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

Facilitators and barriers to the implementation of the biobehavioral survey among incarcerated individuals and correctional personnel in Mozambique, 2021- a descriptive study

Mozambique implemented in 2021 a formative assessment in 22 prisons to identify the operational and logistical needs for the second round of the Biobehavioral Survey (BBS). Barriers and facilitators that could be anticipated in conducting BBS in prisons, in preparation for implementation, was evaluated using semi-structured questionnaires administered to key informants (directors and other kind of managers staff). The data were cleaned and analyzed using Microsoft Excel, and the categorical variables were summarized by means of simple frequencies and percentages. In most prisons the current prison capacity far exceeds the theoretical capacity, 40.9% have a theoretical capacity of ≥ 50 inmates, 81.8% have inmates who exceed their theoretical capacity. In the country half of the prisons receive only male inmates, and only one female, 54.5% of the prisons visited have inmates under 18 years of age, 72.7% of the prisons had a private space available for the survey, the penitentiary establishments have the physical space for study; ensuring the safety of staff within the facilities; involvement of correctional officers and a clinical focal point. However, barriers such as time management due to prison opening hours, prison laws, restrictions, or permits for research may change without notice due to security, lockdowns, riots, or other situations that may hinder the implementation of research. The implementation of successive and regular rounds of BBS in different environments, contexts and populations constitute opportunities for generating information and indicators not always captured by programmatic data and not only as an opportunity for offering and making healthcare available in prison environments that in a routine context, but these populations normally have also not had equal opportunities. Currently, little is known about the implementation of a BBS in a correctional environment and only a few barriers can be anticipated, for Mozambique's context, these challenges and obstacles can be overcome through clear communication and collaboration with officials at all levels.

Higher methadone dose at time of release from prison predicts linkage to maintenance treatment for people with HIV and opioid use disorder transitioning to the community in Malaysia

BACKGROUND

Incarcerated people with HIV and opioid-dependence often experience poor post-release outcomes in the absence of methadone maintenance treatment (MMT). In a prospective trial, we assessed the impact of methadone dose achieved within prison on linkage to MMT after release.

METHODS

From 2010 to 2014, men with HIV (N = 212) and opioid dependence before incarceration were enrolled in MMT within 6 months of release from Malaysia's largest prison and followed for 12-months post-release. As a prospective trial, allocation to MMT was at random and later by preference design (predictive nonetheless). MMT dosing was individually targeted to minimally achieve 80 mg/day. Time-to-event analyses were conducted to model linkage to MMT after release.

FINDINGS

Of the 212 participants allocated to MMT, 98 (46 %) were prescribed higher dosages (≥80 mg/day) before release. Linkage to MMT after release occurred in 77 (36 %) participants and significantly higher for those prescribed higher dosages (46% vs 28 %; p = 0.011). Factors associated with higher MMT dosages were being married, on antiretroviral therapy, longer incarceration periods, having higher levels of depression, and methadone preference compared to randomization. After controlling for other variables, being prescribed higher methadone dosage (aHR: 2.53, 95 %CI: 1.42-4.49) was the only independent predictor of linkage to methadone after release.

INTERPRETATION

Higher doses of methadone prescribed before release increased the likelihood of linkage to MMT after release. Methadone dosing should be introduced into international guidelines for treatment of opioid use disorder in prisons and further post-release benefits should be explored.

FUNDING

National Institute of Drug Abuse (NIDA).

Mass Probation: Effects of Sentencing Severity on Mental Health for Black and White Individuals

BACKGROUND

Incarceration is associated with negative impacts on mental health. Probation, a form of community supervision, has been lauded as an alternative. However, the effect of probation versus incarceration on mental health is unclear. Our objective was to estimate the impact on mental health of reducing sentencing severity at individuals' first adult criminal-legal encounter.

METHODS

We used the US National Longitudinal Survey on Youth 1997, a nationally representative dataset of youth followed into their mid-thirties. Restricting to those with an adult encounter (arrest, charge alone or no sentence, probation, incarceration), we used parametric g-computation to estimate the difference in mental health at age 30 (Mental Health Inventory-5) if (1) everyone who received incarceration for their first encounter had received probation and (2) everyone who received probation had received no sentence.

RESULTS

Among 1835 individuals with adult encounters, 19% were non-Hispanic Black and 65% were non-Hispanic White. Median age at first encounter was 20. Under hypothetical interventions to reduce sentencing, we did not see better mental health overall (Intervention 1, incarceration to probation: RD = -0.01; CI = -0.02, 0.01; Intervention 2, probation to no sentence: RD = 0.00; CI = -0.01, 0.01) or when stratified by race.

CONCLUSION

Among those with criminal-legal encounters, hypothetical interventions to reduce sentencing, including incremental sentencing reductions, were not associated with improved mental health. Future work should consider the effects of preventing individuals' first criminal-legal encounter.

Intensified pulmonary tuberculosis case finding among HIV-infected new entrants of a prison in Malaysia: implications for a holistic approach to control tuberculosis in prisons

PURPOSE

This intensified case finding study aimed to evaluate the prevalence of tuberculosis (TB) disease among people with HIV entering the largest prison in Malaysia.

DESIGN/METHODOLOGY/APPROACH

The study was conducted in Kajang prison, starting in July 2013 in the men's prison and June 2015 in the women's prison. Individuals tested positive for HIV infection, during the mandatory HIV testing at the prison entry, were consecutively recruited over five months at each prison. Consented participants were interviewed using a structured questionnaire and asked to submit two sputum samples that were assessed using GeneXpert MTB/RIF (Xpert) and culture, irrespective of clinical presentation. Factors associated with active TB (defined as a positive result on either Xpert or culture) were assessed using regression analyses.

FINDINGS

Overall, 214 incarcerated people with HIV were recruited. Most were men (84.6%), Malaysians (84.1%) and people who inject drugs (67.8%). The mean age was 37.5 (SD 8.2) years, and median CD4 lymphocyte count was 376 cells/mL (IQR 232-526). Overall, 27 (12.6%) TB cases were identified, which was independently associated with scores of five or more on the World Health Organization clinical scoring system for prisons (ARR 2.90 [95% CI 1.48-5.68]).

ORIGINALITY/VALUE

Limited data exists about the prevalence of TB disease at prison entry, globally and none from Malaysia. The reported high prevalence of TB disease in the study adds an important and highly needed information to design comprehensive TB control programmes in prisons.

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.

Interventions Designed to Improve HIV Continuum of Care Outcomes for Persons with HIV in Contact with the Carceral System in the USA

PURPOSE OF REVIEW

To describe existing evidence and identify future directions for intervention research related to improving HIV care outcomes for persons with HIV involved in the carceral system in the USA, a population with high unmet HIV care needs.

RECENT FINDINGS

Few recent intervention studies focus on improving HIV care outcomes for this population. Successful strategies to improve care outcomes include patient navigation, substance use treatment, and incentivizing HIV care outcomes. Technology-supported interventions are underutilized in this population. Notable gaps in the existing literature include intervention research addressing HIV care needs for cisgender and transgender women and those under carceral supervision in the community. Future research should address existing gaps in the literature and respond to emergent needs including understanding how the changing HIV care delivery environment resulting from the COVID-19 pandemic and the approval of new injectable ART formulation shape HIV care outcomes in this population.

Factors affecting optimal adherence to antiretroviral therapy and viral suppression amongst HIV-infected prisoners in South Ethiopia: a comparative cross-sectional study

BACKGROUND

Maintaining optimal adherence and viral suppression in people living with HIV (PLWH) is essential to ensure both preventative and therapeutic benefits of antiretroviral therapy (ART). Prisoners bear a particularly high burden of HIV infection and are highly likely to transmit to others during and after incarceration. However, the level of treatment adherence and viral suppression in incarcerated populations in low-income countries is unknown. This study aimed to determine factors affecting optimal adherence to antiretroviral therapy and viral suppression amongst HIV-infected prisoners in South Ethiopia.

METHODS

A comparative cross-sectional study was conducted between June 1, 2019 and May 31, 2020 to compare the level of adherence and viral suppression between incarcerated and non-incarcerated PLWH. Patient information including demographic, socio-economic, behavioral, and incarceration-related characteristics were collected using a structured questionnaire. Medication adherence was assessed according to self-report and pharmacy refill. Plasma viral load measurements undertaken within the study period were prospectively extracted to determine viral suppression. Univariate and multivariate logistic and fractional regression models were used to analyse data.

RESULTS

Seventy-four inmates living with HIV (ILWH) and 296 non-incarcerated PLWH participated in the study. While ILWH had a significantly higher pharmacy refill adherence compared to non-incarcerated PLWH (89 vs 75%), they had a slightly lower dose adherence (81% vs 83%). The prevalence of viral non-suppression was also slightly higher in ILWH (6.0%; 95% confidence interval (CI): 1.7-14.6%) compared to non-incarcerated PLWH (4.5%; 95%CI: 2.4-7.5%). Overall, missing ART appointments, dissatisfaction with ART services, inability to comply with a specified medication schedule, and types of methods used to monitor the schedule (e.g., news time on radio/TV or other social cues) were significantly associated with non-adherence according to self-report. In ILWH specifically, accessing ART services from a hospital, inability to properly attend clinic appointments, depressive symptoms, and lack of social support predicted NA. Viral non-suppression was significantly higher in males, people of age 31to 35 years and in those who experienced social stigma, regardless of their incarceration status.

CONCLUSIONS

Sub-optimal dose adherence and viral suppression are generally higher in HIV-infected prisoners in South Ethiopia compared to their non-incarcerated counterparts. A multitude of factors were found to be responsible for this requiring multilevel intervention strategies focusing on the specific needs of prisoners.

Healthcare-induced trauma in correctional facilities: a qualitative exploration

BACKGROUND

While incarcerated people are known to experience trauma at higher rates than the general population, little is known about how the correctional health system contributes to trauma rates.

METHODS

We conducted 20 semi-structured qualitative interviews with men who were recently released from a correctional system to understand their experiences with healthcare systems and medical staff during incarceration. Using reflexive thematic analysis within a critical realist framework, we coded and analyzed the data iteratively to refine and unify emerging themes.

RESULTS

The unanticipated concept of healthcare-induced trauma emerged and was revealed in three overall themes: (1) healthcare leading to fear of serious illness or death, (2) healthcare leading to fear of people, including healthcare providers, correctional staff, and other incarcerated people, and (3) the correctional institutional, social, and physical environment leads to fear of place.

CONCLUSIONS

Healthcare in correctional settings has the potential to induce trauma, even when the medical conditions addressed are not life-threatening. Future research should examine the factors contributing to the development of healthcare-induced trauma in correctional settings and develop interventions to prevent and address this phenomenon.

Linking criminal justice-involved individuals to HIV, Hepatitis C, and opioid use disorder prevention and treatment services upon release to the community: Progress, gaps, and future directions

Improving HIV and Hepatitis C Virus (HCV) management among people involved in the criminal justice (CJ) system who use drugs, in particular those with opioid use disorder (OUD), requires effective approaches to screening, linkage, and adherence to integrated prevention and treatment services across correctional and community agencies and providers. This manuscript reviews the literature to explore gaps in HIV, Hepatitis C, and OUD prevention, treatment, and delivery cascades of care for persons involved in the CJ system. Specifically, we compare two models of linkage to prevention and treatment services: Peer/Patient Navigation (PN) wherein the PN links CJ-involved individuals to community-based infectious disease (ID) and substance use prevention and treatment services, and Mobile Health Units (MHU) wherein individuals are linked to a MHU within their community that provides integrated ID and substance use prevention and treatment services. The most notable finding is a gap in the literature, with few to no comparisons of models linking individuals recently released from the CJ system to integrated HIV, Hepatitis C, and OUD prevention and treatment and other harm reduction services. Further, few published studies address the geographical distinctions that affect service implementation and their effects on these substance use, ID and harm reduction care cascades. This manuscript makes specific recommendations to fill this gap through a detailed evaluation of PN and MHU linkage models to co-located and integrated HIV, Hepatitis C, and OUD prevention and treatment services across different communities within the U.S.

A Dyadic Analysis of Criminal Justice Involvement and Sexual HIV Risk Behaviors Among Drug-Involved Men in Community Corrections and Their Intimate Partners in New York City: Implications for Prevention, Treatment and Policies

People in community corrections have rates of HIV and sexual risk behaviors that are much higher than the general population. Prior literature suggests that criminal justice involvement is associated with increased sexual risk behaviors, yet these studies focus on incarceration and use one-sided study designs that only collect data from one partner. To address gaps in the literature, this study used the Actor Partner-Interdependence Model with Structural Equation Modeling (SEM), to perform a dyadic analysis estimating individual (actor-only) partner-only, and dyadic patterns (actor-partner) of criminal justice involvement and greater sexual risks in a sample of 227 men on probation and their intimate partners in New York City, United States. Standard errors were bootstrapped with 10,000 replications to reduce bias in the significance tests. Goodness of fit indices suggested adequate or better model fit for all the models. Significant actor-only relationships included associations between exposures to arrest, misdemeanor convictions, time spent in jail or prison, felony convictions, lifetime number of incarceration events, prior conviction for disorderly conduct and increased sexual risk behaviors. Partner only effects included significant associations between male partners conviction for a violent crime and their female partners' sexual risk behaviors. Men's encounters with police and number of prior misdemeanors were associated with their own and intimate partners' sexual risk behaviors. Women's prior arrest was associated with their own and intimate partners' sexual risk behaviors. The results from the present study suggest that men on probation and their intimate partners' criminal justice involvement are associated with increased engagement in sexual risk behaviors. It is necessary to conduct greater research into developing dyadic sexual risk reduction and HIV/STI prevention interventions for people who are involved in the criminal justice system.

Social and Structural Factors Associated with Sustained Viral Suppression Among Heterosexual Black Men with Diagnosed HIV in the United States, 2015-2017

This paper describes sociodemographic, sexual risk behavior, and clinical care factors associated with sustained viral suppression (SVS) among heterosexual Black men with diagnosed HIV in the US. Sample was 968 men, 2015-2017 cycles of Medical Monitoring Project. We used prevalence ratios and a multivariable logistic regression model to identify independent predictors of SVS. About 9% of sexually active men had sex that carries a risk of HIV transmission. Nearly 2/3 lived at or below the poverty level, 13% were under or uninsured, 1/4 experienced food insecurity and 15% reported recent homelessness. About 26% were not engaged in HIV care, 8% not currently taking antiretroviral therapy (ART) and 59% had SVS. Among men taking ART, care engagement and adherence were the only significant independent predictors of SVS. Efforts to increase VS should focus on increasing ART use, care engagement, and ART adherence, and include strategies that address the social and structural factors that influence them.

Returning to care after incarceration with HIV: the French Guianese experience

Background

HIV prevalence in correctional facilities may be 2 to 10 times higher than in the general adult population. Antiretroviral therapy (ART) interruption is frequent after an incarceration. This, in combination with post-release high-risk behaviors, may have detrimental consequences on the epidemic. Although return to care after release from correctional facilities has been described in many North American settings, data from South America seemed scarce.

French Guiana is the only French territory located in South America. In 2014, HIV prevalence was estimated at 1.2% among pregnant women and oscillated around 4% in the only correctional facility.

Method

HIV-infected adults released from the French Guiana correctional facility between 2007 and 2013 were included in a retrospective cohort survey. The first objective was to describe the cascade of care in the 4 years following release. The secondary objectives were to describe contacts with care and to identify factors associated with return to HIV care, 1 year after release.

Results

We included 147 people, mostly males (81.6%). The median time before the first ambulatory consultation was 1.8 months. Within 1 year after release, 27.9% came for unscheduled emergency consultations, 22.4% were hospitalized. Within 4 years after release, 40.0–46.5% were in care, 22.4% archieved virological success.

Being on ART when incarcerated was associated with HIV care (aIRR: 2.0, CI: 1.2–3.0), whereas being HIV-diagnosed during the last incarceration was associated with poor follow-up (aIRR: 0.3, CI: 0.1–0.9).

Conclusion

The risk of HIV-follow-up interruption is high, after an incarceration with HIV. ART supply should be sufficient to cover the timespan following release, several months if possible. Those not on ART at the time of incarceration may require special attention, especially those newly HIV-diagnosed while in custody. Comprehensive programs are necessary to support ex-offenders to stay on ART after incarceration.

A systematic review and meta-analyses on initiation, adherence and outcomes of antiretroviral therapy in incarcerated people

BACKGROUND

Incarcerated people are at increased risk of human immunodeficiency virus (HIV) infection relative to the general population. Despite a high burden of infection, HIV care use among prison populations is often suboptimal and varies among settings, and little evidence exists explaining the discrepancy. Therefore, this review assessed barriers to optimal use of HIV care cascade in incarcerated people.

METHODS

Quantitative and qualitative studies investigating factors affecting linkage to care, ART (antiretroviral therapy) initiation, adherence and/or outcomes among inmates were systematically searched across seven databases. Studies published in English language and indexed up to 26 October 2018 were reviewed. We performed a narrative review for both quantitative and qualitative studies, and meta-analyses on selected quantitative studies. All retrieved quantitative studies were assessed for risk of bias. Meta-analyses were conducted using RevMan-5 software and pooled odds ratios were calculated using Mantel-Haenszel statistics with 95% confidence interval at a p<0.05. The review protocol has been published at the International Prospective Register of Systematic Reviews (PROSPERO; Number: CRD42019135502).

RESULTS

Of forty-two studies included in the narrative review, eight were qualitative studies. Sixteen of the quantitative studies were eligible for meta-analyses. The narrative synthesis revealed structural factors such as: a lack of access to community standard of HIV care, particularly in resource limited countries; loss of privacy; and history of incarceration and re-incarceration as risk factors for poor HIV care use in prison populations. Among social and personal characteristics, lack of social support, stigma, discrimination, substance use, having limited knowledge about, and negative perception towards ART were the main determinants of suboptimal use of care in incarcerated people. In the meta-analyses, lower odds of ART initiation was noticed among inmates with higher baseline CD4 count (CD4 ≥500celss/mm3) (OR = 0.37, 95%CI: 0.14-0.97, I2 = 43%), new HIV diagnosis (OR = 0.07, 95%CI: 0.05-0.10, I2 = 68%), and in those who lacked belief in ART safety (OR = 0.32, 95%CI: 0.18-0.56, I2 = 0%) and efficacy (OR = 0.31, 95%CI: 0.17-0.57, I2 = 0%). Non-adherence was high among inmates who lacked social support (OR = 3.36, 95%CI: 2.03-5.56, I2 = 35%), had low self-efficiency score (OR = 2.50, 95%CI: 1.64,-3.80, I2 = 22%) and those with depressive symptoms (OR = 2.02, 95%CI: 1.34-3.02, I2 = 0%). Lower odds of viral suppression was associated with history of incarceration (OR = 0.40, 95%CI: 0.35-0.46, I2 = 0%), re-incarceration (OR = 0.09, 95%CI: 0.06-0.13, I2 = 64%) and male gender (OR = 0.55, 95%CI: 0.42-0.72, I2 = 0%). Higher odds of CD4 count <200cells/mm3 (OR = 2.01, 95%CI: 1.62, 2.50, I2 = 44%) and lower odds of viral suppression (OR = 0.20, 95%CI: 0.17-0.22, I2 = 0%) were observed during prison entry compared to those noticed during release.

CONCLUSION

Given the high HIV risk in prison populations and rapid movements of these people between prison and community, correctional facilities have the potential to substantially contribute to the use of HIV treatment as a prevention strategy. Thus, there is an urgent need for reviewing context specific interventions and ensuring standard of HIV care in prisons, particularly in resource limited countries.

Extended-release Naltrexone Improves Viral Suppression Among Incarcerated Persons Living with HIV and Alcohol use Disorders Transitioning to the Community: Results From a Double-Blind, Placebo-Controlled Trial

OBJECTIVE

To determine whether extended-release naltrexone (XR-NTX) would improve or maintain viral suppression (VS) among incarcerated individuals with HIV and alcohol use disorders (AUDs) transitioning to the community.

DESIGN

A randomized, double-blind, placebo-controlled trial was conducted among incarcerated individuals with HIV and AUDs transitioning to the community from 2010 through 2016.

METHODS

Eligible participants (N = 100) were randomized 2:1 to receive 6 monthly injections of XR-NTX (n = 67) or placebo (n = 33) starting at release and continued for 6 months. The primary and secondary outcomes were the proportion that maintained or improved VS at <200 and <50 copies per milliliter from baseline to 6 months, respectively, using an intention-to-treat analysis.

RESULTS

Participants allocated to XR-NTX improved VS from baseline to 6 months for <200 copies per milliliter (48.0%-64.2%, P = 0.024) and for <50 copies per milliliter (31.0%-56.7%, P = 0.001), whereas the placebo group did not (<200 copies/mL: 64%-42.4%, P = 0.070; <50 copies/mL: 42.0%-30.3%, P = 0.292). XR-NTX participants were more likely to achieve VS than the placebo group at 6 months (<200 copies/mL: 64.2% vs. 42.4%; P = 0.041; <50 copies/mL: 56.7% vs. 30.3%; P = 0.015). XR-NTX independently predicted VS [<200 copies/mL: adjusted odds ratio (aOR) = 2.68, 95% confidence interval (CI) = 1.01 to 7.09, P = 0.047; <50 copies/mL: aOR = 4.54; 95% CI = 1.43 to 14.43, P = 0.009] as did receipt of ≥3 injections (<200 copies/mL: aOR = 3.26; 95% CI = 1.26 to 8.47, P = 0.010; <50 copies/mL: aOR = 6.34; 95% CI = 2.08 to 19.29, P = 0.001). Reductions in alcohol consumption (aOR = 1.43, 95% CI = 1.03 to 1.98, P = 0.033) and white race (aOR = 5.37, 95% CI = 1.08 to 27.72, P = 0.040) also predicted VS at <50 copies per milliliter.

CONCLUSIONS

XR-NTX improves or maintains VS after release to the community for incarcerated people living with HIV and AUDs.

Reduced Sexual Risk Behaviors Among Persons With HIV After Release From the Criminal Justice System

Background

HIV prevalence is 3 times greater for those in the criminal justice system than the general population, with an assumed increase in sexual risk behaviors (SRBs) postrelease. HIV viral suppression impacts HIV transmission; however, studies of SRBs among persons with HIV leaving the criminal justice system are limited, and no studies have examined viral suppression in relation to SRBs in persons leaving the criminal justice system.

Methods

Data were examined from 2 double-blind placebo-controlled trials of extended-release naltrexone among persons with HIV and alcohol use or opioid use disorder. Participants self-reported sexual activity, including number of sexual partners, sex type, and condom use. HIV viral suppression was evaluated prerelease and at 6 months.

Results

Thirty days before incarceration, 60% reported having sex compared with 41% and 46%, respectively, at months 1 and 6 postrelease. The number of sex partners and sexual intercourse events decreased from pre-incarceration to months 1 and 6 postrelease. Condom use increased but was not statistically significant. Of the 11 (9.7%) who reported having sex without a condom 1 month postrelease, only 2 did not have viral suppression (VS; HIV VL <200 copies/mL), whereas the 7 (6.5%) who reported SRBs at 6 months all had VS.

Conclusions

After release, SRBs decreased, and among those who reported SRBs, most were virally suppressed, and thus risk of transmitting HIV was low.

Effect of Patient Navigation on Transitions of HIV Care After Release from Prison: A Retrospective Cohort Study

Antiretroviral therapy is successfully administered to people living with HIV while they are incarcerated in most US prison systems, but interruptions in treatment are common after people are released. We undertook an observational cohort study designed to examine the clinical and psychosocial factors that influence linkage to HIV care and viral suppression after release from a single state prison system. In this report we describe baseline characteristics and 6-month post-incarceration HIV care outcomes for 170 individuals in Wisconsin. Overall, 114 (67%) individuals were linked to outpatient HIV care within 180 days of release from prison, and of these, 90 (79%) were observed to have HIV viral suppression when evaluated in the community. The strongest predictor of linkage to care in this study was participation in a patient navigation program: Those who received patient navigation were linked to care 84% of the time, compared to 60% of the individuals who received only standard release planning (adjusted OR 3.69, 95% CI 1.24, 10.96; P < 0.01). Findings from this study demonstrate that building and maintaining intensive patient navigation programs that support individuals releasing from prison is beneficial for improving transitions in HIV care.

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.

Extended-Release Naltrexone Improves Viral Suppression Among Incarcerated Persons Living With HIV With Opioid Use Disorders Transitioning to the Community: Results of a Double-Blind, Placebo-Controlled Randomized Trial

OBJECTIVE

To determine whether extended-release naltrexone (XR-NTX) would improve or maintain viral suppression (VS) among prisoners or jail detainees with HIV and opioid use disorder (OUD) transitioning to the community.

DESIGN

A 4-site, prospective randomized double-blind, placebo-controlled trial was conducted among prison and jail inmates with HIV and OUD transitioning to the community from September 2010 through March 2016.

METHODS

Eligible participants (N = 93) were randomized 2:1 to receive 6 monthly injections of XR-NTX (n = 66) or placebo (n = 27) starting at release and observed for 6 months. The primary outcome was the proportion that maintained or improved VS (<50 copies/mL) from baseline to 6 months.

RESULTS

Participants allocated to XR-NTX significantly improved to VS (<50 copies/mL) from baseline (37.9%) to 6 months (60.6%) (P = 0.002), whereas the placebo group did not (55.6% at baseline to 40.7% at 6 months P = 0.294). There was, however, no statistical significant difference in VS levels at 6 months between XR-NTX (60.6%) vs. placebo (40.7%) (P = 0.087). After controlling for other factors, only allocation to XR-NTX (adjusted odds ratio = 2.90; 95% confidence interval = 1.04 to 8.14, P = 0.043) was associated with the primary outcome. Trajectories in VS from baseline to 6 months differed significantly (P = 0.017) between treatment groups, and the differences in the discordant values were significantly different as well (P = 0.041): the XR-NTX group was more likely than the placebo group to improve VS (30.3% vs. 18.5%), maintain VS (30.3% vs. 27.3), and less likely to lose VS (7.6% vs. 33.3%) by 6 months.

CONCLUSIONS

XR-NTX improves or maintains VS after release to the community for incarcerated people living with HIV with OUD.

Use of an mHealth Intervention to Improve Engagement in HIV Community-Based Care Among Persons Recently Released from a Correctional Facility in Washington, DC: A Pilot Study

We examined the preliminary effectiveness of a computerized counseling session plus post-incarceration text messaging intervention (CARE + Corrections) to support ART adherence and linkage/engagement in community care among recently incarcerated persons with HIV in Washington, D.C. Recently incarcerated persons with HIV ≥ 18 years old were recruited from the D.C. jail or community outreach and randomized to CARE + Corrections or control arm. Participants completed assessments at baseline, 3-months and 6-months. Multivariable random effects modeling identified predictors of suppressed viral load (≤ 200 copies/mL) and engagement in HIV care at 6 months. Participants (N = 110) were aged 42 (IQR 30-49); 58% male, 24% female, 18% transgender, 85% Black, and lifetime incarceration was a median of 7 years (IQR 2-15). More controls had a regular healthcare provider at baseline. Although not statistically significant, intervention participants had increased odds of viral suppression versus controls at 6 months (AOR 2.04; 95% CI 0.62, 6.70). Those reporting high ART adherence at baseline had higher odds of viral suppression at follow-up (AOR 10.77; 95% CI 1.83, 63.31). HIV care engagement was similar between the two groups, although both groups reported increased engagement at 6 months versus baseline. We observed a positive but non-significant association of viral suppression in the CARE + Corrections group, and care engagement increased in both groups after 6 months. Further attention to increasing viral suppression among CJ-involved persons with HIV upon community reentry is warranted.

Past year and prior incarceration and HIV transmission risk among HIV-positive men who have sex with men in the US

Three quarters of new HIV infections in the US are among men who have sex with men (MSM). In other populations, incarceration is a social determinant of elevations in viral load and HIV-related substance use and sex risk behavior. There has been limited research on incarceration and these HIV transmission risk determinants in HIV-positive MSM. We used the Veterans Aging Cohort Study (VACS) 2011-2012 follow-up survey to measure associations between past year and prior (more than one year ago) incarceration and HIV viral load and substance use and sex risk behavior among HIV-positive MSM (N = 532). Approximately 40% had ever been incarcerated, including 9% in the past year. In analyses adjusting for sociodemographic factors, past year and prior incarceration were strongly associated with detectable viral load (HIV-1 RNA >500 copies/mL) (past year adjusted odds ratio (AOR): 3.50 95% confidence interval (CI): 1.59, 7.71; prior AOR: 2.48 95% CI: 1.44, 4.29) and past 12 month injection drug use (AORs > 6), multiple sex partnerships (AORs > 1.8), and condomless sex in the context of substance use (AORs > 3). Past year incarceration also was strongly associated with alcohol and non-injection drug use (AOR > 2.5). Less than one in five HIV-positive MSM recently released from incarceration took advantage of a jail/prison re-entry health care program available to veterans. We need to reach HIV-positive MSM leaving jails and prisons to improve linkage to care and clinical outcomes and reduce transmission risk upon release.

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.

Connecting Corrections and HIV Care: Building a Care Coordination Program for Recently Incarcerated Persons Living with HIV in Virginia

Incarcerated individuals are disproportionately affected by HIV and often experience risk factors associated with poor maintenance of HIV care upon release. Therefore, the transition period from incarceration to the community is a particularly critical time for persons living with HIV to ensure continuity of care and treatment. By building relationships with Department of Corrections staff and community partners, the Virginia Department of Health developed a program to link recently incarcerated persons living with HIV to care and treatment immediately upon release from correctional facilities across Virginia. Findings show that clients served by the program have better outcomes along the HIV continuum of care than the overall population living with HIV in Virginia. This paper describes the development, implementation and health outcomes of the Care Coordination program for recently incarcerated persons living with HIV in Virginia.

Potential drivers of HIV acquisition in African-American women related to mass incarceration: an agent-based modelling study

Background

The United States has the highest incarceration rate in the world. Incarceration can increase HIV risk behaviors for individuals involved with the criminal justice system and may be a driver of HIV acquisition within the community.

Methods

We used an agent-based model to simulate HIV transmission in a sexual-contact network representing heterosexual African American men and women in Philadelphia to identify factors influencing the impact of male mass incarceration on HIV acquisition in women. The model was calibrated using surveillance data and assumed incarceration increased the number of sexual contacts and decreased HIV care engagement for men post-release. Incarceration of a partner increased the number of sexual contacts for women. We compared a counterfactual scenario with no incarceration to scenarios varying key parameters to determine what factors drove HIV acquisition in women.

Results

Setting the duration of male high-risk sexual behavior to two years post-release increased the number of HIV transmissions to women by more than 20%. Decreasing post-release HIV care engagement and increasing HIV acquisition risk attributable to sexually transmitted infections (STIs) also increased the number of HIV transmissions to women. Changing the duration of risk behavior for women, the proportion of women engaging in higher risk behavior, and the relative risk of incarceration for HIV-infected men had minimal impact.

Conclusion

The mass incarceration of African American men can increase HIV acquisition in African American women on a population-level through factors including post-release high-risk behaviors, disruption of HIV care engagement among formerly incarcerated men, and increased STI prevalence. These findings suggest that the most influential points of intervention may be programs seeking to reduce male risk behaviors and promote HIV care engagement post-release, as well as STI testing and treatment programs for recently incarcerated men, as well as women with incarcerated partners.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6304-x) contains supplementary material, which is available to authorized users.

Prevalence of HIV Viral Load Suppression Among Psychiatric Inpatients with Comorbid Substance Use Disorders

A consistently suppressed viral load enables HIV (+) patients to live longer, healthier lives and reduces the probability of transmitting the virus. Since the prevalence of HIV is four times higher among those with psychiatric disorders than in the general population, it is likely that this group would also have greater difficulty remaining in care and achieving viral suppression. A secondary data analysis utilizing screening data from the Preventing AIDS Through Health (PATH) for Triples (PFT) Study were examined to assess HIV load suppression among 254 psychiatric inpatients with comorbid substance use disorders in Philadelphia. Viral load results from the past 12 months were obtained from medical records for 63 inpatients identified as HIV (+). The sample was predominately African American (76%), male (56%), and the average age was 43 years. Psychiatric disorders included depression (64%), schizophrenia (21%), and bipolar disorder (13%) with patients reporting use of alcohol (73%), cocaine (64%), cannabis (29%) and opioids (16%) prior to admission. Among this high risk sample of HIV (+) patients, about one-half (52%) achieved viral suppression, with recent opioid users six times more likely to have a detectable viral load than non-opioid users (OR 6.0; CI 1.1-31.7, p = .035). The 52% viral load suppression rate among psychiatric inpatient was higher than expected, given that the CDC's national suppression rate among those diagnosed with HIV in the general population is 58%. However, individuals with mental illness and substance use disorders require constant surveillance, monitoring, and supportive services to achieve viral suppression. Many of those who were virally suppressed were engaged in Philadelphia's extensive treatment network, whereas those who were detectable and enrolled in the PFT intervention were often homeless with unstable psychiatric symptoms and current substance use disorders, particularly opioid abuse.

Retention in HIV care during the 3 years following release from incarceration: A cohort study

BACKGROUND

Sustained retention in HIV care (RIC) and viral suppression (VS) are central to US national HIV prevention strategies, but have not been comprehensively assessed in criminal justice (CJ) populations with known health disparities. The purpose of this study is to identify predictors of RIC and VS following release from prison or jail.

METHODS AND FINDINGS

This is a retrospective cohort study of all adult people living with HIV (PLWH) incarcerated in Connecticut, US, during the period January 1, 2007, to December 31, 2011, and observed through December 31, 2014 (n = 1,094). Most cohort participants were unmarried (83.7%) men (77.0%) who were black or Hispanic (78.1%) and acquired HIV from injection drug use (72.6%). Prison-based pharmacy and custody databases were linked with community HIV surveillance monitoring and case management databases. Post-release RIC declined steadily over 3 years of follow-up (67.2% retained for year 1, 51.3% retained for years 1-2, and 42.5% retained for years 1-3). Compared with individuals who were not re-incarcerated, individuals who were re-incarcerated were more likely to meet RIC criteria (48% versus 34%; p < 0.001) but less likely to have VS (72% versus 81%; p = 0.048). Using multivariable logistic regression models (individual-level analysis for 1,001 individuals after excluding 93 deaths), both sustained RIC and VS at 3 years post-release were independently associated with older age (RIC: adjusted odds ratio [AOR] = 1.61, 95% CI = 1.22-2.12; VS: AOR = 1.37, 95% CI = 1.06-1.78), having health insurance (RIC: AOR = 2.15, 95% CI = 1.60-2.89; VS: AOR = 2.01, 95% CI = 1.53-2.64), and receiving an increased number of transitional case management visits. The same factors were significant when we assessed RIC and VS outcomes in each 6-month period using generalized estimating equations (for 1,094 individuals contributing 6,227 6-month periods prior to death or censoring). Additionally, receipt of antiretroviral therapy during incarceration (RIC: AOR = 1.33, 95% CI 1.07-1.65; VS: AOR = 1.91, 95% CI = 1.56-2.34), early linkage to care post-release (RIC: AOR = 2.64, 95% CI = 2.03-3.43; VS: AOR = 1.79; 95% CI = 1.45-2.21), and absolute time and proportion of follow-up time spent re-incarcerated were highly correlated with better treatment outcomes. Limited data were available on changes over time in injection drug use or other substance use disorders, psychiatric disorders, or housing status.

CONCLUSIONS

In a large cohort of CJ-involved PLWH with a 3-year post-release evaluation, RIC diminished significantly over time, but was associated with HIV care during incarceration, health insurance, case management services, and early linkage to care post-release. While re-incarceration and conditional release provide opportunities to engage in care, reducing recidivism and supporting community-based RIC efforts are key to improving longitudinal treatment outcomes among CJ-involved PLWH.

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.

Syndemic effect of mental illness and substance use on viral suppression among recently-incarcerated, HIV-infected individuals in the CARE+ Corrections study

Few studies on HIV-related syndemics of co-occurring and mutually reinforcing psychosocial conditions have assessed clinical outcomes in criminal justice (CJ)-involved populations. Baseline data from the CARE+ Corrections study were used to quantify co-occurring mental illness and substance use and examine syndemic effects on viral suppression among 106 CJ-involved HIV-infected individuals. Ninety-one (86%) reported a mental illness diagnosis, 30 (28%) reported hazardous alcohol use, and 61 (58%) were drug dependent. Eighteen (17%) experienced all three conditions. Drug dependence was clustered with mental illness (prevalence odds ratio [POR] 3.20, 95% CI 1.01-10.14) and hazardous alcohol use (POR 2.61, 95% CI 1.03-6.56). The association between syndemic score, representing the number of conditions reported by each individual, and viral suppression was not statistically significant, although 86% of participants with none of these conditions were virally suppressed, compared to 56% of those with all three (p = 0.56). Mental illness and substance use were concentrated in this sample, indicating a need for integrated care services.

A Randomized Controlled Trial of Intensive Case Management (Project Bridge) for HIV-Infected Probationers and Parolees

Individuals on probation and parole are disproportionately at high risk for HIV infection and experience significant barriers to accessing health care. This study was a two-group randomized controlled trial conducted at a community corrections office and was designed to link HIV positive probationers/parolees to HIV treatment in the community. HIV positive participants were assigned to one of the two treatment conditions: (1) Project Bridge (PB), an intensive case-management intervention; or (2) treatment as usual (TAU), involving standard referral to treatment. We hypothesized that PB would be more effective than TAU in terms of initiating individuals in community HIV treatment. We found no difference in rates of, or time to, treatment initiation when comparing the PB to TAU (all ns > 0.05). Additionally, there was no statistically significant difference between HIV medication regiment initiation by treatment condition (p > 0.05). Despite limitations, we found that probationers and parolees were willing to be screened and linked to treatment.

Healthcare resources are inadequate to address the burden of illness among HIV-infected male prisoners in Malaysia

Purpose Criminalization of drug use in Malaysia has concentrated people who inject drugs (PWID) and people living with HIV into prisons where health services are minimal and HIV-related mortality is high. Few studies have comprehensively assessed the complex health needs of this population. The paper aims to discuss these issues. Design/methodology/approach From October 2012 through March 2013, 221 sequentially selected HIV-infected male prisoners underwent a comprehensive health assessment that included a structured history, physical examination, and clinically indicated diagnostic studies. Findings Participants were mostly PWID (83.7 percent) and diagnosed with HIV while incarcerated (66.9 percent). Prevalence of hepatitis C virus (90.4 percent), untreated syphilis (8.1 percent), active (13.1 percent), and latent (81.2 percent) tuberculosis infection was several fold higher than non-prisoner Malaysian adults, as was tobacco use (71.9 percent) and heavy drinking (30.8 percent). Most (89.5 percent) were aware of their HIV status before the current incarceration, yet few had been engaged previously in HIV care, including pre-incarceration CD4 monitoring (24.7 percent) or prescribed antiretroviral therapy (ART) (16.7 percent). Despite most (73.7 percent) meeting Malaysia's criteria for ART (CD4 <350 cells/ μL), less than half (48.4 percent) ultimately received it. Nearly one-quarter (22.8 percent) of those with AIDS (<200 cells/ μL) did not receive ART. Originality/value Drug addiction and communicable disease comorbidity, which interact negatively and synergistically with HIV and pose serious public health threats, are highly prevalent in HIV-infected prisoners. Interventions to address the critical shortage of healthcare providers and large gaps in treatment for HIV and other co-morbid conditions are urgently needed to meet the health needs of HIV-infected Malaysian prisoners, most of whom will soon transition to the community.

Manifestations of HIV stigma and their impact on retention in care for people transitioning from prisons to communities

BACKGROUND

While most people living with HIV who are incarcerated in United States receive appropriate HIV care while they are in prison, interruptions in antiretroviral therapy and virologic failure are extremely common after they are released. The purpose of this study was to describe whether and how HIV stigma influences continuity of care for people living with HIV while they transition from prison to community settings.

METHODS

We conducted semi-structured, telephone-based interviews with 32 adults who received HIV care while residing in a Wisconsin state prison, followed by a second interview 6 months after they returned to their home community. Interview transcripts were analyzed by an interdisciplinary research team using conventional content analysis. We identified themes based on commonly-reported experiences that were characterized as internalized stigma, perceived stigma, vicarious stigma, or enacted stigma.

RESULTS

All four forms of HIV stigma appeared to negatively influence participants' engagement in community-based HIV care. Mechanisms described by participants included care avoidance due to concerns about HIV status disclosure and symptoms of depression and anxiety caused by internalized stigma. Supportive social relationships with clinic staff, professional case managers and supportive peers appeared to mitigate the impact of HIV stigma by increasing motivation for treatment adherence.

CONCLUSIONS

HIV stigma is manifest in several different forms by people living with HIV who were recently incarcerated, and are perceived by patients to negatively influence their desire and ability to engage in HIV care. By being cognizant of the pervasive influence of HIV stigma on the lives of criminal justice involved adults, HIV care providers and clinical support staff can ameliorate important barriers to optimal HIV care for a vulnerable group of patients.

Predictors of linkage to HIV care and viral suppression after release from jails and prisons: a retrospective cohort study

BACKGROUND

Incarceration provides an opportunity for engagement in HIV care but is associated with poor HIV treatment outcomes after release. We aimed to assess post-release linkage to HIV care (LTC) and the effect of transitional case management services.

METHODS

To create a retrospective cohort of all adults with HIV released from jails and prisons in Connecticut, USA (2007-14), we linked administrative custody and pharmacy databases with mandatory HIV/AIDS surveillance monitoring and case management data. We examined time to LTC (defined as first viral load measurement after release) and viral suppression at LTC. We used generalised estimating equations to show predictors of LTC within 14 days and 30 days of release.

FINDINGS

Among 3302 incarceration periods for 1350 individuals between 2007 and 2014, 672 (21%) of 3181 periods had LTC within 14 days of release, 1042 (34%) of 3064 had LTC within 30 days of release, and 301 (29%) of 1042 had detectable viral loads at LTC. Factors positively associated with LTC within 14 days of release are intermediate (31-364 days) incarceration duration (adjusted odds ratio 1·52; 95% CI 1·19-1·95), and transitional case management (1·65; 1·36-1·99), receipt of antiretroviral therapy during incarceration (1·39; 1·11-1·74), and two or more medical comorbidities (1·86; 1·48-2·36). Reincarceration (0·70; 0·56-0·88) and conditional release (0·62; 0·50-0·78) were negatively associated with LTC within 14 days. Hispanic ethnicity, bonded release, and psychiatric comorbidity were also associated with LTC within 30 days but reincarceration was not.

INTERPRETATION

LTC after release is suboptimal but improves when inmates' medical, psychiatric, and case management needs are identified and addressed before release. People who are rapidly cycling through jail facilities are particularly vulnerable to missed linkage opportunities. The use of integrated programmes to align justice and health-care goals has great potential to improve long-term HIV treatment outcomes.

FUNDING

US National Institutes of Health.

At the intersection of criminal justice involvement and sexual orientation: Dynamic networks and health among a population-based sample of young Black men who have sex with men

Mass incarceration of young Black men has a significant impact on their network composition and stability that, in turn, may have major implications for health and well-being. A sub-group of young Black men with criminal justice involvement (CJI) identify as gay, bisexual or are non-identified men who have sex with men (hereafter MSM). This paper focuses on the potential effects of CJI on the composition of Black MSM social and sexual networks, their stability over time, and concomitant health and social outcomes. We use data from the UConnect study, a population-based cohort of young Black MSM 16-29 years of age (n=618) selected using respondent-driven sampling in Chicago from 2013-2016. Both confidant and sexual network name generators and interpreters were administered at 9-month intervals over three waves of data collection. Ego and dyadic-level data were collected on behaviors prevalent among MSM and including factors associated with network CJI, network stability, and health outcomes. Generalized Structural Equation Models (GSEM) were utilized to determine the relationship between CJI network composition, network stability and behaviors prevalent among young Black MSM and their networks. In the UConnect cohort, 46% had at least once been detained, arrested or spent time in jail or prison. In addition, 20% of participants reported incident CJI over the study period. Respondents with a history of CJI were significantly more likely to have CJI homophily in their confidant and sexual networks. Multivariate analyses demonstrate that the association between one's history of CJI, housing instability and drug use is partially explained by one's network CJI. In addition, a higher prevalence of network CJI is associated with increased turnover in the confidant network, and this network instability is also related to important health and social outcomes. This analysis describes the networks of criminal justice involved men among a representative sample of young Black MSM and demonstrates the relationship between CJI network homophily, network stability and their impact on several key health and social outcomes relevant to this population.

First description of HTLV-1/2 seroprevalence in HIV-infected inmates in Mozambique

No study has yet been conducted to estimate the burden of co-infection of HIV and HTLV-1/2 in inmates in sub-Saharan Africa. To investigate prevalence of co-infection in inmates in Mozambique, a total of 2140 inmates were screened for HIV, of which 515 were HIV seropositive. All HIV seropositive inmates were further screened for HTLV infection, and eight (1.55%) were co-infected. Co-infection was higher in females (3.45% [2/58; CI: 0.42-11.91]) as compared to males (1.35% [6/445; CI: 0.55-3.06]). Early screening of HTLV in prisons is urgently needed in Mozambique in order to improve the care provided to incarcerated individuals, including initiation of ART.

Jail Booking as an Occasion for HIV Care Reengagement: A Surveillance-Based Study

OBJECTIVES

To examine population and HIV care outcomes of people living with HIV/AIDS (PLWHA) at their first incarceration of 2014 in 2 county jails in King County, Washington.

METHODS

Using HIV surveillance data linked with jail booking data, we examined demographic information, viral loads, CD4 counts, and incarceration details for the period prior to jail booking, during incarceration, and year following jail release.

RESULTS

In 2014, 202 PLWHA were incarcerated, 51% of whom were virally nonsuppressed at booking. This population represented approximately 3% of all HIV-diagnosed persons and 7% of virally nonsuppressed persons in King County. Within a year of release, 62% were virally suppressed, compared with 79% of the general HIV-diagnosed population in King County.

CONCLUSIONS

Incarcerated PLWHA are disproportionately virally nonsuppressed compared with nonincarcerated PLWHA up to a year after release from jail. Public Health Implications. Coordination of health information exchange between the health department and jails could enhance public health efforts to improve the HIV care continuum.

High mortality among male HIV-infected patients after prison release: ART is not enough after incarceration with HIV

Context

French Guiana is a South American French territory, where HIV prevalence consistently exceeds 1% in the adult population. In the only correctional facility, HIV prevalence fluctuates at around 4%.

Aims

After describing the population of HIV-positive inmates, we aimed to evaluate mortality after release from the correctional facility, and to identify its predictive factors.

Rationale

Outside North American settings, data on treatment outcome and vital status of HIV-positive former inmates are scarce. There were no data in French Guiana. Filling this gap represents a basis for potential improvements.

Methods

All HIV-infected adults released from an incarceration of 30 days or more, between 2007 and 2013, were enrolled in a retrospective cohort study. Mortality was described over time, one to seven years following release, using Kaplan-Meier estimates. Factors associated with mortality were identified through a non-parametric survival regression model.

Results

147 former inmates were included. The male to female ratio was 4.4. The median age was 37.3 years. The majority were migrants, 25.8% were homeless, 70.1% suffered from substance abuse, with 34.0% of crack-cocaine users. On admission, 78.1% had an early HIV-stage infection (CDC-stage A), with a median CD4 count of 397.5/mm3, 34.0% had one comorbidity, mainly hypertension. Upon release, 50.3% were on ART. Reasons for not being treated were not fulfilling the criteria for 74.6%, and refusing for 15.1%. Before release, 84.5% of the patients on ART had a viral load≤200cp/ml. After release, 8.2% of the cohort had died, with a crude incidence of 33.8/1000 person-years. All recorded deaths were males, with an incidence of 42.2/1000 person-years. Comparing with the age-specific mortality rates for males in French Guiana, the standardized mortality ratio was 14.8. In multivariate analysis, factors associated with death were age and CD4 count before release.

Conclusion

Despite access to ART while incarcerated, with good virological outcome, the post-release mortality was very high for males, almost 15 times what is observed in the general male population living in French Guiana, after age standardization. Access to ART in correctional facilities may be a necessary, but not sufficient condition to protect male inmates from death after release.

Mass incarceration, public health, and widening inequality in the USA

In this Series paper, we examine how mass incarceration shapes inequality in health. The USA is the world leader in incarceration, which disproportionately affects black populations. Nearly one in three black men will ever be imprisoned, and nearly half of black women currently have a family member or extended family member who is in prison. However, until recently the public health implications of mass incarceration were unclear. Most research in this area has focused on the health of current and former inmates, with findings suggesting that incarceration could produce some short-term improvements in physical health during imprisonment but has profoundly harmful effects on physical and mental health after release. The emerging literature on the family and community effects of mass incarceration points to negative health impacts on the female partners and children of incarcerated men, and raises concerns that excessive incarceration could harm entire communities and thus might partly underlie health disparities both in the USA and between the USA and other developed countries. Research into interventions, policies, and practices that could mitigate the harms of incarceration and the post-incarceration period is urgently needed, particularly studies using rigorous experimental or quasi-experimental designs.

The Influence of Neurocognitive Impairment, Depression, and Alcohol Use Disorders on Health-Related Quality of Life among Incarcerated, HIV-Infected, Opioid Dependent Malaysian Men: A Moderated Mediation Analysis

Prior research has widely recognized neurocognitive impairment (NCI), depression, and alcohol use disorders (AUDs) as important negative predictors of health-related quality of life (HRQoL) among people living with HIV (PLWH). No studies to date, however, have explored how these neuropsychological factors operate together and affect HRQoL. Incarcerated male PLWH (N = 301) meeting criteria for opioid dependence were recruited from Malaysia's largest prison. Standardized scales for NCI, depression, alcohol use disorders (AUDs) and HRQoL were used to conduct a moderated mediation model to explore the extent to which depression mediated the relationship between NCI, HRQoL, and AUDs using an ordinary least squares regression-based path analytic framework. Results showed that increasing levels of NCI (B = -0.1773, p < 0.001) and depression (B = -0.6147, p < 0.001) were negatively associated with HRQoL. The effect of NCI on HRQoL was significantly (Sobel z = -3.5600, p < 0.001) mediated via depression (B = -0.1230, p < 0.001). Furthermore, the conditional indirect effect of NCI on HRQoL via depression for individuals with AUDs was significant (B = -0.9099, p = 0.0087), suggesting a moderated mediation effect. The findings disentangle the complex relationship using a moderated mediation model, demonstrating that increasing levels of NCI, which can be reduced with HIV treatment, negatively influenced HRQoL via depression for individuals with AUDs. This highlights the need for future interventions to target these complex interplay between neuropsychological factors in order to improve HRQoL among PLWH, particularly incarcerated PLWH with AUDs.

Routine or targeted HIV screening of Indonesian prisoners

PURPOSE

Routine HIV screening of prisoners is generally recommended, but rarely implemented in low-resource settings. Targeted screening can be used as an alternative. Both strategies may provide an opportunity to start HIV treatment but no formal comparisons have been done of these two strategies. The paper aims to discuss these issues.

DESIGN/METHODOLOGY/APPROACH

The authors compared yield and costs of routine and targeted screening in a narcotic prison in Indonesia. Routine HIV screening was done for all incoming prisoners from August 2007-February 2009, after it was switched for budgetary reasons to targeted ("opt-out") HIV screening of inmates classified as people who inject drugs (PWIDs), and "opt-in" HIV testing for all non-PWIDs.

FINDINGS

During routine screening 662 inmates were included. All 115 PWIDs and 93.2 percent of non-PWIDs agreed to be tested, 37.4 percent and 0.4 percent respectively were HIV-positive. During targeted screening (March 2009-October 2010), of 888 inmates who entered prison, 107 reported injecting drug use and were offered HIV testing, of whom 31 (29 percent) chose not to be tested and 25.0 percent of those tested were HIV-positive. Of 781 non-PWIDs, 187 (24 percent) came for testing (opt-in), and 2.1 percent were infected. During targeted screening fewer people admitted drug use (12.0 vs 17.4 percent). Routine screening yielded twice as many HIV-infected subjects (45 vs 23). The estimated cost per detected HIV infection was 338 USD for routine and 263 USD for targeted screening.

ORIGINALITY/VALUE

In a resource limited setting like Indonesia, routine HIV screening in prison is feasible and more effective than targeted screening, which may be stigmatizing. HIV infections that remain unrecognized can fuel ongoing transmission in prison and lead to unnecessary disease progression and deaths.

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.

Effect of social relationships on antiretroviral medication adherence for people living with HIV and substance use disorders and transitioning from prison

BACKGROUND

This paper examines how family and social relations facilitate and inhibit adherence to antiretroviraltherapy (ART) for people living with HIV (PLH) who have underlying substance use disorders and are transitioningto the community post-incarceration.

METHODS

Combining the methods of inductive close reading and constantcomparison, we analyzed the data from 30 semi-structured interviews of PLH who had recently transitioned to thecommunity within the previous 90 days.

RESULTS

Three central themes were anticipated as important socialrelationships post-release: self-reported family, friends and clinicians. Among these, four sub-themes (social isolation, 'double jeopardy', search for belonging, and trust and respect) emerged, highlighting how they impacted ART adherence. Post-release, participants returned to resource-poor communities where they experienced socialisolation. ART adherence was enabled by having a purpose in life, which correlated with having robust family support structures. Many former prisoners felt that a chasm between them and their families existed, both because of HIV stigma and their addiction problems. In this context, relationships with untrustworthy friends from their druguse networks led to relapse of drug use and risky behaviors, jeopardizing participants' ART adherence and persistence. To avoid the double jeopardy, defined as seeking friends for support but who were also the ones who contributed to drug relapse, participants searched for new social anchors, which often included their healthcare providers who represented trusted and respected persons in their life.

CONCLUSIONS

While some former prisonersperceived doctors as uncaring and their relationships asymmetrical, positive relationships with these providers,when respect and trust was mutual, reinforced the participants' sense of belonging to what they called 'the world that don't do drugs' and motivated them to adhere to ART.

Correlates of retention on extended-release naltrexone among persons living with HIV infection transitioning to the community from the criminal justice system

BACKGROUND

The acceptability of and retention on extended-release naltrexone (XR-NTX), an FDA-approved medication for the treatment of alcohol and opioid use disorders, among persons living with HIV disease (PLH) under criminal justice setting (CJS) supervision has not been evaluated to date.

METHODS

Two double-blind placebo-controlled randomized trials of XR-NTX for inmates with HIV disease transitioning to the community with (1) alcohol use disorders (AUDs) or (2) opioid use disorders, are underway. Reasons for not accepting XR-NTX and an evaluation of differences in demographic features between those who were retained on study drug and those who did not return for their second injection post-release are discussed.

RESULTS

70% of eligible persons consented to participate; almost 90% received their first injection; and almost 60% returned for their first injection after release. Variables found to be associated (p<0.10) with returning for the second injection included: not meeting criteria for hazardous drinking (p=0.035; OR 0.424 (CI 0.191-0.941)); being prescribed antiretroviral therapy (p=0.068; OR 2.170 (CI 0.943-4.992)); expressing experiencing serious depression 30 days prior to incarceration (p=0.068; OR 1.889 (CI 0.955-3.737)); not having a positive cocaine urine screen on the day of release (DOR) (p=0.011; OR 0.258 (CI 0.091-0.729)); and not meeting criteria for an AUD plus any substance use disorder (p=0.068; OR 0.521 (CI 0.259-1.048)). Only positive cocaine urine test on DOR was statistically significant after multivariate regression analyses (p=0.005; OR 0.207 (CI 0.068-0.623)).

CONCLUSION

CJS based XR-NTX programs are highly acceptable among PLH, however retention on XR-NTX after release is negatively impacted by relapse to cocaine use.

Influence of Jail Incarceration and Homelessness Patterns on Engagement in HIV Care and HIV Viral Suppression among New York City Adults Living with HIV/AIDS

Objectives

Both homelessness and incarceration are associated with housing instability, which in turn can disrupt continuity of HIV medical care. Yet, their impacts have not been systematically assessed among people living with HIV/AIDS (PLWHA).

Methods

We studied a retrospective cohort of 1,698 New York City PLWHA with both jail incarceration and homelessness during 2001–05 to evaluate whether frequent transitions between jail incarceration and homelessness were associated with a lower likelihood of continuity of HIV care during a subsequent one-year follow-up period. Using matched jail, single-adult homeless shelter, and HIV registry data, we performed sequence analysis to identify trajectories of these events and assessed their influence on engagement in HIV care and HIV viral suppression via marginal structural modeling.

Results

Sequence analysis identified four trajectories; 72% of the cohort had sporadic experiences of both brief incarceration and homelessness, whereas others experienced more consistent incarceration or homelessness during early or late months. Trajectories were not associated with differential engagement in HIV care during follow-up. However, compared with PLWHA experiencing early bouts of homelessness and later minimal incarceration/homelessness events, we observed a lower prevalence of viral suppression among PLWHA with two other trajectories: those with sporadic, brief occurrences of incarceration/homelessness (0.67, 95% CI = 0.50,0.90) and those with extensive incarceration experiences (0.62, 95% CI = 0.43,0.88).

Conclusions

Housing instability due to frequent jail incarceration and homelessness or extensive incarceration may exert negative influences on viral suppression. Policies and services that support housing stability should be strengthened among incarcerated and sheltered PLWHA to reduce risk of adverse health conditions.

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.

Sex-Related Disparities in Criminal Justice and HIV Treatment Outcomes: A Retrospective Cohort Study of HIV-Infected Inmates

OBJECTIVES

We evaluated sex-related differences in HIV and criminal justice (CJ) outcomes.

METHODS

We quantified sex-related differences in criminal offenses, incarcerations, and HIV outcomes among all HIV-infected inmates on antiretroviral therapy (ART) in Connecticut (2005-2012). Computed criminogenic risk scores estimated future CJ involvement. Stacked logistic regression models with random effects identified significant correlates of HIV viral suppression on CJ entry, reflecting preceding community-based treatment.

RESULTS

Compared with 866 HIV-infected men on ART (1619 incarcerations), 223 women (461 incarcerations) were more likely to be younger, White, and medically insured, with shorter incarceration periods (mean = 196.8 vs 368.1 days), mostly for public disorder offenses. One third of both women and men had viral suppression on CJ entry, correlating positively with older age and having treated comorbidities. Entry viral suppression inversely correlated with incarceration duration for women and with criminogenic risk score for men.

CONCLUSIONS

In the largest contemporary cohort of HIV-infected inmates on ART, women's higher prevalence of nonviolent offenses and treatable comorbidities supports alternatives to incarceration strategies. Sex-specific interventions for CJ populations with HIV effectively align public health and safety goals.

The HIV Care Cascade Before, During, and After Incarceration: A Systematic Review and Data Synthesis

We conducted a systematic literature review of the data on HIV testing, engagement in care, and treatment in incarcerated persons, and estimated the care cascade in this group. We identified 2706 titles in MEDLINE, EBSCO, and Cochrane Library databases for studies indexed to January 13, 2015, and included 92 for analysis. We summarized HIV testing results by type (blinded, opt-out, voluntary); reviewed studies on HIV care engagement, treatment, and virological suppression; and synthesized these results into an HIV care cascade before, during, and after incarceration. The HIV care cascade following diagnosis increased during incarceration and declined substantially after release, often to levels lower than before incarceration. Incarceration provides an opportunity to address HIV care in hard-to-reach individuals, though new interventions are needed to improve postrelease care continuity.

Outcomes of on-site antiretroviral therapy provision in a South African correctional facility

We evaluated a novel on-site antiretroviral therapy (ART) programme in a South African correctional facility using routinely collected programme data, from a retrospective cohort of adult inmates starting ART between 03/2007 and 03/2009 followed-up to 09/2009. We report (1) mortality (using survival analysis); (2) retention in the programme (to 09/2009); and (3) virological suppression at six and 12 months (<400 copies/ml) following ART initiation. In total, 404 started ART (median age 33 years; 91.3% men; median baseline CD4 cell count 152 cells/µl [interquartile range 85-225]). Among 299 starting ART for the first time (ART-naïve), 23 deaths occurred during 252 person-years (median follow-up nine months). Mortality rates were 17.2 at 0-6 months (95% confidence interval 10.9-26.9) and 2.8 at >6 months (95% confidence interval 1.1-7.5)/100 person-years; p < 0.001. At 09/2009, 35.6% (144/404) remained in the correctional facility, with 94.4% (136/144) retained in the programme; 38.4% (155/404) were released; and 20.0% (81/404) transferred to another facility. ART-naïve patients in care six and 12 months after ART initiation, 94.7% (124/131) and 92.5% (74/80) were virologically suppressed, respectively. High early mortality warrants the early identification and management of HIV-positive inmates. The high mobility of inmates necessitates systems for facilitating continuity of care. Good virological responses and retention supports decentralising HIV care to correctional facilities.