HIV and Sexually Transmitted Infection Vulnerability Among Heterosexual Couples Involved in the Criminal Justice System—The Corrections Connection

Incarceration and HIV are inextricably interwoven in the United States, bound by long-standing structural policies and practices of the criminal justice system.¹ Widespread incarceration of people of color in the United States has far-reaching social and sexual network–level implications that, in turn, enhance individual-level vulnerability to HIV.² Drug and other policies differentially affect people of color, including increased penalties for crack cocaine; one strike, you’re out policies in public housing; and differential sentencing for the same offense. Thus, people of color, especially black American individuals, are disproportionately represented in the correctional population and disproportionately affected by HIV infection and its complications.³ Criminal justice settings represent a critical site for HIV testing, prevention, and care to decouple the corrections-HIV connection.⁴ However, only in applying these interventions beyond the individual level, to the couple, to the network, and to the community levels, will they be most effective.

In an innovative move, El-Bassel and colleagues⁵ apply their extensive experience with relationship-based HIV and sexually transmitted infection (STI) prevention for heterosexual couples⁶ to men under community supervision and their female partners. All eligible men reported substance use or substance use treatment in the past 90 days. In this randomized clinical trial, El-Bassel and colleagues⁵ compared the 5-session Protect and Connect (PACT) intervention group with a 1-session HIV counseling, testing, and referral (CTR) control group. In total, 230 couples (460 participants, of whom 341 [74.1%] were black or African American and 87 [18.9%] were Hispanic or Latino) were randomized to each group. Participants completed a behavioral questionnaire at baseline and at 3, 6, and 12 months and underwent rapid oral fluid HIV testing and nucleic acid amplification–based testing of self-collected vaginal (women) and urine (men) specimens for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis at baseline and 12 months. The primary outcomes of the trial were STI incidence over 12 months and number of acts of condomless vaginal and/or anal intercourse with the study partner, non–study partners, and all partners in the previous 90 days.

In addition to CTR, the PACT intervention addressed couples-based communication of sexual and substance use behaviors; barriers to condom use; personalized HIV risk assessment; biomedical HIV prevention options; linkage to HIV, STI, and substance abuse treatment; reproductive health; overdose response and prevention; harnessing one’s social network to support HIV risk reduction; and goal setting related to HIV/STI and overdose risk and protective behaviors. One hundred thirty-seven participants (59.6%) in the PACT intervention group attended all five 45- to 90-minute sessions, and 100% of those randomized to the CTR group completed the single session. Approximately 90% of participants returned for at least 1 follow-up assessment in both groups.

Save for a younger mean age in the PACT group, the control and intervention groups were well balanced. Seven percent of the population (32 participants) had HIV-positive results, and 16.9% (78 participants) had an STI (21 [4.6%] had chlamydia; 8 [1.7%], gonorrhea; 51 [11.1%], trichomoniasis). At 12 months, 10 new STI cases were found in the PACT group and 8 new STI diagnoses in the CTR group. No new HIV infection occurred in either group. During the entire follow-up period, compared with the CTR group, PACT participants reported 32% (95% CI, 0.45-0.99) fewer acts of condomless sex with their study partners, 70% fewer (incidence rate ratio, 0.30; 95% CI, 0.12-0.74) acts of condomless sex with non–study partners, and 40% fewer (incidence rate ratio, 0.60; 95% CI, 0.42-0.85) acts of condomless sex with all partners in the previous 90 days. Participants in the PACT group were also less likely to report drug or alcohol use during their last sexual encounter and reported fewer sexual partners in the previous 90 days. In addition, PACT participants reported more conversations with their partners about HIV prevention and higher condom use intentions and self-efficacy.

In this novel application of couple-based HIV and STI prevention to substance use–involved men under community supervision and their female partners, PACT participants reported substantial and consistent reductions in behaviors leading to HIV and STI acquisition and transmission. However, the association with STI incidence was not impressive, perhaps reflecting the modest sample size, relatively short duration of follow-up, and/or relatively few acts of condomless sex with non–study partners. It is also conceivable that additional counseling, or subsequent sessions designed to boost the outcome of the intervention, may be needed to achieve a stronger association with STI acquisition.

These results suggest that wider implementation of couple-level corrections-based behavioral interventions has the potential to reduce HIV and STI among people of color involved in the criminal justice system. The PACT intervention also addressed biomedical HIV prevention, substance use treatment, and overdose prevention. In the United States, access to these important prevention modalities is limited among women as well as black and Latino people, with low pre-exposure prophylaxis (PrEP) uptake among individuals who use drugs.^7,8 Thus, relationship-based programs to increase knowledge and use of PrEP and medication-assisted treatment will further strengthen their value to HIV in the correctional setting and will promote parity in access to these interventions.

However, behavioral HIV prevention should be viewed as part of a broader project to improve the health of people involved in the criminal justice system. Criminal justice involvement and HIV overlap with, and intensify, the epidemics of substance use, hepatitis C virus (HCV), and STI. Health care practitioners, researchers, and public health officials must advocate for access to routine, opt-out, integrated HIV, HCV, and STI screening in correctional settings, along with community standards of care that include access to condoms; PrEP; medication-assisted treatment; and treatment for HIV, STI, and HCV. With an integrated, syndemic approach, we can begin to disrupt the connection between corrections and HIV, STI, HCV, and substance use.

Published: March 29, 2019. doi:10.1001/jamanetworkopen.2019.1165

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Menza TW et al. JAMA Network Open.

Corresponding Author: Kenneth H. Mayer, MD, The Fenway Institute, Fenway Health, 1340 Boylston St, Boston, MA 02215 (kmayer@fenwayhealth.org).

Conflict of Interest Disclosures: None reported.