In this randomized controlled trial we found that an intensive case management intervention spanning the periods of incarceration and release of HIV-infected individuals was as effective for released prisoners as a comprehensive pre-release discharge planning program in terms of accessing medical care over the year following release. Further, there were no statistically significant differences of either re-incarceration or social service use between the study groups.
Importantly, we observed high rates of accessing non-urgent medical care in both study arms. At 6 months following release, approximately 90% of participants in each arm had at least one clinical care appointment. However, at 4 weeks following release, at which time those prescribed antiretrovirals would have exhausted their supply of medication provided on release, only two thirds of the BCM participants and half the SOC participants had seen a healthcare provider. This finding is consistent with data from Texas where filling of antiretroviral prescriptions immediately following prison release was found to be extremely low [8
]. These observations point to a continued need to develop strategies to engage HIV-infected releasees in care immediately after release.
In addition, despite on-going case management in the BCM arm, social service use reported by participants was not higher among those receiving this intervention. This was surprising as our hypothesis was that the BCM intervention would address pressing needs that compete for priority with health care. While, a substantial proportion did receive these services, these results may indicate that either BCM insufficiently addressed these needs or that there were limited resources available in the communities to which releasees returned.
We found that accessing HIV care post-release was not influenced by prisoners’ gender, first diagnosis of HIV during the current incarceration, or antiretroviral use. However, those with a history of depression had significantly more clinic visits after their release. Although depressed patients may be more motivated to seek medical care, the ARTAS Study found the opposite—a reduced effect of case management on access to care among depressed participants [13
As well, intensive BCM did not appear to reduce recidivism when prison and jail incarceration were considered together. On the other hand, compared to participants in the SOC arm, fewer of those assigned to BCM were returned to prison (i.e., convicted and sentenced), although more were jailed (i.e., arrested and held). Arrest may not always be a result of individual behavior and can be influenced by local police policies and practices. Whether the differences in prison and jail re-incarceration observed are meaningful remain unclear.
Overall, our findings raise questions about the value of intensive aftercare programs for improving linkage to care and services for HIV-infected releasees. Although such programs exist in several states and positive outcomes have been reported, there has not been rigorous comparative study of the efficacy of such programs. In this trial, an intensive post-release motivational case management intervention did not provide measurable benefits over a pre-release program in which basic discharge planning services, including referrals to medical clinics, completion of medication access forms and investigation of housing options, were provided by prison nurses dedicated to the care of those with HIV and other infectious diseases.
Few studies have examined interventions to improve access to HIV care and services and, to our knowledge, only one, the ARTAS study, was a randomized trial [13
]. ARTAS also tested a Strengths Model-based case management intervention versus a more passive standard referral process but, unlike the BRIGHT study, did so among newly diagnosed, non-incarcerated, HIV-infected patients in four US cities. It is noteworthy that in the ARTAS study the case management intervention was found to be more efficacious than standard of care (78% vs. 60% accessing HIV care at 6 months); however, the intervention was found to be less effective in several subgroups, including those with depressive symptoms [13
The absence of significant differences between post-release outcomes between the intensive case management participants before and after prison release and participants in the standard pre-release discharge planning program for HIV-infected inmates may be due to several factors. Perhaps most important is that although those assigned to the case management intervention accessed care at a high rate, so, too, did control group participants. These rates may indicate that medical care is relatively accessible for HIV-infected former prison inmates in North Carolina. Further, incarceration itself and the HIV care rendered in prison may have led to an enhanced appreciation among inmates for post-release medical care, motivating them to engage in care upon their release regardless of study assignment. Data we collected from participants in this and our preliminary studies of HIV-infected releasees suggest, however, that access to care is perceived by most as a challenge. Qualitative interviews we conducted with a subset of study participants found strikingly consistent responses indicating that (re)establishment of medical care after release was not considered a priority by former inmates, and was considered secondary to concerns about returning to substance abuse and reconciliation with family [22
]. Participation in this trial itself, during which questions were regularly asked regarding access to care, may have served also to motivate participants to seek medical care (i.e., the Hawthorne effect). Lastly, it is also possible that the standard discharge planning being provided to HIV-infected inmates was equally effective as our intensive bridging case management intervention, despite the lack of a post-release component and a high case load among the nurses responsible for pre-release planning. It may be that once a threshold for the subject of post release access to care is reached, aftercare adds little to a well-considered pre-release discharge plan.
Several additional considerations limit the interpretation of our findings. Our sample size precludes detection of small to moderate, but meaningful differences between the two study interventions. The nearly identical rates of access to care and re-incarceration we observed would suggest that a much larger study would likely be necessary to detect what may be relatively modest differences in effect size. Additionally, the study conditions may have influenced the standard of care arm either directly via contamination (e.g., prison nurses adopting techniques used by the BCMrs) or indirectly if the prison nurses, aware their work was serving as a control for an alternative intervention, redoubled their efforts. In addition, access to care was self-reported by participants. Attempts to confirm clinic visits were often difficult due to clinic concerns for patient privacy, despite signed medical information release forms. However, clinical records were collected for over 50% of participants and among this large subset of individuals with available clinic records, no difference in linkage to care between arms was observed and self-report was found to be as accurate as medical records. Lastly, the primary outcome of interest in this study was access of medical care and not the benefits afforded by such care such as post-release medication adherence or viral suppression. Therefore, whether BCM or other aftercare interventions have an effect on these important outcomes remains unknown.
In conclusion, we found high rates of HIV medical care access after prison release among incarcerated HIV-infected individuals. An intensive and motivational case management program spanning incarceration and release was not associated with a greater likelihood of accessing care, receiving major social services or preventing re-incarceration compared to a pre-release discharge planning program without post-release follow-up. While there may be other benefits of continued case management following prison release that were not measured, these findings call into question the value of intensive after care programs for HIV-infected prison releasees.