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Incarceration is a crisis among African-Americans, and the prevalence of HIV/AIDS in incarcerated men and women is three to five 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 African-American populations’ 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.
Widespread incarceration is a growing crisis in the African-American community. It results from the cumulative effects of poverty and under-education, the loss of the manufacturing job base in urban centers, the breakdown of Black families, the war on drugs, disparate sentencing laws, and discrimination within the criminal justice system. These factors contribute to numerous racial/ethnic health disparities, including HIV/AIDS. Given that the levels of HIV/AIDS in incarcerated men and women are three to five times that of the general population,1 that significant gaps in HIV treatment and prevention exist in incarcerated settings (Sylla M, “HIV treatment in U.S. jails and prisons,” Bulletin of Experimental Treatments for AIDS, in press, http://www.sfaf.org/beta/), and that concern about African-American men being infected with HIV during incarceration is prevalent among African Americans,2 we focus this article on pertinent research and related issues surrounding the epidemics of HIV/AIDS and incarceration. HIV transmission does occur in custody; however, many experts conclude from the available data that most HIV-infected inmates are likely infected prior to entering jail or prison.3–8 Nevertheless, incarceration contributes to HIV risk in African-American communities in a myriad of other ways (to be discussed below) and has the potential to affect treatment outcomes. These factors warrant increased intervention and focused study to better understand and address the impact of incarceration on the African American HIV/AIDS epidemic.
Incarceration rates in the United States have skyrocketed since 1970 and now directly or indirectly affect a substantial portion of African-American families. Approximately, 2.2 million Americans are incarcerated, a nearly 400% increase since 1980.9 An additional five million people are on parole or probation.10 In just the 12-year period from 1986 through 1997, incarceration rates for African Americans nearly doubled.11 One in 21 African-American men and one in 279 African-American women are currently incarcerated,12 and it is estimated that almost one in three African-American men will be imprisoned at some point during their lives.13 Rates of imprisonment for African-American men are 6.6 times higher than for White men and 2.6 times higher than for Hispanic men. Rates for African-American women are 3.8 times higher than for White women and 2.4 times higher than for Hispanic women.12 Perhaps most telling of the community-level impact of these trends are data indicating that approximately 7% of African-American children have one or more parents who are currently in jail or prison.14
Persons at risk for incarceration are more likely than others to be at high risk for HIV infection. This is particularly true for females, as prisons are the only setting in the U.S. where HIV prevalence is higher in females than in males, with approximately 2.6% of female and 1.8% of male state prison inmates known to be HIV infected.1 Incarcerated populations have a high prevalence of characteristics that are often related to risky behavioral practices and HIV infection. These risk characteristics include drug use,15,16 low socioeconomic status,17 exchange of sex for money or drugs,18 multiple sex partners,19 and a high prevalence of bacterial sexually transmitted infections (STIs),20–23 mental illness,24 and histories of sexual abuse and assault.17 In addition, incarcerated individuals are more likely to be African American, and compared to other racial/ethnic groups, non-Hispanic Blacks experience higher rates of HIV infection in every behavioral risk group.25 African-Americans constitute just 13% of the American population25 but make up 44% of all prison and jail inmates12 and half of all newly reported HIV infections.25
Further, African-American females make up two-thirds of newly reported HIV cases in females and 34% of all female inmates.25 Finally, research has shown that HIV-infected people are frequently incarcerated during the course of their disease, with an estimated 20–26% of all Americans living with HIV/AIDS incarcerated at some point in each year.26
High incarceration and re-incarceration rates negatively impact African-American communities by reducing opportunities for economic and educational advancement; diminishing political participation; decreasing the numbers of available sexual and marriage partners for African-American women; disrupting existing sexual relationships and family lives; and changing norms related to sex, monogamy, violence, and drug use.27–31 These patterns are particularly evident in urban areas with very high incarceration rates. One researcher estimated that three quarters of African-American males in Washington, D.C., could expect to be incarcerated in their lifetimes and that in neighborhoods with the highest incarceration rates, the male-to-female gender ratio is just 62:100.30 Incarceration can, however, also provide a window of opportunity for reaching at-risk individuals with generally low healthcare access for HIV-related prevention, testing, and care services.28,32,33 For example, one study indicated that 75% of HIV-infected inmates initiated their first antiretroviral treatment while incarcerated.34 Unfortunately for those receiving HIV-related care, incarceration and/or release can sometimes disrupt HIV treatment regimens and lead to a loss of access to vital ancillary services.28,31,35 Given the complex and interrelated ways in which incarceration impacts inmates, their personal networks, and the contexts in which sexual relationships occur in African-American communities, research, resources, and interventions are needed to reduce the dramatic Black/White disparities in incarceration rates, ameliorate the negative consequences of high incarceration rates, and document the impact of various incarceration-related policies on HIV treatment, adherence, and care utilization.
In-custody HIV transmission can occur through sexual activity, needle sharing for drug injection, tattooing with unsterilized equipment, and contact with blood or mucous membranes through violence. A number of published case studies and a smaller number of retrospective cohort studies have described cases of HIV transmission in U.S. inmates that occurred during incarceration.36–42 More recently, the Centers for Disease Control and Prevention (CDC) examined HIV seroconversion in 68 of 88 prison inmates known to have seroconverted between 1992 and 2005 in the majority (63%) African-American Georgia state prison inmate population. It should be noted that the known seroconverters represented a small percentage (9%) of HIV-infected prisoners housed in October 2005.43 Three other retrospective U.S.-based studies estimated HIV incidence rates in incarcerated men that ranged from 0 to 0.41% per year.37,39,41 In three studies involving a total of almost 6000 prison inmates who had been continuously incarcerated since 1977 or 1978, 52 identified HIV cases were likely to have seroconverted during incarceration periods of more than 15 years each (Coe and Schumann, unpublished data, 1995).40,42 Other data indicate that incarcerated individuals report higher participation in risky behaviors outside rather than inside of prison and jail settings.3,5,6 For example, a Los Angeles-based case-control study to examine the impact of incarceration on HIV risk in African-American men did not find that incarceration was a risk factor for infection and found that those men who reported anal sex with other men were more likely to report this activity prior to and after, rather than during, periods of incarceration.6 Finally, the large number of studies finding high HIV prevalence in inmates at jail or prison entry (Harawa NT, Bingham TA, Butler QR, et al., unpublished data),37,44–49 and in female inmates who are unlikely to be infected through in-custody sexual transmission,44,45,47,49 further indicates that the elevated HIV prevalences seen in inmates compared with the general population may result largely from transmission occurring prior to rather than during incarceration.
HIV testing at entry is mandatory in 20 state prison systems; however, testing prior to release is required in just three. With such inconsistent testing policies, no system-wide data exist on the rates of intra-prison HIV transmission. Although, testing is made available in all other correctional settings and is generally required in cases of sex-related crime charges and potential exposure of infectious body fluids to personnel or other inmates,1 recommendations for universal offering of HIV testing in correctional institutions50 are a long way from being met. Other HIV-prevention services are available in an inconsistent or incomplete fashion throughout the system. They include provision of audiovisual or written educational materials, instructor-led educational modules, peer-education programs, prevention case management, and access to condoms; 51–55 however, the latter is limited to only two prison and five jail systems in the U.S. (<1% of the incarcerated population).2,8 Bleach, for the cleaning of injection equipment, is distributed in just one facility.51 Although in-custody needle exchange programs have been successfully implemented in a number of international settings56 and community-based exchange programs exist in many U.S. cities, no U.S. prison or jail facilities provide needle exchange.51 This is true despite estimates that significant portions of incarcerated populations are injection drug users.26
Treatment for HIV infection is made available throughout the correctional system as part of the medical care constitutionally required for inmates. Nevertheless, limitations to this care include insufficient provider expertise, nursing shortages, and inadequate access to HIV pharmaceuticals.(Sylla M, “HIV Treatment in U.S. Jails and Prisons,” Bulletin of Experimental Treatments for AIDS, in press. www.sfaf.org/beta/.),57 For example, only 43% of correctional care providers recently surveyed stated that an HIV specialist was “often” available to see patients at the facility where they worked, and 38% reported that a specialist was never available. Conversely, 93% of respondents involved with community HIV care reported that an HIV specialist was “often” available to see patients at the clinic/hospital where they worked, and none reported that a specialist was “never” available.58 Further, delays in HIV treatment and care of new inmates and treatment interruptions, resulting from transfers or disciplinary actions, can lead to missed medications and the possible emergence of drug-resistant HIV strains, particularly in jail settings.(Sylla, Ibid.) Finally, HIV stigma, the lack of privacy, and provider distrust may also reduce utilization of HIV treatment in many jail and prison settings.56,57 For example, inmates often lack any type of real confidentiality to prevent information about their HIV status from reaching guards or other inmates, disclosure can lead to ostracism or abuse, and known HIV-infected prisoners are sometimes segregated or prevented access to certain programs and privileges available to other prisoners.(Sylla, Ibid.)
Research is needed to determine how both incarceration itself and the high rates of incarceration within African-American communities affect HIV risk behaviors and HIV incidence among (1) those incarcerated, (2) the sexual partners and personal networks of those left behind, and (3) the community at large. A small number of cross-sectional studies have examined HIV-related behaviors in incarcerated persons3,5,6,60,62 and partners of recently incarcerated individuals,52,61–63 and qualitative and contextual research has documented the negative influences of incarceration on the expectations of sexual partners.27,29,31 In addition, at least one ecologic study has associated changes in AIDS incidence in African-American communities with increases in incarceration rates of African-America men.64 These studies provide a template for moving forward with research that more comprehensively examines the complex influences of incarceration on HIV risk over time. Addressing these questions will require cross-sectional and longitudinal studies to examine individual-level risk behaviors during periods of incarceration and release, HIV antibody status at entry and release from jail or prison, and population-level changes in infection rates and risk behaviors over periods in which incarceration rates rise or fall.
Given the widespread concern about the contribution of HIV transmission during incarceration to high HIV rates in African-American men, research is needed to estimate the percentage of all HIV infections in African-American men that are directly attributable to transmission during incarceration. The benefit of such information is that it will help to both garner resources for in-custody HIV prevention efforts and properly direct community concerns regarding the role of incarceration in the HIV epidemic. The commonly held belief that HIV transmission through male-to-male sex during incarceration is a principal reason for elevated rates of HIV in African-American communities may inadvertently stigmatize incarcerated African-American men and distract attention and political will from addressing the other effects of incarceration outlined here8 and the other factors that contribute to the high HIV prevalence in African-American communities. These other factors include unprotected consensual sex between men outside of jails and prisons; sharing of needles and injection equipment; concurrent sexual partnerships and other sexual mixing patterns; lack of access to health care, effective prevention education, and other resources; racism; gender inequalities; and homophobia.
Much of the information on deficits in access to appropriate medical care for HIV infection during incarceration is based on anecdotal evidence or legal actions that took place in certain jail or prison systems.(for example 65) Systematic state-by-state data are needed on inmates’ levels of access to appropriate medical care for HIV infection in federal, state, and local jurisdictions. More than 95% of prison inmates will be released at some point during their lifetime,66 and many will face competing needs and comorbid conditions (e.g., mental illness and substance dependence) that may hinder HIV care utilization and treatment adherence on release. The immediate post-release period has been identified as involving very high risk for mortality,67 and few services are currently in place to ensure continuity of medical care on release.28,32 Hence, more transitional HIV case-management programs, which have been successfully implemented in a number of facilities,7,68 are urgently needed. To most effectively broaden transitional HIV case management services, more data are needed on the current penetration of these programs and the best practices for their implementation.
To better assess how high incarceration rates affect HIV risk behaviors and rates among each group, we suggest the following types of research in each potentially affected segment of the African-American community:
Such research will focus much needed attention on a population and a problem that is frequently ignored or marginalized. Further, by illustrating the ways in which incarceration impacts not just those who are detained but their partners, families, and communities, the research has the potential to marshal political will for programs and policies that reduce the damaging impact of widespread incarceration on African-American populations’ ability to successfully address the HIV/AIDS epidemic. Although this manuscript’s goal was to suggest ways to advance research on the impact of incarceration on the African American HIV/AIDS epidemic, we also wish to underscore the urgency of implementing policy changes that will lower overall incarceration rates, reduce racial/ethnic inequities in sentencing, improve in-custody medical treatment, enhance continuity of care on release, and otherwise facilitate the successful reentry and reintegration into society of former prisoners.
We acknowledge the following people for their comments and suggestions on early drafts: Olga Grinstead, Rhondee Benjamin-Johnson, Vincent Jones, Sharif Sawires and Mary Sylla. We would also like to thank Sangeeta Fernandes and Faith Muhlenburg for their support. This article was supported in part by grants from the UCLA/DREW Project EXPORT, NCMHD, P20MD000148/ P20MD000182 from NCMHD, California HIV/AIDS Research Program (CHRP) - funded Institute for Community Health Research (CH05-DREW-616; CH05-LAC-617; CH05-RAND-618) and the NIMH-funded UCLA/Drew /RAND Center for HIV Identification, Prevention and Treatment Services (CHIPTS) (5P30MH058107).