Incarceration of People Living with HIV/AIDS: Implications for Treatment-as-Prevention

Contact with the criminal justice system, including incarceration, is a common experience for many people living with HIV/AIDS. Optimism has recently been expressed that correctional facilities could be important locations for treatment-as-prevention (TasP)-based initiatives. We review recent findings regarding the effect of incarceration on patterns of HIV transmission, testing, treatment initiation and retention. We found that the prevalence of HIV infection among incarcerated individuals remains higher than analogous non-incarcerated populations. Recent studies have shown that voluntary HIV/AIDS testing is feasible in many correctional facilities, although the number of previously undiagnosed individuals identified has been modest. Studies have implied enhanced linkage to HIV/AIDS treatment and care in jails in the United States was associated with improvements in the HIV cascade of care. However, for many individuals living with HIV/AIDS, exposure to the correctional system remains an important barrier to retention in HIV/AIDS treatment and care. Future research should evaluate structural interventions to address these barriers and facilitate the scale-up of TasP-based efforts among individuals living in correctional settings.     

HIV infection among incarcerated women: epidemic behind bars

Approximately 1 in 109 adult women was under the care, custody, or control of adult criminal justice authorities on any given day in 1998, the year for which the most recent statistics on women in correctional institutions are available. Of the 84,400 women who were in prison in 1998, a large percentage--37% in state facilities and 72% in federal prisons--were charged with drug-related offenses. Besides drug use, an additional determinant of HIV infection among incarcerated women may be prior exposure to physical and sexual abuse. Linkages among histories of childhood sexual abuse, physical abuse, drug use, and sex work are believed to explain the disproportionately high prevalence of HIV infection among incarcerated women. Historically, HIV services have had to compete with other demands on correctional budgets for funding and personnel time, even though the correctional health care unit is a unique and highly cost-effective access point for providing HIV prevention and care for high-risk populations of women. Coalition building between correctional staff and medical staff (and, in some cases, departments of public health) has enabled some correctional institutions for women to establish outstanding programs for HIV-infected women. By diagnosing HIV and instituting a plan for treatment, correctional facilities for women can play a critically important role in the reduction of morbidity and mortality among HIV-infected women in high-risk populations.     

Trust and the acceptance of and adherence to antiretroviral therapy

BACKGROUND: Antiretroviral therapy (ART) has resulted in reduced AIDS incidence and mortality. Socially marginalized individuals with HIV infection, particularly injection drug users (IDUs), have received less ART and derived less benefit than others. Little is known about the therapeutic process necessary to promote acceptance of and adherence to ART among marginalized HIV-infected populations. We report on the correlates of both acceptance of and adherence to ART among HIV infected prisoners, most of whom are IDUs. DESIGN: Using a cross-sectional survey design within four ambulatory prison HIV clinics, 205 HIV-infected prisoners eligible for ART were recruited between March and October 1996. MEASUREMENTS: Detailed interviews were conducted that included personal characteristics, health status and beliefs, and validated standardized scales measuring depression, health locus of control, social desirability and trust in physician, medical institutions and society. Acceptance and adherence were documented by self-report and validated for a subset by pharmacy review. Clinical information was obtained from standardized chart review. Adherence was defined as having taken > or = 80% of ART. RESULTS: The acceptance of (80%) and adherence to (84%) ART among this group of prisoners was high. Multiple regression models demonstrated that correlates of acceptance of and adherence to ART differed. Acceptance was associated with trust in physician (8% increase for each unit increase with trust in physician scale) and trust in HIV medications (threefold reduction for those mistrustful of medication). Side effects (OR = 0.09), social isolation (OR = 0.08), and complexity of the antiretroviral regimen (OR = 0.33) were associated with decreased adherence. The prevalence of health beliefs suggesting an adverse relationship between ART and drugs of abuse was high (range 59 to 77%). Adherence did not differ among those receiving directly observed therapy (82%) or self-administration (85%). CONCLUSIONS: ART can be successfully administered within a correctional setting. Trust and the therapeutic relationship between patient and physician remain central in the ART initiation process. Characteristics of the therapeutic agents and the degree of social isolation predict adherence. These results may inform the design of interventions to improve both acceptance of and adherence to ART particularly among marginalized populations who have not derived full benefit from these potent new therapies.     

HIV among people who use drugs: a global perspective of populations at risk

This article examines the epidemiology of HIV among selected subgroups of drug users around the world who are "most at risk"--men who have sex with men, female sex workers, prisoners, and mobile populations. The underlying determinants of HIV infection among these populations include stigma, physical and sexual violence, mental illness, social marginalization, and economic vulnerability. HIV interventions must reach beyond specific risk groups and individuals to address the micro-level and macro-level determinants that shape their risk environments. Public health interventions that focus on the physical, social, and health policy environments that influence HIV risk-taking in various settings are significantly more likely to impact the incidence of HIV and other blood-borne and sexually transmitted infections across larger population groups.     

Housing Status and the Health of People Living with HIV/AIDS

Individuals who are homeless or living in marginal conditions have an elevated burden of infection with HIV. Existing research suggests the HIV/AIDS pandemic in resource-rich settings is increasingly concentrated among members of vulnerable and marginalized populations, including homeless/marginally-housed individuals, who have yet to benefit fully from recent advances in highly-active antiretroviral therapy (HAART). We reviewed the scientific evidence investigating the relationships between inferior housing and the health status, HAART access and adherence and HIV treatment outcomes of people living with HIV/AIDS (PLWHA.) Studies indicate being homeless/marginally-housed is common among PLWHA and associated with poorer levels of HAART access and sub-optimal treatment outcomes. Among homeless/marginally-housed PLWHA, determinants of poorer HAART access/adherence or treatment outcomes include depression, illicit drug use, and medication insurance status. Future research should consider possible social- and structural-level determinants of HAART access and HV treatment outcomes that have been shown to increase vulnerability to HIV infection among homeless/marginally-housed individuals. As evidence indicates homeless/marginally-housed PLWHA with adequate levels of adherence can benefit from HAART at similar rates to housed PLWHA, and given the individual and community benefits of expanding HAART use, interventions to identify HIV-seropositive homeless/marginally-housed individuals, and engage them in HIV care including comprehensive support for HAART adherence are urgently needed.     

Cost-effectiveness of HIV screening for incarcerated pregnant women

Antiretroviral therapy (ART) initiated on a prenatal basis in HIV-infected pregnant women is a highly effective method for preventing mother-to-child HIV transmission. We developed a decision analytic model to project the clinical and economic outcomes of alternative HIV screening strategies (voluntary prenatal screening [VPS], routine prenatal screening [RPS], and mandatory newborn screening [MNS]) for a high-risk population of incarcerated pregnant women. Data for the decision model came from the HIV voluntary counseling and testing program at Connecticut's sole correctional facility for women and a comprehensive anonymously linked serosurvey of all inmates who entered the facility during the 2-year period beginning in October 1994. Based on serosurvey results, in the absence of any HIV screening program, 2.5 cases of pediatric HIV infection would be expected per 1000 pregnancies. Multiplied by the discounted lifetime cost per case of $247,000, this translates to a cost of $624 per testing-eligible prison entrant. Entrants were considered eligible if they were pregnant and their HIV status was unknown. MNS would save money, cost $364 per eligible entrant, and simultaneously reduce the rate of infections to 1.1 per 1000 pregnancies. Doing both MNS and RPS is most effective in reducing the rate of new infections (down to 0.2 per 1000 pregnancies). It would, however, increase costs to $430 per eligible entrant. This would result in an incremental cost of $73,603 per additional pediatric HIV case averted when compared with MNS alone. If mandatory newborn testing was not considered a feasible option, RPS would dominate VPS and would be cost-saving compared with no screening. RPS compares favorably with alternative uses of HIV prevention and treatment resources. In correctional facilities where voluntary newborn screening is already in place, our findings show that there remains a small marginal benefit to be realized from switching to RPS. In settings where HIV screening policies are not in place, however, the implementation of RPS can be expected to significantly reduce pediatric HIV cases and net health care expenditures.     

Progress in HIV reduction and prevention among injection and noninjection drug users

Substantial progress has been made in reducing HIV among injection drug users (IDUs) in the United States, despite political and social resistance that reduced resources and restricted access to services. The record for HIV prevention among noninjecting drug users is less developed, although they are more numerous than IDUs. Newer treatments for opiate and alcohol abuse can now be integrated into primary HIV care; treatment for stimulant abuse is less developed. All drug users present challenges for newer HIV prevention strategies (eg, "test and treat," nonoccupational postexposure prophylaxis and preexposure prophylaxis, contingency management, and conditional cash transfer). A comprehensive HIV prevention program that includes multicomponent multilevel approaches (ie, individual, network, structural) has been effective in HIV prevention among IDUs. Expanding these approaches to noninjecting drug users, especially those at highest risk (eg, minority men who have sex with men) and incorporating these newer approaches is a public health priority.     

Breaking down the walls: the prison pen pals project

The prison health system provides little specialized treatment or chronic care for prisoners living with HIV and AIDS. In addition, inmates often feel isolated because of treatment by people who fear their infection. The Prison Pen Pals Project was created in June 1985, by the People With AIDS Coalition (PWAC), in an attempt to lessen the feeling of isolation, and provide information and support to prisoners living with HIV/AIDS. Through this program, which officially started in January 1990, HIV-positive inmates can share their experiences and feelings with other HIV-positive nonincarcerated participants. Contact information is provided for people who want to volunteer for the project.     

Management of HIV-associated tuberculosis in resource-limited settings: a state-of-the-art review

The HIV-associated tuberculosis (TB) epidemic remains a huge challenge to public health in resource-limited settings. Reducing the nearly 0.5 million deaths that result each year has been identified as a key priority. Major progress has been made over the past 10 years in defining appropriate strategies and policy guidelines for early diagnosis and effective case management. Ascertainment of cases has been improved through a twofold strategy of provider-initiated HIV testing and counseling in TB patients and intensified TB case finding among those living with HIV. Outcomes of rifampicin-based TB treatment are greatly enhanced by concurrent co-trimoxazole prophylaxis and antiretroviral therapy (ART). ART reduces mortality across a spectrum of CD4 counts and randomized controlled trials have defined the optimum time to start ART. Good outcomes can be achieved when combining TB treatment with first-line ART, but use with second-line ART remains challenging due to pharmacokinetic drug interactions and cotoxicity. We review the frequency and spectrum of adverse drug reactions and immune reconstitution inflammatory syndrome (IRIS) resulting from combined treatment, and highlight the challenges of managing HIV-associated drug-resistant TB.     

Prevention of mother-to-child transmission of HIV--successes, controversies and critical questions

In a relatively short period of time enormous strides have been made in the field of mother-to-child transmission (MTCT) of HIV. Timing, mechanisms and risk factors for transmission have been elucidated and a large number of drug regimens have been shown to effectively reduce the risk of HIV infection in the child. A number of observations can be gleaned from the work that has been done to design and implement HIV perinatal prevention programs. First, pregnancy is a critical time to identify women with HIV infection and to link them and their families to ongoing HIV care and treatment In addition to providing perinatal prevention intervention, pregnancy serves as an entry point into the health-care system. There is a unique opportunity to link prevention and treatment efforts, two programmatic areas often viewed as conflicting and competing. Second, the evolution of perinatal prevention in high-resource settings and, to an increasing extent, more resource-constrained areas, reflects the interplay of science and public-health policy. Results of clinical trials and epidemiologic studies have progressively provided recommendations and guidelines for HIV counseling, testing and treatment for perinatal prevention. In many ways, the successes of perinatal prevention in the USA attest to the success of the dynamic interaction between health, science, and public policy. There is great hope and expectation that the next decade will be equally successful as care and treatment becomes increasingly available in resource-constrained settings. Third, a key element of perinatal prevention is the provision of safe and effective family planning to women of childbearing years. Many women, particularly in low-resource settings, have multiple pregnancies, influenced by cultural imperatives and limited access to safe, affordable contraception. Enhancing these services will enable women to make informed decisions about their health, their families, and their futures. Finally, it is critical to remember that primary prevention of HIV infection in women holds the true key to perinatal prevention. While work must continue to identify more efficacious and safe regimens to prevent MTCT, preventing women from becoming HIV-infected should remain the true measure of success.     

HIV感染罪犯个性特征和心理健康

目的通过比较HIV感染罪犯与对照组罪犯的个性特征和心理健康状况,分析HIV感染罪犯心理健康的相关因素。方法采用中国罪犯心理评估个性分测验(COPA-PI)和症状自评量表(SCL-90)进行评定。结果 HIV感染罪犯SCL-90总分、阳性项目均数以及各因子分均显著高于国内常模(P<0.001)和对照组的狱内罪犯(Ps<0.0001);个性特征方面,内外倾、情绪稳定性、同众性、冲动性、攻击性、报复性、信任感、焦虑感、心理变态倾向、犯罪思维模式与对照组的狱内罪犯差异显著(ts=-3.03、-5.36、-4.54、-3.70、-3.72、-2.97、-2.68、-7.44、-3.84、-4.15,P<0.05),并与SCL-90得分显著相关(P<0.05)。结论 HIV感染罪犯心理健康状况较差,其个性特征和心理健康状况相关。     

Policy implications of integrating buprenorphine/naloxone treatment and HIV care

Researchers, practitioners, and policymakers have long recognized the potential benefits of providing integrated substance abuse and medical care services, particularly for special populations such as people living with HIV/AIDS. Buprenorphine, an office-based pharmacological treatment for opioid dependence, offers new opportunities for integrating drug treatment into HIV care settings. However, the historical separation between the drug treatment and medical care systems has resulted in a host of policy barriers. The Buprenorphine and HIV Care Evaluation and Support initiative, a multisite demonstration project to assess the feasibility and effectiveness of integrating buprenorphine/naloxone into HIV care settings, provided an opportunity to evaluate if and how policy barriers affect efforts to integrate HIV care and addiction treatment. We found that financing issues, workforce and training issues, and the operational consequences of some conceptual differences between HIV care and addiction treatment are barriers to the full integration of buprenorphine into HIV care. We recommend changes to financing and reimbursement policies, programs to strengthen the addiction treatment skills of physicians, and cross training between the fields of addiction, medicine, drug treatment, and HIV medicine. By addressing some of the policy barriers to integration, this promising new treatment can help the thousands of people living with HIV/AIDS who are also opioid dependent.     

Deadly Public Policy: What the Future Could Hold for the HIV Epidemic among Injection Drug Users in Vancouver

The scope and scale of the HIV outbreak that occurred among injection drug users in Vancouver in the late 1990s was unprecedented and resulted in some 2,000 new HIV infections, with incidence rates reaching 18 per 100 person-years. This outbreak, localized mainly in one neighbourhood, cost the Canadian health care system more than 1 billion dollars to diagnose, care and treat. A number of factors combined to stabilize HIV incidence: 1) HIV prevalence became saturated among those at highest risk; 2) several public health policies focused on drug users were implemented, including increased and additional decentralized needle exchange programs, expanded methadone maintenance services, better addiction treatment services, improved housing, and mental health programs; and 3) increased access and expansion of Highly Active Antiretroviral Therapy. To ensure that a similar outbreak never occurs again in Vancouver and other cities, future health policy must consider the political, psychosocial and socioeconomic factors that contributed to this outbreak. These policies must address the unintended adverse consequences of past policies and their repercussions for marginalized individuals living in this community and beyond.     

Substance Use: Impact on Adherence and HIV Medical Treatment

Substance use is highly prevalent among people living with HIV/AIDS, is often comorbid with other mental health problems, related to poor HIV medical outcomes, and, is associated with poor medication and treatment adherence. The current review reports on the recent state of the literature in terms of substance use and its relation to HIV medication and treatment adherence, and offers recommendations for advancing treatment and secondary HIV prevention efforts. Identifying substance users within HIV primary care and developing, evaluating, and refining integrative substance use-mental health-adherence interventions may be clinically important targets for effective disease management and may contribute to secondary HIV prevention efforts.     

Methadone treatment practices and outcome for opiate addicts treated in drug clinics and in general practice: results from the National Treatment Outcome Research Study.

BACKGROUND: General practitioners (GPs) are increasingly urged to become more involved in the care and treatment of drug misusers. Little information is available about the effectiveness of treatments delivered in primary health care or specialist settings. The impact of treatment setting is investigated as part of the National Treatment Outcome Research Study (NTORS). This is the largest study of treatment outcome for drug misusers ever conducted in the United Kingdom (UK). AIM: This paper presents six-month treatment outcomes for patients who received community-based methadone treatment in either a specialist drug clinic or a general practice setting. METHOD: A prospective, multisite follow-up study of treatment outcome was conducted with 452 opiate addicts who had been given methadone treatment in primary health care and specialist clinic settings. Outcome data are presented for substance use behaviours, health, and crime. RESULTS: Improvements at follow-up were found among both the GP and the clinic-treated groups in drug-related problems, health, and social functioning. Problems at intake were broadly comparable among the clinic-based and the GP patients. Similar levels and types of improvement were found for both groups at six-month follow-up. CONCLUSIONS: Results demonstrate the feasibility of treating opiate addicts using methadone in primary health care settings, and show that treatment outcomes for such patients can be as satisfactory as for patients in specialist drug clinics. The GPs in our study are unrepresentative in their willingness to be actively involved with problem drug users; moreover, several services treated relatively large numbers of drug users. Issues surrounding the growth of 'GP specialists' are discussed.     

HIV-associated tuberculosis and cryptococcosis in resource-limited settings

Tuberculosis (TB) and cryptococcosis are common infectious complications in HIV in resource-limited settings and contribute substantial morbidity and mortality. The increasing access to highly active antiretroviral treatment (HAART) has invited numerous challenges such as timing of HAART, cotreatment (drug dosages and interaction), immune reconstitution syndromes, and withdrawal of chemoprophylaxis. Numerous small studies propose the feasibility of concomitant TB/HIV treatment that needs to be confirmed in large, randomized trials. Treatment of acute cryptococcocal meningo-encephalitis with amphoterecin B is fraught with logistic problems in resource-limited settings. An effective safe dose of fluconazole as monotherapy needs to be determined in phase II studies. Current management guidelines extrapolated from developed countries may not necessarily apply and need validation in resource-limited settings.     

Toward a comprehensive approach to HIV prevention for people who use drugs

Comprehensive HIV prevention interventions are increasingly recognized as critical in the global effort to reduce HIV transmission among people who use injection drugs. Scientific evidence clearly shows that a variety of biomedical, behavioral, and structural interventions can prevent and reduce injection drug user-driven HIV epidemics, yet social and structural barriers to their implementation remain. This review discusses the scientific evidence on the effectiveness of individual programs for reducing HIV incidence among people who use injection drugs and how, by integrating individual programs as complements within a comprehensive HIV prevention approach, it is possible to achieve, and to sustain, greater results than those of individual programs alone. The article concludes with a discussion of a critical research priority; namely, to improve the implementation of comprehensive HIV prevention interventions in settings of prevalent injection drug use and to overcome the often complex barriers that impede them. Such an effort will require more than research alone, however. It will also require the ongoing commitment of policymakers, public health officials, and the affected communities themselves to use comprehensive HIV treatment and prevention as the most effective strategy to reduce new HIV infections.     

The continuing crisis of AIDS in prison

There is growing recognition of the need for improved HIV/AIDS treatment in US prisons. Inmates routinely experience delayed appointments with infectious disease specialists, as well as a lack of treatment information, violations of confidentiality, and are excluded from programs such as work release and food service jobs. This report examines the statistics of prisoners living with HIV, the rates of infection, and legislative and policy changes to help prisoners deal more effectively with the disease. Also discussed are the following five issues facing the millennium regarding HIV in prisons: strengthening education and prevention programs, improving access to medical care, expanding discharge planning, and cultivating the role of former prisoners living with HIV/AIDS.     

Case management and health-related quality of life outcomes in a national sample of persons with HIV/AIDS

OBJECTIVE: To examine whether having a case manager is associated with better physical and mental health scores. BACKGROUND: HIV/AIDS is a condition characterized by a variety of medical and social needs that vary between individuals and over time. Case management has been advocated as a means to improve problems of access, cost and outcomes of HIV/AIDS care. METHODS: We analyzed data from a nationally representative sample of 2,251 HIV-positive persons receiving care in the in the HIV Costs and Services Utilization Study (HCSUS). Participants were interviewed at baseline and approximately 18 months later. Data were collected on use of case management, sociodemographics, antiretroviral therapy and health-related quality of life. We examined bivariate and multivariate associations of case management at baseline with change in self-reported physical health and mental health at follow-up. RESULTS: We found that having contact with a case manager at baseline significantly predicted improvement in physical health (regression coefficient=1.02, p<0.05) among those not receiving HAART. We found no association of case management with mental health among those not receiving HAART and those receiving HAART in multivariate analysis. CONCLUSIONS: Our findings support a beneficial relationship between case managers and physical health for patients with HIV but only among those not already receiving recommended treatment with HAART.     

Building a durable response to HIV/AIDS: implications for health systems

The remarkable rise in investments for HIV control programs in 2003-2010 enabled an unprecedented expansion of access to HIV services in low-income and middle-income countries. By the end of 2010, more than 5.2 million people were receiving antiretroviral therapy (ART), which transformed HIV infection, once a death sentence, into a long-term illness. The rapid expansion in the number of persons receiving ART means that health systems must continue to provide acute life-saving care for those with advanced HIV/AIDS although also providing chronic care services to expanding cohorts of more stable patients who are doing well on ART. This expansion also means a transition from an emergency response to the epidemic, characterized by a public health approach, to a more integrated and durable approach to HIV prevention, care, and treatment services that fosters individualized care for those requiring long-term antiretroviral treatment. Yet most low-income and middle-income countries, which have weak health systems, are poorly prepared to make this transition. In this article, we highlight the challenges health systems face in developing a sustained and durable response to HIV/AIDS. The article analyses the readiness of health systems to combine rapid expansion of ART access with long-term treatment and continuity of care for a growing cohort of patients. We argue that effective management of a transition from an emergency AIDS response to long-term programatic strategies will require a paradigm shift that enables leveraging investments in HIV to build sustainable health systems for managing large cohorts of patients receiving ART although meeting the immediate needs of those who remain without access to HIV treatment and care.