Falling Through the Cracks: Risk Factors for Becoming Lost to HIV Care After Incarceration in a Southern Jail.

Using a retrospective cohort analysis of inmates released from Dallas County Jail between January 2011 and November 2013, this study characterizes people living with HIV/AIDS (PLWHA) who are lost to care after release from jail. We used Kaplan-Meier analysis to estimate the risk of becoming lost to post-release HIV care and a Cox proportional hazards regression model to identify associated factors. The majority of individuals (78.2%) were men and 65.5% were black. Of the incarcerations that ended with release to the community, approximately 43% failed to link to community HIV care. Non-Hispanic Whites were more likely than Hispanics or Blacks to drop out of care after release. Individuals with histories of substance use or severe mental illness were more likely to become lost, while those under HIV care prior to incarceration and/or who had adhered to antiretroviral therapy (ART) were more likely to resume care upon release. Targeted efforts such as rapid linkage to care and re-entry residence programs could encourage formerly incarcerated individuals to re-engage in care.

HIV Care After Jail: Low Rates of Engagement in a Vulnerable Population.

The criminal justice system is a critical area of focus to improve HIV outcomes and reduce health disparities. We analyzed demographic, incarceration, socioeconomic, and clinical data for HIV-positive persons released to the community from the Dallas County Jail (1450 incarcerations, 1111 unique individuals) between January 2011 and November 2013. The study population was 68% black and 14% Hispanic; overall linkage to care within 90 days of release was 34%. In adjusted analyses, Hispanics were more likely to link than whites (aOR 2.33 [95% CI: 1.55-3.50]), and blacks were as likely to link as whites (aOR 1.14 [95% CI: 0.84-1.56]). The majority of HIV-positive jail releases did not re-engage in HIV care after release, though Hispanics were twice as likely as other groups to link to care. Further efforts are needed to improve the transition from jail to community HIV care with particular attention to issues of housing, mental illness, and substance use.

Cost analysis of tuberculin skin test and the QuantiFERON-TB Gold In-tube test for tuberculosis screening in a correctional setting in Dallas, Texas, USA.

BACKGROUND: Tuberculosis (TB) disproportionately affects immigrants, HIV-infected individuals, and those living in crowded settings such as homeless shelters and correctional facilities. Although the majority of jails and prisons use a tuberculin skin test (TST) for latent tuberculosis infection (LTBI) screening, limited data exist on the clinical performance and costs of the TST compared to interferon gamma release assays (IGRAs) in this setting. METHODS: A prospective pilot study comparing cost between TST and an IGRA (QuantiFERON Gold In-tube, QFT-GIT) for the detection of LTBI in a convenience sample of inmates entering the Dallas County Jail (DCJ) was conducted June-October 2014. Participants completed a risk questionnaire, TST placement, QFT-GIT testing, and were offered opt-out HIV-Ab testing. LTBI prevalence based on TST and QFT-GIT results, an evaluation of discordant results and a cost analysis are presented. RESULTS: A total of 529 subjects were enrolled. The majority were male (75 %), and 46 % were Black, 29 % White, and 24 % Hispanic. Most (85 %) had been previously incarcerated. Over 28 % of participants were released prior to TST reading, with paired QFT-GIT and TST results available for 351 subjects. Of these, nine (2.6 %) tested positive by TST and 47 (13.4 %) tested positive by QFT-GIT. It costs $23.27 more per inmate per year to screen with QFT-GIT than TST in this population, though the cost per LTBI case detected was nearly three times higher for TST than QFT-GIT ($1247 v $460). CONCLUSIONS: We found a substantially higher rate of QFT-GIT positivity compared to TST in this sample of individuals entering the Dallas County Jail. Although no gold standard exists, this finding may indicate under-recognized LTBI in this setting. QFT-GIT as an initial screening tool was more time-efficient, had four-fold fewer labor costs and provided results on more individuals when compared with the TST. The overall cost of QFT-GIT was $23.27 more per inmate per year, though the cost per LTBI case detected was nearly three times higher for TST than QFT-GIT. Further research is needed to determine the long-term performance of IGRA testing in the correctional setting and the public health implications of pairing QFT-GIT screening with other tests for communicable diseases.

The HIV Care Cascade Before, During, and After Incarceration: A Systematic Review and Data Synthesis.

We conducted a systematic literature review of the data on HIV testing, engagement in care, and treatment in incarcerated persons, and estimated the care cascade in this group. We identified 2706 titles in MEDLINE, EBSCO, and Cochrane Library databases for studies indexed to January 13, 2015, and included 92 for analysis. We summarized HIV testing results by type (blinded, opt-out, voluntary); reviewed studies on HIV care engagement, treatment, and virological suppression; and synthesized these results into an HIV care cascade before, during, and after incarceration. The HIV care cascade following diagnosis increased during incarceration and declined substantially after release, often to levels lower than before incarceration. Incarceration provides an opportunity to address HIV care in hard-to-reach individuals, though new interventions are needed to improve postrelease care continuity.

Acceptability of HIV Testing Among Jail Inmates When Combined With a Blood Test for Tuberculosis.

Incarcerated individuals are at high risk of HIV and tuberculosis (TB), though combined screening in the criminal justice system is limited. Newer blood tests for TB provide a unique opportunity to combine HIV and TB testing in corrections. Entering jail inmates were offered routine opt-out HIV testing along with TB screening, both via blood draw. Of the 529 individuals enrolled, 524 (99%) agreed to HIV testing. Testing identified 13 (2.5%) previously diagnosed HIV infections and one new positive. One quarter (138, 26%) of participants had never been tested for HIV and were more likely to be young, Hispanic, born outside of the United States, and incarcerated for the first time. Combined HIV/TB testing had high acceptability among individuals entering jail.