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The Intertwined Epidemics of HIV Infection, Incarceration, and Substance Abuse: A CalAction

Willie Sutton, the immaculately dressed bank robber, is credited with Suttons Law: when asked whyobbed banks, he responded, because thats where the money is! Why should those of us concer

with human immunodeficiency virus (HIV) and substance abuse epidemics work in jails? Because ts where the money is!

The United States has extraordinarily high rates of incarceration. In 2009, >12 million men and wom

passed through US jails. These individuals are most often male, belong to a minority race, have ocioeconomic status, are engaged in active substance abuse, and are at risk for HIV infection aother sexually transmitted infections. The prevalence of HIV infection is 5 times higher in state aederal correctional systems in the United States than in the general public.

n this issue of the Journal, Milloy et al describe the dose-response effect of incarceration eventsnonadherence to HIV antiretroviral therapy (ART) among injection drug users. From 1996 through 20490 injection drug users were recruited and followed up for a median of >2 years. Of importance, mhan half of the participants were incarcerated during the study period, with a median numbencarceration episodes of 3. The crude incarceration rate was 52 per 100 person-years. Incarceratwas the rule rather than the exception. The authors evaluated the impact of incarceration adherence to ART. Compared with individuals with no history of incarceration, participants with 1 o

ncarcerations had almost double the odds of nonadherence at each follow-up visit (odds ratio [O1.91). The OR increased to 2.8 for 35 incarceration episodes and 3.59 for >5 incarceration events. Telationship persisted after adjusting for factors, including sex, cocaine use, and methad

maintenance therapy.

Are multiple incarcerations causally related to poor adherence, or is it an association? Certainly tructural events of incarceration frequently lead to interruptions in ART. Jail is chaotic, and secuather than healthcare is the priority. More often than not, it takes days for individuals to idenhemselves as being HIV infected, have medications confirmed, and receive their ART. Stigma a

other concerns will often lead to inmates hiding their HIV-positive status. Significant interruptionART may also occur at the time of release from prison or jail. A recent study of released prisonerTexas found that only 5% filled ART prescriptions in time to avoid an interruption, and only 30%

illed prescriptions 60 days after release. In addition, interruptions in ART may occur after relebecause of resumption of substance-using behaviors, and this can lead to further HIV transmissionhe community.

ndividuals with multiple incarcerations are probably different from injection drug users who do not ncarcerated; therefore, this relationship may also be an association. Individuals with multncarcerations are more likely to have more intensive substance abuse problems, mental hedisorders, and other behaviors that are associated with poor adherence. In many ways, whether elationship between incarceration events and nonadherence is an association or is causal does

matter. These data from the British Columbia Center for Excellence in HIV and AIDS Care aremportant contribution, because they highlight the need for intensive HIV treatment interventionsndividuals involved with the criminal justice system.

The US response to the intertwined epidemics of HIV incarceration and substance abuse has not badequate. The vast majority of individuals incarcerated in the United States pass through jails and prison (13 million vs 743,000 in 2007). Most jails in the United States do not offer routine opt-out esting. This is a particular travesty, considering that the demographic group that has the highest ra

of HIV infection in this country is African American men, which is also the population most likely toncarcerated. An opt-out approach to testing is preferable to opt-in. In North Carolina, changing fropt-in to routine opt-out HIV testing among persons entering prison resulted in 30% more prisonbeing tested (61% vs 91%), and 22 additional HIV infections were identified. Inmates who opt-in avolunteer for HIV testing have lower prevalence of HIV infection than did those who are not tested

he general inmate population. Routine HIV testing is cost effective in outpatient and inpatient setti

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when the prevalence of undiagnosed HIV infection is at least .1%. Because of the increased prevaleof HIV infection among incarcerated populations, it is reasonable to assume that routine opt-out esting in jails and prisons is also costeffective, but this is a priority for future research efforts.

Testing for HIV infection in jails is just the beginning. Availability of ART, comprehensive confidential HIV care, and appropriate HIV-related laboratory testing in facilities is necessary. Linkao community HIV care after release is a crucial intervention that can lead to improved ART adhereates. Studies conducted in Connecticut and North Carolina have demonstrated that inmates receiv

ART had better virologic outcomes if they remained incarcerated, compared with those released aeincarcerated, underscoring the risk of treatment interruptions between corrections and

community. Medical case management that facilitates the linkage from corrections to the commuhas worked in multiple settings. However, research has also shown that a case managemntervention bridging incarceration and release was no more effective than a less intensive prereledischarge planning program in supporting health care usefor HIV-infected individuals released frprison. In some settings, community-based case management is needed. In other communitiesprerelease discharge planning program will be adequate. Concurrent with linkage to community providers and access to ART, management of addiction and comorbid mental health disordernecessary to optimize HIV outcomes. Recent studies have demonstrated the benefit of opeplacement therapy in certain injection drug use populations transitioning to the community.

n the past few years, incarceration has been recognized as a key intervention site to address the epidemic. The Health Resources and Services Administration (HRSA) has supported a Special Projec

National Significance, Enhancing Linkages to HIV Primary Care and Services in Jail Settings, to kicksand enhance HIV testing and linkage programs in 10 US jails. The National Institutes of Health (Nationstitute on Drug Abuse, National Institute of Mental Health, and National Institute of Allergy nfectious Diseases) has recently funded 10 R01 grants under the Seek, Test, and Treat: Addressing n the Criminal Justice Systeminitiative. States that have implemented comprehensive testing programs aimed at decreasing the burden of HIV infection among drugusers involved with the crimustice system have observed a decrease in injection drug userelated new diagnoses. On the othand, the fact that most jails do not routinely test for HIV infection or link individuals after releaseHIV care programs demonstrates how much more needs to be done.

There is a need for more federal and public health guidance on this issue in the United States. Althohe Centers for Disease Control and Prevention (CDC) has published helpful guidelines on HIV testin

correctional facilities, more could be done to bolster the HIV public health efforts in correctioettings. The CDC, in collaboration with local departments of health, could begin to evaluate HIV test

and treatment in correctional facilities to establish a basic standard of care. Through the Ryan WhComprehensive AIDS Resources Emergency Act, HRSA receives client-level data on HIV-infecpersons. These data could be used to examine outcomes and linkage among persons involved with criminal justice system. The Department of Justice and the Federal Bureau of Prisons also have opportunity to play a leadership role in addressing public health interventions that are feasible acost-effective.

n the past 5 years, data have been published demonstrating the importance of opt-out HIV testingails, the benefit of the initiation of ART, and the importance of programs to link individuals with car

he community after release. The medical, public health, and correctional leadership in the UniStates needs to come together to advance the implementation of these programs as soon as possibl