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. Author manuscript; available in PMC: 2013 Mar 30.
Published in final edited form as: Women Health. 2012;52(2):119–134. doi: 10.1080/03630242.2011.649396

Prevalence and Predictors of Sexually Transmitted Infections in Hazardously-Drinking Incarcerated Women

Celeste M Caviness 1, Bradley J Anderson 1, Michael D Stein 1,2
PMCID: PMC3323107  NIHMSID: NIHMS364115  PMID: 22458289

Abstract

Incarcerated women are at high risk for sexually transmitted infections (STI). Left untreated, these infections can have severe adverse health effects. This study presents prevalence rates of Trichomonas, Chlamydia, and Gonorrhea, and factors related to having an STI in a sample of 245 hazardously-drinking incarcerated women who reported heterosexual intercourse in the previous 3 months. Vaginal swabs were collected following the self-report baseline assessment. Participants averaged 34.1 (± 8.9) years of age; 174 (71.3%) were non-Hispanic Caucasian, 47 (19.3%) were African-American, 17 (7.0%) were Hispanic, and 6 (2.5%) were of other racial or ethnic origins. Twenty-three percent of participants tested positive for Chlamydia, Trichomonas, or Gonorrhea. Being African-American, more frequent sex with a casual partner, and reporting more than one male partner were significantly positively related to STI, while more frequent sex with a main partner was inversely related. Due to the high rates of infection in this population, jail admission provides a public health opportunity to access a concentrated group of STI-infected women. STI testing targeted at specific demographic factors, for instance younger age, will miss infected women. Risky sexual partnerships, as well as the benefit of maintaining stable main partnerships may be important topics during STI prevention interventions.

Keywords: prevalence, sexually transmitted infections, incarceration, women

Introduction

Trichomonas (TV), Chlamydia (CT), and Gonorrhea (GC) are three of the most frequently occurring sexually transmitted infections (STI) among women, who are affected by STI at higher rates than men (Centers for Disease Control and Prevention November 2009; Datta et al. 2007; Plitt et al. 2005). Despite nearly 913,000 cases of CT and nearly 163,000 cases of GC in women reported to the Centers for Disease Control (CDC) in 2009 (Centers for Disease Control and Prevention 2010), these numbers likely underestimate the actual occurrence and prevalence of STI in the general female population. Recent estimates suggest the actual number of new CT cases may be roughly three times higher, and GC cases may be close to four and a half times higher, while TV cases, which are not reported to the CDC, may number as many as 7.4 million (Weinstock, Berman, and Cates 2004).

Although many cases of CT, GC, and TV are asymptomatic, women face serious health consequences if infections are not diagnosed and treated. Pelvic inflammatory disease (PID), ectopic pregnancy, and infertility are long-term concerns associated with both CT and GC (Centers for Disease Control and Prevention 2007 2010). Untreated TV can lead to preterm delivery and low infant birth weight, and women infected with TV are more likely to have a concurrent STI. Importantly, those infected with TV may be at increased risk of acquisition and transmission of HIV (Allsworth, Ratner, and Peipert 2009; Centers for Disease Control and Prevention 2007; McClelland et al. 2007; Shafir, Sorvillo, and Smith 2009). Given the prevalence of TV in the general population, and the relative dearth of public health attention to this infection, this association is particularly alarming (Van der Pol 2007).

Incarcerated women are among the sub-populations of women at highest risk for STIs. STI prevalence data from women entering jails in thirty eight states in 2008 indicate CT positivity of 8.5% and GC positivity of 2.6% (Centers for Disease Control and Prevention November 2009), both much higher than general population estimates. Data collected as part of clinical trials at adult correctional facilities found CT prevalence at intake between 2.5–13% and GC prevalence of 2.3–10% (Hardick et al. 2003; Mertz et al. 2002; Willers et al. 2008), with TV rates ranging from 22–47% (Shuter et al. 1998; Willers et al. 2008).

African American women shoulder a disproportionate burden of STI in non-incarcerated samples (Allsworth, Ratner, and Peipert 2009; Centers for Disease Control and Prevention 2009; Datta et al. 2007; Gollub et al. 2010; Helms et al. 2008; Plitt et al. 2005; Sutton et al. 2007), but among incarcerated female populations, racial disparities are less consistent. No significant racial differences were found in TV (Freeman et al. 2010; Shuter et al. 1998; Willers et al. 2008), or CT and GC rates (Willers et al. 2008) in studies of incarcerated women. However, racial differences have been noted in other studies, with one report finding ethnic or racial minorities at increased risk for CT and GC (Mertz et al. 2002), while another reported white race to be a risk factor for CT and GC (Hardick et al. 2003) in detained women.

STIs are correlated with age in the general population and among detained women. CT and GC are found in the highest prevalence among detained women under 25 years old (Hardick et al. 2003; Mertz et al. 2002). The opposite is true of TV however, with older age significantly associated with infection (Freeman et al. 2010), consistent with findings from community samples (Helms et al. 2008; Sutton et al. 2007).

In addition to demographics, the behavioral characteristics often found in incarcerated female populations are important factors in prevalent STIs. Women who have high numbers of lifetime sexual partners (Sutton et al. 2007), or a main plus a casual partner (Gollub et al. 2010) have higher risk for TV infection. Commercial sex work, which is frequent among incarcerated women (Fickenscher et al. 2001) has also been associated with STI infection (Willers et al. 2008). Additionally, compared to jailed adult men, jailed women are less likely to report always use using a condom, and more likely to report never using condoms (Freudenberg et al. 2007).

Elevated rates of substance use (Freudenberg et al. 2007; Hogben, St. Lawrence, and Eldridge 2001; Henderson 1998) have also been reported in incarcerated populations. Women have a higher prevalence than male detainees of illicit drug use, substance use disorders, and arrests for drug related charges (Freudenberg et al. 2007; Binswanger et al. 2010). Cocaine use is associated with increased TV risk in pregnant detained women (Shuter et al. 1998) and poly-substance-using, non-incarcerated, African-American women (Miller et al. 2008). Additionally, exchanging drugs for sex may increase risk for STI.

Hazardous drinking, defined as four or more drinks in a day, or more than seven drinks per week for women (National Institute on Alcohol Abuse and Alcoholism 2005), occurs frequently among incarcerated women (Caviness et al. 2009; Freudenberg et al. 2007). Approximately one-third of incarcerated women have lifetime history of alcohol use disorders (Teplin, Abram, and McClelland 1996; Grella and Greenwell 2007; Jordan et al. 1996), and high rates of women are under the influence of alcohol at the time of arrest (El-Bassel et al. 1995; Greenfeld and Snell 1999). Given the strong connection between alcohol consumption and risky sexual behavior (Logan, Cole, and Leukefeld 2002; Thompson, Kao, and Thomas 2005; Stein et al. 2009; Stein et al. 2010; Barta et al. 2008; Kiene et al. 2009), drinking, especially at hazardous levels, may be an important risk factor for STIs. The extant literature suggests sexual encounters with new or casual partners are riskier when alcohol is consumed prior to sex (Barta et al. 2008; Kiene et al. 2009). Alcohol is also often used with other drugs, including cocaine, the most frequently used illicit drug among female arrestees (National Institute of Justice (U.S.) 2003), which also increases risky sexual behavior and STI prevalence (Miller et al. 2008; Shuter et al. 1998).

Although prevalence rates of STI in incarcerated women have been previously examined, to our knowledge prior studies did not look at partner type or multiple risky sexual behaviors. Additionally, few studies have looked at TV, GC, and CT prevalence in the same cohort. Finally, we are not aware of other studies that have examined STI prevalence among hazardous drinkers. This investigation had two purposes. First, we estimated the prevalence of GC, CT, and TV infection in a sample of hazardously drinking, heterosexually active, incarcerated women. Second, we examined factors associated with STI in this high risk population, including partner type and multiple types of sexual risk.

Methods

Study Site

No county jails exist in the geographically small state of Rhode Island; instead all inmates are housed by the Rhode Island Department of Correction (RI DOC) at the Adult Correctional Institute (ACI). The ACI operates as a unified, centralized and comprehensive state correctional system, and encompasses all jail, prison and rehabilitative services, including community corrections (probation/parole). However, the Women’s Facility at the ACI functions like jails throughout the nation, with the majority of women returning to the community within 30 days of commitment (Hebert et al. 2008).

Participants

All newly incarcerated women over a 40-month period from February 2004 to June 2007 were eligible for screening. Participants were eligible if they: 1) spoke English, 2) had reliable contact information, 3) were likely to be released in the next 14 days, 4) endorsed having unprotected heterosexual sex at least three days in the previous three months, and 5) endorsed hazardous alcohol consumption, defined by NIAAA binge criteria, at least three times in the past three months, or a score of 8 or above on the Alcohol Use Disorders Identification Test (AUDIT) (Saunders et al. 1993). After a check for comprehension, participants provided written informed consent to participate.

During the enrollment period 1,616 women were approached for screening, 1,415 agreed to be screened. A total of 396 met alcohol and sexual risk criteria but 115 of those women were ineligible for other reasons (i.e. sentenced, living out of state); 281 were eligible. A total of 245 agreed to participate and enrolled in a randomized clinical trial of a brief intervention to reduce alcohol use and HIV risk (Stein et al. 2010). Of those ineligible, 467 did not meet hazardous alcohol criteria, 212 did not meet sexual risk criteria and 340 met neither hazardous alcohol nor sexual risk criteria. The trial protocol was approved by the Miriam Hospital Institutional Review Board, the Office for Human Research Protection, and the RI DOC’s Medical Research Advisory Group. Additionally, a Certificate of Confidentiality was obtained from the federal government to further protect the information collected from study participants.

Study Design and Procedure

Screening was conducted confidentially, without compensation, in a private room without surveillance, beginning with informed verbal consent. During the consent process, it was stressed that refusal to be screened would have no negative impact on services the women would normally receive, their disciplinary status or regular scheduled medical visits. If verbal consent was given, the screening questions were read to the inmate and answers recorded by the research assistant (RA).

Eligible women were invited to participate in the study. Study participants provided written informed consent and were enrolled in the protocol. After completion of the consent process, the RA read aloud the survey questions and recorded answers for the 45-minute baseline survey. In addition to the survey, respondents were also asked to give two vaginal swabs to test for Trichomonas and Gonorrhea and Chlamydia. Both swabs were collected at the same time after the survey. If a participant tested positive for any of the STIs, she was treated free of charge, either at the ACI, or by the research team. Participants were paid $20, in the form of a money order mailed to them upon release from the ACI, for time spent completing the baseline survey.

Measures

Sexually transmitted infection (STI)

The primary outcome was a dichotomous indicator scored 1 if the participant tested positive for TV, CT, or GC on a biological assay. C. trachomatis and N. gonorrhoeae testing was performed using DNA amplification of endocervical swabs (Becton Dickinson BDProbe Tem™ ET; Becton, Dickinson and Company, Franklin Lakes, New Jersey). Trichomonas vaginalis testing was performed using sterile cotton swab collection and InPouch™ culture (Biomed Diagnostics, White City, Oregon). Tests were collected during the baseline assessment. Both testing methods have shown excellent sensitivity and specificity; CT and GC sensitivity has a range from 89–100% and specificity has a range of 96–100% (Borchardt and Smith 1991; Sood et al. 2007; Gaydos et al. 2004; Van Dyck et al. 2001).

Time Line Followback (TLFB)

Participants were asked to recall their past 90-day sexual and alcohol history at baseline, using the Timeline Followback method (Sobell and Sobell 1996). This calendar-based assessment procedure uses prompts of important dates, (e.g., birthdays or holidays) to elicit recall of behavioral health data. Respondents were asked to recall days they consumed alcohol and how many drinks on each day. They were also asked to recall vaginal or anal sex on each day with both main and casual (partner other than main) male partners and whether they used a condom for each encounter. Using the TLFB data, we constructed summary measures of days of heavy (≥ 4 drinks/day) alcohol use, days sexually active with main and casual partners, and days unprotected sex with main and casual partners.

Other Measures of Sexual Risk Taking

The baseline questionnaire included the scored items from the Risk Assessment Battery (Metzger, Woody, and Navaline 1993). Participants were asked to report the number of males with whom they had sex and whether they had exchanged sex for money or drugs during the 3-months prior to incarceration (commercial sex work).

Lifetime History of STI

Participants were asked if they had ever been told by a health care provider that they had Trichomonas, Chlamydia, or Gonorrhea. Responses were coded yes/no for the three individual items.

Substance Use

Cocaine and opiate use were assessed using an adaptation of the Addiction Severity Index (McLellan et al. 1992). Separate dummy variables were generated to indicate any use of cocaine or any use of opiates (either heroin or other opiates) in the 90 days prior to baseline.

Data Analysis

Analytical Methods

This is a secondary analysis of baseline data collected during the afore-mentioned randomized control trial (Stein et al. 2010). We used descriptive statistics to summarize the characteristics of the full study sample and by STI status. To facilitate comparisons with multivariate models, we present the unadjusted effect on the odds of testing STI+ for each background characteristic. For descriptive analyses, we also constructed dichotomous indicators, coded 1 if the participant reported any sex with main and casual partners, respectively, in the 90 days prior to baseline. Several of the variables used to describe sexual behaviors of participants in this sample were derived from the same Timeline Followback questions (e.g., having any casual partners, frequency of sex with casual partners, and frequency of unprotected sex with casual partners); other variables were highly co-linear (e.g., engaging is commercial sex work, having sex with casual partners, and having multiple male partners). We relied on stepwise forward selection to identify the indicators of sexual risk-behaviors most strongly associated with STI in this cohort. Background characteristics (age, race/ethnicity, days of heavy alcohol use, living with sex partner, lifetime history of STI, and recent use of cocaine or opiates) were entered as covariates prior to stepwise selection of sexual risk-taking indicators. Measures significant at the .05 level, based on the likelihood ratio chi-square test, were included in the final model. Model fit was assessed using the Hosmer-Lemeshow goodness of fit statistic (Hosmer and Lemeshow 2000).

Results

Participants averaged 34.0 (± 8.8) years of age; 174; 174 (71.3%) were non-Hispanic Caucasian, 47 (19.3%) were African-American, 17 (7.0.0%) were Hispanic, and 6 (2.5%) were of other racial or ethnic origins. Hispanics and all other ethnic minorities were combined for subsequent analyses (Table 1). Three women reported being HIV-positive. During the 90 days prior to baseline, participants reported consuming four or more drinks on 39.6 (± 30.4) days, and 166 (67.8%) and 103 (42.2%) said they had used cocaine or opiates within the past 90 days, respectively. Half (n = 122) said they were currently living with a sex partner at the time of assessment and 116 (47.4%) reported a lifetime history of testing positive for CT, TV, or GC.

Table 1.

Baseline Characteristics by STI Status and Unadjusted Effects on the Odds of Testing STI+.

COHORT (n = 244) STI− (n = 188) STI+ (n = 56) OR (95% CI)a
Mean (± SD) or n (%) Mean (± SD) or n (%) Mean (± SD) or n (%)
Years of Age 34.0 (± 8.8) 34.3 (± 8.9) 33.1 (± 8.6) 0.87 (0.64; 1.17)
Race/Ethnicity
 African-American 47 (19.3%) 30 (16.0%) 17 (30.4%) 2.02* (1.02; 4.06)
 Other Racial/Ethnic Minority 23 (9.4%) 22 (11.7%) 1 (1.8%) 0.16 (0.02; 1.24)
 Caucasian 174 (71.3%) 136 (72.3%) 38 (67.9%) [REF]
Days Heavy Alcohol Use/90 Days 39.6 (± 30.4) 40.1 (± 30.7) 37.7 (± 29.7) 0.92 (0.68; 1.25)
Recent Cocaine Use (Past 90 Days) 166 (68.0%) 120 (63.8%) 46 (82.1%) 2.65* (1.26; 5.57)
Recent Opiate Use (Past 90 Days) 103 (42.2%) 72 (42.0%) 24 (42.9%) 1.03 (0.56; 1.89)
Lives with Sex Partner (Yes) 122 (50.0%) 97 (51.6%) 25 (44.6%) 0.75 (0.41; 1.36)
Lifetime History of STI 116 (47.5%) 83 (44.2%) 33 (58.9%) 1.83* (1.00; 3.35)
Days Sexually Active/90 Days 39.2 (± 28.2) 39.6 (± 28.0) 37.8 (± 29.2) 0.93 (0.69; 1.26)
Any Main Partners (Yes) 215 (88.1%) 170 (90.4%) 45 (80.4%) 0.43* (0.19; 0.98)
Days with. Main Partner/90 Days 31.7 (± 27.8) 34.2 (± 28.0) 23.2 (± 25.6) 0.64** (0.45; 0.90)
Days Unprotd. with Main Partner/90 Days 31.4 (± 28.1) 34.0 (± 28.4) 22.8 (± 25.3) 0.63** (0.45; 0.89)
Any Casual Partners (Yes) 101 (41.4%) 66 (35.1%) 35 (62.5%) 3.11** (1.67; 5.76)
Days with Casual Partner/90 Days 9.1 (± 20.7) 6.2 (± 16.1) 19.0 (± 29.9) 1.66** (1.27; 2.18)
Days Unprotd. with Casual Partner 5.7 (± 15.8) 4.2 (± 12.9) 10.9 (± 22.3) 1.42** (1.09; 1.85)
Multiple Male Partners (Yes) 104 (42.6%) 67 (35.6%) 37 (66.1%) 3.55** (1.89; 6.65)
Sex Work (Yes) 66 (27.1%) 40 (21.3%) 26 (46.4%) 3.23** (1.72; 6.06)
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a

Unadjusted (bivariate) effects on the odds of testing STI+. Continuous variables were standardized to zero mean and unit variance prior to estimating odds-ratios and give the expected change in the odds of testing STI+ for a 1 standard deviation increase in the corresponding predictor. 95% CI estimates and tests of significance were based on robust Huber-White variance estimators.

On average, participants reported having sex on 39.2 (± 28.3) of the 90 days prior to baseline assessment (Table 1). The mean number of days on which participants were sexually active with a main partner was 31.7 (± 27.8) days and they had unprotected sex with main partners on an average of 31.4 (± 28.1) days; participants used condoms on 3.7% of the days on which they were sexually active with main partners. On average, participants were sexually active with casual partners on 9.1 (± 20.7) days, and had unprotected sexual intercourse with casual partners on 5.7 (± 15.8) days. Participants reported using condoms on 60.1% of the days on which they were sexually active with casual partners. One-hundred-four (42.6%) said they had had two or more male sex partners, and 66 (27.1%) said they had engaged in commercial sex work.

Fifty-six (23.0%) of participants tested positive for CT, TV, or GC. STI-specific prevalence rates were 2.9%, 20.5%, and 2.5% for CT, TV, and GC, respectively. Five (2.0%) participants tested positive for multiple STIs.

Results of bivariate analyses indicated that testing STI+ was associated significantly with race/ethnicity (LR2 = 10.48), df = 2, < .01); African-Americans were significantly more likely to test STI+ than either non-Hispanic Caucasians (OR = 2.02 p < .05) or those in other racial/ethnic groups (OR = 12.47, p < .05) (Table 1). The estimated odds of testing STI+ was 6.14 (p = .08) times higher among non-Hispanic Caucasians than among those of other racial or ethnic origins. Recent cocaine use, reporting a lifetime history of STI, being sexual activity with casual partners, reporting multiple male partners, and engaging in commercial sex work were all associated positively with testing STI+. Being sexually active with main partners was associated with a lower likelihood of testing STI+ (Table 1).

Because prior studies have reported different patterns of association, we explored the bivariate relationship between age and each of the STIs for which participants were tested. Younger age was associated with a higher likelihood of testing positive for all three STIs; however, the association was not statistically significant for TV (OR = 0.95, 95% CI 0.69; 1.31, p = .76), CT (OR = 0.68, 95% CI 0.31; 1.50, p = .337) or GC (OR = 0.44, 95%, 95% CI 0.17; 1.15, p = .096). Results regarding associations with CT or GC should be interpreted cautiously because only 7 and 6 participants, respectively, tested positive for these specific STIs in this cohort.

Consistent with bivariate analyses, STI+ was associated significantly with race/ethnicity after adjusting for other covariates entered in the final model; African-Americans had the highest adjusted odds of testing STI+ Table 2. After adjusting for other background characteristics and indicators of sexual risk taking, neither recent cocaine use nor self-reported lifetime history of STI were associated significantly with testing STI+. After entering all demographic characteristics and measures of substance use, stepwise forward selection was used to identify the most salient behavioral correlates of testing STI+. Testing STI+ was positively and significantly associated with frequency of sexual activity with casual partners (OR = 1.46, p < .05) and with reporting multiple male partners (OR = 2.27, p < .05). Testing STI+ was inversely and significantly associated with frequency of sexual activity with main partners (OR = 0.67, p < .05).

Table 2.

Multiple Logistic Regression Models Estimating the Association of Background Characteristics, Substance Use, and Sexual-Risk Taking Behaviors with the Likelihood of Testing STI+ (n = 244).

Entered Covariatesa OR (95% CI)b
Years of Agec 0.85 (0.59; 1.23)
Race/Ethnicityd
 African-American 2.50* (1.11; 5.65)
 Other Ethnic Minority 0.20 (0.02; 1.67)
 Non-Hispanic Caucasian [REF] [1.00]
Self-Reported Lifetime History of STI (Yes) 1.14 (0.54; 2.38)
Lives with Sex Partner 1.46 (0.73; 2.94)
# Days Heavy Alcohol Use/90 Daysc 0.70 (0.48; 1.02)
Used Cocaine (Yes) 1.81 (0.76; 4.28)
Used Opiates (Yes) 1.84 (0.67; 5.07)
Stepwise Forward Selection
Any Main Partners (Yes) NS
Days Sex with Main Partners/90 Daysc 0.67* (0.47; 0.94)
Days Unprotd. Sex with Main Partner/90 Daysc NS
Any Casual Partners (Yes) NS
Days Sex with Casual Parnter/90 Daysc 1.46* (1.05; 2.04)
Days Unprotd. Sex with Casual Partner/90 Daysc NS
Multiple Male Partners (Yes) 2.27* (1.03; 5.024)
Commercial Sex Work (Yes) NS
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*

P < .05;

**

p < .01

a

Background characteristics (age, ethnicity, lifetime history of STI, living with sex partner, frequency of heavy alcohol use, and current use of cocaine and opiates) were entered as covariates prior to stepwise to selection of sex-risk indicators. The reported coefficients and 95% CI estimates were adjusted for all variables entered in the final model.

b

Reported 95% confidence interval estimates were based on robust Huber-White variance estimators. The likelihood ratio test was used to identify the most salient sex-risk predictors during stepwise selection.

c

All continuous covariates were standardized to zero mean and unit variance prior to estimation.

d

A likelihood-ratio difference test for the effect of ethnicity was statistically significant (LR2 = 10.13, df = 2, p = .006) in Model 1. Relative to other ethnic minorities Non-Hispanic Caucasians and African-Americans were estimated to be 5.11 (95%CI 0.64; 40.88, p = .125) and 12.77 (95%CI 1.49; 109.73, p = .020) times more likely to test STI+, respectively.

Discussion

In this sample of hazardously drinking, heterosexually active, incarcerated women, the prevalence rates were 2.9% for CT, 20.5% for TV, and 2.5% for GC. These results are comparable to other incarcerated female samples (Hardick et al. 2003; Mertz et al. 2002; Willers et al. 2008; Shuter et al. 1998), but have not to our knowledge, been reported from a single sample in which associations with multiple sexual and other behaviors and partner type have been analyzed. These TV and GC rates were nearly 10 times higher than rates in non-incarcerated samples of women (Allsworth, Ratner, and Peipert 2009; Sutton et al. 2007; Datta et al. 2007). Prevalence of CT was similar to general population estimates (Datta et al. 2007).

Age was not significantly related to having a STI. Of note, only adults (18 years or older) were enrolled in the clinical trial, and the mean age of study participants was 34 years. CT and GC infections are most frequently found in samples of adolescents and emerging adults (Centers for Disease Control and Prevention November 2009), and we were surprised to find high rates of CT and GC in our cohort, although TV has been reported in other older incarcerated samples. It is possible that regardless of age, women in this sample were engaging in risky sexual activity most frequently associated with younger women and perhaps living in neighborhoods or having greater social contact with high-risk males. Given that CT and GC infection in young women aged 15–24 years is greater than six and five times more prevalent, respectively, than in women aged 30–34 years (Centers for Disease Control and Prevention 2010), our findings may be especially concerning for younger incarcerated women in our region, but suggest that all incarcerated women should be screened (Kraut-Becher et al. 2004; Barry et al. 2009).

Belonging to a racial or ethnic minority group was significantly related to STI in our sample, which is consistent with some findings in incarcerated women (Bonney et al. 2008; Mertz et al. 2002), but inconsistent with others (Shuter et al. 1998; Willers et al. 2008; Freeman et al. 2010; Hardick et al. 2003). These findings are similar however, to those found in non-incarcerated women in the general population (Centers for Disease Control and Prevention 2009; Allsworth, Ratner, and Peipert 2009; Buhi, Marhefka, and Hoban 2010) and drug-using samples of women (Gollub et al. 2010; Plitt et al. 2005). Given the well-documented disparities in access to sexual health care across racial and ethnic groups (Parrish and Kent 2008; Mayberry, Mili, and Ofili 2000; Kang-Kim et al. 2008), these findings are particularly worrisome. Prevention, testing, and treatment efforts need to be cognizant of differential access and work harder to reach this important underserved population.

Consistent with previous literature, increased sex with casual partners, and having multiple male partners were associated with testing STI positive (Sutton et al. 2007; Gollub et al. 2010; Willers et al. 2008). Commercial sex work did not enter the final stepwise model, however, due to the high co-linearity between having multiple male partners and commercial sex work. Thus, it is possible that STI risk is also related to commercial sex work, as suggested by the bivariate findings.

Interestingly, more frequent sex with a main partner reduced the odds of STI in this sample. We speculate that sex with a steady partner indicated a more stable, committed partnership, thereby perhaps lowering the risk of contact with higher risk partners. Of note, living with a sex partner was not protective. A similar explanation for complementary findings was suggested for a sample of STI clinic patients tested for recurrent Chlamydial infections (Rietmeijer et al. 2002). Despite any shielding effect main sexual partnerships may have, study participants with main partners still had high rates of STI, suggesting that their main partners may have other concurrent partnerships that introduced STIs into the primary relationship.

Similar to findings from previous work (Shuter et al. 1998; Miller et al. 2008), recent cocaine use was bivariately associated with STIs. This is especially relevant given the high percentage of incarcerated women who use cocaine regularly (Freudenberg et al. 2007). Cocaine use did not remain significant in the final, stepwise model. It is possible that cocaine use and risky sexual behavior are linked in a causal pathway to STI acquisition, and therefore the addition of sexual risk to the full model attenuates the association between cocaine use and STI. Interestingly, alcohol use was not associated with STIs. This population was recruited specifically for hazardous alcohol consumption, and all drank heavily, thus it is possible that alcohol consumption did not vary enough to test this relationship adequately. It is also possible that alcohol use increases sexual activity, but is not related to increases in unsafe sexual behavior, a result we have found in previous studies (Anderson and Stein 2011).

This study had important strengths. First, we included TV, which is often overlooked in the study and testing of STIs (Van der Pol 2007). Second, this study found high rates of CT and GC in a population older than those typically considered high risk. This has important implications for targeted screening and testing in jails as infected women may be missed if screening is based on age alone. Our study demonstrated the feasibility of utilizing self-collected vaginal swabs, which, if implemented beyond research studies, would reduce the time required by jail staff for widespread screening. Finally, our findings indicated that jails could provide an important contact point with medical personnel that may be otherwise unavailable to this underserved population.

This study also had important limitations. We included only hazardously drinking jailed women who were sexually active with male partners. Despite heavy alcohol use in jailed women (Caviness et al. 2009; Freudenberg et al. 2007), results found here may not generalize to non-drinking women, women who are not sexually active, lesbians, and men. Second, self-report can be subject to recall and social acceptability biases. When possible, interviewing techniques were used to minimize error and bias (Schroder, Carey, and Vanable 2003). We note the high co-linearity among some indicators used to describe participants’ sexual behaviors. The use of stepwise selection in multiple logistic regression models allowed us to identify the strongest correlates of testing STI+ in this cohort, but this does mean that other measures of sexual-risk taking were not associated with STI. Finally, we used in-person pen and paper interviews to collect data related to sexual risk behaviors. Although evidence is compelling that computer-assisted interviewing is preferable when asking for sensitive personal information such as sex risk (Fairley et al. 2010; Richens et al. 2010), we were unable to bring computers into the prison setting.

Findings from this study highlight the high prevalence rates of STI in a sample of hazardously drinking, heterosexually active incarcerated women, especially among racial and ethnic minorities, cocaine users, and those with multiple, risky male partnerships. STIs increase risk for PID and pregnancy complications, and increase susceptibility and transmission of HIV (Centers for Disease Control and Prevention 2007 2007; McClelland et al. 2007). Comprehensive screening and treatment during incarceration should be offered. Due to the high rates of infection in this population, and their rapid release to the community after arrest (Hebert et al. 2008), jail admission provides a public health opportunity to access a concentrated group of STI-infected women, and through treatment, follow up, and partner notification, perhaps reduce STIs in a high risk, vulnerable population.

Acknowledgments

This study was funded by the National Institute on Alcoholism and Alcohol Abuse AA 014495. Dr. Stein is a recipient of NIDA Award K24 DA000512.

Footnotes

Trial registered at clinicaltrials.gov; Clinical Trial #NCT00237003.

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