Most HIV-infected inmates are eligible for ART
Connecting with medication right away [is the] problem
A new study with surprising results about the low percentage of HIV-infected inmates accessing antiretroviral therapy (ART) post-release could be seen as a model for following this population.
"We knew there was a problem where a lot of inmates returned to prison with higher viral loads and t-cell counts than they had when they left, but there was nothing in the literature that showed the actual rates of linkage to care among HIV-infected inmates," says Jacques G. Baillargeon, PhD, an associate professor of epidemiology in the department of preventive medicine and community health at the University of Texas Medical Branch in Galveston, TX.
"We looked at all the [HIV-infected] inmates released over this four-year period," Baillargeon says. "And we know the vast majority of inmates at the time of release don't have access to health insurance, private health insurance." So it was safe for investigators to assume that no one had an alternative source of care within the first couple of months of their release from prison, he adds.
In fact, about 99% of HIV-infected inmates are eligible for ART through the AIDS Drug Assistance Program (ADAP), says Dwayne R. Haught, MSN, RN, manager of the HIV medication program, which is an AIDS Drug Assistance Program (ADAP) and part of the Texas Department of State Health Services in Austin, TX.
All of the Texas inmates infected with HIV were released with a 10-day supply of medications, so investigators used ADAP records to see whether they had access to ART within 10 days, when their supply would end, or at 30 days or at 60 days post-release.1
The study found that only 30% of HIV-infected inmates received ART within 60 days. It also found that inmates with an undetectable viral load upon release were more likely to fill a prescription within 10, 30, and 60 days.1
And inmates who were helped in filling out a Texas ADAP application were more likely to fill a prescription within the same time period. About 55% of the inmates studied received ADAP assistance. Inmates who were in prison for more than a year and those released on parole were more likely to have received the assistance.1
Also, older inmates were more likely to have filled an antiretroviral prescription within 60 days than were inmates under age 30.1
Texas ADAP workers assisted investigators as they obtained the data and were interested in the results, Baillargeon says.
The study highlights some gaps in ADAP that need to be filled, Haught says.
"It's connecting with medication right away that's a problem," Haught notes.
"We have a pre-discharge application," he adds. "But what happens is when people are incarcerated and released the application has an address that they don't necessarily go back to, so we need to verify the information."
Build the bridge
Rather than have discharged inmates wait for days or weeks to receive final approval and their medications, the key is to prescribe ART through a bridge program, Haught suggests.
Everyone in HIV and public health care should be concerned about the ART gap in re-entry of inmates because of the high risk of these infected individuals transmitting HIV to others in the community, Baillargeon says.
"A lot of people have recognized that this initial month or two is a critical time for inmates," Baillargeon says. "Many are likely to be vulnerable to engaging in high-risk behaviors, and when they're not accessing medications they can develop HIV drug resistance and as a result be even more contagious."
The next step in this research is to find out why inmates re-entering the community do not access HIV care, he says.
"What socio-behavioral factors are at work here, and what is the timeline for that?" he says. "What happens during that first week, second week, and third week that might explain why they aren't getting their ADAP application done?"
Further research is needed to inform interventions aimed at this population.
"We want to get in and figure out what's happening," Baillargeon says. "That's the way we'll ultimately be able to develop effective intervention strategies for discharge planning."
Reference
- Baillargeon J, Giordano TP, Rich JD, et al. Accessing antiretroviral therapy following release from prison. JAMA. 2009;301(8):848-857.
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