Recent Incarceration and HIV Risk Among Women Who Use Heroin.

Importance: 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. Objective: 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. Exposure: The exposure was recent incarceration, defined as self-report of being held in prison or jail in the past 6 months. Main Outcomes and Measures: 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. Results: 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). Conclusions and Relevance: 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.