Nearly all Texas state prisoners who receive antiretroviral therapy while incarcerated experience some treatment interruption following their release, according to a new NIDA-funded study by Dr. Jacques Baillargeon of the University of Texas Medical Branch in Galveston. More than two-thirds of these interruptions last longer than 60 days, during which time ex-prisoners may develop higher viral loads that increase their risk of disease progression and transmission to others.
These results highlight a national public health problem, according to Dr. Baillargeon, who notes that prison discharge planning and community-based HIV care in Texas is similar to that in other states. The study also indicated that simply helping prisoners with the paperwork necessary to obtain free federally funded antiretroviral therapy can substantially reduce treatment interruptions.
A Time of Increased Risk
Because rates of HIV infection among inmates are currently several-fold those of the general population, U.S. prisons have become focal sites in efforts to control the virus. Although most HIV-infected inmates receive antiretroviral therapy during incarceration, many have extremely limited access to health care systems in the months immediately following their release, Dr. Baillargeon says. As a result, they confront obstacles to continuing treatment at the same time they face expanded opportunities to initiate or resume injection drug use, unprotected sex, and other HIV risk behaviors. Along with the risks of disease progression and transmission, discontinuation of antiretroviral therapy may lead to medication-resistant HIV.
To examine medication use among recently released inmates, Dr. Baillargeon and colleagues collaborated with the Texas Department of Criminal Justice, which oversees one of the largest state prison systems in the United States. Texas administers a federally funded program, the AIDS Drug Assistance Program (ADAP), to help ex-prisoners continue their antiretroviral treatment during the time it takes them to locate treatment services in the community. During standard discharge planning, HIV-infected inmates receive a four-page application form for a free 30-day supply of the medication through ADAP, along with a 10-day supply of antiretroviral medication and information on accessing community HIV treatment.
Partway through the 4-year study, Texas prisons phased in a new discharge program (see box) for inmates with HIV. Coordinators succeeded in providing 55 percent of those eligible with formal assistance in completing and submitting the ADAP application.
Assistance Increases Fulfillment
The researchers examined all prescriptions in the Texas ADAP database. They found that about 5 percent of released inmates filled the initial 30-day prescription during the first 10 days after their release, and 18 percent did so during the first 30 days. Inmates who received assistance from a caseworker to complete and submit the ADAP application filled their prescriptions at rates about double those who did not receive the help. At 60 days after release, those who had received assistance continued to show an advantage—34 percent versus 26 percent.
Although similar percentages of each ethnic group received assistance with the ADAP, Hispanic and African-American participants were less likely than whites to continue antiretroviral treatment during the first 10 and 30 days after release. Those disparities disappeared, however, by 60 days.
Texas Prison Discharge Planning for Inmates With HIV
Prisons in Texas adhere to a specific plan for releasing inmates with HIV. Thirty days before the release of any inmate, the prison notes whether he or she is receiving antiretroviral therapy. On the day of release, those who have been on the therapy receive:
- A copy of recent HIV laboratory test results
- A 10-day supply of antiretroviral medication
- A list of clinicians who provide care to patients with HIV in the released inmate's home community
- An application to the AIDS Drug Assistance Program (ADAP) to receive a 30-day supply of antiretroviral medication; and, if resources permit, assistance in completing and submitting the form
- An ADAP medication certification signed by a physician
- A toll-free phone number and instructions to call an ADAP caseworker for assignment to a local pharmacy.
Although the federally funded ADAP program has eligibility requirements that include an inability to pay for medications, the Texas Department of Corrections found that virtually every inmate leaving its prison system qualifies.
Individuals not on parole filled the initial antiretroviral prescription within 30 and 60 days of release at lower rates than parolees, who had parole officers to encourage them, says Dr. Baillargeon. Furthermore, participants whose HIV infection was under control in prison, as indicated by an undetectable viral load, were more likely to fill the initial prescription than those with measurable amounts of HIV in their blood. Dr. Baillargeon notes that some individuals, while in prison, are better than others at adhering to antiretroviral regimens, and that this difference in behavior may continue after release.
Among those who filled the initial 30-day prescription through ADAP, only 6 percent accessed the medication for a second month without interruption. This finding suggests that former inmates with HIV may need additional assistance coordinating their health care during the first few months after release.
The study included 2,115 inmates with HIV released between January 2004 and December 2007. Of the participants, 83 percent were male, and 58 percent had committed a drug-related crime. The study population was 60 percent African-American, 27 percent white, and 13 percent Hispanic. Although demographic characteristics of prison inmates vary from state to state, Dr. Baillargeon says that he expects the study results to apply across the Nation.
In a subsequent analysis of clinical data from 1,750 HIV-infected inmates returning to the community in one Texas county, Dr. Baillargeon and colleagues found that only 20 percent of former inmates enrolled in an HIV clinic within 30 days of release. Only 28 percent did so within 90 days. At both assessment times, those who received enhanced discharge planning were about 50 percent more likely than those who did not to enroll in a clinic, suggesting that enhanced discharge programs may increase continuity of HIV care among newly released inmates.
"Our findings document that a low percentage of former prisoners access antiretroviral therapy in a timely fashion after release. This observation may underlie the results of prior studies that reported loss of both immune function and viral suppression among offenders who return to the criminal justice system," says Dr. Baillargeon.
A Step in the Right Direction
The results of the study spurred the Texas Department of State Health Services to hold a summit on antiretroviral therapy continuance after prison release. Summit participants, including Dr. Baillargeon, proposed additional steps public health officials might take—for example, providing transportation assistance or vouchers to facilitate released prisoners' contact with health care providers. In future research, Dr. Baillargeon's team plans to identify psychosocial and practical barriers that prevent former prisoners from accessing antiretroviral therapy. The team's goal is to develop interventions to remove such obstacles.
"This collaboration between the researchers and the Texas Department of Criminal Justice represents a step in the right direction toward fighting the HIV epidemic, and NIDA applauds their effort to address an important public health problem for the Nation," says Dr. Dionne Jones of NIDA's Division of Epidemiology, Services and Prevention Research. Because helping inmates complete and submit the ADAP forms was inexpensive, such assistance may prove a cost-effective and valuable component of efforts to improve medication continuance.
"Followup care after release might further enhance the proportion of former prisoners with HIV who continue medication," says Dr. Jones. "Former prisoners often face many difficulties—including family estrangement, unemployment, lack of housing and transportation, and vulnerability to drug relapse—as they try to re-integrate into the community."
NIDA recently expanded its own efforts to fight HIV among prisoners. The Institute, along with the National Institute of Mental Health and the National Institute of Allergy and Infectious Diseases, is newly supporting 12 research teams as they examine ways to identify persons with HIV within the criminal justice system and link them to effective therapy during periods of incarceration and after community re-entry. Over the next 5 years, the teams will compare different methods of identifying HIV-positive offenders and engaging and retaining them in treatment. Some of the projects will create and compare systems to better integrate and coordinate HIV management efforts. The grants will also support randomized controlled trials among large groups of HIV-positive parolees and probationers, comparing various approaches for linking them to treatment and social services in their communities.
Baillargeon, J.G., et al. Enrollment in outpatient care among newly released prison inmates with HIV infection. Public Health Reports 125 Supplement 1:64–71, 2010. [Full Text (PDF, 303KB)]
Baillargeon, J.G., et al. Accessing antiretroviral therapy following release from prison. JAMA 301(8):848–857, 2009. [Full Text (PDF, 119KB)]