Why incarceration matters for HIV in women and girls

[ Director's Notes: The following post is adapted from my opening comments at the March 10th, 2017 briefing on Mass Incarceration, Drug Policy, and HIV/AIDS, sponsored by the Congressional AIDS Caucus and hosted by the Honorable Rep. Barbara Lee. The Center for Public Health and Human Rights had led the research and development of a special Lancet issue on HIV and related infections among prisoners. In honor of National HIV in Women and Girls Awareness Day, this post focuses on the deep consequences of incarceration on HIV risk in women and girls - and in particular - minority women and girls in the United States. ] 

In developing the special Lancet issue on HIV and related infections among prisoners, we as physicians and researchers set out to investigate the impact of incarceration on HIV, viral hepatitis, and TB.  We looked at this globally. And we asked the investigator Laurie Shrage, from Florida International University to look specifically at this interactions among African American women in the U.S.  To unpack this, we need to understand some fundamentals about mass incarceration and HIV in the US, and the disproportionate impact of both on African American individuals, families, and communities.  First in 2016 the CDC reports that AA men are some 6 times as likely to have HIV infection as white men and twice as likely as Latino men.  For AA women, the disparity is even sharper—AA women and girls are 20 times as likely to have HIV as white women and nearly 5 times as likely as Latinas.  Yet when we look at individual level risks, like numbers of partners and condom use, black women are not riskier, and in some studies have less behavioral risks for HIV than other groups.  And nearly half of all Americans who have died of AIDS since the beginning of the epidemic have been African American, despite accounting for only 12% of the US population.   What accounts for the difference?

In contrast to many other groups at risk for HIV Infection, black women have overwhelmingly heterosexual risks for HIV infection—about 87% according to CDC, so it’s not substance use.  We have to go beyond the individual and look at social and structural risks for HIV among AA women.  This is where mass incarceration of AA men plays such critical roles.  The incarceration rate, as you’ll  hear from my colleagues, is hugely racially biased—AA men have 6 times the incarceration rate as white men, and twice that of Latinos.  And because so much of this mass incarceration is attributed to harsh drug policing and sentencing policies, incarceration is also associated with HIV and viral hepatitis among these men.  Some 14% of all Americans living with HIV Infection cycle through the criminal justice system each year.  When we looked at the available data on HIV in the criminal justice system, it turns out that HIV infection while in detention is not that common, and doesn’t account for the differences in HIV acquisition among this population.  Treatment outcomes for state and federal prisons, as you’ll hear from Dr. Jody Rich, are also quite good, with better levels of HIV control—what we call viral suppression—with antiviral therapy than among the non-incarcerated population.  So those factors don’t explain the disparities.

What does differ dramatically is what happens post-release.  And that is frequent and very troubling treatment interruptions.  It’s critical to understand that when a man or woman is living with HIV infection and is successfully treated, they are virally suppressed, and are thus dramatically less likely to transmit to others.  Conversely, when treatment is interrupted, the virus comes back, often to very high levels, and the person is again infectious.   The available data on continuity of care in the US shows that the majority of people released from incarceration have some treatment interruptions, and many have long periods off therapy before they gain health care access and can get back on treatment.  Data on recidivists in Texas, for example showed that fewer than 1 in 10 were virally suppressed at a subsequent arrest.  So mass incarceration is a social reality for low income AA men, and HIV is highly concentrated among men from these same communities, and those living with HIV face frequent treatment interruptions as they return to partners, families and communities.  This is a kind of epidemiologic perfect storm.  And we think it at least partially explains why AA women and girls face such extraordinarily high rates of HIV.

To reduce HIV risk for AA women and girls we need to address the structural factors that behind this health disparity.  This will mean reducing incarceration rates for both AA men and women, which will in turn require drug policy reform, and on improving access to health care, particularly post-release.  Most prisoners are released.  They are a part of our communities, and we have to do better at insuring continuity of care for these Americans.