Most prison inmates with HIV do not receive appropriate treatment immediately following release

February 24, 2009

Approximately 80 percent of HIV-infected Texas prison inmates did not fill an initial prescription for antiretroviral therapy within 30 days of their release from prison, potentially increasing their risk for harmful health consequences because of an interruption of treatment, according to a study in the February 25 issue of JAMA.

"The U.S. prison system has become an important front in the effort to treat and control the spread of human immunodeficiency virus (HIV) infection, serving as the principal screening and treatment venue for thousands of individuals with or at high risk for HIV infection who have limited access to community-based health care. Many inmates are offered HIV testing for the first time while incarcerated, and three-quarters of inmates with HIV infection initiate treatment during incarceration," the authors write.

Because the majority of former inmates are without private or public health insurance for the first several months after release, accessing antiretroviral therapy (ART) in a timely manner represents a challenge. "Those who discontinue ART at this time are at increased risk of developing a higher viral burden, resulting in greater infectiousness and higher levels of drug resistance, potentially creating reservoirs of drug-resistant HIV in the general community," they add. The extent to which HIV-infected inmates experience ART interruption following release from prison is unknown.

Jacques Baillargeon, Ph.D., of the University of Texas Medical Branch, Galveston, and colleagues conducted a study in the nation's largest state prison system to determine the proportion of HIV-infected inmates who filled a prescription for ART medication within 60 days following their release from prison. The study included all 2,115 HIV-infected inmates released from the Texas Department of Criminal Justice prison system between January 2004 and December 2007 who were receiving ART before release.

Among the entire study group, an initial prescription for ART medication was filled by 115 (5.4 percent) of the former inmates within 10 days of release, by 375 (17.7 percent) within 30 days, and by 634 (30.0 percent) within 60 days. The authors found that Hispanic and African American inmates were less likely to fill a prescription within 10 days and 30 days compared with non-Hispanic whites. Inmates with an undetectable viral load were more likely to fill a prescription than inmates with a detectable viral load at release. Inmates released on parole were more likely to fill a prescription within 30 days and 60 days than inmates with a standard, unsupervised release. Inmates who received formal assistance in completing an AIDS Drug Assistance Program application were more likely to fill a prescription than inmates who received no such assistance.

"In this 4-year study of HIV-infected inmates released from the nation's largest state prison system, we found that only 5 percent of released inmates filled a prescription for ART medications soon enough (i.e., within 10 days after release) to avoid treatment interruption," the authors write. In all of the subgroups examined, at least 90 percent of the former inmates experienced a treatment interruption; more than 70 percent had a treatment interruption that lasted at least 30 days, and more than 60 percent had a treatment interruption that lasted at least 60 days.

"These exceedingly high rates of treatment interruption suggest that most inmates face significant administrative, socioeconomic, or personal barriers to accessing ART when they return to their communities. Future prospective and in-depth qualitative studies are needed to more rigorously examine these barriers. Adequately addressing a public health crisis of this scale and complexity will require carefully coordinated efforts between academic institutions, the criminal justice system, and public health agencies," the researchers write. "In particular, greater coordination between state and local agencies, health care institutions, and community-based organizations is needed to reduce this high rate of treatment interruption among newly released inmates."

More info: JAMA. 2009;301[8]:848-857.

Source: JAMA and Archives Journals