Barriers to HIV Prevention for People Who Exchange Sex
Ninety-five percent of the 169 individuals Human Rights Watch interviewed indicated that they had received HIV prevention information, with one out of four having received such information in the last week, and three out of four having received it in the last year. Participants reported receiving HIV prevention information from their medical providers, outreach services, school, friends, and while in jail.
However, despite high levels of HIV prevention and testing awareness, Human Rights Watch found that for many people who exchange sex for money, drugs, or life necessities in New Orleans, the ability to protect themselves from HIV remains out of reach. Human Rights Watch identified two substantial barriers to HIV prevention in New Orleans: 1) lack of access to clean syringes for injection drug users; and 2) the harassment by police of individuals for carrying condoms—in effect, the criminalization of condom possession.
The lack of clean needles in New Orleans has a devastating effect on the ability of people who inject drugs to protect themselves from HIV and hepatitis C. The 30 injection drug users interviewed who exchange sex for money, drugs, or life necessities ranged in age from 19 to 55. Their survey responses reveal that these individuals live a fragile existence: 53 percent live in housing situations that they consider to be “unstable”; 93 percent are unemployed; 80 percent have no health insurance; 80 percent had been arrested for prostitution; and, 96 percent had spent time in jail. Only 13 percent reported “never” sharing needles, and when asked the reason that needles were shared, 70 percent reported that “clean needles were not available.” Some declined to answer, but nearly half of the injection drug users who answered the question reported that they have HIV, and 53 percent reported having hepatitis C.
Of those who reported living with HIV, 64 percent of people injecting drugs were in treatment. In contrast, only 17 percent of individuals who said that they had hepatitis C reported receiving treatment. Figure 4 provides a summary of their answers to selected questions about housing, incarceration and other issues.
The stark reality is that the public health system has utterly failed to protect these individuals from two extremely serious but fully preventable diseases. Camilla, an injection drug user who has lived in New Orleans for 17 years, told Human Rights Watch she has seen people buy dirty needles for five dollars due to shortages in the city. She said that, “I don’t understand why there is no harm reduction here, no clean needles for people. It is such a simple thing. Why should people have to suffer?”
Police Harassment for Possession of Condoms
Municipal court records show approximately 300 misdemeanor arrests a year since January 2011 for prostitution, solicitation of prostitution, prostitution loitering, and crimes against nature for compensation. However, Human Rights Watch found that many complaints about police activity involve street harassment that does not necessarily result in arrest. Specifically, individuals reported that police stops for suspected prostitution frequently included the officer associating an individual’s possession of condoms with criminal activity. Human Rights Watch has documented this practice in other major US cities and found that when police comment on, confiscate or threaten arrest based on condom possession as evidence of prostitution; this reduces condom use among sex workers and those perceived to be sex workers. Both the survey results and individual testimonies indicate that this practice and its harmful consequences are a substantial problem in the streets of New Orleans.
In response to the question “Have you been harassed by police for carrying condoms?”, 44 of 169 participants (26 percent) responded in the affirmative, with 15 reporting that this incident had occurred in the last six months, and one reporting harassment for condoms only two days earlier. Further analysis showed that the practice significantly impacted transgender women, as 24 of the 44 persons who had experienced harassment for condoms were transgender women, 16 were non-transgender women, and three were men (Figure 5).
Juliet, an African-American transgender woman, 31, described the following incident with a police officer, which occurred in August 2011:
He was going through my purse calling me a “thing” and asking me what I needed all those condoms for. He ran my name and luckily that time I didn’t have no attachments so he let me go with a warning. 
Anna, a white transgender woman, 35, said that in 2012:
I was driving and I was pulled over and he searched me and found [condoms] and told me I was disgusting and a disgrace to America.
Cleo, a white woman, 36, said that in March 2013:
In the French Quarter I was at [a bar] with a man and the cops asked only the trans women to go outside and they searched us. If we had condoms we got arrested for attempted solicitation.
Barbara, a 26-year-old African-American transgender woman, stated:
I was walking down the street and I was stopped by the police and they searched me for condoms and called me a whore.
According to the Office of the Public Defender, condoms are not used to support prostitution charges in court in Louisiana. But our research found that this police harassment for carrying condoms remains harmful for individuals and for public health. Even one incident can spread quickly by word of mouth and discourage others from carrying condoms for fear of arrest. Fifty-eight of 169 respondents (36 percent) said they have carried fewer condoms than they needed for fear of trouble from the police. One African-American transgender woman said she had not been personally harassed for condom possession but was still fearful because she has “seen the harassment by police happen to others.” Another stated, “I’ve seen other girls being harassed and I learn to be cautious. I hide [condoms] under my wigs.”
In other US cities, some sex workers have reported to Human Rights Watch that their fear of carrying condoms has resulted in unprotected sex with clients. Similarly, in New Orleans, we found that 48 of 169 people surveyed (30 percent) stated that their fear of carrying condoms due to police harassment has resulted in unprotected sex. Selena, a 24-year-old African-American transgender woman, stated:
I’ve seen my friends harassed by police officers while I was on the block trying to earn some money and it made me afraid to carry condoms. … I see them go to jail for it so I know not to do it. Then I try not to let the customer penetrate me without a condom.
Police Profiling, Abuse and Misconduct
Individuals we spoke with indicated that harassment for condoms was often accompanied by other human rights violations including profiling of transgender women for prostitution, verbal abuse, and in some cases sexual misconduct. Sheryl, an African-American transgender woman, 24, said:
I was leaving the drop in clinic when police stopped me, searched my purse and found the condoms I just got from the drop in clinic..asked me was I working because I was arrested for prostitution in the past. They just kept trying to convince me I was working when I was really on my way back to my room.
Frannie, a 26-year-old white transgender woman stated:
In the French Quarter they harassed me and ran my name and found I had sex convictions…. He asked me if I was a transvestite which is crazy because that is very disrespectful. Then he asked to see my purse and he took the condoms from me and said, “What are you doing with all these? Your faggot ass probably got AIDS already. Now get off the streets and don’t let me see you again tonight.”
Nine individuals described specific incidents of alleged sexual misconduct.
Belle, a 17-year-old transgender woman alleged that in April 2013:
In the French Quarter [the police officer] asked what I was doing and I said I was waiting for friends. He got out of his car and asked to see my ID and then he say I looked like a suspect and asked if I had any weapons in my purse. Then he went through my purse and found the condoms then he started asking me how much I charge for a blow job. He said if I wanted to go free I had to give him a blow job because the condoms were reason enough to bring me in so I did it and he let me go.
Jennifer, an 18-year-old African-American transgender woman told Human Rights Watch that in June 2012, “I was made to give oral sex because he figured out I was prostituting. I did it but I felt raped and sad.”
Juanita, a 29-year-old Hispanic woman said:
In December 2012 I was pulled out of a bar by a police officer from New Orleans. He asked me to get into the car. He asked me a lot of questions about me such as how I feel, how I get into this business, if I was interested in quitting with this lifestyle and offered me a payment to practice oral sex on him. I did it and got my money and left.
Individuals were not systematically asked if they had filed a formal complaint in cases of police misconduct. Distrust of the police, however, as well as fear of retaliation was reported by some. Theresa, a 31-year-old transgender woman, told Human Rights Watch:
No I never complained about the police when I was working the street. I have to make a living and see the same cops every night, that would be crazy for me to do that as they be retaliating on me for sure.
Concerns about retaliation by the police were raised in the Consent Decree between the NOPD and the federal government. The decree contains an entire section on new policies and procedures required to ensure that citizen complaints are investigated properly without retaliatory measures.
Human Rights Watch met with Officer Frank Robertson, Public Relations Officer in the New Orleans Police Department and Sgt. Nicole Barbe who acts as a liaison to the LGBT community. Neither said they were aware of any harassment by NOPD officers relating to condom possession, and they expressed concern about the practice from a public health perspective. Sergeant Barbe emphasized the changes that the NOPD were making under new policies for community policing based on non-discrimination and anti-bias. The NOPD now requires a minimum of 40 hours of training per year for both cadets at the police academy and for all officers on new procedures that includes understanding of transgender issues and the consequences of violating the transgender policy, which can include termination. The NOPD has also participated in the city’s Gay Pride parade and other public LGBT festivities in recent years, and according to Barbe the NOPD is “working hard to get on track with the LGBT community.”
Lack of Access to Health Care
Human Rights Watch found that healthcare coverage for many people who exchange sex for money, drugs, and life necessities in New Orleans was tenuous or non-existent. Fewer than 45 percent of those surveyed reported having health insurance coverage; 85 percent of injection drug users had no health insurance, 48 percent of transgender participants had no coverage, and 87 percent of Hispanic respondents reported no health insurance coverage. Of persons covered by insurance, nearly 30 percent were on Medicaid. Unfortunately, many persons currently covered by health insurance in New Orleans may lose it by the end of 2014, when a special program providing coverage to residents of a four-parish area that includes New Orleans is set to expire.
Under a Medicaid Section 1115 grant waiver program, the Greater New Orleans Community Health Connection expands access to health care for residents of New Orleans by funding community health clinics to serve uninsured individuals who meet income eligibility requirements but are not otherwise eligible for Louisiana Medicaid. After a period of intense advocacy by health officials and advocates, this program has been extended for one year but no commitment has been made to renew this funding after December 31, 2014. If this program had been allowed to expire, an estimated 63,000 people in New Orleans would have lost health insurance coverage. Renewal of the program will depend upon continued commitment and collaboration among city, state and federal health officials.
Barriers to Sustaining HIV Treatment
In recent years, treatment has become the cornerstone of both HIV prevention and care. Public health and HIV experts have increasingly emphasized the importance of early and universal access to anti-retroviral medication not only to improve individual outcomes but to reduce the risk of transmission of the virus to others. The approach characterized as “Treatment as Prevention” has gained traction both in the US and globally based on studies indicating that sufficient suppression of the virus through anti-retroviral therapy can dramatically reduce the possibility of transmission from one person to another and in communities as a whole.
Key to the success of this approach, however, is the ability of the person to sustain a lifetime course of anti-retroviral medication that must be taken on a daily basis. Continuity is particularly important with anti-retroviral drugs as adherence has been strongly associated with suppressing the virus, life expectancy and avoiding resistance to HIV medications. As stated by the US Centers for Disease Control: “The prevention benefit of treatment can only be realized with effective treatment, which requires linkage to and retention in care, and adherence to anti-retroviral therapy.”
Human Rights Watch examined the ability of people who exchange sex for money, drugs, and life necessities in New Orleans to sustain their HIV treatment regimens. Of the 82 participants who were HIV-positive, 70 reported that they were currently receiving treatment for this condition, of which 61 people were taking anti-retroviral drugs. Survey participants were asked, “Have you ever missed a dose of your HIV medication?” Of the 61, 51 (83 percent) reported having missed doses, with 40 (65 percent) stating that they missed doses in the last year. Twenty-five people (40 percent) reported missing doses more than 10 times.
People reported a variety of reasons for missing doses ranging from drug use, jail time, lack of food, lack of housing, and simply forgetting. The responses of the participants when asked why doses were missed provide insight into the multitude of problems people face as they try to adhere to a strict medication regimen on a low income:
“Two months ago in prison didn’t have meds for a month and a week when in jail.”
“Couldn’t think about taking my meds I needed to make some money to live.”
“I got depressed and did not take it. Like 3 doses.”
“I was waiting for Social Security and did not have the money to pay for it. 6 doses.”
“Out of food and money. Food’s expensive.”
“I was unstable. Trying to get money to take care of myself and just didn’t make it to the clinic to get a refill of meds.”
“When I’m smoking or shooting up I don’t take medication.”
“I’m homeless. I leave my meds where I sleep and I can’t remember where I left them.”
“I’d like to be tested again…but I want stable housing before addressing health concerns.”
Two issues emerged from the investigation as primary barriers to maintenance of HIV treatment for people who exchange sex for money, drugs, and life necessities: lack of housing and incarceration.
Lack of Access to Housing as a Barrier to Sustaining HIV Treatment
Human Rights Watch found that people exchanging sex for money, drugs, and life necessities in New Orleans faced severe housing problems, with 30 percent reporting that they were “unstably housed.” Of the 82 HIV-positive participants in the Human Rights Watch survey, 17 (21 percent) were unstably housed. Comments from individuals indicated high levels of concern with housing issues.
Stacy, a 52-year-old African-American woman, said: “I wish the services would get better in NOLA. Especially with housing. You have to wait a long time.”
Alfred, a 36-year-old African-American man, said:
The city doesn’t want to help us. I’ve been homeless since Katrina and it is not until now thanks to UNITY [that I have housing] but that is not even final. …Lack of housing causes many people to hustle out on the street.
The state response to an urgent housing shortage for low-income people has been woefully inadequate. Louisiana has relied almost exclusively on federal aid to address what the director of UNITY calls “the housing crisis for poor people” in New Orleans. The federal government has directed more than $120 billion toward recovery since Katrina, but the majority of the money has gone to emergency relief rather than rebuilding, rental assistance or long-term housing programs.
State support for affordable housing has been meager. The Louisiana State Housing Trust Fund was created by the legislature in 2003 for the purpose of promoting affordable housing for low-income people, but support for the fund has dried up after an initial contribution of $25 million. Other than an additional $31,000 from a state income tax check-off program that expired in 2010, no state funds have been provided to the Trust. The Fund, however, like state housing trusts throughout the country, is well established as an effective mechanism for increasing affordable housing stock. Even with minimal support the Fund has created 35 affordable housing developments with 322 units of new housing.
In dire need of additional financing, the Louisiana Housing Alliance and other advocates in the state have commenced a grass roots campaign to build support for legislative action to “fund the fund.” The many options include a small tax on real estate transactions or allocation of monies received from the Mortgage Settlement Fund. The fund resulted in 2012 from a lawsuit brought by 49 states and the federal government challenging mortgage and foreclosure practices prior to and during the economic recession. Louisiana received approximately $21 million from the mortgage settlement, and the Louisiana Housing Alliance has proposed that some of these dollars be allocated for low-income housing.
Incarceration as a Barrier to Sustaining HIV Treatment
Along with race, gender, poverty and unemployment, the environment of risk for HIV infection and for poorer health outcomes includes a higher likelihood of incarceration. Each year, one in six persons living with HIV spends time in a correctional facility in the United States. In New Orleans, this ratio is likely to be higher, as Louisiana leads the nation in rates of incarceration with a rate 48 percent higher than the national average, while its two major cities lead the nation in rates of new HIV infections. Injection drug users and people who exchange sex are at risk for both HIV and arrest for engaging in these activities. Of the 82 people living with HIV in the Human Rights Watch survey, 62 (75 percent) had spent time in jail or prison. Of injection drug users, 96 percent reported being incarcerated.
Many public health experts characterize correctional settings as places of opportunity to provide HIV testing, counseling, and treatment. The HIV testing program at the Orleans Parish Prison, for example, identified 43 new cases of HIV in 2012, approximately 10 percent of all new cases reported in New Orleans. But the negative impact of incarceration on individual and community health far outweigh any benefit, particularly when one examines the totality of the experience from arrest to release.
For injection drug users, arrest and incarceration has been shown to increase risk of HIV and hepatitis C by interrupting established networks for needle use. Upon release from jail or prison, people who use drugs find new partners, whose HIV status may not be known, for needle-sharing. For this reason, medically supervised safe injection sites in Canada and other countries, where police have agreed to refrain from arrest, have resulted in lower rates of HIV and hepatitis infection among people using drugs at the site. For those who have HIV, arrest can impede access to medical care in multiple ways.
A medical case manager at NO/AIDS Task Force told Human Rights Watch of her client, a transgender woman, who had tested positive for HIV in jail and made an appointment with her to begin treatment:
I have a client now who has been arrested for sex work at least 10 times in the last three years. She has missed 10 appointments with me because she keeps going to jail. I still haven’t met with her and she is still not in care.
As a leading expert on HIV and corrections recently stated, “Of all the life events that knock people out of HIV care, going to jail is one of the biggest disruptors.”
Cycles of arrest for sex work and drug crimes harshly impact communities as well. Human Rights Watch has documented the racial bias underlying drug law enforcement for decades in the United States. In New Orleans, black men over 18 are 53 percent of the city’s population but 84 percent of those incarcerated in the Orleans Parish Prison. The National HIV/AIDS Strategy notes the increased vulnerability of partners, families and minority communities as a whole as a result of relentless incarceration:
High rates of incarceration within certain communities can also be destabilizing. When large numbers of men are incarcerated, the gender imbalance in the communities they leave behind can fuel HIV transmissions by increasing the likelihood that remaining men will have multiple, concurrent relationships with female partners. This in turn increases the likelihood that a single male would transmit HIV to multiple female partners.
Arrest and incarceration frequently causes delay and interruption of HIV treatment. The Orleans Parish Prison is one of the few local jails in the state that has an HIV testing and treatment program. The prison offers HIV tests to every prisoner whose stay is expected to last more than one week. Every prisoner testing positive, regardless of how long their sentence may be, meets with an HIV social worker from NO/AIDS Task Force to facilitate linkage to treatment upon their release. HIV specialists from LSU Medical Center provide treatment services via telemedicine to HIV-positive prisoners.
But delays and treatment interruptions are still a concern. Even in the most efficient law enforcement systems, the period between arrest and official intake at the jail is usually a minimum of 72 hours. At Orleans Parish Prison, inmates expected to “roll out” within days are not offered HIV testing at all, and those already on HIV medication face delays in resuming their regimens. The prison permits family members to bring a prisoner’s medication to the facility, but for those who have no family nearby, the medical team deems it necessary to verify their medications. A fax is sent to local pharmacies to confirm the prisoner’s medication and only upon reply is an order submitted. Newly diagnosed patients must wait to see the HIV specialist before medications are ordered, and reports of how long this process can take varied from two weeks to three months. Dr. Samuel Gore, Medical Director of Orleans Parish Prison, said they try to provide every HIV-positive prisoner with a prescription upon release, but this is not always possible as many releases occur without the knowledge of medical staff. 
Transgender Women, Jail and HIV
For transgender women, the cycle of arrest and incarceration can be particularly devastating. Transgender advocates recently released “Injustice at Every Turn,” a survey of nearly 6,500 transgender persons in the United States that depicted a population in crisis. The report documented pervasive discrimination, a poverty level four times higher than the general population, and twice the unemployment rate of non-transgender people, often leaving sex work as the only option for survival. Each of these factors, in addition to vulnerability to HIV and AIDS, was more pronounced in transgender persons of color. Among those surveyed, the self-reported HIV prevalence was four times higher than in the general US population. Rates of HIV among for those who had engaged in sex work were higher than 15 percent. Incarceration rates were seven times higher than the general US population, with one of two African-American transgender persons having spent time in jail or prison.
Human Rights Watch found that many transgender women in New Orleans carried fewer condoms out of fear of arrest. For transgender women, arrest not only threatens already tenuous employment and housing prospects but frequently results in abuse by police and by other prisoners and staff while incarcerated. Human Rights Watch, Amnesty International and others have documented abuse of LGBT people by police and in detention inside the United States. In New Orleans, transgender survey participants reported police profiling them as sex workers and subjecting them to verbal abuse and sexual misconduct. Others cited unsafe conditions while in custody: “In prison the cops don’t give a fuck they see you get your ass kicked and they don’t do anything.”
Rape and other forms of assault remain a major problem in US prisons. The Orleans Parish Prison (OPP) is a dangerous place for anyone and particularly for LGBT individuals. The prison is currently under a Consent Judgment requiring extensive federal oversight of its operations. A federal court in June 2013 found that “OPP fails to adequately protect inmates from harm and serious risk of harm from staff and other inmates.” The court cited the opinions of correctional experts that “OPP is totally dysfunctional in terms of overall security” and that it is “an unsafe facility for both staff and inmates.” Another expert cited by the court stated that Orleans Parish Prison was “likely the worst large city jail in the United States…plagued by suicides and other in-custody deaths, rapes and other sexual assaults, stabbings and severe beatings.”
Since 2011, the organization BreakOUT! has sought to end abuses in the criminal justice system against LGBT youth of color in New Orleans, with a particular emphasis on protecting the rights of transgender women. BreakOUT! was at the forefront of the successful campaign for the New Orleans Police Department policy on interaction between police and members of the transgender community, and is a member of the community advisory board that monitors police behavior. Wesley Ware, the director of Breakout!, told Human Rights Watch that young transgender women working with BreakOUT! were frequently arrested for prostitution, solicitation and “crimes against nature.” Ware submitted testimonies from BreakOUT! members in 2011 to the federal commission for the Prisoner Rape Elimination Act about high levels of violence experienced by LGBT persons at Orleans Parish Prison. The Prison Rape Elimination Act applies to all state and municipal detention facilities in the US, and establishes procedural requirements intended to ensure the protection of LGBT individuals in custody. Among other provisions, the Act requires screening for vulnerability to violence, housing classification decisions to be made on a case-by-case basis, and prohibits segregation of LGBT prisoners unless such action is pursuant to a court order.
Ware told Human Rights Watch:
One transgender woman [in custody] was charged with attempt to escape when she ran from a prisoner who was trying to rape her. Another had bones broken when she refused to give a prisoner oral sex. OPP is a nightmare for them.
HIV and the Hispanic Community in New Orleans
Since Hurricane Katrina, the Hispanic population in Louisiana increased by 44 percent with many Hispanic men moving to New Orleans to seek construction jobs as the city began to rebuild. According to public health officials, HIV case rates are not disproportionate to the size of the population, but the reliability of this data is uncertain due to a small and rapidly fluctuating population. Poor health outcomes following an HIV diagnosis, however, are well documented. Hispanics are one of the groups most likely to develop AIDS within six months of an HIV test, indicating that many are not tested until late in the disease. In New Orleans, 41 percent of Hispanics with HIV are not in treatment.
Access to health care is problematic. Federal law bars undocumented immigrants from being eligible for Medicaid, and imposes a five-year waiting period for legal immigrants to apply for the program. In Louisiana, most Hispanic people rely on hospital emergency rooms for their health care, but some may not qualify for free services. According to advocates, many avoid health care altogether because a bill from the hospital means the government might try to track you, or someone living with you, down.
Human Rights Watch survey participants included 23 Hispanics who exchanged sex for money, drugs, or life necessities. Table 6 illustrates key results, showing that 11 were undocumented; six were employed, with annual income ranging from zero to $20,000 dollars; 20 had no insurance. Of the 23 Hispanic survey participants, 11 reported having HIV, and of these, 9 were receiving treatment.
Human Rights Watch has documented the harsh impact of police interference with condom possession on sex workers who have immigrated to the United States. Immigrants, particularly those who are undocumented, have a heightened fear of arrest because any contact with the police can lead to deportation if they are undocumented. But even those who are documented harbor fear of the police, since prostitution is a deportable offense.Hispanic participants in the Human Rights Watch survey indicated that fear of police activity reduced their willingness to carry condoms. Only two participants reported having been harassed themselves, but nine said they carried fewer condoms for fear of police interference, and all nine said that fear of carrying condoms due to police had resulted in unprotected sex.
Edgar, a 25-year-old Hispanic man, stated in Spanish, “I think it is unfair that cops would arrest someone for carrying condoms, that is why I sometimes have unprotected sex.”
 Note that not all of the 30 injection drug users answered the questions of whether they are HIV-positive or have hepatitis C, so the percentages reflect only the percentage of those answering those questions, x and y respectively.
 Human Rights Watch interview with Camilla A., New Orleans, July 30, 2013.
 Municipal Court of New Orleans, Prostitution Cases Filed from 1/1/2011-6/30/13, obtained by public records request and on file with Human Rights Watch.
 Human Rights Watch, Sex Workers at Risk: Condoms as Evidence of Prostitution in Four US Cities.
 Quotations are from HRW survey forms unless otherwise indicated.
 Human Rights Watch telephone interview with Stella Cziment and Jee Park, Office of the Public Defender, Special Litigation Department, New Orleans, June 10, 2013.
 Human Rights Watch interview with Theresa L., New Orleans, September 6, 2013.
United States of America v. City of New Orleans, 2:12-CV-01924-SM-JCW (E.D. LA), Consent Decree filed 7/24/12,
 Human Rights Watch interview with Sgt. Nicole Barbe, LGBT Community Liaison Officer, New Orleans Police Department, New Orleans, September 8, 2013.
 Human Rights Watch interview with Max Ciardullo, White House Fellow for Healthy Communities, New Orleans Department of Health, New Orleans, May 23, 2013.
 Myron S. Cohen et al., “Prevention of HIV-1 Infection with Early Anti-Retroviral Therapies,” New England Journal of Medicine, vol. 365 (2011), pp. 493-505.
 AidsInfo, “Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents: Adherence to Antiretroviral Therapy,” March 27, 2012, http://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf (accessed September 2013).
 Human Rights Watch interview with Martha Kegel, Executive Director of UNITY, New Orleans, July 29, 2013.
 Greater New Orleans Community Data Center, “Facts for Features of Katrina Recovery,” August 28, 2013, http://www.gnocdc.org/Factsforfeatures/HurricaneKatrinaRecovery/; Elizabeth Ferris, “Housing and Disasters: Thoughts on Katrina and Haiti,” Brookings Institution, August 21, 2012, http://www.brookings.edu/blogs/up-front/posts/2012/08/21-haiti-katrina-ferris (accessed August 31, 2013).
 National Conference of State Legislatures, “National Mortgage Settlement Summary,” undated, http://www.ncsl.org/issues-research/banking/national-mortgage-settlement-summary.aspx (accessed August 31, 2013).
 Human Rights Watch interview with Nathan Cataline, Community Engagement Coordinator, Louisiana Housing Alliance, September 4, 2013.
 Anne C. Spaulding et al., “HIV/AIDS Among Inmates of and Releasees from US Correctional Facilities, 2006: Declining Share of Epidemic but Persistent Public Health Opportunity,” PLoS One (2009), accessed September 10, 2013 doi:10.1371/journal.pone.0007558.
 State of Louisiana, HIV/AIDS Strategy for Prevention Treatment and Care 2012-2013, p. 20.
 Data received from Orleans Parish Prison, on file with Human Rights Watch. No data are available for new infections for 2012, but in 2011, 421 persons were newly diagnosed with HIV. Louisiana Department of Health and Hospitals, “Louisiana HIV/AIDS Quarterly Report,” March 2012, http://www.dhh.louisiana.gov/assets/oph/Center-PHCH/LouisianaHIVFirstQuarter2012.pdf, p. 15.
 Will Small et al., “Impacts of Intensified Police Activity on Injection Drug Users: Evidence from an Ethnographic Investigation,” International Journal of Drug Policy, vol. 17, issue 2 (2009), pp. 85-95; Thomas Kerr et al., “The Public Health and Social Impacts of Drug Market Enforcement: A Review of the Evidence,” International Journal of Drug Policy, vol. 16, issue 2 (2005), pp.210-220. Scott Burris et al., “Racial Disparities in Injection-Related HIV: A Case Study of Toxic Law,” Temple University Law Review, vol. 82, no. 5 (2011), pp. 1263-1307.
 Thomas Kerr et al. “Findings from the Evaluation of Vancouver’s Pilot Medically-Supervised Safe Injecting Facility-Insite,” British Columbia Centre for Excellence in HIV/AIDS, 2009, http://www.cfenet.ubc.ca/sites/default/files/uploads/publications/insite_report-eng.pdf (accessed September 10, 2013).
 Human Rights Watch interview with Megan McIntyre, Medical Case Manager, NO/AIDS Task Force, New Orleans, April 23, 2013.
 Woodruff Health Sciences Center, Emory News Center, “HIV/AIDS: Studies Shed Light on Benefits of Enhancing Links to Primary Care and Services in Jail Settings and Beyond,” November 27, 2012, http://news.emory.edu/stories/2012/11/jj_spaulding_hiv_jail_studies/ (accessed September 10, 2013).
 Human Rights Watch, Targeting Blacks: Drug Law Enforcement and Race in the United States.
 Petrice Sams-Abiodun and Gregory Rattler, Recognizing the Underutilized Economic Potential of Black Men in New Orleans.
 The White House “National HIV/AIDS Strategy for the United States,” July 2010, http://www.whitehouse.gov/sites/default/files/uploads/NHAS.pdf.
 Human Rights Watch interview with Dr. Samuel Gore, Medical Director, Orleans Parish Prison, New Orleans, July 29, 2013.
 Malik Jaffer et al., “Improving Medical Care for Patients with HIV in New York City Jails,” Journal of Correctional Health Care, vol. 18 (2012), pp. 1-5.
 Human Rights Watch interview with Dr. Samuel Gore, Medical Director, Orleans Parish Prison, New Orleans, July 29, 2013.
 Human Rights Watch interview with Dr. Samuel Gore, Medical Director, Orleans Parish Prison, New Orleans, July 29, 2013; Human Rights Watch telephone interview with Dr. Lynn Besch, LSU Medical Center, New Orleans, June 12, 2013; Human Rights Watch interview with Megan McIntyre, Medical Case Manager, NO/AIDS Task Force, New Orleans, April 23, 2013.
 Human Rights Watch interview with Dr. Samuel Gore, Medical Director, Orleans Parish Prison, New Orleans, July 29, 2013.
 National Center for Transgender Equality and the National Gay and Lesbian Task Force, “Injustice at Every Turn: A Report of the National Transgender Discrimination Survey,” February 3, 2011, http://www.thetaskforce.org/reports_and_research/ntds (accessed September 10, 2013).
 Amnesty International, “Stonewalled: Police Abuse and Misconduct Against Gay, Lesbian, Bisexual and transgender People in the United States,” September 2005, http://www.amnesty.org/en/library/asset/AMR51/122/2005/en/2200113d-d4bd-11dd-8a23-d58a49c0d652/amr511222005en.pdf (accessed September 10,2013); Human Rights Watch, Sex Workers at Risk: Condoms as Evidence of Prostitution in Four US Cities.
 Human Rights Watch, No Escape: Male Rape in US Prisons, April 2001, http://www.hrw.org/reports/2001/04/01/no-escape-male-rape-us-prisons; Jamie Fellner, Human Rights Watch, “Stop Prison Rape Now,” The Daily Beast, September 4, 2013, http://www.thedailybeast.com/articles/2013/09/04/stop-prison-rape-now.html (accessed September 10,2013).
 Order Approving Consent Judgment and Certifying Plaintiff Class, Jones et al. v. Gusman, Civil Action 12-859, Eastern District of Louisiana, filed June 16, 2013, pp. 18-19.
 Breakout! Testimony before Prison Rape Elimination Commission, New Orleans, September 15, 2013. On file with Human Rights Watch.
 Prison Rape Elimination Act, 2003, 28 CFR 115.42 et seq.
 Human Rights Watch interview with Wesley Ware, Director of BreakOUT! New Orleans, May 21, 2013.
 State of Louisiana, HIV/AIDS Strategy for Prevention, Treatment and Care Services, 2012-2015, p. 56.
 New Orleans Health Department, “Transmutation: New Orleans Eligible Metropolitan Area Comprehensive Plan 2012-2014,” April 2012, http://norapc.org/downloads/5c7f5565b7f0c96e1ba7f0af69c9a48b/1169e6403c374323cbc946043e9a8d95/Transmutation%20NOEMA%20Comprehensive%20Plan%202012%202014.pdf.
 Personal Responsibility and Work Opportunity Reconciliation Act, 1996, PL 104-193, as amended by the Illegal Immigration Reform and Immigrant Responsibility Act, PL 104-208; Kaiser Family Foundation, “Medicaid and SCHIP eligibility for Immigrants,” April 1, 2006, http://kaiserfamilyfoundation.files.wordpress.com/2013/01/7492.pdf (accessed august 16, 2013).
 Human Rights Watch interview with Jacinta Gonzales, Executive Director, Workers Center for Racial Justice, New Orleans, February 24, 2013.
 Human Rights Watch, Sex Workers at Risk: Condoms as Evidence of Prostitution in Four US Cities.
 Immigration and Nationality Act of 1952, as amended, (INA) section 212.
“Me parace injusto que la policia lo lleve preso a uno por tener condones consigo. Pore so algunas veces tengo sexo sin proteccion.”