The findings of this study are somewhat consistent with other studies examining the relationship between HIV status and criminal justice involvement. In this sample of men in MMTPs, participants with a lifetime history of incarceration were over five times more likely to report being HIV positive compared to participants with no history of incarceration, odds higher than those reported in previous studies (Maruschak 2005
; Rich et al. 1999
). Past research has often pointed toward the high rates of substance abuse to explain the levels of HIV/AIDS in prisons and jails (Harrison and Beck 2003
; Swartz et al. 2004
). Yet, in our sample comprised entirely of men with serious substance abuse histories, incarceration history indicated a significant increase in the likelihood of HIV positive status, suggesting that substance abuse alone may not explain the higher rates of HIV in justice-involved men. Men with both substance abuse problems and criminal justice involvement appear to share increased HIV risk over men with substance abuse alone.
A key finding in this study is the strong relationship between sex trading and recent criminal justice involvement. More specifically, criminal justice involvement was most closely associated with selling sex for money or drugs. Considering that only four men in the sample had sex with a man in the past 6 months, and the majority of those reporting sex trading over their lifetime reported it as primarily or exclusively with women suggests that the sex trading risks reported above entail primarily sexual activity with women. Nonetheless, the importance of this finding is magnified by the extremely high risk for HIV infection and transmission among male sex workers (Estcourt et al. 2000
; Newman et al. 2004
). Previous studies have linked sex trading behaviors to crack cocaine use (Joe and Simpson 1995
; Latkin et al. 2003
), which is consistent with current analysis of this study's data showing that those who used crack were more likely to be involved in sex trading (Orellana et al. 2007
Furthermore, our study finds that recent arrest (and not incarceration) is associated with increased likelihood of unprotected vaginal sex and multiple sex partners, which is consistent with prior research suggesting that criminal justice-involved men in the community have equivalent or even increased risk of HIV infection compared to their incarcerated counterparts (Belenko et al. 2004
; Spaulding et al. 2002
). These findings highlight the need for research on risky sex behaviors among justice-involved men in community settings, namely men recently arrested or briefly detained in jails and short-term correctional centers.
This study is limited by several factors. The sample focuses on men with female primary sexual partners, which may limit the generalizability of results to all men on methadone. Second, criminal justice involvement is measured in terms of arrest and incarceration, which are essentially consequences of illegal behavior. While it would be more difficult to measure actual criminal behavior in this sample, such measurement may serve to better explain related behaviors in terms of HIV risk. Lastly, this study bears the characteristics of a major metropolitan center in terms of criminal justice practices, substance abuse, and HIV/AIDS, which may not be generalizable to all communities. Continued research on the association between criminal justice involvement and HIV risk for men on methadone would benefit from studies representing a variety of geographic and population density areas.
Despite these limitations, this paper's findings on the associations between incarceration history and HIV status underscore the need for delivery of effective HIV prevention models for substance abusing men who have spent time in correctional settings. Engaging men with a history of incarceration in HIV prevention may reduce transmission among these men and their sexual partners, and methadone treatment programs could be an important venue for outreach. Although MMTPs have provided HIV education and counseling for over two decades, more attention needs to be given to gender-specific HIV prevention for men with a history of incarceration, which may constitute a large portion of the client population. Counselors and other staff could include a history of incarceration in their clinical assessment, and use this as a marker for HIV risk. Peer-led prevention interventions, a successful approach among IDUs (Latkin 1998
), could target previously incarcerated men, which would move the focus beyond the individual level to social network and community norms (Metzger and Navaline 2003
Additionally, those who are involved in both substance abuse and the criminal justice system have higher odds of selling sex for money or drugs. While the proportion of this sample that recently engaged in sex trading was relatively small, this group represents a population in great need of focused HIV prevention/education efforts. And although incarceration settings are identified as an opportunity for initiation of treatment and intervention (Rich et al. 1999
), there is considerable need for prevention intervention efforts for justice-involved men in the community, where they have increased access to HIV risk opportunities.
The findings of this study emphasize the importance of future research that investigates the instrumental variables involved in the increased risk of HIV/AIDS for community-based, substance abusing offenders, as well as the need for focused prevention work with male offenders in the community. Although progress has been made in HIV prevention science, there are only a few evidence-based HIV intervention preventions for men with criminal justice involvement. More emphasis should be given to the design of gender-specific HIV intervention and dissemination of evidence-based models for such high-risk individuals in a variety of criminal justice settings. Addressing the severity of HIV risk for substance abusing men with criminal justice involvement will require integrated efforts at intervention and treatment from correctional settings, community criminal justice entities, substance abuse treatment, and the HIV/AIDS prevention community.