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. 2022 Aug 10;36(8):291–299. doi: 10.1089/apc.2022.0083

Characterization of Risk Factors Among Individuals with a History of Incarceration Presenting to a Sexually Transmitted Infections Clinic: Implications for HIV and STI Prevention and Care

Matthew J Murphy 1,2,3,✉, Brooke G Rogers 2,4,5, Laura C Chambers 1,5, Alexandra Zanowick-Marr 5, Drew Galipeau 5, Madeline Noh 1, Ty Scott 1, Siena C Napoleon 1,5, Jennifer Rose 6, Philip A Chan 1,2,5
PMCID: PMC9419926  PMID: 35951448

Abstract

More than 2 million people are incarcerated in the United States with many millions more processed through correctional facilities annually. Communities impacted by incarceration are also disproportionately impacted by the HIV and sexually transmitted infection (STI) epidemics. However, relatively little is known about the behaviors that place individuals with a history of incarceration at risk for HIV/STI acquisition. We utilized clinical data from patients presenting to an STI clinic located in Providence, Rhode Island. A latent class analysis was conducted on reported HIV acquisition risk behavior and STI testing results on a total of 1129 encounters where a history of incarceration was reported. A total of three classes were identified. Class 1 (N = 187, 11%), more frequently reported 10+ sexual partners (45%), an STI diagnosis (48%) and sex while intoxicated (86%) in the past year as well as identifying as a man who has sex with other men (60%). Class 2 (N = 57, 5%) was more likely to report giving (53%) and receiving (44%) money/drugs for sex in the past year as well as a history of injecting drugs (61%) and using methamphetamine (60%). Class 3 (N = 885, 78%) most frequently reported 0–2 sexual partners (48%), identified as Black (27%), Hispanic/Latino (69%) and a man who only has sex with women (80%). Class 1 had significantly higher odds ratio (1.8, 95% confidence interval = 1.3–2.5) of testing HIV/STI positive. The results provide important insights into risk subgroups for those with a history of incarceration at risk of HIV/STI acquisition.

Keywords: HIV/STI risk, incarceration, latent class analysis, PrEP implementation

Introduction

There were ∼34,800 new HIV diagnoses in the United States in 2019.1 Although there has been some success in reducing the number of new cases, HIV continues to disproportionately impact specific populations, often concentrating within socially marginalized groups, including racial and ethnic minorities, men who have sex with men (MSM), sex workers, and people with substance use disorders including people who inject drugs.2–11 Many of these populations are also disproportionately impacted by incarceration due to systemic injustices in our legal and correctional systems.12–18

This is underscored by the fact that individuals with a history of incarceration have a rate of HIV infection that is three to five times that of their non-incarcerated counterparts19,20 and one in seven people living with HIV pass through the criminal justice (CJ) system each year.21 In addition to the vulnerability to HIV acquisition, CJ-involved individuals are disproportionately impacted by bacterial sexually transmitted infections (STIs), including syphilis, gonorrhea, and chlamydia.22,23 Bacterial STI positivity is also linked to HIV acquisition risk24,25 and is an indication for initiation of HIV prevention therapy such as pre-exposure prophylaxis (PrEP).26,27

Incarceration can be a very disruptive experience and the period of community re-entry can present a number of health risks. These include substance use relapse and overdose, mental health episodes and suicide attempts, and acquisition of STI and HIV.10,28–32 During the immediate postrelease period, there is a significant risk of HIV transmission.33–37 Moreover, CJ individuals face a number of barriers accessing health care upon community re-entry, including access to HIV prevention and treatment services.38,39

Despite the disproportionate impact of HIV on incarcerated populations and the health risks of the community re-entry period, little is known about the behaviors that place individuals with a history of incarceration at risk for HIV acquisition when in the community. There is also high variability in access to HIV prevention, screening, and treatment services in CJ institutions.40–43 In addition, analyses of other groups at increased risk of HIV acquisition such as MSM have shown that there may be subgroups with unique or elevated risk for HIV acquisition based on the number of sex partners, substance use patterns, and participation in sex work among other behaviors.44

Improved understanding of HIV acquisition risk behaviors and their populational patterns may help facilitate more robust HIV prevention programming. This includes the implementation of PrEP in the CJ setting for individuals before community re-entry, which holds a significant,45–47 although largely unrealized,48–50 opportunity to reduce HIV transmission and achieve the goals of the national effort to End the HIV Epidemic (EHE).51,52 Although the CDC's updated 2021 STI guidelines recommend initiating PrEP during a period of incarceration,26 particularly among individuals who test positive for an STI while incarcerated, relatively little is known about potential barriers to PrEP use upon community re-entry.46

Feasibility of PrEP implementation within correctional systems and the resources required to successfully support PrEP programming are largely unknown. Barriers experienced by populations impacted by incarceration include a lack of access to PrEP clinical providers, stigma, costs associated with PrEP clinical care, competing health priorities, and difficulty adhering to a daily medication regimen among others.48 There is a need to develop tailored strategies to improve HIV and STI testing and prevention, including PrEP initiation, during periods of incarceration as well as linkage to care in the community upon release.53 Strategies to ensure adherence to PrEP regimens, which are adapted to the needs of incarcerated individuals during the potentially chaotic postrelease period, will be critical to effective PrEP programming in this setting.

The objective of this study is to better understand the factors that place populations impacted by CJ involvement at risk for HIV and STI acquisition by evaluating sociodemographic and behavioral characteristics of patients who report a history of incarceration when presenting to an urban low-barrier STI clinic. We then discuss potential implications for STI and HIV prevention programming, including PrEP implementation in the CJ setting.

Methods

Study design and sample

We conducted a cross-sectional study of clinical encounters among patients who reported a history of incarceration while attending The Miriam Hospital STI Clinic located in Providence, Rhode Island between January 1, 2012 and June 30, 2020.

All patients presenting for HIV or STI testing are asked to complete a visit intake form, which includes demographics, behavioral risk factors, and other conventional HIV surveillance information. These data are all self-reported and after a clinical encounter, staff enter collected data into a Research and Electronic Data Capture database.54,55

Data for this study were de-identified encounter-level data from the REDCAP database. Specifically, we reviewed self-reported intake information on age, race, ethnicity, gender, sexual behavior history, STI history, substance use history, and incarceration history. We also reviewed laboratory test results from the clinical encounter for HIV (antibody testing), syphilis (treponemal and non-treponemal), gonorrhea [urine, rectal, and pharyngeal nucleic acid amplification testing, nucleic acid amplification testing (NAAT)], and chlamydia (urine, rectal, and pharyngeal NAAT) results.

Latent class analysis

We used latent class analysis (LCA) to identify groups of individuals at highest risk for HIV/STI based on specific variables. The purpose of this analysis was to identify subgroups of individuals with a higher prevalence of HIV/STI based on self-reported behavioral information to inform tailored HIV and STI prevention approaches. LCA is a statistical approach56,57 that generates latent classes based on patterns of data, with the goal of grouping similar individuals.44

We tested a series of LCA models with between two and four classes using the poLCA package58 in RStudio Version 1.1.463. We specified a maximum of 5000 iterations for the estimation algorithm to achieve convergence, as well as 10 repetitions of each model to retain that with the lowest Bayesian Information Criterion (BIC). We used a variety of indices to determine the best model fit and, thus, the optimal LCA solution. Indices included the BIC and Akaike Information Criterion (AIC), which are measures of the relative fit of a statistical model to a set of data compared with other models and used for model selection (lower AIC and BIC values indicate better model fit); the chi-squared goodness-of-fit statistic; entropy, which measures the extent to which classes are distinct from each other (entropy values >0.8 indicate better distinction of classes59); and the interpretability of the classes.

Self-reported measures used in the LCA included number of sex partners in the past year, any prior STI diagnosis in the past year, gave money/drugs for sex in the past year (sex work), received money/drugs for sex in the past year (sex work), any sex while intoxicated in the past year, any partners with unknown HIV status in the past year, ever having been forced to have sex, ever having injected drugs, as well as lifetime history of methamphetamine, cocaine, and opioid use (without a prescription). Demographic covariates included age group, race, ethnicity, and a combined measure of gender and sexual orientation. Encounters with complete information on the self-reported behavioral measures and demographic covariates were included in the LCA.

Our primary outcome was any positive HIV/STI test at the encounter, based on test results for HIV, syphilis, gonorrhea, and/or chlamydia. Per standard clinic procedures, patients were tested for HIV and STIs based on self-reported risk information and shared clinical decision-making. After identifying the LCA model with the optimal number of classes based on criteria described earlier, we fit a logistic regression model with robust standard errors to compare odds of HIV/STI test positivity across classes.

Significance was defined as alpha <0.05, and all tests were two-sided. This study was a retrospective review of clinical data collected during visits at an STI clinic and was approved by The Miriam Hospital's Institutional Review Board.

Results

Sample characteristics

Of 1184 clinical encounters between January 1, 2012 through June 30, 2020 among patients who reported a history of incarceration, 1129 (95%) had complete information on the self-reported behavioral measures and demographic covariates for the LCA and were included in this study (Table 1). The majority of patients (68%) were between the ages of 25 and 44 years. Patients identified as White (45%); African American (24%); other, multiple, or unknown races (31%); and Hispanic or Latino ethnicity (29%). Women made up 15% of the sample, whereas men who only had sex with women made up 67% of the sample followed by MSM, and other sexual and gender minorities who comprised 18% of the sample.

Table 1.

Characteristics of Patients with a History of Incarceration Attending a Sexually Transmitted Infections (STIs) Clinic

 
  
 HIV/STI test resulta
  Total (N = 1129), n (%) Negative (N = 839), n (%) Positive (N = 253), n (%)
Sociodemographics
 Age group (years)
  ≤24 213 (19) 145 (17) 61 (24)
  25–44 766 (68) 575 (69) 167 (66)
  ≥45 150 (13) 119 (14) 25 (10)
 Race
  Black or African American 266 (24) 201 (24) 55 (22)
  White 511 (45) 387 (46) 107 (42)
  Other, multiple, or unknown 352 (31) 251 (30) 91 (36)
 Ethnicity
  Hispanic or Latino 327 (29) 230 (27) 87 (34)
  Non-Hispanic or Latino or unknown 802 (71) 609 (73) 166 (66)
 Gender and sexual orientation
  Woman 171 (15) 137 (16) 29 (11)
  MSM and other sexual and gender minorities 202 (18) 119 (14) 76 (30)
  Man who has sex with women only 756 (67) 583 (69) 148 (59)
Health and behavioral history
 No. of sex partners in the past 12 months
  0–2 469 (42) 373 (44) 74 (29)
  3–4 268 (24) 196 (23) 67 (26)
  5–9 221 (20) 158 (19) 58 (23)
  10+ 171 (15) 112 (13) 54 (21)
 STI diagnosis in the past year 241 (21) 150 (18) 76 (30)
 Gave money/drugs for sex in the past year 172 (15) 132 (16) 36 (14)
 Received money/drugs for sex in the past year 84 (7) 54 (6) 26 (10)
 Sex while intoxicated in the past year 620 (55) 452 (54) 147 (58)
 Sex partner with unknown HIV status in the past year 492 (44) 369 (44) 113 (45)
 Ever forced to have sex 133 (12) 95 (11) 35 (14)
 Ever injected drugs 149 (13) 107 (13) 31 (12)
 Ever used methamphetamines 39 (3) 17 (2) 17 (7)
 Ever used cocaine 67 (6) 42 (5) 21 (8)
 Ever used opioids without a prescriptionb 60 (5) 37 (4) 18 (7)
Any HIV/STI positive at this encountera 253 (23) — 253 (100)
  HIV positivea 4 (<1) — 4 (2)
  Syphilis serology positivea 56 (12) — 56 (38)
  Gonorrhea positive (urogenital, oral, or rectal)a 79 (7) — 79 (32)
  Chlamydia positive (urogenital, oral, or rectal)a 148 (14) — 148 (59)
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a

Among patients with some relevant laboratory test results.

b

Includes street opioids and prescription opioids used without a prescription.

MSM, man who has sex with men; STI, sexually transmitted infection.

Among the sexual behavior HIV acquisition risk factors that were surveyed, patients most frequently reported 0–2 sexual partners during the past year (42%). In addition, 15% of patients reported giving money/drugs for sex and 7% received money/drugs for sex during the past year. Overall, 44% of patients reported a sex partner with an unknown HIV status and 55% reported sex while intoxicated in the past year. Among the substance use behaviors surveyed, 13% of patients reported ever injecting drugs. Within the study sample, 26% of patients tested positive for an STI; chlamydia was the most frequently diagnosed (14%) followed by positive syphilis serology (12%), gonorrhea (7%), and HIV (<1%).

Latent class analysis

These 1129 unique encounters were included in the LCA. A comparison of model fit indices demonstrated that a three-class solution was preferable (Table 2). Compared with models that contained two or four classes, the three-class solution provided the lowest BIC, AIC, chi-squared goodness-of-fit values, indicating the best model fit, as well as good entropy, suggesting adequate distinction of classes, with a substantial improvement in the interpretability of classes over other models.

Table 2.

Latent Class Analysis Fit Indices for Models with Two to Four Classes

Model Maximum log-likelihood (no. of parameters) AIC BIC Chi-squared goodness of fit Entropy
Two classes −5433 (34) 10,934 11,105 16,275 0.74
Three classes −5271 (55) 10,652 10,929 4682 0.77
Four classes −5677 (76) 11,506 11,888 16,760 0.99
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AIC, Akaike information criterion; BIC, Bayesian information criterion.

When we compared the prevalence of any HIV/STI across classes, Class 3 had the lowest prevalence (21%) followed by Class 2 (31%) and Class 1 (32%) (Table 3). Compared with Class 3, members of Class 1 had significantly higher [odds ratio (OR) = 1.8, 95% confidence interval (CI) = 1.3–2.5] and Class 2 had somewhat higher (OR = 1.7, 95% CI = 0.9–3.1) odds of testing HIV/STI positive.

Table 3.

Odds of Testing any HIV/Sexually Transmitted Infections (STIs) Positive at This Encounter by Latent Class

  Total (N = 1092), n HIV/STI test result
 OR (95% CI)
Negative (N = 839), n (row %) Positive (N = 253), n (row %)
Class 1 181 123 (68) 58 (32) 1.8 (1.3–2.5)
Class 2 52 36 (69) 16 (31) 1.7 (0.9–3.1)
Class 3 859 680 (79) 179 (21) Ref.
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Among patients with some laboratory test results.

CI, confidence interval; OR, odds ratio; Ref, referent group; STI, sexually transmitted infection.

Class 1: Most likely to test HIV/STI positive

Among the full sample of patients with a history of incarceration, 11% had the highest probability of being members of Class 1, the class most likely to test positive for HIV/STI (Tables 4 and 5). Individuals in this class most frequently reported 10 or more sexual partners during the past year (45%). Compared with Classes 2 and 3, individuals in Class 1 were more likely to report a prior STI diagnosis during that same time period (48%) as well as having sex while intoxicated (86%) and sex with a partner of unknown HIV status (86%). Class 1 also had the highest frequency of ever having been forced to have sex (41%). This class reported some injection drug use (32%), less than Class 2 (61%) but more than Class 3 (6%). Class 1 most frequently identified as White (71%) and MSM or another sexual and gender minority (60%). This class also had the highest proportion of individuals 24 years old or younger (24%).

Table 4.

Prevalence of Classification Variables by Latent Class

  Class 1 (N = 187), n (%) Class 2 (N = 57), n (%) Class 3 (N = 885), n (%)
No. of sex partners past 12 months
 0–2 28 (15) 19 (33) 422 (48)
 3–4 18 (10) 9 (16) 241 (27)
 5–9 56 (30) 11 (19) 154 (17)
 10+ 85 (45) 18 (32) 68 (8)
STI diagnosis in the past year 90 (48) 25 (44) 126 (14)
Gave money/drugs for sex in the past year 78 (42) 30 (53) 64 (7)
Received money/drugs for sex in the past year 51 (27) 22 (39) 11 (1)
Sex while intoxicated in the past year 160 (86) 38 (67) 422 (48)
Sex partner with unknown HIV status in the past year 161 (86) 28 (49) 303 (34)
Ever forced to have sex 76 (41) 19 (33) 38 (4)
Ever injected drugs 59 (32) 35 (61) 55 (6)
Methamphetamine use history 4 (2) 34 (60) 1 (<1)
Cocaine use history 0 (0) 54 (95) 13 (1)
Opioid use history (without a prescription) 1 (1) 49 (86) 10 (1)
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STI, sexually transmitted infection.

Table 5.

Sociodemographics and HIV/Sexually Transmitted Infections (STIs) Test Positivity at This Encounter by Latent Class

  Class 1 (N = 187), n (%) Class 2 (N = 57), n (%) Class 3 (N = 885), n (%)
Sociodemographics
 Age group (years)
  ≤24 44 (24) 4 (7) 165 (19)
  25–44 120 (64) 40 (70) 606 (68)
  ≥45 23 (12) 13 (23) 114 (13)
 Race
  Black or African American 25 (13) 3 (5) 238 (27)
  White 133 (71) 39 (68) 339 (38)
  Other, multiple, or unknown 29 (16) 15 (26) 308 (35)
 Ethnicity
  Hispanic or Latino 43 (23) 10 (18) 274 (31)
  Non-Hispanic or Latino or unknown 144 (77) 47 (82) 611 (69)
 Gender and sexual orientation
  Woman 52 (28) 18 (32) 101 (11)
  MSM and other sexual and gender minorities 112 (60) 16 (28) 74 (8)
  Man who has sex with women only 23 (12) 23 (40) 710 (80)
Any HIV/STI positive at this encountera 58 (32) 16 (31) 179 (21)
 HIV positive 3 (2) 0 (0) 1 (<1)
 Syphilis serology positive 25 (29) 6 (14) 25 (7)
 Gonorrhea positive (urogenital, oral, or rectal) 18 (10) 8 (16) 53 (6)
 Chlamydia positive (urogenital, oral, or rectal) 25 (14) 4 (8) 119 (14)
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a

Among patients with some laboratory test results.

MSM, man who has sex with men; STI, sexually transmitted infection.

Class 2: Substance use and sex work

Class 2 was the smallest of the three classes, with only 5% of patients with a history of incarceration having a high probability of membership in this class. Notably, Class 2 members reported a lifetime history of substance use more often than other classes. Specifically, 61% of Class 2 members reported ever injecting drugs (61%), 95% reported ever using cocaine, 86% reported ever using opioids without a prescription, and 60% reported ever using methamphetamine. This class also contained the highest proportion of individuals who reported participating in transactional sex, including those who gave (53%) and received (39%) money or drugs for sex in the past year.

This class also had a high proportion of individuals reporting ever being forced to have sex (33%) although not as high as Class 1. In addition, this class had a high proportion of patients reporting >10 sexual partners in the past 12 months (32%), although not as high a proportion as Class 1 (45%). This class had the lowest proportion of individuals aged 24 years and younger (7%) compared with the other classes and had slightly higher proportions of those 45 and older (23%) and 25–44 (70%) compared with the other classes. This class also had the lowest proportion of African Americans (5%) and Hispanic/Latino individuals (18%).

Class 3: Fewer risk factors and lower likelihood of HIV/STI positivity

The vast majority of patients with a history of incarceration had the highest probability of being members of Class 3 (n = 885, 78%). Class 3 had the highest proportion of individuals reporting 0–2 sexual partners for the past year (48%) and the lowest proportion of individuals reporting a prior STI diagnosis (14%), sex while intoxicated (48%), sex with a partner with an unknown HIV status (34%), and giving (7%) or receiving (1%) money or drugs for sex in the past year. This group also had the smallest proportion of individuals reporting ever having injected drugs (6%) or being forced to have sex (4%). Class 3 had the highest proportion of individuals identifying as Black (27%); other, multiple, or unknown race (35%); and Hispanic or Latino (31%). This group had, by far, the highest proportion if men who reported only having sex with women (80%).

Discussion

This LCA of individuals presenting to an urban low-barrier STI clinic and reporting a history of incarceration provides important insights into the characteristics and behaviors of a population that is uniquely vulnerable to STI/HIV acquisition. The results suggest that tailored HIV/STI prevention interventions may be appropriate for each “class” of person at risk, because their characteristics and reported behaviors are quite distinct.

Class 1 members had the highest prevalence of HIV/STI. This class reported higher numbers of sexual partners, more sex while intoxicated and with partners of unknown HIV status and the greatest proportion of individuals identifying as men who have sex with men or other sexual and gender minorities. Class 2, in contrast, was the smallest subgroup, but more frequently endorsed participating in sex work, substance use, including injection drug use. Although the greater likelihood to test positive for HIV or another STI than the reference group did not attain statistical significance, this may be due in part to the class's small size. Available data and prior studies suggest that individuals with similar characteristics to Class 2 are disproportionately represented in CJ settings and frequently experience incarceration.60,61

Class 3, by far the largest class of STI clinic patients with a history of incarceration, reported low numbers of sexual partners along with fewer sexual HIV/STI acquisition factors such as sex with a partner of unknown HIV status, sex while intoxicated, or participation in commercial sex work. This class had the highest proportion of individuals identifying as a man who only had sex with women as well as a racial or ethnic minority. In addition, this class reported a lower proportion of injection drug and other substance use apart from a slightly higher reported history of cocaine use compared with Class 1. Although Class 3 was the least likely to test positive for HIV or another STI, and was used as the reference class for HIV/STI positivity comparisons, prevalence was still relatively high (21%).

The strengths of this study must be interpreted in light of its limitations. Of note, patients' self-reported behavioral data were collected anonymously. This is advantageous in that we are likely to have had more honest reporting and disclosure of stigmatized behaviors. However, it also means that some patients may have contributed more than one clinical counter to our LCA, which we could not identify and account for in the analysis. In addition, because data were collected as part of routine clinical encounters, some patients did not have comprehensive STI testing of HIV, syphilis, gonorrhea, and chlamydia. There may be a number of reasons why this occurred, including known HIV seropositivity, patient refusal, or a lack of clinical indication for testing. For individuals who received any STI testing during the included encounter, missing results were considered negative.

Populations presenting to a low-barrier urban STI clinic in Providence, RI are likely to differ from those not presenting for care in correctional settings and in other sociodemographic settings such as health services in rural areas or outside of the northeastern United States. This includes individuals or groups who are more likely to forego care or seek care from other sources. It is also important to note that individuals with similar HIV/STI acquisition risks as Classes 1 and 2 may be more disproportionately represented in correctional settings than in this sample.

Given the many barriers that individuals with a history of injection drug use, substance use, and sex work encounter, particularly those with a history of incarceration, face accessing health services in the community, there continues to be a need for a greater understanding of the HIV and STI acquisition risk among these population subgroups experiencing incarceration. Additional research is key to developing effective tailored testing strategies and prevention services during a period of incarceration and upon community re-entry. On this note, it is crucial that the factors investigated in this study should also be considered in the transition of care between prison and community re-entry, among both people living with HIV (PLWH), and those at-risk for HIV.

At the same time, the results from this study highlight the diversity of HIV/STI acquisition risk. There are several effective interventions for STI/HIV prevention, including regular testing, condom use, and HIV PrEP or PrEP. All of these have the potential to improve the health of those individuals who have a history of CJ involvement; however, the combination of these strategies may need to differ depending on the subgroup. For example, the interventions that work for a middle-aged Latina woman who is partnered in sexually violent relationship may need to differ than those of a single White gay man. Our findings of three unique classes of patients suggest that to improve sexual health within this population, programming should be responsive and thoughtful to these unique experiences and not prescribed as a “one-size-fits-all.” This is underscored by recent research that has shown that even among highly vulnerable populations with a recent STI diagnosis, there may be a low self-perceived risk of HIV acquisition.62

The CDC's updated STI guidelines provide key recommendations on HIV and other STI testing and prevention services that should be made available within correctional settings.26,27 Increasing the availability of opt-out testing upon incarceration has been shown to increase STI diagnoses and has been linked with decreased community transmission.63 The increased availability of condoms, largely limited to urban jails in major metropolitan areas and a small number of state prison facilities, may also help limit the spread of STI's during periods of incarceration.64 The guidelines also recommend the initiation of PrEP in correctional settings for individuals at increased risk of HIV acquisition and recent STI positivity.

While an effective HIV prevention intervention, particularly for individuals with a recent STI diagnosis, the availability of PrEP in correctional settings, along with many other HIV and STI prevention services, is largely unknown and highly variable.65 Given the disruptive impact of incarceration on other aspects of health care service provision,66 and the known risk of HIV acquisition in the immediate postincarceration period,19–21,34–37 ensuring individuals are able to initiate PrEP while incarcerated or, if they had initiated PrEP in the community before incarceration, are able to continue in the immediate postrelease period is critical. In addition, the impact of incarceration on access to PrEP care and use among this population is largely unknown requiring a rigorous research focus with the development of tailored interventions to the diverse populations impacted by incarceration.

The CDC's recently updated PrEP guidelines recommend increasing options for daily oral PrEP use including the use of long-acting injectable PrEP,67 expediting PrEP initiation when possible and acknowledging the potential utility of “on-demand” or 2-1-1 PrEP dosing.27 Increased PrEP options combined with a focus on rapid PrEP initiation may help facilitate PrEP implementation in correctional settings. It is clear, however, that expanding and tailoring HIV and STI testing and prevention programming in correctional settings and postincarceration are key to addressing these communicable diseases' disproportionate burden on populations impacted by incarceration.

Authors' Contributions

Conceptualization, writing—original draft, review, and editing by M.J.M. and B.G.R. Methodology and data curation by L.C.C. Data curation by A.Z.-M. Writing—review and editing by D.G., M.N., and T.S. Project administration by S.C.N. Methodology and supervision by J.R. Supervision by P.A.C.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

M.J.M. and B.G.R. are supported in part by a research grant from Gilead Sciences (IN-US-276-5463). M.J.M. is also supported by the National Institute of Health (1K23DA054003-01A1). L.C.C. is supported by the National Institutes of Health (Grant Nos. T32DA013911 and R25MH083620 trainee support).

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