Time to bring HIV research to justice?

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  • Professor Curt Beckwith from the Alpert Medical School of Brown University heads up a training programme which equips researchers with the tools and skills they need to study the prevention and treatment of infectious diseases in criminal justice system populations. These populations show disproportionate burdens of HIV and hepatitis C virus infection as well as health disparities, making their effective treatment vital to turn the tide of disease progression worldwide.

    Professor Beckwith studies criminal justice-involved populations in the United States (US), which has the highest incarceration rate in the world. More than 2.1 million people are in prisons or jails (more local, short-term holding facilities), which equates to approximately 670 inmates per 100,000 residents. At year-end 2015, almost 7 million people were involved with the criminal justice system (CJS), or 1 in 37 of all US adults.

    The CJS cycle
    Those involved in the CJS often get caught in a recurrent cycle of incarceration where they continually move between the community, correctional facilities, and community supervision including probation (court ordered supervision in the community) and parole (conditional supervised release following a prison term). The policy of incarcerating individuals committing crimes related to substance abuse, has created a public health synergistic epidemic or “syndemic”: the aggregation of two or more concurrent or sequential epidemics or disease clusters in a population with biological interactions. This is known to exacerbate the prognosis and burden of disease.

    Prison populations are characterised by a greatly elevated prevalence of Human Immunodeficiency Virus (HIV), addiction, and other psychiatric disorders.

    Syndemics develop under health disparity, such as that caused by poverty or incarceration, and many epidemiologists and medical anthropologists seek to understand the effects of these social conditions on health. A syndemic approach to the study of a disease departs from the biomedical approach of diagnostically isolating, studying, and treating diseases as distinct entities. Instead, social contexts and co-morbidities are considered to create a clearer picture of individual health effects and outcomes.

    Seek, test, treat and retain for HIV among CJS populations

    The Seek, Test, Treat, and Retain strategy to control the HIV epidemic can be applied to criminal justice populations. There are multiple opportunities to provide HIV testing and counselling services, linkage to HIV care and treatment, and to re-engage persons as they re-enter the criminal justice system.

    Infection, incarceration, intervention
    Prof Beckwith notes that, “Criminal justice involved populations are characterised by a greatly elevated prevalence of Human Immunodeficiency Virus (HIV), addiction, and other psychiatric disorders.” For example, HIV prevalence is three times higher among incarcerated populations in the US than in the general population, and it has been estimated that 1 in 7 HIV-positive persons pass through correctional facilities in any given year. He goes on to identify correctional facilities as providing a unique opportunity to deliver HIV treatment and prevention interventions, particularly for substance users, who he describes as “disenfranchised” from health care services in their communities.

    The mass incarceration of substance users has also disproportionately affected particular ethnic groups; African Americans and Hispanics are incarcerated at rates six and two times those of whites, respectively. The U.S. National AIDS Strategy was first released in 2010, and in 2015 was updated to cover the period to 2020. This constitutes a five-year plan that details principles, priorities, and actions to guide the national response to the HIV epidemic. It calls for reduction in HIV incidence and reductions in racial disparities in HIV infection.

    Correcting the record
    As Prof Beckwith highlights, for many individuals, particularly ethnic minorities, incarceration represents an opportunity to reach individuals for HIV testing, treatment, and prevention services. HIV-positive persons who have difficulty accessing HIV treatment in the community and individuals who are at increased risk of HIV infection due to multiple and co-occurring risk factors can be engaged in treatment and prevention efforts when they pass through a correctional facility, with the goal of linking them to community-based services upon release.

    Prof Beckwith with colleague Dr Flanigan at Rhode Island Department of Corrections.

    Given the large criminal justice system infrastructure in the US and the mandate to provide healthcare that is commensurate with community standards, the CJS should be leveraged to improve health outcomes. The provision of HIV testing, counselling, and care, as well as the delivery of effective substance dependence treatment and HIV and hepatitis C virus (HCV) prevention interventions are key to this. Prof Beckwith points to the far-reaching value of effective interventions: “Accomplishing these interventions and enhancing the ability to provide seamless linkage to care for individuals upon their release from the correctional setting has the potential to improve the health of inmates, their families, and the communities to which they return, thereby addressing the disparity in health outcomes faced by these populations and having a ripple effect beyond the prison walls.”

    Forgotten populations?
    For various reasons, the criminal justice system and affected populations remain an understudied field in clinical research. Current research projects in the United States are limited to a relatively small number of investigators who have a particular focus on this area. There is clearly a need to increase the number and capacity of investigators working with criminal justice populations, so that this additional disparity can be addressed.

    Prof Beckwith believes the best approach is to increase the number of early-career scientists appropriately trained to conduct substance use and HIV research among incarcerated or community supervised populations. To expand the number of training opportunities and address this gap in training: “We developed The Lifespan/Brown Criminal Justice Research Training Program on Substance Use and HIV (CJRT) to provide a focused mechanism for developing researchers with the skills and education necessary to conduct multidisciplinary research among CJS populations.”

    The training programme was funded in 2014 by the National Institute on Drug Abuse and is led by Prof Beckwith and an experienced team of investigators from Lifespan/Brown University in Providence, Rhode Island. These investigators collectively have several decades of experience conducting research related to substance use, HIV, and associated co-morbidities among CJS populations both locally and across the United States. The programme they have devised is designed to prepare junior investigators, from a wide range of scientific disciplines, for research careers in the field which will be funded by National Institutes of Health  grants.

    Equipping for study
    One unique aspect of the programme is the semi-annual workshops, which create an opportunity to bring together the diverse group of scholars for collaborative learning experiences. These short courses are focused on specific training needs such as those related to professional development and advancement. This might include topics such as grant proposal development and scientific writing. They also create an ongoing collaborative forum for mentorship and networking surrounding research-in-progress, as well as didactic educational seminars supporting specific research skills.

    To maximise their impact, one of these is held in conjunction with the Academic and Health Policy Conference on Correctional Health (), an annual conference which brings together researchers, clinicians, educators and policy makers. This gives the researchers the chance to meet with these and other grant funding leaders, creating opportunities to share evidence, build their networks and learn about emerging research and relevant policy updates in the field of correctional health care. Participants are also encouraged to apply for additional advanced training opportunities such as relevant coursework at their home institution and short courses offered at other institutions in specific content and research methods.

    The CJRT provides a training mechanism for developing researchers focused on HIV, substance use, and other co-morbidities among CJS populations.

    Partners to success
    Critically, each programme participant is matched with a mentor or team of mentors based on their research interests and the location where their research is to be conducted. The aim is to link all programme participants with primary mentors as early in their programme involvement as possible to maximise the benefit of the mentor-mentee relationship. Through this mentoring process, participants can develop projects that are of sufficient scope to produce preliminary findings, vital for subsequent grant applications. It also enables them to disseminate these results through national meetings and peer-reviewed literature, further bolstering their portfolio and improving their chances of securing future funding. Participants can even apply for an internal grant to support these research projects.

    “The CJRT programme benefits from a robust institutional research environment,” says Prof Beckwith: “The academic community offers an outstanding environment for advanced training in research among CJ-involved populations related to HIV, viral hepatitis, sexually transmitted infections, substance use, mental health, and racial disparities in HIV infection.” By training and equipping the next generation of research scientists, Prof Beckwith and his colleagues hope their research will help to reduce the burden of HIV infection in CJS populations worldwide. Their goal is to advance the health and human rights of CJ-populations, particularly among the minority ethnic groups which are disproportionately represented.

    Why is it so important that additional research efforts are directed at criminal justice populations, and what effect do you think this will have on the drive to reduce the incidence of HIV and the current racial disparities in infection rates?

    There is a tremendous opportunity to leverage the criminal justice system to deliver public health interventions to persons who need them most. However, there is a significant discrepancy between the magnitude of this opportunity and the number of public health researchers seeking to capitalise upon it. Through our training programme, we aim to shrink this gap in the scientific workforce. Too often, correctional systems are disconnected from clinical research. Yet, through successful academic-public health-correctional partnerships, health outcomes can be improved. This reduces health disparities and serves to decrease the transmission of communicable diseases such as HIV within the community at-large.

    References

    • Rich JD, Wohl DA, Beckwith CG, Spaulding A, Lepp NE, Baillargeon J, Gardner A, Avery A, Altice FL, Springer S, et al. HIV-related research in correctional populations: Now is the time. Current HIV/AIDS Reports. 2011; 8: 288-296. https://doi.org/10.1007/s11904-011-0095-3
    • Beckwith CG, Zaller ND, Fu JJ, Montague BT, Rich JD. Opportunities to Diagnose, Treat, and Prevent HIV in the Criminal Justice System. JAIDS 2010; 55 (Supplement 1): S49-S55. http://doi.org/10.1097/QAI.0b013e3181f9c0f7
    • Flanigan TP, Zaller N, Beckwith CG, Bazerman LB, Rana A, Gardner A, Wohl DA, Altice FL. Testing for HIV, sexually transmitted infections, and viral hepatitis in jails: Still a missed opportunity for public health and HIV prevention. JAIDS 2010; 55 (Supplement 2): S78-S83. http://doi.org/10.1097/QAI.0b013e3181fbc94f

  • Research Objectives
    Professor Beckwith conducts HIV and HCV research in CJ-involved populations in the US. He has developed a training programme to equip early career scientists with the skills to conduct multidisciplinary research in these populations.

    Funding

    • NIH/NIDA (R25DA037190)
    • Providence-Boston Center for AIDS Research (P30AI042853)

    Collaborators

    • Amy Nunn, ScD, Associate Professor of Behavioral and Social Sciences at the Brown University School of Public Health
    • Bradley Brockmann, JD, Center for Prisoner Health and Human Rights, The Miriam Hospital
    • Timothy P. Flanigan, MD, Professor of Medicine, Division of Infectious Diseases, Alpert Medical School of Brown University & The Miriam Hospital
    • osiah D. Rich, MD, MPH, Professor of Medicine and Epidemiology, Division of Infectious Diseases, Alpert Medical School of Brown University & The Miriam Hospital

    Bio
    Curt Beckwith is an expert on the diagnosis, treatment, and longitudinal care of HIV, HCV, and associated conditions among persons involved with the criminal justice system. He is an infectious diseases clinician, educator, and researcher. His research informs the development and implementation of healthcare programmes for vulnerable and marginalised populations.

    Contact
    Curt G. Beckwith, M.D., Associate Professor of Medicine
    Division of Infectious Diseases
    Alpert Medical School of Brown University

    The Miriam Hospital
    164 Summit Ave
    Providence, RI 02906, USA

    E: CBeckwith@Lifespan.org
    T: +1 401 793 4765
    W:

  • Time to bring HIV research to justice?

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