Among its many positive characteristics, the United States holds two unfortunate and reciprocal distinctions. America has the largest incarcerated population of any other nation in the world and has the highest rate of AIDS diagnosis (second highest rate of HIV infection) of any other industrialized nation. While the annual rate of new HIV infections in the United States has remained stubbornly high -- approximately 50,000 per year -- the number of adults under federal, state or local supervision has more than quadrupled since 1980 from 1.8 million to 7.1 million in 2010. Despite comprising only 5 percent of the global population, the U.S. accounts for 25 percent of all the world's incarcerations.
To mark National Black HIV/AIDS Awareness Day, the National Minority AIDS Council has released a new report with Housing Works titled "Mass Incarceration, Housing Instability and HIV/AIDS." Over the last three decades the epidemics of mass incarceration and HIV/AIDS have become increasingly concentrated among economically disadvantaged people of color, especially African Americans. African Americans make up only 13 percent of America's population, but account for 44 percent of new HIV infections and almost half of all AIDS diagnoses, with Black gay men facing the heaviest HIV burden of any population in the country. At the same time, despite similar rates of criminal conduct, African American males are more than six times as likely to be incarcerated as their White counterparts.
These disturbing trends are inextricably linked, with mass incarceration playing a major role in driving the domestic HIV/AIDS epidemic. Each year an estimated 22-28 percent of Black men living with HIV pass through a correctional facility. And while it is often assumed that risk behavior and exposure to HIV while in prison explains this link, evidence actually suggests that the greatest risk for individuals and their communities occurs during the periods just before and after a prison stay. This is because incarceration is a significant risk factor for both homelessness and housing instability. Indeed, evidence is mounting that housing status is a significant predictor of HIV treatment effectiveness and risk behaviors.
Access to safe, affordable housing has been a consistent concern for Americans living with HIV or AIDS since the beginning of the epidemic. Loss of income, poor health, interruption of intimate relationships, and pre-existing social disadvantages combine to make it difficult or impossible for many people living with HIV to secure or maintain adequate housing. A history of incarceration only exacerbates these pressures. In fact, a recent multi-site study of HIV-positive men entering jail found that 43 percent of those newly diagnosed with HIV infection and 44 percent of those previously diagnosed were homeless at the time they were jailed. Another study 1 from Connecticut found that 26 percent of recently discharged prisoners were homeless, with an additional 54 percent near homeless.
From a moral standpoint, this is reprehensible. From an economic and public health perspective, it is insanity. High rates of incarceration and related economic and social marginalization fuel the increasing burden of HIV and other chronic diseases among low income communities of color, devastating not only the health of the individual, but also the health of the entire community. We must engage in a serious discussion about our culture of mass incarceration, including our sentencing of non-violent offenders to lengthy prison terms. For those who are incarcerated, housing assistance and medical care must be provided upon their release. Further, given the stigma and discrimination experienced by formerly incarcerated individuals, community-based supports are essential to help them navigate the health system and access services that will enable them to avoid recidivism.
Recognizing recent advancements in medical science and health policy, including treatment as prevention and the Affordable Care Act, Hillary Clinton outlined a vision of an AIDS-free generation in 2011. While expanding health care coverage will significantly improve our ability to combat the spread of HIV and improve health outcomes for those already living with the disease, it will not bring an end to the epidemic on its own. Our nation must tackle the social inequities that persist in our culture if we are to truly realize that vision. Tackling the epidemics of homelessness and incarceration must be at the forefront of that effort.
1. Saber-Tehrani, A.S., Springer, S.A., Qiu, J., Herme, M., Wickersham, J., Altice, F.L. (2012). Rationale, study design and sample characteristics of a randomized controlled trial of directly administered antiretroviral therapy for HIV-infected prisoners transitioning to the community - A potential conduit to improved HIV treatment outcomes. Contemporary Clinical Trials, 33(2): 436-44.