The collateral social and health harms of mass incarceration and its inherent racial inequality have long disproportionately impacted Black communities, and that extends to HIV incidence. Back in 2009, Rucker C. Johnson, Ph.D., and Steven Raphael, Ph.D., of the University of California-Berkeley wrote about their research into the effects of men’s jail and prison experience on women’s HIV risk. “Given the sizable racial differentials in incarceration rates at the beginning of the AIDS epidemic and the increases in these differentials thereafter, our model estimates suggest that the lion’s share of the racial differentials in AIDS infections rates for both men and women are attributable to racial differences in incarceration trends.” Now, over a decade later, a current modeling study recommends providing pre-exposure prophylaxis (PrEP) to Black women whose male partner has recently been in jail or prison, as well as couples-based PrEP. The study’s authors concluded: “These findings provide strong support for criminal justice informed interventions alongside efforts to end mass incarceration.”
Researchers speaking at the 2021 virtual American Association for the Advancement of Science (AAAS) Annual Meeting in February echoed this sentiment in presenting the latest findings on racial inequities in incarceration and their relationship to HIV prevalence and treatment outcomes.
Racism Is Embedded in Mass Incarceration
If you follow the data, it’s clear that racism is a driving force behind the disproportionate impact of the criminal justice system on Black communities. In Pennsylvania alone, between 2007 and 2017, the risk of having been in a state prison by the time a man turned 32 was 19% for Black men, compared to 3% for white men, explained Bruce Western, Ph.D., the Bryce professor of sociology and social justice and co-director of the Justice Lab at Columbia University, at the meeting. Similarly disconcerting are 2018 data from the Vera Institute of Justice, a national research and policy nonprofit, that found an astonishing 335 of every 100,000 Black residents of New York City were in jail or prison, compared to 36 of every 100,000 white residents.
Much of that disparity stems from unequal enforcement of laws, especially those against substance use. While drug use rates are similar across racial and ethnic groups, arrests are not. When Shytierra Gaston, Ph.D., an assistant professor in Georgia State University’s department of Criminal Justice and Criminology, analyzed police officers’ justifications for searching people who were subsequently arrested for drug offenses, she found a troubling trend. Officers frequently cited neighborhood conditions and a perception that someone appeared nervous as the basis for proactive policing, such as stops and surveillance, when reporting on a Black person. In contrast, most white people were arrested as a reaction to a 911 call or to overtly suspicious activity, such as erratic driving. “These factors suggest that there need to be institutional changes that are made to minimize the stops and contacts by police with Black Americans,” Gaston concluded in her AAAS presentation.
Black people also make up 56% of those in jail for drug offenses, while comprising only 14% of all drug users in the U.S., addiction specialist Lipi Roy, M.D., M.P.H., reported in a presentation for the Poynter Institute. At Rikers Island, New York City’s largest correctional facility, where Roy previously served as the chief of addiction medicine, more than half of those entering the system have been affected by substance use. Yet, the facility is one of only 2% of U.S. jails that allow access to medications for opioid use disorder. Methadone, the most common of these drugs, has been shown to lower the risk of acquiring HIV sixfold.
HIV and HCV Prevalence Are Much Higher Among the Prison Population
Both HIV and hepatitis C (HCV) are much more prevalent in U.S. correctional facilities than in the general population, with an estimated 20% of people in jail or prison living with HCV and almost 2% living with HIV. In the general population, 1% have HCV and 0.34% live with HIV. In 2018, 42% of all new HIV diagnoses in the U.S. were among Black people, with 4% of diagnoses among men and 8% among women attributed to injection drug use, according to the U.S. Centers for Disease Control and Prevention (CDC). It also reports that in prison or jail, Black men are five times as likely to be diagnosed with HIV than white men, and Black women twice as likely as white women.
While most people involved in the criminal justice system eventually return to the community, parole conditions may inhibit their ability to continue HIV, HCV, or substance use treatment. For example, limitations on movement may not allow for visiting a clinic across county lines, or payments for fees and fines may leave little money for the food needed to go with medications.
For many, choosing to seek treatment results in technical violations of their parole conditions, landing them back in jail. “When we sentence someone to prison, we dramatically increase their risk of going to prison a second time,” said David Harding, Ph.D., a professor in the sociology department at the University of California-Berkeley, at the meeting. The carceral system’s “motorized revolving door,” as he put it, disparately impacts Black people. His 2017 study estimated the likelihood of a return to jail within five years of release at 18.4% for nonwhite people, compared to 14.3% for white people. Conversely, the likelihood of a new jail or prison sentence was higher for whites (9.2%) than for nonwhites (4.3%). The current system must be fundamentally re-thought along a harm-reduction and continuity-of-care model that helps people to reintegrate into society, added Harding.
HIV Treatment Barriers for Black Men Are Barriers for Black Women
Adjusting to life in the broader community is made more difficult by the multiple levels of stigma Black men with criminal justice involvement face. Living with HIV is an additional stigma, which keeps some from disclosing their serostatus, in turn making treatment adherence even more challenging. Treatment interruptions, low adherence, and lack of disclosure, combined with women’s perceived inability to enforce safe-sex practices because of competition for the few available men, make HIV transmission more likely, argued Wendy Sawyer and Emily Widra, researchers at the Prison Policy Initiative, concluding: “To better protect Black women from HIV infection, we need to eliminate the gap in HIV/AIDS treatment for Black men released from prisons and jails.”
One way to do so may be through the uptake of long-acting injectable antiretrovirals, wrote Jacob A. Pluznik, B.Sc., of Emory University and colleagues in an editorial published this month in the Journal of Acquired Immune Deficiency Syndromes. The first such antiretroviral, cabotegravir/rilpivirine (Cabenuva), was approved this year in the U.S.; it requires a month-long, oral, “lead-in” phase before starting monthly injections. If the lead-in and first injection were given prior to release, a person returning to the community would have a window during which they could deal with subsistence needs before they would have to get to a clinic. Ultimately, such a medication bridge would benefit not only the person themselves, but also their partner(s).
“The welfare of communities is directly connected to the welfare of people in prison,” added Western. He was referring to the COVID-19 pandemic, but the statement applies equally to HIV.