Transcript Prevalence and Correlates of HIV Risk Behaviors of Inmates

Prevalence and Correlates of HIV
Risk Behaviors of Inmates in a
State Prison System
Titilayo Abiona, MD, FMCPH
HIV/AIDS Research and Policy Institute
05/15/2008
College Retreat 2008
Background
• Higher HIV/AIDS rates among inmates vs.
general population
• HIV prevalence between 4 & 10x higher
among inmates than in the general
population
• Inmates engage in risk behaviors before,
during & after incarceration
• What is the exact mechanism linking
incarceration with HIV infection?
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Conceptual Model
4.
HIV transmission
occurs
from infected inmates
to uninfected partners
and vice versa
-Risk Behaviors
3.
HIV infected and
uninfected
inmates released
into the community
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1.
HIV infected and
uninfected
persons in the
community go to
prison
-Risk Behaviors
2.
Some inmates get HIV
in prison
-Risk Behaviors
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Overall Aim of the
HIV/Incarceration Study
• Examine the plausible links between
incarceration and HIV infection
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Specific Objectives
• Describe pre-incarceration risk behaviors
of inmates
• Identify and quantify the prevalence of risk
behaviors during incarceration
• Determine the sociodemographic
correlates of risk behaviors during
incarceration
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Methods
• Study Location
– 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
– based on
• estimate of condom use rate among adults in the US =36%
• 95% CI
• maximum acceptable difference from true proportion = 3%
– A minimum sample size of 1025 was calculated
– Over-sampling done to adjust for non-participation
– 2,000 inmates finally selected
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Methods
• Sampling Technique
– Multi-stage sampling technique
– 1st stage, correctional facilities in Illinois stratified by
level of security into maximum, medium, and
minimum
– 2nd stage, 17 facilities randomly selected. 15 male, 2
female.
– 3rd stage, random selection of participants from
current inmate lists provided by the Illinois
Department of Corrections (IDOC)
– Actual number of inmates selected from each prison
depended on the overall number of inmates in the
prison
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Methods
• Data Collection Method
– Questionnaire
• Questionnaire
– Structured
– Sections:
• Demographic information
• Incarceration history
• Lifetime behaviors and within 6 months before incarceration
– Sexual Behavior, Injection Drug use, Needle Sharing,
Tattooing, Body Piercing
• Behaviors during incarceration
– Sexual Behavior, Injection Drug use, Needle Sharing,
Tattooing, Body Piercing
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Methods
• Questionnaire cont’d
– Items written in simple English = 6th grade reading
level.
– Test-retest reliability of questions established with the
Pearson’s product moment correlation coefficient, r
•
•
•
•
•
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0.71 (p=0.001) - drug use
0.78 (p <0.001) - tattooing
0.79 (p=0.03) - body piercing
0.74 for questions - sexual behavior
Cronbach’s alpha (KR-20) for internal consistency = 0.0803
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Methods
• Data Analysis
– Statistical Package for Social Sciences (SPSS) 15
– Frequencies and percentages of demographic data
and HIV risk behaviors
– Multivariate logistic regression analysis to assess
predictors of having sexual intercourse in prison.
• Significant variables in the unadjusted analysis entered into
multivariate logistic regression model
• Adjusted odds ratios (AOR) and 95% confidence intervals
(CI) were calculated
• p-value < 0.05 accepted for statistical significance
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Methods
• Ethical Considerations
– Approved by the CSU Institutional Review Board
(IRB)
– Confidentiality ensured by:
• No personal identifying information on questionnaire
• Facilities identified using codes
• Survey information not shared with prison staff, law
enforcement or court systems
• Questionnaires locked in a file cabinet at the Institute and will
be destroyed after five years
• Only the Principal Investigators and authorized study
personnel had access to the data
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Results and Discussion
• 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
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Table 1: Sociodemographic Characteristics of Participants
Characteristic
Women,% n=526
Men, % n=1293
P-Value
Mean Age (SD)
36.4 (9.7)
35.4 (10.1)
0.05
Marital Status
Never Married
Married/Cohabiting
Previously Married
50.1
21.9
28.0
56.1
19.7
24.2
0.07
Ethnicity
White
African American
Hispanic/Latino
Other (Native Americans etc)
39.1
51.3
4.6
5.0
26.6
57.2
11.0
5.2
No. of Times Incarcerated
1-3
4-6
7 and more
85.2
12.8
2.0
77.6
17.3
5.1
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<0.001
<0.001
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Table 1: Sociodemographic Characteristics of Participants Cont’d
Characteristic
Women,%
n=526
Men, %
n=1293
No. of Years Spent in Prison
during Current Sentence
<1
1-3
4-6
7 or more
40.1
30.9
10.8
18.2
20.9
29.8
16.7
32.0
Ever Had HIV Testing
Yes
No
91.1
8.9
84.5
15.5
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P-Value
<0.001
<0.001
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Table 2: Pre-Incarceration Risk Behaviors
Behavior
Sample
Size
Frequency
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 781
the 6 months before arrest
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 nonprofessional artist
878
364
41.4
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Figure 1: % of Respondents reporting Multiple Vaginal Sexual Partners
in the 6 Months before Arrest (n= 1762)
Percentage
50
42.4
34
40
30
23.9
24.4
24
17.1
20
10
0
2-3 Partners
Male
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>3 Partners
Female
Overall
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Figure 2: % of Respondents reporting Multiple Anal Sexual Partners in
the 6 Months before Arrest (n= 1762)
Percentage
20
15
11.1
10.6
10
9.7
9.1
10
4.6
5
0
2-3 Partners
Male
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> 3 Partners
Female
Overall
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Figure 3: % of Respondents who never/rarely used Condoms in the 6
Months before Arrest
100
80
64.8
69.6
70.8
69.7
66
70
60
40
20
0
Vaginal Sex
Male
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Anal Sex
Female
Overall
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Figure 4: % of Respondents who did not use Condoms during last
Sexual Intercourse
Percentage
100
79.7
82.2
80.4
82.4
76.3
78.1
80
60
40
20
0
Vaginal Sex
Male
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Anal Sex
Female
Overall
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Figure 5: % of Respondents who had ever Injected Drugs
Percentage
25
20.5
20
14.6
15
12.1
10
5
0
Male
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Female
Overall
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Figure 6: Injection Drug Use among Ever Users in the Six Months
before Arrest
Percentage
70
60
53.7
56.6
54.9
50
40
30
20
10
0
Male
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Female
Overall
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Figure 7: % of Injection Drug Users who had ever Shared
Needles
Percentage
70
59.1
55.7
50.9
60
50
40
30
20
10
0
Male
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Female
Overall
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Figure 8: Needle Sharing in the 6 Months before Arrest among
Respondents who had ever Shared Needles
Percentage
60
50
48.1
44.3
45.8
40
30
20
10
0
Male
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Female
Overall
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Figure 9 % of Respondents who obtained Tattoos and Body Piercing
from non-professional artists
Percentage
100
77
80
72.6
62.3
48.1
60
41.4
32.2
40
20
0
Tattoo
Male
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Body Piercing
Female
Overall
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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)
Vaginal
41.8
Oral
54.4
Anal
14.6
0
10
20
30
40
50
60
Percentage
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Figure 11: Context of Sexual Intercourse during Incarceration (n=158)
Consensual
93%
Forced
7%
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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 Security
Maximum
Medium
Minimum
21/327 (6.4)
39/911 (4.3)
89/554 (16.1)
1
0.65 (0.38-1.13)
2.79 (1.70-4.58)
1
0.59 (0.28-1.22)
0.99 (0.41-2.37)
No. of Years spent in Prison During Current Incarceration
<1
1 or more
11/475 (2.3)
138/1306 (10.6)
1
4.98 (2.67-9.29)
1
10.54 (3.63-10.65)
No. of Times Incarcerated
1-3
4 or more
135/1370 (9.9)
9/348 (2.6)
1
0.24 (0.12-0.48)
1
0.39 (0.17-0.90)
Gender
Female
Male
90/521 (17.3)
56/1250 (4.5)
1
0.23 (0.16-0.32)
1
0.44 (0.21-0.95)
Ethnicity
White
African American
Hispanic/Latino
Others- Native Americans, Asian Americans etc.
46/533 (8.6)
86/973 (8.8)
8/164 (4.9)
9/92 (9.8)
1
1.03 (0.71-1.49)
0.54 (0.25-1.18)
1.15 (0.54-2.43)
Bold Figures: 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 Status
Never Married
Married/Living with someone as Married
Previously Married
96/957 (10.0)
23/364 (6.3)
28/452 (6.2)
1
0.61 (0.38-0.97)
0.59 (0.38-0.92)
1
0.52 (0.23-1.15)
0.77 (0.40-1.48)
Sexual Orientation
Heterosexual
Bisexual
Gay/Lesbian
61/1368 (4.5)
62/161 (38.5)
19/51 (37.3)
1
13.42 (8.92-20.18)
12.72 (6.82-23.72)
1
9.58 (4.68-19.61)
4.60 (1.59-13.32)
Age
<40
40 or more
108/1164 (9.3)
39/579 (6.7)
1
0.71 (0.48-1.03)
Got Tattoos in Prison
No
Yes
57/915 (6.2)
51/300 (17.0)
1
3.13 (2.04-4.55)
1
3.68 (2.13-6.35)
Bold Figures: p<0.05
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Conclusions
• Inmates engage in risk behaviors before
and during incarceration
• Length of stay in prison, sexual orientation
and receiving a tattoo in prison were
associated with risk behaviors in prison
• Findings support both the importation and
deprivation models of inmate behavior
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Recommendations
• HIV prevention intervention should be
commenced as soon as possible after
incarceration
• Recreational activities should be provided
for inmates
• Condom use policy in prison needs 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
• Risk Behaviors of Partners of Inmates
• Prospective Study of Risk Behaviors and
HIV transmission in Prison
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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 ScottWilliams, 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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