HIV care continuum in prison: initiation, adherence and outcomes of antiretroviral therapy amongst prisoners in South Ethiopia

Author: Terefe Fuge

Fuge, Terefe, 2021 HIV care continuum in prison: initiation, adherence and outcomes of antiretroviral therapy amongst prisoners in South Ethiopia, Flinders University, College of Medicine and Public Health

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Introduction: Incarcerated people bear a disproportionately high burden of HIV infection relative to general populations. However, they often have sub-optimal outcomes across the HIV care continuum (HCC) (i.e., timely initiation of antiretroviral therapy (ART), adherence and viral suppression) and little is known about the contributing factors to this particularly in low-and middle-income countries. The aim of this thesis was to identify and explore circumstances affecting the HCC in the South Ethiopian prison system relative to the local community-based settings and prison systems at an international level.

Methods: A mixed methods approach was employed involving both quantitative and qualitative methods. The quantitative arm encompassed meta-analysis of 17 eligible international studies and a prospective cohort study involving 76 incarcerated and 319 non-incarcerated people living with HIV (PLWH). The qualitative arm involved in-depth interviewing of 11 inmates living with HIV (ILWH) and 11 relevant service providers. Various univariate and multivariate regression models were used to analyse cohort data and a phenomenological approach to abstract meanings attributed to the lived experiences of in-depth interview participants.

Results: The meta-analysis identified a lower likelihood of ART initiation in ILWH who had a higher baseline CD4 count, lacked belief in ART and in those with more recent diagnosis. The odds of adherence were lower in ILWH who experienced depression, lacked self-efficacy to consistently use ART and in those who lacked social support. Male ILWH were significantly less likely to have viral suppression compared to female ILWH.

The prevalence of delay in ART initiation in prisoners (20%) was comparable to non-incarcerated people. However, a significantly low number of prisoners (19%) were able to initiate ART on the test date relative to their non-incarcerated counterparts (50%). Rural residence, being a daily labourer, failure to disclose HIV status and missing a pre-ART appointment were significantly associated with lower odds of ART initiation independent of imprisonment. Female gender, perceived social stigma and having HIV diagnosis due to ill-health independently predicted failure to commence ART on the test date in both incarcerated and non-incarcerated people. The qualitative study revealed four main themes as barriers to early ART initiation in prisoners: a lack of access to HIV testing, poor linkage to care due to insufficient health staff training, uncooperativeness of prison officers and loss of privacy regarding HIV status. Nonetheless, peer education and support, and an opportunity created by the prison environment to gain vicarious experiences, and to easily access HIV-infected individuals appeared to facilitate early initiation of ART in prisoners.

While ILWH had a significantly higher pharmacy refill adherence compared to non-incarcerated PLWH (89% vs 75%), they had a slightly lower dose adherence (81% vs 83%). The prevalence of viral failure was also slightly higher (6%) in ILWH compared to non-incarcerated PLWH (4.4%). The overall dose non-adherence was significantly associated with missing ART appointments, level of satisfaction with ART services, patient ability to comply with a medication schedule and the types of methods used to monitor the schedule. In ILWH specifically, accessing ART services from a hospital compared to a health centre, inability to always attend clinic appointments, experience of depression and a lack of social support predicted non-adherence. Viral failure was significantly higher in males, people aged 31 to 35 years and in those who experienced social stigma, regardless of their incarceration status.

Several themes emerged in the qualitative study in relation to barriers of adherence amongst prisoners, some of which are essentially akin to those influencing ART initiation; limited access to ART services, insufficient health care provider support, uncooperative security system, loss of patient privacy, a lack of status disclosure due to social stigma, depression related to imprisonment and food supply insufficiency negatively influenced adherence. Themes that emerged as facilitators of adherence included: ILWH’s self-efficacy to disclose their HIV status and cope with the negative influences of social stigma, the presence of peer support and a unique environment created by imprisonment for some ILWH to refrain from health damaging behaviours.

Conclusions: The prevalence of sub-optimal HCC outcomes in the South Ethiopian prison system is generally high, representing lower achievements with regard to reaching international targets. A multitude of interrelated factors including: structural, inter-institutional, institutional, interpersonal and intrapersonal circumstances influenced the HCC in this HIV key population requiring multilevel interventional approaches as suggested in this thesis.

Keywords: antiretroviral therapy initiation, medication adherence, viral suppression, prisoners, South Ethiopia

Subject: Medicine thesis

Thesis type: Doctor of Philosophy
Completed: 2021
School: College of Medicine and Public Health
Supervisor: Dr Emma Miller