Enrollment in Outpatient Care Among Newly Released Prison Inmates with HIV Infection

The incidence of human immunodeficiency virus (HIV) infection in the U.S. prison population is estimated to be more than three times that of the general population.1–3 For many HIV-infected inmates, incarceration provides opportunities for treatment, counseling, and education that were not available to them in the community.4,5 A substantial number of these individuals initiate HIV-related care for the first time during their incarceration and demonstrate high levels of adherence to their treatment regimens.6,7 Several studies have found that the provision of antiretroviral therapy (ART) in the correctional setting is associated with highly positive immunologic and virologic outcomes.8,9 As an example, Springer et al. found that nearly 60% of 1,866 Connecticut prisoners who received ART had achieved an undetectable viral load by the end of their incarceration period.8 Preliminary evidence suggests that the benefits of receiving ART during incarceration are generally not sustained after release into the community. In two studies of state prisoners who received ART while incarcerated, release from prison was associated with deleterious changes in both HIV ribonucleic acid (RNA) levels and CD4 lymphocyte counts.8,9 The investigators were unable to establish whether these post-release outcomes were a result of suboptimal medication adherence vs. complete discontinuation of ART; however, a study of more than 2,000 inmates treated with ART while incarcerated found that only 30% filled an initial prescription for ART medications within 60 days of their release.10 Still, little information is available about the extent to which released inmates initiate community-based HIV-related outpatient care or the specific factors associated with successful linkage to such clinical care.11 Most of the available literature is limited primarily to descriptions of the components of continuity-of-care programs for soon-to-be-released HIV-positive inmates.12–14 To address this research deficit, we conducted a retrospective cohort study of 1,750 HIV-infected inmates released from the Texas prison system between 2004 and 2007. Our objectives were to determine the proportion of released inmates who enrolled in a community-based HIV outpatient clinic during the first 90 days after release and to identify variables associated with utilization of HIV-related care.