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African Americans, HIV, and mass incarceration
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Lancet July 14 2016
The disproportionate rates of HIV infection among African Americans are perplexing. In 2014, about 44% of new HIV infections and 48% of AIDS diagnoses in the USA were among African Americans, although they represent just 12% of the overall population.1 The US Centers for Disease Control and Prevention (CDC) reports, in 2016, that the HIV incidence rate for black men is more than six times that of white men, and more than twice that of Hispanic men.2 The HIV incidence rate for black women is 20 times that of white women, and nearly five times that of Hispanic women.2 Furthermore, African Americans represent close to half of all patients with AIDS in the USA who have died during this epidemic.2
HIV/AIDS prevention and treatment services in the USA have largely focused on individuals with a history of high-risk behaviours, such as injection drug use or unprotected sex. Although white young adults who engage in such high-risk behaviours are at increased risk for HIV, young black adults without these usual risk factors are nevertheless at higher than average risk for HIV.3 One 2010 study showed that condom use was, in fact, higher for black and Hispanic individuals than for other racial groups.4 To explain the higher rates of HIV/AIDS among African Americans, we need to examine structural factors, such as access to health care or disease prevalence within communities.
African Americans differ from other groups mainly with regard to socioeconomic vulnerability—that is, their probability of living in poverty, being homeless, or spending time in a detention facility. A 2016 study showed that, by 2011, the incarceration rate for black men was six times that of white men and more than twice that of Hispanic men.5 The incarceration rate for black women was 2Š5 times higher than the rate for white women and roughly twice the rate of Hispanic women.5 Rates of incarceration and of HIV/AIDS have skyrocketed for African Americans during the past three to four decades. These two issues are linked for several reasons.
First, people at increased risk for HIV, such as injection drug users and sex workers, often end up in prison due to zero-tolerance policies in the USA for these activities.6, 7 As a result, HIV prevalence is 3–5 times higher in prisons and jails than in the general population.5, 8 Second, harm-reduction programmes—eg, provision of condoms and clean needles to high-risk populations—are almost non-existent in US correctional facilities.8Yet, many prisoners engage in consensual sex, drug use, and tattooing while in detention. Third, many prisons have high rates of violence, including sexual assault.9 Fourth, incarceration can limit or interrupt a person's access to health care. Effective HIV services that allow for preventing, testing, and treating infection are often absent.10 Individuals whose infections are detected and treated while detained are likely to find their treatment is interrupted upon release, or if they are re-detained.9 Most of these people quickly rebound with a high HIV viral load during treatment interruptions, rendering them infectious for sexual partners.9 With some 14% of all Americans living with HIV cycling through the criminal justice system each year, these common treatment interruptions may play the most important role in the markedly increased likelihood for African Americans to encounter a sexual partner with HIV and who is not virally suppressed.11
Since women represent less than 10% of the prison population in the USA, the disproportionately high incarceration rates for African American women do not explain the sharp increase in HIV/AIDS rates among this group. Instead, one influential study concluded that the disparity in HIV/AIDS rates between black and white populations is best explained by the hyperincarceration of black men.12 The spike in HIV/AIDS rates among black women seems to be due primarily to their increased risk of having an infected partner. The CDC estimates that 87% of African American women with HIV become infected through heterosexual sex, and only a small percentage through injection drug use or other pathways.1
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