Health Care Practices and Associated Service Needs in a Sample of HIV-Positive Incarcerated Men in Puerto Rico

Introduction

Individual and social determinants affect populations in prison, creating major health inequities and producing health disparities, not only among incarcerated individuals but also among their communities. ^{1 -3} Global incarceration rates have been estimated at 146 per 100 000 people, with the United States having the highest prison population rate in the world (743 per 100 000 people). ⁴ Puerto Rico serves as a bridge between the United States and the Caribbean region, which has extraordinarily high rates of imprisonment; among the 12 countries and territories with the highest prison rates, 8 are located in the Caribbean. ⁴ Puerto Rico has an extraordinarily high prison population rate (303 per 100 000), including over 11 000 incarcerated individuals; 98% of whom are men. ⁴

Incarceration and HIV have been seen as dual epidemics. ⁵ Social and behavioral determinants presented by individuals with a history of imprisonment, including the implementation of punitive laws toward drugs, increase the risk of HIV infection among people with a history of incarceration. ^{6 -9} The HIV prevalence among incarcerated populations has been reported to be disproportionally high. HIV surveillance and HIV research in prison have largely been limited to high-income countries, therefore making it difficult to establish a precise number of prisoners affected with HIV/AIDS. Nonetheless, rates of HIV infection among incarcerated individuals have been reported to be as high as 50% in developing countries. ¹⁰ This disparity trend has also been evidenced in the Caribbean and particularly in Puerto Rico. Recent reports have evidenced that 6.9% of the prison population in Puerto Rico has been diagnosed with HIV, the highest HIV prevalence rate among incarcerated persons in the Caribbean. ^9,11

The Puerto Rican correctional system houses more than 10 500 men and 250 women in more than 30 facilities distributed in 7 correctional centers, including jails or intake centers (short-term facilities) and prisons (long-term facilities) organized to house adults (≥21 years), young adults (≥18, but, <21), and women in separated facilities within the system. ^9,11 Consistent with an HIV epidemic mostly driven by injection drug use (IDU) and a territory with punitive laws toward drugs, 73.8% of the incarcerated population in Puerto Rico has a history of problematic use of drugs. The most commonly used illicit drugs reported by inmates with a history of substance use are cocaine (36.2%), heroin (34.8%), and marijuana (25.6%). About two-thirds (66.0%) of the correctional population in Puerto Rico had committed some offense associated with substance use, ¹¹ and 80% of prisoners have been incarcerated more than once in their lifetime. ¹²

Coinfection of HIV and other blood-borne infections are also common among incarcerated populations. In Puerto Rico, a study completed in 1998 documented a prevalence of hepatitis C virus (HCV) of 49.3% among inmates in the correctional system. ¹³ In 2008, a health profile of the correctional population evidenced an HCV prevalence of 32.5% and among these, 73.5% had an HIV and HCV coinfection. ¹² Injection drug use and unsafe tattooing practices have been documented as the leading causes for HCV infection in this population. ¹⁴

Correctional facilities may offer an opportunity to address the needs of HIV-positive populations that may not have access to health services in their communities. Not surprisingly, there is a call to increase attention to HIV services during incarceration and comprehensive approaches toward understanding and decreasing the disproportionate disease burden among incarcerated individuals in the island. Furthermore, there is a need to better understand the health care needs of incarcerated populations in order to improve the health outcomes when inside the prison and to assure continuity of care once released from prison. ¹¹ Following this scenario, the objective of this analysis is to provide a preliminary assessment of the behavioral and continuity of care practices of a sample of HIV-positive incarcerated men in Puerto Rico.

Methodology

Data were collected during a pilot study where the main goal was to assess the use of HIV genotype testing among HIV-positive incarcerated men in Puerto Rico. ¹⁵ Eligibility was restricted to a random sample of HIV-positive sentenced incarcerated men with a viral load of more than 250 (or a detectable viral load) and who had no prior experience with HIV genotype testing. Eligible participants were identified through a simple random selection applying inclusion criteria using electronic medical records. Participation in the study was voluntary and participants provided written consent. A questionnaire was completed by participants under the supervision of a nurse who also obtained clinical information from prisoners’ medical charts. The survey asked for self-reported information in the following domains: demographic characteristics; HIV-related information including the date and setting of initial HIV diagnosis and experience with HIV testing and treatment; and behavioral risk practices prior to incarceration. The secondary data analysis was approved by the Human Research Subjects Protection Office of the University of Puerto Rico–Medical Sciences Campus. The Statistical Package for Social Sciences (SPSS) version 21 was used to complete the descriptive statistical analysis.

Results

A total of 37 men (95% response rate) housed in 6 of the 7 correctional centers in Puerto Rico participated in the study. In general, the sample had a mean age of 39 years (range 29-50 years) and had been imprisoned for an average of 8 years. As included in Table 1, most were housed in medium (46.0%) or minimum (40.5%) security level facilities, and most (85.7%) had a prior history of incarceration. In all, 73.0% reported using drugs (when actively using the drug or IDU) as their primary risk factor for HIV infection, with 97.3% of them reporting lifetime history of alcohol or drug use. Cocaine was the most (78.4%) frequently used substance. Mean current CD4 count was 453 (range, 39-1039), mean viral load was 15 155 (range, 250-230 676), and roughly one-fifth (21.6%) had had an AIDS diagnosis at some point in their medical history. Consistent with high rates of injection risk, most (83.8%) had also been diagnosed with HCV during their lifetime.

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Table 1.

Demographics, Risk Factors, and HIV Care in a Random Sample of HIV-Positive Incarcerated Men in Puerto Rico.

	HIV-Positive Men (N = 37)
	n	%
Custody level
Minimum	15	40.5
Medium	17	46.0
Maximum	5	13.5
Previously incarcerated	30	85.7
Ever diagnosed with AIDS	8	21.6
Hepatitis C virus diagnosis	31	83.8
Reported HIV risk practices
Drug use	27	73.0
Unprotected sex with women	19	51.4
Unprotected sex with men	7	18.9
Unsafe tattoo practices	5	13.5
Blood transfusion	3	8.1
Lifetime use of alcohol and other illicit/illegal drugs	36	97.3
Cocaine	29	78.4
Marihuana	28	75.7
Alcohol	13	35.1
Pills (ecstasy, MDMA, etc)	11	29.7
Heroin	11	29.7
Crack	9	24.3
Benzodiazepines	3	8.1
Place of first HIV test
Correctional facility	31	83.8
Community health center	3	8.1
HIV/STI clinic	3	8.1
Previous use of HIV medications	27	73.0
Have ever interrupted HIV medications	15	55.6
Have ever received HIV care outside a correctional facility	13	35.1
HIV/STI clinic	8	21.6
Public clinic	2	5.4
Public hospital	1	2.7
Private hospital	1	2.7

Abbreviations: MDMA, 3-4 methylenedioxymethamphetamine; STI, sexually transmitted infection.

Particularly noteworthy, 83.8% had their first HIV screening test in a correctional facility. Other first HIV tests were performed in community health centers (8.1%) and HIV/sexually transmitted infection (STI) clinics (8.1%). In all, 73.0% reported ever having taken antiretroviral treatment and more than half of them (55.6%) reported treatment interruption at some point during treatment. Of those who reported discontinuation in the use of HIV medication (n = 14), 50% indicated the reason was negative side effects. However, participants also reported other reasons for discontinuing HIV medication issues associated with system-level barriers such as reentering the community (n = 2) and transferring from housing facilities within the correctional system (n = 2).

Only about a third (35.1%) reported receiving HIV treatment services in the community following their last release from a correctional setting. These services were mostly provided at publicly funded treatment centers (21.6%) situated in regional HIV/STI clinics throughout the island or at other public clinics (5.4%).

Discussion

As evidenced by the participants of this study, correctional facilities represent the main point of access to HIV screening and treatment for the populations that circulate through the prison system in Puerto Rico. Although other community-level services were also reported as point of entry to HIV care, a correctional facility was the first site for HIV testing among most (83.8%) of the participants of this study. Therefore, correctional settings may represent a major opportunity to engage HIV-positive men in care and potentially reduce the risk of transmission of HIV and HCV at the community level. Optimizing correctional heath care requires systemic interventions that facilitate retention in HIV care by early engagement into community services during the community reentry process. It is suggested to develop and test macro-level interventions that address issues related to adherence, access, and retention in care for prisoners with comorbidities—including HCV infection and substance disorders—and risk reduction strategies.

Although the conditions associated with imprisonment—such as overpopulation and limited access to social and health services—may be considered challenging for the general well-being of inmates, incarceration may also represent an opportunity to improve the health status of those affected by HIV. First, 85.7% of the participants of this study have been incarcerated more than once; a scenario that is shared with most of the correctional population in Puerto Rico and that implies that for some people prisons embody a unique context for health care access and utilization. Consistent with other publications, ^11,16 high levels of HIV risks associated with drug use were reported among HIV-positive men within the Puerto Rico prison population. A high rate of HIV and HCV coinfection (83.8%) was reported in this sample. Previous population-based research has estimated the prevalence of HCV in Puerto Rico at 2.3%; 76.1% among people with a history of injecting drug use, 17.5% among those with a history of imprisonment, and 5.2% coinfection with HIV. ¹⁷ Although there is no HCV surveillance system or articulated prevention programs in Puerto Rico, the data from this study contribute in supporting the needs for combined strategies to prevent transmission and facilitate access to care for groups that may be at increased risk of acquiring or living with HIV and HCV coinfection. Special attention should be given to the needs of individuals with problematic use of drugs, particularly for the provision of harm reduction strategies, drug detoxification, and maintenance treatments.

This study is limited to a random sample of HIV-positive incarcerated men in Puerto Rico who voluntarily participated in a pilot project. Due to the small sample, analyses were limited to descriptive statistics, and generalizations to other incarcerated men are not possible. Nonetheless, to our knowledge, this is the first report available from a random sample of HIV-positive incarcerated men in Puerto Rico. Although the sample is limited, it nevertheless expands and amplifies the growing body of evidence in support of making better use of correctional facilities as a gateway for health care to populations that otherwise may not be linked to services in the community. Furthermore, the demographic characteristics of the participants of this study were similar to those of the general population of men in the Puerto Rico correctional system, and there is some justification for generalizing these results. ^11,12

Because consistent engagement in care can improve health outcomes for people with HIV/AIDS ¹⁸ and their partners, ¹⁹ correctional facilities are key venues for mounting an effective response to the epidemic. Beyond behavioral risks of HIV or HCV infection among incarcerated populations, future studies must address the systemic challenges at the community and the correctional level that might be associated with risks of infection, screening, retention in care, and adherence among individuals with a history of incarceration. Based on current practices and general recommendations on HIV testing in prison, ¹¹ it is encouraged to study the feasibility of routinizing testing for HCV infection and assessing the impact of treating for HCV in the correctional facilities. These efforts may contribute to better care for incarcerated individuals and their communities.