Behavioral, Structural Vulnerabilities in Women With HIV Identified After Recent Incarceration

Recently incarcerated women who are using heroin had an increased incidence of behaviors that put them at risk for both HIV and adverse HIV outcomes, according to a study published in JAMA Network Open.¹ Stopping HIV care was also prevalent in women who were incarcerated and using heroin.

Drug-related offenses are a primary reason for incarceration throughout the globe, with approximately 35% of the global population in prison being indicted on offenses related to drugs. People who use drugs in jail are often at increased risk of complications, including death, both while they are in jail and when they are released.² Women who use heroin may be at an increased risk of vulnerability, as criminalization of heroin and prevalence of HIV are both high. This study aimed to identify factors of recent incarceration in women who use heroin in Tanzania, characterize their history of incarceration, and estimate the association between adverse outcomes of HIV and drug use and incarceration.¹

Recently incarcerated women using heroin had increased prevalence of behaviors that put them at risk of HIV | Image credit: methaphum - stock.adobe.com

Women who used heroin from November 2018 to February 2019 were included in the cross-sectional survey. Women who were 18 years or older, lived in Dar es Salaam, and reported use of heroin in the previous 30 days were eligible. All women self-reported their history of incarceration, including their reason for arrest and the number of arrests in the previous 6 months. All women were asked if they had undergone testing for HIV in the previous 6 months and their HIV status as the primary outcomes. Secondary outcomes were HIV care status and sexual concurrency.

There were 195 women who used heroin who were included in the study and whose median (IQR) age was 33 (27-39) years. Using drugs was the most common reason for arrest (51.5%) and 61.0% had been incarcerated in the past 6 months.

Women who used heroin and were recently incarcerated were more likely to use heroin for at least 10 years (26.9%) and report homelessness (43.2%) compared with women who used heroin with no recent history of incarceration. Women who used heroin and were recently incarcerated were also more likely to report a history of transactional sex. A total of 87.4% of women who used heroin and were recently incarcerated reported symptoms of anxiety that were moderate or severe.

Higher sexual concurrency was associated with recent incarceration (adjusted prevalence ratio [aPR], 1.43; 95% CI, 1.16-1.78). The women who were using heroin and had HIV had 9 times the prevalence of HIV care interruptions (aPR, 9.74; 95% CI, 1.22-77.22). Stimulant use within the previous 6 months (aPR, 5.60; 95% CI, 1.63-19.28) and a higher prevalence of lifetime nonfatal overdose (aPR, 1.62; 95% CI, 1.01-2.61) were also associated with incarceration.

There were some limitations to this study. These findings may not apply to women who used heroin in other settings. Causal associations could not be evaluated due to the cross-sectional design of the study. Information bias is possible due to the self-reported data. The study from which the secondary analysis was conducted was not originally meant to assess incarceration.

"Women who use drugs are highly vulnerable, not only to drug use-related problems, but also to HIV and other infections. Our study is one of the first to examine how incarceration intersects with drug use to put these women at even greater risk," said Kaitlyn Atkins, PhD, MPH, co-author of the study. "Our findings show that, in the Tanzanian context where drug use is criminalized, women who have been incarcerated report increased risks related to sexual behavior, violence, mental health, and disengagement from health care."

The researchers concluded that the elevated use of stimulants and concurrent partnerships in women using heroin who were incarcerated could increase the risk of HIV in these women both during and after incarceration. "Policy reforms and new collaborations between public health, law enforcement, and legal experts are needed to ensure better protections for these women," Atkins said.

References

1. Atkins K, Walkder D, Noon K, et al. Recent incarceration and HIV risk among women who use heroin. JAMA Netw Open. 2025;8(1):e2454455. doi:10.1001/jamanetworkopen.2024.54455
2. Criminal justice drugfacts. National Institute on Drug Abuse. June 2020. Accessed January 14, 2025. https://nida.nih.gov/publications/drugfacts/criminal-justice