Barriers to ART Adherence Post-Incarceration

In this podcast, Tawandra Rowell-Cunsolo, PhD, discusses her recent study, which identified 4 barriers to optimal antiretroviral therapy adherence among individuals with HIV who were formerly incarcerated, as well as potential interventions to improve adherence.


  • Rowell-Cunsolo T, Hu G. Barriers to optimal antiretroviral therapy adherence among HIV-infected formerly incarcerated individuals in New York City. PLoS One. Published online: June 1, 2020. doi:10.1371/journal.pone.0233842

Tawandra Rowell-Cunsolo, PhD, is an assistant professor of Social Welfare Science (in Nursing) at the Columbia University School of Nursing in New York, and an incoming assistant professor at the University of Wisconsin Madison School of Social Work.



Christina Vogt: Hello everyone, and welcome back to another podcast. I’m Christina Vogt, associate editor of the Consultant360 Specialty Network. Today, I’m joined by Dr Tawandra Rowell-Cunsolo, who is an Assistant Professor of Social Welfare Science (in Nursing) at the Columbia University School of Nursing in New York, and an incoming assistant professor at the University of Wisconsin Madison School of Social Work. Thank you for joining me today.

Dr Rowell-Cunsolo: Thank you for having me.

Christina Vogt: Today, we will be discussing her recent study, “Barriers to optimal antiretroviral therapy adherence among HIV-infected formerly incarcerated individuals in New York City,” which was published in PLoS One. So first, you and your colleague noted in your study that individuals with HIV who were formerly incarcerated often have difficulty adhering to ART post-incarceration. Could you elaborate on this, as well as the 4 barriers to optimal ART adherence revealed in your study?

Dr Rowell-Cunsolo: Sure. So, we were interested in discussing any challenges to transitioning into the community for HIV-infected, formerly incarcerated individuals. So, these were people who were getting out of prisons and jails in the area who had HIV, and we know sometimes with HIV, it can be a pretty complicated regimen, and it's a lifelong resident at the time–at the moment–so, there is no cure for HIV. So, these are people who have to take this medication regimen to stay healthy for a long period of time. So, we know that it's a high-risk population. We know that they struggle a lot once they come home because, for some of them, they've learned of their diagnosis while they were incarcerated for the first time. They're learning how to manage this very complicated regimen, and a very strict one at that. You have to be at least 90% adherent to see some of the benefits.

So, when we began to discuss this with them, like “what are some of the challenges that they experienced? What are some of the barriers to maintain sort of this optimal adherence that they do pretty well at sustaining when they're incarcerated?” We were able to uncover 4 areas that they mentioned. The first one was just medication burden. Part of it is, for HIV, their antiretroviral therapy can mean taking a single tablet, or it can mean up to 3 or 4 medications. And so, a lot of them struggled with the pure number of medications that they had to take on a very regular basis–sometimes 3 times a day, sometimes it could be with food, sometimes without, so that was really a struggle for them.

Also, forgetfulness. A lot of them just mentioned, and people with other chronic conditions also have this struggle as well, but they had a busy schedule, partly due to some of their community supervision mandates. So, some of them were enrolled in substance use treatment programs, some of them had to check in with a parole or probation officer on a very regular basis, some of them have very strict guidelines for their housing environment. So, sometimes their medication regimen sort of fell to the bottom of the list, and they would just forget to take their medication very regularly.

Also, a lot of them had mental health and emotional difficulties. Sometimes, they were diagnosed with a psychological condition. Sometimes, it was just based on their emotions, a range of emotions that they were experiencing based on their current status as formerly incarcerated, as HIV-infected, sometimes as a substance user as well. So, they were sort of coming to terms with what that meant for them as they were transitioning into the community. So, sometimes their mental health was based on their medication, you know, their condition. Just seeing the pure number of pills that they had to take, but also kind of reckoning with their condition and what that means for like their life long-term. Also, sometimes, there was conflict or at least perceived conflict between substance use and medication adherence. Some of the participants got conflicting advice from medical providers. Sometimes, they were told, if you're going to use drugs, you know, you shouldn't be taking your medication. Sometimes, it was the opposite: even if you're using drugs, make sure that you try to make your medication a priority. But for many of them, they were choosing to prioritize substance use. So, if they were using drugs and they were high and things like that, again, they wouldn't take their medication. It's like that wasn't a priority for them at the time.

So those are kind of the 4 areas that we uncovered during the research. Those are the things that they mentioned they really struggled with post-incarceration.

Christina Vogt: How can health care practitioners best support patients with HIV who were formerly incarcerated when it comes to care engagement and ART adherence, especially in reference to interventions mentioned in your study, such as mobile-based text messaging reminders and programs that integrate substance use and mental health treatment into HIV-related care?

Dr Rowell-Cunsolo: I think, for providers, and I'm sure several of them are already doing this, but just the recognition that this is a population that may need more closer monitoring. And, it's not like their HIV infection can be treated in isolation. They have a range of comorbidities, and they're also dealing with substance use and other things because they're transitioning into the community. So, some of the basic necessities, you know, housing, food and things like that–sometimes these are all things that they have trouble obtaining. So, just remembering that when they're being treated, that there are a range of things that they are experiencing at the moment that may have an impact on their health as well.

And, for using interventions and things like that, what I noticed about this population was that mobile phone adoption was pretty high, even though some of them are still learning how to use their mobile phone. Some of them had been incarcerated for a very long time, so they were learning how to use technology. But, I know that a lot of providers use text messaging technology for appointment reminders and things like that, so that's a tool that could sort of be expanded to promote medication adherence, in my opinion.

Christina Vogt: What is the next step in terms of future research in this area?

Dr Rowell-Cunsolo: For future research, I really want to look at designing and testing interventions, medication adherence interventions, for this population. I think that we need to sort of review a range of modalities to do that. I think some of them should be technology-based because it's just sort of moving with the times. And again, this is a population that–all of them had cell phones, and even though they were learning how to use them, it’s not–it doesn't mean that we would have to use very sophisticated technology. These reminder systems and tools like that are things that could work.

Also, kind of looking at interventions that help develop collaboration between different providers so that text messaging can be used collaboratively. So, if you have someone who's there like as a primary care physician, but someone else may be a psychiatrist, if they could somehow form a collaboration where they could use this system to kind of give just general medication guidelines and general health guidelines as well to this population, I think that may be beneficial.

Christina Vogt: And lastly, what key takeaways do you hope to leave with infectious disease specialists and related health care practitioners on this topic?

Dr Rowell-Cunsolo: I think that, for HIV infected, formerly incarcerated individuals, there’s still very limited research, and more information is needed to design interventions for this population. We really want to be able to use the most targeted and effective tools to promote medication adherence. I think, for this study, it was just a reminder that HIV-infected, formerly incarcerated individuals have a range of unique needs, and that their status cannot be treated in isolation. So, I just think that this is a reminder that they have a range of needs that should be considered when we're trying to promote health and wellness among this population.

Christina Vogt: Thanks again for joining me today, Dr Rowell-Cunsolo.

Dr Rowell-Cunsolo: Thank you for having me.

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