STD Services in Detention in Los Angeles CountyMelina R. Boudov, MA

Project Director

LA County Infertility Prevention Project

mboudov@ladhs.org

Detention: excellent opportunity for STD Control and Prevention

High risk population – “core transmitters” “Screening” vs. “testing” Always some form of medical intake Technological advances

Non-invasive and minimally invasive tests (urine and blood)

Rapid TAT Single dose treatment

“Captive” population for follow-up and Rx

Detention: challenges for STD Control and Prevention “Total” institution

Dynamic competing priorities confidentiality

Staff Security training

Clients Complex issues Follow-up

Juvenile Detention:

CDC recommendsCT and GC screening for all females in

juvenile detention Targeted CT screening for high risk

women in non-traditional settings Need to maximize use of limited

resources – evidence-based programs

Challenges in STD Care in Juvenile Detention Confidentiality Staff

ProbationHealth

ClientsComplex needs –adolescence, high riskHighly transient

STD Screening at LAC Juvenile Hall: Background LAC screening females in Juvenile Hall

since 1996 as part of CDC’s STD Jail Prevalence Monitoring Project

Males and females tested at medical intake

Consistently high rates of CT and GC

STD Screening at LAC Juvenile Hall: Background Excellent treatment rates Enhanced follow-up for females testing

positive through Project YES!STD case managementPartner servicesIntensive individualized health educationReferralNationally recognized model

Setting: LAC Juvenile Hall

Approximately 23,000 youth per year incarcerated

~20% female Three facilities – Central, Los Padrinos

and Barry J. Nidorf Juvenile Halls

Setting: Delivery of Care

LAC Juvenile Court Health Services provides all medical care at LAC Juvenile Halls

LAC Department of Probation LAC STD Program and LACIPP

Chlamydia Testing and Prevalence at LAC Juvenile Halls by Gender, 2003

17,551

817

4,232

583

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

Males Females

Total # testedTotal # positive

(4.7%) (13.8%)

#

JH CT PREVALENCE AMONG MALES, BY RACE/ETHNICITY, 2003n=817

7.9%

3.0%1.8%

3.7%3.8%

0.0%

5.0%

10.0%

15.0%

20.0%

AfricanAmerican

White Asian/PI Hispanic Unk/Other

JH CT PREVALENCE AMONG FEMALES, BY RACE/ETHNICITY, 2003n=583

17.1%

11.1%9.9%

12.7%13.1%

0.0%

5.0%

10.0%

15.0%

20.0%

AfricanAmerican

White Asian/PI Hispanic Unk/Other

CHLAMYDIA PREVALENCE AMONG PREGNANT JH CLIENTS, 2003

140

0

20

40

60

80

100

120

140

NUMBER OFPREGNANTCLIENTSNUMBER POSITIVEFOR CHLAMYDIA

35 (28.6%)

Number of clients

Chlamydia Prevalence by Age Among Females, LAC Juvenile Hall, 2003 number screened=4,232 number cases=583

0% 0%

5%

12% 13%15% 16%

13% 14%

0%

5%

10%

15%

20%

25%

30%

11 12 13 14 15 16 17 18 19

Age

(2)1 (24) (133) (420)

*

* Percent positive1 Total number screened

(810) (1,060) (1,077) (636) (57)

Adult Detention:LAC Twin Towers Jail Background

1999 prevalence study indicated high CT rates among new female bookings

Data informed screening guidelines More than 6,000 screened annually

Screening Guidelines: Twin Towers

All new bookings age 30 and younger

And women over 30 if: Pregnant Arrested for prostitution or sex-related

charge

Screening Results: Twin Towers, 2003

6,241 new female admittees were tested for CT and GC

CT prevalence of 14%, GC prevalence of 4%

Of the 874 women with CT, 108 (12.4%) also had GC

Of the 247 women with GC, 108 (43.7%) also had CT

Chlamydia Prevalence Among Women Screened at Twin Towers by Race/Ethnicity, 2003, n=874

HISPANIC37.0%

AI/AN0.8%

UNK/OTHR 5.8%

WHITE22.9%

ASIAN2.1%

BLACK35.7%

293360

17729

188

Chlamydia Prevalence by Age Among Female Inmates at Twin Towers, 2003

number screened=6,241 number cases=874

19%

6%4%5%

7%

13%

16%

23%

0%

5%

10%

15%

20%

25%

18-19 20-24 25-29 30-34 35-39 40-44 45-49 50+

Age

(692) (2,387) (2,126) (448) (254) (180) (90) (53)

Chlamydia Prevalence By Age Among Female Inmates at Twin Towers, 2003 number screened=5,523 number cases=829

6%

12%11%13%13%

16%14%14%

18%16%16%

23%23%

0%

5%

10%

15%

20%

25%

30%

18 19 20 21 22 23 24 25 26 27 28 29 30(324) (366) (502) (469) (458) (513) (439) (462) (431) (429) (407) (398) (325)(462)

Age

Juvenile Hall and Twin Towers Chlamydia Prevalence, 2003

22.8%

15.0%13.8%

0%

5%

10%

15%

20%

25%

Juvenile Hall, 11-19(n=4,232)

Twin Towers, 18-30yrs old (n=5,523)

Twin Towers, 18-19yrs old (n=690)

CHLAMYDIA PREVALENCE AMONG PREGNANT TWIN TOWERS CLIENTS, 2003

392

0

50

100

150

200

250

300

350

400

NUMBER OFPREGNANTCLIENTSNUMBER POSITIVEFOR CHLAMYDIA

42 (10.7%)

Number of clients

CHLAMYDIA PREVALENCE AMONG POSSIBLY PREGNANT TWIN TOWERS CLIENTS, 2003

242

0

50

100

150

200

250

NUMBER OFPOSSIBLYPREGNANTCLIENTSNUMBER POSITIVEFOR CHLAMYDIA

27 (11.2%)

Number of clients

Gonorrhea Screening at LAC Twin Towers and LAC Juvenile Hall, 2003

Females screened at intake to Juvenile Hall

Until the last quarter of 2002, all CT positives from Twin Towers were reflexively tested for GC

In 2003, all new female bookings were screened for both CT and GC (adopted GenProbe Aptima2)

Gonorrhea Prevalence by Age Among Females, LAC Juvenile Hall, 2003 number screened=4,175 number cases=154

0% 0%

4% 3% 3% 4% 4% 3%

7%

0%

5%

10%

15%

20%

25%

30%

11 12 13 14 15 16 17 18 19

(2) (24) (132) (411) (802) (1,041) (1,060) (634) (55)

Gonorrhea Prevalence by Age Among Females, LAC Twin Towers Jail, 2003 number screened=5,523 number cases=222

1%

4%4%3%3%4%4%3%

6%4%6%

4%6%

0%

5%

10%

15%

20%

25%

30%

18 19 20 21 22 23 24 25 26 27 28 29 30(324) (366) (502) (469) (458) (513) (439) (462) (431) (429) (407) (398) (325)

Adult Detention:LAC Twin Towers Jail: Challenges

Time, space Clients – off streets, no privacy, multiple needs Short detention time

Treatment and follow-up Field therapy project

Adult Detention:LAC Twin Towers Jail: Field Therapy

More than half of CT+ clients released untreated One field worker for Rx and partner services In 2005, additional 7% of the clients received Rx Of those located, 85% received field Rx

Adult Detention:LAC Men’s Central Jail Background

2000 Syphilis outbreak led to partnership with LAC Sheriff's Dept for active STD surveillance

Voluntary screening (until late 2005)Self-identified MSM inmates in K-11 unitTrustees (General Population inmates)

About 1,200 screened annually

Demographics – 2003

{

{

{

Inmate Type

Age

Race

General Population

HispanicAfrican-American

White

MSM

18-1920-2930-39

50+40-49

OtherUnknown

n = 1,101

Overview - 2003

1,101 Inmates Screened

864 CT/GC 844 Syphilis 956 HIV

CT Positivity = 4.7%(n = 41)

GC Positivity = 2.4%(n = 21)

Early Syphilis = 1.2%(n = 10)

HIV Prevalence = 7.2%(n = 69)

Overall MSM GP

STD/HIV Morbidity by Inmate Type - 2003

9.4%

6.2%

4%3.1% 2.9%

0%

2.8%1.5% 1%

0%

14.3%

11.2%

7.6%6.7%

5.6%

0

5

10

15

20

18-19 20-29 30-39 40-49 50+

Age

Chl

amyd

ia P

erce

nt P

ositi

ve

Total MSM GP

Chlamydia by Age - 2003

Total positive = 41 (prevalence = 4.7%); MSM = 9 (prevalence = 1.8%); GP = 32 (prevalence = 8.9%)

4.5%

6.8%

2.9%

6.3%

1.01%1.9% 1.9%

5.3%

10.4%11.3%

4.8%

7.3%

0

5

10

15

20

African American Hispanic White Unknown

Race

Chl

amyd

ia P

erce

nt P

ositi

ve

Total MSM GP

Chlamydia by Race/Ethnicity - 2003

Total positive = 41 (prevalence = 4.7%); MSM = 9 (prevalence = 1.8%); GP = 32 (prevalence = 8.9%)

0%

2.6%3%

1.2%

0%0%

2.8%3%

2%

0%0%

2.4%

3.4%

0% 0%0

1

2

3

4

5

18-19 20-29 30-39 40-49 50+

Age

Gon

orrh

ea P

erce

nt P

ositiv

eTotal MSM GP

Gonorrhea by Age - 2003

Total positive = 21 (prevalence = 2.4%); MSM = 13 (prevalence = 2.6%); GP = 8 (prevalence = 2.2%)

2.2%

3.2%

2.1% 2.5%

1.5%

4.8%

3.2%

0%

3.5%

1.7%

0%

4.9%

0

2

4

6

8

10

AfricanAmerican

Hispanic White Unknown

Race

Gon

orrh

ea P

erce

nt P

ositiv

e Total MSM GP

Gonorrhea by Race/Ethnicity - 2003

Total positive = 21 (prevalence = 2.4%); MSM = 13 (prevalence = 2.6%); GP = 8 (prevalence = 2.2%)

0%

2%

0.9%0.6%

0%0%

3.4%

1.1% 1%

0%0% 0%

0.7%

0% 0%0

1

2

3

4

5

18-19 20-29 30-39 40-49 50+

Age

Per

cent

Ear

ly S

yphi

lis

Total MSM GP

Early Syphilis by Age - 2003

Total Early Syphilis = 10 (prevalence = 1.2%); MSM = 9 (prevalence = 1.9%); GP = 1 (prevalence = 0.3%)

1.7% 1.4%

0.4%

1.4%

2.8% 3%

0%

2.8%

0% 0%

1.1%

0%0

2

4

6

8

10

AfricanAmerican

Hispanic White Unknown

Race

Per

cent

Ear

ly S

yphi

lisTotal MSM GP

Early Syphilis by Race/Ethnicity - 2003

Total Early Syphilis = 10 (prevalence = 1.2%); MSM = 9 (prevalence = 1.9%); GP = 1 (prevalence = 0.3%)

0%

7.3% 8.2% 6.9% 5.6%

0%

12.4% 12.8%10.8%

14.3%

0% 0% 1.3% 1.4% 0%0

10

20

30

40

50

18-19 20-29 30-39 40-49 50+

Age

HIV

Per

cent

Pos

itiv

e

Total MSM GP

HIV by Age – 2003

Total positive = 69 (seroprevalence = 7.2%); MSM = 66 (seroprevalence = 12.1%) ; GP = 3 (seroprevalence = 0.7%)

Based on HIV counseling session 7 newly identified cases; CI = 0.8 per 100 in 2003

8.6%6.1% 4.4%

2.1%

16.3%14%

6.1%

18.4%

1.6% 0.8% 0% 0%0

10

20

30

40

50

AfricanAmerican

Hispanic White Unknown

Race

HIV

Per

cent

Pos

itiv

eTotal MSM GP

HIV by Race/Ethnicity - 2003

Total positive = 69 (seroprevalence = 7.2%); MSM = 66 (seroprevalence = 12.1%) ; GP = 3 (seroprevalence = 0.7%)

Based on HIV counseling session 7 newly identified cases; CI = 0.8 per 100 in 2003

Adult Detention:LAC Men’s Central Jail: Challenges

Rise in Syphilis rates led to sexual network study Revealed a lot of sex (and infection) within K-11

Illegal AND public health risk Policy change re:condom access and Compulsory universal Syphilis screening Confidentiality and public health