Sexually Transmitted Diseases:
Unprotected Sex With Multiple Partners: Implications for HIV Prevention Among Young Men With a History of Incarceration
Margolis, Andrew D. MPH*; MacGowan, Robin J. MPH*; Grinstead, Olga PHD†; Sosman, James MD‡; Kashif, Iqbal MPH*; Flanigan, Timothy P. MD§; the Project START Study Group
From the *Division of HIV/AIDS Prevention, National Center for HIV, STD, TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia; the †Center for AIDS Prevention Studies, University of California-San Francisco, San Francisco, California; the ‡Department of Medicine, University of Wisconsin Medical School, Madison, Wisconsin; and the §Department of Medicine, The Miriam Hospital and Brown Medical School, Providence, Rhode Island
The authors thank the study participants and the members of the Project START Study group for their contributions to the study. Project START Study Group members are John Askew, Lisa Belcher, Gina Best, Diane Binson, Jessica Berzowski, Don Bourque, Jeff Buckles, Mark Charles, Achintya N. Dey, Melissa Dispigno, Gloria Eldridge, Christine Fitzgerald, Timothy Flanigan, Marty Fortenberry, Juarlyn Gaiter, Kellie Green, Olga Grinstead, Jacki Hecht, Kashif Iqbal, Daryl Johnson, Jaclynn Kurpewski, Deborah Kacanek, Anthony King, Carolyn King, Katie Kramer, Melanie Krapf, Annette Lerma, Ricky Lugo, Moribe Lumumba, Robin MacGowan, Kelly Malen, Andrew Margolis, Tim McAuliffe, Kathleen McCartney, Jax McKee-Shapter, Jill Nealey-Moore, Kathleen Morrow, Susan Moss, Mobette Nacua, Ann O'Leary, Stephanie Paton, Michael Patterson, Barbara Reed, Ricardo Reed, Merjo Roca, Noel Rosado, David Seal, Rodney Simms, James Sosman, Kimberly Starr, Daniel Strother, Jerry Vardaman, John M. Williamson, Richard Wolitski, Meghan Woods, William Woods, and Barry Zack. The authors also thank Marie Morgan, Cari Courtenay-Quirk, and Lee Warner (all CDC) for their critical review of the manuscript.
This study was funded by CDC through cooperative agreement number 97,050.
All research activities were approved by Institutional Review Boards at the CDC, Jackson State University, Medical College of Wisconsin, Brown University/the Miriam Hospital, and the University of California San Francisco. All participants provided written consent. Data was protected by a Federal Certificate of Confidentiality. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
Correspondence: Andrew D. Margolis, MPH, Prevention Research Branch, Division of HIV/AIDS Prevention, National Center for HIV, STD, TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, Mail Stop E-37, Atlanta, GA 30333. E-mail: AMargolis@cdc.gov.
Received for publication April 29, 2005, and accepted July 19, 2005.
Objectives: The objectives of this study were to describe preincarceration risk behaviors of young men and identify correlates of unprotected sex with multiple partners during the 3 months before incarceration.
Study: Data on preincarceration risk behaviors were obtained from 550 men, aged 18 to 29 years, in state prisons in California, Mississippi, Rhode Island, and Wisconsin. Correlates of unprotected sex with multiple partners were determined by logistic regression.
Results: Of 550 participants, 71% had multiple sex partners, 65.1% had sex with a partner they perceived as risky, and 45.3% engaged in unprotected sex with multiple partners. Men who drank heavily (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.11–2.54) or who had a risky partner (OR, 3.90; 95% CI, 2.60–5.85) were more likely to report unprotected sex with multiple partners. Men who attended religious gatherings (OR, 0.66; 95% CI, 0.46–0.96) or lived in stable housing (OR, 0.69; 95% CI, 0.48–1.00) were less likely to report unprotected sex with multiple partners.
Conclusions: Most participants engaged in behaviors that could result in a sexually transmitted disease, including HIV. Prevention programs should address the relationship between heavy alcohol use and risky sexual behavior. Discharge planning should address housing needs. Faith-based community organizations may play an important role for some young men in their transition to the community.
IN THE UNITED STATES, APPROXIMATELY 2 million persons are incarcerated.1 An additional 4 million persons are on parole or probation. In 2001, the rate of incarceration was one of every 146 U.S. residents,1 a rate surpassing that of any other industrialized nation.2 Black and Latino men are disproportionately represented among people incarcerated.1 Most incarcerated men are eventually released,3 and many are reincarcerated.4
Most persons entering correctional facilities have a history of high-risk sexual behaviors and substance abuse.5–10 High rates of sexually transmitted diseases (STDs), including HIV infection, have been documented among persons entering the correctional system.11,12 Correctional systems have the potential to make important contributions to public health by providing much-needed prevention services to this otherwise hard-to-reach high-risk population. However, the extent of these services has primarily been limited to HIV testing and counseling13–15 and other programs that concentrate more on education than on behavior change.16 Few correctional systems have been able to institute comprehensive HIV prevention and treatment programs.16 Factors such as overcrowding, staff availability, budget restrictions, and a primary focus on custody and security have limited the provision of comprehensive HIV prevention services.17
A broader understanding of the sexual practices among incarcerated men before incarceration may help researchers design innovative, cost-effective, and population-specific HIV-prevention programs that address the needs of these men after release and that are also suitable for the operational constraints of the correctional environment.
In this article, we explore the sexual risk behaviors practiced before incarceration by young men who were recruited into Project START, a federally funded research study comparing the efficacy of 2 HIV, STD, and hepatitis prevention interventions for young men being released from prison. The study was conducted by researchers at the Centers for Disease Control and Prevention (CDC), Jackson State University (Jackson, MS), the Miriam Hospital/Brown Medical School (Providence, RI), the Medical College of Wisconsin Center for AIDS Intervention Research (Milwaukee, WI), the University of California-San Francisco Center for AIDS Prevention Studies (San Francisco, CA), and Centerforce—a community-based organization (San Rafael, CA).
Study participants were recruited from one state prison in Rhode Island, Mississippi, and California and from 5 state prisons in Wisconsin. Participants were men who were 1) 18 to 29 years of age at the time of enrollment, 2) incarcerated for at least 90 days, 3) scheduled to be released from prison within 14 to 60 days, 4) able to provide informed consent, 5) able and willing to provide basic personal postrelease contact information, 6) able to communicate in English, and 7) released to an unrestricted environment within a site-specified catchment area.
Potential study participants were identified by reviewing monthly prison lists containing the names of men who were 18 to 29 years of age and who were scheduled for release. When the number of potentially eligible participants exceeded recruitment goals, potential participants were approached according to their release date or randomly selected for approach.
All interviews were conducted in prison by using laptops and audio-computer-assisted self-interview (ACASI) technology (Nova Research Co., Bethesda, MD) in Mississippi, Rhode Island, and Wisconsin, and through interviewer-administered questionnaires in California (where correctional restrictions prohibited computers in the prison). The assessment items addressed sexual behavior, substance use, resource utilization, lifetime testing for infectious diseases, and other demographic characteristics. Men who completed the survey were provided a $30 incentive in Mississippi and Wisconsin and a $40 incentive in the other 2 sites. Participants obtained the funds after they were released from prison.
The sexual behavior survey assessed behaviors during the 3 months before incarceration. Partner-by-partner behaviors included an assessment of the frequency of sexual activity (oral, vaginal, and anal sex) and condom use with the 2 most recent main partners and the 2 most recent casual partners. For example, “During the 3 months before your incarceration, about how many times did you and [your partner] have vaginal sex?” and “Of the [number] times that you and [your partner] had anal sex, about how many times did you wear a condom?” A main sex partner was defined as someone to whom the participant felt a special emotional attachment or commitment, and a casual partner was defined as someone with whom the participant did not have a committed relationship. Sexual behaviors with additional partners were assessed collectively for main partners and collectively for casual partners. Partner-specific risk was assessed by asking participants whether they thought any of the following were true for their partner(s): injected drugs, smoked crack cocaine, traded sex for drugs or money, had multiple sex partners, had been diagnosed with an STD, or was HIV-positive. For the purpose of these analyses, a partner with any of these characteristics was defined as a risky sex partner. Unprotected sex with multiple partners was defined as having unprotected vaginal or anal intercourse with 2 or more partners during the 3 months before incarceration.
Alcohol and drug use referred both to lifetime behaviors and activities engaged in during the 3 months before incarceration. Substances were assessed separately: alcohol, marijuana, crack cocaine, powder cocaine, heroin, PCP (phencyclidine), LSD (lysergic acid diethylamide), amphetamines (speed, speedball), ecstasy, or sedatives. For example, “Have you ever injected drugs, including steroids?” and “During the 3 months before your incarceration, how often did you use crack?” Heavy alcohol use was defined as 5 or more drinks 1 or more days per week.
For the purpose of these analyses, stable housing was defined as living in one house or apartment and whether the participant or someone else owned or rented it. Unstable housing was defined as living in any place that was not a house or apartment (e.g., motel, boarding house, jail, drug treatment facility, or on the street) or living in multiple dwellings during the 3 months before incarceration. Employment was defined as a full-time or part-time job. Accessing health-related services encompassed general medical care; testing or educational services for HIV, an STD, or hepatitis; alcohol or drug treatment; child or family programs; anger-management programs; or other programs. Involvement in religious services, prayer ceremonies, or meetings referred to attendance at such gatherings during the 3 months before incarceration.
Data analyses were conducted by using SPSS software (Statistical Package for the Social Sciences, version 12.0). The chi-squared test was used to determine significant findings at the univariate level (P ≤0.05). All significant univariate associations were entered into a stepwise logistic regression model (P ≤0.05). The final model includes variables associated with unprotected sex with multiple partners.
A total of 591 men were eligible for the study; however, 30 (5.1%) refused participation. The remaining 561 men were enrolled in the study, and 550 (98%) completed the assessment and met all of the other Project START eligibility requirements (Table 1). The age of the participants ranged from 18 to 29 years (mean, 23.1 years). Just over half (51.8%) of the men were black. Total time incarcerated since the age of 18 ranged from 2 to 155 months (median, 32.5 months). Most of the men were not married (92.9%), and more than one third (36.0%) reported having been given a diagnosis of an STD, including 2 participants who were HIV-positive, 3 who had hepatitis B infection, and 6 who had hepatitis C infection. Injection drug use (past or present) was reported by 8%.
Most of the men (71.8%) reported marijuana use (77.5%) and heavy alcohol consumption (71.8%) during the 3 months before incarceration. Half (49.8%) of the men also reported using other drugs (crack cocaine, powder cocaine, heroin, PCP, LSD, amphetamines, ecstasy, or sedatives). Almost half (48.2%) of the men reported unstable housing. Many (58.4%) had accessed health-related services in the community during the reporting period.
Most (95.7%) of the men were sexually active during the 3 months before their current incarceration; all but 12 (2.2%) reported sex only with female partners. Almost three fourths (71.3%) of the men reported multiple sex partners (median, 4; range, 2–123), and nearly two thirds (65.1%) reported having had a partner they perceived to be risky.
Almost half (45.3%) of the men reported unprotected sex with multiple partners during the 3 months before incarceration (Table 2). Almost all had vaginal sex (98.4%), and approximately half (46.2%) had anal sex (data not shown). Participants reporting unprotected sex with multiple partners included approximately half of those who reported having ever had an STD (53.0%), and slightly more than half reporting a risky sexual partner (57.0%). There were significant differences in unprotected sex with multiple partners by site; race/ethnicity; STD diagnosis; stable housing; attending religious services, prayer ceremonies, or meetings; heavy alcohol use; and having a risky sexual partner. Specifically, men who had ever had an STD diagnosis or who had reported unstable housing, heavy alcohol use, a risky sex partner, or no attendance at religious services, prayer ceremonies, or meetings during the 3 months before incarceration were more likely to report unprotected sex with multiple partners.
The variables that were independently associated with unprotected sex with multiple partners in multivariate analyses were having a risky partner; heavy alcohol use; attending religious services, prayer ceremonies, or meetings; and stable housing. Men who reported having had a risky sexual partner (odds ratio [OR], 3.90; 95% confidence interval [CI], 2.60–5.85), compared with men who did not, were more likely to report unprotected sex with multiple partners. Men who reported heavy alcohol use (OR, 1.68; 95% CI, 1.11–2.54), compared with those who did not, were also more likely to have had unprotected sex with multiple partners. Men who attended religious services, prayer ceremonies, or meetings (OR, 0.66; 95% CI, 0.46–0.96), compared with those who did not, were less likely to have had unprotected sex with multiple partners. Additionally, men with stable housing (OR, 0.69; 95% CI, 0.48–1.00), compared with men with unstable housing, were less likely to report unprotected sex with multiple partners.
Many of the incarcerated young men in our study reported preincarceration sexual risk behaviors that could result in HIV/STD transmission. Most of these risk behaviors involved sex with female partners. These findings support research that has demonstrated significant risk behavior and infectious disease history among men entering prison.7,10,18 In this cohort, heavy alcohol consumption, risky sexual partnerships, lack of involvement in organized religion, and lack of stable housing appear to be associated with sexual risk. Having ever had an STD did not significantly reduce the likelihood of engaging in unprotected sex with multiple partners.
The variables most strongly associated with increased unprotected sex with multiple partners were a risky sex partner and heavy alcohol use. Nearly half of the men who drank heavily reported engaging in unprotected sex with multiple partners, as did slightly more than half of the men with a risky partner. Our findings related to increased sexual risk among men with risky partners may be explained by social network research, which has found that persons typically choose sex partners who are likely to engage in sexual behaviors similar to their own.19,20 Although research findings related to alcohol use and sexual risk behavior have varied, depending on the specific population being studied,21 a recent review of studies in which event-level methods were used suggests that alcohol use is typically associated with high-risk sexual behavior.22 In formative research with men released from prison, we found that for men with multiple partners, alcohol and drug use in conjunction with sex was the only factor independently associated with unprotected vaginal sex with at least one partner.5 Additionally, research involving sentenced male prisoners showed a trend toward increased HIV risk among men who drank alcohol heavily (4 or more drinks/day).18
Men who attended religious services, prayer ceremonies, or meetings were significantly less likely to engage in unprotected sex with multiple partners. A possible explanation for this may be that involvement in religious services, prayer ceremonies, or meetings brought these young men into contact with persons (e.g., clergy, congregants) who provided a positive influence. However, this association remains somewhat unclear given that attendance at these events could be a marker for other influences that were not quantitatively measured (e.g., faith or religiosity, effect of family, core group of friends, maturity, social responsibility, or participation in other structured activities). A correlation has been found between religious faith and fewer HIV risk behaviors among a sample of injection drug users,23 and more recently, an inverse relationship has been found between HIV-risk behavior and strength of spirituality and religious faith among inner-city cocaine users.24
In our sample, stable housing was independently associated with less sexual risk. Although studies have documented the concurrence of HIV infection and homelessness,25,26 the relationship between housing stability and HIV/STD prevention is less well defined. In a recent study, housing status was strongly associated with sexual risk behaviors: homeless and marginally housed persons were at greater risk than those who were stably housed.27 However, investigators did not establish a causal relationship between housing status and HIV risk. In another study, housing was associated with better health outcomes among people transitioning from prison to the community.28 Nonetheless, the provision of adequate housing for men who have been incarcerated is difficult in many communities because of limited resources, long waiting lists, and policies that exclude persons with felony convictions.29 As a result, men returning to the community are often forced to live with friends or relatives who may have contributed to their substance abuse and sexual risk-taking behaviors before incarceration.30
Although unadjusted associations were observed between race/ethnicity, geographic site, and sexual risk, these associations did not remain significant in multivariate analyses. Although it is difficult to offer compelling explanations for these observations, the associations suggest important areas of focus for further research and are likely to have important implications for the refinement of prevention programs for this population.
Using health-related services in the community seemed to be acceptable to these young men. However, the use of health services was not associated with lower rates of unprotected sex with multiple partners. This could be because these services may not have addressed the reduction of sexual risk. Allowing community-health service providers, particularly those that provide HIV/STD prevention, to serve men during incarceration, could further facilitate the use of these services after release. This could also reduce correctional facility costs associated with the provision of comprehensive prevention programs during incarceration.
Reaching young men at risk for HIV, hepatitis, and STDs before incarceration is ideal but may not always be possible. However, correctional facilities offer an opportunity to engage these men in prevention programs.31 A new emphasis on providing incarcerated people with comprehensive prevention programs has been emerging. The Centers for Disease Control and Prevention and the Health Resources and Services Administration funded demonstration projects to develop comprehensive programs to prevent HIV/STD, tuberculosis, hepatitis, and substance abuse and to promote health care; these programs would begin during incarceration and continue after release.32 The Jacksonville Jail, Duval County Florida, for example, has integrated an open-door policy, which allows access to incarcerated men by community-based organizations and other medical and mental health professionals.33 As a result, these providers are able to maintain continuity of care during incarceration.33 The Hampden County, Massachusetts, Correctional Center has integrated into its system a public health model that includes disease screening, patient health education, prevention, treatment, discharge planning, and continuity of care after release.34 These examples indicate a willingness on the part of correctional systems to collaborate with community-based health services agencies and represent a positive direction that can have an important effect on public health.
Our study had limitations. Because the lengths of incarceration differed, the reporting of substance use and sexual behaviors during the 3 months before incarceration may not be accurate for all men. Men who were incarcerated for a longer period may have had more difficulty recalling activities they engaged in during the 3 months before incarceration. All data were reported by young men during incarceration, and therefore, may have been influenced by social desirability responses and other situational biases. The use of A-CASI in sites permitting this technology may have allowed for greater privacy to participants, thereby minimizing some of these concerns to the extent possible. Additionally, this study involved young men 18 to 29 years of age recruited from 4 state prison systems; therefore, research findings may not be representative of all correctional populations.
The advancement of prevention programs in correctional institutions requires a progressive approach on the part of correctional administrators and community-based healthcare providers and the support of the public health research community. The high prevalence of sexual risk in this sample suggests that prevention programs should incorporate basic prevention messages, condom skills-building exercises, and population-specific behavioral risk-reduction planning. The relationship between heavy alcohol use and risky sexual behavior should be emphasized. Postrelease transition planning should include referrals to services that can help these men find stable housing. Faith-based community organizations may play an important role for some young men in their transition to the community.
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