Implementing Preexposure Prophylaxis for HIV Prevention in a Statewide Correctional System in the United States

Abstract

HIV disproportionately affects populations experiencing incarceration. Preexposure prophylaxis (PrEP) is an effective approach to preventing HIV acquisition among populations at increased risk of acquiring HIV. Yet few, if any, efforts have been made to offer PrEP in correctional settings. Beginning in November 2019, the Rhode Island Department of Corrections (RIDOC) implemented a systemwide PrEP initiation program with linkage to PrEP care in the community upon reentry. Incarcerated individuals identified as being potentially at increased risk of HIV acquisition during standard clinical screenings and medical care were referred to a PrEP care provider for potential PrEP initiation. Of the 309 people who met with a PrEP care provider, 35% (n = 109; 88 men, 21 women) agreed to initiate PrEP while incarcerated. Clinical testing and evaluation were completed for 82% (n = 89; 69 men, 20 women) of those who agreed to initiate PrEP. Of those, 54% (n = 48; 29 men, 19 women) completed the necessary clinical evaluation to initiate PrEP, were determined to be appropriate candidates for PrEP use, and had the medication delivered to a RIDOC facility for initiation. Only 8 people (4 men, 4 women) were successfully linked to a PrEP care provider in the community after release. The RIDOC experience demonstrates notable levels of PrEP interest and moderate levels of PrEP uptake among this population. However, PrEP engagement in care after release and persistence in taking PrEP when in the community were relatively poor, indicating a need to better understand approaches to overcoming barriers to PrEP care in this unique setting.

The United States has one of the highest incarceration rates in the world, resulting in critical health disparities, particularly related to the HIV epidemic.^{1 -4} Incarceration and the immediate postrelease period comprise a disruptive process with important social, behavioral, and clinical implications for HIV acquisition and transmission.^5,6 Expanded HIV testing and prevention in correctional settings with linkage services to community health care providers can be an effective public health measure to reduce HIV incidence. ⁷ Preexposure prophylaxis (PrEP) is an effective approach to preventing HIV recommended by the Centers for Disease Control and Prevention (CDC) for use in populations at increased risk for HIV acquisition, including people in correctional settings.^8,9 Despite the known efficacy of PrEP, relatively little is known about PrEP availability, uptake, and initiation in correctional settings and successful strategies for linking people to care after release.^{8 -12} We describe the experience of PrEP implementation in a state correctional system in the United States. To our knowledge, this study is the first of its kind. We then discuss implications for PrEP implementation in this setting and the need for future research to identify successful approaches to improve outcomes along the PrEP continuum of care among populations affected by incarceration.

Purpose

We present the results of the initial implementation of a PrEP program among all people identified as at increased risk of HIV acquisition who were experiencing incarceration in a unified, statewide correctional system. We characterized PrEP interest, uptake, use, and linkage to care in the community and implications for future PrEP implementation efforts in correctional settings.

Methods

Beginning in November 2019, the Rhode Island Department of Corrections (RIDOC) began offering PrEP through 2 industry-supported research studies. RIDOC is a unified, statewide correctional system in Cranston, Rhode Island, where all people who are either awaiting trial or are sentenced to a period of confinement are housed in facilities managed by the same correctional and medical administration on the same state-run campus. Up to 1200 people are newly detained at a RIDOC facility each month, with an average overall detained population of >2500 people. Approximately 10 000 people pass through RIDOC detention facilities annually. ¹³ People can be detained in 6 facilities during their period of incarceration. Five facilities house men experiencing incarceration, including 1 facility that houses all people awaiting trial (setting for study 1), and another 4 facilities house people who are sentenced to a period of incarceration. ¹⁴ A sixth facility houses all women experiencing incarceration, including those who are awaiting trial and those sentenced to a period of detention (setting for study 2). ¹⁰

The PrEP program was built on long-standing, nurse-led, universal screening processes, which occur shortly after a person is initially incarcerated. Nurses ask a standardized series of questions related to HIV acquisition risk, including questions about substance use and sexual behaviors, symptoms associated with sexually transmitted infections (STIs), and other medical and health-related issues shortly after arrival to RIDOC facilities. To facilitate PrEP provision, RIDOC modified this screening process so that both men and women who were screened as being at potentially increased risk of HIV acquisition were referred to a single RIDOC-identified PrEP care provider (M.M.) for potential PrEP initiation and enrollment in the study. To further complement the intake nursing screening process, primary care medical staff and substance use clinical staff were also encouraged to refer people at increased risk of HIV acquisition to the PrEP program. In addition, because only 1 facility houses people who self-identify as female, and this facility includes both those awaiting trial and those sentenced to a period of detention, study staff referred people for PrEP evaluation based on planned dates for community reentry. One PrEP physician identified as the primary PrEP care provider oversaw the clinical evaluation for PrEP candidacy, medication initiation, and discharge planning for linkage to a PrEP care provider in the community upon reentry.

Upon referral to a PrEP care provider, based on provider availability, people were offered the opportunity to undergo CDC-recommended clinical testing for PrEP initiation, including HIV, STIs, hepatitis B, and creatinine testing, to assess potential candidacy for PrEP use. Those who did not meet CDC guidelines for PrEP initiation, such as those who were subsequently found to be HIV positive, were provided clinically appropriate care and excluded from study participation. The medication offered during this period was oral daily emtricitabine/tenofovir (FTC/TDF; ie, Truvada) because of its proven efficacy and recommended use for all people at increased risk of HIV acquisition. ⁸ Those who met clinical criteria for PrEP use and expressed an interest in initiating PrEP while incarcerated were ordered either a 30-day prescription for men or a 60-day prescription for women to allow for greater buildup of FTC/TDF in vaginal tissue. The medication was delivered to the facility prior to release (approximately 7 days prior to release for men and 21 days prior to release for women) so it could be started, and then the remaining pills were provided upon community reentry. The timing of delivery was based on planned release dates provided by RIDOC and/or the person’s self-reported expected release date. People were instructed to continue taking medication in the interim before being linked to a PrEP care provider in the community. All enrolled people were offered support from study staff in navigating community linkage to PrEP care.

All community partner clinics were located in Providence, Rhode Island, the state’s main urban center. Women were referred to Planned Parenthood of Rhode Island, and men were linked either to the state’s main academic PrEP/STI clinic or a community-based comprehensive primary care clinic offering PrEP services. Navigation services included assistance with health insurance activation, scheduling appointments at partner clinics, and addressing geographic limitations to accessing a PrEP care provider, such as developing a travel plan to attend appointments. As part of these navigation activities, type and frequency of contact were recorded, including during the pre- and postrelease periods.

Study staff collected self-reported data during clinical and navigation encounters on PrEP initiation, adherence, and postrelease PrEP appointment attendance during this period. Reasons for participant loss to follow-up, both before and after release, were recorded for each enrolled person. Both studies received institutional review board (IRB) approval through the Lifespan IRB designated to review studies involving incarcerated populations.

Outcomes

From November 1, 2019, through April 1, 2022, a total of 814 referrals to the PrEP care provider were generated during routine screening and clinical care (Figure 1). Approximately 38% (n = 309; 255 men, 54 women) were evaluated by the prescribing physician. During that evaluation, the PrEP care provider discussed HIV acquisition risk factors, reviewed the risks and benefits of using PrEP, and assessed interest in PrEP initiation.

Figure 1.

Preexposure prophylaxis (PrEP) referral cascade in a state correctional system, Rhode Island, November 1, 2019, through April 1, 2022.

Of the 309 men and women who met with a PrEP care provider, 35% (n = 109; 88 men, 21 women) agreed to initiate PrEP and enrolled in a study to receive the medication for free (Figure 2). Clinical testing and evaluation (eg, screening for PrEP eligibility) were completed for 82% (n = 89; 69 men, 20 women) of participants. Of those, 54% (n = 48; 28 men, 20 women) completed the necessary clinical evaluation to initiate PrEP, were determined to be appropriate candidates for PrEP use, and had the medication delivered to a RIDOC facility for initiation. From this group, 79% (n = 38; 20 men, 18 women) confirmed that they initiated medication while incarcerated. All men and women were offered continued support from a PrEP navigator to connect to PrEP care providers in the community to continue the medication. Eight people (4 men, 4 women) were successfully linked to a PrEP care provider in the community after release.

Figure 2.

Preexposure prophylaxis (PrEP) care continuum in a state correctional system, Rhode Island, November 1, 2019, through April 1, 2022. Abbreviation: RIDOC, Rhode Island Department of Corrections.

Lessons Learned

We encountered several barriers to PrEP implementation during the RIDOC experience. To conceptualize the barriers encountered as people move through the PrEP continuum of care, we propose an adapted, ¹⁵ 2-sided, socioecological model for PrEP implementation in correctional settings (Figure 3). This 2-sided model acknowledges complex, multilevel considerations, both during the period of detention in a correctional setting and upon returning to the community. We categorized these barriers as individual, interpersonal, and structural level. Future research will be key to characterizing the effect of these barriers on PrEP implementation in this setting and developing interventions to address barriers that are unique to this public health context.

Figure 3.

Dual-sided socioecological model characterizing barriers to preexposure prophylaxis (PrEP) implementation among populations experiencing incarceration and upon community reentry.

Our initial experience showed feasibility and acceptability of offering PrEP in a correctional setting. However, substantial efforts had to be made to recruit and retain participants. The prescribing physician, or PrEP care provider, had to serve as a champion for PrEP implementation, meeting with medical and correctional staff to encourage a flow of referrals. In the role as champion, this physician also worked to add PrEP to the formulary at RIDOC, so that upon completion of the studies and funding for medications, people would be able to have a sustainable source of medication. Implementation of sustainable PrEP programming will require correctional systems and the communities they serve to direct resources to support PrEP clinical care and medication provision. In addition, greater knowledge of PrEP’s use among correctional nursing staff and clinical providers is critical for successful implementation. These barriers, among others, pose challenges for scaling up (ie, increasing access in settings where PrEP is already available) and scaling out (ie, making PrEP available in more correctional settings) of PrEP programs to meet the needs of the correctional population. At the same time, this approach may be highly cost-effective when considering the broader health care costs associated with incident cases of HIV.

In the correctional setting, structural barriers to PrEP implementation and scaling are particularly important. Medical leadership at RIDOC provided support to implement PrEP and study its use. However, for PrEP to be provided at RIDOC, it had to be financed externally, requiring our study team to pursue industry support to cover medication costs. The costs of clinical care for PrEP initiation and administration of the medication itself are likely to pose a considerable challenge to correctional systems with competing budgetary priorities. Even if correctional systems are able to cover the cost of medication, another key barrier is the availability of clinical staff and processes to identify people who might be at increased risk of HIV acquisition, perform the recommended clinical evaluation to safely initiate PrEP, and conduct recommended testing, such as HIV, creatinine, and hepatitis B serologies. Given the resources (ie, personnel and financial) required to successfully scale PrEP programming, challenges are likely to be posed by the resource limitations in this environment, the disproportionate impact of many disease processes on populations experiencing incarceration, and changing health priorities underscored by the emergence of the COVID-19 pandemic. Critical but basic activities, such as completing laboratory testing and delivering medication prior to a person’s release, were important limiting factors in facilitating PrEP initiation during a period of incarceration.

Beyond the inclusion of PrEP in pharmacy formularies and the allocation of sufficient clinical resources to ensure effective initiation, the interpersonal level of barriers to the scaling of PrEP is important to consider. Correctional clinical staff, including physicians and nurses, require tailored training on PrEP care to ensure its appropriate use. While it is largely unknown how familiar clinical providers in correctional facilities are with PrEP, the experience at RIDOC suggests that increasing familiarity with PrEP will expand the number of people identified as appropriate candidates. In addition, integrating PrEP care into general medical practice in correctional settings should facilitate PrEP initiation.^11,16 In the RIDOC implementation experience, the limited number of designated PrEP care providers, as well as other clinical providers with PrEP-prescribing experience, likely led to fewer evaluations for PrEP initiation than if there had been more PrEP care providers and slowed the clinical evaluation required to start taking PrEP while incarcerated.

Experience at the individual level, gleaned from participants’ communication with study staff, showed that while interest in initiating PrEP was high, several recurring challenges limited people’s interest in starting PrEP and taking the medication. Those who declined PrEP initiation noted several factors that motivated them to decline, including low self-perceived risk of HIV acquisition and fear of side effects, among others. In addition, some people who initially agreed to take the medication subsequently withdrew from the PrEP program or the study. Mistrust of correctional staff, including security and clinical staff who may be involved with the distribution and monitoring of medication administration, was a reason noted for withdrawing from PrEP care after initially agreeing to start preventive therapy. Additional research is needed to more fully characterize individual motivations or hesitancy to initiating PrEP in this unique social and structural environment.

Discharge planning in anticipation of the date and time of community reentry is a uniquely challenging element affecting effective PrEP implementation in correctional settings. Because the PrEP program in Rhode Island occurred in a unified, statewide correctional facility that houses both people who are awaiting trial and people who are sentenced to a period of detention, our preliminary experience underscored important considerations for discharge planning prior to community reentry that are unique to both pretrial and sentenced populations. Pretrial detention is often unpredictable in its length because a formal detention period has not been assigned to these people. Thus, initiating people during the pretrial setting will require tailored discharge planning approaches to expedite the clinical care associated with PrEP initiation and to ensure the availability of PrEP upon discharge from a correctional facility. People sentenced to a predetermined period, typically in prison facilities, tend to receive more structured discharge planning services, including planning for continuity of clinical care after release, than those received by individuals in jails or those who have not been sentenced to a predetermined period, thereby potentially facilitating planning for this population.

Once incarcerated people return to the community, the barriers to PrEP use change in important ways. Rhode Island expanded Medicaid as a result of the Affordable Care Act, which has meant that most people returning to the community after a period of incarceration are covered by some form of health insurance.^11,17 This expansion of coverage greatly facilitates the linkage to PrEP care in the community because PrEP is also considered a routine part of primary and preventive care by the state’s insurers. However, one challenge is identifying geographically accessible general medical providers who are knowledgeable about PrEP. Despite receiving navigation services after release to help link them to care in the community, many people experience unstable housing and limited access to the internet and telephones, which makes postrelease communication and coordination with health service providers particularly difficult. The challenging socioeconomic context during the period of community reentry, as well as competing health and survival needs, poses challenges to PrEP adherence and to linkage to and retention in care in the community.

Because populations disproportionately affected by incarceration are also disproportionately and uniquely vulnerable to HIV acquisition, offering PrEP during a period of incarceration with linkage to care in the community has the potential to reduce new HIV infections and bring us closer to ending the HIV epidemic in the United States. ¹⁸ Future research is needed to characterize the barriers to retention and persistence in PrEP care in this population and the role that other PrEP formulations, including injectable and event-driven PrEP, may provide in facilitating PrEP uptake and adherence. Both long-acting and event-driven PrEP may improve uptake among incarcerated people who are hesitant to take a daily medication and those who may encounter substantial challenges adhering to a daily pill regimen.