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.
2. Kahn RH, Mosure DJ, Blank S, et al. Chlamydia trachomatis and Neisseria gonorrhoeae prevalence and coinfection in adolescents entering selected US juvenile detention centers, 1997–2002. Sex Transm Dis 2005; 32:255–259.
4. Goldenson J, Hennessy M. Public health and its relation to correctional health care. Sex Transm Dis 2009; 36(suppl 2):S3–S4.
5. Joesoef R, Weinstock HS, Kent C, et al. Sex and age correlates of chlamydia prevalence in adolescents and adults entering correctional facilities, 2005: Implications for screening policy. Sex Transm Dis 2009; 36(suppl 2):S67–S71.
6. McDonnell DD, Levy V, Morton TJ. Risk factors for chlamydia among young women in a Northern California juvenile detention facility: Implications for community intervention. Sex Transm Dis 2009; 36(suppl 2):S29–S33.
7. Barry PM, Kent CK, Klausner JD. Risk factors for gonorrhea among heterosexuals-San Francisco, 2006. Sex Transm Dis 2009; 36(suppl 2):S62–S66.
8. McIntyre AF, Studzinski A, Beidinger HA, et al. STD, HIV/AIDS, and hepatitis services in Illinois County jails. Sex Transm Dis 2009; 36(suppl 2):S37–S40.
9. Burke R, Rhodes J. Lessons learned on the implementation of jail syphilis screening in Nashville, Davidson County Jail, 1999–2005. Sex Transm Dis 2009; 36(suppl 2):S14–S16.
10. Miller JL, Samoff E, Bolan G. Implementing chlamydia screening programs in juvenile correctional settings: The California experience. Sex Transm Dis 2009; 36(suppl 2):S53–S57.
11. Macgowan R, Margolis A, Richardson-Moore A, et al. Voluntary rapid human immunodeficiency virus (HIV) testing in jails. Sex Transm Dis 2009; 36(suppl 2):S9–S13.
12. Shrestha RK, Sansom SL, Richardson-Moore A, et al. Costs of voluntary rapid HIV testing and counseling in jails in 4 states-advancing HIV prevention demonstration project, 2003–2006. Sex Transm Dis 2009; 36(suppl 2):S5–S8.
13. Spaulding AC, Jacob Arriola KR, Hammett T, et al. Rapid HIV testing in rapidly released detainees: Next steps. Sex Transm Dis 2009; 36(suppl 2):S34–S36.
14. Javanbakht MKP. MSM jail screening, Los Angeles. Sex Transm Dis 2009; 36(suppl 2):S17–S21.
15. Barry PM, Kent CK, Scott KC, et al. Is jail screening associated with a decrease in chlamydia positivity among females seeking health services at community clinics? - +San Francisco, 1997–2004. Sex Transm Dis 2009; 36(suppl 2):S22–S28.
16. Pathela P, Hennessy RR, Blank S, et al. The contribution of a urine-based jail screening program to citywide male chlamydia and gonorrhea case rates in New York City. Sex Transm Dis 2009; 36(suppl 2):S58–S61.
17. Broad J, Cox T, Rodriguez S, et al. The impact of discontinuation of male STD screening services at a large urban county jail—Chicago, 2002–2004. Sex Transm Dis 2009; 36(suppl 2):S49–S52.
18. Tuli K, Kerndt P. Preventing sexually transmitted infections among incarcerated men who have sex with men: A cost-effectiveness analysis. Sex Transm Dis 2009; 36(suppl 2):S41–S48.