Atkins Kaitlyn, Walker D'Andre, Noon Kathryn, Nwakama Chijindu, Snyder Alana, Luswetula Adela, Mbwambo Jessie, Likindikoki Samuel, Saleem Haneefa
Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.
School of Applied Sciences, The University of Mississippi, Oxford.
JAMA Netw Open. 2025 Jan 2;8(1):e2454455. doi: 10.1001/jamanetworkopen.2024.54455.
Women who use heroin in sub-Saharan Africa face elevated HIV risk linked to structural vulnerability including frequent incarceration. However, little is known about the association between incarceration and drug use and HIV outcomes among women who use heroin in Africa.
To estimate associations between incarceration and adverse HIV-related and drug use-related outcomes among women who used heroin.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study included participants from Dar es Salaam, Tanzania, who were recruited using respondent-driven sampling. Eligible participants were women who used heroin who were aged 18 years or older and reported past-month heroin use. Data were collected from November 2018 to February 2019 and analyzed from September 2023 to May 2024.
The exposure was recent incarceration, defined as self-report of being held in prison or jail in the past 6 months.
Main outcomes were self-reported HIV testing in the past 6 months, self-reported HIV status, and lifetime nonfatal overdose. Associations between recent incarceration and outcomes were examined using modified Poisson regression with robust variance estimation.
This study included 195 women who used heroin (median [IQR] age, 33 [27-39] years); 119 women (61%) reported incarceration in the past 6 months. In bivariate analyses, incarceration was associated with transactional sex (111 of 119 [93.3%]), symptoms of anxiety (104 of 119 [87.4%]), physical violence victimization (83 of 118 [70.3%]), and stigma from family (eg, 99 of 119 women [83.2%] reported being treated differently) and health care clinicians (eg, 46 of 119 women [38.7%] reported receiving poor health care). In adjusted analyses, incarceration was associated with higher prevalence of sexual concurrency (101 of 119 [84.9%] vs 41 of 76 [54.0%]; aPR, 1.43; 95% CI, 1.16-1.78), stimulant use (26 of 119 [21.9%] vs 3 of 76 [4.0%]; aPR, 5.60; 95% CI, 1.63-19.28), and lifetime nonfatal overdose (51 of 119 [42.9%] vs 17 of 76 [22.4%]; aPR, 1.62; 95% CI, 1.01-2.61). Among women who used heroin living with HIV, incarceration was associated with stopping HIV care (9 of 27 [33.3%] vs 1 of 24 [4.2%]; aPR, 9.74; 95% CI, 1.22-77.22).
In this cross-sectional study of HIV-related outcomes among recently incarcerated women who used heroin in sub-Saharan Africa, behavioral and structural vulnerabilities associated with incarceration were identified, which may exacerbate HIV disparities. Elevated stimulant use among recently incarcerated women who used heroin is of particular concern, given associations with adverse HIV outcomes. In the context of highly criminalized drug use, interventions targeting policing practices may be effective at reducing incarceration-associated risks. Findings could inform development and evaluation of multilevel interventions to reduce service interruptions and ensure linkage to HIV and substance use services during incarceration and reentry.
在撒哈拉以南非洲，使用海洛因的女性面临着与结构性脆弱性相关的更高的艾滋病毒感染风险，包括频繁被监禁。然而，对于非洲使用海洛因的女性中，监禁与药物使用及艾滋病毒感染结果之间的关联知之甚少。
评估使用海洛因的女性中，监禁与不良艾滋病毒相关及药物使用相关结果之间的关联。
设计、背景和参与者：这项横断面研究纳入了来自坦桑尼亚达累斯萨拉姆的参与者，通过应答驱动抽样进行招募。符合条件的参与者为年龄在18岁及以上、报告过去一个月使用过海洛因的使用海洛因的女性。数据于2018年11月至2019年2月收集，并于2023年9月至2024年5月进行分析。
暴露因素为近期被监禁，定义为自我报告在过去6个月内曾被关押在监狱或看守所。
主要结局为过去6个月内自我报告的艾滋病毒检测、自我报告的艾滋病毒感染状况以及终身非致命性过量用药。使用修正泊松回归和稳健方差估计来检验近期监禁与结局之间的关联。
本研究纳入了195名使用海洛因的女性（年龄中位数[四分位间距]为33[27 - 39]岁）；119名女性（61%）报告在过去6个月内曾被监禁。在双变量分析中，监禁与交易性行为（119名中的111名[93.3%]）、焦虑症状（119名中的104名[87.4%]）、身体暴力受害（118名中的83名[70.3%]）以及来自家庭的耻辱感（例如，119名女性中的99名[83.2%]报告受到不同对待）和医疗保健临床医生的耻辱感（例如，119名女性中的46名[38.7%]报告接受的医疗保健较差）相关。在多变量分析中，监禁与更高的性伴重叠患病率相关（119名中的101名[84.9%]对比76名中的41名[54.0%]；调整后的风险比，1.43；95%置信区间，1.16 - 1.78）、兴奋剂使用（119名中的26名[21.9%]对比76名中的3名[4.0%]；调整后的风险比，5.60；95%置信区间，1.63 - 19.28）以及终身非致命性过量用药（119名中的51名[42.9%]对比76名中的17名[22.4%]；调整后的风险比，1.62；95%置信区间，1.01 - 2.61）。在感染艾滋病毒的使用海洛因的女性中，监禁与停止艾滋病毒护理相关（27名中的9名[33.3%]对比24名中的1名[4.2%]；调整后的风险比，9.74；95%置信区间，1.22 - 77.22）。
在这项对撒哈拉以南非洲近期被监禁的使用海洛因的女性中艾滋病毒相关结局的横断面研究中，确定了与监禁相关的行为和结构性脆弱性，这可能会加剧艾滋病毒感染差异。鉴于与不良艾滋病毒结局的关联，近期被监禁的使用海洛因的女性中兴奋剂使用增加尤其令人担忧。在药物使用高度刑事化的背景下，针对警务实践的干预措施可能有效地降低与监禁相关的风险。研究结果可为制定和评估多层次干预措施提供信息，以减少服务中断，并确保在监禁期间及重新融入社会过程中与艾滋病毒和物质使用服务的联系。
