Date Published: October 9, 2018
Publisher: Public Library of Science
Author(s): Kelsey B. Loeliger, Jaimie P. Meyer, Mayur M. Desai, Maria M. Ciarleglio, Colleen Gallagher, Frederick L. Altice, Alexander C. Tsai
Abstract: BackgroundSustained retention in HIV care (RIC) and viral suppression (VS) are central to US national HIV prevention strategies, but have not been comprehensively assessed in criminal justice (CJ) populations with known health disparities. The purpose of this study is to identify predictors of RIC and VS following release from prison or jail.Methods and findingsThis is a retrospective cohort study of all adult people living with HIV (PLWH) incarcerated in Connecticut, US, during the period January 1, 2007, to December 31, 2011, and observed through December 31, 2014 (n = 1,094). Most cohort participants were unmarried (83.7%) men (77.0%) who were black or Hispanic (78.1%) and acquired HIV from injection drug use (72.6%). Prison-based pharmacy and custody databases were linked with community HIV surveillance monitoring and case management databases. Post-release RIC declined steadily over 3 years of follow-up (67.2% retained for year 1, 51.3% retained for years 1–2, and 42.5% retained for years 1–3). Compared with individuals who were not re-incarcerated, individuals who were re-incarcerated were more likely to meet RIC criteria (48% versus 34%; p < 0.001) but less likely to have VS (72% versus 81%; p = 0.048). Using multivariable logistic regression models (individual-level analysis for 1,001 individuals after excluding 93 deaths), both sustained RIC and VS at 3 years post-release were independently associated with older age (RIC: adjusted odds ratio [AOR] = 1.61, 95% CI = 1.22–2.12; VS: AOR = 1.37, 95% CI = 1.06–1.78), having health insurance (RIC: AOR = 2.15, 95% CI = 1.60–2.89; VS: AOR = 2.01, 95% CI = 1.53–2.64), and receiving an increased number of transitional case management visits. The same factors were significant when we assessed RIC and VS outcomes in each 6-month period using generalized estimating equations (for 1,094 individuals contributing 6,227 6-month periods prior to death or censoring). Additionally, receipt of antiretroviral therapy during incarceration (RIC: AOR = 1.33, 95% CI 1.07–1.65; VS: AOR = 1.91, 95% CI = 1.56–2.34), early linkage to care post-release (RIC: AOR = 2.64, 95% CI = 2.03–3.43; VS: AOR = 1.79; 95% CI = 1.45–2.21), and absolute time and proportion of follow-up time spent re-incarcerated were highly correlated with better treatment outcomes. Limited data were available on changes over time in injection drug use or other substance use disorders, psychiatric disorders, or housing status.ConclusionsIn a large cohort of CJ-involved PLWH with a 3-year post-release evaluation, RIC diminished significantly over time, but was associated with HIV care during incarceration, health insurance, case management services, and early linkage to care post-release. While re-incarceration and conditional release provide opportunities to engage in care, reducing recidivism and supporting community-based RIC efforts are key to improving longitudinal treatment outcomes among CJ-involved PLWH.
Partial Text: Along the HIV care continuum, retention in HIV care (RIC) is necessary for providing antiretroviral therapy (ART) and achieving viral suppression (VS), which reduces individual morbidity, mortality, and forward transmission [1–4]. Most incident HIV infections in the US are acquired from people living with HIV (PLWH) who are either undiagnosed or diagnosed but not retained in HIV care [5–7]. Poor RIC is associated with minority race/ethnicity, younger age, substance use disorders, and incarceration [8–12], although few studies have assessed longitudinal RIC beyond 6- or 12-month follow-up periods [13–16].
To our knowledge, this is one of the longest assessments of RIC and VS in a large cohort of individuals with HIV released from prison or jail. Despite HIV being a chronic condition that requires lifelong treatment, prior longitudinal RIC studies in the general population have not accounted for the complex impact of incarceration and the unique vulnerabilities it represents for many PLWH [8,11,14–16]. By comprehensively linking multiple CJ and community-based data sources, we were able to follow all CJ-involved PLWH statewide, including those re-incarcerated. We identified major correlates of optimal HIV treatment outcomes and found that the impact of re-incarceration is complex and dependent on time spent in facilities and conditions of release. These findings offer new insights into potential strategies to improve RIC and VS in CJ-involved PLWH.