People living with HIV who spent time in Connecticut correctional facilities and received transitional case management were more likely to be promptly linked to care after their release than those who did not receive such services, a study published in The Lancet found. The study found several factors that negatively impacted linkage to care when released from custody, including sentences less than 30 days, serving more than one year, conditional release, and reincarceration.
"[Linkage to care] after release is suboptimal but improves when inmates' medical, psychiatric, and case management needs are identified and addressed before release," note the authors in the study. "People who are rapidly cycling through jail facilities are particularly vulnerable to missed linkage opportunities. The use of integrated programmes to align justice and health-care goals has great potential to improve long-term HIV treatment outcomes."
The retrospective study reviewed all HIV-positive adults released from Connecticut prison and jails from 2007 to 2014. The researchers together analyzed corrections administrative records, pharmacy prescriptions, state HIV/AIDS surveillance data, and case management records. They defined linkage to care as having a viral load measurement taken after return to the community.
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Instead of simply reviewing individual people as the baseline, researchers used the number of releases from custody, because so many people churn in and out of the system. In fact, about 82% of post-release periods identified represented a return to a Connecticut correctional facility by someone who had been previously imprisoned in the state.
The study found that, during the eight-year study period, 21% of post-release linked to care episodes happened within 14 days, and 34% happened within 30 days.
Alma Norris, program manager of Project TLC at AIDS Connecticut, said her organization assists many people who are released from prison in the state. When it's time for people with HIV to be released from prison or jail, infectious disease nurses at the state's correctional facilities and halfway houses provide the referrals, she noted. Case managers at Project TLC then help clients access medical care and assist with emergency housing and enrollment in entitlement programs, adding up to approximately 325 referrals a year. Many of the referrals are people who, as the study suggests, are cycling in and out of corrections. "Recidivism is one of the challenges that we experience with clients," said Norris.
The number of people in Connecticut jails or prisons has grown more than five-fold since 1969, according to the state's Department of Corrections (DoC). In 2015, the department reported 16,025 people in correctional facilities, 230, or 1.5%, of whom were living with HIV, according to the Bureau of Justice Statistics. Health care in Connecticut's prisons and jails is provided by UConn Health's Correctional Managed Health Care division. According to its website, the division currently treats 220 people living with HIV. UConn Health's policy, written in 2001, requires staff to offer HIV testing only if the person entering jail or prison reports behaviors that place him or her at risk of acquiring the virus. People may not tell the intake officer about such activities, and therefore not get tested. "Many inmates do not disclose their high-risk behaviors, such as anal sex or injection drug use, because they fear being stigmatized," the U.S. Centers for Disease Control and Prevention observed in 2017.
Another 3,955 people were on supervised release in 2015, the Connecticut DoC reports. In The Lancet study, conditional release significantly lowered the odds that a person would be promptly linked to care (30-day adjusted odds ratio 0.79). The longer between returning to the community and getting HIV care, the lower the proportion of those with undetectable viral loads, the study also found. HIV-positive people who are virally suppressed cannot transmit HIV to their partners. More HIV-positive people with detectable viral loads in a given location also means more people who can pass on the virus. A study of 12 U.S. cities found that higher prison release rates correlated with higher community HIV prevalence rates. This is also evident in Connecticut: The cities with the highest HIV rates in 2016 -- Bridgeport, Hartford, New Haven, and Waterbury -- house correctional facilities or border counties that have such institutions.
"For many [people living with HIV], this time during incarceration may be the only time they have access to HIV care," the National Center for Innovation in HIV Care's report on model programs for release planning asserts. However, organizations must also ensure that care continues when people return to the community, the report adds. As The Lancet study shows, linkage to care after release is often poor. That study's authors concluded: "The most cost-effective, ethical, and beneficial strategy for continuity of HIV care is probably to avoid incarceration altogether."