PrEP Uptake, HIV Care Continuum Have Improved for Adults in Federal Custody

Rates of HIV pre-exposure prophylaxis (PrEP) receipt, including initiation and continued treatment, have increased among adults in custody (AIC) in the US Federal Bureau of Prisons (FBOP), according to a study published in Emerging Infectious Diseases. The HIV care continuum was also shown to have improved in the previous 2 decades.

The CDC estimates that 13% of people living with HIV (PLWH) are undiagnosed, which makes ending the HIV epidemic difficult. HHS has launched a campaign to reduce the number of new infections of HIV by 2030 with the 4 pillars of diagnosis, treatment, prevention, and response. The FBOP is among several government entities is aiming to use these pillars to reduce the number of new infections, including by screening for HIV, offering antiretroviral therapy, and enabling access to PrEP. This study aimed to describe the HIV testing and treatment program implemented by the FBOP as well as the implementation of the PrEP program.

PrEP | Image credit: Bowonpat - stock.adobe.com

Guidelines for treating AIC with HIV were established in 2004. All AIC are informed that HIV screening is part of their laboratory screening when they are entered into custody and can opt out if they prefer. If HIV is detected, treatment is started when the AIC is both willing and able to start therapy. The FBOP created the HIV Clinical Pharmacist Consultants program in 2004 to help with patient management, which includes viewing laboratory findings, managing prescriptions, and providing expert consultation.

The rate of new HIV infections in custody is low, but prevention is a goal of the BFOP due to most AICs returning to their community. Providers can identify AICs who are at increased risk of HIV infections, such as those who are intravenous drug users. The HIV Clinical Practice Guidelines were updated in 2021 to properly address the use of oral PrEP. AICs who are identified as being at risk or those who self-refer for evaluation can start receiving oral PrEP if they have had sex with a PLWH, have inconsistent usage of condoms, have used drugs, have had more than 1 partner, shared needles, or had a sexually transmitted infection within 6 months of custody, among other factors. Any AIC who requested PrEP could also receive it.

PrEP is started in AICs approximately 30 days before they are released from custody to assess their response to treatment. All AIC taking PrEP are given a 90-day supply if they respond well to treatment. Uptake in AICs was encouraged by a multimodal strategy. A webinar was provided to discuss harm-reduction strategies with health care providers and a PrEP fact sheet was created to answer questions about how it should be prescribed. Strategies to increase uptake were also developed at individual FBOP institutions, including running clinics for AICs who will be released within 90 days.

The present study aimed to assess the effectiveness of these interventions. The number of people who entered custody between April 1, 2021, and March 25, 2023, after the PrEP program was initiated, was collected using the FBOP electronic medical record. The HIV care continuum was also evaluated using the same electronic medical record, which included counting the number of AICs who had been offered at least 1 test for HIV, the number who were positive, and the number on treatment. The number of patients with an undetectable viral load was also counted.

A total of 303,817 people either entered custody or were transferred between facilities in the time frame of this study. Infrequent condom use (48.3%) and never using a condom (36.7%) were the most frequently reported risk factors for HIV.

There were 139,789 AICs as of June 2, 2023, who were in custody for 90 days or more. A total of 89.6% had been offered at least 1 HIV test, of which 1.0% had a positive result. All AICs with HIV had been offered antiretroviral treatment and 99.3% had started it. A total of 95.5% of the patients who had been on treatment for 90 days or more (92.6% of those who initiated treatment) had an undetectable viral load. There were 28 patients who started PrEP within 90 days of their release in 2022, which increased to 41 patients as of June 2023.

There were some limitations to this study. Not all HIV risk factors are included in the intake screening. The intake screening also does not assess the predicted risk of HIV for an AIC after they are released. There may be some duplicate records for AICs due to intake screening occurring both when they are initially in custody and when they are transferred to a new facility.

The researchers concluded that educating AICs and employees in promoting PrEP availability for this population will be a continuing priority for the FBOP, including addressing barriers to getting the education to as many AICs and employees as possible. Pharmacists will be included in this effort to further improve patient outcomes.

Reference

Huang XH, Thompson E, Rodriguez T. HIV care continuum and preexposure prophylaxis program in Federal Bureau of Prisons, United States. Emerg Infect Dis. Published online March 30, 2024. doi:10.3201/eid3013.230799