The vast majority of individuals released from prison in Texas who were taking antiretroviral therapy interrupt their HIV treatment, a study published in the February 25th edition of the Journal of the American Medical Association shows.
The study found that 80% of individuals treated with anti-HIV drugs in prison had not obtained a prescription for antiretroviral treatment within 30 days of their release from prison.
US prisons provide important opportunities for HIV testing and the provision of antiretroviral therapy for people going through the criminal justice system in that country. Many inmates are tested for HIV for the first time when incarcerated and it is estimated that approximately 75% of HIV-positive prisoners start HIV treatment whilst behind bars.
There is concern, however, that the challenges that many former inmates encounter after their release from prison mean that many individuals discontinue their HIV treatment. This can involve the risk of HIV disease progression, the emergence of resistance, or the onward transmission of HIV.
To gain a better understanding of the extent to which prisoners interrupt their HIV treatment following their release from incarceration, researchers from Texas performed a retrospective analysis on released prisoners to see how many of them obtained antiretroviral drugs in the 60 days after their release from jail.
The study population involved 2115 HIV-positive individuals released from a Texan prison between 2004 and the end of 2007. Most (83%) were men, 60% were African-American and 18% had been diagnosed with a major psychiatric disorder.
HIV treatment was initiated in prison in accordance to US guidelines. At the time of release, 45% of patients had a CD4 cell count above 350 cells/mm3, and 55% had an undetectable viral load (below 50 copies/ml).
In order to obtain free HIV treatment after release from prison, individuals were required to submit an application to the Texas AIDS Drug Assistance Program (ADAP). A total of 55% of individuals were provided with assistance completing this application.
On release from prison, the ex-prisoners were provided with ten days of HIV treatment. The investigators found that only 5% of individuals filled a new prescription within the first ten days following their release from incarceration. A prescription for antiretroviral drugs was dispensed to 18% of individuals within 30 days of their release and to 30% within 60 days of their release.
Of the 1090 former prisoners who filled their first prescription for antiretroviral drugs after their release from prison, 88% filled a second prescription.
These results meant that only 2% of individuals obtained antiretroviral drugs after their release from prison in time to avoid a treatment interruption. A total of 12% of individuals experienced a treatment interruption of between one and 30 days, 10% an interruption of between 31 and 90 days, and 3% an interruption that lasted between three months and one year. Furthermore, 3% of individuals never filled a prescription for HIV treatment.
The investigators then looked at the factors associated with obtaining HIV treatment within ten, 30 and 60 days of release from prison.
Factors associated with not obtaining antiretroviral drugs within ten days of release included:
- Race – Hispanic (p = 0.008) and African-American (p
- Viral load – patients with a detectable viral load were less likely to obtain anti-HIV drugs than those with an undetectable viral load (p
- Help with the ADAP application – patients not helped with their ADAP application were less likely to obtain HIV treatment.
These factors remained significant for 30 days, although by 60 days race had ceased to be important.
“We found that 90% or more of released inmates did not fill a prescription for antiretroviral therapy medication soon enough to avoid treatment interruption and that more than 80% did not fill a prescription within 30 days of release. These exceedingly high rates of treatment interruption suggest that most inmates face significant administrative, socioeconomic, or personal barriers to accessing antiretroviral therapy when they return to their communities,” comment the investigators.
They conclude, “adequately addressing a public health crisis of this scale and complexity will require carefully co-ordinated efforts between academic institutions, the criminal justice system, and public health agencies.”
Baillargeon J et al. Accessing antiretroviral therapy following release from prison. JAMA 301: 848-857, 2009.