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. Author manuscript; available in PMC: 2023 Sep 28.
Published in final edited form as: AIDS Behav. 2023 Jan 12;27(8):2513–2522. doi: 10.1007/s10461-023-03978-5

Characterizing HIV Syndemics and the Role of Incarceration Among Men Who have Sex with Men Presenting for Care at a Sexually Transmitted Infections Clinic

Brooke G Rogers 1,2, Matthew Murphy 1,3, Alexandra Zanowick-Marr 1, Laura Chambers 1,2, Michaela Maynard 1, Drew Galipeau 1, Emily Toma 1, Alexi Almonte 1, Siena Napoleon 1, Philip A Chan 1
PMCID: PMC10336172  NIHMSID: NIHMS1904375  PMID: 36633764

Abstract

Men who have sex with men (MSM) with a history of incarceration experience unique risk factors for HIV acquisition. The current study examined unique risk factors for HIV among MSM with a history of incarceration presenting to a sexually transmitted infections (STI) clinic. We analyzed self-reported behavioral data from clinical encounters among patients attending the clinic between January 2012 and April 2021. There were 17,221 unique visits, of which 5988 were MSM. Of these, 4.34% (N = 206) were MSM with a history of incarceration. MSM with a history of incarceration were significantly more likely to report a range of behavioral risk factors for HIV, yet also were significantly less likely to perceive themselves at risk for HIV. Future research and practice should develop culturally tailored biobehavioral HIV prevention services and consider embedding these programs within criminal justice settings to better reach this at-risk group.

Keywords: Men who have sex with men, HIV, Prevention, Incarceration, Criminal justice

Introduction

Globally and within the U.S., HIV remains a condition that is overrepresented in socially and structurally marginalized groups, including individuals with a history of incarceration [1, 2]. Incarceration rates are higher among individuals with multiple marginalized identities [3] and who engage in behaviors that place them at risk for HIV (e.g. drug use, sex work) [4]. Incarceration itself can be an extremely disruptive process interrupting stability in various domains of life [5, 6] and the time period immediately following is associated with increased behavioral risk taking related to HIV infection (e.g. substance use, sexual activity) [7, 8].

In the U.S., men who have sex with men (MSM), which is inclusive of gay, bisexual, and other sexual minority men as well as men who have sex with men for money, drugs, or to have their needs met (e.g. male sex workers), represent 70% of people living with HIV in the U.S. [9] and a similar percentage of incident HIV cases [10]. However, risk within this group is not evenly distributed. Individuals who are subject to more overlapping layers of marginalization and/or risk tend to be more affected by HIV [11–13]. There are significant racial and ethnic disparities, with Black and Latino men having a higher relative risk for HIV than White men [10, 14]. Additionally, MSM who use drugs, and specifically stimulants, have approximately a 1 in 3 annual incidence of HIV [15]. Although racial/ethnic minorities and people who use drugs are overrepresented in criminal justice settings [16, 17], few studies have focused on how a history of incarceration itself might be uniquely associated with risk for HIV within a sample of MSM.

For MSM affected by incarceration and at risk for HIV, there are multiple other factors and systems that create vulnerability including poverty, marginal housing, trauma, substance use, and mental health issues [18–20]. One framework for considering these factors across various levels of influence is the “syndemics” model, which posits that co-occurring “synergistic epidemics” operate to create a reciprocal vulnerability for health conditions, including HIV [21–23]. Individuals with a history of incarceration represent a vulnerable population for myriad health conditions as a result of systemic inequities, which perpetuate disadvantage. Upon release, individuals often experience significant upheaval including, but not limited to, loss/change of employment, loss/change of housing, loss of meaningful or romantic relationships, and loss/change in parental rights. These factors further disrupt individuals’ lives and can create a cycle of barriers to achieving optimal health and wellbeing, including HIV/STI acquisition risk.

The goal of the current study was to examine demographic and behavioral data among MSM with a history of incarceration to better understand their unique risks for STIs/HIV compared to MSM who have not been incarcerated, and specifically answer the following research question: Do MSM with a history of incarceration meaningfully differ from others with regards to their HIV risk behaviors?

Methods

Participants and Procedures

We conducted a retrospective review of self-reported behavioral data from clinical encounters among patients attending a hospital-based STI Clinic affiliated with a large academic medical center in Providence, Rhode Island between January 2012 and April 2021. All patients presenting for HIV or STI testing were asked to complete a clinical intake form at their visit, which was used to inform their care and clinical programs. Data presented within this manuscript are what patients reported on this form which included demographics, behavioral risk factors, and other conventional HIV surveillance information. Clinic staff entered the data from forms as well as the results of any HIV and STI laboratory tests from that encounter into a HIPAA-compliant Research and Electronic Data Capture database, REDCap [24, 25]. We utilized de-identified encounter-level data from the REDCap database for this study. The focus of this study was specifically to examine the unique behavioral risk factors for HIV among MSM who reported a history of incarceration in comparison to MSM without that history. Study procedures were approved by The Miriam Hospital Institutional Review Board under an existing protocol to review de-identified clinical data.

Measures

Demographics Sex and gender were assessed with two questions. The first question asked, “What is your gender identity?” with option choices of: man, woman, transwoman, transman, genderqueer/agender/nonbinary. The second question asked, “What was your sex assigned at birth?” with option choices of: male, female, and intersex. Sexuality was assessed using the question, “How do you identify?” with answer choices of heterosexual, gay, lesbian, bisexual, queer, pansexual, asexual, and other. Race was also assessed, and individuals responded as to whether they identified as Caucasian/White, African American/Black, Asian, Pacific Islander, Native American, or Other. Ethnicity was assessed as identifying as Hispanic/Latino or Not Hispanic/Latino.

HIV risk perception HIV risk perception was assessed with one question, “What is your risk of becoming HIV infected?” with answer choices of: no risk, low risk, medium risk, and high risk.

Sexual behavior Sexual behavior was assessed by a stem question “In the past 12 months, with how many men have you had anal sex with?” The respondent then listed the number of anal sex partners for receptive only sex, insertive only sex, and “vers,” or sex where they were both receptive and insertive sex partners. Of these, individuals were then asked with how many sex partners with whom they did not use a condom, how many were known to be HIV positive, and how many were known to use injection drugs.

Other HIV risk behaviors Other HIV risk behaviors were assessed using the stem question “In the past 12 months, have you…?” and asking about a series of HIV risk behaviors including doing sex work, paying for sex with a sex worker, anonymous sex, sex while intoxicated or high, etc. with answer choices of Yes/No.

Alcohol use Alcohol use was assessed with the AUDIT-C, which assesses frequency and quantity of alcohol consumption on a typical day of drinking [26].

Substance use Substance use was assessed by the following question, “Which of the following substances have you used?” Individuals indicated lifetime and past 30-day use of the following substances: cannabis, cocaine, prescription stimulants, methamphetamine, inhalants, sedatives, hallucinogens, street opioids, prescription opioids, other (write-in).

Injection drug use Injection drug use was assessed by three items. The first question was, “Have you EVER injected drugs?” with the answer choices of yes or no. The second question asked, “If yes, did you ever share needles?” with the answer choices of yes or no. The third question asked the date of the last injection drug use.

Incarceration history Incarceration history was assessed with one item, “Have you EVER been incarcerated (i.e. in jail/prison)?” with the answer choices of yes or no.

Analytic Plan

Demographic information, behavioral risk, and substance use were examined descriptively. Chi-square tests were used to calculate differences between groups. Final analyses used logistic regression to compare HIV risk factors between MSM with a history of incarceration to those without that history while adjusting for the effects of age, gender, race, and ethnicity.

For this study, MSM was a variable coded from answers to three questions on the clinic intake form. These questions asked the individual for their gender, sexual identity, and reported sexual partners. We broadly defined MSM as an individual who identified as “Male” or “Transmale” and one of the following sexual identities: “Gay”, “Bisexual”, “Queer”, “Pansexual”, or “Other.” Otherwise, an individual was considered MSM if they described themselves as: “A man who only has sex with other men”, “A man who has sex with both men and women” “A transman who only has sex with other men”, or “A transman who has sex with both men and women”.

Results

The total sample included over 7221 unique visits to the STI clinic. Of those, 5988 were MSM. Of those, 3.4% (n = 206) reported a history of incarceration. The sample of MSM with a history of incarceration was comparable to the total sample of MSM with regards to demographic information. There were two notable differences: MSM with a history of incarceration were more likely to be between the ages of 25 and 44 and were more likely to identify as bisexual or “other” sexual orientation than gay (Table 1).

Table 1.

Sample characteristics for men who have sex with men (MSM) at an STI clinic (N = 5986)

Demographics Total MSM (n = 5986) Yes (n = 206) No (n = 5780)
n (%) n (%) n (%)
Age
 0–17 years 15 (0.3%) 0 (0.0%) 15 (0.3%)
 18–24 years 1525 (25.5%) 27 (13.1%) 1498 (25.9%)
 25–44 years 3143 (52.5%) 139 (67.5%) 3004 (52.0%)
 45–64 years 1144 (19.1%) 38 (18.4%) 1106 (19.1%)
 65+ years 156 (2.6%) 2 (1.0%) 154 (2.7%)
Gender
 Male 5921 (99.2%) 202 (99.0%) 5719 (99.2%)
 Female 0 (0.0%) 0 (0.0%) 0 (0.0%)
 Transgender (male to female) 0 (0.0%) 0 (0.0%) 0 (0.0%)
 Transgender (female to male) 10 (0.2%) 0 (0.0%) 10 (0.2%)
 Genderqueer/agender/nonbinary/other 34 (0.6%) 2 (1.0%) 32 (0.6%)
Sexual orientation
 Heterosexual 80 (2.0%) 5 (4.0%) 75 (2.0%)
 Homosexual 2981 (75.0%) 72 (57.1%) 2909 (75.5%)
 Bisexual 700 (17.6%) 33 (26.2%) 667 (17.3%)
 Other 215 (5.4% 16 (12.7%) 199 (5.2%)
Race
 White 3940 (65.9%) 142 (69.3%) 3798 (65.8%)
 Black 687 (11.5%) 20 (9.8%) 667 (11.6%)
 Asian 262 (4.4%) 2 (1.0%) 260 (4.5%)
 Cape Verdean 20 (0.3%) 0 (0.0%) 20 (0.3%)
 American Indian/Alaska Native 13 (0.2%) 1 (0.5%) 12 (0.2%)
 Native Hawaiian or Pacific Islander 14 (0.2%) 1 (0.5%) 13 (0.2%)
 More than one race 181 (3.0%) 10 (4.9%) 171 (3.0%)
 Other 691 (11.6%) 24 (11.7%) 667 (11.5%)
 Prefer not to answer 172 (2.9%) 5 (2.4%) 167 (2.9%)
Ethnicity*
 Hispanic/Latinx 1156 (19.4%) 39 (18.9%) 1117 (19.4%)
 Not Hispanic/Latinx 4475 (74.9%) 150 (72.8%) 4325 (75.0%)
 Other 3 (0.1%) 1 (0.5%) 2 (0.0%)
 Prefer not to answer 338 (5.7%) 16 (7.8%) 322 (5.6%)
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For this assessment, men who have sex with men (MSM) was a variable coded from an individual’s answer to three questions on the clinic intake form. These questions asked the individual for their gender, sexual identity, and reported sexual partners. An individual was considered MSM if they identified as “Male” or “Transmale” as well as one of the following sexual identities—“Gay”, “Bisexual”, “Queer”, “Pansexual”, or “Other”. Otherwise, an individual was considered MSM if they reported one of the following for their answer to sexual identity—“A man who only has sex with other men”, “A man who has sex with both men and women” “A transman who only has sex with other men”, or “A transman who has sex with both men and women”

Significant p-values are those ≤ 0.05, p-value from X2 test (categorical variables) are in bold

*

Over 20% of cells have an expected count below 5

MSM with a history of incarceration were significantly more likely to report use of all substances than MSM without that history (Table 2). MSM with a history of incarceration were also significantly more likely to report a range of behavioral risk factors for HIV (ps < 0.001) than MSM without that history (Table 3). Notably, despite a high level of behavioral risk factors compared to other MSM, MSM with an incarceration history were significantly less likely to perceive themselves at risk for HIV (p < 0.001) (Table 3).

Table 2.

Substance use by incarceration history

Total MSM n = 5986 Incarcerated MSM*
Yes n = 206 No n = 5780 X2 (p-value)
n (%) n (%) n (%)
Cannabis 12.22 (0.001)
 Used 855 (70.6%) 34 (97.1%) 821 (69.8%)
 Never used 356 (29.4%) 1 (2.9%) 355 (30.2%)
Cocaine 26.57 (0.001)
 Used 234 (39.6%) 19 (95.0%) 215 (37.7%)
 Never used 357 (60.4%) 1 (5.0%) 356 (62.3%)
Stimulants 25.35 (0.001)
 Used 217 (27.0%) 17 (94.4%) 200 (36.0%)
 Never used 357 (73.0%) 1 (5.6%) 356 (64.0%)
Meth 49.49 (0.001)
 Used 138 (27.9%) 20 (95.2%) 118 (24.9%)
 Never used 357 (72.1%) 1 (4.8%) 356 (75.1%)
Inhalants 34.56 (0.001)*
 Used 132 (21.3%) 14 (93.3%) 118 (24.9%)
 Never used 357 (78.7%) 1 (6.7%) 356 (75.1%)
Sedatives 34.02 (0.001)
 Used 186 (34.3%) 19 (95.0%) 167 (31.9%)
 Never used 357 (65.7%) 1 (5.0%) 356 (68.1%)
Hallucinogens 22.60 (0.001)
 Used 226 (38.8%) 16 (94.1%) 210 (37.2%)
 Never used 357 (61.2%) 1 (5.9%) 356 (62.9%)
Street opioids 65.54 (0.001)*
 Used 55 (13.3%) 11 (91.7%) 44 (11.0%)
 Never used 357 (86.7%) 1 (8.3%) 356 (89.0%)
Rx opioids 41.26 (0.001)*
 Used 129 (26.6%) 16 (94.1%) 113 (24.1%)
 Never used 357 (73.5%) 1 (5.9%) 356 (75.9%)
Other 41.11 (0.001)*
 Used 19 (5.1%) 3 (75%) 16 (4.3%)
 Never used 356 (94.9%) 1 (25.0%) 355 (95.7%)
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Fisher’s exact test used to determine the significance of an association between the study’s target population and drug use

Significant p-values are those ≤ 0.05, p-value from X2 test (categorical variables) are in bold

*

Over 20% of cells have an expected count below 5, p-value may not be considered significant

Table 3.

Behavioral risk factors by incarceration history (N = 5986)

Total MSM n = 5986 Total MSM by incarceration history
Yes n = 206 No n = 5780
Mean (std. error) Mean (std. error) Mean (std. error) t (p-value)
Total sex partners (past year) 9.19 (0.236) 15.19 (2.815) 8.98 (0.223) − 4.76 (0.001)
n (%) n (%) n (%) X2 (p-value)
AUDIT-C score 6.49 (0.090)*
 Low risk 565 (52.9%) 14 (56.0%) 551 (52.8%)
 Moderate risk 335 (31.4%) 5 (20.0%) 330 (31.6%)
 High risk 131 (12.3%) 3 (12.0%) 128 (12.3%)
 High risk 37 (3.5%) 3 (12.0%) 34 (3.3%)
Have you ever…
 Received a blood transfusion or transplant 109 (2.3%) 6 (3.6%) 103 (2.3%) 1.18 (0.288)
 Used intranasal cocaine 570 (12.2%) 81 (48.5%) 489 (10.8%) 213.49 (0.001)
 Been forced to have sex 285 (4.8%) 52 (25.4%) 233 (4.0%) 198.52 (0.001)
 Had sex with someone positive for Hep C 94 (2.0%) 21 (12.5%) 73 (1.6%) 97.2 (0.001)*
 Gotten a tattoo 1386 (29.7%) 105 (62.9%) 1281 (28.5%) 91.38 (0.001)
In the past 12 months, have you…
 Exchanged sex for drugs/money/something you needed 157 (2.6%) 36 (17.6%) 121 (2.1%) 187.71 (0.001)
 Had sex with a person in exchange for drugs or money 294 (4.9%) 51 (24.9%) 243 (4.2%) 179.85 (0.001)
 Had sex with an anonymous partner (i.e. one night stand) 3523 (58.9%) 149 (72.7%) 3374 (58.4%) 16.60 (0.001)
 Had sex while intoxicated and/or high 1906 (31.9%) 133 (64.9%) 1773 (30.7%) 106.14 (0.001)
 Had sex with someone whose HIV status you did not know 2476 (41.5%) 123 (60.3%) 2353 (40.8%) 30.86 (0.001)
 Been diagnosed with an STI 1737 (29.1%) 75 (36.6%) 1662 (28.8%) 5.77 (0.019)
 Used amphetamines (i.e. crystal meth) 278 (4.9%) 55 (28.4%) 223 (4.1%) 237.52 (0.001)
 Used “poppers” 1714 (30.2%) 82 (42.3%) 1632 (29.7%) 13.96 (0.001)
 Met a partner online 807 (59.0%) 27 (69.2%) 780 (58.7%) 1.74 (0.247)
Self-assessed HIV risk 53.97 (0.001)
 None 330 (6.3%) 25 (14.3%) 305 (6.0%)
 Low 476 (9.1%) 14 (8.0%) 462 (9.1%)
 Medium 2864 (54.5%) 66 (37.7%) 2798 (55.1%)
 High 1210 (23.0%) 40 (22.9%) 1170 (23.1%)
 N/A 372 (7.1%) 30 (17.1%) 342 (6.7%)
Drug injection
 Have you ever injected drugs? 135 (2.3%) 54 (26.6%) 81 (1.4%) 555.41 (0.001)*
 Have you ever shared needles? 41 (36.0%) 28 (56.0%) 13 (20.3%) 15.52 (0.001)
Last injection 8.27 (0.309)*
 Less than a week ago 18 (18.4%) 13 (28.9%) 5 (9.4%)
 1–2 weeks ago 8 (8.2%) 3 (6.7%) 5 (9.4%)
 3–4 weeks ago 7 (7.1%) 3 (6.7%) 4 (7.5%)
 1–6 months ago 16 (16.3%) 5 (11.1%) 11 (20.8%)
 7–12 months ago 4 (4.1%) 1 (2.2%) 3 (5.7%)
 1–2 years ago 7 (7.1%) 2 (4.4%) 5 (9.4%)
 2–5 years ago 8 (8.2%) 4 (8.9%) 4 (7.5%)
 Over 5 years ago 30 (30.6%) 14 (31.1%) 16 (30.2%)
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Contingency test used to determine the significance of an association between the study’s target population and categorical risk factors. Independent sample T-test used to size of differences relative to variation within continuous risk behaviours (total sex partners)

Significant p-values are those ≤ 0.05 are in bold

*

Over 20% of cells have an expected count below 5

When entered into a logistic regression model and adjusting for covariates of age and race, MSM with an incarceration history (compared to a reference group of MSM without an incarceration history) were significantly more likely to report use of intranasal cocaine, being forced to have sex, having sex with someone positive for Hepatitis C virus, tattoos, history of sex work/exchange sex, and having sex while high or intoxicated. Of note, MSM with an incarceration history were four times more likely to report ever using amphetamines (e.g. crystal methamphetamine) (AOR 4.688, 95% CI 3.090–7.113), 25 times more likely to report ever injecting drugs (AOR 25.004, 95% CI 17.097–36.569), and almost five times more likely to report ever sharing needles (AOR 4.993, 95% CI 2.185–11.407).

Upon examining substance use specifically, lifetime use of cocaine, crystal methamphetamine, and street opioids were significantly associated with an incarceration history among MSM while other substances (e.g., cannabis, hallucinogens, sedatives, etc.) were not. When looking at use in the past 30 days of substances, only crystal methamphetamine was significantly associated with incarceration such that MSM who had a history of incarceration were seven times more likely (AOR 7.452; 95% CI 2.223–24.987) to have used crystal methamphetamine in the last 30 days.

Discussion

This study uniquely evaluated HIV risk factors among MSM with a history of incarceration presenting to a small, urban, hospital-based STI clinic. We found that MSM with a history of incarceration engaged in HIV risk behaviors (e.g., lifetime substance use, having sex while high or intoxicated, forced sex, injection drug use, sharing needles, use of crystal methamphetamine in the last 30 days) at significantly higher amounts and frequencies than other MSM presenting to the same clinic during the same period of time.

MSM with a history of incarceration were significantly more likely to report engaging in sex work, using stimulants and other drugs, use of injection drugs, and sharing needles—all behaviors that are associated with increased relative risk of HIV. Ironically, however, this population was also significantly less likely to perceive themselves at risk for HIV than other MSM, suggesting lower levels of health education or literacy around HIV risk behaviors [27, 28] or perhaps an optimism bias (i.e. “it won’t happen to me”) [29] or denial about their own engagement in behavior that may confer HIV risk [30]. Much of the existing HIV prevention trials among MSM have been largely focused on community samples of sexual minority men [31, 32]. Thus, the current research study addresses an important gap within the existing research to explore risk factors for HIV among a sample of incarcerated MSM, which is inclusive of a subset of men who do not identify as LGBTQ+ but engage in sexual behavior with men [33, 34]. This group of men is harder to reach (due to even further marginalization and stigmatization) and also is underrepresented in our existing HIV prevention evidence-base [35]. This group may experience same-sex attraction and/ or engage in same-sex sexual behaviors but continue to identify as heterosexual [36]. Individuals may be questioning or exploring their sexual identity and not yet comfortable identifying as LGBTQ+ [37] or experience either internalized stigma (e.g., internalized homonegativity) or feel unsafe disclosing their identity due to anticipated social stress and stigma [38, 39]. Finally, incarcerated MSM may have engaged in some form of exchange sex or sex work to obtain money, drugs, housing, or otherwise have their needs met [40, 41]. Due to the illegal nature of many of these activities, this population is overrepresented within populations of individuals with a history of incarceration and uniquely vulnerable to HIV.

However, the needs of MSM with a history of incarceration may be different both due to their incarceration history and/or because they may not identify as sexual minority men or may not be comfortable with their identities [35, 42]. People with bisexual identities encounter more psychosocial stress and stigma than individuals with gay or heterosexual identities namely because they feel marginalized both in heterosexual and queer spaces and experience invalidation of their identity in multiple settings [43, 44]. These individuals report higher rates of substance use, mental health problems, and suicidal ideation than their heterosexual or gay counterparts, and, sexual risk behavior placing them at increased risk for STIs [44]. Our data indicate that MSM with a history of incarceration were less likely to identify as gay and more likely to identify as heterosexual than other MSM in our sample. Due to the differences between MSM who do not identify as LGBTQ+ and those who do not but still engage in sex with men (either because they identify as heterosexual and engage in sex work or because they experience extreme internalized homonegativity) existing interventions may need to be adapted to fit the sexual health needs of this population [45]. MSM with a history of incarceration are also more likely to report having engaged in sex work. Prior work with men who engage in sex work has shown that they may face additional stigma and challenges in engaging in HIV prevention behaviors including taking pre-exposure prophylaxis, or PrEP [46, 47]. The unique needs of this population may differ from the larger MSM group and should be considered when developing and testing interventions either in the community or criminal justice settings [48, 49].

The study findings must be interpreted in light of the study limitations. Notably, these data were from STI care visits in the community. Data were collected at one clinic within a specific geographic setting within the U.S. and may or may not be generalizable to STI clinic samples of MSM in other parts of the U.S. However, we imagine that the relationships observed between substance use, sex work, sexual identity, and incarceration and the intersection of these issues are likely generalizable to similar samples in other regions. All data were collected via self-report and are subject to the same limitations of all self-report data. Given the sensitive nature of these questions, estimates may be an underrepresentation of the number of individuals who have experienced incarceration or engaged in behaviors that place them at high risk for HIV (e.g. sex work, sharing needles). It is also possible that those who seek care in the community post-release may differ systematically from those who never seek specialty STI care or those who remain incarcerated. However, this sample approximates the group of individuals who may be at highest risk for HIV and are rarely included in clinical trials due to the challenges of conducting research within the criminal justice setting. Additionally, to facilitate willingness to answer these questions, data were collected anonymously and stored separately from other medical information thus limiting the ability to compare with other health data. Data were collected at the visit level, which means that it is possible some of these observations are repeat responses from the same individuals. While this enhances the likelihood that responses are valid and reported accurately it may also mean that some observations were counted more than once. Additionally, because data were not nested within individuals longitudinally, we are unable to say anything meaningful about change over time or temporal relationships between these variables. All data were treated as cross-sectional data and are thus subject to the same limitations as all cross-sectional data.

Future research should seek to expand this work to study HIV risk behavior within criminal justice settings and potential avenues for intervention. Importantly, although incarceration can be a time of considerable upheaval for individuals, it may also present an opportunity for intervention [50–52]. In a seminal paper on public health interventions, Glass and McAttee [53] present a model for understanding behavioral sciences within public health and suggest that interventions to modify behavior should be occurring at multiple levels of influence. One of their key suggestions was using existing structures and systems (e.g. schools, churches, etc.) at the “mezzo-level” of influence as places of health behavior change. STI care clinics and the criminal justice system represent such places as they both uniquely capture those most at risk for a variety of adverse health outcomes. Within STI clinics, it may be useful to consider integrating screening for other health issues including mental health, alcohol use, and substance use that often co-occur with STI and HIV risk [54]. For example, screening, brief intervention, and referral to treatment, or “SBIRT” interventions, have been tested primarily in primary care but have also been scaled out to STI clinics to address alcohol and substance use with preliminary efficacy [55, 56]. Additionally, the results from this study indicate that there should be greater integration of STI and substance use clinical care services. Given the relationship between substance use and HIV/STI acquisition risk, MSM with a history of incarceration are likely to require tailored social services including housing, job training, food benefits, and other wrap around services facilitated by social work teams similar to what is present at primary care, substance use, and HIV care clinics that addresses key socioeconomic determinants of health. These services could be especially beneficial to those recently released from prison as they can offer a “medical home” and connection to other services to support health [57–59].

Similarly, changes could be made within the prison system to address HIV risk through use of evidence-based prevention interventions. Sexual risk reduction counseling [60], substance use treatment [61], harm reduction supplies [62, 63], and the prescription of PrEP [64] are all evidence-based approaches to reducing HIV risk that could be offered within jail or prison settings to reduce HIV risk. However, little is known about how these approaches can be best be applied in populations of MSM who may not identify as LGBTQ+. Incarceration presents specific risks for engaging in HIV-related behaviors upon release (e.g. substance use, sexual behavior), but also presents an opportunity for public health intervention including HIV testing, education, and linkage to STI/HIV and/or PrEP services. Prior research has also identified interventions for HIV that have been implemented within prison settings, however, many of these were behavioral in nature and we now have the ability to offer medications like PrEP as a biological prevention strategy [65].

Finally, at the population-level, these inequities occur within societal structures that place some individuals at higher risk for incarceration than others. While much can be done to address individual level health and HIV prevention within STI clinics and correctional settings, these interventions cannot adequately address the larger systemic issues that face individuals involved with the criminal justice system. To fully address systemic inequity requires advocacy and policy change to mitigate the effects of legal issues (e.g., reducing drug-related possession charges from felonies to misdemeanors, allowing records to be expunged after a period of time) and offer support to individuals trying to reintegrate into society after a period of incarceration.

Conclusions

The current study identified that MSM with a history of incarceration self-reported significantly more behavioral risk factors for HIV, but also perceived themselves at lower risk than other MSM. Given these findings, it seems that developing tailored biobehavioral prevention strategies for this population is a current unmet need. As such, the adaptation and implementation of comprehensive sexual health services and culturally tailored HIV prevention inclusive of biobehavioral approaches for MSM who are incarcerated and/or have a history of incarceration is an important area of future research. To maximally close the gap in care for this population it will likely be important to include MSM with lived experience with incarceration to inform and enhance the development of these interventions so that they are tailored to the unique needs of the population and more likely to be feasible, acceptable, and effective.

Funding

B.G.R. and M.M. are supported in part by a research grant from Gilead Sciences (IN-US-276-5463). B.G.R. and M.M. also receive support in the form of developmental awards from the Providence/Boston Center for AIDS Research P30AI042853. M.M. author time also came from 1K23DA054003-01A1 (Murphy). L.C.C. is supported by the National Institutes of Health Grants T32DA013911 and R25MH083620. P.A.C. is on staff at the Rhode Island Department of Health and the Rhode Island Public Health Institute.

Footnotes

Code Availability Not applicable.

Ethical Approval This study has been approved by Lifespan’s Institutional Review Board and meets guidelines set by Lifespan’s Human Research Protections Program, Protocol #502613. The Lifespan Institutional Review Board granted a waiver of written informed consent to conduct a retrospective review of clinic data.

Consent to Participate Data reviewed as part of this study were obtained during clinical visits and as part of the informed consent process to receive care all patients consent to having their data used for clinical research purposes.

Consent for Publication Not applicable.

Declarations

Conflict of interest All authors declare that they have no potential conflicts of interest.

Data Availability

All data generated or analyzed during this study is included in this published article. There are no publicly available data or materials.

References

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Associated Data

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Data Availability Statement

All data generated or analyzed during this study is included in this published article. There are no publicly available data or materials.

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