Responding to the Burden of STD, HIV, and Viral Hepatitis in Correctional Populations through Program Collaboration and Integration

Chow, Joan M. MPH, DrPH*; Joesoef, M Riduan MD, PhD†; Kent, Charlotte PhD‡; Weinstock, Hillard MD, MPH†; Fenton, Kevin MD, PhD†

Sexually Transmitted Diseases:
doi: 10.1097/OLQ.0b013e3181949359
Author Information

From the *California Department of Public Health, Sexually Transmitted Disease Control Branch, Richmond, California; †Division of STD Prevention, Centers for Disease Control, Atlanta, Georgia and ‡San Franciso Department of Public Health, San Francisco, California

The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy.

Correspondence: Joan M. Chow, MPH, DrPH, Chief, Epidemiology Unit, Epidemiology and Surveillance Section, California Department of Public Health, 850 Marina Bay Parkway, Bldg. P, 2nd Floor, Richmond, CA 94804. E-mail:

Received for publication November 7, 2008, and accepted November 10, 2008.

Article Outline

OVER 2 MILLION INDIVIDUALS ARE estimated to be incarcerated in the United States and this number is projected to increase.1 This special supplement of Sexually Transmitted Diseases (STD) focuses on significant developments in national and local efforts to confront the disproportionately and consistently high burden of STD, human immunodeficiency virus (HIV), and viral hepatitis found in the large and growing US correctional population. Addressing health disparities in racial and ethnic groups is a high priority for the Centers for Disease Control and Prevention and the National Center for HIV/AIDS, viral hepatitis, STD, and tuberculosis prevention; responding to the burden of disease in correctional populations, which are disproportionately comprised of minorities, is a critical strategy for reducing these disparities.2,3

Local, state, and federal jurisdictions face considerable challenges due to shrinking budgets ineffectively serving the multifaceted health problems and high risk health behaviors prevalent in correctional populations. However, entry into the correctional system also offers an important opportunity for primary, secondary, and tertiary prevention strategies to be implemented, particularly in the area of communicable diseases. The development of effective multifaceted control strategies to identify infection early upon entry into detention is necessary to prevent ongoing transmission in the community upon release (which usually occurs within a week) and within detention. The articles and an editorial from the San Francisco County Sheriff in this Journal Supplement underscore the importance of collaborative approaches involving public health departments, and correctional health care and corrections professionals to develop effective integrated programs and services for these populations.4

Articles have been chosen related to the sexual health of correctional populations including behavioral risk factors for infection, prevalence estimates to identify target subpopulations in need of screening, assessment of local correctional program capacity to provide quality STD care, implementation of screening and treatment programs, cost-effectiveness analyses of screening interventions, and evaluation of impact of STD/HIV screening in correction populations on communities. Joesoef et al. reported on chlamydia data collected from a large sample of participating juvenile correctional facilities and jails across the United States showing consistently higher Chlamydia trachomatis prevalence among young females compared with males and among black detainees compared with those of other racial/ethnic groups.5 McDonnell et al. reported on demographic and sexual risk behavioral data among female juvenile detainees collected over a 4-year period; they demonstrate that this population has a consistently high prevalence of sexual risk behaviors including low rates of condom use and high chlamydia rates.6 Barry et al. presented a different perspective on the role of incarceration through a case-control study of gonorrhea among heterosexuals.7 Their finding that female gonorrhea cases were more likely than population controls to report recent incarceration for themselves and for their recent sex partners emphasizes how recently incarcerated populations may facilitate ongoing transmission and might serve as a point of intervention in high STD prevalence networks.

Articles that address the challenges of implementing STD/HIV screening in state and local correctional settings recognize numerous issues related to the availability of resources, such as clinical staff and laboratory facilities, needed to conduct screening, diagnose, treat, and ensure partner management. McIntyre et al. reported the results of a survey of Illinois correctional providers that indicated significant gaps in STD, HIV/AIDS, and hepatitis services across facilities associated with limited funding and staffing.8 Burke and Rhodes reported on a collaboration between the local health department and North Carolina jails to facilitate syphilis screening through assignment of a disease intervention specialist.9 Miller et al. reported on the feasible and successful implementation of diverse chlamydia screening programs throughout California juvenile detention facilities. Correctional settings pose unique challenges, often due to their local governance and physical structures; Miller et al. also provided useful insights into eliminating structural barriers to increase screening coverage of young females.10

There are 2 sets of articles that describe the outcomes of screening efforts and the cost-effectiveness of these efforts. The first set of articles specifically address expanding the use of rapid HIV testing within jails: MacGowan et al. reported on the yield of previously undiagnosed HIV infection in 4 city jail programs, and Shrestha et al. examined the cost-effectiveness associated with these programs.11,12 The editorial by Spaulding comments on the importance of maintaining confidential rapid HIV results and linking detainees with positive results to HIV care upon release to the community.13 The second set of articles describe HIV and STD screening in a jail facility in Los Angeles that is specifically for men who identify as gay or bisexual. Javanbakht found a high prevalence of previously unidentified HIV infection, but a low prevalence of urethral chlamydial and gonococcal infections.14 This innovative program recently began rectal and pharyngeal screening for chlamydia and gonorrhea, and we await their findings from these common sites of infection among men who have sex with men. A cost-effectiveness analysis presented by Tuli and colleagues on STD/HIV screening in gay and bisexual incarcerated populations in Los Angeles suggests significant cost-savings that might be applicable in other jails.18

Finally, 3 articles report on the considerable potential impact of correctional screening programs on reduction of community-level disease, particularly in urban areas with large correctional populations.15–17 In New York City, after chlamydia screening was implemented among young men in jails, more infections among men were reported from jails than from the 10 New York City STD clinics combined.16 The Chicago experience is also noteworthy for a significant decline in reported STD cases after that city’s successful jail screening program was discontinued for lack of funds. Barry et al. reported on an ecologic study that suggests that jail screening might explain declines in chlamydia rates in high morbidity neighborhoods in San Francisco. Additional studies are needed to test their findings in other communities.

In sum, these articles lend considerable evidence for recommendations to expand access to STD/HIV and viral hepatitis services in correctional facilities. They highlight opportunities for increasing intersectoral leadership, cross-program collaboration, and integrating services at the client level through innovative partnerships, funding, and joint strategic planning. Indeed, through partnerships between correctional and public health agencies, the data further confirm that integrated services may provide better and more efficient care for the most vulnerable among us. As program collaboration and service integration are especially feasible in correctional settings, this should further support its application as a key strategy for tackling disease syndemics in this arena. However, it will require programs to demonstrate a willingness to encourage cross-agency thinking, risk taking, and doing work that is beyond the experience, mission, and task of any single agency. Finally, as we look to the future, especially within the realities of funding challenges or threats to program sustainability, continued investment in research and program evaluation will be required to identify promising practices and policies for wider dissemination and implementation. By reducing the disease burden in these populations, we all stand to benefit.

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