Transitional community adherence support for people leaving incarceration in South Africa: a pragmatic, open-label, randomised controlled trial.

BACKGROUND: People released from correctional facilities face multifactorial barriers to continuing HIV treatment. We hypothesised that barriers faced in the first 6 months of community re-entry would be decreased by a multilevel group-based and peer-led intervention, the Transitional Community Adherence Club (TCAC). METHODS: We did a pragmatic, open-label, individually randomised controlled trial in five correctional facilities in Gauteng, South Africa. Participants aged 18 years and older and receiving antiretroviral therapy (ART) in correctional facilities were enrolled before release and randomly assigned (1:2) to either passive referral (usual care) or TCACs. TCACs followed a 12-session curriculum over 6 months and were facilitated by trained peer and social workers. Participants were followed up by telephone and in person to assess the primary outcome: post-release enrolment in HIV treatment services at 6 months from the date of release. We did an intention-to-treat analysis to determine the effectiveness of TCACs compared with usual care. The trial was registered with the South African National Clinical Trials Register (DOH-27-0419-605) and ClinicalTrials.gov (NCT03340428). This study is completed and is listed as such on ClinicalTrials.gov. FINDINGS: From March 1, to Dec 13, 2019, we screened 222 individuals and enrolled 176 participants who were randomly assigned 1:2 to the usual care group (n=59) or TCACs (n=117). 175 participants were included in the final analysis. In the usual care group, 21 (36%) of 59 participants had enrolled in HIV treatment services at 6 months, compared with 71 (61%) of 116 in the TCAC group (risk ratio 1·7, 95% CI 1·2-2·5; p=0·0010). No adverse events were reported. INTERPRETATION: We found strong evidence that a differentiated service delivery model with curriculum and peer support designed specifically to address the needs of people with HIV returning from incarceration improved the primary outcome of enrolment in HIV treatment services. Our approach is a reasonable model to build further HIV treatment continuity interventions for individuals in the criminal justice system in South Africa and elsewhere. FUNDING: National Institute of Mental Health.

Opioid use and HIV treatment services experiences among male criminal justice-involved persons in South Africa: a qualitative study.

BACKGROUND: Opioid use disorder (OUD) is overrepresented among people with criminal justice involvement; HIV is a common comorbidity in this population. This study aimed to examine how formerly incarcerated men living with HIV and OUD in South Africa experienced HIV and OUD services in correctional facilities and the community. METHODS: Three focus group discussions were conducted with 16 formerly incarcerated men living with HIV and OUD in Gauteng, South Africa. Discussions explored available healthcare services in correctional facilities and the community and procedural and practice differences in health care between the two types of settings. Data were analyzed thematically, using a comparative lens to explore the relationships between themes. RESULTS: Participants described an absence of medical services for OUD in correctional facilities and the harms caused by opioid withdrawal without medical support during incarceration. They reported that there were limited OUD services in the community and that what was available was not connected with public HIV clinics. Participants perceived correctional and community HIV care systems as readily accessible but suggested that a formal system did not exist to ensure care continuity post-release. CONCLUSIONS: OUD was perceived to be medically unaddressed in correctional facilities and marginally attended to in the community. In contrast, HIV treatment was widely available within the two settings. The current model of OUD care in South Africa leaves many of the needs of re-entrants unmet. Integrating harm reduction into all primary care medical services may address some of these needs. Successful HIV care models provide examples of approaches that can be applied to developing and expanding OUD services in South Africa.