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Brief incarceration interrupted ART, led to virologic failure in IDUs
Westergaard RP. Clin Infect Dis. 2011; 53:725-731.
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Recent data suggest the risk for virologic failure increased sevenfold among HIV-infected injection drug users who were briefly incarcerated.
“Efforts should be made to ensure continuity of care both during and after incarceration to improve treatment outcomes and prevent viral resistance in this vulnerable population,” Ryan P. Westergaard, MD, MPH, of the University of Wisconsin School of Medicine and Public Health, and colleagues wrote in the study.
Westergaard and colleagues set out to determine whether incarceration and subsequent release were associated with virologic failure among HIV-infected injection drug users (IDUs) previously who were successfully treated with antiretroviral therapy ART.
The cohort included participants from the prospective, community-based cohort study ALIVE, who received ART between 1998 and 2009, and successfully achieved an HIV RNA level below the limit of detection (less than 400 copies/mL). Patients were followed for the development of virologic failure and whether they reported any brief incarcerations (admission to a correctional facility for more than 7 days but less than 30 days).
Of the 437 participants who achieved undetectable HIV RNA during at least one study visit, 69% were male; 95% were black; 40% reported at least one incarceration during follow-up; and 26.3% experienced virologic failure after a median of 6 months.
After adjusting for demographic characteristics, drug use and HIV disease stage, the researchers reported that brief incarceration was strongly associated with virologic failure (OR=7.7; 95% CI, 3.0-19.7), whereas incarceration lasting more than 30 days was not (OR=1.4; 95% CI, 0.8-2.6).
“Brief incarceration, which likely represents jail stays, was the strongest predictor of virologic failure of all the covariates that we considered, increasing the odds of failure by more than sevenfold,” the researchers wrote. “This finding is consistent with the hypothesis that jail stays, rather than imprisonment, confer the highest risk of interruption of HIV care and subsequent treatment failure.”
Disclosure:This study was supported by NIH, National Institutes of Drug Abuse (Grants R01DA04334 and R01DA12568); and National Center for Research Resources (grant KL2RR025006-03 to R. W.).
The study conducted by Westergaard and colleagues has provocative findings – that incarceration was a frequent disruptor of HIV care for a cohort studied followed from 1998-2009. In the US, HIV-infected individuals have a high rate of incarceration. While the authors cite a paper based on 1997 data estimating 22% to 31% of HIV-infected Americans passed through a correctional facility that year, by 2006, the percentage had likely decreased to 16.9% – still a very high portion of the US epidemic. The median length of stay in a correctional facility in the Westergaard study was 119 days. These short stays likely represented stays in jails, which are short-term correctional facilities, as opposed to prisons. Indeed, 95% of releasees in the US leave jails rather than prisons. Interventions to enhance linkages to HIV care in the community after release from jail are needed. Since 2007, HRSA has funded a Special Project of National Significance (SPNS) to develop model programs of “Enhanced Linkages.” Ten demonstration sites have developed interventions to increase the likelihood that jail releasees with HIV access care post-discharge. Results are pending but may shed light on “what works” for this vulnerable population.
– Anne Spaulding, MD, MPH
Rollins School of Public Health and School of Medicine, Emory University
Disclosure: Dr. Spaulding reports no relevant financial disclosures.