Newly identified HIV infections in correctional facilities, United States, 2007

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.

HIV and Viral Hepatitis Among Imprisoned Key Populations

Prisons and other closed facilities create opportunities for transmission of human immunodeficiency virus (HIV) and viral hepatitis during detention and after release. We conducted a systematic review and meta-analysis of peer-reviewed publications (2005-2015) to describe the prevalence of HIV, hepatitis C virus, and hepatitis B virus among key populations in prisons worldwide and to compare estimates of infection with those of other prison populations. Most data were reported for people who inject drugs (PWID; n = 72) and for men who have sex with men (MSM; n = 21); few data were reported on sex workers (SW; n = 6), or transgender women (n = 2). Publications were identified from 29 countries, predominantly middle- and high-income countries. Globally, PWID had 6 times the prevalence of HIV (pooled prevalence ratio (PPR) = 6.0, 95% CI: 3.8, 9.4), 8 times the prevalence of hepatitis C virus (PPR = 8.1, 95% CI: 6.4, 10.4), and 2 times the prevalence of hepatitis B virus (PPR = 2.0, 95% CI: 1.5, 2.7) compared with noninjecting prisoner populations. Among these articles, only those from Iran, Scotland, Spain, and Italy included the availability of methadone therapy; 2 articles included information on access to needle exchange programs by PWID detainees. HIV prevalence was more than 2 times higher among SW (PPR = 2.6, 95% CI: 2.2, 3.1) and 5 times higher among MSM (PPR = 5.3, 95% CI: 3.5, 7.9) compared with other prisoners. None of these articles reported HIV prevention coverage among SW or transgender women; 1 described HIV and sexually transmitted infection screening for MSM in prison. Prevention programs specific to key populations are important, particularly for populations that are criminalized and/or may cycle in and out of prison.

Incorporation of Social Determinants of Health in the Peer-Reviewed Literature: A Systematic Review of Articles Authored by the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

OBJECTIVES

Social determinants of health (SDHs) are the complex, structural, and societal factors that are responsible for most health inequities. Since 2003, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) has researched how SDHs place communities at risk for communicable diseases and poor adolescent health. We described the frequency and types of SDHs discussed in articles authored by NCHHSTP.

METHODS

We used the MEDLINE/PubMed search engine to systematically review the frequency and type of SDHs that appeared in peer-reviewed publications available in PubMed from January 1, 2009, through December 31, 2014, with a NCHHSTP affiliation. We chose search terms to identify articles with a focus on the following SDH categories: income and employment, housing and homelessness, education and schooling, stigma or discrimination, social or community context, health and health care, and neighborhood or built environment. We classified articles based on the depth of topic coverage as "substantial" (ie, one of ≤3 foci of the article) or "minimal" (ie, one of ≥4 foci of the article).

RESULTS

Of 862 articles authored by NCHHSTP, 366 (42%) addressed the SDH factors of interest. Some articles addressed >1 SDH factor (366 articles appeared 568 times across the 7 categories examined), and we examined them for each category that they addressed. Most articles that addressed SDHs (449/568 articles; 79%) had a minimal SDH focus. SDH categories that were most represented in the literature were health and health care (190/568 articles; 33%) and education and schooling (118/568 articles; 21%).

CONCLUSIONS

This assessment serves as a baseline measurement of inclusion of SDH topics from NCHHSTP authors in the literature and creates a methodology that can be used in future assessments of this topic.

Can TasP Approaches Be Implemented in Correctional Settings?: A review of HIV testing and linkage to community HIV treatment programs

High rates of HIV in correctional populations makes evaluation of programs that increase HIV testing in correctional settings and linkage to HIV treatment upon release, and understanding key implementation issues of these programs, essential to reducing new HIV infection. We conducted a systematic search for studies of outcomes or implementation issues of programs that promote HIV testing or that promote linkage to community HIV treatment post-release. Thirty-five articles met inclusion criteria: nine HIV testing initiatives and four linkage programs. HIV testing uptake rates were between 22% and 98% and rates of linkage to community treatment were between 79% and 84%. Findings suggest that some programs may be effective at reducing HIV transmission within the communities to which inmates return. However, attention to implementation factors, such as organizational culture and staff collaborations, appears critical to the success of these programs. Future research using rigorous design and adequate comparison groups is needed.

Global burden of HIV, viral hepatitis, and tuberculosis in prisoners and detainees

The prison setting presents not only challenges, but also opportunities, for the prevention and treatment of HIV, viral hepatitis, and tuberculosis. We did a comprehensive literature search of data published between 2005 and 2015 to understand the global epidemiology of HIV, hepatitis C virus (HCV), hepatitis B virus (HBV), and tuberculosis in prisoners. We further modelled the contribution of imprisonment and the potential impact of prevention interventions on HIV transmission in this population. Of the estimated 10·2 million people incarcerated worldwide on any given day in 2014, we estimated that 3·8% have HIV (389 000 living with HIV), 15·1% have HCV (1 546 500), 4·8% have chronic HBV (491 500), and 2·8% have active tuberculosis (286 000). The few studies on incidence suggest that intraprison transmission is generally low, except for large-scale outbreaks. Our model indicates that decreasing the incarceration rate in people who inject drugs and providing opioid agonist therapy could reduce the burden of HIV in this population. The prevalence of HIV, HCV, HBV, and tuberculosis is higher in prison populations than in the general population, mainly because of the criminalisation of drug use and the detention of people who use drugs. The most effective way of controlling these infections in prisoners and the broader community is to reduce the incarceration of people who inject drugs.

Rapid HIV Screening in an Urban Jail: How Testing at Exit With Linkage to Community Care Can Address Perceived Barriers

Despite recommendations from the CDC, only 36 % of jails offer routine HIV screening to inmates. Our purpose was to explore the feasibility of rapid HIV testing at release from an urban jail, and to identify potential barriers to this process. This project was incorporated into an established partnership between the jail, local academic medical center, and local public health department. We offered rapid HIV testing at the time of release to 507 jail inmates over a 7 week period of 2013. Three hundred and two (60 %) inmates elected testing. All participating inmates received individual test counseling, HIV prevention education, and linkage to care in the community prior to release. All tested inmates received results before release; one inmate screened positive for HIV and was linked to care. Previous HIV testing was the most frequently cited reason given (60 %) among the 205 inmates who declined at the time of the study. Utilizing the partnership between the jail, public health, and an academic medical center, we found that rapid HIV testing at exit was feasible and acceptable in this urban jail setting and could provide immediate linkage to care for those in need.

HIV Testing, HIV Positivity, and Linkage and Referral Services in Correctional Facilities in the United States, 2009-2013

BACKGROUND

Because of health disparities, incarcerated persons are at higher risk for multiple health issues, including HIV. Correctional facilities have an opportunity to provide HIV services to an underserved population. This article describes Centers for Disease Control and Prevention (CDC)-funded HIV testing and service delivery in correctional facilities.

METHODS

Data on HIV testing and service delivery were submitted to CDC by 61 health department jurisdictions in 2013. HIV testing, HIV positivity, receipt of test results, linkage, and referral services were described, and differences across demographic characteristics for linkage and referral services were assessed. Finally, trends were examined for HIV testing, HIV positivity, and linkage from 2009 to 2013.

RESULTS

Of CDC-funded tests in 2013 among persons 18 years and older, 254,719 (7.9%) were conducted in correctional facilities. HIV positivity was 0.9%, and HIV positivity for newly diagnosed persons was 0.3%. Blacks accounted for the highest percentage of HIV-infected persons (1.3%) and newly diagnosed persons (0.5%). Only 37.9% of newly diagnosed persons were linked within 90 days; 67.5% were linked within any time frame; 49.7% were referred to partner services; and 45.2% were referred to HIV prevention services. There was a significant percent increase in HIV testing, overall HIV positivity, and linkage from 2009 to 2013. However, trends were stable for newly diagnosed persons.

CONCLUSIONS

Identification of newly diagnosed persons in correctional facilities has remained stable from 2009 to 2013. Correctional facilities seem to be reaching blacks, likely due to higher incarceration rates. The current findings indicate that improvements are needed in HIV testing strategies, service delivery during incarceration, and linkage to care postrelease.

Opt-Out HIV Testing of Inmates in North Carolina Prisons: Factors Associated with not Wanting a Test and not Knowing They Were Tested

Opt-out HIV testing is recommended for correctional settings but may occur without inmates' knowledge or against their wishes. Through surveying inmates receiving opt-out testing in a large prison system, we estimated the proportion unaware of being tested or not wanting a test, and associations [prevalence ratios (PRs)] with inmate characteristics. Of 871 tested, 11.8 % were unknowingly tested and 10.8 % had unwanted tests. Not attending an educational HIV course [PR = 2.34, 95 % confidence interval (CI) 1.47-3.74], lower HIV knowledge (PR = 0.95, 95 % CI 0.91-0.98), and thinking testing is not mandatory (PR = 9.84, 95 % CI 4.93-19.67) were associated with unawareness of testing. No prior incarcerations (PR = 1.59, 95 % CI 1.03-2.46) and not using crack/cocaine recently (PR = 2.37, 95 % CI 1.21-4.64) were associated with unwanted testing. Residence at specific facilities was associated with both outcomes. Increased assessment of inmate understanding and enhanced implementation are needed to ensure inmates receive full benefits of opt-out testing: being informed and tested according to their wishes.

Routine testing for blood-borne viruses in prisons: a systematic review

Background: People in prison have a higher burden of blood-borne virus (BBV) infection than the general population, and prisons present an opportunity to test for BBVs in high-risk, underserved groups. Changes to the BBV testing policies in English prisons have recently been piloted. This review will enable existing evidence to inform policy revisions. We describe components of routine HIV, hepatitis B and C virus testing policies in prisons and quantify testing acceptance, coverage, result notification and diagnosis. Methods: We searched five databases for studies of both opt-in (testing offered to all and the individual chooses to have the test or not) and opt-out (the individual is informed the test will be performed unless they actively refuse) prison BBV testing policies. Results: Forty-four studies published between 1989 and 2013 met the inclusion criteria. Of these, 82% were conducted in the USA, 91% included HIV testing and most tested at the time of incarceration. HIV testing acceptance rates ranged from 22 to 98% and testing coverage from 3 to 90%. Mixed results were found for equity in uptake. Six studies reported reasons for declining a test including recent testing and fear. Conclusions: While the quality of evidence is mixed, this review suggests that reasonable rates of uptake can be achieved with opt-in and, even better, with opt-out HIV testing policies. Little evidence was found relating to hepatitis testing. Policies need to specify exclusion criteria and consider consent processes, type of test and timing of the testing offer to balance acceptability, competence and availability of individuals.

Positive Transitions (POST): Evaluation of an HIV Prevention Intervention for HIV-Positive Persons Releasing from Correctional Facilities

People with HIV who are released from custody frequently do not maintain the viral suppression and other health benefits achieved while incarcerated. This study was conducted to provide preliminary evidence of efficacy of an intervention to reduce HIV risk behaviors and increase use of HIV medical services following release from custody. People with HIV were recruited from San Francisco County jails, San Quentin State Prison and the California Medical Facility (Vacaville, CA), and randomly assigned to the "standard of care" or POST intervention. POST consisted of 4 sessions pre-release and 2 sessions post-release, focusing on HIV prevention and access to care. Behavioral data were obtained for the 3 months before incarceration and 3 months after release. Although POST participants reported a statistically significant increase in receiving health care at HIV clinics (62.5-84.4 %), there were no significant differences between the POST and control participants with respect to any primary outcomes.

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.

Screening for Hepatitis C as a Prevention Enhancement (SHAPE) for HIV: an integration pilot initiative in a Massachusetts County correctional facility

OBJECTIVES

The Massachusetts Department of Public Health (MDPH) and the Barnstable County Sheriff's Department (BCSD) in Massachusetts initiated a pilot program in July 2009 offering education and hepatitis C virus (HCV) antibody testing to inmates and detainees, concurrent with routine HIV testing. The initiative was implemented to assess the feasibility of integrating HCV screening into an HIV screening program in a correctional setting and the efficacy of linking HCV antibody-positive inmates to clinical care upon release.

METHODS

Through the Screening for Hepatitis C as a Prevention Enhancement initiative, HCV and HIV testing were offered to inmates and detainees shortly after admission, and by request at any time during incarceration. In preparation for release, referrals were made to community-based medical providers for HCV follow-up care. Data from BCSD were compared with routine surveillance data received by MDPH. Confirmatory HCV test results received by April 15, 2012, were considered indicators of appropriate post-release clinical care.

RESULTS

From July 2009 through December 2011, 22% (n=596) and 25% (n=667) of 2,716 inmates/detainees accepted HCV and HIV testing, respectively. Of those tested for HCV antibody, 20.5% (n=122) were positive. Of those tested for HIV antibody, 0.8% (n=5) were positive. Of the inmates who tested HCV positive at BCSD and had been released, 37.8% were identified as receiving post-release medical care.

CONCLUSIONS

We determined that integration of HCV education and screening into correctional facilities is feasible and reveals high rates of HCV infection. Although this model presupposes programmatic infrastructure, elements of the service design and integration could inform a range of correctional programs. Effective linkage to care, while substantial, was not routine based on our analysis, and may require additional resources given its cost and complexity.

Prevalence of human immunodeficiency virus and hepatitis C virus among French prison inmates in 2010: a challenge for public health policy

We evaluated prevalence of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) among prison inmates in France in 2010, in a cross-sectional single-day study based on a two-stage design. Sampling favoured larger establishments and included all types of prisons. Establishments were stratified by geographical region. Estimates were adjusted by post-stratification of the total population of inmates in France. From 60,975 inmates in all 188 prisons on the sampling day, 2,154 were selected from 27 prisons, and 1,876 questionnaires completed. HIV prevalence was estimated at 2.0% (95% confidence interval (CI): 0.9–4.2), 2.6% (95% CI: 0.7–8.8) in women and 2.0% (95% CI: 0.9–4.3) in men; 75% of inmates were receiving treatment for HIV. HCV prevalence was estimated at 4.8% (95% CI: 3.5–6.5) and was higher for women (11.8%; 95% CI: 8.5–16.1) than men (4.5%; 95% CI: 3.3–6.3). Almost half of HCV-infected inmates had chronic hepatitis C and 44% were receiving or had received treatment. HIV and HCV prevalence was six times higher than in the general population, and 2.5% of inmates had viraemic hepatitis C. The moment of incarceration provides an ideal opportunity for testing and treating, limiting spread of HCV and improving patients' prognosis.

HIV among persons incarcerated in the USA: a review of evolving concepts in testing, treatment, and linkage to community care

PURPOSE OF REVIEW

People who are incarcerated have a disproportionately high risk of HIV infection. They also tend to have risk factors associated with underutilization of antiretroviral therapy (ART) such as substance abuse, mental illness, and poor access to care. In this review, we describe how incarceration is a marker of vulnerability for suboptimal HIV care, and also how criminal justice settings may be leveraged as a platform for promoting testing, linkage, and retention in HIV care for a high-risk, marginalized population.

RECENT FINDINGS

In both prisons and jails, routine, opt-out HIV testing strategies are more appropriate for screening correctional populations than traditional, risk-based strategies. Rapid HIV testing is feasible and acceptable in busy, urban jail settings. Although ART is successfully administered in many prison settings, release to the community is strongly associated with inconsistent access to medications and other structural factors leading to loss of viral suppression.

SUMMARY

Collaborations among HIV clinicians, criminal justice personnel, and public health practitioners represent an important strategy for turning the tide on the HIV epidemic. Success will depend upon scaled-up efforts to seek individuals with undiagnosed infection and bring those who are out-of-care into long-term treatment.