Interventions to Improve HIV Care Continuum Outcomes for People With HIV Who Have Incarceration Experience: A Narrative Review

Abstract

People with HIV who are reentering the community after incarceration encounter multiple barriers to engagement in HIV care and treatment. We conducted a narrative review of recent interventions (2020–2023) developed to address barriers and improve HIV-related health outcomes for people with HIV and incarceration experience in the United States. This review yielded 6 interventions published in the peer-reviewed literature and 4 interventions from the gray literature (ie, informally published interventions). Eight interventions used the strategy of providing reentry services to support engagement in HIV care and social services after release from incarceration. Of the peer-reviewed studies, only 2 reported statistically significant improvements in HIV-related outcomes. Gray literature interventions lacked the methodological details necessary to interpret findings. Systems-level and multilevel interventions were promising but need more rigorous study. To end the HIV epidemic, more innovation is needed to address barriers to care for people with HIV and incarceration experience.

This review found few effective interventions for people with HIV reentering the community after incarceration. Most interventions delivered navigational and case management support. Systems-level and multilevel interventions were promising, but more innovation and rigorous study methods are needed.

People who experience incarceration have a higher prevalence of HIV as compared with the general adult population. In 2021, nearly 12 000 people in US state and federal prisons had a diagnosis of HIV, representing 1.1% of all incarcerated individuals [1]. Among all people with HIV in the United States, an estimated 5.4% were incarcerated in jail or prison in the previous year [2]. Being Black/African American or Hispanic/Latino/a/Latine, experiencing poverty and homelessness, and/or having mental health or substance use disorders is disproportionately associated with incarceration and HIV infection, a syndemic rooted in stigma, racism, and other inequities [2–5]. While incarceration is far more common among men than women [6, 7], incarcerated women have a higher prevalence of substance use and mental health disorders than incarcerated men, and they may have poorer HIV-related health outcomes [4, 8, 9]. In addition, sexual minority people with HIV are more vulnerable to incarceration as compared with heterosexual people with HIV [8, 10].

The Centers for Disease Control and Prevention (CDC) recommends routine opt-out HIV testing for all people entering correctional facilities, unless the prevalence of undiagnosed HIV infection among a facility's population is <0.1% [11]. Biomedical HIV prevention (ie, preexposure prophylaxis) for people without HIV is not included in these recommendations [11]. The CDC also advises that incarcerated people with an HIV diagnosis receive HIV treatment according to federally approved clinical practice guidelines, including immediate access to antiretroviral therapy (ART) [11, 12]. Although implementation of these CDC guidelines varies among jurisdictions and facilities, people with HIV and incarceration experience tend to have better HIV health-related outcomes in correctional settings as compared with community settings [13–15]. This difference in outcomes likely occurs because many prison settings provide structured access to medical care and daily dispensing of ART [15]. Conversely, jails often contribute to disruptions in continuity of care [15, 16].

For the reentry period, the CDC recommends that discharge plans expedite engagement with community-based HIV care and provide a temporary supply of ART (eg, 30 days) for people with HIV [11]. After release from incarceration, however, people with HIV experience a steep decline in viral suppression and other HIV care continuum outcomes [17], suggesting that these services are not consistently offered or are inadequate for meeting people's needs [2, 18, 19]. Moreover, people reentering the community encounter multiple barriers to navigating health systems and engaging in care [3]. Having a conviction history can render a person ineligible for certain public benefits and can limit employment and housing opportunities [20]; this experience of unstable housing and unemployment makes it difficult to prioritize HIV care [19, 21–23]. In addition, untreated substance use disorders and mental illness, which are common in this population [24], can interfere with HIV care engagement and medication adherence [18, 21, 25–27]. Lack of health insurance and inadequate coordination between the correctional facility and community-based HIV care can also disrupt linkage to care and retention in care [2, 18, 19]. Reincarceration can create further complexity in managing HIV [18]. For these reasons, people with HIV and recent incarceration experience are less likely to be in care and achieve viral suppression than those without recent incarceration experience [2, 8, 28]. When people with recent incarceration experience are able to link to and stay engaged in HIV care, however, they achieve viral suppression at similar rates to the general community of people with HIV [29].

To end the HIV epidemic in the United States, it is imperative to identify and implement a range of interventions that support engagement along the HIV care continuum, including linkage to HIV care, retention in care, adherence to ART, and viral suppression, for people with HIV and recent incarceration experience. Recent reviews of interventions for this population, which included publications through 2018 and through 2021, have found few interventions with evidence of effectiveness, indicating a need for more innovation and research in this field [30–32]. In addition, only 1 of these recent reviews searched for and included promising interventions beyond what is published in the peer-reviewed literature. The purpose of our current review article, therefore, is to provide a more up-to-date and expansive assessment of interventions for people with HIV and recent incarceration experience. Our review covers the years 2020 through 2023 and includes interventions published in peer-reviewed journal articles as well as interventions that have not been formally evaluated or published.

This review was conducted as part of Using Innovative Intervention Strategies to Improve Health Outcomes Among People With HIV (2iS), a 4-year cooperative agreement (2021–2025) in collaboration with the Health Resources and Services Administration (HRSA) HIV/AIDS Bureau, funded through HRSA's Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance Program [33]. The initiative seeks to identify, implement, and evaluate interventions designed to improve HIV-related health outcomes among people with HIV across 4 focus areas, including people with incarceration experience, with the longer-term goal of disseminating effective interventions for replication. The interventions are being implemented and evaluated in geographically dispersed RWHAP settings, which provide direct medical care and support services to more than half of all people with diagnosed HIV in the United States [33].

METHODS

To identify interventions in the peer-reviewed literature, we searched PubMed, PsycInfo, and Embase for articles published between 1 January 2020 and 31 December 2023, using combinations of the following search terms in the title and abstract fields: HIV, incarcerate, incarceration, prison, correctional facility, correctional facilities, jail, release, post-release, post release, re-entry, reentry, reintegration, interventions, strategies, and best practices. We also scanned previous review articles to look for interventions missed by our search terms.

Due to the limited number of intervention studies in the peer-reviewed literature, we searched for interventions that have not been formally published (referred to here as gray literature) but have promising outcomes based on program evaluations. To identify these types of interventions, we searched TargetHIV.org, a website that disseminates HIV care training and resources for HRSA's RWHAP. TargetHIV serves as a repository of conference posters and presentations, webinars, fact sheets, intervention manuals, and other materials. To look for relevant literature on TargetHIV, we searched for materials tagged under the key population “incarcerated”; we also entered the following terms into the search tool: incarceration, prison, jail, re-entry, and reentry.

For this review, intervention inclusion criteria were as follows:

• The intervention was designed for people with HIV who are currently incarcerated or had been incarcerated within the last 5 years.

• The intervention study or evaluation quantitatively measured at least 1 of the following outcomes after release from incarceration: linkage to HIV care, retention in HIV care, adherence to ART, viral load reduction, or viral suppression.

• The intervention was conducted in the United States.

We restricted interventions to those conducted in the United States for conceptual clarity and because of a lack of available interventions from countries with similar health care systems and HIV epidemics.

RESULTS

Our search yielded 6 interventions reported in the peer-reviewed literature [34–40] and 4 interventions in the gray literature [41–45] for a total of 10 interventions. One peer-reviewed article combined the findings from 2 interventions that both took place in the same prison; we therefore decided to report these 2 interventions as a single intervention [40]. Table 1 provides a summary of intervention descriptions, settings, eligibility criteria, and participant demographics.

Table 1.

Interventions Designed to Support People With HIV and Incarceration Experience, 2020–2023

First Author or Developer (Year)	Name: Description	Incarceration Stage and Facility Type	Intervention Setting	Additional Eligibility Criteria	Demographics
Reentry services
Moyd (2022) [42]	Support Outreach and Re-entry: Prerelease reentry needs assessment and plan for medical care (2 sessions) provided by staff of community-based organization; coordinated by health department	Prerelease in jails and prisons	Maryland: 28 jails and prisons	None	85% male, 72% Black
Crable (2021) [34]	Project Bridge (adapted for people under community supervision): Intensive case management provided by social worker and outreach worker, transportation to appointments, weekly meetings for 3 mo, services for 12 mo	Postrelease from jails and prisons	Baltimore, MD: health center	On parole or probation, not engaged in HIV care	78% male, 96% Black
Hoff (2023) [35]	Community health worker plus reentry organization intervention (CHW+): Community health workers (ie, formerly incarcerated people) provide navigation to health care and substance use disorder treatment and to a reentry organization for help with employment, housing, and recidivism; clients also receive case management; begins within 60 d of release through 6 mo	Postrelease from county jail	Dallas, TX: reentry organization, community	Detectable viral load, not adherent, or not engaged in HIV care; at-risk substance use or substance use disorder	77% male, 71% Black
Health Resources and Services Administration (2020) [41]	Transitional Care Coordination From Jail Intake to Community HIV Primary Care: Transitional care coordinator starts prerelease planning within 48 h of jail intake; provides HIV education; assists with linkage to medical care and community services and obtaining discharge medications and insurance; postrelease transitional coordination for ≥90 d	Pre- and postrelease from jails	Camden, NJ; Las Vegas, NV; Chapel Hill, NC. Prerelease: jails. Postrelease: HIV care clinics, health department	None	84% male, 73% non-White
Sugarman (2023) [40]	Louisiana state prisons prerelease programs: (1) Ryan White Prerelease Program—6 meetings with a specialist from the state public health office to facilitate linkage to care upon release; (2) Medicaid Justice-Involved Prerelease Enrollment Program—for Medicaid-eligible people, 2 prerelease case management visits and option to enroll in a managed care organization case management program at postrelease	Prerelease in prisons	Louisiana: 8 state prisons	None	82% male, 77% Black
Tucker (2020) [43, 44]	Safe and Sound Return Partnership: Postrelease intensive case management and peer navigation for housing and employment from a community-based HIV organization. A city-wide task force was formed to increase coordination of medical, housing, mental health, and employment resources; all staff and peers received training on trauma and stigma.	Postrelease from jails and prisons	Chicago, IL: HIV service organization	Not engaged in HIV care, unhoused, unemployed or underemployed	78% male, 84% Black
Brody (2020) [45]	Design for the Margins: Pre- and postrelease intensive reentry case management; low-barrier entry to substance use disorder treatment and housing assistance; all-staff training on the causes of HIV and incarceration; outreach medical services	Pre- and postrelease from jails and prisons	Boston, MA. Prerelease: jails and prisons. Postrelease: health center, community	Unhoused	67% male, 56% Hispanic/Latino/a/ Latine
Wiersema (2020) [38]	Transitional Care Coordination in Puerto Rico: Pre- and postrelease care coordination and case management for 12 mo; transportation and accompaniment to health care; island-wide provider network to support reentry care and services; consortium of health, housing, and social service organizations; stakeholder convening	Pre- and postrelease from jails and prisons	Puerto Rico. Prerelease: federal detention center, 12 local facilities. Postrelease: transitional care organization, community	None	75% male, race/ethnicity not reported
Community-based group interventions
Rowell-Cunsolo (2020, 2023) [36, 37]	Project ADHerence Education and Risk Evaluation (ADHERE): Three 2-h group educational sessions on adherence, HIV health, and goal setting; sexually transmitted infection/HIV transmission, drug use, and sexual decision making; content review and risk reduction goals	Postrelease from jails and prisons	New York, NY: community	Not virally suppressed, history of illegal drug use	72% male, 77% Black
Wimberly (2020) [39]	Yoga for stress reduction: 12 weekly 90-min sessions of hatha yoga class and handouts for self-practice at home, plus standard HIV care	Postrelease from jails and prisons	Philadelphia, PA: community-based organization	Substance use disorder	68% male, 78% Black

Settings and Demographics

All 10 interventions were implemented in at least 1 location designated an Ending the HIV Epidemic priority jurisdiction (collectively, priority jurisdictions represent US local areas where more than half of new HIV diagnoses occur) [46], with 5 interventions (50%) taking place in mid-Atlantic US cities and states [34, 36, 37, 39, 41, 42]. One intervention was located in Puerto Rico [38], and the remaining interventions took place in cities scattered across the United States [35, 40, 43–45]. Interventions were delivered in a variety of correctional settings (local jails, state and federal prisons) and community settings (primary care organizations, HIV care clinics, community reentry organizations, and nonspecified community spaces).

With regard to participant demographics, all interventions had a majority of male participants (range, 67%–85%), and 7 interventions had a majority of participants who reported their race as Black/African American (range, 71%–96%) [34–37, 39, 40, 42, 44]. These demographics reflect the disproportionality of Black/African American men in the United States who are incarcerated [47] and who have HIV [48]. The majority race or ethnicity for the other interventions was non-White or Hispanic/Latino/a/Latine and was not reported for the Puerto Rico–based intervention [38, 41, 45].

Intervention Strategies

Reentry Services for Returning Citizens: Transitional Care Coordination

The standard of HIV care for people who are reentering the community after incarceration is the same as the standard for all people with HIV [12]. Usual care involves taking ART and visiting an HIV provider at least every 6 months for laboratory tests and for monitoring medication adherence, side effects, and response. It is recommended that all patients be assessed for needs and assigned a case manager accordingly, although the intensity level of case management does not always meet the acuity of needs [12]. “Reentry services,” also known as “transitional care coordination,” is an intervention strategy to provide additional help with engaging in HIV care and supportive social services upon returning to the community after incarceration. Receiving intensive health navigation and case management support during this period is crucial because of uncertainty with housing and employment, as well as challenges with mental health and substance use disorders, all of which can interfere with HIV care linkage, retention, and ART adherence [17, 32, 49–51]. Reentry services are typically offered by a specialist or team of specialists during the period prior to the client's release, immediately after the client's release, or both.

Of the 10 interventions from our review, 8 (80%) included the strategy of reentry services [34, 35, 38, 40–42, 44, 45]. These interventions differed according to the timing of reentry service delivery. Specifically, 2 interventions were conducted entirely within the jail or prison (ie, prerelease) [40, 42]; 3 took place before and after release from incarceration (ie, pre- and postrelease) [38, 41, 45]; and 3 were delivered postrelease only [34, 35, 43, 44]. Of note, 1 of the postrelease reentry interventions was delivered to people under community supervision who were not necessarily in the transitional stage of the postrelease period [34]. Among the interventions with a prerelease component, the number of prerelease visits by a specialist ranged from 2 to 8. For the interventions with a postrelease component, clients received reentry services anywhere from 90 days to 12 months.

The types and intensity of services differed among the reentry interventions. While each intervention involved a needs assessment and individualized plan for linking clients with HIV to community-based HIV care, some interventions provided postrelease case management for engagement in social and supportive services and/or navigation for accessing care and services, such as housing and employment resources [34, 35, 38, 41, 43, 45]. In some interventions, reentry specialists provided HIV treatment education, life skills coaching, accompaniment to court, direct observation of medication adherence, and/or enrollment of clients in health insurance and drug assistance programs [40, 41 , 45]. Additionally, 2 of the interventions focused on hiring peers (ie, people with HIV and/or lived experience in prison or jail) to provide postrelease care and service navigation [35, 43, 44]. The rationale for hiring peers is that people with shared lived experience potentially have a greater capacity to build trust and rapport with clients and thus more effectively engage them in care than those who are not peers [52, 53].

All the reentry interventions required coordination between a correctional facility and community partner, such as the public health department or an HIV service organization. Three reentry interventions, however, included additional organizational- or systems-level components [38, 44, 45]. The Design for the Margins intervention, for example, implemented organization-wide changes within a health center for people experiencing homelessness [45]. The health center added low-barrier entry to substance use disorder treatment (eg, same-day buprenorphine inductions), trained the entire organization in social factors contributing to HIV-related health outcomes and incarceration, integrated behavioral health care with primary care, and expanded its outreach team's capacity to bring care directly to people living in homeless encampments. The Transitional Care Coordination intervention, which was implemented across Puerto Rico, created a network of HIV care, housing, and social service organizations with integrated services to support community reentry for people with HIV [38]. The implementers also organized an annual stakeholder convening of 42 organizations to further build collaborations and increase workforce capacity for the reentry population [54]. Similarly, the Safe and Sound Return Partnership intervention in Chicago, Illinois, developed a task force of housing, medical, and employment providers across the city to increase cross-sector coordination and deliver trauma-informed services to people with HIV and reentry populations [44].

Community-Based Group Interventions

Two interventions from this review did not include reentry services [36, 39]; instead, these interventions involved community-based group sessions for people with HIV and recent incarceration experience who had substance use disorder and/or use illegal substances. One of the interventions [39] held 12 weekly group yoga classes to reduce the stress associated with reentry after incarceration, theorizing that stress reduction could lead to higher adherence and care engagement. The other group intervention, Project ADHerence Education and Risk Evaluation (ADHERE) [36, 37], involved three 2-hour educational sessions on medication adherence, HIV health, and sexual and drug risk reduction. This intervention was compared with a single hour-long group session on adherence.

Study and Evaluation Designs

Among the 6 interventions published in the peer-reviewed literature, 2 were studied in randomized controlled trials (RCTs) [34, 39], 2 in pilot RCTs [35, 36], 1 in a retrospective cohort study [40], and 1 in a pre- and posttest study [38]. The gray literature interventions had limited descriptions of evaluation designs or analysis methods. From what could be discerned from the documents reviewed, 1 intervention had a pre- and posttest evaluation design [41], and the other 3 had postintervention outcomes only [42, 44, 45].

HIV Care Continuum Outcomes

Due to the heterogeneity of methodology among interventions, we organized the HIV care continuum outcomes according to whether the intervention was reported in the peer-reviewed or gray literature. See Table 2 for a summary of intervention outcomes.

Table 2.

HIV Care Continuum Outcomes of Interventions for People With HIV and Incarceration Experience, 2020–2023

First Author (Year); Publication Type	Name: Description	Study Design (Comparison Condition) and Sample Size	HIV Care Continuum Outcomesa
Peer-reviewed literature
Crable (2021) [34]	Project Bridge: Intensive reentry case management for people under community supervision	RCT (TAU: list of HIV clinics); N = 100	18 mo LTC: No significant between-group differences Adherence: No significant between-group differences
Hoff (2023) [35]	Community health worker plus reentry organization intervention (CHW+): Intensive postrelease reentry peer navigation, access to reentry organization, and case management	Pilot RCT (TAU: list of HIV clinics); N = 31	6 mo Adherence: No significant between-group differences VS: No significant between-group differences 12 mo Retention (clinic attendance): No significant between-group differences
Rowell-Cunsolo (2020, 2023) [36, 37]	Project ADHerence Education and Risk Evaluation (ADHERE): Three 2-h community-based educational sessions	Pilot RCT (1-h education group); N = 32	3 mo Adherence: Control group had significantly better adherence (43.7% vs 35.7%, P < .05) VL: Control group was significantly more likely to experience a reduction in VL (risk ratio, 0.25; 95% CI, .07–.92)
Sugarman (2023) [40]	Louisiana state prison prerelease programs: Prerelease reentry sessions	Retrospective cohort study (no intervention); N = 681	Within 30 d after release LTC: Intervention group had significantly higher LTC than comparison group (47% vs 37%, P = .014; χ2 = 9.21, P = .002) 12 mo Retention: No significant between-group differences VS: No significant between-group differences
Wiersema (2020) [38]	Transitional Care Coordination in Puerto Rico: Pre- and postrelease care coordination and case management with island-wide consortium of care and service organizations	Pre- and posttest; N = 69	Within 30 d after release LTC: 74.1% 6 and 12 mo LTC: A greater proportion of clients were LTC than at baseline (χ2 [df = 2] = 15.2, P < .01) 12 mo LTC (received care at least once): 97.1% Retention: 78.6% VS: 84.6%
Wimberly (2020) [39]	Yoga for stress reduction: Community-based yoga classes	RCT (TAU: case management, free healthcare); N = 73	3 mo Adherence: No significant between-group differences VL: No significant between-group differences
Gray literature
Tucker (2020) [43, 44]; conference poster, implementation manual	Safe and Sound Return Partnership: Postrelease intensive reentry case management and peer navigation; city-wide, cross-sector task force	Postintervention; N = 109	2020 preliminary data LTC: 87% within 3 mo Retention: 80% VS: 72%
Moyd (2022) [42]; conference presentation	Support Outreach and Re-entry: Prerelease reentry sessions	Postintervention; N = 68	2021 annual data Retention: 53% VS: 72.5%
Brody 2020 [45]; conference presentation slides	Design for the Margins; Pre- and postrelease intensive reentry case management; low-barrier entry to care and services	Postintervention; N = 27	2019 annual data VS: 77%
Health Resources and Services Administration (2020) [41]; implementation manual, reports	Transitional Care Coordination: From Jail Intake to Community HIV Primary Care: Pre- and postrelease reentry navigation and support	Pre- and posttest; N = 229	2016–2019 LTC: 28% within 30 d, 53% within 120 d VS: 80% at 120 d (increase from 58% at baseline)

Abbreviations: LTC, linkage to care; RCT, randomized controlled trial; TAU, treatment as usual; VL, viral load; VS, virally suppressed.

^aAdherence refers to adherence to antiretroviral treatment. Retention refers to retention in care. VL and VS refer to the amount of HIV particles in a blood sample and an undetectable VL, respectively.

Peer-Reviewed Literature

Among the 5 peer-reviewed studies with a comparison group [34–37 , 39, 40], only the prerelease Louisiana state prisons program cohort study found a statistically significant positive association between the intervention and an HIV care continuum outcome [40 ]. Specifically, people with HIV who received 2 to 6 prerelease reentry meetings had a 60% higher adjusted odds of linking to HIV care within 30 days of release than people with HIV who did not receive an intervention (47% vs 37%, P = .014; χ² = 9.21, P = .002) [40]. Upon follow-up at 12 months, however, the intervention group did not have significantly better retention in care or viral suppression outcomes than the comparison group.

Three of the other peer-reviewed studies with comparison groups included Project Bridge and Community Health Worker Plus Re-Entry Organization, both postrelease reentry interventions, and the postrelease community-based yoga sessions intervention. Medication adherence outcomes improved in all 3 interventions, but there were no statistically significant differences between the intervention and control groups [34, 35, 39]. Possible explanations for the lack of significant between-group differences in these studies include the similarities between the intervention and usual care in the area where the study took place [24], being underpowered to detect differences [25, 39], inadequate duration of follow-up [39], and limited intervention activities during the onset of the COVID-19 pandemic [25].

Finally, 1 intervention found that the control group had better HIV care continuum outcomes than the intervention group. Specifically, in the pilot RCT of ADHERE (a 3-part educational group intervention), the intervention group had significantly worse adherence (35.7% vs 43.7%, P < .05) and was less likely to experience viral load reduction (risk ratio, 0.25; 95% CI, .07–.92) at 3 months postintervention than the control group (a single brief educational session) [36].

The 1 peer-reviewed study without a comparison group was the pre- and posttest evaluation of the multilevel, systems-level reentry intervention called Puerto Rico Transitional Care Coordination. This evaluation found a large and statistically significant improvement among people with HIV receiving HIV medical care at 6 and 12 months postrelease (94.3% and 97.1%, respectively), as compared with the 6 months prior to incarceration (68.6%; χ²[df = 2] = 15.2, P < .01). Additionally, viral suppression decreased slightly but not significantly 12 months after incarceration (92.3% while incarcerated vs 84.6% at 12 months) [38].

Gray Literature

Among the 4 interventions described in the gray literature, all 4 reported between 72% and 80% average viral suppression at the final measurement period (range, 120 days–12 months); yet, these analyses may not have accounted for participants with missing laboratory data and/or participants who were not linked to or retained in care. The multilevel, systems-level reentry intervention called Safe and Sound [44] reported 87% linkage to care at 3 months and 80% retention in care at 1 year, whereas the 2 individual-level reentry interventions had less optimal outcomes: 53% linkage at 4 months (Transitional Care Coordination From Jail Intake to Community HIV Primary Care) [41] and 53% retention at 1 year (Support Outreach and Reentry) [42]. Transitional Care Coordination clients who had an encounter with the transitional care coordinator within 5 weeks postrelease, however, were more likely to ever link to care than those who did not have any postrelease encounters (P < .001) [41]. Again, none of these interventions explained their methodology, making it difficult to compare outcomes.

Additional Outcomes

Among the reentry intervention studies that measured non–HIV care continuum outcomes (not shown in tables), the Community Health Worker Plus intervention demonstrated statistically significant improvements in stimulant use, employment, housing stability, and food security as compared with controls who received treatment as usual [35]. In the transitional care coordination intervention in Puerto Rico, fewer participants reported food insecurity or needing transportation to access care at 6 and 12 months postincarceration, as compared with the 6 months prior to incarceration [38]. ADHERE and control participants both demonstrated significant reductions in substance use [36]. Finally, a 2018 analysis of the RCT on yoga for stress reduction among people with HIV and recent incarceration experience found that the intervention had a statistically significant medium-sized effect on reducing substance use [55].

DISCUSSION

If the United States is to end the HIV epidemic, it is imperative to improve outcomes among people with the most complex and pervasive barriers to linkage to care, ART adherence, retention in care, and viral suppression [56], which includes people with recent incarceration experience. In this review, we found only 10 interventions that were designed to improve HIV care continuum outcomes for this population, despite expanding our search to include informal publications from the gray literature. Moreover, only 2 of these interventions demonstrated statistically significant evidence of improvement in HIV-related outcomes as compared with usual care. Previous reviews of interventions for this population have also found a limited number of effective interventions [30–32]. Thus, there appear to be few interventions available for replication and scale-up to address barriers to HIV care engagement and viral suppression among people with recent incarceration experience in the United States.

Most of the interventions in our review focused on providing reentry services to support people with HIV returning to the community; 3 of these interventions incorporated organizational changes or systems-level cross-coordination of social services. While the multilevel, systems-level interventions in our review reported promising pre- and posttest and postintervention findings, more rigorous research is needed to better understand the impact of these interventions [38, 44]. Given the complex factors that impede engagement in HIV care during community reentry and beyond, combining systems-level interventions with individual-level support may be an effective path forward [22, 49]. The complex needs of people with HIV and incarceration experience, combined with service gaps across the United States [57, 58], also suggest a need to build the internal capacity of HIV care organizations to provide supportive wrap-around services. Design for the Margins is an example of an intervention that built the internal capacity of an HIV care organization to provide intensive reentry services as well as integrated low-barrier entry to substance use disorder treatment, mental health care, housing services, and outreach-based services [45]. Again, more research is needed to understand the efficacy and effectiveness of such approaches.

This review revealed gaps in the recent literature. First, although previous studies have demonstrated positive impacts on HIV care continuum outcomes for injectable extended-release medications that treat substance use disorders and for small financial incentives for care engagement [59, 60], these strategies did not appear in our search for interventions. There also have not yet been studies on providing long-acting injectable [61, 62] ART to people leaving incarceration who need a bridging strategy while linking to care in the community. With long-acting injectable ART, people who have an undetectable viral load upon release would be able to maintain viral suppression for at least a month even if they are unable to quickly acquire a prescription and link to care [61, 62].

Additionally, our search did not find any interventions that directly addressed mental health, even though untreated mental illness, such as depression and anxiety, is prevalent among people with HIV and recent incarceration experience [63, 64] and is known to be associated with poor HIV health outcomes [65, 66]. More strategies and innovations are needed that address mental health and substance use disorders among people with HIV and incarceration experience. Finally, the United States could benefit from adapting successful reentry interventions developed in other countries with similar HIV epidemics and care delivery; however, to our knowledge, neither the peer-reviewed nor gray literature includes such interventions.

In sum, there are limited interventions designed for people with HIV and recent incarceration experience, and few of these have demonstrated improving outcomes over standard of care. More research on innovative and emerging interventions for people with HIV and recent incarceration experience is critical for the future of the HIV epidemic in the United States.

Notes

Author contributions . M. D. conducted the literature search, curated the data, and completed the analysis. H. G. conceptualized the manuscript, reviewed the methodology, validated the findings, and wrote the manuscript. A. S. K. conceptualized and supervised the development of the manuscript. M. D., K. K., N. S. C., D. P., M. P. M., J. S., J. M., S. C., K. H. M., and A. S. K. reviewed, provided comments for, and helped to edit the manuscript. N. S. C., D. P., and M. P. M. reviewed, provided comments for, and provided regulatory guidance for the manuscript. M. D., H. G., and A. S. K. finalized the manuscript based on comments from all authors and other reviewer feedback.

Disclaimer . The views expressed in this publication are solely the opinions of the authors and do not necessarily reflect the official policies of the US Department of Health and Human Services or the Health Resources and Services Administration, nor does mention of the department or agency names imply endorsement by the US government.

Financial support. This work was supported by the US Department of Health and Human Services, Health Resources and Services Administration (U90HA42153).

Potential conflicts of interest . A. S. K. declares royalties as editor of a McGraw Hill textbook on transgender and gender-diverse health care and an American Psychiatric Association Publishing textbook on gender-affirming psychiatric care. All other authors report no conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest.