To our knowledge, this is the first prospective trial to characterize the HCV care cascade in the transition from a correctional setting to the community. It is also the first cohort study to describe factors associated with linkage to HCV care after incarceration. These data provide preliminary evidence that a combined TCC and patient navigation strategy may be effective in achieving timely linkage to HCV care for a subset of PLWHCV after incarceration in jail.
Linkage rates in our study are similar to those reported in other corrections-based public health programs and pilot studies from other jurisdictions. In a Rhode Island-based rapid HCV testing pilot study in which participants received a questionnaire, informational video, and a referral, 4/15 (27%) participants with confirmed viremia linked to HCV care.25 In a Massachusetts program in which participants with HCV received referrals to HCV care, 14/82 (17%) and 31/82 (38%) had laboratory evidence of linkage to HCV care within 6 and 12 months, respectively.26 In an HCV testing and linkage to care program in South and North Carolina, participants received HCV post-test counseling, a referral, appointment scheduling, and patient navigation (in North Carolina only). In South and North Carolina, respectively, 2/7 (29%) and 10/18 (56%) participants who were referred attended their first HCV appointment.27
All of these studies suggest there are substantial challenges associated with linkage to HCV care. Moreover, data from South Carolina, Massachusetts, and Rhode Island demonstrate these barriers are not overcome with education, referral, and appointment scheduling alone. While data from North Carolina suggest better linkage rates may be achievable with patient navigation, the small sample size limits the generalizability of the results and, still, only roughly half of participants linked to HCV care. Our intervention was modeled on the evidence-informed TCC intervention used in NYC jails to facilitate linkage to HIV care after incarceration. For PLWHIV, linkage rates associated with this program approach 75%.18 Yet, the linkage rate was substantially lower among monoinfected PLWHCV in our study.
Several factors may account for the higher linkage rate among PLWHIV than PLWHCV. First, in our study we used telephone-based patient navigation with appointment accompaniment if requested as the community portion of the intervention. The TCC intervention for PLWHIV after incarceration in the NYC jails includes an extensive network of community resources, linkage agreements with community providers, dedicated community case managers funded through Ryan White Part A, and housing assistance.28 We were not able to provide such extensive services due to resource limitations and believe such services could have improved linkage rates.18
We hypothesize there are several other key differences leading to higher linkage rates among PLWHIV than PLWHCV. First, due to the earlier response of health care systems to the HIV epidemic at the federal, state, and local levels and relatively longstanding availability of effective ART, many PLWHIV are more informed about their HIV diagnoses and the effectiveness of ART. As an example, Loeliger et al. demonstrated that an HIV diagnosis of greater than one year predicted retention in HIV care among justice-involved PLWHIV.17 PLWHCV may be relatively unaware of the short- and long-term consequence of HCV infection and the effectiveness of DAA therapy. With increased collective HCV- and DAA-related knowledge, linkage rates may marginally improve over time.
Additionally, relationships with medical providers prior to incarceration have been shown to result in higher linkage rates among PLWHIV.16,29,30 Our study mirrors this finding given a preference to be linked to one’s existing health system was associated with linkage to HCV care. Among PLWHIV who reported no prior history of HIV medical services, Molitor et al. identified a linkage rate of 29%.31 Very few of our study participants reported an existing relationship with an HCV provider prior to incarceration, and our linkage rate was similar. Taken together, these findings suggest increased familiarity with the healthcare system may facilitate linkage to care.
Active substance use disorders also likely contribute to lower linkage rates among PLWHCV. Injection drug use is the number one risk factor for HCV in the U.S., and nearly two-thirds of our study participants reported injection drug use thirty days prior to incarceration. Substance use disorders are known to complicate linkage among PLWHIV.32 In our study, injection drug use was not associated with linkage to HCV care; however, taking methadone prior to incarceration was. Opioid agonist therapy is an evidence-based strategy leading to more stability from active drug use and higher linkage to care among PLWHIV.20 While we do not have follow-up data on continuation of methadone, we presume many of these participants continued on methadone as those who were on methadone prior to incarceration at the time of this study were generally maintained in the NYC jails unless they were expected to be transferred to prison based on available legal criteria. Given that the period after incarceration is associated with a high risk for active drug use and theoretical risk for HCV transmission,33-36 rapid linkages to HCV and substance use disorder treatment are a high priority. The importance of linkage interventions among people who inject drugs is further underscored by risk of overdose after incarceration.37
Reporting a history of drinking alcohol to intoxication prior to incarceration was negatively associated with linkage to HCV care. Data are limited on the impact of alcohol use on linkage to care following incarceration. However, alcohol has been shown to be negatively associated with DAA adherence among people who inject drugs.38 Drinking alcohol to intoxication in the 30 days prior to incarceration was not associated with linkage to care; however, it did show a similar trend. Therefore, screening and treatment of alcohol use disorders should also be considered an integral component of HCV linkage to care programs.
Feeling family or a loved one were concerned about the participants’ wellbeing was also associated with linkage to HCV care in our study. The role of social support in promoting linkage to care after incarceration among PLWHCV is not known; however, there is evidence among PLWHIV that a lack of social support is a barrier. The use of patient or peer navigators with racial/ethnic concordance or shared life experience have been proposed as an important strategy.31,39,40 This may be even more important for those who lack support from family or a loved one. In our study, a navigator with a master’s level of education performed patient navigation that was mostly telephonic. It is possible peer navigation with active outreach might have resulted in a higher linkage rate.
We did not identify a statistically significant relationship between reincarceration and linkage to HCV care. Reincarceration has been demonstrated to be a complicating factor in linkage to and retention in HIV care. However, since incarcerated persons have access to stable medical services, it can also be leveraged to improve HIV-related outcomes.17,41,42 In our study, reincarceration was more common in the 180 days after index incarceration than linkage to HCV care and was an equally common initial event to linkage to HCV care. If individuals are reincarcerated, communication can be interrupted and HCV linkage appointments may be missed. Conversely, reincarceration may be an opportunity to reengage individuals with HCV who have not yet linked to care, as was the case for three participants in this study. For those who initiate HCV treatment in the community and are at risk of ongoing justice-involvement, education should be provided to make jail healthcare staff aware to avoid HCV treatment interruption.
This study has limitations. First, as a single arm trial, we are unable to determine if the observed linkage rate was directly attributable to the intervention. Moreover, the moderate sample size could lead to decreased statistical power to detect associations. However, we believe our study provides important preliminary data on the rate and factors associated with linkage to HCV care after incarceration in jail following the implementation of a combined case management and patient navigation strategy. Second, the study took place in one large urban area, and community partners were able to schedule HCV appointments within 2-4 weeks after incarceration, which may limit generalizability. Third, our sample may not have been representative of PLWHCV in the jail population as a whole since the median duration of time between enrollment and community return was 34 days, and detainees with the shortest lengths of stay were not able to be recruited. Fourth, demographics and covariates like mental illness were obtained through self-report, which may under- or overestimate true rates. Lastly, follow-up for linkage to HCV care was conducted over 180 days after the index incarceration and participants who were lost to follow-up could have linked to non study-affiliated clinics so our linkage and retention outcomes may be underestimated.