Gender Differences in HIV Care among Criminal Justice-Involved Persons: Baseline Data from the CARE+ Corrections Study

Experiences of Justice-Involved People Transitioning to HIV Care in the Community After Prison Release in Lusaka, Zambia: A Qualitative Study

INTRODUCTION

In sub-Saharan Africa (SSA), incarcerated people experience a higher HIV burden than the general population. While access to HIV care and treatment for incarcerated people living with HIV (PLHIV) in SSA has improved in some cases, little is known about their transition to and post-release experience with care in the community. To address this gap, we conducted a qualitative study to describe factors that may influence post-release HIV care continuity in Zambia.

METHODS

In March-December 2018, we recruited study participants from a larger prospective cohort study following incarcerated and newly released PLHIV at 5 correctional facilities in 2 provinces in Zambia. We interviewed 50 participants immediately before release; 27 (54%) participated in a second interview approximately 6 months post-release. Demographic and psychosocial data were collected through a structured survey.

RESULTS

The pre-release setting was strongly influenced by the highly structured prison environment and assumptions about life post-release. Participants reported accessible HIV services, a destigmatizing environment, and strong informal social supports built through comradery among people facing the same trying detention conditions. Contrary to their pre-release expectations, during the immediate post-release period, participants struggled to negotiate the health system while dealing with unexpected stressors. Long-term engagement in HIV care was possible for participants with strong family support and a high level of self-efficacy.

CONCLUSION

Our study highlights that recently released PLHIV in Zambia face acute challenges in meeting their basic subsistence needs, as well as social isolation, which can derail linkage to and retention in community HIV care. Releasees are unprepared to face these challenges due to a lack of community support services. To improve HIV care continuity in this population, new transitional care models are needed that develop client self-efficacy, facilitate health system navigation, and pragmatically address structural and psychosocial barriers like poverty, gender inequality, and substance use.

Women Living with HIV in Italian Prison Settings: Results from the Gender-Specific ROSE Network

BACKGROUND

Incarcerated women are a minority in the Italian prison population. The lack of prevention and awareness of HIV infection and the lack of access to treatment make the treatment path difficult.

METHODS

we conducted a multi-center study including incarcerated women living with HIV (WLWH).

RESULTS

The study included 85 WLWH with a mean age of 41.7 ± 8.7 years, and 58.8% (50/85) of them were Italian. Principally, HIV transmission was related to sexual intercourse, 47% of all patients were PWIDs, and 62.5% of them were on opioid substitution therapy (OST). Overall, 56.4% of the included patients had a CD4+ cell count of >500 cells/mmc. Among the participants, 92.9% were on antiretroviral therapy, 87.3% had treatment before incarceration, and 83.5% were virologically suppressed. Among the 13 non-virally-suppressed patients, 53.8% were unaware of their serological status before incarceration and had started HAART but were still not virologically suppressed; 46.2% (6/13) had a lack of compliance or had suspended the treatment before incarceration and restarted it after admission. All patients with chronic hepatitis C underwent treatment with direct-acting antivirals and reached a sustained virological response.

CONCLUSIONS

the detention of these women could represent an occasion for the patients' healthcare provision and use, and the creation of a gender-specific network can be an effective strategy for reaching this population.

Interventions Designed to Improve HIV Continuum of Care Outcomes for Persons with HIV in Contact with the Carceral System in the USA

PURPOSE OF REVIEW

To describe existing evidence and identify future directions for intervention research related to improving HIV care outcomes for persons with HIV involved in the carceral system in the USA, a population with high unmet HIV care needs.

RECENT FINDINGS

Few recent intervention studies focus on improving HIV care outcomes for this population. Successful strategies to improve care outcomes include patient navigation, substance use treatment, and incentivizing HIV care outcomes. Technology-supported interventions are underutilized in this population. Notable gaps in the existing literature include intervention research addressing HIV care needs for cisgender and transgender women and those under carceral supervision in the community. Future research should address existing gaps in the literature and respond to emergent needs including understanding how the changing HIV care delivery environment resulting from the COVID-19 pandemic and the approval of new injectable ART formulation shape HIV care outcomes in this population.

A Systematic Review up to 2018 of HIV and Associated Factors Among Criminal Justice-Involved (CJI) Black Sexual and Gender Minority Populations in the United States (US)

Black men who have sex with men (BMSM) and Black transgender women (BTW) are impacted by dual epidemics of HIV and incarceration. We advanced understanding of the relationship between criminal justice involvement, HIV, and other key HIV-related characteristics among these key populations in the US. We conducted a systematic review up to 2018 and 47 articles met the inclusion criteria of scientific publications involving quantitative findings of US-based HIV-related studies focused on criminal justice-involved (CJI) BMSM and BTW. Overall, there was a dearth of studies focused specifically on BTW. Criminal justice involvement was relatively high among BMSM and BTW and more pronounced among BTW. The current evidence favors no association between incarceration and HIV acquisition among BMSM with limited information about BTW. Criminal justice involvement was associated with a greater likelihood of STIs among BMSM with mixed results for sexual risk behaviors. Criminal justice settings served as an important venue for HIV testing/diagnosis for both BMSM and BTW. However, these settings were not conducive for subsequent stages of the HIV care continuum. Studies pointed to an independent association between criminal justice involvement, substance use, housing instability, and greater odds of incarceration among BMSM who were unemployed and had limited education. Future incarceration was associated with high levels of perceived racism among BMSM. Among young BMSM, high network criminal justice prevalence was also associated with sexual risk behaviors, poorer mental health outcomes, drug use, and housing instability. CJI BMSM and BTW represent a critical subpopulation to end the HIV epidemic in the US.

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

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

Dating Behaviors of Older Black Women

The complexities of older Black women's dating behaviors and preferences were uncovered in this phenomenology study with 14 older Black single and/or widowed women. The participants recognized that, as older Black women, their sexuality did not simply pertain to whether they were dating, it encompassed various factors that influenced their decisions about whether to date. These factors were categorized into three major themes: pursuing intimacy, dating preferences, and barriers to dating. The adoption of the Black feminist standpoint theory helped to understand their dating experiences in the context of the participants' Blackness. The women's subjective experiences with dating and the challenges that they face as older Black women demonstrated the complexities and intersections of race, gender, class, and age within this contextual analysis. These findings hold important practical implications for understanding the influence of the older women's Blackness on their experiences and how it shapes their dating behavior. These understandings will help social workers and gerontologists better appreciate and validate older Black women's self-determination in their dating choices and the need to support them.

HIV care outcomes among transgender persons with HIV infection in the United States, 2006-2021

OBJECTIVES

HIV prevalence is an estimated 14% among transgender women (TW) and 3% among transgender men (TM). HIV care is vital for viral suppression but is hindered by transphobia and HIV stigma. We assessed HIV care outcomes among transgender persons (TG) with HIV in the United States.

DESIGN

Systematic review and meta-analysis of peer-reviewed journal articles.

METHODS

We searched multiple electronic databases and Centers for Disease Control and Prevention's HIV Prevention Research Synthesis database for 2006-September 2020. Eligible reports were US-based studies that included TG and reported HIV care outcomes. Random-effects models were used to calculate HIV care outcome rates. The protocol is registered with PROSPERO (CRD42018079564).

RESULTS

Few studies reported outcomes for TM; therefore, only TW meta-analysis results are reported. Fifty studies were identified having low-to-medium risk-of-bias scores. Among TW with HIV, 82% had ever received HIV care; 72% were receiving care, and 83% of those were retained in HIV care. Sixty-two percent were currently virally suppressed. Among those receiving HIV care or antiretroviral therapy (ART), 67% were virally suppressed at last test. Sixty-five percent were linked to HIV care 3 months or less after diagnosis. Seventy-one percent had ever been prescribed ART. Approximately 66% were taking ART, and 66% were ART-adherent. Only 56% were currently adherent the previous year.

CONCLUSIONS

HIV care outcomes for TW were not ideal, and research gaps exists for TM. High heterogeneity was observed; therefore, caution should be taken interpreting the findings. Integrating transgender-specific health needs are needed to improve outcomes of transgender persons across the HIV care continuum.

HIV Drug Resistance and Transmission Networks Among a Justice-Involved Population at the Time of Community Reentry in Washington, D.C

Justice-involved (JI) populations bear a disproportionate burden of HIV infection and are at risk of poor treatment outcomes. Drug resistance prevalence and emergence, and phylogenetic inference of transmission networks, understudied in vulnerable JI populations, can inform care and prevention interventions, particularly around the critical community reentry period. We analyzed banked blood specimens from CARE+ Corrections study participants in Washington, D.C. (DC) across three time points and conducted HIV drug resistance testing using next-generation sequencing (NGS) at 20% and 5% thresholds to identify prevalent and evolving resistance during community reentry. Phylogenetic analysis was used to identify molecular clusters within participants, and in an extended analysis between participants and publicly available DC sequences. HIV sequence data from 54 participants (99 specimens) were analyzed. The prevalence of transmitted drug resistance was 14% at both thresholds, and acquired drug resistance was 47% at 20%, and 57% at 5% NGS thresholds, respectively. The overall prevalence of drug resistance was 43% at 20%, and 52% at 5% NGS thresholds, respectively. Among 34 participants sampled longitudinally, 21%–35% accumulated 10–17 new resistance mutations during a mean 4.3 months. In phylogenetic analysis within the JI population, 11% were found in three molecular clusters. The extended phylogenetic analysis identified 46% of participants in 22 clusters, of which 21 also included publicly-available DC sequences, and one JI-only unique dyad. This is the first study to identify a high prevalence of HIV drug resistance and its accumulation in a JI population during community reentry and suggests phylogenetic integration of this population into the non-JI DC HIV community. These data support the need for new, effective, and timely interventions to improve HIV treatment during this vulnerable period, and for JI populations to be included in broader surveillance and prevention efforts.

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

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

Impact of Abstinence and of Reducing Illicit Drug Use Without Abstinence on Human Immunodeficiency Virus Viral Load

BACKGROUND

Substance use is common among people living with human immunodeficiency virus (PLWH) and a barrier to achieving viral suppression. Among PLWH who report illicit drug use, we evaluated associations between HIV viral load (VL) and reduced use of illicit opioids, methamphetamine/crystal, cocaine/crack, and marijuana, regardless of whether or not abstinence was achieved.

METHODS

This was a longitudinal cohort study of PLWH from 7 HIV clinics or 4 clinical studies. We used joint longitudinal and survival models to examine the impact of decreasing drug use and of abstinence for each drug on viral suppression. We repeated analyses using linear mixed models to examine associations between change in frequency of drug use and VL.

RESULTS

The number of PLWH who were using each drug at baseline ranged from n = 568 (illicit opioids) to n = 4272 (marijuana). Abstinence was associated with higher odds of viral suppression (odds ratio [OR], 1.4-2.2) and lower relative VL (ranging from 21% to 42% by drug) for all 4 drug categories. Reducing frequency of illicit opioid or methamphetamine/crystal use without abstinence was associated with VL suppression (OR, 2.2, 1.6, respectively). Reducing frequency of illicit opioid or methamphetamine/crystal use without abstinence was associated with lower relative VL (47%, 38%, respectively).

CONCLUSIONS

Abstinence was associated with viral suppression. In addition, reducing use of illicit opioids or methamphetamine/crystal, even without abstinence, was also associated with viral suppression. Our findings highlight the impact of reducing substance use, even when abstinence is not achieved, and the potential benefits of medications, behavioral interventions, and harm-reduction interventions.

Non-HIV chronic disease burden among transgender populations globally: A systematic review and narrative synthesis

Chronic disease is a growing concern for research, policy and clinical care. While the global burden of HIV for transgender populations has been comprehensively covered in recent systematic reviews, the same is not true for the burden of other chronic disease. The objective of this study was to review the literature on non-HIV chronic disease burden for transgender populations worldwide. A systematic review was conducted of Medline, Embase, CINAHL, PsycINFO and LGBT Life bibliographic databases for peer-reviewed scientific studies with non-HIV chronic disease prevalence data for transgender populations published any date up to February 15, 2019 without restriction on country or study design. A total of 93 studies and 665 datapoints were included in this review, comprising 48 distinct chronic disease outcomes in seven groups (cancer, cerebro/cardiovascular conditions, chronic liver and kidney disease, mental health and substance use conditions, metabolic and endocrine disorders, musculoskeletal and brain disorders, respiratory conditions, and unspecified and other conditions). The empirical literature on chronic disease among global transgender populations focuses on mental health morbidity, demonstrating an evidence gap on chronic physical health morbidity, particularly beyond that of sexual health. This review identified important gaps including in age-related conditions, inflammation-related disease and studies designed explicitly to investigate chronic disease burden among transgender populations. There is a need for high quality evidence in this area, including longitudinal population-based studies with appropriate comparison groups, and consistent measurement of both transgender status and chronic conditions.

Contemporary transgender health experience and health situation in prisons: A scoping review of extant published literature (2000-2019)

Background: Many jurisdictions globally have no specific prison policy to guide prison management and prison staff in relation to the special needs of lesbian, gay, bisexual and transgender (LGBT) prisoners despite the United Nations for the Treatment of Prisoners Standard Minimum Rules and the updated 2017 Yogyakarta Principles on the Application of International Human Rights Law in relation to Sexual Orientation and Gender Identity. Within LGBT prison groups, transgender people represent a key special population with distinct needs and rights, with incarceration rates greater than that of the general population, and who experience unique vulnerabilities in prisons. Aims/Method: A scoping review was conducted of extant information on the transgender prison situation, their unique health needs and outcomes in contemporary prison settings. Fifty-nine publications were charted and thematically analyzed. Results: Five key themes emerged: Transgender definition and terminology used in prison publications; Prison housing and classification systems; Conduct of correctional staff toward incarcerated transgender people; Gender affirmation, health experiences and situational health risks of incarcerated transgender people; and Transgender access to gender-related healthcare in prison. Conclusions: The review highlights the need for practical prison based measures in the form of increased advocacy, awareness raising, desensitization of high level prison management, prison staff and prison healthcare providers, and clinical and cultural competence institutional training on transgender patient care. The review underscores the need to uphold the existing international mandates to take measures to protect incarcerated transgender people from violence and stigmatization without restricting rights, and provide adequate gender sensitive and gender affirming healthcare, including hormone therapy and gender reassignment.

Recent Incarceration as a Primary Barrier to Virologic Suppression Among Women Living with HIV: Results from a Longitudinal Community-Based Cohort in a Canadian Setting

Women living with HIV (WLWH) are disproportionately represented among incarcerated populations yet there is a paucity of research on how incarceration shapes HIV treatment outcomes for women. Data is drawn from SHAWNA (Sexual health and HIV/AIDS: Women's Longitudinal Needs Assessment), a longitudinal community-based open research cohort with cis and trans WLWH in Metro Vancouver, Canada (2010-2017). Multivariable logistic regression using generalized estimating equations (GEE) longitudinally modeled the effect of incarceration on virologic suppression (HIV plasma VL < 50 copies/mL), adjusting for potential confounders. Amongst 292 WLWH, the majority (74%) had been incarcerated in their lifetime and 17% were incarcerated over the study period. Exposure to recent incarceration was independently correlated with reduced odds of virologic suppression (AOR: 0.42, 95% CI 0.22-0.80). This study suggests critical need for research and interventions to better address factors shaping ART adherence and retention in care for WLWH, both within correctional centres and following release from prison.

The Implementation of a Text Messaging Intervention to Improve HIV Continuum of Care Outcomes Among Persons Recently Released From Correctional Facilities: Randomized Controlled Trial

Background

Previously incarcerated individuals have suboptimal linkage and engagement in community HIV care. Mobile health (mHealth) interventions have been shown to be effective in addressing these gaps. In Washington, District of Columbia (DC), we conducted a randomized trial of an SMS text messaging–based mHealth intervention (CARE+ Corrections) to increase linkage to community HIV care and antiretroviral treatment adherence among HIV-infected persons involved in the criminal justice system.

Objective

This study aimed to describe the SMS text messaging–based intervention, participant use of the intervention, and barriers and facilitators of implementation.

Methods

From August 2013 to April 2015, HIV-positive incarcerated individuals were recruited within the DC Department of Corrections, and persons released in the past 6 months were recruited within the community via street-based recruitment, community partnerships, and referrals. Participants were followed for 6 months and received weekly or daily SMS text messages. Formative research resulted in the development of the content of the messages in 4 categories: HIV Appointment Reminders, Medication Adherence, Prevention Reminders, and Barriers to Care following release from jail. Participants could customize the timing, frequency, and message content throughout the study period.

Results

Of the 112 participants enrolled, 57 (50.9%) were randomized to the intervention group and 55 (49.1%) to the control group; 2 control participants did not complete the baseline visit, and were dropped from the study, leaving a total of 110 participants who contributed to the analyses. Study retention was similar across both study arms. Median age was 42 years (IQR 30-50), 86% (49/57) were black or African American, 58% (33/57) were male, 25% (14/57) were female, and 18% (10/57) were transgender. Median length of last incarceration was 4 months (IQR 1.7-9.0), and median lifetime number of times incarcerated was 6.5 (IQR 3.5-14.0). Most participants (32/54, 59%) had a baseline viral load of <200 copies/mL. Nearly all participants (52/57, 91%) chose to use a cell phone provided by the study. The most preferred Appointment Reminder message was Hey how you feeling? Don’t forget to give a call and make your appointment (19/57, 33%). The most preferred Medication Adherence message was Don’t forget your skittles! (31/57, 54%), and 63% (36/57) of participants chose to receive daily (vs weekly) messages from this category at baseline. The most preferred Prevention Reminder message was Stay strong. Stay clean (18/57, 32%). The most preferred Barriers to Care message was Holla at your case manager, they’re here to help (12/57, 22%). Minor message preference differences were observed among participants enrolled in the jail versus those from the community.

Conclusions

Participants’ ability to customize their SMS text message plan proved helpful. Further large-scale research on mHealth platforms is needed to assess its efficacy among HIV-infected persons with a history of incarceration.

Trial Registration

ClinicalTrials.gov NCT01721226; https://clinicaltrials.gov/ct2/show/NCT01721226

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

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

Violence and other social structural factors linked to incarceration for women living with HIV in Metro Vancouver: need for trauma-informed HIV care in prisons and post-Release

Despite women living with HIV (WLWH) being disproportionately criminalized and overrepresented within correctional facilities, there remains limited longitudinal research with WLWH examining factors that make WLWH vulnerable to incarceration. Data are drawn from SHAWNA (Sexual health and HIV/AIDS: Women's Longitudinal Needs Assessment), a community-based research cohort with cisgender and transgender WLWH in Metro Vancouver, Canada. Multivariable logistic regression using generalized estimating equations (GEE) and an exchangeable working correlation matrix was used to prospectively model correlates of recent incarceration exposure over a seven-year period. Amongst 289 WLWH, 76% had been incarcerated in their lifetime, and 17% had experienced recent incarceration. In multivariable GEE analysis, younger age (AOR: 0.92 per year older, 95% CI: 0.89-0.96), recent homelessness (AOR: 2.81, 95% CI: 1.46-5.41), recent gender-based (physical and/or sexual) violence (AOR: 2.26, 95% CI: 1.20-4.22) and recent opioid use (AOR: 1.83, 95% CI: 1.00-3.36), were significantly associated with recent incarceration. Lifetime exposure to gender-based violence by police (AOR: 1.97, CI: 0.97-4.02) was marginally associated with increased odds of recent incarceration. This research suggests a critical need for trauma-informed interventions for WLWH during and following incarceration. Interventions must be gender specific, include housing and substance use supports, and address the impact of gender-based violence.

Correlates of Durable Viral Suppression (DVS) Among Criminal Justice-involved (CJI) Black Men Living with HIV in Louisiana

Durable viral suppression (DVS) is needed to reduce HIV transmission risk and prevent new HIV infections. We examined changes in viral suppression and correlates of DVS among 97 criminal justice-involved (CJI) Black men living with HIV in Louisiana enrolled in a linkage, re-engagement, and retention in care intervention. Most participants (75%) were Black men who have sex with men. Forty-four percent (44%) were virally suppressed at baseline and only 20% had achieved DVS over a 12-month period. Multinomial logistic regression analyses showed that compared with DVS participants, those with no viral suppression (NVS) and some viral suppression (SVS) were more likely to have lived with HIV for a longer period of time and were less likely to be adherent at baseline. Medication adherence was critical for DVS among this sample of CJI Black men living with HIV who represent a high priority population for HIV care and treatment interventions.

Housing First: Unsuppressed Viral Load Among Women Living with HIV in San Francisco

While poverty is an established barrier to achieving success at each step of the HIV care continuum, less is known about specific aspects of poverty and how they overlap with behavior in exceptionally low-income individuals who live in well-resourced areas. We considered unsuppressed viral load over 3 years among women living with HIV in San Francisco who used homeless shelters, low-income hotels and free meal programs. One-hundred twenty study participants were followed; 60% had > 1 unsuppressed viral load and 19% were unsuppressed at every visit. Across six-month intervals, the odds of unsuppressed viral load were 11% higher for every 10 nights spent sleeping on the street [Adjusted Odds Ratio (AOR) 1.11, 95% CI 1.02-1.20]; 16% higher for every 10 nights spent sleeping in a shelter (AOR/10 nights 1.16, 95% CI 1.06-1.27); 4% higher for every 10 nights spent sleeping in a single-room occupancy hotel (AOR/10 nights 1.04, 95% CI 1.02-1.07); and over threefold higher among women who experienced any recent incarceration (AOR 3.56, 95% CI 1.84-6.86). Violence and recent use of outpatient health care did not significantly predict viral suppression in adjusted analysis. While strategies to promote retention in care are important for vulnerable persons living with HIV, they are insufficient to ensure sustained viral suppression in low-income women experiencing homelessness and incarceration. Results presented here in combination with prior research linking incarceration to homelessness among women indicate that tailored interventions, which not only consider but prioritize affordable housing, are critical to achieving sustained viral suppression in low-income women living with HIV.

History of Incarceration Among Women with HIV: Impact on Prognosis and Mortality

Objectives: To identify factors associated with incarceration among women and examine the relationship between incarceration and human immunodeficiency virus (HIV)-related outcomes. Materials and Methods: We analyzed longitudinal data from 3324 women (2372 with HIV and 952 uninfected) from 2007 to 2016 in the Women's Interagency HIV Study, a U.S. cohort of women with and without HIV. Lifetime history of incarceration before first study visit was used as the outcome and then as a predictor for HIV outcomes and mortality. Using multivariable models, we assessed associations between socio-demographic, behavioral, and clinical characteristics and incarceration, and between incarceration and HIV outcomes, including mortality. Results: Overall, 1256 (38%) of women reported ever being incarcerated. Women who had a history of drug use had a 44% greater prevalence of incarceration compared with those who did not use drugs. Sexual minority women and women who experienced physical and sexual abuse had a 47% and 28%, respectively, greater prevalence of incarceration than heterosexual women and those not abused. For the 862 women with HIV and a history of incarceration, having an incarceration history was independently associated with less viral suppression (adjusted prevalence ratios = 0.95; confidence intervals [CI]:0.90-1.00 p = 0.04) and higher likelihood of death (adjusted hazard ratios = 1.39; CI:1.04-1.86 p = 0.03). Conclusions: Incarceration is common in this cohort and may put women with HIV at increased odds of worse HIV outcomes and mortality than those without a history of incarceration. Addressing the intersecting epidemics of HIV, substance use, and incarceration by providing needed treatment and resources and avoiding criminalization may improve health outcomes in vulnerable women with HIV.

Use of an mHealth Intervention to Improve Engagement in HIV Community-Based Care Among Persons Recently Released from a Correctional Facility in Washington, DC: A Pilot Study

We examined the preliminary effectiveness of a computerized counseling session plus post-incarceration text messaging intervention (CARE + Corrections) to support ART adherence and linkage/engagement in community care among recently incarcerated persons with HIV in Washington, D.C. Recently incarcerated persons with HIV ≥ 18 years old were recruited from the D.C. jail or community outreach and randomized to CARE + Corrections or control arm. Participants completed assessments at baseline, 3-months and 6-months. Multivariable random effects modeling identified predictors of suppressed viral load (≤ 200 copies/mL) and engagement in HIV care at 6 months. Participants (N = 110) were aged 42 (IQR 30-49); 58% male, 24% female, 18% transgender, 85% Black, and lifetime incarceration was a median of 7 years (IQR 2-15). More controls had a regular healthcare provider at baseline. Although not statistically significant, intervention participants had increased odds of viral suppression versus controls at 6 months (AOR 2.04; 95% CI 0.62, 6.70). Those reporting high ART adherence at baseline had higher odds of viral suppression at follow-up (AOR 10.77; 95% CI 1.83, 63.31). HIV care engagement was similar between the two groups, although both groups reported increased engagement at 6 months versus baseline. We observed a positive but non-significant association of viral suppression in the CARE + Corrections group, and care engagement increased in both groups after 6 months. Further attention to increasing viral suppression among CJ-involved persons with HIV upon community reentry is warranted.

Women, incarceration and HIV: a systematic review of HIV treatment access, continuity of care and health outcomes across incarceration trajectories

OBJECTIVE

The aim of this study was to systematically review the literature on gendered implications of incarceration for HIV outcomes and engagement in care for women living with HIV (WLWH).

DESIGN

We systematically searched seven bibliographic databases, for peer-reviewed English-language studies, published between 2007 and 2017 reporting on incarceration, women (transgender inclusive) and HIV.

METHODS

Articles were included for evaluation if they reported outcomes for at least one of three measures of interest: viral load, antiretroviral therapy (ART) adherence or engagement in care among WLWH along incarceration trajectories.

RESULTS

Out of 1119 studies, 24 (2%) met the inclusion criteria. Of these 24 studies, the majority (n = 23) were conducted in the USA, 19 included samples of women and men and seven studies were transgender inclusive. Our review did not reveal clear sex differences in HIV outcomes during periods of incarceration; however, studies reporting postincarceration outcomes demonstrated significant sex disparities in all three outcomes of interest. Following incarceration, women were less likely to be virally suppressed, less likely to achieve optimal ART adherence and less likely to be engaged in care.

CONCLUSION

Despite growing numbers of incarcerated WLWH globally, there is a substantial gap in research examining the impact of incarceration on HIV outcomes for WLWH. Significant sex disparities in HIV outcomes and engagement in care exist along incarceration trajectories for WLWH, especially postincarceration. For improved health outcomes, research is needed to examine the experiences of WLWH throughout incarceration trajectories to develop interventions tailored to the specific needs of WLWH both during and following incarceration.

Experiences of transgender prisoners and their knowledge, attitudes, and practices regarding sexual behaviors and HIV/STIs: A systematic review

Background: Despite transgender people being more visible in prison systems, research suggests they are at higher risk of experiencing sexual violence compared to other prisoners. Research also suggests that transgender prisoners experience harassment, and physical and sexual assault by fellow prisoners, and prison officers who lack transgender-specific health knowledge. There exist no systematic reviews on the experiences of transgender people in prisons. This review aims to fill this research gap. The following question developed in consultation with transgender, sexual health/HIV and corrective services stakeholders has guided the systematic review: What are transgender and gender-diverse prisoners' experiences in various prison settings and what are their knowledge, attitudes and practices regarding sexual behaviors and HIV/STIs? Methods: The review followed the PRISMA guidelines and searches were conducted in four databases for the period of January 2007 to August 2017. Studies were assessed against predetermined inclusion and exclusion criteria. Included studies were peer-reviewed, written in English with online full-text availability and reported data on transgender and gender-diverse prisoner experiences relevant to the research question. Results: Eleven studies (nine qualitative, one quantitative, one mixed-methods; nine in USA, two in Australia) met the criteria for review. Four studies were of high quality, six were of good/acceptable quality, and one study was of modest quality. Transgender and gender-diverse prisoners reported a range of challenges which included sexual assault, discrimination, stigma, harassment, and mistreatment. Information on their sexual health and HIV/STIs knowledge, attitudes, practices is in short supply. Also, their lack of access to gender-affirming, sexual health/STIs and mental health services is commonplace. Conclusions: The experiences of transgender prisoners as reported in this review are almost uniformly more difficult than other prisoners. Their "otherness" is used as a weapon against them by fellow prisoners through intimidation and violence (including sexual) and by prison officers through neglect and ignorance.

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

Background

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

Methods

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

Results

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

Conclusions

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

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.