Participant characteristics are described in . We did not specifically ask about HIV, HCV or other medical or psychiatric diagnoses; however, seven participants disclosed they had HCV and one participant disclosed HIV infection. These numbers are likely an underestimate given that we only have this information for those participants who volunteered it. Based on analysis of interview transcripts, we created a conceptual model of the multiple factors impacting rates of HIV/HCV infection, progression, and transmission in former inmates (). Four major themes had particular importance to our participants in the re-entry period.
Participant Characteristics (n=29)
Conceptual Model of Factors Impacting HIV-related Health Outcomes
- Risk behaviors for acquiring or transmitting HIV and/or HCV infection were prevalent in the immediate post-release period. These risk behaviors included poly-substance use, unprotected sex, the exchange of sex for drugs or money, non-consensual sex reported by women, and limited availability of sterile injecting equipment. These risk behaviors were highly linked to drug and alcohol use. For instance, one 46 year old woman with multiple incarcerations described the relationship between release from prison, drinking alcohol and having unprotected sex:
“…this is why like I am trying very hard not to drink or anything because I make stupid decisions…but in the past, yep. I got out [of prison], I drank and I had unprotected sex…”
A 28 year old mother, who had been incarcerated four times, described how the use of alcohol and marijuana led to other risky behaviors:
“It’s [alcohol] a gateway drug, you know? They start drinking, you meet people at the bar, people have dope, you’re already intoxicated…Most people start out with drinking, smoking pot and that leads to other things.”
This participant was enrolled in a criminal justice funded addiction treatment program, and when she reflected on her experiences after release from prison during member checks, she also related the fact that non-consensual sexual encounters led to potential exposure to HIV:
“How many times you were taken advantage of and you stuffed it away or how many times you were raped and didn’t tell anybody about it ‘cause you were scared… How many times you fell asleep and you just don’t know what happened”
Drug use was also a major contributor to risky behavior in the post-release period. Despite knowledge of the risks associated with sharing injecting equipment, the same 28 year old woman described the occurrence of risky needle use:
“If there is only one needle and there’s two of you, they’re going to share…When you’re in your addiction, you don’t care. You don’t think about the possibilities of what that person has, you just think about the high you’re going to get from using that needle.”
Several participants described risky behaviors associated with exchanging sex and drugs. Transactional sex was described as one method for quickly acquiring drugs in the immediate post-release period. One 43 year old man explained:
“[I’ve had] unprotected sex with these females that be out here [of prison] and it doesn’t take much to get one of them. All you have to do is give them a few dollars or some crack.”
One woman described her perception that recently released women turned to exchanging sex for money or drugs because they did not have housing or money after release.
“They got people they go to. They got tricks or sugar daddies, pimps that it’s easy for them to find.”
A 33 year old single mother of three children described the practice of exchanging sex in prison and how that related to risky behavior after release.
“There’s a lot of prostitution like even in prison… really a high rate of girls turn to sex with other women when they’re in prison… then they get out and they just keep using that behavior of getting drugs for sex.”
In probing further about sexual risk, a 45 year old male with two young children highlighted the theme of misogyny when he discussed exchanging sex for drugs:
“If they got girlfriends or wives or…I guess you can call them (laughing) hood rats…when a female starts doing any kind of drug like meth or speed…I mean meth or cocaine or anything, they get addicted like that.…so, they’ll do whatever they gotta do to get it.”
Finally, lack of access to condoms and sterile injection equipment amplified the risk of transmitting or acquiring HIV or HCV. One 47 year old male described his sexual encounters in the period after his release:
“When I got out, I did have intercourse…with a lady and I don’t know if she had it [HIV] or not. I: Did you use a condom? R: No. I didn’t have ‘em.”
Former inmates described the challenges in finding clean needles after relapsing to methamphetamine use after release:
“Stores won’t sell you needles if you’re not a diabetic and you look like a junky…if you go to a Walgreen’s at 3:00 in the morning to get a needle, they’re not going to sell you one ‘cause they know why you’re there… And then you would go use somebody else’s needle.”
In summary, former inmates commonly described risk behaviors for the spread of HIV/HCV in the immediate post-release period. Alcohol often instigated a spiral of escalating drug use and unsafe sexual practices. Despite the high rates of drug use and unprotected sex in the post-release period, former inmates did not use condoms or clean needles to reduce risk, mostly due to lack of immediate availability.
1. The second major theme was the immediacy with which former inmates engaged in risky behaviors after release from prison. Participants described feeling overwhelmed by the lack of structure and competing needs they faced after release. Most returned to chaotic environments where they were surrounded by drug use. The 28 year old woman interviewed while in substance abuse treatment described how the neighborhood to which one returns contributes to the immediate engagement in risky behavior:
“Any normal person that just got out doesn’t have anything but the clothes on their back and a week voucher in some [obscenity] hotel on the bad side of town, what are the odds for them to actually do something with that? There is none. There is like one percent that might make it out of there… They go back to what they knew before and so they fall back amid the old people, places and things and that’s where it [drug use and transactional sex] happens.”
Participants of both genders described an “as soon as I get out…” mentality that led to risky behavior in the first few days after release. Participants implied that this sense of urgency decreased with time after release. For instance, a young woman with four prior incarcerations described resuming drug use and sexual activity immediately after her release during a prior incarceration:
“I used [drugs] within the first two days…People that have been locked up for a long time, they just get out and pretty much want to have sex, you know?... you feel like you have to make up for all that lost time”
Both male and female participants described an urgency to engage in sexual activity after release from prison, which led to increased risk behaviors. A 43 year old male stated:
“The biggest threat to my safety probably would be going to put myself in a situation that I have done in the past, just to get with a female, just ’cause it’s been a while since I’ve had sex.”
Many of our interviews revealed the importance of masculine self-identity contributing to a sense of urgency to have sex after release:
“…if I find another piece of [obscenity], you know, I’m not dumb. I’m only human. I’m a man and then being out of prison, you know, being locked up that whole year and it’s pretty rough.”
In summary, we found that former inmates engaged in risky sexual and drug behavior in the immediate days after release, due in part to a sense a deprivation during incarceration, as well as returning to the same environments in which they were living prior to incarceration.
3. The third major theme was the factual errors and misconceptions about HIV/HCV transmission revealed by former inmates. When study participants were asked about how they might have put themselves at risk for HIV or HCV, one 22 year old male who was attempting to reconcile with his girlfriend and young son revealed misunderstanding the ability of birth control to prevent sexually transmitted infections (STI’s) and denial about the potential for infidelity by his partner:
“The only risk that I can think of would be intercourse with my girlfriend … it’s unprotected but she’s on birth control …from what she said she’s not been with anybody since I went away.”
A 24 year old male believed that transmission of HIV and HCV was related to basic hygiene:
“The DOC [Department of Corrections] putting me at risk by sending me to a [shelter] that people who do have Hepatitis C and the people ain’t clean and they’re not cleaning up after themselves, so that’s a risk for them, you know, for me.”
A 45 year old male correctly noted the transmission risk from drug use and sexual contact, but mistakenly believed HCV could be acquired from sharing water bottles:
“My understanding of the determining factors to being able to contract it [HCV or HIV] are sex which I haven’t had any of since I’ve been out in any shape or form, intravenous drug use and I don’t do that or…you know, blood transfusions. And Hep C possibly drinking after somebody and I try to drink from own water bottle.”
In summary, our interviews revealed common misunderstandings about how HIV and HCV are transmitted.
4. The fourth major theme was the common challenges faced in accessing health care and medications after release putting patients at risk for worsening health status and interruption in care. Participants commonly described long wait times to be screened for indigent care services. A 48 year old male with HCV described this process:
“I’ve spent quite a bit of time down there learning the ropes on what you have to do to get this free health care because you know how it’s free health care, but by golly you’re going to wait quite a long time and you gotta kind of know, you know, the ins and outs.”
Participants described difficulty obtaining needed medications after being released without them or with only a short-term supply. A 40 year old African American man with HIV revealed stopping his anti-retrovirals because he was concerned the side effects would prevent him from complying with parole requirements:
“They gave me a [30 day] supply of medication, but I’m not able to take the medication because the medication knock me out and I might not hear the page…If I don’t make these calls, that can be taken for escape for me not calling back…so I just don’t take my medication.”
At the same time, he readily acknowledged the risks associated with medication non- adherence:
“I: In the period of time after your release, what was the biggest threat to your health? R: Not taking my [HIV] meds.”
Other barriers related to obtaining health care in the immediate post-release time period ranged from lack of insurance, not knowing where and how to access care, and not being able to obtain needed medications. These factors were perceived by our participants to have a direct negative impact on health status after release.