Inadequate HIV care after incarceration: case closed

At any given moment, one in 99 adults in the USA are behind bars in prisons and jails, often for offenses related to the use or sale of illicit substances.1 This mass incarceration overwhelmingly affects racial and ethnic minority men; the lifetime risk of incarceration is more than 30% for African-American men, compared with 17% for white men.2 Drug laws that strictly penalise the possession, use, and sale of illicit substances, and the less overt targeting of minorities for search and arrest, have led to people with HIV infection also being disproportionately incarcerated

Postrelease mortality among persons hospitalized during their incarceration

Purpose: Health and mortality of people released from incarceration have received increased attention, and yet little is known about the postrelease experiences of those hospitalized during incarceration. Methods: For persons incarcerated and released from the North Carolina (NC) state prison system between January 1, 2008, and June 30, 2015, we examined postrelease mortality from 2008 to 2016 by history of prison hospitalization. Results: Among 111,479 released persons, 0.9% (n = 1010) were hospitalized during their incarceration, and of those, 10.5% (n = 106) died during follow-up compared with 3.2% (3511/110,469) of other released persons. Those hospitalized in prison had a higher postrelease death rate (adjusted hazard ratio: 2.44), a lower 8-year conditional probability of survival (0.80 vs. 0.94), and were more likely to die from chronic causes (79.2% vs. 51.0%) than other released persons. The postrelease standardized mortality rate among men hospitalized in prison was 3.1 times higher than that of those not hospitalized and 7.1 times the rate of all NC men. Conclusions: People hospitalized during incarceration constitute a particularly vulnerable, yet relatively easily identifiable priority population to focus health interventions supporting continuity of care after prison release. Yet such efforts may be particularly challenging in NC and other Medicaid non-expansion states

Voter Registration among People with HIV in North Carolina

Persons with HIV (PWH) represent a socially and medically vulnerable population who often depend on public resources. We examined voter registration among PWH in North Carolina. Sixty-four percent were registered to vote. Registration was lower among PWH who were young, Hispanic, publicly insured or uninsured, and who had poor HIV health status

Great Expectations: HIV Risk Behaviors and Misperceptions of Low HIV Risk among Incarcerated Men

Incarcerated populations have relatively high HIV prevalence but little has been reported about their aggregate HIV risk behaviors or perceptions of risk. A random selection of HIV-negative men (n = 855) entering a US state prison system were surveyed to assess five risk behaviors and his self-perceived HIV risk. Using multivariate logistic regression, we identified factors associated with having elevated actual but low perceived risk (EALPR). Of the 826 men with complete data, 88% were at elevated risk. While 64% of the sample had risk perceptions concordant with their actual risk, 14% had EALPR (with the remainder at low actual but high perceived risk). EALPR rates were lower in those with a pre-incarceration HIV test but higher for those with a negative prison entry HIV test. HIV testing counseling should assess for discordance between actual and perceived risk and communicate the continued risk of HIV despite a negative result

Detection of undiagnosed HIV among state prison entrants

substantial proportion of individuals infected with the human immunodeficiency virus (HIV) in the United States enter a correctional facility annually.1,2 Therefore, incarceration presents an opportunity for HIV detection. Even thoughmany states have adopted policies of mass HIV screening of inmates,2-4 the extent to which HIV testing on prison entry detects new infections is unclear

Long-Acting Injectable Antiretroviral Therapy: An Opportunity to Improve Human Immunodeficiency Virus (HIV) Treatment and Reduce HIV Transmission among Persons Being Released from Prison Facilities

To the Editor—Antiretroviral therapy (ART) has decreased human immunodeficiency virus (HIV) morbidity and mortality. However, efficacy is dependent upon adherence, which is influenced by behavioral, social, and structural factors. Among these, incarceration can negatively impact ART adherence

“Inside these fences is our own little world”: Prison-based hiv testing and hiv-related stigma among incarcerated men and women

Correctional facilities offer opportunities to provide comprehensive HIV services including education, testing, treatment, and coordination of post- release care. However, these services may be undermined by unaddressed HIV stigma. As part of a prison-based HIV testing study, we interviewed 76 incarcerated men and women from the North Carolina State prison system. The sample was 72% men, median age 31.5 years (range: 19 to 60). Thematic analysis revealed high levels of HIV-related fear and stigma, homophobia, incomplete HIV transmission knowledge, beliefs that HIV is highly contagious within prisons (“HIV miasma”), and the View of HIV testing as protective. Interviewees described social distancing behaviors and coping mechanisms they perceived to be protective, including knowing their HIV status and avoiding contact with others and shared objects. Interviewees endorsed universal testing, public HIV status disclosure, and segregation of HIV-positive inmates. Intensified education and counseling efforts are needed to ameliorate entrenched HIV-transmission fears and stigmatizing beliefs

Implementing a Prison Medicaid Enrollment Program for Inmates with a Community Inpatient Hospitalization

In 2011, North Carolina (NC) created a program to facilitate Medicaid enrollment for state prisoners experiencing community inpatient hospitalization during their incarceration. The program, which has been described as a model for prison systems nationwide, has saved the NC prison system approximately $10 million annually in hospitalization costs and has potential to increase prisoners’ access to Medicaid benefits as they return to their communities. This study aims to describe the history of NC’s Prison-Based Medicaid Enrollment Assistance Program (PBMEAP), its structure and processes, and program personnel’s perspectives on the challenges and facilitators of program implementation. We conducted semi-structured interviews and a focus group with PBMEAP personnel including two administrative leaders, two “Medicaid Facilitators,” and ten social workers. Seven major findings emerged: 1) state legislation was required to bring the program into existence; 2) the legislation was prompted by projected cost savings; 3) program development required close collaboration between the prison system and state Medicaid office; 4) technology and data sharing played key roles in identifying inmates who previously qualified for Medicaid and would likely qualify if hospitalized; 5) a small number of new staff were sufficient to make the program scalable; 6) inmates generally cooperated in filling out Medicaid applications, and their cooperation was encouraged when social workers explained possible benefits of receiving Medicaid after release; and 7) the most prominent program challenges centered around interaction with county Departments of Social Services, which were responsible for processing applications. Our findings could be instructive to both Medicaid non-expansion and expansion states that have either implemented similar programs or are considering implementing prison Medicaid enrollment programs in the future

Financial Barriers and Lapses in Treatment and Care of HIV-Infected Adults in a Southern State in the United States

Antiretroviral (ARV) adherence has largely been considered from the perspective of an individual's behavior with less attention given to potential structural causes for lapses in treatment, such as the cost of medications and care. HIV medication expense is typically covered by third party payers. However, private insurance premiums and deductibles may rise, or policies terminated such as with a change in employment. Likewise, a patient's eligibility for publicly funded coverage like state AIDS Drug Assistance Programs (ADAP) or Medicaid can also be lost. We conducted a one-Time survey of a sample of 300 patients receiving HIV care at a single large academic center in the south of United States to examine lapses in HIV therapy due to financial reasons. We found that during the prior year, financial issues including medication cost or coverage led to a lapse in ARVs in 10% (n = 31) of participants. However, of the 42% (n = 125) participants who had been enrolled in ADAP at any time during the prior year, 21% (n = 26) reported an ARV lapse due to problems with ADAP or medication cost. Respondents cited ADAP's required semi-Annual renewal process and other administrative issues as the cause of ARV lapses. The median duration of missed ARVs was 2 weeks (range of <1-23 weeks). Non-HIV medication and transportation to and from clinic costs were also identified as financial burdens to care by respondents. In conclusion, although conducted at a single medical center and one state, this study suggests that a significant minority of HIV-infected patients encounter financial barriers to ARV access, and this is paradoxically more common among those enrolled in the state ADAP. Streamlining, supporting, and simplifying ADAP renewal procedures will likely reduce lapses in ARV adherence and persistence

Spacetime as a membrane in higher dimensions

By means of a simple model we investigate the possibility that spacetime is a membrane embedded in higher dimensions. We present cosmological solutions of d-dimensional Einstein-Maxwell theory which compactify to two dimensions. These solutions are analytically continued to obtain dual solutions in which a (d-2)-dimensional Einstein spacetime "membrane" is embedded in d-dimensions. The membrane solutions generalise Melvin's 4-dimensional flux tube solution. The flat membrane is shown to be classically stable. It is shown that there are zero mode solutions of the d-dimensional Dirac equation which are confined to a neighbourhood of the membrane and move within it like massless chiral (d-2)-dimensional fermions. An investigation of the spectrum of scalar perturbations shows that a well-defined mass gap between the zero modes and massive modes can be obtained if there is a positive cosmological term in (d-2) dimensions or a negative cosmological term in d dimensions.Comment: 30 pages, 4 figures in 10 files, epsf. This early brane world paper is being placed on the archive to make it more easily accessible, as its results are used in a new brane world construction in an accompanying submissio