In this 4-year study of HIV-infected inmates released from the nation's largest state prison system, we found that only 5% of released inmates filled a prescription for ART medications soon enough (ie, within 10 days after release) to avoid treatment interruption. Furthermore, only 18% of inmates filled a prescription for ART medications within 30 days of release, and 30% did so within 60 days. While other studies have documented loss of both immune function and viral suppression among recidivist populations,5,7
to our knowledge this is the first study to assess continuity of HIV pharmacotherapy among released inmates. In all of the subgroups we examined, at least 90% of the former inmates experienced a treatment interruption; more than 70% had an interruption that lasted at least 30 days, and more than 60% had an interruption that lasted at least 60 days.
The Strategies for Management of Antiretroviral Therapy (SMART) study demonstrated that even a small number of treatment interruptions leads to poorer clinical outcomes, independent of baseline CD4 cell count.22
Previous studies suggest that a large proportion of HIV-infected inmates discontinue their ART regimen, while often resuming high-risk behaviors such as injection drug use and prostitution.11,14,23
In combination, these behaviors may result in poor health outcomes for former inmates and the creation of reservoirs of drug-resistant HIV in the general community.11,13,14
Moreover, because a higher viral burden also predicts greater infectiousness, former inmates who fail or discontinue ART may be more likely to infect their contacts.24,25
In view of these risks, a careful examination of policies and procedures related to the release of HIV-infected inmates is warranted. In particular, greater coordination between state and local agencies, health care institutions, and community-based organizations is needed to reduce this high rate of treatment interruption among newly released inmates.
Our study provides some evidence for improving this low rate of linkage to community-based ART after release from prison. We found that HIV-infected inmates who received formal assistance with the completion and submission of ADAP applications had significantly higher rates of filling an ART prescription on release compared with inmates who did not receive this service. An inmate's release from prison represents a move from a highly structured environment in which clinical care and administration of medications can be carefully supervised to a setting in which multiple socioeconomic and psychological factors can adversely affect treatment adherence and access to care.7
Released prisoners, as they transition back to their home communities, are faced immediately and simultaneously with a multitude of social and economic challenges.8
It is not surprising that those who received formal assistance accessing the community-based medication system exhibited better outcomes. Because this intervention can be implemented at relatively low cost and with little infrastructure, it has potential broad applicability across US prison systems.
We also found that inmates released on parole had higher rates of filling an ART prescription at 30 and 60 days than those with a standard, unsupervised release. It is possible that parolees' mandatory recurring visits with parole officers and participation in substance abuse or mental health treatment programs are associated with higher rates of adherence to medical treatment such as ART. Because of legal and ethical considerations, however, participation in or adherence to treatment for HIV or any other physical health condition cannot be imposed as a condition of parole. Nonetheless, in view of the higher risks of treatment interruption among released inmates not placed on parole, targeted case management programs for this group may be warranted. However, it is acknowledged that being released on parole may not always be helpful if individuals do not keep their appointments with their officer and because of limited resources available in this regard.
Our finding that inmates with undetectable viral loads had higher rates of ART initiation may indicate that this subgroup demonstrated favorable medication adherence during incarceration and continued this behavior following release. It is important to consider that educational interventions designed to improve HIV knowledge and treatment adherence during incarceration may ultimately lead to improved continuity of ART following release.
African Americans and Hispanics were less likely to have filled an ART prescription at 10 and 30 days after release compared with non-Hispanic whites. This finding is consistent with previous community-based research indicating that minority populations may experience more socioeconomic barriers to health care than their nonminority counterparts.26-28
It is noteworthy that we found no significant difference across the 3 racial/ethnic groups in the proportion of inmates who received ADAP application assistance. Future investigations that examine the specific health care barriers faced by African Americans as well as Hispanics following release from prison may be warranted. It is noted that none of the study participants were Mexican nationals, who would thus potentially be able to obtain antiretroviral medications in Mexico.
Our finding that inmates 30 years and older were more likely than their younger counterparts to obtain a prescription by 60 days is consistent with several community-based studies that reported that older HIV-infected patients demonstrated better adherence to ART29,30
and better linkage to and retention in HIV care31,32
than younger patients. Each of these demographic disparities highlights the importance of developing targeted interventions for specific subgroups who may be at increased risk for treatment interruption.
Our analysis of the group of released inmates who filled a second ADAP prescription showed that the vast majority did not fill their second prescription soon enough to avoid a substantial treatment interruption. This finding offers some insight into the difficulty released inmates experience in linking with HIV clinics in the general community. To receive a second 30-day supply of ART medication from ADAP, the former inmate must obtain a written prescription by completing a medical visit to a community-based HIV clinic. Our finding that only 6% of inmates who filled their initial ADAP prescription within 60 days accessed their second prescription without interruption suggests that in the months following release, inmates may need additional assistance in navigating the health care system and addressing behavioral and social barriers to treatment.
The results of this study may have been influenced by several limitations. It is possible that some released inmates may have received ART medications from a source other than ADAP. Within the first 30 days of release, however, this number would likely have been exceedingly small, given that the vast majority of inmates have no health benefits on release from prison. In their study of a representative sample of more than 800 newly released US prison inmates, Mallik-Kane and Visher8
reported that 75% of former inmates had no public or private health insurance 2 to 3 months after community reentry, and 65% still had no insurance by 8 to 10 months.
All HIV-infected inmates released from prison in Texas and who do not have private insurance qualify for ADAP. Because almost all of these individuals are from disadvantaged socioeconomic backgrounds, it is unlikely that many released inmates would have accessed ART from other sources. Even inmates who eventually receive public health care benefits receive their initial 30-day supply of ART medications as well as a substantial portion of subsequent medication from ADAP. However, because 60 days may have been enough time for a small but significant proportion of released inmates to gain access to ART through other sources—including Medicare and Medicaid—our analyses focusing on the percentage of inmates who filled an ADAP prescription by 60 days should be interpreted with caution.
Another potential limitation is that it was difficult to determine the extent to which the higher rates of ART initiation among inmates who received ADAP application assistance might reflect an underlying selection bias. Although HIV discharge planning coordinators did not target specific clinical or demographic subgroups of inmates to receive ADAP application assistance, it is possible that unmeasured behavioral characteristics may have resulted in inmates either seeking or being selected for such assistance. However, our analyses of the study factors across the 2 subgroups showed that, with the exception of parole status and duration of incarceration, all demographic and clinical characteristics were relatively evenly distributed. In particular, we observed no statistically significant differences in CD4 cell count or viral load across the 2 ADAP application assistance subgroups.
Additionally, our use of multivariate modeling permitted simultaneous adjustment for several potential confounding factors. Nevertheless, the high likelihood of unmeasured confounding and selection bias associated with ADAP application assistance limits our ability to make strong inferences about this finding. A randomized trial is needed to more rigorously examine the role of this factor in accessing ART following release from prison.
The retrospective nature of this study limited our ability to assess a number of important social and behavioral characteristics. In particular, because information on injection drug use—which is prevalent among HIV-infected individuals and has long been associated with poor ART adherence33,34
—was unavailable, we were unable to examine its effect on filling an ART prescription. Additionally, the inmate's potential fear of stigmatization associated with receiving HIV treatment following release represents an important barrier to ART adherence among community-based samples35-37
that we were unable to assess. To fully characterize these and other important determinants of obtaining ART after release, in-depth qualitative studies are needed.
Despite these limitations, we believe that this study has important strengths. It represents the largest investigation of newly released prison inmates with HIV infection and is the first to examine continuity of ART for all inmates released statewide. Because this study was carried out in the nation's largest state prison system,15
these findings have a high degree of statistical power. Moreover, given that the HIV screening and treatment policies of the TDCJ are comparable with those of most other state prisons,38
these findings are likely generalizable to other US correctional systems. No published information is available on the extent to which US prison systems provide released inmates with assistance or information related to ADAP services. It is likely, however, that ADAP represents the optimal initial source of ART medications for the vast majority of released inmates in the United States. ADAP has long served as a bridge to services for impoverished HIV-positive persons and is the most expeditious pathway to obtaining ART drugs during the immediate postrelease period.39
In conclusion, we found that 90% or more of released inmates did not fill a prescription for ART medication soon enough to avoid a treatment interruption and that more than 80% did not fill a prescription within 30 days of release. These exceedingly high rates of treatment interruption suggest that most inmates face significant administrative, socioeconomic, or personal barriers to accessing ART when they return to their communities. Future prospective and in-depth qualitative studies are needed to more rigorously examine these barriers. Adequately addressing a public health crisis of this scale and complexity will require carefully coordinated efforts between academic institutions, the criminal justice system, and public health agencies.