How Does Incarceration Impact the Spread of HIV?

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Baltimore has one of the higher HIV rates among U.S. cities. It's also the city that one-third of the people in Maryland's state prisons call home.

What do the two have to do with each other? A lot, according to "The Global Burden of HIV, Viral Hepatitis, and Tuberculosis in Prisoners and Detainees", a recent study on HIV and incarceration worldwide. Though the authors don't examine individual cities, or even countries, they note that mass incarceration, particularly the cycling of people in and out of jails and prisons, has contributed to the spread of not only HIV, but also viral hepatitis and tuberculosis.

But it's not just Baltimore, or even Maryland. The authors estimate that, of the approximately 10.2 million people incarcerated on any given day, 3.8 percent (or 389,000 people) are living with HIV. In the United States, prisons in Florida, Maryland and New York have higher rates of HIV prevalence than any country outside sub-Saharan Africa. At the same time, incarceration in the United States disproportionately impacts people of color, particularly African Americans.

Andrea Wirtz, Ph.D., one of the study's co-authors and an assistant scientist at Johns Hopkins Bloomberg School of Public Health, is quick to clarify that it's not that HIV transmission is rampant within U.S. jails and prisons. The availability of antiretroviral therapy in prison actually keeps the risk of transmission low behind bars, she told The risk arises once people are released and have difficulties continuing their medications. These interruptions mean they are no longer virally suppressed and thus are more at risk of transmission. "It's right after release that there's an increased risk of overdose and HIV transmission," she explained.

Release Can Be Risky for HIV

Across the globe, over 30 million people are released from prison and return to their home communities each year. It's the time just after release when the risk of HIV transmission increases. Even a short time behind bars means disruptions in treatment, causing viral loads to increase. Once people are released, their sexual partners or those with whom they inject drugs are at risk for HIV.

The racial disparities of arrest and incarceration -- and the accompanying disruption in antiretroviral treatment -- put black women in the U.S. at particular risk. Chris Beyrer, M.D., another of the study's co-authors and a professor at Johns Hopkins University, noted that, despite having lower levels of individual sexual risk, African-American women are five times more likely to become HIV positive than Latina or white women. "So how do we understand that?" he asked a media delegation from Black AIDS Institute at the 2016 International AIDS Conference, as reported by Emerge Media Online. One underlying driver is the mass incarceration of African-American men and the interruptions in treatment upon release, he said. "People are sometimes released with three days' worth of antivirals [and told,] 'Be sure to follow up and get your appointment'. How likely is that to happen?"

Higher Rates in Women

But not just post-prison sex increases women's risk. Women in jails and prisons face a higher risk of infection than both their male counterparts and non-criminalized women. In most regions of the world, HIV prevalence is higher for women behind bars than their male counterparts. Closer to home, the New York City Department of Health found that women incarcerated at Rikers Island, the second largest jail in the country, have a prevalence rate 14 times higher than the city's general female population.

On the state level, nearly 12 percent of women in New York State prisons were living with HIV in 2010, a rate that is more than double that of their imprisoned male counterparts and far above the rate of the general public. The Correctional Association of New York, an organization that monitors New York State prison conditions, noted that "experiences that lead women to be criminalized and incarcerated, including addiction, being prostituted, engaging in sex work, and experiencing domestic violence and trauma, put women at greater risk for contracting the virus."

To Test or Not to Test

Jack Beck is the director of the Correctional Association's Prison Visiting Project. Before that, as the senior supervising attorney at the Prisoners' Rights Project of the Legal Aid Society, he was the lead attorney on a class-action lawsuit on behalf of state prisoners with HIV. That litigation led to the 2009 Department of Health Oversight of HIV/HCV Bill, requiring the NYS Department of Health to review HIV and hepatitis C care in state prisons each year. Initially, the Department found that nearly half of all people with HIV in New York State prisons had not been identified by prison staff, but Beck says that the numbers may now be lower.

New York's state prison system does not have mandatory HIV testing, Beck explained. Though it offers HIV testing in each of its prisons, "it was the worried well who were getting tested." Those who already knew their status might decide against disclosing to prison medical staff, even if it meant going without their medications. "You can't keep secrets inside," Beck stated. "If you're put on a list of the people going to see the infectious disease doctor, then you're letting people know that you're HIV positive." In prison environments, even today, people living with HIV often face stigma, ostracism and even violence, leading many to prefer foregoing needed treatment.

While New York does not require HIV testing, every person entering the state prison system has blood drawn for other medical tests. Some of that blood is then sent to the state's AIDS Institute for anonymous HIV and hepatitis testing. Those tests have indicated that the numbers of people with HIV in New York State prisons are lower than previously thought. In 2014, the Department of Health found that, of the 49,224 people incarcerated on December 31, 1,109 matched cases in the HIV registry for an HIV prevalence of 2.3 percent (2.2 percent for men and 3.7 percent for women). According to an email from the assistant public information officer at the state's Department of Corrections and Community Services to, at the end of 2015 approximately two percent (or 1,011 people of the 52,280 in custody) had HIV; of those, 358 had been diagnosed with AIDS.

According to Beck, these lower numbers reflect the lower prevalence of HIV throughout the state. Outside of prisons, HIV infection is going down, including among injection drug users. "It's an indication that harm reduction works," Beck says, referring to the availability of sterile syringes and other services for drug users in New York. Furthermore, the number of people incarcerated solely for drug use has declined.

Inconsistencies in HIV Care

However, HIV care remains inconsistent throughout New York's prison system. The Department of Health found that, of those identified, only 75% were receiving treatment. Furthermore, people in prison reported problems getting their medications and sometimes going without medications for up to four months.

Access to treatment frequently stops shortly after a person walks out the prison gates. In New York, which releases between 22,000 and 24,000 people each year, people are supposed to be given two weeks' worth of medication, known as "walking meds." Only a few prisons help people enroll in Medicaid before leaving prison; most, however, are left to navigate the process on their own upon release. In Maryland, the majority of the nearly 16,000 people released from jails or prisons between 2014 and 2016 walked out without medical coverage.

But follow-up care is crucial. In New York City, approximately 10,000 people are detained each day on Rikers Island. In 2011, 3.5 percent of those entering a New York City jail self-disclosed as being HIV-positive and another 1.1 percent tested positive through follow-up and care an opt-in HIV testing program. Unlike people in state or federal prisons, the majority of people in jails are awaiting trial or sentencing; a minority may be serving short (less than one year) sentences.

In New York City jails, people with HIV are offered transitional care services, including referrals to community-based care. From 2008 to 2011, the city's Department of Health conducted follow-up interviews with people who utilized these transitional care services. Researchers found that, six months after their release from Rikers, a greater percentage were taking antiretroviral medications (92.6 percent up from 55.6 percent during the initial interview), were adhering to their medications (93 percent up from 81 percent) and had an undetectable viral load.

Addressing the Basics of Food and Shelter

But not just access to HIV-related services made the difference, they also found a significant reduction in unstable housing and food insecurity. Noting that the nearly 200 people who were lost to follow-up interviews after release had reported some degree of housing and/or food insecurity, researchers pointed out, "Housing instability is a fundamental barrier to successful retention in care for most people since basic needs such as food and housing are typically prioritized over health care needs." In other words, medical care alone is not enough. "Addressing all of a client's most pressing needs, such as housing, substance abuse treatment, and mental health care needs as well as referrals to primary medical care, are core components of this approach," they concluded.

After examining the impact of incarceration on HIV worldwide, Wirtz and her fellow researchers concluded that one obvious response would be to reduce the prison population. "Mass incarceration of people who inject drugs is a key driver of the ever-growing population of prisoners," they concluded. Decriminalization of drug use, providing alternatives to incarceration and ensuring access to antiretroviral therapy and opioid agonist therapy behind bars are key to reducing the burden of infections in the world's prison population -- and the communities to which they return.