Transmitted Diseases, and Incarceration Among Women: National
and Southern Perspectives
Hammett, Theodore M. PhD; Drachman-Jones, Abigail BA
From Abt Associates Inc., Cambridge, Massachusetts
Correspondence: Theodore M. Hammett, PhD, Abt Associates Inc.,
55 Wheeler Street, Cambridge, MA 02138-1168. E-mail: firstname.lastname@example.org.
Received for publication February 16, 2005, and accepted May 25,
Objective: The objective of this study was to explore the
relationships between incarceration and emerging increases in
HIV and sexually transmitted diseases (STDs) in the rural south,
particularly among black women of low socioeconomic status.
Study Design: The study used secondary data on correctional
populations, incarceration rates, admissions to correctional
facilities (prisons and jails), HIV and STD prevalence among
inmates, and national and state HIV surveillance data.
Results: Simultaneous consideration of these disparate data
suggests some important patterns. Nationally, increasing
proportions of inmates are women, and blacks and Latinos/as of
low socioeconomic status are disproportionately represented in
inmate populations. Incarceration rates are higher in the south
(790 per 100,000) than in other regions and, within the south,
rates are about the same for rural and urban counties (1194 and
1160). The prevalences of HIV and STDs are higher among female
than male inmates (for HIV, approximately 3% to 2% nationally),
and among the highest regional burdens of HIV are found among
releasees from southern correctional facilities (26% of all
people living with HIV in the south in 1999 were released from a
prison or jail that same year) and among southern women
releasees (15% of all women with HIV were correctional releasees).
Taken together, these figures suggest that many southern women
with HIV/AIDS and STDs, especially poor black women from rural
areas, are found in prisons and jails, perhaps more so than in
other parts of the country. At the same time, only small
percentages of newly reported cases of AIDS among women in the
south are diagnosed in correctional facilities (0.6-7%,
depending on the state).
Conclusions: Given the concentrations of rural black women with
HIV/AIDS and STDs in southern correctional facilities, it is
important to recognize that prisons and jails are critical
settings in which to deploy programs for the prevention,
diagnosis, and treatment of infectious diseases and other health
problems. Such interventions, as well as interventions focused
on the rural communities themselves, would benefit not only
inmates and releasees, but also the larger public health.
AS THE FACE OF THE HIV epidemic in the United States has changed
since the 1980s, blacks and Latinos/as, drug users, and women
have played larger roles in the overall epidemiologic profile.1
A study of HIV surveillance statistics in Alabama from 1981 to
1995 found that case rates among black women increased 170-fold,
as opposed to 80-fold for black men, 50-fold for white men, and
23-fold for white women.2
These changes have also occasioned some regional shifts. At
first concentrated in the northeast and on the west coast, the
epidemic now includes larger proportions of HIV/AIDS cases in
the southeast; in 2001, an estimated 44% of incident AIDS cases
and 39% of people living with AIDS were from the south.1
In addition, there has been substantial attention to the growth
of HIV and sexually transmitted diseases (STDs) in rural
settings, particularly but not only in the south. HIV/AIDS is
still predominantly an urban epidemic nationwide,3 but the
proportions of new cases reported from rural places are higher
in the south than elsewhere.4-6 According to McKinney,4 in 1999,
the south had the highest rate of HIV cases among nonurban
individuals (11 per 100,000 population) of any region and the
highest proportion of HIV cases diagnosed among nonurban people
(12%). As shown in a study of HIV in Florida, increases in case
reports are being seen in rural areas of the south.7 Increasing
incidence of HIV in the small-town and rural south, where the
background prevalence of infection remains very low, has been
associated with sexual networks involving multiple partners,
concurrent sexual partnerships, and co-occurrence of STDs.8-10
High rates of gonorrhea and other STDs have also been reported
in the rural south.11 These have been attributed to the extreme
poverty and very limited healthcare resources in many rural
settings, as well as to crack cocaine use and the related
practice of selling sex for drugs, and the greater fear of
public exposure for people seeking medical treatment for STDs in
small communities.11 One study showed that black women in rural
Missouri were less likely than suburban and urban women to
believe themselves at risk for HIV and STDs or to engage in
sexual risk reduction such as using condoms and accessing HIV
counseling and testing during pregnancy.12
Patterns of incarceration may play a role in these emerging
patterns of morbidity. Blacks and Latinos/as are vastly
overrepresented among correctional inmates. Blacks make up
approximately 13% of the U.S. population but over 40% of jail
and prison inmates. (Prisons, operated by state and federal
governments, largely confine people convicted of felonies with
sentences of more than 2 years, whereas jails, operated mostly
by county and city governments, hold pretrial detainees and
individuals convicted of misdemeanors or lesser felonies serving
shorter sentences.) In 2002, 12% of black men in their 20s were
incarcerated as opposed to 1.6% of white men in this age
group.13,14 Black and Latina women also make up an increasing
share of inmate populations.15,16 In addition, inmates are
disproportionately of low social-economic status and without
access to adequate health care.17
HIV, STDs, and other infectious diseases are much more prevalent
among correctional inmates than in the total U.S. population.17
The burden of disease is also much more severe among inmates and
releasees from correctional facilities. Approximately one fourth
of all people in the United States who are living with HIV or
AIDS in a given year pass through a correctional facility that
same year.18 The equivalent proportions of those with hepatitis
C infection and tuberculosis disease are approximately one third
and more than 40%, respectively.18 Inmates are also
disproportionately burdened with a range of chronic disease and
In most jurisdictions and nationally, HIV prevalence is higher
among women inmates than among men-approximately 3% vs. 2%
overall.19 The higher HIV prevalence among women may be
attributable to the fact that, according to some measures,
higher proportions of female than male inmates have histories of
drug use.20 Also, many women inmates are at risk through sexual
relationships with drug users, even if they are not themselves
drug users, and through their involvement in sex work.21
This article explores possible relationships among regional,
rural-urban, and gender-based patterns of HIV/AIDS, STDs, and
incarceration. It examines the prevalence and burden of HIV/AIDS
and STDs among inmates by gender and region; incarceration rates
by region, race, gender, and rural vs. urban residence; and the
diagnosis and reporting of HIV among women inmates in the south.
Finally, some recommendations are offered for interventions to
address the patterns identified.
Materials and Methods
This article used secondary data on correctional populations,
incarceration rates (per 100,000 population), numbers of
admissions to correctional facilities by sentencing county, and
HIV prevalence among inmates, all collected by the Bureau of
Justice Statistics (BJS), U.S. Department of Justice. National
and state HIV surveillance data from the Centers for Disease
Control and Prevention (CDC) and state health departments were
also used. The analysis involved no formal statistical testing
but instead relied on simultaneous consideration of disparate
data sources to identify possible patterns and relationships.
We updated an analysis previously published in a paper on the
burden of HIV/AIDS and other infectious diseases among inmates
of and releasees from correctional facilities.18 In the analysis
presented in that paper, the burden of HIV disease was
calculated by taking the state-level HIV prevalence rates among
inmates provided by BJS19 and, assuming that these rates are
also applicable to those being released from correctional
facilities, applied them to the estimated number of different
people released in a given year (i.e., adjusted to eliminate
people with multiple incarcerations in the same year18). This
yielded an estimate of the number of people with HIV being
released, which we then divided into the estimated total number
of people living with HIV or AIDS in the United States to
produce a proportion of all people living with HIV who are
released from, or pass through, a correctional facility in a
given year.18 This percentage burden was calculated by gender,
state, and geographic region.
For the analysis presented here, we applied the HIV prevalence
rates for prison inmates exactly as provided in the BJS report19
to releasees, but increased the regional jail prevalence figures
by 50%. This differential methodology was based on the fact that
many of the state prison systems in the south have mandatory HIV
testing so the prevalence figures they report to BJS should be
representative of the total inmate population. However, very
few, if any, jails have mandatory HIV testing so the prevalence
figures they report are based on voluntary testing only. Several
studies have shown that HIV prevalence rates found in mandatory
testing or masked serosurveys were several times higher than HIV
seropositivity rates based on voluntary testing.22-25 This is
because many HIV-positive inmates will not come forward for
voluntary testing if they think that they already know their
status or are fearful of violations of their confidentiality or
related discrimination. In our previous analysis of the burden
of HIV among releasees from correctional facilities,18 a rather
conservative 50% adjustment was made to reported HIV prevalences
from state prison systems without mandatory testing and to jail
prevalences. The resulting figures should be considered rough
estimates of the numbers of cases among inmates and releasees.
Estimates of STD prevalence among inmates were based on data
assembled and reported by the CDC. For 2000, 10 states provided
statistics on chlamydia, gonorrhea, or syphilis to CDC's Jail
STD Prevalence Monitoring Project, whereas 5 states submitted
data to the Syphilis Elimination Initiative and 2 to the
Innovations in Syphilis Prevention Project. In addition, 14
states provided at least 100 test results from correctional
facilities to the Regional Infertility Programs and 5 states
responded to special CDC data requests. In total, these data
represent approximately 327,000 syphilis tests, 120,000
chlamydia tests, and 145,000 gonorrhea tests.26 These data are
based on testing done by correctional facilities and represent a
variety of testing coverage levels and groups tested. Most
facilities do not screen routinely for STDs so it may be assumed
that these CDC-compiled figures are based on incomplete
Incarceration rates (individuals incarcerated per 100,000
population) by region, race/ethnicity, and gender used in the
analysis represent published figures from the BJS based on
numbers of prison and jail inmates as of June 30, 2001. They do
not reflect the total number of people incarcerated over the
Analysis of state prison admissions according to the counties
from which inmates were sentenced (rural vs. urban) was based on
1993-1998 prison admissions data from BJS's National Corrections
Reporting Program maintained at the Interuniversity Consortium
for Political and Social Research (ICPSR) at the University of
Michigan. We matched the sentencing counties by Federal
Information Processing Standards (FIPS) codes, categorizing all
counties included in Metropolitan Statistical Areas (MSAs) as
urban and all others as rural. Incarceration rates for these
counties were calculated on the basis of population statistics
from the 2000 census.
The last set of data are on the diagnosis of AIDS among women in
correctional settings in the south. We can determine the number
of AIDS cases diagnosed among women in correctional settings
from state surveillance data (the CDC case report form includes
a place to record whether the case was diagnosed in a
correctional facility) and the percentage that cases diagnosed
in corrections represent of all cases among women reported by
Table 1 shows the HIV prevalence among male and female inmates
of state prisons in the south in 1999. This reveals that overall
HIV prevalence among inmates in the south is second highest (to
the northeast) among regions. Moreover, prevalence is generally
higher among women than among men. In several jurisdictions,
notably Delaware, the District of Columbia, Maryland, and North
Carolina, the prevalence among women is 2 to 3 times higher than
Table 2 summarizes data from the CDC on STD prevalence among
women entering juvenile facilities, adult state prisons, and
adult city/county jails in 2000. This shows that the average
prevalences of seroreactivity to syphilis and positivity for
chlamydia and gonorrhea are generally higher among women
entering correctional facilities in the south than in the other
regions of the United States.30 As already noted, these average
prevalences were based on data reflecting varying degrees of
We are able to estimate the burden of HIV infection among
correctional releasees by region and by gender. compares the
burden of HIV infection among releasees from state prisons and
city/county jails across geographic regions in the United States
showing that the south has the highest overall burden of HIV
infection among correctional releasees. The prevalence of HIV
among prisoners and releasees in the south is lower than in the
northeast, but the burden of infection among releasees is higher
because of the larger absolute numbers of inmates and releasees
in the south. In Table 4, the burden of HIV infection among
female releasees in the south is compared with that in other
regions of the country, showing that the burden among women
being released from southern prisons and jails is second highest
(to the northeast) among regions. An estimated 15% of all women
living with HIV in the south in 1999 were released from a prison
or jail that year. This finding is also related to the larger
number of women incarcerated and released in the south, despite
a lower prevalence of HIV than in the northeast.
It is difficult to calculate estimates of the total numbers of
correctional releasees with evidence of syphilis, chlamydia, or
gonorrhea (the numerators) because of the scattered prevalence
data that are available. It is also difficult to estimate the
total number of people in the United States with evidence of
STDs (the denominators) because the available data represent
incident cases rather than prevalent cases. As a result of these
data limitations, we are unable to develop credible estimates of
the burden of these STDs among people being released from
correctional facilities. However, some fragmentary data indicate
that the burden of STDs among correctional inmates may be high.
In 1996, for example, 22% of all early syphilis cases diagnosed
among women in Chicago were found at Cook County jail31; in
1999, 25% of all reported early syphilis cases in Chicago were
diagnosed at the jail (H. Beidinger, Chicago Department of
Public Health, unpublished data).
Table 5 confirms the basis of the comparatively high burden of
HIV infection among southern releasees, revealing that
incarceration rates are higher in the south than elsewhere. This
is true overall as well as for men and women separately.32
Incarceration rates for racial and ethnic minorities are much
higher than for whites in the south, but this is true in all
regions of the country and rates for minorities are generally
not higher in the south than elsewhere. Incarceration rates for
subgroups may be sensitive to the size and geographic
concentration of these groups within the overall population. For
example, blacks are much less concentrated in urban areas in the
south than in other parts of the country.
Data on counties from which state prison inmates were sentenced
revealed average incarceration rates for rural counties in the
south are about the same as for urban counties (1194 and 1160
per 100,000, respectively). This is also true for men and women
Data from 7 southern states for 1999 and 2000 reveal that very
small numbers and percentages of AIDS cases among women were
reported as having been diagnosed in correctional facilities.
These percentages (0.6-7.0%, depending on the state [state
surveillance data, personal communications, June-July
2004])35,36 are far lower than the estimated burden of HIV found
among women being released from southern correctional facilities
Simultaneous consideration of these disparate data on the
prevalence and burden of HIV/AIDS and STDs among correctional
inmates and releasees in the south, the incarceration rates for
men and women from rural and urban counties in this region, and
the diagnosis of AIDS among women correctional inmates in the
south suggest some important patterns. Nationally, increasing
percentages of inmates are women, and blacks and Latinos/as of
low socioeconomic status are disproportionately represented in
inmate populations. Incarceration rates are higher in the south
(790 per 100,000) than in all other regions, and within the
south, these rates are similar for residents of rural and urban
counties. The latter may come as a surprise to those who assume
that higher incarceration rates are found in urban areas. In the
south, more serious rural poverty and rural drug use, especially
of crack cocaine, may help to explain the relatively high
incarceration rates for rural residents.11
The prevalences of HIV and STDs are higher among women than men
inmates-for HIV, approximately 3% to 2% nationally. The second
highest regional burdens of HIV among total and women releasees
from correctional facilities are found in the south-26% of all
people living with HIV in 1999, and 15% of all women living with
HIV were released from a prison or jail that same year. There
remain higher burdens of HIV among inmates in the northeast,
probably because of the longstanding higher prevalence of HIV
among injection drug users in that region, but the south is
closing the gap. By contrast, the higher prevalences of STDs
found among southern inmates may reflect the prevalence of risky
sexual practices in rural and urban settings.
Taken together, the data reviewed in this article suggest that
many southern women with HIV/AIDS and STDs, especially
low-income black women from rural counties, are found in prisons
and jails-perhaps more so than in other parts of the country.
This pattern may mean, in turn, that the epidemics of HIV and
STDs among southern women (and men) may be more linked to
incarcerated populations than in other parts of the country.
There is now a substantial literature that attributes the
increasing problems of HIV/AIDS and STDs among black women of
low socioeconomic status in the rural south, at least in part,
to shortages of suitable male sexual partners and consequent
increases in concurrent, unstable, and high-risk sexual
partnerships.9,10,37 The shortage of men is itself a result of
high rates of incarceration among black men and their loss to
the pool of potential sexual partners. It may be that high rates
of incarceration among poor black women from these same rural
areas will, ironically, have the effect of equalizing the gender
ratio of available sexual partners. However, high incarceration
rates for women and men may also exacerbate the problem by
further reducing the numbers of female and male sexual partners
available in the community and increasing the likelihood of
high-risk concurrent sexual partnerships.
At the same time, the data presented here suggest that only a
small percentage of total AIDS cases reported among women in a
number of southern states are being diagnosed in correctional
facilities. This discrepancy probably results from a combination
of factors, including the following: many female inmates with
AIDS may have been diagnosed in the community before they were
incarcerated; there may also be problems with the reporting of
AIDS cases diagnosed in correctional facilities (AIDS case
reporting is not required by law); and finally, there may be
service gaps and programmatic problems with diagnosing HIV and
AIDS in correctional settings. In many correctional facilities,
healthcare providers may not be particularly proactive in HIV
case finding and the burden falls on the inmates to request
testing.38 These policies may be partly attributable to
correctional health providers' concerns about straining already
The inferences drawn in this article from the combined
consideration of disparate data sources are subject to several
limitations related to specific data types. First, we think that
the across-the-board 50% upward adjustment of reported jail HIV
prevalence figures is supportable, and indeed probably
conservative, based on evidence from the literature. However, we
concede that for particular jurisdictions, such an adjustment
could lead to exaggeratedly high or low prevalence estimates.
Second, the STD data on which we based our conclusions about
higher prevalences among women inmates in the south come from
scattered data representing varying levels of testing coverage.
It is also possible that testing coverage has increased
differentially in the south in response to evidence of
increasing STD problems there. Such differential coverage could
exaggerate interregional differences in prevalence. Third, our
conclusions on HIV diagnoses among women inmates in the south
are also based on scattered data that may be themselves subject
to reporting problems.
Despite these limitations, we believe that our findings point to
some important programmatic recommendations. Community-based
interventions to address the problems of concurrent partnerships
and other high-risk sexual behaviors in the rural south are
urgently needed as are improved interventions in correctional
facilities. Because of the concentrations among inmate
populations of people at high risk for HIV/AIDS, STDs,
hepatitis, tuberculosis, other infectious diseases, and a range
of other health problems,17 prisons and jails are critical
settings in which to deploy effective and efficient prevention,
diagnosis, and treatment programs. Correctional systems
currently follow diverse HIV and STD testing policies, including
mandatory, routine, voluntary, and on request.29,38,40 Optimum
programs should include broad availability, more aggressive
marketing of voluntary counseling and testing (VCT) for HIV in
correctional facilities, and the linkage of VCT to high-quality
HIV treatment. STD testing and treatment should also be made
more widely available in correctional facilities, particularly
in jails where inmate turnover is rapid, and inmates with risk
factors or STD symptoms should be encouraged to take advantage
of these services.
These interventions will benefit not only the inmates and
releasees themselves and their families and partners, but also
the larger public health.41-43 In this instance, interventions
for women in southern prisons and jails stand to benefit the
rural communities in the south, and particularly those with
large black populations, that have been identified as settings
of growing epidemics of HIV/AIDS and STDs. Improvement of
programs to help people with, or at risk for, HIV/AIDS and STDs
being released from correctional facilities to link with
services in the community and actually obtain community-based
services should be a particular priority.
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