Fifteen cART adherence support programs relevant to transitioning prisoners infected with HIV are summarized in Table 3. Prisoners face many obstacles to maintaining adherence to cART after release, including (1) insufficiently treated SUDs and/or psychiatric disorders that result in decreased motivation to adhere to treatment recommendations [62
], (2) homelessness that results in decreased adherence as a result of migration and social destabilization [63
], (3) unemployment that results in the inability to meet basic needs [64
], (4) sometimes complicated antiretroviral regimens, and (5) multiple other comorbidities, including viral hepatitis and tuberculosis, that often complicate selection of antiretroviral regimens [65
]. Irrespective of the individual’s reasons for not continuing or poorly adhering to therapy, it is critical to establish effective ways to overcome problematic adherence.
Excellent cART adherence and persistence suppresses HIV-1 RNA levels and increases CD4+ cell count, thereby keeping persons infected with HIV healthy and free from AIDS-associated opportunistic infections [11
]. Interventions aimed at improving adherence to medical therapies form an important component of any strategy to improve health outcomes and depend upon factors relating to the patient, the characteristics of the medications or intervention, the interpersonal aspects of the patient-provider relationship, and the general system in which care is provided [66
]. Some examples of adherence support that have been demonstrated to be effective in other community settings include the use of reminders, adherence counseling support, contingency management, and directly administered antiretroviral therapy (DAART). These approaches are likely to be useful; however, they have not been fully tested for released prisoners.
Cues and reminders may be useful for patients for whom a major reason for missed doses is “forgetting,” either because of their lifestyles, comorbid mental illness, or HIV-associated cognitive impairment [67
]. Drug users may also link medication with dosing of illicit drugs [68
]. In terms of absolute cost, many of these adherence reminders are quite inexpensive. Their simplicity and affordability facilitate their integration with other adherence interventions, yet their impact on adherence is modest.
Adherence counseling strategies have been shown to change patients’ knowledge, attitudes, and beliefs about medical treatment and to improve their adherence to at-times-complicated medication regimens [69
]. In terms of both cost-effectiveness and scalability, it will be important to determine who may best deliver the counseling. Peer-driven interventions can be affordable and acceptable; however, interventions by professionally trained counselors might, despite their added cost, be more effective and replicable, especially if such interventions are validated and provided in a manualized format.
Contingency management has its roots in the mental health treatment community, where it has been used to manage SUDs [70
]. Participants are rewarded for positive health behaviors (eg, excellent adherence), and a series of sanctions are imposed for negative health behaviors. Such interventions may take the form of direct financial compensation; token economy systems, such as vouchers [41
]; positive and negative reinforcing medications (eg, methadone dosing or disulfiram) [41
], and material incentives (eg, bus tokens and electronic items like paid telephones and reminders). Preliminary data support the use of contingency management for HIV treatment adherence [71
], yet randomized controlled trials have not been conducted. Although, in some instances, contingency management has proven to be cost-effective, the absolute costs involved in bringing it to scale may be prohibitive, although contingency management is not as costly as the antiretroviral medications themselves and, as such, would represent an incremental cost to provision of cART.
A meta-analysis of DAART suggests that such programs are not beneficial overall [72
]; however, individuals who were at particular risk for nonadherence (eg, drug users or prisoners) were not differentially examined. A subsequent meta-analysis did, however, support the use of DAART among individuals at high risk for nonadherence, especially drug users [73
]. DAART offers a highly monitored and structured setting for released prisoners and does not promote genotypic resistance [26
]. A recent randomized controlled trial of DAART among released prisoners confirms its benefit on HIV treatment outcomes for the target population, yet the cost-effectiveness of this strategy has yet to be explored [42
Treatment of SUDs
Table 3 describes 14 treatment programs for SUDs relevant to prisoners infected with HIV. Relapse prevention is among the most pressing needs facing released prisoners, because relapse to substance misuse often results in reincarceration. Furthermore, drug overdose is the leading cause of death among released prisoners, and usually occurs within 2 weeks of release [74
]. Over 80% of prisoners infected with HIV have SUDs prior to incarceration, and untreated SUDs are associated with decreased adherence to cART [75
]. Evidence-based substance abuse treatment options, especially for opioid and alcohol dependence, involve medication-assisted therapy (MAT); however, behavioral interventions may also be beneficial [65
Although not tested in subjects infected with HIV, behavioral interventions are most effective for incarcerated persons when delivered over a sustained period as therapeutic communities (TCs). They must be continued after release, however, and are therefore labor intensive and costly [76
]. TCs address polysubstance drug use, reduce recidivism, and facilitate re-entry, but they must be tailored to individual goals and behaviors and require support systems within the community. Although head-to-head comparisons of TCs with MAT are not available, MAT is the most effective treatment for opioid and alcohol dependence [65
], is relatively less costly, and can be implemented without prolonged periods of incarceration [78
]. describes currently available US Food and Drug Administration–approved pharmacotherapies. Therapeutic communities and opioid substitution therapy using methadone and buprenorphine [78
] and treatment of alcohol use disorders (AUDs) in correctional settings have been reviewed [79
], and details about their implementation are beyond the scope of this article. Methadone, buprenorphine, and extended-release naltrexone, along with relevant pharmacokinetic drug interactions, have also been reviewed in the treatment of SUDs in community settings [65
]. Methadone, when initiated before community reentry, is more effective than is postrelease methadone or referrals at improving drug treatment outcomes and relapse prevention treatment among prisoners infected with HIV [45
]. Buprenorphine, with its excellent safety profile and relative lack of federally legislated constraints, provides new possibilities for the treatment of released prisoners with opioid dependence [78
], has recently been adopted in several jail settings, and is safe and effective for released HIV-infected prisoners in sustaining HIV treatment outcomes [46
]. Although US correctional settings have yet to actualize the benefits of buprenorphine treatment, its use among French prisoners has proven effective since 1996 [80
]. Several studies have demonstrated the efficacy and acceptance of buprenorphine in released prisoners (Supplementary Table 1
). Applying these models of treatment to correctional and prison-release programs should be carefully considered for those with HIV infection to reduce recidivism rates, reduce HIV-related risk behaviors, and enhance adherence to antiretroviral therapy.
Available and Evidence-Based Medication Assisted Therapies (MATs)
AUDs contribute greatly to ongoing HIV transmission and to poor access to and adherence with antiretroviral therapy [81
]. In 2002, almost 50% of jail inmates reported pre-incarceration symptoms of alcohol abuse or dependence [82
], and almost 60% of state and federal prisoners reported drinking alcohol at the time of their offense [83
]. AUDs have been associated with increased HIV-related risk-taking behaviors [84
] and poor adherence to cART [85
], resulting in reduced likelihood of achieving HIV virological suppression. Moreover, 30% of patients infected with HIV are co-infected with hepatic C virus (HCV), and this number approaches 60% in the Northeast, where injection drug use contributes significantly to HIV transmission [86
]. AUDs and chronic HCV infection are the 2 most common causes of end-stage liver disease (ESLD), and concomitant alcohol use is associated with hepatic steatosis [87
] and accelerated progression to ESLD among individuals infected with HCV [88
]. Thus, there is an urgent need to effectively treat AUDs among prisoners infected with HIV. Although extended-release naltrexone has been demonstrated to be effective for treating AUDs, its efficacy and safety among subjects infected with HIV has not been critically evaluated [79
Because many HIV-infected drug users who interface with correctional settings often use several mind-altering substances, multiple intervention modalities may be needed, including MAT and behavioral and cue-based therapies. Integrating these components into prison-release programs may not only reduce the harm from recurrent substance abuse but also secondarily benefit other needs, such as adherence to cART and engagement in care.
Treatment for Mental Illness
Table 3 describes the 2 published psychiatric treatment programs for HIV-infected released prisoners. An estimated 56% of state prisoners, 45% of federal prisoners, and 64% of local jail inmates self-report having mental illness [89
], yet as few as 26%–39% of those with documented psychiatric conditions were receiving psychiatric medications at the time of arrest. After incarceration, only 46%–69% were eventually treated [89
]. Increasing financial constraints and inconsistent screening practices in prisons and jails are common reasons for undiagnosed or untreated mental illness in criminal justice settings.
Mental illness, especially major depressive disorder, is associated with decreased cART adherence and decreased retention in medical care and with increased HIV-associated risk-taking behaviors [90
] and reincarceration [62
]. Therefore, comprehensive postrelease plans should incorporate diagnosis and treatment of mental illness and transition to community mental health treatment programs.
Mental health diversion programs provide mental illness treatment as an alternative to criminal sanctions for persons with serious psychiatric disease within the CJS. Within jail diversion programs, interventions occur before and after an individual is charged with a crime. Prearrest programs (1) use trained police officers to serve as liaisons to the mental health system, (2) utilize mental health professionals to provide consultations to police officers in the field, and (3) coordinate efforts between police and mental health workers. Postarrest programs divert those with serious mental illness to community-based programs at the time of arraignment by using specialty court-based diversion programs. Community-based programs may also try to integrate medical treatment, case management, and educational programs for released offenders with chronic medical and psychiatric conditions and can assist with creating linkages to the community [17
]. Although there is no gold standard for continuity of psychiatric care for HIV-infected correctional populations, comprehensive reentry programs should incorporate mental health treatment.
Reducing HIV Risk Behaviors
Four programs designed to change HIV risk behaviors among HIV-infected or high-risk prisoners are presented in Table 3. Enhanced HIV testing is greatly needed within correctional settings. There is significant heterogeneity in terms of screening and testing for HIV infection, including no screening, screening based solely on symptoms or self-reported risk, voluntary testing, routine testing, and mandatory testing [91
]. Irrespective of strategy, identifying HIV infection results in decreased HIV-associated risk-taking behaviors [92
]. Once diagnosed, HIV infection can be effectively treated, and when viral replication is sufficiently suppressed, HIV transmission is impressively reduced, even in the setting of high-risk behavior [93
]. As such, current guidelines recommend routine HIV testing in a number of settings, including prisons and jails [94
]. Documented successful demonstrations of routine HIV testing strategies have been documented in jail settings. Routine testing has not been achieved, however, because of logistical, financial, and legal constraints. Some of these constraints have been addressed by using rapid HIV diagnostic tests [95
] and testing within the first 24 hours after incarceration [96
Treatment of Sexually Transmitted Infections for Primary and Secondary Prevention
Subjects in jails report significant sexual risk-taking prior to their incarceration, and in certain cases, albeit with markedly reduced prevalence, during their incarceration [9
]. Prisoners often have other sexually transmitted infections (STIs) in addition to HIV infection upon entrance to correctional facilities. Without diagnosis and treatment of STIs, individuals may experience associated medical complications along with an increased risk of HIV transmission upon release, especially in the setting of concomitant ulcerative genital disease, such as syphilis [98
]. Screening for STIs, particularly in jail settings, where turnover is rapid, can provide significant HIV infection preventive services to this high-risk population [99
] and have a significant effect upon reducing community rates of STIs [100
]. Unfortunately, most prevention efforts have been limited to HIV counseling and testing, and few STI treatment programs have been systematically evaluated with respect to HIV infection prevention.
Behavioral and Biomedical Interventions
Increased detection and treatment of HIV infection and other STIs are part of the landscape of HIV prevention efforts. Behavioral interventions that facilitate HIV risk reduction and adherence to cART are effective and essential [101
]. Recent data that support the use of pre-exposure prophylaxis using oral tenofovir among men who have sex with men [102
] and a tenofovir-containing microbocide vaginal gel for women [103
] provide initial support for the use of biological agents in the primary prevention of HIV infection. They have not yet established a role in HIV-infected prisoners, however, with the exception of treating their serodiscordant partners. Little is known about using these approaches as secondary prevention for HIV-infected individuals who have been released from prison.
Our literature search was limited to published manuscripts in English and French and described interventions for transitioning care for prisoners infected with HIV or related populations. Although our literature search was designed to be comprehensive, some articles may have been missed. In some domains, there was little literature available specific to incarcerated HIV-infected populations, so comparisons were drawn to similar populations. These conclusions may need to be refined once further studies are conducted that focus on criminal justice populations infected with HIV.