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

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.

Interruptions in HIV and Behavioral Health Care for Criminal-Legal Involved People Living with HIV Following Implementation of Decarceration and Shelter in Place in San Francisco, California

Decarceration policies, enacted for SARS-CoV-2 mitigation in carceral settings, potentially exacerbated barriers to care for people living with HIV (PWH) with criminal legal involvement (CLI) during Shelter-in-Place (SIP) by limiting opportunities for engagement in provisions of HIV and behavioral health care. We compared health care engagement for PWH with CLI in San Francisco, California before and after decarceration and SIP using interrupted time series analyses. Administrative data identified PWH booked at the San Francisco County Jail with at least one clinic encounter from 01/01/2018-03/31/2020 within the municipal health care network. Monthly proportions of HIV, substance use, psychiatric and acute care encounters before (05/01/2019-02/29/2020) and after (03/01/2020-12/31/2020) SIP and decarceration were compared using Generalized Estimating Equation (GEE) log-binomial and logistic regression models, clustering on the patient-level. Of 436 patients, mean age was 43 years (standard-deviation 11); 88% cisgender-male; 39% white, 66% homeless; 67% had trimorbidity by Elixhauser score (medical comorbidity, psychotic disorder or depression, and substance use disorder). Clinical encounters immediately dropped following SIP for HIV (aOR = 0.77; 95% CI: 0.67, 0.90) and substance use visits (aRR = 0.83; 95% CI: 0.70, 0.99) and declined in subsequent months. Differential reductions in clinical encounters were seen among Black/African Americans (aRR = 0.93; 95% CI: 0.88, 0.99) and people experiencing homelessness (aRR = 0.92; 95% CI: 0.87, 0.98). Significant reductions in care were observed for PWH with CLI during the COVID-19 pandemic, particularly among Black/African Americans and people experiencing homelessness. Strategies to End the HIV Epidemic must improve engagement across diverse care settings to improve outcomes for this key population.

Adapting and Implementing an Evidence-Based Reentry Intervention for Incarcerated Transgender Women: Lessons Learned

Incarceration is a significant public health issue that disproportionately impacts transgender (trans) women, particularly those of color. The cycle of incarceration interacts with high levels of substance use, mental illness, and HIV to produce a high disease burden among trans women, but, to date, there are no published studies of trans-specific reentry support interventions. Informed by the Model of Gender Affirmation, we systematically adapted and pilot tested the evidence-based Project START intervention to create Girlfriends Connect (GC), a reentry support intervention for trans women incarcerated in a county jail. Qualitative interviews with trans women (10 prerelease and 6 postrelease) and community social service providers and jail staff (n = 7) who serve justice-involved transgender women, as well as input from a community advisory board, informed our adaptation. We then conducted a pilot randomized controlled trial (n = 14) and a service implementation project (n = 16) of GC to examine its feasibility and acceptability. Lessons learned include the importance of peer facilitators, facilitated referral to gender-affirming community resources, and obtaining programmatic buy-in from jail staff and administration. Results indicate that GC is feasible and acceptable, and holds promise in improving the health of transgender women reentering the community after a period of incarceration.

Long-Acting Injectable Therapy for People with HIV: Looking Ahead with Lessons from Psychiatry and Addiction Medicine

Long-acting injectable antiretroviral medications are new to HIV treatment. People with HIV may benefit from a treatment option that better aligns with their preferences, but could also face new challenges and barriers. Authors from the fields of HIV, substance use treatment, and mental health collaborated on this commentary on the issues surrounding equitable implementation and uptake of LAI ART by drawing lessons from all three fields. We employ a socio-ecological framework beginning at the policy level and moving through the community, organizational, interpersonal, and patient levels. We look at extant literature on the topic as well as draw from the direct experience of our clinician-authors.

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.

Strategies to improve HIV care outcomes for people with HIV who are out of care

OBJECTIVE

The aim of this study was to evaluate the effectiveness of five intervention strategies: patient navigation, appointment help/alerts, psychosocial support, transportation/appointment accompaniment, and data-to-care on HIV care outcomes among persons with HIV (PWH) who are out of care (OOC).

DESIGN

A systematic review with meta-analysis.

METHODS

We searched CDC's Prevention Research Synthesis (PRS) Project's cumulative HIV database to identify intervention studies conducted in the U.S., published between 2000 and 2020 that included comparisons between groups or prepost, and reported at least one relevant outcome (i.e. re-engagement or retention in HIV care, and viral suppression). Effect sizes were meta-analyzed using random-effect models to assess intervention effectiveness.

RESULTS

Thirty-nine studies reporting on 42 unique interventions met the inclusion criteria. Overall, intervention strategies are effective in improving re-engagement in care [odds ratio (OR) = 1.79;95% confidence interval (95% CI): 1.36-2.36, k = 14], retention in care (OR = 2.01; 95% CI: 1.64-2.64, k = 22), and viral suppression (OR = 2.50;95% CI: 1.87-3.34, k = 27). Patient navigation, appointment help/alerts, psychosocial support, and transportation/appointment accompaniment improved all three HIV care outcomes. Data-to-care improved re-engagement and retention but had insufficient evidence for viral suppression.

CONCLUSION

Several strategies are effective for improving HIV care outcomes among PWH who are OOC. More work is still needed for consistent definitions of OOC and HIV care outcomes, better reporting of intervention and cost data, and identifying how best to implement and scale-up effective strategies to engage and retain OOC PWH in care and reach the ending the HIV epidemic goals.

Access to HIV care in jails: Perspectives from people living with HIV in North Carolina

Most incarcerations for people living with HIV (PLWH) occur in jails, yet studies of HIV care during jail incarceration are limited. As part of a larger study to explore the ethical considerations in extending public health HIV surveillance to jail settings, we conducted semi-structured interviews with twenty-three PLWH with more than 300 distinct jail incarcerations post HIV diagnosis in 21 unique North Carolina jails. Interviews included questions about HIV disclosure in jail, the type of HIV care received in jail, and overall experiences with HIV care in jail. We report on participants' experiences and perspectives in four domains: access to HIV care in jail; impact of jail incarceration on continuity of HIV care; privacy and stigma; and satisfaction with HIV care in jail. Although most participants received HIV medications and saw providers while in jail, almost half reported that their greatest challenge in regard to HIV care was obtaining their HIV medications in the face of limited jail resources or policies that made access to medications difficult. Findings from this study suggest that jail leadership should review internal policies regarding HIV medications to ensure that PLWH can receive them quickly upon entry into jail. Findings also suggest that more external resources are needed, for example from state and local health departments, so that jails can provide timely HIV medications for PLWH incarcerated in their facilities.

Costs and Consequences of Eliminating a Routine, Point-Of-Care HIV Screening Program in a High-Prevalence Jail

INTRODUCTION

This study aims to assess the public health impact of eliminating a longstanding routine HIV screening program and replacing it with targeted testing. In addition, costs, outcomes, and cost effectiveness of routine screening are compared with those of targeted testing in the Fulton County Jail, Atlanta, Georgia.

METHODS

A published mathematical model was used to assess the cost effectiveness and public health impact of routine screening (March 2013-February 2014) compared with those of targeted testing (January 2018-December 2018) from a health system perspective. Costs, outcomes, and other model inputs were derived from the testing programs and the published literature, and the cost effectiveness analysis was conducted from 2019 to 2020.

RESULTS

Routine screening identified 74 more new HIV infections over 1 year than targeted testing, resulting in an estimated 10 HIV transmissions averted and 45 quality-adjusted life-years saved, and was cost saving. The missed opportunity to diagnose infections because routine screening was eliminated resulted in an estimated 8.4 additional HIV transmissions and $3.7 million in additional costs to the healthcare system.

CONCLUSIONS

Routine HIV screening in high-prevalence jails is cost effective and has a larger impact on public health than targeted testing. Prioritizing sustained funding for routine, jail-based HIV screening programs in high-prevalence areas may be important to realizing the national HIV prevention goals.

Jail-Based Data-to-Care to Improve Continuity of HIV Care: Perspectives and Experiences from Previously Incarcerated Individuals

Incarceration can disrupt retention in HIV care and viral suppression, yet it can also present an opportunity to reengage people living with HIV (PLWH) in care. Data-to-care (D2C) is a promising new public health strategy that uses HIV surveillance data to improve continuity of care for PLWH. The goal of this study was to examine perspectives on and experiences with D2C among PLWH who had recently been incarcerated in jail. Semistructured, qualitative interviews were conducted with 24 PLWH in community and prison settings about (1) knowledge of and experiences with D2C and (2) attitudes about implementing D2C in the jail setting. Participants who had been contacted for D2C described their interactions with state public health workers favorably, although almost half were not aware that the state performs HIV surveillance and D2C. While most participants indicated they would welcome assistance from the state for reengaging in care, they also framed retention in care as an individual responsibility. Most participants supported the idea of jail-based D2C. A vocal minority expressed adamant opposition, citing concerns about the violation of privacy and the threat of violence in the jail setting. Findings from this study suggest that D2C interventions in jails could be beneficial to reengaging PLWH in care, and acceptable to PLWH if done in a way that is sensitive to the needs and concerns of incarcerated individuals. If implemented, jail-based D2C programs must be designed with care to preserve privacy, confidentiality, and the autonomy of incarcerated individuals.