Preliminary Evidence of Significant Gaps in Continuity of HIV Care among Excarcerated Populations in Puerto Rico

Introduction

HIV/AIDS is a widespread and serious problem among incarcerated populations worldwide; and in many countries, rates of HIV among people living in jails or prisons are significantly higher than those in the general population. In the United States, for example, there are 2.29 million incarcerated individuals, ¹ with an estimated 1.5% rate of HIV infection, much higher than the general US population. ² Consistent with the overrepresentation of ethnic/racial minority groups in the overall prison population, the highest HIV prevalence is observed among minorities. ^2,3

Puerto Rico has one of the highest HIV incidence rates in the United States (45 per 100 000), ⁴ roughly twice that of the overall Hispanic population in the United States. ^5,6 Puerto Rico also has a large prison population, with some 12 000 individuals in custody (330 per 100 000 incarceration rate per capita). ¹ A large proportion of the incarcerated population in PR has a history of drug use (73.8%) ⁷ and one of the highest rates of HIV, ² including 6.7% among adult (≥21 years) males and 14.3% among adult females. Fifty-five percent of those with HIV meet criteria for antiretroviral therapy, with the vast majority of those who meet clinical criteria receiving HIV care (88%). ⁸

Existing policies in the Puerto Rico Correctional System require HIV screening at intake, optional annual retesting, and enrollment in HIV treatment. ⁸ However, HIV services are entirely directed to management of HIV within the prison itself. There are no systems for linking HIV-positive individuals to community-based care and no monitoring of enrollment and retention in HIV care in the community. Moreover, as an unintended consequence of the fact that HIV care in the prison is delivered as directly observed therapy (DOT), HIV-positive inmates have little or no experience in independently managing their own HIV care since in the prison context, there is no opportunity to develop the types of adherence skills that are critical for realizing long-term clinical benefits from HIV treatment. Given that Puerto Rico has one of the highest incidence of HIV in the United States and one of the highest per capita rates of HIV infection in its prison population, the latter is a particularly urgent issue since this group comprises a substantial pool of HIV infections. The purpose of this article is to provide a preliminary assessment of gaps in continuity of HIV care after release from prison.

Methods

This report describes data from an ongoing epidemiological study being conducted by researchers in the School of Public Health at the University of Puerto Rico, in collaboration with Centro Latinoamericano de Enfermedades de Transmisión Sexual (CLETS) one of the largest, publicly funded HIV/sexually transmitted infection (STI) treatment centers in the San Juan metropolitan area. Initiated in 2009, the study involves random selection of participants from the clinic waiting room at CLETS, written informed consent, and participation in a brief behavioral risk survey interview. The behavioral assessment consists of 4 main sections: sociodemographic characteristics (including history of incarceration), lifetime and current drug use, sexual initiation and current sexual activity, and questions about health history and health services utilization, including questions about what types of services participants were seeking at the time of the interview. Following completion of the interview, a targeted chart review is conducted for recovery of selected clinical data, including current STI, HIV status, CD4 count, and viral load.

All study procedures have been reviewed and approved by the Human Research Subjects Protection Office of the University of Puerto Rico—Medical Sciences Campus. Since the analysis is based on small number of individuals in which incarceration history, HIV status, and HIV treatment enrollment can be determined, the discussion is limited to descriptive statistics.

Results

Between October 2009 and December 2010, the study sample included 461 men and 318 women. Nearly a quarter of the men (23.7%, n = 109) and 9.1% (n = 29) of women reported a history of at least 1 incarceration. Among those with an incarceration history, two thirds (67.8%, n = 74) of men and over a quarter of the women (27.6%, n = 8) have had 2 or more incarcerations. Among those with a history of incarceration, 43.1% (n = 47) of the men and 37.9% (n = 11) of the women are HIV positive.

Among those HIV-positive men with history of incarceration, 10.6% (n = 5) reported current injection drug use (last 3 months) and two thirds (65.9%, n = 31) were also sexually active during this period. Of those HIV-positive women with a history of incarceration, none reported injection risk but over half (54.5%, n = 6) were sexually active. Thus, both drug injection and sexual transmission risks are prevalent in this group.

With an interest in understanding barriers to enrollment in community-based care following release from prison, we examined data from 10 individuals (8 men and 2 women) who self-reported being HIV positive, had a history of incarceration, and were enrolling in the clinic for the first time on the day in which they were interviewed. In examining the interval between the date of their release from prison and the date of their enrollment in HIV care at CLETS, we found that, on average, there was a 4-year gap between release from prison and enrollment in HIV care at the CLETS clinic. Clinical data for these patients recovered from the targeted chart review reflected this extended discontinuity in treatment. Mean CD4 count in this group was low (386.7, standard deviation [SD] = 168.8, range =160-702). Mean viral load was high (17 991.86, SD = 31 236.74, range ≤ 75-89 015). In qualitative interviews with clinic staff regarding continuity in care following incarceration, clinicians reported that HIV-positive patients with a history of incarceration generally appeared for HIV treatment only after the development of advanced HIV disease (typically via referral following hospitalization for HIV-related opportunistic infection) and none could recall ever having received a direct referral from the prison-based HIV services system.

Discussion

There are several limitations to the types of inferences that can be made from this data. Although the CLETS clinic is a major provider of HIV services in the San Juan metro area, the subsample of HIV-positive individuals with a history of imprisonment described here is small, and our findings may not be generalizable to all HIV-positive prisoners released from Puerto Rico Correctional System. Moreover, the measures that were applied in this study were not constructed for the specific purpose of assessing continuity in HIV care following release and there are a number of additional questions that cannot be examined with the available data. For example, we do not know whether these individuals were enrolled in HIV care during their incarceration, although it is likely since evaluation of prison-based treatment services indicates high rates of treatment enrollment during detention (88%) ⁸ . Additionally, we do not know what their health status was, including CD4 count and viral load, at the time that they were released.

These limitations notwithstanding, the data suggest that HIV-positive men and women released from the Puerto Rico Correctional System are at high risk of discontinuity in HIV care following release from prison. The mean 4-year interval is not trivial and substantially exceeds those found in other recent studies of HIV-positive populations released to the community. ^{9 –11} Failure to maintain HIV-positive individuals in care following the release may be expected to confer substantial risk of preventable mortality and morbidity among individuals in this group. Additionally, HIV modeling studies have shown that early and sustained enrollment in care, if coupled with high rates of treatment compliance, may contribute to significant reductions in circulating virus and ultimately to reduction in HIV incidence in the community. ^{12 –15} However, both individual and community-level benefits of HIV treatment while in custody may be significantly diminished if continuity in care is not maintained after release. On the contrary, it may accelerate the development of treatment resistance, including diffusion of treatment-resistant virus among drug and sexual partners.

Given the high HIV incidence rates in Puerto Rico, there is a critical need to reduce secondary transmission among HIV-positive individuals, particularly those at high risk of continued involvement in behavioral risk. Puerto Rico has a large prison population with high rates of HIV infection. There is an urgent need for development of system- and individual-level interventions that will effectively engage and retain this population in community-based HIV care. Moreover, since HIV treatment in prisons is administered as DOT, interventions are needed to prepare prisoners to manage their own treatment after their release, including adherence training and guidance in accessing and utilizing community-based treatment services. More effective systems for retaining this population in care may be expected to contribute to improved health outcomes in this group and may also reduce the risk of secondary infection among their drug and sexual partners. This is an especially important goal given high HIV incidence rates in Puerto Rico.