STI/HIV-related sexual behaviors clustered among the formerly incarcerated and their sexual partners in this urban NC setting. Men and women reporting recent incarceration or recent sexual partnership with someone who spent time incarcerated were much more likely to report multiple new sexual partnerships and transactional sex in the past 4 weeks than those without recent exposure to incarceration. Adjustment for demographic and socioeconomic confounding variables had little effect. In fully adjusted models adjusting for substance abuse variables, men’s personal incarceration and women’s sexual partnership with someone who had been incarcerated appeared to be independently associated with multiple new partnerships. However, the strong overlap between incarceration, partner incarceration, and substance abuse had substantial effects in some multivariable models.
Estimating an association between incarceration and sexual risk behaviors independent of confounding factors was a primary study objective. However, the reality is that incarceration and substance abuse were highly correlated among our respondents and the members of their sexual networks. We hypothesize that incarceration, substance abuse, and partner influences reciprocally contributed to one another and worked in tandem to increase sexual risk behaviors.
Although the NC PLACE Study was cross-sectional in design, incarceration exposures likely preceded sexual partnership outcomes. Therefore, we interpret these findings to suggest that incarceration not only was associated with but contributed to the development of risky sexual partnerships concurrently with other adverse factors. To disentangle the relationships among incarceration, substance abuse, and partner influences, a large longitudinal study would be necessary, although estimating independent effects of each of these factors on sexual risk behavior would still be difficult given the high correlation among them. The high prevalence of incarceration among this sample indicates the population-level importance of incarceration as a potential factor of STI/HIV transmission and highlights the need for more careful investigation of these relationships.
Our results confirm the association between personal incarceration and risky sexual partnerships observed in previous exploratory analyses. History of incarceration was associated with concurrent sexual partnerships among HIV-positive6
African Americans in North Carolina and among a household sample of Seattle residents5
and with sex workers among intravenous drug users in Vancouver.8
These previous studies were limited by the broad categorization of incarceration as ever incarceration in the past 10 years or during the lifetime. The incarceration may have occurred much earlier than the sexual behavior outcomes measured, limiting the interpretation of the relationship.
We improved measurement of the association between personal incarceration and risky sexual behaviors by capturing recent exposure to incarceration, within the past 12 months for most measures, and obtaining data on sexual partnership outcomes in the past 4 weeks. In addition, we controlled for potential confounding factors identified through conceptual models representing the hypothesized causal effect of incarceration on sexual partnership. However, measurement of partner’s incarceration was based on respondent report, an important limitation because many respondents may not be able to accurately report on their partners’ prior experiences. Further, constraints on questionnaire length prevented more refined measurement of the timing and duration of the partner’s incarceration. Another measurement limitation was the failure to measure recent incarceration among women. Because of the high prevalence of male incarceration at the national level,16
when designing the NC PLACE Method sexual behavior survey, we were primarily interested in exploring the effect of male incarceration on partner vulnerability to STI/HIV infection.
The NC PLACE Study results also confirm prior findings that incarceration of a recent partner is an important factor associated with risky sexual partnerships. Having a recent partner who was ever incarcerated was associated with concurrent sexual partnerships among HIV-positive and HIV-negative African Americans in North Carolina.6,7
The current study suggested that multiple sexual partnerships and transactional sex, in addition to partnership concurrency, were likely important variables in the pathway between incarceration and elevated levels of STI/HIV infection among those whose sexual partners had a history of incarceration.
The disruptive effect of incarceration on relationships has been well documented and provides a rationale for why incarceration may be causally associated with risky sexual partnership. Incarceration physically separates partners in stable relationships, which can lead to loneliness and emotional division17–24
and could result in partnership dissolution.20,22,25
For example, among the NC PLACE Study sample, approximately 10% reported that incarceration was a reason that a serious sexual partnership of 1 year or longer in duration permanently ended. Absence of a stable partnership may contribute to multiple, new, or concurrent partnerships among the partners of prisoners during the incarceration20
or among the prisoners at the time of release.26
During an incarceration, the prisoner’s partner may seek other partners to fill an emotional or financial void.20
Absence of a partner, combined with freedom from restrictions on sexual behavior, may lead newly released prisoners to risky sexual partnerships.26
Isolating an effect of incarceration independent of factors such as substance abuse and partner characteristics not only is difficult methodologically, but may be inappropriate from a public health perspective. Numerous studies have indicated the strong associations between substance abuse and both incarceration27
and risky behaviors and/or sexually transmitted infections.28–43
When interpreting results for the purpose of planning interventions, whether substance abuse preceded or resulted from incarceration is irrelevant. The reality is that these two adverse experiences were highly interconnected, and that HIV interventions, whether based in the community or in prisons, should include substance abuse programs to improve uptake of HIV prevention.
The NC PLACE Study recruited individuals socializing at sites identified as places where people meet new sexual partners, a sample expected to have risky sexual behaviors and, likely, elevated levels of other adverse experiences such as incarceration and substance abuse. Estimates were therefore not representative of the general population living in the NC study city, a study limitation. However, a distinct strength of the PLACE method is access to a high-risk population in particular need of STI/HIV intervention. High prevalence of both incarceration and sexual risk behaviors among the NC PLACE Study sample enabled estimation of the associations between incarceration and risky sexual partnership variables, despite the modest sample size. The NC PLACE Study indicated that the subpopulation of individuals exposed to incarceration experienced particular vulnerability to STI/HIV-related sexual behaviors above and beyond an already high-risk referent group.
The observation of a strong association between incarceration history and sexual risk behaviors supports the need for STI/HIV prevention efforts targeting former prisoners and their partners. Given high rates of recidivism, prison- and jail-based STI/HIV interventions should be strengthened, such as STI/HIV testing and STI/HIV prevention education based in correctional facilities. In addition, community-based efforts should be designed for partners of those incarcerated and newly released prisoners. In particular, whereas it is encouraging that reported condom use with recent new partners was high among this sample, condom use misreporting because of recall or social desirability biases is also likely;44
HIV prevention targeting those affected by incarceration should include increased access to condoms and promotion of condom use. Social venues where those with a history of incarceration are likely to socialize and meet new sexual partners, such as those identified in the NC PLACE Study, are prime candidates for community-based interventions including condom promotion and HIV/AIDS education and HIV testing. Inclusion of substance abuse treatment in HIV/AIDS prevention programming developed for those affected by incarceration will likely be a critical component of decreasing HIV-related sexual behaviors and improving health.