THE POPULATION PASSING THROUGH correctional facilities has disproportionately high rates of sexually transmitted diseases (STD) and HIV/AIDS, high-risk sexual practices, and substance use.1–10 For some detainees, jail may be the first exposure to primary health care.8,11 The rapid turnover among this population leaves only a small window of opportunity to provide STD, HIV/AIDS, and hepatitis screening and treatment. Jail-based screening programs provide unique opportunities for early intervention: for the individual through detection and treatment, and for the community through interrupting disease transmission when detainees return to the community. However, several studies have examined the level of health services in large county jails or facilities in areas of high STD morbidity and found that most facilities do not offer routine STD screening.6,12 Another key finding was that nearly half of the detainees were released within 2 days of admission, often before test results were available and treatment was provided to identified cases.
Nearly 17,000 persons are incarcerated in the 91 Illinois adult county jails every year.12 Jail-based STD testing and treatment is an effective case identification strategy. During 2000, 1.5% of the 40,350 chlamydia cases, 6.1% of the 24,812 gonorrhea cases, and 14.5% of the 794 early syphilis—i.e., primary, secondary, and early latent infections—cases reported to the Illinois Department of Public Health (IDPH) as part of routine surveillance activities were identified at county jails, including Cook County Jail in Chicago, Illinois. Routine STD screening at Cook County Jail identified 498 (2.5%) of the 19,792 chlamydia, 1405 (9.4%) of the 14,872 gonorrhea, and 110 (18.9%) of the 581 early syphilis cases reported in Chicago during 2000. Although specific data for HIV disease identified at Illinois jails were not available for this analysis, HIV prevention efforts benefit from early identification and treatment of STDs, especially in high-risk populations. These surveillance data raised concerns about missed opportunities for case identification in the absence of routine screening programs. To assist IDPH in identifying opportunities and barriers to service provision to this underserved population, we conducted a survey of all adult county jails in Illinois (n = 91) to assess the level of STD (chlamydia, gonorrhea, and early syphilis), hepatitis (A, B, and C), and HIV/AIDS services to detainees.
A comprehensive survey tool was developed by IDPH and the Chicago Department of Public Health STD, HIV/AIDS, and hepatitis programs. The person responsible for medical care in each of the 91 adult county jails in Illinois was contacted by telephone. After hearing a brief description of the purpose and scope of the project, the respondents were invited to participate in the survey. Upon acceptance, a copy of the survey was faxed to the site and the respondent was offered the opportunity to answer the survey over the phone or to complete and return it via facsimile.
Respondents provided information about their jail population, STD, HIV/AIDS, and hepatitis services offered to detainees, and sources of funding for those services. Responses to questions about opportunities and barriers to service provision were compared with IDPH county-level surveillance data to evaluate whether jails in counties with high STD or HIV/AIDS morbidity were offering adequate services. IDPH county-level surveillance data (2000) for chlamydia, gonorrhea, early syphilis, hepatitis (A, B, and C), and HIV/AIDS were used for this comparison. High morbidity counties were defined as those with STD, HIV/AIDS, and hepatitis case rates among the top quartile of all Illinois counties during 2000, whereas low morbidity areas were those among the bottom quartile.
As part of the survey, all respondents were offered technical assistance, STD laboratory services and medications, staff training, or educational materials from IDPH. Where not separately reported, hepatitis results are included with STD data. The completed surveys were entered into a database, merged with county-specific surveillance data, and univariate analysis was performed using SPSS version 11.5 (SPSS Inc., Chicago, IL).
Jail-Based STD and HIV/AIDS Testing and Medical Care
Eighty-one (89.0%) of the 91 adult county jails in Illinois completed the survey (Table 1). Forty (49.3%) of the 81 facilities provide on-site testing for STDs and 44 (54.3%) for HIV/AIDS (Table 2). Of these, only 4 offer “routine” STD screening of detainees at intake or within a specified period of time (e.g., 7–14 days after admission), using selective screening criteria and the ability to opt out of testing. Most facilities indicated that detainees are tested only if symptoms are present or upon detainee request. All facilities reported that HIV/AIDS medical care is available to detainees daily, on demand, or every other week.
Forty-one (50.6%) of the 81 facilities do not provide on-site STD testing and 37 (45.7%) do not provide on-site HIV/AIDS testing (Table 2). Most reported that no STD, HIV/AIDS, or hepatitis services are offered at the jail because detainees are transported elsewhere for services. The remainder of jails indicated that such services were not needed in their facilities, detainees were not incarcerated long enough to provide services, or service provision was too expensive.
Service Providers and Funding Sources
Local physicians or health departments provide nearly 80% of the STD and HIV/AIDS services at county jails in Illinois, although several facilities rely on jail staff or contract agencies (data not shown). The local health department was the most frequently reported service provider for prevention counseling, education, and discharge planning, whereas local hospital laboratories were the primary provider for specimen testing, and local physicians or hospitals for treatment. Nearly all facilities reported specimen testing and treatment services, whereas fewer than half reported on-site testing and discharge planning services (Table 3). The primary source of funding for STD services was the city/county government or sheriff’s department, although 20% require the detainee to copay for services (data not shown). Four facilities receive no funding for any STD, HIV/AIDS, or hepatitis services. Among those, 2 facilities do not offer on-site services, whereas the other 2 offer services only under court order.
Opportunities and Barriers for Service Provision
Nearly one-third of respondents reported no barriers to service provision, whereas 43.2% cited cost and 14.8% indicated limited staff as the foremost barrier (data not shown). Overall, nearly two-thirds (63.0%) of facilities indicated a willingness to increase services if assistance such as laboratory support or free STD medications was provided. Among those, nearly half (47.1%) reported cost and 11.8% cited limited staff time as the primary barrier, whereas the remaining one-third reported no barriers.
Jail-based STD testing and treatment is an effective case identification strategy to prevent complications from STDs and reduce transmission. Although incarceration and security are the priorities for jails, it is encouraging that nearly half of the facilities in Illinois offer on-site STD and HIV/AIDS services. These results are consistent with other reports of services offered in county and city jails.1,6,7,12,13 However, there are significant opportunities to enhance services in Illinois jails, particularly for screening and discharge planning programs. For example, to facilitate such services for chlamydia and gonorrhea, the state health department provides jails in Illinois with free test kits, laboratory testing, and treatment. Despite this incentive, most facilities reported that STD and HIV testing was available upon detainee request or if symptoms were present, but only 4 jails offered routine screening. Furthermore, routine screening programs were not available at facilities in most of the counties with very high chlamydia, gonorrhea, early syphilis, and HIV/AIDS case rates (data not shown). In general, the jails that reported no need for services were located in counties with low STD, HIV/AIDS, and hepatitis case rates, although case rates may increase with implementation of jail screening programs. Because a substantial proportion of the most prevalent infections—chlamydia and gonorrhea—are asymptomatic, lack of screening poses a serious problem in a high-risk population. Moreover, nearly 60% of the facilities surveyed reported that no discharge planning services were provided, which is of particular concern for detainees diagnosed with early syphilis, HIV/AIDS, or hepatitis. These results suggest missed opportunities for prevention and control at the community level, as well as the potential for jails to reduce their health care costs by identifying and treating women infected with uncomplicated chlamydia and gonorrhea thus preventing the development of costly complications that might require hospitalization such as pelvic inflammatory disease and ectopic pregnancy.
Although women accounted for only a small percentage of the detained population in Illinois jails at the time of this survey, national trends suggest that the proportion of women passing through correctional systems is increasing.12,14 The high proportion of asymptomatic STDs found among women has considerable implications, as untreated STDs add the threat of serious and costly sequelae to women’s reproductive systems.15–17 As the presence of women in the correctional system grows, so, too, will the need for early identification and treatment of STDs and HIV/AIDS.
Illinois counties and their jails are very diverse with regard to population, size, and service capacity. We found a wide range of case rates for chlamydia, gonorrhea, syphilis, hepatitis, and HIV/AIDS, demonstrating a significant difference in disease burden from county to county. Although other studies have sampled large jails or those in areas with high STD morbidity such as Cook County Jail in Chicago, more than half of our sample were small (<50 beds) facilities located in nonurban areas, which may be more representative of jails in the United States than other studies. With this degree of diversity comes a need for tailored STD, HIV/AIDS, and hepatitis programming that integrates county-specific STD morbidity, daily jail census, and available resources. At a minimum, STD diagnostic and treatment services should be available on-site or accessible for all county jails. Further, implementation of selective screening criteria upon admission should be encouraged as it may be the most efficient use of limited resources in any jail, especially those in counties with high rates of STDs. Increased STD screening coverage may enhance understanding of the magnitude of undetected disease. This can inform the development of additional programs to address other aspects of prevention and control, such as discharge planning. Our experience demonstrates that needs assessments are effective tools in identifying opportunities to implement and enhance services, as well as to recognize and overcome barriers at county jails.
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