Frederick L. Altice, MD

Fewer than half of people with HIV who were released from prison remained in treatment for HIV 3 years later, new research involving more than 1000 formerly incarcerated individuals shows.

Even one year after release, only two-thirds of formerly incarcerated participants were retained in care, researchers at the Yale School of Medicine found in what they say is the largest study of its kind to explore what happens to prisoners with HIV once they return to the general population.

“One of the key elements to keeping people with HIV healthy and reducing the likelihood that they can infect others if they are engaging in HIV risk behaviors is retaining them in HIV care,” senior author Frederick L. Altice, MD, Professor of Medicine, Epidemiology, and Public Health at Yale, told MD Magazine®.

The researchers found the rate of viral suppression also declined significantly over time among the released prisoners. However, in a perverse twist, retention in care improved among those who were re-incarcerated, the study showed.

The findings suggest that dedicated resources are needed to optimize HIV care while people are in prison and to link them to care after they are released, Altice and colleagues from Yale and the Connecticut Department of Correction wrote in PLOS Medicine.

The keys for optimizing retention in care and viral suppression after release include making sure individuals have insurance, including Medicaid expansion for prisoners during incarceration; effectively linking them to care soon after release; providing effective HIV treatment in prison; and providing more transitional case management, Altice said.

Those efforts are important because one-sixth of the 1.2 million people with HIV in the US transition through a prison or jail each year. This makes them a key population who may need specially tailored services.

“Since HIV disease is a lifelong, chronic disease, we must develop strategies to more effectively retain them in care over a lifetime,” Altice said.

To track this vulnerable population, the authors merged Connecticut databases on people living with HIV who were released from prisons or jails in the state between 2007 and 2011.

The study considered 1094 individuals who were 18 years or older and were confirmed to have HIV before their release. The team then observed them through the end of 2014.

The researchers found that continuous retention in care declined to 67.2% in the first year, 51.3% in the second year, and 42.5% in the third.

Individuals who were not re-incarcerated and who demonstrated retention in care in the community had significantly higher viral suppression rates compared with re-incarcerated individuals, the authors wrote.

At the same time, individuals who were re-incarcerated showed higher retention in care, the team found.

Asked about this divergence, Altice said that one interpretation is that individuals whose lives are chaotic are more likely to do things that cause disruptions, such as getting arrested. Such circumstances make them less likely to take their HIV medication.

“Re-incarceration thus serves in our cohort as a way to re-engage these patients into care,” Altice said. “But when arrested, they are less likely to be taking their medications properly, which is why viral suppression levels are reduced.”

Previous papers by the team showed that treating underlying substance use disorders during the transitional period is associated with markedly improved viral suppression levels. Similarly, getting HIV patients with substance use or psychiatric disorders into housing significantly improves HIV treatment outcomes, Altice said.

“I would suggest that all incarcerated individuals with HIV be screened for and treated for alcohol and/or opioid use disorders during incarceration, continuing it after release and providing them with housing,’’ Altice said. “I would argue that ‘referral’ to these services is insufficient.”

Many other projects underway targeting prisoners and HIV. These include using various medications to treat addiction during and before release. This effort can also reduce overdose, since 51% of all overdoses in Connecticut last year occurred in people recently released from prison, Altice said.

“The reason for focusing on people with HIV is to ensure both individual health but also public health since those who are effectively engaged in care and virally suppressed will not contribute to new infections,” he said. “The incredibly destabilizing forces of release from prison or jail require invigorated efforts to keep them engaged.”

The study, "Retention in HIV care during the 3 years following release from incarceration: A cohort study" was published in PLoS Medicine.