Abstract
Few studies on HIV-related syndemics of co-occurring and mutually reinforcing psychosocial conditions have assessed clinical outcomes in criminal justice (CJ)-involved populations. Baseline data from the CARE+ Corrections study were used to quantify co-occurring mental illness and substance use and examine syndemic effects on viral suppression among 106 CJ-involved HIV-infected individuals. Ninety-one (86%) reported a mental illness diagnosis, 30 (28%) reported hazardous alcohol use, and 61 (58%) were drug dependent. Eighteen (17%) experienced all three conditions. Drug dependence was clustered with mental illness (prevalence odds ratio [POR] 3.20, 95% CI 1.01–10.14) and hazardous alcohol use (POR 2.61, 95% CI 1.03–6.56). The association between syndemic score, representing the number of conditions reported by each individual, and viral suppression was not statistically significant, although 86% of participants with none of these conditions were virally suppressed, compared to 56% of those with all three (p = 0.56). Mental illness and substance use were concentrated in this sample, indicating a need for integrated care services.
Keywords: criminal justice system, HIV, syndemics, mental illness, substance use
Introduction
HIV infection, mental illness, and substance use disorders are highly prevalent in the criminal justice (CJ) system, and often co-occur (Baillargeon et al., 2008; Di Paola, Altice, Powell, Trestman, & Springer, 2014; Dumont, Brockmann, Dickman, Alexander, & Rich, 2012; Springer, Spaulding, Meyer, & Altice, 2011). These conditions can present substantial challenges to HIV treatment engagement and medication adherence, and may impede viral suppression (Carrico, Bangsberg, et al., 2011; Carrico, Riley, et al., 2011; Chander et al., 2009; Meyer, Chen, & Springer 2011; Pence, Miller, Gaynes, & Eron, 2007; Springer, Azar, & Altice, 2011; Yehia et al., 2015). Syndemic theory is increasingly used to characterize such co-occurring and mutually-reinforcing health and social conditions and help explain health disparities (Halkitis, Wolitski, & Millett, 2013; Tsai & Burns, 2015). Researchers have demonstrated that higher syndemic burden, measured as an additive score representing the number of syndemic conditions, is associated with reduced odds of viral suppression and higher viral load among various populations, including HIV-positive people who inject drugs and women of color (Friedman et al., 2015; Mizuno et al., 2015; Sullivan, Messer, & Quinlivan, 2015).
Most research on HIV-related syndemics has focused on HIV risk (Robinson, Knowlton, Gielen, & Gallo, 2016). The relationship between viral suppression and syndemic psychiatric and substance use disorders has not been evaluated among CJ-involved individuals. A recent systematic review found that clinical outcomes among released inmates represent the largest gap in the literature (Iroh, Mayo, & Nijhawan, 2015).
Using baseline data from the CARE+ Corrections study, we aimed to determine whether mental illness, hazardous alcohol use, and drug dependence are independent correlates of viral suppression and assess the relationship between viral suppression and syndemic burden of these conditions among recently-incarcerated, HIV-infected individuals.
Methods
Study Population
Baseline data collected between August 2013 and April 2015 were obtained from the CARE+ Corrections study, a randomized controlled trial testing a computerized counseling intervention to improve linkage to care and medication adherence among HIV-infected individuals released from District of Columbia correctional facilities within the previous six months (Beckwith et al., 2017). Of 497 individuals screened, 112 study-eligible participants were enrolled. Two participants (1.8%) did not complete the baseline visit and four (3.6%) did not complete the baseline HIV plasma viral load measurement; the final analytic sample size was 106.
Measures
Participants self-reported ever being diagnosed with schizophrenia, depression, bipolar disorder/manic depression, a personality disorder, or another mental illness. Alcohol use and drug dependence in the year prior to incarceration were measured using validated instruments (WHO-Alcohol Use Disorders Identification Test and TCU Drug Dependence scale) (Daeppen, Yersin, Landry, Pe, & Decrey, 2000; Pankow et al., 2012). Syndemic score was calculated by summing the number of conditions reported. This method has been used in the literature to investigate the effect of cumulative psychosocial factors on the outcome of interest (Friedman et al., 2015; Mizuno et al., 2015; Sullivan et al., 2015; Tsai & Burns, 2015).
Plasma viral load was obtained for all participants via blood draw or medical record abstraction, and blood samples were tested using the Roche Cobas AmpliPrep/Cobas Taqman HIV-1 Test, Version 2.0. Dichotomous viral suppression was defined as plasma viral load <200 copies/mL.
Demographic, clinical, and behavioral variables were examined as potential confounders. Variables not considered as potential confounders were race/ethnicity, as 85.5% identified as Black or African American, and ART receipt and adherence, as ART use can be a causal link between psychosocial conditions and viral suppression (Sullivan et al., 2015).
Statistical analysis
Chi-square and Fisher’s exact tests were used to assess differences in mental illness, hazardous alcohol use, drug dependence, and ordinal syndemic score by viral suppression. Bivariate associations between these conditions were assessed to determine the extent to which they were clustered within the sample (Mizuno et al., 2015; Sullivan et al., 2015). Multivariable logistic regression was used to examine associations between the independent variables and the dependent variable, viral suppression, including interaction terms. P-values <0.05 were considered statistically significant.
Potential confounders found to be associated with viral suppression in bivariate analyses at p≤0.20 were gender, time of HIV diagnosis, and CD4 count. Single imputation with the sample median was used for one missing CD4 count. We chose a priori to adjust for age.
Prevalence odds ratios (POR) and 95% confidence intervals were calculated. Analyses were conducted using SAS software version 9.4.
Results
Median age was 41 years (IQR 30–49) (Table 1), 58% of participants were male, 24% were female, and 19% were male to female transgender. Fifty-two percent had been diagnosed with HIV for at least 10 years. More than 80% reported taking HIV medication during their recent incarceration. Median lifetime number of times in jail or prison was seven (IQR 4–15), and median time spent in jail or prison was 84 months (IQR 24–180), or 7 years. Overall, 66% of participants were virally suppressed.
Table 1.
Baseline characteristics of 106 recently-incarcerated, HIV-infected participants in the CARE+ Corrections study
| Total (N=106)a | |
|---|---|
| Median age (IQR), years | 41 (30−49) |
| Gender | |
| Male | 61 (57.55) |
| Female | 25 (23.58) |
| Transgender (MTF) | 20 (18.87) |
| Current employment status | |
| Employed | 5 (4.72) |
| Unemployed | 44 (41.51) |
| Other | 57 (53.77) |
| Education | |
| Less than high school | 27 (25.47) |
| High school or greater | 79 (74.53) |
| Health insurance pre-incarceration | 93 (87.74) |
| Healthcare provider pre-incarceration | 88 (83.02) |
| Median times in jail/prison (IQR) | 7 (4−15) |
| Median lifetime spent in jail/prison (IQR), months | 84 (24−180) |
| Recruitment site | |
| Jail | 33 (31.13) |
| Community | 73 (68.87) |
| Psychological support pre-incarceration | 61 (57.55) |
| Alcohol treatment pre-incarceration | 25 (23.58) |
| Drug treatment pre-incarceration | 34 (32.08) |
| HIV treatment during incarceration | 87 (82.08) |
| Time since HIV diagnosis | |
| <1 year | 11 (10.38) |
| 1−4 years | 14 (13.21) |
| 5−9 years | 26 (24.53) |
| ≥10 years | 55 (51.89) |
| CD4 count | |
| ≤200 cells/uL | 10 (9.43) |
| >200 cells/uL | 96 (90.57) |
| Virally suppressed (<200 copies/mL) | 70 (66.04) |
IQR (interquartile range); MTF (male to female)
a All values are n (%) unless otherwise indicated
Eighty-six percent of participants reported a mental illness diagnosis (Table 2), with 80% reporting depression and 58% reporting bipolar or manic depressive disorder diagnoses. Twenty-eight percent scored in the hazardous alcohol use category, while 58% were drug dependent. Only 7% had neither mental illness, hazardous alcohol use, nor drug dependence, while 32% had one, 44% had two, and 17% had all three conditions. The odds of being drug dependent were greater among those with mental illness and those with hazardous alcohol use (POR 3.20, 95% CI: 1.01–10.14; POR 2.61, 95% CI 1.03–6.59, respectively). No significant association was observed between mental illness and hazardous alcohol use (Table 3).
Table 2.
Frequencies and prevalence odds ratios for syndemic factors and baseline viral suppression among 106 recently-incarcerated, HIV-infected participants in the CARE+ Corrections study
| Total n (%) |
Virally suppressed n (%) |
p-value | Unadjusted POR (95% CI) |
Adjusted PORa (95% CI) | |
|---|---|---|---|---|---|
| Mental illness diagnosis | 0.26 | ||||
| Yes | 91 (85.85) | 58 (63.74) | 0.44 (0.12–1.67) | 0.34 (0.08–1.49) | |
| No | 15 (14.15) | 12 (80.00) | 1.00 (ref) | 1.00 (ref) | |
| Hazardous alcohol use (12 months pre-incarceration) | 0.71 | ||||
| Yes | 30 (28.30) | 19 (63.33) | 0.85 (0.35–2.05) | 0.58 (0.19–1.76) | |
| No | 76 (71.71) | 51 (67.11) | 1.00 (ref) | 1.00 (ref) | |
| Drug dependence (12 months pre-incarceration) | 0.59 | ||||
| Yes | 61 (57.55) | 39 (63.93) | 0.80 (0.35–1.82) | 0.80 (0.30–2.11) | |
| No | 45 (42.45) | 31 (68.89) | 1.00 (ref) | 1.00 (ref) | |
| Syndemic scoreb | 0.56 | ||||
| 0 | 7 (6.60) | 6 (85.71) | 1.00 (ref) | 1.00 (ref) | |
| 1 | 34 (32.08) | 22 (64.71) | 0.31 (0.03–2.84) | 0.14 (0.01–1.67) | |
| 2 | 47 (44.34) | 32 (68.09) | 0.36 (0.04–3.22) | 0.17 (0.02–1.79) | |
| 3 | 18 (16.98) | 10 (55.56) | 0.21 (0.02–2.10) | 0.09 (0.01–1.26) |
POR (prevalence odds ratio); CI (confidence interval)
a Adjusted for age, gender, time of HIV diagnosis, and CD4 count
b Syndemic score is comprised of mental illness, hazardous alcohol use, and drug dependence
Table 3.
Bivariate associations between syndemic factors among 106 recently-incarcerated, HIV-infected participants in the CARE+ Corrections study
| Unadjusted POR (95% CI) | ||
|---|---|---|
| Mental illness | Hazardous alcohol use | |
| Mental illness | -- | -- |
| Hazardous alcohol use | 0.39 (0.13–1.18) | -- |
| Drug dependence | 3.20 (1.01–10.14) | 2.61 (1.03–6.59) |
POR (prevalence odds ratio); CI (confidence interval)
Table 2 displays frequencies and PORs for viral suppression by exposure category. While these differences were not statistically significant, fewer participants with mental illness, hazardous alcohol use, or drug dependence were virally suppressed compared to those without each condition (63.7% vs. 80.0%, p=0.26; 63.3% vs. 67.11%, p=0.71; 63.9% vs. 68.9%, p=0.59, respectively). Fewer participants with syndemic score 3 were virally suppressed (55.6%) compared to syndemic scores 2 (68.1%), 1 (64.7%), and 0 (85.7%), (p=0.56). There was a trend towards lower odds of viral suppression with each condition, after adjusting for the set of confounders (Table 2). The smallest POR was observed for syndemic score 3 (POR 0.09, 95% CI 0.01–1.26). Interaction terms were not significant.
Discussion
We assessed mental illness and substance use among a sample of recently-released, HIV-infected individuals and found that 61% of participants reported at least two psychosocial conditions. Our findings demonstrate strong associations between hazardous alcohol use and drug dependence, and mental illness and drug dependence, which is consistent with previous research (Klinkenberg & Sacks, 2004). There was a trend towards lower odds of viral suppression for those with mental illness, hazardous alcohol use, drug dependence, and those with the highest syndemic score. More than 80% of participants without mental illness, hazardous alcohol use, and drug dependence were virally suppressed, compared to 56% of those with all three. The overall proportion of viral suppression in this sample (66%) was relatively high compared to other studies estimating rates of viral suppression to be 40% during incarceration and 21% after release (Iroh et al., 2015).
Previous research has emphasized the importance of mental health and substance use treatment for HIV care outcomes (Himelhoch et al., 2009; Meyer et al., 2014). Substance use treatment in particular is scarce in correctional facilities and the community; instead, the most common services are drug education and low intensity counseling (Belenko, Hiller, & Hamilton, 2013). If sufficient services do exist, release from facilities can result in discontinuity of care (Meyer et al., 2011). Although this study was not designed to examine mental health or substance use treatment, the prevalence of these conditions and the trend towards lower odds of viral suppression contributes to the evidence-base indicating the need for integrated care services. Interventions that integrate mental health, substance use, and HIV treatment could more effectively meet the needs of this population (Klinkenberg & Sacks, 2004).
This cross-sectional data analysis had several limitations. Mental illness and substance use were self-reported. The sample size was small, decreasing statistical power and precluding a complete examination of disease interaction. Additional computation, such as calculation of the attributable proportion of risk due to interaction, would have been necessary to identify departures from additivity. These methods require large sample sizes to achieve adequate statistical power (Tsai & Burns, 2015), and can be misleading when calculated using odds ratios that do not approximate relative risk (Kalilani & Atashili, 2006). The findings from this study cannot be fully generalized to the greater population of recently-incarcerated, HIV-infected individuals due to convenience sampling methods.
Conclusion
This analysis was conducted to examine the effect of mental illness and substance use disorders on viral suppression among recently-incarcerated, HIV-infected individuals. Incarceration itself is an independent risk factor for HIV infection (Maru, Basu, & Altice, 2007) and a predictor of treatment non-adherence among people with HIV (Meyer et al., 2011). With the high prevalence of HIV, mental illness, and substance use disorders in the CJ system, further research is needed to determine whether a syndemic approach to intervention development may improve HIV outcomes both during incarceration and upon community reentry.
Acknowledgements
We would like to acknowledge funding from the National Institutes of Health, National Institute on Drug Abuse (R01DA030747), and institutional support from the Providence-Boston Center for AIDS Research P30AI42853 and the District of Columbia Center for AIDS Research P30AI117970. We would also like to acknowledge our District of Columbia Department of Corrections partners (Drs. Beth Mynett and Reena Chakraborty) and community based partners for their support and assistance in conducting this work. Lastly, we would like to thank the study participants without whom we could not do this work.
Funding: This work was supported by the National Institutes of Health, National Institute on Drug Abuse under Grant R01DA030747. Institutional support was received from the Providence-Boston Center for AIDS Research P30AI42853 and the District of Columbia Center for AIDS Research P30AI117970.
Footnotes
Conflict of Interest: The authors declare that they have no conflict of interest.
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