THE PREVALENCE OF HUMAN immunodeficiency virus (HIV) infection among jail inmates is estimated at 1.2% to 1.8%, or 4 to 6 times the prevalence (0.3%) in the US population.1 However, many jail inmates are not routinely offered HIV testing.2 Providing jail inmates with conventional HIV testing serology (standard HIV enzyme immunoassay) has been challenging, given that many inmates are likely to be released before receiving their test results and given that locating and providing HIV test results to persons released from custody is difficult and resource-intensive. In recent years, however, several simple-to-use rapid antibody tests have become available,3 making HIV testing and the provision of results in jails more feasible.
The Centers for Disease Control and Prevention (CDC) launched a new initiative, Advancing HIV Prevention, in 2003 to expand HIV testing in nontraditional settings, including jails.4 The jail component of the initiative was implemented through demonstration projects, led by state health departments, in 4 areas, where voluntary rapid HIV testing and counseling were offered to inmates upon entry into jail. The goals of the demonstration project were to increase the availability of HIV testing; increase the proportion of HIV-infected inmates who knew their serostatus; refer HIV-infected inmates to care, treatment, and prevention services; and reduce HIV transmission.
The health departments reported outcomes including the number of inmates tested, the number of preliminarily positive results from rapid testing, the number of confirmed infections, and the number of new diagnoses of HIV (i.e., excluding inmates who had previously received confirmation of their HIV infection). Details about implementation of the demonstration project and outcomes are described elsewhere.5 In this article, we present an assessment of the costs (variable and fixed) of delivering rapid HIV counseling and testing in jails. In addition to our key measure—the number of inmates with a new diagnosis of HIV infection—we estimated the average cost of testing HIV-infected and HIV-negative inmates and the program costs per new diagnosis.
The jail-based HIV counseling and testing demonstration projects were implemented in 4 project areas: Florida (Broward County jails, Fort Lauderdale); Louisiana (Orleans Parish Prison, New Orleans); New York (18 upstate county jails); and Wisconsin (Milwaukee House of Correction, Milwaukee, and Rock County Jail, Janesville).5
We estimated annual program costs from a provider’s perspective and expressed costs in 2005 dollars. We obtained program costs retrospectively from each project area by using standardized collection forms. We categorized total program costs as fixed or variable.6,7 Fixed costs included program management (planning, administration, and supervision), training, travel, and durable goods and equipment. Variable costs included counseling and testing time, nondurable goods and supplies, and test kits—rapid test kits and control for inmates who tested HIV negative and thus required a single test and for those inmates who tested HIV positive and thus required confirmatory testing.
Personnel costs were based on time spent in each of the program activities (e.g., counseling, testing, training, travel, administration, and supervision) performed by personnel from the health department, a community-based organization, and corrections department. We multiplied the time associated with each activity by the wage plus benefits of the employee who performed the activity. We used local reimbursement rates to estimate vehicle mileage costs. We amortized the costs of office computers and other equipment over the expected life of the equipment by using a 3% discount rate.6,8 We excluded costs related to program evaluation.
The programs provided HIV counseling and testing services in jails from December 1, 2003, through May 31, 2006.5 For this analysis, we used testing outcome data for the period March 1, 2004, through February 28, 2005. We estimated the average cost of testing an HIV-negative and an HIV-infected inmate as well as the average cost per newly diagnosed HIV infection: The total program cost for each project area was divided by the number of inmates in that area with a new diagnosis.
During the 1-year period of this cost analysis, the project areas tested a total of 17,433 jail inmates (Table 1). The number tested ranged from 2185 to 6463 among the 4 project areas. A total of 152 jail inmates (range, 4–81 per project area) received a new diagnosis of HIV infection. HIV seropositivity rates among tested inmates ranged from 0.2% to 1.3%. The total cost of the counseling and testing programs ranged from $101,153 to $198,532. We estimated the average cost per newly diagnosed HIV infection at $2451 to $25,288 for the 4 project areas. The wide variance in cost accorded with HIV prevalence in the tested jail population (Fig. 1).
The average total cost of testing an HIV-negative inmate was estimated at $29.46 to $44.98, and the cost of testing an HIV-infected inmate was $71.37 to $137.72 (Table 2). The average variable cost of testing programs in the 4 project areas ranged from $21.22 to $32.56 for an HIV-negative inmate and from $49.06 to $83.47 for an HIV-infected inmate. We estimated the variable costs at 61% to 86% of total program costs. Test kit costs and time spent on counseling and testing composed most of the variable costs. The costs associated with counseling and testing time for an inmate whose test results were negative ranged from $5.00 to $11.74; the costs for an inmate whose rapid test was reactive (requiring confirmatory testing) ranged from $6.67 to $17.08. The variations in these costs were attributable to differences in time spent on counseling and testing (Table 3) as well as wage rates in the project areas.
CDC provided OraQuick rapid test kits to all project areas through a bulk purchase ($8 for each test kit). The cost of performing confirmatory testing ranged from $27.40 to $61.44. The costs of providing confirmed HIV-positive results and referring HIV-infected patients to risk-reduction counseling and care were estimated at $4.17 to $22.46 per inmate.
We estimated the fixed cost for each inmate tested at $5.77 to $18.19. This amount was 14% to 39% of the total program cost for the 4 project areas. The program management cost, including staff time for planning, supervision, and administration, was $4.70 to $8.99 per inmate. Travel cost was a substantial portion of the program cost in Wisconsin and New York, mainly because of the need for health department staff to commute to distant jails. The cost of training counselors and testers was $0.06 to $0.75 per inmate. The Florida health department incurred the lowest of these training costs because it was able to hire previously trained personnel to perform counseling and testing.
Jails can be an important venue for the HIV counseling and testing of persons at high risk for infection. Between March 1, 2004, and February 28, 2005, 4 project areas tested in total 17,433 inmates (range per project area: 2185–6463) and diagnosed 152 new HIV infections (range per project area: 4–81). Nearly all inmates received their rapid HIV test results.5 Inmates with a confirmed positive test result were referred to their jail’s medical unit and to HIV prevention services. In most project areas, health department disease intervention specialists assisted with delivering confirmatory results to inmates who were released before their results became available.
We found that the cost of identifying a new HIV infection among jail inmates ranged from $2451 to $25,288. Because these estimates are derived from the total program cost in each project area divided by the number of inmates with a new diagnosis, the costs are highly sensitive to the prevalence of undiagnosed HIV infection among inmates tested in each project area. We found that the average cost of testing HIV-negative or HIV-infected inmates, independent of underlying HIV prevalence rates, varied substantially from project area to project area. The variation was due primarily to differences in staff time spent on counseling and testing, travel to the jails, and local wage rates.
In the literature, HIV counseling and testing costs vary according to the types of costs analyzed.9–13 Although some studies analyzed only providers’ counseling and testing time and test costs, others included clients’ time and travel costs. Ekwueme and colleagues performed a cost analysis of HIV counseling and testing, comparing 3 testing technologies. From the perspective of the health care provider and excluding clients’ time and travel costs, they estimated that rapid HIV testing—the diagnostic technology used in this jail demonstration project—would cost $28 per HIV-negative inmate and $104 per HIV-positive inmate.10 Gorsky and colleagues used a prospective observational cohort study to estimate HIV counseling and testing program costs (including counseling and testing staff time, testing costs, and administrative overhead) at 3 drug treatment centers in Connecticut and Massachusetts. They reported an average program cost of $384 per HIV-negative person and $412 per HIV-infected person.11 When only the direct cost of counseling and testing and staff time were included, Gorsky’s estimates were $72 per HIV-negative person and $101 per HIV-infected person. The high cost per HIV-negative person may have been because of the greater pretest counseling time in the Gorsky’s study. Thus, our average costs per HIV-negative person and HIV-infected person tested are within the range reported in the literature.
There are several things to consider when interpreting our results. Only 2 of the project areas—Louisiana and Wisconsin—involved correctional staff substantially in the testing program. Adding correctional officers’ time in locating and escorting inmates to and from the HIV counseling and testing session increased the average cost of providing testing to an HIV-negative inmate by 5.4% to $32.54 in Louisiana and by 6.5% to $47.74 in Wisconsin. Additionally, the cost we assigned to OraQuick rapid test kits was based on a bulk-purchase price available to CDC at the time. This price may not be uniformly available. Other HIV testing technologies with different costs also are likely to become available.
Our cost analysis indicates potential opportunities for achieving greater program efficiencies. The project areas varied substantially in counseling and testing time and associated costs (Table 3). If pretest prevention counseling for all individuals and posttest prevention counseling for those who test HIV-negative were eliminated,14 then about 0.25 hours on average per inmate of counseling and testing staff time could be saved. With this change, we estimated that the average cost of testing an HIV-negative inmate would decrease by 8.1% to 18.0% ($2.50–$6.40). Other inmates could receive information about HIV risk reduction and testing through videos displayed in waiting areas or in writing. In addition, some of the project areas were able to reduce the waiting time for health department staff by having a group of inmates wait for counseling and testing rather than escorting each inmate from cell or dormitory to the testing site.
One caution about our results is that we collected program costs retrospectively; thus, the results may have been subject to recall bias. We tried to account for all activities and goods related to counseling and testing in the jails, but some may have been unintentionally omitted.
This jail-based rapid HIV testing demonstration project resulted in improved access to HIV testing, increased voluntary testing of inmates, and the identification of previously undiagnosed cases of HIV infection. Our cost analysis specifies the resources needed to identify HIV infection among jail inmates and shows the variance in costs in the project areas. Understanding the costs and effectiveness of HIV testing programs can help policymakers and program managers determine where scarce resources will have the greatest impact, set realistic budgets for new testing programs, and streamline programs when practical to increase efficiency.
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