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Prevalence and Correlates of HIV Risk Behaviors of Inmates in a

State Prison System

Titilayo Abiona, MD, FMCPH Adedeji Adefuye, MD, MPH, FRIPHJoseph Balogun, PT, PhD, FACSM Patricia Sloan, EdD, RN, FAAN

College of Health Sciences, Chicago State University

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Background

• Higher HIV/AIDS rates among inmates vs. general population

• HIV prevalence ~ 4 & 10x higher among inmates than in the general population

• What is the exact mechanism linking incarceration with HIV infection?

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Conceptual Model1.

HIV infected and uninfected persons in the community

go to prison-Risk Behaviors

2. Some inmates get

HIV in prison-Risk Behaviors

3. HIV infected and

uninfected inmates released

into the community

4.HIV transmission occurs from infected inmates

to uninfected partners and vice versa

-Risk Behaviors

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Background

• Inmates engage in risk behaviors before, during & after incarceration

• Examining risk behaviors of inmates is essential for understanding the role of incarceration in HIV infection

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Specific Objectives

• Describe pre-incarceration risk behaviors of inmates

• Identify and quantify risk behaviors during incarceration

• Determine the socio-demographic characteristics associated with risk behaviors during incarceration

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Methods

• Study Location– 17 randomly selected Illinois Correctional Facilities

• Study Design– Cross-Sectional Descriptive

• Study Population– Male and female inmates – 18 years of age or older– Continuously incarcerated for at least six months– Able to speak and write English

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Methods• Sample Size Determination

– Computer Programs for Epidemiologists (PEPI) version 4.0– A minimum sample size of 1025 was calculated – Over-sampling done to adjust for non-participation– 2,000 inmates finally selected

• Multi-stage sampling technique• Data collected with a structured questionnaire• Statistical Analysis: SPSS 15. Descriptive and Inferential

Analysis done• Study protocol approved by the CSU IRB

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Results• 1,819 participants: 1, 293 (71.1%)men and 526

(28.9%) women completed the survey• Response rate = 91%• Overall average response rate to survey

questions = 96%• Number of participants that responded to each

question varied• 71% (1293)of participants were men

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Table 1: Socio-demographic Characteristics of ParticipantsCharacteristic Women,% n=526 Men, % n=1293 P-Value

Mean Age (SD) 36.4 (9.7) 35.4 (10.1) 0.05

Marital StatusNever MarriedMarried/CohabitingPreviously Married

50.121.928.0

56.119.724.2

0.07

EthnicityWhiteAfrican AmericanHispanic/LatinoOther (Native Americans etc)

39.151.34.65.0

26.657.211.05.2

<0.001

No. of Times Incarcerated1-34-67 and more

85.212.82.0

77.617.35.1

<0.001

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Table 1: Sociodemographic Characteristics of Participants Cont’d

Characteristic Women,% n=526

Men, % n=1293

P-Value

No. of Years Spent in Prison during Current Sentence<11-34-67 or more

40.130.910.818.2

20.929.816.732.0

<0.001

Ever Had HIV TestingYesNo

91.18.9

84.515.5

<0.001

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Table 2: Pre-Incarceration Risk BehaviorsBehavior Sample

SizeFrequency Percentage

2 or more Vaginal Partners in the 6 months before arrest

1762 1037 58.9

2 or more Anal Partners in the 6 months before arrest

1741 333 19.1

Never/Rarely Used Condoms for Vaginal Sex in the 6 months before arrest

1653 1097 66.4

Never/Rarely Used Condoms for Anal Sex in the 6 months before arrest

781 547 70.0

Ever Injected Drugs 1740 255 14.7

Ever Shared Needles 255 142 55.7

Obtained Tattoo from non-professional artist 1100 799 72.6

Obtained Body Piercing from non-professional artist

878 364 41.4

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Figure 1: % of Respondents who never/rarely used Condoms in the 6 Months before Arrest

Vaginal Sex Anal Sex0

20

40

60

80

100

64.8 69.769.6 70.8

Male Female

P < 0.05

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Figure 2: % of Respondents who did not use Condoms during last Sexual Intercourse

Vaginal Sex Anal Sex0

20

40

60

80

100 79.776.3

82.2 82.480.4 78.1

Male Female Overall

Percentage

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Figure 5: % of Respondents who had ever Injected Drugs

Male Female0

5

10

15

20

25

12.1

20.5

P < 0.001

Percentage

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Figure 9 % of Respondents who obtained Tattoos and Body Piercing from non-professional artists

Tattoo Body Piercing0

20

40

60

80

100 77

48.1

62.3

32.2

Male Female

P < 0.001P < 0.001

Percentage

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Table 3: Risk Behaviors during Incarceration

Behavior Sample Size Frequency Percentage

Sexual Intercourse 1783 158 8.9

Injection Drug Use 1754 15 0.9

Needle Sharing 1754 10 0.6

Tattooing 1777 295 16.6

Body Piercing 1766 24 1.4

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Figure 10: Types of Sexual Intercourse during Incarceration (n=158)

Anal

Oral

Vaginal

0 10 20 30 40 50 60

14.6

54.4

41.8

Percentage

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Figure 11: Context of Sexual Intercourse during Incarceration (n=158)

Consensual93%

Forced7%

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Table 4: Characteristics and Behaviors Associated with Sexual Intercourse during Incarceration

Characteristic Frequency (%) Unadjusted Odd’s Ratio (CI)

Adjusted Odd’s Ratio (CI)

Level of Prison SecurityMaximumMediumMinimum

21/327 (6.4)39/911 (4.3)89/554 (16.1)

10.65 (0.38-1.13)1.02 (1.70-4.58)

10.60 (0.29-1.24)0.90 (0.37-2.16)

No. of Years spent in Prison During Current Incarceration<11 or more

11/475 (2.3)138/1306 (10.6)

14.98 (2.67-9.29)

110.57 (3.60-31.04)

No. of Times Incarcerated1-34 or more

135/1370 (9.9)9/348 (2.6)

10.24 (0.12-0.48)

10.36 (0.16-0.79)

GenderFemaleMale

90/521 (17.3)56/1250 (4.5)

10.23 (0.16-0.32)

10.47 (0.21-1.03)

EthnicityWhiteAfrican AmericanHispanic/LatinoOthers- Native Americans, Asian Americans etc.

46/533 (8.6)86/973 (8.8)8/164 (4.9)9/92 (9.8)

11.03 (0.71-1.49)0.54 (0.25-1.18)1.15 (0.54-2.43)

11.26 (0.70-2.27)0.59 (0.20-1.75)1.59 (0.52-4.84)

P < 0.001; P <0.05

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Table 4: Characteristics and Behaviors Associated with Sexual Intercourse during Incarceration Cont’d

Characteristic Frequency (%) Unadjusted Odd’s Ratio (CI)

Adjusted Odd’s Ratio (CI)

Marital StatusNever MarriedMarried/Living with someone as MarriedPreviously Married

96/957 (10.0)23/364 (6.3)28/452 (6.2)

10.61 (0.38-0.97)0.59 (0.38-0.92)

10.53 (0.23-1.20)0.74 (0.37-1.48)

Sexual OrientationHeterosexualBisexualGay/Lesbian

61/1368 (4.5)62/161 (38.5)19/51 (37.3)

113.42 (8.92-20.18)12.72 (6.82-23.72)

111.84 (5.73-24.47)6.72 (2.32-19.40)

Age<4040 or more

108/1164 (9.3)39/579 (6.7)

10.71 (0.48-1.03)

11.25 (0.66-2.39)

Got Tattoos in PrisonNoYes

57/915 (6.2)51/300 (17.0)

13.13 (2.04-4.55)

13.83 (2.20-6.65)

P < 0.001

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Conclusions• Inmates engage in risk behaviors before

and during incarceration• Longer duration of stay in prison, non

heterosexual orientation and receiving a tattoo in prison were associated with sexual intercourse in prison

• Findings support both the importation and deprivation models of inmate behavior

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Recommendations

• HIV prevention interventions should be commenced as soon as possible after incarceration

• Current policies about risk reduction mechanisms in prison need review

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Study Limitations• Possible Underreporting- Social Desirability Bias• Use of a self administered questionnaire and Social

desirability bias may affect results and generalizability of findings

• Non response to questions may be a source of bias • The small numbers of inmates reporting HIV risk

behaviors in prison prevented the identification of independent risk factors for some behaviors

• Inmates who were selected but refused to participate in the study may differ significantly from those who participated. This may have affected the prevalence of the risk behaviors reported.

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Future Research

• The role of tattooing in HIV transmission: risk marker or mode of transmission?

• Risk behaviors of partners of inmates• Spatial analysis of inmate residencies after

release, distribution of HIV cases, and HIV prevention services in Illinois

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Acknowledgements• Illinois General Assembly and the Illinois Department of

Public Health- Funding• Dr. Mainza Lukobo-Durrell- contribution to

conceptualizing the study• Research assistants –Josie McDonald, Wayne Scott-

Williams, Jerry Goldstein and Emmanuel Osunkoya- for their dedication throughout the period of the study

• State Representative Constance Howard- co-sponsoring the bill which created the African American HIV/AIDS Response Act and for her personal involvement in establishing the collaboration between the Institute and IDOC

• IDOC officials-support in facilitating data collection

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