Can TasP Approaches Be Implemented in Correctional Settings?: A review of HIV testing and linkage to community HIV treatment programs

Abstract

High rates of HIV in correctional populations makes evaluation of programs that increase HIV testing in correctional settings and linkage to HIV treatment upon release, and understanding key implementation issues of these programs, essential to reducing new HIV infection. We conducted a systematic search for studies of outcomes or implementation issues of programs that promote HIV testing or that promote linkage to community HIV treatment post-release. Thirty-five articles met inclusion criteria: nine HIV testing initiatives and four linkage programs. HIV testing uptake rates were between 22% and 98% and rates of linkage to community treatment were between 79% and 84%. Findings suggest that some programs may be effective at reducing HIV transmission within the communities to which inmates return. However, attention to implementation factors, such as organizational culture and staff collaborations, appears critical to the success of these programs. Future research using rigorous design and adequate comparison groups is needed.

Full text

Can TasP Approaches Be Implemented in Correctional Settings?
A review of HIV testing and linkage to community HIV treatment
programs
Katherine S. Elkington, PhD,
HIV Center for Clinical and Behavioral Studies, Division of Gender, Health and Sexuality,
Columbia University and New York State Psychiatric Institute
Jessica Jaiswal, MPH, MPhil,
Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University
Anya Y. Spector, PhD,
New York City Department of Health and Mental Hygiene
Heidi Reukauf, MPH, RN,
New York State Department of Health, AIDS Institute
James M. Tesoriero, PhD,
New York State Department of Health, AIDS Institute
Denis Nash, PhD, and
Epidemiology and Biostatistics Program, City University of New York, School of Public Health and
Hunter College
Robert H. Remien, PhD
HIV Center for Clinical and Behavioral Studies, Division of Gender, Health and Sexuality,
Columbia University and New York State Psychiatric Institute
Abstract
High rates of HIV in correctional populations makes evaluation of programs that increase HIV
testing in correctional settings and linkage to HIV treatment upon release, and understanding key
implementation issues of these programs, essential to reducing new HIV infection. We conducted
a systematic search for studies of outcomes or implementation issues of programs that promote
HIV testing or that promote linkage to community HIV treatment post-release. Thirty-five articles
met inclusion criteria: nine HIV testing initiatives and four linkage programs. HIV testing uptake
rates were between 22% and 98% and rates of linkage to community treatment were between 79%
and 84%. Findings suggest that some programs may be effective at reducing HIV transmission
within the communities to which inmates return. However, attention to implementation factors,
such as organizational culture and staff collaborations, appears critical to the success of these
programs. Future research using rigorous design and adequate comparison groups is needed.
Please address all correspondence to Katherine S. Elkington at New York State Psychiatric Institute and Columbia University, 1051
Riverside Drive, #15, New York, NY 10032. Phone: 212-568-4208. ke2143@cumc.columbia.edu.
HHS Public Access
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J Health Care Poor Underserved
. Author manuscript; available in PMC 2017 September 15.
Published in final edited form as:
J Health Care Poor Underserved
. 2016 ; 27(2A): 71–100. doi:10.1353/hpu.2016.0047.
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Keywords
HIV testing; HIV treatment; linkage; corrections
In 2010, as an approach to eliminating the US HIV epidemic, the National HIV/AIDS
Strategy1 placed an emphasis on reducing community viral load by increasing early
identification of HIV infection, rapid linkage to HIV care, treatment initiation with optimal
medication adherence, and sustained retention in care of HIV-positive individuals. This
approach, known as Treatment as Prevention (TasP) is emerging as a promising strategy to
prevent HIV.2,3 It is estimated that the HIV seroprevalence among adults in correctional
facilities (jails or prisons) is approximately three times higher than the general population
(1.5% compared with 0.5%),4,5 with prevalence among prison populations exceeding 5% in
some states (e.g., New York).6 However, among correctional populations, many individuals
living with HIV continue to face barriers to testing and treatment, remaining undiagnosed or
failing to engage in HIV care. A recent review of testing, treatment, and linkage to care
efforts for incarcerated and recently released populations found that rates of linkage to care
upon release were substantially lower than the national average (36% versus 62%); during
incarceration, rates of linkage to care were much higher for incarcerated populations
compared with the general population (76% vs 62%).7 Given the high rates of HIV in
correctional populations and the significant barriers to enrolling in community treatment
once released, identifying and evaluating those programs that successfully address barriers
to HIV testing while in correctional settings and linkage to HIV treatment upon release into
the community are essential to public as well as correctional health.
Adults involved in the criminal justice system are disproportionally racial/ethnic minorities,8
of lower socioeconomic status and are at significant risk for HIV due to a confluence of
individual and contextual/structural factors.9–12 Once an individual has contracted HIV,
there are similar multi-level factors within correctional settings and the community that
present significant obstacles to HIV testing in correctional settings, and access and retention
in HIV treatment and care in the community. In particular, concerns about stigma and
discrimination, medical mistrust around quality of care and/or provider intentions, and a lack
of medical confidentiality have been cited by inmates as significant barriers to accessing
testing and disclosure in correctional settings.13–17
Key structural barriers within correctional settings also make providing HIV testing difficult.
For example, in jail or detention settings (in contrast with prisons) inmates may not remain
incarcerated for a sufficient period of time and may be released without the opportunity to be
tested or to obtain the test results.17 Furthermore, in the majority of states, HIV testing
within correctional facilities is not mandatory or routine, and despite the CDC’s
recommendation, only 7–39% of prisons do so routinely and just over a third of jails offer
HIV testing.13,18 In correctional settings where HIV testing is available, biases within the
facility may hamper who is actually offered testing. For example, while prisoners with
histories of drug use were 10% more likely to be tested, over 60% of men reporting sexual
risk behaviors were never tested, and African American and Hispanic inmates are 30% less
likely than their White counterparts to be tested.19,20 Therefore, inmates in these settings
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must on their own initiative seek HIV testing; the absence of the routine offer of an HIV test
may result in many missed opportunities to identify HIV cases among this high-risk
population.
Upon release into the community, inmates also face numerous challenges to succesful
linkage and retention in HIV treatment and care. Prevalent barriers to accessing and
remaining in HIV care include lack of adequate housing;21–23 lack of health insurance post-
release; difficulty securing employment; psychaitric and substance abuse problems; re-
incarceration;21,24–27 and the experience of multiple, intersecting stigmatized identities
related to HIV status, criminal history, race/ethnicity, poverty, substance use, mental illness,
or sexual orientation. For example, once linked to care, a lack of stable housing can pose
serious challenges to such tasks as making and keeping appointments, consistently taking
one’s medications, and storing medications safely. Similarly, the transition back into the
community may disrupt sobriety achieved while incarcerated or any psychiatric care the
individual was receiving while incarcerated.
Despite these barriers to testing and linkage to treatment, correctional facilities have been
identified as critical settings in which to reduce HIV burden via TasP approaches of
increasing HIV testing and linkage to treatment and care in the community.13,17
Recognizing that challenges on multiple levels hamper inmates’ ability to access and remain
consistently engaged in care, several HIV testing delivery strategies and linkage programs to
HIV treatment in the community have been developed and implemented to combat these
barriers and improve the medical and psychosocial health of correctional populations.
However, many of the barriers that limit inmate access to HIV testing in correctional settings
and linkage to care in the community post-release may also influence the successful
implementation of these programs. Improvements in the implementation, and consequently
in the optimal delivery, of HIV services in correctional settings are critical in order
successfully to mount TasP approaches to HIV reduction and successfully move HIV-
positive inmates along the HIV continuum of care.28
In order to understand where and how to allocate scarce resources within both correctional
settings and the community, it is necessary to understand the effectiveness
and
implementation of these programs. Such data will allow researchers, policymakers,
correctional health practitioners, community-based organizations and HIV medical
practitioners to make informed decisions about which programs to implement, adapt or even
develop in the context of system or organizational characteristics that influence
implementation. Thus, we conducted a systematic review of programs designed to
specifically address two parts of the cascade that are critical to TasP approaches within
correctional populations: HIV testing in correctional settings to identify HIV-positive
inmates and linkage of HIV-positive inmates to HIV care in the community post-release. The
goals of the paper are two: (1) to review the effectiveness of HIV testing and linkage to
community treatment programs and describe key components of these programs; and (2) to
review facilitators and barriers to the implementation of these programs in correctional and
community settings.
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Methods
Procedures
A systematic review of the published literature was performed by three of the authors (KSE,
JJ, AYS) to identify 1) empirical studies of programs or strategies that increase uptake of
testing in correctional settings and 2) empirical studies of programs that promote linkage to
treatment and care post-release. Studies of such endeavors were selected for review if they
were 1) conducted in the United States, 2) were published over the past 15 years (between
2000 and 2015), 3) were published in peer-reviewed journals, 4) reported outcome data (i.e.,
not solely program description) or described implementation findings of programs with
published outcome data, and 5) were reported in English.
The literature search was conducted via Medline (searchable through PubMed), PsycINFO
and SocIndex databases (online databases in the social and health sciences). Additionally,
studies were obtained through bibliographic review of acquired publications. Search term
categories for the first search (HIV testing within corrections facilities) included:
‘correctional’ OR ‘incarcerated’ OR ‘inmates,’ OR ‘jail’ AND ‘HIV testing’ OR ‘linkage,’
OR ‘HIV treatment.’ Search term categories for the second search (linkage to community
HIV care post release) included: ‘incarcerated’ OR ‘inmates’ OR ‘correctional’ OR ‘prison,’
OR ‘jail’ AND ‘HIV,’ OR ‘transition,’ OR ‘linkage,’ OR ‘intervention,’ OR ‘program,’ OR
‘community,’ OR ‘post-release.’
Data synthesis
Three authors (KSE, JJ, AYS) read the full text of all included studies and gathered
information on study site, characteristics of study samples, characteristics of testing or
linkage programs, and relevant outcomes (e.g., testing uptake; percent HIV-positive case
detection; percent linked to treatment) as reported by each study. The majority of studies
included in the review did not include a control group or control period or include changes
in program outcomes (i.e., pre-post data). Therefore, were unable to generate effect sizes for
intervention outcomes, making a meta-analysis of included studies not possible.
Results
The systematic review of the databases for empirical studies of programs or strategies that
increase uptake of testing in correctional settings resulted in 320 potential articles, of which
296 were excluded based on a careful review of title and abstract. Out of 24 articles whose
full-text was reviewed, 11 met the aforementioned inclusion criteria and were included in the
review. A bibliographic review of these publications found three additional manuscripts to
be included. In total, 14 articles met inclusion criteria and were included in this review (see
Figure 1).
The systematic review of the databases for empirical studies of programs that promote
linkage to treatment and care in the community post-release resulted in 577 potential articles
to be included in the review. Out of 52 articles whose full-text was reviewed, 17 met the
aforementioned inclusion criteria and were included in the review. A bibliographic review of
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these publications found four additional studies to be included. In total, 21 articles met
inclusion criteria and were included in this review (see Figure 2).
A total of 35 articles are included in this review. The majority of the studies across both
literature searches employed a post-test only design (n=14; i.e., only present rates of testing
or linkage following implementation of the program without providing rates of testing or
linkage prior to program implementation), which precludes evaluation of program effect.
Eight programs employed a pre-posttest design or had a comparison group, n=7 were
(randomized) control trials; n=6 solely describe implementation of the programs. First, we
review the effectiveness of (1) programs that improve HIV testing in correctional facilities
and (2) programs that improve linkage to HIV care and treatment in the community; we
provide description of key components of each type of program. Second, we review
facilitators and barriers that influence the implementation of these two types of programs in
correctional and community settings.
Effectiveness of HIV Testing and Linkage to HIV Community Care Programs
Programs improving HIV testing in correctional facilities
Our review of HIV testing programs documented three related strategies that were
implemented to address the challenges of HIV testing in correctional settings: 1) routine opt-
out voluntary HIV testing, 2) timing of HIV testing, and 3) use of rapid HIV testing to
ensure prisoners’ receipt of results. Table 1 provides more detailed information about the 14
HIV testing programs reviewed. Of note, several studies examined feasibility and
acceptability of multiple testing strategies (i.e., routine, opt-out rapid testing) at the same
time, precluding our ability to make declarative statements about specific methods.
Routine opt-out HIV testing—The CDC has recommended routine opt-out HIV testing
for all patients in health care settings, including correctional settings, since 2006.29 Routine
opt-out testing has been conceptualized as a policy measure to protect the public’s health as
well as to preserve the privacy and human rights of the incarcerated individual by
prioritizing access to health care screening, while maintaining the individual’s ultimate right
to refuse.30 Eight published articles examined the feasibility and/or efficacy of routine opt-
out testing in correctional setting and found acceptance/uptake rates between 22% and
90%,31–39—with significant increases the uptake of HIV testing in studies that compared
pre-routine opt-out testing protocols. Rates in detection of HIV cases ranged from 0.03 to
2%, with confirmed
new
cases ranging from 0.13% to 0.8%. Of note, data from one study38
are derived from the “Enhancing Linkages to HIV Primary Care and Services in Jail
Settings” (EnhanceLink), which is a 20-site initiative to determine how best to detect HIV
and secure linkages to treatment within jails and in the community after release.38,40
Three studies31,34,37 conducted in jail and prison settings provided data comparing opt-out
to inmate-request strategies. These studies found increases in uptake of HIV testing between
21% and 85% when opt-out was implemented. Two studies in jail and prison settings also
examined differences between opt-in and opt-out strategies, and found increases between
18%–21%8 after opt-out strategies were implemented.34,39 Changes in detection of new HIV
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infections increased from 1.8 new cases per year during on-request testing to 5.1 with opt-in
and to 7.6 opt-out testing policies.34
One study, as part of the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS), the
HIV Services and Treatment Implementation in Corrections trial (HIV-STIC) examined the
success of a process improvement model to implement improved HIV services across the
HIV care continuum (prevention, testing, linkage to community treatment) using 14 cluster-
randomized trials. Pearson et al.35 found that out of two cluster-randomized trials focused on
increasing opt-out HIV testing, there was no significant overall effect of increased HIV
testing between experiment and control conditions (logOR=0.16, 95%CI: −0.24–0.57).
Trial-specific analyses revealed a significant effect for one trial (logOR=0.37SE=0.07) and
closer examination of both intervention sites reported increases in uptake of testing of up to
23%.41
Timing of HIV test—Three studies, two of which were randomized control trials (RCTs),
examined how timing of HIV testing influenced uptake in jail settings; no studies examined
timing of testing in prison facilities. Kavasery and colleagues examined the effect of when a
test was offered on testing uptake in controlled trials of routine opt-out HIV testing for
males33 and females.32 Comparing testing on the same day as intake (immediate), the day
after intake (early) or several days after intake (delayed), they found males were between 2.4
and 3.0 times more likely to accept testing if offered same-day or next-day after intake
compared with seven days post-intake.33 Females offered early testing were 2.3 and 2.7
times more likely to accept testing compared with immediate and delayed testings,
respectively.32 Similarly, an evaluation of a routine jail-based HIV testing in Rhode Island29
found that routinely offering HIV testing to all detainees within 24 hours of admission to jail
resulted in capturing 29% of newly diagnosed inmates. Taken together these findings
suggest that approaching inmates for screening as early as possible in the detention or
incarceration process (within 24–48 hours) will result in a substantial increase in testing
uptake as well as detection of new cases before release in jail settings.
Rapid HIV testing—Eight published manuscripts, representing six different HIV testing
initiatives, examined the feasibility and acceptability of providing (opt out) rapid HIV
testing in jails;32,33,37,39,42–45 again, no studies examined rapid testing in prisons. The
advantage of this method of testing over traditional testing methods is that it increases the
likelihood that test results are received by the inmate prior to turnover, transfer, or release;13
rapid-testing can be available in as little as 20 minutes whereas traditonal testing methods
can take from 7–14 days to get results. Rates of acceptance of rapid HIV testing across all
eight studies ranged from 22% to 98%, of which almost all tested inmates received their
results (89.5%–100%). Between 0.6% and 2.0% of tests were positive, and rates of
new
HIV
detection ranged from 0.0% to 0.89%. Only two studies had comparison or baseline groups,
noting an increase between 21%–67% in rates of HIV testing following implementation of
rapid testing.37,39 Spaulding and colleagues39 also compared acceptance of different
methods of rapid testing (oral swab or finger-stick) with each other as well as with
traditional serum blood test. Acceptance rate of the serum test was 43.2% compared with
64.3% for rapid-oral HIV testing; rate of new preliminary positives was 0.43% with rapid-
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oral HIV testing. When finger-stick rapid HIV testing was implemented, acceptance of
testing went to 81.32% and rate of new preliminary positives increased to 0.52%.
Programs improving linkage to HIV treatment and care in the community
Our review of programs to improve linkage to HIV treatment and care in the community
revealed two approaches. The first is a ‘correctional system-based’ approach that focuses on
improving staff ability and/or expanding staff capacity within the correctional setting. The
second is a ‘correctional system—community setting partnership’ approach, in which
correctional facilities partner with agencies within community settings (e.g., community-
based organizations [CBOs], hospitals, health departments, and community-based
organizations) to deliver linkage programs to inmates while incarcerated and upon release.
We review linkage to HIV community treatment and care programs according to these two
approaches. Table 2 provides more detailed information about the linkage programs,
including program description and definition of linkage, reviewed here.
Correctional-system based approach—Two studies of correctional-system based
approaches, one of which was an RCT, linked between 35%–65% of HIV-positive inmates to
at least one HIV care appointment within four weeks post-release.46–48 A common element
of these programs was that inmates met with department of corrections (DOCS) case
managers to plan post-release care for a period of time pre-release. Specifically, in the
Bridges to Good Care and Treatment (BRIGHT) program, DOCS case managers were
required to meet with participants at a minimum of every two weeks prior to release, twice a
week the first week following release, weekly for the following two weeks and then at
approximately two-week intervals up to six months after release.48 Despite intensive case
management, an RCT of the intervention found BRIGHT participants compared with the
standard of care (SOC) were not significantly more likely to attend an HIV appointment
within four, 12 or 24 weeks post-release.46
The second program, designed by the University of Mississippi (MS) Medical Center and
adopted by the MS Department of Corrections,47 also included an electronic sharing of
medical records component in addition to face- to face meetings with DOCS and community
case managers within six months prior to release. Specifically, MS DOCS and the Statewide
HIV Community Service Delivery Network shared the same medical records system. This
method of medical record sharing between DOCS and the community Network permitted
90% of discharged inmates to have a scheduled appointment at an HIV clinic upon release.
Over the course of the intervention, the average number of days from release to linkage
(defined as first contact with a provider) decreased from 79 to 40 days. However only 35%
actually attended the appointment within 30 days; and inmates were only provided with a
30-day supply of antiretroviral (ARVs) medications.
Correctional system-community setting partnership approach—Five different
programs have been developed that involved community organizations entering DOCS
facilities and conducting the linkage work: Positive Transitions, and the HIV-STIC program,
both RCTs, EnhanceLink-COMPASS, EnhanceLink-Project Bridge, and the Corrections
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Demonstration Project. Documented by 19 different manuscripts across multiple sites, these
programs reported linkage rates between 79%–88.4%.
Positive Transitions (POST), a six-session (four pre and two post-release) intervention to
decrease HIV risk and increase access to care for HIV-positive inmates, was evaluated using
an RCT design49. Participants from jails and prisons were randomized prior to release to
either the SOC condition, transitional case management (TCM), or POST, which also
included TCM. Comparing behaviors in the three months prior to incarceration to three
months post-incarceration, participants in POST reported a within-group significant increase
from 62.5% to 84.4% in access to HIV care at a clinic. However, the magnitude of change
was not significantly different from the SOC group (44.4% to 63.0%).
As part of the HIV-STIC multi-site randomized trial comparing the change team approach,
which comprised both correctional and community HIV staff, to standard HIV training of
correctional staff, Pearson et al35 found across 7 cluster randomized trails, 88.4% of HIV-
positive participants were linked to care (compared with 69.5% in control arm), with neither
overall significant effect of successful linkage to HIV treatment and care (logOR=0.70;
95%CI:−0.33–1.74) or site-specific effects.
In EnhanceLink the collaboration between correctional settings and community
organizations was a key feature of the initiative. The manner in which this collaboration was
implemented varied from site to site (see Draine et al.40 for detailed program description),
and two different linkage programs were implemented: COMPASS and Project Bridge (see
Table 2 for detailed program description). Cumulatively across all 10 sites, 9,837 HIV-
positive inmates were offered linkage to transitional services including housing, drug
treatment, medical care and social services and 82% accepted the offer.38 Of those inmates
enrolled in the client-level portion of the multi-site evaluation (n=1,386) across all sites,
79% were linked to care and 74% received additional community services within 30 days
post release.50 Site-specific or subsample data from EnhanceLink reveal that between
55.6%–100% of inmates were linked to care upon relase (see Table 2).22,23,51–56
The Corrections Demonstration Project (CDP) is a five-site initiative to enhance
collaboration between public health, correctional facilities and community-based health
providers to improve continuity of care for HIV-positive inmates post-release.57 Case
management services were offered that started inside the facility and continued for six
months post-release from either a jail or a prison facility. Approximately 97% of those
enrolled in the program reported having a primary location for HIV treatment and care
during the follow-up period. Data on HIV service linkage was not described, but a
significant increase between pre- and post-incarceration was noted for use of substance
abuse treatment (34% vs. 62%, respectively). Of note, a key feature of the program was to
meet the inmate ‘at the gate’ upon release. However, “logistical impediments” (pg. 667) to
successful implementation of this program resulted in 54% of participants not being met
upon release and not linked. Comparison between the two groups found participants met at
the gate upon release were more likely to engage in drug treatment and not engage in sex
exchange in the six months post-release than those who are not ‘met at the gate.’ This
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finding suggests a key element of case management post-release linkage programs occurs
immediately upon release into the community.
Implementation of HIV Testing and Linkage to HIV Community Care
Programs
The translation of evidenced-based HIV testing, linkage, treatment, and prevention programs
into real-world settings can be challenging. Implementation of these programs for
inmates/ex-offenders appears to be particularly challenging at both structural and individual
levels. Below we describe facilitators and barriers to implementation experienced with the
testing or linkage programs reviewed above. Facilitators and barriers are reviewed at
structural (system/staff and policy) and individual levels, and separately for testing and
linkage programs. In some instances, implementation issues were discussed as part of the
manuscript in which outcome data were reported, whereas in others, manuscripts were
written specifically to detail the implementation process.
Implementation of programs improving HIV testing in correctional settings
Correctional system/staff—All reported barriers related to implementation of HIV
testing programs and initiatives were at the system level. With opt-out testing models, high
turnover/rapid release of inmates in jails was cited as a considerable barrier to providing
results of testing if rapid testing was not implemented as part of the protocol and the
provision of confirmatory testing if rapid testing was used.32,33,37,58 These findings suggest
that correctional systems may need to develop procedures to accomplish screening and result
delivery within 24–48 hours, and engage public health infrastructure (i.e., Department of
health and local CBOs) when necessary to track participants who did not receive their
screening result or receive confirmatory testing.40 Qualitative evaluation of correctional
medical staff perspectives revealed opt-out, rapid-testing improved and streamlined the
testing and linkage to treatment process within correctional facilities, but staff noted the
delivery of positive HIV test results during the initial highly-active intake period was
considered difficult43,58
Implementation of programs improving linkage to HIV treatment in the community
Correctional system/staff—A critical barrier to successful implementation of linkage
programs was the difference between correctional and HIV/AIDS community agency
mission and culture.36,59,60 Correctional agencies’ focus on security contrasted with the HIV
community agencies’ focus on health and well-being of inmates. Additionally, policies and
procedures within corrections agencies also hindered implementation of programs. For
example, correctional facilities, focused on security, often limited access of community HIV
agencies to inmates or required community organizations to have correctional escorts that
were often unavailable.
Strong communication and collaborative relationships with correctional staff were also
critical.36,60 Regardless of administrative mandates, relationships with on the ground
workers were seen as the linchpin to successfully getting programs, or their specific
elements, to work. For example, programs designed to meet a participant immediately upon
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release (at the gate) were only able to do so with excellent communication with correctional
staff who would inform program staff if inmates were being released early, moved, or
otherwise advancing unexpectedly through or out of the system.59,61 Additionally,
communication between corrections agencies, CBOs and state or county level departments
of health was often problematic; the latter was perceived to be far removed from the issues
facing frontline staff.
Community setting/staff—Community-based organization staff involved in CDP
described one of the biggest obstacles to successful linkage and engagement in HIV
treatment and care was getting their participants enrolled in support or auxiliary services
(e.g., housing, substance use treatment) due to low availability of services. Furthermore,
because participants had criminal records, especially drug charges, staff described that
participants were often ineligible for these services. Indeed, discrimination related to
multiple stigmatized identities (e.g., HIV-positive, ex-offender, substance user or mentally ill
and minority status) prevented ex-inmates from accessing and remaining in services upon
release.48,59,58 Establishing stable housing was highlighted as a particular barrier to
successful linkage to HIV treatment and care. In a related vein, finding employment was a
significant barrier despite innovative methods tried by staff members to identify positions
that would be friendly towards those with a criminal history (e.g., soliciting opportunities at
Alcoholics Anonymous meetings; identifying employment agencies that would work with
ex-offenders).61
Staff also described difficulties with “long-distance” linkage. In many instances inmates are
incarcerated far from home, and therefore the local CBO who initially works with the inmate
pre-release is not well-placed to assist the inmate locate services in his/her community upon
release. Community-based organizations engaged in on-site linkage frequently described
insufficient communication between themselves and local CBOs in the inmates
neighborhood resulting in many inmates getting lost upon release.59
Policy—Securing health insurance was a significant barrier to accessing services, including
medical care. Although several states have developed mechanisms to address the gap in
coverage immediately post-release (e.g., NYS with AIDS Drug Assistance Program), lack of
Medicaid coverage upon release remains one of the most significant barriers to successfully
implementing linkage to care programs.59
Individual—At the individual level, linkage staff described significant difficulty convincing
participants that medical care was a priority, when other basic needs (i.e., shelter) were
unaddressed.58,59,61 Similarly, engaging participants to begin and remain in auxiliary
services, such as substance abuse or mental health treatment, was a challenge. Staff
described the importance of establishing trusting relationships with inmates and noted that
the brief nature of some programs (less than six months) hampered their ability to engage
with and thus successfully work with inmates upon release.61 Finally, individuals with
various comorbidities, especially substance use, appeared to be less successful at linking to
and obtaining HIV care.47 Substance use emerged as a significant barrier to adherence in
treatment and care, either directly or indirectly via unstable housing and relationships.48
Findings from the EnhanceLink program indicate that individuals who were more likely to
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be linked to care included those who were White, male, aged 40 years and older, those who
received HIV or medication education while in jail, had a completed discharge plan upon
release, and whose release was known in advance by EnhanceLink staff.50,51 Comparing
characteristics of those lost-to follow-up to those who successfully linked, Teixeira and
colleagues52 found those lost-to-follow-up were more likely to be younger, non-Hispanic
Black, female or transwomen. Indeed, Meyer and colleagues51 found that incarcerated
females fair less well at each point of the HIV continuum than their male counterparts.
Finally, the HIV-STIC study was designed to examine implementation strategies aimed at
improving HIV services for inmates or those under community supervision. The study
focused on improving acceptability (i.e., staff perceived value in improving HIV services),
feasibility (i.e., practical considerations of services improvements) and organizations support
(i.e., organizational acceptance of and commitment to planned improvements to HIV
services). It was hypothesized that improvements in these implementation factors via a local
change team (the implementation strategy) comprised of correctional, medical and
community staff would in turn improve HIV services for inmates. The study found that over
13 months, the medical staff in the experimental arm showed increases in feasibility and
acceptability compared with the control arm. This was not the case for correctional staff who
reported decreases in feasibility of implementing improved HIV services. There were no
differences in changes in organizational support across arms over time. Taken together, these
findings indicate that differences in staff attitudes may highlight the potential differences in
mission between medical and correctional staff, particularly in the context of unchanging
organizational support.36,60 Evaluation of client outcomes (i.e., increases in HIV testing and
linkage to community treatment upon release) were negligible.35 However, inmates in
experimental correctional facilities did demonstrate an increase in awareness of HIV and
perceived relevance of HIV services.41
Discussion
The programs reviewed here provide important information on the results and components
of HIV testing and linkage to community treatment programs for HIV-positive inmates both
while in correctional settings and once released into the community. The results of the
testing programs varied widely, with HIV testing acceptance rates ranging from 22% to 98%
depending on the modality and timing offered. Similarly, results from linkage programs also
showed wide variability (35%–84%) depending on program type and site-specific
implementation issues. Taken together, these findings suggest that TasP approaches to HIV
in correctional settings may be effective at reducing HIV transmission within the
communities to which inmates return upon release. However, attention to key
implementation factors, such as culture and mission of the respective correctional and public
health agencies and strong staff collaborations, appears critical to the success of both testing
and linkage to community treatment programs, and thus to TasP approaches of reducing
HIV.
Overall, testing programs that offered rapid, opt-out HIV testing, implemented within 48
hours, reported the highest rates of testing uptake and were identified as effective, feasible
and acceptable methods of increasing uptake of testing and delivery of results to almost all
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participants tested. Elements of these programs, therefore, addressed two key system barriers
to HIV testing in correctional settings: high inmate turnover and timely return of positive
results. However, the ability of these programs to identify
new
HIV positive cases was
limited (up to 0.91% tested were new cases). Based on a cost-effective analysis, researchers
have advised that routine, opt-out HIV testing only be provided in facilities where
prevalence of previously undiagnosed HIV infection has been documented to be more than
0.1%.62
Success of HIV testing programs to detect new HIV infection may be improved if programs
address known individual-level barriers to HIV testing within correctional settings.
Correctional settings are in a unique position to facilitate testing and initiation of ART more
equitably compared with the general population due to access to free medical care and
providers.63 However, barriers to HIV testing within correctional settings identified in the
broader literature, such as HIV-related stigma, confidentiality concerns, and mistrust of
correctional medical care, were not addressed by the majority of programs designed to
promote testing of HIV-positive inmates in correctional settings, nor were these potential
barriers examined to determine how they may have influenced testing uptake and program
outcomes. Greater exploration of individual-level barriers and facilitators to successful
testing is necessary via qualitative or mix-method inquiry in order to develop meaningful
policy and programming in order to increase uptake of HIV testing and the identification of
HIV-positive individuals while they are incarcerated.15
The success of correctional-based and collaborative approaches to linkage was also highly
variable. While different definitions of linkage make comparison across programs difficult,
linkage rates appear higher among collaborative approaches (79%–84%) compared with
correctional-based approaches (35%–65%), and rates for each were similar to linkage rates
noted in the general population (62%7). However, one correctional-based and two
collaborative approach linkage programs evaluated by RCTs showed no significant
improvement of the experimental program compared with SOC in any of the studies. These
findings, corroborated by staff reports, suggest that HIV linkage to treatment programs may
need to be substantially intensified with respect to length and access to or provision of
auxiliary support services to meet the needs of this high-risk, high-need population.
The success of these linkage-to-community care programs may be also hampered by
additional factors at multiple levels that interfere with their implementation. Yet, we have a
limited understanding of barriers and facilitators to implementation of programs that seek to
link HIV-positive inmates to community services upon release. Furthermore, in contrast to
research that has examined implementation strategies to optimize HIV testing programs
(e.g., time of testing, opt-out vs opt-in testing, rapid testing), almost no work has developed
and examined key implementation strategies to linkage. Improving implementation, and
subsequently the success and sustainability of linkage programs in routine practice, should
be a critical focus of future research. Studies that described implementation barriers to
linkage programs found that navigating the contrasting culture and mission between
correctional settings and HIV CBOs, as well as achieving commitments to the programs at
the level of jail or prison administration were essential for case management, referral, and
other key linkage elements to be successfully achieved. The CJ-DATS: HIV-STIC
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intervention is the only study found as part of this review that examined an implementation
strategy targeting organizational-level barriers to improve uptake of HIV services across the
care continuum.28,35,41,60 Emerging findings from this study suggest a complex interaction
of staff and system level factors that influence the successful rollout and uptake of evidence-
based practices for HIV for inmates. Future research that employs a multi-level, ecological
model to examine implementation facilitators and barriers at system-, staff-, and inmate-
levels will help inform the development of implementation strategies for linkage programs
that can successfully work within correctional settings and that will allow the scale-up and
sustainability of efficacious programs across various correctional and community settings.
The combination of more intensive linkage programs for inmates with structural or
organizational-level interventions may significantly improve the success of linking inmates
to HIV treatment upon release.
Finally, we found that studies of HIV testing and linkage to HIV community care programs
were variable in their methodology and overall quality. Specifically, three key limitations of
the testing and linkage program literature precluded a rigorous evaluation of the efficacy of
these approaches, and are thus avenues for future research. First, the study designs used to
assess efficacy of these interventions. As noted, the majority of programs (n=14) were
evaluated with a single-arm, post-test design in which testing uptake or linkage rates were
reported as evidence of program success without comparison to rates of testing uptake or
linkage before the program was implemented or to a standard of care/comparison group. In
particular, the three linkage program evaluation studies that used controlled designs
(BRIGHT, POST, HIV-STIC) found no difference between the intervention and standard of
care. Future studies that employ more rigorous study design (e.g., RCT or a quasi-
experimental design) are needed in order to identify successful testing and linkage strategies
to be disseminated throughout correctional settings. The second limitation to determining
efficacy of linkage programs is the lack of consensus among researchers on definitions for
linkage and retention in treatment employed by researchers (e.g., attendance at appointment
within 30 days, 60 days, 90 days) (see Table 2). A clear and consensually understood
meaning of successful linkage will allow comparison across programs and close
examination of those programmatic elements that confer success. Finally, we are lacking
reliable or valid measurement strategies that can be used to track offenders over time.
Montague and colleagues64 recommend using innovative technological strategies to develop
scalable metrics with which to assess adequacy of linkage to care after release. Without such
metrics it is challenging to determine how well interventions succeeded and how ex-
offenders are using services post release. The authors recommend using de-identified client
level data from Ryan White-funded programs that serve post-release prisoners in order to
track programs’ successes and challenges in engaging and retaining ex-offenders in
treatment and services. Using aggregated data may help identify best practices by examining
those programs that are successful and replicating key components across settings.
In conclusion, despite the significant need to provide HIV testing to inmates in correctional
facilities and link HIV-positive inmates to HIV treatment and care upon release in the
community, there are few programs that have been developed and implemented to address
this need. This review identified nine separate HIV testing initiatives and four linkage to
HIV community treatment programs, the evaluation of which was hampered by limited data
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that described changes in HIV testing uptake or linkage success. Moreover, implementation
difficulties appeared to limit the success of linkage programs and much work remains to be
done to optimize these programs. Nonetheless, several programs demonstrated substantial
success, reporting rates of HIV testing uptake (98%) and linkage to HIV treatment (84%)
that are higher than those reported in the general population,65 suggesting that TasP
approaches to HIV prevention and elimination in this high risk and high need population can
indeed be effective.
Acknowledgments
Funding: This research was supported by several grants from the National Institute of Mental Health
(P30MH43520; PI: R. H. Remien; K01MH089832, PI: K.S. Elkington) and by a grant from the Centers for Disease
Control and Prevention (CDC) (U62PS003692; PI: J.M. Tesoriero). The authors have no competing interests to
declare.
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public health priority. Virulence. 2012 May 1; 3(3):319–24. Epub 2012 May 1. http://dx.doi.org/
10.4161/viru.20432. [PubMed: 22561157]
65. Gardner EM, McLees MP, Steiner JF, et al. The spectrum of engagement in HIV care and its
relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011 Mar 15;
52(6):793–800. http://dx.doi.org/10.1093/cid/ciq243. [PubMed: 21367734]
Elkington et al. Page 18
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Figure 1.
Systematic search strategy for empirical studies on programs or strategies that increase
uptake of testing in correctional settings
Elkington et al. Page 19
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Figure 2.
Systematic search strategy for empirical studies of programs that promote linkage to
treatment and care in the community post-release
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Elkington et al. Page 21
Table 1
Description and findings from n=14 studies of HIV testing programs in correctional facilities
Author, year Sample, site Study Design Testing Strategy Approach Time of HIV test offering/delivery Offered %(n) Tested %(n)
Identified HIV+/
Reactive testa,b* %
(n) Newly HIV+ Identifieda,c
%(n)
Beckwith et al., 201238 Multi-site:
Baltimore
N=72,000 inmates
12-month uptake data
2-month baseline data Routine opt-out HIV testing
Rapid (oral) HIV test Jail intake or 3–4 days after intake during
syphilis testing Baltimore: 13% (9268)
of total intakes Baltimore:
Baseline: 0.4%
12m: 22% (2066)
Baltimore:
12m: 2% (42) Baltimore:
12m: 0.34% (7)
Philadelphia
N=39,181 inmates Philadelphia: 100%
(39,181) of total intakes Philadelphia:
Baseline: 10%
12m: 69% (27,000)
Philadelphia:
12m: 0.6% (156) Philadelphia:
12m: 0.28% (75)
Washington DC
N=17,903 Inmates Washington DC: 89%
(15,982) of total intakes Washington DC:
Baseline: 12%
12m: 79% (12,546)
Washington DC:
12m: 0.8% (106) Washington DC:
12m: 0.48% (60)
Jail
Beckwith et.al., 201144 N= 1,364 newly detained male
inmates;
Jail
Pilot program uptake
No baseline/control group Rapid (oral) HIV test Jail intake or within 24 hours 1,364 enrolled in pilot
program 98% (1343) 0.8% (12) .07% (1)
Beckwith et al., 200743 N=113 male inmates; mean age 29;
46% white; 25% Black; 17%
Hispanic
Jail
Pilot program uptake
No baseline/control group Rapid (oral) HIV test Within 48 hours of jail intake 100 enrolled in pilot
program 95% (95) 1% (1) 0% (0)
CDC, 201129 N= 34,278 male inmates
Prison Comparison groups across 3 testing
policies (59) months:
Voluntary testing=19 months
Opt-in=31 months
Opt-out= 9 months
Routine opt-out HIV testing
Enzyme immunoassay/Western blot On request
During intake to all those not know to be
HIV+
Voluntary testing:
N=12,202
Opt-in testing: N=
16,908
Opt-out testing: N=5,168
Voluntary testing: 5% (610)
Opt-in testing: 72% (12,173)
Opt-out testing: 90% (4,651)
N/A Voluntary testing: 0.50%
(3)
Opt-in testing: 0.11% (13)
Opt-out testing: 0.13% (6)
CDC, 201031 N=140,739 jail admissions (male
and female)
Jail
Evaluation of 7 years of HIV testing
records; program uptake
No baseline/control group
Routine opt-out HIV testing;
Timing of HIV test
Enzyme immunoassay/Western blot
Jail intake, within 24 hours 140, 739 73% (102,229) 1.2% (1259) 0.17% (169)
Kavasery, Maru, Sylla et al,
200933 N=298 male inmates; mean age 35;
19% Hispanic; 35% black; 46%
white/other
Jail
RCT of timing of HIV test delivery
(3-weeks) Routine opt-out HIV testing
Rapid (oral) test
Timing of HIV test
1Immediate: day of
admission (n=103)
2Early: 1 day later (n=98)
3Delayed: 7 days later
(n=97)
Immediate: 95% (98)
Early: 76% (74)
Delayed: 51% (49)
Immediate: 45% (46)
Early: 53% (52)
Delayed: 33% (32)
Early>Delayed
Imm.>Delayed
1.38% (2) 0.69% (1)
Kavasery, Maru, Homonoff, et
al., 200932 N=323 female inmates; mean age
33.6; 51% white/other; 32% black;
Jail
RCT of timing of HIV test delivery
(5-weeks) Routine opt-out HIV testing
Rapid (oral) test
Timing of HIV test
1Immediate: day of
admission (n=108)
2Early: 1 day later (n=108)
3Delayed; 7 days later
(n=107)
Immediate: 86% (93)
Early: 81% (87)
Delayed: 63% (67)
Immediate: 55% (59)
Early: 73% (79)
Delayed: 50% (54)
Early>Imm
Early>Delayed
1.04%* (2) 0% (0)
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Author, year Sample, site Study Design Testing Strategy Approach Time of HIV test offering/delivery Offered %(n) Tested %(n)
Identified HIV+/
Reactive testa,b* %
(n) Newly HIV+ Identifieda,c
%(n)
Kendrick et al, 200446 N=2128 Female detainees;
Jail, (STD clinic, & emergency
department)
Program uptake data
(4.5 months)
No baseline/control group
Rapid HIV test
“SUDS” rapid test Jail intake (initial medical examination) 2128 enrolled 46% (988) 0.91% (9) 0.91% (9)
Liddicoat et al., 200635 N=1004 inmates; 91% male; 48.1%
African American
Prison
Pre-post trial with historical 12-
month control comparison group
(5 months)
Routine opt-out HIV testing
Blood drawn enzyme immunoassay Intervention: Prison intake
Control: upon request Intervention: 1,004
enrolled
Control: 1723
Intervention: 73.1% (734)
Control: 18% (318) Intervention: 0.3%
(2)
Control: Not
provided
Intervention: 0.3% (2)
Control: Not provided
MacGowan et al., 200945 N=550,000 male and female
intakes;
Jail
Program uptake data
(2.5 years)
No baseline/control group
Rapid HIV testing 24 or 72 hours post intake Not reported 33,211 1.3% (440) 0.8% (269)
Pearson et al., 201436 N=6600 Male and female intakes
Jail and prison Cluster randomized trials on
matched pairs of facilities;
(2.5 years)
Routine opt-out HIV testing Not provided Site 1:1650
Site 2: 1650 Site 1 Not provided Not provided
Exp:
48.1% (794) Cont:
49.2% (812)
Site 2
Exp:
52.90% (873) Cont:
43.69% (721)
Site 2:
Exp >Cont.
Spaulding et al., 201440 N=30,316 male and female intakes
Jail Baseline: 3 months Baseline: opt-in serum HIV testing Jail intake or at medical evaluation within
14 days of intake Baseline: 5218 Baseline 43.2% (2253) Baseline: 3.16% Baseline: Not reported
Phase 1: 14.5 months Phase 1: opt-out oral rapid HIV test Phase 1: 18,869 Phase 1: 64.3% (12,141) Phase 1: Not
reported Phase 1: 0.43% (52)
Phase 2: 12 months Phase 2: opt-out finger stick HIV test Phase 2: 20,947 Phase 2: 81.32% (17,035) Phase 2: 1.33% (226) Phase 2: 0.52% (89)
Spaulding et al., 201339 N=877,119 admissions
20 Jails Program uptake data (3 years)
No baseline/control group Routine opt-out HIV testing Jail intake 56.9% (499,131) 42.13% (210,267) 0.62 % (1,312) 0.39 % (822)
Swan et al., 201537,
e
N=3300
d
Male and female intakes
Jail and prison
Cluster randomized trials on
matched pairs of facilities
(10 months)
Routine opt-out HIV testing Not provided Not provided Site 1
d
:
Baseline=4%
Post-intervention= 8%
Site 2
d
:
Baseline:=3%
Post-intervention=26%
Not provided Not provided
a
%= identified by the testing method being evaluated (e.g. rapid testing as opposed to confirmatory screening);% includes false positives
b
%=number tested positive/number offered tested
c
%=number tested newly positive/number offered tested
d
Sites described represent experimental sites only.
e
Subset of Pearson et al. not included in determination of overall rates of linkage
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RCT=Randomized control trial; Exp=Experimental group; Cont.=Control group
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Table 2
Description and findings from n=21 studies of linkage programs to HIV care in the community upon release
Author, year Sample, site Study Design Linkage Program Approacha% Linked to care in the
community Program Description
Konkle-Parker et
al. 201148 N=676; 78.9% male;
83.9% African
American; 50% ≥40
years
Prison
Program uptake
No baseline group/
comparison
Definition of linkage:
Contact with provider within
30 days of release
Correctional-system based
30 days or less:
35%
At some point post release:
61%
Significant decrease in the
number of days from release
to linkage in care from 79 to
40 days.
MISSISSIPPI
Description:
a discharge planning program
coordinated between corrections and
community case managers
Pre-release contact
: DOCS case managers
(CM) and community CM meet with
participants within 6 months pre-release
Post-release contact
: Not described;
participants had to attend community clinic to
receive CM and ancillary services; DOCS CM
and community CM coordinate.
Unique elements:
Medical record sharing
between DOCS and community network.
Wohl et al.
201147
b
N=104; 62.5% male,
9.6% white, 67.3%
African American
Prison
RCT: BCM vs SOC; assessed
4, 12, 24 and 48 weeks after
prison release
Definition of linkage:
≥1
appointment within 4 weeks
post-release
Correctional-system based No significant differences in
linkage between groups
4 weeks:
BRIGHT=65.1%
SOC= 54.4%
12 weeks
:
BRIGHT=88.4%
SOC=78.3%.
24 weeks:
BRIGHT= 90.7%
SOC=89.1%
48 weeks
:
No change from 24 weeks
Bridging Case Management (BCM)-
BRIGHT
Description:
client-led case management for
inmates transitioning back into community
Pre-release contact
: DOCS case managers
(CM) meet with participants at a minimum of
every 2 weeks before release
Post-release contact
: 2 × week in 1st week; 1 ×
week in 2–3 weeks; 1 × 2 weeks in 4–24
weeks
Unique elements
: motivational; primarily
directed by the client rather than the case
manager
Arriola et al.
200752 n=226 from five sites;
67% white; 20% African
American
Jail and prison
Pre-post design; baseline and
6-month follow up interviews
Definition of linkage:
Not
described
correctional system – community
setting partnership Linkage to HIV services not
reported.
46% met by case manager at
release; associated with
better substance use and
sexual risk outcomes
CDP (Corrections Demonstration Project)
Description:
Department of Health,
correctional facilities and community-based
organizations developed case management-
based linkage programming
Pre-release contact
: case manager assesses
discharge planning needs
Post-release contact
: 30-day services/status
form completed at 30 day intervals
Unique elements:
Case managers attempted to
meet client as soon as possible after release
(“at the gate”) to transport to housing or drug
treatment
MacGowan et al
201450 n=73; 88 % men; 56 %
non-Hispanic black;
mean age 41 years old.
Correctional facilities
(jails, prison, medical
facility)
RCT
Definition of linkage:
at least
one appointment 3 months
post-release
Correctional system – Community
setting partnership POST
Baseline: 62.5%
3m post: 84.4%
SOC:
Baseline: 44.4%
3m post: 63.0%
POST
Description:
a linkage intervention with
community CM, focused on HIV prevention,
adherence and access to HIV services
Pre-release contact
: 4 sessions pre-release with
community CM
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Author, year Sample, site Study Design Linkage Program Approacha% Linked to care in the
community Program Description
No significant differences
between POST and SOC
Post-release contact
: 2 sessions post-release
with community CM
Pearson et al.
201436
c
14 cluster-randomized
trials at 9 sites
Prison and jail
RCT (cluster)
Definition of linkage:
contact
with community HIV
treatment
Correctional system – Community
setting partnership Experimental: 88.4%
Control: 69.5%
No significant differences
between experiment and
control groups
HIV-STIC
Description:
modified Network for the
Improvement of Addiction Treatment (NIATx)
process improvement model to improve access
to HIV services using a Local Change Team
(LCT), which comprised correctional and
community HIV staff.
Staff/organizational-level intervention; linkage
programs not described.
Booker et al.
201351 N=1021; 68.6% male;
60% Black, 19.7%
white; 24.3% Hispanic,
46.5% between 40–49
years old
Jail
Program uptake
No baseline/control group
Definition of linkage:
provider appointment,
VL/CD4 test or prescription
refil within 30 days post-
release
Correctional system – Community
setting partnership 79% linked to care EnhanceLink
*
Description
: a 20 site evaluation project
designed to identify HIV-positive people in jail
and link them to community-based care
following release.
Spaulding et al.
201339 20 jails, N=877,119
inmates; no
demographic data
provided
Jail
Program uptake
No baseline group/
comparison
Definition of linkage
:
attendance at appointment 30
days post-release
Correctional system – Community
setting partnership Across all sites:
9,837 HIV positive inmates
were offered linkage
82% accepted
EnhanceLink
*
Description
: a 20 site evaluation project
designed to identify HIV-positive people in jail
and link them to community-based care
following release.
Altoff et al.
201263 N=867 across 10 jails;
68% male; 58% African
American, 23% White;
mean age 43 years old
Jail
Program uptake
No baseline/control group
Definition of linkage:
1 clinic
visit during each quarter in
the 6 month post-release
period.
Correctional system – Community
setting partnership First quarter: 58 %
Second quarter: 47% Site-specific/subsample study of
EnhanceLink
*
Beckwith,
Bazerman et al
201464
n=64; 89% male, 44%
Black, 30% Hispanic,
23% white
Jail
Retrospective review of
medical records
No baseline group/
comparison
Definition of linkage:
Appointment within 90 days
of release
Correctional system – Community
setting partnership 58% linked post-release.
12.5% linked within 90 days. Site-specific/subsample study of
EnhanceLink
*
Jordan et al.
201365 N= 4845; NYC
Department of
Corrections, Rikers
Island jails
Jail
Pre-post design
Definition of linkage:
Linked
to community health provider
within 30 days of release
Correctional system – Community
setting partnership Pre: 70%
Post: 74% Site-specific/subsample study of
EnhanceLink
*
Meyer et al
201456 N=867; 68% male; 59%
Black, 223% Hispanic;
mean age 43
Jail
Pre-post design
Baseline and 6 months
Definition of linkage:
Clinic
appointment, usual HIV
provider 6 months post
release
Correctional system – Community
setting partnership Usual HIV provider
Baseline: 65% women, 73%
men
6m: 50% women, 63% men
6m:
Site-specific/subsample study of
EnhanceLink
*
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Author, year Sample, site Study Design Linkage Program Approacha% Linked to care in the
community Program Description
HIV clinic appointment:
61.2%
Teixeira et al.
201557 N=434; 78% male,
56.7% non-Hispanic
Black, 35.5% Latino,
49% between 40–49
years old
Jail
Pre-post design
Baseline and 6 months
Definition of linkage
: Usual
HIV provider in past 30 days
Correctional system – Community
setting partnership Baseline: 83.6% linked
6 months: 92.9% Site-specific/subsample study of
EnhanceLink
*
Nunn et al
201066 N=20; 75% male; 40%
African American; 25%
Hispanic; 40% aged 20–
39; 60% aged 40–49.
Jail
Qualitative, in-depth
interviews.
Definition of linkage
: Not
defined
Correctional system – Community
setting partnership 100% linked Site-specific/subsample study of
EnhanceLink
*
Rich et al.
200123 N=97; 71% male,; 51%
Black, 35% White; mean
age 39 years
Prison
Program uptake
No baseline/control group
Definition of linkage:
kept
referral appointment
Correctional system – Community
setting partnership 75% linked with medical
care in community; 100%
received HIV-related medical
services
Site-specific/subsample study of
EnhanceLink
*
Zaller et al
200822 N=59, 68% male; 38%
white, 45% Black; mean
age 42 years
Prison
Program uptake
No baseline/control group
Definition of linkage
:
described
Correctional system – Community
setting partnership 95% received HIV related
medical care Site-specific/subsample study of
EnhanceLink
*
*
EnhanceLink linkage program (i.e. COMPASS or Bridge) not specified; RCT=randomized control trial; SOC=standard of care
a
Approach = ‘
correctional-system based’
approach that focuses on improving staff ability and/or expanding staff capacity within the correctional setting or ‘
correctional system – community setting
partnership
’ approach, in which correctional facilities partner with agencies within community settings (e.g. CBOs, hospitals, health departments) to deliver linkage programs to inmates while incarcerated
and upon release.
b
Haley et al. 201449: implementation study for BCM (see manuscript for review of findings)
c
Visher et al. 201454 and Swan et al 201537: implementation study for HIV-STIC (see manuscript for review of findings)
d
Meyers et al. 200353, Robillard et al. 2003 62 and Robillard et al. 201155 implementation study for CDP (see manuscript for review of findings)
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