Abstract
We evaluated highly active anti-retroviral therapy (HAART) use and risk behaviors among 177 inmates who were HIV infected and were released and reincarcerated in San Francisco, Calif, jails over a 12-month period. During the month preceding reincarceration, HIV transmission risk behaviors were common among respondents, and 59% of those with a history of antiretroviral use were not taking HAART. HAART discontinuation was independently associated with homelessness, marijuana use, injection drug use, and not receiving community medical care. Postrelease interventions for inmates who are HIV infected are needed.
A quarter of the adults who are HIV infected in the United States pass through correctional facilities annually.1 Incarceration represents an opportunity to provide critical HIV prevention and health services, including highly active antiretroviral therapy (HAART).2–6 The structured environment of jail and prison promote high rates of medication adherence,7–9 leading to favorable virological and immunologic outcomes.8,10–12 However, 2 recent studies documented rising viral loads and falling CD4 cell counts among prisoners who were released and then rein-carcerated.11,12 These results suggest that ex-offenders may have difficulty transitioning from a situation in which antiretroviral therapy is taken in a structured and often directly observed setting to one in which medications must be self-managed while facing the challenges of community reentry.12 Homelessness, joblessness, drug use, mental illness, and inconsistent health care among recently released inmates who are HIV infected likely contribute to discontinuation of or low adherence to treatment.5,11,12
To our knowledge, no studies to date have directly assessed HAART use and adherence or factors associated with HAART use among recently released inmates. Furthermore, few studies have described the postrelease sexual and drug-related behaviors in this population.13,14 To better understand antiretroviral use and HIV transmission behaviors of recently released inmates, we studied 177 inmates who were HIV infected and were released and then reincarcerated in the San Francisco, Calif, jail system in a 12-month period.
METHODS
Participants and Recruitment
The San Francisco Department of Public Health’s Forensic AIDS Project provides medical care, case management, discharge planning, and community referrals for all inmates who are HIV infected and who were identified through voluntary testing and inmate disclosure. Inmates taking HAART are released with a 7-day medication supply and a 1-month refill prescription. In 2001, a demonstration grant15–17 enhanced Forensic AIDS Project services by linking inmates who are HIV infected with community case managers before release and providing 5 months of postrelease supportive services.16,17
From April 2001 through June 2003, Forensic AIDS Project providers approached all inmates who were HIV infected to determine participation interest. Interested individuals were referred to research associates who confirmed eligibility, obtained written informed consent, and conducted interviews in private rooms. Inmates were eligible if they (1) were at least 18 years old, (2) spoke English or Spanish, and (3) had at least 2 weeks of jail time remaining in their sentence. Those with a planned transfer to another correctional facility or a documented mental health condition requiring community psychiatric placement were ineligible.
Analyses were restricted to 177 inmates who had been released from San Francisco jails at any point during the 12 months prior to the first day of their current incarceration (68% of the study participants).
Measures
The interview assessed sociodemographics, incarceration history, and use of services the month preceding reincarceration. The date participants last visited a community provider for HIV-related medical care was compared with their release date to determine the proportion receiving postrelease care. Participants prioritized the service they thought they would need most when released.
The Center for Epidemiological Studies Depression Scale was used to screen for depression18 with the standard cutoff score of 16 or higher.19 Two or more positive responses on the CAGE Questionnaire indicated past or present alcohol dependence.20,21 Sexual and drug use behaviors the month preceding reincarceration were measured. Serodiscordant unprotected sexual intercourse included any anal or vaginal intercourse with partners of opposite or unknown HIV status when a condom was not used.
Participants were given a pill card with pictures to determine antiretroviral use during the month preceding reincarceration. Antiretroviral use was classified as HAART according to recommendations from the International AIDS Society–USA Panel.22,23 Participants were also asked how many times a week they missed at least 1 dose or did not take a full dose of medication (dichotomized as never or less than once a week vs once a week or more).
Statistical Methods
Among participants with a history of anti-retroviral therapy use (n = 108), we used χ2 analyses to assess factors associated with lack of HAART use during the month preceding reincarceration. We entered variables associated with lack of HAART use in bivariate analyses (P ≤ .05) into a logistic regression model simultaneously; age, gender, race/ethnicity, and AIDS diagnosis were forced into the model. A correlation matrix of all multivariate parameter estimates detected no serious multicollinearity; deviance and Pearson residuals confirmed good model fit. Analyses were conducted with SAS version 9.0 (SAS Institute Inc, Cary, NC).
RESULTS
Overall, participants were economically disadvantaged, and repeat incarceration was common. More than half of the participants were homeless the month preceding reincarceration, and housing was their most pressing postrelease service need. Community behavioral risk taking included serodiscordant unprotected sexual intercourse (27%–38%) and distributive syringe sharing (17%). Almost two thirds had a history of antiretroviral use (n = 108); however, 59% of this group (n = 64) did not use HAART the month preceding reincarceration. Among HAART users (n = 44), 52% missed medication doses once a week or more (Table 1 ▶).
TABLE 1—
Characteristics of 177 HIV-Positive Jail Inmates Who Were Released and Reincarcerated in a 12-Month Period: San Francisco, Calif, January 2000 to June 2003
| No. (%) or Median (Range) | |
| Demographics | |
| Median age, y | 39.5 (22–62) |
| Gender | |
| Men | 145 (82) |
| Women | 20 (11) |
| Transgender, male-to-female | 12 (7) |
| Race/Ethnicity | |
| African American | 95 (54) |
| White | 58 (33) |
| Hispanic | 18 (10) |
| Othera | 6 (3) |
| Educationb | |
| Less than high school or general equivalency diploma | 62 (35) |
| High school or general equivalency diploma | 63 (36) |
| More than high school | 51 (29) |
| Homelessc (month preceding reincarceration) | 94 (53) |
| Health insuranceb | |
| None | 81 (48) |
| Public | 85 (50) |
| Private | 4 (2) |
| ADAP or Medicaid coverage for HIV medications (month preceding reincarceration) | 108 (61) |
| Median monthly income (month preceding reincarceration),b,d $ | 900 (0–24 000) |
| Documented AIDS diagnosis | 60 (34) |
| Median jail and prison incarcerationsb | 17 (3–130) |
| Community service use | |
| Receipt of HIV medical careb (between release and reincarceration) | 106 (61) |
| Case management visitb (month preceding reincarceration) | 68 (39) |
| Mental health provider visit (month preceding reincarceration) | 31 (18) |
| Alcohol or drug treatment (month preceding reincarceration) | 50 (28) |
| Anticipated postrelease service needsb | |
| Housing | 97 (55) |
| HIV medical care | 22 (13) |
| Substance abuse treatment | 16 (9) |
| Case management | 11 (6) |
| Other servicese | 29 (17) |
| Depression and alcohol drug dependence | |
| Depression: Center for Epidemiological Studies Depression Scale score ≥ 16b | 137 (78) |
| Alcohol dependence: CAGE score ≥ 2 | 75 (42) |
| Drug use (month preceding reincarceration) | |
| Crack cocaine (noninjection) | 103 (58) |
| Marijuana (nonprescription) | 90 (51) |
| Methamphetamine (noninjection) | 46 (26) |
| Heroin (noninjection) | 22 (12) |
| Cocaine (noninjection) | 14 (8) |
| Amyl nitrites | 8 (5) |
| Club drugs (MDMA, GHB, ketamine, LSD) | 6 (3) |
| Injection drug useb | 91 (52) |
| Receptive syringe sharingf | 22 (24) |
| Distributive syringe sharingb,f | 15 (17) |
| Sharing other drug equipmentf | 31 (34) |
| Sexual behaviors | |
| Men who had sex with men (month preceding reincarceration) | |
| Serodiscordant/unknown UAIg | 11 (27) |
| Men who had sex with women (month preceding reincarceration) | |
| Serodiscordant/unknown UVIh | 23 (28) |
| Women who had sex with men (month preceding reincarceration) | |
| Serodiscordant/unknown UVIh | 13 (38) |
| Male-to-female transgender people who had sex with men (month preceding reincarceration) | |
| Serodiscordant/unknown UAIg | 8 (38) |
| Antiretroviral therapy history | |
| History of antiretroviral therapyb | |
| Yes | 108 (62) |
| No | 65 (38) |
| HAART use (month preceding reincarceration)i | |
| Yes | 44 (41) |
| No | 64 (59) |
| Missed HAART doses (month preceding reincarceration)b,j | |
| Never or less than once a week | 20 (48) |
| More than once a week | 22 (52) |
Note. ADAP = AIDS Drug Assistance Program; MDMA = methylenedioxymethamphetamine, GHB = γ-hydroxybutyrate, LSD = lysergic acid diethylamide; UAI = unprotected anal intercourse; UVI = unprotected vaginal intercourse; HAART = highly active antiretroviral therapy.
a“Other” included American Indian (4), Asian/Pacific Islander (1), and Creole (1).
bMissing data: education (1), health insurance (7), median income (4), median lifetime incarcerations (8), community HIV medical care (3), community case management (2), history of antiretroviral use (4), HAART adherence (2), depression (2), injection drug use (1), distributive syringe sharing (1).
cHomeless was defined as having spent at least 1 night on streets, in parks, in abandoned buildings, or in shelters during the month preceding reincarceration.
dCombines all illegal and legal sources of income, including benefits (before taxes).
eOther services included food assistance, education, job training, financial benefits, mental health care, and family services; each represented less than 5% of the sample.
fAmong injection drug users (n = 91).
gAmong men who had sex with men (n = 41) and transgender persons who had sex with men (n = 8).
hAmong men who had sex with women (n = 81) and women who had sex with men (n = 13).
iAmong those who ever used antiretroviral therapy (n = 108).
jAmong those who used HAART the month preceding reincarceration (n = 44).
In the multivariate model, lack of HAART use during the month preceding reincarceration was significantly associated with homelessness, marijuana use, injection drug use, and not receiving community medical care (Table 2 ▶).
TABLE 2—
Factors Associated With Lack of Highly Active Antiretroviral Therapy (HAART) Use the Month Preceding Reincarceration in Jail: San Francisco, Calif, January 2000 to June 2003
| No HAART Use (n = 64),a No. (%) | HAART Use (n = 44),a No. (%) | AOR (95% CI) (n = 106)b | |
| Age | |||
| ≤ Median (39.5 y) | 34 (53) | 19 (43) | 0.59 (0.22, 1.53) |
| > Median | 30 (47) | 25 (57) | Reference |
| Gender | |||
| Men | 48 (75) | 36 (82) | 0.39 (0.12, 1.26) |
| Women or transgender | 16 (25) | 8 (18) | Reference |
| Race | |||
| African American | 31 (48) | 27 (61) | 1.15 (0.43, 3.09) |
| Other | 33 (52) | 17 (39) | Reference |
| Education | |||
| Less than a high school or general equivalency diploma | 28 (44) | 13 (30) | . . . |
| High school or general equivalency diploma | 36 (56) | 30 (70) | |
| Homeless | |||
| Yes | 38 (59) | 16 (36)* | 2.71 (1.04, 7.08)* |
| No | 26 (41) | 28 (64) | Reference |
| Monthly income | |||
| ≤ Median ($900) | 31 (48) | 26 (62) | . . . |
| > Median | 33 (52) | 16 (38) | |
| AIDS diagnosis | |||
| Yes | 32 (50) | 21 (48) | 1.78 (0.67, 4.75) |
| No | 32 (50) | 23 (52) | Reference |
| No. of times previously incarcerated | |||
| ≤ Median (17 times) | 27 (43) | 18 (45) | . . . |
| > Median | 36 (57) | 22 (55) | |
| Received postrelease HIV medical care | |||
| Yes | 36 (57) | 35 (81) | Reference |
| No | 27 (43) | 8 (19)** | 3.08 (1.05, 9.05)* |
| Case management visit | |||
| Yes | 26 (41) | 16 (37) | . . . |
| No | 37 (59) | 27 (63) | |
| Mental health provider visit | |||
| Yes | 9 (14) | 9 (20) | . . . |
| No | 55 (86) | 35 (80) | |
| Alcohol or drug treatment | |||
| Yes | 16 (25) | 13 (30) | . . . |
| No | 48 (75) | 31 (70) | |
| Depression (Center for Epidemiological Studies Depression Scale score ≥ 16) | |||
| Yes | 51 (81) | 34 (79) | . . . |
| No | 12 (19) | 9 (21) | |
| Alcohol abuse (CAGE score ≥ 2)c | |||
| Yes | 26 (41) | 12 (27) | . . . |
| No | 38 (59) | 32 (73) | |
| Marijuana use (nonprescription) | |||
| Yes | 42 (66) | 15 (34)*** | 3.63 (1.39, 9.52)** |
| No | 22 (34) | 29 (66) | Reference |
| Crack cocaine use (noninjection) | |||
| Yes | 43 (67) | 24 (55) | . . . |
| No | 21 (33) | 20 (45) | |
| Methamphetamine use (noninjection) | |||
| Yes | 19 (30) | 6 (14)* | 1.31 (0.40, 4.30) |
| No | 45 (70) | 38 (86) | Reference |
| Injection drug use | |||
| Yes | 41 (64) | 19 (44)* | 3.17 (1.16, 8.67)* |
| No | 23 (36) | 24 (56) | Reference |
Note. AOR = adjusted odds ratio; CI = confidence interval. Ellipsis indicates that the variable was not entered in multivariate mode.
aWe used the χ2 test to assess group differences in HAART use among 108 participants with a history of any antiretroviral use; 4 participants had missing data for antiretroviral use.
bBased on logistic regression with simultaneous entry (probability of not using HAART modeled); 2 participants were not included because of missing data on 1 or more variables.
cCAGE is a 4-question alcoholism screening instrument whose name is a mnemonic designating an individual who has attempted to “cut down” on alcohol consumption, is “annoyed” by criticism of his or her drinking, feels “guilty,” and needs an “eye-opener” drink in the morning. The presence of 2 or more of these characteristics is considered indicative of an alcohol use disorder.
*P ≤.05; **P ≤.01; ***P ≤.001.
DISCUSSION
Although nearly three fourths of the inmates who are HIV infected in San Francisco jails who need antiretroviral therapy take it,10 we observed alarmingly low rates of HAART use and adherence among inmates who were released into the community and then reincarcerated. Our results support results of recent studies that documented loss of clinical benefits from HAART postrelease.11,12 Suboptimal HAART use while in the community compromises the personal health of ex-offenders and may increase HIV transmission,24–26 including transmission of drug-resistant strains.27,28 This is particularly troubling given the rates of serodiscordant unprotected sexual intercourse and distributive syringe sharing we observed and others have reported.14,29–31
Consistent with studies among the urban poor, we identified several barriers to post-release HAART use that may be amenable to intervention, including homelessness,32,33 injection drug use,34–36 marijuana use,37 and inconsistent medical care33,38,39; however, we did not find an association with depression.34,40–42 Many exoffenders have limited access to food, refrigeration, and a safe place to store medications,43 and the provision of stable housing may be a necessary first step44 toward sustaining postrelease HAART use. Also, more drug treatment options11,45–47 are urgently needed, and comprehensive programs that link inmates who are HIV infected to health services,48–52 support medication adherence,43 and reduce behavioral risk taking13,53–55 are essential.
Our study may have overestimated community risk, because the month preceding rein-carceration is often unstable and chaotic.54 Additionally, research has shown that use of self-report to document HIV medication adherence is limited,56 and temporality could not be established with our cross-sectional design.
Despite these limitations, our results highlight the need for coordinated public health interventions that begin during incarceration and continue postrelease. Such interventions are critical to improving health outcomes for inmates who are HIV infected and preventing further HIV transmission in the community.
Acknowledgments
The Corrections Demonstration Grant, jointly funded by the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration, funded the intervention. Supplemental evaluation funding was provided by the state of California, Office of AIDS, and the CDC.
We appreciate assistance in all aspects of the study from Continuum HIV Day Services; San Francisco Department of Public Health, Forensic AIDS Project; San Francisco Department of Public Health, AIDS Office; and the San Francisco Sheriff’s Department. Specifically, we would like to thank Cicily Emerson for study coordination; Naomi Akers, Ari Bachrach, Octavia Baker, Alice Heimsoth, Jessie James, Jelousy Jiggets, Zappa Montag, and Jessie Wofsy for participant interviewing; and Hilda Erlenbach, Christine Geoghegan, Shoshana Hall, Susan Halperin, and Sharon Hofer for participant recruitment.
We would like to dedicate this brief to Michael Pendo (August 10, 1964–November 15, 2005), who directed the study and was committed to improving the health of inmates and other underserved populations.
Human Participant Protection All study protocols and materials received approval from the Committee on Human Research at the University of California, San Francisco, and the Data Governance Committee of San Francisco General Hospital. In addition, a Certificate of Confidentiality protecting study participants was obtained from the Centers for Disease Control and Prevention.
Peer Reviewed
Contributors K. Clements-Nolle designed the research study, conducted the data analysis, and drafted the brief. R. Marx contributed to study design and assisted with writing and revising the brief. M. Pendo directed the study and assisted with writing early drafts of the brief. E. Loughran coordinated field aspects of the study, conducted chart reviews for analysis, and contributed to revisions of the brief. M. Estes coordinated participant recruitment and contributed to revisions of the brief. M. Katz provided guidance on study design and data analysis and assisted with writing and revising the brief.
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