Strengthening Prevention and Treatment of HIV,Viral Hepatitis,Sexually Transmitted Infections,and Tuberculosis Among Women Who Are Justice System-Involved: CDC Recommendations and Resources

Abstract

Women who are currently or formerly incarcerated experience disproportionately high rates of certain infections and diseases, including HIV, viral hepatitis, sexually transmitted infections (STIs), and tuberculosis (TB). These disparities are shaped by overlapping social and structural conditions such as substance use, trauma, poverty, and limited access to health care. Incarceration can be a critical point of intervention to provide health care access for women who otherwise might not be able to prioritize their own health. However, the effectiveness of these efforts is often limited by variable lengths of incarceration, stigma, limited resources, and fragmented systems of care. This report outlines opportunities to strengthen prevention, treatment, and linkage to care for HIV, viral hepatitis, STIs, and TB among women who are justice system-involved. Specifically, by summarizing recommendations from the U.S. Centers for Disease Control and Prevention (CDC), including those found in the Summary of CDC Recommendations for Correctional Settings, this report seeks to support care around screening, vaccination, and treatment for women at three key stages: intake, during incarceration, and at release. Guidance is also provided for incarcerated women during and after pregnancy, including recommendations for infection screening and unique aspects of chronic care management. Additional strategies are reviewed, including point-of-care testing, to support health engagement and health care continuity, peer mentorship, and coordinated reentry planning. CDC resources are highlighted throughout the report to assist correctional health staff, clinicians, and public health departments in improving outcomes for this population.

Keywords

justice system incarceration HIV hepatitis STI TB

Introduction

At the end of 2022, nearly one million adult women were under U.S. correctional supervision, with rates rising disproportionately compared with men, since 2012.¹ Women who are justice-involved are more likely to experience increased risk for human immunodeficiency virus (HIV), viral hepatitis (hepatitis B and hepatitis C), syphilis, chlamydia, gonorrhea, trichomoniasis, and tuberculosis (TB).^2–7 During 2011–2012, approximately one-quarter of women incarcerated in prisons and one-fifth in jails report ever being diagnosed with viral hepatitis, sexually transmitted infection (STI), or TB.⁶ In 2023, 18.6% of women with primary and secondary syphilis reported recent incarceration,⁸ and in 2023, the prevalence of HIV among incarcerated women was 2.5 times higher than in the general population.^2,9

Women who are pregnant and incarcerated are especially vulnerable to poor health outcomes. An estimated 3% of women entering jails and 4% entering prisons are pregnant.^10,11 Infections can have serious reproductive and pregnancy-related consequences, including long-term sequelae such as pelvic inflammatory disease and ectopic pregnancy that may affect future fertility, as well as adverse pregnancy outcomes including fetal loss, preterm birth, congenital anomalies, and low birth weight.¹² Amid the opioid epidemic, hepatitis C has risen sharply, with 20.2% of pregnant incarcerated women reported to have hepatitis C in 2016–2017.^13,14 Both hepatitis C and syphilis can be vertically transmitted and are associated with serious infant outcomes.¹² From 2018 to 2021, 8.5% of women with syphilis during pregnancy had a history of incarceration.¹⁵ Many women face barriers to consistent prenatal care, health management, and prevention services before, during and after incarceration.¹⁶

Co-occurring substance use disorders, mental health conditions, and histories of trauma are prevalent among incarcerated women, creating a syndemic that amplifies vulnerability and worsens health outcomes.^17–20 About half of incarcerated persons experience both mental health and substance use disorders,²¹ with women in jails more likely than men to report serious mental health disorders.²² Infections often co-occur with these conditions as they share intersecting risk factors. For example, congenital syphilis risk increases among women with co-occurring substance use during pregnancy and a history of homelessness.¹⁵ Racial and ethnic differences in female incarceration rates are associated with further health inequities. In 2022, non-Hispanic Black and Hispanic women were incarcerated at 1.6 and 1.3 times the rate of non-Hispanic white women, respectively.²³ A California study found increased odds of severe maternal morbidity among Black and Hispanic women residing in counties where residents who are Black are disproportionately incarcerated compared with residents who are white.²⁴

Clear and comprehensive screening, prevention, and treatment strategies for HIV, viral hepatitis, STIs, and TB are needed in correctional settings.²³ To support this, the U.S. Centers for Disease Control and Prevention (CDC) developed the Summary of CDC Recommendations for Correctional Settings in 2024, which consolidates existing evidence-based guidance on these topics, including guidance for women who are pregnant.²⁵ While many of the CDC’s recommendations are applicable to both men and women, this article focuses specifically on guidance and resources for women, given their unique health needs and disproportionate risks in correctional settings. This report highlights the burden of infections among justice-involved women and provides resources to help correctional health professionals and public health practitioners implement strategies that improve women’s health outcomes during and after incarceration.

Recommendations at Intake for Nonpregnant Women

General intake screening and vaccination

Screening and vaccination for infections at intake are critical for protecting the health of both correctional staff and residents, especially given the limited access to health care many residents face prior to custody.²⁷ Early detection enables timely treatment, reduces transmission, supports public health coordination, and facilitates appropriate care during and after incarceration.^13,28 Screening (see Callout Box 1, which outlines recommendations for nonpregnant women at intake) and vaccination for infections should be integrated into the intake clinic workflow and linked to accessible care to ensure timely treatment.

Callout Box 1- CDC Recommended Actions for Screening of Non-Pregnant Women upon Intake to a Correctional or Detention Facility

CDC recommends the following screening^a for nonpregnant women upon intake to a correctional or detention facility:

Human Immunodeficiency Virus (HIV) infection: All women based on institutional prevalence of undiagnosed HIV infection^b

Hepatitis B Virus (HBV) infection^c: All women

Hepatitis C Virus (HCV) infection^d: All women

Tuberculosis:

•

All women should be immediately screened for symptoms of pulmonary TB.^e

•

In facilities with nonminimal TB risk^f, all women should be further screened with a tuberculin skin test (TST), an interferon gamma release assay (IGRA), or a chest radiograph within 7 days of arrival.

•

In facilities with minimal TB risk^f, women who have one or more clinical condition or other factor that increases their likelihood of infection or of progressing to TB disease should be further screened with a TST, an IGRA, or a chest radiograph within 7 days of arrival.

Chlamydia and Gonorrhea: Women ≤35 years

Syphilis: All women based on local area and institutional prevalence^g

Trichomonas: Women aged ≤35 years

^aOpt-out screening is recommended for HIV, HBV infection, HCV infection, and STIs. Opt-out screening is when the patient is notified that testing will be performed unless the patient declines.

^bFacilities should initiate screening unless prevalence of undiagnosed HIV infection in their facility population has been documented to be <0.1%. In the absence of existing data for HIV prevalence, facilities should initiate voluntary HIV screening. Such screening is no longer warranted in facilities able to establish that the diagnostic yield is <1 per 1,000 persons screened.

^cTest for hepatitis B surface antigen (HBsAg), antibody to hepatitis B surface antigen (anti-HBs), and total antibody to hepatitis B core antigen (anti-HBc). For a chart outlining interpretations and recommended actions based on HBV serology findings, see Hepatitis B Vaccination, Screening, and Linkage to Care: Best Practice Advice from the American College of Physicians and the Centers for Disease Control and Prevention.

^dTest for antibody to hepatitis C virus (anti-HCV) followed by automatic reflex to HCV RNA if positive.

^ePersons should be screened for symptoms of pulmonary TB by being asked if they have had a prolonged cough (i.e., >3 weeks), hemoptysis (i.e., bloody sputum), or chest pain.

^fA facility has minimal TB risk if (a) no cases of infectious TB have occurred in the facility in the last year, (b) the facility does not house substantial numbers of persons with risk factors for TB (e.g., HIV infection, injection drug use), (c) the facility does not house substantial numbers of persons who have arrived in the U.S. within the previous 5 years from areas of the world with high rates of TB, or (d) employees in the facility are not otherwise at risk for TB. All other facilities should be categorized as a nonminimal TB risk facility.

^gThere is no CDC-recommended syphilis prevalence threshold for facilities to use as a basis for initiating screening. The current Healthy People 2030 goal is to reduce the rate of primary and secondary syphilis cases among females aged 15–44 years to 4.6 per 100,000 population, and facilities could consider using this rate as a threshold for initiating (or stopping) their syphilis screening program.²⁶ In 2023, 1,415 counties and county equivalents (45.1% of counties and county equivalents with available data) had a rate of primary and secondary syphilis among 15–44 year old women greater than 4.6 per 100,000.²⁶ During the same year, 76.6% of the U.S. population resided in these counties and county equivalents.⁸ Correctional facilities should stay apprised of syphilis prevalence as it changes over time, see https://www.cdc.gov/std/treatment-guidelines/correctional.htm.

CDC recommends opt-out HIV screening for all persons at intake,²⁹ meaning testing is performed unless declined. Women aged 35 years or younger should also receive opt-out screening for chlamydia, gonorrhea, and trichomoniasis.^29,30 Opt-out syphilis screening should be offered to women, guided by local area and institutional prevalence.^29,30 Jurisdictions can consider using the Healthy People 2030 goal of 4.6 primary and secondary syphilis cases per 100,000 population of females aged 15–44 years as the local prevalence threshold to initiate a screening program.²⁶ Screening for hepatitis B virus (HBV) infection and hepatitis C virus (HCV) infection should be conducted at intake.³¹ The hepatitis B vaccine series should also be initiated for all juveniles and adults without written documentation of previous completion of a hepatitis B vaccine series.^29,32 General guidance for hepatitis B vaccine series can be found at Hepatitis B Vaccine Administration.³³ All persons with signs or symptoms of TB disease or positive results of TB testing should be medically evaluated for TB disease. A complete medical evaluation for TB disease has five components: (1) medical history, (2) physical examination, (3) test for TB infection (TB blood test or TB skin test),³⁴ (4) chest radiograph, and (5) bacteriologic examination (sputum smear microscopy, nucleic acid amplification testing, culture, and drug susceptibility testing). A diagnosis of latent TB infection is made if a person has a positive TB blood test or TB skin test result, and a medical evaluation does not indicate TB disease.

Given the rapid turnover, shorter stays, limited health care services and staffing at jails, it could be difficult to complete standard laboratory-based testing or provide follow-up for these infections before people leave custody.¹⁷ Prisons, which typically have longer stays, allow for more structured screening and treatment but still face challenges such as resource limitations, staffing shortages, and costs.¹⁷ In both prisons and jails, data on recent patient testing are not always available to facility staff, the patients themselves, or staff at other facilities to which patients may be transferred after testing. One promising approach to help address these challenges is the use of point-of-care tests (POCTs).

Point-of-care tests

POCTs are efficient in correctional settings because they use fingerstick blood, oral fluid, urine, or vaginal swab testing, without the need for phlebotomy or sending samples to external laboratories. By offering rapid results (e.g., <20 minutes), POCTs allow for treatment during the same encounter as testing. Types of POCTs and their respective diseases are described in detail in Table 1.

Table 1.

Point-of-Care Tests for HIV, Hepatitis B and Hepatitis C, Sexually Transmitted Infections, and Tuberculosis

Diseases	Point-of-care test (POCT)	Considerations
HIV	CDC recommends that all people with reactive HIV POCTs have their results confirmed with a laboratory-based antigen/antibody (Ag/Ab) assay.^29,35 Most HIV POCTs are antibody tests. An FDA-approved Ag/Ab POCT is available.	Ag/Ab POCTs improve the detection of early HIV infection relative to other POCTs, which look for antibodies to HIV in the blood or oral fluids. Antibody tests that use venous blood can detect HIV sooner than tests done with blood from a finger stick or with oral fluid. Laboratory-based Ag/Ab tests offer greater sensitivity for detecting early-stage infections compared with POCTs.
Hepatitis B virus (HBV)	As of August 2025, there is no FDA-approved HBV POCT, although there is an HBV POCT in development.³⁶	Triple panel screening for HBV is recommended at least once in a lifetime for all adults and includes hepatitis B surface antigen (HBsAg), antibody to hepatitis B surface antigen (anti-HBs), and total antibody to hepatitis B core antigen(anti-HBc).
Hepatitis C virus (HCV)	The currently available POCT for HCV infection includes one and two-step diagnostic algorithms and should be considered in jails with sufficient testing capacity (often large jails) based on encounter type, client volume, and hepatitis C prevalence.³⁷ The one-step diagnostic algorithm is a viral first testing strategy using HCV RNA POCT and³⁷ the two-step diagnostic algorithm includes HCV antibody POCT and, if positive, HCV RNA POCT.³⁷ For further information, CDC Considerations for the Implementation of Point-of-Care Testing for the Diagnosis of Hepatitis C Virus Infection can provide additional guidance.³⁷	People with a reactive HCV antibody test should have the sample reflexed for HCV RNA testing to confirm current infection during a single visit.³⁸ A positive antibody test result indicates prior exposure to HCV and either current infection or past infection that resolved through spontaneous clearance or successful treatment.³⁸
Chlamydia and Gonorrhea	The POCT for chlamydia and gonorrhea involves testing urine, self-collected vaginal swabs, or clinician-collected endocervical, pharyngeal, or rectal swabs using FDA-cleared nucleic acid amplification tests (NAATs).^29,39	A test of cure for chlamydia should occur four weeks after treatment completion for women who are pregnant. A test of cure for pharyngeal gonorrhea should occur 7–14 days after treatment. Reinfection testing should be performed 3 months after treatment for all people diagnosed with chlamydia and gonorrhea.²⁹
Syphilis	There are two types of syphilis tests: treponemal tests and nontreponemal tests. Both tests are needed to confirm a diagnosis of syphilis along with a medical history and physical exam.⁴⁰ Syphilis POCTs use whole blood, serum, or plasma from a fingerstick. There are two currently available syphilis POCTs in the United States: the Syphilis Health Check Treponemal Antibody Test and the ChemBio DPP HIV-Syphilis, both of which are treponemal-only tests.^40,41 Treponemal tests remain positive for life in a majority of people despite treatment; as such, they should not be used in people with previously treated syphilis.^40,41 For people without previous syphilis treatment, a positive syphilis POCT can be followed by immediate presumptive treatment while awaiting confirmation with nontreponemal serologic testing.^40,41 For further information, the Considerations for the Implementation of Point of Care (POC) Test for Syphilis can provide additional guidance.⁴¹	After treatment for syphilis, follow-up testing should be performed per CDC guidelines.²⁹
Trichomoniasis	NAATs are the preferred testing modality for T. vaginalis. However, an antigen-based POCT, OSOM Trichomonas rapid test (OSOM Trich), is available for T. vaginalis. The Osom rapid test provides results in 10–15 minutes from clinician-collected vaginal specimens, with sensitivity of 82–95% and specificity of 97–100%. Studies have shown that self-collected vaginal specimens using the OSOM Trich yield >99% correct performance and interpretation, with 96% agreement compared with clinician interpretation.²⁹	The OSOM Trich should not be used with men because of low sensitivity.²⁹ Reinfection testing should be performed 3 months after treatment for all people diagnosed with trichomoniasis.^29,42
Tuberculosis (TB)	Although standard cultures to confirm TB disease can take 2–6 weeks to grow Mycobacterium tuberculosis complex (MTB), the Xpert MTB/RIF (Rifampin) assay can detect MTB and resistance to rifampin in less than 2 hours. The Xpert MTB/RIF assay can quickly identify possible multidrug-resistant TB (MDR TB). As with other NAA tests, the Xpert MTB/RIF assay should be interpreted along with clinical, radiographic, and other laboratory findings.	Regardless of the Xpert MTB/RIF result, patient specimens should also have mycobacterial culture to ensure isolates are available for drug susceptibility testing and genotyping.

Several factors might complicate the ready adoption of POCTs in corrections. Specifically, facilities might have procurement mechanisms that do not include POCTs, they might be costly, and the process for obtaining a Clinical Laboratory Improvement Amendments certificate of waiver and maintaining this status can be cumbersome. Additionally, staff turnover can make it difficult to ensure consistent training test protocols and posttest counseling.^37,41,43 Collaboration with the local health departments (LHD) could support procurement and training and also help ensure mandatory reporting of infections, even when tests are not sent to a laboratory.⁴⁴ Furthermore, each POCT has unique considerations that could affect implementation in any given correctional facility (Table 1).

Screening implementation considerations

To ensure effective intake screening, correctional facilities can tailor protocols to their population and setting. Jails may prioritize POCT strategies with immediate on-site treatment or linkage to highly accessible community clinicians, including partnerships with health departments for postrelease follow-up, while prisons can incorporate more comprehensive screening and treatment initiation within their facilities. Common implementation challenges include the costs of tests and medications, procurement limitations, along with limited staffing. Despite these challenges, robust intake screening improves health outcomes, reduces transmission, and strengthens public health protections across correctional systems and in community settings.

When screening for STIs among women who are justice-involved, the method of specimen collection (vaginal, cervical, or urine) should be carefully considered. Urine-based testing may be preferred by some due to a history of trauma and repeated exposure to invasive procedures such as cavity searches.^45–47 Whenever possible, women should be offered a choice between vaginal, cervical, and urine-based screening methods.⁴⁵ The use of self-collected vaginal swabs should also be encouraged, as research supports their reliability, and they may improve comfort, privacy, and screening uptake.^46,47

Recommendations during Incarceration for Nonpregnant Women

While intake screening is already standard practice in many correctional facilities, follow-up testing during incarceration is equally important. Women who initially test negative for an infection may later test positive (i.e., seroconvert) or be exposed during their custody stay. Infection is associated with some behaviors, such as injection drug use, unregulated tattooing, and sexual activity, and these behaviors can occur within correctional settings and increase vulnerability to a new infection or reinfection.⁴⁸ For example, sexual exposure to infections can result from sexual assault by another person who is incarcerated or by staff, or from consensual sex.⁴⁹ These examples are not exhaustive and do not encompass other prohibited behaviors (e.g., substance use) that may also increase infection risk. Given these realities, it is important to integrate trauma-informed (i.e., approaches that recognize the widespread impact of trauma, identify signs and symptoms of trauma, and integrate this knowledge into practice), confidential, and nonpunitive approaches into testing, diagnosis, and treatment.^50,51 Retesting policies should reflect these ongoing risks to support timely diagnosis and care. Forensic evidence collection and management of pregnancy or physical and psychological trauma are beyond the scope of these guidelines. For guidance on hepatitis A and B vaccination and treatment for HIV, hepatitis B, and hepatitis C, syphilis, chlamydia, gonorrhea, trichomoniasis, and TB for nonpregnant women, see Callout Box 2.

Callout Box 2. CDC Recommended Actions for Nonpregnant Women during Incarceration or Detention for Vaccination and Treatment

CDC recommends vaccinating nonpregnant women during incarceration or detention for:

Hepatitis A virus (HAV) infection:

•

Begin/complete hepatitis A vaccine series for^a,h: o

All juveniles

All adults at risk for HAV infection (e.g., MSM, PWID)^b

All adults at risk for severe adverse outcomes of HAV infection^c

•

Consider vaccinating all people during a community HAV outbreak propagated by person-to-person transmission^d

•

As postexposure prophylaxisⁱ

HBV infection:

•

Begin/complete hepatitis B vaccine series for all juveniles and adults^e,h

•

As postexposure prophylaxis^j

CDC recommends treating nonpregnant women with diagnosed infections during incarceration or detention using the following guidelines:

HIV infection: HHS Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV

HBV infection^f: Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance

HCV infection^f: Recommendations for Testing, Managing, and Treating Hepatitis C

Tuberculosis:^g Treatment for Tuberculosis Disease (CDC website)

Latent Tuberculosis Infection: Guidelines for the Treatment of Latent Tuberculosis Infection: Recommendations from NTCA and CDC, 2020 (short-course, rifamycin-based regimens are preferred)

Syphilis/Gonorrhea/Chlamydia/Trichomonas: CDC 2021 STI Treatment Guidelines

^aUnless documentation is available showing completion of the vaccine series.

^bFor a full list of risk factors for HAV infection, see full HAV guidance document https://www.cdc.gov/mmwr/volumes/69/rr/rr6905a1.htm.

^cPeople at risk for severe outcomes from hepatitis A include those with chronic liver disease or HIV infection.

^dPre-exposure vaccination in populations at risk for hepatitis A is an effective outbreak control strategy. Because correctional facilities house people who are at increased risk (e.g., people experiencing homelessness and persons who use drugs), vaccination in correctional settings can help to control community outbreaks of hepatitis A. Vaccination can also help control transmission inside facilities.

^eUnless documentation is available showing completion of the vaccine series, or there is serologic evidence of immunity or infection, see https://cdc.gov/hepatitis-b/hcp/diagnosis-testing.

^fAll people diagnosed with chronic HBV or HCV infection should be evaluated to determine the presence and extent of liver disease and candidacy for antiviral therapy. Recommendations for Testing, Managing, and Treating Hepatitis C | HCV Guidance

^gPeople who have pulmonary TB symptoms or an abnormal chest radiograph should be evaluated to rule out TB disease; if TB disease is excluded as a diagnosis, LTBI treatment should be considered if the TST or IGRA result is positive.

^hComplete vaccine series whereas in custody if the person has not been released prior to the minimum time required between doses.

ⁱSee Prevention of Hepatitis A Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices, 2020 for guidance on administering vaccine and/or immune globulin as postexposure prophylaxis for HAV infection.

^jSee Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices for guidance on testing and administering vaccine and/or immune globulin as postexposure prophylaxis for HBV infection. Recommendations depend upon vaccination status.

Evidence-based strategies to promote testing and treatment for women in carceral settings

A range of evidence-based strategies, described below, can improve health outcomes for women in correctional settings by enhancing access to testing, treatment, education, and supportive services. While not covered in detail in this article, additional strategies include risk-reduction counseling, preventative measures such as preexposure prophylaxis, Medicaid Section 1115 Waivers that cover certain prerelease services, and medication for opioid use disorder.

Peer support and mentorship

Peer mentorship programs can enhance engagement, trust, and health literacy among incarcerated women. Mentors with lived experience of incarceration and relevant health conditions can provide credible support, reduce stigma, and promote adherence to care.^52,53 In the New Mexico state prison system, Project ECHO and the Peer Education Program expanded HCV treatment, supplemented with virtual mentorship. From December 2020 to June 2023, 1,685 incarcerated persons initiated HCV treatment, with approximately 90% achieving sustained virologic response. Simplified protocols, expert tele-mentoring, and peer education led to the program’s success.⁵² Correctional health systems could adopt peer mentorship models, supported by training and tele-mentoring, to increase engagement, reduce stigma, and strengthen treatment outcomes.

Health education

Public health and health care professionals can receive training from the CDC-funded National Network of STD Clinical Prevention Training Centers (PTCs) to support health education programming. The PTCs provide a variety of training, resources, and tools to enhance skills and knowledge in various areas, including STD prevention and infection control.⁵⁴ Providing comprehensive information on sexual and reproductive health, including STI prevention, contraception, and pregnancy care, can empower women to make informed decisions. Integrating evidence-based health education programs, supported by national training resources, can strengthen prevention efforts and improve health literacy among incarcerated women.

Sexual and reproductive health

Incarcerated women experience gynecological conditions at higher rates than their nonincarcerated counterparts, including irregular menstrual bleeding and vaginal discharge.⁵⁵ Studies have found that up to 30% of incarcerated women report abnormal vaginal symptoms, with discharge being one of the most common complaints.^56,57 Among nonpregnant women, vaginal discharge is often perceived as abnormal and may be associated with heightened concern, particularly among those with a history of substance use disorder. While evaluation is warranted to rule out infections such as bacterial vaginosis, trichomoniasis, or STIs, clinicians should not dismiss these concerns simply because they are common and should approach them with sensitivity and trauma-informed care, particularly given the high prevalence of sexual trauma and medical neglect among incarcerated women.^57,58 Incarceration is also a critical time for general sexual and reproductive health education. It is important for clinicians to employ trauma-informed approaches and ensure comprehensive reproductive health services are available during incarceration.

Communicating results

A qualitative study highlighted that many incarcerated people do not receive their lab results, especially when results are normal.⁵⁹ While abnormal findings may be communicated, the absence of information about normal results creates uncertainty and contributes to mistrust.⁵⁹ Without access to patient portals, women are fully dependent on correctional health staff for updates. Facilities should ensure all women are informed of both normal and abnormal results, using trauma-informed approaches and clear, timely communication. Designating staff for result follow-up and partnering with health departments can help standardize this process and promote patient-centered care.

Partner services

Partner testing and treatment should be performed after a diagnosis of any STI. Expedited Partner Therapy (EPT), also referred to as Patient–Delivered Partner Therapy, allows for treatment of partners of women diagnosed with some STIs (e.g., chlamydia, gonorrhea, trichomoniasis) without a prior clinical visit. While EPT has been effective in community settings, its use in jails and prisons is limited because women in custody often cannot readily contact their sex partners or may be unwilling to disclose partner information because of fear of punishment. EPT is further underutilized in these settings due to provider discomfort, legal uncertainty, and lack of protocols.^61,62 Incarcerated women may instead rely on collaboration between correctional health staff, LHDs and disease intervention specialist (DIS), who can engage partners outside of the facility to ensure testing and treatment. Models of jails working with LHDs to facilitate DIS access have demonstrated feasibility (e.g., linkage of jail registries with syphilis monitoring data).⁶² Given the high STI burden in these settings, expanding partner services is a critical opportunity for improving care and reducing reinfection. Establishing clear protocols, providing clinician training, and strengthening partnerships with LHDs and local clinicians are needed for correctional facilities to expand partner services.

Recommendations for Perinatal Women

Routine pregnancy screening at intake is critical to ensure recommended prenatal care, but is often missed due to limited resources and competing priorities. Many jails do not conduct universal pregnancy screening, even though they may serve as the only point of health care access for some women.⁶³ Given that women may be in custody for only a short time, sometimes just a few weeks, failure to screen for pregnancy can result in missed diagnoses for conditions with serious maternal and fetal health implications. A 2022 study found that only 31% of jails reported routinely screening for pregnancy at intake, underscoring a significant gap in care and a lost public health opportunity.⁶³ In contrast, prisons are generally more consistent with intake screening and often follow a standardized checklist approach. Universal pregnancy screening should be implemented in a way that is informative and non-coercive, offering women the choice to opt-out with a clear explanation of its importance for health and safety during incarceration.⁶⁴

Callout Box 3 - CDC Recommended Actions for Screening, Vaccination, and Treatment of Pregnant Women

CDC recommends screening pregnant women during incarceration or detention:

HIV infection: Screen during each pregnancy and repeat testing may be warranted.

HBV infection: Screen during each pregnancy

HCV infection: Screen during each pregnancy

Syphilis: Screen during each pregnancy

•

at intake (consider intake as the first prenatal visit)

•

at 28 weeks

•

at delivery.

Chlamydia and Gonorrhea:

•

Screen all pregnant women <25 years of age.

•

Screen pregnant women ≥25 years of age who are at increased risk.^a

•

Retest during the 3rd trimester for women under 25 years of age or at increased risk.

CDC recommends vaccinating pregnant women during incarceration or detention:

HAV infection: Vaccinate pregnant women who are^b,c:

•

At risk for HAV infection^d

•

At risk for severe outcomes from HAV infection.^e

HBV infection: Vaccinate all juveniles and adults (including pregnant women).^c,f

CDC recommends treating pregnant women with diagnosed infections during incarceration or detention using the following guidelines:

HIV infection: For treatment recommendations, see HHS Recommendations for the Use of Antiretroviral Drugs During Pregnancy.

HBV infection: For treatment recommendations, see CDC Screening and Referral Algorithm for HBV Infection among Pregnant Women.

HCV infection: Direct-acting antiviral drugs for HCV infection are not approved for use during pregnancy; treatment should be considered after delivery.

Tuberculosis and Latent Tuberculosis Infection:

•

Begin treatment for Tuberculosis disease as soon as Tuberculosis is detected.^g

•

For most pregnant women, treatment for Latent Tuberculosis Infection can be delayed until 2–3 months postpartum to avoid administering unnecessary medication during pregnancy.

•

For women who are at high risk for progression from Latent Tuberculosis Infection to Tuberculosis disease, especially those who are a recent contact of someone with infectious Tuberculosis, treatment for Latent Tuberculosis Infection should not be delayed on the basis of pregnancy alone, even during the first trimester.

•

For treatment recommendations, see CDC Treatment for Tuberculosis Disease & Pregnancy.

Syphilis/Chlamydia/Gonorrhea: For treatment recommendations, see CDC Sexually Transmitted Infections Treatment Guidelines: Pregnant Women.

^aPregnant women at increased risk for chlamydia (e.g., those aged ≥25 years who have a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has an STI) and gonorrhea (e.g., those with other STIs during pregnancy or those with a new sex partner, more than one sex partner, a sex partner with concurrent partners, or a sex partner who has an STI or is exchanging sex for money or drugs) should be screened at first prenatal visit. All persons diagnosed with chlamydia or gonorrhea should be rescreened 3 months after treatment (e.g., new sexual partner, unprotected sex, STI history). See CDC’s Pregnancy Screening Recommendations and Screening for Chlamydia and Gonorrhea: U.S. Preventive Services Task Force Recommendation Statement | JAMA | JAMA Network for additional information.

^bUnless documentation is available showing completion of the vaccine series.

^cComplete vaccine series while in custody if the person has not been released prior to the minimum time required between doses.

^dFor a full list of risk factors for HAV infection, see full HAV guidance document https://www.cdc.gov/mmwr/volumes/69/rr/rr6905a1.htm.

^ePeople at risk for severe outcomes from hepatitis A infection include those with chronic liver disease or HIV infection.

^fUnless documentation is available showing completion of the vaccine series, or there is serologic evidence of immunity or infection, see https://cdc.gov/hepatitis-b/hcp/diagnosis-testing.

^gPregnant women who are being treated for drug-resistant TB should receive counseling about the risk to the fetus.

To ensure comprehensive infection testing for incarcerated women who are pregnant, facilities should prioritize completing recommended testing for HIV, HBV infection, HCV infection, syphilis, chlamydia, and gonorrhea. Women who are pregnant should also be tested for TB using established criteria. Additionally, repeat testing for HIV, syphilis, chlamydia, and gonorrhea should be performed as indicated during the early third trimester to identify any new or persistent infections.^29,30 Treatment should occur as soon as possible after diagnosis to minimize poor outcomes and loss to follow-up. All pregnant women should be tested during each pregnancy, regardless of vaccination status or testing history for HBV (preferably in the first trimester/first prenatal visit) and HCV.^13,28,65 However, pregnant individuals with a history of appropriately timed triple panel testing (i.e., screening during the current pregnancy, preferably at the first prenatal visit) and no subsequent risk for HBV exposure may only require HBsAg testing.⁶⁵ Those who test positive for hepatitis B surface antigen (HBsAg) should receive confirmatory testing per manufacturer’s guidelines, and HBV DNA testing to determine whether antiviral therapy is needed to prevent perinatal HBV transmission.^65–68 Hepatitis C treatment is not currently approved during pregnancy, but testing is important to ensure recommended prenatal care and to ensure that treatment is provided postpartum.^{13,52,69–71} For recommended screening, vaccination, and treatment during pregnancy for HIV, hepatitis B, hepatitis C, syphilis, chlamydia, gonorrhea, and TB, see Callout Box 3.

Given the current epidemics of syphilis and congenital syphilis, rapid diagnosis and treatment of syphilis should be prioritized for anyone who is pregnant or of reproductive age because congenital syphilis can result in stillbirth, neonatal death, and severe infant morbidity.⁷² Higher rates of congenital syphilis have been observed among populations with increased incarceration rates.⁷² The only option for treating women with syphilis during pregnancy is intramuscular benzathine penicillin G, which can be expensive and difficult to stock in jails and prisons.²⁹ It is important to establish a relationship with the LHD to facilitate timely, proactive solutions to the administration of benzathine penicillin G, especially during pregnancy. These might include keeping a supply of benzathine penicillin G from the health department on-site and maintaining records to facilitate decreased pricing through the health department. Another possibility is having regular check-ins with a health department staff member to facilitate on-site treatment either as needed or on a regular schedule (e.g., every Tuesday and Thursday). While one intramuscular injection is adequate for treating primary, secondary, and early latent syphilis, three injections at seven-day intervals are needed for treating latent syphilis and syphilis of unknown duration.²⁹ It is important that no more than nine days pass between injections or else the treatment course should be re-initiated— this can be challenging to arrange at discharge from jail or prison and requires an active hand-off to the new care provider.²⁹ If treatment is initiated prior to 24 weeks gestation, repeat testing should be performed at 28 weeks and at delivery; if it is 24 weeks gestation or later then repeat testing should only be performed at delivery.²⁹ Additional testing should be performed as indicated based on new signs or symptoms or a known exposure.²⁹

There is increased morbidity and mortality associated with TB during pregnancy, and women in the correctional system are at elevated risk for TB infection.⁷³ As such, it is critically important that women who are pregnant and exhibit signs or symptoms of TB, or who test positive for TB infection, receive a prompt and thorough medical evaluation for TB disease. If active TB disease is diagnosed, treatment should be initiated without delay. Most women who are pregnant can delay treatment for latent TB infection until two or three months postpartum or until after delivery to reduce the risk of liver toxicity, which is higher during pregnancy. However, treatment should not be delayed for women who are pregnant and at an increased risk of progressing to TB disease, even during the first trimester.⁷⁴ This includes women who are pregnant and have weakened immune systems, such as people with HIV and a low CD4 count, or those who have recently been in close contact with someone with infectious TB disease. Treatment should be coordinated with the TB control program within the respective jurisdiction and initiated based on the woman’s risk factors including social history, comorbidities (particularly HIV infection), and concomitant medications. Several treatment regimens are recommended for managing latent TB infection during pregnancy. For current treatment options, see Tuberculosis Clinical Care and Treatment During Pregnancy.⁷⁴ Health care providers can contact their state or local TB program or the TB Centers of Excellence for expert consultation.^75,76

Finally, it is critically important that written records of all screening, vaccination, and treatment be provided at discharge to facilitate appropriate clinical care for the women who are pregnant and their neonate. Upon release from a correctional facility, women may be eligible for Medicaid,⁷⁷ including pregnancy Medicaid, a subsidized health insurance program which covers prenatal care visits and labor and delivery.⁷⁸ A provision in the American Rescue Plan Act of 2021 aimed to improve maternal health and address racial differences by giving states the option to extend Medicaid coverage to 12 months postpartum.⁷⁹ As part of pre-release planning, enrolling eligible women who are pregnant in Medicaid can help ensure timely access to prenatal care, infection testing and treatment, and coordinated services to support continuity of care after release.⁸⁰

Recommendations for Release for All Women

In 2019, approximately 2.5 million women were released from jail and prisons.^81,82 Women returning to the community following incarceration can face myriad challenges accessing infectious disease care and prevention services, including lack of health insurance coverage and transportation, stigma associated with their incarceration history, as well as difficulties navigating competing priorities such as finding employment or housing and childcare concerns.^83,84 Pre-release planning and coordination can help ensure women with infections and other diseases continue to receive life-saving treatment without interruption. Addressing reentry needs is crucial to help women prioritize their own health and their child’s health, support continuity of care, and reduce the risk of poor health outcomes post-release. Reentry services can support housing stability, economic self-sufficiency, parenting needs, and physical and mental health. These services are especially important for women with children, who may require assistance with family reunification, childcare, and access to women-centered healthcare, including reproductive and behavioral health services.^85,86

Callout Box 4 - CDC Recommended Actions for Women for Release Planning and Linkage to Care

CDC recommends the following considerations for women as part of pre-release services or after release from a correctional or detention facility:

HIV:

•

Provide women with HIV an adequate supply of antiretroviral medication upon release to bridge the gap until the patient can receive care from a community-based HIV provider.

•

Provide information on pre-exposure prophylaxis (PrEP) to all women who are known to be at risk of HIV infection in their community.

Viral Hepatitis and HIV:

•

Refer women with HBV infection, HCV infection, or HIV to community-based medical and social services as needed to support continued medical care, risk-reduction, and treatment for substance use disorder.

Tuberculosis and Latent Tuberculosis Infection:

•

Communicate with state/local public health and community healthcare providers to facilitate treatment completion after release for women under treatment for Tuberculosis/Latent Tuberculosis Infection.

•

Provide women being treated for Tuberculosis or Latent Tuberculosis Infection counseling on the importance of completing a full course of Tuberculosis or Latent Tuberculosis Infection treatment.

Syphilis, Gonorrhea, Chlamydia, and Trichomoniasis:

•

Arrange for completion of treatment and follow-up testing for all women as indicated through a health department or local clinician.

HIV, Viral Hepatitis, and STIs:

•

Provide women with HIV, viral hepatitis, or any STI with counseling on how to prevent transmission to household, sexual, and drug-use contacts as applicable (including risk reduction and condom use).

•

Provide all women or their identified health care provider with a personal immunization record upon release as well as information about all infection test results and treatment provided.

Partnerships between correctional facilities, public health departments, healthcare facilities, and community organizations can support continuity of care through strategies such as medication bridging, referral to health departments or community clinicians, and linkage to community-based medical and social services. For guidance on release planning and linkage to care for women for HIV, viral hepatitis, STIs, and TB, see Callout Box 4.

Reentry organizations can also aid in care continuity for HIV and for other infectious and chronic diseases. One study found that rates of access to HIV care, treatment, and viral suppression increased during incarceration but fell dramatically upon release, resulting in worse HIV treatment outcomes post-release than during incarceration.⁸⁷ Another study found that, compared with men, women were significantly less likely to be retained in community-based HIV care, to have a prescription for antiretroviral therapy, and to achieve viral suppression by 6 months post-release.⁸⁸ In each of these studies, reentry services were not a reported part of the pre-release process. To address these disparities, correctional settings and public health departments can build connections with local Ryan White HIV/AIDS Programs during incarceration and prior to release for women with HIV, which is especially important for pregnant women to maintain viral suppression and prevent perinatal HIV transmission.^58,89

One key strategy to promote linkage to care upon reentry is peer and patient navigation. A meta-analysis of studies involving people who inject drugs found that patient navigation and care coordination were associated with a three-fold higher likelihood of linkage to hepatitis C care.⁹⁰ Non-stigmatizing, non-judgmental, person-centered, and compassionate support from patient navigators are consistently viewed as invaluable for achieving hepatitis C care and treatment goals by people who were recently released from prison.⁸³

Public programs such as Medicaid, Medicare, Social Security Insurance and Social Security Disability Insurance, and the Affordable Care Act health insurance marketplace all have provisions in place to allow formerly incarcerated women to apply for coverage upon release; Medicaid coverage is now suspended rather than terminated during incarceration, facilitating faster reactivation.^77,91–93 Women with children may also benefit from applying for Children’s Medicaid, the Children’s Health Insurance Program, and the Women, Infant, and Children’s program for additional health coverage and nutrition support.^94–96 Federally qualified health centers and other local indigent health care programs can also fill in gaps in health insurance coverage and linkage to care for women who do not qualify for the above programs or are underinsured.⁹⁷ Reentry organizations and peer/patient navigators often provide assistance and support with health insurance enrollment as well, highlighting the critical role that these services play.^52,53,85,86

Conclusions

This report discussed CDC recommendations for screening, vaccination, and treatment of women at three points along the incarceration timeline: intake, during incarceration, and at the time of release. These recommendations aim to strengthen the prevention and management of HIV, viral hepatitis, STIs, and TB among women affected by the justice system, many of whom face persistent structural barriers to care.

Many women enter jails and prisons with untreated or undiagnosed infections due to social, structural, and economic conditions. Health services provided during incarceration can serve as a temporary contact point with care, but this interaction is often limited by varying lengths of stay, fragmented health systems, stigma of incarceration, and challenges with coordination between correctional facilities and community providers. Perinatal women impacted by incarceration experience increased health risks and require timely screening with treatment, access to prenatal care, and coordinated planning to maintain continuity of care following release.

The CDC has developed resources to support these efforts. Key resources include:

CDC Recommendations for Correctional Settings,²⁵

HIV testing implementation guidance for correctional settings,⁹⁸

Prevention and Control of Infections with Hepatitis Viruses in Correctional Settings,⁴

Advancing Hepatitis C Elimination through Opt-Out Universal Screening and Treatment in Carceral Settings, United States,⁷⁰

CDC Sexually Transmitted Infections Treatment Guidelines, 2021: Persons in Correctional Facilities,²⁹ and

Prevention and Control of Tuberculosis in Correctional and Detention Facilities: Recommendations from CDC.⁹⁹

Improving infection prevention and treatment for women affected by the justice system requires coordinated efforts across correctional health services, public health departments, and community partners. Such collaboration is essential to ensure consistent and patient-centered care, reduce health disparities, and strengthen public health outcomes for justice-involved women.

Authors’ Contributions

D.B.: Drafted the original article. D.B., L.S., A.B., K.M., S.P.W., M.N., R.T., R.J.S., and M.M.: Were involved in the study conception, design, writing, review, and editing. M.M.: Supervision. All authors have read and approved the final article.

Footnotes

Acknowledgments

The authors thank Dr. Carolyn Sufrin (Johns Hopkins University) for her valuable discussion and expert insights that contributed to the development of this article.

Disclaimer

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Author Disclosure Statement

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding Information

The authors received no financial support for the research, authorship, and/or publication of this article.

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