Abstract
Incarcerated individuals, who are overrepresented among those infected with HIV, experience multiple barriers to optimal antiretroviral therapy (ART) adherence after incarceration. Substance use is highly prevalent among legal system-involved individuals and is commonly associated with suboptimal medication adherence. This manuscript describes the development and pilot test results of two interventions designed to improve ART adherence among formerly incarcerated individuals living with HIV (PLWH). Thirty participants were randomized and completed a multi-session ART adherence and risk reduction intervention or a brief ART adherence intervention. Participants were interviewed at baseline, 1-month, and 3-month follow-up. While past 30-day ART adherence improved in both groups, participants in the brief intervention group took a higher proportion of their ART medication. Multi-session intervention group participants experienced greater reductions in substance use and problematic experiences associated with drug use. ART medication adherence interventions can potentially improve treatment outcomes among PLWH who experience incarceration.
Introduction
Thousands of people living with HIV (PLWH) are released from incarceration annually, and many of the individuals being released from jail or prison face the challenge of following a treatment plan as they adjust to post-incarceration life. Furthermore, the vast majority of incarcerated individuals are from marginalized communities, including racial and ethnic minority groups and low-income populations (Carson, 2021; Dolan & Carr, 2015), who tend to be disengaged from the health care system (Alegria et al., 2016; Corscadden et al., 2018; Travers et al., 2017). Low patient engagement is associated with increased risk for poor health outcomes among PLWH, including lower quality of life and premature mortality (Iacob et al., 2017; Trepka et al., 2015).
Antiretroviral therapy (ART), which is the only evidence-based strategy for treating HIV, has evolved into a highly effective form of treatment over the past several decades. However, sustained HIV replication suppression requires at least 90% adherence to an ART regimen (Bezabhe et al., 2016; Liu et al., 2006; Raffa et al., 2008; Tchakoute et al., 2022), a threshold that may be difficult to reach and maintain, particularly for members of populations that are commonly disconnected from the health care system (Fuge et al., 2020). Relatively high rates of initiation and maintenence of ART regimens among incarcerated PLWH produce significant public health benefits (Meyer et al., 2014; Springer et al., 2004). However, formerly incarcerated PLWH face several barriers to optimal adherence post-incarceration, and the health benefits gained during periods of incarceration are lost once these individuals return to their home communities (Iroh et al., 2015; Loeliger et al., 2018; Meyer et al., 2014; Stephenson et al., 2005; Wohl et al., 2011).
Structural factors such as unstable housing, gaps in health insurance coverage, stigma associated with having HIV, and a history of incarceration may limit the ability of formerly incarcerated individuals to engage in HIV care and maintain optimal ART adherence (Baillargeon et al., 2009; Booker et al., 2013; Dennis et al.; 2015; DiPrete et al., 2019; Fu et al., 2013; Haley et al.; 2014; Katzen, 2011; Loeliger et al., 2018; Rich et al., 2013; Stephenson et al., 2005; Westergaard et al., 2013). Accessing providers in a timely manner to prevent treatment disruption during their return to the community has been identified as a primary concern among formerly incarcerated PLWH (Loeliger et al., 2018; Rowell-Cunsolo et al., 2020b; Wohl et al., 2011). Additionally, substance use challenges, which are commonly experienced by formerly incarcerated people who use drugs (Chamberlain et al., 2019; Owens et al., 2018), compound and complicate the ability to overcome many of these structural and community-level barriers (Dennis et al., 2015).
Substance use is also associated with poorer ART adherence (Gonzalez et al., 2011), which may impact medication adherence by impairing judgment and reducing engagement in care (Nicholas et al., 2014; Rowell-Cunsolo & Hu, 2020). Prior research suggests that formerly incarcerated PLWH may prioritize drug use over the maintenance of an ART regimen (Rowell-Cunsolo & Hu, 2020). This may, in turn, result in suboptimal treatment outcomes that place them at a greater risk for acquiring more serious HIV-associated comorbidities and/or increases the likelihood that they will experience other adverse events such as HCV acquisition, overdose, or re-incarceration (de Andrade et al., 2018; Håkansson, & Berglund, 2012; Stone et al., 2018).
Medication adherence interventions have the potential to reduce substance use and increase adherence among PLWH (Parsons et al., 2018; Sorensen et al., 2012; Spaan et al., 2020), which can lower HIV transmission rates in vulnerable communities. For example, ART adherence interventions have produced significant gains in treatment outcomes, including reducing HIV risk behaviors and improving disease management competency (Amico et al., 2006; Gwadz et al., 2015; Kalichman et al., 2011; Simoni et al., 2010). However, few interventions have sought to influence both substance use and medication adherence; studies that have attempted this either required participants to be active in a substance use treatment program (Lucas et al., 2010; Samet et al., 2019) or reported that the behavioral intervention did not substantially reduce substance use among participants (Ingersoll et al., 2015; Myers et al., 2018; Starks et al., 2022).
The design of adherence interventions typically overlook the needs and interests of formerly incarcerated individuals, and there is not yet sufficient evidence on how well such interventions work among key populations, including legal system-involved individuals (Chaiyachati et al., 2014). A recently published literature review identified 16 controlled clinical trials within the past decade that investigated interventions aimed at improving ART adherence or community care engagement for PLWH leaving prison settings (Moher et al., 2022). However, an exploration of CDC’s Compendium of Evidence-Based Interventions for ART Adherence found only five ART interventions aimed at “criminal-justice involved” populations and only two interventions were identified once “substance use” was included in the search. The patterns described above highlight the need for more accessible interventions that target underserved populations to improve adherence to ART regimens, reduce overdose rates, and lower HIV transmission potential among formerly incarcerated individuals. By addressing the sharp decline in ART adherence post-incarceration (Iroh et al., 2015; Meyer et al., 2014; Underhill et al., 2014), such tools could generate considerable improvements in community health.
This manuscript describes the development and pilot test results of two interventions designed to improve ART adherence. The first intervention consisted of a multi-component intervention designed to improve ART adherence while simultaneously reducing substance use and condomless sexual behaviors, thereby reducing the likelihood of HIV transmission. The second intervention exclusively focused on improving ART adherence. The results of the pilot test will also be described, with a specific focus on changes in substance use at three time points (baseline, 1-month, and 3-month follow-up).
The research team developed and tested the interventions in the following three steps: First, we conducted an assessment of participant needs based on prior empirical data and feedback from a community advisory board (CAB). Second, we designed two appropriate and relevant interventions—a combination ART adherence and risk reduction intervention and an abbreviated version of this intervention—based on the information collected in the first step. During this process, we determined and selected the most appropriate intervention components, using successful risk-reduction behavioral interventions as a guide (Kalichman et al., 2011; Wolitski, 2006). To our knowledge, there were only a few combination behavioral interventions designed to promote linkage to care post-incarceration, improve ART adherence, and/or reduce HIV-related risk behaviors that had been developed and empirically tested for legal system-involved PLWH prior to the creation of these interventions (Copenhaver et al., 2009; Reznick et al., 2013; Wohl et al., 2011). Based on the dearth of adherence interventions developed for individuals with legal system involvement, we created two interventions to ensure that all participants in the pilot testing phase received some type of support.
Third, we completed a pilot test of the newly designed interventions among a segment of the target population. The current manuscript focuses specifically on components of the multi-component intervention related to substance use and medication adherence; the results for intervention components related to condomless sexual behavior outcomes have been reported elsewhere (Rowell-Cunsolo et al., 2020a).
Intervention Development
Assessment of Participant Needs
To better understand the unique needs of potential participants and to identify existing evidence-based interventions that simultaneously address ART adherence and HIV risk behaviors, we conducted a comprehensive review of the empirical literature on ART adherence interventions as well as findings from our previous qualitative and quantitative research. We prioritized the literature on ART adherence among legal system-involved populations to ensure that we were considering any new developments in the field as we designed the interventions.
The findings from our previous research indicated that formerly incarcerated individuals, including PLWH, sometimes use illicit drugs within hours of being released (Rowell-Cunsolo et al., 2018), engage in condomless sex (Rowell-Cunsolo et al., 2022) and re-enter drug-enticing environments (i.e., neighborhoods or shelters) post-incarceration (Mkuu et al., 2019). These findings convinced us that the multi-component intervention should include content on the role of drug use as a driver of risk behaviors; furthermore, this content should consider the lived experiences of PLWH who have experienced incarceration.
Numerous medication adherence behavioral interventions have aimed to improve adherence among PLWH, while simultaneously seeking to reduce substance use and abuse. We identified interventions that used a range of strategies including education or counseling, patient navigation, and peer support (Kalichman et al., 2011; Metsch et al., 2016; Underhill et al., 2014). Interventions that have been designed specifically to improve treatment outcomes among PLWH who use drugs indicate that harm reduction strategies are critical to improving medication adherence (Dutta et al., 2012; Lambers et al., 2011). In addition, numerous studies have found that education on identifying triggers for substance use is important for preventing relapse or increased consumption (Gilbert et al., 2006; Heslin et al., 2013), and strategies for identifying and managing stigma can improve medication adherence and reduce engagement in high-risk behaviors (Katz et al., 2013). However, as mentioned previously, our review of the literature identified only a few ART adherence behavioral interventions that target those who have experienced incarceration (Amico et al, 2006; Reznick et al., 2013; Wohl et al., 2011).
We also explored using a group-based approach for both interventions based on prior research indicating that group environments can foster experiential learning and personal growth through discussions, can increase social support and skills that facilitate the disclosure of HIV status, and can have a positive influence on risk-reducing behavior, especially in relation to increased ART adherence (Hyde et al., 2005; Jones et al., 2007; Kalichman et al., 2011; Langebeek et al., 2014). A group structure also encourages productive social engagement, facilitates the creation of a shared identity, provides opportunities to share information about experiences and local resources, and offers peer support (Barnett et al., 2014; Haslam et al., 2010; Mimiaga et al., 2016). These benefits help combat the social isolation that is common among individuals diagnosed with stigmatizing conditions such as HIV (Rintamaki et al., 2006). Finally, asking participants to share their action plans with one another promotes social support, which is beneficial to persistent substance users (Dobkin et al., 2002).
CAB Engagement
In addition to reviewing the empirical research, we created and convened an eight-member CAB to ensure that we were responsive to the needs of PLWH who have experienced incarceration. CAB members were asked to provide their thoughts about the research project, raise any concerns about the study design or recruitment techniques, and recommend possible additional CAB members. All members of the CAB were formerly incarcerated individuals, seven of the eight members were from minoritized populations, and two members were involved in our previous research studies. The research team met with the CAB multiple times during the planning and implementation process to discuss the recruitment approach, study design (including measures used), and to review and help refine intervention content. In addition to providing guidance on intervention content, CAB members helped raise awareness of the study and design recruitment flyers. CAB members were paid $50 for attending each 1-hour meeting. During intervention development CAB members were especially insistent that we remain mindful of the following: (a) language used to describe our participants (i.e., not referring to participants as ex-offenders); (b) including information on harm reduction strategies which were generally inaccessible in correctional settings (Sander et al, 2019); and (c) adding additional recruitment sites. CAB members also helped facilitate study enrollment by sharing recruitment flyers with others in their network. Once the pilot testing had been conducted, the research team shared the results with CAB members.
ADHERE Intervention Sessions
Based on the empirical findings reviewed above, we developed a multi-session ART adherence and risk reduction intervention, Project ADHerence Education and Risk Evaluation (ADHERE). Project ADHERE was created specifically for PLWH who use drugs and have experienced incarceration, with the goal of improving HIV treatment outcomes and reducing potential spread to other individuals (see Table 1 for an outline of the ADHERE intervention content). Each session was two hours long. We opted to deliver the interventions using a group-based approach, ask participants to share their action plans with each other, incorporate harm reduction strategies, include content on drug use as a driver of risk behaviors, and discuss strategies for identifying and managing stigma. Intervention content related to ART adherence and risk reduction was presented in three sessions.
Multi-session Adherence Intervention: Outline of Session Activities.
Note. ART = antiretroviral therapy.
Previous research suggests that HIV-infected individuals may possess limited knowledge of HIV disease progression (Kalichman et al., 1999). Although research has increasingly shown that with optimal ART adherence and undetectable VLs, HIV transmission is rare (Attia et al., 2009; Castilla et al., 2005; Cohen et al., 2011; Del Romero et al., 2010; Donnell et al., 2010), the extent to which this information has been communicated to individuals who are diagnosed with HIV during incarceration is largely unknown. Therefore, the first session introduced participants to the importance of improved immune functioning and explained the concept of “viral load.” The session provided guidance in establishing clear and sustainable medication adherence goals, offered information on transmission potential, particularly when VL is detectable (Loutfy et al., 2013), and communicated that there is currently no cure for HIV. Information on appropriate ways to take medication (e.g., at the correct time, how to handle missed doses, etc.) was also discussed during this session.
The second session of the Intervention focused on reducing high-risk behaviors, including condomless sexual behaviors and problematic substance use. Intervention modules on substance use covered four topics: (a) identifying triggers for drug use, (b) recognizing how drug use can impact sexual decision making, (c) the impact of drugs on medication adherence, and (d) harm reduction and managing addiction. Participants received education on STI/HIV transmission modes as well as assistance in devising an appropriate adherence and risk reduction plan.
During the second and third intervention sessions, participants were asked to report their progress and discuss any challenges they experienced while attempting to implement their medication adherence and risk reduction plans. Participants were also asked to establish short- and long-term goals to guide them in their newly developed adherence and risk reduction plans. The third and final intervention session included a brief review of the first two sessions. Participants in the ADHERE group received the following: (a) a referral packet containing detailed information on resources and ancillary services that could be accessed as needed and (b) a “safety” kit containing latex condoms and instructions on the appropriate use of condoms, which was developed by the New York City Department of Health and Mental Hygiene. A graduation ceremony was held to reward participants for completing the program.
In addition to the multi-session ADHERE intervention, we created a brief one-session intervention,
Pilot Testing Methodology
The interventions were pilot tested to determine whether they could potentially improve medication adherence and reduce HIV risk-related behaviors, including problematic drug use. To test the potential impact of the ADHERE intervention, we conducted a pilot study with 32 HIV-infected formerly incarcerated individuals who met the following inclusion criteria: (a) HIV-positive, (b) released from prison or jail within the previous 5 years, (c) a history of substance abuse, (d) 18 years of age or older, and (e) detectable viral load (at least 20 copies/mL).
Recruitment flyers that listed a phone number for individuals to call if interested in participating were distributed to community agencies that provide a variety of services, including housing and employment assistance, health services, and substance use treatment. Flyers were distributed by research assistants to agencies located in all five boroughs of New York City. When potential participants called the phone number listed on the flyer, a screening interview was scheduled to establish eligibility. While the recruitment approach was largely passive, research assistants also gave presentations to groups of formerly incarcerated individuals to raise awareness and answer questions about study procedures. Those who met the inclusion criteria were asked to complete a baseline interview immediately following the screening interview. All study-related interviews and meetings took place in a private office or conference room. This study protocol was approved by the Columbia University Irving Medical Center's (CUIMC) institutional review board. Block randomization was used to assign participants to the 3-session (ADHERE) or brief 1-session intervention (MACE). Assessments occurred at baseline, 1-month follow-up, and 3-month follow-up. Participants had their blood drawn by a phlebotomist for VL testing to determine eligibility (Quantiplex HIV-1 ribonucleic acid [RNA] v3.0 Assay, Chiron Corporation, Emeryville, CA, USA). The study flow chart is shown in Figure 1. Participants received $50 for completing intervention sessions, $60 for completing the 1-month assessment, and $75 for completing the 3-month assessment. Although 35 participants were randomized to a condition, our analysis is focused on the 30 participants who received their assigned intervention in its entirety. Due to the limited sample size, and our interest in pilot testing intervention content and study methodology, this approach was deemed appropriate (Coe et al., 2018; Egede et al., 2017; Jarbandhan et al., 2022; Whitehead et al., 2016). All intervention sessions were held, and assessments were conducted over the course of six months, from July to December 2016. Both interventions were delivered by a PhD-prepared researcher with extensive research experience and knowledge on substance use among legal system-involved populations. Intervention sessions were attended by a maximum of eight participants per session.
Consort diagram.
Pilot Study Measures
Socio-Demographic Characteristics
Participants were asked to provide their age, race and ethnicity, and gender. They were also asked about their sexual orientation, education, household income, and whether they had experienced homelessness in the past.
Substance Use
Participants were asked to report the type of substance(s) used within the past 30 days and the past 3 months. These included alcohol, marijuana, crack or powder cocaine, ecstasy or other party drugs, illicit sedatives or tranquilizers, methamphetamines, heroin, illicit methadone, or other illicit opiate-based drugs. They were also asked whether they ever used more than one drug during a drug-use session to measure polydrug use (McCabe et al., 2006). The Drug Abuse Screening Test (DAST-10) (Skinner, 1982) was also administered, and a score was generated. The DAST-10 measures problems related to drug use that the participant has experienced and has been shown to have high internal validity and internal consistency, with a Cronbach's α ≥ 0.80 (Villalobos-Gallegos et al., 2015).
ART Adherence
Using the Medication Adherence Self-Report Inventory (MASRI), participants were asked what percentage of their ART medication they had taken over the past month (Walsh et al., 2002). The MASRI is a well-validated instrument used to measure medication adherence, including the proportion and timing of doses taken, and has a sensitivity of up to 87% and specificity of 83%–98% for measuring medication non-adherence among individuals with a variety of chronic conditions (Koneru et al., 2007; Walsh et al., 2002).
Treatment Engagement
We asked participants whether they had visited with a provider within the previous three months.
Ability to Take HIV Medication
Using the Single-Item Self-Rating Adherence scale, participants were asked “Thinking about the past 4 weeks, on average how would you rate your ability to take all your HIV antiretroviral medications as your doctor prescribed?” (Feldman et al., 2013).
Data Analysis
We first calculated descriptive statistics for the sample. The analysis of substance use outcomes was restricted to the most prevalent substances used by sample members: alcohol, marijuana, crack or powder cocaine, and heroin; research has shown significant associations between these substances and suboptimal treatment outcomes (Håkansson & Jesionowska, 2018; Kalichman et al., 2014). We conducted intervention group comparisons using two-tailed independent t-tests to assess differences in continuous variables. Fisher's exact tests were used for binary variables and categorical variables due to the small sample size. Variables were considered statistically significant at the p < .01, p < .05, and p < .1 levels.
Results
Table 2 presents baseline demographic and behavioral characteristics by intervention condition. Among the 35 participants who were randomized into intervention conditions, 32 enrolled, and 30 completed the study. All (100%) participants who completed their assigned intervention also completed the 1-month and 3-month follow-up assessments. The MACE group included 16 participants, and the ADHERE group included 14 participants. As Table 2 indicates, there were no statistically significant demographic differences between participants in the two groups. Overall, the average age of participants was 49.8 years (SD = 8.01 years, range = 33–65 years). The sample was largely comprised of male (73.3%), Black (66.7%), and unmarried (91%) participants. About a third (33%) of the participants identified as lesbian, gay, bisexual, transgender, or queer (LGBTQ). Approximately 73% had completed a high school education or the equivalent; 73.3% reported a household income of less than $850 per month. Forty percent of the sample reported experiencing homelessness at some point post-incarceration. On average, participants had been incarcerated for approximately two years during their most recent incarceration and had been living in the community for less than two years. Participants had been incarcerated 14 times, on average, since the age of 18 (SD = 21.5). On average, participants had been living with HIV for over 20 years. At baseline, over 90% indicated that they had visited with a medical provider over the past 3 months. All participants reported a history of polydrug use.
Baseline Characteristics for MACE and ADHERE Group Participants (N = 30).
Medication Adherence
Self-reported percentage of ART medication taken in the past month is compared by intervention condition in Table 3. Overall, 60% of all participants improved their ART medication adherence from baseline to 3-month follow-up, according to self-reports. Participants in both groups reportedly took a higher percentage of their medication at the 1-month and 3-month follow-up assessments compared to baseline. For both groups, the average self-reported percentage of medication taken was greater at the 1-month follow-up assessment compared to the 3-month assessment. On average, MACE participants reported greater increases in medication doses taken at both follow-up timepoints compared to ADHERE participants relative to baseline levels. Self-rated ability to take HIV medication is also compared by intervention group in Table 3. Both groups reportedly improved their ability to take their HIV medications; these improvements were evident at 1-month follow-up followed by a smaller improvement at 3-month follow-up.
Medication Adherence and Substance Use at Baseline, 1-Month, and 3-Month Follow-up (N = 30).
Note. DAST-10 = Drug Abuse Screening Test.
The p-values below compare MACE and ADHERE values at each of the three timepoints.
* p < .05.
Substance Use
Overall, a smaller number of participants in each group reported substance use at 1-month follow-up compared to baseline. Substance use is compared by intervention condition in Table 3. Across the four types of substances (alcohol, marijuana, crack, and heroin) reported in Table 3, the ADHERE group reported reductions in substance use among a greater number of participants than did the MACE group at 1-month and 3-month follow-ups, with a larger reduction at 1-month follow-up compared to 3-month follow-up. For instance, the number of ADHERE participants who used alcohol in the past 3 months at 3-month follow-up decreased compared to baseline, but the number of MACE participants who used alcohol in this same time frame increased. The number of participants who used marijuana, crack, and heroin declined during the 3-month follow-up period in both groups; the differences in substance use between the two groups, however, were not statistically significant at any of the three timepoints. Participants in the ADHERE group on average experienced reductions in the DAST-10 score over the 3-month period, while DAST-10 scores for MACE participants were variable over this period—they were on average lower at 1-month follow-up but increased slightly at 3-month follow-up.
Discussion
The results suggest that a multicomponent medication adherence intervention has the potential to improve medication adherence and reduce substance use among PLWH who have a history of incarceration. The potential impact was greater in the short-term (1-month), suggesting that the impact of the intervention may be diminished over time. Participants exposed to the brief intervention reported greater improvements in medication adherence, but smaller reductions in substance use. Although practically all participants indicated that they were engaged in care, suboptimal medication adherence was common. While treatment engagement was high, the rates of 30-day ART adherence were generally below the 90% adherence threshold recommended for optimizing treatment outcomes. The findings align with previous research indicating that HIV-infected formerly incarcerated individuals are in need of adherence support (Iroh et al., 2015).
Antiretroviral treatment strategies that reduce the burden of a daily pill-taking regimen may be warranted for this population. The U.S. Food and Drug Administration (FDA) recently approved the first injectable drug regimen for adults living with HIV, which allows patients to replace their daily oral medication with a bimonthly injectable medication (Durham & Chahine, 2021). While the injectable drug regimen requires clinic visits every other month for injection and has only been approved for patients who have already reached viral suppression using an oral medication (Durham & Chahine, 2021), the high level of treatment engagement reported by the study sample suggests that this may be a feasible treatment for PLWH who have a history of incarceration. To maximize the benefit to PLWH, continued research is needed to develop a safe and effective injectable drug regimen that does not require patients to have already achieved viral suppression. Although a substantial proportion of participants reported substance use at each time point, the results indicated that substance use, including problematic drug use as measured by the DAST-10, declined among ADHERE study participants and decreased slightly or increased among MACE participants, who were not exposed to any content on substance use during their intervention session. This result suggests that combination adherence interventions may be needed to facilitate reductions in substance use; such interventions have been shown to improve a range of HIV treatment outcomes, including improving medication adherence, reducing viral load, and reducing HIV risk behaviors (Amico et al., 2006; Gwadz et al., 2015; Kalichman et al., 2011; Parsons et al., 2018; Sorensen et al., 2012; Spaan et al., 2020). However, the potential impact of both interventions was greater immediately after the intervention (i.e., 1-month) than at the 3-month follow-up, which may indicate that improvements may not be sustainable. These findings are comparable to those from research on previous interventions designed to reduce substance use and/or HIV risk behaviors (Kalichman et al., 2011; Simoni et al., 2010). Future research on these interventions should identify areas for refinement and consider the use of booster sessions to extend the impact of the intervention.
This study highlights the need for intensive services and support to promote optimal ART adherence among formerly incarcerated PLWH, and social workers can play a key role in coordinating care as well as integrating behavioral health interventions into these services. Interventions with post-release case management services have been shown to successfully engage and retain recently incarcerated PLWH in medical care by employing peer navigators who coordinate health services and connect PLWH with non-medical services (Myers et al., 2018). Peer navigation interventions focused on counseling PLWH to promote goal setting and retention in HIV care have been shown to prevent loss of viral suppression (Cunningham et al., 2018), suggesting that future tailored interventions that include these components have the potential to both improve retention in care and promote viral suppression among PLWH who experience incarceration. Finally, interventions that provide assistance with substance use treatment screening and/or referrals may be appropriate for this population and is an underexplored area of research (Chaiyachati et al., 2014).
Overall, given the small sample size, we were unable to conclude the superiority of either intervention. Though MACE participants reported greater improvements in ART adherence and this intervention may appear more feasible to implement given its brevity, the ADHERE intervention may offer greater potential benefit to participants because of the inclusion of risk-reduction education. Given the barriers to ART medication adherence and increased risk of other negative treatment outcomes previously described in this manuscript these additional benefits are critical for formerly incarcerated PLWH. We were also unable to determine the extent to which participants’ medication regimens changed or the rationale for any adjustments, and thus, we cannot determine the impact of regimen changes on participants’ adherence levels. This limitation highlights the importance of collaborations between physicians and behavioral scientists for the development and implementation of comprehensive treatment plans, especially for those who have experienced disruptions in care because of incarceration. Given that integrating behavioral health interventions into medical HIV treatment improves ART adherence (Kalichman et al., 2011), the development of collaborative and integrative health care support is crucial to further improving treatment outcomes.
Limitations
Although the findings offer insight into potential impact of a combination ART adherence and risk-reduction behavioral intervention, the study has a few notable limitations. First, the small sample size prevents us from making strong conclusions about the interventions’ impacts on ART adherence and substance use. Second, the use of a convenience sampling approach may have prevented us from enrolling individuals who are disengaged from the services offered at the recruitment sites. Finally, participants may have underreported the magnitude of their drug use and other stigmatizing behaviors and provided more socially desirable responses (Hunt et al., 2015). Despite these limitations, we believe that this study offers important information that can be used to develop interventions and programs for this key affected population.
Conclusions
In summary, the results suggest that ART adherence interventions have the potential to improve medication adherence and reduce substance use. However, optimizing treatment outcomes for PLWH who have a history of drug use and incarceration may require even greater support. Future behavioral interventions designed to improve ART adherence among this population should include educational components while involving peer navigators, physicians, or health care services in more meaningful ways. Future interventions should also seek to test a range of strategies and modalities to promote engagement in the HIV Care Continuum, including integrating substance use treatment. In practice, social workers should implement behavioral interventions that educate and empower PWLH who have a history of incarceration.
Footnotes
Clinical trial registration
NCT03300908.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institute on Drug Abuse (grant number: K01DA036411).
