Date of Award

January 2019

Document Type


Degree Name

Medical Doctor (MD)



First Advisor

Jaimie P. Meyer


Background: The number of women involved in criminal justice systems (WICJ) and women who use opioids has been dramatically increasing in the United States. An often-overlooked aspect of healthcare for women at risk of HIV infection (either WICJ or women who use drugs) is reproductive health. We aim to provide a framework, informed by a systematic review and primary data, to guide future interventions addressing the sexual and reproductive health (SRH) needs of women at risk of HIV infection.

Methods: We completed a systematic literature review of the pregnancy prevention and planning needs of US WICJ published in English from 2000-2018. We identified 2,674 articles and three independent reviewers determined that 24 articles (14 descriptive studies in adults, 6 descriptive studies in adolescents and 3 interventional studies) met inclusion criteria. In parallel, a reproductive health assessment was administrated to 76 women enrolling in two ongoing HIV prevention studies (either WICJ or women who use drugs on drug treatment (WWUD)) and analyzed in the context of the Behavioral Health Model for vulnerable populations.

Results: The literature review demonstrates contraception underutilization and negative pregnancy attitudes among WICJ (in a wide variety of settings), resulting in frequent negative SRH outcomes (unintentional pregnancies, abortions and miscarriages). Our survey of 59 WICJ and 18 WWUD demonstrates multiple sociocultural, medical and psychiatric comorbidities that predispose women to health care underutilization, producing incongruent SRH behaviors (58.1% do not use contraception, while only 10.5% want more children) and negative SRH outcomes (75% report teenage pregnancy, 45%/ 48% have a history of miscarriage and abortions, respectively, and over two-thirds have a prior unplanned pregnancy). Despite this, 90.5% have received some up-to-date preventative SRH care.

Conclusion: Overall, WICJ and WWUD in need of HIV prevention interventions are also at risk of multiple negative SRH outcomes. Connections to the criminal justice system and drug treatment facilities offer opportunities to address the multilevel barriers to care faced by these populations. Women at risk of HIV infection need targeted, gender-responsive, trauma-informed interventions that incorporate HIV and pregnancy prevention while addressing the multiple structural, interpersonal and sociocultural barriers specific to these populations.


This thesis is restricted to Yale network users only. It will be made publicly available on 06/01/2022