HIV disproportionately affects populations experiencing incarceration. Preexposure prophylaxis (PrEP) is an effective approach to preventing HIV acquisition among populations at increased risk of acquiring HIV. Yet few, if any, efforts have been made to offer PrEP in correctional settings. Beginning in November 2019, the Rhode Island Department of Corrections (RIDOC) implemented a systemwide PrEP initiation program with linkage to PrEP care in the community upon reentry. Incarcerated individuals identified as being potentially at increased risk of HIV acquisition during standard clinical screenings and medical care were referred to a PrEP care provider for potential PrEP initiation. Of the 309 people who met with a PrEP care provider, 35% (n = 109; 88 men, 21 women) agreed to initiate PrEP while incarcerated. Clinical testing and evaluation were completed for 82% (n = 89; 69 men, 20 women) of those who agreed to initiate PrEP. Of those, 54% (n = 48; 29 men, 19 women) completed the necessary clinical evaluation to initiate PrEP, were determined to be appropriate candidates for PrEP use, and had the medication delivered to a RIDOC facility for initiation. Only 8 people (4 men, 4 women) were successfully linked to a PrEP care provider in the community after release. The RIDOC experience demonstrates notable levels of PrEP interest and moderate levels of PrEP uptake among this population. However, PrEP engagement in care after release and persistence in taking PrEP when in the community were relatively poor, indicating a need to better understand approaches to overcoming barriers to PrEP care in this unique setting.

Incarceration harms health. Individuals released from carceral facilities have high rates of suicide, overdose, psychiatric hospitalization, and death. Yet, some of the most often cited literature on post-release mortality precedes the COVID-19 pandemic and the introduction of fentanyl in the illicit drug supply, both adding significant risk to the well-being of incarcerated individuals. Incarceration takes many different forms. Jails, typically operated by local municipalities, are short-term facilities with rapid turn over and short stays. In contrast, prisons are usually state-run, housing individuals with multiyear sentences. The variability of jails and prisons makes comparing health outcomes challenging; a state-run prison in Washington is very different than a jail in New York City. Even within one state, aggregated data are often unavailable as county- and state-run facilities do not share or make available their data.

Background: Incarceration is associated with negative impacts on mental health. Probation, a form of community supervision, has been lauded as an alternative. However, the effect of probation versus incarceration on mental health is unclear. Our objective was to estimate the impact on mental health of reducing sentencing severity at individuals' first adult criminal-legal encounter. Methods: We used the US National Longitudinal Survey on Youth 1997, a nationally representative dataset of youth followed into their mid-thirties. Restricting to those with an adult encounter (arrest, charge alone or no sentence, probation, incarceration), we used parametric g-computation to estimate the difference in mental health at age 30 (Mental Health Inventory-5) if (1) everyone who received incarceration for their first encounter had received probation and (2) everyone who received probation had received no sentence. Results: Among 1835 individuals with adult encounters, 19% were non-Hispanic Black and 65% were non-Hispanic White. Median age at first encounter was 20. Under hypothetical interventions to reduce sentencing, we did not see better mental health overall (Intervention 1, incarceration to probation: RD = -0.01; CI = -0.02, 0.01; Intervention 2, probation to no sentence: RD = 0.00; CI = -0.01, 0.01) or when stratified by race. Conclusion: Among those with criminal-legal encounters, hypothetical interventions to reduce sentencing, including incremental sentencing reductions, were not associated with improved mental health. Future work should consider the effects of preventing individuals' first criminal-legal encounter.

This Viewpoint explains the Medicaid Reentry Section 1115 Demonstration Opportunity of April 2023 and recommends strategies to optimize this opportunity for community connection and mental health care.

Since 2014, Medicaid expansion has been implemented in many states across the US, increasing health care access among vulnerable populations, including formerly incarcerated people who experience higher mortality rates than the general population. To examine population-level association of Medicaid expansion with post-release mortality from all causes, unintentional drug overdoses, opioid overdoses, poly-drug overdoses, suicides, and homicides among formerly incarcerated people in Rhode Island (RI), which expanded Medicaid, compared with North Carolina (NC), which did not expand Medicaid during the study period.