Assessing the Effect of Recent Incarceration in Prison on HIV Care Retention and Viral Suppression in Two States.

The prevalence of HIV among people in correctional facilities remains much higher than that of the general population. Numerous studies have demonstrated the effectiveness and acceptability of HIV treatment for individuals incarcerated in US prisons and jails. However, the period following incarceration is characterized by significant disruptions in HIV care. These disruptions include failure to link in a timely manner (or at all) to community care post-release, as well as not being retained in care after linking. We used a retrospective, propensity-matched cohort design to compare retention in care between HIV-positive individuals recently released from prison (releasees) who linked to care in Ryan White HIV/AIDS Program (RWHAP) clinics and RWHAP patients without a recent incarceration history (community controls). We also performed analyses comparing viral load suppression of those retained in both groups. This study shows that even for those who do successfully link to care after prison, they are 24 to 29 percentage points less likely to be retained in care than those already in community care. However, we found that for those who did retain in care, there was no disparity in rates of viral suppression. These findings provide valuable insight regarding how best to address challenges associated with ensuring that HIV-positive individuals leaving prison successfully move through the HIV care continuum to become virally suppressed.

Use of viral load surveillance data to assess linkage to care for persons with HIV released from corrections.

Incarcerated people remain a priority group in efforts to control and reverse the HIV epidemic. Following release, social instability and reengagement in key transmission risk behaviors increase the risk of secondary transmission of HIV. Targeted programs have been developed to facilitate reengagement in care on reentry. Evaluation of the impact of these initiatives requires a systematic, confidential, framework for assessment of linkage to care for persons released from corrections. By linking HIV viral load surveillance data to corrections release data, the time to the first laboratory monitoring service in the community as well as the virologic status can be assessed. Using this method, we linked release data for sentenced individuals released from Massachusetts state correctional facilities in 2012 to HIV surveillance data from the Massachusetts HIV/AIDS Surveillance Program (MHASP) for the years 2012-2013. We identified 41 individuals with HIV released in 2012. Ninety-one percent had identified virologic assessments post release, 41% within 30 days. Thirty-three percent did not have a viral load assessed for more than 90 days and 31% had detectable virus at the time of their initial assessment. Persons with longer incarcerations (> 180 days) were more likely to have suppressed viral load at the time of follow-up (p = 0.05). This work demonstrates the important value of HIV laboratory surveillance data and correctional release data as a tool to assess linkage to care following release from corrections. We encourage jurisdictions to explore utilizing similar methodology to evaluate the effectiveness of the linkage to HIV care after release from incarceration.

Cost-utility of HIV Testing Programs Among Men Who Have Sex with Men in the United States.

Few groups in the United States (US) are as heavily affected by HIV as men who have sex with men (MSM), yet many MSM remain unaware of their infection. HIV diagnosis is important for decreasing onward transmission and promoting effective treatment for HIV, but the cost-effectiveness of testing programs is not well-established. This study reports on the costs and cost-utility of the MSM Testing Initiative (MTI) to newly diagnose HIV among MSM and link them to medical care. Cost and testing data in 15 US cities from January 2013 to March 2014 were prospectively collected and combined to determine the cost-utility of MTI in each city in terms of the cost per Quality Adjusted Life Years (QALY) saved from payer and societal perspectives. The total venue-based HIV testing costs ranged from $18,759 to $564,284 for nine to fifteen months of MTI implementation. The cost-saving threshold for HIV testing of MSM was $20,645 per new HIV diagnosis. Overall, 27,475 men were tested through venue-based MTI, of whom 807 (3 %) were newly diagnosed with HIV. These new diagnoses were associated with approximately 47 averted HIV infections. The cost per QALY saved by implementation of MTI in each city was negative, indicating that MTI venue-based testing was cost-saving in all cities. The cost-utility of social network and couples testing strategies was, however, dependent on whether the programs newly diagnosed MSM. The cost per new HIV diagnosis varied considerably across cities and was influenced by both the local cost of MSM testing implementation and by the seropositivity rate of those reached by the HIV testing program. While the cost-saving threshold for HIV testing is highly achievable, testing programs must successfully reach undiagnosed HIV-positive individuals in order to be cost-effective. This underscores the need for HIV testing programs which target and engage populations such as MSM who are most likely to have undiagnosed HIV to maximize programmatic benefit and cost-utility.

Systematic Assessment of Linkage to Care for Persons with HIV Released from Corrections Facilities Using Existing Datasets.

Populations in corrections continue to have high prevalence of HIV. Expanded testing and treatment programs allow persons to be identified and stabilized on treatment while incarcerated. However, these gains and frequently lost on reentry. Systemic frameworks are needed to monitor linkage to care to guide programs supporting linkage to care. To assess the adequacy of linkage to care on reentry, incarceration data from the National Corrections Reporting Program and data from the Ryan White Services Report from 2010 to 2012 were linked using an encrypted client identification (eUCI). Time from release to the first visit and presence of detectable HIV RNA at linkage were assessed. Multivariate survival analyses were performed to identify associations between patient characteristics and time to linkage. Among those linking, only 43% in Rhode Island and 49% in North Carolina linked within 90 days, and 33% in both states had detectable viremia at the first visit. Those not previously in care and with shorter incarceration experiences longer linkage times. Persons identified as black, had median times greater than 1 year. Using existing datasets, significant gaps in linkage to care for persons with HIV on release from corrections were demonstrated in Rhode Island and North Carolina. Systemically implementing this monitoring to evaluate changes over time would provide important information to support interventions to improve linkage in high-risk populations. Using national datasets for both corrections and clinical data, this framework equally could be used to evaluate experiences of persons with HIV linking to care on release from corrections facilities nationwide.

Transitions to Care in the Community for Prison Releasees with HIV: a Qualitative Study of Facilitators and Challenges in Two States.

One in seven people living with HIV in the USA passes through a prison or jail each year, and almost all will return to the community. Discharge planning and transitional programs are critical but challenging elements in ensuring continuity of care, maintaining treatment outcomes achieved in prison, and preventing further viral transmission. This paper describes facilitators and challenges of in-prison care, transitional interventions, and access to and continuity of care in the community in Rhode Island and North Carolina based on qualitative data gathered as part of the mixed-methods Link Into Care Study of prisoners and releasees with HIV. We conducted 65 interviews with correctional and community-based providers and administrators and analyzed the transcripts using NVivo 10 to identify major themes. Facilitators of effective transitional systems in both states included the following: health providers affiliated with academic institutions or other entities independent of the corrections department; organizational philosophy emphasizing a patient-centered, personal, and holistic approach; strong leadership with effective "champions"; a team approach with coordination, collaboration and integration throughout the system, mutual respect and learning between corrections and health providers, staff dedicated to transitional services, and effective communication and information sharing among providers; comprehensive transitional activities and services including HIV, mental health and substance use services in prisons, timely and comprehensive discharge planning with specific linkages/appointments, supplies of medications on release, access to benefits and entitlements, case management and proactive follow-up on missed appointments; and releasees' commitment to transitional plans. These elements were generally present in both study states but their absence, which also sometimes occurred, represent ongoing challenges to success. The qualitative findings on the facilitators and challenges of the transitional systems were similar in the two states despite differences in context, demographics of target population, and system organization. Recommendations for improved transitional systems follow from the analysis of the facilitators and challenges.

Survey of US Correctional Institutions for Routine HCV Testing.

To ascertain HCV testing practices among US prisons and jails, we conducted a survey study in 2012, consisting of medical directors of all US state prisons and 40 of the largest US jails, that demonstrated a minority of US prisons and jails conduct routine HCV testing. Routine voluntary HCV testing in correctional facilities is urgently needed to increase diagnosis, enable risk-reduction counseling and preventive health care, and facilitate evaluation for antiviral treatment.

Survey finds that many prisons and jails have room to improve HIV testing and coordination of postrelease treatment.

Early diagnosis of HIV and effective antiretroviral treatment are key elements in efforts to reduce the morbidity and mortality associated with HIV. Incarcerated populations are disproportionately affected by HIV, with the disease's prevalence among inmates estimated to be three to five times higher than among the general population. Correctional institutions offer important opportunities to test for HIV and link infected people to postrelease treatment services. To examine HIV testing and policies that help HIV-positive people obtain treatment in the community after release, we administered a survey to the medical directors of the fifty state prison systems and of forty of the largest jails in the United States. We found that 19 percent of prison systems and 35 percent of jails provide opt-out HIV testing, which is recommended by the Centers for Disease Control and Prevention (CDC). Additionally, fewer than 20 percent of prisons and jails conform to the CDC's recommendations regarding discharge planning services for inmates transitioning to the community: making an appointment with a community health care provider, assisting with enrollment in an entitlement program, and providing a copy of the medical record and a supply of HIV medications. These findings suggest that opportunities for HIV diagnosis and linking HIV-positive inmates to community care after release are being missed in the majority of prison systems and jails.

Jails, HIV testing, and linkage to care services: an overview of the EnhanceLink initiative.

Over 9 million persons in the United States (US) are admitted each year to jails. HIV prevalence among detainees is higher than the general population, which creates a public health need for linking HIV-infected detainees to services during jail and after release. The EnhanceLink initiative was funded as demonstration projects in 10 communities at 20 separate jails across the US. Grantees implemented and evaluated innovative models of HIV testing in jails and linkage of HIV-infected individuals to community services post release. In this paper, we describe services delivered with the EnhanceLink initiative. During 877,119 admission events, 210,267 inmates agreed to HIV testing and 822 new diagnoses of HIV were made. The majority of persons served with transitional services were previously diagnosed before the current incarceration. Cumulatively, 9,837 HIV+ persons were offered linkage and transitional services and 8,056 (82 %) accepted the offer. EnhanceLink demonstrated the feasibility of HIV testing in jail settings and provision of linkage services to enhance continuity of HIV care post-release.

Linkage to HIV care for jail detainees: findings from detention to the first 30 days after release.

Of people living with HIV in the US, ~16 % or over 150,000 individuals passed through a correctional facility in 2006. Given the enormous impact of HIV within incarcerated populations, facilitating continuity of care from jails to the community is particularly important in reducing morbidity and mortality for releasees. Grantees participating in the Enhancing Linkages to HIV Primary Care in Jail Settings Initiative developed models for identifying HIV-positive detainees during incarceration and linking them to care following release. In this sample of 1,021 HIV-infected releasees, 79 % received clinical services and 74 % received additional community services within 30 days post-release. Our analysis found several significant factors associated with linkage including: receipt of HIV or medication education in jail, having a completed discharge plan at release, staff awareness of clients' release date, and stable housing on the 30th day post-release. In addition, a subset of participants who had both jail and community viral load assessments showed a statistically significant increase in suppressed viral load. EnhanceLink data suggest that jails may be effective settings to engage individuals in care.

Tracking linkage to HIV care for former prisoners: a public health priority.

Improving testing and uptake to care among highly impacted populations is a critical element of Seek, Test, Treat and Retain strategies for reducing HIV incidence in the community. HIV disproportionately impacts prisoners. Though, incarceration provides an opportunity to diagnose and initiate therapy, treatment is frequently disrupted after release. Though model programs exist to support linkage to care on release, there is a lack of scalable metrics with which to assess adequacy of linkage to care after release. The linking data from Ryan White program Client Level Data (CLD) files reported to HRSA with corrections release data offers an attractive means of generating these metrics. Identified only by use of a confidential encrypted Unique Client Identifier (eUCI) these CLD files allow collection of key clinical indicators across the system of Ryan White funded providers. Using eUCIs generated from corrections release data sets as a linkage tool, the time to the first service at community providers along with key clinical indicators of patient status at entry into care can be determined as measures of linkage adequacy. Using this strategy, high and low performing sites can be identified and best practices can be identified to reproduce these successes in other settings.

Prevalence of HIV infection and prior HIV testing among young men who have sex with men. The Baltimore young men's survey.

Data are presented from the Baltimore Young Men's Survey, a cross-sectional, venue-based sample survey of risks associated with HIV and report of a prior HIV test, conducted between 1996 and 2000, and enrolling 843 young men who have sex with men (MSM) aged 15-29 years. HIV prevalence was 12.1% overall and racial disparities in HIV prevalence were pronounced (range, 2.9% among non-Hispanic whites to 27.1% among non-Hispanic blacks). Risks independently associated with being HIV-positive were: being between 26 and 29 years of age, being non-Hispanic black or of other/mixed race, having had 20 or more lifetime male sex partners, having been diagnosed with a sexually transmitted disease (STD), and not being currently enrolled in school. The majority of participants (78.9%) reported a prior HIV test. In multivariate analysis, being older, having had five or more lifetime male sex partners, having had anal intercourse with males, reporting an STD diagnosis, and reporting recent unprotected anal sex were associated with report of a prior HIV test. Prevention efforts must address high HIV prevalence among young non-Hispanic black MSM and must make testing and effective counseling for young MSM readily available.

Racial disparities in HIV incidence among young men who have sex with men: the Baltimore Young Men's Survey.

Recent reports have demonstrated racial disparities in the prevalence of HIV infection among men who have sex with men (MSM). The objectives of this study are to investigate whether racial disparities exist in HIV incidence among young MSM in Baltimore, MD and to examine potential explanations for differences. Data were collected by the Baltimore Young Men's Survey, a cross-sectional venue-based survey (1996 to 2000) enrolling MSM aged 15 to 29 years. HIV incidence was ascertained using the serologic testing algorithm for recent HIV seroconversion. HIV incidence was 4.2% per year (95% confidence interval [CI]: 1.2 to 10.5) among 843 participants. There were substantial racial differences in HIV incidence, ranging from 0 among Hispanics to 11.0% per year (95% CI: 5.5 to 19.7) among non-Hispanic blacks. In multivariate analysis, among MSM at risk for HIV acquisition, race was not associated with unprotected anal intercourse. Independent risks included having more than 4 recent male sexual partners (adjusted odds ratio [AOR] = 1.6, 95% CI: 1.0 to 2.4) and being under the influence of drugs while having sex (AOR = 1.6, 95% CI: 1.1 to 2.3). Non-Hispanic blacks were no more likely than non-Hispanic whites to report these risk behaviors. Possible alternative explanations for the observed racial disparities in HIV incidence and implications for prevention are explored.

Managed care for AIDS patients: is bigger better?

CONTEXT: Medicaid provides funds for the majority of AIDS-related health care services in the United States. In an effort to stabilize steeply rising Medicaid costs, managed care programs are replacing traditional fee-for-service Medicaid services. OBJECTIVE: To assess the impact of patient volume on the quality of care received by AIDS patients within a state's Medicaid managed care system. DESIGN: Cohort study of AIDS patients who were enrolled in Medicaid at any time from July 1997 through December 1998. Patient charts were reviewed and abstracted. Additional information on the AIDS patients' mode of exposure, date of AIDS diagnosis, and vital status were obtained from the state's HIV/AIDS surveillance database. PATIENTS AND SETTING: All known AIDS patients enrolled in the Maryland Medicaid managed care program were eligible. A total of 1052 of 1585 patient records were reviewed and analyzed. MAIN OUTCOME MEASURES: CD4 and viral load tests; preventive health care including screening for sexually transmitted infections; placement of tuberculin purified protein derivative (PPDs); hepatitis B and C screening; vaccination for hepatitis B; vaccination for pneumococcal pneumonia; Papanicolaou test screening; medication utilization including receipt of antiretroviral therapy and prophylaxis against Pneumocystis carinii pneumonia; case management services; and mortality. RESULTS: Health care quality indicators were examined by comparing the performance of clinical sites that saw a low volume of Medicaid AIDS patients per site (1-15 patients), a medium volume (16-100 patients), and a high volume (101-500 patients). High-volume sites performed better on virtually all quality indicators. There were few differences in performance between low- and medium-volume sites. High-volume sites experienced a greater number of patient deaths; this was true after adjusting for potential confounders such as age, use of antiretrovirals, time since AIDS diagnosis, appropriate laboratory monitoring, and hospitalizations. CONCLUSIONS: Variations in quality of care for AIDS patients were observed in a statewide managed care system. These variations existed despite provisions to ensure quality care such as an enhanced payment system for managed care organizations providing services for AIDS. High-volume sites were more likely to adhere to Public Health Service guidelines and may offer the best opportunity to provide high-quality AIDS care.

Prevalence of HIV, syphilis, hepatitis B, and hepatitis C among entrants to Maryland correctional facilities.

Although high prevalence of hepatitis C virus (HCV) in correctional institutions has been established, data are sparse regarding the comorbidities of hepatitis B virus (HBV), HCV, and human immunodeficiency virus (HIV), all of which may complicate the management of HCV. This study sought to estimate the prevalence and correlates associated with HCV prevalence among entrants into the Maryland Division of Correction and the Baltimore City Detention Center. Participants included all newly incarcerated entrants between January 28 and March 28, 2002. Excess sera with identifiers removed from samples drawn for routine syphilis testing were assayed for antibodies to HIV and HCV and for HBV surface antigen and surface and total core antibodies. Separately, all HIV-positive specimens were tested using the serological testing algorithm for recent HIV seroconversion. Of the 1,081 inmates and 2,833 detainees, reactive syphilis serology was noted in 0.6% of the combined population; HIV seroprevalence was 6.6%; HCV prevalence was 29.7%; and 25.2% of detainees and prisoners had antigen or core or surface antibodies to HBV. A multivariate analysis of predictors of HCV positivity indicated that detainees, women, whites, older age groups, those who were HIV seropositive, and individuals with past or present infection with HBV were significantly more likely to be positive for HCV. These data indicate that hepatitis C remains an important public health concern among entrants to jail and prison and is complicated with coinfections that need to be addressed for effective treatment.

HIV prevention with jail and prison inmates: Maryland's Prevention Case Management program.

Prevalence of HIV infection and AIDS cases is higher among inmates of correctional facilities than among the general population, especially for female inmates. This creates a strong need for effective HIV prevention with this population. Maryland's Prevention Case Management (PCM) program provides individual or group counseling to inmates nearing release to promote changes in risk behavior. Pretest and posttest surveys assess changes in perceived risk, condom attitudes, condom use self-efficacy, self-efficacy to reduce injection drug risk and other substance use risk, and behavioral intentions during participation in the program. Client contact logs, kept by counselors, document the number and duration of sessions, and the specific modules, completed by participants. Over a 4-year period, PCM records identified 2,610 participants in the program. Pre-intervention and postintervention data were available for 745 participants, with client contact log records available for 529 (71%) of these individuals. Significant, positive changes were found in self-reported condom attitudes, self-efficacy for condom use, self-efficacy for injection drug use risk, self-efficacy for other substance use risk, and intentions to practice safer sex post-release. Inmate populations are a crucial audience for HIV/AIDS testing, treatment, and prevention efforts. The Maryland PCM program has documented positive changes in participants' attitudes, self-efficacy, and intentions related to HIV risk, over a 4-year period.