RESEARCH ARTICLE

Retention in HIV care during the 3 years
following release from incarceration: A cohort
study
Kelsey B. Loeliger ID1,2, Jaimie P. Meyer ID1*, Mayur M. Desai ID3, Maria M. Ciarleglio ID4,
Colleen Gallagher5, Frederick L. Altice1,2,6

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1 AIDS Program, Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut, United
States of America, 2 Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New
Haven, Connecticut, United States of America, 3 Department of Chronic Disease Epidemiology, Yale School
of Public Health, New Haven, Connecticut, United States of America, 4 Department of Biostatistics, Yale
School of Public Health, New Haven, Connecticut, United States of America, 5 Health and Addiction Services
Quality Improvement Program, Connecticut Department of Correction, Wethersfield, Connecticut, United
States of America, 6 Centre of Excellence in Research in AIDS, University of Malaya, Kuala Lumpur,
Malaysia
* jaimie.meyer@yale.edu

Abstract
OPEN ACCESS
Citation: Loeliger KB, Meyer JP, Desai MM,
Ciarleglio MM, Gallagher C, Altice FL (2018)
Retention in HIV care during the 3 years following
release from incarceration: A cohort study. PLoS
Med 15(10): e1002667. https://doi.org/10.1371/
journal.pmed.1002667

Background
Sustained retention in HIV care (RIC) and viral suppression (VS) are central to US national
HIV prevention strategies, but have not been comprehensively assessed in criminal justice
(CJ) populations with known health disparities. The purpose of this study is to identify predictors of RIC and VS following release from prison or jail.

Academic Editor: Alexander C. Tsai,
Massachusetts General Hospital, UNITED STATES
Received: March 29, 2018
Accepted: September 5, 2018
Published: October 9, 2018
Copyright: © 2018 Loeliger et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: Because of the highly
confidential nature of the data (related to people’s
HIV status and incarcerations), access to data is
highly regulated by the Connecticut Departments of
Correction and Public Health. Data are available to
researchers who receive permission from these
organizations and meet criteria for access to
confidential data. Interested researchers should
contact Suzanne Speers (suzanne.speers@ct.gov)
or Kirsten Shea (kshea@uchc.edu).

Methods and findings
This is a retrospective cohort study of all adult people living with HIV (PLWH) incarcerated in
Connecticut, US, during the period January 1, 2007, to December 31, 2011, and observed
through December 31, 2014 (n = 1,094). Most cohort participants were unmarried (83.7%)
men (77.0%) who were black or Hispanic (78.1%) and acquired HIV from injection drug use
(72.6%). Prison-based pharmacy and custody databases were linked with community HIV
surveillance monitoring and case management databases. Post-release RIC declined
steadily over 3 years of follow-up (67.2% retained for year 1, 51.3% retained for years 1–2,
and 42.5% retained for years 1–3). Compared with individuals who were not re-incarcerated, individuals who were re-incarcerated were more likely to meet RIC criteria (48% versus 34%; p < 0.001) but less likely to have VS (72% versus 81%; p = 0.048). Using
multivariable logistic regression models (individual-level analysis for 1,001 individuals after
excluding 93 deaths), both sustained RIC and VS at 3 years post-release were independently associated with older age (RIC: adjusted odds ratio [AOR] = 1.61, 95% CI = 1.22–
2.12; VS: AOR = 1.37, 95% CI = 1.06–1.78), having health insurance (RIC: AOR = 2.15,
95% CI = 1.60–2.89; VS: AOR = 2.01, 95% CI = 1.53–2.64), and receiving an increased
number of transitional case management visits. The same factors were significant when we

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Retention in HIV Care After Prison-Release

Funding: The National Institute on Drug Abuse
(NIDA) provided funding for this project through
grants F30DA041247 (KBL), K23DA033858 (JPM),
K24DA017072 (FLA), R01DA030768 (FLA), and
R01DA030762. The project was also supported by
the Yale University Medical Scientist Training
Program under the National Institute of General
Medical Sciences (NIGMS) T32GM007205 and the
Yale Center for Interdisciplinary Research in AIDS
(CIRA) under the National Institute of Mental Health
(NIMH) P30MH062294. The funders had no role in
study design, data collection and analysis, decision
to publish, or preparation of the manuscript.

assessed RIC and VS outcomes in each 6-month period using generalized estimating equations (for 1,094 individuals contributing 6,227 6-month periods prior to death or censoring).
Additionally, receipt of antiretroviral therapy during incarceration (RIC: AOR = 1.33, 95% CI
1.07–1.65; VS: AOR = 1.91, 95% CI = 1.56–2.34), early linkage to care post-release (RIC:
AOR = 2.64, 95% CI = 2.03–3.43; VS: AOR = 1.79; 95% CI = 1.45–2.21), and absolute time
and proportion of follow-up time spent re-incarcerated were highly correlated with better
treatment outcomes. Limited data were available on changes over time in injection drug use
or other substance use disorders, psychiatric disorders, or housing status.

Competing interests: I have read the journal’s
policy and the authors of this manuscript have the
following competing interests: FLA reports
Speakers Bureau: Simply Speaking HIV, Gilead
Sciences, Merck, Clinical Care Options (role:
speaker); Grants: NIH, NIDA, HRSA, SAMHSA,
Gilead Foundation (role: PI); Advisory Board:
Merck, Gilead (role: member/consultant). JPM
reports Scientific Advisory Board: Gilead Sciences
(role: member/consultant); Grants: NIDA, Doris
Duke Charitable Foundation, and Gilead
Investigator Sponsored Award (role: PI); Faculty:
Clinical Care Options.

In a large cohort of CJ-involved PLWH with a 3-year post-release evaluation, RIC diminished significantly over time, but was associated with HIV care during incarceration, health
insurance, case management services, and early linkage to care post-release. While reincarceration and conditional release provide opportunities to engage in care, reducing
recidivism and supporting community-based RIC efforts are key to improving longitudinal
treatment outcomes among CJ-involved PLWH.

Abbreviations: AOR, adjusted odds ratio; ART,
antiretroviral therapy; CJ, criminal justice; CTDOC,
Connecticut Department of Correction; CTDPH,
Connecticut Department of Public Health; eHARS,
Enhanced HIV/AIDS Reporting System; \GEE,
generalized estimating equation; IDU, injection
drug use; PLWH, people living with HIV; RIC,
retention in HIV care; VL, viral load; VS, viral
suppression.

Conclusions

Author summary
Why was this study done?
• HIV prevention and treatment strategies aim to reduce HIV-related morbidity, mortality, and transmission by retaining people with HIV in care and sustaining them on antiretroviral treatment to achieve viral suppression (VS).
• Few prior studies had described long-term retention in HIV care (RIC) or VS for people
incarcerated in prisons or jails and transitioning to communities. In fact, incarceration
periods are often excluded from studies of RIC. This is an important knowledge gap
because HIV and incarceration are overlapping epidemics that disproportionately affect
people who are already marginalized by homelessness, substance use and psychiatric
disorders, and socioeconomic status.

What did the researchers do and find?
• We merged statewide databases from the Connecticut Department of Correction and
Connecticut Department of Public Health on all people living with HIV who were
released from prisons or jails in Connecticut, US, between 2007 and 2011. We followed
each individual in this cohort for 3 years after release from prison/jail to examine RIC
and VS.
• Among 1,094 individuals included in the study, continuous RIC declined over time
(67.2% retained during year 1, 51.3% retained during years 1–2, and 42.5% retained during all 3 years). Compared with individuals who were not re-incarcerated, individuals
who were re-incarcerated were more likely to meet RIC criteria (48% versus 34%; p <
0.001) but less likely to have VS (72% versus 81%; p = 0.048).

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Retention in HIV Care After Prison-Release

• Successful RIC and achievement of VS was associated with older age (RIC: adjusted
odds ratio [AOR] = 1.61; VS: AOR = 1.37), having health insurance (RIC: AOR = 2.15;
VS: AOR = 2.01), being treated for HIV while in prison (RIC: AOR = 1.33; VS: AOR =
1.91), receiving case management services during follow-up (RIC: AOR = 1.79; VS:
AOR = 1.31), and early linkage to care in the community following release (RIC: AOR =
2.64; VS: AOR = 1.79). In addition, receiving an increased number of case management
visits after release and spending an increased proportion of follow-up time re-incarcerated were correlated with better RIC and VS outcomes.

What do these findings mean?
• Dedicated resources are needed to optimize people’s HIV care while they are in prison
and to link them to care following release. Although prior studies suggest that prison
provides a temporary window of opportunity to reconnect people to care, sustained
retention in care and continuity of care ultimately require keeping people in the community longer and avoiding incarceration.

Introduction
Along the HIV care continuum, retention in HIV care (RIC) is necessary for providing antiretroviral therapy (ART) and achieving viral suppression (VS), which reduces individual morbidity, mortality, and forward transmission [1–4]. Most incident HIV infections in the US are
acquired from people living with HIV (PLWH) who are either undiagnosed or diagnosed but
not retained in HIV care [5–7]. Poor RIC is associated with minority race/ethnicity, younger
age, substance use disorders, and incarceration [8–12], although few studies have assessed longitudinal RIC beyond 6- or 12-month follow-up periods [13–16].
The US has the highest incarceration rate globally (910 per 100,000 adults) [17,18], with
one-sixth of the country’s 1.2 million PLWH cycling through prisons or jails annually [19]. Yet
incarcerated PLWH are frequently censored or excluded altogether from RIC studies [20]. For
PLWH engaged in community-based care, frequent brief incarcerations disrupt care, and
undermine ART adherence and VS [21–25]. When healthcare is optimized during incarceration, the highly structured environment can be an opportunity to reengage PLWH in care, initiate ART, and achieve VS, though this is often unsustained after release [26–28].
While several recent studies have elucidated challenges with linkage to community care
post-release [29–32], the longitudinal impact of incarceration on continuity of HIV care
remains poorly understood. Prior studies of RIC that have included criminal justice (CJ)–
involved PLWH have been limited by short follow-up [33–35], exclusion of PLWH re-incarcerated during follow-up [34], recall biases in self-reported incarceration and ART use
[9,21,24], reliance on ART prescription refill data [25], and inability to comprehensively link
community and CJ data [26,28]. Because RIC is currently defined as having a clinic visit with
viral load (VL) assessment at least every 6 months, a window of observation beyond 1 year is
needed to better understand RIC [36]. Furthermore, a more nuanced understanding of longitudinal RIC among incarcerated PLWH is important for the development of future policies
and interventions to address deficiencies within both CJ and community systems of care.

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Retention in HIV Care After Prison-Release

We therefore assessed 3-year RIC and VS in a large retrospective cohort of incarcerated
PLWH. We had hypothesized that having health insurance and successfully linking to care
would predict sustained RIC, but did not presuppose how recidivism would impact outcomes.
Because we linked all community and CJ data within an integrated CJ system, we were able to
examine “real world” outcomes in CJ-involved PLWH, accounting for re-incarcerations during follow-up and HIV-1 RNA levels obtained in both CJ and community settings.

Methods
Setting
The Connecticut Department of Correction (CTDOC) has been described previously [32].
Healthcare within CTDOC is guided by federally monitored clinical protocols requiring VL
assessment within 96 hours of arrival, with continued monitoring every 3 months during
incarceration. ART is prescribed according to national guidelines, which, at the time of observation, used CD4-based criteria.

Data sources
As previously published [32], we combined comprehensive custody and pharmacy data from
the CTDOC with the Connecticut Department of Public Health (CTDPH) Enhanced HIV/
AIDS Reporting System (eHARS) surveillance and CAREWare service utilization databases.
The eHARS surveillance system is maintained by CTDPH to be >95% complete. In the original data analysis plan, we prespecified linkage to and retention in care as major outcomes of
interest (S1 Text).

Study population
There were 1,094 individuals who met the following inclusion criteria (Fig 1): (1) were 18
years old with confirmed HIV before release from CTDOC; (2) were included in CTDOC and
CTDPH databases; (3) were incarcerated at least once for >24 hours between January 1, 2007,
and December 31, 2011; and (4) had 3 years of observation data after release (through
December 31, 2014). For individuals never re-incarcerated, their only incarceration period
was analyzed as their index incarceration. For participants with multiple eligible incarcerations
(n = 538), we randomly selected 1 incarceration period to treat as each individual’s index
incarceration/release to avoid differentially biasing the sample toward earlier incarceration
periods (when fewer resources were available for HIV treatment and care) or later incarceration periods (with less time to observe outcomes or re-incarcerations). Random selection of
index incarceration periods is consistent with an approach justified in prior studies of hospital
readmissions and avoids inflating the association between re-incarceration during follow-up
and the RIC and VS outcomes [37,38]. Subsequent re-incarcerations were recorded as covariates. Individuals entered the cohort starting on the day of index release from a CTDOC facility
and were followed for 3 years or until death. For logistic regression models assessing outcomes
after 3 years of follow-up, 1,001 PLWH were included, after excluding 93 deaths. For models
using generalized estimating equations (GEEs), the full cohort of 1,094 PLWH contributed
6,227 complete 6-month follow-up periods (prior to death).

Data merging
CTDOC databases were securely transferred to the CTDPH, where on-site data managers
matched individuals to eHARS and CAREWare databases [32]. CTDOC inmate numbers are
routinely reported to the CTDPH by facility nursing supervisors when a new HIV case is

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Fig 1. Participant flow diagram. CTDOC, Connecticut Department of Correction; CTDPH, Connecticut Department of Public Health; DOC, Department of
Correction; DPH, Department of Public Health.
https://doi.org/10.1371/journal.pmed.1002667.g001

diagnosed in prison or by eHARS managers as part of routine data management. Inmate numbers were thus available for a majority of individuals in CTDPH databases. Rather than solely
relying on inmate number, the match was done using the Link Plus probabilistic record linkage program developed by the Centers for Disease Control and Prevention (https://www.cdc.
gov/cancer/npcr/tools/registryplus/lp.htm), with confirmatory data points including name,
date of birth, race, and sex. The merged dataset was further restricted to PLWH currently living in Connecticut (excluding 97 individuals), then de-identified and securely provided to
investigators for analysis (Fig 1).

Measures
Recorded HIV-1 RNA VLs served as the proxy for routine HIV care clinic visits (both in
prison/jail and in the community), which has demonstrated validity in multiple other settings

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and is consistent with core indicators for national HIV surveillance [39,40]. Using national
RIC guidelines, we defined “sustained 3-year RIC” as having 1 VL measured during every
6-month period during the 3-year follow-up period, with 60 days between VLs in adjacent
periods [36]. Because RIC does not necessarily predict VS and because VL was measured at
different frequencies during follow-up, we created a “terminal VS” outcome, defined as having
VL < 400 copies/ml measured within the last 6-month period of the 3-year follow-up [1,26].
Using time period as the unit of analysis, additional major outcomes were (1) “RIC over time”
(defined as having 1 VL measured during a 6-month period) and (2) “VS over time” (defined
as having 1 VL measured during a 6-month period with the last measured VL being <400
copies/ml). We concluded that the use of a binary outcome in accordance with the standard
definitions of RIC would be more appropriate than a survival analysis strategy (which examines time to an event) and would thus provide more clinically meaningful results. PLWH without VL assessments at least every 6 months were defined as being out of care; missing VLs
were conservatively assigned VL  400 copies/ml (non-suppression) by convention [41],
which applied to 24.5% (245/1,001) of the individuals and 23.0% (1,432/6,227) of the analyzed
6-month periods in the final multivariable models [42]. VLs were not missing at random, and
therefore multiple imputation was not performed. For example, compared to the 756 people
with VLs recorded during the last 6-month period of observation, the 245 people with missing
VLs were significantly more likely to be uninsured, to have been recently diagnosed with HIV,
to have been diagnosed with HIV during index incarceration, to have had fewer re-incarcerations or less time spent re-incarcerated, and to have had fewer case management visits. There
were no significant differences between individuals missing and not missing VLs in terms of
age, race/ethnicity, or sex. Using the Behavioral Model for Vulnerable Populations framework
[43], adapted for CJ populations [44], we examined a broad range of predisposing, enabling/
disabling, and need severity factors as potential predictors of RIC and VS over time. Continuous variables that were not normally distributed were categorized or calculated as described
below.
Predisposing factors. Predisposing factors included demographic characteristics (sex,
race/ethnicity, education level, and marital status), source of HIV transmission, and time since
HIV diagnosis. Sex was dichotomized as male/female based on available data; there was no
consistent information available on the number of individuals who were transgender, intersex,
or gender-nonconforming. Age was dichotomized at the sample median of 45 years. CTDPH
databases assessed prior injection drug use (IDU) based on the original HIV risk, and time
since HIV diagnosis was calculated by subtracting release date from HIV diagnosis date.
Enabling/Disabling factors. Enabling/disabling factors included year of release, whether
HIV was diagnosed during the index incarceration, and health insurance coverage (dichotomous; time-varying in GEE models), which was assessed every 6–12 months in the CAREWare
database and dichotomized as yes (public or private insurance) or no (“none”, “unknown”, or
“not reported”); if healthcare or social service resources were used without having formal
health insurance, persons were designated as uninsured. Using previous criteria, early linkage
to care was defined as VL assessment within 14 days after index release [32]. Length of incarceration was calculated using dates and types of movements into and out of facilities and analyzed categorically. Generally, shorter incarcerations (30 days) corresponded to jail
detentions, whereas longer incarcerations (365 days) involved prison sentences. Conditions
of release were categorized as unsupervised, conditional release (e.g., parole or transitional
housing), or release on bond. Because length of incarceration and conditions of release are
closely associated, we created 1 multilevel categorical variable. Re-incarceration (recidivism)
was defined as spending >24 hours in a CTDOC facility after initial release. To fully explore
the potential effect of re-incarceration, we examined it in 4 ways: dichotomous (re-

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Retention in HIV Care After Prison-Release

incarcerated during follow-up or not; time-varying in GEE models), categorical (number of
times re-incarcerated during follow-up), total number of days spent in a CTDOC facility during the 3-year follow-up, and percentage of each 6-month period spent in a CTDOC facility
(time-varying). Case management visit dates were used to create a dichotomous variable for
receipt of case management services during each 6-month period (time-varying) and total
number of case management visits over the 3-year follow-up period. CTDOC provides additional psychiatric case management services for those with serious mental illness, but these are
not consistently recorded in CAREWare.
Need severity factors. The last VL measured during the index incarceration (within 90
days of release) was used to determine VS status prior to release. ART prescription during
incarceration was extracted from pharmacy data and coded dichotomously. Prescribed medications to treat psychiatric disorders (i.e., antipsychotics, antidepressants, or other neuropsychiatric medications), treatment for an opioid use disorder (i.e., medication-assisted therapy
with methadone, buprenorphine, or naltrexone as brief supervised withdrawal or maintenance
therapy), and treatment of other medical comorbidities were each coded dichotomously. The
number of medical conditions other than HIV treated during the incarceration period was
summed [44]. As previously described [32], inmates are assigned psychiatric need and addiction severity scores on intake (5-point scale) to determine service programming, with 1–2 (no
or low severity), 3 (moderate, requiring treatment), and 4–5 (severe, needing residential or
intensive outpatient treatment). Increased psychiatric need was further assessed by combining
psychiatric severity score and psychiatric disease treatment to create a 4-category psychiatric
need variable (lower severity [score 1–2], untreated; lower severity, treated; higher severity
[score 3–5], untreated; higher severity, treated) [32]. Additional information on psychiatric
and substance use diagnoses was unavailable.

Statistical analysis
To examine RIC and VS over time, Cochrane–Armitage tests for trend were used to compare
the proportion of PLWH with RIC or with VS during year 1, years 1–2, and years 1–3. Chisquared tests were used to compare RIC for re-incarcerated individuals and those who were
not re-incarcerated. Among PLWH with RIC, we assessed the proportion with terminal VS
using chi-squared tests. Logistic regression was used to model predictors of 3-year sustained
RIC and terminal VS. Then, we examined each 6-month period of the 3-year follow-up period
for RIC and VS over time using a logit GEE, assuming an autoregressive correlation structure
to account for intra-individual correlation. Observations on the same individual were not
assumed to be independent; rather, the GEE model allowed us to account for correlated release
periods for the same individual and to calculate appropriate standard errors when performing
statistical inference. Individuals who died during follow-up were excluded from logistic regression models but could contribute any complete 6-month time periods before death to the GEE
models; including the incomplete periods during which PLWH died did not change effect estimates nor model fit.
For model building, relevant variables within the Behavioral Model for Vulnerable Populations with clinical significance or bivariate associations significant at p < 0.20 were included in
full multivariable models. To minimize the Akaike information criterion and maximize the
area under the receiver operating characteristic curve, backward selection was used to generate
final parsimonious models, including variables with p < 0.05. Sex, race/ethnicity, and recidivism were assessed for significance in parsimonious models a priori. Final logistic regression
models were also assessed for fit using Hosmer–Lemeshow goodness-of-fit tests (p > 0.05).
Based on tolerance, variance inflation factor, and eigenvalue diagnostics, final models did not

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have significant multicollinearity. Interactions between race/ethnicity, sex, and recidivism
were not found to be statistically significant. Due to small numbers of individuals treated for
opioid withdrawal, this variable was only assessed in GEE models. All analyses were performed
using SAS version 9.4 (SAS Institute).

Ethics approval
The CTDOC Research Advisory Committee and institutional review boards at Yale University
and CTDPH approved all procedures. Participant consent was waived because all data were
previously collected and de-identified for analysis.

Results
Sample description
Table 1 summarizes selected characteristics of the included 1,094 PLWH. Half (52.3%) were
>45 years old, and most were male (77.0%) and of racial/ethnic minorities (81.8%). Most HIV
infections were related to IDU (72.6%) and were not recently diagnosed (96.1%).

Description of retention in care and viral suppression over 3 years
Continuous post-release RIC (i.e., having 1 VL measured during every 6-month period, with
60 days between VLs in adjacent periods) [36] and VS significantly declined with each additional year of follow-up (Figs 2 and 3, respectively). Excluding deaths (n = 35 in year 1, n = 30
in year 2, and n = 28 in year 3), RIC rates were significantly higher among individuals who
were re-incarcerated compared with those who were not within each time frame (Fig 2).
Among those retained, however, re-incarcerated individuals were less likely to be virally suppressed than individuals who were not re-incarcerated; this pattern was consistent across all 3
years but statistically significant in year 1 and years 1–3 only.
For all individuals, only re-incarcerated individuals, and only individuals who were not reincarcerated, there was a statistically significant decline in RIC over time (Cochran–Armitage
test 1-way p < 0.001). There was a statistically significant difference in RIC rate between individuals who were re-incarcerated and those who were not across all time points (χ2 p < 0.001).
Among those retained, individuals who were not re-incarcerated had higher VS rates compared to re-incarcerated individuals at the end of year 1 (χ2 p = 0.021) and year 3 (χ2 p =
0.048).
Individuals with detectable viral levels during these time frames were considered virally
suppressed if their last viral level within the time frame of interest was <400 copies/ml. For
both definitions of VS (i.e., VS at the end of every year and at the end of every 6-month
period), there was a statistically significant decline in sustained VS over time (Cochran–Armitage test 1-way p < 0.001).

Factors predicting sustained retention in care and VS after 3 years
The 1,001 PLWH who were alive 3 years after release (n = 93 died) were demographically similar to the overall sample, and 41.5% of PLWH met criteria for sustained RIC (Table 2). In the
final model, sustained RIC was independently associated with older age (>45 years), having
health insurance, being re-incarcerated for >90 days during follow-up, receiving >30 case
management visits, and being linked to care or re-incarcerated within 14 days after initial
release. VS prior to release was not independently associated with RIC, although not having a
VL measured prior to release was negatively associated with RIC.

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Retention in HIV Care After Prison-Release

Table 1. Description of the full sample of 1,094 individuals initially released from prison or jail during 2007–
2011.
Variable

Full sample n (%)
(n = 1,094 individuals)

Predisposing factors
Age at time of release
45 years

422 (47.7%)

>45 years

572 (52.3%)

Sex†
Female

252 (23.0%)

Male

842 (77.0%)

Race/ethnicity
White

198 (18.1%)

Black

452 (41.2%)

Hispanic

404 (36.9%)

Other

41 (3.8%)

Education level
<High school

508 (46.4%)

High school

586 (53.6%)

Marital status‡
Not married

887 (83.7%)

Married

173 (16.3%)

Injection-drug-use-related source of HIV transmission
No

300 (27.4%)

Yes

794 (72.6%)

Time since HIV diagnosis
1 year

43 (3.9%)

>1 year

1,051 (96.1%)

Enabling or disabling factors
Any health insurance
No insurance/none reported

478 (43.7%)

Yes

616 (56.3%)

HIV diagnosed during index incarceration
No

1,072 (98.0%)

Yes

22 (2.0%)

Year of release
2007–2008

430 (39.3%)

2009–2010

469 (42.8%)

2011

195 (17.8%)

Length of incarceration and conditions of release
Incarcerated 30 days, release without conditions

199 (18.2%)

Incarcerated 30 days, conditional or bonded release

144 (13.2%)

Incarcerated 31–364 days, release without conditions

383 (35.0%)

Incarcerated 31–364 days, conditional or bonded release

206 (18.8%)

Incarcerated 365 days, release without conditions

71 (6.5%)

Incarcerated 365 days, conditional release (none were released on bond)

91 (8.3%)

Number of re-incarcerations
0

556 (50.8%)

1

274 (25.1%)

2

153 (14.0%)

3

111 (10.2%)

Days spent re-incarcerated
0–6 (<1 week)

567 (51.8%)

7–30

52 (4.8%)

31–90

96 (8.8%)

(Continued)

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Retention in HIV Care After Prison-Release

Table 1. (Continued)
Variable

Full sample n (%)
(n = 1,094 individuals)

91–180

171 (15.6%)

181–365

162 (14.8%)

>365

46 (4.2%)

Number of transitional case management visits
0

599 (54.8%)

1–5

116 (10.6%)

6–14

162 (14.8%)

15–30

115 (10.5%)

>30

102 (9.3%)

Early linkage to care (within 14 days of index release)
No

836 (76.4%)

Yes

230 (21.0%)

Re-incarcerated within 14 days

28 (2.6%)

Need severity factors
Prescribed ART during incarceration
No

458 (41.9%)

Yes

636 (58.1%)

Virally suppressed prior to release§
No

487 (44.5%)

Yes

357 (32.6%)

Viral load not drawn prior to release

250 (22.9%)

Number of medical comorbidities||
0

677 (61.9%)

1

232 (21.2%)

2

185 (16.9%)

Psychiatric need
Lower severity score, untreated

505 (46.2%)

Lower severity score, treated

53 (4.8%)

Higher severity score, untreated

205 (18.7%)

Higher severity score, treated

331 (30.3%)

Addiction severity score¶
1–2

163 (15.2%)

3

708 (66.0%)

4–5

201 (18.8%)

Treated for an opioid use disorder during index incarceration
No

1,091 (99.7%)

Yes

3 (0.3%)



Numbers listed are n (%) out of the total number of individuals who were initially eligible for analysis (n = 1,094),
including those who were found to have died during follow-up (n = 93). Percentages may not sum to 100% due to

rounding.
†

Transgender males (n = 1) were included the male category, and transgender females (n = 2) were included in the
female category.

‡

There were n = 34 individuals with a missing or unreported marital status during their index incarceration.

§

In 4% of cases, a viral load was drawn within 90 days prior to release, but the viral load value itself was not reported.
These cases were included in the “no” viral suppression category because viral suppression could not be confirmed.

||

Medical comorbidities broadly included gastrointestinal disease, cardiovascular disease, hyperlipidemia, diabetes,

other endocrine disease, viral hepatitis C, hematologic disorders, hypercoagulable states, hypertension,
immunological and autoimmune conditions, neurological conditions, pregnancy, pulmonary disease, renal failure,
and urological conditions including benign prostatic hypertrophy.
¶

There were n = 22 individuals whose addiction severity scores were never assessed during their index incarceration.

https://doi.org/10.1371/journal.pmed.1002667.t001

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Retention in HIV Care After Prison-Release

Fig 2. Longitudinal sustained retention in HIV care (RIC), based on frequency of HIV-1 RNA viral testing, and percentage with viral suppression (VS) at 1, 2, and
3 years post-release, stratified by whether individuals were re-incarcerated (recidivist) at some point during the follow-up period. There was a statistically significant
difference in RIC rates between individuals were re-incarcerated and individuals who were not re-incarcerated across all time points (χ2 p < 0.001). Among those
retained, individuals who were not re-incarcerated had higher VS rates compared to re-incarcerated individuals at end of year 1 (χ2 p = 0.021) and year 3 (χ2 p = 0.048).

Statistically significant decline in RIC compared with initial 1-year rates (McNemar’s test p < 0.001).  Statistically significant decline in RIC compared with sustained
2-year rates (McNemar’s test p < 0.001).
https://doi.org/10.1371/journal.pmed.1002667.g002

Overall, 54.4% of individuals demonstrated terminal VS after 3 years of follow-up (Table 2),
which was independently associated with age > 45 years, having health insurance, and receiving increased numbers of case management visits. Unlike RIC, VS was not independently
associated with the percentage of overall follow-up time spent re-incarcerated. In addition,
although VS before release and early linkage to care were not significantly correlated with terminal VS, ART prescribed during incarceration was positively associated with terminal VS.

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Retention in HIV Care After Prison-Release

Fig 3. Longitudinal HIV viral suppression (VS) at 1, 2, and 3 years post-release. ⎑Individuals with detectable viral loads during these time frames were considered
virally suppressed if their last viral load within the time frame of interest was <400 copies/ml.  Statistically significant decline in VS compared with initial 1-year rates
(McNemar’s test p < 0.001).  Statistically significant decline in VS compared with sustained 2-year rates (McNemar’s test p < 0.001).
https://doi.org/10.1371/journal.pmed.1002667.g003

Factors predicting retention in care and VS over time
The full cohort of 1,094 PLWH contributed 6,227 6-month follow-up periods, with 77.0% of
periods meeting the criteria for RIC (Table 3). Independent correlates of RIC per 6-month
period were age > 45 years, being diagnosed with HIV >1 year prior to release, having health
insurance, having a short (30 days) initial incarceration period followed by conditional or
bonded release, re-incarceration, increased proportion of follow-up time spent re-incarcerated, receipt of case management services, and early linkage to care post-release. Compared
with having a short index incarceration with unconditional release (i.e., “time served”), being

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Retention in HIV Care After Prison-Release

Table 2. Logistic regression model of sustained retention in care and HIV viral suppression.
Variable

Total n (%)†
(n = 1,001
individuals)

Sustained 3-year retention in care
Row n
(%)‡ with
retention

Unadjusted
model OR
(95% CI)

pValue

Terminal viral suppression
Parsimonious
padjusted model Value
OR (95% CI)

Row n (%)§
with viral
suppression

Unadjusted
model OR
(95% CI)

Referent

243 (49.1%)

Referent

pValue

Parsimonious
padjusted model Value
OR (95% CI)

Predisposing
factors
Age at time of
release
45 years

495 (49.5%)

179
(36.2%)

Referent

>45 years

506 (50.6%)

236
(46.6%)

1.54 (1.20–
1.99)

Female

237 (23.7%)

87
(36.7%)

Referent

Male

764 (76.3%)

328
(42.9%)

1.30 (0.96–
1.75)

White

177 (17.7%)

69
(39.0%)

Referent

Black

416 (41.6%)

175
(42.1%)

1.14 (0.79–
1.63)

Hispanic

371 (36.1%)

154
(41.5%)

Other

37 (3.7%)

<High school
High school

<0.001 1.61 (1.22–2.12) <0.001 302 (59.7%)

1.54 (1.20–
1.97)

Referent
<0.001 1.37 (1.06–1.78) 0.018

Sex||
123 (51.9%)

Referent

422 (55.2%)

1.14 (0.85–
1.53)

102 (57.6%)

Referent

0.485

230 (55.3%)

0.91 (0.64–
1.30)

0.600

1.11 (0.77–
1.60)

0.574

194 (52.3%)

0.81 (0.56–
1.16)

0.242

17
(46.0%)

1.33 (0.65–
2.72)

0.433

19 (51.4%)

0.78 (0.38–
1.58)

0.484

456 (45.6%)

187
(41.0%)

Referent

236 (51.8%)

Referent

545 (54.5%)

228
(41.8%)

1.04 (0.80–
1.33)

309 (56.7%)

1.22 (0.95–
1.57)

Not married

814 (84.2%)

344
(42.3%)

Referent

442 (54.3%)

Referent

Married

153 (15.8%)

62
(40.5%)

0.93 (0.66–
1.32)

87 (56.9%)

1.11 (0.78–
1.57)

No

281 (28.1%)

107
(38.1%)

Referent

148 (52.7%)

Referent

Yes

720 (71.9%)

308
(42.8%)

1.22 (0.92–
1.61)

397 (55.1%)

1.11 (0.84–
1.46)

1 year

42 (4.2%)

11
(26.2%)

Referent

16 (38.1%)

Referent

>1 year

959 (95.8%)

404
(42.1%)

2.05 (1.02–
4.13)

529 (55.2%)

2.00 (1.06–
3.78)

419 (41.9%)

122
(29.1%)

Referent

175 (41.8%)

Referent

0.090

0.368

Race/ethnicity

Education level

0.792

0.118

Marital status¶

0.691

0.561

Injection drug
use

0.175

0.480

Time since HIV
diagnosis

0.044

0.033

Enabling or
disabling factors
Any health
insurance
No insurance/
none reported

Referent

Referent
(Continued)

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Retention in HIV Care After Prison-Release

Table 2. (Continued)
Variable

Total n (%)†
(n = 1,001
individuals)

Sustained 3-year retention in care

Terminal viral suppression
Row n (%)§
with viral
suppression

Row n
(%)‡ with
retention

Unadjusted
model OR
(95% CI)

pValue

582 (58.1%)

293
(50.3%)

2.47 (1.89–
3.22)

<0.001 2.15 (1.60–2.89) <0.001 370 (63.6%)

No

979 (97.8%)

410
(41.9%)

Referent

Yes

22 (2.2%)

5 (22.7%)

2.45 (0.90–
6.69)

2007–2008

382 (38.2%)

136
(35.6%)

Referent

2009–2010

432 (43.2%)

185
(42.8%)

1.36 (1.02–
1.80)

2011

187 (18.7%)

94
(50.3%)

1.83 (1.28–
2.61)

Incarcerated 30 175 (17.5%)
days, release
without
conditions

71
(40.6%)

Referent

Incarcerated 30 125 (12.5%)
days, conditional
or bonded
release

61
(48.8%)

1.40 (0.88–
2.22)

Incarcerated 31–
364 days, release
without
conditions

353 (35.3%)

138
(39.1%)

Incarcerated 31–
364 days,
conditional or
bonded release

190 (19.0%)

Incarcerated
365 days,
release without
conditions
Incarcerated
365 days,
conditional
release (none
were released on
bond)

Yes

Parsimonious
padjusted model Value
OR (95% CI)

Unadjusted
model OR
(95% CI)

pValue

Parsimonious
padjusted model Value
OR (95% CI)

2.43 (1.88–
3.15)

<0.001 2.01 (1.53–2.64) <0.001

HIV diagnosed
during index
incarceration
537 (54.9%)

Referent

8 (36.4%)

2.13 (0.88–
5.11)

181 (47.4%)

Referent

0.036

241 (55.8%)

1.40 (1.06–
1.85)

0.017

<0.001

123 (65.8%)

2.13 (1.49–
3.07)

<0.001

88 (50.3%)

Referent

0.157

74 (59.2%)

1.43 (0.90–
2.28)

0.127

0.94 (0.65–
1.36)

0.744

185 (52.4%)

1.09 (0.76–
1.56)

0.646

76
(40.0%)

0.98 (0.64–
1.48)

0.912

107 (56.3%)

1.28 (0.84–
1.93)

0.249

70 (7.0%)

26
(37.1%)

0.87 (0.49–
1.53)

0.620

41 (58.6%)

1.40 (0.80–
2.45)

0.242

88 (8.8%)

43
(48.9%)

1.40 (0.84–
2.34)

0.201

50 (56.8%)

1.30 (0.78–
2.18)

0.317

0

493 (49.3%)

169
(34.3%)

Referent

251 (50.9%)

Referent

1

250 (25.0%)

101
(40.4%)

1.30 (0.95–
1.78)

142 (56.8%)

1.27 (0.93–
1.72)

0.081

0.092

Year of release

Length of
incarceration
and conditions
of release

Number of reincarcerations

0.102

0.129
(Continued)

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Retention in HIV Care After Prison-Release

Table 2. (Continued)
Variable

Total n (%)†
(n = 1,001
individuals)

Sustained 3-year retention in care
Row n
(%)‡ with
retention

Unadjusted
model OR
(95% CI)

pValue

Terminal viral suppression
Parsimonious
padjusted model Value
OR (95% CI)

Row n (%)§
with viral
suppression

Unadjusted
model OR
(95% CI)

pValue

2

147 (14.7%)

82
(55.8%)

2.42 (1.66–
3.52)

<0.001

86 (58.5%)

1.36 (0.94–
1.97)

0.106

3

111 (11.1%)

63
(56.8%)

2.52 (1.66–
3.83)

<0.001

66 (59.5%)

1.41 (0.93–
2.15)

0.104

0–6 (<1 week)

502 (50.2%)

171
(34.1%)

Referent

Referent

254 (50.6%)

Referent

7–30

46 (4.6%)

17
(37.0%)

1.14 (0.61–
2.12)

0.693

1.29 (0.66–2.51) 0.456

26 (56.5%)

1.27 (0.69–
2.33)

0.443

31–90

89 (8.9%)

37
(41.6%)

1.38 (0.87–
2.18)

0.173

1.47 (0.90–2.41) 0.122

49 (55.1%)

1.20 (0.76–
1.88)

0.438

91–180

163 (16.3%)

77
(47.3%)

1.73 (1.21–
2.48)

0.003

1.92 (1.29–2.84) 0.001

95 (58.3%)

1.36 (0.95–
1.95)

0.088

181–365

155 (15.5%)

80
(51.6%)

2.07 (1.43–
2.98)

<0.001 2.36 (1.51–3.66) <0.001 89 (57.4%)

1.32 (0.92–
1.89)

0.138

>365

46 (4.6%)

33
(71.7%)

4.91 (2.52–
9.58)

<0.001 5.82 (2.80–
12.11)

2.23 (1.16–
4.28)

0.016

0

532 (53.2%)

183
(34.4%)

Referent

1–5

110 (11.0%)

40
(36.4%)

1.09 (0.71–
1.67)

6–14

150 (15.0%)

73
(48.7%)

15–30

111 (11.1%)

>30

Parsimonious
padjusted model Value
OR (95% CI)

Days spent reincarcerated

<0.001 32 (69.6%)

Number of
transitional case
management
visits
Referent

254 (47.7%)

Referent

Referent

0.694

0.75 (0.47–1.19) 0.224

72 (65.5%)

2.07 (1.35–
3.18)

<0.001 1.69 (1.09–2.63) 0.020

1.81 (1.25–
2.61)

0.002

1.12 (0.74–1.68) 0.604

87 (58.0%)

1.51 (1.05–
2.18)

0.027

1.23 (0.84–1.79) 0.295

54
(48.7%)

1.81 (1.20–
2.73)

0.005

0.83 (0.51–1.36) 0.462

61 (55.0%)

1.34 (0.89–
2.01)

0.168

1.08 (0.70–1.65) 0.731

98 (9.8%)

65
(66.3%)

3.76 (2.38–
5.92)

<0.001 1.84 (1.11–3.03) 0.017

71 (72.5%)

2.88 (1.79–
4.63)

<0.001 2.04 (1.25–3.34) 0.005

No

774 (77.3%)

281
(36.3%)

Referent

408 (52.7%)

Referent

Yes

205 (20.5%)

120
(58.5%)

2.48 (1.81–
3.39)

<0.001 2.31 (1.65–3.24) <0.001 125 (61.0%)

1.40 (1.02–
1.92)

0.035

Re-incarcerated
within 14 days

22 (2.2%)

14
(63.6%)

3.07 (1.27–
7.41)

0.013

12 (54.6%)

1.08 (0.46–
2.52)

0.865

No

415 (41.5%)

147
(35.4%)

Referent

191 (46.0%)

Referent

Yes

586 (58.5%)

268
(45.7%)

1.54 (1.19–
1.99)

354 (60.4%)

1.79 (1.39–
2.31)

Early linkage to
care (within 14
days of index
release)
Referent

2.63 (1.03–6.74) 0.044

Need severity
factors
Prescribed ART
during
incarceration

0.001

Referent
<0.001 1.39 (1.06–1.82) 0.016
(Continued)

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Retention in HIV Care After Prison-Release

Table 2. (Continued)
Variable

Total n (%)†
(n = 1,001
individuals)

Sustained 3-year retention in care
Row n
(%)‡ with
retention

Unadjusted
model OR
(95% CI)

pValue

Terminal viral suppression
Parsimonious
padjusted model Value
OR (95% CI)

Row n (%)§
with viral
suppression

Unadjusted
model OR
(95% CI)

Referent

220 (50.1%)

Referent

pValue

Parsimonious
padjusted model Value
OR (95% CI)

Virally
suppressed
prior to release
No

439 (43.9%)

186
(42.4%)

Referent

Yes

333 (33.3%)

150
(45.1%)

1.12 (0.84–
1.49)

0.458

0.92 (0.67–1.26) 0.616

209 (62.8%)

1.68 (1.26–
2.24)

<0.001

Viral load not
drawn prior to
release

229 (22.9%)

79
(34.5%)

0.72 (0.51–
1.00)

0.049

0.65 (0.45–0.93) 0.020

116 (50.7%)

1.02 (0.74–
1.41)

0.894

0

626 (62.5%)

237
(37.9%)

Referent

320 (51.1%)

Referent

1

215 (21.5%)

97
(45.1%)

1.35 (0.99–
1.85)

0.061

132 (61.4%)

1.52 (1.11–
2.09)

0.009

2

160 (16.0%)

81
(50.6%)

1.68 (1.19–
2.39)

0.004

93 (58.1%)

1.33 (0.93–
1.89)

0.114

Lower severity
score, untreated

457 (45.7%)

181
(39.6%)

Referent

234 (51.2%)

Referent

Lower severity
score, treated

50 (5.0%)

21
(42.0%)

1.10 (0.61–
2.00)

0.743

35 (70.0%)

2.22 (1.18–
4.18)

0.371

Higher severity
score, untreated

187 (18.7%)

75
(40.1%)

1.02 (0.72–
1.45)

0.906

103 (55.1%)

1.17 (0.83–
1.64)

0.013

Higher severity
score, treated

307 (30.7%)

138
(45.0%)

1.25 (0.93–
1.67)

0.142

173 (56.4%)

1.23 (0.92–
1.65)

0.162

1–2

158 (16.1%

52
(32.9%)

Referent

78 (49.4%)

Referent

3

644 (66.7%

274
(42.6%)

1.51 (1.05–
2.18)

0.028

359 (55.8%)

1.29 (0.91–
1.83)

0.150

4–5

179 (18.3%)

78
(43.6%)

1.57 (1.01–
2.46)

0.045

96 (53.6%)

1.19 (0.77–
1.82)

0.435

Number of
medical
comorbidities

Psychiatric need

Addiction
severity score

p-Values in bold are statistically significant (< 0.05).


Sample is restricted to individuals who were alive at the end of the 3-year follow-up period; there were 93 deaths, resulting in 1,001 individuals eligible for analysis,
among whom 41.5% (415/1,001) were retained in care continuously for 3 years and 54.4% (545/1,001) had a viral load < 400 copies/ml at the end of the 3 years.

†

Numbers listed are n (%) out of the total number of individuals (n = 1,001). Percentages may not sum to 100% due to rounding.

‡
§

Numbers listed are the row n (%) of individuals who experienced the outcome of sustained retention in care. Percentages should not be expected to sum to 100%.
Numbers listed are the row n (%) of individuals who experienced the outcome of viral suppression after 3 years of follow-up. Percentages should not be expected to

sum to 100%.
||
¶

Transgender males (n = 1) were included the male category, and transgender females (n = 2) were included in the female category.
Incarceration periods for individuals with missing/unreported marital status (n = 34) were excluded from the bivariate analysis, such that the total n = 1,025.



Incarceration periods where the addiction severity score was never assessed (n = 20) were excluded from the bivariate analysis, such that the total n = 1,039.

OR, odds ratio.
https://doi.org/10.1371/journal.pmed.1002667.t002

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Retention in HIV Care After Prison-Release

incarcerated for 1 year with unconditional release was associated with significantly poorer
RIC. RIC was also significantly less likely during the final 6-month follow-up period after the
index release. Regarding need severity factors, receiving ART and being treated for a medical
comorbidity during incarceration were positively associated with RIC, while no VL obtained
before release was negatively associated with RIC.
VS was reported in 50.9% of the eligible 6-month periods (Table 3). In GEE models, independent correlates of VS per 6-month period were age > 45 years, IDU-related transmission
risk, having health insurance, having a short index incarceration period (30 days) followed
by conditional or bonded release, increased percentage of follow-up time spent re-incarcerated, receipt of case management services, and early linkage to care. Unlike for RIC, disabling
factors for VS were re-incarceration and a medium length of incarceration (31–364 days) followed by unconditional release. VS was also significantly better for more contemporary
releases and during the final 6-month follow-up period after the index release. Receipt of ART,
VS, and untreated high psychiatric need during incarceration were need severity factors each
positively associated with VS over time.

Discussion
To our knowledge, this is one of the longest assessments of RIC and VS in a large cohort of
individuals with HIV released from prison or jail. Despite HIV being a chronic condition that
requires lifelong treatment, prior longitudinal RIC studies in the general population have not
accounted for the complex impact of incarceration and the unique vulnerabilities it represents
for many PLWH [8,11,14–16]. By comprehensively linking multiple CJ and community-based
data sources, we were able to follow all CJ-involved PLWH statewide, including those re-incarcerated. We identified major correlates of optimal HIV treatment outcomes and found that
the impact of re-incarceration is complex and dependent on time spent in facilities and conditions of release. These findings offer new insights into potential strategies to improve RIC and
VS in CJ-involved PLWH.
Rates of sustained RIC and VS significantly declined over time, with re-incarcerated individuals demonstrating higher RIC rates than individuals who were not re-incarcerated, across
all 3 years. Re-incarceration likely represents “forced” reengagement in care, but was not necessarily associated with VS itself. Rather, the length of time one spent in correctional facilities
was associated with RIC and VS per 6-month interval and over the 3 years of observation.
These findings speak not only to the potential for incarceration to facilitate reengagement in
HIV care within a structured setting that can provide appropriate care and resources
[21,25,26], but also to the potential for re-incarceration to interrupt HIV care. Re-incarceration itself was associated with worse VS outcomes, which is consistent with literature showing
an association between incarceration, ART non-adherence, and virological failure [21,24,25].
Short-term benefits gained during incarceration appear to be outweighed by the long-term
harm incarceration inflicts on physical and mental health, especially after release [45].
Individuals who were not re-incarcerated and who demonstrated RIC in the community
had significantly higher VS rates compared with re-incarcerated individuals, underscoring the
importance of better supporting community-based RIC through expanded enabling resources
like case management and health insurance and minimizing recidivism, which is disruptive
both medically and socially [46,47]. This finding is consistent with that from a recent study in
North Carolina and Rhode Island showing that PLWH released from prison and retained in
community care (without being re-incarcerated) had similar VS rates to PLWH continuously
engaged in community care [48]. Sentencing policies, particularly for drug-related or nonviolent offenses, should be modified to encourage community-based CJ rehabilitation and

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Retention in HIV Care After Prison-Release

Table 3. Binomial generalized estimating equations of retention in care and viral suppression per 6-month follow-up period.
Total n
(%)† (n =
6,227
6-month
periods)

Retention in care over time
Row n
(%)‡ with
retention

Unadjusted
model OR
(95% CI)

45 years

3,020
(48.5%)

2,226
(73.7%)

Referent

>45 years

3,207
(51.5%)

2,569
(80.1%)

1.45 (1.20–
1.76)

Female

1,454
(23.4%)

1,125
(77.4%)

Referent

Male

4,773
(76.7%)

3,670
(76.9%)

0.98 (0.79–
1.21)

White

1,111
(17.8%)

849
(76.4%)

Referent

Black

2,584
(41.5%)

2,028
(78.5%)

1.13 (0.87–
1.45)

0.369

1,315 (50.9%) 0.90 (0.71–
1.13)

0.356

Hispanic

2,299
(36.9%)

1,735
(75.5%)

0.94 (0.72–
1.22)

0.617

1,127 (49.0%) 0.82 (0.65–
1.04)

0.100

Other

233 (3.7%)

183
(78.5%)

1.12 (0.65–
1.92)

0.680

131 (56.2%)

0.644

<High school

2,850
(45.8%)

2,174
(76.3%)

Referent

High school

3,377
(54.2%)

2,621
(77.6%)

1.10 (0.91–
1.33)

Not married

5,048
(83.8%)

3,906
(77.4%)

Referent

Married

975
(16.2%)

738
(75.7%)

0.89 (0.69–
1.16)

No

1,733
(27.8%)

1,280
(73.9%)

Referent

Yes

4,494
(72.2%)

3,515
(78.2%)

1.27 (1.03–
1.56)

1 year

253 (4.1%)

155
(61.3%)

Referent

>1 year

5,974
(95.9%)

4,640
(77.7%)

2.22 (1.40–
3.53)

4,267
(68.5%)

3,128
(73.3%)

Referent

Variable

Viral suppression over time
pValue

Parsimonious
adjusted model
OR (95% CI)

pValue

Row n (%)§
with viral
suppression

Unadjusted
model OR
(95% CI)

pValue

Parsimonious
adjusted model
OR (95% CI)

pValue

Predisposing
factors
Age at time of
index release
Referent
<0.001 1.30 (1.07–1.57)

1,331 (44.1%) Referent
0.008

1,836 (57.3%) 1.70 (1.44–
2.00)

Referent
<0.001 1.44 (1.22–1.71)

<0.001

Sex||
693 (47.7%)
0.855

Referent

2,474 (51.8%) 1.17 (0.97–
1.41)

0.102

Race/ethnicity
594 (53.5%)

Referent

1.11 (0.72–
1.69)

Education level
1,433 (50.3%) Referent
0.325

1,734 (51.4%) 1.07 (0.91–
1.27)

0.411

Marital status
2,533 (50.2%) Referent
0.401

516 (52.9%)

1.10 (0.87–
1.39)

751 (43.3%)

Referent

0.420

Injection drug
use

0.025

2,416 (53.8%) 1.49 (1.23–
1.81)

Referent
<0.001 1.31 (1.07–1.60)

0.009

Time since HIV
diagnosis
Referent
<0.001 1.66 (1.05–2.62)

86 (34.0%)
0.029

Referent

3,081 (51.6%) 2.13 (1.33–
3.42)

0.002

Enabling or
disabling factors
Health
insurance
No insurance/
none reported

Referent

1,966 (46.1%) Referent

Referent
(Continued)

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Retention in HIV Care After Prison-Release

Table 3. (Continued)
Total n
(%)† (n =
6,227
6-month
periods)

Retention in care over time
Row n
(%)‡ with
retention

Unadjusted
model OR
(95% CI)

pValue

1,960
(31.5%)

1,667
(85.1%)

1.60 (1.36–
1.88)

<0.001 1.61 (1.34–1.94)

Incarcerated 30
days, release
without
conditions

1,106
(17.8%)

834
(75.4%)

Referent

Incarcerated 30
days, conditional
release

78 (1.3%)

67
(85.9%)

2.22 (0.97–
5.05)

0.058

2.29 (1.00–5.27)

Incarcerated 30
days, bonded
release

712
(11.4%)

573
(80.5%)

1.39 (0.96–
2.02)

0.077

Incarcerated 31–
364 days, release
without
conditions

2,201
(35.4%)

1,652
(75.1%)

1.00 (0.75–
1.32)

Incarcerated 31–
364 days,
conditional
release

1,062
(17.1%)

825
(77.7%)

Incarcerated 31–
364 days, bonded
release

116 (1.9%)

Variable

Yes

Viral suppression over time
Parsimonious
adjusted model
OR (95% CI)

pValue

Row n (%)§
with viral
suppression

Unadjusted
model OR
(95% CI)

<0.001 1,201 (61.3%) 1.41 (1.25–
1.60)

pValue

Parsimonious
adjusted model
OR (95% CI)

pValue

<0.001 1.18 (1.02–1.38)

0.028

Length of index
incarceration and
conditions of
index release
Referent

519 (46.9%)

Referent

Referent

0.050

52 (66.7%)

2.20 (0.96–
5.02)

0.061

2.38 (1.08–5.28)

0.033

1.66 (1.14–2.40)

0.008

384 (53.9%)

1.33 (0.97–
1.82)

0.072

1.58 (1.16–2.17)

0.004

0.979

0.77 (0.58–1.02)

0.068

1,028 (46.7%) 1.03 (0.80–
1.31)

0.840

0.76 (0.59–0.97)

0.029

1.19 (0.87–
1.62)

0.282

0.80 (0.58–1.10)

0.169

572 (53.9%)

1.38 (1.04–
1.82)

0.025

0.86 (0.65–1.14)

0.299

92
(79.3%)

1.28 (0.64–
2.58)

0.487

0.99 (0.52–1.89)

0.986

50 (43.1%)

0.85 (0.45–
1.60)

0.620

0.67 (0.37–1.22)

0.193

Incarcerated
420 (6.7%)
365 days, release
without
conditions

312
(74.3%)

0.95 (0.62–
1.44)

0.799

0.55 (0.36–0.84)

0.006

228 (54.3%)

1.38 (0.94–
2.01)

0.099

0.69 (0.47–1.02)

0.060

Incarcerated
365 days,
conditional
release (none
released on bond)

532 (8.5%)

440
(82.7%)

1.64 (1.09–
2.46)

0.018

0.96 (0.62–1.48)

0.863

334 (62.8%)

2.03 (1.43–
2.87)

<0.001 1.16 (0.82–1.63)

0.397

No

5,325
(85.5%)

3,931
(73.8%)

Referent

Yes

902
(14.5%)

864
(95.8%)

5.24 (4.04–
6.79)

0%

5,019
(80.6%)

3,653
(72.8%)

Referent

1%–50%

749
(12.0%)

698
(93.2%)

4.35 (3.31–
5.71)

<0.001 2.56 (1.67–3.91)

<0.001 367 (49.0%)

0.98 (0.85–
1.14)

0.812

51%–100%

459 (7.4%)

444
(96.7%)

8.69 (5.34–
14.16)

<0.001 5.39 (3.15–9.22)

<0.001 306 (66.7%)

1.72 (1.40–
2.11)

<0.001 2.52 (1.91–3.32)

Reincarcerated
Referent
<0.001 2.27 (1.44–3.58)

2,696 (50.6%) Referent
<0.001 471 (52.2%)

0.99 (0.86–
1.13)

Referent
0.836

0.65 (0.51–0.81)

<0.001

Percent time
spent reincarcerated
Referent

2,494 (49.7%) Referent

Referent
1.38 (1.08–1.76)

0.010
<0.001

(Continued)

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Retention in HIV Care After Prison-Release

Table 3. (Continued)
Total n
(%)† (n =
6,227
6-month
periods)

Retention in care over time
Row n
(%)‡ with
retention

Unadjusted
model OR
(95% CI)

2007–2008

2,405
(38.6%)

1,777
(73.9%)

Referent

2009–2010

2,677
(43.0%)

2,074
(77.5%)

1.24 (1.00–
1.52)

0.046

1,418 (53.0%) 1.49 (1.24–
1.80)

<0.001 1.04 (0.85–1.27)

0.712

2011

1,145
(18.4%)

944
(82.5%)

1.65 (1.25–
2.16)

<0.001

700 (61.1%)

<0.001 1.60 (1.24–2.06)

0.003

No

5,126
(82.3%)

3,803
(74.2%)

Referent

Yes

1,101
(17.7%)

992
(90.1%)

2.32 (1.91–
2.82)

No

4,798
(77.1%)

3,541
(73.8%)

Referent

Yes

1,296
(20.8%)

1,142
(88.1%)

2.77 (2.15–
3.57)

<0.001 2.64 (2.03–3.43)

<0.001 824 (63.6%)

1.95 (1.59–
2.39)

<0.001 1.79 (1.45–2.21)

<0.001

Re-incarcerated
within 14 days
without any
community viral
load

133 (2.1%)

112
(84.2%)

1.91 (0.82–
4.47)

0.135

0.295

66 (49.6%)

1.07 (0.60–
1.91)

0.811

0.874

0 to <6 months

1,080
(17.3%)

853
(79.0%)

Referent

522 (48.3%)

Referent

6 to <12 months

1,059
(17.0%)

826
(78.0%)

0.95 (0.80–
1.12)

0.519

1.02 (0.85–1.23)

0.802

511 (48.3%)

1.00 (0.89–
1.12)

0.978

1.00 (0.87–1.15)

1.000

12 to <18 months 1,039
(16.7%)

796
(76.6%)

0.87 (0.73–
1.04)

0.123

0.86 (0.71–1.05)

0.132

519 (50.0%)

1.06 (0.93–
1.22)

0.357

1.04 (0.89–1.22)

0.607

18 to <24 months 1,029
(16.5%)

789
(76.7%)

0.87 (0.73–
1.05)

0.139

0.88 (0.72–1.08)

0.228

535 (52.0%)

1.15 (1.00–
1.33)

0.058

1.14 (0.96–1.35)

0.137

24 to <30 months 1,019
(16.4%)

775
(76.1%)

0.84 (0.70–
1.01)

0.071

0.84 (0.68–1.04)

0.104

535 (52.5%)

1.18 (1.01–
1.36)

0.032

1.14 (0.96–1.36)

0.133

30 to 36 months

1,001
(16.1%)

756
(75.5%)

0.83 (0.69–
0.99)

0.038

0.81 (0.65–0.99)

0.041

545 (54.5%)

1.28 (1.10–
1.48)

0.001

1.26 (1.06–1.49)

0.010

No

2,577
(41.4%)

1,855
(72.0%)

Referent

994 (38.6%)

Referent

Yes

3,650
(58.6%)

2,940
(80.6%)

1.63 (1.35–
1.97)

Variable

Viral suppression over time
pValue

Parsimonious
adjusted model
OR (95% CI)

pValue

Row n (%)§
with viral
suppression

Unadjusted
model OR
(95% CI)

pValue

Parsimonious
adjusted model
OR (95% CI)

pValue

Year of index
release
1,049 (43.6%) Referent

2.02 (1.60–
2.56)

Referent

Transitional case
management
services
Referent
<0.001 1.79 (1.44–2.22)

2,489 (48.6%) Referent
<0.001 678 (61.6%)

1.48 (1.28–
1.70)

Referent
<0.001 1.31 (1.12–1.53)

<0.001

Early linkage to
care
Referent

1.57 (0.68–3.63)

2,277 (47.5%) Referent

Referent

1.05 (0.56–1.98)

Time since index
release††
Referent

Referent

Need severity
factors
Prescribed ART
during index
incarceration
Referent
<0.001 1.33 (1.07–1.65)

0.011

2,173 (59.5%) 2.46 (2.07–
2.91)

Referent
<0.001 1.91 (1.56–2.34)

<0.001

(Continued)

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Retention in HIV Care After Prison-Release

Table 3. (Continued)
Total n
(%)† (n =
6,227
6-month
periods)

Retention in care over time
Row n
(%)‡ with
retention

Unadjusted
model OR
(95% CI)

No

2,744
(44.1%)

2,112
(77.0%)

Referent

Yes

2,059
(33.1%)

1,653
(80.3%)

1.23 (0.98–
1.54)

0.068

1.06 (0.84–1.33)

0.620

1,302 (63.2%) 2.37 (1.96–
2.87)

<0.001 1.94 (1.59–2.37)

<0.001

Viral load not
drawn prior to
release

1,424
(22.9%)

1,030
(72.3%)

0.77 (0.61–
0.97)

0.029

0.71 (0.56–0.91)

0.006

675 (47.4%)

0.117

0.130

0

3,874
(62.2%)

2,872
(74.1%)

Referent

1

1,334
(21.4%)

1,079
(80.9%)

1.49 (1.17–
1.90)

0.001

1.29 (1.01–1.66)

0.046

750 (56.2%)

1.48 (1.21–
1.83)

<0.001

2

1,019
(16.4%)

844
(82.8%)

1.73 (1.33–
2.24)

<0.001 1.29 (0.96–1.74)

0.096

599 (58.8%)

1.64 (1.31–
2.07)

<0.001

Lower severity
score, untreated

2,853
(45.8%)

2,146
(75.2%)

Referent

Lower severity
score, treated

312 (5.0%)

255
(81.7%)

1.47 (0.97–
2.23)

0.069

199 (63.8%)

2.06 (1.38–
3.09)

<0.001 1.47 (0.97–2.21)

0.068

Higher severity
score, untreated

1,166
(18.7%)

889
(76.2%)

1.04 (0.80–
1.34)

0.772

598 (51.3%)

1.15 (0.91–
1.45)

0.233

1.36 (1.07–1.72)

0.011

Higher severity
score, treated

1,896
(30.5%)

1,505
(79.4%)

1.28 (1.02–
1.60)

0.035

1,017 (53.6%) 1.31 (1.08–
1.59)

0.006

1.07 (0.87–1.31)

0.510

1–2

957
(15.7%)

685
(71.6%)

Referent

3

4,030
(66.0%)

3,129
(77.6%)

1.38 (1.07–
1.79)

0.013

2,110 (52.4%) 1.38 (1.09–
1.75)

0.008

4–5

1,118
(18.3%)

874
(78.2%)

1.44 (1.05–
1.97)

0.024

561 (50.2%)

0.091

6,209
(99.7%)

4,779
(77.0%)

Referent

Variable

Viral suppression over time
pValue

Parsimonious
adjusted model
OR (95% CI)

pValue

Row n (%)§
with viral
suppression

Unadjusted
model OR
(95% CI)

pValue

Parsimonious
adjusted model
OR (95% CI)

pValue

Virally
suppressed prior
to index releas
Referent

1,190 (43.4%) Referent

1.19 (0.96–
1.47)

Referent

1.18 (0.95–1.47)

Number of
medical
comorbidities
Referent

1,818 (46.9%) Referent

Psychiatric need
1,353 (47.4%) Referent

Referent

Addiction
severity score
during index
incarceration‡‡
425 (44.4%)

Referent

1.29 (0.96–
1.73)

Treated for an
opioid use
disorder during
index
incarceration
No

3,152 (50.8%) Referent
(Continued)

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Retention in HIV Care After Prison-Release

Table 3. (Continued)
Variable

Yes

Total n
(%)† (n =
6,227
6-month
periods)

Retention in care over time
Row n
(%)‡ with
retention

Unadjusted
model OR
(95% CI)

pValue

18 (0.3%)

16
(88.9%)

2.17 (0.35–
13.42)

0.405

Viral suppression over time
Parsimonious
adjusted model
OR (95% CI)

pValue

Row n (%)§
with viral
suppression

Unadjusted
model OR
(95% CI)

pValue

15 (83.3%)

4.84 (0.71–
33.10)

0.108

Parsimonious
adjusted model
OR (95% CI)

pValue

p-Values in bold are statistically significant (< 0.05).
Sample is restricted to 6-month follow-up periods where individuals were alive at the end of the 6-month period. There were 6,227 6-month post-release periods (1,080



individual-based clusters) eligible for analysis, of which there were 4,795 (77.0%) 6-month post-release periods during which at least 1 viral load was drawn (retained in
care) and 3,167 (50.9%) 6-month post-release periods in which the last viral level obtained was <400 copies/ml (virally suppressed).
Numbers listed are n (%) out of the total number of 6-month time periods (n = 6,227). Percentages may not sum to 100% due to rounding.

†
‡

Numbers listed are the row n (%) of 6-month time periods during which the individual experienced the outcome of retention in care. Percentages should not be

expected to sum to 100%.
§
Numbers listed are the row n (%) of 6-month time periods during which the individual experienced the outcome of viral suppression. Percentages should not be
expected to sum to 100%.
||
¶

Transgender males (n = 1) were included the male category, and transgender females (n = 2) were included in the female category.
Follow-up periods for individuals with missing/unreported marital status (n = 204) were excluded from the bivariate analysis, such that the total n = 6,023.



Variable refers to the 6-month interval rather than the individual or index incarceration.

††

In a sensitivity analysis of probability of viral suppression over time (by Cochran–Armitage test), there was a significant trend toward higher probability of viral
suppression with increased time since initial release.

‡‡

Follow-up periods where the addiction severity score was never assessed (n = 122) were excluded from the bivariate analysis, such that the total n = 6,105.

OR, odds ratio.
https://doi.org/10.1371/journal.pmed.1002667.t003

engagement in community-based healthcare and to facilitate access to post-release resources
like psychiatric and addiction treatment, both of which improve RIC and reduce recidivism
[49–54].
Engaging PLWH in the HIV care continuum during and immediately after release significantly impacts longitudinal RIC. PLWH whose VLs were adequately monitored, who were
prescribed ART, or who achieved VS before release had better RIC over time. Also, early linkage to care (within 2 weeks) post-release was associated with sustained 3-year RIC as well as
RIC and VS over time. Paradoxically, prisons/jails influence longitudinal HIV treatment outcomes, especially when community-based resources are inadequate. Many PLWH likely benefit from CJ-based services as a safety net as long as these services are integrated, continuous,
and align health and justice priorities. If jail/prison services are comprehensive and coordinated, jails and prisons can serve as highly effective “patient-centered medical homes” [55].
Despite these opportunities, the uneven and often disjointed care provided in CJ settings and
the detrimental medical and social consequences alongside the excessive financial burden associated with mass incarceration in the US favor supporting less costly, integrated community
healthcare systems to improve care for PLWH [45,54,56–59].
Having a short index incarceration with subsequent supervised release was associated with
increased RIC and VS over time relative to both short and longer incarcerations with unconditional release. PLWH with brief incarcerations may not lose their social and medical community-based ties [60] and consequently, with post-release support from CJ supervision, may
better reintegrate back into the community [58]. Conditional release may also facilitate RIC by
providing an access point for PLWH to engage in social and medical services, whereas PLWH
released on bond may represent a population with greater financial resources or social support
that improves their ability to navigate the healthcare system [29].

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Retention in HIV Care After Prison-Release

In randomized trials, transitional case management services for incarcerated PLWH are no
better than pre-release discharge planning at improving post-release linkage to care and retention [32,33,61]. Within an integrated prison/jail system, and when targeted to those most in
need, case management may require a differentiated service delivery model that caters to
PLWH at highest risk for recidivism. Differentiated service delivery is a client-centered
approach that simplifies and targets key services (e.g., health insurance and treatment for
addiction and psychiatric disorders) needed along the HIV continuum to reduce unnecessary
burdens on the health system [33,34,62]. In the absence of such services, multiple stressors and
barriers to care can lead to substance use relapse, high-risk behaviors, and suboptimal healthcare engagement, such as defaulting from ART, which undermine VS [63–65]. Unlike prior
studies, findings here demonstrate that transitional case management is a key enabling factor
that is strongly associated with RIC and VS. Despite the important role of case management to
facilitate health insurance and community services to improve RIC and VS [32,65], most
PLWH (54.8%) did not receive these services, and health insurance coverage remained low
(56.3%) over 3 years of follow-up. This indicates an urgent need to expand the provision of
case management services both during and after the transition to the community.
When RIC and VS did not significantly improve despite numerous case management visits,
it is likely that those PLWH had multiple severe medical and social needs. Thus, the positive
effect of case management may be masked by the higher baseline need of those who received
these services compared with those who were not targeted to receive case management. Unlike
in Connecticut, most states terminate insurance benefits during incarceration [62], with findings here supporting the need to reexamine policies that promote continuation of, reactivation
of, or potentially new enrollment into insurance before release.
Unlike previous studies [20,56], IDU transmission risk and high psychiatric need correlated
with VS over time. While IDU and psychiatric need were not associated with frequency of
transitional case management utilization, such individuals may have received additional psychiatric case management to link and retain them in treatment for psychiatric or substance use
disorders, which could have improved VS. Also, some PLWH with an IDU history died early
during follow-up, including from drug overdose [66], which limited our ability to clearly assess
the role of current or past IDU on longitudinal HIV treatment outcomes.
Other limitations of the study included limited data regarding post-release housing status
and psychiatric and substance use disorders. Addiction and psychiatric severity scores were
our best indicators for comorbidities that potentially impact RIC in the community. We also
could not fully measure brief fluctuations in insurance status.
Strengths of the study included the ability to follow both individuals who were re-incarcerated and those who were not, for an extended period of time, and to account for many factors
that changed over time, including health insurance status. Instead of using prescription refill
or clinic visit data to approximate RIC and VS, our outcomes were constructed using reliably
and systematically reported biological data and used standardized, generalizable, and clinically
justifiable definitions of RIC and VS. Defining missing VL data as indicating being out of care
and not having VS may have biased findings, but is a standardized analytic convention that
provides conservative estimates [40,41,67], given that a very small proportion of PLWH may
have moved out of state and not been fully measured despite extensive efforts by CTDPH to
cross-check interstate databases. Finally, we minimized typical database linkage challenges
through the use of complete databases (aside from psychiatric case management data), reliable
variables for individual matching, and CTDPH database managers with considerable experience linking data.
Despite some limitations, this study is, to our knowledge, one of the first to extensively identify correlates of longitudinal RIC and VS for all PLWH in a CJ setting, while simultaneously

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Retention in HIV Care After Prison-Release

describing and accounting for the complex impact of incarceration. RIC decreases markedly
after release from prison/jail, but several key factors correlate with improved RIC and VS after
release, including provision of HIV care during incarceration, health insurance, case management, and early linkage to care post-release. While re-incarceration and conditional release
facilitate engagement in care for some PLWH, our findings strongly indicate that strategies that
reduce recidivism and support community-based RIC will yield better treatment outcomes
than using re-incarceration as a mechanism to promote RIC in this population. Improving RIC
and VS will, however, require policy changes, including expanding health insurance through
new enrollments and avoiding suspension; expanding and targeting transitional case management to those at risk for recidivism and poor health outcomes; aligning community supervision
(i.e., probation and parole) with healthcare by promoting continued care for HIV, psychiatric
disorders, and addiction (which often requires health insurance) to avoid recidivism; and
screening for and treating psychiatric and substance use disorders, and continuing these treatments post-release. Such changes in policy will likely positively influence HIV treatment outcomes while diminishing the negative consequences of mass incarceration, especially for racial/
ethnic minorities in the US.

Supporting information
S1 Checklist. STROBE checklist.
(DOC)
S1 Table. Characteristics of all 1,094 individuals and their incarceration experiences, stratified based on the frequency of transitional case management services provided during the
3-year follow-up.
(DOCX)
S1 Text. Signed applications for protocol approval from CTDOC and CTDPH, including
data on planned analyses.
(PDF)

Acknowledgments
This research was conducted in collaboration with CTDOC and CTDPH. We thank Kathleen
Maurer, Patrick Hynes, Cheryl Cepelak, and Heidi Jenkins for assisting with study design,
guiding the interpretation of our findings, and fostering the inter-institutional collaborations
that made this study possible. We also thank Kirsten Shea, Suzanne Speers, Michael Ostapoff,
and Melanie Alvarez for their invaluable assistance with data collection, extraction, and linkage; no compensation was received for these contributions. Finally, we sincerely thank Paula
Dellamura for her crucial administrative support.
The content is solely the responsibility of the authors and does not necessarily represent the
official views of the National Institutes of Health.

Author Contributions
Conceptualization: Kelsey B. Loeliger, Jaimie P. Meyer, Mayur M. Desai, Maria M. Ciarleglio,
Colleen Gallagher, Frederick L. Altice.
Data curation: Kelsey B. Loeliger, Jaimie P. Meyer.
Formal analysis: Kelsey B. Loeliger, Jaimie P. Meyer.
Funding acquisition: Kelsey B. Loeliger, Jaimie P. Meyer, Frederick L. Altice.

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Retention in HIV Care After Prison-Release

Investigation: Kelsey B. Loeliger, Jaimie P. Meyer, Frederick L. Altice.
Methodology: Kelsey B. Loeliger, Jaimie P. Meyer, Mayur M. Desai, Maria M. Ciarleglio, Frederick L. Altice.
Project administration: Kelsey B. Loeliger, Jaimie P. Meyer.
Resources: Kelsey B. Loeliger, Jaimie P. Meyer, Colleen Gallagher.
Software: Kelsey B. Loeliger.
Supervision: Jaimie P. Meyer, Mayur M. Desai, Maria M. Ciarleglio, Colleen Gallagher, Frederick L. Altice.
Validation: Kelsey B. Loeliger.
Visualization: Kelsey B. Loeliger.
Writing – original draft: Kelsey B. Loeliger.
Writing – review & editing: Kelsey B. Loeliger, Jaimie P. Meyer, Mayur M. Desai, Maria M.
Ciarleglio, Colleen Gallagher, Frederick L. Altice.

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