1. 1 Prevalence and Correlates of HIV Risk Behaviors of Inmates in a State Prison System Titilayo Abiona, MD, FMCPH Adedeji Adefuye, MD, MPH, FRIPH Joseph Balogun, PT, PhD, FACSM Patricia Sloan, EdD, RN, FAAN College of Health Sciences, Chicago State University

2. 2 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?

3. 3 Conceptual Model 1. 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

4. 4 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

5. 5 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

6. 6 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

7. 7 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

8. 8 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

9. 9 Table 1: Socio-demographic Characteristics of Participants CharacteristicWomen,% n=526Men, % n=1293P-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 <0.001 No. of Times Incarcerated 1-3 4-6 7 and more 85.2 12.8 2.0 77.6 17.3 5.1 <0.001

10. 10 Table 1: Sociodemographic Characteristics of Participants Cont’d CharacteristicWomen,% n=526 Men, % n=1293 P-Value 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 <0.001 Ever Had HIV Testing Yes No 91.1 8.9 84.5 15.5 <0.001

11. 11 Table 2: Pre-Incarceration Risk Behaviors BehaviorSample Size FrequencyPercentage 2 or more Vaginal Partners in the 6 months before arrest 1762103758.9 2 or more Anal Partners in the 6 months before arrest 174133319.1 Never/Rarely Used Condoms for Vaginal Sex in the 6 months before arrest 1653109766.4 Never/Rarely Used Condoms for Anal Sex in the 6 months before arrest 78154770.0 Ever Injected Drugs174025514.7 Ever Shared Needles25514255.7 Obtained Tattoo from non-professional artist110079972.6 Obtained Body Piercing from non-professional artist 87836441.4

12. 12 Figure 1: % of Respondents who never/rarely used Condoms in the 6 Months before Arrest P < 0.05

13. 13 Figure 2: % of Respondents who did not use Condoms during last Sexual Intercourse Percentage

14. 14 Figure 5: % of Respondents who had ever Injected Drugs Percentage

15. 15 Figure 9 % of Respondents who obtained Tattoos and Body Piercing from non-professional artists Percentage

16. 16 Table 3: Risk Behaviors during Incarceration BehaviorSample SizeFrequencyPercentage Sexual Intercourse17831588.9 Injection Drug Use1754150.9 Needle Sharing1754100.6 Tattooing177729516.6 Body Piercing1766241.4

17. 17 Figure 10: Types of Sexual Intercourse during Incarceration (n=158) Percentage

18. 18 Figure 11: Context of Sexual Intercourse during Incarceration (n=158)

19. 19 Table 4: Characteristics and Behaviors Associated with Sexual Intercourse during Incarceration CharacteristicFrequency (%)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) 1.02 (1.70-4.58) 1 0.60 (0.29-1.24) 0.90 (0.37-2.16) 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 10.57 (3.60-31.04) 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 0.36 (0.16-0.79) Gender Female Male 90/521 (17.3) 56/1250 (4.5) 1 0.23 (0.16-0.32) 1 0.47 (0.21-1.03) 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) 1 1.26 (0.70-2.27) 0.59 (0.20-1.75) 1.59 (0.52-4.84) P < 0.001; P <0.05

20. 20 Table 4: Characteristics and Behaviors Associated with Sexual Intercourse during Incarceration Cont’d CharacteristicFrequency (%)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 0.53 (0.23-1.20) 0.74 (0.37-1.48) 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 11.84 (5.73-24.47) 6.72 (2.32-19.40) Age <40 40 or more 108/1164 (9.3) 39/579 (6.7) 1 0.71 (0.48-1.03) 1 1.25 (0.66-2.39) Got Tattoos in Prison No Yes 57/915 (6.2) 51/300 (17.0) 1 3.13 (2.04-4.55) 1 3.83 (2.20-6.65) P < 0.001

21. 21 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

22. 22 Recommendations HIV prevention interventions should be commenced as soon as possible after incarceration Current policies about risk reduction mechanisms in prison need review

23. 23 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.

24. 24 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

25. 25 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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