Linking Persons With HIV, Discharged From Jail, With Community Care

Study Overview
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Brief Summary
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This is a prospective cohort study of outcomes of individuals who entered jail during a period during which one of three serial HIV testing strategies is implemented. This study involves two sub-studies. One sub-study will examine referrals to HIV prevention programs for persons testing negative for HIV while in jail. The second sub-study will monitor antiviral use among those testing positive for HIV.

Detailed Description
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Incarcerated Americans on any given day represent one in 40 (2.5%) Persons Living with HIV (PLWH) in this country, but those ever incarcerated over the course of a year represent 17% of the US epidemic. PLWH are a diverse group in terms of awareness and management of their disease. A portion may be aware of their HIV status and on treatment. This subgroup is at risk of disruption in care if incarcerated. Others may be aware of their status, but untreated, while still others may be unaware of their HIV status. The latter group is of particular importance in terms of the HIV epidemic in criminal justice settings, as a recent meta-analysis indicated that up to 15% of individuals entering jail have undiagnosed infections. Good management of PLWH during a period of incarceration is critical. Ensuring that care relationships are maintained or newly established will improve health outcomes among PLWH and reduce the risk of transmission once they are discharged. As the median length of stay in jail is short (median < 7 days), rapid HIV testing is critical. Maximizing the yield and speed of HIV testing in a jail environment has the potential to promote rapid entry into care, or rapid re-engagement if persons have fallen out of care. For those testing negative, it can hasten the referral to Pre-Exposure Prophylaxis (PrEP) services. How correctional facilities offer HIV testing and begin treatment affects long-term outcomes. Because of the rapid churn of jail, point-of-care (POC) rapid testing may lead to a higher percentage of patients receiving test results before leaving jail, compared to conventional assays. Fourth generation laboratory-based antigen/antibody (Ag/Ab) testing can diagnosis more persons with acute HIV infection, who may be in the window period before the POC test turns positive, but has a several hour test turn-around time, and those tested may leave jail before receiving their result. Using both tests for every entrant would permit the jail to experience the benefit of both methods but at greater expense. Collaborating with Washington, DC's city jail, known as DC Department of Corrections (DC DOC), and Unity Healthcare, the network of Federally Qualified Health Centers in Washington DC, which also provides care within the DC DOC, this study has a unique opportunity to measure rapidity of testing, linkage to and commencement of care, and achievement of viral suppression, along with costs of HIV identification. This study uses a unique, time-sensitive opportunity to compare three separate strategies of universal HIV screening and treating. The strategies of POC testing, 4th generation laboratory-based Ag/Ab testing, and a combination of the two tests will be compared in the DC jail. A rigorous assessment of the three strategies in terms of their feasibility, process measures, and cost-effectiveness on an institutional level will help to guide implementation decisions in jails across the US. One sub-study will assess the number of persons testing negative who are referred to prevention programs after leaving the jail. A second sub-study will examine antiviral use after jail release, among PLWH.

Official Title
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Linking Persons With HIV, Discharged From Jail, With Community Care: a Direct Comparison of the Costs and Effects of Three HIV Management Strategies in the District of Columbia Department of Corrections

Conditions
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Human Immunodeficiency Virus

Intervention / Treatment
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* Diagnostic Test: Point-of-Care (POC) Rapid HIV Test
* Diagnostic Test: Fourth Generation Antigen/antibody (Ag/Ab) HIV Test


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria for Those Testing Negative for HIV: Able to understand and speak English Confirmed HIV negative status Planning to stay in the metropolitan DC area upon jail release Candidate for PrEP using attached screening instrument and interested in taking it Inclusion Criteria for Those Testing Positive for HIV: Able to understand and speak English Confirmed HIV positive status Planning to stay in the metropolitan DC area upon jail release Exclusion Criteria: none

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| POC Testing Alone<br>POC HIV testing (the current standard of care) will be conducted for persons entering jail during the first two-month period. | Diagnostic Test: Point-of-Care (POC) Rapid HIV Test<br>* Point-of-care (POC) rapid HIV testing provides results within minutes, however, it cannot reliably detect new infections. It can take up to 90 days after exposure for HIV infections to be diagnosed with POC rapid testing.<br>|
| POC and 4th Generation Testing<br>POC plus 4th Generation HIV Testing will be conducted for persons entering jail during the second two-month period. | Diagnostic Test: Point-of-Care (POC) Rapid HIV Test<br>* Point-of-care (POC) rapid HIV testing provides results within minutes, however, it cannot reliably detect new infections. It can take up to 90 days after exposure for HIV infections to be diagnosed with POC rapid testing.<br>Diagnostic Test: Fourth Generation Antigen/antibody (Ag/Ab) HIV Test<br>* Fourth generation laboratory-based antigen/antibody (Ag/Ab) HIV testing can detect acute HIV infections (as early as 18 days after exposure), but it takes several hours to process.<br>|
| 4th Generation Testing Alone<br>4th Generation HIV Testing will be conducted for persons entering jail during the third two-month period. | Diagnostic Test: Fourth Generation Antigen/antibody (Ag/Ab) HIV Test<br>* Fourth generation laboratory-based antigen/antibody (Ag/Ab) HIV testing can detect acute HIV infections (as early as 18 days after exposure), but it takes several hours to process.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of Entrants Tested | The number of entrants receiving an HIV test within 24 hours of intake will be examined. | Up to 24 hours | 
| Percentage of PLWH Identified in First 24 Hours | The percentage of PLWH identified within the first 24 hours of admission, among all PLWH who enter, will be examined. | Up to 24 hours | 
| Number of New HIV Diagnosed Prior to Discharge | The number of persons with a new diagnosis of HIV who receive test results before discharge will be examined. | Up to Jail Discharge | 
| Number of Entrants with Acute HIV Infection Identified | The number of entrants identified having an acute HIV infection will be examined. | Up to 5 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Time Until Receipt of Positive Test Result | The time (in hours) from the positive test result in persons not previously diagnosed and receipt of test report. | Up to 5 days | 
| Time Until Receipt of Antiviral Dose | The time (in days) from entry until receipt of first dose of antiviral in the jail, for PLWH. | Up to Jail Discharge | 
| Time Until Viral Suppression | For all PLWH, the time (in days) from entry to achieving viral suppression, if not suppressed at baseline. | 6 months after positive HIV intake test | 
| Time Until Meeting with Discharge Planner | For all PLWH, the time (in days) from intake to meeting the discharge planner. | Up to Jail Discharge | 
| Number of Participants Taking PrEP | For those consenting to the first sub-study, the number of high-risk persons who test negative for HIV who successfully link to PrEP within 2 months of jail release and stay on PrEP for at least 6 months will be examined. | 2 months after jail release, 6 months after jail release | 
| Number of PLWH who Attend Clinic Visits | For persons living with HIV who consent to the second sub-study, the percentage of persons previously and newly diagnosed who make clinic visits at least once every 6 months will be examined. | 1 year | 
| Number of PLWH with Viral Suppression | For persons living with HIV who consent to the second sub-study, the percentage of persons previously and newly diagnosed who are virally suppressed 6 months after sub-study enrollment. | 6 months | 
| Cost of Each Testing Strategy | A cost-effectiveness analysis using the intermediate process measures will be conducted. Units of resource items, such as tests and staff time, will be multiplied by their unit costs to calculate total costs. Wage ranges provided by DOC and Unity Healthcare will be used to price staff time; market values will be used for all other items. Costs will then be summed by testing strategy. | 6 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Correctional settings, HIV/AIDS