HIV Treatment in the Criminal Justice System: Critical Knowledge and Intervention Gaps

"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.

Linking criminal justice-involved individuals to HIV, Hepatitis C, and opioid use disorder prevention and treatment services upon release to the community: Progress, gaps, and future directions

Improving HIV and Hepatitis C Virus (HCV) management among people involved in the criminal justice (CJ) system who use drugs, in particular those with opioid use disorder (OUD), requires effective approaches to screening, linkage, and adherence to integrated prevention and treatment services across correctional and community agencies and providers. This manuscript reviews the literature to explore gaps in HIV, Hepatitis C, and OUD prevention, treatment, and delivery cascades of care for persons involved in the CJ system. Specifically, we compare two models of linkage to prevention and treatment services: Peer/Patient Navigation (PN) wherein the PN links CJ-involved individuals to community-based infectious disease (ID) and substance use prevention and treatment services, and Mobile Health Units (MHU) wherein individuals are linked to a MHU within their community that provides integrated ID and substance use prevention and treatment services. The most notable finding is a gap in the literature, with few to no comparisons of models linking individuals recently released from the CJ system to integrated HIV, Hepatitis C, and OUD prevention and treatment and other harm reduction services. Further, few published studies address the geographical distinctions that affect service implementation and their effects on these substance use, ID and harm reduction care cascades. This manuscript makes specific recommendations to fill this gap through a detailed evaluation of PN and MHU linkage models to co-located and integrated HIV, Hepatitis C, and OUD prevention and treatment services across different communities within the U.S.

Socio-Structural and Neighborhood Predictors of Incident Criminal Justice Involvement in a Population-Based Cohort of Young Black MSM and Transgender Women

Black men who have sex with men (MSM) and transgender women are disproportionately affected by criminal justice involvement (CJI) and HIV. This study recruited 618 young Black MSM and transgender women in Chicago, IL, using respondent-driven sampling between 2013 and 2014. Random effects logistic regression evaluated predictors of incident CJI over 18 months of follow-up. Controlling for respondent age, gender and sexual identity, spirituality (aOR 0.56, 95% CI 0.33-0.96), and presence of a mother figure (aOR 0.41, 95% CI 0.19-0.89) were protective against CJI. Economic hardship (financial or residential instability vs. neither aOR 2.23, 95% CI 1.10-4.51), two or more past episodes of CJI vs. none (aOR 2.66, 95% CI 1.40-5.66), and substance use (marijuana use vs. none aOR 2.79, 95% CI 1.23-6.34; other drug use vs. none aOR 4.49, 95% CI 1.66-12.16) were associated with CJI during follow-up. Research to identify and leverage resilience factors that can buffer the effects of socioeconomic marginalization may increase the effectiveness of interventions to address the socio-structural factors that increase the risk for CJI among Black MSM and transgender women. Given the intersection of incarceration, HIV and other STIs, and socio-structural stressors, criminal justice settings are important venues for interventions to reduce health inequities in these populations.

Linking individuals on probation to health care: a pilot randomized trial

BACKGROUND

Probation offices represent a location where at-risk individuals in need of health care appear on a known and regular basis. We sought to study how providing linkages to health care could improve the proportion of underserved, justice-involved individuals accessing the health care system. This study tested a linkage and referral to health care intervention for individuals on probation designed by a local change team that brought together actors from multiple agencies and tasked them with increasing general practitioner physician access for probationers. The pilot trial randomized 400 individuals on probation in Delaware during 2016-2018 to determine the effectiveness of placing a health navigator in an urban probation office to refer people to an appointment with a primary care physician. The project also tested the impact of offering an incentive to probationers for attending a doctor's appointment.

RESULTS

Referral by a health navigator to a primary care physician was associated with a modest but significant increase in the proportion of individuals accessing care through a general practitioner physician. Offering an incentive had no significant impact on keeping the medical appointment above the effect of referral by the health navigator.

CONCLUSIONS

Probation offices represent a location where at-risk individuals in need of health care appear on a known and regular basis. This study highlights how providing linkages to health care can improve the proportion of underserved individuals accessing the health care system.

Coordinating across correctional, community, and VA systems: applying the Collaborative Chronic Care Model to post-incarceration healthcare and reentry support for veterans with mental health and substance use disorders

BACKGROUND

Between 12,000 and 16,000 veterans leave incarceration annually. As is known to be the case for justice-involved populations in general, mental health disorders (MHDs) and substance use disorders (SUDs) are highly prevalent among incarcerated veterans, and individuals with MHDs and SUDs reentering the community are at increased risk of deteriorating health and recidivism. We sought to identify opportunities to better coordinate care/services across correctional, community, and VA systems for reentry veterans with MHDs and SUDs.

METHODS

We interviewed 16 veterans post-incarceration and 22 stakeholders from reentry-involved federal/state/community organizations. We performed a grounded thematic analysis, and recognizing consistencies between the emergent themes and the evidence-based Collaborative Chronic Care Model (CCM), we mapped findings to the CCM's elements - work role redesign (WRR), patient self-management support (PSS), provider decision support (PDS), clinical information systems (CIS), linkages to community resources (LCR), and organizational/leadership support (OLS).

RESULTS

Emergent themes included (i) WRR - coordination challenges among organizations involved in veterans' reentry; (ii) PSS - veterans' fear of reentering society; (iii) PDS - uneven knowledge by reentry support providers regarding available services when deciding which services to connect a reentry veteran to and whether he/she is ready and/or willing to receive services; (iv) CIS - lapses in MHD/SUD medications between release and a first scheduled health care appointment, as well as challenges in transfer of medical records; (v) LCR - inconsistent awareness of existing services and resources available across a disparate reentry system; and (vi) OLS - reentry plans designed to address only immediate transitional needs upon release, which do not always prioritize MHD/SUD needs.

CONCLUSIONS

Applying the CCM to coordinating cross-system health care and reentry support may contribute to reductions in mental health crises and overdoses in the precarious first weeks of the reentry period.

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.

Methamphetamine use drives decreases in viral suppression for people living with HIV released from a large municipal jail: Results of the LINK LA clinical trial

BACKGROUND

People living with HIV (PLWH) often experience decreases in HIV viral suppression (VS) after release from jail. The Linking Inmates to Care in LA (LINK LA) peer navigation intervention helped maintain VS 12 months after release from jail compared to standard of care. In this study, we analyzed correlates of substance use and tested whether substance use was an independent correlate of decreased VS in LINK LA participants.

METHODS

We analyzed LINK LA data collected at baseline, 3, and 12 months. We defined high-risk drug use as any reported methamphetamine, cocaine, or opioid use in the 30 days prior to a study visit (or jail entry at baseline). We used generalized linear mixed models to test associations of sociodemographic variables with type of substance used, and we tested correlates of VS while controlling for time, the intervention, and their interaction.

RESULTS

At baseline (n = 356), 71% of participants reported high-risk drug use: 58%, methamphetamine; 17%, cocaine; 7%, heroin; and 4%, prescription opioids. Non-Hispanic Whites and those younger than 35 were most likely to use methamphetamine; Blacks were most likely to use cocaine; people who inject drugs were most likely to use opioids. Participants who used high-risk drugs had 53% lower adjusted odds than non-users of maintaining VS (AOR 0.47, 95% CI 0.31-0.70, p < 0.001).

CONCLUSION

High-risk drug use, dominated by methamphetamine use, independently correlated with decreased VS among recently incarcerated PLWH. Improving HIV care continuum outcomes among populations leaving jail requires attention to efforts to address high-risk drug use.

A novel application of process mapping in a criminal justice setting to examine implementation of peer support for veterans leaving incarceration

BACKGROUND

Between 12,000 and 16,000 veterans leave incarceration every year, yet resources are limited for reentry support that helps veterans remain connected to VA and community health care and services after leaving incarceration. Homelessness and criminal justice recidivism may result when such follow-up and support are lacking. In order to determine where gaps exist in current reentry support efforts, we developed a novel methodological adaptation of process mapping (a visualization technique being increasingly used in health care to identify gaps in services and linkages) in the context of a larger implementation study of a peer-support intervention to link veterans to health-related services after incarceration ( https://clinicaltrials.gov/ , NCT02964897, registered November 4, 2016) to support their reentry into the community.

METHODS

We employed process mapping to analyze qualitative interviews with staff from organizations providing reentry support. Interview data were used to generate process maps specifying the sequence of events and the multiple parties that connect veterans to post-incarceration services. Process maps were then analyzed for uncertainties, gaps, and bottlenecks.

RESULTS

We found that reentry programs lack systematic means of identifying soon-to-be released veterans who may become their clients; veterans in prisons/jails, and recently released, lack information about reentry supports and how to access them; and veterans' whereabouts between their release and their health care appointments are often unknown to reentry and health care teams. These system-level shortcomings informed our intervention development and implementation planning of peer-support services for veterans' reentry.

CONCLUSIONS

Systematic information sharing that is inherent to process mapping makes more transparent the research needed, helping to engage participants and operational partners who are critical for successful implementation of interventions to improve reentry support for veterans leaving incarceration. Even beyond our immediate study, process mapping based on qualitative interview data enables visualization of data that is useful for 1) verifying the research team's interpretation of interviewee's accounts, 2) specifying the events that occur within processes that the implementation is targeting (identifying knowledge gaps and inefficiencies), and 3) articulating and tracking the pre- to post-implementation changes clearly to support dissemination of evidence-based health care practices for justice-involved populations.

Syndemic effect of mental illness and substance use on viral suppression among recently-incarcerated, HIV-infected individuals in the CARE+ Corrections study

Few studies on HIV-related syndemics of co-occurring and mutually reinforcing psychosocial conditions have assessed clinical outcomes in criminal justice (CJ)-involved populations. Baseline data from the CARE+ Corrections study were used to quantify co-occurring mental illness and substance use and examine syndemic effects on viral suppression among 106 CJ-involved HIV-infected individuals. Ninety-one (86%) reported a mental illness diagnosis, 30 (28%) reported hazardous alcohol use, and 61 (58%) were drug dependent. Eighteen (17%) experienced all three conditions. Drug dependence was clustered with mental illness (prevalence odds ratio [POR] 3.20, 95% CI 1.01-10.14) and hazardous alcohol use (POR 2.61, 95% CI 1.03-6.56). The association between syndemic score, representing the number of conditions reported by each individual, and viral suppression was not statistically significant, although 86% of participants with none of these conditions were virally suppressed, compared to 56% of those with all three (p = 0.56). Mental illness and substance use were concentrated in this sample, indicating a need for integrated care services.

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.

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.

Caregivers' Support Network Characteristics Associated with Viral Suppression among HIV Care Recipients

Informal care receipt is associated with health outcomes among people living with HIV. Less is known about how caregivers' own social support may affect their care recipient's health. We examined associations between network characteristics of informal caregivers and HIV viral suppression among former or current drug using care recipients. We analyzed data from 258 caregiver-recipient dyads from the Beacon study, of whom 89% of caregivers were African American and 59% were female. In adjusted logistic regression analysis, care recipients had lower odds of being virally suppressed if their caregiver was female, was caring for youth involved in the criminal justice system, and had network members who used illicit drugs. Caregivers' greater numbers of non-kin in their support network was positively associated with viral suppression among care recipients. The findings reveal contextual factors affecting ART outcomes and the need for interventions to support caregivers, especially HIV caregiving women with high-risk youth.

A two-state comparative implementation of peer-support intervention to link veterans to health-related services after incarceration: a study protocol

BACKGROUND

Approximately 600,000 persons are released from prison annually in the United States. Relatively few receive sufficient re-entry services and are at risk for unemployment, homelessness, poverty, substance abuse relapse and recidivism. Persons leaving prison who have a mental illness and/or a substance use disorder are particularly challenged. This project aims to create a peer mentor program to extend the reach and effectiveness of reentry services provided by the Department of Veterans' Affairs (VA). We will implement a peer support for reentry veterans sequentially in two states. Our outcome measures are 1) fidelity of the intervention, 2) linkage to VA health care and, 3) continued engagement in health care. The aims for this project are as follows: (1) Conduct contextual analysis to identify VA and community reentry resources, and describe how reentry veterans use them. (2) Implement peer-support, in one state, to link reentry veterans to Veterans' Health Administration (VHA) primary care, mental health, and SUD services. (3) Port the peer-support intervention to another, geographically, and contextually different state.

DESIGN

This intervention involves a 2-state sequential implementation study (Massachusetts, followed by Pennsylvania) using a Facilitation Implementation strategy. We will conduct formative and summative analyses, including assessment of fidelity, and a matched comparison group to evaluate the intervention's outcomes of veteran linkage and engagement in VHA health care (using health care utilization measures). The study proceeds in 3 phases.

DISCUSSION

We anticipate that a peer support program will be effective at improving the reentry process for veterans, particularly in linking them to health, mental health, and SUD services and helping them to stay engaged in those services. It will fill a gap by providing veterans with access to a trusted individual, who understands their experience as a veteran and who has experienced justice involvement. The outputs from this project, including training materials, peer guidebooks, and implementation strategies can be adapted by other states and regions that wish to enhance services for veterans (or other populations) leaving incarceration. A larger cluster-randomized implementation-effectiveness study is planned.

TRIAL REGISTRATION

This protocol is registered with clinicaltrials.gov on November 4, 2016 and was assigned the number NCT02964897 .

HIV risk inside U.S. prisons: a systematic review of risk reduction interventions conducted in U.S. prisons

HIV prevalence in correctional populations is approximately five times that of the general adult population. This systematic review examines the broad question of HIV prevention and interventions to reduce inmate HIV-related risk behaviors in U.S. federal and state prisons. We conducted a systematic review of multiple databases and Google Scholar to identify behavioral, biomedical, social, and policy studies related to HIV among U.S. prison populations from 1980-2014. Studies were excluded if they did not focus on HIV, prison inmates, if they were conducted outside of the U.S., if they involved juvenile offenders, or if they included post-release outcomes. Twenty-seven articles met the study criteria. Evidence suggests that research related to the HIV care continuum, risk behaviors, gender, prevention (e.g., peer education), and policy are key topics to enhance HIV prevention interventions in the criminal justice system. This review provides a prison-specific overview of HIV in U.S. correctional populations and highlight effective interventions, including inmate peer education. There is an urgent need to continue to implement HIV prevention interventions across all prisons and improve the quality of life among those at heightened risk of HIV infection.

The Influence of Medication Attitudes on Utilization of Antiretroviral Therapy (ART) in Indonesian Prisons

Negative attitudes toward HIV medications may restrict utilization of antiretroviral therapy (ART) in Indonesian prisons where many people living with HIV (PLH) are diagnosed and first offered ART. This mixed-method study examines the influence of medication attitudes on ART utilization among HIV-infected Indonesian prisoners. Randomly-selected HIV-infected male prisoners (n = 102) completed face-to-face in-depth interviews and structured surveys assessing ART attitudes. Results show that although half of participants utilized ART, a quarter of those meeting ART eligibility guidelines did not. Participants not utilizing ART endorsed greater concerns about ART efficacy, safety, and adverse effects, and more certainty that ART should be deferred in PLH who feel healthy. In multivariate analyses, ART utilization was independently associated with more positive ART attitudes (AOR = 1.09, 95 % CI 1.03-1.16, p = 0.002) and higher internalized HIV stigma (AOR = 1.03, 95 % CI 1.00-1.07, p = 0.016). Social marketing of ART is needed to counteract negative ART attitudes that limit ART utilization among Indonesian prisoners.

Black Americans and Incarceration: A Neglected Public Health Opportunity for HIV Risk Reduction

Black Americans are incarcerated at disproportionate rates, largely due to racial differences in the application of drug laws. Human immunodeficiency virus (HIV) prevalence rates among Black Americans are also disproportionately high. Moreover, availability of and access to HIV prevention services in correctional settings are limited. Recognizing that Blacks are at an elevated risk of contracting HIV, and that incarceration worsens health outcomes, this paper addresses the importance of implementing comprehensive prison-based HIV programs and prevention interventions to improve the health of this vulnerable population. In the absence of a vaccine, prevention interventions can serve as an effective method of systematically addressing HIV-related health disparities. Prevention strategies offered within correctional settings provide a unique opportunity to engage a high-risk population when its members may be receptive to behavior modification.

Alcohol use disorders and antiretroviral therapy among prisoners in Argentina

PURPOSE

While Argentina has significantly improved access to HIV care and antiretroviral therapy (ART) for both the general population and prisoners, the prevalence of alcohol use disorders (AUDs) among HIV-infected prisoners and their relationship to accessing ART in Argentina is currently unknown. This study aims to characterize the substance abuse patterns of HIV-infected prisoners in Argentina and to assess the independent correlates of receipt of pre-incarceration ART.

DESIGN/METHODOLOGY/APPROACH

An anonymous, cross-sectional survey of 100 HIV-infected federal prisoners was conducted in the Buenos Aires municipality from July-December 2010. AUDs were assessed using the AUDIT scale.

FINDINGS

A majority (63 per cent) of participants met criteria for AUDs, 45 per cent of subjects were diagnosed with HIV in prison and one-quarter had initiated ART during the current incarceration. In addition, over one-third (35 per cent) of participants did not receive ART during the pre-incarceration period despite receiving it upon incarceration. This correlated significantly with the presence of having an AUD (AOR 0.20, 95 per cent CI 0.06-0.74, p = 0.016).

PRACTICAL IMPLICATIONS

AUDs are prevalent among HIV-infected prisoners in Argentina and are significantly related to negative secondary HIV prevention and treatment outcomes. While Argentina has provided an exemplary model of HIV-related health care reform within its prisons, future efforts to provide screening and treatment for AUDs are needed to improve the health of the nation’s incarcerated population.

ORIGINALITY/VALUE

This paper is the first to describe pre-incarceration drug and alcohol use disorders and issues related to access to ART among prisoners in Argentina.

Sex-Related Disparities in Criminal Justice and HIV Treatment Outcomes: A Retrospective Cohort Study of HIV-Infected Inmates

OBJECTIVES

We evaluated sex-related differences in HIV and criminal justice (CJ) outcomes.

METHODS

We quantified sex-related differences in criminal offenses, incarcerations, and HIV outcomes among all HIV-infected inmates on antiretroviral therapy (ART) in Connecticut (2005-2012). Computed criminogenic risk scores estimated future CJ involvement. Stacked logistic regression models with random effects identified significant correlates of HIV viral suppression on CJ entry, reflecting preceding community-based treatment.

RESULTS

Compared with 866 HIV-infected men on ART (1619 incarcerations), 223 women (461 incarcerations) were more likely to be younger, White, and medically insured, with shorter incarceration periods (mean = 196.8 vs 368.1 days), mostly for public disorder offenses. One third of both women and men had viral suppression on CJ entry, correlating positively with older age and having treated comorbidities. Entry viral suppression inversely correlated with incarceration duration for women and with criminogenic risk score for men.

CONCLUSIONS

In the largest contemporary cohort of HIV-infected inmates on ART, women's higher prevalence of nonviolent offenses and treatable comorbidities supports alternatives to incarceration strategies. Sex-specific interventions for CJ populations with HIV effectively align public health and safety goals.

A comparison of psychiatric diagnoses among HIV-infected prisoners receiving combination antiretroviral therapy and transitioning to the community

BACKGROUND

The criminal justice system (CJS), specifically prisons and jails, is ideally suited for uniform screening of psychiatric (PD) and substance use disorders (SUDs) among people living with HIV/AIDS (PLWHA), who are concentrated in these settings. By accurately diagnosing PDs and SUDs in these controlled settings, treatment can be initiated and contribute to improved continuity of care upon release. In the context of PLWHA, it may also improve combination antiretroviral treatment (cART) adherence, and reduce HIV transmission risk behaviors.

METHODS

A retrospective data analysis was conducted by creating a cohort of PLWHA transitioning to the community from prison or jail enrolled who were enrolled in a controlled trial of directly administered antiretroviral (DAART). Participants were systematically assessed for PDs and SUDs using the Mini International Neuropsychiatric Interview (MINI), a standardized psychiatric assessment tool, and compared to diagnoses documented within the correctional medical record.

RESULTS

Findings confirm a high prevalence of Axis I PDs (47.4%) and SUDs (67.1%) in PLWHA even after prolonged abstinence from alcohol and drugs. Although prevalence of PDs and SUDs were high in the medical record, there was fair to poor agreement among PDs using the MINI, making evident the potential benefit of more objective and concurrent PD assessments to guide treatment.

CONCLUSIONS

Additional PD diagnoses may be detected in PLWHA in CJS using supplementary and objective screening tools. By identifying and treating PDs and SUDs in the CJS, care may be improved and may ultimately contribute to healthier outcomes after community release if patients are effectively transitioned.

Efficacy of a process improvement intervention on delivery of HIV services to offenders: a multisite trial

OBJECTIVES

We tested a modified Network for the Improvement of Addiction Treatment (NIATx) process improvement model to implement improved HIV services (prevention, testing, and linkage to treatment) for offenders under correctional supervision.

METHODS

As part of the Criminal Justice Drug Abuse Treatment Studies, Phase 2, the HIV Services and Treatment Implementation in Corrections study conducted 14 cluster-randomized trials in 2011 to 2013 at 9 US sites, where one correctional facility received training in HIV services and coaching in a modified NIATx model and the other received only HIV training. The outcome measure was the odds of successful delivery of an HIV service.

RESULTS

The results were significant at the .05 level, and the point estimate for the odds ratio was 2.14. Although overall the results were heterogeneous, the experiments that focused on implementing HIV prevention interventions had a 95% confidence interval that exceeded the no-difference point.

CONCLUSIONS

Our results demonstrate that a modified NIATx process improvement model can effectively implement improved rates of delivery of some types of HIV services in correctional environments.

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.

Optimization of human immunodeficiency virus treatment during incarceration: viral suppression at the prison gate

IMPORTANCE

Human immunodeficiency virus (HIV) management in correctional settings is logistically feasible, but HIV-related outcomes before release have not been recently systematically examined.

OBJECTIVE

To evaluate HIV treatment outcomes throughout incarceration, including jail and prison.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of longitudinally linked demographic, pharmacy, and laboratory data on 882 prisoners within the Connecticut Department of Correction (2005-2012) with confirmed HIV infection, who were continually incarcerated 90 days or more, had at least 2 HIV-1 RNA and CD4 lymphocyte measurements, and were prescribed antiretroviral therapy.

MAIN OUTCOMES AND MEASURES

Three electronic databases (correctional, laboratory, and pharmacy) were integrated to assess HIV viral suppression (HIV-1 RNA levels, <400 copies/mL) on intake and release. Secondary outcomes were mean change in log-transformed HIV-1 RNA levels and mean change in CD4 lymphocyte count during incarceration. Demographic characteristics, prescribed pharmacotherapies, receipt of directly observed therapy, and duration of incarceration were analyzed as possible explanatory variables for HIV viral suppression in logistic regression models.

RESULTS

Among 882 HIV-infected prisoners with 1185 incarceration periods, mean HIV-1 RNA level decreased by 1.1 log10 and CD4 lymphocyte count increased by 98 cells/µL over time, with a higher proportion achieving viral suppression by release compared with entry (70.0% vs 29.8%; P < .001); 36.9% of antiretroviral therapy (ART) regimens were changed during incarceration. After adjusting for baseline HIV-1 RNA level, prerelease viral suppression correlated with female sex (adjusted odds ratio, 1.81; 95% CI, 1.26-2.59) and psychiatric disorder severity below the sample median (adjusted odds ratio, 1.50; 95% CI, 1.12-1.99), but not race/ethnicity, incarceration duration, ART regimen or dosing strategy, or directly observed therapy.

CONCLUSIONS AND RELEVANCE

Though just one-third of HIV-infected prisoners receiving ART entered correctional facilities with viral suppression, HIV treatment was optimized during incarceration, resulting in the majority achieving viral suppression by release. Treatment for HIV within prison is facilitated by a highly structured environment and, when combined with simple well-tolerated ART regimens, can result in viral suppression during incarceration. In the absence of important and effective community-based resources, incarceration can be an opportunity of last resort to initiate continuous ART for individual health and, following the "treatment as prevention" paradigm, potentially reduce the likelihood of HIV transmission to others after release if continuity of HIV care is sustained.

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.

Disease progression and characteristics of HIV-infected women with and without a history of criminal justice involvement

Early HIV diagnosis followed by prompt linkage to and consistent retention in HIV-related care is important to decrease morbidity and mortality. Progression to AIDS is of particular interest in HIV-positive women with a history of criminal justice-involvement due to their lack of access to care in the community and poor retention in HIV primary care. In this retrospective cohort study, we characterize the risk of developing AIDS among HIV-infected women with and without a history of criminal justice-involvement. Mean time to AIDS diagnosis was longer [123 ± 3.26 months] for women with no criminal justice-involvement when compared to women who were arrested or who went to prison. Women who were arrested (HR: 1.92, 95% CI: 1.43, 2.58) and women who went to prison (HR: 2.27, 95% CI: 1.52, 3.39) had an increased risk of developing AIDS when compared to women without criminal justice-involvement.

Gender differences in baseline health, needs at release, and predictors of care engagement among HIV-positive clients leaving jail

Women represent a significant and growing segment of jail detainees and persons living with HIV. This paper examines gender differences in health status, care and social service needs, and care engagement among jail releasees with HIV. Data are from 1,270 participants in the HRSA-funded Enhancing Linkages to HIV Primary Care and Social Services multisite demonstration project (EnhanceLink). Compared to men, more women reported homelessness, reduced adherence to prescribed ART, worse health, more severe substance use disorders, and more chronic health conditions. Men and women generally reported different needs post-release. As the number of expressed needs increased, women were more likely to drop out of care. Our findings suggest that effective and gender-specific strategies are required to identify needs, link services between jails and communities, and sustain retention of women with HIV in programs after release from criminal justice settings.

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.

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.

Urology on the inside: managing the needs of the incarcerated

Objective:

Despite a substantial body of literature on prisoner health and the management of specific conditions that affect incarcerated persons, there remains a paucity of data pertaining to the specific urological needs of prisoners. Additionally, no study has documented the impact of prison referrals on a department of urology.

Materials and methods:

A year-long prospective study was performed in a university hospital recording all contact made by detained persons with the department of urology.

Results:

A total of 77 clinical encounters were made by 47 detained patients from seven different institutions over 12 months. All patients were male. The most common reason for urological consultation was investigation of lower tract symptoms, but a total of 18 separate complaints were recorded, including acute trauma.

Conclusions:

The presence of several places of detention impacts significantly on a department’s workload. Management of persons detained under Home Office Licence in a general hospital poses several challenges, including confidentiality and security issues, privacy and patient concerns and prison personnel secondments. The transient nature of the prisoner population can pose difficulties for planned admissions and outpatient follow-up.

Frequent emergency department use among released prisoners with human immunodeficiency virus: characterization including a novel multimorbidity index

OBJECTIVES

The objective was to characterize the medical, social, and psychiatric correlates of frequent emergency department (ED) use among released prisoners with human immunodeficiency virus (HIV).

METHODS

Data on all ED visits by 151 released prisoners with HIV on antiretroviral therapy (ART) were prospectively collected for 12 months. Correlates of frequent ED use, defined as having two or more ED visits postrelease, were described using univariate and multivariate models and generated medical, psychiatric, and social multimorbidity indices.

RESULTS

Forty-four (29%) of the 151 participants were defined as frequent ED users, accounting for 81% of the 227 ED visits. Frequent ED users were more likely than infrequent or nonusers to be female; have chronic medical illnesses that included seizures, asthma, and migraines; and have worse physical health-related quality of life (HRQoL). In multivariate Poisson regression models, frequent ED use was associated with lower physical HRQoL (odds ratio [OR] = 0.95, p = 0.02) and having not had prerelease discharge planning (OR = 3.16, p = 0.04). Frequent ED use was positively correlated with increasing psychiatric multimorbidity index values.

CONCLUSIONS

Among released prisoners with HIV, frequent ED use is driven primarily by extensive comorbid medical and psychiatric illness. Frequent ED users were also less likely to have received prerelease discharge planning, suggesting missed opportunities for seamless linkages to care.

Partner violence and health among HIV-infected jail detainees

PURPOSE

Little is known about the association of intimate partner violence (IPV) with specific HIV-treatment outcomes, especially among criminal justice (CJ) populations who are disproportionately affected by IPV, HIV, mental, and substance use disorders (SUDs) and are at high risk of poor post-release continuity of care.

DESIGN/METHODOLOGY/APPROACH

Mixed methods were used to describe the prevalence, severity, and correlates of lifetime IPV exposure among HIV-infected jail detainees enrolled in a novel jail-release demonstration project in Connecticut. Additionally, the effect of IPV on HIV treatment outcomes and longitudinal healthcare utilization was examined.

FINDINGS

Structured baseline surveys defined 49 percent of 84 participants as having significant IPV exposure, which was associated with female gender, longer duration since HIV diagnosis, suicidal ideation, having higher alcohol use severity, having experienced other forms of childhood and adulthood abuse, and homo/bisexual orientation. IPV was not directly correlated with HIV healthcare utilization or treatment outcomes. In-depth qualitative interviews with 20 surveyed participants, however, confirmed that IPV was associated with disengagement from HIV care especially in the context of overlapping vulnerabilities, including transitioning from CJ to community settings, having untreated mental disorders, and actively using drugs or alcohol at the time of incarceration.

ORIGINALITY/VALUE

Post-release interventions for HIV-infected CJ populations should minimally integrate HIV secondary prevention with violence reduction and treatment for SUDs.