HIV/AIDS, Sexually Transmitted Diseases, and Incarceration Among Women: National and Southern Perspectives
Hammett, Theodore M. PhD; Drachman-Jones, Abigail BA
Author Information
http://journals.lww.com/stdjournal/Fulltext/2006/07001/HIV_AIDS,_Sexually_Transmitted_Diseases,_and.4.aspx
From Abt Associates Inc., Cambridge, Massachusetts
Correspondence: Theodore M. Hammett, PhD, Abt Associates Inc., 55 Wheeler Street, Cambridge, MA 02138-1168. E-mail: ted_hammett@abtassoc.com.
Received for publication February 16, 2005, and accepted May 25, 2005.
Abstract
 

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 mental illness.17
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 testing.27-29
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 full year.
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 the state.

Results
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 among men.19
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 testing coverage.

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 separately.33,34
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 (15%; ).
Discussion
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 overtaxed budgets.39
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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