Managing Sexually Transmitted Diseases in Jails
Correctional environments are increasingly being recognized as settings in which society's infectious diseases are concentrated.1 Most studies on infectious disease in correctional facilities address prisons, but infectious diseases are even more prevalent in jails. In particular, sexually transmitted diseases (STDs) may be more common in jail settings than in prisons, as inmates who are sentenced and sent to prison will typically have been in jail long enough to have been diagnosed and treated for some STDs.
Although there have been some notable successes in identifying these diseases, rapid turnover and frequent movement of inmates makes jails difficult settings in which to quantify the prevalence of various diseases. There is also a tendency to deal only with urgent medical conditions in jails, with mental illness, drug withdrawal, and tuberculosis commanding the most attention. As a result, other chronic illnesses and STDs may not be addressed routinely in the jail setting.
This discussion will focus on the epidemiology, diagnosis and treatment of four of the most common STDs found in the jail setting: syphilis, gonorrhea, chlamydia, and genital herpes. The connection between genital-ulcerative STDs and the acquisition and transmission of HIV will also be discussed. The viral hepatitides, which may be sexually transmitted, will not be included in this discussion.
Health officials in the U.S. were alarmed to find that after declining for many years, syphilis rates began to increase in early 2000.2 The 2001 rate was 2.2 cases per 100,000, up from the rate of 2.1 cases per 100,000 in 2000.3 (See Table 1.) There is a large geographical variation in the rates of primary and secondary syphilis, with the highest rates reported in the South. The reported rates of syphilis are higher in correctional environments than in the non-incarcerated population. In 1990, an outbreak of syphilis in New York City led to intake syphilis screening and control initiatives in NYC jails. In one jail, syphilis was found in 3.3% of new inmates who were screened.4
Gonorrhea and Chlamydia
After decreasing for several years, the rates of gonorrhea and chlamydia in the U.S. have increased sharply.5 In addition to a 9% increase in the number of cases from 1997-1999, recent studies have reported a change in antibiotic susceptibility for gonorrhea, with susceptibility to azithromycin and fluoroquinolones decreasing in Hawaii and California in 2001.6, 7
The overall reported rates of gonorrhea and chlamydia in the U.S. in 2000 were 131.6/100,000 and 257.5/100,000, respectively. There is a high prevalence of Neisseria gonorrhea and Chlamydia trachomatis in jails and juvenile detention centers, especially among women, as documented in a screening of women entering facilities in Chicago, IL, Birmingham, AL, and San Francisco, CA. The rates ranged from five to nine percent for gonorrhea, and twice that for chlamydia, with a range of 11% to 17%. One to two percent of women in this sample were found to be infected with both diseases.8
The reported rates of gonorrhea and chlamydia in women are dependent upon how aggressively screening is performed. Many women with these infections are asymptomatic, and small amounts of vaginal discharge may go unnoticed. Left untreated, infection can lead to pelvic inflammatory disease, salpingoophoritis, tubo-ovarian pregnancy and sterility. The greatest risk for acquiring gonorrhea and chlamydia is in younger, sexually active women, as their less mature cervices have been found to be more vulnerable to infection.
Men with gonorrhea tend to present with symptoms of pain, dysuria, tenesmus, and anal and/or penile discharge, with signs and symptoms dependent upon the site of infection. Chlamydia infection may present with scant urethral discharge or florid symptoms. The rate of asymptomatic disease is unknown for both of these infections.9
Because most facilities do not perform intake screening for gonorrhea or chlamydia on asymptomatic men, the prevalence of disease is difficult to estimate.10 In the year 2000, most facilities reporting chlamydia in males were juvenile prisons. Their rates ranged from 0.8% in Oregon to 13% in Texas. Rates from the few jail facilities that reported ranged from 5.4% in Northern California to 21% in Northern Florida.11
Genital herpes is a lifelong infection characterized by recurrent outbreaks of HSV serotypes 1 and/or 2. HSV-2, the most common cause of recurrent episodes of genital herpes simplex, is notoriously under-diagnosed. It is believed that most people with HSV do not know they have it and since it can be spread with asymptomatic shedding of virus, it is particularly easy to transmit. Estimates are that 50 million people in the U.S. have genital HSV infection.12
Besides the discomfort of repeated genital herpes outbreaks and the transmission of HSV-2 during symptomatic and asymptomatic periods, there have been concerns that recurrent HSV may play a role in HIV acquisition and transmission. In a study by Schacker et al., 12 men with HIV disease were studied. HIV-1 was isolated from 25 of 26 HSV-2 lesions during recurrence in all 12 of the men for 67% of the days when genital lesions were noted. None of the 12 were on antiviral therapy for HSV during the study. Only three of the 12 were on therapy for HIV disease.13 The increased risk of HIV acquisition is estimated to be anywhere from two to four times higher when HSV infection is present.14 A preliminary study from Africa suggested that suppressive therapy with acyclovir for patients with HSV-2 could be an effective method for decreasing the risk of HIV acquisition.15
When discussing diagnosis or treatment for any illness within corrections, it is important to be aware of the differences between jails and prisons.
Recognition of these differences does not suggest that diagnosis and management of STDs in either of these two environments is simple, but highlights the challenges. In prisons, one of the priorities is preventing the introduction of STDs into the inmate population; there may be less concern and urgency regarding transmission to the outside community. In jails, the priorities include diagnosis and treatment within the jail, with great concern for decreasing transmission to the community and prison facilities.
Many have looked at the jail environment as key to controlling STDs, noting high rates of untreated sexually transmitted diseases within minority communities with high incarceration rates.16 A similar argument has been made for collaboration between jails, prisons, and departments of health to diagnosis, track, and report STD trends in corrections.17 Due to the high rates of STDs within jails, and the subsequent impact on outside communities, several strategies have evolved to address the issues paramount in jail environments.
In 1997, an assessment of the STD services within city and county jails indicated that most facilities treated for STDs based on symptoms or by arrestee request and did not routinely screen asymptomatic inmates. Less than half of the jails assessed had a policy of offering routine screening, and even in those facilities with routine screening, fewer than half of the inmates were tested for syphilis, gonorrhea, or chlamydia. In those facilities using symptomatic screening for STDs, less than eight percent of women and less than three percent of men were tested. This study also documented a common feature of jails: approximately half of arrestees were released within 48 hours and most facilities received the inmates' test results more than 48 hours after admission.18
The diagnosis of STDs requires a high index of suspicion, a thorough non-judgmental sexual history, and a careful genital exam. All inmates should be screened for STDs and the type of screening in a facility should be based on prevalence as measured by the population served.
Due to the absence of signs and symptoms in many of those who are infected, it may be difficult to diagnose syphilis unless the medical provider happens upon a chancre of primary syphilis or is convinced a disseminated skin rash is secondary syphilis. Otherwise, syphilis is most often diagnosed by serologic testing using the non-treponemal Rapid Plasma Reagin (RPR) test or the Venereal Disease Research Laboratory (VDRL) test. Confirmatory specific treponemal tests include the fluorescent treponemal antibody absorbed (FTA-ABS) or MHA-TP. Most laboratories will automatically confirm the positive non-treponemal test results with specific treponemal results. The use of one serologic test without confirmation is insufficient for diagnosis because false-positive non-treponemal results may be secondary to other medical conditions.
The rapid RPR test is used to qualitatively diagnosis syphilis. In high-prevalence settings, in cases where other signs/symptoms of syphilis exist, and when history of treatment is non-existent or unreliable, positive results can be used to justify empiric treatment while awaiting quantitative results and confirmatory treponemal tests. This is especially useful in the jail setting where patients may not be available in 48 hours when most test results return.
The results of non-treponemal tests correlate with disease activity and will usually revert to negative following successful treatment, though they may remain positive at low titer in some individuals. This condition is referred to as "serofast."
Treponemal antibody tests usually remain positive for years, and sometimes for the lifetime of the patient, regardless of treatment or disease activity. Fifteen to 25 percent of people may revert to negative two to three years after successful treatment.
Previously, gonorrhea and chlamydia required invasive examinations for samples and either microscopic examination of fluid to detect intracellular gram-negative diplococci for GC, or culture to detect both. Currently, nucleic amplification tests can be used on fluid samples, including urine, and sensitively diagnose both these infections.
Primary genital herpes simplex infections often present with significant signs and symptoms of pain at the vesicle, pustule, or ulcer sites, slight fever, and inguinal lymphadenopathy dependent upon the extent of lesions. Recurrences are often less symptomatic, may present with a prodrome of itching or burning or may go completely unnoticed. History and visual signs usually make a clinical diagnosis fairly straightforward, but viral culture can help identify which form of HSV the patient has, and this has prognostic significance. Generally HSV-1 recurs with less frequency than HSV-2.
The success of treatment for STDs depends upon an accurate diagnosis, the correct antibiotic or antiviral therapy, and the proper duration of treatment. Multiple guidelines documenting treatment choices are available; the most user-friendly version is the Sexually Transmitted Diseases Treatment Guidelines published by the CDC, which are regularly updated.
Education on the prevention of acquisition and spread of STDs should be included with any treatment recommendations. The CDC's Prevention Advisory Committee has recommended integration of STD and HIV programs, but current increases in STDs among HIV-positive men who have sex with men (MSM) highlights the overall failure of this integration to date.19
Although this article addressed only four of the many STDs, these four are significantly prevalent within jails. There has been a resurgence in sexually transmitted diseases in recent years and the correctional environment is not exempt from this increase in case rates. If anything, the jail environment is a startling example of this resurgence. Diagnosis and treatment within corrections, especially jails, can have an impact on the prevalence of disease within jails and the communities they serve.
Obviously, most arrestees do not enter the correctional environment for the sole purpose of receiving health care. However, it is incumbent upon medical providers to do what they can to approach patients and determine and address their health needs, even with limited resources and time. This is true even for patients who are not aware of these health needs. This approach is important regarding STDs, as patients may have minimal or no symptoms, leading to transmission of these infections inside and outside the jail setting.
Karl Brown, M.D. is Infectious Diseases Supervisor at Rikers Island Jail, New York City, NY. He is a consultant to Bristol-Myers Squibb, Gilead and Abbott Laboratories.
This article was provided by Brown Medical School. It is a part of the publication HEPP Report.