Prevalence and Management of Sexually Transmitted Infections in Correctional Settings: A Systematic Review

Abstract

Admissions to jails and prisons in the United States number 10 million yearly; persons entering locked correctional facilities have high prevalence of sexually transmitted infections (STIs). These individuals come disproportionately from communities of color, with lower access to care and prevention, compared with the United States as a whole. Following PRISMA guidelines, the authors present results of a systematic review of literature published since 2012 on STIs in US jails, prisons, Immigration and Customs Enforcement detention centers, and juvenile facilities. This updates an earlier review of STIs in short-term facilities. This current review contributed to new recommendations in the Centers for Disease Control and Prevention 2021 treatment guidelines for STIs, advising screening for Trichomonas in women entering correctional facilities. The current review also synthesizes recommendations on screening: in particular, opt-out testing is superior to opt-in protocols. Carceral interventions—managing diagnosed cases and preventing new infections from occurring (eg, by initiating human immunodeficiency virus preexposure prophylaxis before release)—can counteract structural racism in healthcare.

The incarceration rate in the United States leads the world [1]. Of confined adults on 31 December 2019, 1.43 million dwelt in US prisons; approximately 734 500 were in a US jail [2]. Prison populations were 93% male [3], and jail populations 85% male [4]. The proportion of the jailed population identified as black in 2019 was 34%, markedly disproportional to the US population as a whole (14%) [4]. The key differences between prisons and jails in the United States are lengths of stay. Prisons hold persons found guilty of a felony; on average, residents stay 3 years. Jails house persons awaiting trial or serving misdemeanor sentences of less than a year. Characterized by rapid population turnover, US jails admit 10.3 million persons a year [4], with typical median length of stay of 2 days to 2 weeks [5]. In the United States, 95% of admissions to and releases from confinement occur in the jail setting [6]. The US juvenile justice system runs parallel to the adult system and confines a population about 2% the size of that in the justice system for adults.

Reflecting a long-standing observation that sexually transmitted infections (STIs) are more common among persons entering correctional facilities than in the general population, the Centers for Disease Control and Prevention (CDC) incorporated guidelines on the management of STIs in jails, prisons, and juvenile facilities in 2010 [7]. These recommendations were supported by evidence reviewed from 1990 to 2009 and are summarized elsewhere [8]. Early studies established that adolescents in juvenile facilities were more likely to be sexually active than age-matched individuals in the general population [9]. Consequently, multiple studies found that the prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (gonococcus [GC]) in juvenile detention facilities was several-fold higher than the prevalence among youth not involved in the legal system [8]. Similarly, owing to risky sexual encounters before jail entry, STIs may be 10–20-fold higher among adults entering detention than among their peers in the outside community [8].

The relationship between carceral and community health is bidirectional. High rates of STIs in correctional settings are driven by disparities in social determinants of health among those entering institutions, who are disproportionately black and Indigenous compared with the overall US population. The same populations affected by the incarceration epidemic are disproportionally affected by STIs [10]. In addition to structural racism, social determinants affecting the sexual health of populations moving through the criminal justice system include intergenerational poverty, which is associated with poorer health outcomes.

The mechanisms for promoting poverty include removing an adult wage earner from their family. When a parent is removed from the household, children are more likely to face incarceration in adulthood. After incarcerated persons are releases, their criminal records lead to lower lifetime earnings and less economic opportunity for their children. Jails disproportionately detain those in poverty, who usually have less access to private and personalized legal representation (and hence are detained in jail rather than bonding out and free). These individuals also have reduced access to private insurance and less individualized healthcare. Drivers of poor sexual health in the community are changes in sexual partners and concurrent sexual partnerships. Sexual partners of incarcerated persons may link with new partners, which can increase in transmission of STIs. Incarceration also lowers the community’s male-to-female ratios, which can promote concurrent sexual partnerships among the remaining individuals [11].

We conducted a systematic review of published data on STIs in correctional settings through 2019 that informed the 2021 CDC treatment guidelines for STIs. For this review, we conducted a second search of the literature in March 2021 to incorporate new data that have emerged in the interim. This document summarizes the combined results of both searches.

METHODS

A comprehensive review was performed of published literature from major databases. Scopus was searched on 31 December 2018; MEDLINE/PubMed, CINAHL, Cochrane, and Embase comprised the clinical databases searched on 28 February 2019. The review was performed on several key topics of interest including (1) the current prevalence of STIs in juvenile and adult correctional settings (eg, CT, GC, syphilis, Trichomonas vaginalis [TV], human immunodeficiency virus [HIV], and hepatitis C virus [HCV]); (2) diagnosis and treatment of STIs in correctional settings; (3) community impact of STIs in the correctional setting; and (4) evidence of interventions to address STIs (eg, vaccines and HIV preexposure prophylaxis [PrEP]). PubMed search statements for the prevalence search are shown in Box 1. Similar search terms were used for the other databases. Additional articles were added if referenced by other articles or if they referenced articles retrieved by the search. See Table 1 for the Population, Intervention, Comparison, Outcomes, Type of study, Type of question (PICOTT) eligibility criteria. Scopus, MEDLINE, CINAHL, Cochrane, and Embase were queried a second time at the start of March 2021 to add articles that were published between the last time the search was performed and 1 March 2021. The PRISMA flow diagram (Figure 1) reflects the cumulative number of articles retrieved, screened, and reviewed.

Box 1: PubMed Search Statement.

(jail∗ OR prison∗ OR detention OR inmate∗ OR incarcerat∗ OR correctional OR “Prisons”[Mesh:NoExp]) AND (sexually transmitted OR STD OR STDs OR STI OR STIs OR syphilis OR CT OR gonorrh∗ OR HIV OR human immunodeficiency virus OR herpes OR HPV OR human papillomavirus OR trichomon∗ OR venereal) AND (Prevalence OR “statistics and numerical data” [Subheading]) AND ((“2012/01/01”[PDAT]: “3000/12/31”[PDAT]) AND “humans”[MeSH Terms] AND English[lang]). PubMed search statements for the prevention interventions search included: (jail∗ OR prison∗ OR detention OR inmate∗ OR incarcerat∗ OR correctional OR “Prisons”[Mesh:NoExp]) AND (sexually transmitted OR STD OR STDs OR STI OR STIs OR syphilis OR CT OR gonorrh∗ OR HIV OR human immunodeficiency virus OR herpes OR HPV OR human papillomavirus OR trichomon∗ OR venereal) AND (intervention∗ OR vaccine∗ OR effectiveness: OR implement∗ OR pre-exposure prophylax∗) AND ((“2012/01/01”[PDAT]: “3000/12/31”[PDAT]) AND “humans”[MeSH Terms] AND English[lang]).

Table 1.

Eligibility Criteria

PICOTT Elements	Inclusion Criteria	Exclusion Criteria (Not Strictly Used)
Population	Persons inside (or recently released from) a jail, prison or juvenile justice facility, with an emphasis on jurisdictions in the US; articles published since 2012	Persons not dwelling in a locked facility; non-US studies on prevalence (non-US prevention/implementation studies okay if they provide lessons learned applicable to US)
Intervention	Prevention (including vaccines, behavioral interventions, PrEP), screening and treatment for diseases that are sexually transmitted	Prevention, screening, and treatment for diseases acquired via nonsexual route
Comparison	Persons in community setting; same jurisdiction, adjusted for age, gender, race, etc	…
Outcomes	Sexually transmitted infections newly acquired, diagnosed, and/or treated	Less emphasis on HBV, HCV, and HIV in terms of management of extant infections
Type of study (eg, observational, experimental, qualitative)	Quantitative studies; English only; after 2012, to the present	Qualitative studies (with exceptions when qualitative data help explain quantitative data)
Type of question (eg, therapy, diagnosis, harm, prognosis, prevention)	Prevention, diagnosis/prevalence, and therapy	Prognosis

Abbreviations: HBV, hepatitis B virus; HCV, hepatitis C virus; HIV, human immunodeficiency virus; PICOTT, Population, Intervention, Comparison, Outcomes, Type of study, Type of question; PrEP, preexposure prophylaxis.

Figure 1.

Prisma flow diagram.

Abbreviations: HBV, hepatitis B virus; HCV, hepatitis C virus; HIV, human immunodeficiency virus; STIs, sexually transmitted infections.

RESULTS

Figure 1 shows the PRISMA flow diagram. The initial database query resulted in 3095 matches, when duplicates were excluded. Pairs of reviewers eliminated articles and abstracts to include 43 with findings that significantly contributed to the evidence base for the 2019 meeting. The second query resulted in 493 additional matches and yielded 23 articles that provided additional data for this review. A number from this second pull from the literature represented articles that were in abstract form at the time of the initial query. Tables of evidence identify articles specific to the prevalence and prevention of STIs, respectively (Tables 2 and 3). Only the most final form of a study report is listed, rather than the earlier abstract and the subsequent published manuscript.

Table 2.

Overview of Literature Reviewed on Correctional Prevalence of Sexually Transmitted Infections, 2013–2021

Reference	Year	Authors	Study Population	Study Design	Exposure or Intervention/Outcome Measure	Main Findings: Outcome Measure (OR, RR, Proportions)	Strengths and Limitations	Implications for Update
Reviews
[10]	2016	Nijhawan	Data on US correctional systems and those who live in it	Expert review	Determination of social factors that contribute to high rates of STIs in correctional systems. Effectiveness of HIV care cascade in recently released individuals and persons inside the correctional system.	Upward trend in incarceration rates since 1980s. Those in the correctional system often experience high rates of substance use disorders. Individuals are often released already having an infectious disease and since they are asymptomatic, the disease continues to be spread not only inside the jail or prison, but also outside in the community.	Strength: thorough analysis of epidemiology of incarceration throughout the US and STIs.	Jails/prisons need to effectively test, treat infectious diseases to reduce community burden. It is feasible; positively affects health of community.
[12]	2020	Nowotny et al	Data on county individual STI rates and incarceration rates	Cross-sectional survey; modeling	Mixed models, including random effects models	CT rates by county, and to a lesser extent GC rates, seem to depend on incarceration rate.	Limitation: does not prove causation.	Strengthens public health argument that incarceration and STI epidemics are linked.
[13]	2020	Fuge et al	Narrative review (quantitative/qualitative studies); meta-analyses on selected quantitative studies	Narrative review of effective interventions	NA	Lack of social support, stigma, discrimination, substance use, limited knowledge, and negative perception toward ART were main determinants of suboptimal use of care in incarcerated people. In meta-analyses, lower odds of ART initiation associated with higher baseline CD4 cell count, new HIV diagnosis, and lack of belief in ART safety and efficacy. Nonadherence was associated with lacking social support, low self-efficiency score, and depressive symptoms.	Retrieved quantitative studies assessed for risk of bias. Meta-analyses were conducted using RevMan-5 software, and pooled ORs were calculated using Mantel-Haenszel statistics with 95% CI at a P < .05.	Shows factors associated with ART initiation, adherence, and viral load suppression. Supports interventions to increase knowledge, self-efficacy, and social support.
[14]	2019	Francis-Graham et al	Synthesis of literature on prison-based opt-out testing (UK)	Expert review/scoping study	Measuring the proportion intake offered a test and the proportion offered that accepted testing	“Default effect” influences who accesses opt-out testing. Decision to accept testing was influenced by concerns about confidentiality, fear of a positive diagnosis, personal interpretation of risk, discomfort with invasive procedures, trust in healthcare, and fidelity of the opt-out offer.	Good-quality study that provides insight to residents’ perception of HIV testing in correctional facilities	Provided a point to consider (behavioral component) when offering STI tests in correctional facilities.
[15]	2018	Falla et al	EU/EEA at-risk populations: people in prison, MSM, and PWID	Systematic review	Estimates of prevalence in study population; sources: literature published in 2005–2015; national surveillance; PWID data extracted from the European Monitoring Centre for Drugs and Drug Addiction repository	Prioritize PWID for HBV/HCV screening and treatment. MSM not a high-risk group for chronic hepatitis B but considered a key population owing to complex interaction of HBV/HCV and HIV.	Strong study design; however, some studies cited are of variable methodology and quality.	Provided some data on hepatitis B/C prevalence in European prisons, but no direct effect on US guidelines.
Trials
[16]	2018	Williams et al	Men aged 18–60 y, ≤45 d after release from county jail in the Southeast (N = 255); English-speaking; minority; EtOH/drug use.	RCT	Educational; 5 sessions, 2h per session over 3wk. Testing for STD/HIV at baseline and 3-mo follow-up. (Design had 6-mo follow-up but data not presented owing to attrition.)	Baseline self-reported STD history (CT, GC, syphilis, warts, HSV, lice, scabies) in 12%. Baseline STD prevalence, 10% (2% in GC, syphilis, and HIV; 4% in CT). New CT/GC/syphilis prevalence at 3 mo, 8% (GC, 3%; CT, 4%; syphilis, 1%; 0 new HIV infections).	Behavioral and biological outcomes. Not powered for reduction in STDs. Participants in their mid-30s. Large attrition (20% after enrollment, 50% before 3-mo follow-up) limits generalizability. Possible that contamination of control group lead to null findings.	Modest contribution theoretically. Educational sessions should decrease incidence and reinfection cases, but the evidence presented is not enough to expand on such projects.
Observational studies
[17]	2014	Satterwhite et al	166 Juvenile detention centers that booked >500 juveniles yearly or ≥1 in jurisdiction. Part of requirement of Comprehensive STD Prevention Systems grant	Cross- sectional	CT screening and CT positivity. Prevalence of 2 CDC performance metrics: (1) CT screening and (2) CT positivity	Of 166 reporting juvenile detention facilities, 126 (75.9%) reported sufficient data to be included. Highest screening rate is in the Western region (63.2%), and highest positivity in the Midwest region (17.1%). A significant increase in positivity with decreasing screening prevalence suggests for testing based on clinical symptoms and not screening. Overall screening coverage of only 55.2%.	Large convenience sampling of aggregate data. No demographic, other data available for analysis. Authors suggest that symptom-based testing misses asymptomatic cases. At some centers almost all test positive (suggesting that only symptomatic were tested.)	Results were considered in reporting prevalence cases.
[18]	2013	Donaldson et al	514 Juvenile justice system–involved females in Baltimore City	Cross- sectional	Assess acceptability of case manager’s interventions to offer GC/CT screening to females during mandated visits	A total of 102 females accepted screening. Of samples that could be tested, 18% were positive for CT and 3% for GC; 58% of females were asymptomatic and 79% were treated; 20% also requested pregnancy tests and 3% were positive. Overall, results from satisfaction surveys from females and case managers were positive.	Strength: study uses an innovative approach to screening a high-risk population. Limitations: intervention was implemented in 1 community supervision unit; limits generalizability. Sample too small compared with no. of females passing through the system. Case managers may have targeted girls perceived at higher risk of infection.	Individuals under community supervision should be included in efforts of STI screening and treatment. If community supervision took place near clinics offering STI and family planning services, resources could be consolidated and services expanded.
[19]	2016	Torrone et al	Juvenile detention facility (urban)	Cross-sectional	Correlations between positive screening and factors associated with STDs or hypothesized to be associated with or predictive of CT infection in detention setting. Proportion of positivity associated with combinations of 10 risk factors (1–5).	No combination of risk factors would result in >85% positivity with <70% total screening (eg, no gains in efficiency).	Single large urban jail. Arbitrary definition of efficiency.	Supports guidelines to test young females for STIs since they are considered high risk; however, this may not be feasible.
[20]	2016	Burghardt et al	Juvenile detention adolescents (aged 10–19 y) in 12 California counties (California CT screening project)	Time series	All CT testing results from 2003–2004 compared with 2013–2014 (n = 59 518). Trends in proportions of females screened, CT positivity, treatment by age, race/ethnicity, and facility volume.	Screening rates were75.1%–79.4%. CT positivity decreased from 14.8% (2003–2004) to 11.5% (2013–2014) (P < .001). Overall documented treatment decreased (form 88.8% in 2005–2006 to 79% in 2013–2014; P < .001). Treatment within 7 d increased (from 80.1% in 2005–2006 to 88.8% in 2013–2014; P < .001). Median cost per positive CT result, $708 (IQR, $669–894), with lowest cost for facilities with high CT positivity. Highest positivity in those aged 15–19 y and black of Hispanic.	Partially incomplete FY data from several sites; unavailable data for part of study period; females aged 10–12 and 18–19 y were smallest groups; inability to determine some treatment given in the field.	Informative study—no direct impact on guidelines
[21]	2017	Levanon Seligson et al	Persons ever in New York City jails from 2001 to 2005	Cross-sectional	Prevalence of GC/CT, HIV, syphilis, and tuberculosis	Persons who were ever incarcerated had higher prevalence of HIV. If they used the adult homeless shelter system, prevalence was also higher for tuberculosis compared with their counter parts. Females who were ever in jail had higher prevalence of GC and syphilis.	Undermatched and underestimated data. Some data are not generalizable. Analysis fails to indicate timing of disease acquisition (before or after intake).	Promotes need to develop sex-specific correctional system and community-based interventions to reduce burden of STIs.
[22]	2013	Parvez et al	Adult women in jail (include 16–18-y-olds)	Cross- sectional	Results of CT/NG screening among FSWs and non-FSWs incarcerated in NYC jails. Percentage of women reporting female sex work and percent CT/NG positivity among FSWs.	Data from 1 January 2009 to 31 December 2010. Of 10 115 women receiving STI testing, 723 (7.1%) had ≥1 STI: CT (6.2%), NG (1.7%), or both (<1%); 66.1% were treated before release from jail. Of 10 828 women, 9.0% had HIV.	Descriptive variables were self-reported and thus subject to recall or social desirability bias.	Very informative; useful to report
[23]	2014	Javanbakht et al	Large urban Jail (women only)	Cohort	Screening for CT/GC (plus syphilis and HIV) in selected populations (aged ≤30 y, pregnant or maybe pregnant, prostitution or sex-related charges). Syphilis/HIV screening was offered to all. Positivity of CT, GC, and HIV.	A total of 76 207 women were screened, revealing a CT prevalence of 11.4%; GC, 3.1%; early syphilis, 1.4%; and HIV, 1.1%. Proportions of positive test results (after screening) was) reported as prevalence.	Study provides useful data and connects conclusions with a positive broader public health impact; however, the true prevalence is masked by the screening criteria for GC/CT. An alternate study design might report data by patients and not by test and allow for research to discern coinfected individuals.	Results were considered in reporting STI prevalence cases.
[24]	2020	Lederman et al	Opt-out testing in summer 2018, at 2 detention facilities with different operational requirements and detainee demographic characteristics. Half opted out; 494 tested	Cross-sectional	Tested for GC/CT/syphilis, hepatitis B, and HIV	A total of 42 (8.5%) tested positive for ≥1 STI; positivity rates were 6.7% (n = 33) for CT, 0.8% (n = 4) for syphilis, 0.8% (n = 4) for GC, 0.6% (n = 3) for hepatitis B, and 0.2% (n = 1) for HIV. Most were treated before release. The estimated cost to detect any STI ranged from $500 to $961; the estimated cost to identify 1 person with HIV ranged from $22 497 to $43 244. Most were asymptomatic. Women were less likely to test positive, but not significantly so.	Study design did not allow for inferring causality. Results not generalizable to all immigration detention facilities. Self-reported risk factor variables could cause response bias. STI screening limited to urine/blood testing. Since study was retrospective, reasons for opt-out testing were inferred.	ICE detention facilities are an important place to search for cases.
[25]	2019	Clifton and Ingebretsen	Total of 5412 youth screened	Cross- sectional	Positive screen for STI risk factors	Potentially higher than expected prevalence of risky sexual behaviors in this population; 3.2% of respondents reported being trafficked. No numerator/denominator of respondents given.	Positive screen prevalence not stated. No control population.	Potentially reinforces the importance of screening in a detention setting.
[26]	2013	Gopalappa et al	Males in jail in Maricopa County (Arizona)	Cross- sectional, cost-effective-ness	CT/GC screening and CT/GC positivity by age group	Overall: CT, 7%, GC, 4.6%. By age <20 y: 18% (CT) and 7% (GC); 20–29 y, 9%–11%, and 7%, respectively; 30–39 y, 3%–8% and 2%–3%; ≥40 y, 0% and 0%–3%.	Needs clarification of methods	Documents high prevalence
[27]	2020	Mulamreddy et al	Retrospective chart review 2018–2019; 741 youth presenting for intake physical or sick visit related to STIs at juvenile detention center in Texas.	Cross- sectional	Prevalence of extragenital GC/CT on pharyngeal and anorectal testing (PCR). Answers to questions about oral and anal sex on intake physical form.	Of these youth 36.3% reported performing oral sex, and 4.3% reported receiving anal sex. Of those reporting oral sex, 33.5% had an oral swab sample sent for testing; 2.35 % were positive for CT, 2.35 % were positive for GC. Of those reporting anal sex, 25.9% had an anal swab sample sent and 42.9% were positive for CT, none were positive for GC. Of youth with a positive oral or anal test result (for either CT or GC), 25% had a negative urine result for these infections. Associated risk factors for having a positive extragenital test were lack of condom use, and >2 partners over a 12-mo period.	Adds data on GC/CT prevalence (especially in those positive at oral/anal sites)	Little previously known about extragenital GC/CT in justice system–involved youth. Emphasizes importance of extragenital screening questions.
[28]	2018	Clifton	1968 Youth screened	Cross- sectional	Positive urine screen for CT and GC	Females screen at a higher rate than the general population and males at a lower rate. Rates of positivity are correlated with age. Urban youth and females have higher positivity. Self-reported condom use correlated with lower and high-risk behavior with higher positivity.	A helpful prospective study matched with community data.	As with the Harmon et al. [44], reinforces the opportunities of detention-based screening and treatment.
[29]	2020	Oshin et al	355 Young women in juvenile detention in Houston	Cross-sectional	NAAT for TV	Of 28 (7.9%) who tested positive for TV, 50% had coinfection with GC/CT and 44% were asymptomatic. Predictors of TV were being African American, having symptoms, and number of sexual ­partners in prior 12 mo.	Prospective study of young women in juvenile detention	Supports routine screening for TV in addition to GC/CT for young women in juvenile detention
[30]	2018	Beyda et al	543 Youth in juvenile detention	Cross-sectional	NAAT for TV	Of 16 (3%) testing positive for TV, 13 were young women (7 asymptomatic) 3 were young men (1 asymptomatic. TV prevalence 10.8% among young women (13/118) and 0.7% among young men (3/425); 5 received test of cure, all negative.	Prospective epidemiological study with all youth in facility submitting a sample	Suggests need for screening in detained young women but not young men
[31]	2013	Javanbakht et al	Testing in 4 venues (including juvenile detention facility and adult correctional facility) of 1215 women in Los Angeles. Leftover specimens from CT/GC tests. Population: females in juvenile justice system and in jail.	Cross- sectional	Determine prevalence of Trichomonas in detained youth and adults in Los Angeles, California. NAATs were used in all women. NAATs were tested using the APTIMA TV assay.	Women in jail had the highest prevalence of the 4 venues (22%).	Limitation: tests were performed on remnant specimens collected routinely for CT and GC screening. In jail settings, women in older groups (>30 y) were probably tested because of symptoms, sexual contact with positive persons, or potentially higher risk (overestimation of prevalence).	Need for TV screening and treatment (particularly for women in jail and young females in juvenile detention settings)
[32]	2012	Nijhawan et al	Women ≥18 y old entering the RIDOC	Cross- sectional	Examine prevalence and routine screening for TV among newly admitted women. Self-collected sample tested using the APTIMA TV culture media.	378 Samples were evaluated. Prevalence of TV infection by APTIMA TMA testing was 14% (53 of 378 samples).	Limitation: results cannot be generalized to other incarcerated women in other states, as study was conducted in a location serving as the only jail and prison in Rhode Island; many women did not participate; survey data based on self-report; self-collected swab sample was inadequate for 2% of women.	Confirms TV is more common in certain groups of women (eg, older persons, black persons). Imperative that incarcerated women receive healthcare services, including TV screening and treatment during and after incarceration.
[33]	2018	Bose	Examined bureau of justice statistics data	Cross-sectional	Spatial distribution	HIV distributions in prison populations differ by region. HIV infection in state and federal prisons 5× greater than in nonincarcerated population. State-level spatial mapping, Pearson correlation coefficient and Moran I statistic (univariate and bivariate) were computed based on these demographic characteristics, using QGIS and Geoda software. Pattern of spatial disparity in overall, male, and female HIV infection rates across state prisons was significant; especially in Southern and Southeastern states. Positive correlations with being nonwhite, female, non-US residents, or aged <18 y in 2000 and 2010.	Quantifies differences in HIV prevalence in prisons compared with the community, regional variability in the US, and demographic differences within correctional settings.	HIV prevalence differs geographically.
[34]	2019	Culbert et al	Incarcerated people with HIV (N = 150) in Indonesia	Cross- sectional	Cross-sectional study on ART adherence	People with HIV receiving methadone had 6-fold higher adjusted odds of being highly adherent to ART. ART use was also associated with HIV status disclosure, drug dependency, health service satisfaction and perceived need for medical treatment, and negatively associated with chance locus of control.	Cross-sectional analysis using data from an RCT to assess evidence-based medication adherence intervention that was culturally adapted for the Indonesian prison setting.	Role for OAT in improving adherence to ART in corrections
[35]	2020	Takada et al	356 Adult cisgender men and transgender women living with HIV in Los Angeles County Jail	Cross- sectional	NA—examined association between life chaos and HIV-related outcomes	Adjusting for sociodemographics, HIV-related stigma, and social support, higher life chaos was associated with greater likelihood of diagnosis while incarcerated, lower likelihood of engagement in care, and lower adherence.	Secondary data from large RCT. Assessed life chaos using the Confusion, Hubbub, and Order Scale.	Important data on role of improving life chaos on HIV outcomes
[36]	2014	Varan et al	State prison populations	Cross- sectional survey	Survey of state prison medical directors of their prison populations	National survey of all state prison systems; the prevalence of antibodies can vary >6-fold, from <8% to 48%.	Provides specific data on prevalence in CJ system	Correctional facilities are important sites for STI screening and treatment implementation.
[37]	2021	Francisco-Natanauan et al	Retrospective analysis of 2208 detained youth offered voluntary STI testing in Hawaii.	Cross- sectional	Prevalence of CT/GC in detained youth accepting testing and proportion of youth treated before discharge from facility.	First study to address treatment inadequacy in this population (>50% with STIs leaving detention while infected). High prevalence of STIs in both male and female youth. Indicates need for universal and timely testing; if rapid testing is unavailable, empiric treatment should be considered.	Repeated positive testing may have appeared as reinfection if readmission occurred before test result and even if empiric therapy was given. Data are specific to local prevalence and available testing and management options.	Reaffirms national data indicating that justice system–involved youth are at high risk for STIs and should have universal STI screening and treatment.
[38]	2018	Baćak and Ridgeway	Private public prison survey	Cross- sectional	Check for mental health and HIV programs	Differences were small if prisons were matched	Compares programs in private and public prisons	Important evidence to cite
Ecological studies
[39]	2015	Stoltey et al	Females <25 y old in San Francisco neighborhoods—2010	Ecological study	Data modeling determining association between incarceration rates and CT incidence. CT case rate in relation to census tract-level incarceration rate.	Possible assoc between incarceration rates and CT incidence (RR, 2.489; 95% CI, 1.764–3.429); association decreased as poverty increased. For every 1% increase in incarceration rate in a census tract, CT incidence is expected to increase by 149% (95% CI, 76%–243%) on average after controlling for the proportion of African American residents, households with female head of household, vacant housing units, households that received food stamps; for census tracts modeled to have no incarceration, every 1% increase in population with income below poverty level in a census tract, CT incidence increased by 1.8% (95% CI, .1%–3.6%) on average after adjustment for other risk factors in the model.	Inability to geocode all CT cases (more issues with women aged 20–24 y) and all incarcerated individual addresses.	Good model, was considered in providing guidelines for testing incarcerated women (<25 years old ) for CT. The model still needs to be adjusted to provide an accurate estimate.

Abbreviations: ART, antiretroviral therapy; CDC, Centers for Disease Control and Prevention; CI, confidence interval; CJ, criminal justice; CT, Chlamydia trachomatis; EU/EEA, European Union/European Economic Area; GC, Neisseria gonorrhoeae (gonococcus); HBV, hepatitis B virus; HCV, hepatitis C virus; HIV, human immunodeficiency virus; ICE, Immigration and Customs Enforcement; IQR, interquartile range; MH, Mental health; MSM, men who have sex with men; NA, not available; NAAT, nucleic acid amplification test; OAT, opiate agonist therapy; OR, odds ratio; RCT, randomized controlled trial; RIDOC, Rhode Island Department of Corrections; RR, relative risk; STD, sexually transmitted disease; STI, sexually transmitted infection; TV, Trichomonas vaginalis; UK, United Kingdom.

Table 3.

Overview of Literature Reviewed on Correctional Sexually Transmitted Infections Prevention, 2012–2021

Reference	Year	Authors	Study Population	Study Design	Exposure or Intervention/Outcome Measure	Main Findings: Outcome Measure (OR, RR, Proportions)	Strengths and Limitations	Implications for Update
Reviews
[14]	2019	Francis-Graham et al	Synthesis of literature on prison-based opt-out testing (UK)	Expert review/scoping report	Measuring the proportion offered a test at intake and the proportion of those offered who accepted testing.	“Default effect” influences who accesses opt-out testing. “Decision to accept testing was influenced by concerns about confidentiality, fear of a positive diagnosis, a resident’s personal interpretation of risk, discomfort with invasive procedures, trust in healthcare, and the fidelity of the opt-out offer.”	Good-quality study that provides insight on residents’ perception of HIV testing in correctional facilities.	Was used to support and recommend the opt-out healthcare service for incarcerated persons.
[15]	2018	Falla et al	EU/EEA at-risk populations: people in prison, MSM, and PWID	Systematic review	Estimates of prevalence in the study population: sources: literature published during 2005–2015 and national surveillance focal points	Prioritize PWID for HBV/HCV screening and treatment. MSM not a high-risk group for chronic hepatitis B but considered a key population owing to complex interaction of HBV/HCV and HIV	Strong study design;	Informative, was considered in classifying high-risk groups (eg, MSM) for testing and treatment.
[40]	2017	Abara et al	Patients of all ages of varying risk factors, including residents of correctional facilities	Expert review	Vaccination, screening, and linkage to care to reduce the burden of HBV. Review of current guidelines, randomized trials, intervention studies on hepatitis B vaccination, screening and linkage to care findings. Published data between January 2005 and June 2017 were used.	Clinicians should vaccinate all unvaccinated adults against HBV and should screen high-risk persons for HBV (HBsAg, antibody to hepatitis B core antigen, and antibody to HBsAg). They should provide or refer all patients identified with HBV (HBsAg positive) for posttest counseling and hepatitis B-directed care.	Authors collaborated from the CDC, ACP, and Alaska Native Tribal Health Consortium. High-quality data.	Results were used in generating vaccination recommendation in correctional facilities (HBV).
[41]	2015	Iroh et al	Meta-analysis	Expert review	Literature review	HIV cascade after diagnosis increased during stay in correctional facility and decreased after release. Few are virally suppressed after release.	Need to work on linkage to care. Available literature can be biased toward correctional facilities that enforce extra efforts of screening and treating HIV.	Efforts to increase opt-out HIV testing need to be developed throughout the correctional system.
[42]	2021	Woznica et al	Analysis of 27 quantitative and qualitative reports	Expert review	Literature review of interventions to improve HIV care among people released from a correctional facility; classification of intervention levels and strategies.	There are interventions that attest to improvement in clinic attendance by people formerly in the correctional system.	Studies included: individual, biomedical, organizational and multilevel literature. Review included RCTs, case studies, and quasi-experimental studies. Both jail and prison studies were included.	Supports peer-assisted programs and strategies to reduce substance use.
[43]	2016	Elkington et al	Systematic review of 35 articles	Systematic review	Analyzing articles describing programs and initiatives that promote HIV testing or linkage programs and strategies to include uptake of testing.	Strategies found to address challenges of HIV: opt-out voluntary HIV testing, timing of HIV testing, use of rapid testing. Approaches such as improving correctional staff ability and capacity and developing partnerships between correctional facilities and community agencies would improve delivery of linkage to care programs during incarceration and on release. Some programs reported high rates of success, with 98% HIV testing uptake and 84% linkage to treatment. Both rates are higher than in the general ­population.	Limitations of studies included for review: programs were evaluated by posttest design in which linkage rates were reported rather than comparing rates of testing uptake or linkage before program; lack of uniform definitions for linkage and retention; lack of valid measures to track people over time and evaluate treatment compliance.	Few proper programs that provide HIV treatment and linkage to care have been carried out efficiently. All correctional systems need to develop such programs.
Interventions and trials
[44]	2018	Harmon et al	Poster at the Academic and Health Policy Conference on Correctional Health Care, Houston, Texas, 2018. Data on both adult jail and a juvenile facility.	Trial	Opt-out GC/CT screening by jail nurses vs local health department opt-in screening program for detained women in 2 jails. No. of tests, percentage of persons tested, percent positive.	CT positivity rates were essentially the same (8% vs 10%), and GC rates exactly the same (7%). Positivity remains high with opt-out testing. Proportion of the population reached was 8-fold greater with nurse-led opt-out screening (84% vs 10% for opt-in). Same results in juvenile facility.	Just 2 jails. Women are a small percentage of the population.	Supports opt-out testing.
[45]	2014	Cole et al	Women in a jail	Trial	Results of screening test; percent positivity and predictors of positivity	Opt-out screening increased the diagnoses >4-fold (from 9.3 to 40.8 cases/mo).	Observation of change in program	Supported the opt-out recommendation
[46]	2015	Shaikh et al	Adults in a large urban jail—Omaha Nebraska	Intervention trial	Opt-out pilot GC/CT screening embedded in opt-in screening program in a Nebraska jail. Comparison of pilot opt-out and opt-in programs in terms of yield. Percent positivity, unadjusted and adjusted for demographic and risk factor variables in binary and multivariate logistic regression models	Opt-out vs out-in screening: no difference in GC, higher yield of CT in unadjusted and adjusted models	Sampling was by convenience and did not include all facilities.	Supported the opt-out recommendation.
[47]	2015	Spaulding et al	Large urban adult jail	Intervention	Nurse-led opt-out rapid HIV POC testing. (1) Negative, (2) new preliminary positive, (3) previously diagnosed positive, and (4) preliminary positive, confirmed negative; linkage to care defined as keeping 1 appointment after release (record review).	Opt-out HIV POC testing was feasible with an offer rate of 69.10% and acceptance rate of 81.32%; 89 new confirmed positives were identified; 458 previously and newly identified persons were linked to HIV care.	Observation of change in program without control group	Supported the opt-out recommendation.
[48]	2016	Lucas et al	All residents in a California state prison	Intervention	Wall-mounted condom dispensing machines; pre- and postintervention rates of penal code violations related to sexual misconduct, contraband, controlled substances, and violence.	Distributing condoms using the pilot model would cost <$2/y per resident. Results suggest that providing discreetly located dispensing machines is an acceptable, feasible, low-cost option to prevent STD transmission and poses no safety or security risk in a typical medium-security prison.	Good evidence with cost-effectiveness analysis	Support emphasizing condom use and feasibility of condom distribution recommendation.
[49]	2013	Wohl et al	All sentenced individuals entering the NCDPS between June 2008 and April 2009 were studied. Entrants underwent HIV screening within 2wk of prison entry.	Intervention	A total of 10 756 during opt-in and 12 617 during opt-out entered the NCDPS, comparing HIV case detection opt-in vs opt-out testing policies (10 756 for opt-in and 12 617 for opt-out testing) entered the NCDPS; comparing HIV case detection for opt-in vs opt-out policies.	Proportion of entering residents receiving an HIV test during opt-in compared with that after adoption of opt-out HIV testing: sharp and large increase in proportion of residents tested for HIV in this state prison system, from nearly 60% to >95%. Significant difference between before (58.8%) and during (95.2%) opt-out testing, (P < .001).	Good quality, sufficient no., but may not be generalizable.	Supports opt-out recommendation.
[50]	2016	Rosen et al	Adults in a Large urban jail	Intervention	Program change from opt-in to out-out HIV screening (compared with HIV testing performed on blood samples from routine syphilis testing). Absolute and risk difference in annual no. of cases detected with opt-in vs opt-out testing.	Significant difference in proportion tested during opt-in vs opt-out screening: 58.8% vs 95.2% (P = .001). Total of 368 HIV cases detected (177 with opt-in, 191 with opt-out screening) (P = .34). Proportion of cases detected: 0.76 (134/177) for opt-in vs 0.90 (172/191) for opt-out testing (estimated risk difference, of 0.14; 95% CI, .07–.22). With estimated 402 HIV-positive annual entrants (based on 25 000 annual population), opt-out testing would have detected 56 (402 × 0.14) additional HIV cases compared with opt-in.	Observation of change in program without control group. Given the low no. of HIV-positive persons (n = 20) who entered prison without record of a previous diagnosis, analyses examined case detection regardless of previous diagnosis.	Supported the opt-out recommendation.
[51]	2012	Costumbrado et al	4719 Residents (specifically men who have sex only with men) in Los Angeles county jail 2007–2010	Intervention	Administration of hepatitis A and B vaccines, using an accelerated schedule and targeting high-risk residents. Vaccine uptake and likelihood of being vaccinated based on STI history.	Hepatitis vaccination initiatives can be successfully implemented in an urban jail among an extremely high-risk population 3931 hepatitis A/B doses administered to 1633 residents; 77% received 2 doses, 58% 3 doses, 11% booster dose.	Vaccination program for incarcerated populations. Limitations: inability to measure vaccine acceptance rates to determine factors increasing program enrollment, retention; no serology data to compare long-term seroconversion between patients with or without booster doses; hepatitis serology unavailable for most, so chronic infection unidentified. Those screening positive for STIs were 1.3× more likely to be vaccinated (95% CI, 1.2–1.4) than those who were negative	Was considered in recommending vaccination guidelines for incarcerated people.
[16]	2018	Williams et al	Men aged 18–60 y, ≤45 d after release from county jail in the Southeast (N = 255); English-speaking; minority; EtOH/drug use.	RCT	Educational; 5 sessions, 2h per session over 3wk. Testing for STD/HIV at baseline and 3-mo follow-up. (Design had 6-mo follow-up but data were not presented owing to attrition.) STD knowledge, condom skills, condom negotiation, condom use, perceived risk, no. of partners. Prevalent and incident HIV, CT, GC, and syphilis.	Increase in knowledge, condom skills, partner communication. No change in condom use, perceived risk, or no. of partners. No change in STD rates. Baseline self-reported STD history, 12%. Baseline STD prevalence, 10%. New CT/GC/syphilis at 3 mo, 8%. No new HIV infections.	Behavioral and biological outcomes. Not powered for reduction in STD. Participants in their mid-30s. Large attrition (20% after enrollment, 50% before 3-mo follow-up). Limits generalizability. Possible contamination of control group leading to null findings.	Informative, was considered in putting emphasis on the behavioral component in STI testing.
[52]	2015	Fogel et al	Incarcerated women aged 18–60 y in 2 prisons in North Carolina (N = 521); English speaking, male sex partners, HIV negative; <6 mo left to serve.	RCT	Adapted HIV/STI behavioral intervention “POWER”; 8 sessions 1.5h each over 4wk. Control with single session. Baseline CT/GC testing and follow-up at 3 and 6 mo. Sexual risk behavior: no. of sex partners, condom use. Knowledge and perceptions of barriers. Prevalent and incident CT and GC. Secondary outcomes of drug use and employment.	Increase in condom use with main and casual partners at 6 mo. No change in no. of partners. Increase HIV knowledge. No difference in drug use, employment. CT/GC at baseline was 4%; at 3 mo, 4.6% in controls and 6.8% in intervention group; at 6 mo, 4.4% in controls and 5.8% in intervention group.	Behavioral and biological outcomes. Not powered for reduction in STD. Participants in their mid-30s. Attrition (32% at 3 mo, 40% by 6 mo) limits generalizability.	Targeted behavioral interventions should be developed (such as POWER) to reduce risk of transmission of STIs among women within and released from the correctional system.
[53]	2014	DiClemente et al	African American females aged 13–17 y (N = 188) in juvenile detention in Georgia, 2011–2012	RCT	HIV/STI sexual risk-reduction intervention (Imara) vs standard detention center care (STI testing, treatment, counsel). Imara intervention included 3 individual counseling sessions (1.5 hour each) on condom use self-efficacy.	At 3 mo after intervention: participants reported higher condom use self-efficacy, HIV/STI knowledge and condom use skills (all P < .001) compared with controls. No significant diff between trial conditions (incident GC/CT infections, condom use or no. of vaginal sex partners).	Small no., short-term follow-up, limited generalizability.	Informative, but issues with feasibility were considered. No direct contribution to guidelines.
[54]	2018	Staton et al	400 Rural women in rural Appalachian jails	Clinical trial	NIDA standard vs NIDA standard + Motivational interviewing HIV	Both groups showed decreased risky behavior at 3-mo follow-up. No significant difference between groups.	Participants were nearly 100% white and rural, potentially limiting generalizability.	Consider NIDA standard as element of treatment during incarceration.
[55]	2018	Cunningham et al	Men with HIV leaving the Los Angeles County Jail	RCT	RCT to test whether intervention kept more persons HIV suppressed; outcome analysis limited to binary viral suppression rather than fluctuations in viral load level.	Adjusted probability of viral suppression declined from 52% at baseline to 30% among controls, while those in the peer navigation arm maintained viral suppression at 49% from baseline to 12 mo, for a difference-in-difference of 22% (95% CI, .03–.41; P = .02).	Peers were paired to participants based on experience similar to that of released people. Program was designed as behavioral change intervention rather than service. LINK LA study: “improved self-reported retention in HIV primary care.” Limitations: some measures collected by correctional staff, covariates and secondary outcomes were self-reported by participants.	Evidence for an intervention that can maintain engagement
[56]	2021	Schmiege et al	Cluster-randomized design, 460 justice system–involved adolescents residing in detention facilities—2010–2014, Southwestern US.	RCT	Evaluation of additive benefit of including EtOH and THC use content in theory-based sexual risk reduction intervention (SRR vs SRR/EtOH content vs SRR/EtOH + THC content). Outcomes: risky sexual behavior q 3 mo ×1 y; condom use attitudes; self-efficacy; peer norms; behavioral intentions.	All 3 interventions associated with decreased sexual risk up to 1 y later (assessment of condom use and frequency of intercourse); motivational enhancement therapy can be readily disseminated to juvenile justice settings.	No true control (though having controls had ethical issues); did not address incidence of new STIs.	Motivational enhancement therapy (the mode of delivery) is more important than specific content for youth in this SRR intervention.
[57]	2013	Butler et al	Phone survey in 2 state prison systems	Nonblinded controlled trial	Condoms available in 1 system and not in the other. 1. Did sexual activity increase with condom availability? 2. Were condoms used in anal sex if available?	1. No—activity does not change. 2. Condoms were used if available.	Self-reported data	Supports the recommendation of providing condoms.
[58]	2020	Lucas et al	Incarcerated adults in California prisons	Intervention	Legislated condom access program. Condoms were made available via self-serve dispensers at 33 adult male prisons. Safety and security, cost, and no. of condoms accessed July 2015 to July 2016.	Condoms distributed: 354/ 1000 population/m. Cost estimated at $0.60 per person per year. No safety issues identified.	Descriptive with discrete measurable process outcomes	Providing condoms to incarcerated persons is safe and low cost and may reduce risk of STIs.
Observational studies
[21]	2017	Levanon Seligson et al	Persons ever at Rikers between 2001–2005 and at borough houses in Brooklyn, Manhattan, and the Bronx during study period	Cohort	Examination of overall and cause-specific mortality, STI rate, STIs prevalence and rates, and homelessness rates were done by descriptive analyses.	Ever-incarcerated females had the highest HIV, GC, and syphilis rates. Homeless adults after release also have higher rates of STIs (HIV, GC, and tuberculosis).	Data may be undermatched and underestimated. Some data are not generalizable. Analysis failed to indicate if acquisition of STI happened after intake.	Supports jail-based screening, treatment, and case management. Programs are needed that target released and homeless individuals.
[59]	2020	Holloway et al	Retrospective record review 2018–2019 (seen by physician): 741 youth presenting for intake physical at large urban juvenile detention facility (Houston, Texas)	Cross-sectional	How often youth reported possible trafficking; testing for pregnancy and STIs (which STIs not listed)	Significant differences in youth having forced sex compared with all youth for reports of oral sex, anal sex, and testing positive for ≥1 STI (P < .05). Higher prevalence of oral sex, anal sex, and having ≥1 STI also suggests a greater risk for extragenital STIs among victims of sex trafficking (but extragenital testing was not done in this setting).	Analysis notable, but no data on specific STIs. Unclear why so few youths reported trafficking when prevalence is reported to be high in this population.	Does not change screening guidelines themselves, but highlights higher prevalence of STIs in trafficked youth and addresses the importance of a sensitive screening tool for sex trafficking in justice system–involved youth.
[60]	2018	Biswas et al	People in California	Cross-sectional	Exposure to jail, and other factors. Gaps in prevention.	Approximately 13% of pregnant women who gave birth to an infant with congenital syphilis were incarcerated.	Jails are still important for CS control, even in era of rising proportion of cases among MSM, even in state with universal coverage.	Supports congenital syphilis testing and treatment guidelines with the special population considered (incarcerated pregnant women).
[61]	2016	Grodensky et al	Adult residents were sampled from 7 intake prisons in North Carolina; n = 936 (for analysis)	Cross-sectional	Survey and a routine HIV blood test: percentage of residents perceiving the test to be voluntary or not and desired to be tested or not	Of residents, 38% perceived test to be voluntary; 89% wanted to be tested.	Good-quality study that provides insight to residents’ perception of HIV testing in correctional facilities	Supports opt-out recommendation.
[62]	2019	Allison et al	Juvenile study (216 adolescents) parallel to adult study below	Cross-sectional	Cross-sectional study that explores attitudes of adolescents toward receiving HPV immunizations at the jail by conducting surveys.	Most adolescents had never heard about HPV. Juveniles want vaccine to prevent HPV. Adverse effects, pain from needles, and confidentiality were concerns communicated.	Low response rate that can be due to limited contact with parents for consent. Lack of trust in correctional staff among adolescents in jail when asked for desire to participate.	Supports immunization in correctional facilities. Clinic-correctional partnerships can address needs of these populations.
[63]	2018	Allison et al	571 Adult residents of 3 Kansas jails from October 2016 to January 2017	Cross-sectional	Survey assessing current HPV knowledge and vaccine knowledge, intention, and uptake.	Low uptake of HPV vaccine and high interest in receiving the vaccine in jails may indicate that vaccination should be available for jail populations. Expanding HPV vaccine programs or partnerships to facilitate provision in jails could increase residents’ knowledge of and intention to receive vital health services.	Knowledge and vaccine awareness may not improve uptake. Per ACIP/CDC, vaccine recommended for men and women through age 26 y; mean age of study participants was 33 y. Unclear whether clinical outcomes would change after vaccination in older groups, when younger groups are the target population for vaccination before HPV exposure.	Was considered in providing vaccination guidelines; however, there was a lot to consider other than the reported high interest in receiving vaccination.
[64]	2020	Brinkley-Rubinstein et al	Men in medical intake <48h after arrest at the RIDOC	Cross-sectional	Men were screened for HIV during intake at RIDOC in July and September 2017. Men completed surveys in a private setting. Survey included questions on HIV risks, HIV testing history, interest in HIV testing, and knowledge and interest in PrEP. Descriptive analyses were conducted.	Of 417 incarcerated men, 88% had never heard of PrEP. More white men had heard of PrEP but more men of color were interested/willing to take PrEP for HIV prevention. PrEP education programs should be targeted to those at the intersection of multiple risk factors and to men of color, who may be less aware of PrEP.	Strengths: individuals completed the survey in isolation, limiting social desirability bias in their responses. Limitations: PrEP care requires routine screening for HIV, as well as monitoring for adverse effects of the drug, which can raise costs. Individuals screened in the first 48h may still be under the influence of alcohol or other substances, which may affect their answers to PrEP screening questions. Individuals may not be willing to disclose their history of HIV risk behavior to correctional entities; RIDOC is a statewide prison and jail system, whereas most correctional facilities in other states are either a jail of prison.	Supports recommendations on PrEP education and acceptability among people within the correctional system.
[65]	2020	Harmon et al	Males ≤30 and females ≤ 35 y old booked into Fresno County Jail from April 2016 to December 2017	Cross-sectional	Linking jail census and laboratory data to syphilis surveillance data to assess screening coverage.	Of those eligible by age, 30% were screened for syphilis; 3% were incident cases (mostly females), and 52% of those received recommended treatment. Groups results for doxycycline and penicillin treatment.	Reasonable implementation program—screening for syphilis and focusing on females owing to the implications for congenital syphilis, which is on the rise. Jurisdictions can put STD screening in their Request for proposals and subsequent proposals.	Used in the recommendation of screening for males ≤30 and females ≤35 y old, with a focus on females, considering the increasing rate of congenital syphilis and its impact on the community. Was considered in recommending STI screening protocol in the Request for proposals.
Ecological studies
[39]	2015	Stoltey et al	Females <25 y old in San Francisco neighborhoods in 2010	Ecological model	Data modeling determining association between incarceration rates and CT incidence. CT case rate in relation to census tract-level incarceration rate.	Association between incarceration rates and CT incidence (RR, 2.489; 95% CI, 1.764–3.429); association decreased as poverty increased. For every 1% increase in incarceration rate in a census tract, CT incidence is expected to increase by 149% (95% CI, 76% to 243%) on average after controlling for several factors, every 1% increase in population with income below poverty level in a census tract, CT incidence increased by 1.8% (95% CI, .1% to 3.6%) on average after adjustment for other risk factors in the model.	Ecological fallacy; inability to geocode all CT cases (more issues with 20–24 y-olds) and all incarcerated individual addresses.	Informative, was used in reporting prevalence cases of CT.
Modeling studies/cost studies
[26]	2013	Gopalappaet al	Asymptomatic males in jail in Maricopa County, Arizona; all age groups and ≤35 y	Cross-sectional, cost-effective-ness	CT/GC screening, 2 time periods by 2 d of entry and at medical evaluation at 8–14 d. CT/GC infections averted in females, relative cost per infection averted.	Testing at 2 d: age ≤35 y, 995 infections averted ($710/case); all ages, 1100 infections averted); Testing at 8–14 d: age ≤35 y, 491 infections averted ($860/case); all ages, 556 infections averted).	Model of study has limitations: costs for sequelae or infection in men and women were not accounted for. Downstream transmission from women to others was not estimated. Assuming sexual behavior is equivalent to that of the general population would not account for other high-risk behavior.	Documents high prevalence
[66]	2013	Owusu-Edusei,et al	Published literature on national epidemic; modeled a large community and a small community	Modeling	Screening and treating of CT; change in CT prevalence	Large community: CT prevalence decreased by 13%. Sensitivity analysis shows wide range, depending on reach of screening and treatment. Small community decreased by 54%.	Magnitude of potential decreases is great.	Used in CT screening recommendation.
[67]	2019	Spaulding et al	Men and women entering Fulton County Jail	Cost-effective-ness	As above, but also had data about mega-jails in high-impact cities, which were removed from final write-up because of space limitations.	HIV testing in the jail of a targeted county could be cost saving to society	Of the 50 largest jails, 80% are in 48 counties that the US Department of HHS has targeted for HIV elimination.	Supports testing
[68]	2021	Hutchinson et al	Men and women entering Fulton County Jail	Cost-effectiveness	Cost analysis	HIV testing in the jail of a targeted county could be cost saving to society	Cost-effectiveness builds on other data regarding the importance of testing.	Supports testing
[69]	2015	Knittel et al	Heterosexual urban residents in US, aged 20–25 y	Modeling	Data modeling determining association between male incarceration rates and differences in community sexual behavior. Male incarceration rates compared with differences in sexual behaviors in communities with high vs low incarceration rates	No. of sexual partners in past year increases with incarceration (additional 9–17 partners for males and 5–12 partners for females in past year). At incarceration rates >12%, there was no significant additional effect of incarceration on males, but for females the no. of partners continues to rise.	Does not account for modifications in sexual decision making (when additional partners are sought during incarceration). STD transmission not explicitly included in model.	Informative but was not considered in recommendations owing to many variables affecting the results.
[70]	2015	Lima et al	Records from CJ system facilities	Modeling	Modeled the effect of a HIV-Test, treat, retain strategy on the estimated cumulative no. of new (acquired) infections and mortality rate, and on the HIV prevalence at the end of 10 y. Assessed effect of increasing condom use in all settings. Incidence rates, cases averted.	Aggressive implementation of a CJ system–focused HIV-Test, treat, retain strategy has the potential to interrupt HIV transmission and reduce mortality, benefiting the community at large.Increased condom use was vital for decreasing the burden of the HIV epidemic in all settings.	Feasible but may be difficult to apply as it requires behavioral modification to increase acceptance of using condoms.	Although there was a feasibility concern with the application of this study, it does support emphasis on the behavioral component recommendation.
Qualitative studies
[71]	2018	Lea et al	Jail with an MSM unit—Los Angeles	Qualitative study	Experiences in jail, how institution shapes choice and behavior; how to reduce risk	Sex happens; 1 condom a week is not sufficient.	Study uses secondary data, and data were collected from a nonrandom sample.	Supports the recommendation condom use and distribution.
[58]	2020=	Lucas et al	Incarcerated adults in California prisons	Intervention	Legislated condom access program. Condoms were made available via self-serve dispensers at 33 adult male prisons. Safety and security, cost, and no. of condoms accessed July 2015 to July 2016	Condoms distributed: 354 per 1000 population per month. Cost estimated at $0.60 per person per year. No safety issues identified.	Descriptive with discrete measurable process outcomes	Providing condoms to incarcerated persons is safe and low cost and may reduce risk of STIs.
[72]	2019	Parsons and Cox	Incarcerated individuals	Arguments for intervention	Authors presented reasons to consider implementing PrEP. They looked first at present HIV harm reduction efforts, then at common objections to PrEP provision.	Common objections to provision of PrEP do not seem to be applicable to prison populations; risk compensation cannot take place, adherence is easily monitored in a prison setting, and there is good reason to expect financial savings. PrEP is unlikely to be available to residents after release; rehabilitation is key in ensuring they do not return to a high risk of infection once they leave prison.	Discussion is importance owing to the significantly heightened risk of HIV infection residents are subject to. Not only do effective HIV prevention interventions in prisons contribute to fair healthcare access for incarcerated individuals, but also to the wider fight against HIV. Authors demonstrate that PrEP has potential as a new approach and call for further research in this area.	Explore the potential of PrEP in correctional care, which could be complementary to, and indeed less problematic than, other harm reduction measures while mapping onto overarching prison policies.
[73]	2021	Ramsey et al	Women in an integrated, statewide jail and prison located in the Northeastern US	Qualitative study of results of an intervention	Motivational interviewing-navigation study intervention consisting of individual qualitative interviews in phase 1 is being tested in the framework of the social ecological model.	The time immediately after release from incarceration appears to be a particularly high-risk period for HIV-related risk behavior among women.	Sample size not big enough to allow for finding significant differences between treatment conditions; recruitment occurs in 1 facility, so results are not generalizable.	It is essential to develop tailored interventions that reduce HIV risk as women reenter the community.Engaging at-risk women in PrEP care before and after release from incarceration may reduce their risk of acquiring HIV.
[74]	2019	Peterson et al	26 Participants who identified as MSM involved in the CJ system, specifically the RIDOC	Individual informant interviews—qualitative study	Semistructured interviews were carried out with participants who answered questions about knowledge of PrEP, their interest in this method, risks of HIV, and their overall incarceration experience.	Findings explore how distrust may hinder PrEP uptake and other HIV prevention efforts in CJ settings as well as after release. There were 3 major themes relating to institutional distrust and commonly mentioned in interviews: lack or privacy, lack of autonomy because participants felt they couldn’t exert authority over medical decisions, and feelings of dehumanization. Many participants discussed how lack of privacy may instill fear that medical care is not confidential. Findings also corroborate existing research on institutional distrust among MSM, who are often reluctant to access health services owing to stigma related to sexual orientation/identity. There is a need for greater privacy efforts and cultural humility.	Mostly white participants; RIDOC is a statewide prison and jail system, whereas most correctional facilities in other states are either a jail or prison.	There is a need for greater privacy measures in CJ settings (especially surrounding medical care), patient-centered care that considers patient priorities and preferences, and cultural humility training for CJ staff. Future studies should more broadly investigate institutional distrust in CJ settings.
[75]	2019	Peterson et al	Study included39 incarcerated individuals enrolled in a structured medication for addiction treatment program at the RIDOC	Individual interview	Using semistructured, qualitative interviews, HIV risk perceptions and PrEP awareness and interest were assessed. Analysis was conducted using a generalized, inductive method in NVivo 12, qualitative data analysis software.	Overall, 64% of participants felt they were not at risk, and 31% were interested in taking PrEP. Of the 12 participants who were interested in PrEP uptake, 6 were female and 6 male. All interested participants had graduated from high school. Barriers to PrEP use included fear of adverse effects, reluctance to add medications to regimen, and worry about adherence and deprioritization of PrEP.	Limitations: sample was mostly white, risk perception was self-reported and may be subject to bias, sample included only participants with opioid use disorder who were enrolled in a medication for addiction treatment program; RIDOC is a statewide prison and jail system, whereas most correctional facilities in other states are either a jail or prison.	Medication for addiction treatment programs for people in the CJ system may serve as useful linkage spaces to PrEP information, access, and retention. Future research is warranted in how to increase knowledge of and interest in PrEP. Future research should also explore building a continuum of PrEP from prison/jail to communities.
[76]	2020	Zaller et al	Study included 21 jailed persons in Pulaski County regional detention facility (Arkansas)	Individual informant interviews—qualitative study	Using in-depth qualitative interviews with participants selected based on specific self-reported risk behaviors, researchers questioned knowledge of PrEP and HIV, interest and perceptions about the method inside and outside the correctional facility, and possible impediments to implementing PrEP program.	Knowledge of PrEP was low among participants, but willingness to take PrEP was high, perceived risk of HIV was low and healthcare was not often a priority after release. Regarding barriers to taking PrEP, many study participants discussed fears of both medication effects and individuals in the community finding out that they were taking PrEP. An important additional barrier endorsed by many participants i is participants’ perception that their lives after release from jail may be too chaotic to adhere to PrEP. Another important barrier was fear of relapse to drug use, PrEP availability, and the need to take PrEP daily to achieve maximum protection.	Majority male in the sample; small sample sizes overall; study was conducted in a single county jail in the most urban area of a very rural state, which can limit generalizability of results; data were self-reported; study included only individuals who felt comfortable disclosing their HIV risk behaviors; screening was conducted during the jail intake process, often a chaotic period; people may also have significant reluctance to disclose any behavior they feel may affect their treatment by jail staff or other individuals detained in the jail.	Often individuals do not (or cannot) prioritize accessing healthcare on community reentry owing to competing needs, such as housing and employment. Future PrEP and other HIV prevention interventions need to incorporate approaches to address the challenges faced immediately after release from CJ settings.
[77]	2019	Brinkley-Rubinstein et al	26 MSM inside the RIDOC	Individual informant interviews—qualitative study	Study was conducted by semistructured, qualitative interviews to determine knowledge and attitudes regarding PrEP and level of disclosure of sexual identity and/or orientation	Participants disclosed sexual identity and/or orientation at different levels. Considering these variations, the CDC approach to PrEP would not be best; the WHO’s screening procedures would provide the most positive attitudes toward PrEP. Participants stated that PrEP should be offered to everyone, not just MSM, to reduce stigma and discrimination; using external organizations rather than correctional staff would increase trust at time of disclosure.	Limitations: RIDOC is not representative of other correctional facilities; RIDOC has a larger proportion of white people, and this is not generalizable to other correctional system populations; results could be biased given that men who did not disclose sexual orientation were not included in the study.	Involving medical staff from outside the correctional institution and screening for PrEP in a way that considers threats due to sexual orientation would increase PrEP uptake.

Abbreviations: ACIP, American College of Immunization Practices; CDC, Centers for Disease Control and Prevention; CI, confidence interval; CJ, criminal justice; CT, Chlamydia trachomatis; EtOH, ethanol; EU/EEA, European Union/European Economic Area; GC, Neisseria gonorrhoeae HBsAg, hepatitis B surface antigen; HBV, hepatitis B virus; HCV, hepatitis C virus; HHS, Health and Human Services; HIV, human immunodeficiency virus; HPV, human papillomavirus; HSV, herpes simplex virus; MSM, men who have sex with men; NCDPS, North Carolina Department of Public Safety; NIDA, National Institute on Drug Abuse; OR, odds ratio; POC, point-of-care; PWID, people who inject drugs; RCT, randomized controlled trial; RIDOC, Rhode Island Department of Corrections; RR, relative risk; SRR, sexual risk reduction; STD, sexually transmitted disease; STI, sexually transmitted infection; THC, tetrahydrocannabinol; UK, United Kingdom; WHO, World Health Organization.

Prevalence of STIs in Correctional Settings

Overview and Multiorganism Studies

The articles containing data on CT, GC, syphilis, TV, HIV, and viral hepatitis prevalence showed that justice system–incarcerated populations continue to have higher prevalence than populations in community venues. Incarceration rates in a jurisdiction are correlated with its prevalence of CT and, to a lesser extent, GC [12]. Although mere correlation does not explain causation, other mechanisms, such as the shared social determinants outlined in the introduction, help explain the link [12].

Age groups with heightened prevalence have a wider spectrum of age in carceral settings compared with the community—both the very young and the relatively more mature age groups. A nationwide study of large juvenile facilities, with a 76% response rate, showed that among females, prevalence of CT averaged 15%, but prevalence was inversely proportional to the percentage of the population tested. This suggested that some facilities targeted persons perceived to have infection and likely missed asymptomatic cases [17]. Routinely testing all juvenile justice–involved individuals for GC and CT, regardless of symptoms, remains a high-yield, and acceptable, intervention [17–20]. No nationwide, representative sample of incarcerated adults has been researched since termination of the CDC’s Jail STD Monitoring Project in the late 1990s [78]. Nevertheless, several large studies reporting on screening adults in a single correctional system have demonstrated the continued high prevalence of infection [20–23].

In New York City’s Rikers Island, among 244 298 individuals incarcerated at least once in the period of 2001–2003, the cumulative incidence of STI was higher among ever-incarcerated women than nonincarcerated women [21]. Syphilis rates were 13.6-fold higher than among women in the community. Rates among ever-incarcerated and nonincarcerated men were 2.3-fold higher for syphilis and 1.4-fold higher for GC, but the difference for CT was not statistically significant. During 2001–2005, the prevalence of HIV was 4 times higher among ever-incarcerated people than among nonincarcerated New Yorkers (6888 vs 1652 per 100 000), with the prevalence in women almost twice as high as that in men [21]. Reasons for heightened risk for women include high rates of “engaging in sex work, … substance use, exchanging sex for other needs, having multiple sex partners and unprotected sex, being homeless, and experiencing intimate partner violence or childhood abuse.” [21]

Data from the same jail during the period from 1 January 2009 to 31 December 2010 demonstrated that 10 115 women received STI testing, and 723 (7.1%) had GC [22]. The Los Angeles Jail STI program used a strategy of targeting the roughly 30% of women at highest risk of infection: those <30 years of age, pregnant, and/or booked for a sex-related criminal allegation. It screened 76 207 women admitted between 2002 and 2012. Among these high-risk women, the prevalence of CT was 11.4%; of GC, 3.1%; of early syphilis, 1.4%; and of HIV, 1.1% [23]. Among 59 518 admissions of female adolescents into a dozen juvenile detention facilities in California, the prevalence of CT ranged from 11.5% to 14.8% between 2003 and 2014 [20].

New studies have targeted immigrants and minors who have been trafficked. A pilot study of opt-out STI screening in 2 Immigration and Customs Enforcement detention centers found, among 494 persons screened, 42 (8.5%) had ≥1 STI [24]. Prevalence among women versus men did not differ significantly. Treatment in the facility improved the health of communities in the United States and abroad, depending on trajectories of persons after release. A study in a Texas youth detention facility that queried residents about being trafficked found that among the 16 of 741 youth (2.2%) with such a history, forced oral and anal sex was common, and 56.3% had 1 STI [59]. These findings justify more studies regarding extragenital infections among trafficked youth in other juvenile facilities. A study conducted between 2015 and 2018 throughout all of the Utah juvenile justice facilities found among the 5412 who were asked screening questions, 3.2% of those who responded reported being trafficked [25]. Given the thousands of individuals who pass through juvenile facilities, this percentage of youth with a trafficking history could account for a substantial proportion of all minors who are trafficked, and STI screening in juvenile detention facilities could be a way to address their sexual health needs.

Specific Infections

Syphilis

Studies continue to show that the prevalence of syphilis is much higher in jail populations than in the community. Local epidemiology can help guide testing strategies for jails. In 2017, half of all counties had zero cases of primary and secondary syphilis [79]; testing in these counties’ local jails is likely to have a low yield. A study in the Los Angeles County Women’s Jail showed the likelihood of primary, secondary and early latent syphilis rose with increasing age [23]. A second study in California showed that a substantial portion (13%) of pregnant women who gave birth to an infant with congenital syphilis had been incarcerated. Failure to test and treat women in jail is a missed opportunity to prevent congenital syphilis, since infection of any stage (including latent) can result in vertical transmission [60].

CT/GC

The prevalence of CT and GC is variable but much higher in juvenile and adult jail facilities than in the general public. The prevalence among women in the Los Angeles County Jail and men in the Maricopa (Arizona) County Jail was inversely related to age [23, 26]. CT and GC are so widespread in juvenile facilities that incarcerated youth of all ages should be included in testing programs regardless of reported or presumed risk. Targeting subgroups does not increase the efficiency of finding cases [19]. A study among youths involved in a Southeastern juvenile justice system in 2018 revealed that among those who reported performing oral sex and had pharyngeal testing, 2.4% were positive for GC. For those who reported engaging in anal sex, 43% were positive for rectal CT [27]. Data on the efficacy of self-collection of rectal swab samples for STI detection support having patients perform specimen collection [80]. Screening for infections may provide a good return on investment.

Findings of a study based on previously gathered prevalence data suggested that CT treatment in jails will decrease the prevalence in the community when there is a high incarceration rate for the census tract [66]. Another study based in the 18 Utah Juvenile Justice facilities revealed that girls were more receptive to screening than boys and the general population, and girls had a higher positivity rate for both infections. The study also concluded that rates of positivity were correlated with age. Youth 15–19 years old had a CT and GC positivity rate of 8%, and those aged ≥19 years had a positivity rate of 22%. Self-reported condom use was correlated with a lower positivity rate [28].

Screening for Trichomonas

Adding to evidence published in 2012, at the cusp of our review period, TV infection has been found to be highly prevalent in jailed women and detained girls, ranging from 8% to 22%, so adding TV testing is reasonable when testing for GC and CT [29–32]. With nucleic acid amplification testing for this STI available, it is possible to routinely screen these individuals even when asymptomatic. When comparing the prevalence of TV in young females and males, young females were more likely to be infected. Of females who tested positive in a study carried out in 2020, 50% had coinfection with CT or GC, while 44% were asymptomatic [30, 31].

HIV Infection

Since the 2013 review referenced above, of STIs in correctional settings [8], the United Nations has issued a human rights document upholding the dignity of incarcerated persons, which includes the governmental responsibility to provide healthcare [81]. Known as The Nelson Mandela Rules, it includes a strong statement supporting the care and treatment for persons living with HIV, which depends on identifying persons in need of services [81]. Like other STIs, HIV is more prevalent in prisons than the surrounding community; nonetheless, the gap between carceral settings and the community is closing. In 1991, HIV prevalence in US prisons was 2.2%; in 2015, 1.3% of persons in prison were HIV infected [82].

The distribution of HIV prevalence is not uniform. Of the 50 largest jails, 80% are in 48 counties that the US Department of Health and Human Services has targeted for HIV elimination [67]. Overall, the prevalence is 5 times higher in prisons than in the outside community [33]. Within systems, prevalence in women is higher than that in men, and southern states have higher prevalence than other regions [21, 33]. A recent study demonstrated that HIV testing in the jail of a targeted county could be cost saving to society [68]. Correctional institutions thus have the potential to contribute to the implementation of HIV treatment as a prevention strategy.

A systematic review and meta-analyses by Fuge et al [13] revealed barriers to optimal use of the HIV care cascade in incarcerated populations. Lack of social support, substance use, limited knowledge, and negative perception of antiretroviral therapy (ART) were some of the main determinants of suboptimal use of care in incarcerated populations. Nonadherence to ART was associated with a lack of social support, low self-efficacy score, and depressive symptoms [13]. People with HIV may have decreased access to treatment before incarceration as well as other determinants of suboptimal use of care. Infected individuals may hide HIV status, skip doses, or waive ART completely to preserve privacy in a setting that may be hostile [34]. In addition, life chaos may also be an obstacle to HIV care continuity for people with HIV who become incarcerated. Higher life chaos was positively associated with likelihood of HIV diagnosis while incarcerated [35].

HCV Infection

Likewise, the distribution of HCV infection in prison settings is not homogenous but concentrated in states (or regions) where injection drug use is more common, and jurisdictions that more aggressively prosecute drug use. According to 3 national surveys of prison medical directors of state prison systems reporting their exact enumeration of cases, the prevalence of antibodies can vary >6-fold, from <8% to 51% [36, 83, 84]. A 2019 study of HCV prevalence reported conducting a systematic review of articles published between 2013 and 2017 on HCV carceral prevalence [85] and made the assumption that geography did not influence prevalence in the carceral setting, in part by deciding “a priori” [86] to exclude an article published in their targeted time frame [36] that demonstrated varying prevalence by state [86, 87]. One critique stated that “jurisdictions with robust surveillance systems … have case counts that suggest large discrepancies between surveillance and these published estimates.” [84, 88]. Whether improved therapeutics for hepatitis C have lowered the prevalence of associated HCV viremia has not yet been captured by the US literature.

Prevention of STIs in Correctional Settings

Screening Overview

In a position statement, the National Commission on Correctional Healthcare advocates for coordination of screening for STIs with local health departments [89]. Screening continues to find many cases, but treatment and further care are sometimes challenging.

How to Screen: Opt-Out vs Opt-In Screening

A 2018 synthesis of the literature described a salutary “default effect” when persons were introduced to opt-out testing—more will access testing, especially if offered at the start of the stay for short-stay facilities. The “decision to accept testing was influenced by concerns about confidentiality, fear of a positive diagnosis, a prisoner’s personal interpretation of risk, discomfort with invasive procedures, trust in healthcare, and the fidelity of the opt-out offer.” [14] A nurse-led opt-out GC/CT testing program in a California jail found an 8-fold increase in the number of women reached over a previous strategy of having the local health department conduct opt-in testing. The prevalence of STIs did not change, meaning that the prior program was not targeting women at a higher-than-normal probability of infection [44]. Similarly, changing GC/CT screening in Chicago’s jail to opt-out screening increased the number of cases found 4-fold [45]; similar results were found in Nebraska [46].

A retrospective analysis in Hawaii conducted from 2014–2017 concluded that not only did women choose testing more often than men when offered voluntary testing, but in those women, only half of the STIs had been treated. In men, only 39% of STIs had been treated; there is a need for universal and timely testing [37].

In an Atlanta jail, not only did rapid HIV point-of-care tests have a high yield (226 diagnoses per 17 035 tests conducted), but also 89 persons, or 1 of 7 identified as living with HIV by testing or history, had a previously undiagnosed infection [47]. Conventional, laboratory-based testing is appropriate at prison reception; screening at prison entry helps link persons to the full continuum of HIV care [48]. Screening may find many previously diagnosed [49], but in a North Carolina prison, having testing become part of normal services increased by 14% the number of people living with HIV identified and funneled into care [50]. A major risk of an opt-out program is failure to convey that testing is voluntary [61]. The main benefit of routinizing testing, by making it opt-out yet neither coercive nor without consent, appears to be that more entrants with a previous diagnosis link to care during their incarceration [50].

Pathogens to Target

As noted above, testing for GC/CT, and TV for women, has high yield in younger entrants. Women aged ≤35 and men aged <30 years housed in correctional facilities should be screened for GC/CT. Women aged ≤35 years housed in correctional facilities should also be screened for TV. Both GC/CT and TV screening should be conducted at intake and offered in an opt-out manner. HIV and syphilis testing can be justified based on local epidemiology. Given the number of entrants to carceral settings who have ever injected drugs, it is reasonable to test for HBV and HCV [15].

Vaccination

Correctional facilities can prevent infectious disease by vaccination, but completing lengthy vaccine series can be a challenge for jails. If uninfected and not immune to HBV, a person should receive the vaccination, even in jails [40]. An article published in 2012, just before our review period, provided an accelerated schedule for vaccination, which may be helpful for short-term facilities [51]. Interest in receiving human papillomavirus vaccine is high among girls in juvenile facilities [62, 63]. Those <18 years of age are eligible for the Vaccines for Children Program, which is federally funded to provide vaccines at no cost to children who cannot otherwise receive vaccines owing to inability to pay [90].

Behavioral Interventions Inside Correctional Facilities to Reduce STI Acquisition After Release

With regard to what behavioral interventions among persons either incarcerated or exiting correctional facilities are successful, a theme of “nothing works” appears in the literature [91]. A largely educational intervention among men in a southeastern jail with follow-up 6 months after release did not change prevalence of GC/CT and syphilis from 10% at baseline [16]. Adoption of an evidence-based motivational and skills-building intervention to imprisoned women increased condom use after release but had no significant effect on the incidence of new STIs [52]. Adoption of a similar skill-building intervention for detained girls resulted in higher condom use self-efficacy and skills and HIV/STI knowledge (all P < .001) but changed neither condom use nor incident GC/CT infections compared with controls [53]. In a study among rural women at risk for HIV, educational interventions and motivational interviewing decreased HIV risk behavior at follow-up, but results were not significant [54].

A meta-analysis of HIV management in jails and prisons showed that release from the carceral environment is the most profound disrupter of linkage to care [41]. We will not duplicate the work of 2 excellent reviews of best practices on linking persons to HIV care in the carceral setting [13] and in the community setting after release [42]. These reviews show that behavioral interventions delivered to persons living with HIV before their release to help them maintain viral suppression after release have little effect. An intervention with the clearest proof of efficacy is to link people living with HIV to peer navigators during detention and to maintain that linkage in the community [55]. A randomized trial to reduce risky sexual behavior among justice-involved adolescents evaluated the additive benefit of including alcohol-focused and cannabis-focused content use in theory-based sexual risk reduction interventions. The findings suggested that motivational enhancement therapy may be successful as an intervention among at-risk youth. Risky sexual behavior decreased from baseline to 3-month follow-up and the effect was maintained throughout the subsequent year [56].

Condoms in Carceral Settings

Sexual acts happen in jails [71]; availability of condoms does not increase sexual behavior [57]. Reports on STI prevention measures included outcomes of condom distribution via a dispenser placed in discrete locations of California correctional facilities. An article authored by staff of the California Department of Corrections and Rehabilitation reported that residents found this low-cost program an acceptable and feasible option to prevent the transmission of STIs [58]. Custody staff reported no safety or security risk. Nothing in the California reports suggested that the distribution via a dispenser was an essential and indispensable component of the program, superior to distribution of condoms via medical services (as is done in the Washington, DC, jail and elsewhere.) [58]

HIV PrEP

While much has been published on managing HIV in correctional facilities, literature on the effectiveness of starting PrEP in correctional facilities is sparse. PrEP can prevent spread of HIV in the carceral setting, but more importantly, it can prevent HIV acquisition after release, since immediately after release the risk for HIV acquisition is high [72, 73]. Studies on PrEP that have focused on justice system–involved populations have dealt with linkage to PrEP services and knowledge of PrEP. Initial knowledge of PrEP was low, and most incarcerated populations were unfamiliar with the approach to prevention [64, 73]. However, education and information on PrEP led to expressions of interest in receiving PrEP during and after incarceration.

There is a need for better privacy measures in carceral settings to facilitate research, interaction, and data collection, as well as implementation of any PrEP intervention [74]. Future studies should more broadly investigate institutional distrust in criminal justice settings to address concerns of participants who feel stigmatized and hesitant to contribute to a study, as well as addressing adherence to a PrEP program intervention [75]. While one study focused on identifying barriers to linkage to care for an incarcerated population [76], another introduced a novel intervention plan and a pilot study for linkage to care after incarceration [73]. Best practices need to be developed for identifying good candidates for PrEP [77].

Community Impact of Screening in Correctional Facilities

Infectious diseases in jails, and to a lesser extent prisons, are closely linked to the community’s health. An agent-based computational model showed that increasing male incarceration leads to an increase in sexual partners for both men and women in the community. Increasing rates of incarceration can disrupt stable relationships and can thus lead to increased rates of STIs and HIV [69]. An ecological study demonstrated that a 1% increase in incarceration rates in a census tract was associated with a 149% increase in CT prevalence among young women in the same community; testing and treating detained young people could substantially affect adolescent CT rates [39]. Others have similarly demonstrated that a jail-based CT screen-and-treat program has the potential to reduce CT prevalence in communities with high incarceration rates [66]. Gopalappa et al [26] demonstrated that screening jailed men for GC and CT would be cost-effective in averting infections in women in the community. Targeting men <35 years of age increased the cost-effectiveness; further limiting testing to this age group did not lead to substantially fewer infections found. Testing within 2–3 days from intake had highest yield [26].

Screening for syphilis in correctional facilities is another opportunity for early detection and treatment to prevent STIs community wide [65]. Routine screening for syphilis in a California jail was followed by adequate treatment by the private medical vendor in 52% of those found to be infected, with either penicillin or doxycycline [65]. Not stated in the article was that the latter took much longer to administer and thus might not always be completed before release. Nonetheless a jail testing program that targets women of childbearing age can increase the likelihood of the program reducing the risk for congenital syphilis community-wide. Hence, screening for syphilis and other STIs could be stated in the list of services that a medical vendor company soliciting the business of a jail must provide. Doing so in California helped sustain a syphilis screening program.

The first national-level study conducted in 2017 examined availability of HIV/AIDS-related programs and found that private prisons offered fewer of these programs than public prisons. However, differences were reduced when public prisons were matched by facility characteristics [38]. A review of HIV testing and linkage to care programs supported the notion that jail-based services could promote HIV treatment as prevention [43]. Mathematical modeling supports the benefit of a test-treat-retain policy in interrupting HIV transmission and reducing mortality rates, with benefit to the community at large among incarcerated black men who have sex with men (MSM). Condom use within the correctional setting was vital for decreasing the burden of the HIV epidemic in all settings [70].

DISCUSSION

We explored whether new trends were emerging in the prevalence and management of STIs in correctional settings and found that evidence on the best practices for prevention and management of these infections have moderately changed. The most important new recommendation is to add TV screening to the screening of women entering custody. The high prevalence of STIs in correctional facilities and the strong association between incarceration rates and STIs support continued STI screening in these settings. The opportunity for public health agencies to engage with government partners in the correctional setting has been unevenly embraced, even when interventions in jails can be not just cost-effective but cost saving to society at large. The recommendations in Box 2 were informed by high-quality evidence that supported the screening, treatment, and prevention of STIs in correctional facilities.

Box 2: Recommendations Based on Literature Reviewed.

Screening—General Recommendations

1. Conduct screening tests as early as possible, such as at intake in jails, and as fast as possible

2. Use short turnaround tests, such as point-of-care tests, in short-term facilities, or for short-term patients in other carceral settings.

3. When screening for sexually transmitted infections (STIs), use opt-out rather than opt-in for screening, as long as patient is competent and informed and offer is voluntary and not coercive.

4. When insufficient funds are allocated to the jail to test all, local epidemiology and potential consequences of missing diagnoses can guide what and whom to prioritize, such as syphilis testing for pregnant women in endemic areas.

Screening—Disease-Specific Recommendations

Do not change recommended justice system–involved subpopulations to screen, and when to screen, that were listed in the 2015 guidelines, but add Trichomonas screening to what should be screened:

1. GC/CT: Girls and women ≤35 years old and boys and men <30 years old in correctional facilities should be routinely screened for GC/CT at intake.

2. TV: Girls and women ≤35 years old in correctional facilities should be routinely screened for TV at intake. Nucleic acid amplification testing can be used to routinely screen individuals, particularly asymptomatic women and girls.

3. Syphilis: Correctional facilities should stay apprised of syphilis prevalence as it changes over time. Universal, opt-out screening should be conducted on the basis of the local area and institutional prevalence of early (primary, secondary, and early latent) infectious syphilis. In short-term facilities, when release date is uncertain, screening during the intake process would reach the most individuals.

   1. If a jurisdiction records zero cases of early syphilis for several years, then routine, universal screening in the jail may not be warranted. Clinicians nonetheless need to maintain a high index of suspicion for syphilis, and test when history, symptoms, or signs suggest the diagnosis.

   2. If the jail and/or jurisdiction-wide male-to-female ratio of early syphilis is <2, then a substantial heterosexual epidemic exists; men and women in jail both need screening, and treatment of women of reproductive age at any stage of disease may decrease rates of congenital syphilis.

   3. If the jail and jurisdiction-wide male to female ratio is >2, there may be a significant concentration of the epidemic among men who have sex with men (MSM). Jail efforts to target MSM should intensify. Some large urban jails have housing pods where transgender women and MSMmay choose to reside; testing of individuals living in these units should be stressed.

4. Viral hepatitis: No new evidence changes recommendations that all youth and adults entering correctional facilities should be screened at intake for viral hepatitis, including hepatitis B and C infection, as well as tested for hepatitis A virus infection if symptomatic. Vaccination for and hepatitis A and B virus should be offered if the person is unimmunized and susceptible.

5. Human immunodeficiency virus (HIV): All youth and adults entering correctional facilities should be screened for HIV at intake in an opt-out manner.

   1. In jails, point-of-care testing should be done so that entrants can receive results before release.

   2. In the setting of opt-out HIV testing, confidentiality should be safeguarded in order to establish trust with healthcare workers.

6. General principles: Health services in jails, as well as prisons, is often contracted to outside vendors; thus putting STI screening in a jurisdiction’s request for vendor proposals and subsequent contracts will help sustain screening.

Treatment—Recommendations: Treatment for STIs in correctional settings should be given as soon as possible, particularly in jails. A short course of treatment may be the only feasible regimen in short-term correctional facilities.

1. Penicillin is the only recommended treatment for syphilis for nonallergic patients in the 2021 Centers for Disease Control and Prevention (CDC) treatment guidelines for STIs.

2. Benzathine penicillin for syphilis rather than doxycycline twice daily for 14 or 28 days, for early or late stage respectively, not only is consistent with the guidelines but also addresses the need for rapid completion if adherence after release is uncertain.

3. For CT, the 2021 CDC STI treatment guidelines recommend doxycycline 100mg twice a day for 7 days.

4. In the 2021 guidelines, single-dose azithromycin is an alternative treatment for Chlamydia trachomatis if adherence to the whole course cannot be assured. This may apply to some individuals about to leave jail in states without Medicaid expansion.

Prevention—Recommendations

1. Jurisdictions receive the level of in-jail STI services that they request. If hard hit by STIs, a county can have an aggressive response by including STI screening in their jail health contracts with medical vendors, if care is privatized.

2. Promote and provide condoms to prevent STIs, as they are feasible and very effective.

3. Promote education, behavioral interventions: these have had a moderate effect where evaluated.

4. Vaccinate when it is feasible: there is resident demand for an human papillomavirus vaccine. Vaccine for Children programs pay for vaccines for those <18 years old; the major barrier for jails to vaccinate adults is cost.

5. Preexposure prophylaxis (PrEP) in correctional settings: it appears that starting PrEP with high-risk individuals leaving a correctional facility will be feasible; more studies are needed.

Limitations include using a restricted number of STIs in the search terms, thus possibly limiting the range of STIs reported in the review, for example, Mycoplasma genitalium. While the thousands of article titles and abstracts were screened by 2 independent reviewers, important publications may have been overlooked by both. For example, an ecological analysis linking male incarceration rates and STI diagnoses using multivariate growth models controlling for covariates, which met criteria in Table 1, was nonetheless found to have been missed, after the literature review was completed [92]. We also missed a systematic review by British authors of mostly US literature showing that opt-out (compared with opt-in) testing for HIV in carceral settings had higher yield, but unequitable uptake by age—older individuals accessed testing at significantly lower rates, a finding that should influence practice [93].

Areas of future research could include analysis of the benefit of 3-site testing in all incarcerated women, not just those trafficked, and MSM. Now that STI treatment guidelines specifically mention that rectal/pharyngeal testing for GC/CT can be considered for females (particularly those <25 years of age) on the basis of reported sexual behaviors or exposure, shared clinical decision making between patient and clinician can govern whether such testing should take place. A second recommendation would be for studies that include a broader age range for CT/GC/TV, to assess the prevalence beyond age 35 years, so that the age threshold when STI screening is no longer warranted in carceral settings could be better defined. A study that assesses the benefit of annual HCV screening for those in prison with a baseline negative status or with a history of successful treatment would be helpful. We need to better understand (and prevent) transmission of HCV in prison. Finally, investigating the administration of long acting injectable drugs for HIV ART and PrEP to persons about to be released may be helpful, especially once these agents are approved for those with irregular adherence to therapeutic regimens.

In conclusion, correctional settings can be an important touchpoint for improving health outcomes, including sexual health, among communities of color, those economically challenged, and other subpopulations that the epidemic of confinement disproportionately affects. Incarceration disrupts the lives of Americans at rates experienced nowhere else in the civilized world, but until the criminal justice system is reformed, public health agencies can strive to optimize interventions to mitigate the STI epidemic among those it affects.

Notes

Acknowledgments. Thanks to Shenita Peterson, MPH, the reference librarian who helped us access literature.

Supplement sponsorship. This supplement is sponsored by The Centers for Disease Control and Prevention.

Potential conflicts of interest. A. C. S. reports recent grants through her institution from the National Science Foundation, Cellex, Gilead Sciences, the Bill & Melinda Gates Foundation, and the National Institutes of Health. She has received personal fees from and served on an advisory board for Gilead Sciences and reports the following: honoraria through third parties funded by Gilead, AbbVie, and Merck; fees to herself and/or her institution from the National Commission on Correctional Health Care, the National Sheriff’s Association, the Harris County Sheriff’s Office, and the California Department of Corrections and Rehabilitation; test kits from Bioltyical Laboratories; and travel expenses from Guardian. She also participated on a data safety monitoring board or advisory board for Emory University, outside the submitted work. B. R. G. reports grants or contracts from the Bureau of Justice Assistance, Department of Justice, and Indivior, as well as honoraria from Georgetown University, outside the submitted work; he also reports stock or stock options from ChemoCentryx. A. E. N. reports grants from Gilead Sciences, outside the submitted work. Z. W. reports grants from the Massachusetts Department of Public Health, Division of STD Prevention, and royalties from UpToDate, outside the submitted work. P. A. C. reports grants or contracts from the National Institutes of Health, the Substance Abuse and Mental Health Services Administration, and the Rhode Island Department of Health, outside the submitted work. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

The Rollins Investigational Team on STIs in Corrections: Alyssa Clausen; Samantha R. Levano, MPH; Ciara Michel, MPH; Lindsay Pett; Jacob A. Pluznik, MPH; Danielle Richard, Veena Ramanna, MPH; and Allie Vega