HIV and Re-Incarceration: Time for a Comprehensive Approach

COMMENT

Individuals who are released from prison have complex health needs that are too often unmet by the health care system.^1,2 In The Lancet HIV, Jaimie Meyer and colleagues³ describe longitudinal treatment outcomes for a cohort of people living with HIV/AIDS who repeatedly interact with the criminal justice system. Their analysis demonstrated very low rates of viral suppression for multiply-incarcerated individuals who spent a median of 329 days living in the community between periods of incarceration. While national surveillance data suggest that more than 70% of people who are prescribed antiretroviral therapy (ART) achieve viral suppression, only 31% of patients incarcerated more than once, all of whom previously received ART, had viral suppression at the time of re-incarceration.

Who are “recidivists” and why do they fare so poorly in the current era of highly-effective and well-tolerated HIV treatment? In Connecticut as elsewhere in the U.S., incarceration disproportionately affects persons of color, the poor, and those with mental illness and substance use disorders. These same characteristics are markers for increased risk of HIV, viral hepatitis and other chronic conditions.⁴ Among those incarcerated and released, recidivism appears to signify a high-risk group within a high risk group: In previous research, recidivism was associated with the presence of major psychiatric disorders, homelessness, and low access to medical care.⁵ The observed association between recidivism and suboptimal HIV treatment outcomes is therefore not surprising.

The extent to which incarceration leads directly to poor health or simply represents a frequent experience shared by those in society with the highest risk of disease is not fully understood. Cohort studies have suggested that for some HIV-infected patients who successfully achieve viral suppression while living in the community, incarceration is an independent risk factor for treatment interruption and viral rebound.^6,7 It is also clear that the period immediately following release from prison is associated with extraordinary levels of vulnerability. During the first 2 weeks after release from prison, residents of Washington state were 129 times more likely to die from a drug overdose than members of the general public and 12 times more likely to die of any cause.⁸ On the other hand, prisons provide medical treatment to many who do not access care in the community, and by temporarily removing individuals from environments that reinforce hazardous behavior such as excessive drug and alcohol use, may serve as a bridge to lifestyle changes that can be lifesaving. The challenge for both corrections and public health, is to extend the obligation to protect and promote health for incarcerated persons to beyond the prison gate.

While the disruptive effect of incarceration on HIV treatment is now well-documented, there is no reason to expect that the long-term control of other chronic medical and psychiatric conditions is any better. Common conditions that are overrepresented in criminal justice involved populations such as diabetes, depression, bipolar disorder, chronic lung disease similarly require consistent adherence and medical supervision. Comprehensive strategies to support the complex health challenges of formerly-incarcerated patients are needed. Various approaches to this have been implemented and are being evaluated, including the Transitions Clinic model^9,10 and post-release patient navigation.¹¹ It is clear that prisoners with complex chronic medical conditions need both comprehensive discharge planning, including efficient record transfer, as well as an understanding of the urgency of immediate linkage to care on the part of community providers. Developing successful strategies to support transitions in HIV care will have collateral benefits as correctional systems learn lessons that can be easily applied to other conditions such as hepatitis C virus.¹²

Meyer and colleagues’ paper shines much-needed light on a population of adults in dire need of extra support for accessing and consistently utilizing health services. Achieving substantial declines in HIV transmission through “treatment as prevention” will not be possible without focused interventions addressing the causes of treatment failure for patients involved in the criminal justice system. To date, incarceration has been shown to be generally deleterious for HIV control, but it nonetheless provides opportunities to test, treat, and link individuals to care who may otherwise go undiagnosed for years. We should take advantage of both the structured environments and mandated access to services given to those who are incarcerated as well as the opportunities available to many by the affordable care act¹³ in order to improve health and promote sustained engagement in care after release.