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Research capacity building is intrinsic to the work of the Institute for Global Health & Infectious Diseases (IGHID), nurturing trainees here and around the world. Eli Arant, MD, a third-year infectious diseases fellow in the T-32 training program, represents this training at its best, moving the literature forward in an area with limited research.

UNC Hospitals has provided HIV care to the state prison system, in some capacity, for the past 30 years, and made great strides in helping advance HIV screening and antiretroviral therapy for incarcerated populations. But like most incarceration systems, emphasis has been heavily on treatment, while prevention has primarily focused on education. Through the Institute for Global Health and Infectious Diseases, Becky White, MD, MPH and David Rosen, MD, MPH, MSPH, associate professors in the Division of Infectious Diseases, are working to improve HIV care for this population.

Becky White, MD, MPH, sees patients at Central Prison in downtown Raleigh. She also directs HIV services for the N.C Department of Adult Correction Division of Prisons (Credit: Carolina Journal)

Mentors Inspire Research

Becky White directs HIV services for the N.C Department of Adult Correction Division of Prisons and leads the formerly incarcerated transitions project for pre-exposure prophylaxis (FIT for PrEP), an effort to change the prevention paradigm to a comprehensive effort that integrates the most effective HIV prevention to date. David Rosen‘s research is focused on the intersection between incarceration and public health, particularly among people living with HIV. It was against this backdrop that Dr. Arant found a research path.

Local and Global Value

“Eli’s work will not only move the field forward in North Carolina and the U.S., but people internationally look to see what we’re doing because in a lot of places they can’t do this kind of research,” explained White.

Dr. Arant (left), with support from Dr. White (right), began seeing patients in the prison system via telemedicine, which helped her understand the structure of the legal system, the population and challenges that exist. These experiences enriched her work with Dr. Rosen.

Fellowship Training in North Carolina:
An Interview With Eli Arant, MD

How did you come to work with the incarcerated population in your fellowship?

Arant worked with David Rosen, MD, PhD, MSPH, to study HIV care for the criminally charged.

“I was a first-year fellow on a busy inpatient consult service, and I can remember Dr. Becky White coming in and introducing herself to us. She said she would love to have a fellow on her research team, and I think that was the first time someone had directly expressed that, although everyone was very welcoming. It was her open invitation that sort of engaged me in wanting to serve this population.

“I joined Dr. White, and worked with her to analyze qualitative data looking at the barriers and facilitators to PrEP prevention, and I wrote a paper about FIT for PrEP.

“After that, I started thinking about how I wanted to spend my research time for the rest of my fellowship. I decided to work with Dr. David Rosen who has done a lot of research on both jail and prison populations. “

How is care administered in jail versus prison?

“HIV viral suppression and engagement care is pretty consistent during prison incarceration, with dedicated care, now available via telemedicine, and before COVID, it meant going out to clinics. But in jail, which could be for a number of days or weeks, it’s less consistent. An individual often leaves jail and comes back, sometimes their medications are provided, sometimes they aren’t.

“We wanted to know if, when someone gets a criminal charge, does that affect HIV care? And we were interested specifically in criminal charges without incarceration. This meant looking at someone who experienced a charge, but didn’t end up being incarcerated for whatever reason, who just had legal involvement. We focused on that population to determine whether the charge period had an effect on HIV control.”

Why was the “charge” period important?

“We chose the charge period based on the way the legal data is documented within the North Carolina legal systems when someone is charged in criminal court. The legal system typically recognizes an individual’s legal activity as a case. And a case can have multiple charges handled in a bundle, usually with a sentencing that resolves, with the charges either being dropped or the individual becoming incarcerated, or being sentenced with probation or paying fines. We looked at individuals with a single period of criminal charges both for ease of analysis, and because that’s the way most people in our study experienced the legal system.

“We used a combination of three different data sets: North Carolina court records, jail records and records from the N.C. Department of Public Health. One challenge in our analysis is that we didn’t have data for jail incarcerations for the whole state. We had figure out how to account for them in our analysis because no one has really done any work in this space.”

What did you learn in this study?  

“We observed a slight increase in viral suppression associated with the criminal charge period. And the first question we had was, is this a true finding? Or, is it just a reflection of who we have data on? Did we have viral loads on people with charges who are for some reason more involved in the health system and come to their appointments? We also considered viral loads immediately after or within a year of when criminal charges ended. We wondered if this could perhaps be a time when an individual is more likely to want to get back on track, and if one looked further down the road, would the situation change? These were some of our thoughts on the contradictory findings in terms of the viral suppression outcome.

“We also found it took longer for charges to be resolved, for people with HIV, compared to those without HIV, and that brought up the question—do these individuals have the appropriate access to legal services during this time of criminal charge.”

How could this study improve care for these patients? What are the next steps?

“Since this was the first project looking at this population, it would be good to do a similar analysis in another state, or in another way, because we don’t have any other literature to either support or refute the findings. But we do need to get a better sense of what is needed, and to hear from this population about their specific needs, such as an integration of a legal team with the healthcare team. This input could be used to develop stronger treatment and prevention practices.”

How did working in telemedicine enhance your research study?

“Seeing patients via telemedicine in the prison system certainly helped me become more familiar with the structure of the legal system and the population, and the challenges that exist, even though that wasn’t exactly the population of interest for the study with Dr. Rosen. I think telemedicine enriched my understanding and helped me think about the results in a more holistic way.”

What’s next for you?

“I’ll soon be moving to complete further training in transplant infectious diseases here at UNC, for a year of mostly clinical time on the inpatient and outpatient immunocompromised host services. I’ll be taking care of patients who have solid organ transplants, as well as bone marrow transplants, and those with hematologic malignancies. I also hope to continue research that I’ve started with HIV.”