From the *Rollins School of Public Health, Emory University, Atlanta, Georgia; †Abt Associates Incorporated, Cambridge, Massachusetts; ‡Health Resources and Services Administration, HIV/AIDS Bureau, Special Projects of National Significance (SPNS), Rockville, Maryland
Correspondence: Anne C. Spaulding, MD, MPH, Rollins School of Public Health, Emory University, Atlanta, GA. E-mail: Aspauld@emory.edu.
Received for publication April 17, 2007, and accepted April 23, 2007.
In the article by MacGowan. et al. in this issue of Sexually Transmitted Diseases, the researchers showed that voluntary rapid human immunodeficiency virus (HIV) testing in jails is feasible and acceptable to jail administrators and inmates, based on the 2004–2006 Center for Disease Control and Prevention (CDC) Rapid HIV Testing in Jail Demonstration Project.1 One medical director involved in the project has been quoted as saying that rapid testing in his jail is “a match made in heaven.”2 Although all jail administrators may not resort to celestial terms to describe advances in testing technology, rapid assays do fit the environment of a jail, where half of all inmates leave within 48 hours.3 Rapid testing should be used to encourage behavior change to improve quality of life and prevent transmission of HIV to others, and to link those who test positive to a system of disease management.
After the success of the CDC demonstration project at showing that rapid testing is feasible in jails, the challenge to jails, public health departments, and acquired immune deficiency syndrome service organizations is to fill in gaps in knowledge regarding how to operationalize rapid HIV testing in jails on a larger scale. A fundamental question, which will be answered differently at different jails, is: at what point in the intake process should HIV testing be offered? If too soon after arrival, some persons may be under the influence of drugs and alcohol, and they would not be able to provide voluntary consent. But, especially in jails that have more rapid turnover than those in the demonstration project, as each hour after entry passes, the number of detainees remaining dwindles until few are left to test and less time is available to confirm preliminarily positive test results on site. The demonstration project gives insight into the process of jail-based testing but leaves open many questions about when and how to identify HIV-positive persons, and how to establish linkages to care.
Identifying HIV-Positive Persons
An important finding of the CDC demonstration project was that the 39% of the 269 newly identified cases were among detainees “whose only disclosed risk was heterosexual intercourse;” this was the most commonly reported risk behavior.1 In testing programs that target inmates for HIV testing based on reported high-risk behaviors, detainees whose only risk behavior is heterosexual intercourse might not be identified. Although some inmates may have acquired HIV through heterosexual activity, others may be unwilling to disclose other risk factors for a variety of reasons. As with community-based testing programs, the jail health providers or HIV testing counselors from outside agencies may not be able to gain the trust of all newly admitted persons during the 10–20-minute period that it takes to perform a rapid test. As a result, not all detainees will confide the most intimate details of their lives at the time of the HIV test. Furthermore, admitting to behaviors such as injection drug use or commercial sex work could be felt to represent an admission of guilt to the criminal justice charges they are facing and they may fear the information would not stay confidential. The lesson learned from the demonstration project is for jails to move away from targeting HIV testing to those reporting high-risk behavior and instead, offer testing to all inmates, when possible. Offering HIV testing in a routine manner in conjunction with other routine medical tests should help to reduce stigmatization.
Even if jail health services do move away from focusing voluntary HIV testing efforts on those inmates disclosing, or perceived to be engaging in, high-risk behavior, toward routine testing of all inmates (or all inmates incarcerated for a certain period), testing still might not be embraced by those needing it most. Staff might not consistently offer HIV testing to all inmates or HIV-infected inmates might refuse testing at substantial rates. Jails need to train staff and create policies that encourage widespread testing as well as to develop deliberate social marketing campaigns for their HIV testing programs so that all, not just the worried well, recognize the benefits of HIV testing and have the opportunity to learn their HIV status. It is also important to develop and implement effective measures for ensuring that detainees have a real option to refuse testing and that the confidentiality of all HIV testing and other patient information are maintained.
At a recent consultancy meeting of experts in jail health (which included MacGowan), one participant described a 1998 masked seroprevalence survey of all routine blood specimens drawn at Rikers Island jail in New York City, which showed that 8% of men and 18% of women were HIV positive.4,5 In the voluntary testing and counseling program at the jail, about 4% of HIV tests were returning positive in the late 1990s (Alvarez, personal communication). Those already aware of their positive status would not volunteer for testing, so a somewhat lower percentage of seropositivity in the voluntary testing program than in the masked survey would be expected. On the other hand, the magnitude of the difference might have reflected that the testing program accommodated the “worried well” at the expense of informing some of the positive but unaware persons of their status.
CDC estimates that of the 1.1 million Americans who are HIV positive, one quarter, i.e., 225,000, do not know their status.6 Given that 20%–26% of all HIV-infected Americans have been estimated to pass through correctional facilities annually,7 it can be speculated that some of the 225,000 who do not know their status can be found in jails. If jail-based HIV testing programs were to proliferate to reach most of the 9 million unique individuals passing through jails annually,8 and the rate of seropositivity remained the same 0.8% as in the jail demonstration project, the 72,000 individuals so identified would represent a substantial portion of the 225,000 Americans infected with HIV but are unaware of their status.6
Making and Maintaining Linkages to HIV Care in Jail and in the Community
Although learning one’s HIV status may lead to behavior changes that reduce the risk of transmitting the infection to others,6 an individual’s health status will only be improved if a linkage is made and maintained to comprehensive HIV care in jail and, especially, in the community after release. Medical services are an important component of HIV care, but recently released jail inmates may prioritize other basic needs such as safe housing, drug treatment, and mental health counseling over HIV care.9 Interventions that promote HIV testing and linkages to care must be adequately evaluated for effectiveness.
An inherent tension exists between practicality of program implementation and scientific rigor in program evaluation. From 1999 to 2004, the Health Resources and Services Administration (HRSA) and CDC spent approximately $40 million on a Corrections Demonstration Project that at many sites incorporated intensive discharge planning and case management into programs to expand HIV services to jail and prison inmates.4 In this case, an experimental design was not used in the evaluation of the project due in part to the complexity of the project (there were 7 demonstration sites working in multiple types of correctional facilities). Nevertheless, the evaluation did use a longitudinal research design, which allowed for the measurement of change over time.10 Over the course of the project, approximately 6500 clients received discharge planning across all 3 facility types (jails, prisons, and juvenile facilities). The client-level evaluation found that seeing a provider (for HIV care, mental health care, and substance abuse treatment) in the first 30 days postrelease was associated with connecting with a provider in subsequent months and visiting an HIV care provider during the first 6 months postrelease was associated with taking HIV medication.11 But before concluding that case management is always effective, one should review a recent evaluation of a case management program on Rikers Island that randomized participants to either case management or less intense care. The evaluation showed that enrollment in case management, although increasing participation in drug treatment programs, did not decrease actual risky behavior in the short term when compared with members of the control group.12
Effect of HIV Rapid Testing in Jails on HIV Transmission in the Community
Voluntary counseling and testing programs have been a cornerstone of HIV prevention, especially in resource-poor settings.13,14 Routine rapid HIV testing in jails can confer a myriad of benefits community-wide. More people take the test and virtually all test-takers are informed of their results. All test recipients can be counseled on safe sex practices after the test-taker and the counselor view the test strips together: Prevention counseling can be tailored to the results. Given MacGowan’s finding that a substantial minority of new positives did not disclose risk factors other than heterosexual sex, many individuals routinely tested in jails might not test in the community until they become symptomatic. Men and women testing positive can link with care, and treatment has been shown to reduce the infectiousness of the virus, which can reduce infections among those who do not change their risk behaviors. Infected women of childbearing age who know their status can lessen the risk of mother to child transmission. Inclusion of strong partner notification and referral services, coordinated by the department of public health, in jail rapid testing programs would further benefit the community, as new cases are identified there. Those testing positive need support to prevent transmission of the infection to others both during their incarceration and once they return to the community. Programs also should not forget those testing HIV negative. CDC recommendations on HIV testing still encourage counseling if feasible.15
A New Initiative
With an awareness of many of the issues raised in this commentary, HRSA has recently announced an initiative for Enhancing Linkages to HIV Primary Care in Jail Settings, which includes an Evaluation Support Center led by faculty of the Rollins School of Public Health at Emory University, along with colleagues at Abt Associates Inc. The Evaluation Support Center will provide technical assistance and support to demonstration sites chosen by HRSA to implement and evaluate models for identifying new HIV-infected jail inmates and linking them to HIV care. Emory and Abt will also work with the grantees to develop a cross site evaluation of the project, which should result in generalizable knowledge about how to ensure that HIV-infected inmates find the services they need and are willing to access upon returning to the community. Ideally, this initiative will provide information on how best to encourage jail detainees to undergo voluntary testing, link HIV-positive individuals with services, and ensure the linkages are maintained. The ultimate goal of the projects will be to link those identified as positive with appropriate HIV primary care as well as to reduce HIV transmission in the disadvantaged communities to which most inmates return. It is expected that the findings of this cross-site evaluation will impact HIV testing policies and procedures in jails around the United States.
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