The intertwined epidemics of HIV infection, incarceration, and substance abuse: a call to action.

Willie Sutton, the immaculately dressed bank robber, is credited with Sutton’s Law: when asked why he robbed banks, he responded, ‘‘because that’s where the money is! ’’ [1] Why should those of us concerned with human immunodeficiency virus (HIV) and substance abuse epidemics work in jails? ‘‘Because that is where the money is! ’’ The United States has extraordinarily high rates of incarceration. In 2009, . 12 million men and women passed through US jails [2]. These individuals are most often male, belong to a minority race, have low socioeconomic status, are engaged in active substance abuse, and are at risk for HIV infection and other sexually transmitted infections. The prevalence of HIV infection is 5 times higher in state and federal correctional systems in the United States than in the general public[3]. In this issue of the Journal, Milloy et al[4] describe the dose-response effect of incarceration events on nonadherence to HIV antiretroviral therapy (ART) among injection drug users. From 1996 through 2008, 490 injection drug users were recruited and followed up for a median of . 2 years. Of importance, more than half of the participants were incarcerated during the study period, with a median number of incarceration episodes of 3. The crude incarceration rate was 52 per 100 person-years. Incarceration was the rule rather than the exception. The authors evaluated the impact of incarceration on adherence to ART. Compared with individuals with no history of incarceration, participants with 1 or 2 incarcerations had almost double the odds of nonadherence at each follow-up visit (odds ratio [OR], 1.91). The OR increased to 2.8 for 3–5 incarceration episodes and 3.59 for . 5 incarceration events. This relationship persisted after adjusting for factors, including sex, cocaine use, and methadone maintenance therapy. Are multiple incarcerations causally related to poor adherence, or is it an association? Certainly the structural events of incarceration frequently lead to interruptions in ART. Jail is chaotic, and security rather than healthcare is the priority. More often than not, it takes days for individuals to identify themselves as being HIV infected, have medications confirmed, and receive their ART. Stigma and other concerns will often lead to inmates hiding their HIVpositive status. Significant interruptions in ART may also occur at the time of release from prison or jail. A recent study of released prisoners in Texas found that only 5% filled ART prescriptions in time to avoid an interruption, and only 30% had filled prescriptions 60 days after release [5]. In addition, interruptions in ART may occur after release because of resumption of substance-using behaviors, and this can lead to further HIV transmission in the community. Individuals with multiple incarcerations are probably different from injection drug users who do not get incarcerated; therefore, this relationship may also be an association. Individuals with multiple incarcerations are more likely to have more intensive substance abuse problems, mental health disorders, and other behaviors that are associated with poor adherence. In many ways, whether the relationship between incarceration events and nonadherence is an association or is causal does not matter. These data from the British Columbia Center for Excellence in HIV and AIDS Care are an important contribution, because they highlight the need for intensive HIV treatment interventions for individuals involved with the criminal justice system. Received 11 January 2011; accepted 18 January 2011. Potential conflicts of interest: T.F. has stock ownership in BMS, Gilead, Abbot, Merck, and GlaxoSmithKline. C.G. B. : no conflicts. Correspondence: Timothy P. Flanigan, MD, Alpert Medical School of Brown University and The Miriam Hospital, 164 Summit Ave, Providence, RI 02906 (tflanigan@lifespan.org). The Journal of Infectious Diseases 2011;203:1201–3 The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. permissions@oup.com 0022-1899 (print)/1537-6613 (online)/2011/2039-0001$14.00 DOI: 10.1093/infdis/jir034