To get their perspectives on the role of routine screening for HIV infection in correctional settings, IDCR intern Christine Devore recently spoke with Dr. Joseph Bick, Chief Medical Officer, California Medical Facility, and Dr. David Paar, Associate Professor of Medicine at the University of Texas.

Christine Devore (CD): What do you see as the most significant barriers to implementing routine HIV testing in correctional facilities?

Dr. Joe Bick (JB): One of the first barriers would be the enormous volume of inmates. Over three million Americans are currently incarcerated and an estimated ten million Americans enter and leave incarceration in any given year, many of whom have only short stays in jail or prison. As a result, there are many logistical challenges to ensuring routine testing in that type of setting. Incarcerated persons are moved frequently and such moves are not always coordinated between custody and medical systems. Trying to keep track of people as they move through the penal system can be difficult. Making HIV testing routine has major workload implications for correctional staff, as care providers must ensure that every inmate who undergoes HIV testing is provided with pre and post-test counseling. Ensuring that every person who tests positive has access to HIV knowledgeable providers will be difficult for many correctional facilities. Another perceived barrier is the associated cost of HIV testing and counseling. While increased testing will certainly lead to a decrease in morbidity and mortality, prevention of costly hospitalizations, and decreased risk of further transmission of HIV, the individual jail or prison may not feel the effects of these benefits.

David Paar (DP): I gave a talk last fall about the CDC's guidelines at a correctional meeting that included people from the community who provide services to inmates in prisons. Many of these workers were very concerned about implementing these guidelines in the prison. Some thought that prisons should not viewed as a health care setting, while others thought it would be logistically impossible for most prisoners to give informed consent if the CDC guidelines were implemented. That being said, I'm in favor of the CDC's new testing policies. I believe that these policies can and should be implemented. I think it is best to test prisoners upon intake, although the volume of inmates being processed would make testing difficult.

CD: Some states have laws or regulations that dictate the HIV testing policies in prisons and jails. Does your state have any laws that could pose as barriers to implementing the CDC's recommendations?

JB: HIV testing regulations and laws vary from state to state. In California, there are policies and laws that can serve as disincentives for inmates to opt for HIV testing. Some of these laws can lead to restrictions on job assignments, potential housing sites, and educational opportunities for incarcerated persons. Inmates who are HIV+ may be subject to harsher penalties if they participate in activities that involve sharing blood or bodily fluids than their HIV negative peers would face. Although some of the state's regulations are valid and reasonable, they can lead to patients deciding to forgo voluntary or opt-out testing.

DP: Texas recently passed legislation that would make HIV testing mandatory in prisons on intake. Texas had previously held a policy of routine, opt-out testing that was first implemented in 1988. Texas also passed legislation in the fall of 2005 that required prisoners to be tested before release. Although few new cases of HIV were discovered this way, the program was well-received by inmates in that there are no documented refusals for testing that I am aware of.

CD: The CDC suggests that providers do not need separate, written consent for HIV testing. Rather, "general consent for medical care should be considered sufficient to encompass consent for HIV testing." Do you feel that this form of consent is appropriate in the correctional setting?

JB: My personal opinion is that some type of written consent is still worthwhile in the correctional setting. The process of being booked into a jail or a prison can be an extremely disorienting experience for many people. Many of the inmates may be under the influence of alcohol or drugs upon intake and could be unsure as to what types of medical care and testing they are allowed to refuse. As a result, some type of separate consent process for HIV testing is valuable if we are going to truly have informed consent in the correctional setting.

DP: I believe that the longer and more complicated the consent process, the less number of people who are actually tested. Of course, everybody should be informed of testing and understand what's going on. In Texas, we use a policy of oral consent for testing. Inmates don't have to sign a consent form; we simply ask them if they want to be tested for HIV. I think that allowing oral consent could violate a person's ability to give proper consent if the process is done hastily, but we can also limit a person's ability to consent by making the process overly complicated with several forms.

CD: Could the CDC's recommendations for informed consent deepen feelings of mistrust between correctional care providers and their inmates?

JB: I think so. I believe that many of our patients are already distrustful of authority and do not implicitly understand that when we ask them if we can provide general medical care, that that also involves testing for HIV and other sexually transmitted diseases. I think it's valuable to have a separate conversation with each inmate to discuss why they should want to know their HIV status, as well as the possible benefits and outcomes of testing. This process of gaining informed consent can certainly be streamlined, but I feel that it is still valuable to keep HIV testing consent separate from consent for general medical care.

CD: How do issues of confidentiality affect HIV testing in the correctional setting?

JB: I think confidentiality can be a significant barrier to testing, both in the correctional setting and in other settings. Confidentiality is one of the reasons why anonymous testing elsewhere in the country has been so valuable. Once a person tests positive in a correctional setting or elsewhere, it automatically signals a chain of events that a person cannot control, including the possibility that those results will impact access to work, career choice, health care insurance, and life insurance.

For example, one challenge for our population is the ability to afford a college education after incarceration. In this country, many people join the military in order to be compensated for their education, but people who are known to be HIV positive are prohibited from joining the military. As a result, inmates who are concerned about the confidentiality of their HIV test results or of the impact of these results on their future might refuse testing. No matter how hard we stress the issue of confidentiality in the correctional setting, it's impossible to have a diagnosis such as HIV not be known by a significant portion of the employees and residents of a correctional facility. An inmate's HIV serostatus becomes part of both their medical file and custodial file. Their status is considered in every decision about housing, programming, work, school, and release. In addition, fellow inmates are very adept at figuring out a person's HIV status based upon what type of doctor an inmate sees, what medicines he receives, and how often he receive medicines.

DP: Confidentiality is an issue that is important to everybody, both in and out of the correctional setting. In my experience, most inmates will often risk a breech of confidentiality in order to know their own HIV status. While maintaining confidentiality is a major priority for care providers, it is also very difficult to keep a person's HIV status confidential in the correctional setting. Most inmates recognize and accept this risk when they undergo testing. I don't think that the implementation of the new guidelines, per se, will affect confidentiality.

CD: Patient mistrust of care providers is often cited as a barrier to HIV testing and treatment in the correctional setting. What steps can correctional providers take to alleviate these feelings of mistrust?

JB: Trust is not just a correctional issue. There a number of studies that demonstrate that patients' adherence to therapy is directly related to their belief that the therapy is going to help them and their trust for their care provider. If you're in an environment where you think your provider is not HIV knowledgeable and you don't believe that the medicines themselves are going to be of any value, then you have little incentive to get tested. Patients should be educated as to how they can benefit from knowing their HIV status by decreasing their likelihood to get sick and increasing their lifespan.

DP: I think it's important for care providers to demonstrate compassion in dealing with inmates. For example, care providers must respect an inmate's decision to refuse an HIV test, as forcing a test would only engender mistrust. I feel strongly that inmates should always have the right to opt-out of HIV testing.

CD: What do you think are the most important steps for facilities to take in implementing the CDC's guidelines for regular, mandatory opt-out HIV testing?

JB: I think it's important for each correctional system to have an in-depth conversation with everyone who will be impacted by the CDC's guidelines, including medical staff, custody officers, inmates, and the pharmaceutical staff. There is tremendous room for benefit by implementing guidelines, but also significant opportunities for doing harm if the guidelines are not implemented in a thoughtful way. For example, if a facility implements routine testing for inmates as they leave the facilities, it is likely that some of the inmates who are tested will not receive their results. Most people assume that, if they didn't hear anything about their test results, then the results must have been good. Patients could then return to the community and unknowingly pass HIV to other people.

DP: First of all, facilities must discern what steps need to be taken in order to implement routine testing. In most systems, this will require more than sending a memorandum describing the needed changes. Facilities must really examine the recommendations, understand them, and understand what needs to be done to implement them. For example, facilities need to consider how many inmates they intake, how many blood drawers they have, and how many counselors they have. Facilities must then use this assessment to prepare for a likely increase in the number of inmates being tested.

CD: The CDC recommends annual testing for at-risk populations as a minimum. Do you feel that annual testing is appropriate for incarcerated individuals?

JB: I would say that there's ample evidence that HIV transmission occurs in the correctional setting, albeit in low levels. The overall majority of people leaving prison with HIV were infected at entry, although we do have some data that demonstrates new cases of HIV-infection occurring during incarceration. So I think that, at least in some select correctional settings, it would be worthwhile to have follow-up, if not annual, testing. The most cost-effective part of testing will be testing people when they enter the system. I do think there is some additional benefit to testing at-risk individuals either at annual time frames or at the time of release.

DP: I think annual testing is appropriate. I think exactly how you target the "at-risk" population is questionable. Obviously, facilities can use self-reported questionnaires to determine individuals' behaviors that place them at risk for HIV infection. I think that providing annual voluntary testing for all inmates might be easier than attempting to assess which individuals are at risk. Facilities can also offer some sort of HIV education program so that people know what behaviors can lead to infection.

CD: What are the greatest benefits to implementing routine HIV testing?

JB: We know that up to a quarter of persons infected with HIV don't know their serostatus and that the prevalence among the incarcerated population is five to ten times higher than among general population. We also know that when routine opt-out testing has been implemented in corrections, inmates have generally accepted testing. Inmates are a high-risk population, who might not have tested in a setting outside of corrections. As a result, we have the opportunity to test a large population of at risk people who do not know their status.

In addition, the available therapies can decrease the likelihood of a person becoming sick with opportunistic infection and can extend their lives. This has been demonstrated both in the free community and correctional setting. We have opportunity to benefit the particular individuals with HIV. We also have the opportunity to decrease transmission of HIV to sexual and drug-using partners. Lastly, we have an opportunity to save the health care system money. People who are diagnosed with HIV when they present with an AIDS-associated infection or cancer, cost the health care system a lot of money. So initiating treatment earlier can not only benefit that person and any people they've infected, but the general health care system as well.

DP: The statistics vary, but supposedly a quarter of Americans living with HIV do not know that they are HIV positive. Incarceration provides a unique opportunity to educate, test, and treat at-risk persons in order to interrupt the HIV epidemic.

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