Randomized Controlled Trial of an Intervention to Maintain Suppression of HIV Viremia After Prison Release: The imPACT Trial

Abstract

Background HIV-infected individuals transitioning from incarceration to the community are at risk for loss of viral suppression. We compared the effects of imPACT, a multi-dimensional intervention to promote care engagement after release, to standard care on sustaining viral suppression after community re-entry. Methods This trial randomized 405 HIV-infected inmates being released from prisons in Texas and North Carolina with HIV-1 RNA levels <400 copies/mL to imPACT versus standard care. The imPACT arm received motivational interviewing pre- and post-release, referral to care within 5 days of release, and a cellphone for medication text reminders. The standard care arm received routine discharge planning and a cellphone for study staff contact. The primary outcome was the difference between arms in week 24 post-release viral suppression (HIV-1 RNA <50 copies/mL) using intent-to-treat analysis with multiple imputation of missing data. Results The proportion with 24-week HIV-1 RNA <50 copies/ml was 60% and 61% in the imPACT and standard care arms, respectively (odds ratio for suppression 0.95 (95% CI, 0.59 to 1.53)). By week 6 post-release, 86% in the imPACT arm versus 75% in the standard care arm attended at least one non-emergency clinic visit (P = 0.02). At week 24, 62% in both arms reported not missing any antiretroviral doses in the past 30 days (P >0.99). Conclusions Higher rates of HIV suppression and medical care engagement than expected based on prior literature were observed among HIV-infected patients with suppressed viremia released from prison. Randomization to a comprehensive intervention to motivate and facilitate HIV care access after prison release did not prevent loss of viral suppression. A better understanding of the factors influencing prison releasees' linkage to community care, medication adherence, and maintenance of viral suppression is needed to inform policy and other strategic approaches to HIV prevention and treatment.

Lessons Learned From the Implementation of Seek, Test, Treat, Retain Interventions Using Mobile Phones and Text Messaging to Improve Engagement in HIV Care for Vulnerable Populations in the United States

“…Although the imPACT intervention (of which mobile phone distribution and texted ART reminders comprised only one component) was not successful at maintaining virologic suppression in those released from prison, it did significantly improve attendance at an outpatient clinic appointment. 34 These results highlight the likely role and potential challenge of multiple contextual factors that are known to disrupt virologic suppression after incarceration, including environments with high rates of substance use, poverty, homelessness, discrimination, lack of employment, and lack of health insurance. 35–38 …”

Observational study of continuity of HIV care following release from correctional facilities in South Africa

“…Compared to some of these prior studies, our observed self-reported linkage to care was higher. Specifically, the proportion of ex-inmates linking to care in studies from the United States ranges from 28 to 95%; a median of 36% was calculated in a metaanalysis [10][11][12][13][14][15][21][22][23][24][25][26]. There are several possible reasons for the potentially higher linkage to care that we observed.…”

“…We excluded from the primary outcome analysis participants who were known to have been re-incarcerated (consistent with prior analyses [15]), known to have died, or withdrew consent. Descriptive statistics were used to characterize the population.…”

“…Most studies on this transition, to date, are from the United States. These studies have reported post-release linkage to care from 28 to 95% with a median reported in a metaanalysis of 36% [10][11][12][13][14][15]. Differences in care delivery, the criminal justice system, and the social fabric in South Africa compared to the United States may lead to differences in retention in care following corrections release.…”

Censoring of HIV Viremia Data of Reincarcerated Individuals: A Response to Wohl et al

“…The recent publication of Wohl et al describes a randomized controlled trial of the imPACT intervention, which had the laudable aim of preventing loss of HIV viral suppression in persons leaving prison by facilitating care access after release 1 . The objectives of the imPACT intervention are important, as engagement of vulnerable persons in care will be key to lowering community viral load.…”