"They Just Don't Care": Justice-Involved Women, HIV Prevention, and the Death of Hope

Introduction: Women prisoners are up to 15 times more likely to be HIV+ than women in the general population (De Groot & Uvin, 2005). Incarcerated women have multiple HIV risk factors both before and after imprisonment, including: sex work, drug/alcohol addiction, physical, emotional and sexual abuse (DeGroot & Maddow, 2006). Incarceration provides an opportunity to deliver risk-reduction interventions tailored to women. HIV prevention activities in prisons are limited and few focus on the needs/challenges of women (Epperson et al, 2009). Given their high HIV risk, it is crucial that HIV prevention interventions be provided and tailored to justice-involved women. This formative qualitative study examines this issue by listening directly to the voices of formerly incarcerated women. Through semi-structured interviews we explored their views on HIV risks contexts unique to women with recent incarceration. Findings will be used to inform future HIV risk reduction interventions for justice-involved women.

Method: Qualitative semi-structured interviews were conducted with 28 formerly incarcerated women. Inclusion criteria: >age 18, English-speaking, HIV- status, recent heterosexual activity. Mean age =36.6(SD:8.28), 60%Caucasian, 36%Black, 4%Hispanic. Women were questioned in three domains: risks of contracting HIV for themselves/other women; why women engage in HIV risk behaviors; and how/when women protect themselves from contracting HIV. Interviews, lasting 60-120 minutes, were conducted and taped by trained research assistants. Two investigators independently coded transcripts with Nvivo7 using open coding, compared codes, came to consensus on code definition/use, and iteratively recoded. Codes were organized into categories and themes by investigators, using field notes, data review, and discussion to build consensus (Padgett, 1998).

Results: Three themes of particular interest emerged. Risk Depersonalization: Women expressed concern for HIV-infection risk among their family/friends; few expressed concern for their own risk. Many distanced themselves from ideas of risk and said they protected themselves, yet later in the interview described ongoing risky sexual activities. Relationship Ambivalence: Many women expressed frustration with men, describing partner concurrency and condom refusal, but stated they did not use condoms because they were in long-term relationships. Interestingly, many of these women qualified confidence in their partner's fidelity with laughter and ambivalent statements such as “at least I hope so.” Loss of Hope: The most striking theme involved why women engaged in HIV-risk behaviors. Women described a number of reasons: addiction, abuse, low self-esteem, difficulty finding work and housing post-incarceration, weaving these elements into a larger picture where women are trapped, have given up, “just don't care anymore” and see no hope and no reason for self-protection.

Conclusions: HIV prevention interventions for justice-involved women should move beyond education on condom use and safer sex mechanics, focusing on dynamic and contextual issues that promote women's HIV-risk behaviors. This includes addressing denial/ambivalence about risk and relationships and the need for condom use with long-term partners. Most important is the need to address the hopelessness women experience when caught in the nexus of addiction, abuse, poor self-esteem and community/policy barriers to employment and safe housing, which result in a sense of failure and loss of motivation for self-care.