- What is the potential need for rapid HIV testing in correctional facilities?
- What type of testing (opt-in, opt-out, voluntary, mandated, standard, rapid) does the literature suggest?
- What are the benefits of rapid HIV testing in these settings?
Key take-home messages
- HIV rates are particularly high in correctional settings. In the U.S., HIV prevalence is five times higher in state and federal correctional systems than in the general population(1).
- In Canada, HIV prevalence is also higher among persons in prison than in the general population. In 2006, 1.64% of people in Canadian federal prisons were reported to be HIV positive vs. 0.3% in the general adult population(2).
- The Centers for Disease Control and Prevention (CDC) advocates for voluntary and routine testing in all correctional settings and suggests that testing be conducted through opt-out rather than opt-in procedures(3,5).
- As a result of many prisoners leaving jail before standard HIV test results can be given or follow-up blood work can be collected, rapid testing in correctional facilities should be used(4).
- The CDC recommends: conventional blood testing or rapid testing with conventional confirmation in prisons and rapid testing with conventional confirmation in jails(5).
The issue and why it’s important
Given that the prevalence of HIV/AIDS is significantly higher among those in correctional settings1 and that these individuals represent a large and diverse group, these facilities offer an ideal setting for public health interventions and research(6). The rate of incarceration is higher among minority races and ethnicities – as a result, HIV testing in correctional settings can reduce HIV/AIDS health disparities experienced by these populations(7). It is important for individuals to become aware of their HIV serostatus as soon as possible as it greatly improves their capacity to seek and access medical care, which can result in improved quality of life and prevent the spread of the virus(7).
The literature indicates a need for more HIV testing in correctional settings. In a 2002 survey, only 21.6% of inmates reported that they received an HIV test after admission(7). Another study noted that fewer than 5% of correctional facilities offer HIV testing at all(6).
What we found
The literature shows that while prisoners in correctional facilities often welcome HIV testing8, the procedure is not consistently available.6,7 For a 12-month period in 2008, three large correctional facilities in the U.S. implemented a rapid HIV testing program. As a result of the program, HIV testing increased more than six fold. All three facilities continued to provide care during incarceration periods and the program costs were integrated into existing budgets9. In another rapid testing program, 98% who were offered testing completed it. Of these individuals, an overwhelming percentage favoured rapid testing to venipuncture10. In one study, 88% of respondents preferred rapid testing to the standard HIV testing method11. A qualitative study demonstrated that most participants had their first HIV test while incarcerated, with one stating: “I’m doing nothing else, might as well get tested.”8
According to the literature, opt-out testing was widely viewed as preferable to opt-in testing.6, 10, 12 The opt-in testing approach is one in which “a person is offered an HIV test that he or she may elect to accept, decline, or defer,” while in the opt-out approach “a person is notified that an HIV test will be performed unless he or she declines or defers testing” 13. After a comprehensive review of the Rhode Island Department of Corrections (RIDOC) HIV testing program, routine opt-out testing was supported by the researchers.10
Such programs would improve the health of the correctional population and serve as examples for future research and cost analyses.6 In North Carolina, opt-out testing programs have resulted in much higher participation rates than opt-in programs. Among prisoners, opt-in programs resulted in 60% being tested while opt-out programs resulted in 90% being tested.12
According to key stakeholders and correctional staff in one study, rapid HIV testing was consistently preferred over conventional testing methods10. In another study involving health care workers in New York City, 90% of respondents believed that HIV testing in correctional settings was important and 87% were confident in recommending rapid HIV testing14. According to a survey of 154 prisoners involved in the RIDOC testing program, 98% reported that, if possible, they would like their HIV test results sooner rather than later.11
Although results from rapid testing are available in 10-30 minutes, additional tests are sometimes required. Results are reported as reactive, non-reactive, or invalid. A reactive result (also called a preliminary positive) has to be confirmed with a blood or oral fluid test before an HIV-positive diagnosis can be made.5
For prisoners with short incarceration periods, collecting follow-up blood work after a preliminary positive can be challenging as they may be in court, bonded out, or released.15
In the U.S., jail sentences tend to be significantly shorter than prison sentences, creating a stronger need for rapid HIV testing in jails. Quick delivery of rapid HIV test results will allow prisoners to learn their HIV status sooner and may motivate them to seek HIV care.4
RIDOC reviewed its HIV testing program among prisoners from 2000 to 2007, who were tested within 24 hours of incarceration. Results showed that if testing had been delayed for seven days, 43% of detainees would not have been tested. If it was delayed for 48 hours, 29% would not have been tested.16 In another study, all participants who underwent rapid HIV testing received their results while fewer than 30% who did a follow-up visit received results from their standard HIV test, supporting the use of rapid HIV testing in correctional settings.4
According to a 2009 CDC report, the organization recommends conventional blood testing or rapid testing with conventional confirmation in prisons and rapid testing with conventional confirmation in jails.15
What we did
We searched PubMed using a combination of text terms (HIV AND test* AND prison*) and limited the search results to English articles published in the US, Canada, UK, and Australia from 2007 to present. We also searched the Cochrane Library and DARE using the following text terms: HIV AND test* AND prison* and scanned the HIV and Acquired Immune Deficiency Syndrome categories on HealthEvidence.ca for any potentially relevant systematic reviews. Lastly, we reviewed the references in the studies found.
Factors that may impact local applicability
The literature discussed dealt exclusively with HIV testing in jails and prisons in the United States. While these findings may be relevant to correctional facilities in Canadian setting, these two countries have different correctional systems, penalties, HIV infection rates and populations. Therefore findings should be interpreted with caution as they may not be generalizable.
- Beckwith CG, Zaller ND, Fu JJ, Mon-tague BT, Rich JD. Opportunities to diagnose, treat, and prevent HIV in the criminal justice system. Journal of acquired immune deficiency syndromes. 2010;55 Suppl 1:S49-S55.
- Populations at risk. Public Health Agency of Canada. Ottawa: PHAC; 2007.
- Seal DW, Eldridge GD, Zack B, Sosman J. HIV testing and treat-ment with correctional populations: people, not prisoners. Journal of health care for the poor and under-served. 2010;21(3):977-85.
- Beckwith CG, Liu T, Bazerman LB, DeLong AK, Desjardins SF, Posh-kus MM, et al. HIV risk behavior before and after HIV counseling and testing in jail: a pilot study. Journal of acquired immune defi-ciency syndromes (1999). 2010;53(4):485-90.
- HIV Testing Implementation Guid-ance for Correctional Settings. Centers for Disease Control and Prevention. 2009. p. 1-38.
- Malek M, Bazazi AR, Cox G, Rival G, Baillargeon J, Miranda A, et al. Implementing opt-out programs at Los Angeles county jail: a gateway to novel research and interven-tions. Journal of correctional health care : the official journal of the National Commission on Correc-tional Health Care. 2011;17(1):69-76.
- Macgowan R, Margolis A, Richard-son-Moore A, Wang T, Lalota M, French PT, et al. Voluntary rapid human immunodeficiency virus (HIV) testing in jails. Sexually trans-mitted diseases. 2009;36(2 Suppl):S9-13.
- Kacanek D, Eldridge GD, Nealey-Moore J, MacGowan RJ, Binson D, Flanigan TP, et al. Young incarcer-ated men’s perceptions of and experiences with HIV testing. Amer-ican journal of public health. 2007;97(7):1209-15.
- Beckwith CG, Nunn A, Baucom S, Getachew A, Akinwumi A, Herdman B, et al. Rapid HIV testing in large urban jails. American journal of public health. 2012;102 Suppl 2(1254074, 3xw):S184-S6.
- Beckwith CG, Bazerman L, Cornwall AH, Patry E, Poshkus M, Fu J, et al. An evaluation of a routine opt-out rapid HIV testing program in a Rhode Island jail. AIDS education and prevention : official publication of the International Society for AIDS Education. 2011;23(3 Suppl):96-109.
- Beckwith CG, Cohen J, Shannon C, Raz L, Rich JD, Lally MA. HIV testing experiences among male and fe-male inmates in Rhode Island. The AIDS reader. 2007;17(9):459-64.
- Dramatic results for opt-out HIV testing in prison. Proportion of HIV tests increased quickly. AIDS alert. 2010;25(7):76-7.
- Recommended HIV Testing Defini-tions and Examples. Centers for Disease Control and Prevention, HIV Testing Definitions Work Group, Division of HIV/AIDS Prevention. 2011.
- Sabharwal CJ, Muse KH, Alper H, Begier E, McNeill M, Galeta G, et al. Jail-based providers’ perceptions of challenges to routine HIV testing in New York City jails. Journal of cor-rectional health care : the official journal of the National Commission on Correctional Health Care. 2010;16(4):310-21.
- Rapid HIV testing underused in jails. Obstacles include consent, counseling laws. AIDS alert. 2009;24(3):28-9.
- Routine jail-based HIV testing – Rhode Island, 2000-2007. Centers for Disease Control and Prevention, Morbidity and mortality weekly report. 2010;59(24):742-5.
Rapid Response Service. Rapid HIV Testing in Correctional Facilities. Toronto, ON: Ontario HIV Treatment Network; August, 2012.
David Gogolishvili, Jason Globerman, and Jamie McCallum.