The impact of antiretroviral therapy in a cohort of HIV infected patients going in and out of the San Francisco county jail

Abstract

Background: Jails are an important venue of HIV care and a place for identification, treatment and referral for care. HIV infected inmates in the San Francisco County jail are offered antiretroviral treatment (ART), which many take only while in jail. We evaluated the effect of ART administration in a cohort of jail inmates going in and out of jail over a nine year period.

Methodology/principal findings: In this retrospective study, we examined inmates with HIV going in and out of jail. Inmates were categorized by patterns of ART use: continuous ART - ART both in and out of jail, intermittent ART - ART only in jail; never on ART - eligible by national guidelines, but refused ART. CD4 and HIV viral load (VL) were compared over time in these groups. Over a 9 year period, 512 inmates were studied: 388 (76%) on intermittent ART, 79 (15%) on continuous ART and 45(9%) never-on ART. In a linear mixed model analysis, inmates on intermittent ART were 1.43; 95%CI (1.03, 1.99) times and those never on ART were 2.89; 95%CI (1.71, 4.87) times more likely to have higher VL than inmates on continuous ART. Furthermore, Inmates on intermittent ART and never-on ART lost 1.60; 95%CI (1.06, 2.13) and 1.97; 95%CI (0.96, 3.00) more CD4 cells per month, respectively, compared to continuously treated inmates. The continuous ART inmates gained 0.67CD4 cells/month.

Conclusions/significance: Continuous ART therapy in jail inmate's benefits CD4 cell counts and control of VL especially compared to those who never took ART. Although jail inmates on intermittent ART were more likely to lose CD4 cells and experience higher VL over time than those on continuous ART, CD4 cell loss was slower in these inmates as compared to inmates never on ART. Further studies are needed to evaluate whether or not intermittent ART provides some benefit in outcome if continuous ART is not possible or likely.

Figure 1. Local average of CD4 counts over time by treatment pattern: intermittent, continuous, and never-on treatment.

In the figure, a Continuous ART inmate is noted with pink plus (dotted line), and Intermittent ART inmate is noted with a gray circle (solid line), and the yellow triangles (dashed line) mark the Eligible but Never on treatment inmates.

Figure 2. Expected CD4 over time by for a 30 year-old Caucasian male, as predicted from a linear mixed effects model.

Baseline CD4 counts and viral load (VL) over time are taken to reflect the baseline status of the inmates by the pattern of medication intake: CD4 cells at 330 cells/ml at baseline and a VL of 800 copies/ml for an inmate who was continuously treated; CD4 cells at 330 cells/ml at baseline and a VL of 7,500 copies/ml for an inmate who was intermittently treated; CD4 cells at 430 cells/ml at baseline and a VL of 8,000 copies/ml for an inmate who was never treated.

Figure 3. Local average of viral load (VL) over time by treatment pattern: intermittent, continuous, and never-on treatment.

In the figure, a Continuous ART inmate is noted with pink plus (dotted line), and Intermittent ART inmate is noted with a gray circle (solid line), and the yellow triangles (dashed line) mark the Eligible but Never on treatment inmates.