ORIGINAL RESEARCH ARTICLE

A systematic review and meta-analysis of the prevalence of

chlamydia, gonorrhoea and syphilis in incarcerated persons

F G Kouyoumdjian MD MPH*, D Leto MD†, S John MD†, H Henein MD‡ and S Bondy PhD*
†
*University of Toronto, Dalla Lana School of Public Health, Toronto; Division of Infectious Diseases, McMaster University, Hamilton, Canada;
‡
Faculty of Medicine, Ain Shams University, Cairo, Egypt

Summary: Communicable diseases are common in people who are incarcerated. We aimed to define the prevalence of chlamydia,
gonorrhoea and syphilis in people who are incarcerated and to identify subgroups with the highest risk of infection. We searched
for prevalence studies of chlamydia, gonorrhoea or syphilis in incarcerated populations. Pooled estimates were generated, and
meta-regression was conducted. Random effects models yielded pooled prevalence estimates of 5.75% (95% confidence interval
[CI] 5.01, 6.48) and 12.31% (95% CI 10.61, 14.01) for chlamydia in men and women, 1.4% (95% CI 1.09, 1.70) and 5.73% (4.76,
6.69) for gonorrhoea in men and women, and 2.45% (95% CI 2.08, 2.82) and 6.10% (95% CI 4.75, 7.46) for syphilis in men and women,
respectively. Each infection was associated with female gender in meta-regression models. Chlamydia, gonorrhoea and syphilis are
highly prevalent in these populations. Primary and secondary prevention efforts could improve individual and population health.

Keywords: sexually transmitted infection, prevalence, chlamydia, gonorrhoea, syphilis, jail, prison

INTRODUCTION and Treponema pallidum in incarcerated populations, and also

1 to identify subgroups with the highest rates of infection.
An estimated 10.6 million people are incarcerated worldwide,
and evidence indicates that people who are incarcerated have
poor health status relative to the general population in terms
METHODS
of mental illness, communicable diseases, certain chronic dis-
eases and overall mortality upon release.2 Accurate data on Protocol
the burden of disease in incarcerated populations can inform Methods of the search strategy, inclusion criteria, data to be
health care, institutional policy, research and advocacy efforts, extracted, and analysis were specified in advance and docu-
each of which could improve the health of this population. mented in a protocol. The protocol was modified based on
The bacterial sexually transmitted infections (STIs) chlamy- specific questions about study eligibility, specifically to
dia, gonorrhoea and syphilis, are attractive targets for public exclude prevalence data that were not specific to a particular
health action in incarcerated populations: they are common, pathogen and to exclude studies of only individuals who
easily transmitted and associated with significant sequelae; sought clinic attention, and the analysis plan was modified
they are easy, fast and inexpensive to diagnose; and they are based on the availability of data in the selected studies, specifi-
curable with short courses of antibiotics. Further, identifying cally on age and study period.
and treating people who are incarcerated may address the
overall burden of chlamydia in the general population,3,4 by
decreasing incident infections in new partners, and by decreas- Eligibility criteria
ing prevalent infections if coupled with contact tracing.
Studies were included if they presented original data on the
While many studies and several reviews have identified that
point prevalence of chlamydia, gonorrhoea and/or syphilis
these bacterial STIs are common in people who are incarcer-
in people who were incarcerated. To avoid significant misesti-
ated,5 – 8 there has been no systematic effort to quantify the
mation of the overall prevalence in incarcerated populations,
prevalence of these infections and to specify risk factors
studies were excluded if they included only persons with
across incarcerated populations internationally. In this study,
symptoms, if they included only persons who sought clinical
we therefore aimed to systematically review the peer-reviewed
attention, if they included only those who were seen in
literature and to conduct a meta-analysis to obtain estimates of
follow-up for another STI, if they included only neonates or
the prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae
prepubescents or if they were conducted in the context of an
outbreak. Studies were only included if they reported at
Correspondence to: F G Kouyoumdjian, University of
least two of prevalence, number of cases and number of
Toronto, Dalla Lana School of Public Health, 155 College
people tested, as well as if the data provided were specific
Street, 6th Floor, Toronto, Ontario, Canada M5T 3M7
to a particular pathogen, to allow for meaningful interpret-
Email: fiona.kouyoumdjian@utoronto.ca
ation of the prevalence data. Studies were included if they

International Journal of STD & AIDS 2012; 23: 248 –254. DOI: 10.1258/ijsa.2011.011194
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 Kouyoumdjian et al. Bacterial STI prevalence in incarcerated persons
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used swabs or urine samples for gonorrhoea or chlamydia,
and if they used serological tests or tests for direct detection
of T. pallidum for syphilis.
Information sources and search
Studies were identified by searching electronic databases and
manually searching the reference lists of eligible articles and
review articles. No limits were applied for language. The
search was applied to MEDLINE (1966– present), EMBASE
(1980–present) and Web of Science (1900–present), with the
most recent search conducted on 19 March 2010. We used the
following search terms: ‘sexually transmitted diseases’ or ‘sexu-
ally transmitted infection’ AND ‘jail’ or ‘inmate’ or ‘prison’, and
limited the search for abstracts.
Study selection
Eligibility assessment was performed independently by two
reviewers in a standardized fashion (DL, SJ, FGK, HH, Guy
LeBlanc and Jeffrey Pernica). Disagreements between reviewers
were resolved by consensus, often in discussion with a third
reviewer. Records were excluded first on the basis of review of
titles and abstracts, and then full articles were reviewed for
records that were not excluded.
Data collection process
A data collection form was developed, pilot tested by three
reviewers (DL, SJ, FGK) and then revised accordingly. Data
were extracted independently by two reviewers (DL, SJ, FGK,
HH, Gay LeBlanc, Jeffrey Pernica), and disagreements were
resolved by discussion. Two authors were contacted for clarifi-
cation about the data presented. Both authors responded: one
provided the information requested and the other did not
have the data available. In the second case, there was inconsis-
tency between the prevalence reported and the number of cases
per population, so we used the number of cases. Duplicate pub-
lications and data were excluded by comparing author names,
the number of cases and persons tested, and the geographical
locations of studies.
Data items
Information was extracted on study characteristics such as
study period, geographic location and type of facility; partici-
pant characteristics including gender and age; testing details
such as type of tests used and anatomic sites tested; the out-
comes of prevalence and standard error of syphilis and of ure-
thral or cervical chlamydia and gonorrhoea for the overall
population tested and for subgroups including by gender and
age category; and type of testing programme and participation
rate. Where prevalences from tests with differing sensitivity
were reported in a study, e.g. in studies comparing two tests
or studies that reported prevalences for varying dilutions of
non-treponemal tests, the result reflecting the more sensitive
testing was extracted. However, if the authors specified that
they were able to distinguish past infection from current infec-
tion and reported both test positivity and current cases, e.g. for
syphilis, only the prevalence of current cases was extracted. If
the study period was not specified, it was assumed to be two
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249
years prior to the date of publication. The mean year was calcu-
lated for each study. If the age range was not specified, and the
manuscript indicated that the study was of adults or was con-
ducted in an adult facility, the lower age limit was assumed to
be 18 years. Similarly, if the age range was not specified and the
manuscript indicated that the study was conducted in a juven-
ile facility, the upper age limit was assumed to be 18 years. A
variable was created to represent age (as a continuous variable)
for the specific prevalence estimates. This was assigned as the
age- and sex-specific mean age for the estimate, where reported,
or approximated from information available using median,
midpoint of range or estimated mean age based on population
type (e.g. adult or juvenile). For chlamydia and gonorrhoea,
tests were grouped into culture, nucleic acid, antigen, a combi-
nation of these or unspecified, and for syphilis, test types were
grouped into treponemal, non-treponemal, both or unspecified.
Risk of bias in individual studies
Two areas of potential bias were identified a priori, and assessed
for in each article by two reviewers independently: how study
subjects were selected and recruited (i.e. inclusion and exclu-
sion criteria, and whether the study described participants in
routine screening programmes, volunteers in a study or other-
wise) and the participation rate.
Analysis
The primary outcome measure was the percent positivity for
chlamydia, gonorrhoea or syphilis. Forest plots were constructed
for each STI showing sex- and age group-specific prevalences as a
percent with Wald 95% confidence intervals (CI) and using exact
Poisson standard errors for studies with no positive cases. Pooled
prevalence rates were calculated using the DerSimonian and
Laird method and inverse-variance weights, for all studies and
for studies conducted since 2000. Pooled estimates based on
fixed and random effects models were presented with raw
study data in forest plots. Heterogeneity I-square (I 2) values
were obtained using logit transformed proportions, corrected
using 0.5 as the numerator for estimates with no positive cases.
For each STI, meta-regression was carried out using a random
effects negative binominal regression model to determine the stat-
istical significance of study-level covariates and to directly esti-
mate the prevalence rate ratio (PRR), with a priori selection of
the following variables for inclusion: age and gender were
retained in all models, and geographical region and test type
were considered for inclusion where statistically significant after
age and sex adjustment. In the case of non-convergence of nega-
tive binomial models, alternative meta-regression models using
the logit of prevalence as the effect were utilized to examine
the influence of covariates and the Akaike information criteria
was used to select between non-nested models comparing trans-
formations of continuous covariates, as used to ensure that
assumptions of linearity were met. We assessed for the possibility
of publication or reporting bias by looking for asymmetry in
Funnel plots and conducting the Egger test.9
RESULTS
A total of 60 articles were included in the review and
meta-analysis. As shown in Figure 1, database searching ident-
ified 331 records and review of reference lists identified 30
250 International Journal of STD & AIDS Volume 23 April 2012
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Figure 1 Flow diagram of the study selection process
additional titles. After removing duplicate studies, 355 records
remained, one of which could not be retrieved despite attempts
to contact the journal and author, and 268 of which were
excluded after reviewing titles and abstracts. Eighty-six articles
underwent full review, and of these, 60 were eligible for
inclusion in the review and meta-analysis.3,10 – 68
Study characteristics
Of the 60 studies included, 42 were based in the USA, seven in
Brazil, three in the UK, two in Australia and one in each of
France, Ghana, India, Jamaica, Mozambique and Pakistan
(Table 1). The studies were based in various types of correctional
facilities, though most studies did not define the populations
served by the facility (e.g. whether inmates were admitted
based on length of sentence, nature of charge or conviction,
etc.). Based on stated type of facility or age groups included, 24
studies included only juveniles, 30 studies included only
adults, and six studies included both juveniles and adults.
Chlamydia data were included from 39 studies: 12 including
only women and 14 including only men. Of these 39 studies
with data on chlamydia, 30 used nucleic acid amplification
testing (NAAT), four used culture, three used antigen, one
included a mix of NAAT and culture, and one did not specify
the test. Gonorrhoea data were included from 30 studies: 10
included only women and 11 included only men. Of these 30
studies with data on gonorrhoea, 17 used NAAT, 11 used
culture, one used antigen and one did not specify the test.
With respect to testing for chlamydia and gonorrhoea across
the studies included, NAAT was only used after 1997, and
since 1997 NAAT was used in 30 of the 33 studies reporting
chlamydia data and 17 of the 21 studies reporting gonorrhoea
data. Syphilis data were included from 30 studies: 10 included
only men and seven included only women. Of these 30 studies
with data on syphilis, four studies used only non-treponemal
tests, four studies used only treponemal tests, 20 studies used
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both treponemal and non-treponemal tests, and the test was
not specified for two studies. Half of the studies of syphilis
were done prior to 1995 and half were done after 1995.
Risk of bias within studies
Participation rate was not reported for 18 studies, was not con-
sistently measured in three studies, and was not relevant for
one paper that included only people referred for physical exam-
ination. Of the remaining 39 studies, 17 reported participation
rates greater than 75% and three had rates less than 50%. Few
studies reported how those who were included in the study dif-
fered from those who were not included, e.g. in terms of age,
gender, or the nature of charges or convictions. Most studies
either retrospectively assessed a routine screening programme
or enrolled a random sample of or consecutively admitted
inmates to the correctional facility. In many studies, only
people who were admitted for a certain period of time were
tested. Some studies included only people who were sexually
active and many studies included only those who were
admitted to the facility during specific times of the day. Data
were reported in several studies only for subjects with complete
data on all variables of interest.
Results of individual studies
The prevalence of chlamydia in women and men varied across
studies, ranging from 1.3% to 31% in women and from 0% to
16.3% in men, with relatively high rates in persons in their late
teens and early 20s, as shown in Figure 2, available online only at
http://www.ijsa.rsmjournals.com/cgi/content/full/23/4/248/DC1.
The pattern for gonorrhoea was similar by age, as shown in Figure 3,
available online only at http://www.ijsa.rsmjournals.com/cgi/
content/full/23/4/248/DC1, with a range in prevalence from
0.35% to 18.4% in women and from 0% to 6.7% in men. For syphilis,
the variation across age groups was less pronounced (Figure 4,
available online only at http://www.ijsa.rsmjournals.com/cgi/
content/full/23/4/248/DC1), with a range in prevalence in
women between 0% and 36.1% and in men between 0% and 20.6%.
Syntheses of results
There was significant heterogeneity across studies for each of
chlamydia, gonorrhoea and syphilis, with I 2 values of greater
than 90% overall and for men and women, respectively. The
syphilis prevalence from one study10 was identified as a poten-
tial outlier in bivariate analyses but was found to have little influ-
ence on multivariable models. All observations were retained.
Pooled estimates from random effects models indicate an
overall prevalence for chlamydia of 8.94% (95% CI 8.16, 9.73),
as shown in Table 2. For gonorrhoea, the overall prevalence
was 3.31% (95% CI 2.87, 3.75), and for syphilis, the overall
prevalence was 2.89% (95% CI 2.56, 3.23). For studies since
2000 (by mean year), the pooled prevalence was 7.81% (95%
CI 6.85, 8.76) for chlamydia, 2.38% (95% CI 1.82, 2.94) for
gonorrhoea and 2.12% (95% CI 1.57, 2.68) for syphilis. The
pooled estimates were statistically significantly higher for
women than for men when all data were included for each
pathogen, as well as using data on chlamydia and gonorrhoea
from studies conducted since 2000.
For each pathogen, the random effects pooled estimate
of prevalence was higher than the fixed effects pooled
 Kouyoumdjian et al. Bacterial STI prevalence in incarcerated persons 251
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Table 1 Studies included in systematic review of published studies of the prevalence of chlamydia, gonorrhoea and syphilis in
incarcerated populations3,10 – 68
Study Period Country Type of facility Gender STIs
Adjei et al. (2008) 2004 –2005 Ghana 8 regional prisons M, F S
Alexander-Rodriguez et al. (1987) 1983 –1984 USA Juvenile detention centre M, F G, S
Altaf et al. (2009) 2002 Pakistan Juvenile prison M C, G
Andrinopoulos et al. (2010) 2006 Jamaica Adult correctional facility M C, G, S
Baillargeon et al. (2003) 1999 –2001 USA Prisons, jails, substance abuse felony punishment facilities M, F S
Barry et al. (2007) 2003 –2005 USA Youth detention centre, adult jail M, F C, G
Barry et al. (2009) 1997 –2004 USA Adult jails M, F C
Bauer et al. (2004), adult jail 2000 –2002 USA 12 adult jails, 20 juvenile facilities M, F C
Bell et al. (1985) 1981 USA Juvenile detention centre F C, G, S
Beltrami et al. (1997) 1993 USA County jail M, F S
Beltrami et al. (1998) 1993 –1994 USA Jail M C, G
Bernstein et al. (2006) 1999 USA 6 prisons M, F C, G
Bickell et al. (1991) 1988 USA Jail F G, S
Blake et al. (2004) 2001 –2003 USA 2 juvenile detention facilities M C
Blank et al.(1997) 1993 USA Correctional facility F S
Butler et al. (2001) 1996 Australia 27 correctional facilities M, F S
Catalan-Soares (2000) 1994 Brazil Prison M S
Cohen et al. (1992) 1989 USA County jail M S
Crosby et al. (2006) 2001 –2003 USA 8 regional youth detention centres M, F C, G
De Andrade et al. (1989) 1988 Brazil Adult penitentiary M S
De Ravello et al. (2005) 1998 –1999 USA Prison F C, G, S
Ellerbeck et al. (1989) 1986 USA State prison M G
Evens et al. (1999) 1998 USA 3 jails, 3 juvenile detention centres F C, G
Fialho et al. (2008) 2004 –2005 Brazil Juvenile detention M, F S
Gabriel et al. (2008) 2003 –2005 UK Youth offenders institute F C
Hardick et al. (2003) 1999 –2000 USA Detention centre F C, G
Heimberger et al. (1993) 1989 –1990 USA County jail M, F S
Hirst et al. (2009) 2007 UK Young offender centre M C
Holmes et al. (1993) 1988 USA Jail F C, G, S
Javanbakht et al. (2009) 2000 –2005 USA County jail M C, G, S
Joesoef et al. (2009) 2005 USA 141 juvenile, 22 adult facilities M, F C
Kahn et al. (2002) 1994 –1998 USA Jail M, F S
Kahn et al.(2005) 1997 –2002 USA 14 juvenile detention centres M, F C, G
Katz et al. (2004) 2000 –2001 USA Juvenile detention centre F C, G
Kelly et al. (2000) not provided USA 2 juvenile detention centres M, F C
Lofy et al. (2006) 1998 –2002 USA 4 juvenile detention centres F C
Lopes et al. (2001) 1997 –1998 Brazil Adult penitentiary F S
Massad et al. (1999) 1993 –1994 Brazil Prison M S
McDonnell et al. (2009) 2002 –2005 USA Juvenile detention facility F C
Menon-Johansson et al. (2005) missing UK Young offenders’ institution M C
Mertz et al. (2002) 1998 –2000 USA Jails F C, G
Miranda et al. (2000) 1997 Brazil State prison F C, G, S
Miranda et al. (2001) 1999 Brazil Juvenile justice system M, F S
Nguyen et al. (2004) 2000 USA 2 jails, 2 youth correctional facilities M C
O’Brien et al. (1988) missing USA Juvenile detention centre M C, G
Oh et al. (1994) 1990 –1992 USA Juvenile detention facility M C, G, S
Oh et al. (1998) 1996 –1997 USA Juvenile detention centre M, F C, G
Pack et al. (2000) 1997 USA Juvenile detention facility M C, G
Risser et al. (2001) 1998 –1999 USA Juvenile detention centre M, F C
Robertson et al. (2005) 2002 –2003 USA Juvenile detention centre M, F C, G
Silberstein et al. (2000) 1993 –1995 USA County jail M, F S
Singh et al. (1999) Missing India District jail M S
Solomon et al. (2004) 2002 USA Prison system M, F S
Spaulding et al. (2009) 1999 USA Combined jail –prison M, F C, G
Trick et al. (2006) 2004 USA County jail M C, G
Vaz et al. (1995) 1990 –1991 Mozambique 3 prisons, 1 jail M, F S
Verneuil et al. (2009) 2000 –2003 France Prison remand centre M C, G, S
Watkins et al. (2009) 2005 –2007 Australia 13 prisons M, F C, G, S
Willers et al. (2008) 2002 –2003 USA Jail F C, G
Wood et al. (1993) 1990 –1991 USA Juvenile detention centres M C, G, S

STIs ¼ sexually transmitted infections; M ¼ male; F ¼ female; C ¼ chlamydia; G ¼ gonorrhoea; S ¼ syphilis

Some studies reported on the same study populations. Data were included in meta-analysis only from the latest or most comprehensive source

estimate. A funnel plot for each pathogen revealed significant
asymmetry, with a tendency towards higher-prevalence
estimates in smaller studies. Consistent with this, the Egger
test revealed significant small study effects, at P , 0.01 for
each STI.
Meta-regression
Given the paucity of studies from different regions, we
excluded geographical region from the multivariable models.
For chlamydia, study year and test type were collinear, which
precluded them from both being included in the multivariable

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252 International Journal of STD & AIDS Volume 23 April 2012
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Table 2 Pooled estimates of the prevalence of STIs in incar-

including only data from 1997 onwards indicated that study
cerated populations from fixed and random effects models, year was no longer significantly associated with infection,
by STI and gender although there was still an inverse association.
Fixed effects model, % Random effects model, % The best-fit model for syphilis included gender, study year,
(95% CI) (95% CI) age and test type (Table 3). Female gender was associated
Chlamydia with an infection rate 2.71 times the rate in men (95% CI 1.53,
Overall 5.68 (5.61, 5.75) 8.94 (8.16, 9.73) 4.79), and study year was inversely associated with infection
Male 5.01 (4.93, 5.09) 5.75 (5.01, 6.48) by a factor of 0.5 per decade from 1981 (95% CI 0.29, 0.85).
Female 7.92 (7.77, 8.07) 12.31 (10.61, 14.01) Age was not a significant factor, with a PRR of 1.13 (95% CI
Gonorrhoea 0.94, 1.37) per five years. Compared with a combination of tre-
Overall 1.50 (1.44, 1.57) 3.31 (2.87, 3.75)
ponemal and non-treponemal testing, non-treponemal tests
Male 1.11 (1.03, 1.18) 1.4 (1.09, 1.70)
Female 2.95 (2.80, 3.1) 5.73 (4.76, 6.69) alone were 2.72 times as likely to be associated with infection
Syphilis
(95% CI 1.36, 5.41) and treponemal tests alone were 7.03 times
Overall 0.69 (0.66, 0.71) 2.89 (2.56, 3.23) as likely to be associated with infection (95% CI 2.44, 20.24).
Male 0.63 (0.60, 0.65) 2.45 (2.08, 2.82)
Female 1.66 (1.55, 1.77) 6.10 (4.75, 7.46)

STIs ¼ sexually transmitted infections; CI ¼ confidence interval

Pooled estimates were calculated using inverse-variance weights and
DerSimonian and Laird method
model simultaneously; we excluded test type given that so few
studies used tests other than NAAT. In a model with gender,
study year and age, women had an adjusted prevalence rate
1.89 times the rate for men (95% CI 1.58, 2.25) (Table 3). Age
was also a statistically significant predictor of infection, and
was best modelled with an age and age-squared term, reflecting
an inverted U-shaped relationship with infection in which
prevalence was highest roughly between ages 13 and 20 and
lower outside this range. The PRR decreased by a factor of
0.79 (95% CI 0.63, 0.98) by decade from 1981; however,
looking specifically at data since 1997 (when NAAT was
almost exclusively used), the year of study was no longer a sig-
nificant predictor of infection though still was inversely associ-
ated with infection.
For gonorrhoea, the best-fit model included gender, study
year, age and test type (Table 3). Female gender was associated
with prevalence 3.36 times the prevalence for men (95% CI 2.37,
4.75). Age and test type relative to NAAT did not statistically
significantly predict infection. Study year by decade showed a
significant decrease in infection rate of 0.53 times (95% CI
0.30, 0.91) by decade from 1981. However, a separate model
Table 3 Prevalence rate ratios (PRRs) of STIs in incarcerated
populations from random effects negative binomial models,
by STI
Chlamydia, Gonorrhoea, Syphilis,
PRR (95% CI) PRR (95% CI) PRR (95% CI)
Gender, female 1.89 (1.58, 2.25) 3.36 (2.37, 4.75) 2.71 (1.53, 4.79)
versus male
Year of study, per 0.79 (0.63, 0.98) 0.53 (0.30, 0.91) 0.5 (0.29, 0.85)
decade from
†
1981
Age, per 5 years, 0.88 (0.80, 0.98) 0.87 (0.76, 1.01) 1.13 (0.94, 1.37)
centred at 20.5
‡ findings are valid.
§ §
Age-squared 0.92 (0.88, 0.96)
STIs ¼ sexually transmitted infections; CI ¼ confidence interval
Model also included test type
†
Year when study was conducted, by decade, with the first category of 1981–
1990, etc.
‡
§
Age of participants in five-year intervals with a zero value assigned to age 20.5
Polynomial (squared) terms were not included, as they did not improve the fit of
these models
CONCLUSIONS
This analysis identified very high rates of chlamydia, gonor-
rhoea and syphilis in incarcerated persons, in particular in
women. These findings are an important contribution to the
STI literature; the meta-analytic methods summarize data
across diverse studies and points in time, yielding estimates
of prevalence that are more precise than those produced by
individual studies and identifying common risk factors across
settings. Another strength of these analyses is that the
meta-regression identifies specific risk factors for infection.
There are several limitations to this study. Information on
participation rates and on populations included, as well as
age- and sex-specific prevalences were inconsistently reported.
The lack of available studies and of population-based preva-
lence data from various geographical regions precluded analy-
sis of the data while controlling for region, and regional
variation in prevalence may be responsible for some of the het-
erogeneity in the analyses. Certain study procedures such as
limited times of recruitment and specific inclusion and exclu-
sion criteria may have led to selection bias. Another potential
issue in terms of representativeness is that screening pro-
grammes may be instituted more often in the context of recog-
nition of high rates of disease, so that studies may have been
conducted in populations that differ from the overall incarcer-
ated population. In terms of the inclusiveness of this review,
only the peer-reviewed literature was included due to resource
constraints, which may mean that relevant data from the grey
literature were excluded. The asymmetry of the funnel plots
and the Egger test results suggest a bias where small studies
with higher prevalence may have been more likely to be pub-
lished and therefore included in this analysis. This may lead
to an overestimation of the prevalence, which may be exagger-
ated further using random effects models in which small
studies have relatively greater influence, and which are
clearly indicated here given very high heterogeneity across
studies. However, the fact that random and fixed effects
models converged in revealing high rates suggests that these
Compared with population-based STI studies from the
US,69,70 Europe71 – 73 and China,74 the pooled estimates for
gender-specific prevalence from fixed effects models are
several folds higher, though notably it would also be important
to compare age-specific data given the associations identified in
this study between age and infection. We hypothesize that the
significant differences between these population-based esti-
mates and the estimates for the incarcerated population

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 Kouyoumdjian et al. Bacterial STI prevalence in incarcerated persons
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derived from our study are due, at least in part, to a truly higher
prevalence in the incarcerated population, which is potentially
a reflection of both high-risk behaviours and poor access to
screening and other clinical services.
Correctional facilities provide a valuable opportunity to offer
accessible and acceptable health interventions,2 though simul-
taneously significant barriers may exist to implementation,
including costs, the short length of admissions, shortage of
space and staff, and confidentiality.6 The high rates of the bac-
terial STIs found in these analyses suggest the need for effective
primary and secondary prevention programmes for people
who are incarcerated, which may include general or targeted
screening, sex education and condom access in correctional
facilities and in the community. Particular attention should be
paid to strategies that address STI infections in women, given
the high relative risks of infection found in these analyses,
while recognizing that they represent a minority of the incarcer-
ated population globally. Cost-effectiveness analyses and com-
munity engagement would both be valuable in determining
how best to prevent and treat STIs in this population;
however, while this knowledge is being produced, immediate
action may be warranted for STI control.
ACKNOWLEDGEMENTS
We are grateful to Dr Guy LeBlanc and Dr Jeffrey Pernica for
assisting in the review of abstracts and full texts. This work
was supported in part by the Physicians’ Services
Incorporated Foundation (grant R08-54) to FGK.
Conflict of interest: None of the authors have any conflicts of
interest.
REFERENCES
1 Walmsley R. World Prison Population List. 8th edn. London: King’s College
London International Centre for Prison Studies, 2009
2 Fazel S, Baillargeon J. The health of prisoners. Lancet 2011;377:956 –65
3 Barry PM, Kent CK, Scott KC, et al. Is jail screening associated with a decrease
in chlamydia positivity among females seeking health services at community
clinics? – San Francisco, 1997 –2004. Sex Transm Dis 2009;36:S22 –28
4 Kahn RH, Peterman TA, Arno J, et al. Identifying likely syphilis transmitters:
Implications for control and evaluation. Sex Transm Dis 2006;33:630 –35
5 Bick JA. Infection control in jails and prisons. Clin Infect Dis 2007;45:
1047–55
6 Templeton DJ. Sexually transmitted infection and blood-borne virus screening
in juvenile correctional facilities: a review of the literature and
recommendations for Australian centres. J Clin Forensic Med 2006;13:30 –36
7 Joesoef MR, Kahn RH, Weinstock HS. Sexually transmitted diseases in
incarcerated adolescents. Curr Opin Infect Dis 2006;19:44 –48
8 Cohen DA, Kanouse DE, Iguchi MY, et al. Screening for sexually transmitted
diseases in non-traditional settings: a personal view. Int J STD AIDS
2005;16:521– 27
9 Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis
detected by a simple, graphical test. BMJ 1997;315:629– 34
10 Adjei AA, Armah HB, Gbagbo F, et al. Correlates of HIV, HBV, HCV and
syphilis infections among prison inmates and officers in Ghana: a national
multicenter study. BMC Infect Dis 2008;8:33
11 Alexander-Rodriguez T, Vermund SH. Gonorrhea and syphilis in incarcerated
urban adolescents: prevalence and physical signs. Pediatrics 1987;80:561– 64
12 Altaf A, Janjua NZ, Kristensen S, et al. High-risk behaviours among juvenile
prison inmates in Pakistan. Public Health 2009;123:470 –75
13 Andrinopoulos K, Kerrigan D, Figueroa JP, et al. Establishment of an HIV/
sexually transmitted disease programme and prevalence of infection among
incarcerated men in Jamaica. Int J STD AIDS 2010;21:114– 19
14 Baillargeon J, Bradshaw P. The Association of infectious disease diagnoses
with incarceration-related factors among prison inmates. J Correct Health Care
2003;10:15– 33
Downloaded from std.sagepub.com at MCMASTER UNIV LIBRARY on April 7, 2015
253
15 Barry PM, Kent CK, Scott KC, et al. Optimising sexually transmitted infection
screening in correctional facilities: San Francisco, 2003 –5. Sex Transm Infect
2007;83:416– 18
16 Bauer HM, Chartier M, Kessell E, et al. Chlamydia screening of youth and
young adults in non-clinical settings throughout California. Sex Transm Dis
2004;31:409– 14
17 Bell TA, Farrow JA, Stamm WE, et al. Sexually transmitted diseases in females
in a juvenile detention center. Sex Transm Dis 1985;12:140 –44
18 Beltrami JF, Cohen DA, Hamrick JT, Farley TA. Rapid screening and treatment
for sexually transmitted diseases in arrestees: a feasible control measure. Am J
Public Health 1997;87:1423 –26
19 Beltrami JF, Farley TA, Hamrick JT, et al. Evaluation of the Gen-Probe PACE 2
assay for the detection of asymptomatic Chlamydia trachomatis and Neisseria
gonorrhoeae infections in male arrestees. Sex Transm Dis 1998;25:501 –04
20 Bernstein KT, Chow JM, Ruiz J, et al. Chlamydia trachomatis and Neisseria
gonorrhoeae infections among men and women entering California prisons. Am
J Public Health 2006;96:1862 –66
21 Bickell NA, Vermund SH, Holmes M, et al. Human papillomavirus,
gonorrhea, syphilis, and cervical dysplasia in jailed women. Am J Public Health
1991;81:1318–20
22 Blake DR, Gaydos CA, Quinn TC. Cost-effectiveness analysis of screening
adolescent males for Chlamydia on admission to detention. Sex Transm Dis
2004;31:85– 95
23 Blank S, McDonnell DD, Rubin SR, et al. New approaches to syphilis control:
finding opportunities for syphilis treatment and congenital syphilis
prevention in a women’s correctional setting. Sex Transm Dis 1997;24:218– 26
24 Butler T, Robertson P, Kaldor J, Donovan B. Syphilis in New South Wales
(Australia) prisons. Int J STD AIDS 2001;12:376 –79
25 Catalan-Soares BC, Almeida RT, Carneiro-Proietti AB. Prevalence of HIV-1/2,
HTLV-I/II, hepatitis B virus (HBV), hepatitis C virus (HCV), Treponema
pallidum and Trypanosoma cruzi among prison inmates at Manhuacu, Minas
Gerais State, Brazil. Rev Soc Bras Med Trop 2000;33:27 –30
26 Cohen D, Scribner R, Clark J, Cory D. The potential role of custody facilities in
controlling sexually transmitted diseases. Am J Public Health 1992;82:552– 56
27 Crosby R, Voisin D, Salazar LF, et al. Family influences and biologically
confirmed sexually transmitted infections among detained adolescents. Am J
Orthopsychiatry 2006;76:389 –94
28 de Andrade AL, Martelli CM, Sousa LC, et al. [Seroprevalence and risk factors
for syphilis in prisoners in Goias, Brazil]. Rev Inst Med Trop Sao Paulo
1989;31:177– 82
29 de Ravello L, Brantley MD, Lamarre M, et al. Sexually transmitted infections
and other health conditions of women entering prison in Georgia, 1998 –1999.
Sex Transm Dis 2005;32:247 –51
30 Ellerbeck EF, Vlahov D, Libonati JP, et al. Gonorrhea prevalence in the
Maryland state prisons. Sex Transm Dis 1989;16:165– 67
31 Evens A, Kee R, Broussard D, et al. High prevalence of chlamydial and
gonococcal infection in women entering jails and juvenile detention centers –
Chicago, Birmingham, and San Francisco, 1998. MMWR Morb Mortal Wkly Rep
1999;48:793– 96
32 Fialho M, Messias M, Page-Shafer K, et al. Prevalence and risk of blood-borne
and sexually transmitted viral infections in incarcerated youth in Salvador,
Brazil: opportunity and obligation for intervention. AIDS Behav
2008;12:S17 –S24
33 Gabriel G, Burns T, Scott-Ram R, et al. Prevalence of Chlamydia trachomatis and
associated risk factors in women inmates admitted to a youth offenders
institute in the UK. Int J STD AIDS 2008;19:26 –29
34 Hardick J, Hsieh YH, Tulloch S, et al. Surveillance of Chlamydia trachomatis and
Neisseria gonorrhoeae infections in women in detention in Baltimore, Maryland.
Sex Transm Dis 2003;30:64 – 70
35 Heimberger TS, Chang HG, Birkhead GS, et al. High prevalence of syphilis
detected through a jail screening program. A potential public health measure
to address the syphilis epidemic. Arch Intern Med 1993;153:1799 –804
36 Hirst H, Dinsmore WW. Chlamydia Screening Programme, HMP Hydebank
Wood Young Offender Centre, Belfast, Northern Ireland, UK. Int J STD AIDS
2009;20:360– 66
37 Holmes MD, Safyer SM, Bickell NA, et al. Chlamydial cervical infection in
jailed women. Am J Public Health 1993;83:551 –55
38 Javanbakht M, Murphy R, Harawa NT, et al. Sexually transmitted infections
and HIV prevalence among incarcerated men who have sex with men, 2000 –
2005. Sex Transm Dis 2009;36:S17 –S21
39 Joesoef MR, Weinstock HS, Kent CK, et al. Sex and age correlates of chlamydia
prevalence in adolescents and adults entering correctional facilities, 2005:
implications for screening policy. Sex Transm Dis 2009;36:S67 –S71
40 Kahn RH, Mosure DJ, Blank S, et al. Chlamydia trachomatis and Neisseria
gonorrhoeae prevalence and coinfection in adolescents entering selected US
juvenile detention centers, 1997 –2002. Sex Transm Dis 2005;32:255 –59
254 International Journal of STD & AIDS Volume 23 April 2012
................................................................................................................................................
41 Kahn RH, Scholl DT, Shane SM, et al. Screening for syphilis in arrestees:
usefulness for community-wide syphilis surveillance and control. Sex Transm
Dis 2002;29:150 –56
42 Katz AR, Lee MV, Ohye RG, et al. Prevalence of chlamydial and gonorrheal
infections among females in a juvenile detention facility, Honolulu, Hawaii.
J Commun Health 2004;29:265– 69
43 Kelly PJ, Owen SV, Peralez-Dieckmann E, Martinez E. Health interventions
with girls in the juvenile justice system. Womens Health Issues 2007;17:227 –36
44 Lofy KH, Hofmann J, Mosure DJ, et al. Chlamydial infections among female
adolescents screened in juvenile detention centers in Washington State, 1998 –
2002. Sex Transm Dis 2006;33:63 –67
45 Lopes F, Latorre MR, Campos Pignatari AC, Buchalla CM. [HIV, HPV, and
syphilis prevalence in a women’s penitentiary in the city of Sao Paulo, 1997 –
1998]. Cad Saude Publica 2001;17:1473 –80
46 Massad E, Rozman M, Azevedo RS, et al. Seroprevalence of HIV, HCV and
syphilis in Brazilian prisoners: preponderance of parenteral transmission.
Eur J Epidemiol 1999;15:439– 45
47 McDonnell DD, Levy V, Morton TJM. Risk factors for chlamydia among
young women in a northern California juvenile detention facility: implications
for community intervention. Sex Transm Dis 2009;36:S29 –S33
48 Menon-Johansson AS, Winston A, Matthews G, et al. The first point prevalence
study of genital Chlamydia trachomatis infection in young male inmates in the
UK. Int J STD AIDS 2005;16:799 –801
49 Mertz KJ, Schwebke JR, Gaydos CA, et al. Screening women in jails for
chlamydial and gonococcal infection using urine tests feasibility, acceptability,
prevalence, and treatment rates. Sex Transm Dis 2002;29:271 –76
50 Miranda AE, Adriana MZ. Prevalence of HIV infection and syphilis among
adolescents in a juvenile justice system. DST- J Bras Doencas Sex Transm
2001;13:35– 39
51 Miranda AE, Vargas PM, St Louis ME, Viana MC. Sexually transmitted
diseases among female prisoners in Brazil: prevalence and risk factors.
Sex Transm Dis 2000;27:491 –95
52 Nguyen MS, Ratelle S, Tang Y, et al. Prevalence and indicators of Chlamydia
trachomatis infections among men entering Massachusetts Correctional
facilities: policy implications. J Correct Health Care 2004;10:543– 54
53 O’Brien SF, Bell TA, Farrow JA. Use of a leukocyte esterase dipstick to detect
Chlamydia trachomatis and Neisseria gonorrhoeae urethritis in asymptomatic
adolescent male detainees. Am J Public Health 1988;78:1583 –84
54 Oh MK, Cloud GA, Wallace LS, et al. Sexual behavior and sexually transmitted
diseases among male adolescents in detention. Sex Transm Dis 1994;21:127 –32
55 Oh MK, Smith KR, O’Cain M, et al. Urine-based screening of adolescents in
detention to guide treatment for gonococcal and chlamydial infections.
Translating research into intervention. Arch Pediatr Adolesc Med
1998;152:52 – 56
56 Pack RP, Diclemente RJ, Hook EW 53rd, Oh MK. High prevalence of
asymptomatic STDs in incarcerated minority male youth: a case for screening.
Sex Transm Dis 2000;27:175 –77
57 Risser JM, Risser WL, Gefter LR, et al. Implementation of a screening program
for chlamydial infection in incarcerated adolescents. Sex Transm Dis
2001;28:43– 46
Downloaded from std.sagepub.com at MCMASTER UNIV LIBRARY on April 7, 2015
58 Robertson AA, Thomas CB, St Lawrence JS, Pack R. Predictors of infection
with Chlamydia or gonorrhea in incarcerated adolescents. Sex Transm Dis
2005;32:115– 22
59 Silberstein GS, Coles FB, Greenberg A, et al. Effectiveness and cost-benefit of
enhancements to a syphilis screening and treatment program at a county jail.
Sex Transm Dis 2000;27:508 –17
60 Singh S, Prasad R, Mohanty A. High prevalence of sexually transmitted and
blood-borne infections amongst the inmates of a district jail in Northern India.
Int J STD AIDS 1999;10:475 –78
61 Solomon L, Flynn C, Muck K, Vertefeuille J. Prevalence of HIV, syphilis,
hepatitis B, and hepatitis C among entrants to Maryland correctional facilities.
J Urban Health 2004;81:25 – 37
62 Spaulding AC, Clarke JG, Jongco AM, Flanigan TP. Small reservoirs: jail
screening for gonorrhea and Chlamydia in low prevalence areas. J Correct
Health Care 2009;15:28 –34
63 Trick WE, Kee R, Murphy-Swallow D, et al. Detection of chlamydial and
gonococcal urethral infection during jail intake: development of a screening
algorithm. Sex Transm Dis 2006;33:599 –603
64 Vaz RG, Gloyd S, Folgosa E, Kreiss J. Syphilis and HIV infection among
prisoners in Maputo, Mozambique. Int J STD AIDS 1995;6:42 –46
65 Verneuil L, Vidal JS, Ze Bekolo R, et al. Prevalence and risk factors of the
whole spectrum of sexually transmitted diseases in male incoming prisoners
in France. Eur J Clin Microbiol Infect Dis 2009;28:409– 13
66 Watkins RE, Mak DB, Connelly C. Testing for sexually transmitted infections
and blood borne viruses on admission to Western Australian prisons. BMC
Public Health 2009;9:385
67 Willers DM, Peipert JF, Allswoth JE, et al. Prevalence and predictors of
sexually transmitted infection among newly incarcerated females. Sex Transm
Dis 2008;35:68 –72
68 Wood VD, Shoroye A. Sexually transmitted disease among adolescents in the
juvenile justice system of the District of Columbia. J Natl Med Assoc
1993;85:435– 39
69 Datta SD, Sternberg M, Johnson RE, et al. Gonorrhea and chlamydia in the
United States among persons 14 to 39 years of age, 1999 to 2002. Ann Intern
Med 2007;147:89 –96
70 Gottlieb SL, Pope V, Sternberg MR, et al. Prevalence of syphilis seroreactivity
in the United States: data from the National Health and Nutrition Examination
Surveys (NHANES) 2001– 2004. Sex Transm Dis 2008;35:507 –11
71 Goulet V, de Barbeyrac B, Raherison S, et al. Prevalence of Chlamydia
trachomatis: results from the first national population-based survey in France.
Sex Transm Infect 2010;86:263 –70
72 Fenton KA, Korovessis C, Johnson AM, et al. Sexual behaviour in Britain:
reported sexually transmitted infections and prevalent genital Chlamydia
trachomatis infection. Lancet 2001;358:1851 –54
73 Klavs I, Rodrigues LC, Wellings K, et al. Prevalence of genital Chlamydia
trachomatis infection in the general population of Slovenia: serious gaps in
control. Sex Transm Infect 2004;80:121 –23
74 Parish WL, Laumann EO, Cohen MS, et al. Population-based study of
chlamydial infection in China: a hidden epidemic. JAMA 2003;289:1265 –73
(Accepted 17 October 2011)