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Abstract
Under the Affordable Care Act, up to thirteen million adults have the opportunity
to obtain health insurance through an expansion of the Medicaid program. A great deal
of effort is currently being devoted to eligibility verification, outreach, and enrollment.
We look beyond these important first-phase challenges to consider what people who
are transitioning back to the community after incarceration need to receive effective
care. It will be possible to deliver cost-effective, high-quality care to this population
only if assistance is coordinated between the correctional facility and the community,
and across diverse treatment and support organizations in the community. This article
discusses several examples of successful coordination of care for formerly incarcerated
people, such as Project Bridge and the Community Partnerships and Supportive Services
for HIV-Infected People Leaving Jail (COMPASS) program in Rhode Island and the Transitions
Clinic program that operates in ten US cities. To promote broader adoption of successful
models, we offer four policy recommendations for overcoming barriers to integrating
individuals into sustained, community-based care following their release from incarceration.
Interruption of antiretroviral therapy (ART) during the first weeks after release from prison may increase risk for adverse clinical outcomes, transmission of human immunodeficiency virus (HIV), and drug-resistant HIV reservoirs in the community. The extent to which HIV-infected inmates experience ART interruption following release from prison is unknown. To determine the proportion of inmates who filled an ART prescription within 60 days after release from prison and to examine predictors of this outcome. Retrospective cohort study of all 2115 HIV-infected inmates released from the Texas Department of Criminal Justice prison system between January 2004 and December 2007 and who were receiving ART before release. Proportion of inmates who filled an ART prescription within 10, 30, and 60 days of release from prison. Among the entire study cohort (N = 2115), an initial prescription for ART was filled by 115 (5.4%) inmates within 10 days of release (95% confidence interval [CI], 4.5%-6.5%), by 375 (17.7%) within 30 days (95% CI, 16.2%-19.4%), and by 634 (30.0%) within 60 days (95% CI, 28.1%-32.0%). In a multivariate analysis of predictors (including sex, age, race/ethnicity, viral load, duration of ART, year of discharge, duration of incarceration, parole, and AIDS Drug Assistance Program application assistance), Hispanic and African American inmates were less likely to fill a prescription within 10 days (adjusted estimated risk ratio [RR], 0.4 [95% CI, 0.2-0.8] and 0.4 [95% CI, 0.3-0.7], respectively) and 30 days (adjusted estimated RR, 0.7 [95% CI, 0.5-0.9] and 0.7 [95% CI, 0.5-0.9]). Inmates with an undetectable viral load were more likely to fill a prescription within 10 days (adjusted estimated RR, 1.8 [95% CI, 1.2-2.7]), 30 days (1.5 [95% CI, 1.2-1.8]), and 60 days (1.3 [95% CI, 1.1-1.5]). Inmates released on parole were more likely to fill a prescription within 30 days (adjusted estimated RR, 1.3 [95% CI, 1.1-1.6]) and 60 days (1.5 [95% CI, 1.4-1.7]). Inmates who received assistance completing a Texas AIDS Drug Assistance Program application were more likely to fill a prescription within 10 days (adjusted estimated RR, 3.1 [95% CI, 2.0-4.9]), 30 days (1.8 [95% CI, 1.4-2.2]), and 60 days (1.3 [95% CI, 1.1-1.4]). Only a small percentage of Texas prison inmates receiving ART while incarcerated filled an initial ART prescription within 60 days of their release.
In the United States, 10 million inmates are released every year, and human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) prevalence is several-fold greater in criminal justice populations than in the community. Few effective linkage-to-the-community programs are currently available for prisoners infected with HIV. As a result, combination antiretroviral therapy (cART) is seldom continued after release, and virological and immunological outcomes worsen. Poor HIV treatment outcomes result from a myriad of obstacles that released prisoners face upon reentering the community, including homelessness, lack of medical insurance, relapse to drug and alcohol use, and mental illness. This article will focus on 5 distinct factors that contribute significantly to treatment outcomes for released prisoners infected with HIV and have profound individual and public health implications: (1) adaptation of case management services to facilitate linkage to care; (2) continuity of cART; (3) treatment of substance use disorders; (4) continuity of mental illness treatment; and (5) reducing HIV-associated risk-taking behaviors as part of secondary prevention.
This study obtained comprehensive health information from newly admitted correctional inmates. Interviews were conducted with 1198 inmates on day 3 of their incarceration. Interviewers found a high prevalence of chronic medical and mental health issues, limited access to health care, high rates of infections and sexually transmitted diseases, substantial substance abuse, other unhealthy behaviors and violence, and a strong desire for help with health-related problems. The data document the need to apply the public health approach to correctional health care, including detection and early treatment of disease, education and prevention to facilitate health and behavior change, and continuity of care into the community.
[1
] Kavita Patel ( ) is a fellow at and managing director of the Engelberg Center for
Health Care Reform, Brookings Institution, in Washington, D.C.
[2
] Amy Boutwell is president of Collaborative Healthcare Strategies, in Lexington, Massachusetts.
[3
] Bradley W. Brockmann is executive director of the Center for Prisoner Health and
Human Rights, the Miriam Hospital, in Providence, Rhode Island.
[4
] Josiah D. Rich is a professor of medicine and epidemiology at Brown University and
director and cofounder of the Center for Prisoner Health and Human Rights, the Miriam
Hospital.
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