People who are HIV positive and who have been in prison face challenges accessing services.

By Hyun Namkoong

Graham Cotton smokes a rolled cigarette in the backyard of his home, which still bears the scorch marks from a kitchen fire in November. Bags of clothes, old mattresses and assorted items lay discarded in the yard while he talks about the choices he has made, and how he has survived since he was diagnosed with HIV in prison a decade ago.

Graham Cotton
Graham Cotton. Photo credit: Hyun Namkoong

“I’m a walking miracle, and people don’t even see that up and down Franklin Street,” said Cotton, who is 42 years old and lives just outside Chapel Hill.  “I’m supposed to be full-blown [AIDS], right now today. Supposed to be dead.”

Cotton believes he contracted HIV in prison, but it’s hard to know for sure because for years North Carolina did not routinely test inmates as they entered and left prison.

In North Carolina, there are more than 37,000 people in prison. In 2008, the state ranked sixth in the nation for the number of state inmates who are HIV positive.

HIV care behind bars

North Carolina policy now mandates HIV screening upon intake of all inmates, followed by additional screening every four years and then a final test before release. The federal and state prison systems are required by law to provide care for inmates who test positive for HIV.

“I got diagnosed in ’94 at Central [Prison],” Cotton said.

“They have appointments every three to six months, just like somebody outside of prison. The care is provided by UNC Infectious Disease,” said Carol Golin, a health-behavior researcher at UNC-Chapel Hill’s Gillings School of Public Health.

The highly controlled prison environment restricts access to substances such as crack cocaine and heroin, which are risk factors for HIV infection and can reduce the effectiveness of antiretroviral therapy.

“People in prison actually do better on HIV therapy than people in the community, said David Wohl, co-director for HIV Services for the N.C. Department of Corrections and an associate professor at UNC-Chapel Hill.

The prison regimen of meals, a place to sleep and access to health care improves people’s responses to HIV treatment.

“It’s this three-hots-and-a-cot phenomenon,” he said.

Juggling meds, food, shelter, job

Once released, former prisoners are provided with a 30-day supply of antiretroviral drugs and are linked up with HIV care coordinators who help them make appointments on the outside.

But the sudden transition from prison to the outside can be a jarring experience for some, especially people who have little social support.

“We didn’t have a place to live, no money coming in,” Cotton said. “Off and on, we was [living] on the streets.”

Graham Cotton shows the back of his house, where a kitchen fire last winter destroyed part of the structure.
Graham Cotton shows the back of his house, where a kitchen fire last winter destroyed part of the structure. Photo credit: Hyun Namkoong

“[People] need to prioritize a place to live, trying to get work, having an income,” Golin said. “There are a lot of practical barriers. There may be stigma about going to the doctor.”

Tasks such as getting transportation for doctor’s appointments, paying for health care and achieving some semblance of financial security can be difficult for people who are both formerly incarcerated and HIV positive.

A criminal record sends red flags to employers, who are often unwilling to hire people who have been incarcerated. Federal zero-tolerance policies also prohibit anyone who has a criminal record related to a drug conviction from accessing government services such as housing assistance or loans for college.

Agencies such as XDS Inc. provide transportation and support for clients who are developmentally disabled and struggling with an addiction to substances, as is the case with Cotton.

“Off and on, I was taking medicine, but I was in the world of drugs,” Cotton said of his life after prison. “And I didn’t have an agency like XDS to treat me as a client.”

Upon release from prison, people often return to their hometowns. But, ironically, that can increase their risk of recidivism or relapse into substance abuse because they return to old networks, old streets and old habits.

Forty percent of North Carolinians released from prison in fiscal year 2010-11 were re-arrested within two years of release.

“[People] are back in environments that can be toxic,” Wohl said.

Changing policy

Researchers say that policies need to change in order to help former inmates with HIV be more successful once they’re released. But there are many hurdles to overcome and the problem is so multifaceted that it eludes an easy fix.

Researchers can measure incidence rates and demographics, but they say it’s harder to measure what are known as “structural factors,” things like poverty and criminal-justice policies.

Researcher Carol Golin in her office at UNC-Chapel Hill.
Researcher Carol Golin in her office at UNC-Chapel Hill. Photo credit: Hyun Namkoong

“I do behavioral interventions, but they can only do so much when people are faced with environmental constraints that just make it really, really, really hard to be successful,” Golin said.

Wohl pointed to incarceration rates that disproportionately affect black communities as an example of a problem that requires “bigger, sweeping changes” in order to make a “lasting, durable impact.”

Blacks represent 57 percent of the state’s prison population but only 22 percent of the general population.
HIV infection rates are also highest in the black population.

Experts say there’s a relationship between the high incarceration rate and the high HIV rate, calling them parallel epidemics affecting people who have limited access to health care.

“I think Medicaid expansion would be fantastic for most of our folks,” Wohl said. “To not expand Medicaid to cover hundreds of thousands of people I think is just going to doom people to continue in this cycle.”

Researchers say the parallel epidemics in black America result in communities that are left behind to grapple with the loss of a significant number of their members.

“This needs to change, and people aren’t that aware of it,” Golin said. “[I]t affects all of us, not just people who are incarcerated.”

Creative Commons License

Republish our articles for free, online or in print, under a Creative Commons license.

Hyun Namkoong

Hyun graduated from the UNC-Chapel Hill Gillings Global School of Public Health in the health behavior department and she worked as the NC Health News intern from Jan-Aug 2014.