Design and setting

This study was part of a larger study exploring the feasibility of a formerly incarcerated program for pre-exposure prophylaxis services in North Carolina (NC) [20]. The NC Formerly Incarcerated Transition (FIT) Program is part of a national program called the Transitions Clinic Network [21]. The purpose of the Transitions Clinic Network is to link people formerly in prisons or other closed settings to primary care. The program is delivered by community health workers formerly in prisons or closed settings who have successfully re-entered into their local communities. In addition, the program partners with community health centers and re-entry organizations who provide primary care and social services respectively. People formerly in prisons or other closed settings who participate in the Transitions Clinic Network are more likely to be linked to primary care, less likely to use emergency services and less likely to be re-incarcerated [22].

The recruitment period of the parent study took place between March 1^st, 2019 and December 31^st 2019. During, clients formerly in prisons or other closed settings as well as community stakeholders (e.g. community health workers, community health center clinicians, re-entry personnel) who were part of the NC FIT program were interviewed. All participants provided informed written and verbal consent. Participants interviewed over the telephone were sent a written consent document via email prior to questioning. Interviewers read the approved IRB verbal consent form verbatim to participants at the start of the interview. Consent was NOT waived. In this study, we limit our analysis to the Formerly Incarcerated Transition program clients or FIT clients.

Inclusion and exclusion criteria

As set by the parent study, FIT client participants had to be greater than 18 years of age and able to understand and speak English. Participants also had to be in the program post-release (jail and/or prison) for at least 6 months. They had to be able to provide verbal and written consent. Participants were excluded who were unable to provide consent including those with severe mental illness requiring immediate treatment or with mental illness limiting their ability to participate. Recruitment and interviews occurred from March 2019 through July 2019. Participants were recruited through community health clinic flyers, community health workers and community health clinician personnel. All FIT client study participants were offered a $25 gift card as an incentive for participation.

This study was approved by the Office of Human Research Ethics Non-Biomedical Institutional Review Board at the University of North Carolina at Chapel Hill and the North Carolina Department of Adult Correction’s Human subjects review committee, and the Department of Health and Human Services’ Office for Human Research Protections (OHRP).

Qualitative data analysis

A qualitative descriptive study was conducted. This pragmatic approach was chosen “because a straightforward description of a phenomenon [was] desired” [22]. In addition, we chose the qualitative descriptive design because our purpose was to inform intervention development.

We used Bowen’s feasibility framework to develop our semi-structured interview guide. Bowen’s feasibility framework asserts that there are eight general areas of potential feasibility (e.g., acceptability, adaptation) depending on the study objectives. In our interview guide, we included four of Bowen’s domains (acceptability, demand, integration, and expansion) [23]. In addition, we added PrEP implementation domains (PrEP knowledge, PrEP barriers, and PrEP facilitators) to our interview guide.

All interviews were recorded and transcribed word for word by a professional transcription service. Initially, all of the authors read all of the transcripts. Then, we re-read the transcripts to identify potential themes and codes. We then reviewed these initial codes. From these codes, we produced key subthemes. We used thematic analysis to identify broad emergent themes (Table 1). Next, we identified quotes that were illustrative of the overarching themes. Finally, we reviewed the themes again before we defined and named them. The finale themes were categorized into PrEP information during incarceration, risky behaviors during incarceration, and PrEP initiation prior to release.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Summary of thematic claims.

https://doi.org/10.1371/journal.pone.0311289.t001

PrEP information during incarceration

Clients formerly in prisons or other closed settings believed that they should be educated about PrEP and given PrEP related materials during incarceration. They also believed that exposure to PrEP during incarceration was essential. A 60-year-old male expressed, “I don’t know about the next person, but I know first you need exposure to the idea. You need the information to get to you otherwise you’re gonna continue to move off that side of your brain that always gives you routine. I would say, you know, there’s no real barrier if it’s readily available, but, you know, if you’re not–you don’t have no knowledge of it then you–that’s the last thing on your mind.”

Interviewed FIT clients also recommended regularly scheduled informational seminars on PrEP by community members. This was suggested from a 45-year-old male, “maybe having a representative go maybe to the prisons and jails and maybe speak with the caseworkers about setting up like a small seminar every so often to people that are within 60 days of getting out or something like that…a seminar would be like perfect.” Another 34-year-old male participant shared that people in prisons or other closed settings would be less likely to adhere to PrEP upon release if they were not made aware during incarceration. He stated, “a lot of people are not just going to get out and be like, let me go learn about this pill, just because I’m out of jail.”

Risky behaviors during incarceration

FIT client participants stated that high risk behaviors occur during incarceration often in unsanitary conditions. A 36-year-old female participant explains, “you never know. They do dirty things in jail and [laughs] they could get it in there too.” Additionally, the unsanitary behaviors and environment of correctional facilities is a concern for individuals. “I don’t know. I mean, honestly, it probably would be a good thing to have when you’re–to take when you’re in jail just because of all–it’s very–it’s not clean and if you have a cut or how many people are raped in jail all the time, you just never know when it could be transferred to you.

During incarceration, some individuals might engage in high-risk HIV transmission activities more than they would in the community. A 46-year-old female participant says, "you might find yourself in a certain situation where you wouldn’t normally find yourself in and might make decisions that you wouldn’t normally make and, you know, so you might—the medication might come in handy ’cause—you know? And also, you know, a lot of times there’s—take place and bad things happen to good people or whatever. You know what I mean”?

PrEP initiation prior to release

FIT clients believed that initiating PrEP during incarceration would allow people in prisons or other closed settings time to routinize PrEP medication taking behavior. A 57-year-old male participant explained that “…if you’ve already started the regimen…it’ll make the transition from there to out here a lot more easier to continue… ’Cause once you get out you gonna hit the floor running…things that you may have planned to do you don’t execute. So, if you start them on a regimen prior it could be like second nature to do.” Further, a 40-year-old male elucidated, “I think that transitioning and stuff like that should be done before people come out of prison, and the sad thing is a lot of people don’t understand that–a lot of organizations, the government, society doesn’t understand that people need–especially after doing a long time, they need to have that transition before.” While in correctional facilities, participants explain they would have already initiated PrEP. They would learn to implement a novel medication regimen and adjust to the new routine. A 46-year-old female FIT client participant details with a simile, "…you could already have [PrEP] instilled into your daily function… it would be like brushing your teeth. It’s just something you always do every single day…or eating breakfast. Drinking coffee. You know, something that’s just already there.” The same participant furthers with, “I think [PrEP implementation in correctional facilities] probably would be a good idea just to get in the practice of taking it and having it because that way, it’ll already be sealed…it’ll already be a function and a daily routine.” However, some participants had concerns of potential side effects of the new PrEP medication. They suggest starting PrEP while in a controlled and monitored environment would assuage fears and promote adherence upon release. FIT client, a 32-year-old female advised, “I would [implement PrEP] before the release because then, honestly, when [incarcerated individuals] get out, they’re probably gonna be taking other kinds of drugs so if they do have a side effect, you don’t know if it’s from that or if it’s from a different drug. And so, I think it would benefit to do it while they’re in jail so that if there is any type of side effect, you know that that’s what it’s from.” A 36-year-old male participant also suggested, “…going in and getting it in their system so that their body doesn’t have any kind of reactions to it. Get them comfortable taking something every day so that they won’t forget to take it when they get out.”