About one in five men living with HIV in the U.S. passes through a correctional facility annually. Jails and prisons are seen therefore as key intervention sites to promote HIV treatment as prevention, and the National Institutes of Health has specifically funded “seek, test, treat, and retain” projects focused on correctional facilities. However, almost no research has examined inmate’s perspectives on HIV treatment or their strategies for retaining access to antiretroviral therapy (ART) during incarceration. This paper presents the results of a descriptive, cross-sectional study examining whether, how, and why HIV positive men access health services and adhere to ART as they enter and exit the criminal justice system. Data were obtained from qualitative, semi-structured interviews conducted with HIV positive men and male-to-female transgendered persons [n=42] recently released from male correctional facilities in Illinois, USA. Interviews focused on disclosure and taking ART while incarcerated. Over 60% of study participants reported missed doses or sustained treatment interruption (>2 weeks) because of incarceration. The leading causes of treatment interruption were failure to disclose their HIV status and delayed prescribing, followed by intermittent dosing, out-of-stock medications, confiscation of medications, and medication strikes. Interpersonal violence, a lack of safety, and perceived threats to privacy were frequently cited as barriers to one’s willingness and ability to access and adhere to treatment. Strategies for continuing treatment in jail/prison among those receiving ART when arrested included requesting an HIV test, timing disclosure, managing relations with correctional officers, enlisting family members, avoiding conflict with other inmates, faking mental illness, and hiding medication. Substantial improvements in ART access and adherence are likely to follow organizational changes that make incarcerated people feel safer, facilitate HIV status disclosure, and better protect the confidentiality of inmates receiving ART. Jails and prisons perceived as unsafe are not conducive to the treatment of HIV because inmates often believe an HIV-positive status raises their chances of being subjected to violence. This more immediate concern overrides concern about HIV. For ART to be accepted by inmates, healthy choices also should appear to be reasonable choices
