Predictors of post-release primary care utilization among HIV-positive ...

AIDS Care, May 2006; 18(4): 290 /301

Predictors of post-release primary care utilization among HIV-positive prison inmates: A pilot study

A. J. HARZKE1, M. W. ROSS1, & D. P. SCOTT2 1

WHO Center for Health Promotion and Prevention Research, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas and 2Sage Associates, Inc. Houston, Texas, USA

Abstract The primary aims of this exploratory pilot study were (1) to determine the proportion of a sample of HIV-positive inmates utilizing primary care after recent release, and (2) to identify variables associated with utilization of primary care at the time of a post-release interview. Sixty HIV-positive, male and female state prison inmates were interviewed approximately three months prior to release, and 30 were interviewed again between seven and 21 days after release. Variables associated with having utilized primary care at the time of a post-release interview (x2 p -values B/0.20) included: taking anti-HIV medications at the time of release, no alcohol use since release, living in the same place as before incarceration and rating of housing situation as ‘comfortable’ or ‘very comfortable’. For exploratory purposes, these variables were entered into a logistic regression model. The model correctly classified 80% of cases overall. Future studies are required to ascertain whether these results would obtain with a statistically adequate sample size.

Introduction The disproportionately high burden of HIV/AIDS among inmates in US prisons is well documented (Hammett et al., 2002; Kassira et al., 2001; Maruschak, 2004; Sabin et al., 2001). The Bureau of Justice Statistics (BJS) recently reported the overall prevalence of confirmed AIDS cases in US prisons (0.48%) in 2002 was nearly 3.5 times the prevalence in the general population (0.14%). BJS data indicated 2,053 females and 19,297 males in state prisons were confirmed HIV-positive in 2002, representing 3% and 1.9% of female and male inmates, respectively (Maruschak, 2004). The number of HIV-positive prisoners released annually, although not precisely known, may be as many as half the number of HIV-positive prisoners in custody on a given day (Hammett et al., 2002). The immediate post-release period has been anecdotally described as a critical period for ensuring continuity of care (Hammett et al., 2001; Rich et al., 2001). HIV-positive prison inmates are released with 7/30 days of anti-HIV medications and, in that time frame often must secure or re-establish reimbursement sources for primary care and medication. HIVpositive releasees, like many other inmates, may face the challenges of meeting basic subsistence needs (e.g., housing, clothing, food) and resisting

relapse into substance abuse. However, published studies focusing specifically on HIV-positive releasees are few and provide limited information about factors potentially affecting post-release continuity of care (Conklin et al., 1998; Rich et al., 2001; Richie et al., 2001; Springer et al., 2004; Stephenson et al., 2005). Two studies have documented that a significant proportion of HIV-positive prison releasees, who were treated with antiretroviral therapy and achieved undetectable viral loads while incarcerated, showed substantial rebounds on viral load tests when reincarcerated (Springer et al., 2004; Stephenson et al., 2005). These studies suggest HIV-positive releasees may be vulnerable to discontinuities in care. These studies, however, did not analytically explore the potential causes for this vulnerability. Differences between releasees who experienced viral rebound versus those who experienced sustained therapeutic effects were not examined. Reports from on-going evaluation studies of three reintegration/transitional assistance programs (Conklin et al., 1998; Rich et al., 2001; Richie et al., 2001) have indicated high rates of post-release primary care utilization among HIV-positive program participants. These studies, however, have focused primarily on specific program components as independent variables and have given only limited

Correspondence: Amy Jo Harzke, Centre for Health Promotion and Prevention Research, School of Public Health, University of HoustonTexas, PO Box 20036, Suite 2570C, Houston, Texas 77030, USA. Tel: /1 (713) 500 9975. Fax: /1 (713) 500 9750. E-mail: [email protected] ISSN 0954-0121 print/ISSN 1360-0451 online # 2006 Taylor & Francis DOI: 10.1080/09540120500161892

Primary care utilization among HIV-positive inmates analytical attention to factors potentially mediating, modifying or confounding program effects, such as participants’ background characteristics (e.g., age, gender, race/ethnicity) and their specific needs (e.g., stage of disease, substance abuse, mental health issues) and available resources (e.g., health insurance, housing, transportation). These factors have been associated with various measures of health care utilization in HIV-positive persons (Andersen et al., 2000; Cunningham et al., 1999; Heckman et al., 1998; Hellinger et al., 2004; Shapiro et al., 1999) and have been shown to influence effects of ancillary services on entry or retention in primary care among HIV-positive, non-incarcerated persons (Ashman et al., 2002; Chan et al., 2002; Conover & WhettenGoldstein, 2002; Lo et al., 2002; Messeri et al., 2002). Additionally, only one of these evaluation studies included a control group (Richie et al., 2001). This control group was comprised of HIVpositive inmates who elected not to enroll in the program, but the potential effects of volunteer bias were not addressed. Taken together, these evaluation studies suggest certain program components might support continuity of care for some HIV-positive releasees, but these studies provide little information about which HIV-positive releasees may be more or less likely to benefit and who may be at greatest risk. This purpose of this exploratory pilot study was to learn about HIV-positive releasees and factors potentially affecting their post-release health care utilization. The specific aims were to determine what proportion of HIV-positive male and female state prison inmates used primary care after recent release and to identify variables associated with utilization of primary care at the time of a post-release interview (7 /21 days after release). The results of the study may ultimately assist correctional health care providers and public health leaders in identifying HIVpositive releasees at greatest risk for discontinuities in care and in designing more effective and efficient transitional assistance programs. Methods Procedures Participants were from two large state prisons (one for males, one for females) in the Southwestern USA. The facilities housed only inmates with sentences of two years or less. Criteria for participation were as follows: at least 18 years of age, serving a sentence in one of the study sites, diagnosed HIVpositive by a physician (prior to or during their incarceration), English-speaking and willingness to sign an informed consent form. The sample was purposefully constructed to include at least 40% females.

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Pre-release data were collected between July 2002 and January 2003. Prison medical staff identified potential participants. A liaison from the prison medical system visited each of the facilities (six visits to male facility, four visits to female facility) and individually approached every HIV-positive inmate on the unit on that day about participating in a pre-release interview. All who were approached gave consent for participation in the pre-release interview. Interviews were scheduled within two weeks of obtaining consent. Interviews were conducted approximately three months prior to release. The first author conducted the interviews (60 /90 minutes) in private offices within the medical areas at the study sites. When each pre-release interview was completed, the participant was asked if he or she agreed to be interviewed again after their release. After obtaining consent, the interviewer and participant scheduled a tentative meeting time. The participant was provided with the interviewer’s contact information (a cell phone number, specifically designated for the project). The participant was instructed to confirm their appointment with the interviewer upon release. The participant provided phone numbers of places where they might be staying immediately after release. If the participant did not contact the interviewer within the first seven days after release, the interviewer attempted to contact the participant by telephone (one to two times per week). If direct contact was made with a participant within three weeks, the participant was considered eligible for the post-release interview until six weeks post-release and considered lost to follow-up thereafter. The first author conducted most post-release interviews (45 / 60 minutes) at the main county HIV clinic and two community-based agencies serving people with HIV/ AIDS. A small number of post-release interviews were conducted by telephone because participants returned or relocated to regions outside the metropolitan area. Participants received $15 upon completion of the post-release interview. Study procedures were approved and monitored by a university institutional review board and by the research, evaluation and development unit of the state department of criminal justice. Interview schedules In both interviews, a semi-structured interview format was utilized that combined both qualitative and quantitative questions in multiple domains. The present study was limited to analysis of quantitative items. The pre-release interview schedule included 125 quantitative items addressing the following domains: demographic information, socioeconomic status, social support, criminal history, medical

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history (related to HIV and Hepatitis B or C, where applicable), medical care, medications, payment sources, case management/provision of referrals or information, mental health history and substance abuse history. The post-release interview included 80 quantitative items. These items addressed aspects of participants’ post-release experience with respect to the following domains: transportation, housing, employment, income, social support, sexual and sexually protective behaviors, alcohol or illicit substance use, sources of assistance (for housing, transportation, food and other basic needs), medication adherence and access to medical care, psychiatric care and other supportive services. Items in the pre-release interview relevant to demographics, criminal history and substance abuse history were adapted from a study of incarcerated women by Mullen et al. (unpublished, personal communication). All other items were developed specifically for this study. Analysis Descriptive statistics were calculated, using means and standard deviations for interval data and frequencies and proportions for categorical data. To investigate potential biases associated with differential attrition, chi-square (x2) tests of independence were conducted to assess the associations of variables measured at pre-release with completion of the postrelease interview. Chi-square tests of independence were also conducted to identify variables measured at post-release that were associated with having utilized medical care by the time of the post-release interview. Post-release interviewees were considered ‘in care’ if they had been seen by a primary HIV-care provider or if they had an appointment to be seen by such a provider. Chi-square values obtained for all 2 /2 tables were adjusted using the Yates’ correction for continuity (which produces an estimate similar to Fisher’s exact test). Categories were collapsed for some variables to avoid inappropriately small cell sizes (e.g., 20% or more cells with expected values B/5), but only if it made conceptual sense to do so. Variables with x2 p -values of B/0.20 and appropriate cell sizes were considered noteworthy. For each variable identified as associated with primary care utilization at the time of the postrelease interview (x2 p -valuesB/0.20 and appropriate cell sizes), crude odds ratios with 95% confidence intervals (Fisher’s exact) were calculated for ease of interpretability and for use in subsequent power analyses and sample size calculations. These variables were also simultaneously entered into a logistic regression model to explore their relative predictive strength and significance and the overall ability of

the model to predict primary care status (in care versus not in care). All calculations and analyses described above were conducted using STATA 8.0. Post-hoc power analyses and sample size calculations were conducted for each potential predictor variable (Power and Sample Size Calculations, version 2.1.31; Dupont & Plummer, 1990). Power analyses assumed a retrospective case-control study and specified a /0.05 and Fisher’s exact test. The ratio of post-release participants not in care to those in care was assumed to be m , the ratio of controls to cases. The percentage of those not in care who reported a characteristic of interest was assumed to be p0 , the probability of exposure among controls. Sample size calculations specified a /0.05 and 1-b /0.80 and considered multiple values for odds ratios. Results Participant background characteristics Consent was obtained from 66 eligible prison inmates and 60 completed the pre-release interview. Six eligible inmates were not interviewed due to being released prior to the scheduled interview or being repeatedly unavailable due to their ‘in-house’ work schedule or off-site medical appointments. Detailed pre-release data are shown in the Appendix, stratified by interview completion status. The initial sample was comprised predominantly of African-Americans (65%) and heterosexuals (60%), with slightly more men (55%) than women. A majority indicated less than 12 years of formal education, incomes of less than US$15,000 annually and unemployment or inability to work for more than one year. More than two-thirds (71.7%) did not live in their own home or apartment at any time during the year prior to incarceration, and more than a quarter (26.7%) perceived themselves as homeless. The initial sample reported high rates of substance use in the year prior to incarceration (83.3% crack cocaine, 80% alcohol, 36.7% marijuana use). More than 80% would spend 12 months or less in state prison for their current incarceration. The average duration of HIV infection was 5.7 years (mean /4.5 years; range /0.08 /17 years). Among those able to report results from their most recent viral load test (n /34), the mean value was 58,270 (SD /141,610; range /0 /750,000). Among those able to report results from their most recent CD4/ count (n /46), the mean value was 403.41 (SD /288.07; range /15 /1,134). Twothirds (66.7%) reported ever having taken anti-HIV medications. Excluding those diagnosed during their concurrent incarceration (n /9, all males), nearly 40% of those initially interviewed had not received

Primary care utilization among HIV-positive inmates regular HIV-related care in the year prior to incarceration (operationalized as getting bloodwork and/ or seeing a physician at least every three months). About half (48.3%) had public insurance or reimbursement for health care. More than a third (35%) received their HIV-positive diagnosis while in a correctional facility. Forty-five percent reported coinfection with Hepatitis C and 45% reported ever being treated for a psychological or emotional problem. Attrition Thirty participants completed the post-release interview. Five participants were interviewed beyond the 21-day period due to scheduling difficulties. Excluding these five, post-release interviews were conducted 11 days after release on average (mean / 11.5, SD /4.93). Compared to those who were lost to follow-up, more post-release participants were: male, lived in their own house or apartment in the year before incarceration, had annual household incomes in categories ranging from $10 /34K, had two or more ‘close’ family members, had a spouse or main partner (versus being separated, divorced or widowed), had CD4/ counts of less than 200 and rated prison health care as ‘excellent’ or ‘good’. More non-completers had taken medications for psychiatric conditions other than depression, such as schizophrenia, bipolar disorder and post-traumatic stress disorder. No significant differences were found between post-release interview completers and non-completers with respect to substance abuse or criminal history. Participant post-release characteristics Most post-release participants relied on family and friends for post-release assistance. Almost half were transported by family (n /11) or friends (n /2) to their destination city upon release and the remainder utilized prison-provided transportation. Most stayed with family members (n /16) or friends (n /6) immediately after release, while others stayed in halfway houses, shelters or motels. Two participants indicated experiencing one or more nights without a place to sleep, but nearly a third (n /9) considered themselves homeless. None were employed. Twelve (40%) reported no income source of any kind. The majority of those with any income source relied on their spouses or family members (n /10). Seventeen participants reported receiving post-release transportation assistance from family or friends and eight from community-based agencies or clinics. Almost half (n /14; 10 in care) reported receipt of other assistance for meeting basic needs (e.g., clothes,

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hygiene packs). Twelve participants (five in care) had used alcohol, two (in care) had used crack cocaine and two (not in care) had used marijuana since release. Eighteen post-release participants (12 in care) were taking daily medications (anti-HIV medications, prophylaxis for opportunistic infections or medications for other conditions) just prior to release and received a ten-day supply upon release. Of these, six reported obtaining more medications before running out and another six reported they would obtain medications before running out. All 12 of these participants indicated having some type of reimbursement source for their medications. The remaining six participants reported they had run out of medications for one or more of the following reasons: attending to basic survival needs, no money or reimbursement source, not knowing how to get more medications, hospitalization and stopped taking due to side effects. The range of missed doses was from three days to more than two weeks. All 18 participants reported high levels of adherence while they were taking medications post-release (i.e., before running out). Primary care utilization Eighteen post-release participants (60%) were in care at the time of the post-release interview. Of these, 14 had previously been patients of their postrelease provider. Of those considered in care, nine had been seen by a provider and nine had an appointment. Seven were seen by their provider within the first seven days after release. Similarly, six of the eight in care participants who saw a social service provider did so within seven days after release. The two post-release participants taking psychiatric medications just prior to release had accessed both psychiatric care and HIV primary care. Variables associated with primary care utilization after release Variables associated with being in care at postrelease interview are shown in Table I. In a logistic regression model comprised of these four variables, the medications variable was not significant at the B/0.2 level, no alcohol use was significant at the B/0.1 level and the two housing-related variables (i.e., living in same place as before incarcerated and rating of housing situation as ‘very comfortable’ or ‘comfortable’) were significant at the B/0.05 level. The model correctly classified 80% of cases overall (83.3% of those in care, 75% of those not in care), with an omnibus x2 value of 17.39 (p / 0.002), pseudo-R2 value of 0.44 (maximum likelihood) and

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Table I. Variables associated with primary care utilization at post-release interview.* In care N/18 n

Not in care N/12 n

Housing Currently living in same place as before incarcerated Yes No

8 10

1 11

Comfort level in current living situation Very comfortable/Comfortable Less than comfortable to Very uncomfortable

12 6

Substance use No alcohol use since release Yes No Transitional medical care Taking anti-HIV medications at the time of release Yes No

Domain/variable

Odds ratio

95% confidence interval (exact)

p (2-sided)

8.80

0.84 /425.15

0.05

4 8

4

0.68 /25.34

0.13

13 5

5 7

3.64

0.61 /22.37

0.14

11 7

3 9

4.71

0.76 /34.92

0.07

*Table presents odds ratios and confidence intervals for variables initially identified as associated with post-release primary care utilization through x2 tests (x2 p -values B/0.20).

a two log-likelihood value of 22.99. Exclusion of the medications variable modestly improved sensitivity for classifying those not in care (77.8%) but did not change the percentage of cases correctly classified overall. Post-hoc power analysis and sample size calculation Power analyses indicated a power (1/b) of 0.45, 0.46, 0.53 and 0.69, respectively, for taking antiHIV medications at the time of release, no alcohol use since release, housing comfort and living in the same place as prior to incarceration. For the latter of these variables, a sample size of 469 would be sufficient to capture an odds ratio /2. This sample size would be adequate for logistic regression analysis including these four variables. Discussion Excluding newly diagnosed cases, nearly 40% of those interviewed prior to release (n /60) had not received regular HIV-related care in the year prior to incarceration, reflecting poor rates of primary care utilization compared to HIV-positive persons more generally (Andersen et al., 2000; Shapiro et al., 1999). This is not unexpected, given that the ‘free world’ lives of pre-release interviewees appeared to be affected by multiple factors previously shown to affect health care utilization negatively in nonincarcerated HIV-positive persons: many pre-release participants had low levels of income and education, inadequate or marginal housing and substance abuse and mental health problems (Andersen et al., 2000; Cunningham et al., 1999; Shapiro et al., 1999;

Taylor et al., 2004); less than half of pre-release participants had insurance or reimbursement for health care (Shapiro et al., 1999); and less than half reported ever having a case manager or caseworker to assist in accessing reimbursement sources, housing assistance, substance abuse treatment and mental health care (Ashman et al., 2002; Conover & Whetten-Goldstein, 2002; Lo et al., 2002; Messeri et al., 2002). HIV-positive releasees’ utilization of primary care after recent release was similarly poor, with only 60% of post-release participants (n /30) being in care within 21 days after release. Moreover, our data may over-estimate the proportion in care. Those lost to follow-up were more likely to be female, to be separated, divorced or widowed, to have fewer close family members, to have taken medication for a major non-depressive, psychiatric illness and to have not lived in their own home or apartment in the year prior to incarceration. Given the prior evidence for unfavorable patterns of health care utilization among HIV-positive women (Andersen et al., 2000; Hellinger & Encinosa, 2004; Shapiro et al., 1999) and HIV-positive persons with inadequate housing (Cunningham et al., 1999) and mental health issues (Palmer et al., 2003; Taylor et al., 2004; Tucker et al., 2003), it is likely that the proportion of those utilizing primary care post-release would have been less encouraging if those lost to follow-up had been located and interviewed. Our results suggest that housing stability, housing comfort and lack of alcohol use may be especially strong predictors of post-release primary care utilization. These findings are commensurate with

Primary care utilization among HIV-positive inmates previous research demonstrating the association of inadequate or marginal housing with poorer health care utilization (Cunningham et al., 1999) and the association of housing assistance with entry and retention in primary care among HIV-positive persons (Conover & Whetten-Goldstein, 2002; Lo et al., 2002; Messeri et al., 2002). Our findings appear consistent with previous studies indicating an association of alcohol use with less favorable rates of primary care utilization and antiretroviral adherence (Conigliaro et al., 2004; Tucker et al., 2003; 2004). In a larger sample, the inclusion of these variables in logistic regression analyses may potentially achieve correct classification of health care utilization for 80% of those followed-up. This study had several limitations. The small sample size limits generalizability of findings and calls into question the precision and validity of the analytic results. However, analyses were intended to be exploratory and power calculations aid in the interpretation of results. The small sample size also motivated us to limit assessment of variables associated with being in care to those measured at the post-release interview. However, post-release variables measured may be more amenable to intervention than many of the background, pre-release characteristics measured. A larger sample would permit modeling of both background and postrelease variables, which may be particularly important for assessing post-release behaviors possibly influenced by prior experience (e.g., 14 of the 18 in care had previously been patients of their post-release provider). Variables were categorized or re-categorized in some cases to permit selected statistical analyses and misclassification of categories is possible. Differential attrition may potentially bias analyses of post-release data. This was addressed partially through comparison of those who completed the post-release interview with those who did not. The study’s restricted time frame, single postrelease data collection point and single measure of health care utilization (i.e., primary care), limits what knowledge may be gleaned about health care utilization among HIV-positive releasees. Finally, the validity of self-reported data in incarcerated populations is unknown. These limitations not withstanding, this pilot study contributes to current knowledge about HIVpositive releasees and the factors that might support or hinder post-release primary care utilization during the immediate post-release period. Our findings are consistent with prior studies suggesting poor health care utilization in this population and the impact of housing circumstances and alcohol on health care utilization among HIV-positive persons. These findings, although preliminary, provide a useful starting point in the development of a set of indicators for

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assessing inmates’ risk of discontinuities in HIVrelated care after release. Larger studies with multiple data collection points and outcome measures are needed. Such studies hold the promise of aiding correctional healthcare providers and public health leaders in understanding HIV-positive releasees’ patterns of health care utilization over time, in identifying those most vulnerable and, ultimately, in designing more effective and efficient transitional assistance programs tailored to the unique needs and resources of inmates returning to the community and seeking HIV-related treatment. Acknowledgements This research was supported by the 2002 National AIDS Foundation Challenge Award and by Health Resources Services Administration, grant #U69 HA00062-02. Ms Harzke is supported by a Behavioral Science Education Cancer Prevention and Control grant from the National Cancer Institute/ NIH, #2R25CA57712. The Texas Department of Criminal Justice supported this research under Research Agreement #212-RM02. The opinions expressed herein are solely those of the authors and do not necessarily represent the position of the Texas Department of Criminal Justice or other supportive agencies or institutions. References Andersen, R., Bozette, S., Shapiro, M., St. Clair, P., Crystal, S., Goldman, D., et al. (2000). Access of vulnerable groups to antiretroviral therapy among persons in care for HIV disease in the United States. Health Services Research , 35 , 389 /416. Ashman, J.J., Conviser, R., & Pounds, M.B. (2002). Associations between HIV-positive individuals’ receipt of ancillary services and medical care receipt and retention. AIDS Care , 14 (Suppl. 1), S109 /S118. Chan, D., Absher, D., & Sabatier, S. (2002). Recipients in need of ancillary services and their receipt of HIV medical care in California. AIDS Care , 14 (Suppl. 1), S73 /S83. Conigliaro, J., Madenwald, T., Bryant, K., Braithwaite, S., Gordon, A., Fultz, S.L., et al. (2004). The veterans aging cohort study: Observational studies of alcohol use, abuse and outcomes among human immunodeficiency virus-infected veterans. Alcoholism: Clinical and Experimental Research , 28 , 313 /321. Conklin, T.J., Lincoln, T., & Flanigan, T.P. (1998). A public health model to connect correctional health care with communities. American Journal of Public Health , 88 , 1249 /1251. Conover, C.J., & Whetten-Goldstein, K. (2002). The impact of ancillary services on primary care use and outcomes for HIV/ AIDS patients with public insurance coverage. AIDS Care , 14 (Suppl. 1), S59 /S71. Cunningham, W.E., Andersen, R.M., Katz, M.H., Stein, M.D., Turner, B.J., Crystal, S., et al. (1999). The impact of competing subsistence needs and barriers on access to medical care for persons with human immunodeficiency virus receiving care in the United States. Medical Care , 37 , 1270 /1281. Dupont, W.D., & Plummer, W.D. (1990). Power and sample size calculations: A review and computer program. Controlled Clinical Trials , 11 , 116 /128.

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Hammett, T.M., Harmon, P., & Rhodes, W. (2002). The burden of infectious disease among inmates and releasees from correctional facilities, 1997. American Journal of Public Health , 92 , 1789 /1794. Hammet, T., Roberts, C., & Kennedy, S. (2001). Health-related issues in prisoner re-entry. Crime and Delinquency, 47 , 390 / 409. Heckman, T.G., Somlai, A.M., Peters, J., Walker, J., Otto-Salaj, L., Galdabini, C.A., & Kelly, J.A. (1998). Barriers to care among persons living with HIV/AIDS in urban and rural areas. AIDS Care , 10 , 365 /375. Hellinger, F.J., & Encinosa, W.E. (2004). Antiretroviral therapy and health care utilization: A study of privately insured men and women with HIV disease. Health Services Research , 39 , 949 /967. Kassira, E.N., Bauserman, R.L., Tomoyasu, N., Caldeira, E., Swetz, A., & Solomon, L. (2001). HIV and AIDS surveillance among inmates in Maryland prisons. Journal of Urban Health , 78 , 256 /263. Lo, W., MacGovern, T., & Bradford, J. (2002). Association of ancillary services with primary care utilization and retention for patients with HIV/AIDS. AIDS Care , 14 (Suppl. 1), S45 /S57. Maruschak, L.M. (2004). HIV in prisons and jails, 2002. Bureau of Justice Statistics Bulletin , NCJ 205333 , 1 /11. Messeri, P.A., Abramson, D.M., Aidala, A.A., Lee, F., & Lee, G. (2002). The impact of ancillary HIV service on engagement in medical care in New York City. AIDS Care , 14 (Suppl. 1), S15 / S29. Palmer, N.B., Salcedo, J., Miller, A.L., Winiarski, M., & Arno, P. (2003). Psychiatric and social barriers to HIV medication adherence in a triply-diagnosed methadone population. AIDS Patient Care and STDs , 17 , 635 /644. Rich, J.D., Holmes, L., Salas, C., Macalino, G., Davis, D., Ryczek, J., & Flanigan, T. (2001). Successful linkage of medical care and community services for HIV-positive offenders being released from prison. Journal of Urban Health , 78 , 279 /289. Richie, B.E., Freudenberg, N., & Page, J. (2001). Re-integrating women leaving jail into urban communities: A description

of a model program. Journal of Urban Health , 78 , 290 / 303. Sabin, K.M., Frey, R.L., Horsley, R., & Greby, S.M. (2001). Characteristics and trends of newly identified HIV infections among incarcerated populations: CDC HIV voluntary counseling, testing and referral system, 1992 /1998. Journal of Urban Health , 78 , 241 /255. Shapiro, M.F., Morton, S.C., McCaffrey, D.F., Senterfitt, J.W., Fleishman, J.A., Perlman, J.F., et al. (1999). Variations in the care of HIV-infected adults in the United States: Results from the HIV cost and services utilization study. Journal of the American Medical Association , 281 , 2305 /2315. Springer, S.A., Pesanti, E., Hodges, J., Macura, T., Doros, G., & Altice, F.L. (2004). Effectiveness of antiretroviral therapy among HIV-infected prisoners: Reincarceration and the lack of sustained benefit after release to the community. Clinical Infectious Diseases , 38 , 1754 /1760. Stephenson, B., Wohl, D., Golin, C.E., Tien, H.C., Stewart, P., & Kaplan, A.H. (2005). Effect of release from prison and reincarceration on the viral loads of HIV-infected individuals. Public Health Reports , 120 , 84 /88. Taylor, S.L., Burnam, M.A., Sherbourne, C.D., Andersen, R., & Cunningham, W.E. (2004). The relationship between type of mental health provider and met and unmet mental health needs in a nationally representative sample of HIV-positive patients. Journal of Behavioral Health Services and Research , 31 , 149 / 163. Tucker, J.S., Burnam, M.A., Sherbourne, C.D., Kung, F.Y., & Gifford, A.L. (2003). Substance use and mental health correlates of non-adherence to antiretroviral medications in a sample of patients with human immunodeficiency virus infection. American Journal of Medicine , 114 , 573 /580. Tucker, J.S., Orlando, M., Burnam, M.A., Sherbourne, C.D., Kung, K.Y., & Gifford, A.L. (2004). Psychosocial mediators of antiretroviral non-adherence in HIV-positive adults with substance use and mental health problems. Health Psychology, 23 , 363 /370.

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Appendix. Pre-release interview participant background characteristics by interview completion status.

Domain/characteristic(s) Demographics Gender Male Female Race/ethnicity African-American White/Caucasian Latino/Hispanic Age 20 /29 years 30 /39 years 40 /49 years 50/ years Sexual orientation/preference Heterosexual/ ‘straight’ Homosexual/ ‘gay’ or ‘lesbian’ Bisexual None of the above/Refused Socioeconomic indicators Education* Less than 12 years formal education High school diploma Participated in GED classes Participated in vocational training One or more college courses Employment (in year before incarceration)* Employed for wages Self-employed (legal) Self-employed (illegal) Unemployed more than one year Unable to work Income (total household) Less than $10K annually $10 /14,999 K annually $15 /24,999 K annually $25 /34,999 K annually $35 K or more annually Don’t know Housing (in year before incarceration)* Own house or apartment Someone else’s house or apartment** Hotel/motel/shelter/on the streets Perceive self as homeless Perceived quality of housing/living situation Very comfortable/Comfortable Less than comfortable, but okay Not comfortable/Very uncomfortable Financial insecurity (inability to pay) Food House payment or rent Utility bills Doctor visits Prescribed medication Other None of the above Perceived standard of living Very comfortable/ ‘well-off’ Living Comfortably Just getting by Nearly poor Poor

Completed pre-release interview only (N/30) n (%)

Completed pre- and post-release interviews (N/30) n (%)

14 (46.7) 16 (53.3)

19 (63.3) 11 (36.7)

19 (63.3) 9 (30) 2 (6.7)

20 (66.7) 8 (26.7) 2 (6.7)

6 13 6 5

(20) (43.3) (20) (16.7)

4 13 8 5

(13.3) (43.3) (26.7) (16.7)

17 4 6 3

(56.7) (13.3) (20) (10)

19 4 5 2

(63.3) (13.3) (16.7) (6.7)

18 12 18 16 6

(60) (40) (60) (53.3) (20)

20 10 14 9 10

(66.7) (20) (46.7) (30) (30)

10 1 5 15 6

(33.3) (3.3) (16.7) (50) (20)

10 4 2 15 7

(33.3) (13.3) (6.7) (50) (23.3)

14 1 4 1 7 3

(46.7) (3.3) (13.3) (3.3) (23.3) (10)

4 11 4 4 3 4

(13.3) (36.7) (13.3) (13.3) (10) (13.3)

5 15 14 14

(16.7) (50) (20) (46.7)

12 17 2 2

(40) (56.7) (6.7) (6.7)

11 (36.7) 11 (36.7) 8 (26.7)

17 (56.7) 9 (30) 4 (13.3)

14 10 6 5 5 2 12

(46.7) (33.3) (20) (16.7) (16.7) (6.7) (40)

13 9 10 4 3 1 13

(43.3) (30) (33.3) (13.3) (10) (3.3) (43.3)

0 10 15 0 5

(0) (33.3) (50) (0) (16.7)

0 11 13 2 4

(0) (36.7) (43.3) (6.7) (13.3)

298

A. J. Harzke et al.

Appendix (Continued )

Domain/characteristic(s) Medical history Year of HIV diagnosis 2001 /2003 1996 /2000 1991 /1995 1986 /1990 1985 or earlier Received HIV diagnosis in a correctional facility Received HIV diagnosis during current incarceration Received AIDS diagnosis Results of most recent CD4/ count Less than 200 200 /499 500 or more Don’t know Results of most recent viral load 100K or more 50 /99K 5 /19K Less than 5K, but not undetectable Undetectable Don’t know Received diagnosis of Hepatitis B Received diagnosis of Hepatitis C Received Hepatitis diagnosis in a correctional facility Received regular** medical care in previous year*** Hospitalized in previous year Ever taken anti-HIV medications prior to incarceration Reimbursement source(s) for medical care* County (i.e. Harris County Gold Card or other county program) Medicaid Medicaid/Medicare Veterans’ Administration Insurance through spouse’s employment Insurance through own employment or self-paid insurance Out of pocket Other None of the above Don’t know Case management and referrals Ever had a case manager or case worker Received referrals or other assistance in accessing reimbursement Received information regarding how to access care once releaseda Perceived quality of health care while incarcerated Excellent/good Fair/poor Perceived quality of health Excellent/good


8 7 10 4 1 7

(26.7) (23.3) (33.3) (13.3) (3.3) (23.3)


9 8 9 4 0 14

(30) (26.7) (30) (13.3) (0) (46.7)

3 (10)

6 (20)

11 (36.7)

9 (30)

3 11 10 6

(10) (36.7) (33.3) (20)

8 9 5 8

(26.7) (30) (16.7) (26.7)

3 2 4 2 6 13 2 13 6

(10) (6.7) (13.3) (6.7) (20) (43.3) (6.7) (43.3) (20)

3 4 2 3 5 13 4 14 6

(10) (13.3) (6.7) (10) (16.7) (43.3) (13.3) (46.7) (20)

15 (50)

16 (53.3)

5 (16.7) 19 (63.3)

8 (26.7) 21 (70)

8 (26.7)

6 (20)

5 0 2 1

5 1 2 0

(16.7) (0) (6.7) (3.3)

1 (3.3) 0 3 10 2

(0) (10) (33.3) (6.7)

15 (50) 7 (23.3) 13 (43.3)

(16.7) (3.3) (6.7) (0)

2 (6.7) 1 5 8 1

(3.3) (16.7) (26.7) (3.3)

12 (40) 9 (30) 7 (23.3)

4 (13.3) 26 (86.7)

9 (30) 21 (70)

13 (43.3)

13 (43.3)


299


Domain/characteristic(s) Fair/poor Mental health history Mental health treatment Ever treated by psychologist/ psychiatrist for a psychiatric/ emotional problem Ever received mental health care in a correctional setting Currently taking psychiatric medications Ever taken medication for a psychological or emotional problem Depression Bipolar disorder Anxiety disorder Schizophrenia Other or unable to name diagnosis Perceived current mental health status Excellent/good Fair/poor Criminal history Number of incarcerations at state jail or prison One Two Three Four or more Length of current state prison incarceration 0 /6 months 7 /12 months 13 /18 months 19 /24 months 25 months or more Total lifetime incarceration 0 /6 months 7 /12 months 13 /18 months 19 /24 months 25 /36 months 37 /48 months 49 /60 months 61 months or more Charge(s) related to current incarceration Shoplifting/vandalism Drug-related (list various options) Forgery Prostitution Parole or probation violation Burglary, larceny, breaking and entering Robbery Assault Arson/Rape/Homicide/Manslaughter Contempt of court Disorderly conduct, vagrancy, public intoxication Driving while intoxicated Major driving violations Theft (including by check, credit card, fraud, etc.) Trespassing



17 (56.7)

17 (56.7)

15 (50)

12 (40)

5 (16.7)

3 (10)

5 (16.7)

2 (6.7)

17 (56.7)

15 (50)

71 4 5 2 6

10 3 1 1 4

(23.3) (13.3) (16.7) (6.7) (20)

(33.3) (10) (3.3) (3.3) (13.3)

11 (3.3) 19 (63.3)

10 (3.3) 20 (66.7)

16 7 4 3

(53.3) (23.3) (13.3) (10)

12 11 4 3

(40) (36.7) (13.3) (10)

8 18 3 0 1

(26.7) (60) (10) (0) (3.3)

11 13 6 0 0

(36.7) (43.3) (20) (0) (0)

5 4 3 4 6 0 0 8

(16.7) (13.3) (10) (13.3) (20) (0) (0) (26.7)

4 6 2 5 6 3 0 4

(13.3) (20) (6.7) (16.7) (20) (10) (0) (60)

0 17 3 2 3 0

(0) (56.7) (10) (6.7) (10) (0)

1 20 2 1 4 0

(3.3) (66.7) (6.7) (3.3) (13.3) (0)

1 0 0 0 0

(0) (0) (0) (0) (0)

0 0 0 0 0

(0) (0) (0) (0) (0)

1 (3.3) 0 (0) 2 (6.7)

0 (0) 0 (0) 1 (3.3)

0 (0)

0 (0)

300

A. J. Harzke et al.


Domain/characteristic(s) Other Lifetime charges (i.e., ‘ever charged’) Shoplifting/vandalism Drug-related charges Forgery Prostitution Parole or probation violation Burglary, larceny, breaking and entering Robbery Assault Arson Rape Homicide or manslaughter Contempt of court Disorderly conduct, vagrancy, public intoxication Driving while intoxicated Major driving violations Theft (including by check, credit card, etc.) Trespassing Other Substance abuse history Substances used in year prior to present incarceration Alcohol Marijuana Cocaine (smoke crack) Cocaine (snort) Cocaine (inject) Heroin (snort) Heroin (inject) Downers/tranquilizers Stimulants/amphetamines Hallucinogens Pain killers Inhalants Frequency of useb Alcohol Daily 4 /6 times per week 2 /3 times per week Once a week 2 /3 times per month Once a month Less than once a month Frequency of use Marijuana Daily 4 /6 times per week 2 /3 times per week Once a week 2 /3 times per month Once a month Less than once a month Frequency of use Cocaine (smoke crack) Daily 4 /6 times per week 2 /3 times per week Once a week



1 (3.3)

1 (3.3)

7 24 7 12 16 4

(23.3) (80) (23.3) (40) (53.3) (13.3)

7 26 3 10 18 5

(23.3) (86.7) (10) (33.3) (60) (16.7)

5 6 1 0 0 3 6

(16.7) (20) (3.3) (0) (0) (10) (20)

1 3 0 0 0 1 10

(3.3) (10) (0) (0) (0) (0) (33.3)

4 (13.3) 1 (3.3) 3 (10)

6 (20) 5 (20) 5 (20)

2 (6.7) 6 (20)

3 (10) 7 (23.3)

24 10 26 3 4 1 2 3 3 3 3 1

(80) (33.3) (86.7) (10) (13.3) (3.3) (6.7) (10) (10) (10) (10) (3.3)

24 12 24 4 3 0 0 1 2 1 6 0

(80) (40) (80) (13.3) (10) (0) (0) (3.3) (6.7) (3.3) (20) (0)

11 3 5 4 1 0 0

(36.7) (10) (16.7) (13.3) (3.3) (0) (0)

10 3 1 5 1 3 1

(33.3) (10) (3.3) (16.7) (3.3) (10) (3.3)

4 0 1 0 2 0 1

(13.3) (0) (3.3) (0) (6.7) (0) (3.3)

6 1 0 0 0 1 4

(20) (3.3) (0) (0) (0) (3.3) (13.3)

11 5 3 0

(36.7) (16.7) (10) (0)

10 6 2 2

(33.3) (20) (6.7) (6.7)


301


Domain/characteristic(s) 2 /3 times per month Once a month Less than once a month Ever received substance abuse treatment in Residential treatment Halfway house Outpatient treatment Correctional facility Other Number of times in residential treatment Once Twice Three times Four or more times Length of stay in residential treatment* Less than 14 days (or ‘less than two weeks’)c 14 /29 days (‘more than two weeks, less than a month’) 30 days (‘a month’) 31 /59 days (‘more than a month, but less than two’) 60 days (‘two months’) 61 /89 days (‘more than two months, less than three’) 90 days (‘three months’) 91 /119 days (‘more than three months, less than six’) 120 days or more (‘six months or more’) Unspecified/missing values Social support Primary relationship status Living with spouse/main partner Spouse/main partner, not living together Separated/divorced/widowed Single/No steady partner Number of close friends None One Two Three or more Number of close family members None One Two Three or more



3 (10) 1 (3.3) 2 (6.7)

4 (13.3) 0 (0) 0 (0)

12 10 6 14 9

(40) (33.3) (20) (46.7) (30)

18 8 11 17 6

(60) (26.7) (36.7) (56.7) (20)

5 4 1 2

(16.7) (13.3) (3.3) (6.7)

9 4 4 1

(30) (13.3) (13.3) (3.3)

1 (3.3)

2 (6.7)

1 (3.3)

5 (16.7)

5 (16.7) 0 (0)

7 (23.3) 1 (3.3)

0 (0) 0 (0)

2 (6.7) 0 (0)

2 (6.7) 1 (3.3)

4 (13.3) 1 (3.3)

2 (6.7)

4 (13.3)

2 (6.7)

2 (6.7)

8 (26.7) 8 (26.7)

7 (23.3) 3 (10)

2 (6.7) 12 (40)

8 (26.7) 12 (40)

5 6 7 12

(16.7) (20) (23.3) (40)

4 4 9 13

(13.3) (13.3) (30) (43.3)

8 8 3 11

(26.7) (26.7) (10) (36.7)

4 5 10 11

(13.3) (16.7) (33.3) (36.7)

*More than one answer possible. **‘Regular’ care was operationalized as getting bloodwork and/or seeing a physician at least every three months. ***Nearly two-thirds of those who received care went to a single public HIV clinic. a This cannot be interpreted in a straightforward manner as responses may be contingent upon individual differences in time between interview and release date. b Frequency of use reported only for most commonly used drugs (e.g., alcohol, marijuana and crack cocaine). c Language in quotation marks indicates actual language used during the interview.