Prisons concentrate a high number of people living with human immunodeficiency virus (HIV) in southern Africa. Post-release disruptions in care often lead to adverse clinical outcomes. HIV prevalence among incarcerated individuals is several-fold higher (14.3 to 27.4%) than in the general adult population (9.4%) in Zambia. Evidence shows that HIV treatment is effective during incarceration, but such benefits frequently diminish after release because of health system, psychological, and structural barriers. Substance use disorders, specifically unhealthy alcohol use (UAU), are highly prevalent among incarcerated individuals and are known to compromise antiretroviral therapy (ART) adherence and increase HIV disease progression. No earlier African study has examined the impact of UAU on HIV viral suppression after prison release.
This study aimed to evaluate post-release HIV clinical outcomes and the link between UAU and loss of viral suppression among Zambian reentrants living with HIV. The study hypothesized that post-release UAU would significantly increase the risk of losing viral suppression among individuals who were virally suppressed before release.
Researchers conducted a prospective cohort study from March 2017 to December 2018 at five correctional centers in Lusaka and the Central Provinces of Zambia. Eligible participants were adults living with HIV, enrolled in national ART programs, and scheduled for release within 30 days. Participants completed a baseline pre-release assessment and a follow-up assessment about 6 months post-release. Viral load testing was performed at both time points, and participants were screened for substance use using validated tools: Alcohol Use Disorders Identification Test (AUDIT) for post-release alcohol use, the AUDIT-C for pre-incarceration drinking, and the Drug Use Disorders Identification Test (DUDIT) for drug use. The primary outcome was post-release HIV viral suppression (viral load <1000 copies/mL), and the primary exposure was post-release UAU (AUDIT score ≥8). Statistical analyses involved Poisson regression to estimate unadjusted and adjusted risk ratios, with covariates selected using a directed acyclic graph (DAG). Sensitivity analyses used inverse probability weighting and a stricter viral suppression threshold (<60 copies/mL).
Of 396 eligible individuals, 296 were enrolled (74.7%), of whom 237 (80.3%) were men, and the median age was 34 years. At baseline, 80.3% (n=237) were virally suppressed, and the median CD4+ count was 378 cells/mL. Participants had been incarcerated for a median of 7.4 months and had received ART for a median of 14.2 months. Before incarceration, 19.7% (n=58) reported unhealthy alcohol use, and only 6.1% (n=18) reported drug use. No participants reported alcohol use during incarceration. Post-release outcomes were available for all participants by national electronic medical records: 86.1% (n=254) were alive and retained in care, 12.5% (n=37) were lost to follow-up, and 1.4% (n=4) had died.
Viral suppression reduced from 80.3% pre-release to 71.5% (n=211) post-release. Of the 251 participants who completed the study follow-up, 7.2% (n=18) reported UAU, and 7.2% (n=18) reported unhealthy drug use (UDU), with 12% (n=30) reporting either UAU or UDU, and 2.4% reporting both.
Unsuppressed viral load was strongly linked with UAU (prevalence ratio [PR]: 3.35, 95% confidence interval [CI]: 1.82 to 6.15, P < 0.001) and UDU (PR: 2.82, 95% CI: 1.39 to 5.71, P: 0.004) at follow-up in exploratory analyses. Unsuppressed viral load was linked to younger age (25 to 29 vs 35 to 39 years, PR: 4.20, 95% CI: 1.48 to 11.91, P: 0.007), shorter ART duration (6 to 24 months vs >24 months, PR: 2.40, P: 0.02) and prerelease viremia (PR: 3.11, 95% CI: 1.78 to 5.43, P < 0.001).
The primary adjusted analysis focused on 205 participants who were virally suppressed before release and completed post-release assessments. These participants had longer ART exposure. In adjusted models, UAU was significantly associated with loss of viral suppression (adjusted risk ratio [RR]: 4.07, 95% CI: 1.97 to 8.42, P < 0.001), and UDU showed a similar association (adjusted RR: 3.84, 95% CI: 1.43 to 10.30, P: 0.008). These findings remained significant in sensitivity analysis using inverse probability weighting and a stricter viral suppression threshold (<60 copies/mL). This confirmed the robustness of the link between substance use and HIV treatment disruption.
This study shows that Zambian reentrants living with HIV face a substantial risk of losing viral suppression after release from prison, and both unhealthy alcohol and drug use significantly increase this risk. These findings highlight the urgent need for integrated transitional HIV care models that address substance use as a critical barrier to treatment continuity.
References: Herce ME, Smith HJ, Mai V, et al. Alcohol Use and HIV Suppression After Release from Prison Among People with HIV in Zambia. JAMA Netw Open. 2025;8(12):e2547295. doi:10.1001/jamanetworkopen.2025.47295
