All-cause mortality among people with HIV released from an integrated system of jails and prisons in Connecticut, USA, 2007-14: a retrospective observational cohort study

Prescribing methadone in prison predicts linkage to HIV care after release from prison: A randomized and patient preference trial

PURPOSE

The transition from prison is hazardous, especially for people with HIV and opioid use disorder. To determine the impact of methadone on linkage to HIV care in people with HIV and opioid use disorder, we prospectively compared those allocated to pre-release methadone or not.

METHODS

A prospective, open-label trial of 310 people with HIV and opioid use disorder at Malaysia's largest prison were allocated to pre-release methadone up to 24 weeks before release or not by randomization (n = 64) or preference (n = 246); 296 were included in the final analytical sample. Directed acyclic graphing was used to theorize the relationship between pre-release methadone and post-release linkage to HIV care and identify confounding variables. An inverse probability weighted Cox proportional hazards model estimated the impact of pre-release methadone on linkage to HIV care through 360 days after release.

RESULTS

Overall, 218 (73.6 %) of 296 study participants initiated methadone before release. Receiving pre-release methadone significantly predicted linkage to HIV care at all time points through 360 days (aHR = 1.87; 95 % CI 1.15-2.85) after release. The corresponding numbers needed to treat with pre-release methadone for one increased linkage to HIV care at 30 and 360 days were 14 (95 % CI 9.2-62.4) and 5 (95 % CI 3.4-22.0), respectively.

CONCLUSIONS

While treatment with methadone should be available to everyone with opioid use disorder, it should especially be included as part of an HIV treatment-as-prevention strategy for people in prisons, especially by the time of release. It can optimize HIV treatment outcomes by jumpstarting the HIV treatment cascade.

Operationalization of Status Neutral Human Immunodeficiency Virus Care for Criminal-Legal Involved Populations

The United States has the highest number of people incarcerated in the world. Criminal-legal involved populations, including people who are incarcerated in jails and prisons and people who are under community carceral control through probation or parole are at an increased risk for human immunodeficiency virus (HIV). Increasing access to HIV testing, treatment and prevention is necessary to curb the HIV epidemic. This chapter outlines the history of HIV testing in jails and prisons and suggests a Status Neutral HIV Care Framework for improving access to HIV prevention services.

Medicaid Inmate Exclusion Policy and Infectious Diseases Care for Justice-Involved Populations

The Medicaid Inmate Exclusion Policy (MIEP) prohibits using federal funds for ambulatory care services and medications (including for infectious diseases) for incarcerated persons. More than one quarter of states, including California and Massachusetts, have asked the federal government for authority to waive the MIEP. To improve health outcomes and continuation of care, those states seek to cover transitional care services provided to persons in the period before release from incarceration. The Massachusetts Sheriffs' Association, Massachusetts Department of Correction, Executive Office of Health and Human Services, and University of Massachusetts Chan Medical School have collaborated to improve infectious disease healthcare service provision before and after release from incarceration. They seek to provide stakeholders working at the intersection of criminal justice and healthcare with tools to advance Medicaid policy and improve treatment and prevention of infectious diseases for persons in jails and prisons by removing MIEP barriers through Section 1115 waivers.

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).

HIV Care Continuum Among People Living With HIV and History of Arrest and Mental Health Diagnosis

OBJECTIVE

Justice involvement and psychiatric comorbidities contribute to excess HIV morbidity, yet their interaction is poorly understood. We examined associations of this overlap with HIV outcomes among people living with HIV (PLWH).

METHODS

We conducted a retrospective cohort study of PLWH aged 13 years and older residing in Marion County (Indianapolis), IN, during 2018 (n = 5730) using linked HIV surveillance, arrest, and clinical data. We used univariable and multivariable regression to evaluate main and interaction effects of 2010-2017 arrest and mental health diagnosis on 2018 linkage to care (LTC), retention in care (RIC), and undetectable viral load (UVL).

RESULTS

LTC decreased among those with, versus without, an arrest (P = 0.02), although mental health diagnoses had no significant effect on LTC. When controlling for demographics and substance use disorder, analyses indicated a protective effect of arrest history on odds of RIC (adjusted odds ratio [aOR] = 1.54) and UVL (aOR = 1.26). Mental health diagnosis also increased odds of RIC (aOR = 2.02) and UVL (aOR = 1.95). Post hoc tests demonstrated that these results were mediated by outpatient care utilization, although an arrest or mental health diagnosis did increase odds of RIC among PLWH and a history of low outpatient utilization.

CONCLUSIONS

Outpatient care utilization improves HIV outcomes, even among those with justice involvement and psychiatric comorbidities. Holistic approaches to care can increase utilization. Implementation of "no wrong door" approaches, such as integration of mental health care in the primary care setting, simplifies health care navigation and improves access. Among those arrested, access to a Behavioral Court program can improve, rather than disrupt, HIV care.

Record linkage studies of drug-related deaths among adults who were released from prison to the community: a scoping review

BACKGROUND

There are public health concerns about an increased risk of mortality after release from prison. The objectives of this scoping review were to investigate, map and summarise evidence from record linkage studies about drug-related deaths among former adult prisoners.

METHODS

MEDLINE, EMBASE, PsychINFO and Web of Science were searched for studies (January 2011- September 2021) using keywords/index headings. Two authors independently screened all titles and abstracts using inclusion and exclusion criteria and subsequently screened full publications. Discrepancies were discussed with a third author. One author extracted data from all included publications using a data charting form. A second author independently extracted data from approximately one-third of the publications. Data were entered into Microsoft Excel sheets and cleaned for analysis. Standardised mortality ratios (SMRs) were pooled (where possible) using a random-effects DerSimonian-Laird model in STATA.

RESULTS

A total of 3680 publications were screened by title and abstract, and 109 publications were fully screened; 45 publications were included. The pooled drug-related SMR was 27.07 (95%CI 13.32- 55.02; I 2 = 93.99%) for the first two weeks (4 studies), 10.17 (95%CI 3.74-27.66; I 2 = 83.83%) for the first 3-4 weeks (3 studies) and 15.58 (95%CI 7.05-34.40; I 2 = 97.99%) for the first 1 year after release (3 studies) and 6.99 (95%CI 4.13-11.83; I 2 = 99.14%) for any time after release (5 studies). However, the estimates varied markedly between studies. There was considerable heterogeneity in terms of study design, study size, location, methodology and findings. Only four studies reported the use of a quality assessment checklist/technique.

CONCLUSIONS

This scoping review found an increased risk of drug-related death after release from prison, particularly during the first two weeks after release, though drug-related mortality risk remained elevated for the first year among former prisoners. Evidence synthesis was limited as only a small number of studies were suitable for pooled analyses for SMRs due to inconsistencies in study design and methodology.

M. SP, Ku HC, Wu YL, Ko NY. Global overview of suicidal behavior and associated risk factors among people living with human immunodeficiency virus: A scoping review

Death by suicide is a major public health problem. People living with human immunodeficiency virus (PLHIV) have higher risk of suicidal behavior than the general population. The aim of this review is to summarize suicidal behavior, associated risk factors, and risk populations among PLHIV. Research studies in six databases from January 1, 1988, to July 8, 2021, were searched using keywords that included "HIV," "suicide," and "risk factors." The study design, suicide measurement techniques, risk factors, and study findings were extracted. A total of 193 studies were included. We found that the Americas, Europe, and Asia have the highest rates of suicidal behavior. Suicide risk factors include demographic factors, mental illness, and physiological, psychological, and social support. Depression is the most common risk factor for PLHIV, with suicidal ideation and attempt risk. Drug overdosage is the main cause of suicide death. In conclusion, the current study found that PLHIV had experienced a high level of suicidal status. This review provides an overview of suicidal behavior and its risk factors in PLHIV with the goal of better managing these factors and thus preventing death due to suicide.

Diagnosis, Treatment, and Prevention of HIV Infection among Detainees: A Review of the Literature

Detainees are one of the most vulnerable populations to human immunodeficiency virus (HIV). This is mostly caused by the lack of knowledge on the topic among the inmates; the lack of prophylaxis; the high percentage of risky behaviors in jail, such as sexual abuse, unprotected sexual intercourses, and injective drug use; and the generally low perception of the risk of transmission. It has also been observed that the problem does not cease to exist at the moment of release, but it also may be aggravated by the weak support system or the total absence of programs for people living with HIV/AIDS (PLWHA) to avoid discontinuation of antiretroviral drugs. Difficulty in providing housing and jobs and, therefore, a form of stability for ex-detainees, also contributes to none adherence to antiretroviral therapy. Among the detainees, there are also categories of people more susceptible to discrimination and violence and, therefore, to risky behaviors, such as black people, Hispanics, transgender people, and men who have sex with men (MSM). We reviewed the literature in order to provide a more complete picture on the situation of PLWHA in jail and to also analyze the difficulties of ex-detainees in adhering to HIV therapy.

Impact of prerelease methadone on mortality among people with HIV and opioid use disorder after prison release: results from a randomized and participant choice open-label trial in Malaysia

INTRODUCTION

Mortality is elevated after prison release and may be higher in people with HIV and opioid use disorder (OUD). Maintenance with opioid agonist therapy (OAT) like methadone or buprenorphine reduces mortality in people with OUD and may confer benefits to people with OUD and HIV leaving prison. Survival benefits of OAT, however, have not been evaluated prospectively in people with OUD and HIV leaving prison.

METHODS

This study prospectively evaluated mortality after prison release and whether methadone initiated before release increased survival after release in a sample of men with HIV and OUD (n = 291). We linked national death records to data from a controlled trial of prerelease methadone initiation conducted from 2010 to 2014 with men with HIV and OUD imprisoned in Malaysia. Vital statistics were collected through 2015. Allocation to prerelease methadone was by randomization (n = 64) and participant choice (n = 246). Cox proportional hazards models were used to estimate treatment effects of prerelease methadone on postrelease survival.

RESULTS

Overall, 62 deaths occurred over 872.5 person-years (PY) of postrelease follow-up, a crude mortality rate of 71.1 deaths per 1000 PY (95% confidence interval [CI] 54.5-89.4). Most deaths were of infectious etiology, mostly related to HIV. In a modified intention-to-treat analysis, the impact of prerelease methadone on postrelease mortality was consistent with a null effect in unadjusted (hazard ratio [HR] 1.3, 95% CI 0.6-3.1) and covariate-adjusted (HR 1.2, 95% CI 0.5-2.8) models. Predictors of mortality were educational level (HR 1.4, 95% CI 1.0-1.8), pre-incarceration alcohol use (HR 2.0, 95% CI 1.1-3.9), and lower CD4+ T-lymphocyte count (HR 0.8 per 100-cell/mL increase, 95% CI 0.7-1.0).

CONCLUSIONS

Postrelease mortality in this sample of men with HIV and OUD was extraordinarily high, and most deaths were likely of infectious etiology. No effect of prerelease methadone on postrelease mortality was observed, which may be due to study limitations or an epidemiological context in which inadequately treated HIV, and not inadequately treated OUD, is the main cause of death after prison release.

TRIAL REGISTRATION

NCT02396979. Retrospectively registered 24/03/2015.

Interest without uptake: A mixed-methods analysis of methadone utilization in Kyrgyz prisons

HIV incidence continues to increase in Eastern Europe and Central Asia (EECA), in large part due to non-sterile injection drug use, especially within prisons. Therefore, medication-assisted therapy with opioid agonists is an evidence-based HIV-prevention strategy. The Kyrgyz Republic offers methadone within its prison system, but uptake remains low. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a framework for identifying people who would potentially benefit from methadone, intervening to identify OUD as a problem and methadone as a potential solution, and providing referral to methadone treatment. Using an SBIRT framework, we screened for OUD in Kyrgyz prisons among people who were within six months of returning to the community (n = 1118). We enrolled 125 people with OUD in this study, 102 of whom were not already engaged in methadone treatment. We conducted a pre-release survey followed by a brief intervention (BI) to address barriers to methadone engagement. Follow-up surveys immediately after the intervention and at 1 month, 3 months, and 6 months after prison release assessed methadone attitudes and uptake. In-depth qualitative interviews with 12 participants explored factors influencing methadone utilization during and after incarceration. Nearly all participants indicated favorable attitudes toward methadone both before and after intervention in surveys; however, interest in initiating methadone treatment remained very low both before and after the BI. Qualitative findings identified five factors that negatively influence methadone uptake, despite expressed positive attitudes toward methadone: (1) interpersonal relationships, (2) interactions with the criminal justice system, (3) logistical concerns, (4) criminal subculture, and (5) health-related concerns.

Prevalence and correlates of incarceration following emergency medical services response to overdose

BACKGROUND

To describe the prevalence of incarceration among survivors of non-fatal overdose addressed through an emergency medical services (EMS) response, and compare incarceration by whether the emergency was for opioid-involved or stimulant-involved overdose.

METHODS

Administrative records on 192,113 EMS incidents and 70,409 jail booking events occurring between January 1, 2019 and December 31, 2020 in Indianapolis, Indiana were record-linked at the event level. Incarceration taking place within 6-hours of an EMS incident was associated with that incident. Logistic regression was used to calculate adjusted odds ratios (AOR) of incarceration after an overdose.

RESULTS

Among all EMS incidents, 2.6% were followed by incarceration. For overdose EMS incidents, the prevalence of incarceration was 10.0%. Overdose incidents had higher odds than non-overdose incidents of leading to a charge of felony, booked on a warrant, and transferred to another law enforcement agency upon release. Prevalence of incarceration following a stimulant-involved overdose was 21.3%, compared to 9.3% for opioid-involved overdose survivors. Compared to persons from other EMS incidents, overdose survivors had greater odds of incarceration (AOR=3.48, 95% confidence interval (CI)= 3.22, 3.75, p < .001), with opioid-involved overdoses (AOR=3.03, 95% CI=2.76, 3.33, p < .001) and stimulant-involved overdoses (AOR=6.70, 95% CI=5.26, 8.55, p < .001) leading to higher odds of incarceration.

CONCLUSION

Incarceration in county jail followed one in ten overdose-involved EMS responses. As illicit drug consumption increasingly involves stimulants, the frequency of incarceration following these events is likely to increase. Policy changes and interventions are needed to reduce incarceration after overdose emergencies.

Mortality among clients in the New York city HIV Care Coordination Program (CCP): incidence and associated clinical factors

PURPOSE

We examined psychosocial factors (housing, drug use, incarceration history or mental health) and care factors (comorbidities and acute care) associated with all-cause and HIV-related mortality while enrolled in the New York City Ryan White HIV Care Coordination Program (CCP), an intensive case management program for people with barriers to HIV care and treatment.

METHODS

We used hazards regression (HR) to understand factors associated with mortality.

RESULTS

8,135 people (13,479.4 person years [PY]) enrolled in the CCP from March 2011 to December 2016. The all-cause mortality rate while enrolled was 28.8 per 1000 PY (N = 388), with 43% of deaths (N = 167) related to HIV (12.4 per 1000 PY). Controlling for demographics and clinical status, the variables associated with increased hazards of all-cause mortality included hospitalizations or emergency-department visits prior to enrollment (aHR_{Hospitalizations}: 2.54; 95% Confidence Interval 2.07-3.11 and aHR_ED: 1.54; 1.24-1.92) or a diabetes or Hepatitis C diagnosis at enrollment (aHR_Diabetes: 1.80; 1.36-2.37 and aHR_HCV: 1.78; 1.37-2.30). These factors also increased the hazards of HIV-related mortality.

CONCLUSIONS

CCP and similar case management programs should systematically screen enrolling clients for a history of acute care and comorbidities, as they may be important markers of need for more intensive engagement and follow-up to prevent death.

Impact of cumulative incarceration and the post-release period on syringe-sharing among people who inject drugs in Tijuana, Mexico: a longitudinal analysis

BACKGROUND AND AIMS

Syringe-sharing among people who inject drugs, which can occur during incarceration and post-release, has been linked with increased risk of blood-borne infections. We aimed to investigate the cumulative effect of repeated incarceration and the post-release period on receptive syringe-sharing.

DESIGN

Ongoing community-based cohort, recruited through targeted sampling between 2011 and 2012 with 6-month follow-ups.

SETTING

Tijuana, Mexico.

PARTICIPANTS

Sample of 185 participants (median age 35 years; 67% female) with no history of incarceration at study entry, followed to 2017.

MEASUREMENTS

Cumulative incarceration and post-release period were constructed from incarceration events reported in the past 6 months for each study visit. Receptive syringe-sharing in the past 6 months was assessed as a binary variable. We used logistic regression with generalized estimating equations to examine the association between cumulative incarceration events and the post-release period with receptive syringe-sharing over time. Missing data were handled through multiple imputation.

FINDINGS

At baseline, 65% of participants engaged in receptive syringe-sharing in the prior 6 months. At follow-up, 150 (81%) participants experienced a total of 358 incarceration events [median = 2, interquartile range (IQR) = 1-3]. The risk of receptive syringe-sharing increased with the number of repeated incarcerations. Compared with never incarcerated, those with one incarceration had 1.28 [95% confidence interval (CI) = 0.97-1.68] higher adjusted odds of syringe-sharing; two to three incarcerations, 1.42 (95% CI = 1.02-1.99) and more than three incarcerations, 2.10 (95% CI = 1.15-3.85). Participants released within the past 6 months had 1.53 (95% CI = 1.14-2.05) higher odds of sharing syringes compared with those never incarcerated. This post-release risk continued up to 1.5 years post-incarceration (adjusted odds ratio = 1.41, 95% CI = 1.04-1.91), but then waned.

CONCLUSIONS

A longitudinal community cohort study among people who inject drugs suggested that the effects of incarceration on increased injecting risk, measured through syringe-sharing, are cumulative and persist during the post-release period.

Decisional considerations for methadone uptake in Kyrgyz prisons: The importance of understanding context and providing accurate information

BACKGROUND

The Kyrgyz Republic (Kyrgyzstan) is one of few countries in Eastern Europe and Central Asia to provide methadone within its prisons, but uptake of this program has been suboptimal, in part because methadone uptake may have personal or social risks and consequences. Decision aids are evidence-based strategies that are designed to inform the patient's choice by objectively providing information that incorporates patient preferences.

METHODS

We conducted qualitative interviews in Kyrgyz and Russian with currently and formerly incarcerated people (n = 36) in Kyrgyzstan from October 2016 to September 2018. Interviews explored factors influencing methadone utilization in prisons. Transcripts were coded by five researchers using content analysis. A secondary thematic analysis was conducted to determine factors specific to initiation or continuation of methadone treatment in prisons.

RESULTS

We identified six interrelated themes affecting an individual's decision to initiate or continue methadone treatment: 1) informal prison governance (incarcerated people governing themselves); 2) informal prison economy; 3) perceived and objective benefits of methadone treatment; 4) perceived and objective side effects of methadone treatment; 5) distrust of formal prison administration (medical and correctional staff); and 6) desire for a "cure" from addiction.

CONCLUSION

Respondents' perceptions about benefits, side effects, and addiction as a curable disease are not consistent with the available evidence. An evidence-based, informed decision-making aid would need to address the six themes identified here, of which several are specific to the Kyrgyz prison context. Unlike decision aids elsewhere, the unique aspects of incarceration itself alongside the informal governance system strongly present within Kyrgyz prisons will need to be incorporated into decisional processes to promote HIV prevention and treatment in a region with high rates of HIV transmission and mortality.

Frequency and Duration of Incarceration and Mortality Among US Veterans With and Without HIV

BACKGROUND

Exposure to incarceration is associated with increased risk of mortality, and HIV is cited as a leading cause of death. Yet, few studies have examined the association between incarceration and mortality among people with HIV (PWH), specifically whether and how increasing exposure to incarceration increases risk of mortality. We compared mortality by different incarceration exposures and HIV status.

METHODS

We conducted a prospective cohort study of participants in the Veterans Aging Cohort Study from January 2011 to August 2017 (N = 5367). The primary exposure was incarceration by 3 measures: (1) any (ever/never); (2) frequency; and (3) cumulative duration. Stratifying by HIV status and controlling for age, race, and sex, we used Cox Proportional Hazard models to estimate adjusted hazard ratios (AHRs) and 95% confidence intervals (CIs).

RESULTS

Incarceration was associated with increased risk of mortality compared with those never incarcerated for PWH (AHR 1.37; 95% CI: 1.13 to 1.66) and those uninfected (AHR 1.24; 95% CI: 0.99 to 1.54), but the association was only statistically significant among PWH. Increasing frequency of incarceration was associated with higher risk of mortality in both groups: for PWH, AHRs 1.13, 1.45, and 1.64 for 1, 2-5; 6+ times, respectively, for uninfected, AHRs 0.98, 1.35, and 1.70 for 1, 2-5, and 6+ times, respectively.

CONCLUSIONS

PWH were at increased risk of mortality after incarceration, and repeated exposure to incarceration was associated with mortality in both groups in a dose-response fashion. This increased risk of mortality may be mitigated by improving transitional health care, especially HIV care, and reducing incarceration.

Falling Through the Cracks: Risk Factors for Becoming Lost to HIV Care After Incarceration in a Southern Jail

Using a retrospective cohort analysis of inmates released from Dallas County Jail between January 2011 and November 2013, this study characterizes people living with HIV/AIDS (PLWHA) who are lost to care after release from jail. We used Kaplan-Meier analysis to estimate the risk of becoming lost to post-release HIV care and a Cox proportional hazards regression model to identify associated factors. The majority of individuals (78.2%) were men and 65.5% were black. Of the incarcerations that ended with release to the community, approximately 43% failed to link to community HIV care. Non-Hispanic Whites were more likely than Hispanics or Blacks to drop out of care after release. Individuals with histories of substance use or severe mental illness were more likely to become lost, while those under HIV care prior to incarceration and/or who had adhered to antiretroviral therapy (ART) were more likely to resume care upon release. Targeted efforts such as rapid linkage to care and re-entry residence programs could encourage formerly incarcerated individuals to re-engage in care.

The relationship between incarceration history and overdose in North America: A scoping review of the evidence

INTRODUCTION

Rates of opioid overdose (OD) have risen to unprecedented numbers and more than half of incarcerated individuals meet the criteria for substance use disorder, placing them at high risk. This review describes the relationship between incarceration history and OD.

METHODS

A scoping review was conducted and criteria for inclusion were: set in North America, published in English, and non-experimental study of formerly incarcerated individuals. Due to inconsistent definitions of opioid OD, we included all studies examining OD where opioids were mentioned.

RESULTS

The 18 included studies were all published in 2001 or later. Four associations between incarceration history and OD were identified: (1) six studies assessed incarceration history as a risk factor for OD and four found a significantly higher risk of OD among individuals with a history of incarceration compared to those without; (2) nine studies examined the rate of OD compared to the general population: eight found a significantly higher risk of fatal OD among those with a history of incarceration and three documented the highest risk of death immediately following release; (3) six studies found demographic, substance use and mental health, and incarceration-related risk factors for OD among formerly incarcerated individuals; and (4) four studies assessed the proportion of deaths due to OD and found a range from 5 % to 57 % among formerly incarcerated individuals.

DISCUSSION

Findings support the growing call for large-scale implementation of evidence-based OD prevention interventions in correctional settings and among justice-involved populations to reduce OD burden in this high-risk population.

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.

Prisons: ignore them at our peril

PURPOSE OF REVIEW

People with HIV and HCV are concentrated within criminal justice settings globally, primarily related to criminalization of drug use. This review examines updated prevention and treatment strategies for HIV and HCV within prison with a focus on people who inject drugs and the challenges associated with the provision of these services within prisons and other closed settings and transition to the community.

RECENT FINDINGS

The prevalence of HIV and HCV are several-fold higher in the criminal justice system than within the broader community particularly in regions with high prevalence of injecting drug use, such as Asia, Eastern Europe and North America and where drug use is criminalized. Strategies to optimize management for these infections include routine screening linked to treatment within these settings and medication-assisted treatments for opioid dependence and access to syringe services programs. We build upon the 2016 WHO Consolidated Guidelines through the lens of the key populations of prisoners. Linkage to treatment postrelease, has been universally dismal, but is improved when linked to medication-assisted therapies like methadone, buprenorphine and overdose management. In many prisons, particularly in low-income and middle-income settings, provision of even basic healthcare including mental healthcare and basic HIV prevention tools remain suboptimal.

SUMMARY

In order to address HIV and HCV prevention and treatment within criminal justice settings, substantial improvement in the delivery of basic healthcare is needed in many prisons worldwide together with effective screening, treatment and linkage of treatment and prevention services to medication-assisted therapies within prison and linkage to care after release.

Evaluation of HIV risk and outcomes in a nationally representative sample of incarcerated women in Azerbaijan, Kyrgyzstan, and Ukraine

Eastern European and Central Asian (EECA) is the only region globally where HIV incidence continues to rise. HIV is concentrated among high risk groups like prisoners. HIV prevalence is higher among women than men in both prisons and communities. Data are lacking on the HIV care continuum among female prisoners to inform effective HIV prevention and treatment interventions. This study examined HIV risk, prevalence of infectious diseases, access to care, and psychiatric comorbidities among a representative sample of 220 female prisoners in Azerbaijan, Kyrgyzstan, and Ukraine. Prevalence of comorbid substance use and psychiatric disorders was high with nearly one-third reporting pre-incarceration drug injection and alcohol use disorder (AUD). Half of the sample reported anxiety and depression. Among the subset of 26 (11.8%) women testing HIV+, 44% had CD4 counts <350 cells/μL but less than 2% were on antiretroviral therapy (ART). Most (88.5%) women with HIV were in Ukraine, where women also experienced higher rates of hepatitis C than in Azerbaijan or Kyrgyzstan. Women in Kyrgyzstan prisons experienced higher rates of syphilis compared to the other two countries. Findings suggest that, to achieve global HIV prevention and treatment targets, HIV testing and linkage to care must be scaled up among incarcerated women in the EECA.

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.