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SUMMER 2007
Letter From the Editor
Dear Corrections Colleagues, As the introduction to most every article on the topic of HIV in corrections is obliged to remind us, there are a lot of people infected with the virus entering, living in and leaving our prisons and jails. Therefore, it is not surprising to hear renewed calls for correctional facilities to become a centerpiece of a broad effort to identify persons unaware of their HIV infection. The Centers for Disease Control and Prevention (CDC) recent recommendation that HIV testing be expanded to general healthcare settings has certainly fueled the latest interest in HIV screening in these settings and follow-up CDC statements regarding testing in correctional facilities are expected. No rationale individual can disagree that incarceration provides a valuable opportunity to detect infectious diseases such as HIV, other sexually transmitted diseases, latent tuberculosis and viral hepatitis. Indeed, to not look for such infections among incarcerated individuals in our country would smack of callousness and willful disregard. But, as always, the devil is in the details. How and when should HIV screening be done? Mandatory testing in prisons is not uncommon but raises important concerns regarding autonomy. Rapid HIV testing seems well suited for jails but some inmates are jailed for less than 48 hours and are often inebriated or intoxicated, making informed consent problematic. Is it best to test at entry only or annually during incarceration? Logistically, widespread testing will draw personnel and resources from other valuable healthcare activities. In addition, testing can be perceived as an un-funded mandate with the cost of testing itself and the expense of health care of those detected not typically provided for by those making HIV testing recommendations. The cost of antiretroviral therapy for a small proportion of prison or jail inmates can strain the zero-sum budgets of these facilities. The many facets of this topic are reflected in the perspectives and commentaries we have assembled in this issue of the IDCR. Drs. Curt Beckwith and Michael Poshkus from Rhode Island have published widely on HIV screening in their state and provide their rationale for calls for ramped-up voluntary, opt-out testing for HIV as part of a comprehensive program to manage HIV/AIDS in correctional settings. Ravi Kavasery and Rick Altice, MD both of Yale offer their own view of the challenges to HIV screening of inmates. Topping off these thoughtful perspectives is a candid interview with Drs. Joe Bick and David Paar, experts in correctional healthcare, on their takes on testing. Reading these articles, it becomes evident, even for someone such as myself who feels that HIV testing of persons in our jails and prisons must be greatly expanded, that the proposition is not a 'slam-dunk'. Screening for HIV in jails and prisons is a priority but has to be accompanied by recognition that additional cases of HIV infection will be detected and that these individuals will require counseling, care and referral. If the CDC's dreams of expanded testing are to be realized, state and federal support needs to materialize. Otherwise, we are left with well-intentioned and justified recommendations that we can argue over implementing but which do not lead to the reductions in new cases of HIV we can all agree we want to see. Sincerely, David A. Wohl, MD |
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