Great Expectations: HIV Risk Behaviors and Misperceptions of Low HIV Risk among Incarcerated Men

A Multicomponent Strategy to Improve HIV Pre-Exposure Prophylaxis in a Southern US Jail: Protocol for a Type 3 Hybrid Implementation-Effectiveness Trial

BACKGROUND

Pre-exposure prophylaxis (PrEP) is an effective approach for preventing HIV infection, but it is underutilized by populations who may benefit the most, including people living in the Southern United States and those involved in the criminal legal (CL) system. Improving the access and use of PrEP for these groups could decrease HIV-related health disparities. Beyond individual outcomes, HIV prevention for CL-involved people can have a significant public health impact on HIV incidence due to a high turnover between jails and the community.

OBJECTIVE

We will develop, implement, and evaluate a multicomponent PrEP implementation strategy for the Dallas County Jail (DCJ) to increase the initiation of this HIV-preventive intervention for CL-involved individuals.

METHODS

This is a type 3 hybrid implementation-effectiveness study that takes a combined approach by assessing the implementation of a strategy to identify candidates for PrEP at the DCJ and linking them to PrEP providers upon community re-entry while also gathering information about clinical outcomes. The approach is guided by the EPIS (exploration, preparation, implementation, sustainment) framework. Initial formative work (exploration) involves qualitative interviews of diverse key stakeholders to identify factors that may influence linkage to PrEP after jail release. These findings will undergo rapid qualitative analysis (preparation) to inform the adaptation of a multicomponent jail PrEP implementation strategy protocol. This approach, which will include an electronic health record (EHR) prediction model and integration of a PrEP patient navigator into the jail health team, will allow medical providers and the navigator at the DCJ to engage individuals most likely to benefit in shared decision-making about PrEP and navigate them to community PrEP care (implementation) in a process that begins before release from jail and ends with successful care linkage. Regular quantitative and qualitative evaluations of this approach will allow for ongoing stakeholder input, refinement of the implementation strategy, and maintenance of the program (sustainment).

RESULTS

Findings from 26 qualitative interviews (9 formerly incarcerated individuals, 9 county jail staff, and 8 employees of community organizations) have been obtained, analyzed, and mapped to an implementation strategy formalized in a jail PrEP protocol. An HIV risk prediction model based on EHR data to identify individuals most likely to benefit from PrEP has been developed and internally validated and is ready to be deployed. We anticipate the availability of preliminary study findings in 2026.

CONCLUSIONS

This study will provide key insights into the feasibility and effectiveness of a PrEP implementation strategy among people at increased risk of HIV acquisition in an urban jail in Southern United States. This practical and scalable strategy can be used as a model for other urban jails to address HIV-related inequities.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/64813.

HIV risk perception and PrEP uptake among black MSM in Mississippi

INTRODUCTION

Rates for HIV are disproportionately higher for Black men who have sex with men (MSM) compared to other MSM in the U.S. While there is evidence that low perceived risk of HIV infection may increase HIV vulnerability, few studies have examined this relationship among Black MSM in the Southern U.S. where the HIV rates are the highest in the country. This study examined the association between perceived HIV risk and PrEP adoption among Black MSM in a medium-size city in Mississippi.

METHODS

Data were drawn from a subsample of the "ACCELERATE!" intervention, an innovative and sustainable community-driven project to improve health outcomes among Black MSM. The outcome of interest was PrEP uptake, a binary variable derived from responses to the question "Have you taken PrEP in the last year?". The perceived risk of HIV, an independent variable, is measured by self-report of an individual's assessment of their vulnerability of contracting HIV defined as low versus high risk. Covariates included age and socio-environmental factors (health insurance, incarceration and discrimination) Sample characteristics were provided using means and standard deviations for continuous variables and proportions for categorical variables. Exact logistic regression was used to assess the association between perceived HIV risk and PrEP adoption, adjusting for covariates.

RESULTS

A total of 84 HIV negative Black men with a median age of 30 (min = 18, max = 69) years were available for analyses. Approximately 16% of participants reported experiencing incarceration and 57% reported experiencing discrimination. Seven out of ten respondents reported having low perceived risk, and 28.6% (24/84) reported having high perceived risk for HIV. There were 73 participants (86.9%) who reported PrEP use in the last year. We observed a higher proportion of participants with high perceived risk that reported lower uptake of PrEP. After adjusting for age, socioeconomic variables, and risky sexual behaviors, higher levels of perceived risk of HIV were associated with decreased odds of PrEP uptake (OR = 0.20, 95% CI: 0.04-0.94, p = 0.040).

CONCLUSION

The role of HIV risk perception on PrEP adoption is complex among Black MSM in Mississippi. Higher levels of perceived risk of HIV were associated with lower odds of PrEP adoption among Black MSM. This inverse relationship between HIV risk perception and PrEP adoption suggests social- and structural- factors play a critical role in decision-making on PrEP initiation among Black MSM in Jackson. In addition, further longitudinal studies are needed to understand the complex interactions between perceived risk and PrEP use.

Self-perception of risk for HIV acquisition among people in prisons in Iran: A nationwide survey in 2017

BACKGROUND

Self-perception of risk for HIV acquisition is crucial for promoting preventive behaviors among people in prisons. This cross-sectional study examined self-perception of HIV risk and associated factors among people in prisons in Iran.

METHODS

In 2017, we conducted a cross-sectional study in Iran using multistage random sampling approach to recruit participants from 33 prisons in Iran. Eligible participants were adult people in prisons for at least one week. Data were collected via gender-matched face-to-face interviews using a standard HIV risk assessment questionnaire. Multivariable logistic regression models were built to identify correlates of high self-perceived HIV risk. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were reported.

RESULTS

Among 5,422 HIV-negative participants (94.0% men; mean age 35.7 years), 6.8% (95% CI: 6.1-7.5%) reported high self-perception of risk for HIV acquisition. Among these, 3.6%, 5.2%, and 8.4% reported zero, one, and more than one risky behavior, respectively. Higher odds of high self-perceived risk were associated with being < 30 years old (AOR: 1.50; 95% CI: 1.13-2.00), having never got married (AOR: 1.58; 95% CI: 1.12-2.23), engaging in condomless sex (AOR: 1.56; 95% CI: 1.13-2.16), same-sex practices among men (AOR: 1.90; 95% CI: 1.43-2.51), and recent sexually transmitted infection symptoms (AOR: 2.18; 95% CI: 1.19-3.57).

CONCLUSIONS

A notable gap exists between actual HIV risk behaviors and self-perceived risk among people in prisons in Iran. Targeted prison-based educational interventions are essential to improve risk awareness and promote HIV prevention behaviors among this marginalized population.

HIV Risk and Interest in Preexposure Prophylaxis in Justice-Involved Persons

Preexposure prophylaxis (PrEP) is underused in persons who use drugs and justice-involved persons. In an ongoing randomized controlled trial in 4 US locations comparing patient navigation versus mobile health unit on time to initiation of HIV medication or PrEP for justice-involved persons who use stimulants or opioids and who are at risk for or living with HIV, we assessed HIV risk factors, perceived HIV risk, and interest in PrEP. Participants without HIV (n = 195) were 77% men, 65% White, 23% Black, and 26% Hispanic; 73% reported a recent history of condomless sex, mainly with partners of unknown HIV status. Of 34% (67/195) reporting injection drug use, 43% reported sharing equipment. Despite risk factors, many persons reported their risk for acquiring HIV as low (47%) or no (43%) risk, although 51/93 (55%) with PrEP indications reported interest in PrEP. Justice-involved persons who use drugs underestimated their HIV risk and might benefit from increased PrEP education efforts.

Characterizing HIV Syndemics and the Role of Incarceration Among Men Who have Sex with Men Presenting for Care at a Sexually Transmitted Infections Clinic

Men who have sex with men (MSM) with a history of incarceration experience unique risk factors for HIV acquisition. The current study examined unique risk factors for HIV among MSM with a history of incarceration presenting to a sexually transmitted infections (STI) clinic. We analyzed self-reported behavioral data from clinical encounters among patients attending the clinic between January 2012 and April 2021. There were 17,221 unique visits, of which 5988 were MSM. Of these, 4.34% (N = 206) were MSM with a history of incarceration. MSM with a history of incarceration were significantly more likely to report a range of behavioral risk factors for HIV, yet also were significantly less likely to perceive themselves at risk for HIV. Future research and practice should develop culturally tailored biobehavioral HIV prevention services and consider embedding these programs within criminal justice settings to better reach this at-risk group.

HIV Risk perception and eligibility for pre-exposure prophylaxis in women involved in the criminal justice system

Women involved in the criminal justice system (WICJ) are at high risk of acquiring HIV and would benefit from HIV pre-exposure prophylaxis (PrEP) but there are no studies in this population to inform PrEP implementation programs. We conducted a cross-sectional survey of HIV-uninfected, cis-gender women on probation, parole and/or recently released from prison/jail to assess PrEP awareness, eligibility, potential barriers to uptake, and the PrEP care continuum. The 125 WICJ surveyed reported high rates of HIV risk behaviors including recent transactional sex (22.4%) and unsafe injection practices (14.4%). Despite 33% (n = 42) meeting eligibility criteria for PrEP, only 25% were aware of PrEP and one person was currently using it. Just 16.7% of those who were PrEP eligible perceived they were at risk for HIV. Following a brief explanation of PrEP, 90% said they would try it if recommended by their physician. Compared to those not PrEP eligible (n = 83), PrEP eligible women were less likely to be stably housed or have a primary care provider, and were more likely to be violence-exposed, charged with drug possession, have lifetime substance use, or living with Hepatitis C infection. WICJ frequently engage in HIV risk behaviors that make them eligible for PrEP. Uptake may be limited by lack of PrEP awareness or underestimation of personal HIV risk. WICJ report receptiveness to PrEP and represent an important population for targeted PrEP implementation programs.