Syphilis Control Among Incarcerated Men Who Have Sex With Men: Public Health Response to an Outbreak

After the epidemic years of 1986 through 1990, rates of syphilis steadily declined in the United States to an all-time low of 2.5 cases per 100 000 population in 1999.1 Such declines led the Centers for Disease Control and Prevention (CDC) to create a national plan for syphilis elimination.2 Nevertheless, multiple areas of the United States continue to experience disease outbreaks and a resurgence of sexually transmitted diseases (STDs) among men who have sex with men (MSM).3–8 Because syphilis is increasingly characterized by sporadic outbreaks, rapid outbreak response should include enhanced surveillance of groups at high risk (e.g., incarcerated MSM).

Although correctional facilities have historically been a useful setting for control of infectious syphilis through screening and prophylactic treatment,9,10 the mass screening and treatment of a population segregated on the basis of sexual orientation has not been previously reported. Los Angeles County Men’s Central Jail (LACMCJ) maintains an inmate unit that houses approximately 300 selfidentified MSM voluntarily segregated from the general inmate population.

During an outbreak of syphilis among MSM,7,8 the Los Angeles County Sexually Transmitted Diseases Program (LACSTDP) initiated a syphilis control program in the MSM unit of LACMCJ that consisted of screening, mass prophylactic treatment, high-risk behavior detection, and education. The segregation of MSM from other inmates presented the opportunity to screen and treat patients with syphilis and detect risk behaviors among newly incarcerated MSM.

METHODS

Voluntary screening of all inmates in the MSM unit of LACMCJ for syphilis and human immunodeficiency virus (HIV) began in March 2000. All current and newly incarcerated inmates were offered screening with informed consent. Pre- and posttest counseling and risk reduction counseling was provided by LACSTDP public health investigators and field services staff. New syphilis cases were defined as persons who had had reactive antibody tests and who had not been not previously treated. Chlamydia and gonorrhea screening were added for all new MSM inmates in April 2000.

The LACSTDP began prophylactically treating inmates with single-dose (1 g) azithromycin in April 2000. All inmates were offered azithromycin, regardless of whether they accepted screening or the behavioral survey. Those who accepted took the treatment under observation. Azithromycin prophylaxis for new inmates was discontinued in August 2000.

A voluntary behavioral survey was offered, with informed consent, to all inmates entering the MSM unit beginning in June 2000, whether or not they accepted syphilis screening or azithromycin prophylaxis. The survey was administered in a classroom as part of new inmate processing. To ensure confidentiality, data were handled by LACSTDP staff and kept in a secure location.

RESULTS

From March through August 2000, 811 inmates were screened for syphilis, and 38 (5%) tested positive. Of the 38 inmates with positive tests, 29 had previously treated syphilis and nine had newly identified syphilis (1 primary, 1 secondary, and 7 early latent). Two cases were identified in preoperative male-to-female transgender persons. Inmates who tested positive for syphilis reported a total of 135 partners but provided names for only 5. Consensual high-risk sex among MSM while incarcerated was reported by some inmates. A total of 765 inmates accepted azithromycin therapy (94% acceptance). A total of 73 inmates (9%) tested positive for HIV, 20 (2%) for chlamydia, and 7 (1%) for gonorrhea.

Demographic and behavioral characteristics of inmates completing the survey are summarized in Table 1 ▶. Newly incarcerated MSM were predominantly White and younger than 35 years; approximately one third were Black. Eight percent identified as transgender persons, 87% had been incarcerated before, and 20% had a history of prostitution. Four percent of the inmates presented with symptoms of syphilis (oral or genital lesions) at the time of survey.

TABLE 1.

—Characteristics and Prevalence of Sexually Transmitted Diseases (STDs)Among Incarcerated Men Who Have Sex With Men (n = 430): Los Angeles, Calif

	% of Sample	% STD Prevalence (No.)
Age, y
18–25	23	17 (17/98)
26–35	40	24 (41/173)
36–45	30	27 (34/128)
≥46	7	13 (4/31)
Race
African American/Black	35	30 (45/150)
White	60	19 (48/257)
Asian/Pacific Islander	1	0 (0/4)
Native American/other	4	16 (3/19)
Transgender	8	29 (10/35)
Previous incarceration	87	24 (88/374)
Symptoms (oral or genital lesions) at interview	4	11 (2/18)
Sexual partners
Men	63	26 (72/274)
Both men and women	37	15 (24/156)
No. of sexual partnersa
0–5	78	23 (78/335)
≥6	22	19 (18/95)
Insertive anal sexa	51	22 (48/220)
Receptive anal sexa	41	28 (50/178)
No condom use with main partner	76	22 (71/327)
No condom use with other partner	70	23 (70/301)
History of prostitution	20	24 (20/85)
Venues for meeting sexual partnersa
Bathhouses	15	31 (20/65)
Sex clubs	13	25 (14/56)
Bars	32	24 (32/136)
Anonymous sexa	36	21 (32/156)

^aIn previous 6 months.

DISCUSSION

Screening in the correctional setting aided in disease control during an outbreak by enabling identification and treatment of 9 new cases of syphilis and 29 previously treated cases. The high acceptance of azithromycin prophylaxis indicates the feasibility of mass therapy as a disease containment measure among incarcerated MSM. Although the effectiveness of the azithromycin prophylaxis could not be evaluated because of the rapid turnover of the inmate population, the effectiveness of mass treatments has been documented.11–13 The mass therapy intervention to treat incubating syphilis was justified, given that 4% of surveyed inmates were experiencing symptoms of syphilis.

Surveillance at LACMCJ detected high-risk behaviors among newly incarcerated MSM. Failure to use condoms and anonymous sex with different partners appeard to be common practice for this population, which has a 9% HIV prevalence. Although the incarcerated population of MSM may not represent the nonincarcerated MSM population, concomitant increases in the practice of high-risk sex among other populations of MSM have been reported elsewhere.5,7,14,15 Public health interventions should target incarcerated MSM because these individuals, as they revolve through the correctional system, exhibit highest-risk sexual behaviors.

Given the amount of high-risk sex among MSM within prisons, condoms should be made available in prisons. Alternatively, stricter enforcement of bans on sex between inmates could decrease the spread of STDs. Another critical concern is whether transgender inmates should be housed in a separate unit. Qualitative interviews at the jail demonstrate that housing transgender inmates with the MSM population may provide the opportunity for crossover infection between the 2 groups.

The increased prevalence of HIV in this population indicates the need for specialized HIV/AIDS case managers in correctional facilities. Given the increased transmissibility of STDs with HIV coinfection, potential disease reservoirs (e.g., correctional facilities) present public health challenges and opportunities to integrate HIV and STD prevention services. Because of the yield from the disease control program, the LACSTDP has added permanent staff to continue screening all newly incarcerated MSM for STDs. Prevention and risk reduction education as well as HIV case management have been integrated into standard inmate education and services.

Syphilis outbreak response plans should include mechanisms to reach incarcerated MSM, who are especially vulnerable because of coinfection with HIV and participation in high-risk sex.