Sexually Transmitted Diseases:
High Prevalence of Asymptomatic STDs in Incarcerated Minority Male Youth: A Case for Screening
Pack, Robert P. PhD*; Diclemente, Ralph J. PhD†; Hook, Edward W. III MD‡; Oh, M. Kim MD§
*From the Department of Community Medicine, West Virginia University School of Medicine, Morgantown, West Virginia; the †Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia; and the Departments of ‡Internal Medicine and §Pediatrics, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
Supported by Dissertation Research Award #RO3 MH57177‐01 from the National Institute of Mental Health Office on AIDS (Dr. Pack).
Correspondence: Robert Pack, PhD, Assistant Professor, West Virginia University School of Medicine, Department of Community Medicine, P.O. Box 9190, Morgantown, WV 26506‐9190. E‐mail: firstname.lastname@example.org
Received for publication May 15, 1999, revised September 30, 1999, and accepted October 8, 1999.
Background and Objectives:: To assess STD prevalence among a sample of incarcerated minority male youth in a southern US city.
Methods:: A consecutive entrant, cross‐sectional study of 284 minority males 14 to 18 years was performed. All adolescents were screened for gonorrhea and chlamydia using ligase chain reaction tests.
Results:: Eighteen percent of youth were identified as having either gonorrhea, chlamydia, or both. Approximately 84% of those with sexually transmitted diseases (STDs) self‐reported having no symptoms. Failure to use condoms in the past month was significantly associated with a positive test result for STDs (odds ratio = 1.9, 95% CI = 1.1‐3.3).
Conclusions:: The findings indicate an urgent need for routine STD screening and STD‐prevention programs for adolescent males in detention facilities. A study of 284 detained black male adolescents revealed 18% prevalence of gonorrhea, chlamydia, or both. Approximately 84% of those with sexually transmitted diseases self‐reported not having symptoms.
SEXUALLY TRANSMITTED DISEASES (STDs) disproportionately affect young adults and teen‐agers.1 However, STD risk is not uniform among adolescents. Adolescents who are incarcerated in juvenile‐detention facilities may have relatively high STD prevalence.2–6 Screening for STDs within this group is particularly complex, posing a possible threat to confidentiality and competing with other activities, such as counseling and court appearances. Thus, measures that facilitate screening are needed.
In most studies of incarcerated adolescent males, STDs are assessed by culture methods using urethral swab specimens.2–6 Newer nucleic acid amplification technologies, such as ligase chain reaction (LCR) assays (LCx, Abbott Laboratories, Abbott Park, IL), have proven to be sensitive, highly specific nonculture methods of STD detection.7–8 Further, through simplified urine specimen collection, these newer methods hold considerable promise for increasing STD screening in nonclinical settings such as detention facilities.9 Although these newer diagnostic techniques offer considerable advantages over conventional assessment procedures, they are infrequently used for incarcerated youth.10
The objective of this study was to assess the prevalence of gonorrhea and chlamydia among minority adolescent males remanded to a juvenile‐detention facility using LCR to test voided urine specimens.
From May 1997 to November 1997, consecutive black male adolescents entering the youth‐detention facility in Birmingham, Alabama, were asked to complete an interview and provide a urine sample within the first 3 days of their detention. Groups of two to six persons were recruited, informed about the nature of the study, and interviewed in a classroom. Recruitment occurred after the detainees were released from school, on weekdays, and on Sunday afternoons. The available subject pool included persons who were detained on the evening after the interviews took place and who had not been released by the time the interviews were completed the following day. All respondents completed informed consent procedures, which were approved by the Institutional Review Board of the University of Alabama at Birmingham and the detention center.
STDs were assessed by LCR (LCx, Abbott Laboratories) for Neisseria gonorrhoeae7 and Chlamydia trachomatis8 using first‐voided urine samples collected at the time of interview for the stated purpose of STD screening. Following collection, urine samples were refrigerated until analysis at the University of Alabama at Birmingham School of Medicine, Department of Infectious Diseases within 1 day of collection, per the manufacturer's instructions.7,8
The study sample was composed of 297 male youth who were detained during the period of May 1997 to November 1997. All participants were black, and the STD screen was linked to a culture‐specific and gender‐specific study of psychosocial predictors of risk behavior. Of these 297 youth, 13 (4%) were duplicates, reported nonsense or random entries on the questionnaire, or did not have a complete data record. These persons were eliminated from further data analysis. The 284 remaining participants ranged in age from 14 to 18 years (mean, 16 years). The refusal rate was 2.5%.
Each adolescent was interviewed only once, even if they returned to the facility after having been released, which was common. Of the 284 subjects, 83% of respondents reported having been arrested more than once, and the median number of previous arrests was three. Sixty‐five percent of participants reported more than one admission to a juvenile detention facility, and the median number of detention stays was two. Twenty percent of respondents reported having been detained or incarcerated in the past 3 months before completing the survey. During the 6‐month data collection period, recidivism gradually decreased the available pool of participants.
The majority of participants (98%) reported having engaged in sexual intercourse. The onset of sexual activity typically occurred at an early age (mean, 11.9 years; range, 5‐18 years). The median number of lifetime sexual partners was 11. The average age of the respondent's first sexual partner was significantly older (13.9 years; t = 63.20, df = 273; P < 0.05). The median number of partners in the month before incarceration was three, and the median number of sexual intercourse episodes in the month before incarceration was five. In the month before incarceration, 37% reported using condoms consistently, 20% reported using condoms more than half of the time they engaged in sexual intercourse, and 14% reported never using condoms.
Sexually Transmitted Disease Prevalence
Fifty‐one of 284 adolescents (18.0%) were found to have gonorrhea, chlamydia, or both (Table 1). Nineteen subjects (6.7%) tested positive for N gonorrhoeae, and 41 subjects (14.4%) tested positive for C trachomatis. Nine subjects (3.2%) tested positive for both STDs. Failure to use condoms in the past month was significantly associated with a positive test result (odds ratio = 1.9, 95% CI = 1.1‐3.3).
Asymptomatic infections were common. Only 7 of 51 participants (13.7%) with a positive test result self‐reported urogenital symptoms such as dysuria or penile discharge. Of the 41 persons who tested positive for chlamydia only, 4 (10.3%) reported experiencing symptoms. None of the 19 persons who tested positive for gonorrhea only reported having symptoms. Of the nine persons who tested positive for both organisms, three (33.3%) reported current urogenital symptoms. Physical examinations were not performed.
A history of STDs was reported by 56 adolescents (19.7%) in the sample, 12 of whom (21.4%) tested positive for current infection. Of the 56 adolescents reporting a history of STDs, 31 (55.4%) reported having had gonorrhea. Only 14% of adolescents reported a history of chlamydial infection, yet 80% of adolescents who tested positive for an STD tested positive for current chlamydial infection. Older age was not significantly associated with the presence of an STD, although there was an older‐age trend for gonorrhea prevalence.
The current study of incarcerated minority youth observed an 18% prevalence of gonorrhea and/or chlamydia, which is among the highest STD prevalence ever identified among incarcerated male youth.3 Oh et al10 conducted a study in which urine specimens were collected upon detention for use in court‐ordered drug screening. Of the 217 male adolescents who participated in the study, approximately 10% (22) tested positive for gonorrhea, chlamydia, or both.10
In the current study, 84% of persons who tested positive for either gonorrhea or chlamydia self‐reported not experiencing symptoms such as dysuria or penile discharge. Moreover, only 14% of the respondents reported a personal history of commonly asymptomatic chlamydial infections, yet 80% of the persons who tested positive for chlamydia had no symptoms. Although it should be noted that physical genital examination of the participants was not performed, the asymptomatic infections would not have been identified without screening. Thus, following incarceration‐which tends to be brief in this population‐these highly sexually active, asymptomatic youth would be likely to spread infection to others. However, even overt urethritis may be functionally “asymptomatic” if it does not lead to cessation of unprotected sex or effective medical treatment.
Another point of concern regarding the current study is the relatively young age of sexual debut among the study population, and the fact that their first sexual partners were significantly older. Further, this population reports dramatically higher numbers of sexual partners, an earlier onset of sexual activity, and more sexual episodes than nonincarcerated youth.11
There are several possible explanations for the higher STD prevalence observed in the current study compared with other reported studies of similar populations.2–6 First, in other studies, the use of urethral swabs for STD screening was potentially a disincentive to participate.2–6 However, low refusal rates in earlier studies within this population indicate that there was not a significant bias against urethral‐swab screening.4,5 A sampling bias was not present in the current study. Second, treatable bacterial STDs tend to be more common the southern United States. Third, LCR is more sensitive than culture tests; less sensitive tests were used in similar studies conducted in Birmingham and else‐where.2–6 Fourth, white males were excluded from the current study. It is well documented that black adolescents in the southern United States are at greater risk for STD compared with white adolescents.12 Most likely, a combination of the above factors account for the difference between the STD prevalence observed in the current study and in previous studies of incarcerated male youth.
Detained adolescents represent an important population within which to screen for and treat STDs and to influence sexual risk behavior.13,14 The advent of sensitive and affordable urine‐based STD screening techniques, such as LCR, will make screening easier and more accurate.9 Our findings support the recommendation of STD screening for all newly incarcerated adolescent males, regardless of symptoms, STD history, or self‐reported risk behavior, which is in accordance with the recommendations of the American Medical Association Guidelines on Adolescent Preventive Services.15 Because more than 500,000 adolescents per year are detained in short‐term public detention facilities16 (85‐90% of which are male), comprehensive STD screening within this population could substantially decrease the prevalence of gonorrhea and chlamydia in the community.
Although enhanced screening and treatment are critical components of any strategy to reduce STDs and their adverse sequelae, the opportunity for primary prevention cannot be overlooked. STD screening should be augmented by effective behavioral, sexual‐risk reduction interventions. Further prevention research is urgently needed with this population; however, health care providers in detention and incarceration facilities should initiate STD screening of adolescents as standard‐of‐care clinical practice.
1. Institute of Medicine. The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: National Academy Press; 1997.
2. Shafer MA, Hilton JF, Ekstrand M, Keogh J, Gee L, DiGiorgio-Haag L, Shalwitz J, Schachter J. Relationship between drug use and sexual behaviors and the occurrence of sexually transmitted diseases among high risk youth. Sex Transm Dis 1993; 20:307–313.
3. Alexander-Rodriguez T, Vermund SH. Gonorrhea and syphilis in incarcerated urban adolescents: prevalence and physical signs. J Pediatr 1987; 80:561–564.
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9. Orr DP, Fortenberry JD. Screening adolescents for sexually transmitted infections (editorial). JAMA 1998; 280:564–565.
10. Oh MK, Smith KR, O'Cain M, Kilmer D, Johnson J, Hook EW. Urine-based screening of adolescents in detention to guide treatment for gonococcal and chlamydia infections. Arch Pediatr Adolesc Med 1998; 152:52–56.
11. Centers for Disease Control and Prevention. Youth risk behavior surveillance-United States, 1997. MMWR 1998; SS-3:47.
13. Glaser, JB. Sexually transmitted diseases in the incarcerated: an underexploited public health opportunity. Sex Transm Dis 1998; 25:308–309.
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15. Elster AB, Kuznets NJ, eds. AMA guidelines for adolescent preventive services (GAPS): recommendations and rationale. Baltimore: Williams and Wilkins; 1994.
16. Snyder HN, Sickmund M, eds, for the National Center for Juvenile Justice. Juvenile Offenders and Victims: A National Report (publication no. NCJ 153569). Washington, DC: US Dept of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention; 1995.
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