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Female Trouble: Studies Look at the Factors That Lead Women to HIV and Incarceration

May/June 2012

"Well, I'm 36 years old, I'm an African American woman in prison, I'm HIV-positive, and my favorite color is purple."

Female Trouble: Studies Look at the Factors That Lead Women to HIV and Incarceration

For the past year I have been conducting a study of women like this one, interviewing them about their lives and their risk for HIV. My research has me focused on risk -- which is substantial. According to the latest report from the CDC, in 2009 one in every 139 women in the U.S. will be diagnosed with HIV in her lifetime, with numbers jumping to one in 32 African American women.1 But I was losing sight of the fact that these were real people with families and dreams and, yes, favorite colors.

Just because I was thinking about HIV did not mean that they were. Women in prison have high rates of poverty, mental illness, histories of physical and sexual abuse, substance abuse, and lack of social support. It can be a disheartening setting for those with an eye toward public health but also a galvanizing one. Where I work in North Carolina, the prevalence of HIV among incarcerated African American women has been twice that of free African American women for years. What makes being in prison so risky?

Most women in prison are not there for a life sentence -- they do their time, often for a financial or drug-related crime, and return to life outside bars, typically within a year. This is where real life comes in: money, food, sex, families, violence, mental illness, and the temptation to return to whatever activities led to the prison sentence. As one woman told me, "It's there. It's always there." Too often this endangers a released woman's health, either through neglect of her own HIV care or, in the case of an HIV-negative woman, substance abuse and sex that put her at risk of contracting HIV.

When health care providers think about preventing HIV in high-risk women, we think about sex being exchanged for money, drugs, food, housing, or survival, or "transactional" sex. It is a logical target, as women who have been in prison have a higher rate of transactional sex and may be more likely to rely on it again. Transactional sex is an important risk factor for HIV in itself and in the vulnerability it conveys -- a woman having sex for survival may not be able to negotiate condom use or other safer-sex measures. She may have an increased number of partners.

Many of the women in our study who reported a history of transactional sex knew they were putting themselves at risk. Many of them had been tested for HIV in the past. But what about women who don't see themselves as at risk? What about women who trust their partners, or assume their partners are HIV-negative, or who think this is a disease that affects other people? This is the more insidious problem. If something about being in prison, a combination of factors in a woman's life that led her to that point, increases HIV risk, this represents a key opportunity for testing, prevention, and change.


The rate of new HIV infection was found to be five times higher than the national average for African American women, comparable to rates in some countries in Sub-Saharan Africa.

Several studies have looked at the practice of "opt-out" HIV testing, or testing that is performed unless a person specifically declines, among men and women entering jail or prison. The findings on jailed populations found that, in 2007, the majority of persons "opting in" to HIV testing who tested HIV-positive on jail entry were not previously known to be HIV-positive. Of these, the percentage of women who were diagnosed HIV-positive for the first time when entering jail was almost twice that of men. Included in the highest-risk groups for a new HIV diagnosis were individuals from the southern U.S., African Americans, women, and people between the ages of 40 and 49.

This study also noted that 30% of newly-diagnosed men and women identified themselves as at "no risk" or reported only "low-risk" sexual partnerships. Importantly, these numbers do not include jailed men and women who "opt out," many of whom were already known to be HIV-positive and didn't want to go through another test.2 Jail stays are usually shorter than prison stays and may represent an abbreviated opportunity for public health intervention if people are released quickly without going to prison. Another recent study compared the practice of "opt-in" to "opt-out" HIV testing among people entering prison and found that there was a low rate of previously undetected HIV. The people who were HIV-positive tended to know they were positive entering prison, unlike the earlier study of jailed men and women.3

Entering prison is a memorable and defining period, one of forced sobriety and guaranteed food and shelter but accompanied by a host of other burdens, stressors, and painful reminders. Amidst this chaos, these men and women may not be experiencing the wake-up call that an HIV test represents for many outside the prison walls. We may not be catching new cases at the time they enter prison, but that does not change lifetime HIV risk for many and for women in particular.


Another large study from the HIV Prevention Trials Network (HPTN), called HPTN 064 or the ISIS study, looked at women living in areas with a high prevalence of poverty and HIV in the Northeast and Southeast U.S. Most women were African American or Hispanic. The rate of new HIV infection was found to be five times higher than the national average for African American women, comparable to rates in some countries in Sub-Saharan Africa. The same study also looked at these women and their male partners and found that in many of these partnerships, one or both partners had never been tested for HIV. The results of the study's HIV testing found more than five times as many serodiscordant (when one partner is HIV-positive and the other is HIV-negative) partnerships than were reported by study participants.4,5 Transactional sex is risky, but sometimes a partnership is too.

What does this tell us about African American women in prison and their lifetime risk of HIV? Quite a bit. Many of these women are returning to the communities studied in the ISIS study. Most of these women get HIV from male partners -- intravenous drug use is less common in the Southeast U.S. -- in communities with high rates of both HIV and incarceration like the ones in the ISIS study. The majority of men and women in prison in North Carolina are African American, as are the majority of those in prison who are HIV-positive. Incarceration and HIV are dual epidemics that, in our state, feed off crack cocaine, poverty, and destabilized relationships. Repeat incarcerations are the norm. This is the "real life" stuff that the women in my study face when they leave prison.6,7

Other recent studies have underscored the high-risk period following release and shown a greatly increased risk of death in the few weeks following prison release. This risk remained increased for years following release.8,9 Living a healthy life as an HIV-positive person may not be in the cards for our patients. Their risk of death is increased by a number of other factors, including mental illness and poor access to health care. The prison system in our state tries to offer a range of resources to women about to face this turbulent time: safer sex education, mental health counseling, and, if the period of incarceration is long enough, sometimes substance abuse treatment, GED preparation, or job training. But with relatively short prison sentences, the threat of budget cuts, and a population with an overwhelming range of needs, we can always do more to help keep women who are being released from prison healthy.

I am asked all the time why people don't just use condoms and why women don't insist on them. If their lifetime risk of HIV or another sexually transmitted infection is so high, why don't they? These are real women in situations that are all too common. None of them is clueless about the fact that a condom may protect her, but the condom question is much more knotty. A history of sexual and/or physical abuse is very common and, for some women, speaking up may not be an option. Many of these women view their relationships as committed ones, ones in which they choose to forgo a condom as an indication of trust or deference to a partner's preference. Maybe they hope to become pregnant. Maybe they don't feel comfortable negotiating condom use, or think that HIV is something that happens to other people. They are complicated people, with complicated lives and favorite colors, and it is clear that we can do better in helping them lead the healthy lives they deserve.

Claire Farel, M.D., M.P.H., is an Infectious Diseases physician and HIV clinical researcher at the University of North Carolina. Her research interests lie in the intersection of incarceration and HIV risk, especially among women.


  1. Centers for Disease Control and Prevention. HIV Among Women. Accessed on March 18, 2012.
  2. Vanhandel, M., et al., Newly Identified HIV Infections in Correctional Facilities, United States, 2007. Am J Public Health, 2012.
  3. Wohl, DA, Golin, C et al. Adoption of Opt-out HIV Screening in a State Prison System Had Limited Impact on Detection of Previously Undiagnosed HIV Infection: Results from a Blinded HIV Seroprevalence Study. Poster presented at: The 19th Conference on Retroviruses and Opportunistic Infections.
  4. Hodder, S, Justman, J, et al. The HPTN 064 (ISIS Study) -- HIV Incidence in Women at Risk for HIV: US. Poster presented at: The 19th Conference on Retroviruses and Opportunistic Infections.
  5. Hageman, KM, Paz-Bailey G, et al. HIV Testing and Serostatus Knowledge among Partnerships at Increased Risk for HIV Infection -- Heterosexual Partner Study among Black and Hispanic Women in 16 Cities: US, 2006-2007. Poster presented at: The 19th Conference on Retroviruses and Opportunistic Infections.
  6. Adimora, A.A., V.J. Schoenbach, and I.A. Doherty, HIV and African Americans in the southern United States: sexual networks and social context. Sex Transm Dis, 2006. 33(7 Suppl): p. S39-45.
  7. Khan, M.R., et al., Timing and duration of incarceration and high-risk sexual partnerships among African Americans in North Carolina. Ann Epidemiol, 2008. 18(5): p. 403-10.
  8. Binswanger, I.A., et al., Release from prison--a high risk of death for former inmates. N Engl J Med, 2007. 356(2): p. 157-65.
  9. Binswanger, I.A., et al., Risk factors for all-cause, overdose and early deaths after release from prison in Washington state. Drug Alcohol Depend, 2011. 117(1): p. 1-6.

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This article was provided by Positively Aware. It is a part of the publication Positively Aware. Visit Positively Aware's website to find out more about the publication.
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