Comprehensive and expeditious linkage to appropriate care is vital for people being released from correctional facilities who are living with HIV and experience behavioral health conditions. In the United States, the incarcerated population, including prisons and local jails, has an HIV rate of up to five times greater than the general population (Ammon et al., 2018; Kaminsky et al., 2026; Khazi-Syed et al., 2024; Scheyett et al., 2010). There are approximately one in seven individuals living with HIV incarcerated in the United States every day (Ammon et al., 2018; Fuller et al., 2019; Hammett et al., 2015; Rowell-Cunsolo et al., 2020). Medical treatment, including anti-retroviral (ART) medications, is often available in correctional facilities, but in the immediate post-release period, treatment rates lessen to even lower rates than before incarceration (Ammon et al., 2018). Often, external considerations interfere with the successful linkage to care. A comprehensive program that includes HIV care, primary medical care, behavioral health including substance use treatment, intensive case management, care coordination, and facilitation by peer navigators and/or community health workers with similar lived experience is needed to meet this challenge.
Behavioral Health Considerations
Behavioral health and linkage to appropriate HIV care are serious concerns regarding the transition of individuals living with HIV returning to the community from incarceration. Individuals living with HIV have higher rates of mental health conditions compared to individuals not living with HIV. The literature has revealed that depression was up to two times higher for individuals living with HIV (Scheyett et al., 2010). Scheyett et al. (2010) state “Management of depression and/or enhancing coping skills prior to release may be essential to successful linkage to community-based care” (p. 6). Kaminsky et al. (2026) state “In fact, lengthy stays in carceral facilities are associated with poorer mental health outcomes, such as depression and anxiety” (p. 669).
Women releasees living with HIV have higher rates of accumulated trauma as well as other mental health conditions (Johnson et al., 2022). Johnson et al. (2022) state “Importantly, greater trauma exposure is linked to poor treatment adherence and poor HIV related health outcomes” (p. 2). Trauma can negatively affect treatment adherence and HIV outcomes. There are approximately 1.8 million women released from jails annually in the United States, and approximately 81,000 of the 1.8 million are released from state prisons. Approximately 80% report chronic medical (including HIV) and behavioral health (including substance use) issues. Approximately 15% reported only seeking care for either medical and/or behavioral health outside of an emergency room setting within the first year of release from incarceration (Johnson et al., 2022).
HIV Care Considerations
While incarcerated, many individuals living with HIV generally receive HIV care including ART (Ammon et al., 2018; Rowell-Cunsolo et al., 2020). It is often due to inadequate discharge planning and the process of transition that the health benefits achieved tend to weaken, as HIV-positive releasees report medical and ART treatment disruption (Rowell-Cunsolo et al., 2020). The literature has revealed that the longer it takes to establish linkage to HIV care, the lower the probability of better health outcomes (Woznica et al., 2021; Ammon et al., 2018). “Successful linkage and retention in care, prescription refill, and viral load suppression among reentrants are critical for overall HIV epidemic control goals” (Woznica et al., 2021, p. 27).
The immediate post-release period represents a particularly vulnerable time for individuals living with HIV. The literature reveals several reasons for poor HIV care after release, including difficulty accessing ART, lack of adherence with ART if accessed, and other competing needs such as compliance with community supervision, vocational and financial issues, food insecurity, public assistance and insurance issues, housing insecurity, transportation, childcare, safety issues, as well as unmet mental health and substance use concerns (Springer et al., 2011). As competing priorities increase, engagement in HIV care and behavioral health treatment may decline, placing individuals at greater risk for treatment disruption, loss of viral suppression, worsening mental health symptoms, return to substance use, and other adverse health outcomes. These findings underscore the importance of rapid, comprehensive, and coordinated linkage to care immediately following release. This clearly indicates the importance of a comprehensive linkage-to-care model.
Comprehensive Linkage to Care Considerations
The literature reveals that a comprehensive re-entry program performing linkage to care for HIV-positive releasees with behavioral health issues should consist of the following components. The program should include case management services, ART and medical services, mental health treatment services that include services for substance use, and HIV prevention services (Hammett et al., 2015; Springer et al., 2011; Fuller et al., 2019). The case management component would assist clients in obtaining insurance and public assistance, among other services such as food pantries. Care coordination services would facilitate medical appointment scheduling and transportation for the client. The medical services would include HIV care as well as primary medical care. A behavioral health unit, including psychiatry, would provide counseling and treatment for clients identified with mental health and substance use issues. There would also be an HIV prevention component to make available PrEP/PEP, condoms, and education. Ideally, this would be located centrally in a clinical yet trauma-informed setting.
The comprehensive re-entry program should also include peer navigation and/or community health workers to best provide culturally competent services to clients (Khazi-Syed et al., 2024; Woznica et al., 2021; Ammon et al., 2018; Westergaard et al., 2019; Rowell-Cunsolo et al., 2020; Johnson et al., 2022). The lived experience of these workers, whether living with HIV and/or having a history of incarceration, can greatly ease the transition from incarceration to the complex and often confusing system of linkage to care through understanding, experience, and empathy.
Marc Liff, LCSW ACSW, is a Senior Clinical Social Worker at SUNY Downstate Health Sciences University’s Special Treatment and Research Program (STAR). He can be reached at 718-270-2299 or [email protected].
Lamont Bryant, BS, MPS, is a B2B Project Manager at SUNY Downstate Health Sciences University’s Special Treatment and Research Program (STAR). He can be reached at 718-270-6775 or [email protected].
Christopher Carpenter, BS, is a B2B Community Health Worker at SUNY Downstate Health Sciences University’s Special Treatment and Research Program (STAR). He can be reached at 718-270-8014 or [email protected].
References
Ammon, A., Iroh, P., Tiruneh, Y., Li, X., Montague, B. T., Rich, J. D., & Nijhawan, A. E. (2018). HIV care after jail: Low rates of engagement in a vulnerable population. Journal of Urban Health. 95:488-498 https://doi.org/10.1007/s11524-018-0231-0
Fuller, S. M., Koester, K. A., Maiorana, A., Steward, W. T., Broaddus, M. R., Lass, K., Zamudia-Haas, S., Byrd Quinlivan, E., & Meyers, J. M. (2019). “I don’t have to do this all by myself”: Systems navigation to ensure continuity of HIV care for persons leaving prison. AIDS and Behavior. 23: s14-s24 https://doi.org/10.1007/s10461-018-2050-4
Hammett, T. M., Donahue, S., LeRoy, L., Montague, B. T., Rosen, D. L., Solomon, L., Costa. M., Wohl, D., Rich, J. D. (2015). Transitions to care in the community for prison releasees with HIV: A qualitative study of facilitators and challenges in two states. Journal of Urban Health: Bulletin of the New York Academy of Medicine. 92 (4). doi.org/10.1007/s11524-015-9968-x
Johnson, K. A., Hunt, T., Puglisi, L. B., Maeng, D., Epa-Llop, A., Elumn, J. E., Nguyen, A., Leung, A., Chen, R., Shah, Z., Wang, J., Johnson, R., Chapman, B. P., Gilbert, L., El-Bassel, N., & Morse, D. S. (2022). Trauma, mental health distress, and infectious disease prevention among women recently released from incarceration. Frontiers in Psychiatry. 20, May, 2022 doi.org/10.3389/fpsyt.2022.867445
Kaminsky, C. J., Cherenack, E. M., Fernandez-Nocito, S., Biondo, J., Pan, Y., Dauria, E. F., Johnson, K. A., Palella, F., Mimiaga, M. J., Kwait, J., Wingood, G., Chandran, A., Hanna, D. B., Ramirez, C., Philbin, M. M., & Jones, D. L. (2026). Psychosocial, behavioral, and HIV-related health among men living with HIV who have a history of incarceration. AIDS and Behavior. 30:668-679 https://doi.org/10.10007/s10461-025-04887-5
Khazi-Syed, A., Hoff, E., Salyards, M., Hansen, L., Campalans, N., Pulitzer, Z., Melton-Crain, C., Nguyen, H., Shavit, S., Walker, R., & Nijhawan, A, E. (2024). The role of community health workers in re-entry of people with HIV and substance use disorder released from jail: A mixed methods evaluation of a pilot study. Health and Justice. 12:45 https://doi.org/10.1186/s40352-024-00301-9
Rowell-Cunsolo, T. L., Hu, G., & Haile, R. (2020). “It’s like I was out there by myself”: The receipt of re-entry support among HIV infected formerly incarcerated individuals in New York City. Health and Justice. 8:6 https://doi.org/10.1186/s40352-020-00108-4
Scheyett, A., Parker, S., Golin, C., White, B., Pettus Davis, C., & Wohl, D. (2010). HIV infected prison inmates: Depression and implications for release back to communities. AIDS and Behavior. 14 (2). 300-307 doi: 10.1007/s10461-008-9443-8
Springer, S. A., Spaulding, A. C., Meyer, J. P., & Altice, F. L. (2011). Public health implications for adequate transitional care for HIV infected prisoners: Five essential components. HIV/AIDS. CID 2011:53. 469-479 DOI: 10.1093/cid/cir446
Westergaard, R. P., Hochstatter, K. R., Andrews, P. N., Kahn, D., Schumann, C. L., Winzenreid, A. E., Sethi, A. K., Gangnon, R. E., & Sosman, J. M. (2019). Effect of patient navigation on transitions of HIV care after release from prison: A retrospective cohort study. AIDS and Behavior. 23 (9). 2549-2557 doi: 10.1077/s10461-019-02437-4
Woznica, D. M., Fernando, N. B., Bonomo, E. J., Owczarzak, J., Zack, B., & Hoffmann, C. J. (2021). Interventions to improve HIV care continuum outcomes among individuals released from prison or jail: Systematic literature review. Acquired Immune Deficiency Syndrome. 86 (3). 271-285
