Love on Lockdown: How Social Network Characteristics Predict Separational Concurrency Among Low Income African-American Women

Love on Lockdown: How Social Network Characteristics Predict Separational Concurrency Among Low Income AfricanAmerican Women Kelly M. King, Carl A. Latkin & Melissa A. Davey-Rothwell

Journal of Urban Health Bulletin of the New York Academy of Medicine ISSN 1099-3460 J Urban Health DOI 10.1007/s11524-015-9951-6

1 23

Your article is protected by copyright and all rights are held exclusively by The New York Academy of Medicine. This e-offprint is for personal use only and shall not be selfarchived in electronic repositories. If you wish to self-archive your article, please use the accepted manuscript version for posting on your own website. You may further deposit the accepted manuscript version in any repository, provided it is only made publicly available 12 months after official publication or later and provided acknowledgement is given to the original source of publication and a link is inserted to the published article on Springer's website. The link must be accompanied by the following text: "The final publication is available at link.springer.com”.

1 23

Author's personal copy Journal of Urban Health: Bulletin of the New York Academy of Medicine doi:10.1007/s11524-015-9951-6 * 2015 The New York Academy of Medicine

Love on Lockdown: How Social Network Characteristics Predict Separational Concurrency Among Low Income African-American Women Kelly M. King, Carl A. Latkin, and Melissa A. Davey-Rothwell ABSTRACT One out of nine African-American men between the ages of 20 and 34 is

behind bars, resulting in many African-American women losing their primary romantic partners to incarceration. Research suggests that partner incarceration may contribute to increased risk of sexually transmitted infections (STIs)/human immunodeficiency virus (HIV); however, factors associated with women’s decisions to begin new sexual partnerships following partner incarceration (i.e., separational concurrency) have not been well studied. This study examined the social context relevant to initiating separational concurrency, following incarceration of a primary male partner. Crosssectional secondary data analysis of 6-month follow-up data from the CHAT Project, a social-network based HIV/sexually transmitted disease (STD) prevention study in Baltimore, MD, USA. Participants were N=196 African-American women, who reported ever having had a partner who was incarcerated for at least 6 months during the relationship. The majority (81.5 %) of women were unemployed with a mean age of 41.7 years. Over half of the sample (59.5 %) reported having used crack or heroin at least once in the previous 12 months; 48.5 % of the women had experienced physical abuse, with over half of the sample reporting a lifetime history of emotional abuse (54.6 %). Separational concurrency, defined as answering yes to the item, BWhile [your] partner was incarcerated, did you have any other sexual partners?,^ was the primary outcome measure. After adjusting for age, drug use and unemployment the multiple logistic regression model found that women who reported a history of physical or emotional abuse were over two times as likely to report separational concurrency than women without an abuse history [adjusted odds ratio (AOR), 2.24; 95 % CI, 1.24, 4.05; p=.007 and AOR, 2.44; 95 % CI, 1.33, 4.46; p=.004, respectively]. Individuals who reported a higher number of drug-using sex partners (AOR, 2.49; 95 % CI, 1.4, 4.5; p=.002), sex exchange partners (AOR, 4.0; 95 % CI, 1.8 8.9; p=.001), and sexual partners who engaged in concurrency (AOR: 2.67; 95 % CI: 1.5, 4.8; p=.001) were significantly more likely to report separational concurrency. Conversely, participants who reported more female kin in their social networks (AOR, .808; 95 % CI, .67, .97; p=.025), having known network members a longer time (AOR, .997; 95 % CI, .993, .999; p=.043), and higher levels of trust for network members (AOR, .761; 95 % CI, .63, .92; p=.005) were significantly less likely to report separational concurrency. Results of this study demonstrate that social network characteristics may be crucial to understanding separational concurrency among African-American urban women who have lost a partner to incarceration. Social network and other resource-based interventions, which provide instrumental, social, and economic resources to women who have experienced the loss of a partner to incarceration, may be important tools in

King, Latkin, and Davey-Rothwell are with the Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21231, USA. Correspondence: Kelly M. King, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21231, USA. (E-mail: [email protected])

Author's personal copy KING ET AL.

empowering women and helping to reduce the disproportionate burden of STIs/HIV among low income, African-American women. KEYWORDS Incarceration, Separational concurrency, Social networks, HIV/AIDS prevention

BACKGROUND AND SIGNIFICANCE As of 2010, there were approximately 2.3 million individuals housed in state prisons and jails in the USA, representing more than a 300 % increase since 1980.1 The direct cost associated with keeping individuals behind bars has been estimated at $74 billion dollars per year,2 while the physical, emotional, and social Bcosts^ associated with incarceration are immeasurable. Huge racial disparities exist in rates of incarceration in the USA, with African-American men over six times more likely to be incarcerated than their white counterparts.3 Currently, one out of nine AfricanAmerican men between the ages of 20 and 34 is behind bars,4 resulting in many African-American women losing partners to incarceration. Incarceration has a significant impact on the public’s health. While institutionalized, individuals are at increased risk of infectious disease [e.g., human immunodeficiency virus (HIV), hepatitis C, tuberculosis],5,6 chronic diseases (e.g., diabetes, hypertension), and experience negative health outcomes associated with stigma and stress following release, regardless of length of sentence.7–9 Incarceration serves as a mediator for many of the social determinants of health in American society. Specifically, incarceration acts directly on access to housing, education, and employment—structures that underpin morbidity and mortality across domains of health.10 Incarceration shapes HIV risk indirectly by altering male/female ratios in neighborhoods, which has been associated with increased sexually transmitted infection (STI)/HIV prevalence at the community level.11–13 This relationship functions in two ways. First, diminishing the number of men in the community may directly increase HIV risk through partner concurrency. Here, gender redistribution results in a larger number of women having sex with a fewer number of shared male partners, increasing the chances of both contracting and infecting a larger proportion of partners, if any one male partner has an STI/HIV.14–16 Secondly, disparate male/female gender ratios in communities may exacerbate existing male dominant power dynamics in heterosexual relationships, further limiting women’s ability to negotiate condom use and monogamy, and placing them at increased risk for STI/HIV.17,18 A surplus of available female partners places an increased premium on the reduced number of Beligible^ male partners, lending more power to men in selecting mates or determining the nature of sexual relationships.19 Incarceration further impedes community and social network resources by limiting opportunities for economic advancement, both by removing men from the workforce and reducing opportunities for gainful employment upon reentering the community. Diminished access to traditional masculine domains (e.g., securing licit employment, providing financial stability) has been associated with increased intimate partner violence20,21 and the adoption of more traditional male dominant gender ideologies within interpersonal relationships.17,18,22 Adherence to such traditional gender ideologies has been found to be associated with greater HIV risk behavior among African-

Author's personal copy SOCIAL NETWORK CHARACTERISTICS AND SEPARATIONAL CONCURRENCY

American men, e.g., number of sexual partners and greater partner concurrency.23,24 Thus, there are a variety of complex and layered channels through which incarceration places low-income African-American women at increased risk of STI/ HIV simply by virtue of living in communities disproportionately impacted by the existing structure of the criminal justice system. Impact on Relationships Partner incarceration also places significant strain on primary romantic relationships. Previous research has estimated that approximately 40 % of relationships with men incarcerated for a month or longer dissolve at the time of incarceration.14 Among relationships which persist, stigma associated with being the wife or girlfriend of an incarcerated person may limit women’s access to much needed social and financial support, forcing women to rely more heavily on extended family members for instrumental assistance.25,26 The impact of partner incarceration may be especially severe for substance-abusing women, resulting in spikes in substance use25 or even the initiation of injection drug use27 in the weeks following incarceration events. A qualitative study by Gorbach and Stoner28 identified separational concurrency as a unique type of concurrent partnership, referring to the initiation of new sexual partnerships during periods of separation from a main partner as a result of factors such as geographical distance or incarceration. Separational concurrency, reported by many of the participants in the study, was most often with sexual partners termed Bfuckbuddies^ who participants reported having previous caring but nonintimate relationships with and who understood the temporary nature of the sexual partnership. For the majority of participants, condom use was much less likely when outside partners were Bfuckbuddies^ given the emotional, although nonmonogamous, nature of these relationships. Additionally, despite engaging in separational concurrency, the majority of participants did not report using condoms with their main partner when reunited, so as not to threaten the intimacy of these partnerships. Thus, the authors argue that separational concurrency likely places individuals at increased STI/HIV risk given the increased risk of outside infection from both outside and main partners.28 Separational concurrency is especially likely in response to partner incarceration. Adimora et al.29 found that participants who reported that any of their three most recent sexual partners had been incarcerated were significantly more likely to have had concurrent partnerships. As detailed above, separational concurrency is a risk factor for STI/HIV acquisition, and previous research has established a variety of pathways through which incarceration increases the potential for engaging in multiple, concurrent sexual partnerships.13–16 Little research to date, however, has tried to understand the impact of incarceration on sexual risk from the perspective of the women experiencing the incarceration of a primary partner. Thus, little is known about the underlying mechanisms motivating women to initiate or maintain separational concurrency in the wake of this major life change. One recent qualitative study by Cooper et al.25 assessed the pathways through which partner incarceration impacted the lives of N=17 substance-abusing women and found that, immediately following the incarceration of their primary partner, the majority of women were not emotionally ready to begin new romantic or sexual partnerships. Regardless, approximately 20 % (N=4) of women in the study reported initiating new sexual partnerships with male Bacquaintances,^ viewing these relationships as Bvital lifelines for survival^ in response to destabilization in housing and diminished income

Author's personal copy KING ET AL.

associated with partner incarceration.25 Results of this qualitative study also highlighted the absence of family support and heightened feelings of social isolation among women who lost an intimate partner to prison.25 No studies to date, however, have attempted to quantitatively assess separational concurrency despite its relevance to the sexual and emotional health of African-American women. Having a partner incarcerated is a life event that is often associated with changes across many domains of life (e.g., housing, income, social relationships). Previous qualitative work has begun to elucidate the pathways through which this experience places women at increased risk for HIV/AIDS;25 however, the factors associated with women’s engaging in separational concurrency following partner incarceration have not been adequately studied. Since partner incarceration is likely to cause disruptions in women’s social relationships, a social network approach is ideal for assessing the nature of such disruptions and identifying those women who may be most at risk for separational concurrency. Many studies have documented the protective or detrimental impact of social networks on health outcomes. In African-American communities, family has been found to play a particularly important protective role in relation to a variety of health outcomes.30,31 Specifically, drug users who reported more kin in their social networks were significantly less likely to engage in sex exchange.30 Strong familial relationships have also been found to provide women with emotional and instrumental support, reducing the need to depend on sexual partners for such resources.32 A recent study by Grieb, Davey-Rothwell, and Latkin33 found that individuals who reported more kin relationships and higher levels of trust for sexual partners were significantly less likely to engage in concurrent partnerships. Conversely, reporting a high number of network members who use drugs has been associated with multiple sexual partnerships,34 while reporting higher numbers of sexual network members with an STI is a risk factor for individual STI/HIV tramsmission.35 The objective of the current study is to build upon previous qualitative and social network research to better understand the social context relevant to engaging in separational concurrency following the incarceration of a primary male partner among low-income, African-American women in Baltimore. Study Context Baltimore City has one of the highest rates of incarceration in the country with nearly 35,000 city residents institutionalized or on probation/parole annually. Of the large number of individuals interfacing with the criminal justice system in Maryland, 56 % are from Baltimore City, although city residents only make up 11 % of the state’s overall population.36 Moreover, among cities in the USA with the largest jails, Baltimore has the highest percentage of its population in jail (with rates nearly three times that of New York City, Chicago, and Los Angeles), resulting in large numbers of men displaced from their communities.37 Our hypothesis, consistent with prior qualitative research, is that the social networks of women who engage in separational concurrency, following partner incarceration, will be less close and provide fewer resources compared with the social networks of women who do not initiate new sexual partnerships. METHODS This study was a cross-sectional analysis of 6-month follow-up data from the CHAT Project, a social-network-based HIV/STI prevention study in Baltimore, MD, USA.

Author's personal copy SOCIAL NETWORK CHARACTERISTICS AND SEPARATIONAL CONCURRENCY

Eligibility criteria for the CHAT project included being female, African American, age 18–55, a current Baltimore city resident, no injection drug use in the past 6 months, reported heterosexual activity in the past 6 months, and any of the following: sex with two or more partners, having a high sexual risk partner in the past 90 days (e.g., partner who engaged in injection drug use, crack use, paid for commercial sex, or had sex with another man), and receiving an STI diagnosis in the past 6 months. Recruitment for index participants took place at local health clinics, community agencies, and through street outreach. Additionally, network members identified by index participants were also recruited into the study. Participants in the present study included a subset of 196 (30.9 %) African-American women from the parent study, who reported ever having had a male partner who was incarcerated for at least 6 months during the relationship. After obtaining written informed consent, participants answered survey questions assessing individual and social network factors. Participants were compensated $35 for returning for the 6-month visit. All study procedures were approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board.

Measures Partner incarceration was assessed with one yes/no item, which asked, BHave you EVER had a sexual partner who was incarcerated for at least 6 months during the relationship?^ Employment status was assessed with one yes/no item, which asked participants whether or not they had been employed in the previous 6 months. Separational concurrency was measured with one yes/no item, which asked participants, BWhile [your] partner was incarcerated, did you have any other sexual partners?^ Abuse history was measured with two yes/no items, which asked participants, BHave you ever experienced physical abuse?^ and BHave you ever experienced emotional abuse?^ Drug use was assessed with one yes/no item, which asked participants, BIn the past 12 months, have you used heroin or cocaine in any form?^ Social network variables were collected using an inventory, comprised of data from participants about their social network members. Participants were asked to report the first name and last initial of individuals who provide material, emotional, and informational social support and then provide information about the nature of their relationship with these individuals. Network characteristics assessed in the current study included items such as the participant’s number of current sexual partners who used drugs, number of current sexual partners that provided resources to participants in exchange for sex, the number of STID-positive sexual partners the participant had in the past 90 days, and the number of current sexual partners who had other concurrent sexual partners. Questions designed to assess the nature of relationships between participants and network members were also incorporated into the analysis, including the following items: level of trust participants felt towards their network members, length of time (in months) they had known network members, and how many network ties were female kin.37,38 To assess trust for network members, participants were to rate how much they trusted each of their network members using a 10-point likert scale, with response options ranging from 1—BDon’t trust at all^ to 10—BTrust with my life,^ with higher scores represented higher levels of trust. The internal consistency for the network inventory was .85,

Author's personal copy KING ET AL.

with an estimated test–retest reliability of 80 % for persons the respondents reported encountering regularly.39 Data Analysis The primary outcome for this study was the dichotomous variable measuring incarceration-related separational concurrency, which asked whether or not participants had other sexual partners while their main partner was incarcerated (yes/no). First, chi-squared tests for categorical variables and t tests for continuous variables were conducted to assess bivariate relationships between predictor variables and separational concurrency (Table 1). Next, logistic regression models were constructed to examine the extent to which individual and social network characteristics were predictive of separational concurrency. AIC scores and likelihood ratio tests were used to identify insignificant variables in order to derive the final model. The Hosmer and Lemeshow goodness-of-fit test was used to determine the goodness of fit for the final model.40 Data were analyzed using Stata 13.1. RESULTS Full descriptive statistics for the sample are presented in Table 1. Out of the N=196 participants included in the present analysis, the majority 81.5 % were unemployed with a mean age of 41.7 years. Over half of the sample (59.5 %) reported having used crack or heroin at least once in the previous 12 month, and 48.5 % of the women had experienced physical abuse, with over half of the sample reporting a lifetime history of emotional abuse (54.6 %). In terms of network characteristics, women reported a mean social network size of 7.21, with an average of 2.37 female kin network members. On average, they reported knowing their network members for 225.4 months, with a mean trust score of 8.38. Women who engaged in separational concurrency were significantly more likely to report a history of physical (p=.015) and emotional abuse (p=.015), lower mean ages (p=.029), and a higher number of sexual partners with a sexually transmitted disease (STD) (p=.041), who they received resources from in exchange for sex (p=.0001), who reported having other concurrent partnerships (pG.001), and who used drugs (p=.005), compared to women who did not engage in separational concurrency. Finally, women who engaged in separational concurrency reported knowing network members for significantly shorter periods of time (p=.008) and having lower levels of trust for network members (p=.004). Results of logistic regressions (see Table 2 for crude OR and 95 % confidence intervals) showed that women who engaged in separational concurrency were significantly more likely to be younger (p=.031), have experienced physical (p=.016) or emotional abuse (p=.015), have more sex partners who provide them resources in exchange for sex (p=.001), more sex partners who have other concurrent partnerships (p=.001), and more drug using sex partners (p=.007). Additionally, they have known network members for shorter amounts of time (p=.009), have lower levels of mean trust for network members (p=.006), and have weaker overall social networks, compared to women who did not engage in separational concurrency (pG.001) (Table 2). After testing for potential effect modification between network strength and drug use, age, and unemployment by creating interaction terms and adding them to potential models, none of these contributed significantly to the final model. The

Author's personal copy SOCIAL NETWORK CHARACTERISTICS AND SEPARATIONAL CONCURRENCY

TABLE 1

Baseline characteristics Separational concurrency

Demographics Employment status (%) Unemployed Physical abuse (%) Yes Emotional abuse (%) Yes Drug use in past year (%) Yes Age (years) Mean SD Network characteristics Total no. of nets in network Mean SD No. of sex partners in network with STD Mean SD No. of sex partners in network exchange $ for sex Mean SD No. of sex partners in network with concurrency Mean SD No. of drug using sex partners Mean SD No. of female kin in network Mean SD Mean length of time known nets Mean SD Mean trust for nets Mean SD

Yes (n=98)

No (n=98)

Total (n=196)

85.7

77.6

81.5

57.14

39.8

63.3

45.92

58.16

61.22

40.49 7.98

42.9 7.92

41.67

7.48 2.93

6.94 3.16

7.21

p value 0.14 .016* 48.47 .015* 54.6 .662 59.5 .029*

.213

.041* .144 .465

.041 .199

.092

.536 1.07

.714 .296

.304

.629 1.15

.122 .359

.374

.474 .663

.245 .455

.359

.0001**

.000***

.005**

.081 2.16 1.51

2.58 1.79

2.37 .008**

205.6 94.5

233.87 108.2

225.4 .004**

8.03 1.74

8.72 1.57

8.38

*pG.05, **pG.01, ***pG.001

adequacy of fit for the final multiple logistic regression model was assessed with the Hosmer–Lemshow goodness-of-fit test, which resulted in a chi-square of 1.87, with a p value of .985, indicating that the model was an appropriate fit for the data. After adjusting for age, unemployment and drug multiple logistic regression models found that women who reported a history of physical or emotional abuse were over two times as likely to report separational concurrency than women without an abuse history [adjusted odds ratio (AOR), 2.24; 95 % CI, 1.24, 4.05;

Author's personal copy KING ET AL.

TABLE 2

Crude and adjusted relative odds of separational concurrency Adjusteda

Crude

Unemployed Age (in years) Used drugs in past year Physical abuse Emotional abuse No. of sex partners with STD No. of sex partners exchange $ for sex No. of sex partners with concurrency No. of drug using sex partners No. of female kin in network Mean length of time known nets Mean trust for nets

p value

AOR

95 % CI

p value

(.83–3.6) (.927–.996) (.497, 1.56) (1.14, 3.56) (1.15, 3.59) (.962, 7.29)

0.143 0.031 0.662 0.016 0.015 0.059

1.91 .959 .924 2.24 2.44 2.69

(.891, (.924, (.505, (1.24, (1.33, (.918,

.096 .028* .797 .007** .004** .071

3.95

(1.81, 8.62)

0.001

4.00

(1.8, 8.89)

.001**

2.71

(1.53, 4.83)

0.001

2.67

(1.47, 4.84)

.001**

2.07

(1.22, 3.49)

0.007

2.49

(1.40, 4.45)

.002**

.835

(.463, 1.50)

0.549

.808

(.670, .973)

.025*

.996

(.993, .999)

0.009

.997

(.993, .999)

.043*

.769

(.637, .929)

0.006

.761

(.628, .922)

.005**

OR

95 % CI

1.74 .961 .880 2.02 2.03 2.65

4.09) .996) 1.69) 4.05) 4.46) 7.88)

a

Adjusted model controls for age, unemployment and drug use

*pG.05, **pG.01, ***pG.001

p=.007 and AOR, 2.44; 95 % CI, 1.33, 4.46; p=.004, respectively]. Individuals who reported a higher number of drug using sex partners (AOR, 2.49; 95 % CI, 1.4, 4.5; p=.002), sex exchange partners (AOR, 4.0; 95 % CI, 1.8 8.9; p=.001), and sexual partners who engaged in concurrency (AOR, 2.67; 95 % CI, 1.5, 4.8; p = .001) in their sexual networks were significantly more likely to report separational concurrency. Conversely, participants who reported more female kin in their social networks (AOR, .808; 95 % CI, .67, .97; p=.025), having known network members a longer time (AOR, .997; 95 % CI, .993, .999; p=.043), and higher levels of trust for network members (AOR, .761; 95 % CI, .63, .92; p=.005) were significantly less likely to report separational concurrency. DISCUSSION Results of this study demonstrate that social network characteristics may be crucial to understanding separational concurrency among African American urban women who have lost a partner to incarceration. Women who engaged in separational concurrency had Bweaker^ established networks, marked by lower mean levels of trust, knowing network members for shorter lengths of time, fewer female family ties, and more high risk sexual partnerships. These results mirror the qualitative findings from the study of Cooper et al. 25, which suggested that new relationships formed following partner incarceration were frequently transactional in nature and often linked to drug use. Additionally, they are in line with previous social network research, which has found familial relationships, higher levels, or trust and fewer drug using network members to be protective against sexual risk behavior.33–35

Author's personal copy SOCIAL NETWORK CHARACTERISTICS AND SEPARATIONAL CONCURRENCY

These findings suggests that many women may not have the luxury of turning to family/friends for instrumental, financial, and social support after losing a partner. Our survey did not ask directly about the stigma associated with losing a partner to incarceration, but future research should investigate the impact of such stigma (as well as the stigma associated with engaging in separational concurrency) on the strength of social ties with family members, friends, and sexual partners. Although the present study contributes significantly to the extant literature, there are several limitations worth noting. First, due to the cross-sectional nature of the data, it is impossible to parse out the directionality of the relationships observed. The social network data refers to participants’ current social networks, which may or may not coincide with social networks at the time of their partners to incarceration. As such, it is possible that, instead of social network characteristics placing participants at increased risk of separational concurrency, the act of engaging in separational concurrency alters social networks in key ways. For example, it could be that relationships with incarcerated partners draw participants away from their kin network (both before and after incarceration). Furthermore, drug use may lead women away from support networks and increase the likelihood of beginning a relationship with partner who will be incarcerated. Future longitudinal quantitative research, which can establish temporality, should critically evaluate these relationships over time. Additionally, the majority of our sample reported unemployment in the previous 6 months, and it was found to be a strong predictor of separational concurrency. Future research should include participants with a wider range of socioeconomic stability in order to more closely assess the impact of class on this outcome. Similarly, future samples should include comparison groups of white women who have lost partners to incarceration to more carefully parse out the impact and intersections of race and class. Social-network-based interventions, which provide instrumental, social, and economic resources to women who have experienced the loss of a partner to incarceration, may be important tools in reducing the disproportionate burden of STIs/HIV among low-income, African-American women. As we see from the current analysis, half of the participants in our study initiated new, high-risk sexual partnerships following the incarceration of their partner, while the remainder did not. This finding alone provides support for the necessity of targeted research, campaigns, and interventions, which move beyond conceptualizing low-income African American women as a discrete Brisk group^ to provide a more nuanced understanding of incarceration impacts the communities men leave behind. Interventions focused directly on women who have incarcerated partners to enhance their current social network relationships, especially with female kin, may help to reduce the negative impact of separational concurrency, which may result from seeking potentially high risk partners out of emotional and physical need. It is also important to take note of the high rates of physical and emotional abuse experienced by women who engage in separational concurrency. In the case of abuse, women with scarce financial resources do not have as many alternatives in the face of abusive relationships, compared to women with more secure socioeconomic status. Additionally, women of color experience discrimination in hiring, more intensive childcare obligations, and often even further barriers to seeking help in the face of intimate partner violence (e.g., cultural pressure not press charges in response to domestic violence and further contribute to the disproportionate incarceration of African American men).41 Although we are unable to infer causality from the findings of the present study, it seems likely that instability in housing,

Author's personal copy KING ET AL.

social support, and finances following partner incarceration may activate these layered dimensions of risk, helping us to understand women’s decisions to enter into sexual partnerships with men who are active drug users, are engaging in concurrent partnerships, or in exchange for much needed resources. As such, these findings point to a pressing need for increased resources and attention devoted to drug treatment and employment opportunities in this population. ACKNOWLEDGMENTS Research reported in this publication was supported by the National Institute on Mental Health (R01 MH66810 & 1K01MH096611-01A1), the National Institute on Drug Abuse (R01 DA016555) and the Johns Hopkins Center for AIDS Research (1P30AI094189). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

REFERENCES 1. Pew Charitable Trusts. Collateral costs: incarceration’s effect on economic mobility. Washington, DC: The Pew Charitable Trusts; 2010. 2. Pew Charitable Trusts. Prison count 2010: state population declines for the first time in 3 8 y e a r s . h t t p : / / w w w. p e w s t a t e s . o r g / u p l o a d e d F i l e s / P C S _ A s s e t s / 2 0 1 0 / Pew_Prison_Count_2010.pdf. Accessed April 2010. 3. Mauer M, King RS. Uneven justice: state rates of incarceration by race and ethnicity. Washington, DC: The Sentencing Project; 2007. 4. Pew Charitable Trusts. One in 100: behind bars in America 2008. Washington, DC: The Pew Charitable Trusts; 2008. 5. Freudenberg N. Jails, prisons, and the health of urban populations: a review of the impact of the correctional system on community health. J Urban Heal. 2001. http:// link.springer.com/article/10.1093/jurban/78.2.214. Accessed May 20 2014. 6. Dumont D, Brockmann B. Public health and the epidemic of incarceration. Public Heal. 2012. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3329888/. Accessed May 20 2014. 7. Schnittker J, John A. Enduring stigma: the long-term effects of incarceration on health. J Health Soc Behav. 2007. http://hsb.sagepub.com/content/48/2/115.short. Accessed May 20 2014. 8. Wilper A, Woolhandler S. The health and health care of US prisoners: results of a nationwide survey. Public Heal. 2009. http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2661478/. Accessed May 20 2014. 9. Dumont D, Allen S. Incarceration, community health, and racial disparities. Heal care. 2013. http://muse.jhu.edu/journals/journal_of_health_care_for_the_poor_and_underserved/v024/ 24.1.dumont.html. Accessed May 20 2014. 10. Maryland Department of Public Safety and Correctional Services. Maryland Division of Correction, Annual Report FY2010. Baltimore, Maryland: The Division; 2010. 11. Thomas J, Gaffield M. Social structure, race, and gonorrhea rates in the southeastern United States. Ethn Dis. 2003; 13: 362–8. http://www.ishib.org/ED/journal/ethn-13-03362.pdf. Accessed May 15, 2014. 12. Thomas JC, Sampson LA. High rates of incarceration as a social force associated with community rates of sexually transmitted infection. J Infect Dis. 2005; 191(Suppl 1): S55– 60. doi:10.1086/425278.

Author's personal copy SOCIAL NETWORK CHARACTERISTICS AND SEPARATIONAL CONCURRENCY

13. Thomas JC. From slavery to incarceration: social forces affecting the epidemiology of sexually transmitted diseases in the rural South. Sex Transm Dis. 2006; 33(7 Suppl): S6– 10. doi:10.1097/01.olq.0000221025.17158.26. 14. Khan M, Behrend L. Dissolution of primary intimate relationships during incarceration and associations with post-release STI/HIV risk behavior in a southeastern city. Sex Transm Dis. 2011; 38(1): 43–7. doi:10.1097/OLQ.0b013e3181e969d0.DISSOLUTION. 15. Adimora AA, Schoenbach VJ, Doherty IA. Concurrent sexual partnerships among men in the United States. Am J Public Health. 2007; 97(12): 2230–7. doi:10.2105/ AJPH.2006.099069. 16. Pouget E, Kershaw T. Associations of sex ratios and male incarceration rates with multiple opposite-sex partners: potential social determinants of HIV/STI transmission. Public Heal. 2010; 125(Suppl 4): 70–80. http://www.pubmedcentral.nih.gov/ articlerender.fcgi?artid=2882977&tool=pmcentrez&rendertype=abstract. Accessed May 15, 2014. 17. Wingood G, DiClemente R. Application of the theory of gender and power to examine HIV-related exposures, risk factors, and effective interventions for women. Heal Educ Behav. 2000; 27(5): 539–65. http://www.ncbi.nlm.nih.gov/pubmed/11009126. Accessed May 15, 2014. 18. Kerrigan D, Andrinopoulos K, Chung S, Glass B, Ellen J. Gender ideologies, socioeconomic opportunities, and HIV/STI-related vulnerability among female, AfricanAmerican adolescents. J Urban Health. 2008; 85(5): 717–26. doi:10.1007/s11524-0089292-9. 19. Adimora A. Social context of sexual relationships among rural African Americans. Sex Transm. 2001. http://journals.lww.com/stdj ournal/Abstract/2001/02000/ Social_Context_of_Sexual_Relationships_Among_Rural.2.aspx. Accessed May 19 2014. 20. Cunradi C, Caetano R, Schafer J. Socioeconomic predictors of intimate partner violence among white, black, and Hispanic couples in the United States. J Fam Violence. 2002. http://link.springer.com/article/10.1023/A:1020374617328. Accessed May 20 2014. 21. Reed E, Raj A, Miller E, Silverman J. Losing the Bgender^ in gender-based violence: The missteps of research on dating and intimate partner violence. Violence Against Women. 2010. http://www.cce.csus.edu/conferences/cdph/evaw_tdv10/docs/confMaterials_v2/ 3B.LosingGenderin GenderBasedViolence_ElizabethReed.pdf. Accessed May 20 2014. 22. Sobo E. Finance, romance, social support, and condom use among impoverished innercity women. Hum Organ. 1995. http://sfaa.metapress.com/index/ g568548023132n37.pdf. Accessed May 20 2014. 23. Bowleg L, Teti M, Massie J. BWhat does it take to be a man? What is a real man?^: ideologies of masculinity and HIV sexual risk among Black heterosexual men. Cult Heal. 2011. http://www.tandfonline.com/doi/abs/10.1080/13691058.2011.556201. Accessed May 20 2014. 24. Carey M, Senn T, Seward D, Vanable P. Urban African-American men speak out on sexual partner concurrency: findings from a qualitative study. AIDS Behav. 2010. http:// link.springer.com/article/10.1007/s10461-008-9406-0. Accessed May 20 2014. 25. Cooper HL, Clark CD, Barham T, Embry V, Caruso B, Comfort M. BHe was the story of my drug use life^: a longitudinal qualitative study of the impact of partner incarceration on substance misuse patterns among african american women. Subst Use Misuse. 2013:176–188. doi:10.3109/10826084.2013.824474 26. Browning S, Miller R, Spruance L. Dividing the ties that bind: black men and their families. J Afr Am Men. 2001; 6(1): 87–102. 27. Payne J. Women drug users in North Cumbria: what influences initiation into heroin in this non-urban setting? Sociol Health Illn. 2007; 29(5): 633–55. doi:10.1111/j.14679566.2007.01016.x. 28. Gorbach P, Stoner B. BIt takes a village^: understanding concurrent sexual partnerships in Seattle, Washington. Sex Transm. 2002. http://journals.lww.com/stdjournal/Abstract/2002/ 08000/_It_Takes_a_Village___Understanding_Concurrent.4.aspx. Accessed May 19 2014.

Author's personal copy KING ET AL.

29. Adimora AA, Schoenbach VJ, Martinson F, Donaldson KH, Stancil TR, Fullilove RE. Concurrent sexual partnerships among African Americans in the rural south. Ann Epidemiol. 2004; 14: 155–60. doi:10.1016/S1047-2797(03)00129-7. 30. Latkin C, Hua W, Forman V. The relationship between social network characteristics and exchanging sex for drugs or money among drug users in Baltimore, MD, USA. Int J STD. 2003. http://std.sagepub.com/content/14/11/770.short. Accessed May 19 2014. 31. Taylor R, Roberts D. Kinship support and maternal and adolescent well-being in economically disadvantaged African-American families. Child Dev. 1995. http:// onlinelibrary.wiley.com/doi/10.1111/j.1467-8624.1995.tb00953.x/full. Accessed May 19, 2014. 32. Senn T, Scott-Sheldon L. Sexual partner concurrency of urban male and female STD clinic patients: a qualitative study. Arch Sex. 2011. http://link.springer.com/article/10.1007/ s10508-010-9688-y. Accessed May 19 2014. 33. Grieb SMD, Davey-Rothwell M, Latkin CA. Social and sexual network characteristics and concurrent sexual partnerships among urban African American high-risk women with main sex partners. AIDS Behav. 2012; 16(4): 882–9. doi:10.1007/s10461-0110030-z. 34. Pilowsky D, Hoover D. Impact of social network characteristics on high-risk sexual b e ha v i o r s a m o n g n o n - i n j e c t i o n d r u g u s e r s . S u b s t U s e . 2 0 0 7 . h t t p : / / informahealthcare.com/doi/abs/10.1080/10826080701205372. Accessed May 19 2014. 35. Aral SO, Adimora AA, Fenton KA. Understanding and responding to disparities in HIV and other sexually transmitted infections in African Americans. Lancet. 2008; 372(9635): 337–40. doi:10.1016/S0140-6736(08)61118-6. 36. Walsh N. Baltimore behind bars: how to reduce the jail population, save money and i m p r o v e p u b l i c s a f e t y. 2 0 1 0 . h t t p s : / / w w w. n c j r s . g o v / A p p / P u b l i c a t i o n s / abstract.aspx?ID=252877. Accessed May 15 2014. 37. Latkin C, Mandell W, Vlahov D, Oziemkowska M, Celentano D. People and places: behavioral settings and personal network characteristics as correlates of needle sharing. JAIDS J Acquir Immune Defic Syndr. 1996; 13(3): 273–80. 38. Latkin CA, Knowlton AR, Hoover D, Mandell W. Drug network characteristics as a predictor of cessation of drug use among adult injection drug users: a prospective study. Am J Drug Alcohol Abuse. 1999; 25(3): 463–73. 39. Barrera M. A method for assessing social support networks in community survey research. Connections. 1980; 3: 8–13. 40. Lemeshow S, Hosmer D. A review of goodness of fit statistics for use in the development of logistic regression models. Am J Epidemiol. 1982. http://aje.oxfordjournals.org/ content/115/1/92.short. Accessed May 15 2014. 41. Crenshaw K. Mapping the margins: intersectionality, identity politics, and violence against women of color. Stanford Law Rev. 1991. http://www.jstor.org/stable/1229039. Accessed May 20 2014.