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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