Linking HIV-positive jail inmates to treatment, care, and social services after release: results from a qualitative assessment of the COMPASS Program

"They Give you a bus Ticket and They Kick you Loose": A Qualitative Analysis of Post-Release Experiences among Recently Incarcerated Women Living with HIV in Metro Vancouver, Canada

To explore the transition from correctional facilities to community among women living with HIV in Vancouver, Canada, we interviewed 19 recently incarcerated women and 6 service providers. Findings highlighted heightened risk of violence at release, a lack of immediate supports, challenges accessing safe housing and addictions treatment, and interruptions in HIV treatment and care. In the face of structural barriers, women blamed themselves for not being able to break the cycle of incarceration. There is a critical need for enhanced pre-release planning with a priority on housing and substance use services, alongside supports that are trauma-and violence-informed and culturally safe.

"I Don't Feel Judged, I Don't Feel Less of a Person" - Engaged and Supportive Providers in the HIV Care Experiences of Black Sexual Minority Men Living with HIV

Background

Black sexual minority men (BSMM) in the Southern region of the United States experience a disproportionate burden of HIV. Research findings suggest that having supportive patient-provider relationships are critical for sustained HIV care engagement. The present study explores the role of supportive healthcare providers in the care engagement among BSMM living with HIV (BSMM+) in the US South.

Methods

Semi-structured qualitative interviews were conducted with BSMM+ in Texas (n=27) to explore perceived barriers and facilitators of sustained care engagement. Interviews lasted 60 minutes on average, were transcribed, coded, and analyzed using applied thematic analysis.

Findings

Participants described how important having relationships with engaged and supportive HIV care and service providers is to sustained engagement in care and positive HIV clinical outcomes. Supportive providers were characterized as non-judgmental, meeting patients' needs, and making patients feel "seen". Less supportive providers were described as making their patients "feel like a number" and having lack of follow through on proposed support and resources. Supportive providers were associated with increased care engagement of their patients while less supportive providers often led to patients switching providers, losing touch with services, and getting off track with their care.

Discussion

We found that among BSMM+ an important facilitator of sustained care engagement was having positive, affirming, and knowledgeable healthcare providers, while negative and dismissive experiences with providers was a notable barrier to care engagement. This work highlights the need for a scale up of comprehensive, ongoing trainings in patient-centered and person-first communication for providers. Further, manageable provider caseloads can facilitate more thorough patient interactions where tailored HIV care and education can be provided in a safe and non-judgmental environment.

Motivation and accessing care among drug treatment court involved women: A sequential, mixed-methods approach

Drug treatment courts (DTC) address substance use disorders (SUD) but not cooccurrencing HIV or hepatitis C virus (HCV). This pilot explored feasibility and preliminary outcomes of the Women's Initiative Supporting Health (WISH) intervention and health-related motivation, both based in self-determination theory (SDT) regarding HIV/HCV and SUD treatment. WISH feasibility study: 79 DTC women completed a one-time survey regarding motivation and willingness to engage in future interventions. WISH intervention: 22 women from DTC with SUD and HIV or HCV received a 6-session, peer motivational enhancement health behavior-oriented interventions. Recruitment strategies were feasible. SDT-based measures demonstrated internal consistency in this under-studied population, with perceived competence/autonomy associationed with motivation to reduce HIV/HCV/SUD risk. Women DTC participants indicated acceptance and showed internally consistent results in SDT-based motivation measures These WISH feasibility and intervention pilot studies lay a foundation for future studies addressing motivation to access healthcare among women DTC participants.

Odds of HIV among incarcerated drug users: a systematic review and meta-analysis of Asian countries

Background

HIV makes up a large portion of infectious diseases globally. People injecting drugs in prisons are at high risk for contracting HIV infection. Prisons house ~10.2 million people globally, making them a high-risk setting for HIV transmission. This systematic review summarizes the available data on the odds of developing HIV infection among imprisoned people who inject drugs (PWIDs) in Asian regions.

Methods

The authors electronically assessed published studies from January, 2000 to December, 2022, including studies that investigated the odds of HIV in imprisoned PWIDs. We extensively searched PubMed, ERIC, and Cochrane Central and Google Scholar with no constraints in language or time. All the observational studies evaluating the chances of HIV in Asian prisoners with an exposure group of PWIDs and a control group of non-injecting-drug users were included in our analysis.

Results

The databases search yielded 254 potential studies, 10 observational studies of which having a total of 17 333 participants were included. A low or moderate risk of bias was reported in all the studies except one case-control. The pooled analysis showed a significant association between PWIDs and the chances of contracting HIV infection (Odds ratio=6.40; 95% CI=3.89-10.52; P<0.00001; I2=53%).

Conclusion

This study found a vital correlation between injecting-drug usage during imprisonment and HIV transmission speed. The results of this meta-analysis support the need to prevent HIV and conducting treatment programs in high-risk settings like prisons.

Pathways From Recent Incarceration to Antiretroviral Therapy Adherence: Opportunities for Interventions to Support Women Living With HIV Post Release From Correctional Facilities

ABSTRACT

Women living with HIV are increasingly incarcerated and experience suboptimal HIV health outcomes post release from incarceration. Drawing on cohort data with cisgender and trans women living with HIV (Sexual Health and HIV/AIDS: Women's Longitudinal Needs Assessment), we used path analysis to investigate pathways from recent incarceration to optimal antiretroviral therapy (ART) adherence. We tested direct effects between recent incarceration, mediating variables, and ART adherence, along with indirect effects between incarceration and ART adherence through each mediator. We assessed model fit using chi-square, root-mean-square error of approximation (RMSEA), and comparative fit index (CFI). Our hypothesized model fit well to the data (χ2(1)=1.100; p=.2943; CFI = 1.000; RMSEA = 0.007). Recent experiences of homelessness, criminalized substance use, and gender-based violence each fully mediated the pathway between recent incarceration and optimal ART adherence. Findings highlight the need for safe and supportive housing, supports for criminalized substance use, and trauma and violence-informed care and practice post release from incarceration.

A qualitative inquiry into the patient-related barriers to linkage and retention in HIV care within the community setting

Background

People with the Human Immunodeficiency Virus (PWH) experience barriers to care within the community that impedes their progress from when they discover that they are HIV positive to becoming virally suppressed. For individuals with HIV to achieve sustained viral suppression, they must be linked to care to start receiving anti-retroviral therapy and remain retained in care for continuous treatment. However, HIV surveillance data shows that many PWH are not linked to care and become lost to continuous follow-up care. Although pharmacists, PWH, and social workers interact with one another and are aware of their roles in HIV care, their perspectives on barriers to linkage and retention in care have not been investigated collectively.

Objectives

Explore the perspectives of PWH, pharmacists, and social workers on barriers to linkage and retention of HIV care within the community setting.

Methods

Convenience sampling was used to recruit 15 stakeholders (five PWH, five community pharmacists, and five social workers) who participated in 1-h, semi-structured interviews based on three domains of the Patient-centered Medical Home Model including (1) experiences (individual and system-level barriers to care experienced by PWH), (2) activities (social workers and pharmacists initiatives that impact adherence to care)and (3) interventions (critical issues pharmacists can address in the community to engage PWH in their HIV care). We conducted a directed content analysis based on deductive coding. To establish rigor, we focused on Lincoln and Guba's criteria of rigorous qualitative methodology: credibility, dependability, confirmability, and transferability. Similarities and divergences of themes were discussed during data analysis and agreement was reached before interpretation.

Results

Emergent themes uncovered barriers to linkage and retention in HIV care as HIV-related stigma, having mental health illnesses including a history of substance abuse and social determinants of health such as homelessness, food insecurity, and insurance issues.

Conclusion

The perspectives of pharmacists, social workers, and PWH can provide insight into barriers that should be identified and addressed in people living with HIV to enhance their linkage and retention in care.

Multiple Disadvantage and Social Networks: Toward an Integrated Theory of Health Care Use During Reentry From Criminal Justice Settings

Research consistently finds the disproportionate negative health impact of the criminal justice system on racial and ethnic minorities. Yet less is known about the underlying mechanisms of health care utilization during community reintegration. We contribute to the literature theoretically by integrating two perspectives: network theory of social capital and multiple disadvantage hypothesis and providing a more nuanced explanation of health service use during reentry. We identify incarceration history as a unique disadvantaged status that precludes people from accessing social networks and social capital. We further elaborate on the phenomenon of racialized reentry and illustrate how multiple disadvantaged statuses are linked to social networks and health care.

Scoping review of interventions to link individuals to substance use services at discharge from jail

INTRODUCTION

Individuals with substance use disorders (SUD) must be linked to community-based SUD treatment and other services upon their release from jail, given their high service needs and risks for relapse, recidivism, and opioid-related overdose following release.

METHOD

This scoping review identified 14 studies (28 affiliated publications) that used experimental or quasi-experimental designs to evaluate jail re-entry interventions for individuals with SUD. The team coded intervention components, study characteristics, and study outcomes based on a service continuum for treatment linkage and retention and for post-release substance use and criminal justice outcomes.

RESULTS

This review included 4 randomized controlled trials (RCT) for linkage to treatment with medications for opioid use disorder (MOUD); 4 RCTs and 4 quasi-experimental studies for linkage to non-specific SUD treatment; and 2 RCTs for linkage to HIV + SUD services. Most studies (9/14) used case management and/or peer or patient navigation as the core intervention; 2 studies provided medical management for MOUD induction and/or facilitated referral to MOUD in the community; and 3 studies used motivational-based linkage interventions. A qualitative analysis of study outcomes found evidence to support the effectiveness of a diverse range of interventions to link individuals to community-based SUD treatment, MOUD, and other services at re-entry, but limited support for intervention effects on longer-term outcomes, including treatment retention, medication adherence, recidivism, and substance use.

CONCLUSION

Future controlled trials and implementation studies should help to unpack and examine core components of jail re-entry interventions and their successful implementation to enhance treatment retention and improve post-release outcomes.

Incarceration History and HIV Care Among Individuals Living with HIV in Florida, 2014-2018

The present study examines the HIV continuum of care outcomes among people living with HIV (PLWH) who have either recent (< 12-months) or distal (> 12-months) incarceration history compared to those without an incarceration history. A self-administered survey (as part of the Florida Cohort Study (n = 932)) was used to collect data on demographic information, linkage to care, retention in care, HIV medication adherence, viral suppression, and incarceration history. Those with recent incarceration history were least likely to report HIV medication adherence greater than or equal to 95% of the time (χ² = 8.79; p = 0.0124), always take their medications as directed (χ² = 15.29; p = 0.0005), and to have durable viral suppression (χ² = 16.65; p = 0.0002) compared to those distally or never incarcerated. In multivariable analyses, those never and distally incarcerated had greater odds of care linkage ([vs recently incarcerated] AOR = 2.58; CI: 1.31, 5.07; p = 0.0063, AOR = 2.09; CI: 1.11, 3.95; p = 0.0228, respectively). Those never incarcerated had greater odds of taking ART as directed ([vs recently incarcerated] AOR = 2.53; CI: 1.23 - 5.19; p = 0.0116). PLWH with an incarceration history may need more on-going monitoring and follow-up HIV care than those without previous incarceration regardless of when incarceration occurred.

Knowledge, attitudes, and acceptability of direct-acting antiviral hepatitis C treatment among people incarcerated in jail: A qualitative study

Introduction

While U.S. jails are critical sites for engagement in HCV care, short lengths-of-stay often do not permit treatment in jail. Therefore, linkage to HCV care after incarceration is crucial. However, little is known about HCV treatment acceptability among justice-involved individuals in U.S. jails. The goal of this study was to understand knowledge, attitudes, and acceptability of HCV treatment among people living with HCV in the New York City (NYC) jail system.

Methods

We recruited 36 HCV-antibody-positive individuals in the NYC jails using clinical data reports and performed semi-structured interviews to explore participants’ attitudes toward HCV treatment in jail and following return to the community. We continued interviews until reaching thematic saturation and analyzed interviews using an inductive, thematic approach.

Results

Participants were mostly male, Latina/o, with a mean age of 40 years. Nearly all were aware they were HCV antibody-positive. Two thirds of participants had some awareness of the availability of new HCV therapies. Key themes included: 1) variable knowledge of new HCV therapies affecting attitudes toward HCV treatment, 2) the importance of other incarcerated individuals in communicating HCV-related knowledge, 3) vulnerability during incarceration and fear of treatment interruption, 4) concern for relapse to active drug use and HCV reinfection, 5) competing priorities (such as other medical comorbidities, ongoing substance use, and housing), 6) social support and the importance of family.

Conclusions

Patient-centered approaches to increase treatment uptake in jail settings should focus on promoting HCV-related knowledge including leveraging peers for knowledge dissemination. In addition, transitional care programs should ensure people living with HCV in jail have tailored discharge plans focused on competing priorities such as housing instability, social support, and treatment of substance use disorders.

HIV and risk behaviors among visitors of inmates at the Great Tehran Prison, Iran, 2018

Objectives

The objective of the present study was to determine the prevalence of HIV and risk behaviors among the inmates' visitors at the Great Tehran Prison in 2018.This population is more likely to be infected with HIV due to their relationship with inmates. However, they have not been prioritized to the other populations in comparison to inmates who are usually prioritized over others.

Method

Using a convenient sampling method, we recruited inmates' visitorsat the Great Tehran Prison in 2018. An anonymous questionnaire collected information on the participant's demographic characteristics, relationship withinmate, imprisonment history, drug-related risk behaviors, and HIV-related risk behaviors.Rapid HIV blood test detected HIV positive people. To examine the association between risk behaviors and HIV infection, we used a multivariate logistic regression model to calculate the adjusted Odds Ratio (OR)(adjusted Odds ratio of 23.140, 95% CI OD: 1.994-268.5).

Results

1131 visitors were asked to participate in the study; out of which 1120 consented (99%).Out of the 1120 participants, 55.2% were female, and the majority (72.4%) aged older than 35 years. Of those who had a sexual partner, 50% did not usea condom in the last 6 months. Overall, HIV prevalence was 0.4% in the inmate visitors, but it was significantly higher among those with a history of drug injection(p=0.003).

Conclusion

Our findings indicated that overall the HIV prevalence is low amonginmates' visitors; Subgroups with a history of injection have high HIV prevalence which needs to beprioritized for HIV screening and treatment.

Observational study of continuity of HIV care following release from correctional facilities in South Africa

BACKGROUND

We sought to describe linkage to care, ART continuity, and factors associated with linkage to care among people with HIV following release from incarceration in South Africa.

METHODS

We conducted a study of South African correctional service community reentrants who were receiving ART at the time of release. The study was implemented in three of 46 correctional service management areas. Participants were enrolled prior to corrections release and followed up to 90 days post-release to obtain self-reported linkage to care status and number of days of ART provided at corrections release. Clinic electronic and paper charts were sought and abstracted to verify self-reported linkage to care. Log-binomial regression, adjusted for facility, was used to identify associations with post-release linkage to care (self-reported and verified). We sought to specifically assess for associations with HIV diagnosis during index incarceration, ART initiation during index incarceration, and duration of incarceration.

RESULTS

From May 2014 to December 2016, 554 inmates met eligibility and 516 (93%) consented to participate; 391 were released on ART, 40 of whom were excluded from analysis post-release. Of the remaining 351, 301 (86%) were men and the median age was 35 years (interquartile range 30, 40). Linkage to care was self-reported by 227 (64%) and linkage to care could be verified for 121 (34%). At most, 47% of participants had no lapse in ART supply. Initiating ART during the index incarceration showed a trend toward increased self-reported post-release linkage to care. Age > 35 years was associated with increased verified linkage to care while HIV diagnosis outside of a correctional setting and ART initiation during the index incarceration showed trends toward association with increased verified linkage to care.

DISCUSSION

The results of our study are the first description of retention in care following correctional facility release from an African setting and indicate high levels of attrition during the transition from correctional facility to community care. Initiating ART within a correctional facility did not impair post-release linkage to care.

Using the barriers and facilitators to linkage to HIV care to inform hepatitis C virus (HCV) linkage to care strategies for people released from prison: Findings from a systematic review

Elimination of hepatitis C virus (HCV) among short-term sentenced prison populations will require improved access to HCV care and specific strategies dedicated to linkage upon release. Prison-based HCV care has lagged behind HIV care, but much can be learned from HIV studies. We performed a systematic review to identify individual-, provider- and system-level barriers and facilitators to linkage to HCV and HIV care among released inmates. We searched MEDLINE, Scopus, the Cochrane Central Register of Controlled Trials and Embase, and performed a grey literature search for English articles published up to November 2018. Two searches were conducted, one each for HCV and HIV; 323 and 684 unique articles were identified of which two and 27 studies were included, respectively. Facilitators to linkage to HCV care included social support, having an existing primary care provider, and receipt of methadone, whereas barriers included a perceived lack of healthcare information and a lack of specialized linkage to care programs. The principal facilitators to linkage to HIV care included social support, treatment for substance use and mental illness, the provision of education, case management, discharge planning and transportation assistance. Important barriers were unstable housing, age <30 years, HIV-related stigma, poor providers' attitudes and the lack of post-release reintegration assistance. While HCV care-specific studies are needed, much can be learned from linkage to HIV care studies. Ultimately, a multi-pronged approach, addressing several individual-level social determinants of health, and key provider- and system-level barriers may be an appropriate starting point for the development of HCV linkage to care strategies.

Using concept mapping to inform the development of a transitional reintegration intervention program for formerly incarcerated people with HIV

Background

Accessing HIV-related care is challenging for formerly incarcerated people with HIV. Interventions informed by the perspectives of these individuals could facilitate engagement with care and address competing priorities that may act as barriers to this process.

Methods

We used concept mapping to identify and prioritize the main obstacles to engaging with HIV-related care following prison release. In brainstorming sessions, formerly incarcerated people with HIV generated responses to a focused prompt regarding the main barriers to reengaging with care. These were consolidated in 35 statements. Next, participants sorted the consolidated list of responses into groups and rated each from lowest to highest in terms of its importance and feasibility of being addressed. We used cluster analysis to generate concept maps that were interpreted with participants.

Results

Overall, 39 participants participated in brainstorming sessions, among whom 18 returned for rating and sorting. Following analysis, a seven-cluster map was generated, with participants rating the ‘Practical Considerations’ (e.g. lack of transportation from prison) and ‘Survival Needs’ (e.g. securing housing and food) clusters as most important. Although ratings were generally similar between women and men, women assigned greater importance to barriers related to reconnecting with children.

Conclusions

Using concept mapping, we worked with formerly incarcerated people with HIV to identify and prioritize key challenges related to accessing health and social services following prison release. Transitional intervention programs should include programs and processes that address meeting basic subsistence needs and overcoming logistical barriers related to community re-entry.

Linkage to hepatitis C care after incarceration in jail: a prospective, single arm clinical trial

Background

Hepatitis C virus (HCV) is a major public health problem in correctional settings. HCV treatment is often not possible in U.S. jails due to short lengths of stay. Linkage to care is crucial in these settings, but competing priorities complicate community healthcare engagement and retention after incarceration.

Methods

We conducted a single arm clinical trial of a combined transitional care coordination (TCC) and patient navigation intervention and assessed the linkage rate and factors associated with linkage to HCV care after incarceration.

Results

During the intervention, 84 participants returned to the community after their index incarceration. Most participants were male and Hispanic, with a history of mental illness and a mean age of 45 years. Of those who returned to the community, 26 (31%) linked to HCV care within a median of 20.5 days; 17 (20%) initiated HCV treatment, 15 (18%) completed treatment, 9 (11%) had a follow-up lab drawn to confirm sustained virologic response (SVR), and 7 (8%) had a documented SVR. Among those with follow-up labs the known SVR rate was (7/9) 78%. Expressing a preference to be linked to the participant’s existing health system, being on methadone prior to incarceration, and feeling that family or a loved one were concerned about the participant’s wellbeing were associated with linkage to HCV care. Reporting drinking alcohol to intoxication prior to incarceration was negatively associated with linkage to HCV care.

Conclusion

We demonstrate that an integrated strategy with combined TCC and patient navigation may be effective in achieving timely linkage to HCV care. Additional multicomponent interventions aimed at treatment of substance use disorders and increasing social support could lead to further improvement.

Trial registration

Clinicaltrials.gov NCT04036760 July 30th, 2019 (retrospectively registered).

Evaluating Fidelity to a Modified NIATx Process Improvement Strategy for Improving HIV Services in Correctional Facilities

In a study aimed at improving the quality of HIV services for inmates, an organizational process improvement strategy using change teams was tested in 14 correctional facilities in 8 US states and Puerto Rico. Data to examine fidelity to the process improvement strategy consisted of quantitative ratings of the structural and process components of the strategy and qualitative notes that explicate challenges in maintaining fidelity to the strategy. Fidelity challenges included (1) lack of communication and leadership within change teams, (2) instability in team membership, and (3) issues with data utilization in decision-making to implement improvements to services delivery.

Multi-Site Evaluation of Community-Based Efforts to Improve Engagement in HIV Care Among Populations Disproportionately Affected by HIV in the United States

This study assesses effects of a community-based intervention across seven sites in the United States on HIV care utilization and study retention, among people living with HIV (PLWH). A two-armed study was conducted from 2013 to 2016 in each of seven community-based agencies across the United States. Each site conducted interventions involving community engagement approaches in the form of case management or patient navigation. Control conditions were standard of care involving referral to HIV clinical care. Participants (N = 583) were adults reporting erratic or no HIV care in the past 6 months. Longitudinal survey data on demographics, behavioral risks, and HIV care were collected from participants at baseline, before service delivery, and at 6-month follow-up. Unadjusted and adjusted generalized linear mixed models were used to assess the intervention effects on HIV care utilization and study retention. Participants were majority black (75.5%), cisgender male (55.1%), and heterosexual (55.4%). No significant intervention effect was observed on HIV care utilization, although both groups improved significantly over time [adjusted odds ratio (AOR): 2.09, 95% confidence interval (CI): 1.30-3.37]. Intervention participants were more likely to be retained in the study (AOR: 1.50, 95% CI: 1.03-2.20). Community intervention did not affect HIV care utilization more than standard of care, but intervention participants were more likely to be retained in the study, suggesting that such approaches support relationship building in ways that can facilitate follow-up of socially vulnerable PLWH. More research is needed to understand how such community efforts can support better HIV care utilization in these populations.

HIV treatment outcomes among formerly incarcerated transitions clinic patients in a high prevalence setting

BACKGROUND

Incarceration disproportionately affects people living with HIV/AIDS. When people are released from jail or prison, they face multiple barriers to HIV care, and those who do engage in care may have suboptimal HIV treatment outcomes. A limited number of studies have investigated HIV treatment outcomes among people who have been released from incarceration.

METHODS

We conducted a retrospective cohort study comparing HIV viral load (VL) suppression and retention in care 12 months after entry into care among patients of a post-incarceration Transitions Clinic (TC) and a comparison group who received HIV care in the same community. Of 138 participants, 38 TC patients were matched to 100 non-TC controls based on age, race/ethnicity, gender, and date of HIV care entry.

RESULTS

There was no significant difference in clinical study outcomes between TC and non-TC patients: 63% vs. 67% (p = 0.67) were retained in care and 54% vs. 63% (p = 0.33) had suppressed VL at 12 months. After adjusting for substance use disorder and viral load suppression at the start of treatment, the odds ratio of TC patients' 12-month retention was 0.60 (95% CI 0.25-1.49) and VL suppression was 0.44 (95% CI 0.16-1.23) compared with non-TC patients.

CONCLUSIONS

Our findings show HIV care outcomes for patients at a post-incarceration Transitions Clinic that are similar to those of community-based comparison patients. The transitions clinic model, which provides medical, behavioral health, and supportive services to formerly incarcerated people, may be an effective model of care for this population; however, more scholarship is needed to quantify the components most effective in supporting retention in care and viral load suppression.

HIV Prevalence and Correlations in Prisons in Different Regions of the World: A Review Article

The prevalence of HIV is substantially higher among prisoners than the general population, while the incidence varies considerably in different regions around the world. If we consider Sub-Saharan Africa as one region with the highest prevalence of HIV, data on African prisoners would be limited. Despite the low prevalence of HIV in the Middle East and North Africa, its incidence is rising in these regions with a few exceptions; there are insufficient data on HIV prevalence in prisons. A similar situation is present in both Pacific and Central Asia as well as in Eastern Europe. A high rate of infection is mainly observed among prisoners in Western and Central parts of Europe, since the data from these are more available than other parts. Nowadays, the sexual transmission mode and tattooing are important ways in HIV risks among prisoners after injecting drug use as the most common route of HIV transmission in all regions. However, it is difficult to compare and analyze the prevalence of HIV among prisoners in different regions regarding the limited data and different methods which they used in collecting data. Eventually, it can certainly be said that prisons are one of the high-risk places for HIV transmission; on the other hand, can be a suitable place for implementing HIV case-finding, linkage to treatment and harm reduction programs.

Patient navigators effectively support HIV-infected individuals returning to the community from jail settings

Purpose Patient navigation is an evidence-based approach for enhancing medical and support service co-ordination and ensuring linkage to medical care for people living with HIV released from jail. The paper aims to discuss this issue. Design/methodology/approach This brief describes the benefits of patient navigation and issues to consider when implementing a navigator program. The authors use process data to describe the type and amount of navigation services delivered as part of a randomized study, the "The San Francisco Navigator Project." Findings Navigation programs are able to accommodate a range of service needs; most clients required multiple types of services, particularly during the first two months after release. Originality/value Navigation programs should be prioritized because they provide unique and essential support for people leaving jail during the particularly vulnerable time immediately after release navigation plays a crucial role in retaining individuals in care and preventing onward transmission of HIV.

Balancing the Rights to Protection and Participation: A Call for Expanded Access to Ethically Conducted Correctional Health Research

Incarcerated individuals, over 95% of whom are eventually released, experience high burdens of chronic disease and behavioral health and social risk factors. Understanding the health needs of this population is critical to ensuring that general medicine physicians in prisons and in the community are adequately prepared to meet those needs. However, people in prison are significantly underrepresented in health research. In response to historical exploitation of prisoners in medical experimentation, federal guidelines appropriately require additional oversight for, and limit the scope of, research in prisons. Yet, according to a 2006 Institute of Medicine report, these requirements have produced inconsistent local regulations that often limit opportunities for incarcerated individuals to participate in research, and can slow the development of innovative medical interventions to improve their health. In this article, we describe the historical context surrounding regulations on research involving individuals in prison, the harms that can arise from excessive limitations to research in such settings, and the benefits of greater access to ethically conducted research in prison. We conclude with recommended actions that can be taken by general medicine researchers, correctional leaders, and policymakers to achieve consistent access to health research for incarcerated populations.

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.

Predictors of HIV Care Engagement, Antiretroviral Medication Adherence, and Viral Suppression Among People Living with HIV Infection in St. Petersburg, Russia

Over 1 million HIV infections have been diagnosed in Russia, and HIV care uptake and viral suppression are very low. 241 HIV-positive individuals in St. Petersburg were enrolled through social networks, provided blood for viral load testing, and completed measures of medication-taking adherence, readiness, and self-efficacy; psychosocial well-being; and substance use. Outcomes included attending an HIV care appointment in the past 6 months, >90% ART adherence, and undetectable viral load. 26% of participants had no recent care appointment, 18% had suboptimal adherence, and 56% had detectable viral load. Alcohol use consistently predicted all adverse health outcomes. Having no recent care visit was additionally associated with being single and greater past-month drug injection frequency. Poor adherence was additionally predicted by lower medication-taking self-efficacy and lower anxiety. Detectable viral load was additionally related to younger age. Comprehensive interventions to improve HIV care in Russia must address substance abuse, anxiety, and medication-taking self-efficacy.

The relationship between gastrointestinal symptom attribution, bothersomeness, and antiretroviral adherence among adults with HIV

Patients who attribute their symptoms to HIV medications, rather than disease, may be prone to switching antiretrovirals (ARVs) and experience poor retention/adherence to care. Gastrointestinal (GI) symptoms (e.g., nausea/vomiting) are often experienced as a side effect of ARVs, but little is known about the relationship of symptom attribution and bothersomeness to adherence. We hypothesized that attribution of a GI symptom to ARVs is associated with a reduction in adherence, and that this relationship is moderated by the bothersomeness of the symptom. Data for our analysis come from the pre-randomization enrollment period of a larger study testing an adherence improvement intervention. Analyses revealed that patients with diarrhea who attributed the symptom to ARVs (compared to those who did not) had significantly worse adherence. We did not find a significant moderating effect of bothersomeness on this relationship. Incorporating patient beliefs about causes of symptoms into clinical care may contribute to improved symptom and medication management, and better adherence.

Fostering a "Feeling of Worth" Among Vulnerable HIV Populations: The Role of Linkage to Care Specialists

To address barriers to adequate engagement in medical care among people living with HIV, Wisconsin's AIDS/HIV Program created a new position, the Linkage to Care (LTC) Specialist. Specialists provide intensive, short-term case management and patient navigation services for small caseloads of individuals at high risk of disengaging with medical care. Clients are eligible if they are newly diagnosed with HIV or new to medical care, recently released from incarceration, recently out of care, nonadherent to scheduled medical care visits, or have detectable viral load while in care. Interviews with 30 clients of Specialists were conducted to understand experiences with the program and medical care. Common themes included the ability of Specialists to navigate complex systems of care and support services, the unique role Specialists played in their clients' lives, and the challenges of transitioning out of the program. Although the primary goal of Specialists is to address barriers to medical care, they often adopted a holistic approach that also included housing, financial assistance, and other social determinants of health. Descriptions of the Specialist's role in implementation manuals focus on their functional roles and the services provided. However, clients often discussed the emotional support they received, especially for clients without strong social support networks. Many clients also desired an ongoing relationship with their Specialists even after discharge, but had been able to establish independence and self-efficacy. The LTC Specialists are resource-intensive considering their small caseloads, but fill an important gap in existing, often overtaxed case management systems.

Addressing Structural Barriers to HIV Care among Triply Diagnosed Adults: Project Bridge Oakland

People who are "triply diagnosed" with HIV, mental health issues, and substance-related disorders face tremendous barriers connecting to and remaining in HIV care. Authors of this article implemented Project Bridge Oakland (PBO), an intervention based on harm reduction and trauma-informed care, to help maintain continuity of care for triply diagnosed adults through cycles of criminal justice involvement. From August 2011 to December 2014, a clinical social worker and an HIV physician provided intensive case management for 19 clients living in Oakland, California. By working with clients across a multitude of community, clinic, and correctional spaces while maintaining a low threshold for services, the social worker was able to engage a severely marginalized population in HIV care. This article details the PBO strategies for assisting with a wide range of services needed for community stabilization, navigating criminal justice involvement, and establishing a therapeutic relationship through mundane practices such as eating and waiting for appointments. This article illustrates how programs aimed at stabilizing triply diagnosed clients in the community and connecting them to HIV care require coordination among providers, outreach to engage clients, ample time to work with them, and flexibility to account for the complexities of their day-to-day lives and experiences.

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

Context

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

Aims

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

Rationale

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

Methods

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

Results

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

Conclusion

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Enhancing Public Health HIV Interventions: A Qualitative Meta-Synthesis and Systematic Review of Studies to Improve Linkage to Care, Adherence, and Retention

Although HIV services are expanding, few have reached the scale necessary to support universal viral suppression of individuals living with HIV. The purpose of this systematic review was to summarize the qualitative evidence evaluating public health HIV interventions to enhance linkage to care, antiretroviral drug (ARV) adherence, and retention in care. We searched 19 databases without language restrictions. The review collated data from three separate qualitative evidence reviews addressing each of the three outcomes along the care continuum. 21,738 citations were identified and 24 studies were included in the evidence review. Among low and middle-income countries in Africa, men living with HIV had decreased engagement in interventions compared to women and this lack of engagement among men also influenced the willingness of their partners to engage in services. Four structural issues (poverty, unstable housing, food insecurity, lack of transportation) mediated the feasibility and acceptability of public health HIV interventions. Individuals living with HIV identified unmet mental health needs that interfered with their ability to access HIV services. Persistent social and cultural factors contribute to disparities in HIV outcomes across the continuum of care, shaping the context of service delivery among important subpopulations.

It's Not Just the Pills: A Qualitative Meta-Synthesis of HIV Antiretroviral Adherence Research

Antiretroviral therapy (ART) improves the health and longevity of people living with HIV infection (PLWH) and also prevents transmission of the virus. Yet, lack of adherence to ART regimens has been a persistent problem, even with simpler regimens. Guidelines that deal with ART adherence are based almost solely on quantitative studies; this focus ignores the context and complexity of patients' lives. Guidelines are also focused on the individual. We argue that the solution is to include the broader communities in which patients live, and to deal with systemic disparities that persist worldwide; this can be done in part through demedicalizing HIV care for healthy PLWH. We present findings from a qualitative meta-synthesis of 127 studies conducted around the world on the last two pillars of the HIV treatment cascade: starting and remaining on ART until optimal viral suppression is achieved. We use Maslow's hierarchy of needs to frame our findings.

Routine or targeted HIV screening of Indonesian prisoners

PURPOSE

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

DESIGN/METHODOLOGY/APPROACH

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

FINDINGS

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

ORIGINALITY/VALUE

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

Barriers and facilitators of interventions for improving antiretroviral therapy adherence: a systematic review of global qualitative evidence

INTRODUCTION

Qualitative research on antiretroviral therapy (ART) adherence interventions can provide a deeper understanding of intervention facilitators and barriers. This systematic review aims to synthesize qualitative evidence of interventions for improving ART adherence and to inform patient-centred policymaking.

METHODS

We searched 19 databases to identify studies presenting primary qualitative data on the experiences, attitudes and acceptability of interventions to improve ART adherence among PLHIV and treatment providers. We used thematic synthesis to synthesize qualitative evidence and the CERQual (Confidence in the Evidence from Reviews of Qualitative Research) approach to assess the confidence of review findings.

RESULTS

Of 2982 references identified, a total of 31 studies from 17 countries were included. Twelve studies were conducted in high-income countries, 13 in middle-income countries and six in low-income countries. Study populations focused on adults living with HIV (21 studies, n=1025), children living with HIV (two studies, n=46), adolescents living with HIV (four studies, n=70) and pregnant women living with HIV (one study, n=79). Twenty-three studies examined PLHIV perspectives and 13 studies examined healthcare provider perspectives. We identified six themes related to types of interventions, including task shifting, education, mobile phone text messaging, directly observed therapy, medical professional outreach and complex interventions. We also identified five cross-cutting themes, including strengthening social relationships, ensuring confidentiality, empowerment of PLHIV, compensation and integrating religious beliefs into interventions. Our qualitative evidence suggests that strengthening PLHIV social relationships, PLHIV empowerment and developing culturally appropriate interventions may facilitate adherence interventions. Our study indicates that potential barriers are inadequate training and compensation for lay health workers and inadvertent disclosure of serostatus by participating in the intervention.

CONCLUSIONS

Our study evaluated adherence interventions based on qualitative data from PLHIV and health providers. The study underlines the importance of incorporating social and cultural factors into the design and implementation of interventions. Further qualitative research is needed to evaluate ART adherence interventions.

Barriers and Facilitators of HIV Care Engagement: Results of a Qualitative Study in St. Petersburg, Russia

Russia has a large HIV epidemic, but medical care engagement is low. Eighty HIV-positive persons in St. Petersburg completed in-depth interviews to identify barriers and facilitators of medical HIV care engagement. The most commonly-reported barriers involved difficulties accessing care providers, dissatisfaction with the quality of services, and negative attitudes of provider staff. Other barriers included not having illness symptoms, life stresses, low value placed on health, internalized stigma and wanting to hide one's HIV status, fears of learning about one's true health status, and substance abuse. Care facilitators were feeling responsible for one's health and one's family, care-related support from other HIV-positive persons, and the onset of health decline and fear of death. Substance use remission facilitated care engagement, as did good communication from providers and trust in one's doctor. Interventions are needed in Russia to address HIV care infrastructural barriers and integrate HIV, substance abuse, care, and psychosocial services.

Clinical care of incarcerated people with HIV, viral hepatitis, or tuberculosis

The burden of HIV/AIDS and other transmissible diseases is higher in prison and jail settings than in the non-incarcerated communities that surround them. In this comprehensive review, we discuss available literature on the topic of clinical management of people infected with HIV, hepatitis B and C viruses, and tuberculosis in incarcerated settings in addition to co-occurrence of one or more of these infections. Methods such as screening practices and provision of treatment during detainment periods are reviewed to identify the effect of community-based treatment when returning inmates into the general population. Where data are available, we describe differences in the provision of medical care in the prison and jail settings of low-income and middle-income countries compared with high-income countries. Structural barriers impede the optimal delivery of clinical care for prisoners, and substance use, mental illness, and infectious disease further complicate the delivery of care. For prison health care to reach the standards of community-based health care, political will and financial investment are required from governmental, medical, and humanitarian organisations worldwide. In this review, we highlight challenges, gaps in knowledge, and priorities for future research to improve health-care in institutions for prisoners.

Facilitators and barriers in HIV linkage to care interventions: a qualitative evidence review

OBJECTIVE

To synthesize qualitative evidence on linkage to care interventions for people living with HIV.

DESIGN

Systematic literature review.

METHODS

We searched 19 databases for studies reporting qualitative evidence on linkage interventions. Data extraction and thematic analysis were used to synthesize findings. Quality was assessed using the Critical Appraisal Skills Programme tool and certainty of evidence was evaluated using the Confidence in the Evidence from Reviews of Qualitative Research approach.

RESULTS

Twenty-five studies from 11 countries focused on adults (24 studies), adolescents (eight studies), and pregnant women (four studies). Facilitators included community-level factors (i.e., task shifting, mobile outreach, integrated HIV, and primary services, supportive cessation programs for substance users, active referrals, and dedicated case management teams), and individual-level factors (encouragement of peers/family and positive interactions with healthcare providers in transitioning into care). One key barrier for people living with HIV was perceived inability of providers to ensure confidentiality as part of linkage to care interventions. Providers reported difficulties navigating procedures across disparate facilities and having limited resources for linkage to care interventions.

CONCLUSION

Our findings extend the literature by highlighting the importance of task-shifting, mobile outreach, integrated HIV, and primary care services. Both community and individual-level factors may increase the feasibility and acceptability of HIV linkage to care interventions. These findings may inform policies to increase the reach of HIV services available in communities.

Integrating correctional and community health care for formerly incarcerated people who are eligible for Medicaid

Under the Affordable Care Act, up to thirteen million adults have the opportunity to obtain health insurance through an expansion of the Medicaid program. A great deal of effort is currently being devoted to eligibility verification, outreach, and enrollment. We look beyond these important first-phase challenges to consider what people who are transitioning back to the community after incarceration need to receive effective care. It will be possible to deliver cost-effective, high-quality care to this population only if assistance is coordinated between the correctional facility and the community, and across diverse treatment and support organizations in the community. This article discusses several examples of successful coordination of care for formerly incarcerated people, such as Project Bridge and the Community Partnerships and Supportive Services for HIV-Infected People Leaving Jail (COMPASS) program in Rhode Island and the Transitions Clinic program that operates in ten US cities. To promote broader adoption of successful models, we offer four policy recommendations for overcoming barriers to integrating individuals into sustained, community-based care following their release from incarceration.

Rasch Analysis and Differential Item Functioning of a Social Support Measure in Jail Inmates With HIV Infection

The protective effects of social support on health have been documented in a variety of groups. For HIV-infected persons released from correctional settings, strong social support may be particularly important for obtaining effective postrelease medical treatment and supportive services. Researchers and program evaluators seeking to improve access and adherence to postrelease HIV medical care in this population need accurate measures for the level and type of social support, but current measures have not been fully validated for incarcerated individuals with HIV infection. We used the Rasch model to test the Medical Outcomes Study (MOS) social support survey. Data for the analysis were collected as part of the EnhanceLink project in the five urban jails where the MOS was administered. Findings indicate that the MOS survey items may not capture the entire variability of person abilities. Respondents showed problems in discriminating among response options, indicating potential systematic bias. In addition, while there was no significant gender difference, overall levels of social support differed by gender. Further research is warranted to develop more effective social support measurement tools that can better guide interventions for persons transitioning from jail and prison to the community.

Systematic Assessment of Linkage to Care for Persons with HIV Released from Corrections Facilities Using Existing Datasets

Populations in corrections continue to have high prevalence of HIV. Expanded testing and treatment programs allow persons to be identified and stabilized on treatment while incarcerated. However, these gains and frequently lost on reentry. Systemic frameworks are needed to monitor linkage to care to guide programs supporting linkage to care. To assess the adequacy of linkage to care on reentry, incarceration data from the National Corrections Reporting Program and data from the Ryan White Services Report from 2010 to 2012 were linked using an encrypted client identification (eUCI). Time from release to the first visit and presence of detectable HIV RNA at linkage were assessed. Multivariate survival analyses were performed to identify associations between patient characteristics and time to linkage. Among those linking, only 43% in Rhode Island and 49% in North Carolina linked within 90 days, and 33% in both states had detectable viremia at the first visit. Those not previously in care and with shorter incarceration experiences longer linkage times. Persons identified as black, had median times greater than 1 year. Using existing datasets, significant gaps in linkage to care for persons with HIV on release from corrections were demonstrated in Rhode Island and North Carolina. Systemically implementing this monitoring to evaluate changes over time would provide important information to support interventions to improve linkage in high-risk populations. Using national datasets for both corrections and clinical data, this framework equally could be used to evaluate experiences of persons with HIV linking to care on release from corrections facilities nationwide.

Incarcerated Black Women in the Southern USA: A Narrative Review of STI and HIV Risk and Implications for Future Public Health Research, Practice, and Policy

Incarcerated black women in the southern USA are understudied despite the high prevalence of sexually transmitted infections (STI) and human immunodeficiency virus (HIV). These incarceration and health disparities are rooted in centuries of historically inequitable treatment. Amidst the current dialogue on mass incarceration in the south and its relationship to the health of the black community, individual and environmental risk factors for STI/HIV transmission are seldom paired with discussions of evidence-based solutions. A narrative review of the literature from January 1995 to May 2015 was conducted. This sample of the literature (n = 18) revealed that partner concurrency, inconsistent condom use, sex work, previous STI, and drug abuse augmented individual STI/HIV risk. Recommended interventions include those which promote healthier relationships, cultural competence, and gender specificity, as well as those that enhance prevention skills. Policy recommendations include improving cultural sensitivity, cultural competence, and cultural humility training for clinicians, as well as substantially increasing funding for prevention, treatment, and rehabilitative services. These recommendations are timely given the recent national attention to incarceration, STI, and HIV disparities, particularly in the southern USA.

HIV treatment and care among Italian inmates: a one-month point survey

Background

HIV infection, with an estimated prevalence be between 2 and 50 times those of the general adult population is a major health challenge for prison authorities worldwide. Since no nationwide surveillance system is present in Italy, data on HIV prevalence and treatment in prisons are limited to only a few and small observational studies. We aimed to estimate HIV prevalence and obtain an overview on diagnostic and therapeutic activities concerning HIV infection in the Italian penitentiary system.

Methods

We piloted a multi-centre cross-sectional study investigating the prevalence of HIV infection and assessing HIV-related medical activities in Italian correctional institutions.

Results

A total of 15,675 prisoners from 25 institutions, accounting for approximately one-fourth of the prison inmates in Italy, were included in the study, of whom, 97.7 % were males, 37.1 % foreigners and 27 % had a history of intravenous drug addiction. HIV-tests were available in 42.3 % of the total population, with a known HIV Infection proportion of 5.1 %. In the month prior to the study, 604 of the 1,764 subjects who entered prison were tested for HIV, with a HIV-positive prevalence of 3.3 %. Among the 338 HIV-positive prisoners, 81.4 % were under antiretroviral treatment and 73.5 % showed undetectable HIV-RNA. In 23/338 (6.8 %) a coinfection with HBV and in 189/338 (55.9 %) with HCV was also present. Among the 67 (19.8 %) inmates with HIV who did not receive HIV treatment, 13 (19.5 %) had T-CD4+ count <350 cells/mm³ and 9 (69.2 %) of these had refused the treatment. The majority of the inmates with HIV-infection were on a PI-based (62.5 %) or on NNRTIs-based (24.4 %) regimen. Only a minority of patients received once daily regimens (17.2 %).

Conclusions

Although clinical and therapeutic management of HIV infection remains difficult in Italian prisons, diagnostics, treatment and care were offered to the majority of HIV-infected inmates. Specific programs should be directed towards the prison population and strict cooperation between prison and health institutions is needed to increase HIV treatment.

Facilitators of HIV Medical Care Engagement Among Former Prisoners

Linkage to and retention in medical care is a concern for HIV-positive individuals leaving custody settings in the United States. The minimal existing research points to low rates of entry into care in the months following release and lapsed viral control among releasees who are subsequently reincarcerated. We conducted seven small focus group discussions with 27 HIVpositive individuals who were recently incarcerated in a California State prison to understand those factors that facilitated linkage to and retention in HIV care following their release. We used a consensual approach to code and analyze the focus group transcripts. Four main themes emerged from the analysis: (1) interpersonal relationships, (2) professional relationships, (3) coping strategies and resources, and (4) individual attitudes. Improving HIV-related outcomes among individuals after their release from prison requires strengthening supportive relationships, fostering the appropriate attitudes and skills, and ensuring access to resources that stabilize daily living and facilitate the process of accessing care.

Transitions to Care in the Community for Prison Releasees with HIV: a Qualitative Study of Facilitators and Challenges in Two States

One in seven people living with HIV in the USA passes through a prison or jail each year, and almost all will return to the community. Discharge planning and transitional programs are critical but challenging elements in ensuring continuity of care, maintaining treatment outcomes achieved in prison, and preventing further viral transmission. This paper describes facilitators and challenges of in-prison care, transitional interventions, and access to and continuity of care in the community in Rhode Island and North Carolina based on qualitative data gathered as part of the mixed-methods Link Into Care Study of prisoners and releasees with HIV. We conducted 65 interviews with correctional and community-based providers and administrators and analyzed the transcripts using NVivo 10 to identify major themes. Facilitators of effective transitional systems in both states included the following: health providers affiliated with academic institutions or other entities independent of the corrections department; organizational philosophy emphasizing a patient-centered, personal, and holistic approach; strong leadership with effective "champions"; a team approach with coordination, collaboration and integration throughout the system, mutual respect and learning between corrections and health providers, staff dedicated to transitional services, and effective communication and information sharing among providers; comprehensive transitional activities and services including HIV, mental health and substance use services in prisons, timely and comprehensive discharge planning with specific linkages/appointments, supplies of medications on release, access to benefits and entitlements, case management and proactive follow-up on missed appointments; and releasees' commitment to transitional plans. These elements were generally present in both study states but their absence, which also sometimes occurred, represent ongoing challenges to success. The qualitative findings on the facilitators and challenges of the transitional systems were similar in the two states despite differences in context, demographics of target population, and system organization. Recommendations for improved transitional systems follow from the analysis of the facilitators and challenges.

Emergency department use among HIV-infected released jail detainees

Release from short-term jail detention is highly destabilizing, associated with relapse to substance use, recidivism, and disrupted health care continuity. Little is known about emergency department (ED) use, potentially a surrogate for medical, psychiatric, or social instability, by people living with HIV/AIDS (PLWHA) leaving jails. All ED visits were reviewed from medical records for a cohort of 109 PLHWA in the year following release from county jail in Connecticut, between January 1, 2008 and December 31, 2010. Primary outcomes were frequency and timing of ED visits, modeled using multivariate negative binomial regression and Cox proportional hazards regression, respectively. Demographic, substance use, and psychiatric disorder severity factors were evaluated as potential covariates. Overall, 71 (65.1%) of the 109 participants made 300 unique ED visits (2.75 visits/person-year) in the year following jail-release. Frequency of ED use was positively associated with female sex (incidence rate ratios, IRR 2.40 [1.36-4.35]), homelessness (IRR 2.22 [1.15-4.41]), and recent substance use (IRR 2.47 [1.33-4.64]), and inversely associated with lifetime drug severity (IRR 0.01 [0-0.10]), and being retained in HIV primary care (IRR 0.80 [0.65-0.99]). Those in late or sustained HIV care used the ED sooner than those not retained in HIV primary care (median for late retention 16.3 days, median for sustained retention 24.9 days, median for no retention not reached at 12 months, p value 0.004). Using multivariate modeling, those who used the ED earliest upon release were more likely to be homeless (HR 1.98 [1.02-3.84]), to be retained in HIV care (HR 1.30 [1.04-1.61]), and to have recently used drugs (HR 2.51 [1.30-4.87]), yet had a low lifetime drug severity (HR 0.01 [0.00-0.14]). Among PLWHA released from jail, frequency of ED use is high, often soon after release, and is associated with social and drug-related destabilizing factors. Future interventions for this specific population should focus on addressing these resource gaps, ensuring housing, and establishing immediate linkage to HIV primary care after release from jail.

Different Patterns of Drug Use and Barriers to Continuous HIV Care Post-Incarceration

Individuals with a drug use history often experience drug use relapse when they are released from incarceration. This article explores the processes by which a sample of adults experienced relapse post-incarceration and consequently experienced HIV treatment interruption. Data are from in-depth interviews with 25 formerly incarcerated HIV-positive adults who have a self-reported history of drug use. Findings reveal that each participant relapsed post-incarceration. Some participants relapsed immediately after release; others remained drug free until something "triggered" a relapse. Once a participant relapsed, factors that contributed to HIV treatment interruption included re-incarceration, a lack of concern for HIV care, and the overlap of symptoms between addiction and HIV infection. The relationship between drug use and HIV treatment interruption was exacerbated when the participant reported also having a mental health disorder. Cessation of drug use facilitated HIV treatment engagement for participants. The implications of these findings for policy and practice are discussed.

"My older clients fall through every crack in the system": geriatrics knowledge of legal professionals

With the number of older adult arrestees and prisoners increasing rapidly, legal professionals increasingly provide front-line identification and response to age-related health conditions (including cognitive and physical impairments) that may affect legal outcomes, such as the ability to participate in one's defense or stay safe in jail. The goals of this study were to assess the ability of legal professionals to recognize and respond to age-related conditions that could affect legal outcomes and to identify recommendations to address important knowledge gaps. This was a mixed quantitative-qualitative study. Legal professionals (N = 72) in the criminal justice system were surveyed to describe their demographic characteristics, expertise, and prior aging-related training and to inform the qualitative interview guide. Those surveyed included attorneys (district attorneys (25%), public defenders and legal advocates (58%)), judges (6%), and court-affiliated social workers (11%). In-depth qualitative interviews were then conducted with a subset of 10 legal professionals who worked with older adults at least weekly. Results from the surveys and interviews revealed knowledge deficits in four important areas: age-related health, identification of cognitive impairment, assessment of safety risk, and optimization of services upon release from jail. Four recommendations to close these gaps emerged: educate legal professionals about age-related health, train professionals to identify cognitive and sensory impairment, develop checklists to identify those at risk of poor health or safety, and improve knowledge of and access to transitional services for older adults. These findings suggest that geriatrics knowledge gaps of legal professionals exist that may contribute to adverse medical or legal outcomes for older adults involved in the criminal justice system and that partnerships between healthcare and legal professionals are needed to address these challenges.

High seroprevalence of Toxoplasma gondii infection in inmates: A case control study in Durango City, Mexico

PURPOSE

The seroprevalence of infection with the parasite Toxoplasma gondii and the association with risk factors has not been determined in inmates. Through a case-control study, 166 inmates from a state correctional facility in Durango City, Mexico and 166 age- and gender-matched non-incarcerated subjects were examined for the presence of anti-T. gondii IgG and IgM antibodies using enzyme-linked immunoassays.

RESULTS

Seroprevalence of anti-T. gondii IgG antibodies was higher in inmates (35, 21.1%) than in controls (14, 8.4%) (OR = 2.90; 95% CI: 1.43-5.94; P = 0.001). Anti-T. gondii IgM antibodies were detected in two (1.2%) inmates and in seven (4.2%) controls (P = 0.17). Multivariate analysis of socio-demographic, incarceration, and behavioral characteristics of inmates revealed that T. gondii seropositivity was associated with being born out of Durango State (OR = 3.91; 95% CI: 1.29-11.79; P = 0.01). In addition, T. gondii seroprevalence was higher (P = 0.03) in inmates that had suffered from injuries (17/56: 30.4%) than those without such history (18/110: 16.4%).

CONCLUSIONS

The seroprevalence of T. gondii infection in inmates in Durango City is higher than the seroprevalences found in the general population in the same city, indicating that inmates may represent a new risk group for T. gondii infection. Further research on T. gondii infection in inmates is needed.

Patient navigation facilitates medical and social services engagement among HIV-infected individuals leaving jail and returning to the community

HIV-infected individuals leaving jails, facilities typically used to confine accused persons awaiting trial or to incarcerate persons for minor offenses, often face barriers to engagement with medical and social-support services. Patient navigation is a model that may ease these barriers by supporting individuals in negotiating fragmented and highly bureaucratic systems for services and care. While there is evidence linking navigation to a reduction in health disparities, little is known about the mechanisms by which the model works. We present findings of an ethnographic study of interactions between navigators and their clients: HIV-infected men and women recently released from jails in San Francisco, California. We conducted 29 field observations of navigators as they accompanied their clients to appointments, and 40 in-depth interviews with clients and navigators. Navigators worked on strengthening clients' abilities to engage with social-services and care systems. Building this strength required navigators to gain clients' trust by leveraging their own similar life experiences or expressing social concordance. After establishing meaningful connections, navigators spent time with clients in their day-to-day environments serving as mentors while escorting clients to and through their appointments. Intensive time spent together, in combination with a shared background of incarceration, HIV, and drug use, was a critical mechanism of this model. This study illustrates that socially concordant navigators are well positioned to facilitate successful transition to care and social-services engagement among a vulnerable population.

Transitional care coordination in New York City jails: facilitating linkages to care for people with HIV returning home from Rikers Island

New York City (NYC) jails are the epicenter of an epidemic that overwhelmingly affects Black and Hispanic men and offer a significant opportunity for public health intervention. The NYC Department of Health and Mental Hygiene instituted population based approaches to identify the HIV-infected, initiate discharge planning at jail admission, and facilitate post-release linkages to primary care. Using a caring and supportive 'warm transitions' approach, transitional care services are integral to continuity of care. Since 2010, over three-quarters of known HIV-infected inmates admitted to jails received discharge plans; 74 % of those released were linked to primary care. The EnhanceLink initiative's new Health Liaison, a lynchpin role, facilitated 250 court-led placements in medical alternatives to incarceration. Transitional care coordination programs are critical to facilitate continuity of care for people with chronic health conditions including the HIV-infected returning home from jail and for the public health of the communities to which they return.

Linkage to HIV care for jail detainees: findings from detention to the first 30 days after release

Of people living with HIV in the US, ~16 % or over 150,000 individuals passed through a correctional facility in 2006. Given the enormous impact of HIV within incarcerated populations, facilitating continuity of care from jails to the community is particularly important in reducing morbidity and mortality for releasees. Grantees participating in the Enhancing Linkages to HIV Primary Care in Jail Settings Initiative developed models for identifying HIV-positive detainees during incarceration and linking them to care following release. In this sample of 1,021 HIV-infected releasees, 79 % received clinical services and 74 % received additional community services within 30 days post-release. Our analysis found several significant factors associated with linkage including: receipt of HIV or medication education in jail, having a completed discharge plan at release, staff awareness of clients' release date, and stable housing on the 30th day post-release. In addition, a subset of participants who had both jail and community viral load assessments showed a statistically significant increase in suppressed viral load. EnhanceLink data suggest that jails may be effective settings to engage individuals in care.