Because prisons and jails house a population facing a disproportionate share of the burden of HIV infection and many of whom are unaware of their HIV status, these facilities serve as important sites for the testing and treatment of HIV.¹ Routine HIV testing presents a promising opportunity for correctional institutions to provide individuals with knowledge of their HIV status, education and counseling services, and access to treatment both within the correctional setting and upon release into the community. Traditionally, prisons and jails have operated outside of the purview of our public health infrastructure. Screening of HIV within these settings provides an innovative approach to facilitate community-correctional linkages.

Jails are distinct from prisons due to their high rate of turnover, varying states of intoxication, lack of uniform intake procedures, and typically brief lengths of stay. In order to implement successful routine HIV testing programs in jails, a number of logistical challenges must be properly addressed before implementation can be successful.

A major challenge to implementing routine HIV testing in jails is choosing the optimal time to conduct testing.² Although immediate testing at intake might confer the largest public health benefit since many inmates will be released within the first few days of incarceration, such a testing approach creates additional logistical challenges. While there is never an ideal time to deliver "bad news", the timing of delivering non-emergent bad medical news (such as a preliminary positive result in an asymptomatic patient) must be carefully considered. Newly incarcerated detainees experience high rates of suicidal behavior, acute intoxication and abstinence syndromes, and psychological distress at the time of entry.^3,4 It is currently unclear from the empirical literature if individuals under such stresses have medical competence to "opt out" of routine testing. If individuals do not "opt out" and are provided with a "preliminary positive" despite their fragile circumstances, they are almost certainly unprepared to consider and respond to the consequences of a preliminary positive HIV test result.^{5, 6}

"The costs for providing care will remain a concern in our nation's jails. Jails are often under local jurisdiction and resources are often limited."

It is daunting to imagine routine HIV testing upon intake at some of the largest and busiest jails. Several hundred people may be processed daily, with intake procedures taking place 24 hours a day. While routine HIV testing might be sufficiently managed, it is often the case that staffing is suboptimal. Adding HIV testing (with associate HIV counseling for preliminary positives) will require additional inmate movement within the facility, working with inmates in various states of intoxication and withdrawal, and squeezing additional service requirements into the already-limited available time. All of this would have to be accomplished through coordinated efforts with custodial staff who typically try to avoid any unnecessary movement within the facility.

One of the unresolved issues for routine testing in jails is ensuring delivery of confirmatory HIV test results for those who test preliminarily positive. Confirmatory test results often require up to a week to receive and, given the high rates of release early in the course of incarceration, many individuals will be released without truly knowing their status. Community public health systems must be adequate to provide contact tracing after release to ensure delivering confirmatory results. For individuals who remain incarcerated, additional resources will be required to provide routine and necessary testing and provision of antiretroviral medications if medically indicated.

The costs for providing care will remain a concern in our nation's jails. Jails are often under local jurisdiction and resources are often limited. Determining who will pay for testing, counseling, and treatment must also be taken into consideration. The ability to link with public health and national health care programs must be included; not the least of these is the Medicaid program.

Prisons and jails are excluded from both general disease-specific programs (funds are channeled to public health departments and publicly run health care facilities) and third party payers (insurance, Medicare, and Medicaid typically stop upon confinement).

Although government funded programs such as Medicare, Medicaid and Ryan White subsidies exist to offset the costs of treatment, the incarcerated remain the only demographic group in this country that is broadly and specifically excluded from federal and state third party coverage for their care. On the other hand, local legislation and other legal precedents at least tacitly require that correctional facilities in the United States provide the community standard of medical care for HIV-infected inmates. Prisons and jails already face significant resource limitations in providing existing medical services to their continually increasing inmate population. It is estimated that one quarter of HIV-infected individuals in the United States pass through a correctional facility every year and it is believed that anywhere from one third to one half of these persons are unaware of their HIV status.^7-9 If this is indeed the case, then prison and jail administrators face a huge financial disincentive for conducting widespread HIV screening programs in their facilities.

"Serious ethical considerations are also raised when correctional settings test individuals for HIV and initiate treatment without ensuring adequate follow-up and treatment services upon re-entry into the community."

Extensive cost-benefit analyses support expanded HIV screening in all settings where the HIV seroprevalence of undiagnosed is greater than 1%.^{10, 11} In jails, however, there is a political disincentive for correctional administrators to be viewed as providing care and spending scarce resources on prisoners. In the case of routine testing in jails in the current funding environment, jails will bear the direct costs of these programs but will not directly reap the benefits. The case for prisons may differ as many of these individuals are incarcerated for prolonged periods of time. It will therefore require a shift in philosophy by jail administrators to promote a more societal approach, perhaps with the assistance of public health incentives and support. In order for routine HIV testing to be adopted by jails, they must become part of the larger public health infrastructure. By doing so, the costs of screening and treatment could be shared more globally by the rest of society.

Programs that facilitate linkage to community-based treatment for HIV-infected prisoners are another important challenge that must be addressed for jail screening to be successful. As marginalized members of society, those with criminal records do not enjoy steady access to health care in the community and some are chronically subjected to episodic care.¹² Furthermore, because of the high rate of recidivism among the incarcerated, one of the major challenges to treating HIV-infected individuals is providing continuity of care as they cycle in and out of the correctional system. Understanding the effects of the unstructured interruptions in HAART care for these individuals remains an important area of study.¹³ Serious ethical considerations are also raised when correctional settings test individuals for HIV and initiate treatment without ensuring adequate follow-up and treatment services upon re-entry into the community.

Despite these obstacles, routine HIV testing programs represent best public health practices and should be implemented. The authors are calling for review and consideration not only of the implementation of broad testing, but also for resolution of the associated challenges. While there are currently initiatives to overcome these obstacles, we still do not know how to resolve them all, even on a limited scale, much less if testing were to become universal in jails. The authors also want to underscore the mounting need for a public health approach to the delivery of correctional health care, including access to the general funding mechanisms that serve so much of the American public.

Funding: The authors would like to thank the National Institute on Drug Abuse for provision of a career award for Dr. Altice (K24 DA 017072).

References:
^1. Springer SA, Altice FL. Managing HIV/AIDS in correctional settings. Curr HIV/AIDS Rep. Nov 2005;2(4):165-170.
^2. Kavasery R, Altice FL. Observations on Implementing Routine HIV Testing in Jails. AIDS Patient Care STDS. In Press.
^3. Frottier P, Fruhwald S, Ritter K, Eher R, Schwarzler J, Bauer P. Jailhouse Blues revisited. Soc Psychiatry Psychiatr Epidemiol. Feb 2002;37(2):68-73.
^4. Felthous AR. Preventing jailhouse suicides. Bull Am Acad Psychiatry Law. 1994;22(4):477-488.
^5. Basu S, Smith-Rohrberg D, Hanck S, Altice FL. HIV testing in correctional institutions: evaluating existing strategies, setting new standards. AIDS Public Policy J. Spring-Summer 2005;20(1-2):3-24.
^6. Beckwith CG, Atunah-Jay S, Cohen J, et al. Feasibility and acceptability of rapid HIV testing in jail. AIDS Patient Care STDS. Jan 2007;21(1):41-47.
^7. Sabin KM, Frey RL, Jr., Horsley R, Greby SM. Characteristics and trends of newly identified HIV infections among incarcerated populations: CDC HIV voluntary counseling, testing, and referral system, 1992-1998. J Urban Health. Jun 2001;78(2):241-255.
^8. Hammett TM, Harmon MP, Rhodes W. The burden of infectious disease among inmates of and releasees from US correctional facilities, 1997. Am J Public Health. Nov 2002;92(11):1789-1794.
^9. Nation's capital implements new jail HIV testing. AIDS Policy Law. Aug 11 2006;21(15):9.
^10. Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States--an analysis of cost-effectiveness. N Engl J Med. Feb 10 2005;352(6):586-595.
^11. Varghese B, Peterman TA, Holtgrave DR. Cost-effectiveness of counseling and testing and partner notification: a decision analysis. Aids. Sep 10 1999;13(13):1745-1751.
^12. Thompson AS, Blankenship KM, Selwyn PA, et al. Evaluation of an innovative program to address the health and social service needs of drug-using women with or at risk for HIV infection. J Community Health. Dec 1998;23(6):419-440.
^13. Springer SA, Pesanti E, Hodges J, Macura T, Doros G, Altice FL. Effectiveness of antiretroviral therapy among HIV-infected prisoners: reincarceration and the lack of sustained benefit after release to the community. Clin Infect Dis. Jun 15 2004;38(12):1754-1760.

Back to Top