City and county jails in the United States record almost 12 million admissions and releases every year, representing 9 million unique individuals.1 Several studies show that individuals entering jail have a high prevalence of sexually transmitted infections (STI)2–4; however, there are few data on STI positivity among this population after release. Given the current limitations of jail-based STI services,5 it is likely that a portion of STI positivity in the postincarceration period reflects untreated or undiagnosed STI acquired before or during incarceration as well as STI acquired postrelease. Furthermore, the period after release from jail is often characterized by high-risk sexual behaviors, including unprotected sex, concurrent sexual partners, sex for money, and drug and alcohol use.6,7 Environmental-level factors such as poverty, unemployment, and even physical neighborhood deterioration may also impact STI risk after release from jail,8–10 but there are few data on this population.
Understanding the burden of and risk for STI after release from jail is essential to inform public health strategies on STI testing and prevention in this vulnerable population.11–13 Untreated STI can lead to increased health care costs and serious health problems, particularly for women,14 and a lack of access to STI services likely contributes to furthering a cycle of poor health and disadvantage among justice-involved individuals.15 Using available population-level public health data, we investigated STI test positivity, including chlamydia, gonorrhea, and syphilis, and factors associated with positivity among individuals in the 1 year after release from jail in a large metropolitan area.
MATERIALS AND METHODS
We conducted a retrospective cohort study of jailed men and women in Marion County (Indianapolis), Indiana, with individually linked STI positive test result data to estimate the overall prevalence of chlamydia, gonorrhea, and syphilis infection and factors associated with STI positivity in the 1-year period after a jail stay. There are 2 main jail facilities within Marion County, and both are included in this analysis. These facilities do house juveniles who are charged with more serious offenses, although most juvenile offenders are sent to the Juvenile Detention Center, which is not included in this analysis. Jail stay data were obtained in collaboration with the Marion County Sheriff’s Office, and STI positivity data were obtained in collaboration with Marion County Health Department. Data on jail stays from July 1, 2003, to April 30, 2008, and STI positivity data from July 1, 2000, to April 30, 2009, were included. Sexually transmitted infection positivity data were included for a wider date range so that we could obtain a history of STI infection during the 36 months before the first possible jail stay date, and infections diagnosed during at least the 12 months after the last possible jail release date. Individuals from jail stay data were linked to STI positivity records with identifiers including first and last name, sex, month, day and year of birth, and social security number, using a probabilistic matching algorithm described elsewhere.16,17 Multiple probabilistic matching algorithms were performed, with different weights given to different identifiers to reduce the likelihood of dependence on a single identifier. We reviewed pair probabilities from all sets of the matching algorithm output to identify threshold probabilities, above which the pairs were considered true matches. Pairs above threshold in each algorithm output were merged to identify all likely matches between the incarceration and clinical data sources. All individuals with 1 or more jail stays between July 1, 2003, and April 30, 2008, were included in the study, and there were no exclusion criteria. This study was approved by the institutional review board at Indiana University School of Medicine in Indianapolis, Indiana, with a waiver of informed consent, and by the Marion County Sheriff’s Office.
STI Positivity Data. The primary outcome measure for this study was a positive test result for chlamydia, gonorrhea, or syphilis in the 1 year after release from jail. The lack of this outcome did not imply a lack of infection, as our data source did not identify those who tested negative or individuals not tested. Positivity for most of chlamydia and gonorrhea were defined by nucleic acid amplification tests on urine, cervical swab, or urethral swab specimens, although the type of test was not specified. Positivity for syphilis (primary or secondary) was defined by rapid plasma reagin test or venereal disease research laboratory test as an antibody titer greater than 1:8, as commonly reported elsewhere,18 regardless of previous positive test results. In the case of a positive syphilis test result, only 1 positive test result in the 1 year after release from jail was included to avoid potential double counting of the same infection.
Jail Stay Data. Various demographic, clinical, and crime characteristics were described and analyzed, including sex, age, race, history of STI infection (prior 36 months to jail stay), history of jail stay, length of jail stay, and reason for jail stay (“charge”). Charge was categorized based on the Unified Crime Report classifications.19 Neighborhood characteristics were described using geocoded residential address data at time of jail stay.
Descriptive statistics were calculated using demographic, STI, jail history, and neighborhood characteristics based on the first jail stay during the study period. Rates of chlamydia, gonorrhea, and syphilis positivity per 100,000 people were calculated in the periods 12 months before and 12 months after the first jail stay and were stratified by sex, age, and race. Preincarceration and postincarceration rates of STI positivity were compared with each other, as well as compared with rates published by the 2011 Centers for Disease Control and Prevention (CDC) STD Surveillance Report.14 The results are shaded to assist in illustrating overall trends between the 3 column categories: darkest gray indicates rates more than 1000 per 100,000, dark gray indicates rates between 100 and 999 per 100,000, light gray indicates rates between 10 and 99 per 100,000, and lightest gray indicates rates less than 10 per 100,000. Cells with fewer than 10 individuals are indicated by a dash (–) and were not included. Two-tailed P values were calculated to test for significant differences in rates between preincarceration and postincarceration. Cox proportional hazard analyses were performed for each STI and stratified by sex while controlling for age, race, STI history, charge, length of stay, and jail history to investigate associations between STI positivity in the postincarceration period and demographic, clinical, and other factors. All jail stays were used for hazard analyses, censoring time after a subsequent jail stay in the same year so that periods to the same STI were not double counted. Neighborhood characteristics were not significantly associated with STI risk in the regression model and were omitted from Cox proportional hazard analysis. The period prevalence of each STI was calculated for the 1-year period after release from first jail stay, as well as second and third jail stay among individuals with multiple incarcerations during study period, to assess how rates of STI positivity change with subsequent interactions with the justice system. For simplicity, these results are only displayed for individuals of black or white race and aged 24 years or less, as these individuals generally had the highest rates of STI. All analyses were performed using STATA/SE version 10 (College Station, TX).20
A total of 118,670 individuals were incarcerated in Marion County jails in Indiana between 2003 and 2008 and were included for analysis. At first jail stay within the study period, median age was 30 years. More than three quarters of individuals jailed during this period were men, and black individuals were disproportionately represented (42%; Table 1). Ten percent of individuals were diagnosed as having an STI in the 36 months before their first jail stay in the study period, with chlamydia being the most common (7%). More than half of jail stays were less than 48 hours (64%), and only 9% were greater than 30 days. Intoxication-related charges were most common, and prostitution and other sex-related crimes accounted for a small percentage of overall charges. Individuals lived in Census block groups that were disproportionally poor with high unemployment rates (mean, 39%), low male-to-female ratios (73% living in block groups with a male-to-female ratio <1), and high proportion of female-headed households (mean, 39%).
Our cohort had significantly higher rates of STI compared with the general population; rates of chlamydia were between 2 and 7 times higher, rates of gonorrhea were between 5 and 24 times higher, and rates of syphilis were between 19 and 32 times higher compared with rates in the general population (Table 2). Chlamydia and gonorrhea infections were most common in adults younger than 30 years, whereas syphilis affected older adults, and all STI were diagnosed among blacks and women disproportionately. Compared with the general population, however, our cohort exhibited less divergence in STI rates between blacks and whites than occurs among individuals in the general population, however, meaning that rates of STI positivity were more similar among whites and blacks in our cohort. Also noteworthy was that black women in our cohort had higher rates of syphilis than men, whereas in the general population, men of any race have higher syphilis rates than do women. Sexually transmitted infection positivity rates were similar in the 1 year prior and 1 year after release from jail stay with a few exceptions. Notably, adolescent men and women and white women of any age generally had higher rates of chlamydia and gonorrhea, respectively, in the 1 year after release.
Adjusted Cox Proportional Hazard Ratios of STI Positivity in the 1 Year Postrelease
In general, younger age (<20 years) was associated with a significantly increased likelihood of chlamydia (in men and women) and gonorrhea (in men only) test positivity in the 1-year after a jail stay (Table 3). Older men and women were at greater risk for syphilis, with men aged 35 to 39 years having 6-fold greater risk and men older than 50 years having a 12-fold greater risk compared with men 20 to 24 years of age. Compared with white men, black men were significantly more likely to have tested positively for chlamydia (hazard ratio [HR], 3.3), gonorrhea (HR, 4.0), and syphilis (HR, 2.5), whereas black women had an increased risk only of syphilis (HR, 6.0). Latino compared with white individuals was associated with a significantly decreased risk for chlamydia (in women only) and gonorrhea (in men and women), whereas Latino women had significantly higher risk for syphilis positivity (HR, 21.3).
Previous diagnosis of STI in the 36 months before incarceration was the only factor that significantly increased the likelihood of all types of STI in both men and women, with more recent STI infection (<12 months before incarceration) associated with greater risk. Prostitution was the only charge significantly associated with all infections in women in the postrelease period (chlamydia HR, 2.0; gonorrhea HR, 1.6; syphilis HR, 2.2), whereas for men, a prostitution charge was associated only with syphilis (HR, 2.4). Drug-related charge was significantly associated with increased risk among men and women for chlamydia, but not gonorrhea or syphilis. A jail stay of longer than 2 days had a significantly decreased risk of chlamydia and gonorrhea positivity. Finally, a history of previous incarceration within the study period was significantly associated with increased risk for all STI among men and women, with the strongest increased risk associated with a more recent incarceration.
Multiple Jail Stays and STI Positivity Risk
Many individuals were incarcerated more than once over the course of the study period, with 44.7% in jail 2 or more times. Individuals with 2 or more jail stays had higher rates of STI during the 12 months before and after first jail stay, compared with the overall cohort (Table 4). For example, among all black women younger than 18 years, the period prevalence of chlamydia and gonorrhea after first jail stay was 12.2% and 4.6%, respectively. Among black women younger than 18 years with 2 or more jail stays, the period prevalence for chlamydia and gonorrhea after first jail stay was 29.6% and 11.1%, respectively.
Individuals with a history of a jail stay in our cohort had significantly higher rates of chlamydia, gonorrhea, and syphilis positivity both before and after jail stays compared with the general population. As expected, younger age was consistently associated with an increased risk of chlamydia and gonorrhea, whereas older age was associated with an increased risk of syphilis. Previous STI diagnosis, recent jail stay, and criminal charges like prostitution and drug-related offenses were factors associated with increased STI positivity.
Several findings related to race and STI positivity were inconsistent with trends in the general population. For example, for women in this cohort, black race was not a significant risk factor for chlamydia or gonorrhea. In 2011, the CDC estimated that black women had rates of chlamydia 6 times the rate of white women and gonorrhea 15 times that of white women,14 but a differential risk of STI after release from jail was not evident in this study. This finding may reflect the risk profile of incarcerated women who may be more likely to have common risk behaviors, leading to less significant differences in positivity between races. Furthermore, in 2010, black women were incarcerated (including jail and prison) at a rate 3 times that of white women.21 Because white women were disproportionately underrepresented by race, white women who were jailed may have had a higher risk of infection. Interestingly, black women had considerably higher rates of syphilis than did black men in this cohort, perhaps reflecting increased exposure among women engaged in commercial sex.
Few studies have investigated STI among individuals recently released from jail. In a study of 178 young men released from prison, Sosman et al.22 reported that at 6 months postrelease, 26% tested positive during a screening program for at least 1 STI. In another study, Stein et al.23 found that among a group of 190 women enrolled in an alcohol intervention study, 10% tested positive for STI at 6 months postrelease from a correctional facility. These studies had small sample sizes and inclusion based on consent for STI testing postrelease.22,23 We did not find STI rates that reached these levels in this cohort, but we relied on public health data sources that did not include negative test results so we could not assess overall prevalence.
We did not assess risk behaviors, so it is unclear whether individuals in this cohort had more, less, or similar risk behaviors before versus after incarceration. Studies have shown that men and women released from correctional settings often engage in high-risk sexual behaviors such as unprotected sex, multiple sexual partners, concurrent sexual relationships, and drug and alcohol use in the period immediately after release, but few have preincarceration data.24–26 Our finding that certain charges like prostitution and drug offenses were generally associated with increased risk of STI positivity may serve as proxy risk behaviors and could be used as indicators to prompt more intensive jail-based STI testing postrelease.
Spending time in jail may lead to offenders being cut off from social and sexual networks maintained before incarceration, and to entering new, higher-risk sexual networks or adopting higher-risk behaviors.27,28 It is unclear how the length of stay in jail affects these networks, given that the time spent in jail is typically only a few days, and we found that a longer jail stay (>2 days) was generally associated with a decreased risk of STI positivity after release. It is possible that individuals jailed longer than a few days were more likely to access opt-in STI testing offered through jails in Marion County, receive the necessary treatment, and thus not test positive in the 1-year after release (assuming effective treatment and no reinfection). The low number of positive tests reported from jails, however, suggests that this was a small number of individuals (per 100,000 individuals, positivity rates during jail stays in the study period were 239 for chlamydia, 162 for gonorrhea, and 21 for syphilis). Repeated incarceration was associated with significantly greater risk for STI positivity. Although prospectively one does not know who will be jailed more than once, repeated incarceration could serve as an indicator for targeted STI screening at subsequent jail encounters.
Upon release and reentry into society, offenders often face difficulties finding employment and housing, suffer from higher rates of morbidities and substance abuse, and have difficulties accessing health care.12,13,29 Neighborhood-level factors such as unemployment, poverty, and female-headed households were not significantly associated with STI positivity when individual-level characteristics were included; however, there may not have been enough variability within this cohort to detect significant differences. Several studies among the general population have found that neighborhood characteristics are associated with STI and other health outcomes, particularly among adolescents.30,31 A study by Dembo et al.32 found that community disadvantage, as defined by 4 indicators (income level, proportion minority, female-headed households, and unemployment), was significantly associated with STI independent of individual-level factors among a group of newly arrested juveniles. The association between STI and community-level factors among recent offenders should be further investigated.
There are several limitations of this study. First, because not all individuals (including those recently jailed) are screened routinely for STI, our findings are limited to those individuals who sought care within the county and received STI testing at in-county locations, and for whom positivity data were reported to the health department. Marion County has an active surveillance program in which positive STI test results are automatically reported to the health department from laboratories, limiting a reporting bias. Differential care-seeking behavior and/or screening may occur among this population, however, contributing to biased findings. Second, we did not have a number of important variables, including records of negative STI tests, data related to treatment, or individual-level socioeconomic data like health insurance status or behavioral data, although we attempted to use a number of proxy variables to investigate behavioral factors. Third, it is unknown whether all individuals in the disparate data sets were appropriately linked. Missing or incorrect data, the use of aliases by individuals, or legal name changes may affect the sensitivity and specificity of record linkages. It is also possible due to in- or out-migration that STI diagnoses were missed for certain individuals who were recently jailed. Finally, this analysis is restricted to a single metropolitan area and may not be generalizable to other urban communities. We had significantly smaller numbers of Latinos, especially Latino women, compared with whites and blacks. In addition, local events such as the syphilis outbreak during the study period may have influenced testing patterns, although it is unlikely to differentially affect the testing of jailed individuals because there are no standard testing procedures for this population.
This study found high rates of STIs among a cohort of individuals released from jail, but more data on factors related to STI risk, testing, and points of care among this population are needed. In the meantime, our data suggest that individuals recently released from jail will benefit from more regular STI testing and from increased collaboration and data sharing between public health and criminal justice systems.
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