Brief incarceration is associated with an increased risk of
virological failure for injecting drug users taking HIV therapy, US
investigators report in the October 1st edition of Clinical Infectious Diseases.
Spending between seven and 30 days behind bars increased the
risk of HIV treatment failure sevenfold. However, longer periods of
imprisonment were not associated with virological rebound.
“Pretrial detention centers are often described as hectic
environments where over-crowding, insufficient communication with care
providers, and unpredictable lengths of stay make delivery of health care
challenging,” write the authors.
HIV disproportionately affects marginalised groups, and in
the US rates of imprisonment are significantly higher among HIV-positive
individuals than in the general population.
In any given year between a quarter
and one-third of all HIV-positive individuals in the US pass through the justice
system, spending time behind bars.
“By disrupting access to usual sources of care…incarceration
may cause interruptions in treatment for HIV infection,” comment the
They therefore hypothesised that: “incarceration my be an
important but overlooked cause of treatment failure for individuals receiving
ART [antiretroviral therapy].”
To test this theory that looked at the viral load of 437
injecting drug users who received HIV treatment in Baltimore between 1998 and
2009. All suppressed their viral load to below 400 copies/ml. A series of
analyses were performed to see if spending time behind bars increased the risk
of viral load rebounding.
The patients were monitored every six months. At each visit
they were asked if they had been incarcerated, and if so, whether the period of
incarceration was between seven and 30 days or over 30 days.
Over a median of 6.6 years of follow-up, a total of 175 (40%)
of individuals reported at least one period of incarceration and 26% of
patients had multiple incidents of imprisonment.
Brief periods behind bars account for 19% of all reported
Overall, virological failure occurred in 26% of patients. A
viral load above 400 copies/ml was present at 53% of follow-up visits when an
incarceration had been reported, compared with 25% of visits when there had
been no incarceration.
In the first set of statistical analysis both brief (OR =
6.6; 95% CI, 2.1-19.8) and longer (OR = 1.7; 95% CI, 1.0-3.0) periods of
incarceration were associated with an increased risk of viral load rebounding
to above 400 copies/ml.
The investigators then controlled for potentially
confounding factors such as demographics, current patterns of drug and alcohol
use, and HIV disease stage.
They found that brief incarceration remained significantly
associated with an increased risk of treatment failure (OR = 7.7; 95% CI,
3.0-19.7). However, the relationship between longer periods of imprisonment and
treatment failure ceased to be significant (OR = 1.4; 95% CI, 0.8-2.6).
Medical care for people in detention awaiting trial is
often chaotic, note the investigators. In contrast, longer periods of
imprisonment can facilitate the provision of good quality health care: “Many
patients receive ART for the first time in prison, and treatment for comorbid
psychiatric and substance use disorders in prison may facilitate better levels
of ART adherence than some IDUs [injecting drug users] sustain in community
Restricting analysis to patients whose viral load rebounded
above 1000 copies/ml also showed that shorter (OR = 4.1; 95% CI, 1.6-6.9), but
not longer (OR = 1.7; 95% CI, 0.9-2.3) periods of incarceration increased the
risk of virological failure.
Clinic attendance and use of HIV therapy was poorer for
patients who had a recent experience of incarceration than those who did not
spend time behind bars (27% vs. 47%).
Incarceration was also associated with higher rates of HIV
risk behaviours, including sharing injecting equipment (p = 0.002) and the use
of shooting galleries (p < 0.001).
“Loss of virologic control after incarceration may
facilitate increased transmission of HIV,” comment the investigators, “future
studies should evaluate the contribution of loss of virological control among
recently incarcerated persons to community viral load estimates.”
The authors conclude: “our data show that incarceration is a
strong marker of increased vulnerability to virologic failure for IDUs using
ART…our study findings highlight that improved strategies to indentify and
successfully link HIV-infected inmates to appropriate HIV care are urgently