POSITIVELY AWARE May/June 2012
Progress through resiliency. Syndemics, stregnths, and HIV among Men who have sex with Men.
Disconnected - Incarceration cuts you off from your social network-andHIV thrives on that.
Most people are not surprised to learn that HIV infections cluster in jail and prison inmates. At any given time, there are over 2.2 million adults in U.S. jails and prisons, and one of every seven HIV-infected Americans are released from these facilities each year.1 Correctional facilities are holding places for those among the most economically and socially disadvantaged in the U.S.
These populations are disproportionately affected by adverse life circumstances and behaviors, such as drug use, that drive HIV risk. However, the process of incarceration itself may also contribute to infection transmission.
Having a history of incarceration or having an intimate partner who has been incarcerated are correlates of HIV risk behaviors and sexually transmitted infection, independent of important factors such as poverty and substance use.2, 3, 4, 5, 6, 7 There is emerging evidence to suggest that incarceration may lead to HIV risk because incarceration disrupts social and sexual networks, and HIV thrives on network disruption.
Because incarceration removes an individual from society, it is expected that ties between offenders and members of their networks will be weakened. This can be a positive event for the offender if ties in the community were negative influences. For example, some inmates are wary of returning home after incarceration for fear of again encountering family members, friends, and acquaintances who were part of a lifestyle that led to the incarceration, such as one characterized by drug use or trade.8
However, one unintended effect of incarceration is to weaken and, in some cases, permanently fracture ties to committed partners, family members, and friends who are positive influences and who provide important sources of social support. Losing a committed partner, in particular, has potential consequences for an inmate’s HIV risk. Those who are in committed partnerships are less likely to engage in multiple sexual partnerships.9, 10 Consequently, the destabilization and dissolution of committed relationships that occurs during incarceration could promote HIV risk-taking upon release.
Many inmates are in committed relationships when they leave for jail or prison, and many of these relationships end during the incarceration. 11, 12, 13, 14, 15 We interviewed a sample of HIV-positive men incarcerated in North Carolina prison facilities to learn more about the committed relationships of prison inmates.14
Among the inmates, 52% reported having a primary partner at the time of incarceration. The inmates’ lives had been highly interconnected with those of their partners. The majority of inmates reported that prior to the incarceration they had lived together with their partners (85%), had seen their partners daily or nearly daily (88%), and had been in long-term relationships with them, for six months or longer (64%) or on and off for a number of years (30%). Over half reported that their partners in the community had relied on them financially. Inmates who were in committed relationships prior to the incarceration reported much lower levels of pre-incarceration multiple partnerships and sex trade than those who did not have committed partners, highlighting the protective effect of these partnerships. Over half of inmates’ relationships had ended during the incarceration. These findings suggested to us that those who have lost a primary partner during incarceration may experience heightened levels of sexual risk-taking as they re-enter the community.
We also interviewed a number of individuals at social venues in a North Carolina city to assess how commonly people in the community reported having been in a relationship that was interrupted by incarceration.15 The results told the same story—incarceration-related relationship disruption and dissolution was common.
Among men who had ever been incarcerated for one month or longer, 43% had a marital or non-marital primary partner at the time of the longest prior sentence. Among women, 22% had ever had a primary partner who had been incarcerated for one month or longer. Of those who were in a relationship that was disrupted by incarceration, more than 40% of men and 30% of women reported the relationship ended during the incarceration. Further, those who had lost a partner during incarceration were twice as likely to report recent multiple partnerships as those who remained with their committed partner during the incarceration.
It’s not surprising that relationships end during incarceration, given the barriers to maintaining ties during detention. Incarceration physically divides prisoners from their intimate partners, making maintenance of the relationship difficult. Partners may speak infrequently by telephone, as calling is restricted by prison regulations, is monitored for security purposes, and is expensive.16 Likewise, logistical and financial obstacles can prevent visitation, especially because many inmates are held far from their home communities.16 Even when visitation occurs, physical contact is often prohibited and lack of privacy prevents partners from maintaining intimacy during the incarceration.17 For example, in many states, conjugal visits are not permitted. Even written communication is affected, as prisons screen incoming letters for security reasons. Physical separation during incarceration can lead to loneliness and emotional division which puts considerable stress on relationships during incarceration.18, 19, 20
Consequences of instability
Loss of a partner during incarceration may contribute to HIV risk during re-entry in a number of ways. First, if an inmate loses a stable partner during incarceration, upon release, he may seek new partners and potentially engage in multiple partnerships and/or buy sex for money or drugs to meet needs for sexual and emotional companionship. In addition, losing a partner during incarceration may lead to distress and mental health problems. Specifically, incarceration weakens social cohesion and support networks when an individual most needs them—during the stressful periods of incarceration and re-entry.21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45 An inmate may experience stress during the incarceration due to loss of freedom, isolation, and stigma.18 The period of re-entry is also highly stressful, because released inmates must negotiate a place to live, employment, re-establishing family ties, and returning to high-risk situations.16,19 Social support may buffer the stress associated with incarceration and re-entry by enabling the inmate to cope, thereby reducing negative emotional and behavioral responses.46 However, losing a partner may lead to distress and diminish mental health.47,48 In turn, the former inmate may self-medicate with drugs or sex.
While incarceration disrupts existing networks, it also helps form new ones and may lead to involvement in high-risk social and sexual networks. There is evidence that incarceration introduces inmates into high-risk networks characterized by high levels of drug trade and use (i.e., gangs).49,50 The networks may have high levels of sexual risk-taking and infection, thereby leading to increased risk of sex with an infected partner.51, 52, 53 Hence, by destabilizing existing networks, incarceration may influence HIV risk not only by increasing the numbers of partners a former inmate has but also by changing the types of partners a former inmate may have sex with.
Finally, when offenders leave for jail or prison, they leave behind loved ones. During an incarceration, the prisoner’s partner may seek other partners to fill an emotional or financial void.18 We have found that incarceration is associated with elevated levels of HIV risk behaviors not only of the offender but also of their sexual partners.2, 3, 4, 5, 6, 7
Given the high rates of incarceration in many U.S. communities, the influence of incarceration on inmates and their families is high. The fracturing of networks that occurs during incarceration appears to influence HIV risk-taking. For these reasons, it is critical to promote efforts which will diminish the disruptive effects of incarceration on healthy relationships, and to understand the public health implications of incarceration-related relationship disruption.
Maria R. Khan is an Assistant Professor in the Department of Epidemiology and Biostatistics at the University of Maryland College Park School of Public Health. Her recent work has focused on investigating STI/HIV among those with a history of incarceration. She was recently funded by the National Institute on Drug Abuse to study how incarceration-related dissolution of relationships influences the HIV risk of African American men released from prison.
Matthew W. Epperson is an Assistant Professor in the School of Social Service Administration at The University of Chicago. His primary focus is intervention research on co-occurring problems of HIV, substance abuse, mental illness, and criminal justice involvement. Before earning his PhD in social work from Columbia University, Dr. Epperson spent 15 years as a social worker in behavioral health and criminal justice settings.
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- Khan MR, Wohl DA, Weir SS, et al. Incarceration and risky sexual partnerships in a southern US city. J Urban Health. 2008;85 (1):100-13.
- Khan MR, Miller WC, Schoenbach VJ, et al. Timing and duration of incarceration and high-risk sexual partnerships among African Americans in North Carolina. Ann Epidemiol. 2008;18 (5):403-10.
- Epperson M, El-Bassel N, Gilbert L, Orellana ER, Chang M. Increased HIV Risk Associated with Criminal Justice Involvement among Men on Methadone. AIDS Behav. 2008;12 (1):51-7.
- Khan MR, Doherty IA, Schoenbach VJ, Taylor EM, Epperson MW, Adimora AA. Incarceration and high-risk sex partnerships among men in the United States. J Urban Health. 2009;86 (4):584-601.
- Khan MR, Epperson MW, Mateu-Gelabert P, Bolyard M, Sandoval M, Friedman SR. Incarceration, sex with an STI- or HIV-infected partner, and infection with an STI or HIV in Bushwick, Brooklyn, NY: a social network perspective. Am J Public Health. 2011;101 (6):1110-7.
- Epperson MW, Khan MR, El-Bassel N, Wu E, Gilbert L. A Longitudinal Study of Incarceration and HIV Risk Among Methadone Maintained Men and Their Primary Female Partners. AIDS Behav. 2011;15 (2):347-55.
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