Pathways from recent incarceration to ART adherence: Opportunities for interventions to support women living with HIV post-release from correctional facilities

Abstract

Women living with HIV are increasingly incarcerated and experience sub-optimal HIV health outcomes post-release from incarceration. Drawing on cohort data with cisgender and trans women living with HIV (Sexual Health and HIV/AIDS: Women’s Longitudinal Needs Assessment), we used path analysis to investigate pathways from recent incarceration to optimal antiretroviral therapy (ART) adherence. We tested direct effects between recent incarceration, mediating variables, and ART adherence, along with indirect effects between incarceration and ART adherence through each mediator. We assessed model fit using chi-square, root mean square error of approximation (RMSEA), and comparative fit index (CFI). Our hypothesized model fit well to the data (χ2(1)=1.100;p=0.2943;CFI=1.000;RMSEA=0.007). Recent experiences of homelessness, criminalized substance use, and gender-based violence each fully mediated the pathway between recent incarceration and optimal ART adherence. Findings highlight the need for safe and supportive housing, supports for criminalized substance use, and trauma and violence-informed care and practice post-release from incarceration.

INTRODUCTION

Globally, the number of women who are incarcerated is growing (Penal Reform International, 2021). Yet the majority of women continue to be incarcerated for non-violent and survival-related crimes (Corsten, 2007; Kajstura, 2017), and involvement in the criminal justice system among women is often a marker of significant and gendered structural inequities (Currie, 2004; Herbst et al., 2016; McKendy & Ricciardelli, 2019; Standing Senate Committee on Human Rights, 2021). Imprisonment has become an inadequate strategy to address underlying social problems, including poverty, racism, and unemployment (Davis, 2016). In Canada, the substantial overrepresentation of Indigenous¹ women who are incarcerated (Statistics Canada, 2011; The Correctional Investigator Canada, 2020), is a direct reflection of the ongoing harms of settler colonialism (Truth and Reconciliation Commission of Canada, 2015a) situated within calls for action to end the over-incarceration of Indigenous people (Truth and Reconciliation Commission of Canada, 2015b). Indigenous women make up 40% of women incarcerated at provincial facilities (sentences 2 years less a day, remand) (Clark, 2019), and nearly 50% in federal facilities (sentences over 2 years) (The Correctional Investigator, 2021), despite accounting for only 4% of adult women in Canada (Arriagada, 2016). Given the over-criminalization of marginalized women, correctional facilities also see disproportionate rates of HIV. Women living with HIV are overrepresented within correctional settings globally (Dolan et al., 2016) as well as within Canada (Public Health Agency of Canada, 2014; The Correctional Investigator Canada, 2015).

Access and adherence to antiretroviral therapy (ART) in correctional settings remains sub-optimal for people living with HIV (Uthman, Oladimeji, & Nduka, 2017). Though knowledge is limited with regards to how specific institutional processes within correctional facilities might facilitate or hinder continuity of care, research across North America points to HIV-related stigma in correctional facilities as one possible barrier to engagement and retention in HIV care during incarceration (Erickson, Shannon, Ranville, Pooyak, et al., 2021; Muessig et al., 2016; Roberson, White, & Fogel, 2009; Small, Wood, Betteridge, Montaner, & Kerr, 2009). However, there is a growing body of research highlighting sub-optimal HIV health outcomes among people living with HIV post-release from incarceration (Dennis et al., 2015; Haley et al., 2014; Joseph et al., 2015; Milloy et al., 2011; Spaulding et al., 2013; Westergaard, Kirk, Richesson, Galai, & Mehta, 2011). Furthermore, along incarceration trajectories, women experience sub-optimal engagement in HIV care compared to men (Erickson et al., 2019). This is increasingly apparent in the post-release period, where women face substantial challenges with retention, adherence, and maintaining HIV viral suppression (Erickson et al., 2019). Multicenter data from the United States (US) highlights that 6-months post-release from incarceration women are half as likely as men to achieve viral suppression (J. P. Meyer et al., 2014). Evidence suggests that incarceration has additional sustained and harmful impacts for women living with HIV, including increased rates of mortality post-release (J. P. Meyer, 2019).

Current research falls short in explicitly identifying the pathways from recent incarceration to sub-optimal HIV health outcomes among women, and a gap in knowledge exists that exposes specific areas of intervention that could improve post-release health outcomes. Evidence from high-income settings suggests that the period of transition from custody to community presents immense challenges for women (Pyper & Lalic, 2021), including barriers to and limited supports in accessing healthcare, housing, addictions treatment and employment opportunities (R. Martin, Buxton, Smith, & Hislop, 2012). Research from cohorts of women living with HIV across Canada exemplifies how incarceration is experienced alongside other structural inequities (e.g., homelessness, experiences of violence, and criminalized² substance use) (Erickson, Pick, Ranville, Martin, et al., 2020; Gormley et al., 2020).

Findings from the US demonstrate that among people living with HIV, women are significantly more likely to report both homelessness and criminalized substance use following incarceration (J. P. Meyer et al., 2014), factors that are also associated with increased rates of recidivism (Fu et al., 2013). Furthermore, research has shown that housing insecurity or homelessness (Cornelius et al., 2017; Duff et al., 2016; Kerkerian et al., 2018; Zhao, 2021) and substance use (Chitsaz et al., 2013; Friedman et al., 2009; Goldenberg et al., 2016; Gonzalez, Mimiaga, Israel, Andres Bedoya, & Safren, 2013; Haley et al., 2014; Kerkerian et al., 2018; Y. Zhang et al., 2018) – by way of interference and impairment in daily life (Gonzalez, Barinas, & O’Cleirigh, 2011) – can create barriers to optimal HIV health, including through impacts on sub-optimal ART adherence and unsuppressed viral load. Unsurprisingly, stable housing can assist in both reducing relapse to substance use in the post-release period as well as facilitating adherence to ART (Buchanan, Kee, Sadowski, & Garcia, 2009; Ghose et al., 2019). Given this evidence, it is important to consider homelessness, along with criminalized substance use, as potential mediators in the pathway between recent incarceration and sub-optimal ART adherence.

Another potential mediator in this pathway is gender-based violence. Gendered power dynamics and violence are linked to sub-optimal HIV outcomes for women, including through reduced uptake of and retention in HIV treatment (Donastorg et al., 2014; Duff et al., 2016; Espino et al., 2015; Hatcher, Smout, Turan, Christofides, & Stöckl, 2015; Lichtenstein, 2006; Machtinger, Haberer, Wilson, & Weiss, 2012). Experiences of gender-based violence perpetuated against women involved in the criminal justice system are extremely high (McMillan, Aslam, Crowe, Seddon, & Barry, 2021), and studies show that women living with HIV specifically experience high rates of violence and trauma (Erickson, Pick, Ranville, Martin, et al., 2020; Lichtenstein, 2006; Orza et al., 2015), including relative to the general population of women (Machtinger, Wilson, Haberer, & Weiss, 2012). Qualitative research indicates several ways by which intimate partner violence, for example, can impact ART adherence among women, including through increased stress leading to medication forgetfulness, having to leave home without medications, and partners throwing away medications (Roberts et al., 2016). Among a cohort of marginalized women living with HIV in Canada, participants who reported recent experiences of gender-based violence had increased odds of needing supports (e.g., improved access to food, addictions support, improved housing, peer supports, transportation support) to maintain ART adherence (Erickson, Shannon, Ranville, Magagula, et al., 2021). Gender-based violence can also lead to insecure housing and homelessness (Gilroy, McFarlane, Maddoux, & Sullivan, 2016), as well as increased substance use as a coping-method (Gezinski, Gonzalez-Pons, & Rogers, 2021).

Sub-optimal HIV health outcomes post-release from incarceration cannot be separated from the structural inequities and challenges faced by women upon release. Yet despite mounting evidence demonstrating increased vulnerabilities and sub-optimal HIV health outcomes during this time, supports and tailored interventions for and by women living with HIV post-release from incarceration remain scarce across North America. Studies that center the experiences and health outcomes of women living with HIV remain limited and few studies have explored in detail the relationship between recent incarceration and ART adherence among women. A better understanding is needed of the factors that mediate the relationship between recent incarceration and ART adherence. The aim of this study was to explore and highlight the pathways from recent incarceration to ART adherence via social and structural factors to elucidate specific considerations for interventions for improved HIV health outcomes for women involved in the criminal justice system.

METHODS

Study design and sampling

This analysis draws on 9 years (January 2010 – February 2019) of data from an open longitudinal community-based research cohort, known as the Sexual Health and HIV/AIDS: Women’s Longitudinal Needs Assessment (SHAWNA), with self-identified cisgender (cis) and trans women³ living with HIV aged 14+ who live and/or access HIV services in Metro Vancouver. As described in existing publications drawing on this data: SHAWNA launched following “extensive community-based consultations with women living with HIV, HIV care providers, and policy experts on research priorities and gaps in services…and is guided by a Positive Women’s Advisory Board. Participants have been invited to enroll in the cohort through outreach by a team of Peer Research Associates (PRAs), self-referrals, and referrals from HIV care providers, peer navigators, HIV/AIDS organizations and clinical outreach” (Erickson, Shannon, Ranville, Magagula, et al., 2021, p.4–5). Interviews take place at the community research office, or a confidential space identified by the participants. All participants sign an informed consent. Again, as previously described, participants “complete an interviewer-administered questionnaire by trained community interviewers and [voluntary] HIV monitoring and STI/ HCV testing with a sexual health research nurse. SHAWNA interviews are conducted semi-annually and focus on experiences navigating HIV care, community supports, sexual and reproductive health, and treatment outcomes. Participants receive an honorarium of $50CAD at each visit for their time, expertise and travel” (Erickson, Shannon, Ranville, Magagula, et al., 2021, p.5). The project is committed to meaningful inclusion of women living with HIV throughout the research project with cis and trans women living with HIV represented across project staff and advisories. This study holds ethical approval through both Providence Health Care/University of British Columbia Research Ethics Board (H14–01073/H19–03442), and BC Women’s Hospital.

Path analysis and primary variables of interest

Path analysis is used to evaluate causal models by examining the relationship between one or several outcomes and two or more explanatory variables (Klem, 1995). It is helpful in providing estimates and significance of hypothesized causal connections. We drew on, and conceptualized path analysis as an extension of multiple regression, to help further elucidate the mechanisms through which incarceration might influence HIV outcomes in the post-release period.

Variables in the SHAWNA study are either time-fixed (i.e., socio-demographic characteristics such as race or birthplace), or time-updated to reflect recent occurrences at each semi-annual study visit. Key variables in the path analysis model, along with potential confounders (outlined below) are based on knowledge gathered through previous research along with conversations among women living with HIV involved in the SHAWNA project, through advisory boards and working groups. The outcome for this analysis was optimal ART adherence, defined as ≥95% adherence to ART (Paterson et al., 2000; Wood et al., 2006). We used ≥95% as an outcome to continue to advocate for increased structural supports to enhance optimal adherence among marginalized women. Participants were asked to self-report adherence during the last 3–4 weeks prior to the study visit on a slider scale from 0%–100% (Walsh, Mandalia, & Gazzard, 2002). The use of this variable was based on prior research suggesting self-report as a robust measure of ART adherence, including a 2006 review of 77 studies that employed self-report measures of ART adherence (Simoni et al., 2006), along with specific studies highlighting the validity of scale-based (i.e., visual analog scale) self-report ART adherence measures (Buscher, Hartman, Kallen, & Giordano, 2011; Walsh et al., 2002), and studies with women living with HIV validating other self-report HIV outcomes measures (i.e., self-report HIV viral load) (A. Carter et al., 2017). We categorized participants as having optimal adherence (i.e., ≥95%) versus sub-optimal adherence (inclusive of participants not on ART at the time of the interview). The primary explanatory variable for this analysis was recent incarceration defined as being held overnight or longer in city jail or at a provincial or federal correctional facility in the last 6 months. The mediators in this analysis included the following variables, capturing events in the last 6 months at each study visit: homelessness (i.e., sleeping on the street for one night or longer), criminalized substance use (i.e., any use of injection or non-injection drugs, excluding cannabis and alcohol [e.g., opioids {heroin, morphine, dilaudid, oxycotin, percs/vicodin/demerol, fentanyl etc.} and stimulants {crystal meth, crack cocaine, cocaine, ecstasy etc.}]), and experiences of gender-based violence (i.e., physical or sexual violence by any perpetrator).

Confounders in the path analysis model

Hypothesized confounders for all pathways in the path analysis model were included a priori and based on results from previously published studies from the SHAWNA cohort exploring the relationship between recent incarceration and HIV viral load (Erickson, Pick, Ranville, Brashcel, et al., 2020) and the correlates of incarceration among women living with HIV (Erickson, Pick, Ranville, Martin, et al., 2020). As described in the same detail as previous SHAWNA publications (L. J. Zhang et al., 2021), confounders included age (measured continuously in years); high school graduate at baseline; lifetime diagnoses of any mental health condition; race (self-identify as Indigenous [First Nations, Métis, or Inuit], Black or otherwise racialized [Latinx, South/East Asian, Middle Eastern, other] vs. only reporting white); gender identity (gender minority at any study visit, inclusive of trans [transgender, transsexual, other transfeminine identity], gender diverse [non-binary, genderqueer], Two-Spirit⁴, vs cisgender at all visits); and sexual orientation (sexual minority at any study visit [lesbian, gay, bisexual, queer, asexual, Two-Spirit] vs. heterosexual at all study visits)⁵. For the pathways between recent incarceration and the mediators, recent sex work (i.e., exchanged sex for money, food, goods or other in the last 6 months) was included as an additional confounder, but this was not hypothesized to affect adherence.

Statistical Analyses

Consistent with prior studies from our team drawing on path analysis (Deering et al., 2020), we calculated descriptive statistics, including medians and interquartile ranges (IQR) for continuous variables and frequencies and proportions for categorical variables, for the overall sample. We used path analysis to investigate pathways from recent incarceration to ART adherence through mediators of gender-based violence, homelessness, and criminalized substance use by exploring the strength and associations of these mediators when adjusted for each other. The aim of using path analysis is to look at systems as a whole by including multiple mediators in one model. Including all mediators together in one model - conceptualized based on the literature - acknowledges that these pathways are not happening separately from each other.

In line with previous methods, “path analysis was conducted using a weighted least-squares approach, with mean and variance adjustment to evaluate the hypothesized model” (Deering et al., 2020, p.5) using repeated measures among participants (Asparouhov, 2005). We tested the direct effects between recent incarceration, mediating variables, and ART adherence, as well as indirect effects between incarceration and ART adherence mediated by gender-based violence, homelessness, and criminalized substance use. We assumed all mediators were correlated with each other and adjusted for confounder variables as described above.

As is standard in reporting path analysis (Deering et al., 2020), standardized coefficients, standard errors, critical ratios, and p-values are presented for the direct and indirect pathways investigated. The strength and direction of direct and indirect effects are represented by standardized coefficients. In line with Deering et al., “path analysis model fit was assessed using chi-square, root mean square error of approximation (RMSEA), and comparative fit index (CFI)”. A score of <0.05 for RMSEA and a score >0.90 for CFI indicate an acceptable model fit (Mueller & Hancock, 2008; Suhr, 2008). Statistical significance was set at p < 0.05, and as in previous studies with the same approach “observations with missing responses on exogenous variables were excluded from the path analysis” (Deering et al., 2020, p.5). The pairwise present approach was used for missing data on endogenous variables (i.e., all mediators and the main outcome). This resulted in only 27/1950 (1.4%) observations and 4/336 (1.2%) participants being excluded entirely from analysis.

All p-values are two-sided. SAS software version 9.4 (SAS Institute Inc., Cary, NC, USA) and Mplus version 8.2 (Muthén & Muthén, Los Angeles, CA, USA) were used for statistical analyses.

RESULTS

Among 336 women enrolled in the SHAWNA cohort over the 9-year follow up (January 2010-February 2019), there were 1950 observations, with a median number of 5 study visits (IQR: 3–7). Baseline characteristics are presented in Table I. The median age was 43 (IQR: 36–50). Of the sample, 7.1% self-identified as trans and 92.9% were cisgender women; as we capture gender fluidity over time, 1.2% reported being gender diverse at some point in the study. Overall, 9.8% of participants reported gender minority identity and 32.7% of participants reported sexual minority identity. Among Indigenous participants, 12.6% reported Two-Spirit identity. Indigenous women accounted for 56.9% of the sample, indicative of the over-representation of Indigenous women who have been marginalized and are living with HIV in the Metro Vancouver region. In total, 5.4% identified as Black, 3.6% as otherwise racialized, and 34.2% identified as white. Lifetime diagnosis of a mental health condition was reported by 62.5%, less than half (47.9%) of participants had graduated from high school, and overall, 44.1% engaged in recent sex work at baseline.

TABLE I.

Baseline characteristics of women living with HIV in the SHAWNA cohort 2010–2019 (n= 336)

Characteristics	Prevalence n, (%)	Missing
Age, years (median, IQR)	43 (36–50)	0
Gender minority identity∞	33 (9.8)	2
Sexual minority identity×	110 (32.7)	1
Race		0
Indigenousβ	191 (56.9)
Black	18 (5.4)
Otherwise racialized±	12 (3.6)
White	115 (34.2)
Graduated high school	161 (47.9)	0
Lifetime diagnoses of any mental health condition	210 (62.5)	0
Interpersonal Factors
Gender-based violenceα*	62 (18.5)	16
Sex work*	148 (44.1)	1
Structural exposures
Criminalized substance use*	236 (70.2)	2
Incarceration*	30 (8.9)	5
Homelessness*	74 (22.0)	2
HIV specific variables
Optimal ART adherence (≥95%)μ	198 (58.9)	2

^∞Trans [transgender, transsexual, other transfeminine identity], gender diverse [non-binary, genderqueer], Two-Spirit, other

^×Lesbian, gay, bisexual, asexual, Two Spirit, queer, other

^βFirst Nations, Métis, or Inuit

^±Latinx, South/East Asian, Middle Eastern, other

^αPhysical/sexual

^μIn the last 3–4 weeks

^*In the last 6 months

With regards to our primary variables of interest, within the last 6 months at the time of their baseline interview, 8.9% of participants had experienced a recent incarceration. In addition, 22.0% experienced recent homelessness, 70.2% reported any recent criminalized substance use (of these, 48.2% reported injection use and 63.7% reported non-injection use; 66.4% reported any stimulant use, while 42.9% reported any opioid use), and 18.5% experienced recent gender-based violence. At baseline, only 58.9% of participants reported optimal ART adherence (≥95%) in the last 3–4 weeks, which is comparable to optimal adherence among a national cohort of women living with HIV in Canada (60.7% at study visit) (Gormley et al., 2020).

Path Analysis

After missing data were excluded, 332 participants with 1923 observations were included in the path analysis. Model fit indices suggest our hypothesized model fit well to the data (χ2(1) = 1.100; p = 0.2943; CFI = 1.000; RMSEA = 0.007). Figure I illustrates the path diagram with standardized coefficients for all significant direct effects. All mediator variables were significantly correlated with each other (gender-based violence and criminalized substance use: Φ = 0.403, p<0.001; gender-based violence and homelessness: Φ = 0.221, p<0.001; criminalized substance use and homelessness: Φ = 0.197, p=0.004). Table II presents the results for all direct and indirect pathways of interest. The direct paths from recent incarceration to homelessness (β = 0.708, p<0.001), recent criminalized substance use (β = 0.366, p=0.035), and recent gender-based violence (β = 0.663, p<0.001) were significant. Recent homelessness (β = −0.104, p=0.050), recent criminalized substance use (β = −0.254, p<0.001), and recent gender-based violence (β = −0.149, p=0.019), each had a significant negative direct effect on optimal ART adherence. The direct path from incarceration to optimal ART adherence was not significant (β = −0.170, p=0.309), with indirect paths suggesting this was fully mediated by recent homelessness (indirect β = −0.074, p=0.064), recent criminalized substance use (indirect β = −0.093, p=0.066) and recent gender-based violence (indirect β = −0.099, p=0.028).

FIGURE 1.

Pathways from incarceration to optimal ART adherence

TABLE II.

Standardized parameter estimates from the path analysis model of incarceration and optimal ART adherence among women living with HIV in Metro Vancouver, Canada, 2010–2019 (n = 336)^†

Pathway	Standard coefficient	Standard error	Critical ratio	p-value
Direct Paths
Gender Based-Violence α *
Incarceration*	0.663	0.130	5.120	<0.001
Homelessness *
Incarceration*	0.708	0.140	5.054	<0.001
Criminalized Substance Use *
Incarceration*	0.366	0.174	2.104	0.035
Optimal ART Adherence (≥95%) μ
Incarceration*	−0.170	0.167	−1.017	0.309
Gender-based violenceα*	−0.149	0.063	−2.350	0.019
Homelessness*	−0.104	0.053	−1.956	0.050
Criminalized substance use*	−0.254	0.070	−3.646	<0.001
Indirect Paths
From Incarceration* → Optimal ART Adherence (≥95%)μ
Total indirect path	−0.266	0.066	−4.013	<0.001
Through gender-based violenceα*	−0.099	0.045	−2.190	0.028
Through homelessness*	−0.074	0.040	−1.853	0.064
Through criminalized substance use*	−0.093	0.050	−1.842	0.066

^†All pathways were adjusted for age, race, sexual orientation, gender identity, education, and lifetime diagnoses of any mental health condition. Recent sex work was adjusted for in pathways between incarceration and the mediators of interest.

^*Time updated to capture events in the last 6 months

^μTime updated to capture events in the last 3–4 weeks

^αPhysical/sexual

DISCUSSION

Given sub-optimal HIV health outcomes among women living with HIV in the period post-release from correctional facilities, this study addresses a gap in the current knowledge and highlights key considerations for the development of interventions aimed at improving overall wellbeing and health of marginalized women along incarceration trajectories. Research from the US has studied a range of interventions designed to support and enhance HIV care outcomes post-release from incarceration for people living with HIV (Brantley et al., 2019; Cunningham et al., 2018; Jordan et al., 2013; Khawcharoenporn, Zawitz, Young, & Kessler, 2013; MacGowan et al., 2015; Myers et al., 2018; Reznick, McCartney, Gregorich, Zack, & Feaster, 2013; Wohl et al., 2017, 2011), however, results commonly lack a gender-based analysis, making it challenging to draw critical conclusions of the effectiveness of interventions based on gender. Recognizing women living with HIV as a unique population within the criminal justice system, calls have been made for policies and interventions that are responsive to the needs of women (J. P. Meyer, 2019). Our research adds an important gendered lens when considering post-release interventions by highlighting the interconnectedness of homelessness, criminalized substance use, and gender-based violence as factors that play a critical role in health outcomes. Although these barriers to health are systemic and structural and require resourced solutions, findings from this study provide important insights for how policy and programming might help to mitigate harms by improving supports and referrals for marginalized women living with HIV upon release from custody.

Housing is a primary unmet need among people living with HIV leaving custody (Nunn et al., 2010), and in our study homelessness was a significant mediator along the pathway from incarceration to optimal ART adherence. Transitional or second stage housing specific to people leaving correctional settings aims to provide a safe environment post-release with structured supports (Desai, 2012), and US-based research outlines clear benefits of supportive transitional housing for women living with HIV post-release from incarceration, including as a crucial support for ART access and adherence (Ghose et al., 2019). However, evidence suggests that transitional housing in Canada remains limited and unsafe for women (National Inquiry into Missing and Murdered Indigenous Women and Girls, 2019a), and our findings elucidate an urgent need for resources dedicated to increased gender-specific housing options upon release from correctional settings. Given the high rates of gender-based violence among marginalized women who experience incarceration (Erickson, Pick, Ranville, Martin, et al., 2020; McMillan et al., 2021), along with research highlighting the relationship between gender-based violence and housing precarity among women living with HIV specifically (Zhao, 2021), there is an ongoing need for gender-specific approaches to housing stability (Desai, 2012; Fotheringham, Walsh, & Burrowes, 2014). Housing options could include self-contained units in women-only buildings (Currie, 2004; Desai, 2012), along with communal areas that foster social support surrounding community reintegration, and supports for women who have children (Desai, 2012; Ghose et al., 2019). Given substantial gaps in gender affirming housing for trans, Two-Spirit, and gender diverse people within women-centered programs (Lyons et al., 2016), women-centred housing must include and enforce trans and gender-inclusive policies to promote accessibility and safety for trans, Two-Spirit, and gender-diverse people.

This research also highlights the substantial impact of criminalized substance use on ART adherence post-release from incarceration. This relationship is of critical concern given the heightened risk for overdose and death among people leaving correctional settings (Binswanger et al., 2007; Gan et al., 2021), which has been heightened by the ongoing overdose crisis in North America, and specifically the province of British Columbia where this research takes place (British Columbia Coroners Service, 2022; Centers for Disease Control and Prevention, 2021). Research and policy has stressed the importance of housing first principles (i.e., viewing housing as a human right which should not be conditional on abstaining from criminalized substances) in supporting people upon release from incarceration (Desai, 2012). Growing research points to the importance of gender-specific transitional housing that is low-barrier in terms of drug use (Ghose et al., 2019), while other work highlights the need for drug-free living environments in the post-release period (Desai, 2012). Central to this work of course is the emphasis on client-centered care that provides meaningful options and choice when it comes to housing options and associated supports (Centre for Addictions Research of BC, 2011; Desai, 2012). The inclusion of harm reduction principles (National Harm Reduction Coalition, 2021) within housing strategies (Centre for Addictions Research of BC, 2011), ensuring that gender-specific housing options are also within proximity to pre-existing harm reduction and substance use services (Zhao, 2021), and supporting women to access services tailored to their individual goals and needs (Springer, Spaulding, Meyer, & Altice, 2011) will be essential in supporting women’s health and wellbeing. Finally, to redress the overincarceration of marginalized women, decriminalizing illicit substance use and ending the war on drugs remains paramount (Canadian Drug Policy Coalition, 2021; C. Carter & MacPherson, 2013; Wood et al., 2010).

Last, this research highlights and points to a critical need for continued efforts to address the alarmingly high rates of violence perpetuated against marginalized women, including women living with HIV. This includes specific calls to action to tackle and eliminate ongoing and systematic violence perpetuated against Indigenous, Black and other racialized women (C. M. Martin & Walia, 2019; Maynard, 2017; National Inquiry into Missing and Murdered Indigenous Women and Girls, 2019b). Our findings emphasize that at the very minimum it is essential that all supports and services for women leaving correctional settings, including for housing, addiction needs, and HIV care, be trauma and violence-informed, and equipped with appropriate referrals to services for women experiencing violence. Trauma and violence-informed care (TVIC) principles have expanded from a trauma-informed care framework - that aims to realize and understand the impact of trauma and integrate knowledge around trauma into policies and practice (SAMHSA’s Trauma and Justice Strategic Initiative, 2014) – “to account for the intersecting impacts of systemic and interpersonal violence and structural inequities” (Equip Health Care, 2021, p.1). Central to TVIC is safety and autonomy for the service user (BC Centre for Excellence for Women’s Health; BC Ministry of Health; Vancouver Island Health Authority, 2013). TVIC is a fundamental component of creating culturally safe spaces for Indigenous people (First Nations Health Authority 2016). The creation of culturally safe housing spaces and associated services that meet the needs of Indigenous women (Bingham, 2020; First Nations Health Authority, 2016) is of critical importance in light of the significant over-representation of Indigenous women within the criminal justice system in Canada (The Correctional Investigator Canada, 2018) and other countries with a history of settler colonialism (Australian Law Reform Commission, 2018; Department of Corrections, 2007; The Sentencing Project, 2020). Mandated education for service providers surrounding colonialism, the residential school system, intergenerational trauma, and the systematic over incarceration of Indigenous people (Truth and Reconciliation Commission of Canada, 2015a), is critical in the delivery of culturally safe care for Indigenous women involved in the criminal justice system. Overall, adopting culturally safe, TVIC and practice into service delivery is a manageable yet fundamental step in ensuring that the lived experiences of women are recognized, and that supports and services acknowledge the complexities of trauma and ongoing experience of gender-based violence when tailoring services to marginalized women.

Limitations

This study had several limitations to consider. Results should not be interpreted as causal and there is potential for reverse directionality between recent incarceration and the mediators. Clinical measures of HIV viral load are often regarded as the gold standard in measuring HIV health (Cogswell, Ohadi, & Avila, 2016), and used as a hard marker for ART adherence. Despite this however, the specific purpose of this study was not to look at HIV viral load, but rather to investigate which mechanisms might influence participants’ ability to maintain optimal adherence in the post-release period. As mentioned previously, evidence suggests that self-reported ART adherence measures, including scale-based measures, are robust for measuring adherence (Buscher et al., 2011; A. Carter et al., 2017; Simoni et al., 2006). Further, although self-report measures have the potential to introduce social desirability (Latkin, Edwards, Davey-Rothwell, & Tobin, 2017), the SHAWNA research team employs strategies to build and maintain long-lasting and trusting relationships with study participants in order to minimize responder bias. Our study’s sample size may not provide power to detect some associations, though effective sample size is increased through the use of longitudinal data. Given the small number of participants who had a recent incarceration, we did not have adequate statistical power to present our path analysis model stratified by potential key variables, including race or gender identity, which potentially could have highlighted differences in post-release experiences and retention in care for different groups. Larger samples are needed, including those led by and/or bringing to the forefront the perspectives of Indigenous women as well as trans women, Two-Spirit, and gender diverse people, to be able to draw out intersectional analysis and elucidate considerations for tailored interventions. Future research could also explore more complex pathways, including how additional mediators through for example, experiences of HIV-related stigma, ongoing mental health concerns or symptoms, food insecurity, or being connected to community programs and services post-release, might impact pathways from incarceration to optimal ART adherence. Additional research could explore how different criminal charges (and subsequent bail conditions), along with length of stay in custody, might impact post-release trajectories and health outcomes.

Conclusion

Recent homelessness, criminalized substance use, and experiencing gender-based violence emerged as important mediators along the pathway from recent incarceration to optimal ART adherence among women living with HIV post-release from correctional facilities. Findings provide important insights into the gendered impacts of incarceration and highlight critical considerations for interventions in the post-release period. To improve ART adherence and subsequent HIV health outcomes among women post-release from incarceration, there is an urgent need for expanded services and interventions. Dedicated resources to increase the availability of accessible, safe, and gender-specific housing – including transitional housing following release from correctional facilities – remains urgent. There is also a critical need for post-release supports to include an emphasis on tailored approaches to adequate care and supports surrounding criminalized substance use and heightened levels of violence, while ensuring that services and programs are trauma and violence-informed and sensitive to the ongoing impacts of gender-based violence among marginalized women.

Key considerations:

• To improve ART adherence and subsequent HIV health outcomes among women post-release from incarceration, there is an urgent need for expanded services and interventions.

• This includes a need for increased accessible, safe, and gender-specific housing options for women leaving correctional facilities and resources to support the needs of women who use criminalized substances, including low-barrier hosing options with an emphasis on harm reduction.

• Given high rates of historical and ongoing violence experienced by women living with HIV involved in the criminal justice system, services and programming should be trauma and violence-informed as well as culturally safe