Most epidemiological studies evaluating the prevalence of infectious diseases in correctional facilities have neglected the prevalence in jails. While rapid turnover of inmates within jails makes it difficult to measure and quantify sexually transmitted infection (STI) prevalence, an assessment conducted by the Centers for Disease Control and Prevention (CDC) in 1997 found that only 12-47% of jails offered routine testing for syphilis, gonorrhea, or chlamydia, and most offered testing only to symptomatic individuals or those who requested testing.1 In those jails using symptomatic screening for STIs, less than 8% and 3% of women and men, respectively, were tested. This study also documented a common feature of jail testing schema: approximately 50% of arrestees were released within 48 hours after intake, yet most facilities received the inmates' STI test results more than 48 hours after admission.2
The focus of medical care within jails tends to be on urgent and/or acute medical conditions, such as mental illnesses, drug withdrawal, trauma and tuberculosis, rather than on STIs (see table 1). If more focus was made on appropriate diagnosis and treatment of STIs in jails, their transmission among inmates in prisons should decrease since jails are often the initial point of entry into a correctional facility. Some have made a strong argument for collaboration between jails, prisons, and health departments to diagnose, track, and report STI trends in corrections.3 This has largely been limited by a lack of resources.
This article will focus on the epidemiology, diagnosis and treatment of the most common STIs found within jails: syphilis, gonorrhea, chlamydia, and herpes simplex virus (HSV). The relationship between HSV and the acquisition and transmission of HIV, and the prevalence and prevention of hepatitis A and B will also be addressed.
After an all-time low in 2000, the prevalence of syphilis in the general US population increased for the third consecutive year in 2003.4 Between 2002 and 2003, primary and secondary syphilis increased by 4.2%, from 2.4 cases5 to 2.5 cases per 100,000. In 2003, the median percentage of reactive syphilis tests for adult women and men entering correctional facilities was 7.5% and 2.3%, respectively (see table 2). While more than 60% of all primary and secondary syphilis cases occur among men who have sex with men (MSM), a more recent analysis6 suggests that waning immunity within communities may also contribute to easier acquisition of disease.
There is significant geographical variation in the prevalence of syphilis, with the highest rates reported in southern states and in corrections. In 1990, an outbreak of syphilis in New York City (NYC) led to intake syphilis screening and control initiatives in NYC jails. In one NYC jail, syphilis was identified in 3.3% of incoming inmates who were screened.7
The prevalence of gonorrhea in the general US population increased until 2003 when rates decreased 4.8% from 122 cases per 100,000 in 2002 to 116.2 cases per 100,000 in 2003.8 In 2003, the median gonorrhea positivity for both adult women and men entering corrections was 1.8%.
The prevalence of chlamydia in the general population increased 5.1% from 289.4 cases per 100,000 in 2002 to 304.3 cases per 100,000 in 2003. In 2003, the median chlamydia positivity for adult women and men entering corrections was 6.3% and 6.4%, respectively. Most male facilities reporting chlamydia infection were juvenile facilities; rates ranged from 1.3 per 100,000 in a Colorado juvenile facility to 16 per 100,000 in a Pennsylvania adult facility. Reported rates of chlamydia among female facilities range from 1.3 per 100,000 in a Montana facility to 33.5 per 100,000 in an Oklahoma facility, and these estimates are likely under-representative.9 Generally, the rate of diagnosed gonorrhea is half the rate of diagnosed chlamydia, and many authorities believe that both of these STIs are under-reported.
The rate of asymptomatic chlamydia and gonorrhea among men is unknown.10 Because most correctional facilities do not perform intake screening for gonorrhea or chlamydia, the prevalence of asymptomatic disease is difficult to estimate.11 Unpublished data from a recent study on male inmates in the NYC jail system revealed a relatively high rate of asymptomatic chlamydial infection, especially in males 35 years and older. This finding led to the current universal screening for chlamydia and gonorrhea in all males older than 35 years in NYC jails. Additionally, NYC jails test all males for chlamydia and gonorrhea, regardless of age, when they present with signs/symptoms of urethritis. Universal STD screening for females also occurs in NYC jails.
Genital HSV is notoriously under-diagnosed, both in the general population and in corrections. Infection is life-long with rare to frequent recurrences of symptomatic and asymptomatic genital shedding of two serotypes of virus; most commonly HSV-2, and sometimes, HSV-1. There is scant data on HSV prevalence rates, but nationwide, it is estimated that 50 million individuals (one of every five Americans) have genital HSV infection.12
In addition to the discomfort of repeated outbreaks and the risk of transmission, there is also concern that, like other ulcerative STDs, HSV may play a role in the transmission and acquisition of HIV. In a study by Schacker et al, HIV was isolated from HSV-genital ulcers13 and an increased risk of HIV acquisition was estimated at 2 to 4 times greater when HSV was present.14 The results of a preliminary study in Africa suggested that suppressive therapy with acyclovir for patients infected with HSV-2 could be effective in decreasing the risk of HIV acquisition.15
The prevalence of acute Hepatitis B virus (HBV) infections has decreased by more than 60% in the general US population, from a rate of 8.5 per 100,000 in 1990 to 2.8 per 100,000 in 2002. High rates of disease continue among men 25-39 years and in women 40 years and older. Notably, persons belonging to these age groups represent a large core population of incarcerated individuals.
While there have been several outbreaks of HBV in correctional facilities,16 there have not been any reported outbreaks of hepatitis A virus (HAV) in corrections.
The diagnosis of STIs within corrections requires a high index of suspicion, a thorough, non-judgmental sexual history, and a careful genital examination. All inmates should be screened for STIs, particularly when they first enter the system, and screening should be based on prevalence as measured by the population served (see table 4).
The absence of signs and symptoms of syphilis in infected individuals often makes diagnosis difficult. When a chancre or generalized rash is present in the clinical setting, laboratory testing should be used for confirmatory purposes. Syphilis is most often diagnosed by serologic testing using the non-treponemal Rapid Plasma Reagin (RPR) or the Venereal Disease Research Laboratory (VDRL) test. Treponemal tests include the Fluorescent Treponemal Antibody Absorbed [FTA-ABS] and T. pallidum Particle Agglutination [TP-PA]) and are used to confirm non-treponemal test results. The result of one serologic test result in an asymptomatic inmate without laboratory confirmation (i.e., treponemal test) is insufficient for diagnosis because false-positive non-treponemal results may be secondary to other medical conditions.
In high prevalence settings, in cases where signs/symptoms of syphilis exist, and where the history of successful treatment is absent or unreliable, a Rapid RPR test can be used to justify empiric treatment while awaiting confirmatory treponemal test results. Rapid RPR tests are particularly useful in jail settings where patients may not be available when confirmatory treponemal test results return, typically 48 hours later.
The results of non-treponemal tests correlate with disease activity and 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% of people may revert to negative two to three years after successful treatment.
Men with gonorrhea tend to present with symptoms of pain, dysuria, tenesmus, and penile and/or anal discharge, dependent upon the mode of acquisition. Chlamydia infection may present with scant urethral discharge or symptoms. In contrast to men, women infected with gonorrhea and chlamydia are often asymptomatic and therefore go undetected and untreated for longer periods of time. Left untreated, infection can lead to pelvic inflammatory disease, tubo-ovarian pregnancy, and sterility.
The most dramatic change in the diagnosis of STIs has occurred in the laboratory diagnoses of gonorrhea and chlamydia. Previously, invasive swabs inserted for samples were required for culture or microscopic examination. Now, nucleic amplification testing of fluid samples, including urine, sensitively diagnoses both gonorrhea and chlamydia. Medical providers should note that when the nucleic amplification test is repeated soon after treatment completion, the repeat test result may be positive. Consequently, it will be unclear if the person has been newly infected or has a residual positive test.
The clinical diagnosis of genital herpes is fairly straightforward when the patient presents with pain, vesicles, pustules, or genital ulcers. These symptoms, in conjunction with a slight fever and inguinal adenopathy, are not uncommon in primary genital HSV. Recurrences tend to be less symptomatic, but itching, burning, and tingling at the site of infection or proximal sites may help clarify the diagnosis. Viral cultures taken with a swab from the base of an open ulcerative lesion can identify which type of HSV the patient is infected with, regardless of the presence of symptoms. This has prognostic significance, as genital HSV-2 disease recurs more frequently than genital HSV-1.
For asymptomatic or vaguely symptomatic persons, which represents the majority of HSV infections, diagnosis can be made with type-specific serology. Western blot is the gold standard, but other assays are now available and more cost effective. Serology is also helpful in determining primary HSV from recurrent disease. Individuals who are HSV-2 seropositive and are otherwise unaware of their infection may be regularly or intermittently shedding virus from the genital region and therefore infecting sex partners. Giving an inmate this information provides the opportunity to also educate about risk of HIV acquisition (given the known increased risk in the presence of HSV-2), particularly in the MSM population.
Promoting safe sex education, abstinence and safe sexual practices, including the use of condoms, before, during, and after incarceration is extremely important. Early screening, diagnosis, and treatment are also prudent to prevent transmission within, and outside of, corrections.
The prevention of HBV and HAV offers added avenues of prevention, including education regarding risk of intravenous and other forms of drug abuse, tattooing risk, and the utility of pre- and post-exposure vaccination. Pre-exposure vaccination is now recommended during incarceration, regardless of incarceration length.17 Correctional facilities should develop methods to determine completion of vaccine series or appropriate referral upon discharge. There are several approaches to vaccination, as outlined in table 3.
Successful STI treatment depends upon accurate diagnosis, correct antibiotic or antiviral prescription, and proper treatment duration. Multiple guidelines are available, including the Sexually Transmitted Diseases Treatment Guidelines published and regularly updated by the CDC.12 (see "STI 101" in this issue for treatment chart)
Antimicrobial resistance is an important concern in the treatment of gonorrhea. In April 2004 the CDC changed its' recommendations regarding the use of Fluoroquinolones for the treatment of gonorrhea. Fluoroquinolones are no longer recommended for the treatment of gonorrhea in MSM, or for the treatment of any case of gonorrhea in California, Hawaii, and Washington. These recommendations are based on the following: (1) strains of N. gonorrhea with decreased susceptibility to Azithromycin were identified in Missouri in 1999; (2) strains of N. gonorrhea with decreased susceptibility to Fluroquinolones were identified in Hawaii and California in 2001;18 (3) an increase in the rate of Fluroquinolone resistance from 2.2% to 4.4% was identified in the United States in 2003.
Education to prevent transmission and acquisition of STIs should be included with any treatment recommendation. The CDC's Prevention Advisory Committee has recommended integration of STI and HIV education programs, but the continuing increase in STIs among MSM may signal a failure of this integration.19
This article focused on three of many bacterial STIs and three sexually transmissible viral infections. These diseases are highly prevalent within correctional facilities and have experienced a resurgence in recent years. While acquisition of healthcare is typically not a priority for inmates, especially upon entry into jails, medical personnel, social workers, and correctional officers can, and should, encourage at-risk individuals to seek necessary treatment for STIs, and promote education, surveillance, and appropriate STI screening. This is a difficult task in an era of diminishing resources and limited time, but is very important in that STIs, even when asymptomatic, can have devastating effects on an individual, and on the communities in which we all live.
For helpful up-to-date information on the management of STDs, click here (includes an image gallery, CDC guidelines, and more).
Opportunities for STD clinical training may be found here.
Karl Brown, M.D., works at Rikers Island Jail. Disclosures: Consult: Bristol-Myers Squibb, Gilead, GSK and Abbott Laboratories, Speaker's Bureau: Glaxo-Smith Kline.