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J Acquir Immune Defic Syndr. 2020 Feb 10. doi: 10.1097/QAI.0000000000002325. [Epub ahead of print]

Frequency and duration of incarceration and mortality among US Veterans with and without HIV.

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Cambridge Health Alliance, Harvard Medical School, Boston, MA, United States.
Veterans Affairs CT Healthcare System, West Haven, CT, United States.
National Clinician Scholars Program, New Haven, CT, United States.
Yale School of Medicine, New Haven, CT, United States.
Population Health, New York University School of Medicine, New York, NY, United States.



Exposure to incarceration is associated with increased risk of mortality, and HIV is cited as a leading cause of death. Yet, few studies have examined the association between incarceration and mortality among people with HIV (PWH), specifically whether and how increasing exposure to incarceration increases risk of mortality. We compared mortality by different incarceration exposures and HIV status.


We conducted a prospective cohort study of participants in the Veterans Aging Cohort Study (VACS) from January 2011 to August 2017 (N=5,367). The primary exposure was incarceration by three measures: 1) any (ever/never); 2) frequency; and 3) cumulative duration. Stratifying by HIV status and controlling for age, race, and gender, we used Cox Proportional Hazard models to estimate adjusted hazard ratios (AHRs) and 95% confidence intervals (CIs).


Incarceration was associated with increased risk of mortality compared with those never incarcerated for PWH (AHR 1.37; 95% CI, 1.13-1.66) and those uninfected (AHR 1.24; 95% CI, 0.99-1.54), but the association was only statistically significant among PWH. Increasing frequency of incarceration was associated with higher risk of mortality in both groups: for PWH, AHRs 1.13, 1.45, and 1.64 for 1, 2-5; 6+ times, respectively; for uninfected, AHRs 0.98, 1.35, and 1.70 for 1, 2-5, and 6+ times, respectively.


PWH were at increased risk for mortality following incarceration and repeated exposure to incarceration was associated with mortality in both groups in a dose-response fashion. This increased risk for mortality may be mitigated by improving transitional healthcare, especially HIV care, and reducing incarceration.

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