Strategies to enhance linkages between care for HIV/AIDS in jail and community settings

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

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

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.

Improving Post-Release Care Engagement for People Living with HIV Involved in the Criminal Justice System: A Systematic Review

Given sub-optimal HIV care outcomes for people living with HIV (PLWH) post-release from incarceration, we systematically searched peer-reviewed literature (2010-2021) describing controlled trial interventions aimed at improving Antiretroviral Therapy (ART) adherence and care linkage following release from correctional facilities for PLWH. Of 392 studies, 16 (4%) met the inclusion criteria. All studies were conducted in the United States and involved some form of intensive case management. Trials that scored highest in terms of study quality provided cell phones for engagement, reported sustained viral load suppression as a measurable outcome to infer ART adherence, and measured longitudinal data collected for at least 3-to-6 months following release. The two trials that demonstrated improved HIV viral load suppression involved Peer Navigators, and incentivized undetectable viral load, respectively. Facilitating support for addictions and addressing other social and structural barriers to achieving optimal health is also of vital importance in bridging care gaps for PLWH.

Interventions to Improve HIV Care Continuum Outcomes Among Individuals Released From Prison or Jail: Systematic Literature Review

BACKGROUND

HIV care continuum outcomes deteriorate among people returning from incarceration. Interventions to improve care outcomes postincarceration have been characterized by substantial heterogeneity in approach, outcome metrics, and results. A large number of recently published interventions have not been systematically reviewed.

METHODS

We searched peer reviewed and scholarly databases for published and gray literature describing interventions to improve HIV care continuum outcomes among individuals released from prison or jail. We systematically screened quantitative and qualitative intervention reports published through 2018, then extracted and analyzed study data using a classification scheme that we developed for categorizing intervention levels and strategies.

RESULTS

We included 23 reports from the peer-reviewed literature, 2 from gray literature, and 2 from conference abstracts (27 total). Seventeen studies were classified as individual level, 3 as biomedical level, 2 as organizational level, and 5 as multilevel. Nine studies were randomized controlled trials, 4 of which reported power calculations. Fifteen studies were quasiexperimental; one was a case study. Eleven studies were conducted in prisons, 7 in jails, and 9 in both prisons and jails. Of 11 studies reporting hypothesis tests, 5 found statistically significant effect sizes on primary outcomes.

CONCLUSIONS

Interventions that demonstrate postrelease improvements in clinic attendance and viral suppression include patient navigation strategies, especially involving peer support, and substance use treatment strategies.

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

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

Juvenile justice staff endorsement of HIV/STI prevention, testing, and treatment linkage

BACKGROUND

While involvement in the legal system offers an opportunity to educate, screen, and treat high-risk youth, research shows that staff attitudes toward these practices can serve as barriers to implementation. The current study investigates the degree to which JJ staff endorse HIV prevention, testing, and treatment linkage practices with youth under community supervision and examines differences between individuals who supervise youth (e.g., juvenile probation officer) and those working in non-supervisory roles (e.g., case manager, assessment specialist).

METHODS

Juvenile justice staff consenting to participation in JJ-TRIALS completed an initial staff survey (N = 501). Survey items measured perceived importance of HIV/STI prevention (4 items); perceived importance of HIV/STI testing (7 items); and perceived importance of HIV/STI treatment linkage (8 items).

RESULTS

Confirmatory Factor Analysis (CFA) was computed (SAS CALIS procedure) for each of the three domains. Findings suggest that while staff recognize that youth are at risk for HIV/STIs and require provision of HIV/STI prevention and treatment linkage, attitudes concerning the importance of procuring or providing testing services for youth is substantially lower. Furthermore, analytic models comparing staff with and without supervision responsibilities (computed using SAS PROC MIXED) indicated that attitudes differed by site and staff responsible for supervision rated HIV treatment linkage practices as less important compared to non-supervising staff.

CONCLUSIONS

Establishing partnerships with health agencies equipped with resources and skillsets to provide HIV/STI testing and related services may be an effective model to promote greater awareness and use of best practices among JJ staff and more effectively address the unmet needs of this high-risk population of youth.

Adaptation of an Evidence-Based Intervention to Reduce HIV Risk in an Underserved Population: Young Minority Men in New York City Jails

To address HIV-risk among justice-involved minority men, New York City Health + Hospitals Correctional Health Services implemented a modified version of Choosing Life: Empowerment, Action Results (CLEAR), an evidence-based intervention to influence behavior. A total of 166 young (i.e., 20-29 years old) minority (e.g., non-Hispanic Black or Latinx) men at risk for HIV and incarcerated in New York City jails completed the adapted group-format intervention and corresponding evaluation assessments. Participants showed significantly improved HIV knowledge on the 18-item HIV-KQ-18 scale (mean increase = 3.11 correct, from 13.23 [SD = 3.80] pre-intervention to 16.34 [SD = 2.29] post-intervention). Similarly, participant summary scores for substance use risk, sexual risk, and health promotion improved significantly. At 90 days after jail release, participants reported improved "CLEAR thinking," reduced risk behaviors and improved health-promoting behaviors. Health and HIV-prevention education programs implemented in the jail setting may help reduce health inequities and improve health outcomes.

Jail-Based Case Management Improves Retention in HIV Care 12 Months Post Release

Continuous and coordinated HIV care is essential for persons living with HIV to benefit from the advances in medical treatment of the disease. Approximately one in seven individuals living with HIV pass through correctional facilities annually. While sentenced individuals may receive discharge planning services, detainees in local jails usually do not. The multisite evaluation of the EnhanceLink initiative demonstrated that jail based services including discharge planning were associated with high rates of linkage to community HIV care upon release. Follow up for the multisite evaluation was limited to 6 months. This paper extends follow up to 12 months at one site and demonstrates that clients who were linked by the jail based case manager to a Ryan White community based case manager were more than nine times more likely to be retained in care at 12 month post release. (OR 9.39, CI 1.11-79.12).

A randomized controlled study of intervention to improve continuity care engagement among HIV-infected persons after release from jails

Short-term stay, multiple jail admissions and social and financial difficulties are significant obstacles for continuity care engagement (CCE) after release among HIV-infected jail detainees. However, data existing on interventions or strategies to increase post-release CCE among this population are limited. We conducted a randomized controlled study among HIV-infected detainees at Cook County Jail during 2011-2014. The intervention group received telephone contact within 2-4 days of release by a continuity clinic coordinator, who scheduled and informed the ex-detainees of their appointment date within 6 weeks post-release plus standard of care, while the control group received standard of care. The standard of care included comprehensive discharge planning, offering substance abuse treatment and provision of information on how to self-schedule an appointment with the chosen clinics. Of the 166 detainees enrolled, 56 were excluded due to being sent to prison or re-incarcerated within 6 weeks. The final cohort included 55 detainees in each of the groups. The rate of CCE within 6 weeks after release was significantly higher in the intervention group compared to the control group (58% vs. 33%; P = .007). In multivariable logistic regression analysis, being in the control group was the only factor associated with no CCE within 6 weeks (adjusted odds ratio 2.66; 95% confidence interval 1.18-6.00; P = .02). The study findings suggest that the simple telephone contact intervention significantly improved CCE among HIV-infected jail detainees.

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.

Risk behaviors and HIV care continuum outcomes among criminal justice-involved HIV-infected transgender women and cisgender men: Data from the Seek, Test, Treat, and Retain Harmonization Initiative

Background

Transgender persons are highly victimized, marginalized, disproportionately experience incarceration, and have alarmingly increased rates of HIV infection compared to cis-gender persons. Few studies have examined the HIV care continuum outcomes among transgender women (TW), particularly TW who are involved with the criminal justice (CJ) system.

Methods

To improve our understanding of HIV care continuum outcomes and risk behaviors among HIV-infected TW who are involved with the CJ system, we analyzed data from the National Institute on Drug Abuse-supported Seek, Test, Treat, Retain (STTR) Data Harmonization Initiative. Baseline data were pooled and analyzed from three U.S. STTR studies to examine HIV risk and care continuum indicators among CJ-involved HIV-infected TW compared to cisgender men (CM), matched on age (within 5 years) and study at a ratio of 1:5.

Results

Eighty-eight TW and 440 CM were included in the study. Among matched participants, TW were more likely to report crack and cocaine use compared to CM (40%,16% respectively, p<0.001); both TW and CM reported high rates of condomless sex (58%, 64%, respectively); TW were more likely than CM to have more than one sexual partner (OR = 2.9, 95% CI: 1.6, 5.2; p<0.001) and have engaged in exchange sex (OR = 3.9, 95% CI: 2.3, 6.6; p<0.001). There were no significant differences between TW and CM in the percentage currently taking ART (52%, 49%, respectively), the mean percent adherence to ART (77% for both groups), and the proportion who achieved viral suppression (61%, 58%, respectively).

Conclusions

HIV-infected CJ-involved TW and CM had similar use of ART and viral suppression but TW were more likely than matched CM to engage in exchange sex, have multiple sexual partners, and use crack/cocaine. TW and CM had similarly high rates of condomless sex and use of other drugs. TW require tailored risk reduction interventions, however both CJ-involved TW and CM require focused attention to reduce HIV risk and improve HIV continuum of care outcomes.

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.

Effectiveness of a Peer Navigation Intervention to Sustain Viral Suppression Among HIV-Positive Men and Transgender Women Released From Jail: The LINK LA Randomized Clinical Trial

IMPORTANCE

Diagnosis of human immunodeficiency virus (HIV) infection, linkage and retention in care, and adherence to antiretroviral therapy are steps in the care continuum enabling consistent viral suppression for people living with HIV, extending longevity and preventing further transmission. While incarcerated, people living with HIV receive antiretroviral therapy and achieve viral suppression more consistently than after they are released. No interventions have shown sustained viral suppression after jail release.

OBJECTIVE

To test the effect on viral suppression in released inmates of the manualized LINK LA (Linking Inmates to Care in Los Angeles) peer navigation intervention compared with standard transitional case management controls.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial conducted from December 2012 through October 2016 with people living with HIV being released from Los Angeles (LA) County Jail. All participants were (1) 18 years or older; (2) either men or transgender women diagnosed with HIV; (3) English speaking; (4) selected for the transitional case management program prior to enrollment; (5) residing in LA County; and (6) eligible for antiretroviral therapy.

MAIN OUTCOMES AND MEASURES

Change in HIV viral suppression (<75 copies/mL) over a 12-month period.

INTERVENTIONS

During the 12-session, 24-week LINK LA Peer Navigation intervention, trained peer navigators counseled participants on goal setting and problem solving around barriers to HIV care and adherence, starting while the participants were still in jail. After their release, they continued counseling while they accompanied participants to 2 HIV care visits, then facilitated communication with clinicians during visits.

RESULTS

Of 356 participants randomized, 151 (42%) were black; 110 (31%) were Latino; 303 (85%) were men; 53 (15%) were transgender women; and the mean (SD) age was 39.5 (10.4) years. At 12 months, viral suppression was achieved by 62 (49.6%) of 125 participants in the peer navigation (intervention) arm compared with 45 (36.0%) of 125 in the transitional case management (control) arm, for an unadjusted treatment difference of 13.6% (95% CI, 1.34%-25.9%; P = .03). In the repeated measures, random effects, logistic model the adjusted probability of viral suppression declined from 52% at baseline to 30% among controls, while those in the peer navigation arm maintained viral suppression at 49% from baseline to 12 months, for a difference-in-difference of 22% (95% CI, 0.03-0.41; P = .02).

CONCLUSIONS AND RELEVANCE

The LINK LA peer navigation intervention was successful at preventing declines in viral suppression, typically seen after release from incarceration, compared with standard transitional case management. Future research should examine ways to strengthen the intervention to increase viral suppression above baseline levels.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01406626.

The Effect of Patient Navigation on the Likelihood of Engagement in Clinical Care for HIV-Infected Individuals Leaving Jail

OBJECTIVES

To compare the effectiveness of patient navigation-enhanced case management in supporting engagement in HIV care upon release from jail relative to existing services.

METHODS

We randomized 270 HIV-infected individuals to receive navigation-enhanced case management for 12 months or standard case management for 90 days following release from jail between 2010 and 2013. Participants were interviewed at 2, 6, and 12 months after release. We abstracted medical data from jail and city health records.

RESULTS

Patient navigation-enhanced case management resulted in greater linkage to care within 30 days of release (odds ratio [OR] = 2.15; 95% confidence interval [CI] = 1.23, 3.75) and consistent retention over 12 months (OR = 1.95; 95% CI = 1.11, 3.46). Receipt of treatment for substance use disorders in jail also resulted in early linkage (OR = 4.06; 95% CI = 1.93, 8.53) and retention (OR = 2.52; 95% CI = 1.21, 5.23). Latinos were less likely to be linked to (OR = 0.35; 95% CI = 0.14, 0.91) or retained in (OR = 0.28; 95% CI = 0.09, 0.82) HIV care.

CONCLUSIONS

Patient navigation supports maintaining engagement in care and can mitigate health disparities, and should become the standard of care for HIV-infected individuals leaving jail.

Predictors of linkage to HIV care and viral suppression after release from jails and prisons: a retrospective cohort study

BACKGROUND

Incarceration provides an opportunity for engagement in HIV care but is associated with poor HIV treatment outcomes after release. We aimed to assess post-release linkage to HIV care (LTC) and the effect of transitional case management services.

METHODS

To create a retrospective cohort of all adults with HIV released from jails and prisons in Connecticut, USA (2007-14), we linked administrative custody and pharmacy databases with mandatory HIV/AIDS surveillance monitoring and case management data. We examined time to LTC (defined as first viral load measurement after release) and viral suppression at LTC. We used generalised estimating equations to show predictors of LTC within 14 days and 30 days of release.

FINDINGS

Among 3302 incarceration periods for 1350 individuals between 2007 and 2014, 672 (21%) of 3181 periods had LTC within 14 days of release, 1042 (34%) of 3064 had LTC within 30 days of release, and 301 (29%) of 1042 had detectable viral loads at LTC. Factors positively associated with LTC within 14 days of release are intermediate (31-364 days) incarceration duration (adjusted odds ratio 1·52; 95% CI 1·19-1·95), and transitional case management (1·65; 1·36-1·99), receipt of antiretroviral therapy during incarceration (1·39; 1·11-1·74), and two or more medical comorbidities (1·86; 1·48-2·36). Reincarceration (0·70; 0·56-0·88) and conditional release (0·62; 0·50-0·78) were negatively associated with LTC within 14 days. Hispanic ethnicity, bonded release, and psychiatric comorbidity were also associated with LTC within 30 days but reincarceration was not.

INTERPRETATION

LTC after release is suboptimal but improves when inmates' medical, psychiatric, and case management needs are identified and addressed before release. People who are rapidly cycling through jail facilities are particularly vulnerable to missed linkage opportunities. The use of integrated programmes to align justice and health-care goals has great potential to improve long-term HIV treatment outcomes.

FUNDING

US National Institutes of Health.

Childhood Adversities and Substance Misuse Among the Incarcerated: Implications for Treatment and Practice in Correctional Settings

BACKGROUND

Incarcerated populations have high rates of childhood adversities and substance use problems. Moreover, childhood adversities are well-documented predictors of substance misuse.

OBJECTIVE

To investigate the impact of childhood sexual and physical abuse, caregiver abuse of drugs or alcohol, and time spent in foster care on several substance misuse outcomes.

METHODS

Data comes from a sample of 16,043 incarcerated men and women in the United States Survey of Inmates in State and Federal Facilities. Bivariate analyses revealed differences by sex in childhood adversities and socioeconomic characteristics. Logistic regression analyses assessed the data for a link between childhood adversities and substance misuse after adjusting for other variables. Analyses were stratified by sex to show differences in predictors of substance misuse between men and women.

RESULTS

Childhood adversities increased the risk of many substance misuse outcomes. The prevalence of physical abuse, sexual abuse, foster care, and caretaker abuse of drugs or alcohol were greatest for inmates who reported injecting and sharing drugs. Growing up with a caregiver that used drugs or alcohol was a consistent predictor of increased risk of substance misuse for men and women. However, childhood sexual abuse increased risk for only women.

CONCLUSIONS

Inmates who experience physical abuse, sexual abuse, foster care involvement and caretakers who use drugs and alcohol are at an increased risk of substance misuse, injecting drug use and syringe sharing. Implications suggest correctional HIV prevention and substance misuse programs must address unresolved trauma and important gender differences.

Transitional care for formerly incarcerated persons with HIV: protocol for a realist review

BACKGROUND

Little is known about the mechanisms that influence the success or failure of programs to facilitate re-engagement with health and social services for formerly incarcerated persons with HIV. This review aims to identify how interventions to address such transitions work, for whom and under what circumstances.

METHODS

We will use realist review methodology to conduct our analysis. We will systematically search electronic databases and grey literature for English language qualitative and quantitative studies of interventions. Two investigators will independently screen citations and full-text articles, abstract data, appraise study quality and synthesize the literature. Data analysis will include identifying context-mechanism-outcome configurations, exploring and comparing patterns in these configurations, making comparisons across contexts and developing explanatory frameworks.

DISCUSSION

This review will identify mechanisms that influence the success or failure of transition interventions for formerly incarcerated individuals with HIV. The findings will be integrated with those from complementary qualitative and quantitative studies to inform future interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016040054.

Women in community corrections in New York City: HIV infection and risks

Although the incidence of HIV among women on probation, parole and alternatives to incarceration programs is significant to public health, drivers of this concentrated epidemic among women under community corrections remain understudied. This study examined prevalence of HIV and sexually transmitted infections and the associations between substance use, socio-demographic factors and the prevalence of biologically-confirmed HIV and other sexually transmitted infections among a sample of 337 substance-using women recruited from community correction sites in New York City. Prevalence of HIV was 13% and sexually transmitted infections was 26% ( Chlamydia, trachomatis and Neisseria gonorrhea). After adjusting for covariates, HIV-positive women were 1.42 times more likely to use crack/cocaine than HIV-negative women (95% CI = 1.05-1.92). HIV-positive women were 25% less likely than HIV-negative women to report any unprotected vaginal and anal sex with their main partner (95% CI = 0.57-0.99). They were 70% less likely than HIV-negative women to report unprotected vaginal sex with a non-paying casual partner (95% CI = 0.1-0.9) and 22% less likely to report unprotected vaginal sex across all partners (95% CI = 0.61-0.99). Community corrections settings may be optimal venues to launch HIV/sexually transmitted infections prevention that have potential to reach and engage an ever-growing number of substance-using women.

What the Affordable Care Act means for people with jail stays

About one in six people expected to enroll in Medicaid under health reform expansions and nearly one in ten expected to enroll in qualified health plans through the health insurance Marketplaces will have spent some time in jail during the past year. People who have spent time in jail frequently cycle in and out of incarceration; have high rates of chronic physical, mental health, and substance use conditions; and historically have been uninsured and without access to continuous health care. The Affordable Care Act may not change the quality of health care in jails, but its provision of better access to care before and after people are incarcerated could have positive long-term effects on both the health of those individuals and overall health care costs. Achieving these results will require careful planning and coordination among jail health care programs, Medicaid, and Marketplace health plans. The use of electronic health records by jails and community providers could help ensure that treatments are consistent no matter where a patient resides. Policy makers and health plans could also ensure continuity of care by including in their networks some of the same safety-net providers that are under contract to furnish care to jail inmates.

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.

Epidemiological Criminology: Contextualization of HIV/AIDS Health Care for Female Inmates

Worldwide, women are increasingly being incarcerated. One unintended consequence is the increase in unhealthy female offenders. Among the more serious health concerns are HIV and AIDS. Challenges associated with caring for women with HIV/AIDS impacts not only disease management and infection control within correctional facilities but also the prisoners' home communities where they will need health care, drug and alcohol rehabilitation, housing assistance, and employment opportunities. No bridging theory has been presented that links prison and community health concerns with criminal justice policy. This article not only presents recommendations for effective HIV/AIDS policy but also suggests epidemiological criminology as a means of explicit merging of health with justice issues and consequently provides a bridging framework.

Prevalence and Predictors of Mental/Emotional Distress Among HIV+ Jail Detainees at Enrollment in an Observational Study

This study evaluates the prevalence of mental/emotional distress and its specific correlates among people living with HIV/AIDS (PLWHA) in 20 jail systems across the United States. Of the 878 PLWHA jail detainees, 52% had high levels of mental/emotional distress, defined by the composite Addiction Severity Index score. High mental/emotional distress was found to be associated with the inmate living in a city with lower income inequality, lower health ranking, and higher degree of danger. Proximate variables included being female, bisexual orientation, poorer physical health, and increased severity of substance abuse. Inmates in jails with accredited health services and those satisfied with family support had lower mental/emotional distress scores. These findings indicate the need for expanded mental health assessment of PLWHAs entering jail.

HIV-infected men who have sex with men, before and after release from jail: the impact of age and race, results from a multi-site study

The US HIV/AIDS epidemic is concentrated among men who have sex with men (MSM). Black men are disproportionately affected by incarceration and Black MSM experience higher infection rates and worse HIV-related health outcomes compared to non-Black MSM. We compared HIV treatment outcomes for Black MSM to other HIV-infected men from one of the largest cohorts of HIV-infected jail detainees (N = 1270) transitioning to the community. Of the 574 HIV-infected men released, 113 (19.7%) self-identified as being MSM. Compared to other male subgroups, young Black MSM (<30 years old, N = 18) were significantly less likely: (1) before incarceration, to have insurance, access to an HIV healthcare provider, and use cocaine; (2) during incarceration, to receive a disease management intervention; and (3) in the 6 months post-release, to link to HIV care. Interventions that effectively link and retain young HIV-infected Black MSM in care in communities before incarceration and post-release from jail are urgently needed.

Strategies for hepatitis C testing and linkage to care for vulnerable populations: point-of-care and standard HCV testing in a mobile medical clinic

Despite new Hepatitis C virus (HCV) therapeutic advances, challenges remain for HCV testing and linking patients to care. A point-of-care (POC) HCV antibody testing strategy was compared to traditional serological testing to determine patient preferences for type of testing and linkage to treatment in an innovative mobile medical clinic (MMC). From 2012 to 2013, all 1,345 MMC clients in New Haven, CT underwent a routine health assessment, including for HCV. Based on patient preferences, clients could select between standard phlebotomy or POC HCV testing, with results available in approximately 1 week versus 20 min, respectively. Outcomes included: (1) accepting HCV testing; (2) preference for rapid POC HCV testing; and (3) linkage to HCV care. All clients with reactive test results were referred to a HCV specialty clinic. Among the 438 (32.6 %) clients accepting HCV testing, HCV prevalence was 6.2 % (N = 27), and 209 (47.7 %) preferred POC testing. Significant correlates of accepting HCV testing was lower for the "baby boomer" generation (AOR 0.67; 95 % CI 0.46-0.97) and white race (AOR 0.55; 95 % CI 0.36-0.78) and higher for having had a prior STI diagnosis (AOR 5.03; 95 % CI 1.76-14.26), prior injection drug use (AOR 2.21; 95 % CI 1.12-4.46), and being US-born (AOR 1.76; 95 % CI 1.25-2.46). Those diagnosed with HCV and preferring POC testing (N = 16) were significantly more likely than those choosing standard testing (N = 11) to be linked to HCV care within 30 days (93.8 vs. 18.2 %; p < 0.0001). HCV testing is feasible in MMCs. While patients equally preferred POC and standard HCV testing strategies, HCV-infected patients choosing POC testing were significantly more likely to be linked to HCV treatment. Important differences in risk and background were associated with type of HCV testing strategy selected. HCV testing strategies should be balanced based on costs, convenience, and ability to link to HCV treatment.

The Impact of Implementing a Test, Treat and Retain HIV Prevention Strategy in Atlanta among Black Men Who Have Sex with Men with a History of Incarceration: A Mathematical Model

BACKGROUND

Annually, 10 million adults transition through prisons or jails in the United States (US) and the prevalence of HIV among entrants is three times higher than that for the country as a whole. We assessed the potential impact of increasing HIV Testing/Treatment/Retention (HIV-TTR) in the community and within the criminal justice system (CJS) facilities, coupled with sexual risk behavior change, focusing on black men-who-have-sex-with-men, 15-54 years, in Atlanta, USA.

METHODS

We modeled the effect of a HIV-TTR strategy on the estimated cumulative number of new (acquired) infections and mortality, and on the HIV prevalence at the end of ten years. We additionally assessed the effect of increasing condom use in all settings.

RESULTS

In the Status Quo scenario, at the end of 10 years, the cumulative number of new infections in the community, jail and prison was, respectively, 9246, 77 and 154 cases; HIV prevalence was 10815, 69 and 152 cases, respectively; and the cumulative number of deaths was 2585, 18 and 34 cases, respectively. By increasing HIV-TTR coverage, the cumulative number of new infections could decrease by 15% in the community, 19% in jail, and 8% in prison; HIV prevalence could decrease by 8%, 9% and 7%, respectively; mortality could decrease by 20%, 39% and 18%, respectively. Based on the model results, we have shown that limited use and access to condoms have contributed to the HIV incidence and prevalence in all settings.

CONCLUSIONS

Aggressive implementation of a CJS-focused HIV-TTR strategy has the potential to interrupt HIV transmission and reduce mortality, with benefit to the community at large. To maximize the impact of these interventions, retention in treatment, including during the period after jail and prison release, and increased condom use was vital for decreasing the burden of the HIV epidemic in all settings.

Health outcomes for HIV-infected persons released from the New York City jail system with a transitional care-coordination plan

OBJECTIVES

We sought to assess 6-month outcomes for HIV-infected people released from New York City jails with a transitional care plan.

METHODS

Jail detainees in New York City living with HIV who accepted a transitional care plan during incarceration were asked to participate in a multi-site evaluation aimed at improving linkages to community-based care. The evaluation included a 6-month follow-up; HIV surveillance data were used to assess outcomes for those considered lost to follow-up.

RESULTS

Participants (n=434) completed baseline surveys during incarceration in a jail in New York City. Of those seen at 6 months (n=243), a greater number were taking antiretroviral medications (92.6% vs 55.6%), had improved antiretroviral therapy adherence (93.2% vs 80.7%), and reported significant reductions in emergency department visits (0.20 vs 0.60 visits), unstable housing (4.15% vs 22.4%), and food insecurity (1.67% vs 20.7%) compared with baseline.

CONCLUSIONS

Transitional care coordination services facilitate continuity of care and improved health outcomes for HIV-positive people released from jail.

Incarceration of people living with HIV/AIDS: implications for treatment-as-prevention

Contact with the criminal justice system, including incarceration, is a common experience for many people living with HIV/AIDS. Optimism has recently been expressed that correctional facilities could be important locations for treatment-as-prevention (TasP)-based initiatives. We review recent findings regarding the effect of incarceration on patterns of HIV transmission, testing, treatment initiation and retention. We found that the prevalence of HIV infection among incarcerated individuals remains higher than analogous non-incarcerated populations. Recent studies have shown that voluntary HIV/AIDS testing is feasible in many correctional facilities, although the number of previously undiagnosed individuals identified has been modest. Studies have implied enhanced linkage to HIV/AIDS treatment and care in jails in the United States was associated with improvements in the HIV cascade of care. However, for many individuals living with HIV/AIDS, exposure to the correctional system remains an important barrier to retention in HIV/AIDS treatment and care. Future research should evaluate structural interventions to address these barriers and facilitate the scale-up of TasP-based efforts among individuals living in correctional settings.

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.

Validation of a Brief Measure of Opioid Dependence: The Rapid Opioid Dependence Screen (RODS)

The Rapid Opioid Dependence Screen (RODS) is an 8-item measure of opioid dependence designed for quick, targeted screening in clinical and research settings. Based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition, criteria, the RODS has an average administration of less than 2 minutes and can easily be administered as a stand-alone instrument or as part of a comprehensive interview. This study reports on the initial validation of the RODS among a sample of 97 newly incarcerated, HIV-positive individuals. Using the Mini International Neuropsychiatric Interview as the primary measure of opioid dependence, the RODS showed good-to-strong sensitivity (.97), specificity (.76), positive predictive value (.69), and negative predictive value (.98), while concordance analysis revealed moderate diagnostic agreement (κ = .67). Psychometric properties revealed strong internal consistency (α = .92) and inter-item correlations (.66 to .87).

Efficacy of a group-based multimedia HIV prevention intervention for drug-involved women under community supervision: project WORTH

IMPORTANCE

This study is designed to address the need for evidence-based HIV/STI prevention approaches for drug-involved women under criminal justice community supervision.

OBJECTIVE

We tested the efficacy of a group-based traditional and multimedia HIV/STI prevention intervention (Project WORTH: Women on the Road to Health) among drug-involved women under community supervision.

DESIGN, SETTING, PARTICIPANTS, AND INTERVENTION

We randomized 306 women recruited from community supervision settings to receive either: (1) a four-session traditional group-based HIV/STI prevention intervention (traditional WORTH); (2) a four-session multimedia group-based HIV/STI prevention intervention that covered the same content as traditional WORTH but was delivered in a computerized format; or (3) a four-session group-based Wellness Promotion intervention that served as an attention control condition. The study examined whether the traditional or multimedia WORTH intervention was more efficacious in reducing risks when compared to Wellness Promotion; and whether multimedia WORTH was more efficacious in reducing risks when compared to traditional WORTH.

MAIN OUTCOMES AND MEASURES

Primary outcomes were assessed over the 12-month post-intervention period and included the number of unprotected sex acts, the proportion of protected sex acts, and consistent condom use. At baseline, 77% of participants reported unprotected vaginal or anal sex (n = 237) and 63% (n = 194) had multiple sex partners.

RESULTS

Women assigned to traditional or multimedia WORTH were significantly more likely than women assigned to the control condition to report an increase in the proportion of protected sex acts (β = 0.10; 95% CI = 0.02-0.18) and a decrease in the number of unprotected sex acts (IRR = 0.72; 95% CI = 0.57-0.90).

CONCLUSION AND RELEVANCE

The promising effects of traditional and multimedia WORTH on increasing condom use and high participation rates suggest that WORTH may be scaled up to redress the concentrated epidemics of HIV/STIs among drug-involved women in the criminal justice system.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01784809.

Gender disparities in HIV treatment outcomes following release from jail: results from a multicenter study

OBJECTIVES

We assessed gender differences in longitudinal HIV treatment outcomes among HIV-infected jail detainees transitioning to the community.

METHODS

Data were from the largest multisite prospective cohort study of HIV-infected released jail detainees (n = 1270)-the Enhancing Linkages to HIV Primary Care and Services in Jail Setting Initiative, January 2008 and March 2011, which had 10 sites in 9 states. We assessed baseline and 6-month HIV treatment outcomes, stratifying by gender.

RESULTS

Of 867 evaluable participants, 277 (31.9%) were women. Compared with men, women were more likely to be younger, non-Hispanic White, married, homeless, and depressed, but were similar in recent alcohol and heroin use. By 6 months postrelease, women were significantly less likely than men to experience optimal HIV treatment outcomes, including (1) retention in care (50% vs 63%), (2) antiretroviral therapy prescription (39% vs 58%) or optimal antiretroviral therapy adherence (28% vs 44%), and (3) viral suppression (18% vs 30%). In multiple logistic regression models, women were half as likely as men to achieve viral suppression.

CONCLUSIONS

HIV-infected women transitioning from jail experience greater comorbidity and worse HIV treatment outcomes than men. Future interventions that transition people from jail to community-based HIV clinical care should be gender-specific.

Incarceration as a catalyst for worsening health

The primary aim of this paper is to explicate the mechanisms through which incarceration affects health. Guided by theories that emphasize the compounding nature of inequality and with a focus on those that are disproportionately impacted by the drastic increase of incarceration over the last three decades, an exploration of these mechanisms is undertaken. This investigation provides a better understanding of the issues that are faced by incarcerated individuals in the incarceration environment, after release, and via macro-level policy. Finally, a hypothetical heuristic framework is presented that illustrates the ways in which incarceration affects individual, family and community level health. Implications for policy intervention programs and future research that serve to address diminished health among incarcerated populations are discussed.

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.

HIV-positive and in jail: race, risk factors, and prior access to care

Black individuals represent 13 % of the US population but 46 % of HIV positive persons and 40 % of incarcerated persons. The national EnhanceLink project evaluated characteristics of HIV-positive jail entrants at ten sites and explored associations between race and HIV disease state. Between 1/2008 and 10/2011, 1,270 study participants provided demographic and clinical data. Adjusted odds ratios (aORs) were calculated for advanced HIV disease (CD4 < 200 cells/mm(3)) and uncontrolled viremia (viral load > 400 copies/ml) for Black (n = 807) versus non-Black (n = 426) participants. Sixty-five percent of HIV-positive jail participants self-identified as Black. Among all participants, fewer than half had a high school diploma or GED, the median number of lifetime arrests was 15, and major mental illness and substance abuse were common. Black participants were more likely to be older than non-Black participants, and less likely to have health insurance (70 vs 83 %) or an HIV provider (73 vs 81 %) in the prior 30 days. Among all male study participants (n = 870), 20 % self-identified as homosexual or bisexual. Black male participants were more likely to be homosexual or bisexual (22 vs 16 %) and less likely to have a history of injection drug use (20 vs 50 %) than non-Black male participants. Advanced HIV disease was associated with self-identification as Black (aOR = 1.84, 95 % CI 1.16-2.93) and time since HIV diagnosis of more than two years (aOR = 3.55, 95 % CI 1.52-8.31); advanced disease was inversely associated with age of less than 38 years (aOR = 0.41, 95 % CI 0.24-0.70). Uncontrolled viremia was inversely associated with use of antiretroviral therapy (ART) in the prior 7 days (aOR = 0.25, 95 % CI 0.15-0.43) and insurance coverage in the prior 30 days (aOR = 0.46, 95 % CI 0.26-0.81).

CONCLUSIONS

The racial disparities of HIV and incarceration among Black individuals in the US are underscored by the finding that 65 % of HIV-positive jail participants self-identified as Black in this ten-site study. Our study also found that 22 % of Black male participants self-identified as men who have sex with men (MSM). We believe these findings support jails as strategic venues to reach heterosexual, bisexual, and homosexual HIV-positive Black men who may have been overlooked in the community. Among HIV-positive jail entrants, Black individuals had more advanced HIV disease. Self-identification as Black was associated with a lower likelihood of having health insurance or an HIV provider prior to incarceration. HIV care and linkage interventions are needed within jails to better treat HIV and to address these racial disparities.

Patterns of homelessness and implications for HIV health after release from jail

This empirical study examines the association between substance abuse, mental illness, health behaviors and different patterns of homelessness among recently released, HIV-infected jail detainees. Using longitudinal data from a 10-site study, we examine correlates of homelessness, transitions to and from stable housing and the effect of housing on HIV treatment outcomes. Based on our analysis, we found evidence that the transitions from homelessness are closely associated with a reduction in the use of alcohol and illicit drugs, a decline in drug addiction severity, and an improvement in mental health. In addition, we found evidence that disparities in the housing status contributed substantially to the observed gap in the HIV treatment outcomes between homeless and non-homeless patients, including in achievement of virological suppression over time.

Contribution of substance use disorders on HIV treatment outcomes and antiretroviral medication adherence among HIV-infected persons entering jail

HIV and substance use are inextricably intertwined. One-sixth of people living with HIV/AIDS (PLWHA) transition through the correctional system annually. There is paucity of evidence on the impact of substance use disorders on HIV treatment engagement among jail detainees. We examined correlates of HIV treatment in the largest sample of PLWHA transitioning through jail in 10 US sites from 2007 to 2011. Cocaine, alcohol, cannabis, and heroin were the most commonly used substances. Drug use severity was negatively and independently correlated with three outcomes just before incarceration: (1) having an HIV care provider (AOR = 0.28; 95 % CI 0.09-0.89); (2) being prescribed antiretroviral therapy (AOR = 0.12; 95 % CI 0.04-0.35) and (3) high levels (>95 %) of antiretroviral medication adherence (AOR = 0.18; 95 % CI 0.05-0.62). Demographic, medical and psychiatric comorbidity, and social factors also contributed to poor outcomes. Evidence-based drug treatments that include multi-faceted interventions, including medication-assisted therapies, are urgently needed to effectively engage this vulnerable population.

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.

The role of jails in engaging PLWHA in care: from jail to community

HIV testing in jails has provided public health officials with the opportunity to not only identify new cases of HIV but to also reestablish contact with previously diagnosed individuals, many of whom never entered care following diagnosis or entered care but then dropped out. The presence of inmates throughout the HIV/AIDS continuum of care suggests that jails can play a strategic role in engaging persons living with HIV and AIDS in care. In order to be successful in structuring HIV/AIDS programs in jails, health care and correctional officials will be well-served to: (1) understand the HIV/AIDS continuum of care from the standpoint of engagement interventions that promote participation; (2) be aware of jail, community, and prison interventions that promote engagement in care; (3) anticipate and plan for the unique barriers jails provide in implementing engagement interventions; and, (4) be creative in designing engagement interventions suitable for both newly and previously diagnosed individuals.

Planning for success predicts virus suppressed: results of a non-controlled, observational study of factors associated with viral suppression among HIV-positive persons following jail release

In the United States, jail frequently disrupts access to HIV care. EnhanceLink, a 10-site demonstration project promoting linkage to HIV primary care upon jail discharge, offered an opportunity to gauge how many releasees had favorable clinical outcomes. Individual level data were available on 1270 participants. Persons never discharged from the correctional environment were excluded. Multivariate logistic regression identified factors associated with viral suppression 6 months post discharge (6M-VL < 400). Among 1082 individuals eligible for follow-up evaluation, 25.7 % had 6M-VL < 400. 6M-VL < 400 was associated with case managers assessing whether help was needed for linkage to HIV-related medical services and clients keeping an appointment with a case manager. The adjusted odds ratio (aOR) of 6M-VL < 400 associated with attending a meeting with an HIV care provider within 30 days of release was 1.85. The results of this non-controlled, observational study support further development and rigorous evaluation of transitional care programs for HIV-positive jailed persons across the country.

Jails, HIV testing, and linkage to care services: an overview of the EnhanceLink initiative

Over 9 million persons in the United States (US) are admitted each year to jails. HIV prevalence among detainees is higher than the general population, which creates a public health need for linking HIV-infected detainees to services during jail and after release. The EnhanceLink initiative was funded as demonstration projects in 10 communities at 20 separate jails across the US. Grantees implemented and evaluated innovative models of HIV testing in jails and linkage of HIV-infected individuals to community services post release. In this paper, we describe services delivered with the EnhanceLink initiative. During 877,119 admission events, 210,267 inmates agreed to HIV testing and 822 new diagnoses of HIV were made. The majority of persons served with transitional services were previously diagnosed before the current incarceration. Cumulatively, 9,837 HIV+ persons were offered linkage and transitional services and 8,056 (82 %) accepted the offer. EnhanceLink demonstrated the feasibility of HIV testing in jail settings and provision of linkage services to enhance continuity of HIV care post-release.

Post-release substance abuse outcomes among HIV-infected jail detainees: results from a multisite study

HIV-infected individuals with substance use disorders have a high prevalence of medical and psychiatric morbidities that complicate treatment. Incarceration further disrupts healthcare access and utilization. Without appropriate diagnosis and treatment, drug relapse upon release exceeds 85 %, which contributes to poor health outcomes. A prospective cohort of 1,032 HIV-infected jail detainees were surveyed in a ten-site demonstration project during incarceration and six-months post-release, in order to examine the effect of predisposing factors, enabling resources and need factors on their subsequent drug use. Homelessness, pre-incarceration cocaine and opioid use, and high drug and alcohol severity were significantly associated with cocaine and opioid relapse. Substance abuse treatment, though poorly defined, did not influence post-release cocaine and opioid use. An approach that integrates multiple services, simultaneously using evidence-based substance abuse, psychiatric care, and social services is needed to improve healthcare outcomes for HIV-infected persons transitioning from jails to the community.

Jails as an opportunity to increase engagement in HIV care: findings from an observational cross-sectional study

Linkage, engagement, retention and adherence to care are necessary steps along the HIV care continuum. Progression through these steps is essential for control of the disease and interruption of transmission. Identifying and re-engaging previously diagnosed but out-of-care patients is a priority to achieve the goals of the National HIV/AIDS strategy. Participants in the EnhanceLink cohort who were previously diagnosed HIV+ (n = 1,203) were classified as not-linked to of care and non-adherent to medication prior to incarceration by self report. Results based on multivariate models indicate that recent homelessness as well as high degrees of substance abuse correlated with those classified as not-linked to care and non-adherent to medications while having insurance was associated with being linked to care and adherent to care. The majority of detainees reported being linked to care but not currently adherent to care confirming that jails are an important site for re-engaging HIV+ individuals.

Cost analysis of enhancing linkages to HIV care following jail: a cost-effective intervention

We are not aware of published cost-effectiveness studies addressing community transitional programs for HIV-infected jail detainees. To address this gap, data from 9 sites of EnhanceLink, a project that enrolled HIV-infected releasees from jails across the US, were examined. Figures on the number of clients served, cost of linkage services, number of linkages and 6-month sustained linkages to community HIV care, and number of clients achieving viral suppression were assessed for subjects released in the first quarter of 2010 (n = 543). The cost analysis included all costs that participating service agencies incurred. A cost-effectiveness analysis was conducted to estimate the new HIV cases averted by EnhanceLink and the cost per quality-adjusted life year saved by the program. The mean cost per linked client was $4,219; the mean cost per 6-month sustained linkage was $4,670; and the mean cost per client achieving viral suppression was $8,432. Compared to standard care, the cost per additional quality-adjusted life year saved was $72,285, suggesting that the EnhanceLink interventions were cost-effective from the societal perspective.

Correlates of retention in HIV care after release from jail: results from a multi-site study

Retention in care is key to effective HIV treatment, but half of PLWHA in the US are continuously engaged in care. Incarcerated individuals are an especially challenging population to retain, and empiric data specific to jail detainees is lacking. We prospectively evaluated correlates of retention in care for 867 HIV-infected jail detainees enrolled in a 10-site demonstration project. Sustained retention in care was defined as having a clinic visit during each quarter in the 6 month post-release period. The following were independently associated with retention: being male (AOR = 2.10, p ≤ 0.01), heroin use (AOR 1.49, p = 0.04), having an HIV provider (AOR 1.67, p = 0.02), and receipt of services: discharge planning (AOR 1.50, p = 0.02) and disease management session (AOR 2.25, p ≤ 0.01) during incarceration; needs assessment (AOR 1.59, p = 0.02), HIV education (AOR 2.03, p ≤ 0.01), and transportation assistance (AOR 1.54, p = 0.02) after release. Provision of education and case management services improve retention in HIV care after release from jail.

Understanding the revolving door: individual and structural-level predictors of recidivism among individuals with HIV leaving jail

Incarceration, particularly when recurrent, can significantly compromise the health of individuals living with HIV. Despite this, the occurrence of recidivism among individuals with HIV has been little examined, particularly among those leaving jail, who may be at especially high risk for return to the criminal justice system. We evaluated individual- and structural-level predictors of recidivism and time to re-incarceration in a cohort of 798 individuals with HIV leaving jail. Nearly a third of the sample experienced at least one re-incarceration event in the 6 months following jail release. Having ever been diagnosed with a major psychiatric disorder, prior homelessness, having longer lifetime incarceration history, having been charged with a violent offense for the index incarceration and not having health insurance in the 30 days following jail release were predictive of recidivism and associated with shorter time to re-incarceration. Health interventions for individuals with HIV who are involved in the criminal justice system should also target recidivism as a predisposing factor for poor health outcomes. The factors found to be associated with recidivism in this study may be potential targets for intervention and need to be further explored. Reducing criminal justice involvement should be a key component of efforts to promote more sustainable improvements in health and well-being among individuals living with HIV.

Adherence to HIV treatment and care among previously homeless jail detainees

HIV-infected persons entering the criminal justice system (CJS) often experience suboptimal healthcare system engagement and social instability, including homelessness. We evaluated surveys from a multisite study of 743 HIV-infected jail detainees prescribed or eligible for antiretroviral therapy (ART) to understand correlates of healthcare engagement prior to incarceration, focusing on differences by housing status. Dependent variables of healthcare engagement were: (1) having an HIV provider, (2) taking ART, and (3) being adherent (≥95% of prescribed doses) to ART during the week before incarceration. Homeless subjects, compared to their housed counterparts, were significantly less likely to be engaged in healthcare using any measure. Despite Ryan White funding availability, insurance coverage remains insufficient among those entering jails, and having health insurance was the most significant factor correlated with having an HIV provider and taking ART. Individuals interfacing with the CJS, especially those unstably housed, need innovative interventions to facilitate healthcare access and retention.

Understanding the relationship between social support and physical and mental well-being among jail detainees living with HIV

Inmates face a disproportionate burden of HIV. This study sought to explore the relationship between social support and physical and mental well-being and the possibility that housing stability moderates this relationship among jail detainees living with HIV. Data for this cross-sectional analysis come from 438 clients who underwent a structured interview. Results indicate a significant positive relationship between social support and both types of well-being ( ps < .05); the experience of homelessness was associated with less mental well-being ( p < .01). There was no evidence of moderation. Results highlight the importance of social support and economic considerations in understanding well-being among HIV+ jail detainees.

Health impact of incarceration on HIV-positive African American males: a qualitative exploration

Previous research suggests that incarceration can have a negative effect on health. These health effects have an especially profound impact on HIV-positive individuals. As such, the current study investigates how incarceration affects the health of 12 African American HIV-positive formerly incarcerated males recruited via an AIDS Service Organization. Individuals were enrolled via purposive sampling and engaged in a series of in-depth interviews over a yearlong period (n=46). Participants ranged in age from 33 to 61 years. Most had finished high school, were not employed at time of first and last interview, and most were primarily residing at a homeless shelter. The time incarcerated ranged among participants from 3 months to 3 years. Findings suggest that health is impacted via limited and delayed access to medication, stigma, and poor quality of medical care while incarcerated. Health continues to worsen after release, largely due to incarceration's impact on individuals' social context. Macro-level policy limits opportunity to fulfill basic needs such as housing and hinders one's ability to be gainfully employed. Moreover, stigma, loss of social support, and a delay in accessing HIV-related services deleteriously impacts individuals' mental and physical health status. Implications for practice, policy and future research are also discussed.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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