Early identification of HIV: empirical support for jail-based screening

Reimbursing incarcerated individuals for participation in research: A scoping review

BACKGROUND

Little is known about global practices regarding the provision of reimbursement for the participation of people who are incarcerated in research. To determine current practices related to the reimbursement of incarcerated populations for research, we aimed to describe international variations in practice across countries and carceral environments to help inform the development of more consistent and equitable practices.

METHODS

We conducted a scoping review by searching PubMed, Cochrane library, Medline, and Embase, and conducted a grey literature search for English- and French-language articles published until September 30, 2022. All studies evaluating any carceral-based research were included if recruitment of incarcerated participants occurred inside any non-juvenile carceral setting; we excluded studies if recruitment occurred exclusively following release. Where studies failed to indicate the presence or absence of reimbursement, we assumed none was provided.

RESULTS

A total of 4,328 unique articles were identified, 2,765 were eligible for full text review, and 426 were included. Of these, 295 (69%) did not offer reimbursement to incarcerated individuals. A minority (n = 13; 4%) included reasons explaining the absence of reimbursement, primarily government-level policies (n = 7). Among the 131 (31%) studies that provided reimbursement, the most common form was monetary compensation (n = 122; 93%); five studies (4%) offered possible reduced sentencing. Reimbursement ranged between $3-610 USD in total and 14 studies (11%) explained the reason behind the reimbursements, primarily researchers' discretion (n = 9).

CONCLUSIONS

The majority of research conducted to date in carceral settings globally has not reimbursed incarcerated participants. Increased transparency regarding reimbursement (or lack thereof) is needed as part of all carceral research and advocacy efforts are required to change policies prohibiting reimbursement of incarcerated individuals. Future work is needed to co-create international standards for the equitable reimbursement of incarcerated populations in research, incorporating the voices of people with lived and living experience of incarceration.

Factors associated with HIV testing and treatment among young Black MSM and trans women in three jail systems

Black men who have sex with men (BMSM) and transgender women (BTW) are disproportionately affected by incarceration and HIV. We assessed factors associated with HIV testing and viral suppression among 176 incarcerated BMSM and BTW in Chicago, IL; Los Angeles, CA; and Houston, TX. In multivariable logistic regression, having a sexual orientation of bisexual, heterosexual, or other vs. gay or same-gender loving was associated with higher odds of testing in custody (aOR 8.97; 95% CI 1.95 - 41.24). Binge drinking (aOR 0.19; 95% CI 0.04 - 0.92) and being unemployed prior to incarceration (aOR 0.03; 95% CI 0.00 - 0.23) were associated with lower odds of testing; participants in Los Angeles were also more likely to be tested than those in Chicago. Being housed in protective custody (aOR 3.12; 95% CI 1.09-9.59) and having a prescription for ART prior to incarceration (aOR 2.58; 95% CI 1.01-6.73) were associated with higher odds of viral suppression when adjusted for site and duration of incarceration, though the associations were not statistically significant in the full multivariable model. Future research should examine structural and process level factors that impact engagement in HIV testing and treatment among detained BMSM and BTW.

Prisons: ignore them at our peril

PURPOSE OF REVIEW

People with HIV and HCV are concentrated within criminal justice settings globally, primarily related to criminalization of drug use. This review examines updated prevention and treatment strategies for HIV and HCV within prison with a focus on people who inject drugs and the challenges associated with the provision of these services within prisons and other closed settings and transition to the community.

RECENT FINDINGS

The prevalence of HIV and HCV are several-fold higher in the criminal justice system than within the broader community particularly in regions with high prevalence of injecting drug use, such as Asia, Eastern Europe and North America and where drug use is criminalized. Strategies to optimize management for these infections include routine screening linked to treatment within these settings and medication-assisted treatments for opioid dependence and access to syringe services programs. We build upon the 2016 WHO Consolidated Guidelines through the lens of the key populations of prisoners. Linkage to treatment postrelease, has been universally dismal, but is improved when linked to medication-assisted therapies like methadone, buprenorphine and overdose management. In many prisons, particularly in low-income and middle-income settings, provision of even basic healthcare including mental healthcare and basic HIV prevention tools remain suboptimal.

SUMMARY

In order to address HIV and HCV prevention and treatment within criminal justice settings, substantial improvement in the delivery of basic healthcare is needed in many prisons worldwide together with effective screening, treatment and linkage of treatment and prevention services to medication-assisted therapies within prison and linkage to care after release.

HIV-positive in the darkness of a correctional facility: more vulnerable and less treated

In French Guiana, 4.5-5.0% of HIV-infected persons experienced an incarceration between 2007 and 2013. A cross-sectional survey was performed to describe the epidemiology and treatment outcomes of a population of HIV-infected inmates in French Guiana. The study population was patients released between 1/2007 and 12/2013, after >30 days of incarceration (n = 147). A secondary objective aimed to identify its main specificities, relative to both the general inmate population and the nonincarcerated HIV population. The socioeconomic situation of HIV-infected inmates was particularly precarious, relative to other detainees: 58.1% had never attended school (versus 5.5%, p < 0.01), 31.0% were homeless (versus 8.5%, p < 0.01), 63.9% were repeat offenders (versus 46.6%, p < 0.01), 33.3% were crack cocaine users (versus 9.8-12%, p < 0.01). The frequency of hypertension and chronic B hepatitis was also higher. Only 50.3% of inmates were on antiretroviral therapy (ART) versus 92.6% in the hospital HIV population (p < 0.001). Among untreated patients, 15.1% refused ART. Among those treated, 81.3% were virologically suppressed. Although comparisons were biased, HIV-positive inmates had more psychosocial vulnerabilities than the general inmate population. Despite ART availability and excellent treatment outcomes, undertreatment was a fact not completely explained by patient refusal. HIV-infected inmates should benefit from increased attention by health care and social workers.

Jail, an unappreciated medical home: Assessing the feasibility of a strengths-based case management intervention to improve the care retention of HIV-infected persons once released from jail

Background

Linkage to and retention in care for US persons living with HIV (PLWH) after release from jail usually declines. We know of no rigorously evaluated behavioral interventions that can improve this. We hypothesized that a strengths-based case management intervention that we developed for PLWH leaving jail would increase linkage/retention in care (indicated by receipt of laboratory draws) and a suppressed HIV viral load (VL) in the year following release.

Methods and findings

We conducted a quasi-experimental feasibility study of our intervention for PLWH jailed in Atlanta. We recruited 113 PLWH in jail starting in 2014. “SUCCESS” (Sustained, Unbroken Connection to Care, Entry Services, and Suppression) began in jail and continued post-release. Subjects who started the intervention but subsequently began long-term incarcerations were excluded from further analysis. Persons who were retained in the intervention group were compared to contemporaneously incarcerated PLWH who did not receive the intervention. Identities were submitted to an enhanced HIV/AIDS reporting system (eHARS) at the state health department to capture all laboratories drawn. Both community engagement and care upon jail return were assessed equally. For 44 intervention participants released to Atlanta, 50% of care occurred on subsequent jail stays, as documented with EventFlow software. Forty-five receiving usual services only were recruited for comparison. By examining records of jail reentries, half of participants and 60% of controls recidivated (range: 1–8 returns). All but 6 participants in the intervention and 9 subjects in the comparison arm had ≥1 laboratory recorded in eHARS post-release. Among the intervention group, 52% were retained in care (i.e., had two laboratory studies, > = 3 months apart), versus 40% among the comparison group (OR = 1.60, 95% CI (0.71, 3.81)). Both arms showed improved viral load suppression.

Conclusions

There was a trend towards increased retention for PLWH released from jail after SUCCESS, compared to usual services. Measuring linkage at all venues, including jail-based clinics, fully captured engagement for this frequently recidivating population.

Trial registration

ClinicalTrials.gov NCT02185742

Acceptability of HIV Testing Among Jail Inmates When Combined With a Blood Test for Tuberculosis

Incarcerated individuals are at high risk of HIV and tuberculosis (TB), though combined screening in the criminal justice system is limited. Newer blood tests for TB provide a unique opportunity to combine HIV and TB testing in corrections. Entering jail inmates were offered routine opt-out HIV testing along with TB screening, both via blood draw. Of the 529 individuals enrolled, 524 (99%) agreed to HIV testing. Testing identified 13 (2.5%) previously diagnosed HIV infections and one new positive. One quarter (138, 26%) of participants had never been tested for HIV and were more likely to be young, Hispanic, born outside of the United States, and incarcerated for the first time. Combined HIV/TB testing had high acceptability among individuals entering jail.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Infectious Diseases and the Criminal Justice System

The United States leads the world in incarceration, which disproportionately affects disadvantaged individuals, including those who are mentally ill, poor, homeless and racial minorities. Incarceration is disruptive to families and communities and contributes to health disparities in sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). The objective of this grand rounds is to review (1) the epidemiology of incarceration in the United States, (2) the social factors which contribute to high rates of STIs in incarcerated individuals and (3) the HIV care cascade in incarcerated and recently released individuals. Routine screening and treatment for STIs and HIV in the criminal justice system can identify many new infections and has the potential to both improve individual outcomes and reduce transmission to others. Increased collaboration between the department of health and department of corrections, as well as partnerships between academic institutions and the criminal justice system, have the potential to improve outcomes in this vulnerable population.

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.

Establishing an HIV Screening Program Led by Staff Nurses in a County Jail

CONTEXT

Human immunodeficiency virus (HIV) testing in jails provides an opportunity to reach individuals outside the scope of traditional screening programs. The rapid turnover of jail populations has, in the past, been a formidable barrier to offering routine access to testing.

OBJECTIVE

To establish an opt-out, rapid HIV testing program, led by nurses on the jail staff, that would provide undiagnosed yet infected detainees opportunities to learn their status regardless of their hour of entry and duration of stay.

DESIGN

Jail nurses offered rapid, opt-out HIV testing.

SETTING

Fulton County Jail in Georgia, United States.

PARTICIPANTS

A total of 30 316 persons booked to Fulton County Jail.

INTERVENTION

In late 2010, we performed a preliminary evaluation of HIV seroprevalence. Starting January 1, 2011, HIV testing via rapid oral mucosal swab was offered to entrants. In March 2013, finger stick was substituted. Detainees identified as positives were assisted with linkage to care.

MAIN OUTCOME MEASURES

To estimate an upper limit of overall HIV prevalence among entrants, we determined seroprevalence by age and gender group. To measure program performance, we checked offer and acceptance rates for tests and rate of linkage to care among previously known and newly identified HIV+ detainees.

RESULTS

The initial seroprevalence of HIV in Fulton County Jail was at least 2.18%. Between March 2013 and February 2014, 89 new confirmed positives were identified through testing. During these 12 months, 20 947 bookings were followed by an offer of HIV testing (69.10% offer rate), and 17 035 persons accepted (81.32% acceptance rate). A total of 458 previously and newly identified persons were linked to HIV care. Linkage was significantly higher among those aged 40 years and older (P < .05).

CONCLUSIONS

A nurse-led, rapid HIV testing model successfully identified new HIV diagnoses. The testing program substantially decreased the number of persons who are HIV-infected but unaware of their status and promoted linkage to care.

Assessment of HIV Knowledge in Correctional Facility Health Care Workers: A Pilot Study of an Educational Intervention

HIV rates are disproportionately higher in the incarcerated compared to the general population. Unfortunately, HIV sero-positive inmates report perceived discrimination and missed antiretroviral doses. Correctional facility nursing competency in HIV management may mitigate these concerns. Using validated knowledge instruments, the authors measured baseline HIV knowledge in correctional facility nurses from 3 correctional facilities in Alberta, Canada, and quantified changes after a targeted educational workshop. Basic HIV knowledge increased significantly, whereas perceived need for further HIV education significantly decreased postintervention. This study demonstrates that correctional facility nurses may not receive ideal HIV education during employment and that targeted HIV workshops can significantly increase knowledge and confidence when caring for affected individuals.

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

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

Evidence-based interventions to enhance assessment, treatment, and adherence in the chronic Hepatitis C care continuum

BACKGROUND

With the explosion of newly available direct acting antiviral (DAA) Hepatitis C virus (HCV) treatments that demonstrate 95% sustained virologic response (SVR) rates, evidence-based strategies are urgently needed to achieve real-world effectiveness in challenging patient populations. While HIV is incurable, lessons from over 30 years of experience overcoming obstacles to the HIV treatment cascade could be applied to the HCV context.

METHODS

Using Institute of Medicine guidelines, we conducted a systematic review of published interventions from PubMed, Medline, GoogleScholar, EmBASE, and PsychInfo bibliographic databases and citation indices. Abstracts were first screened by three independent reviewers and studies were included if they involved original research, described a specific intervention, were published in English in a peer-reviewed journal between 2001 and 2014, and had full text available.

RESULTS

Evidence-based interventions to enhance HCV assessment, treatment, and adherence generally fell into one of 4 categories, including those involving: (1) diagnosis or case-finding; (2) linkage to HCV care; (3) pre-therapeutic evaluation or treatment initiation; or (4) treatment adherence. While most available eligible studies described interventions using non-contemporary interferon-based HCV treatments, future research will need to address how these interventions apply to the context of well-tolerated, simple, oral treatment regimens. In some cases, we explored how HIV-specific interventions might be modified to fit the HCV spectrum of care engagement.

CONCLUSIONS

Evidence-based interventions should be strategically incorporated into HCV treatment implementation efforts to most effectively deliver treatment and maximize treatment outcomes.

The HIV Care Cascade Before, During, and After Incarceration: A Systematic Review and Data Synthesis

We conducted a systematic literature review of the data on HIV testing, engagement in care, and treatment in incarcerated persons, and estimated the care cascade in this group. We identified 2706 titles in MEDLINE, EBSCO, and Cochrane Library databases for studies indexed to January 13, 2015, and included 92 for analysis. We summarized HIV testing results by type (blinded, opt-out, voluntary); reviewed studies on HIV care engagement, treatment, and virological suppression; and synthesized these results into an HIV care cascade before, during, and after incarceration. The HIV care cascade following diagnosis increased during incarceration and declined substantially after release, often to levels lower than before incarceration. Incarceration provides an opportunity to address HIV care in hard-to-reach individuals, though new interventions are needed to improve postrelease care continuity.

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.

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.

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.

The feasibility of implementing the HIV seek, test, and treat strategy in jails

To successfully implement the Seek, Test, and Treat (STT) strategy to curb the HIV epidemic, the criminal justice system must be a key partner. Increasing HIV testing and treatment among incarcerated persons has the potential to decrease HIV transmission in the broader community, but whether it is feasible to consider the implementation of the STT within jail facilities is not known. We conducted a retrospective review of Rhode Island Department of Corrections (RIDOC) medical records to assess whether persons newly diagnosed in the jail were able to start ART and be linked to community HIV care after release. From 2001 to 2007, 64 RIDOC detainees were newly diagnosed with HIV. During their index incarcerations, 64% were informed of positive confirmatory HIV test results, 50% completed baseline evaluations, and 9% began ART. Linkage to community care was confirmed for 58% of subjects. Subjects incarcerated for >14 days were significantly more likely to receive HIV test results and complete baseline evaluation (p<0.001). A similar association was not observed for ART initiation until incarceration length reached 60 days (p<0.001). There was no association between incarceration length and linkage to care. This comprehensive analysis demonstrates that length of incarceration impacts HIV test result delivery, baseline evaluation, and ART initiation in the RIDOC. Jails are an important venue to "Seek" and "Test"; however, completing the "Treat" part of the STT strategy is hindered by the transient nature of this criminal justice population and may require new strategies to improve linkage to care.

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

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

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.

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.

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.

Routine HIV screening during intake medical evaluation at a County Jail - Fulton County, Georgia, 2011-2012

Fulton County Jail (FCJ) in Atlanta, Georgia, is one of the 50 largest jails in the nation, with an average daily census of 2,269 detainees. During January 1, 2011-March 15, 2012, FCJ implemented a demonstration project to integrate routine rapid human immunodeficiency virus (HIV) screening into the medical intake process. This report summarizes the results. Nearly 59% of persons booked (22,920 of 39,073) received an intake medical evaluation, and voluntary oral fluid HIV rapid screening was offered, except to those who disclosed a previous HIV diagnosis (473 [2.1%]) or were not able to provide consent. An HIV test was offered on 18,869 visits, and 12,141 HIV tests were conducted. All persons with a reactive result (120 [1.0%]) underwent confirmatory HIV testing unless they subsequently disclosed a previous HIV diagnosis. This project identified 52 persons with newly diagnosed HIV infection; 48 by rapid testing (0.4% of those tested) during the study period. All received medical care in the facility and referral for community services on release. Without this HIV screening project, these persons likely would have been diagnosed later in the course of their infection, resulting in delayed access to care and treatment, and possible transmission of HIV to their partners. Linkage to community services is critical, and coordination with the public health system and community-based organizations are essential to ensure access to HIV care and retention in treatment for persons with HIV released from jail.

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.

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.