Frequent emergency department use among released prisoners with human immunodeficiency virus: characterization including a novel multimorbidity index.

OBJECTIVES: The objective was to characterize the medical, social, and psychiatric correlates of frequent emergency department (ED) use among released prisoners with human immunodeficiency virus (HIV). METHODS: Data on all ED visits by 151 released prisoners with HIV on antiretroviral therapy (ART) were prospectively collected for 12 months. Correlates of frequent ED use, defined as having two or more ED visits postrelease, were described using univariate and multivariate models and generated medical, psychiatric, and social multimorbidity indices. RESULTS: Forty-four (29%) of the 151 participants were defined as frequent ED users, accounting for 81% of the 227 ED visits. Frequent ED users were more likely than infrequent or nonusers to be female; have chronic medical illnesses that included seizures, asthma, and migraines; and have worse physical health-related quality of life (HRQoL). In multivariate Poisson regression models, frequent ED use was associated with lower physical HRQoL (odds ratio [OR] = 0.95, p = 0.02) and having not had prerelease discharge planning (OR = 3.16, p = 0.04). Frequent ED use was positively correlated with increasing psychiatric multimorbidity index values. CONCLUSIONS: Among released prisoners with HIV, frequent ED use is driven primarily by extensive comorbid medical and psychiatric illness. Frequent ED users were also less likely to have received prerelease discharge planning, suggesting missed opportunities for seamless linkages to care.

Adherence to HIV treatment and care among previously homeless jail detainees.

HIV-infected persons entering the criminal justice system (CJS) often experience suboptimal healthcare system engagement and social instability, including homelessness. We evaluated surveys from a multisite study of 743 HIV-infected jail detainees prescribed or eligible for antiretroviral therapy (ART) to understand correlates of healthcare engagement prior to incarceration, focusing on differences by housing status. Dependent variables of healthcare engagement were: (1) having an HIV provider, (2) taking ART, and (3) being adherent (≥95% of prescribed doses) to ART during the week before incarceration. Homeless subjects, compared to their housed counterparts, were significantly less likely to be engaged in healthcare using any measure. Despite Ryan White funding availability, insurance coverage remains insufficient among those entering jails, and having health insurance was the most significant factor correlated with having an HIV provider and taking ART. Individuals interfacing with the CJS, especially those unstably housed, need innovative interventions to facilitate healthcare access and retention.

Correlates of STI symptoms among female sex workers with truck driver clients in two Mexican border towns.

BACKGROUND: Female sex workers (FSW) are at increased risk for HIV and other STI due to occupation-related risks and exposures. Long-distance truck drivers have been implicated in the spread of HIV, but less is known about HIV/STI risks of FSW servicing truck drivers, especially in North America. As part of an international collaborative pilot study, we interviewed FSWs servicing truck driver clients along two major transportation corridors to explore factors associated with recent STI symptoms. METHODS: A cross-sectional study of 200 FSW was conducted in Mexico: 100 from Nuevo Laredo (U.S. border); 100 from Ciudad Hidalgo (Guatemalan border). Eligibility criteria included age ≥18 years, speaking English or Spanish, and having ≥1 truck driver client in the past month. The main outcome was reporting any recent STI symptoms, defined as experiencing genital/anal warts, genital ulcers/sores, genital itching, or abnormal vaginal discharge in the past 6 months. Logistic regression was used to identify correlates of recent STI symptoms. RESULTS: Median age of FSW was 29 years, 74% were single, 87% had <9th grade education, and median income was 4000 pesos/month ($300 USD). Sex work occurred at a bar/cantina for 70%. One-quarter had never been tested for HIV, 53% reported lifetime drug use, 22% reported drinking alcohol before/during transactional sex and 17% reported recent STI symptoms. After controlling for age and study site, factors associated with STI symptoms were lifetime drug use (AOR 2.9, 95% CI 1.2-6.9), drug use before/during sex (AOR 2.8, 95% CI 1.1-7.1), alcohol use before/during sex (AOR 5.2, 95% CI 2.2, 12.6), forced sex ever (AOR 2.6, 95% CI 1.1-6.1), lifetime history of arrest (AOR 2.3, 95% CI 1.0-5.0), and being surveyed in Nuevo Laredo rather than Ciudad Hidalgo (AOR 4.8, 95% CI 2.0-10.0). CONCLUSIONS: The associations we observed between recent STI symptoms and drug and alcohol use suggest that interventions are needed that promote consistent and effective safer sex practices, especially while under the influence of alcohol or other substances.

Emergency department use by released prisoners with HIV: an observational longitudinal study.

BACKGROUND: Many people living with HIV access healthcare systems through the emergency department (ED), and increased ED use may be indicative of disenfranchisement with primary HIV care, under-managed comorbid disease, or coincide with use of other healthcare resources. The goal of this study was to investigate ED use by HIV-infected prisoners transitioning to communities. METHODS: We evaluated ED use by 151 HIV-infected released prisoners who were enrolled in a randomized controlled trial of directly administered versus self-administered antiretroviral therapy in Connecticut. Primary outcomes were quantity and type of ED visits and correlates of ED use were evaluated with multivariate models by Poisson regression. RESULTS: In the 12 months post-release, there were 227 unique ED contacts made by 85/151 (56%) subjects. ED visits were primarily for acute febrile syndromes (32.6%) or pain (20.3%), followed by substance use issues (19.4%), trauma (18%), mental illness (11%), and social access issues (4.4%). Compared to those not utilizing the ED, users were more likely to be white, older, and unmarried, with less trust in their physician and poorer perceived physical health but greater social support. In multivariate models, ED use was correlated with moderate to severe depression (IRR = 1.80), being temporarily housed (IRR = 0.54), and alcohol addiction severity (IRR = 0.21) but not any surrogates of HIV severity. CONCLUSIONS: EDs are frequent sources of care after prison-release with visits often reflective of social and psychiatric instability. Future interventions should attempt to fill resource gaps, engage released prisoners in continuous HIV care, and address these substantial needs.

HIV testing behaviors among Latinos in Baltimore City.

In the US, HIV disproportionately affects Latinos who often present late in the disease. Baltimore has seen a recent rapid growth in its Latino population paralleled by an increasing impact of HIV/AIDS among Latinos. From 2009 to 2010, we performed a cross-sectional survey of Latinos accessing the Baltimore City Health Department (BCHD) Latino Outreach services to assess self-report of previous HIV testing, with particular attention to migration history and risk behaviors. Of 247 Latinos (46% male) accessing BCHD outreach services, 96% were foreign-born. Self-perceived HIV risk was not associated with actual risk behaviors or HIV testing. In multivariate models, previous HIV testing was correlated with knowledge of HIV transmission modes and knowing that a person with HIV can appear healthy. Consistent with CDC recommendations, HIV screening among Latino immigrants should not be limited to individuals with self-perceived risk for HIV. Promoting key pieces of HIV knowledge may improve HIV testing behaviors.

A systematic review of HIV/AIDS survival and delayed diagnosis among Hispanics in the United States.

HIV/AIDS disproportionately affects Hispanics. Our objective was to determine the risk of late diagnosis and rate of survival after HIV/AIDS diagnosis among Hispanics compared to other racial/ethnic groups. We performed a systematic review of the PubMed database for peer-reviewed articles published between January 2000 and September 2010. Primary outcomes included survival after HIV/AIDS diagnosis and delayed diagnoses. The definition of delayed diagnosis varied by study, ranging from concurrent HIV/AIDS diagnosis to diagnosis of AIDS within 3 years of HIV diagnosis. We found that Hispanics are at significantly greater risk for delayed diagnosis than non-Hispanic whites. Hispanic males and foreign-born Hispanics had the highest risk of late diagnosis. Available data on survival were heterogeneous, with better outcomes in some Hispanic subgroups than in others. Survival after antiretroviral initiation was similar between Hispanics and Whites. These findings emphasize the need for culturally-sensitive strategies to promote timely diagnosis of HIV infection among Hispanics and to examine the health outcomes and needs of high risk Hispanic subgroups.

HIV risk behaviors differ by workplace stability among Mexican female sex workers with truck driver clientele.

BACKGROUND: In a study of female sex workers (FSW) servicing truck driver clients in Mexican border cities, we evaluated differences in HIV/STI risk behaviors by workplace. DESIGN AND METHODS: Our study was cross-sectional and its population comprised 100 FSWs from Nuevo Laredo (US border) and 100 FSWs from Ciudad Hidalgo (Guatemalan border). The main outcome was primary place of sex work defined as unstable (street, vehicle, gas station, etc.) vs stable (bar, brothel, and hotel). Logistic regression was used to identify correlates associated with trading sex at unstable workplaces in the last month. RESULTS: Of the FSW surveyed, 18% reported an unstable workplace. The majority of FSW surveyed were young (<30), single, had <9th grade education, and had worked in the sex trade for a median of 4.9 years. After controlling for study site, FSW with unstable vs. stable workplaces were more likely to have a majority/all truck driver clientele, but were less likely to have visited a gynecologist in the last year (OR 0.1, 95%CI 0.03-0.4) or ever had an HIV test (OR 0.1, 95%CI 0.06-0.3), and there was a trend towards lower condom use self-efficacy scores (OR 0.8 per unit increase, 95%CI 0.7-1.0). On multivariate regression, unstable workplace was associated with having majority/all truck driver clientele, being surveyed in Nuevo Laredo, and decreased odds of ever having an HIV test. CONCLUSIONS: Among Mexican FSW with truck driver clients, providing safe indoor spaces for sex work may help facilitate public health interventions that improve HIV/STI and reproductive health outcomes.

HIV Treatment in the Criminal Justice System: Critical Knowledge and Intervention Gaps.

The criminal justice system bears a disproportionate burden of the HIV epidemic. Continuity of care is critical for HAART-based prevention of HIV-related morbidity and mortality. This paper describes four major challenges to successful management of HIV in the criminal justice system: relapse to substance use, homelessness, mental illness, and loss of medical and social benefits. Each of these areas constitutes a competing priority upon release that demands immediate attention and diverts time, energy, and valuable resources away from engagement in care and adherence to HAART. Numerous gaps exist in scientific knowledge about these issues and potential solutions. In illuminating these knowledge deficits, we present a contemporary research agenda for the management of HIV in correctional systems. Future empirical research should focus on these critical issues in HIV-infected prisoners and releasees while interventional research should incorporate evidence-based solutions into the criminal justice setting.

Advances in the prevention of heterosexual transmission of HIV/AIDS among women in the United States.

Despite recent advances in testing and treatment, the incidence of HIV/AIDS in the United States has remained stagnant with an estimated 56,300 new infections every year. Women account for an increasing proportion of the epidemic. The vulnerability of women to HIV stems from both increased biologic susceptibility to heterosexual transmission and also the social, economic, and structural disadvantages they often confront. This review describes the main reasons for the increased vulnerability of U.S. women to HIV transmission with particular emphasis on specific high-risk groups including: non-Hispanic blacks, women who use drugs, women with a history of incarceration, and victims of intimate partner violence. Although behavioral approaches to HIV prevention may be effective, pragmatic implementation is often difficult, especially for women who lack sociocultural capital to negotiate condoms with their male partners. Recent advances in HIV prevention show promise in terms of female-initiated interventions. These notably include female condoms, non-specific vaginal microbicides, and antiretroviral oral and vaginal pre-exposure prophylaxis. In this review, we will present evidence in support of these new female-initiated interventions while also emphasizing the importance of advocacy and the political support for these scientific advances to be successful.