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Published in final edited form as: Crime Law Soc Change. 2023 Sep 8;81(2):127–141. doi: 10.1007/s10611-023-10112-y

Criminal justice involvement, structural vulnerability and social safety net services among people living with HIV in Baltimore

Natalie Flath 1, Jordan J White 2, Karin Tobin 3, Carl Latkin 3
PMCID: PMC13132513  NIHMSID: NIHMS2166341  PMID: 42079452

Abstract

Mass incarceration has shaped the environment of HIV transmission, yet there is limited research on the conditions that enhance or mitigate access to health and social resources for people living with HIV (PLWH) with criminal justice (CJ) involvement. This paper aims to explore structural vulnerability, social safety net services, and criminal justice involvement among PLWH. Among a communitybased sample of 336 PLWH in Baltimore, Maryland, we compared measures of structural vulnerability and access to safety net services on the outcome of either recent involvement or no involvement in the CJ system. CJ involved PLWH were more likely to be structurally vulnerable and more likely to be enrolled in temporary social services and apply for permanent income. Enrollment in longer-term social services did not differ by CJ involvement, and neither did application for housing assistance. The results shed light on the socio-economic context of CJ involvement among PLWH. As the HIV epidemic persists, focusing research on the impediments to structural wellbeing, such as the drivers of criminal justice involvement, are important.

Keywords: Structural vulnerability, HIV, Criminal justice, Social policy, HIV services

Background

The United States incarcerates more people than any other country in the world (Sawyer & Wagner, 2020). In 2019, 1.5 million people were incarcerated in the U.S. and since the COVID-19 outbreak, 8.7 million have been admitted to a jail facility (Bronson & Carson, 2019; Minton & Zeng, 2021). Involvement in the criminal justice system further extends into supervision, with approximately 3.9 million Americans on probation in 2020 and 860,000 on parole (Kaeble, 2021). Mass incarceration has substantially affected racial and ethnic minorities and those living in poverty, leaving an enduring and pernicious social, economic, and health toll on hyper-policed and incarcerated communities (Blankenship et al., 2005; Allen et al., 2016; Tonry, 1995; Wohl, 2016). Moreover, the incarceration epidemic has played a significant role in shaping infectious disease epidemics (Wohl, 2016), such as the COVID-19 pandemic. In late 2020, COVID-19 cases were five times higher among incarcerated persons than the general population (Flattening the Curve, 2020). Throughout the world, criminalized populations, compared to non-incarcerated individuals, also experience higher burdens of HIV/AIDS and reduced access to HIV prevention and care (Dolan et al., 2016). In the United States, HIV prevalence in correctional settings is approximately 1.3%, where it is markedly greater than the general population of approximately 0.3–0.4% overall (Center for Disease Control, 2020).

The disproportionately high number of HIV and AIDS cases among incarcerated populations is also shaped by structural factors such as economic marginalization, racial discrimination, residential segregation, and restrained access to healthcare (Adimora et al., 2006; Aral et al., 2008). Structural factors drive the conditions that mitigate access to resources and minimize health risks (Straus & Bacon, 1951). These conditions accumulate and create precarity, such as homelessness, residential transience, low-earning incomes, unemployment, and underemployment (Quesada et al., 2011). Referred to as structural vulnerability to HIV infection, these material circumstances shape everyday experiences and create a context in which access to care is limited and HIV risk behaviors occur (Blum et al., 2002; Rhodes et al., 2012). For example, one study found that among an urban population composed mainly of African-American lower-income women, as characteristics of structural vulnerability gradually increased, so did HIV risk on multiple risk indicators; i.e., reports of multiple sexual partners, recent drug use, and sexually transmitted infections (German & Latkin, 2012).

One factor that shapes structural vulnerability is the criminal justice system. Todd Clear’s, 2009 theory of coercive mobility explains how ongoing removal and return from correctional institutions re-enforces conditions of structural vulnerability (Frost & Gross, 2012; Clear, 2009). The cyclical and reinforcing relationship between structural vulnerability and criminal justice involvement particularly impacts minoritized and structurally marginalized communities (Lynch & Sabol, 2004). The effects of removing large numbers of people out of under-resourced communities and into detention settings manifests in broader instability of local labor and housing markets and contributes to a greater need to access public safety net services compared to non-institutionalized populations (Holzer, 2007; Raphael & Stoll, 2009). Not only does a criminal record impose barriers to social services (e.g., public housing, student loans, civic engagement through voting), but also removes a large segment of community support. Communities experiencing high incarceration rates are also more likely to be food insecure and lack access to quality healthcare and affordable housing. This dynamic, in turn, makes it harder to obtain social services, job training, and higher earning wages, perpetually reinforcing economic disadvantage (Boushey & Gundersen, 2001; Chavkin et al., 2000; Wall et al., 2000).

Mass incarceration has been documented to contribute to the circumstances that have shaped HIV transmission, yet there is limited research on the reinforcing relationships between structural vulnerability and criminal justice involvement among people living with HIV (PLWH). It is important to understand where opportunities and gaps in the service systems for PLWH arise while also understanding the structural factors that produce conditions of resource constraints and reliance on safety net services to meet the needs of PLWH. The time after release from prisons or jails is a particularly vulnerable time for PLWH (Wohl et al., 2011). Engaging in healthcare and sustaining a suppressed viral load post-release remains challenging (Baillargeon et al., 2009, 2010). Interruption in care and treatment, due to criminal justice involvement, is associated with poor medication adherence, increased viral load, and HIV-related morbidity and mortality (Rosen et al., 2008; Springer et al., 2007). Access to care is further disrupted by barriers related to returning to impoverished and under-resourced neighborhoods (MacGowan et al., 2003). Structural barriers that characterize these neighborhoods include limited housing and insurance (Alexander, 2020; Katzen, 2011; Stephenson et al., 2005). Furthermore, reentry related needs of securing housing and food are often prioritized over healthcare among PLWH (Dennis et al., 2015).

Public services are allocated specifically to support people living with HIV. To improve access to HIV care among medically underserved people living with HIV, the United States authorized the HIV/AIDS medical care Ryan White Program in 1990 (Ryan White HIV/AIDS Program, 2016). The services function to fill a gap where private and public healthcare options do not exist. Therefore, Ryan White services respond to the local economy and safety net infrastructure and vary by state. In the US, safety net programs aim to extend a basic level of social stability for low-income communities (Orthner et al., 2004). Although safety net services are available with restrictions and qualifying is often cumbersome, these include state-level temporary cash assistance and Social Security Programs (more permanent income), in addition to medical insurance (i.e., Medicaid, Medicare, Veterans Affairs), food assistant programs (SNAP), housing benefits (Housing Opportunities for Persons with AIDS (HOPWA) and Housing Choice Voucher Program (formerly known as Sect. 8). Social Security Income (SSI) and Social Security Disability (SSDI) are federal programs that provide monthly benefits to Americans that meet specific criteria of disability (Monthly Statistical Snapshot, 2020). For PLWH, evidence of disability encompasses advanced HIV-related illness. Accessing disability income is often one of the only forms of consistent financial resources for people experiencing multiple stigmas (i.e., HIV, poverty, and criminal justice involvement) (Angell, 2011; Lopez et al., 2018). For those who do not qualify or are awaiting approval, state-sanctioned services of temporary cash may serve as a provisional safety net. Social Security eligibility can also serve as an access point into qualifying for additional state-subsidiaries such as health insurance, food assistance, and housing programs (Dennis et al., 2014; Rosenheck et al., 2000).

This paper investigates criminal justice involvement, structural vulnerability, and social safety net services among a community-based sample of PLWH in Baltimore, Maryland (MD). Given the cross-sectional nature of the sample, we postulate that the role of the cyclical, re-enforcing dynamics of criminal justice involvement on the HIV risk environment in a city like Baltimore can be preliminary observed by evaluating the relationships of structural vulnerability, social safety net services, and criminal justice involvement among PLWH. As the coercive mobility hypothesis provides a framework to study structural vulnerability and criminal justice involvement, it is novel to apply the coercive mobility theory to understand the structural factors that shape the circumstances of PLWH. For decades the Baltimore Police Department has imposed constant policing and surveillance in structurally impoverished neighborhoods, which has resulted in officially sanctioned racially-biased enforcement practices (Department of Justice, 2016). A recent investigation by the Department of Justice found that “law enforcement strategies produced severe and unjustified disparities in the rates of stops, searches, and arrests of African-Americans.” The report continues in that, “Baltimore’s law enforcement practices at times exacerbate the longstanding structural inequalities in the city by encouraging officers to have unnecessary, adversarial interactions with community members that increase exposure to the criminal justice system.” For example, from 2010 to 2014, 44% of total stops were reported in two police districts that comprise only 12% of city residents; neighborhoods of majority African-American residents living below the Federal Poverty Level thresholds.

Within the same structurally impoverished conditions, low-income PLWH are able to access supportive services such as legal aid for applying to disability and housing benefits (Ryan White Program, 2014). Specifically, the local Ryan White Program links case managers to PLWH before release from detention facilities to ensure continuity of HIV care and social services post-release (Moyd, 2018). To understand the role of social instability and criminal justice involvement among PLWHA, this study aims to identify correlates of structural vulnerability and safety net services unique to PLWH with CJ involvement. Given the coercive mobility framework, the authors hypothesize that although social services are specifically available to PLWHA, there will be a greater need for temporary assistance and higher levels of structural vulnerability among those with CJ involvement. Moreover, across the sample, there will be high need for permanent service supports.

Methods

Population

This analysis includes the total sample of participants enrolled in a larger parent HIV prevention randomized control trial (RCT) that aimed to train PLWH as peer leaders. Recruitment and enrollment began on May 2014 and ended May 2017. The recruitment frequency was linked to the RCT intervention. Professional research staff with extensive experience recruiting and interviewing people who use drugs initially screened a total of 1,406 people. Participants were recruited via community-based outreach methods and by word of mouth. Potential participants were approached at community centers, drug treatment and health clinics, and street blocks with open-air drug market activity. Individuals were asked if interested in volunteering in a peerleadership health study. Interested individuals could call in or be screened in person.After initial screening, 835 potential participants were referred to the communitybased research center. Two-hundred and eighty-two met final inclusion criteria as they were confirmed HIV-positive at the time of the interview, were 18 years or older, and lived in the Baltimore metro area. These index participants were asked to further recruit social network members who were 18 years and older. A total of 568 index and network members comprised the study sample. Networks who were not HIV positive were excluded from this analysis for a total of 336 index and network individuals. The community-based research team recruited PLWH predominantly from zip codes of high federal poverty rates and population compositions of more than 65% of African-American/Black residents. The location of the zip codes superimposed the areas of high HIV prevalence rates and systematically targeted police enforcement outlined in the DOJ investigative report (Department of Justice, 2016). After informed consent at the community-based research center, participants completed an interview-administered survey and an Audio Computer Assisted Self-Interview (ACASI) for items related to HIV risk behavior and drug use. Participants received $35 in compensation for their time. All protocols and procedures were approved by the Johns Hopkins Bloomberg School of Public Health’s Institutional Review Board.

Covariates

Structural vulnerability

Measures of structural vulnerability represent instability inherent of economic and social resource structures in urban populations and indirectly increase HIV risk. Based on previous literature, four measures that reflect the broader social and economic conditions on PLWH’s lived experiences are education level (i.e., high school, GED, or higher vs. less than high school obtainment), annual income level (i.e., dichotomized at the median reported level of less than $10,000 vs. higher), and housing stability (residential mobility and recent homelessness) (Brantley et al., 2017; House et al., 1988; Mizuno et al., 2015), and employment status. As German and Latkin (2012) document, employment represents social instability; however, it is excluded from the analysis due to high levels of unemployment and collinearity between the other measures of structural vulnerability (German & Latkin, 2012). A measure of recent homelessness was created based on a response to the question, “have you slept for at least one week in any of the following places: a squatting place, an abandoned building, a car, a homeless shelter, a park or on the street in the past 6 months?” or reported to currently living in a room, boarding, halfway house, or shelter/welfare hotel. Housing stability was further operationalized by level of housing permanence, either a more fixed or shorter-term housing situation, which can confer stability in other aspects of one’s life (German et al., 2007). Residential mobility was classified as an indication of currently living in the same place for less than or longer than three months.

Safety net services

To better elucidate the dynamics of coercive mobility on access to social and health services among PLWH, we include factors related to the uptake and application for public safety net services. As previously identified as facilitators to HIV medical care post-incarceration, in this analysis, safety net services were reports of current enrollment in public health insurance (i.e., Medicaid, Medicare, Veterans Affairs), temporary cash assistance and social security income (SSI) programs and recent application for SSI, state housing or food assistance in the previous six months of the interview (not mutually exclusive) (Dennis et al., 2015). Temporary cash assistance included benefits received from Maryland State. Social Security Income Programs (SSI, SSDI, VA, Retirement) are federal programs that provide monthly benefits to people with limited or no income deemed disabled, blind, or over sixty-five years old.

Socio-demographic

Demographic and recent drug use variables were mean age, gender (male, female, and transgender), race/ethnicity (Black/African-American, White, Other), and reports of injection or illicit drug use (cocaine/crack/heroin) in the previous six months.

Outcome

To understand the role of criminal justice involvement on the lives of a communitybased sample of low-income PLWH, the outcome of interest was defined as self-report of any time spent in a jail, prison, or other correctional facilities in the last two years. The two-year period encompasses time to include the consequences that may manifest during the administrative life of general criminal justice involvement, resulting in a life disruption due to interfacing with the CJ system, i.e., probation, parole, court proceedings, and pretrial detention sanctions (arrests).

Analysis

Criminal justice involvement on socio-demographic, structural vulnerability, and social service indicators were explored using descriptive analyses. Bivariable differences were calculated using mean t-tests or chi-square tests at three different p-levels, p < 0.05, 0.01, and 0.001. Multivariable regression analyses were performed for each indicator of structural vulnerability and safety net service on criminal justice involvement. Given the indicators are interrelated, we did not control for confounders outside of socio-demographic characteristics known to be related to criminal justice involvement: age, gender, race, and recent drug use. Given the outcome of interest was greater than 10%, Poisson regression with robust variance was used to produce adjusted prevalence ratios.

Results

As demonstrated in Table 1, the majority of the 336 participants were Black, male, and low-income. Eighteen-percent (n = 62) reported histories of justice involvement. Substance use characteristics did not differ by CJ involvement; however, more than half (58%) of those CJ involved reported recent illicit drug use.

Table 1.

Socio-demographic, structural vulnerability, and safety net service factors compared among 336 people living with HIV by criminal justice involvement in Baltimore City

Criminal Justice Involveda Not Involved
n (%) n (%)
62 (18) 274 (82)
Socio-Demographic
Mean Age (SD)*** 44 (9) 50 (10)
Gender
 Male 41 (66) 151 (55)
 Female 21 (34) 116 (42)
 Transgender 0 7 (3)
Race/Ethnicity
 Black/African-American 51 (82) 254 (93)
 White 10 (16) 15 (5)
 Other 5 (2) 1 (2)
Substance Use
 Injection Drug Use <6 mo 12 (19) 43 (16)
 Illicit Drug Use <6 mo 36 (58) 151 (55)
Structural Vulnerability
 Annual income < 10,000* 49 (82) 180 (66)
 Education: High school or less 21 (34) 105 (38)
 Homeless < 6 mo** 22 (36) 54 (20)
 Residential Mobility: Lived in one place 3 months or less** 18 (29) 39 (14)
Safety Net Services
 Enrolled: Public Health Insuranc^ 55 (89) 234 (85)
 Enrolled: Temporary Cash Assistance** 25 (40) 65 (24)
 Enrolled: Social Security*** 32 (52) 200 (73)
 Applied: Social Security < 6 mo* 21 (34) 56 (20)
 Applied: Housing Assistance < 6 mo* 23 (37) 87 (32)
 Applied: Food Assistance < 6 mo** 39 (63) 119 (43)
Open in a new tab
a

Incarcerated in a jail, prison or other correctional facility in the last two years

*

Statistically significant T-test or Chi-Squared difference at

*

p < 0.05,

**

0.01,

***

0.001

^

93% reported having public insurance, i.e., Medicaid, Medicare or VA

Structural vulnerability

People living with HIV with criminal justice involvement were more likely to be structurally vulnerable in contrast to PLWH with no involvement (Table 1). At greater proportions, CJ involved PLWH reported low annual incomes, recent homelessness, and residential transience (i.e., living in one place for three months or less). Structural vulnerability differences remained after controlling for socio-demographic characteristics and drug use (Table 2). Compared to PLWH with no recent criminal justice involvement, PLWH with CJ involvement had higher adjusted prevalence odds of earning lower incomes at the sample median of $10,000 per year (adjusted prevalence ratio (aPR) 2.29 95% Confidence Interval (CI) 1.26, 4.17), homelessness (aPR 1.60 95% CI 1.02, 2.51), and housing transience (aPR 1.91 95% CI 1.22, 2.98). There were no differences by educational attainment.

Table 2.

Multivariable model of structural vulnerability and criminal justice involvement among 336 PLWH

aPR^ 95% CI^^
Structural Vulnerability Indicators
 Annual income < 10,000 2.29 1.26, 4.17
 Education: High school or less vs. higher 1.04 0.65, 1.67
 Homeless < 6 mo 1.60 1.02, 2.51
 Residential Transience: Lived in one place 3 months or less vs. more 1.91 1.22, 2.98
Open in a new tab
a

Incarcerated in a jail, prison or other correctional facility in the last two years

^

aPR (adjusted prevalence ratio)

^^

95% Confidence Interval

Each model adjusted for age, gender, race, and illicit drug use in the last six months

Boldface indicates statistical with the 95% CI bounds

Safety net services

CJ involved PLWH were more likely to access temporary cash assistance and recently apply for food assistance and longer-term financial support (social security income), compared to PLWH without systems involvement (Table 1). Enrollment in an SSI program was higher for PLWH with no CJ involvement. After adjusting for sociodemographic and drug use characteristics in the model, PLWH with systems involvement remained more likely to access temporary cash assistance (aPR 1.81 95% CI 1.15, 2.86), to recently apply for food assistance (aPR 1.62 95% CI 1.02, 2.58) and social security income (aPR 1.63 95% CI 1.02, 2.61) compared to PLWH with no involvement (Table 3). Enrollment in health insurance and SSI, as well as recent applications for housing assistance, did not differ by CJ involvement.

Table 3.

Multivariable model of safety net services and criminal justice involvement among 336 PLWH

aPR^ 95% CI^^
Safety Net Services
 Enrolled: Public Health Insurance 1.31 0.65,2.67
 Enrolled: Temporary Cash Assistance 1.81 1.15, 2.86
 Enrolled: Social Security 0.68 0.41, 1.13
 Applied: Social Security < 6 mo 1.63 1.02, 2.61
 Applied: Housing Assistance < 6 mo 1.15 0.73, 1.82
 Applied: Food Assistance < 6 mo 1.62 1.02, 2.58
Open in a new tab
a

Incarcerated in a jail, prison or other correctional facility in the last two years

^

aPR (adjusted prevalence ratio)

^^

95% Confidence Interval

Each model adjusted for age, gender, race, and illicit drug use in the last six months

Boldface indicates statistical significance with the 95% CI bounds

Discussion

Criminal justice involvement is a known barrier to engagement in HIV treatment and care (Stephenson et al., 2005). Disruption in care is further exacerbated by the process of return from detention to structurally impoverished communities. We applied the theory of coercive mobility to understand the dynamics of structural vulnerability and criminal justice (CJ) involvement in a community-based sample of people living with HIV and AIDS (PLWH) who were recruited from neighborhoods characterized by high levels of poverty and racially-biased policing (Department of Justice, 2016).We found that CJ involved PLWH were more likely to be structurally vulnerable and more likely to report enrollment in temporary social services. PLWHA with CJ involvement were also more likely to apply for permanent income sources (i.e., social security programs). Enrollment in more permanent social services, although highly reported, such as public health insurance, did not differ by criminal justice involvement, and neither did application for housing assistance. The findings are supportive of the coercive mobility hypothesis that explain the conditions that shape HIV risk. Reliance on immediate social safety services provides insight into potential disturbances of CJ involvement among PLWA, while the need for longer-term social supports despite CJ involvement may indicate a broader instability of local labor and housing markets among PLWH living in environments where prison cycling is socially disruptive. This paper contributes to research because much research to date has focused on community-level interventions to reduce HIV incidence and promote engagement and retention in HIV care; while the mechanisms of social instability on community-level health and access to social services remain understudied. One large retrospective cohort study of PLWH cycling through correctional facilities in Connecticut found that linkage to care post-release was associated with supportive case management during transition into the community (Loeliger et al., 2018). However, previous research has shown that even with access to supportive case management, structurally vulnerable PLWH continue to experience hurdles in accessing more comprehensive social services, such as SSI (Lopez et al., 2018).

First, we observed that indicators of structural vulnerability were greater among PLWHA with CJ involvement. This may produce a greater need for provisional public service support to meet basic needs (e.g., temporary cash and food assistance) as indicated by higher levels of temporary social service needs among CJ involved participants. Our findings expand upon the HIV literature by demonstrating a connection between co-occurring structural vulnerabilities and need for public assistance among PLWH with CJ involvement histories. It is known that structural vulnerabilities are common among individuals with a history of incarceration (Center for Poverty Solutions, 2002). HIV research has also documented barriers to engagement in HIV care imposed by housing and financial instability after release from detention (Dennis et al., 2015; Zelenev et al., 2013). When structural conditions of social stability, such as access to housing and jobs are not available, SSI and housing first programs may bridge a gap; however, despite a national social welfare program, U.S. social policies have not slowed increasing socio-economic inequality (Reisch, 2018). The state of social policy is concerning, given that existing evidence underscores the importance of SSI among eligible justice-involved populations. One study examined the role of application and denial for SSI among homeless veterans with psychiatric conditions and found that an SSI award resulted in higher incomes and quality of life. Beneficiaries spent more on housing, food, clothing, and transportation and reported less substance use to cope with stress (Rosenheck et al., 2000). Additionally, approval for SSI benefits improved access to housing and reduced recidivism (Dennis et al., 2014). Nonetheless, large holes in the American safety net persist. Since the 1980s, government aid increased among people with incomes at or above the 150–200% federal poverty line, however assistance to families below 150% of the poverty level decreased (The Congressional Budget Office, 2019).

Although these results revealed structural conditions that may have produced resource constraints unique to PLWH with CJ involvement, findings also point toward the conditions of structural disadvantage that are present despite criminal justice involvement. For example, there were no differences between applications for housing assistance and criminal justice involvement, although reports were high. It is also notable that temporary cash assistance and recent application for more permanent income sources, such as SSI, were more common among justice-involved PLWH, yet enrollment in SSI was not associated with CJ history. Moreover, application for SSI was proportionately high across participants, and income across the participants were below poverty thresholds. The theory of coercive mobility explains that ongoing removal and return of community residents as a result of incarceration re-enforces concentrated poverty, limited housing opportunities, and lower-earning wage jobs, while also destabilizing meaningful economic alternatives through social network disruption (Lynch & Sabol, 2004). The need to access permanent income sources across the PLWHA sample signifies a possible role of coercive mobility. The structural conditions that produce the need for securing housing and income from sources outside of the formal economy, may appear as SSI need for people with HIV.

There are several limitations. The nature of a cross-sectional analysis limits the ability to assess bi-directional cyclical effects between structural vulnerability, social safety net service utilization, and criminal justice involvement (Dumont et al., 2013). Results should be interpreted with caution, as the re-enforcing nature of coercive mobility cannot be determined. We are not able to delineate whether the individual circumstances of structural vulnerability, such as homelessness, contributed to CJ involvement and vice versa. Additionally, the outcome of criminal justice involvement included a duration (prior two years of any type of detention), limiting our understanding of temporal and overlapping connections between structural vulnerability and social safety net engagement linked to justice involvement. It is likely that the community sample does not reflect community members who are serving long sentences, and this may explain a lower CJ prevalence of 18%. On the contrary, it may be that the sample reflects individuals with briefer criminal justice interactions, such as an overnight jail stay. This may underestimate our findings. However, the sample is comprised of a social network of PLWHA who live in neighborhoods with high incarceration rates. The majority of people who are jailed continue to be monitored in the community through probation or parole (Spaulding et al., 2009). While we are not able to delineate between CJ interaction types, we assessed the experiences of general CJ involvement among a social network of PLWHA and observed notable trends related to access to social and health services.

Another limitation pertains to the social safety net measures. We combined different services into one question, restraining our ability to examine the effects of individual safety net programs. We were also unable to account for service eligibility, therefore drawing broad interpretations of access and need for each service. Furthermore, these findings are not representative of the diverse environments across America, as social disadvantage is compounded by various levels of historic racial and social exclusion and may not be generalizable. The implementation of criminal justice resources as well as the investment in social services vary across geographies. In addition Maryland is a Medicaid expansion state, and as a result, low-income individuals have increased access to health insurance and case management services (Ryan White Program, 2014). In urban and rural settings across the United States where Medicaid expansion has not occurred, such as in the southern US, which has high levels of HIV, barriers to social services may be more pervasive. The variation warrants further study of how prison cycling patterns structural vulnerability and service access. Future research is warranted to understand the dynamics of mass incarceration on the structural conditions and resource constraints among PLWH in different settings. Despite limitations, the results delineate key aspects of the structural context of criminal justice involvement on the experiences of PLWH.

Conclusions

There is limited research on broader community disruption that produces social instability and reliance on the social safety net on PLWH lived experience. These findings are one of the first to examine coercive mobility on the lives of low-income people living with HIV. As the HIV epidemic persists, addressing the drivers of structural vulnerability creates the possibility of adequately addressing the roots of HIV transmission. Future research on the social determinants of health is necessary for understanding the conditions that contribute to hyper-incarceration, economic instability, and health inequities. Moreover, intervention research should center marginalized communities as developers of their own programs. Dismantling mass incarceration and investing in civil society institutions could have the most profound health impact on communities who have borne the weight of targeted law enforcement for decades, such as in Baltimore City (Clear, 2009; Wohl, 2016). Addressing the root causes of structural vulnerability, such as the drivers of hyper-incarceration, and investing in civil society institutions, is key in our response to HIV.

Acknowledgements

The authors extend sincere gratitude to the recruitment and data collection team at the Lighthouse Studies at Peer Point at Johns Hopkins Bloomberg School of Public Health.

Funding

The research was funded by the National Institutes of Health/National Institute on Drug Abuse (R01 DA032217 & R01 DA040488).

Footnotes

Ethics approval and consent to participate All protocols and procedures were approved by the Johns Hopkins Bloomberg School of Public Health’s Institutional Review Board. All participants agreed to participate after the consent process.

Consent for publication Not applicable.

Competing interests The authors declare that they have no conflict of interest.

Data Availability

The datasets generated and/or analyzed during the current study are not publicly available as the outcome paper has not yet been published, but they are available from the principle investigator upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets generated and/or analyzed during the current study are not publicly available as the outcome paper has not yet been published, but they are available from the principle investigator upon reasonable request.

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