According to Nelson Mandela, who spoke about the disproportionate burden of HIV infection on women at a recent event in South Africa, the world wide epidemic of HIV is taking on the face of a woman.1 Due to their status in society and for physiological reasons discussed in greater detail below, women are disproportionately at risk for HIV infection, and this is particularly true for women who are incarcerated.
The overall prevalence of HIV infection among U.S. women is approximately 0.2%; incarcerated women are 15 times more likely to be HIV-infected compared to women in the general population. In several states, nearly one in 10 incarcerated women are HIV-infected. At year-end 2002, 3% of all incarcerated women in U.S. state prisons were HIV-infected, compared to 2% of incarcerated men in U.S. state prisons (see table 1). More than 10% of female inmates in two states (New York and Maryland) were known to be HIV-infected.2
Incarcerated women have higher prevalence rates of HIV infection than incarcerated men because the behaviors for which they are incarcerated put them at risk for HIV infection.3,4 They are often injection drug users (IDUs), sexual partners of IDUs, have supported themselves through sex work, and more often than not, they have been forced to have (unprotected) sex or trade sex for housing and food.5 Women who are more likely to be HIV-infected in the U.S. also belong to subgroups of the population that are at increased risk of incarceration: women living in poverty, women who lack marketable job skills,6 and certain ethnic groups (African American, Hispanic). Many of the women at highest risk for HIV infection are unaware of their risk, have little or no access to HIV prevention, and are afraid, for fear of violence, to ask their partners to use condoms.7
These risk factors are clearly demonstrated in one of the most recent published studies of incarcerated women. Researchers in Brazil interviewed and evaluated 290 incarcerated females and found prevalence rates for HIV, hepatitis C virus (HCV), and syphilis of 13.9%, 16.2%, and 22.8%, respectively. The most significant risks for HIV infection included HIV-infected sexual partners, casual partners, partners who inject drugs, and a history of sexually transmitted infections (STIs). Even women with a single sex partner presented a significant risk for HIV infection, reflecting their vulnerability for acquiring HIV infection, most likely due to their trust in their partner who did not use a condom. While the use of injectable drugs was associated with HIV infection, the study results pointed to sexual behavior as the most important component of HIV transmission in the incarcerated female population.8
Mental illness is a common co-morbidity for HIV-infected incarcerated women. A number of studies have linked prior childhood experiences of abuse and neglect with women's healthcare needs, mental health needs, and HIV risk behaviors. According to self-reported data, 33%-65% of incarcerated women in the US report prior sexual abuse and 19%-42% report a history of childhood sexual abuse.9,10 These percentages are likely under-representative of the prevalence of abuse histories among incarcerated women, but they are still two-fold higher than the prevalence of such histories among women who are not incarcerated.
Mental health problems contribute to the high prevalence of HIV infection among incarcerated women and make the management of their HIV care substantially more challenging. In a recent US study, 25% of women discontinued highly active antiretroviral therapy (HAART) for at least six months during study follow-up of five years, and women who discontinued HAART were more likely to be depressed than those who did not discontinue medication.11 Access to treatment for depression may be helpful for improving the management of HIV-infected incarcerated women.
Since many incarcerated women have experienced childhood sexual abuse and adult sexual trauma, gynecological and obstetric examination takes special care and sensitivity. Some of the issues that may interfere with the examination of sexually abused women include their need to trust the examiner, their need for control (wishing to control the time and place of the exam), their fear of disclosure, and their fear of having their body touched during the exam.12 Sensitive gynecological healthcare providers are critically important members of the correctional HIV management team.
HIV transmission estimates vary by the type of exposure. Per-event transmission probability estimates are 0.7% (about one in 150) per episode of intravenous needle or syringe sharing, and 0.09% (less than one in 1,000) after a mucous membrane exposure (such as a splash to eyes or mouth). The risk for HIV transmission per episode of receptive penile-anal sexual intercourse is estimated at 0.1%- 3.0%, while the risk per episode of receptive vaginal intercourse is estimated at 0.1%-0.2%. While published estimates of the risk for HIV transmission from receptive oral exposure do not exist, instances of suspected transmission have been reported.13,14
Data has suggested that men with HIV infection are biologically more likely to transmit HIV than women, due to increased genital shedding of HIV-1, leading to the thought that male-to-female transmission is more efficient than female-to-male transmission during asymptomatic infection (early in HIV disease). However, the risk of transmission during symptomatic infection does not appear to vary.15 In a recent study in Uganda, plasma HIV RNA levels and genital ulcer disease, but not gender, were the main determinants of HIV transmission.16 There is also recent data that shows higher levels of HIV in semen versus female genital tract secretions. Collectively, these data may suggest that women are at a greater risk for infection as compared to men.
Additionally, incarcerated women, in general, and HIV-infected incarcerated women in particular, have remarkably high rates of STIs and gynecologic infections, which are associated with higher risks of HIV infection.15 At year-end 2003, 1.8%, 6.3%, and 7.5% of incarcerated women tested positive for gonorrhea, chlamydia, and syphilis, respectively.17 In younger women, cervical ectopy (extra mucosal tissue around the entry to the cervical canal) makes the cervix more vulnerable to HIV infection.18
High rates of STIs are associated with high risk for HIV infection for three main reasons:
High rates of syphilis among incarcerated women have prompted a number of studies assessing methods of syphilis screening and treatment in the correctional setting. Several studies have shown the efficacy of administering qualitative rapid plasma reagin (RPR) testing for syphilis.19,20 A study conducted at a New York City jail found that qualitative nontreponemal syphilis testing, online access to the local syphilis registry, and immediate treatment (if indicated), following admission, increased the rate of syphilis treatment from 7% to 84% of cases.21
Testing for or making a diagnosis of an STI provides an important opportunity for healthcare providers to counsel inmates about the issue of HIV transmission. HIV testing should be offered at each HIV encounter. Rapid HIV testing (see table 2) is a particularly important tool for getting HIV-infected women into care; more than 98% of individuals are able to receive their test results and most enter care following rapid test diagnosis.22
Between 1998-1999, 1,400 women gave birth within prisons. During this time, in Georgia alone, more than 150 women who entered prison were pregnant.24 Both the number of HIV-infected women giving birth in prisons and the extent of prenatal screening for HIV infection that is performed in federal and state prisons are unknown at this time. Even though mother-to-child transmission (MTCT) of HIV has been all but eradicated in the U.S., MTCT still occurs among high-risk women who seek care late in the course of pregnancy. Between 280-370 U.S. babies continue to be born each year with HIV infection.25 Prior to the institution of MTCT prevention, transmission from HIV-infected mother to child ranged from 16%-25% in North America and Europe. Today, the risk of perinatal transmission can be less than 2% with effective antiretroviral therapy (ART), elective cesarean section as appropriate, and formula feeding.
The correctional setting clearly provides a critical opportunity to reach women who may not have accessed pre-natal testing in the community and routine pre-natal screening in correctional settings may be cost-effective.26 According to standards set forth by Centers for Disease Control and Prevention (CDC), thorough and non-judgmental discussion of HIV testing and ART is a required component of all pre-natal care.27
Certain aspects of long-term incarceration, such as shelter, food, and sobriety may be health promoting for high-risk pregnant women and have been reported to improve their pregnancy outcomes.28 However, few correctional facilities allow women to house their infants in a nursery at the institution after delivery (residential programs for infants exist in only 11 states and select federal facilities). Most correctional facilities remove newborns from their mothers during or immediately after the hospital stay.
Most incarcerated women are mothers and were the custodial parent of a minor child prior to incarceration. In 1998, 70% of women in jails, 65% of women in state prisons, and 59% of women in Federal prisons had at least one child under the age of 18 at home. The total number of minor children whose mothers were in federal or state prisons increased from 61,000 in 1991 to 110,000 in 1998. In 1998, 84% and 64% of minor children whose mothers were in federal and state prisons, respectively, lived with their mothers before their mothers entered prisons. Women are allowed to receive visits by their children. However, these visits are infrequent; 56% of women do not see their children at all while they are incarcerated.29 The impact of this separation on the wellbeing of the mother and the bond between the mother and infant deserves further study.
The prevalence of HCV is much greater among incarcerated populations than the general public. The incidence of HCV in the US general population has been estimated at 1.8%, while the incidence among state and federal facilities in 1999 was 2.1%. Incarcerated females typically have high rates of HCV infection. In 1994, 63.5% of female inmates entering the California correctional system were found to be anti-HCV positive, compared to 39.4% of male inmates.30 Testing for and appropriately treating HCV and hepatitis B virus (HBV) co-infection among incarcerated females should be a routine component of HIV care.31 For more information on testing and treating HCV and HBV, please refer to CDC's Sexually Transmitted Diseases Treatment guidelines -- 2002.32,33
Because incarcerated women have a high prevalence of HIV infection, multiple sources of HIV risk in their lives, and limited access to HIV testing and counseling services outside of prison or jail, there should be multiple opportunities for women to say "yes" to HIV counseling and education while they are incarcerated (see table 3). However, the incarcerated woman's fear of stigmatization by her peers and correctional staff can have a negative impact on the detection and management of HIV/AIDS in prisons and jails. The closed setting of correctional institutions makes confidentiality difficult to maintain (particularly if a clinic or care provider is identified as being associated with HIV), though total confidentiality should always be the goal. Peer HIV/AIDS education programs may reduce stigmatization among prisoners and increase the general awareness of HIV in the incarcerated female population.34
Factors that are likely to encourage incarcerated women to become tested include concern about the impact of HIV infection on their present or future children, and about having contracted HIV infection in the context of having acquired other STIs. Many incarcerated women may have been tested for HIV during prior pregnancies and may therefore be familiar with the concepts and procedures related to HIV testing. However, younger women (with fewer arrests, fewer pregnancies, and fewer opportunities to interact with HIV testers and counselors) may be less familiar with the concept of HIV testing, and hence, more fearful.
In many facilities the list of "risk factors" will include virtually every female prisoner in the institution. With HIV/AIDS prevalence rates approximately 15 times higher among incarcerated women compared to the general population, HIV testing should be regularly offered and easily available to all women prisoners.
Ideally, correctional management of HIV would include a network of interconnected services that would address the needs of HIV-infected incarcerated women. These services might include clinical medical services, physical and sexual abuse recovery programs, drug treatment, and mental health services. They may also include vocational training and skills building workshops that, by helping women to become socio-economically more powerful, facilitate their ability to continue to effectively manage their healthcare needs and to prevent HIV transmission upon prison release. The opportunity to test and treat HIV-infected pregnant women who are incarcerated should not be missed. Finally, discharge planning programs initiated during incarceration can help connect women to community medical services, drug treatment, support services that provide child care, safe affordable housing, job training and employment opportunities that will all serve to increase their ability to continue to care for their own health needs. Incarceration provides a critical opportunity for the education, diagnosis, and medical care of HIV-infected women and high-risk HIV seronegative women, as well as a critically important public health opportunity to reduce the spread of HIV.
Bloom B, Owen B & Covington S. Gender Responsive Strategies: Research, Practice, and Guiding Principles for Women Offenders. 2003. Washington, DC: National Institute of Corrections.
Boudin K, Carrero I, Clark J, Flournoy VV, Loftin K, Martindale S, Martinez M, Mastroieni E, Richardson S. ACE: A Peer Education and Counseling Program Meets the Needs of Incarcerated Women With HIV/AIDS Issues. Journal of the Association of Nurses in Aids Care. 1999 10(6):90-98.
Browne A, Miller B, Maguin E. Prevalence and severity of lifetime physical and sexual victimization among incarcerated women. Int J Law Psychiatry. 1999; 22:301-322.
De Groot AS & Cuccinelli D. "Put her in a cage: Childhood sexual abuse, incarceration, and HIV infection" in The Gender Politics of HIV in Women: Perspectives on the Pandemic in the United States. J Manlowe & N Goldstein, eds. 1997. New York: New York University Press.
Women, Children, and HIV Web site (http://WomenChildrenHIV.org): The François-Xavier Bagnoud (FXB) Center at the University of Medicine and Dentistry of New Jersey, and the University of California San Francisco's Center for HIV Information created this website, which contains a comprehensive, Internet-based library of practically applicable materials on mother and child HIV infection including preventing mother-to-child HIV transmission (PMTCT), infant feeding, clinical care of women and children living with HIV infection, and the support of orphans.
Anne S. De Groot, M.D., Brown University, has nothing to disclose. Susan Cu Uvin, M.D., Brown University, has nothing to disclose.