Barriers to linking high-risk jail detainees to HIV pre-exposure prophylaxis

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

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

Characterizing Interest in and Uptake of Preexposure Prophylaxis for HIV Prevention Among Men in a US State Correctional System

BACKGROUND

People experiencing incarceration are disproportionately impacted by HIV and are potential candidates for HIV preexposure prophylaxis (PrEP). We explored factors associated with PrEP interest and PrEP uptake and described barriers to PrEP uptake among incarcerated men in a state correctional system.

METHODS

From September 2019 to July 2022, incarcerated men at the Rhode Island Department of Corrections were screened for PrEP eligibility and referred to a PrEP initiation study. We used bivariate analyses and multivariable logistic regression models to explore factors associated with PrEP interest and uptake in the screening sample.

RESULTS

Of the men screened and determined to be eligible for PrEP, approximately half (50%) were interested in taking PrEP. Individuals identifying as men who have sex with men (adjusted odds ratio, 4.46; 95% confidence interval, 1.86-11.4) and having multiple female sex partners (adjusted odds ratio, 2.98; 95% confidence interval, 1.47-6.27) were more likely to express interest in PrEP (interested/not interested) than those not reporting these behavioral factors. Preexposure prophylaxis uptake (yes/no) was 38%. Lack of PrEP interest, low self-perceived risk of HIV acquisition, and unpredictable lengths of incarceration were the most frequently encountered barriers to PrEP uptake.

CONCLUSIONS

Men reporting sexual transmission behaviors were more interested in PrEP and had higher uptake than other men. Preexposure prophylaxis interest and HIV risk factors were both moderately high, which suggests that men experiencing incarceration should be screened for and offered PrEP as part of standard clinical care. Study findings have important implications for research and practice to adapt PrEP care to correctional systems.

HIV policies in Australian prisons: a structured review assessing compliance with international guidelines

Globally, people living with the Human Immunodeficiency Virus (HIV) are over-represented in incarcerated populations. The current study aimed to provide a national (Australian) snapshot of current HIV prison policies against the United Nations' (UN) 15 key HIV interventions for prisons. Publicly available policies, reports, and data were obtained, and interviews were conducted with prison health staff in five of eight Australian jurisdictions. We rated whether policies were compliant, partially compliant, or not compliant to the UN interventions and assigned an overall grade (A to E, where A = most compliant and E = least compliant) for each jurisdiction. Three jurisdictions received a B grade, three received a C grade, and two were not assessed due to insufficient data. In all jurisdictions HIV policies fell short of full compliance to most UN interventions. Prison-based needle and syringe programs and initiatives beyond education to reduce HIV transmission from body modification procedures (eg, tattooing) were absent in all jurisdictions. No condom programme existed in one jurisdiction and access issues were reported in others. Opioid substitution therapy, and peer-education access varied across and within most jurisdictions. Findings indicate that more action is required to meet the UN recommended interventions for HIV prevention in prisons.

HIV/Sexually Transmitted Infection Screening and Eligibility for HIV Preexposure Prophylaxis Among Women Incarcerated in an Urban County Jail

BACKGROUND

Incarcerated women experience high rates of HIV and sexually transmitted infections (STIs); few are offered HIV preexposure prophylaxis (PrEP). We aimed to examine HIV/STI screening rates in this population and identify PrEP eligibility.

METHODS

Results of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) urine and HIV/syphilis screening in cisgender women in the Dallas County Jail were compiled from January to October 2020. An electronic health record review was conducted for a subgroup in March 2020 to identify PrEP eligibility.

RESULTS

Overall, 4398 of 13,292 women were screened for CT and 4389 of 13,292 for GC, and among them, 479 (11%) screened for HIV and 562 (13%) for syphilis. Furthermore, 462 of 4398 (11%) were positive for CT, 323 of 4389 (7%) were positive for GC, 10 of 479 (2%) had positive HIV test results, of whom 6 (1.3%) were new diagnoses and 75 (13%) had a reactive rapid plasma reagin test. In March 2020, of 541 women screened, 90 tested positive for CT or GC. Of these 90, 70 (78%) did not receive HIV or syphilis screening, including women with these risk factors: 10 (14%) were homeless, 11 (16%) reported heroin use, and 10 (14%) reported methamphetamine use. Based on the presence of an acute bacterial STI, 17% (96 of 541) were PrEP eligible.

CONCLUSIONS

Incarcerated women had high STI rates and other risk factors for HIV acquisition, although only 1 in 5 with acute STIs (11% overall) was also screened for HIV or syphilis. HIV prevention efforts should include comprehensive STI/HIV screening, linkage to treatment, and identification of PrEP candidates.

Implementation strategies to screen, refer and link women involved in the carceral system to PrEP for HIV prevention

PURPOSE

Women involved in the carceral system (CS) experience several conditions that increase their risk for HIV (e.g. high rates of substance use, psychiatric disorders, histories of victimization). The purpose of this study is to explore perspectives on potential strategies to connect women in the CS to pre-exposure prophylaxis (PrEP) services.

DESIGN/METHODOLOGY/APPROACH

This study conducted in-depth interviews with 27 women involved in the CS eligible for PrEP. Using vignettes, interviews explored attitudes, barriers and facilitators toward PrEP screening, referral and linkage facilitated via a CS stakeholder, an mHealth application or providing PrEP service referrals during detention via a navigator.

FINDINGS

Most women were, on average, 41.3 years, from racial and ethnic minority groups (56% black/African American; 19% Latinx). Inductive thematic analysis revealed CS involved women expressed mostly positive attitudes toward CS-based PrEP implementation. Younger women were more accepting of and interested in mHealth interventions. Implementation facilitators included leveraging relationships with trusted allies (e.g. "peers") and existing systems collaborations. Recommended implementation strategies included providing HIV and PrEP-specific education and training for system stakeholders and addressing issues related to privacy, system mistrust and stigma.

ORIGINALITY/VALUE

Results provide a critical foundation for the implementation of interventions to improve PrEP access for women involved in the CS and have important implications for implementation strategies for all adults involved in the CS. Improving access to PrEP among this population may also support progress toward addressing national disparities in PrEP uptake, where women, black and Latinx populations have substantial unmet need.

Initial implementation of HIV pre-exposure prophylaxis for people who are incarcerated in Zambia: a cross-sectional observational study

BACKGROUND

There are over 23 000 incarcerated people in Zambia, a population which has higher HIV prevalence than the general population yet has no access to HIV prevention. To evaluate the feasibility of HIV pre-exposure prophylaxis (PrEP) implementation in Zambian criminal justice facilities, we offered PrEP services to incarcerated people and aimed to describe early implementation outcomes.

METHODS

In this cross-sectional observational study, we implemented a PrEP programme between Oct 1, 2020, and March 31, 2021, supporting 16 criminal justice facilities in four Zambian provinces. Before implementation, we held stakeholder engagement meetings with Zambia Correctional Service officials to discuss PrEP benefits, and trained Zambia Correctional Service health-care workers in PrEP management using the national PrEP training package. People who were incarcerated and screened positive for substantial HIV risk by use of a standardised HIV risk assessment tool were offered voluntary HIV testing and counselling. Those who tested positive were linked to antiretroviral therapy, and those who tested negative and met national HIV prevention eligibility criteria were offered PrEP. We assessed PrEP uptake and used descriptive statistics to characterise programme beneficiaries and the cascade of PrEP services.

FINDINGS

During the study period, we reached 12 367 people older than 15 years with HIV risk assessment and counselling, including 11 794 (95·4%) men and 573 (4·6%) women. Of these, 2610 people received HIV testing, with 357 (13·7%) testing HIV positive; positivity was significantly higher in women (20·6%) than men (13·2%, p=0·011). 1276 people were identified as HIV negative and PrEP eligible. Of these, 1190 (93·3%) initiated PrEP. The age group with the highest proportion reached and initiated on PrEP was those aged 25-29 years, representing 19·2% (2377 of 12 367) of all people reached and 24·1% (287 of 1190) of those who initiated PrEP.

INTERPRETATION

Delivery of PrEP to people who are incarcerated is feasible with adequate resourcing and support to the criminal justice health system, and can result in high uptake among eligible individuals. Further assessment is needed of PrEP persistence and adherence, and the perceptions of people who are incarcerated regarding their HIV risk and preferences for combination HIV prevention services.

FUNDING

US President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention.

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.

Infectious disease surveillance in U.S. jails: Findings from a national survey

While infectious diseases (ID) are a well-documented public health issue in carceral settings, research on ID screening and treatment in jails is lacking. A survey was sent to 1,126 jails in the United States to identify the prevalence of health screenings at intake and characteristics of care for ID; 371 surveys were completed correctly and analyzed. Despite conflicting Centers for Disease Control (CDC) guidance, only seven percent of surveyed jails test individuals for HIV at admission. In 46% of jails, non-healthcare personnel perform ID screenings. Jails in less urban areas were more likely to report healthcare screenings performed by correctional officers. Survey findings indicate that HIV, HCV and TB testing during jail admissions and access to PrEP are severely lacking in less urban jails in particular. Recommendations are provided to improve ID surveillance and address the burden of ID in correctional facilities.

Study protocol of a randomized controlled trial comparing two linkage models for HIV prevention and treatment in justice-involved persons

Background

Persons involved in the justice system are at high risk for HIV and drug overdose upon release to the community. This manuscript describes a randomized controlled trial of two evidence-based linkage interventions for provision of HIV prevention and treatment and substance use disorder (SUD) services in four high risk communities to assess which is more effective at addressing these needs upon reentry to the community from the justice system.

Methods

This is a 5-year hybrid type 1 effectiveness-implementation randomized controlled trial that compares two models (Patient Navigation [PN] or Mobile Health Unit [MHU] service delivery) of linking justice-involved individuals to the continuum of community-based HIV and SUD prevention and treatment service cascades of care. A total of 864 justice-involved individuals in four US communities with pre-arrest histories of opioid and/or stimulant use who are living with or at-risk of HIV will be randomized to receive either: (a) PN, wherein patient navigators will link study participants to community-based service providers; or (b) services delivered via an MHU, wherein study participants will be provided integrated HIV prevention/ treatment services and SUD services. The six-month post-release intervention will focus on access to pre-exposure prophylaxis (PrEP) for those without HIV and antiretroviral treatment (ART) for people living with HIV (PLH). Secondary outcomes will examine the continuum of PrEP and HIV care, including: HIV viral load, PrEP/ ART adherence; HIV risk behaviors; HCV testing and linkage to treatment; and sexually transmitted infection incidence and treatment. Additionally, opioid and other substance use disorder diagnoses, prescription, receipt, and retention on medication for opioid use disorder; opioid and stimulant use; and overdose will also be assessed. Primary implementation outcomes include feasibility, acceptability, sustainability, and costs required to implement and sustain the approaches as well as to scale-up in additional communities.

Discussion

Results from this project will help inform future methods of delivery of prevention, testing, and treatment of HIV, HCV, substance use disorders (particularly for opioids and stimulants), and sexually transmitted infections for justice-involved individuals in the community.

Trial registration: Clincialtrials.gov NCT05286879 March 18, 2022.

Prevalence and Management of Sexually Transmitted Infections in Correctional Settings: A Systematic Review

Admissions to jails and prisons in the United States number 10 million yearly; persons entering locked correctional facilities have high prevalence of sexually transmitted infections (STIs). These individuals come disproportionately from communities of color, with lower access to care and prevention, compared with the United States as a whole. Following PRISMA guidelines, the authors present results of a systematic review of literature published since 2012 on STIs in US jails, prisons, Immigration and Customs Enforcement detention centers, and juvenile facilities. This updates an earlier review of STIs in short-term facilities. This current review contributed to new recommendations in the Centers for Disease Control and Prevention 2021 treatment guidelines for STIs, advising screening for Trichomonas in women entering correctional facilities. The current review also synthesizes recommendations on screening: in particular, opt-out testing is superior to opt-in protocols. Carceral interventions-managing diagnosed cases and preventing new infections from occurring (eg, by initiating human immunodeficiency virus preexposure prophylaxis before release)-can counteract structural racism in healthcare.

Structural Issues Associated with Pre-exposure Prophylaxis Use in Men Who Have Sex with Men

BACKGROUND

Limited access to healthcare has been associated with limited uptake of pre-exposure prophylaxis (PrEP) for HIV among men who have sex with men (MSM). This descriptive analysis examined, in a near universal healthcare setting, differences between MSM reporting using versus not using PrEP in the past 12 months.

METHOD

Data come from the 2017 Boston sample of the National HIV Behavioral Surveillance (NHBS) system, containing a venue-based and time-spaced sample of 530 MSM. The analysis used descriptive frequencies and tests of bivariate associations by PrEP use using Fisher's exact test.

RESULTS

Five hundred four respondents had data necessary to determine if PrEP was indicated, and 233 (43.9%) had an indication for PrEP. Of these 233 participants, 117 (50.2%) reported using PrEP in the past 12 months. Not being out, in terms of disclosing one's sexual orientation to a healthcare provider, lack of health insurance, limited access to healthcare, and history of incarceration were all significantly associated with not using PrEP in the past 12 months. Race/ethnicity was not significantly associated with PrEP use in the past 12 months.

CONCLUSIONS

In the setting of Massachusetts healthcare expansion and reform, and in a sample somewhat uncharacteristic of the population of individuals experiencing difficulties accessing PrEP, structural and demographic factors remain potent barriers to PrEP uptake. Targeted PrEP expansion efforts in Massachusetts may focus on identifying vulnerable subgroups of MSM (e.g., underinsured or criminal justice system-involved MSM) and delivering evidence-based interventions to reduce stigma and promote disclosure of same-sex behavior in healthcare settings.