ResearchImplementation Brief

The substantial association between incarceration and HIV infection in the US is well-documented. HIV prevalence among prison populations is four times that observed in the general population [1], with the HIV rate in some US prison systems higher than the national prevalence of any country outside sub-Saharan Africa [2]. HIV spread occurs in prison [3] but most transmissions occur in the community prior to incarceration and after release. Partners of incarcerated individuals also face elevated HIV risk. Because incarceration is a social determinant of HIV in that it disrupts social networks and has links to diminished mental health and increased drug use, sex risk behavior, and infection transmission, alternatives to incarceration also should be considered as a component of HIV prevention. In addition, because current and former incarcerated individuals and members of their networks constitute priority populations for HIV prevention, HIV testing, treatment, and prevention efforts should be available to those housed in our jails and prisons and during community re-entry.

1. Jails and prisons should devote resources to HIV testing, treatment, and behavioral risk reduction during incarceration and release. 
   The CDC recommends opt-out HIV testing in correctional settings [4] as it dramatically increases the number of incarcerated individuals tested. HIV care in prison achieves excellent viral suppression during incarceration [5] that is often lost after release [6]. Pre-release discharge planning and post-release case management and support (e.g., transportation, accompanying clients to visits) is linked to improved retention in care [7] and viral suppression [8], though thus far randomized trials have failed to confirm the effectiveness of case management interventions in improving post-release retention in care and outcomes for HIV-positive incarcerated individuals [9]. Jail and prison-based programs also appear to reduce behavioral risk [10].
2. Jails and prisons should distribute HIV prevention tools, such as condoms. 
   Studies of in-prison HIV transmission and other sexually transmitted infections (STIs) highlight the reality that sexual activity occurs behind bars and that jail and prison condom distribution is needed. While most US correctional facilities do not allow for condom distribution [11], a handful of prison and jail systems have made condoms available to incarcerated individuals with no reported increases in sexual activity or discipline/operational issues [12]. We need research studies that examine the influence of correctional facility-based condom promotion on disease reduction. Syringe access is not available for people who inject drugs incarcerated in US correctional facilities and very few countries have such programs in prisons. However, on the strength of the evidence that syringe access is highly effective in reducing HIV transmission in community settings, syringe exchange programs should be initiated and evaluated in US prisons [13].
3. Treatment of substance use, mental disorders, and other sexually transmitted infections (STI) can improve HIV treatment and prevention efforts.
   Given the high burden of substance use and psychiatric disorders and sexual risk evidenced by high STI rates in incarcerated individuals, screening and treating these conditions within criminal justice settings and continuing the treatment post-release is crucial for individual and public health [14]. United Nations agencies and the World Health Organization recommend treatment of opioid use disorders with methadone or buprenorphine as a critical component of HIV treatment and prevention in correctional settings [15]. Doing so improves viral suppression and increased CD4 count [16]. Unfortunately, in the US, only a handful of jails and prisons offer these recommended drug treatments.
4. Jails and prisons should reduce barriers to staying in touch with loved ones and foster prosocial ties. 
   While criminal justice systems focus on keeping incarcerated individuals away from society, strategies to maintain healthy relationships between incarcerated individuals and their family and other committed partners should be prioritized, including facilitating ongoing communication in person, by telephone, or through use of other new media technologies and locating incarcerated individuals closer to their families when possible. This is because incarceration-related disruption of social networks is linked to post-release increases in mental disorders, alcohol and non-injection drug use, and HIV-related sex risk behavior [17].
5. The effect of reducing incarceration for non-violent offenders on HIV, health, and well-being should be studied. 
   For the first time in over 30 years, incarceration rates in the US have slowly begun to decline in some of the US states, driven in large part by changes in sentencing laws [18]. Alternatives to incarceration that effectively engage individuals at risk for incarceration in effective treatment for substance use and psychiatric disorders are crucial to mitigate HIV risk-taking, prevent HIV transmission, and reduce risk to members in their social networks. The vast majority of non-violent offenses are drug offenses; strategies that engage high risk drug users in community treatment rather than incarcerate them would markedly reduce HIV incidence and prevalence over the next 10 to 15 years [19]. Collaborations between policy makers, jail/prison officials, and researchers are needed to understand the influences of different decarceration policies on HIV risk.

We need to evaluate the impact of recent declines in incarceration to understand which decarceration policies should be implemented nationally to best improve well-being and health. At the same time, provision of services in correctional settings and during release is a human right and an important component of HIV prevention. Such services should address transmission and acquisition risk by addressing multiple risk factors and should include quality HIV testing, treatment, and prevention services; mental health and substance use treatment; and STI treatment.

For further information on this Brief contact CDUHR at CDUHR@nyu.edu.

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