Unknown Quantities: HIV, Viral Hepatitis, and Sexually Transmitted Infections in Community Corrections

To the Editor

At year-end 2011, 4.8 million adults in the United States were serving terms of probation or parole,¹ collectively referred to as “community corrections.” As with incarcerated populations, people in community corrections are disproportionately from backgrounds of social and economic disadvantage, and racial and ethnic minorities are heavily overrepresented.^1,2 These risk factors for poor health combine with behavioral risk factors, particularly substance use, to produce a population that is at high risk for infectious diseases.^2,3

We sought to review the prevalence of HIV, viral hepatitis, and sexually transmitted infections (STI) among the US community corrections population. In March 2013, we searched PubMed and the National Criminal Justice Reference Service for articles reporting data on the prevalence of HIV, hepatitis B virus, hepatitis C virus (HCV), or other STI (including syphilis, gonorrhea, chlamydia, trichominiasis, human papillomavirus, or genital herpes). Searches were limited to articles published from 2000 onward.

We identified just 8 relevant studies (9 publications).^2,4–11 These suffered from various methodological weaknesses including nonrandom sampling, low response rates, and the use of self-reported data rather than serological testing. Of 3 studies that conducted HCV antibody testing, none undertook confirmatory testing to assess current infection. We conclude that there are insufficient data to permit a meaningful assessment of the prevalence of the selected infectious diseases in the community corrections population.

The lack of data regarding HIV, viral hepatitis, and STI prevalence in community corrections clients is concerning. In 2011, around 1 in every 50 US adults was under community corrections supervision. If just 1 in 5 of these is at risk for blood-borne viral infections or STI, this equates to almost a million people. Inconsistent condom use with casual sex partners has been reported by 17% to 79% of community corrections clients,^4,9,12 and around one-quarter report lifetime injection drug use. ^3,4,9,13 The lack of infectious disease prevalence data in the presence of these risk behaviors suggests an urgent need for large-scale epidemiological studies. Ideally, these would include a complete or sufficiently large random sample of community corrections clients in a city, region, or state, with serological testing to provide an accurate estimate of past exposures and current infections.

An alternative or complement to epidemiological studies may be the introduction of routine infectious disease screening in community corrections settings. At present, only 18% of community corrections clients receive HIV or HCV screening and just 0.02% receive STI testing.¹⁴ Screening could be accompanied by brief educational interventions focusing on risk reduction, tailored to include referrals to relevant local services. In addition to the benefits of screening to individuals, infectious disease screening would generate valuable data describing risk behaviors and disease burden in the community corrections population, providing an evidence base from which to develop harm reduction and treatment interventions that are specific to the local context.