According to the Centers for Disease Control and Prevention, HIV diagnoses dropped by 19 percent from 2005 to 2014. The statistics suggest education, condoms, and PrEP (a pill that, when taken properly, reduces the risk of HIV infection by over 90 percent) have worked to prevent the spread of the virus. A closer look at the numbers, though, reveal a troubling trend: While diagnoses for all gay and bisexual men increased slightly by six percent, they skyrocketed by 87 percent for African American and Latino gay and bisexual men. Although diagnoses fell for all women, rates of transmission for African American women remained several times higher than rates for white women. In 2014, African Americans received 44 percent of new HIV diagnosis.
Researchers have pinpointed several reasons for the disparity, namely a lack of access to services that provide education and STI prevention materials in poor, black neighborhoods. Increasingly, researchers and HIV advocates are also singling out another potential cause of transmission: incarceration. A growing body of research suggests that prison and jails can be some of the biggest risk factors in HIV transmission, and that's led some researchers to ask why jails' and prisons' federal, state, and county-level administrators aren't doing more to stop the virus's spread.
"HIV prevention in prisons and especially in jails, is egregious," says Jason Lydon, the community minister of Black and Pink, a nonprofit that advocates for LGBTQ prisoners. "The refusal to give prisoners PrEP or condoms, it's a human rights violation."
HIV rates in prisons are five to seven times higher than in the general population, according to the Center for HIV Law and Policy. The first reason is simply demographics: African Americans have much higher rates of incarceration and also have higher rates of HIV, as do trans women of all races. Prison populations also skew young, and young people are at a higher risk of HIV infection than older Americans. According to Lydon, another reason for the high rates is that the same factors that cause people to be at increased risk for HIV transmission—like working as a sex worker or using intravenous drugs—also are associated with an increased risk of imprisonment because they're criminalized behaviors. All of that together means that in a given year, 25 percent of all Americans who have HIV will be incarcerated according to a study performed by Dr. Russell A. Brewer.
Despite the high levels of HIV and AIDS in prisons, advocates say there isn't being enough done to stop further transmission. Prisons actually tend to be good, though not great, at treating HIV and AIDS, but treatment does not equal prevention. It's not clear exactly how many states offer regular HIV testing testing for prisoners, but one survey found 73 percent of inmates said they'd been tested for HIV since entering the system. One recent study found that 90 percent of prisons offer antiretroviral therapy, the main type of treatment for people living with HIV.
According to Jason Lydon of Black and Pink, the federal Bureau of Prisons recently boasted of getting 88 percent of its HIV positive prisoners to a point where their viral load was undetectable—a sign that antiretroviral treatment is working well. But, Lydon says, there's no reason that number can't be higher, at 98 or 99 percent. "At 12 percent that are not undetectable, to me what that means is that they're providing inadequate treatment," he says.
When asked a number of questions about their prevention methods, a spokesperson for the Bureau of Prisons said, "The Bureau of Prisons is committed to stopping the spread of HIV in prisons."
However, Lydon and other advocates say that prison treatment isn't the biggest weak point of HIV care. The bigger problem comes from jails, where incarcerated people cycle in and out of facilities in days or weeks, as opposed to months or years, and where there's not the same mandate to provide long-term care as there is in prisons.
Data on jails is scarce because they are under the control of their respective counties or other local governments, and they lack a responsibility to coordinate policy with one another. A Human Rights Watch review of jails in Louisiana, a state where both HIV and incarceration rates are high, found HIV services severely lacking.
"In jails, there's no oversight, and no transparency," says Megan McLemore, a senior researcher at HRW and the author of the report. "It's a sprawling system of locally run jails that do what they want. And they don't even want to do testing because they don't want to pay for treatment."
The HRW report found that only five of the 104 jails in Louisiana were doing routine HIV testing. It also found that jail essentially guaranteed an interruption in treatment or prevention; if someone is talking antiretroviral drugs or PrEP when they enter a jail, they likely stop receiving them once inside. According to McLemore and others, that's why studies have found that people's viral load and risk of transmitting HIV to others tend to spike after leaving jail.
"That period right immediately after incarceration is a high-risk time," says Josiah Rich, a professor of medicine and epidemiology at Brown University who works with incarcerated people in Rhode Island.
Even though jails are currently providing inadequate HIV care, Rich says that's where the biggest opportunity lies for preventing, diagnosing, and treating HIV, as approximately 10 million people cycle through the system each year.
"That's where the biggest bang for your buck is," Rich says. "Where there's rapid turnover, so you can diagnose people, and scramble to get them hooked up to care when they get out."
According to Rich, the transmission of HIV while in prison or jail is not as big a risk factor as transmission afterwards; sex, sexual assault, and needle sharing does occur, but it appears to occur at lower levels than on the outside. Still, the lack of condoms, PrEP, and needle exchanges means that when sex and drug use does occur in jails and prisons, the activities can be riskier than they are on the outside. Only about one percent of prisons offer condoms, and needle exchanges are "virtually nonexistent" according Leonard Rubenstein, the director of the program on human rights, health, and conflict at the Johns Hopkins Bloomberg School of Health. Prisoners often resort to creating their own improvised condoms with items like rubber gloves to prevent transmission. Researchers say offering condoms in prisons and jails would mean authorities would be acknowledging that disallowed behavior occurs under their watch. If condoms are a stretch, PrEP may be a long ways off from entering America's incarceration system.
When incarcerated people lack prevention methods and experience gaps in HIV treatment, this has serious repercussions for people outside of prisons as well. Researchers believe part of the reason HIV rates are so much higher for black women, for example, is because black men are incarcerated at high rates; they experience a higher risk of exposures to HIV and a greater chance that there will be gaps in health care that would prevent HIV transmission once they're released. "We were having a hard time understanding why rates were going up for Latinas and African American women," says Laurie Shrage, a professor at Florida International University who has studied HIV in prisons. "Prison is the missing link."
If the US wants to take the crisis of HIV in African American communities seriously, researchers and HIV advocates say they must treat prisoners with the same time-tested health practices that are used on the outside, which includes making condoms and PreP available and ensuring HIV-positive incarcerated people continue receiving their HIV treatment.
"This is the basis of a pragmatic and humane health approach," says Chris Beyrer, a professor of public health and human rights at the Johns Hopkins Bloomberg School of Public Health. "We have to recognize that people engage in all kinds of behaviors inside and outside prison, illegal and not. Condoms and PrEP in prisons is harm reduction, but it's also about rights: When people are incarcerated, you are taking their ability to make healthy choices away."