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Prison Facilities - Incarceration and Communities

Prison Facilities - Incarceration and Communities. Andrew H. Kaplan UNC Prison Working Group Center for the Health of Vulnerable Communities. Dual Epidemics. Excess Prevalence of STIs Among African Americans. In some studies, AA men report more sex partners

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Prison Facilities - Incarceration and Communities

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  1. Prison Facilities - Incarceration and Communities Andrew H. Kaplan UNC Prison Working Group Center for the Health of Vulnerable Communities

  2. Dual Epidemics

  3. Excess Prevalence of STIs Among African Americans • In some studies, AA men report more sex partners • SES differences - excess STIs persist after controlling for SES • Stigma/down low • Attitudes towards sexual behavior

  4. Marriage rates

  5. Community-level factors • Little sexual mixing - prevalence in partner pool • Sexual network structure promotes STI spread - core to periphery • Sexual concurrency

  6. Community-level factors • Little sexual mixing - prevalence in partner pool • Sexual network structure promotes STI spread - core to periphery • Sexual concurrency • Gender ratios - male marriageable pool ratio

  7. Gender ratios • Survival probabilities • Incarceration

  8. Incarceration • 2 million people incarcerated at any one time in US - about a 300% increase since 1980 • 600,000 people released every year • 10,000,000 people pass through the jail system every year • If current trends continue, 5% of the population can expect to spend at least one night in jail during their lifetime • 3 million children have a parent in prison

  9. Is incarceration among the contextual factors that discourage monogamy among African Americans? • Gender ratios - AA men (13%) of US population account for about 60% of prison inmates. • One-third of AA men between the ages of 20 and 29 are under correctional supervision

  10. Impact of incarceration • Gender ratios • Disrupted relationships - “correctional concurrency”

  11. Nexus between HIV and Incarceration

  12. Nexus between HIV and Incarceration

  13. Nexus between HIV and Incarceration

  14. Nexus between HIV and Incarceration

  15. Nexus between HIV and Incarceration

  16. Impact of incarceration • Gender ratios • Disrupted relationships - “correctional concurrency” • Spread of STI’s within prison

  17. Impact of incarceration • Gender ratios • Disrupted relationships - “correctional concurrency” • Spread of STI’s within prison • Normalization of incarceration and effect on normative community values of sex, violence and drug use • Diversion of resources

  18. Models • Migration

  19. Models • Migration • Slavery

  20. The spirit of the Africans in America did not break. Yet the spirit of their captors was corrupted. Small men took on the powers and airs of tyrants and masters. Years of unpunished brutality and bullying and rape produced a dullness and hardness of conscience. Christian men and women became blind to the clearest commands of their faith and added hypocrisy to injustice. A republic founded on equality for all became a prison for millions. And yet, in the words of the African proverb, “no fist is big enough to hide the sky.” All the generations of oppression under the laws of man could not crush the hope of freedom and defeat the purposes of God.

  21. The spirit of the Africans in America did not break. Yet the spirit of their captors was corrupted. Small men took on the powers and airs of tyrants and masters. Years of unpunished brutality and bullying and rape produced a dullness and hardness of conscience. Christian men and women became blind to the clearest commands of their faith and added hypocrisy to injustice. A republic founded on equality for all became a prison for millions. And yet, in the words of the African proverb, “no fist is big enough to hide the sky.” All the generations of oppression under the laws of man could not crush the hope of freedom and defeat the purposes of God. George W. Bush

  22. HIV+ men and women are more likely to have partners who have been incarcerated In a study of 244 African-American men and women with and without HIV infection in North Carolina: • HIV+ men were 6x more likely to have had a sexual partner who had been incarcerated in previous year than HIV- men • HIV+ women were 4x more likely to have had a sexual partner who had been incarcerated in previous year than HIV- women • A quarter (26%) of the HIV+ women with <10 lifetime partners and low profile risk behavior reported that one of their last 3 sex partners had been incarcerated, as did 48% of all HIV+ men and 81% of all HIV+ women. • Further, 24% of HIV+ women and 65% of HIV+ men had themselves been incarcerated during the past 10 years. (Adimora A, et al, JAIDS 2003)

  23. Study Design/Methods • Prospective, observational cohort study • May 2001-August 2003 • All subjects are HIV+ prison inmates PRE-RELEASE POST-RELEASE RECIDIVISTS Within 3 months prior to release: In-depth face-to-face interview regarding pre-incarceration HIV transmission risk behaviors Asked to call study coordinator using toll-free pager 30-60 days following release: Telephone interview concerning actual risk behaviors post-release Released and now re-incarcerated In-depth face-to-face interview regarding inter-incarceration HIV transmission risk behaviors

  24. Study Design/Methods • Prospective, observational cohort study • May 2001-August 2003 • All subjects are HIV+ prison inmates PRE-RELEASE POST-RELEASE RECIDIVISTS Within 3 months prior to release: In-depth face-to-face interview regarding pre-incarceration HIV transmission risk behaviors Asked to call study coordinator using toll-free pager 30-60 days following release: Telephone interview concerning actual risk behaviors post-release Released and now re-incarcerated In-depth face-to-face interview regarding inter-incarceration HIV transmission risk behaviors

  25. Subjects • 170 subjects enrolled • Pre-Release n=86 • Mean age = 36 years (18-55 years) • 57% Women • 74% African-American • 4% Native American • 83% Self-Described as Heterosexual • 8% Married • 50% have at least high school education

  26. Subjects • Pre-Release n=86 • Average length of current incarceration is 410 days • Average length of current sentence is 416 days (21 days – 10 years) • 76% have been free since diagnosed with HIV infection

  27. Subjects • Recidivists n=84 • Mean age = 35 years (21-51 years) • 32% Women • 80% African-American • 2% Native American • 73% Self-Described as Heterosexual • 11% Married • 57% have at least high school education • Median time free between incarcerations was < 2 years

  28. Results: Pre-Release (n=86) • 72% had a Main Sex Partner prior to incarceration, 57% of whom were reported to be HIV-, 13% did not know partner’s HIV status • 78% of subjects with a Main Sex Partner reported unprotected sex with that person in the year prior to incarceration • 42% said they felt pressured not to use condom with Main Partner prior to incarceration • 21% stated they were forced to have sex against their will with Main Partner some of the time in the year prior to imprisonment

  29. Results: Pre-Release (n=86) • 67% of inmates had at least one Other Sex Partner prior to imprisonment (mean # = 8) • 64% of participants with one or more Other Sex Partners reported that at least one of these was HIV- • 72% of subjects with Other Sex Partners reported unprotected sex with at least one of their other sex partners in the year prior to incarceration

  30. Results: Pre-Release (n=86) • 21% of the cohort reported giving someone drugs and 17% money for sex in the year before arrest • 28%received money and 28% drugs for sex • Of the 65 diagnosed with HIV prior to this incarceration, 37% had told all their sex partners they were HIV-infected.

  31. Results: Pre-Release (n=86) • Expected behaviors post release: • 66% expected to have sex within a year of release • 46% expected to have unsafe sex within year post release • 33% felt it would be “very” or “somewhat’ likely they would infect their Main Partner post release • 30% planned to have a sex partner other than their Main Partner within a year • 24% said they planned to only have sex with HIV+ partners following release

  32. Results: Post-Release • Of the 86 subjects released • 2 died of HIV-related illnesses and 5 were re-incarcerated prior to the 30-60 day telephone follow-up • Post-release interviews have thus far been conducted among 95% of eligible releasees (n=75) a mean of 43 days post-release

  33. Results: Post-Release (n=75) • 48%an average 9 days post-release (range: 1 hour to 31 days) • 7% of subjects had a new sex partner since release • 93% had a Main Sex Partner, of whom 56% were reported to be HIV-. 82% of releasees returned to their prior Main Sex Partner

  34. Results: Post-Release • 26% of subjects with a Main Sex Partner had unprotected sex with that partner following release • 100% of subjects reported that they disclosed their HIV+ status to their Main Sex Partner but only 63% said they told all sex partners they were HIV+ • Given their current sex behavior, 29% of releasees felt that it was “very” or “somewhat” likely that they would infect their HIV- Main Sex Partner • Since release, 15% of subjects reported using street drugs at least once a week • 12% of releasees report using crack cocaine and 2% injected drugs (all denied needle-sharing)

  35. Results: Post-Release • 3 subjects (2 men) reported having sex while incarcerated all with same sex prisoners

  36. Results: Recidivists (n=84) • Mean time from last sex to incarceration was 204 days (1 hour-10 years) • 36% had a new sex partner during time free • 82% had a Main Sex Partner and 57% were reported to be HIV- • 60% had unprotected sex with their Main Partner while free • 49% had at least 1 Other Sex Partner while out (mean #=7) • 57% of Other Partners were HIV- and 17% of unknown status • 43% had unprotected sex with at least 1 Other Partner while free

  37. Results: Recidivists (n=84) • 37% had told all their partners they were HIV+ • 31% thought it “very” or “somewhat” likely they infected someone while free • 5% shared needles • 11% knew of someone they infected via sex or needle sharing

  38. Unsafe sex among HIV+ prison releases • 86 HIV+ state prison inmates surveyed • within 3 months before release from prison • 30-45 days after release • 78 re-incarcerated HIV+ inmates surveyed Wohl D, et al. CROI. 2003.

  39. UNC ID Clinic • In comparison, in a recent survey of 107 HIV-infected patients attending the UNC Infectious Diseases Clinic (33% Women, 74% African-American, 44% Heterosexual, 86% Married) : • 44% of subjects reported having unprotected sex with their Main Sex Partner in the previous year. • 53% reported unprotected sex in the same time period with at least one Other Sex Partner. (Strauss R, et al. APHA 2001)

  40. 1000000 Pre-release Reincarceration 100000 10000 1000 100 Recidivists Viral Load Increases Among HIV+ Recidivists HIV-1 RNA (copies/ml) Stephenson B, Wohl D et al 13th World AIDS Conf, Durban. 2000

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