Unprotected Sex With Multiple Partners: Implications for HIV Prevention Among Young Men With a History of Incarceration

Adapting and Implementing an Evidence-Based Reentry Intervention for Incarcerated Transgender Women: Lessons Learned

Incarceration is a significant public health issue that disproportionately impacts transgender (trans) women, particularly those of color. The cycle of incarceration interacts with high levels of substance use, mental illness, and HIV to produce a high disease burden among trans women, but, to date, there are no published studies of trans-specific reentry support interventions. Informed by the Model of Gender Affirmation, we systematically adapted and pilot tested the evidence-based Project START intervention to create Girlfriends Connect (GC), a reentry support intervention for trans women incarcerated in a county jail. Qualitative interviews with trans women (10 prerelease and 6 postrelease) and community social service providers and jail staff (n = 7) who serve justice-involved transgender women, as well as input from a community advisory board, informed our adaptation. We then conducted a pilot randomized controlled trial (n = 14) and a service implementation project (n = 16) of GC to examine its feasibility and acceptability. Lessons learned include the importance of peer facilitators, facilitated referral to gender-affirming community resources, and obtaining programmatic buy-in from jail staff and administration. Results indicate that GC is feasible and acceptable, and holds promise in improving the health of transgender women reentering the community after a period of incarceration.

HIV and risk behaviors among visitors of inmates at the Great Tehran Prison, Iran, 2018

Objectives

The objective of the present study was to determine the prevalence of HIV and risk behaviors among the inmates' visitors at the Great Tehran Prison in 2018.This population is more likely to be infected with HIV due to their relationship with inmates. However, they have not been prioritized to the other populations in comparison to inmates who are usually prioritized over others.

Method

Using a convenient sampling method, we recruited inmates' visitorsat the Great Tehran Prison in 2018. An anonymous questionnaire collected information on the participant's demographic characteristics, relationship withinmate, imprisonment history, drug-related risk behaviors, and HIV-related risk behaviors.Rapid HIV blood test detected HIV positive people. To examine the association between risk behaviors and HIV infection, we used a multivariate logistic regression model to calculate the adjusted Odds Ratio (OR)(adjusted Odds ratio of 23.140, 95% CI OD: 1.994-268.5).

Results

1131 visitors were asked to participate in the study; out of which 1120 consented (99%).Out of the 1120 participants, 55.2% were female, and the majority (72.4%) aged older than 35 years. Of those who had a sexual partner, 50% did not usea condom in the last 6 months. Overall, HIV prevalence was 0.4% in the inmate visitors, but it was significantly higher among those with a history of drug injection(p=0.003).

Conclusion

Our findings indicated that overall the HIV prevalence is low amonginmates' visitors; Subgroups with a history of injection have high HIV prevalence which needs to beprioritized for HIV screening and treatment.

Great Expectations: HIV Risk Behaviors and Misperceptions of Low HIV Risk among Incarcerated Men

Incarcerated populations have relatively high HIV prevalence but little has been reported about their aggregate HIV risk behaviors or perceptions of risk. A random selection of HIV-negative men (n = 855) entering a US state prison system were surveyed to assess five risk behaviors and his self-perceived HIV risk. Using multivariate logistic regression, we identified factors associated with having elevated actual but low perceived risk (EALPR). Of the 826 men with complete data, 88% were at elevated risk. While 64% of the sample had risk perceptions concordant with their actual risk, 14% had EALPR (with the remainder at low actual but high perceived risk). EALPR rates were lower in those with a pre-incarceration HIV test but higher for those with a negative prison entry HIV test. HIV testing counseling should assess for discordance between actual and perceived risk and communicate the continued risk of HIV despite a negative result.

Factors Associated With Receiving Rapid HIV Testing Among Individuals on Probation or Parole

Despite the strong correlation between HIV and corrections, testing and prevention efforts have largely been ignored among community corrections populations. The current study is a secondary analysis to compare characteristics of individuals under community corrections supervision who completed rapid HIV testing with those who refused such testing (N = 2,382) in Baltimore, Maryland, and Providence, Rhode Island. Results indicate that the following variables were significantly associated with the receipt of rapid HIV testing: being female (p = .024), Black race (p = .004), homeless (p = .016), early age of crime onset (p = .001), more drug use during the past 90 days (p = .033), and previously tested for hepatitis C virus/hepatitis B virus (p = .024). Such findings make it especially important that individuals under community supervision be linked with services in the community to ensure that HIV testing and health care planning occur simultaneously.

Pathways to HIV-Related Behavior Among Heterosexual, Rural Black Men: A Person-Centered Analysis

We investigated the psychosocial mechanisms linking personal and contextual risk factors to HIV-related behavior among 498 rural Black men. We characterized HIV-related behavior in terms of profile groups and hypothesized that contextual and personal risk factors (childhood adversity, community disadvantage, incarceration, and racial discrimination) would predict HIV-related behavior indirectly via two psychosocial mechanisms: impulsivity and negative relational schemas. Study results documented three HIV-related behavior profile groups. The Safer group reported low levels of risky behavior. The Risk-Taking group reported inconsistent condom use and elevated substance use. The Multiple Partners group reported the highest numbers of partners and relatively consistent condom use. Risk factors predicted profile groups directly and indirectly through psychosocial mechanisms. Impulsivity mediated the association between community disadvantage and membership in the risk-taking group. Negative relational schemas mediated the associations of childhood experiences and community disadvantage with membership in the multiple partners group. Specificity in pathways suggests the need for targeted interventions based on multidimensional characterizations of risk behavior.

A Randomized Study of Incentivizing HIV Testing for Parolees in Community Aftercare

HIV risk-behaviors are high in criminal justice populations and more efforts are necessary to address them among criminal justice-involved substance abusers. This study examines the role of incentives in promoting HIV testing among parolees. Participants were randomly assigned to either an incentive (n = 104) or education group (control; n = 98), where the incentive group received a voucher for testing for HIV. Bivariate comparisons showed that a larger proportion of those in the incentive group received HIV testing (59% versus 47%), but this was not statistically significant (p = .09). However, in a multivariate logistic regression model controlling for covariates likely to influence HIV-testing behavior, those in the incentive group had increased odds of HIV testing in comparison to those in the education group (OR = 1.99, p < .05, CI [1.05, 3.78]). As a first of its kind, this study provides a foundation for further research on the utility of incentives in promoting HIV testing and other healthy behaviors in criminal justice populations.

Economic, Legal, and Social Hardships Associated with HIV Risk among Black Men who have Sex with Men in Six US Cities

We assessed whether economic, legal, and social hardships were associated with human immunodeficiency virus (HIV) risk among a sample of Black men who have sex with men (MSM) and whether associations were moderated by city of residence. The study analyzed baseline and follow-up data from HIV Prevention Trials Network 061 (N = 1553). Binary logistic regression assessed associations between hardships and HIV risk indicators. Multivariate regressions were used to test if city of residence had a moderating effect for hardships and HIV risks. Adjusted analyses showed that Black MSM with recent job loss were more likely to engage in condomless insertive anal intercourse (adjusted odds ratios (AOR) = 1.37, 95% CI 1.01-1.87) and that those with recent financial crisis were more likely to have had two or more male sexual partners in the past 6 months (AOR = 1.65; 95% CI 1.18-2.29). Black MSM with recent convictions were more likely to have a sexually transmitted infection at 6 months (AOR = 3.97; 95% CI 1.58-9.94), while those who were unstably housed were more likely to have a sexually transmitted infection at 12 months (AOR = 1.71; 95%CI 1.02 = 2.86). There were no city of residence and hardship interaction effects on HIV risks. Hardships are important factors that influence HIV risk for Black MSM. Integrating strategies that address structural factors that influence HIV risk may enhance HIV prevention interventions implementation efforts.

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.

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.

HIV testing and counselling in Estonian prisons, 2012 to 2013: aims, processes and impacts

We present data from an observational cohort study on human immunodeficiency virus (HIV) prevention and control measures in prisons in Estonia to assess the potential for HIV transmission in this setting. HIV testing and retesting data from the Estonian prison health department were used to estimate HIV prevalence and incidence in prison. Since 2002, voluntary HIV counselling and testing has routinely been offered to all prisoners and has been part of the new prisoners health check. At the end of 2012, there were 3,289 prisoners in Estonia, including 170 women: 28.5% were drug users and 15.6% were infected with HIV. Of the HIV-positive inmates, 8.3% were newly diagnosed on prison entry. In 2012, 4,387 HIV tests (including retests) were performed in Estonian prisons. Among 1,756 initially HIV-negative prisoners who were in prison for more than one year and therefore tested for HIV twice within 12 months (at entry and annual testing), one new HIV infection was detected, an incidence of 0.067 per 100 person-years (95% confidence interval (CI): 0.025–5.572). This analysis indicates low risk of HIV transmission in Estonian prisons. Implementation of HIV management interventions could impact positively on the health of prisoners and the communities to which they return.

Neighborhood context and Black heterosexual men's sexual HIV risk behaviors

The effects of neighborhood context on sexual risk behavior are understudied, particularly for Black heterosexual men who do not inject drugs or report heavy drug use. Evidence of a generalized HIV epidemic (>1 %) among Black heterosexuals in low-income urban U.S. communities underscores the importance of examining the effects of neighborhood context on Black heterosexual men's sexual risk, however. We used structural equation modeling to test the pathways between neighborhood context (neighborhood disorder, personal violence, neighborhood threats), depression, substance use, and sexual risk behavior. Participants were 526 self-identified Black heterosexual men, ages 18-45, recruited via randomized venue-based probability sampling in Philadelphia, PA. Analyses of model fit statistics from Mplus indicated statistically significant direct pathways between neighborhood context, depression, substance use, and sexual risk behavior. The total indirect effect of neighborhood context on sexual risk behavior through substance use was also significant. The study's results highlight a need for more research on neighborhood context and sexual HIV risk, and for multilevel interventions to address the effects of negative neighborhood context on Black heterosexual men's sexual HIV risk.

The influence of religion on sexual HIV risk

This systematic review examines the relationship between religion and sexual HIV risk behavior. It focuses primarily on how studies have conceptualized and defined religion, methodologies, and sexual risk outcomes. We also describe regions where studies were conducted and mechanisms by which religion may be associated with sexual risk. We included 137 studies in this review, classifying them as measuring: (1) only religious affiliation (n = 57), (2) only religiosity (n = 48), and (3) both religious affiliation and religiosity (n = 32). A number of studies identified lower levels of sexual HIV risk among Muslims, although many of these examined HIV prevalence rather than specific behavioral risk outcomes. Most studies identified increased religiosity to be associated with lower levels of sexual HIV risk. This finding persists but is weaker when the outcome considered is condom use. The paper reviews ways in which religion may contribute to increase and reduction in sexual HIV risk, gaps in research, and implications for future research on religion and HIV.

Perceived susceptibility to AIDS predicts subsequent HIV risk: a longitudinal evaluation of jail inmates

Theories of health behavior change suggest that perceived susceptibility to illness precedes health-protective behavior. We used a cross-lagged panel design to explore the relationship between perceived susceptibility to AIDS, and HIV risk behavior pre-incarceration and post-release in a sample of 499 jail inmates, a group at high risk for HIV. We also explored moderators of this relationship. HIV risk was calculated with a Bernoulli mathematical process model. Controlling for pre-incarceration HIV risk, perceived susceptibility to AIDS predicted less post-release HIV risk; the reverse relationship was not supported. Consistent with health behavior change theories, perceived susceptibility seemed to partially guide behavior. However, this relationship was not true for everyone. African-Americans and individuals high in borderline personality features exhibited no relationship between perceived susceptibility and changes in HIV risk. This suggests that targeted interventions are needed to use information about risk level to prevent HIV contraction.

The high prevalence of incarceration history among Black men who have sex with men in the United States: associations and implications

OBJECTIVES

We examined lifetime incarceration history and its association with key characteristics among 1553 Black men who have sex with men (BMSM) recruited in 6 US cities.

METHODS

We conducted bivariate analyses of data collected from the HIV Prevention Trials Network 061 study from July 2009 through December 2011 to examine the relationship between incarceration history and demographic and psychosocial variables predating incarceration and multivariate logistic regression analyses to explore the associations between incarceration history and demographic and psychosocial variables found to be significant. We then used multivariate logistic regression models to explore the independent association between incarceration history and 6 outcome variables.

RESULTS

After adjusting for confounders, we found that increasing age, transgender identity, heterosexual or straight identity, history of childhood violence, and childhood sexual experience were significantly associated with incarceration history. A history of incarceration was also independently associated with any alcohol and drug use in the past 6 months.

CONCLUSIONS

The findings highlight an elevated lifetime incarceration history among a geographically diverse sample of BMSM and the need to adequately assess the impact of incarceration among BMSM in the United States.

Cost and threshold analysis of an HIV/STI/hepatitis prevention intervention for young men leaving prison: Project START

The objectives of this study were to: (a) estimate the costs of providing a single-session HIV prevention intervention and a multi-session intervention, and (b) estimate the number of HIV transmissions that would need to be prevented for the intervention to be cost-saving or cost-effective (threshold analysis). Project START was evaluated with 522 young men aged 18-29 years released from eight prisons located in California, Mississippi, Rhode Island, and Wisconsin. Cost data were collected prospectively. Costs per participant were $689 for the single-session comparison intervention, and ranged from $1,823 to 1,836 for the Project START multi-session intervention. From the incremental threshold analysis, the multi-session intervention would be cost-effective if it prevented one HIV transmission for every 753 participants compared to the single-session intervention. Costs are comparable with other HIV prevention programs. Program managers can use these data to gauge costs of initiating these HIV prevention programs in correctional facilities.

Rapid HIV testing for individuals on probation/parole: outcomes of an intervention trial

Many probationers and parolees do not receive HIV testing despite being at increased risk for obtaining and transmitting HIV. A two-group randomized controlled trial was conducted between April, 2011 and May, 2012 at probation/parole offices in Baltimore, Maryland and Providence/Pawtucket, Rhode Island. Male and female probationers/parolees were interviewed (n = 1,263) and then offered HIV testing based on random assignment to one of two conditions: (1) On-site rapid HIV testing conducted at the probation/parole office; or (2) Referral for rapid HIV testing off site at a community HIV testing clinic. Outcomes were: (1) undergoing HIV testing; and (2) receipt of HIV testing results. Participants were significantly more likely to be tested on-site at a probation/parole office versus off-site at a HIV testing clinic (p < 0.001). There was no difference between the two groups in terms of receiving HIV testing results. Findings indicate that probationers/parolees are willing to be tested on-site and, independent of testing location, are equally willing to receive their results. Implications for expanding rapid HIV testing to more criminal justice related locations and populations are discussed.

Substance use and sexual behavior among men prior to parole revocation: prevalence and correlates

Men's risk behavior during a 3-month period prior to parole revocation was assessed. Frequent alcohol use was higher among men who had more children, were homeless, or had a history of alcohol and other drug abuse treatment. The use of drugs was greater among men who were younger or had a history of sexually transmitted infection (STI). The use of hard drugs was higher among men who had history of injection drug use. Unprotected vaginal or anal sex was increased among men who were younger, single, or had a history of STIs. Sex with a high-risk partner was greater among men who were older, used hard drugs, or had a history of STIs. Findings highlight the importance of developing risk-reduction programs for men on parole.

Access to housing subsidies, housing status, drug use and HIV risk among low-income U.S. urban residents

BACKGROUND

Much research has shown an association between homelessness and unstable housing and HIV risk but most has relied on relatively narrow definitions of housing status that preclude a deeper understanding of this relationship. Fewer studies have examined access to housing subsidies and supportive housing programs among low-income populations with different personal characteristics. This paper explores personal characteristics associated with access to housing subsidies and supportive housing, the relationship between personal characteristics and housing status, and the relationship between housing status and sexual risk behaviors among low-income urban residents.

METHODS

Surveys were conducted with 392 low-income residents from Hartford and East Harford, Connecticut through a targeted sampling plan. We measured personal characteristics (income, education, use of crack, heroin, or cocaine in the last 6 months, receipt of welfare benefits, mental illness diagnosis, arrest, criminal conviction, longest prison term served, and self-reported HIV diagnosis); access to housing subsidies or supportive housing programs; current housing status; and sexual risk behaviors. To answer the aims above, we performed univariate analyses using Chi-square or 2-sided ANOVA's. Those with significance levels above (0.10) were included in multivariate analyses. We performed 2 separate multiple regressions to determine the effects of personal characteristics on access to housing subsidies and access to supportive housing respectively. We used multinomial main effects logistic regression to determine the effects of housing status on sexual risk behavior.

RESULTS

Being HIV positive or having a mental illness predicted access to housing subsidies and supportive housing, while having a criminal conviction was not related to access to either housing subsidies or supportive housing. Drug use was associated with poorer housing statuses such as living on the street or in a shelter, or temporarily doubling up with friends, acquaintances or sex partners. Living with friends, acquaintances or sex partners was associated with greater sexual risk than those living on the street or in other stable housing situations.

CONCLUSIONS

Results suggest that providing low-income and supportive housing may be an effective structural HIV prevention intervention, but that the availability and accessibility of these programs must be increased.

History of arrest and associated factors among men who have sex with men

Incarceration has been proposed to be a driving factor in the disproportionate impact of HIV in African-American communities. However, few data have been reported on disparities in criminal justice involvement by race among men who have sex with men (MSM). To describe history of arrest and associated factors among, we used data from CDC's National HIV Behavioral Surveillance system. Respondents were recruited by time-space sampling in venues frequented by MSM in 15 US cities from 2003 to 2005. Data on recent arrest (in the 12 months before the interview), risk behaviors, and demographic information were collected by face-to-face interview for MSM who did not report being HIV-positive. Six hundred seventy-nine (6.8%) of 10,030 respondents reported recent arrest. Compared with white MSM, black MSM were more likely to report recent arrest history (odds ratio (OR), 1.6; 95% confidence interval (CI), 1.3-2.1). Men who were less gay-identified (bisexual [OR, 1.5; 95% CI, 1.1-1.9] or heterosexual [OR, 2.0; 95% CI, 1.2-3.5]) were more likely to report recent arrest than homosexually identified men. In addition, men who reported arrest history were more likely to have used non-injection (OR, 3.0; 95% CI, 2.4-3.6) and injection (OR, 4.7; 95%, 3.3-6.7) drugs, exchanged sex (OR, 2.7; 95% CI, 2.1-3.4), and had a female partner (OR, 1.5; 95% CI, 1.2-2.0) in the 12 months before interview. Recent arrest was associated with insertive unprotected anal intercourse in the 12 months before interview (OR, 1.4; 95% CI, 1.2-1.7). Racial differences in arrest seen in the general US population are also present among MSM, and history of arrest was associated with high-risk sex. Future research and interventions should focus on clarifying the relationship between criminal justice involvement and sexual risk among MSM, particularly black MSM.

Linkage to care for HIV-infected heterosexual men in the United States

In the United States, the human immunodeficiency virus (HIV) epidemic among heterosexual men disproportionately affects individuals involved with the criminal justice system, injection drug and other substance users, and racial and ethnic minorities. These overlapping populations confront similar social and structural disparities that contribute to HIV risk and limit access to HIV testing, treatment, and care. In this review, we discuss barriers to linkage to comprehensive HIV care for specific subpopulations of heterosexual men and examine approaches for enhancing linkage to care for this diverse population.

A longitudinal study of incarceration and HIV risk among methadone maintained men and their primary female partners

This study examines the longitudinal relationship between personal and sexual partner incarceration and subsequent HIV risk behaviors among drug-involved men and their primary female sexual partners. A random sample of 356 men in methadone treatment in New York City were interviewed at baseline, 6 and 12 months; these men also reported information on their primary female sexual partners. Female partner recent incarceration was associated with subsequent increase in multiple partnerships for the male participants (AOR: 3.31; 95% C.I.: 1.26-8.72, P < .05). Female partner incarceration was also associated with reduced likelihood of subsequent unprotected sex between primary partners (AOR: .13; 95% C.I.: .05-.40, P < .01); this finding is somewhat unique and warrants further investigation. Findings support the notion of mutual influence in the case of female partner incarceration, which is associated with both female partner and male partner risk behaviors. HIV prevention implications are discussed, including the need for couple-based HIV prevention interventions targeting couples affected by incarceration.

HIV, alcohol dependence, and the criminal justice system: a review and call for evidence-based treatment for released prisoners

BACKGROUND

People with both HIV and alcohol use disorders (AUDs) are disproportionately concentrated within the U.S. criminal justice system; approximately one-quarter of all people with HIV cycle through the system each year. HIV-infected prisoners with AUDs face many obstacles as they transition back to the community. Specifically, although they have impressive HIV treatment outcomes during the period of incarceration while they are free from alcohol; upon [corrected] release, however, they face inordinate challenges including relapse to alcohol use resulting in significant morbidity and mortality.

OBJECTIVE

To review the existing literature regarding the relationship of HIV and treatment for AUDs within the criminal justice system in an effort to determine "best practices" that might effectively result in improved treatment of HIV and AUDs for released prisoners.

METHODS

PubMed, PsychInfo and Medline were queried for articles published in English from 1990 to 2009. Selected references from primary articles were also examined.

RESULTS

Randomized controlled trials affirm the role of pharmacotherapy using naltrexone (NTX) as the therapeutic option conferring the best treatment outcome for AUDs in community settings. Absent from these trials were inclusion of released prisoners or HIV-infected individuals. Relapse to alcohol abuse among HIV-infected prisoners is associated with reduced retention in care, poor adherence to antiretroviral therapy with consequential poor HIV treatment outcomes and higher levels of HIV risk behaviors.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Untreated alcohol dependence, particularly for released HIV-infected prisoners, has negative consequences both for the individual and society and requires a concentrated effort and rethinking of our existing approaches for this vulnerable population.

Opportunities to diagnose, treat, and prevent HIV in the criminal justice system

Persons involved with the criminal justice system are at risk for HIV and other transmissible diseases due to substance use and related risk behaviors. Incarceration provides a public health opportunity to test for HIV, viral hepatitis, and other sexually transmitted infections, provide treatment such as highly active antiretroviral therapy, and link infected persons to longitudinal comprehensive HIV care upon their release for such comorbidities as addiction and mental illness. Delivering health interventions inside prisons and jails can be challenging, yet the challenges pale in comparison to the benefits of interventions for inmates and their communities. This article reviews the current state of delivering HIV testing, prevention, treatment, and transition services to incarcerated populations in the United States. It concludes with summary recommendations for research and practice to improve the health of inmates and their communities.

HIV testing and treatment with correctional populations: people, not prisoners

Institutional policies, practices, and norms can impede the delivery of ethical standard-of-care treatment for people with HIV in correctional settings. In this commentary, we focus on the fundamental issues that must be addressed to create an ethical environment in which best medical practices can be implemented when working with correctional populations. Thus, we consider ethical issues related to access to services, patient privacy, confidentiality, informed consent for testing and treatment, and issues related to the provision of services in an institutional setting in which maintenance of security is the primary mission. Medical providers must understand and navigate the dehumanization inherent in most correctional settings, competing life demands for incarcerated individuals, power dynamics within the correctional system, and the needs of family and significant others who remain in the community.

Associations of sex ratios and male incarceration rates with multiple opposite-sex partners: potential social determinants of HIV/STI transmission

OBJECTIVES

Racial/ethnic disparities in heterosexual transmission of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) have been hypothesized to be related to the high rate of incarceration and the shortage of men in black communities. This study tested associations of having multiple sex partners with these factors.

METHODS

Racial/ethnic-specific Census data on the sex ratio and the male incarceration rate were categorized into tertiles and matched with individual data from the National Health and Nutrition Examination Survey 1999-2004 by county of residence for non-Hispanic black, non-Hispanic white, and Mexican American participants. We used logistic regression analyses to examine whether these factors were associated with having multiple opposite-sex partners in the past year.

RESULTS

Sex ratios and incarceration rates varied greatly by race/ethnicity; however, we observed significant associations within each racial/ethnic group. Non-Hispanic black men in counties with a greater shortage of males (adjusted odds ratio [AOR] = 1.9; 95% confidence interval [CI] 1.1, 3.5) and a greater number of incarcerated males (AOR = 1.6; 95% CI 1.1, 2.3) in the non-Hispanic black population had significantly greater odds of having two or more partners. Those in two low sex-ratio categories (AOR = 2.4; 95% CI 1.0, 5.8 and AOR = 4.1; 95% CI 1.6, 10.0) and one high incarceration-rate category (AOR = 2.1; 95% CI 1.2, 3.6) had significantly greater odds of having five or more partners.

CONCLUSION

Sex ratios and incarceration rates were associated with the number of opposite-sex partners in some groups. Because the risk of HIV/ STI transmission depends, in part, on the number of partners, it is important to determine the causal relationships among these associations to help better understand racial/ethnic HIV/STI disparities and improve prevention programs and interventions.

Examining the temporal relationship between criminal justice involvement and sexual risk behaviors among drug-involved men

Although criminal justice involvement has repeatedly been associated with human immunodeficiency virus (HIV)/sexually transmitted infection prevalence and sexual risk behaviors, few studies have examined whether arrest or incarceration uniquely contributes to sexually risky behavior. We examined the temporal relationship between criminal justice involvement and subsequent sexual HIV risk among men in methadone maintenance treatment in New York City. A random sample of 356 men was interviewed at baseline (time 1), 6-month (time 2), and 12-month (time 3) follow-ups. Propensity score matching, negative binomial, and multiple logistic regression were used to isolate and test the effect of time 2 arrest and incarceration on time 3 sexual risk behaviors. Incidence of time 2 criminal justice involvement was 20.1% for arrest and 9.4% for incarceration in the prior 6 months. Men who were arrested at time 2 demonstrated increased number (adjusted incidence rate ratio [IRR] = 1.62; 95% confidence intervals [CI] = 1.11, 2.37) and proportion (IRR = 1.36; 95% CI = 1.07, 1.72) of unprotected vaginal sex acts at time 3. Men incarcerated at time 2 displayed increased number (IRR = 2.07; 95% CI = 1.23, 3.48) and proportion (IRR = 1.45; 95% CI = 1.06, 1.99) of unprotected vaginal sex acts at time 3. Within this sample of drug-involved men, arrest and incarceration are temporally associated with and may uniquely impact successive sexual risk-taking. Findings underscore the importance of HIV prevention interventions among individuals with low-intensity criminal justice involvement. Developing prevention efforts aimed at short-term incarceration, community reentry, and alternatives to incarceration settings will address a large and under-researched segment of the criminal justice population. Alternative approaches to current criminal justice policy may result in public health benefits.

Pairing HIV-positive prisoners with volunteer life coaches to maintain health-promoting behavior upon release: a mixed-methods needs analysis and pilot study

Drawing on individuals who volunteer in US prisons to mentor HIV-infected inmates returning to the community may promote successful transitions. Evaluations published in the scientific literature of such community linkage programs are scant. Our quantitative and qualitative methods needs analysis and pilot study entailed interviewing convenience samples of 24 HIV-positive persons recently released from Georgia correctional facilities and 12 potential volunteer mentors. Both releasees and potential mentors were open to the establishment of a mentoring program. Releasees wanted nonjudgmental mentors. Releasees and volunteers had statistically significant differences in marital status, education, current employment, and possession of a driver's license but not in degree of religious involvement and attitudes toward condom use. A volunteer-staffed program, perhaps more aptly named "life coaching" than mentoring, to help HIV-infected persons to transition from prison to the community may be feasible. Success will require adequately trained volunteers and a straightforward program.

Substance use, mental health problems, and behavior at risk for HIV: evidence from CJDATS

This study examined the relationships between substance abuse, mental health problems and HIV risk behavior in offenders discharged from prison and referred to substance abuse treatment programs. Data from 34 sites (n = 1,358) in a federally-funded cooperative agreement, the Criminal Justice Drug Abuse Treatment Studies (CJDATS), were analyzed. Among parolees referred to substance abuse treatment, self reports for the six-month period before the arrest resulting in their incarceration revealed frequent problems with both substance use and mental health. HIV risk behavior was operationalized as either (a) unsafe injection drug use, e.g., sharing needles and/or sharing injection equipment, or (b) unsafe sex, e.g., sex without a condom. The findings were that (1) unsafe injection drug use was associated with unsafe sex and vice versa, (2) unsafe sex behavior was related to frequency of drug use, and (3) unsafe sex behavior was related to frequency of alcohol use. In these samples, mental health problems did not have a significant effect on risk behavior, controlling for other variables. Future research should probe this "nonfinding" using standardized diagnostic and symptom measures to provide greater detail on the mental health problems (e.g., age of onset, frequency, and severity of the problem).

The relationship between housing status and HIV risk among active drug users: a qualitative analysis

This paper examines the relationship between housing status and HIV risk using longitudinal, qualitative data collected in 2004-2005, from a purposeful sample of 65 active drug users in a variety of housed and homeless situations in Hartford, Connecticut. These data were supplemented with observations and in-depth interviews regarding drug use behavior collected in 2001-2005 to evaluate a peer-led HIV prevention intervention. Data reveal differences in social context within and among different housing statuses that affect HIV risk or protective behaviors including the ability to carry drug paraphernalia and HIV prevention materials, the amount of drugs in the immediate environment, access to subsidized and supportive housing, and relationships with those with whom drug users live. Policy implications of the findings, limitations to the data, and future research are discussed.

Moving upstream: ecosocial and psychosocial correlates of sexually transmitted infections among young adults in the United States

OBJECTIVES

We determined the associations of ecosocial factors and psychosocial factors with having a prevalent sexually transmitted infection (STI), recent STI diagnoses, and sexual risk behaviors.

METHODS

Young adults aged 18 to 27 years in the National Longitudinal Study of Adolescent Health (n=14322) provided ecosocial, psychosocial, behavioral, and STI-history data. Urine was tested for Chlamydia trachomatis and Neisseria gonorrhoeae by ligase chain reaction and for Trichomonas vaginalis, human papillomavirus, and Mycoplasma genitalium by polymerase chain reaction.

RESULTS

Prevalent STI was associated with housing insecurity (adjusted odds ratio [AOR] = 1.3; 95% confidence interval [CI] = 1.00, 1.72), exposure to crime (AOR=1.4; 95% CI=1.02, 1.80), and having been arrested (AOR=1.4; 95% CI=1.07, 1.84). STI prevalence increased linearly from 4.9% for 0 factors to 14.6% for 4 or more (P < .001, for trend). Nearly all contextual conditions predicted more lifetime partners and earlier sexual debut. Recent STI diagnosis was associated with childhood sexual abuse, gang participation, frequent alcohol use, and depression, adjusted for sexual risk behaviors.

CONCLUSIONS

Often present before sexual debut, contextual conditions enhance STI risk by increasing sexual risk behaviors and likelihood of exposure to infection. These findings suggest that upstream conditions such as housing and safety contribute to the burden of STIs and are appropriate targets for future intervention.

Health and health behaviors in HIV-infected jail inmates, 1999 and 2005

Incarcerated HIV-infected persons in San Francisco have benefited from intensive case management in jail and postrelease, which includes but is not focused on interventions to prevent transmission. In this population of predominately injection drug users (IDUs), we had the opportunity to examine interview data from 1999 and 2005 that included health characteristics and risk factors. Those in 2005 were less likely to be satisfied with social support and less likely to be partnered; more likely to have some form of health insurance. On average, health was perceived in both periods to be better the longer the person had been in jail. Injection drug use was reported lower in 2005, but a subset of nearly a quarter in each survey time period reported sharing needles. Persons in 2005 were less likely to report they always used condoms as compared to those in 1999 (odds ratio 0.26, 95% confidence interval 0.12-0.59, p = 0.001). While there were differences in study design and methodology, this comparison demonstrated overall similarities in characteristics of HIV-infected inmates. Findings echo those of others, in other populations of HIV-infected persons. Reasons could include HIV prevention fatigue or decay in effectiveness of prevention messages. Despite an established program for case management and links to services, renewed efforts are needed to maintain effectiveness of prevention strategies to this high-risk population.

Incarceration, African Americans and HIV: advancing a research agenda

Incarceration is a crisis among African Americans, and the prevalence of HIV/AIDS in incarcerated men and women is 3-5 times that of the general population. We explore the potential implications of the widespread incarceration of African Americans on HIV risk and HIV outcomes in: 1) the current and formerly incarcerated, 2) their sexual partners, and 3) the communities impacted by incarceration. We set forth a research agenda for understanding and ameliorating the negative impacts incarceration and conclude that the African-American population's ability to successfully address the HIV/AIDS epidemic requires a coordinated and evidence-based response to the challenge of effectively preventing, managing and treating HIV in populations affected by incarceration.

Substance use and sexual behavior during incarceration among 18- to 29-year old men: prevalence and correlates

An A-CASI survey of 197 men with a history of incarceration, ages 18-29, revealed that 50% and 17% of participants, respectively, had used substances or had sex while confined. Univariate regression analyses indicated that these two behaviors were correlated and both were associated with being older, having spent more years incarcerated, being sexual abused, and being involved with gangs and violence during incarceration. Multiple regression analyses showed that the likelihood of any substance use during incarceration was higher for men who were affiliated with a gang. Men were more likely to have had sex during incarceration if they reported having had a male sex partner in the community. The prevalence of sexual behavior also differed across sites. Findings document the occurrence of substance use and sexual behavior among incarcerated men, and highlight the need for continued research into the context of these behaviors.

A longitudinal, qualitative analysis of the context of substance use and sexual behavior among 18- to 29-year-old men after their release from prison

Substance use, sexual behavior, and reincarceration among 89 men from 5 state prisons across the USA, aged 18-29 years, were examined in relation to individual patterns of coping with community reintegration after their release from prison. Analyses of a series of qualitative interviews conducted over a 6-month period post-release revealed three global reintegration coping patterns: moving toward successful reintegration, resuming behavioral patterns that preceded incarceration, and reintegrating through withdrawal or isolation. Four key contextual factors that differentiated these three coping patterns were the consistency and extensiveness of social relationships, the nature of social support, and the degree of structural stability (e.g., stable employment and housing). Participants were assigned a Likert scale score (1 for poor rating to 3 for better rating) for their pattern of global reintegration and for their rating on each of the four contextual factors across the longitudinal qualitative interviews. Collectively, these five factors differentiated the prevalence and frequency of substance use, patterns of sexual behavior, and incidence of reincarceration as assessed by a quantitative survey administered 6 months post-release. Poorer ratings on all five contextual indices were related to the use of substances other than marijuana and alcohol. Men with less consistent social relationships reported more sexual partners. However, vaginal or anal sex without a condom was associated with greater social consistency and greater structural stability, possibly due to the presence of a steady main partner. Reincarceration was significantly associated with poorer global reintegration ratings, more negative social support, and less structural stability. These findings highlight the need to consider the role of social and structural support systems in HIV and sexually transmitted infection risk reduction interventions for men after their release from prison.

Relative efficacy of a multisession sexual risk-reduction intervention for young men released from prisons in 4 states

OBJECTIVES

We compared the effects of an enhanced multisession intervention with a single-session intervention on the sexual risk behavior of young men released from prison.

METHODS

Young men, aged 18 to 29 years, were recruited from US prisons in 4 states and systematically assigned to the prerelease single-session intervention or the pre- and postrelease enhanced intervention. Both interventions addressed HIV, hepatitis, and other sexually transmitted infections; the enhanced intervention also addressed community reentry needs (e.g., housing, employment). Assessment data were collected before intervention, and 1, 12, and 24 weeks after release.

RESULTS

A total of 522 men were included in intent-to-treat analyses. Follow-up rates ranged from 76% to 87%. Unprotected vaginal or anal sex during the 90 days before incarceration was reported by 86% of men in the enhanced intervention and 89% in the single-session intervention (OR=0.78; 95% CI=0.46, 1.32). At 24 weeks, 68% of men assigned to the enhanced intervention reported unprotected vaginal or anal sex compared with 78% of those assigned to the single-session intervention (OR=0.40; 95% CI=0.18, 0.88).

CONCLUSION

Project START demonstrated the efficacy of a sexual risk-reduction intervention that bridges incarceration and community reentry.