Post-Release Substance Abuse Outcomes Among HIV-Infected
Jail Detainees: Results from a Multisite Study
Archana Krishnan•Jeffrey A. Wickersham•
Ehsan Chitsaz•Sandra A. Springer•
Alison O. Jordan•Nick Zaller•Frederick L. Altice
? Springer Science+Business Media New York 2012
disorders have a high prevalence of medical and psychi-
atric morbidities that complicate treatment. Incarceration
further disrupts healthcare access and utilization. Without
appropriate diagnosis and treatment, drug relapse upon
release exceeds 85 %, which contributes to poor health
outcomes. A prospective cohort of 1,032 HIV-infected jail
detainees were surveyed in a ten-site demonstration project
during incarceration and six-months post-release, in order
to examine the effect of predisposing factors, enabling
resources and need factors on their subsequent drug use.
Homelessness, pre-incarceration cocaine and opioid use,
and high drug and alcohol severity were significantly
associated with cocaine and opioid relapse. Substance
abuse treatment, though poorly defined, did not influence
post-release cocaine and opioid use. An approach that
HIV-infected individuals with substance use
integrates multiple services, simultaneously using evi-
dence-based substance abuse, psychiatric care, and social
services is needed to improve healthcare outcomes for
HIV-infected persons transitioning from jails to the
detainees ? Substance abuse treatment ? Addiction severity ?
Heroin ? Cocaine ? Homelessness
HIV/AIDS ? Substance use disorders ? Jail
The United States has the highest incarceration rate in the
industrialized world [1, 2], resulting in the imprisonment of
one in every 100 citizens . Approximately ten million
people are jailed annually in the U.S., half of whom are
released within two days . The incarcerated population
is comprised of medically and socially vulnerable indi-
viduals, many of whom have undiagnosed and untreated
mental illnesses, substance use disorders (SUDs) and HIV/
AIDS [5, 6]. Released jailed detainees also have difficulty
in transitioning to the community, obtaining housing,
finding work, and accessing vital healthcare [7, 8].
For people living with HIV/AIDS (PLWHA), access to
antiretroviral therapy (ART) is critical in order to maintain
viral suppression; however, incarceration and re-entry into
the community post-release have a disruptive effect on
their medical treatment . It has been shown that the
period immediately after release is a highly vulnerable time
for HIV-infected individuals; they experience decreased
access to ART , poor virological and immunological
treatment outcomes [11, 12] and high rates of HIV risk
behaviors [13, 14]. In fact, HIV-infected prisoners who are
released to the community, lose the benefits achieved
A. Krishnan (&) ? J. A. Wickersham ? E. Chitsaz ?
S. A. Springer ? F. L. Altice
Section of Infectious Diseases, AIDS Program, Yale University
School of Medicine, 135 College St., Suite 323, New Haven,
CT 06510-2283, USA
F. L. Altice
A. O. Jordan
New York City Department of Health and Mental Hygiene,
125 Worth Street, New York, NY 10013, USA
Warren Alpert Medical School of Brown University,
222 Richmond Street, Providence, RI 02903, USA
F. L. Altice
Division of Epidemiology of Microbial Diseases,
Yale University School of Public Health, 135 College St.,
Suite 323, New Haven, CT 06510-2283, USA
through access to ART provided within a correctional
setting . For PLWHA with SUDs—a chronic and
relapsing disease—medical and psychiatric co-morbidities
further complicate HIV treatment and adherence [15–17].
Left undiagnosed or untreated, relapse to drug or alcohol
use post-release exceeds 85 %, which further contributes to
the poor health outcomes of these released jail detainees
. This vicious cycle remains uninterrupted unless evi-
dence-based substance abuse treatments (SATs) are intro-
duced at the time of incarceration or immediately upon
Linking HIV-infected inmates to HIV primary care
services upon release from correctional settings, including
jails, is essential to improving health outcomes among the
recently incarcerated . This is especially important for
PLWHA, since one-sixth of all PLWHA in the U.S. tran-
sition through correctional facilities annually [4, 20]. Apart
from potential medical problems and SUDs, released
PLWHA detainees also encounter complications arising
from social instability, lack of insurance coverage and
homelessness [7, 8, 21]. Jails may serve as effective venues
for disease screening and initiation of community-based
interventions for HIV therapy and SUDs . Yet, rela-
tively little evidence exists to support this claim ,
especially due to the short-term periods detainees remain in
these settings . A deeper understanding of the complex
contribution of multiple co-factors, including individual
and social factors, environmental determinants, and treat-
ment for SUDs—on post-release outcomes is needed. We
therefore sought to examine substance abuse outcomes
among a large cohort of HIV-infected jail detainees post-
release to better inform researchers, healthcare providers
and policy makers.
Sample and Study Design
This HRSA-funded Special Projects of National Signifi-
cance (SPNS) initiative was funded to design, implement,
and evaluate innovative methods for transitioning PLWHA
from the jail setting to post-release services, such as
healthcare, HIV medical care, substance abuse treatment
and other supplementary services . The initiative fol-
lowed a cohort of detained HIV-infected individuals from
incarceration, release, and through the provision of various
individual site interventions. HIV-infected inmates were
identified either as previously diagnosed or through routine
HIV testing  through referral to HIV services at ten sites
in nine different states (CT, GA, IL, MA, NY, OH, PA, SC,
RI) . A more detailed description of the methods of the
initiative is included as an appendix to this supplement.
After referral by the clinical staff, participants were
offered transitional services by EnhanceLink staff. Indi-
viduals opting to participate in the initiative’s evaluation
underwent informed consent procedures and were inter-
viewed during incarceration (baseline) and after release at
the six-month time period. In addition to the two inter-
views, a post-release review was completed by case man-
agers for each inmate one-month after release from jail.
The multisite study was approved by both central and site-
specific Institutional Review Boards; a Certificate of
Confidentiality provided additional protections to subjects.
Eligibility requirements included being 18 years or older,
HIV-infected, and currently incarcerated within a desig-
nated jail. Duration of detention was not an eligibility
criterion for participation and participants could be
approached at any time after referral. All sites provided at a
minimum, some element of case management services
Figure 1 depicts the disposition of study participants.
After providing informed consent, 1,270 eligible partici-
pants were enrolled between January 2008 and March
2011. Of the enrolled subjects, 1,255 completed the base-
line interview during which they provided information
about their criminal justice history, living conditions,
family and social relationships, HIV and health status,
medical status, health information and relevant demo-
graphic information. In addition, they were asked about
drug/alcohol use, psychiatric status, HIV medication utili-
zation, and housing status 30 days prior to incarceration.
Among the 1,255 with complete baseline data, 223 indi-
viduals were excluded from further analysis because they
were ineligible to provide follow-up data; reasons for
ineligibility included being sentenced to long jail terms,
early re-incarceration, death, or deportation . The final
analytic sample consisted of 1,032 subjects who had a
completed post-release assessment at the one-month period
after release. By the six-month post-release assessment,
449 of the 1,032 eligible participants had moved or were
lost to follow-up, leaving 583 subjects with complete data,
including baseline and observable data at the six-month
post-release period. The post-release interviews docu-
mented participants’ release information, receipt of case
management services, utilization of psychiatric and SAT,
medical health status, drug and alcohol use, psychiatric
status, and living conditions.
Dependent Variable of Interest
Due to research suggesting that drug and alcohol relapse
occurs soon after release [18, 19], and that cocaine and
heroin are among the most widely abused drugs , the
two dependent variables of interest employed in this study
were: (1) any cocaine use at the end of the six-month post-
release assessment, and (2) any opioid (heroin, opiates/
analgesics/painkillers) use at the end of the six-month post-
Independent Variables of Interest
The analytical approach in this study was guided by the
Behavioral Model for Healthcare Utilization in Vulnerable
Populations [28, 29]. At its fundamental basis, this con-
ceptual model asserts that predisposing factors, enabling
resources, and need factors collectively influence utiliza-
tion of healthcare services and subsequent healthcare out-
comes, such as substance abuse outcomes. Predisposing
factors are demographic and social characteristics (i.e., age,
gender, employment status etc.) that have a critical impact
on healthcare utilization. Enabling resources are personal
and community resources that positively influence linkage
to care; e.g., having access to health insurance and sub-
stance abuse treatment or evidence-based treatment. Need
factors are determined by an individual’s perceived health
needs or priorities, current health status, severity of illness,
and medical co-morbidities. The Healthcare Behavioral
model was adapted for the current study (see Fig. 2) by
incorporating factors that are salient for HIV-infected jail
detainees; these served as independent variables in our
All the independent variables in this study except
for addiction severity were measured by study-specific
instruments. Demographic variables included self-reported
measures of age, gender, relationship status, race, educa-
tion and employment status. Housing status was defined
previously as being homeless or not in the 30 days prior to
incarceration;  baseline recent drug use was defined as
any cocaine and opioid use 30 days prior to incarceration
and pre-incarceration mental illness was operationalized as
having had experienced one of the following in the 30 days
before incarceration—serious depression, serious anxiety,
hallucinations, trouble understanding, concentrating or
remembering; trouble controlling violent behavior, serious
thoughts of suicide, attempted suicide, having had pre-
scribed medication for psychological problems.
Psychiatric treatment was assessed using two variables:
(1) inpatient treatment, operationalized as number of times
having been treated in a hospital for psychological or
emotional problems during lifetime and (2) outpatient
treatment, operationalized as having been treated as a pri-
vate patient for psychological or emotional problems dur-
ing lifetime. Substance abuse treatment was assessed using
two variables which were both dichotomously defined: (1)
the case manager having made contact with a community
service provider to obtain substance abuse services for the
client and (2) the client attending at least one session of the
SAT program after release. Data on whether medication-
assisted therapy (MAT) was used to treat alcohol or drug
dependence was not collected.
Substance use addiction severity was measured by the
Addiction Severity Index (ASI) fifth edition . The ASI
drug and alcohol composite scores (CS) were reported as
both continuous variables ranging from zero to one (with
one indicating more severe addiction), and as dichotomous
Fig. 1 Participant disposition
variables by implementing previously validated cut-off
points:[0.17 defined severe alcohol problems and [0.16
defined severe drug problems. An ASI drug CS cut-off of
0.16 has been shown to have 84 % sensitivity (84 % of
patients meeting DSM-IV criteria were identified) and
81 % specificity (81 % of patients not meeting diagnostic
criteria were accurately identified). Similarly, an ASI
alcohol CS cut-off of 0.17 has been shown to have 85 %
sensitivity and 80 % specificity . Severity of mental
illness was evaluated with the ASI psychiatric CS and was
measured as both a continuous (zero to one) and dichoto-
mous variable with a cut-off at 0.22. Similar thresholds
have been used in studies looking to identify severe psy-
chiatric illness [32, 33].
Data were analyzed using SPSS 19 (IBM, New York).
Prior to analysis, all the independent variables except
demographics were binary-coded. In order to examine the
enabling resources, need factors) on the two dependent
variables (cocaine use and opioid use at the end of the six-
month post-release assessment), logistic regression was
used. Univariate analysis was first conducted for each
independent variable with the two distinct outcomes using
the Wald test. Factors with probability value less than 0.10
were then included in the final multivariate model. This
approach to the final regression model had the best good-
ness of fit using the Aikake Information Criterion (AIC).
Table 1 provides the baseline characteristics of the study
sample. In general, the subjects were predominantly single,
African-American, heterosexual men in their mid-forties.
Almost half of the sample reported not having finished high
school and three-fifths reported being unemployed in the
period before incarceration. Although a majority had stable
housing and medical insurance prior to incarceration, cor-
relation analysis revealed that baseline homelessness was
negatively correlated with having insurance at baseline
(r = -0.16, p\0.001), suggesting that individuals with-
out stable housing were more likely to lack insurance.
Since subject attrition in this study was high, it is likely that
subjects with unstable housing and medical insurance were
the ones who were lost to follow-up. There is some evi-
dence of this, as the percentage of people surveyed at the
six-month post-release interview had lower rates of
homelessness and higher rates of insurance. This strongly
suggests that those without stable housing or insurance
were more likely to be missing from the sample at six-
In order to understand the factors that may have lead to
large-scale subject attrition, a comparison of retained and
lost participants was performed using baseline social
characteristics such as homeless and insurance coverage,
substance use, mental illness and previous psychiatric care.
(p\0.01) of subjects who dropped out or were lost to
follow-up by the six-month post-release assessment were
homeless (41.1 % vs. 32.4 %) before incarceration. Par-
ticipants with observations at six-months post-release were
significantly more likely to have medical insurance
(80.2 % vs. 68.7 %) prior to incarceration. Additionally,
participants lost to follow-up were significantly more likely
to have pre-incarceration mental illness (72.4 % vs.
62.4 %) compared to those who were retained. The indi-
viduals without follow-up data, however, were no more
likely to have: (1) used cocaine in the 30 days before
incarceration; (2) had higher severity of drug and alcohol
use; (3) had severe psychiatric illness; and (4) had higher
mean ASI alcohol, drug and psychiatric composite scores
Fig. 2 Conceptual model for
post-release substance abuse
outcomes among HIV-infected
compared to those who had complete follow-up data. Thus,
for the dependent variables of interest—heroin and cocaine
use at six-months post-release—these characteristics did
not differ, allowing important comparisons for substance
use to be assessed.
The univariate and multivariate analyses for factors
associated with active use of cocaine at the end of the six-
month post-release assessment are presented in Table 3.
Although a number of factors were significantly associated
with persistent cocaine use in the univariate analysis,
the multivariateanalysis showedthat post-release
homelessness (AOR = 1.88, 95 % CI 0.90, 3.94), both
high alcohol use (AOR = 2.03, 95 % CI 0.95, 4.34) and
high drug use (AOR = 11.79, 95 % CI 5.70, 24.36)
severity, and pre-incarceration cocaine use (AOR = 1.97,
95 % CI 0.99, 3.90) were significantly associated with
increased cocaine use at the six-month post-release period.
Receiving health insurance after release, however, signifi-
cantly decreased the likelihood of post-release cocaine use
(AOR = 0.42, 95 % CI 0.17, 1.03).
Table 4 illustrates the univariate and multivariate anal-
yses for factors associated with opioid use at the end of the
six-month post-release assessment. Similar to the findings
for cocaine use at the end of the six-month post-release
observation period, several factors were significant in the
univariate analysis. In the multivariate analysis, however,
pre-incarceration opioid use and high drug use severity at
the six-month post-release observation portended a 32- and
25-fold increased risk respectively, for ongoing opioid use
six-months after release. Being in a committed relationship
(AOR = 4.14, 95 % CI 1.21, 14.22) was also associated
with increased association with the dependent variable.
The results from this study show that SUDs and rates of
mental and psychiatric illness are highly prevalent among
PLWHA entering jails. Compared to the general U.S. pop-
ulation , this sample had a higher rate of drug use, with
nearly half experiencing high drug use severity. Co-morbid
mental illness was also high, with three-fifths of this sample
reporting having experienced some formofmental illnessor
psychiatric distress in the 30 days prior to incarceration.
nearly half of the sample. Similarly, one quarter of the
sample reported active opioid use at the time of incarcera-
tion. The disturbingly high use of heroin and cocaine among
this population of HIV-infected jail detainees highlights the
importance of screening and initiating treatment for these
conditions upon entry into jail. This is particularly salient
negative adverse consequences related to HIV treatment
outcomes, including access to HIV care, retention in HIV
care, access to and adherence with ART [15, 18]. One of the
most significant findings in our study is that pre-incarcera-
tion heroin and cocaine use are associated with relapse after
release. This supports the notion that SUDs are chronic and
relapsing conditions and that in the absence of treatment
during incarceration, patients are highly vulnerable to
relapse post-release. Left untreated, HIV-infected patients
in jail settings with SUDs are vulnerable to relapse,
re-incarceration, and the same negative HIV treatment out-
comes experienced at the time of imprisonment [15, 18].
Table 1 Baseline characteristics of study participants (N = 1,032)
Age in years (Mean, SD)(44.3, 8.87)
Male 704 (68.2 %)
Female 306 (29.7 %)
Transgender17 (1.7 %)
White205 (19.9 %)
Black627 (60.8 %)
Single571 (55.3 %)
Separated/Divorced/Widowed1,315 (12.6 %)
Married/Committed 329 (31.8 %)
Heterosexual802 (77.7 %)
Homosexual 96 (9.3 %)
Some high school511 (49.5 %)
High school diploma/GED344 (33.3 %)
College159 (15.4 %)
Full-time work93 (9.0 %)
Part-time work117 (11.4 %)
Unemployed646 (62.6 %)
Homelessness prior to incarceration
Yes372 (36.0 %)
No 657 (63.7 %)
Insurance prior to incarceration
Yes774 (75.0 %)
No255 (24.7 %)
Homelessness at six-months post-release (N = 583)
Yes111 (19.0 %)
No468 (80.3 %)
Insurance at six-months post-release (N = 583)
Yes505 (86.6 %)
No74 (12.7 %)
Table 2 Comparison of baseline social characteristics, substance use disorders and psychiatric co-morbidities of jail detainees who completed
study and who were lost to follow-up
Completed follow-up (N = 583)
Lost to follow-up (N = 449)
Homelessness188 (32.4 %) 184 (41.1 %)
\0.001 Has insurance467 (80.2 %) 307 (68.7 %)
Cocaine use in the 30 days prior to incarceration279 (47.9 %)226 (50.3 %) ns
Opioid use in the 30 days prior to incarceration 150 (25.7 %)109 (24.3 %)ns
Mean ASI Score—Drugs (SD)0.22 (0.28)0.22 (0.18) ns
Mean ASI Score—Alcohol (SD)
High drug use severity (ASI[0.16)
High alcohol use severity (ASI[0.17)
0.23 (0.63)0.25 (0.63) ns
291 (53.0 %)240 (57.3 %) ns
190 (33.3 %) 154 (35.6 %)ns
Experienced mental illness (30 days pre-incarceration)364 (62.4 %)325 (72.4 %)
ns Inpatient treatment for psychiatric illness186 (31.9 %)155 (34.5 %)
Outpatient treatment for psychiatric illness153 (26.2 %)128 (28.5 %) ns
Mean ASI Score—Psychiatric (SD)
High severity of psychiatric illness (ASI[0.22)
0.28 (0.31)0.32 (0.30)ns
289 (50.2 %)242 (55.5 %) ns
Opioid use is defined as having either used heroin or other opiates/analgesics/painkillers
ASI addiction Severity Index, SD standard Deviation, ns not Significant
Table 3 Factors associated with cocaine use at the end of the six-month post-release assessment
Factors Univariate analysisMultivariate analysis
(95 % CI)
(95 % CI)
\0.011.91 (1.20, 3.05)ns–
3.27 (0.86, 12.41) ns–
Mental illness (six-months post-release)2.03 (1.28, 3.24) ns
Insurance (six-months post-release) 0.42 (0.24, 0.74)0.42 (0.17, 1.03)
Homelessness (pre-incarceration)1.59 (1.01, 2.51)
Homelessness (six-months post-release)4.24 (2.62, 6.88)1.88 (0.90, 3.94)
Inpatient treatment for psychiatric illness1.60 (1.01, 2.52)–
High alcohol use severity (pre-incarceration)1.55 (0.98, 2.45)ns
High alcohol use severity (six-months post-release)5.02 (3.03, 8.31)2.03 (0.95, 4.34)
High drug use severity (six-months post-release)20.61 (11.47, 37.05)11.79 (5.70, 24.36)
High severity of psychiatric illness (six-months post-release)2.39 (1.52, 3.77) –
Cocaine use (30 days pre-incarceration) 2.38 (1.50, 3.78)1.97 (0.99, 3.90)
Univariate analyses were performed for age, race, relationship status, sexual orientation, education, outpatient treatment for mental illness,
utilization of substance abuse treatments, severity of drug use and psychiatric illness at baseline; however, none of these were significant
CI confidence Interval, OR odds ratio, AOR adjusted odds ratio, ns not significant
The finding that initial receipt of substance abuse
treatment itself did not decrease the likelihood of opioid or
cocaine use six-months post-release is of concern.
Although other studies have shown that evidence-based
interventions such as MAT provided after release is
effective, [35, 36] it is unclear whether evidence-based
interventions were deployed in EnhanceLink, nor is it
known if study participants remained engaged in treatment.
Hence, it is likely that our measurement was insufficient to
explain the quality of retention in the intervention, which
has been demonstrated in other post-release studies .
Unfortunately, evidence-based SAT provided in criminal
justice settings is limited, and when provided in jail set-
tings, typically is comprised of supervised withdrawal
(‘‘detox’’) and without provision of aftercare services .
Similarly, medication-assisted therapies such as methadone
or buprenorphine used for treating opioid dependence [37,
38] or extended released naltrexone used for alcohol or
opioid dependence  is rarely provided in either jail or
prison settings in the U.S. or available upon release unless
the patient relapses. Thus, even though our conceptual
model suggests that SAT would be an enabling resource, it
is unlikely to serve in this capacity due to the quality and
duration of the post-release intervention. Recent data sug-
gest that even in the presence of an evidence-based treat-
ment like buprenorphine for the treatment of opioid
dependence, it is retention in treatment that has the highest
correlation with HIV treatment outcomes [35, 40].
With respect to the application of Vulnerable Popula-
tions Behavioral Model for Healthcare Utilization (Fig. 2)
in explaining substance abuse outcomes, a key predispos-
ing factor was homelessness. According to Maslow’s
Hierarchy of Needs, basic needs such as food and housing
far outweigh secondary needs such as healthcare manage-
ment . Thus, an individual’s ability to access medical
care to manage their HIV status or SUDs is contingent on
being able to first address food and housing issues [42, 43].
In a previous study of released PLWHA detainees, home-
lessness and food insecurity were shown to decrease the
likelihood of managing access to HIV care and antiretro-
viral treatment outcomes . It may be that in the larger
scheme of things, PLWHA suffering from SUDs do not
prioritize SATs in view of their unstable social and envi-
ronmental conditions. Using a ‘‘Housing First’’ approach or
even initiating evidence-based substance abuse treatment
and continuing it upon release to the community, is an
appropriate way to deal with individuals grappling with a
host of co-morbid conditions in addition to their HIV
The only factor associated with a decrease in post-
release cocaine use was having health insurance. Since
insurance has been shown to have a positive influence in
Table 4 Factors associated with opioid use at the end of the six-month post-release assessment
Factors Univariate analysisMultivariate analysis
(95 % CI)
(95 % CI)
\0.052.18 (1.19, 3.98) ns–
2.77 (0.87, 8.86)ns–
Married3.29 (1.34, 8.11) ns
2.63 (1.21, 5.73)4.14 (1.21, 14.22)
3.81 (2.06, 7.04) ns–
High alcohol use severity (six-months)2.23 (1.14, 4.36) ns–
High drug use severity (pre-incarceration)3.17 (1.53, 6.18) ns
High drug use severity (six-months)19.80 (9.80, 40.01)25.06 (8.02, 78.34)
High severity of psychiatric illness (six-months)2.29 (1.25, 4.17)–
Cocaine use (30 days pre-incarceration)3.61 (1.84, 7.08) ns
Opioid use (30 days pre-incarceration)12.56 (6.21, 25.41)31.86 (9.08, 111.84)
Univariate analyses were performed for age, race, sexual orientation, education, employment status, insurance, mental illness, utilization of
substance abuse treatments, and severity of alcohol use and psychiatric illness at baseline; however, none of these were significant. Opioid use is
defined as having either used heroin or other opiates/analgesics/painkillers
CI confidence Interval, OR odds ratio, AOR adjusted odds ratio, ns not significant
ART adherence and better healthcare management , it
may also be that it provides PLWHA with a sense of
security, thereby allowing them to effectively manage their
health, including seeking substance abuse treatments.
Moreover, having health insurance is often a pre-requisite
to entering or even continuing substance abuse treatment.
Despite the obvious importance of this enabling resource
especially for a population with a high prevalence of sub-
stance abuse and mental disorders, federal and state med-
ical entitlementsare actually
incarceration and it is often a challenge to reinstate these
benefits before a person relapses to drug use . Cor-
recting such deficiencies in healthcare coverage along with
providing housing stability may be the first concrete step in
conquering substance abuse and achieving positive HIV
health outcomes. The extent to which the Affordable Care
Act will address this limitation in the current healthcare
environment is not yet known. In fact, this study has
demonstrated that those experiencing homelessness and
lack of insurance coverage are significantly more likely to
drop out of treatment programs and thereby are unable to
benefit from post-release SATs, mental health counseling
and other supplementary services.
Central to this study is the finding that both pre-incar-
ceration cocaine and opioid use, in addition to the severity
of SUDs, was significantly associated with post-release
drug relapse. Specifically, those who had used cocaine and
opioids before incarceration and had severe drug and
alcohol addictions were most likely to continue abusing
these substances six-months after release. Although this
finding is in consensus with other studies in the literature
that support the chronic disease model with high rates of
relapse among PLWHA, especially those with co-morbid-
ities such as mental illness and SUDs; [16, 17] the sheer
magnitude of the effect in this study—32-fold in the case of
opioid use—strongly supports identification and treatment
at the point of entry to jail. Recent data from a quality
improvement program at Rikers Island’s Project KEEP
supports the use of higher levels of methadone in order to
improve linkage to care upon release from jail .
Despite the value of evidence-based SATs, it seems that
the most vulnerable subset of our sample—those suffering
from chronic SUDs, mental illness, and homelessness—
either dropped out or were unable to reap the benefits of
post-release substance abuse therapies. This suggests that
resources may be best used to target those who are most
susceptible to relapse, especially in resource-constrained
settings such as jails.
This study has addressed a unique space in the re-entry
literature—PLWHA transitioning through jail settings.
Jails offer an opportune setting for implementing transi-
tional healthcare programs since most inmates eventually
re-enter communities rather than transition to prisons
[4, 5, 9]. Utilizing jails as a setting to identify, diagnose and
treat infectious diseases  has potential health benefits
for incarcerated individuals as well as the community .
Very few re-entry studies have been examined in jail set-
tings [23, 46]. This study extends important findings about
prison-based community re-entry programs to the context
of jails, and is thus well-poised to make a significant
contribution by demonstrating the importance of health
intervention and adherence programs for PLWHA transi-
tioning from jail to the community. Such programs that
target PLWHA in jails could ultimately have a profound
impact on HIV treatment and curtail transmission in the
This study is the first comprehensive analysis of sub-
stance abuse outcomes following the receipt of SAT, HIV
medical care and other ancillary services, as part of the
EnhanceLink program to transition PLWHA from the jail
setting into the community. In order to maximize the
positive impact of post-release interventions for incarcer-
ated PLWHA with varied co-morbid conditions, it is
essential to develop and implement programs that can
integrate substance abuse and mental health treatments. For
the most vulnerable individuals—those facing multiple
social, medical and environmental barriers, the answer to
achieving positive health outcomes could lie in a multi-
pronged or integrated high-impact intervention  uti-
lizing substance abuse treatment, mental health counseling,
housing assistance and social service programs.
Despite the important findings obtained from this study,
there are a few limitations. Although the study was lon-
gitudinal in nature, measurements of substance use and
mental illness were measured only periodically and spe-
cifically after six-months post-release. The reliance on self-
reports for a majority of behavioral and healthcare
utilization measures may have limited the scope of find-
ings. As such, we can only make correlations and not
determine causality. Self-reports have been shown to be a
useful method of data collection; however, in the context of
this study, the time delay between actual behavior and
interview may have introduced potential recall bias.
The most pressing limitation in the analysis was subject
attrition. By the six-month post-release interview, there
were no data for more than 40 % of the sample. Some of
the reasons for losses to follow-up across the sites are
described in the Appendix. After comparing the retained
and non-retained study participants, not surprisingly those
not retained were significantly more likely to be socially
vulnerable, with increased likelihood of being homeless
and uninsured. Fortunately, however, the substance use
characteristics, including the two dependent variables were
no different at baseline, thereby minimizing the influence
of not including them in the analysis. Given that those for
whom we did not have data were more likely to be
homeless and uninsured, both of which are associated
with worse substance use outcomes, our findings likely
‘‘underestimate’’ the true influence of pre-incarceration
drug use and drug use severity on the outcomes here. For
that reason, the independent variables used are likely to
remain the same, yet the magnitude is likely to be greater.
Despite these limitations, this study provides important
insights into addressing substance use disorders among
PLWHA entering jail and emphasizes the importance of
incorporating evidence-based interventions that are both
appropriate and feasible in jail populations.
PLWHA who enter jails have an extraordinary burden of
SUDs, not only in terms of magnitude, but also in severity.
Effective substance abuse treatments can have a positive
impact on adherence to ART for incarcerated HIV patients;
hence it is crucial that future healthcare initiatives take this
need into consideration before adopting new treatment
strategies. Despite the urgent need for active substance
abuse treatment as a supplement to ART for HIV-infected
incarcerated drug users, jails often do not adopt this strat-
egy [36, 38]. It is time to address the culture that ignores
the chronic and relapsing nature of drug dependence and
focuses on a continuous model of care that comprehen-
sively addresses the multiple co-morbidities of PLWHA
who transition through the criminal justice system. An
integrated mixed approach to HIV care needs to be
implemented, one that potentially includes federal housing
and insurance programs, evidence-based substance abuse
treatments and continued community supported adherence
Enhancing Linkages to HIV Primary Care Services Initiative—an
HRSA-funded Special Project of National Significance, and through
career development awards from the National Institute on Drug
Abuse for Drs. Altice (K24 DA017072) and Springer (K02
DA032322, SAS). The authors would like to acknowledge the data
management support provided by Maua Herme and administrative
support provided by Paula Dellamura. The authors would especially
like to thank the study participants for their time and involvement in
this project, and the countless research assistants for their hard work
and dedication in collecting, collating, entering and cleaning the
Funding for this study was possible through the
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