The Intertwined Epidemics of HIV Infection, Incarceration, and Substance Abuse: A Call to Action Willie Sutton, the immaculately

dressed bank robber, is credited with Suttons Law: when asked why he robbed banks, he responded, because thats where the money is! Why should those of us concerned with human immunodeficiency virus (HIV) and substance abuse epidemics work in jails? Because that is where the money is! The United States has extraordinarily high rates of incarceration. In 2009, >12 million men and women passed through US jails. These individuals are most often male, belong to a minority race, have low socioeconomic status, are engaged in active substance abuse, and are at risk for HIV infection and other sexually transmitted infections. The prevalence of HIV infection is 5 times higher in state and federal correctional systems in the United States than in the general public. In this issue of the Journal, Milloy et al describe the dose-response effect of incarceration events on nonadherence to HIV antiretroviral therapy (ART) among injection drug users. From 1996 through 2008, 490 injection drug users were recruited and followed up for a median of >2 years. Of importance, more than half of the participants were incarcerated during the study period, with a median number of incarceration episodes of 3. The crude incarceration rate was 52 per 100 person-years. Incarceration was the rule rather than the exception. The authors evaluated the impact of incarceration on adherence to ART. Compared with individuals with no history of incarceration, participants with 1 or 2 incarcerations had almost double the odds of nonadherence at each follow-up visit (odds ratio [OR], 1.91). The OR increased to 2.8 for 35 incarceration episodes and 3.59 for >5 incarceration events. This relationship persisted after adjusting for factors, including sex, cocaine use, and methadone maintenance therapy. Are multiple incarcerations causally related to poor adherence, or is it an association? Certainly the structural events of incarceration frequently lead to interruptions in ART. Jail is chaotic, and security rather than healthcare is the priority. More often than not, it takes days for individuals to identify themselves as being HIV infected, have medications confirmed, and receive their ART. Stigma and other concerns will often lead to inmates hiding their HIV-positive status. Significant interruptions in ART may also occur at the time of release from prison or jail. A recent study of released prisoners in Texas found that only 5% filled ART prescriptions in time to avoid an interruption, and only 30% had filled prescriptions 60 days after release. In addition, interruptions in ART may occur after release because of resumption of substance-using behaviors, and this can lead to further HIV transmission in the community. Individuals with multiple incarcerations are probably different from injection drug users who do not get incarcerated; therefore, this relationship may also be an association. Individuals with multiple incarcerations are more likely to have more intensive substance abuse problems, mental health disorders, and other behaviors that are associated with poor adherence. In many ways, whether the relationship between incarceration events and nonadherence is an association or is causal does not matter. These data from the British Columbia Center for Excellence in HIV and AIDS Care are an important contribution, because they highlight the need for intensive HIV treatment interventions for individuals involved with the criminal justice system.

The US response to the intertwined epidemics of HIV incarceration and substance abuse has not been adequate. The vast majority of individuals incarcerated in the United States pass through jails and not prison (13 million vs 743,000 in 2007). Most jails in the United States do not offer routine opt-out HIV testing. This is a particular travesty, considering that the demographic group that has the highest rates of HIV infection in this country is African American men, which is also the population most likely to be incarcerated. An opt-out approach to testing is preferable to opt-in. In North Carolina, changing from opt-in to routine opt-out HIV testing among persons entering prison resulted in 30% more prisoners being tested (61% vs 91%), and 22 additional HIV infections were identified. Inmates who opt-in and volunteer for HIV testing have lower prevalence of HIV infection than did those who are not tested in the general inmate population. Routine HIV testing is cost effective in outpatient and inpatient settings

when the prevalence of undiagnosed HIV infection is at least .1%. Because of the increased prevalence of HIV infection among incarcerated populations, it is reasonable to assume that routine opt-out HIV testing in jails and prisons is also costeffective, but this is a priority for future research efforts. Testing for HIV infection in jails is just the beginning. Availability of ART, comprehensive and confidential HIV care, and appropriate HIV-related laboratory testing in facilities is necessary. Linkage to community HIV care after release is a crucial intervention that can lead to improved ART adherence rates. Studies conducted in Connecticut and North Carolina have demonstrated that inmates receiving ART had better virologic outcomes if they remained incarcerated, compared with those released and reincarcerated, underscoring the risk of treatment interruptions between corrections and the community. Medical case management that facilitates the linkage from corrections to the community has worked in multiple settings. However, research has also shown that a case management intervention bridging incarceration and release was no more effective than a less intensive prerelease discharge planning program in supporting health care usefor HIV-infected individuals released from prison. In some settings, community-based case management is needed. In other communities, a prerelease discharge planning program will be adequate. Concurrent with linkage to community HIV providers and access to ART, management of addiction and comorbid mental health disorders is necessary to optimize HIV outcomes. Recent studies have demonstrated the benefit of opiate replacement therapy in certain injection drug use populations transitioning to the community. In the past few years, incarceration has been recognized as a key intervention site to address the HIV epidemic. The Health Resources and Services Administration (HRSA) has supported a Special Project of National Significance, Enhancing Linkages to HIV Primary Care and Services in Jail Settings, to kickstart and enhance HIV testing and linkage programs in 10 US jails. The National Institutes of Health (National Institute on Drug Abuse, National Institute of Mental Health, and National Institute of Allergy and Infectious Diseases) has recently funded 10 R01 grants under the Seek, Test, and Treat: Addressing HIV in the Criminal Justice Systeminitiative. States that have implemented comprehensive testing and programs aimed at decreasing the burden of HIV infection among drugusers involved with the criminal justice system have observed a decrease in injection drug userelated new diagnoses. On the other hand, the fact that most jails do not routinely test for HIV infection or link individuals after release to HIV care programs demonstrates how much more needs to be done. There is a need for more federal and public health guidance on this issue in the United States. Although the Centers for Disease Control and Prevention (CDC) has published helpful guidelines on HIV testing in correctional facilities, more could be done to bolster the HIV public health efforts in correctional settings. The CDC, in collaboration with local departments of health, could begin to evaluate HIV testing and treatment in correctional facilities to establish a basic standard of care. Through the Ryan White Comprehensive AIDS Resources Emergency Act, HRSA receives client-level data on HIV-infected persons. These data could be used to examine outcomes and linkage among persons involved with the criminal justice system. The Department of Justice and the Federal Bureau of Prisons also have the opportunity to play a leadership role in addressing public health interventions that are feasible and cost-effective. In the past 5 years, data have been published demonstrating the importance of opt-out HIV testing in jails, the benefit of the initiation of ART, and the importance of programs to link individuals with care in the community after release. The medical, public health, and correctional leadership in the United States needs to come together to advance the implementation of these programs as soon as possible.