The ripple effects of incarceration on HIV
How incarceration affects the transmission of HIV in communities and how we can intervene to stop it
In public health, we often refer to healthcare as a human right. Currently in the United States, the only people guaranteed health care by law are individuals who are incarcerated. In a 1976 court case, the Supreme Court ruled that the depriving people who are incarcerated health care constituted cruel and unusual punishment. Unfortunately, this ruling did not guarantee access to quality care within facilities or access to care after release.
Lately, reports of medical abuse and neglect in correctional facilities have made the news; people are not receiving medical care and there have been deaths due to preventable causes Abhorrent practices such as releasing sick people in order to avoid paying for their cost of treatment and even re-arresting those who recover, show how the current structure of care can fall desperately short. These failures are often tied to the existence of for-profit healthcare organizations seeking to minimize expenses.
Mass incarceration impacts millions of Americans and African Americans are disproportionately affected due to systemic and institutionalized racism. Incarceration disrupts lives, breaks up families, and leaves a lasting legacy of stigma and discrimination that can make it harder to live a fulfilling, healthy life.
I recently published a study showing that delivering a high level of medical care to individuals living with HIV upon their release from correctional facilities not only benefits those receiving care, but can prevent HIV transmissions within the communities to which they return. We used an agent-based model that simulates a virtual population of “agents” or people (similar to the popular Sims games). Our model simulated African American men and women living in Philadelphia and included the movement of men in and out of correctional facilities based on current incarceration rates.
“This study emphasizes the potential role that prison- and community-based interventions for individuals experiencing incarceration can have in decreasing HIV transmissions among women in the community. “
In our model, incarceration could break apart existing relationships between men and women. The post-release period was also related to higher risk sexual behaviors such as multiple and/or concurrent relationships (having more than one partner at a time) and an increased risk of sexually transmitted infections. Men who were living with HIV and incarcerated were likely to fall out of care once they left a correctional facility. All of these dynamics drove up HIV transmissions in the community.
When we implemented an intervention within the model to improve HIV care engagement and decrease sexual risk behaviors, we were able to prevent these transmissions. When we implemented a “90–90–90 scenario”, where 90% of men entering a correctional facility are tested for HIV, 90% of those diagnosed are given antiretrovirals, and 90% of those treated achieve viral suppression (where they can no longer transmit HIV to others), 29% of all HIV transmissions to women were prevented. A combination scenario in which we paired the 90–90–90 intervention with another intervention that prevented an increase in sexual risk behaviors averted 37% of HIV transmissions to women. This study emphasizes the potential role that prison- and community-based interventions for individuals experiencing incarceration can have in decreasing HIV transmissions among women in the community.
This care begins while individuals are incarcerated. When paired with access to antiretroviral medication that enables individuals living with HIV to live as long as individuals who are not living with HIV, quality medical care during and immediately after incarceration can set people up for success. Peer navigators and case managers can ease the transition to the outside world following release and help patients feel empowered to stay in care. For example, these programs can provide free transportation to medical appointments, offer appointment reminders via the phone or in-person, and ensure people have health insurance. They improve people’s health and can decrease HIV transmissions for the entire community.
We need to prioritize the delivery and quality of health care to individuals experiencing incarceration. Compared to the general population, people experiencing incarceration are substantially more likely to have a serious mental illness and nearly half meet clinical criteria for substance use disorder. Many of these individuals have gone without health care, for a variety of reasons including lack of insurance, limited access, or distrust of the medical system, for years before entering a correctional facility. The majority will return to their communities.
If we are seeking to make a lasting impact to improve the health of the most vulnerable within our society, we have a responsibility to do so by delivering a high level of care during a critical window of time — doing so has the potential to improve health for everyone.
For more information on our study or to share feedback, please contact Joella Adams at joella_adams@brown.edu
