More than 2 million people are estimated to be incarcerated in the United States, and approximately 5 million offenders are supervised in the community on probation or parole.1 Persons who are or have been incarcerated have poor health outcomes, with high death rates2 and higher levels of chronic disease, mental illness, and substance abuse, compared with the nonincarcerated population. Correctional populations also have much higher rates of infectious diseases compared with the general population, and this includes sexually transmitted infections (STI). The prevalence of chlamydia and gonorrhea among a representative sample of persons entering jails and juvenile correctional facilities is consistently among the highest observed in any venue.3 The prevalence of syphilis and HIV among adult inmates is also substantial, and 1 in 3 is infected with hepatitis C, compared with less than 2% in the noninstitutionalized US population.4 An innovative cross-agency match of the New York City (NYC) jail population with citywide HIV, tuberculosis (TB), STI, death, and homeless shelter registries found that HIV prevalence and gonorrhea and syphilis case rates among persons who had been incarcerated were 3 to 4 times higher compared with the nonincarcerated population; there were also higher rates of HIV prevalence, new HIV diagnosis, and syphilis among people who had been incarcerated than among nonincarcerated residents of the lowest-income neighborhoods in NYC (unpublished data). There is clearly a significant burden of STI among incarcerated individuals. Outside the jail/prison, many are very difficult to reach with diagnostic, treatment, and prevention initiatives. Although incarceration presents an opportunity to reach them, they remain greatly underserved. A recent survey of 431 adult correctional agencies found that most prisons and jails provided TB screening, HIV testing, and other medical services, but comprehensive screening for STIs was largely absent across prison, jail, and community corrections settings.5
This journal has published several articles about STI among correctional populations. In 2009, a special supplement included reports on risk factors for STI among the incarcerated,6,7 results of screening efforts that yielded significant numbers of previously undiagnosed infections,8,9 and challenges to implementing STI/HIV screening in state and local correctional settings. Many barriers to screening were cited, including the lack of funding, staffing, and laboratory facilities needed to conduct screening, diagnosis, treatment, and partner management. Approaches to overcoming some of these barriers were also presented.10,11 In this issue of the journal, Joanna Cole and her colleagues12 add to the literature on this topic by describing an effective female chlamydia/gonorrhea opt-out screening program in Cook County jail (Chicago, IL). Opt-out screening increased detection of disease by more than 4-fold relative to the pre–opt-out period (when screening was performed based on inmate request) and resulted in a treatment rate of 70%, consistent with treatment rates in other jurisdictions that conduct chlamydia screening programs.13,14 Their study highlighted the well-recognized difficulty of assuring treatment for inmates who have short durations of jail stay. It also brought up other challenges: despite practices that facilitate screening, such as screening at intake and the opt-out process, many inmates refused screening (almost one-quarter in this study), and among those that accepted, a high proportion of them had “incomplete” tests; that is, they did not get screened. Higher STI screening rates can be achieved by increasing acceptance of STI screening by linkage with other tests (e.g., TB, HIV), expediting screening before transfer or release from intake, ensuring prompt transfer of specimens to testing laboratories, and correctly documenting opt-out status in medical records.
The article of Cole et al. on the Cook County jail opt-out program is noteworthy given Chicago’s prior experience with jail screening among men. In the year after Cook County’s universal jail screening program was discontinued for lack of funds in 2003, reported cases of male chlamydia and gonorrhea in Chicago dropped by 33% and 20%, respectively.15 Shrinking budgets pose a serious problem to implementing STI screening programs and detecting large amounts of disease. Strategies to overcome resource constraints and other challenges (e.g., accessing medical records at jails, timely treatment of inmates, connecting former inmates to community services) rely on collaborative approaches that involve public health departments, correctional health care, and corrections professionals. Program collaboration and service integration are feasible in correctional settings, but they require agencies to partner and work on tasks that may be outside the usual domain of any single agency. Some jurisdictions have directed health department funding to correctional health care programs, incorporated health department staff in correctional facilities to provide STI screening, provided corrections with health department disease prevention specialists, arranged for testing to be performed by local public health laboratories that have procured discounts, or instituted regular meetings between public health and correctional staff to discuss public health issues. As an example, in NYC, incarcerated individuals are committed to the custody of the Department of Corrections, which is responsible for their care, custody, and control. The NYC Charter, however, specifies that inmate medical care is the responsibility of the Department of Health and Mental Hygiene. The Department of Health and Mental Hygiene contracts out the provision of direct service health and mental health care to a private correctional health services vendor, while directing policy and providing oversight and management.
Identifying and treating infections among the incarcerated has implications for the larger community. In its landmark 2002 report to Congress on The Health Status of Soon-to-be-Released Inmates, the National Commission on Correctional Health Care reported that the failure to treat communicable diseases among the incarcerated was likely to have significant adverse effects on society.16 More studies on the public health impact of jail-based screening are needed, but ecological studies and mathematical models suggest that jail-based chlamydia screening and treatment can lead to significant decreases in chlamydia prevalence in communities with high incarceration rates.17,18 Responding to the burden of disease in correctional populations, which disproportionately comprise minorities, could also be a critical step in reducing observed health disparities in racial and ethnic groups.19 Incarceration provides a window of opportunity for the delivery of health care services and health promotion and prevention messages to underserved populations. Furthermore, by reducing the disease burden in these populations, a population-wide benefit may be realized.
2. Binswanger IA, Stern MF, Deyo RA, et al. Release from prison—A high risk of death for former inmates. N Engl J Med 2007; 356: 157–65.
3. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2011. Atlanta: US Department of Health and Human Services; 2012.
5. Cropsey KL, Binswanger IA, Clark CB, et al. The unmet medical needs of correctional populations in the United States. J Natl Med Assoc 2012; 104: 487–92.
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. 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.
9. 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.
10. 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.
11. 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.
12. Cole J, Hotton A, Zawitz C, et al. Opt-out screening for chlamydia trachomatis and neisseria gonorrhea in female detainees at Cook County Jail in Chicago, IL. Sex Transm Dis 2014; 41: 161–165.
14. Franklin WB, Katyal M, Mahajan R, et al. Chlamydia and gonorrhea screening using urine-based nucleic acid amplification testing among males entering New York City jails: A pilot study. J Correct Health Care 2012; 18 (2): 120–30.
15. 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.
17. 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.
18. Owusu-Edusei K Jr, Gift TL, Chesson HW, et al. Investigating the potential public health benefit of jail-based screening and treatment programs for chlamydia. Am J Epidemiol 2013; 177 (5): 463–73.