Women, HIV, and the Criminal Justice System: Prison Health Is Public Health
Interventions should be directed at increasing provider knowledge and proficiency in prescribing PrEP, as well as encouraging providers to screen for PrEP eligibility.
The number of US women involved in the criminal justice systems (ICJS) has ballooned since 1970.1-3 In 2015, approximately 110,000 women were imprisoned in local jails, 111,000 were in state or federal prison, almost 950,000 were on probation, and 113,000 were on parole.1-3 These women are at high risk for infection with HIV. Jaimie P. Meyer, MD, MS, FACP, assistant professor of medicine in the section of Infectious Diseases' AIDS Program at the Yale School of Medicine in New Haven, Connecticut, and her colleagues are studying the issue of HIV in people ICJS and working to identify opportunities to reduce the risk for transmission, particularly in women ICJS.
Dr Meyer and her associates recently published findings from a survey of 125 Connecticut women ICJS concerning HIV risk and prevention.4 Eligible participants were adult women without HIV infection who were on probation, parole, or pretrial supervision or had been released from prison or jail in the past 60 days.4 The women were questioned about demographic characteristics, participation in behaviors that increase the risk for HIV, the use of healthcare resources over the past year, and knowledge and beliefs regarding HIV and antiretroviral pre-exposure prophylaxis (PrEP).4
The US Food and Drug Administration (FDA) approved Truvada® (Gilead, Foster City, California) in 2012 after clinical trials established its safety and efficacy in people with a substantial risk for HIV infection.5 According to the Centers for Disease Control and Prevention (CDC), consistent use of PrEP reduces the risk for HIV infection by up to 44% to 92% in high-risk individuals.6 However, many people who might benefit from PrEP are not using it. In an interview with Infectious Disease Advisor, Dr Meyer discussed the findings of her group's survey and how the investigators analyzed the data to identify trends and barriers to PrEP use in women ICJS.
Infectious Disease Advisor: How significant is the risk for HIV transmission in women ICJS?
Jaimie P. Meyer, MD, MS, FACP: Women ICJS are disproportionately at risk for contracting HIV compared with women in the general population. Their increased risk is related to substance use, including use of injected drugs, and sex, including engagement in transactional sex (ie, the exchange of sex for money, drugs, or other goods). Some women ICJS have overlapping sex and drug-use partners, which doubles their HIV risk.
These women also disproportionately experience comorbid medical conditions (eg, chronic hepatitis C infection, other sexually transmitted infections), psychiatric illnesses (eg, depression or trauma), and social situations (eg, homelessness, poverty, or exposure to partner violence) associated with an increased risk for HIV infection. As a result, women ICJS represent a key target population for HIV prevention and treatment strategies that aim to end AIDS. Women in this population are also considered at “substantial risk of HIV acquisition,” which qualifies them for PrEP according to CDC-based guidelines.7
Our survey of 125 women on probation in Connecticut who did not have HIV determined that 42 (33.6%) respondents met criteria for PrEP eligibility: in the 12 months before the survey, 22% of women had transactional sex and 17% had 4 or more sex partners; and in the previous 6 months, 14% had engaged in unsafe injection practices, and .8% had sex with someone who was HIV-positive.4
Infectious Disease Advisor: What did you find were possible obstacles to implementing PrEP programs in women ICJS?
Dr Meyer: Only 32 of the 125 women we surveyed (26%) were aware of PrEP as an HIV prevention option. Even more problematic for PrEP program implementation, few women were able to assess their HIV risk accurately. Only 8% considered themselves at risk for HIV.4 Many women who were clearly engaging in high-risk sex and drug-related behaviors also underestimated their HIV risk — only 17% of PrEP-eligible women recognized they had a high risk for HIV.4
Other barriers to PrEP implementation we identified in this population were related to their interactions with healthcare providers. Although most women surveyed were insured and had a primary care provider (PCP), they did not discuss HIV risk or HIV prevention options with their PCP. The fact that PrEP is not entering the patient-provider conversation compounds the problem of having only a limited number of providers available and willing to prescribe PrEP.
Infectious Disease Advisor: What are some steps public health systems could take to increase adoption of PrEP in high-risk women?
Dr Meyer: PrEP programs can be scaled up by undertaking several approaches: (1) increase the pool of trained providers available and willing to assess HIV risk and prescribe PrEP by offering professional medical education, training, and support; (2) empower high-risk women as healthcare consumers by increasing public (and perhaps social) messaging about PrEP for women; (3) develop PrEP or HIV prevention programs specifically in women in settings that already serve high-risk women, including criminal justice settings and drug treatment programs.
Infectious Disease Advisor: What effect might efforts by prisons to cut spending have on the risk for HIV infection in female inmates and could that affect the risk for HIV in the community at large?
Dr Meyer: Incarcerating people and providing healthcare in prisons is expensive. Data from the Pew Charitable Trusts show departments of correction in the United States collectively spend more than $8 billion per year on healthcare in prison,8 where access is protected by law (guaranteed under the 8th Amendment). When federal and state budgets are cut, however, prisons may be forced to reduce resources, staffing, and supplies for healthcare, particularly in states where Medicaid is suspended or terminated during incarceration and healthcare spending therefore depends on state budgets. Cost cutting inevitably limits women's potential of being diagnosed with HIV in prison or of receiving timely and comprehensive care for HIV. This lapse has broader implications when women then transition from prisons or jails back to communities, given that more than 90% of new HIV infections are transmitted by people who are unaware they have HIV or were diagnosed but are not engaged in care. Prison health is public health.
Infectious Disease Advisor: Once an inmate receives an HIV diagnosis, what might help promote continuity of care once the inmate returns to the community?
Dr Meyer: Few US prisons provide universal opt-out testing for HIV, despite housing an extremely high-risk population. When incarcerated individuals are found to have HIV, however, we know they can be successfully linked to care during incarceration and have their care optimized (ie, attain viral suppression) prior to release. People are best able to transition to community-based care when they have their multiple medical, psychiatric, and case management (including insurance) needs identified and effectively addressed during incarceration.
Infectious Disease Advisor: What contributes to the disparity in HIV prevalence between black women and women from other racial or ethnic groups even though black women appear less likely to engage in high-risk behaviors?9
Dr Meyer: To my knowledge, there are few data on HIV prevalence in women under community supervision, including probation and parole. This is due, in part, to the fact that women under community supervision are rarely routinely tested for HIV and probation or parole programs are often not health-oriented. In community-based populations, however, black women are significantly more likely to have HIV than women from other racial/ethnic groups because they are embedded within higher risk networks. They are known as a population at “substantial risk” for HIV. So even if they engage in the same amount of sex- and drug-related risk behaviors, their risk for being exposed to HIV is much higher. This suggests the need for targeted intervention.
Infectious Disease Advisor: Are you involved in developing any programs or interventions that you want to mention?
Dr Meyer: Women ICJS are often at risk for HIV and yet have traditionally not accessed many of the highly effective HIV prevention tools in our armamentarium. My goal is to develop effective HIV prevention and treatment interventions tailored to this population. We are currently developing and testing an HIV prevention decision aid for women in drug treatment programs and demonstrating the feasibility and acceptability of providing PrEP to women ICJS and members of their risk networks. We are also thinking about ways we can simultaneously address women's reproductive health and HIV prevention needs and working to generate probation-to-care strategies to deliver interventions in a seamless and meaningful way.
Infectious Disease Advisor: Would you like to add any concluding remarks?
Dr Meyer: Because women make up a minority of people ICJS and people living with HIV, they are often left out of the public conversation. As clinicians and clinical researchers, it is important that we continue to draw attention to the specific HIV prevention needs of women ICJS and design interventions to address these needs.
- Swavola E, Riley K, Subramanian R. Overlooked: women and jails in an era of reform. New York: Vera Institute of Justice, 2016. Accessed May 14, 2018.
- Carson EA, Anderson E; Bureau of Justice Statistics. Prisoners in 2015. Published December 2016. Accessed May 6, 2018.
- Kaeble D, Bonczar TP; Bureau of Justice Statistics. Probation and parole in the United States, 2015. Published December 2016. Accessed May 6, 2018.
- Rutledge R, Madden L, Ogbuagu O, Meyer JP. HIV risk perception and eligibility for pre-exposure prophylaxis in women involved in the criminal justice system [published March 11, 2018]. AIDS Care. doi:10.1080/09540121.2018.1447079.
- US Department of Health and Human Services. Pre-exposure prophylaxis (PrEP). Updated May 15, 2017. Accessed May 7, 2018.
- Centers for Disease Control and Prevention. HIV risk and prevention: pre-exposure prophylaxis (PrEP). Updated April 25, 2018. Accessed May 5, 2018.
- Centers for Disease Control and Prevention. Preexposure prophylaxis for the prevention of HIV infection in the United States – 2017 update: a clinical practice guideline. Published 2017. Accessed May 5, 2018.
- PEW Charitable Trusts. Prison health care: costs and quality. How and why states strive for high-performing systems. Updated December 8, 2017. Accessed May 6, 2018.
- Henry J Kaiser Family Foundation. Black Americans and HIV/AIDS: the basics. Published February 6, 2018. Accessed May 6, 2018.