HIV Testing and Treatment Program, 2004–2023

FBOP HIV Clinical Practice Guidelines were established to treat PLWH. Since 2016, FBOP guidelines have recommended an opt-out strategy for HIV screening, in which all adults in custody (AICs) are informed that an HIV test will be performed as part of the standard laboratory screening upon entry into custody. If the AIC choses to opt-out of voluntary testing, a refusal is documented. Current guidelines recommend initiating treatment as soon as the patient is willing and able to start and provides scenarios when rapid initiation (i.e., same day as diagnosis) might be indicated (9). In December 2004, FBOP created an HIV Clinical Pharmacist Consultants program to enhance patient management. Currently, 15 pharmacist consultants with specialized HIV training assist with managing all PLWH in FBOP custody, including reviewing laboratory findings, clinical encounters, and prescription profiles to ensure appropriate HIV care. Consultants also serve as a resource for providers seeking expert consultation in HIV management.

PrEP Program, 2021–2023

Although rates of new HIV infections during incarceration are low (10), >95% of AICs will return to their communities (11), where they might engage in behaviors that place them at risk for HIV infection, including intravenous drug use and unprotected sex (6–8). Recognizing the opportunity to decrease the risk for HIV transmission, FBOP updated its HIV Clinical Practice Guidelines in April 2021 to include guidance for oral PrEP (9).

Under the FBOP PrEP program, providers can identify patients with HIV risk factors or patients may self-refer for evaluation for PrEP. FBOP guidance identifies the following risk factors that might indicate an HIV-negative patient is at high risk for HIV infection upon release: vaginal or anal sex 6 months before or at any time during incarceration and partner with HIV, inconsistent use of condoms with partner(s) of unknown HIV status or at high risk for HIV, sex while using drugs, and/or >1 sex partner; sexually transmitted infection 6 months before or at any time during incarceration; shared needles for intravenous drug use 6 months before or at any time during incarceration, or might engage in intravenous drug use upon release. Working under a collaborative practice agreement, pharmacists can also perform patient assessments and prescribe PrEP. Although obtaining a detailed sexual activity and drug use history is a major part of the assessment, patients might be hesitant to disclose high-risk behaviors because of fear of discipline or stigma. Consequently, and consistent with CDC PrEP guidelines (5), confirmed high-risk behavior is not a requirement to provide PrEP to any releasing AIC who requests it.

To ensure adequate time to assess response to treatment and coordinate continuity of care before release, PrEP is initiated ≈30 days before release from custody, and a social worker creates a customized release plan to include scheduling a follow-up appointment for the patient in the community. Patients are also given a Release Resources for PrEP handout to assist with obtaining PrEP access should they be unable to complete their scheduled appointment. Upon release, a 90-day supply of PrEP medication is sent with the patient to allow ample time for linkage to care.

Promoting the PrEP Program within FBOP

FBOP uses a multi-modal strategy to educate providers about the PrEP guidance and to encourage uptake among AICs. HIV Clinical Pharmacist Consultants developed a webinar for healthcare providers discussing harm-reduction strategies including PrEP. To educate AICs, HIV Clinical Pharmacists developed a PrEP Fact Sheet reviewing the basics of how PrEP works, how to start PrEP within the FBOP, and how to access medication. In addition, Clinical Pharmacists developed a bulletin that was posted nationally through the FBOP internal computer system available to all AICs in both English and Spanish. This bulletin informs AICs that PrEP is available for any person who is at risk for HIV infection and will soon be releasing to the community and encourages self-referral to Health Services providers for more information. The bulletin also states a 90-day supply of medication will be sent upon release and provides information about programs that might help pay for PrEP in the community.

Individual FBOP institutions have also developed strategies to increase PrEP uptake. For example, the United States Medical Center for Federal Prisoners in Springfield, Missouri, developed a pharmacist-led Harm Reduction Clinic. This clinic began in 2021 and initially focused on providing nasal naloxone to reduce overdose deaths after release from custody. In June 2022, the clinic was expanded to offer PrEP as well. To identify potentially eligible patients, every month the clinic generates a roster of AICs due to be released from custody within 90 days and schedules patients for an appointment with a pharmacist. Providers can also refer patients to the clinic, and self-referrals are encouraged. If a patient with a release date >90 days in the future is referred to the clinic, they receive harm reduction education and are rescheduled for evaluation for PrEP 90 days before their projected release date.

During the Harm Reduction clinic, pharmacists and patients discuss HIV risk factors, prevention methods, and resources, as well as information about what PrEP is, PrEP indications, and possible and anticipated side effects. PLWH are provided education about promoting PrEP use for existing or future HIV-negative partners. Pharmacists also perform medication reconciliation and discuss the patient’s overall health conditions to improve health literacy and continuity of care upon reentry. If PrEP is indicated, the pharmacist will order appropriate laboratory tests, provide monitoring and follow-up with the patient after initiation, and assist the patient with continuity of care coordination with a FBOP social worker. To ensure all necessary components of a harm reduction visit are included and to standardize the workflow and documentation process, the HIV Clinical Pharmacists developed a notes template for visits.

FBOP Population and HIV Risk Factors

During April 1, 2021–March 25, 2023, a total of 303,817 intakes were completed for persons who newly entered FBOP custody or transferred between FBOP facilities. The most common self-reported HIV risk factor was infrequent condom use (146,665 [48.3%]), followed by never using a condom (111,592 [36.7%]) (Table).

HIV Care Continuum

Figure

Figure. Number and percentage of adults in custody of the US FBOP for >90 days as of June 2, 2023, who had been diagnosed with HIV, offered treatment, accepted...

An evaluation of FBOP electronical medical record data for AICs in FBOP custody for >90 days showed that as of June 2, 2023, there were 139,789 AICs. Of those, 117,950 (89.6%) had been offered >1 HIV test. Of those, 1,208 (1.0.%) had a positive test result, 100% of PLWH had been offered antiretroviral treatment, and 1,199 (99.3%) had initiated treatment. As of the end of the study period, 1,110 patients had been on treatment >90 days; of those, 1,060 (95.5%) had an undetectable viral load (Figure).

Preliminary Data for PrEP Initiation

In 2022, a total of 28 patients from 24 institutions initiated PrEP within 90 days of release from FBOP custody. As of June 2023, a total of 41 patients from 29 institutions had initiated PrEP. To enable further analysis, the FBOP is developing a dashboard to include the number of AICs screened for PrEP eligibility, the number offered PrEP, and the percentage who accepted.