Novel Public Health Programs Screen, Treat Inmates for STDs

Local jails have historically lacked programs for routine STD screening of detainees. Yet arrestees are at high risk for STDs, and no matter how narrow the window of opportunity, experts are calling for increased efforts at screening and treating this population. "In terms of case detection, [jails] are one of the higher yield sites," said Richard Kahn, MS, an epidemiologist at the CDC. "In juveniles [in 1997], the median percentage for chlamydia among women entering juvenile facilities was 15 percent positivity, with a range of 1.5 percent to 28 percent. Positivity was greater than 10 percent in 17 of the 24 facilities that reported." Among 115 facilities reviewed in the study, researchers found that fewer than half had a policy of offering routine testing for chlamydia, gonorrhea or syphilis to arrestees. Even in jails with routine testing, fewer than half of arrestees were tested for the three infections, and most testing was conducted among arrestees who had symptoms.

A 1998 CDC report indicated that the prevalence of STDs among women entering jails and juvenile detention centers in Chicago, Baltimore and San Francisco was high: 35 percent had syphilis; 27 percent had chlamydia; and 8 percent had gonorrhea. "I think that overall, [jail] detection screening is going to find some of your highest rates of STDs anywhere in your community," said Charlotte Kent, MPH, chief of the epidemiology unit for the San Francisco STD Control program of the city's Health Department.

In San Francisco, males and females who come into youth detention are offered screening for chlamydia within 12 hours, Kent said. Gonorrhea screening is offered only to females, because prevalence of the disease in area males is low. If detainees are released before STD results are available, disease intervention specialists (DIS) follow up with them in the community and try to confirm they have been treated, either by a clinic or a private provider. The DIS also provide field-delivered therapy, meeting detainees who have been released and giving them antibiotics. "Between people being treated while they're still incarcerated and the work of our staff, we're able to get about 85 percent of the people who are positive treated," Kent said.

In December, the St. Louis Health Department started a pilot project, the St. Louis City Correctional Health Initiative (CHI), to establish a freestanding STD clinic within the city jail. According to Bill Dotson, chief of the Center on the Health of Specific Populations for the Health Department, the four key parts of CHI are:

• Medical evaluation and treatment at the time of arrest or detainment, plus referral to permanent health care providers.

• Court-mandated health assessment and treatment as a condition of release.

• Aggressive case management and follow-up with released prisoners to assure compliance with mandated health programs.

• Data collection and evaluation to better understand the burden of disease in the incarcerated population.

Dotson estimates the clinic may save up to $500,000 a year for the city by handling health problems on-site instead of transporting detainees to a hospital emergency room. In addition, "emergency room visits do not generally address such public health concerns as STDs, tuberculosis, and hepatitis, which occur at higher rates in this population," Dotson said. "If we can come in there and provide some basic medical screening at intake and medical follow-up, with care as needed in the holdover facility, then we can prevent [ER visits]."

In addition, a database was created to follow detainees and refer them to more permanent medical situations. The data assessment is being shared by the project, the city courts, and Glaxo SmithKline. Judge Jim Sullivan of the city's 22nd municipal district is also involved in the process, making referrals for health care a condition of review before sentencing. "Then that will be looked at favorably before the disposition of the sentence," said Dotson. "We're looking at that as a way to enhance compliance."

Judges may require health education and testing as a condition of release. Before the CHI, the city Health Department was already providing testing and education on STDs and HIV through its Health Education and Training (HEAT) program. As required by local ordinance, the department also provides STD testing for anyone arrested for prostitution. In addition to STD testing, Dotson said that two local AIDS services organizations -- Recruiting Blacks Against AIDS and the Effort for AIDS -- educate and counsel men arrested for prostitution and other sexual offenses. Dotson said he would like to see all detainees tested for HIV and other STDs, but as with many such programs, funding is an issue.

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