Policy analysisStigma, sexual risks, and the war on drugs: Examining drug policy and HIV/AIDS inequities among African Americans using the Drug War HIV/AIDS Inequities Model
Introduction
HIV/AIDS disproportionately affects African American communities. HIV rates among African American males and females are approximately seven and nineteen times higher than rates for White males and females, respectively (Prejean et al., 2011). Behaviour, however, does not fully explain these differences and social determinants are increasingly recognised as drivers of HIV disparities (Dean & Fenton, 2010). Moreover, although uptake of new prevention technologies (e.g. pre-exposure prophylaxis) and “treatment as prevention” approaches are emerging as important strategic priorities to address HIV, these tactics may have limited effectiveness if not accompanied by efforts to understand structural contexts that influence disparities (Golub, Operario, & Gorbach, 2010). One of the most notable social determinants affecting African Americans, drug policy and its consequences for African American communities, is an increasingly recognised accelerant of racial/ethnic HIV disparities in the U.S. Despite this, there is a need for models to examine the role and various mechanisms by which drug policy impacts HIV vulnerability among African Americans. Understanding this is crucial for elucidating the causes of these disparities in HIV rates and for informing intervention development to allay high HIV rates. As such, the Drug War HIV/AIDS Inequities Model is introduced to address this gap in the literature.
Scholars have highlighted the underpinnings and deleterious effects of modern drug policy on communities of colour (Alexander, 2010; Drucker, 2013; Travis, Western, & Redburn, 2014). Inequitable criminal justice policies and practices escalated by a collection of “get tough on crime policies” including the Drug War has continued the legacy of legally sanctioned oppression against African Americans in the U.S. This oppression began with the Transatlantic Slave Trade, solidified itself within the fabric of American society during slavery, and persisted with “Jim Crow” laws that economically and socially deprived African Americans (Alexander, 2010). Today, racial castes are often maintained through inequitable policing and sentencing of African Americans who are commonly poor and resource-deprived. There are numerous negative after-effects associated with mass incarceration including unfavourable economic outcomes, disrupted family structures, and negative health-related outcomes (Alexander, 2010, Drucker, 2013, Travis et al., 2014). Research has suggested that an adverse byproduct of the Drug War and mass incarceration (massive escalation of imprisonment, particularly of African Americans that often live in poor neighbourhoods of concentrated disadvantaged) furthers exacerbation of the HIV burden among African Americans (Adimora & Schoenbach, 2002; Blankenship, Smoyer, Bray, & Mattocks, 2005; Lichtenstein, 2009).
Previous research has examined HIV and the Drug War with a focus on transmission vectors involving drug use in general and injection drug use (IDU) in particular (Blankenship et al., 2005). Such research explores the intersection of substance use behaviour and how criminal justice approaches to address this behaviour increase HIV risk. These studies also explore the legislative subversion of evidence-based risk-reduction approaches such as needle exchange and condom distribution in prisons (Blankenship et al., 2005). Although this research increases understanding of the role of drug policy in facilitating HIV risk, there is less research exploring the Drug War’s impact on African-American HIV vulnerability beyond substance use (Blankenship et al., 2005). There are several mechanisms by which the Drug War facilitates HIV disparities that are unrelated to actual drug use; however, studies examining them remain disconnected in the research literature. Furthermore, there are few models used to understand the Drug War’s impact on HIV vulnerability and its contributions to racial/ethnic HIV/AIDS disparities. To address these deficits, this study develops the Drug War HIV/AIDS Inequities Model and examines the multiple pathways by which the Drug War increases HIV vulnerability for African Americans. These pathways include (1) sexual networking, (2) resource deprivation, and (3) social marginalization. This study seeks to examine HIV vulnerability as a result of drug policy and enforcement that is independent of drug use behaviour to highlight the importance of this social determinant on HIV disparities. The study begins by providing a historical perspective on the Drug War, then discusses the impact of the Drug War on mass incarceration of African Americans, explores the effects of Drug War related mass incarceration on HIV vulnerability, and concludes with the Drug War’s impact on social marginalization and HIV vulnerability. The study introduces various figures and mechanisms by which drug policy impacts HIV vulnerability, discusses them in detail, and integrates the individual figures and mechanisms into the Drug War HIV/AIDS Inequities Model.
Before explication of this model, it is important to provide a historical perspective of the Drug War. Law enforcement has been used to enforce institutional racism throughout American history (Alexander, 2010, Blackmon, 2009, Reichel, 1988). Slave patrols monitored the behaviour of the African American workforce of the south, policemen were the first line of labour acquisition for debt peonage (a post-thirteenth amendment approach to reinstating de facto slavery wherein African Americans were arbitrarily charged with crimes [often vagrancy], levied exorbitant penalties, and compelled to work for little money), and police provided formal resistance to civil rights protests in many jurisdictions (Alexander, 2010, Blackmon, 2009, Reichel, 1988). Criminal justice reforms such as “three-strikes” policies, extended sentences, and, of most interest to this study, Drug War policy and subsequent policing practices and sentencing continues a form of African American disenfranchisement (Alexander, 2010). However, unlike the reforms that occurred before the 1980s, the Drug War has significantly contributed to mass incarceration of African Americans that contributes to striking HIV disparities.
Although some form of national prohibition against substance use has been implemented in the U.S. since the early 20th century, the Drug War came to greater prominence in the 1980’s under the Reagan regime. This multifaceted approach coupled a robust social norming campaign (i.e. the “Just Say No” campaign) with sweeping legislation that escalated penalties for possession and distribution of illicit substances. This legislation, particularly the Anti-Drug Abuse Act, financially supported and incentivized increased policing and prosecution of drug crimes. It also established new mandatory minimums for prison sentences based on drug type and quantity. According to the Executive Office of the President (as cited by Beckett, 1997) federal spending on drug enforcement increased substantially as FBI antidrug funding increased by a factor of almost 12 ($8 million–$95 million) between 1980–1984. Similarly, according to the U.S. Office of National Drug Policy Drug Enforcement Agency (1992) spending increased from $86 million to $1 billion between 1981–1991 (as cited by Beckett, 1997).
Mass incarceration has escalated substantially since the 1980s and these policies have contributed to it (Travis et al., 2014). Approximately 1.5 million people in the U.S. are in prison and the incarceration rate is the highest among all Organization for Economic Cooperation and Development (OECD) countries (Organization for Economic Cooperation and Development, 2010). The U.S. prison population has expanded approximately 400% and the incarceration rate has escalated nearly 5-fold (from 133 per 100,000 to 612 per 100,000) from 1980–2014 (Cahalan, Parsons, US Bureau of Justice Statistics, & Westat inc., 1987; Carson, 2015). In comparison, the incarceration rate only tripled in the previous 100 years prior to Reagan’s reforms (Cahalan et al., 1987). These increases are significantly attributable to drug policy, as the national arrest rate for drug possession increased 122% overall and 205% for African Americans, specifically (Synder, 2011). The incarceration rate for drug offenses has increased at twice the rate of other crimes (Travis et al., 2014). Recent data indicates that approximately 46% (N = 85,124) of federal inmates are incarcerated for drug crimes (Federal Bureau of Prisons, 2016). Between 1980 and 2009, the arrests rates for drug possession and drug sale/manufacture for African Americans was 3 and 4 times higher (respectively) than the rates for Whites (Synder, 2011). High incarceration rates persist in the U.S. as these policies have continued, and in some aspects escalated, through successive federal administrations with few notable modifications.
Section snippets
The Drug War and police practices
At this point it is beneficial to introduce the Drug War HIV/AIDS Inequities Model. Drawing upon critical race theory (a theoretical perspective that recognises the integration of racism into American society and institutions), this model emphasizes institutional racism within a legal framework. Overall, this model posits that Drug War era criminal justice reformations have increased HIV vulnerability among African American individuals and communities by exacerbating sexual risks, resource
HIV vulnerability in prison
Fig. 2 (pathway 2a) delineates the relationship between mass incarceration of African Americans and increased exposure to HIV risk factors. More specifically, large numbers of African Americans in correctional facilities increases HIV vulnerability due to greater HIV prevalence in these environments and restricted access to effective prevention devices.
Modern drug policy has helped increase the number of African American males in correctional facilities. Approximately 1 in 3 African American
The Drug War, resource deprivation, and HIV
Fig. 3 highlights the deleterious effects of social marginalization and stigma on HIV vulnerability. The figure explicates the effects of various types of social marginalization and demonstrates the direct and indirect pathways of impacting HIV vulnerability. Social marginalization is preceded by over-policing and disproportionate sentencing, as these factors engender and increase exposure to conditions and social environments wherein Drug War victims are more likely to experience social
Conclusion and future directions
Using the scientific literature from various disciplines, we organized the Drug War HIV/AIDS Inequities Model to serve as a tool for framing the relationship between policy, criminal justice practice, and HIV-related factors (stigma, sexual-networking, care-engagement, and risk behaviour) that impact HIV vulnerability and disparities. The model can not only guide intervention development to remediate racial/ethnic HIV disparities at various points of intervention, but also improve the
Conclusion
The Drug War HIV/AIDS Inequities Model posits that inequitable criminal justice practices facilitate HIV vulnerability through mechanisms that increase sexual risks and stigma. Policy and social interventions to reduce HIV risks associated with policing, incarceration, and post-incarceration have the potential to reduce racial/ethnic HIV disparities, particularly for African Americans. Future studies should test the Drug War HIV/AIDS Inequities Model, inform modifications when needed, and apply
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