Sexually transmitted infections and HIV prevalence among incarcerated men who have sex with men, 2000-2005

A Systematic Review up to 2018 of HIV and Associated Factors Among Criminal Justice-Involved (CJI) Black Sexual and Gender Minority Populations in the United States (US)

Black men who have sex with men (BMSM) and Black transgender women (BTW) are impacted by dual epidemics of HIV and incarceration. We advanced understanding of the relationship between criminal justice involvement, HIV, and other key HIV-related characteristics among these key populations in the US. We conducted a systematic review up to 2018 and 47 articles met the inclusion criteria of scientific publications involving quantitative findings of US-based HIV-related studies focused on criminal justice-involved (CJI) BMSM and BTW. Overall, there was a dearth of studies focused specifically on BTW. Criminal justice involvement was relatively high among BMSM and BTW and more pronounced among BTW. The current evidence favors no association between incarceration and HIV acquisition among BMSM with limited information about BTW. Criminal justice involvement was associated with a greater likelihood of STIs among BMSM with mixed results for sexual risk behaviors. Criminal justice settings served as an important venue for HIV testing/diagnosis for both BMSM and BTW. However, these settings were not conducive for subsequent stages of the HIV care continuum. Studies pointed to an independent association between criminal justice involvement, substance use, housing instability, and greater odds of incarceration among BMSM who were unemployed and had limited education. Future incarceration was associated with high levels of perceived racism among BMSM. Among young BMSM, high network criminal justice prevalence was also associated with sexual risk behaviors, poorer mental health outcomes, drug use, and housing instability. CJI BMSM and BTW represent a critical subpopulation to end the HIV epidemic in the US.

HIV Risk and Prevention Outcomes in a Probability-Based Sample of Gay and Bisexual Men in the United States

BACKGROUND

Although gay and bisexual men (GBM) represent the largest group of HIV-infected individuals in the United States, nearly all evidence on their HIV risk and prevention outcomes derive from nonprobability samples.

SETTING

A probability-based cohort of GBM (N = 502) from 45 states and Washington, DC.

METHODS

Cross-sectional survey.

RESULTS

Among HIV-negative/unknown/untested GBM, only 6.7% reported using pre-exposure prophylaxis (PrEP) in the past 6 months. Two-thirds (63.3%) of PrEP users reported daily adherence in the past week. Over half (54.2%) of GBM reported not using a condom during anal sex with their most recent male partner; of these men, 93.8% were not on PrEP. Most GBM had been tested for HIV (80.7%) and other sexually transmitted infections (67.1%) in their lifetime, with 45.2% having tested for HIV during the past year. Among those ever tested, 14.1% reported being HIV infected, whereas an additional 8.9% reported testing positive for at least one other sexually transmitted infection after their most recent test. All HIV-positive GBM reported being currently on antiretroviral treatment, and 94.7% reported an undetectable viral load, but nearly one-third (30.4%) reported not taking their medication every day during the past month. A majority of HIV-negative/unknown/untested GBM (64.3%) reported that they had never discussed HIV prevention with their primary health care provider.

CONCLUSIONS

Our findings present a decidedly mixed picture regarding the success of the US National HIV/AIDS Strategy in meeting its stated goals of addressing HIV risk among the general population of GBM.

Prevalence of Trichomonas vaginalis Infection Among US Males, 2013-2016

Background

Trichomoniasis results from adhesion of Trichomonas vaginalis to the mucous membrane of the urethra or vagina. It has been estimated to have a higher incidence rate than both gonorrhea and chlamydia combined. Although females can experience both clinical symptoms and obstetrical complications, male infections are largely asymptomatic and often unreported. We aim to estimate the prevalence of trichomoniasis in US males using the National Health and Nutrition Examination Survey (NHANES) database.

Methods

The NHANES database was queried for all men aged 18-59 years during the years 2013-2016. During these years, the survey included urine testing for trichomoniasis using transcription-mediated amplification. Information was also obtained regarding patient demographics and other sexually transmitted infections.

Results

Overall, 0.49% of men aged 18-59 years tested positive for trichomoniasis. The highest rate was seen in black men (3.6%). There was no significant association with trichomoniasis and age. Higher rates of infection were seen in smokers, those with herpes simplex virus type 2 (HSV-2) infection, men who had sex at an early age, those with less condom usage, and those with more lifetime sexual partners.

Conclusion

The rates of trichomonas infection in US males are lower than in women. Infections are strongly associated with black males, HSV-2 infection, and other factors known to increase rates of sexually transmitted infection. This information may be helpful for counseling, screening, and management of patients.

Using Syndemics Theory to Examine HIV Sexual Risk Among Latinx Men Who Have Sex with Men in Philadelphia, PA: Findings from the National HIV Behavioral Surveillance

Latinx men who have sex with men (MSM) continue to be disproportionately impacted by HIV/AIDS. Identifying the role of multiple syndemic factors associated with sexual risk behaviors is imperative in order to develop effective prevention and treatment strategies. Cross-sectional data for this study were derived from three cycles of the Philadelphia portion of the National HIV Behavioral Surveillance System. This study explored the impact of syndemic factors - heavy drinking, exchange sex, and homophobic discrimination - on sexual HIV risk behaviors, operationalized as number of male partners, and condomless anal intercourse (CAI) with main and casual partners among Latinx MSM (n=464). Analyses took two forms: a syndemic approach, using the cumulative number of conditions as an independent variable; and a non-syndemic approach, incorporating each condition as a unique factor. In multivariable syndemic analyses, participants with two or more factors reported more male partners and more CAI casual male partners than those with none. In non-syndemic models, homophobic discrimination and exchange sex were significantly positively associated with total number of male partners, while heavy drinking was associated with more casual CAI partners. Quantitative results indicate that syndemic and non-syndemic approaches vary in their relative capacity to account for sexual risk among Latinx MSM.

Sexually Transmitted Infections Detected During and After Incarceration Among People with Human Immunodeficiency Virus: Prevalence and Implications for Screening and Prevention

BACKGROUND

Incarceration and human immunodeficiency virus (HIV) are associated with sexually transmitted infections (STIs); however, little is known about STI prevalence among people living with HIV (PLWH) during and after incarceration.

METHODS

Electronic medical records from the Dallas County Jail and community HIV clinics were reviewed to determine the frequency and results of testing for gonorrhea, chlamydia, syphilis, and hepatitis B virus (HBV) among PLWH incarcerated in Dallas County Jail between 2010 and 2013. HIV viral loads (VL) and evidence of STI symptoms and treatment were also collected.

RESULTS

During 2473 incarcerations, 6 (3%) of 190 tests were positive for gonorrhea, 7 (4%) of 190 for chlamydia, 231 (21%) of 1082 for syphilis, of which 53 (23%) were new diagnoses, and 48 (5%) of 1005 for HBV surface antigen. Among 1631 releases to the community, 808 followed up in community clinics, where 21 (4%) 553 tests were positive for gonorrhea, 23 (4%) of 555 for chlamydia, 150 (19%) of 808 for syphilis, of which 31 (21%) were new diagnoses, and 24 (6%) of 421 for HBV surface antigen. The majority of new STI cases, 51 (80%) of 64 in jail and 43 (77%)of 56 in the community, had a concurrent detectable (>200 copies/mL) HIV VL.

CONCLUSIONS

Testing for gonorrhea and chlamydia was low, particularly in jail, which was attributed to testing protocols. High proportions of PLWH tested positive for syphilis and HBV infection in both settings. The majority of patients with active STIs had a detectable HIV VL. Routine, opt-out screening for STIs for PLWH during and after incarceration has the potential to identify a high proportion of STIs and improve secondary HIV prevention.

The multiplex social environments of young Black men who have sex with men: How online and offline social structures impact HIV prevention and sex behavior engagement

In the United States, young Black men who have sex with men (YBMSM) remain disproportionately affected by HIV. The social networks in which YBMSM are embedded are generally understood to be critical factors in understanding their vulnerability. In this study, we acknowledge the relational richness of YBMSMs' social environments (what we define as multiplexity) and their increasing prioritization of online social networking sites (SNS). Specifically, we investigate whether protective and/or risky features of YBMSMs' Facebook friendships and group affiliations are related to their HIV prevention and sex behavior engagement, while also accounting for features of their offline confidant (or support) and sex networks. Using data from a population-based cohort study of YBMSM living in Chicago (N=268), we perform a series of multiple logistic regression analyses to examine associations between features of YBMSMs' Facebook, confidant, and sexual networks with three prevention outcomes and three sex behavior outcomes, while also controlling for factors at the individual and structural levels. Results show that network features play a more significant role in predicting engagement in sex behaviors than prevention behaviors. Specifically, having more confidants, having confidants who are family members, meeting sex partners online, having more YBMSM Facebook friends, belonging to Facebook groups with an LGBTQ focus, and having greater subject diversity in one's Facebook group affiliations were significantly associated with one or more sex behavior outcomes. We conclude with a discussion of the implications of our findings for HIV prevention intervention efforts.

Knowledge, interest, and anticipated barriers of pre-exposure prophylaxis uptake and adherence among gay, bisexual, and men who have sex with men who are incarcerated

Criminal justice (CJ) settings disproportionately include populations at high risk for acquiring HIV, and CJ-involved individuals are often at the intersection of multiple overlapping risk factors. However, few studies have examined attitudes about pre-exposure prophylaxis (PrEP) among incarcerated men who have sex with men (MSM). This study explored interest in, knowledge of, and barriers to PrEP uptake among gay, bisexual, and other men who have sex with men at the Rhode Island Department of Corrections. Using semi-structured interviews, 26 MSM were interviewed about PrEP knowledge, interest, timing preferences for provision (e.g. before or after release), and barriers to uptake and adherence during community re-entry. Interviews were coded and analyzed using a general inductive approach. Participants demonstrated low initial knowledge of PrEP but high interest after being told more about it. Participants self-identified risk factors for HIV acquisition, including condomless sex and substance use. In addition, participants preferred provision of PrEP prior to release. Post-release barriers to PrEP uptake and adherence included 1) concerns about costs of PrEP medications; 2) anticipated partner or family disapproval; 3) lack of access to transportation; 4) unstable housing; 5) compounding impacts of multiple hardships leading to a de-prioritization of PrEP and 6) fears of future re-incarceration. These results point to the need for future PrEP interventions among incarcerated populations that address incarceration and PrEP related barriers during community re-entry via wraparound services that address PrEP and incarceration-related barriers.

Context-Appropriate Interventions to Prevent Syphilis: A Narrative Review

BACKGROUND

The success of an intervention to prevent syphilis will depend on the context and the goal of the intervention. To help programs choose interventions, we reviewed major changes in context and types of interventions that may be effective.

METHODS

We reviewed the literature on the changing context of syphilis in the United States and interventions to prevent syphilis, focusing on articles that included evidence of effectiveness.

RESULTS

Populations acquiring syphilis are constantly changing. Currently, incidence is very high among men who have sex with men (MSM). Among adults, late disease caused by syphilis has become rare. Congenital syphilis incidence has been low but is increasing, and morbidity and mortality remain high when babies are infected. Congenital syphilis now causes more deaths than syphilis among adults.Routine screening of MSM can identify and treat infections before they progress to disease (secondary prevention). Screening rates are highest when done as part of routine standing orders. Partner notification effectiveness has decreased, partly because many partners are anonymous. Most congenital syphilis can be prevented by screening pregnant women; it has been eliminated in areas where intense primary prevention efforts eliminated syphilis among women.

CONCLUSIONS

So far, no program has stopped the increasing rates of infection among MSM, but secondary prevention efforts have prevented most disability. Congenital syphilis is increasing, and can be decreased by screening pregnant women and stopped by intensive efforts to prevent infection among women.

Risk-Based HIV Testing at Los Angeles County Men's Central Jail

Incarcerated populations tend to be disproportionately affected by HIV and sexually transmitted infections (STIs), and men who have sex with men (MSM) are an especially high-risk subset of these populations. Despite the Centers for Disease Control and Prevention's recommendations for universal HIV screening, a lack of resources and high inmate turnover make it difficult to implement such guidelines in jails. From September 2013 to May 2016, the Infection Control Unit of the Los Angeles County Jail used existing resources to implement a voluntary, risk-based HIV educational and screening program targeting MSM inmates during early incarceration. The results revealed a high percentage of previously unknown HIV infections (8.5% = 57 of the 671 tested) and some unknown non-HIV STI cases. In the absence of resources for universal HIV screening, the risk-based approach is a sustainable and cost-effective approach for improving HIV surveillance in the correctional setting.

Determinants of HIV Incidence Disparities Among Young and Older Men Who Have Sex with Men in the United States

This study sought to determine why young men who have sex with men (MSM) have higher HIV incidence rates than older MSM in the United States. We developed hypotheses that may explain this disparity. Data came from peer-reviewed studies published during 1996-2016. We compared young and older MSM with respect to behavioral, clinical, psychosocial, and structural factors that promote HIV vulnerability. Compared with older MSM, young MSM were more likely to have HIV-discordant condomless receptive intercourse. Young MSM also were more likely to have "any" sexually transmitted infection and gonorrhea. Among HIV-positive MSM, young MSM were less likely to be virally suppressed, use antiretroviral therapy, and be aware of their infection. Moreover, young MSM were more likely than older MSM to experience depression, polysubstance use, low income, decreased health care access, and early ages of sexual expression. These factors likely converge to exacerbate age-associated HIV incidence disparities among MSM.

Expanding syphilis testing: a scoping review of syphilis testing interventions among key populations

INTRODUCTION

Syphilis is an important sexually transmitted infection (STI). Despite inexpensive and effective treatment, few key populations receive syphilis testing. Innovative strategies are needed to increase syphilis testing among key populations. Areas covered: This scoping review focused on strategies to increase syphilis testing in key populations (men who have sex with men (MSM), sex workers, people who use drugs, transgender people, and incarcerated individuals). Expert commentary: We identified many promising syphilis testing strategies, particularly among MSM. These innovations are separated into diagnostic, clinic-based, and non-clinic based strategies. In terms of diagnostics, self-testing, dried blood spots, and point-of-care testing can decentralize syphilis testing. Effective syphilis self-testing pilots suggest the need for further attention and research. In terms of clinic-based strategies, modifying default clinical procedures can nudge physicians to more frequently recommend syphilis testing. In terms of non-clinic based strategies, venue-based screening (e.g. in correctional facilities, drug rehabilitation centres) and mobile testing units have been successfully implemented in a variety of settings. Integration of syphilis with HIV testing may facilitate implementation in settings where individuals have increased sexual risk. There is a strong need for further syphilis testing research and programs.

Age-Specific Global Prevalence of Hepatitis B, Hepatitis C, HIV, and Tuberculosis Among Incarcerated People: A Systematic Review

PURPOSE

This study aims to compare the global prevalence of hepatitis B, hepatitis C, HIV, and tuberculosis in incarcerated adolescents and young adults (AYAs) and older prisoners.

METHODS

This study is a systematic review and meta-analysis of studies reporting the age-specific prevalence of each infection in prisoners. We grouped age-specific prevalence estimates into three overlapping age categories: AYA prisoners (<25 years), older prisoners (≥25 years), and mixed category (spanning age 25 years). We used random effects meta-analysis to estimate the relative risk (RR) of each infection in AYAs versus older prisoners.

RESULTS

Among 72 studies, there was marked heterogeneity in prevalence estimates among AYA prisoners for all infections: hepatitis B (.4%-25.2%), hepatitis C (.0%-70.6%), HIV (.0%-15.8%), and active tuberculosis (.0%-3.7%). The pooled prevalence of HIV (RR = .39, 95% confidence interval .29-.53, I² = 79.2%) and hepatitis C (RR = .51, 95% confidence interval .33-.78, I² = 97.8%) was lower in AYAs than in older prisoners.

CONCLUSIONS

The prevalence of HIV and hepatitis C is lower in AYA prisoners than in older prisoners. Despite lower prevalence, acquisition begins early among incarcerated populations. There is an urgent need for targeted, age-appropriate prevention, treatment, and harm reduction measures in and beyond custodial settings to reduce the incidence of infection in these extremely vulnerable young people.

Structural Interventions in HIV Prevention: A Taxonomy and Descriptive Systematic Review

One of the four national HIV prevention goals is to incorporate combinations of effective, evidence-based approaches to prevent HIV infection. In fields of public health, techniques that alter environment and affect choice options are effective. Structural approaches may be effective in preventing HIV infection. Existing frameworks for structural interventions were lacking in breadth and/or depth. We conducted a systematic review and searched CDC's HIV/AIDS Prevention Research Synthesis Project's database for relevant interventions during 1988-2013. We used an iterative process to develop the taxonomy. We identified 213 structural interventions: Access (65%), Policy/Procedure (32%), Mass Media (29%), Physical Structure (27%), Capacity Building (24%), Community Mobilization (9%), and Social Determinants of Health (8%). Forty percent targeted high-risk populations (e.g., people who inject drugs [12%]). This paper describes a comprehensive, well-defined taxonomy of structural interventions with 7 categories and 20 subcategories. The taxonomy accommodated all interventions identified.

Outcomes from a Homegrown HIV Prevention Program for Extremely High-risk, Substance-using Men who have Sex with Men with Multiple Health Disparities

From February 2010 through December 2014, 585 substance-using MSM were enrolled into a "homegrown" risk reduction intervention. Participants evidenced significant iterative factor reductions in the odds of substance use including alcohol (AOR=0.79) and marijuana (AOR=0.78; both p≤0.05) and marginally significant reductions in the odds of methamphetamine use (AOR=0.83; p≤0.07). Participants also evidenced significant reductions in sexual risks including the odds of reporting drug/alcohol use before or during sex (AOR=0.80) and of condomless anal intercourse (AOR=0.72; all significant at p≤0.05). Results demonstrate that the homegrown intervention was effective at reducing HIV risk behaviors among high-risk MSM.

Incarceration Rates and Traits of Sexual Minorities in the United States: National Inmate Survey, 2011-2012

OBJECTIVES

To report characteristics of sexual minority US inmates.

METHODS

We drew our data from the National Inmate Survey, 2011-2012, a probability sample of inmates in US prisons and jails. We determined weighted proportions and odds ratios with 95% confidence intervals to estimate differences between sexual minority and heterosexual inmates.

RESULTS

Sexual minorities (those who self-identify as lesbian, gay, or bisexual or report a same-sex sexual experience before arrival at the facility) were disproportionately incarcerated: 9.3% of men in prison, 6.2% of men in jail, 42.1% of women in prison, and 35.7% of women in jail were sexual minorities. The incarceration rate of self-identified lesbian, gay, or bisexual persons was 1882 per 100 000, more than 3 times that of the US adult population. Compared with straight inmates, sexual minorities were more likely to have been sexually victimized as children, to have been sexually victimized while incarcerated, to have experienced solitary confinement and other sanctions, and to report current psychological distress.

CONCLUSIONS

There is disproportionate incarceration, mistreatment, harsh punishment, and sexual victimization of sexual minority inmates, which calls for special public policy and health interventions.

Bacterial Sexually Transmitted Disease Screening Outside the Clinic--Implications for the Modern Sexually Transmitted Disease Program

BACKGROUND

The development of noninvasive nucleic acid amplification tests for chlamydia and gonorrhea has facilitated innovation in moving sexually transmitted disease (STD) screening to nonclinical settings. However, limited data are available to inform local STD programs on evidence-based approaches to STD screening in nonclinical settings in the United States.

METHODS

We conducted a systematic review of the literature published since 2000 related to chlamydia, gonorrhea, and syphilis screening in US correctional settings, bathhouses and sex venues, self-collected at-home testing, and other nonclinical sites.

RESULTS

Sixty-four articles met eligibility criteria and were reviewed. Although data on testing volume and positivity were available, there were scarce data on the proportion of new positives treated and the programmatic costs for the various screening programs. Screening in correctional settings identified a sizable amount of asymptomatic infections. The value and sustainability of screening in the other nonclinical settings examined was not clear from the published literature.

CONCLUSIONS

Local and state health departments should explore the development of sustainable jail and juvenile detention screening programs for STDs. Furthermore, local programs should pilot outreach and home-based STD screening programs to determine if they are identifying asymptomatic persons who would not have otherwise been found. Local programs are encouraged to present and publish their findings related to non-clinic-based screening to enhance the limited body of literature; data on the proportion of new infections treated and the local program costs are needed.

Global burden of HIV, viral hepatitis, and tuberculosis in prisoners and detainees

The prison setting presents not only challenges, but also opportunities, for the prevention and treatment of HIV, viral hepatitis, and tuberculosis. We did a comprehensive literature search of data published between 2005 and 2015 to understand the global epidemiology of HIV, hepatitis C virus (HCV), hepatitis B virus (HBV), and tuberculosis in prisoners. We further modelled the contribution of imprisonment and the potential impact of prevention interventions on HIV transmission in this population. Of the estimated 10·2 million people incarcerated worldwide on any given day in 2014, we estimated that 3·8% have HIV (389 000 living with HIV), 15·1% have HCV (1 546 500), 4·8% have chronic HBV (491 500), and 2·8% have active tuberculosis (286 000). The few studies on incidence suggest that intraprison transmission is generally low, except for large-scale outbreaks. Our model indicates that decreasing the incarceration rate in people who inject drugs and providing opioid agonist therapy could reduce the burden of HIV in this population. The prevalence of HIV, HCV, HBV, and tuberculosis is higher in prison populations than in the general population, mainly because of the criminalisation of drug use and the detention of people who use drugs. The most effective way of controlling these infections in prisoners and the broader community is to reduce the incarceration of people who inject drugs.

Infectious Diseases and the Criminal Justice System

The United States leads the world in incarceration, which disproportionately affects disadvantaged individuals, including those who are mentally ill, poor, homeless and racial minorities. Incarceration is disruptive to families and communities and contributes to health disparities in sexually transmitted infections (STIs) and human immunodeficiency virus (HIV). The objective of this grand rounds is to review (1) the epidemiology of incarceration in the United States, (2) the social factors which contribute to high rates of STIs in incarcerated individuals and (3) the HIV care cascade in incarcerated and recently released individuals. Routine screening and treatment for STIs and HIV in the criminal justice system can identify many new infections and has the potential to both improve individual outcomes and reduce transmission to others. Increased collaboration between the department of health and department of corrections, as well as partnerships between academic institutions and the criminal justice system, have the potential to improve outcomes in this vulnerable population.

[Sexually transmitted infections in male prison inmates: risk of development of new diseases]

OBJECTIVE

To measure incidence and main risk factors related to sexually transmitted infections (STIs) in Daroca Prison (Zaragoza, Spain).

METHOD

A retrospective cohort study (2005-2013) to measure the incidence of STI and a cross-sectional study to measure risk factors.

RESULTS

Of the 203 inmates, 79 developed an STI, 37 had a previous STI, 55.2% lacked knowledge on STI prevention, and 28.9% showed behaviours unfavourable for STI prevention. The incidence rate was 6.5 STIs per 1,000 inmates-year. The most frequent STIs were hepatitis B (39.7%), Ureaplasma urealyticum (19.1%), herpes simplex (16.2%) and HIV (8.8%). The risk (hazard ratio, HR) of acquiring a new STI was significantly higher in inmates with a history of previous STI (HR=2.61; 95%CI: 1.01 to 6.69), and was at the limit of significance for non-preventive behaviour (HR=2.10; 95%CI: 0.98 to 4.53), but not in knowledge related to STIs (HR=1.33; 95%CI: 0.58 to 3.07).

CONCLUSION

The most important risk factors in prison are behaviours related to STIs and previous history of STIs. Other factors are being a repeat offender, injecting drug use, or being in a methadone programme. Health personnel and peer education can facilitate prevention and control.

Epidemiology of Sexually Transmitted Infections Among Offenders Following Arrest or Incarceration

OBJECTIVES

We sought to estimate rates of sexually transmitted infections (STIs) among criminal offenders in the 1 year after arrest or release from incarceration.

METHODS

We performed a retrospective cohort study of risk of having a positive STI (chlamydia, gonorrhea, or syphilis) or incident-positive HIV test in the 1 year following arrest or incarceration in Marion County (Indianapolis), Indiana. Participants were 247,211 individuals with arrest or incarceration in jail, prison, or juvenile detention between 2003 and 2008.

RESULTS

Test positivity rates (per 100,000 and per year) were highest for chlamydia (2968) and gonorrhea (2305), and lower for syphilis (278) and HIV (61). Rates of positive STI and HIV were between 1.5 and 2.8 times higher in female than male participants and between 2.7 and 6.9 times higher for Blacks than Whites. Compared with nonoffenders, offenders had a relative risk of 3.9 for chlamydia, 6.6 for gonorrhea, 3.6 for syphilis, and 4.6 for HIV.

CONCLUSIONS

The 1-year period following arrest or release from incarceration represents a high-impact opportunity to reduce STI and HIV infection rates at a population level.

Predictors identifying those at increased risk for STDs: a theory-guided review of empirical literature and clinical guidelines

SummarySexually transmitted diseases (STDs) are leading causes of substantial morbidity worldwide. Identification of risk factors for estimating STD risk provides opportunities for optimising service delivery in clinical settings, including improving case finding accuracy and increasing cost-efficiency by limiting the testing of low-risk individuals. The current study was undertaken to synthesise the evidence supporting commonly cited chlamydia and gonorrhoea risk factors. The level of empirical support for the following predictors was strong/moderate: age, race/ethnicity, multiple lifetime sexual partners, sex with symptomatic partners and concurrent STD diagnosis. The following predictors had weak evidence: socio-economic status, transactional sex, drug/alcohol use, condom use and history of STD diagnosis. The most frequently listed predictors among nine clinical guidelines were younger age and multiple sexual partners; the least consistently listed predictor was inconsistent condom use. We found reasonably good concordance between risk factors consistently listed in the recommendations and predictors found to have strong empirical support in the literature. There is a need to continue building the evidence base to explicate the mechanisms and pathways of STD acquisition. We recommend periodic reviews of the level of support of predictors included in clinical guidelines to ensure that they are in accordance with empirical evidence.

Voluntary STD testing and treatment program at a metropolitan correctional facility: evaluation of test acceptability and associated risk factors

Few studies have addressed challenges of diagnosis and treatment of sexually transmitted diseases (STDs) within correctional facilities. Initiatives that screen all inmates can be cost-prohibitive, while symptom-based screening undoubtedly fails to recognize significant numbers of asymptomatically infected persons. This study discusses a voluntary STD screening and treatment program developed at the Douglas County (Nebraska) Department of Corrections where student volunteers interviewed, screened, and educated 456 inmates. Inmate urine samples and interview responses about risk behaviors and motivators for participation in the screening program were analyzed. The results support the ongoing project method to screen and treat inmates in the community correctional facility. Risk factor analysis suggests that targeted testing and treatment efforts may have a role in providing cost-effective care for STD among the incarcerated population.

Sexually transmitted infections among incarcerated women: findings from a decade of screening in a Los Angeles County Jail, 2002-2012

OBJECTIVES

We describe and report findings from a screening program to identify sexually transmitted infections (STIs) and HIV among female inmates in Los Angeles County Jail.

METHODS

Chlamydia and gonorrhea screening was offered to entering female inmates. Women were eligible if they were (1) aged 30 years or younger, or (2) pregnant or possibly pregnant, or (3) booked on prostitution or sex-related charges. Voluntary syphilis and HIV testing was offered to all women between 2006 and 2009. This analysis reports on data collected from 2002 through 2012.

RESULTS

A total of 76,207 women participated in the program. Chlamydia prevalence was 11.4% and gonorrhea was 3.1%. Early syphilis was identified in 1.4% (141 of 9733) and the overall prevalence of HIV was 1.1% (83 of 7448). Treatment levels for early syphilis and HIV were high (99% and 100%, respectively), but only 56% of chlamydia and 58% of gonorrhea cases were treated.

CONCLUSIONS

Screening incarcerated women in Los Angeles County revealed a high prevalence of STIs and HIV. These inmates represent a unique opportunity for the identification of STIs and HIV, although strategies to improve chlamydia and gonorrhea treatment rates are needed.

Condom distribution in jail to prevent HIV infection

To determine if a structural intervention of providing one condom a week to inmates in the Los Angeles County Men’s Central Jail MSM unit reduces HIV transmissions and net social cost, we estimated numbers of new HIV infections (1) when condoms are available; and (2) when they are not. Input data came from a 2007 survey of inmates, the literature and intervention program records. Base case estimates showed that condom distribution averted 1/4 of HIV transmissions. We predict .8 new infections monthly among 69 HIV-negative, sexually active inmates without condom distribution, but .6 new infections with condom availability. The discounted future medical costs averted due to fewer HIV transmissions exceed program costs, so condom distribution in jail reduces total costs. Cost savings were sensitive to the proportion of anal sex acts protected by condoms, thus allowing inmates more than one condom per week could potentially increase the program’s effectiveness.

Seroadaptation in a sample of very poor Los Angeles area men who have sex with men

Data from 635 very poor men who have sex with men (MSM) were used to identify seroadaptation with 1,102 male partners reported between 2005 and 2007 in Los Angeles as part of the Sexual Acquisition and Transmission of HIV Cooperative Agreement Program. The mean age of the sample was 41.7 years; 53 % had experienced homelessness in the past year. Condoms were reported in 51 % of sexual events involving anal intercourse. HIV seroconcordance was reported in 41 % of sexual partnerships among HIV-positive participants. HIV-positive men were more likely to have oral-only or unprotected receptive anal intercourse and less likely to have unprotected insertive anal intercourse with HIV-negative or unknown partners compared to HIV-positive partners. Even in the face of poverty, HIV-positive MSM report mitigating risks of HIV-transmission though seroadaptation in the context of modest rates of condom use.

Syphilis outbreak at a California men's prison, 2007-2008: propagation by lapses in clinical management, case management, and public health surveillance

This field report describes an investigation to identify cases to control a syphilis outbreak in a prison and determine whether clinical, case management, and surveillance practices influenced the outbreak occurrence, detection, or management. Key performance measures were assessed to evaluate timeliness and quality of clinical and case management activities and surveillance practices. Thirty cases were found. Prior to the investigation, median times for clinical and reporting/surveillance measures were 15 days from primary and secondary (P&S) symptom onset to exam, 7 days from P&S exam to treatment, and 63 days from serologic test to the state's receipt of case. After the investigation, these measures improved to 8, 4.5, and 28 days, respectively. Lack of adherence to surveillance and clinical management protocols likely contributed to this outbreak, which was curtailed by aggressive control measures.

A systematic review and meta-analysis of the prevalence of chlamydia, gonorrhoea and syphilis in incarcerated persons

Communicable diseases are common in people who are incarcerated. We aimed to define the prevalence of chlamydia, gonorrhoea and syphilis in people who are incarcerated and to identify subgroups with the highest risk of infection. We searched for prevalence studies of chlamydia, gonorrhoea or syphilis in incarcerated populations. Pooled estimates were generated, and meta-regression was conducted. Random effects models yielded pooled prevalence estimates of 5.75% (95% confidence interval [CI] 5.01, 6.48) and 12.31% (95% CI 10.61, 14.01) for chlamydia in men and women, 1.4% (95% CI 1.09, 1.70) and 5.73% (4.76, 6.69) for gonorrhoea in men and women, and 2.45% (95% CI 2.08, 2.82) and 6.10% (95% CI 4.75, 7.46) for syphilis in men and women, respectively. Each infection was associated with female gender in meta-regression models. Chlamydia, gonorrhoea and syphilis are highly prevalent in these populations. Primary and secondary prevention efforts could improve individual and population health.

The Health of Jail Inmates

Jails are often referred to as “reservoirs of disease” and presented as the origin of infectious diseases or for the development of chronic diseases. The present article argues that the data behind this metaphor are generally taken from nonrepresentative studies by analyzing non-TB-focused studies of jail inmate health issues published in both health and criminal-justice-related journals. Issues such as the use of extremely large jail systems, geographic location, diseases studied, and the lack of attention to jail processes are examined. The article explores the “length of stay” variable from booking to release known as “flow” and how the flow of detainees through jails over time affects who is left for data collection. Data on releases from a large Florida urban jail system for a 1-year period are analyzed to determine the impact of factors associated with release decisions. These, in turn, are related to the representativeness and generalizability of the observed data in previous research and analyzed in terms of potential bias for our understanding of the relationship between jail populations and community health. Issues of health-focused practice standards and recommendations issued without reference to “flow” factors are discussed. Finally, suggestions how criminologists and criminal justice researchers can inform the research on health among jail inmates are canvassed.

Implementing opt-out programs at Los Angeles county jail: a gateway to novel research and interventions

Routine opt-out screening and vaccination programs are effective methods for improving public health in correctional populations. Jail-based rapid testing for HIV, hepatitis B and C, tuberculosis, syphilis, gonorrhea, and chlamydia can improve urban health by increasing diagnosis and linkage to care for infectious diseases. In addition, jail-based vaccination programs would significantly benefit community health and lower costs associated with tertiary level care. The paucity of ethical and rigorous scientific research among incarcerated populations excludes these marginalized members of society from potential advancements in correctional medicine and public health. Routine opt-out testing programs would not only benefit the health of the correctional population but also serve as platforms for future research. Trials measuring the efficacy of new rapid tests, screening methods, novel vaccine delivery systems, or accelerated vaccine regimens would be greatly beneficial.

HIV and hepatitis B and C incidence rates in US correctional populations and high risk groups: a systematic review and meta-analysis

BACKGROUND

High Human Immunodeficiency Virus (HIV) prevalence and high risk behaviors have been well documented within United States (US) correctional systems. However, uncertainty remains regarding the extent to which placing people in prison or jail increases their risk of HIV infection, and regarding which inmate populations experience an increased incidence of HIV. Describing these dynamics more clearly is essential to understanding how inmates and former detainees may be a source for further spread of HIV to the general US population.

METHODS

The authors conducted a systematic review and meta-analysis of studies describing HIV incidence in US correctional facility residents and, for comparison, in high risk groups for HIV infection, such as non-incarcerated intravenous drug users (IVDU) and men who have sex with men (MSM) in the US. HIV incidence rates were further compared with Hepatitis B and Hepatitis C Virus rates in these same populations.

RESULTS

Thirty-six predominantly prospective cohort studies were included. Across all infection outcomes, continuously incarcerated inmates and treatment recruited IVDU showed the lowest incidence, while MSM and street recruited IVDU showed the highest. HIV incidence was highest among inmates released and re-incarcerated. Possible sources of heterogeneity identified among HIV studies were risk population and race.

CONCLUSIONS

Although important literature gaps were found, current evidence suggests that policies and interventions for HIV prevention in correctional populations should prioritize curtailing risk of infection during the post-release period. Future research should evaluate HIV incidence rates in inmate populations, accounting for proportion of high risk sub-groups.

Sex and condom use in a large jail unit for men who have sex with men (MSM) and male-to-female transgenders

Few data are available on factors contributing to sexual activity and condom use in custody settings, particularly among self-identified sexual minority prisoners. To address this gap, we undertook a study of sexual behavior and condom use of 101 randomly-selected men who have sex with men (MSM) and male-to-female transgender inmates in a segregated Los Angeles jail unit that has weekly condom access. Most survey participants (53%) reported anal sex during custody. Although 65% of these reported using condoms, 75% also reported having sex without condoms. Qualitative interviews (n=17) indicate a wide range of reasons for participating in protected and unprotected sex during custody, the use of cues within the custody environment to assess potential partners' HIV status, and support for increased condom availability. Findings also indicate that high-risk sex occurs frequently in this unit and that condom distribution likely prevents a substantial amount of related HIV/STD risk.