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Sexually Transmitted Diseases:
Editorial

Sexually Transmitted Diseases in the Incarcerated: An Underexploited Public Health Opportunity

GLASER, JORDAN B. MD

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From the Staten Island University Hospital, Staten Island, New York

Correspondence to Jordan B. Glaser, MD, Staten Island University Hospital, Division of Infectious Diseases, 475 Seaview Ave, Staten Island, NY 10305.

IN THIS ISSUE, Shuter and associates report a high prevalence (46.9%) of culture‐proven Trichomonas vaginalis infection among 213 pregnant women incarcerated at New York City's largest jail. Although pregnant women generally have higher rates of trichomoniasis than nonpregnant women,1 the authors and other researchers have found that nonpregnant female inmates also have high rates of infection (22% to 44%).2 These findings are not surprising since inmates are overrepresented by groups at high risk for sexually transmitted conditions, e.g., minorities, the poor, substance and/or alcohol abusers.

Over 1.2 million individuals are incarcerated in the United States on a given day. Ten million inmates are released per year. At midyear 1996, there was an estimated 615 incarcerated persons per 100,000 U.S. residents, two thirds in the custody of states and the Federal government, and one third in local jails. This represents an annual growth rate of 7.7% in prisons and 4.2% in jails since 1990.3 This increase was disproportionate by gender because women are more likely than men to be incarcerated for a drug offense. At midyear 1996, women accounted for 6.3% of all prison inmates nationwide (69,000), up from 4.1% in 1980. The female population in local jails reached 10.8% (55,700).4 Although their numbers are small compared with men, over one million women are released per year.

There is a high prevalence of human immunodeficiency virus (HIV) and other sexually transmitted conditions among the incarcerated.2 The prevalence of HIV varies nationwide. Vlahov and coworkers5 found HIV‐1 seroprevalences of 2.1% to 7.6% for men and 2.7% to 14.7% for women consecutively entering 10 unidentified correctional systems in the United States. Higher prevalences were found among men (18.0%) and women (26.3%) entering the New York City Correctional System in 1989.6 Although the rate of HIV infection among men incarcerated in New York City declined to 7% in 1996, the high prevalence of HIV among women has not changed.7 Female inmates have higher rates of HIV than male inmates because of higher rates of injection drug use (IDU), sex with injection drug users, prostitution, and exchange of sex for drugs. For example, 20% of female inmates entering the New York prisons in 1992 admitted to exchanging sex for money or drugs, and a similar percentage was infected with HIV.3 There is also a high prevalence of other sexually transmitted conditions among the incarcerated. The reported prevalence ranges among men were high for gonorrhea (1.1% to 5.2%), syphilis (1.9% to 3%), and hepatitis B markers (19% to 47%).2 The prevalence ranges among women were also elevated for gonorrhea (8% to 14%), chlamydia (4.6% to 27%), and syphilis (0% to 34%).3

The need for public health interventions during the period of confinement is both large and compelling. Voluntary HIV testing should be offered to those at risk. All inmates should undergo admission screening for syphilis, gonorrhea, chlamydial infection, and hepatitis B. Tuberculin skin testing should be performed annually. Inmates should be evaluated for a variety of immunizations including hepatitis B and hepatitis A. Female inmates should undergo admission screening pregnancy since as many as 8% of newly incarcerated women have been found to be pregnant.8 Cervical cytological examination should be performed if there is no documentation of such an examination within the past 12 months.

Unfortunately, many of these personal and public health needs have not been met. Annual tuberculin skin testing programs were not put into effect until multidrug‐resistant tuberculosis outbreaks were documented in the correctional setting. Vaccination programs have been adequate for prevention of influenza among the general inmate population and of pneumococcus among HIV‐infected inmates. However, other vaccination efforts (e.g., hepatitis B) have been grossly underfunded. These efforts may also be hindered by the relative short duration of incarceration of subgroups such as jail inmates, or the frequent transfers of inmates in some prison systems. Funding for centralized electronic information systems has been lacking.

Screening of pregnant and nonpregnant female inmates for T. vaginalis is not routinely performed. Gestational trichomoniasis has been associated with premature rupture of membranes, premature labor, low birth weight, and postabortal infection.9,10 It is unclear whether some or all of these adverse outcomes are related to other organisms or conditions associated with trichomoniasis such as bacterial vaginosis and Mycoplasma hominis. It is also unclear if treatment of trichomoniasis will prevent these adverse outcomes. However, screening and treatment of pregnant women at high risk for trichomoniasis should be initiated while awaiting results of ongoing studies on trichomoniasis treatment and pregnancy outcome.10 Pregnant inmates with trichomoniasis should be treated with 2 g of metronidazole in a single dose.11

Screening of nonpregnant female inmates also is warranted because trichomoniasis is often asymptomatic12 and because of the high prevalence rate of infection in this population. Trichomoniasis has been implicated as a cofactor in the transmission of HIV and has been associated with HIV seropositivity.13,14 Most methods of detection are specific. Culture is the most sensitive technique. A variety of commercially available kits has made screening much easier. As with any diagnostic or preventative intervention in the correctional setting, the in‐house cost must be weighed against the patient and public health benefit. Usually these latter benefits make the intervention cost‐effective.

Shuter and associates used multivariate analysis to show a significant association of trichomoniasis in pregnancy with crack use and a positive serological test for syphilis. All three conditions have been associated with HIV infection.

The authors correctly suggest that correctional health care providers need to increase their efforts at HIV and sexually transmitted diseases prevention and treatment for women and men in the criminal justice system. However, these efforts will be in vain without budgets that are adequate to address prevention, drug treatment, and medical care. We cannot afford to allow correctional health to remain a neglected stepchild of the health care system.

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References

1. Brown MT. Trichomoniasis. Practitioner 1972; 209:639-644.

2. Glaser JB, Greifinger RB. Correctional health care: A public health opportunity. Ann Intern Med 1993; 118:139-145.

3. Greifinger RB, Glaser JB. Desmoteric medicine and the public's health. In: Puisis M, ed. Clinical Practice in Correctional Medicine. Saint Louis: Mosby, 1998:290-302.

4. U.S. Department of Justice. Prison and jail inmates at midyear 1996. Bureau of Justice Statistics Bulletin. January 1997; NCJ-162843.

5. Vlahov D, Brewer F, Castro KG, Narkunas JP, Salive ME, Ullrich J, et al. Prevalence of antibody to HIV-1 among entrants to US correctional facilities. JAMA 1991; 265:1129-1132.

6. Weisfuse IB, Greenberg BL, Back SD, Makki HA, Thomas P, Rooney WC, et al. HIV-1 infection among New York City inmates. AIDS 1991; 5:1133-1138.

7. Torian LV, Makki HA, Weisfuse IB. Changes in HIV seroprevalence in entrants to the New York City Correctional System, 1992-1996. In: Program and abstracts of the 5th Conference on Retroviruses and Opportunistic Infections, February 1-5, 1998, Chicago, IL, Foundation for Retrovirology and Human Health, Alexandria, VA, p. 106 [abstract 142].

8. Holmes MD, Safyer SM, Bickell NA, et al. Chlamydial cervical infection in jailed women. Am J Public Health 1993; 83:551-555.

9. Heine P, McGregor JA. Trichomonas vaginalis: A reemerging pathogen. Clin Obstet Gynecol 1993; 36:137-144.

10. Saurina GR, McCormack WM. Trichomoniasis in pregnancy. Sex Trans Dis 1997; 24:361-362.

11. Centers for Disease Control and Prevention. 1998 Guidelines for treatment of sexually transmitted diseases. MMWR 1998; 47(No. RR-1):74-75.

12. Rein MF. Trichomonas vaginalis. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. New York: Churchill Livingstone, 1995:2493-2497.

13. Laga M, Manoka A, Kivuvu M et al. Non-ulcerative sexually transmitted diseases as risk factors for HIV-1 transmission in women: Results from a cohort study. AIDS 1993; 7:95-102.

14. Dallabetta GA, Miotti PG, Chiphangwi JD, et al. High socioeconomic status is a risk factor of human immunodeficiency virus type 1 (HIV-1) infection but not for sexually transmitted diseases in women in Malawi: Implications for HIV-1 control. J Infect Dis 1993; 167:36-42.

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