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The Interlinking of HIV and Incarceration

Introduction
“In the past few years, incarceration has been recognized as a key intervention site to
address the HIV epidemic” (Flanigan & Beckwith, 2011). Notably, incarceration is only a
subtopic under the abstract concept of the prison industrial complex (PIC). Therefore,
understanding the PIC can help discern, what the relationship between HIV and incarceration is,
and can further examine why incarceration can be an essential intervention in addressing the HIV
epidemic. Firstly, it’s important to note that HIV is a sexually transmitted disease that is mostly
acquired through two major social phenomena: sexual activity and drug abuse. Secondly, it is
necessary to branch out into systemic issues such as poverty and the law and order politics that
are interrelated with the workings of the PIC. Lastly, deducing what biopolitics and social capital
are can be imperative to analyzing the relationship between HIV and incarceration.

Prison Industrial Complex

To begin with, Angela Davis coined the name, prison industrial complex because she was
stunned by the resemblance of the prison network with the military industrial complex due to
“the extent to which prison building and operation [have been] attract[ing] vast amounts of
capital—from the construction industry to food and health care provision,” (Davis, 2003).
Respectively, the name encourages the broadening of what a prison is, beyond just the physical
structure. In other words, the PIC, in our modern society, is extensive and abundant in the
amount of landscapes it takes ownership of. Additionally, the PIC must be analyzed through the
intersectionality theory, that “conceptualizes multiple categories of social identities, privilege,
and oppression simultaneously, as they are co-existing and interdependent in one’s everyday
experience” (Sun et al., 2018). That’s why I will be investigating several factors contributing to
the interlinking of HIV and incarceration. Due to how extensive the PIC is, it’s difficult to
pinpoint where the relationship between HIV and incarceration initially stems from. It’s common
for many individuals to believe that the relationship started within prison walls and elongated
out. However, “available data suggest that the vast majority of incarcerated persons with HIV
infection do not acquire their infection in prison or jail” (Wohl et al. 2006). What this implies is
that HIV is brought into prison walls through the influence of several prison landscapes. I would
like to argue that the main pathway is through hospitals.
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Hospital-to-Prison Pipeline
While shadowing an infectious diseases physician at UW Medicine, I encountered several
HIV patients that failed their drug tests. Interestingly, it wasn’t because they were overdosing on
medication. Instead, the tests showed extremely elevated levels that could not have resulted
solely from human metabolism. To put in context, many of the HIV patients are current drug
users that are slowly weaning off of narcotics and opioids through lowered prescription dosages.
In addition to their drug addiction, many are living in extreme poverty, seeking shelter and food.
As a result of all the obstacles they are facing, many do resort to selling their prescribed
medications on the streets in order to survive. Not only is that illegal and provides a direct route
to prison, it also prevents further medical treatment. For example, when the patient comes back
for his or her check-up, s/he will mostly likely drop an unsold pill into their urine, in hopes of
passing the test and remaining a patient. Yet, what many patients don’t know and/or don’t
understand is, that dropping a pill directly into the urine sample increases the concentration of
drug presence immensely. In the end, most of these patients are given warnings, but after several
warnings, they are released as patients and turned away by the medical system. Exclusion from
the medical system is extremely harmful for these patients as it exacerbates existing problems
they are facing, like joblessness and homelessness that could eventually lead the individual back
to prison. Surprisingly, “it has been estimated that each year, about 25% of all HIV-infected
persons in the United States spend time in a correctional facility” (Okie, 2007). What’s more
concerning is that, after they are released, “an individual’s criminal history can limit treatment
entry” (Harawa et al. 2017). Thus, it can be argued that similar to the school-to-prison pipeline,
there is also a hospital-to-prison pipeline that is growing in size. It’s concerning that physicians
seem ignorant towards the social determinants that are affecting whether or not their patients are
showing up on time to their appointments and/or taking the correct dosages of medications. Even
if a patient is able to remain sober, “he or she would have to pay restitution and then be
reincarcerated if s/he failed to comply” (Harawa et al., 2017). From this experience alone, it’s
evident the healthcare system is involved with the prison industrial complex in the sense that it is
strengthening ties between HIV and incarceration.
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Criminalization of Drugs and Poverty

It’s evident that the hospital-to-prison pipeline is facilitated by systemic issues such as
poverty and homelessness. For starters, many individuals in poverty end up doing commercial
sex work as a source of income or of drugs. Besides getting drugs and money in return, there is
an increased risk of acquiring sexually transmitted infections such as HIV (Nihawan, 2016). In a
situation like this, it’s quite likely that the at-risk individual will be incarcerated as a matter of
illegal drug possession. That is because the federal government’s “War on Poverty” was
“replaced first by a war on crime and then by a war on drugs as stringent sentences were attached
to narcotics and other drug offenses” (Bonds, 2012). In other words, these so-called Wars are just
cover ups for increasing penal punishment against drug offenses, which are far more common
among minorities and people in poverty. In the eyes of the federal government, the solution to
many systemic issues like poverty and homelessness is to incriminate those people who are
contributing to the issue at hand. Specifically, “the prison industrial complex has created a “shift
toward a more punitive and less rehabilitative approach to public safety, [leading to] large scale
imprisonment disproportionately affecting racial and ethnic minorities and people living in
poverty” (Wohl, 2016). Working as part of the prison industrial complex, the federal
government’s shift from the War on Poverty to the War on Drugs “reflected a national focus not
only on criminal drug use and mandatory sentencing laws, but also on the malignant spread of
crack cocaine across the nation” (Wohl et al., 2006). Simultaneously, the HIV epidemic was
spreading across the nation. However, this wasn’t a mere coincidence. Instead, “the policies that
were established to arrest and imprison those involved in the use and trafficking of illicit
substances inadvertently targeted for incarceration those with an elevated risk of HIV” (Wohl,
2016). Put differently, the criminalization of drugs was a means of targeting poor and disposable
communities that indirectly impacted the HIV-infected population which happened to be
considered one of many disposable communities.
Ironically, many disposable communities “offered up investments, tax breaks, and cheap
land as incentives to prisons” in addition to “governments financing their growing prison
systems…[As a result,] the [already] limited resources [for the communities] were further
directed away from public welfare and social investments” (Bonds, 2012). In essence, the
expected return from prisons is completely disproportionate to the investment into prisons by the
communities that are targets for prison expansion. And yet, governments and poor communities
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continue to invest “disproportionately high amount of money on prisons and police, revealing
that when it comes to government expenditures, it is not so much a question of whether to spend
or not, but of how government spending is distributed” (Wang, 2018). Fundamentally,
governments are consciously aware of where their spending goes, but many of these
“disposable” citizens are subconsciously falling into the misconception that prisons can generate
revenue for the people and solve systemic issues such as poverty. They are in fact fueling the
system that is victimizing them. When resources are placed in growing prison landscapes and not
public education and accessible healthcare, community members that were poor and vulnerable
originally are still poor, vulnerable and at risk of becoming incarcerated. HIV-positive
individuals, especially, that lack proper sexual education and medical treatment continuously
recycle back into prison, further prompting more funding because the general public’s
unemployment and poverty rates are seemingly decreased as a result of individuals being
incarcerated. Bonds summarizes perfectly that “the criminalization of poverty and the expansion
of the prison-industrial complex clearly demonstrate that rather than diminishing in power or
withdrawing from the lives of the poor, the state has instead extended and redefined its role
through surveillance, regulation, and incarceration” (Bonds, 2012). In this context, “the state” is
working within the PIC and is successfully manipulating disposable individuals into prison: the
place where individuals are hidden from the public.

Biopolitics
Contrary to sovereign power, biopolitics focuses on correcting the population as a whole.
However, it’s almost impossible to promote the entire population’s livelihood because
populations are divided into separate communities. Along those lines, through the lens of
biopolitics, HIV-infected individuals are deemed “‘aleatory,’ unpredictable, and potentially
destabilizing elements of a population” (Wang, 2018). Yet, for Esposito, the goal of biopolitics is
still to absorb the entire population, even the “contagions, germs, pollutants, or infections”
(Wang, 2018). Ultimately, in order to maintain the wellbeing of the majority of the population,
the HIV communities and other “biological threats [towards the] improvement of the species”
(Wang, 2018) are included by exclusion. What that means is by excluding HIV individuals into
prison walls is still seen as including them within the population. It’s especially obvious when
examining “existing laws and policies that are governing scientifically proven HIV interventions,
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such as NSP and OST,” (Strathdee et al., 2015) that there is a clear barrier in wanting to help
HIV individuals integrate back into society. Simply put, “increasing the provision of OST in
prison to people who inject drugs by 20% would decrease the HIV rate by 28%” (Smart, 2016).
This seems like a reasonable approach to take, but because of “random urine drug screens and
arresting PWIDs who attend NSPs or OST programs, [it] hereby actively discourages access to
such programs” (Strathdee et al., 2015) and further prevents these programs from being instilled
in other prisons. In essence, these random searches and tests are biopolitical-driven approaches
to controlling the HIV population from disrupting the livelihood of the larger population.
Fundamentally, biopolitics creates the framework that HIV individuals are “deserving criminals”
(Muhammad, 2011) due to their destabilizing nature that shall be dismissed in order to preserve
the well-being of the population. Essentially, it can be concluded that HIV-infected individuals
should be contained and distanced from the general population by placing them in none other
than prisons.

Law and Order Politics, Social Capital and Self-Blame

“Critics of U.S. penal policies contend that incarceration has exacerbated the HIV
epidemic among blacks, who are disproportionately represented in the prison population,
accounting for 40% of inmates” (Okie, 2007). It’s obvious that the areas where crack use is high
is also where African Americans are racially segregated and where policing is targeted at. Along
with systemic issues, crack use is one of several “mechanisms [leading to] low African
Americans male-female ratios [leading to concurrent partnerships] … leading to increased HIV
incidence” (Gerberry & Joshi, 2017). Initially, it’s easy to place the blame on African American
women for entering into several new sexual relationships that can obviously increase HIV
infection. Yet, through carefully analysis, the real antagonist is the criminalization of systemic
issues, that are perpetuating the disruption of relationships that “may have been protective
against sexually transmitted infections” (Wohl, 2016). Furthermore, these punitive law and order
politics influences policing that are “often not consistent with established laws and policy, and
often undermine health and human rights” (Strathdee et al., 2015). For example, “in Bronx, New
York, urban ‘planned shrinkage’ directed against African-American and Hispanic communities
was implemented through the systematic denial of municipal services and was also associated
with increased incidence of drug use and HIV” (Rhodes et al., 2005). This ties into the concept
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of social capital which is “conceptualized as collective resources generated through social

connections that individuals or groups can access [and] may be an important determinant of
HIV/AIDS prevention, transmission, and treatment outcomes” (Ransome et al., 2018).
Essentially, by limiting available social resources geared towards HIV communities and
minorities, it becomes extremely difficult for these already vulnerable communities to be
resilient against homelessness, poverty, and the criminalization of drugs. Virtually, this explicit
example demonstrates how extensive the objective and consequences of the PIC are. On the
other hand, social networks can facilitate “early post-release substance use by picking [up
prisoners] from jail with illegal substances on hand, as a way of welcoming them home”
(Harawa et al., 2017). That said, it’s easy to critique this welcoming gesture as the trigger for
reincarceration, however, it’s important to take note that those loved ones lack the proper social
resources needed to educate them on drug abuse and addiction. Without that, the mindset is to
welcome their loved ones back with more drugs.
Speaking of mindset, surprisingly, many HIV-positive individuals believe that prisons are
safe spaces. In a study done on HIV-positive inmates, many “participants noted their priority was
to survive rather than daily medication intake in an unsafe environment” (Sun et al., 2018). This
is related to the fact that for many HIV-infected people, especially Black men, prison offers
safety from neighborhood violence (Sun et al., 2018). Due to possible harm inflicted from their
neighborhoods, prisons have developed into safe spaces which is ironic since prisons, among
other landscapes within the PIC, is what contributes to the dangers of their unstable
communities. Moreover, HIV-positive prisoners note that they “experience a system with
structures and regulations that automate care and facilitate adherence through regimented
schedules, pill calls, universal health care, shelter, proximity to services” (Harawa et al., 2017)
that aren’t easily accessible on the outside of prison walls. Consequently, HIV-positive
individuals may seek reincarceration in hopes of survival. On the other hand, “most jails in the
United States do not offer routine opt-out HIV testing [which] is a particular travesty,
considering that the demographic group that has the highest rates of HIV infection in this country
is African American men, which is also the population most likely to be incarcerated” (Flanigan
& Beckwith, 2011). Additionally, it has been found that when HIV-positive individuals
“experienced challenges, the blame on [thy] self stems from the belief that individuals are
responsible for their actions, yet it also contributed to shame and internalized stigma” (Sun et al.,
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2018). What this justifies is the fact that vulnerable individuals, like HIV-infected individuals,
have been ingrained to view challenges and failures as self-directed issues. As a result, it makes
them easy to manipulate in turning towards the prison in an effort of getting help or to avoid
shame. Yet, once inside, the shame of having HIV can prevent individuals from identifying
themselves as HIV-positive. This could very likely contribute to why “recent incarceration was
associated with an 81% increase in HIV acquisition risk” (Zaller et al, 2018). That means that
HIV-negative prisoners entering prison has more than a 50% chance of becoming infected. And
prisons make it more difficult for prisoners to admit their status since “prison-based HIV care
fails to be supportive of patient autonomy or privacy” (Harawa et al., 2017). In an effort to avoid
shame by the outside community, HIV-positive individuals are faced with the consequences of
the stigma that goes along with having HIV in prison. Not only are there repercussions from
fellow inmates, the fact the it is an internalized stigma further deteriorates the already vulnerable
well-being of HIV-positive prisoners.

Conclusion
All in all, it’s extremely noticeable that HIV-infected individuals are easy targets for the
prison industrial complex. With the priority to survive from their vicious disease and societal
obstacles, HIV-positive individuals are vulnerable under the oppressive PIC that is working
throughout their lives in the forms of heightened policing, denial of medical treatment, lack of
social resources, etc. What’s most alarming is that even in settings such as hospitals, where
vulnerable individuals are supposedly treated, HIV-infected individuals are neglected in
treatment and services that can help relieve social pressures they are facing that accentuates their
vulnerability. That said, it’s understandable why addressing incarceration can be essential in
resolving the HIV epidemic.
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