Running head: HIV MEDICATION COMPLIANCE AND INCARCERATION

Integrative Review of Factors Impacting Medication Compliance among HIV-Positive Inmates

Shannon Richardson
Bon Secours Memorial College of Nursing

HIV MEDICATION COMPLIANCE AND INCARCERATION

Abstract
Treatment compliance among HIV-positive offenders is a matter that warrants further research. With a
large number of HIV-positive people cycling through correctional facilities, it is important to gain
insight on factors that lead to sub-optimal compliance rates. Very few studies exist providing adequate
data regarding the impact that incarceration has on the administration of antiretroviral therapy for this
particular population. Elements regarding patient history and the environment within in the
correctional setting must be examined to identify their degree of impact upon adhering to prescribed
treatment regimens. Qualitative and quantitative data was collected from studies to identify factors
believed to cause the greatest impact. Information was also noted that incarceration may also have a
positive correlation regarding decreased viral load and better treatment outcomes for those serving
longer sentences in comparison to those with a history of recidivism or short sentences.

HIV MEDICATION COMPLIANCE AND INCARCERATION

Integrative Review of Factors Impacting Medication Compliance among HIV Positive Inmates
Over the years, there has been amazing leaps in the progression of treatment of the Human
Immunodeficiency Virus (HIV). The introduction of new medications to combat the illness has led to
better outcomes, quality of life, and decreased the rates of morbidity and mortality for those infected.
In order to continue to make strides in the treatment of HIV, adherence to antiretroviral therapy (ART)
is essential. Studies such as the one conducted by Meyer et al show that there is an increased incidence
of HIV infection among those incarcerated, with prevalence rates in some states exceeding that of subSaharan African countries (2013). Many correctional facilities have implemented opt-out policies for
HIV testing, which has led to increased testing and detection of HIV positive offenders. This is
important because many of those subjected to incarceration are part of a vulnerable population, with
behavioral practices that place them at increased risk for contracting the HIV virus. They also often
lack access to healthcare, leading to late delayed detection and treatment. Because a large number of
HIV positive individuals cycle through the correctional setting, it is important to investigate the
relationship between incarceration and compliance to ART.
During incarceration, HIV positive persons are exposed to several factors, some of which are
environmental, that grossly impact their ability to adhere to prescribed medication regimens. The
purpose of this paper is to identify factors present during incarceration that have an effect on
medication compliance among HIV positive inmates. Various studies were reviewed to identify
common themes present. The writer of this paper has a special interest in this topic due to experience
working with the prison population. During this experience, several factors such as security policies
and procedures, inadequate supply of medications upon intake, and lack of privacy were the most
commonly observed issues that negatively impact care.
Search Methods

HIV MEDICATION COMPLIANCE AND INCARCERATION

A literature review was completed using articles obtained from online databases. The databases
used were Pubmed and Lippincotts Nursing Reference Center powered by EBSCO Host. Terms
entered for the search were: prison, incarceration, correctional setting, HIV, positive,
HAART, antiretroviral, treatment, compliance, and adherence. The search was limited to
journal articles published within the past five years. Of the results provided, only five of the articles
were selected. Qualitative and quantitative studies were used for the literature review.
Search outcomes
The initial search on Pubmed yielded 14 results after restrictions were applied limiting results to
journal articles published within the past five years. The abstracts of the articles were reviewed to
check for relevance and usefulness. Of the articles found, only two were relevant to the specific topic
stated. The others listed focused on factors related to compliance post release among this population,
and on treatment of Tuberculosis within the correctional setting. A total of three articles retrieved from
Pubmed were used for this literature review. Key search terms were then interchanged which provided
two additional articles. The same process was used, with similar results when conducting searches
using Lippincotts Nursing Reference Center. Two articles werek retrieved from this online database.
Literature Review
This review was completed using a descriptive, correlational design. According to Fain, this type
of research design is used to identify and explain the type and degree to which relationships exist
(2013). Although relationships are identified, and magnitudes measured, it is not necessary to clarify
the cause of the underlying factors.
Literature sample
Articles used for the literature review consisted of two qualitative articles and three quantitative
articles. Two of the studies were conducted outside the United States, and contained information that
could be useful in addressing the issue of compliance among incarcerated HIV-positive persons. The

HIV MEDICATION COMPLIANCE AND INCARCERATION

qualitative study conducted by Small et al examined the burden that incarceration caused among the
HIV-positive, intravenous drug users (IDUs) of British Colombia (2009). Paparizos et al conducted
research that sought evaluate adherence to treatment among imprisoned HIV-positive patients and to
identify factors that influence it in Athens, Greece (2013). Roberson examined the lack of privacy and
impact of mental illness within a female correctional setting for those receiving ART (2012).
Information was also obtained based on the experiences of the incarcerated women. Studies conducted
by Meyer et al (2014) and Westgaard, Spaulding, and Flanigan (2013) took a broader approach, and
provided useful information regarding the increased testing rates within correctional facilities and how
that has led to an increased number of HIV-positive persons, newly diagnosed within the correctional
setting . Both studies also examined the periods prior to, during, and post incarceration and the impact
on treatment compliance. Table 1 provides a summary of the above mentioned articles.
Upon completion of the literature review, it was noted that there were common themes
regarding factors influencing compliance. The majority of articles reviewed stated that incarceration
had a negative impact on adhering to medication regimens, while others stated that satisfactory
compliance was possible within the correctional setting. Each article reviewed contained a different
element that had been missed by other articles, adding to the importance of conducting a literature
review.
Factors Specific to Incarceration
Several environmental factors specific to the prison setting were noted among the articles
reviewed. Of those identified, policies and procedures was a cause for impaired medication
compliance (Westgaard et al, 2013). In the prison, medications are administered during pill line, which
is where groups of offenders come to the medical department and stand in line to receive their
medications. Complaints were made that some staff made no attempts to be discrete, and lack of
privacy was an issue that the population complained about (Small et al, 2009).

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Interruption of Treatment
Interruption of treatment was the leading cause of low compliance rates among HIV-positive
persons incarcerated (Small et al, 2009). For those with a history of recidivism, shorter jail or prison
sentences, and recent initiation of ART, incarceration posed a major risk to treatment adherence.
Medications were often not available upon intake, transfer, or prior to discharge. Delays in receiving
medications were also noted when subjects experienced short stays in jail holding cells and smaller
facilities. Many of those interviewed stated they opted to wait for release before attempting to obtain
medications due to the inability to obtain them in the past. Many also chose not to disclose their status
to the medical department. It was also noted that incarceration among IDUs likely lead to
discontinuation of ART.
Factors Related to Patient History
Qualitative studies were able to provide more specific patient information regarding other issues
impacting compliance. The article written by Small et al followed a group of IDUs, and found that
they had additional obstacles to overcome in regards to medication compliance (2009). In addition to
struggling with addiction, a large number of subjects chose not to take medications as prescribed due to
their environment. Because offenders are not guaranteed privacy, they feared that others would
become aware of their status, and they would be discriminated against. In this case, discrimination was
inclusive of being denied access to goods, services, injectable drugs, and drug paraphernalia. This
particular study mentioned how some of the offenders experienced verbal and physical abuse regarding
their status.
Mental illness also complicated adherence to treatment. Those diagnosed with HIV that
suffered from severe mental illness, or mental illness that was not adequately managed showed a direct
negative correlation based on severity of the illness (Meyer et al, 2014). The study also found that
undiagnosed or undertreated psychiatric conditions contributed to poor ART compliance, and poor

HIV MEDICATION COMPLIANCE AND INCARCERATION

outcomes post release. Almost half of the population was prescribed psychiatric medications, with
approximately one-third of the group taking anti-depressants. There was a high incidence of
depression noted among HIV-positive offenders.
Increased Compliance
Compliance rates for the studies reviewed considered taking medications 95% of the time was
satisfactory, with the exception of the Westgaard et al article that decreased the compliance level from
95%, to 85 percent (2013). The majority of the research data showed that incarceration led to a
decrease in compliance. Studies conducted by Roberson (2012) and Small et al (2009) showed that
increased compliance was noted among the studied population. In Robersons study, the issue with
lack of privacy was addressed by allowing offenders to self-administer medications, which eliminated
the inadvertent disclosure of status during the pill line (Roberson, 2012). Longer periods of
incarceration reflected decreased viral loads and increased CD4 lymphocytes, which is consistent with
maintaining viral suppression (Small et al, 2009). It was thought that the decreased exposure to risky
behaviors such as drug and sex trade was the cause for maintaining viral suppression among this
population (Meyer et al, 2014). Women also had better treatment outcomes and ART was more
beneficial to this group. It was believed that this was related to the fact that there was only one
correctional facility for females. Having a solitary facility for women meant that they were not
subjected to numerous transfers and had the opportunity to build trust with their provider, experiencing
a better continuity of care.
Findings
All studies reviewed showed that incarceration has the potential to cause negative outcomes in
regards to compliance, which leads to ineffective management of HIV within the population specified.
The research showed that factors such as lack of privacy, lack of resources, fear of stigma and abuse,
mental illness, and history of substance abuse were among the top variables. While there were both

HIV MEDICATION COMPLIANCE AND INCARCERATION

qualitative and quantitative data to support that there was a decrease in treatment compliance, there was
also data available that supports that correctional facilities can aid in initiation, and ART compliance.
Increased ART compliance was noted among those that were serving longer sentences (Small et al,
2009). It was also noted that decreased compliance was noted post release. To determine whether a
decrease in compliance was noted, data inclusive of lab values to check the RNA viral load, CD4
counts, and number of filled prescriptions were monitored in the studies conducted by Small et al
(2009) and Paparizos et al (2013).
Discussion
Implications
Data collected showed that there is an extreme need to address more than the disease process
when considering medication compliance. In order to increase compliance rates, healthcare providers
need to take a different approach and keep in mind that there are other factors that must be addressed
even though they may not appear to be an immediate issue. In the hospital setting, the education
approach used is that discharge planning begins upon admission. This same approach should be
taken during incarceration by providing information and addressing some of the issues that may be
related to the current incarceration, such as history of mental illness and substance abuse. The study
conducted by Roberson showed the impact that provision of mental health services had on female
offenders (2012). One of the subjects interviewed stated that she had difficulty accepting her diagnosis
and was not willing to take the prescribed ART. She then stated how she had struggled with depression
and that she was currently being counseled by mental health, and prescribed medications to manage her
psychiatric condition. The study conducted by Meyers et al showed similar findings (2014).
Limitations
Many factors regarding circumstances and availability of literature were present and restricted
the full potential of this research paper. The author of this paper lacks experience conducting research

HIV MEDICATION COMPLIANCE AND INCARCERATION

critiques, literature reviews, and writing research papers. Initially, finding information that was current
and relevant to the discussed topic was difficult, and required reformulating the research question and
search terms. The researcher also had to make the search criteria more generalized in order to produce
maximum search results when using online databases. Of the articles found, it was noted that
information regarding ethical considerations and methods were lacking. Because the number of articles
that met the search criteria was minimal, the quality of the articles used within the literature review was
affected. Limited resources to online journals also restricted the ability to produce optimal materials
due to membership requirements and associated fees. Another limitation to this paper is that there
were restrictions placed on the number of articles to be used, and the articles collected had to have been
published within the last five years. Five articles were reviewed for this integrative critique, making it
difficult to conduct a comprehensive literature review. There also may have been an element of bias
due to the experience that the writer has with the prison population regarding barriers within the
correctional system that impacted care. Several of the articles seemed to lack information regarding
such factors that this writer has observed within this population. There was also no mention of
interventions to obtain ART when the supply was inadequate in instances such as upon intake and
transferring to alternate facilities.
Conclusion
The reviewed literature has provided valuable information about the variables that impact
medication compliance among HIV-positive offenders. Although statistical data, lab values, and
patient interviews were obtained, data gathered from interviewing medical personnel responsible for
coordinating, such as nurses and physicians, would have been helpful in terms of evaluating
interventions implemented to increase compliance. The articles provided descriptive information
regarding the views and experiences of the population, but some of the studies contained information
that was vague, leaving the reader to wonder about elements not included. Conducting further research

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11

using comparative observation with control groups among those that have factors present such as
mental illness, history of substance abuse, and initiation of treatment in relation to diagnosis will be
helpful in further understanding dynamics among the various subsets within the population. Further
research is encouraged to gain data that previous studies lacked in efforts to improve compliance and
decrease rates of morbidity and mortality among those infected with HIV. Putting forth the effort to
examine this special population will improve outcomes for those incarcerated, while also improving the
health of community populations.

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13

Table 1
Table of Evidence
Author
s (Year)

Title of
Article

Meyer
, J. P.,
Ceped
a, J.,
Wu, J.,
Treat
man,
R. L.,
Altice,
F. L., &
Spring
er, S.
A.
(2014)

Optimi
zation
of
human
immun
odefici
ency
virus
treatm
ent
during
incarce
ration:
Viral
suppre
ssion
at the
prison
gate
Adheren
ce to
antiretro
viral
therapy
among
HIV
infected
prisoners

Papariz
os et al,
2013

Data
base

Keywo
rds
used
in
search

Resear
ch
Design

Pub
med

HIV
treatm
ent
compli
ance in
prison

Retrosp
ective
cohort
longitu
dinal

Pub
med

prison Quantit
and
ative
HIV
medica
tion
compli
ance

Data
Colle
ction

Subjects Sam
plin
g
Met
hod
s
-lab
HIV
Purp
value positive osiv
s
males
e,
and
coh
interv females ort
iews
within
the
obser Connecti
vation cut
Departm
ent of
Correcti
ons

Patien
t
interv
iews,
clinic
al
progr
ess of
diseas
e and
lab
result
s

93 HIV
positive
patients
that
served a
prison
sentence
and had
been
treated
at A.
Sygros
Hospital
in
Athens,

Data Analysis

Concl
usion

Statistial
analysis
-viral
suppresion
and CD4 labs
upon intake
and release
-SAS version
9.3

Purp -unable to
osiv identify
e

sever
al
eleme
nts
lacki
ng
from
meth
ods
sectio
n
ethica
l

HIV MEDICATION COMPLIANCE AND INCARCERATION

HIV
Pub
Westerg among med
aard,R. person
s
P.,
Spauldi incarce
rated
ng,A.
in the
C.,&
Flaniga US: A
n,T.P. review
of
(2013)
evolvin
g
concep
ts of
testing,
treatm

Greece

Quantit
incarce ative
ration
and hiv
medica
tion
compli
ance

Datab
ase
-lab
value
s
CDC
statist
ics

HIV
positive
offender
s within
US
judicial
system

Data unknown
base
/coh
ort

15
conce
rns
prese
nt (no
menti
on of
IRB
appro
val or
infor
med
conse
nt)
count
ry of
origin
for
study
may
be
reaso
n for
lack
of
detail
s
-lacks
validi
ty
useful
,
provi
ded
additi
onal
backg
round
infor
matio
n on
topic

HIV MEDICATION COMPLIANCE AND INCARCERATION

ent
and
linkage
to
commu
nity
care
Medical
Roberso privacy
n,D.W and
.(2012) antiretr
oviral
therap
y
among
HIVinfecte
d
female
inmate
s
Small, The
W.,
impactof
Wood, incarcera
E.,
tionupon
Better adherenc
idge,
etoHIV
G.,
treatment
Monta among
ner, J., HIV
&
positive
Kerr, T injection
.
drug
(2009) users:a
.
qualitativ
estudy

Lippi
ncott
s
Nursi
ng
Refer
nce
Cnet
er/E
BSC
O
Host

prison
and hiv
medica
tion
compli
ance

Qualita
tiveethnogr
aphy

Interv
iews/s
urvey
and
obser
vation

12 HIV- Coh
positive ort
incarcer
ated
females
in
correctio
nal
facility
within
the U.S.

Lippi
ncott
s
Nursi
ng
Refer
ence
Cent
er/
EBS
CO
Host

prison Qualita
and hiv tive
medica
tion
compli
ance

interv
iew

HIV
positive
IDUs in
British
Columbi
a;
member
s of
another
cohort
study

17

-qualitative
descriptive
approach

-qualitative
Recr descriptive
uite
d
fro
m
coh
ort
stud
y

HIV MEDICATION COMPLIANCE AND INCARCERATION

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F.A. Davis Co.
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