title: Optimization of human immunodeficiency virus treatment during incarceration: viral suppression at the prison gate.
abstract: OBJECTIVE
  Human immunodeficiency virus (HIV) management in correctional settings is logistically feasible, but HIV-related outcomes before release have not been recently systematically examined.
  
  
  OBJECTIVE
  To evaluate HIV treatment outcomes throughout incarceration, including jail and prison.
  
  
  METHODS
  Retrospective cohort study of longitudinally linked demographic, pharmacy, and laboratory data on 882 prisoners within the Connecticut Department of Correction (2005-2012) with confirmed HIV infection, who were continually incarcerated 90 days or more, had at least 2 HIV-1 RNA and CD4 lymphocyte measurements, and were prescribed antiretroviral therapy.
  
  
  METHODS
  Three electronic databases (correctional, laboratory, and pharmacy) were integrated to assess HIV viral suppression (HIV-1 RNA levels, <400 copies/mL) on intake and release. Secondary outcomes were mean change in log-transformed HIV-1 RNA levels and mean change in CD4 lymphocyte count during incarceration. Demographic characteristics, prescribed pharmacotherapies, receipt of directly observed therapy, and duration of incarceration were analyzed as possible explanatory variables for HIV viral suppression in logistic regression models.
  
  
  RESULTS
  Among 882 HIV-infected prisoners with 1185 incarceration periods, mean HIV-1 RNA level decreased by 1.1 log10 and CD4 lymphocyte count increased by 98 cells/µL over time, with a higher proportion achieving viral suppression by release compared with entry (70.0% vs 29.8%; P < .001); 36.9% of antiretroviral therapy (ART) regimens were changed during incarceration. After adjusting for baseline HIV-1 RNA level, prerelease viral suppression correlated with female sex (adjusted odds ratio, 1.81; 95% CI, 1.26-2.59) and psychiatric disorder severity below the sample median (adjusted odds ratio, 1.50; 95% CI, 1.12-1.99), but not race/ethnicity, incarceration duration, ART regimen or dosing strategy, or directly observed therapy.
  
  
  CONCLUSIONS
  Though just one-third of HIV-infected prisoners receiving ART entered correctional facilities with viral suppression, HIV treatment was optimized during incarceration, resulting in the majority achieving viral suppression by release. Treatment for HIV within prison is facilitated by a highly structured environment and, when combined with simple well-tolerated ART regimens, can result in viral suppression during incarceration. In the absence of important and effective community-based resources, incarceration can be an opportunity of last resort to initiate continuous ART for individual health and, following the "treatment as prevention" paradigm, potentially reduce the likelihood of HIV transmission to others after release if continuity of HIV care is sustained.
authors.affiliation: AIDS Program, Yale University School of Medicine, New Haven, Connecticut2Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, Connecticut.
authors.forename: Jaimie P
authors.initials: JP
authors.lastname: Meyer
authors.affiliation: Epidemiology of Microbial Diseases, Yale University School of Public Health, New Haven, Connecticut.
authors.forename: Javier
authors.initials: J
authors.lastname: Cepeda
authors.affiliation: Correctional Managed Healthcare, University of Connecticut, Farmington.
authors.forename: Johnny
authors.initials: J
authors.lastname: Wu
authors.affiliation: Correctional Managed Healthcare, University of Connecticut, Farmington.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Trestman
authors.affiliation: AIDS Program, Yale University School of Medicine, New Haven, Connecticut3Epidemiology of Microbial Diseases, Yale University School of Public Health, New Haven, Connecticut5Centre of Excellence on Research in AIDS, University of Malaya, Kuala Lumpur, Mala.
authors.forename: Frederick L
authors.initials: FL
authors.lastname: Altice
authors.affiliation: AIDS Program, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Sandra A
authors.initials: SA
authors.lastname: Springer
mesh_terms: D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D003237:Connecticut; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000821:virology; D015497:HIV-1 / Q000302:isolation & purification*; D006801:Humans; D008297:Male; D011329:Prisoners / Q000706:statistics & numerical data*; D011330:Prisons / Q000706:statistics & numerical data*; D012044:Regression Analysis; D012189:Retrospective Studies; D016896:Treatment Outcome; D019562:Viral Load / Q000187:drug effects / Q000639:trends*
chemical_list: D044966:Anti-Retroviral Agents