 possible pill counts (median: 4; IQR 1-6). Average adherence over follow-up was 80.3% (95% CI 77.5, 83.1) and 81.0% (78.3, 83.6) of expected doses taken in the imPACT and SC arms, respectively. There was no difference between arms when accounting for missing data using multiple imputation (mean difference = - 0.2 percentage points [- 3.7, 3.3]), controlling for study site and week of follow-up. Of the 936 (40.9%) pill counts that were missed, 212 (22.7%) were due to re-incarceration. Those who missed pill counts for any reason were more likely to be unsuppressed, suggesting that they had lower adherence. However, missingness was balanced between arms. Among PLWH released from prison, ART adherence averaged > 80% in both study arms over 6 months-a level higher than seen with most other chronic diseases. However, missing data may have led to an overestimate of adherence. Factors independent of the intervention influence ART adherence in this population and should be identified to inform future targeted interventions.

Criminal Justice System Involvement as a Risk Factor for Detectable Plasma HIV Viral Load in People Who Use Illicit Drugs: A Longitudinal Cohort Study

Among HIV-positive people who use illicit drugs (PWUD) in our setting, repeated periods of incarceration adversely affect ART adherence in a dose-dependent manner. However, the impact of non-custodial criminal justice involvement on HIV-related outcomes has not been previously investigated. Data were obtained from a longitudinal cohort of HIV-positive PWUD in a setting of universal no-cost ART and complete dispensation records. Multivariate generalized estimating equations were used to calculate the longitudinal odds of having a detectable HIV VL (VL) associated with custodial and non-custodial CJS exposure. Between 2005 and 2014, 716 HIV-positive ART-exposed PWUD were recruited. In multivariate analysis, both custodial [Adjusted odds ratio (AOR) 0.61, 95% CI 0.45-0.82] and noncustodial (AOR 0.78, 95% CI 0.62-0.99) involvement in the criminal justice system was associated with detectable HIV VL. Among HIV-positive PWUD, both custodial and non-custodial criminal justice involvement is associated with worse HIV treatment outcomes. Our findings highlight the need for increased ART adherence support across the full spectrum of the criminal justice system.

Medical nutrition therapy in Canadian federal correctional facilities

Background

Under- and over nutrition as well as nutrition risk factors such as communicable and non-communicable diseases are a common and major cause of morbidity and mortality in correctional facilities. Consequently, medical nutrition therapy (MNT), a spectrum of nutrition services aimed at optimizing individual well-being, is being recognized as integral to the health of people who experience incarceration. However, there is a paucity of research that explores the delivery of MNT in correctional facilities.

Methods

A scoping review combined with secondary analysis of qualitative data (field notes, in-depth stakeholder interviews) from a 2-year ethnographic study about food insecurity and incarceration was undertaken to gain insights about the delivery of corrections-based MNT in Canada. Thematic analysis of all documents was done using an interpretive framework.

Results

An understanding about MNT was developed within three themes: 1) specialized service provision in a unique environment; 2) challenges with the provision of MNT; and 3) consideration of corrections-based MNT alternatives. An incarcerated individual’s nutritional health was conceptualized as culminating from various factors that included dietary intake and health status, enabling environments, access to quality health services, and clinical nutrition services. Nutrition care practices, which range from health promotion to rehabilitation, are challenged by issues of access, visibility, adequacy, and environmental barriers. Their success is dependent on demand (e.g., ability of recipient to act) and factors that enable quality health and food services. Advancing corrections-based MNT will require policies that provide supportive food and health environments and creating sustainable services by integrating alternatives such as peer approaches and telehealth.

Conclusions

Professional associations, government, researchers and other stakeholders can help to strengthen corrections-based MNT by fostering shifts in thinking about the role of health practitioners in these contexts, preparing future health professionals with the specialized skills needed to work in these environments, generating evidence that can best inform practice, and cultivating collaborations aimed at crime prevention, successful societal reintegration, and the reduction of recidivism.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3926-3) contains supplementary material, which is available to authorized users.

Women, incarceration and HIV: a systematic review of HIV treatment access, continuity of care and health outcomes across incarceration trajectories

OBJECTIVE

The aim of this study was to systematically review the literature on gendered implications of incarceration for HIV outcomes and engagement in care for women living with HIV (WLWH).

DESIGN

We systematically searched seven bibliographic databases, for peer-reviewed English-language studies, published between 2007 and 2017 reporting on incarceration, women (transgender inclusive) and HIV.

METHODS

Articles were included for evaluation if they reported outcomes for at least one of three measures of interest: viral load, antiretroviral therapy (ART) adherence or engagement in care among WLWH along incarceration trajectories.

RESULTS

Out of 1119 studies, 24 (2%) met the inclusion criteria. Of these 24 studies, the majority (n = 23) were conducted in the USA, 19 included samples of women and men and seven studies were transgender inclusive. Our review did not reveal clear sex differences in HIV outcomes during periods of incarceration; however, studies reporting postincarceration outcomes demonstrated significant sex disparities in all three outcomes of interest. Following incarceration, women were less likely to be virally suppressed, less likely to achieve optimal ART adherence and less likely to be engaged in care.

CONCLUSION

Despite growing numbers of incarcerated WLWH globally, there is a substantial gap in research examining the impact of incarceration on HIV outcomes for WLWH. Significant sex disparities in HIV outcomes and engagement in care exist along incarceration trajectories for WLWH, especially postincarceration. For improved health outcomes, research is needed to examine the experiences of WLWH throughout incarceration trajectories to develop interventions tailored to the specific needs of WLWH both during and following incarceration.

Understanding and Improving the Health of People Who Experience Incarceration: An Overview and Synthesis

The world prison population is growing at a rate that exceeds the rate of population growth. This issue of Epidemiologic Reviews comprises articles in which researchers summarize what is known about some of the key health issues facing people in prison, particularly in relation to human immunodeficiency virus and other blood-borne viral infections. A key recurring theme is that addressing the health needs of people in prison is important to reducing health inequalities at the population level—that prisoner health is public health. The reviews also highlight some critical evidence gaps, notably the lack of evidence from low- and middle-income countries, and the limited number of longitudinal studies in which health behaviors, health outcomes, or health service experiences after release from prison are documented. Despite growing evidence of the poor health of detained adolescents, none of the included reviews considered this population. Further research on the health of young people who cycle through juvenile detention should be a priority. Despite a rapidly growing literature on the health of people who experience incarceration, some critical health issues remain poorly understood, and there has been insufficient attention devoted to co-occurring health conditions and the consequent need for coordinated care. Key populations in custodial settings remain understudied, limiting capacity to develop targeted, evidence-based responses to their health needs. The quality of many studies is suboptimal, and although rigorous, independent research in correctional settings can be challenging, it is not impossible and is critical to laying the groundwork for evidence-based reform.

Lack of health insurance among juvenile offenders: a predictor of inappropriate healthcare use and reincarceration?

OBJECTIVES

Relationships between the health insurance status and healthcare use among justice-involved youths transitioning into adulthood is an underexplored topic, even if transition to adulthood is a crucial time period for healthcare outcomes. To fill in these knowledge gaps, this study had two aims: (1) to examine trajectories of health insurance coverage and healthcare use among serious juvenile offenders transitioning into adulthood; and (2) to explore associations between the lack of health insurance, healthcare use and reincarceration.

STUDY DESIGN

We conducted a secondary analysis on the data of the US longitudinal Pathways to Desistance study between ages 20 and 23 years (2000-2010).

METHODS

Participant data on health insurance coverage, healthcare use, reincarceration and sociodemographic variables (n = 1215) were extracted and analysed using descriptive statistics, generalized linear regressions and cross-lagged panel models.

RESULTS

About half of the young offenders had no health insurance coverage or intermittent coverage between the age of 20 and 23 years. Emergency services were used (≥17.4%), notably more by insured participants and were increasingly used over time. Being uninsured at the age of 20 years was associated with reincarceration at the age of 23 years (b = -0.052, p = 0.014, odd-ratio = 0.95), but incarceration at the age of 20 years did not predict the insurance status at the age of 23 years (b = 0.009, p = 0.792).

CONCLUSIONS

Serious juvenile offenders, especially if uninsured, faced major barriers to accessing health care and often reported an inappropriate healthcare use. This likely led to reincarceration. The lack of continuity of care and of access to health care may, therefore, increase health disparities, and efforts are needed to mitigate detrimental outcomes, by effective in and out of detention coordination of health insurance coverage and among health services.

Accumulation of Jail Incarceration and Hardship, Health Status, and Unmet Health Care Need Among Women Who Use Drugs

BACKGROUND

Jail is frequently described as a "revolving door," which can be profoundly destabilizing to people moving in and out of the system. However, there is a dearth of research attempting to understand the impacts of the accumulation of incarceration events on women who use drugs. We examined the association of the frequency of jail incarceration with hardship, perceived health status, and unmet health care need among women who use drugs.

METHODS

Our community-based sample included women who use heroin, methamphetamine, crack cocaine, and/or powder cocaine (N = 624) in Oakland, California, from 2012 to 2014. Poisson regression models with robust variances were built to estimate adjusted prevalence ratios between the frequency of jail incarcerations and measures of hardship, perceived health, and unmet health care need, adjusting for a set of a priori specified covariates.

RESULTS

We observed associations between high levels of jail frequency and higher levels of homelessness (p = .024), feeling unsafe in their living situation (p = .011), stress (p = .047), fair to poor mental health (p = .034), unmet mental health care need (p = .037), and unmet physical health care need (p = .041). We did not observe an association between jail frequency and unmet subsistence needs score or fair to poor physical health.

CONCLUSIONS

We observed associations between higher levels of jail frequency and a higher prevalence of hardship, poor mental health, and unmet health care need. Our findings suggest areas for additional research to untangle the impacts of frequent incarceration on women's health and well-being.

Unmet Mental Health and Social Service Needs of Formerly Incarcerated Women Living with HIV in the Deep South

Due to the disproportionate burden of HIV among incarcerated women in the United States, jails and prisons have been identified as key sites for health service delivery. Recidivism remains high, potentially reflecting unmet mental health and social service needs of incarcerated women, especially during the postrelease adjustment period. However, little published research has investigated this possibility directly. We conducted semi-structured, in-depth interviews with previously incarcerated women living with HIV, and other key informants, and completed service-availability mapping in two Alabama cities. Key findings were: (a) discharge planning and postrelease support services to manage risky environments were absent, (b) postrelease services were concentrated in a few community-based organizations, (c) mental health and substance abuse treatment during re-entry was essential to prevent relapse, and (d) social support was crucial for postrelease adjustment. We propose a novel conceptual model with key steps to establish continuous care for previously incarcerated women living with HIV.

Evaluating concurrent validity of criminal justice and clinical assessments among women on probation

BACKGROUND

Women in the criminal justice (CJ) system experience complex and comorbid medical, psychiatric, and substance use disorders, which often contribute to CJ involvement. To identify intersections between CJ and health needs, we calculated Spearman r correlations between concurrent CJ and clinical assessments from women on probation in Connecticut who were enrolled in a clinical trial. We examined longitudinal trends in CJ risk scores over 9 years of observation (2005-2014), modeling time to probation recidivism with shared gamma frailty models and comparing contiguous time points by Wilcoxon matched-pairs signed rank tests.

RESULTS

Women (N = 31) were predominantly white (67.7%) with at least some high school education (58.1%) and mostly unemployed (77.4%) and unstably housed (83.9%). Most met clinical criteria for severe substance use and/or psychiatric disorders. Concurrent measures of substance use, mental health, social support, partnerships, and risk by the Level of Service Inventory-Revised (LSI-R) and clinical assessments were not significantly correlated. The LSI-R personal/emotional sub-score, however, positively correlated with the Addiction Severity Index psychiatric composite score (r = 0.40, 95% CI 0.03-0.68, p = 0.03). After adjusting for age, race and number of previous events, having some high school education versus none marginally decreased the hazard for probation recidivism and having > 5 inpatient psychiatric admissions versus none increased the hazard of probation recidivism 7-fold (HR 7.49, 95% CI 1.33-42.12, p = 0.022). Women with 0-1 recurrent probation terms (n = 16) had a significantly lower mean LSI-R score than those with 2-4 recurrent probation terms (35.9 [SD 6.4] versus 39.2 [SD 3.0], p = 0.019), but repeated LSI-R scores did not change over time, nor vary significantly beyond the group mean.

CONCLUSIONS

In this small, quantitative study of women on probation, widely used CJ assessment tools poorly reflected women's comorbid medical, psychiatric, and substance use needs and varied minimally over time. Findings illustrate the limitations of contemporary CJ assessment tools for women with complex needs. The field requires more comprehensive assessments of women's social and health needs to develop individualized targeted case plans that simultaneously improve health and CJ outcomes.

Improving Health Care Linkages for Persons: The Cook County Jail Medicaid Enrollment Initiative

The Affordable Care Act has created an unprecedented opportunity to enroll criminal justice-involved individuals in Medicaid. Many jurisdictions within Medicaid expansion states are launching efforts to enroll this population in health insurance and provide connections to services in the community. This study examined one early initiative to enroll individuals in Medicaid during the intake process at the Cook County Jail in Illinois. Several elements were identified as critical to the program's success: key early planning decisions made within the context of a cross-agency group, a high level of dedication among partnering organization leaders, program buy-in among security personnel, and the unique way in which Cook County verifies inmate identity for Medicaid enrollment purposes. These features can potentially guide other jurisdictions attempting to implement similar initiatives.

Systematic review of qualitative evaluations of reentry programs addressing problematic drug use and mental health disorders amongst people transitioning from prison to communities

BACKGROUND

The paper presents a systematic review and metasynthesis of findings from qualitative evaluations of community reentry programs. The programs sought to engage recently released adult prison inmates with either problematic drug use or a mental health disorder.

METHODS

Seven biomedical and social science databases, Cinahl, Pubmed, Scopus, Proquest, Medline, Sociological abstracts and Web of Science and publisher database Taylor and Francis were searched in 2016 resulting in 2373 potential papers. Abstract reviews left 140 papers of which 8 were included after detailed review. Major themes and subthemes were identified through grounded theory inductive analysis of results from the eight papers. Of the final eight papers the majority (6) were from the United States. In total, the papers covered 405 interviews and included 121 (30%) females and 284 (70%) males.

RESULTS

Findings suggest that the interpersonal skills of case workers; access to social support and housing; and continuity of case worker relationships throughout the pre-release and post-release period are key social and structural factors in program success.

CONCLUSION

Evaluation of community reentry programs requires qualitative data to contextualize statistical findings and identify social and structural factors that impact on reducing incarceration and improving participant health. These aspects of program efficacy have implications for reentry program development and staff training and broader social and health policy and services.

Correlates of Hepatitis C Virus Infection in the Targeted Testing Program of the New York City Jail System

OBJECTIVE

The objective of this study was to understand predictors of hepatitis C virus (HCV) antibody positivity in a large urban jail system in New York City.

METHODS

We examined demographic characteristics, risk behaviors, and HCV antibody prevalence among 10 790 jail inmates aged 16 to 86 who were screened from June 13, 2013, to June 13, 2014, based on birth cohort or conventional high-risk criteria. We used logistic regression analysis to determine predictors of HCV antibody positivity.

RESULTS

Of the 10 790 inmates screened, 2221 (20.6%) were HCV antibody positive. In the multivariate analysis, HCV antibody positivity was associated most strongly with injection drug use (IDU; adjusted odds ratio [aOR] = 35.0; 95% confidence interval [CI], 28.5-43.0). Women were more likely than men to be infected with HCV (aOR = 1.3; 95% CI, 1.1-1.5). Compared with non-Hispanic black people, Hispanic (aOR = 2.1; 95% CI, 1.8-2.4) and non-Hispanic white (aOR = 1.7; 95% CI, 1.5-2.1) people were more likely to be infected with HCV. Non-IDU, recidivism, HIV infection, homelessness, mental illness, and lower education level were all significantly associated with HCV infection. The prevalence rate of HCV infection among a subset of inmates born after 1965 who denied IDU and were not infected with HIV was 5.6% (198 of 3529). Predictors of HCV infection among this group included non-IDU as well as being non-Hispanic white, Hispanic, recidivist, and homeless.

CONCLUSION

These data reveal differences in HCV infection by sex, race/ethnicity, and socioeconomics in a large jail population, suggesting that a focused public health intervention is required and that universal screening may be warranted. Further sensitivity and cost-benefit analyses are needed to make this determination.

Intersecting epidemics of HIV, HCV, and syphilis among soon-to-be released prisoners in Kyrgyzstan: Implications for prevention and treatment

BACKGROUND

Central Asia is afflicted with increasing HIV incidence, low antiretroviral therapy (ART) coverage and increasing AIDS mortality, driven primarily by people who inject drugs (PWID). Reliable data about HIV, other infectious diseases, and substance use disorders in prisoners in this region is lacking and could provide important insights into how to improve HIV prevention and treatment efforts in the region.

METHODS

A randomly sampled, nationwide biobehavioural health survey was conducted in 8 prisons in Kyrgyzstan among all soon-to-be-released prisoners; women were oversampled. Consented participants underwent computer-assisted, standardized behavioural health assessment surveys and testing for HIV, HCV, HBV, and syphilis. Prevalence and means were computed, and generalized linear modelling was conducted, with all analyses using weights to account for disproportionate sampling by strata.

RESULTS

Among 381 prisoners who underwent consent procedures, 368 (96.6%) were enrolled in the study. Women were significantly older than men (40.6 vs. 36.5; p=0.004). Weighted prevalence (%), with confidence interval (CI), for each infection was high: HCV (49.7%; CI: 44.8-54.6%), syphilis (19.2%; CI: 15.1-23.5%), HIV (10.3%; CI: 6.9-13.8%), and HBV (6.2%; CI: 3.6-8.9%). Among the 31 people with HIV, 46.5% were aware of being HIV-infected. Men, compared to women, were significantly more likely to have injected drugs (38.3% vs.16.0%; p=0.001). Pre-incarceration and within-prison drug injection, primarily of opioids, was 35.4% and 30.8%, respectively. Independent correlates of HIV infection included lifetime drug injection (adjusted odds ratio [AOR]=38.75; p=0.001), mean number of years injecting (AOR=0.93; p=0.018), mean number of days experiencing drug problems (AOR=1.09; p=0.025), increasing duration of imprisonment (AOR=1.08; p=0.02 for each year) and having syphilis (AOR=3.51; p=0.003), while being female (AOR=3.06; p=0.004) and being a recidivist offender (AOR=2.67; p=0.008) were independently correlated with syphilis infection.

CONCLUSION

Drug injection, syphilis co-infection, and exposure to increased risk during incarceration are likely to be important contributors to HIV transmission among prisoners in Kyrgyzstan. Compared to the community, HIV is concentrated 34-fold higher in prisoners. A high proportion of undiagnosed syphilis and HIV infections presents a significant gap in the HIV care continuum. Findings highlight the critical importance of evidence-based responses within prison, including enhanced testing for HIV and sexually transmitted infections, to stem the evolving HIV epidemic in the region.

Integrating correctional and community health care for formerly incarcerated people who are eligible for Medicaid

Under the Affordable Care Act, up to thirteen million adults have the opportunity to obtain health insurance through an expansion of the Medicaid program. A great deal of effort is currently being devoted to eligibility verification, outreach, and enrollment. We look beyond these important first-phase challenges to consider what people who are transitioning back to the community after incarceration need to receive effective care. It will be possible to deliver cost-effective, high-quality care to this population only if assistance is coordinated between the correctional facility and the community, and across diverse treatment and support organizations in the community. This article discusses several examples of successful coordination of care for formerly incarcerated people, such as Project Bridge and the Community Partnerships and Supportive Services for HIV-Infected People Leaving Jail (COMPASS) program in Rhode Island and the Transitions Clinic program that operates in ten US cities. To promote broader adoption of successful models, we offer four policy recommendations for overcoming barriers to integrating individuals into sustained, community-based care following their release from incarceration.

Mortality over 12 years of follow-up in people admitted to provincial custody in Ontario: a retrospective cohort study

BACKGROUND

We aimed to define rates and causes of death in custody and after release in people admitted to provincial custody in Ontario, and to compare these data with data for the general population.

METHODS

We linked data on adults admitted to provincial custody in Ontario in 2000 with data on deaths between 2000 and 2012. We examined rates and causes of death by age, sex, custodial status and period after release, and compared them with data for the general population, using indirect adjustment for age.

RESULTS

Between 2000 and 2012, 8.6% (95% confidence interval [CI] 8.3%-8.8%) of those incarcerated died in provincial custody or after release. The crude death rate was 7.1 (95% CI 6.9-7.3) per 1000 person-years. The standardized mortality ratio for those incarcerated in 2000 was 4.0 (95% CI 3.9-4.1) overall and 1.9 (95% CI 1.5-2.4) while in provincial custody. The most common causes of death were injury and poisoning (38.2% of all deaths), including overdose (13.6%) and suicide (8.2%), diseases of the circulatory system (15.8%) and neoplasms (14.5%). In the 2 weeks after release, the standardized mortality ratio was 5.7 overall and 56.0 for overdose. Life expectancy was 72.3 years for women and 73.4 for men who experienced incarceration in 2000.

INTERPRETATION

Mortality was high for people who experienced incarceration, and life expectancy was 4.2 years less for men and 10.6 years less for women compared with the general population. Efforts should be made to reduce the gap in mortality between people who experience incarceration and those who do not. Time in custody could serve as an opportunity to intervene to decrease risk.

Mortality over 12 years of follow-up in people admitted to provincial custody in Ontario: a retrospective cohort study

BACKGROUND

We aimed to define rates and causes of death in custody and after release in people admitted to provincial custody in Ontario, and to compare these data with data for the general population.

METHODS

We linked data on adults admitted to provincial custody in Ontario in 2000 with data on deaths between 2000 and 2012. We examined rates and causes of death by age, sex, custodial status and period after release, and compared them with data for the general population, using indirect adjustment for age.

RESULTS

Between 2000 and 2012, 8.6% (95% confidence interval [CI] 8.3%-8.8%) of those incarcerated died in provincial custody or after release. The crude death rate was 7.1 (95% CI 6.9-7.3) per 1000 person-years. The standardized mortality ratio for those incarcerated in 2000 was 4.0 (95% CI 3.9-4.1) overall and 1.9 (95% CI 1.5-2.4) while in provincial custody. The most common causes of death were injury and poisoning (38.2% of all deaths), including overdose (13.6%) and suicide (8.2%), diseases of the circulatory system (15.8%) and neoplasms (14.5%). In the 2 weeks after release, the standardized mortality ratio was 5.7 overall and 56.0 for overdose. Life expectancy was 72.3 years for women and 73.4 for men who experienced incarceration in 2000.

INTERPRETATION

Mortality was high for people who experienced incarceration, and life expectancy was 4.2 years less for men and 10.6 years less for women compared with the general population. Efforts should be made to reduce the gap in mortality between people who experience incarceration and those who do not. Time in custody could serve as an opportunity to intervene to decrease risk.

Health status of prisoners in Canada: Narrative review

OBJECTIVE

To review the literature for quantitative research on the health status of persons in custody in provincial, territorial, and federal correctional facilities in Canada, and summarize recent evidence.

QUALITY OF EVIDENCE

A search was performed in research databases and the websites of relevant Canadian governmental and non-governmental organizations for quantitative studies of health conducted between 1993 and 2014. Studies were included that provided quantitative data on health status for youth or adults who had been detained or incarcerated in a jail or prison in Canada.

MAIN MESSAGE

The health status of this population is poor compared with the general Canadian population, as indicated by data on social determinants of health, mortality in custody, mental health, substance use, communicable diseases, and sexual and reproductive health. Little is known about mortality after release, chronic diseases, injury, reproductive health, and health care access and quality.

CONCLUSION

Health status data should be used to improve health care and to intervene to improve health for persons while in custody and after release, with potential benefits for all Canadians.

Access to primary care in adults in a provincial correctional facility in Ontario

Background

Little is known about access to primary care either prior to or following incarceration in Canada. International data demonstrate that the health of people in prisons and jails is poor, and access to primary care in the community may be inadequate for incarcerated persons. We aimed to describe the primary care experience of adults in custody in a provincial correctional facility in Ontario in the 12 months prior to admission.

Methods

We conducted a written survey, and invited all persons in the institution to participate, excluding those in segregation.

Results

One hundred and twenty-five persons participated, 16.8 % of whom were women. The median age was 33. In the 12 months prior to admission to custody, 32.2 % (95 % CI 23.5–40.8 %) of respondents did not have a family doctor or other primary care provider and 48.2 % (95 % CI 38.8–57.6 %) had unmet health needs. Participants reported a mean of 2.1 (SD = 2.8) emergency department visits in the 12 months prior to admission.

Conclusions

Study participants report a lack of access to primary care, a high mean number of emergency department visits, and high unmet health care needs in the 12 months prior to incarceration. Time in custody may present an opportunity for connecting this population with primary care and improving health.

Explaining poor health-seeking among HIV-infected released prisoners

Purpose

– Little is understood about the self-described barriers that recently released HIV-infected prisoners face when accessing healthcare and adhering to medications. The purpose of this paper is to elucidate these barriers from the perspective of released prisoners themselves.

Design/methodology/approach

– A qualitative assessment using 30 semi-structured interviews explored individuals’ self-reported acute stressors and barriers to health-seeking during community re-integration for recidivist prisoners. Leventhal’s Self-Regulation Model of Illness (SRMI) is applied to examine both structural and psychological barriers.

Findings

– The SRMI explains that individuals have both cognitive and emotional processing elements to their illness representations, which mediate coping strategies. Cognitive representations of HIV that mediated treatment discontinuation included beliefs that HIV was stigmatizing, a death sentence, or had no physiological consequences. Negative emotional states of hopelessness and anger were either acute or chronic responses that impaired individuals’ motivation to seek care post-release. Individuals expressed feelings of mistrust, fatalism and denial as coping strategies in response to their illness, which reduced likelihood to seek HIV care.

Originality/value

– Interventions for HIV-infected individuals transitioning to the community must incorporate structural and psychological components. Structural support includes housing assistance, employment and health insurance, and linkage to mental health, substance abuse and HIV care. Psychological support includes training to enhance agency with medication self-administration and HIV education to correct false beliefs and reduce distress. Additionally, healthcare workers should be specifically trained to establish trust with these vulnerable populations.

Facilitators of HIV Medical Care Engagement Among Former Prisoners

Linkage to and retention in medical care is a concern for HIV-positive individuals leaving custody settings in the United States. The minimal existing research points to low rates of entry into care in the months following release and lapsed viral control among releasees who are subsequently reincarcerated. We conducted seven small focus group discussions with 27 HIVpositive individuals who were recently incarcerated in a California State prison to understand those factors that facilitated linkage to and retention in HIV care following their release. We used a consensual approach to code and analyze the focus group transcripts. Four main themes emerged from the analysis: (1) interpersonal relationships, (2) professional relationships, (3) coping strategies and resources, and (4) individual attitudes. Improving HIV-related outcomes among individuals after their release from prison requires strengthening supportive relationships, fostering the appropriate attitudes and skills, and ensuring access to resources that stabilize daily living and facilitate the process of accessing care.

HIV-infected men who have sex with men, before and after release from jail: the impact of age and race, results from a multi-site study

The US HIV/AIDS epidemic is concentrated among men who have sex with men (MSM). Black men are disproportionately affected by incarceration and Black MSM experience higher infection rates and worse HIV-related health outcomes compared to non-Black MSM. We compared HIV treatment outcomes for Black MSM to other HIV-infected men from one of the largest cohorts of HIV-infected jail detainees (N = 1270) transitioning to the community. Of the 574 HIV-infected men released, 113 (19.7%) self-identified as being MSM. Compared to other male subgroups, young Black MSM (<30 years old, N = 18) were significantly less likely: (1) before incarceration, to have insurance, access to an HIV healthcare provider, and use cocaine; (2) during incarceration, to receive a disease management intervention; and (3) in the 6 months post-release, to link to HIV care. Interventions that effectively link and retain young HIV-infected Black MSM in care in communities before incarceration and post-release from jail are urgently needed.

Time Since Release from Incarceration and HIV Risk Behaviors Among Women: The Potential Protective Role of Committed Partners During Re-entry

After release from incarceration, former female inmates face considerable stressors, which may influence drug use and other risk behaviors that increase risk for HIV infection. Involvement in a committed partnership may protect women against re-entry stressors that may lead to risky behaviors. This study measured the association between time since release from incarceration (1-6 months ago, and >6 months ago versus never incarcerated) and HIV risk behaviors and evaluated whether these associations differed by involvement in a committed partnership. Women released within the past 6 months were significantly more likely to have smoked crack cocaine, used injection drugs and engaged in transactional sex in the past month compared to never-incarcerated women and women released more distally. Stratified analyses indicated that incarceration within the past 6 months was associated with crack cocaine smoking, injection drug use and transactional sex among women without a committed partner yet unassociated with these risk behaviors among those with a committed partner.

Health-related factors predict return to custody in a large cohort of ex-prisoners: new approaches to predicting re-incarceration

Background

Numerous poor health outcomes have been documented in the world’s large and growing population of prisoners and ex-prisoners. Repeat justice involvement and incarceration is normative for ex-prisoners in most countries. This study aimed to identify important health-related predictors of re-incarceration and to quantify their contribution to predicting re-incarceration.

Methods

Participants were 1 325 adult ex-prisoners in Queensland, Australia. We developed a multivariate Cox proportional hazards model for re-incarceration including health-related covariates from a pre-release survey.

Results

In addition to well-established risk factors (criminal history, drug-related sentence, younger age, male gender and Indigenous ethnicity), several health-related variables were important risk factors for re-incarceration in multivariate analyses, including risky use of cannabis (hazard ratio 1.27; 95% confidence interval 1.06, 1.51), amphetamines (HR 1.20; 95%CI 0.99, 1.46) or opioids (HR 1.33; 95%CI 1.08, 1.63) prior to incarceration, central nervous system medication prescription (HR 1.28; 95%CI 1.06, 1.54), reporting that maintaining physical health post-release was not important (HR 1.52; 95%CI 0.98, 2.36) and poverty prior to incarceration (HR 1.24; 95%CI 1.02, 1.52). Sedentary behaviour (HR 0.82; 95%CI 0.68, 1.00), obesity (HR 0.81; 95%CI 0.64, 1.02), multiple lifetime chronic illnesses (HR 0.85; 95%CI 0.71, 1.01) and a history of self-harm (HR 0.72; 95%CI 0.59, 0.88) were associated with a reduced risk of re-incarceration. Inclusion of health-related variables in the model improved prediction of re-incarceration compared to a model with only demographic and criminal justice predictors, leading to an increase in adjusted proportion of explained variation of 0.051 (95%CI 0.031, 0.107).

Conclusions

Health-related factors predict re-incarceration after adjustment for demographic and criminal justice factors. Further research is required to establish the reproducibility of our findings and understand the causal pathways linking health at release from prison to re-incarceration.

Electronic supplementary material

The online version of this article (doi:10.1186/s40352-015-0022-6) contains supplementary material, which is available to authorized users.

Improving public health by respecting autonomy: using social science research to enfranchise vulnerable prison populations

It is widely recognised that prisoners constitute a vulnerable population that is subject to numerous health inequalities and merits special protection. Improving prisoners' access to healthcare by ensuring adherence to the principle of equivalence has been the main focus of efforts to ensure that their health is not jeopardised. However, another means of respecting prisoners' autonomy and improving their health is to involve them (and prison staff) in social science research within prisons. Such research not only produces valuable data which can be used to assess whether the principle of equivalence is being respected; it also enfranchises prisoners by allowing them to air concerns about perceived ill-treatment and influence their environment. If prison authorities enable such research and adjust policy accordingly, both they and prisoners will benefit from the increased level of respect for prisoners' autonomy, and the improvements in individual and public health that flow from this. Conducting social science research in prisons enables the creation of a virtuous cycle of respect that makes prisons safer and healthier places.

Research on the health of people who experience detention or incarceration in Canada: a scoping review

Background

We conducted a scoping review to define the extent and type of quantitative health status research conducted from 1993 to 2014 with people who have experienced detention or incarceration in correctional facilities in Canada.

Methods

We searched 15 databases, reviewed reference lists and relevant websites, and consulted with key stakeholders to identify eligible studies. We reviewed records for eligibility and extracted relevant data from eligible articles.

Results

We identified 194 studies that were eligible for inclusion. Most studies were conducted with males and with persons in federal facilities, and focused on mental health, substance use, and social determinant of health outcomes.

Conclusions

Health status data are limited for several outcomes, such as chronic disease, injury and sexual and reproductive health, and for persons in provincial facilities and post-release. Efforts should be made to improve data collection and knowledge dissemination, so that relevant data can be used more effectively to improve health and health care in this population.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1758-6) contains supplementary material, which is available to authorized users.

The Impact of Implementing a Test, Treat and Retain HIV Prevention Strategy in Atlanta among Black Men Who Have Sex with Men with a History of Incarceration: A Mathematical Model

Background

Annually, 10 million adults transition through prisons or jails in the United States (US) and the prevalence of HIV among entrants is three times higher than that for the country as a whole. We assessed the potential impact of increasing HIV Testing/Treatment/Retention (HIV-TTR) in the community and within the criminal justice system (CJS) facilities, coupled with sexual risk behavior change, focusing on black men-who-have-sex-with-men, 15–54 years, in Atlanta, USA.

Methods

We modeled the effect of a HIV-TTR strategy on the estimated cumulative number of new (acquired) infections and mortality, and on the HIV prevalence at the end of ten years. We additionally assessed the effect of increasing condom use in all settings.

Results

In the Status Quo scenario, at the end of 10 years, the cumulative number of new infections in the community, jail and prison was, respectively, 9246, 77 and 154 cases; HIV prevalence was 10815, 69 and 152 cases, respectively; and the cumulative number of deaths was 2585, 18 and 34 cases, respectively. By increasing HIV-TTR coverage, the cumulative number of new infections could decrease by 15% in the community, 19% in jail, and 8% in prison; HIV prevalence could decrease by 8%, 9% and 7%, respectively; mortality could decrease by 20%, 39% and 18%, respectively. Based on the model results, we have shown that limited use and access to condoms have contributed to the HIV incidence and prevalence in all settings.

Conclusions

Aggressive implementation of a CJS-focused HIV-TTR strategy has the potential to interrupt HIV transmission and reduce mortality, with benefit to the community at large. To maximize the impact of these interventions, retention in treatment, including during the period after jail and prison release, and increased condom use was vital for decreasing the burden of the HIV epidemic in all settings.

A systematic review of randomized controlled trials of interventions to improve the health of persons during imprisonment and in the year after release

We systematically reviewed randomized controlled trials of interventions to improve the health of people during imprisonment or in the year after release. We searched 14 biomedical and social science databases in 2014, and identified 95 studies. Most studies involved only men or a majority of men (70/83 studies in which gender was specified); only 16 studies focused on adolescents. Most studies were conducted in the United States (n = 57). The risk of bias for outcomes in almost all studies was unclear or high (n = 91). In 59 studies, interventions led to improved mental health, substance use, infectious diseases, or health service utilization outcomes; in 42 of these studies, outcomes were measured in the community after release. Improving the health of people who experience imprisonment requires knowledge generation and knowledge translation, including implementation of effective interventions.

Emergency department use among HIV-infected released jail detainees

Release from short-term jail detention is highly destabilizing, associated with relapse to substance use, recidivism, and disrupted health care continuity. Little is known about emergency department (ED) use, potentially a surrogate for medical, psychiatric, or social instability, by people living with HIV/AIDS (PLWHA) leaving jails. All ED visits were reviewed from medical records for a cohort of 109 PLHWA in the year following release from county jail in Connecticut, between January 1, 2008 and December 31, 2010. Primary outcomes were frequency and timing of ED visits, modeled using multivariate negative binomial regression and Cox proportional hazards regression, respectively. Demographic, substance use, and psychiatric disorder severity factors were evaluated as potential covariates. Overall, 71 (65.1%) of the 109 participants made 300 unique ED visits (2.75 visits/person-year) in the year following jail-release. Frequency of ED use was positively associated with female sex (incidence rate ratios, IRR 2.40 [1.36-4.35]), homelessness (IRR 2.22 [1.15-4.41]), and recent substance use (IRR 2.47 [1.33-4.64]), and inversely associated with lifetime drug severity (IRR 0.01 [0-0.10]), and being retained in HIV primary care (IRR 0.80 [0.65-0.99]). Those in late or sustained HIV care used the ED sooner than those not retained in HIV primary care (median for late retention 16.3 days, median for sustained retention 24.9 days, median for no retention not reached at 12 months, p value 0.004). Using multivariate modeling, those who used the ED earliest upon release were more likely to be homeless (HR 1.98 [1.02-3.84]), to be retained in HIV care (HR 1.30 [1.04-1.61]), and to have recently used drugs (HR 2.51 [1.30-4.87]), yet had a low lifetime drug severity (HR 0.01 [0.00-0.14]). Among PLWHA released from jail, frequency of ED use is high, often soon after release, and is associated with social and drug-related destabilizing factors. Future interventions for this specific population should focus on addressing these resource gaps, ensuring housing, and establishing immediate linkage to HIV primary care after release from jail.

HIV in people reincarcerated in Connecticut prisons and jails: an observational cohort study

BACKGROUND

Reincarceration in prison or jail correlates with non-sustained HIV viral suppression, but HIV treatment outcomes in released prisoners who are reincarcerated have not recently been systematically assessed despite advances in antiretroviral treatment (ART) potency, simplicity, and tolerability.

METHODS

In a retrospective cohort of reincarcerated inmates with HIV in Connecticut (2005-12), we used longitudinally linked demographic, pharmacy, and laboratory databases to examine correlates of viral suppression. The primary outcome was viral suppression on reincarceration, defined as viral load lower than 400 RNA copies per mL.

FINDINGS

Of 497 prisoners and jail detainees with HIV, with 934 reincarcerations, individuals were mostly unmarried, uninsured, and black men prescribed a protease-inhibitor-based ART regimen. During the median 329 days (IQR 179-621) between prison release and reincarceration, the proportion of incarceration periods with viral suppression decreased significantly from 52% to 31% (mean HIV-RNA increased by 0·4 log₁₀; p<0·0001), lower than Connecticut's HIV-infected prison population and those prescribed ART nationally. 158 (51%) of 307 individuals with viral suppression on release had viral suppression on reincarceration. Viral suppression on reincarceration was associated with increasing age (adjusted odds ratio [aOR] 1·04, 95% CI 1·01-1·07), being prescribed non-nucleoside reverse transcriptase inhibitor-based regimens (1·63, 1·14-2·34), and having higher levels of medical or psychiatric comorbidity (1·16, 1·03-1·30).

INTERPRETATION

Identification of individuals most at risk for recidivism and loss of viral suppression might mitigate the risk that repeated reincarceration poses to systems of public health and safety.

FUNDING

Bristol-Myers Squibb Virology, Patterson Trust, and National Institute on Drug Abuse.