Optimizing HIV and Hepatitis C Continuum of Care Outcomes for Criminal Justice-Involved Populations
While many in the field of infectious disease research and medicine have noted the decline in new investigators and practitioners entering the workforce, the HIV Medicine Association and the Infectious Diseases Society of America Foundation have teamed up to do something about it. Over the summer, they announced a program to fund 15 medical students in the U.S. for clinical learning and research projects, each to be paired with an experienced mentor to support the student's research area of interest.
As part of a series of interviews with a mentor/mentee pair, we spoke with Curt G. Beckwith, M.D., associate professor of medicine in the Division of Infectious Diseases with the Alpert Medical School of Brown University. He has dedicated much of his career to clinical research focused on improving the diagnosis, treatment, and longitudinal care of HIV infection among substance users, particularly those in the criminal justice system. His mentee, Sugi Min, is a third-year medical student at the Alpert Medical School. His research interests revolve around improving access to treatment and care for people living with HIV and hepatitis C (HCV).
Jeanine Barone: Given that HCV is common among people who are in the criminal justice system, what are the barriers to implementing rapid hepatitis C virus testing?
Curt Beckwith: Testing for HCV is a two-step process. Step 1 indicates previous exposure to HCV. If the test is positive, the client needs to complete Step 2, which indicates whether the individual has HCV virus in their blood. If the test is positive, then the client has "chronic" HCV infection. A major challenge with this two-step testing is that clients may not return to receive results from the Step 1 test. As a result, they won't know whether they need to complete Step 2 testing, nor will they learn their HCV status. The rapid HCV test eliminates any delay in receiving results from the Step 1 test, and this is particularly helpful when testing is being offered in community settings among high-risk patients, such as in a probation office. If the rapid HCV test result is delivered right away, efforts can be made to link the patient to Step 2 testing and, hopefully, increasing the chances that they will learn their HCV status. Rapid HCV testing can be used in probation/parole offices or in jails, where there is a rapid turnover of persons entering and exiting the facility. Despite the potential of rapid HCV testing in these correctional settings, uptake has been limited due to implementation and financial constraints.
JB: What are the barriers HIV-positive transgender women and men who have sex with men (MSM) may face during their incarceration with regard to HIV treatment?
CB: In many correctional facilities in the United States, HIV treatment is readily available, and access to treatment may be better than what persons experience in their community. However, reliably accessing HIV treatment inside a prison or jail is dependent on several things, including the existence of an HIV treatment program that is able to identify persons who are living with HIV, and able to provide access to providers and HIV medications in a confidential and non-stigmatizing manner. Transgender persons and MSM already face discrimination inside correctional facilities and, consequently, may not acknowledge risk factors for HIV and/or HIV-positive status due to fear of stigma and further discrimination.
JB: What are some things that can account for poor adherence to antiretroviral therapy (ART) during incarceration?
CB: In addition to stigma and fear of discrimination, there are other practical issues that may influence access and adherence to ART during incarceration. Incarcerated persons should be able to access HIV providers and take their medications in a manner that does not inadvertently disclose their HIV-positive status. If this is not possible, persons may be less likely to take their daily medications if they feel that picking up their HIV medications acknowledges their HIV-positive status to non-medical persons (e.g., other inmates or correctional officers). Allowing persons to keep their own supply of HIV medications is one strategy that has been used to overcome some of these barriers.
JB: What are some things that could improve ART adherence both within and once people are released from the criminal justice system?
CB: A very important intervention that can improve HIV adherence both within correctional facilities and after release is medication-assisted treatment (MAT) for opioid addiction (e.g., methadone, buprenorphine, naltrexone). Without MAT, persons living with HIV who also suffer from opioid use disorder will go through opioid withdrawal at the time of incarceration, which may contribute to HIV treatment interruption. And use of MAT at the time of release may prevent return to opioid use in the community, which can also disrupt treatment. Unfortunately, the use of MAT inside of correctional facilities remains rare.
JB: Why are you especially interested in working with a population involved in the criminal justice system?
Sugi Min: At Brown, first- and second-year medical students practice their clinical skills at various community sites with different physician-mentors. For one afternoon every week, I had access to the infirmary of the men's maximum-security facility, where I practiced my clinical skills while getting to know some of these patients. I intentionally say patients, rather than inmates, because when you're in the clinic, you start to forget that you're housed in maybe the most secure buildings in the state, surrounded by people who have committed some serious crimes, and see them with the same compassion as you would with any other patient in a hospital. When I learned more about the unique vulnerabilities and health consequences associated with incarceration, and that those involved with the criminal justice system are among the most marginalized groups anywhere, I knew I wanted to make an impact.
JB: What sparked your interest in studying HIV and hepatitis C virus infections?
SM: Several years back, I was enthralled by two movies I had watched in quick succession -- Dallas Buyers Club and Philadelphia -- that depicted the cultural story of HIV in ways I was not familiar with. The natural history of HIV infection -- from its terror to the discovery of antiretrovirals to now focusing on strategies to most effectively prevent, diagnose, and treat patients worldwide -- is an amazing success story that intersects culture, politics, and science. HCV has become really fascinating to me since I started medical school, because it was around that time when direct-acting antivirals to effectively treat HCV first became available. I can imagine what it must have been like to be in the HIV field back when the first effective ART regimens to treat HIV became available. That same opportunity is available now, this time with HCV, and it makes it so worthwhile to work in a time that is so exciting for the natural history of this illness.
JB: What are the two projects you are working on with Dr. Beckwith?
SM: The first study is an investigation of HIV drug resistance patterns among people who have a history of incarceration. HIV-[positive] people involved in the criminal justice system often experience multiple treatment interruptions due to high rates of recidivism and reincarceration. Multiple treatment interruptions are thought to be one of the factors related to the development of treatment resistance, and this is particularly relevant to the criminal justice population. Our team will conduct resistance testing and analysis on blood samples of study participants who [have contracted] HIV and have a recent history of incarceration and explore the emergence of new resistance mutations that emerge. The other is a study which investigates a novel hepatitis C testing and linkage-to-care program in a probation and parole office. Offering a rapid HCV testing program within the probation and parole office and linking positively identified patients for treatment evaluation is an intervention that we are excited to investigate.
Jeanine Barone is a scientist and journalist with an eclectic background. She's a nutritionist and exercise physiologist who regularly writes about travel, health, fitness, and food for numerous top-tier publications. Jeanine enjoys active travel, especially long-distance cycling and cross-country skiing.