Barriers and facilitators to implementing status-neutral HIV care in an urban jail system

People who use drugs face barriers to accessing HIV prevention tools. The status-neutral model for HIV care starts with the HIV test and offers linkage to HIV treatment if the person tests positive and linkage to pre-exposure prophylaxis (PrEP) if the person tests negative. The goal of this study was to evaluate barriers and facilitators impacting the implementation of a status-neutral HIV model of care in the jail setting. Between June and August 2024, we recruited people working in and incarcerated in the jails operated by the Suffolk County Sheriff’s Department (Jail and House of Correction) for in-depth interviews. The Consolidated Framework for Implementation Research (CFIR) 2.0 guided interview development. Interviews were recorded, transcribed, coded, and analyzed using rapid thematic analysis (RTA) methods. Relevant themes were mapped onto CFIR domains. We conducted 28 interviews: 13 with correctional and clinical staff and 15 with incarcerated people. Clinical and administrative staff members indicated that strong relationships with state and local agencies and the state’s proactive approach to preventative carceral healthcare helped facilitate HIV treatment and prevention pathways. Incarcerated individuals identified issues in the system used to report health needs and unreliable test result delivery mechanisms as major barriers. Staff also identified barriers, including understaffing, but overwhelmingly endorsed the jails’ existing systems of accessing and delivering care. Findings identified multiple potential intervention targets to enhance a status-neutral approach to HIV testing and treatment in jail settings, including leveraging existing partnerships, and educational opportunities for staff. Strategies that reinforce a patient-centered institutional culture (with a focus on incarcerated individuals’ health), improve care continuity for transitions into and out of jail, and highlight gaps in healthcare delivery are critical for successful implementation of status-neutral HIV care in jails.