A popular perception, fueled by media portrayals of prisons and jails is that as a result of (consensual or forced) sexual activity during incarceration, male prisoners become exposed to HIV and subsequently infect their partners after release. The recent report of transmission of HIV within the Georgia department of corrections provided evidence for HIV acquisition during incarceration and feeds the characterization of correctional facilities as breeding grounds for HIV.¹ However, while it is undeniable that transmission of HIV occurs within correctional facilities, the available data indicate that the majority of HIV-infected inmates enter prison or jail with infection. ^2-4

Subsumed by discussions of intramural spread of HIV in prisons and jails is consideration of the potentially greater, albeit indirect, contributions of incarceration to the general HIV epidemic. Emerging data suggest that incarceration, as a socially disruptive force, creates conditions favoring the spread of HIV and other sexually transmitted infections (STIs), especially in minority communities where incarceration and HIV/STIs are endemic. In this brief Spotlight we describe the potential impact that large-scale incarceration of men, particularly African-American men, may have on the spread of HIV/STIs to African-American women within their communities of origin.

African-American women bear a significant burden of the HIV epidemic. From the beginning of the epidemic through 2004, an estimated 84,900 women have died from AIDS - most African-American - and AIDS continues to be a leading cause of death among African-American women.⁵ According to the Centers for Disease Control and Prevention (CDC), 14% of adults and adolescents living with AIDS in 1992 were female but as of the end of 2004, this proportion had grown to 23%.⁵ Two thirds (68%) of the 45,146 women diagnosed with HIV/AIDS during 2001-2004 in the 33 states reporting HIV diagnoses were African-American; 16% were white. The vast majority of HIV-infected women acquire the infection from hetersoexual contact; CDC data indicate that an estimated 70% of women diagnosed with AIDS in 2004 reported sex with a man as the likely mode of HIV transmission (figure 1). ⁶

Factors that may contribute to racial disparities in HIV and STI rates include those related to health care access and utilization, sexual behaviors and sexual network attributes, distribution of STIs that facilitate HIV transmission and substance use.⁷ However, a cogent overarching explanation for the markedly increased HIV rates among African-Americans remains elusive.

Available data indicate that differences in sex partner number do not fully explain racial disparities in HIV/STIs.⁸ Rather, the available evidence suggests that concurrency of sexual partners (the overlapping of sexual relationships in time) and dissortative sexual mixing (sexual partnerships among persons at different levels of risk for HIV/STIs) differs between African-Americans and whites and may provide, at least, a partial explanation for these disparities.^9-11 Data from the 1995 National Survey of Family Growth (NSFG) indicate that concurrency of sexual partnerships was more common among African-American women than white women (21% versus 11%), and that the black-white differences in concurrency were largely due to decreased marriage rates among African-Americans and earlier age at first sexual intercourse.¹¹ Other data support a role for dissorative sexual mixing in increasing exposure to HIV/STIs among African-American women. In one recently published case-control study of risk behaviors among African-American men and women, a substantial proportion of HIV-infected African-American women reported few risk factors for HIV acquisition and relatively low numbers of previous sexual partners.⁸

Mounting evidence strongly suggests that the convergence of social contextual factors influence individuals behaviors associated with HIV/STI infection and play a critical role in heterosexual HIV transmission among African-American women. Among these factors are aspects of an individual's environment that may influence individual behaviors by destabilizing partnerships, altering the sex ratio and changing social norms to promote partnership concurrency and sexual mixing. ^8,12-14

In the U.S., there exists a low ratio of men to women among African-Americans. The severity and persistence of the scarcity of men among African-Americans is unparalleled, eclipsed only by the male shortages experienced in some nations post-WWII.15 A higher death rate among African-American males, due to infant mortality, disease, and violence, accounts for some of this imbalance.¹⁶ Incarceration, which is epidemic in many African-American communities futher exacerbates this low sex ratio. African-Americans comprise 12% of the U.S. population, but represent over 40% of federal and state prison inmate population.¹⁷ The U.S. Department of Justice predicts that one in three African-American men will be imprisoned during their lifetime (versus < 5% of white men).18 The disproportionate arrest and incarceration of African-American has resulted in a pervasiveness of incarceration that has led to imprisonment becoming a 'normal' part of life for many young African-American men, replacing other traditional life events (e.g., marriage).¹⁹

In addition to contributing to the scarcity of men, incarceration may foster HIV/STI transmission in several other ways. First, incarceration directly affects sexual networks by disrupting existing partnerships. The incarcerated partner may form risky partnerships with other inmates - a group with a high prevalence of HIV, HBV and HCV infection.^1,4,20-22 Second, the partner remaining in the community forfeits the social and sexual companionship of the incarcerated partner and may pursue other partnerships to meet these needs.⁸ Loss of a partner to incarceration can also lead to economic losses and less personal safety/security - additional potential motivations for a forming new intimate partnership(s). Incarceration of a partner has been associated with greater prevalence of sexual concurrency among young adults in Seattle.²³ While incarceration may be a marker for sexual risk behaviors, it can also promote sexual partner concurrency by temporarily removing a partner from the relationship. With the absence of her partner, a woman may enter into a new relationship and in a community where HIV is relatively prevalent, her exposure to HIV infection is, therefore, increased. A qualitative study of concurrent partnerships among adults described "separational" concurrency among persons with partners who were frequently incarcerated.²⁴ Third, incarceration adversely impacts the social fabric of the communities of origin of the incarcerated. A prison record usually makes men less employable,²⁵ contributing to high community unemployment rates. Therefore, incarceration can shrink not only the absolute number of men but also the proportion of men who are financially attractive as partners. Unemployment also increases the likelihood of poverty and resultant instability of long-term partnerships.^26,27 Lastly, mass imprisonment distorts social norms. The 'downstream' effects of incarceration may be detected in the emergence of a prison/jail culture in communities where incarceration becomes normative 28 - potentially further influencing sexual behavior and sexual networks.⁸

Studies in the sociology and criminal justice literature provide ample evidence of a deleterious effect of incarceration on families and communities, including African-American communities.^29-36 Although the male partner may be criminally involved prior to incarceration, these men often contribute some of their gains to their partner and this loss of income can be devastating for women straining to live at or near poverty levels.²⁹ The financial burden of incarceration for those left behind is further compounded by the loss of assistance with childcare and the expenses related to maintaining contact with the incarcerated man.^29-33 Importantly, the loss of a male partner has been found to increase the risk of partnership dissolution.³⁴ In one study, spousal absence due to incarceration or military service was associated with a two-fold risk of marital dissolution.35 Qualitative studies find that incarceration of a man leads to loneliness among female partners.^33-36

Lastly, several investigations have described HIV/STI transmission risk behavior among prison releasees, including HIV-infected former inmates.^37-38 Coupled with data demonstrating a loss of the viral suppression achieved during in-prison HIV care following release ^39,40 a picture of increased infectiousness and renewed risk behavior on community re-entry emerges and reinforces calls to improve pre- and post-release HIV prevention strategies.

The high rates of HIV and other STIs among African-American women remains unexplained and likely is results from the confluence of behavior, social and economic factors. The available evidence suggests that the disruptive effects of incarceration on relationships and communities already burdened with HIV and other STIs may facilitate the spread of these infections and place African-American women at increased risk for infection. Further study of the effects of incarceration on the partners and the communities inmates leave behind are required to better understand the unintended public health consequences of incarceration and to develop appropriate strategies to reduce the impact of incarceration on HIV/STI transmission.