Women’s Intersectional Risks for HIV and Incarceration and Implications for Interventions

In this issue of the Journal, Knittel et al.¹ report on findings from a retrospective cohort study of incarceration incidence and prevalence among HIV negative but at-risk women across 11 sites in the Women’s Interagency HIV Study (WIHS).² The cohort began enrolling in 1993 and questions about incarceration were added in 2007. Analyses from the WIHS cohort are always strengthened by the breadth of data and this undertaking is no exception, with observational data derived from nearly 11,500 study visits with 970 women across a median of 5.5 years. The authors applied this data to evaluate: 1) the prevalence of lifetime incarceration among the total cohort beginning in 2007; 2) lifetime and incident incarceration duration and frequency among a subset of 290 women; 3) risk factors for incident incarcerations among a subset of 603 women; and 4) prevalence of partners’ incarcerations among 614 women with available data. To my knowledge, this is the first systematic analysis of incarceration incidence and prevalence among such a large cohort of women at-risk for HIV.

The authors found that nearly half of the sample (46.7%) had lived experiences of incarceration at baseline and were incarcerated at a rate of 5.5 per 100 person-years over the course of study follow-up, which far exceeds the already high incarceration rate for women in the U.S. overall.³ Bivariate and multivariate models identified key risk factors for incident incarceration that included prior incarceration and ongoing sex exchange, injection and non-injection drug use, and unstable housing within the 6 months prior to study baseline. Thus, even among a sample of women who are identified as being at-risk of HIV, those with the greatest degree of ongoing HIV risk are those most often incarcerated. Moreover, one-fifth of participants had male sexual partners who were incarcerated prior to or during the women’s study involvement. This study confirms intersectional risks for both criminal justice involvement and HIV among a key population of women, which has important implications for interventions that can address health disparities.

First, findings should inform how we assess women’s risk for HIV and identify intervenable moments for HIV prevention. HIV pre-exposure prophylaxis (PrEP) is an evidence-based effective HIV prevention strategy for women but is highly under-scaled, limiting potential public health impact. Expanded access to HIV testing and PrEP is central to the U.S. strategy to end the HIV epidemic,⁴ wherein women involved in criminal justice are a key priority population. Yet there are multi-level barriers to women’s PrEP access,⁵ including limited tools for providers to accurately assess women’s PrEP eligibility. All women involved in criminal justice are PrEP eligible under World Health Organization criteria⁶ by virtue of their “substantial risk” for HIV.⁷ Current CDC clinical criteria, however, require that women accurately estimate and disclose their own and their partner’s sex and drug use behaviors, thereby missing a substantial portion of women who might benefit from PrEP.^{7, 8} What if instead, criminal justice involvement was applied as a proxy for HIV risk, as suggested by Knittel et al?^{1, 9} Incarceration may be more socially acceptable and feasible for women to assess and disclose than other HIV risk behaviors like sex exchange or injection drug use. While a woman may not know if her male partner has other concurrent sex partners, she is likely to know whether he has been recently incarcerated. And while she may be hesitant to disclose to a healthcare provider that she is exchanging sex, she may be able to overcome the stigma of disclosing her recent incarceration because it has wide-ranging implications for her overall health, housing, and insurance status. By incorporating incarceration into a standardized risk assessment tool for healthcare providers, women’s PrEP access could be enabled.

Emerging data suggests that criminal justice systems themselves can also be important touchpoints for implementing PrEP in key populations.¹⁰ While no prisons or jails (to my knowledge) currently provide PrEP during incarceration, pre-release discharge planning could include linking women to HIV testing and PrEP services in communities.¹¹ PrEP implementation within criminal justice systems meets women where they are, rather than requiring women to navigate complex and often siloed traditional healthcare systems that have high barriers to entry.

Beyond working within existing structures, findings should also drive criminal justice reform efforts for the most socially vulnerable and marginalized women. In multivariable models, Knittel et al. found that women with prior incarcerations had a 5-times higher risk of being incarcerated during follow-up compared to women without any lifetime incarceration.¹ This finding likely reflects women being re-incarcerated for violations of probation or parole, although it is difficult to parse out from the data presented because charged offenses were not assessed. Most technical violations, in turn, result from failures to appear in court or ongoing substance use. The multivariate model confirms that any non-injection drug use was associated with a 57% higher risk of incident incarceration. Criminalization of women’s substance use is detrimental to women’s health because cyclic reincarcerations disrupt women’s social structures and continuity of care, compounding health disparities. In contrast, evidence-based treatment for substance use disorders, including medication for opioid use disorder, reduces substance use-related morbidity, mortality, and recidivism.¹² Treatment for substance use disorders is also effective HIV prevention for women, effectively “killing two birds with one stone.”¹³

Given comprehensive data on structural vulnerabilities in this study, it was somewhat surprising to see that there were no significant racial differences in risk for incident incarceration. National data has shown repeatedly that Black women bear a greater burden of HIV (and HIV risk).¹⁴ Black communities also disproportionately experience mass incarceration, though the racial gap in women’s incarceration has narrowed over the past decade.¹⁵ It is unclear whether a lack of association between incarceration and race in this study reflects that narrowing or whether the study was underpowered to detect racial differences (with just 12 non-Hispanic White women being incarcerated).

In exposing women’s co-occurring vulnerabilities to HIV and incarceration, this study is a call to arms, demanding action. Effective HIV prevention and criminal justice reform interventions must be tailored to meet the unique needs of women and systematically adapted to local contexts using implementation science. Given: 1) the potential power of PrEP to mitigate women’s HIV risk and 2) the effectiveness of drug treatment in reducing both criminal justice involvement and HIV risk, these interventions should be at the center of US strategies to End the HIV Epidemic in women.