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In the United States, 10 million inmates are released every year, and human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) prevalence is several-fold greater in criminal justice populations than in the community. Few effective linkage-to-the-community programs are currently available for prisoners infected with HIV. As a result, combination antiretroviral therapy (cART) is seldom continued after release, and virological and immunological outcomes worsen. Poor HIV treatment outcomes result from a myriad of obstacles that released prisoners face upon reentering the community, including homelessness, lack of medical insurance, relapse to drug and alcohol use, and mental illness. This article will focus on 5 distinct factors that contribute significantly to treatment outcomes for released prisoners infected with HIV and have profound individual and public health implications: (1) adaptation of case management services to facilitate linkage to care; (2) continuity of cART; (3) treatment of substance use disorders; (4) continuity of mental illness treatment; and (5) reducing HIV-associated risk-taking behaviors as part of secondary prevention.
Systematic identification and treatment of human immunodeficiency virus (HIV) infection remains the best way to reduce the 56000 incident infections annually in the United States . To achieve this goal, a substantial number of infected individuals need to initiate and adhere to combination antiretroviral therapy (cART) [2, 3]. The sheer magnitude of the incarcerated population and the disproportionate prevalence of HIV infection and acquired immune deficiency syndrome (AIDS) within the criminal justice system (CJS)  results in 16.9% of all HIV-infected individuals in the US being within the CJS annually . Interventions that facilitate initiation of and adherence to cART among HIV-infected prisoners upon release thus play an important role in stemming the HIV epidemic in the United States.
Improved HIV care provided within prisons has markedly reduced mortality, such that, by 2008, the HIV-associated mortality among prisoners had achieved near parity with that among the community . Despite these achievements, released prisoners infected with HIV not only continue to experience increased HIV-related mortality  but have worsened HIV treatment outcomes, represented by increases in HIV type 1 (HIV-1) RNA levels and decreases in CD4+ lymphocyte counts . The rate of re-incarceration among released prisoners infected with HIV remains high, with nearly one third being re-incarcerated within 3 months of their release . When HIV is effectively treated in correctional settings, continuity of care and cART not only benefit the individual but has the potential to decrease the possibility of HIV transmission to others after release. Secondary HIV prevention, particularly by maintaining viral suppression , is crucial to reducing HIV infection incidence given the known high prevalence of HIV-associated risk behaviors reported by newly released inmates infected with HIV . Although prisons house the majority of incarcerated persons, jails interface with a significantly larger number of individuals with or at risk for HIV infection. Prisons and jails differ significantly, however, with regard to HIV management, and these differences are depicted in Table 1.
Multiple reasons contribute to poor postrelease HIV treatment outcomes, including lack of access to medications or medical entitlements, abrupt medication discontinuation, and poor adherence to cART . Antiretroviral therapy nonpersistance or nonadherence independently contributes to poor HIV treatment outcomes . Either of these may result from a lack of interest (especially in the setting of undertreated mental illness), competing needs (eg, needs associated with active alcohol or drug use as well as basic needs, such as housing, food, employment, child care, and basic safety), or a combination of these factors. Effective linkages that sustain clinical benefit after release remain urgently needed. Figure 1 depicts common comorbidities and effective treatment modalities; Table 2 describes existing prison-release programs for prisoners infected with HIV. The transitional process from highly structured prison settings to community settings is seemingly insurmountable, including high levels of homelessness and poor social support .
In the following sections, we discuss the current state of knowledge on prison- and jail-release programs and provide insight into future program development. We describe 5 distinct programmatic themes (Figure 2) for transitioning prisoners infected with HIV: (1) adaptation of case management (CM) services, (2) adherence approaches to ensure continuity of cART to preserve the benefit of treatment after the confines of incarceration, (3) initiation and/or continuity of evidence-based treatment of substance use disorders (SUDs), (4) linkages with appropriate treatment for mental illness, and (5) reducing HIV risk-taking behaviors as part of secondary prevention.
A systematic search strategy was undertaken using PubMed, OvidSP, and MEDLINE with the following key words: “HIV,” “AIDS,” “prison,” “jail,” “incarceration,” “transition,” “case management,” “antiretroviral therapy,” “adherence interventions,” “substance abuse,” “opioids,” “alcohol,” “mental illness,” “HIV risk behaviors,” and “secondary prevention.” Studies were included if they enrolled individuals with or at risk for HIV infection and had demographic characteristics associated with involvement with the criminal justice system, especially prison or jail. Selected conference abstracts were also reviewed. Five content areas that dealt with transitional care interventions were decided a priori. In some of these 5 domains, there was a dearth of published literature involving incarcerated subjects infected with HIV; in these instances, relevant material was sought that involved similar subjects who represented persons at high risk for criminal justice involvement (eg, HIV-uninfected prisoners or HIV-infected community cohorts with risk profiles similar to those of prisoners). This allowed for limited extrapolation to the population of interest. Clinical findings from each of the interventional studies and meta-analyses of randomized trials are summarized in Supplementary Table 1.
Case management involves the coordination of medical and psychosocial care for individuals with complex medical needs and involves different levels of interaction and assistance among different groups of people, such soon-to-be-released prisoners infected with HIV . Supplementary Table 1 summarizes 8 examples of CM programs. Community linkages are different and sometimes only involve passive referrals (eg, providing a list of agencies that help with benefits, health care, or acquiring a job or shelter). Effective discharge planning may ultimately result in community-based decreased HIV transmission by effectively engaging HIV-infected persons in care and maintaining virological suppression with continuous cART .
CM services are currently the mainstay of prisoner-release programs for inmates infected with HIV, with the goal of providing a seamless system of care and reducing recidivism, maintaining overall health, and averting drug use. Despite advocacy for costly intensive CM interventions , a randomized controlled trial comparing prerelease discharge planning was as effective at linking subjects to HIV care as was intensive CM provided before and after prison release ; however, CD4+ count and viral suppression outcomes were not reported. Depending on the intensity of the discharge planning and the amount of available services that link people to the community, CM may serve some role for criminal justice populations, yet randomized controlled trials of these interventions have yet to confirm their benefit. A 10-site, national demonstration project that focuses on linking HIV-infected jail detainees to community care will have clinical outcomes and is currently underway .
Most prisoners lose medical and social entitlements upon incarceration and are ineligible to reapply until released, often leaving a considerable gap in the provision of care until entitlements are restored. More recently, several states have moved towards temporarily suspending instead of terminating medical insurance upon incarceration, thereby suggesting a possible shift through introducing structural interventions that might promote continuity of care by policy makers . Changing the eligibility requirements to allow prereleased inmates to plan reintegration into the community effectively may improve health outcomes and reduce recidivism; however, such structural interventions have not yet been assessed.
Fifteen cART adherence support programs relevant to transitioning prisoners infected with HIV are summarized in Supplementary Table 1. 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 , (2) homelessness that results in decreased adherence as a result of migration and social destabilization , (3) unemployment that results in the inability to meet basic needs , (4) sometimes complicated antiretroviral regimens, and (5) multiple other comorbidities, including viral hepatitis and tuberculosis, that often complicate selection of antiretroviral regimens . 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 . 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 . 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 . Drug users may also link medication with dosing of illicit drugs . 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 . 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 . 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 ; positive and negative reinforcing medications (eg, methadone dosing or disulfiram) , 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 , 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 ; 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 . DAART offers a highly monitored and structured setting for released prisoners and does not promote genotypic resistance . 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 .
Supplementary Table 1 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 . Over 80% of prisoners infected with HIV have SUDs prior to incarceration, and untreated SUDs are associated with decreased adherence to cART . Evidence-based substance abuse treatment options, especially for opioid and alcohol dependence, involve medication-assisted therapy (MAT); however, behavioral interventions may also be beneficial .
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 . 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, 77], is relatively less costly, and can be implemented without prolonged periods of incarceration . Table 3 describes currently available US Food and Drug Administration–approved pharmacotherapies. Therapeutic communities and opioid substitution therapy using methadone and buprenorphine  and treatment of alcohol use disorders (AUDs) in correctional settings have been reviewed , 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 . 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 . 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 , has recently been adopted in several jail settings, and is safe and effective for released HIV-infected prisoners in sustaining HIV treatment outcomes . Although US correctional settings have yet to actualize the benefits of buprenorphine treatment, its use among French prisoners has proven effective since 1996 . 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.
AUDs contribute greatly to ongoing HIV transmission and to poor access to and adherence with antiretroviral therapy . In 2002, almost 50% of jail inmates reported pre-incarceration symptoms of alcohol abuse or dependence , and almost 60% of state and federal prisoners reported drinking alcohol at the time of their offense . AUDs have been associated with increased HIV-related risk-taking behaviors  and poor adherence to cART , 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 . 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  and accelerated progression to ESLD among individuals infected with HCV . 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 .
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.
Supplementary Table 1 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 , 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 . 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  and reincarceration . 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 . Although there is no gold standard for continuity of psychiatric care for HIV-infected correctional populations, comprehensive reentry programs should incorporate mental health treatment.
Four programs designed to change HIV risk behaviors among HIV-infected or high-risk prisoners are presented in Supplementary Table 1. 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 . Irrespective of strategy, identifying HIV infection results in decreased HIV-associated risk-taking behaviors . 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 . As such, current guidelines recommend routine HIV testing in a number of settings, including prisons and jails . 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  and testing within the first 24 hours after incarceration [96, 97].
Subjects in jails report significant sexual risk-taking prior to their incarceration, and in certain cases, albeit with markedly reduced prevalence, during their incarceration . 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 . Screening for STIs, particularly in jail settings, where turnover is rapid, can provide significant HIV infection preventive services to this high-risk population  and have a significant effect upon reducing community rates of STIs . 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.
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 . Recent data that support the use of pre-exposure prophylaxis using oral tenofovir among men who have sex with men  and a tenofovir-containing microbocide vaginal gel for women  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.
Released prisoners infected with HIV face many challenges upon reentry to the community. Case management services alone appear to be insufficient, because they are often unable to effectively address the multiple complex needs that are often required. Although uniform structural approaches may overcome some barriers, effective programs will require integrated approaches and individualized treatment plans. Existing community resources are insufficient to address these complex needs. Innovative solutions are urgently needed that involve partnerships between all existing stakeholders, including individual inmates, the CJS, and communities to overcome existing impediments.impediments.
Financial support.This work was supported by the National Institutes on Drug Abuse (R21 DA019843, R01 DA025943, and R01 DA017059 to F. L. A; R01 DA030762 to F. L. A. and S. A. S; K24 DA017072 to F. L. A.; and K23 DA019381 to S. A. S.); the National Institutes on Alcohol Abuse and Alcoholism (R01 AA018944 to F. L. A. and S. A. S.); the National Institute of Mental Health (T32 MH020031 to J. P. M.); the Centers for Disease Control and Prevention (UR6PS000391 to F. L. A.); the Health Resources and Services Agency (H97 HA 08541 to F. L. A. and U90HA07632 to A. C. S.); and the Substance Abuse and Mental Health Services Agency (H79TI019806 to F. L. A.).
Potential conflicts of interest.All authors: No reported conflicts.
All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed in the Acknowledgments section.