Assessing the HIV care cascade in a large southern prison system

 描述(申请人提供)：艾滋病毒和监禁的双重流行在美国的重叠是有据可查的，监狱人口中艾滋病毒的流行率是普通人口的三倍多。监狱被广泛认为是应对艾滋病毒流行的重要场所：对感染艾滋病毒的囚犯进行检测和治疗，并在囚犯获释后将其纳入以社区为基础的艾滋病毒护理，这既可以改善他们的健康，也可以减少他们在囚犯返回的社区传播艾滋病毒的风险。这一策略通常被称为搜索、测试、治疗和保留(STTR)。有几项由国立卫生研究院赞助的正在进行和已完成的研究，以评估针对刑事司法人口的STTR战略的组成部分。大多数人把重点放在如何增加囚犯中的艾滋病毒检测或改善从监狱到社区的艾滋病毒护理的连续性。然而，很少有研究涉及监禁期间影响进入和保留艾滋病毒护理的因素。考虑到多达63%的已知艾滋病毒阳性(HIV+)囚犯在获释时没有获得病毒抑制，文献中的这一差距是显著的。在监狱中未能获得常规的艾滋病毒护理可能预示着无法进入 出院时的社区艾滋病毒护理，导致健康状况不佳和传播风险增加。最近，一系列艾滋病毒护理被用来将艾滋病毒护理概念化，从检测感染开始，到抑制病毒复制。这一流行模式的优点是，它提供了艾滋病毒护理进展阶段差距的快照；一个限制是，级联不能向患者传达纵向护理模式。列举这一级联是为了提供社区对护理参与度的估计，但艾滋病毒护理级联并未应用于惩教环境，在那里，发现和治疗艾滋病毒的机会和障碍可能与社区不同。我们建议审查艾滋病毒护理级联，并确定进入和维持护理以及在一个大型南方监狱系统实现病毒抑制的障碍和促进者。在这个过程中，我们将评估级联结果在监狱环境中的效用。具体地说，我们计划估计监狱艾滋病毒护理级联每个阶段的囚犯比例。然后，我们将评估横截面级联指标是否为纵向护理模式提供了合理的替代，我们将确定相关的个人和系统级别的因素 未能与监狱艾滋病毒护理联系起来并保持这种状态。最后，我们将进行访谈，从HIV+囚犯和监狱HIV护理提供者的角度了解关爱的障碍和促进者。这些拟议活动是设计和评价干预措施的关键步骤，以加强实施STTR模式，最终目标是改善艾滋病毒感染以上囚犯的健康，减少他们在监狱和返回的社区中的传播风险。

 DESCRIPTION (provided by applicant): The overlap in the dual epidemics of HIV and imprisonment in the U.S. is well-documented with a prevalence of HIV among prison populations more than three times that of the general population. Prisons are widely recognized as an important setting to address the HIV epidemic: testing and treating HIV-infected prisoners and linking those prisoners into community-based HIV care upon their release may both improve their health and reduce their risk of transmission in communities to which prisoners return. This strategy is commonly referred to as Seek, Test, Treat, and Retain (STTR). There are several NIH-sponsored ongoing and completed studies to evaluate components of the STTR strategy for criminal justice populations. Most focus on ways to increase HIV testing among inmates or improve continuity of HIV care from prisons and jails to the community. However, little research has addressed factors influencing entry into and retention in HIV care during imprisonment. This gap in the literature is significant considering that as many as 63% of known HIV-positive (HIV+) prisoners have not attained viral suppression at their time of release. Failure to attain routine HIV care in prison may portend a high likelihood of failure to enter into community HIV care at release, resulting in poor health and a heightened risk of transmission. Recently, a cascade of HIV care has been used to conceptualize HIV care across a continuum that starts with detection of infection and ends in suppression of viral replication. The strength f this popular model is that it provides a snap shot of gaps across progressive stages of HIV care; a limitation is that the cascade does not convey patients longitudinal patterns of care. This cascade has been enumerated to provide community estimates of engagement in care, but the HIV care cascade has not been applied to correctional settings, where opportunities and barriers to detect and treat HIV may be distinct from those in the community. We propose to examine the HIV care cascade and identify barriers and facilitators to entering and maintaining care and achieving viral suppression in a large southern prison system. In the process, we will evaluate the utility of the cascade outcomes in a prison setting. Specifically we plan to estimate the proportion of prisoners across each stage of the prison HIV care cascade. We will then evaluate whether the cross- sectional Cascade metrics provide a reasonable surrogate for longitudinal patterns of care, and we will identify individual- and system-level factors associated with failing to link into and retain prison HIV care. Finally, we will conduct interviews to understand barriers and facilitators to care from the perspectives of HIV+ prisoners and prison HIV care providers. These proposed activities are key steps in designing and evaluating interventions to strengthen the implementation of the STTR model, with the ultimate goal of improving the health of HIV+ prisoners and diminishing their risk of transmission in prison and in the communities to which they return.