A team of Yale researchers has identified some of the key factors that determine whether individuals released from incarceration continue to receive HIV care after leaving prison.

Led by School of Medicine and School of Public Health professor Frederick Altice, the researchers analyzed retention in HIV care during the three years following individuals’ release from incarceration. Post release, researchers found that factors such as housing, substance abuse treatment, case management and health insurance predict retention in HIV care and the end goal — viral suppression. The study was published on Oct. 9 in PLOS Medicine.

“In many cases, [HIV positive] individuals may actually do quite well while incarcerated — they can get on medication for HIV, they can get their viral loads suppressed pretty well,” said Kelsey Loeliger MED ’19 SPH ’19, the first author of the paper. “But then, we were interested in what happens after release. And what we found was, after release, the number of people who are continuously retained in care goes down over time — but there are certain things that can prevent this.”

The researchers examined engagement in care over a long period of time by merging data from the Connecticut Department of Correction and the Department of Public Health. This analysis also enabled them to evaluate, for the first time, how HIV treatment during incarceration compares to treatment after returning home, according to study co-author and professor at the medical school Jaimie Meyer SPH ’14.

The team found that among 1,094 HIV-positive individuals incarcerated in Connecticut prisons between 2007 and 2011, less than half were successfully retained in HIV care over the three years following their release.

Mayur Desai, an epidemiology professor at the School of Public Health and co-author of the study, identified three potential areas of improvement in public policy that could enhance HIV care following release. These included health insurance, transitional case management services and linkage to care within two weeks following release.

“Relatively modest investments in quickly linking former prisoners to care and providing supportive services in the community can have tremendous benefits in terms of both keeping them engaged in care and sustaining a low HIV viral load,” Desai said.

Case managers, for example, meet with individuals to gauge their needs and help connect them to the appropriate resources, Loeliger explained.

Sandra Springer, a professor at the medical school, previously evaluated HIV-positive incarcerated individuals in two separate studies. She stressed the importance of preventing individuals from relapsing as a result of opioid or other substance abuse. Substance use, Springer said, interferes with individuals’ ability to adhere to HIV therapy after release.

Both Loeliger and Springer identified case management, health insurance, substance abuse treatment and housing as indicators of retention in HIV care. Springer also noted that the lack of public transportation might make getting to appointments difficult.

Loeliger said making the first appointment with a health care provider is a crucial first step, as it provides the clinic with the individual’s record.

She stressed that getting an individual to HIV care is a multifaceted process, as they might face other, more immediate challenges, such as lack of housing and substance use disorders.

“We should transform the criminal justice system into one that is less about punishing people and more about recognizing why individuals are engaging in illegal activities firstly and then [about] meeting people in the middle,” Loeliger said. “I would like to see a shift … toward providing people with access to resources that can keep them out of prison — and also help them be healthier and more active and productive members of society.”

Springer, who was not involved in the study, noted that the analysis was limited to Connecticut, so results may differ by state. She noted Connecticut’s status as a Medicaid expansion state and said more research should be done regarding non-Medicaid expansion states.

In 2016, there were 10,400 people living with HIV infection in Connecticut, according to the Connecticut Department of Public Health.

Eui Young Kim | euiyoung.kim@yale.edu

Correction, Oct. 22: A previous version of this article stated that in 2016, there were 2,693 people living with HIV in Connecticut. The number of people living with HIV was in fact 10,400 in 2016, according to the Connecticut Department of Public Health.