COVID-19 And HIV: Overlapping Pandemics For Criminal Justice-Involved Individuals

Over the course of the COVID-19 pandemic, policy makers have looked to the lessons learned from the HIV pandemic. Both the COVID-19 and the HIV pandemics have demonstrated disparate effects due to structural inequities. The burden of both COVID-19 and HIV has been placed on vulnerable groups living in social conditions that make prevention of these diseases difficult to impossible. A population acutely affected by inequities in both COVID-19 and HIV is those with criminal justice (CJ) involvement. HIV prevalence among CJ-involved adults is three times higher than in the general population. In the context of the COVID-19 pandemic, jails and prisons are at high risk and make up many single-site cluster outbreaks.

Mass incarceration has been defined as a “system of social and racial control” that fosters racial inequality, reinforces stereotypes that are the basis for racial discrimination, and, consequently, produces health inequities. The system of mass incarceration has allowed COVID-19 to enter our country’s prisons, jails, and communities most impacted by mass incarceration at astounding rates. Congregate living settings, including jails and prisons, have become epicenters of the pandemic. Incarcerated people often have poor health when they enter prison due to limited health care access and structural determinants of health that lead to incarceration. Their health often also worsens while incarcerated, and it is impossible for individuals to prevent COVID-19 through practicing social distancing in carceral settings. In addition to prisons and jails themselves, communities that incarcerated individuals return home to also bear a high burden of COVID-19. For example, Black Americans are both overrepresented in the CJ system itself and are more likely to live in areas with high poverty rates, have limited health care access, and have higher rates of jobs in service industries where they are less able to work from home, which increases their exposure to COVID-19.

It has been well-documented that those with CJ involvement and their communities are at high risk for HIV for similar reasons that they are at high risk for COVID-19 (for example, limited access to medical care, poverty, and so forth). In addition, post-release, many individuals engage in substance use and sexual behaviors that increase their risk for HIV acquisition. Given that CJ-involved individuals are thus at high risk for both HIV and COVID-19, it is critically important that both HIV prevention and the HIV care cascade remain in place for this population during the COVID-19 pandemic to lessen the impact of these overlapping, compounding pandemics on the health of people who are involved in the CJ system.

First, the HIV pre-exposure prophylaxis (PrEP) care continuum is critical to HIV prevention. PrEP is a daily pill that reduces the risk of HIV infection in people at high risk of acquiring HIV via sexual transmission by more than 90 percent. Yet, PrEP uptake and adherence relies on community-based organizations, primary care, and peer navigation. Peer and community-based navigation in particular are known to improve patient engagement and increase medication adherence, which is particularly needed for populations that experience systemic barriers to HIV prevention and care. (Peer navigation provides direct assistance to patients via lay staff members that are peers of patients, often formerly incarcerated people, to navigate complex health care systems in a way that promotes trust and lowers stigma. It has been successful at linking HIV positive individuals to care after release from prison and shows promise for linking individuals to PrEP.) During COVID-19, these pathways have been disrupted, and around 9 percent of PrEP users who are gay, bisexual, or men who have sex with men have reported that they were unable to access PrEP. Peer and community navigators have begun offering telehealth rather than in-person visits, which are sometimes difficult to access for those without high-speed internet or reliable phones. Many providers stopped making referrals to primary care providers who can prescribe PrEP early in the pandemic. Additionally, around one-third of those leaving incarceration prefer to have PrEP prescribed before leaving, but COVID-19 also decreases this possibility as medical systems in carceral settings are overwhelmed by COVID-19 and, more broadly, have limited to no funding for preventative health care.

Second, among people living with HIV, COVID-19 also poses great risk. While HIV itself may not alter one’s risk for acquiring COVID-19, people living with HIV often face multiple comorbidities (for example, older age, cardiovascular disease, pulmonary disease) and social determinants of health (for example, housing insecurity, food insecurity) that heighten the risk for severe illness from COVID-19. People living with HIV are also at risk for discontinuing anti-retroviral therapy (ART) during the pandemic; those that discontinue ART are more likely to develop severe HIV disease, which may put them at risk of developing severe COVID-19. Even before the pandemic, individuals were unlikely to continue ART after leaving incarceration due to a lack of linkage to care; at this time, this could increase their risk of both severe HIV and severe COVID-19 infection. Additionally, people newly diagnosed with HIV that need to initiate ART may delay care for fear of COVID-19, and people taking ART may discontinue during COVID-19 due to lockdowns, recent unemployment, and, if they lack income or medical insurance, a lack of knowledge of or access to patient assistance programs. Similar to PrEP, community-based organizations, primary care, and peer navigation are critical components to people initiating and staying on ART after an HIV diagnosis. With these services disrupted during the COVID-19 pandemic and many services switching to telehealth, the most vulnerable patients are the most likely to discontinue ART, leading to worse health and a higher likelihood of transmitting HIV to others.

Given the concentration of both HIV and COVID-19 among the incarcerated and those involved in the CJ system, there is a need to focus on this intersection rather than each disease individually. Additionally, given COVID-19’s severe impact on those involved in the CJ system, it is important to rethink how HIV prevention and treatment can be restructured in a way to withstand this and future disruptions. Research to date has not explored the intersection of CJ involvement, being at high risk for HIV or being HIV-positive, and being at high risk for exposure to and serious illness from COVID-19. As the COVID-19 pandemic continues, it is increasingly pressing that public health professionals and researchers find innovative ways to focus on the health of these vulnerable communities and community members, provide linkages to HIV- and COVID-19-related care between CJ and community settings, and push for decarceration of our communities.

The prevalence of COVID-19 continues to be high in prisons and jails and will likely continue to be high as the Delta variant grows and other variants emerge, vaccination efforts wax and wane, and decarceration is not realized. HIV prevalence also remains high among this population. To disrupt the impact of the COVID-19 pandemic on the health of CJ-involved individuals and their access to HIV prevention and care, novel strategies are required. We now present possible strategies for delivering both PrEP and ART during the COVID-19 pandemic to CJ-involved populations, recognizing the underserved nature and vulnerability of these community members.

Mobile Clinics

Rather than relying on telehealth, mobile clinics should go into communities to deliver PrEP and ART outside of the standard workday. PrEP and ART services have much to learn from innovations in the substance use field. Mobile clinics have successfully been used for substance use treatment and are often seen as attractive, accessible, and acceptable to high-risk and hard-to-reach individuals. Given that we have also seen an increase in fatal overdoses during the pandemic, due to increases in stress and isolation of already vulnerable individuals as well as difficulties accessing services, bundling PrEP and ART services with substance use mobile clinics offers a time-sensitive opportunity to address substance use and HIV in the same location. Additionally, there is high comorbidity between HIV and substance use, particularly among those with CJ involvement, making this innovation particularly pertinent.

Beyond COVID-19, there is a need for integrating substance use treatment, HIV prevention and treatment, and other health care for the CJ-involved population, which often lacks high-quality health care post-release due to a lack of insurance, stigma, and the need to prioritize basic needs (for example, food and shelter).

Co-Located Health Care Services

In addition to mobile clinics, PrEP and ART services should be co-located alongside other health care services. These could include substance use services such as needle exchanges and syringe dispensaries, which remain crucial for the health of injection drug users during the COVID-19 pandemic. Alternatively, given the now-high frequency of community-based COVID-19 testing and vaccine units, PrEP and ART services could be offered alongside these COVID-19 units.

Self-Administered Tests And Medications

Another innovation would be to allow people to receive PrEP pill packets in larger quantities and to self-administer HIV tests, requiring patients to go to clinics less frequently. Self-administered HIV tests have been found to increase testing frequency and to not increase sexual risk-taking behaviors. And [email protected]—a home-care system with all components of an in-person PrEP visit—has been piloted and found to be highly acceptable and in-demand, with more than one-third of participants reporting greater likelihood of sustaining PrEP care under this model. We suspect that an even greater proportion would be sustained in care if [email protected] were available during the COVID-19 pandemic; in fact, a similar model has been found to be effective in Brazil during the pandemic.

Patient Assistance Programs

High copayments, a lack of insurance, and high costs for PrEP have consistently been cited as barriers to initiating and sustaining PrEP. While many patient assistance programs exist (for example, drug manufacturer Gilead’s patient assistance program), many are unaware of them or are still unable to cover laboratory or medical visit costs when these costs are not covered by patient assistance. Therefore, it is critical, especially given the co-occurring economic crisis that COVID-19 has sprung, to eliminate copays for PrEP and to increase awareness of patient assistance programs for individuals that now qualify due to COVID-19 economic crisis. While a small burden on health care insurers, consistent PrEP use is associated with a significant decrease in lifetime HIV risk, increased life expectancy, and decreased lifetime treatment costs, resulting in high cost-effectiveness.

Access To PrEP Before Release

Given that many leaving incarceration prefer to have PrEP prescribed before release, it is even more important to link formerly incarcerated persons to PrEP at release from prison or jail during the COVID-19 pandemic. While national guidance highlights the importance of access to medication during incarceration and linkage to community providers post-release, only 14 percent of state prisons and 30 percent of jails meet best practices for HIV testing; 19 percent of state prisons and 17 percent of jails meet best practices for discharge planning; and no prisons or jails provide PrEP. Community re-entry comes with many challenges itself, including securing housing, transportation, and employment, which can lead to a de-prioritization of PrEP; the stressors of the COVID-19 pandemic have heightened the challenges of community re-entry. Additionally, given the decarceration of prisons and jails that has begun during the COVID-19 pandemic, there are more people leaving jails and prisons than before the pandemic, highlighting the need for linkage to care among this population. Therefore, it is important for individuals to be prescribed PrEP and linked to a local clinic upon leaving carceral facilities, preferably through peer navigation.

Through providing training to CJ-based clinicians and developing standards and best practices specific to these settings, it is possible for PrEP to be initiated while people are in prisons and jails. Furthermore, through providing training to probation and parole officers and developing standards and best practices specific to community supervision, it is likely that PrEP would be more successfully initiated and sustained for individuals on community supervision. Critically, the cost of PrEP treatment and care will need to be considered and will vary by states’ Medicaid expansion. The Biden administration and Congress should prioritize funding these initiatives, and alternative funding mechanisms, such as industry-sponsored patient assistance programs in correctional facilities, should be considered.

Due to structural inequities, adults involved in the CJ system are disproportionately impacted by both HIV and COVID-19. COVID-19 infection rates continue to be higher among those incarcerated in prisons and jails and will likely remain this way for the foreseeable future due to crowded congregate spaces, inadequate testing and health care, high-volume inflow and outflow of staff, lack of personal protective equipment, low vaccination rates, and a general neglect of welfare. To reduce the impact of the pandemic on CJ-involved individuals and their access to HIV prevention and care, there is thus an urgent need to focus on innovative ways to deliver both PrEP for HIV prevention and ART for HIV treatment during the COVID-19 pandemic to those with CJ involvement. Through focusing on the intersection of HIV and COVID-19 among CJ-involved individuals, we can work toward achieving health equity among our nation’s most-often forgotten residents.