To the Editor—Antiretroviral therapy (ART) has decreased human immunodeficiency virus (HIV) morbidity and mortality [1]. However, efficacy is dependent upon adherence, which is influenced by behavioral, social, and structural factors. Among these, incarceration can negatively impact ART adherence [2–4]. The time after release from incarceration, termed community reentry, can be a period of poor ART adherence, subsequent viral rebound, and potential HIV transmission to sexual and substance-using partners [3, 5, 6]. A recent review demonstrated that linkage to care and adherence were significantly worse during community reentry compared to the periods prior to and during incarceration [2]. Innovative approaches to improve adherence to ART during community reentry are urgently needed given that criminal justice populations have an increased prevalence of HIV compared to the general population [7, 8].
Long-acting injectable (LAI) ART is a future alternative to oral ART that can address the challenges of daily adherence [9]. LAI ART should be considered for individuals who are leaving correctional institutions in an effort to maintain viral suppression. The use of LAI medications has been successful for many other indications [10–12]. Now, similar drug delivery technology has been developed for ART that allows for dosing every 4–8 weeks, bringing hope of consistent therapeutic ART levels between doses, viral suppression, and lower risk of transmission. Clinical trials have demonstrated similar potency, efficacy, and side effect profiles between LAI and oral ART [13–17]. However, to be eligible for LAI, one must first achieve viral suppression using oral ART.
Given that most HIV-infected individuals in prison have access to oral ART and more often achieve viral suppression [2] but have poor adherence during community reentry, LAI ART should be investigated as an option for persons being released from prison. Individuals could be transitioned to LAI ART prior to release, thus providing uninterrupted ART during community reentry. Following linkage to community care, LAI ART could be continued or a transition to oral ART could occur.
However, there are potential challenges to this approach that must be investigated. Linkage to HIV care is necessary, yet remains an obstacle for this population. Therefore, any LAI ART intervention should be offered in combination with supportive services. There will also be practical considerations such as determining patient eligibility and training correctional and community providers. The cost of LAI ART, which is currently undetermined, may also pose challenges to constrained correctional budgets. Additionally, a number of ethical concerns should be considered, including the need to assure voluntary decision making among patients regarding HIV treatment options. Finally, use of LAI ART would likely be limited to persons who are incarcerated for at least 6 months to sufficiently confirm viral suppression on oral ART and the ability to transition patients to LAI ART prior to release.
Considering the potential benefits, use of LAI ART should be explored among incarcerated persons nearing release. First, though, we must identify how to successfully implement LAI ART programs in correctional settings with linkage to treatment in the community. Therefore, research investigating the feasibility, acceptability, and efficacy of LAI ART in this population must be prioritized.
Notes
Financial support. This work was supported by the Providence/Boston Center for AIDS Research (P30AI043853 to C. G. B.); the National Institute on Drug Abuse (R25DA037190 to L. B.-R. and C. G. B., R25DA035692 and T32DA013911 to L. B.-R.); and the Center for AIDS Research at the University of North Carolina, Chapel Hill (P30AI50410 to D. L. R. and L. B.-R.).
Potential conflicts of interest. All authors: No reported conflicts of interest. 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.
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