HIV persists as a critical public health priority, disproportionally impacting Black men who have sex with men (BMSM). Approximately one-third of BMSM are currently living with HIV and if these rates persist, projections suggest 50% will acquire HIV in their lifetime (1, 2). Though BMSM report less drug use, fewer male sexual partners, and have comparable rates of unprotected anal intercourse than White MSM, they face a much greater risk of acquiring HIV (2, 3). Other sexually transmitted infections (STI), including gonorrhea and syphilis, are also disproportionately more common among BMSM (4). These infections can cause serious complications if left undetected and untreated and increase the risk of acquiring or transmitting HIV (5, 6). Given that individual-level drug and sex risk behaviors do not fully explain heightened infection risk among BMSM, there is a need to consider the potential importance of social and structural factors that may drive HIV/STI infection in this population.

Incarceration has consistently been associated with HIV/STI risk among heterosexual populations (7–12). Though incarceration is prevalent among BMSM with up to 60% having experienced incarceration in their lifetime (13–15), there has been little research examining its effects on HIV/STI risk specifically within this group. Extant studies on the relationship between incarceration and HIV/STI risk among MSM have been conducted primarily in non-generalizable samples (e.g., young MSM, specific geographic regions, those living with HIV) (16–19). Extant studies often fail to estimate effects by race among MSM, despite evidence that the burden of incarceration is much higher for BMSM compared to White MSM (16, 18). Within the studies that have done so, the findings regarding effects among BMSM are somewhat inconsistent. One study found that the interaction between Black race and history of incarceration was associated with increased HIV/STI risk behavior (16) while another found that White MSM had higher risk (18). Finally, no known studies have examined lifetime cumulative number of incarcerations among BMSM rather than a dichotomous indicator of prior history. Considering that increasing number of incarceration events has demonstrated a dose-response relationship with HIV-related risk in other populations (20), there is a need to understand the total burden on incarceration among BMSM.

Incarceration may influence HIV/STI risk among BMSM by working through several pathways. HIV/STI may be transmitted during the incarceration (21) considering the high prevalence of untreated infections and same-sex segregation in correctional facilities (22). As has been observed in heterosexual populations, incarceration disrupts social, sexual, and support networks as well as capital (23–26). After release, network disruption may lead to new, multiple, and/or concurrent partnerships, proximate determinants of HIV/STI (27). Reduced social capital and economic instability may also lead to other HIV/STI risk factors such as engagement in transactional sex, substance use, and depression (28, 29); the relationships among incarceration and these factors may be bi-directional or cyclical, considering that transactional sex, substance use, and poor mental health may also lead to contact with the criminal justice system (30). Because of the limited research on the role of incarceration on HIV/STI risk among BMSM, there is a need to examine this association in this population.

Two factors that may play a particularly important role in the relationship between incarceration and HIV/STI risk among BMSM are violence victimization (31, 32) and internalized homophobia (33), with high levels identified among BMSM (34), and which are strong correlates of HIV/STI risk (33, 35–37). Incarceration may further exacerbate victimization among BMSM, with one in five individuals who are incarcerated reporting violence perpetrated by other inmates or correctional facility staff (38, 39). Experiencing violence can result in emotional distress, difficulties adjusting to the community after release, greater risk of drug use and sexual risk behaviors, and sexual violence, leading directly to HIV/STI transmission (40–44). Another potentially important pathway from incarceration to HIV/STI among BMSM may be internalized homophobia. Incarceration is stigmatizing (40) and stigma has been shown to inhibit the development of protective network ties, resulting in social isolation, emotional distress, depressive symptoms, and HIV/STI-related infection transmission (41–43). Groups that are already highly stigmatized, such as racial and sexual and gender minorities, may be particularly vulnerable to internalizing stigma due to their incarceration (44) and homophobic attitudes within correctional facilities (45–48). However, research on the interplay between incarceration, social/structural factors (i.e., violence and internalized homophobia), and HIV/STI risk has been limited.

The purpose of the current study is to address a gap in the extant literature by measuring associations between the lifetime burden of incarceration and HIV/STI risk among BMSM. We used baseline data from The HIV Prevention Trials Network 061 Study (HPTN 061; the Brothers Study) to measure cross-sectional associations between lifetime number of incarcerations, HIV/STI risk indicators including sexual risk behaviors, and STI infection. Given the potential for incarceration-related increases in victimization and stigmatization that may translate to HIV/STI-related risk-taking, we also examined associations between incarceration and hypothesized mediators of violence and internalized homophobia as well as associations between these factors and other HIV/STI risk factors (Figure 1).

In this US sample of BMSM, history of incarceration and repeat incarcerations were common: sixty percent of the sample had been incarcerated at least once in their lifetime, as has been documented previously (14), and of those, many had cycled through the criminal justice system numerous times, with 24% reporting 3–9 prior incarcerations and 15% reporting 10 or more. Increasing exposure to incarceration was associated in a dose-response fashion with risk of transactional sex and also suggested low-level incarceration may be linked to elevations in chlamydia and moderate levels of incarceration were associated with syphilis. Our analyses also suggested that incarceration was associated with violence exposure, an established HIV/STI risk factor (36, 37). Our findings are among the first to document associations between the cumulative burden of incarceration, sexual risk behaviors, and STI infection among BMSM, a population facing a disproportionately elevated risk of both HIV/STI and incarceration compared to the general population (1, 13, 14). Future research using longitudinal data should measure the prospective relationships linking incarceration, violence, and HIV/STI risk and investigate mediating paths among these factors in this population.

To date, there is limited information about the relationships between incarceration and HIV/STI-related risk behaviors among BMSM (13, 16, 18, 52). Most prior studies on the incarceration-HIV/STI link have been conducted in population-based samples composed largely of heterosexual populations (8, 9, 12, 53–56). Findings from those studies suggest that incarceration is associated with 1.5–2 times greater likelihood of sexual risk behaviors including multiple and/or concurrent partnerships and buying and selling sex (57), and we likewise observed comparable relationships between incarceration and transactional sex in this sample of BMSM. Incarceration-related disruptions of networks including primary partnerships may result in buying sex after release from incarceration, while incarceration-related impacts on economic stability may result in selling sex, which may increase the risk of HIV/STI infection (8, 58). We did not observe a strong association between incarceration and multiple partnerships as has been observed in primarily heterosexual samples (55, 56, 59, 60). The extent to which incarceration may increase risk not only of high-risk sex such as transactional sex among BMSM, as well as elevations in partnership exchange rates, warrants further investigation.

Even prior to adjusting for covariates, STI prevalence was not higher among those with incarceration histories compared to those with no prior incarceration. In fact, we observed those with highest levels of repeat incarceration had consistently lower rates of STI, a finding that may reflect improved access to STI screening and treatment during incarceration compared to when in the community, and/or decreased access to new partners while incarcerated and decreased social mobility after incarceration (61). It is also possible that individuals who cycle through jails and prisons frequently have higher levels of drug and sex risk-taking (55) and potentially greater perceived risk of infection, which may lead them to seek care. That said, in analyses adjusting for covariates, low and moderate incarceration levels appeared to be associated with a higher prevalence of STI and suggest that the experience of detainment and release may be linked among many involved in the criminal justice system to sexual risk-taking and also to increased risk of infection. Our results are aligned with a study conducted among young BMSM, which found that prior CJI was linked to better HIV care continuum metrics although frequent and cyclic CJI adversely impacted HIV care (62). These findings underscore the importance of frequent STI screening for BMSM involved in the criminal justice system (63).

We hypothesized that violence and internalized homophobia may potentially link incarceration to HIV/STI risk. We did not observe an association between incarceration and internalized homophobia or between internalized homophobia and HIV/STI risk. The nature of this cross-sectional study may have precluded the ability to detect an association considering the incarceration may have occurred much earlier in a participant’s lifetime and their feelings of internalized homophobia measured at the time of this study have subsequently evolved. However, the elevated experience of violence, reported by over three-quarters of participants, demonstrated a modest dose-response relationship with increasing incarceration frequency. In turn, violence was linked to approximately 50% higher prevalence of transactional sex. Exposure to violence may increase HIV/STI risk by heightening a number of psychosocial factors (e.g., substance use, depression) that are also associated with sexual risk behaviors such as condomless sex, sex after drug use, and sex with multiple partners (64). The already-prevalent experience of violence among BMSM in the community may be exacerbated by violence experienced within the criminal justice system (38, 39), considering that violence frequently co-occurs with high incarceration rates in communities where economic inequity and social disadvantages are high. Improving our understanding of the relationships among incarceration, violence, and HIV/STI risk is critical, as is preventing the unacceptably high levels of violence experienced by BMSM in general, particularly those who cycle through the criminal justice system.

Prevention efforts are needed to reduce the grossly disproportionate exposure to incarceration among Black men including BMSM in the US. In 2017, the rate of incarceration in the US dropped to its lowest level in 20 years yet a vast racial/ethnic disparity persists, and Black individuals are still approximately six times more likely to be imprisoned compared to White individuals (65). Further, sexual minority individuals such as MSM have historically been overrepresented in the criminal justice system and therefore disproportionately exposed to violence therein (31), heightening the urgency for alternatives to incarceration, especially for this population. In addition to primary prevention efforts to reduce incarceration, HIV/STI prevention interventions tailored to BMSM impacted by the criminal justice system should be strengthened. Extant HIV/STI interventions for individuals involved in the criminal justice system are efficacious (66), though none are culturally tailored for MSM (67), let alone BMSM. A simulation study on the effects of a test, treat, retain, and condom use intervention for BMSM in the criminal justice system in Fulton County, Georgia, found that such an intervention strategy has the potential to substantially reduce HIV incidence, prevalence, and mortality among BMSM in jails and prisons as well as those within the community (68). However, to inform the development of similar interventions that are tailored and target the salient factors for this population, we must continue to examine the pathways linking incarceration to HIV/STI risk for BMSM.

Several limitations of the present study should be noted. Cross-sectional data present challenges when making inferences. We are unable to determine the temporal relationships between incarceration and the outcomes, and there is potential for reverse causality. For example, individuals who engage in transactional sex may be more likely to come in contact with the police and be incarcerated; while we do not know where the transactional sex occurred, it was common to meet sex partners, including transactional partners, in public places within studies conducted around the same period as HPTN 061, which could increase risk of encountering police (69, 70). The issue of temporality may be especially important for the measure of STI; even if incarceration did precede STI acquisition, the infection could have been treated and hence we did not detect an association. Future analyses with longitudinal data would allow for more rigorous assessment of temporality among these indicators. The self-reported measures are vulnerable to social desirability and recall bias, particularly for potentially highly stigmatized factors such as incarceration and sexual behavior. Although these data represent a large sample from diverse regions of the US, the current findings may not be generalizable to all BMSM and recruitment and context differ across the six cities included in this study. Incarceration was measured by participants’ response to a question asking how many times in their lifetime they had spent one or more nights in jail/prison, but given the range of reported number of incarcerations (from one to as many as >300 times), it is possible that a small number of participants misinterpreted the question and reported the total number of nights they had been incarcerated in their lifetime.

This study contributes to and strengthens emerging evidence documenting the detrimental effects of incarceration, which unduly impacts already marginalized and vulnerable groups including BMSM. Our findings highlight that the epidemics of incarceration and HIV/STI among BMSM are interconnected and may be exacerbated by violent experiences. Preventing criminal justice involvement and mitigating its negative effects are crucial and may be a promising means of reducing HIV/STI risk among BMSM.