HAART is effective in prisoners, but benefit may be lost upon release

Inmates respond well to anti-HIV therapy during incarceration, but this benefit is often lost after release, according to an American study published in the June 15^th edition of Clinical Infectious Diseases. The results suggest the need for effective community-based programs to assist former prisoners after they are released.

The average daily prison population in the United States recently surpassed two million - the highest per capita incarceration rate in the world. Due in large part to the increase in incarceration for drug-related crimes, prisoners have disproportionately high rates of drug addiction, mental illness, and infectious diseases such as HIV and hepatitis C. The rate of HIV infection among prisoners is estimated to be five times the rate observed in the general population. About two-thirds of HIV-infected inmates are first diagnosed and about three-quarters begin antiretroviral therapy while incarcerated, indicating that they generally do not access HIV testing and medical care in community settings.

Researchers from Yale University and the University of Connecticut conducted a retrospective cohort study of data collected from inmates incarcerated in prisons run by the Connecticut Department of Corrections, which operates 17 facilities for men and one for women. In July 2003, the average daily inmate census was about 19,000.

Each facility has an HIV nurse specialist, experts from the Yale University AIDS Program and others provide care on a contract basis, therapy is provided in accordance with U.S. federal HIV treatment guidelines, and all antiretroviral medications approved by the U.S. Food and Drug Administration are available. HIV-infected prisoners scheduled for release are referred for transitional case management by a community-based organization. This process begins three months prior to the end of incarceration and continues for at least 30 days after release, or until a community-based case manager can take over. Prisoners receive at minimum a two-week supply of medications, a medical appointment with an HIV care provider, and emergency housing and food assistance.

The researchers collected retrospective data on 1866 HIV-infected inmates who were prescribed antiretroviral therapy during incarceration for at least six months between January 1997 and December 2002. This included pharmacy records, laboratory data, demographic information, and information about prison admission and release dates. Complete data were available for 1099 prisoners.

Most of the prisoners receiving HAART were men (81%). The mean age was 39 years for men and 36 years for women; 50% were black, 33% were Hispanic, and 17% were white. The mean duration of incarceration was 478 days, and 12% were incarcerated for at least six months on two or more occasions.

While receiving antiretroviral therapy during incarceration, inmates’ mean viral load decreased by 0.93 log₁₀ copies/mL and the mean CD4 cell count increased by 74 cells/mL (p < .0001). Fifty-nine percent (59%) achieved an undetectable viral load (below 400 copies/mL) by the end of incarceration. Women on average experienced greater declines in HIV RNA, although women and men were equally likely to achieve an undetectable viral load. “These results are comparable to or better than those found in most community clinic settings,” the researchers stated, adding that “incarcerated populations that are disproportionately affected by higher rates of HIV infection, mental illness, and injection drug use achieve impressive outcomes in the correctional setting, although these persons have otherwise done poorly in community settings.”

However, this benefit is often not sustained when former prisoners are released into the community. Of the 292 individuals (27%) who were reincarcerated after having been out of prison for at least three months (median 127 days), the mean CD4 cell count decreased by 80 cells/mm³ and the mean viral load increased by 1.14 log₁₀ copies/mL (p < .0001).

It cannot be inferred that one-quarter of all ex-inmates will not sustain the benefits of HAART, since reincarcerated individuals likely represent those who fail to achieve a stable lifestyle outside prison, including those who return to drug use and crime.

It was not clear whether the released inmates who lost virological control of HIV adhered poorly to therapy or stopped taking their anti-HIV medications altogether (although the observed outcomes are consistent with those seen in other studies in which patients completely discontinued HAART). Poor adherence and treatment discontinuation increase the risk of drug resistance, in turn raising concern about the transmission of drug-resistant HIV within the community through unprotected sex or needle-sharing.

Given that a transitional case management program is in place in Connecticut, the study suggests that more comprehensive programs are needed to help former inmates sustain the benefits of HIV therapy and avoid reincarceration. The researchers suggested that such efforts should include post-release medical, mental health, and drug treatment services, as well as needle exchange programs and opiate substitution therapy with methadone or buprenorphine, both within prisons and in the community. (Drug substitution programs are absent in U.S. prisons with the exception of New York City).

“Clearly, case management alone is not sufficient,” the authors concluded. “Development of alternative strategies for continuing care after release to the community is desperately needed to avoid increased morbidity and mortality among these individuals and the transmission of multidrug-resistant HIV to their sex and drug-use partners.”

In an editorial in the same issue, Amy Boutwell and Josiah D. Rich from Brown University Medical School note that the high prevalence of HIV among incarcerated individuals presents a tremendous public health opportunity, since “[p]risons and jails are key points of contact with millions of individuals at high risk of HIV infection who are largely out of the reach of the medical system in the community.”