Survival Analysis from 1998-2010 of a Closed Prisoner Cohort Incarcerated in the Georgia Department of Corrections Open Access

Abstract

Background: The high prevalence of HIV among the population flowing in and out of correctional facilities each year has made state prisons a target for HIV interventions. The effect of comorbid mental illness in these populations is of concern, as any barriers to HIV treatment adherence and compliance can have severe health consequences in this vulnerable population.

Objective: This study aims to evaluate the interaction of HIV infection with severe mental illness and its effect on mortality in a cohort of prisoners once incarcerated in the Georgia Department of Corrections.

Methods: Survival analysis was performed using a Cox proportional hazards model to evaluate the interactive effects of HIV and severe mental health issues on a cohort of prisoners from 1998-2010. Time dependent interaction terms were introduced to maintain the proportionality assumption, causing hazard ratios to be time sensitive. Sensitivity analysis was performed to assess the stability of a final model when undiagnosed deaths attributed to HIV caused reclassification of diagnosed persons as HIV infected.

Results: A total of 22,351 inmates were followed. 792 (3.5%) were HIV positive; of these, 124 (15.7%) had a recorded psychiatric problem. HIV positive status was associated with a marked increase in mortality (β=2.12, 95% CI: 1.88, 2.37), but over time this effect became less pronounced. Mild mental illness was associated with reduced hazard (β =-0.95, 95% CI: -1.52, -0.388), though over time this effect was diminished. The interaction between HIV and mental illness was significantly protective for more severe mental illness (β=-0.82, 95% CI: -1.58,-0.07).

Discussion: The protective effects of mental health illness on mortality may be due to the benefits of more intensive case management found within prison settings for those who require mental health services. The extension of these benefits to all of the HIV infected subpopulation is warranted.

Table of Contents

TABLE OF CONTENTS

LIST OF TABLES i

LIST OF FIGURES ii

INTRODUCTION 1

BACKGROUND 2

METHODS 10

RESULTS 17

DISCUSSION 24

REFERENCES 30

TABLES 35

FIGURES 42

APPENDIX A: Calculation of Admissions and Releases 49

APPENDIX B: SAS Code and Output 50

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Epidemiology
Keyword	HIV Prison SMI Severe Mental Illness
Committee Chair / Thesis Advisor	Spaulding, Anne C, Emory University
Partnering Agencies	Georgia state or local agency (not a health department)

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