To Understand Challenges Black Men With HIV Face on Re-Entry From Prisons, an Intersectional Approach Is Needed, Study Shows

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There are multiple reasons why re-entry into communities from prison for black men with HIV is a difficult proposition, according to a recent study published in Social Science and Medicine. The researchers show that the intersectionality framework is applicable to understanding the challenges these men face after serving time in prison.

Researchers from the University of Wisconsin-Madison and Emory University conducted qualitative interviews with 16 HIV-positive black men imprisoned in different Wisconsin Department of Corrections facilities. Two interviews were conducted with study participants: one prior to release and one six months following release.

The study findings surfaced seven themes that explain the challenges: intersectional identities and social positions, family support, neighborhood violence, relationship with law enforcement, employment, mental health concerns, and medical care and medication management. To put a finer point on it, a black man released from a Wisconsin detention center living with HIV, a criminal record, and a history of substance use may face barriers to employment and housing, as well as in navigating general society amidst racism, homophobia, and institutional stigma against HIV-positive persons and drug users. These intersectional themes can affect health outcomes from medication adherence to feelings of self-worth and community connectedness.

"Using an intersectional perspective allowed us to provide the reader with a deeper understanding of their experience," said Natasha Crooks, Ph.D., RN, of Emory University, one of the study's four authors.

This "intersectionality" framework -- a concept coined by black feminist legal scholar Kimberlé Crenshaw in 1989 -- provides a mechanism for analyzing multiple systems of oppression and how they affect a person's life. Crenshaw's critical analysis was first applied to legal case in which a black woman filed for race and gender discrimination in the workplace. The judge dismissed her case because white women and black men were working at the same company, thus, neither of her legal claims was found to have standing. In analyzing the case, Crenshaw wrote that black women's experiences with oppression in America are "intersectional" in that racism and sexism occur concurrently for them and cannot be isolated from one another. In recent years, the term "intersectionality" has gained more attention within academic and activist spaces.

Researchers in this study sought to apply this framework to the re-entry experiences of black men with HIV. Improving re-entry outcomes can be challenging without a multi-pronged approach that considers various intersecting identities and needs. Using the intersectional lens, the need arises for, as the researchers write, "an in-depth understanding of the interactive, systemic, and dynamic nature" of HIV care, treatment, and prevention for vulnerable populations.

Factors that lead to incarceration often do not disappear upon release. In addition, the stigma of being labeled a "criminal" or a "convicted felon" can carry ramifications that affect employment opportunities, the right to vote, participation in jury selection, eligibility for financial aid and credit, and the ability to live in public housing. HIV stigma and fears of being re-imprisoned due to HIV criminalization further complicate disclosure of status, social support, and engagement in medical care. The need for HIV care, as well as to find transportation and access to care, add to the list of challenges.

The U.S. leads the developed world in having the largest prison population. At the end of 2016, the Bureau of Justice Statistics estimated that 2.2 million people were locked up in the U.S., including 1.5 million in federal and state prisons and close to 741,000 in locally run jails. Another four million people were under supervision, either on parole or probation. Black males are incarcerated at disproportionate rates. Though black males made up only 12% of the adult U.S. population in 2016, they represented 33% of the individuals behind bars.

Wisconsin has the highest incarceration rate of black men in the country. According to the 2010 U.S. Census, it had an incarceration rate of nearly 13% for black men -- close to double the national average and three percentage points higher than the second-ranked state, Oklahoma. About 43% of all men in Wisconsin's prisons are black.

"[W]hile the overall HIV prevalence in Wisconsin is at or near the national rate, the degree of racial disparities in HIV diagnoses is dramatic," said Ryan Westergaard, M.D., Ph.D., M.P.H., with the University of Wisconsin-Madison and one of the study's authors. "So, while we don't think of Wisconsin as a region of high disease burden similar to the U.S. South, the severity of health disparities make it an important context to study these issues," he added.

Westergaard said that HIV risk often corresponds with various forms of social and economic disadvantage. Wisconsin's largest city, Milwaukee, has a great deal of concentrated urban poverty and is often named the most racially segregated city in the nation.

Related: This Week in HIV Research: The Yawning Post-Prison Care Gap

Blacks make up roughly 6.7% of Wisconsin's population, yet they make up 36.8% of people living with HIV in that state. The rate of black males living with an HIV diagnosis in Wisconsin is 10.2 times that of white males, according to 2015 surveillance reports.

"The stories shared by participants in this study showed how these vulnerabilities take distinct forms, which may operate in unique, but overlapping ways," Westergaard said. "The challenges associated with re-entry, including homelessness [and] joblessness can really compound the other barriers encountered by people living with HIV when they try to remain engaged in care, which might include HIV stigma, institutionalized racism, and homophobia."

Linkage to care, in addition to strong interpersonal relationships with family, friends, and community, is paramount for a successful re-entry process. Viral suppression is possible but can be a challenge when navigating an ever-changing health care system outside prison.

"One of our most exciting findings was that specific programs and policies designed for vulnerable populations could function as social community support," Crooks said. "Our participants that were in linkage to care programs noted the value in developing a supportive relationship with their parole officers or even the study coordinator who facilitated the interviews for this study. They described feeling like they had 'someone who cared about them.'"

"We have found that a key ingredient is the 'warm handoff,'" said Westergaard.

For instance, Westergaard advocates that the clinic case manager who works with patients while they are incarcerated helps prepare for the release date, facilitates an appointment being made at a community-based clinic within a week, and communicates the transitional care plan to the receiving clinic.

"In our Madison clinic, similar to all Ryan White-funded HIV programs, we have a team of medical case managers who help support patients' social service needs, but we have designated one case manager who specifically focuses on the transitions of care for incarcerated patients who are preparing to be released," he said.

Westergaard suggests that one strategy for community-based organizations could be hosting a "re-entry fair." In Madison each month, several community-based organizations host a fair for people getting back on their feet after being incarcerated, featuring topics such as housing, employment assistance, or access to health care.

"Raising awareness that there are people in our community who need extra help with these issues and connecting them to service providers and volunteers willing to lend a hand seems like a productive strategy," he said.

HIV stigma -- sometimes in tandem with sexual orientation -- poses potential barriers to re-entry for gay or bisexual black men leaving prison. Black gay and bisexual men seemed to fear that disclosing their HIV status would compound their level of isolation and lack of social support from family members after release.

"Many of the participants that self-identified as gay or bisexual described that their families were unaware of their HIV status," said Crooks. "Many of the participants did not disclose this information to their families as they felt like their HIV status would become the central focus of who they were, as opposed that just being one aspect of their identity. They also feared that the social support of their families would go away if they disclosed their HIV status, and many did not want to take the risk."

People living with HIV and returning from prison face many intersectional obstacles that researchers, providers, and community-based organizations should consider for future research -- and when designing interventions.

The University of Wisconsin-Madison researchers have announced that the School of Medicine will offer a course in fall 2018 on how best to provide care to former prisoners as they struggle to re-enter their communities.