Chapel Hill, NC – New research published in JAMA Network Open highlights a critical challenge facing people living with HIV as they re-enter the community after incarceration. A Zambia study led by Michael Herce, MD, MPH, MSCR, an investigator at the UNC Institute for Global Health and Infectious Diseases—in collaboration with colleagues from the Centre for Infectious Disease Research in Zambia (CIDRZ), Zambia Ministry of Health, University of California at Davis, and the University of New South Wales and James Cook University in Australia—found that individuals who reported unhealthy alcohol use after release from prison were over three times as likely to have an unsuppressed HIV viral load and four times as likely to lose HIV viral suppression upon return to the community, compared to those who did not engage in unhealthy alcohol use.
“We’ve known that when people leave prison, their HIV disease gets worse,” said Dr. Herce, Associate Professor of Medicine at the UNC School of Medicine and Director of Implementation Science for CIDRZ. “They lose viral suppression, the major marker of HIV disease control, and they have a difficult time linking to HIV care in the community. We know this mostly from studies done in North America, but we have less information about the intricate reasons why and how this happens in countries with high HIV prevalence in sub-Saharan Africa.”
The new study builds on prior work, where people in prison were universally tested and treated for HIV in Zambia and supported by peer educators to continue treatment, typically resulting in excellent viral suppression during incarceration.
“Postrelease we found that individuals were doing worse clinically, which was somewhat expected, but never studied in Zambia. And what we effectively showed was a major reason why this was happening in the African context. People living with HIV were engaged in unhealthy alcohol use after leaving prison.”
This is the first study to document the link between alcohol use and HIV suppression postrelease in an African setting. Findings suggest integrated care models that can address both substance use disorders, especially alcohol use disorders, and HIV care continuity, are needed for this vulnerable population.
Study Design
The study enrolled 295 incarcerated people living with HIV (median age 34; 80.3% male) from five prisons and surrounding communities in Zambia between March 2017 and November 2019. Participants had been receiving antiretroviral therapy for a median of over a year at the time of their release.
The research team utilized study visits before and after prison release to assess HIV-associated health behaviors and changes in clinical outcomes, and worked with participants to conduct follow up study visits in the community at a time and place of their choosing. The main exposure and health behavior of interest was alcohol use after prison release, measured using the World Health Organization’s Alcohol Use Disorders Identification Test. The primary outcome was HIV-1 viral load suppression defined as having fewer than 1,000 copies of HIV-1 RNA per milliliter of plasma. Mixed-effects Poisson regression was used to estimate the association between postrelease unhealthy alcohol use and the loss of HIV viral suppression.
Major Findings
- Decrease in Viral Suppression upon Community Re-entry: Overall, documented viral suppression decreased from 80.3% for people living with HIV while incarcerated to 71.5% after returning to the community.
- Association with Unsuppressed Viral Load: Post-release unhealth alcohol use was strongly associated with an unsuppressed viral load in the community, showing a prevalence ratio of 3.35 (95% CI: 1.82-6.15). Unhealthy drug use also showed a significant association (prevalence ratio of 2.82; 95% CI, 1.39-5.71).
- Loss of Viral Suppression: Among the 205 participants who had achieved viral suppression before release, indicating good HIV disease control during incarceration, post-release unhealthy alcohol use was associated with four-fold the risk of losing that suppression (adjusted risk ratio, 4.07; 95% CI, 1.97-8.42).
New transitional care models that include support from people with lived experience of incarceration and that address structural and psychosocial barriers to HIV care, especially alcohol and drug use, could help people living with HIV to sustain HIV viral suppression after release from prison in sub-Saharan Africa.
The research team included Helene J. Smith, Vivien Mai, Chilambwe Mwila, Mirriam Nanyagwe, Tina Kayumba, Sisa Hatwiinda, Clement Moonga, Stephanie M. Topp, Izukanji Sikazwe, Jake M. Pry and Monde Muyoyeta. Find the paper here: JAMA Network Open.
UNC Institute for Global Health and Infectious Diseases
Established in 2007, the UNC Institute for Global Health & Infectious Diseases at the UNC School of Medicine started over 30 years ago with infectious disease physician researchers studying HIV in China and Malawi. Through the years, our work has expanded to include emerging pathogens, cancer, women’s health and vector-borne disease like malaria–shaping policy through evidence-based research around the world. At UNC-Chapel Hill, the Institute facilitates research excellence while nurturing emerging scientists to advance patient care and practice, addressing the most important global health issues of our time–through research, training and service.