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Background: Cancer is the leading cause of death in people living with HIV. In the United States, nearly 1 in 4 people living with HIV are women, more than half of whom rely on Medicaid for healthcare coverage. Objective: The objective of this study is to evaluate the cancer burden of women living with HIV on Medicaid. Design: We conducted a cross-sectional study of women 18–64 years of age enrolled in Medicaid during 2012, using data from Medicaid Analytic eXtract files. Methods: Using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes, we identified women living with HIV (n = 72,508) and women without HIV (n = 17,353,963), flagging the presence of 15 types of cancer and differentiating between AIDS-defining cancers and non-AIDS-defining cancers. We obtained adjusted prevalence ratios and 95% confidence intervals for each cancer and for all cancers combined, using multivariable log-binomial models, and additionally stratifying by age and race/ethnicity. Results: The highest adjusted prevalence ratios were observed for Kaposi's sarcoma (81.79 (95% confidence interval: 57.11–117.22)) and non-Hodgkin's lymphoma (27.69 (21.67–35.39)). The adjusted prevalence ratios for anal and cervical cancer, both of which were human papillomavirus-associated cancers, were 19.31 (17.33–21.51) and 4.20 (3.90–4.52), respectively. Among women living with HIV, the adjusted prevalence ratio for all cancer types combined was about two-fold higher (1.99 (1.86–2.14)) in women 45–64 years of age than in women 18–44 years of age. For non-AIDS-defining cancers but not for AIDS-defining cancers, the adjusted prevalence ratios were higher in older than in younger women. There was no significant difference in the adjusted prevalence ratios for all cancer types combined in the race/ethnicity-stratified analyses of the women living with HIV cohort. However, in cancer type–specific sub-analyses, differences in adjusted prevalence ratios between Hispanic versus non-Hispanic women were observed. For example, the adjusted prevalence ratio for Hispanic women for non-Hodgkin's lymphoma was 2.00 (1.30–3.07) and 0.73 (0.58–0.92), respectively, for breast cancer. Conclusion: Compared to their counterparts without HIV, women living with HIV on Medicaid have excess prevalence of cervical and anal cancers, both of which are human papillomavirus related, as well as Kaposi's sarcoma and lymphoma. Older age is also associated with increased burden of non-AIDS-defining cancers in women living with HIV. Our findings emphasize the need for not only cancer screening among women living with HIV but also for efforts to increase human papillomavirus vaccination among all eligible individuals. [ABSTRACT FROM AUTHOR]

Background Heroin use may work synergistically with human immunodeficiency virus (HIV) infection to cause greater immune dysregulation than either factor alone. Unraveling how this affects end-organ disease is key as it may play a role in the excess mortality seen in people with HIV (PWH) who use heroin despite access to care and antiretroviral therapy. Methods This is a prospectively enrolled, cross-sectional study of adults with and without HIV who use and do not use heroin using (18)F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) to compare tissue-specific inflammation including aortic (target-to-background ratio [TBR]), splenic, and bone marrow (standardized uptake value [SUV]). Results A total of 120 participants were enrolled. The unadjusted mean difference in aortic TBR was 0.43 between HIV-positive [HIV+] heroin+ and HIV+ heroin-negative [heroin−] (P =.02); however, among HIV−, aortic TBR was similar regardless of heroin-use status. Further, HIV-by-heroin-use status interaction was significant (P =.02), indicating that the relationship between heroin use and higher aortic TBR depended on HIV status. On the other hand, both HIV (1.54 vs 1.68; P =.04, unadjusted estimated means for HIV+ vs HIV−) and heroin use were associated with lower bone marrow SUV, although the effect of heroin depended on sex (heroin-use-by-sex interaction, P =.03). HIV-by-heroin-use interaction was not significant for splenic or bone marrow SUV. Conclusions Aortic inflammation was greatest in PWH who use heroin, but paradoxically, bone marrow activity was the least in this group, suggesting complex and possibly divergent pathophysiology within these different end organs. [ABSTRACT FROM AUTHOR]

Objective aim Identify and eliminate barriers to HIV testing in primary care and to decrease the rates of patients never being tested, and limit unnecessary repeat testing. Setting Primary care clinics within an urban publicly funded safety net hospital and community health system in Cleveland, Ohio. Reported HIV prevalence among male Cleveland residents is 1193.5/100 000. Design A time series analysis using statistical process control was used. Methods Primary care encounters of patients aged 13-64 years from selected sites were reviewed throughout the initiative for HIV testing prior to the visit and associated with the visit. Results Run charts of the proportion of men and women never tested for HIV demonstrated marked improvement and special cause variation with six sequential quarters falling outside of the trend lines. Evaluation of encounters associated with a first HIV test confirmed testing occurring within primary care rather than elsewhere in the health system. Conclusions Implementing an electronic medical record-based reminder effectively increased HIV testing among primary care patients not previously tested, while education and practice feedback alone did not. [ABSTRACT FROM AUTHOR]

Women represent a significant and growing segment of jail detainees and persons living with HIV. This paper examines gender differences in health status, care and social service needs, and care engagement among jail releasees with HIV. Data are from 1,270 participants in the HRSA-funded Enhancing Linkages to HIV Primary Care and Social Services multisite demonstration project (EnhanceLink). Compared to men, more women reported homelessness, reduced adherence to prescribed ART, worse health, more severe substance use disorders, and more chronic health conditions. Men and women generally reported different needs post-release. As the number of expressed needs increased, women were more likely to drop out of care. Our findings suggest that effective and gender-specific strategies are required to identify needs, link services between jails and communities, and sustain retention of women with HIV in programs after release from criminal justice settings. [ABSTRACT FROM AUTHOR]

Retention in care is key to effective HIV treatment, but half of PLWHA in the US are continuously engaged in care. Incarcerated individuals are an especially challenging population to retain, and empiric data specific to jail detainees is lacking. We prospectively evaluated correlates of retention in care for 867 HIV-infected jail detainees enrolled in a 10-site demonstration project. Sustained retention in care was defined as having a clinic visit during each quarter in the 6 month post-release period. The following were independently associated with retention: being male (AOR = 2.10, p ≤ 0.01), heroin use (AOR 1.49, p = 0.04), having an HIV provider (AOR 1.67, p = 0.02), and receipt of services: discharge planning (AOR 1.50, p = 0.02) and disease management session (AOR 2.25, p ≤ 0.01) during incarceration; needs assessment (AOR 1.59, p = 0.02), HIV education (AOR 2.03, p ≤ 0.01), and transportation assistance (AOR 1.54, p = 0.02) after release. Provision of education and case management services improve retention in HIV care after release from jail. [ABSTRACT FROM AUTHOR]

Incarceration, particularly when recurrent, can significantly compromise the health of individuals living with HIV. Despite this, the occurrence of recidivism among individuals with HIV has been little examined, particularly among those leaving jail, who may be at especially high risk for return to the criminal justice system. We evaluated individual- and structural-level predictors of recidivism and time to re-incarceration in a cohort of 798 individuals with HIV leaving jail. Nearly a third of the sample experienced at least one re-incarceration event in the 6 months following jail release. Having ever been diagnosed with a major psychiatric disorder, prior homelessness, having longer lifetime incarceration history, having been charged with a violent offense for the index incarceration and not having health insurance in the 30 days following jail release were predictive of recidivism and associated with shorter time to re-incarceration. Health interventions for individuals with HIV who are involved in the criminal justice system should also target recidivism as a predisposing factor for poor health outcomes. The factors found to be associated with recidivism in this study may be potential targets for intervention and need to be further explored. Reducing criminal justice involvement should be a key component of efforts to promote more sustainable improvements in health and well-being among individuals living with HIV. [ABSTRACT FROM AUTHOR]

In the United States, jail frequently disrupts access to HIV care. EnhanceLink, a 10-site demonstration project promoting linkage to HIV primary care upon jail discharge, offered an opportunity to gauge how many releasees had favorable clinical outcomes. Individual level data were available on 1270 participants. Persons never discharged from the correctional environment were excluded. Multivariate logistic regression identified factors associated with viral suppression 6 months post discharge (6M-VL < 400). Among 1082 individuals eligible for follow-up evaluation, 25.7 % had 6M-VL < 400. 6M-VL < 400 was associated with case managers assessing whether help was needed for linkage to HIV-related medical services and clients keeping an appointment with a case manager. The adjusted odds ratio (aOR) of 6M-VL < 400 associated with attending a meeting with an HIV care provider within 30 days of release was 1.85. The results of this non-controlled, observational study support further development and rigorous evaluation of transitional care programs for HIV-positive jailed persons across the country. [ABSTRACT FROM AUTHOR]

Linkage, engagement, retention and adherence to care are necessary steps along the HIV care continuum. Progression through these steps is essential for control of the disease and interruption of transmission. Identifying and re-engaging previously diagnosed but out-of-care patients is a priority to achieve the goals of the National HIV/AIDS strategy. Participants in the EnhanceLink cohort who were previously diagnosed HIV+ ( n = 1,203) were classified as not-linked to of care and non-adherent to medication prior to incarceration by self report. Results based on multivariate models indicate that recent homelessness as well as high degrees of substance abuse correlated with those classified as not-linked to care and non-adherent to medications while having insurance was associated with being linked to care and adherent to care. The majority of detainees reported being linked to care but not currently adherent to care confirming that jails are an important site for re-engaging HIV+ individuals. [ABSTRACT FROM AUTHOR]

Black individuals represent 13 % of the US population but 46 % of HIV positive persons and 40 % of incarcerated persons. The national EnhanceLink project evaluated characteristics of HIV-positive jail entrants at ten sites and explored associations between race and HIV disease state. Between 1/2008 and 10/2011, 1,270 study participants provided demographic and clinical data. Adjusted odds ratios (aORs) were calculated for advanced HIV disease (CD4 < 200 cells/mm) and uncontrolled viremia (viral load > 400 copies/ml) for Black (n = 807) versus non-Black (n = 426) participants. Sixty-five percent of HIV-positive jail participants self-identified as Black. Among all participants, fewer than half had a high school diploma or GED, the median number of lifetime arrests was 15, and major mental illness and substance abuse were common. Black participants were more likely to be older than non-Black participants, and less likely to have health insurance (70 vs 83 %) or an HIV provider (73 vs 81 %) in the prior 30 days. Among all male study participants (n = 870), 20 % self-identified as homosexual or bisexual. Black male participants were more likely to be homosexual or bisexual (22 vs 16 %) and less likely to have a history of injection drug use (20 vs 50 %) than non-Black male participants. Advanced HIV disease was associated with self-identification as Black (aOR = 1.84, 95 % CI 1.16-2.93) and time since HIV diagnosis of more than two years (aOR = 3.55, 95 % CI 1.52-8.31); advanced disease was inversely associated with age of less than 38 years (aOR = 0.41, 95 % CI 0.24-0.70). Uncontrolled viremia was inversely associated with use of antiretroviral therapy (ART) in the prior 7 days (aOR = 0.25, 95 % CI 0.15-0.43) and insurance coverage in the prior 30 days (aOR = 0.46, 95 % CI 0.26-0.81). Conclusions: The racial disparities of HIV and incarceration among Black individuals in the US are underscored by the finding that 65 % of HIV-positive jail participants self-identified as Black in this ten-site study. Our study also found that 22 % of Black male participants self-identified as men who have sex with men (MSM). We believe these findings support jails as strategic venues to reach heterosexual, bisexual, and homosexual HIV-positive Black men who may have been overlooked in the community. Among HIV-positive jail entrants, Black individuals had more advanced HIV disease. Self-identification as Black was associated with a lower likelihood of having health insurance or an HIV provider prior to incarceration. HIV care and linkage interventions are needed within jails to better treat HIV and to address these racial disparities. [ABSTRACT FROM AUTHOR]

HIV-infected persons entering the criminal justice system (CJS) often experience suboptimal healthcare system engagement and social instability, including homelessness. We evaluated surveys from a multisite study of 743 HIV-infected jail detainees prescribed or eligible for antiretroviral therapy (ART) to understand correlates of healthcare engagement prior to incarceration, focusing on differences by housing status. Dependent variables of healthcare engagement were: (1) having an HIV provider, (2) taking ART, and (3) being adherent (≥95% of prescribed doses) to ART during the week before incarceration. Homeless subjects, compared to their housed counterparts, were significantly less likely to be engaged in healthcare using any measure. Despite Ryan White funding availability, insurance coverage remains insufficient among those entering jails, and having health insurance was the most significant factor correlated with having an HIV provider and taking ART. Individuals interfacing with the CJS, especially those unstably housed, need innovative interventions to facilitate healthcare access and retention. [ABSTRACT FROM AUTHOR]