HIV Knowledge and Perceived Risk Among Black Men and Women Who Are Incarcerated in Kentucky

Abstract

In the United States, Black men and women who are incarcerated bear a disproportionate and inequitable burden of HIV infection. While HIV knowledge does not consistently predict HIV risk behaviors, HIV knowledge can inform one’s perceptions of their risk for HIV. We examined gender differences in HIV knowledge and perceived risk of contracting HIV (N = 424) among Black men and women who were incarcerated and nearing community reentry from seven prisons in Kentucky. Our results demonstrated that women reported greater levels of HIV knowledge and perceived greater risk for contracting HIV than their male counterparts. Implications for HIV prevention interventions are discussed.

Keywords

HIV AIDS Black African American minority health health education

Black men and women in the United States bear a disproportionate and inequitable burden of HIV, including the highest proportion of new HIV diagnoses compared with other racial/ethnic groups (Centers for Disease Control and Prevention [CDC], 2021). In 2018, Black people comprised 13% of the U.S. population but accounted for 42% of new HIV diagnoses (CDC, 2021). Furthermore, in Kentucky Black men and women account for 30% of all new HIV diagnoses despite only making up 10% of the entire state population (Kentucky Cabinet for Health and Family Services, Department for Public Health, 2019). Additionally, Black women in Kentucky report the highest percentage (53%) of concurrent HIV/AIDS diagnoses compared with any other racial/ethnic group (Kentucky Cabinet for Health and Family Services, Department for Public Health, 2019). While Black men and women in the general population show disparate rates of HIV because of a variety of social and structural factors, history of incarceration exacerbates these inequities.

Mass incarceration increases HIV vulnerability among Black men and women due to the greater prevalence of HIV within prisons and limited access to effective prevention tools (Kerr & Jackson, 2016). For example, the prevalence of HIV among incarcerated individuals is approximately five times higher than among the general population (Joint United Nations Programme on HIV/AIDS [UNAIDS], 2017). However, the World Health Organization (WHO) estimates that this risk is actually higher, suggesting people who are incarcerated are 15 times more likely to be HIV positive than those who are not (WHO, 2019). In 2017, Black Kentuckians made up 22% of people in jail and 21% of people in prison despite only making up 9% of the total state population, placing them at a disproportionate risk of HIV transmission (Vera Institute of Justice, 2019).

Among Black men with a history of incarceration, elevated HIV risk may be related to increased sexual risk behaviors post-incarceration (Ricks et al., 2015), in addition to increased risk because of racism, stigma, and discrimination (CDC, 2021). Moreover, research has shown Black women with a history of incarceration have worse HIV outcomes (e.g., less viral suppression and increased likelihood of mortality) compared with non-incarcerated Black women (Cohen et al., 2019). Thus, understanding the perceived HIV risk and knowledge of HIV transmission among Black incarcerated men and women is important for reducing their likelihood of HIV contraction and transmission to their partners upon community reentry, especially in Kentucky.

Since 2016, HIV infection rates have steadily increased in Kentucky (Kentucky Cabinet for Health and Family Services, Department for Public Health, 2019). In 2018, investigators from the CDC were called into Kentucky to investigate the spike in HIV cases from 2016 to 2018 (Thompson, 2018). In addition, the counties with the highest incarceration rates are in rural areas (Vera Institute of Justice, 2019), which are less likely to have access to HIV education, free testing, and syringe programs. Despite the state and CDC efforts to increase clean syringe exchange programs in the state and the number of free HIV testing sites, incarcerated Black men and women nearing community reentry are still at high risk of HIV transmission.

The purpose of this study was to (1) investigate the correlation between HIV knowledge and perceived risk of HIV contraction among Black men and women who are incarcerated in Kentucky, and (2) analyze gender differences in HIV knowledge and perceived risk. We hypothesized HIV knowledge would be positively correlated with perceived HIV risk among both Black men and women, and that Black women would report higher knowledge and perceived risk.

Methods

Participants and Procedures

Data for these analyses were derived from two larger studies: The Black Women in the Study of Epidemics (B-WISE) and the Helping Incarcerated Men (HIM) study. Participants in the B-WISE study were recruited in Kentucky from three women-only prisons between 2008 and 2012 (n = 240). All participants were eligible for parole within 60 days. Participants received $25 on their prison account for completing the baseline survey.

HIM study participants (n = 205) were recruited in 2015 and 2016 from four minimum to medium security prisons across the state of Kentucky with the highest percentages of Black male prisoners. Participants in this study were eligible for community reentry within 120 days of survey completion and were compensated $25 on their prison accounts for completing the study. Informed consent was obtained from participants in both studies. Furthermore, both studies were approved by the Kentucky Department of Corrections Research Ethics Committee and the University of Kentucky Institutional Review Board.

We merged the B-WISE and HIM samples into a single data set and limited the combined sample to participants who were not missing data on the variables included in the analyses (n = 424; 21 participants [4.7%] were excluded due to missing data). Most participants were single, heterosexual, and on average, were approximately 36 years old (see Table 1).

Table 1

Demographics, HIV Knowledge, and Perceived Risk of Black Incarcerated Men and Women (N = 424)

Demographics and HIV Variables	Women (n = 236)	Men (n = 188)
Age (years), M ± SD (minimum, maximum)	36.28 ± 9.57 (20, 62)	36.24 ± 11.22 (19, 88)
Education (years), M ± SD (minimum, maximum)	11.56 ± 2.11 (5, 20)	11.30 ± 2.01 (0, 16)
HIV positive, M ± SD (minimum, maximum)	9 (3.8)	5 (2.6)
Married, M ± SD (minimum, maximum)	32 (13.6)	20 (10.6)
Single, M ± SD (minimum, maximum)	141 (59.7)	117 (61.9)
Sexual preference, M ± SD (minimum, maximum)
Men only	163 (69.1)	5 (2.7)
Women only	50 (21.2)	179 (95.2)
Men and women	23 (9.7)	4 (2.1)
Perceived risk of contracting HIV, M ± SD (minimum, maximum)
No chance	69 (29.2)	64 (34.0)
Some chance (25%)	67 (28.4)	76 (40.4)
Half chance (50%)	51 (21.6)	32 (17.0)
High chance (75%)	29 (12.3)	11 (5.9)
Sure chance (100%)	20 (8.5)	5 (2.7)
HIV knowledge, M ± SD (minimum, maximum)	19.20 ± 2.21 (8, 22)	18.48 ± 2.29 (9, 22)

Measures

Demographics

Participants reported their current age, education level (in years), current HIV status, marital status, and the sexual preference of their partners.

HIV Knowledge

We measured HIV knowledge using a modified version of the 45-item HIV Knowledge scale. Only 22 items regarding sexual transmission were used in the current study to reduce respondent burden during the interview (Alarid & Marquart, 2009). The highest score that a participant could receive was 22. Sample items included “Taking the birth control pill keeps a woman from getting HIV/AIDS” and “HIV/AIDS can be spread by receiving oral sex.” Participants indicated whether they believe each statement about HIV is true (1) or false (0). The total number of questions participants answered correctly were summed, with higher scores indicating greater HIV knowledge. The Kuder-Richardson reliability coefficient was 0.61, indicating a moderate level of reliability.

Perceived HIV Risk

Participants were asked, “What best describes your risk of contracting HIV?” Response options were (0) no risk, 0%, (1) some chance, 25%; (2) half chance, 50%; (3) high chance, 75%; and (4) sure chance, 100%.

Analysis

We analyzed data using STATA version 16. We conducted descriptive statistics on sociodemographic and HIV-related variables, and bivariate correlations to examine the relationship between HIV knowledge, HIV risk, gender, age, and education. We explored gender differences in HIV risk using an ordered logistic regression. We further examined gender differences in HIV knowledge using an independent sample t-test.

Results

Data on sociodemographic variables, HIV knowledge, and perceived HIV risk are presented in Table 1. HIV Knowledge scores were high with a mean score of 20 (range = 8–22). Bivariate correlations showed HIV knowledge was positively correlated with education, such that participants with more years of education reported higher HIV knowledge (r = .18, p < .001). Results of bivariate correlations also showed there was no significant correlation between HIV knowledge and perceived risk (r = .08, p = .07). However, gender was correlated with HIV knowledge and perceived risk. Black women had significantly higher HIV knowledge (r = .29, p < .001) and perceived greater HIV risk than Black men (r = .17, p < .001) (see Table 2). Results of ordinal logistic regression showed Black women were 1.71 times more likely to be in a higher risk perception category than Black men (OR = 1.71, SE = .18, 95% CI [.21–.90], p = .002). Results of the independent sample t-test also confirmed there were significant mean differences in HIV knowledge, t(423) = −3.29, p = .001, with women reporting higher HIV knowledge.

Table 2

Bivariate Correlation

Variables	1	2	3	4	5
1. Age	—
2. Education	−.04	—
3. Gender (female)	.01	.06	—
4. HIV risk	−.04	−.06	.17*	—
5. HIV knowledge	−.03	.18*	.29*	.09	—

p < .001.

Discussion

In this study, we examined the relationship between HIV knowledge and perceived HIV risk among incarcerated Black men and women in Kentucky. As hypothesized, women were more likely to perceive higher HIV risk than men. Black women represent the fastest growing population of new HIV cases (CDC, 2020). Although Black women perceive they are at higher risk of contracting HIV, it is evident that there are still barriers that prevent them from engaging in protective behaviors (e.g., power dynamics in heterosexual relationships, access to condoms, condom negotiation skills, motivation, perceived norms, etc.).

Although sexual risk behaviors may occur within prisons, prisoners face greater risk of HIV transmission upon community reentry (Blankenship & Smoyer, 2013). Upon reentry, there are numerous factors that may elevate formerly incarcerated Black men and women’s HIV risk, including racism and discrimination, poverty, unstable employment and housing, unprotected sex, using drugs and alcohol before sex, sexual and partner concurrency, transactional sex, limited access to health care, and sexual networks with high-risk partners (Kerr & Jackson, 2016). To reduce the likelihood of transmission, policies and interventions that address structural risk factors, as well as individual-level interventions, are needed. HIV research on heterosexual Black men is scarce, and HIV prevention programs specifically for men nearing community reentry are limited (Bowleg & Raj, 2012; Kerr & Jackson, 2016); therefore, more community programs are needed for this specific population. In addition, HIV incidence is higher among people repeatedly incarcerated compared with those who are consistently incarcerated, thus examining pathways to reducing recidivism is essential to reducing HIV risk among Black men and women (Gough et al., 2010).

There was a positive significant relationship between years of education and HIV knowledge. In our sample, 61.5% of Black men reported being incarcerated before the age of 18 which likely impacted their access to formal health education. Therefore, Black men may learn inaccurate information about HIV from informal sources, such as fellow prisoners, prior to incarceration. Because Black men and women are more likely than their White counterparts to be incarcerated before they turned 18 (The Sentencing Project, 2014), prisons may present opportunities for Black men and women to learn more about HIV in a formal education setting.

On average, our sample had high HIV knowledge scores. As hypothesized, women reported higher levels of HIV knowledge than men. For women, higher levels of HIV knowledge may have translated into a greater understanding of their perceived HIV risk. Significant gender differences in knowledge may highlight how Black women receive more public health messages around HIV risk reduction than Black men (Higgins et al., 2010) and bear the responsibility for safer sex behaviors (Bowleg et al., 2015). As a result, Black men, especially heterosexual Black men, may feel a false sense of security about their HIV risk (Bowleg et al., 2015). Furthermore, since 92% of Black women contract HIV from heterosexual sex (CDC, 2020), interventions tailored for heterosexual Black men can help reduce Black women’s HIV vulnerability.

Limitations

Because this is a secondary analysis, gender categories reported in this study were limited to “men” and “women” rather than a full spectrum of gender identity. We were unable to analyze the association between perceived HIV risk and participation in sexual risk behaviors while incarcerated due to constraints on the protocol, which limits our ability to determine whether perceived risk and actual risk are in alignment for these participants. In addition, we did not ask participants what type, if any, sexual health and/or HIV education they received or when they received it to determine the process through which they acquired their HIV knowledge. Finally, we used secondary data from two non-probability samples with a modified version of the HIV knowledge scale, which limits generalizability to non-incarcerated populations.

Future Directions

Research has shown mass incarceration further exacerbates the HIV burden among Black men and women (Lichtenstein, 2009). Although this study provides implications for individual-level HIV education programs and community-level counseling, structural-level factors need to be addressed to ultimately reduce HIV disparities (Golub et al., 2010). Our findings support Kerr and Jackson’s (2016) implications for reducing HIV vulnerability among prison populations which includes (1) linking prisoners to care upon community reentry; (2) increasing access to sexual risk reduction programs for those that are currently incarcerated, formerly incarcerated, and their partners; and (3) reducing stigma surrounding HIV within prisons and community organizations. Future studies should examine the dissemination of sex and HIV education in formal and informal settings throughout the life span of incarcerated Black men and women.

Footnotes

Authors’ Note

S. Thrasher is now affiliated to Louisiana State University, Baton Rouge, LA, USA.

Authors’ Note:

This research would not have been possible without the Department of Corrections participation; however, the findings and ideas presented are solely those of the authors. We appreciate the participants who shared their stories and acknowledge the contribution of the research team. This research was funded by the National Institute on Drug Abuse (R01-DA022967, PI: Oser & K08-DA032296, PI: Stevens-Watkins). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

ORCID iDs

S. Thorpe

C. N. Hargons

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