Racial Disparities, Legal Systems and Incarceration

Drivers of HIV Risk Behaviour among Black Men in the United States

Lisa Bowleg, of George Washington University, presented the results of the Menhood study into black men’s sexual HIV risk behaviors. She explained that, while study results often report what participants already know, documenting the information we already know is a way to move policy change forward. Qualitative research, in particular, provides an opportunity to harvest insights from participants’ understanding of how social drivers affect their lives.

This five-year mixed-method study was entering the second of three phases at the time of the Summit, and Bowleg discussed the results of focus group interviews conducted during phase one. Bowleg explained that, among black people in the US, HIV is a generalized epidemic and the framework of risk groups is less useful. Her research group was more interested in identifying factors – including social and structural factors – that could impact HIV risk at the neighborhood level.

Most neighborhoods in the study had a median household income of $25,000, which maps onto HIV prevalence in Washington D.C. Of the 83 men who participated in phase one of the study, 56 were unemployed and 66 had a history of incarceration – Bowleg pointed out that these numbers are related, since having a criminal record can prevent someone from getting a job.

In speaking to participants, researchers heard that HIV was one of many stressors and pressing priorities competing for participants’ attention, and that more visible stressors, like police presence, were often of higher concern. Participants also knew that HIV was concentrated in low-income black neighborhoods, and spoke about how small social networks contribute to risk. They also identified unemployment, substance use and boredom as drivers of risk behavior.

In reviewing the National Institute for Health Research AIDS Research Priorities, released on August 12, 2015, Bowleg noted that the high priorities in HIV research were vaccines, antiretroviral therapy, cure research and research into comorbidities, whereas behavioral studies (involving drug use, sex or social conditions that have multiple negative outcomes including HIV/AIDS) were named as low priorities for AIDS-designated funds. She expressed concern about the future of social and structural interventions in this shifting funding environment.

Further Information


Mass Incarceration, Policing and Racial Disparities in the United States

Kim Blankenship, of American University, discussed mass incarceration and hyper-policing as social determinants of health, particularly for racial minorities. Blankenship noted that researchers such as Jason Schnittker have argued that mass incarceration is a fundamental social determinant of health and that it is increasingly viewed as a major force in perpetuating social inequality in general and racial inequality in particular.

There is a lot of public discussion around mass incarceration and as that heats up, we can add the voices of HIV/AIDS scholars and activists to be demanding that something be done about it.

Blankenship explained that the United States incarcerates more people per capita than all but one other country in the world. The present incarceration rate is quadruple that of 1980, and is disproportionately distributed by race and ethnicity. As of 2013, the incarceration rate for black men was six times the rate for white men, and 2.5 times the rate for Hispanic men. The incarceration rate for black women was twice that for white women.

Racial minorities are also subject to hyper-policing. Blankenship explained that a small number of poor minority neighborhoods are viewed as places where crimes are likely to take place and where residents are potential criminals, making them subject to a higher level of surveillance. This has led scholars such as Michelle Alexander to contend that mass incarceration is a contemporary form of race control in the United States.

At a population level, incarceration is associated with racial disparities and greater risk for sexually-transmitted infections. Blankenship noted that most research has focussed on personal incarceration – which correlates with greater likelihood of unprotected vaginal sex, transactional sex, having a partner who has multiple partners and STI infection. Among black communities, a history of incarceration is also associated with HIV risk, less use of condoms, concurrent partnerships and multiple partners.

Blankenship emphasized the need for more research on the mechanisms linking HIV and incarceration, and on how to measure the impact of mass incarceration accurately. She explained that, in a New Haven study she’s working on, her team is trying to determine how to measure the impact of involvement in the criminal justice system among 300 people recently released for non-violent drug offenses. Some of the relevant factors include employment, housing stability and visitation policies.

Further Information


Incarceration: Impact and Interventions

HIV/HCV in Quebec’s provincial detention centres: Prevalence, related risk factors, access to services and care. Comparing cross-sectional data from 2003 and 2014

Yohann Courtemanche, Centre de recherche, Centre Hospitalier Universitaire de Quebec

Prisoners are a stigmatized, high-risk population for HIV and HCV infections. The last study on Quebec’s provincial prisoners from 2003 showed a high prevalence of HIV, HCV and risky behaviors. The aim of this study was to update the epidemiological data on HIV/HCV in Quebec’s inmate population, with a methodology allowing for optimal comparison with the 2003 study. Cross-sectional data were obtained from male and female prisoners in seven detention centers: 1362 men and 251 women participated in the 2014 study. HIV prevalence was lower in 2014 than in 2003 among both men (1.9% vs. 2.3%) and women (0.8% vs. 8.8%). HCV prevalence was also lower in 2014 than in 2003 for men (11.9% vs. 16.5%,) and women (19.6% vs. 29.1%). Issues examined include declines in HIV/HCV prevalence, treatment adequacy, access to services and opportunities to increase testing, treatment and harm reduction strategies.


Male incarceration rates, spatial access to sexual health care, and sexually transmitted infections: A moderation analysis

Emily Dauria, Department of Psychiatry and Human/Health Behavior, Alpert Medical School, Brown University

Compared to other regions of the country, the southern region of the US consistently has the highest burden of sexually transmitted infections. Incarceration rates have emerged as a potentially powerful determinant of the prevalence of newly-diagnosed STIs, with the forceful removal of men en masse from neighborhoods potentially altering the local composition of sexual networks in ways that facilitate STI transmission. Multiple intersecting factors may help explain complex health outcomes like STIs. One up-stream factor that may be associated with poorer health outcomes and STI transmission is reduced spatial access to health care (i.e. increased distance and travel time to health care providers). Health care visits present critical opportunities for the testing and treatment of STIs. The aim of this cross-sectional study was to explore whether the relationship between male incarceration rates and newly-diagnosed STI prevalence is moderated by spatial access to health care facilities that offer STI treatment and prevention services. We hypothesized that greater spatial access to sexual health care will decrease the magnitude of the relationship between rates of male incarceration and the prevalence of newly-diagnosed STIs.


Transitional health care coordination: Linking incarcerated people living with HIV/AIDS to care and services in the community

Nilda Ricard, Director Health Services and Drop-In Center, The Fortune Society

The Fortune Society’s Drop-In Center program is a service delivery model which provides pre- and post-release care to people living with HIV/AIDS who are currently incarcerated in New York City jails and New York state prisons. The Fortune Society is one of New York City’s leading providers of social services for recently released prisoners and a member of the Transitional Health Care Consortium. The Transitional Health Care Consortium works in collaboration with the New York City Department of Health and Mental Hygiene and the New York City Department of Corrections to link newly released people living with HIV to vital services in the community. Services include care coordination, intake assessment, care plan development, on-going non-medical case management, escort and maintenance in care, and other contract funded services. The also include post-release services such as client assistance, accompaniment, and outreach for patient re-engagement.


CARE+ CORRECTIONS TRIAL: Technology and the HIV-positive returning citizen: A qualitative evaluation

Claudia Trezza, Milken Institute School of Public Health, George Washington University

Individuals recently released from the criminal justice system, locally referred to as “returning citizens,” and diagnosed as HIV-positive experience significant challenges and barriers to linkage and engagement in community HIV care and services subsequent to release. Innovative efforts such as mHealth interventions (CARE+ Corrections) seek to optimize the reentry experience for HIV+ returning citizens to increase linkage to care and ancillary services. The CARE+ Corrections study is a randomized trial conducted in the District of Columbia. The two part intervention consists of: 1) an interactive one-session computerized motivational interview which provided counseling and linkage support, and 2) cell phone text messaging to support linkage and engagement in care and adherence to medications. A qualitative evaluation of the implementation of the CARE+ Corrections intervention is also being conducted among study participants. The research explores perceptions of the innovative mhealth technology and barriers to engaging in HIV care upon return to the community.


Legal Systems: Impact and Interventions

Legal interventions that can reduce health disparities

Scott A. Schoettes, Senior Attorney and HIV Project National Director, Lambda Legal, and Member of the U.S. Presidential Advisory Council on HIV/AIDS


Administrative, regulatory and litigation advocacy for people living with HIV

Carmel Shachar, Clinical Instructor of Law, Centre for Health Law and Policy Innovation, Harvard Law School

The Affordable Care Act (ACA) is an existing framework that contains a number of provisions to increase preventive care and to address social determinants of health; however, State adoption of these initiatives are optional, resulting in fragmented implementation. Resources and tools within the ACA, such as integrated health care homes and free preventive services, have the potential to improve care received by people living with HIV. States now have the opportunity to take advantage of existing proven programs with flexibility for local innovation. Adopting the full range of ACA opportunities available, including Medicaid expansion, reduced elimination of cost sharing for many preventive services, and Medical Health Home programs, would allow States to increase the value of health care by adopting a preventative, early-intervention based health care delivery system and advance health of low-income, vulnerable populations nationwide including those living with HIV. Analysis suggests several ways to reshape health care for low-income vulnerable populations through ACA-based tools.


Legal services: A critical innovation in HIV/AIDS continuums of care

Patrice Paldino, Supervising Attorney, Legal Services, Broward County, Florida

The provision of legal services is critical to the success of interdisciplinary continuums of care. People living with HIV face a number of legal issues which directly impact their stability and mental and physical health. For three years, the HOPWA program at Legal Aid Service of Broward County has provided free legal services to help HOPWA clients maintain or acquire safe and affordable housing and to assist them in transitions to self-sufficiency. A holistic model of direct legal services is needed to overcome systemic barriers to stable housing and resolve root cause issues that impact housing so people living with HIV can achieve improved mental and physical health.


Providing holistic support for LGBT and HIV/AIDS activists fleeing their countries due to persecution

Audu Kadiri, Housing Works Inc.

The Housing Works Asylum Project provides lifesaving assistance to HIV-positive and other LGBT activists from target countries around the world who are facing political persecution for their sexual orientation, gender identity and activism. Asylum Project participants receive housing, medical and mental health care, case management, legal representation, financial assistance, job training and other vital services as they apply for asylum and assimilate into U.S society. They also receive tools to continue their work as advocates in their home countries. An overview of the project discusses lessons learned as well as recommendations.