Structures of survival: Syndemic pathways to care among people with HIV involved with the criminal legal system

BACKGROUND: Criminal legal system (CLS) involvement intersects syndemically with HIV, mental illness, substance use, and exposure to violence. Mass incarceration remains both a cause and consequence of racialized health inequities in the U.S. The post-release period is particularly vulnerable for people living with HIV (PLWH) who experience CLS involvement, underscoring the need for care models attuned to their structural and psychosocial contexts. This study examines how syndemic pathways and cumulative life experiences shape HIV care trajectories among people with HIV involved with the CLS. METHODS: Guided by a life-course and syndemic framework, we conducted 21 adapted Life History Calendar (A-LHC) interviews in Miami, Florida, an epicenter of both incarceration and HIV. Participants co-constructed visual timelines and in-depth narratives were analyzed using rapid qualitative analysis to identify trajectories, transitions, and turning points in HIV care. RESULTS: Findings reveal that early trauma, housing instability, substance use, and incarceration cluster and accumulate across the life course, contributing to disrupted HIV care. Participants navigated care within contexts of poverty, institutional mistrust, and unstable housing, yet many demonstrated resilience through faith, recovery, and social support. CLS involvement simultaneously disrupted and occasionally facilitated re-engagement in care. CONCLUSION: This study highlights developmental and structural pathways that shape HIV care continuity among people with HIV involved with the CLS. The A-LHC method offers a feasible tool for capturing temporal and syndemic complexity, informing trauma-informed, life-course-based, and system-integrated approaches to care.