Abstract
Objective:
Black individuals in the U.S. are arrested and incarcerated at a significantly higher rate than White individuals, and incarceration is associated with increased HIV vulnerability. Pre-exposure prophylaxis (PrEP) reduces the risk for HIV transmission, but little is known about the relationship between HIV risk behavior and willingness to use PrEP among Black individuals with an arrest history.
Method:
868 individuals completed a nationally representative survey and provided baseline data on sexual risk. Participants were grouped as those with a history of arrest (N= 226) and those with no history of arrest (N=619) based on self-reported arrest history. Our study examined HIV risk behaviors associated with willingness to use PrEP between those with arrest history and those without arrest history.
Results:
Participants with an arrest history were more likely to have a lifetime history of anal sex (p<0.0001) and sexually transmitted diseases (p=0.0007). A history of multiple sexual partners in the past 3 months was associated with PrEP willingness in individuals with an arrest history [aPR 2.61 (1.77, 3.85), p<0.0001], adjusting for other covariates in the model.
Conclusions:
Differences in risk behavior and willingness to use PrEP exist by arrest history. Understanding these risk behaviors are necessary to increase access to PrEP. PrEP uptake and adherence interventions, when recommended and made available for individuals at substantive risk of HIV infection at the time of arrest and during incarceration, are essential to reducing the spread of HIV in correctional facilities and in communities to which they return.
Keywords: HIV risk, PrEP, Willingness, Arrest history, Correctional facilities
Introduction
HIV prevalence is 5 times higher among prison inmates than in the general population [1]. Prior studies suggest that, compared with individuals with no criminal justice (CJ) involvement, individuals with histories of arrest and incarceration are more likely to report higher rates of sexually transmitted diseases (STDs), multiple sexual partners, inconsistent condom use, and are more likely to report drug use during sex [2–7]. Individuals who have a history of arrest also have higher rates of mental health challenges, which increase their risk of substance use disorder and other HIV risk behaviors [8, 9].
CJ settings present an important opportunity to provide and link at-risk individuals to PrEP services. Individuals who frequently come into contact with CJ systems are those from populations with a higher risk of HIV infection (i.e., people who inject drugs, Black men who have sex with men, commercial sex workers) [10–15]. HIV risk is substantially high upon release from prisons or jails, during re-entry to the community, when they face numerous competing risks such as substance use relapse, unstable housing, unemployment, lack of health insurance, loss of social support, stigma and discrimination, and untreated psychiatric disorders [16]. These intersecting risks, exacerbated by involvement with the CJ systems, make it crucial to engage these subpopulations in HIV prevention interventions at the time of arrest, during incarceration, and during community re-entry.
Pre-exposure prophylaxis (PrEP) can dramatically reduce rates of HIV transmission if taken daily by HIV-negative individuals. The U.S. Food and Drug Administration (FDA) approved the use of emtricitabine/tenofovir disoproxil fumarate (Truvada) and emtricitabine/tenofovir alafenamide (Descovy) in 2012 and 2019 respectively as PrEP for the prevention of HIV infection. The World Health Organization (WHO) has also recommended PrEP as part of comprehensive HIV prevention for key populations at risk of HIV infection [17, 18], which includes adults with criminal justice involvement [19]. Despite these recommendations, implementing PrEP in criminal justice settings and during community re-entry for individuals at high risk remains low [20, 21]. PrEP’s optimal impact among inmates and subpopulations they intersect with after release depends on its awareness, acceptability, uptake, and adherence.
In the U.S., more than 10 million individuals are arrested per year [22]. Given the higher risk for undiagnosed HIV infection within this population, routine HIV testing has been suggested during the intake process [23]. HIV testing has been implemented successfully in several intake settings and has led to earlier diagnosis and treatment [24, 25]. The provision of an HIV test ensures the identification of PrEP candidates. Understanding best practices for PrEP screening and linkage during the course of an individual’s CJ involvement is essential. This could happen at the time of arrest, during the first medical visit, or during re-entry to the community. Thus, the purpose of our study was to determine willingness to use PrEP among a national sample of Black individuals with an arrest history, many of whom are at high risk and would benefit from PrEP use during initial contact with the CJ system.
Methods
Study Sample and Data Collection
Data for this study were drawn from the National Survey on HIV in the Black Community (NSHBC), a nationally representative survey of Black/ African-Americans in the U.S. [26]. The survey was conducted from February to April 2016. Participants were drawn from a probability-based web panel designed to represent adults living in U.S. households. Panel members were recruited through address-based sampling and random-digit dialing to ensure that households served by cell phones and without landline service were included. Households without internet access were provided with hardware and access.
Survey Development
Cognitive interviews were performed to develop the survey with a sample of 30 self-identified Black individuals in the Boston area between the ages of 18–50 (mean age was 39.1) to evaluate potential sources of response bias. Participants were recruited by word-of-mouth and flyers from local community-based organizations. Interviews were conducted at community-based settings and assessed respondent motivation, question comprehension, ability to recall information, cultural applicability, and the impact of social desirability bias regarding sensitive questions. The final survey comprised of questions and scales edited based on these findings.
Inclusion Criteria and Participants:
Eligible participants had to: self-identify as Black/African American; be between 18 and 50 years of age; and be able to provide written informed consent. Ethical approval was obtained from the Boston Children’s Hospital Institutional Review Board. 1,969 Black participants were sampled from the national web panel of more than 55,000 respondents. Of those 1,969 participants, 896 (46%) consented to complete a brief socio-demographic survey confirming their age and race. Of the 896 who consented, 868 (97%) were eligible and completed the NSHBC. Surveys were administered via email. Participants completed the survey in 13 minutes (median). For the purpose of our study, of the 868 who completed the survey, 13 participants who reported known HIV infection were excluded. Post-stratification weights were created so that estimates represent adults living in the U.S. households according to benchmarks from the 2016 population survey [27].
Study Measures
Socio-Demographic Characteristics:
Demographic characteristics included age, gender identity, marital status, annual income, employment status, education level, and U.S. region. Arrest history, regardless of subsequent conviction or plea, was measured by asking participants to answer yes or no with the following statement, “In your lifetime, have you ever been arrested?”
Sexual Risk:
Participants were asked if they had multiple sexual partners in the past 3 months, condomless sexual activity in the past 3 months, and a lifetime history of anal sex and STDs.
PrEP Willingness:
PrEP willingness was assessed by asking participants to answer yes or no with the statement; “If a pill (drug/medication) that could prevent transmission of HIV from an infected (HIV positive) sex partner to an uninfected (HIV negative) partner were available I would take it.”
Statistical Analysis
Descriptive statistics (such as mean, standard deviation, frequency, and percent) were used to summarize data. A chi-square test or two-sample t-test was used to assess the association between arrest history and various demographic and sexual risk variables. Bivariate analyses using post-stratification weighted robust Poisson regression models were conducted to identify the potential associations between covariates of interest and PrEP willingness. To adjust for the effect of several covariates simultaneously, multivariate post-stratification weighted robust Poisson regression models were used. Multivariate models controlling for the possible confounding effects of participants’ age and sex included covariates that were significant in the bivariate models (p<0.05), and were constructed separately for those with and without an arrest history. Prevalence ratios (PRs), adjusted prevalence ratios (aPRs), 95% confidence intervals (CIs), and p-values were calculated. A two-sided significance level of 0.05 was used for all statistical tests. SAS version 9.4 was used to conduct all statistical analyses.
Results
Demographic Characteristic (Table 1)
Table 1:
Descriptive Statistics for Demographics of Study Sample, by Arrest History
| Characteristic | Total (n=855) | History of Arrest (n=226) | No History of Arrest (n=619) | P-value2 |
|---|---|---|---|---|
| Age, mean (SD) | 33.59 (9.20) | 35.86 (8.58) | 32.77 (9.30) | <0.0001 |
| Gender, n (%) | <0.0001 | |||
| Male | 340 (45.6) | 127 (61.4) | 208 (39.6) | |
| Female | 515 (54.4) | 99 (38.6) | 411 (60.4) | |
| Marital Status, n (%) | 0.0821 | |||
| Single (never married, widowed, divorced, separated) | 533 (61.6) | 130 (56.5) | 395 (63.1) | |
| Others (married, living/cohabiting with partner) | 322 (38.4) | 96 (43.5) | 224 (36.9) | |
| Employed, n (%) | 610 (71.6) | 151 (68.5) | 450 (72.6) | 0.2488 |
| Education Level, n (%) | <0.0001 | |||
| <High School | 58 (11.0) | 32 (21.2) | 26 (7.5) | |
| High School or GED | 175 (32.7) | 42 (25.3) | 131 (35.1) | |
| Some College or higher | 622 (56.3) | 153 (53.5) | 462 (57.4) | |
| Annual Income, n (%) | 0.0144 | |||
| <$25,000 | 314 (24.9) | 98 (31.8) | 210 (22.1) | |
| $25,000 - $49,000 | 208 (26.9) | 54 (24.8) | 150 (27.3) | |
| $50,000 and above | 333 (48.2) | 74 (43.4) | 259 (50.6) | |
| U.S. Region, n (%) | 0.2562 | |||
| Northeast | 149 (18.2) | 32 (16.5) | 117 (19.0) | |
| Midwest | 172 (17.1) | 57 (20.6) | 113 (15.8) | |
| South | 433 (54.1) | 111 (54.5) | 316 (53.9) | |
| West | 101 (10.6) | 26 (8.4) | 73 (11.3) | |
| PrEP Willingness | 225 (26.0) | 78 (22.8) | 145 (34.3) | 0.0008 |
Unweighted counts, weighted percentages
P-values generated from two-sample t-tests for continuous variables and chi-square tests of independence for categorical variables
A total of 868 participants completed the survey. There were 226 participants reporting a history of arrest. The average age (SD) of participants with a history of arrest was 35.9 (8.58) years, and the majority were males (61.4% vs. 38.6% female). More than half of those with an arrest history (56.5%) were single, 68.5% were employed, 22.8% reported willingness to use PrEP, 31.8% had annual household incomes less than $25,000 per year, and more than half (53.5%) reported some college or higher degrees. Demographics differences between individuals with a history of arrest and those with no arrest history are presented in Table 1. Compared to individuals with no history of arrest, those who reported arrest history were more likely to be males, older, and willing to use PrEP. There was also a significant association between arrest history and both level of education and income.
Sexual Risk and HIV Testing by Arrest History (Table 2)
Table 2:
Risk-Related Variables and HIV Testing, by Arrest History
| Characteristic | Total (n=855) | History of Arrest (n=226) | No History of Arrest (n=619) | P-value2 |
|---|---|---|---|---|
| Condomless Sex, last 3 months | 410 (57.8) | 126 (63.4) | 284 (56.1) | 0.0729 |
| Multiple Partners, last 3 months | 80 (9.4) | 28 (11.6) | 51 (8.5) | 0.1689 |
| Anal Sex, lifetime | 308 (35.7) | 121 (51.3) | 184 (29.5) | <0.0001 |
| History of STD, lifetime | 211 (28.0) | 78 (36.9) | 132 (24.4) | 0.0007 |
| HIV Testing, last 12 months | 248 (27.6) | 87 (36.2) | 160 (24.5) | 0.0009 |
Unweighted counts, weighted percentages
P-values generated from chi-square test of independence
Sexual risk and HIV testing differ between individuals with a history of arrest and those without an arrest history. Compared to individuals without an arrest history, those with an arrest history were more likely to: have a lifetime history of anal sex (51.3% vs. 29.5%; p<0.0001), have a lifetime history of STD (36.9% vs. 24.4%; p=0.0007) and have tested for HIV in the last 12 months (36.2% vs. 24.5%; p=0.0009). There were no significant differences between individuals who had an arrest history and those without an arrest history in terms of condomless sex and multiple sexual partners in the past 3 months.
Models for Willingness to Use PrEP (Table 3)
Table 3:
Bivariate and Multivariate (MVA) Robust Poisson Models for PrEP Willingness, by Arrest History
| Factors | Bivariate for Group with an Arrest History | Bivariate for Group with no Arrest History | MVA for Group with an Arrest History (N=225) | MVA for Group with no Arrest History (N=602) | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| N | PR (95%CI) | p-value | N | PR (95%CI) | p-value | aPR (95%CI) | p-value | aPR (95%CI) | p-value | |
| Male (ref: female) | 225 | 0.84 (0.54, 1.31) | 0.4360 | 615 | 0.83 (0.56, 1.24) | 0.3748 | 0.78 (0.51, 1.19) | 0.2501 | 0.85 (0.58, 1.24) | 0.4036 |
| Age 25 to 34 (ref: all other ages) | 225 | 1.03 (0.63, 1.69) | 0.9167 | 615 | 1.14 (0.78, 1.66) | 0.4869 | 0.94 (0.60, 1.49) | 0.8055 | 1.08 (0.75, 1.56) | 0.6690 |
| Unemployed (ref: employed) | 225 | 1.15 (0.73, 1.82) | 0.5498 | 615 | 1.37 (0.92, 2.02) | 0.1184 | ||||
| Income <25K (ref: >=25K) | 225 | 1.14 (0.74, 1.76) | 0.5554 | 615 | 1.41 (0.99, 2.00) | 0.0538 | ||||
| Single (ref: others) | 225 | 1.48 (0.90, 2.44) | 0.1242 | 615 | 1.69 (1.13, 2.53) | 0.0101 | 1.69 (1.13, 2.53) | 0.0113 | ||
| Educational level <High school (ref: >=High school) | 225 | 1.33 (0.77, 2.30) | 0.3136 | 615 | 1.66 (0.88, 3.15) | 0.1182 | ||||
| Condomless Sex, last 3 months | 207 | 1.24 (0.77, 2.00) | 0.3842 | 507 | 0.99 (0.67, 1.45) | 0.9478 | ||||
| Multiple Partners, last 3 months | 225 | 2.51 (1.72, 3.68) | <0.0001 | 606 | 1.79 (1.09, 2.96) | 0.0225 | 2.61 (1.77, 3.85) | <0.0001 | 1.46 (0.87, 2.43) | 0.1483 |
| Anal Sex, lifetime | 225 | 1.14 (0.72, 1.79) | 0.5815 | 609 | 1.54 (1.06, 2.23) | 0.0231 | 1.46 (1.01, 2.12) | 0.0429 | ||
| HIV Testing, last 12 months | 218 | 1.14 (0.73, 1.79) | 0.5648 | 590 | 1.25 (0.83, 1.89) | 0.2753 | ||||
| History of STD, lifetime | 208 | 1.39 (0.88, 2.20) | 0.1525 | 511 | 1.39 (0.94, 2.08) | 0.1011 | ||||
| Knowledge of PrEP | 225 | 1.27 (0.68, 2.37) | 0.4525 | 613 | 1.37 (0.88, 2.13) | 0.1597 | ||||
HIV risk behaviors and PrEP willingness differ between individuals with an arrest history and those without an arrest history. Among participants with an arrest history, in bivariate analysis, multiple sexual partners in the past 3 months [PR 2.51 (1.72, 3.68), p<0.0001] was associated with PrEP willingness. In multivariate analysis, adjusting for all other covariates in the model, multiple sexual partners in the past 3 months [aPR 2.61 (1.77, 3.85), p<0.0001], remained significant.
In the bivariate analysis for participants with no arrest history, individuals who reported single marital status [PR 1.69 (1.13, 2.53), p=0.0101], multiple sexual partners in the past 3 months [PR 1.79 (1.09, 2.96), p=0.0225] and had a lifetime history of anal sex [PR 1.54 (1.06, 2.23), p=0.0231] were more willing to use PrEP compared to their respective counterparts. In multivariate analysis, adjusting for all other covariates in the model, single marital status [aPR 1.69 (1.13, 2.53), p=0.0113] and a lifetime history of anal sex [aPR 1.46 (1.01, 2.12), p=0.0429], remained significant.
Discussion
Our study demonstrated that HIV risk behaviors and willingness to use PrEP differ between individuals with an arrest history and those without an arrest history. Individuals with a history of arrest were significantly more likely to have a lifetime history of anal sex and STDs. We found an increased willingness to use PrEP among individuals with an arrest history who reported a history of multiple sexual partners. Willingness to use PrEP was also associated with single marital status and a lifetime history of anal sex in those with no arrest history. These findings suggest that participants might be more willing to use PrEP because they have a higher likelihood of engaging in risky sexual behaviors. This confirms that uptake and adherence to PrEP are directly related to and influenced by one’s risk perception [18, 28].
Risk behaviors among individuals with a history of arrest might be explained by a confluence of factors they experience at the individual and community-level (such as poverty, mental health issues, unemployment, substance abuse, inconsistent condom use, and housing instability) that heighten their risk of HIV infection [10, 29–32]. These data reinforce the notion from previous studies that adults who have a history of criminal justice involvement should at least be screened for HIV risk and PrEP eligibility [28, 33, 34]. Therefore, clinical screening for arrest history as a social determinant of health may be needed to identify and respond to the health needs of Black individuals.
Implementing effective PrEP interventions at any time during arrest and incarceration and during community re-entry requires identification of best practices for the timing of screening and linkage to PrEP services, establishing guidelines and standards of PrEP care, determining the feasibility and acceptability of CJ-based PrEP provision, and training CJ-healthcare providers to assess and address risk and indication for PrEP [18]. It is crucial that healthcare providers, public health practitioners, researchers, and those who work in the legal system fully understand the drivers of PrEP willingness and how to implement effective PrEP interventions in this key population. As biomedical HIV prevention expands, correctional facilities may serve as an effective platform to provide linkage to PrEP for at-risk individuals during the course of their CJ involvement.
Limitations
First, although our study was designed as a nationally representative study with a modest sample size, findings may not be generalizable to other groups. Second, because our sample was drawn from a web panel who either had internet access or were provided with internet access before joining the panel, we did not include individuals who were incarcerated, homeless, or transiently housed. Third, all data were self-reported and subject to recall bias and social desirability. We attempted to minimize recall bias by asking participants to recall behavior within a short timeframe (e.g., history of condomless sex and multiple sexual partners within the past 3 months). Finally, we could not establish the time of arrest and the amount of time spent in jails and brief detention sentences versus longer stays in residential or prison settings.
Conclusion
This study helps demonstrate the association between HIV risk behaviors and willingness to use PrEP among a national sample of Black Americans. Our findings suggest that differences exist in risk behaviors and willingness to use PrEP among individuals with an arrest history and those without an arrest history. Understanding these risk behaviors are necessary to increase access to PrEP. PrEP uptake and adherence interventions, when recommended and made available for individuals at substantive risk of HIV infection at the time of arrest and during incarceration, are essential to reducing the spread of HIV infection in correctional facilities and in communities to which they return. Future research should build upon this study to intervene along the PrEP continuum for individuals involved with the criminal justice system, including facilitating PrEP uptake and adherence and linkage to other HIV prevention services.
Acknowledgements
We want to thank the National Advisory Committee who created the survey. This publication was made possible with help from the Harvard University Center for AIDS Research (CFAR), an NIH funded program (P30 AI060354).
Funding: This study was supported by grants from Harvard University Center for AIDS Research (HU CFAR NIH/NAIDS P30-AI 060354). Dr. Bogart was also supported by P30MH058107.
Footnotes
Declarations
Ethical Approval: Ethical approval was obtained from the Boston Children’s Hospital Institutional Review Board.
Informed Consent: Informed consent was obtained from all individual participants included in the study.
Data, Material and/or Code availability: All data and materials as well as SAS version 9.4 support our findings and comply with field standards.
This Author Accepted Manuscript is a PDF file of a an unedited peer-reviewed manuscript that has been accepted for publication but has not been copyedited or corrected. The official version of record that is published in the journal is kept up to date and so may therefore differ from this version.
Conflicts of interest: The authors have no conflicts of interest to declare with respect to the research, authorship, and/or publication of this article.
Contributor Information
Ugochukwu Uzoeghelu, Harvard Medical School, Boston, MA..
Laura M. Bogart, RAND Corporation, Santa Monica, CA.
Taylor Mahoney, Boston University School of Public Health, Boston, MA.
Musie S. Ghebremichael, Harvard University, Boston, MA.
Jelani Kerr, University of Louisville, Louisville, KY.
Bisola O. Ojikutu, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA.
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