A new monitoring approach developed by researchers from The Miriam Hospital could close a major gap by providing the ability to track whether HIV-positive prisoners are getting the community-based HIV care they need once they are released.
Reporting in the journal Virulence, researchers say this new tool could play a major role in preventing the spread of the disease and could guide future strategies to improve the quality of care for prisoners, a population disproportionately affected by HIV.
“Jails and prisons are an opportunity to diagnose and treat inmates with HIV, but when they are released, their care is suddenly interrupted, and many former prisoners may have limited or no access to treatment for many months, or they may stop taking their HIV medications altogether,” says lead study author Brian Montague, D.O., of The Miriam Hospital. “This is a huge public health problem, because during this treatment gap, ex-offenders are not only putting their own health in jeopardy, but they are also more likely to infect others.”
Although there is a strong national push for continuity of care for HIV-positive inmates transitioning to their communities, Montague says there is no systematic framework to evaluate how successfully these individuals are being connected to and actually receiving care once they are released.
“We need to understand the various factors that influence access to post-release HIV care as well as the quality of care being provided if we want to move the needle on the HIV epidemic,” he says. “The method we’ve developed can be done systematically with existing data and, when validated, could guide future strategies to improve the quality of care for this vulnerable population.”
Currently, an estimated 1.1 million people in the United States are infected with HIV. HIV/AIDS rates in jails or prisons are three times greater than that of the general population: each year, an estimated one in seven individuals infected with HIV passes through a correctional facility, suggesting that there is a disproportionate number of HIV-positive individuals in the criminal justice system. For many individuals, incarceration is the only time they will access HIV testing, education, counseling and treatment services.
During the transition back to the community, recently released prisoners face a number of challenges, including finding employment, securing housing and, in many cases, coping with substance use and mental health problems. All of these obstacles represent a possible barrier to HIV care.
In their report, Montague and colleagues from the University of North Caroline at Chapel Hill, Abt Associates, Inc. and the University of Texas Medical Branch studied clinical data from the Ryan White HIV/AIDS Program to track if HIV-positive ex-offenders are receiving community follow-up care. Ryan White is the only federal program designed to support services for people with HIV/AIDS and is a major source of care for inmates who have been recently released. Starting in 2009, all Ryan White funded HIV/AIDS care programs were required to submit encrypted, client-level data to the federal government to provide a clear picture of all individuals receiving care who receive care from Ryan White providers throughout the nation.
Researchers say linking Ryan White data with corrections release data could be the key to developing a system that can measure the level and quality of follow-up HIV care in the community, such as the time it takes former prisoners to schedule their first appointment and their health status at their first clinic visit. The system proposed uses a confidential identifier developed for Ryan White data reporting to link the release data sets with clinical data from community providers. The metrics developed from this linkage can also be used to monitor quality improvement and program development, allowing for the ability to share best practices among community providers and care sites.
Montague says the system is currently being validated in Rhode Island. Preliminary data from this study suggests the metrics are able to identify, with promising accuracy, the portion of prisoners being linked to care following release. If proven successful, this strategy for linking correctional release and clinical data could be applied to other data sets, such as Medicaid or state HIV viral load surveillance data, to evaluate service linkage across a variety of care environments. The researchers believe this will be critical particularly in light the expected changes in health coverage under the Affordable Care Act.
“It’s important that both medical providers and correctional care systems recognize the importance of supporting the transition to community care and retaining ex-offenders in HIV treatment,” he said. “By identifying best practices and encouraging their implementation on a broader scale, we can reduce the risks that prisoners and recently released inmates face when they re-enter the community, which could have a considerable impact on the incidence of HIV in this country.”
The research was one of 12 grants awarded by the National Institute on Drug Abuse, part of the National Institutes of Health (NIH), in 2010 as part of its Seek, Test, and Treat: Addressing HIV in the Criminal Justice System. It is the NIH’s largest research initiative to date to aggressively identify and treat HIV-positive inmates, parolees and probationers and help them continue care when they return to their home communities.
Study co-authors include Josiah D. Rich, M.D., and Amy Nunn, Ph.D., from The Miriam Hospital and The Warren Alpert Medical School of Brown University; Traci Green, MSc, Ph.D. from Rhode Island Hospital and Alpert Medical School; David L. Rosen, Ph.D., and David A. Wohl, M.D., from the University of North Carolina at Chapel Hill; Liza Solomon, Ph.D., and Michael Costa from Abt Associates Inc.; Jacques Baillargeon, Ph.D., from the University of Texas Medical Branch; and David P. Paar M.D., from SUNY Upstate Medical University, all on behalf of the LINCS Study Group. Montague, Nunn and Rich are also associated with the Center for Prisoner Health and Human Rights, based at The Miriam Hospital.
The principal affiliation of Brian T. Montague, D.O., is The Miriam Hospital (a member hospital of the Lifespan health system in Rhode Island), and direct financial and infrastructure support for this project was received through the Lifespan Office of Research Administration. Dr. Montague is also an assistant professor of medicine at The Warren Alpert Medical School of Brown University.