Criminal justice-involved populations are disproportionately affected by HIV. Each year, in the U.S., 150,000 people living with HIV leave a correctional facility and likely don’t receive HIV medical services and treatment. Marginalized populations are at increased risk of both HIV acquisition and incarceration, and this dual risk is amplified among communities of color.
The 2022–2025 HIV National Strategic Plan was released in December 2021 by the White House Office of National AIDS Policy, which had been disbanded by the previous administration. The updated Strategic Plan recognizes structural racism as a driver of HIV outcomes, emphasizes the role of harm reduction services in the national response to HIV, and includes objectives to increase the capacity of correctional settings to diagnose and treat HIV. However, the plan overlooks the role of HIV prevention strategies within correctional settings. Two such evidence-based strategies (the most effective based on research)—medication for opioid use disorder (MOUD) and HIV pre-exposure prophylaxis (PrEP)—are the focus of this article.
Prevention after being detained
Ending the HIV epidemic will require a comprehensive plan to prevent HIV among people most impacted by the criminal justice system. Besides the HIV National Strategic Plan—which serves as a roadmap for the Department of Health and Human Services’s cross-agency initiative to reduce new HIV infections by 90 percent by 2030—there have been some efforts to understand and address the HIV epidemic in the criminal justice system. In 2009, the Centers for Disease Control and Prevention (CDC) released HIV testing and reentry guidance1 for correctional settings. Two national multi-site trials provided evidence to support HIV testing in correctional settings and linkage to community HIV care services post-release.
The EnhanceLink2 Project was a 5-year (2007–2012) special initiative funded by the Human Resources and Services Administration (HRSA) to evaluate approaches to link people living with HIV (PLWH) released from incarceration to community HIV care. EnhanceLink included 10 jails, and each developed their own approach that included jail-based HIV testing and case management for pre-release planning and post-release continuity of care. Evaluation of the EnhanceLink found that jail HIV testing and reentry services were feasible and cost-effective approaches to reduce HIV transmission.
The HIV Services and Treatment Implementation in Corrections trial,3 funded by the National Institute on Drug Abuse, evaluated a process improvement intervention to improve HIV services in 14 jails and prisons. Again, the trial provided evidence that HIV testing, treatment, linkage, and prevention services are feasible in correctional settings, although the intervention was only found to be effective in improving prevention services.
In 2020, HRSA’s Ryan White HIV/AIDS Program4 convened an expert panel to address the needs of PLWH in prisons and jails, highlighting the importance of access to medication during incarceration and linkages to community providers at release. Despite these efforts, in a national survey,5 only 14 percent of state prisons and 30 percent of jails met CDC best practices for HIV testing, and only 19 percent of state prisons and 17 percent of jails met CDC best practices for discharge planning.
Jails and prisons are the only settings in which courts have recognized a constitutionally protected right to health care in the U.S. Although the criminal justice system has historically failed to deliver adequate health care, incarceration may be a platform6 to improve outcomes among populations most affected by the twin epidemics of incarceration and HIV. Implementing evidence-based HIV prevention strategies in correctional settings is key to preventing HIV transmission among marginalized communities.
Populations at risk for acquiring HIV are disproportionately affected by the criminal justice system
Transgender women, Black women, Black men who have sex with men,7 and people who inject drugs are disproportionately impacted by the criminal justice system and identified as priority populations by the HIV National Strategic Plan. The contribution of incarceration to the HIV epidemic is most profound among low-income Black communities and is a stark example of how structural racism leads to worse health outcomes.
Although Black Americans are less likely to use drugs8 compared to their White counterparts, Black Americans are five times more likely9 to be incarcerated for a drug offense. Nearly one in five10 transgender women experience incarceration in their lifetime, and Black transgender women are three times11 more likely to be incarcerated compared to their White counterparts. While incarcerated, more than one-third12 of Black transgender women report being sexually assaulted.
The HIV epidemic in the U.S. is concentrated among Black men who have sex with men, who have a lifetime risk of HIV diagnosis of one in two,13 compared to one in 11 among their White counterparts. Racial disparities are also stark among transgender women, with an estimated HIV prevalence of 44.2 percent14 among Black transgender women compared to 6.7 percent among their White counterparts. More than half15 of Black men who have sex with men are likely to have experienced incarceration in their lifetime, and criminal justice involvement among Black men may also contribute to HIV acquisition among Black cisgender women16 in the community setting. Incarceration disrupts social support networks and jeopardizes post-release employment and housing. A criminal record compounds the discrimination and lack of opportunity already experienced by racial, sexual, and gender minoritized populations.
The criminal justice system has been a cornerstone of structural racism17 since the end of the Jim Crow era and has significantly contributed to racial inequity in HIV outcomes. The lifetime risk of HIV diagnosis18 among Black men is one in 20 and among Black women is one in 48, compared to one in 132 for White men and one in 880 for White women. Strengthening HIV services in correctional settings will not only improve HIV outcomes among priority populations identified by the HIV National Strategic Plan but will also advance the overarching goal of reducing health inequity. To recognize racism as a serious public health threat, the updated HIV National Strategic Plan must demonstrate a commitment to people and communities who disproportionately experience incarceration.
Medication for opioid use disorder
More than one in six19 male inmates, and one in four female inmates, regularly use opioids prior to incarceration, and the risk of fatal overdose increases up to 129-fold20 among recently released prisoners. The Bureau of Justice Statistics21 estimates that approximately 60 percent of people who are incarcerated in the U.S. meet criteria for substance use dependence or abuse, yet less than 1% receive MOUD while incarcerated. Current evidence22 supports providing MOUD in correctional settings; starting MOUD during incarceration23 can significantly reduce the risk of overdose, reduce injection-related HIV risk behaviors, and increase community treatment engagement post-release.24 Providing MOUD prior to release and incorporating MOUD into re-entry programs has been associated with HIV viral load suppression25 after re-entry, improving the lives of PLWH who have been incarcerated and decreasing the risk of transmission among communities disproportionately impacted by incarceration.
Despite such evidence and the recommendations by federal agencies31 within the Department of Health and Human Services and the National Academies of Science, Engineering, and Medicine,32 the importance of MOUD in correctional settings is missing from the HIV National Strategic Plan. Recently the Centers for Disease Control and Prevention33 released a report describing an alarming increase in overdose deaths among Black adolescents and adults. By omitting correctional MOUD, the HIV National Strategic Plan reinforces inequity in HIV outcomes among Black communities more likely to experience incarceration and threatens to stymie efforts to end the HIV epidemic.
In its report “Use of Medication-Assisted Treatment for Opioid Use Disorder in Correctional Settings,”40 the Substance Abuse and Mental Health Services Administration41 details six areas to enhance delivery of MOUD in the criminal justice system: 1) overcoming stigma; 2) addressing threats to safety and security; 3) advancing staff knowledge and skills; 4) covering the cost of MOUD; 5) establishing MOUD providers in correctional institutions; and 6) building partnerships with community-based treatment. The report includes several examples42 of successful MOUD programs in the criminal justice system across county and state settings that could have informed the HIV National Strategic Plan.
Pre-exposure prophylaxis
HIV transmission during incarceration43 is more likely to occur among Black inmates and men who have sex with men, and it is also associated with prison tattooing. Despite the elevated risk of HIV transmission within jails and prisons, most inmates do not have access to methods to prevent HIV infection, such as clean needles, condoms, and, vitally, daily PrEP,44 which prevents up to 99 percent of HIV transmission from sex and more than 70 percent of HIV transmission from intravenous drug use. In fact, PrEP has yet to be implemented45 in any correctional setting. Barriers to implementing PrEP in correctional settings may include lack of knowledge among clinicians, HIV-related stigma in correctional settings,46 and inability of some facilities to run laboratory tests for HIV, kidney function, hepatitis B antibodies, and other indicators of disease.
Fortunately, best practices for corrections-based provision of PrEP are being developed.47 Lauren Brinkley-Rubinstein and colleagues48 detail a path toward implementing PrEP for people involved in the criminal justice system that includes providing training to criminal justice-based clinicians, developing standards and protocols specific to criminal justice settings, and identifying best practices within correctional facilities. In a study49 evaluating PrEP knowledge among 417 inmates, only 12 percent knew about PrEP, but 25 percent were interested in initiating PrEP; thus, a clear starting point for implementing medical HIV prevention within the criminal justice system is HIV education.
If integrated into the criminal justice system, the benefits of PrEP may continue post-release. Recently released people who inject drugs50 are more likely to acquire HIV. The communities that inmates return to post-release51 experience higher rates of HIV incidence. Black Americans face further barriers to HIV prevention and are seven times52 less likely to have a prescription for PrEP compared to White Americans.
Next-generation PrEP formulations, such as long-acting injectable cabotegravir, could be an important approach to providing HIV prevention during community reentry. However, people involved in the criminal justice system will not benefit from advances in PrEP if implementation of HIV prevention strategies within jails and prisons is not a policy priority.
The roadmap to ending the HIV epidemic goes through jails and prisons
Charting the course for ending the HIV epidemic must include county and state correctional facilities as stakeholders to successfully implement HIV prevention programs in jails and prisons. Non-medical HIV prevention strategies, such as condoms and clean needles, are supported by decades of evidence but have failed to become widely available in the criminal justice system. Without federal support and funding, HIV prevention strategies, such as MOUD and PrEP, will meet the same fate.
More than a decade53 of research has demonstrated the feasibility and efficacy of HIV prevention in correctional settings. Today, incarceration continues to play a central role in accelerating the HIV epidemic. Failing to support evidence-based HIV prevention strategies in the criminal justice system reinforces racial inequity in HIV outcomes.
The updated HIV National Strategic Plan, which will define federal HIV policy through 2025, has opened the door to implementing HIV prevention services in jails and prisons by including an objective focused on increasing the capacity of correctional settings to diagnose and treat HIV. However, an additional step must now be taken to support the evidence-based implementation of PrEP and MOUD in correctional settings. Federal agencies such as HRSA or CDC should update their guidelines to incorporate PrEP and provide recommendations for integrating MOUD into HIV treatment and prevention services in correctional settings. Additionally, the Biden administration and Congress could support increased funding for implementation of HIV treatment and prevention in the criminal justice system.
The challenge of implementing MOUD and PrEP across the diversity of U.S. correctional settings is formidable and will require robust leadership, expertise, funding, and partnership at the federal, state, and local levels. The scope and suffering of the HIV epidemic demands action, and we must use every tool and strategy at our disposal.
Federal Policy
Despite the oversight in the HIV National Strategic Plan, since the Affordable Care Act was enacted there has been increasing momentum in federal legislation to strengthen access to medication for opioid use disorder (MOUD) in correctional settings. People who are incarcerated are subject to Medicaid and Medicare’s inmate exclusion policy, which prohibits the use of federal funds to provide medical care in correctional settings. However, in 201626 the Centers for Medicaid and Medicare (CMS) published guidance for state Medicaid agencies to suspend, rather than terminate, Medicaid eligibility and benefits for people who are incarcerated, as well as provide screening and enrollment services during a period of incarceration. The 2018 SUPPORT Act27 prohibited the termination of Medicaid eligibility for juveniles, and included provisions to convene stakeholders to develop best practices for providing MOUD in correctional settings. To facilitate the implementation of the SUPPORT Act, CMS published further guidance28 that acknowledged the inmate exclusion policy as detrimental to continuity of care. Last year, there was bipartisan support for the Medicaid Reentry Act of 202129 that would authorize Medicaid to reimburse healthcare services in the last 30 days of incarceration and strengthen reentry services. Unfortunately, the act was a casualty of Congress’s failure to pass President Joe Biden’s Build Back Better Bill. This past February the Biden administration released a statement30 to establish a Medicare special enrollment period of six months following release from incarceration. The HIV National Strategic Plan fails to leverage these federal policy initiatives to support improving correctional HIV services.
HIV Reentry Services
Federal efforts to strengthen MOUD in correctional settings have motivated policy change to improve reentry services. The updated HIV National Strategic Plan, however, seems to be out-of-sync with these efforts, and misses an opportunity to elevate the importance of improving HIV reentry services on the national stage. Without HIV reentry services, gains made in correctional settings, such as achieving viral load suppression and increased linkage and retention in HIV care, are lost upon release.34 The consequences can be fatal. In the year following release from incarceration, PLWH have a seven-times greater risk of death35 compared to the general population. Most of those deaths, attributed to HIV/AIDS, are preventable with antiretroviral therapies (ART). Unfortunately, a study36 of 2015 PLWH released from incarceration found that only 18% filled a prescription for ART within 30 days of release. Another study37 of 1,350 PLWH released from incarceration found that 34% were linked to HIV care within 30 days of release. However, a recent systematic review38 identified 16 controlled clinical trials aimed at improving post-incarceration ART adherence and engagement in HIV care. Promising approaches included intensive case management, peer navigation, financial incentives, and providing cell phones. Without engagement in care or receipt of antiretroviral therapies, PLWH released from incarceration are more likely to have detectable HIV viral loads that can lead to community HIV transmission. In a study39 of nine U.S. cities, a 10-person increase in prison release rates within a given ZIP code increased the overall 5-year HIV diagnosis rate by four percent. The HIV National Strategic Plan recognizes barriers to care experienced by people released from correctional facilities, but does not acknowledge this evidence base for HIV reentry services and neglects to commit specific strategies to improving HIV reentry services.
Daniel Teixeira da Silva, MD, MSHP is a general internist and pediatrician, post-doctoral fellow in the National Clinician Scholars Program at the University of Pennsylvania, and associate fellow at the Leonard Davis Institute. His research focuses on structural and psycho-social determinants of HIV seroconversion, implementation of HIV prevention services, and engagement in care among people living with HIV or at increased risk for HIV seroconversion. He aims to improve health care services for marginalized populations and address policy gaps that reinforce inequity in HIV seroconversion, with a focus on the criminal justice system.
Chethan Bachireddy, MD, MSHP is a general internist, HIV specialist, associate clinical professor at Virginia Commonwealth University, an adjunct senior fellow at the Leonard Davis Institute of Health Economics, and the chief medical officer at Virginia Medicaid.
Reprinted with permission.
Adapted from an article that originally appeared on healthaffairs.org.