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SUMMER 2007
Main Article:
Perspective:
HIV Behind Bars: Meeting the Need for HIV Testing, Education, and Access to Care Curt G. Beckwith, M.D. Medical School of Brown University Michael Poshkus, M.D. The Rhode Island Department of Corrections and the Warren Alpert Medical School of Brown University Disclosures:Nothing to disclose Introduction Over the last several decades, the proportion of persons incarcerated in the United States has been steadily increasing. The United States incarcerates the greatest number and the highest proportion of persons compared to any other country and by mid-year 2005, more than two million persons were incarcerated in the United States, representing one in every 145 individuals.1 Studies have demonstrated that prior to incarceration, persons engage in increased rates of high-risk behaviors including substance use and risky sex.2-6 In addition, there is a higher prevalence of HIV within the correctional setting compared to the community among both males and females.7-9 In a 1997 study, it was estimated that approximately one-quarter of all HIV-infected persons in the United States passed through the correctional system in one year.10 The AIDS rate has been estimated to be more than three times greater in prison than in the community.11 There are less data on the HIV prevalence in jails compared to prisons. However, the estimated jail HIV prevalence rates range from 2.1-2.5%.12 Given high rates of risk behavior in inmates and the increased HIV prevalence rates behind bars, correctional HIV testing programs provide an opportunity for persons at risk of infection to access HIV testing services, education, and for HIV-infected persons to receive care. Persons entering correctional systems are often marginalized in their communities due to factors such as active substance abuse, mental health disorders, and racial disparities relative to the delivery of health care.5,13 This marginalization leads to decreased access to health care in the community. Incarceration, therefore, may be the only chance for many to access HIV testing services and have an opportunity to receive HIV care. This may be particularly true for racial and ethnic minorities who are disproportionately incarcerated in the United States and are also disproportionately infected with HIV.14 According to the Centers for Disease Control and Prevention (CDC), blacks and Hispanics accounted for 48% and 18% respectively of all HIV/AIDS cases diagnosed in 2005 in the US.15 Incarceration provides an opportunity to intervene and provide HIV testing, medical care, and linkage to HIV services upon release from the correctional setting. Advantages to HIV Screening in Correctional Settings There are unique advantages to correctional HIV programs. When incarcerated, health care and prevention programs can be effectively administered because clients are logistically easier to access, clients are relieved from the financial burdens of medical care, and at least theoretically, are not engaged in ongoing risk behavior.14 Correctional HIV testing programs have the potential to increase the number of at-risk persons tested for HIV as well as to increase the number of persons who are aware of their HIV serostatus. HIV-infected inmates can be educated about their infection, learn how it is transmitted to others, and receive prevention counseling, and antiretroviral therapy can be initiated when indicated. Addiction treatment and mental health services can be provided in conjunction with HIV care, which serves to improve adherence with therapy both inside and outside of the correctional environment. In addition, a detailed reentry plan can be formulated to link the inmate to HIV clinical care, mental health treatment, and substance use treatment in the community upon release. Further, HIV-uninfected inmates can receive prevention counseling, which may reduce their risk of subsequent HIV infection. Critical to the implementation of a quality correctional HIV health program is a routine HIV testing policy. HIV testing is offered in all state correctional systems within the United States; however, local policies typically govern the manner by which testing is offered. Correctional testing policies include (1) mandatory upon entrance or exit; (2) routinely offered, but not mandatory; (3) voluntary, upon request by an inmate; (4) performed when clinically indicated, as deemed by the correctional medical staff; and (5) ordered by the court. Most correctional facilities offer HIV testing when requested by the inmate or when a clinical syndrome consistent with HIV infection has been identified.16 Approaches to HIV Screening in Prisons and Jails Recently the CDC has issued recommendations for expanded HIV testing in health care settings. The lynchpin of these recommendations is the proposal that HIV testing be conducted for patients in all health care settings after the patient is notified that testing will be performed unless the patient declines (i.e. "opt-out" screening).17 We strongly support a universal, routine, opt-out HIV testing policy in correctional settings whereby all inmates would undergo HIV testing upon entrance to the correctional facility unless declined. The ability of the inmate to decline testing is paramount because opt-out testing must be differentiated from mandatory testing. Routine opt-out testing has the advantages of decreasing stigma associated with requesting an HIV test and makes HIV testing accessible to all inmates. In an effort to improve the delivery of HIV testing services to those at risk of infection, the CDC has also recommended that voluntary opt-out HIV screening be performed in correctional health care facilities.18 Mandatory HIV testing of inmates is performed in a number of correctional institutions. While mandatory testing certainly accomplishes the objective of increasing testing among incarcerated individuals, we favor a routine opt-out policy over mandatory testing given the advantages listed above. We hope that correctional administrators and health care providers capitalize upon the opportunity that incarceration presents by engaging at-risk persons who are marginalized from the health care system. The goal should be to provide high-quality health care to individuals who cannot, or do not, otherwise access it. This includes a comprehensive HIV counseling and testing program that is accessible to all. Incarcerated persons should have the ability to make health care decisions, such as opting-out of an HIV test if they so choose, unless there is a court order denying them of that right. HIV testing should not be punitive. Rather, the delivery of HIV and other medical services to inmates should be a component of the therapeutic and rehabilitative services from which incarcerated individuals can benefit. Because all persons who enter the correctional system are, at one time or another, held in a jail system, routine HIV testing in jails offers the most comprehensive approach to HIV screening because screening at this point will reach the greatest number of people. However, jails have rapid turnover rates and short inmate stays, complicating HIV screening efforts.16 With the Food and Drug Administration (FDA) approval of a variety of rapid HIV tests, new opportunities for correctional screening programs have emerged. Rapid testing technology provides definitive antibody-negative and preliminary antibody-positive test results in approximately 20 minutes. Although preliminary positive rapid tests need to undergo confirmatory western blot testing, rapid test results can be delivered immediately in conjunction with result-specific post-test counseling and risk reduction interventions. To promote knowledge of HIV status among inmates, routine HIV testing policies should be considered by correctional administrations and the utilization of rapid HIV testing should be evaluated for use in jail settings. Rapid HIV testing programs with point-of-care test result delivery have been successful in a number of non-correctional settings including labor and delivery, community outreach programs, outpatient clinics and emergency rooms.18-24 Rapid testing has been shown to be preferred over standard HIV testing among patients attending an urgent care center due to results being available within one testing session.25 In the April 2006 issue of IDCR, the Broward County Jail reported on its successes with voluntary rapid HIV testing in their jail system.26 A pilot of study of rapid HIV testing at the Rhode Island Department of Corrections jail demonstrated that rapid testing was acceptable to jail detainees, was feasible to perform, and improved HIV test result delivery.27 Further investigation into the utilization of rapid HIV testing in the jail setting is needed including examination of rapid testing: 1) in facilities with different HIV testing policies; 2) among male and female inmates; 3) with respect to the influence of rapid HIV testing on subsequent HIV risk behavior in the community; 4) in conjunction with development of effective HIV prevention programs for use in jails; 5) with respect to cost effectiveness; and 6) with respect to safety in reducing needle-stick exposures among providers. "We strongly support a universal, routine, opt-out HIV testing policy in correctional settings whereby all inmates would undergo HIV testing upon entrance to the correctional facility unless declined."An effective HIV testing policy upon incarceration is only appropriate if comprehensive HIV clinical care services are provided within the correctional facility after diagnosis. These services should include a baseline medical evaluation with determination of CD4+ cell count and HIV plasma viral load, initiation of antiretroviral therapy for appropriate patients, prophylaxis of opportunistic infections, and screening for other conditions, including other sexually transmitted infections, tuberculosis, viral hepatitis, drug addiction, and mental illness. Vaccination for hepatitis B virus should be performed in all susceptible patients, given the risk factors for hepatitis B virus infection are identical to those for HIV infection. Furthermore, HIV care providers working inside a correctional setting must have effective lines of communication developed with community-based HIV providers so ongoing treatment plans can be continued inside and outside the correctional setting with minimal interruption. This communication is critical to the ongoing care of persons who continually cycle through the correctionalsystem.Conclusion Incarceration is a reality of our current justice system. But, incarceration brings with it an opportunity to engage our society's most at-risk individuals. We encourage and support the development of comprehensive correctional HIV programs that are comprised of the following elements: 1) routine voluntary opt-out HIV testing upon incarceration; 2) comprehensive medical evaluation; 3) provision of HIV care during incarceration, and 4) implementation of detailed re-entry practices that engage community providers. Further work is needed to make this type of program more prevalent across the United States. This requires a multidisciplinary effort with input from correctional and community HIV providers, correctional medical staff, administrators, correctional officers, mental health providers, inmate advocates, and discharge planning staff, to name a few. The goal is to promote HIV education and health among our inmates that translates into reduced HIV morbidity and mortality in our communities.
References: 1. Harrison PM, Beck AJ. Prison and Jail Inmates at Midyear 2005. Bureau of Justice Statistics, U.S. Department of Justice, May 2006. NCJ 213133. 2. MacGowan RJ, Margolis A, Gaiter J, et al. Predictors of risky sex of young men after release from prison. Int J STD & AIDS 2003;14:519-23. 3. Margolis AD, MacGowan RJ, Grinstead O, et al. Unprotected sex with multiple partners: Implications for HIV prevention among young men with a history of incarceration. Sex Trans Dis 2006;33:175-80. 4. Wohl AR, Johnson D, Jordan W, et al. High-risk behaviors during incarceration in African-American men treated for HIV at three Los Angeles public medical centers. J Acquir Immune Defic Syndr 2000;24:386-92. 5. Conklin TJ, Lincoln T, Tuthill RW. Self-reported health and prior health behaviors of newly admitted correctional inmates. Am J Public Health 2000;90:1939-41. 6. Mumola CJ. Substance abuse and treatment of state and federal prisoners, 1997. Bureau of Justice Statistics, U.S. Department of Justice, 1999. NCJ 172871. 7. Altice FL, Mostashari F, Selwyn PA, et al. Predictors of HIV infection among newly sentenced male prisoners. J Acquir Immune Defic Syndr 1998;18:444-53. 8. Arriola KR, Kennedy SS, Coltharp JC, et al. Development and implementation of the Cross-site Evaluation of the CDC/HRSA Corrections Demonstration Project. AIDS Educ Prev 2002;14(Suppl A):107-18. 9. Rich JD, Dickinson BP, Macalino G, et al. Prevalence and incidence of HIV among incarcerated and reincarcerated women in Rhode Island. J Acquir Immune Defic Syndr 1999;22:161-66. 10. Hammett T, Harmon M, Rhodes W. The burden of infectious diseases among inmates of and releasees from US correctional facilities, 1997. Am J Public Health 2002;92;1789-94. 11. Maruschak LM. HIV in prisons, 2001. Bureau of Justice Statistics, US Department of Justice, 2004. NCJ 202293. 12. Maruschak LM, HIV in Prisons and Jails 2002, Bureau of Justice Statistics, US Department of Justice, 2004. NCJ 205333. 13. Glaser JB. Sexually transmitted diseases in the incarcerated. An underexploited public health opportunity. Sex Trans Dis 1998;25:308-09. 14. Braithwaite RL, Arriola KRJ. Male prisoners and HIV prevention: A call for action ignored. Am J Public Health 2003;93:759-63. 15. HIV/AIDS Surveillance Report 2005: Atlanta: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Infectious Diseases, Division of HIV/AIDS:1-54. 16. Spaulding A, Stephenson B, Macalino G, et al. Human immunodeficiency virus in correctional facilities: a review. Clin Infect Dis 2002;35:305-12. 17. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Morb Mortal Wkly Rep. 2006;55:2-17. 18. Bulterys M, Jamieson DJ, O'Sullivan MJ, et al. Rapid HIV-1 testing during labor: A multicenter study. JAMA. 2004;292:219-23. 19. Forsyth BW, Barringer SR, Walls TA, et al. Rapid HIV testing of women in labor; too long a delay. J Acquir Immune Defic Syndr. 2004;35:151-54. 20. Centers for Disease Control and Prevention. Rapid point-of-care testing for HIV-1 during labor and delivery-Chicago, IL, 2002. MMWR Morb Mortal Wkly Rep 2003;52:866-68. 21. Keenan PA, Keenan JM. Rapid HIV testing in urban outreach: a strategy for improving posttest counseling rates. AIDS Educ Prev 2001;13:541-50. 22. Spielberg F, Branson BM, Goldbaum GM, et al. Choosing HIV counseling and testing strategies for outreach settings. J Acquir Immune Defic Syndr 2005;38: 348-55. 23. Kendrick SR, Kroc KA, Withum D, et al. Outcomes of offering rapid point-of-care HIV testing in a sexually transmitted disease clinic. J Acquir Immune Defic Syndr 2005;38:142-46. 24. Kelen GD, Shahan JB, Quinn TC. Emergency department-based HIV screening and counseling: experience with rapid and standard serologic testing. Ann Emerg Med 1999;33:147-55. 25. Hutchinson AB, Corbie-Smith G, Thomas SB, et al. Understanding the patient's perspective on rapid and routine HIV testing in an inner-city urgent care center. AIDS Educ Prev 2004;16:101-14. 26. May JP, Welch M, Jackson R. Rapid HIV Testing at the Broward County Jail, Florida. Infectious Diseases in Corrections Report; 2006; Available at http://www.idcronline.org. Accessed June 20, 2007. 27. Beckwith CG, Atunah-Jay S, Cohen J, et al. Feasibility and acceptability of rapid HIV testing in jail. AIDS Patient Care STDs 2007;21:41-47. |
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