In the United States, heterosexual contact accounts for most HIV diagnoses among women.1 HIV prevalence is highest among black and Latina women and those of low socioeconomic status (SES).1 Black and Latina women and women of low socioeconomic status make up most of the growing number of incarcerated women,2 which between 2000 and 2010 grew twice as fast as men under correctional supervision.3 The national rate of those under correctional supervision (probation, parole, jail, or prison) in 2013 was 1 in 35 adults.3 Among women, rates of imprisonment are highest for black women ages 30–34 years (264 per 100,000 black women of the same age), followed by Latina (174 per 100,000) and white women (163 per 100,000). Black women were between 1.6 and 4.1 times as likely to be imprisoned as white women of any age group.2
Circumstances that lead to incarceration among women also lead to their increased risk of HIV infection.4 Women who are involved in the criminal justice system experience poverty, and substance abuse, and may engage in exchange sex (receiving money or drugs in exchange for sex with a partner).4,5 Women with few resources may exchange sex for food and shelter, as well as for illicit drugs among those who use them, both of which may lead to incarceration and HIV infection. Imprisoned women are twice as likely to be living with HIV as imprisoned men and evidence suggests most infections occur before incarceration as opposed to during; HIV prevalence among female prison inmates nationally was 3% in 1999.6 Recidivism is common and inmates frequently move between prison or jail and their home communities.7 As incarceration can disrupt sexual networks, women released from jail may find establishing monogamous sexual relationships with male partners challenging because their partners may engage with a number of other women and continue multiple or concurrent relationships.8 Involvement in the correctional system has been associated with multiple partnerships among adults in urban areas and sexually transmitted infections (STI), including HIV among jailed or imprisoned women.5,9
Jails and prisons provide important opportunities for HIV prevention.10 Currently, HIV prevention efforts for incarcerated populations in the United States are not comprehensive or standardized. A 2012 survey found few state prisons and large jails in the United States conforming to Centers for Disease Control and Prevention (CDC) recommendations for opt-out HIV testing during intake and linkage to care on release into the community.11 Linkage to care is particularly challenging in facilities like jails, where the incarcerated population may be more transient and have shorter incarceration lengths.12 Furthermore, women in correctional facilities have markedly fewer resources to address their health and medical needs, compared with imprisoned or jailed men.4 Specifically, female inmates have greater unmet substance use and mental health needs than male inmates. Understanding the rate of HIV testing and STI diagnoses among those who report incarceration is important.
Little is known about the prevalence of incarceration among low-income heterosexual women and its association with sexual behaviors and health services use. Most research on incarceration and HIV risk-related behaviors has used small convenience samples of jailed5 or local populations.9 Incarcerated individuals are disproportionately low income and less educated compared with nonincarcerated individuals13 and reside in low income, urban communities of color in US cities.14,15 Furthermore, HIV prevalence among heterosexuals is higher among those with low SES.16 Examining the association between incarceration and HIV-related behaviors specifically among low-SES communities may help identify additional prevention service needs. We used data from the National HIV Behavioral Surveillance (NHBS) system, which specifically recruits heterosexual men and women from high-poverty urban communities in the United States, to assess heterosexual women at increased risk for HIV infection. We evaluated prevalence of past and recent incarceration and compared HIV risk-related behaviors and health services use between women with, and without, a history of incarceration.
Sample and Procedures
NHBS monitors HIV-related behaviors among populations at risk for acquiring HIV in metropolitan statistical areas (MSAs) with high prevalence of AIDS.17 In 2013, NHBS collected data among heterosexuals in 20 MSAs.1 Respondents in the 2013 NHBS cycle were recruited using respondent-driven sampling (RDS), a peer-referral recruitment strategy.18 RDS is a social network-based sampling method in which individuals recruit those they know based on a chain referral model; it is primarily used for hard to reach populations. Eligibility for the survey was restricted to persons who were male or female, aged 18–60 years, resided in the participating MSA, able to complete the survey in either English or Spanish, reported vaginal or anal sex with an opposite sex partner in the previous 12 months, and provided informed consent. The RDS recruitment process continued until the sample size of heterosexual persons of low SES was reached or the sampling period ended. Low SES was defined as having completed no more than a high school education or having a household income at or below the US Department of Health and Human Services poverty guidelines.19 Details on recruitment methods are provided elsewhere.20
Data on incarceration history were drawn from responses to the question: “Have you ever been held in a detention center, jail, or prison for more than 24 hours?” If respondents indicated “no” then they were classified as “never incarcerated.” For respondents who answered “yes” they answered the question, “During the past 12 months, have you been held in a detention center, jail, or prison for more than 24 hours?” Respondents who indicated “no” were classified as “ever incarcerated” and those who indicated “yes” were classified as “recently incarcerated.” This measure may include individuals who have served a prison sentence and those who were detained for various reasons but for whom criminal charges may not have been filed. We evaluated age, race/ethnicity, education, poverty, homelessness, and region of residence as potential confounders.
Outcomes for this analysis were selected sexual risk behaviors with male partners, last partner's characteristics, substance use, HIV testing, and any STI diagnosis, all within the previous year. Sexual risk behaviors included exchange sex, total number of sex partners, casual sex partners, and casual condomless vaginal sex partners. Exchange sex in previous 12 months was based on respondents' report of receiving “things like money or drugs” in exchange for vaginal, oral, or anal sex with a main or causal partner within the previous 12 months. The number of casual sex partners was based on respondents' reports of male vaginal, oral, or anal sex partners to whom they did not feel committed. The number of casual condomless vaginal sex partners in the previous year was based on respondent's report of male casual sexual partners with whom a condom was not used during sex. These continuous responses were dichotomized: 0–2 partners and 3+ partners (multiple). Last partner characteristics were based on reports of whether their last male sex partner ever injected drugs, used crack/cocaine, was previously incarcerated, had sex with a man, and had a concurrent sex partner in the previous year. Respondents' answers were recoded as: “definitely did/probably did” responses as “yes” and “definitely did not/probably did not” responses as “no.” We examined the type of facility the respondent reported providing their most recent HIV test and whether recently jailed respondents received an HIV test while incarcerated. Regarding HIV sero-status, a nonreactive rapid test was considered a definitive negative result; a reactive (preliminary positive) rapid test result was considered a definitive positive only when confirmed by supplemental laboratory testing (eg, western blot, immunofluorescence assay, or nucleic acid amplification test).
We used separate log-linked Poisson regression models with generalized estimating equations with an exchangeable correlation matrix, clustered by recruitment chain, to assess the association between incarceration history and both sociodemographic characteristics and HIV-related behaviors. City and respondent's personal network size were included in each model to address variation within cities and some of the methodological complexities associated with RDS. For sociodemographics, we report the P-values of the Wald χ2 generated from the models. To assess the independent association between incarceration and each outcome, adjusted prevalence ratio (aPR) and confidence interval (CI) were estimated by including in each model the sociodemographic characteristics associated with incarceration in the Wald χ2 tests. These characteristics included: race/ethnicity (non-Hispanic black, Hispanic, and other), age (18–24, 25–29, 30–39, 40–49, and 50+), education (<high school, high school, and at least some college), and poverty level. The same confounders were included in all models. For the outcome of recent HIV test, we excluded respondents who were considered to be long-standing HIV positive (someone who tested positive more than year before the interview) and aware of their status. We used SAS 9.4 to conduct all statistical analyses and the standard alpha 0.05 cutoff.
During the 2013 data collection period, 6003 women were screened to participate in NHBS, and of those 656 (10.9%) did not meet eligibility criteria and were excluded from this analyses. Of the 5228 eligible women, 5154 consented to both survey and HIV test, completed the survey with valid responses as assessed by the interviewer, had completed responses for variables used in this analysis. Analyses in which HIV testing behavior was the outcome excluded 86 women who were considered to be long-standing HIV positive and aware of their status, reducing the sample to 5070.
Among the 5154 women included in this analysis, 590 (11%) reported being recently incarcerated, 1856 (36%) reported being ever incarcerated, and 2708 (53%) reported never being incarcerated (Table 1). Combined, nearly half of women in the sample had been incarcerated at some point in their lifetime. Recent incarceration was most commonly reported among women who: were aged 30–39 years old (15%), had less than a high school education (15%), had an annual income at or below the federal poverty level (12%), or were homeless (21%).
Multiple Sex Partners
Overall, women who reported recent or past incarceration were more likely to report multiple (3 or more) male sex partners, casual male sex partners, and casual condomless vaginal sex partners in the previous year. To illustrate, 42% of recently incarcerated (PR = 2.93, 95% CI: 1.98 to 4.32) and 31% of ever incarcerated women (PR = 2.49, 95% CI: 1.60 to 3.88) reported having multiple casual partners in the past 12 months, compared with 25% of never incarcerated women (Table 2). After adjusting for confounders, recently incarcerated (aPR = 2.13, 95% CI: 1.55 to 2.93) and ever incarcerated (aPR = 1.81, 95% CI: 1.26 to 2.6) were factors significantly associated with having multiple casual sex partners (Table 2). Similarly, women who reported recent and past incarceration were significantly more likely to report multiple casual condomless vaginal sex partners; 25% of recently incarcerated (PR = 3.2, 95% CI: 2.05 to 4.98) and 19% of ever incarcerated women (PR = 2.19, 95% CI: 1.61 to 2.98), compared with 14% of never incarcerated women. After adjusting for confounders, recently and ever incarcerated were associated with multiple casual condomless vaginal sex partners (aPR = 1.94, 95% CI: 1.40 to 2.68 and aPR = 1.59, 95% CI: 1.16 to 2.20, respectively).
Women who reported recent and past incarceration were more likely to report receiving money or drugs in exchange for sex in the past 12 months; 50% of recently incarcerated (PR = 2.56, 95% CI: 2.25 to 2.92) and 38% of ever incarcerated women (PR = 1.93, 95% CI: 1.68 to 2.22), compared with 20% of never incarcerated women. After adjusting for confounders, the factors recently and ever incarcerated were associated with recent exchange sex (aPR = 1.91, 95% CI: 1.69 to 2.17 and aPR = 1.54, 95% CI: 1.36 to 1.74, respectively).
Last Partner Characteristics
Overall, women who reported recent and past incarceration were more likely to report believing that their last partner ever injected drugs, used crack/cocaine, was incarcerated, had sex with a man, and had a concurrent sex partner. To illustrate, 23% of recently incarcerated women (PR = 2.75, 95% CI: 2.23 to 3.39) and 18% of ever incarcerated women (PR = 2.19, 95% CI: 1.82 to 2.63) reported having a partner who ever injected drugs, compared with 8% of those never incarcerated. After adjusting for confounders, the factors recently incarcerated (aPR = 2.05, 95% CI: 1.66 to 2.53) and ever incarcerated (aPR = 1.63, 95% CI: 1.35 to 1.95) were significantly associated with having a last partner who ever injected drugs. In addition, 79% of recently incarcerated women (PR = 1.48, 95% CI: 1.37 to 1.59) and 72% of ever incarcerated women (PR = 1.33, 95% CI: 1.25 to 1.43) reported that their last partner had been incarcerated, compared with 54% of those never incarcerated. After adjusting for confounders, the factors recently and ever incarcerated were associated with having a last partner who had been incarcerated (aPR 1.39, 95% CI: 1.29 to 1.50 and aPR 1.31, 95% CI: 1.23 to 1.40, respectively). Associations between the factors incarceration and last sex partner ever using crack/cocaine, ever having had sex with a man, and having concurrent sex partners remained significant in multivariable analyses.
Women who were recently and ever incarcerated were more likely to report both injection drug use and noninjection drug use. To illustrate, 11% of recently (PR = 9.61, 95% CI: 6.62 to 13.94) and 5% of ever incarcerated women (PR = 4.17, 95% CI: 2.58 to 6.73) reported injection drug use, compared with 1.2% of those never incarcerated. After adjusting for confounders, the magnitude of the prevalence ratios for recently incarcerated (aPR = 5.12, 95% CI: 3.37 to 7.79) and ever incarcerated (aPR = 2.37, 95% CI: 1.57 to 3.56) were reduced, but incarceration remained significantly associated with injection drug use. In addition, 78% of recently (PR = 1.66, 95% CI: 1.5 to 1.84) and 66% of ever incarcerated women (PR = 1.42, 95% CI: 1.3 to 1.55) reported noninjection drug use, compared with 47% of those never incarcerated. After adjusting for confounders, the factors recently (aPR = 1.59, 95% CI: 1.45 to 1.74) and ever incarcerated (aPR = 1.42, 95% CI: 1.31 to 1.53) were associated with noninjection drug use.
Health Service Use and HIV Prevalence
Overall, women who reported incarceration were more likely to report an STI diagnosis and HIV test in the previous year. Recent STI diagnosis was reported by 19% of recently incarcerated (PR = 1.89, 95% CI: 1.56 to 2.28) and 11% of ever incarcerated women (PR = 1.10, 95% CI: 0.93 to 1.31), compared with 10% of those never incarcerated. After adjusting for confounders, the factors recently and ever incarcerated were associated with a recent STI diagnosis (aPR = 1.77, 95% CI: 1.46 to 2.14 and aPR = 1.22, 95% CI: 1.01 to 1.46, respectively). Regarding HIV testing, 52% of recently incarcerated (PR = 1.35, 95% CI: 1.23 to 1.48) and 40% of ever incarcerated women (PR = 1.05, 95% CI: 0.97 to 1.14) were tested for HIV within the previous year, compared with 38% of never incarcerated women. After adjusting for confounders, the factors recently and ever incarcerated were associated with receiving a recent HIV test (aPR = 1.32, 95% CI: 1.21 to 1.44 and aPR = 1.13, 95% CI: 1.05 to 1.21, respectively). HIV prevalence was higher among women recently (3.7%, PR = 1.87, 95% CI: 0.94 to 3.71) and ever incarcerated (4.2%, PR = 2.08, 95% CI: 1.23 to 3.55), compared with those never incarcerated (2%). After adjusting for confounders, the factors recently and ever incarcerated were associated with being HIV positive (aPR = 1.66, 95% CI: 1.09 to 2.52 and aPR = 1.59, 95% CI: 1.12 to 2.28, respectively). Last, about a third of the women (35%) jailed within the previous year received an HIV test while in detention (not in table).
Nearly half of the women in this sample reported having been in jail or prison at some point in their lifetime and about one in 10 reported being in jail or prison within the 12 months preceding their interview. The national imprisonment rate for adult women in 2014 was 84 per 100,000.2 The high rate of incarceration in this low income, low-education sample is consistent with data that show socially and economically disadvantaged groups are more likely to be under correctional supervision.21 We found that women recently and ever incarcerated reported multiple behaviors that increase their HIV risk: multiple partners, exchange sex, substance use, and having partners with similar risks. Our sample primarily consisted of women from racial/ethnic minority groups, a third had less than a high school education, most lived at or below the federal poverty level, and nearly one in 4 had been homeless within the past year.
Women with a history of incarceration contend with multiple, intersecting challenges, eg, economic deprivation, homelessness, and physical and sexual abuse, that are associated with exchange sex and substance abuse, both of which are illegal behaviors that could result in incarceration.22,23 Exchange sex and substance use are associated with higher prevalence of HIV infection among women,5 so we highlight those behaviors to expound on the association between incarceration and HIV risk. In our sample, we found the prevalence of injection drug use is 5-times as high among recently incarcerated women compared with those never incarcerated. Women in state and federal prisons are more likely to be incarcerated for drug or property offenses than men.2,3 Incarcerated women are also more likely to have substance use disorders2 and report frequent drug use and use of harder drugs, compared with men.22 Relatedly, drug use is associated with exchange sex among women.5,23
We found the prevalence of exchange sex to be twice as high among recently incarcerated women compared with those never incarcerated. Women who exchange sex are frequently arrested, street-based sex workers much more so, but the prevalence of exchange sex among incarcerated women has not been well-documented until recently. A survey conducted among women in Rhode Island Department of Corrections facilities found 27% reported a history of exchange sex23; in our sample we found half of women recently incarcerated, and 38% of those ever incarcerated, reported exchange sex. A study on women in New York City jails found elevated rates of HIV infection, multiple sex partners, and drug use among sex workers compared with inmates who were not sex workers.5 On release, previously incarcerated women contend with lack of work opportunity, uncertain housing, and other stressors and barriers that can further encourage illegal or hazardous work like exchange sex.4,24 Recidivism is quite common and inmates' ability to re-enter their home communities has individual-and community-level implications.8
Our findings suggest women with a history of incarceration are embedded in sexual networks of partners who are at risk of HIV infection.8 Sex partners of women with a history of incarceration were reported to be more likely to have been incarcerated, use injection drugs and crack cocaine, have had sex with a man, and concurrent sex partners. Research shows that sexual and intimate relationships influence women's risk of incarceration through multiple pathways.4 Illegal activity, like exchange sex and substance abuse, are often introduced by male partners in the context of an intimate relationship.25 Abusive partners may cause low-income women to lose employment, housing, and social welfare benefits through battery and harassment.26 Without support, such women have few choices to garner resources and may engage in exchange sex and substance use to cope.27 We found that women with a history of incarceration were likely to have partners who had been incarcerated. Previous research shows that incarceration among men is associated with concurrent partnerships, multiple partnerships, and condomless sex,4,28 suggesting partners of women with a history of incarceration engage in risky sexual behaviors. Women's sex partners' risk is particularly important because heterosexual contact accounts for virtually all new infections among women.1 These findings suggest HIV-reduction strategies for women may need to address male sexual partners' risks.
We found that women in this sample with a history of incarceration had a 4% prevalence of HIV infection, compared with 2% among women never incarcerated. Prevalence of HIV testing was also higher among those with a history of incarceration, suggesting that HIV testing is being offered at jails and prisons. Targeted testing with linkage to care among this group would help identify new infections and reduce further transmission to sexual and injection partners. It is important that testing occur at admission or during custody at the jail or prison and not during the prerelease process before women return to their communities.29 A recent report indicates most US states are not testing all inmates for HIV at admission or during custody,30 which could indicate some HIV-infected inmates do not get treatment for infection while in custody.
Limitations to this analysis should be considered. The heterosexual cycle of NHBS samples low-SES heterosexuals in metropolitan areas, and it may not be representative of all heterosexuals in urban environments or those in nonurban environments. RDS sampling weights were not used in our analysis and point estimates may be biased by over-or under-represented subgroups of the sample; however, we account for potential sampling biases by accounting for recruitment chains and adjusting for respondent's network size in the Poisson models with generalized estimating equation. Because the survey was administered by an interviewer, certain behaviors might have been under-or over-reported. For example, respondents may have underreported socially undesirable behaviors (eg, exchange sex, drug use). Furthermore, we do not have data on respondents' reasons for detainment, so we cannot infer whether incarceration was because of reported illegal behaviors, like exchange sex. In addition, we do not know when respondents were detained in relation to their interview date, the length of their detainment (except that it was at least 24 hours), or whether the respondent was in a local jail, state, or federal prison. Last, since data used in this analysis are cross-sectional, we cannot infer causality.
These findings highlight the need for research, programmatic, and policy efforts to address determinants of both incarceration and HIV infection among vulnerable women. Incarcerated women exhibit a greater need for comprehensive health and mental health services because of their higher rate of substance abuse, psychiatric disorders, and poverty,4,31 therefore, diverting at-risk women to appropriate mental health and drug treatment services can maximize their protection from being incarcerated at the outset.32 Linking individuals to safe and adequate housing and social services, for example, can mitigate the link between poverty, incarceration, and risk-related behaviors, like exchange sex.4,33 For women who are already in jail or prison, providing quality comprehensive services can simultaneously promote HIV risk reduction and treat HIV-infected women. Increased access to HIV testing could help identify HIV-positive women and facilitate linkage to treatment and care.33 Initiatives that promote rehabilitation and healthy re-entry into communities can reduce recidivism and increase the health of women and their home communities.24,34 Despite evidence of the effectiveness of HIV interventions in correctional settings,33 strained budgets prevent implementation of such initiatives.35 However, prioritizing the health needs of women in correctional facilities could directly reduce HIV incidence at the individual and community level.10
We thank the NHBS participants.
For the full list of NHBS Study Group participants, please see Supplemental Digital Content, http://links.lww.com/QAI/B37.
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