Background

One in 100 individuals in the United States (US) are under community supervision (e.g. parole) by the criminal justice (CJ) system. Black and Hispanic individuals, sexual and gender minorities, underserved rural populations, and the socioeconomically disadvantaged (all NIH-designated health disparity populations) are disproportionately arrested, incarcerated, and assigned to parole. They are also at increased risk for acquisition of HIV infection. The estimated prevalence of HIV infection among CJ involved individuals is 3x higher than the general population, and post-release, individuals experience multi-level barriers to HIV prevention efforts. However, existing HIV prevention approaches—behavioral risk reduction, promotion of condom use, and HIV counseling and testing—have been insufficient for reducing HIV incidence among those who have recent CJ experience. Therefore, innovative HIV prevention strategies are urgently needed post-release. Pre-exposure prophylaxis (PrEP) is a once daily medication that has demonstrated efficacy in preventing HIV among at-risk groups. Nevertheless, our preliminary research finds that few individuals with recent CJ experience are aware of PrEP and nothing is known about PrEP acceptability, initiation, and sustained use among parolees recently released from prison or how these patterns may vary by individual, social and structural factors.

Objective

The estimated HIV prevalence among CJ-involved individuals is three times higher than the general population. Parolees on post-release supervision after release experience multi-level obstacles (e.g., lack of access to housing, employment) that act as barriers to HIV prevention efforts, making existing approaches to HIV prevention insufficient for reducing HIV incidence. PrEP is a once daily medication (emtricitabine/tenofovir, FTC/TDF) that has demonstrated efficacy in preventing HIV among at-risk groups. Little is known about PrEP knowledge, acceptability, initiation, and sustained use among parolees recently released from prison or how these patterns vary by individual (HIV risk factor, sociodemographic characteristics), social (stigma, social support), and structural (housing, employment) factors. Therefore, we will conduct an observational, multi-site cohort study in North Carolina, Kentucky, and Florida—the Study of Personal Experiences with Accessing Care in the South Study (SPECS). This study is guided by the Social Ecological Model and the NIMHD Minority Health and Health Disparities Research Framework,

which both have a focus extending beyond the individual and acknowledge that multi-level (individual, social, and structural) factors play a role in the perpetuation of persistent health disparities. The specific aims of the study are: 1) characterize PrEP knowledge and acceptability among parolees; 2) identify the multi-level factors that predict PrEP initiation and sustained use among parolees; 3) qualitatively assess the multi-level factors that affect PrEP acceptability, initiation and sustained use to inform future intervention development. The project will be the first observational cohort study that includes a CJ involved population at extreme risk for HIV acquisition. Our study is aligned with the following high priority topics as defined by the NIH, NIMHD Science Visioning, and Office of AIDS Research: a) advancing evaluation of approaches to improve minority health or to reduce health disparities; and b) reducing incidence of HIV/AIDS and implementing strategies to improve entry into prevention services.

Outcomes

Aim 1 is to characterize PrEP knowledge and acceptability among people recently placed under community supervision (probation/parole) within the past 12 months. We will observe and estimate the proportion of who have prior PrEP knowledge and high, average, and low PrEP acceptability. We will also assess the relationship between individual (e.g. HIV risk behaviors, socio-demographics, health service utilization), social (e.g. stigma, social support), and structural (e.g. housing access, employment access, reincarceration) factors and PrEP knowledge and acceptability at baseline. Aim 2 is to identify the multi-level factors that predict PrEP initiation and sustained use among parolees. We will examine the relationship between individual, social, and structural factors and PrEP initiation at 6-month follow-up and sustained use at 6, 12, and 18 month follow-ups. Aim 3 is to qualitatively assess the multi-level factors that affect PrEP acceptability, initiation and sustained use to inform future intervention development. We will conduct 75 interviews (n=25 at each site) stratified into three groups: a) people under community supervision who never initiated PrEP b) people under supervision who initiated but did not sustain PrEP use, and c) people under supervision who initiated and sustained PrEP use. Interviews will be informed by quantitative findings in aims 1 and 2, but will include the following four domains: (i) risk compensation, (ii) knowledge, acceptability, and experience related to PrEP initiation/sustained use, (iii) the multi-level barriers and facilitators of PrEP initiation and sustained use and suggestions for future PrEP intervention components, and (iv) interest in new PrEP modalities.

Benefits

The expected outcomes of this study include: 1) a clear understanding of PrEP knowledge, acceptability, initiation, and sustained use among parolees at risk of HIV infection in three diverse Southern states; and 2) data needed to develop a roadmap for expanded and tailored PrEP interventions among CJ populations. This project is part of a longer-term research agenda focused on developing effective interventions and policies to address disparities in PrEP knowledge, acceptability, initiation, and sustained use among a particularly marginalized and vulnerable population.

Study Team/ Roles

• Lauren Brinkley-Rubinstein, PhD, Assistant Professor (UNC-CH), PI
• David Wohl, MD, Professor (UNC-CH), Co-Investigator
• Katie Mollan, Senior Biostatistician (UNC-CH), Biostatistics Expert
• Kathryn Nowotny, PhD, Professor (University of Miami), Consortium PI
• Carrie Oser, PhD, Professor (University of Kentucky), Consortium PI
• Nickolas Zaller, PhD, Professor (University of Arkansas), Consortium PI

Funding Organization

• The National Institute on Minority Health and Health Disparities (NIH)
• The grant lasts for five years from 2018-2023

Presentation

• Brinkley-Rubinstein, L. (2019, March). HIV infection among people who are incarcerated. Invited talk at the Southeast AIDS Education and Training Center coordinated by Vanderbilt University, Nashville, TN.

Contact

Lauren Brinkley-Rubinstein  | Lauren_Brinkley@med.unc.edu

333 S. Columbia St.

341b MacNider Hall

Chapel Hill, NC 27599

Learn More

The National Institute on Minority Health and Health Disparities webpage

 

Last updated: 7/28/2020