Examination of an interventionist-led HIV intervention among criminal justice-involved female prisoners

Leveraging the U.S. Criminal Justice System to Access Women for HIV Interventions

The criminal justice (CJ) system can be leveraged to access women for HIV prevention and treatment programs. Research is lacking on effective implementation strategies tailored to the specific needs of CJ-involved women. We conducted a scoping review of published studies in English from the United States that described HIV interventions, involved women or girls, and used the CJ system as an access point for sampling or intervention delivery. We identified 350 studies and synthesized data from 42 unique interventions, based in closed (n = 26), community (n = 7), or multiple/other CJ settings (n = 9). A minority of reviewed programs incorporated women-specific content or conducted gender-stratified analyses. CJ systems are comprised of diverse access points, each with unique strengths and challenges for implementing HIV treatment and prevention programs for women. Further study is warranted to develop women-specific and trauma-informed content and evaluate program effectiveness.

Physical and Mental Health Disparities for Young Women with Arrest Histories

Young women ages 18 to 25 make up approximately 30 percent of women arrested in the United States. Although health disparities have been found for incarcerated adults, health concerns for this subpopulation of women have not been as closely examined. Aiming to fill this gap in the literature, this study examined national data for young women ages 18 to 25 who participated in the National Survey of Drug Use and Health. Physical and mental health concerns were compared for young women with and without arrest histories. Young women with arrest histories had significantly higher odds ratios of multiple physical health concerns and all forms of mental health concerns, including recent suicide attempts. This study indicates that history of arrest is significantly associated with health disparities for young women and thus expands and builds gender-specific knowledge for the field of criminal justice epidemiology. Given the intersecting needs of physical health, mental health, and criminal justice involvement, the fields of public health and social work may contribute to gender-responsive interventions that incorporate health promotion specifically for this population of women.

Sex-Related Disparities in Criminal Justice and HIV Treatment Outcomes: A Retrospective Cohort Study of HIV-Infected Inmates

OBJECTIVES

We evaluated sex-related differences in HIV and criminal justice (CJ) outcomes.

METHODS

We quantified sex-related differences in criminal offenses, incarcerations, and HIV outcomes among all HIV-infected inmates on antiretroviral therapy (ART) in Connecticut (2005-2012). Computed criminogenic risk scores estimated future CJ involvement. Stacked logistic regression models with random effects identified significant correlates of HIV viral suppression on CJ entry, reflecting preceding community-based treatment.

RESULTS

Compared with 866 HIV-infected men on ART (1619 incarcerations), 223 women (461 incarcerations) were more likely to be younger, White, and medically insured, with shorter incarceration periods (mean = 196.8 vs 368.1 days), mostly for public disorder offenses. One third of both women and men had viral suppression on CJ entry, correlating positively with older age and having treated comorbidities. Entry viral suppression inversely correlated with incarceration duration for women and with criminogenic risk score for men.

CONCLUSIONS

In the largest contemporary cohort of HIV-infected inmates on ART, women's higher prevalence of nonviolent offenses and treatable comorbidities supports alternatives to incarceration strategies. Sex-specific interventions for CJ populations with HIV effectively align public health and safety goals.

Context of risk for HIV and sexually transmitted infections among incarcerated women in the south: individual, interpersonal, and societal factors

Incarcerated women are disproportionately affected by HIV and sexually transmitted infections (STIs) due to risk factors before, during, and after imprisonment. This study assessed the behavioral, social, and contextual conditions that contribute to continuing sexual risk behaviors among incarcerated women to inform the adaptation of an evidenced-based behavioral intervention for this population. Individual, in-depth interviews were conducted with 25 current and 28 former women prisoners to assess HIV/STI knowledge, perceptions of risk, intimate relationships, and life circumstances. Interviews were independently coded using an iterative process and analyzed using established qualitative analytic methods. Major themes identified in the interviews involved three focal points: individual risk (substance abuse, emotional need, self-worth, perceptions of risk, and safer sex practices); interpersonal risk (partner pressure, betrayal, and violence); and risk environment (economic self-sufficiency and preparation for reentry). These findings highlight the critical components of HIV/STI prevention interventions for incarcerated women.

HIV prevention for adults with criminal justice involvement: a systematic review of HIV risk-reduction interventions in incarceration and community settings

We summarized and appraised evidence regarding HIV prevention interventions for adults with criminal justice involvement. We included randomized and quasi-randomized controlled trials that evaluated an HIV prevention intervention, enrolled participants with histories of criminal justice involvement, and reported biological or behavioral outcomes. We used Cochrane methods to screen 32,271 citations from 16 databases and gray literature. We included 37 trials enrolling n = 12,629 participants. Interventions were 27 psychosocial, 7 opioid substitution therapy, and 3 HIV-testing programs. Eleven programs significantly reduced sexual risk taking, 4 reduced injection drug risks, and 4 increased testing. Numerous interventions may reduce HIV-related risks among adults with criminal justice involvement. Future research should consider process evaluations, programs involving partners or families, and interventions integrating biomedical, psychosocial, and structural approaches.

Reducing risky relationships: a multisite randomized trial of a prison-based intervention for reducing HIV sexual risk behaviors among women with a history of drug use

Women involved in the criminal justice system, particularly those with a history of drug use, are at elevated risk of HIV infection, yet few HIV prevention interventions have been tailored for delivery to incarcerated women. Drawing on the Relational Model, the Reducing Risky Relationships for HIV (RRR-HIV) intervention was developed and evaluated in a multisite randomized clinical trial. Women with weekly drug use prior to incarceration (n = 444) who were incarcerated within correctional institutions in four states were randomized to (1) the RRR-HIV intervention consisting of an HIV educational video, five group sessions, and one postrelease booster session or (2) a control condition consisting of the HIV educational video. The RRR-HIV intervention combined didactic and interactive content regarding seven "thinking myths" about intimate relationships that may result in decisions to engage in risky sexual behaviors. Data were collected while women were still incarcerated and approximately 90 days following release from prison by trained interviewers. A negative binomial regression (NBR) model of unprotected sexual behaviors at the 90-day follow-up indicated that RRR-HIV participants reported fewer unprotected sexual behaviors than women in the control condition once the analysis was adjusted for study site. Future studies should examine the sustainability of the RRR-HIV intervention's effect on risk reduction. Implementation research is needed to determine whether delivery of this intervention by correctional staff or peers, rather than research staff, yields similar reductions in unprotected sexual behaviors.

Feeling good in your own skin: the influence of complimentary sexual stereotypes on risky sexual attitudes and behaviors in a community sample of African American women

Although negative racial stereotypes may affect the mental and physical health of African Americans, little research has examined the influence of positive or complimentary racial stereotypes on such outcomes. More specifically, this study explored the relationship between African American women's endorsement of complimentary stereotypes about their sexuality and attitudes/behaviors that have been associated with sexual risk. Data were gathered from 206 African American women as part of the Black Women in the Study of Epidemics project. Multivariate regression models were used to examine associations between women's endorsement of complimentary stereotypes about their sexuality and selected sex-related attitudes and behaviors. Participants' endorsement of complimentary sexual stereotypes was significantly positively associated with beliefs that having sex without protection would strengthen their relationship (B = .28, SE = .10, p < .01) and that they could use drugs and always make healthy choices about using protection (B = .31, SE = .09, p < .01). Significant positive associations were also found between complimentary sexual stereotypes and the number of casual sexual partners women reported in the past year (B = .29, SE = .15, p = .05) as well as their willingness to have sex in exchange for money or drugs during that time (B = .78, OR = 2.18, p < .05). These findings suggest that endorsement of complimentary sexual stereotypes by African American women can lead to increased risk behavior, particularly relating to possible infection with HIV or other sexually transmitted infections.

Risky relationships: targeting HIV prevention for women offenders

HIV is a health issue for women offenders who are at particularly high risk. Women's prisons can be opportune settings for HIV prevention interventions. How women perceive partner relationships could be central to targeting HIV interventions. Consequently, this study examines changes in women offenders' risky relationships. Baseline and follow-up data are presented from 344 women offenders. Intent-to-treat analysis is used as well as analysis of covariance to control for baseline values. Findings indicate that women released to the community from prison who were randomized into the prevention intervention were significantly more likely to report changes in five of seven risky relationship thinking myths. Findings suggest that a relationship theory-based prevention intervention for reducing HIV risk could be promising for women offenders reentering the community after prison. Additional research is suggested.

Causal mediation of a human immunodeficiency virus preventive intervention

BACKGROUND

Assessing mediation is important because most interventions are designed to affect an intermediate variable or mediator; this mediator, in turn, is hypothesized to affect outcome behaviors. Although there may be randomization to the intervention, randomization to levels of the mediator is not generally possible. Therefore, drawing causal inferences about the effect of the mediator on the outcome is not straightforward.

OBJECTIVES

The aim of this study was to introduce an approach to causal mediation analysis using the potential outcomes framework for causal inference and then discuss this approach in terms of the scientific questions addressed and the assumptions needed for identifying and estimating the effects.

METHODS

The approach is illustrated using data from the Criminal Justice Drug Abuse Treatment Studies: Reducing Risky Relationships-HIV intervention implemented with 243 incarcerated women re-entering the community. The intervention was designed to affect various mediators at 30 days postintervention, including risky relationship thoughts, beliefs, and attitudes, which were then hypothesized to affect engagement in risky sexual behaviors, such as unprotected sex, at 90 days postintervention.

RESULTS

Using propensity score weighting, we found the intervention resulted in a significant decrease in risky relationship thoughts (-0.529, p = .03) and risky relationship thoughts resulted in an increase in unprotected sex (0.447, p < .001). However, the direct effect of the intervention on unprotected sex was not significant (0.388, p = .479).

DISCUSSION

By reducing bias, propensity score models improve the accuracy of statistical analysis of interventions with mediators and allow researchers to determine not only whether their intervention works but also how it works.

Considerations in HIV prevention for women affected by the criminal justice system

Within the national dialogue of HIV prevention strategies, relatively little consideration is given to the millions of women and girls affected by the criminal justice system, either through their own incarceration or that of their partners. Statistics indicate that these women and girls are disproportionately infected or at risk for HIV and other sexually transmitted infections and much of this risk is directly related to the dynamics and circumstances that led to their incarceration or relationships with incarcerated men. As we look for the link between public health and correctional health within our National HIV/AIDS Strategy, it is imperative that the risks, obstacles, and opportunities facing women and girls affected by incarceration are brought into the discussion. Gender-responsive HIV prevention policies and practices must be developed to address the unique risks and opportunities for these women and girls. This paper presents data on HIV risk and other health issues specific to this community of women and girls, discusses key factors for consideration when developing gender-responsive HIV strategies for these communities, and makes recommendations for inclusion in the National HIV/AIDS Strategy and other state and local HIV prevention efforts.

Relationship influence and health risk behavior among re-entering women offenders

BACKGROUND

Studies have shown that relationships can influence health risk behaviors such as drug use among women offenders. This study takes an exploratory look at the positive and negative influences of parents, peers, and partners for women prisoners to better understand their health risk behavior for HIV, including risky sex and drug use.

METHODS

The current study includes secondary analysis of cross-sectional data from women offenders enrolled in three protocols of the National Institute on Drug Abuse-funded Criminal Justice Drug Abuse Treatment Studies cooperative agreement. Baseline interviews were completed with incarcerated women preparing for community re-entry and focused on behaviors during the 6 months before incarceration. Relationship influences during the 6 months before prison were categorized as "positive" or "negative" for the women offenders.

FINDINGS

Multivariate regression models suggested that positive parental influence was significantly associated with reduced HIV risk and reduced drug use in the 6 months before incarceration. However, negative peer influence increased drug use including both risky needle behavior and any drug use in the 6 months before incarceration.

CONCLUSION

These data suggest that, although relationships are generally important to women, particular types of relationship influences may be related to risky behavior. Implications for targeting re-entry interventions for women offenders are discussed.

A critical review of HIV-related interventions for women prisoners in the United States

This article reviews the literature on HIV-related interventions for U.S. women prisoners, with a focus on identifying strategies that enabled women to practice safer sex, reduce drug use, and to avoid recidivism. A comprehensive search indicated that only nine such interventions were evaluated in professional journals between 1994 and 2009. These interventions involved behavioral programs for women at risk for HIV and discharge planning for women releases who were either infected with or at risk for HIV. Four interventions for incarcerated women achieved successful outcomes regarding self-empowerment and safer sex skills; 3 prison-release interventions resulted in less recidivism if not reduced HIV risk. Each intervention was nominally women-centered, with prison-release programs lacking protocols that were designed specifically for women. Based on evidence that women-centered interventions were desirable for this population, such interventions should be given high priority in criminal justice policy and care provision during the HIV epidemic.