Currently, 1.1 million people living in the U.S., of many different races, genders and ethnic backgrounds, are HIV positive. Although the epidemic has been controlled and managed in majority populations, minority groups are having more trouble battling the virus, and it is being contracted at epidemic levels in the black community, especially among black women and LGBTQ people. The spike in HIV among black women may be caused in part by the lack of treatment options for another population: formerly imprisoned persons. This group's needs require immediate attention before the problem gets out of control.
On July 14, in an article for NBC News entitled "For Many Prisoners With HIV, Getting Care Is Harder After Release," writer John Paul Brammer provided a detailed look at the problems facing HIV-positive formerly imprisoned people as they re-integrate into U.S. society. According to the article, researchers at the University of North Carolina (UNC) and Texas Christian University found that 40% of the individuals they interviewed were unable to maintain viral suppression six months after returning to their communities. When you intersect this data with the fact that black Americans are incarcerated at five times the rate of white Americans, you begin to see an environment where the masses who are incarcerated become part of a key population within the HIV spectrum. (This isn't to say that HIV is usually contracted in prison; research has shown that most HIV-positive incarcerated persons enter jail with a prior diagnosis.)
David Wohl, M.D., of the UNC School of Medicine, told Brammer that continuing with care is the biggest factor driving this problem. "By and large, people get great HIV care in prison," Wohl said, "But when they get out, they come back to a system that isn't taking care of them, and they have to face issues with housing and employment." He added, "Getting out is something people want to do, but it's stressful, and taking care of your virus might not be the most important thing to do."
The HIV community has begun to shift to a system focused on treatment as prevention (TasP) through antiretroviral treatment in order to suppress the virus in those who are positive, while keeping those who negative from contracting the virus through pre-exposure prophylaxis (PrEP). However, formerly incarcerated persons reintroduced into society face a lack of resources to maintain such care when transitioning back into the community. Because the recidivism rate of the black male population is 81% within five years of release, the vicious cycle of being "in and out of jail" coincides with a cycle of being "in and out" of HIV treatment. These cycles directly affect the rise in HIV among black women.
According to Chris Beyrer, M.D., president of the International AIDS Society, black women in the U.S. have a lower individual level of sexual risk than Latino or even white women, yet their HIV infection rate is more than five times higher. He identifies the mass incarceration of African-American men and their lack of access to HIV care after release as the fundamental reason for this disparity.
According to philosopher Laurie Shrage, commenting in a recent issue of The Lancet: "Incarceration rates have quadrupled in the USA in the past several decades, and this has reduced the number of men in black communities, and therefore the number of available partners for heterosexual black women. This fact, together with ongoing racial segregation, contributes to the formation of insular sexual networks with overlapping, concurrent partners."
In essence, if one man who is HIV positive and not on treatment is released from prison, due to limited dating pools, he could have multiple sex partners who are black women. Additionally, stigma within the community often prevents these same men from properly disclosing their status, increasing the chances of transmission.
As a former director of testing for a community-based organization (CBO) in Washington, D.C., I am all too familiar with the plight of the black community dealing with the virus. Because of these intersections, as part of assessments, questions about prior incarceration are asked to determine risks. However, with this new data, CBOs should address this issue differently. CBOs seek out those persons who are HIV positive and have fallen out of the traditional health care system. These organizations utilize community health workers to seek and find such people and return them to care. Armed with this data, CBOs and AIDS service organizations (ASOs) should become aligned with the prison system, serving as the middle men to help people transition from incarceration to the community with no lapse in treatment. CBOs and ASOs should have designated CHWs who work with inmates prior to release to ensure that they have a doctor, a health care facility that can handle prescriptions and treatment, and treatment plan with that facility.
The HIV issues facing black communities are severe and require that prisons, CBOs, ASOs and health care facilities work in tandem to eliminate the virus within them. If we are ever going to have an HIV-free generation, we must work to keep those who are most vulnerable from falling through society's cracks.