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Anne Spaulding, MD, Rebecca Ballard Lubelczyk, MD and Timothy Flanigan, MD

The authors are with Brown University School of Medicine and Rhode Island and Miriam Hospitals, Providence. Anne Spaulding is also with the Rhode Island Department of Corrections, Cranston.

Correspondence: Requests for reprints should be sent to Anne Spaulding, MD, 39 Howard Ave, Cranston RI 02910 (e-mail: anne_spaulding_md{at}brown.edu).

	INTRODUCTION

TOP INTRODUCTION REDUCING SYPHILIS TRANSMISSION... TAILORING PREVENTION TO THE... COLLABORATION FOR EFFECTIVE... References

 
In this issue of the Journal, Wolfe et al. describe an outbreak of syphilis in an Alabama prison system.¹ Their study demonstrates that inmates in correctional facilities do have sexual contact with each other and that unprotected sex can have devastating consequences. In this investigation, syphilis was transmitted when inmates had sex in a jail (a short-stay facility for inmates awaiting trial) and then returned to prison (a long-term facility for convicted offenders) and had contact with new partners there. Fortunately, no HIV was transmitted in this outbreak, although risk factors for such a spread were, of course, present.

	REDUCING SYPHILIS TRANSMISSION IN JAILS AND PRISONS

TOP INTRODUCTION REDUCING SYPHILIS TRANSMISSION... TAILORING PREVENTION TO THE... COLLABORATION FOR EFFECTIVE... References

 
Wolfe et al. provide insight into ways of curbing syphilis epidemics in jails and prisons. The frequency of syphilis testing should be increased—each prisoner should be tested during an annual screening, during an outbreak in the facility, and on transfer between prisons or return to a prison from a jail. Health services in correctional facilities should eliminate treatment delays; such delays (e.g., laboratory results were not returned on time, and follow-up visits were delayed for 3 months) may partially account for the epidemic described by Wolfe et al. Department of Corrections health services should forge better links with public health services in the community—especially for inmates who return to the community quickly. Better yet, correctional health services should quicken the turnaround for test results in jails. Both health departments and correctional facilities benefit from a partnership that facilitates sexually transmitted disease (STD) testing and treatment in jails in areas with high rates of syphilis.²

Complacency about an infection that disproportionately affects people of color and the poor is unconscionable when these populations constitute the principal clientele of health services based in prisons. Control of syphilis—to the point where no sustained transmission occurs—should be a priority of correctional health services everywhere. Nowhere in the United States is this more true than in the Southeast.³ Alabama was the site of the notorious Tuskegee study; the Alabama Department of Corrections sits in one of the areas hardest hit by syphilis.

	TAILORING PREVENTION TO THE CORRECTIONAL SETTING

TOP INTRODUCTION REDUCING SYPHILIS TRANSMISSION... TAILORING PREVENTION TO THE... COLLABORATION FOR EFFECTIVE... References

 
As Wolfe et al. correctly note, "Reducing sexual transmission of disease in correctional settings is a public health priority and will require innovative prevention strategies."^{1 (p1220)} We in academia and public health have too long neglected correctional facilities as a key locus for developing and evaluating effective prevention strategies for inmates, both in jail and on release into the community. The assumption that interventions that work in the community will automatically work in prisons is flawed.

Sex in the community is more likely to be consensual, whereas sex behind bars can be a mutually desired activity or coercive—a tool used to establish a hierarchy. Is there an opportunity for negotiating condom use in the latter situation? It is difficult to study what proportion of liaisons between inmates are coercive, especially among men who do not identify themselves as homosexual.⁴ Some publications dealing with the topic of coercive sexual relations in prison cite first-person accounts rather than systematic research of large groups.^5,6

Structural interventions, such as better lighting, better shower and sleeping arrangements, and improved supervision of common areas—in conjunction with additional training of correctional staff—need to be implemented and evaluated for their effectiveness in reducing unwelcome, nonconsensual sexual activity. Violence and coercion may also diminish in an atmosphere where inmates have opportunities to participate in meaningful activities, such as substance abuse rehabilitation, educational programs, and job training.

Although condoms are often available in European prisons, they are allowed in few US correctional facilities. The rationale often given is that condoms filled with drugs can be swallowed and used as vehicles to move drugs behind bars. However, there are no similar prohibitions against plastic storage bags, which could also be used to hide contraband. One reason for banning condoms may be that making prophylactics available could be interpreted as condoning sexual relations. There are laws forbidding sodomy in correctional facilities, most likely because coercive sexual relations decrease the feeling of safety among more vulnerable prisoners.

Abt Associates and the Bureau of Justice Statistics have jointly conducted periodic surveys of HIV prevention services in state prisons and large city jails. Prisons in Vermont and Mississippi, along with jails in New York City; Philadelphia, Pa; San Francisco, Calif; and Washington, DC, have permitted condom distribution. No jurisdictions that have permitted condoms have reversed their rules and subsequently banned latex barriers because of proven security risks.⁵

The American Public Health Association's new guidelines for health care of inmates in correctional facilities are being drafted as we write this editorial. At the 2000 annual meeting in Boston, a partial draft was distributed that stated, "Regardless of institutional regulations, sexual activity occurs within jails and prisons and may have significant health consequences, which must be recognized and addressed by the health care providers." The presentation panel noted that the final draft of the guidelines, due out sometime in 2001, will advocate the distribution of condoms to inmates.⁷

Condom accessibility may indeed help to reduce transmission of STDs in correctional facilities. In prisons or jails where condoms are available, the impact on the incarcerated populations should be more closely evaluated by means of monitored studies to determine whether there are reductions in transmission rates. However, even though STDs tend to be more prevalent in the incarcerated population than in the general population, they are still infrequent—there appears to be little acquisition or seroconversion in prisons. It may be difficult to study the effectiveness of accessibility to condoms in reducing such rare events.

	COLLABORATION FOR EFFECTIVE INTERVENTIONS

TOP INTRODUCTION REDUCING SYPHILIS TRANSMISSION... TAILORING PREVENTION TO THE... COLLABORATION FOR EFFECTIVE... References

 
Advocates for improved public health among the underserved need to work in collaboration with correctional health care providers and administrators to develop effective interventions. The institutional challenges of working within corrections must be overcome to pilot-test and implement innovative programs. Routine screening for STDs, linked with rapid treatment, should be routine. Improved education, combined with jail-based prevention programs, has been well accepted in various correctional settings. Perhaps some day correctional facilities in Alabama will have bowls of condoms available in the shower rooms, a strategy that focus groups of former New York inmates thought would be the most acceptable method of distribution in a correctional facility.⁴ Correctional health care practitioners, meanwhile, need to work with custody services to promote a safe environment for all inmates, especially those vulnerable to coercive sexual relations.

	Acknowledgments

 
We wish to acknowledge the Lifespan/Tufts/Brown Center for AIDS Research for partial support.

	Footnotes

 
A. Spaulding, R. B. Lubelczyk, and T. Flanigan collaborated equally in the writing of this editorial.

Accepted for publication January 21, 2001.

	References

TOP INTRODUCTION REDUCING SYPHILIS TRANSMISSION... TAILORING PREVENTION TO THE... COLLABORATION FOR EFFECTIVE... References

 
1. Wolfe MI, Xu F, Patel P, et al. An outbreak of syphilis in Alabama prisons: correctional health policy and communicable disease control. Am J Public Health.2001;91:1220–1225.[Abstract/Free Full Text]

2. Syphilis screening among women arrestees at the Cook County jail—Chicago, 1996. MMWR Morb Mortal Wkly Rep.1998;47:432–433.[Medline]

3. The National Plan to Eliminate Syphilis From the United States. Atlanta, Ga: Division of STD Prevention, National Center for HIV, STD, and TB Prevention; October 1999.

4. Mahon N. New York inmates' HIV risk behaviors: the implications for prevention policy and programs. Am J Public Health. 1996;86:1211–1215.[Abstract/Free Full Text]

5. Hammet TM, Harmon P, Maruschak LM. 1996–1997 Update: HIV/AIDS, STDs, and TB in Correctional Facilities. Available at: http://www.ojp.usdoj.gov/nij. Accessed May 29, 2001.

6. DeGroot AS, Hammett TM, Scheib RG. Barriers to care of HIV infected inmates: a public health concern. AIDS Reader.1996;6(3):78–87.

7. Cohen M, Thorton K, Cohen R, deLone M. Highlights of the third edition of the APHA Standards for Health Care in Correctional Institutions. Paper presented at: Annual Meeting of the American Public Health Association; November 12–16, 2000; Boston, Mass.

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This Article Extract Full Text (PDF) Submit a response Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Spaulding, A. Articles by Flanigan, T. Search for Related Content PubMed PubMed Citation Articles by Spaulding, A. Articles by Flanigan, T. Related Collections HIV/AIDS Other Infections Sexual Health