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Does Anything Work? Improving HIV Care Engagement for Individuals Transitioning out of Correctional Settings

Pluznik, Jacob A. BSca; Nijhawan, Ank E. MD, MPH, MSCSb; Spaulding, Anne C. MD, MPHa

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JAIDS Journal of Acquired Immune Deficiency Syndromes: March 1, 2021 - Volume 86 - Issue 3 - p 286-287
doi: 10.1097/QAI.0000000000002599
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Maintaining continuity of care among persons living with HIV (PLWH) who are moving through correctional facilities is a topic of critical importance to combatting the US HIV epidemic. During incarceration, rates of engagement in HIV care and attainment of viral suppression surpass rates in the community; however, rates of linkage to care drastically decrease after release from custodial settings.1 This trend results from a combination of many factors, including PLWH prioritizing basic subsistence needs over medical treatment postrelease, the barriers of intrusive probation requirements, the prevalence of co-occurring substance use disorders and/or psychiatric disorders, and limited social support networks. The study by Woznica et al in this issue aimed to review interventions at various points in the HIV care continuum to improve engagement in HIV care among formerly incarcerated individuals after release.2 The authors included 27 reports in their systematic review and determined that postrelease improvements in clinic attendance and viral suppression were associated with interventions that encompassed peer support and substance use treatment strategies. Most interventions analyzed in the review, however, were unable to improve engaging PLWH in care as they transitioned back to the community.

The association between social support and engagement in the HIV care continuum for individuals released from jails and prisons has been noted in previous expert reviews. Springer et al outlined 5 social support factors that substantially contributed to superior treatment outcomes for PLWH who were released from prisons3 that were similar to the findings of Woznica et al. The 5 social support factors found to have notable effects on engagement in care encompassed a variety of services, including the adaptation of case management services to facilitate linkage to care, continuity of antiretroviral therapy (ART), treatment of substance use disorders, continuity of mental illness treatment, and secondary prevention measures to reduce HIV-associated risk-taking behaviors.3 Despite the current social support services offered for PLWH after being released from incarceration, researchers have struggled to demonstrate further improvement to HIV care engagement through these methods. Although some studies, such as the LINK LA clinical trial, found that peer support interventions helped sustain viral suppression, other studies showed intense psychosocial support did not further improve engagement in community care for this population.4–6 These inconclusive results emphasize that peer support interventions are beneficial in certain settings but are still largely insufficient. This quest mirrors one that criminologists have pursued in trying to reduce recidivism. Pessimism had led to the 1974 pronouncement that “nothing works” in regard to rehabilitation; eventually, some evidence-based practices evolved.7 Building on evidence-based postincarceration linkage to care (mental health, substance use treatment, and HIV care) programs, innovations in the delivery of ART could impact treatment continuity and viral suppression. Directly administered ART (DAART) has been studied for PLWH who have had difficulty engaging in care and adhering to ART, although this is very labor intensive.8 The development of new treatment methods in the form of novel long-acting antiretroviral injectables provides an opportunity to improve HIV outcomes for formerly incarcerated populations.

A sustained-release medication providing a cushion of time before redosing may achieve what behavioral interventions have heretofore not been able to: sustained viral suppression among those recently released from jail or prison. According to 2 recently published studies, the effects of one such long-acting injectable regimen, combined cabotegravir and rilpivirine, demonstrated both maintenance of HIV-1 viral suppression in PLWH and treatment satisfaction.9,10 The International Antiretroviral Society-USA recently included these long-acting agents in their 2020 guidelines for the treatment and prevention of HIV, even in advance of approval by regulatory agencies.11 This novel all-injectable alternative to daily oral treatment regimens provides potential for improved adherence; however, studies published to date were conducted solely among patients who demonstrated good adherence to treatment, affecting the generalizability of these findings.

The use of these new treatment methods could prove groundbreaking for correctional settings in terms of improving continuity of care for PLWH after incarceration. As public health researchers, we suggest initially conducting further implementation studies of long-acting injectable treatments for incarcerated persons who are known to be adherent until additional studies are conducted among populations who are less adherent, not adherent, or whose adherence status is unknown. The LATITUDE study ( number, NCT03635788) is one such phase III trial that is currently underway and evaluating the efficacy, safety, and durability of long-acting antiretroviral therapy compared with the all-oral standard of care among participants with a history of suboptimal treatment adherence. After more studies of adherence-challenged populations are completed, correctional providers could move forward with undertaking a larger-scale adoption of long-acting injectable antiretroviral therapy. With the advent of new ART formulations, a future systematic review of interventions to improve sustained viral suppression during transition from corrections to the community may show at last that “something works.”


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