Sharon Parker

Multilevel challenges to engagement in HIV care after prison release: a theory-informed qualitative study comparing prisoners’ perspectives before and after community reentry

BackgroundAlthough prison provides the opportunity for HIV diagnosis and access to in-prison care, following release, many HIV-infected inmates experience clinical setbacks, including nonadherence to antiretrovirals, elevations in viral load, and HIV disease progression. HIV-infected former inmates face numerous barriers to successful community reentry and to accessing healthcare. However, little is known about the outcome expectations of HIV-infected inmates for release, how their post-release lives align with pre-release expectations, and how these processes influence engagement in HIV care following release from prison.MethodsWe conducted semi-structured interviews (24 pre- and 13 post-release) with HIV-infected inmates enrolled in a randomized controlled trial of a case management intervention to enhance post-release linkage to care. Two researchers independently coded data using a common codebook. Intercoder reliability was strong (kappa = 0.86). We analyzed data using Grounded Theory methodology and Applied Thematic Analysis. We collected and compared baseline sociodemographic and behavioral characteristics of all cohort participants who did and did not participate in the qualitative interviews using Fisher’s Exact Tests for categorical measures and Wilcoxon rank-sum tests for continuous measures.ResultsMost participants were heterosexual, middle-aged, single, African American men and women with histories of substance use. Substudy participants were more likely to anticipate living with family/friends and needing income assistance post-release. Most were taking antiretrovirals prior to release and anticipated needing help securing health benefits and medications post-release. Before release, most participants felt confident they would be able to manage their HIV. However, upon release, many experienced intermittent or prolonged periods of antiretroviral nonadherence, largely due to substance use relapse or delays in care initiation. Substance use was precipitated by stressful life experiences, including stigma, and contact with drug-using social networks. As informed by the Social Cognitive Theory and HIV Stigma Framework, findings illustrate the reciprocal relationships among substance use, experiences of stigma, pre- and post-release environments, and skills needed to engage in HIV care.ConclusionThese findings underscore the need for comprehensive evidence-based interventions to prepare inmates to transition from incarceration to freedom, particularly those that strengthen linkage to HIV care and focus on realities of reentry, including stigma, meeting basic needs, preventing substance abuse, and identifying community resources.

Retention in care outcomes for HIV pre-exposure prophylaxis implementation programmes among men who have sex with men in three US cities.

Despite the efficacy of pre‐exposure prophylaxis (PrEP) in preventing HIV transmission, few studies have evaluated PrEP use and retention in care outcomes in real‐world settings outside of clinical trials.

Project Power: Adapting an Evidence-Based HIV/STI Prevention Intervention for Incarcerated Women

Incarcerated women are a critical population for targeted HIV/STI prevention programming; however, there is a dearth of evidence-based, genderspecific behavioral interventions for this population. Systematically adapting existing evidence-based interventions (EBIs) can help fill this gap. We illustrate the adaptation of the HIV/STI prevention EBI, Project Safe, for use among incarcerated women and delivery in prisons. Project POWER, the final adapted intervention, was developed using formative research with prison staff and administration, incarcerated and previously incarcerated women, and input of community advisory boards. Intervention delivery adaptations included: shorter, more frequent intervention sessions; booster sessions prior to and just after release; facilitator experience in prisons and counseling; and new videos. Intervention content adaptations addressed issues of empowerment, substance use, gender and power inequity in relationships, interpersonal violence, mental health, reentry, and social support. This illustration of the adaption process provides information to inform additional efforts to adapt EBIs for this underserved population.

A Latent Class Analysis of Risk Factors for Acquiring HIV Among Men Who Have Sex with Men: Implications for Implementing Pre-Exposure Prophylaxis Programs.

Current Centers for Disease Control and Prevention (CDC) guidelines for prescribing pre-exposure prophylaxis (PrEP) to prevent HIV transmission are broad. In order to better characterize groups who may benefit most from PrEP, we reviewed demographics, behaviors, and clinical outcomes for individuals presenting to a publicly-funded sexually transmitted diseases (STD) clinic in Providence, Rhode Island, from 2012 to 2014. Latent class analysis (LCA) was used to identify subgroups of men who have sex with men (MSM) at highest risk for contracting HIV. A total of 1723 individuals presented for testing (75% male; 31% MSM). MSM were more likely to test HIV positive than heterosexual men or women. Among 538 MSM, we identified four latent classes. Class 1 had the highest rates of incarceration (33%), forced sex (24%), but had no HIV infections. Class 2 had <5 anal sex partners in the previous 12 months, the lowest rates of drug/alcohol use during sex and lower HIV prevalence (3%). Class 3 had the highest prevalence of HIV (7%) and other STDs (16%), > 10 anal sex partners in the previous 12 months (69%), anonymous partners (100%), drug/alcohol use during sex (76%), and prior STDs (40%). Class 4 had similar characteristics and HIV prevalence as Class 2. In this population, MSM who may benefit most from PrEP include those who have >10 sexual partners per year, anonymous partners, drug/alcohol use during sex and prior STDs. LCA is a useful tool for identifying clusters of characteristics that may place individuals at higher risk for HIV infection and who may benefit most from PrEP in clinical practice.

Risk Profiles of Women Experiencing Initial and Repeat Incarcerations: Implications for Prevention Programs.

Incarcerated women experience myriad individual, interpersonal, and structural factors leading to arrest and rearrest. This study examined risk profiles of women experiencing initial and repeat incarcerations. The sample included 521 women recruited from two prisons in North Carolina and enrolled in a HIV/STD risk-reduction intervention trial. Variables included socio-demographics, structural/economic factors, sexual and substance use behaviors, STDs, victimization history, and depressive symptoms. Bivariate and multivariable analyses identified risk differences. Compared to women incarcerated for the first time, women with repeat incarcerations reported significantly greater economic instability, substance use and sexual risk behaviors, laboratory-confirmed STDs, and victimization during childhood and adulthood. Multivariable logistic regression found women with repeat incarcerations experienced greater unstable housing, injection drug use, crack cocaine use, concurrent sex partners, and childhood sexual victimization. Findings can inform the development of prevention programs by addressing economic instability, sexual risk, and substance use among women prisoners.

Sexuality, sexual practices, and HIV risk among incarcerated African-American women in North Carolina.

BACKGROUND Women who have been in prison carry a greater lifetime risk of HIV for reasons that are not well understood. This effect is amplified in the Southeastern United States, where HIV incidence and prevalence is especially high among African-American (AA) women. The role of consensual sexual partnerships in the context of HIV risk, especially same-sex partnerships, merits further exploration. METHODS We conducted digitally recorded qualitative interviews with 29 AA women (15 HIV positive, 14 HIV negative) within 3 months after entry into the state prison system. We explored potential pre-incarceration HIV risk factors, including personal sexual practices. Two researchers thematically coded interview transcripts and a consensus committee reviewed coding. RESULTS Women reported complex sexual risk profiles during the 6 months before incarceration, including sex with women as well as prior sexual partnerships with both men and women. Condom use with primary male partners was low and a history of transactional sex work was prevalent. These behaviors were linked with substance use, particularly among HIV-positive women. CONCLUSIONS Although women may not formally identify as bisexual or lesbian, sex with women was an important component of this cohorts sexuality. Addressing condom use, heterogeneity of sexual practices, and partner concurrency among at-risk women should be considered for reducing HIV acquisition and preventing forward transmission in women with a history of incarceration.

Routine HIV Screening in an Urban Community Health Center: Results from a Geographically Focused Implementation Science Program

Objective. CDC has recommended routine HIV screening since 2006. However, few community health centers (CHCs) routinely offer HIV screening. Research is needed to understand how to implement routine HIV screening programs, particularly in medically underserved neighborhoods with high rates of HIV infection. A routine HIV screening program was implemented and evaluated in a Philadelphia, Pennsylvania, neighborhood with high rates of HIV infection. Methods. Implementation science is the study of methods to promote the integration of research findings and evidence into health-care policy and practice. Using an implementation science approach, the results of the program were evaluated by measuring acceptability, adoption, and penetration of routine HIV screening. Results. A total of 5,878 individuals were screened during the program. HIV screening was highly accepted among clinic patients. In an initial needs assessment of 516 patients, 362 (70.2%) patients reported that they would accept testing if offered. Routine screening policies were adopted clinic-wide. Staff trainings, new electronic medical records that prompted staff members to offer screening and evaluate screening rates, and other continuing quality-improvement policies helped promote screenings. HIV screening offer rates improved from an estimated 5.0% of eligible patients at baseline in March 2012 to an estimated 59.3% of eligible patients in December 2014. However, only 5,878 of 13,827 (42.5%) patients who were offered screening accepted it, culminating in a 25.2% overall screening rate. Seventeen of the 5,878 patients tested positive, for a seropositivity rate of 0.3%. Conclusion. Routine HIV screening at CHCs in neighborhoods with high rates of HIV infection is feasible. Routine screening is an important tool to improve HIV care continuum outcomes and to address racial and geographic disparities in HIV infection.

The Path to Implementation of HIV Pre-exposure Prophylaxis for People Involved in Criminal Justice Systems

The criminal justice (CJ)-involved population in the United States (US) is among the most vulnerable to and heavily impacted by HIV [1]. HIV prevalence is three to five times higher among incarcerated populations than in the general population [2] and one in seven people living with HIV (PLH) pass through CJ systems each year [3]. Among racial and ethnic minorities, HIV and incarceration are even more closely intertwined: one of every five HIV-infected black or Hispanic/Latino adults passes through CJ systems annually [4]. Individuals involved in CJ systems experience a confluence of factors at the individual (e.g., substance abuse, mental health issues, childhood abuse), interpersonal (e.g., inconsistent condom use, intimate partner violence exposure), and community level (e.g., housing instability, unemployment, poverty, disengagement from medical services, stigma) that increase their risk of HIV [5–15]. HIV risk is exceptionally high immediately following release from prisons or jails, termed “community re-entry,” when relapse to substance use, discontinuous healthcare engagement, homelessness and under-insurance compounds, and other health disparities [16] Additionally, individuals from populations with an elevated risk of HIV acquisition (i.e., Black men who have sex with men [MSM], people who inject drugs [PWID], commercial sex workers [CSWs]) frequently come into contact with CJ systems [14, 17–21]. These subpopulations that experience intersecting risk, exacerbated by CJ involvement, need to be engaged in HIV prevention interventions. However, traditional HIV prevention approaches alone, such as risk reduction counseling and condom distribution programs, have had limited success with currently and recently incarcerated populations [22, 23]. One possible innovative strategy to address HIV risk during community re-entry is to implement pre-exposure prophylaxis (PrEP) uptake and adherence interventions. Many individuals with recent CJ involvement may be clinically indicated for PrEP due to engaging in high-risk and overlapping sexual and substance use networks. In addition, the World Health Organization has recently introduced the concept of “substantive risk” as a precursor to PrEP initiation. Those at “substantive risk of HIV” include any individuals belonging to a group that has a disproportionate burden of HIV, which includes those with a history of incarceration [22]. Despite these recommendations, PrEP implementation in real-world settings including CJ settings and during community reentry among at-risk populations remains low [24, 25] and, to our knowledge, PrEP linkage is not currently available in any closed CJ settings in the US. PrEP’s optimal impact depends on awareness, acceptability, uptake, and adherence among high-risk groups living in the community. PrEP awareness and acceptability vary (depending on the population) [16], and uptake and adherence to PrEP is influenced by social and structural factors such as access to health services, copayments, social norms, and, for recently incarcerated individuals in particular, an often chaotic postrelease environment. Recently incarcerated individuals often face numerous competing priorities during community reentry such as intersectional stigma, discrimination, loss of * Lauren Brinkley-Rubinstein Lauren_Brinkley@med.unc.edu

African American Clergy Perspectives About the HIV Care Continuum: Results From a Qualitative Study in Jackson, Mississippi

Mississippi has some of the most pronounced racial disparities in HIV infection in the country; African Americans comprised 37% of the Mississippi population but represented 80% of new HIV cases in 2015. Improving outcomes along the HIV care continuum, including linking and retaining more individuals and enhancing adherence to medication, may reduce the disparities faced by African Americans in Mississippi. Little is understood about clergys views about the HIV care continuum. We assessed knowledge of African American pastors and ministers in Jackson, Mississippi about HIV and the HIV care continuum. We also assessed their willingness to promote HIV screening and biomedical prevention technologies as well as efforts to enhance linkage and retention in care with their congregations. Four focus groups were conducted with 19 African American clergy. Clergy noted pervasive stigma associated with HIV and believed they had a moral imperative to promote HIV awareness and testing; they provided recommendations on how to normalize conversations related to HIV testing and treatment. Overall, clergy were willing to promote and help assist with linking and retaining HIV positive individuals in care but knew little about how HIV treatment can enhance prevention or new biomedical technologies such as pre-exposure prophylaxis (PrEP). Clergy underscored the importance of building coalitions to promote a collective local response to the epidemic. The results of this study highlight important public health opportunities to engage African American clergy in the HIV care continuum in order to reduce racial disparities in HIV infection.