Importance of PrEP for People Involved in Criminal Justice Systems

Adults involved in the criminal justice systems (ICJS) are significantly more likely to be diagnosed with HIV than people in the general population.^1-3 Pre-exposure prophylaxis (PrEP), if taken consistently, reduces the risk for HIV transmission by up to 92% in high-risk populations, which includes inmates and adults under correctional supervision.^1,3,4 Despite the clear benefits of PrEP, many people at high risk for HIV infection are not familiar with or do not have access to PrEP.^2,5 In addition, some physicians who serve high-risk patients lack information about PrEP or are uncomfortable discussing it with their patients.^6,7 In 2015, member states of the United Nations unanimously adopted the goal of ending AIDS by 2030.⁸ Achieving such an ambitious goal will partly depend on raising awareness of the risk for HIV transmission among adults ICJS and other populations with the most risk and increasing uptake of PrEP to reduce the rate of new infections.

Burden of HIV in People ICJS

Globally, almost 400,000 inmates are living with HIV, which includes approximately 18,000 adults incarcerated in US state and federal prisons.^1,9 According to the Centers for Disease Control and Prevention (CDC), inmates in state and federal prisons are 5 times more likely to have HIV than people who are not incarcerated.² Lauren Brinkley-Rubinstein, PhD, an assistant professor of social medicine at the University of North Carolina in Chapel Hill and a core faculty member of the UNC Center for Health Equity Research, studies the intersection between incarceration and HIV. In an interview with Infectious Disease Advisor, Dr Brinkley-Rubinstein said there are various reasons why people ICJS have an increased risk for HIV infection, and that some, such as drug use, stigma, and poverty, are “shared risk factors for both criminal justice involvement and HIV acquisition.” Other risk factors in this cohort include mental health issues, a history of childhood or partner abuse, inconsistent condom use, unemployment, housing instability, and being disengaged from medical services.¹⁰

Incarceration exacerbates HIV risk. “For instance, individuals with a history of incarceration have been shown to be more likely to share needles with fellow injectors and engage in increased risky sexual behavior postrelease,” noted Dr Brinkley-Rubinstein. In the United States, the intersection between HIV and incarceration appears even stronger for racial and ethnic minorities.¹⁰ For example, black people make up 12% of the US population but account for 33% of the prison population.¹¹ Among jailed populations, black men are 5 times as likely and black women are at least twice as likely to have an HIV diagnosis than their white counterparts.² Rates of incarceration and HIV infection in the United States are also higher for Latino men than for white men.^2,12

Although adults ICJS have a higher risk for HIV infection, “research has shown that most transmission of HIV happens in the community, and very little transmission actually occurs in correctional facilities,” stated Dr Brinkley-Rubinstein. The mass incarceration of black men and incarceration’s positive correlation with HIV risk may partly explain why black women make up a disproportionate share of new HIV infections in women,¹³ despite being less likely to engage in high-risk behaviors for HIV infection.¹⁴

Preventing HIV Transmission Postrelease

The CDC recently reported that in 2015, an estimated 1.1 million Americans (500,000 African-Americans, 300,000 Latinos, and 300,000 whites) had a substantial risk for HIV and could have benefited from PrEP, yet only 90,000 prescriptions for PrEP were filled.¹⁵ Looking at PrEP prescriptions filled at retail or mail order pharmacies in 2015, the CDC found that 14,600 prescriptions were filled for African Americans or Latinos compared with 42,000 for whites. The CDC and the World Health Organization recommend PrEP for populations at substantial risk of acquiring HIV infection,^10,16 which implicitly includes persons ICJS. The CDC recommends tenofovir monotherapy or Truvada (Gilead, Foster City, CA), given once daily.¹⁶ In a randomized trial that compared PrEP vs placebo in men who have sex with men, treatment was associated with a 44% reduction in the incidence of HIV (95% CI, 15%-63%; P =.005).¹⁷ Another trial randomly assigned HIV-serodiscordant heterosexual couples to a PrEP regimen or placebo for 36 months.¹⁸ Compared with placebo, tenofovir monotherapy reduced the risk for HIV transmission by 67% (95% CI, 44%-81%; P <.001), and the combination of tenofovir-emtricitabine reduced transmission risk by 75% (95% CI, 55%-87%; P <.001).¹⁸ Risk reduction was similar for HIV-negative men and women. Limited evidence also associates tenofovir monotherapy with a reduced risk for HIV transmission among HIV-negative users of injectable drugs.¹⁹

Screening inmates for HIV is an important first step in determining whether they are eligible for PrEP. Guidelines from the CDC recommend correctional facilities offer all inmates an HIV test at the time of incarceration, during incarceration, and immediately before release.² Federal law and most states do not require correctional facilities to provide HIV testing per the CDC guidelines, however, and financial constraints may prevent facilities from doing so.^2,20 The stigma of HIV and laws criminalizing HIV exposure may also discourage some people ICJS from getting tested for HIV or undergoing PrEP screening.²¹ “There has to be more thought put into how best to implement PrEP screening procedures in correctional facilities….[M]any incarcerated people may understandably be unwilling to disclose risky behavior to correctional administrators,” Dr Brinkley-Rubinstein said.

Once an inmate’s HIV status has been ascertained, HIV prevention interventions are needed that target people ICJS and the subpopulations they intersect with after release. “Important strategies to consider for people ICJS include linkage to antiretroviral therapy for those who are HIV positive and linkage to PrEP postrelease and/or beginning PrEP before people are released so they build up adherence,” Dr Brinkley-Rubinstein added. Lack of awareness or lack of acceptance of PrEP among inmates, clinicians, and high-risk groups living in the communities inmates return to after release is an obstacle to increasing PrEP uptake.¹⁰ Dr Brinkley-Rubinstein said an obstacle specific to improving PrEP uptake and adherence in the criminal justice-involved population is that “issues related to health may be a low priority during community re-entry due to the fact that people have many, many responsibilities to take care of postrelease.” She said necessities such as reestablishing relationships and finding a job or a place to live take priority over PrEP for inmates after release. “That’s why linkage to other services that address other issues created by incarceration, such as lack of access to housing or employment, should be an important part of any HIV-related postrelease intervention,” she explained.

References

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2. Centers for Disease Control and Prevention. HIV by group: HIV among incarcerated populations. https://www.cdc.gov/hiv/group/correctional.html. Updated February 12, 2018. Accessed May 8, 2018.
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4. Centers for Disease Control and Prevention. HIV risk and prevention: pre-exposure prophylaxis (PrEP). https://www.cdc.gov/hiv/risk/prep/index.html. Updated April 25, 2018. Accessed May 5, 2018.
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11. Gramlich J; PEW Research Center. The gap between the number of blacks and whites in prisons is shrinking. http://www.pewresearch.org/fact-tank/2018/01/12/shrinking-gap-between-number-of-blacks-and-whites-in-prison/. Published January 12, 2018. Accessed May 8, 2018.
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20. Tarver BA, Sewell J, Oussayef N. State laws governing HIV testing in correctional settings. J Correct Health Care. 2016;22(1):28-40.
21. Yang YT, Underhill K. Rethinking criminalization of HIV exposure – lessons from California’s new legislation. N Engl J Med. 2018;378:1174-1175.