DESPITE SURVEILLANCE AND prevention efforts directed at venues where men who have sex with men (MSM) meet sexual partners, many marginalized populations, particularly those incarcerated, are overlooked in these efforts.1,2 As a result, new approaches are needed to connect with this high-risk, hard-to-reach group. The ability of correctional facilities to provide access to elusive high-risk populations makes them an ideal location for screening and prevention measures.3 In some instances, correctional facilities have noted higher prevalence of sexually transmitted infections (STIs) than other institutions serving high-risk populations.4 From 1989 to 1999 positive HIV-antibody tests conducted at the state correctional institution accounted for nearly one third of all positive HIV tests reported to the Rhode Island Department of Health.5 The Corrections Demonstration Project noted that within 5 county jails, including both men and women, 17% of screened inmates tested positive for HIV, 6% tested positive for chlamydia, and 3% for gonorrhea.6 Although there is limited data on incarcerated MSM, published reports indicate that among incarcerated adult males the prevalence of chlamydia, gonorrhea, and syphilis ranges from 3.1% to 6.6%, 1.5% to 2.2%, and 0.3% to 1.1%, respectively.2,7–9
By providing care to those who would otherwise have limited access to services, jails/prisons serve as a site of entrance into the health care system for many underserved individuals.3,10 The disease burden among correctional facilities and the potential benefit from programs aimed at STI and HIV prevention, screening, and treatment within correctional facilities are substantial.3,8,11,12 At midyear of 2005, an estimated 747,529 inmates were being held in jails around the United States.13 The total number of incarcerated held in American federal or state prisons or local jails was over 2 million.13 Furthermore, in the late 1990s, an estimated 20% to 26% of all persons living with AIDS passed through a correctional facility.14,15 The dynamic relationship between jails, prisons, and the nonincarcerated population is furthered by studies documenting increased risk of STIs and HIV among those with a history of incarceration.16,17 Despite the elevated risks of MSM and the role correctional facility screening and treatment can play in disease prevention within both the correctional institution and the nonincarcerated community, little data are available on incarcerated MSM populations.
The objective of this report is to describe findings from a voluntary HIV and STI screening program in a segregated MSM unit of Los Angles County Men’s Central Jail from March 2000 through December 2005. Previous reports using data collected within the first couple years of screening noted high HIV prevalence and high-risk behavior among this population.2 This study aims to provide more complete demographic data, including trends in STIs and HIV, over the study period and to examine the prevalence of recidivism and reinfections among repeatedly incarcerated MSM.
Materials and Methods
Study Setting and Participants
The Los Angeles County Men’s Jail, which has an annual intake of approximately 140,000 inmates and an average daily census of 6000 inmates, also contains a separate unit for inmates classified as MSM. Upon intake, inmates who self-identify as MSM undergo a screening process to confirm classification into the MSM unit. Specifically, a questionnaire is administered by the Sheriff’s department asking inmates to identify and define behaviors, local settings, and venues relating to the MSM community. The average daily census of the MSM unit is about 300 inmates, with an annual intake of approximately 3000 inmates.
Prevention programs in the unit include HIV prevention classes, individual level HIV education and prevention, condom distribution, and HIV and STI testing. Starting in March 2000, the Los Angeles County Sexually Transmitted Disease Program (STDP) implemented voluntary chlamydia, gonorrhea, syphilis, and HIV screening in the MSM unit of the Men’s Jail. However, in response to an increase in early syphilis cases, mandatory screening for syphilis was started in March 2005. Generally, inmates were offered testing upon completion of jail intake procedures and were informed of their rights to refuse testing. Urine samples were provided for chlamydia and gonorrhea nucleic acid amplification tests and blood samples were collected for syphilis and HIV screening. All HIV tests were conducted using the standard testing algorithm (not rapid testing). Positive test results were routed to dedicated STDP field staff for treatment, case management, and partner referral and notification services as appropriate.
Data Collection and Analysis
Demographic information, including date of birth and race/ethnicity, as well as laboratory testing information, including the type of STI tested for (chlamydia, gonorrhea, syphilis, HIV) and the date of specimen collection, were recorded for each inmate who participated in the screening program. Among inmates who tested positive for chlamydia, gonorrhea, or syphilis, treatment status and date of treatment, as well as syphilis disposition were obtained from the STDP disease registry database. In addition, booking-related information, including date of incarceration and date of release, was abstracted from the inmate information system available through the Los Angeles Sheriff’s Department.
Descriptive statistics including means and frequency distributions were conducted for the total sample as well as by STI test type and positivity. Differences between groups were evaluated using t-test for continuous variables and chi-square methods for categorical variables. Trends in STI/HIV prevalence over time were examined using the Cochran-Armitage test for trend. The unadjusted univariate associations with STI and HIV prevalence were calculated using logistic regression analysis. All data were entered and maintained in Microsoft Access database and all data analyses were conducted using SAS version 9.1 (SAS Institute Inc., Cary, NC).
From March 2000 through December 2005, a total of 7004 self-identified MSM inmates were screened for chlamydia, gonorrhea, syphilis, or HIV. Because of limited resources and staff time, the number of inmates tested declined in 2003 and 2004; however, a substantial increase in testing was seen in 2005 as a result of mandatory syphilis testing (Table 1). The majority of inmates who participated in the screening program were 25 years or older (80%; mean age = 35 years), with blacks comprising the single largest racial group (37%) (Table 1). Those who participated in the screening program were similar in terms of demographics when compared with the overall demographics of those in the MSM unit. Specifically, the overall average age among the MSM inmates was 35 years, with 35% to 40% identifying as white, 20% to 25% Hispanic, 35% to 40% black, and 2% to 3% other [Unpublished data, Los Angeles Sheriff’s Department (LASD), 2005]. Furthermore, 8% to 15% of the inmates self-identified as transgender; however, none had undergone sexual reassignment surgery (Unpublished data, LASD, 2005). It should also be noted that although there was a steady decline in the number of inmates screened after inception of the program in 2000, there was a considerable increase in the number tested in 2005 as a result of the change from voluntary to mandatory syphilis screening in March 2005 (Table 1).
The prevalence of chlamydia and gonorrhea infection by age and race/ethnicity is summarized in Table 2. The overall prevalence of chlamydia was 3% (127 of 4157) and decreased with age. In fact, those 25 years and younger were over 4-times more likely to test positive for chlamydia when compared with those 35 years and older [odds ratio (OR) = 4.2; 95% confidence interval (CI): 2.6–6.7]. Likewise, those in the youngest age groups had the highest prevalence of gonorrhea infection (3.2%) when compared with those in the older age groups (0.9%). Treatment information was only available for cases occurring after 2002. Overall, 65% of chlamydia and gonorrhea cases were treated (35 of 54 and 22 of 34, respectively). The majority of untreated cases were released from custody before diagnosis.
Among the 6011 inmates who tested for syphilis, 8.2% (494 of 6008) had a positive confirmatory test with 1.6% (95 of 6008) being identified as early syphilis (Table 3). The prevalence of early syphilis was highest among Hispanics who were more than twice as likely to have early syphilis when compared with whites (OR = 2.5; 95% CI: 1.5–4.3). Also, among early syphilis cases with treatment information (cases after 2002), 96% received treatment (51 of 53).
Among the 7004 inmates who participated in the screening program, 4658 accepted HIV testing. Although the reason for refusal of HIV-testing was not documented, in a number of cases the inmate reported being HIV seropositive. Based on the total number of HIV tests conducted, the overall seroprevalence of HIV was 13.4% (625 of 4658) with the prevalence being highest among those over 35 years of age (14.0%) and blacks (16.3%). Among the inmates who were incarcerated more than once and underwent HIV testing (1737), 33 were HIV seropositive after having tested negative at prior bookings, resulting in an HIV incidence of 1.9%.
Based on estimates from the sheriff’s department, approximately 90% of inmates in the MSM unit reported having been incarcerated in the past (Unpublished data, LASD, 2005). Although the overall recidivism among those who participated in the screening program is unknown, 15% of inmates (1048 of 7004) who were tested for STIs/HIV were incarcerated and retested at least once more and as many as 14-times over the 5-year period. The median number of incarcerations among these recidivists was 2, with the median time to reincarceration of 316 days (range, 6–2100). Interestingly, the prevalence of chlamydia was lower among recidivists (2.4%) when compared with nonrecidivists (3.5%; P = 0.0458) (Table 4). However, a greater proportion of recidivists were diagnosed with early syphilis (2.1% and 1.5%, respectively, P = 0.0849). Finally, there were no statistically meaningful differences in the level of STI and HIV morbidity across the years (Fig. 1).
Results of this study indicate that screening among incarcerated MSM in Los Angeles yielded a high prevalence of STIs and HIV. Although other correctional facilities segregate MSM inmates from the general population, this is 1 of the first programs to offer screening for STIs including HIV to this population. Given the uniqueness of the study population, comparisons in terms of levels of STIs and HIV are difficult; however, the results for HIV prevalence are striking. Previous studies of incarcerated individuals in Los Angeles have noted a HIV prevalence of 2.4% among men, with other correctional facilities reporting prevalences of 3.0% to 6.6%, all of which are lower than the 13.4% HIV seroprevalence noted in this study.18–21 However, the true prevalence is most likely much higher than that estimated in this study. In fact, based on a survey conducted in the MSM unit in 2000/2001, almost 30% of inmates self-reported as being HIV seropositive.22 The probable underestimation of HIV seroprevalence in this project is partly attributed to the voluntary nature of the screening program and the fact that a number of inmates know their HIV status and opt-out of HIV screening. In fact, only 67% of those screened chose to have an HIV test. Although a number of cases chose not to test because they were known to be HIV seropositive, documentation and comparison of those who tested to those who refused testing may provide additional information, which can increase testing in similar settings. Furthermore, although there was no information on the disposition of the HIV infections identified (new vs. chronic infection), an analysis of inmates who had previously tested HIV seronegative through the program revealed a relatively high percentage of seroconversion (1.9%) over the 5-year follow up period. Although this proxy measure for HIV incidence is most likely an underestimate of the true risk for HIV among this group, given its reliance on inmates not only being reincarcerated but also participating in the voluntary screening program, it demonstrates the ability to reach an extremely high-risk, hard-to-reach population. Given the need for innovative HIV prevention strategies, findings from this report certainly demonstrate the potential impact the identification, treatment and partner referral services may have on the HIV epidemic.
The prevalence of bacterial STIs was also relatively high among this population. Although no comparable sentinel surveillance data are available, levels of chlamydia and early syphilis were similar to those among men seen at an STD clinic serving primarily gay and lesbian clients.23 In this group, the prevalence of chlamydia was 4.3% and early syphilis was seen in 1.9% of clients.23 Chlamydial and gonococcal infections were especially high among inmates younger than 35 years of age. The highest prevalence was among men younger than 25 years of age. Although this finding is consistent with most studies of chlamydia and gonorrhea infections, which show the highest prevalence among adolescents and young adults, these findings may in fact represent an underestimate of the true extent of morbidity. Recent studies among MSM indicate that the majority of chlamydia and gonorrhea infections occur at nonurethral sites.24 In fact, it was estimated that more than 70% of chlamydia infections and 64% of gonorrhea infections among MSM would be missed without routine rectal and pharyngeal screening.24 Although rectal and pharyngeal screening, particularly in a jail setting, may not be as convenient as the collection of urine samples, the high potential for missed opportunities for the identification and treatment of these bacterial STIs warrant their consideration. This is especially significant given the high prevalence of HIV among this population and the increased risk of HIV acquisition in the presence of other STIs.25–27
The findings of this project should be interpreted in light of some limitations. Most importantly, the data for this project were collected as part of public health surveillance. Therefore, the extent of data, including information on reasons for not participating in the screening program as well as more extensive risk behavior data, are limited. Also, the testing data represent each encounter with the system and not an individual inmate. This has particular relevance for the HIV testing data, in that multiple tests may represent multiple encounters by the same inmate and not the number of persons who test positive or negative. Nonetheless, the surveillance data provide a useful and unique description of STI and HIV prevalence among incarcerated MSM.
STI and HIV screening among MSM in jail successfully reaches an at-risk population, particularly one that may have limited access to or be underserved by the health care system. Identification of STI and HIV infected MSM inmates, as well as the return of these inmates to the incarcerated setting afford a unique opportunity for targeted STI/HIV prevention measures including treatment and linkage to community and partner referral services. In addition, given the dynamic relationship between jails, prisons, and the nonincarcerated community, screening, and treatment among this population may serve as primary prevention for the sex partners of these inmates. This analysis also suggests that incarcerated populations, particularly MSM, represent a unique opportunity to access a hard-to-reach, high-risk population.
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