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Three-quarters of HIV Positive Prisoners Decrease Adherence to Antiretroviral Therapy after Release

A large proportion of HIV positive former prisoners take their antiretroviral therapy (ART) irregularly after they are released from incarceration, thereby raising the risk of treatment failure and disease progression, according to a study in the September 22, 2009 issue of the open-access online journal PLoS One.

Nitika Pant Pai from McGill University Health Center and colleagues conducted a retrospective analysis of more than 500 inmates with HIV as they went in and out of jail in San Francisco over a 9 year period between 1996 and 2005.

"Jails are an important venue of HIV care and a place for identification, treatment and referral for care," the study authors wrote as background. In the San Francisco County jail, HIV positive inmates are offered ART, but many stay on treatment only while incarcerated.

Most inmates (85%) were men and about half (51%) were African-American.
All were incarcerated at least twice (median 5 times), and the mean sentence period was about 3 months.

Inmates were categorized by patterns of ART use:

• Continuous ART (both in and out of jail);
• Intermittent ART (only in jail);
• Never on ART (eligible according to U.S. treatment guidelines, but refused therapy).

Results

Among 512 inmates followed for 9 years:

• 388 (76%) were on intermittent ART;
• 79 (15%) were on continuous ART;
• 45 (9%) never on ART.

Patients who took ART continuously were older on average than those who interrupted or stopped treatment (38 vs 35 years), and were followed longer in jail before release.

In a linear mixed model analysis, inmates on intermittent ART were 1.43 times more likely to have higher HIV viral load than inmates on continuous ART.

Inmates never on ART were 2.89 times more likely to have higher viral load compared with those on continuous treatment.

With regard to CD4 cell count, inmates on intermittent ART lost 1.60 cells/mm3 more per month, and never-treated individuals lost 1.97 cells/mm3 more per month, compared with people on continuous treatment.

Inmates in the continuous ART group, in contrast, gained 0.67 cells/mm3 per month.

Based on these findings, the study authors concluded, "Continuous ART therapy in jail inmates benefits CD4 cell counts and control of viral load especially compared to those who never took ART."

"Although jail inmates on intermittent ART were more likely to lose CD4 cells and experience higher viral load over time than those on continuous ART, CD4 cell loss was slower in these inmates as compared to inmates never on ART," they continued. "Further studies are needed to evaluate whether or not intermittent ART provides some benefit in outcome if continuous ART is not possible or likely."

In their discussion of the findings, the researchers recommended that in order to maintain the benefits of ART outside jails, "effective community transition and prison release programs that focus on antiretroviral therapy management along with linkages to community providers, stabilization of housing, and community based support services are needed."

Division of Clinical Epidemiology, Division of Infectious Diseases, McGill University Health Center, Montreal, Canada; Forensic AIDS Project, Department of Public Health, San Francisco, CA: Department of Epidemiology & Biostatistics, McGill University, Montreal, Canada; Division of Epidemiology, University of California at Berkeley, Berkeley, CA: University of California at San Francisco, Positive Health Program, San Francisco General Hospital, San Francisco, CA.

10/30/09

Reference
NP Pai, M Estes, EE Moodie, and others. The Impact of Antiretroviral Therapy in a Cohort of HIV Infected Patients Going in and out of the San Francisco County Jail. PLoS One 4(9):e7115. September 22, 2009. (Free full text