Female sex workers (FSWs) and
female prisoners experience elevated HIV prevalence relative to the general
population because of unprotected sex and unsafe drug use practices, but the
antecedents of these behaviors are often structural in nature. We review the
literature on HIV risk environments for FSWs and female prisoners, highlighting
similarities and differences in the physical, social, economic, and
policy/legal environments that need to be understood to optimize HIV
prevention, treatment, and policy responses. Sex work venues, mobility, gender
norms, stigma, debt, and the laws and policies governing sex work are important
influences in the HIV risk environment among FSWs, affecting their exposure to
violence and ability to practice safer sex and safer drug use behaviors. Female
prisoners are much more likely to have a drug problem than do male prisoners
and have higher HIV prevalence, yet are much less likely to have access to HIV
prevention and treatment and access to drug treatment in prison. Women who
trade sex or are imprisoned and engage in substance use should not be
considered in separate silos because sex workers have high rates of
incarceration and many female prisoners have a history of sex work. Repeated
cycles of arrest, incarceration, and release can be socially and economically
destabilizing for women, exacerbating their HIV risk. This dynamic interplay
requires a multisectoral approach to HIV prevention and treatment that
appreciates and respects that not all women are willing, able, or want to stop
sex work or drug use. Women who engage in sex work, use drugs, or are
imprisoned come from all communities and deserve sustained access to HIV
prevention and treatment for substance use and HIV, helping them and their
families to lead healthy and satisfying lives...
Although female prisoners are much more likely than male
prisoners to have a drug problem, they are much less likely than men to have
access to drug treatment in prison. For example, in Iran, methadone maintenance
was available in men’s prisons long before it was available in women’s prisons.
At a minimum, full access to free evidence-based drug and alcohol treatment
should be offered to all women who need it, both inside and outside prison.
Alternatives to incarceration for drug-involved women are also needed. Because
most women are in prison for nonviolent offenses and pose no risk to the
public, we call on all governments to grant amnesty to women imprisoned on drug
possession offenses. Serious attention should be paid to development and
implementation of noncustodial sentences for women, particularly during
pregnancy and when they have young children.
Given the complex HIV/STI prevention needs of drug-involved
FSWs and incarcerated women, a broad set of gender-specific HIV/STI prevention
tools for this population need to be identified, developed, and implemented, as Figure 1 suggests.
Although some interventions for FSWs who are drug or alcohol dependent have
been developed,60,61 there are few
evidence-based HIV/STI prevention interventions for incarcerated women or those
under community supervision. An example is Project POWER, which is a behavioral
intervention aimed to reduce risk of acquiring or transmitting HIV and STIs
among incarcerated women returning to their communities.62 POWER was adapted based
on formative research with prison staff and administration, incarcerated and
previously incarcerated women, and community advisory boards. A randomized
trial using this adaptation with 521 women in 2 North Carolina correctional
facilities showed that POWER participants had significantly less occasions of
unprotected sex with both main and casual male partners. POWER participants
also reported significantly fewer barriers to using condoms and greater HIV
knowledge, health-protective communication, and tangible social support.
However, the intervention had no significant effects on incident STIs.63
Because of the high rates of serious mental illness along
with substance use disorders in incarcerated women49 who rarely receive
treatment for these conditions, there is a need for targeted attention to the
chronic medical, psychiatric, and drug treatment needs of women at risk for
incarceration, in jail and after release. Lessons can be learned from a
successful pilot project treating major depressive disorders in prison settings
conducted in Rhode Island, USA, where of the 25 study participants, 72% were
free of all depressive disorders after treatment...64
Below: HIV risk environment and opportunities for intervention and prevention among FSWs and prisoners.
By: Steffanie A. Strathdee, PhD,* Brooke S. West, PhD,* Elizabeth Reed, ScD,* Babak Moazan, BSc,† Tasnim Azim, MBBS, PhD,‡ and Kate Dolan, PhD§
*Department of Medicine, University of
California San Diego, La Jolla, CA
†Non-Communicable Diseases Research Center,
Endocrinology and Metabolism Population Sciences Institute, Tehran University
of Medical Sciences, Tehran, Iran
‡Centre for HIV/AIDS, ICDDR, B, Dhaka,
Bangladesh
§Program of International Research and
Training, National Drug and Alcohol Research Centre, University of New South
Wales, Sydney, Australia
Correspondence to: Steffanie A. Strathdee, PhD, Department
of Medicine, University of California San Diego, 9500 Gilman Drive, Mailstop
0507, La Jolla, CA 92093, ude.dscu@eedhtartss
