https://orcid.org/0000-0002-1754-1730
ABSTRACT
While Pre-exposure prophylaxis (PrEP) is efficacious in preventing HIV, little is known about PrEP use among those on community supervision. The Southern Pre-Exposure Prophylaxis Study (SPECS) investigates barriers and facilitators for PrEP initiation and use among adults on community supervision (e.g., probation, parole). Challenges to PrEP use in this setting are abundant. SPECS uses a mixed-methods sequential design, including a multi-site, prospective cohort study in three southern states – North Carolina, Florida, and Kentucky. This analysis describes individual demographic, criminal legal, and HIV risk factor characteristics, by site and enrollment status. Pooled association analyses accounted for site via stratified statistical tests. Between June 2019-March 2020, SPECS screened 702 individuals and enrolled 276 participants (39%). Of those who were eligible, 98% agreed to enroll. Age, gender, and sexual orientation varied by enrollment and by site, while race/ethnicity varied by site but not enrollment status. Criminal legal histories varied by enrollment and HIV risk factors varied by site. SPECS provides a granular and detailed assessment of HIV risk in three diverse southern settings. It highlights how the level and type of HIV risk varies by location and by nature of criminal legal involvement and calls for the need for context-specific interventions for HIV prevention.
Introduction
One in 59 individuals in the United States (US) are under community supervision (e.g., probation, parole) by the criminal legal (CL) system (Kaeble & Cowhig, Citation2018). Black and Hispanic individuals, people in poverty, and those with substance use disorders are disproportionately involved (Horowitz & Utada, Citation2018; Phelps, Citation2018). In the Southern US, where there is a confluence of racial discrimination, poverty, substance use, and voter disenfranchisement, CL involvement is highest (Wagner & Sawyer, Citation2018). Disparities in CL system involvement mirror HIV disparities, with those at highest risk of HIV living in the Southern US and concentrated in the CL system; HIV prevalence among CL-involved adults is three times that of the general population (Westergaard et al., Citation2013). After release from incarceration, individuals have unmet basic needs – due to limited housing and employment opportunity, movement restrictions, and disrupted social networks – and subsequently (re)engage in behavior that increases HIV risk (e.g., condomless sex, injection drug use) (L. M. Adams et al., Citation2013). HIV risk is particularly heightened in the South given its high HIV-related stigma, poverty, HIV prevalence, and racial inequity (Reif et al., Citation2017).
Pre-Exposure Prophylaxis (PrEP) is credited with recent reductions in HIV incidence (The Centers for Disease Control and Prevention, Citation2021). Yet, uptake has been slow, little is known about PrEP use among those on community supervision, and challenges are abundant (e.g., regular clinical appointments) (Huang et al., Citation2018).
SPECS (The Southern Pre-Exposure Prophylaxis Study), the parent study, is designed to close the knowledge gap regarding PrEP among those on community supervision in North Carolina (NC), Kentucky (KY), and Florida (FL) (LeMasters et al., Citation2021). Sites were chosen given their variable urbanicity, racial/ethnic profiles, and HIV risk profiles (AIDSVu, Citation2021; United States Census Bureau, Citation2020). Our goal was to examine demographic differences and similarities in PrEP eligibility by enrollment status and site. SPECS began in the summer 2019 and this analysis includes screenings prior to March 2020 when recruitment was paused due to the COVID-19 pandemic.
Materials & methods
Individuals are eligible for SPECS if they are 18 years or older, were placed on community supervision within the last 12 months, are HIV negative, and are eligible for PrEP. SPECS researchers recruited individuals in waiting rooms at probation and parole offices and conducted screening in private rooms. This analysis assessed demographic, CL, and HIV risk factor characteristics, stratified by site and enrollment. Associations were assessed using Cochran-Mantel-Haenszel tests for dichotomous and ordinal variables, Van Elteren tests for continuous variables, and conditional logistic regression models with Wald Chi-Square tests for categorical variables. P-values were not adjusted for multiplicity. Tests were not performed on HIV risk factors, which were required for eligibility. Complete case analyses were conducted. Windows SAS version 9.4 (Cary, NC) was used.
Results
Demographic information
Demographic information is in . Between June 2019 and March 2020, SPECS screened 702 individuals and enrolled 276 (39%). Most ineligible individuals did not qualify for PrEP (96%) by Centers for Disease Control and Prevention criteria. Percent enrolled varied by site, with 41% (95/229) enrolled in FL, 52% (126/242) in KY, and 24% (55/231) in NC. Across sites, median age was lower among those enrolled vs. not enrolled (34 vs. 37 years, p-value < 0.0001). Predominantly, men were screened, though this varied by site. Among those who completed screening, women were more likely to enroll (women: 51%, men: 36% enrolled, p-value 0.0051). Sexual orientation varied by enrollment. While 88% of those screened identified as heterosexual, LGBQI individuals were more likely to enroll among those who completed screening (LGBQI: 58%, heterosexual: 37% enrolled, p-value 0.0014). This varied by site with 8%, 18%, and 23% of those enrolled in FL, NC, and KY, respectively, being LGBQI. Race/ethnicity did not vary by enrollment but varied by site. Of those screened in FL, half were Black Non-Hispanic and 26% White Hispanic. In KY, 61% were White Non-Hispanic and 30% Black Non-Hispanic. In NC, 58% were Black Non-Hispanic and 27% White Non-Hispanic.
Table 1. Participant characteristics and criminal legal information at screeningTable Footnotea.
CL histories
CL history is in . Community supervision within the last year was an eligibility requirement for SPECS and 95% of those enrolled were incarcerated in the past year. More individuals had been in prison than jail, but a higher percentage of those who were in jail enrolled compared to those in prison. CL involvement type did not vary by enrollment after controlling for site. While half of those enrolled in FL and NC were recently in jail, 33% of those enrolled in KY were. Parole and probation varied by enrollment, with those on probation more likely to enroll (probation: 43%, parole: 37% enrolled, p-value 0.020). Community supervision status varied by site with one-third on probation in KY, and two-thirds in FL and NC. Enrolled individuals spent fewer months incarcerated than those not enrolled, but this varied by site. Time since release was associated with enrollment; those enrolled were released for longer than those not enrolled (p-value < 0.0001).
PrEP eligibility
HIV risk factors for PrEP eligibility are summarized in . Most enrolled (72%) qualified by having one HIV risk factor. The most common risk factor (90%) was having condomless sex without confirming a partner’s HIV status. Nearly all enrolled had sex within the last six months, as compared to half of those not enrolled. Of those who had sex, most cisgender men had sex with cisgender women only and most cisgender women had sex with cisgender men only. Thirteen individuals screened had sex with a disclosed HIV positive partner in the past six months and 12 enrolled. While almost all enrolled in FL and KY did not confirm their partner’s HIV status before having condomless sex, 66% of those enrolled in NC did not. A higher percentage of those enrolled in KY and NC had condomless sex with a partner who injects drugs than in FL. It was more common in FL and NC to have had condomless sex with a partner who is a sex worker or is transgender.
Table 2. CDC HIV Risk Factors in the Past 6 MonthsTable Footnotea.
Few individuals, regardless of enrollment status, had been recently diagnosed with a sexually transmitted infection (STI). However, most of those recently diagnosed were enrolled. Few enrolled (10%) had shared injecting material equipment, but most of those who did enrolled. The highest proportion of those enrolled with a recent STI or who shared injecting equipment was in NC.
Discussion
Demographic and enrollment characteristics varied by site, highlighting HIV’s context-specific nature. Sites were chosen for their distinct demographic characteristics and HIV risk factors (e.g., the proportion of individuals that inject drugs), which have implications for PrEP program advertisements and initiation strategies. Additionally, when behaviors vary by demographic information within sites (e.g., race/ethnicity), there are implications for targeting HIV prevention efforts. PrEP barriers historically differ by race and sexual orientation, with Black individuals often experiencing medical mistrust and Black and LGBQI individuals being stigmatized by providers (Cahill et al., Citation2017).
It is important to consider CL histories between enrolled and not enrolled individuals. Prior literature shows increases in HIV infection post-release, particularly in the South (J. W. Adams et al., Citation2018; Ojikutu et al., Citation2018). This literature focuses on (1) the lack of HIV testing and care within carceral settings, which contributes to increased viral load for people living with HIV and (2) increased HIV spread after returning to communities. Our study expands on this by focusing on high-risk individuals that are HIV-negative at re-entry and explores their CL histories. For example, those recently in jail were more likely to enroll than those recently in prison. Additionally, those enrolled spent fewer months incarcerated than those not enrolled. Thus, while individuals may be at higher HIV risk soon after release, this risk may be heightened for those that served shorter jail sentences versus longer prison sentences. Importantly, those enrolled had been released from incarceration for longer than those not enrolled. Future work should consider the type and timing of CL involvement of those at increased HIV risk.
The COVID-19 pandemic disrupted data collection and paused recruitment. The pandemic also has implications for altering CL patterns due to fewer parole and probation regulations (e.g., urine drug screens), as parole and probation violations are frequently causes of reincarceration (Alper et al., Citation2018; The Prison Policy Initiative, Citation2022). Additionally, HIV risk patterns may have shifted during the pandemic, given social distancing practices and economic hardships. One study reported an increase in drug use and the number of sexual partners during COVID-19 for men who have sex with men (Stephenson et al., Citation2021). It remains unclear how HIV risk patterns among those with CL involvement are affected.
Conclusions
SPECS is an important step in understanding HIV risk among those on community supervision. While prior work has characterized this population as being at high risk for HIV post-release, this study provides a granular and detailed assessment of that risk (L. M. Adams et al., Citation2013). Level and nature of HIV risk varies by location, demographic information, and nature of CL involvement, which calls for context specific HIV prevention interventions adapted for those with CL involvement.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
References
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