Incarceration and High-Risk Sexual Partnerships among Men in the United States

Introduction

Incarceration is associated with multiple and concurrent sexual partnerships, which are determinants of sexually transmitted infections (STI) and HIV. The associations between incarceration and high-risk sexual partnerships may exist, in part, because incarceration destabilizes stable sexual partnerships which are protective against high-risk sexual partnerships. We estimated associations between incarceration and high-risk partnerships among drug users and nonusers separately, to assess differences in associations by drug use and to control for confounding by drug use.

Methods

Using the 2002 National Survey of Family Growth, we conducted multivariable analyses to estimate associations between incarceration in the past year and engagement in multiple partnerships, concurrent partnerships, and unprotected sex in the past year, by status of illicit drug use (defined as use of cocaine, crack, or injection drugs in the past year), among adult men in the United States.

Results

Illicit drug users were much more likely than nonusers of drugs to have had concurrent partnerships (16% and 6%, respectively) and multiple partnerships (43% and 17%, respectively). Analyses adjusting for age, race, educational attainment, poverty status, marital status, cohabitation status, and age at first sex indicated that, among nonusers of illicit drugs, incarceration in the past year (yes versus no) was associated with concurrent partnerships (adjusted prevalence ratio (aPR): 1.64, 95% confidence interval (CI): 1.17-2.30), multiple partnerships (aPR: 1.52, 95% CI: 1.31-1.76), and unprotected sex with multiple partners (aPR: 1.89, 95% CI: 1.28-2.80). The associations between incarceration and concurrency were comparable among illicit drug users and nonusers of illicit drugs. Among illicit drug users, those who were recently incarcerated had higher levels of concurrent partnerships than those with no recent incarceration history (aPR: 2.14, 95% CI: 1.21-3.79). The associations between incarceration and multiple partnerships and unprotected sex were significantly weaker among illicit drug users than nonusers of illicit drugs. Among illicit drug users, incarceration was not associated with multiple partnerships (aPR: 1.07, 95% CI: 0.83-1.40) or unprotected sex with multiple partners (aPR: 0.70, 95% CI: 0.39-1.26); these risk behaviors were common irrespective of incarceration history.

Discussion

Incarceration was associated with high-risk partnerships in both users and nonusers of illicit drugs. Men with illicit drug use and incarceration histories may experience particular vulnerability to STI/HIV, as a result of having disproportionate levels of concurrent partnerships and high levels of unprotected sex. We hypothesize that incarceration works with drug use and other adverse social and economic factors, which reciprocally contribute to one another and work in tandem to increase sexual risk behaviors. To establish whether incarceration is causally associated with high-risk sexual partnerships and acquisition of STI/HIV, a longitudinal study should be conducted that accurately measures incarceration, STI/HIV, and illicit drug use to disentangle the specific effects of each variable of interest on risk behavior and STI/HIV acquisition. These findings support the need for correctional facility- and community-based STI/HIV prevention efforts targeting current and former prisoners, including STI/HIV prevention education and STI/HIV testing and care.