HIV Pre-Exposure Prophylaxis (PrEP) Among People Involved in the Criminal Justice Systems in the United States: A Systematic Review

Background and Purpose
People involved in the criminal justice system (PICJ) face disproportionately high rates of HIV risk, stemming from various factors such as injection drug use, sexual risk behaviors, and limited access to healthcare services. HIV pre-exposure prophylaxis (PrEP) has emerged as a crucial biomedical intervention to mitigate HIV transmission among at-risk populations. Despite its potential benefits, the utilization of PrEP among PICJ remains suboptimal, highlighting the need for a comprehensive understanding of the barriers and facilitators to its uptake within this vulnerable demographic. The aim of this systematic review is to elucidate the factors influencing the utilization of PrEP among individuals involved in the criminal justice system, thereby informing targeted interventions to improve PrEP uptake and reduce HIV incidence in this population.

Methods
A comprehensive search strategy was employed across six electronic databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, including PubMed, PsycINFO, and Web of Science, to identify relevant studies published up to Jan 2024. Additionally, manual searches of reference lists from eligible studies were conducted to ensure inclusivity. Titles and abstracts of retrieved articles were screened for relevance, and full-text articles were assessed against predetermined eligibility criteria. Data extraction and synthesis were conducted using thematic analysis to identify common themes and patterns related to PrEP utilization among PICJ.

Results
From an initial pool of 712 records, a total of 20 articles met the eligibility criteria and were included in the final synthesis. The majority of included studies (60%) utilized qualitative methodologies to explore the experiences and perceptions of PICJ regarding PrEP. Geographically, the studies were predominantly conducted in the Northeast (n=12) and South (n=5) regions of the United States, with a notable absence of research in the Midwest. Subgroup analyses revealed variations in the focus of studies, with seven articles specifically examining PrEP utilization among women, five focusing on sexual minority men, and two exploring the experiences of Black/African American individuals within the criminal justice system. The general awareness of PrEP was high, but the willingness and uptake of PrEP remain low. Themes identified as key barriers to utilizing PrEP included competing priorities that could impede attendance at PrEP appointments, lack of stable housing and transportation, perceived stigma and partner/family disapproval, medical mistrust, and fears of future re-incarceration. Facilitators included optimized prescription procedures and the help of a patient navigator upon reentry.

Conclusions and Implications
The findings of this systematic review underscore the urgent need for tailored interventions to address the multifaceted barriers hindering PrEP uptake among PICJ. Such interventions should not only focus on individual-level factors but also address broader structural determinants of health, including housing insecurity and stigma reduction efforts. Furthermore, collaboration between criminal justice agencies, healthcare providers, and community-based organizations is essential to ensure comprehensive and equitable access to PrEP services for individuals involved in the criminal justice system. By addressing these barriers and leveraging facilitators identified in this review, policymakers and healthcare practitioners can enhance the effectiveness of PrEP delivery and ultimately reduce HIV incidence among PICJ.