Dissolution of primary intimate relationships during incarceration and implications for post-release HIV transmission

Impact of post-incarceration care engagement interventions on HIV transmission among young Black men who have sex with men and their sexual partners: an agent-based network modeling study

Background

Understanding the impact of incarceration on HIV transmission among Black men who have sex with men is important given their disproportionate representation among people experiencing incarceration and the potential impact of incarceration on social and sexual networks, employment, housing, and medical care. We developed an agent-based network model (ABNM) of 10,000 agents representing young Black men who have sex with men in the city of Chicago to examine the impact of varying degrees of post-incarceration care disruption and care engagement interventions following release from jail on HIV incidence.

Methods

Exponential random graph models were used to model network formation and dissolution dynamics, and network dynamics and HIV care continuum engagement were varied according to incarceration status. Hypothetical interventions to improve post-release engagement in HIV care for individuals with incarceration (e.g., enhanced case management, linkage to housing and employment services) were compared to a control scenario with no change in HIV care engagement after release.

Finding

HIV incidence at 10 years was 4.98 [95% simulation interval (SI): 4.87, 5.09 per 100 person-years (py)] in the model population overall; 5.58 (95% SI 5.38, 5.76 per 100 py) among those with history of incarceration, and 12.86 (95% SI 11.89, 13.73 per 100 py) among partners of agents recently released from incarceration. Sustained post-release HIV care for agents with HIV and experiencing recent incarceration resulted in a 46% reduction in HIV incidence among post-incarceration partners [incidence rate (IR) per 100 py = 5.72 (95% SI 5.19, 6.27) vs. 10.61 (95% SI 10.09, 11.24); incidence rate ratio (IRR) = 0.54; (95% SI 0.48, 0.60)] and a 19% reduction in HIV incidence in the population overall [(IR per 100 py = 3.89 (95% SI 3.81-3.99) vs. 4.83 (95% SI 4.73, 4.92); IRR = 0.81 (95% SI 0.78, 0.83)] compared to a scenario with no change in HIV care engagement from pre-to post-release.

Interpretation

Developing effective and scalable interventions to increase HIV care engagement among individuals experiencing recent incarceration and their sexual partners is needed to reduce HIV transmission among Black men who have sex with men.

Funding

This work was supported by the following grants from the National Institutes of Health: R01DA039934; P20 GM 130414; P30 AI 042853; P30MH058107; T32 DA 043469; U2C DA050098 and the California HIV/AIDS Research Program: OS17-LA-003; H21PC3466.

Age Differences in the Associations Between Incarceration and Subsequent Substance Use, Sexual Risk-Taking, and Incident STI Among Black Sexual Minority Men and Black Transgender Women in the HIV Prevention Trials 061 Cohort

Incarceration can lead to different risk behaviors often due to increased distress and disruption of social networks. It is not well known, however, how these associations may differ by age. In this study, we measure age differences in longitudinal associations between incarceration and substance use, sex risk, and sexually transmitted infection (STI) among Black sexual minority men and Black transgender women (BSMM/BTW). We recruited BSMM/BTW from 2009 to 2011 that were part of the HIV Prevention Trials Network 061 study. We compared those less than 30 years old (n = 375) to those 30 years old or greater (n = 794) examining substance use, sex risk, and STI infection stratified by age. Logistic regression with inverse probability weighting was used for the statistical analysis. Approximately 59% of the sample reported incarceration history. In adjusted analysis, incarceration was more strongly associated with alcohol use and stimulant use among older individuals as was sexual risk behaviors including buying and selling sex. Concurrent partnerships were associated with the younger age groups. STI incidence was associated with younger individuals while associations with HIV infection were similar for the two age groups. Understanding differences in substance use and STI risk among age cohorts is imperative to the design and implementation of re-entry programs. Younger BSMM/BTW participating in re-entry support programs may benefit in particular from HIV/STI prevention and care efforts, while post-release substance abuse treatment and harm reduction programs should target older individuals with continued substance abuse.

HIV/Sexually Transmitted Infection Screening and Eligibility for HIV Preexposure Prophylaxis Among Women Incarcerated in an Urban County Jail

BACKGROUND

Incarcerated women experience high rates of HIV and sexually transmitted infections (STIs); few are offered HIV preexposure prophylaxis (PrEP). We aimed to examine HIV/STI screening rates in this population and identify PrEP eligibility.

METHODS

Results of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) urine and HIV/syphilis screening in cisgender women in the Dallas County Jail were compiled from January to October 2020. An electronic health record review was conducted for a subgroup in March 2020 to identify PrEP eligibility.

RESULTS

Overall, 4398 of 13,292 women were screened for CT and 4389 of 13,292 for GC, and among them, 479 (11%) screened for HIV and 562 (13%) for syphilis. Furthermore, 462 of 4398 (11%) were positive for CT, 323 of 4389 (7%) were positive for GC, 10 of 479 (2%) had positive HIV test results, of whom 6 (1.3%) were new diagnoses and 75 (13%) had a reactive rapid plasma reagin test. In March 2020, of 541 women screened, 90 tested positive for CT or GC. Of these 90, 70 (78%) did not receive HIV or syphilis screening, including women with these risk factors: 10 (14%) were homeless, 11 (16%) reported heroin use, and 10 (14%) reported methamphetamine use. Based on the presence of an acute bacterial STI, 17% (96 of 541) were PrEP eligible.

CONCLUSIONS

Incarcerated women had high STI rates and other risk factors for HIV acquisition, although only 1 in 5 with acute STIs (11% overall) was also screened for HIV or syphilis. HIV prevention efforts should include comprehensive STI/HIV screening, linkage to treatment, and identification of PrEP candidates.

Fatherhood, Behavioral Health, and Criminal Legal System Contact over the Life Course

Life course theories suggest that fathers' lifetime criminal legal system contact could contribute to poor parent-child outcomes via deterioration in couple relationship quality and fathers' behavioral health. Using paired, longitudinal data from the Multi-site Family Study (N = 1,112 couples), the current study examines the influence of three dimensions of fathers' life course legal system contact on individual and parent-child outcomes. In fitted models, accumulated system contact in adulthood predicts fathers' later depressive symptoms and drug misuse, which in turn predict diminished father-child relationship quality (as reported by both co-parents). Fathers who were older at the time of their first arrest had poorer relationships with their children's mothers and, in turn, poorer behavioral health and parent-child outcomes. Conditions of confinement during fathers' most recent prison stay do not significantly predict later parent-child outcomes, net of the influence of age at first arrest and accumulated criminal legal system contact in adulthood.

PrEP and HIV prevention decision-making among social network members of women who have experienced incarceration: a qualitative study

ABSTRACTIncarceration and HIV are a syndemic for US women, yet very few women who have experienced incarceration use pre-exposure prophylaxis (PrEP) for HIV. We conducted semi-structured interviews with 32 participants recruited by women who have experienced incarceration from their social networks, informed by the modified social ecological model for PrEP. Emergent themes from the interviews included individual-level (low personal HIV risk assessment, personal responsibility for HIV prevention, and decisions in addiction versus recovery), network-level (influential sex partners and the importance of trust, supportive treatment peers, and high-risk but indifferent drug use networks), community-level (stigma, and mitigation of stigma in supportive substance use disorder treatment environments), and public policy-level (incarceration and PrEP cost and access) determinants. PrEP interventions for women who have experienced incarceration and their networks will need to incorporate contingency planning into HIV risk assessment, navigate complex network dynamics, and be situated in trusted contexts to address structural barriers.

When State Violence Comes Home: From Criminal Legal System Exposure to Intimate Partner Violence in a Time of Mass Incarceration

Exceptionally high rates of partner violence perpetration are evident among men returning from prison. Two bodies of scholarship, one on family stress and another on exposure to state violence, each suggest that criminal legal system exposure could promote partner violence perpetration via changes in men's behavioral health and interpersonal approach and in couples' conflict dynamics. Such relationships have not been tested in quantitative research. Structural equation models were fitted to longitudinal, couples-based survey data from the Multi-site Family Study on Incarceration, Parenting, and Partnering. Participants included men returning from a state prison term in five U.S. states (N = 1112) and their committed intimate or co-parenting partners (N = 1112). Models tested hypothesized pathways from three dimensions of criminal legal system exposure to later partner violence perpetration. In fitted models, men's childhood criminal legal system exposure predicts their post-prison partner violence perpetration via adult post-traumatic stress symptoms, reactivity, avoidance, and dysfunctional couple conflict dynamics. Men's cumulative criminal legal system exposure in adulthood predicts their post-prison partner violence perpetration via addiction and dysfunctional couple conflict. These initial results suggest that mass-scale incarceration could worsen partner violence via men's psychological and interpersonal adaptations to criminal legal system contact, particularly when such contact is sustained or occurs at a developmentally significant period in the life course.

The influence of social relationships on PrEP attitudes among women with incarceration experience in the Southeastern USA

Women who have experienced incarceration face a disproportionately high risk of acquiring HIV. Despite efficacy of pre-exposure prophylaxis (PrEP) for HIV, very few women with incarceration histories are using PrEP. Our objective was to learn how sexual, drug-use and social relationships shape decisions about PrEP among women who have experienced incarceration. We used an inductive approach to analyse data from four focus groups undertaken with women who had previously experienced incarceration recruited from three community-based organisations. We identified public policy (medical distrust, lack of prevention in prisons and jails, and cost and coverage of PrEP); community (incarceration stigma, gossip as prevention); social and sexual network (positive peer and parenting relationships, distrust of sexual partners, and networks as a source of risk); and individual-level (active addiction or recovery, change after incarceration, and medical concerns) factors influencing the use of PrEP. Actions and interventions to improve PrEP uptake among women who have experienced incarceration must take account of the multilevel context of HIV prevention decisions.

Incarceration, Social Support Networks, and Health among Black Sexual Minority Men and Transgender Women: Evidence from the HPTN 061 Study

Support from social networks buffers against negative effects of stress but is disrupted by incarceration. Few studies examine incarceration, social support networks, and health among Black sexual minority men (BSMM) and Black transgender women (BTW). We conducted a secondary analysis using HIV Prevention Trials Network 061 (HPTN 061), a sample of BSMM/BTW recruited from six US cities. We measured associations between recent incarceration reported at six months follow-up and social support networks at twelve months follow-up, and cross-sectional associations between support networks and twelve-month health outcomes (e.g., sexual partnerships, substance use, healthcare access and depressive symptoms). Among the analytic sample (N = 1169), recent incarceration was associated with small medical support networks (adjusted risk ratio [aRR] 1.16, 95% CI 1.01, 1.34) and small financial support networks (aRR 1.18, 95% CI 1.04, 1.35). Support networks were associated with multiple partnerships (adjusted prevalence ratio [aPR] 0.77, 95% CI 0.65, 0.90), unhealthy alcohol use (aPR 1.20, 95% CI 0.96, 1.51), and depressive symptoms (aPR 1.16, 95% CI 0.99, 1.36). Incarceration adversely impacts social support networks of BSMM/BTW, and support networks were associated with a range of important health outcomes.

Characterization of Risk Factors Among Individuals with a History of Incarceration Presenting to a Sexually Transmitted Infections Clinic: Implications for HIV and STI Prevention and Care

More than 2 million people are incarcerated in the United States with many millions more processed through correctional facilities annually. Communities impacted by incarceration are also disproportionately impacted by the HIV and sexually transmitted infection (STI) epidemics. However, relatively little is known about the behaviors that place individuals with a history of incarceration at risk for HIV/STI acquisition. We utilized clinical data from patients presenting to an STI clinic located in Providence, Rhode Island. A latent class analysis was conducted on reported HIV acquisition risk behavior and STI testing results on a total of 1129 encounters where a history of incarceration was reported. A total of three classes were identified. Class 1 (N = 187, 11%), more frequently reported 10+ sexual partners (45%), an STI diagnosis (48%) and sex while intoxicated (86%) in the past year as well as identifying as a man who has sex with other men (60%). Class 2 (N = 57, 5%) was more likely to report giving (53%) and receiving (44%) money/drugs for sex in the past year as well as a history of injecting drugs (61%) and using methamphetamine (60%). Class 3 (N = 885, 78%) most frequently reported 0-2 sexual partners (48%), identified as Black (27%), Hispanic/Latino (69%) and a man who only has sex with women (80%). Class 1 had significantly higher odds ratio (1.8, 95% confidence interval = 1.3-2.5) of testing HIV/STI positive. The results provide important insights into risk subgroups for those with a history of incarceration at risk of HIV/STI acquisition.

Incarceration and Subsequent Pregnancy Loss: Exploration of Sexually Transmitted Infections as Mediating Pathways

Background: Incarceration is linked to risk of sexually transmitted infection (STI) postrelease among women. There has been little examination of incarceration's association with related sexual and reproductive outcomes such as pelvic inflammatory disease (PID) and pregnancy loss, or the role of STI in this relationship and whether these relationships differ between Black and White women. Methods: Using data from the National Longitudinal Study of Adolescent to Adult Health, we examined cross-sectional associations between incarceration (Wave IV; 2007-2008; ages 24-34) and history of STI and PID (n = 5,968), and longitudinal associations between incarceration and later pregnancy loss in mid-adulthood (Wave V; 2016-2018; ages 34-43) among women who had ever been pregnant (n = 2,353); we estimated racial differences. Using causal mediation, we explored whether STI mediated associations with pregnancy loss. Results: Incarceration was associated with a history of STI (White adjusted prevalence ratio [APR]: 1.54, 95% confidence interval [CI] 1.14-2.06; Black APR: 1.26, 95% CI 1.02-1.56); the association between incarceration and PID was null among White women (APR: 0.99, 95% CI 0.47-2.09) and elevated among Black women (APR: 2.82, 95% CI 1.36-5.83). Prior incarceration did not appear associated with pregnancy loss among White women (APR: 1.01, 95% CI 0.70-1.45), but was associated among Black women (APR: 1.38, 95% CI: 0.97-1.97), with STI appearing to partially mediate. Conclusions: Pregnancy loss may be elevated among Black women who have been incarcerated, and incarceration-related increases in STI may account for some of this association.

Characterisation of social support following incarceration among black sexual minority men and transgender women in the HPTN 061 cohort study

OBJECTIVE

To examine longitudinal associations between recent incarceration and subsequent social support among black sexual minority men and transgender women, and whether associations differed between those who did and did not have support prior to incarceration.

DESIGN

A secondary analysis in 2020 of data from the HIV Prevention Trials Network 061, a cohort study of black sexual minority men and transgender women recruited in 2009-2010 and followed for 12 months.

SETTING

Six US cities (Atlanta, Boston, Los Angeles, New York City, San Francisco and Washington DC).

PARTICIPANTS

Individuals ≥18 years of age who identified as black, reported being male or assigned male at birth, reported ≥1 unprotected anal intercourse event with a male partner in the past 6 months, and reported on incarceration at the 6-month follow-up visit.

EXPOSURE

Having spent ≥1 night in jail/prison in the past 6 months reported at the 6-month follow-up visit.

OUTCOME

Social support measured using a six-item scale assessing frequency of emotional/informational, affectionate and tangible support (range 6-30); and dichotomous indicators of low support for each item (ie, receiving that form of support none/little of the time).

RESULTS

Among participants who returned for the 6-month visit (N=1169), 14% had experienced incarceration in the past 6 months. Mean support score was 20.9; 18.9 among those with recent incarceration versus 21.2 among those without. Recent incarceration predicted lower support (adjusted β -2.40, 95% CI -3.94 to -0.85). Those recently incarcerated had increased risk of lacking emotional/informational (eg, no one to talk to adjusted risk ratio (aRR) 1.55, 95% CI 1.13 to 2.13) and affectionate (aRR 1.51, 95% CI 1.11 to 2.04) but not tangible support. Effects appeared somewhat stronger among those who had support at baseline.

CONCLUSIONS

Incarceration may reduce support on re-entry among black sexual minority men and transgender women, populations unequally targeted for incarceration and at risk for low support.

Lifetime Burden of Incarceration and Violence, Internalized Homophobia, and HIV/STI Risk Among Black Men Who Have Sex with Men in the HPTN 061 Study

Black men who have sex with men (BMSM) have disproportionate HIV/STI acquisition risk. Incarceration may increase exposure to violence and exacerbate psychosocial vulnerabilities, including internalized homophobia, which are associated with HIV/STI acquisition risk. Using data from HIV Prevention Trials Network 061 (N = 1553), we estimated adjusted prevalence ratios (APR) and 95% confidence intervals (CIs) for associations between lifetime burden of incarceration and HIV/STI risk outcomes. We measured associations between incarceration and HIV/STI risk outcomes with hypothesized mediators of recent violence victimization and internalized homophobia. Compared to those never incarcerated, those with 3-9 or ≥ 10 incarcerations had approximately 10% higher prevalence of multiple partnerships. Incarceration burden was associated with selling sex (1-2 incarcerations: APR: 1.52, 95% CI 1.14-2.03; 3-9: APR: 1.77, 95% CI 1.35-2.33; ≥ 10: APR: 1.85, 95% CI 1.37-2.51) and buying sex (≥ 10 incarcerations APR: 1.80, 95% CI 1.18-2.75). Compared to never incarcerated, 1-2 incarcerations appeared to be associated with current chlamydia (APR: 1.47, 95% CI 0.98-2.20) and 3-9 incarcerations appeared to be associated with current syphilis (APR: 1.46, 95% CI 0.92-2.30). Incarceration was independently associated with violence, which in turn was a correlate of transactional sex. Longitudinal research is warranted to clarify the role of incarceration in violence and HIV/STI risk in this population.

A Dyadic Analysis of Criminal Justice Involvement and Sexual HIV Risk Behaviors Among Drug-Involved Men in Community Corrections and Their Intimate Partners in New York City: Implications for Prevention, Treatment and Policies

People in community corrections have rates of HIV and sexual risk behaviors that are much higher than the general population. Prior literature suggests that criminal justice involvement is associated with increased sexual risk behaviors, yet these studies focus on incarceration and use one-sided study designs that only collect data from one partner. To address gaps in the literature, this study used the Actor Partner-Interdependence Model with Structural Equation Modeling (SEM), to perform a dyadic analysis estimating individual (actor-only) partner-only, and dyadic patterns (actor-partner) of criminal justice involvement and greater sexual risks in a sample of 227 men on probation and their intimate partners in New York City, United States. Standard errors were bootstrapped with 10,000 replications to reduce bias in the significance tests. Goodness of fit indices suggested adequate or better model fit for all the models. Significant actor-only relationships included associations between exposures to arrest, misdemeanor convictions, time spent in jail or prison, felony convictions, lifetime number of incarceration events, prior conviction for disorderly conduct and increased sexual risk behaviors. Partner only effects included significant associations between male partners conviction for a violent crime and their female partners' sexual risk behaviors. Men's encounters with police and number of prior misdemeanors were associated with their own and intimate partners' sexual risk behaviors. Women's prior arrest was associated with their own and intimate partners' sexual risk behaviors. The results from the present study suggest that men on probation and their intimate partners' criminal justice involvement are associated with increased engagement in sexual risk behaviors. It is necessary to conduct greater research into developing dyadic sexual risk reduction and HIV/STI prevention interventions for people who are involved in the criminal justice system.

Estimating the Roles of Racism and Homophobia in HIV Testing Among Black Sexual Minority Men and Transgender Women With a History of Incarceration in the HPTN 061 Cohort

Black sexual minority men (BSMM) and Black transgender women (BTW) have disproportionately high HIV prevalence, making HIV testing critical for treatment and prevention. Racism and homophobia may be barriers to testing among BSMM/BTW, particularly in the context of previous incarceration. We analyzed a subsample (n = 655) of HIV-negative, previously incarcerated BSMM/BTW in the HIV Prevention Trials Network 061 study, generating prevalence ratios and interaction terms testing associations between experienced racism and homophobia with past-year HIV testing. Both racism (aPR = 0.83, 95% CI [0.70, 0.98]) and homophobia (aPR: 0.68, 95% CI [0.48, 0.98]) were associated with lower testing, although their interaction was associated with unexpectedly higher testing (Interaction aPR = 1.77, 95% CI [1.25, 2.49]). Among BSMM/BTW with a history of incarceration, racism and homophobia are barriers to HIV testing. Positive interactions between racism and homophobia could be explained by numerous factors (e.g., resilience, coping) and warrants further study.

Incarceration and Number of Sexual Partners After Incarceration Among Vulnerable US Women, 2007-2017

Objectives. To examine whether women's incarceration increases numbers of total and new sexual partners.Methods. US women with or at risk for HIV in a multicenter cohort study answered incarceration and sexual partner questions semiannually between 2007 and 2017. We used marginal structural models to compare total and new partners at visits not following incarceration with all visits following incarceration and visits immediately following incarceration. Covariates included demographics, HIV status, sex exchange, drug or alcohol use, and housing instability.Results. Of the 3180 participants, 155 were incarcerated. Women reported 2 partners, 3 or more partners, and new partners at 5.2%, 5.2%, and 9.3% of visits, respectively. Relative to visits not occurring after incarceration, odds ratios were 2.41 (95% confidence interval [CI] = 1.20, 4.85) for 2 partners, 2.03 (95% CI = 0.97, 4.26) for 3 or more partners, and 3.24 (95% CI = 1.69, 6.22) for new partners at visits immediately after incarceration. Odds ratios were similar for all visits following incarceration.Conclusions. Women had more total partners and new partners immediately and at all visits following incarceration after confounders and loss to follow-up had been taken into account.

Sexual Risk and Criminal Justice Involvement Among Women Who Use Drugs

Criminal justice system involvement among US women is associated with increased risk for HIV/sexually transmitted infections, yet effects of different forms of criminal justice involvement on intimate relationships are not well understood. This study examined associations between arrest, probation, and jail incarceration on the number of sexual partners, sexual concurrency, and consistent condom use for drug-using women (n = 631) in Oakland, California. We used logistic and negative binomial regression and adjusted for demographics, sex exchange and drug use. Probation was associated with higher rates of sexual partnership and concurrency (IRR 1.87, 95% CI [1.11, 3.15]; OR 3.64, 95% CI [1.08, 12.20]). Incarceration lasting over 12 weeks was associated with higher rates of sexual partnership (IRR 2.23, 95% CI [1.41, 3.51]). Women incarcerated once in the past year had higher odds of concurrency (OR 2.15, 95% CI [1.01, 4.57]). Our results reinforce the need for risk-reduction interventions and criminal justice diversion for women who use drugs.

Self-reported sexually-transmitted infections and criminal justice involvement among women who use drugs

Background

Women involved in the criminal justice system in the United States have high rates of sexually transmitted infections (STI). It is unknown whether criminal justice involvement is a marker for other risk behavior, such as sex exchange or drug use, or criminal justice involvement itself increases risk directly.

Methods

This study examines the relationship between STI and the frequency and duration of arrest, probation, and incarceration in a sample of women who use drugs (n = 394) in Oakland, California who reported having been tested for STI in the past six months. Logistic regression models of STI using criminal justice measures as independent variables were used, and subsequent estimates were adjusted for demographics, sex exchange, specific drugs used, and number of sexual partners.

Results

Any time spent in jail in the past year was associated with higher odds of recent STI (UOR = 2.28, 95%CI [1.41–3.51]), and short incarcerations (2–3 weeks) in jail most substantially increased the odds of an STI diagnosis (UOR = 7.65, 95%CI [1.03, 56.68]). Arrest and probation were not significantly associated with STI. After adjusting for the covariates, particularly sex exchange and opioid use, none of the criminal justice-related variables were significantly associated with STI.

Conclusions

A substantial portion of the increased risk of STI that is associated with criminal justice involvement for women who use drugs is likely due to sex exchange. Longitudinal studies are needed to temporally separate criminal justice exposures, drug use, sex exchange, and STI outcomes.

•

Criminal justice involvement is common for women who use drugs.

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Short jail incarcerations (2–3 weeks) were associated with an increased odds of STI, largely accounted for by sex exchange and opioid use.

•

Qualitative studies that examine why women's sexual partnerships, opioid use, and sex exchange change after incarceration are needed.

The Relationship Between Economic Deprivation, Housing Instability and Transactional Sex Among Women in North Carolina (HPTN 064)

Transactional sex is associated with socioeconomic disadvantage and HIV risk but few studies in the United States (US) have examined both individual and area-level predictors of transactional sex or distinguished transactional sex from sex work. We combined data from HIV Prevention Trials Network 064 study and the US Census to estimate prevalence ratios (PR) for the relationship between census-level and individual measures of economic deprivation and housing instability on transactional sex in 417 women in North Carolina. Increased transactional sex was associated with food insecurity (PR 1.86; 95%; CI 1.57, 2.19), housing instability (PR 1.33; 95% CI 1.11, 1.59), substance abuse (PR 1.90; 95% CI 1.64, 2.19) and partner incarceration (PR 1.32; 95% CI 1.09, 1.61). Census-level indicators were not associated with transactional sex, adjusted for individual-level covariates. Interventions should support housing stability and financial opportunities among southern African American women to reduce HIV risk, particularly among women with incarcerated partners.

Reduced Sexual Risk Behaviors Among Persons With HIV After Release From the Criminal Justice System

Background

HIV prevalence is 3 times greater for those in the criminal justice system than the general population, with an assumed increase in sexual risk behaviors (SRBs) postrelease. HIV viral suppression impacts HIV transmission; however, studies of SRBs among persons with HIV leaving the criminal justice system are limited, and no studies have examined viral suppression in relation to SRBs in persons leaving the criminal justice system.

Methods

Data were examined from 2 double-blind placebo-controlled trials of extended-release naltrexone among persons with HIV and alcohol use or opioid use disorder. Participants self-reported sexual activity, including number of sexual partners, sex type, and condom use. HIV viral suppression was evaluated prerelease and at 6 months.

Results

Thirty days before incarceration, 60% reported having sex compared with 41% and 46%, respectively, at months 1 and 6 postrelease. The number of sex partners and sexual intercourse events decreased from pre-incarceration to months 1 and 6 postrelease. Condom use increased but was not statistically significant. Of the 11 (9.7%) who reported having sex without a condom 1 month postrelease, only 2 did not have viral suppression (VS; HIV VL <200 copies/mL), whereas the 7 (6.5%) who reported SRBs at 6 months all had VS.

Conclusions

After release, SRBs decreased, and among those who reported SRBs, most were virally suppressed, and thus risk of transmitting HIV was low.

Pre-exposure prophylaxis awareness and interest among participants in a medications for addiction treatment program in a unified jail and prison setting in Rhode Island

People who are incarcerated are at increased risk for HIV (human immunodeficiency virus) acquisition upon release, and one possible intervention for prevention is the use of pre-exposure prophylaxis (PrEP) upon release. The present study assessed HIV risk perceptions as well as PrEP awareness and interest among 39 people who were incarcerated and enrolled in a structured Medication for Addiction Treatment (MAT) program at the Rhode Island Department of Corrections using semi-structured, qualitative interviews. Analysis was conducted using a generalized, inductive method in NVivo 12. While PrEP awareness was low across the study sample, some participants were interested in PrEP uptake or learning more about PrEP after they were provided with an overview of it. PrEP interest strongly related to current perceived HIV risk. Potential barriers included side effects, adherence, and reluctance to take medications in general. MAT programs for people who are criminal justice (CJ) involved may serve as useful linkage spaces to PrEP information, access, and retention.

A conceptual model for understanding post-release opioid-related overdose risk

Post-release opioid-related overdose mortality is the leading cause of death among people released from jails or prisons (PRJP). Informed by the proximate determinants framework, this paper presents the Post-Release Opioid-Related Overdose Risk Model. It explores the underlying, intermediate, proximate and biological determinants which contribute to risk of post-release opioid-related overdose mortality. PRJP share the underlying exposure of incarceration and the increased prevalence of several moderators (chronic pain, HIV infection, trauma, race, and suicidality) of the risk of opioid-related overdose. Intermediate determinants following release from the criminal justice system include disruption of social networks, interruptions in medical care, poverty, and stigma which exacerbate underlying, and highly prevalent, substance use and mental health disorders. Subsequent proximate determinants include interruptions in substance use treatment, including access to medications for opioid use disorder, polypharmacy, polydrug use, insufficient naloxone access, and a return to solitary opioid use. This leads to the final biological determinant of reduced respiratory tolerance and finally opioid-related overdose mortality. Mitigating the risk of opioid-related overdose mortality among PRJP will require improved coordination across criminal justice, health, and community organizations to reduce barriers to social services, ensure access to health insurance, and reduce interruptions in care continuity and reduce stigma. Healthcare services and harm reduction strategies, such as safe injection sites, should be tailored to the needs of PRJP. Expanding access to opioid agonist therapy and naloxone around the post-release period could reduce overdose deaths. Programs are also needed to divert individuals with substance use disorder away from the criminal justice system and into treatment and social services, preventing incarceration exposure.

Trends in Geographic Rates of HIV Diagnoses Among Black Females in the United States, 2010-2015

BACKGROUND

HIV diagnoses among females in the United States declined 22% from 2010 to 2015, including a 27% decline in diagnoses among black females. Despite this progress, disparities persist. Black females accounted for 60% of new HIV diagnoses among females in 2015. Geographic disparities also exist. This article describes geographic differences in HIV diagnoses among black females in the United States, from 2010 to 2015.

MATERIALS AND METHODS

We examined HIV surveillance data from 2010 to 2015 to determine in which geographic areas decreases or increases in HIV diagnoses occurred. We used data from the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention's (NCHHSTP) AtlasPlus to calculate percent changes in HIV diagnosis rates by geographic region for black females ≥13 years of age.

RESULTS

The number of new HIV diagnoses declined 27% among black females from 2010 to 2015. The highest rates of HIV diagnosis per 100,000 population of black females, from 2010 to 2015, were in the Northeast and the South. In 2015, five of the eight states reporting the highest rates of HIV diagnosis (i.e., the highest quartile) were in the South.

CONCLUSIONS

HIV diagnosis rates decreased nationally among black females, but the decreases were not uniform within regions or across the United States. Some states experienced increases, and black females in the South and Northeast remain disproportionately affected. Additional research is needed to ascertain factors associated with the increases to continue progress toward reducing HIV-related disparities among females in the United States.

Examining factors associated with unprotected sexual behavior among Black Americans postrelease from incarceration in New York City

Black Americans are overrepresented among incarcerated individuals and those infected with sexually transmitted infections. We assessed unprotected sexual behavior among 165 formerly incarcerated Black Americans in New York City, New York. Most participants (63%) reported engaging in unprotected sexual behavior post-incarceration. According to our regression results, less time spent in jail and reporting multiple sexual partnerships were associated with a greater likelihood of engaging in unprotected sexual behavior. High rates of unprotected sexual behavior may place formerly incarcerated Black Americans at risk for sexually transmitted infections. Discharge planning programs that include STI/HIV prevention information and education may be useful for this population.

Past year and prior incarceration and HIV transmission risk among HIV-positive men who have sex with men in the US

Three quarters of new HIV infections in the US are among men who have sex with men (MSM). In other populations, incarceration is a social determinant of elevations in viral load and HIV-related substance use and sex risk behavior. There has been limited research on incarceration and these HIV transmission risk determinants in HIV-positive MSM. We used the Veterans Aging Cohort Study (VACS) 2011-2012 follow-up survey to measure associations between past year and prior (more than one year ago) incarceration and HIV viral load and substance use and sex risk behavior among HIV-positive MSM (N = 532). Approximately 40% had ever been incarcerated, including 9% in the past year. In analyses adjusting for sociodemographic factors, past year and prior incarceration were strongly associated with detectable viral load (HIV-1 RNA >500 copies/mL) (past year adjusted odds ratio (AOR): 3.50 95% confidence interval (CI): 1.59, 7.71; prior AOR: 2.48 95% CI: 1.44, 4.29) and past 12 month injection drug use (AORs > 6), multiple sex partnerships (AORs > 1.8), and condomless sex in the context of substance use (AORs > 3). Past year incarceration also was strongly associated with alcohol and non-injection drug use (AOR > 2.5). Less than one in five HIV-positive MSM recently released from incarceration took advantage of a jail/prison re-entry health care program available to veterans. We need to reach HIV-positive MSM leaving jails and prisons to improve linkage to care and clinical outcomes and reduce transmission risk upon release.

Dissolution of Committed Partnerships during Incarceration and STI/HIV-Related Sexual Risk Behavior after Prison Release among African American Men

Incarceration is strongly associated with post-release STI/HIV risk. One pathway linking incarceration and STI/HIV risk may be incarceration-related dissolution of protective network ties. Among African American men released from prison who were in committed partnerships with women at the time of incarceration (N = 207), we measured the association between committed partnership dissolution during incarceration and STI/HIV risk in the 4 weeks after release. Over one-quarter (28%) experienced incarceration-related partnership dissolution. In adjusted analyses, incarceration-related partnership dissolution was strongly associated with post-release binge drinking (adjusted odds ratio (AOR) 4.2, 95% confidence interval (CI); 1.4-15.5). Those who experienced incarceration-related partnership dissolution were much more likely to engage in multiple/concurrent partnerships or sex trade defined as buying or selling sex (64%) than those who returned to the partner (12%; AOR 20.1, 95% CI 3.4-175.6). Policies that promote maintenance of relationships during incarceration may be important for protecting health.

A Randomized Controlled Trial of Intensive Case Management (Project Bridge) for HIV-Infected Probationers and Parolees

Individuals on probation and parole are disproportionately at high risk for HIV infection and experience significant barriers to accessing health care. This study was a two-group randomized controlled trial conducted at a community corrections office and was designed to link HIV positive probationers/parolees to HIV treatment in the community. HIV positive participants were assigned to one of the two treatment conditions: (1) Project Bridge (PB), an intensive case-management intervention; or (2) treatment as usual (TAU), involving standard referral to treatment. We hypothesized that PB would be more effective than TAU in terms of initiating individuals in community HIV treatment. We found no difference in rates of, or time to, treatment initiation when comparing the PB to TAU (all ns > 0.05). Additionally, there was no statistically significant difference between HIV medication regiment initiation by treatment condition (p > 0.05). Despite limitations, we found that probationers and parolees were willing to be screened and linked to treatment.

The Committed Intimate Partnerships of Incarcerated African-American Men: Implications for Sexual HIV Transmission Risk and Prevention Opportunities

Incarceration is thought to influence HIV transmission by disrupting partnerships that provide support and protect against sex risk-taking. Current correctional facility-based family-strengthening programs focus on marital partnerships, a minority of inmates' partnerships. Research on the sex partnerships of incarcerated African-American men and the types of partnerships most likely to protect against HIV-related sex risk is limited. Improved understanding can inform expansion of correctional facility-based family-strengthening programs to a greater proportion of protective partnerships and HIV risk reduction programs to partnerships vulnerable to sex risk. Project DISRUPT is a cohort study of African-American men being released from prison in North Carolina who were in committed heterosexual partnerships at prison entry. Using baseline survey data (N = 189), we conducted latent class analysis (LCA) to identify subgroups of participants with distinct relationship profiles and measured associations between relationship characteristics and multiple partnerships of inmates and their partners in the six months before incarceration. LCA indicated a two-class solution, with relationships distinguished by satisfaction/stability (satisfied/stable class: 58.0%; dissatisfied/unstable class: 42.0%); each class had comparable relationship length and levels of marriage and cohabitation. Dissatisfied/unstable relationships were associated with multiple partnerships among participants (AOR 2.93, 95% CI 1.50, 5.72) and partners (AOR 4.95, 95% CI 1.68, 14.58). Satisfaction indicators-versus length, marriage, or cohabitation-were the strongest independent correlates of inmates' and partners' multiple partnerships. Pre-incarceration economic deprivation, mental disorder symptoms, substance use, and violence in relationships were associated with dissatisfaction/instability. Prison-based programs designed to maintain healthy partnerships, strengthen relationship skills, and reduce HIV risk-taking and violence in relationships are warranted and should be targeted to both marital and nonmarital partnerships. Programming also should address the poverty, mental illness, and substance use factors that threaten relationship satisfaction/stability and increase HIV risk.

Patterns of Mood and Personality Factors and Associations With STI/HIV-Related Drug and Sex Risk Among African American Male Inmates

BACKGROUND

Research on the association between antisocial personality disorder (ASPD) with comorbid mental disorders and sexually transmitted infection (STI)/HIV risk among inmates is scant despite the high prevalence of psychopathology and of STI/HIV in this population.

METHODS

We used baseline data from Project DISRUPT, a cohort study conducted among incarcerated African American men (n = 207), to measure associations between ASPD and STI/HIV risk. We also conducted latent class analyses (LCAs) to identify subgroups defined by ASPD with comorbid stress, depression, and borderline personality disorder symptoms and measured associations between latent class membership and STI/HIV risk.

RESULTS

Approximately 15% had ASPD and 39% reported depression. Controlling for sociodemographics, stress, and depression, ASPD was independently associated with illicit [AOR = 3.23, 95% confidence interval (CI): 1.18-8.87] and injection drug use (AOR: 5.49, 95% CI: 1.23-24.42) but not with sexual risk. LCAs suggested that those at high risk of ASPD were likely to experience co-morbid mental disorders. ASPD comorbid with these disorders was linked to drug and sex risk.

CONCLUSIONS

STI/HIV prevention for inmates should incorporate diagnosis and treatment of ASPD and comorbid disorders, and interventions to address ASPD-related factors (e.g., impulsivity) that drive STI/HIV risk.

HIV-Related Sexual Risk among African American Men Preceding Incarceration: Associations with Support from Significant Others, Family, and Friends

We evaluated the association between social support received from significant others, family, and friends and HIV-related sexual risk behaviors among African American men involved in the criminal justice system. Project DISRUPT is a cohort study among African American men released from prison in North Carolina (N = 189). During the baseline (in-prison) survey, we assessed the amount of support men perceived they had received from significant others, family, and friends. We measured associations between low support from each source (<median value) and participants' sex risk in the 6 months before incarceration. Low levels of social support from significant others, family, or friends were associated with poverty and homelessness, mental disorders, and substance use. Adjusting for age, poverty, and other sources of support, perceiving low support from significant others was strongly associated with multiple partnerships (fully adjusted odds ratio (OR) 2.64, 95% confidence interval (CI) 1.29-5.42). Low significant other support also was strongly associated with sex trade involvement when adjusting for age and poverty status (adjusted OR 3.51, 95% CI 1.25-9.85) but further adjustment for low family and friend support weakened the association (fully adjusted OR 2.81, 95% CI 0.92-8.55). Significant other support was not associated with other sex risk outcomes including concurrent partnerships, anal sex, or sex with an STI/HIV-infected partner. Low family support was associated with multiple partnerships in analyses adjusting for age and poverty (adjusted OR 1.98, 95% CI 1.05-3.76) but the association weakened and was no longer significant after adjusting for other sources of support (fully adjusted OR 1.40, 95% CI 0.65-3.00); family support was not correlated with other risk behaviors. Friend support was not significantly associated with sex risk outcomes. Indicators of overall support from any source were not associated with sex risk outcomes. Helping inmates maintain ties may improve economic security and well-being during community re-entry, while supporting and strengthening relationships with a significant other in particular may help reduce sex risk. Studies should evaluate the protective effects of distinct support sources to avoid masking effects of support and to best understand the influence of social support on health.

Condom use and incarceration among STI clinic attendees in the Deep South

Background

Incarceration history is associated with lower rates of condom use and increased HIV risk. Less is known about duration of incarceration and multiple incarcerations’ impact on condom use post-release.

Methods

In the current study, we surveyed 1,416 adults in Mississippi about their incarceration history and sexual risk behaviors. Generalized estimating equations (GEE) were used to test associations between duration of incarceration, multiple incarcerations, socio-demographic factors, substance use, sexual behavior, and event level condom use at last sex.

Results

After adjusting for covariates, having been incarcerated for at least 6 months two or more times remained significantly associated with condomless sex.

Conclusions

This study found a strong, independent relationship between condom use and multiple, long-term incarceration events among patients in an urban STI clinic in the Deep South. The results suggest that duration of incarceration and multiple incarcerations have significant effects on sexual risk behaviors, underscoring the deleterious impact of long prison or jail sentences on population health. Our findings also suggest that correctional health care professionals and post-release providers might consider offering comprehensive sexual and reproductive health services and those providing community care should consider screening for previous incarceration as a marker of risk.

Risk Profiles of Women Experiencing Initial and Repeat Incarcerations: Implications for Prevention Programs

Incarcerated women experience myriad individual, interpersonal, and structural factors leading to arrest and rearrest. This study examined risk profiles of women experiencing initial and repeat incarcerations. The sample included 521 women recruited from two prisons in North Carolina and enrolled in a HIV/STD risk-reduction intervention trial. Variables included socio-demographics, structural/economic factors, sexual and substance use behaviors, STDs, victimization history, and depressive symptoms. Bivariate and multivariable analyses identified risk differences. Compared to women incarcerated for the first time, women with repeat incarcerations reported significantly greater economic instability, substance use and sexual risk behaviors, laboratory-confirmed STDs, and victimization during childhood and adulthood. Multivariable logistic regression found women with repeat incarcerations experienced greater unstable housing, injection drug use, crack cocaine use, concurrent sex partners, and childhood sexual victimization. Findings can inform the development of prevention programs by addressing economic instability, sexual risk, and substance use among women prisoners.

Infectious Diseases and the Criminal Justice System

The United States leads the world in incarceration, which disproportionately affects disadvantaged individuals, including those who are mentally ill, poor, homeless and racial minorities. Incarceration is disruptive to families and communities and contributes to health disparities in sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). The objective of this grand rounds is to review (1) the epidemiology of incarceration in the United States, (2) the social factors which contribute to high rates of STIs in incarcerated individuals and (3) the HIV care cascade in incarcerated and recently released individuals. Routine screening and treatment for STIs and HIV in the criminal justice system can identify many new infections and has the potential to both improve individual outcomes and reduce transmission to others. Increased collaboration between the department of health and department of corrections, as well as partnerships between academic institutions and the criminal justice system, have the potential to improve outcomes in this vulnerable population.

Efficacy of a Computerized Intervention on HIV and Intimate Partner Violence Among Substance-Using Women in Community Corrections: A Randomized Controlled Trial

OBJECTIVES

To test the efficacy of a computerized, group-based HIV and intimate partner violence (IPV) intervention on reducing IPV victimization among substance-using women mandated to community corrections.

METHODS

Between November 2009 and January 2012, we randomly allocated 306 women from community corrections in New York City to 3 study arms of a computerized HIV and IPV prevention trial: (1) 4 group sessions intervention with computerized self-paced IPV prevention modules (Computerized Women on the Road to Health [WORTH]), (2) traditional HIV and IPV prevention intervention group covering the same HIV and IPV content as Computerized WORTH without computers (Traditional WORTH), and (3) a Wellness Promotion control group. Primary outcomes were physical, injurious, and sexual IPV victimization in the previous 6 months at 12-month follow-up.

RESULTS

Computerized WORTH participants reported significantly lower risk of physical IPV victimization, severe injurious IPV victimization, and severe sexual IPV victimization at 12-month follow-up when compared with control participants. No significant differences were seen between Traditional WORTH and control participants for any IPV outcomes.

CONCLUSIONS

The efficacy of Computerized WORTH across multiple IPV outcomes highlights the promise of integrating computerized, self-paced IPV prevention modules in HIV prevention groups.

Social support quality and availability affects risk behaviors in offenders

BACKGROUND

People involved in the justice system are at 2.5 times the risk of HIV infection compared to the general population, which is further complicated by substance abuse. The purpose of this study was to evaluate the role of social network quality and quantity on unprotected sex, criminal risk, and substance use.

METHODS

We used data from 330 drug-involved offenders. Structural equation modeling (SEM) was used to model and test path directionality and magnitude between the latent constructs of social support quality and quantity on risky behaviors.

RESULTS

The SEM indicated the latent construct of social support quality was significantly associated with reduced sexual risk behavior (β = -0.27), criminal risk (β = -0.26), and reduced substance use (β = -0.33). Additionally, the proposed model found that social support quantity was significantly positively associated with increased sexual risk behavior (β = 0.40) and substance use (β = 0.20).

CONCLUSIONS

Social support quality is an important predictor of risky behaviors; as the quality of an offender's social support increases, engagement in risky behaviors decreases. Probationers who had broader social support availability also had increased substance use and unprotected sex. Probation systems may be able to reduce substance use and STD/HIV infection risk in offenders by strengthening the quality of social support networks.

Black Americans and Incarceration: A Neglected Public Health Opportunity for HIV Risk Reduction

Black Americans are incarcerated at disproportionate rates, largely due to racial differences in the application of drug laws. Human immunodeficiency virus (HIV) prevalence rates among Black Americans are also disproportionately high. Moreover, availability of and access to HIV prevention services in correctional settings are limited. Recognizing that Blacks are at an elevated risk of contracting HIV, and that incarceration worsens health outcomes, this paper addresses the importance of implementing comprehensive prison-based HIV programs and prevention interventions to improve the health of this vulnerable population. In the absence of a vaccine, prevention interventions can serve as an effective method of systematically addressing HIV-related health disparities. Prevention strategies offered within correctional settings provide a unique opportunity to engage a high-risk population when its members may be receptive to behavior modification.

Modeling the community-level effects of male incarceration on the sexual partnerships of men and women

Men who have been incarcerated experience substantial changes in their sexual behavior after release from jail and prison, and high rates of incarceration may change sexual relationship patterns at a community level. Few studies, however, address how rates of incarceration affect community patterns of sexual behavior, and the implications of those patterns for HIV and STD risk. We describe a "proof of principle" computational model that tests whether rates of male incarceration could, in part, explain observed population-level differences in patterns of sexual behavior between communities with high rates of incarceration and those without. This validated agent-based model of sexual partnership among 20-25 year old heterosexual urban residents in the United States uses an algorithm that incarcerates male agents and then releases them back into the agent community. The results from these model experiments suggest that at rates of incarceration similar to those observed for urban African American men, incarceration can cause an increase in the number of partners at the community level. The results suggest that reducing incarceration and creating a more open criminal justice system that supports the maintenance of inmates' relationships to reduce instability of partnerships for men who are incarcerated may have important sexual health and public health implications. Incarceration is one of many social forces that affect sexual decision-making, and incarceration rates may have substantial effects on community-level HIV and STD risks.

Structural Interventions for HIV Prevention Among Women Who Use Drugs: A Global Perspective

We briefly review extant literature on the contextual sources of HIV risk among drug users—the drug user risk environment—and on structural interventions to address drug user vulnerability to HIV. We argue that issues of gender inequality and gendered power relations are largely absent from this literature. We then identify 5 contextual factors that are critical for understanding women's HIV-related vulnerability and whose impacts are exacerbated among women who use drugs, including a division of reproductive labor in which women bear primary responsibility for family caretaking, women's lack of full access to or control of productive resources and decision making, women's vulnerability to sexual and physical violence, and especially, intimate partner violence, women's (particularly heterosexual women's) relationship dependency and limited power in sexual interactions, and harmful gender norms that reinforce these other factors. We discuss a range of structural interventions and structural intervention approaches with the potential to address these contextual factors and call for more research, both to better understand the risk environment of women who use drugs and the impacts of structural interventions on it. We argue that our understanding of and ability to impact on the HIV-related risk environment of drug users is incomplete if we do not fully incorporate the analysis of gender inequality and gendered power relations.

STI/HIV Sexual Risk Behavior and Prevalent STI Among Incarcerated African American Men in Committed Partnerships: The Significance of Poverty, Mood Disorders, and Substance Use

African Americans face disproportionate sexually transmitted infection including HIV (STI/HIV), with those passing through a correctional facility at heightened risk. There is a need to identify modifiable STI/HIV risk factors among incarcerated African Americans. Project DISRUPT is a cohort study of incarcerated African American men recruited from September 2011 through January 2014 from prisons in North Carolina who were in committed partnerships with women at prison entry (N = 207). During the baseline (in-prison) study visit, participants responded to a risk behavior survey and provided a urine specimen, which was tested for STIs. Substantial proportions reported multiple partnerships (42 %), concurrent partnerships (33 %), and buying sex (11 %) in the 6 months before incarceration, and 9 % tested positive for an STI at baseline (chlamydia: 5.3 %, gonorrhea: 0.5 %, trichomoniasis: 4.9 %). Poverty and depression appeared to be strongly associated with sexual risk behaviors. Substance use was linked to prevalent STI, with binge drinking the strongest independent risk factor (adjusted odds ratio: 3.79, 95 % CI 1.19-12.04). There is a continued need for improved prison-based STI testing, treatment, and prevention education as well as mental health and substance use diagnosis.

Substance Use and HIV Among Female Sex Workers and Female Prisoners: Risk Environments and Implications for Prevention, Treatment, and Policies

Female sex workers (FSWs) and female prisoners experience elevated HIV prevalence relative to the general population because of unprotected sex and unsafe drug use practices, but the antecedents of these behaviors are often structural in nature. We review the literature on HIV risk environments for FSWs and female prisoners, highlighting similarities and differences in the physical, social, economic, and policy/legal environments that need to be understood to optimize HIV prevention, treatment, and policy responses. Sex work venues, mobility, gender norms, stigma, debt, and the laws and policies governing sex work are important influences in the HIV risk environment among FSWs, affecting their exposure to violence and ability to practice safer sex and safer drug use behaviors. Female prisoners are much more likely to have a drug problem than do male prisoners and have higher HIV prevalence, yet are much less likely to have access to HIV prevention and treatment and access to drug treatment in prison. Women who trade sex or are imprisoned and engage in substance use should not be considered in separate silos because sex workers have high rates of incarceration and many female prisoners have a history of sex work. Repeated cycles of arrest, incarceration, and release can be socially and economically destabilizing for women, exacerbating their HIV risk. This dynamic interplay requires a multisectoral approach to HIV prevention and treatment that appreciates and respects that not all women are willing, able, or want to stop sex work or drug use. Women who engage in sex work, use drugs, or are imprisoned come from all communities and deserve sustained access to HIV prevention and treatment for substance use and HIV, helping them and their families to lead healthy and satisfying lives.

Partner Incarceration and African-American Women's Sexual Relationships and Risk: A Longitudinal Qualitative Study

Racialized mass incarceration is associated with racial/ethnic disparities in HIV and other sexually transmitted infections (STIs) in the US. The purpose of this longitudinal qualitative study was to learn about the processes through which partner incarceration affects African-American women's sexual risk. Four waves of in-depth qualitative interviews were conducted in 2010-2011 with 30 women in Atlanta, Georgia (US) who had recently incarcerated partners. Approximately half the sample misused substances at baseline. Transcripts were analyzed using grounded theory. For over half the sample (N = 19), partner incarceration resulted in destitution, and half of this group (N = 9) developed new partnerships to secure shelter or food; most misused substances. Other women (N = 9) initiated casual relationships to meet emotional or sexual needs. When considered with past research, these findings suggest that reducing incarceration rates among African-American men may reduce HIV/STIs among African-American women, particularly among substance-misusing women, as might rapidly linking women with recently incarcerated partners to housing and economic support and drug treatment.

The case for improving the health of ex-prisoners

The global prison population exceeds 10 million and continues to grow; more than 30 million people are released from custody annually. These individuals are disproportionately poor, disenfranchised, and chronically ill. There are compelling, evidence-based arguments for improving health outcomes for ex-prisoners on human rights, public health, criminal justice, and economic grounds. These arguments stand in stark contrast to current policy and practice in most settings. There is also a dearth of evidence to guide clinicians and policymakers on how best to care for this large and growing population during and after their transition from custody to community. Well-designed longitudinal studies, clinical trials, and burden of disease studies are pivotal to closing this evidence gap.

Prevalence and risk factors associated with HIV infection, hepatitis and syphilis in a state prison of São Paulo

Given the importance of the control of sexually transmitted infections in the general population and specifically in the prison system, we rolled out this cross-sectional study in 2007. Standard questionnaires and blood samples were accessed among 680 prisoners. The protocol was approved by the Ethics Committee. We determined the following seroprevalences: HIV, 1.8% (95%CI = 0.1-3.3); HBV, 21.0% (95%CI = 17.8-25.1); HBV, 5.3% (95%CI = 3.5-7.6) and syphilis 5.3% (95%CI = 3.5-7.6). Logistic regression identified significant associations with (p < 0.05): HIV: injectable drug use (OR = 15.4), age over 30 years (OR = 13.3), cocaine use (OR = 5.4) and crack-cocaine use (OR = 5.2); HBV: injectable drug use (OR = 3.4), history of previous sexually transmitted infection (OR = 2.3), age over 30 years (OR = 1.9) and more than 5 years in prison (OR = 2.2); HCV: injectable drug use (OR = 9.65), marijuana use in prison (OR = 2.9) and age over 30 years (OR = 8.4) and for syphilis: homosexual relationship (OR = 7.8) and previous syphilis reported (OR = 7.7). These prevalences remain high when compared to the general population, however, HIV infection had decreased compared with previous studies in prisoners while the other studied infections remained unchanged. Preventive actions to reduce sexual and parenteral risk have been advocated. However, measures capable of controlling these infections still have not made an impact.

Effects of incarceration on risky Sex: focus group data from Two New England states

Background

Human Immunodeficiency Virus (HIV) risk and interpersonal violence are interconnected public health problems facing incarcerated women. Prison may provide an opportune time to conduct HIV prevention activities with high-risk women.

Methods

This study used qualitative analysis to explore how incarceration affected women’s experiences of and thoughts about sex and sex risk. Twenty-one incarcerated women who had engaged in unprotected sex with a male in the 90 days prior to incarceration and experienced interpersonal violence in their lifetime participated in semi-structured focus groups at four women’s prison facilities in two New England States.

Results

Themes that emerged from these focus groups include: a) incarceration increased sexual desire for some women but decreased it for others, b) education and exposure to women with HIV during incarceration increased women’s intentions to use condoms after release, c) women recognized that partners were often unfaithful while women were incarcerated, d) women felt empowered by mental health/substance use treatment and sobriety in prison, and e) practical difficulties of re-entry challenged women’s resolve to practice safe sex after release.

Conclusion

Themes illuminate possible directions for public health interventions for this population at high risk for HIV.

Electronic supplementary material

The online version of this article (doi:10.1186/2194-7899-2-8) contains supplementary material, which is available to authorized users.

Sexual HIV Risk Among Male Parolees and Their Female Partners: The Relate Project

BACKGROUND

The massively disproportionate impact of America's prison boom on communities of color has raised questions about how incarceration may affect health disparities, including disparities in HIV. Primary partners are an important source of influence on sexual health. In this paper, we investigate sexual HIV risk among male-female couples following a man's release from prison.

METHODS

We draw upon data from the Relate Project, a novel cross-sectional survey of recently released men and their female partners in Oakland and San Francisco, California (N=344). Inferential analyses use the actor-partner model to explore actor and partner effects on sexual HIV risk outcomes.

RESULTS

Dyadic analyses of sexual HIV risk among male parolees and their female partners paint a complex portrait of couples affected by incarceration and of partners' influences on each other. Findings indicate that demographic factors such as education level and employment status, individual psycho-social factors such as perception of risk, and relationship factors such as commitment and power affect sexual HIV risk outcomes.

CONCLUSION

The Relate Project provides a novel dataset for the dyadic analysis of sexual risk among male parolees and their female partners, and results highlight the importance of focusing on the couple as a unit when assessing HIV risk and protective behaviors. Results also indicate potentially fruitful avenues for population-specific interventions that may help to reduce sexual health disparities among couples affected by incarceration.

Consequences of Family Member Incarceration: Impacts on Civic Participation and Perceptions of the Legitimacy and Fairness of Government

Political participation and citizens' perceptions of the legitimacy and fairness of government are central components of democracy. In this article, we examine one possible threat to these markers of a just political system: family member incarceration. We offer a unique glimpse into the broader social consequences of punishment that are brought on by a partner's or parent's incarceration. We argue that the criminal justice system serves as an important institution for political socialization for the families of those imprisoned, affecting their attitudes and orientations toward the government and their will and capacity to become involved in political life. We draw from ethnographic data collected by one of the authors, quantitative data from the National Longitudinal Study of Adolescent Health, and interviews with recently released male prisoners and their female partners. Our findings suggest that experiences of a family member's incarceration complicate perceptions of government legitimacy and fairness and serve as a barrier to civic participation.

Incarceration as a catalyst for worsening health

The primary aim of this paper is to explicate the mechanisms through which incarceration affects health. Guided by theories that emphasize the compounding nature of inequality and with a focus on those that are disproportionately impacted by the drastic increase of incarceration over the last three decades, an exploration of these mechanisms is undertaken. This investigation provides a better understanding of the issues that are faced by incarcerated individuals in the incarceration environment, after release, and via macro-level policy. Finally, a hypothetical heuristic framework is presented that illustrates the ways in which incarceration affects individual, family and community level health. Implications for policy intervention programs and future research that serve to address diminished health among incarcerated populations are discussed.

Felon disenfranchisement in the United States: a health equity perspective

Approximately 13% of African American men are disqualified from voting because of a felony conviction. I used ecosocial theory to identify how institutionalized racism helps perpetuate health disparities and to explore pathways through which felon disenfranchisement laws may contribute to racial health disparities in the United States. From a literature review, I identified 2 potential pathways: (1) inability to alter inequitable public policies that differentially allocate resources for health; and (2) inability to reintegrate into society by voting, which contributes to allostatic load.

Incarceration, high-risk sexual partnerships and sexually transmitted infections in an urban population

OBJECTIVES

The authors examined the associations between personal and partner incarceration, high-risk sexual partnerships and biologically confirmed sexually transmitted infection (STI) in a US urban population.

METHODS

Data from a probability survey of young adults 15-35 years of age in Baltimore, Maryland, USA, were analysed to assess the prevalence of personal and partner incarceration and its association with several measures of high-risk sexual partnerships including multiple partners, partner concurrency and current STI.

RESULTS

A history of incarceration was common (24.1% among men and 11.3% among women). Among women with an incarcerated partner in the past year (15.3%), the risk of current STI was significantly increased (adjusted prevalence ratio=2.3, 95% CI 1.5 to 3.5). Multiple partners (5+) in the past year and partner concurrency were disproportionately high among men and women who had been incarcerated or who had sexual partner(s) or who had recently been incarcerated. These associations remained robust independent of personal socio-demographic factors and illicit drug use.

CONCLUSIONS

Incarceration may contribute to STI risk by influencing engagement in high-risk behaviours and by influencing contact with partners who engage in risky behaviours and who hence have elevated risk of infection.