Street-level bureaucracy and relational autonomy in HIV status-neutral care implementation: A study of jail staff and incarcerated individuals.

In the U.S., nearly 8 million people are incarcerated in jail each year, a majority of whom are structurally vulnerable and at elevated risk for poor health, including HIV. Jails have been identified as strategic settings for health interventions, offering opportunities to deliver "status neutral" HIV services (testing, prevention, and linkage to care) to people who may otherwise have intermittent access to care. To understand barriers and facilitators to integrating HIV care into routine jail health services, we conducted semi-structured, in-person interviews with 15 incarcerated individuals and 13 jail staff at two county jails. While interview guides focused on HIV care, participants largely reflected on the provision of healthcare in jail more generally. Both groups converged on their understanding of institutional constraints (e.g., resource and capacity limitations; an absence of protocols), with staff additionally highlighting organizational silos and threats to their clinical autonomy as obstacles to adopting status-neutral HIV care. However, staff and incarcerated individuals diverged on care experiences. Staff described respect for patient autonomy, whereas incarcerated individuals described feeling unheard, invalidated, or subject to care delays. Participants' reactions to these limitations varied and are interpreted using concepts of street-level bureaucracy and relational autonomy, which highlight how frontline decision-making and interpersonal dynamics interact in carceral settings to restrict clinical staff autonomy, and in turn, medical autonomy of incarcerated individuals. Our findings show that the provision of routine healthcare and integration of status-neutral HIV care requires addressing institutional constraints and relational dynamics that shape perceived autonomy and trust in carceral settings.