Objective: To understand associations of punitive policies to the population prevalence of injection drug users and to HIV seroprevalence among injectors. Design and methods: A lagged-cross-sectional analysis of metropolitan statistical area data. Estimates of drug injectors per capita and of HIV seroprevalence among injectors in 89 large US metropolitan areas were regressed on three measures of legal repressiveness (hard drug arrests per capita; police employees per capita; and corrections expenditures per capita) controlling for other metropolitan area characteristics. Results: No legal repressiveness measures were associated with injectors per capita; all three measures of legal repressiveness were positively associated with HIV prevalence among injectors. Conclusions: These findings suggest that legal repressiveness may have little deterrent effect on drug injection and may have a high cost in terms of HIV and perhaps other diseases among injectors and their partners – and that alternative methods of maintaining social order should be investigated.

HIV continues to be transmitted at unacceptably high rates among African Americans, and most HIV-prevention interventions have focused on behavioral change. To theorize additional approaches to HIV prevention among African Americans, we discuss how sexual networks and drug-injection networks are as important as behavior for HIV transmission. We also describe how higher-order social structures and processes, such as residential racial segregation and racialized policing, may help shape risk networks and behaviors. We then discuss 3 themes in African American culture—survival, propriety, and struggle—that also help shape networks and behaviors. Finally, we conclude with a discussion of how these perspectives might help reduce HIV transmission among African Americans.