Women & Health, 54:694–711, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0363-0242 print/1541-0331 online DOI: 10.1080/03630242.2014.932888

Context of Risk for HIV and Sexually Transmitted Infections Among Incarcerated Women in the South: Individual, Interpersonal, and Societal Factors CATHERINE I. FOGEL, PhD, RNC (WHCNP), FAAN School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA

DEBORAH J. GELAUDE, MA, MONIQUE CARRY, PhD, and JEFFREY H. HERBST, PhD Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA

SHARON PARKER, PhD, MSW, MS, ANNA SCHEYETTE, PhD, MSW, LCSW, and A. NEEVEL, BA School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA

Incarcerated women are disproportionately affected by HIV and sexually transmitted infections (STIs) due to risk factors before, during, and after imprisonment. This study assessed the behavioral, social, and contextual conditions that contribute to continuing sexual risk behaviors among incarcerated women to inform the adaptation of an evidenced-based behavioral intervention for this population. Individual, in-depth interviews were conducted with 25 current and 28 former women prisoners to assess HIV/STI knowledge, perceptions of risk, intimate relationships, and life circumstances. Interviews were independently coded using an iterative process and analyzed using established qualitative analytic methods. Major themes identified in the interviews involved three Received May 7, 2013; revised July 16, 2013; accepted August 13, 2013. Address correspondence to Catherine I. Fogel, PhD, RNC (WHCNP), FAAN, School of Nursing, The University of North Carolina at Chapel Hill, Carrington Hall, CB #7460, Chapel Hill, NC 27599-7460. E-mail: [email protected] Color versions of one or more of the figures in the article can be found online at www. tandfonline.com/wwah. 694

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focal points: individual risk (substance abuse, emotional need, self-worth, perceptions of risk, and safer sex practices); interpersonal risk (partner pressure, betrayal, and violence); and risk environment (economic self-sufficiency and preparation for reentry). These findings highlight the critical components of HIV/STI prevention interventions for incarcerated women. KEYWORDS women prisoners, HIV/STI prevention, sexual risk, substance abuse, relationship abuse, reentry, behavioral intervention

INTRODUCTION In the fourth decade of the epidemic, HIV continues to devastate women’s lives. In 2011, women accounted for 20.8% of all Americans diagnosed with HIV infection (Centers for Disease Control and Prevention [CDC], 2013). Of the total number of HIV infections in U.S. women in 2011, 63% occurred in African Americans, 17% in whites, and 17% in Hispanics/Latinas (CDC, 2013). Many southern states report persistently high rates of sexually transmitted infections (STIs), including gonorrhea, syphilis, and HIV among women (CDC, 2011a; North Carolina Department of Health and Human Services, 2012). Known risk factors for HIV include poverty, lack of access to medical care, low educational levels, low socioeconomic status, history of a previously incarcerated male partner, and exposure to STIs (Altice et al., 2005; Dean & Fenton, 2010; Harawa & Adimora, 2008; Havens et al., 2009; Khan et al., 2008; Kramer and Comfort, 2011; Lichtenstein & Malow, 2010). A recent systematic review and meta-analysis of 60 studies reporting the prevalence of chlamydia, gonorrhea, and syphilis among incarcerated populations indicated that incarcerated persons, especially women, experience high rates of STIs (Kouyoumdijan et al., 2012). In the United States, women entering adult corrections facilities in 2011 had a 7.4% positivity rate for Chlamydia, which was 11 times as high as the reported case rate (.65%) for the general population of women (CDC, 2011a). Regarding HIV, it was estimated that nationwide 1.9% of incarcerated adult women were HIV-positive, compared to 1.5% of incarcerated men (Maruschak & Beavers, 2009). The rate of HIV among incarcerated women is 13 times as high as the CDC’s 2008 estimated prevalence rate of .15% for adolescent and adult women in the U.S. (CDC, 2012). Further, it is estimated that annually 22,723 women living with HIV are released from a correctional facility, suggesting an important public health opportunity for prevention (Spaulding et al., 2009). Rates of incarceration are higher among women in the South than in any other region (Maruschak & Beavers, 2009). Once released from prison, women often encounter numerous challenges that can further enhance their risk of HIV and STIs, such

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as a return to substance abuse, multiple concurrent partners, exchanging sex for drugs or money, and mental health illnesses including depression (Fogel, 1999; Stein, Caviness, and Anderson, 2012; Sutcliff et al., 2010). However, these behaviors do not occur in a vacuum. Sexual risk behaviors occur within the context of sexual partnerships located within a wider sexual network, and transmission risk often occurs within the context of social and structural determinants of health (Dean & Fenton, 2010; Sharpe et al., 2012). Social determinants that can influence women prisoners’ HIV risk include poor social support systems and relationships (Stanton-Tindall et al., 2011), the impact of childhood abuse (Tripodi & Pettus-Davis, 2013), and extensive intimate partner abuse (Havens et al., 2009). At the societal level, the ability to reduce a woman’s risk of HIV/STI transmission following release from prison may be impacted by homelessness, poverty, unstable living conditions, an inability to find employment, low education, and mental health and social policies (Green et al., 2012; Khan et al., 2008; Kramer & Comfort, 2011; van Olphen et al., 2009). Due to the high HIV/STI risk profiles of incarcerated women, prisons and jails can be important settings for the delivery of prevention interventions, and incarceration is a time when women can consider behavioral change while away from the people, places, and things that encourage or reinforce their risky behavior (Abad et al., 2013). STI/HIV prevention activities in prisons and jails are limited. Only 10% of state and federal prisons and 5% of city and county jails offer HIV prevention programs, and few are offered to women (Havens et al., 2009). Moreover, there are few evidence-based behavioral interventions (EBI) that address the STI and HIV risk-reduction needs of this population (CDC, 2011b). In a critical review of HIV prevention interventions for incarcerated women, Lichtenstein and Malow (2010) found that interventions were only nominally women-centered and did not result in reductions in HIV risk behaviors. Given high rates of HIV and STIs and a paucity of efficacious interventions for incarcerated women, it is important to develop interventions to meet the needs of these women. As the development of new HIV prevention interventions is resource and time intensive, an alternative approach is to adapt an existing EBI for this population. We used a systematic process (McKleroy et al., 2006) to adapt an existing EBI, Project S.A.F.E. (Shain et al., 1999), for women in prison. Project S.A.F.E is a three-session, small group intervention originally developed for African American and Mexican American women with newly diagnosed non-viral STIs. The first phase of the adaptation process involved formative qualitative research to gather information to ascertain the HIV/STI prevention needs of incarcerated women in the South (the adaptation is described in Fasula et al., 2013), and the second phase involved evaluating the efficacy of the adapted intervention (Project P.O.W.E.R.) in a randomized controlled trial. This article presents the findings from the formative qualitative research to describe the

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individual, interpersonal, and social conditions that contributed to sexual risk behaviors of incarcerated women in the South.

METHODS Study Sample In-depth interviews were conducted with 25 current and 28 former women prisoners to document the behavioral, social, and contextual conditions of their lives, and examine how these may contribute to sexual risk behavior following their release from prison. The study protocol was reviewed and approved by the Institutional Review Boards of the University of North Carolina, Chapel Hill, the CDC, and the North Carolina Department of Corrections (NCDOC), and written, signed informed consent was obtained from all study participants. Data were collected between September 2008 and June 2009. Women were eligible for the study if they were aged 18 or older, HIVnegative, and had prior sexual activity with a man. An additional criterion for current prisoners was a sentence length of 12 months or less so these women could remember sexual activity prior to incarceration and project experiences post-release. Women who were intoxicated or under the influence of drugs, exhibited an inability to focus or understand explanations, were unable to speak English, or had symptoms of acute psychosis, as determined by the NCDOC Mental Health personnel and/or NCDOC Social Workers, were excluded. Current prisoners were recruited from the North Carolina Correctional Institute for Women (NCCIW), the state’s primary processing facility and largest women’s state prison housing over 1,100 inmates. Women were also recruited at the minimum security Fountain Correctional Center for Women (FCCW) that houses over 500 women. Research staff compiled a list of women with sentences of 12 months or less who had no more than 6 months remaining on their sentence and were currently housed at NCCIW or FCCW. The sentencing data and current addresses were obtained from the NCDOC database. Current women prisoners were randomly selected to participate in the study. Women were approached by a trained female research assistant who explained the study to a potential participant and asked if she was willing to participate. If the woman met all study criteria, informed consent was obtained by a trained research assistant. All current prisoners had sentences ranging from 4 to 10 months, with the majority having sentences of 8 months. Network sampling was used to recruit former women prisoners by using “word of mouth” referrals to access socially marginalized and hard-to-reach populations (Burns & Grove, 2001). Specifically, research staff contacted women who had formerly been incarcerated in the prisons listed above, and

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had participated in previous studies conducted by the principal investigator. In addition, former prisoners who enrolled in the study were asked if they knew of other former women prisoners who might be interested in participating in the study. If a woman indicated interest, she was enrolled following the same process used for current prisoners described above. Sentences of former prisoners ranged from 4 months to 6 years, with the majority serving less than 12 months. Former prisoners were incarcerated from 2003 to 2007.

Data Collection Procedures Trained research assistants conducted semi-structured qualitative interviews lasting 60 to 120 minutes that were digitally recorded. Interviews with current prisoners took place in a private room in the program office at NCCIW and FCCW. Interviews with former prisoners took place in the participants’ home or at a pre-determined public location. The qualitative interview guide was designed to elicit HIV/STI knowledge, risk behaviors, and risk reduction efforts of current and former prisoners. The interview guide was theoretically guided by and incorporated the major areas of the AIDS Risk Reduction Model (ARRM): awareness, susceptibility, response efficacy, personal efficacy, skills attainment (sexual/communication/negotiation skills), and social support (Catania, Kegeles, & Coates, 1990). For example, questions included, “Are you concerned about Sexually Transmitted Infections (STIs) and HIV/AIDS for yourself, your family or your friends?”; “In your present situation, do you think you can catch an STI or HIV? Why?”; “When do you protect yourself and when don’t you?”; “What do you think places women in harm’s way (at risk for catching HIV/STIs)?”; “Is there anyone you can talk to about or go to for support in using safer sex practices?”; “What would you recommend we teach women about STI/HIV?” Former prisoners received $30 and a cosmetic case containing condoms, lubricant, and body lotion for participating in the study. Current prisoners received a small snack for their participation, and were mailed a cosmetic case containing condoms, lubricant, and body lotion after their release. Demographic data consisted of age, education, race/ethnicity, incarceration status (misdemeanor/felon), previous/current living arrangements, and previous/current work status. Demographics were collected by selfreports and verified using the NCDOC public offender website (North Carolina Department of Public Safety, 2013). In-depth interviews included 12 questions with probes to elicit information about STI/HIV knowledge, male-female relationships, sexual risk behaviors, perceptions of personal risk, motivations to reduce risk, factors that facilitate and prevent use of sexual risk reduction practices, attitudes toward safer sex practices, resumption of sexual activity after release, conditions of life, lifestyle and daily living concerns, personal intimate relationships prior to incarceration, and sources of social support. All interviews were transcribed verbatim, independently

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reviewed for transcription accuracy, and uploaded into NVivo 9 qualitative analysis software (QSR International, Doncaster, Australia).

Data Analysis Transcripts were reviewed and segmented for coding following standard procedures (Bernard, 2006; Miles & Huberman, 1994). Two to three researchers independently read and coded each transcript. Coding consisted of two phases: (1) initial coding during which meaning units (words, lines, segments, and incidents) were identified and coded, and (2) focused coding during which the initial codes that seemed the most useful were identified and entered into a codebook (Miles & Huberman, 1994). The resulting codes reflected the major themes and patterns in the data, and included specific beliefs, attitudes, opinions, and values of the participants. The codebook underwent multiple iterations until it satisfactorily reflected the themes present in the data (Miles & Huberman, 1994). Inter-coder reliability, or the extent to which two independent coders agree upon how codes were assigned to the text, was assessed and coders agreed upon the assignment of codes 87% of the time. If disagreements emerged, they were resolved by consensus discussion by the coders and other members of the research team.

RESULTS The 25 current prisoners ranged in age from 18 to 50 years (mean = 30.7 years); completed an average of 11.9 years of education; 52% were white; 60% were incarcerated due to a felony conviction (such as robbery, repeated drug offenses, or writing false checks); most lived with a husband/boyfriend, parents, or minor children; and less than one-third had a full-time job prior to incarceration (Table 1). The 28 former prisoners ranged in age from 21 to 54 years (mean = 36.6 years); completed an average of 12.2 years of education; 61% were white; 93% were incarcerated due to a felony conviction (such as robbery or repeated substance abuse offenses); most lived with their children and other family; and nearly one-third had a full-time job. A greater percentage of former prisoners were incarcerated for a felony conviction than current prisoners (93% versus 60%, p < 0.05). At the time of the research, the women in the study prisons were 54% white, 43% African American, less than 1% Hispanic, and 2% Native American (North Carolina Department of Public Safety, 2013). Study participant racial/ethnic characteristics were similar to those of the prison at the time of the research (Table 1). In their responses to interview questions, both current and former women prisoners identified similar HIV risk factors that were organized into three major thematic categories consistent with the micro, mezzo, and

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TABLE 1 Demographic Characteristics of Current and Former Women Prisoners in North Carolina, 2008–2009 Characteristics Age 18–24 25–34 35–44 45+ Education Mean (range) > High school High school/GED < High school Race Black/African American Caucasian/Anglo Hispanic Incarceration status Felon Misdemeanor Living arrangements Alone Husband/boyfriend Male friend/acquaintance Female friend/acquaintance Parents Children Other family Husband/boyfriend family Homeless/in shelter Full-time work status at time of incarceration or currently

Current prisoners (n = 25) 13 3 5 4

Former prisoners (n = 28) 3 10 13 2

11.9 years (8–16 years) 10 8 7

12.2 years (9–18 years) 8 13 7

12 (48%) 13 (52%) 0 (0%)

10 (35%) 17 (61%) 1 (4%)

15 (60%) 10 (40%)

26 (93%) 2 (7%)

3 11 0 1 8 8 6 1 0 7

2 5 1 6 6 12 7 1 2 9

(12%) (44%) (0%) (4%) (32%) (32%) (24%) (4%) (0%) (28%)

(7%) (18%) (4%) (21%) (21%) (43%) (25%) (4%) (7%) (32%)

macro levels found in the social ecological perspective (Brofenbrenner, 1979): (1) individual factors that interfere with women utilizing safer sex practices (microsystem); (2) interpersonal factors that increase a woman’s risk of contracting HIV and other STIs (mesosystem); and (3) social, economic, and political factors that create a risk environment for women (exo-/macrosystem) (Figure 1). In addition, women provided recommendations for developing behavioral risk reduction interventions to help women in prison decrease their risk of acquiring STIs/HIV post-release.

Individual Risk Women identified individual-level behaviors they believed increased their personal risk for HIV and other STIs, and influenced the probability of having an infected partner. Personal risk factors identified included substance abuse,

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Exo-/Macrosystem Employment instability Risk environments Stigma Re-entry

Microsystem

Individual HIV/STD Risk Behavior

Mesosystem

Low self-worth

Violence

Emotional needs

Betrayal

Substance use

Abuse Partner pressure

FIGURE 1 Ecological systems of HIV/STI behavioral risk for incarcerated women.

emotional need, low self-worth, experiences of early childhood abuse, and misperceptions of individual risk and safer sex practices. Substance abuse. The majority of the women interviewed discussed drug use and abuse as a major barrier to sexual protection. Drug use often clouded judgment and was a powerful force leading to a lack of concern for personal well-being and safety. As one woman noted: “I wasn’t worried about me or taking care of myself, I was just worried about getting high.” Women identified a strong connection between drug use and sex work. Sex work was often viewed as a way to support addiction, and as an escape mechanism. In fact, more than three-quarters of the women described how substance abuse and sex work led to a cycle of unsafe behavior, placing them in a vulnerable position with men. As stated by one woman: “I tried to be smart, but there were times where I had to have that dope, and I didn’t have protection because I didn’t have the money. It was either do that or do without . . . so I did it anyway.” Emotional need. Nearly half of the women stated that being in love distorted their perception of risk and increased their willingness to engage in high-risk behaviors. Women talked about searching for love and using sex to get attention from a man. As one woman noted: “I think a lot of girls

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choose not to make a guy wear a condom because they want to have a baby, they want to find that love . . . a lot of women do it because they want to attract the man.” Women described how prior relationships shaped their emotional need. As one woman expressed it: “One of the biggest things that I’ve noticed is because you’re vulnerable . . . and you’re looking for affection or trying to fill that void of having another partner, you typically go for anything. . . . ” Self-worth. Three-quarters of the women identified how low self-worth placed them at risk for HIV/STIs. As stated by one woman: “Low self-esteem, I think, has something to do with it because they just don’t care about themselves or what happens to them. I think that’s [a] reason why a woman would not choose to use protection.” Another women was acutely aware of how her lack of self-worth led to risky sexual experiences and stated: “I grew up knowing nothing but basically that people would not love me not unless I had sex with them. . . . So, I went through life feeling [that] with what happened to me, that as I met someone, as soon as I got with them, the first time they asked me to have sex with them, I did.” Women also talked about how low self-worth contributed to their substance abuse. One woman stated: “It’s just totally like ‘I’m nobody, I’m nothing. I’m just a piece of crap’. That’s why you don’t care, you don’t care. All you want to do is smoke, or shoot up . . . it takes everything from you, your self-esteem, you have nothing.” Experiencing childhood abuse contributed to experiences of low self worth. As one woman explained: “I still had issues as a result of what happened to me in my childhood [sexual abuse] and one of those things [was] that I was looking for the love, and most of the times I ended up looking for love in all the wrong places.” Perception of individual risk and safer sex practices. Over three-quarters of the women were aware of their HIV risk and unsafe sex. As one woman expressed: “This nurse told me when she gave me my HIV results . . . ‘you’re subject to getting HIV’. So that stuck with me too. I don’t want it [HIV] ‘cause I don’t know who you doing and who they doing and whoever you doing is doing somebody . . . don’t know what they got and don’t want what they got.” Despite knowledge and awareness of risk factors, nearly two-thirds of the women expressed difficulty overcoming the pressures of sex work and drug abuse. Despite many women engaging in risky behavior, less than one-quarter of the women insisted their partners use condoms: “I think you need to protect yourself with all partners to be honest because you never know. Just ‘cause they have a smiling face and talk to you good doesn’t mean that they don’t have anything.” This insistence often stemmed from a strong desire for self-preservation. As one woman expressed it: “If you don’t use condoms, then you can’t have sex . . . . If you don’t care about yourself, nobody else will. You got to think of ‘self first.” Interestingly, women found it easier to ask sex work partners to use condoms than intimate partners. As one

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woman said: “It’s a different trust issue . . . I’m just laying with you for money [versus] I’m seeing you every day. It’s a different thing.” Overall, the majority of women had a clear sense of their personal risk, and understood the benefits of practicing safer sex. For those who participated in sex work prior to incarceration, the sentiment was similar: “I don’t want to go back because I know that it’ll cost me everything. My dignity, my self-respect . . . it’ll cost me everything that I worked for or just that my peace, my inner peace, and my approval of myself now.”

Interpersonal Risk Women frequently identified their relationships with men as problematic, dangerous, and increasing their risk for HIV/STIs. Over three-quarters viewed just being a woman as a risk factor due to domestic violence and rape. Interpersonal risk factors that emerged in the interviews include partner pressure, betrayal, and experiences of violence as a child and adult. Partner pressure. Over half of the women noted subtle and overt pressures related to safer sex practices in their relationships with men. They mentioned that if they loved a partner, they wanted to demonstrate their trust by not insisting he use condoms. Women reported men often got defensive when they were asked to use condoms. They frequently stated that their partners often came up with excuses to not use condoms—“‘Oh, I won’t feel anything,’ or ‘I won’t have that sensation,’ or ‘I won’t be able to keep an erection or something like that’”—leaving women to feel powerless and placing the desire to be safe in a sexual relationship against the need for intimacy, trust, and love. Trust and betrayal. At least half of the women stated they wanted to trust their partners, but this was not always realistic. Nearly half of the women reported feeling betrayed in their relationships, and several mentioned that their partners refused to use condoms even though they had other known sex partners. As one woman said: “I love him or I would’ve left him years ago . . . I probably should be more cautious ‘cause he’s not faithful and I know that. I don’t know, I guess ignorance is bliss. You just don’t think about it at that time or moment, you just don’t think about it.” When this woman was asked if she thought her partner used protection with other people he has sex with, she replied “No.” Another woman expressed that it is difficult for men to remain faithful: “I think that’s just his nature. You either accept that or you don’t, and I’m just not ready to leave him.” Violence. Women frequently mentioned experiences of violence with partners and others as putting them at risk for HIV/STIs. More than half of the women believed that unresolved physical, emotional, and sexual trauma experienced during childhood left them vulnerable to abusive and violent adult relationships. One-third of women reported a history of childhood sexual and physical abuse. In the words of one woman: “I was molested at

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age 12 or 13 by my daddy . . . . At 13 years old, I consented to sex with my boyfriend, but I was still being molested.” Women also described feelings of low self-worth given their experiences of violence and abuse: “When you have abuse at home, you’re not going to have good self-esteem. I don’t care what situation you’re in, if you’re abused at home, you’re not going to have good self-esteem, you can’t.” Another participant stated: “We all have different experiences, we all have had different traumas, but the effect is still the same . . . whether it be physical or psychological abuse, it affects how you interact with another person.” One woman, who had experienced abuse at a young age, also described repeated abuse in her intimate adult relationship: “And so, you know he had a drinking problem, when he drank it became more of a problem . . . so basically, I was trying to find a way to get away . . . every time I would try to leave him it would be a threat towards my family or towards my life . . . so I was trying to be amicable and leave on good terms. I thought we were on good terms, but then it’s like night and day, he just snapped and he pistol whipped me over 20 times in the head.” For women in violent and abusive relationships, practicing safe sex or insisting on condom use was not a priority. Women talked about their need to heal from early abusive relationships as a first step in their recovery. They commonly expressed how difficult it was to do this: “I always look in the mirror and I tell myself: ‘It weren’t your fault,’ so I just keep on moving, you know what I’m saying, but sometimes I go back to them other places and feel like it and I get to crying and stuff. But then I just say ‘Oh Lord, please take it away.’”

Risk Environments Social, political, and economic factors, such as employment instability, low educational attainment, and the social stigma of being an ex-felon, created environments that contributed to increased HIV/STI risk. Women were often not prepared for reentry into their communities after incarceration. In many cases, women had no option other than to return to risky environments. Women considered this a driving force for re-engaging in STI/HIV risk behavior. Employment instability. The majority of women were under-employed in jobs that were low paying and did not cover basic living expenses. Often, women stated that they were unable to find employment due to their criminal backgrounds, or that they lacked employable job skills, or that they were living in areas in which few jobs were available. More than half found it difficult to provide for themselves and their families, and found themselves re-engaged in a cycle of low self-worth, substance abuse, and sex work. As one woman stated, “It’s hard, once you get into that lifestyle to get out of it because you’re so used to that money coming that you can’t get that

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money doing something else with your education and your criminal background.” Women also stated that, because their criminal backgrounds played a significant role in their inability to obtain a job, they were at increased risk for relapse and recidivism. As one woman stated: . . . even if you try to open that door to take a change to start over, someone always shuts it, because you’ve already got all those bad things and negative things against you. You know what I’m saying. . . . If the person is willing to change and shows a commitment to change, then someone needs to give them that chance, and that’s the main problem. A lot of people don’t get that chance so they end up going back to what they know and next thing you know, they have a disease or they’re dead.

Returning to risk environments. Over three-quarters of women shared that leaving prison and returning to the same community where they engaged in risky behavior is a significant contributor to continued risk. As one woman said: “If you’re going right back to the projects, right back to the boyfriend who sells, right back to the mother who uses, what can you expect?” Many women considered active avoidance of pre-incarceration social networks as an important way to prevent returning to the circumstances that placed them in jeopardy. Those lacking other resources or options for reentry found it nearly impossible to avoid returning to their pre-incarceration risk behavior. One woman recounted: “My brother and his girlfriend come pick me up and we went and got a motel and got dope. So there I was right back, the same day I was released.” Preparing for reentry. Women commonly viewed their postincarceration reentry into their communities as stressful. Former prisoners suggested that women should try to locate an alternative community upon release: “They’re not supposed to let you just go back to where you [come from] . . . it’s kind of like they say, God doesn’t like you to dwell too long where you fell, he wants you to get up and move on.” Women emphasized that the relationship stresses that accompany reentry may necessitate professional support: “And it’s hard unless you have someone working with you— or a counselor or someone that you’re able to talk to—to kind of [de]cipher those emotions through. It’s enough to emotionally pull you down.”

Recommendations for Risk-Reduction Interventions for Incarcerated Women in the U.S. South At the end of the interviews, women were asked if they had recommendations for interventions to help women in prison decrease their risk of acquiring STIs/HIV post-release. A variety of recommendations were provided, including peer-mentoring, self-esteem enhancement, personal

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motivation, specific and graphic education, skills acquisition, and reentry support. Specific recommendations are detailed in Table 2.

DISCUSSION Women prisoners experience a myriad of factors that contribute to increased HIV/STI risk. Interventions addressing the unique needs of incarcerated women are critically needed. This study explored HIV/STI risk behaviors among former and current incarcerated women to better understand how personal, interpersonal, and social and economic factors influenced risk. The study was part of a larger project to adapt an existing evidence-based HIV-risk reduction intervention for incarcerated women (Fasula et al., 2013). Many of the individual risk factors identified by former and currently incarcerated women are similar to those identified in the research literature. These include history of substance abuse, sex work, and exchange of sex for drugs, money, or other resources (Bernstein et al., 2006; Havens et al., 2009; Kramer & Comfort, 2011; Stein, Caviness, & Anderson, 2012). The women interviewed also identified interpersonal determinants that increased their HIV risk, including intimate partner violence and the impact of childhood sexual abuse (Stanton-Tindall et al., 2011). Finally, women described social and economic risk environments that contribute to ongoing risk and identified the need for additional support and preparation for reentry to prevent re-engagement in risk behaviors, and relapse and recidivism (Khan et al., 2008; Kramer & Comfort, 2011). In particular, women identified difficulty avoiding established risk environments that originally led them to engage in HIV/STI risk behaviors. Women also identified emotional need as a risk factor for HIV and STIs, and perceived emotional need for love as distorting their perception of their personal risk, which made them willing “to do anything for love” (Raiford, Seth, & DiClemente, 2013). Closely related to emotional need was an individual’s sense of self-worth. Women spoke of feeling low self-worth related to sex work, substance abuse, and experiences of childhood sexual abuse and intimate partner violence. Trauma and abuse were persistent themes throughout the interviews. Further, women identified that unresolved childhood trauma made them vulnerable to abuse in their adult relationships, impeding their ability to protect themselves from HIV/STIs. Release from prison and reentry into the community was identified as a source of risk. Further, lack of alternatives to returning to risk environments, experiences of stigma due to ex-felon status, and employment instability, were seen as potentially leading to HIV/STI risk behavior. The findings of this study should be viewed within the context of several limitations. First, we only interviewed a small sample of current and former prisoners in North Carolina. Thus, the sample cannot be considered

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TABLE 2 Recommendations for HIV/STI Risk Reduction Interventions by Incarcerated Women in North Carolina, 2008–2009 Recommendation Peer Mentoring: Having former prisoners deliver content seen as inspiring and understood Self-Esteem Enhancement: Teach positive traits on building self-esteem

Developing Personal Motivation: Encourage women to examine and accept their life history to assist in developing motivation for change Specific and Graphic Education: Provide basic facts of how women catch STIs/HIV, including the signs, symptoms, and pictures of specific diseases Skills Acquisition: How to access condoms and condom demonstrations; provide a broader set of skills within risk interventions, including relationship skills and survival skills

Reentry Support: Developing a specific plan, specific community resources, and how to access them

Illustrative quotations “You can teach skills but you have to help the woman care about herself, and expect to have a future before she will see the need for protection “Being put down and being made to feel less a person . . . that’s all they’ve had in their brain growing up . . . build them up, let them know ‘hey, you can do this’, find out whatever it is they’re good at and accentuate the positive . . . all it takes is one kind word for them to see ‘Hey, you know, maybe I ain’t that bad and maybe I can do something.” “They need to start thinking more about themselves. Not just for the moment. You have to think about your future . . . don’t just think of that moment.” “I think the message to get across is . . . that these diseases can twist and warp your life, they can be fatal. And to do that these days, you’ve got to be just as graphic as possible.” “You need to teach life skills . . . they need job-skills classes . . . they need things like how to interact, a lot of women don’t know how to talk . . . they don’t know how to carry on an intelligent conversation, how to build a resume, how to talk to people to get a job, how to get out in this world and put yourself out there to where you can get better things, they need to teach that.” “Two of the key things that I think that will help women not recidivate, and that’s healthy relationships. Like, there’s not relationship training inside of the prison. One of our statistics is 98% of women incarcerated have suffered from domestic violence or sexual assault of some sort; those issues are not being addressed within the prison system . . . so I definitely think relationship training and number two is parenting skills.” “It’s the people that come in from the outside . . . that helped me, that made me want to be better. It made me feel good about myself. When I got home, I knew I could call . . . and I did when I got home. And that gave me an incentive for when I was getting out.” “What to use, how to go about it, where to go to get tested, sexually what you can do to protect yourself from it. . . . ”

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representative of the larger population of all women prisoners in the South or nationally. Second, current prisoners included women who had sentences of one year or less, and may not reflect the views and experiences of women incarcerated for longer sentences. Third, it is important to acknowledge the possibility of social desirability bias when conducting research on sensitive issues, such as sexual activity, domestic violence, and substance abuse. Non-judgmental presentation of the interview questions and the substantial experience of the project staff in conducting research with incarcerated women suggest that women prisoners were willing to discuss the topics addressed in this study. It is also possible that women prisoners realized that the project staff already knew about the behaviors that led to their conviction, and had no reason to not disclose their knowledge, attitudes, and beliefs.

CONCLUSION The findings from this study have important implications for the development of HIV and STI prevention interventions for incarcerated women. Interventions for incarcerated women need to address the complex interplay of factors placing women prisoners at risk for acquiring STIs and HIV, including individual, interpersonal, and social and community factors that impact their lives before, during, and after incarceration. Prevention efforts should address co-occurring or syndemic effects of mental health, violence against women, and substance abuse that can increase and complicate HIV/STI risk (Illangasekare et al., 2013; Sharpe et al., 2012). The formative research findings presented in this article have been used to adapt an EBI for incarcerated women (Fasula et al., 2013), and the efficacy of the adapted intervention is currently being tested in a randomized control trial. As the HIV epidemic continues to disproportionally impact women in the South and incarcerated women remain at very high risk for HIV and other STIs, it is important that future research consider the findings of this study when developing impactful prevention interventions for these high-risk populations of women.

ACKNOWLEDGMENTS The authors would like to acknowledge other members of the project team, including Drs. Amy Fasula, Neetu Abad, and Juarlyn Gaiter at the CDC, Jamie Crandell, Karl Gustafson, Angela Edwards, and Madison Hayes at the University of North Carolina at Chapel Hill, and Dr. Rochelle Shain—the original developer of Project S.A.F.E.—at the Department of OB/GYN, University of Texas Health Science Center at San Antonio. The authors would also like to express their gratitude to the women who participated in this study for their important contributions to the fight against HIV/AIDS. The findings and

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conclusions in this report are those of the authors and do not necessarily represent the views of the U.S. Centers for Disease Control and Prevention. The authors report no real or perceived vested interests that relate to this article (including relationships with pharmaceutical companies, biomedical device manufacturers, grantors, or other entities whose products or services are related to topics covered in this manuscript) that could be construed as a conflict of interest.

FUNDING This study was funded by a cooperative agreement (5UR6PS000670-05) from the Centers for Disease Control and Prevention.

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